Presented by:

Day Egusquiza, President

AR Systems, Inc.

Karen Kvarfordt, RHIA, CCS-P, CCDS

President, DiagnosisPlus, Inc.

It’s on your doorstep! The biggest change to happen in Health Information Management and the Revenue Cycle

in more than 30 years!

Preparation is the key!Will YOUYOU be ready?

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WHOWHO (World Health Organization) owns & publishes ‘ICD’ (International Classification of Diseases).

WHOWHO endorsed ICD-10 in 1990; members began using ICD-10 or modifications in 1994.

United States United States is the only industrialized country not not using ICD-10 for our coding & reporting of diseases, illnesses, and injuries. Why?

What makes us so different?What makes us so different?

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United Kingdom (1995) Denmark, Finland, Iceland, Norway, Sweden (1994 –

1997) France (1997) Australia (1998) Belgium (1999) Germany (2000) Canada (2001) U.S. (U.S. (20152015) ) ((ReimbursementReimbursement + + Case Mix + HIPAA Case Mix + HIPAA

Standard Transaction Act 2003Standard Transaction Act 2003))

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What is the benefit to the provider?What is the benefit to the provider?◦Dramatic improvement in the assignment of costs to Dramatic improvement in the assignment of costs to

procedures performed.procedures performed. ICD-10 will allow us to develop meaningful estimates

about what a disease state or a procedure costs us, while ICD-9 is limited in what it can do in this regard.

◦ Identify opportunities to avoid cost & improve lives.Identify opportunities to avoid cost & improve lives. Additional information in an ICD-10 diagnosis code

includes severity and specific comorbidity, but it can also include information about demographics and some of the underlying reasons for the diagnosis.

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Share higher-quality data with other health Share higher-quality data with other health care providers.care providers.◦ICD-10 increases the amount of “specificspecific”

information in every diagnosis code and makes this more valuable to other providers.

For example, ICD-9 has a code for laceration of an artery.

ICD-10 lets you know if that artery was in someone’s finger or in their heart.

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Reimbursements will better align Reimbursements will better align with activity & cost. with activity & cost. ◦Payers will reimburse severe & complex cases better and simple cases at lower rates.How? By the diagnosis codesBy the diagnosis codes!

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Imagine you had a patient who was noncompliant with their medical therapy. In ICD-9, the only code we have available is V15.81 (personal history of noncompliance with medical treatment).

Is the patient noncompliant because of their own personal reason? Or something else?

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Z9111 (Patient’s noncompliance with dietary regimen) Z91120 (Patient's intentional underdosing of medication regimen due to financial hardship) Z91128 (Patient’s intentional underdosing of medication regimen for other reason) Z91130 (Patient’s unintentional underdosing of medication regimen due to age-related debility) Z91138 (Patient’s unintentional underdosing of medication regimen for other reason)

Shows whether or not the patient’s noncompliance was Shows whether or not the patient’s noncompliance was intentional, but also identifies if the patient needs some form intentional, but also identifies if the patient needs some form

of assistance from social services, etc.of assistance from social services, etc.

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Non-HIM Uses For ICD-9-CM-Non-HIM Uses For ICD-9-CM-Preparing for ICD-10-CM – as Preparing for ICD-10-CM – as we move from 15,000 codes to we move from 15,000 codes to

over 70,000 codesover 70,000 codes

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Rollout ‘monthly dedicated specialty specific’ audit and training.

EX) May is ER month. Coders dual code an identified sample of ER claims. Identify ‘at risk’ documentation by provider. Turn into ‘easy to implement documentation.

EX) If the facility has a CDI team, work cooperatively with the coding team to ‘coach/que’ the ER providers thru their month.

EX) Do an month end dual coding – show improvement or challenges.

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Physician dictates, hospital coders code, UB is created.

NEW: Why not share the codes with the providers who are attached to the account? Why repeat the same coding process in the office?

NEW: Brown bag coding luncheons with the provider offices. Office brings samples to code, hospital coders code while teaching ICD 10 concepts. (TX: Lunch & Learn weekly)

NEW: Hospital becomes the outsourcing company to assist small practices with coding.

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Scheduling –precerts, eligibility. Claims submission with scrubber –both

ICD 9 and ICD 10 codes ( Min-1 yr ability to rebill, do duality with IT systems.)

Medical necessity CPT codes – software, manual processes, cheat sheets

Recurring accounts – will need new precerts & recoded after 10-1-2014

Payer acceptance of new ICD 10 codes PLUS ICD 9 codes – 2 batches

Payer contract language – Dx codes Payer remark codes/denial codes CDM – Hardcoded RT/LT needs to

match with the soft coded RT/LT ICD10 Trauma/Tumor registry - translated All IT systems within the organization

837/835 HIPAA transaction sets – new for ICD 10 locators

Quality of care indicators – translated P4P indicators/Outcome Measures –

translated Decision Support, utilization patterns,

benchmarking – translated Medical care review – by provider, by dx,

by LOS New business plan research/future

healthcare trends – translated Monitoring and analyzing the incidence

of disease & other health problems –translated & new

Embedded dx attached to CPT codes Not case sensitive Revise forms to include new ICD 10

codes.

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Beyond the coders… PFS leadership as payers may reject based on ICD -10

coding and medical necessary codes & denial software. PFS leadership and contracting to ensure contracts can

accept both ICD-9 and ICD-10 on the UBs post go live. UR and all care mgt as payers will need to be able to do

pre-certifications and concurrent review with ICD-10. Decision support and all areas using ICD-9/10 coding for

tracking, reporting, etc. (Trauma registry, Tumor registry, outcome comparisons, contracting, etc.).

IT leadership must be involved to ensure all impacted areas are ready. A team leader or leaders are identified.

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UB submissions with ICD-9 and ICD-10 - conversion dates

Denials with new reasons –as ICD-10 is far more specific

Contract language that addresses ICD-10 inclusions/exclusions

Claim scrubbers/payer scrubbers – ABN issues (LCD/NDC dx codes), ‘if ‘ rules, edits

Pre-authorization process/coverage WC and Liability are not subject to HIPAA

standard transactions. Will they convert?

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Will they deny ‘unspecified” dx? How many digits will they require to have a ‘pre

authorization ‘ match? Testing – test pt type, create claim, thru scrubber,

to payer to payment. When start? Post go live? Accept DOS with ICD 9 after go live? If delayed, notify CMS/HIPAA Standard

Transaction 2003. Track and trend all payer issues – report to hospital

association.

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The challenges… What?What? For each Lab NCD, the ICD-9-CM codes and descriptions will

have to be translated to

ICD-10-CM versions. When?When? ◦ (A) Prepare preliminary versions of ICD-10-CM translations of Lab

NCDs by end of January 2011 (for use in testing system functions).◦ (B) Prepare ICD-10-CM versions for full ICD-10-CM implementation

in 2015

◦ HEY – look at MLN Matters MM8197 3-15-13HEY – look at MLN Matters MM8197 3-15-13◦ “ICD conversion from ICD-9 to related code infrastructure of

the Medicare shared systems as they relate to CMS’ NCDs.”

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Translate all ICD-9-CM codes and descriptors in each Lab NCD’s table of covered codes to the ICD-10-CM equivalent(s).

Provide these translated tables to the CMS contractor, so that the tables can be incorporated into the ‘codelist spreadsheet’ which will be processed for use by the shared systems for claims processing (update 2/13 – NCDs available).

GoalGoal: Allow consistent and “seamlessseamless” transition of claims for providers of laboratory test services.

(CONTINUE TO WATCH for payer updates)

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Will payers, vendors (claim submission and scrubber) and other IT systems be able to handle ICD-9-CM as well as ICD-10-CM and ICD-10-PCS at the same time?

Rebills of pre-conversion, medical necessity software, scrubbers, ensuring all payers are ready to convert AND test with each payer = critical to the successful conversion.

P.S. Don’t forget all payers (Medicaid too!)

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Make a master list of all vendors who currently support any ICD-9 activity. (Think Y2K)

Look at all items /ordering tools where ICD-9 codes are present. Need reviewed and revised.◦ Lab requisitions◦Online ordering of services that also requests ICD-9

codes◦Physician super bills/encounter forms with pre-printed

ICD-9 codes◦Dept. specific ‘cheat sheets’ for covered dx. (Yep we

know you have them!)

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3M or other encoder Main frame /main IT system Radiology-doc billing, radiology’s

own system Clearing house/claims Hospital employed doctor’s

software for billing SNF/RUG software for grouper HH/HHRG software for grouper Lab – pathology doc billing, lab’s

own system Internal electronic medical record

used for coding Software used for Trauma &

Tumor Registry

Decision support Scheduling software All tied Medical Necessity

software in different areas – main frame, bolt on software, individual areas screening

Infection Control software Cardiology – EKG system Itemized statements with dx as

needed by the payer/pt Clinical quality reporting software Cheat sheets in each dept! OR software Occupational Med software

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What is ICD-10-CM What is ICD-10-CM and and

ICD-10-PCS?ICD-10-PCS?

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Department of Health and Human Services (HHS) mandated that HIPAA covered entities must update medical medical coding sets.coding sets.

Diagnosis Diagnosis code set changes from ICD-9-CMICD-9-CM to ICD-10-CMICD-10-CM. Hospital inpatientinpatient procedureprocedure code set changes from ICD-9-CMICD-9-CM (Volume 3) to ICD-10-PCSICD-10-PCS. No impact on CPT and/or HCPCS codes. Yeah!No impact on CPT and/or HCPCS codes. Yeah!

We will still report CPT codes for all outpatient We will still report CPT codes for all outpatient procedures/services & physician hospital visits to procedures/services & physician hospital visits to

Observation and Inpatients (E&Ms).Observation and Inpatients (E&Ms).

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ICD-10-CM (ICD-10-CM (DiagnosesDiagnoses))◦Will be used by allall hospitals, providers, clinics,

lab, radiology, psych, rehab, nursing homes, etc. ICD-10-PCS (ICD-10-PCS (ProceduresProcedures))◦Will be used onlyonly for hospital claims for inpatientinpatient

hospital procedures hospital procedures CPT/HCPCS – No change! CPT/HCPCS – No change! ◦Procedures for Hospital Outpatients, Physician

Visits, Lab and Radiology Outpatients, etc.

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Revised Date: Revised Date: October 1, 2015 October 1, 2015 Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures).

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CMS clarifies policy for processing split claims for hospital encounters that span the ICD-10 implementation date.◦ MLN (Medical Learning Network) Matters Number: SE1325MLN (Medical Learning Network) Matters Number: SE1325

Split ClaimsSplit Claims◦Require providers split the claim so all ICD-9 codes ICD-9 codes remain

on one claim with Date of Service (DOS) through SeptemberSeptember 30, 201530, 2015, and all ICD-10 codes ICD-10 codes placed on the other claim with DOS beginning October 1, 2015 and laterOctober 1, 2015 and later.

◦ Same guidance for Same guidance for InpatientInpatient and and Outpatient Outpatient encounters!encounters!

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Diagnosis CodingDiagnosis Coding(ICD-10-CM)(ICD-10-CM)

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ICD-9-CMICD-9-CM

◦ 3 - 53 - 5 digits or characters ◦ 1st character is numeric ornumeric or

alphaalpha (E or V codes) ◦ 22ndnd – 5 – 5thth characters are

numericnumeric◦ Decimal placed after the first

3 characters◦ 1717 Chapters and “V” & “E”

codes are ‘supplementalsupplemental’

◦ 14,00014,000 diagnosis codes

ICD-10-CMICD-10-CM

◦ 3 - 73 - 7 digits or characters◦ 1st character is alphaalpha (all

letters used except “U”)◦ 22ndnd – 7 – 7thth characters can be

alpha and/or numericalpha and/or numeric◦ Decimal placed after the first

3 characters (the same!)◦ 2121 Chapters and “V” & “E”

codes are ‘notnot’’ supplemental

◦ 69,000+69,000+ diagnosis codes

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X X XX X X X X XX X X XX

CategoryEtiology, anatomic site, severity

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Extension

Greater “specificity and detail” in all diagnosis codes!◦ But…is there supporting physician documentation in the But…is there supporting physician documentation in the

medical record?medical record? 34,250 (50%) of all ICD-10-CM codes are related to

the musculoskeletal system 17,045 (25%) of all ICD-10-CM codes are related to

fractures◦ 10,582 fracture codes will distinguish ‘right’ vs. ‘left’

25,00025,000 (36%) of all ICD-10-CM diagnosis codes will now distinguish right vs. left

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Combination codes for conditions and common symptoms or manifestations

E10.21 Type 1 diabetes mellitus withwith diabetic nephropathy Combination codes for poisonings and external

causes T42.4x5AA Adverse effect of benzodiazepines, initial encounterinitial encounter

Added laterality (left vs. right) M94.2111 Chrondromalacia, rightright shoulder

Added 7th character extensions for episode of care S06.01xAA Concussion with loss of consciousness of 30 minutes

or less, initial encounterinitial encounter

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AA Initial encounter

DD Subsequent encounter

SS Sequelae (disease progression)

Coders will need to look for the episode of care. Is this the patient’s 1st visit for treatment or is it for routine follow-up? Is it clearly documented in the medical record?

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Examples of “SubsequentSubsequent” care: Cast change or removal External or internal fixation removal Medication adjustment Follow-up visits following fracture

treatment For aftercare, the acute injury code acute injury code with the

7th character ‘D’, ‘E’, or ‘F’ is assigned.◦Do not assign the aftercare “Z” codes!

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Gustilo-AndersonGustilo-Anderson classification identifies the ‘severityseverity of soft tissue damageof soft tissue damage’ in openopen fractures – may be new to coders and physicians◦ Type IType I: Wound is smaller than 1 cm, clean, and generally

caused by a fracture fragment that pierces the skin (low energy injury)

◦ Type IIType II: Wound is longer than 1 cm, not contaminated, and w/o major soft tissue damage or defect (low energy injury)

◦ Type IIIType III: Wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.

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I10 Essential (primary) hypertension S01.02xxAA Laceration with foreign body of scalp, initialinitial

encounterencounter S01.02xxDD Laceration with foreign body of scalp,

subsequent encountersubsequent encounter S02.2xxxxAA Fracture of nasal bones, initial encounterinitial encounter for

closed fracture H65.011 Acute serous otitis media, rightright ear H65.022 Acute serous otitis media, leftleft ear H65.033 Acute serous otitis media, bilateralbilateral

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On any given day, anything can happen!On any given day, anything can happen!

W17.82xA Fall from (out of) grocery cart, initial encounter

V94.4xxA Injury to barefoot water-skier, initial encounter

W61.43xA Pecked by turkey, initial encounterY93.C2 Activity, handheld interactive electronic device, i.e., cellular phoneAre we querying the provider for this level of detail? Who wants it? The payer?Have internal discussions, contact payers, gather excellent data= Decide.

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CMS has created GEMs (General Equivalence Mappings) to assist hospitals with cross walking ICD-9-CM ►ICD-10-CM/PCS “forward mapping” & ICD-10-CM/PCS ◄ ICD-9-CM “backward mapping”. The correlation between the 2 code sets for some codes is fairly close, but not a straight correlation for others, i.e. OB, etc.

Not always 1 to 11 to 1 crosswalk from ICD-9-CM to ICD-10-CM (www.cms.gov/ICD10/11b15_2013_ICD10PCS.asp)

Available on CMS’s website

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ICD-9-CM Code Diagnosis ICD-10-CM CodeV20.2 Routine infant or child examination Z00.129 (Encounter for routine child exam without

abnormal findings). Z00.121 (Encounter for routine child exam with abnormal findings). “Use additional

code(s) to identify abnormal findings”.

250.00 DM w/o complications, type II or unspecified E11.9 (Type II DM without complications)

V04.81 Need for prophylactic vaccination and inoculation Z23 (Encounter for immunization). “At this time in ICD-10-CM there is only one code for

immunizations”.

401.1 Hypertension, benign I10 (Essential [primary] hypertension). “ICD-10-CM does not differentiate between hypertension that is controlled or uncontrolled, benign or malignant and

there is only one code”.

427.31 Atrial fibrillation I48.0 (Atrial fibrillation)I48.1 (Atrial flutter)

786.50 Chest pain, unspecified R07.0 (Chest pain, unspecified). “ICD-10-CM expands upon chest pain symptoms and

unspecified code may no longer be necessary”.

465.9 URI J06.9 (Acute upper respiratory infection, unspecified)

724.2 Lumbago M54.5 (Low back pain)

466.0 Bronchitis, acute J20.0 (Acute bronchitis, unspecified). “ICD-10-CM includes 10 choices for acute bronchitis”.

729.5 Limb pain M79.604 (Pain in right leg)

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We will still look up the diagnosis codes the same way as we do today. Yeah!#1 - Look up diagnostic terms in the Alphabetic Index…and then#2 - Verify the code number in the Tabular List

That’s it!That’s it!

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ICD-9-CM (Volume 3)ICD-9-CM (Volume 3) (ProceduresProcedures)

◦Min. characters: 33◦Max. characters: 44◦NumericNumeric format◦Decimal point◦ 3,0003,000 procedure codes

ICD-10-PCSICD-10-PCS (ProceduresProcedures)

◦Min. characters: 77◦Max. characters: 77◦ AlphanumericAlphanumeric format◦NoNo decimal point◦ 71,92071,920 procedure

codes

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Seven Character Alphanumeric Code◦AllAll procedure codes will be seven seven

characters long◦“II” and “OO” (letters) are never used

Can you guess why?Can you guess why? 34 possible values for each character◦Digits 0 – 9◦Letters A-H, J-N, P-Z

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Root

Section Operation Approach Qualifier

Body Body Device

System Part

1 2 3 4 5 6 7

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SectionSection: Identifies general type of procedure

Body SystemBody System: Identifies general body system

Root OperationRoot Operation: Specifies objective of procedure

Body PartBody Part: Identifies specific part of body system on which procedure is being

performed

ApproachApproach: Technique used to reach the site of the procedure

DeviceDevice: Identifies devices that remain after procedure is completed

QualifierQualifier: Provides additional information about a procedure, if necessary

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ICD-10-PCSICD-10-PCS codes are assigned based on the intent of operation intent of operation rather than the operation name operation name as in ICD-9-CMICD-9-CM.

Can be a big difference!Can be a big difference! Coders and CDI specialists will need to

review surgical reports to identify root operations and surgical approaches and to also understand various eponyms for high-volume procedures.

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44-year-old male patient is known to have diverticulitis of the colon and has noticed melena occasionally for the past week. The initial impression was acute bleeding from diverticulitis. Patient was scheduled for colonoscopy. Colonoscopy identified the cause of the bleeding to be angiodysplasia of the ascending colon.

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K55.21 Angiodysplasia of colon with hemorrhage (569.85)

K57.32 Diverticulitis of large intestine without perforation or abscess without

bleeding (562.11)

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0DJD8ZZ0DJD8ZZ Inspection of Lower Intestinal Tract, via Natural or

Artificial Opening Endoscopic (45.23)

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Patient with hypertension and COPD is admitted for bilateral inguinal hernia repair. H&P states that the left side is recurrent. The operative report states that the surgeon repaired a left direct and right indirect inguinal hernias with mesh, via open approach.

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K40.2 Bilateral inguinal hernia without obstruction or gangrene (550.92)

I10 Essential (primary) hypertension (401.9)

J44.9 Chronic obstructive pulmonary disease, unspecified (496)

Notice anything familiar to ICD-9-CM?Notice anything familiar to ICD-9-CM?

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0YUA0JZ0YUA0JZ Replacement of Bilateral Inguinal Region using Synthetic Substitute,

Open Approach (53.16)

◦Code options include 3 specific devicesdevices (6(6thth)) Autologous Tissue Substitute (7) Synthetic Substitute (JJ) Nonautologous Tissue Substitute (K)

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What Will ICD-10 Cost?What Will ICD-10 Cost?

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CMS estimates cost to the private sector for implementation of ICD-10 will exceed $130 million.

Hay Group White Paper in 2006 estimated cost for hospitals ranged from $35K - $150K for < 100 beds, to $500K to $2 million for 400+ beds.

AAPC indicates current documentation = 50% could be coded.

AHIMA indicates after ICD-10 coders will be 50% slower for up to 3 months ++ 50% more physician queries.

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Potential Hidden CostsPotential Hidden Costs

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Back log of uncoded claims with ICD-9 while trying to get coders ready for ICD-10. Remote/outsourced coding may need to occur as well as OT.

Rejected claims from payers who are not ready to accept UB-04 with ICD-10 PLUSPLUS ICD-9 as necessary.

Vendor software rejecting ICD-10 or edits not working correctly thus slowing claim submission. Manual intervention to ensure claims are submitted and accepted.

New software if existing software for related ICD-10 work is not compatible.

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Cost to conduct a ‘risk assessment‘risk assessment’ to assess current documentation patterns for providers and care givers.

Potential salary adjustments for the coders. Cost to conduct training for providers and care givers on

enhanced documentation. Cost to review EMR or other software to adapt to

enhanced documentation requirements. Cost to conduct a ‘readiness assessment’readiness assessment’ pre go live to

determine readiness of coders, documentation and vendors.

Cost of moving ‘related’ work from the coders during training period, i.e., drug administration/charge capture.

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Loss of productivity – rebills, denials, rejections, EOB work, medical necessity rejections/follow-up (PFS+)

Loss of productivity – excessive physician queries, coder slow down with new coding process (HIM)

Growth in the discharged not final billed (DNFB)… Potential impact to the Case Mix Index Cost of a project manager (1 yr. contract staff to coordinate all the

IT, testing, training, documentation assessments) Cost of implementing a Clinical Documentation Improvement (CDI)

program Cost of EMR changes and training of all impacted staff Cost of any changes to the functionality of the any software and

training costs

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TypeType ICD 9/minutesICD 9/minutes ICD 10/minutesICD 10/minutes

Inpt acute care 8.99 15.99

Outpt acute care 4.18 9.03

Physician practice 3.04 6.70

Free standing ASC 2.27 4.82

Nursing/SNF 6.71 12.98

Rehab facility 4.97 10.94

Additional time projected by CMS

2 minutes additional for each encounter

30% estimated loss in productivity

Mentorship program /formal 30% less productive – alternatives? Back fill with remote coding Explore Computer Assisted Coding –uses

natural language processing, cost analysis◦Outpt ancillary –high potential usage (MN screening)◦Other outpt areas – depending on how well the

provider is documenting new elements of ICD 10. (Queries)

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AHIMA estimates approximately 1616 hours of coding training is needed for outpatient coders outpatient coders and 5050 hours for inpatient codersinpatient coders.

Additional time may be needed to refresh anatomy & physiology (A&P) fundamentals.

Learn foundational knowledge before more intensive training.

Allow time for practice, practice, practice (key!) Down time during training and practice time. And don’t forget the NON-HIM training needs.

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The time is NOWNOW, if you have not already started! Plan weekly, monthly, and yearly implementation

goals. Assess impact on your organization, systems,

processes, staff and productivity. Start your ICD-10 training by assessing your

coders’ preparedness.

◦Test coding staff on basic anatomy & physiology◦Quizzes – identifies areas in which further training may

be needed◦Start early and conduct ongoing assessments so that

all of your coders will be ready

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Communicate to leadership, managers & staff Create & maintain organizational awareness Create ICD-10 Planning or Implementation

Committee Assess organizational impact for: billing, billing, EMREMR,

system vendors, physician educationphysician education for coding & documentation, coderscoders, billers, reimbursement analysts, compliance, business operations, financefinance (budget, reimbursement, cash flow), managed care contracts, data, reports.

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Physician DocumentationPhysician Documentation

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1.1. Laterality (left vs. right) 25,000+ codes!Laterality (left vs. right) 25,000+ codes!

2.2. Stage of Care (initial, subsequent & sequelae)Stage of Care (initial, subsequent & sequelae)

3.3. Specific Diagnosis (acute vs. chronic)Specific Diagnosis (acute vs. chronic)

4.4. Specific Anatomy (specific bone in the hand)Specific Anatomy (specific bone in the hand)

5.5. Associated and/or Related ConditionsAssociated and/or Related Conditions

6.6. Cause of Injury (hit by baseball, fall)Cause of Injury (hit by baseball, fall)

7.7. Documentation of Additional Symptoms or ConditionsDocumentation of Additional Symptoms or Conditions

8.8. Dominant vs. Non-Dominant SideDominant vs. Non-Dominant Side

9.9. Tobacco Exposure or UseTobacco Exposure or Use

10.10. Gustilo-Anderson ScaleGustilo-Anderson Scale

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LateralityLaterality!! left vs. right vs. bilateralFor bilateral sites, the final character of the codes in ICD-10-CM indicate laterality.Right side is always character 11 (RTRT)Left side is always character 22 (LTLT)Bilateral code is always character 33 (RTRT & LTLT) But wait! Not all codes will have a ‘bilateral’ distinction, i.e., carpal tunnel, etc.“Unspecified” side code is also provided should the side not be documented in the medical record.

Did we just lose our specificity?Did we just lose our specificity?

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Joint pain Joint effusion Injury Fractures Start working with your physicians

Dislocations now to get them in the habit of

Arthritis documenting laterality!

Cerebral infarction Extremity atherosclerosis Pressure ulcers Cancers, neoplasms (breast, lung, bones, etc.)

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“Additional Code” will be captured related to tobacco tobacco exposure and useexposure and use◦Exposure to environmental tobacco smoke◦Exposure to tobacco smoke in the perinatal period◦History of tobacco use

Persistent Asthma◦ 3 levels of severity:

MildMild persistent – more than two times per week ModerateModerate persistent – daily and may restrict physical activity SevereSevere persistent – throughout the day with frequent severe

attacks limiting the ability to breathe

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Diabetes mellitus codes are expanded to include the classification of the diabetesclassification of the diabetes andand the manifestationmanifestation by using 4th or 5th characters. ◦Moving from 1 category of “250” ► 5 categories in ICD-10!◦ ICD-9-CM = 59 diagnosis codes ◦ ICD-10-CM = 200+ diagnosis codes!200+ diagnosis codes!

Whether or not diabetes is stated as ‘controlled’ or ‘uncontrolled’ is notnot a factor in ICD-10.

E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E11.41 Type 2 diabetes with diabetic mononeuropathy E09.52 Drug or chemical induced diabetes mellitus with

diabetic peripheral angiopathy with gangrene

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ICD-10-CM in the Tabular List states:◦ I10I10 Essential (primary) hypertension◦ Includes: High blood pressure◦Hypertension (arterial) (benignbenign) (essential) (malignantmalignant) (primary)

(systemic)◦Excludes1: Hypertensive disease complicating pregnancy,

childbirth and the puerperium ◦Excludes2: Essential (primary) hypertension involving

vessels of brain, essential (primary) hypertension involving vessels of eye

No longer matters whether hypertension is malignant No longer matters whether hypertension is malignant or benign in ICD-10-CM!or benign in ICD-10-CM!

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ICD-10-CM contains a separate category (F17) for nicotine dependence with further subcategories to identify the specific tobacco productspecific tobacco product and nicotine induced disorder. Some examples:

Cigarettes Chewing tobacco Cigar, etc.

ICD-9 has only one diagnosis code 305.1!305.1!

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Finally! ICD-10-CM neoplasm codes can provide information on whether a neoplasm occurred in a right-sidedright-sided or left-sidedleft-sided body part.

ButBut…we need to have this documented by the doc in the medical record. Is it?

Includes a tabular list and an alphabetic index just like in ICD-9-CM.

ICD-10-CM neoplasm guidelines are very similar to those found in ICD-9-CM. However, there are a few variations! Anemia is one!

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Burn codes identify: ◦Thermal burns, except for sunburns, that

come from a heat source. Also burns resulting from electricity and/or radiation.

Addition of the term “corrosioncorrosion” is new in ICD-10-CM.◦Corrosions are burns due to due to chemicals.

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““UnderdosingUnderdosing” will be a new term in ICD-10-CM and is defined as taking less taking less of a medication that is prescribed by a physician and/or manufacturer’s instructions with a resulting negative health consequence. Financial Reasons (#1) Patient Non-Compliance

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It is anticipated that you will see a significant increaseincrease in the # of physician queries that will be generated from ICD-10.

Existing coding queries will most likely have to be “updated” as you will be asking for different documentation to capture “specificity”.

Make sure they are not ‘leading’ the physician to document one way or another!

Consider making the query part of the permanent medical record (physician addendum).

Track and trend for patterns and then do more education!

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Think concurrent inpatient coding. Immediate interaction with the provider and other

caregivers on weak or incomplete documentation. Have coders on the floor with the care team. Back

office coding results in ‘chasing’ the provider = delay in coding = delay in cash.

Expand the CDI team…to include both UR needs/severity of illness & intensity of service PLUS specificity/laterality/ and other unique.

ICD-10 needs as identified thru queries and risk audits.

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What’s Next?What’s Next?

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WhenWhen? By late 2012 (Already done, right?) WhoWho? Key leaders in the revenue cycle/IT and HIM. Will a

designated project leader need identified? WhatWhat? Create master list of all revenue cycle areas, IT, HIM

and physician issues HowHow? Identify timelines for when components will be done,

who does it, results reviewed, testing, with ownership and timelines for completion

Key benchmarks for completion done beginning 1st Q 2015 or once final go live date is established

After go live, complete a 2nd set of benchmark assessments with barriers, delays, more education, etc.

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Phase 1: Goal: 1st Q 2014 Awareness training of leadership Awareness training of coders –

inpt/all others/providers Conduct a risk assessment risk assessment of

current documentation patterns Track and trend ALL queries for a

defined period of time Using the query, develop provider

education –with structured rollout time frames

Develop master list of impact areas – coders, PFS, IT, providers, etc.

Develop structured coder education –based on type of pt.

Phase 2: End of 2014 and after to live

Conduct a readiness assessment readiness assessment – audit of documentation, testing of coders/per pt type, review of all IT functions, new forms, software testing, payer, contracting, etc.

Coding comparison for case mix impact, MS-DRG

Aggressively code all pending ICD-9 accounts prior to Oct. 2015

Remote/outsourced coding before/during transition and training needed

Contract coding company should have a ‘preparedness plan’

Contract ICD-10 program manager or dedicated staff (Think Y2K)

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Make a master list of all software where ICD-9 is being used. This will be essential to the seamless implementation of ICD-10 (or less anguish).

Contact each vendor NOW to identify their roll out plan for compliance and when they will be ready to test.

Test with each vendor early in 2015 or as soon as they are available for testing.

Keep Sr. Leadership well aware of the status of ALL software testing and compliance. Be prepared to make changes if compliance is not achieved with testing 9 months prior to go live.

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Documentation Audits◦CDI (Clinical Documentation Improvement) department can

start now conducting ICD-10 documentation audits this year – risk assessments of current documentation practices.

◦Audit top 25 ICD-9-CM principal diagnosis codes and map to ICD-10-CM codes and begin auditing to determine whether the records contain the necessary clinicalclinical information to support the ICD-10-CM principal diagnosis code.

Coding Audits◦ Target certain inpatient cases for review based on the MS-

DRG assignment or the CC’s because both of these IP PPS components will undergo changes when reconfigured with the ICD-10-CM codes.

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Possible decrease in cash flow due to:◦Increase in time to code medical records◦Learning curves, potential increase in errors◦Decreased coder productivity, when, or will it

recover◦System, vendor or software issues◦Potential reimbursement impact due to payer

systems, claim edits or processing issues◦Expect denials and underpayments

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Defense for 2015 Defense for 2015

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It’s never too late to start! Provide adequate system and coding resources for

go live:◦Will you need additional coding support? Need contracted

coders? Who will handle the coding of ‘prior to’ accounts vs. ‘go live’ accounts? Possible concurrent coding?

Post go live auditing & monitoring of:◦Coding & Documentation coding queries!◦Systems, data, reports◦Claims (UB & 1500), payments, denials

Audit and then more auditing from a RISK to a READINESS environment… Remember, we are ALL in this together!Remember, we are ALL in this together!

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That’s ICD-10!That’s ICD-10!

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www.ahima.org/icd10

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp

www.cms.gov/ICD10

www.who.int/classifications/icd/en

www.cms.gov/ICD10/Te110/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=1&sortOrder=descending&itemID=cms1246998&intNumPerPage=10• CMS Sponsored Teleconference “Case Study in Translating Lab

NCD” (5-18-11) PowerPoint slides #23 & #24

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THANKS A TON! THANKS A TON!

Day Egusquiza, PresidentAR Systems, Inc

daylee1@mindspring.comdaylee1@mindspring.com (208) 423-9036(208) 423-9036

www.arsystemsdayegusquiza.comwww.arsystemsdayegusquiza.com

Karen Kvarfordt, RHIA, CCS-P, CCDSAHIMA Certified ICD-10 TrainerPresident, DiagnosisPlus, Inc.

diagnosisplus1@live.comdiagnosisplus1@live.com

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