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© 2008 AHIMA ACE AHIMA ACE July 14, 2009 July 14, 2009 ICD-10-CM/PCS Update ICD-10-CM/PCS Update

AHIMA ICD-10-CM/PCS Update August 2009

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Page 1: AHIMA ICD-10-CM/PCS  Update August 2009

© 2008

AHIMA ACEAHIMA ACEJuly 14, 2009July 14, 2009

ICD-10-CM/PCS UpdateICD-10-CM/PCS Update

Page 2: AHIMA ICD-10-CM/PCS  Update August 2009

© 2008

ICD-10-CM/PCS – the ACE Agenda ICD-10-CM/PCS – the ACE Agenda

Thumbnail Sketch of ICD-10-CM/PCS Requirements The Project(s): 5010 and ICD Project Steps Resources Discussion and Questions

Page 3: AHIMA ICD-10-CM/PCS  Update August 2009

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New Federal RegulationsNew Federal Regulations

Final Federal Regulations – January 16, 2009 HIPAA Modifications - Transactions

Medical Data Modifications Code Set Standards ICD-10-CM and ICD-10-PCS

Effective – March 17, 2009 Transaction Compliance Date – January 1, 2012* ICD-Code Set Standards – October 1, 2013

* January 1, 2011 – Testing for Transactions Begin? January 1, 2013 – Medicaid Rx Related

Page 4: AHIMA ICD-10-CM/PCS  Update August 2009

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New Federal RegulationsNew Federal Regulations

Transactions UpgradesTransactions Upgrades All HIPAA Entities All ASC X12 and NCPDP HIPAA transactions

Code Sets Adoption Code Sets Adoption ICD-9-CM diagnosis codes to ICD-10-CM All healthcare settings ICD-9-CM procedure codes to ICD-10-PCS All hospital inpatient services All other sites continue to us CPT® and HCPCS codes

Page 5: AHIMA ICD-10-CM/PCS  Update August 2009

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HIPAA Modification - TransactionsHIPAA Modification - Transactions

Transactions include: X12 837 – Claims (Dental, Professional, Institutional)

X12 837/D.0 – Retail Pharmacy (supplies and professional services)

X12 837 – Coordination of Benefits (DPI)

X12 270/271 – Eligibility for a Health Plan (DPI)

X12 276/277 – Healthcare Claim Status (DPI)

X12 834 – Enrollment and Disenrollment (HP) X12 835 – Healthcare Payment and Remit X12 278 – Referral Certification & Authorization NCPDP D.0 – Various Pharmacy

Page 6: AHIMA ICD-10-CM/PCS  Update August 2009

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HIPAA Modification - TransactionsHIPAA Modification - Transactions

Estimate over 800 changes (updates from over six years of use)

HIPAA testing will be a key to ICD-10-CM/PCS implementation ● Testing begins January 1, 2011 ● Providers and Payers ● Test scheduling and coordination

Page 7: AHIMA ICD-10-CM/PCS  Update August 2009

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Modifications to Medical Data Code SetModifications to Medical Data Code Set

Effective – March 17, 2009

Compliance – October 1, 2013 ICD-9-CM (V 1&2) ►ICD-10-CM – diagnoses ICD-9-CM (V 3) ► ICD-10-PCS* – procedures I/P No change to use of CPT® or HCPCS

Depend on HIPAA transaction updates

* Procedure Coding System

Page 8: AHIMA ICD-10-CM/PCS  Update August 2009

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Impact of Coding System ChangeImpact of Coding System Change

• Data trending challenges

– Maintenance of crosswalks among coding systems for longitudinal data analysis

– Potential for faulty decisions due to distorted, inaccurate, or misinterpreted data

Page 9: AHIMA ICD-10-CM/PCS  Update August 2009

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Impact – Other Healthcare ProvidersImpact – Other Healthcare Providers

• Non-inpatient facilities including physician offices will only use ICD-10-

CM, NOT ICD-10-PCS

• CPT® will continue to be used by Part B providers to describe procedures

Page 10: AHIMA ICD-10-CM/PCS  Update August 2009

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Mapping between Old & New SystemsMapping between Old & New Systems

10

GEMs Maps

GEMs Maps

= GEMs Crosswalks

• General equivalence maps (GEMs) between ICD-9-CM and ICD-10-CM/PCS have been developed

ICD-9-CM ICD-10-PCS via CMS web site

ICD-9-CM ICD-10-CM via CMS /NCHS web sites

Page 11: AHIMA ICD-10-CM/PCS  Update August 2009

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Mapping between Old & New SystemsMapping between Old & New Systems

• Reimbursement map added to CMS web site in 2009– Intended for use by payers – Temporary mechanism – Allows claims processing by legacy systems– Allows for data collection for reimbursement changes

• Maps should NOT be used for coding medical records

Page 12: AHIMA ICD-10-CM/PCS  Update August 2009

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Implications of the Transition – Who? Implications of the Transition – Who?

● Providers ● Hospitals ● Physicians ● Outpatient facilities ● Post-acute providers (home health agencies, skilled nursing facilities, etc.)

● Health Plans or Payers ● Third party administrators ● Employers

Page 13: AHIMA ICD-10-CM/PCS  Update August 2009

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Implications of the Transition – Who? Implications of the Transition – Who?

● Others ● Laboratories ● Free standing ancillaries ● Researchers ● Public health agencies et al. ● Data collection agencies/organizations (registries) ● Vendors ● Clearinghouses ● Business associates and partners

● ● Patients Patients

Page 14: AHIMA ICD-10-CM/PCS  Update August 2009

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Implementation – Two Systems, One or Implementation – Two Systems, One or three? three?

50105010

ICD-10-CM/PCS

01/012010

01/012011

01/012012

01/012013

10/012013

01/012014

ImplementationImplementationTestingTesting

Implementation Implementation TestingTesting

ARRAARRAMeaningful Use”

Page 15: AHIMA ICD-10-CM/PCS  Update August 2009

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X12/NCPDP HIPAA Transactions Implementation Testing Compliance

ICD-10-CM/ICD-10-PCS Implementation Testing Compliance

New Systems (RFIs & RFPs)

Implementation Implementation

Education &Education &TrainingTraining

Page 16: AHIMA ICD-10-CM/PCS  Update August 2009

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Remember Resources Key supporters and worker bees Systems and other resources Vendors and Consultants HIPAA transactions are important What can be done in parallel? Other systems needs Internal v external schedules New systems Business goes on as usual (?)

Implementation Implementation

Page 17: AHIMA ICD-10-CM/PCS  Update August 2009

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Impact of Coding System Change:Impact of Coding System Change: 7 Steps 7 Steps

1. Develop Strategy

2. Communicate

3. Assess Readiness

4. Inventory Process/ System Impact

5. Plan Training

6. Documentation Improvement

7. Develop Budget

Page 18: AHIMA ICD-10-CM/PCS  Update August 2009

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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Develop StrategyDevelop Strategy

• Develop organizational implementation strategy

– Establish sponsors!! (Who for what?)– Establish a multi-disciplinary implementation

planning team and designate leader(s)– Develop internal timeline, including resources

required– Develop organization-wide implementation plan

Page 19: AHIMA ICD-10-CM/PCS  Update August 2009

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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:CommunicateCommunicate

• Communication management strategies

– Minimize “fear of change” factor– Communication is key– Facility-wide

Page 20: AHIMA ICD-10-CM/PCS  Update August 2009

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• Build awareness

– Orient key personnel – Basic familiarity with structure,

organization, and unique features of new systems

– Understand how ICD-10-CM/PCS fits into electronic health record and nationwide health information infrastructure

Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:CommunicateCommunicate

Page 21: AHIMA ICD-10-CM/PCS  Update August 2009

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• Assess organizational readiness for electronic data standard changes (5010)

– Affected staff– Information systems– Documentation process and work flow (Where in the world

is ICD-9-CM?)

– Data availability and use (How is it used now – in the future?)

– Organizational capacity– Local, state, regional trading partners

Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Assess ReadinessAssess Readiness

Page 22: AHIMA ICD-10-CM/PCS  Update August 2009

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Reporting• Provider profiling• Quality measurement• Utilization

management• Disease management

registries• Other registries• State reporting

systems

• Fraud management• Aggregate data

reporting• Clinical systems• Patient assessment

data sets (e.g., MDS, PAI, OASIS)

• Managed care reporting system (HEDIS)

Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:InventoryInventory

Support Systems•Case mix systems•Utilization management•Quality management•Case Management

Clinical Systems•Clinical protocols•Test ordering systems•Clinical reminder systems•Medical necessity software•Disease management systems•Decision support systems•Clinical systems•Pharmacy systems

Billing/ Financial•DRG grouper•Conversion of other payment methodologies•National and local coverage determinations•System logic and edits•Billing systems•Financial systems•Claim submission systems•Compliance checking systems

Registration•Registration and scheduling systems•Advance Beneficiary software•Performance measurement systems•Medical necessity edits

Page 23: AHIMA ICD-10-CM/PCS  Update August 2009

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Phase 1 – Impact Assessment: InventoryPhase 1 – Impact Assessment: Inventory

• Determine length of time for legacy and new coding systems*

• Determine which reports require modification • Forms redesign**• Budgetary implications hardware/software• Vendor readiness and timelines• Build flexibility for future upgrades

* Providers and Plans **Paper or ???

Page 24: AHIMA ICD-10-CM/PCS  Update August 2009

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Phase 1 – Impact Assessment: InventoryPhase 1 – Impact Assessment: Inventory

• Orient IS personnel on specifications of code sets

• Perform comprehensive systems audit– Inventory databases and systems– Screens and input– Map electronic data flow to inventory all

reports containing ICD-9-CM– Detailed analysis of system changes needed

Page 25: AHIMA ICD-10-CM/PCS  Update August 2009

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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:InventoryInventory

• Field size expansion

• Alphanumeric composition

• Use of decimals

• Redefinition of code values

• Longer code descriptions

• Edit and logic changes

• Modification of table structures

• Expansion of flat files containing diagnosis codes

• Systems interfaces

Determine required software changesDetermine required software changes

Page 26: AHIMA ICD-10-CM/PCS  Update August 2009

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• Assess educational needs and develop budget plan• Who will need education?• What type and level of education will they need?• How will the education be delivered?• Education for HIM and Coding

• Education on benefits • Overall electronic health record• Structure, organization and unique features• Monitor AHIMA ICD-10 web site• Reading articles• News/announcements

Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Plan TrainingPlan Training

Page 27: AHIMA ICD-10-CM/PCS  Update August 2009

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• Anatomy and Physiology

• Medical Terminology

• Official Coding Guidelines

• Attention to Documentation

• Reference look-up skills

• Education, Education, Education

Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Plan TrainingPlan Training

Page 28: AHIMA ICD-10-CM/PCS  Update August 2009

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Phase 1 – Impact Assessment: Phase 1 – Impact Assessment: Plan TrainingPlan Training

• Multiple categories of users of coded data will require varying levels of training

• Different categories of coders will require varying levels of training

• Coders working in settings that will not be using ICD-10-PCS will only require ICD-10-CM training

• Training for physician practice coders working in a medical specialty area can be focused on particular code categories

Page 29: AHIMA ICD-10-CM/PCS  Update August 2009

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Who Else Requires Education Within Your Organization?

• Coders

• Other HIM

• Clinicians

• Senior management

• Information systems

• Quality management

• Utilization management

• Accounting

• Business Office

• Auditors and consultants

• Patient access and registration

• Clinical department managers

• Ancillary departments

• Data analysts

• Researchers

• Epidemiologists

• Software vendors

• Performance improvement

• Compliance

• Data quality management

• Data security

• Data analysts

Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Plan TrainingPlan Training

Page 30: AHIMA ICD-10-CM/PCS  Update August 2009

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• Conduct gap analysis of coding and documentation practices

• Assess adequacy of staff knowledge• Measure coding professionals’ baseline knowledge of

anatomy, physiology, pharmacology, and medical terminology

• Identify areas of weakness and provide targeted education if necessary

• Assess adequacy of medical record documentation to support level of detail in new coding systems – implement documentation improvement strategies as needed

Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Documentation ImprovementDocumentation Improvement

Page 31: AHIMA ICD-10-CM/PCS  Update August 2009

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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Develop BudgetDevelop Budget

• Develop budget• Departmental budget responsible for costs

• Systems, hardware, software, education• Increased staffing?

• Impact on productivity and accuracy– Short-term (during learning curve) and long-term– More sophisticated computer-assisted coding technologies and

advances in mapping from clinical terminologies will improve productivity and accuracy

• Consulting services– Backlogs– Monitoring coding accuracy– Other support

• Allocation over several year timeframe

Page 32: AHIMA ICD-10-CM/PCS  Update August 2009

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““Lessons Learned” from Other CountriesLessons Learned” from Other Countries

• Begin now – Don’t wait!

• Importance of planning and preparation

• Six-month learning curve

• Vendor readiness is extremely important

• Communication is critical

• Targeted significant ICD-9/ICD-10 comparability issues

Page 33: AHIMA ICD-10-CM/PCS  Update August 2009

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Bottom Line on Preparation (Goals)Bottom Line on Preparation (Goals)

• Maintain coding productivity

• Maintain coding accuracy

• Reduce claims rejections and denials

• Maintain account receivables

• Proper claims payment

• Reduce risk of compliance issues

• Decisions based on improved data

Page 34: AHIMA ICD-10-CM/PCS  Update August 2009

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Next StepsNext Steps

• Read the Final Rules and analysis

• Begin preparing for the transition to ICD-10-CM/PCS and new HIPAA electronic transactions standards NOW!

• Watch for more information from AHIMA

Page 35: AHIMA ICD-10-CM/PCS  Update August 2009

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Resources Resources

National Center for Health Statistics – CDC ICD-10-CM www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

Centers for Medicare and Medicaid Services ICD-10-PCS www.cms.hhs.gov/ICD10

ICD-10 and HIPAA Federal Register Notices www.access.gpo.gov/su_docs/fedreg/a080822c.html

Page 36: AHIMA ICD-10-CM/PCS  Update August 2009

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Resources Resources

AHIMA ICD-Ten Webpage www.ahima.org/icd10

Analysis of Final Rule for the Adoption of the ICD-10-CM and ICD-10 PCS Code Sets www.ahima.org/dc (under analysis)

Analysis of the Final Rule Modifications to the HIPAA Electronic Transaction Standards www.ahima.org/dc (under analysis)

Page 37: AHIMA ICD-10-CM/PCS  Update August 2009

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Resources Resources

Publications eAlert Journal of AHIMA Advance ICD-Ten AHIMA Website: www.ahima.org ICD-10: www.ahima.org/icd10 Communities of Practice Education programs

Page 38: AHIMA ICD-10-CM/PCS  Update August 2009

© 2008

Dan Rode, MBA, CPHS, FHFMADan Rode, MBA, CPHS, FHFMAVice President, Policy and Government RelationsVice President, Policy and Government RelationsAmerican Health Information Management AssociationAmerican Health Information Management Association1730 M Street, NW, Suite 5021730 M Street, NW, Suite 502Washington, DC 20036Washington, DC 20036Telephone: (202) 659-9440Telephone: (202) 659-9440E-Mail: [email protected] E-Mail: [email protected]

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