10/2/2013

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HCCA HAWAII 2013 REGIONAL CONFERENCE

Jeri Leong, RN, CPC, CPC-H, CPC-I, CPMAHealthcare Coding Consultants of Hawaii LLC

Hot Topics in Billing and Coding: Transitioning to ICD-10

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Our Goals

• Introduce ICD-10

• Engage your organization

for the ICD-10 transition

• Identify potential

compliance risks

• Discuss tools that may

assist with your transition

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ICD-10 Transition: Five Phases

1. Engage and Educate Physicians and Staff

2. Assess Current Readiness and Impact

3. Create a Timeline and Transition Plan

4. Implement a Transition Plan

5. Conduct Post Transition Analysis and

Reporting

Most Physician Practices are in Phase 1

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ICD-9 and ICD-10: Background

• Evolved from earlier versions of ICD

• ICD-9 code set published for billing purposes in 1990

• U.S. last industrialized nation to implement ICD-10

• ICD-9-CM is outdated:– Over 30 years old

– Many categories are at capacity

– No longer descriptive enough

• Two parts: ICD-10-CM and ICD-10-PCS

• ICD-10-CM – 69,000 codes, ICD-9-CM – 14,000 codes

• Implementation date of October 1, 2014

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ICD 10: Getting Started

• Learn the important differences between ICD-10 and

ICD 9 codes

• Discover how to use an ICD-10 mapping system to

achieve what’s needed for documentation and

selection of codes

• Determine what documentation changes need to

occur to comply with increased code “specificity”

• Embrace the benefits and opportunities of ICD-10-CM

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ICD-9-CM and ICD-10-CM

ICD-9-CM ICD-10

� 3-5 numeric digits in length � 3-7 Alpha-Numeric

characters in length

� First digit may be alpha

(E or V) or numeric;

� Digits 2-5 are numeric

� Character one is alpha;

character two is numeric;

characters 3-7 are alpha or

numeric

� Lacks detail � Very specific

� Lacks laterality � Has laterality

� Approximately 14,000 codes � Approximately 69,000

available codes

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ICD-10-CM vs. ICD-9 Code Structure

ICD-10-CM Code Format

Ex: Epilepsy, unspecified, intractable, without status epilepticus

ICD-9 345.91

ICD-10 G40.919

ICD-9-CM Code Format

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ICD-10 Format

• Codes are alpha numeric

• All letters of the alphabet except U

• “V” codes are now Z codes

• “E” codes are now V,W,X,Y codes

• Second through seventh characters are

a combination of letters and numbers

• “O is not an 0…...”

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Clinician Coding Workflow

– Code Volume – 14,000 to 69,000

– Some code descriptions are completely different

• ICD-9 - Congenital bowleg deformity

• ICD-10 – Congenital bowing of long bones of leg

• ICD-9 - Posttraumatic stress disorder

• ICD-10 - Post-traumatic stress disorder

– Description length increases an average of 25 to 45

characters

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7th Character Extenders

• Certain ICD-10 codes have applicable seven characters

• Seventh character is required for these codes and must always be in the 7th

position

• If a code does not have six characters, a placeholder must be used to fill the character space

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7th Character Extenders

M80.08xA Age related osteoporosis with

current pathological fracture, vertebra(e),

initial encounter

S61.421D Laceration with foreign body of

right hand, subsequent encounter

T21.31xS Burn of third degree of chest,

sequela

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Trimesters

• Episode of care (delivered, antepartum,

postpartum) is no longer applicable

• Most codes have a final character identifying

the trimester of pregnancy in which the

condition occurred

• Some conditions or complications occur during

certain trimesters, thus not all conditions

include codes for all three trimesters

• Weeks of gestation code also appended

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OB/ Weeks of Gestation

Example:

• O91.112 Abscess of breast associated

with pregnancy, 2nd trimester

• Z3A.16 16 weeks of gestation pregnancy

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Health Maintenance

• Z23 is for an encounter for inoculations

and vaccinations

• Z codes also describe encounters for

routine examinations

• Some codes distinguish exams with and

without abnormal findings

• Other Z codes describe special exams such

as WWE, pre-op, etc.

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• ICD-10 includes codes for laterality

• Codes for left side, right side and

bilateral are available in some chapters

H60.332 Swimmer’s ear, left ear

H65.06 Acute serous otitis media, recurrent,

bilateral

S63.511A Sprain of carpal joint of right wrist,

initial encounter

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Laterality

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Unspecified Codes

• Similar to ICD-9, ICD-10 does contain

“unspecified” codes

• Coding guidelines advise use of

“unspecified” in circumstances where the

medical record does not contain sufficient

information required to assign a more

specific code

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Unspecified = Claim Delay?

“Physicians may be ICD-10 compliant, but if they

abuse the “other” or “unspecified” codes, payment

will not occur if a more specific alternative exists.”David Winkler

Michigan Blue Cross’ Director of Technical Program Management

Justifying the medical necessity of your

services and procedures depends on the

accuracy and specificity of diagnostic coding!

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Documentation:

The KEY to Success

• HCCH recommends chart reviews to determine if current documentation is sufficient for assigning ICD-10 codes

– Identify your top 20 billed ICD-9 codes

– Compare your current documentation with the increased specificity of ICD-10

– Is there sufficient documentation for the assignment of an equivalent ICD-10 code (manual or electronic)?

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Tools for Success: GEMs Translation

GEMs=General Equivalence Mapping:• A mapping tool that attempts to include all valid

relationships between the codes in ICD-9-CM and

ICD-10-CM

• An excellent training tool to be used to familiarize

differences between ICD 9 and ICD-10 and may also

be used to select the correct ICD-10 code.

• The mapping identifies one-to-one and one-to-many

code relationships

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ICD-10 GEMs Transition Software

• You’ll want to search by code and description

• It should be bi-directional: ICD-9 to ICD-10

and vice versa

• Look for the ability to perform code searches

and store frequently used codes (“Favorites”

or “Cheat Sheet”)

• Make sure you have a print function so you

can create training tools

• Can be a stand alone or integrated product

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How Will You Use a Crosswalk?

• Quick lookup for commonly used codes

• Performance Measure reporting

• Administrative purposes: Evaluating

insurance contracts, pre-authorizations,

surgery scheduling; updating referral

slips

• Clinical documentation improvement

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Next Steps

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Transitioning to ICD-10:

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ICD-10 Transition: Impact Assessment

• The impact assessment should evaluate:

– Physician office process and workflow

– Referrals and pre-authorizations

– Payers and business partners

– Budget and productivity

– Billing software and EHR readiness

– Claims – running dual systems until ??

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ICD-10: Billing Staff - Productivity

– Up to 40 % increase in keystrokes -full

keyboard

– Code lookups – books and EHR may have

completely different wording for some codes

– GEMS should not be your sole resource—may

pose a compliance risk if documentation does

not support assigned codes

– An unspecified ICD-9 code will crosswalk to

unspecified ICD-10;documentation must

support the use of a more specified code

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ICD-10 Transition: Training

Work with your organization to:

• Identify those who code, or have a need to know the codes

• Develop staff training - not all staff require the same level of training (role based training)

•Professional Coding Associations recommend:� Providers 6 – 12 hours

� Coders 16 hours (for outpatient coders)

� Other Staff 2-8 hours (depending on involvement)

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ICD-10: Worker’s Comp and Auto

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• Workers Comp and Auto insurance are HIPAA

exempt, therefore may not change to ICD-10

• A claim submitted to payer -- benefit limit may

be reached or TPL is changed;

– Charges will need to be resubmitted to private

insurance with ICD-10; reverse may be true for

private insurance identified as WC or auto

– May be difficult to crosswalk due to specificity of

ICD-10

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ICD 10: Readiness Checklist

Evaluate internal processes:

1. Conduct a practice impact assessment

2. Update ICD 10 coding resources (manual,

encoder or online lookups)

3. Perform chart audits to identify areas for CDI

4. Provide ongoing documentation feedback for

physicians

5. Evaluate transition software

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ICD-10: Benefits

• More specific diagnoses = reduced denials

• Describing higher diagnostic complexity may support a higher complexity procedure or service payment

• Better data with which to justify payment, including pay-for-performance or diagnosis-based reimbursement (e.g., PCMH or ACO models)

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Other Benefits of ICD-10-CM

• More patient information can be recorded, especially in the EHR environment

• Better describe new diseases

• Reduced requests for additional information

• Improved tracking and reporting for public health surveillance and risk management

• Increased information that can justify quality and outcomes assessment

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(808) 947-CODE (947-2633)

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Mahalo!