The Impacts of ICD-10 on Your Part C Program - Dasy Center · PDF file• Differences...
42
Robin Nelson, Kim Wedel and Maureen Greer November 13, 2013 The Impacts of ICD-10 on Your Part C Program
-
Upload
nguyennhan -
Category
Documents
-
view
215 -
download
1
Transcript of The Impacts of ICD-10 on Your Part C Program - Dasy Center · PDF file• Differences...
Robin Nelson, Kim Wedel and Maureen Greer November 13, 2013
The Impacts of ICD-10 on Your Part C Program
• Gain an understanding of ICD-10, and how it differs from ICD-9.
• Gain an understanding of the effects of the transition from ICD-9 to ICD-10 on Part C programs, state data systems, data analysis and reporting.
• Be able to identify resources to help manage the necessary changes associated with the transition from ICD-9 to ICD-10.
2
Objectives
• Essentials of ICD-10 • Differences between ICD-10 and ICD-9 • Impacts of the transition to ICD-10 on your program ▫ Eligibility ▫ Billing ▫ Data/billing systems ▫ Data analysis and reporting
• Resources
3
Agenda
• International Classification of Diseases • ICD-10 is the updated version of codes
used for coding: ▫ Diagnoses for all providers (ICD-10-CM) ▫ Hospital inpatient procedures (ICD-10-PCS)
• ICD-10-CM is the US “clinical modification” of the WHO ICD-10 code set
• ICD-10-PCS is a U.S. creation
4
What is the ICD-10?
Presenter
Presentation Notes
ICD-10 is an updated version of the ICD-9 code sets. The ICD-10 code set was originally developed by the World Health Organization. The release of the full ICD-10 by WHO occurred in 1994. It was published in 42 languages by 2002. So, most countries have been using the ICD-10 for about 10 years. Several countries have taken this code set and modified it for use in their medical systems. The United States, through the National Center for Health Statistics, has developed the ICD-10-CM (or clinical modification) of the code set for use in this country. The Centers for Medicare and Medicaid Services has created a new code set, ICD-10-PCS, for use.
CPT Codes Common Procedure Terminology
HCPCS Codes Healthcare Common Procedure
Coding System
5
Codes NOT Affected by ICD-10-CM
Presenter
Presentation Notes
CPT codes are used for all outpatient/ambulatory procedures, including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement. HCPCS is a collection of standardized codes that represent medical procedures, supplies, products and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers.
ICD-10-CM Compliance Deadline
• October 1, 2014 • Based on DATE OF SERVICE, not date of transaction
or claim submission • Use ICD-9-CM dx code if date of service is before
October 1, 2014 • Use ICD-10-CM dx code if date of service is on or
after October 1, 2014 • NO transition period
6
Presenter
Presentation Notes
The transition to ICD-10 is required for everyone covered by HIPAA. ICD-10 compliance means that a HIPAA-covered entity uses ICD-10 codes for health care services provided on or after October 1, 2014. The original compliance date was Oct. 1, 2013, but was delayed due to intense pressure from several groups, foremost the AMA.
• 3 to 7 characters • Position 1 is alpha, not case
sensitive • Position 2 is numeric • Positions 3 to 7 are alpha or
numeric (alpha are not case sensitive)
• Almost 69,000 codes
ICD-10-CM • 3 to 5 characters • First position is numeric or
alpha (V or E) • Positions 2 to 5 are numeric
• 13,600 codes
ICD-9-CM
7
Major Changes: ICD-9 vs. ICD-10
Presenter
Presentation Notes
About 5 times the number of codes in ICD-10-CM.
8
Structure of ICD-10-CM Diagnosis Codes
Presenter
Presentation Notes
Each position has a specific meaning Tabular List contains categories, subcategories and codes. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
• Much greater specificity • Full description and consistency within the code set • Uses modern terminology for descriptions • Creation of combination diagnosis/symptom codes
to reduce the number of codes needed to fully describe a condition
• Enables laterality (right vs. left designations) • Type of encounter, e.g., initial vs. subsequent
9
More Specific Changes
Presenter
Presentation Notes
The new code set provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code. Some codes distinguish between initial vs. subsequent encounter. The terminology has been modernized and has been made consistent throughout the code set. There are codes that are a combination of diagnoses and symptoms, so that fewer codes need to be reported to fully describe a condition. It makes a difference whether the right or left limb is the subject of the problem Some codes also specify initial vs. subsequent encounter
• R62.51 – Failure to thrive (excludes child under 28
days old) • E70.0 – Classical phenylketonuria (PKU) • Q04.0 – Congenital malformation of corpus callosum • Q71.811 – Congenital shortening of right upper limb
• R45.2 – Unhappiness
10
Examples of ICD-10-CM Codes
Presenter
Presentation Notes
Here are some examples of codes in ICD-10-CM R45.1 – Restlessness and agitation R45.82 – Worries R45.4 – Irritability and anger
W21.00 Struck by hit or thrown ball, unspecified type
W21.01 Struck by football W21.02 Struck by soccer ball W21.03 Struck by baseball W21.04 Struck by golf ball W21.05 Struck by basketball W21.06 Struck by volleyball W21.07 Struck by softball W21.09 Struck by other hit or thrown ball W21.31 Struck by shoe cleats Stepped on by shoe cleats W21.32 Struck by skate blades Skated over by skate blades W21.39 Struck by other sports foot wear
W21.4 Striking against diving board W21.11 Struck by baseball bat W21.12 Struck by tennis racquet W21.13 Struck by golf club W21.19 Struck by other bat, racquet
or club W21.210 Struck by ice hockey stick W21.211 Struck by field hockey stick W21.220 Struck by ice hockey puck W21.221 Struck by field hockey puck W21.81 Striking against or struck by
football helmet W21.89 Striking against or struck by
other sports equipment W21.9 Striking against or struck by
unspecified sports equipment
11
Examples of ICD-10-CM Specificity
Presenter
Presentation Notes
An example of the extent of the specificity
ICD-9-CM ICD-10-CM
1. INFECTIOUS AND PARASITIC DISEASES (001-139) 2. NEOPLASMS (140-239) 3. ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES, AND IMMUNITY DISORDERS (240-279) 4. DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (280-289) 5. MENTAL DISORDERS (290-319) 6. DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS (320-389) 7. DISEASES OF THE CIRCULATORY SYSTEM (390-459) 8. DISEASES OF THE RESPIRATORY SYSTEM (460-519) 9. DISEASES OF THE DIGESTIVE SYSTEM (520-579) 10. DISEASES OF THE GENITOURINARY SYSTEM (580-629)
1. CERTAIN INFECTIOUS AND PARASITIC DISEASES (A00-B99) 2. NEOPLASMS (C00-D49) 3. DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (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
Tabular Lists (Chapters)
Presenter
Presentation Notes
The tabular lists, which represent the major “Chapters”, are not that different. Some examples of this are that sense organs are now separate from nervous system disorders; injuries are grouped by anatomical site (e.g., injuries of the head, injuries of the leg) instead of an injury category (fracture, bruise); and postoperative complications are now part of the specific body system chapter.
ICD-9 ICD-10
11. COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM (630-679) 12. DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE (680-709) 13. DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE (710-739) 14. CONGENITAL ANOMALIES (740-759) 15. CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD (760-779) 16. SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS (780-799) 17. INJURY AND POISONING (800-999) * SUPPLEMENTARY CLASSIFICATION OF FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES (V01-V89) * SUPPLEMENTARY CLASSIFICATION OF EXTERNAL CAUSES OF INJURY AND POISONING (E800-E999)
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 GENITOURINARY SYSTEM (N00-N99) 15. PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM (O00-O9A) 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 LAB. FINDINGS (R00-R99) 19. INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXERNAL CAUSES (S00-T88) 20. EXTERNAL CAUSES OF MORBIDITY (V00-Y99) 21. FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES (Z00-Z99)
13
Tabular Lists (Chapters) (continued)
• Tools you can use to convert data from ICD-9-CM to ICD-10-CM, and 10 to 9 (crosswalks)
• Mapping is bi-directional ▫ ICD-9 to ICD-10 is called forward mapping ▫ ICD-10 to ICD-9 is called backward mapping
• May be multiple translation alternatives for a code being looked up, all of which are equally plausible
• Not a substitute for learning how to use ICD-10-CM
14
General Equivalence Mappings (GEMs)
Presenter
Presentation Notes
Designed to be used to convert coded data. To both create and maintain the GEMs, all reasonable code translation alternatives are included in its respective GEM, based on the complete meaning of the code being looked up. May not need GEMs when a small number of ICD-9-CM codes are being converted to ICD-10-CM .
• Not always an exact, one-to-one conversion • Could be one to many, many to one or many to many • GEMS ▫ Not always a clear map ▫ Have flags for exact vs. approximate ▫ Not just data conversion
▫Need clinical review/decision-making
15
Issue: No Clear Mapping
Presenter
Presentation Notes
GEMS – 9 to 10, and 10 to 9 One of the major issues is that there is no “easy” mapping or translation from ICD-9 to ICD-10 codes. There are some one-to-one correspondences, but often there are one-to-many, many-to-one, many-to-many, or no correspondence at all. This will be a major implementation consideration. There are some tables that have been published, but much more study needs to be done to determine how coding will change.
741.00 - Spina bifida with hydrocephalus, unspecified region Converts approximately to:
ICD-10-CM Q05.4 Unspecified spina bifida with hydrocephalus
Or: ICD-10-CM Q07.01 Arnold-Chiari syndrome with spina bifida
Or: ICD-10-CM Q07.02 Arnold-Chiari syndrome with hydrocephalus
Or: ICD-10-CM Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus
16
Conversion of ICD-9-CM code 741.00 to ICD-10-CM
Presenter
Presentation Notes
Example of a 9 code “converted” to 10
• Incorporates much greater specificity and clinical information, which results in improved ability to measure health care services
• Increased sensitivity when refining grouping and reimbursement methodologies
• Enhanced ability to conduct public health surveillance
• ICD-9-CM running out of codes
17
Benefits of ICD-10-CM
Presenter
Presentation Notes
For those who work in behavioral health: The ICD-9 is compatible with DSM-IV-TR, but there are differences between the ICD-10 and DSM-V. ICD-11 will be more compatible with DSM-V.
• Changes to clinical and administrative systems, including documentation
• Changes in business processes • Changes to IT systems (client and billing), and testing • Changes to data analyses • Training – not just coders ▫ program, admin and systems staff
18
Provider Impacts
Presenter
Presentation Notes
Not just business as usual, e.g., with “normal” annual updates to code sets The first step to accurate coding is for the documentation to reflect what the provider has observed. Coding must be supported by medical documentation. American Health Information Management Association (AHIMA) recommends training begin no more than six to nine months before the October 1, 2014, compliance deadline. Training needs will vary for different organizations, but it is projected to take 16 hours for outpatient coders
• New coding system will likely mean new coverage policies, new medical review edits, new reimbursement schedules
• Expect increased reject, denials, and pends as both plans and providers get used to new codes (CMS)
• Revenue impacts of specificity ▫ Denials ▫ Additional documentation
19
Provider Impacts (continued)
Presenter
Presentation Notes
Studies of the required documentation have indicated that more documentation is required to support the increased specificity of the code set. We should expect providers to have to spend about 15% more time on asking questions, observing, and documenting their findings to support the ICD-10-CM code set. Even with increased documentation, we can expect, with better coding, an increase in denials or pending claims, and the need for providers to submit additional documentation to support the codes.
• Coverage determinations • Payment determinations • Medical review policies • Plan structures • Statistical reporting • Actuarial projections • Fraud and abuse monitoring • Quality measurements
20
Medicaid Plan Impacts
Presenter
Presentation Notes
At least with Medicaid, there probably will not be immediate changes to medical policies (and reimbursement) right away – there just isn’t the time or resources to change them.
21
QUESTIONS
Eligibility
Billing and Related Business Processes
Electronic Data and/or Billing Systems
Data Analysis and Reporting
Specific Impacts on Part C
22
Impact on Eligibility • If you use a list of diagnoses, via ICD-9 codes, to
specify eligible established conditions: ▫ What will the list look like using ICD-10 codes? ▫ How will you “convert” ICD-9 codes to ICD-10 codes? ▫ What level of specificity will it have? What impact will the level of specificity have on
communications with physicians, family members, other referral sources
▫ When will you require (switch to) ICD-10 codes?
23
Presenter
Presentation Notes
Your approach may depend on whether your codes for eligibility are “linked” to your billing codes. If eligibility and billing codes are not connected or “linked”, you’ll have more flexibility in how you present the codes. If they are connected, billing codes must satisfy certain criteria, i.e., be a “legitimate” code – that is, have all the specificity.
EI Example: Down Syndrome ICD-9-CM ICD-10-CM • 758.0 • Q90 – use additional codes to
identify any associated physical conditions and degree of intellectual disabilities
• Q90.0 Trisomy 21, nonmosaicism
• Q90.1 Trisomy 21, mosaicism • Q90.2 Trisomy, translocation • Q90.9 Down Syndrome,
unspecified
24
EI Example: Cleft Lip/Palate ICD-9-CM ICD-10-CM • 749.0 Cleft palate • 749.1 Cleft lip • 749.2 Cleft palate with cleft lip
▫ Unspecified ▫ Unilateral, complete ▫ Unilateral, incomplete ▫ Bilateral, complete ▫ Bilateral, incomplete
• Q35 Cleft palate • Q35.1 Cleft hard palate • Q35.3 Cleft soft palate • Q35.5 Cleft hard palate with
cleft soft palate • Q35.7 Cleft uvula • Q35.7 Cleft palate, unspecified • Q36 Cleft lip • Q36.0 Cleft lip, bilateral • Q36.1 Cleft lip, median • Q36.9 Cleft lip, unilateral
25
Presenter
Presentation Notes
.00 .01 .02 .03 .04
EI Example: Cleft Lip/Palate (continued)
ICD-9-CM ICD-10-CM • 749.0 Cleft palate • 749.1 Cleft lip • 749.2 Cleft palate with cleft lip
• Q37 Cleft palate with cleft lip • Q37.0 Cleft hp with bilateral cleft lip • Q37.1 Cleft hp with unilateral cleft lip • Q37.2 Cleft sp with bilateral cleft lip • Q37.3 Cleft sp with unilateral cleft lip • Q37.4 Cleft hard & soft, bilateral • Q37.5 Cleft hard & soft, unilateral • Q37.8 Unspecified cp with bilateral • Q37.9 Unspecified cp with unilateral
26
Impact on Eligibility – Recap and State Perspective
• If you use a list of diagnoses, via ICD-9 codes, to
specify eligible established conditions: ▫ What will the list look like using ICD-10 codes? ▫ How will you “convert” ICD-9 codes to ICD-10 codes? ▫ What level of specificity will it have? What impact will the level of specificity have on
communications with physicians, family members, other referral sources
▫ When will you require (switch to) ICD-10 codes?
27
Presenter
Presentation Notes
Your approach may depend on whether your codes for eligibility are “linked” to your billing codes. If eligibility and billing codes are not connected or “linked”, you’ll have more flexibility in how you present the codes. If they are connected, billing codes must satisfy certain criteria, i.e., be a “legitimate” code – that is, have all the specificity.
Impact on Billing
• Understand payer processes/practices ▫ Business rules ▫ Medical policies
• Coding guidelines for ICD-10-CM; use valid codes
• Related processes, e.g., forms and documentation
28
Presenter
Presentation Notes
Rules and medical policies will likely change over time. Watch out for those changes. If denials and pends, may have cash flow problems. Because you have time to submit claims, must run ICD-9 and ICD-10 at the same time. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable. A three-character code is to be used only if it is not further subdivided. Understand how you use NEC (not elsewhere classified) and NOS (not otherwise specified). Identify every place you currently use ICD-9 codes.
Examples of Billing Codes ICD-9-CM ICD-10-CM • 315.9 - Unspecified Delay in
Development
• 783.40 - Lack of normal physiological development, unspecified
• 783.42 - Delayed milestones
• F81.9 - Developmental disorder of scholastic skills, unspecified
• F89 - Unspecified disorder of psychological development
• R62.50 - Unspecified lack of expected normal physiological development in childhood
• R62.0 - Delayed milestone in childhood
29
Presenter
Presentation Notes
Notice the two options in 10 for the first example, 315.9, unspecified delay in development
More Billing Code Examples • R62 - Lack of expected normal physiological
development in childhood and adults ▫ R62.0 - Delayed milestone in childhood ▫ R62.5 - Other and unspecified lack of expected normal
physiological development in childhood R62.50 - Unspecified lack of expected normal
physiological development in childhood R62.51 - Failure to thrive (child) R62.52 - Short stature (child) R62.59 - Other lack of expected normal physiological
development in childhood
30
Examples of Billing Codes (continued) ICD-9-CM ICD-10-CM • 315.32 – Mixed receptive-
expressive language disorder
• 728.85 – Spasm of muscle
• F80.2 – Mixed receptive-
expressive language disorder • H93.25 - Central auditory
processing disorder
• M62.4xx – More than 20 codes
31
Presenter
Presentation Notes
Contracture of muscle – right upper arm, left upper arm, right forearm, right thigh, right lower leg, etc.
Impact on Data System Design • Change in length/format of data field • ICD-9-CM Drop-downs ▫ By name/condition and by ICD-9 code ▫ Search by text string and/or by code
• Options for ICD-10-CM ▫ Arrange alphabetically or by code ▫ Follow tabular (chapter) organization ▫ Level of specificity May depend on relationship to billing processes
32
Presenter
Presentation Notes
Remember change from 9 to 10 means change from 3-5 characters to 3-7 characters If you use codes to designate qualifying conditions, how will you organize and display them?
If working with a vendor, ask: • When will your ICD-10 compliant system be ready? • Are there any additional costs involved for upgrades
or ongoing maintenance? • What is the basis of your crosswalk or mapping
strategy? • Will your product support dual coding? • What is your external testing strategy? • Do you have a contingency plan if you’re not ready
by October 2014?
33
Presenter
Presentation Notes
Especially for billing
Impact on Data Analysis and Reporting
• Depends on the level of specificity of the data you collect
• Depends on your desired level of specificity for reporting
• Depends on your audience • Existing data (9 codes) vs. new data (10 codes)
34
Presenter
Presentation Notes
How will you handle existing data (ICD-9) codes?
Sample Report Using Categories Condition Percent Chromosomal Anomalies 22 Symptoms and Ill-Defined Conditions 15 Diseases of the Nervous System 13 Congenital Anomalies--Brain/Spinal Cord 12 Congenital Anomalies--Musculoskeletal & Other 12 Conditions Originating in Perinatal Period 8 Congenital Anomalies--Facial Clefts 6 Congenital Anomalies - Other 4 Autism Spectrum Disorders 4 Endocrine, Nutritional and Metabolic Diseases 2 Other 2
35
Presenter
Presentation Notes
Group by chapters or categories and sub-categories; remember tabular structure did not change that much.
Sample Report Using Individual Dx
Most Prevalent Qualifying Diagnoses Down Syndrome Failure to Thrive Plagiocephaly Seizure Disorders Microcephaly Hydrocephalus Spina Bifida Autism
36
Presenter
Presentation Notes
List of individual, specific conditions
Next Steps: Get Ready • Identify any/all places where you use ICD-9 codes. • Identify data systems and interfaces that need
changes. • Include clinical review of conversion of codes for
eligibility from ICD-9 to ICD-10. • For billing, be sure to test claims and transactions
well in advance – first internally, then externally with payers.
• Decide how you will handle data/reporting.
37
Presenter
Presentation Notes
Where do you use diagnoses and ICD-9 codes? What are the interfaces that may need to be changed? What databases need to be changed? Be sure to test claims and transactions well in advance, both within your organization and with your payers and other business partners, e.g., clearinghouses or third-party billing services
CMS Web Resources: Basic Education
• CMS – ICD-10-CM http://www.cms.gov/Medicare/Coding/ICD10/index.html ▫ Introduction fact sheet ▫ FAQs ▫ Updates from CMS
38
Presenter
Presentation Notes
You can sign up for email updates from CMS
Web Resources: Basic Education • NCHS/CDC – Basic ICD-10-CM Information
http://www.cdc.gov/nchs/icd/icd10cm.htm • AHIMA - ICD-10-CM Education/Training
http://www.ahima.org/icd10/ • AAPC – ICD-10-CM Training/Implementation
http://www.aapc.com/ICD-10/ • WEDI – ICD-10-CM Implementation
http://www.wedi.org/topics/icd-10
39
Presenter
Presentation Notes
Two major, national coding organizations: American Health Information Management Association – Health Information Mgmt American Association of Professional Coders-- provide education and professional certification to physician-based medical coders WEDI – workgroup on electronic data interchange, advises HHS on health IT issues, including ICD-10 readiness
More Web Resources • American Speech-Language-Hearing Association
(ASHA) – mapping for audiology and SLP http://www.asha.org/Practice/reimbursement/coding/ICD-10/
• General Equivalence Mappings (GEMS) http://www.cms.gov/Medicare/Coding/ICD10/index.html • Lists of Codes and Descriptions http://www.cdc.gov/nchs/icd/icd10cm.htm
40
Web Resources on Implementation
• CMS ICD-10 Implementation Guide (see Resources tab)
https://implementicd10.noblis.org/ • CMS Implementation Timelines/Planning http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html
41
Presenter
Presentation Notes
For information on timelines, project planning and management, checklists
QUESTIONS
42
