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ICDICDICDICD----10 Preparation for Non10 Preparation for Non10 Preparation for Non10 Preparation for Non----Coders in the Revenue Coders in the Revenue Coders in the Revenue Coders in the Revenue CycleCycleCycleCycle

September 24, 2015

Arkansas HFMA Revenue Cycle Seminar

Susan Wallace, MEd, RHIA, CCS, CCDS, CDIP, FAHIMA

Program ObjectivesProgram ObjectivesProgram ObjectivesProgram Objectives

�Explain the impact of the ICD-10 code set to hospital operations.

�List examples of new features and requirements to assure reporting accuracy.

�Demonstrate an increased understanding of the impact of ICD-10 changes on their role within the healthcare facility.

2

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HowHowHowHow is coded is coded is coded is coded ddddata ata ata ata uuuused?sed?sed?sed?

�Public Report Cards

�Research

�Epidemiology

�Outcomes

� Statistical Analysis

� Financial and Strategic Planning

�Evaluation of Quality of Care

�Communication to Support Patient’s Treatment

� Insurance Coverage Determination

�Reimbursement

3

Payment for Inpatient StaysPayment for Inpatient StaysPayment for Inpatient StaysPayment for Inpatient Stays

Physician Documentation: Pneumonia

Diagnoses & Procedures Coded

Codes on Claim Submitted

MS-DRG 179 Pneumonia

without CC / MCC

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Coding and Documentation Is The Key To:Coding and Documentation Is The Key To:Coding and Documentation Is The Key To:Coding and Documentation Is The Key To:

Coded Data

Payment

Public Reports

Quality Reports

VBP

HAC

NCHS / WHO

Hospital Wide ReadmissionHospital Wide ReadmissionHospital Wide ReadmissionHospital Wide ReadmissionHospital CompareHospital CompareHospital CompareHospital Compare 7/1/11 7/1/11 7/1/11 7/1/11 –––– 6/30/146/30/146/30/146/30/14

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RiskRiskRiskRisk----Standardized Mortality RatesStandardized Mortality RatesStandardized Mortality RatesStandardized Mortality Rates

7

Medicare Hospital Quality Chartbook (Sept ‘14)

Hospital ValueHospital ValueHospital ValueHospital Value----Based PurchasingBased PurchasingBased PurchasingBased PurchasingDomain WeightsDomain WeightsDomain WeightsDomain Weights

25% 25% 25%

25% 25% 25%

40%

10%

30% 25%

20%25%

0%

20%

40%

60%

80%

100%

FY16 FY17 FY18

Experience Efficiency Outcomes Process Clinical Care Safety

8

Coded Claims Data / Risk Adjustment

Affects All Domains Except Experience

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Hospital ValueHospital ValueHospital ValueHospital Value----Based PurchasingBased PurchasingBased PurchasingBased PurchasingBaseline vs Performance PeriodsBaseline vs Performance PeriodsBaseline vs Performance PeriodsBaseline vs Performance Periods

9

Program Year 2017 2018 2019Baseline Period

Performance Period

2011 2012 2013 2014 2015 2016

FY17

FY18

FY19

FY20

FY21

2010

WhatWhatWhatWhat is changing?is changing?is changing?is changing?

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WhenWhenWhenWhen is is is is iiiit t t t cccchanging?hanging?hanging?hanging?

� Inpatient Discharges as of 10/1/15

�Outpatient dates of service 10/1/15

�See billing instructions for claims spanning implementation date

WhyWhyWhyWhy is it changing?is it changing?is it changing?is it changing?

� ICD-9 Insufficient detail

� Insufficient room for expansion

� Provide greater clinical detail and specificity in describing diagnoses and procedures

� Lack of current terminology / technology (1979)

� Updated to be consistent with current clinical practice

�Worldwide morbidity reporting

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Who Remembers 1979?Who Remembers 1979?Who Remembers 1979?Who Remembers 1979?

1979 Trivia1979 Trivia1979 Trivia1979 Trivia

�Age 65+ Avg LOS 10.8 days

�OB Avg LOS “only 3.7 days”

�% Pts w/ >1 diagnosis 48%

�Top volume IP Procedures (exclude delivery)� Biopsy� Digestive system endoscopy� D&C

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Prevalence of ICDPrevalence of ICDPrevalence of ICDPrevalence of ICD----10101010106 countries use for morbidity; 106 countries use for morbidity; 106 countries use for morbidity; 106 countries use for morbidity; 11 11 11 11 use for reimbursement / case mixuse for reimbursement / case mixuse for reimbursement / case mixuse for reimbursement / case mix

� Created by WHO (World Health Organization) in 1994

Canada

• Began

adopting in

2001

• Over a 5-year

implementatio

n

• Only use

diagnosis

codes

• Use for

statistical

purposes, not

billing

Brazil

• Adopted in 1998

South Africa

• Adopted in 1996

United Kingdom

• Adopted in 1995

Germany

• Adopted in

1998

• Use ICD-10-

AM for

morbidity

• Implementatio

n took 3 years

Australia

• Adopted in

1998

• Implementation

took 2 years

Countries who have adopted ICD-10

China

• Adopted in 2002

Russia

• Adopted in 1999

Netherlands

• Adopted in

2013

ICDICDICDICD----10 Benefits10 Benefits10 Benefits10 BenefitsCMS MLN Matters SE 1239CMS MLN Matters SE 1239CMS MLN Matters SE 1239CMS MLN Matters SE 1239

�Measure quality, safety, and efficacy of care

�Reduce need for attachments to explain patient’s condition

�Design payment systems and process claims for reimbursement

�Conduct research, epidemiological studies, and clinical trials

�Set health policy

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HowHowHowHow is it changing?is it changing?is it changing?is it changing?

Diagnoses

14,567 ICD-9-CM

69,823

ICD-10-CM

Procedures

3,882

ICD-9-CM

71,974

ICD-10-PCS

Biggest Changes Biggest Changes Biggest Changes Biggest Changes –––– ICDICDICDICD----10101010----CMCMCMCM

Category

Injury / Poisoning

External causes of morbidity / mortality

Musculoskeletal System / Connective Tissue

Pregnancy, Childbirth, Puerperium

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Reasons for Reasons for Reasons for Reasons for CCCChangehangehangehange

�Added codes for laterality (1/3 of changes)

� Right, left, bilateral

�Added codes for episode of care for select conditions (25%)

� Initial vs subsequent episode or sequela (late effect)

�Distinguish between acute and chronic conditions

Payer OptionsPayer OptionsPayer OptionsPayer Options

Accept ICD-10 Codes

Map back to ICD-9

“equivalent”

Apply based on ICD-9

methodology

Accept ICD-10 Codes

based on increased ICD-10 specificity

CMS ICD-10 MS-DRG /NCD/

LCD policies

Require ICD-9 Codes

per current methodology

Non-HIPAA entities

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ICDICDICDICD----10 Impact to Future Inpatient Reimbursement10 Impact to Future Inpatient Reimbursement10 Impact to Future Inpatient Reimbursement10 Impact to Future Inpatient Reimbursement

�“After CMS has gathered sufficient coded ICD-10-CM/PCS data to make adjustments based on the increased specificity of the ICD-10-CM/PCS codes, CMS would propose updates to the ICD-10-CM/PCS version of the MS-DRGs.”

CMS

Unspecified Codes May Result In…Unspecified Codes May Result In…Unspecified Codes May Result In…Unspecified Codes May Result In…

�Payers questioning “unspecified” diagnosis codes

�Delays in prior approval:

� Laboratory and imaging tests

� Referrals

� Elective surgeries

�More claim rejections and appeals

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CMS / AMA AgreementCMS / AMA AgreementCMS / AMA AgreementCMS / AMA AgreementPosted July 5Posted July 5Posted July 5Posted July 5----6, 20156, 20156, 20156, 2015

23

�“While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not denyphysician or other practitioner claims billed under the Part B physician fee schedule….”

�“However, a valid ICD-10 code will be required on all claims starting on October 1, 2015.”

CMS / AMA Agreement Q&ACMS / AMA Agreement Q&ACMS / AMA Agreement Q&ACMS / AMA Agreement Q&APublished July 27, 2015Published July 27, 2015Published July 27, 2015Published July 27, 2015

� “…Guidance only applies to Medicare fee-for-service claims from physician

or other practitioner claims billed under the Medicare Fee-for-Service Part

B physician fee schedule.”

� “…the recent Guidance does not change the coding specificity required by

the NCDs and LCDs.”

� “…submitters will know that it was rejected because it was not a valid code

versus a denial for lack of specificity required for a NCD or LCD or other

claim edit.”

� “…the audit and quality program flexibilities only pertain to post payment

reviews.”24

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ICD-10-CM Diagnosis Code Structure

1 2 3 4 5 6 7

�Le

tte

r

�N

um

be

r

�N

um

be

r

�Le

tte

r

�N

um

be

r

�Le

tte

r

�N

um

be

r

�Le

tte

r

�N

um

be

r

�Le

tte

r

�N

um

be

r

�Le

tte

r

Category Subcategory Exte

nsio

nExpanded Field Lengths for Codes and DescriptionsExpanded Field Lengths for Codes and DescriptionsExpanded Field Lengths for Codes and DescriptionsExpanded Field Lengths for Codes and DescriptionsAlphanumericAlphanumericAlphanumericAlphanumeric

ICD-10-CM Diagnoses (69,823)

�3 to 7 Characters

�Decimal after 3rd Character

� I50.9

�HIPAA required for all health claim diagnoses

ICD-10-PCS Procedures (71,974)

�7 Characters, No Decimal

� Letters I and O not used

�HIPAA required for inpatient procedures

� Will hospital use for internal reporting of outpatient procedures?

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New Features: New Features: New Features: New Features: More More More More Info in CodeInfo in CodeInfo in CodeInfo in Code

�K57.21 – Diverticulitis of large intestine with perforation and abscess with bleeding

�E11.341 – Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema

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

Coding ExampleCoding ExampleCoding ExampleCoding Example---- ICDICDICDICD----10101010----CM:CM:CM:CM:Increased Length of Code DescriptionsIncreased Length of Code DescriptionsIncreased Length of Code DescriptionsIncreased Length of Code Descriptions

�S72.461A Displaced supracondylar fracture with intracondylar extension of lower end of right femur, initial encounter, closed fracture

�S72.391H Other fracture of shaft of right femur, subsequent encounter for open fracture type I or II with delayed healing

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ICDICDICDICD----10101010----PCS Procedure Codes PCS Procedure Codes PCS Procedure Codes PCS Procedure Codes Only for Hospital IP ClaimsOnly for Hospital IP ClaimsOnly for Hospital IP ClaimsOnly for Hospital IP Claims

0

•S

ect

ion

L•

Bo

dy S

yste

mB

•R

oo

t O

pe

rati

on

5

•B

od

y P

art

0

•A

pp

roa

ch

Z

•D

evic

e

Z

•Q

ua

lifi

er

ICDICDICDICD----10101010----PCS IllustrationsPCS IllustrationsPCS IllustrationsPCS Illustrations

�0FB03ZX - Excision of liver, percutaneous approach, diagnostic

�0DQ10ZZ - Repair, upper esophagus, open approach

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GEMs UsesGEMs UsesGEMs UsesGEMs Uses

�Translation of data for:

� Tracking quality

� Recording morbidity / mortality

� Calculating reimbursement

� Converting ICD-9 based application to ICD-10

�NOT substitute for assigning ICD-10 codes

Free CMS ResourcesFree CMS ResourcesFree CMS ResourcesFree CMS Resourceswww.CMS.gov/ICD10www.CMS.gov/ICD10www.CMS.gov/ICD10www.CMS.gov/ICD10

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Good ResourceGood ResourceGood ResourceGood Resourcewww.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10

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ICDICDICDICD----10 Reimbursement Mappings10 Reimbursement Mappings10 Reimbursement Mappings10 Reimbursement Mappingswww.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10

� Identify best matching ICD-9-CM code that can be used for reimbursement purposes for

each ICD-10 code.

� All ICD-10-CM/PCS codes are in the “ICD-10 Reimbursement Mappings”; however, all

ICD-9-CM codes are not included.

� Consists of two crosswalks:

� ICD-10-CM to ICD-9-CM for diagnosis codes; and

� ICD-10-PCS to ICD-9-CM for procedure codes.

� CMS is not using the “ICD-10 Reimbursement Mappings” for any purpose. We are

converting our systems and applications to acceptICD-10-CM/PCS codes directly.

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Planning for the TransitionPlanning for the TransitionPlanning for the TransitionPlanning for the Transition

�Will report request forms require revision?

�What happens when requestor is unfamiliar with ICD-10 codesets?

�How will requests that span 10/1/15 (such as 2015 calendar year requests) be handled?� Jan-Sept per ICD-9 and Oct-Dec per ICD-10?

� Use GEMS to translate?

35

DRGDRGDRGDRG----Based ReportsBased ReportsBased ReportsBased Reports

� ICD-10 codes occasionally map to different DRG than ICD-9 counterpart!

�Should any DRG-based report include a parenthetical notation that notes the ICD-10 implementation date?

� i.e. calendar year DRG report requests

�Will Case-Mix Index (CMI) reports flag the transition date?

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WhatWhatWhatWhat is reportable?is reportable?is reportable?is reportable?Whose documentation is used for coding?Whose documentation is used for coding?Whose documentation is used for coding?Whose documentation is used for coding?

�Any physician involved in the care and treatment of the patient, including documentation by consultants, anesthesiologists, as long as there is nothing conflicting from the attending physician.

� NOT diagnostic test results, i.e. pathology or radiology reports, echocardiogram, rhythm strips, etc.

�Nurse practitioners and physician assistants if they are considered legally accountable for establishing a diagnosis.

37

ICDICDICDICD----10101010----CM CM CM CM Outpatient Coding GuidelineOutpatient Coding GuidelineOutpatient Coding GuidelineOutpatient Coding Guideline

� J. Code all documented conditions that coexist at time of visit and require or affect patient care treatment or management.

�Do not report conditions previously treated that no longer exist.

�“History” codes may be used if the historical condition or family history has an impact on current care or influences treatment.

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Medical NecessityMedical NecessityMedical NecessityMedical Necessity

�National Coverage Determinations (NCD)

�Local Coverage Determinations (LCD)

�List of CPT codes and corresponding diagnosis codes that establishes “medical necessity” for the procedure

�NCDs and LCDs for ICD-10 have been published to the appropriate websites

Local Coverage DeterminationsLocal Coverage DeterminationsLocal Coverage DeterminationsLocal Coverage DeterminationsMLN Matters MM8348 MLN Matters MM8348 MLN Matters MM8348 MLN Matters MM8348

�All ICD-10 LCDs and associated ICD-10 articles will be published on the Medicare Coverage Database (MCD) no later than April 10, 2014.

�All LCDs and Articles will receive a new LCD/Article ID number.

� i.e., LCD ID 1234 might become LCD ID 4567

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New for ICDNew for ICDNew for ICDNew for ICD----10101010----CMCMCMCM

�Combination codes for atherosclerotic heart disease with angina pectoris.

� NOT necessary to use additional code for angina

CAD

Angina

CAD w/ Angina

Angina OptionsAngina OptionsAngina OptionsAngina Options

�I20.1, Angina pectoris with documented spasm

�I20.8, Other forms of angina pectoris

�I20.9, Unspecified angina pectoris

�I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris

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Cardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab Programs

�Medicare Coverage with these Conditions:

�Acute MI within past 12 months; or

�Coronary artery bypass surgery; or

�Current stable angina pectoris; or

�Heart valve repair or replacement; or

�PTCA or coronary stenting; or

�Heart or heart-lung transplant; or

�Stable, chronic heart failure

http://acsteam.net

NCD

ALERT

Cardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab Programs

413.0 Angina decubitus I20.8

Other forms of angina

pectoris

413.1 Prinzmetal angina I20.1

Angina pectoris with

documented spasm

413.9

Other and unspecified

angina pectoris I20.8

Other forms of angina

pectoris

413.9

Other and unspecified

angina pectoris I20.9

Angina pectoris,

unspecified

http://acsteam.net

NCD

ALERT

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Cardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab Programs

�What about Combination Codes for Coronary Artery Disease with Stable Angina??

�I25.1XX

�I25.7XX

http://acsteam.net

NCD

ALERT

Errors? Edits? ASK A CODERErrors? Edits? ASK A CODERErrors? Edits? ASK A CODERErrors? Edits? ASK A CODER

�115 pages of ICD-10-CM diagnosis coding guidelines

�15 pages of ICD-10-PCS procedure coding guidelines

�123,336 new codes!

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CMS Claims Processing Instructions IssuedCMS Claims Processing Instructions IssuedCMS Claims Processing Instructions IssuedCMS Claims Processing Instructions Issued

�Billing and Payment FAQs

�MLN Matters SE1325 Institutional Services Split Claims Billing Instructions for Medicare FFS Claims that Span the ICD-10 Implementation Date

�MLN Matters SE1408 Medicare FFS Claims Processing Guidance for Implementing ICD-10

�MLN Matters SE1410 Special Instructions for ICD-10 Coding on Home Health Episodes that Span October 1, 2015

47

CMS Billing FAQCMS Billing FAQCMS Billing FAQCMS Billing FAQOP Date of Service / IP DischargeOP Date of Service / IP DischargeOP Date of Service / IP DischargeOP Date of Service / IP Discharge

9/30/15• ICD-9-CM Dx ONLY

• ICD-9 / CPT Procedures

10/1/15

• ICD-10-CM Dx ONLY

• ICD-10-PCS / CPT Procedures

Otherwise Returned / Rejected

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OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15

�Services prior to 10/1/15: bill separately with ICD-9

�Keep all charges within same LIDOS � Line item date of service

�Do NOT split single item services whose timeframes cross midnight 9/30/15. Use “from” date� ED = date patient enters ED

� OBS = date observation care begins

OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15Emergency DepartmentEmergency DepartmentEmergency DepartmentEmergency Department

�Arrives ED 9/30/15 @ 1900, discharged 10/1/15 @ 0100

� LIDOS = 9/30/15 ICD-9 codes 1st claim

� 10/1/15 charges ICD-10 codes, 2nd claim

�No services actually provided 10/1/15?

� Only 1 claim ICD-9 codes

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OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP ObservationOP ObservationOP ObservationOP Observation

�Admit to OBS 9/29/15 @ 1400, discharged 10/1/15 @ 0800

� LIDOS = 9/28-29/15 ICD-9 codes, 1st claim

� 10/1/15 charges ICD-10 codes, 2nd claim

Encounter Spans 10/1/15Encounter Spans 10/1/15Encounter Spans 10/1/15Encounter Spans 10/1/15Admit within 3 Day Payment WindowAdmit within 3 Day Payment WindowAdmit within 3 Day Payment WindowAdmit within 3 Day Payment Window

�OP Surgery 9/29/15 @ 1400, admitted as IP 9/30/15 @ 1000, with discharge 10/2/15 @ 0800

� Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient bill if rendered within three days of admission, the claim must be billed with ICD-10 for those bundled outpatient services

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IP Encounter Spans 10/1/15IP Encounter Spans 10/1/15IP Encounter Spans 10/1/15IP Encounter Spans 10/1/15

�Admitted as IP 9/28/15

�Discharged Home 10/2/15

�All billed based on 10/2/15 discharge

� ICD-10 codes

PostPostPostPost----Implementation ActivityImplementation ActivityImplementation ActivityImplementation Activity

�Tracking initial ICD-10 charts coded

� Determine volume per each service type

Coding

Claim

Remit

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