of 40 /40
ICD-10 Conversion Awareness Training 05/30/12 The term ICD-10 used throughout this presentation refers to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure ) codes. It does not include the ICD-10 set of codes used for mortality statistics. Presenters Dr. Nina Jo Muse Mirsa Douglass Steve Eichner

ICD-10 Awareness Training Conference... · – Required use of ICD-10-CM (diagnosis) and ICD-10-PCS (procedures) in HIPAA standard transactions. • ICD-10-CM (diagnosis) will be

  • Author

  • View

  • Download

Embed Size (px)

Text of ICD-10 Awareness Training Conference... · – Required use of ICD-10-CM (diagnosis) and ICD-10-PCS...

  • ICD-10 ConversionAwareness Training


    The term ICD-10 used throughout this presentation refers to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure ) codes.

    It does not include the ICD-10 set of codes used for mortality statistics.

    PresentersDr. Nina Jo MuseMirsa DouglassSteve Eichner

  • Disclosure to Participants

    6/8/2012 2

    Requirements for Successful Completion of Continuing Education Activity Requires:1. Completing the registration form,2. Signing the “Sign – in” Sheet,3. Attending the entire educational activity, Disclosure to Participants4. Participating in education activities instructed, and5. Completing the participant evaluation.

    Commercial Support:This educational activity received no commercial support.

    Disclosure of Conflict of InterestThe speakers and planning committee have disclosed no conflict of interest.

    Non-Endorsement StatementAccredited status does not imply endorsement by Department of State Health Services, Continuing Education Service Program of America Nurses Credentialing Center of any commercial product displayed in conjunction with this activity.

    Off-Label UseThe speakers did not disclose the use of products for a purpose other than what it had been approved for by the Food and Drug Administration.

    Expiration Date for Awarding Contact HoursComplete the attendance sheet and evaluation by the end of the conference.

  • ICD-10 Awareness Training Objectives• Describe the intent of the federal mandate

    related to ICD-10 and identify who the mandate applies to.

    • Briefly describe the difference between ICD-9 coding and ICD-10 coding.

    • Explain the connection between HIPAA and the federal mandate for ICD-10 conversion.

    • Describe important operational impacts resulting from the hard switch conversion.

    • Describe how the ICD-10 conversion may impact your specific work area.

    6/8/2012 3

  • ICD-10 Federal Mandate• January 16, 2009 - A final rule from the US DHHS

    Centers for Medicare and Medicaid Services (CMS) mandates the use of ICD-10 code sets for HIPAA standard transactions.

    • Who does the rule apply to?– Applies to covered entities (i.e., health plans, health

    care clearinghouses, and health care providers ) who transmit health information in electronic form in connection with HIPAA standard transactions.

    – This includes providers and payers who do not deal with Medicaid and Medicare claims.

    6/8/2012 4

  • • HIPAA encompasses many regulations with some illustrated below..

    • Privacy Rule – A patient information privacy rule (i.e., privacy rights) • Security Rule - An electronic patient information security rule• Electronic Data Interchange Rule – transaction standards law so that

    healthcare companies may exchange medical, billing and patient information more efficiently.

    Health Insurance Portability Accountability Act (HIPAA) of 1996

    6/8/2012 5

  • Data Interchange Rule-Health Insurance Portability Accountability

    Act (HIPAA) of 1996Before HIPAA, entities used different systems to process patient bills and other administrative information.

    Considerable time was spent to ensure claims had proper formats, codes and other details required by different insurers and payers.

    The HIPAA Electronic Data Interchange Rule (EDI Rule) allowed for the adoption of national standards for electronic health care transactions. (Keep in mind this pertains to HIPAA transactions.)

    National standards provide a common language for exchanging electronic data and a common coding structure for classifying diagnosis and procedures.

    6/8/2012 6

  • “HIPAA Standard Transaction” Defined

    • HIPAA standard transaction defined– simply means these transactions are transmitted

    using standard formats specified in HIPAA regulations.

    – HIPAA regulations mostly specify standards developed by the Accredited Standards Committee (ASC) X12N (Insurance Subcommittee).

    6/8/2012 7

  • NOTE: Above is a sample of HIPAA standard transactions. The complete list is included in the HIPAA EDI Rule.

    6/8/2012 8


  • ASC X12 Standards and ICD Codes

    • ASC X12 are standards used for formatting information for the electronic transmission of healthcare transactions.

    • The ASC X12 standards incorporate coding sets (i.e., ICD-9, ICD-10-CM, and ICD-10-PCS which are common languages used to identify diagnosis and procedures).

    6/8/2012 9

  • What About 5010??

    • 5010 is simply describing a version of X12 HIPAA standard transactions.

    • The version upgrade to 5010 was necessary so that HIPAA standard transactions could accommodate the more complex ICD-10 code set.

    • Remember, the ICD-10 code sets are incorporated in the ASC X12 transaction standard.

    6/8/2012 10

  • Healthcare Clearinghouses and HIPAA Transactions

    Healthcare Clearinghouse

    Insurance Carrier or


    Healthcare Related Entity

    DSHS Contractors TMHPHMOMCO, etc…

    Sends billing files with claim info

    Secure transmission of transactions in ASC X12 format

    HIPAA Standard Transactions

    Secure transmission of transaction responses in ASC X12 formatSends response reports

    Not necessarily HIPAA Standard Transactions

    6/8/2012 11

  • Coding Standards BackgroundDiagnostic and medical procedure information is captured during patient encounters to track clinical progress.

    Initially, diagnostic and procedural information is captured in narrative form.

    Coding facilitates the classification of diagnosis and procedures to: Determine eligibility File claims for payment Conduct research Track diseasesMeasure population health Describe cause of death

    In general, coding translates words into numbers or alphanumeric strings, e.g. “1AB3E47”.

    Standardized coding makes data collection and data analysis easier. ICD is a coding standard.

    6/8/2012 12

  • American Medical Association (AMA)

    Centers for Medicare & Medicaid Services (CMS)

    Major Coding StandardsInternational Classification of Diseases (ICD)


    ICD-9-CM(diagnostic codes)

    ICD-9-PCS(procedure codes)

    Current Procedural Terminology (CPT)


    Diagnostic & Statistical Manual of Mental Disorders (DSM)


    managed by

    managed by

    managed by

    managed by

    World Health Organization (WHO)

    National Center for Health Statistics (NCHS)

    managed by

    American Psychiatric Association (APA)

    6/8/2012 13

  • Common Procedure Terminology (CPT)• CPT and ICD are two different coding sets used in different

    circumstances. – Separate coding system– Developed by a separate organization– Designed to be used for a separate provider type

    • Developed by the American Medical Association.– Created by doctors, to be used by doctors

    • Used for physician services whether inpatient or outpatient.

    • CPT is not impacted by ICD-10 conversion.

    IMPORTANT: The final rule for ICD-10 conversion does not affect CPT coding. This is because CPT is devised for coding services not covered under ICD-10-PCS.

    6/8/2012 14

  • Diagnostic and Statistical Manual of Mental Disorders (DSM)

    • Current version is DSM-IV.• Developed by American Psychiatric Association.• To provide a more detailed evidence-based diagnostic

    system than what was originally provided by ICD. • Used only in the United States by behavioral health

    professionals for diagnosis coding.• The APA and the DSM committee had input into the

    formation of ICD-10.• ICD-10 behavioral health coding was based on DSM-IV.• DSM-IV code are ICD-9 codes (from Chapter 5-Mental


    6/8/2012 15

  • International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM)

    ICD-9-CMClinical Modification

    For use in the US

    Diagnosis codesUsed by physicians and

    other individual providers

    Procedure codesUsed by hospitals, not

    individual physicians or providersReferred to as ICD-9-PCS

    Volume 1 & 2 (CMS)

    Volume 3(NHCS)


    Used internationallyDevised as a

    mortality coding toolMost of the world

    currently uses the latest version, ICD-10

    6/8/2012 16

  • ICD-9 to ICD-10

    6/8/2012 17

  • Example from Chapter 5- Mental Disorders

    – All diagnoses related to alcohol

    ICD-911 Codes(22 DSM IVDiagnoses)

    ICD-1047 Codes

    6/8/2012 18

  • ICD-9-CM Coding Structure

    • 3 –5 character• All characters are numeric (Chapters 1-17)• Other chapters: first character is letter (E or

    V), remainder are numeric

    • Decimal after the first three characters (xxx.)

    6/8/2012 19

  • ICD-10 Coding Structure• 3 –7 characters

    – First character is always a letter (U is not used)– Second and third characters are numeric– Decimal placed after the first three characters– Fourth, fifth, sixth and seventh characters may be

    letters or numeric– Seventh Digit Extension

    • Visit encounter (initial: A; subsequent: D) • Sequelae = S• injuries and external causes

    6/8/2012 20

  • Coding

    Category Severity, Etiology, Anatomic Site


    Category Manifestation, Etiology, Anatomic Site

    ICD-9 CM Code:(Chapters 1-17)

    ICD-10 Code:

    = Number= Letter= Alphanumeric

    3 0 4 . 7 1

    F 1 9 . 2 0

    6/8/2012 21

  • Mapping Between ICD-9 and ICD-10

    • All other diagnosis mappings will either lose information or make assumptions.

    • Imperfect mapping will impact revenue, costs, risks and relationships

    • 95% of ICD-10 diagnosis codes will not map exactly to ICD-9 codes

    • 75% of all ICD-9 diagnosis codes will not map exactly to ICD-10 codes

    6/8/2012 22

  • General Equivalency Mappings (GEMS)

    • Does not resolve the one to many scenarios – Over 30% of transactions reviewed have codes

    that include one-to-many mapping options

    • Does not provide mappings for all Codes • Only 52% of codes have the same

    relationships both directions

    6/8/2012 23

  • ICD-9 – ICD-10 Mappings

    1:1 Exact

    1:1 Approximate

    1: Many Single

    1: Many Both(Single and Combination)c

    1: Many Combination

    Many: 1 Combination

    No Mapping

    Code Missing(Requires Research)


    Very High Risk

    High Risk

    Moderate Risk

    Low Risk

    Risk Undetermined

    Complexity of mappings will determine risk of inaccurate processing

    6/8/2012 24

  • ICD-9 – ICD-10 MappingsExact Match Minimizes Risk

    Low RiskExact match indicates matching definitions 1:1 Exact


    Complexity of mappings will determine risk of inaccurate processing

    No exact matches in alcohol-related diagnoses in Chapter 5

    6/8/2012 25

  • ICD-9 – ICD-10 MappingsModerate Risk

    Moderate RiskMatching clinical meanings with differing language


    1:1 Approximate

    Complexity of mappings will determine risk of inaccurate processing

    Alcohol withdrawalwith perceptual disturbance291.81

    Alcohol dependence with withdrawal with perceptual disturbanceF10.232

    6/8/2012 26

  • ICD-9 – ICD-10 MappingsHigh Risk

    High RiskSeveral options for a similar clinical meaning with increased specificity. Choose 1


    1: Many Single

    Complexity of mappings will determine risk of inaccurate processing

    Alcohol-Induced Mood Disorder291.89

    Alcohol Use, Unspecified – with Alcohol-Induced Mood DisorderF10.94

    Alcohol Abuse with Alcohol-Induced Mood DisorderF10.14

    Alcohol Dependence with Alcohol-Induced Mood DisorderF10.24

  • ICD-9 – ICD-10 MappingsVery High Risk

    Very High RiskAn ICD-9 code maps to 2 or more ICD-10 codes in combination in order to maintain clinical parity


    1: Many Both(Single and Combination)

    Complexity of mappings will determine risk of inaccurate processing

    No examples in alcohol-related diagnoses in Chapter 5

    6/8/2012 28

  • ICD-9 – ICD-10 MappingsVery High Risk


    Complexity of mappings will determine risk of inaccurate processing

    2 or more ICD-9 codes map to a single ICD-10 code

    Many: 1 Combination

    Alcohol Intoxication Delirium291.2

    Alcohol Abuse with Intoxication DeliriumF10.121

    Alcohol Abuse305.00

    6/8/2012 29

  • ICD-9 – ICD-10 MappingsVery High Risk


    Complexity of mappings will determine risk of inaccurate processing

    Very High RiskNo Mapping

    Alcohol Dependence on Agonist Therapy

    6/8/2012 30

  • Impact on DSHS and Providers• What does the final rule compliance mean?

    – Required use of ICD-10-CM (diagnosis) and ICD-10-PCS (procedures) in HIPAA standard transactions.

    • ICD-10-CM (diagnosis) will be used by all providers in every health care setting.

    • ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures.

    • ICD-10-PCS will not be used on physician claims, even those for inpatient settings.

    6/8/2012 31

  • IMPORTANT: There is no grace period for ICD-10 conversion.There is no phased-in approach. It is a hard switch from ICD-9 to ICD-10.

    IMPORTANT: For a period of time, both ICD-9 and ICD-10 will be in play. Claims will be based on the date of service or date of discharge, not the date of transmission. Claims for services or discharge performed before October 1, 201X, but submitted on or after it, should be submitted, processed, and adjudicated using ICD-9 . Services/discharges performed October 1 or later should be submitted and processed using ICD-10.

    6/8/2012 32

  • Types of Impacts

    Business Aspects(Policy and Processes)

    Technical Aspects

    Outreach Training

    ICD Conversion

    6/8/2012 33

  • Business Impacts• Reviewing policies, written and unwritten

    – Codes, regulations, etc.• Mapping ICD-9 codes to ICD-10 codes (DSHS function)

    – Mapping for clinical intent– Mapping for cost neutrality for reimbursements

    • Developing strategies for delayed reimbursement (setting aside funds, additional human resources to manage activity)

    • Updating documentation and forms w/ICD-10• Reviewing changes on reports (i.e., trending)• Updating contracts• Outreach to stakeholders• Training clinicians and coders

    6/8/2012 34

  • Technical Impacts• Information systems handling ICD-9 codes and

    ICD-10 codes simultaneously.

    • Updating information systems to accommodate new code structure.

    • Meeting processing and storage capacity requirements to house increased volume of codes.

    • Testing information systems and processes with all partners.

    6/8/2012 35

  • Partner Outreach & Training Impacts• In general, ICD-10 code sets contain more specificity &

    acuity (level of detail) than ICD-9. • Physicians must include more details in narrative notes

    about diagnosis and procedures for patients for coders to identify the proper ICD-10 code.

    • Coders must have greater knowledge in anatomy & medicine overall to accurately code.

    • Partners must be aware of… – DSHS policy changes,– Expectations and timing of claims testing, for both ICD-9

    and ICD-10,– Monitoring demands of ensuring compliance of current or

    future EMR, EHR and/or practice management vendors

    6/8/2012 36

  • ICD-10 Conversion Enterprise EffortHHSC ICD-10 Project

    Manager Don Rau

    DARS ICD-10 Coordinator

    DFPS ICD-10 (Foster Care

    Health Passport)

    DSHS ICD-10 Coordinator

    Mirsa Douglass

    DADS ICD-10Coordinator

    HHSC ICD-10 Coordinator

    HHSC ICD-10 Policy Workgroup

    HHSC ICD-10 Outreach


    HHSC ICD-10 Data Mgmt Workgroup

    Other Workgroups

    6/8/2012 37

  • DSHS Project Team

    6/8/2012 38

  • Industry Resources• www.icd10hub.com/

    – Offered by American Association of Professional Coding and Navicure, the site includes timelines, white papers, and related news stories.

    • www.ahima.org/icd10– The American Health Information Management

    Association site is filled with training materials for coders and other staff.

    • www.cms.gov/icd10– The official CMS site.

    6/8/2012 39


  • Thank You– MHSA Contact Information

    • Project Coordinator - Steve [email protected], (512) 467-5448

    • Business Lead - Valerie Shown [email protected], (512) 206-5927

    • Business Lead - Nina Jo Muse [email protected], (512) 467-5434

    6/8/2012 40

    mailto:[email protected]�mailto:[email protected]�mailto:[email protected]

    ICD-10 Conversion�Awareness Training Disclosure to ParticipantsICD-10 Awareness Training ObjectivesICD-10 Federal MandateHealth Insurance Portability Accountability Act (HIPAA) of 1996Data Interchange Rule-Health Insurance Portability Accountability Act (HIPAA) of 1996“HIPAA Standard Transaction” DefinedSlide Number 8ASC X12 Standards and ICD CodesWhat About 5010??Healthcare Clearinghouses and HIPAA TransactionsCoding Standards BackgroundMajor Coding StandardsCommon Procedure Terminology (CPT)Diagnostic and Statistical Manual of Mental Disorders (DSM)International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM)ICD-9 to ICD-10Example from Chapter 5- Mental DisordersICD-9-CM Coding StructureICD-10 Coding StructureCoding Mapping Between ICD-9 and ICD-10General Equivalency Mappings (GEMS)ICD-9 – ICD-10 MappingsICD-9 – ICD-10 Mappings�Exact Match Minimizes RiskICD-9 – ICD-10 Mappings�Moderate RiskSlide Number 27Slide Number 28Slide Number 29Slide Number 30Impact on DSHS and ProvidersSlide Number 32Types of ImpactsBusiness ImpactsTechnical ImpactsPartner Outreach & Training ImpactsICD-10 Conversion Enterprise EffortDSHS Project TeamIndustry ResourcesThank You