ICD-10 International Classification of Diseases – CM “Time to Plan for Transition” March 28,...

ICD-10International

Classification of Diseases – CM “Time

to Plan for Transition”

March 28, 201411:00 am – 12:00 pm

PRESENTED BY

Rhonda Anderson, RHIA, President

rhonda@ahis.net

714-299-0573 (mobile)

Anderson Health Info. Systems, Inc.

940 W. 17th Street, Suite B

Santa Ana, CA 92706

Tel. 714-558-3887 Fax 714-558-1302

Office@ahis.net

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OBJECTIVES

• Participants will identify:– Dates for New ICD-10– Documentation support– Some general coding guidelines– YOUR Work plan

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ICD—10 “HAS TWO PARTS”

• ICD-10 CM – Clinical Modification – Skilled Nursing will use “CM”

• ICD-10 PCS – Procedural Code System (used for procedures, operations within the hospital inpatient setting)

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HIPAA

• Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)

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FINAL REGULATION

• January 15, 2009 Final Regulation Released

• EXCHANGE the ICD-9 for the ICD-10 by October 1 (originally 2013, changed to 2014)

• ICD-10 for billing purposes as far as ability to accept the code known as “5010” was required by October, 2011

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WHAT DOES ICD-10 COMPLIANCE MEANS?

• ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD-10 codes

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WHO IS AFFECTED??

• Freestanding providers

• Ancillary services – “that means all of us really” who provide services and bill for them under Medicare, Medi-Cal and private insurances

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WHO IS AFFECTED?? -2

• Developed for the provider and the coder….(person who may review the documentation and determine if code is accurate)

• Consistent, complete documentation in the medical record is a major emphasis

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WHO IS AFFECTED?? -3

• More specific in documentation to support the ICD-10 diagnostic code convention, general and specific coding guidelines

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REVIEW OF FEW DETAILS

• No you will NOT code!

• You will need– To provide your Board of Directors with some

information about the importance– To know your resources– Identify your own champions– Obtain assurance from the computer system– To know that coding is correct

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WHY ICD-10 IS HAPPENING?

• ICD-10 CM/PCS – Increased level of Increased level of detail detail – Required for medicine advancements in

technology– $$, improved data quality for clinical and

financial decision making– To support value based purchasing and

facilitate quality reporting

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WHY ICD-10 IS HAPPENING? -2

• ICD-9 codes have limited data about resident’s medical condition & hospital inpatient procedures

• ICD-9 is 30 years old

• Has outdate and obsolete terms

• Inconsistent with current medical practices

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STATE MEDICAID PROG. NEED TO TRANSITION TO ICD-10

• Like everyone else covered by HIPAA, state Medicaid programs must comply with ICD-10

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CODES CHANGE EVERY YEAR

• ICD-10 codes will be updated every year

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ICD-10 DIFFERENCES

• Organization – Two volumes

• Structure – Alphanumeric categories rather than numeric categories.(has “includes and excludes notes:– Categories are three digits– Chapters – re-arranged– Titles have Changed – examples on

following slides

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ICD-10 DIFFERENCES -2

CHAPTER ICD-9-CM ICD-10-CM

1 Infectious and Parasitic Diseases

Certain Infectious and Parasitic Diseases

2 Neoplasms Malignant Neoplasms

6 Diseases of the Nervous System

and Sense Organs

Diseases of the Nervous System

7 Disease of the Circulatory System

Diseases of the Eye and Adnexa

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ICD-10 DIFFERENCES -3

CHAPTER ICD-9-CM ICD-10-CM

8 Diseases of the Respiratory

System

Diseases of the Ear and Mastoid Process

9 Diseases of the Digestive System

Diseases of the Circulatory System

10 Diseases of the Genitourinary

System

Diseases of the Respiratory System

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ICD-10 DIFFERENCES -4

CHAPTER ICD-9-CM ICD-10-CM

13 Diseases of the Musculoskeletal

System and Connective Tissue

Diseases of the Musculoskeletal

System and Connective Tissue

14 Congenital Anomalies

Disease of the Genitourinary System

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ICD-9 DIFFERENCES

• Lacks detail

• Lacks laterality Difficult to analyze dated due to non-specific and do not adequately define diagnoses needed for medical research

• Does not support interoperability because it is not used in other countries

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ICD-10

• Code composition – increased specificity

• Level of detail

• May consist of up to 7 digits with the seventh digit extensions representing visit encounter or sequelae as stated above

• Includes full code titles and no reference back to common 4th and 5th digits)

• V and E codes are no longer supplemental

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ICD-9-CM DIAGNOSIS CODES – FORMAT & STRUCTURE

• 3-5 characters in length

• Approximately 14,000 codes

• First digit may be alpha (E or V) or numeric

• Digits 2-5 are numeric

• Always at least three digits,

• Decimal placed after the first three characters

• Limited space for new codes

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ICD-10-CM DIAGNOSIS CODES – FORMAT & STRUCTURE

• 3-7 characters in length

• Approximately 68,000 codes

• Digit 1 is alpha, digit 2 and 3 are numeric; digit 4-7 are alpha or numeric

• Decimal placed after the first 3 characters,

• All letters used except “U”

• Flexible for adding new codes

• Very specific

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CODE FORMAT

ICD-9-CM Code Format ICD-10-CM Code Format

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FIVE-SIX CHARACTER SUBDIVISION

• Way too much detail…but it looks like this!!– J10.8 – Influenza due to other influenza virus

with other manifestations– J10.81 – Influenza gastroenteritis– J10.89 – Influenza with other manifestations:

• Influenzal encephalopathy• Influenzal myocarditis

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FIVE-SIX CHARACTER SUBDIVISION -2

• Way too much detail…but it looks like this!!– ANOTHER EXAMPLE – WITH SPECIFICITY

AND LATERALITY:• S55.011 Laceration of ulnar artery at forearm

level, right arm

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ICD-10 STRUCTURE

• Index and Tabular list similar to ICD-9

• ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list

• Former V=codes are now Z =codes and Z =codes and in Chapter 21. Factors Influencing in Chapter 21. Factors Influencing Health Status and Contact with Health Health Status and Contact with Health Services (NEW)…Services (NEW)…

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ICD-10-CM DIAGNOSIS CODES

• Specificity improves coding accuracy and depth of data for analysis

• Detail improves the accuracy of data used in medical research

• Supports interoperability and the exchange of health care data between other countries and the U.S.

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MAPPING TOOLS

• Mapping from ICD-9 to 10 tools are available, General Equivalence Mappings (GEMS) – translation dictionary for diagnoses

• Called “GEMS” – general equivalence mappings

• CM – GEMS available

• PCS – GEMS just available last of September (acute hospital mostly)

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GEM FILES

• Do not despair…you vendor should prepare as much of a crosswalk as possible

• NOTE: will require some conversion for long term resident’s diagnoses by the effective date of ICD-10

• Later TRAININGTRAINING and how to use them…Key to early review!!!

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THE WORKPLAN

TRANSITION TO ICD-10

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IMPLEMENTATING ICD-10

• Notification to Board – Click here for HO #1 (ICD-10 for Governing

Body)

• Timeline– Click for HO #2 (ICD-10-CM Expanded Imple

mentation Plan (Part 2))

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IMPROVE DOCUMENTATION NOW

• All of the information that is required to code according to ICD-10 is information that is necessary to an individual’s care and is already documented in the medical record

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ICD-10 CODES REQUIRE

• Clear focus to better documentation

• Absolutely critical to the success of ICD-10

• Good resident care:– Affect so many facets of health care

downstream– Quality measures to analytics, research,

payment and surveillance– Must be as accurate as possible

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ICD-10 CODES REQUIRE -2

• Good resident care (cont.)– Accurate coding require physician’s efforts to

provide good documentation as well as nursing

– No reason to delay implementation of good documentation practices

– Information that is required to code according to ICD-10 is information necessary to resident and is already documented in the medical record

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ICD-10 CODES REQUIRE -3

• Good resident care (cont.)– What are you documenting today?– Ways more appropriately document?– Failure to fully properly document has

medical, financial, and even regulatory ramifications

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DEVELOP THE RELATIONSHIP BETWEEN CLINICIANS

• Clinicians (DON) do not need to understand all of the intricacies of coding, and coders do not need to understand all of medicine – but the 2 must work together to ensure optimal accuracy

• Who codes need to understand basic anatomy and pathophysiology increase in questions from coders

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STRATEGIES FOR TRAINING

• Leadership those individuals who are responsible for moving things through the organization:– Understand what the impact of ICD-10 will be– What challenges anticipated

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STRATEGIES FOR TRAINING -2

• Training Medical Record, MDS/PPS, DON, Medical Director:– Have training– Parallel coding taking the same cases and

coding them accurate to ICD-9 and ICD-10– Parallel training and testing – Start in early 2014

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STRATEGIES FOR TRAINING -3

• Leadership should understand enough about the coding changes to understand the implications:– Documentation– Business practices– MDS / Medicare PPS– $$ impact for training, implementation and

billing

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RESOURCES

• HIM Consultant – Be sure ICD-10 Certified or Specialized Training

• Centers for Medicare & Medicaid Services (CMS)

• Includes official codes and guidelines

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ICD-10 CODE SETS

• www.cms.gov/ICD10

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WHY PREPARE NOW?

• Major understanding for providers, payers and vendors

• Will drive business and systems changes, hospital, SNF, Physicians, Outpatient, et’l, from large national health plans to small provider offices, laboratories, medical testing centers

• Staff time – start looking who affects now and what they need to know

• Financial resources• Also option for ICD-10 transition

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TYPES OF TRAINING – PROVIDERS / STAFF

• Six months before the compliance deadline

• Projected to take 16 hours for coders to 50 hours

• ICD-10 resources and training materials available:– Through CMS– Professional associations, societies,

software/system vendors, HIM Consultants

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ICD-10 PROJECT PLAN

• Develop and complete an ICD-10 project plan:– Identify each task, deadline and who is

responsible– Develop plan for communicating with staff

and business parts about ICD-10– Estimate and secure budget

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ICD-10 PROJECT PLAN -2

• Check with:– HIM Consultants,– Payers,– Software/systems vendors– Clearinghouses– Billing services– Labs– Physicians

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ICD-10 PROJECT PLAN -3

• Check out:– Systems changes– A timeline– Costs– Testing plans

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ICD-10 PROJECT PLAN -4

• Evaluate current documentation

• Identify most commonly used diagnoses by checking out:– Reports – past coding Medicare coverage

issues “ADR”– Documentation to support those diagnoses– Medical staff / Medical Director support– Clinical documentation improvements

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SPECIFIC INFO. NEEDED TO ACCURATELY CODE

• Diabetes Mellitus– Type of diabetes– Body system affected– Complication or manifestation– If type 2 diabetes, long-term insulin use

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SPECIFIC INFO. NEEDED TO ACCURATELY CODE -2

• Fractures– Site– Laterality– Type– Location

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REVIEW CHANGES IN DOC. REQUIREMENTS

• Injuries– External cause – cause of the injury, more

applicable to op– Place of occurrence – home, at work, in the

car, etc. • More related to op we will have some references

– Activity code– External code status – indicate if the injury

was related to military, work, or other

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LOOK AT SAMPLES IN BACK OF POWERPOINT

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TRANSITION & TESTING

• March 2014 to September 2014

• March 1, 2013 – December 31, 2013– Conduct high level training on ICD-10 for

clinicians– Codes to prepare for testing– Clinical documentation

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TRANSITION & TESTING -2

• April 1, 2014– ICD-10 codes for diagnoses– Test data and reports for accuracy

• January 1, 2014 – April 1, 2014– Review, coder and clinical preparation– Begin detailed ICD-10 coding training (6-9

months)– Work with Consultants and vendors to

complete transition to production – ready ICD-10 systems

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COMPLETE TRANSITION / FULL COMPLIANCE

• October 1, 2014

• Complete ICD-10 transition for full compliance– ICD-9 codes continue to be used for services

provided before October 1, 2014– ICD-10 diagnosis and inpatient procedure

codes required for services provided on or after October 1, 2014

– Monitor systems correct errors if needed

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PRINCIPAL DIAGNOSIS

• Circumstances of inpatient admission always govern the selection of PRINCIPAL DIAGNOSIS:– “that condition established after study to be

chiefly responsible for occasioning the admission of the resident to the hospital (facility) care”

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PRINCIPAL DIAGNOSIS -2

• The references and correct coding guidelines HAVE BEEN USED IN THE PAST – NOW THERE ARE NEW CODING GUIDELINES – TAKE PRECEDENCE IN ICD-10

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PRINCIPAL DIAGNOSIS -3

• WE WILL TEACH THE NEW WE WILL TEACH THE NEW GUIDELINES!!!GUIDELINES!!!

• The importance of consistent, The importance of consistent, complete documentation in the complete documentation in the medical record cannot be medical record cannot be overemphasized. Without such overemphasized. Without such documentation the application of all documentation the application of all coding guidelines is difficult!!coding guidelines is difficult!!

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HIPAA

• Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)

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HIPAA -2

• Not part of this presentation – HIPAA Changes– Privacy Notice

– Business Associate

– Minimum Necessary

– Rights to restrict use/disclosure

– Right to Access electronic and manual Protected Health Information

– HITECH Changes for Breach and Fines

– Impermissible Use

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QUESTIONS & ANSWERS

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SOME EXAMPLES

Reference ONLYReference ONLY

Slides from here to end of ppt. Slides from here to end of ppt. on coding – sample referenceson coding – sample references

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ICD-10 NEW FEATURES

• Combination Codes for Condition s and Combination Codes for Condition s and Common Symptom or ManifestationsCommon Symptom or Manifestations – specify…This example reflects specificity down to the type of artery – and would related to post follow up care but the Dx. Given at the hospital would carry, too.

• I25.110 – Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris

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ICD-10 NEW FEATURES -2

• Added Laterality – EXAMPLES– C50.212 Malignant neoplasm of upper-inner

quadrant of left female breast– I80.01, Phlebitis and thrombophlebitis of

superficial vessels of right lower superficial vessels of right lower extremityextremity

– L80.213, Pressure Ulcer of right hip, Stage right hip, Stage IIIIII

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A FEW CODES YOU WILL LEARN

• Added examples of specificity:Added examples of specificity:– A41.9 Sepsis without cause organismA41.9 Sepsis without cause organism –

Sepsis, unspecified– Severe Sepsis – A41.9 Sepsis unspecified

for the infection. Additional code for organ must be identified

– UROSEPSIS is not allowed as a dx

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A FEW CODES YOU WILL LEARN -2

• Septic Shock – EXAMPLE OF SPECIFICITY– Circulatory failure associated with severe

sepsis; represents a type of acute organ dysfunction. Underlying infection sequenced first, followed by code R65.21 Severe sepsis R65.21 Severe sepsis with septic shock. Add additional codes with septic shock. Add additional codes for other acute organ dysfunction.for other acute organ dysfunction.

• New guidelines for sequencing Severe Sepsis• Must be clear if it is present on admission

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ICD-10 NEW FEATURES -3

• Expanded CodesExpanded Codes (injury, diabetes alcohol/substance abuse, postoperative complications)– E08.22 DiabetesDiabetes due to underlying condition

with diabetic chronic kidney disease

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CHAPTER 4 – E00-E89

• Endocrine, nutritional and metabolic diseases– Diabetes Mellitus

• Combination codesCombination codes• Includes the body system affected and

complications affecting the body system• Many codes particular category as are necessary

to describe all of the complications of the disease may be used

• Sequenced base on the reasonfor a particular encounter

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CHAPTER 4 – ENDOCRINE, NUTRITIONAL…(E00-E89)

• Endocrine, nutritional and metabolic diseases – SPECIFICITY– Secondary Diabetes Mellitus:

• Category E08 due to underlying condition• Category E09 for drug/chemical induced• Use code Z79.4 for residents who routinely use

insulin; also assigned for long-term (current) use

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CHAPTER 9 – DISEASES OF CIRCULATORY SYS. (I00-I99)

• Hypertension with Heart Disease– Heart conditions classified to I50 or I51.4-

I51.9 are assigned to, a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive)

– Use an additional code from category I50

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CHAPTER 10 – DISEASES OF RESPIRATORY SYS. (J00-J99)

• Chronic Obstructive Pulmonary Disease (COPD) and Asthma– Acute exacerbation of chronic

obstructive bronchitis and asthma

– J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation

• Acute Respiratory Failure– Principle diagnosis when it is the condition

established after study to be chiefly responsible

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CHAPTER 13 – DISEASE OF MUSCULOSKELETAL (M00-M99)

• Site and laterality:Site and laterality:– Designations

– Represents the bone, joint or the muscle

– Where more than one bone, joint or muscle is involved, such as osteoarthritis, use the assigned “multiple sites” code; if not available, use multiple codes to indicate the sites

– Bone vs. Joint – Certain conditions where the bone may be affected at the upper & lower end; site designation will be the bone, not the joint

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LET’S SEE SOME CODES

• Sequencing of codes is determined by Sequencing of codes is determined by the reason for admission/encounter - the reason for admission/encounter - Hypertensive RetinopathyHypertensive Retinopathy– H35.03 Hypertensive Retinopathy,– 031 – Right eye, 032, left eye, 033, bilateral,– 039 – Unspecified (and this would be a ??

For billing most likely)!!– I10 – Essential Primary Hypertension.

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ICD-10 NEW FEATURES

• An example S42.321A Displaced transverse fracture of shaft of humerus, right arm, initial encounter for closed fracture

• This means more specific documentation from the physician (the initial encounter may not have been in your setting)

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REPEATED FALLS

• Code R29.6 Repeated fallsCode R29.6 Repeated falls for use for encounters when a resident has recently fallen and the reason for the fall is being investigated. Code Z91.81, History of falling, is for use when a resident has fallen in the past is at risk for future falls. Both codes may be assigned

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CODING OF TRAUMATIC FRACTURES

• Fractures of specified sites are coded Fractures of specified sites are coded individually by siteindividually by site

• S-codes…need to pay attention to level of detail furnished by medical record content

• Fracture not indicated as open or closed, displaced, initial vs. subsequent encounter for fractures. (use 7th character extension for initial encounter (A.B.C) There are specific instructions related to this area (#18)

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AFTERCARE

• Aftercare codes cover situations when the initial treatment of a disease has been performed and the resident requires continued care during the healing or recovery phase or the long term consequences of the disease

• Z code should not be used if treatment is directed at a current acute disease

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REMINDER

• MAKE YOUR LIST OF DUTIES YOU MAKE YOUR LIST OF DUTIES YOU SEE IMPORTANT WHEN YOU RETURN SEE IMPORTANT WHEN YOU RETURN TO YOUR FACILITYTO YOUR FACILITY

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THANKS FOR ATTENDING

Rhonda Anderson, RHIA, President

rhonda@ahis.net

714-299-0573 (mobile)

Anderson Health Information Systems, Inc.

940 W. 17th Street, Suite B

Santa Ana, CA 92706

714-558-3887

office@ahis.net

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