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Administrators, TPR Coordinator and Billing Agents
IEP Health Related Services
Identifying ICD-10-CM Codes
May, 2015
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US Department of Health and Human Services:
Center for Medicaid and Medicare Services (CMS)
Federal Regulations: 45 CFR 162.1002
Health care providers, health plans and clearinghouses must use ICD-10-CM codes
services on and after October 1, 2015
Healthcare Industry’s version of Data Driven Decision Making
Why is ICD-10-CM reporting required?
MHCP Enrolled Providers – Individualized Education Program (IEP):
Hot Topics• ICD-10-CM Reporting for Schools (DHS-7092) (PDF),
• Sign up to get email notices of new Provider Updates, Provider News, etc.
Find Informationon the DHS Website
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The ICD-10-CM code sets identify:
Signs and symptomsAbnormal findingsComplaintsSocial circumstancesExternal causes of injury or diseasesMedical diagnoses
What are the ICD-10-CM Codes Sets?
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Schools must provide an ICD-10-CM code for each billable IEP health related service.
These services include: Mental health (CTSS) Nursing Occupational therapy Physical therapy Speech-language pathology and audiology PCA Transportation Assistive Technology Interpreter Services
What Does this Mean for Schools?
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Who Determines the ICD-10-CM Codes?
Provider Diagnosis
Signs/Symptoms
Primary Care (MD, PA, APRN (Advan Pract RN) x o
Professional Nurses (LSN/PHN/RN, not LPN) o x
Occupational Therapists o x
Physical Therapists o x
Speech-Language Pathologists; Audiology
x x
School Psychologist o x
Mental Health Professionals x o
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The IEP health related service professional who is training, directing, supervising or ordering the service, selects the ICD-10-CM code(s) for:
PCA services Special Transportation Assistive Technology Interpreter services
In most cases it is the same ICD-10-CM code used by the professional.
Who Determines the ICD-10-CM Codesfor other IEP health related services?
Understanding the ICD-10-CM Code Structure
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- Identify the correct ICD-10-CM Codes: AskAm I treating the disease / disorder? or
Am I treating a sign/symptom?
- For treating disease/disorder, check the student record or contact the primary care provider.
- For treating sign/symptom, select the ICD-10-CM that represents the problem being addressed in the services
What do your IEP health related service professionals need to do? - 1
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The ICD-10-CM code must:
Clearly represent the child’s medical need as identified in the child’s IEP / IFSP
Logically relate to the IEP provider/service
Relate to the activities / tasks provided
Be valid, billable and specific to the child
Be medically necessary codes, not education codes
What do your IEP health related service professionals need to do? - 2
To qualify for Special Education a child must be eligible in one of these Educational Disability categories:
Speech/Language Impaired Developmental Cognitive disability – mild to moderate Developmental Cognitive disability – severe to profound Physically Impaired Visually Impaired Specific Learning disability Emotional/Behavioral Disorders (EDB) Deaf-Blind Other Health Disabilities Autism Spectrum Disorder Developmental Delay Traumatic Brain Injury Disabled Severely Multiply Impaired
Special Education Disability Categories
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A medical diagnoses is a criteria for eligibility for these Special Education Disability Categories: Other Health Disabilities, Physical Impairments and Traumatic Brain Injury
Speech/language pathologists and audiologists determine the diagnoses for Speech/Language Impairments
Mental Health Professionals provide DSM 5/ICD-10-CM diagnoses when CTSS is included in the child’s IEP needs and plan.
Annually, medical orders are required for students needing medication or certain treatments.
School Sources for Medical Diagnoses
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IEP Evaluation Report:• Summarizes medical need• States health related services are required during
school day
IEP Assessment and Plan describe:• Health problem, signs/ symptoms/ condition• Plan of care/Treatment Plan; why and what services
are necessary, when, by whom, how often
Special Education Records Align with ICD-10-CM
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1) Staff will need time to learn and practice how to do ICD-10-CM codes.
2) Set up a procedure for IEP health related services professionals to identify and document ICD-10-CM Codes in a student’s FILE, not in the IEP Plan.
(See example or use computer documents.)
2) Workflow: Determine how the Biller gets the codes (along with other daily reports).
What do Administrators, TPR Coordinators and Billing Agents need to do?
Optional Summary Sheet
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When a child has been diagnosed with a disease disorder from a primary care provider, report that diagnosis code as the Primary diagnosis for all claims for the child
When providing health related services for a sign, symptom, or condition resulting from the disease or disorder, report that code as Secondary, Tertiary and so on
When no medical disease or disorder has been identified, report the sign, symptom or condition code that identifies the IEP health related service that is being provided as the Primary diagnosis code
What do Billing Agents need to do?
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Codes need to be valid and billable
Watch for code notations and rules
Check with your vendors:
Batch submissions: No decimal points
For MN-ITS, decimal points are removed.
Watch for ICD-10-CM Code Notations
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Run a dual system– All 2014-15 claims (and through Sept. 30) claims will
use ICD-9 315.9.– For services provided on and after Oct. 1, ICD-10-CM
codes must be used.
Refer to the HIPPA implementation guide (find the Washington Publishing Company – 5010 Guide)
Make room for more than one code per claim
Batch submissions: No decimal points
What do Vendors need to do?
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Visit the following websites for additional guidance:
Center for Medicare & Medicaid Services (CMS) – ICD-10: Provides history, requirements, and coding sources
Centers for Disease Control and Prevention (CDC) – ICD-10: Provides history, requirements, and coding sources
ICD10Data.com: Example of a commercial website that can be used to find appropriate ICD-10-CM codes
MHCP Enrolled Providers – ICD-10, Minnesota DHS webpage: Provides periodic updates about ICD-10-CM Implementation
Online Resources for ICD-10-CM Reporting and Coding
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Use ICD-9 Code 315.9 for dates of service on or before September 30, 2015
Use ICD-10-CM Codes for dates of service on or after October 1, 2015
Window of opportunity: Districts need codes when you start billing for Oct. 1 services, late November.
Reminder:
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What is already in place?
What infrastructure changes are needed?
- Computer/software (district or vendor)
- Work flow: Identify codes, get codes to TPR biller
Who are your the early adopters?
Start with the easy/doable codes.
Change is hard. Staff need time and energy.
Things for Administrators to Think About
Webinar recordings: MHCP Enrolled Providers – Individualized Education Program (IEP) Trainings
DHS – MDE StaffJenny Roth, DHS IEP Services Coordinator
(651) 431-2622; [email protected]
Ruth Ellen Luehr, MDE Special Education Interagency Education Specialist
(651) 582-8403; [email protected]
RESOURCES
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