18
© 2014 Corcoran Consulting Group (800) 399-6565 Preparing for ICD-10-CM Mary Pat Johnson, COMT, CPC, COE, CPMA Senior Consultant Corcoran Consulting Group Financial Disclosure Mary Pat Johnson is a Senior Consultant at Corcoran Consulting Group and acknowledges a financial interest in the subject matter of this presentation. ICD-10 is more specific than ICD-9 Attention to detail Consider primary diagnosis, cause and/or related conditions Key Points in Code Selection ICD-10-CM Changes Everything • Physicians • Administrators Coders / Billers • Technicians • Receptionists IT Staff Billing companies Who is Impacted? Payer policies • Pre-authorizations • PQRS Tracking of services • Marketing • Forms Practice management system How does ICD-10 Impact?

Preparing for ICD-10-CM - Corcoran Consulting Group · Preparing for ICD-10-CM Mary Pat Johnson, COMT, ... • ICD-10 copywritten by the World Health Organization ... • Eye codes

Embed Size (px)

Citation preview

© 2014 Corcoran Consulting Group (800) 399-6565

Preparing for ICD-10-CM

Mary Pat Johnson, COMT, CPC, COE, CPMA

Senior Consultant

Corcoran Consulting Group

Financial Disclosure

Mary Pat Johnson is a Senior Consultant at Corcoran Consulting Group and acknowledges a financial interest in the subject matter of this presentation.

• ICD-10 is more specific than ICD-9

• Attention to detail

• Consider primary diagnosis, cause and/or related conditions

Key Points in Code Selection ICD-10-CM Changes Everything

• Physicians

• Administrators

• Coders / Billers

• Technicians

• Receptionists

• IT Staff

• Billing companies

Who is Impacted?

• Payer policies

• Pre-authorizations

• PQRS

• Tracking of services

• Marketing

• Forms

• Practice management system

How does ICD-10 Impact?

© 2014 Corcoran Consulting Group (800) 399-6565

• International Classification of Diseases, 10th

Revision, Clinical Modification

• Developed by U.S. National Center for Health Statistics (NCHS) in 1993

• ICD-10 copywritten by the World Health Organization (WHO)

• ICD-10-CM replaces ICD-9-CM, volumes 1 and 2

• United States is one of last countries to adopt ICD-10

History of ICD-10-CM

• ICD-9 is >30 years old, outdated, obsolete terminology

• Outdated codes producing inaccurate and limited data

• Inconsistent with current medical practice

• Does not provide enough detail

Why Replace ICD-9 ! ?

• Much greater specificity and clinical information

• Use of most specific code(s) is not optional

• Provides better data to:

• Measure care

• Process claims

• Track public health

• Identify fraud and abuse

• Conduct research

ICD-10-CM

• Codes that allow comparison of mortality and morbidity data

• Increased number of concepts and codes provided

• Disease classifications include health related conditions

ICD-10-CM

• More accurate payment for new procedures

• Fewer rejected claims

• Fewer improper claims

• Better understanding of new procedures

• Improved disease management

Benefits of ICD-10

Source: Federal Register, Vol. 74, No. 11 1/16/09

• Final rule for adoption of ICD-10-CM

• Published in January 16, 2009 Federal Register (45 CFR part 162)

• Compliance date is October 1, 2013

• Initial delay to October 1, 2014

Deadline

© 2014 Corcoran Consulting Group (800) 399-6565

• March 31, 2014 - HR 4302 signed by President Obama

• SGR formula – temporary fix

• ICD-10 delayed … “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard code sets under section 1173(c) of the SSA and section 162.1001 of 45CFR”

ICD-10 Delayed Again…

ICD-9

• 17 Chapters

• 14,000 codes

• 3-5 digits

• First digit is numeric or alpha (E or V)

• Digits 2-5 are numeric

Compare and Contrast

ICD-10

• 21 Chapters

• ~ 69,000 codes

• 3-7 digits

• Digit 1 is alpha

• Digit 2 is numeric

• Digits 3-7 are alpha or numeric (alpha digits are not case sensitive)

ICD-9

Example:

• Central corneal ulcer –370.03

Compare and Contrast

ICD-10

Example:

• Central corneal ulcer right – H16.011

• Central corneal ulcer left – H16.012

• Central corneal ulcer bilateral – H16.013

• Central corneal ulcer unspecified – H16.019

• General Equivalence Mappings

• No “simple” crosswalk contained in this file

• GEM file is NOT a crosswalk, it is a mapping

• Expect annual update of files

• Eye codes translation is fairly straightforward

“GEM”

• Two sets of files

• ICD-9 to ICD-10

• ICD-10 to ICD-9

• Each file contains “code pairs” – one from each set

“GEM” Files

• No decimal point in the codes

• Three columns

• Third column describes additional attributes

• Flags (approximate, no map, combination)

• Combination entry

• 1 indicates “on” (Approximate)

• 0 indicates “off” (Direct hit, but verify)

“GEM” Files

© 2014 Corcoran Consulting Group (800) 399-6565

36610 H259 00000

36611 H2589 10000

36612 H25099 10000

36613 H25039 10000

36614 H25049 10000

36615 H25019 10000

36616 H2510 10000

36617 H2589 10000

36618 H2520 10000

36619 H25819 10000

36619 H2589 10000

GEM File LayoutSenile Cataract Example

I-9 I-10 + Flags

“1” in the first position in flag column = approximate

• Use GEMS

• Translating lists of codes

• Converting a system or application

• To study differences in meaning between two systems

• Use Code Books

• Translating short list of codes

• Access to medical record

“GEM” Files

• Introduction

• Conventions and Guidelines

• Alphabetic Index to Diseases

• Neoplasm Table

• Table of Drugs and Chemicals

• Index to External Causes

• Tabular List of Diseases

Organization of ICD-10-CM

1. Alphabetic Index

• Index of Diseases and Injury

• Index of External Causes of Injury

• Table of Neoplasms

• Table of Drugs and Chemicals

2. Tabular List

• Categories

• Subcategories

• Codes

Conventions for the ICD-10-CMFormat

• Define terms

• Provide direction

• Wound, superficial (see also specified injury type)

• Provide coding instructions

• Trichiasis (eyelid) – H02.059

• with entropion – see Entropion

Alphabetic Index Notes

• Categories

• 3 characters – Chapter 7 – Disorder of the Eye and Adnexa (H00-H59)

• Subcategories

• 4th character further defines site, etiology, manifestation or state of disease or condition

• 5th & 6th character increases specificity

Tabular List

© 2014 Corcoran Consulting Group (800) 399-6565

• 7th Character Extension

• Some categories have applicable 7th characters

• Last character

• If code is not six digits, use “x” as placeholder

• “x” as placeholder

• For when characters are needed for expansion

Tabular List

• A initial encounter

• D subsequent encounter

• S sequela

7th Character Extension

ExampleCorneal Abrasion

• Category – Chapter 19 – Injury, Poisoning . . .

S05 – Injury of eye and orbit

• Subcategory – 5th S05.0 – Injury of conjunctiva and corneal abrasion without foreign body

• Specificity – x 7th S05.01 – Injury of conjunctiva and corneal abrasion without foreign body right eye

• Valid code – S05.01xA -- Injury of conjunctiva and corneal abrasion without foreign body right eye; initial encounter

ExampleCorneal Abrasion

For glaucoma staging, 7th denotes severity of disease

• 1 = mild 0 = unspecified

• 2 = moderate 4 = indeterminate

• 3 = severe

7th Character Extension

7th character “is to be assigned to each code in subcategory H40.12 to designate the stage of glaucoma”

• Low-tension Glaucoma

• H40.12

• Low-tension Glaucoma, bilateral (cannot stop here!)

• H40.123

• Low-tension Glaucoma, right eye, moderate stage

• H40.1212

• Low-tension Glaucoma, left eye, severe stage

• H40.1223

Example: Glaucoma Staging

© 2014 Corcoran Consulting Group (800) 399-6565

Laterality

• Right and left designation1 = right

2 = left

3 = bilateral

0 or 9 = unspecified

Terminology“Laterality”

• Example

H25.11 Age-related nuclear cataract, right eye

H25.12 Age-related nuclear cataract, left eye

H25.13 Age-related nuclear cataract, bilateral

H25.10 Age-related nuclear cataract, unspecified eye

Exception example (diseases of eyelids)

• H02.011 Cicatricial entropion of right upper eyelid

• H02.012 Cicatricial entropion of right lower eyelid

• H02.013 Cicatricial entropion of right eye, unspecified eyelid

• H02.014 Cicatricial entropion of left upper eyelid

• H02.015 Cicatricial entropion of left lower eyelid

• H02.016 Cicatricial entropion of left eye, unspecified eyelid

• H02.019 Cicatricial entropion of unspecified eye, unspecified eyelid

Terminology“Laterality”

• Single code used to classify two diagnoses

1. Diagnosis with an associated manifestation

2. Diagnosis with an associated complication

Terminology“Combination Code”

• Examples

E11.321 – Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema

H59.032 – Cystoid macular edema following cataract surgery, left eye

Other “Conventions”

• Instructs that two codes may be required to fully describe a condition; sequencing depends on severity of conditions and reason for the encounter.

Terminology“Code Also”

• Example

H18.03 – Corneal deposits in metabolic disorders

Code also associated metabolic disorder

© 2014 Corcoran Consulting Group (800) 399-6565

• “See” follows a main term in the index indicating that it is necessary to go to that term to locate the correct code.

• “See Also” follows a main term in the index indicating that another term may also be useful.

Terminology“See” and “See Also”

• Examples Lesion

eyelid – see Disorder, eyelid

Retinochoroiditis (see also Inflammation, chorioretinal)

• Etiology / manifestation rule; the underlying condition is listed first with the manifestation listed second.

• “Code first” will be listed at the etiology code; “Use additional code” will be listed at the manifestation code.

Terminology“Code First / Use Additional Code”

• Example

H42 – Glaucoma in diseases classified elsewhere

Code first underlying condition, such as: aniridia (Q13.1)

Q13.1 – Absence of iris

Aniridia

Use additional code for associated glaucoma (H42)

• “Excludes 1” – excluded code should never be used at the same time as the code above excludes 1 note.

• “Excludes 2” – represents “Not included here”; Condition excluded not part of condition represented by the code; patient may have both conditions at the same time; may use both codes when appropriate.

Terminology“Excludes”

• Examples

H01.0 – Blepharitis

Excludes 1blepharoconjunctivitis (H10.5-)

H00.1 – Chalazion

Meibomian (gland) cyst

Excludes 2 infected meibomiangland (H00.02-)

• When the term “and” is used in a narrative statement, it represents and / or.

Terminology“and”

• Example

T26.11 – Burn of cornea and conjunctival sac, right eye

• NEC

• “Not elsewhere classifiable”

• Represents “other specified”

• Detail for which a specific code does not exist

• NOS

• “Not otherwise specified”

• Represents “unspecified”

• For when a more specific code cannot be assigned

Abbreviations How to find a code

© 2014 Corcoran Consulting Group (800) 399-6565

• Diagnosis codes are to be used and reported to the highest number of characters available.

• Signs and symptoms are acceptable when a definitive diagnosis has not been established by the provider.

• Do not code diagnoses documented as “probable”, “suspected”, “questionable”, “rule out”, or “working diagnosis” or other similar terms indicating uncertainty.

General Guidelines

• Multiple codes may be required for a single condition that affects multiple body systems.

• Principal diagnosis should be based on the condition that prompted the visit and was the primary focus of treatment.

• Code all documented conditions that coexist at the time of the visit, and require or affect patient care treatment or management.

• Do not code conditions that were previously treated and no longer exist.

General Guidelines

1. Look up the main term in the Alphabetical Index, scan subterm entries if needed. Review continued lines / additional subterms.

2. Note parenthetical terms that help with code selection but do not affect code assignment

How to Use the ICD-10-CM

3. Pay attention to the following index instructions in the Alphabetical Index

• “see”, “see also”, and “see category” cross-references

• “with” and “without” notes

• “omit code” notes

• “due to” subterms

• other instructions found in note boxes, such as “code by site”

4. Do not code from the Alphabetical Index without verifying the accuracy of the code from the Tabular List

How to Use the ICD-10-CM (continued)

5. Read all instructional material in Tabular Index, including

• “includes” and “excludes” notes

• “use additional code” and “code first underlying disease”

• “code also”

• fourth-, fifth-, sixth-, and seventh- digit requirements

6. Consult the ICD-10-CM guidelines for use of specific codes

7. Confirm and assign the correct code

How to Use the ICD-10-CM (continued)

CC: cataracts, OU, slow decrease VA during past 6 mos, trouble reading, glare worsening

Dx: Nuclear sclerotic cataracts OD>OS

Tx: Schedule phaco IOL OD

Cataract Example

ICD-9: 366.16 Nuclear Sclerotic Cataract

What is the appropriate ICD-10 code?

© 2014 Corcoran Consulting Group (800) 399-6565

Step 1: Alpha Index: Search “cataract”

• Cataract (cortical) (immature) (incipient) H26.9

Step 2: Under “cataract” search “nuclear sclerotic”

• - nuclear

• - - sclerosis —see Cataract, senile, nuclear

Cataract

• Step 3: See Cataract Senile Nuclear

• - senile H25.9

• - - brunescens —see Cataract, senile, nuclear

• - - combined forms H25.81-

• - - coronary —see Cataract, senile, incipient

• - - cortical H25.01-

• - - hypermature —see Cataract, senile, morgagnian type

• - - incipient (mature) (total) H25.09-

• - - - cortical —see Cataract, senile, cortical

• - - - subcapsular —see Cataract, senile, subcapsular

• - - morgagnian type (hypermature) H25.2-

• - - nuclear (sclerosis) H25.1-

Cataract

• Step 4: Go to H25.1- in Tabular List

• H25.1 Age-related nuclear cataract• Cataracta brunescens

• Nuclear sclerosis cataract

• H25.10 Age-related nuclear cataract, unspecified eye

• H25.11 Age-related nuclear cataract, right eye

• H25.12 Age-related nuclear cataract, left eye

• H25.13 Age-related nuclear cataract, bilateral

• Step 5: No additional instructions in tabular list

• Step 6: No additional guidelines

• Step 7: Assign code

Cataract

CC: Cataracts, OD, slow decrease VA during past 6 mos, trouble reading, glare worsening

Dx: Nuclear sclerotic cataracts OD>OS

Tx: Phaco IOL OD

H25.13 NS, Cataract, OU

Cataract

1. Certain Infectious and Parasitic Diseases (A00-B99)

2. Neoplasms (C00-D49)

3. Diseases of the Blood and Blood-forming Organs (D50-D89)

4. Endocrine, Nutritional and Metabolic Diseases (E00-E90)

5. Mental and Behavioral Disorders (F01-F99)

6. Diseases of Nervous System (G00-G99)

7. Diseases of Eye and Adnexa (H00-H59)

Chapters

8. Diseases of Ear and Mastoid Process (H60-H95)

9. Diseases of Circulatory System (I00-I99)

10.Diseases of Respiratory System (J00-J99)

11.Diseases of Digestive System (K00-K94)

12.Diseases of Skin and Subcutaneous Tissue (L00-L99)

13.Diseases of the Musculoskeletal System and connective Tissue (M00-M99)

14.Diseases of Genitourinary System (N00-N99)

Chapters

© 2014 Corcoran Consulting Group (800) 399-6565

15.Pregnancy, Childbirth, and the Puerperium (O00-O99)

16.Newborn (Perinatal) Guidelines (P00-P96)

17.Congenital Malformations, Deformations, and chromosomal Abnormalities (Q00-Q99)

18.Symptoms, Signs, and Abnormal Clinical and Lab Findings, NEC (R00-R99)

Chapters

19.Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)

20.External Causes of Morbidity (V01-Y99)

21.Factors Influencing Health Status and Contact with Health Services (Z00-Z99)

Chapters

• Diabetes mellitus

• Combination codes that include

• Type of diabetes mellitus

• Body system affected

• Complications affecting body system

• Sequenced based on reason for encounter

Ch. 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

• Five diabetes mellitus categories

• E08 Diabetes mellitus due to an underlying condition

• E09 Drug or chemical induced diabetes mellitus

• E10 Type 1 diabetes mellitus

• E11 Type 2 diabetes mellitus

• E13 Other specified diabetes mellitus

*Use E11 if record does not indicate type of DM, but does indicate insulin use.

Diabetes Mellitus

Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines

• All categories except E10 (Type 1 DM) require use of additional code to indentify any insulin use

• Z79.4 – Long term (current) use of insulin

Diabetes MellitusInsulin use

Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines

• E11.9 Type 2 DM without complications

• E10.339 Type 1 DM with moderate NPDR without macular edema

• E11.321 Type 2 DM with mild NPDR withmacular edema

&

• Z79.4 Long-term current use of insulin (if documented)

Diabetes MellitusExamples

© 2014 Corcoran Consulting Group (800) 399-6565

Case Study

While sitting at the 10th tee box, your patient is struck in the left eye with a golf ball causing a traumatic hyphema. Code this encounter with ICD-10 codes.

19.Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)

20.External Causes of Morbidity (V01-Y99)

21.Factors Influencing Health Status and Contact with Health Services (Z00-Z99)

Chapters

S05.12xA Contusion of eyeball and orbital tissues, left eye, initial encounter

V86.59xA Driver of golf cart injured in nontrafficaccident

W21.04xA Struck by golf ball

Y92.39 Golf course as place of occurrence

Y93.53 Activity, golf

Case StudyICD-10 Codes

• Laterality

• Is your assessment specific to which eye or eyelid?

• Etiology / Manifestation

• Does your chart note list both the disease and the associated manifestation?

• Specificity

• Is the impression as specific as possible for a particular condition?

Documentation Considerations

• Diabetic

• Cataract OD from injury

• Hypertension

• Shingles

• HIV positive

Documentation ConsiderationsHistory – ROS

Old New

• Type II diabetes on insulin

• Cataract OD caused by driver side airbag

• Hypertension; history of tobacco use

• Shingles w/ear infection

• Asymptomatic HIV

• Eyelid laceration

• FB sensation OD, poor “blink” 3 days

• Elevated IOP; seen at health fair

Documentation ConsiderationsHistory – HPI & PFSH

Old New

• Laceration right eyelid from contact with a chisel (workbench tool)

• FB sensation OD, poor “blink” 3 days; recent dx of Bell’s palsy

• Family history of glaucoma

© 2014 Corcoran Consulting Group (800) 399-6565

• Chalazion OS

• BDR OU

• Iritis OU

• Hyphema OD

• No maculopathy

Documentation ConsiderationsImpression

• Chalazion LLL

• Type II diabetes with mild NPDR w/out macula edema; taking insulin

• Chronic iritis OU

• Traumatic hyphema OD

• RA taking plaquenil; no ocular disease

Old New

• Myopia

• CME

• Ptosis

• Complex cataract

Documentation ConsiderationsImpression

• Myopia OU; regular astigmatism OD

• CME OD after cataract sx

• Mechanical ptosis OU

• NS cataract OD, floppy iris syndrome, adverse effect of Tamsulosin

Old New

Common Patient Syndromes

• R46.0 – Low level of personal hygiene

• R19.6 – Halitosis (bad breath)

• History and Timeline

• Gather resources

• Assess and Improve Documentation

• Practice, Practice, Practice

• One Step at a Time

Key Points in Preparation

• Practice early, practice often!

• You are asking people to change habits or patterns

• This takes time and practice

• Continue reporting ICD-9 for claims submission

• “Double code” a few of claims with ICD-10 codes

• Compare your answers with each other

• Use for training and glossary most common codes

Begin Using ICD-10 Codes

• Divide tasks in to workable segments

• refractive error and cataract codes

• glaucoma

• cornea and external eye codes (plastics)

• retina and diabetes code

• Injuries and infections

• Use this time to assess tools available to you

• Apps, websites etc

• Use this time to educate staff

• History taking, documentation, anatomy

Begin Using ICD-10 Codes

© 2014 Corcoran Consulting Group (800) 399-6565

Resources

• www.cms.gov/ICD10/

• www.aapcps.com

• www.ahima.org

• www.cdc.gov/nchs/icd.htm

• www.who.int/en/

Resource Links

• “Apps”

• Apple – iPhone

• Android

• World Health Organization

• AAPC Code Translator

• http://www.aapc.com/ICD-10/codes/index.aspx

• Others

• http://www.icd10data.com/

Useful Aids

For additional assistance or confidential consultation, please contact us at:

(800) 399-6565

or

www.CorcoranCCG.com

[email protected]

More help…

APPENDIX

_______________________________________________________________________________________ 560 E. Hospitality Lane ▪ Suite 360 ▪ San Bernardino, California 92408 ▪ Telephone: (800) 399-6565

FAX (909) 890-1333 ▪ www.corcoranccg.com

 

How To SEARCH For A Code Within ICD‐10‐CM  

 General guidelines: 1. ALPHABETIC index a place to START 2. TABULAR List is most specific – code from here! 3. Report HIGHEST number of characters possible  Specific guidelines: 1. Identify reason for visit/encounter 

a. Diagnoses b. Problems c. Complaints d. Signs and symptoms 

i. Used for reporting when no related definitive diagnosis is established 

e. Conditions i. Report those that are an integral part of a disease process 

1. Do not use additional codes ii. Conditions that are not an integral part of a disease process 

1. Code when present (see below if “multiple conditions”)  

2. Multiple coding for a single condition a. Required for 

i. Any condition with a “use additional code” note b. May be needed for 

i. Fully describing a condition, such as ii. Late effects iii. Complication codes iv. Obstetric codes 

 3. Acute and chronic conditions 

a. If both are present i. Code both ii. Sequence acute code first 

__________________________________________________________________________________________ 560 E. Hospitality Lane ▪ Suite 360 ▪ San Bernardino, California 92408 ▪ Telephone: (800) 399-6565

FAX (909) 890-1333 ▪ www.corcoranccg.com

 4. Combination code 

a. Single code to classify either i. Two diagnoses ii. Diagnosis with associated secondary process iii. Diagnosis with associated complication 

b. Do not use multiple codes if combination code identifies all elements  

5. Late effects (sequelae) a. Residual effect after acute phase of injury/illness b. No time limit c. Condition code sequenced first, late effect code sequenced second d. Do not use with acute injury code 

 6. Impending or threatened condition 

a. If condition did occur, code as diagnosis b. If condition did not occur, reference “impending”, “threatened” 

i. If subentry terms for “impending” or “threatened” are listed: 1. Assign the appropriate code 

ii. Are not listed: 1. Code existing underlying conditions 

c. Do not code the impending/threatening condition  

7. Reporting same diagnosis code more than once a. Each code may be used once per encounter 

 8. Laterality 

a. For codes that can have bilateral sites b. Final character of code indicates laterality (0 or 9, 1, 2, 3) c. If no bilateral code is provided, assign separate codes for right and left 

sides     9. RARE for Ophthalmology: 

Documentation for BMI and pressure ulcer stages a. May be based on documentation from clinicians who are not the patient’s 

provider b. Associated diagnosis must be documented by patient’s provider 

c. BMI codes are always secondary diagnoses