ICD-10 is here – Can you believe it??

Lynn Kuehn, MS, RHIA, CCS-P, FAHIMAKuehn Consulting, LLC

Learning Objectives

• At the end of today’s session, you will be able to:– Identify what ICD-10 is and isn’t– Explain who is affected by the system changes– Compare ICD-9-CM with ICD-10-CM and PCS– Summarize what the industry has learned so far– Participate in open question and answer session

at the end of the presentation

Facilities Using the New Code Set

Physician

ICD-10-CMCPT /

HCPCS

Long Term HealthcareICD-10-CM

CPT / HCPCS

Other Outpatient ProvidersICD-10-CM

CPT / HCPCS

HospitalInpatient

ICD-10-CMICD-10-PCSOutpatientICD-10-CM

CPT / HCPCS

Only required for reporting procedures

performed on hospital inpatients

Who Must be Compliant?

ICD-10 Compliant

Hospitals

Physicians

Outpatient Facilities

Home Health Agencies

Home Medical Equip.

Reference Labs

Health plans & payors

State Medicaid Programs

CDC

HIE/RHIO

Medical Devices

Code Set Freeze

•Limited Code Updates

2012-2015

•Regular Code Updates

10/1/2016

Physician Offices, ED, Clinics, etc.

Physician sees patient in the office for fever, nausea and vomiting. Diagnosis: Gastroenteritis

Then Now

ICD-9-CM Diagnosis Code ICD-10-CM Diagnosis Code

CPT/HCPCS CPT/HCPCS

Physician Offices, ED, Clinics, etc.

Physician sees patient in the office for fever, nausea and vomiting. Diagnosis: Gastroenteritis

Then Now

558.9 Noninfectious gastroenteritis and colitis

K52.9 Noninfective gastroenteritis and colitis

CPT/HCPCS (Office E/M code) CPT/HCPCS (Office E/M code)

Surgeons’ Work

Surgeon performs a cholecystectomy for acute cholecystitis with cholelithiasis.

Then Now

ICD-9-CM Diagnosis Code ICD-10-CM Diagnosis Code

CPT/HCPCS CPT/HCPCS

Surgeons’ Work

Surgeon performs a cholecystectomy for acute cholecystitis with cholelithiasis.

Then Now

574.00 Calculus of gallbladder with acute cholecystitis, without obstruction

K80.00 Calculus of gallbladder with acute cholecystitis, without obstruction

CPT/HCPCS CPT/HCPCS

Hospital’s Work

The patient has an open cholecystectomy as an inpatient with acute cholecystitis with cholelithiasis.

Then Now

ICD-9-CM Diagnosis Code ICD-10-CM Diagnosis Code

ICD-9-CM Procedure Code ICD-10-PCS Procedure Code

Hospital’s Work

Surgeon performs an open cholecystectomy for acute cholecystitis with cholelithiasis.

Then Now

574.00 Calculus of gallbladder with acute cholecystitis, without obstruction

K80.00 Calculus of gallbladder with acute cholecystitis, without obstruction

51.22 Cholecystectomy 0FT40ZZ Open resection of gallbladder

Fact or Myth

ICD-10-CM and ICD-10-PCS is a Medicare administrative system

a. Trueb. False

World Health Organization

• Develops and maintains the base system for use in tracking death statistics worldwide

• U.S. version isICD-10-CM for diagnoses

Fact or Myth

Providers will not get paid if they submit an unspecified diagnosis code

a. Trueb. False

Unspecified Codes

A04.9 Bacterial intestinal infection, unspecified

K92.2 Gastrointestinal hemorrhage, unspecified

R11.2 Nausea with vomiting, unspecified

S37.90xA Unspecified injury of unspecified urinary and pelvic organ

Fact or Myth

ICD-10 is those crazy codes that no one cares about.

a. Trueb. False

Leading Cause of Death, by age for 2010

DATA IMPACT

Data Impact

• Changes to multiple information systems and applications

• Increased system storage capacity• Redesign of reports and forms• Modification of patient assessment data sets• Data trending challenges

Data Trending Challenges

• Differences in code sets go beyond changes in code titles or level of specificity – Terminology, definitions, meaning of code, or

instructions for code assignment may have changed

• When linking coded data, differences need to be reconciled– Method used to reconcile differences may vary

Data Trending Challenges

• Flawed decisions may be made due to reliance on distorted, inaccurate, or misinterpreted data or comparability problems

• Caution should be exercised when interpreting data across transition

Reports Inventory and Conversion

External• CORE measures• Benchmarking• Registries• Regulatory• HIE• State Reporting

Internal• Patient Care• Quality & UR• Registries• Billing & Reimbursement• Research• Regulatory

What is ICD-10-CM?

• Based on ICD-10 published by the World Health Organization

• NCHS developed ICD-10-CM and guidelines• ICD-10-CM is used for morbidity classification• ICD-10-CM in public domain, however cannot

be altered except through the Coordination and Maintenance Committee process

ICD-10-CM Structure

S 3 2 0 1 0 A

Characters 1-3Category

Character 4-6Anatomic Site,

Etiology, Severity

Character 7Additional info when

needed

Site Etiology Severity

How Data is Organized

ICD-10-CM: Similarities to ICD-9-CM

• Divided into Alphabetic Index and Tabular List– Structure and format are the same– Index is alphabetical list of terms and their

corresponding codes• Alphabetic Index lists main terms in alphabetical order

with indented subterms under main terms• Index is divided into 2 parts: Index to Diseases and

Injuries and Index to External Causes

Index Example

Hemiplegia G81.9-- alternans facialis G83.89- ascending NEC G81.90- - spinal G95.89- congenital (cerebral) G80.8- - spastic G80.2- embolic (current episode) I63.4-- flaccid G81.0-- following- - cerebrovascular disease I69.959- - - cerebral infarction I69.35-- - - intracerebral hemorrhage I69.15-- - - nontraumatic intracranial hemorrhage NEC I69.25-- - - specified disease NEC I69.85-

ICD-10-CM: Similarities to ICD-9-CM

• Many conventions have same meaning– Abbreviations, punctuation, symbols, notes such

as “code first” and “use additional code”• Non-specific codes (“unspecified” or “not

otherwise specified”) are available to use when detailed documentation to support more specific code is not available

ICD-10-CM: Differences from ICD-9-CM

• Code titles are complete (no need to refer back to a category, subcategory, or subclassification level to determine complete meaning of code)

ICD-10-CM: Differences from ICD-9-CM

ICD 10 CM – Conventions‑ ‑

Exclude NotesExclude1: Means NOT CODED HERE

Code being excluded is never used with codeThe two conditions cannot occur togetherExample:

R23.0 Cyanosis Excludes1: acrocyanosis (I73.8)

cyanotic attacks of newborn (P28.2)

ICD 10 CM – Conventions‑ ‑

Exclude NotesExclude2: Means NOT INCLUDED HERE

Excluded condition is not part of the condition represented by the code

Acceptable to use both codes together if patient has both conditions

Example:

R93.6 Abnormal findings on diagnostic imaging of limbs Excludes2: Abnormal findings in skin and subcutaneous tissue

(R93.8)

Valid ICD-10-CM Codes

R54 Age-related physical debilityN02.0 Recurrent and persistent hematuria with

minor glomerular abnormalityC40.01 Malignant neoplasm of scapula and long

bones of right upper limbQ76.426 Congenital lordosis, lumbar regionT48.1x1A Poisoning by skeletal muscle relaxants

[neuromuscular blocking agents], accidental (unintentional), initial encounter

ICD 10 CM – Format‑ ‑

• Place holder “x”– Maintains the integrity of the meaning of certain

characters• Example: T48.1x1S Poisoning by skeletal muscle

relaxants [neuromuscular blocking agents], accidental (unintentional), sequela

– Used when a shorter code requires 7th character extension

• Example: W89.1xxA

ICD-10-CM: Differences from ICD-9-CM

• Addition of 7th character– Used in certain chapters to provide information

about the characteristic of the encounter– Must always be used in the 7th character position– If a code has an applicable 7th character, the code

must be reported with an appropriate 7th character value in order to be valid

ICD-10-CM 7th Character:Injuries & External Causes

A Initial encounter D Subsequent encounter S Sequela

Note: For aftercare of an injury, assign acute injury code with 7th character “D”

Principal and First Listed Diagnosis

• Principal diagnosis: Used in inpatient setting. “...that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”, UHDDS definition

• First listed diagnosis: The first listed code in all other health care settings.

• Both are based first on sequencing instructions and conventions in the classification.

New Features

Combination codes for conditions and

common symptoms or manifestations

Combination codes for poisonings and

external causes

Added laterality

Expanded codes (injury, diabetes,

alcohol/substance abuse, postoperative complications)

Injuries grouped by anatomical site

rather than injury category

Combination Codes – Examples

• I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

• E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

• K71.51 Toxic liver disease with chronic active hepatitis with ascites

• K50.012 Crohn’s disease of small intestine with intestinal obstruction

• N41.01 Acute prostatitis with hematuria

Diagnosis Code Comparison

ICD-9-CM ICD-10-CMConsists of 3 to 5 digits Consists of 3 to 7 characters

1st digit is numeric or alpha, using E or V 1st character is alpha, using all letters except U

2nd digit is numeric 2nd Character is numeric

3rd, 4th, and 5th digits are numeric 3rd to 7th Characters can be alpha or numeric

Always at least 3 digits Always at least 3 characters

Decimal place after the first 3 digits Decimal place after the first 3 characters

Alpha characters are not case sensitive Alpha characters are not case sensitive

What is ICD-10-PCS?

• ICD-10 (international version) does not contain a procedure coding system

• CMS awarded a contract to 3M Health Information Systems to develop a new procedure coding system

• The new system is intended for reporting INPATIENT procedures only

• CPT and HCPCS will still be used where currently in place

• ICD-10-PCS is available in the public domain and available from the CMS website

ICD-10-PCS Code Structure

2 3 4 5 6 71

Section

Body System

Root Operation

Body Part

Approach

Device

Qualifier

Esophageal Biopsy in ICD-9

• Characters have no meaning• It’s just a number!• And, we’ve been out of these numbers for

years….

2 2 44 .

Endoscopic Esophageal Biopsy in PCS

D B 5 8 Z X0

Medical-Surgical

Gastro-intestinal

Excision

Esophagus

Via Natural Opening

Endoscopic

No Device

Diagnostic

ICD-10-PCS System Attributes

• Completeness– All substantially different procedures have a

unique code• Expandability

– The structure of the system allow incorporation of new procedures as unique codes

ICD-10-PCS System Attributes

• Standardized terminology– Includes definitions of the terminology used

(Definitions may vary from common usage)• Multiaxial structure

– Each character has the same meaning within a section and across sections to the extent possible

ICD-10-PCS Code Structure

• Codes comprised of seven components, called characters

• Individual units for each character have a letter or number assigned as a “value”

• 34 possible values:– Digits 0-9– Letters A-H, J-N, and P-Z– No I or O

Building an ICD-10-PCS Code

• Index provides first 3 characters of code, associated with a code table

• Table is referenced to build the last 4 characters of the code

• Table arranged in rows to allow only valid character combinations

Step 1 - Alphabetic Index

• Uses root operations as main entries• Contains references for

– Devices– Body Parts

• Guides you to the correct table• Open appendectomy (Resection):

Step 2 - PCS Tables

• Final coding decision = 0DTJ0ZZ0 Section = Medical and SurgicalD Body System = Gastrointestinal SystemT Resection = Cutting out or off, without replacement, all of a body partBody Part Approach Device Qualifier

1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 4 Esophagogastric Junction5 Esophagus 6 Stomach 7 Stomach, Pylorus 8 Small Intestine 9 Duodenum A Jejunum B Ileum C Ileocecal Valve E Large Intestine F Large Intestine, Right G Large Intestine, Left H Cecum J Appendix K Ascending Colon L Transverse ColonM Descending ColonN Sigmoid ColonP Rectum Q Anus

0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic

Z No Device Z No Qualifier

Building a PCS Code

Procedure Code Comparison

ICD-9 Procedures • 3-4 digits• All digits are numerical

• Numerical by body system

• Decimal after 2 digits

ICD-10-PCS• 7 characters • Characters are both

numerical and alpha• Each character has a

specific value. A character (0) in a different position has a different value/meaning

• No decimals

What If We Didn’t Plan Well?

• Get a line of credit ASAP if insufficient reserves on hand

• It’s not too late to work the implementation checklists or ask for help– Implementation talent may be available if their

previous assignments went well and are complete• Be prepared to react to what happens between

October 21 and 30 when the EOBs arrive. – READ THEM!!

What We’ve Learned So Far

• Physician Practices and other Outpatient Billing:– Up-to-date systems that can transmit ICD-10

codes are working well– Codes with the correct number of characters pass

through the systems on test without issue• Scrubber software or similar pre-bill edit software is

vital to catch missing characters

– Medical necessity edits are still an unknown commodity

What We’ve Learned So Far

• Hospital Inpatient Billing:– Medicare states there should be no more than

1 percent in DRG change with ICD-10 if the documentation works with the code set.

– Dual coding studies in 2015 have shown this to be reasonably true

– If the DRG changes, CHECK the coding for accuracy

• Inaccurate coding is the chief cause of DRG change

What We’ve Learned So Far

• Hospital Inpatient Billing:– Hospitals with greater than 3 percent change

should consider:• Real time analysis of each DRG “abnormality” as the

case is coded• Documentation review for diagnoses• Additional intense ICD-10-PCS training for coders to

increase decision making skills– Determining the differences between 31 root operations

is difficult without the right tools and significant practice

FreeDigitalPhotos.net

Thank you!

Contact Information:

Lynn Kuehn, MS, RHIA, CCS-P, FAHIMAKuehn Consulting, LLC

1155 S. Springdale Road Waukesha, WI 53186O: 262-574-1064 C: 414-807-4589

lkuehn1@wi.rr.com www.KuehnConsulting.com

62