Special Guest Posting by Coding Quality Specialist, Megha Patel, CCS, CPC- Official Coding Guideline Changes

Good afternoon, all.  Today, we're lucky to have a special guest post, by one of SCAN's Coding Quality Specialists, Megha Patel, CCS, CPC.  Megha has done a lot of hard work for us, compiling all the significant changes to the Official Guidelines for Coding and Reporting, beginning with the switch from ICD-9-CM to ICD-10-CM:

ICD -9 to ICD-10 Official Coding Guideline Updates

1.      10/01/2015:

ICD-9 to ICD-10 updated October 1, 2015.

·         CAD with Angina: Use combination codes for CAD with Angina, A causal relationship can be assumed in a patient with both Atherosclerosis and angina pectoris. It is not necessary to code Angina Pectoris separately.

·         Sequelae of CVA: Weakness due to previous CVA should be coded as Hemiplegia/Hemiparesis.

·         Sequelae of CVA: Hemiplegia/Hemiparesis/Monoplegia identify whether the dominant or non-dominant side of affected.  If provider didn’t documented dominant or non-dominant, the default is to assume the right side is the dominant side. If left side affected, the default is non-dominant.

·         DM with Hyperglycemia: Uncontrolled DM, Inadequately Controlled, Out of controlled, Poorly Controlled should be coded as Hyperglycemia.

·         Diabetes Ketoacidosis: ICD-10 CM does not provide a specific code for Type II diabetic Ketoacidosis. Assign code E13.10 Other Specified Diabetes with Ketoacidosis as per Coding Clinic First Quarter of 2013.

2.      03/18/2016:

·         DM with Complications Assumed relationship. The guidelines published in the first quarter 2016 issue of AHA Coding Clinic on pg. 11. According to this clarification, the subterm “with” in the index should be interrupted as a link between diabetes and any of those conditions indented under the word “with”.

** The linkage between diabetes and Osteomyelitis used to be assumed in ICD-9 but it is not assumed in ICD -10 (10/01/2015-10/01/2016 Not coded). There is no assumed relationship till October 1, 2016.

3.      10/01/2016:

·         Uncontrolled DM: Uncontrolled DM is classified by type and whether it is hyperglycemia or hypoglycemia. There is no default code for “uncontrolled DM”. Effective Oct. 1, 2016, uncontrolled diabetes can be referenced as Hyperglycemia or Hypoglycemia.

·          Hypertension with CHF: Presumes a causal relationship between hypertension and heart involvement. 

·         COPD with Asthma: COPD with asthma only coded as J44.9. If type of asthma not documented J45.909 should not be coded.  “Unspecified” is not type of asthma.

4.      10/01/2017:

·         Diabetic Ketoacidosis: October 1, 2017 updated with new codes for Diabetes Ketoacidosis (Type II). E11.10 Type II DM with Ketoacidosis w/o Coma and E11.11 Type II DM with Ketoacidosis w/ Coma.

·         COPD, Emphysema and Chronic Bronchitis all documented: Assign J449 only, because J43.9 Emphysema has Exclude 1 note (Emphysema with chronic bronchitis). J44.9 has Include note Chronic Bronchitis with emphysema. (J439 is Emphysema without Chronic Bronchitis) (J449 is Emphysema with Chronic Bronchitis).

·         COPD with Emphysema: J43.9 Emphysema assigned as Emphysema is specific type of COPD.

·         Emphysema with an Acute Exacerbation of COPD: Assign J43.9. Both codes have Exclude 1 note to each other. J439 is without Chronic Bronchitis and J449 is with Chronic Bronchitis. Emphysema is type of COPD so Acute Exacerbation of COPD is covers in J43.9.

Thanks, Megha--for doing all the heavy lifting!

Remember, you can always download the full text of the ICD-10-CM guidelines on our website, at http://hccuniversity.com/asset/154d663f-95bf-4a59-a1fd-a6e4eb7c8477

An Important Reminder From our Encounter Data Team

Hello SCAN Provider Partners,

The January CMS Encounter Data Sweep deadline has been extended! This is the FINAL CMS sweep impacting 2016 DOS (2017 payment) and requires the submission of encounters for DOS range 01/01/2016 à12/31/2016. CMS currently plans a 75% RAPS and Fee for Service and 25% EDS and Fee for Service blended risk score based on 2016 DOS.

Additionally, TODAY is the CMS Final Deadline Date for the March CMS Encounter Data Sweep, which requires the submission of encounters for DOS range 01/01/2017 à12/31/2017. CMS currently plans a 85% RAPS and Fee for Service and 15% EDS and Fee for Service blended risk score based on 2017 DOS.

SCAN has one date for you to manage towards for the January 2018 sweep (2016 DOS):

Ø  SCAN Deadline for Provider Partners: EOB Friday, April 27, 2018 – RAPS only

o   After this deadline, SCAN will NOT process any RAPS files received for the January CMS sweep

*Note: 2016 DOS EDS deadline has been extended to September 2018

SCAN has two dates for you to manage towards for the March 2018 sweep:

Ø  SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018 – closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018 – closed

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

1. Review your SCAN monthly Encounter Submission Reports
1. March reports were uploaded to the SCAN Encounter Data Portal on 3/2/2018. The next ESRs will be uploaded the first week of April 2018.

2.     Review your SCAN Encounter HCC Reconciliation Reports

1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

  

3. Review your SCAN All DX Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§ QUESTION: What is the All Diagnoses (DX) Reconciliation report?

§ ANSWER: A report containing all diagnosis codes received from your group for dates of service 01/01/2016 -> 12/31/2016 and 01/01/2017 -> 12/31/2017.

2. This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.

4. Review your SCAN PCN Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§  QUESTION: What is the Patient Control Number (PCN) Reconciliation report?

§  ANSWER: A report containing a list of all the PCNs received from your group for dates of service 01/01/2016 -> 12/31/2016 and 01/01/2017 -> 12/31/2017. The PCN field provides you with the ID received from you for each encounter (a.k.a. claim ID). You may reconcile the list of PCNs against your system to ensure that SCAN has received all of your PCNs. If any are missing on our list that exist in your system, then you can identify those as needing to be submitted to SCAN immediately

2. If you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.

*The above reports are designed to help you ensure that all possible encounter data for SCAN members has been sent to SCAN to meet the CMS health plan cut-off date of May 4, 2018 for the January Sweep (RAPS only) and March 2, 2018 for the March Sweep.

Additional Steps:

5. Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare

6. Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link
1. It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.
2. Send these files sooner than later; please do not to wait until April 27, 2018 to upload your 2016 DOS files for the January Sweep (RAPS only). Additionally, please do not wait until February 23, 2018 to upload your 2017 DOS files for the March Sweep.
3. ICE files should only be used to submit additional DX codes or deletes of DX codes.

§ SCAN expects to receive all original encounter data records via your normal clearinghouse workflow.

7. Follow up on additional cleanup requests (contact your respective HCI representative with your direct questions)
1. Provider Name Mismatch (PNM) rejection reports
2. Rendering Provider/Entity (RPX) rejection reports
3. EDS Full Encounter Data rejection reports
4. Invalid DX rejection reports
5. ICE File Pend reports

f.     POS 21, 22, and 23 reports

What are the Timelines?

1. Last day to submit all 01/01/2016 -> 12/31/2016 DOS encounters for RAPS to your Clearinghouse: 04/27/2018
2. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2016 -> 12/31/2016 to SCAN: 04/27/2018
3. January CMS Sweep RAPS deadline for SCAN: 05/04/2018
4. Submit all 01/01/2017 -> 12/31/2017 DOS encounters to your Clearinghouse: 02/23/2018
5. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2017 -> 12/31/2017 to SCAN: 02/23/2018
6. March CMS Sweep deadline for SCAN: 03/02/2018

* Remember: SCAN has two dates for provider partners to manage towards for the January and March Sweep:

Ø  January Sweep SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017- closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  January Sweep SCAN Deadline (RAPS only) for Provider Partners: EOB Friday, April 27, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

Ø  March Sweep SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018- closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  March Sweep SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018- closed

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

Please be prepared for continued communication from SCAN. We look forward to supporting and working with you during this upcoming sweep period!

  

If you have any questions or concerns, please feel free to contact me directly or reach out to SCAN’s HCI Representative:

o   Michelle Nguyen: MNguyen3@scanhealthplan.com

Best regards,

Christina Cabiltes

Supervisor, HCI Projects