Preparing Now For ICD-10-CM

Page 1September 27, 2014

Prepared for Tennessee Orthopaedic Society

Preparing Now For ICD-10-CM

Tennessee Orthopaedic Society

September 27, 2014



• Transition and impact of ICD-10

• ICD-10: Visualized

• High-level review of what’s new in ICD-10-CM coding conventions and guidelines

• Review common diagnoses and documentation requirements in ICD-10

• Project management approach to ICD-10 operational considerations

Learning Objectives



Transition and Impact



What’s new?

NEW compliance date for ICD-10: October 15, 2015

• The ICD-10 delay is forcing organizations to reassess their timelines and budgets for complying with the code change.

• CMS is offering multiple in-person educational options as their well as web-based education.



Making the Transition is Not Optional

• All “covered entities” as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required to adopt ICD-10 codes for use in all HIPAA transactions.

• ICD-10 codes are the foundation for reimbursement and will represent most or a large portion of the data points for healthcare analytics.

• Electronic data interchange (EDI) is the transport tool for claims.

• Lack of operational readiness – systems and staff training – could negatively impact practice business.



Two Sets of Codes are Being Replaced

ICD-10-CM• Diagnosis Coding System – Used to

report the patient’s condition (i.e., what’s wrong with the patient)

• Direct replacement for ICD-9-CM Volumes 1 & 2

• Will be used in all settings – hospital inpatient, hospital outpatient, physician office, etc.

• Like ICD-9-CM, developed and maintained by the World Health Organization (WHO) and the National Center for Health Statistics within the Centers for Disease Control

ICD-10-PCS• Procedure Coding System – Used to

report surgical procedures performed

• Direct replacement for ICD-9-CM Volume 3

• Only used in a hospital inpatient setting (and only for reporting facility services)

• Like ICD-9-CM Volume 3, ICD-10-PCS was developed and is maintained by CMS



Who is Impacted by ICD-10?Everyone!

• Physician Documentation• Physician Integration• Physician Performance

• Staffing Effectiveness• Assessment of Revenue

Impact• Process Improvement• Decision Support Reporting

Impact

• Documentation Analysis• ICD-10 Education• Process Improvement• Monitoring

Physician Office

Post Acute Services

• Front – Scheduling, Access Areas• Middle – Coding, CDI, Case

Management• Back – Billing, Reimbursement

Health Information

Management

ICD-10

Revenue Process

PhysicianOperational Planning

Information Technology

• IT Systems• Capability, Communication• Functionality• Vendor Preparedness



What Does ICD-10-CMLook Like?



ICD-9 vs. ICD-10Issue ICD-9-CM ICD-10-CM

Volume of codes Approximately 13,600 Approximately 69,000

Composition of codes Mostly numeric, with E and V codes alphanumeric.

Valid codes of three, four, or five digits.

All codes are alphanumeric, beginning with a letter and with a mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits.

Duplication of code sets Currently, only ICD-9-CM codes are required. No mapping is necessary.

For a period of up to two years, systems will need to access both ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD-9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits, and outcomes studies.

Source: http://www.aapc.com/icd-10/faq.aspx#why



ICD-10-CM Organization

Index to Diseases and Injuries

Official GuidelinesTabular List of Diseases and

Injuries

The CM Manual divided into three main parts:

21 Chapters

Expanded injury codes grouped by site vs. type

of injury

Laterality (left and right)

V and E codes incorporated into

main classification

Added a placeholder X



Anatomy of an ICD-10-CM Code

3-7 Alphanumeric characters (digits)

X X X X X X X.

1st character – Alpha (A-Z)

2nd character - Numeric

3rd - 7th characters –

Alpha or Numeric

Decimal placed after

the first 3 characters

• All letters but U are used

• The letters I & O are used only in the 1st character position

• Each letter is associated with a particular chapter (Except C&D Neoplasms)



X X X X

Category

.Etiology, anatomic

site, severity

Added code extensions (7th character) for

obstetrics, injuries, and

external causes of injury

ICD-10-CM Characters and Extensions

X X XAMS 0 2 6. 5 x A

Alpha (Except U)

2 - 7 Numeric or Alpha

Additional Characters



• Partial solution: these are tools to convert ICD-9 to ICD-10 and vice versa.

• To assist with the transition, cross-walking between the code sets will assist you with identifying the differences between ICD-9 and ICD-10.

• Not a high percentage of accuracy (very few one-to-one matches) due to increased specificity of ICD-10 versus ICD-9.

Crosswalk



GEMsGEMs (General Equivalence Mappings) are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, including data for:

– Tracking quality

– Recording morbidity/mortality

– Calculating reimbursement

– Converting any ICD-9-CM-based application to ICD-10-CM/PCS

The GEMs are not a substitute for learning how to use the ICD-10 codes. More information about GEMs and their use can be found on the CMS website at:

http://www.cms.gov/Medicare/Coding/ICD10/index.html

(select from the left side of the web page ICD-10-CM to find the most recent GEMs)




How Does the Mapping Work?

ICD-9-CM

• 719.46 Pain in joint, lower leg

ICD-10-CM

• M25.561 Pain in right knee

• M25.562 Pain in left knee

• M25.569 Pain in unspecified knee



Percentages of Types of Matches

Mapping Categories

ICD-10 to ICD-9

ICD-9 to ICD-10

No Match 1.2% 3.0%

1-to-1 Exact Match 5.0% 24.2%

1-to-1 Approximate Match with 1 Choice 82.6% 49.1%

1-to-1 Approximate match with Multiple Choices 4.3% 18.7%

1-to-Many Matches with 1 Scenario 6.6% 2.1%

1-to-Many Matches with Multiple Scenarios 0.2% 2.9%

Source: http://www.ama-assn.org/ama1/pub/upload/mm/399/crosswalking-between-icd-9-and-icd-10.pdf



High-Level Review of ICD-10 Coding Conventions and

Guidelines



Marks the Spot

• ICD-10-CM uses a placeholder character “X” which allows for future code expansion.

• Where indicated as a placeholder the X must be used in order for the code to be valid. (The X is not case sensitive).

• A dash (-) at the end of an Index entry indicates that additional characters are required; review the tabular section for selection.

XPlaceholder Character



Place an X in the 5th and 6th digit

ICD-10-CM utilizes a placeholder: Character “X” is used as a 5th character placeholder in certain 6 character codes

• To fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character

Examples:

• S72.8x1A – Other fracture of right femur, initial encounter

• M48.8x6 – Other specified spondylopathies, lumbar region

• S03.4xxA – Sprain of jaw, initial encounter



Sequela – Late Effect

• A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.

• There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.

• Coding of sequela generally requires two codes sequenced in the following order:

– The condition or nature of the sequela is sequenced first.

– The sequela code is sequenced second.



Laterality

• Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right, or bilateral.

• If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

• If the side is not identified in the medical record, assign the code for the unspecified side.

Examples:

– M24.412 – Recurrent dislocation, left shoulder

– M65.321 – Trigger finger, right index finger

– L89.012 – Pressure ulcer of right elbow, stage II



More Information Reported, Higher Level of Detail in Coding



Greater Specificity and Detail in Orthopedic Coding:

• 34,250 of all ICD-10-CM codes are related to the musculoskeletal system.

• 17,045 of all ICD-10-CM codes are related to fractures.

• 10,582 of fracture codes distinguish right from left.

• 25,000 of all ICD-10-CM codes distinguish right from left.



Musculoskeletal • There are several changes and expansion to the

musculoskeletal code system in ICD-10.

• Most codes in this section require additional documentation to correctly code site and laterality to the highest level of specificity, which include:

– Documentation of site and laterality

– More specific information for fractures and injuries

– Identification of episode of care

– Additional coding instructions surrounding osteoporosis

– Reorganization of codes

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=mOOtIh3CBUcsRM&tbnid=fwO3tBNSvq5kSM:&ved=0CAUQjRw&url=http://www.chiropracticlakemary.com/736696/2013/08/02/a-brief-look-at-the-musculoskeletal-system.html&ei=0gF0UrD6FMnA4AOBp4DYDA&bvm=bv.55819444,d.cWc&psig=AFQjCNFBBjZ-8CNkHpae6OXKQDZO6tl0yg&ust=1383420622486990



Fracture SpecificityFractures Require Greater Specificity:

• Type of fracture

• Specific anatomical site

• Displaced vs nondisplaced

• Laterality

• Routine vs delayed healing

• Nonunion

• Malunion

• Type of encounter

– Initial

– Subsequent

– Sequela



Episode of Care – Fractures

Assigning episode of care 7th characters for fractures is a bit more complicated because the episode of care provides additional information about the fracture including:

• Whether the fracture is open or closed.

• Whether healing is routine or with complications such as delayed healing, nonunion, or malunion.



Episode of Care – Fractures7th Characters

• Initial encounter for closed fractureA• Initial encounter for open fractureB• Subsequent encounter for fracture with routine healingD• Subsequent encounter for fracture with delayed healingG• Subsequent encounter for fracture with nonunionK• Subsequent encounter for fracture with malunionP• SequelaS

If the fracture is not documented as open or closed, it is coded to closed.

Additionally, if the fracture is not documented as displaced or not displaced, it should be coded as displaced.



• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

J

• subsequent encounter for open fracture type I or II with nonunionM

• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

N

• subsequent encounter for open fracture type I or II with malunionQ

• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

R

Episode of Care –Open Fractures

• initial encounter for open fracture type I or II initial encounter for open fracture NOS

B

• initial encounter for open fracture type IIIA, IIIB, or IIICC

• subsequent encounter for open fracture type I or II with routine healing

E

• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

F

• subsequent encounter for open fracture type I or II with delayed healing

H

The open fracture designations are based on the Gustilo open fracture classification



Resources Available

• http://www.cms.gov/Medicare/Coding/ICD10/index.html

• http://www.ahima.org/icd10/

• http://www.aapc.com/icd-10/index.aspx

• http://www.cdc.gov/nchs/icd/icd10.htm

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


http://www.ahima.org/icd10/

http://www.aapc.com/icd-10/index.aspx

http://www.cdc.gov/nchs/icd/icd10.htm

http://www.who.int/classifications/icd/en/



Project Management



ICD-10 Project Overview

Successful Go-Live

Training

Testing

Communications

Planning



Updated ICD-10 TimelinePYA

May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov DecPlanningIdentify resourcesCreate project teamAssess effectsCreate project planSecure budget

CommunicationsInform staffContact vendorsContact payersMonitor vendor prepMonitor payer prep

TestingHigh-level training for test teamLevel 1: internal

Level 2: external1

Comprehensive TrainingDocumentationCoding

2October 1, 2015 is the NEW compliance date for ICD-10.

2014 2015

GO LIVE

Confirm ongoing practice schedule to correspond with

new "go live"2 date

1Monitor external testing periods - go to http://www.cahabagba.com/news/icd-10-volunteer-testing/ to apply for volunteer testing opportunity - DEADLINE 10/3/14.



Planning: Major Activities

Identify resources

Create project plan

and team

Assess effects

Secure budget



Planning:Sample Activities

• Assess practice pre-authorization form and/or templates for code changes needed.

• Review pre-authorization workflow processes and affected staff for ICD-10 training needs.



Planning

• Review all National Coverage Determination (NCD) and Local Coverage Determination (LCD) policies used in the practice for updated code sets from ICD-9 to -10.

http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html

• Review any practice internal codes for denials or quality training that are tied to ICD-9 and create an ICD-10 migration plan for these codes to be updated.






Planning

• Determine the best superbill solution for the practice specialty; is an electronic solution an option?

• Assess current superbill process based on potential list of ICD-10 codes for the practice.



Planning

• Communicate with the ICD-10 leadership team at each facility - whether hospital, ASC, or nursing home - where practice physicians are working. They should be informed about the ICD-10 training process requirements for the practice physicians.

• Compile a top 10 list of the current practice denials relating to diagnosis codes, then create ICD-10 training materials around these codes.



Planning

• Review all customized reports for reference to ICD-9 and make sure updates are made for ICD-10. (e.g. billing, quality reporting, clinical trials, etc.)

• Review all monthly management reports for physicians, and referrals which may contain a filter or data field relating to ICD-9. Be sure the data field is set to accommodate ICD-10.



Planning

• Create a troubleshooting plan “decision tree” for denials issues (like disaster plan). Who does what, when, based on the problem?

When in danger, or in doubt, run in circles, scream and shout. - Infantry Journal, Vol. 35, (1929), p. 369.



Communication: Major Activities

Monitor vendors

and payers

Contact vendors

and payers

Inform staff



Communications: Sample Activities

• Create a checklist by payer regarding their ICD-10 readiness and claims filing timeline requirements; monitor and update in the months leading up to the new deadline.

• Create a checklist by payer for pre-authorization coding transition dates to ensure compliance; monitor and update in the months leading up to the new deadline.



Communications

• Verify payer timing requirements for ICD-10 use in pre-certification and pre-authorization processes (i.e., pre-cert work completed prior to ICD-10 'go-live' date may need to be done in ICD-10 codes for visits after 'go-live' date).

• Review any commercial payer quality reporting processes to be sure any ICD-9 linked data is updated to ICD-10.



Testing: Major Activities

Train the Testing Team

Internal Testing

External Testing



Testing

• Testing Team

– Identify members

– Assign duties and focus

• Who will test the PM/EHR system(s)?

• Who will test with the clearinghouse(s)?

• Who will test with the payers?

– Develop feedback form, timeline, and follow-up steps



Testing: What to test?

• Internally:

– Provider/staff process for selecting ICD-10 codes in PM/EHR system

– Within the system screens, are the ICD-9/10 fields big enough for the new code format?

– Run reports which contain ICD-9/10 codes

• Are all digits showing?

• If the code description is included, is it understandable?



Training: Major Activities

Documentation

Coding



Training

• Create an ICD-9 workflow map throughout the office: moving to each work area examine processes – daily, weekly, monthly, random-use – for ICD-9 involvement in order to develop appropriate staff training and focus areas.

• Prepare ICD-10 training based on job-type group, i.e., clinicians, front desk staff, billing, etc. and tailor content based on job duties associated with ICD-9.



Training

• If you determine that an outside vendor will be hired for training assistance, allow 2-3 months prior to training for decision making and contracting. However, keep in mind that vendors and trainers will start filling up as the deadline nears.



Project Management

Making the difference



Thank you!

Linda ClenDeningConsulting Manager

Pershing Yoakley & Associates, P.C.(865) 684-2735

[email protected]

Healthcare

Preparing Now For ICD-10-CM