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ICD-10-CM An Introduction 2013
Bobbi Buell, MBAonPoint Oncology [email protected]
Inspire panic---this is not that far away.
Create an awareness of ICD-10-CM.Start to consider the impact the
conversion to ICD-10 will have on your operations.
Start to understand what it means and does not mean in Oncology.
Latest UpdateThis is happening 10/1/2014
CMS intimated that the deadline would not be postponed.
The AMA still vehemently opposes this deadline.
Hospitals have spent millions on it.
You be the judge.
Implications of the Transition – Who?
ProvidersHospitalsPhysiciansOutpatient facilitiesPost-acute providers (home health agencies,
skilled nursing facilities, etc.)
Health Plans or PayersThird party administrators Employers
4
Implications of the Transition – Who?
Others LaboratoriesFree standing ancillaries Researchers Public health agencies et alData collection agencies/organizations (tumor
registries) Vendors ClearinghousesBusiness associates and partners
Patients
5
ICD-9-CM vs. ICD-10-CM
1) ICD-9-CM is out of date and running out of space for new codes on the procedural side.
• Lacks specificity and detail• No longer reflects current medical practice
2) ICD-10 is the international standard to report and monitor diseases and mortality, making it important for the U.S. to adopt ICD-10 based classifications for reporting and surveillance.
3) ICD codes are the core elements of HIT systems, conversion to ICD-10 is necessary to fully realize benefits of HIT adoption.
Reimbursement Issues With ICD-9?
Example: Fracture of WristSkateboarder fractures right wrist
A month later, fractures left wristICD-9 would require additional documentation to find
out which wrist was fractured ICD-10-CM describes in fracture codes
Left versus rightInitial or subsequent encounterRoutine healing , delayed healing, nonunion or
malunion
There Are Benefits of ICD-10
Reflects more emerging technologies, particularly PCS
Captures the details of EMRs
Might reduce ADRs from payers due to more specificity
Statistical outcomes will be more measurable and specific
May support better epidemiological trending
What is ICD-10-CM?CM = Clinical modification to ICD-10 used
around the world
Consultation withPhysician groupsClinical codersOther users of ICD-9-CM
Who Runs The Show?National Center for Health Statistics (NCHS) is
the federal agency that is responsible for maintaining the diagnostic coding systems in the U.S.
CMS partners with them to oversee publicly available coding systems
WHO oversees ICD-10 without the –CM
The American Health Information Management Association (AHIMA) oversees education and training
ICD-10-CM code book retains the same traditional format Index
Tabular
Process of coding is similarLook up a condition in the Index
Confirm the code in the Tabular
ICD – 9-CM ICD – 10-CM
13,600 codes 69,000 codes
Code book contains 17 chapters Code book contains 21 chapters
Consists of 3 to 5 characters Consists of 3 to 7 characters
1st character is alpha or numeric 1st character is alpha
Only utilizes letters E and V Utilizes all letters (except U)
Second, third, fourth, and fifth characters are always numeric
Second characteris always numeric
Third, fourth, fifth, sixth, and seventh
characters can be alpha or numeric
Shorter code descriptions because of lack of specificity and abbreviated code titles
Longer code descriptions because of greater clinical detail and
specificity and full code titles
Character ChangesICD-9-CM ICD-9-CM
ChapterICD-10-CM ICD-10-CM
Chapter
001-139 Chapter 1 Infectious or Parasitic Disease
A0-B99
140-239 Chapter 1 Neoplasms C00-D49
320-389 Chapter 6 Diseases of the Nervous System
G00-G99
Chapter 7 Diseases of the Eye and Adnexa
H00-H59
Chapter 8 Diseases of the Ear and Mastoid
H60-H95
ICD-9-CM CODE
A - Category of code
B - Etiology, anatomical site, and manifestation
ICD-10-CM CODE
A - Category of code
B - Etiology, anatomical site, and/or severity
C - Extension 7th character for obstetrics,
injuries, and external causes of injuryA B
A B C
XX .
ICD-9-CM Structure – Format
XX XX XX XX55EE 1 4 0 0.VV
Category Etiology, Anatomic Site, Manifestation
4
Numeric or Alpha
(E or V) Numeric
3 – 5 Characters
XX XX XX XX
Category
.Etiology, Anatomic
Site, Severity
Added code extensions (7th character) for obstetrics, injuries, and external causes of injury
ICD-10-CM Structure – Format
XX XX XXAAMMS 3 2 0. 1 0 A
Additional Characters
Alpha (Except U)
2 - 7 Numeric or Alpha
3 – 7 Characters
Characteristics of ICD-10-CMICD-10-CM far exceeds its predecessors in the
number of concepts and codes provided
The disease classification has been greatly expanded to include health-related conditions and to provide greater specificity at the sixth digit level and with the seventh digit extension
By the way, the 6th and 7th digit extensions ARE NOT optional for the codes where they are present
Arrangement of Volumes of ICD-10
Volume 1: Main classifications
Volume 2: Instruction/ Guidance to users
Volume 3: Alphabetical Index
ICD-10 has 21 chapters against 17 Chapters in ICD-9
Chapters of ICD-10Chapters I to XVII: Diseases and other morbid
conditions
Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.
Chapter XIX: Injuries, poisoning and certain other consequences of external causes.
Chapter XX: External causes of morbidity and mortality,
Chapter XXI: Factors influencing health status and contact with health services.
What You Should Worry About
The codes you most frequently use Can you run a report from your PM or EMR system
that shows you all ICD-9’s that you have billed more than 50-100 times over the past 2-3 years? Your limits will depend upon your size.
These are the codes you need to know and translate.
You do not need to know 69,000 codes
But, physicians need to access to non-cancer codes to use when they are evaluating and/or managing patients
General Equivalence Mappings
ICD-9 Code
Description (Source)
820.8 Fracture of unspecified part of neck of femur, closed
ICD-9 Code
Description(Target)
820.8 Fracture of unspecified part of neck of femur, closed
Forward Mapping
Backward Mapping
GEMS Example #1
GEMS Example #2
GEMS #3
GEMS Example #4
Other Major Differences With ICD-10
Use additional codes
Sequelae
Combination codes
Differences in anemia
Mandatory 6th and 7th digits
Cancer DifferencesLaterality
Mandatory’ use additional’ codes—look at lung cancer
6th digits (check out skin and breast cancers)
Much more detail and confusion surrounding lymphoma
More detail in myeloid leukemia
Help with CUP
And this must be documented….
Preparing for ICD-10
32
Checklist: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht
2011 2012 2013 2014
Awareness and Impact
Assessment Preparing for
Implementation
Go Live Preparati
on
Post – Implementation
Phase I
Phase II
Phase III
Phase IV
Year
Where to Start?
Diagnostic codes are everywhere – used by every person, every process, every system….– Superbills– Payments/EOBs/ERAs– Referrals– Contracts– EMRs
But, again, this is limited to codes you actually use
34
Diagnostic Codes are Ubiquitous
Solo Practitioner Or Small Group (2-10) Practice Implementation Planning
1. Organize Implementation Effort2. Establish Communication Plan3. Conduct Impact Analysis4. Contact System Vendors5. Estimate Budget6. Implementation Planning7. Develop Training Plan8. Analyze Business Processes9. Education and Training 10.Policy Change Development 11.Deployment of Code12.Implementation Compliance
35Source: AAPC
2013 Plan
Organize Implementation Effort
Enlist staff person (coder, biller, manager) to oversee effort who will be key point person― Prepare information to share with other providers
and staff― Identify work and scope for implementation
Should be a team effort involving all medical practice staff and the staff needs to believe that this will actually happen.
If everyone is not signed on to this, your effort will not work long term
37
Organize Implementation Effort
Examine the level of coding you have in your practice—who is certified? Who has experienced a change before, e.g. E/M, admin codes? Who is equipped to deal with this?
Look at all areas that will impact practice and identify each one that will be affected― List of codes― Practice management system― Electronic Medical Record (EMR), if applicable― Superbills― Clinical areas and pharmacy
Schedule regular meetings to share information with physicians and discuss progress and barriers of implementation.
38
Establish Communication Plan
How will point person communicate with all staff?Most practices communicate via meetings or
memos No need to change method of communications Develop regular schedule for ICD-10 progress efforts
Monthly until 6 months prior to implementation Bi-weekly thereafter
Include information, publications, and articles
Document all meetings and what was discussed herein and make sure you are tracking with your plan.
39
Conduct Impact Analysis
• Take this step prior to development of budget• In depth look at resources required for
implementation• Maybe check for a little process improvement
• Helps determine what costs might be involved as well as work processes
40
Potential Areas that will be Impacted!
Clinical Area- Patient Coverage- Superbills- ABN’s
PhysiciansDocumentationCode SpecificityProblem lists
• Nurses– Forms– Documentation– Prior Authorization
• Managers– Policies & Procedures– Vendor/Payer Contracts– Budgets– Training Plan
Potential Areas that will be Impacted!For those that can’t read the small print…
Source: AAPC 2012
LabDocumentationReporting
Billing Policies & ProceduresTraining
Pharmacy
Infusion Room
• Coding– Code Set– Clinical
Knowledge– Concurrent Use
• Front Desk– Referrals/ History
codes– Systems
Potential Areas that will be Impacted!
Source: AAPC 2012
List Every Area That Uses Codes
Geographical
Technological
Processes
Vendors
Payers
Paper
Etc
What It Looks like
Source: AMA ICD-10 Project
Conduct Impact AnalysisDevelop reasonable timeline that can be
accomplished in your practice―Map out a project plan on a simple Excel
spreadsheet with benchmarks and status of completion
Managers and/or coders should get physician approval for the project plan and its impact on the practice. Make sure you show and tell them the level of work it will take.
46
From Impact Analysis Develop a plan for
ProcessesDepartmentsTraining
Then, go to the next step…
Vendor Readiness
Contact System Vendors
• Will they be able to accommodate the need to move to ICD-10? Really? Were they ready for 5010?
• What plans do they have in place for implementation?
• Will they have new tools in place to help you with ICD-10? Will these have a cost? Will they create savings? How long will they run parallel coding?
• When will they have software available for testing?
• Will we need new hardware or is current hardware sufficient?
• What is the cost?
50
Estimate BudgetBudget considerations should include
Hardware costsSoftware costs and licensingTrainingParallel codingPhysician QueryProductivity losses Jeopardy to cash flow
Some notable budget estimates follow this slide…
51
Develop BudgetDevelop Budget
Cost Breakdown Example Education $ 2,500 Process Analysis $ 7,000 Changes to Super bills $ 3,000 IT Costs $ 7,500 Increased Documentation $44,000 Cash Flow Disruption $20,000
TOTAL $84,000
ICD-10 Implementation $: AMA
53(c) onPoint Oncology LLC
ICD-10 Implementation $$: MGMA
54(c) onPoint Oncology LLC
Ask Yourself
How much did 5010 really cost your practice?
2014
Implementation Planning
Break down planning into stages that fit your size and structure…Training for a very small practice does not need to
begin until 6 months prior to implementation
Review superbills or chargemaster or order entry charges and remove rarely used codes
Crosswalk common codes from ICD-9-CM to ICD-10-CMLook up codes in ICD-10-CM book and use GEMs, if
necessary, but this is a very general and not necessarily accurate way of coding.
Some vendors now have side-by-side coding, which facilitates the learning process.
You should parallel codes for some period
57
Develop Training Plan
Who needs training?PhysiciansCodersBilling staffAdministrative staffNurses, MAs, Pharmacy
Required number of hours depends on their role and coding interface
What resources are available in your area?
58
Develop Training PlanMany organizations will have several mechanisms
for trainingDistance learningWorkshopsConferencesAudio ConferencesWebinarsBooks
Establish training schedule or just “Train the Trainer”, but this must be a trusted coding person who also can communicate necessary information to clinicians.
Having systems that facilitate clinicians and coders to be around the codes in 2014 are helpful.
59
Develop Training Plan
Determine if temporary staff or overtime will be necessary during training period
What materials will the office need for ongoing support after training?BooksSoftware (code look up programs)Other
60
Analyze Payer Processes
Identify all payer systems and processes that currently use ICD-9-CM
Review existing medical policies related to ICD-9-CM
Which contracts tied to reimbursement are tied to a particular diagnosis? Which payers have policies for cancer drugs that are tied to ICD-9? How will this be impacted?
Modify any contract agreements with health plans
Ascertain their timelines for testing ICD-10 acceptance
61
Policy Change/ Payment Impact
After health plans complete and change medical policy for procedures and services a specialty providesReview new payment policies Identify opportunities to improve coding processesCommunicate policy changes to applicable staffFind out the policy switch-over date (might not be
10/1/2014)
How long will they accept ICD-9-CM claims?
Good news: many payers have ICD-10 right on their sites right now!!! Check it out!!!
62
Education and Training
• Formal education should begin approximately 6-8 months prior to implementation
• Large practices may need to begin earlier to accommodate all staff who need training
• Use various methods of training: on-line, distance, “Boot Camps”
• Training time depends on their role
• Physicians and coders/billers will need more training time than administrative staff
63
Deployment of Code Should receive all updated software no later
than 7/31/2014 for implementation of your charge documents. And, that is cutting it mighty close…
Vendor delivers software update with ICD-10-CM, but you should also know how long ICD-9 will be on-line.
Vendors shouldTest system Integrate software into your systemsMake internal customizationsTest systems with clearinghouses, payers,
electronic claims transmission (end to end)Ensure that the vendor will maintain updates to
code during transition period 64
Testing of CodeDoes your PM system transmit ICD-10 codes?
What does your clearinghouse do?
Is your coding translated to incentive programs, PQRS? EHR?
Does the process from documentation to billing work?
Where are the snafus?
Implementation Compliance
Compliance date for implementation – October 1, 2014
Ensure you are staffed for the change.
Make sure lines of credit are in place.
Monitor compliance activities to identify any problems.
QA chart to billing coding and do this until it looks clean.
Pursue vendor and payer problems as necessary.
66
67
Other Considerations
Consider use of electronic tools to facilitate coding process–Could reduce costs and claims rejections–Could increase productivity and coding accuracy
Don’t convert superbills/charge documents too early– Things can change and you don’t want to up your
costs
– Assign ICD-10-CM codes directly, not by applying ICD-9-CM to ICD-10-CM map—it’s good practice’!!
ResourcesResourcesICD-10-CM Online
http://www.cdc.gov/nchs/icd/icd10cm.htm
GEMs Mapping Files
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2011/
Preparation Check List
http://www.ahima.org/downloads/pdfs/resources/checklist.pdf
CMS ICD-10 Information
https://www.cms.gov/ICD10/
Basic Education SitesNCHS – Basic ICD-10-CM Information
http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
CMS – ICD-10-PCS Informationhttp://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp
AHIMA - ICD-10 Educationhttp://www.ahima.org/icd10/index.asp
WEDI – ICD-10 Implementationwww.wedi.org
70
CDC’s Web ResourcesGeneral ICD-10 information
http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm
ICD-10-CM files, information, and General Equivalence Mappings (GEM) between ICD-10-CM and ICD-9-CMhttp://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm
71
AHA’s Resources• Regulatory member advisories
• Presentations and articles
• ICD-10 audio seminar series
• Central Office on ICD-9-CM
http://www.ahacentraloffice.org
• AHA Central Office ICD-10 Resource Center
http://www.ahacentraloffice.org/ICD-10
In Summary… The time to start is YESTERDAY
The first thing you need to do is determine where change needs to happen and how much it will cost. Physicians may have no idea that this will be a line item.
Hospitals are way ahead of practices. They are doing dual coding right now! So, do not count on delays!
Physicians need to be trained---do not let them off the hook---documentation is very different under ICD-10-CM.
Check out your payer polcies---some are already translated!
What did you learn from 5010 that will help you with this?
Marshall the resources that are available at no charge and there are a lot.
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CAN Web SiteThe latest newsFormsRegulationsNewslettersPresentationshttp://can.communityoncology.org
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[email protected]@yahoo.com800-795-2633
Newsletter is free!
Send all RAC information to me at the ABOVE E-mails or FAX to 650-618-8621
Go to our website: http://www.onpointoncology.com