Speaking before the Georgia Pediatric Practice Managers Association, PYA Consultant and ICD-10-CM Trainer Kim-Marie Walker addressed recent ICD-10 developments along with basic guidance for the transition, including: • Comparison of ICD-9 and ICD-10 • ICD-10 organizational and structural differences • Vendor recommendations and available resources • Transition planning and roles

1. Page 0April 25, 2014
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Preparing Now For ICD-10-CM
Georgia Pediatric
Practice Managers Association
April 25, 2014

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• Updates
• ICD-9 and ICD-10
Comparison
• ICD-10 Organization and
Structural Differences
• Vendor Recommendations
and Resources Available
• Discuss Transition Planning
and Roles
Agenda

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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.

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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

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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

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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

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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.

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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

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What does ICD-10-CM
look like?

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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

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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 )

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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

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• 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

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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

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If a diagnosis code requires a
7th digit and the code is a
4-digit code, what do you do?

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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

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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

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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

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• 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

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• 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

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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

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More Information Reported,
Higher Level of Detail in
Coding

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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

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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

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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

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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

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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

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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.

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Where can I Find the
ICD-10-CM Codes?

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• 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

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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)

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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

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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

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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)

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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).

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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

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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

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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).

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ACUTE Conjunctivitis
ICD-9
• 372.00 (Acute
conjunctivitis, unspecified
ICD-10
• H10.30 (Unspecified
acute conjunctivitis,
unspecified eye)

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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)

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Diseases of the Respiratory
System
40
National Cancer Institute

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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

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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.

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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

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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

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Documentation Requirements
In order to report acute bronchitis with the
greatest specificity, the infectious agent should
be documented.
4
5

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Croup
ICD-9
• 464.4 (Croup)
ICD-10
• J05.0 (Acute obstructive
laryngitis [croup])
46

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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

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Ankle Sprains/Strains
ICD-9
• 845.00 (Ankle sprain,
unspecified site)
ICD-10
• S93409A (Sprain of
unspecified ligament of
unspecified ankle, initial
encounter)

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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.

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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

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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

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Where Should I be in my
ICD-10-CM Implementation Process?

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Implementation Process
Processes Reports Work Flow
Information
Systems and
Software
All Forms of
Documentation
Analysis of all Departments

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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

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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

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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

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ICD-10 Timeline for
Small-Medium Practices at a Glance-
Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10SmallMediumTimelineChart.pdf

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ICD-10 Timeline for
Large Practices at a Glance
Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10LargePracticesTimelineChart.pdf

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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

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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?

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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

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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

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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?

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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

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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

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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

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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

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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

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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

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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

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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

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• 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

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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

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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

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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

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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

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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.

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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

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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

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Predictions

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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/

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Questions?

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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