Upload
gyala
View
52
Download
0
Embed Size (px)
DESCRIPTION
ICD-10 Are You Ready to S.W.A.P. Presented by Kathy A. Montoya Senior Provider Relations Representative. Agenda. Background Volumes ICD 10 CM ICD 10 PCS General Equivalence Mappings Reimbursement Mappings Preparation Steps. Training Objectives. Increase knowledge Identify obstacles - PowerPoint PPT Presentation
Citation preview
ICD-10 Are You Ready to S.W.A.P.
Presented byKathy A. Montoya
Senior Provider Relations Representative
Agenda Background Volumes
ICD 10 CM ICD 10 PCS
General Equivalence Mappings Reimbursement Mappings Preparation Steps
Training Objectives Increase knowledge Identify obstacles Get on track for implementation
October, 1 2014
Health Insurance Portability and Accountability Act (HIPAA) Administrative simplification provides
standards for Electronic transmission of claims Provider identifiers Privacy Code set
Why The Change ICD-9
Adopted by CMS April 1, 1989 Produces limited data
Patients’ medical conditions Hospital inpatient procedures
30 years old and outdated Limits new code creation
ICD-10-CM/PCS Incorporates greater specificity and clinical
information Improves health care service measurement Helps with refining groupings and
reimbursement methodologies
ICD-10-CM/PCS Enhances ability to do public health
surveillance Decreases need for claims supporting
documentation Updates medical terminology and
classification of diseases
ICD-10-CM/PCS Provides better data for
Claims processing Making clinical decisions Identifying fraud and abuse Conducting research Comparison of mortality and morbidity
ICD 10 Department of Health and Human Services
Final regulation January 15, 2009 October 1, 2014
Guidance available on http://www.cms.gov/ICD10/
ICD-9 It’s Not Over Yet Worker’s compensation Auto insurance
Not required to convert Not planning to change
ICD 10 Developed by
World Health Organization (WHO) http://www.who.int/classifications/icd/en/.
Utilized in other countries Mandated for use in U.S.
October 1, 2014
ICD-10 In use in U.S.
Individual states Report cause of death on certificates
ICD 10 CM National Center for Health Statistics
(NCHS) Developed ICD 10 Clinical Modification (CM) for
U.S. In conjunction with advisory group and
physicians Still in DRAFT
ICD-10General Information
ICD-10 Part 1 ICD-10-CM for diagnosis coding
All U.S. health care setting 3 – 7 digit alphanumeric codes 68,069 ICD-10-CM codes
Increased from 14,025 ICD-9-CM
Provider ClaimsCompliance A Must No delays or grace period ICD-9-CM for dates of service < October 1,
2014 ICD-10 for dates of service ≥ October 1,
2014 Still use CPT and HCPCS
ICD-10 Code Structure
AXX.XXXX
3Categories
Code
4Subcategory
Code
5/6SubclassificationCode/Placeholder
7Extention
Code
ICD-10-CM Structure 3 – 7 characters
1st = alpha 2nd = numeric 3rd – 7th = alpha or numeric Decimal after 3rd character
ICD-10-CM Structure Character “X”
5th or 6th position “Placeholder”
Future expansion “Fill In”
Empty characters
7th Character One use is encounter type
A = Initial encounter D = Subsequent encounter S = Sequela
7th Character R40.2 Coma
Coma NOSUnconsciousness NOS
The appropriate 7th character is to be added to each code from subcategory R40.21-, R40.22-, R40.23-
0 Unspecified time1 In the field [EMT or ambulance]2 At arrival to emergency department3 At hospital admission4 24 hours or more after hospital admission
ICD Codes Describe medical necessity Facilitate payment Evaluate utilization patterns Study appropriateness of health care costs
Incorrect Coding Lead to investigations of fraud and abuse Must be correct Must be consistent
Comparison ICD-9 CM
Groups by type of injury Maximum 5 characters Most codes numeric 17 chapters
ICD-10 CM Groups by site of injury Maximum 7 characters Codes are alpha-
numeric 21 chapters
Changes Found In ICD-10 CM Addition information for ambulatory and
managed care encounters Expanded injury codes Combination codes Reclassification of diseases
Changes Found In ICD-10 CM New code definitions “E” and “V” codes incorporated in main
classifications Category restructuring and code
reorgaization
ICD-10 CM Format Introduction Official Guidelines for Coding and
Reporting Alphabetic Index to Diseases and Injuries Neoplasm Table
ICD-10 CM Format Table of Drugs and Chemicals Index of External Causes Tabular List of Diseases and Injuries
Official Guidelines forCoding and Reporting ICD-9 and ICD-101. Conventions, general coding guidelines
and chapter specific guidelines2. Selection of Principle Diagnosis3. Reporting Additional Diagnosis4. Diagnostic Coding and Reporting
Guidelines for Outpatient Services
Official Guidelines forCoding and Reporting ICD-10
Chapters 3, 7, 8 and 11 Not completed Specialty society involved in creation
Official Guidelines forCoding and Reporting Examples
Chapter 15 Chapter 15 codes have sequencing priority over
codes from other chapters Chapter 15 codes are to e used only on maternal
record, not on newborn
Alphabetic Index ICD-9
Diseases Illness Injury Other reasons for
encounters Table of Drugs and
Chemicals External Causes of Injury
and Poisoning
ICD-10 Diseases Illness Injury Other reasons for
encounters
Neoplasm Table ICD-9
In alpha index Malignant
Primary Secondary Ca in situ
Benign Uncertain Behavior Unspecified
ICD-10 Separate section Malignant Primary Malignant Secondary Malignant Ca in situ Benign Uncertain Unspecified Behavior
Table of Drugs andChemicals ICD-9
Under Alphabetic Index Poisoning Accident Therapeutic Use Suicide Attempt Assault Undetermined
ICD-10 Accidental
(unintentional) Intentional Self-Harm Assault Undetermined Adverse Effect Underdosing
Index of External Causes ICD-9
Under Alphabetic Index Cause of injury Adverse effects
ICD-10 Alphabetic by main
term indicating the event
Tabular List of Diseasesand Injuries ICD-9
17 chapters Based on diseases
2 Supplementary Classification
ICD-10 21 chapters
Based on body system or nature of injury and disease
Chapter ComparisonChapter ICD-9 CM ICD-10 CM
1 Infectious and Parasitic Diseases
Certain Infectious and Parasitic Diseases
2 Neoplasms Malignant Neoplasms
3Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders
Disease of the Blood and Blood-Forming Organs and certain Disorders involving Immune Mechanism
4 Disease of the Blood and Blood-Forming Organs
Endocrine, Nutritional and Metabolic Diseases
Chapter ComparisonChapter ICD-9 CM ICD-10 CM
5 Mental DisordersMental and Behavioral Disorders
6 Diseases of the Nervous System and Sense Organs
Diseases of the Nervous System
7 Diseases of the Circulatory System
Diseases of the Eye and Adnexa
8 Diseases of the Respiratory System
Diseases of the Ear and Mastoid Process
Chapter ComparisonChapter ICD-9 CM ICD-10 CM
9 Diseases of Digestive System
Diseases of the Circulatory System
10 Diseases of the Genitourinary System
Diseases of the Respiratory
11Complications of Pregnancy, Childbirth, and the Puerperium
Diseases of the Digestive System
12 Diseases of the Skin and Subcutaneous Tissue
Diseases of the Skin and Subcutaneous Tissue
Chapter ComparisonChapter ICD-9 CM ICD-10 CM
13Diseases of the Musculoskeletal System and Connective Tissue
Diseases of the Musculoskeletal System and Connective Tissue
14 Congenital Anomalies Diseases of the Genitourinary System
15Certain Conditions Originating in the Perinatal Period
Pregnancy, Childbirth and the Puerperium
Chapter ComparisonChapter ICD-9 CM ICD-10 CM
16 Symptoms, Signs and Ill-Defined Conditions
Certain Conditions Originating in the Newborn (Perinatal) Period
17 Injury and PoisoningCongenital Malformations, Deformations and Chromosomal Abnormalities
18 N/A
Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
Chapter ComparisonChapter ICD-9 CM ICD-10 CM
19 N/AInjury, Poisoning and Certain Other Consequences of External Causes
20 N/A External Causes of Morbidity
21 N/AFactors Influencing Health Status and Contact with Health Services
Chapter ComparisonChapter ICD-9 CM ICD-10 CM
Supplementary Classification
Classification of Factors Influencing Health Status and Contact with Health Services (V Codes)
N/A
Supplementary Classification
Classification of External Cause of Injury and Poisoning (E Codes)
N/A
ICD-10-CM Code Examples F03 Unspecified dementia L60.0 Ingrowing nail J09.12 Influenza due to identified novel
H1N1 influenza virus with other respiratory manifestations
M71.061 Abscess of bursa, right knee T21.31xa Burn of third degree of chest
wall
ICD-10-CM Terminologyand New Feature Laterality
Right = character 1 Left = character 2 Bilateral = character 3 Unspecified = character 0 or 9
ICD-10-CM Terminologyand New Feature
Laterality Examples M54.31 – Sciatica, right side
ICD-10-CM Terminologyand New Feature Combination codes
Diagnosis with associated sign or symptom Diagnosis with associated complication Diagnosis with cause
ICD-10-CM Terminologyand New Feature Combination code example
Conditions with symptoms and manifestations K27.2 – Acute peptic ulcer, site unspecified, with both
hemorrhage and perforation
ICD-10-CM Terminologyand New Feature Combination code example
Poisoning and external cause T51.0x2 – Toxic effect of ethanol, intentional, self-
harm
ICD-10-CM New Features Obstetric codes identify trimester
1 = 1st trimester < 14 weeks, 0 days 2 = 2nd trimester 14 weeks, 0 days to < 28
weeks, 0 days 3 = 3rd trimester 28 weeks, 0 days to delivery 0 or 9 = unspecified
Obstetric Codes Ex: O26.02
Excessive weight gain in pregnancy, second trimester
ICD-10-CM Excluded Indications Codes that should not be reported
together
Separately identifiable conditions Excluded condition not part of reported
condition Can have both condition at same time
Example 1 E11 – Type 2 diabetes
(Excludes1: Gestational diabetes (O24.4-); type 1 diabetes (E10.-)
Example 2 I10 – Essential (primary) Hypertension
Includes: High blood pressure hypertension (arterial) (benigh) (essential) (malignant) (primary) (systemic).
(Excludes 2: Essential (primary) hypertension involving vessels of brain (I60-I69); Essential (Primary) hypertension involving vessels of eye (H35.0)
ICD-10-CM Includes Clinical Concepts
Underdosing Blood type Blood alcohol level Encounter type Indication of healing
ICD-10-CMExpanded Codes Significant expansion of codes
Diabetes Substance abuse Postoperative complications
Distinction made between intraoperative complication and postprocedural disorders
Diabetes Increase from 40 to 122 codes Example
E08.321 – Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema
ICD -10 Terminology Granularity
Level of hierarchy Increased description information
ICD -10 Terminology Morbidity
Rate of disease in population Mortality
Rate of death in population
ICD -10 Terminology Principal or First-listed Diagnosis
Primary reason for encounter
Inpatient setting First code on medical record Principal diagnosis
Other health care settings First-listed code
ICD -10 Terminology Rubric
Group of similar conditions Three character category or four character
subcategory
Steps To Code Correctly Identify diagnosis or reason for encounter Locate in Alphabetic Index Verify in Tabular List Read and interpret notes
Steps To Code Correctly Choose tentative code Find highest level of specificity Consult prompts Assign a code
ICD 10 PCS
ICD-10 Part 2 ICD-10-PCS for inpatient procedure
coding All U.S. Inpatient hospital settings only 7 alpha-numeric digits 72,589 ICD-10-PCS
Increased from 3,824 ICD-9-CM procedure codes
Facility Claims Compliance A Must No delays or grace period ICD-9-CM for dates of discharge < October
1, 2014 ICD-10 for dates of discharge ≥ October 1,
2014 ICD-10-PCS for dates of discharge ≥
October 1, 2014
Structure Differences Codes are longer Greater clinical detail and specificity Updated terminology and classifications
ICD-10-PCS Structure 7 digits Each digit is either alpha or numeric
Alpha digits are not case sensitive Letters O and I are not used to avoid confusion
with numbers 0 and 1 Each character has a
value/meaning/option
ICD-10-PCSCode Examples 0FB03ZX – Excision of liver, percutaneous
approach, diagnostic; and 0DQ10ZZ – Repair upper esophagus, open
approach.
ICD-10-PCS Structure First character specifies the section or
type of procedure 0 = Medical and surgical 1 = Obstetrics 2 = Placement 3 = Administration 4 = Measurement and monitoring
ICD-10-PCS Structure First character continued
5 = Extracorporeal Assistance and Performance
6 = Extracorporeal Therapies 7 = Osteopathic 8 = Other Procedures 9 = Chiropractic
ICD-10-PCS Structure First character continued
B = Imaging C = Nuclear Medicine D = Radiation Oncology F = Physical Rehabilitation and Diagnostic
Audiology G = Mental Health H = Substance Abuse Treatment
Medical and SurgicalFirst Character = “0”
Character Meaning
1 Section
2 Body System
3 Root Operation
4 Body Part
5 Approach
6 Device
7 Qualifier
ChiropracticFirst Character = “9”
Character Meaning
1 Section
2 Anatomical Region
3 Root Operation
4 Body Region
5 Approach
6 Method
7 Qualifier
Radiation OncologyFirst Character = “D”
Character Meaning
1 Section
2 Body System
3 Root Type
4 Body Part
5 Modality Qualifier
6 Isotope
7 Qualifier
Mental HealthFirst Character = “G”
Character Meaning
1 Section
2 Body System
3 Root Type
4 Type Qualifier
5 Qualifier
6 Qualifier
7 Qualifier
ICD-10-PCS Structure Second through seventh characters
Same meanings within a section Different meanings per section Third character = general type of procedure
performed See chart in workbook
Parts of ICD-10-PCS Index
Alphabetic lookup Tables
Different organization than ICD-9 List of codes
Listing of unique procedure codes
ICD-10-PCS Table Example0 Medical and Surgical 2 Heart and Great Vessels 7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part Approach Device Qualifier
0 = Coronary Artery, One site
1 = Coronary Arteries, Two Sites
2 = Coronary Arteries, Three Sites
3 = Coronary Arteries, Four or More Sites
0 = Open
3 = Percutaneous
4 = Percutaneous Endoscopic
4 = Drug=eluting Intraluminal Device
D = Intraluminal Device
T = Radioactive Intraluminal Device
Z = No Device
6 = Bifurcation
Z = No Qualifier
List of Codes - Example Code descriptions for dilation of one
coronary artery (0270) 027004Z Dilation of Coronary Artery, One Site with
Drug-eluting Intraluminal Device, Open Approach 02700DZ Dilation of Coronary Artery, One Site with
Intraluminal Device, Open Approach 02700TZ Dilation of Coronary Artery, One Site with
Radioactive Intraluminal Device,
ICD-10-PCS Character Meanings http://www.cms.gov/ICD10/Downloads/
pcs_final_report2010.pdf
General Equivalence Mappings (GEMs)
Proper Coding GEMs are not a substitute Select codes base on
Patient’s encounter Medical record documentation
GEMs As A Tool Forward mapping
ICD-9 to ICD-10-CM and PCS Backward mapping
ICD-10-CM or PCS to ICD-9 Convert databases such as
Track quality, record morbidity/mortality, calculate reimbursement
GEMs All ICD-10- CM codes
ICD-10-CM to ICD-9-CM GEM All ICD-9-CM diagnosis codes
ICD-9-CM to ICD-10-CM GEM All ICD-10-PCS codes
ICD-10-PCS to ICD-9-CM GEM All ICD-9-CM procedure codes
ICD-9-CM to ICD-10-PCS GEM
Three Steps To Use GEMs Extract
Select all rows containing code Analyze
Note and understand flags on code Refine
Select rows that meet applied mapping requirements
GEM Resources http://www.cms.gov/
ICD10/12_2010_ICD_10_CM.asp#TopOfPage
http://www.cms.gov/ICD10/13_2010_ICD10PCS.asp#TopOfPage
GEM Details One ICD-9-CM diagnosis code represented
by multiple ICD-10-CMs 82002 represented by
S72031A S72031G S72032A S72032G Other codes from GEMs
GEM Details One ICD-10-CM diagnosis code
represented by multiple ICD-9-CMs E11341 represented by
25050 36206 36207
GEM Details Some ICD-10-CM have no ICD-9-CMs
T500x6A T501x6A T502x6A T503x6A T504x6A Others found in GEMs
GEM Details One ICD-9-CM procedure code captured by
multiple ICD-10-PCSs 8659 captured by
JQ10ZZ JQ13ZZ JQ40ZZ JQ43ZZ Others found in GEMs
GEM Formatting Three columns
ICD-10-CM Source system code is on the left side
ICD-9-CM Target system code is in the middle Flags are on the right
GEM Mapping ExampleICD-10 Source
CodeICD-9 Target
CodeFlags
T1500xA 9300 10111
T1500xA E914 10112
T1500xD 9300 10111
T1500xD E914 10112
T1500xS 9085 10000
GEM Mapping Example
T1500xA Foreign body in cornea, unspecified eye, initial encounter
9300 Corneal foreign bodyE914 Foreign body accidentally entering eye and adnexa
T1500xD Foreign body in cornea, unspecified eye, subsequent encounter
9300 Corneal foreign bodyE914 Foreign body accidentally entering eye and adnexa
T1500xS Foreign body in cornea, unspecified eye, sequela
9085 Late effect of foreign body in orifice
GEM Flags 5 digit code (Ex: 10111) First position
1 = translation is approximate match T1500xA 9300 10111 T1500xA E914 10112
0 = translation is identical match 41411 12542 00000
GEM Flags Second position
1 = no plausible translation No Description Found (NODX) 0 = at least one plausible translation
Examples T500x6A NODX 11000 T500x6A NODX 11000 T500x6S NODX 11000
GEM Flags Third position
1 = code maps to more than one code 0 = code maps to single code
T1500xA 9300 10111
T1500xA E914 10112
T1500xD 9300 10111
T1500xD E914 10112
T1500xS 9085 10000
Reasons For No One-To-One Match ICD-10 New concepts not in ICD-9-CM No matching code exist in GEMs Multiple ICD-9-CM codes exist for a single
ICD-10 code Multiple ICD-10 codes exist for a single
ICD-9-CM code
GEM Updates Posted in January Updated annually Access updated GEMs for diagnoses
http://www.cms.gov/ICD10/12_2010_ICD_10_CM.asp
Access updated GEMs for procedures http://www.cms.gov/
ICD10/13_2010_ICD10PCS.asp
Reimbursement Mappings
Reimbursement Mappings CMS developed One-to-one reimbursement crosswalk
Temporary mechanism Codes submitted ≥ October 1, 2014 ICD-10-CM/PSC to reimbursement equivalent
ICD-9-CM codes Utilized GEMs
Reimbursement Mappings Two crosswalks
ICD-10-CM to ICD-9-CM diagnosis code(s) Ex: K50012 crosswalks to 555.0 and 560.9
ICD-10-PCS to ICD-9-CM procedure code Ex: 037544Z crosswalks to DX 395.0 and Procedure
and Intervention codes 00.40, 00.55 and 00.45
Reimbursement Mapping FormatPosition Length Contents
1 8 I-10 code
9 1 Number of I-9 codes this I-10 code maps to. Values 1 through 5.
10 6 First I-9 code
16 6 Second I-9 code
22 6 Third I-9 code
28 6 Fourth I-9 code
34 6 Fifth I-9 code
Reimbursement Mapping Resource ICD-10-CM-PCS to ICD-9 Reimbursement
Mapping Documentation and User Guide http://www.cms.gov/
ICD10/08a_Payer_Resources.asp#TopOfPage.
Reimbursement Mapping Example
00160K6 - Bypass Cerebral Ventricle to Peritoneal Cavity with Nonautologous
Tissue Substitute, Open Approach
03754DZ Dilation of Right Axillary Artery with Intraluminal Device, Percutaneous Endoscopic Approach
Reimbursement Mapping Example
Converting MS-DRGs to ICD-10-CM and ICD-10-PCS CMS Project Convert ICD-9-CM Medicare Severity –
Diagnosis Related Groups (MS-DRGs), version 26.0, to ICD-10-CM and ICD-10-PCS (ICD-10-CM/PCS) codes
Information available at: http://www.cms.gov/
ICD10/17_ICD10_MS_DRG_Conversion_Project.asp#TopOfPage.
Preparation Steps
Other Countries Experiences Problems with implementation
1. Clinical documentation2. IT: space, time and money3. Productivity
ICD-10Are You Ready To S.W.A.P. S = Schedule Training W = Work With Staff A = Adjust Work Processes P = Prepare Now
Basic Steps to Prepare forVersion 5010/ICD 10
Identify system and work processes that use ICD-9 Where are ICD-9 codes used
Identify potential changes
Basic Steps to Prepare forVersion 5010/ICD 10 Assess staff training needs
Find training opportunities Train the trainer
Train on Codes Anatomy, physiology, pathophysiology,
pharmacology Medical terminology
Test YourKnowledge of Anatomy Ulna Proximal phalanges Vomer Basal Ganglia Thymus Tibial nerve
ICD-10
6
4
3
2
5
1
Basic Steps to Prepare forVersion 5010/ICD 10 Contact practice management system
vendor Readiness for 5010 Needed upgrades to hardware/software Costs Implementation dates Training and customer support
Basic Steps to Prepare forVersion 5010/ICD 10 Contact clearinghouses, billing services
About 5010 and ICD-10 compliance Timeframe for transitions
Contact payers ICD-10 affects on contracts, payment
schedules, or reimbursement Timeframe for transitions
Basic Steps to Prepare forVersion 5010/ICD 10 Budget time and costs
ICD-10 implementation System changes Resource materials Training Money in case of implementation problems
Basic Steps to Prepare forVersion 5010/ICD 10 Conduct testing
Payers and clearinghouses Allow time for approval
New Draft1500 Claim Form
New Draft1500 Claim Form
Room for 12ICD-10 CM Codes
New CMS Guidelines Beginning July 1, 2012 Medicare contractors shall not accept new
direct submitter using HIPAA Version 4010A1
All new direct submitters will be required to enroll using HIPAA Version 5010 transactions
Resources American Medical Association www.ama-assn.org/go/5010
Fact Sheets 5010 Checklist Project Plan Template – Helping Practices
Prepare for the New HIPAA Standards 7 Steps
Resources The Centers for Medicare & Medicaid
Services (CMS) Web site www.cms.gov/ICD10
CMS sponsored calls http://www.cms.gov/
ICD10/02c_CMS_Sponsored_Calls.asp#TopOfPage
Resources American Academy of Professional Coders
(AAPC) Countdown to implementation Training Monthly articles Code translator
Resources GEMs and User’s Guides
http://www.cms.gov/ICD1013_2010_ICD10PCS.asp
Workgroup for Electronic Data Interchange (WEDI) http://www.wedi.org
Resources Health Information and Management
Systems Society (HIMSS) http://www.himss.org/icd10
American Health Information Management Association (AHIMA) http://www.ahima.org/ICD10/
Questions?
Complete Evaluations