ICD-10 IMPLEMENTATION ANALYSIS

~BYJessie Joseph

Jyoshna KolisettyRanveer Tula

Sai Sandeep BoyapatiShruthi Gajjala

Introduction Limitation of ICD-9 & Benefits of ICD-10 Comparing ICD 9 and ICD 10 Assessment Phase:

◦ Business Assessment◦ Scenario based vendor assessment

Implementation Phase Testing Phase Conclusions

Project Outline

Introduction

Limitations & Benefits

Implementation Testing Phase

Comparison Study

Conclusion

Introduction to ICD International classification of diseases (ICD) is a standard

diagnostic tool Monitor the incidence and prevalence of diseases and other

health problems. The ICD is revised periodically and is currently in its tenth

revision. ICD is used for reimbursement and resource allocation

decision-making by countries. The code set allows more than 14,400 different codes and

permits the tracking of many new diagnoses.

ICD-10 expands the diagnosis coding an directory, adding increased specificity and detail, which is important to gaining a better understanding of a diagnosis and determining the proper course of treatment.

As the ICD-10 codes become more specific, they also become more complex.

With the increased specificity of ICD-10, codes can be up to seven digits

ICD-9 Code set is no longer maintained by the WHO

The USA is the only developed nation still using ICD-9 All other G-7 nations have transitioned to ICD-10

As of 2002,99 countries have adopted IC-10 or a clinical modification for coding and

reporting morbidity data

As of 2002,138 countries have adopted ICD-10 for coding and

reporting mortality data

ICD-10 Global Perspective

ICD 10 CM/PCS ICD-10-CM/PCS is a diagnosis classification system

developed by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), for coding and reporting in the healthcare environment of the United States.

It consists of two parts:1. ICD-10-CM was developed by the Centers for Disease

Control and Prevention for use in all United States of America health care treatment settings

2. ICD-10-PCS was developed by CMS for use in the U.S. for inpatient hospital settings ONLY

Stakeholders ICD-9 ICD-10

Healthcare executives:CEO,CFO,CIO, CMOCMIO,CNO

Awareness that billing and coding process exist

• Become informed about the changes required for successful ICD-10 adaption

• Communicate the clinical values to the leader

• Influence external stakeholders

Providers • Document care• Assign community used

codes (Physician Offices)

• Commit to increased specialty in clinical documentation

• Accept responsibility for front end coding process

Coders • Assignment of ICD-9 Codes

• Extrapolation from various levels of documentation

• Learn the advanced anatomy

• Learn new code structure

• Commit to accuracy

Icd-9 has several limitations that prevent complete and precise coding and billing of health conditions and treatments, including:

The 30-year-old code set contains outdated terminology and is inconsistent with current medical practice.

Coding may be incomplete if patient records include a limited number of diagnosis codes. For example, the Utah Department of Health Hospital Discharge Database (HDD) captures up to nine diagnosis codes. However, some Utah hospitals record more than nine diagnosis codes.

The HDD includes only the first nine diagnosis codes for these records. ß only conditions that physicians document in patient charts can be coded

The codes themselves lack specificity and detail to support the following:

Accurate anatomical descriptions Differentiation of risk and severity Key parameters to differentiate disease manifestations Optimal claim reimbursement Value-based purchasing methodologies ICD 9 CM codes do not indicate degree of harm

to the patient. ß ICD 9 CM codes do not capture near misses.

Caution should be used when making comparisons among facilities due to coding variation.

Currently, ICD 9 CM codes usually are assigned after the patient is discharged from the hospital. Hence, ICD 9 CM codes provide retrospective, not real-time, patient information 

The lack of detail limits the ability of payers and others to analyze information such as health care utilization, costs and outcomes, resource use and allocation, and performance measurement.

The codes do not provide the level of detail necessary to further streamline automated claim processing, which would result in fewer payer-physician inquiries and potential claim payment delays or denials

ICD-9 has approximately 14,000 codes and ICD-10 has 68000 codes.

New code format allows addition of future codes in appropriate category and location

Updated terminology and disease classification Determine severity of illness and prove medical necessity Grow compensation and reimbursement. Address technology and healthcare reform initiatives Ensure your strong reputation Reduce the hassle of audits

How can you, your practice and your patients benefit from ICD-10?

Determine severity of illness and prove medical necessity

Grow compensation and reimbursement. Address technology and healthcare reform initiatives Ensure your strong reputation Reduce the hassle of audits Improve care

Prevention of fraud and abuse. Improved tracking of public health and risk. Enhanced and more specific coding to categorize

anatomic site, etiology and severity of disease. More detailed data will allow for improved analysis of

disease pattern and the tracking and responding to public health outbreaks.

ICD-9-CM ICD-10-CM

Billable Codes 14,567 69,823

Chapters 19 21

Code Length (excl.period)

3-5 Characters 3-7 Characters

First Character E, V,or 0-9 A-z, Excel U

Other Characters Numeric See Above

Ability to add new codes

Very Limited Unrestricted

Ability to provide detail

Limited Unrestricted

ICD Version Comparison At-A-Glance

Comparing ICD-9-CM & ICD-10-CMICD-10-CM differs from ICD-9-CM in its organization and structure, code composition, and level of detail.

ICD-9-CM ICD-10-CM Consists of three to five characters First digit is numeric or alpha (E or V) Second, third, fourth, and fifth digits are numeric Always at least three digits Decimal placed after the first three characters

Consists of three to seven characters First digit is alpha All letters are used except for U Second and third digits are numeric Fourth, fifth, sixth, and seventh digit can be alpha or

numeric Decimal placed after the first three characters

Code Structure of the ICD-10-CM versus ICD-9-CMICD-10-CM codes may consist of up to seven digits, with the seventh digit extensions representing visit encounter or sequelae for injuries and external causes.

ICD-9-CM Format ICD-10-CM FormatX X X . X X

First three digits represents the category Fourth and fifth digit represents etiology, anatomic

site, manifestation

X X X . X X X X First three digits represents the category Fourth, fifth, and sixth digit represents etiology,

anatomic site, severity Seventh digit represents the extension

Scenario Based Vendor Assessment

Implementation Process

Why?1. Adopt new technology2. Change existing workflow3. Reform care delivery

Steps in implementation:1.Make a Plan Assign target dates for completing steps outlined

here Obtain access to ICD-10 codes. The codes are

available from many sources and in many formats

Implementation phase

Decide role(s) your clearinghouse(s) will play in your transition. Some providers who

are not ready could benefit from contracting with a clearinghouse to submit claims

For ICD-10, clearinghouses can help by: 1.Identifying problems that lead to claims

being rejected 2.Providing guidance about how to fix a

rejected claim (e.g., the provider needs to include more or different data)

Implementation of icd10

Clearinghouses cannot help you code in ICD-10 unless they offer third-party billing/ coding services .2.Train Your Staff ̈ Train staff on ICD-10 fundamentals using the

wealth of free resources from CMS, which include the ICD-10 website Road to 10, Email Updates, National Provider Calls, and webinars.

Free resources are also available from: Medical societies, health care professional associations.

Implementation of icd10

3.Update Your Processes Update hard-copy and electronic forms

(e.g., super bills, CMS 1500 forms)̈ Resolve any documentation gaps identified

while coding top diagnoses in ICD-10 Make sure clinical documentation captures

key new coding concepts:Laterality—or left versus right Initial or subsequent encounter for injuries Trimester of pregnancy

Implementation of icd 10

4.Talk to Your Vendors and Health Plans Call your vendors to confirm the ICD-10

readiness of your practice’s systems Confirm that the health plans,

clearinghouses, and third-party billing services you work with are ICD-10 ready

Ask vendors, health plans, clearinghouses, and third-party billers about testing opportunities

Implementation of icd 10

5.Test Your Systems and Processes : Verify that you can use your ICD-10-ready

systems to: Generate a claim Perform eligibility and benefits verification Schedule an office visit Schedule an outpatient procedure Test your systems with partners like vendors,

clearinghouses, billing services, and health plans; focus on those partners that you work with most often.

Implementation of icd 10

Testing Phase

Error Testing

Internal Testing

External Testing

The Process of proving that a system or process meets requirements and produces consistent and correct results.

It is critical to successful implementation of ICD-10

Testing will ensure ICD -10 compliance across internal policies, processes and systems as well as external trading partners and vendors.

Testing Phase

Unit Testing: Confirms that updates meet the requirements of each individual component in a system.

System Testing: Verifies the integrated system meets requirements for the ICD-10 transition

Regression Testing: Test modified system components to ensure that ICD-10 changes do not cause faults in other system functionality.

Testing Types:

Test plan implications: Test plan to document the strategy and verify that the business process system meet future design specification

Test case implications: Test cases to ensure the system update meets the business requirements

Test Data Implications: use sample data to validate the process errors, trigger and generate a standard environmental model over time.

All testing will result in errors. Correcting the errors before they go live is the main objective for the error testing module

Methods used to resolve the issues are◦ Multiple testing layers to support various

iterations of re-testing in parallel tracks◦ An error tracking system will standard alerts to

report to stakeholders.◦ Developing a schedule for fixing known issues in

the future.

Error Testing

Internal Testing basically concentrate on the significant architectural and system logic changes and focus on testing key business risks.

Evaluating each technical area as well as integration testing across components◦ DB architecture◦ User interface◦ Algorithms

Internal Testing

Error testing is performed by creating a inventory of external entities with whom the datas are exchange and based on that scenario has to generated to preform testing◦ Payers◦ Hospitals◦ Health information exchange◦ Outsourced billing or coding◦ Government entties

External testing

ICD-10 cm and ICD-10pcs must be adopted as soon as possible to reverse the trend of deteriorating health data.

ICD-9 cm code set no longer fits with the needs of the 21st century healthcare system.

Never in US history we used the same version of ICD for 35 years Any changes to do in healthcare industry cost money and ICD-10

is not exception. Benefits: ICD -10 will improve national healthcare initiatives such

as meaningful use, value base purchasing, payment reform and quality reporting.

Without ICD-10 data, there will be serious gaps in the ability to extract important patient health information

It helps to support the public health reporting and move to a payment system based on quality and outcomes.

Conclusion

Higher quality information for measuring healthcare service quality safety and efficiency

Greater coding accuracy and specificity Recognition of advances in clinical practice and technology. Improved ability to measure outcomes, efficacy and costs of new medical

technology Improved ability to track and respond to public health threats Reduced opportunities for fraud and improves fraud detection capabilities Global healthcare data comparability space to accommodate future code

expansion Reduced need for manual review of health records to perform research and

data mining and adjudicate reimbursement claims

Value of ICD-10

REFERENCES International Classification of Diseases, (2005). Centers for Disease

Control and Prevention (CDC). Retrieved from http://www.cdc.gov/nchs/data/dvs/icd10fct.pdf

ICD 10 CM code search, (2014). ICD-10-CM database edition. Retrieved from http://icd10cmcode.com/abouticd10.php

International classification of diseases (ICD), 2016. world health organization (WHO). Retrieved from http://www.who.int/classifications/icd/en/

ICD-10 implementation guide for large practices. Centers for Medicare and Medicaid services. Retrieved from www.CMS.gov/ICD10

http://www.bcbsm.com/content/dam/public/Providers/Documents/help/faqs/icd10-update-mentalhealth.pdf

Thank you!!!