Icd 10 general presentation

ICD 10 BasicsTaino Consultants Inc.

Dr. Jose I. Delgado

Taino Consultants Inc. 2

Battered by

child: E96.794


Grandma got

run over by a

reindeer:

V06.00xA


Problems in

relationship with in laws: Z63.1


Uncongenial work

environment: Z63.1


Crushed by Alligator: W5803XA


What Is ICD-10? ICD-10 is the updated version of codes used for

coding:• Diagnoses for all providers (ICD-10-CM)• Inpatient hospital procedures (ICD-10-PCS)

ICD-10-CM is the US “clinical modification” of the WHO ICD-10 code set

ICD-10-PCS is a U.S. creation These are “classification” code sets


Major Changes from ICD-9 to ICD-10 Not just the usual annual update ICD-10 markedly different from ICD-9 Requires changes to almost all clinical and

administrative systems Requires changes to business processes Changes to reimbursement and coverage Will enable significant improvements in care

management, public health reporting, research, and quality measurement

Why?


Specific Changes Diagnosis Codes (ICD-9 to ICD-10-CM)

• From 5 positions (first one alphanumeric, others numeric) to 7 positions, all alphanumeric

• From 13,000 existing codes to 68,000 codes• Much greater specificity • Full description and consistency within the code set• Uses modern terminology for descriptions• Creation of combination diagnosis/symptom codes

to reduce the number of codes needed to fully describe a condition


Specific Changes Enables laterality (right vs. left designations)

• It makes a difference whether the right or left limb is the subject of the problem

Restructures reporting of obstetric diagnoses• In ICD-9-CM, the patient is classified by diagnosis in

relation to the episode of care. • In ICD-10-CM, the patient is classified by diagnosis in

relation to the patient’s stage of pregnancy


Difference in Organization The ICD-10 codes are organized differently than the

ICD-9 codes Example:

• Sense organs have been separated from nervous system disorders

• Injuries are grouped by anatomical site rather than injury category

• Postoperative complications have been moved to procedure-specific body system chapter


Examples of ICD-10-CM Specificity Sports injuries now coded with sport and reason

for injury• ICD-9 code - Striking against or struck accidentally

in sports without subsequent fall (E917.0)• 24 ICD-10-CM Detail Codes


Examples of ICD-10 Specificity

V43.51 Car driver injured in collision with sport utility vehicle in traffic accident

V43.61Car passenger injured in collision with sport utility vehicle in traffic accident

V43.53 Car driver injured in collision with pick-up truck in traffic accident

V43.63 Car passenger injured in collision with pick-up truck in traffic accident

V55.5 Driver of pick-up truck or van injured in collision with railway train or railway vehicle in traffic accident

V55.6 Passenger in pick-up truck or van injured in collision with railway train or railway vehicle in traffic accident

V73.6 Passenger on bus injured in collision with car, pick-up truck or van in traffic accident

Notes:• On above remember to add 7th digit character: A – initial encounter, D – subsequent encounter or S – sequel • Also remember placeholders when needed (i.e.: V43.51xA)


Place of Occurrence SpecificityY92 Place of occurrence of the external cause• More specificity in rooms of home or public place

Y92.0 Non-institutional (private) residence Y92.010 Kitchen Y92.011 Dining room Y92.012 Bathroom Y92.013 Bedroom Y92.014 Private driveway Y92.015 Private garage Y92.016 Swimming-pool Y92.017 Garden or yardY92.02 Mobile home as the place of occurrence Y92.03 Apartment as the place of occurrence

(Condominium or Co-op apartment) Y92.12 Nursing home as the place of occurrence of the external

cause Y92.14 Prison as the place of occurrence of the external cause Y92.143 Cell of prison as the place of occurrence of the external cause Y92.147 Courtyard of prison as the place of occurrence of the external cause


New Concepts• Timeline changes for postpartum and other conditions

o 072.3 Postpartum coagulation defectso 090.4 Postpartum acute kidney failureo 090.6 Postpartum mood disturbance

• New concepts such as coding trimester & fetus number• New concept such as underdosing that is not seen in ICD-9• New chapters for both eyes & ears, which are currently in the

Nervous Systems & Sense Organs chapter• Many codes in ICD-10-CM include site & laterality (i.e. Chapter

13)o M25.511 Pain in right shouldero M25.512 Pain in left shoulder

• Combination codes that are new in ICD-10-CM


New Concepts• Postoperative & intraoperative complications are now found at

the end of each body system chapter o K91.7- Accidental puncture and laceration of a digestive

system organ or structure during a procedure K91.71 Accidental puncture and laceration of a digestive

system organ or structure during a digestive system procedure

K91.72 Accidental puncture and laceration of a digestive system organ or structure during other procedure

Note: that K91.7 may not be used without additional characters.

• Seven digit extensions to indicate encounter & healing such as nonunion & malunion fractures: • Seventh digit K - subsequent encounter for fracture with

nonunion• Seventh digit P - subsequent encounter for fracture with

malunion


Examples

718.86Knee Instability Lower Leg M23.50Chronic instability of knee, unspecified knee

M23.8X9Other internal derangements of unspecified knee

M23.51 Chronic instability of knee, right kneeM23.52 Chronic instability of knee, left kneeM25.261 Flail joint, right kneeM25.262 Flail joint, left kneeM25.269 Flail joint, unspecified kneeM25.361 Other instability, right kneeM25.362 Other instability, left kneeM25.369 Other instability, unspecified knee

719.41Shoulder Pain Generalized M25.519 Pain in unspecified shoulderM25.511 Pain in right shoulderM25.512 Pain in left shoulder


Structure of ICD-10 PCS


• Documentation of diagnoses and procedures●Codes must be supported by medical documentation●ICD-10-CM codes are more specific●Requires more documentation to support codes●Expect a 15% increase in documentation time (per

American Academy of Professional Coders)●Revenue Impacts of specificity

▫ Denials▫ Additional Documentation

Provider Impacts


• Coverage and Paymento New coding system will mean new coverage policies, new medical

review edits, new reimbursement scheduleso Changes will be made to accommodate increased specificityo May need to discuss changes with patients

Provider Impacts


• Relationship with Plans●Coding more specific and includes severity●Changes will be based on new coding, coverage,

and reimbursement●Difficult to measure what the changes will mean

to overall reimbursement

Provider Impacts


• Billing and Eligibility Transactionso Updated transactions include support for ICD-10o New codes mean more specificityo Expect increased reject, denials, and pendings as

both plans and providers get used to new codes

Provider Impacts


EXCEPTION AND CHALLENGES TO ICD-10

Workers Compensation and Auto carriers are excluded from conversion to ICD-10 How will workers compensation claims be

submitted? How will health plans handle in subrogation?


ICD-10-CM MYTHS Providers will need to change how they practice medicine

Documentation is critical as the same must support the ICD 10 code. In other words, high probability of an increase in time to complete paperwork and collect information from each patient

Providers and coders need to start learning the new code set now Too late. Now is time to cram!!!

They must implement an Electronic Medical Record with ICD-10-CM Electronic records are not required. Paper records are still allowed.

They must hire additional staff to handle the workload Potentially as there is a high probability of an increase in paperwork,

coding and billing process


ICD-10-CM MYTHS ICD-10 is not currently used in the US

No. It has been used to classify causes of death ICD-10 is replacing CPT

No. CPT is the service provided ICD is the reason plus other circumstances related to the cause

Providers do not need to know about – PCSHospital services requires ICD 10 PCS coding

CMS will change the deadline Dates are firm; no delays; no grace period


Latest Guidanceas of Sep 24, 2015

• While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD- 10 code from the right family is submitted, Medicare fee-for-service will process such code and not auditExample o Right Code:

• G43.711 (Chronic migraine without aura, intractable, with status migrainosus).

o Right Family: • G43.701 (Chronic migraine without aura) or • G43.719 (Chronic migraine without aura, intractable without status

migrainosus) Under the audit flexibilities, occurring till Oct 1, 2016, there is no need to audit since they are all in the same family of codes.


Family of Codes• “Family of codes” is the same as the ICD-10

three-character category.

Example: K50 Crohn’s diseaseo K50.00 Crohn's disease of small intestine without

complications o K50.012 Crohn's disease of small intestine with intestinal

obstruction o K50.90 Crohn's disease, unspecified, without

complications


ReminderMedicare review contractors will not deny

physician or other practitioner claims billed under the Part B physician fee schedule

through either automated medical review or complex medical record review based solely

on the specificity of the ICD-10 diagnosis code as long as the physician/ practitioner uses a valid code from the right family of

codes.


REFERENCEShttp://icd10crosswords.com/whats_new.htmCMS ICD 10, ICD-10 Planning and Assessment PresentationICD-10 will be here before you know it…Are you

Ready?, Gianni Gonzalez, HealthCare Management Solutions, LLC

A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html.

http://icd10crosswords.com/whats_new.htm

http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

Dr. Jose I DelgadoTel 904-794-7830

[email protected]

www.tainoconsultants.com

http://www.tainoconsultants.com/

Healthcare

Icd 10 general presentation