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Cap Icd-10 Webinar
The document provides an overview and agenda for a presentation on implementing ICD-10-CM codes. The presentation covers key differences between ICD-9 and ICD-10 coding structures and requirements, impacts to various clinical and administrative areas, and tasks practices can complete to prepare for the transition. Technology considerations are also reviewed, including assessing current systems, understanding code mapping tools, and questions to ask vendors about upgrade plans and dual coding support.
Cap Icd-10 Webinar
- 1. Building Your Path toICD-10 Embracing ICD-10 with Confidence
- 2. An educational programpresented by the Cooperative of American Physicians, Inc. 2
- 3. Today’s Agenda Overviewof ICD-10-CM An Up-to-Date Review The Effects of ICD-10-CM on Your Practice Using Technology Effectively Differences Between ICD-9 and ICD-10 What You Need to Know Determining Your Most Commonly Used Codes Clinical Documentation Provider Challenges 3
- 4. The New (Latest)Deadline October 1, 2015 4
- 5. Why ICD-10? ImproveClinical Communications More (better) data Signs Symptoms Risk Factors Comorbidities Allow U.S. to exchange information internationally 5
- 6. What Is ICD-10? International Classification of Diseases ICD-10-CM: diagnosis code set Updated version of ICD-10-CM Volumes 1 and 2 ICD-10-PCS: code set of inpatient procedure codes Updated version of ICD-9-CM Volume 3 6
- 7. ICD-9 vs. ICD-10 ICD-9ICD-10 Diagnosis: 14,000 codes Diagnosis: 68,000 codes Procedures: 4,000 codes Procedures: 87,000 codes 7
- 8. Code Structure ICD-10-CMCode Structure Characters 1 through 3 = Category Characters 4 through 6 = Etiology, anatomic site, severity, or other clinical detail Character 7 = Extension 8
- 9. Example: S52 Fracture offorearm (category) S52.5 Fracture of lower end of radium (site) S52.52Torus fracture of lower end of radium (type) S52.521 Torus fracture of lower end of right radium (laterality) S52.521A Torus fracture of lower end of right radium, initial encounter for closed fracture (extension = episode of care) 9
- 10. Code Construction A three-charactercode Base code (category) I10 Essential (primary) hypertension Building a five-character code Base code (category) Four characters Five characters E11 E11.4 E11.42 Type 2 diabetes Type 2 diabetes with neurological complications Type 2 diabetes with polyneuropathy Building a seven-character code Base code (category) Four characters Five characters Six characters Seven characters M1A M1A.0 M1A.07 M1A.072 M1A.0721 Chronic gout Idiopathic chronic gout Idiopathic chronic gout, ankle & foot Idiopathic chronic gout, left ankle & foot Idiopathic chronic gout, left ankle and foot, with tophus 1 0
- 11. What Does ThisMean for You? Requires significant changes to clinical and administrative systems that capture and report diagnosis codes Structural differences between ICD-9 and ICD-10 make converting the code set complex Change in character length from ICD-9 to ICD-10 requires system upgrades to expand data fields for longer codes 1 1
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- 13. Front Desk HIPAA Privacypolicies may need to be revised and patients will need to sign the new forms SYSTEMS Updates to systems are likely required and may impact patient encounters 1 3
- 14. Clinical Areas PatientCoverage Health plan policies, payment limitations, and new ABN forms are likely Superbills Revisions required – paper superbills may be impossible ABNs Health plans will revise all policies linked to LCDs or NCDs, etc., ABN forms must be reformatted and patients will require education 1 4
- 15. Nurses / MedicalAssistants Forms Every order must be revised or recreated Documentation Must use increased specificity Prior Authorizations Policies may change, requiring training and updates 1 5
- 16. Physicians & Extenders Documentation The need for specificity dramatically increases by requiring laterality, stages of healing, weeks in pregnancy, episodes of care, and much more Code Training Codes increase from 17,000 to 140,000 – Physicians must be trained 1 6
- 17. Lab Documentation Must useincreased specificity Reporting Health plans will have new requirements for the ordering and reporting of services 1 7
- 18. Coding Code Sets Codeswill increase dramatically. As a result, code books and styles will change completely. Clinical Knowledge More detailed knowledge of anatomy and medical terminology will be required with increased specificity and more codes. Concurrent Use Coders may need to use ICD-9-CM and ICD-10-CM concurrently for a period of time until all claims are resolved. 1 8
- 19. BILLING Policies &Procedures All payer reimbursement policies may be revised. Training Billing department must be trained on new policies and procedures and the ICD-10-CM code set. 1 9
- 20. Managers New Policies& Procedures Any policy or procedure associated with a diagnosis code, disease management, tracking, or PQRS must be revised. Vendor & Payer Contracts All contracts must be evaluated and updated. Budgets Changes to software, training, new contracts, new paperwork will have to be paid for. Training Plan Everyone in the practice will need training on the changes. 2 0
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- 22. It Comes Downto These Four Things! 1. Prepare a Project Plan 2. Perform an Impact Analysis 3. Begin Implementation 4. Convert to ICD-10 and Monitor 2 2
- 23. Let’s Get Started! GetYour Team Together! 2 3
- 24. Eight Tasks toGet Started 1. Identify your current systems and work processes that use ICD-9 codes i. Administrative ii. Clinical iii. Reporting 2. Talk with your practice management system vendor about accommodations for ICD-10 codes i. Review current contract ii. Is there an expense? 2 4
- 25. Tasks: 3. Discuss implementationplans with all clearinghouses, billing services, and payers to facilitate a smooth transition i. Know their implementation plans ii. Can they accommodate both code sets? 4. Talk with payers about how ICD-10 implementation might affect provider contracts i. Coverage determination policies ii. Payment schedules 2 5
- 26. Tasks 5. Identify potentialchange to workflow and business processes i. Clinical documentation ii. Encounter forms or “superbills” iii. Quality reporting iv. Public health reporting 2 6
- 27. Tasks 6. Assess stafftraining needs i. Focus on learning ICD-10 code set and any workflow changes a. Clinical – understand how documentation will affect the ability to code and bill b. Administrative – understand the effects on preauthorization and referrals c. Coding – may need the most training 2 7
- 28. Tasks 7. Conduct testtransactions using ICD-10 codes with payers and clearinghouses i. Consider “dual” coding a. Coding and Billing in both ICD-9 and ICD-10 Helps you prepare for ICD-10 and mitigate the risk of denied claims ii. Watch for testing periods Clearinghouse Payers 2 8
- 29. Tasks 8. Budget fortime and costs related to ICD-10 implementation i. System changes ii. Resource materials iii. Training iv. Reserve fund 2 9
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- 31. 31 Assessing Your Systems SurveyYour Technology Vendors Now . . . . It is imperative that you understand their plans, so you can make your transitions plans. ASK: What are they doing for ICD-10? When are they doing it? Will you have access to both ICD-9 and ICD- 10 in your PMS & EMR? Will GEMs be to used to convert current code databases?
- 32. 32 Prepare for theTransition Identify all internal systems that utilize ICD-10 Understand the changes that are being made to each Database changes to one application/system CAN affect all other interfaced systems Determine the impacts on staff, process, and other systems
- 33. 33 Prepare for theTransition Create a transition timeline by system Identify any new technologies you require EMR * Code Mapping Project Management Tools *If you are not currently using an EMR, ICD-10 is the time to seriously consider this addition to your practice.
- 34. 34 Understanding GEMs Technologyvendors most likely are going to utilize or offer you some variation of GEMs. The GEMs act as a translation dictionary to bridge the language gap between ICD-9–CM and ICD-10-CM/PCS The General Equivalency Mappings (GEMs) database was created by CMS and CDC to help users understand, analyze, and manage the translation of one code set to the other. They also help users create their own applied mappings as needed.
- 35. 35 Understanding GEMs GETFAMILIAR with this database. It has both the potential to help tremendously with this transition to ICD-10 and cause confusion. ICD-10 is not as simple as one- to-one mapping in many cases, and level of detail required will create the need to evaluate many codes that come from the mapping
- 36. Translation Programs /Software Some come with your software Some can be purchased Some are free Icd9data.com and icd10data.com AAPC Beware: Use in conjunction with your books – not instead of! Some are not detailed enough! 36
- 37. Determining If YourSystems Are Ready EHR/Medical Records Billing 3 7
- 38. Ask Vendors Howwill your application, business processes, or system address my needs during the ICD-10 implementation? What is your timeline for the ICD-10 transition? What is your migration strategy for making the change to ICD-10? 3 8
- 39. Ask Vendors Doyou offer an ICD-9/ICD-10 Comparison Utility ? When will we test our system with trading partners? Will you be upgrading my current system to accommodate the ICD-10 codes? Are you training your staff on the ICD-10 system updates? 3 9
- 40. Ask Vendors Canwe use your products to search for codes by the ICD-10 alphabetic and tabular indexes? Do you allow our staff to search codes by clinical concept? Will you maintain tables for each code set? How long will ICD-9 be available for use? 4 0
- 41. Ask Vendors Willyou ensure we have the right tools in place to help select the more specific diagnosis codes? Will you provide specific provider templates for each specialty? 4 1
- 42. ICD-9-CM vs. ICD-10-CM TheDifferences You Need to Know 42
- 43. Organizational & StructuralChanges ICD-10-CM has same hierarchical structure as ICD- 9-CM First three characters are the category of the code All codes within the same category have similar traits E10 – Type 1 diabetes mellitus E11 – Type 2 diabetes mellitus J45 – Asthma J45.2 – Mild intermittent asthma J45.3 – Mild persistent asthma 43
- 44. Organization & Structure Differences are seen in the organization of ICD-10- CM ICD-10-CM has 21 chapters compared to 17 for ICD- 9-CM ICD-9-CM’s V and E code supplemental classifications are incorporated into the main classification of ICD-10-CM Diseases and conditions of the sense organs (eyes and ears) have been separated from the nervous system and have their own chapters 44
- 45. Chapter Description CodeCategory 1 Certain Infectious and Parasitic Diseases A00-B99 2 Neoplasms C00-D49 3 Diseases of the Blood D50-D89 4 Endocrine, Nutritional and Metabolic Diseases E00-E89 5 Mental and Behavioral Disorders F01-F99 6 Diseases of the Nervous System G00-G99 7 Diseases of the Eye and Adnexa * H00-H59 8 Diseases of the Ear and Mastoid Process * H60-H95 9 Diseases of the Circulatory System I00-I99 10 Diseases of the Respiratory System J00-J99 11 Diseases of the Digestive System K00-K94 12 Diseases of the Skin and Subcutaneous Tissue L00-L99 13 Diseases of the Musculoskeletal System and Connective Tissue M00-M99 14 Diseases of the Genitourinaty System N00-N99 15 Pregnancy, Childbirth and the Puerperium O00-O99 16 Certain Conditions Originating in the Perinatal Period P00-P96 17 Congenital Malformations, Deformations and Chromosomal Abnormalities Q00-Q99 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings R00-R99 19 Injury, Poisoning and Certain Other Consequences of External Cause S00-T88 20 External Causes of Morbidity * V01-Y98 21 Factors Influencing Health Status and Contact with Health Services * Z00-Z99 45 ICD-10-CM Chapters * = New Chapters
- 46. Differences from ICD-9to ICD-10 Certain diseases have been reclassified (or reassigned) to a more appropriate chapter in ICD-10-CM Gout has been reclassified from the endocrine chapter in ICD-9 to the musculoskeletal chapter in ICD-10 4 6
- 47. Differences ICD-9-CM classifiedinjuries by type; ICD-10-CM groups injuries first by specific site (e.g., head, arm, leg) and then by type of injury (e.g., fracture, open wound) Post-operative complications have been moved to procedure-specific body system chapters 47
- 48. Differences ICD-10-CM codesare alpha-numeric and can be up to seven characters in length (ICD-9 only 3-5) ICD-10-CM includes full code titles for all codes (no reference back to common fourth and fifth digits) ICD-9: The following fifth-digit subclassification is for use with category 493.0- 493.2. 493.9: 0 unspecified 1 with status asthmaticus 2 with (acute) exacerbation 48
- 49. Differences Addition ofsixth character in some chapters Addition of seventh character for obstetrics, injuries, and external causes of injuries Addition of placeholder X 49
- 50. Using A Placeholder Placeholder Character “X” is used as a placeholder at certain codes to allow for future expansion Poisoning, adverse effect, and underdosing codes (T36-T50) T36.0X1A Poisoning by penicillins, accidental (unintentional), initial encounter T36.0X2A Poisoning by penicillins, intentional self-harm T36.0X3A Poisoning by penicillins, assault T36.0X4A Poisoning by penicillins, undetermined T36.0X5A Adverse effect of penicillins T36.0X6A Underdosing of penicillins 50
- 51. Another Placeholder Example Contact with a cat W55.0 W55.01XD Bitten by a cat, subsequent encounter W55.03XD Scratched by cat, subsequent encounter W55.09XD Other contact with cat 51
- 52. 7th Characters CertainICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters. 52
- 53. New Features inICD-10-CM Combination codes for conditions and common symptoms or manifestations E10.21, Type 1 diabetes mellitus with diabetic nephropathy I25.110, Atherosclerotic heart disease of native coronary artery with unstable angina pectoris K50.112, Crohn’s disease of large intestine with intestinal obstruction Combination codes for poisonings and external causes T36.0X1D, Poisoning by penicillin, accidental (unintentional), subsequent encounter T42.4X5A, Adverse effect of benzodiazepines, initial encounter 5 3
- 54. New Features AddedLaterality H60.332, Swimmer’s ear, left ear M94.211, Chondromalacia, right shoulder S40.259A, Superficial foreign body of unspecified shoulder, initial encounter Added seventh-characters for episode of care M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture S06.0X1A, Concussion with loss of consciousness of 30 minutes or less, initial encounter S52.132B, Displaced fracture of neck of left radius, initial encounter for open fracture Type I or II or initial encounter for open fracture NOS 5 4
- 55. New Features ExpandedCodes (injuries, diabetes, alcohol, and substance abuse, post-operative complications) E11.341, Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema F14.221, Cocaine dependence with intoxication delirium K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure Inclusion of trimesters in obstetrics codes (and elimination of fifth digits for episode of care) O10.012, Pre-existing essential hypertension complicating pregnancy second trimester O99.013, Anemia complicating pregnancy, third trimester 5 5
- 56. New Features Changesin timeframes specified in certain codes Acute myocardial infarction – time period changed from 8 weeks to 4 weeks Time frame for abortion versus fetal death changed from 22 weeks to 20 weeks Added standard definitions for two types of “excludes” notes Excludes1 note indicates “not coded here.” The code being excluded is never used with the code. The two conditions cannot occur together. B06, Rubella (German measles) has an Excludes1 of congenital rubella (P35.0) Excludes2 note indicates “not included here.” The excluded condition is not part of the condition represented by the code. It is acceptable to use both codes together if the patient has both conditions. J04.0, Acute laryngitis has an Excludes2 of chronic laryngitis (J37.0) 5 6
- 57. Determining Your Most CommonlyUsed Codes 57
- 58. Begin Now: 1. Generatea report from your practice management system that identifies all ICD-9 codes used for the past 12 months 1. Sort by frequency 2. Determine your 25-50 most frequently used codes 3. Convert those codes to ICD-10-CM codes 1. Determine differences from ICD-9-CM 2. Determine documentation variables 4. Audit clinical documentation to make sure it supports the coding 58
- 59. Clinical Documentation Challenges withICD-10-CM 59
- 60. Clinical Documentation GoldenRule: If it’s not documented by the physician/provider, it did not happen; therefore, it cannot be coded or billed Objective: To ensure medical record documentation is documented to the fullest extent possible in order to support the greater specificity afforded in the ICD-10-CM (Clinical Modification) code set Some documentation issues will require physicians/providers to capture new information Others involve updated, modified, and otherwise expanded documentation needs 60
- 61. Some Facts: ICD-10-CMcontains multiple combination codes, so documentation must reflect the association between conditions Example: ICD-10: K50.814 – Crohn’s disease of both small and large intestine with abscess ICD-9: 555.2 – Regional enteritis, small intestine with large intestine and 569.5 – Abscess of intestine 61
- 62. Facts: Laterality needsto be documented Example: ICD-10: M05.271 – Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot ICD-9: 714.27 – Rheumatoid arthritis with visceral or systemic involvement, ankle and foot 62
- 63. Documentation Challenges DiabetesMellitus ICD-10 = 200 codes ICD-9 = 59 codes Multiple combination codes are available – the provider will need to document complications to allow for accurate code selection E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication An additional code must be used to report insulin use – Z79.4 63
- 64. Documentation Challenges Injuries– ICD-10-CM features an expanded category for injuries Seventh character extension identifies the encounter type: A = initial encounter D = subsequent encounter for fracture with routine healing G = subsequent encounter for fracture with delayed healing S = sequela of fracture Size and depth of the injury must be coded – needs to be captured from provider’s documentation Cause of the injury should be documented and coded 64
- 65. Documentation Challenges DrugUnderdosing – a new code in ICD-10-CM that identifies situations in which a patient has taken less of a medication than prescribed by the physician Medical condition is sequenced first Underdosing code is listed as a secondary diagnosis Additional code explains why the patient is not taking the medication (e.g., financial reasons) Since this is new, many physicians will not be in the habit of documenting a patient’s reasons for underdosing in the record. 65
- 66. Documentation Challenges CerebralInfarctions Late effects of stroke are differentiated by type of stroke Combination codes for common etiologies/manifestations are included I63.012 designates cerebral infarction due to thrombosis of left vertebral artery I63.031 designates cerebral infarction due to right carotid artery I63.212 designates cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries 66
- 67. Documentation Challenges AcuteMyocardial Infarction (AMI) Age definition for AMI has changed to four weeks rather than eight weeks New categories for subsequent AMI and for complications within 28 days of AMI Different terminology is used and laterality is included I21.01 designates ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 designates ST elevation myocardial infarction (STEMI) involving left anterior descending coronary artery I21.09 designates ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall 67
- 68. Documentation Challenges MusculoskeletalConditions ICD-9 has 8 codes for pathologic fractures; ICD-10-CM has 150+ codes 7th character is used to designate episode of care Traumatic fractures require Type of Fracture Laterality Episode of Care 68 A Warning About “Unspecified” – some may be tempted to take the easy road and code “unspecified” if documentation doesn’t support more specific codes. We warn against this!! While there is an unspecified code in ICD-10, and you can code it all you want, in 2-3 years when you review your severity and risk scores you will be in bad shape because you won’t have the specificity in your codes that you need to justify higher levels and better reimbursement.
- 69. Documentation Challenges Pregnancy Documentation of trimester now required Counted from first day of last menstrual period Must document number of weeks Episodes of care have been deleted Example – O15.03 designates “eclampsia in pregnancy, third trimester” Obstructed labor codes incorporate reason for the obstruction and code extensions are used to identify specific fetus (1-5) affected by obstetric condition Example – O64.1XX2 designates “obstructed labor due to breech presentation, fetus 2” 69
- 70. Documentation Challenges Respiratory/ Vents Some codes require time frames attached to them, which note if a patient has been on a ventilator for less than 24 consecutive hours 24-96 consecutive hours Greater than 96 hours 70
- 71. Some Final Reminders Foran Efficient and Effective Transition 71
- 72. Transition Tips ImportantReminders While clearinghouses can help, they cannot provide the same level of support for the ICD-10 transition as they did for the Version 5010 upgrade (5010 was IT-driven only; ICD-10 is both business process and IT-driven) ICD-10 codes describe a medical diagnosis or procedure and must be selected by the provider and not the clearinghouse, coder or biller Expect audits to focus on clinical documentation to determine if it supports the specificity of ICD-10 codes Keep in mind that covered entities are not to use the ICD-10 code in production (outside of a testing environment) prior to October 1, 2015 CMS Recommends Regular documentation audits after ICD-10 implementation to make sure your clinical documentation supports your ICD-10 coding 72
- 73. Thanks for YourParticipation! Mary Jean Sage The Sage Associates 897-309 Oak Park Blvd., Pismo Beach CA 93449 Tel: 805-904-6311; Fax: 805-904-6313 Email: mjsage@thesageassociates.com Web: www.thesageassociates.com 73