Circular No. 1 of 2024
- Published by NAMAF
Background
The amendment of the medical aid fund rules requires the following information to appear on a healthcare provider claim for the purpose of reimbursement:
“The relevant diagnostic, procedure code, and such other item code numbers communicating the nature and costs of each health service rendered, as determined by the Namibia Association of Medical Aid Funds.”
The International Classification of Diseases and Related Health Problems Tenth Revision (ICD-10) has been adopted by the Medical Aids Funds and the Namibian Association of Medical Funds (NAMAF) as the diagnostic coding standard to support the amendment of the fund rules. The ICD-10 will be implemented in a phased manner and to this end, NAMAF notified healthcare stakeholders in 2023 to prepare for the implementation. Phase 1 was implemented in 2023, whereby healthcare providers are encouraged to submit ICD-10 codes and administrators are advised not to reject any claims that do not contain ICD-10 codes or have incorrect ICD-10 codes.
Detail
In preparation for phase 2, NAMAF is conducting an ICD-10 readiness assessment which entails the analysis of ICD-10 data collected by administrators in 2023/2024. The aim of the assessment is to establish the state of readiness in the healthcare industry for the phase 2 implementation. Thus far data from one administrator has been analysed and the findings are as follows:
- ICD-10 codes are not assigned from a standardized ICD-10 Masterfile.
- ICD-10 fields are not mandatory in billing and coding systems as invalid and incorrect ICD-10
codes appear on claims. - Some providers are submitting modified versions of ICD-10 codes, e.g. ICD-10-CM codes.
- Some providers are submitting CPT codes in the ICD-10 field.
- Some providers are using one ICD-10 code on all claims.
- ICD-10 coding rules are not adhered to in some instances, e.g. codes not valid as primary ICD-10 codes are submitted as a primary diagnosis.
- Assignment of ICD-10 codes at the incorrect level of specificity.
More feasibility studies will be undertaken during the course of this year and findings will be communicated to all healthcare stakeholders.
NAMAF’s ICD-10 implementation strategy entails the following:
- Regular communications to healthcare stakeholders on ICD-10 implementation.
- To make available a standardized ICD-10 electronic file via its website.
- Conduct ICD-10 webinars to healthcare stakeholders (1st webinar was conducted for healthcare providers).
- Engage with different healthcare stakeholders to address ICD-10 coding requirements relevant to each group of stakeholders.
- Develop an ICD-10 Technical Document for software vendors and administrators.
- Share a detailed ICD-10 Phase 2 implementation plan which will become available after the conclusion of the ICD-10 readiness assessment.
- Arrange ICD-10 coding workshops and training.
Phase 2 of the ICD-10 implementation entails:
- Submission of ICD-10 code/s at maximum level of specificity (correct 3, 4, 5- character level).
- Acceptance of ICD-10 codes for ‘unspecified’ conditions by administrators (those codes which contained .8 or .9 as a fourth character).
- Submission of valid primary ICD-10 codes as per the standardised ICD-10 electronic file (first code on the claim-line/header).
- Acceptance of sign and symptom ICD-10 code/s by administrators, if no definitive diagnosis was made.
- Submission of either the referral diagnosis from the diagnosing provider, a sign or symptom code or a code from chapter XXI (Z codes) for non-diagnosing providers.
- Adhering to the combination coding rules pertaining to dagger and asterisk codes, sequelae codes and injury/poisoning and external cause codes.
