NEWCODINGRULES$FOR$ADDICTIONS:THE$ ICD10

NEW CODING RULES FOR ADDICTIONS: THE ICD-‐10/DSM-‐5 AND PROTECTING YOUR ORGANIZATION THROUGH TRANSITION Prepared exclusively for: MAARCH 2014 Annual Conference, St. Paul, MN Behavioral Health Solu/ons, P.A. LiseQe Wright, ExecuTve Director Procen/ve Pat Stream, Customer Success Manager October 29, 2014

© 2014 by LiseQe Wright All Rights Reserved

Agenda • IntroducTon to the ICD System • Understanding ICD/DSM ApplicaTons • Coding and DocumentaTon ImplicaTons • ICD-‐10 OrganizaTonal Readiness: Business Process and Systems Inventory • Payers and TesTng Processes • Risk MiTgaTon Strategies • Staff Training Needs

2 © 2014 by LiseQe Wright All Rights Reserved

Our New ICD-‐10 System: Major Changes

•  1990 World Health OrganizaTon (WHO): “is the standard diagnos.c tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situa.on of popula.on groups. It is used to monitor the incidence and prevalence of diseases and other health problems.” • Massive change from the ICD-‐9 to ICD-‐10 •  Increased specificity: New medical condiTons, treatments, and devices • Naming and Coding System that is more accurate

3 © 2014 by Lisette Wright All Rights Reserved

PosiTve Features of the ICD-‐10 • More Substance Use codes •  BeQer descripTons of condiTons •  Enables us to document more accurately, conTnuity of care • Will allow for geneTc condiTons and other applicable condiTons to our work • Helps us understand the encounter beQer, i.e.: iniTal, subsequent or sequelae (late effects)

•  StandardizaTon, research and development, staTsTcs •  BeQer for IntegraTve care models, co-‐occurring condiTons


What We Have Known Where We Must Go

• DSM-‐IV-‐TR/ICD-‐9 • Aligned

• Example: • MDD, Recurrent Moderate

296.32 • May have known: ICD-‐9

296.32

•  ICD-‐10/DSM-‐5 • Not aligned • Discrepancies with: •  Numbers of diagnoses •  Language •  DocumentaTon •  Payer Requirements •  DiagnosTc Criteria WriQen Policy and Procedure’s will need to be updated as a result


ICD-‐9 Versus ICD-‐10: Details ICD-‐9 CM (1975) ICD-‐10 CM (1990’s; US=2014)

14,000 codes Cannot keep up with medical discovery, knowledge, and treatments No longer supported by WHO

68,000 codes Fundamental overhaul increasing digits, codes, alpha-‐numeric, improved granularity WHO supported

3-‐5 digits Limited CombinaTon Codes 2 Volumes, 17 Chapters

3-‐7 digits Extensive CombinaTon Codes (thus digit expansion) 3 Volumes, 21 Chapters Chapter 5: Mental and Behavioral Disorders

Expansion is limited or full Room to expand without future overhauls (placeholders = “x” for 6th and 7th digits)

Not descripTve enough Significantly more specific and will accommodate future health care needs


“What About The DSM?”

Many people are not aware they were “using” ICD-‐9 codes for Claims

ICD not taught in our graduate schools

Errors in the DSM-‐5 are numerous (A. Frances)

DSM 5 aQempts to align with ICD-‐10, but it is not exactly aligned

We Will Need BOTH Manuals


ICD-‐10 Format: “Funny-‐Looking”

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•  Chapter “F” = Chapter 5 in ICD-‐10 •  “10” Category = drug of choice or condiTon i.e.: alcohol •  Last 4 digits represent the clinical state: eTology, severity, manifestaTon, and placeholders • Note: Some T, Y, N, K, J, R, and other codes are applicable to us and are required for us to document

F 1 0 Digit 6 Digit 4 Digit 5 Digit 7

© 2014 by Lisette Wright All Rights Reserved

Expanded Diagnoses Examples in DSM-‐5 and ICD-‐10 •  Substance Use codes contain the most expansion •  DSM-‐IV-‐TR has 9 diagnoses involving Cannabis •  DSM-‐5 has 22 diagnoses involving Cannabis •  ICD-‐10 has 44 diagnoses involving Cannabis

•  BiPolar ‘s, Schizophrenia/PsychoTc, and Anxiety SecTons are very different between the DSM-‐5 and ICD-‐10 • Many more Major Depressive diagnoses in the ICD-‐10 than in the DSM-‐5


ICD-‐9 To ICD-‐10 Specificity Example: The “One-‐To-‐Many” Concept

291.3 Alcohol-‐Induced Psycho/c Disorder with Hallucina/ons

F10.151 Alcohol Abuse with Alcohol-‐Induced Psycho/c Disorder with Hallucina/ons

F10.251 Alcohol dependence with alcohol-‐induced psychoTc disorder with hallucinaTons

F10.951 Alcohol Use, unspecified with alcohol-‐induced psychoTc disorder with hallucinaTons


There Are More ICD-‐10 Codes than DSM-‐5 Codes

DSM-‐5 ICD-‐10 F51.5 Nightmare Disorder F51.5 Nightmare Disorder

F51.8 Other sleep disorders not due to a substance or known physiological condiTon

F51.05 Insomnia due to other mental condiTon

F51.01 Insomnia Disorder F51.01 Primary Insomnia

F51.13 Hypersomnia due to other mental condiTon

F51.19 Other hypersomnia not due to a substance or known physiological condiTon


CMS on DSM-‐5 and ICD-‐10 •  “In current prac/ce by the mental health field, many clinicians use the DSM-‐IV in diagnosing mental disorders. As of May 19, 2013, the DSM-‐5 was released. Can these clinicians con/nue current prac/ce and use the DSM-‐IV and DSM-‐5 diagnos/c criteria?”

•  Yes. The Introductory material to the DSM-‐IV and DSM-‐5 code set indicates that the DSM-‐IV and DSM-‐5 are “ compaTble” with the ICD-‐9-‐CM diagnosis codes. The updated DSM-‐5 codes are cross walked to both ICD-‐9-‐CM and ICD-‐10-‐CM. As of October 1, 2014, the ICD-‐10-‐CM code set is the HIPAA adopted standard and required for reporTng diagnosis for dates of service on and aper October 1, 2014.

•  Neither the DSM-‐IV nor DSM-‐5 is a HIPAA adopted code set and may not be used in HIPAA standard transacTons. It is expected that clinicians may con/nue to base their diagnos/c decisions on the DSM-‐IV/DSM-‐5 criteria, and, if so, to crosswalk those decisions to the appropriate ICD-‐9-‐CM and, as of October 1, 2014, ICD-‐10 CM codes. In addi/on, it is s/ll perfectly permissible for providers and others to use the DSM-‐IV and DSM-‐5 codes, descriptors and diagnos/c criteria for other purposes, including medical records, quality assessment, medical review, consulta/on and pa/ent communica/ons.

•  Dates when the DSM-‐IV may no longer be used by mental health providers will be determined by the maintainer of the DSM-‐IV/DSM-‐5 code set, the American Psychiatric AssociaTon, hQp://www.dsm5.org

© 2014 by LiseQe Wright All Rights Reserved 12

Understanding ICD-‐10 Coding Rules •  Foreign to most clinicians •  Always been in existence, and BH/SU have goQen off “easy” •  HealthCare Reform and HIPAA commands we are more specific •  Our job is to know what the rules are, then decide how to proceed


“But I Don’t Wanna Give Up My NOS!!!”


A Word About Coding: Yes, It Is HIPAA-‐Mandated!

• Most do not have cerTfied coders •  There are official guidelines and requirements around what you can document or NOT document when it comes to the ICD-‐10 and DSM-‐5 • Gesng clinicians to ship out of NOS mode will be hard • We can, and should, now document and code for co-‐morbid medical condiTons •  Required now to code for IntenTonal Self-‐Harm and/or Self-‐Poisoning

While NOS is even more appealing now, Auditors will be on the look-‐out, and so should you!

© 2014 by Lisette Wright All Rights Reserved 15

Understanding the Official PublicaTons We Will/Should Use Moving Forward 1.  DSM-‐5 2.  ICD-‐10 CM Codes: •  Various sources will have these (EHR, cheat sheets, another lisTng) •  ICD-‐10 CM codes are sancToned and governed by the US

3.  ICD-‐10 CM Tabular Index (2015 already published) •  The document that lists, numerically, all the diagnoses in the ICD-‐10-‐CM •  Typically used by Coding offices

4.  ICD-‐10-‐CM Official Coding Guidelines (annual): •  The rules that tell us exactly how to document to support the diagnosis •  Covertly endorsed by APA (p.23 in DSM-‐5)

5.  ICD-‐10 ClassificaTon of Mental and Behavioral Disorders: Clinical DescripTons and DiagnosTc Guidelines (aka “Blue Book”)


2014 ICD-‐10 CM Official Coding Guidelines

•  Published by: CMS and NaTonal Center for Health StaTsTcs (NCHS) •  Approved by: American Hospital AssociaTon, AHIMA, CMS, and NCHS

•  “These guidelines are a set of rules that have been developed to accompany and compliment…ICD-‐10-‐CM itself….These guidelines are based on the coding and sequencing….Adherence to these guidelines when assigning ICD-‐10CM diagnosis codes is required under HIPAA.”


Level of Detail in Coding and CharTng • Diagnosis codes are to be used and reported at their highest number of characters available •  Example: If a condiTon has 6 digits, then use all 6 digits AND document to account for all 6 aspects of the condiTon

•  A three-‐character code is to be used only if it is not further subdivided •  Example: Do NOT use just F10. Alcohol ______? What?

•  A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable


And… What About Those New DSM-‐5 Codes?

• DisrupTve Mood DysregulaTon Disorder: not listed in either ICD-‐9 or ICD-‐10

•  “Exact” mapping for this DO is not available as a result •  Closest applicable ICD-‐10CM code would be: •  F34.8: Mood Disorder, Other Specified

q How will your clinicians handle this? q What will the insurer pay for? What’s in your payer contract? q How will this be documented? q Can you standardize documentaTon and how?


Upcoming DiagnosTc & Coding Problems

MANY more diagnoses to choose in ICD-‐10

More details and specificity in

documentaTon

Clinicians must know the charTng/coding and documentaTon

rules

The standard has been raised to become more

aligned with the medical industry

Impacts Revenue Cycle: covered/not

diagnoses, documentaTon

Some payers sTll want DSM for PA’s


Nuances, Timelines, and Confusion • Do not underesTmate the subtle, and overt, differences between the ICD-‐10 and the DSM-‐5 •  Know who wants what in terms of clinical documentaTon, diagnoses, and their Tmelines • UTlizaTon of 3 possible code-‐sets at any given Tme •  This will be a major cultural ship in the following processes: •  How clinicians diagnose and document •  The level of specificity to which clinicians will have to document •  Moving away from the NOS categories •  Having to flip through the manuals (likely not done in years) •  HandwriTng/coder improvements


A Word of CauTon…..

Don’t rely on Internet/Google to covert codes

Comparing ICD’s to each other is do-‐able; comparing DSM’s is also do-‐able

Cross-‐comparing the DSM to ICD is much more challenging and not advisable

If possible, you may end up choosing just to operate out of the ICD-‐10 (pro’s/con’s to this decision)


Crosswalk’s: VarieTes •  The APA’s produce their Frequently Used Codes •  AMA has “Reference Tables” • OrganizaTons can produce their own •  CMS/CDC produces GEMS: General Equivalent Mappings: A “sort-‐of” code-‐to-‐code translaTon (no direct path/crosswalk) Ø 18% of codes have mulTple choices in the other code set!

KEEP IN MIND: NO ONE TO ONE CODE MATCH IS POSSIBLE SO CLINICAL JUDGEMENT, SPECIFICITY, AND DOCUMENTATION ARE CRITICAL!



Coding & DocumentaTon ConsideraTons Teach the Coding and DocumentaTon Requirements: THESE ARE VERY SPECIFIC IN THE SU CATEGORY

Know What ConsTtutes Medical Necessity

UTlizaTon of the golden thread: assessment, diagnosis, treatment plan (TP will support medical necessity)

Revise all documents, protocols, assessments, ongoing notes

Strongly consider collaboraTve documentaTon processes


ICD-‐10 Nuances •  “High on drugs” consTtutes Poisoning •  T40.5x1A: Poisoning by cocaine, accidental (unintenTonal), iniTal encounter

•  Then document for the underlying issue: •  F14.151: Cocaine abuse with cocaine-‐induced psychoTc disorder with hallucinaTons

•  Self-‐Injury, Self-‐Poisoning • Medical CondiTons •  Diabetes •  Asthma •  High Blood Pressure •  Others…..


Examples of Substance Use Coding Rules: Note That Clinical Diagnos/c Criteria is a Separate Topic (DSM-‐ICD Wars)


Substance Use


Substance Use


ICD-‐10 Get Ready!

“What’s YOUR Y2K Plan?”

Crosswalks/Reference Materials

Staff Training/EducaTon

TesTng Systems

Vendor Readiness

Payer contracts


Components of OrganizaTonal Readiness 1.  Readiness Assessment: Staff, Culture and Analysis

ICD-‐10, Clinical DocumentaTon & Regulatory Astudes 2.  ICD-‐10 Team and Project Plan

ICD-‐10 Team CommunicaTons, Training Plans Policy and Procedures Review

3.  TesTng and Systems Readiness

Internal Systems External Systems Flow between systems


Internal and External Systems to Assess All diagnosis touch points

Eligibility and Benefit

InformaTon Systems

Prior-‐AuthorizaTon’s

PracTce Management Systems, EHR, eRX, HIE’s, Labs

ReporTng: public health, state, performance

Child Welfare or other regulatory

systems

Super bills, charge sheets, MD visits

Claims and Clearinghouses All Payers

EHR’s: internal logic of CDS, alerts

Business Intelligence/AnalyTcs

Internal databases/registries


Systems Issues to Assess

Capable of dual coding? Submisng ICD-‐9 prior to October 1; ICD-‐10 October 1 forwards

Any upgrades that need to happen? Account for tesTng Tme, possible glitches, and bug fixes

Cost to you for upgrades?

What will be the impact on the organizaTon?


Revenue Cycle and Billing Processes: The Biggest Risk and Impact Area

Payers

TesTng

Risk MiTgaTon


Payers: Who is Doing What When?

• Everyone is doing something different at different Tmes • Example: 18 payer sources = 18 different .melines

• How many payers do you have and what is their respecTve revenue percentage? • Who is your contact person at the Payer? • ICD-‐10/DSM uTlizaTon


Every system that holds, transmits, or analyzes health data will need to be modified

• CMS on TesTng: “Tes.ng will ensure ICD-‐10 compliance across internal policies, processes, and systems, as well as external trading partners and vendors”

• Without thorough internal and external tesTng, you will have no idea if you will be ready or what will happen to your revenue income aper October 1, 2015

• Two Key Factors: •  a) Can you connect AND exchange ICD-‐10 informaTon? • b) Can the payer handle, adjudicate, and process the claim correctly?

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TesTng

© 2014 by Lisette Wright All Rights Reserved

TesTng and Risk MiTgaTon Strategies

Test representaTve

sample

Use different code combinaTons (SU/

BH/primary-‐secondary dx’s)

Emphasize tesTng with large pay

source

Test different provider types (MD, aide, etc)

Test per diems, bundles, individual

CPTs, etc

Waterfall/crossover billing

IncorporaTng the DSM in the system


Revenue Cycle: Denial RemediaTon 1. What pre-‐exisTng claims problems have had with any parTcular payer?

2.  How have they resolved claims problems in the past? 3.  Have contact informaTon: phone numbers, instrucTons, name of person handy

4. What is your Plan B for any parTcular party and how big will the “hit” be?

5.  Establish a process of how denied claims get handled 6. May need 1 FTE the first 6 months for this to handle claims


Staff Training: A CriTcal Factor

Current State of Affairs: The ICD-‐10/DSM-‐5 Coding, DocumentaTon and Clinical Criteria Training cannot be emphasized enough!

Change Management and Astudes in the Culture

PracTce-‐Peer Review-‐Feedback Loop to PracTce More!

© 2014 by Lisette Wright All Rights Reserved 39

Document to SubstanTate Diagnosis •  All the KEY medical concepts, relevant to care now and looking to the future •  ICD-‐9: Code and DescripTon: 292.85 Drug induced sleep disorders •  ICD-‐10: Code and DescripTon : F13.282 Seda.ve, hypno.c or anxioly.c dependence with seda.ve, hypno.c or anxioly.c-‐induced sleep disorder

•  You would then write in your record: “A paTent is evaluated for a [drug induced] [sleeping disorder] that is related to [dependence] on a [sedaTve drug].”


Role-‐Based Training Ø Clinical staff will need to understand not just diagnoses, but also medical necessity & increased specificity in clinical documentaTon expectaTons (MD’s: E & M improvements for Medical Decision Making/LOC); DSM-‐ICD relaTonship

Ø Billing will need to understand coding, crosswalks, when to punt back to clinical

Ø Any intake/pre-‐registraTon staff will need to know basic diagnosTc groups

Ø Compliance: understand reporTng, data collecTon, clinical documentaTon guidelines, adherence, etc.


Training Details

•  5-‐8 hours Intake/Pre-‐CerTficaTon •  20-‐40 hours clinical staff •  25-‐40 for on-‐site billing

Training Time

•  ICD-‐10 Basics for Everyone • Role-‐specific training • Materials to support job duTes •  Screen Shots/EHR Vendor Training

Curriculum

•  ICD-‐10 Basics • Diagnosing (group according to program/age) • Clinical DocumentaTon: NOS, primary/secondary diagnoses, medical condiTons, poinsoning, etc

Clinical Topics


AddiTonal Resources Note that the majority of ICD-‐10 resources are geared towards the medical industry, who is transiToning from ICD-‐9 to ICD-‐10.

Some these resources do not take into account the DSM:

•  CMS: www.cms.gov/Medicare/Coding/ICD10 •  AMA: Express Reference Cards for BH

•  The Clinicians Toolbox: hQp://theclinicianstoolbox.com (ICD-‐10 for BH/SU codes ONLY, produced by a clinician, $27)


Contact InformaTon Behavioral Health SoluTons, P.A. www.behavioralhealthsoluTonsmn.com [email protected] Pat Stream, ProcenTve ProcenTve.com [email protected]


Documents

NEWCODINGRULES$FOR$ADDICTIONS:THE$ ICD10