ICD- 10 is coming -Brenda Edwards

3/9/2011

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ICDICD--10 IS Coming…10 IS Coming…

Are YOU Prepared?Are YOU Prepared?Brenda Edwards, CPC, CPMA, CPC‐I, CEMCKansas Medical Mutual Insurance Company3/9/2011 1

Agenda

• 5010 Implementation• Resources• Responsibilities and Impacts• Code Check

ICD-10-CM may be referred to

as ICD-10, Code Check– Format of ICD‐10‐CM– External causes– Examples

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ICD10, I-10 or simply I10

5010 Implementation5010 Implementation3/9/2011 3

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5010 Implementation

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Vendor Discussion• CORNERSTONE of implementation planning

– If you haven’t had this discussion yet, you are BEHIND!– The sooner the better for your practice!

• Questions to ask:1.Project lead and contact information2.Is the 5010 update part of existing contract or additional $$ to become compliant?

h ll h b l ?3.When will they be 5010 compliant?4.Will they be ready by 1/1/2012?5.How can you test with them?6. Any side user impacts to systems?– If so, will training be included at no additional cost

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5010 Implementation• ALL HIPAA covered entities MUST be compliant by 1/1/2012• Over 850 changes and benefits (process improvement)

• Clarity in identifying information (provider fields)• Improved tracking to match patient to payer • ICD‐10 support• 45 new “Service Type” codes

– Benefits where physician and hospital events are covered by different insurers

– Query to a payer would require response of both hospital and physician service types if coveredservice types if covered

• Reduced “syntax errors” denials (program language problem with patient name)• COB improvements‐identify to payers primary vs. secondary

• Build in time for unexpected delays and setbacks• No regulatory extension‐fines after HIPAA mandated change

– Minimum $100 per transaction up to $50,000 annually!• Not “just a software update”

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ICDICD--10 Resources10 Resources

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CDC

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AAPC

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CMS

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BCBS of KS

New tools coming soon!

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AHIMA

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Compliance Compliance ResponsibilitiesResponsibilities

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Compliance Responsibilities• Are you involved in a planning, steering or implementation committee?• Valuable input from regulatory standpoint

– Learn all you can about ICD‐10 • www.cms.hhs.gov/ICD10• www.cdc.gov/nchs/icd/icd10cm.htm• www.aapc.com/icd‐10

• Compliance auditorsCompliance auditors– Compare current documentation to what will be required

• Improve documentation – Provider and staff education

• Maintain compliance after implementation date• ? New medical necessity edits new code set?

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Impact

Anything related to the diagnosis or Anything related to the diagnosis or medical necessity will changemedical necessity will change

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Effects of Implementation • What if I’m not ready by the compliance deadline?

Any ICD‐9 codes used in transactions for services or discharges on or after October 1, 2013 will be rejected as non‐compliant and the transactions will not be processed. You will have disruptions in your transactions being processed and receipt of your payments. Physicians are urged to set up a line of credit to mitigate any cash flow interruptions that may occur.– www.ama‐assn.org/go/ICD‐10

• Cash flow problems for provider• Increased denied claims• Temporary increase of physician coding errors• Decreased coder productivity• Increased claims re‐billing

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

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Impact to Providers $$$

• Documentation must support the code• New coverage policies, edits, fee schedules• Greater specificity

Anything related to the diagnosis or medical necessity will change

• Explanations to patients• Payer contracts• Testing orders

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Impact to Administrative Staff

• Confusion from every direction (physicians, patients, providers, plans)

• Delay in payments, increased denials and rebilling

• Health plan contract changes

• Increased phone calls and questions from patients

• ABNs• Budget• Training


• Transition period using ICD‐9 and ICD‐10‐CM• Privacy concerns‐more specificity and detail

• System upgrades– Hardware– Software– Interface

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http://www.cms.gov/ICD10/Downloads/Jan122011_ICD10_Call.pdf

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http://www.cms.gov/ICD10/Downloads/Jan122011_ICD10_Call.pdf

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Impact on Health Plans

• Plan structures• Statistical reports• Actuarial projections• New or revised contracts with providers• Coverage and payment determinations


• Medical review policies• Fraud and abuse monitoring• Quality measurements• Testing

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Benefits of Implementation• Greater detail to describe new diseases• Greater specificity in coding• New understanding of diseases due to increased detail• Reduction in error rates

• Reduction in false claims

• Reduction in returned claims, refunds

• 1 in 5 claims paid without additional documentation or questions!

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What About…

• Inpatient hospital admission with a date prior to October 1, 2013 and discharge date after October 1, 2013??? – “Use ICD‐10‐CM codes for all diagnoses on claims for inpatient settings with dates of discharge that occur on or after October 1 2013 ” (MLN Matters SE1019)after October 1, 2013. (MLN Matters SE1019)

• My coding credential?• Training?• Superbills/encounter forms?• What questions haven’t we thought about?

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Code CheckCode Check3/9/2011 27

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ICD-10-CM is Better…REALLY! ICD‐9‐CM ICD‐10‐CM

3‐5 characters Length of code 3‐7 characters

Nearly 15,000 codes Number of codes 69,000 codes and growing

1st‐alpha or numeric2‐5 numeric

Alpha or numeric digits 1‐alpha,2&3‐numeric, 4‐7 alpha or numeric

No room for new codes Space Flexible for addingNo room for new codes Space Flexible for adding

Lacks detail Detail/Specificity Very specific

Lacks laterality Laterality Has laterality (rt/lt)

Non‐specific andinadequate codes

Accuracy More accurately reported conditions due to level of detail

Not used by other countries

Operability Supports interoperability between U.S. and other countries

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ICD-10-CM and ICD-10-PCS

ICD‐10‐CM ICD‐10‐PCS

Clinical modification of World Health Organization’s (WHO) diagnostic system for the United States

•Procedural coding system (PCS) developed for reporting hospital procedural services•PCS has no relationship with WHO•Linked to ICD‐10‐CM‐both systems are components of DRG system which pays hospitalscomponents of DRG system which pays hospitals for Medicare services

After implementation, physicians will still report their services with CPT® codes and diagnoses with ICD‐10‐CM

Hospitals who provide the operating rooms, nursing services and hospital beds for patients will report the procedures under ICD‐10‐PCS

In some instances, ICD‐10‐CM is referred to as simply ICD‐10, ICD10, or just I‐10

The name of ICD‐10‐PCS may be shortened to “PCS.”

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Need to Know

• There is NOT a crosswalk from ICD‐9‐CM to ICD‐10‐CM – Mapping and conversion tools are available– You HAVE to use the coding book in addition to a mapping tool

• Tool may say 380.4 = H61.23• 380.4 Cerumen impaction = H61.2Ø unspecified ear

H61.21 right earH61.22 left earH61.23 bilateral

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Random Tidbits• There are over 200 codes for Diabetes Mellitus alone!• Diagnoses may have single or multiple codes in ICD‐10‐CM

OR there may not be a code! Example– Endometrial thickening does not have a specific code in ICD‐10‐CM

• ICD‐9‐CM – 793.5 nonspecific findings on radiological exam, genitourinary

• ICD‐10‐CM – R93.4 Abnormal findings on diagnostic imaging of urinary organs

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ICD-10-CM is Better…REALLY!• Nearly twice as many categories as ICD‐9• First three digits have common traits

– Each additional digit adds more specificity• Injuries and post‐op complications grouped by anatomical site

not by type of injury/wound• Diseases are arranged according to

– Etiology– Anatomy– Severity

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ICD-10-CM is Better…REALLY!• Laterality• “x” placeholder (a.k.a “dummy placeholder”)

– Used as 5th character and certain 6th character• Allows for future expansion without disturbing 6 character structure• Example T45.7x2 Poisoning by anticoagulant antagonists, vitamin K, and other coagulants, accidental (unintentional) g , ( )

• Alpha extensions specify encounter status for episode of care or identify status of current condition under care– A Initial encounter– D Subsequent encounter– S Sequela (late effect)

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ICD-10-CM Format

xxx“block”

xxx●

Alpha Numeric Alpha or NumericAlpha

(when present)

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Category

4th CharacterSite, etiology, manifestation or state of disease/condition

“S” and “T” codesInjuries and poisonings and external causes

5th and 6th CharacterMost accurate level of specificity regarding diagnosis or condition

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ICD-10-CM Layout

ChapterNumber and Disease Chapter 19 (SØØ‐T88)

Subcategory4th or 5th character with

4,5, or 6 digit level of specificity S55. Ø12

CategoriesSingle disease or related conditions Defines content S55

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Chapter

Category

Don’t forget !

Subcategory

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ICD-10-CM CategoriesBegin to think in Chapters

Category Chapter Heading

A00‐B99 1 Infectious disease & parasites

C00‐D48 2 Neoplasm

D50‐D89 3 Blood diseases

E00‐E90 4 Metabolic & nutritional diseases

Category Chapter Heading

L00‐L99 12 Skin disease

M00‐M99 13 Musculoskeletal (including Dental)

N00‐N99 14 Genitourinary system

O00‐O99 15 Pregnancy and child birth

F01‐F99 5 Mental health

G00‐G99 6 Nervous & sensory systems

H00‐H59 7 Eye disease

H60‐H95 8 Ear disease

I00‐I99 9 Circulatory system

J00‐J99 10 Respiratory system

K00‐K93 11 Digestive system

P00‐P96 16 Newborn

Q00‐Q99 17 Congenital, deformations, chromosomal abnormalities

R00‐R99 18 Signs, symptoms, & abnormal lab

S00‐T88 19 Injury, poisoning, complications, fractures, & other external causes

V01‐Y95 20 External causes of morbidity (“E” codes)

Z00‐Z99 21 Health status/contact with health services (“V” codes)

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Anatomy of a CodeLaceration of ulnar artery at forearm level, left arm, initial encounter

S55 Injury of blood vessels at forearm levelThird digit (Category)

Alpha /numericOutline the chapters

S55.Ø Injury of ulnar artery at forearmFourth digit

Defines site, etiology, manifestation or state of disease/condition

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S55. Ø1 Laceration of ulnar artery at forearm level

Fifth digitMost precise level of specificity

S55. Ø12 Laceration of ulnar artery at forearm level, left arm

Sixth digitDefines more specificity

S55. Ø12A Laceration of ulnar artery at forearm level, left arm, initial encounter

Seventh digitCodes for injuries and poisonings and other external causes

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Chapter 20External Causes

V00‐Y95 20 External causes of morbidity (“E” codes)

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Chapter 20-External Causes of Morbidity (V01-Y95)

• External causes of morbidity and health status/contact with health services (“V” and “E” codes) will be incorporated into main classification

• Are not specified as optional in ICD‐10‐CM (are required)– Identify intent of circumstance

• Unintentional (accidental)• Intentional (self‐harm or assault)• Place of occurrence• Activity

– Secondary codes to be used for single‐condition coding, only provides supplemental information

– Used only one time per patient encounter on initial encounter for treatment

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• Sequencing multiple external cause codes will depend of the sequence of events leading up to injury

• Sequencing priority– Child and adult abuse– Terrorism has priority over all other external causes except above


p y p– Cataclysmic events take sequence over all except the two above– Transport take sequence over all other external causes except those

listed above

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• Place of occurrence and activity codes are sequenced after the primary external cause code– How it happened– What activity– Where it occurred

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• Extensions– V00‐Y35 require extension to indicate the encounter

• A Initial encounter• D Subsequent encounter• S Sequela (late effect)

• Accidental injuriesj– Default for external cause is unintentional– No documentation of intent of injury=unintentional

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• Activity Code “what” (Y93) new with ICD‐10‐CM– Always used with a place of occurrence code (Y92)– 7th character extension is used on primary code

• 1 non‐work related• 2 work related activity done for income• 3 student activity• 4 activity performed while a student, not for income


• 5 Military activity– Y93 is used with

• Conditions due to long term, cumulative effects (Chapter 13)• Used for acute injuries (Chapter 19) • External cause codes if the activity adds additional information on the event (Y99)

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External Cause Codes

• Place of Occurrence Code “where” (Y92)– Location of the patient at the time of injury– Used with activity code (Y93)– Not necessary for poisonings, toxic effects, adverse effects, or under

dosing codes – Sequenced after main external‐cause code

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Real Life ExamplesICD‐9‐CM Brenda was playing in a softball game and tripped and fell while running to second

base. She has contusions to both knees.ICD‐10‐CM

924.11 Contusion of knee

Contusion of unspecified knee, initial encounter, right knee

left kneeFell on same level from tripping

S8Ø.Ø1xAS8Ø.Ø2xAWØ1 ØxxAFell on same level from tripping

Place of occurrence‐ball fieldActivity code‐while playing softball game

WØ1. ØxxAY92.32ØY93.64

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Real Life ExamplesICD‐9‐CM Brenda presented at prompt care following an attack by her domestic cat

while she was watching tv in bed in her 2 story home. She suffered a superficial cat bite to the left hand. The doctor prescribed antibiotics and cleaned the hand and sent her home.

ICD‐10‐CM

882.0 Open wound of hand except finger(s) alone without mention of complication

Other superficial bite of left handInitial encounterBitten by catActivity code‐watching tv

S6Ø.572AW55. Ø1Y93.89

ØPlace of occurrence‐bedroom of a single family house

Y92. Ø13

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Dyspnea and shortness of breath with intercostal pain in let-sided rib cage

ICD‐9‐CM• 786.05 Dyspnea• 786.09 Shortness of breath• 786.50 Intercostal pain

– No code for intercostal, have

ICD‐10‐CM• RØ6.Ø2 Dyspnea

• RØ6. ØØ Shortness of breath

• RØ7 82 Intercostal painto use rib pain which is found under unspecified chest pain

• RØ7.82 Intercostal pain

Intercostal pain is located in the ribs and muscles between the ribs. Increased pain when coughing, breathing or sneezing.

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Twin pregnancy, 35 weeks, with premature rupture of membranes (ROM) and mal-presentation; twin A in breech

position, twin B in transverse presentation.ICD‐9‐CM

• 658.11 Premature ROM, delivered

• 651.01 Twin pregnancy, delivered w/w‐out mention of antepartum condition

ICD‐10‐CM• 042.913 Preterm ROM, unspecified as to

length of time between rupture and onset of labor, third trimester

• 032.1x1 Breech, twin A,

• 032.2x1 Transverse, twin B • 652.21 Breech, twin A, delivered• 652.31 Transverse, twin B,

delivered• V27.2 Twins, both liveborn

(outcome of delivery)

,

• 03Ø. ØØ3 Twin pregnancy, unspecified, third trimester

• Z37.2 Twins, both liveborn (outcome of delivery)

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Stress incontinence (female) with intrinsic sphincteric deficiency

ICD‐9‐CM• 625.6 Stress incontinence,

female• 599.82 Intrinsic (urethral)

sphincter deficiencyU dditi l d t

ICD‐10‐CM• N39.3 Stress incontinence

(male or female)

• N36.42 Intrinsic sphincter deficiency

– Use additional code to identify urinary incontinence (625.6, 788.30‐788.39)

– Use additional code to identify associated urinary stress incontinence (N39.3)

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Slipped and fell in parking lot while walking to car. The parking lot looked wet but was actually black

ice. Fracture to left ankle and left wrist.ICD‐9‐CM• 824.6 Closed fracture

trimalleolar• 814.00 Closed fracture wrist• E885.9 Fall from slipping,

bl

ICD‐10‐CM• S82.855A Nondisplaced trimalleolar

fracture of left lower leg, initial encounter

• S62.1Ø2A Fracture unspecified carpal bone, left wrist, initial encounter

• WØØ Ø A F ll l l d ttripping, or stumbling • WØØ. ØxxA Fall on same level due to ice and snow, initial encounter

• Y92.481 Parking lot (place of occurrence)

• Y93.89 other activity (activity code)

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Takeaway Points • Embrace the change ‐ its coming with you or without you• 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• It’s not quite time to learn the new code sets because of annual• It s not quite time to learn the new code sets because of annual

changes!• Begin implementation NOW!

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Thank you!Thank you!

[email protected]@kammco.comKaMMCOKaMMCO

AAPCCA Board of DirectorsAAPCCA Board of Directors3/9/2011 53

Health & Medicine

ICD- 10 is coming -Brenda Edwards