Learning Objectives - APTA · 15 Pregnancy childbirth and the puerperium 16 Certain conditions...

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Slide 2 Learning Objectives

• Identify the similarities and differences between ICD-9 and ICD-10.

• How to determine the correct ICD-10 codes.• Describe a mapping of ICD-9 to ICD-10 for

common conditions seen by physical therapists.• Recognize strategies and resources, and adapt

practice procedures for transition to ICD-10.• Identify timelines associated with ICD-10

adoption.

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Slide 3 Speakers• Joseph Nichols, MD, is a board certified Orthopedic Surgeon with a long history in health

information technology. He has a wide range of experiences in healthcare information technology on the provider, payer, government and vendor side of healthcare business. He has served in positions in executive management, system design, logical database architecture, product management, consulting and healthcare value measurement for the last 18 of his 35 years in the healthcare industry. He has given over 100 presentations nationally related to ICD-10 over the past 3 years on behalf of CMS, payers, providers, integrated delivery systems, consulting groups, universities, government entities, vendors and trade associations. He co-chairs the WEDI (Workgroup on Electronic Data Interchange) translation and coding sub-workgroup and has received WEDI merit awards 3 years in succession. He is also an AHIMA approved ICD-10 coding trainer. He is currently providing consulting services as the President of Health Data Consulting, Inc.

• Janet Albanese, PT, MPT, MHA, is presently an owner of Access Physical Therapy & Wellness and has served as the Compliance Officer and Director of the billing department for its 19 locations over the past 11 years. She oversees all training and transition related to compliance and billing and is in charge of the current ICD-10 transition. Janet also serves on the payment policy committee for Private Practice Section of the APTA. Janet has over 16 years' experience in the field of Physical Therapy. She earned both her Physical Therapy degree and Health Care Administration degrees from Springfield College.

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ICD-10Impacts and Opportunities

Presented by: Joe Nichols MDDate: March 27, 2014

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Slide 5

ICD-10 Basics

Key coding changes

Coding Challenge

ICD-10 documentation structure – Finding Codes

Mapping the good, the bad and the ugly

Implementation – Getting there in a timely manner

Testing – What, Why, Who and When

Available resources

Source: Health Data Consulting

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Agenda

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Slide 6

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ICD-10 Compliance Date

The compliance date for ICD-10-CM and PCS is October 1, 2014

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The Road to 10: The Small Physician Practice's Route to ICD-10

7The Road to 10: The Small Physician Practice's Route to ICD-10. http://www.roadto10.org

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Slide 8

8

Road to 10: Provider Preparation

Plan Your JourneyTo get you started, it is important to understand where you are on the road to ICD-10 compliance. The action plan provides a pictorial road map and the steps you may find helpful when pinpointing where diagnosis codes are used in your practice, identifying the transition team, preparing a budget for the transition to ICD-10, and arranging for training.

Train Your TeamYour support staff will be a big part of your success. The action plan contains guidelines to get your team started on the path to compliance. The website also highlights additional training resources that may be helpful to your practice.

Update Your ProcessesReviewing current clinical documentation practices and identifying gaps related to ICD-10 is an important step in your transition. The action plan walks you through the steps to update your policies, procedures, forms, and templates.

Engage Your Vendors & PayersCollaboration with technology vendors and payers is key. The action plan contains steps to help ensure system updates, set-up tasks, and compliance risks can be addressed.

Test Your Systems and ProcessesTesting is a critical component of the ICD-10 transition. The action plan walks you through the process of preparing test cases, performing internal and external testing, practicing coding in ICD-10, and validating clinical documentation processes.

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Slide 9

ICD-10 Basics

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ICD-10 international version– Adopted by WHO in 1990– Most countries other than the US currently use ICD-10– ICD-10 (International version) ~ 12,500 diagnostic codes– ICD-10 used for mortality reporting in the US - 1999

ICD-10-CM (US version) – ~ 69,000 diagnostic codes– Final rule published – 2009– Compliance date – October 1, 2014

ICD-10-PCS– ~72,000 codes– Not part of an international standard– Inpatient procedures only– Compliance date – October 1, 2014

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ICD10 Quick Facts


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Slide 11

ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

3 to 5 digitsAlpha “E” and “V” on 1st

characterNo place holder characters

TerminologyIndex and Tabular Structure

Coding GuidelinesApproximately 14,000 codesSeverity parameters limited

Does not include lateralityCombination codes limited

7 digitsAlpha or numeric for any character

Include place holder characters (‘x’)

SimilarSimilarSome what similarApproximately 69,000 codesExtensive severity parametersCommon definition of lateralityCombination codes common

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ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes)


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Slide 12

September 2014 October 2014

ICD-9 ICD-1082111:Open fracture of Shaft of Femur

S72351C:Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC

All codes for femur fractures = 16 All codes for femur fractures = 1530


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Same Condition – Different CodesWhat’s the Difference?

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Key Coding Changes

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Slide 14 ICD-10 StructureIndex Structure (Volume II)

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Slide 15

1 Certain infectious and parasitic diseases2 Neoplasms

3Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

4 Endocrine nutritional and metabolic diseases5 Mental and behavioral disorders6 Diseases of the nervous system7 Diseases of the eye and adnexa8 Diseases of the ear and mastoid process9 Diseases of the circulatory system10 Diseases of the respiratory system11 Diseases of the digestive system12 Diseases of the skin and subcutaneous tissue13 Diseases of the musculoskeletal system and connective tissue14 Diseases of the genitourinary system15 Pregnancy childbirth and the puerperium16 Certain conditions originating in the perinatal period17 Congenital malformations deformations and chromosomal abnormalities18 Symptoms signs and abnormal clinical and laboratory findings not elsewhere classified19 Injury poisoning and certain other consequences of external causes20 External causes of morbidity21 Factors influencing health status and contact with health services

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ICD-10 StructureTabular Structure – Level 1 (Chapters)

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13.1 Infectious arthropathies13.2 Inflammatory polyarthropathies13.3 Osteoarthritis13.4 Other joint disorders13.5 Dentofacial anomalies [including malocclusion] and other disorders of jaw13.6 Systemic connective tissue disorders13.7 Deforming dorsopathies13.8 Spondylopathies13.9 Other dorsopathies13.10 Disorders of muscles13.11 Disorders of synovium and tendon13.12 Other soft tissue disorders13.13 Disorders of bone density and structure13.14 Other osteopathies13.15 Chondropathies13.16 Other disorders of the musculoskeletal system and connective tissue

13.17 Intraoperative and postprocedural complications and disorders of musculoskeletal system not elsewhere classified

13.18 Biomechanical lesions not elsewhere classified

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ICD-10 StructureTabular Structure – Level 2 (Blocks)

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Slide 17

M15 Polyosteoarthritis

M16 Osteoarthritis of hip

M17 Osteoarthritis of knee

M18 Osteoarthritis of first carpometacarpal joint

M19 Other and unspecified osteoarthritis

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ICD-10 StructureTabular Structure – Level 3 (1st 3 Character Categories)

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Slide 18

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ICD-10 StructureTabular Structure (Volume I)

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2466 codes for fractures of the

femur


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Lots of Codes, Lots of Repetition

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Slide 20

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Slide 21

21


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Initial EncounterThe intent is to represent an encounter which is the first encounter for the clinician for a problem. The definition of “active treatment” is somewhat of a grey area.

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Coding ICD-10 CMGuidelines


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Slide 23

Subsequent EncounterThe intent is to represent an encounter for ongoing management and follow up of an initially treated condition.

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Coding ICD-10 CMGuidelines


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Slide 24 Coding: The Prime Directive

The goal of coding is to reflect as accurately as possible key parameters of the patient health condition and/or the

procedures done to maintain or improve that condition.

Coding focused on maximizing payment over accurate definition of the condition begins to cross the boundary of

fraud and abuse.

24 Source: Health Data Consulting

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Coding Challenge

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Slide 26

Example look up for “Coronary Artery Disease” + “Angina”


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Coding ICD-10-CM – ChallengesGetting There

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Slide 27

Distribution of codes related to “Arthritis” at the chapter level

*44% of codes are outside of Inflammatory Arthritis or Osteoarthritis categories

Chapter Description Count

Chapter1 Certain infectious and parasitic diseases 12

Chapter3Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 1

Chapter4 Endocrine nutritional and metabolic diseases 13

Chapter6 Diseases of the nervous system 1

Chapter12 Diseases of the skin and subcutaneous tissue 5

Chapter13 Diseases of the musculoskeletal system and connective tissue 920

Chapter14 Diseases of the genitourinary system 4

Chapter17 Congenital malformations deformations and chromosomal abnormalities 1

Chapter19 Injury poisoning and certain other consequences of external causes 3

Chapter21 Factors influencing health status and contact with health services 2

Source: Health Data Consulting 27

ICD-10 StructureVarying Distributions Across the Tabular Structure

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"If you don't find it in the index, look very carefully through the entire catalogue."

-- Unknown

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Coding ICD-10 CM – ChallengesRelevant Quote

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Slide 29

History

Physical Exam

Internal Record Review

External Record Review

Assessment/Diagnosis

Studies

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Clinical Documentation – The Patient InterfaceWhere It All Begins

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Slide 30

Supports proper payment and reduces denials

Assures accurate measures of quality and efficiency

Addresses the issue of accountability and transparency

Creates a competitive advantage

Provides better business intelligence

Supports clinical research

Supports interoperable sharing of data

It’s just good care!

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DocumentationWhy Is It Important?

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GEMGeneral Equivalency Mapping

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Slide 32

The best match between an ICD-9 and ICD-10 code results in the loss of some concepts in translation or the assumption of some concepts that may or may not be true.

ICD9 (82011):FRACTURE OF EPIPHYSIS (SEPARATION)

(UPPER) OF NECK OF FEMUR OPEN

ICD10 (S72023H):Displaced fracture of epiphysis (separation)

(upper) of unspecified femur, subsequent encounter for open fracture type I or II with delayed healing

Fracture Epiphyseal injury Proximal Femur Open Neck

Fracture Epiphyseal injury Proximal Femur Open Neck Subsequent encounter Type 1 or 2 Delayed Healing

Assumed Concepts

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Code Matching QualityAssumed Concepts


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Slide 33

ICD9 (80084):OPEN FRACTURE OF VAULT OF SKULL WITH OTHER

AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH PROLONGED (MORE THAN 24 HOURS)LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL

ICD10 (S020xxB): Fracture of vault of skull, initial encounter for open

fracture

Fracture Open Vault-Skull Head and Neck Region

Intracranial Hemorrhage Prolonged Loss of consciousness Return to conscious level

Fracture Open Vault-Skull Head and Neck Region Initial encounter Assumed

Concept

Lost Concepts


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Code Matching QualityLost and Assumed Concepts

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Matching can result in a significant distortion of the facts

ICD-10 Procedure Code

ICD-10 Procedure Term

0X6N0Z0 Detachment at Right Index Finger, Complete, Open Approach

0X6N0Z1 Detachment at Right Index Finger, High, Open Approach

0X6N0Z2 Detachment at Right Index Finger, Mid, Open Approach

0X6N0Z3 Detachment at Right Index Finger, Low, Open Approach

0X6P0Z0 Detachment at Left Index Finger, Complete, Open Approach

0X6P0Z1 Detachment at Left Index Finger, High, Open Approach

0X6P0Z2 Detachment at Left Index Finger, Mid, Open Approach

0X6P0Z3 Detachment at Left Index Finger, Low, Open Approach

0X6Q0Z0 Detachment at Right Middle Finger, Complete, Open Approach

0X6Q0Z1 Detachment at Right Middle Finger, High, Open Approach

0X6Q0Z2 Detachment at Right Middle Finger, Mid, Open Approach

0X6Q0Z3 Detachment at Right Middle Finger, Low, Open Approach

…

ICD-9 Procedure Code

ICD-9 Procedure Term

84.01 Finger Amputation


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Code Matching QualityProblematic Match

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Slide 35

Native ICD-9 definition [3] Codes[1 code related specifically to Median nerve injury][2 codes for review related to potential injury]

GEM Bidirectional Map = [15]*

Native ICD-10 definition [33] Codes[27 codes related specifically to median nerve injury][6 codes related to potential injury (Carpal Tunnel/Median nerve lesion)]


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Code Aggregation ExampleMedian Nerve Injury

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Slide 36

Native ICD-9 definition [33] Codes[2 codes for Colles’ fracture][2 codes for Torus fracture of the Radius][1 codes for Pathologic fracture of the Radius][6 codes for fracture of the Forearm][22 codes for other fractures of the Radius]

GEM Bidirectional Map = [336]*

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Code Aggregation ExampleFracture of the Radius


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Native ICD-10 definition [1818] Codes[48 codes for Colles’ fracture][48 codes for Barton’s fracture][48 codes for Smith’s fracture][48 codes for Radial Styloid fracture][48 codes for Galeazzi’s fracture] [36 codes for Torus fracture of the Radius][18 codes for Stress fracture of the Radius][18 codes for Greenstick fracture of the Radius][90 codes for Pathologic fracture of the Radius][45 codes for Bent Bone fracture of the Radius][216 codes for Growth Plate fracture of the Radius][663 codes for other fractures of the Radius]

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Code Aggregation ExampleFracture of the Radius


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Slide 38

ImplementationGetting your ducks in a row

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Slide 39

Short term goals with a long term vision– What solution do I need today?– Will that solution extend to tomorrows needs?

Awareness of touch points with other initiatives– Overlap and conflicts

Down stream impacts– What works well for one business area, may not work well

for another business area

Positioning for competitive advantage– Can you predict risk better than you competitor?– Are you perceived as a supporter and facilitator of the ICD-

10 transition?– Can you manage the “burden of illness” of your population

better than your competitors?

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Implementation Strategy


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1. Assessment – Creating an inventory of impacted systems and processes– Identifying risk

2. Analysis/Planning– Prioritizing focus– Establishing business area specific approaches– Creating specifications for mapping to support implementation

3. Implementation and Operations– Translating codes from ICD-9 to ICD-10 and from ICD-10 to ICD-9 using

crosswalks– Changing analytic models to support both codes– Operationalizing coding to ICD-10 from source information– Changing processing logic to operate directly from ICD-10 codes

4. Leveraging ICD-10 capabilities– Using the enhanced information within ICD-10 codes to improve processing and

analysis based on improved concepts within the ICD-10 codes

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Phases of Transition


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Slide 41

The Scenario:– The identification of some event or condition that we are

familiar with today

– Recreating that event virtually through some verbal or data representation

– Defining a variety of assumptions and variables around this virtual representation

Applying one or more of these scenarios in a Reference Implementation Model (RIM).– Walk through current systems or processes using these

scenarios with varying assumptions and variables to determine if expected results can be achieved and identifying the required changes to achieve those expected results.

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Scenario-Based TestingWhat Is It?


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Slide 42 Leveraging ICD-10Other General Indicators of Severity and Risk

Co-morbidities

Manifestations

Etiology/causation

Complications

Detailed anatomical location

Sequelae

Functional impairment

Biologic and chemical agents

Phase/stage

Lymph node involvement

Lateralization and localization

Procedure or implant related

42 42Source: Health Data Consulting

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Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated

processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support

population risk management More accurate measures of quality and efficiency

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Leveraging ICD-10A Changing World of Cost Containment


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Slide 44

ICD-10 will be a substantial change in the standard for defining the patient’s health state and the institutional procedures performed to maintain or improve that health state.

There are significant impacts and changes to both the clinical and business side of the practice.

Coding accuracy and productivity will be substantially impacted during the transition and will impact both cost and revenue.

There are significant new opportunities to leverage ICD-10 in a new payment environment (ACO).

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SummaryKey Points


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Slide 45

Establish awareness across members of your organization

Clearly define strategic goals

Identify internal and external dependencies

Identify and prioritize key risks

Clearly define all business requirements and implementation tasks

Create a realistic project plan and support it as a priority

Test early and often

Get started now!!

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SummaryAction Items


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ICD-10 Resources

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Slide 47 ICD-10 Resources

• http://www.cms.gov/ICD-10

ICD-10 Website

• www.roadto10.org

Provider Portal

• GEMs Crosswalk documents• http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html

• GEMs 2014 General Equivalence Mappings (Technical Document (zip file)• http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html

Mapping (GEMs)

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Slide 48 ICD-10 Resources (cont’d)

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html?redirect=/mlngeninfo

Medicare Learning Network Articles

• http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html

ICD-10 National Provider Calls

• http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

National Coverage Determinations (NCDs)

• Materials and associated CRs available free on CMS web site for selected NCDs

Medicare Learning Network

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ICD-10 Resources (cont’d)

• 2014 Reimbursement Mappings – Diagnosis Codes and Guides http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html

• 2014 Reimbursement Mappings – Procedure Codes and Guides http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html

• Links to ordering the ICD-10 Pilot Version 31.0 Mainframe and PC version of the ICD-10 MS-DRGs and Medicare Code Editor (FY 2014 version) from NTIS have been placed on the CMS website under the Related Links section at http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html

•http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html?redirect=/mlngeninfo

Medicare Reimbursement Mappings

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7492.pdf

Medicare Claims Processing Guidance for ICD-10

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Slide 50 ICD-10 Resources (cont’d)

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8458.pdf

Home Health Agency

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1409.pdf

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8465.pdf

Medicare Testing Week

• http://www.cms.gov/Medicare/Coding/ICD10/Downloads/CMSReleasesICD-10-PCSFiles.pdf

Unspecified Codes

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Slide 51

51

ICD-10 - A Look Inside

Presented by: Janet Albanese, PT, MSPT, MHA

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• Take a practical look at ICD-10 as it relates to us in Physical Therapy– How to look up a PT related diagnosis in the

ICD-10 system– A look into what we, as a PT practice, are

doing to prepare for implementation– Key impacts ICD-10 will have within your

practice

Objectives

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Slide 53 APTA Web Site: www.APTA.org/icd10

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Slide 54 CMS link to Index and Tabs

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CMS WinZip File

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Slide 56

• Injury Sustained• Right Knee• Instability

Clinical Example

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Slide 57 Step 1: Look up term in

alphabetic index

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Step 1: Look up term in

alphabetic index “Instability”

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Slide 59 Step 1: Look up term in

alphabetic index

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Slide 60 Step 2: Verify code in

tabular list

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Step 2: Verify code in

tabular list

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Slide 62 Step 2: Verify code in

tabular list

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Slide 63 Step 3: Is there a 7th Character?

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Other instability, right knee

Category (first character always

alpha, second character numeric)

Category, anatomic site,

severity

Extension (initial encounter, subsequent

encounter, sequela)

2M 35 6 1

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Slide 65 Side Note…If there was a 7th

Character

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Slide 66 Patient Example:ICD-9 vs ICD-10

ICD 9

ICD 10M25.361 Other instability, right knee

718.86 Other joint derangement, not elsewhere classified of lower leg

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Use Caution in Coding

Instability search yields many options:

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Slide 68

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Slide 69

How does your organization work?

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Reality???

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Slide 71

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Slide 72

• Identify where diagnosis codes are used today: – Documentation– Electronic systems– Submitting claims for payment– Identifying patient eligibility– Getting prior authorization from a payer/ABNs– Reporting and Analysis

ICD-10: Key Practice Impacts

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• Documentation– Specificity– Severity– Other Underlying/Complicating Conditions– Support for Reported Quality Data – Support for Medical Necessity Required for

Coverage in Payer Policies– Auditing for Compliance

ICD-10: Documentation

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Slide 74

• Vendors: Communicate with all vendors to determine readiness – EMR system– Clearinghouse

• Payers: Be prepared for possible delays in cash flow and increased follow-up required

• Policies and Procedure: Updated to reflect changes

• ICD-9 to ICD-10 mapping: Review currently used codes and map them in ICD-10

ICD-10: Areas to Consider

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Slide 75

• Staff Training: All staff that work with the current ICD-9 system must be trained on the ICD-10– Who? – clinicians, coders & billers, front desk,

others– What? – GEMs mapping, knowledge of system– When? – Now vs Later and ongoing….

• Test Competence: Develop further training needed and identify key “champions” that can assist in training

ICD-10: Staff Training

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• APTA– State Chapters– Specific Sections

• CMS• Clearinghouse• Others

– Internally within your organization

ICD-10: Know Your Resources

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Slide 77 APTA Web Site

www.APTA.org/Payment/Coding/ICD10

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Slide 78 Get in on NEXT!

What’s happening at NEXT…• Forward-thinking educational sessions• Engaging opportunities to network with

professional peers• The prestigious Mary McMillan Lecture

Registration is open!

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QUESTIONS

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Learning Objectives - APTA · 15 Pregnancy childbirth and the puerperium 16 Certain conditions...

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