Monthly Archives: January 2014

Payment Reform Initiative in Action: Results from the Frontline in Colorado

A growing area in healthcare is the rise in alternative payment methodologies.  Gone are the days of primarily fee-for-service medicine.  The State of Colorado has recently published the results of an Accountable Care Collaborative (some folks may know this from the other name, Accountable Care Organization or ACO) in a legislative report.  About half of their Medicaid members were enrolled in a Patient-Centered Medical Home where PCPs and dedicated case managers coordinated the medical care as well as non-medical care (e.g. transportation to doctor’s offices, homes sufficiently outfitted w/hand-rails if member is prone to falls).  Result?  The state saved approx. $44 million in 2012.  However, the state invested around $38 million in total program costs including administrative fees.  Hopefully, a good portion of these were up-front costs and the vast majority of these dollars should decrease in subsequent years.

Read more about this here.

ICD-10 and Impacts to Pre-cert/Authorization Process

This is a second article I wrote for WEDI last year in regards to the pre-cert/auth process.  Since I’m working on a payer implementation of ICD-10, my knowledge is primarily from that perspective.  However, it’s still good information for the provider community to keep in mind.  


ICD-10 and the Impacts to the

Pre-cert/Authorization Process:

What You Need to Know

By Gina Park, Director of Consulting Services, Axiom Systems, Inc.

Those of us who have been reading and hearing about ICD-10 in the healthcare industry know that this is DOS (date of service) or DOD (date of discharge) driven compliance.  “You cannot submit claims using ICD-10 diagnosis or ICD-10 procedure codes if the DOS or DOD is before 10/1/14!!” we’ve been beating into the heads of those in our organizations.  We got it, loud and clear.  However, this doesn’t mean that all HIPAA covered entities impacted by ICD-10 will not start speaking the language of ICD-10 until the magical October 1, 2014 date.

What about pre-certs and authorizations?

Typically, a provider will call a payer for prior approval of a procedure a few weeks in advance.  This will obviously not be the case for emergent admissions to inpatient facilities.  The provider will supply the procedure code (CPT-4/HCPCS) as well as the medical condition of the patient in the form of either a diagnosis description or the actual ICD-9 diagnosis code.  The payer will have their pre-cert/authorization policies based on the procedure being requested in the form of CPT-4/HCPCS code(s) and will not be based off the ICD-9 diagnosis code.  However, certain procedures may require the application of clinical criteria that will utilize the diagnosis in order to derive medical necessity.  In summary, the CPT-4/HCPCS procedure code drives the pre-cert/authorization process and not the diagnosis code.  Yay!

For pre-certs and authorizations whose effective periods will span the 10/1/14 compliance, there’s a general rule of thumb to keep in mind:  the corresponding claims must match the authorization.  This means if the authorization has an ICD-9 diagnosis code attached to it, the corresponding claim should also have an ICD-9 diagnosis code attached to it.  The same follows for ICD-10 diagnosis codes.  CMS Transmittal 950 that lays out clear direction on how to submit both institutional and professional claims if the dates span the 10/1/14 compliance date.  For the most part, institutional claims should use the discharge date in determining whether to file the claim w/ICD-9 or ICD-10 and professional claims should split the claim based on date of service.  A HIPAA standard transaction that includes both authorizations and claims cannot be submitted using both ICD-9 and ICD-10 codes.  Scenarios such as long term care, hospice, DME rentals, or lengthy inpatient confinements that get interim billed should follow the same authorization requirement since the claims have to be split.  In the case of interim bills where there is no discharge date, the claim will be filed using ICD-9 if the statement from and through dates are 9/30/14 and prior and a separate interim bill will be filed using ICD-10 if the statement from and through dates are 10/1/14 and later.  Based on how the payer has their claims to authorization adjudication rules setup, it may not match if the diagnosis code is not exact or is a related diagnosis (first 3 characters of the diagnosis code match).

From a cursory review of ICD-10 payer communications to their provider community, health plans will be ready to start accepting auth requests using ICD-10 around the June/July/August timeframe of 2014.  This should give all segments of the healthcare industry time to plan their internal training and process rollouts around prior approvals for a successful rollout next summer.

ICD-10 and DSM-V: What Does One Mean to the Other?

Note: This article I wrote for WEDI was published last Spring prior to the general release of DSM-V.  Update:  The DSM-V manual itself contains associated ICD-10 diagnosis codes.  This was not known at the time of writing the article last year.


DSM-5 and ICD-10: What Does One Mean to the Other?

Submitted by Gina Park, Director of Consulting Services, Axiom Systems;

Co-Chair ICD-10 Coding and Translation SWG

Much of the focus of the conversation surrounding ICD-10 has been around the medical side of things—how the move from ICD-9 to ICD-10 will impact medical benefits, medical reimbursement, and medical claims processing.  What about our mental health counterparts?  While virtually all mental health benefits are adjudicated as medical claims, there a divergence in how these claims get coded that is worth a separate conversation in and of itself.

DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) is the prevailing diagnostic system used by U.S. mental health professionals for the purpose of classifying mental and behavioral disorders today.  DSM-IV is developed and maintained by the American Psychiatric Association (APA).  Although most American mental health professionals have been trained in practice to use DSM-IV, this is NOT the official diagnostic system recognized by the government as well as other payers.  ICD-9 is officially recognized diagnostic system in the United States for reporting all medical AND mental and behavioral health related issues and disorders.  All World Health Organization (WHO) member countries including the United States are required to collect and report health statistics to the WHO using ICD codes as the framework.  This supports the fulfillment of WHO’s mission as an agency of the United Nations to attain the highest possible level of health for all people.  Without the use of a common language, this kind of data comparison and analysis would be quite hard, if not downright impossible.

In 1979, the federal government required ICD-9-CM codes be used for Medicare inpatient diagnostic and procedural billing.  Prior to 1979, DSM codes were acceptable for use in both reporting and reimbursement purposes.  Since 1989, ICD-9-CM has the required coding system to report all outpatient treatment and services for Medicare patients.  Soon after, other payers followed suit.  ICD-9-CM then became the official coding system for diagnostic billing in the United States.  To help mental health professionals transition to using the ICD-9 code set, APA, AHIMA, and a division of the CDC, the National Center for Health Statistics (NCHS) have worked together to develop a coding system for DSM-IV based on ICD-9-CM coding conventions and guidelines.  This group collaborated to minimize incompatibilities to the two diagnostic systems without comprising clinical integrity.  The current similarity between the two coding systems is a deliberate result of this collaborative effort.  For instance, a psychiatrist may use the DSM-IV code 296.3 for recurrent depression.  This corresponds to the ICD-9 diagnosis code 296.3, major depressive disorder, recurrent episode.  Based on how a clinician records encounter data into the clinical record (through EMR or another workflow process), the mental health practitioner may not realize that the DSM-IV code used to diagnose the patient gets transformed into ICD-9-CM codes for billing and reporting purposes.  The DSM-IV code as seen by the mental health practitioner in the clinical record is transformed to the corresponding ICD-9-CM diagnosis code on the submitted bill.

DSM-IV TR (DSM, Fourth Edition, Text Revision) was published in 2000.  This update listed additional diagnostic information for each condition.  This version also provides a crosswalk from the DSM-IV TR diagnostic code to the most compatible ICD-9-CM diagnosis code.  Despite the similarity, significant differences remain in the included disorders, disorder names and definitions, as well as how the categories are organized.

In 1999, work commenced between the federal government and the APA on DSM-5.  This extensive overhaul attempts, much like in ICD-10, how modern day advances in understanding behavioral issues and disorders could be reliably diagnosed by clinicians and other practitioners in the field of mental health.  This lengthy development time can be attributed to the magnitude of the change including the addition of new categories such as learning disorders and behavioral addictions; and the elimination of the current categories of substance abuse and dependence and are to be replaced with the category addiction and related disorders.  After these categories were created, numerous clinical trials were performed in order to test field reliability.  Results were analyzed and resulted in a number of revisions to the DSM-5.

As of date, DSM-5 is slated to be published in May 2013.  CMS has indicated in previous ICD-10 National Provider Calls that the CDC and the APA are working closely together to ensure DSM-5 and ICD-10 are compatible in their ability to work together for the diagnosing and reporting of mental and behavioral health issues.


HIX: Some Medicaid Enrollment Issues Have Surfaced

By Tasia Hooper

More than 100,000 Medicaid eligible persons are still uninsured in at least 21 states.  These individuals have been identified as having applied, or attempted to apply, for coverage during October and November 2013 when the federal health exchange was experiencing technical issues. Twenty-one states are receiving phone calls from the Obama administration advising the fastest method to get these people enrolled is to start the application process over from the beginning with their own state Medicaid agency.  The 100,000 + failed applications do not include failed applications for December 2013.  That number has not yet been released.  White House Senior Communications office Tara McGuiness states that ‘100%’ of the people having issues with Medicaid enrollment are being contacted by the White House, CMS or by their own state’s Medicaid agency.

Technical issues between the federal exchange (not specifically identified issues) and the individual state Medicaid agencies continue to plague the enrollment effort. CMS is working with 10 states to test these enrollment issues.  Initially CMS planned to attempt sending enrollment records for 200 Medicaid eligible applicants to their respective state’s Medicaid agency.  This effort has since been reduced from 200 test cases per state to 50 cases, then 10 cases and in some instances even less than 10 records. Test results were mixed.  Some of these 10 states show records not arriving at all.  Some records that transmitted contained errors including but not limited to incorrect addresses.

Tennessee is a participant in this test program with CMS.  The first test attempt by CMS, in mid-December, showed a test transmission of 10 records.  Three records arrived.  Seven records never arrived and have never been located – literally these seven records disappeared.  Before Christmas CMS attempted another test with Tennessee.  Zero records were transmitted.

Delaware received 50% of their records from the initial CMS test.  

January testing attempts are proving to be more successful.  New Mexico received 162 of 200 records in a test performed on 1/3/2013.  Delaware received 100% of records sent in a similar test of 200 applications.

Private health plan officials continue to say the records transfer issue is not limited to Medicaid.  Unnamed officials maintain they are getting unreliable enrollment reports.

New Mexico had to contact 15, 361 persons regarding Medicaid enrollment failures.  New Mexico also found 45 names in their file from states other than New Mexico.

Utah is manually processing 24,000 records after the federal health exchange failed to send applications back to Utah for processing. 

Utah and New Mexico are set up in a similar manner.  Any New Mexico or Utah resident who qualifies for Medicaid through the federal exchange would have their record returned electronically to the states Medicaid agency for processing.  The federal data returned to the state was missing vital information such as incomplete social security numbers or incorrect addresses.

Maryland has at least 5,000 residents who have tried to enroll in coverage (Medicaid or Commercial) and find themselves with no coverage as of 1/1/2014.  Governor O’Malley has called for a temporary shift for coverage for these residents and is asking they be enrolled under the state’s health insurance program that was established in 2002 for high risk individuals with pre-existing conditions.  This shift in coverage has to be approved by the state legislature.

CMS has offered up contingency plans for the states where the Medicaid enrollment is missing.  CMS will allow the states to use flat files.  These flat files would not be a basis of enrollment, rather a ‘heads up’ to show the states what their potential eligibility will be once automated eligibility transfer begins.

Because of the ongoing issues with the automated eligibility transfers CMS opted to give the 26 states, where Medicaid expansion has occurred the option of solely relying on these flat files as enrollment.  Five of the 26 states accepted this option.

Even the flat file eligibility transfer shows issues.  West Virginia requires Medicaid members pay a portion of their medical care.  These flat files are missing the cost to the West Virginia patients. 

Pennsylvania sent a consumer alert on 12/31/2013 to advise people who had applied for Medicaid on the federal health exchange that they were not enrolled with coverage.  The alert advised telephone calls would be made instructing them to apply directly to the Pennsylvania Department of Public Welfare.  Approximately 25,000 people were affected.

Alabama and Nebraska are relying 100% on CMS to advise Medicaid enrollees to go through their respective state agencies.

New defects noted in recent articles shows that the federal exchange still cannot adjust to changes in a person’s life – example a new baby, new address.  CMS maintains they are still working through all outstanding issues.  CMS further states they are still trying to develop an automated way for the consumer to update their coverage directly through the federal health exchange.

HPID Part I: What Is It?

This is a bit out of order, but this first part of HPID was originally sent out as an email as a part of the Thought Leadership Series on HPID.  We thought it might be helpful to have all of it centrally located on the blog.  Enjoy!

The Thought Leadership Series on HPID by Victor Laguardia


In September 5, 2012, the Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced a final rule that will save time and money for physicians and other health care providers by establishing a unique health plan identifier (HPID). The Health Plan Identifier (HPID) is used to standardize how health plans are identified in transactions to avoid misrouting of transactions and incorrect rejections. Beginning November 7, 2016, health care providers will be required to use an HPID to identify a health plan in standard transactions like claims or eligibility requests.

The final rule introduces a mandatory enumerator for payers, the Other Entity Identifier (OEID), a new process to obtain the HPID and OEID on the Health Plan and Other Entity Enumeration System (HPOES) that is housed within CMS’s Health Insurance Oversight System (HIOS). This system will be used to obtain a HPID or OEID, where there are two different HPID application types, the Controlling Health Plan and Sub health Plan, both with different requirements.

Entity Type Compliance Date for Obtaining HPID  Full Implementation Date for Using HPID in Standard Transactions
Health Plans, excluding Small Health Plans Nov 5, 2014 Nov 7, 2016
Small Health Plans* Nov 5, 2015 Nov 7, 2016
Covered Healthcare Providers N/A Nov 7, 2016
Healthcare Clearinghouses N/A Nov 7, 2016

*Small Health plan is defined by a health plan with annual receipts of $5 million or less.

Concern and Confusion

There is great concern in the industry that by introducing a new, not equivalently mapped, enumeration into the transactions may reintroduce past issues that have been solved, which impacts provider accounts receivable and re-introduces significant privacy and security risks. The Industry wants to understand the perceived ROI. There is broad variation in interpretation in what must be enumerated. This is in part based on the definition of a health plan, the Controlling Health Plan definition and/or the self-insured group health plans inclusion in the HPID Final Rule.

Trading partners of health plans are increasingly concerned that greater enumeration will result in a disruption of the current, well-functioning transaction flows, potentially resulting in payment disruptions and accounts receivable impacts as well as privacy and security breaches due to misrouted transactions. Since the X12 implementation guides will require a new Addenda version, all translator software and editors will have to be updated or all transactions will fail HIPAA edits. With the new notes in the transactions to support HPID, it will also create new rules for translators and HIPAA editors.

Both WEDI and the American Medical Association had presented CMS with recommendations to solve the new rule confusion and the concerns from the industry. On our next communication we will focus on these recommendations.