2. Dear Staff:
Thank you for taking the time to complete this
mandatory learning module on the ICD-10 transition.
This general overview is just that – A general overview.
It is not intended to give you extensive knowledge, nor
do we expect you to be subject matter experts. It is
meant to be a tool to assist you with a basic
understanding of the upcoming changes and the
challenges the transition will present.
We hope you find this information helpful. Enjoy! This
overview should take about ½ hour to complete,
including the short quiz at the end.
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3. • General Overview of ICD-10, not
comprehensive
• Provide understanding that
Status Quo is Unsustainable
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5. • The International Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10-CM)
• System used by physicians and other health care
providers to classify and code all diagnoses,
symptoms and procedures recorded in
conjunction with hospital care in the United
States. Click space bar to continue
6. • ICD-9 is over 30 years old
• Outdated terms
• Limited in the number of
new codes
• Limited data about patient’s
medical conditions and
hospital procedures
• Last industrialized nation to
adopt ICD-10
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7. • ICD-10 is NOT just a coding
project or IT upgrade. It has to be
a well thought out strategic
initiative utilizing time, money and
resources.
• Decrease in physician productivity.
• Decrease in revenue cycle
efficiency.
• 1-Day Conversion: All will change
on 10/1/14.
• Cash flow is very much at risk: No
uniformity of medical necessity
across payers.
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8. ICD-10 Productivity Impact
• Issues with improper and returned claims may account for an estimated $329 million in
productivity losses in 2015.1
• For physician practices, ICD-10 implementation will cost an estimated $28,500 per physician.2
1. “Cost of ICD-10 Conversion: Medium Group Practice (10
Physicians)” Health Data Management Magazine, August 1,
2010, http://www.healthdatamanagement.com/issues
/18_9/health-care-technology-news-icd-10-cost-40914-1.html
2. Clark, “ICD-10 Cost, Timing Concerns Explain AMA Vote”
2011.
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9. The Benefits of Transition:
• Alignment of the US with coding systems
worldwide
• Improved ability to track and respond to
international public health trends
• Greater coding accuracy and specificity
• Higher quality information for measuring
healthcare service quality, safety, and efficiency
• Improved efficiencies and lower costs
• Recognition of advances in medicine and
technology
• Space to accommodate future expansion
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10. The IDC-10 Final Rule was published on January 16, 2009
which identified the timeline for ICD-10-CM. Original
implementation was scheduled for October 2013 but a one
year delay was approved. Implementation is now scheduled
for October 1, 2014. The United States is the last developed
country to migrate to ICD-10. However, we are a multi-payer
system using it for reimbursement, unlike other countries,
which complicates our transition.
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11. Who?
This transition will have a major impact on anyone who
uses health care information that contains a diagnosis
and/or inpatient procedure code, including:
• Hospitals
• Health care practitioners and institutions
• Health insurers and other third-party payers
• Electronic-transaction clearinghouses
• Hardware and software manufacturers and vendors
• Billing and practice-management service providers
• Health care administrative and oversight agencies
• Public and private health care research institutions
Before ICD-10
13. We continue to monitor the MVA and worker’s comp insurances.
Although not required to transition, some will.....some may not. We
will provide more information as it becomes available. This will
necessitate ability to dual code.
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14. Enterprise-Wide Impact:
• Information Systems:
• Broad range of impacted systems
• Coordinated testing of all impacted systems
• Reporting
• Training
• Coding
• Drop in productivity
• the keying of a combination of alpha and numeric
keys will slow down even the most experienced
coders
• Talent Shortage
• Physicians
• Documentation Specificity
• Increase in documentation time, coding questions
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15. • Finance:
• Increase in A/R days
• Impact to cash flow
• Revenue Cycle:
• Increase in denials, inquiries, and
claims adjustments
• Payer contract renegotiations
• New authorization processes
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16. Impact on the Revenue Cycle:
ICD-9 evolved over time
ICD-10 is a massive one day
“earthquake” that will disrupt
this equilibrium
“Aftershocks” of changes to reimbursement for
3, 6, 12 months of rapid change will occur
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17. • Patient access functions will have a
greater impact than many realize,
education and training around
authorization and medical necessity
will be important!
• Due to an increase in code volume,
more procedures will require
authorization.
• ICD-10 codes are required on
requests, prior to 10/1/14, for dates
of service after 10/1/14.
Patient Access – Referral , Scheduling, Pre-Certs/Authorizations
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18. Revenue Cycle: Service Delivery
Added complexity in the authorization process will require
increased involvement from clinical resources for retro or
extended authorizations.
Physician documentation will need
to ensure that medical necessity,
appropriateness of care and proper
authorization is obtainable.
Payers will focus more heavily on
clinical documentation during the
appeals process, therefore staff will
need to be more involved in the
denials management process.
Centers of Medicare and Medicaid
Services (CMS) predicts claims
error rates will reach a high of
6 – 10% in comparison with the
average 3% error rate with ICD-9
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19. Physician
Documentation
• Insufficient documentation to support the specificity required
for the new ICD-10-CM code sets will be one of the largest
problems after the October 1, 2014 implementation.
• If an office is fully prepared for ICD-10-CM, but clinical
documentation has not improved, accurate coding and
proper payment will not be feasible.
It has been widely noted that a small % of today’s
documentation is actually ready for the transition
from ICD- 9 to ICD-10 coding.
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20. Revenue Cycle:
Physician Documentation
• Coders can’t code
• Greater increase in physician queries impacting
physician productivity
• Increased A/R days due to slowed claims
If documentation does not meet requirements……
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21. What Can We Expect?
Adverse short-term impact on practice
revenue stream :
The transition between coding systems might slow down the
practice’s revenue stream. The following may occur as a result of the
ICD-10 transition:
• Payers may not be ready to make the transition, which can result in
slowed processing and payment of claims and more denials. Payers
may examine claims more carefully to identify potential duplicate
billings and/or payments for service dates before and after
October 1, 2014. For example, the same claim submitted once
under the ICD-9 coding system and again under ICD-10.
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22. • Payers may make more requests for medical records to substantiate
specific claims.
• Expect that staff will need to follow-up with payers more often about
claim payment delays, denials, referrals, and other administrative
activities that may affect claim payment during and after the
transition period. Expect higher call volumes to report and resolve
claim/authorization rejections due to incorrect coding.
• Expect the need to emphasize to physicians and other clinicians the
critical importance of proper clinical documentation, and periodically
audit sample records for completeness, accuracy, and consistency
with related claims.
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23. Need for Modification
of Front-End Procedures:
Prior Authorizations/Certifications: Prior authorization has come to the
forefront partly due to the cost
savings it can bring to the payers and
its ability to approve procedures
based on medical necessities.
Providers, on the other hand, are
burdened by the undue pressure
placed on them due to the high number
of services that must be authorized before
they are performed. On the other side of the
health care spectrum, patients are also frustrated
due to the delay caused in the turnaround of the authorizations from the
payers. The next slide includes a few areas provider organizations should
carefully consider as they move forward with their ICD-10 implementation
programs.
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24. Diagnosis code submission
Diagnosis codes play a key role in the approval of prior auth requests. With ICD-10 implementation, these
new codes have increased significantly and present a challenge to the provider who must use the correct
codes for prior auth requests.
Procedure code submission
Submitted ICD-10 codes need to match the procedure codes requested to ensure timely
approval of authorizations. Incorrect mapping might lead to denials and non-payment.
New Procedures
Providers will have to train their employees, including auth requestors, on the new
procedures (i.e., C-section), which might require prior authorizations. Since these are
common procedures and do not require previous authorization, it becomes a bottle neck
for the staff to handle the huge volume of auth. submissions.
Authorization Delays
Due to the existing manual process, information provided in the forms is not sufficient for
payers to make a quick decision. Because of this, the payers end up calling the providers for
additional information to approve the request.
Patient Care
Due to payers requesting additional services for prior auths, delays caused in approving the requests
due to the existing manual process and the introduction of additional codes with ICD-10 have put
excessive pressure on the providers to supply the required patient care in time.
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26. Major Differences Between
ICD-9 and ICD-10 Codes:
ICD-9-CM ICD-10-CM
13,600 Codes 69,000 Codes
Code book contains 17 Chapters Code book contains 21 Chapters
Consists of 3 to 5 characters Consists of 3 to 7 characters
1st character is alpha or numeric 1st character is always alpha
Only utilizes letters E and V Utilizes all letters (except U)
Second, third, fourth, and fifth characters are always
numeric
Second character is always numeric
Third, fourth, fifth, sixth and seventh characters can be
alpha or numeric
Shorter code descriptions because of lack of specificity and
abbreviated code titles
Longer code descriptions because of greater clinical detail
and specificity and full code titles
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27. 2 93 8
Numeric or Alpha
(every letter except U)
Numeric
Category
ICD-9
Alpha
(every letter except U) Numeric
Category Category, anatomic site,
severity
ICD-10
(must be 3 – 7 Characters)
H 6 5 1 1 6
Added code extensions
(7th character) for
Obstetrics, injuries, and
External causes of injury
2 93 8
Numeric or Alpha
(E or V)
Category, anatomic
site, severity
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28. T 1 6 1 X X A
For Example:
The initial visit for a foreign body in the right ear
T16 identifies that this
“foreign body in ear”
1 identifies that
this is the Right Ear
The letter “X” always serves as
a placeholder when a code
contains fewer than six
characters and a seventh
character applies. The “X” also
allows for future expansion of
the codes.
“A” identifies that
this is the initial
encounter
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31. The GEM files were created in an attempt to convert coding between ICD-9 and ICD-10 and is
a joint compilation between the National Center for Health Statistics (NCHS) and the Centers
for Medicare and Medicaid Services (CMS). This effort created a national “translation
dictionary” to ensure consistency in national data. The files were designed to give all sectors
(Health Plans, Providers, Medical Researchers and Medical Software Vendors) using coded data,
a tool to convert and test systems, link data in long term clinical studies, develop application-
specific mappings and analyze data collected during the transition period and beyond.
There are a few ICD-9 and ICD-10 codes whose translation (via GEM) is very straightforward
and easy to match one with another. These are referred to as “one-to-one” (1:1) match. The
one-to-one match does not necessarily mean the two codes are identical, it simply means
there is only one alternative.
ICD-9-CM ICD-10-CM
783.21 Loss of Weight R63.4 Abnormal Weight Loss
For Example:
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32. The GEM files were created in an attempt to convert coding between ICD-9 and ICD-10 and is
a joint compilation between the National Center for Health Statistics (NCHS) and the Centers
for Medicare and Medicaid Services (CMS). This effort created a national “translation
dictionary” to ensure consistency in national data. The files were designed to give all sectors
(Health Plans, Providers, Medical Researchers and Medical Software Vendors) using coded data,
a tool to convert and test systems, link data in long term clinical studies, develop application-
specific mappings and analyze data collected during the transition period and beyond.
There are a few ICD-9 and ICD-10 codes whose translation (via GEM) is very straightforward
and easy to match one with another. These are referred to as “one-to-one” (1:1) match. The
one-to-one match does not necessarily mean the two codes are identical, it simply means
there is only one alternative.
ICD-9-CM ICD-10-CM
783.21 Loss of Weight R63.4 Abnormal Weight Loss
For Example:
33. General Overview: Quiz Time!
1. All entities must transition to ICD-10 prior to 10/1/2014.
A. True
B. False
2. The United States will be the first country to adopt ICD-10?
A. True
B. False
3. IDC-10 is aimed at improving healthcare by tracking general conditions.
A. True
B. False
4. The first digit of an ICD-10 Codes is :
A. Always numeric
B. Always a letter
C. Either a number or a letter
5. What are the benefits of ICD-10?
A. Greater specificity in diagnoses
B. Provides ability to compare data efficiently, effectively worldwide
C. Ability to reflect current medical conditions and procedures
D. All of the above
6. Which of the following statement is true?
A. Every code is ICD-10 will consists of 7 characters
B. ICD-10 codes will consist of 3-7 alpha/numeric characters
C. Every code in ICD-10 will consist of 7 alpha/numeric characters
D. Every code in ICD-10 ends with a numeric character
34. 7. The Transition will have an impact on:
A. Hospitals
B. Health Insurers and other third-party payers
C. Hardware and software manufacturers and vendors
D. Billing and practice management services providers
E. All of the above - Anyone who used healthcare information that contains a diagnosis and /or inpatient procedure
code.
8. ICD-10 preparedness is most important for:
A. Coders
B. Physicians
C. Front-end personnel
D. A and B
E. All of the above
9. If the ICD-10 transition is implemented properly in a practice, providers do not need to be concerned about
delays, denials, or a decrease in revenue?
A. True
B. False
10. A patient was seen in clinic of 9/30/14 but the claim will not be submitted until 10/4/14. Which code set will be
used.
A. ICD-9
B. ICD-10
C. Both
11. Practices can decrease the delays expected with the transition by requesting authorizations for surgeries booked
after 10/1/14 while ICD-9 is still in effect.
A. True
B. False
