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ICD-10 Presentation Takes Coding to New Heights

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PYA Staff Consultant Kim-Marie Walker updated physicians at Robins Air Force Base on the latest in ICD-10 as part of “Soaring Together: A Collaboration in Continuing Medical Education."

PYA Staff Consultant Kim-Marie Walker updated physicians at Robins Air Force Base on the latest in ICD-10 as part of “Soaring Together: A Collaboration in Continuing Medical Education."

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  • 1. Preparing Now For ICD-10-CM Warner Robins AFB CME Event November 1, 2013 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 0
  • 2. Agenda • ICD-9 and ICD-10 Comparison • ICD-10 Organization and Structural Differences • ICD-10-PCS • Vendor Recommendations and Resources Available • Discuss Transition Planning and Roles Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 1
  • 3. ICD-10 vs. ICD-9 Issue 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. 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. Valid codes of three, four, or five 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 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 2
  • 4. What are the benefits of ICD-10? The new, up-to-date classification system will provide much better data needed to: • Measure the quality, safety, and efficacy of care • Reduce the need for attachments to explain the patient’s condition • Design payment systems and process claims for reimbursement • Conduct research, epidemiological studies, and clinical trials • Set health policy • Support operational and strategic planning • Design healthcare delivery systems • Monitor resource utilization • Improve clinical, financial, and administrative performance • Prevent and detect healthcare fraud and abuse • Track public health and risks Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 3
  • 5. • ICD-9 is out of room • Because the classification is organized scientifically, each three-digit category can have only 10 subcategories • Most numbers in most categories have been assigned diagnoses • Medical science keeps making new discoveries, and there are no numbers to assign these diagnoses Benefits: Barriers: Why is the United States moving to ICD-10-CM? • ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care • Streamline claims submissions (code combinations ) • Details will make the initial claim much easier for payers to understand Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 4
  • 6. But… • ICD-10 will influence billing documentation, provider contracting, payment, and other major business functions, as well as IT systems for trend analysis and analytics; claims and documentation in both paper and electronic form have been overhauled. • Moving to ICD-10 is intended to bring the benefits of greater coding accuracy, higher data quality for measuring service and outcomes, more efficiency, lower costs, better use of the electronic health record, and better alignment worldwide, to name a few. Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 5
  • 7. What can we learn from other countries’ implementation? • Planning and preparation are the keys to success – Start early to allow time to understand the impact and come up with solutions • Education and training are all important – Prepare for productivity loss and longer turn around times • Collaborate with others – Share information and experiences to learn what works and what to avoid Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 6
  • 8. CPT (Yes) – Volume 3 (No) Current Procedural Terminology (CPT) • CPT remains for professional procedure coding (these codes are used to describe medical, surgical and diagnostic services to third party payers for reimbursement. ICD-9-CM Volume 3 • ICD-9-CM Volume 3 will be replaced with ICD-10PCS for facility procedure coding • ICD-10-PCS will increase from 4,000 to 200,000 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 7
  • 9. 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 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 8
  • 10. ICD-10-PCS • Each code must have 7 characters • Each can be either alpha or numeric – Numbers 0-9 – Letters A-H, J-N, P-Z • Alpha characters are not case-sensitive • Index provides the first 3 characters of code, associated with a code table • Table is referenced to build the last 4 characters • Table arranged in rows to allow only valid character combinations Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 9
  • 11. Anatomy of an ICD-10-PCS Code 1 2 3 Root Operation Section Body System 1. 2. 3. 4. 5. 6. 7. 4 5 6 Approach Body Part 7 Qualifier Device Section relates to type of procedure Body system refers to general body system Root operation specifies objective of procedure Body part refers to specific part of body system on which procedure is being performed Approach is the technique used to reach the site of the procedure Device specifies devices that remain after procedure is completed Qualifier provides additional information about procedure Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 10
  • 12. How will ICD-10-PCS affect Physician Coding ? • ICD-10-PCS will not affect coding of physicians‟ services in their offices; however, providers should be aware that documentation requirements under ICD-CM-PCS are quite different, so their inpatient medical record documentation will be affected by this change • The ICD-10-PCS codes are for use only on hospital claims for inpatient procedures • ICD-10-PCS codes are not to be used on any type of physician claims for physician services provided to hospitalized patients; these codes differ from the ICD-9-CM procedure codes in that they have 7 characters that can be either alpha (non-case sensitive) or numeric. The numbers 0 - 9 are used (letters O and I are not used to avoid confusion with numbers 0 and 1), and they do not contain decimals. Examples: – 0FB03ZX - Excision of liver, percutaneous approach, diagnostic – 0DQ10ZZ - Repair, upper esophagus, open approach Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 11
  • 13. How will ICD-10-PCS affect Physician Coding ? • Although physicians do not need to know precisely how the system works, the importance of operative report documentation is vital • Hospital coders will need to translate the clinical information from the physician‟s operative report into the new ICD-10-PCS system • Incomplete documentation will result in queries, delaying the billing process Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 12
  • 14. What does ICD-10-CM look like? Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 13
  • 15. ICD-10-CM Organization The CM Manual divided into three main parts: Official Guidelines 21 Chapters Expanded injury codes grouped by site vs. type of injury Index to Diseases and Injuries Laterality (left and right) Tabular List of Diseases and Injuries V and E codes incorporated into main classification Added a placeholder X Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 14
  • 16. Anatomy of an ICD-10-CM Code 3-7 Alphanumeric characters (digits) X X X character – Alpha (A-Z) 1st . X 2nd X X X 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 ) Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 15
  • 17. ICD-10-CM Characters and Extensions Alpha (Except U) 2 - 7 Numeric or Alpha M X X A X 0 2 S Category . X X X 6 5 x Etiology, anatomic site, severity Additional Characters A X Added code extensions (7th character) for obstetrics, injuries, and external causes of injury Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 16
  • 18. Placeholder Character • X Marks the Spot – ICD-10-CM uses a placeholder character “X” this will allow the code future expansion. – Where a placeholder, the X must be used in order for the code to be valid. (The X is not case sensitive.) Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 17
  • 19. 7th Character Extension • Certain ICD-10-CM categories have a 7th character feature; this “character” must always be in the 7th character field. • These extensions are found predominantly in two chapters: – Chapter 19 – Injury, Poisoning and Certain Other Consequences of External Causes – Chapter 15 – Pregnancy, Childbirth and the Puerperium Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 18
  • 20. If a diagnosis code requires a 7th digit and the code is a 4-digit code, what do you do? Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 19
  • 21. 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: • T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter • S03.4xxA- Sprain of jaw, initial encounter • T15.02xD – Foreign body in cornea, left eye, subsequent encounter Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 20
  • 22. Fetus Identification When applicable, a 7th character is to be assigned to identify the fetus to which the complication applies. The following are the 7th characters: • 0 - not applicable or unspecified • 1 - fetus 1 • 2 - fetus 2 • 3 - fetus 3 • 4 - fetus 4 • 5 - fetus 5 • 9 - other fetus Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 21
  • 23. Episode of Care – Fractures 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 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 22
  • 24. Episode of Care – 7th digit • Initial encounter. Initial encounter is defined as the period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An „A‟ may be assigned on more than one claim. – For example, if a patient is seen in the emergency department (ED) for a back injury that is first evaluated by the ED physician who requests a MRI that is read by a radiologist and a consultation by a neurologist, the 7th character „A‟ is used by all three physicians and also reported on the ED claim. – If the patient required admission to an acute care hospital, the 7th character „A‟ would be reported for the entire acute care hospital stay because the 7th character extension „A‟ is used for the entire period that the patient receives active treatment for the injury. Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 23
  • 25. Episode of Care – 7th digit • Subsequent encounter. This is an encounter after the active phase of treatment and when the patient is receiving routine care for the injury during the period of healing or recovery. – For example a patient with a knee injury may return to the office to have joint stability re-evaluated to ensure that it is healing properly. In this case, the 7th character „D‟ would be assigned. • Sequela (Late Effects)The 7th character extension „S‟ is assigned for complications or conditions that arise as a direct result of an injury. There is no time limit when these codes can be used. – An example of a sequela is a scar resulting from a burn. Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 24
  • 26. Episode of Care – Fractures A • Initial encounter for closed fracture B • Initial encounter for open fracture D • Subsequent encounter for fracture with routine healing G • Subsequent encounter for fracture with delayed healing K • Subsequent encounter for fracture with nonunion P • Subsequent encounter for fracture with malunion S • Sequela  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 displaces, it should be coded as displaced. Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 25
  • 27. More Information Reported, Higher Level of Detail in Coding Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 26
  • 28. 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: – C50.511 – Malignant neoplasm of lower-outer quadrant of right female breast – H16.013 – Central corneal ulcer, bilateral – L89.012 – Pressure ulcer of right elbow, stage II Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 27
  • 29. Combination Codes Combination codes for certain conditions and common associated symptoms and manifestations Examples: • K57.21 – Diverticulitis of large intestine with perforation and abscess with bleeding • E11.341 – Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema • I25.110 – Atherosclerotic heart disease of native coronary artery with unstable angina pectoris Combination codes for poisonings and their associated external cause Example: • T42.3x2S – Poisoning by barbiturates, intentional self-harm, sequela (late effect) Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 28
  • 30. ICD-10-CM continued… Obstetric codes identify trimester instead of episode of care. • 1st Trimester – less than 14 weeks 0 days • 2nd Trimester – 14 weeks 0 days to less than 28 weeks 0 days • 3rd Trimester – 28 weeks 0 days until delivery Example: • O26.02 – Excessive weight gain in pregnancy, second trimester Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 29
  • 31. New Clinical Concepts Inclusion of clinical concepts that do not exist in ICD9-CM (e.g., underdosing, blood type, blood alcohol level) Examples: • T45.526D – Underdosing of antithrombotic drugs, subsequent encounter • Z67.40 – Type O blood, Rh positive • Y90.6 – Blood alcohol level of 120–199 mg/100 ml Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 30
  • 32. Codes That Have Been Significantly Expanded A number of codes have been significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications). Examples: • E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy • F10.182 – Alcohol abuse with alcohol-induced sleep disorder • T82.02xA – Displacement of heart valve prosthesis, initial encounter Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 31
  • 33. Post/intra-operative designation Codes for postoperative complications have a distinction made between intraoperative complications and postprocedural disorders Examples: • D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen • D78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 32
  • 34. Additional changes in ICD-10-CM • Injuries are grouped by anatomical site rather than by type of injury. • Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM. • Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge. • New code definitions (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8 weeks) Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 33
  • 35. Use of External Causes If a payer required E-Codes with ICD-9, then continue to submit in ICD-10. In the absence of a mandatory reporting requirement, you are encouraged to report these codes as they add valuable data. This infographic first appeared in the Healthcare IT News and Healthcare Finance News eSupplement, ICD-10 Compliance and Beyond: Completing the Journey. Prepared for Warner Robins AFB – CME Event November 1, 2013 http://www.healthcareitnews.com/infographic/infographic-top-zaniest-icdPage 34 10-codes
  • 36. Where can I find the ICD-10-CM Codes? Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 35
  • 37. Crosswalk • 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 due to increased complexity of ICD-10 versus ICD-9 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 36
  • 38. GEMs GEMs 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 or ICD-10-PCS to find the most recent GEMs) Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 37
  • 39. Practical Mappings GEM Examples – ICD-9 to ICD-10 ICD-9-CM: 902.41 Injury to renal artery ICD-10-CM GEM: S35.403A Unspecified injury of unspecified renal artery, initial encounter Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 38
  • 40. How Does the Mapping Work? ICD-9-CM • 493.92 Asthma, Acute Exacerbation ICD-10-CM • J45.21 Mild, intermittent, w/acute exacerbation • J45.41 Moderate, persistent, w/acute exacerbation • J45.51 Severe, persistent, w/acute exacerbation Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 39
  • 41. 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 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 40
  • 42. Where should I be in my ICD-10-CM Implementation Process? Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 41
  • 43. Implementation Process Analysis of all Departments Processes Reports Work Flow Information Systems and Software All Forms of Documentation Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 42
  • 44. Implementation Issues Training • Will be required for various users • Will require coder retraining – Coding rules and conventions are similar, but not exactly the same • Some short-term loss of productivity is expected during the learning curve • Will require changes in data retrieval/analysis • Will require changes to data systems Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 43
  • 45. Training Coding and Billing Staff • Assess training needs and develop a plan. – Professional coding staff – ICD-10-CM – Determine who will train staff and how this will be accomplished – Factor in time away from work, consider post-testing and ongoing support – Make ICD-10 proficiency part of your coding staff‟s performance goals » ICD-9-CM to ICD-10-CM Dual Coding • Assign staff members to be the “ICD-10 Expert” looking at the impact from the billing to the clinical side . Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 44
  • 46. Training Clinicians • Physicians – focus on codes germane to their practice. • Review clinical documentation improvement efforts and develop new strategies. • Incorporate documentation improvement as component to compliance training. • Ancillary staff – identify needs and level of training needed, nursing, financial services, quality, utilization, ancillary departments… Information Technology • Training to ensure that codes are accurately cross-walked in organization‟s IT systems. Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 45
  • 47. ICD-10 Timeline for Small-Medium Practices at a Glance Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10SmallMediumTimelineChart.pdf Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 46
  • 48. ICD-10 Timeline for Large Practices at a Glance Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10LargePracticesTimelineChart.pdf Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 47
  • 49. ICD 10 & EHR • Analyze EHR for functionality and compliance • Review: – templates – interfaces – default documentation – level of detail • Confirm EHR is updated with the ability to communicate to the billing system in ICD10 language – Is your PM integrated with your EHR? – Look for products to include drop down menus and selection edits – Need appropriate “granularity” to accurately capture correct code Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 48
  • 50. EHR Vendor Questions • Can EHR translate ICD-9 to ICD-10 format? • Can your EHR differentiate date of service for reporting ICD9 or ICD-10? • Will ICD-9 code from previous visit translate in new encounter as ICD-10? • Will system document ICD-10 on and after October 1, 2013? • Are diagnoses linked from diagnostic results? • What are the capabilities of automated and manual documentation entry? • Do you anticipate any pricing changes due to the switch to ICD-10? Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 49
  • 51. Vendor Readiness Our billing software vendor indicates they will be ready for these transitions. What can I do in the meantime, besides train for ICD-10 coding? • Ask your billing software vendor for a detailed schedule of deliverables and begin preparing to test implementation of the modified software at your location. • Be sure to verify the following: – The vendor is addressing the ICD-10 upgrades – The number and schedule of planned ICD-10 software releases – Their ICD-10 conversion plan accommodates your clearinghouse testing schedule – Any related costs to your organization – Customer support and training they will provide Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 50
  • 52. Computer Assisted Coding (CAC) • Is this the answer? – Select the right codes – Ensuring that those codes are justified and supported in the documentation – Interfacing coded data correctly to billing systems – Education billing teams about appropriate codes – Provide documentation and feedback/education to physicians Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 51
  • 53. Clinical Documentation • Preparing for ICD-10 from a clinical documentation perspective is somewhat different than preparing for ICD-10 from a coding perspective • Focusing on increasing the specificity of documentation related to the most current, clinically accurate descriptions of diseases and surgical procedures – Laterality – Initial, Subsequent, or Sequela Encounters Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 52
  • 54. Physician Work Flow • Will the EMR allow the physician to enter a descriptive diagnosis rather than a specific diagnosis code? • Is the physician prepared for the dramatic increase in diagnosis codes now displayed on the drop-down list? • How will the physician‟s workflow change when more time is needed to assign the appropriate diagnosis code? • Can the EMR support a workflow that sends patient encounters to coders for review and assignment of the most specific diagnosis code based on the physician‟s documentation? Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 53
  • 55. How will ICD-10 Benefit the Physicians • Grow compensation and reimbursement • Determine severity and prove medical necessity • Better information about patient populations for use in quality and outcome programs • Reduce the hassle of audits • Gain access to better clinical information Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 54
  • 56. Fact or Fiction ICD-10-CM-based super bills will be too long or too complex to be of much use Fiction (sort of) • Practices may continue to create super bills that contain the most common diagnosis codes used in their practice. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently-used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions. • The super bill conversion process includes: – Conducting a review that includes removing rarely used codes; and – Cross walking common codes from ICD-9-CM to ICD-10-CM, which can be accomplished by looking up codes in the ICD-10-CM code book or using the General Equivalence Mappings (GEM). – Vendors electronic superbill and posting scrubber that assist physicians in the transition to ICD-10. Source: http://www.whiteplume.com/learn-more/icd-10 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 55
  • 57. Payer’s Role • Communicate with your top payers to see what, if any, ICD-10-CM changes will take place prior to the Oct 1, 2014 deadline – When will their testing begin? – What will be required on your end? • Additional staff recourses – Prior authorizations granted for services to be performed after Oct 1, 2014 Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 56
  • 58. Payer Response Will the ICD-10 conversion have an effect on provider reimbursement and contracting? • “Possibly. We are evaluating the impact of ICD-10 on our contracting and clinical operations. The ICD10 conversion is not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately reflect patient status and care.” • http://www.aetna.com/healthcare-professionals/policiesguidelines/icd_10_faq.html Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 57
  • 59. Industry Readiness Survey • The Workgroup for Electronic Data Interchange (WEDI), the leading authority on the use of Health IT to improve the exchange of healthcare information, announced submission of the latest ICD-10 industry readiness survey results to the Centers for Medicare & Medicaid Services (CMS). • Some key results from the survey include: – Almost half of the health plans expect to begin external testing by the end of this year. In the 2012 survey all health plans had expected to begin in 2013. – About half of the providers responded that they did not know when testing would occur and over two fifths of provider respondents indicated they did not know when they would complete their impact assessment and business changes. – About two thirds of vendors indicate they plan to begin customer review and beta testing by the end of this year. This is similar to the number who expected to begin by the end of 2012 in the prior survey. • http://www.wedi.org/news/press-releases/2013/04/11/wedi-provides-vital-icd-10-industry-readinesssurvey-results-to-cms Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 58
  • 60. What do I need to do to get the claim out the door? • Medicare will begin accepting a revised 1500 (version 02/12) on January 6, 2014. – Identify whether they are using ICD-9 or ICD-10 codes – Use as many as 12 codes in the diagnosis field (the current limit is four) – Qualifiers to identify the following providers role (on item 17) • Ordering, Referring, Supervising • Starting April 1, 2014 Medicare will accept only the revised version of the form. – The revised form will give providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 59
  • 61. What do I need to know to get the claim out the door? • Reporting ICD-10 diagnosis codes • Claims submission of diagnosis codes – ICD-9 codes no longer accepted on claims with date of service after October 1, 2014 – ICD-10 codes will not be recognized/accepted on claims before October 1, 2014 – Claims cannot contain both ICD-9 and ICD10 codes-they will be returned as “Unprocessable” • Date span requirements – Outpatient claims-split claim form and use from date – Inpatient claims-use only through date/discharge date for ICD-10 code submission Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 60
  • 62. National Coverage Determinations (NCDs) • CMS is responsible for converting approximately 330 NCDs • Not all are appropriate for translation – Edits based on HCPCS – Older, obsolete technology or considered outdated CMS has determined which NCD should be translated and is in the process of completing system changes for those NCDs http://www.cms.gov/outreach-and-education/medicarelearningnetworkmln/mlnmattersarticles/downloads/MM7818.pdf Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 61
  • 63. Local Coverage Determinations (LCDs) • According to CMS, LCDs are made by the individual Medicare Auditing Contractor (MAC – i.e. CAHABA) • Contractors shall publish all ICD-10 LCDs and ICD-10 associated articles on the Medicare Coverage Database (MCD) no later than April 10, 2014 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8348.pdf Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 62
  • 64. Code Analysis Review top 20-50 diagnosis codes • Evaluate documentation currently in the notes • Crosswalk them to ICD-10 • Review new codes for additional required codes, additional code descriptions and “code also” requirements • Identify areas where additional documentation will be required Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 63
  • 65. Budget How much emergency cash should providers keep in case of cash flow disruption? • Review what happened to your practice with HIPAA 5010, this would be a good baseline; with the transition of ICD-10 there will be delays in reimbursement. • Vendors and Clearinghouses have been working hard, but we will not know the true effects until Oct 1, 2014. • It is recommended that you have up to several months' cash reserves or access to cash through a loan or line of credit to avoid potential headaches. • The amount of money that you will need to set aside will be impacted by the preparation work you do for ICD-10. • Will need to cover at a minimum practice operation expenses for three to six months: – Medical supplies – Payroll – Rent Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 64
  • 66. Budget Determine financial impact, budget, resources, cash reserve needed for ICD-10 migration • Cost of training/decreased staff productivity • Cost of hardware/software upgrades • Forms redesign • Testing costs/Consulting services • Vendor readiness – external testing • Temporary maintenance of dual systems • Cash reserves for denials increase, payment delays, decreased productivity Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 65
  • 67. 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/ Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 66
  • 68. Questions? Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 67
  • 69. Thank you! Kim-Marie Walker, CPC, CCVTC, CHAP AHIMA-Approved ICD-10-CM Trainer Pershing Yoakley & Associates, P.C. (404) 266-9876 kwalker@pyapc.com www.pyapc.com Prepared for Warner Robins AFB – CME Event November 1, 2013 Page 68

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