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ICD-10-CM The transition . . .
Barbara Parker, CPC, CCS-P
How did the delay happen? February 27th CMS announces, “No more delays.”
March 25th (late in the day) House & Senate leadership insert ICD-10 language into HR 4302 Sustainable Growth Rate patch, needed to replace expiring legislation.
No time for floor debate
No opportunity for edits or amendments
March 26th to March 30th contacts made with Congress (mobilized by AHIMA)
March 27th – passes in House, March 31st passes in Senate, April 1st President signs bill
What does it say? Section 212
“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets.”
New implementation date?
To be determined by CMS
April 18th
With enactment of the Protecting Access to Medicare Act of 2014, CMS is examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon. This provision in the statute reads as follows: “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for codes sets under section 1173 (c) of the Social Security Act (42 U.S.C. 1320d-2 (c)) and section 162.1002 of title 45, Code of Federal Regulations.”
APCs Insider, April 18, 2014
Practically, the update offers nothing new for providers left wondering what to do with training and testing timelines that were supposed to be nearing their final stages. Considering it took the agency two weeks from the signing of the bill to merely post a message acknowledging its passing, the promise of guidance “soon” will probably not inspire much confidence in the healthcare community for a quick resolution.
Each day that passes without guidance makes it less likely the agency will find a way to reinstate the October 1, 2014 deadline that providers prefer, according to several polls.
CMS did not say in its statement that it would be providing a new implementation date soon, only that it is “examining the implications” of the provision.
This could mean CMS is looking at ways to reinstate the previous deadline However, time is a factor and Congress must still confirm a new secretary of HHS. October 1, 2015, still seems the most likely implementation date.
Despite CMS finally offering a comment on the delay, the landscape still hasn’t changed for providers. Their best course of action, to prevent the problems faced with previous delays, is to keep the momentum by continuing to fine-tune coder and physician training, and making sure systems are ready for ICD-10 implementation—no matter when it is.
Looking forward
The Small Practice’s Route to ICD-10
Your Practice Specialty
Your Practice Size
Your Vendors
Your Payers
Your ICD-10 Readiness
For example:
Family Practice
1-2 Physicians
Electronic Health Records
Commercial Payers, Medicare, Military Payers
Planning
Key steps are provided
Plan your journey
Update you processes
Engage you vendors and payers
Test your systems and processes
Perform internal testing
Conduct external testing
Practice and validate
Train Your Team
UnderdosingUnderdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less of a medication than is prescribed.
When documenting underdosing, include the following:
Intentional, Unintentional, Non-compliance Is the underdosing deliberate? (e.g., patient refusal)
Reason Why is the patient not taking the medication? (e.g. financial hardship, age-related debility)
Underdosing Codes
Z91.120
Patient’s intentional underdosing of medication regimen due to financial hardship
T36.4x6A Underdosing of tetracyclines, initial encounter
T45.526DUnderdosing of antithrombotic drugs, subsequent encounter
Hypertension
Definition ChangeIn ICD-10, hypertension is defined as essential (primary). The concept of “benign or malignant” as it relates to hypertension no longer exists.When documenting hypertension, include the following:
Type e.g. essential, secondary, etc.
Causal relationship e.g. Renal, pulmonary, etc.
Hypertension Codes
ICD-10 Code Examples
I10 Essential (primary) hypertension
I11.9 Hypertensive heart disease without heart failure
I15.0 Renovascular hypertension
Diabetes Mellitus, Hyperglycemia, Hypoglycemia
Increased Specificity
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.
When documenting diabetes, include the following:
Type e.g. Type 1 or Type 2 disease, drug or chemical induces, due to underlying condition, gestational
Complications What (if any) other body systems are affected by the diabetes condition? e.g. Foot ulcer related to diabetes mellitus
Treatment Is the patient on insulin?
A second important change is the concept of “hypoglycemia” and “hyperglycemia.” It is now possible to document and code for these conditions without using “diabetes mellitus.” You can also specify if the condition is due to a procedure or other cause.
The final important change is that the concept of “secondary diabetes mellitus” is no longer used; instead, there are specific secondary options
Diabetes Mellitus, Hypoglycemia, and Hyperglycemia Codes
E08.65Diabetes mellitus due to underlying condition with hyperglycemia
E09.01
Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
R73.9Transient post-procedural hyperglycemia
R79.9Hyperglycemia, unspecified
InjuriesICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins.
When documenting injuries, include the following:
Episode of Care e.g. Initial, subsequent, sequelae
Injury site Be as specific as possible
Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?
Place of Occurrence e.g. School, work, etc.
Initial encounters may also require, where appropriate:
Intent e.g. Unintentional or accidental, self-harm, etc.
Status e.g. Civilian, military, etc.
Injury CodesExample 1: A left knee strain injury that occurred on a private recreational playground when a child landed incorrectly from a trampoline:
Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
External cause: W09.8xxA, Fall on or from other playground equipment, initial encounter
Place of occurrence: Y92.838, Other recreation area as the place of occurrence of the external cause
Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping
Another InjuryExample 2: On October 31st, Kelly was seen in the ER for shoulder pain and X-rays indicated there was a fracture of the right clavicle, shaft. She returned three months later with complaints of continuing pain. X-rays indicated a nonunion. The second encounter for the right clavicle fracture is coded as
S42.021K, Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.
Documentation for Abdominal Pain
Chief Complaint
“My stomach hurts and I feel full of gas.”
History
47 year old male with mid-abdominal epigastric pain1, associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.
Has had an estimated 13 pound weight loss over the past month.
Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he believes initiated his symptoms.
Patient admits to a history of alcohol dependence2. Consuming 5 – 6 beers per day now, down from 10 – 12 per day 6 months ago. States that he has nausea and sweating with “the shakes” when he does not drink.
Exam
VS: T 99.8°F, otherwise normal.
Mild jaundice noted.
Abdomen distended and tender across upper abdomen3. Guarding is present. Bowel sounds diminished in all four quadrants.
Oral mucosa dry, chapped lips, decreased skin turgor.
Assessment and Plan
1. Dehydration and suspected acute pancreatitis.
2. Admit to the hospital. Orders written and sent to on-call hospitalist.
3. 1L IV NS started in office. Blood drawn for labs.
4. Recommend behavioral health counseling for substance abuse assessment and possible treatment.
5. Patient’s wife notified of plan; she will transport to hospital by private vehicle.
Summary of ICD-10-CM Impacts
Clinical Documentation
Describe the pain as specifically as possible based on location.
When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders. In this encounter note, as the acute pancreatitis is suspected, and the patient’s alcohol intake status is stated, the associated alcoholism code is listed.
Abdominal tenderness may be coded. Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.
Comparison of CodesICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes
789.06Abdominal pain, epigastric
R10.13 Epigastric pain
789.60
Abdominal tenderness, unspecified site
R10.819
Abdominal tenderness, unspecified site
782.4 Jaundice NOS R17 Unspecified jaundice
276.51 Dehydration E86.0 Dehydration
303.90
Other and unspecified alcohol dependence, unspecified
F10.20
Alcohol dependence, uncomplicated
Documentation for Annual Exam
Chief Complaint
“I’m here for my annual check-up.1”
History
73 year old male with history of coronary artery disease, stent placement, hyperlipidemia, HTN and GERD.
Recent admission to hospital following a hypertensive crisis. Discharged home on olmesartan medoxomil 20 mg daily.
Patient stopped taking olmesartan medoxomil due to side effects2,including a headache that began after starting the medication and still exists, and tiredness.
Regular activity includes walking, golfing. Active social life. No complaints of chest pain, or dyspnea on exertion.
Last colonoscopy was 9 months ago. No significant pathology found; some diverticular disease.
Medications were reviewed.
Exam
Chest clear. Heart sounds normal. Mental status exam intact.
EKG shows no changes from prior EKG.
Vitals: BP is 159/95, otherwise normal. Per patient, he had good control of BP on meds, but it has risen without medication.
BUN/creatinine normal limits.
Assessment and Plan
HTN noted on exam today. Change from olmesartan medoxomil to metoprolol tartrate 50 mg once daily, will titrate dosage every two weeks until BP normalizes.
Discussed the importance of daily home BP monitoring, low sodium diet, and taking BP medication as prescribed; he verbalizes understanding.
Schedule follow-up visit in two weeks to evaluate effectiveness of new BP medication therapy, and repeat BUN/creatinine.
Summary of ICD-10-CM ImpactsClinical Documentation
Documenting why the encounter is taking place is important, as the coder may assign a different code based on the type of visit (e.g., screening, with no complaint or suspected diagnosis, for administrative purposes). In this situation, the patient is requesting an encounter without a complaint, suspected or reported diagnosis.
Document that the patient is noncompliant with his medication. This “underdosing” concept can often be coded, along with the patient’s reason for not taking the prescribed medications. Document if there is a medical condition linked to the underdosing that is relevant to the encounter, and ensure the connection is clearly made. The ICD-10-CM terms provide new detail as compared to the ICD-9-CM code V15.81, history of past noncompliance. In this case there was no noted history of noncompliance. In this note the side effects of stopping the medication include headache, which remains as a patient complaint for this encounter. When documenting headache do differentiate if intractable versus non-intractable.
Comparison of CodesICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes
V70.0 Routine medical exam
Z00.01
Encounter for general adult medical examination with abnormal findings
401.9Unspecified essential hypertension
I10Essential (primary) hypertension
339.3
Drug-induced headache, not elsewhere classified
G44.40
Drug-induced headache, not elsewhere classified, not intractable
N/A T46.5X6A
Underdosing of other antihypertensive drugs, initial encounter
N/A Z91.128
Patient’s intentional underdosing of medication regimen for other reason
Other ImpactsAssess if the new patient-centric preventive health incentives for annual exams are relevant to your practice.
For hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans, certain diagnosis codes are used as to determine severity of illness, risk, and resource utilization. HCC impacts are often overlooked in the ICD-9-CM to ICD-10-CM conversion. The physician should examine the patient each year and compliantly document the status of all chronic and acute conditions. HCC codes are payment multipliers.
Test Your Systems and Processes
Testing of key systems and processes is essential to your ICD-10 transition success! To this end, your practice should:
Prepare test cases to validate.
Perform internal testing of systems and work flow processes using ICD-10 diagnosis codes.
Conduct external testing with vendors and payers using data that contains ICD-10 diagnosis codes.
Practice coding in ICD-10 and validate supporting clinical documentation processes.
Identify test scenarios
Isolate the ICD-9 diagnosis codes you use the most. Superbills, encounter forms, system reports, and the Common Codes in your action plan can you help you pinpoint this information.
Find encounters which represent the scenarios
Locate at least ten (10) existing encounters/claims which include the ICD-9 diagnosis codes you identified in step one.
Prepare test cases
Prepare test cases using the encounters identified in step two. Utilize the ICD-9 codes found in the encounters/claims to help identify relevant ICD-10 codes for each scenario.
Suggestions for help Tabular form of the 2014 release of ICD-10-CM codes and Tabular form of the 2014
release of ICD-10-CM codes and descriptions published by the National Center for Health Statistics (NCHS) - ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2014/Open the ICD-10CM_FY2014_Full_PDF.zip file then unzip and save the PDF file named “ICD10CM_FY2014_Full_PDF_Tabular” to your local device
Online ICD-10-CM search tools/applications
Hard copy or electronic publications of 2014 ICD-10-CM code books
Common Codes from your action plan
2014 General Equivalence Mappings (GEMS) Diagnosis Codes and Guide from CMS - http://cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
Crosswalks from your system vendors and largest payers
descriptions published by the National Center for Health Statistics (NCHS) - ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2014/Open the ICD-10CM_FY2014_Full_PDF.zip file then unzip and save the PDF file named “ICD10CM_FY2014_Full_PDF_Tabular” to your local device Online ICD-10-CM search tools/applications Hard copy or electronic publications of 2014 ICD-10-CM code books Common Codes from your action plan 2014 General Equivalence Mappings (GEMS) Diagnosis Codes and Guide from CMS - http://cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html Crosswalks from your system vendors and largest payers
Test
Test systems which store, process, send, receive, or report diagnosis code information.
What to test
Use your test cases to verify the following system functions and processes work properly:
Perform eligibility & benefits verification.
Process a referral.
Process an authorization.
Schedule an office visit.
Schedule an outpatient procedure.
Schedule an inpatient admission.
Prepare to submit quality data.
Prepare to submit public health data.
Update a patient’s history & problems.
Enter and process an order.
Verify that diagnosis-dependent clinical decision support rules issue alerts.
Prepare clinical notes for an encounter.
Code an encounter.
Generate and process a claim.
Perform a claim status inquiry.
Reconcile and post a payment.
Run frequently used reports.
Perform other key tests as needed.
Document test results and retest as needed.
Document your test results. Investigate the cause (data entry, process, system, other) for tests that failed unexpectedly.
Report potential system issues to the applicable technology vendors.
Test fixes installed and changes made to address the problems you identified.
Check out AAPC example documentation
S: Mrs. Finley presents today after having a new cabinet fall on her last week, suffering a concussion, as well as some cervicalgia. She was cooking dinner at the home she shares with her husband. She did not seek treatment at that time. She states that the people that put in the cabinet in her kitchen missed the stud by about two inches. Her husband, who was home with her at the time told her she was “out cold” for about two minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius.
O: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear.
A:
Status post concussion with acute persistent headaches
Cervicalgia
Cervical somatic dysfunction
P: The plan at this time is to send her for physical therapy, three times a week for four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month, sooner if needed.
And the codes are:
S06.0x1A
Concussion with loss of consciousness of 30 minutes or less, initial encounter
G44.311 Acute post traumatic headache, intractable
M54.2 Cervicalgia
M99.01Segmental and somatic dysfunction of cervical region
W20.8xxAStruck by falling object (accidentally), initial encounter
Y93.g3 Activity, cooking and baking
Y92.010Place of occurrence, house, single family, kitchen
Sample superbill-AAPC Website
Superbills: ICD-9 vs. ICD-10
To show the added complexity that providers will face when using ICD-10-CM, the Blue Cross Blue Shield Association converted a superbill from ICD-9-CM to ICD-10-CM.
View the original ICD-9-CM superbill
View the ICD-10-CM superbill created using CMS crosswalks
Recommended ResourcesClinical Documentation
Learn to document patient encounters accurately, in order to ensure that medical records both capture and support the specificity and medical necessity of the ICD-10 codes assigned to the claim.
American Health Information Management Association (AHIMA)
Clinical Documentation for ICD-10 Training
https://secure-content.optimizehit.com/ahima/
American Academy of Professional Coders (AAPC)
ICD-10 Documentation Training for Physicians
http://www.aapc.com/ICD-10/ICD-10-physician-documentation.aspx
Coding
Learn about the differences and similarities between ICD-9 and ICD-10, including combination codes, unspecified codes, addition of a 7th character, excludes notes, and the use of an “x” placeholder. Learn how to assign ICD-10 codes through native coding. Learn anatomy and physiology as it relates to new specificity of ICD-10.
American Academy of Professional Coders (AAPC)
General ICD-10-CM Code Set Training http://www.aapc.co
m/ICD-10/online-icd-10-coding.aspx
World Health Organization (WHO)
ICD-10 Interactive Self Learning Tool http://apps.who.int/
classifications/apps/icd/icd10training/
ICD-10 Overview
Learn about the fundamentals of ICD-10 and how it impacts compliance as well as your revenue cycle.
American Academy of Professional Coders (AAPC)
ICD-10 Traininghttp://www.aapc.com/ICD-10/practice-icd-10-training.aspx
Centers for Medicare and Medicaid Services (CMS)
ICD-10: The Provider Perspective (Presented by Dr. Joe Nichols)
http://www.youtube.com/watch?v=LBXqy386Lfg
Centers for Medicare and Medicaid Services (CMS)
ICD-10: Rural or urban; It impacts all providers (Presented by Dr. Joe Nichols)
http://narhc.org/wp-content/uploads/2013/09/ICD-10-Documentation-Requirements.pdf
When you are done . . . Go bowling
