ICD-10 Cortnie_Simmons


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  • Just as an increase in the number of words in a dictionary doesn’t make it more difficult to use, the greater number of codes in ICD-10-CM/PCS doesn’t necessarily make it more complex to use. In fact with the greater level of specificity it should make it easier.
  • Interviewed 20 departments….Reviewed roles and responsibilities
  • So no a lot of us have seen and or read about the differences in ICD-10 from ICD-9 but lets take a second to review these. 17 Chp in ICD-9 vs 21 in ICD-10
  • So we have talked about the differences and similarities in ICDCM but now lets examine ICD10PCS
  • Doesn’t differentiate between skin or subcutaneous tissueDoesn’t specify site (e.g. scalp, left arm, buttock, abdomen)
  • Add chart, training hours by quarter
  • Add chart, training hours by quarter
  • Chart, budget dollars by quarter and in total
  • SoWhats so hard about ICD-10? I wanted to take today and tomorrow to discuss some of the areas that I beliieve to be challenges for ICD-10. Before we get into detail lets talk a little bit about the sturcture of the codes.
  • The ICD-9 codes have are semi easy to remember- any coder that has been coding for even a little while has memorized several codes. In fact I as 10 year old coder think in codes. When someone tells me they have hypertension I immediately think 401.9 or CHF 428.0 or Respiratory Failure 518.81 or even Non-Compliance V15.81. License plate story!!!! Don’t ask me any of these in ICD-10! However, I will teach you all one code- The Code for Hypertension…..Any guesses? I10
  • Looking at an example in ICD-9 of Closed Fracture of the shaft of the femur we see that the code is 821.01…. Easy to remember. In ICD-10 however the same codes goes to S72.344. There is also additional detail provided to idetnify the type of fracture as well as the location or laterality of the fracture
  • In the ICD-10 PCS example we see even bigger changes. The code many of know for Lap Appendectomy 47.01 is now coded to ODTJ4ZZ. As you can see all characters are used and all charters identify the story of this code when you dive in deeper. One of the interesting things about PCS is that order in which the code is devised is completely different from what we know in ICD-9. We essentially build a code in ICD-10 PCS based on the documentation. Lets look at an example of this
  • So here is an example of The procedure Posterior spinal fusion of the posterior column at L2-L4 levels with BAK cage, interbody fusion device, open. Using your ICD-10 PCS code book you would locate the first 3 characters of the code by using the root operation as well as the body system . So we know by reviewing this procedure that the root operation is a fusion and the body system is located in the lower joints for the Lumbar area. If we had a code book in front of us right now we would be able to determine our first 3 characters are OSG.
  • After locating OSG in the index of the PCS book you can then locate the table for OSG in the back of the PCS book. You can see on this screen that I have provided an exmaple of this. OSG is located at the top of the table. From here you are building the code based on the documentations in the medical record. By our example description we know that the body part involved the lunbarveretbral joints at L2-L4. We also know that the procedure is open with an interbody in internal fixation device, and of the posterior column. You can see on the slide that I have circled all of the characters for you. It is important to note when building your code you always build the code to the right in the same row, For Example you would not have choosen Z no qualifier on row 2 because you started in the 1st row. Another important note and advantage of ICD-10 PCS is that once you know your root operation and body system you can go directly to the table in the back of the book to build the code. So you may not have memorized the whole code but if you know the first 3 characters you can go directly to the table. Lets look at the final code.0SG1031
  • Here is the answer. As you can see each character tells you a story……..
  • I am not going to turn it to Jessica for a polling question. Jessica………..
  • So how important are assessments? As Jessica is compiling the results lets talk a little about this. There are number of assessments that are of assistance in preparing for ICD-10. Coding Assessment, Doc Assessment. Operational Assessments, and IT Assessments. I wanted to talk a little about the importance each of these and provide you some examples. Coding Assessments will assist with determing the Familiarity with anatomy and medical terminology will help with selecting the correct root operations and body parts in ICD-10 PCS. Clin Doc Assessments can look at the current program to ensure that it is effective as well as what deficencies exist for the docuementation needed in ICD-10. Operational assessemtn can help to determine who is affected by ICD-10 and what eedcuatipn is needed. Who currently uses ICD-9 codes, how, and to what extent do they need to be prepared for ICD-10. And IT assessment can help determine what software and hardware updgrades are necessary of ICD-10; what systems are affected; where are the vendors on the being ready?Jessica, can you share the assessment results with us?Now lets look at some examples and talk about these more in detail
  • This slide indicates the overall assessment results of 500 coding professionals that have taken an ICD-10 assessment. The assessment is centered around A&P , term and patho. As you can see the overall score is at about 67% for 500 people and from a categorialpersspecitve A&P was the area in which most coders struggeled. They were given 100 questions aournd these areas and 1 hour to complete all questions. The hour was timed in order to guage their general knowledge on these elements. Lets look at the next slide for additional breakbown
  • This slide show results by credential. Interestingly the RHIA/RHIT credentialed professionals did better than CCS and CPC credetnailed professionals. All 500 people that took the assessment had one or more of the 6 credentials.
  • Doc Assessments are a key factor in preparing for ICD-10. Coders can be trained and ready but the documentaion must be supportive of their code assignment. Mu suggestion is to review……I would also suggest possbily doing more than one of these during the education and training stages of ICD-10. These can be done internally by Coding or CDI staff or outsourced.
  • Doc Assessments are a key factor in preparing for ICD-10. Coders can be trained and ready but the documentaion must be supportive of their code assignment. Mu suggestion is to review……I would also suggest possbily doing more than one of these during the education and training stages of ICD-10. These can be done internally by Coding or CDI staff or outsourced.
  • I wanted to give you an example the importance of understaind the operrations of the organizaiton. This is an example of the number of people determined to potentailly need education in at 250 bed facility. You can see the number of people and the associated recommeded hours to prepare these people for ICD-10
  • This is also an example of the outcomes from a IT assessment. For the 250 bed faciltiy it was determined the 27 prociducts or systems were impacted by ICD-10. Prior to the assessment the facility thought only 12 were impacted. You can see also that vendor readiness was assessed and analyzed based on the identifed systems.
  • I will turn it over to Jessica now for another polling quesitons.
  • Why are we waiting for the Poll results lets talk a little about the documenation challenges for ICD-10?
  • ICD‐10 will require more detailed information than ICD‐9‐CM to select the most accurate code. Physicians do not always provide this level of detail and CDCI™ programs do not query all payers and all diagnoses In some cases this lack of detail will negatively impact DRG assignment. I wanted to disucss some of the areas where major changes can be seen. These being…………… and ICD-10 PCS the entire system. Before we move on Jessica do we have the poll results?
  • Moving to ICD-10 is expected to impact all physicians. Due to the increased number of codes, the change in the number of characters per code, and increased code specificity, this transition will require significant planning, training, software/system upgrades/replacements, updating superbills/charge tickets as well as other necessary investments.
  • So lets look at a couple of quick examples. Here we have USA or Unstable Angina. As a coder we know this code as 411.1. In ICD-10 there are 9 codes to indicate USA. You can see that each code as a different meaining unlike ICd-9
  • Here is also an example of 466.0
  • Lets talk about Diabetes…..
  • Lets talk about Mi
  • In instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester when the complication developed, not the trimester of the discharge. oIf the condition developed prior to the current admission/encounter or represents a pre‐existing condition, the trimester character for the trimester at the time of the admission/encounter should be assigned.
  • This gives an idea of why more documentation is required.
  • Some additional code comparisons for fractures include the following:Index main term in ICD-9 = Reduction/ ICD-10 root operation is RepositionIn ICD-9One code includes both radius and ulna/ICD-10 radius and ulna are classified separatelyLaterality is not specified in ICD-9/ Body Part (Character 4) indicates lateralityAdditional documentation from physicians would include: site of reduction, including laterality; approach and specific type of internal fixation device
  • 4 charts were reviewed (3 knee, 1 hip)Hip replacement lacked type of synthetic material used (i.e. ceramic, polyethylene or metal)
  • In ICD-9 mechanical ventilation was categorized by less than 96 hours and greater than 96 hours. In ICD-10 mechanical ventilation is categorized by less than 24 hours, 24 to 96 hours and greater than 96 hours.
  • Undersoding is new to ICD-10. This applies with a pattient………
  • Why are we waiting for the Poll results lets talk a little about the documenation challenges for ICD-10?
  • So we know there are challenges with ICD-10Productivity- there will be some loss. Some facilities are trying to lessen this blow with parallel coding before October 2013
  • So just a couple of tips to prepare for ICD-10 C and PCS
  • Understand the ICD-1Qfinal rule and itsimplications to your coding position.2. learn about the structure, organization,and unique features of ICD-1Q-CM andICD-1Q-PCS.3. Use assessment tools to identifyareas of strength/weakness in thebiomedical sciences (e.Jj., anatomy andpathOphysiOlogy).4. Review and refresh knowledge ofbiomedical sciences as needed basedon the assessment results.5. Begin studying ICD-1Q-PCSdefinitions(root operations and approaches).6. Begin learning about the generalequivalence mappings (GEMs) betweenBegin learning about the generalequivalence mappings (GEMs) betweenICD-9-CM, ICD-1Q-CM, and ICD-1Q-PCS.Seund Halfoj 2011 tkr~ 20121. ReView code structure and CodingIcCoDn-VJeDnt-iPonCsS. for ICD- J D-CM and2. Learn the fundamentals of thelCD-I D-CM and ICD-) D-PCS systems.3. Analyze and practice applying theGICUDid-)elinQe-sC.M and lCD-I D-PCS Coding4. Continue to study ICD>.1D-PCS definitions(memorize the definitions of approachesand root operations).5. COlltinue to review and refr~shknOWledge of anatomY'andphYSiology concepts. ~Explore available resources like the MLN (Medicare Learning Network) and CMS (Centers for Medicare and Medicaid Services) for links, tips, and frequently asked questions.Familiarize yourself with the new code set. The ICD-10 codes will allow for greater clinical details in describing conditions and a great test for any practice is to take some of your most common codes and using these tools determine the difference ICD-10 will make with that particular code.Become a “coach” for your providers and see if they are coding specific enough to allow for accuracy with the new set.Hone all your skills. Be knowledgeable in coding, anatomy, and physiology.Keep reminding everyone of these changes and help out where you can.
  • A couple of tips for coders and cdi to prepare for ICD-10 as well.Now I will turn it over to Jessica for questions.
  • GEMs- or General Equivalence Mapping are going to be imperative with the ICD-10 change. There are opportunities for us to get into analysis at facilities. Physicians and facilities can determine what codes they utilize the most (based on the diagnosis and procedures that they perform) to determine what codes ICD-10 codes map to the ICD-9 codes.
  • ICD-9 Coding Clinics have been around since 1984. The AHA will be publishing the coding clinic for ICD-10 CM and PCS however there are no plans to translate the previous issues to ICD-10
  • Regulations stated that a total of 50 hours are needed for training and education on ICD-10. Broken down into Who, what, when and how?
  • ICD-10 Cortnie_Simmons

    1. 1. Moving Towards ICD-10 What you don’t know will hurt you!
    2. 2. Cortnie R. Simmons, MHA, RHIA, CCS Director of ICD-10 Program Kforce HealthcareCortnie R. Simmons, MHA, RHIA, CCS is the Director if ICD-10 for Kforce Healthcarewhere she is responsible for implementing ICD-10 CM/PCS related technology andservice offerings for healthcare payers and providers and oversees the rollout ofICD-10 CM/PCS training and education to more than 500 Kforce Consultants.Ms. Simmons has 11 years of HIM consulting and coding experience in healthcare.Ms. Simmons is a graduate of Florida A&M University’s Health Information Management program. Shecompleted her Masters in Health Administration at University of Maryland University College and also hasher certificate in Healthcare Informatics from St. Petersburg College.She has held various roles in HIM and coding with both hospital systems and healthcare vendors. She beganher career as a coding consultant in a large consultant firm where she perfected her skills in ICD-9 CM andCPT coding as a coding auditor and CDI specialist. Ms. Simmons has also spent several years working forHospital Corporation of America where she was responsible for coding and HIM support for severalfacilities, which included training and education, auditing, risk reduction, and results reporting. Ms.Simmons currently serves as the Florida Health Information Management Association Chair for ICD-10 aswell as a member of the AHIMA Clinical Terminology and Classification Practice Council. She also is anadjunct instructor for a Coding and Healthcare Informatics program.Ms. Simmons has experience conducting educational presentations on ICD-9, CPT and ICD-10 to variousorganizations and healthcare facilities across the country including speaking engagements at AHIMA,NCHIMA, FHIMA, and other State Association meetings, workshops, and/or roundtables. In 2010, Ms.Simmons became an AHIMA Certified Train the Trainer for ICD-10 CM and ICD-10 PCS. She hasauthored several coding and compliance-related articles for AHIMA, HCPro and other publications onICD-10 and other coding topics.
    3. 3. Agenda Brief “baseline” overview of ICD-10  Why is it important?  What is it? Comprehensive Preparedness Assessments and why they are important Documentation Challenges in ICD-10 CM/PCS Preparing for Challenges
    5. 5. CMS Goals for ICD-10 CM/PCS Measure quality, safety and efficacy of care Reduce need for attachments to explain patient’s condition Design payment systems and process claims for reimbursement Conduct research, epidemiological studies and clinical trials Set health policy Operational and strategic planning Design health care delivery systems Monitor report utilization Improve clinical, financial and administrative performance Prevent and detect health care fraud and abuse Track public health and health risks 4
    6. 6. Myths vs. FactsMYTH FACT MYTH FACT• Unnecessarily • As with ICD-9- • The • The greater detailed CM, ICD-10- increased number of medical record CM/PCS codes number of codes in ICD- documentation should be based codes in ICD- 10-CM/PCS will be on medical 10-CM/PCS make it easier required when record will make the to find the ICD-10- documentation. new coding right code. CM/PCS is system implemented. impossible to use. 5
    7. 7. Why is Preparing for ICD-10 Important?  ICD-10 is the biggest change to healthcare providers since the creation of Medicare in 1965  Implementing ICD-10 will impact every IT system, process and transaction that contains or uses a diagnosis or procedure code  The devotion of time and resources will be greater than that required for Y2K or MS-DRG readiness
    8. 8. What Entities are Impacted?  Payers  Reimbursement systems  Contracts  Claim systems  Providers  Hospitals  Physicians  HHA’s, Rehabs, SNFs, LTACs  Clearinghouses, Vendors, EmployersSource: American Hospital Association
    9. 9. Who Needs to be Trained? Stakeholders L M H Coders – inpatient and outpatient √ Physicians and Mid Levels √ Clinical documentation specialists √ Case management / UR √ Decision support √ IT professionals √ Patient access and PFS personnel √ Researchers (if applicable) √ Administration √ 8
    10. 10. Educational Tiers/Levels  Staff that require familiarity & Tier 1- awareness of impact of the changes between the two code sets (e.g., Low physicians)  Staff that require a moderate Tier 2- understanding to interpret & use ICD‐10 CM/PCS ( e.g., quality Medium management, UR, compliance)  Staff that require a detailed or expert Tier 3- understanding to apply & interpret ICD‐10‐ CM/PCS (e.g., coders, coding High auditors, clinical documentation specialists)
    11. 11. Education & TrainingExtensive Stakeholder Training will be required throughout the organization 700 5,434 Hours Total Hours: 15,554 600 9,224 Hours Total Count: 1,084 500 Number of Staff 400 300 200 100 896 Hours 0 Tier 1/ Low (457) Tier 2/Medium (608) Tier 3/High (19)
    12. 12. Systems Requiring Assessment for ICD-10 Compliance Accounting Systems  Medical necessity software Clinical systems  Test-ordering systems Physician practice management  Clearinghouse EDI systems systems  Medical record abstracting Aggregate data reporting  Utilization management Decision-support systems  Clinical protocols Provider profiling systems  Payer claims adjudication systems Billing systems  All Custom Reporting systems, Disease management systems  Interface Engine coding, Quality management  Data Extracts & Custom Data Bases Case management  Clinical reminder systems Encoding software  Performance-measurement systems Registration and scheduling  All systems sending and receiving systems clinical information to/from external Case-mix systems resources 11
    13. 13. What Could Happen? Failure to successfully implement could cause cash flow reductions and /or delays through:  Coding and billing backlogs (i.e. DNFB)  Increased claims “downgrades” and rejections Payer contacts at risk due to poor quality ratings Permanent loss in coder productivity (20 – 50%) increasing costs (Also consider coder cost premium near go live) Substantial cost to remediate / replace IT systems
    14. 14. Organizational Cost Projected Organizational Cost by Bed Size Bed Size Projected Organizational Cost 400+ $1,000,000 – 5,000,000 100 – 400 $500,000 – 1,500,000 <100 $100,000 – 250,000American Society of Clinical Oncology 13
    15. 15. 14
    16. 16. Significant Increase in Clinical Granularity ICD-10-CM ICD-9 CM (Diagnosis) (Diagnosis) 5 Digits numeric 7 Alphanumeric >14,000 unique codes Characters >68,000 unique codes ICD-10-PCS (Procedure) ICD-9-CM (Procedure) 7 Alphanumeric 5 Digits Characters >4000 unique codes >72,000 unique codes 15
    17. 17. ICD-9 CM vs. ICD-10 CM Similarities Differences • Index Abbreviations • 3 to 7 characters • Punctuations • First character alpha • Coding Conventions • Excludes 1 and Exclude • Include Notes/Inclusion 2 Notes • 21 Chapters • All Categories are 3 • Combination codes characters • Laterality • Guidelines (coding, • Episode of Care chapter specific) • Expanded codes • Trimester codes • Changes in timeframe
    18. 18. ICD-9 CM vs. ICD-10 PCS Similarities Differences • Used for reporting • Codes are arranged inpatient services into tables and procedures • Codes contain 7 characters • Codes are alphanumeric • Root operations • Each character has a specific meaning17
    19. 19. One ICD-9 Code….. Multiple ICD-10 Codes  OSRB07Z  OSRB0KZ  OSRB0J7  OSRB0J8 8 1 5 1  OSRB0J6  OSRB0J5 Total Hip Replacement  OSRB0JZ  OSR907Z  OSR90KZ  OSR90J7  OSR90J8  OSR90J6  OSR90J5  OSR90JZ
    20. 20. One ICD-9 Code….. Multiple ICD-10 Codes ICD-10-PCS  0H96X0Z Drainage of Back Skin with Drainage Device, External Approach  0H96XZZ Drainage of Back Skin, External Approach  Plus 264 other codes 8 6 0 4 specifying location (e.g. Left upper extremity, elbow, abd omen, genitalia, etc.), Other incision with depth (e.g. skin or subcutaneous tissue) drainage of skin and approach (e.g. external, open subcutaneous tissue , percutaneous, percu taneous endoscopic), and drainage device
    21. 21. 5010 / ICD-10 Timeline Jan 1, 2009 Jan 1, 2010 Jan 1, 2011 Jan 1, 2012 Jan 1, 2013 Phase 1 Phase 2 Phase 3 Phase 4 Phase 1 Phase 2 Phase 3 Phase 4 • Organize steering • Conduct IS inventory • Outline specific tasks/monitor • Evaluate software committee • Assess vendor readiness timeline for completion upgrades • Select leader • Conduct staff • Review budget requirements • Review quality of • Develop meeting awareness sessions • Develop metrics and coded data schedule • Assess/plan for staff monitoring progress • Conduct additional • Identify required training needs • Routine reporting of progress staff training tasks/develop • Identify necessary tools towards completion • Reinforce physician timelines • Identify areas requiring • Implement changes to system documentation • Assign tasks/ operational/policy design/development training responsibilities changes • Test/validate of system changes • Assess case mix • Evaluate health plan • Conduct staff training impact contract implications • Conduct physician training/ • Budget planning address documentation gaps • Identify gaps in health record documentation • 5010 testingSource: American Hospital Association, HIPAA Code Set Rule: 20ICD-10 Implementation, Executive Briefing Copyright © 2011 byAmerican Hospital Association.
    22. 22. HOW TO PREPARE 21
    23. 23. Why are Many Providers not Prepared? Management on overload. Focusing on more immediate priorities e.g. meaningful use, HIE, cost reduction, etc. Easy for management to think there is plenty of time to address ICD-10, “10/1/13 right?” Most industry surveys find less than 10% of providers have started Hospital management is too narrowly focused on coder training as the issue and not the training needs of others as well as the significant process and IT system changes that are required and financial planning matters
    24. 24. Thoughts on Preparedness Get organized – Form a Multi-disciplinary Steering Committee (consider a PMO) Develop a comprehensive approach that includes Operations, IT and Finance Develop a “Roadmap” of key projects and project owners that covers now through 2013 Think past October 2013 as there will be much to do after “go live”
    25. 25. ICD-10 Program Roles Executive Management Sponsor Operations Steering Committee Program Management Office Team Team Team Team External Leader Leader Leader Leader Consultants
    26. 26. Operations Steering Committee Members VP Compliance CIO Lead Coder HIS Director Case Management IT Director Director CDI Team Leader Controller Process Improvement Multi-Disciplinary Team for 280 Bed Hospital
    27. 27. 280 Bed Hospital Work Streams and Projects Work Streams Individual Projects Operations 18 Information Technology 27 Finance 5 Total 50 Does not include 16 additional modules related to Meditech 6.0 Upgrade
    28. 28. Implementation Hours by Quarter9,0008,0007,0006,0005,0004,000 PMO/PM Hrs3,000 Total Hours2,0001,000 35,357 Total Hrs - Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 11 12 12 12 12 13 13 13 13 * Does not include Meditech 6.0 implementation
    29. 29. Implementation Cost/Hours by Work Stream External Cost Parkview HoursWork Incremental Cost Consulting (Consulting/Vendor (Hours – SalariedStream (Parkview) Hours Staff) ) Finance $0 $0 0 63Operation 1,040** $210,600 $588,810** 16,634 s +Fixed Cost IT $0 $431,300 2,724 8,140 PMO $0 $372,000 2,120 4,636 Totals $210,600 1,392,110 5,884 Hrs 29,473 Hrs $1,603,000 35,357 Hrs
    30. 30. Budget by Quarter$350,000$300,000 $1.603 Million$250,000$200,000$150,000$100,000 $50,000 $0 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 11 12 12 12 12 13 13 13 13 * Does not include Meditech 6.0 implementation
    31. 31. Other Considerations  Parallel Coding  When?  What % of accounts and which accounts?  CDI Program  More Staff?  Internally  Staff Augmentation
    32. 32. WHAT’S SO HARD ABOUT ICD-10? 31
    33. 33. ICD-10 CM Code Structure ICD-9-CM ICD-10-CM  3-4 characters  3-7 characters  All characters are  1st character is alpha numeric (except E and V Codes)  2nd character is numeric  All codes have at least  All letters used except U 3 characters (digits)  Decimal after 1st 3 characters32 32
    34. 34. The Entire Code Structure Changes! Diagnosis Code: ICD-9-CM (3 – 5 numbers) 821.01 = Closed Fracture of shaft of femur ICD-10-CM (3 – 7 alpha/numeric characters) S72.344 = Displaced spiral fracture of shaft of right femur 33
    35. 35. ICD-10 PCS Code Structure ICD-9 CM ICD-10 PCS  ICD-9-CM has 3-4  ICD-10-PCS has 7 characters characters  All characters are  Each can be either alpha numeric or numeric  All codes have at least  Numbers 0-9; letters A- 3 characters H, J-N, P-Z  Alpha characters are not case-sensitive  Each code must have 7 characters34 34
    36. 36. The Entire Code Structure Changes Procedure Code: ICD-9-CM (3 -4 numbers) 47.01 Laparoscopic appendectomy ICD-10-PCS (7 alphanumeric characters) ODTJ4ZZ Laparoscopic appendectomy 35
    37. 37. ICD-10 PCS Coding Example Posterior spinal fusion of the posterior column at L2-L4 levels with BAK cage, interbody fusion device, open
    38. 38. ICD-10 PCS Coding Example (cont.) 0: MEDICAL AND SURGICAL S: LOWER JOINTS G: FUSION: Joining together portions of an articular body part rendering the articular body part immobileBody Part Approach Device QualifierCharacter 4 Character 5 Character 6 Character 70 Lunbar Vertebral Joint 0 Open 3 Interbody Internal 0 Anterior Approach, Anterior1 Lumbar Vertebral Joints, 2 3 Percutaneous Fixation Device Column or more 4 Percutaneous 4 Internal Fixation Device 1 Posterior Approach, Posterior3 Lumbosacral Joint Endoscopic 7 Autologous Tissue Column Substitute J Posterior Approach, Anterior H Interbody Synthetic Column Substitute K Lateral Transverse Process J Synthetic Substitute Approach, Posterior Column K Nonautologous Tissue Substitute N Interbody Nonautologous Tissue Substitute Z No Device5 Sacrococcygeal Joint 0 Open 4 Internal Fixation Device Z No Qualifier6 Coccygeal Joint 3 Percutaneous 7 Autologous Tissue7 Sacroiliac Joint, Right 4 Percutaneous Substitute8 Sacroiliac Joint, Left Endoscopic J Synthetic Substitute K Nonautologous Tissue Substitute Z No Device9 Hip Joint, Right 0 Open 4 Internal Fixation Device Z No QualifierB Hip Joint, Left 3 Percutaneous 5 External Fixation DeviceC Knee Joint, Right 4 Percutaneous 7 Autologous TissueD Knee Joint, Left Endoscopic SubstituteF Ankle Joint, Right J Synthetic SubstituteG Ankle Joint, Left K Nonautologous Tissue Subsitute Z No DeviceH Tarsal Joint, RightJ Tarsal Joint, LeftK Metatarsal-Tarsal Joint, RightL Metatarsal-Tarsal Joint, LeftM Metatarsal-Phalangeal Joint, RightN Metatarsal-Phalangeal Joint, LeftP Toe Phalangeal Joint, RightQ Toe Phalangeal Joint, Left
    39. 39. ICD-10 PCS Example Answer 0 S G 1 0 3 1Section: Body Root Body Approach: Device: Qualifier:Med/Surg System: Operation: Part: Open Interbody Posterior Lower Fusion Lumbar Internal Approach, Joints Vertebral Fixation Posterior Joints Device Column 38
    40. 40. Polling Question Have you or your facility participated in any coding or documentation assessments to prepare you for ICD-10?  Yes  No  No but they are in the plans
    41. 41. Assessments – Are they Important? Coding Assessments  Assess current knowledge Anatomy, Physiology, Pathophysiology, and Terminology  Determine areas that need additional focus Clinical Documentation Assessments  Determine the full extent of documentation reviews that will be performed during the course of the ICD‐10 transition. Operational Assessments  Determine who is affected by ICD-10 and what education is needed IT Technology Assessments  Determine what software/hardware upgrades will be necessary
    42. 42. Coding Assessment Results Results by Category76.00% 73.76%74.00%72.00%70.00% 69.64%68.00% 67.27%66.00%64.00% 65.81%62.00%60.00% A&P Terminology Pathophysiology Overall
    43. 43. Coding Assessment Results Results by Credential72.00% 70.55%70.00% 69.38%68.00%66.00%64.00%62.00% 60.92%60.00%58.00%56.00% CCS/CCS-P RHIA/RHIT CPC/CPC-H
    44. 44. Documentation Assessments Quality clinical documentation is a key factor in reporting accuracy & ICD-10-CM/PCS code assignment. Documentation assessments will provide insight into how ICD-9-CM codes will map to ICD-10-CM/PCS & how changes will affect your current high-volume/dollar cases. Assess the current level of specificity & quality of physician clinical documentation practices Review top diagnosis codes, procedure codes &/or MS- DRGs.
    45. 45. Documentation Assessments Determine how frequently unspecified &/or non-descriptive codes were used in the current ICD-9 system. Determine if the documentation required to appropriately assign diagnosis & procedure codes in ICD-10-CM/PCS is present in the medical records reviewed. Findings provide recommendations for documentation improvement and assist in designing the physician education program for your facility &/or organization.
    46. 46. Operational Assessments for Education &Training Stakeholder Training Count Hours Unemployed Physician Office Staff 399 4,389 Other Staff 320 6,655(Admissions, Registration, Nursing, e tc.) Unemployed Physicians 266 2,926 Employed Physicians 38 418 IT 24 72 Hospitalists 18 198 Coders 16 800Clinical Documentation Improvement 3 96 Total 1,084 15,554
    47. 47. Technology Assessments IT Assessment Identified gaps in overall ICD-10 product/system readiness. 27products/systems impacted by ICD-10 with significant implementation overlap requiring careful critical path & resource management • Product Readiness represents the state of IT readiness to implement. Out of 100 IT products used at Product Readiness Parkview, 27 products identified as ICD-10 impacted • Assessed / Analyzed vendor readiness based upon Vendor Readiness products impacted • Two major clusters observed – cluster/dependencies Roadmap & Budget within groups of products & clusters around Meditech Planning upgrade
    48. 48. Polling Question What do you believe the hardest transition to ICD-10 will be?  Supporting documentation  Understanding the ICD-10 codes  ICD-10 code and guideline changes
    50. 50. A Few Documentation Challenges  Diabetes Mellitus  AMI  Pregnancy  Cerebral Infarctions  Injuries  Fractures  Respiratory/Vents  Drug Underdosing  ICD-10 PCS
    51. 51. New Documentation Requirements for ICD-10 Changes in Combination Laterality Timeframes Codes Inclusion of Greater Episode of trimesters in Specificity Care OB Codes 50
    52. 52. There are More Codes and More Detail Unstable AnginaICD-9-CM – 1 CODE ICD-10-CM - 9 CODES 411.1 Intermediate Coronary  I20.0 Unstable Angina Syndrome, including  I25.700 Atherosclerosis of coronary Unstable Angina artery bypass graft(s), unspecified with unstable angina pectoris  I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris  I25.720 Atherosclerosis of autologous artery coronary bypass graft(s) with unstable angina pectoris  I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris 51
    53. 53. There are More Codes and More Detail Acute BronchitisICD-9-CM – 1 CODE ICD-10-CM - 9 CODES 466.0 Acute Bronchitis  J20.0 Acute bronchitis due to Mycoplasma pneumoniae  J20.1 Acute bronchitis due to streptococcus  J20.3 Acute bronchitis due to coxsackievirus  J20.4 Acute bronchitis due to parainfluenza virus  J20.5 Acute bronchitis due to respiratory syncytial virus  J20.6 Acute bronchitis due to rhinovirus  J20.7 Acute bronchitis due to echovirus  J20.8 Acute bronchitis due to other specified organisms  J20.9 Acute bronchitis, unspecified 52
    54. 54. Diabetes Mellitus ICD-9 CM ICD-10 CMCategories 249-250 (59 Codes) Categories E08-E13 (200+ Codes)4th and 5th digit identify Combination codes used to identifymanifestation, complication, or type manifestation and complicationAdditional code for manifestation Type of diabetes is separated by categories in ICD-10 (E10 Type 1, E11 Type 2)Additional code for insulin Z79.4 used for long term insulin usedependency V58.67 Drug induced goes to Drug Code/DRG Inadequately controlled, poorly controlled, out of control are assigned to diabetes by type with hyperglycemia
    55. 55. Myocardial Infarction ICD-9 CM ICD-10 CMCategories 410, 414, and 412 Categories I21 and I224th and 5th digit identify location and I21- is used for NSTEMI and STEMIepisode of careAcute is defined as symptoms lasting I22- was created for subsequent MIless than 8 weeks (occurring within 4 weeks of initial) Acute period changed to 4 weeks or less I22 has to be used with I21; sequencing depends on reason for admission In the event of an untreated or unaddressed MI prior to admission, physicians willneed to determine and document when this occurred. This is particularly important when addressing re‐infarctions or complication of AMI. 54
    56. 56. Pregnancy ICD-9 CM ICD-10 CMCategories 630-679 Categories O00-O9A Code identifies trimester Code identifies the number of fetuses Placeholders are often used in this chapter 55
    57. 57. Pregnancy, Childbirth and Puerperium On pregnancy, childbirth and puerperium charts the episode of care (delivered, antepartum, postpartum) are no longer the axis of classification in assigning diagnosis codes. The trimester in which the condition occurred is now the driving factor. 1st trimester less than 14 weeks 2nd trimester 14 weeks to less than 28 weeks 3rd trimester 28 weeks to delivery 56
    58. 58. Ulcers Ulcers (non pressure) documentation should state the deepest tissue layer exposed (i.e. fat layer, necrosis, necrosis of muscle or skin breakdown only) For pressure ulcers the site, laterality and severity are specified in a single code in ICD- 10 More specific codes for bilateral pressure ulcers of the same site Added new codes for head, sacral, and contiguous sites 57
    59. 59. Pressure Ulcers– What a Difference!ICD-9 CM ICD-10 CM 9 location codes,  125 possible codes second code showing more specific shows stages, location as well as depth 15 codes total Example: Pressure ulcer of right lower back, stage III 58
    60. 60. Cerebral Infarctions Greater Specificity Required  Specific artery involvement  Vertebral artery  Carotid artery  Cerebellar artery  tPA (rtPA) given in a different facility within 24 hours  Glasgow Coma Scale  Laterality59
    61. 61. Trauma Documentation Requirements Assigned separately for each  Require laterality and specific injury location Have a 7th character  Cord injuries of the neck extension to identify the require specific type and the encounter type, with “A” as specific level of the cervical initial encounter and “D” for vertebra involved subsequent encounter  Internal Organ Lacerations/ Lacerations reported as with Contusions and without foreign body  Minor – length and depth – less than 1 cm spleen Puncture wounds are reported separately with and  Moderate – length and depth without foreign body -1 to 3 cm spleen Infected lacerations are  Major – length and depth – reported as both a laceration greater than 3 cm and a wound infection 60
    62. 62. Fractures ICD-9 CM ICD-10 CMCategories 800-829 Default is displaced fractureFracture not indicated as open or Fracture not indicated as open orclosed should be classified as closed should be classified asclosed closedCodes are organized by type of Gustilo-Anderson classification forinjury and then by site assigning the 7th character extension for open fractures Codes are organized by site and then by type Category M80 – non-traumatic fractures 61
    63. 63. Hip and Knee Replacements Type of implant for hip replacements need to be documented (i.e. ceramic on ceramic, ceramic on polyethylene, metal on metal, metal on polyethylene) 62
    64. 64. Mechanical Ventilation In ICD-10 mechanical ventilation is categorized by:  less than 24 hrs,  24 to 96 hrs and  greater than 96 hrs. Length of stay assigned will more than likely be sequenced by number of hours on vent. 63
    65. 65. Underdosing New to ICD-10 Combination codes exist that can identify a situation where a patient has taken less of a medication than prescribed, as well as the specific drug. The medical condition is sequenced first with the underdosing code listed as a secondary diagnosis. Intentional vs. unintentional Underdosing of insulin due to an insulin pump failure
    66. 66. Incision and Drainage Document the following: Site of drainage Type of approach (i.e. open, percutaneous, external) Note if a drainage device was left 65
    68. 68. Current Challenges  Physician Documentation  Education & Training  Productivity  Payer Readiness  System Upgrades
    69. 69. Preparing for ICD-10 CM/PCS Establish Documentation Assessment Methodology  Determine the full extent of documentation reviews that will be performed during the course of the ICD‐10 transition.  Establish types of assessments/reviews  Establish timelines for the performance of the documentation assessments Transitional documentation needs:  Use of queries that use both ICD‐9‐CM terminology and ICD‐10 terminology (MI time frames and capture of OB/pregnancy trimester information)  Template queries that contain multiple choice selections should be cleansed to assure terminology that is obsolete in ICD‐10 (such as urosepsis) is removed.  Cross‐coding of records in both ICD‐9‐CM and ICD‐10‐CM to allow coders and CDS staff to determine if documentation is sufficient and to allow appropriate training in coding
    70. 70. Preparing for ICD-10 CM/PCS Where will the results be disseminated?  Senior leadership  Service line meetings  Senior Committee Meetings  CDS and coding staffs meetings Utilize the assessment results  Physician education materials and Pocket cards  Educational presentations What will be the effect on current physician orders, protocols, etc?
    71. 71. What can you do to prepare? Begin studying Begin learning PCS about GEMs definitions Learn about Refresh the Structure, knowledge of Organization, biomedical and Features sciencesUnderstandthe ICD-10 Next Learn the fundamentals of ICD-10 CM Final Rule Steps and PCS system
    72. 72. Tips for Coders/CDI Specialists Explore available resources like the MLN (Medicare Learning Network) and CMS (Centers for Medicare and Medicaid Services) for links, tips, and frequently asked questions. Familiarize yourself with the new code set. The ICD-10 codes will allow for greater clinical details in describing conditions and a great test for any practice is to take some of your most common codes and using these tools determine the difference ICD-10 will make with that particular code. Become a “coach” for your providers and see if they are coding specific enough to allow for accuracy with the new set. Be knowledgeable in coding, anatomy, and physiology. Keep reminding everyone of these changes and help out where you can.
    73. 73. General Equivalence MapsGEMs – General Equivalence Maps exist to translate data from ICD-9 to ICD-10 or vice versa  Bi-directional  Good for • Databases used for multiple year analyses • Trending • Research studies • Focusing on potential issues between 9 and 10  A single ICD-9 code disease or procedure may now be represented by multiple ICD-10 codes  Cannot arbitrarily pick an ICD-10 code • Might pick a code that does not represent complexity of service you are providing or patients that you are seeing (e.g. an “unspecified” ICD-10 code)– could result in underpayments • Might pick a code that overstates patient complexity or services provided
    74. 74. General Equivalence MappingsUse the GEMs When… You are translating lists of codes, code tables, or other coded data You are converting a system or application containing ICD-9- CM codes You are creating a “one-to-one” applied mapping (aka crosswalk) between code sets that will be used in an ongoing way to translate records or other coded data You want to study the differences in meaning between the ICD-9-CM classification systems and the ICD-10-CM/PCS classification systems by looking at the GEMs entries for a given code or area of classification
    75. 75. AHA Coding Clinics Will they be published for ICD-10? Will ICD-9 be converted to ICD-10?
    76. 76. Maintaining Certification through AHIMA’s Begin earning ICD-10-CM/PCS specific CEUs during the period of 01/01/11 – 12/31/13 CHPS – 1CEU CHDA – 6 CEUs RHIT – 6 CEUs RHIA – 6 CEUs CCS-P – 12 CEUs CCS – 18 CEUs CCA – 18 CEUs ****Note: Multiple credential-holders educate to the highest CEU requirement
    77. 77. Maintaining Certification through AAPC Testing 10/01/12 – 09/30/13 Must pass proficiency to maintain AAPC certification (AHIMA has similar program) Online, timed test 75 questions, open book May utilize any resources available $60 exam fee (take exam twice)
    78. 78. Training ConsiderationsTraining Considerations o WHO? Final Regulation states: • coders  16 hours ICD-10-CM • billing/compliance (diagnosis) • physicians  24 hours ICD-10-PCS • data users (procedures) o WHAT?  10 hours additional • diagnosis coding practice • procedure coding Total training = o WHEN?  50 hours (Inpatient • start now Coders) o HOW?  26 hours (Outpatient • in-house programs Coders) • AHIMA certified trainers
    79. 79. References and resources http://www.cms.hhs.gov/ICD10 http://www.ahima.org/ICD10/ www.contexomedia.com www.hcpro.com http://www.cdc.gov/nchs/icd/icd10cm.htm http://www.who.int/classifications/icd/en/ Final Rule (CMS-0013) http://edocket.access.gpo.gov/2009/pdf/E9- 743.pdf
    80. 80. For More Information Contact:CSimmons2@Kforce.com
    81. 81. Thanks for Coming!
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