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Today’s Agenda Overview of ICD-10-CM
An Up-to-Date Review
The Effects of ICD-10-CM on Your Practice
Using Technology Effectively
Differences Between ICD-9 and ICD-10
What You Need to Know
Determining Your Most Commonly Used Codes
Clinical Documentation
Provider Challenges 3
Why ICD-10?
Improve Clinical Communications
More (better) data Signs
Symptoms
Risk Factors
Comorbidities
Allow U.S. to exchange information internationally
5
What Is ICD-10? International Classification of Diseases
ICD-10-CM: diagnosis code set
Updated version of ICD-10-CM Volumes 1 and 2
ICD-10-PCS: code set of inpatient procedure codes Updated version of ICD-9-CM Volume 3
6
ICD-9 vs. ICD-10
ICD-9 ICD-10
Diagnosis: 14,000 codes Diagnosis: 68,000 codes
Procedures: 4,000 codes Procedures: 87,000 codes
7
Code Structure
ICD-10-CM Code Structure
Characters 1 through 3 = Category
Characters 4 through 6 = Etiology, anatomic site, severity, or other clinical detail
Character 7 = Extension
8
Example:
S52 Fracture of forearm (category)
S52.5 Fracture of lower end of radium (site)
S52.52 Torus fracture of lower end of radium (type)
S52.521 Torus fracture of lower end of right radium (laterality)
S52.521A Torus fracture of lower end of right radium, initial encounter for closed fracture (extension = episode of care)
9
Code Construction A three-character code
Base code (category) I10 Essential (primary) hypertension
Building a five-character code
Base code (category) Four characters Five characters
E11 E11.4 E11.42
Type 2 diabetes Type 2 diabetes with neurological complications Type 2 diabetes with polyneuropathy
Building a seven-character code
Base code (category) Four characters Five characters Six characters Seven characters
M1A M1A.0 M1A.07 M1A.072 M1A.0721
Chronic gout Idiopathic chronic gout Idiopathic chronic gout, ankle & foot Idiopathic chronic gout, left ankle & foot Idiopathic chronic gout, left ankle and foot, with tophus 1
0
What Does This Mean for You?
Requires significant changes to clinical and administrative systems that capture and report diagnosis codes
Structural differences between ICD-9 and ICD-10 make converting the code set complex
Change in character length from ICD-9 to ICD-10 requires system upgrades to expand data fields for longer codes
11
Front Desk
HIPAA Privacy policies may need to be revised and patients will need to sign the new forms
SYSTEMS Updates to systems are likely required and may impact patient encounters
13
Clinical Areas
Patient Coverage Health plan policies, payment limitations, and new ABN forms are likely
Superbills Revisions required – paper superbills may be impossible
ABNs Health plans will revise all policies linked to LCDs or NCDs, etc., ABN forms must be reformatted and patients will require education
14
Nurses / Medical Assistants
Forms Every order must be revised or recreated
Documentation Must use increased specificity
Prior Authorizations Policies may change, requiring training and updates
15
Physicians & Extenders
Documentation The need for specificity dramatically increases by requiring laterality, stages of healing, weeks in pregnancy, episodes of care, and much more
Code Training Codes increase from 17,000 to 140,000 – Physicians must be trained
16
Lab
Documentation Must use increased specificity
Reporting Health plans will have new requirements for the ordering and reporting of services
17
Coding Code Sets Codes will increase dramatically. As a result, code books
and styles will change completely.
Clinical Knowledge More detailed knowledge of anatomy and medical
terminology will be required with increased specificity and more codes.
Concurrent Use Coders may need to use ICD-9-CM and ICD-10-CM
concurrently for a period of time until all claims are resolved.
18
BILLING Policies & Procedures All payer reimbursement policies may be revised.
Training Billing department must be trained on new policies and
procedures and the ICD-10-CM code set.
19
Managers
New Policies & Procedures Any policy or procedure associated with a diagnosis code,
disease management, tracking, or PQRS must be revised.
Vendor & Payer Contracts All contracts must be evaluated and updated.
Budgets Changes to software, training, new contracts, new
paperwork will have to be paid for.
Training Plan Everyone in the practice will need training on the
changes. 20
It Comes Down to These Four Things!
1. Prepare a Project Plan
2. Perform an Impact Analysis
3. Begin Implementation
4. Convert to ICD-10 and Monitor
22
Eight Tasks to Get Started
1. Identify your current systems and work processes that use ICD-9 codes
i. Administrative
ii. Clinical
iii. Reporting
2. Talk with your practice management system vendor about accommodations for ICD-10 codes
i. Review current contract
ii. Is there an expense? 24
Tasks:
3. Discuss implementation plans with all clearinghouses, billing services, and payers to facilitate a smooth transition
i. Know their implementation plans
ii. Can they accommodate both code sets?
4. Talk with payers about how ICD-10 implementation might affect provider contracts
i. Coverage determination policies
ii. Payment schedules 25
Tasks 5. Identify potential change to workflow and
business processes i. Clinical documentation
ii. Encounter forms or “superbills”
iii. Quality reporting
iv. Public health reporting
26
Tasks
6. Assess staff training needs i. Focus on learning ICD-10 code set and any workflow
changes
a. Clinical – understand how documentation will affect the ability to code and bill
b. Administrative – understand the effects on preauthorization and referrals
c. Coding – may need the most training
27
Tasks
7. Conduct test transactions using ICD-10 codes with payers and clearinghouses
i. Consider “dual” coding
a. Coding and Billing in both ICD-9 and ICD-10
Helps you prepare for ICD-10 and mitigate the risk of denied claims
ii. Watch for testing periods
Clearinghouse
Payers 28
Tasks
8. Budget for time and costs related to ICD-10 implementation
i. System changes
ii. Resource materials
iii. Training
iv. Reserve fund
29
31
Assessing Your Systems Survey Your Technology Vendors Now . . . .
It is imperative that you understand their plans, so you can make your transitions plans. ASK:
What are they doing for ICD-10?
When are they doing it?
Will you have access to both ICD-9 and ICD-10 in your PMS & EMR?
Will GEMs be to used to convert current code databases?
32
Prepare for the Transition
Identify all internal systems that utilize ICD-10
Understand the changes that are being made to each Database changes to one application/system CAN
affect all other interfaced systems
Determine the impacts on staff, process, and other systems
33
Prepare for the Transition
Create a transition timeline by system
Identify any new technologies you require EMR *
Code Mapping
Project Management Tools
*If you are not currently using an EMR, ICD-10 is the time to seriously consider this addition to your practice.
34
Understanding GEMs Technology vendors most likely are going
to utilize or offer you some variation of GEMs. The GEMs act as a translation dictionary to bridge the language gap between ICD-9–CM and ICD-10-CM/PCS
The General Equivalency Mappings (GEMs) database was created by CMS and CDC to help users understand, analyze, and manage the translation of one code set to the other. They also help users create their own applied mappings as needed.
35
Understanding GEMs
GET FAMILIAR with this database. It has both the potential to help tremendously with this transition to ICD-10 and cause confusion. ICD-10 is not as simple as one-to-one mapping in many cases, and level of detail required will create the need to evaluate many codes that come from the mapping
Translation Programs / Software
Some come with your software
Some can be purchased
Some are free Icd9data.com and icd10data.com
AAPC
Beware: Use in conjunction with your books – not instead of!
Some are not detailed enough!
36
Ask Vendors
How will your application, business processes, or system address my needs during the ICD-10 implementation?
What is your timeline for the ICD-10 transition?
What is your migration strategy for making the change to ICD-10?
38
Ask Vendors
Do you offer an ICD-9/ICD-10 Comparison Utility ?
When will we test our system with trading partners?
Will you be upgrading my current system to accommodate the ICD-10 codes?
Are you training your staff on the ICD-10 system updates? 3
9
Ask Vendors
Can we use your products to search for codes by the ICD-10 alphabetic and tabular indexes?
Do you allow our staff to search codes by clinical concept?
Will you maintain tables for each code set?
How long will ICD-9 be available for use? 40
Ask Vendors
Will you ensure we have the right tools in place to help select the more specific diagnosis codes?
Will you provide specific provider templates for each specialty?
41
Organizational & Structural Changes
ICD-10-CM has same hierarchical structure as ICD-9-CM
First three characters are the category of the code
All codes within the same category have similar traits
E10 – Type 1 diabetes mellitus
E11 – Type 2 diabetes mellitus
J45 – Asthma
J45.2 – Mild intermittent asthma
J45.3 – Mild persistent asthma
43
Organization & Structure
Differences are seen in the organization of ICD-10-CM
ICD-10-CM has 21 chapters compared to 17 for ICD-9-CM
ICD-9-CM’s V and E code supplemental classifications are incorporated into the main classification of ICD-10-CM
Diseases and conditions of the sense organs (eyes and ears) have been separated from the nervous system and have their own chapters
44
Chapter Description Code Category
1 Certain Infectious and Parasitic Diseases A00-B99
2 Neoplasms C00-D49
3 Diseases of the Blood D50-D89
4 Endocrine, Nutritional and Metabolic Diseases E00-E89
5 Mental and Behavioral Disorders F01-F99
6 Diseases of the Nervous System G00-G99
7 Diseases of the Eye and Adnexa * H00-H59
8 Diseases of the Ear and Mastoid Process * H60-H95
9 Diseases of the Circulatory System I00-I99
10 Diseases of the Respiratory System J00-J99
11 Diseases of the Digestive System K00-K94
12 Diseases of the Skin and Subcutaneous Tissue L00-L99
13 Diseases of the Musculoskeletal System and Connective Tissue M00-M99
14 Diseases of the Genitourinaty System N00-N99
15 Pregnancy, Childbirth and the Puerperium O00-O99
16 Certain Conditions Originating in the Perinatal Period P00-P96
17 Congenital Malformations, Deformations and Chromosomal Abnormalities Q00-Q99
18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings R00-R99
19 Injury, Poisoning and Certain Other Consequences of External Cause S00-T88
20 External Causes of Morbidity * V01-Y98
21 Factors Influencing Health Status and Contact with Health Services * Z00-Z99 45
ICD-10-CM Chapters
* = New Chapters
Differences from ICD-9 to ICD-10
Certain diseases have been reclassified (or reassigned) to a more appropriate chapter in ICD-10-CM
Gout has been reclassified from the endocrine chapter in ICD-9 to the musculoskeletal chapter in ICD-10
46
Differences
ICD-9-CM classified injuries by type; ICD-10-CM groups injuries first by specific site (e.g., head, arm, leg) and then by type of injury (e.g., fracture, open wound)
Post-operative complications have been moved to procedure-specific body system chapters
47
Differences ICD-10-CM codes are alpha-numeric and can be up to
seven characters in length (ICD-9 only 3-5)
ICD-10-CM includes full code titles for all codes (no reference back to common fourth and fifth digits)
ICD-9: The following fifth-digit subclassification is for use with category 493.0- 493.2. 493.9:
0 unspecified
1 with status asthmaticus
2 with (acute) exacerbation
48
Differences
Addition of sixth character in some chapters
Addition of seventh character for obstetrics, injuries, and external causes of injuries
Addition of placeholder X
49
Using A Placeholder
Placeholder Character “X” is used as a placeholder at certain codes to allow for
future expansion
Poisoning, adverse effect, and underdosing codes (T36-T50)
T36.0X1A Poisoning by penicillins, accidental (unintentional), initial encounter
T36.0X2A Poisoning by penicillins, intentional self-harm
T36.0X3A Poisoning by penicillins, assault
T36.0X4A Poisoning by penicillins, undetermined
T36.0X5A Adverse effect of penicillins
T36.0X6A Underdosing of penicillins
50
Another Placeholder Example
Contact with a cat
W55.0
W55.01XD Bitten by a cat, subsequent encounter
W55.03XD Scratched by cat, subsequent encounter
W55.09XD Other contact with cat
51
7th Characters
Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
52
New Features in ICD-10-CM Combination codes for conditions and common
symptoms or manifestations
E10.21, Type 1 diabetes mellitus with diabetic nephropathy
I25.110, Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
K50.112, Crohn’s disease of large intestine with intestinal obstruction
Combination codes for poisonings and external causes
T36.0X1D, Poisoning by penicillin, accidental (unintentional), subsequent encounter
T42.4X5A, Adverse effect of benzodiazepines, initial encounter
53
New Features Added Laterality
H60.332, Swimmer’s ear, left ear
M94.211, Chondromalacia, right shoulder
S40.259A, Superficial foreign body of unspecified shoulder, initial encounter
Added seventh-characters for episode of care M80.051A, Age-related osteoporosis with current
pathological fracture, right femur, initial encounter for fracture
S06.0X1A, Concussion with loss of consciousness of 30 minutes or less, initial encounter
S52.132B, Displaced fracture of neck of left radius, initial encounter for open fracture Type I or II or initial encounter for open fracture NOS
54
New Features Expanded Codes (injuries, diabetes, alcohol, and
substance abuse, post-operative complications) E11.341, Type 2 diabetes mellitus with severe
nonproliferative diabetic retinopathy with macular edema
F14.221, Cocaine dependence with intoxication delirium
K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure
Inclusion of trimesters in obstetrics codes (and elimination of fifth digits for episode of care) O10.012, Pre-existing essential hypertension complicating
pregnancy second trimester
O99.013, Anemia complicating pregnancy, third trimester 55
New Features
Changes in timeframes specified in certain codes Acute myocardial infarction – time period changed from 8 weeks to 4
weeks
Time frame for abortion versus fetal death changed from 22 weeks to 20 weeks
Added standard definitions for two types of “excludes” notes Excludes1 note indicates “not coded here.” The code being excluded
is never used with the code. The two conditions cannot occur together.
B06, Rubella (German measles) has an Excludes1 of congenital rubella (P35.0)
Excludes2 note indicates “not included here.” The excluded condition is not part of the condition represented by the code. It is acceptable to use both codes together if the patient has both conditions.
J04.0, Acute laryngitis has an Excludes2 of chronic laryngitis (J37.0)
56
Begin Now: 1. Generate a report from your practice management
system that identifies all ICD-9 codes used for the past 12 months
1. Sort by frequency
2. Determine your 25-50 most frequently used codes
3. Convert those codes to ICD-10-CM codes
1. Determine differences from ICD-9-CM
2. Determine documentation variables
4. Audit clinical documentation to make sure it supports the coding
58
Clinical Documentation
Golden Rule: If it’s not documented by the physician/provider, it did not happen; therefore, it cannot be coded or billed
Objective: To ensure medical record documentation is documented to the fullest extent possible in order to support the greater specificity afforded in the ICD-10-CM (Clinical Modification) code set
Some documentation issues will require physicians/providers to capture new information
Others involve updated, modified, and otherwise expanded documentation needs
60
Some Facts:
ICD-10-CM contains multiple combination codes, so documentation must reflect the association between conditions
Example:
ICD-10: K50.814 – Crohn’s disease of both small and large intestine with abscess
ICD-9: 555.2 – Regional enteritis, small intestine with large intestine and
569.5 – Abscess of intestine
61
Facts:
Laterality needs to be documented
Example:
ICD-10: M05.271 – Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot
ICD-9: 714.27 – Rheumatoid arthritis with visceral or systemic involvement, ankle and foot
62
Documentation Challenges Diabetes Mellitus
ICD-10 = 200 codes ICD-9 = 59 codes
Multiple combination codes are available – the provider will need to document complications to allow for accurate code selection E10.40 Type 1 diabetes mellitus with diabetic neuropathy,
unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
An additional code must be used to report insulin use – Z79.4
63
Documentation Challenges
Injuries – ICD-10-CM features an expanded category for injuries
Seventh character extension identifies the encounter type:
A = initial encounter
D = subsequent encounter for fracture with routine healing
G = subsequent encounter for fracture with delayed healing
S = sequela of fracture
Size and depth of the injury must be coded – needs to be captured from provider’s documentation
Cause of the injury should be documented and coded
64
Documentation Challenges
Drug Underdosing – a new code in ICD-10-CM that identifies situations in which a patient has taken less of a medication than prescribed by the physician
Medical condition is sequenced first
Underdosing code is listed as a secondary diagnosis
Additional code explains why the patient is not taking the medication (e.g., financial reasons)
Since this is new, many physicians will not be in the habit of documenting a patient’s reasons for underdosing in the record.
65
Documentation Challenges
Cerebral Infarctions
Late effects of stroke are differentiated by type of stroke
Combination codes for common etiologies/manifestations are included
I63.012 designates cerebral infarction due to thrombosis of left vertebral artery
I63.031 designates cerebral infarction due to right carotid artery
I63.212 designates cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries
66
Documentation Challenges
Acute Myocardial Infarction (AMI)
Age definition for AMI has changed to four weeks rather than eight weeks
New categories for subsequent AMI and for complications within 28 days of AMI
Different terminology is used and laterality is included
I21.01 designates ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 designates ST elevation myocardial infarction (STEMI) involving left anterior descending coronary artery
I21.09 designates ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
67
Documentation Challenges Musculoskeletal Conditions
ICD-9 has 8 codes for pathologic fractures; ICD-10-CM has 150+ codes
7th character is used to designate episode of care
Traumatic fractures require
Type of Fracture
Laterality
Episode of Care
68
A Warning About “Unspecified” – some may be tempted to take the easy road and code “unspecified” if documentation doesn’t support more specific codes. We warn against this!! While there is an unspecified code in ICD-10, and you can code it all you want, in 2-3 years when you review your severity and risk scores you will be in bad shape because you won’t have the specificity in your codes that you need to justify higher levels and better reimbursement.
Documentation Challenges
Pregnancy
Documentation of trimester now required
Counted from first day of last menstrual period
Must document number of weeks
Episodes of care have been deleted
Example – O15.03 designates “eclampsia in pregnancy, third trimester”
Obstructed labor codes incorporate reason for the obstruction and code extensions are used to identify specific fetus (1-5) affected by obstetric condition
Example – O64.1XX2 designates “obstructed labor due to breech presentation, fetus 2”
69
Documentation Challenges
Respiratory / Vents
Some codes require time frames attached to them, which note if a patient has been on a ventilator for
less than 24 consecutive hours
24-96 consecutive hours
Greater than 96 hours
70
Transition Tips Important Reminders
While clearinghouses can help, they cannot provide the same level of support for the ICD-10 transition as they did for the Version 5010 upgrade (5010 was IT-driven only; ICD-10 is both business process and IT-driven)
ICD-10 codes describe a medical diagnosis or procedure and must be selected by the provider and not the clearinghouse, coder or biller
Expect audits to focus on clinical documentation to determine if it supports the specificity of ICD-10 codes
Keep in mind that covered entities are not to use the ICD-10 code in production (outside of a testing environment) prior to October 1, 2015
CMS Recommends
Regular documentation audits after ICD-10 implementation to make sure your clinical documentation supports your ICD-10 coding
72
Thanks for Your Participation!
Mary Jean Sage The Sage Associates
897-309 Oak Park Blvd., Pismo Beach CA 93449
Tel: 805-904-6311; Fax: 805-904-6313
Email: [email protected]
Web: www.thesageassociates.com
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