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Preparing Now For ICD-10-CM

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PYA Consulting Manager Linda ClenDening primed attendees of the Tennessee Orthopaedic Society 2014 Annual Meeting with a presentation, “Preparing Now for ICD-10-CM,” which:
Covered the transition, impact, and operational aspects of ICD-10.
Provided a high-level review of what’s new in ICD-10 coding conventions and guidelines.
Reviewed common diagnoses/documentation requirements in ICD-10.

Published in: Healthcare
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Preparing Now For ICD-10-CM

  1. 1. Preparing Now For ICD-10-CM Tennessee Orthopaedic Society September 27, 2014 Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 0
  2. 2. Learning Objectives • Transition and impact of ICD-10 • ICD-10: Visualized • High-level review of what’s new in ICD-10-CM coding conventions and guidelines • Review common diagnoses and documentation requirements in ICD- 10 • Project management approach to ICD-10 operational considerations Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 1
  3. 3. Transition and Impact Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 2
  4. 4. What’s new? NEW compliance date for ICD-10: October 15, 2015 • The ICD-10 delay is forcing organizations to reassess their timelines and budgets for complying with the code change. • CMS is offering multiple in-person educational options as their well as web-based education. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 3
  5. 5. Making the Transition is Not Optional • All “covered entities” as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required to adopt ICD-10 codes for use in all HIPAA transactions. • ICD-10 codes are the foundation for reimbursement and will represent most or a large portion of the data points for healthcare analytics. • Electronic data interchange (EDI) is the transport tool for claims. • Lack of operational readiness – systems and staff training – could negatively impact practice business. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 4
  6. 6. 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 Prepared for Tennessee Orthopaedic Society 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 September 27, 2014 Page 5
  7. 7. Who is Impacted by ICD-10? Everyone! • Staffing Effectiveness • Assessment of Revenue Impact • Process Improvement • Decision Support Reporting Impact Prepared for Tennessee Orthopaedic Society • Documentation Analysis • ICD-10 Education • Process Improvement • Monitoring • Physician Documentation • Physician Integration • Physician Performance September 27, 2014 Page 6 Physician Office Post Acute Services • Front – Scheduling, Access Areas • Middle – Coding, CDI, Case Management • Back – Billing, Reimbursement Health Information Management ICD-10 Revenue Process Physician Operational Planning Information Technology • IT Systems • Capability, Communication • Functionality • Vendor Preparedness
  8. 8. What Does ICD-10-CM Look Like? Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 7
  9. 9. ICD-9 vs. ICD-10 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. Valid codes of three, four, or five digits. Duplication of code sets Currently, only ICD-9-CM codes are required. No mapping is necessary. Source: http://www.aapc.com/icd-10/faq.aspx#why Prepared for Tennessee Orthopaedic Society 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. 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. September 27, 2014 Page 8
  10. 10. ICD-10-CM Organization The CM Manual divided into three main parts: Index to Diseases and Injuries Official Guidelines Prepared for Tennessee Orthopaedic Society Tabular List of Diseases and Injuries September 27, 2014 Page 9 21 Chapters Expanded injury codes grouped by site vs. type of injury Laterality (left and right) V and E codes incorporated into main classification Added a placeholder X
  11. 11. Anatomy of an ICD-10-CM Code 3-7 Alphanumeric characters (digits) X X X . X X X X Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 10 1st character – Alpha (A-Z) 2nd character - Numeric 3rd - 7th characters – Alpha or Numeric Decimal placed after the first 3 characters • All letters but U are used • The letters I & O are used only in the 1st character position • Each letter is associated with a particular chapter (Except C&D Neoplasms)
  12. 12. ICD-10-CM Characters and Extensions . MAS X X 0 X 2 X6 X5 Xx A X Category Etiology, anatomic Prepared for Tennessee Orthopaedic Society site, severity Added code extensions (7th character) for obstetrics, injuries, and external causes of injury September 27, 2014 Page 11 Alpha (Except U) 2 - 7 Numeric or Alpha Additional Characters
  13. 13. 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 (very few one-to-one matches) due to increased specificity of ICD-10 versus ICD-9. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 12
  14. 14. GEMs GEMs (General Equivalence Mappings) are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, including data for: – Tracking quality – Recording morbidity/mortality – Calculating reimbursement – Converting any ICD-9-CM-based application to ICD-10-CM/PCS The GEMs are not a substitute for learning how to use the ICD-10 codes. More information about GEMs and their use can be found on the CMS website at: http://www.cms.gov/Medicare/Coding/ICD10/index.html (select from the left side of the web page ICD-10-CM to find the most recent GEMs) Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 13
  15. 15. How Does the Mapping Work? ICD-9-CM • 719.46 Pain in joint, lower leg Prepared for Tennessee Orthopaedic Society ICD-10-CM • M25.561 Pain in right knee • M25.562 Pain in left knee • M25.569 Pain in unspecified knee September 27, 2014 Page 14
  16. 16. Percentages of Types of Matches Mapping Categories 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 Tennessee Orthopaedic Society ICD-10 to ICD-9 ICD-9 to ICD-10 September 27, 2014 Page 15
  17. 17. High-Level Review of ICD-10 Coding Conventions and Guidelines Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 16
  18. 18. Placeholder Character Marks the Spot • ICD-10-CM uses a placeholder character “X” which allows for future code expansion. • Where indicated as a placeholder the X must be used in order for the code to be valid. (The X is not case sensitive). • A dash (-) at the end of an Index entry indicates that additional characters are required; review the tabular section for selection. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 17
  19. 19. Place an X in the 5th and 6th digit ICD-10-CM utilizes a placeholder: Character “X” is used as a 5th character placeholder in certain 6 character codes • To fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character Examples: • S72.8x1A – Other fracture of right femur, initial encounter • M48.8x6 – Other specified spondylopathies, lumbar region • S03.4xxA – Sprain of jaw, initial encounter Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 18
  20. 20. Sequela – Late Effect • A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. • There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. • Coding of sequela generally requires two codes sequenced in the following order: – The condition or nature of the sequela is sequenced first. – The sequela code is sequenced second. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 19
  21. 21. Laterality • Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right, or bilateral. • If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. • If the side is not identified in the medical record, assign the code for the unspecified side. Examples: – M24.412 – Recurrent dislocation, left shoulder – M65.321 – Trigger finger, right index finger – L89.012 – Pressure ulcer of right elbow, stage II Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 20
  22. 22. More Information Reported, Higher Level of Detail in Coding Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 21
  23. 23. Greater Specificity and Detail in Orthopedic Coding: • 34,250 of all ICD-10-CM codes are related to the musculoskeletal system. • 17,045 of all ICD-10-CM codes are related to fractures. • 10,582 of fracture codes distinguish right from left. • 25,000 of all ICD-10-CM codes distinguish right from left. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 22
  24. 24. Musculoskeletal • There are several changes and expansion to the musculoskeletal code system in ICD-10. • Most codes in this section require additional documentation to correctly code site and laterality to the highest level of specificity, which include: – Documentation of site and laterality – More specific information for fractures and injuries – Identification of episode of care – Additional coding instructions surrounding osteoporosis – Reorganization of codes Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 23
  25. 25. Fracture Specificity Fractures Require Greater Specificity: • Type of fracture • Specific anatomical site • Displaced vs nondisplaced • Laterality • Routine vs delayed healing • Nonunion • Malunion • Type of encounter – Initial – Subsequent – Sequela Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 24
  26. 26. Episode of Care – Fractures Assigning episode of care 7th characters for fractures is a bit more complicated because the episode of care provides additional information about the fracture including: • Whether the fracture is open or closed. • Whether healing is routine or with complications such as delayed healing, nonunion, or malunion. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 25
  27. 27. Episode of Care – Fractures 7th Characters 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 displaced, it should be coded as displaced. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 26
  28. 28. Episode of Care –Open Fractures The open fracture designations are based on the Gustilo open fracture classification • initial encounter for open fracture type I or II initial encounter for open fracture NOS Prepared for Tennessee Orthopaedic Society • subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing J • subsequent encounter for open fracture type I or II with nonunion M • subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion N • subsequent encounter for open fracture type I or II with malunion Q • subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion R September 27, 2014 Page 27 B • initial encounter for open fracture type IIIA, IIIB, or IIIC C • subsequent encounter for open fracture type I or II with routine healing E • subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing F • subsequent encounter for open fracture type I or II with delayed healing H
  29. 29. 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 Tennessee Orthopaedic Society September 27, 2014 Page 28
  30. 30. Project Management Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 29
  31. 31. ICD-10 Project Overview Successful Go-Live Training Testing Communications Planning Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 30
  32. 32. Updated ICD-10 Timeline 2014 2015 Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 31 PYA May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Planning Identify resources Create project team Assess effects Create project plan Secure budget Communications Inform staff Contact vendors Contact payers Monitor vendor prep Monitor payer prep Testing High-level training for test team Level 1: internal Level 2: external1 Comprehensive Training Documentation Coding 2October 1, 2015 is the NEW compliance date for ICD-10. G O L I V E Confirm ongoing practice schedule to correspond with new "go live"2 date 1Monitor external testing periods - go to http://www.cahabagba.com/news/icd-10-volunteer-testing/ to apply for volunteer testing opportunity - DEADLINE 10/3/14.
  33. 33. Planning: Major Activities Assess effects Identify resources Create project plan and team Prepared for Tennessee Orthopaedic Society Secure budget September 27, 2014 Page 32
  34. 34. Planning: Sample Activities • Assess practice pre-authorization form and/or templates for code changes needed. • Review pre-authorization workflow processes and affected staff for ICD-10 training needs. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 33
  35. 35. Planning • Review all National Coverage Determination (NCD) and Local Coverage Determination (LCD) policies used in the practice for updated code sets from ICD-9 to -10. http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html • Review any practice internal codes for denials or quality training that are tied to ICD-9 and create an ICD-10 migration plan for these codes to be updated. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 34
  36. 36. Planning • Determine the best superbill solution for the practice specialty; is an electronic solution an option? • Assess current superbill process based on potential list of ICD-10 codes for the practice. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 35
  37. 37. Planning • Communicate with the ICD-10 leadership team at each facility - whether hospital, ASC, or nursing home - where practice physicians are working. They should be informed about the ICD-10 training process requirements for the practice physicians. • Compile a top 10 list of the current practice denials relating to diagnosis codes, then create ICD-10 training materials around these codes. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 36
  38. 38. Planning • Review all customized reports for reference to ICD-9 and make sure updates are made for ICD- 10. (e.g. billing, quality reporting, clinical trials, etc.) • Review all monthly management reports for physicians, and referrals which may contain a filter or data field relating to ICD-9. Be sure the data field is set to accommodate ICD-10. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 37
  39. 39. Planning • Create a troubleshooting plan “decision tree” for denials issues (like disaster plan). Who does what, when, based on the problem? When in danger, or in doubt, run in circles, scream and shout. - Infantry Journal, Vol. 35, (1929), p. 369. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 38
  40. 40. Communication: Major Activities Inform staff Monitor vendors and payers Prepared for Tennessee Orthopaedic Society Contact vendors and payers September 27, 2014 Page 39
  41. 41. Communications: Sample Activities • Create a checklist by payer regarding their ICD- 10 readiness and claims filing timeline requirements; monitor and update in the months leading up to the new deadline. • Create a checklist by payer for pre-authorization coding transition dates to ensure compliance; monitor and update in the months leading up to the new deadline. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 40
  42. 42. Communications • Verify payer timing requirements for ICD-10 use in pre-certification and pre-authorization processes (i.e., pre-cert work completed prior to ICD-10 'go-live' date may need to be done in ICD-10 codes for visits after 'go-live' date). • Review any commercial payer quality reporting processes to be sure any ICD-9 linked data is updated to ICD-10. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 41
  43. 43. Testing: Major Activities Train the Testing Team Internal Testing Prepared for Tennessee Orthopaedic Society External Testing September 27, 2014 Page 42
  44. 44. Testing • Testing Team – Identify members – Assign duties and focus • Who will test the PM/EHR system(s)? • Who will test with the clearinghouse(s)? • Who will test with the payers? – Develop feedback form, timeline, and follow-up steps Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 43
  45. 45. Testing: What to test? • Internally: – Provider/staff process for selecting ICD-10 codes in PM/EHR system – Within the system screens, are the ICD-9/10 fields big enough for the new code format? – Run reports which contain ICD-9/10 codes • Are all digits showing? • If the code description is included, is it understandable? Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 44
  46. 46. Training: Major Activities Coding Prepared for Tennessee Orthopaedic Society Documentation September 27, 2014 Page 45
  47. 47. Training • Create an ICD-9 workflow map throughout the office: moving to each work area examine processes – daily, weekly, monthly, random-use – for ICD-9 involvement in order to develop appropriate staff training and focus areas. • Prepare ICD-10 training based on job-type group, i.e., clinicians, front desk staff, billing, etc. and tailor content based on job duties associated with ICD-9. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 46
  48. 48. Training • If you determine that an outside vendor will be hired for training assistance, allow 2-3 months prior to training for decision making and contracting. However, keep in mind that vendors and trainers will start filling up as the deadline nears. Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 47
  49. 49. Project Management Making the difference Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 48
  50. 50. Thank you! Linda ClenDening Consulting Manager Pershing Yoakley & Associates, P.C. (865) 684-2735 lclendening@pyapc.com www.pyapc.com Prepared for Tennessee Orthopaedic Society September 27, 2014 Page 49

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