ICD-10 Provider Education

Developmental Disabilities Provider Association

Cathy Munn, MPH RHIA CPHQ

Sr. Consultant

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• Overview of ICD-10 Transition– Industry Update

• Impact of the Change– Providers– Payers

•  Provider Preparation– Translation Examples

• Arkansas DHS Preparation & Planning• Next Steps & Resources

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Agenda

• The change to ICD-10 only applies to Medicaid….• The implementation date for ICD-10 is 10/1/2014…• CPT codes will be replaced with ICD-10 codes…• The ICD-10 code composition will now be

alphanumeric….• ICD-10 is just like any other annual coding update…

Before We Begin…..

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• ICD-9-CM: International Classification of Diseases, 9th revision, Clinical Modification – US transitioned from ICD-8 to ICD-9 in 1979– Annual updates

• ICD-10: Developed by the World Health Organization as the nomenclature for all countries– ICD-10-CM: International Classification of Diseases, 10th

revision, Clinical Modification – US only– ICD-10-PCS: International Classification of Diseases, 10th

revision, Procedure Classification System – US only

ICD-10-CM/PCS

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• Final Rule Originally Published by HHS on January 16, 2009 requiring the adoption of ICD-10 on October 1, 2013

NO GRACE PERIOD– Dates of Service (outpatient) After 10/1/2013– Dates of Discharge (Inpatient) After 10/1/2013

• Federal Mandate Updated Timeline:

– February 14, 2012 – CMS announces they will “reexamine the pace” of implementing ICD-10

– May 17, 2012 – All comments due to HHS for consideration prior to publication of the final rule

– August 27, 2012 – Revised compliance date announced by CMS stating a one-year extension would be granted

– October 1, 2014 is the revised ICD-10 Implementation Compliance Date

Federal Mandate

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• ICD-10-CM (diagnoses) will be used by all providers in every health care setting

• ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures

• No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes

• CPT and HCPCS will continue to be used for physician and ambulatory services including physician inpatient hospital visits

• Release of DSM-V codes occurred in May 2013; however DSM-V is not HIPAA compliant for claims or transactions

Things to Remember

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• Systems will have to utilize both ICD-9-CM and ICD-10-CM for overlap e.g. claims backlog, Arkansas Medicaid allows providers 365 days to submit a claim.

• Inpatient discharges occurring on or after 10-1-2014 will use ICD-10-CM and ICD-10-PCS codes regardless of date of admission.

• Outpatient dates of service occurring on or after 10-1-2014 will use ICD-10-CM codes

• There will be period of time when payers will be processing claims in both ICD-9 and ICD-10

Important Information

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ICD-9 Current State

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ICD-9 lacks the specificity & granularity needed to accurately reflect care provided

Technology & practice patterns have changed dramatically in 30 years

ICD-9 has run out of codes to accurately capture current medical practice

ICD-10 Future State

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Updates terminology & disease classification consistent w/current practice

Expands flexibility for future updates based on technical advances

Enhances research & outcomes data capture & quality measure reporting

• Better data will be available for: – Measuring the quality, safety, and efficacy of care – Designing payment systems and processing claims for

reimbursement – Conducting research, epidemiological studies, and clinical trials – Setting health policy – Operational and strategic planning and designing healthcare

delivery systems – Monitoring resource utilization – Improving clinical, financial, and administrative performance – Preventing and detecting healthcare fraud and abuse – Tracking public health and risks

A Few ICD-10 Benefits

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Other Competing Priorities

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ICD-10: Key to the success

of each initiative

ACOs/ Patient

Centered Medical Home

EHR/ Meaningful

Use

Value Based Purchasing

Public Reporting &

Quality Measures

Alpha Character Narrative Description

A and B Certain infectious and parasitic diseases.

C00 to D48 Neoplasms.

D50 to D89 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism.

E Endocrine, nutritional and metabolic diseases.

F Mental and behavioral disorders.

G Diseases of the nervous system.

H00 to H59 Diseases of the eye and adnexa.

H60 to H95 Diseases of the ear and mastoid process.

ICD-10 Chapter Headings

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ICD-9 vs. ICD-10 Diagnosis Codes

ICD-9 Diagnosis Codes – 13,000 ICD-10 Diagnosis Codes – 68,000

3-5 Characters 3-7 Characters

First character is numeric or alpha (E or V)

First character is alpha

Use of decimal after 3rd character Use of decimal after 3rd character

Characters 2-7 are alpha or numeric – letter U is not used

Use of dummy placeholder “X” for future code expansion

E codes reference External Causes of Injury & Poisoning in ICD-9.E references the Endocrine system in ICD-10

V codes reference Health Status & Contact with Health Services in ICD-9V – Y codes reference External Causes of Morbidity in ICD-10

X X X X

Category:Superficial injury of

knee & lower leg

.Etiology, anatomic

site, severity: Other superficial injuries of knee

1 – Right; 2 – Left; 9 – Unspecified

Added 7th character for obstetrics, injuries, and external causes of injury

Abrasion of the right knee, initial encounter

Structure and Seventh Character

X X X

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AMS 8 0 2. 1 1 A

Additional Characters

Alpha (Except U)

2 Numeric3-7 Numeric or Alpha

3–7 Characters

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ICD-9 Procedure vs. ICD-10-PCS

ICD-9 Procedure Codes – 4,000 ICD-10 Procedure Codes – 87,000

3-4 Digits 7 Digits

All digits are numeric Alpha or numeric composition• Numbers 0 - 9 • Letters O & I are omitted

Example: Artery suture has 1 code Example: Artery suture – 195 coding options

The increase in the number of procedure codes is driven by the increased specificity, granularity & laterality contained within the ICD-10 codes.

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ICD-10 Procedure Code Structure

FY2013 ICD-9-CM procedure Source Code Title

Source Status

FY2013 ICD-10-PCS procedure

Target Code Title

94.27 Other electroshock therapy GZB0ZZZ

Electroconvulsive Therapy, Unilateral-Single Seizure

94.27 Other electroshock therapy GZB1ZZZ

Electroconvulsive Therapy, Unilateral-Multiple Seizure

94.27 Other electroshock therapy GZB2ZZZ

Electroconvulsive Therapy, Bilateral-Single Seizure

94.27 Other electroshock therapy GZB3ZZZ

Electroconvulsive Therapy, Bilateral-Multiple Seizure

94.27 Other electroshock therapy GZB4ZZZ

Other Electroconvulsive Therapy

ECT Code Translation

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Patient Flow Impact

Start Patient Encounter

Diagnose Patient

Code Claim

Submit Claim

Receive Claim

Begin Adjudication

Check Eligibility

Determine Benefits

Select provider &

contract

Check Auth

Price Claim

Payment & Remit

Back end processes

Providers change coding practices based on ICD-10

Update practice management system

Update claims submission process

Update system to accept claims

Update benefit logic& edits

Revise authorization process

Claim priced based on revised fee schedules

Update data repositories to accommodate new coding

Revise for ICD-10 reporting

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Impact on Providers

• Systems• Operations and Processes• Clinical Documentation

• Identify your current systems and work processes that use ICD-9 codes. This could include:– Clinical Documentation– Encounter Forms and Superbills– Practice Management Systems– Electronic Medical Record Systems– Contracts and Fees Schedules– Public Health and Quality Reporting Protocols & Reports

• A good rule of thumb: Wherever ICD-9 codes appear today, ICD-10 codes will need to replace them in the future

System Impacts

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• Talk with your practice management system vendor about accommodations for both ICD-9 and ICD-10 codes– Will your current system require upgrades?– Is the vendor planning system updates for accommodation of

ICD-10 codes?– When will they be ready to install/update?– Are the upgrades included in your current contract?

• Discuss readiness and remediation plans with any clearinghouses or billing services you may use

System Impacts

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• Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition

• Be proactive; don’t wait for vendors to contact you• Ask about their plans for ICD-10 compliance and when

they will be ready to collaboratively test their systems• Ask to see their Remediation Roadmap that supports

their claims of “readiness”• Utilize CMS checklists and resources as a guide

System & Operational Impacts

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• Talk with your payers about how ICD-10 implementation might impact your contracts. Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, fee schedules or reimbursement methodologies

• Understand your metrics:– Coding Productivity– Coding Accuracy – Financial Stability

• Days in A/R• Cash on hand

Operational Impacts

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• Identify potential changes to work flow and business processes

• Consider changes to existing processes including:– Clinical documentation – viewed as an increasing area of

vulnerability & concern in the industry– Prior authorization– Encounter forms and Superbills – Quality and Public Health reporting– Involvement in any Care Management or community

outreach initiatives

Operational Impacts

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• Identify the staff in your office who code, or have a need to know the new codes….anticipate that everyone in your office will require some level of awareness training

• Don’t forget the physicians in the awareness training• There are a wide variety of training opportunities and

materials available through a variety of resources: – Professional Coding Associations – AAPC, AHIMA– Online Courses – ICD10 Monitor, Contexo University, Precyse,

Nuance – Webinars – ICD10 Monitor, HCPro– Onsite Training – Train-the-Trainer approach, Coding Boot Camp– Non-Traditional - Partner with the HIM Department at a nearby

hospital

Operational Impacts

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• Budget for time and costs related to ICD-10 implementation including:– Expenses for system changes and software updates– Resource materials– Training– Modifications to forms and Superbills

• Other budgetary considerations:– Unanticipated payment delays, appeals & denials– Understand your operational metrics – benchmark for efficiency– Establish a line of credit……

• Anticipate something you didn’t plan for or expect….

Operational Impacts

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• Increased size• Increased specificity• Examples can be found at www.ahima.org/icd10

along with other valuable ICD-10-CM resources

Superbills - How Will They Change?

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FY2013 ICD-9-CM Diagnosis Source Code Title

FY2013 ICD-10-CM Diagnosis Target Code Title

299.00Autistic disorder, current or active state F84.0 Autistic disorder

299.01 Autistic disorder, residual state F84.0 Autistic disorder

299.10Childhood disintegrative disorder, current or active state F84.3

Other childhood disintegrative disorder

299.11Childhood disintegrative disorder, residual state F84.3

Other childhood disintegrative disorder

Pervasive Developmental Disorders

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FY2013 ICD-9-CM Diagnosis Source Code Title

FY2013 ICD-10-CM Diagnosis Target Code Title

299.80

Other specified pervasive developmental disorders, current or active state F84.5 Asperger's syndrome

299.80

Other specified pervasive developmental disorders, current or active state F84.8

Other pervasive developmental disorders

299.81

Other specified pervasive developmental disorders, residual state F84.5 Asperger's syndrome

299.81

Other specified pervasive developmental disorders, residual state F84.8

Other pervasive developmental disorders

299.90

Unspecified pervasive developmental disorder, current or active state F84.9

Pervasive developmental disorder, unspecified

299.91

Unspecified pervasive developmental disorder, residual state F84.9

Pervasive developmental disorder, unspecified

Pervasive Developmental Disorders Cont.

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FY2013 ICD-9-CM Diagnosis Source Code Title

FY2013 ICD-10-CM Diagnosis Target Code Title

315.9Unspecified delay in development F81.9

Developmental disorder of scholastic skills, unspecified

315.9Unspecified delay in development F89

Unspecified disorder of psychological development

317Mild intellectual disabilities F70

Mild intellectual disabilities

318.0Moderate intellectual disabilities F71

Moderate intellectual disabilities

318.1Severe intellectual disabilities F72

Severe intellectual disabilities

318.2Profound intellectual disabilities F73

Profound intellectual disabilities

319Unspecified intellectual disabilities F78

Other intellectual disabilities

319Unspecified intellectual disabilities F79

Unspecified intellectual disabilities

Intellectual Disabilities

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ICD-10 Code Definition IQ Level

F70 Mild Intellectual Disabilities IQ level 50 – 55 to approximately 70Mild mental subnormality

F71 Moderate Intellectual Disabilities IQ level 35 – 40 to 50 – 55Moderate mental subnormality

F72 Severe Intellectual Disabilities IQ level 20 – 25 to 35 – 40Severe mental subnormality

F73 Profound Intellectual Disabilities IQ level 20 – 25Profound mental subnormality

NOTE – Borderline intellectual functioning with IQ level above 70 – 84 is coded R41.83

Intellectual Disabilities

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FY2013 ICD-9-CM Diagnosis Source Code Title

FY2013 ICD-10-CM Diagnosis Target Code Title

783.40

Lack of normal physiological development, unspecified R62.50

Unspecified lack of expected normal physiological development in childhood

783.40

Lack of normal physiological development, unspecified R62.59

Other lack of expected normal physiological development in childhood

Developmental Delays

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FY2013 ICD-9-CM Diagnosis Source Code Title

FY2013 ICD-10-CM Diagnosis Target Code Title

343.2 Congenital quadriplegia G80.0Spastic quadriplegic cerebral palsy

343.0 Congenital diplegia G80.1Spastic diplegic cerebral palsy

343.1 Congenital hemiplegia G80.2Spastic hemiplegic cerebral palsy

333.71 Athetoid cerebral palsy G80.3 Athetoid cerebral palsy

343.8Other specified infantile cerebral palsy G80.4 Ataxic cerebral palsy

343.3 Congenital monoplegia G80.8 Other cerebral palsy

343.8Other specified infantile cerebral palsy G80.8 Other cerebral palsy

343.9Infantile cerebral palsy, unspecified G80.9 Cerebral palsy, unspecified

Cerebral Palsy

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FY2013 ICD-9-CM Diagnosis Source Code Title

FY2013 ICD-10-CM Diagnosis Target Code Title

758.0 Down's syndrome Q90.0

Trisomy 21, nonmosaicism (meiotic nondisjunction)

758.0 Down's syndrome Q90.1Trisomy 21, mosaicism (mitotic nondisjunction)

758.0 Down's syndrome Q90.2 Trisomy 21, translocation

758.0 Down's syndrome Q90.9Down syndrome, unspecified

Down’s Syndrome

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• If it’s not documented….it’s not done– Outcome Data– Liability– Reimbursement

Clinical Documentation

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• Clinical documentation improvement “best practices” provide an opportunity for accurate coding and richer clinical data.

• Accurate data will allow us to better understand our patients; their compliance with care management initiatives and which treatments lead to better outcomes.

• Complete clinical documentation will promote accurate coding thus leading to more accurate payment that could legitimately look different than it does today.

Clinical Documentation Practices

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Clinical Scenario

Patient presents to the ER for severe right lower leg pain with an

open leg wound following a fall from a ladder. The physician

documented that the patient had an open transverse fracture of the

shafts of the tibia & fibula.

ICD-9-CM code:• 823.32, Open fracture of shaft, fibula with tibia• E881.0 Accidental fall from ladder

ICD-10-CM codes:• S82.221B Displaced transverse fracture of shaft of right tibia, initial encounter for

open fracture NOS• S82.421B Displaced transverse fracture of shaft of right fibula, initial encounter

for open fracture NOS• W11.XXXA Fall on and from ladder, initial encounter

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Changes to E & V Codes in ICD-10

• E codes reference External Causes of Injury & Poisoning in ICD-9– E code references the Endocrine system in ICD-10

• Thyroid gland disorders: E00 – E07• Diabetes codes: E08 – E13• Disorders of glucose regulation & pancreatic internal secretion: E15 –

E16

• V codes reference Health Status & Contact with Health Services in ICD-9– Z codes reference Health Status & Contact with Health Services

in ICD-10

• V – Y codes reference External Causes of Morbidity in ICD-10

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Other Resources & Reminders

Additional information & resources you might find helpful….

CMS Resources

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CMS Resources

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Arkansas DHS Current State

• Arkansas Medicaid has been working on ICD-10 for over two years• Progress to date:

– Operational assessment complete– Remediation of Medical Policy, Edits and Audits complete– Remediation of Pharmacy Policy & edits nearing completion

– Provider Manuals currently under review– Systems requirements obtained – HP/MMIS, Xerox/ACS & other integrated &

stand alone systems – Arkansas DHS reports, forms, and brochures currently under review– Ongoing Provider Outreach

• Meetings/Webcasts• Provider Bulletins• Newsletters• ICD-10 Website www.humanservices.Arkansas.gov/ICD10

• Internal & external testing scenarios are under development

• Per CMS; external testing should begin October, 2013

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Now What?

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Communication & Planning

• Engage the support of leadership• Define your strategy & approach to ensure success• Understand the financial implications of non-compliance• Ensure everyone understands the impact of ICD-10

– Receptionist– Nursing Staff– Physicians– Coders– Billing Staff – CFO/COO– Senior Practice Management Staff

• Share regular updates & communication briefings with staff

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Operational Assessment

• Understand which systems & processes will be impacted

• Understand the impact that the transition will have on people, process & technology; both internal & external to the practice

– Staff & providers• Education & awareness• Training – just in time

– Workflows • Office through-put • Clinical documentation• Code utilization within the practice – Superbill assessment• Coding & billing turn-around-time/cash flow• Denials & resubmission of claims

– Systems upgrades/enhancements• Practice management systems• Billing transmissions – EDI • Vendor readiness

• Provider practices and specialty departments should examine their patient population in terms of: – High volume/high cost– Patient demographic & payer mix: Medicare, Medicaid,

Commercial insurance– Diagnoses that lead to the highest denial, physician query

and re-bill rates; and– Areas related to quality reporting, improvement

initiatives and published RAC reviews

Documentation Assessment

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• Evaluate your current documentation– Does it specify right vs. left?– Does it provide the specificity needed to accurately assign an

ICD-10 code?

• Conduct a sample audit to evaluate clinical documentation– Review claims coded in ICD-9 and code them in ICD-10– Is the documentation sufficient?

• Share the audit results with the providers– Understanding of the future documentation needs will reduce

queries, pended claims & denials post 10/1/2013

Documentation Assessment

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Testing

• Largest testing effort in the history of healthcare

• Not a routine upgrade with minimal testing before implementation

• Recommended that you employ end to end testing with vendors, providers & payers to include:– Creation of the claim – Submission to payer/EDI vendor/clearinghouse via 837– Adjudication of claim– Reporting back to the provider via EOP/835– Adjustments/denials/resubmissions– Report creation– Denial tracking & analysis

Monitor the AR ICD-10 Website for information regarding testing

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Industry Web Site Resources

• www.CMS.gov/ICD10• www.CMS.gov/NPC• www.AHIMA.org• www.ICD10watch.com• www.AAPC.com• http://www.cms.gov/Medicare/Coding/ICD-10/Downloa

ds/ICD10SmallandMediumPractices508.pdf

• http://www.himss.org/ASP/topics_icd10playbook.asp• www.WEDI.org• www.humanservices.Arkansas.gov/ICD10

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CMS Resources

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For More ICD-10 Information

• White Papers (including but not limited to)– ICD-10 A Primer– ICD-10 Clinical Documentation– ICD-10 Physician Impact– ICD-10 Advantages– ICD-10 Specified or Unspecified

http://healthdataconsulting.com/

• Checklists published by CMS for providers (small, medium and large) at:– http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelin

es.html

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AR Medicaid ICD-10 Website

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Questions & Comments