ICD-10 Is Coming. Are You Prepared? For services provided on and after October 1, 2015, U.S.-based entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use ICD-10 code sets. ICD-9 codes will no longer be accepted on claims for services provided on or after October 1, 2015. ICD-10 consists of two parts:

• ICD-10-CM diagnosis coding which is for use in all U.S. health care settings. • ICD-10-PCS inpatient procedure coding which is for use in U.S. hospital settings.

Medscape recently reported that nearly a quarter of physician practices say they will not be ready for the ICD-10 implementation deadline on October 1, 2015, while another 25 percent say they are unsure whether they’ll be ready. The latest Workgroup for Electronic Data Interchange survey also found that only about 20% of physician practices have started or completed external testing.

ICD-10 will have a substantial impact on you and your practice however, you can mitigate some of the impact by developing an action plan and preparing your practice now. You should also know that you will have some flexibility in coding during the first year after the implementation of ICD-10. While you will be required to use valid ICD-10 codes for services performed on and after October 1, 2015, Medicare claims will not be denied solely because the ICD-10 code submitted wasn’t specific enough as long as the code is from the appropriate family of ICD-10 codes. Coding to the highest level of specificity should be the goal for all claims, however, during the first twelve months after ICD-10 implementation, Medicare will process valid ICD-10 codes from the appropriate family of codes in most circumstances. (See the “Grace Period” section of this newsletter for more information.)

In this ISASS newsletter, you will: • learn ICD-10 basics; • learn how to prepare your practice for the transition to ICD-10; • learn what the “grace period” means for you and your practice; • have access to ICD-9 to ICD-10 crosswalks of commonly used spine codes; and • learn where to go to access additional resources.

Additionally, mark your calendar for a National Provider Call on ICD-10 hosted by CMS on Thursday, August 27 from 2:30-4:00 p.m. ET. You can register for the call titled “Countdown to ICD-10”at the following link:

Countdown to ICD-10 →

ICD-10 Basics 1

Code Structure/Design

! • There are approximately 68,000 ICD-10 codes compared to approximately 14,000

ICD-9 codes—however, approximately 1/3 of the code expansion is due to laterality. Just as you only use a small subset of ICD-9 codes now, you will only use a small subset of ICD-10 codes for services provided on and after October 1, 2015.

• ICD-10 codes are made up of a minimum of 3 characters and a maximum of 7 characters.

•o 1st character: capital letter A-Z, except “U”, which is not used

(Note: some ICD-9 codes overlap ICD-10 codes in the ‘E prefix range’) o 2nd and 3rd character: number o 4th, 5th and 6th character: number or letter, capital or lowercase (not case

sensitive) o 7th character: number or letter, capital or lowercase, only used in specific

chapters of the ICD-10-CM book--predominantly pregnancy (Chapter 15, O00-O9A) and injuries (Chapter 19, S00-T88), but also found in musculoskeletal (Chapter 13, M00-M99), and external causes of morbidity (Chapter 20, V00-Y99)

• Codes with 3 characters are the headings of categories of codes that may be further subdivided by the use of any or all of the 4th, 5th, and 6th characters which provide greater detail of etiology, anatomical site, and severity. NOTE: A code using only the first three characters is only to be used if it is not further subdivided.

• “Default code” is a term that refers to the code listed next to the main term in the Alphabetical Index of the ICD-10 book. It represents that the term is most commonly associated with the main term or is unspecified.

• Characters 4 - 6 correspond to the related etiology (i.e. the cause, set of causes, or manner of causation of a disease or condition, anatomic site, severity, or other vital clinical details).

• Laterality is required for certain codes such as fractures/ burns, ulcers and certain neoplasms. If the laterality is not documented in the medical record, an unspecified code is available. However, providers are encouraged to document/code laterality or

Medtron Software compiled the information on ICD-10 Basics to assist providers in understanding the ICD-10 1

Clinical Modification (CM) codes used by Part B providers.

risk claims being held for medical record review by some carriers.

o As a general rule (confirm proper code selection via ICD-10-CM book):The number ‘1’ is used to indicate right side (Procedure billed should have modifier: RT). The number ‘2’ is used to indicate left side (Procedure billed should have modifier: LT). The number ‘3’ indicates bilateral (Procedure billed should have modifier: 50). The number ‘9’ indicates side is unspecified in the medical record. (For extremity-related and certain other diagnoses, "0" may be required, rather than "9".)

ICD-9-CM vs. ICD-10-CM NOTE: Part B Providers use only the CM (Clinical Modification) version.

*Typically to an unspecified code.

ICD-9: • 3-5 Characters total • First character is numeric or alpha E

or V only • Characters 2-5 are numeric • Always at least 3 characters • Use of decimal after 3 characters • Approximately 14,000 codes

ICD-10: • 3-7 Characters total • First character is alpha • Characters 2-7 are alpha or numeric • Always at least 3 characters • Use of decimal after 3 characters • Approximately 68,000 codes

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ICD-9 to ICD-10 Mapping Results

No Match 3.00%

1 to 1 Exact Match 24.20%

1 to 1 Approximate Match with 1 Choice * 49.10%

1 to 1 Approximate Match with Multiple Choices * 18.70%

1 to Many Match with 1 Scenario 2.10%

1 to Many Match with Multiple Scenarios 2.90%

AAPC 2015 ICD-10-CM Code Set - Section/Category/Chapter Layout

• ICD-10-CM Codes are broken down by code ranges (Chapters) or categories similar to the ICD-9 codes. Below is a description of the various categories and the approximate number of codes in each section.A complete list of ICD-10 codes is available via the CMS Road to ICD-10 website:

View Index List (PDF) →

View Tabular List (PDF) →

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Chapter Specific Nuances

Diseases of the Musculoskeletal System and Connective Tissue-Chapter 13 (M00-M99) Contains specific instructions for conditions involving multiple sites, such as osteoarthritis--there often is a “multiple sites” code available. If no “multiple sites” code is available, the provider should report multiple codes to indicate all of the different sites involved.

Bone vs. Joint: In some cases, the bone is affected at the lower end (i.e., Osteoporosis, M80, M81).Even though the affected area may be located at the joint, the site of the condition is still considered the bone, not the joint.

Acute traumatic vs. Chronic or Recurrent: Many musculoskeletal conditions are the result of previous injury or trauma, or they are recurrent conditions. Most bone, joint, or muscle conditions resulting from healed injuries appear in this Chapter, i.e., the “M” Chapter. This Chapter also includes most recurrent bone, joint, or muscle conditions. So, while a provider would generally code chronic or recurrent injuries using Chapter 13 codes, to code current, acute injuries a provider should be using the appropriate injury code from Chapter 19 (S00-T88).

Injury, Poisoning, and Certain Other Consequences of External Causes -Chapter 19 (S00-T88) Grouped by: • Anatomic site of injury (i.e. first metatarsal) • Laterality (i.e. right, left) • Type of injury (i.e. fracture, segmental, oblique, type I, type II) • Severity (i.e., displaced, non-displaced, superficial, deep, minor, major) • Complications (i.e. delayed healing, malunion, nonunion) • Causal substance (i.e. venom: wasp, snake, scorpion, pesticides: insecticides,

rodenticides) • Episode of care (i.e. initial, subsequent, sequel) • External cause of effects of substance formally identified by supplementary

classifications (i.e. self-harm, adverse effect, accidental)

NOTE: Specific injuries have additional 7th character values (see Chapter 19 Chapter specific coding guidelines via ICD-10-CM book).Injuries such as traumatic injury codes S00-T14.9 are not to be used for normal, healing, surgical wounds or to identify complications of surgical wounds. The code for the most serious injury, as determined by the provider and the focus of the treatments, should be sequenced first.

NOTE: Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

Fractures Open fracture designations are based on the Gustilo open fracture classification. The appropriate 7th character is to be added to each code from category S52:

A = Initial encounter for closed fractureB = Initial encounter for open fracture type I or IIC = Initial encounter for open fracture type IIIA, IIIB, or IIIC D = Subsequent encounter for fracture with routine healingE = Subsequent encounter for open fracture type I or II with routine healingF = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G = Subsequent encounter for fracture with delayed healingH = Subsequent encounter for open fracture type I or II with delayed healingJ = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K = Subsequent encounter for fracture with nonunionM = Subsequent encounter for open fracture type I or II with nonunionN = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunionP = Subsequent encounter for fracture with malunionQ = Subsequent encounter for open fracture type I or II with malunionR = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunionS = Sequela

External Cause of Morbidity-Chapter 20 (V00-Y99) Injury codes are grouped by anatomical site rather than by type of injury. A provider will often submit external cause codes that further describe the scenario that resulted in the injury. These are to be used as secondary diagnosis codes only, which means they further describe the cause of an injury or health condition by capturing how it happened (cause), the intent (intentional or accidental), the place the event occurred, the activity the patient was engaged in at the time of the event, and the person’s status (i.e., civilian or military). Providers can assign as many external cause codes as necessary to explain the patient’s condition to the fullest extent possible. (These codes are not required, see Chapter 20 Chapter specific coding guidelines via ICD-10-CM book.)

Step-By-Step Guide to Prepare your Practice for ICD-10

☑ Make a Plan • Budget for time and costs related to ICD-10 implementation including expenses

for system changes, software updates, resource materials and training. o It is estimated that the conversion to ICD-10 will have an initial impact on

physician practices’ efficiency. Industry estimates up to a 30% reduction in coder productivity due to additional specificity, physician queries, loss of memorized codes, and the learning curve. There could also be a decrease in physician/provider productivity due to additional specificity needed in charting, orders, and authorizations.

• Anticipate delays in reimbursements after the transition to ICD-10. Build cash reserves and talk to your financial institution about establishing or increasing your line of credit.

• Obtain access to ICD-10 codes. The codes are available from many sources and in many formats:

o Code books o CD/DVD and other digital media o Online (e.g. go to www.cms.gov/ICD10 and select “2016 ICD-10-CM and

GEMS” to download 2016 Code Tables and Index) o Practice management systems o Electronic health record products o Smartphone apps

☑ Train your Staff • Train staff on ICD-10 fundamentals using the wealth of free resources from CMS,

which include the o ICD-10 website, o Road to 10, o Email Updates, o National Provider Calls, o and webinars.

• Free resources are also available from: o Medical societies o Hospitals, health systems, health plans and vendors

• Identify top codes. What ICD-9 diagnosis codes does your practice see most often? Target the top 25 to start. You might want to look at common orthopedic diagnosis codes available from Road to 10: http://www.roadto10.org/action-plan/phase-2-train/common-codes-orthopedic/

• Using the documentation available, begin to code current cases in ICD-10 for practice. Flag any cases where more documentation is needed.

☑ Update your Processes • Update hard-copy and electronic forms (e.g. superbills and CMS 1500 forms) • Resolve any documentation gaps identified while coding top diagnosis in ICD-10 • Make sure clinical documentation captures key new coding concepts:

o Laterality- or left vs. right o Initial or subsequent encounter for injuries o Types of fractures

☑ Talk to your Vendors and Health Plans • Call your vendors to confirm the ICD-10 readiness of your practice’s systems • Confirm that the health plans, clearinghouses and third-party billing services you

work with are ICD-10 ready • Ask vendors, health plans, clearinghouses, and third-party billers about testing

opportunities

☑ Test your Systems and Processes • Verify that you can use your ICD-10 ready systems to:

o Generate a claim o Perform eligibility and benefits verification o Schedule an office visit o Schedule an outpatient procedure

o Prepare to submit quality data o Update a patient’s history and problems o Code a patient encounter

• Test your systems with partners like vendors, clearinghouses, billing services, and health plans; focus on those partners that you work with most often. o Medicare providers can conduct acknowledgement testing with your

Medicare Administrative Contractors (MACs) until the October 1 compliance date to confirm that Medicare can accept your ICD-10 claims.

• Explore alternate ways to submit claims to health plans if you think your systems might not be ready for ICD-10 by October 1. o For Medicare providers, options include:

▪ Free billing software available from every MAC website ▪ Part B claims submission by online provider portal (in about 1⁄2 of

MAC jurisdictions) ▪ Paper claims for providers who meet Administrative Simplification

Compliance Act Waiver ▪ NOTE: Each of these options require you to code in ICD-10.

o Ask other health plans you work with about the options they offer.

Grace Period

On July 6, 2015, the American Medical Association and Centers for Medicare and Medicaid Services (CMS) jointly announced agreement on important elements of a “grace period” for the October 1, 2015, implementation of the ICD-10 diagnosis code set. CMS announced that:

• For a one year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.

• To avoid potential problems with mid-year coding changes in CMS quality programs (Physician Quality Reporting System (PQRS), Value Based Modifier (VBM) and Meaningful Use (MU)) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed.

• CMS will establish an ICD-10 Ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition. CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation.

FAQs on the grace period can be found at the following link:

ICD-9 to ICD-10 Crosswalks of Commonly Used Spine Codes

The following crosswalks were developed by the Business of Spine and are intended to assist you in understanding the changes in spine coding from ICD-9 to ICD-10. This coding reference is not intended to serve as a replacement to the International Classification of

Diseases 10th Revision! Clinical Modification (ICD!10!CM) book. Always refer back to the ICD-10 book when coding.

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Where to Find Additional Resources Orthopedics Clinical Concepts Guide →

Background/General ICD-10 Information: CMS – ICD-10 Quick Start Guide CMS NARHC Presentation: ICD-10 – Rural or Urban; It Impacts All Providers CMS PAHCOM National Webinar: ICD-10 – The Provider Perspective CMS – The ICD-10 Transition: An Introduction CMS – ICD-10 Basics for Medical Practices CMS – ICD-10 Basics for Small and Rural Practices AMA – ICD-10 101: What It Is and Why It’s Being Implemented (requires AMA Log-in) AHIMA ICD-10 FAQs AHIMA ICD-10 Toolkit AHIMA ICD!10!CM/PCS Transition: Planning and Preparation Checklist

Clinical Documentation: CMS PAHCOM National Webinar: Clinical documentation Health Condition Categories AHIMA Electronic Documentation Templates Support ICD-10-CM/PCS

Implementation

Coding: AAPC – ICD-10 Codes Medicare Learning Network ICD-10-CM/PCS The Next Generation of Coding CMS – National Coverage Determination (NCD) and Local Coverage Determination

(LCD) code crosswalks

ICD-10-CM Codes and GEMS: 2015 ICD-10-CM Index to Diseases and Injuries 2015 ICD-10-CM Tabular List of Diseases and Injuries CMS – 2016 ICD-10-CM and GEMs AMA – Crosswalking Between ICD-9 and ICD-10 (requires AMA Log-in) CDC – International Classification of Diseases, Tenth Revision, Clinical Modification

(ICD-10-CM) WEDI – WEDI SNIP ICD-10 Crosswalks Primer White Paper WEDI – ICD-10 Crosswalks White Paper: Treasure Map to ICD-10 Resources AHIMA – Putting The ICD-10 GEMs Into Practice

Use of Unspecified Codes in ICD-10: MLN Matters® Article SE1518, “Information and Resources for Submitting Correct

ICD-10 Codes to Medicare” ICD-10 Basics MLN Connects National Provider Call - Call Materials from August 22,

2013 More ICD-10 Coding Basics MLN Connects Call - Call Materials from June 4, 2014 ICD-10 Coding Basics MLN Connects Video - January 2014 Coding for ICD-10-CM: More of the Basics MLN Connects Video - December 2014

Implementation: Planning: Medscape – Transition to ICD-10: Getting Started (requires Medscape Log-in) AHIMA – ICD-10 AMA – Implementing ICD-10 in Your Practice – Part 1 (requires AMA Log-in) AMA – Implementing ICD-10 in Your Practice – Part 2 (requires AMA Log-in) HIMSS – ICD-10 Initiation & Planning WEDI – ICD-10 Roadmap Tool Kit AHIMA Physician Office Implementation Model AHIMA ICD-10 Readiness Assessment and Prioritization Tool for Organizations Small/Medium Practice: Road to 10: Implementation Guide Medscape – ICD-10: A Guide for Small and Medium Practices (requires

Medscape Log-in) Medscape – ICD-10: A Roadmap for Small Clinical Practices (requires

Medscape Log-in) Medscape – ICD-10: Small Practice Guide to a Smooth Transition (requires

Medscape Log-in)

Latest News: CMS – Latest News

Legislation: CMS – Statute and Regulations

Newsletters: CMS – ICD-10 Industry Email Updates

Payers: General: CMS – Payer Resources AHIMA Implementation Model for Health Plans Medicaid Resources: CMS – Medicaid Resources Medicare Resources: CMS – Medicare Fee-for-Service Provider Resources

Testing: CMS – End-to-End Testing AMA – Testing Your Readiness for ICD-10 (requires AMA Log-in) HIMSS – ICD-10 Testing HIMSS/WEDI – ICD-10 National Pilot Program CMS MLN Matters/Testing

Training: AAPC – ICD-10 Training AHIMA – ICD10 Training That’s Right for You HIMSS – Training Plan

Vendors: CMS – Vendor Resources CMS – Questions to Ask Your Systems Vendors about ICD-10 HIMSS – ICD-10 Vendor Readiness: Vital Vendors WEDI – WEDI ICD-10 Vendor Resource Directory

Version 5010: CMS – Versions 5010 and D.0 & 3.0 CMS – Version 5010 Resources WEDI – ICD-10 Impact to HIPAA Transactions

Webinars: CMS – YouTube Channel HIMSS – Webinars & Events (2014) HIMSS – ICD-10 Provider Podcast

PAHCOM – CMS Partnership Webinar Recordings (ICD-10)

ICD-10 Newsletter from Medtron Software →

Health Providers Data Cross Walk Tool →

ICD-10 Information from Private Payers:

Anthem →

Aetna →

Humana →

Cigna →

United →