Page 1September 27, 2014
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Preparing Now For ICD-10-CM
Tennessee Orthopaedic Society
September 27, 2014
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• Transition and impact of ICD-10
• ICD-10: Visualized
• High-level review of what’s new in ICD-10-CM coding conventions and guidelines
• Review common diagnoses and documentation requirements in ICD-10
• Project management approach to ICD-10 operational considerations
Learning Objectives
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Transition and Impact
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What’s new?
NEW compliance date for ICD-10: October 15, 2015
• The ICD-10 delay is forcing organizations to reassess their timelines and budgets for complying with the code change.
• CMS is offering multiple in-person educational options as their well as web-based education.
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Making the Transition is Not Optional
• All “covered entities” as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required to adopt ICD-10 codes for use in all HIPAA transactions.
• ICD-10 codes are the foundation for reimbursement and will represent most or a large portion of the data points for healthcare analytics.
• Electronic data interchange (EDI) is the transport tool for claims.
• Lack of operational readiness – systems and staff training – could negatively impact practice business.
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Two Sets of Codes are Being Replaced
ICD-10-CM• Diagnosis Coding System – Used to
report the patient’s condition (i.e., what’s wrong with the patient)
• Direct replacement for ICD-9-CM Volumes 1 & 2
• Will be used in all settings – hospital inpatient, hospital outpatient, physician office, etc.
• Like ICD-9-CM, developed and maintained by the World Health Organization (WHO) and the National Center for Health Statistics within the Centers for Disease Control
ICD-10-PCS• Procedure Coding System – Used to
report surgical procedures performed
• Direct replacement for ICD-9-CM Volume 3
• Only used in a hospital inpatient setting (and only for reporting facility services)
• Like ICD-9-CM Volume 3, ICD-10-PCS was developed and is maintained by CMS
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Who is Impacted by ICD-10?Everyone!
• Physician Documentation• Physician Integration• Physician Performance
• Staffing Effectiveness• Assessment of Revenue
Impact• Process Improvement• Decision Support Reporting
Impact
• Documentation Analysis• ICD-10 Education• Process Improvement• Monitoring
Physician Office
Post Acute Services
• Front – Scheduling, Access Areas• Middle – Coding, CDI, Case
Management• Back – Billing, Reimbursement
Health Information
Management
ICD-10
Revenue Process
PhysicianOperational Planning
Information Technology
• IT Systems• Capability, Communication• Functionality• Vendor Preparedness
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What Does ICD-10-CMLook Like?
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ICD-9 vs. ICD-10Issue ICD-9-CM ICD-10-CM
Volume of codes Approximately 13,600 Approximately 69,000
Composition of codes Mostly numeric, with E and V codes alphanumeric.
Valid codes of three, four, or five digits.
All codes are alphanumeric, beginning with a letter and with a mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits.
Duplication of code sets Currently, only ICD-9-CM codes are required. No mapping is necessary.
For a period of up to two years, systems will need to access both ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD-9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits, and outcomes studies.
Source: http://www.aapc.com/icd-10/faq.aspx#why
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ICD-10-CM Organization
Index to Diseases and Injuries
Official GuidelinesTabular List of Diseases and
Injuries
The CM Manual divided into three main parts:
21 Chapters
Expanded injury codes grouped by site vs. type
of injury
Laterality (left and right)
V and E codes incorporated into
main classification
Added a placeholder X
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Anatomy of an ICD-10-CM Code
3-7 Alphanumeric characters (digits)
X X X X X X X.
1st character – Alpha (A-Z)
2nd character - Numeric
3rd - 7th characters –
Alpha or Numeric
Decimal placed after
the first 3 characters
• All letters but U are used
• The letters I & O are used only in the 1st character position
• Each letter is associated with a particular chapter (Except C&D Neoplasms)
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X X X X
Category
.Etiology, anatomic
site, severity
Added code extensions (7th character) for
obstetrics, injuries, and
external causes of injury
ICD-10-CM Characters and Extensions
X X XAMS 0 2 6. 5 x A
Alpha (Except U)
2 - 7 Numeric or Alpha
Additional Characters
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• Partial solution: these are tools to convert ICD-9 to ICD-10 and vice versa.
• To assist with the transition, cross-walking between the code sets will assist you with identifying the differences between ICD-9 and ICD-10.
• Not a high percentage of accuracy (very few one-to-one matches) due to increased specificity of ICD-10 versus ICD-9.
Crosswalk
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GEMsGEMs (General Equivalence Mappings) are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM-based data, including data for:
– Tracking quality
– Recording morbidity/mortality
– Calculating reimbursement
– Converting any ICD-9-CM-based application to ICD-10-CM/PCS
The GEMs are not a substitute for learning how to use the ICD-10 codes. More information about GEMs and their use can be found on the CMS website at:
http://www.cms.gov/Medicare/Coding/ICD10/index.html
(select from the left side of the web page ICD-10-CM to find the most recent GEMs)
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How Does the Mapping Work?
ICD-9-CM
• 719.46 Pain in joint, lower leg
ICD-10-CM
• M25.561 Pain in right knee
• M25.562 Pain in left knee
• M25.569 Pain in unspecified knee
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Percentages of Types of Matches
Mapping Categories
ICD-10 to ICD-9
ICD-9 to ICD-10
No Match 1.2% 3.0%
1-to-1 Exact Match 5.0% 24.2%
1-to-1 Approximate Match with 1 Choice 82.6% 49.1%
1-to-1 Approximate match with Multiple Choices 4.3% 18.7%
1-to-Many Matches with 1 Scenario 6.6% 2.1%
1-to-Many Matches with Multiple Scenarios 0.2% 2.9%
Source: http://www.ama-assn.org/ama1/pub/upload/mm/399/crosswalking-between-icd-9-and-icd-10.pdf
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High-Level Review of ICD-10 Coding Conventions and
Guidelines
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Marks the Spot
• ICD-10-CM uses a placeholder character “X” which allows for future code expansion.
• Where indicated as a placeholder the X must be used in order for the code to be valid. (The X is not case sensitive).
• A dash (-) at the end of an Index entry indicates that additional characters are required; review the tabular section for selection.
XPlaceholder Character
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Place an X in the 5th and 6th digit
ICD-10-CM utilizes a placeholder: Character “X” is used as a 5th character placeholder in certain 6 character codes
• To fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character
Examples:
• S72.8x1A – Other fracture of right femur, initial encounter
• M48.8x6 – Other specified spondylopathies, lumbar region
• S03.4xxA – Sprain of jaw, initial encounter
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Sequela – Late Effect
• A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.
• There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.
• Coding of sequela generally requires two codes sequenced in the following order:
– The condition or nature of the sequela is sequenced first.
– The sequela code is sequenced second.
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Laterality
• Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right, or bilateral.
• If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.
• If the side is not identified in the medical record, assign the code for the unspecified side.
Examples:
– M24.412 – Recurrent dislocation, left shoulder
– M65.321 – Trigger finger, right index finger
– L89.012 – Pressure ulcer of right elbow, stage II
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More Information Reported, Higher Level of Detail in Coding
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Greater Specificity and Detail in Orthopedic Coding:
• 34,250 of all ICD-10-CM codes are related to the musculoskeletal system.
• 17,045 of all ICD-10-CM codes are related to fractures.
• 10,582 of fracture codes distinguish right from left.
• 25,000 of all ICD-10-CM codes distinguish right from left.
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Musculoskeletal • There are several changes and expansion to the
musculoskeletal code system in ICD-10.
• Most codes in this section require additional documentation to correctly code site and laterality to the highest level of specificity, which include:
– Documentation of site and laterality
– More specific information for fractures and injuries
– Identification of episode of care
– Additional coding instructions surrounding osteoporosis
– Reorganization of codes
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Fracture SpecificityFractures Require Greater Specificity:
• Type of fracture
• Specific anatomical site
• Displaced vs nondisplaced
• Laterality
• Routine vs delayed healing
• Nonunion
• Malunion
• Type of encounter
– Initial
– Subsequent
– Sequela
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Episode of Care – Fractures
Assigning episode of care 7th characters for fractures is a bit more complicated because the episode of care provides additional information about the fracture including:
• Whether the fracture is open or closed.
• Whether healing is routine or with complications such as delayed healing, nonunion, or malunion.
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Episode of Care – Fractures7th Characters
• Initial encounter for closed fractureA• Initial encounter for open fractureB• Subsequent encounter for fracture with routine healingD• Subsequent encounter for fracture with delayed healingG• Subsequent encounter for fracture with nonunionK• Subsequent encounter for fracture with malunionP• SequelaS
If the fracture is not documented as open or closed, it is coded to closed.
Additionally, if the fracture is not documented as displaced or not displaced, it should be coded as displaced.
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• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
J
• subsequent encounter for open fracture type I or II with nonunionM
• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
N
• subsequent encounter for open fracture type I or II with malunionQ
• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
R
Episode of Care –Open Fractures
• initial encounter for open fracture type I or II initial encounter for open fracture NOS
B
• initial encounter for open fracture type IIIA, IIIB, or IIICC
• subsequent encounter for open fracture type I or II with routine healing
E
• subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
F
• subsequent encounter for open fracture type I or II with delayed healing
H
The open fracture designations are based on the Gustilo open fracture classification
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Resources Available
• http://www.cms.gov/Medicare/Coding/ICD10/index.html
• http://www.ahima.org/icd10/
• http://www.aapc.com/icd-10/index.aspx
• http://www.cdc.gov/nchs/icd/icd10.htm
• http://www.who.int/classifications/icd/en/
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Project Management
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ICD-10 Project Overview
Successful Go-Live
Training
Testing
Communications
Planning
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Updated ICD-10 TimelinePYA
May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov DecPlanningIdentify resourcesCreate project teamAssess effectsCreate project planSecure budget
CommunicationsInform staffContact vendorsContact payersMonitor vendor prepMonitor payer prep
TestingHigh-level training for test teamLevel 1: internal
Level 2: external1
Comprehensive TrainingDocumentationCoding
2October 1, 2015 is the NEW compliance date for ICD-10.
2014 2015
GO LIVE
Confirm ongoing practice schedule to correspond with
new "go live"2 date
1Monitor external testing periods - go to http://www.cahabagba.com/news/icd-10-volunteer-testing/ to apply for volunteer testing opportunity - DEADLINE 10/3/14.
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Planning: Major Activities
Identify resources
Create project plan
and team
Assess effects
Secure budget
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Planning:Sample Activities
• Assess practice pre-authorization form and/or templates for code changes needed.
• Review pre-authorization workflow processes and affected staff for ICD-10 training needs.
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Planning
• Review all National Coverage Determination (NCD) and Local Coverage Determination (LCD) policies used in the practice for updated code sets from ICD-9 to -10.
http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html
• Review any practice internal codes for denials or quality training that are tied to ICD-9 and create an ICD-10 migration plan for these codes to be updated.
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Planning
• Determine the best superbill solution for the practice specialty; is an electronic solution an option?
• Assess current superbill process based on potential list of ICD-10 codes for the practice.
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Planning
• Communicate with the ICD-10 leadership team at each facility - whether hospital, ASC, or nursing home - where practice physicians are working. They should be informed about the ICD-10 training process requirements for the practice physicians.
• Compile a top 10 list of the current practice denials relating to diagnosis codes, then create ICD-10 training materials around these codes.
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Planning
• Review all customized reports for reference to ICD-9 and make sure updates are made for ICD-10. (e.g. billing, quality reporting, clinical trials, etc.)
• Review all monthly management reports for physicians, and referrals which may contain a filter or data field relating to ICD-9. Be sure the data field is set to accommodate ICD-10.
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Planning
• Create a troubleshooting plan “decision tree” for denials issues (like disaster plan). Who does what, when, based on the problem?
When in danger, or in doubt, run in circles, scream and shout. - Infantry Journal, Vol. 35, (1929), p. 369.
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Communication: Major Activities
Monitor vendors
and payers
Contact vendors
and payers
Inform staff
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Communications: Sample Activities
• Create a checklist by payer regarding their ICD-10 readiness and claims filing timeline requirements; monitor and update in the months leading up to the new deadline.
• Create a checklist by payer for pre-authorization coding transition dates to ensure compliance; monitor and update in the months leading up to the new deadline.
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Communications
• Verify payer timing requirements for ICD-10 use in pre-certification and pre-authorization processes (i.e., pre-cert work completed prior to ICD-10 'go-live' date may need to be done in ICD-10 codes for visits after 'go-live' date).
• Review any commercial payer quality reporting processes to be sure any ICD-9 linked data is updated to ICD-10.
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Testing: Major Activities
Train the Testing Team
Internal Testing
External Testing
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Testing
• Testing Team
– Identify members
– Assign duties and focus
• Who will test the PM/EHR system(s)?
• Who will test with the clearinghouse(s)?
• Who will test with the payers?
– Develop feedback form, timeline, and follow-up steps
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Testing: What to test?
• Internally:
– Provider/staff process for selecting ICD-10 codes in PM/EHR system
– Within the system screens, are the ICD-9/10 fields big enough for the new code format?
– Run reports which contain ICD-9/10 codes
• Are all digits showing?
• If the code description is included, is it understandable?
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Training: Major Activities
Documentation
Coding
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Training
• Create an ICD-9 workflow map throughout the office: moving to each work area examine processes – daily, weekly, monthly, random-use – for ICD-9 involvement in order to develop appropriate staff training and focus areas.
• Prepare ICD-10 training based on job-type group, i.e., clinicians, front desk staff, billing, etc. and tailor content based on job duties associated with ICD-9.
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Training
• If you determine that an outside vendor will be hired for training assistance, allow 2-3 months prior to training for decision making and contracting. However, keep in mind that vendors and trainers will start filling up as the deadline nears.
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Project Management
Making the difference
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Thank you!
Linda ClenDeningConsulting Manager
Pershing Yoakley & Associates, P.C.(865) 684-2735