UNDERSTANDING ICD-10-CM

WHAT DOES IT MEAN TO YOUR PRACTICE?HOW SHOULD YOUR OFFICE PREPARE?

- ICD-10 is a diagnostic coding system implemented by the World Health Organization (WHO) in 1993 to replace ICD-9. ICD-10 is in almost every country in the world, except for the United States.

ICD-10 will be the most radical change to the healthcare industry in 20 years.

Practices, billing services and vendors will have to maintain both the ICD-9 & ICD-10 code sets for some time in the future beyond the 10/2014 deadline.

WHAT IS ICD-10?

• Maintained by the US National Center for Health Statistics• Designed for greater clinical specificity

• Anatomic• Procedural• Visit specific information• Technology (Compliance with 5010 is necessary)

◦ Cannot describe 21st century care Many categories are full No detail on patient medical conditions Has outdated and obsolete terminology Used outdated codes Produces inaccurate and limited data Inconsistent with current medical practice

WHAT’S WRONG WITH ICD-9?

ICD-10 CODE SETS EXPLODE

ICD-10-CM - 68,000 diagnosis codes

vs.ICD-9

- 13,000 diagnosis codes

ICD-10 IS A COMPLETELY NEW SET OF CODES

The format is completely different- Codes start with a letter- Up to 7 characters

- Includes modifiers to describe initial, subsequent or sequela visits and other information

- Very specific codes- RT and LT- Upper and lower

- Fewer NOS codes- More guidelines

WHAT DOES

Wikipedia: Sequela is a pathological condition resulting from a disease, injury, or other trauma. Typically, a sequela is a chronic condition that is a complication of an acute condition that begins during that acute condition. This is a contrast to a late effect.

Examples and Uses: Chronic kidney disease, for example, is sometimes a sequela of diabetes, and neck pain is a common sequela of whiplash or other trauma to the cervical vertebrae.

SEQUELA

MEAN ?

WHAT ICD-10 LOOKS LIKE

X X X . X X X X X . X X X X

-----/------- ----/---- ----/----- -----/---- -/- category etiology, category etiology, extension anatomic site, anatomic site, manifestation severity

ICD-9 Format ICD-10 Format

• ICD-10 codes have the potential to reveal more about quality of care, so that the data can be used in a more meaningful way to better understand complications, better design clinically robust algorithms, and better tract the outcomes of care.

• ICD-10 incorporates greater specificity and clinical detail to provide information for clinical decision making and outcomes research.

• This means greater need for physician/practitioner involvement with coding.

ICD-10 vs. ICD 9 DIAGNOSIS – FINGER LACERATIONICD-9- Is it simple or

complicated?- Is there tendon

involvement

- Simple = 883.0

ICD – 10- What finger is it?- Is it the right hand or left

hand?- What part of the finger is

lacerated?- Is it the initial encounter,

subsequent encounter or sequela?

- Is the nail damaged?- Are there fractures?- Is there a Foreign Body?- Are tendons injured?

• Laceration w/o FB right index finger w/o damage to nail, initial encounter

• = S61.210A

FRACTURE CLASSIFICATION IN ICD-10-CM

Fracture coding in ICD-10-CM requires documentation of site, laterality, type of fracture, whether it is displaced or non-displaced, and the stage of healing (encounter), which includes open fracture classification.

TAKE THE FEAR OUT OF ICD-10-CM FRACTURE CODING

A 35-year old man suffered open displaced tibia and fibula fractures of the right leg as the result of an automobile accident. In addition, he lost a lot of blood, also from the right leg

To assign the correct ICD-10-CM code, coders will need to know:• Which leg and which specific bone(s) the

patient injured. (In this example, it’s the right tibia and fibula)

• Whether the fracture is open or closed (in this case, open)

• Whether the fracture is displaced (in this case, displaced)

FRACTURE CODING CONT……

For open fractures, coders will also need to know what type of associated trauma the patient suffered to choose the appropriate character based on the Gustilo-Anderson Classification system.

Gustilo-Anderson Classification System:• ICD-10 categories

• S52 (fracture of forearm)• S72 (fracture of femur)• S82 (Fracture of lower leg, including ankle)

• All the above require additional seventh character extensions.

• A - Initial encounter of for fracture• D – Subsequent encounter for

fracture with routine healing• G – Subsequent encounter for

fracture with delayed healing• K – Subsequent encounter for

fracture with nonunion• P – Subsequent encounter for

fracture with malunion• S - Sequela

SEVENTH CHARACTERS: CODING FOR A CLOSED FRACTURE.

SOME SILLY ICD-10 CODES

V9733xD – “Sucked into jet engine,Subsequent encounter”…. They survived the first time!?

Z631 – “Problems in relationship with in-laws”….really!?Where’s the subsequent encounter?

X35.xxD – “Volcanic eruption, subsequent encounter”…. That’s some really bad luck!

W61.49xA – “Other contact with turkey, initial encounter”….Every Thanksgiving!

Z621 – “Parental overprotection”….aren’t all parents “guilty” of this every now and then.

ICD-10 DOCUMENTATION EXAMPLE:

The following case highlights the increased specificity required to code for ICD-10.

Mrs. Finley Presents today after having a new cabinet fall on her last week. (EXTERNAL CAUSE) suffering a concussion, as well as some cervicalgia.

She was cooking dinner at the home she shares with her husband, (ACTIVITY)

She did not seek treatment at the time (7th CHARACTER)

She states that the people that put in the cabinet in her kitchen (LOCATION) missed the stud by about two inches.

Her Husband, who was home with her at the time told her she was “out cold” for about two minutes. (APPLIED SPECIFICITY) CONCUSSION

The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. (RELIEF OR NO RELIEF).

CONT…..

Patient suffers acute (ACUTE OR CHRONIC) persistent headaches post concussion.

SEVEN CHARACTERS TO CONSIDER WHEN CODING ICD-10

1. EXTERNAL CAUSE: The falling of the cabinet is what caused the injuries. Description of the cause is required.

2. ACTIVITY: In ICD-10 the activity of the patient needs to be documented. An activity code is only used once at the initial encounter.

3. 7TH CHARACTER: Injury codes require a 7th character extender that identifies the encounter. Documentation must be clear so that the correct extender can be applied.

4. LOCATION: Documentation needs to indicate the location of the patient at the time of injury. In ICD-10 the details include the actual room of the house the patient was in when the injury occurred.

5. APPLIED SPECIFICITY: Concussion. For a concussion, documentation needs to include if the patient suffered loss of consciousness.

6. RELIEF OR NO RELIEF: Intractable vs. not intractable are an inherent part of the ICD-10 code for headaches and documentation needs to be clear to assign the appropriate code.

7. ACUTE VS. CHRONIC: Documentation of the patient’s condition must include acute or chronic to assign the most appropriate ICD-10 code

CONT….

ICD-10-CM DESCRIPTION SPECIFICITY

S06.0X1A Concussion with loss of consciousness of 30 minutes or less

Initial encounter

G44.311 Acute post traumatic headache Intractable

M54.2 Cervicalgia

M99.01 Segmental and somatic dysfunction of cervical region

W208XXA Struck by falling object (accidentally)

Initial encounter

Y93.G3 Activity, Cooking and baking

Y92.010 Place of occurrence, house, single family, kitchen

ICD-10 CODES THAT DESCRIBE PATIENTS VISIT

HOW MUCH TIME DO I HAVE TO PREPARE?

On October 1, 2014, the ICD-9 code sets to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets.

For providers who have not yet started to transition to ICD-10, they should take action steps now.

* CMS and the commercial payors are anticipating two years of claims and payments disruptions are possible after October 2014.

UNDERSTAND THE EFFECTS ON YOUR PRACTICE.

PERSONNEL

• Physicians/Nurses• Greater detail requires more

work at the provider/EMR level• ICD-10 coding education• ICD-10 reference materials• Payer code combination

changes with ICD-10

• Billing Office/Coding Specialist• Greater detail requires more research/understanding• ICD-10 coding education and reference materials• Payer code combination changes with ICD-10

• Front Desk/Management• Greater detail required on Encounter/Superbill• ICD-10 code understanding, reference materials• Changes to all printed materials

WHO IS YOUR CODER?

• You• Staff• Certified Professional• Outsourced• Software assisted • EHR

• Who will train them?• When will you train them?• When will YOU learn the new

conventions?• Are updates required?• Where do you find help?

SUMMARY……

You must start NOW! Prepare your practice. Set timelines. ICD-10 Training and Education is a must for staff and

providers. Consider outsourcing billing to professionals Software Compliance for 5010 as the Gateway Code mapping applications to convert ICD-9 to ICD-10 Charting Changes – EMR vs. Paper updates to

accommodate ICD-10 Detailed documentation from the providers is the key to

successful coding and reimbursement.

12 months until compliance and although its tempting to put this out past the 5010 deadline – DO NOT WAIT

Resources for ICD-10

• General Information/Education/Resource Materials* CMS – www.cms.org* HHS – www.hhs.org* AHIMA – www.ahima.org* ICD-10 Made Easy – www.icd10madeeasy.com* Workgroup for EDI – www.wedi.org* ZirMed – http://icd.zirmed.com* AMA – www.ama-assn.org/go/ICD-10* AAOS – www.aaos.org/ICD10

• Mapping of ICD-9 to ICD-10* Practice Management System & EMR Vendors* ZirMed* Navicure* Ingenix

*MedPro Services does not endorse these companies or their services, this is merely a reference to available resources in the industry.

Rebecca Kieffner, President & CEOMedPro Services, Inc.

300 West Second StreetBloomington, IN 47403

Telephone: (812) 334-1333Fax: (812) 334-1444

Toll Free: (866) 633-7768rebecca@medproservices.netwww.orthopaedicsbilling.com