MDS Alert

Published on Thu Apr 28, 2011 PDF

Get up to speed on Medicaid audits, which experts say are coming your way. For one, "the Medicaid Integrity Contractors (MICs) are still kicking around," says attorney Paula Sanders, with Post & Schell in Harrisburg, Pa. She knows of one nursing facility that had a MIC audit and "it still can't figure out what the MIC is trying to determine."

"A program that came about as a result of the Affordable Care Act of 2010," says consultant Nancy Beckley, MS, MBA, CHC, "is the mandatory Medicaid RAC program. Each state Medicaid director must develop a Medicaid RAC program and hire a recovery audit contractor to basically do similar things as the Medicare RAC program." The programs will be run individually by each state, adds Beckley, principal of Nancy Beckley & Associates LLC.

A potential break: "The RAC program will be expanding into Medicaid. However, the date by which the states were to have Medicaid RACs operational has been pushed back from April 1, 2011 indefinitely," says Janice Potter, CPA, MAS, healthcare research specialist at FR&R Healthcare Consulting in Deerfield, Ill. "A new implementation date will be included in the final rule for Medicaid RACs, when that is published," which is anticipated to occur later in 2011.

Up in the air: Sanders notes that while "Medicaid RACs are clearly on the horizon, the interplay between them and the MICs is unclear. Having Medicaid RACs could be duplicative for states that already have active Medicaid integrity programs."

If you're wondering how ICD-9 translates into ICD- 10, take a look at the diagnosis crosswalk posted on CMS' website. You can use it to look up your current ICD-9 code and determine which code set you'll use instead when ICD-10 debuts.

CMS is quick to point out that the crosswalk does not contain exact translations. Instead, the files "attempt to organize those differences in a meaningful way, by linking a code to all valid alternatives in the other code set from which choices can be made, depending on the use to which the code is put," the agency's Crosswalk User's Guide says.

For instance: All of the codes currently in the 010.90-010.96 range (Primary tuberculosis infection...) will translate into the singular code A15.7 (Primary respiratory tuberculosis) under ICD-10.

To read the new crosswalks, which include 2011 ICD-9 codes, visit http://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp.

Providers already should be in Level I compliance, CMS notes on its website. That means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."

By Dec. 31, providers must be in Level II compliance, meaning "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards," CMS says.

By Jan. 1, 2012, all providers must be in full compliance with the HIPAA 5010 regulations. More information on 5010 is at www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp.