Monthly Archives: January 2014


Often in the general discourse of why the United States has to move to ICD-10, it seems like it is being forced upon those of us in healthcare, especially providers.  And the U.S. has the added complexity of the inpatient procedure coding system known as ICD-10-PCS.  The World Health Organization (WHO), the governing body of the ICD code set, did not sanction PCS nor did it have any involvement in its creation or maintenance.  It is strictly for the U.S. as developed by the U.S.  

What in the heck is it?  Why do we need it?

The simple answer (or answers):  to understand how to better develop reimbursement methodologies and therefore drive healthcare policy.

This classification system would help those stakeholders to better understand different aspects of healthcare by better understanding the patient population as it ties to costs and outcomes:

“….[ICD-10-PCS is] a set of tables containing the building blocks for PCS codes. Organized by body system, each body system contains the root operation tables and these tables contain the available choices of body part, approach, device, and qualifier for that root operation. This architecture is tailor made for efficient aggregation, database queries, and policies that can define a patient population with ridiculous ease. ‘All patients who had a laproscopic procedure on the digestive system’ can be stated in this one elegant PCS statement: oD**4**.  In english it says: medical and surgical section, gastrointestinal system, all root operations, all body parts, percutaneous endoscopic approach, all devices, all qualifiers. Written as separate codes, the list would be 1,035 codes long.”

 Read more here.  

Federal Government Extends High Risk Health Plan Coverage

Due to the technical difficulties that previously existed w/the federal exchange as well as the prior (and in some states, existing) issues that left people unable to enroll in a private health plan, HHS announced this week that they are extending the coverage for those covered under the Pre-existing Conditions Insurance Plan (PCIP).  This plan allows people who have previously been denied health coverage by other payers due to pre-existing conditions.  With the inception of the Affordable Care Act, insurers can no longer factor in pre-existing conditions to reject applications or charge a higher rate.  


Thought Leadership Series on HPID, Part 3: Clarifying Some Industry Confusion

The Thought Leadership Series on HPID by Victor Laguardia

On the previous communication we focused on the recommendations presented by WEDI and the American Medical Association (AMA) to CMS regarding some industry concerns. On this communication we will focus on clarifying some of the industry’s confusion and concerns regarding health plan identifier (HPID).


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 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.

Health Plan ID:  What Is It and What Is It Not

There has been confusion of whether all entities are required to get HIPDs and if all of them need to be identified in transactions. Many entities may be required to get HPIDs but these HPIDs will not necessarily be used in the transactions. The final rule does not require that health plans now be identified in the standard transactions if they were not identified before this rule. HPID, due to the HIPAA statutory constraints, is not an all payer standard. It is not intended to give standard identifiers for all payers – only Controlling Health Plans (CHPs) are required to be enumerated. The Final Rule did not change the requirements in the 5010 standards. It merely requires the use of the HPID where the health plan is identified. CMS hopes the industry will look creatively at HPID and The Other Entity Identifier (OEID) usage to make transactions and business processes more efficient

The 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), as well as its future use, is not clearly understood. CMS has explained that the immediate HPOES database product is really a catalog or list of CHPs because it will reflect health plans that have enumerated. At this time and in the near future, CMS does not believe the database will help address transaction routing. CMS would be interested in other potential uses and needs of this information. These potential uses might drive the data that could be captured.

Some in the industry are questioning the value of HPID if only some of the health plans are required to use them in transactions and others are not. CMS has responded with the following two statements:

  • Enumeration of HPIDs provides the universe of health plans.
  • CMS Believes that there is value in using the HPID in the transactions, but is interested in industry’s thoughts/strategies on the future of HPID, whether is change in the standards, best practices or recommendations on regulatory change through the National Committee on Vital and Health Statistics (NCVHS).

CMS has requested projections to the industry, but this request was unclear. CMS is not requesting specific data in terms of projections, but is rather interested in industry’s discussions and analyses of the extent to which the HPID will be used in transactions. CMS is also looking for input from the industry on how to best communicate to ASOs/self-funded group health plans, since they are likely unaware this requirement applies to them, and hopes for collaboration with industry groups such as WEDI in this regard.

Part 2: ICD-10 and What Providers Should Know About Payer Remediation Activities

I have been following ICD-10 related information and news sources for a period of time.  Like any good informed person, I try to be cognizant about not having my blinders on and only focusing on a single source or even a single view of ICD-10.  This means that I should not exclusively focus on payer-related sources for my information although my current assignment is with a payer and most of my professional experience is in that sector of healthcare.  Below is a summary of what I, in my humble opinion, wish providers could know about a typical payer’s ICD-10 impacts and remediation plan.  Please note: I typically am addressing smaller professional provider practices and rural and safety hospitals in this.  I have found that large health systems and hospitals have a good grasp on their respective ICD-10 projects and are in fairly good shape overall with meeting the 10/1/14 compliance date.

1.  Professional providers are reimbursed based on CPT-4/HCPCS codes and not using ICD diagnosis codes.  As mentioned in the previous blog post, Part 1 ICD-10 FAQs and Common Misconceptions, CPT-4/HCPCS codes are governed by the AMA and are NOT being impacted by the move to ICD-10.  However, this doesn’t mean that the move to ICD-10 may not impact overall claims processing, though.  Diagnosis codes most likely are used during benefits assignment during the adjudication process at a payer, e.g. maternity benefits for an office visit.  Depending on how granular the payer was in their configuration will most likely determine how the claim may or may not be affected when ICD-10 codes are introduced on a claim.

2. Impact to individual provider contracts.  There may some provider contracts, that specifically call out certain CPT-4/HCPCS codes billed in conjunction w/a certain diagnosis code range to be reimbursed at xxx dollars.  I have seen an example where certain outpatient office visits for members diagnosed w/HIV/AIDS get paid a certain rate.  However, most payers are trying to phase out the use of this because it turns into a maintenance nightmare.  Most provider contracts renew yearly and most payers have thousands of provider contracts in place at any given moment.  Also, CPT-4/HCPCS codes as well as ICD codes get reviewed and updated each year.  That means that these contracts that have an expired code has to be located, remediated w/the updated code, and then some form of updated contract sent back out to the provider.  Depending on how the master agreement is setup between the  payer and provider, this may have to go through a formal contract negotiation process—AGAIN.

3.  Pre-authorization policies.  Most authorizations policies (for outpatient services or procedures) are based on the CPT-4/HCPCS of the procedure and not the ICD diagnosis code.  Remember, the diagnosis code typically represents the medical condition.  For example, when a provider calls the payer asking for an authorization for, say, whirlpool therapy, the call agent at the insurer will look up CPT code 97022 and find out whether a pre-auth is required.  If it is, then medical necessity will be performed to determine if the member’s medical condition (as denoted by diagnosis code) warrants this treatment.  In this case, the member has a hip joint replacement (ICD-9 diagnosis code V43.64) and the pre-authorization nurse approved the provider’s request.

4.  Provider must provide the ICD-10 code!  Some providers (and even some folks on the payer side) are under the impression that come 10/1/14, payers can ‘cross-walk’ ICD-9 codes over to ICD-10 codes.  Or a provider calls for an authorization but only gives the description for the patient’s medical condition instead of the diagnosis code.  Payers (shouldn’t, anyway) pick and choose the ICD-10 diagnosis code for the provider.  It not only is against industry guidelines since the medical condition given to the payer has to be supported in the patient’s clinical record, it also sets a bad precedent for the provider in not giving them much of an incentive to learn and use ICD-10.

What are some of your thoughts, either on what providers are wanting to know from payers or other topics that payers should be communicating to providers?


Part 1: ICD-10 Frequently Asked Questions and Common Misperceptions

I have been working on an ICD-10 implementation with a payer for quite some time now, since 2010.  I have also been working w/ICD-10 from an industry perspective w/WEDI since late 2008, early 2009.  Most of us know that ICD-10 is not just any ordinary implementation.  It is much different and is forcing all sectors within healthcare to cooperate in unprecedented ways than ever before.  Payers (including state and federal government entities)  are clearly motivated to ensure providers are trained and ready to start coding using ICD-10 come October 1, 2014.  For the most part, large provider organizations such as hospitals and large group practices have the money and know-how on what to do to implement ICD-10 and build in the appropriate time frames to get this done.  However, smaller organizations such as solo physician practices and rural and safety net hospitals may not have the savvy or know-how of how to even begin this body of work.

Since 2009, I have been attending different conferences, webinars, and provider outreach calls through CMS and different state agencies.  Below are some of the most commonly asked questions I’ve been hearing about ICD-10 from provider groups:

1) Q: I am a xxxxxx {orthodontic, home health, DME, physical therapist, dental, etc} practice.  Does ICD-10 affect me? A.  If you are currently using ICD-9 diagnosis codes today to file your claims, then yes, you will be impacted by ICD-10.  Dental practices typically only use diagnosis codes when they file a CMS-1500 claim for a procedure that needs to get filed under the patient’s medical benefits such as a type of dental surgery.  The 837D (dental) transaction is new as of 5010 and includes the ICD version indicator (optional) and diagnosis codes (optional) fields on it.  As an FYI, diagnosis codes maybe filed on a dental claim if the member’s dental plan has enhanced benefits, such as additional routine cleaning visits for pregnant women or members with certain chronic diseases such as diabetes.

2) Q: Does the move to ICD-10 impact procedure codes?  A: ICD-10 does impact inpatient procedure codes that are only used to report out at the header level of facility claims.  This is primarily done for the purpose of DRG calculation.  ICD-10 will NOT impact CPT-4/HCPCS codes.  (These are governed by a different entity altogether, the American Medical Association).

3) Q: Is there a crosswalk between ICD-9 and ICD-10 available for me to use to get my practice ready for ICD-10?  A: CMS has made GEMs (General Equivalency Mappings) available for free on the internet.  GEMs is a forwards (ICD-9 to ICD-10) and backwards (ICD-10 to ICD-9) academic exercise, if you will, of all the potential translation possibilities between the 2 different code sets.  However, ICD-10 is vastly different than ICD-9 and does not contain a one to one map for ALL scenarios.  In order to do a true translation from ICD-9 to ICD-10, one must take into consideration the clinical intent of the code or codes being translated.  For instance, a current medical policy on treating pregnant women who have diabetes may not have the equivalent ICD-10 diagnosis codes listed since ICD-9 does not currently have a single diagnosis code to denote maternal diabetic cases.  However, ICD-10 does.

4) Q: Will my vendor (e.g. EMR, clearinghouse, billing service) get me ICD-10 ready?  A: It depends.  An analysis needs to be performed on how ICD-9 codes are selected today—is it by the clinician on a paper superbill; a picklist on the EMR during the clinical encounter; or does a billing service select it based on the clinical record?  A practice needs to take charge of this and not depend on an outside entity or a hardware or software update to fully remediate them for ICD-10.

5) Q: What is CMS or my other payers doing to train me on using ICD-10?  A: This is a question that I think the industry is really struggling with right now.  The general rule has always been that payers cannot tell providers how to code and especially to code for reimbursement since the claim must be coded based upon facts as documented in the medical record.  It is unethical and can be seen as fraudulent for a payer to tell/suggest a provider to use a specific code in order to get paid.  It’s as simple as that.  There are also industry standard guidelines on how a provider is to submit claims.  For instance, a full E&M visit should not be billed more than once every 3 years since this higher level of service (and therefore reimbursement) is not warranted for an annual checkup.  But, payers need to ensure providers are proficient coding in ICD-10 to ensure disruptions to claims processing and payment and other servicing to providers (and ultimately members) do not occur.

To combat this somewhat, most payers are referring providers to publicly available ICD-10 training-related information posted by different professional healthcare and government groups such as the AMA, AAPC, AHIMA, WEDI, and CMS.