Provider Information Exchanges April 16 th through 24 th 2012

Electronic Data Interchange (EDI)

Presenter:

Christol Green,

Sr. EDI Business Consultant

[email protected]

Provider Information Exchanges

April 16

th

_{through 24}

th

₂₀₁₂

This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.

EDI Agenda

HIPAA 5010 Updates

ICD-10 Information

3

HIPAA 5010 Agenda

Provider 5010 Claim Experience

Anthem 5010 Experience

Escalating 5010 Questions

Anthem EDI 5010 Analysis and Resolutions

For Your Information Slides

•

5010 Testing Notifications

•

Important 5010 Changes

•

EDI Claim Reports

•

Billing Provider and Pay to Address

•

Nine-digit ZIP Code

Provider 5010 Claim Experience

Rejected Claims

Triage Issues -Software, Clearinghouse, Payer

Escalation

Accounts Receivable

Anthem 5010 Experience

Industry is Adjusting to New Mandate

• 5010 is Complex

• Providers, Clearinghouse, Software Vendors, Payers

Industry Experiencing 5010 Related Issues

• Reaction Time-Quick or Slow

• Providers, Clearinghouse, Software Vendors, Payers

Anthem 5010 Approach

• Monitoring daily reject rates, submission volumes, support calls

• Work with Trading Partners directly

• Internal triage and escalation for all 5010 issues

• Identify and implement changes

Escalating 5010 Questions

1st _{Point of Contact} Clearinghouse Vendor In-House Technical Staff 2nd _{Point of Contact}

EDI Solutions Helpdesk

800-470-9630 (option 2) Live Chat/E-mail [email protected] 5010 Questions [email protected] 3rd _{Point of Contact} Provider Network Representative

Anthem EDI 5010 Research and Resolutions

Required when different editing

32066, 60028, 60371- The Claim Filing Indicator (Loop 2000B, SBR09)

must = BL. (Blue Cross/Blue Shield).

Secondary Claim Rejections

60417 (837I) & 60098 (837P)- When Total Charge (2300 CLM02) does Not equal Paid Amount (Loop 2320 AMT02), CAS segments plus Total Paid must equal Total Charge

Top EDI Rejects 5010- March 2012

60001-Member ID Invalid

Netwerkes - About 1/3 of claim

errors were due to a wrong claim

filing indicator, they were sending

“CI” instead of “BL”

60098 Anthem Fix 03/16/2012

60417 Anthem Fix 04/20/2012

Anthem EDI 5010 Research and Resolutions

5010 837P (professional) Claims being returned from our WGS

system, stating submit to your home plan?

Issue:

mapping used Pay To Provider ( Payment/remit address) when Service

Facility field (box 32) was blank to determine Provider location of Service.

Correction:

mapping changed to look first at Service Facility field (box 32) if

blank then use Billing Provider field (box 33) to determine Provider location of

Service.

Anthem EDI 5010 Research and Resolutions

Phone number - hyphens/spaces

277CA Report-Real-time Delivery

**********

Not allowed

Important 5010 Changes

EDI Claim File Reports

• The Enterprise EDI Gateway generates a 999 Interchange Acknowledgment in response to an EDI file submission.

• This process applies Level 1 edits and reports the results.

• Recognize errors occurred and begin a correct/resubmit action, or • Recognize that all transactions were accepted.

999 Interchange Acknowledgment – (for Inbound Transactions)

• The Enterprise EDI Gateway generates a 277CA in response to an EDI file submission. • This process applies edits and reports the results.

• Recognize errors that occurred and begin a correct/resubmit action on specific claims, • Recognize transactions were accepted and, use returned claim numbers for future status

inquiries.

277CA Claims Acknowledgment – (for Inbound 837 Transactions)

• Anthem reports are delivered within 24hours after receipt of the electronic file. • Reports are often re-formatted by the clearinghouse as a service to the provider.

• Review reports daily or as often as submissions occurs and reconcile claim totals and dollars submitted.

• Anthem’s Level 2 Response reports can be used to support timely filing.

• Contact your clearinghouse or vendor for questions about reformatted reports.

EDI Response Report (Level 2)

Important 5010 Changes

Billing Provider and Pay-to Address

For 5010, the Billing Provider must contain a physical street address only and the Pay-to Address is available for the P.O. Box or Lock Box address, if needed. Additionally, the Pay-to Address, submitted only when different from the Billing Provider, may include a P.O. Box, Lock Box,

and/or street address, as applicable. Actual claim payment is sent to the address established on system during the initial set-up and/or contracting, based on the provider's 1099 form.

Therefore, ACTION IS REQUIRED by providers for the following situations:

1. Provider currently submits a P.O. Box or Lock Box address in the Billing Provider

• Determine a physical street address

• Determine if P.O. Box or Lock Box address needed, and submit in Pay-to Address

• Verify with software vendor, clearinghouse, or billing service that correct address is being

submitted

2. Provider changes destination for claim payment; different from that contractually established.

• Notify Provider Relations representative (billing/contracting)

• Verify with software vendor, clearinghouse, or billing service that correct address is being

Important 5010 Changes

Billing Provider and Pay-to Address - Example

Currently, Dr. Provider submits his billing address as "P.O. Box 1234" and is in process

of having his payments sent to a pay-to address different from what was set up

contractually, "1111 Pay-to Street, P.O. Box 1111". He knows that for 5010, he must

submit a physical street address in the Billing Provider loop. To ensure that his claims

are processed and payments made to the correct address, he contacts his provider

representative with his updated information.

BILLING address N301 = P.O. Box 1234 FAIL: P.O. Box is not allowed BILLING address N302 = 123 Billing Street

BILLING address N301 = 123 Billing Street PASS: payment made to address on system Pay-to address N301 = P.O. Box 1234

BILLING address N301 = 123 Billing Street PASS: payment made to address on system Pay-to address N301 = 1111 Pay-to Street

Important 5010 Changes

Nine-digit ZIP codes

When reporting the ZIP code for U.S. addresses in the Billing Provider and Service Facility Location, the full nine digit ZIP code must be provided.

• Dental - Billing Provider (2010AA, N403), Service Facility Location (2310C & 2420D, N403) • Institutional - Billing Provider (2010AA, N403), Service Facility Location (2310E, N403) • Professional - Billing Provider (2010AA, N403), Service Facility Location (2310C & 2420C,

N403)

All valid codes are identified in Code Source 932: Universal Postal Codes, and also accessible from the internet look-up tool: https://www.usps.com

Example: Currently, Dr. Bill Provider submits his ZIP code as '90212'. But he knows that for

5010, he must submit his full nine-digit ZIP code in the Billing Provider loop. He verifies the last four digits of his ZIP code as '2403'.

Claim submission with N403 = 902124321 FAIL: ZIP code is not valid

Claim submission with N403 = 90212 FAIL: ZIP code is not valid, requires 9 digits Claim submission with N403 = 90212 2403 FAIL: spaces are not allowed

Claim submission with N403 = 90212-2403 FAIL: hyphens are not allowed

Important 5010 Changes

Anesthesia Services - Units vs Minutes

Administration of anesthesia must be reported with the correct measurement per the 837 TR3. Institutional (837I) - Service Line (2400, SV204), Quantity measured using 'UN' (units)

Professional (837P) - Service Line (2400, SV103), Quantity measured using 'MJ' (minutes) Providers no longer need to apply a conversion factor to calculate units when reporting on anesthesia services on 837P claim submissions. *If the conversion factor is a concern, please contact your Provider Representative or Relations area.

Example: Today, Dr. Rendering A. Provider submits a claim for laser eye surgery; anesthesia reported in units. But he knows that for 5010, he must submit his anesthesia services in

minutes. He verifies the use of the qualifier 'MJ' for future 5010 claim submissions for anesthesia services.

Service = SV1*HC:00142:QK:QS:P1*2600*UN*7***1~ FAIL: Units are not accepted Service = SV1*HC:00142:QK:QS:P1*2600*MJ*104***1~ PASS: Minutes are accepted

ICD-10:

Agenda

ICD-10 Overview

Impact and Considerations

ICD-10 OVERVIEW

ICD-10:

What is ICD-10?

The International Statistical Classification of Diseases and Related Health

Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization.

ICD-10 consists of two parts:

1. ICD-10-CM (Clinical Modification) is for diagnosis coding, developed by the Centers for Disease Control and Prevention for use in all U.S. health care

treatment settings.

2. ICD-10-PCS (Modification/Procedure Coding System) is for inpatient

procedure coding, developed by the Centers for Medicare & Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings ONLY.

On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released the final rule mandating that everyone covered by the Health Insurance

ICD-10:

CMS Implementation Guidelines

TBD– Compliance date for implementation of ICD-10-CM

(diagnoses) and ICD-10-PCS (procedures) for HIPAA transactions

 ICD-10-CM (diagnoses) will be used by all providers in every healthcare setting

- Inpatient discharges occurring on or after Compliance Date will use ICD-10-CM diagnosis codes

- Ambulatory services provided on or after Compliance Date will use ICD-10-CM diagnosis codes

 ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures

- Inpatient discharges occurring on or after Compliance Date will use ICD-10-PCS codes

- ICD-10-PCS will not be used on physician claims, even those for inpatient visits

ICD-10:

CMS Implementation Guidelines

Single implementation date for all users



ICD-9-CM codes will not be accepted for services provided on or

after

date that is determined



ICD-10-CM/PCS codes will not be accepted for services prior to

date that is determined

CPT & HCPCS



No impact on Current Procedural Terminology (CPT) and

Healthcare Common Procedure Coding System (HCPCS) codes



CPT and HCPCS codes will continue to be used for physician and

ambulatory services, including physician visits to inpatients

ICD-10:

CMS – Non-HIPAA Covered Transactions

Non-HIPAA Covered Entities

 According to CMS, from a practical standpoint, the industry (both HIPAA and non-HIPAA covered entities) is migrating to ICD-10.

 Per National Committee on Vital and Health Statistics testimony, many

non-covered entities such as workers compensation programs, property and casualty insurers, etc. are working toward ICD-10.

CMS and Paper Claims

 Providers can use paper to submit their claims to payers for reimbursement

payments (HIPAA requirements only apply to electronic transactions). However,

CMS will require ICD-10 on all claim submissions, electronic or paper.

– UB-04 (hospitals) paper claim form, also known as the Form CMS-1450, has been upgraded to accommodate ICD-10 codes.

– The National Uniform Claim Committee closed a public comment period on Thursday, July 21, 2011 for revisions to the CMS-1500 Form.

ICD-10:

Diagnosis Code (CM) Comparisons

ICD-9-CM (Volume 1 & 2) ICD-10-CM

3-5 characters in length 3-7 characters in length

Approximately 14,000 codes Approximately 68,000 available codes

First digit may be alpha (E or V) or numeric; digits 2-5 are numeric

Digit 1 is alpha;

Digits 2-3 are numeric;

Digits 4-7 can be alpha or numeric

Limited space for adding new codes Flexible for adding new codes

Lacks detail Very specific

Lacks laterality Includes laterality (i.e., codes identifying right vs. left)

ICD-10:

Diagnosis Code (CM) Example

X X X

.

X X

ICD-9 ICD-10

X X X X X X X

Category Etiology, anatomic Category

site, manifestation Etiology, anatomic site, severity

.

.

Extension Structural Change

Diabetes mellitus with neurological manifestations type I not stated as

uncontrolled 2 5 0

.

6

Type 1 diabetes mellitus with diabetic neuropathy, unspecified

E 1 0

.

4 0

Type 1 diabetes mellitus with diabetic mononeuropathy

E 1 ₀

.

_{4 1}

Type 1 diabetes mellitus with diabetic amyotrophy

E 1 0 4 4

Type 1 diabetes mellitus with other diabetic neurological complication

E 1 0

.

4 9

1

An Example of One ICD-9 code being represented by Multiple ICD-10 codes

ICD-10:

Inpatient Procedure Code (PCS) Comparison

ICD-9-CM (Volume 3) ICD-10-PCS

3-4 numbers in length 7 alpha-numeric characters in length Approximately 4,000 codes Approximately 72,000 available codes

Based on outdated technology Reflects current usage of medical terminology and devices

Limited space for adding new codes Flexible for adding new codes

Lacks detail Very specific

Lacks laterality Includes laterality (i.e., codes identifying left vs. right) Generic terms for anatomic sites Detailed description of anatomic site

Lacks descriptions of methodology and approach for procedures

Provides detailed descriptions of methodology and approach for procedures.

ICD-10:

Inpatient Procedure Code (PCS) Example

X X

.

X X ICD-10 X X X X X X X Category Section Etiology, anatomic site, manifestation Structural Change Body System Root Operation Body

Part Approach Device Qualifier

An Example of an ICD-9 code being represented by an ICD-10 code

ICD-10 0 B H 5 4 G Z Section Body System Root Operation Body

Part Approach Device Qualifier 3 3

.

7 1

ICD-9

Category Etiology, anatomic site, manifestation

Endoscopic insertion or replacement of bronchial valve(s)

Insertion of endobronchial device into right middle lobe bronchus, percutaneous endoscopic approach

0 - medical and surgical B - respiratory

H - insertion

5 - bronchus, middle lobe, right 4 - percutaneous endoscopic G - endobronchial device Z - no qualifier

IMPACTS & CONSIDERATIONS

ICD-10:

ICD-10 Will Affect Everything

Staff

Physicians Nurses Coders Billing Staff Managers

Processes

Billing Coding Medical management Reimbursement accounting

Technology

Management systems System interfaces Software changes

ICD-10:

How will ICD-10 affect Staff?

Physicians/Nurses

 The need for specificity in documentation dramatically increases by requiring laterality, stages of healing, episodes of care, and much more

 Increase time for physicians to document

Coding staff

 Increased anatomy and surgical procedure knowledge  Increase time needed for coders to document

 Potential increase in coding staff to support transition and minimize productivity losses

Managers

 All vendor and payer contracts must be evaluated and updated

 Budget for changes in software, training, new contracts, and new paperwork  Most of staff will need training on the changes

ICD-10:

How will ICD-10 affect Processes?

Billing/coding work flow

 Increased coding queries to physicians for further documentation

 Superbill revisions may be required; paper superbills may be no longer be feasible  May need to use ICD-9-CM and ICD-10-CM concurrently for a period of time until

all claims are resolved

Prior authorization/notification changes

 Increased complexity; changes in requirements

Billing & reimbursement accounting

 Analysis and trending by payer ; payer reimbursement policies change  Changes in coding and data trends; previous data analysis obsolete

 Extensive remapping required (i.e. comparing healthcare outcomes from ICD-9 to ICD-10)

ICD-10:

How will ICD-10 affect Technology?

Management System

 Code field type/size increase to 3 -7 alphanumeric characters in all applications using ICD codes (including all clinical and financial applications where codes are entered/reported)

Redesign System Interfaces

 System interfaces may need redesigning to accommodate changes

Software Changes

 Code editing programs will need to be analyzed, redesigned and tested  Recalculation of DRG groupers and case mix indexes inpatient billing

Electronic Data Exchanges

 Reporting to federal, state, and other regulatory agencies/authorities will need to be analyzed, redesigned to accommodate new data and tested

PLANNING FOR

THE ICD-10 TRANSITION

ICD-10:

What You Can Do Now

It’s NOT too early to start planning!

Make sure you’ve considered all aspects of your practice.

 Be educated. Start reviewing ICD-10 code set changes now.

 Plan. ICD-10 compliance will result in guidance and operational changes from payers. Understand the impact to your practice and plan accordingly.

 Research. Investigate necessary changes to your existing practice work flow and business processes based on your patient population.

 Check with vendors/partners. Ensure your vendors and partners can support your ICD-10 adoption activities and understand their timelines.

 Train. Provide training for staff to handle ICD-10 codes and adapt to coding, authorization and billing changes.

ICD-10:

Anthem Will Be Ready!

Anthem ICD-10 Readiness Statement

Anthem strives to be an industry leader in meeting the requirements of all

mandates, including the implementation of the ICD-10 code set. We recognize that this implementation will represent a transformation of the health care industry, and will impact nearly every part of our business.

We have made several key decisions that will guide our implementation strategy. In addition, we have established teams representing all business and technology functions throughout our organization that are dedicated to researching issues, assessing

systems, reviewing business processes and educating our associates and affiliates about this critical implementation.

Anthem is working to help ensure that our systems, supporting business processes, policies and procedures successfully meet the implementation standards and deadlines without interruption to day-to-day business practices. Anthem will be capable of

accepting and processing ICD-10 diagnosis and inpatient procedure codes on the mandated deadline.

ICD-10:

How Anthem is supporting your implementation

ICD-10 Updates web page



Go to www.anthem.com



Select the Provider link (lower right corner of the page)



Select Wisconsin from the drop down list, and click Enter



From the Provider Home page, under the Communications and

ICD-10:

Additional Resources and Information

Use the industry resources available to you

 Centers for Medicare & Medicaid Services (CMS) – http://www.cms.gov/ICD10/

 Blue Cross and Blue Shield Association (BCBSA) – www.bcbsa.com/issues/icd-10

 AHIMA (American Health Information Management Association) – http://ahima.org/ICD10/  HIMSS (Healthcare Information & Mgt. Systems) – http://www.himss.org/ASP/index.asp

Anthem BCBS WI EDI Contact Information

EDI Solutions Help Desk

Monday – Friday, 8:00 a.m.-5:00 p.m.

Telephone:

800-470-9630 (option 2)

E-mail:

[email protected]

Website:

www.anthem.com/edi

(select state)

Q

uestions ?

Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

Electronic Data Interchange (EDI)