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ICD-10 is here – Can you believe it??
Lynn Kuehn, MS, RHIA, CCS-P, FAHIMAKuehn Consulting, LLC
Learning Objectives
• At the end of today’s session, you will be able to:– Identify what ICD-10 is and isn’t– Explain who is affected by the system changes– Compare ICD-9-CM with ICD-10-CM and PCS– Summarize what the industry has learned so far– Participate in open question and answer session
at the end of the presentation
Facilities Using the New Code Set
Physician
ICD-10-CMCPT /
HCPCS
Long Term HealthcareICD-10-CM
CPT / HCPCS
Other Outpatient ProvidersICD-10-CM
CPT / HCPCS
HospitalInpatient
ICD-10-CMICD-10-PCSOutpatientICD-10-CM
CPT / HCPCS
Only required for reporting procedures
performed on hospital inpatients
Who Must be Compliant?
ICD-10 Compliant
Hospitals
Physicians
Outpatient Facilities
Home Health Agencies
Home Medical Equip.
Reference Labs
Health plans & payors
State Medicaid Programs
CDC
HIE/RHIO
Medical Devices
Code Set Freeze
•Limited Code Updates
2012-2015
•Regular Code Updates
10/1/2016
Physician Offices, ED, Clinics, etc.
Physician sees patient in the office for fever, nausea and vomiting. Diagnosis: Gastroenteritis
Then Now
ICD-9-CM Diagnosis Code ICD-10-CM Diagnosis Code
CPT/HCPCS CPT/HCPCS
Physician Offices, ED, Clinics, etc.
Physician sees patient in the office for fever, nausea and vomiting. Diagnosis: Gastroenteritis
Then Now
558.9 Noninfectious gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis
CPT/HCPCS (Office E/M code) CPT/HCPCS (Office E/M code)
Surgeons’ Work
Surgeon performs a cholecystectomy for acute cholecystitis with cholelithiasis.
Then Now
ICD-9-CM Diagnosis Code ICD-10-CM Diagnosis Code
CPT/HCPCS CPT/HCPCS
Surgeons’ Work
Surgeon performs a cholecystectomy for acute cholecystitis with cholelithiasis.
Then Now
574.00 Calculus of gallbladder with acute cholecystitis, without obstruction
K80.00 Calculus of gallbladder with acute cholecystitis, without obstruction
CPT/HCPCS CPT/HCPCS
Hospital’s Work
The patient has an open cholecystectomy as an inpatient with acute cholecystitis with cholelithiasis.
Then Now
ICD-9-CM Diagnosis Code ICD-10-CM Diagnosis Code
ICD-9-CM Procedure Code ICD-10-PCS Procedure Code
Hospital’s Work
Surgeon performs an open cholecystectomy for acute cholecystitis with cholelithiasis.
Then Now
574.00 Calculus of gallbladder with acute cholecystitis, without obstruction
K80.00 Calculus of gallbladder with acute cholecystitis, without obstruction
51.22 Cholecystectomy 0FT40ZZ Open resection of gallbladder
Fact or Myth
ICD-10-CM and ICD-10-PCS is a Medicare administrative system
a. Trueb. False
World Health Organization
• Develops and maintains the base system for use in tracking death statistics worldwide
• U.S. version isICD-10-CM for diagnoses
Fact or Myth
Providers will not get paid if they submit an unspecified diagnosis code
a. Trueb. False
Unspecified Codes
A04.9 Bacterial intestinal infection, unspecified
K92.2 Gastrointestinal hemorrhage, unspecified
R11.2 Nausea with vomiting, unspecified
S37.90xA Unspecified injury of unspecified urinary and pelvic organ
Fact or Myth
ICD-10 is those crazy codes that no one cares about.
a. Trueb. False
Leading Cause of Death, by age for 2010
DATA IMPACT
Data Impact
• Changes to multiple information systems and applications
• Increased system storage capacity• Redesign of reports and forms• Modification of patient assessment data sets• Data trending challenges
Data Trending Challenges
• Differences in code sets go beyond changes in code titles or level of specificity – Terminology, definitions, meaning of code, or
instructions for code assignment may have changed
• When linking coded data, differences need to be reconciled– Method used to reconcile differences may vary
Data Trending Challenges
• Flawed decisions may be made due to reliance on distorted, inaccurate, or misinterpreted data or comparability problems
• Caution should be exercised when interpreting data across transition
Reports Inventory and Conversion
External• CORE measures• Benchmarking• Registries• Regulatory• HIE• State Reporting
Internal• Patient Care• Quality & UR• Registries• Billing & Reimbursement• Research• Regulatory
What is ICD-10-CM?
• Based on ICD-10 published by the World Health Organization
• NCHS developed ICD-10-CM and guidelines• ICD-10-CM is used for morbidity classification• ICD-10-CM in public domain, however cannot
be altered except through the Coordination and Maintenance Committee process
ICD-10-CM Structure
S 3 2 0 1 0 A
Characters 1-3Category
Character 4-6Anatomic Site,
Etiology, Severity
Character 7Additional info when
needed
Site Etiology Severity
How Data is Organized
ICD-10-CM: Similarities to ICD-9-CM
• Divided into Alphabetic Index and Tabular List– Structure and format are the same– Index is alphabetical list of terms and their
corresponding codes• Alphabetic Index lists main terms in alphabetical order
with indented subterms under main terms• Index is divided into 2 parts: Index to Diseases and
Injuries and Index to External Causes
Index Example
Hemiplegia G81.9-- alternans facialis G83.89- ascending NEC G81.90- - spinal G95.89- congenital (cerebral) G80.8- - spastic G80.2- embolic (current episode) I63.4-- flaccid G81.0-- following- - cerebrovascular disease I69.959- - - cerebral infarction I69.35-- - - intracerebral hemorrhage I69.15-- - - nontraumatic intracranial hemorrhage NEC I69.25-- - - specified disease NEC I69.85-
ICD-10-CM: Similarities to ICD-9-CM
• Many conventions have same meaning– Abbreviations, punctuation, symbols, notes such
as “code first” and “use additional code”• Non-specific codes (“unspecified” or “not
otherwise specified”) are available to use when detailed documentation to support more specific code is not available
ICD-10-CM: Differences from ICD-9-CM
• Code titles are complete (no need to refer back to a category, subcategory, or subclassification level to determine complete meaning of code)
ICD-10-CM: Differences from ICD-9-CM
ICD 10 CM – Conventions‑ ‑
Exclude NotesExclude1: Means NOT CODED HERE
Code being excluded is never used with codeThe two conditions cannot occur togetherExample:
R23.0 Cyanosis Excludes1: acrocyanosis (I73.8)
cyanotic attacks of newborn (P28.2)
ICD 10 CM – Conventions‑ ‑
Exclude NotesExclude2: Means NOT INCLUDED HERE
Excluded condition is not part of the condition represented by the code
Acceptable to use both codes together if patient has both conditions
Example:
R93.6 Abnormal findings on diagnostic imaging of limbs Excludes2: Abnormal findings in skin and subcutaneous tissue
(R93.8)
Valid ICD-10-CM Codes
R54 Age-related physical debilityN02.0 Recurrent and persistent hematuria with
minor glomerular abnormalityC40.01 Malignant neoplasm of scapula and long
bones of right upper limbQ76.426 Congenital lordosis, lumbar regionT48.1x1A Poisoning by skeletal muscle relaxants
[neuromuscular blocking agents], accidental (unintentional), initial encounter
ICD 10 CM – Format‑ ‑
• Place holder “x”– Maintains the integrity of the meaning of certain
characters• Example: T48.1x1S Poisoning by skeletal muscle
relaxants [neuromuscular blocking agents], accidental (unintentional), sequela
– Used when a shorter code requires 7th character extension
• Example: W89.1xxA
ICD-10-CM: Differences from ICD-9-CM
• Addition of 7th character– Used in certain chapters to provide information
about the characteristic of the encounter– Must always be used in the 7th character position– If a code has an applicable 7th character, the code
must be reported with an appropriate 7th character value in order to be valid
ICD-10-CM 7th Character:Injuries & External Causes
A Initial encounter D Subsequent encounter S Sequela
Note: For aftercare of an injury, assign acute injury code with 7th character “D”
Principal and First Listed Diagnosis
• Principal diagnosis: Used in inpatient setting. “...that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”, UHDDS definition
• First listed diagnosis: The first listed code in all other health care settings.
• Both are based first on sequencing instructions and conventions in the classification.
New Features
Combination codes for conditions and
common symptoms or manifestations
Combination codes for poisonings and
external causes
Added laterality
Expanded codes (injury, diabetes,
alcohol/substance abuse, postoperative complications)
Injuries grouped by anatomical site
rather than injury category
Combination Codes – Examples
• I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
• E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
• K71.51 Toxic liver disease with chronic active hepatitis with ascites
• K50.012 Crohn’s disease of small intestine with intestinal obstruction
• N41.01 Acute prostatitis with hematuria
Diagnosis Code Comparison
ICD-9-CM ICD-10-CMConsists of 3 to 5 digits Consists of 3 to 7 characters
1st digit is numeric or alpha, using E or V 1st character is alpha, using all letters except U
2nd digit is numeric 2nd Character is numeric
3rd, 4th, and 5th digits are numeric 3rd to 7th Characters can be alpha or numeric
Always at least 3 digits Always at least 3 characters
Decimal place after the first 3 digits Decimal place after the first 3 characters
Alpha characters are not case sensitive Alpha characters are not case sensitive
What is ICD-10-PCS?
• ICD-10 (international version) does not contain a procedure coding system
• CMS awarded a contract to 3M Health Information Systems to develop a new procedure coding system
• The new system is intended for reporting INPATIENT procedures only
• CPT and HCPCS will still be used where currently in place
• ICD-10-PCS is available in the public domain and available from the CMS website
ICD-10-PCS Code Structure
2 3 4 5 6 71
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
Esophageal Biopsy in ICD-9
• Characters have no meaning• It’s just a number!• And, we’ve been out of these numbers for
years….
2 2 44 .
Endoscopic Esophageal Biopsy in PCS
D B 5 8 Z X0
Medical-Surgical
Gastro-intestinal
Excision
Esophagus
Via Natural Opening
Endoscopic
No Device
Diagnostic
ICD-10-PCS System Attributes
• Completeness– All substantially different procedures have a
unique code• Expandability
– The structure of the system allow incorporation of new procedures as unique codes
ICD-10-PCS System Attributes
• Standardized terminology– Includes definitions of the terminology used
(Definitions may vary from common usage)• Multiaxial structure
– Each character has the same meaning within a section and across sections to the extent possible
ICD-10-PCS Code Structure
• Codes comprised of seven components, called characters
• Individual units for each character have a letter or number assigned as a “value”
• 34 possible values:– Digits 0-9– Letters A-H, J-N, and P-Z– No I or O
Building an ICD-10-PCS Code
• Index provides first 3 characters of code, associated with a code table
• Table is referenced to build the last 4 characters of the code
• Table arranged in rows to allow only valid character combinations
Step 1 - Alphabetic Index
• Uses root operations as main entries• Contains references for
– Devices– Body Parts
• Guides you to the correct table• Open appendectomy (Resection):
Step 2 - PCS Tables
• Final coding decision = 0DTJ0ZZ0 Section = Medical and SurgicalD Body System = Gastrointestinal SystemT Resection = Cutting out or off, without replacement, all of a body partBody Part Approach Device Qualifier
1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 4 Esophagogastric Junction5 Esophagus 6 Stomach 7 Stomach, Pylorus 8 Small Intestine 9 Duodenum A Jejunum B Ileum C Ileocecal Valve E Large Intestine F Large Intestine, Right G Large Intestine, Left H Cecum J Appendix K Ascending Colon L Transverse ColonM Descending ColonN Sigmoid ColonP Rectum Q Anus
0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic
Z No Device Z No Qualifier
Building a PCS Code
Procedure Code Comparison
ICD-9 Procedures • 3-4 digits• All digits are numerical
• Numerical by body system
• Decimal after 2 digits
ICD-10-PCS• 7 characters • Characters are both
numerical and alpha• Each character has a
specific value. A character (0) in a different position has a different value/meaning
• No decimals
What If We Didn’t Plan Well?
• Get a line of credit ASAP if insufficient reserves on hand
• It’s not too late to work the implementation checklists or ask for help– Implementation talent may be available if their
previous assignments went well and are complete• Be prepared to react to what happens between
October 21 and 30 when the EOBs arrive. – READ THEM!!
What We’ve Learned So Far
• Physician Practices and other Outpatient Billing:– Up-to-date systems that can transmit ICD-10
codes are working well– Codes with the correct number of characters pass
through the systems on test without issue• Scrubber software or similar pre-bill edit software is
vital to catch missing characters
– Medical necessity edits are still an unknown commodity
What We’ve Learned So Far
• Hospital Inpatient Billing:– Medicare states there should be no more than
1 percent in DRG change with ICD-10 if the documentation works with the code set.
– Dual coding studies in 2015 have shown this to be reasonably true
– If the DRG changes, CHECK the coding for accuracy
• Inaccurate coding is the chief cause of DRG change
What We’ve Learned So Far
• Hospital Inpatient Billing:– Hospitals with greater than 3 percent change
should consider:• Real time analysis of each DRG “abnormality” as the
case is coded• Documentation review for diagnoses• Additional intense ICD-10-PCS training for coders to
increase decision making skills– Determining the differences between 31 root operations
is difficult without the right tools and significant practice
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Thank you!
Contact Information:
Lynn Kuehn, MS, RHIA, CCS-P, FAHIMAKuehn Consulting, LLC
1155 S. Springdale Road Waukesha, WI 53186O: 262-574-1064 C: 414-807-4589
[email protected] www.KuehnConsulting.com
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