ICD-10:What Do The Experts Have to Say?

Brenda Edwards, CPC, CPMA, CPC-I, CEMCCoding & Compliance Specialist KaMMCO

Who are the Information Sources?• CMS ▫ Centers for Medicare and Medicaid Services

• WHO ▫ World Health Organization

• AAPC ▫ American Academy of Professional Coders

• BCBS of KC ▫ Blue Cross Blue Shield of Kansas City

• AHIMA ▫ American Health Information Management Association

What Needs to Happen Before ICD-10?• Transition to HIPAA 5010 transaction standards

What is 5010?

ELECTRONIC TRANSACTIONS

• The transaction and code sets rule was part of the original HIPAA law from 1996 to adopt standards ▫ ANSI 4010A▫ Adoption of CPT, ICD-9, and HCPCS as standard code sets▫ Standardized electronic reporting format for covered transactions

(claims, remittance, etc.)• Current versions lack functionality▫ 1/2009 Secretary of HHS adopted Version 5010, Version D.0, and

NCPDP 3.0 as the HIPAA standard code sets

What are the Improvements?• More specific reporting of data

▫ Anesthesia all time based (no longer units)▫ Provider physical address no longer P.O. Box (not billing

address)▫ Zip + 4 zip codes (i.e. 66610-9685)

9998 if unknown• Technical reports

▫ More consistent data/less confusing▫ (Transaction 277)

Claims status request and replyRecoupment

• Distinguishes ▫ Principal and admitting diagnosis▫ External cause of injury▫ Patient reason for visit▫ “Present on admission”

• Supports monitoring illness mortality rates• Accommodates ICD-10-CM and ICD-10-PCS

5010 (and ICD-10) Compliance TimelinesDate Compliance StepJanuary 1, 2010 Payers and providers should begin internal testing of Version 5010 standards for electronic

claims

December 31, 2010

Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance

January 1, 2011 • Payers and providers should begin external testing of Version 5010 for electronic claims• CMS begins accepting Version 5010 claims• Version 4010 claims continue to be accepted

December 31, 2011

External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance

January 1, 2012 • All electronic claims must use Version 5010• Version 4010 claims are no longer accepted• ICD-10 end-to-end testing begins

October 1, 2013 • Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures• CPT codes will continue to be used for outpatient services

http://www.cms.gov/ICD10/03_ICD-10andVersion5010ComplianceTimelines.asp#TopOfPage

Steps to Prepare for Version 5010

• Talk with vendors ▫ Accept both 4010 and 5010?

• Discuss implementation plans with clearinghouses, billing services, and payers ▫ Be proactive, don't wait

• Conduct testing on Version 5010 codes with payers and clearinghouses▫ Testing is critical

5010 Transition Information

http://www.cms.gov/MFFS5010D0/

http://www.cms.gov/ICD10/downloads/w5010BasicsFctSht.pdf

ICD-10

• Used throughout the world▫ Classify causes of mortality (death records)

• CM = Clinical Modification for U.S.▫ Used for morbidity (illness) statistics▫ Canada (CA), Australia (AM) and other countries

have developed clinical modifications • Advancing technology• ICD-9 has run out of codes▫ Used for 30 years

• Codes impact all aspects of billing and reimbursement for providers, facilities, and health plans

Why ICD-10-CM?

ICD-10 Provider Office Changes

• It WILL affect every aspect of the provider office

http://www.aapc.com/ICD-10/office-map/index.aspx

Steps to Prepare for ICD-10• Identify your current systems/processes that use ICD-9 codes

▫ ICD-10 codes will take their place• Talk with your payers

▫ How will ICD-10 implementation might affect your contracts? • Identify potential changes to work flow and business processes• Assess staff training needs

▫ Identify staff who need to know the new codes▫ Coding professionals recommend training place 6 months prior to October 1,

2013▫ CPC’s will need to be re-certified

All certified coders are required to pass the validation by September 30, 2014 to maintain certification http://www.aapc.com/ICD-10/faq.aspx#implemented

• Budget for time and costs related to ICD-10 implementation▫ System changes,▫ Resource materials▫ Training▫ Assess costs

Software updates Reprinting of superbills/encounter formsTraining and related expenses

http://www.cms.gov/ICD10/05a_ProviderResources.asp#TopOfPage

CMS FAQ’s

• What should coders be doing now? ▫ Learn structure, organization, and unique features of ICD-10▫ Learn system impact▫ Assess areas of strength/weakness (anatomy, terminology)

Review knowledge conceptsAdditional training to refresh/expand knowledge

▫ Intensive coder training approximately 6 -9 months prior to implementation

Allocate 16 hours of ICD-10 training Adequate for most codersVery proficient ICD-9 coders may not need that much

Full text available at: http://questions.cms.hhs.gov/app/answers/detail/a_id/10024/kw/icd-10

CMS FAQ’s• When will ICD-9 codes stop being accepted?▫ ICD-9-CM codes will not be accepted for services provided on

or after October 1, 2013.▫ Note: ICD-10 codes will not be accepted for services prior to

October 1, 2013

http://questions.cms.hhs.gov/app/answers/detail/a_id/10019/p/8,11,981

• Impact to providers▫ Documentation must support the code▫ New coverage policies, edits, fee schedules▫ Greater specificity▫ Explanations to patients▫ Payer contracts▫ Testing orders▫ Budget▫ Training ▫ System upgrades

HardwareSoftwareInterface

How Painful Will This Be$

• New or revised contracts with providers• Determinations▫ Coverage▫ Payment

• Medical review policies• Plan structures• Statistical reports• Actuarial projections• Fraud and abuse monitoring• Quality measurements• Testing

Impact on Health Plans

• Confusion (physicians, patients, providers, plans)• Increased denials?• Transition period using ICD-9 and ICD-10-CM• Privacy concerns- more specificity and detail• Delay in payment$• Increased phone calls and questions from patients

Impact for Billing and Collections

• Project team and impact analysis• Timeline and budget• Documentation needs analysis• Communication and training plan• IT design and development• Process analysis and needs assessment• Deployment of ICD-10

Steps to ICD-10-CM Implementation

• In the inpatient prospective payment system (IPPS) proposed rule for fiscal year (FY) 2011, CMS states:

▫ We welcome additional input on having the last regular code updates to ICD-9-CM and ICD-10 on October 1, 2011, and to only add codes for new technologies and diseases on October 1, 2012 and 2013. We also welcome additional input on having the next regular update to ICD-10 occur again on October 1, 2014.

• Providers, payers, clearinghouses, and health information technology vendors will not have to simultaneously keep pace with code updates while also reconfiguring their existing systems for ICD-10-CM/PCS.

Freeze on Code Sets?

How Big is THE Change?

•17,000

▫ This number represents only ICD-9-CM codes

•141600

▫ 72,500 ICD-10-PCS▫ 69,100 ICD-10-CM

▫ Room to move up to 155,000

An increase of 1,000 new codes from 2009 to 2010

1,982 added983 deleted

1,029 revised

ICD-9 to ICD-10 ComparisonICD-10 Category ICD-9

A00-B99 Infectious disease and parasites 001-139

C00-D49 Neoplasm 140-239

D50-D89 Blood diseases 280-289

E00-E90 Metabolic and nutritional diseases 240-279

F01-F99 Mental health 290-319

G00-G99 Nervous and sensory systems 320-389

H00-H59 Eye disease 360-379

I00-I99 Circulatory system 390-459

J00-J99 Respiratory system 460-519

K00-K94 Digestive system 520-579

L00-L99 Skin disease 680-709

M00- M99 Musculoskeletal (including Dental) 710-739

ICD-10 Category ICD-9

N00-N99 Genitourinary 580-629

O00-O99 Pregnancy and child birth 630-676

P00-P96 Newborn 764-779

Q00-Q99 Congenital, deformations, chromosomal abnormalities

740-759

R00-R99 Signs, symptoms, and abnormal lab 780-799

S00-T88 Injury, poisoning, complications, fractures, & other external causes

800-999

V01-Y95 External causes of morbidity “E” codes

Z00-Z99 Health status/contact with health services “V” codes

ICD-9 to ICD-10 Comparison

ICD-9 Format

• Classify conditions according to the part of the body affected rather than to those dealing with the underlying generalized disease.

• http://www.who.int/classifications/icd/en/HistoryOfICD.pdf

ICD-10-CM Format

xxx xxx X

CategoryEtiology,

Anatomical Site, Severity

Extension

Alpha

NumericAlpha or Numeric

Categories and Subcategories• First digit

▫ Alpha▫ “U” not used-saved for newly

discovered diseases of unknown etiology

• Second and Third digits▫ Numeric

• Fourth digit▫ Defines site, etiology, manifestation

or state of disease/condition• Fifth digit

▫ Most precise level of specificity• Sixth digit

▫ Defines more specificity• Seventh digit

▫ Codes for injuries and poisonings and other external causes

• S55 Injury of blood vessels at forearm level

• S55.0 Injury of ulnar artery at forearm

• S55.01 Laceration of ulnar artery at forearm level

• S55.012 Laceration of ulnar artery at forearm level, left arm

• S55.012A Laceration of ulnar artery at forearm level, left arm, initial encounter

The “Block”

Categories and Subcategories

Extensionso Dummy placeholders (x)

used in 5th place when there are 6 digits in the code

• T45.7x2 Poisoning by anticoagulant antagonists, vitamin K, and other coagulants, accidental (unintentional)

• ICD-9-CM▫ 729.5 Pain in limb

Pain in Limb

• ICD-10-CM• Over 30 Codes Choices!!!▫ Right, left or unspecified▫ M79.60_ Pain in limb,

unspecifiedStill need to indicate right or left arm or leg

▫ M79.62_ Upper arm/axilla▫ M79.63_ Forearm▫ M79.64_ Hand/finger▫ M79.65_ Thigh ▫ M79.66_ Pain, Lower leg▫ M79.67_ Toe▫ 6th digit 1-9 to indicate

laterality or specific digit

• ICD-9-CM▫ 845.00 Sprains

and strains of ankle, unspecified site

Ankle Sprain • ICD-10-CM• Over 15 Code Choices!▫ Initial or subsequent encounter

(7th digit-A,D, or S)▫ S93.409A Sprain of unspecified

ligament of unspecified ankle, initial encounter

▫ S93.409D Sprain of unspecified ligament of unspecified ankle, subsequent encounter

▫ S93.409S Sprain of unspecified ligament of unspecified ankle, sequela

• ICD-9-CM▫ V22.1 Prenatal care, normal,

other pregnancy

Pregnancy • ICD-10-CM▫ 1st, 2nd or 3rd Trimester ▫ Z34.80 Encounter for supervision of

other normal pregnancy, unspecified trimester

▫ Z34.81 Encounter for supervision of other normal pregnancy, 1st trimester

▫ Z34.82 Encounter for supervision of other normal pregnancy, 2nd trimester

▫ Z34.83 Encounter for supervision of other normal pregnancy, 3rd trimester

▫ Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester

▫ Z34.91 Encounter for supervision of normal pregnancy, unspecified,1st trimester

▫ Z34.92 Encounter for supervision of normal pregnancy, unspecified, 2nd trimester

▫ Z34.93 Encounter for supervision of normal pregnancy, unspecified, 3rd trimester

• ICD-9-CM▫ 381.00 Otitis media, acute

nonsuppurative, unspecified

Otitis Media• ICD-10-CM

▫ Right, left or bilateral▫ Recurrent?▫ H65.191 Other acute nonsuppurative otitis

media, right ear▫ H65.192 Other acute nonsuppurative otitis

media, left ear▫ H65.193 Other acute nonsuppurative otitis

media, bilateral▫ H65.194 Other acute nonsuppurative otitis

media, recurrent, right ear▫ H65.195 Other acute nonsuppurative otitis

media, recurrent, left ear▫ H65.196 Other acute nonsuppurative otitis

media, recurrent, bilateral▫ H65.197 Other acute nonsuppurative otitis

media, recurrent, unspecified ear▫ H65.199 Other acute nonsuppurative otitis

media, unspecified ear

• ICD-9-CM▫ 493.90 Asthma,

unspecified

Asthma• ICD-10-CM▫ Intermittent or persistent▫ Mild, moderate or severe▫ J45.20 Mild intermittent asthma,

uncomplicated▫ J45.30 Mild persistent asthma,

uncomplicated▫ J45.40 Moderate persistent,

uncomplicated▫ J45.50 Severe persistent,

uncomplicated ▫ J45.909 Unspecified asthma,

uncomplicated▫ J45.998 Other asthma

• ICD-9-CM▫ 824.0 Fracture, medial

malleolus (closed)

Ankle Fracture• ICD-10-CM

• Over 12 Coding Choices▫ Traumatic or Pathologic▫ Right or left▫ Displaced or nondisplaced

▫ M84.47_ Pathologicalfracture, ankle, foot and toes (9 codes)

▫ S82.5_ Fracture of medial malleolus (6 codes)

What Training Will AAPC Offer?

2011 2012 2013 2014Onsite Provider Training X

Half-Day Workshop Throughout the Country

X X

Specialty-specific Distance Learning (eLearning)

X X X

Webinars X X X

Audio Conference Courses X X

National Conference Education SessionsX X X

Proficiency Validation ** X X X

Regional Training X

**Proficiency validation will be taken online within the AAPC Member Area. The validation will be composed of 75 questions, timed and open book. All certified coders are required to pass the validation by September 30, 2014 to maintain certification. The proficiency validation may be taken twice for $60.

How Can Local Chapters Help?

▫ Some Examples might be ……Work groups by specialtyMonthly speakersList serveRound table discussionsNetworking events with other coding chaptersTrack payer issuesTrack vendor issues

Know Where to Go Centers for Medicare and Medicaid Services www.cms.govAmerican Academy of Professional Coders www.aapc.comAmerican Health Information Management Association www.ahima.orgAmerican Academy of Family Physicians www.aafp.comAmerican Hospital Association www.aha.orgWorkgroup for Electronic Data Interchange www.wedi.orgAmerican Medical Billing Association www.amba.netHealthcare Information and Management Systems Society www.himss.org

CMS information on 5010 transition:http://www.cms.gov/Versions5010andD0/

• Embrace the change - its coming with you or without you - no grace period!

• Huge book – small subset per specialty• Develop crosswalks that are easy to use• Plant seeds early - train later• Provide general training and move to specific

training• Begin implementation NOW!

Making Lemonade

Old Chinese ProverbTh

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