ICD- 10 is coming -Brenda Edwards


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ICD- 10 is coming -Brenda Edwards

  1. 1. 3/9/2011 ICD- ICD-10 IS Coming… Are YOU Prepared? Brenda Edwards, CPC, CPMA, CPC‐I, CEMC3/9/2011 Kansas Medical Mutual Insurance Company 1 Agenda • 5010 Implementation • Resources • Responsibilities and Impacts ICD-10-CM may be referred to as ICD-10, • Code Check Code Check ICD10, I-10 or – Format of ICD‐10‐CM simply I10 – External causes – Examples3/9/2011 2 5010 Implementation3/9/2011 3 1
  2. 2. 3/9/2011 5010 Implementation3/9/2011 4 Vendor Discussion• CORNERSTONE of implementation planning – If you haven’t had this discussion yet, you are BEHIND! – The sooner the better for your practice!• Questions to ask: 1.Project lead and contact information 2.Is the 5010 update part of existing contract or additional $$ to become     compliant? 3.When will they be 5010 compliant? h ll h b l ? 4.Will they be ready by 1/1/2012? 5.How can you test with them? 6. Any side user impacts to systems? – If so, will training be included at no additional cost3/9/2011 5 5010 Implementation• ALL HIPAA covered entities MUST be compliant by 1/1/2012• Over 850 changes and benefits (process improvement) • Clarity in identifying information (provider fields) • Improved tracking to match patient to payer  • ICD‐10 support • 45 new “Service Type” codes  – Benefits where physician and hospital events are covered by different  insurers – Query to a payer would require response of both hospital and physician  service types if covered service types if covered • Reduced “syntax errors” denials (program language problem with patient name) • COB improvements‐identify to payers primary vs. secondary• Build in time for unexpected delays and setbacks• No regulatory extension‐fines after HIPAA mandated change – Minimum $100 per transaction up to $50,000 annually!• Not “just a software update”3/9/2011 6 2
  3. 3. 3/9/2011 ICD- ICD-10 Resources3/9/2011 7 CDC3/9/2011 8 AAPC3/9/2011 9 3
  4. 4. 3/9/20113/9/2011 103/9/2011 113/9/2011 12 4
  5. 5. 3/9/2011 CMS3/9/2011 13 BCBS of KS New tools coming soon!3/9/2011 14 AHIMA3/9/2011 15 5
  6. 6. 3/9/2011 Compliance Responsibilities3/9/2011 16 Compliance Responsibilities• Are you involved in a planning, steering or implementation committee?• Valuable input from regulatory standpoint – Learn all you can about ICD‐10  • www.cms.hhs.gov/ICD10 • www.cdc.gov/nchs/icd/icd10cm.htm • www.aapc.com/icd‐10• Compliance auditors Compliance auditors – Compare current documentation to what will be required • Improve documentation  – Provider and staff education• Maintain compliance after implementation date• ? New medical necessity edits new code set?3/9/2011 17 Impact Anything related to the diagnosis or3/9/2011 medical necessity will change 18 6
  7. 7. 3/9/2011 Effects of Implementation• What if I’m not ready by the compliance deadline? Any ICD‐9 codes used in transactions for services or discharges on or after  October 1, 2013 will be rejected as non‐compliant and the transactions will  not be processed. You will have disruptions in your transactions being  processed and receipt of your payments. Physicians are urged to set up a  line of credit to mitigate any cash flow interruptions that may occur. – www.ama‐assn.org/go/ICD‐10• Cash flow problems for provider• Increased denied claims• Temporary increase of physician coding errors• Decreased coder productivity• Increased claims re‐billing – Federal Register, Vol. 74, No. 11, 1/16/09 3/9/2011 19 Impact to Providers $$$ Anything related to the diagnosis or medical necessity will change • Documentation must support the code • New coverage policies, edits, fee schedules • Greater specificity • Explanations to patients • Payer contracts • Testing orders 3/9/2011 20 Impact to Administrative Staff Anything related to the diagnosis or medical necessity will change • Increased phone calls and • Confusion from every direction (physicians,  questions from patients patients, providers, plans) • ABNs• Delay in payments, increased denials and  rebilling • Budget• Health plan contract changes • Training • Transition period using ICD‐9 and ICD‐10‐CM • System upgrades• Privacy concerns‐ more specificity and detail – Hardware – Software – Interface  3/9/2011 21 7
  8. 8. 3/9/2011http://www.cms.gov/ICD10/Downloads/Jan122011_ICD10_Call.pdf 3/9/2011 22http://www.cms.gov/ICD10/Downloads/Jan122011_ICD10_Call.pdf 3/9/2011 23 Impact on Health Plans Anything related to the diagnosis or medical necessity will change • Plan structures • Statistical reports • Actuarial projections • New or revised contracts with providers • Coverage and payment determinations • Medical review policies • Fraud and abuse monitoring • Quality measurements • Testing  3/9/2011 24 8
  9. 9. 3/9/2011 Benefits of Implementation• Greater detail to describe new diseases• Greater specificity in coding• New understanding of diseases due to increased detail• Reduction in error rates• Reduction in false claims• Reduction in returned claims, refunds • 1 in 5 claims paid without additional documentation or questions!  3/9/2011 25 What About… • Inpatient hospital admission with a date prior to October 1,  2013 and discharge date after October 1, 2013???  – “Use ICD‐10‐CM codes for all diagnoses on claims for  inpatient settings with dates of discharge that occur on or  after October 1, 2013. (MLN Matters SE1019) after October 1 2013 ”  (MLN Matters SE1019) • My coding credential? • Training? • Superbills/encounter forms? • What questions haven’t we thought about? 3/9/2011 26 Code Check 3/9/2011 27 9
  10. 10. 3/9/2011 ICD-10-CM is Better…REALLY!ICD‐9‐CM ICD‐10‐CM3‐5 characters Length of code 3‐7 charactersNearly 15,000 codes Number of codes 69,000 codes and growing1st‐alpha or numeric Alpha or numeric digits 1‐alpha,2‐5 numeric 2&3‐numeric,       4‐7 alpha or numericNo room for new codesNo room for new codes Space Flexible for adding  Flexible for addingLacks detail Detail/Specificity Very specificLacks laterality Laterality Has laterality (rt/lt)Non‐specific and Accuracy More accurately reported inadequate codes conditions due to level of detailNot used by other  Operability Supports interoperability between countries U.S. and other countries 3/9/2011 28 ICD-10-CM and ICD-10-PCSICD‐10‐CM ICD‐10‐PCSClinical modification of  World Health  •Procedural coding system (PCS) developed for Organization’s (WHO) diagnostic system for the  reporting hospital procedural servicesUnited States •PCS has no relationship with WHO •Linked to ICD‐10‐CM‐both systems are  components of DRG system which pays hospitals  components of DRG system which pays hospitals for Medicare servicesAfter implementation, physicians will still report  Hospitals who provide the operating rooms, their services with CPT® codes and diagnoses with  nursing services and hospital beds for patients ICD‐10‐CM will report the procedures under ICD‐10‐PCSIn some instances, ICD‐10‐CM is referred to as  The name of ICD‐10‐PCS may be shortened to simply ICD‐10, ICD10, or just I‐10 “PCS.” 3/9/2011 29 Need to Know • There is NOT a crosswalk from ICD‐9‐CM to ICD‐10‐CM  – Mapping and conversion tools are available – You HAVE to use the coding book in addition to a mapping tool • Tool may say 380.4 = H61.23 • 380.4 Cerumen impaction =   H61.2Ø unspecified ear H61.21  right ear H61.22  left ear H61.23  bilateral 3/9/2011 30 10
  11. 11. 3/9/2011 Random Tidbits• There are over 200 codes for Diabetes Mellitus alone!• Diagnoses may have single or multiple codes in ICD‐10‐CM OR there may not  be a code!  Example – Endometrial thickening does not have a specific code in         ICD‐10‐CM • ICD‐9‐CM  – 793.5 nonspecific findings on radiological exam, genitourinary • ICD‐10‐CM  – R93.4 Abnormal findings on diagnostic imaging of urinary organs3/9/2011 31 ICD-10-CM is Better…REALLY!• Nearly twice as many categories as ICD‐9• First three digits have common traits – Each additional digit adds more specificity• Injuries and post‐op complications grouped by anatomical site  not by type of injury/wound• Diseases are arranged according to – Etiology – Anatomy – Severity3/9/2011 32 ICD-10-CM is Better…REALLY!• Laterality• “x”  placeholder (a.k.a “dummy placeholder”) – Used as 5th character and certain 6th character • Allows for future expansion without disturbing 6 character structure • Example T45.7x2 Poisoning by anticoagulant antagonists, vitamin K,  g , ( ) and other coagulants, accidental (unintentional) • Alpha extensions specify encounter status for episode of care  or identify status of current condition under care – A Initial encounter – D  Subsequent encounter – S  Sequela (late effect)3/9/2011 33 11
  12. 12. 3/9/2011 Alpha ICD-10-CM Format Alpha Numeric Alpha or Numeric (when present) xxx ● xxx “block” “S” and “T” codes Category Injuries and poisonings  and external causes 5th and 6th Character 4th Character Most accurate level of  Site, etiology, manifestation or  specificity regarding  state of disease/condition diagnosis or condition 3/9/2011 34 ICD-10-CM Layout Chapter Number and Disease Chapter 19 (SØØ‐T88) CategoriesSingle disease or                               Defines content S55related conditions Subcategory 4th or 5th character with                                                     S55. Ø12  4,5, or 6 digit level of specificity 3/9/2011 35 Chapter Category Don’t forget ! Subcategory 3/9/2011 36 12
  13. 13. 3/9/2011 ICD-10-CM Categories Begin to think in Chapters Category Chapter Heading Category Chapter Heading A00‐B99 1 Infectious disease &  L00‐L99 12 Skin disease parasites M00‐ M99  13 Musculoskeletal (including  C00‐D48 2 Neoplasm Dental) D50‐D89 3 Blood diseases N00‐N99  14 Genitourinary system E00‐E90 4 Metabolic & nutritional  O00‐O99  15 Pregnancy and child birth diseases F01‐F99 5 Mental health P00‐P96  16 Newborn G00‐G99 6 Nervous & sensory systems Q00‐Q99  17 Congenital, deformations,  chromosomal abnormalities H00‐H59 7 Eye disease R00‐R99 18 Signs, symptoms, & abnormal lab H60‐H95 8 Ear disease S00‐T88 19 Injury, poisoning, complications,  fractures, & other external causes I00‐I99 9 Circulatory system V01‐Y95  20 External causes of morbidity            (“E” codes) J00‐J99 10 Respiratory system Z00‐Z99  21 Health status/contact with health  services (“V” codes) K00‐K93 11 Digestive system 3/9/2011 37 Anatomy of a Code Laceration of ulnar artery at forearm level, left arm, initial encounter Third digit  (Category)S55 Injury of blood vessels at forearm level Alpha /numeric Outline the chapters Fourth digitS55.Ø Injury of ulnar artery at forearm Defines site, etiology, manifestation or  state of disease/condition Fifth digitS55. Ø1 Laceration of ulnar artery at forearm  Most precise level of specificitylevel  Sixth digitS55. Ø12 Laceration of ulnar artery at forearm  Defines more specificitylevel, left arm Seventh digitS55. Ø12A Laceration of ulnar artery at forearm  Codes for injuries and poisonings and level, left arm, initial encounter other external causes 3/9/2011 38 Chapter 20 External Causes V00‐Y95  20 External causes of morbidity   (“E” codes) 3/9/2011 39 13
  14. 14. 3/9/2011Chapter 20-External Causes of Morbidity (V01-Y95)• External causes of morbidity and health status/contact with health  services (“V” and “E” codes) will be incorporated into main  classification• Are not specified as optional in ICD‐10‐CM (are required) – Identify intent of circumstance • Unintentional (accidental) • Intentional (self‐harm or assault) • Place of occurrence • Activity – Secondary codes to be used for single‐condition coding, only provides  supplemental information  – Used only one time per patient encounter on initial                                       encounter for treatment 3/9/2011 40Chapter 20-External Causes of Morbidity (V01-Y95) • Sequencing multiple external cause codes will depend of the  sequence of events leading up to injury • Sequencing priority – Child and adult abuse – Terrorism has priority over all other external causes except above p y p – Cataclysmic events take sequence over all except the two above – Transport take sequence over all other external causes except those  listed above 3/9/2011 41Chapter 20-External Causes of Morbidity (V01-Y95) • Place of occurrence and activity codes are sequenced after the  primary external cause code – How it happened – What activity – Where it occurred 3/9/2011 42 14
  15. 15. 3/9/2011Chapter 20-External Causes of Morbidity (V01-Y95) • Extensions – V00‐Y35 require extension to indicate the encounter • A  Initial encounter • D  Subsequent encounter • S  Sequela (late effect) • Accidental injuries j – Default for external cause is unintentional – No documentation of intent of injury=unintentional 3/9/2011 43Chapter 20-External Causes of Morbidity (V01-Y95) • Activity Code “what” (Y93) new with ICD‐10‐CM – Always used with a place of occurrence code (Y92) – 7th character extension is used on primary code  • 1 non‐work related • 2 work related activity done for income • 3 student activity • 4 activity performed while a student, not for income • 5 Military activity – Y93 is used with • Conditions due to long term, cumulative effects (Chapter 13) • Used for acute injuries (Chapter 19)  • External cause codes if the activity adds additional                                     information on the event (Y99) 3/9/2011 44 External Cause Codes • Place of Occurrence Code “where” (Y92) – Location of the patient at the time of injury – Used with activity code (Y93) – Not necessary for poisonings, toxic effects, adverse effects, or under  dosing codes  – Sequenced after main external‐cause code 3/9/2011 45 15
  16. 16. 3/9/2011 Real Life ExamplesICD‐9‐CM Brenda was playing in a softball game and tripped and fell while running to second  ICD‐10‐CM base.  She has contusions to both knees. Contusion of unspecified knee, initial  encounter, right knee S8Ø.Ø1xA left knee S8Ø.Ø2xA924.11 Contusion of knee Fell on same level from tripping  Fell on same level from tripping WØ1. ØxxA WØ1 ØxxA Place of occurrence‐ball field Y92.32Ø Activity code‐while playing softball game Y93.64 3/9/2011 46 Real Life ExamplesICD‐9‐CM Brenda presented at prompt care following an attack by her domestic cat  ICD‐10‐CM while she was watching tv in bed in her 2 story home. She suffered a  superficial cat bite to the left hand. The doctor prescribed antibiotics and  cleaned the hand and sent her home.882.0 Open wound of hand except finger(s)  Other superficial bite of left hand alone without mention of complication Initial encounter S6Ø.572A Bitten by cat W55. Ø1 Activity code‐watching tv  Y93.89 Place of occurrence‐bedroom of  Y92. Ø13 Ø a single family house 3/9/2011 47 Dyspnea and shortness of breath with intercostal pain in let-sided rib cage ICD‐9‐CM ICD‐10‐CM • 786.05 Dyspnea • RØ6.Ø2 Dyspnea • 786.09 Shortness of breath • RØ6. ØØ Shortness of  • 786.50 Intercostal pain breath – No code for intercostal, have  to use rib pain which is found  • RØ7.82 Intercostal pain  RØ7 82 Intercostal pain under unspecified chest pain Intercostal pain is located in the ribs and muscles  between the ribs.  Increased pain when  coughing, breathing or sneezing.   3/9/2011 48 16
  17. 17. 3/9/2011 Twin pregnancy, 35 weeks, with premature rupture of membranes (ROM) and mal-presentation; twin A in breech position, twin B in transverse presentation. ICD‐9‐CM ICD‐10‐CM• 658.11 Premature ROM,  • 042.913 Preterm ROM, unspecified as to  delivered  length of time between rupture and onset • 651.01 Twin pregnancy, delivered  of labor, third trimester  w/w‐out mention of antepartum  • 032.1x1 Breech, twin A,  condition   • 032.2x1 Transverse, twin B  ,• 652.21 Breech, twin A, delivered• 652.31 Transverse, twin B,  • 03Ø. ØØ3 Twin pregnancy, unspecified,  delivered third trimester• V27.2 Twins, both liveborn  • Z37.2 Twins, both liveborn (outcome of  (outcome of delivery) delivery) 3/9/2011 49 Stress incontinence (female) with intrinsic sphincteric deficiency ICD‐9‐CM ICD‐10‐CM • 625.6 Stress incontinence,  • N39.3 Stress incontinence  female (male or female) • 599.82 Intrinsic (urethral)  • N36.42 Intrinsic sphincter  sphincter deficiency deficiency  – U Use additional code to  dditi l d t – Use additional code to  identify urinary incontinence  identify associated urinary  (625.6, 788.30‐788.39) stress incontinence (N39.3) 3/9/2011 50 Slipped and fell in parking lot while walking to car. The parking lot looked wet but was actually black ice. Fracture to left ankle and left wrist.ICD‐9‐CM ICD‐10‐CM• 824.6 Closed fracture  • S82.855A Nondisplaced trimalleolar  trimalleolar fracture of left lower leg, initial encounter• 814.00 Closed fracture wrist • S62.1Ø2A Fracture unspecified carpal  bone, left wrist, initial encounter• E885.9 Fall from slipping,  tripping, or stumbling bl • WØØ Ø A F ll WØØ. ØxxA Fall on same level due to  l ld t ice and snow, initial encounter  • Y92.481 Parking lot (place of occurrence) • Y93.89 other activity (activity code) 3/9/2011 51 17
  18. 18. 3/9/2011 Takeaway Points• Embrace the change ‐ its coming with you or without you• 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• It s not quite time to learn the new code sets because of annual  It’s not quite time to learn the new code sets because of annual changes!• Begin implementation NOW!3/9/2011 52 Thank you! bedwards@kammco.com KaMMCO AAPCCA Board of Directors3/9/2011 53 18