Building Your Path to ICD-10

Embracing ICD-10 with Confidence

An educational program presented by the

Cooperative of American Physicians, Inc.

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Today’s Agenda Overview of ICD-10-CM

An Up-to-Date Review

The Effects of ICD-10-CM on Your Practice

Using Technology Effectively

Differences Between ICD-9 and ICD-10

What You Need to Know

Determining Your Most Commonly Used Codes

Clinical Documentation

Provider Challenges 3

The New (Latest) Deadline

October 1, 2015

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Why ICD-10?

Improve Clinical Communications

More (better) data Signs

Symptoms

Risk Factors

Comorbidities

Allow U.S. to exchange information internationally

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What Is ICD-10? International Classification of Diseases

ICD-10-CM: diagnosis code set

Updated version of ICD-10-CM Volumes 1 and 2

ICD-10-PCS: code set of inpatient procedure codes Updated version of ICD-9-CM Volume 3

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ICD-9 vs. ICD-10

ICD-9 ICD-10

Diagnosis: 14,000 codes Diagnosis: 68,000 codes

Procedures: 4,000 codes Procedures: 87,000 codes

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Code Structure

ICD-10-CM Code Structure

Characters 1 through 3 = Category

Characters 4 through 6 = Etiology, anatomic site, severity, or other clinical detail

Character 7 = Extension

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Example:

S52 Fracture of forearm (category)

S52.5 Fracture of lower end of radium (site)

S52.52 Torus fracture of lower end of radium (type)

S52.521 Torus fracture of lower end of right radium (laterality)

S52.521A Torus fracture of lower end of right radium, initial encounter for closed fracture (extension = episode of care)

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Code Construction A three-character code

Base code (category) I10 Essential (primary) hypertension

Building a five-character code

Base code (category) Four characters Five characters

E11 E11.4 E11.42

Type 2 diabetes Type 2 diabetes with neurological complications Type 2 diabetes with polyneuropathy

Building a seven-character code

Base code (category) Four characters Five characters Six characters Seven characters

M1A M1A.0 M1A.07 M1A.072 M1A.0721

Chronic gout Idiopathic chronic gout Idiopathic chronic gout, ankle & foot Idiopathic chronic gout, left ankle & foot Idiopathic chronic gout, left ankle and foot, with tophus 1

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What Does This Mean for You?

Requires significant changes to clinical and administrative systems that capture and report diagnosis codes

Structural differences between ICD-9 and ICD-10 make converting the code set complex

Change in character length from ICD-9 to ICD-10 requires system upgrades to expand data fields for longer codes

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ICD-10 And YOUR Practice

Front Desk

HIPAA Privacy policies may need to be revised and patients will need to sign the new forms

SYSTEMS Updates to systems are likely required and may impact patient encounters

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Clinical Areas

Patient Coverage Health plan policies, payment limitations, and new ABN forms are likely

Superbills Revisions required – paper superbills may be impossible

ABNs Health plans will revise all policies linked to LCDs or NCDs, etc., ABN forms must be reformatted and patients will require education

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Nurses / Medical Assistants

Forms Every order must be revised or recreated

Documentation Must use increased specificity

Prior Authorizations Policies may change, requiring training and updates

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Physicians & Extenders

Documentation The need for specificity dramatically increases by requiring laterality, stages of healing, weeks in pregnancy, episodes of care, and much more

Code Training Codes increase from 17,000 to 140,000 – Physicians must be trained

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Lab

Documentation Must use increased specificity

Reporting Health plans will have new requirements for the ordering and reporting of services

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Coding Code Sets Codes will increase dramatically. As a result, code books

and styles will change completely.

Clinical Knowledge More detailed knowledge of anatomy and medical

terminology will be required with increased specificity and more codes.

Concurrent Use Coders may need to use ICD-9-CM and ICD-10-CM

concurrently for a period of time until all claims are resolved.

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BILLING Policies & Procedures All payer reimbursement policies may be revised.

Training Billing department must be trained on new policies and

procedures and the ICD-10-CM code set.

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Managers

New Policies & Procedures Any policy or procedure associated with a diagnosis code,

disease management, tracking, or PQRS must be revised.

Vendor & Payer Contracts All contracts must be evaluated and updated.

Budgets Changes to software, training, new contracts, new

paperwork will have to be paid for.

Training Plan Everyone in the practice will need training on the

changes. 20

Let’s Get Moving!

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It Comes Down to These Four Things!

1. Prepare a Project Plan

2. Perform an Impact Analysis

3. Begin Implementation

4. Convert to ICD-10 and Monitor

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Let’s Get Started! Get Your Team Together!

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Eight Tasks to Get Started

1. Identify your current systems and work processes that use ICD-9 codes

i. Administrative

ii. Clinical

iii. Reporting

2. Talk with your practice management system vendor about accommodations for ICD-10 codes

i. Review current contract

ii. Is there an expense? 24

Tasks:

3. Discuss implementation plans with all clearinghouses, billing services, and payers to facilitate a smooth transition

i. Know their implementation plans

ii. Can they accommodate both code sets?

4. Talk with payers about how ICD-10 implementation might affect provider contracts

i. Coverage determination policies

ii. Payment schedules 25

Tasks 5. Identify potential change to workflow and

business processes i. Clinical documentation

ii. Encounter forms or “superbills”

iii. Quality reporting

iv. Public health reporting

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Tasks

6. Assess staff training needs i. Focus on learning ICD-10 code set and any workflow

changes

a. Clinical – understand how documentation will affect the ability to code and bill

b. Administrative – understand the effects on preauthorization and referrals

c. Coding – may need the most training

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Tasks

7. Conduct test transactions using ICD-10 codes with payers and clearinghouses

i. Consider “dual” coding

a. Coding and Billing in both ICD-9 and ICD-10

Helps you prepare for ICD-10 and mitigate the risk of denied claims

ii. Watch for testing periods

Clearinghouse

Payers 28

Tasks

8. Budget for time and costs related to ICD-10 implementation

i. System changes

ii. Resource materials

iii. Training

iv. Reserve fund

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Technology and

ICD-10

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Assessing Your Systems Survey Your Technology Vendors Now . . . .

It is imperative that you understand their plans, so you can make your transitions plans. ASK:

What are they doing for ICD-10?

When are they doing it?

Will you have access to both ICD-9 and ICD-10 in your PMS & EMR?

Will GEMs be to used to convert current code databases?

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Prepare for the Transition

Identify all internal systems that utilize ICD-10

Understand the changes that are being made to each Database changes to one application/system CAN

affect all other interfaced systems

Determine the impacts on staff, process, and other systems

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Prepare for the Transition

Create a transition timeline by system

Identify any new technologies you require EMR *

Code Mapping

Project Management Tools

*If you are not currently using an EMR, ICD-10 is the time to seriously consider this addition to your practice.

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Understanding GEMs Technology vendors most likely are going

to utilize or offer you some variation of GEMs. The GEMs act as a translation dictionary to bridge the language gap between ICD-9–CM and ICD-10-CM/PCS

The General Equivalency Mappings (GEMs) database was created by CMS and CDC to help users understand, analyze, and manage the translation of one code set to the other. They also help users create their own applied mappings as needed.

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Understanding GEMs

GET FAMILIAR with this database. It has both the potential to help tremendously with this transition to ICD-10 and cause confusion. ICD-10 is not as simple as one-to-one mapping in many cases, and level of detail required will create the need to evaluate many codes that come from the mapping

Translation Programs / Software

Some come with your software

Some can be purchased

Some are free Icd9data.com and icd10data.com

AAPC

Beware: Use in conjunction with your books – not instead of!

Some are not detailed enough!

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Determining If Your Systems Are Ready

EHR/Medical Records

Billing

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Ask Vendors

How will your application, business processes, or system address my needs during the ICD-10 implementation?

What is your timeline for the ICD-10 transition?

What is your migration strategy for making the change to ICD-10?

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Ask Vendors

Do you offer an ICD-9/ICD-10 Comparison Utility ?

When will we test our system with trading partners?

Will you be upgrading my current system to accommodate the ICD-10 codes?

Are you training your staff on the ICD-10 system updates? 3

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Ask Vendors

Can we use your products to search for codes by the ICD-10 alphabetic and tabular indexes?

Do you allow our staff to search codes by clinical concept?

Will you maintain tables for each code set?

How long will ICD-9 be available for use? 40

Ask Vendors

Will you ensure we have the right tools in place to help select the more specific diagnosis codes?

Will you provide specific provider templates for each specialty?

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ICD-9-CM vs. ICD-10-CM

The Differences You Need to Know

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Organizational & Structural Changes

ICD-10-CM has same hierarchical structure as ICD-9-CM

First three characters are the category of the code

All codes within the same category have similar traits

E10 – Type 1 diabetes mellitus

E11 – Type 2 diabetes mellitus

J45 – Asthma

J45.2 – Mild intermittent asthma

J45.3 – Mild persistent asthma

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Organization & Structure

Differences are seen in the organization of ICD-10-CM

ICD-10-CM has 21 chapters compared to 17 for ICD-9-CM

ICD-9-CM’s V and E code supplemental classifications are incorporated into the main classification of ICD-10-CM

Diseases and conditions of the sense organs (eyes and ears) have been separated from the nervous system and have their own chapters

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Chapter Description Code Category

1 Certain Infectious and Parasitic Diseases A00-B99

2 Neoplasms C00-D49

3 Diseases of the Blood D50-D89

4 Endocrine, Nutritional and Metabolic Diseases E00-E89

5 Mental and Behavioral Disorders F01-F99

6 Diseases of the Nervous System G00-G99

7 Diseases of the Eye and Adnexa * H00-H59

8 Diseases of the Ear and Mastoid Process * H60-H95

9 Diseases of the Circulatory System I00-I99

10 Diseases of the Respiratory System J00-J99

11 Diseases of the Digestive System K00-K94

12 Diseases of the Skin and Subcutaneous Tissue L00-L99

13 Diseases of the Musculoskeletal System and Connective Tissue M00-M99

14 Diseases of the Genitourinaty System N00-N99

15 Pregnancy, Childbirth and the Puerperium O00-O99

16 Certain Conditions Originating in the Perinatal Period P00-P96

17 Congenital Malformations, Deformations and Chromosomal Abnormalities Q00-Q99

18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings R00-R99

19 Injury, Poisoning and Certain Other Consequences of External Cause S00-T88

20 External Causes of Morbidity * V01-Y98

21 Factors Influencing Health Status and Contact with Health Services * Z00-Z99 45

ICD-10-CM Chapters

* = New Chapters

Differences from ICD-9 to ICD-10

Certain diseases have been reclassified (or reassigned) to a more appropriate chapter in ICD-10-CM

Gout has been reclassified from the endocrine chapter in ICD-9 to the musculoskeletal chapter in ICD-10

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Differences

ICD-9-CM classified injuries by type; ICD-10-CM groups injuries first by specific site (e.g., head, arm, leg) and then by type of injury (e.g., fracture, open wound)

Post-operative complications have been moved to procedure-specific body system chapters

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Differences ICD-10-CM codes are alpha-numeric and can be up to

seven characters in length (ICD-9 only 3-5)

ICD-10-CM includes full code titles for all codes (no reference back to common fourth and fifth digits)

ICD-9: The following fifth-digit subclassification is for use with category 493.0- 493.2. 493.9:

0 unspecified

1 with status asthmaticus

2 with (acute) exacerbation

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Differences

Addition of sixth character in some chapters

Addition of seventh character for obstetrics, injuries, and external causes of injuries

Addition of placeholder X

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Using A Placeholder

Placeholder Character “X” is used as a placeholder at certain codes to allow for

future expansion

Poisoning, adverse effect, and underdosing codes (T36-T50)

T36.0X1A Poisoning by penicillins, accidental (unintentional), initial encounter

T36.0X2A Poisoning by penicillins, intentional self-harm

T36.0X3A Poisoning by penicillins, assault

T36.0X4A Poisoning by penicillins, undetermined

T36.0X5A Adverse effect of penicillins

T36.0X6A Underdosing of penicillins

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Another Placeholder Example

Contact with a cat

W55.0

W55.01XD Bitten by a cat, subsequent encounter

W55.03XD Scratched by cat, subsequent encounter

W55.09XD Other contact with cat

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7th Characters

Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.

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New Features in ICD-10-CM Combination codes for conditions and common

symptoms or manifestations

E10.21, Type 1 diabetes mellitus with diabetic nephropathy

I25.110, Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

K50.112, Crohn’s disease of large intestine with intestinal obstruction

Combination codes for poisonings and external causes

T36.0X1D, Poisoning by penicillin, accidental (unintentional), subsequent encounter

T42.4X5A, Adverse effect of benzodiazepines, initial encounter

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New Features Added Laterality

H60.332, Swimmer’s ear, left ear

M94.211, Chondromalacia, right shoulder

S40.259A, Superficial foreign body of unspecified shoulder, initial encounter

Added seventh-characters for episode of care M80.051A, Age-related osteoporosis with current

pathological fracture, right femur, initial encounter for fracture

S06.0X1A, Concussion with loss of consciousness of 30 minutes or less, initial encounter

S52.132B, Displaced fracture of neck of left radius, initial encounter for open fracture Type I or II or initial encounter for open fracture NOS

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New Features Expanded Codes (injuries, diabetes, alcohol, and

substance abuse, post-operative complications) E11.341, Type 2 diabetes mellitus with severe

nonproliferative diabetic retinopathy with macular edema

F14.221, Cocaine dependence with intoxication delirium

K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure

Inclusion of trimesters in obstetrics codes (and elimination of fifth digits for episode of care) O10.012, Pre-existing essential hypertension complicating

pregnancy second trimester

O99.013, Anemia complicating pregnancy, third trimester 55

New Features

Changes in timeframes specified in certain codes Acute myocardial infarction – time period changed from 8 weeks to 4

weeks

Time frame for abortion versus fetal death changed from 22 weeks to 20 weeks

Added standard definitions for two types of “excludes” notes Excludes1 note indicates “not coded here.” The code being excluded

is never used with the code. The two conditions cannot occur together.

B06, Rubella (German measles) has an Excludes1 of congenital rubella (P35.0)

Excludes2 note indicates “not included here.” The excluded condition is not part of the condition represented by the code. It is acceptable to use both codes together if the patient has both conditions.

J04.0, Acute laryngitis has an Excludes2 of chronic laryngitis (J37.0)

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Determining

Your Most Commonly Used Codes

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Begin Now: 1. Generate a report from your practice management

system that identifies all ICD-9 codes used for the past 12 months

1. Sort by frequency

2. Determine your 25-50 most frequently used codes

3. Convert those codes to ICD-10-CM codes

1. Determine differences from ICD-9-CM

2. Determine documentation variables

4. Audit clinical documentation to make sure it supports the coding

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Clinical Documentation Challenges with ICD-10-CM

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Clinical Documentation

Golden Rule: If it’s not documented by the physician/provider, it did not happen; therefore, it cannot be coded or billed

Objective: To ensure medical record documentation is documented to the fullest extent possible in order to support the greater specificity afforded in the ICD-10-CM (Clinical Modification) code set

Some documentation issues will require physicians/providers to capture new information

Others involve updated, modified, and otherwise expanded documentation needs

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Some Facts:

ICD-10-CM contains multiple combination codes, so documentation must reflect the association between conditions

Example:

ICD-10: K50.814 – Crohn’s disease of both small and large intestine with abscess

ICD-9: 555.2 – Regional enteritis, small intestine with large intestine and

569.5 – Abscess of intestine

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Facts:

Laterality needs to be documented

Example:

ICD-10: M05.271 – Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot

ICD-9: 714.27 – Rheumatoid arthritis with visceral or systemic involvement, ankle and foot

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Documentation Challenges Diabetes Mellitus

ICD-10 = 200 codes ICD-9 = 59 codes

Multiple combination codes are available – the provider will need to document complications to allow for accurate code selection E10.40 Type 1 diabetes mellitus with diabetic neuropathy,

unspecified

E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy

E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy

E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy

E10.44 Type 1 diabetes mellitus with diabetic amyotrophy

E10.49 Type 1 diabetes mellitus with other diabetic neurological complication

An additional code must be used to report insulin use – Z79.4

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Documentation Challenges

Injuries – ICD-10-CM features an expanded category for injuries

Seventh character extension identifies the encounter type:

A = initial encounter

D = subsequent encounter for fracture with routine healing

G = subsequent encounter for fracture with delayed healing

S = sequela of fracture

Size and depth of the injury must be coded – needs to be captured from provider’s documentation

Cause of the injury should be documented and coded

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Documentation Challenges

Drug Underdosing – a new code in ICD-10-CM that identifies situations in which a patient has taken less of a medication than prescribed by the physician

Medical condition is sequenced first

Underdosing code is listed as a secondary diagnosis

Additional code explains why the patient is not taking the medication (e.g., financial reasons)

Since this is new, many physicians will not be in the habit of documenting a patient’s reasons for underdosing in the record.

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Documentation Challenges

Cerebral Infarctions

Late effects of stroke are differentiated by type of stroke

Combination codes for common etiologies/manifestations are included

I63.012 designates cerebral infarction due to thrombosis of left vertebral artery

I63.031 designates cerebral infarction due to right carotid artery

I63.212 designates cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries

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Documentation Challenges

Acute Myocardial Infarction (AMI)

Age definition for AMI has changed to four weeks rather than eight weeks

New categories for subsequent AMI and for complications within 28 days of AMI

Different terminology is used and laterality is included

I21.01 designates ST elevation (STEMI) myocardial infarction involving left main coronary artery

I21.02 designates ST elevation myocardial infarction (STEMI) involving left anterior descending coronary artery

I21.09 designates ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

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Documentation Challenges Musculoskeletal Conditions

ICD-9 has 8 codes for pathologic fractures; ICD-10-CM has 150+ codes

7th character is used to designate episode of care

Traumatic fractures require

Type of Fracture

Laterality

Episode of Care

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A Warning About “Unspecified” – some may be tempted to take the easy road and code “unspecified” if documentation doesn’t support more specific codes. We warn against this!! While there is an unspecified code in ICD-10, and you can code it all you want, in 2-3 years when you review your severity and risk scores you will be in bad shape because you won’t have the specificity in your codes that you need to justify higher levels and better reimbursement.

Documentation Challenges

Pregnancy

Documentation of trimester now required

Counted from first day of last menstrual period

Must document number of weeks

Episodes of care have been deleted

Example – O15.03 designates “eclampsia in pregnancy, third trimester”

Obstructed labor codes incorporate reason for the obstruction and code extensions are used to identify specific fetus (1-5) affected by obstetric condition

Example – O64.1XX2 designates “obstructed labor due to breech presentation, fetus 2”

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Documentation Challenges

Respiratory / Vents

Some codes require time frames attached to them, which note if a patient has been on a ventilator for

less than 24 consecutive hours

24-96 consecutive hours

Greater than 96 hours

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Some Final Reminders For an Efficient and Effective Transition

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Transition Tips Important Reminders

While clearinghouses can help, they cannot provide the same level of support for the ICD-10 transition as they did for the Version 5010 upgrade (5010 was IT-driven only; ICD-10 is both business process and IT-driven)

ICD-10 codes describe a medical diagnosis or procedure and must be selected by the provider and not the clearinghouse, coder or biller

Expect audits to focus on clinical documentation to determine if it supports the specificity of ICD-10 codes

Keep in mind that covered entities are not to use the ICD-10 code in production (outside of a testing environment) prior to October 1, 2015

CMS Recommends

Regular documentation audits after ICD-10 implementation to make sure your clinical documentation supports your ICD-10 coding

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Thanks for Your Participation!

Mary Jean Sage The Sage Associates

897-309 Oak Park Blvd., Pismo Beach CA 93449

Tel: 805-904-6311; Fax: 805-904-6313

Email: mjsage@thesageassociates.com

Web: www.thesageassociates.com

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