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ICD-10-CM An overview of changes relevant to behavioral health
Presented by: Donna Pickett - CDC/OPHS/NCHS
Joe Nichols - MD Date: January 24, 2014
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Agenda
• Overview – ICD-10, the basic facts
– How is ICD-10-CM different?
• Clinical documentation - What’s needed to support proper coding in ICD-10-CM?
• What’s changed for behavioral health
• What are the business impacts?
• What do I need to do to prepare?
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ICD10 Quick Facts
• ICD-10 international version
– Adopted by WHO in 1990
– Most countries other than the US currently use ICD-10
– ICD-10 (International version) ~ 12,500 diagnostic codes
– ICD-10 used for mortality reporting in the US - 1999
• ICD-10-CM (US version)
– ~ 69,000 diagnostic codes
– Final rule published – 2012
– Compliance date – Oct 1, 2014
Source: Health Data Consulting
Source: Health Data Consulting
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ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes)
ICD-9-CM Diagnosis Codes
ICD-10-CM Diagnosis Codes
3 to 5 digits Alpha “E” and “V” on 1st character
No place holder characters Terminology
Index and Tabular Structure Coding Guidelines
Approximately 14,000 codes Severity parameters limited
Does not include laterality Combination codes limited
7 digits Alpha or numeric for any character Include place holder characters (‘x’) Similar Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common
Source: Health Data Consulting
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ICD9 Comparison to ICD10-CM
A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug].
Diagnosis Codes – Clinical Example
ICD9 Code Description 29285 Drug induced sleep disorders
ICD10 Code Description
F13282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
Source: Health Data Consulting
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ICD9 Comparison to ICD10-CM
A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug].
Diagnosis Codes – Clinical Example
ICD9 Code Description 29285 Drug induced sleep disorders
ICD10 Code Description
F13282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
Source: Health Data Consulting
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“There are too many Codes”
• There are lots of words in the dictionary, but that doesn’t seem to trouble authors…
• 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system
• 17,045 (25%) of all ICD-10CM codes are related to fractures
• ~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’
• Only a very small percentage of the codes will be used most providers
Source: Health Data Consulting
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Current Distribution of ICD-9 diagnosis codes 3 Years of Data - All claims - All lines of business - 1million Lives
Source: Health Data Consulting
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
5% next5%
… … … … … … … … … … … … … … … … … …
Total Charges by Code 3years - $10 Bill
Charge %
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Varying Code Volume By Clinical Area
Clinical Area ICD-9 Codes ICD-10 Codes Fractures 747 17099 Poisoning and toxic effects 244 4662 Pregnancy related conditions 1104 2155 Brain Injury 292 574 Diabetes 69 239 Anxiety Disorders 27 47 Autism Spectrum Disorders 6 4 Mood related disorders 75 71 Schizophrenia 56 11 Hypertensive Disease 33 14 End stage renal disease 11 5 Source: Health Data Consulting
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Documentation It could be better…
• Incomplete clinical documentation is bad for Payers, Providers and Patients. Billing accuracy Quality measures Population management Risk management Healthcare analytics Patient Care
Bad Mojo is not a diagnosis
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Good Clinical Documentation is Not a New Requirement
• The number and type of new concepts required for ICD-10 are not foreign to clinicians
• The focus of documentation is good patient care
• Patients deserve to have accurate and complete documentation of their conditions
• If other industries understand the value of accurate and complete documentation of data about encounters; shouldn’t we?
Source: Health Data Consulting
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Documentation
• Supports proper payment reduced denials
• Assures accurate measures of quality and efficiency
• Assures accountability and transparency
• Captures the level of risk and severity
• Provides better business intelligence
• Supports clinical research
• Enhances communication with hospital and other providers
• It’s just good care!
Why is it important?
Source: Health Data Consulting
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Coding – The Patient Interface Where it all begins
History
Physical Exam Internal Record Review
External Record Review
Assessment/Diagnosis
Studies
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Getting to the Code A Necessary Step
Back-office Coding
The “Super Bill” Back to the Doctor?
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The Super Bill Not That Super Really…
[Note] For all codes related to fractures of the radius:
•ICD-9 codes = 32
•ICD-10 codes = 1731
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New concepts supported by ICD-10
• Drug “use” vs “dependence” vs “abuse” • Bipolar II • Recurrent depressive disorder • Mood disorder related to physiologic condition • Adjustment insomnia • Adjustment reaction with withdrawal • Asperger's syndrome • Rett's syndrome • Distinguishes between current episode and most recent
episode for bipolar disorders Source: Health Data Consulting
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Removed concepts from ICD-9
• Substance dependence o continuous o episodic
• Amphetamine o Dependence o Abuse
• Bipolar I • Passive-aggressive personality • Pervasive Disorders
o current or active state o residual state
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Removed concepts from ICD-9
• Schizophrenia o Latent o Simple type o Subchronic o Chronic o Subchronic with acute exacerbation o Chronic with acute exacerbation o In remission
Source: Health Data Consulting
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ICD-10-CM
Key coding changes relevant to behavioral health
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Changes in detail and content Code Examples – Substance related sleep disorders:
ICD-10 Code Description
F11182 Opioid abuse with opioid-induced sleep disorder
F11982 Opioid use, unspecified with opioid-induced sleep disorder
F11282 Opioid dependence with opioid-induced sleep disorder
F14182 Cocaine abuse with cocaine-induced sleep disorder
F14282 Cocaine dependence with cocaine-induced sleep disorder
F14982 Cocaine use, unspecified with cocaine-induced sleep disorder
F13182 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced
sleep disorder
… Multiple other substances
ICD-9 Code Description 29285 Drug induced sleep disorders
Source: Health Data Consulting
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More Codes
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Changes in detail and content Code Examples – Substance related abuse:
ICD-10 Code Description
F1110 Opioid abuse, uncomplicated F11120 Opioid abuse with intoxication, uncomplicated F11121 Opioid abuse with intoxication delirium F11122 Opioid abuse with intoxication with perceptual disturbance F1114 Opioid abuse with opioid-induced mood disorder
F11150 Opioid abuse with opioid-induced psychotic disorder with delusions F11151 Opioid abuse with opioid-induced psychotic disorder with hallucinations F11181 Opioid abuse with opioid-induced sexual dysfunction F11182 Opioid abuse with opioid-induced sleep disorder F11188 Opioid abuse with other opioid-induced disorder F1119 Opioid abuse with unspecified opioid-induced disorder
ICD-9 Code Description 30550 (Non-dependent) Opioid abuse, unspecified
More Codes
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Changes in detail and content Code Examples – Schizophrenia:
ICD-9 Code Description
29530 Paranoid type schizophrenia, unspecified
29531 Paranoid type schizophrenia, subchronic
29532 Paranoid type schizophrenia, chronic
29533 Paranoid type schizophrenia, subchronic with acute exacerbation
29534 Paranoid type schizophrenia, chronic with acute exacerbation
29535 Paranoid type schizophrenia, in remission
ICD-10 Code Description F200 Paranoid schizophrenia
Source: Health Data Consulting
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Less Codes
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Changes in detail and content
Health Data Consulting © 2013
Code Examples – Schizoaffective disorder:
ICD-10 Code Description
F250 Schizoaffective disorder, bipolar type
F251 Schizoaffective disorder, depressive type
F258 Other schizoaffective disorders
F259 Schizoaffective disorder, unspecified
ICD-9 Code Description
29570 Schizoaffective disorder, unspecified
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More Codes
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Changes in detail and content
Health Data Consulting © 2013
Code Examples – Post traumatic Stress Disorder:
ICD-10 Code Description
F4310 Post-traumatic stress disorder, unspecified
F4311 Post-traumatic stress disorder, acute
F4312 Post-traumatic stress disorder, chronic
ICD-9 Code Description
30981 Posttraumatic stress disorder
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More Codes
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Changes in detail and content Code Examples – Childhood Emotional Disorders:
ICD-9 Code Description
3130 Overanxious disorder specific to childhood and adolescence
3131 Misery and unhappiness disorder specific to childhood and adolescence
31321 Shyness disorder of childhood
31322 Introverted disorder of childhood
3133 Relationship problems specific to childhood and adolescence
31382 Identity disorder of childhood or adolescence
31383 Academic underachievement disorder of childhood or adolescence
31389 Other emotional disturbances of childhood or adolescence
3139 Unspecified emotional disturbance of childhood or adolescence
ICD-10 Code Description F930 Separation anxiety disorder of childhood F938 Other childhood emotional disorders F939 Childhood emotional disorder, unspecified
Less Codes
Source: Health Data Consulting
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Changes in detail and content Code Examples – Conversion Disorders:
ICD-10 Code Description
F444 Conversion disorder with motor symptom or deficit
F445 Conversion disorder with seizures or convulsions
F446 Conversion disorder with sensory symptom or deficit
F447 Conversion disorder with mixed symptom presentation
F4489 Other dissociative and conversion disorders
F449 Dissociative and conversion disorder, unspecified
ICD-9 Code Description
30011 Conversion disorder
Source: Health Data Consulting
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More Codes
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Changes in detail and content
Health Data Consulting © 2013
Code Examples – Other substance abuse:
ICD-10 Code Description
F550 Abuse of antacids
F551 Abuse of herbal or folk remedies
F552 Abuse of laxatives
F553 Abuse of steroids or hormones
F554 Abuse of vitamins
F558 Abuse of other non-psychoactive substances
ICD-9 Code Description
30592 Other, mixed, or unspecified drug abuse, episodic
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More Codes
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Changes in detail and content Code Examples – Attention Deficit Disorders:
ICD-10 Code Description
F900 Attention-deficit hyperactivity disorder, predominantly inattentive type
F901 Attention-deficit hyperactivity disorder, predominantly hyperactive type
F902 Attention-deficit hyperactivity disorder, combined type
F908 Attention-deficit hyperactivity disorder, other type
F909 Attention-deficit hyperactivity disorder, unspecified type
ICD-9 Code Description
31400 Attention deficit disorder without mention of hyperactivity
31401 Attention deficit disorder with hyperactivity
More Codes
Source: Health Data Consulting
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Business Impacts
• Coding EHR updates Super Bill??? Training Coding software
• Contracting Scope of services Case rates Carve outs
• Billing Billing code updates Charge masters Billing Edits
• Benefits and coverage determinations
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Business Impacts (Cont.)
• Compliance HIPAA Reporting
National State Regional Initiatives
Contract requirement Accreditation
• Reimbursement Pay for performance POA, “never events”, re-admissions, HACs, tiered payment models Network inclusion Denials
• Audits RAC Fraud and abuse Coding
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“ICD diagnosis codes are irrelevant to my business.”
• ICD-9 codes factor into: Payer processing rules
The determination of appropriateness
Measures of quality (pay for performance)
Compliance (meaningful use)
Contracting decisions
Risk adjustments
Fraud waste and abuse
Audits
Authorizations
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“ICD diagnosis codes are irrelevant to my business.”
• ICD-10 codes are likely to factor into: Changes in reimbursement based on both “what”
was done and “why”
Managing financial risks for contracted populations (ACO’s)
Changes in reimbursement based on more robust models of payment adjusted for risk and severity
More sophisticated weighting of payments based on DRGs, episodes or other groupers of care.
Health Data Consulting © 2013 34
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Business Impacts
• Compliance HIPAA Reporting
o National o State o Regional Initiatives
Contract Accreditation
• Reimbursement Pay for performance POA, “Never Events”, Tier Models Network inclusion Denials
• Audits RAC Fraud and abuse Coding
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Cash Flow Impacts inbound and outbound
Increased Cost
Lack of Provider Preparation
Payment Delays
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Implementation Getting your ducks in a row
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Implementation Strategy
• Short term goals with a long term visions What solution do I need today? Will that solution extend to tomorrows needs?
• Awareness of touch points with other initiatives Overlap and conflicts
• Down Stream Impacts What works well for one business area, may bring another business area to
it’s knees
• Positioning for competitive advantage Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator for the transition challenge to
providers and other stakeholders? Can you manage the “burden of illness” of your population better than your
competitors?
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Phases of Transition
1. Assessment Inventory of impacted systems and processes Identifying risk
2. Analysis/Planning Prioritizing focus Establishing business area specific approaches Creating specifications for mapping to support implementation
3. Implementation and Operations Translating codes from 9 to 10 and from 10 to 9 using crosswalks Changing analytic models to support both codes Operationalization of coding to ICD-10 from source information Changing processing logic to operate directly from ICD-10 codes
4. Leveraging ICD10 capabilities Using the enhanced information within ICD-10 codes to improve processing
and analysis based on improved concepts buried within the ICD-10 codes
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Scenario-Based Testing
• The scenario:
The identification of some event or condition that we are familiar with today
Recreating that event virtually through some verbal or data representation
Defining a variety of assumptions and variables around this virtual representation
• Applying one or more of these scenarios in a Reference Implementation Model (RIM).
Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results.
What is it?
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Leveraging ICD-10
Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment.
• Better representation of severity and risk • Recognition of varying levels of complexity • Better claim information to support automated processing
and more rapid reimbursement • Opportunities to reduce audit risk exposure • Improved business intelligence to support population risk
management • More accurate measures of quality and efficiency
A changing world of cost containment
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Q&A
If you have a question that has not been addressed, please send it to us at the ICD-10 Questions Mailbox: [email protected]
Review of Q&A from Attendees
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Online Resources Review of Q&A from Attendees
• CMS - https://www.cms.gov/ICD10/ Coding Documentation (Indexes, Coding Guidelines, Code Files):
http://www.cms.gov/Medicare/Coding/ICD10/index.html General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure
and Diagnosis) GEMs Crosswalk documents:
http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
GEMs 2014 General Equivalence Mappings: http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html
Medicare Learning Network Articles: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html?redirect=/mlngeninfo
Implementation Guides: https://implementicd10.noblis.org
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Online Resources Review of Q&A from Attendees
• CMS - https://www.cms.gov/ICD10/ (Continued) Implementation Guides: https://implementicd10.noblis.org ICD-10 National Provider Calls:
http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html
National Coverage Determinations (NCDs): http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
Medicare Testing Week: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8465.pdf
Medicare Claims Processing Guidance for ICD-10: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7492.pdf
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Online Resources Review of Q&A from Attendees
• CMS - https://www.cms.gov/ICD10/ (Continued) Medicare Reimbursement Mappings 2014 Reimbursement Mappings – Diagnosis Codes and Guides
http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html 2014 Reimbursement Mappings – Procedure Codes and Guides
http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html Links to ordering the ICD-10 Pilot Version 31.0 Mainframe and PC version of the
ICD-10 MS-DRGs and Medicare Code Editor (FY 2014 version) from NTIS have been placed on the CMS website under the Related Links section at http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html?redirect=/mlngeninfo
FAQ, Coordination and maintenance Committee minutes
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Online Resources Review of Q&A from Attendees
• CDC - http://www.cdc.gov/nchs/icd/icd10cm.htm ICD-10-CM files (Alphabetic Indexes, Tabular List, Coding
Guidelines, Codes and Descriptions Files, FY2014 Addenda)
General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis)
GEMs Crosswalk documents: GEMs 2014 General Equivalence Mappings:
Detailed List of Codes Exempt from Diagnosis Present on Admission Requirements
Public Health Transition to ICD-10-CM/PCS
http://www.cdc.gov/nchs/icd/icd10cm_pcs.htm
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Online Resources Review of Q&A from Attendees
• WEDI - http://www.wedi.org/ List serves Workgroups White papers Implementation forums Industry advocacy and issue Access to standards leaders
• AHIMA - http://ahima.org/ Training and certification Extensive documentation libraries Bookstore Communities of practices ICD-10 focused conferences
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Online Resources Review of Q&A from Attendees
• HIMSS - http://www.himss.org/ White papers Bookstore Webinars
• Vendors • Consulting Organization • Online news • Blogs
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Online Resources Review of Q&A from Attendees
• Health Data Consulting white papers: ICD-10 A Primer ICD-10 Physician Impacts Scenario Based Testing ICD-10 The Case for Moving Forward ICD-10 Clinical Documentation – The Role of the Clinician
in Capturing Accurate Data ICD-10 – Specified or Unspecified?
http://healthdataconsulting.com/resources/white-papers/
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