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ICD-10 and You: INTRODUCTION TO AND IMPACT OF
THE NEW CODING SYSTEM ICD 10
Reinhard W. Beel, CEC, CDT, Office Manager Woman's Health Specialists of Carlisle
Consultant, Endocrine Management Consulting 717-798-4820 [email protected]
THE INFORMATION REGARDING REIMBURSEMENT IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENTS NO STATEMENT, PROMISE, OR GUARANTEE BY THE JOHNSON & JOHNSON DIABETES INSTITUTE, LLC CONCERNING LEVELS OF REIMBURSEMENT, PAYMENT, OR CHARGE. SIMILARLY, ALL CPT AND HCPCS CODES ARE SUPPLIED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENT NO STATEMENT, PROMISE, OR GUARANTEE BY THE JOHNSON & JOHNSON DIABETES INSTITUTE, LLC THAT THESE CODES WILL BE APPROPRIATE OR THAT REIMBURSEMENT WILL BE MADE. IT IS NOT INTENDED TO INCREASE OR MAXIMIZE REIMBURSEMENT BY ANY PAYOR. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PAYOR ORGANIZATION WITH REGARD TO ITS REIMBURSEMENT POLICIES.
Outline • Why Are We Changing to ICD-10?
– What’s wrong with ICD-9? • What Is ICD-10?
– Is it the end of the world? • When Do We Change to ICD-10? • ICD-10 Coding Guidelines • Examples
– Getting down to basics • What’s This Going To Cost Me?
– What if it doesn’t work, what about reimbursement? • What Do I Do To Get Ready?
When do we change?
October 1st 2014
There will be no Grace Period
Why are we changing?
• ICD-9-CM is running out of codes. Hundreds of new diagnosis codes are submitted annually.
• ICD-10-CM will allow for more codes and also greater specificity and thus better epidemiological tracking.
• This will allow providers to better identify certain
patients with specific conditions that will benefit from tailored disease management programs, e.g. diabetes, hypertension, asthma.
What Is ICD-10 (History)? • 1850 – International List of Causes of Death are created • 1863 – ILCD is adopted by the International Statistical
Institute • 1948 – WHO took over ICD in its 6th Edition • 1967 – The World Health Assembly adopted the WHO
Nomenclature Regulations that stipulate use of ICD in its most current revision for mortality and morbidity statistics by all Member States
• 1990 – ICD-10 was endorsed by the forty-third World Health Assembly
• 1994 – ICD-10 came into use by WHO member states • 2009 – ICD-10 is available in the six official languages of
WHO (Arabic, Chinese, English, French, Russian and Spanish) as well as in 36 other languages.
What Is ICD-10 (Present)? • ICD-9 – has volume 1 & 2 for outpatient and volume 3 for
inpatient. • ICD-9 CM has approx. 17,000 codes
• ICD-10 CM (clinical modification) – replaces volume 1
and 2 of ICD-9 • ICD-10 CM has approx. 68,105 codes • ICD-10 PCS (procedural coding system) – replaces
volume 3 of ICD-9 • ICD-10 PCS has approx. 86,916 codes (used in inpatient
coding only)
ICD-9 versus ICD-10
• ICD-9 used until September 30th, 2014 • ICD-10 takes effect October 1, 2014 • No Grace Period • ICD-9 Comprised of up to 5 Digit Numerical
Code • ICD-10 Comprised of up to 7 Character,
Alpha/ Numeric Code
Welcome To The Wonderful World
of ICD-10 Coding
ICD-9 versus ICD-10 ICD-9
ICD-10 CM
ICD-10 • First character is alpha, followed by up to six characters • Decimal point after third character • Valid codes can have three, four, five, six, or seven characters • Examples:
– C52 Malignant neoplasm of vagina – D16.5 Benign neoplasm of lower jaw bone – C81.70 Other Hodgkin’s disease, unspecified site – H04.132 Lacrimal cyst, left lacrimal gland – T45.1x2a Poisoning by antineoplastic and
immunosuppressive drugs, intentional self-harm, initial encounter
ICD-10 Categories are identified by 3 Characters
• A Three Character Category (Chapter), that has no further sub-division, is a Code
• Each level of sub-division after a Category, is a Sub-Category (Block)and if not further sub-divided is a Code
• Subcategories are either 4 or 5 Characters • The final level of sub-division of a Sub-
Category (Rubric), is a Code • Codes may be 3,4,5,6 or 7 Characters
Most Amazing Videos - Aircraft Carrier Specificity and Future
Star-Trek inspired Specificity and Future
Organization of ICD-10
• Introduction • Conventions and Guidelines • Alphabetic Index to Diseases • Neoplasm Table • Table of Drugs and Chemicals • Index to External Causes • Tabular List of Diseases
Placeholder Character and 7th Character
• The “X” is used as placeholder at certain codes to allow for future expansion.
• Certain categories have applicable 7th character requirements to be applied to all codes within the category or as noted in the Tabular List instruction
• Where a placeholder exists, the “x” must be used in order for the code to be considered a valid code
THIS SYMBOL INDICATES CODE REQUIRES A SEVENTH CHARACTER FOLLOWING THE PLACEHOLDER “x.” CODES LESS THAN SIX CHARACTERS THAT REQUIRE A SEVENTH CHARACTER MUST CONTAIN PLACEHOLDER “x” TO FILL THE MISSING CHARACTER. THE SEVENTH CHARACTER MUST ALWAYS BE A VALID SEVENTH CHARACTER FOR THAT CODE
Example: O64.0 Obstructed labor due to incomplete rotation of fetal head
The code with placeholder could look like this: O64.0xx1for one Fetus
√ x7th
√ x7th One of the following 7th characters is to be assigned to each code under category O64. 7th character 0 is for single gestation and multiple gestation where the fetus is unspecified. 7th character 1 through 9 are for cases of multiple gestation to identify the fetus for which the code applies. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O64 that has 7th character of 1 through 9. 0 not applicable or unspecified 1 Fetus 1 2 Fetus 2 3 Fetus 3 4 Fetus 4 5 Fetus 5 9 other Fetus
ICD-10 (22 Chapters)
1. Infections and Parasitic Diseases (A00-B99) 2. Neoplasms (C00-D48) 3. Disease of Blood (D50-D89) 4. (Chapter) Endocrine (Blocks - E00-E90) 5. Mental and Behavior (F01-F99) 6. Nervous System (G00-G99) 7. Diseases of the Eye (H00-H59)
ICD-10 (22 Chapters)
8. Diseases of Ear (H60-H95) 9. Diseases of Circulatory System (I00-I99) 10. Diseases of Respiratory (J00-J99) 11. Diseases of Digestive (K00-K99) 12. Diseases of Skin (L00-L99) 13. Diseases of Musculoskeletal (M00-M99) 14. Diseases of GU (N00-N99)
ICD-10 (22 Chapters)
15. Pregnancy and Childbirth (O00-O99) 16. Conditions in Perinatal Period (P00-P99) 17. Congenital Malformations (Q00-Q99) 18. Signs and Symptoms (R00-R99) 19. Injury, Poisoning (S00-T98) 20. External Causes of Disease (V01-Y98) 21. Factors Influencing Health (Z00-Z99) 22. Special Purposes (U00-U99)
Let’s look at some examples…
Example 1: ICD-9
• DM Type 2, with peripheral circulatory disorder, controlled
In ICD-9, the index sends us to 250 in the tabular list, giving us several choices for 4th position where “7” represents: “with peripheral circulatory disorder” and 4 choices for type and control where “0” represents: “Type 2, controlled” ICD-9 ------- 250.70 DM 2 controlled
Do we specify “controlled and uncontrolled” in ICD-10?
1.) Yes, it is part of the combination code 2.) Yes, ICD-10 has a specific code for that 3.) No, ICD-10 does not use these terms
Audience Participation Question 1:
ICD-10
• The approach is different • The documentation is more specific • More steps are involved in finding the code • New terminology is used • Coders need to know their A & P • Providers need to perform and document
more detailed • Providers also need to learn new terms
Terms We Need To Learn
• “Chapters” will have a heading identifying conditions in that section.
• Each chapter is then divided into subchapters or “blocks” further dividing into etiology, anatomical site or severity.
• Each “block” contains “rubrics” that identify closely related conditions.
ICD-10 (22 Chapters)
1. Infections and Parasitic Diseases (A00-B99) 2. Neoplasms (C00-D48) 3. Disease of Blood (D50-D89) 4. (Chapter) Endocrine (Blocks - E00-E90) 5. Mental and Behavior (F01-F99) 6. Nervous System (G00-G99) 7. Diseases of the Eye (H00-H59)
Blocks
E00-E07 DISORDER OF THYROID GLAND
E08-E13 DIABETES MELLITUS
E15-E16 OTHER DISORDERS OF GLUCOSE REGULATION AND PANCREATICINTERNALSECRETION
E20-E35 DISORDER OF OTHER ENDOCRINE GLANDS
E50-E64 OTHER NUTRITIONAL DEFICIENCIES
E65-E68 OVERWEIGHT, OBESITY AND OTHER HYPERALIMENTATION
E70-E90 METABOLIC DISORDERS
Rubrics E11 Type 2 diabetes mellitus
• Includes diabetes mellitus due to insulin secretory defects • E11.0 Type 2 diabetes mellitus w/hyper-osmolarity • E11.2 Type 2 diabetes mellitus w/ kidney complications • E11.3 Type 2 diabetes mellitus w/ophthalmic complications • E11.4 Type 2 diabetes mellitus w/neurological complications • E11.5 Type 2 diabetes mellitus w/circulatory complications
– E11.51 Type 2 diabetes mellitus W/ PERIPHERAL ANGIOPATHY W/O GANGRENE
– E11.52 Type 2 diabetes mellitus W/ PERIPHERAL ANGIOPATHY W/ GANGRENE
– E11.59 Type 2 diabetes mellitus W/ OTHER CIRCULATORY COMPLICATION
• E11.6 Type 2 diabetes mellitus w/ other specified complications • E11.8 Type 2 diabetes mellitus w/ unspecified complications • E11.9 Type 2 diabetes mellitus without complications
Example 1 • DM Type 2, with peripheral circulatory disorder,
controlled Documentation not specific enough for ICD10 ICD-10 Code:
–E11.59 Type 2 diabetes mellitus W/ OTHER CIRCULATORY COMPLICATION
use additional code to identify long term insulin use (Z79.4)
• Z79.4 Long term (current) use of insulin • Report Z79.4 with all codes from Blocks:
– E08 Diabetes mellitus due to underlying conditions • Code first underlying condition
– E09 Drug or chemical induced diabetes mellitus • Code first (T36-T65) to identify drug or chemical
– E11 Type 2 diabetes mellitus – E13 other specified diabetes mellitus
– O24 Diabetes mellitus in pregnancy, childbirth, and the puerperium
• Use additional codes from category E10 or E11 to identify manifestations
• “O” code trump any other code
Example 2 – How specific is the documentation
Subjective: Mrs. Finley presents today after having a new cabinet fall on her last week, suffering a concussion, as well as some cervicalgia. She was cooking dinner at the home she shares with her husband. She did not seek treatment at that time.
External Cause The falling cabinet caused the injuries. Description of the cause is required
Activity In ICD10 the activity of the patient needs to be documented. An activity code is only used once at the initial encounter.
7th Character Injury codes require a 7th character extender that identifies the encounter. Documentation must be clear so that the correct extender can be applied.
She states that the people that put in the cabinet in her kitchen missed the stud by about two inches. Her husband, who was home with her at the time, told her she was “out cold” for about two minutes.
Location Documentation needs to include the location of the patient at the time of the injury or other condition. In ICD-10 the details include the actual room of the house the patient was in when the injury occurred.
Applied Specificity: Concussion For a concussion documentation needs to include if the patient suffered loss of consciousness
The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius.
Relieve or No Relief Intractable versus not intractable are an inherent part of ICD-10 code for headaches and documentation needs to be clear to assign the appropriate code.
Objective: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse 70, respiration are 18. She has full strength in her upper extremities. DTRs in the bicep and tricep are adequate. Grip strength is adequate. Heart rate is regular, and lungs are clear. Assessment: 1: Status post concussion with acute persistent headaches 2: Cervicalgia 3: Cervical somatic dysfunction Plan: ………………………………………………………………
Acute versus Chronic Documentation of the patient’s condition must include acute or chronic to assign the most appropriate ICD-10code
ICD-10 Coding S06.0x1A Concussion with loss of consciousness of 30 minutes or less, Initial encounter G44.311 Acute post traumatic headache, intractable M54.2 Cervicalgia M99.01 Segmental and somatic dysfunction of cervical region W20.8xxA Struck by falling object (accidentally), Initial encounter Y93.g3 Activity, cooking and baking Y92.010 Place of occurrence, house, single family, kitchen xx = Place holders to achieve 7 Character Code
EXAMPLE 3: ICD-9 • 250 Diabetes Mellitus • 250.5 Diabetes Mellitus w/ Ophthalmic
Complications • 250.52 Diabetes Mellitus w/ Ophthalmic
Complications, Type 2, uncontrolled
Complete Code
Audience Participation Question 2:
What is not a valid ICD-9 Code?
1) V58.62 2) 250.52 3) 250.09 4) E932.3
DM Type2 w/ Ophthalmic Complications, Retinopathy, with Macular Edema
not identified as controlled or uncontrolled any longer
E 1 1
E 1 1 . 3
E 1 1 . 3 1
Category - 3 Characters
Sub-Category – 4 Characters
Sub-Category – 5 Characters
E 1 1 . 3 1 1
Code – 6 Characters
T 3 8 . 3 X 1 A
Code – 7 Characters
Diabetes Mellitus Type 2 DM Type2 w/Ophthalmic Complications DM Type2 w/Ophthalmic Comp, w/unspecified Diabetic Retinopathy DM Type2 w/Ophthalmic Comp, w/unspecified Diabetic Retinopathy w/macular edema Poisoning by insulin and oral hypoglycemic drugs, un-intentional, initial encounter Place
holder Un intent ional
Initial encounter
Insulin under dosing
Poisoning by, adverse effect of and under-dosing, hormones, their substitutes and antagonists NEC
Audience Participation Question 3:
What is coded first in ICD-10? 1)Diabetes 2)Pump Malfunction 3)Long Term Use of Insulin
Case: Patient with type 2 diabetes, Diabetic Retinopathy, on an insulin pump, came to the office with high glucose (DM uncontrolled) because his insulin pump malfunctioned.
Example 4
• Patient with type 2 diabetes, • Diabetic Retinopathy, • on an Insulin Pump, came to the office with
high glucose (DM uncontrolled) because his Insulin Pump malfunctioned.
ICD9: Diabetes Mellitus Type 2 uncontrolled 250.52 Long term Insulin use V58.67 adverse effect, insulin E932.3
Code: ICD-10 • Pump Malfunction (first listed code)
(the reason for the encounter) • Diabetes (Identify the Disease) • With or without poisoning by insulin (Condition caused by the malfunction) • Long term Insulin Use (use for Type 2)
(Type 1, implied or presumed on insulin)
Example 4: ICD-10
• T85.614A - (needs 7 characters) – Breakdown (mechanical) of Insulin Pump, initial encounter
• E11.311 - DM Type2 with ophthalmic complications, unspecified Diabetic Retinopathy with macular edema
• T38.3X6A - (needs 7 characters) Poisoning by Insulin and oral hypoglycemic Drugs, under-dosing, initial encounter
• Z79.4 - Long term (current) use of Insulin
DM Type 1
• E10.9 = DM Type 1 without Complications • E10.8 = DM Type 1 unspecified
DM Type 2
• E11.9 = DM Type 2 without Complications • E11.8 = DM Type 2 unspecified
Controlled and Uncontrolled no longer specified
How do we translate between ICD-9 and ICD-10?
What issues need to be considered?
General Equivalence Mappings
What are the GEMs? • A two-way translational dictionary where diagnoses and procedure
codes can be translated to and from ICD-9 CM and ICD-10 CM • Created by collaborative effort of National Center for Health
Statistics (NCHS), CMS, American Hospital Association and 3M Health Information Systems
• Intended to be used by -Health Plans -Providers -Researchers -Vendors
General Equivalence Mappings • Many codes will translate 1 : 1 from ICD-9 to ICD-10 -they may not be identical but simply represent only one alternative • Many codes will translate into more than one code due to the different
structure and higher specificity of ICD-10
ICD-9CM 611.79 Signs and Symptoms in Breast
ICD-10CM N64.51 Induration of the breast N64.52 Nipple discharge N64.53 Retraction of the nipple N64.59 Other signs and symptoms of the breast
What issues need to be considered? • Clinical Issues:
-Documentation Issues/ more specific -New code sets to learn -Changes in coverage by health plans -Orders +Labs; x-ray; other testing • Billing and Coding Issues: -Coding from two systems (ICD-9 and ICD-10) -Productivity issues -Policies and procedures -Referral forms -Super bills / Routing forms -Contracting changes/ Contract Negotiation -Denial management/ impacting cash flow
THE SUPERBILL AND REFERRAL FORMS
• SUPERBILLS with the most common diagnoses codes listed to expedite coding the visit, will undergo significant changes
• ICD-10 has at least 10 times as many codes • Forms will change from 2 sided forms to 9
page forms • New tools may need to be developed
Common Sense
Timeline
NOW • Buy ICD-10 book and start reading the
introduction and chapters • Run an ICD-9 productivity report for a 12-
month period showing the top 100 codes your provider uses
• Begin the process of mapping your ICD-9 codes to ICD-10 codes and creating a master list
• Make sure the provider(s) in your group review the new terminology and start documenting with greater specificity
October 2014 • You have to be ready to go… ???????? • Remember:
DOCUMENTATION DRIVES CORRECT CODING
More so in ICD-10
ICD-10 Start asking Questions NOW!
• Is your office working on ICD-10 implementation? • Will our providers be ready for ICD-10? • Will our documentation be sufficient for ICD-10? • Will our forms be changed for the new codes? • Is our EMR ready for the use of both ICD-9 and ICD-10
simultaneous? • Will our Coders be ready for the new Coding System?
• Is our Revenue Reserve large enough to deal with Problems (Rejections, Re-submissions, Slow-down of Cash-flow)?
If All Else Fails, If You Experience Problems Right Off The Bat…….
DON’T WAIT TOO LONG TO
ASK FOR HELP AND/OR MAKE CHANGES QUICKLY!
Resources
• AAPC Website • http://www.aapc.com/ICD-10/index.aspx • CMS Website on ICD 10 • https://www.cms.gov/ICD10/01_Overview.asp#TopOfPage • CMS website GEM and Reimbursement Mapping Files as well
as User’s Guides • http://www.cms.hhs.gov/ICD10/01m_2009_ICD10PCS.asp • http://www.cms.hhs.gov/ICD10/02m_2009_ICD_10_CM.asp • ICD 10 Coding Companion by Specialty (This Book can be helpful to select the correct codes for services)
Thank you very much!
Reinhard W. Beel, CPC, CEC, CDT Endocrine Management Consulting
717-798-4820 [email protected]
