ICD-10 ConversionAwareness Training
05/30/12
The term ICD-10 used throughout this presentation refers to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure ) codes.
It does not include the ICD-10 set of codes used for mortality statistics.
PresentersDr. Nina Jo MuseMirsa DouglassSteve Eichner
Disclosure to Participants
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Requirements for Successful Completion of Continuing Education Activity Requires:1. Completing the registration form,2. Signing the “Sign – in” Sheet,3. Attending the entire educational activity, Disclosure to Participants4. Participating in education activities instructed, and5. Completing the participant evaluation.
Commercial Support:This educational activity received no commercial support.
Disclosure of Conflict of InterestThe speakers and planning committee have disclosed no conflict of interest.
Non-Endorsement StatementAccredited status does not imply endorsement by Department of State Health Services, Continuing Education Service Program of America Nurses Credentialing Center of any commercial product displayed in conjunction with this activity.
Off-Label UseThe speakers did not disclose the use of products for a purpose other than what it had been approved for by the Food and Drug Administration.
Expiration Date for Awarding Contact HoursComplete the attendance sheet and evaluation by the end of the conference.
ICD-10 Awareness Training Objectives• Describe the intent of the federal mandate
related to ICD-10 and identify who the mandate applies to.
• Briefly describe the difference between ICD-9 coding and ICD-10 coding.
• Explain the connection between HIPAA and the federal mandate for ICD-10 conversion.
• Describe important operational impacts resulting from the hard switch conversion.
• Describe how the ICD-10 conversion may impact your specific work area.
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ICD-10 Federal Mandate• January 16, 2009 - A final rule from the US DHHS
Centers for Medicare and Medicaid Services (CMS) mandates the use of ICD-10 code sets for HIPAA standard transactions.
• Who does the rule apply to?– Applies to covered entities (i.e., health plans, health
care clearinghouses, and health care providers ) who transmit health information in electronic form in connection with HIPAA standard transactions.
– This includes providers and payers who do not deal with Medicaid and Medicare claims.
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• HIPAA encompasses many regulations with some illustrated below..
• Privacy Rule – A patient information privacy rule (i.e., privacy rights) • Security Rule - An electronic patient information security rule• Electronic Data Interchange Rule – transaction standards law so that
healthcare companies may exchange medical, billing and patient information more efficiently.
Health Insurance Portability Accountability Act (HIPAA) of 1996
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Data Interchange Rule-Health Insurance Portability Accountability
Act (HIPAA) of 1996Before HIPAA, entities used different systems to process patient bills and other administrative information.
Considerable time was spent to ensure claims had proper formats, codes and other details required by different insurers and payers.
The HIPAA Electronic Data Interchange Rule (EDI Rule) allowed for the adoption of national standards for electronic health care transactions. (Keep in mind this pertains to HIPAA transactions.)
National standards provide a common language for exchanging electronic data and a common coding structure for classifying diagnosis and procedures.
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“HIPAA Standard Transaction” Defined
• HIPAA standard transaction defined– simply means these transactions are transmitted
using standard formats specified in HIPAA regulations.
– HIPAA regulations mostly specify standards developed by the Accredited Standards Committee (ASC) X12N (Insurance Subcommittee).
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NOTE: Above is a sample of HIPAA standard transactions. The complete list is included in the HIPAA EDI Rule.
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ASC X12 Standards and ICD Codes
• ASC X12 are standards used for formatting information for the electronic transmission of healthcare transactions.
• The ASC X12 standards incorporate coding sets (i.e., ICD-9, ICD-10-CM, and ICD-10-PCS which are common languages used to identify diagnosis and procedures).
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What About 5010??
• 5010 is simply describing a version of X12 HIPAA standard transactions.
• The version upgrade to 5010 was necessary so that HIPAA standard transactions could accommodate the more complex ICD-10 code set.
• Remember, the ICD-10 code sets are incorporated in the ASC X12 transaction standard.
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Healthcare Clearinghouses and HIPAA Transactions
Healthcare Clearinghouse
Insurance Carrier or
Payer
Healthcare Related Entity
DSHS Contractors TMHPHMOMCO, etc…
Sends billing files with claim info
Secure transmission of transactions in ASC X12 format
HIPAA Standard Transactions
Secure transmission of transaction responses in ASC X12 formatSends response reports
Not necessarily HIPAA Standard Transactions
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Coding Standards BackgroundDiagnostic and medical procedure information is captured during patient encounters to track clinical progress.
Initially, diagnostic and procedural information is captured in narrative form.
Coding facilitates the classification of diagnosis and procedures to: Determine eligibility File claims for payment Conduct research Track diseasesMeasure population health Describe cause of death
In general, coding translates words into numbers or alphanumeric strings, e.g. “1AB3E47”.
Standardized coding makes data collection and data analysis easier. ICD is a coding standard.
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American Medical Association (AMA)
Centers for Medicare & Medicaid Services (CMS)
Major Coding StandardsInternational Classification of Diseases (ICD)
ICD-9
ICD-9-CM(diagnostic codes)
ICD-9-PCS(procedure codes)
Current Procedural Terminology (CPT)
CPT-4
Diagnostic & Statistical Manual of Mental Disorders (DSM)
DSM-IV
managed by
managed by
managed by
managed by
World Health Organization (WHO)
National Center for Health Statistics (NCHS)
managed by
American Psychiatric Association (APA)
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Common Procedure Terminology (CPT)• CPT and ICD are two different coding sets used in different
circumstances. – Separate coding system– Developed by a separate organization– Designed to be used for a separate provider type
• Developed by the American Medical Association.– Created by doctors, to be used by doctors
• Used for physician services whether inpatient or outpatient.
• CPT is not impacted by ICD-10 conversion.
IMPORTANT: The final rule for ICD-10 conversion does not affect CPT coding. This is because CPT is devised for coding services not covered under ICD-10-PCS.
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Diagnostic and Statistical Manual of Mental Disorders (DSM)
• Current version is DSM-IV.• Developed by American Psychiatric Association.• To provide a more detailed evidence-based diagnostic
system than what was originally provided by ICD. • Used only in the United States by behavioral health
professionals for diagnosis coding.• The APA and the DSM committee had input into the
formation of ICD-10.• ICD-10 behavioral health coding was based on DSM-IV.• DSM-IV code are ICD-9 codes (from Chapter 5-Mental
disorders)
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International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM)
ICD-9-CMClinical Modification
For use in the US
Diagnosis codesUsed by physicians and
other individual providers
Procedure codesUsed by hospitals, not
individual physicians or providersReferred to as ICD-9-PCS
Volume 1 & 2 (CMS)
Volume 3(NHCS)
ICD-9(WHO)
Used internationallyDevised as a
mortality coding toolMost of the world
currently uses the latest version, ICD-10
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ICD-9 to ICD-10
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Example from Chapter 5- Mental Disorders
– All diagnoses related to alcohol
ICD-911 Codes(22 DSM IVDiagnoses)
ICD-1047 Codes
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ICD-9-CM Coding Structure
• 3 –5 character
• All characters are numeric (Chapters 1-17)
• Other chapters: first character is letter (E or V), remainder are numeric
• Decimal after the first three characters (xxx.)
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ICD-10 Coding Structure• 3 –7 characters
– First character is always a letter (U is not used)– Second and third characters are numeric– Decimal placed after the first three characters– Fourth, fifth, sixth and seventh characters may be
letters or numeric– Seventh Digit Extension
• Visit encounter (initial: A; subsequent: D) • Sequelae = S• injuries and external causes
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Coding
Category Severity, Etiology, Anatomic Site
Extension
Category Manifestation, Etiology, Anatomic Site
ICD-9 CM Code:(Chapters 1-17)
ICD-10 Code:
= Number= Letter= Alphanumeric
3 0 4 . 7 1
F 1 9 . 2 0
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Mapping Between ICD-9 and ICD-10
• All other diagnosis mappings will either lose information or make assumptions.
• Imperfect mapping will impact revenue, costs, risks and relationships
• 95% of ICD-10 diagnosis codes will not map exactly to ICD-9 codes
• 75% of all ICD-9 diagnosis codes will not map exactly to ICD-10 codes
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General Equivalency Mappings (GEMS)
• Does not resolve the one to many scenarios – Over 30% of transactions reviewed have codes
that include one-to-many mapping options
• Does not provide mappings for all Codes
• Only 52% of codes have the same relationships both directions
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ICD-9 – ICD-10 Mappings
1:1 Exact
1:1 Approximate
1: Many Single
1: Many Both(Single and Combination)c
1: Many Combination
Many: 1 Combination
No Mapping
Code Missing(Requires Research)
Risk
Very High Risk
High Risk
Moderate Risk
Low Risk
Risk Undetermined
Complexity of mappings will determine risk of inaccurate processing
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ICD-9 – ICD-10 MappingsExact Match Minimizes Risk
Low RiskExact match indicates matching definitions 1:1 Exact
Risk
Complexity of mappings will determine risk of inaccurate processing
No exact matches in alcohol-related diagnoses in Chapter 5
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ICD-9 – ICD-10 MappingsModerate Risk
Moderate RiskMatching clinical meanings with differing language
Risk
1:1 Approximate
Complexity of mappings will determine risk of inaccurate processing
Alcohol withdrawalwith perceptual disturbance291.81
Alcohol dependence with withdrawal with perceptual disturbanceF10.232
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ICD-9 – ICD-10 MappingsHigh Risk
High RiskSeveral options for a similar clinical meaning with increased specificity. Choose 1
Risk
1: Many Single
Complexity of mappings will determine risk of inaccurate processing
Alcohol-Induced Mood Disorder291.89
Alcohol Use, Unspecified – with Alcohol-Induced Mood DisorderF10.94
Alcohol Abuse with Alcohol-Induced Mood DisorderF10.14
Alcohol Dependence with Alcohol-Induced Mood DisorderF10.24
ICD-9 – ICD-10 MappingsVery High Risk
Very High RiskAn ICD-9 code maps to 2 or more ICD-10 codes in combination in order to maintain clinical parity
Risk
1: Many Both(Single and Combination)
Complexity of mappings will determine risk of inaccurate processing
No examples in alcohol-related diagnoses in Chapter 5
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ICD-9 – ICD-10 MappingsVery High Risk
Risk
Complexity of mappings will determine risk of inaccurate processing
2 or more ICD-9 codes map to a single ICD-10 code
Many: 1 Combination
Alcohol Intoxication Delirium291.2
Alcohol Abuse with Intoxication DeliriumF10.121
Alcohol Abuse305.00
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ICD-9 – ICD-10 MappingsVery High Risk
Risk
Complexity of mappings will determine risk of inaccurate processing
Very High RiskNo Mapping
Alcohol Dependence on Agonist Therapy
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Impact on DSHS and Providers• What does the final rule compliance mean?
– Required use of ICD-10-CM (diagnosis) and ICD-10-PCS (procedures) in HIPAA standard transactions.
• ICD-10-CM (diagnosis) 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.
• ICD-10-PCS will not be used on physician claims, even those for inpatient settings.
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IMPORTANT: There is no grace period for ICD-10 conversion.There is no phased-in approach. It is a hard switch from ICD-9 to ICD-10.
IMPORTANT: For a period of time, both ICD-9 and ICD-10 will be in play. Claims will be based on the date of service or date of discharge, not the date of transmission. Claims for services or discharge performed before October 1, 201X, but submitted on or after it, should be submitted, processed, and adjudicated using ICD-9 . Services/discharges performed October 1 or later should be submitted and processed using ICD-10.
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Types of Impacts
Business Aspects(Policy and Processes)
Technical Aspects
Outreach Training
ICD Conversion
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Business Impacts• Reviewing policies, written and unwritten
– Codes, regulations, etc.• Mapping ICD-9 codes to ICD-10 codes (DSHS function)
– Mapping for clinical intent– Mapping for cost neutrality for reimbursements
• Developing strategies for delayed reimbursement (setting aside funds, additional human resources to manage activity)
• Updating documentation and forms w/ICD-10• Reviewing changes on reports (i.e., trending)• Updating contracts• Outreach to stakeholders• Training clinicians and coders
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Technical Impacts• Information systems handling ICD-9 codes and
ICD-10 codes simultaneously.
• Updating information systems to accommodate new code structure.
• Meeting processing and storage capacity requirements to house increased volume of codes.
• Testing information systems and processes with all partners.
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Partner Outreach & Training Impacts• In general, ICD-10 code sets contain more specificity &
acuity (level of detail) than ICD-9. • Physicians must include more details in narrative notes
about diagnosis and procedures for patients for coders to identify the proper ICD-10 code.
• Coders must have greater knowledge in anatomy & medicine overall to accurately code.
• Partners must be aware of… – DSHS policy changes,– Expectations and timing of claims testing, for both ICD-9
and ICD-10,– Monitoring demands of ensuring compliance of current or
future EMR, EHR and/or practice management vendors
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ICD-10 Conversion Enterprise EffortHHSC ICD-10 Project
Manager Don Rau
DARS ICD-10 Coordinator
DFPS ICD-10 (Foster Care
Health Passport)
DSHS ICD-10 Coordinator
Mirsa Douglass
DADS ICD-10Coordinator
HHSC ICD-10 Coordinator
HHSC ICD-10 Policy Workgroup
HHSC ICD-10 Outreach
Workgroup
HHSC ICD-10 Data Mgmt Workgroup
Other Workgroups
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DSHS Project Team
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Industry Resources• www.icd10hub.com/
– Offered by American Association of Professional Coding and Navicure, the site includes timelines, white papers, and related news stories.
• www.ahima.org/icd10– The American Health Information Management
Association site is filled with training materials for coders and other staff.
• www.cms.gov/icd10– The official CMS site.
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Thank You– MHSA Contact Information
• Project Coordinator - Steve [email protected], (512) 467-5448
• Business Lead - Valerie Shown [email protected], (512) 206-5927
• Business Lead - Nina Jo Muse [email protected], (512) 467-5434
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