ICD-10, Brenda Edwards 07.14.2010


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ICD-10, Brenda Edwards 07.14.2010

  1. 1. ICD-10: What Do The Experts Have to Say? Brenda Edwards, CPC, CPMA, CPC-I, CEMC Coding & Compliance Specialist KaMMCO
  2. 2. Who are the Information Sources? • CMS ▫ Centers for Medicare and Medicaid Services • WHO ▫ World Health Organization • AAPC ▫ American Academy of Professional Coders • BCBS of KC ▫ Blue Cross Blue Shield of Kansas City • AHIMA ▫ American Health Information Management Association
  3. 3. What Needs to Happen Before ICD-10? • Transition to HIPAA 5010 transaction standards What is 5010? ELECTRONIC TRANSACTIONS • The transaction and code sets rule was part of the original HIPAA law from 1996 to adopt standards ▫ ANSI 4010A ▫ Adoption of CPT, ICD-9, and HCPCS as standard code sets ▫ Standardized electronic reporting format for covered transactions (claims, remittance, etc.) • Current versions lack functionality ▫ 1/2009 Secretary of HHS adopted Version 5010, Version D.0, and NCPDP 3.0 as the HIPAA standard code sets
  4. 4. What are the Improvements? • More specific reporting of data ▫ Anesthesia all time based (no longer units) ▫ Provider physical address no longer P.O. Box (not billing address) ▫ Zip + 4 zip codes (i.e. 66610-9685) 9998 if unknown • Technical reports ▫ More consistent data/less confusing ▫ (Transaction 277) Claims status request and reply Recoupment • Distinguishes ▫ Principal and admitting diagnosis ▫ External cause of injury ▫ Patient reason for visit ▫ “Present on admission” • Supports monitoring illness mortality rates • Accommodates ICD-10-CM and ICD-10-PCS
  5. 5. 5010 (and ICD-10) Compliance Timelines Date Compliance Step January 1, 2010 Payers and providers should begin internal testing of Version 5010 standards for electronic claims December 31, Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance 2010 January 1, 2011 • Payers and providers should begin external testing of Version 5010 for electronic claims • CMS begins accepting Version 5010 claims • Version 4010 claims continue to be accepted December 31, External testing of Version 5010 for electronic claims must be complete to achieve Level II 2011 Version 5010 compliance January 1, 2012 • All electronic claims must use Version 5010 • Version 4010 claims are no longer accepted • ICD-10 end-to-end testing begins October 1, 2013 • Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures • CPT codes will continue to be used for outpatient services http://www.cms.gov/ICD10/03_ICD-10andVersion5010ComplianceTimelines.asp#TopOfPage
  6. 6. Steps to Prepare for Version 5010 • Talk with vendors ▫ Accept both 4010 and 5010? • Discuss implementation plans with clearinghouses, billing services, and payers ▫ Be proactive, don't wait • Conduct testing on Version 5010 codes with payers and clearinghouses ▫ Testing is critical
  7. 7. 5010 Transition Information http://www.cms.gov/MFFS5010D0/ http://www.cms.gov/ICD10/downloads/w5010BasicsFctSht.pdf
  8. 8. ICD-10
  9. 9. Why ICD-10-CM? • Used throughout the world ▫ Classify causes of mortality (death records) • CM = Clinical Modification for U.S. ▫ Used for morbidity (illness) statistics ▫ Canada (CA), Australia (AM) and other countries have developed clinical modifications • Advancing technology • ICD-9 has run out of codes ▫ Used for 30 years • Codes impact all aspects of billing and reimbursement for providers, facilities, and health plans
  10. 10. ICD-10 Provider Office Changes • It WILL affect every aspect of the provider office http://www.aapc.com/ICD-10/office-map/index.aspx
  11. 11. Steps to Prepare for ICD-10 • Identify your current systems/processes that use ICD-9 codes ▫ ICD-10 codes will take their place • Talk with your payers ▫ How will ICD-10 implementation might affect your contracts? • Identify potential changes to work flow and business processes • Assess staff training needs ▫ Identify staff who need to know the new codes ▫ Coding professionals recommend training place 6 months prior to October 1, 2013 ▫ CPC’s will need to be re-certified All certified coders are required to pass the validation by September 30, 2014 to maintain certification http://www.aapc.com/ICD-10/faq.aspx#implemented • Budget for time and costs related to ICD-10 implementation ▫ System changes, ▫ Resource materials ▫ Training ▫ Assess costs Software updates Reprinting of superbills/encounter forms Training and related expenses http://www.cms.gov/ICD10/05a_ProviderResources.asp#TopOfPage
  12. 12. CMS FAQ’s • What should coders be doing now? ▫ Learn structure, organization, and unique features of ICD-10 ▫ Learn system impact ▫ Assess areas of strength/weakness (anatomy, terminology) Review knowledge concepts Additional training to refresh/expand knowledge ▫ Intensive coder training approximately 6 -9 months prior to implementation Allocate 16 hours of ICD-10 training Adequate for most coders Very proficient ICD-9 coders may not need that much Full text available at: http://questions.cms.hhs.gov/app/answers/detail/a_id/10024/kw/icd-10
  13. 13. CMS FAQ’s • When will ICD-9 codes stop being accepted? ▫ ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013. ▫ Note: ICD-10 codes will not be accepted for services prior to October 1, 2013 http://questions.cms.hhs.gov/app/answers/detail/a_id/10019/p/8,11,981
  14. 14. How Painful Will This Be$ • Impact to providers ▫ Documentation must support the code ▫ New coverage policies, edits, fee schedules ▫ Greater specificity ▫ Explanations to patients ▫ Payer contracts ▫ Testing orders ▫ Budget ▫ Training ▫ System upgrades Hardware Software Interface
  15. 15. Impact on Health Plans • New or revised contracts with providers • Determinations ▫ Coverage ▫ Payment • Medical review policies • Plan structures • Statistical reports • Actuarial projections • Fraud and abuse monitoring • Quality measurements • Testing
  16. 16. Impact for Billing and Collections • Confusion (physicians, patients, providers, plans) • Increased denials? • Transition period using ICD-9 and ICD-10-CM • Privacy concerns- more specificity and detail • Delay in payment$ • Increased phone calls and questions from patients
  17. 17. Steps to ICD-10-CM Implementation • Project team and impact analysis • Timeline and budget • Documentation needs analysis • Communication and training plan • IT design and development • Process analysis and needs assessment • Deployment of ICD-10
  18. 18. Freeze on Code Sets? • In the inpatient prospective payment system (IPPS) proposed rule for fiscal year (FY) 2011, CMS states: ▫ We welcome additional input on having the last regular code updates to ICD-9-CM and ICD-10 on October 1, 2011, and to only add codes for new technologies and diseases on October 1, 2012 and 2013. We also welcome additional input on having the next regular update to ICD-10 occur again on October 1, 2014. • Providers, payers, clearinghouses, and health information technology vendors will not have to simultaneously keep pace with code updates while also reconfiguring their existing systems for ICD-10- CM/PCS.
  19. 19. How Big is THE Change? •17,000 •141600 ▫ This number represents ▫ 72,500 ICD-10-PCS ▫ 69,100 ICD-10-CM only ICD-9-CM codes ▫ Room to move up to 155,000 An increase of 1,000 new codes from 2009 to 2010 1,982 added 983 deleted 1,029 revised
  20. 20. ICD-9 to ICD-10 Comparison ICD-10 Category ICD-9 A00-B99 Infectious disease and parasites 001-139 C00-D49 Neoplasm 140-239 D50-D89 Blood diseases 280-289 E00-E90 Metabolic and nutritional diseases 240-279 F01-F99 Mental health 290-319 G00-G99 Nervous and sensory systems 320-389 H00-H59 Eye disease 360-379 I00-I99 Circulatory system 390-459 J00-J99 Respiratory system 460-519 K00-K94 Digestive system 520-579 L00-L99 Skin disease 680-709 M00- M99 Musculoskeletal (including Dental) 710-739
  21. 21. ICD-9 to ICD-10 Comparison ICD-10 Category ICD-9 N00-N99 Genitourinary 580-629 O00-O99 Pregnancy and child birth 630-676 P00-P96 Newborn 764-779 Q00-Q99 Congenital, deformations, chromosomal 740-759 abnormalities R00-R99 Signs, symptoms, and abnormal lab 780-799 S00-T88 Injury, poisoning, complications, fractures, & 800-999 other external causes V01-Y95 External causes of morbidity “E” codes Z00-Z99 Health status/contact with health services “V” codes
  22. 22. ICD-9 Format • Classify conditions according to the part of the body affected rather than to those dealing with the underlying generalized disease. • http://www.who.int/classifications/icd/en/HistoryOfICD.pdf
  23. 23. ICD-10-CM Format Numeric Alpha or Numeric Alpha xxx xxx X Etiology, Extension Category Anatomical Site, Severity
  24. 24. Categories and Subcategories The “Block” • First digit ▫ Alpha ▫ “U” not used-saved for newly discovered diseases of unknown etiology • S55 Injury of blood vessels at forearm • Second and Third digits level ▫ Numeric • Fourth digit • S55.0 Injury of ulnar artery at forearm ▫ Defines site, etiology, manifestation or state of disease/condition • S55.01 Laceration of ulnar artery at • Fifth digit forearm level ▫ Most precise level of specificity • Sixth digit • S55.012 Laceration of ulnar artery at ▫ Defines more specificity forearm level, left arm • Seventh digit ▫ Codes for injuries and poisonings • S55.012A Laceration of ulnar artery at and other external causes forearm level, left arm, initial encounter
  25. 25. Categories and Subcategories Extensions • T45.7x2 Poisoning by anticoagulant o Dummy placeholders (x) antagonists, vitamin K, and other used in 5th place when there coagulants, accidental are 6 digits in the code (unintentional)
  26. 26. Pain in Limb • ICD-10-CM • ICD-9-CM • Over 30 Codes Choices!!! ▫ 729.5 Pain in limb ▫ Right, left or unspecified ▫ M79.60_ Pain in limb, unspecified Still need to indicate right or left arm or leg ▫ M79.62_ Upper arm/axilla ▫ M79.63_ Forearm ▫ M79.64_ Hand/finger ▫ M79.65_ Thigh ▫ M79.66_ Pain, Lower leg ▫ M79.67_ Toe ▫ 6th digit 1-9 to indicate laterality or specific digit
  27. 27. Ankle Sprain • ICD-9-CM • ICD-10-CM ▫ 845.00 Sprains • Over 15 Code Choices! and strains of ankle, ▫ Initial or subsequent encounter (7th digit-A,D, or S) unspecified site ▫ S93.409A Sprain of unspecified ligament of unspecified ankle, initial encounter ▫ S93.409D Sprain of unspecified ligament of unspecified ankle, subsequent encounter ▫ S93.409S Sprain of unspecified ligament of unspecified ankle, sequela
  28. 28. Pregnancy • ICD-10-CM ▫ 1st, 2nd or 3rd Trimester ▫ Z34.80 Encounter for supervision of • ICD-9-CM other normal pregnancy, unspecified ▫ V22.1 Prenatal care, normal, trimester other pregnancy ▫ Z34.81 Encounter for supervision of other normal pregnancy, 1st trimester ▫ Z34.82 Encounter for supervision of other normal pregnancy, 2nd trimester ▫ Z34.83 Encounter for supervision of other normal pregnancy, 3rd trimester ▫ Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester ▫ Z34.91 Encounter for supervision of normal pregnancy, unspecified,1st trimester ▫ Z34.92 Encounter for supervision of normal pregnancy, unspecified, 2nd trimester ▫ Z34.93 Encounter for supervision of normal pregnancy, unspecified, 3rd trimester
  29. 29. Otitis Media • ICD-10-CM • ICD-9-CM ▫ Right, left or bilateral ▫ 381.00 Otitis media, acute ▫ Recurrent? nonsuppurative, ▫ H65.191 Other acute nonsuppurative otitis unspecified media, right ear ▫ H65.192 Other acute nonsuppurative otitis media, left ear ▫ H65.193 Other acute nonsuppurative otitis media, bilateral ▫ H65.194 Other acute nonsuppurative otitis media, recurrent, right ear ▫ H65.195 Other acute nonsuppurative otitis media, recurrent, left ear ▫ H65.196 Other acute nonsuppurative otitis media, recurrent, bilateral ▫ H65.197 Other acute nonsuppurative otitis media, recurrent, unspecified ear ▫ H65.199 Other acute nonsuppurative otitis media, unspecified ear
  30. 30. Asthma • ICD-10-CM • ICD-9-CM ▫ Intermittent or persistent ▫ 493.90 Asthma, ▫ Mild, moderate or severe ▫ J45.20 Mild intermittent asthma, unspecified uncomplicated ▫ J45.30 Mild persistent asthma, uncomplicated ▫ J45.40 Moderate persistent, uncomplicated ▫ J45.50 Severe persistent, uncomplicated ▫ J45.909 Unspecified asthma, uncomplicated ▫ J45.998 Other asthma
  31. 31. Ankle Fracture • ICD-9-CM • ICD-10-CM ▫ 824.0 Fracture, medial • Over 12 Coding Choices malleolus (closed) ▫ Traumatic or Pathologic ▫ Right or left ▫ Displaced or nondisplaced ▫ M84.47_ Pathological fracture, ankle, foot and toes (9 codes) ▫ S82.5_ Fracture of medial malleolus (6 codes)
  32. 32. What Training Will AAPC Offer?
  33. 33. 2011 2012 2013 2014 Onsite Provider Training X Half-Day Workshop Throughout the X X Country Specialty-specific Distance Learning X X X (eLearning) Webinars X X X Audio Conference Courses X X X X X National Conference Education Sessions Proficiency Validation ** X X X Regional Training X **Proficiency validation will be taken online within the AAPC Member Area. The validation will be composed of 75 questions, timed and open book. All certified coders are required to pass the validation by September 30, 2014 to maintain certification. The proficiency validation may be taken twice for $60.
  34. 34. How Can Local Chapters Help? ▫ Some Examples might be …… Work groups by specialty Monthly speakers List serve Round table discussions Networking events with other coding chapters Track payer issues Track vendor issues
  35. 35. Know Where to Go Centers for Medicare and Medicaid Services www.cms.gov American Academy of Professional Coders www.aapc.com American Health Information Management Association www.ahima.org American Academy of Family Physicians www.aafp.com American Hospital Association www.aha.org Workgroup for Electronic Data Interchange www.wedi.org American Medical Billing Association www.amba.net Healthcare Information and Management Systems Society www.himss.org CMS information on 5010 transition: http://www.cms.gov/Versions5010andD0/
  36. 36. Making Lemonade • Embrace the change - its coming with you or without you - no grace period! • Huge book – small subset per specialty • Develop crosswalks that are easy to use • Plant seeds early - train later • Provide general training and move to specific training • Begin implementation NOW!
  37. 37. Old Chinese Proverb The Journey Is The Reward