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Preparing Now for ICD-10

The document discusses the transition from ICD-9 to ICD-10 coding systems for healthcare organizations, including the significant delays, structural differences, and benefits of ICD-10 such as improved data quality and enhanced coding accuracy. It highlights the necessity of preparing for the transition through education, collaboration, and understanding the complexities involved in mapping codes between the two systems. Additionally, it provides insights into specific coding details, example scenarios, and the proper use of 7th character extensions in ICD-10.

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Page 0April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Preparing Now For ICD-10-CM Georgia Pediatric Practice Managers Association April 25, 2014
Page 1April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association • Updates • ICD-9 and ICD-10 Comparison • ICD-10 Organization and Structural Differences • Vendor Recommendations and Resources Available • Discuss Transition Planning and Roles Agenda
Page 2April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association What’s new? • On April 1, President Obama signed into law legislation passed by the House and Senate delaying ICD-10 until at least October 1, 2015. • CMS has been silent on what the next steps are for healthcare organizations and how to plan accordingly. • The ICD-10 delay is forcing organizations to reassess their timelines and budgets for complying with the code change, yet at this point there are more questions than answers. • The American Health Information Management Association has requested clarification from CMS on a number of technical issues surrounding the extension of the ICD- 10 deadline, including the exact length of the delay.
Page 3April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10 vs. ICD-9 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. 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. Duplication of code sets Currently, only ICD-9-CM codes are required . No mapping is necessary. 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. Source: http://www.aapc.com/icd-10/faq.aspx#why
Page 4April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association What are the benefits of ICD-10? The new, up-to-date classification system will provide much better data needed to: • Measure the quality, safety, and efficacy of care • Reduce the need for attachments to explain the patient’s condition • Design payment systems and process claims for reimbursement • Conduct research, epidemiological studies, and clinical trials • Set health policy • Support operational and strategic planning • Design healthcare delivery systems • Monitor resource utilization • Improve clinical, financial, and administrative performance • Prevent and detect healthcare fraud and abuse • Track public health and risks
Page 5April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Why is the United States moving to ICD-10-CM? Barriers: • ICD-9 is out of room • Because the classification is organized scientifically, each three-digit category can have only 10 subcategories • Most numbers in most categories have been assigned diagnoses • Medical science keeps making new discoveries, and there are no numbers to assign these diagnoses Benefits: • ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care • Streamline claims submissions (code combinations ) • Details will make the initial claim much easier for payers to understand
Page 6April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association But… • ICD-10 will influence billing documentation, provider contracting, payment, and other major business functions, as well as IT systems for trend analysis and analytics; claims and documentation in both paper and electronic form have been overhauled. • Moving to ICD-10 is intended to bring the benefits of greater coding accuracy, higher data quality for measuring service and outcomes, more efficiency, lower costs, better use of the electronic health record, and better alignment worldwide, to name a few.
Page 7April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association What can we learn from other countries’ implementation? • Planning and preparation are the keys to success – Start early to allow time to understand the impact and come up with solutions • Education and training are all important – Prepare for productivity loss and longer turn around times • Collaborate with others – Share information and experiences to learn what works and what to avoid
Page 8April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association What does ICD-10-CM look like?
Page 9April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10-CM Organization Index to Diseases and Injuries Official Guidelines Tabular List of Diseases and Injuries The CM Manual divided into three main parts: 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
Page 10April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Anatomy of an ICD-10-CM Code 3-7 Alphanumeric characters (digits) X X X X X X X . 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 )
Page 11April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association X X X X Category . Etiology, anatomic site, severity Added code extensions (7th character) for obstetrics, injuries, and external causes of injury ICD-10-CM Characters and Extensions X X XAMS 0 2 6. 5 x A Alpha (Except U) 2 - 7 Numeric or Alpha Additional Characters
Page 12April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association • X Marks the Spot – ICD-10-CM uses a placeholder character “X”—this will allow the code future expansion – Where a placeholder, the X must be used in order for the code to be valid (The X is not case sensitive) Placeholder Character
Page 13April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association 7th Character Extension • Certain ICD-10-CM categories have a 7th character feature; this “character” must always be in the 7th character field • These extensions are found predominantly in two chapters – Chapter 19 – Injury, Poisoning and Certain Other Consequences of External Causes – Chapter 15 – Pregnancy, Childbirth and the Puerperium
Page 14April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association If a diagnosis code requires a 7th digit and the code is a 4-digit code, what do you do?
Page 15April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association 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: • T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter • S03.4xxA- Sprain of jaw, initial encounter • T15.02xD – Foreign body in cornea, left eye, subsequent encounter
Page 16April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Fetus Identification When applicable, a 7th character is to be assigned to identify the fetus for which the complication applies The following are the 7th characters • 0 - not applicable or unspecified • 1 - fetus 1 • 2 - fetus 2 • 3 - fetus 3 • 4 - fetus 4 • 5 - fetus 5 • 9 - other fetus
Page 17April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Episode of Care – Fractures 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
Page 18April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association • Initial encounter. Initial encounter is defined as the period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An ‘A’ may be assigned on more than one claim – For example, if a patient is seen in the emergency department (ED) for a knee injury that is first evaluated by the ED physician who requests a CT that is read by a radiologist and a consultation by an Orthopedist, the 7th character ‘A’ is used by all three physicians and also reported on the ED claim – If the patient required admission to an acute care hospital, the 7th character ‘A’ would be reported for the entire acute care hospital stay because the 7th character extension ‘A’ is used for the entire period that the patient receives active treatment for the injury Episode of Care – 7th digit
Page 19April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association • Subsequent encounter. This is an encounter after the active phase of treatment and when the patient is receiving routine care for the injury during the period of healing or recovery – For example a patient with a knee injury may return to the office to have joint stability re-evaluated to ensure that it is healing properly. In this case, the 7th character ‘D’ would be assigned. • Sequela (Late Effects)The 7th character extension ‘S’ is assigned for complications or conditions that arise as a direct result of an injury. There is no time limit when these codes can be used. – An example of a sequela is a scar resulting from a burn Episode of Care – 7th digit
Page 20April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Episode of Care – Fractures • Initial encounter for closed fractureA • Initial encounter for open fractureB • Subsequent encounter for fracture with routine healingD • Subsequent encounter for fracture with delayed healingG • Subsequent encounter for fracture with nonunionK • Subsequent encounter for fracture with malunionP • SequelaS  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
Page 21April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association More Information Reported, Higher Level of Detail in Coding
Page 22April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10-CM continued… Obstetric codes identify trimester instead of episode of care • 1st Trimester – less than 14 weeks 0 days • 2nd Trimester – 14 weeks 0 days to less than 28 weeks 0 days • 3rd Trimester – 28 weeks 0 days until delivery Example: • O26.02 – Excessive weight gain in pregnancy, second trimester
Page 23April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association New Clinical Concepts Inclusion of clinical concepts that do not exist in ICD- 9-CM (e.g., underdosing, blood type, blood alcohol level) Examples: • T45.526D – Underdosing of antithrombotic drugs, subsequent encounter • Z67.40 – Type O blood, Rh positive • Y90.6 – Blood alcohol level of 120–199 mg/100 ml
Page 24April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Codes That Have Been Significantly Expanded A number of codes have been significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications) Examples: • E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy • F10.182 – Alcohol abuse with alcohol-induced sleep disorder • T82.02xA – Displacement of heart valve prosthesis, initial encounter
Page 25April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Post/intra-operative designation Codes for postoperative complications have a distinction made between intraoperative complications and postprocedural disorders Examples: • D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen • D78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen
Page 26April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Additional changes in ICD-10-CM • Injuries are grouped by anatomical site rather than by type of injury • Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM • Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge
Page 27April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Use of External Causes If a payer required E-Codes with ICD-9, then continue to submit in ICD-10. In the absence of a mandatory reporting requirement, you are encouraged to report these codes as they add valuable data. http://www.healthcareitnews.com/infographic/infographic-top-zaniest-icd- 10-codes This infographic first appeared in the Healthcare IT News and Healthcare Finance News eSupplement, ICD-10 Compliance and Beyond: Completing the Journey.
Page 28April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Where can I Find the ICD-10-CM Codes?
Page 29April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association • 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 due to increased complexity of ICD-10 versus ICD-9 Crosswalk
Page 30April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association GEMs GEMs 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 or ICD-10-PCS to find the most recent GEMs)
Page 31April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association How Does the Mapping Work? ICD-9-CM • 493.92 Asthma, Acute Exacerbation ICD-10-CM • J45.21 Mild, intermittent, w/acute exacerbation • J45.41 Moderate, persistent, w/acute exacerbation left • J45.51 Severe, persistent, w/acute exacerbation
Page 32April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association How Does Mapping Work? ICD-9-CM • 719.46 Pain in joint, lower leg ICD-10-CM • M25.561 Pain in right knee • M25.562 Pain in left knee • M25.569 Pain in unspecified knee
Page 33April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Streptococcal Sore Throat ICD-9 • 034.0 (Streptococcal sore throat) which includes the tonsils/ adenoids and pharynx. ICD-10 • J02.0 (Streptococcal pharyngitis) • J03.0 (Acute tonsillitis) – J03.00 (Acute streptococcal tonsillitis, unspecified) – J03.01 (Acute recurrent streptococcal tonsillitis)
Page 34April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements • In ICD-10, the documentation of strep throat alone will no longer include streptococcal infection of the tonsils. • Streptococcal infection of the tonsils has a separate entry in ICD-10 with further specificity for recurrence and chronicity. • If a patient has a history of streptococcal infections of the tonsils along with chronic tonsillitis the proper codes are: J0301 (Acute recurrent streptococcal tonsillitis) and J3501 (Chronic tonsillitis). • If a patient presents with strep throat and has chronic pharyngitis the proper codes are: J020 (Streptococcal pharyngitis) and J312 (Chronic pharyngitis). • When documenting strep throat, it is important to note the site(s) involved (pharynx, tonsils, or both).
Page 35April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Infectious mononucleosis ICD-9 • 075 (Infectious mononucleosis) with the assumed Epstein-Barr as the assumed cause ICD-10 • B27.90 (Infectious mononucleosis, unspecified without complication
Page 36April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Tobacco Use Disorder ICD-9 – 305.1 (Tobacco use disorder) – Includes tobacco dependence ICD-10 – Z72.0 (Tobacco use) – Does not include tobacco dependence – Tobacco/Nicotine dependence is indexed to F17.2 (Nicotine dependence) • Specified according to tobacco/nicotine source and dependency status
Page 37April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements In order to accurately report tobacco use disorder with the greatest specificity, the nicotine source as well as the patient’s dependency status should be noted within physician documentation. Tobacco/Nicotine dependence—now separately classified according to tobacco/nicotine source (cigarettes, chewing tobacco, or other tobacco products) and the state of the tobacco/nicotine dependency (uncomplicated, in remission, with withdrawal, and with other nicotine-induced disorders).
Page 38April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association ACUTE Conjunctivitis ICD-9 • 372.00 (Acute conjunctivitis, unspecified ICD-10 • H10.30 (Unspecified acute conjunctivitis, unspecified eye)
Page 39April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Otitis Media • Use additional code for any associated perforated tympanic membrane (H72.-) • Use additional code to identify: – Exposure to environmental tobacco smoke (Z77.22) – Exposure to tobacco smoke in the perinatal period (P96.81) – History of tobacco use (Z87.891) – Occupational exposure to environmental tobacco smoke (Z57.31) – Tobacco dependence (F17.-) – Tobacco use (Z72.0)
Page 40April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Diseases of the Respiratory System 40 National Cancer Institute
Page 41April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Asthma • New terminology for asthma • Respiratory condition in more than 1 site (not specifically indexed) classified to lower anatomic site • Additional code notes Asthma Severity—Frequency of Daytime Symptoms • Intermittent—Less than or equal to 2 times per week • Mild Persistent—More than 2 times per week • Moderate Persistent—Daily. May restrict physical activity • Severe Persistent— Throughout the day. Frequent severe attacks limiting ability to breathe 41
Page 42April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Coding Note • In the Tabular there is an Excludes2 note under category J45 for asthma with chronic obstructive pulmonary disease. • By definition, when an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together if the patient has both conditions at the same time.
Page 43April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Acute Bronchitis ICD-9 • 466.0 (Acute bronchitis) – Required separate reporting for identity of organism ICD-10 • J20.9 (Acute bronchitis, unspecified) • Infectious agent built in to some codes. – J02.0-Acute bronchitis due to Mycoplasma pneumoniae – J20.1-Acute bronchitis due to Hemophilus influenzae – J20.2-Acute bronchitis due to streptococcus
Page 44April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Acute Bronchitis In ICD-10, diagnosis codes have been created that define the infectious agent that caused the acute bronchitis. Examples: • J20.0 Acute bronchitis due to Mycoplasma pneumoniae • J20.1 Acute bronchitis due to Hemophilus influenzae • J20.2 Acute bronchitis due to streptococcus • J20.3 Acute bronchitis due to coxsackievirus • J20.4 Acute bronchitis due to parainfluenza virus 44
Page 45April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements In order to report acute bronchitis with the greatest specificity, the infectious agent should be documented. 4 5
Page 46April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Croup ICD-9 • 464.4 (Croup) ICD-10 • J05.0 (Acute obstructive laryngitis [croup]) 46
Page 47April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements In order to code a diagnosis of Croup with the greatest specificity, the type (bronchial, diphtheritic, etc.), the infectious agent, and existing conditions such as: • exposure to environmental tobacco smoke • history of tobacco use • occupational exposure to environmental tobacco smoke • smoke inhalation • tobacco dependence • tobacco use should be documented if present 47
Page 48April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Ankle Sprains/Strains ICD-9 • 845.00 (Ankle sprain, unspecified site) ICD-10 • S93409A (Sprain of unspecified ligament of unspecified ankle, initial encounter)
Page 49April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements Physician documentation should reflect the specific site of the sprain or strain (i.e. long flexor muscle of toe at ankle and foot level, left foot) Further code specificity is provided given site, laterality, and whether the encounter is initial, subsequent, or the sprain is a sequela of another condition.
Page 50April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Sometimes Unspecified Makes Sense… The patient may be early in the course of evaluation The claim may be coming from a provider who is not directly related to diagnosis of the patients condition The clinician seeing the patient may be more of a generalist and not able to define the condition at a level of detail expected by a specialist
Page 51April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Percentages of Types of Matches Mapping Categories ICD-10 to ICD-9 ICD-9 to ICD-10 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
Page 52April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Where Should I be in my ICD-10-CM Implementation Process?
Page 53April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Implementation Process Processes Reports Work Flow Information Systems and Software All Forms of Documentation Analysis of all Departments
Page 54April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Implementation Issues Training • Will be required for various users • Will require coder retraining – Coding rules and conventions are similar, but not exactly the same • Some short-term loss of productivity is expected during the learning curve • Will require changes in data retrieval/analysis • Will require changes to data systems
Page 55April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Training Coding and Billing Staff • Assess training needs and develop a plan – Professional coding staff – ICD-10-CM – Determine who will train staff and how this will be accomplished – Factor in time away from work, consider post-testing and ongoing support – Make ICD-10 proficiency part of your coding staff’s performance goals » ICD-9-CM to ICD-10-CM Dual Coding • Assign staff members to be the “ICD-10 Expert,” looking at the impact from the billing to the clinical side
Page 56April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Training Clinicians • Physicians – focus on codes germane to their practice • Review clinical documentation improvement efforts and develop new strategies • Incorporate documentation improvement as component to compliance training • Ancillary staff – identify needs and level of training needed, nursing, financial services, quality, utilization, ancillary departments… Information Technology • Training to ensure that codes are accurately cross-walked in organization’s IT systems
Page 57April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10 Timeline for Small-Medium Practices at a Glance- Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10SmallMediumTimelineChart.pdf
Page 58April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10 Timeline for Large Practices at a Glance Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10LargePracticesTimelineChart.pdf
Page 59April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association ICD 10 & EHR • Analyze EHR for functionality and compliance • Review: – templates – interfaces – default documentation – level of detail • Confirm EHR is updated with the ability to communicate to the billing system in ICD-10 language – Is your PM integrated with your EHR? – Look for products to include drop down menus and selection edits – Need appropriate “granularity” to accurately capture correct code
Page 60April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association EHR Vendor Questions • Can EHR translate ICD-9 to ICD-10 format? • Can your EHR differentiate date of service for reporting ICD- 9 or ICD-10? • Will ICD-9 code from previous visit translate in new encounter as ICD-10? • Will system document ICD-10 on and after October 1, 2013? • Are diagnoses linked from diagnostic results? • What are the capabilities of automated and manual documentation entry? • Do you anticipate any pricing changes due to the switch to ICD-10?
Page 61April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Vendor Readiness Our billing software vendor indicates they will be ready for these transitions. What can I do in the meantime, besides train for ICD-10 coding? • Ask your billing software vendor for a detailed schedule of deliverables and begin preparing to test implementation of the modified software at your location. • Be sure to verify the following: – The vendor is addressing the ICD-10 upgrades – The number and schedule of planned ICD-10 software releases – Their ICD-10 conversion plan accommodates your clearinghouse testing schedule – Any related costs to your organization – Customer support and training they will provide
Page 62April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Computer Assisted Coding (CAC) • Is this the answer? – Selecting the right codes – Ensuring that those codes are justified and supported in the documentation – Interfacing coded data correctly to billing systems – Educating billing teams about appropriate codes – Providing documentation and feedback/education to physicians
Page 63April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Physician Work Flow • Will the EMR allow the physician to enter a descriptive diagnosis rather than a specific diagnosis code? • Is the physician prepared for the dramatic increase in diagnosis codes now displayed on the drop-down list? • How will the physician’s workflow change when more time is needed to assign the appropriate diagnosis code? • Can the EMR support a workflow that sends patient encounters to coders for review and assignment of the most specific diagnosis code based on the physician’s documentation?
Page 64April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Fact or Fiction ICD-10-CM-based super bills will be too long or too complex to be of much use Fiction (sort of) • Practices may continue to create super bills that contain the most common diagnosis codes used in their practices. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions. • The super bill conversion process includes: – Conducting a review that includes removing rarely used codes; and – Cross walking common codes from ICD-9-CM to ICD-10-CM, which can be accomplished by looking up codes in the ICD-10-CM code book or using the General Equivalence Mappings (GEM). – Vendors electronic superbill and posting scrubber that assist physicians in the transition to ICD-10. Source: http://www.whiteplume.com/learn-more/icd-10
Page 65April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Payer’s Role • Communicate with your top payers to see what if any ICD-10-CM changes will take place prior to the Oct 1, 2014 deadline – When will their testing begin? – What will be required on your end? • Additional staff recourses
Page 66April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Payer Response Will the ICD-10 conversion have an effect on provider reimbursement and contracting? • “Possibly. We are evaluating the impact of ICD-10 on our contracting and clinical operations. The ICD- 10 conversion is not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately reflect patient status and care.” Source: http://www.aetna.com/healthcare-professionals/policies-guidelines/icd_10_faq.html
Page 67April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Industry Readiness Survey • The Workgroup for Electronic Data Interchange (WEDI), the leading authority on the use of Health IT to improve the exchange of healthcare information, announced submission of the latest ICD-10 industry readiness survey results to the Centers for Medicare & Medicaid Services (CMS). • Some key results from the survey include: – Almost half of the health plans expect to begin external testing by the end of this year. In the 2012 survey all health plans had expected to begin in 2013. – About half of the providers responded that they did not know when testing would occur, and over two-fifths of provider respondents indicated they did not know when they would complete their impact assessments and business changes. – About two-thirds of vendors indicate they plan to begin customer review and beta testing by the end of this year. This is similar to the number who expected to begin by the end of 2012 in the prior survey. Source: http://www.wedi.org/news/press-releases/2013/04/11/wedi-provides-vital-icd-10-industry-readiness- survey-results-to-cms
Page 68April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association What do I need to do to get the claim out the door? • Medicare will begin accepting a revised 1500 (version 02/12) on January 6, 2014 – Identify whether they are using ICD-9 or ICD-10 codes – Use as many as 12 codes in the diagnosis field (the current limit is four) – Qualifiers to identify the following providers role (on item 17) • Ordering, Referring, Supervising • Starting April 1, 2014, Medicare will accept only the revised version of the form – The revised form will give providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes
Page 69April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association What do I need to know to get the claim out the door? • Reporting ICD-10 diagnosis codes • Claims submission of diagnosis codes – ICD-9 codes no longer accepted on claims with date of service after October 1, 2014 – ICD-10 codes will not be recognized/accepted on claims before October 1, 2014 – Claims cannot contain both ICD-9 and ICD10 codes—they will be returned as “unprocessable” • Date span requirements – Outpatient claims—split claim form and use from date – Inpatient claims—use only through date/discharge date for ICD-10 code submission
Page 70April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association National Coverage Determinations (NCDs) • CMS is responsible for converting approximately 330 NCDs • Not all are appropriate for translation – Edits based on HCPCS – Older, obsolete technology or considered outdated CMS has determined which NCD should be translated and is in the process of completing system changes for those NCDs http://www.cms.gov/outreach-and-education/medicare- learningnetworkmln/mlnmattersarticles/downloads/MM7818.pdf
Page 71April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Local Coverage Determinations (LCDs) • According to CMS, LCDs are made by the individual Medicare Auditing Contractor (MAC – i.e. CAHABA) • Contractors shall publish all ICD-10 LCDs and ICD-10 associated articles on the Medicare Coverage Database (MCD) no later than April 10, 2014 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8348.pdf
Page 72April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association • Administrators: Confirm capabilities, provide training, review processes • IT staff: Confirm integration in system and documentation • Providers: – Outpatient: Document in support of ICD-10 code selected – Inpatient: CM and PCS codes will have to be supported • Billers: Understand how to look up codes, understand how to query physicians, pull new LCDs • Coders: Understand ICD-10 guidelines and how to properly select ICD-10 codes base on documentation Roles
Page 73April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Priority List Buy the ICD-10-CM Effective October 1, 2014, when released ~Sept 2013. (2014 Draft is available) Make sure all of your systems are up-to-date Billing should have access to both code sets to properly handle new and old claims Consider an encoder or mapping resource if EHR or PM does not have mapping options Update superbill with most used diagnosis codes
Page 74April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Code Analysis Review top 20-50 diagnosis codes • Evaluate documentation currently in the notes • Crosswalk them to ICD-10 • Review new codes for additional required codes, additional code descriptions and “code also” requirements • Identify areas where additional documentation will be required
Page 75April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Budget How much emergency cash should providers keep in case of cash flow disruption? • Review what happened to your practice with HIPAA 5010—this would be a good baseline; with the transition to ICD-10, there will be delays in reimbursement • Vendors and clearinghouses have been working hard, but we will not know the true effects until Oct 1, 2014 • It is recommended that you have up to several months' cash reserves or access to cash through a loan or line of credit to avoid potential headaches • The amount of money that you will need to set aside will be impacted by the preparation work you do for ICD-10 • Will need to cover at a minimum, practice operation expenses for three to six months: – Medical supplies – Payroll – Rent
Page 76April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Budget • Cost of training/decreased staff productivity • Cost of hardware/software upgrades • Forms redesign • Testing costs/consulting services • Vendor readiness – external testing • Temporary maintenance of dual systems • Cash reserves for denials increase, payment delays, decreased productivity Determine financial impact, budget, resources, cash reserve needed for ICD-10 migration
Page 77April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Once I get this claim out the door, am I going to get paid? • The Department of Health and Human Services (HHS) anticipates that the percent of returned claims following the ICD-10 implementation could be more than double what we have seen in the past with ICD-9 updates.
Page 78April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association What do certified coders need to do to get ready for ICD-10? What is the ICD-10 Proficiency Assessment and is it required? (AAPC) • The ICD-10 Proficiency Assessment is the only step of this roadmap required for all certified AAPC members. You should prepare yourself as you would for other exams or assessments. To ensure employers continue to have confidence in a certified coder’s ability to accurately code the current code sets, AAPC certified members will have two years to pass an open-book, online, unproctored assessment. – It will measure your understanding of ICD-10-CM format and structure, groupings and categories of codes, ICD-10- CM official guidelines, and coding concepts. – Required for AAPC credentialed coders, (excluding CPPM®, CPCO™, and CIRCC®), recommended for all others working with the new code set. – Two (2) years to take and pass the assessment, beginning October 1, 2013 (one year before implementation of ICD-10) and ending September 30, 2015 (one year after implementation) **Updated ICD-10-CM proficiency to December 31, 2015. » 75 questions, 3.5 hours, open-book, online, and unproctored » Coders will have two (2) attempts at passing (reaching an 80% score) for the $60 administration fee » ICD-10-CM only (ICD-10-PCS will not be covered in the assessment) » No CEUs given
Page 79April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association AHIMA In order to validate that an AHIMA Certified Professional has gained knowledge of the ICD-10-CM/PCS coding system, CCHIIM has determined that continuing education hours with ICD-10-CM/PCS content will be required, as applicable and relevant to the specific AHIMA credential(s) held by the individual. • The total number of ICD-10-CM/PCS continuing education units (CEUs) required, by AHIMA credential, is as follows: *6 CEUs = 1 day of training http://www.ahima.org/~/media/AHIMA/Files/Certification/ICD10_CEU_FAQs.ashx – CHPS – 1 CEU – CHDA – 6 CEUs – RHIT – 6 CEUs – RHIA – 6 CEUs – CDIP – 12 CEUs – CCS-P – 12 CEUs – CCS – 18 CEUs – CCA – 18 CEUs
Page 80April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Predictions
Page 81April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association 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/
Page 82April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Questions?
Page 83April 25, 2014 Prepared for Georgia Pediatric Practice Managers Association Thank you! Kim-Marie Walker, CPC, CCVTC, CHAP AHIMA-Approved ICD-10-CM Trainer Pershing Yoakley & Associates, P.C. (404) 266-9876 kwalker@pyapc.com www.pyapc.com

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Preparing Now for ICD-10

  • 1.
    Page 0April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Preparing Now For ICD-10-CM Georgia Pediatric Practice Managers Association April 25, 2014
  • 2.
    Page 1April 25,2014 Prepared for Georgia Pediatric Practice Managers Association • Updates • ICD-9 and ICD-10 Comparison • ICD-10 Organization and Structural Differences • Vendor Recommendations and Resources Available • Discuss Transition Planning and Roles Agenda
  • 3.
    Page 2April 25,2014 Prepared for Georgia Pediatric Practice Managers Association What’s new? • On April 1, President Obama signed into law legislation passed by the House and Senate delaying ICD-10 until at least October 1, 2015. • CMS has been silent on what the next steps are for healthcare organizations and how to plan accordingly. • The ICD-10 delay is forcing organizations to reassess their timelines and budgets for complying with the code change, yet at this point there are more questions than answers. • The American Health Information Management Association has requested clarification from CMS on a number of technical issues surrounding the extension of the ICD- 10 deadline, including the exact length of the delay.
  • 4.
    Page 3April 25,2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10 vs. ICD-9 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. 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. Duplication of code sets Currently, only ICD-9-CM codes are required . No mapping is necessary. 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. Source: http://www.aapc.com/icd-10/faq.aspx#why
  • 5.
    Page 4April 25,2014 Prepared for Georgia Pediatric Practice Managers Association What are the benefits of ICD-10? The new, up-to-date classification system will provide much better data needed to: • Measure the quality, safety, and efficacy of care • Reduce the need for attachments to explain the patient’s condition • Design payment systems and process claims for reimbursement • Conduct research, epidemiological studies, and clinical trials • Set health policy • Support operational and strategic planning • Design healthcare delivery systems • Monitor resource utilization • Improve clinical, financial, and administrative performance • Prevent and detect healthcare fraud and abuse • Track public health and risks
  • 6.
    Page 5April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Why is the United States moving to ICD-10-CM? Barriers: • ICD-9 is out of room • Because the classification is organized scientifically, each three-digit category can have only 10 subcategories • Most numbers in most categories have been assigned diagnoses • Medical science keeps making new discoveries, and there are no numbers to assign these diagnoses Benefits: • ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care • Streamline claims submissions (code combinations ) • Details will make the initial claim much easier for payers to understand
  • 7.
    Page 6April 25,2014 Prepared for Georgia Pediatric Practice Managers Association But… • ICD-10 will influence billing documentation, provider contracting, payment, and other major business functions, as well as IT systems for trend analysis and analytics; claims and documentation in both paper and electronic form have been overhauled. • Moving to ICD-10 is intended to bring the benefits of greater coding accuracy, higher data quality for measuring service and outcomes, more efficiency, lower costs, better use of the electronic health record, and better alignment worldwide, to name a few.
  • 8.
    Page 7April 25,2014 Prepared for Georgia Pediatric Practice Managers Association What can we learn from other countries’ implementation? • Planning and preparation are the keys to success – Start early to allow time to understand the impact and come up with solutions • Education and training are all important – Prepare for productivity loss and longer turn around times • Collaborate with others – Share information and experiences to learn what works and what to avoid
  • 9.
    Page 8April 25,2014 Prepared for Georgia Pediatric Practice Managers Association What does ICD-10-CM look like?
  • 10.
    Page 9April 25,2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10-CM Organization Index to Diseases and Injuries Official Guidelines Tabular List of Diseases and Injuries The CM Manual divided into three main parts: 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.
    Page 10April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Anatomy of an ICD-10-CM Code 3-7 Alphanumeric characters (digits) X X X X X X X . 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.
    Page 11April 25,2014 Prepared for Georgia Pediatric Practice Managers Association X X X X Category . Etiology, anatomic site, severity Added code extensions (7th character) for obstetrics, injuries, and external causes of injury ICD-10-CM Characters and Extensions X X XAMS 0 2 6. 5 x A Alpha (Except U) 2 - 7 Numeric or Alpha Additional Characters
  • 13.
    Page 12April 25,2014 Prepared for Georgia Pediatric Practice Managers Association • X Marks the Spot – ICD-10-CM uses a placeholder character “X”—this will allow the code future expansion – Where a placeholder, the X must be used in order for the code to be valid (The X is not case sensitive) Placeholder Character
  • 14.
    Page 13April 25,2014 Prepared for Georgia Pediatric Practice Managers Association 7th Character Extension • Certain ICD-10-CM categories have a 7th character feature; this “character” must always be in the 7th character field • These extensions are found predominantly in two chapters – Chapter 19 – Injury, Poisoning and Certain Other Consequences of External Causes – Chapter 15 – Pregnancy, Childbirth and the Puerperium
  • 15.
    Page 14April 25,2014 Prepared for Georgia Pediatric Practice Managers Association If a diagnosis code requires a 7th digit and the code is a 4-digit code, what do you do?
  • 16.
    Page 15April 25,2014 Prepared for Georgia Pediatric Practice Managers Association 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: • T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter • S03.4xxA- Sprain of jaw, initial encounter • T15.02xD – Foreign body in cornea, left eye, subsequent encounter
  • 17.
    Page 16April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Fetus Identification When applicable, a 7th character is to be assigned to identify the fetus for which the complication applies The following are the 7th characters • 0 - not applicable or unspecified • 1 - fetus 1 • 2 - fetus 2 • 3 - fetus 3 • 4 - fetus 4 • 5 - fetus 5 • 9 - other fetus
  • 18.
    Page 17April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Episode of Care – Fractures 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
  • 19.
    Page 18April 25,2014 Prepared for Georgia Pediatric Practice Managers Association • Initial encounter. Initial encounter is defined as the period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An ‘A’ may be assigned on more than one claim – For example, if a patient is seen in the emergency department (ED) for a knee injury that is first evaluated by the ED physician who requests a CT that is read by a radiologist and a consultation by an Orthopedist, the 7th character ‘A’ is used by all three physicians and also reported on the ED claim – If the patient required admission to an acute care hospital, the 7th character ‘A’ would be reported for the entire acute care hospital stay because the 7th character extension ‘A’ is used for the entire period that the patient receives active treatment for the injury Episode of Care – 7th digit
  • 20.
    Page 19April 25,2014 Prepared for Georgia Pediatric Practice Managers Association • Subsequent encounter. This is an encounter after the active phase of treatment and when the patient is receiving routine care for the injury during the period of healing or recovery – For example a patient with a knee injury may return to the office to have joint stability re-evaluated to ensure that it is healing properly. In this case, the 7th character ‘D’ would be assigned. • Sequela (Late Effects)The 7th character extension ‘S’ is assigned for complications or conditions that arise as a direct result of an injury. There is no time limit when these codes can be used. – An example of a sequela is a scar resulting from a burn Episode of Care – 7th digit
  • 21.
    Page 20April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Episode of Care – Fractures • Initial encounter for closed fractureA • Initial encounter for open fractureB • Subsequent encounter for fracture with routine healingD • Subsequent encounter for fracture with delayed healingG • Subsequent encounter for fracture with nonunionK • Subsequent encounter for fracture with malunionP • SequelaS  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
  • 22.
    Page 21April 25,2014 Prepared for Georgia Pediatric Practice Managers Association More Information Reported, Higher Level of Detail in Coding
  • 23.
    Page 22April 25,2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10-CM continued… Obstetric codes identify trimester instead of episode of care • 1st Trimester – less than 14 weeks 0 days • 2nd Trimester – 14 weeks 0 days to less than 28 weeks 0 days • 3rd Trimester – 28 weeks 0 days until delivery Example: • O26.02 – Excessive weight gain in pregnancy, second trimester
  • 24.
    Page 23April 25,2014 Prepared for Georgia Pediatric Practice Managers Association New Clinical Concepts Inclusion of clinical concepts that do not exist in ICD- 9-CM (e.g., underdosing, blood type, blood alcohol level) Examples: • T45.526D – Underdosing of antithrombotic drugs, subsequent encounter • Z67.40 – Type O blood, Rh positive • Y90.6 – Blood alcohol level of 120–199 mg/100 ml
  • 25.
    Page 24April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Codes That Have Been Significantly Expanded A number of codes have been significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications) Examples: • E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy • F10.182 – Alcohol abuse with alcohol-induced sleep disorder • T82.02xA – Displacement of heart valve prosthesis, initial encounter
  • 26.
    Page 25April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Post/intra-operative designation Codes for postoperative complications have a distinction made between intraoperative complications and postprocedural disorders Examples: • D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen • D78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen
  • 27.
    Page 26April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Additional changes in ICD-10-CM • Injuries are grouped by anatomical site rather than by type of injury • Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM • Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge
  • 28.
    Page 27April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Use of External Causes If a payer required E-Codes with ICD-9, then continue to submit in ICD-10. In the absence of a mandatory reporting requirement, you are encouraged to report these codes as they add valuable data. http://www.healthcareitnews.com/infographic/infographic-top-zaniest-icd- 10-codes This infographic first appeared in the Healthcare IT News and Healthcare Finance News eSupplement, ICD-10 Compliance and Beyond: Completing the Journey.
  • 29.
    Page 28April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Where can I Find the ICD-10-CM Codes?
  • 30.
    Page 29April 25,2014 Prepared for Georgia Pediatric Practice Managers Association • 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 due to increased complexity of ICD-10 versus ICD-9 Crosswalk
  • 31.
    Page 30April 25,2014 Prepared for Georgia Pediatric Practice Managers Association GEMs GEMs 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 or ICD-10-PCS to find the most recent GEMs)
  • 32.
    Page 31April 25,2014 Prepared for Georgia Pediatric Practice Managers Association How Does the Mapping Work? ICD-9-CM • 493.92 Asthma, Acute Exacerbation ICD-10-CM • J45.21 Mild, intermittent, w/acute exacerbation • J45.41 Moderate, persistent, w/acute exacerbation left • J45.51 Severe, persistent, w/acute exacerbation
  • 33.
    Page 32April 25,2014 Prepared for Georgia Pediatric Practice Managers Association How Does Mapping Work? ICD-9-CM • 719.46 Pain in joint, lower leg ICD-10-CM • M25.561 Pain in right knee • M25.562 Pain in left knee • M25.569 Pain in unspecified knee
  • 34.
    Page 33April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Streptococcal Sore Throat ICD-9 • 034.0 (Streptococcal sore throat) which includes the tonsils/ adenoids and pharynx. ICD-10 • J02.0 (Streptococcal pharyngitis) • J03.0 (Acute tonsillitis) – J03.00 (Acute streptococcal tonsillitis, unspecified) – J03.01 (Acute recurrent streptococcal tonsillitis)
  • 35.
    Page 34April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements • In ICD-10, the documentation of strep throat alone will no longer include streptococcal infection of the tonsils. • Streptococcal infection of the tonsils has a separate entry in ICD-10 with further specificity for recurrence and chronicity. • If a patient has a history of streptococcal infections of the tonsils along with chronic tonsillitis the proper codes are: J0301 (Acute recurrent streptococcal tonsillitis) and J3501 (Chronic tonsillitis). • If a patient presents with strep throat and has chronic pharyngitis the proper codes are: J020 (Streptococcal pharyngitis) and J312 (Chronic pharyngitis). • When documenting strep throat, it is important to note the site(s) involved (pharynx, tonsils, or both).
  • 36.
    Page 35April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Infectious mononucleosis ICD-9 • 075 (Infectious mononucleosis) with the assumed Epstein-Barr as the assumed cause ICD-10 • B27.90 (Infectious mononucleosis, unspecified without complication
  • 37.
    Page 36April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Tobacco Use Disorder ICD-9 – 305.1 (Tobacco use disorder) – Includes tobacco dependence ICD-10 – Z72.0 (Tobacco use) – Does not include tobacco dependence – Tobacco/Nicotine dependence is indexed to F17.2 (Nicotine dependence) • Specified according to tobacco/nicotine source and dependency status
  • 38.
    Page 37April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements In order to accurately report tobacco use disorder with the greatest specificity, the nicotine source as well as the patient’s dependency status should be noted within physician documentation. Tobacco/Nicotine dependence—now separately classified according to tobacco/nicotine source (cigarettes, chewing tobacco, or other tobacco products) and the state of the tobacco/nicotine dependency (uncomplicated, in remission, with withdrawal, and with other nicotine-induced disorders).
  • 39.
    Page 38April 25,2014 Prepared for Georgia Pediatric Practice Managers Association ACUTE Conjunctivitis ICD-9 • 372.00 (Acute conjunctivitis, unspecified ICD-10 • H10.30 (Unspecified acute conjunctivitis, unspecified eye)
  • 40.
    Page 39April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Otitis Media • Use additional code for any associated perforated tympanic membrane (H72.-) • Use additional code to identify: – Exposure to environmental tobacco smoke (Z77.22) – Exposure to tobacco smoke in the perinatal period (P96.81) – History of tobacco use (Z87.891) – Occupational exposure to environmental tobacco smoke (Z57.31) – Tobacco dependence (F17.-) – Tobacco use (Z72.0)
  • 41.
    Page 40April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Diseases of the Respiratory System 40 National Cancer Institute
  • 42.
    Page 41April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Asthma • New terminology for asthma • Respiratory condition in more than 1 site (not specifically indexed) classified to lower anatomic site • Additional code notes Asthma Severity—Frequency of Daytime Symptoms • Intermittent—Less than or equal to 2 times per week • Mild Persistent—More than 2 times per week • Moderate Persistent—Daily. May restrict physical activity • Severe Persistent— Throughout the day. Frequent severe attacks limiting ability to breathe 41
  • 43.
    Page 42April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Coding Note • In the Tabular there is an Excludes2 note under category J45 for asthma with chronic obstructive pulmonary disease. • By definition, when an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together if the patient has both conditions at the same time.
  • 44.
    Page 43April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Acute Bronchitis ICD-9 • 466.0 (Acute bronchitis) – Required separate reporting for identity of organism ICD-10 • J20.9 (Acute bronchitis, unspecified) • Infectious agent built in to some codes. – J02.0-Acute bronchitis due to Mycoplasma pneumoniae – J20.1-Acute bronchitis due to Hemophilus influenzae – J20.2-Acute bronchitis due to streptococcus
  • 45.
    Page 44April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Acute Bronchitis In ICD-10, diagnosis codes have been created that define the infectious agent that caused the acute bronchitis. Examples: • J20.0 Acute bronchitis due to Mycoplasma pneumoniae • J20.1 Acute bronchitis due to Hemophilus influenzae • J20.2 Acute bronchitis due to streptococcus • J20.3 Acute bronchitis due to coxsackievirus • J20.4 Acute bronchitis due to parainfluenza virus 44
  • 46.
    Page 45April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements In order to report acute bronchitis with the greatest specificity, the infectious agent should be documented. 4 5
  • 47.
    Page 46April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Croup ICD-9 • 464.4 (Croup) ICD-10 • J05.0 (Acute obstructive laryngitis [croup]) 46
  • 48.
    Page 47April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements In order to code a diagnosis of Croup with the greatest specificity, the type (bronchial, diphtheritic, etc.), the infectious agent, and existing conditions such as: • exposure to environmental tobacco smoke • history of tobacco use • occupational exposure to environmental tobacco smoke • smoke inhalation • tobacco dependence • tobacco use should be documented if present 47
  • 49.
    Page 48April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Ankle Sprains/Strains ICD-9 • 845.00 (Ankle sprain, unspecified site) ICD-10 • S93409A (Sprain of unspecified ligament of unspecified ankle, initial encounter)
  • 50.
    Page 49April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Documentation Requirements Physician documentation should reflect the specific site of the sprain or strain (i.e. long flexor muscle of toe at ankle and foot level, left foot) Further code specificity is provided given site, laterality, and whether the encounter is initial, subsequent, or the sprain is a sequela of another condition.
  • 51.
    Page 50April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Sometimes Unspecified Makes Sense… The patient may be early in the course of evaluation The claim may be coming from a provider who is not directly related to diagnosis of the patients condition The clinician seeing the patient may be more of a generalist and not able to define the condition at a level of detail expected by a specialist
  • 52.
    Page 51April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Percentages of Types of Matches Mapping Categories ICD-10 to ICD-9 ICD-9 to ICD-10 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
  • 53.
    Page 52April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Where Should I be in my ICD-10-CM Implementation Process?
  • 54.
    Page 53April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Implementation Process Processes Reports Work Flow Information Systems and Software All Forms of Documentation Analysis of all Departments
  • 55.
    Page 54April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Implementation Issues Training • Will be required for various users • Will require coder retraining – Coding rules and conventions are similar, but not exactly the same • Some short-term loss of productivity is expected during the learning curve • Will require changes in data retrieval/analysis • Will require changes to data systems
  • 56.
    Page 55April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Training Coding and Billing Staff • Assess training needs and develop a plan – Professional coding staff – ICD-10-CM – Determine who will train staff and how this will be accomplished – Factor in time away from work, consider post-testing and ongoing support – Make ICD-10 proficiency part of your coding staff’s performance goals » ICD-9-CM to ICD-10-CM Dual Coding • Assign staff members to be the “ICD-10 Expert,” looking at the impact from the billing to the clinical side
  • 57.
    Page 56April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Training Clinicians • Physicians – focus on codes germane to their practice • Review clinical documentation improvement efforts and develop new strategies • Incorporate documentation improvement as component to compliance training • Ancillary staff – identify needs and level of training needed, nursing, financial services, quality, utilization, ancillary departments… Information Technology • Training to ensure that codes are accurately cross-walked in organization’s IT systems
  • 58.
    Page 57April 25,2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10 Timeline for Small-Medium Practices at a Glance- Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10SmallMediumTimelineChart.pdf
  • 59.
    Page 58April 25,2014 Prepared for Georgia Pediatric Practice Managers Association ICD-10 Timeline for Large Practices at a Glance Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10LargePracticesTimelineChart.pdf
  • 60.
    Page 59April 25,2014 Prepared for Georgia Pediatric Practice Managers Association ICD 10 & EHR • Analyze EHR for functionality and compliance • Review: – templates – interfaces – default documentation – level of detail • Confirm EHR is updated with the ability to communicate to the billing system in ICD-10 language – Is your PM integrated with your EHR? – Look for products to include drop down menus and selection edits – Need appropriate “granularity” to accurately capture correct code
  • 61.
    Page 60April 25,2014 Prepared for Georgia Pediatric Practice Managers Association EHR Vendor Questions • Can EHR translate ICD-9 to ICD-10 format? • Can your EHR differentiate date of service for reporting ICD- 9 or ICD-10? • Will ICD-9 code from previous visit translate in new encounter as ICD-10? • Will system document ICD-10 on and after October 1, 2013? • Are diagnoses linked from diagnostic results? • What are the capabilities of automated and manual documentation entry? • Do you anticipate any pricing changes due to the switch to ICD-10?
  • 62.
    Page 61April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Vendor Readiness Our billing software vendor indicates they will be ready for these transitions. What can I do in the meantime, besides train for ICD-10 coding? • Ask your billing software vendor for a detailed schedule of deliverables and begin preparing to test implementation of the modified software at your location. • Be sure to verify the following: – The vendor is addressing the ICD-10 upgrades – The number and schedule of planned ICD-10 software releases – Their ICD-10 conversion plan accommodates your clearinghouse testing schedule – Any related costs to your organization – Customer support and training they will provide
  • 63.
    Page 62April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Computer Assisted Coding (CAC) • Is this the answer? – Selecting the right codes – Ensuring that those codes are justified and supported in the documentation – Interfacing coded data correctly to billing systems – Educating billing teams about appropriate codes – Providing documentation and feedback/education to physicians
  • 64.
    Page 63April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Physician Work Flow • Will the EMR allow the physician to enter a descriptive diagnosis rather than a specific diagnosis code? • Is the physician prepared for the dramatic increase in diagnosis codes now displayed on the drop-down list? • How will the physician’s workflow change when more time is needed to assign the appropriate diagnosis code? • Can the EMR support a workflow that sends patient encounters to coders for review and assignment of the most specific diagnosis code based on the physician’s documentation?
  • 65.
    Page 64April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Fact or Fiction ICD-10-CM-based super bills will be too long or too complex to be of much use Fiction (sort of) • Practices may continue to create super bills that contain the most common diagnosis codes used in their practices. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions. • The super bill conversion process includes: – Conducting a review that includes removing rarely used codes; and – Cross walking common codes from ICD-9-CM to ICD-10-CM, which can be accomplished by looking up codes in the ICD-10-CM code book or using the General Equivalence Mappings (GEM). – Vendors electronic superbill and posting scrubber that assist physicians in the transition to ICD-10. Source: http://www.whiteplume.com/learn-more/icd-10
  • 66.
    Page 65April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Payer’s Role • Communicate with your top payers to see what if any ICD-10-CM changes will take place prior to the Oct 1, 2014 deadline – When will their testing begin? – What will be required on your end? • Additional staff recourses
  • 67.
    Page 66April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Payer Response Will the ICD-10 conversion have an effect on provider reimbursement and contracting? • “Possibly. We are evaluating the impact of ICD-10 on our contracting and clinical operations. The ICD- 10 conversion is not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately reflect patient status and care.” Source: http://www.aetna.com/healthcare-professionals/policies-guidelines/icd_10_faq.html
  • 68.
    Page 67April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Industry Readiness Survey • The Workgroup for Electronic Data Interchange (WEDI), the leading authority on the use of Health IT to improve the exchange of healthcare information, announced submission of the latest ICD-10 industry readiness survey results to the Centers for Medicare & Medicaid Services (CMS). • Some key results from the survey include: – Almost half of the health plans expect to begin external testing by the end of this year. In the 2012 survey all health plans had expected to begin in 2013. – About half of the providers responded that they did not know when testing would occur, and over two-fifths of provider respondents indicated they did not know when they would complete their impact assessments and business changes. – About two-thirds of vendors indicate they plan to begin customer review and beta testing by the end of this year. This is similar to the number who expected to begin by the end of 2012 in the prior survey. Source: http://www.wedi.org/news/press-releases/2013/04/11/wedi-provides-vital-icd-10-industry-readiness- survey-results-to-cms
  • 69.
    Page 68April 25,2014 Prepared for Georgia Pediatric Practice Managers Association What do I need to do to get the claim out the door? • Medicare will begin accepting a revised 1500 (version 02/12) on January 6, 2014 – Identify whether they are using ICD-9 or ICD-10 codes – Use as many as 12 codes in the diagnosis field (the current limit is four) – Qualifiers to identify the following providers role (on item 17) • Ordering, Referring, Supervising • Starting April 1, 2014, Medicare will accept only the revised version of the form – The revised form will give providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes
  • 70.
    Page 69April 25,2014 Prepared for Georgia Pediatric Practice Managers Association What do I need to know to get the claim out the door? • Reporting ICD-10 diagnosis codes • Claims submission of diagnosis codes – ICD-9 codes no longer accepted on claims with date of service after October 1, 2014 – ICD-10 codes will not be recognized/accepted on claims before October 1, 2014 – Claims cannot contain both ICD-9 and ICD10 codes—they will be returned as “unprocessable” • Date span requirements – Outpatient claims—split claim form and use from date – Inpatient claims—use only through date/discharge date for ICD-10 code submission
  • 71.
    Page 70April 25,2014 Prepared for Georgia Pediatric Practice Managers Association National Coverage Determinations (NCDs) • CMS is responsible for converting approximately 330 NCDs • Not all are appropriate for translation – Edits based on HCPCS – Older, obsolete technology or considered outdated CMS has determined which NCD should be translated and is in the process of completing system changes for those NCDs http://www.cms.gov/outreach-and-education/medicare- learningnetworkmln/mlnmattersarticles/downloads/MM7818.pdf
  • 72.
    Page 71April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Local Coverage Determinations (LCDs) • According to CMS, LCDs are made by the individual Medicare Auditing Contractor (MAC – i.e. CAHABA) • Contractors shall publish all ICD-10 LCDs and ICD-10 associated articles on the Medicare Coverage Database (MCD) no later than April 10, 2014 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8348.pdf
  • 73.
    Page 72April 25,2014 Prepared for Georgia Pediatric Practice Managers Association • Administrators: Confirm capabilities, provide training, review processes • IT staff: Confirm integration in system and documentation • Providers: – Outpatient: Document in support of ICD-10 code selected – Inpatient: CM and PCS codes will have to be supported • Billers: Understand how to look up codes, understand how to query physicians, pull new LCDs • Coders: Understand ICD-10 guidelines and how to properly select ICD-10 codes base on documentation Roles
  • 74.
    Page 73April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Priority List Buy the ICD-10-CM Effective October 1, 2014, when released ~Sept 2013. (2014 Draft is available) Make sure all of your systems are up-to-date Billing should have access to both code sets to properly handle new and old claims Consider an encoder or mapping resource if EHR or PM does not have mapping options Update superbill with most used diagnosis codes
  • 75.
    Page 74April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Code Analysis Review top 20-50 diagnosis codes • Evaluate documentation currently in the notes • Crosswalk them to ICD-10 • Review new codes for additional required codes, additional code descriptions and “code also” requirements • Identify areas where additional documentation will be required
  • 76.
    Page 75April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Budget How much emergency cash should providers keep in case of cash flow disruption? • Review what happened to your practice with HIPAA 5010—this would be a good baseline; with the transition to ICD-10, there will be delays in reimbursement • Vendors and clearinghouses have been working hard, but we will not know the true effects until Oct 1, 2014 • It is recommended that you have up to several months' cash reserves or access to cash through a loan or line of credit to avoid potential headaches • The amount of money that you will need to set aside will be impacted by the preparation work you do for ICD-10 • Will need to cover at a minimum, practice operation expenses for three to six months: – Medical supplies – Payroll – Rent
  • 77.
    Page 76April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Budget • Cost of training/decreased staff productivity • Cost of hardware/software upgrades • Forms redesign • Testing costs/consulting services • Vendor readiness – external testing • Temporary maintenance of dual systems • Cash reserves for denials increase, payment delays, decreased productivity Determine financial impact, budget, resources, cash reserve needed for ICD-10 migration
  • 78.
    Page 77April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Once I get this claim out the door, am I going to get paid? • The Department of Health and Human Services (HHS) anticipates that the percent of returned claims following the ICD-10 implementation could be more than double what we have seen in the past with ICD-9 updates.
  • 79.
    Page 78April 25,2014 Prepared for Georgia Pediatric Practice Managers Association What do certified coders need to do to get ready for ICD-10? What is the ICD-10 Proficiency Assessment and is it required? (AAPC) • The ICD-10 Proficiency Assessment is the only step of this roadmap required for all certified AAPC members. You should prepare yourself as you would for other exams or assessments. To ensure employers continue to have confidence in a certified coder’s ability to accurately code the current code sets, AAPC certified members will have two years to pass an open-book, online, unproctored assessment. – It will measure your understanding of ICD-10-CM format and structure, groupings and categories of codes, ICD-10- CM official guidelines, and coding concepts. – Required for AAPC credentialed coders, (excluding CPPM®, CPCO™, and CIRCC®), recommended for all others working with the new code set. – Two (2) years to take and pass the assessment, beginning October 1, 2013 (one year before implementation of ICD-10) and ending September 30, 2015 (one year after implementation) **Updated ICD-10-CM proficiency to December 31, 2015. » 75 questions, 3.5 hours, open-book, online, and unproctored » Coders will have two (2) attempts at passing (reaching an 80% score) for the $60 administration fee » ICD-10-CM only (ICD-10-PCS will not be covered in the assessment) » No CEUs given
  • 80.
    Page 79April 25,2014 Prepared for Georgia Pediatric Practice Managers Association AHIMA In order to validate that an AHIMA Certified Professional has gained knowledge of the ICD-10-CM/PCS coding system, CCHIIM has determined that continuing education hours with ICD-10-CM/PCS content will be required, as applicable and relevant to the specific AHIMA credential(s) held by the individual. • The total number of ICD-10-CM/PCS continuing education units (CEUs) required, by AHIMA credential, is as follows: *6 CEUs = 1 day of training http://www.ahima.org/~/media/AHIMA/Files/Certification/ICD10_CEU_FAQs.ashx – CHPS – 1 CEU – CHDA – 6 CEUs – RHIT – 6 CEUs – RHIA – 6 CEUs – CDIP – 12 CEUs – CCS-P – 12 CEUs – CCS – 18 CEUs – CCA – 18 CEUs
  • 81.
    Page 80April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Predictions
  • 82.
    Page 81April 25,2014 Prepared for Georgia Pediatric Practice Managers Association 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/
  • 83.
    Page 82April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Questions?
  • 84.
    Page 83April 25,2014 Prepared for Georgia Pediatric Practice Managers Association Thank you! Kim-Marie Walker, CPC, CCVTC, CHAP AHIMA-Approved ICD-10-CM Trainer Pershing Yoakley & Associates, P.C. (404) 266-9876 kwalker@pyapc.com www.pyapc.com