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ICD:10 It’s a Marathon, Not a Sprint
Master Documentation to Master ICD-10
Kathy Mills Chang, MCS-P, CCPC
The KMCU Way
•Documentation systems based on lots of audits and findings
•Basics are often the most missing items
•Training is the foundation
•Same as 1983----Not!!!
•What are we up against?
Ch-Ch-Ch-Ch-Changes
•Healthcare has been changing for a while
•The changes are getting more rapid and are hitting closer to home
•This event is about awareness
Chiropractic and the OIG
•For the first time since May 2010, the Office of Inspector General, of the Dept. of Health and Human Services, has published a report specifically about chiropractic...or rather, one chiropractor in particular.
OIG Report Facts
•This fellow chiropractor’s dire situation represents the current state of risk that most chiropractors are not even aware they face on a daily basis.
•Is this you?
Getting Started with OIG Compliance
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Reduce Your Risk
•Scrutiny and accountability in healthcare are up
•Affordable Care Act and other state-level documentation and compliance rulings make it more critical than ever to decrease your practice risks.
Learn the Basics to Reduce Your Risk
•Many DCs don’t knowwhat they don’t know, when it comes to compliance in healthcare today!
•OIG Compliance is that rule book that many don’t know they must follow
Who is the OIG?
•Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.
Government’s Healthcare Oversight
•HHS OIG is the largest inspector general's office in the Federal Government, with approximately 1,600 dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs.
•A majority of OIG's resources goes toward the oversight of Medicare and Medicaid — programs that represent a significant part of the Federal budget and that affect this country's most vulnerable citizens.
OIG Strategic Plan 2014-2018
The OIG has a clear an narrow focus for success:
•Goal One: Fight Fraud, Waste, and Abuse
•Goal Two: Promote Quality, Safety, and Value
•Goal Three: Secure the Future
•Goal Four: Advance Excellence and Innovation
Goal One: Fight Fraud, Waste, and Abuse
•Critical to OIG’s mission is fighting fraud, waste, and abuse. We will continue to employ a multi-faceted approach of prevention, detection, and deterrence.• Identify, investigate, and take action when needed•Hold wrongdoers accountable and maximize recovery of
public funds•Prevent and deter fraud, waste, and abuse
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March 2015
3 issued aimed at chiropractic the last several years…the impact has been significant
Work Plan Focus #1-Identify Biggest Issues
Work Plan Focus #1-Identify Biggest Issues
Work Plan Focus #2-Proactive Reviews Work Plan Focus #2-Proactive Reviews
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Work Plan Focus #3-Identify and Address Trends
Work Plan Focus #3-Identify and Address Trends
OIG Compliance vs. HIPAA Compliance
•OIG Compliance relates to fraud and abuse•Documentation, coding, billing and patient financial inconsistencies•Medical necessity and erroneous payment demands•Federal programs with extension through Office of Audit Services
•HIPAA requires covered entities to have contingency plans that establish policies and procedures regarding protected health information•HIPAA also administered by HHS•Office of Civil Rights
OIG Report Facts
•The OIG is not “out to get us all”
•There is enough “low hanging fruit” to take care of the federal budget deficit
•Be aware of the specific errors pointed out in the reports like this
A Warning the Should be Heeded Another Recent Decision
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How This Training Will Protect You!
•Documentation of Case Management
•ICD-10 Awareness
•Risk Management and Risk Avoidance
•Compliance Concerns
Why Is Documentation So Important?
•Ensures quality patient care•Meets licensure
requirements to protect the public•Guards against malpractice
action•Secures appropriate
reimbursement•Because…if it wasn’t
written down, it didn’t happen!
Know your Audience
•Another health care provider
•Your board
•A malpractice attorney
•Third party payer's medical necessity auditor
•Each has different, but necessary requirements of your documentation
What Dr. Diep Didn’t Know That He Didn’t Know!
•The $708,000 recoupment finding to Medicare:• Ignorance of the rules
• Upcoding charges
• Billing Medicare inappropriately
• Poor documentation
• No Policies and SOP
• Ignored help when notified of OIG concerns
OIG Report Facts
•The OIG is not “out to get us all”
•There is enough “low hanging fruit” to take care of the federal budget deficit
•Be aware of the specific errors pointed out in the report
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Problem #1: Stick Out Like a Sore Thumb! Size Matters
•This doctor was in the top 5 in the entire country for volume of CMT codes billed. Top 5!!!!
•He billed an outrageous percentage of 98942, all 5 spinal regions!
So? I’m a Full Spine Adjuster!
•Medical necessity definition dictates that you must prioritize each area of complaint•Every visit:•S + O (P + ART) for every
region treated•2 DX codes for each
region•Treatment plan for
each/short and long term goals
Why It LOOKS Fishy…
The Guideline and Expectation
“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patients condition and provide reasonable expectation of recovery or improvement of function.”
Problem #2: Did Not Understand The Definitions of Maintenance Care
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Understand the Rules
•He ONLY billed AT modifier, never ever moving a patient to maintenance care.
•Even in the details of the rebuttal from his attorney, he also argued that he "never delivered care that was not AT Modifier worthy".
Is All Care Medically Necessary?
Clinically Appropriate Care
• Life enhancing
•Symptom relieving
•Wellness care
•Supportive care
•Maintenance care
Medically Necessary Care
•Yields a significant improvement in clinical findings and patient functionality.
Maintenance
CMS defines Maintenance Therapy as: "Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy."
GA Modifier
What’s Wrong with this Picture?
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Voluntary Use = “MAY I?” ABN for Voluntary Use
Problem #3: Evidently Didn’t Understand Episodic Care
Definition of Case Management
Episodes of Care
•The foundation for an episode is contained in the beginning four steps of documentation.
•There was confusion about what an episode of care is
•Therefore, the documentation necessary was NOT present
Blatant Disregard
•Medicare documentation requirements are published. •We, as doctors, must know how to diagnose, treat in episodes of care and dismiss patients from active treatment.•Have written policies and procedures.
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Any Patients in Your Office in this Circumstance?
Problem #4: Didn’t Understand Requirements and How to Use Software to
Meet Them
Is it Mandatory?
•Came out of the sentencing guidelines•Affordable Care Act: Mandatory Compliance Plans Coming Soon •CMS has NOT finalized the requirements •CMS will advance specific proposals at some point in the future
Just Do it! Compliance Program!
•The truth is, we've been being told that since 2001.
•Get your policies and procedures and OIG compliance plan in place.
• It's too easy to do, and if you don't know how, ask us! We teach this every weekend!! Don't delay.
Risk #1 Risk #2
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Risk #3 Risk #4
Opportunity #1 Opportunity #2
Opportunity #3 Opportunity #4
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What Do I Need to Know?
•What is ICD-10?
•How is it different from ICD-9?
•How will I know which codes to use?
•What steps do I take along the way?
ICD-10 Delay Haven’t We Been Here Before?
Per CMS Acting Administrator, Marilyn Tavenner
•Feb. 6, 2013: “We will not abandon ICD-10”•Too much work has already been done to turn back now•The old system won’t work with new technologies•That would penalize innovators• It is necessary for health care reform
Start Here: What’s ICD-10?
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ICD-9 to ICD-10 Awareness
•What are the codes?
•How are they different?
•What does all of this mean?
•How do we make the transition?
Why in the World Do We Have to Change?
•WHO says so!
•US is the only civilized country NOT on ICD-10
•Too much complaining about costs and time
What’s Wrong with ICD-9?
• ICD-9 is 30 years old
• ICD-9 lacks specificity
• ICD-9 does not reflect new services
• ICD-9 doe not compare costs and outcomes
• ICD-9 is limited (13,000 codes)
What Can I Expect with ICD-10?
• ICD-10 will encompass more precise documentation
• ICD-10 will allow for more accuracy when determining medical necessity for the services rendered
• ICD-10 will allow providers to code more accurately which will contribute to the health care quality improvement initiatives
How Does it Work? How are ICD-9 and ICD-10 Different?ICD-10
ICD-9
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ICD-10 Coding and Documentation
•Site
•Laterality • 5th or 6th digit - Sciatica• Left – M54.31• Right – M54.32
•Episodes of care• 7th digit• A D S
•Injuries
The 7th Character
•A – Initial encounter, while patient is receiving active treatment such as surgery, ER, or evaluation and treatment by a new physician.•D – Subsequent encounter, routine care during the healing or recovery phase, such a cast change, medication adjustment, aftercare and follow up.•S – Sequelae, complications or conditions that arise as a direct result of a condition, such as a degenerative disc disease a year after a neck sprain. Sequelae code (i.e. DDD) is first, then the injury code.
Placeholder “x” character
Placeholder character “x” in positions 4, 5, and/or 6 in certain codes to allow for future expansion.
7th CharactersThe 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder “x” must be used to fill in the empty characters
For Example
ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus.
So What is “Excludes 1” or “Excludes 2”?
•Similar to Correct Coding Initiative Edits for CPT Codes
•Dictates when certain codes can be used together and when not
•The explanation will be helpful in the long run
Remember the CCI Edits?
Excludes 1 - is used when two conditions cannot occur together or “NOT CODED HERE!” Mutually exclusive codes; two conditions that cannot be reported together(A condition may be acquired OR congenital but not both!)
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Remember the CCI Edits?
Excludes 2 – Indicates “NOT INCLUDED HERE.” Although the excluded condition is not part of condition, it is excluded from, a patient may have both conditions at the same time. The excluded code and the code above the excludes can be used together if the documentation supports them.
Read the Instructions!
Read the Instructions! CMS-1500 Claim Form
• Revision 02/12• Changed to match the
electronic format (5010) and ICD-10 codes
• Adds space for eight more diagnosis codes in box 21
• Jan 6th, 2014 – Health plans and clearing houses must accept the form.
• April 1st, 2014 –Providers must use the new form
Find Your Way to the Codes How do I Find the ICD-10 Code?
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Chapter 6: Nervous SystemChapter 13: Musculoskeletal/Connective
Tissue
Site Specifics in Certain Codes Can We Just Crosswalk from ICD-9?
•General Equivalence Mappings (GEMs)
•Some pointing based on the initial set up
•Three possible ways to define subluxation: M99.01, M99.11, or S13.11
•Time will tell
ChiroCode ICD-10
Three Methods using the ChiroCode ICD-10 book:
1. Commonly used code list
2. GEMs code map3. Alphabetic index4. Always confirm
the code using the Tabular list
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Commonly Used Codes List
Cervical Diagnosis in ICD-10
GEMS Code Map
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Best Mapping Tool for Reference GEMs Examples
GEMs Example GEMs Example
Headaches
• In ICD-9, the codes might be:• 339.21 Acute post-traumatic headache
•GEMs suggest:•G44.319 Acute post-traumatic headache, not intractable
NOTE: in the index, G44.319 is next to G44.311 which is the intractable version of this condition.
Intractable means “hard to control or deal with”This must be documented in order to select the correct code
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Conversion Tools Conversion Tools
Medicare’s GEM Guide GEMS FAQ
Alphabetic Index
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But Wait! There’s More!
Confirm with Tabular List!
Confirmation Required One-to-one Mapping
723.1 Cervicalgia
M54.2 Cervicalgia
One-to-Five Mapping
•724.4 Thoracic or lumbosacral neuritis (radicular syndrome of the lower limbs)
• ICD-10 – M54.14, M54.15, M54.16, M54.17, M54.18 Radiculopathy
Combination Mapping
• 724.3 Sciatica
• M54.30 Sciatica, unspecified side• M54.31 Sciatica, right side
• M54.32 Sciatica, left side
OR
• M54.40 Sciatica with lumbago, unspecified • M54.41 Sciatica with lumbago,
right side
• M54.42 Sciatica with lumbago, left side
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Talk About Detail!
•Take 847.0 Cervical Sprain• Could be S13.4xxA• Could be S13.8xxA
•Much more detail is possible in ICD-10
• Item one: sprain of ligaments of the cervical spine
• Item two: sprain of joints and ligaments of other parts of the neck
Coding Whiplash
•Sprain VS. Strain• 847.0: Sprain of Neck
(Includes strain of joint capsule, ligament, muscle, tendon)
•S13.4 _ _ _ Sprain of ligaments of the cervical spine
•S16.1xxA STRAIN of muscle, fascia and tendon at neck level, initial encounter
Sprain Vs. Strain“Exam findings are consistent with the strain and sprain of the ligaments and muscles of the cervical spine and acute traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with another motor vehicle on the interstate. He was not treated at the scene.”
• S13.4xxA Sprain of ligaments of the cervical spine, initial encounter• S16.1xxA Strain of muscles, fascia and tendon at neck level,
initial encounter•G44.311 Acute post-traumatic headache, intractable•V49.40xA Driver injured in collision with unspecified motor
vehicle, traffic accident, initial encounter• Y92.411 Interstate as place of occurrence external cause
Migraines: 44 ChoicesDocumentation must
include:• With or without aura
• Intractable or not intractable
• With or without status migrainosus
• Persistent or chronic
• With or without vomiting
• With or without opthalmoplegic, menstrual, etc.
• Induced by ICD-10 training
Vital Definitions
With Aura: Feelings and symptoms noticed shortly before the headache begins…aka “prodrome”• Blind spots• Seeing zigzags• Flashing lights• Prickling Skin•Weakness (paresthesia)
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Status Migrainosus
•Chronic migraines that last more than 72 hours•The codes DCs usually use are very vague•If that DX comes through, doctors may need help with exact diagnosis
Unspecific Codes are Problematic
Remember 728.85? V – Y Codes
Chapter 20: Guidelines for external causes of morbidity (V00-Y99)•Never sequenced first• Provide data about the cause, intent, place, activity, or
status of the accident or patient•No national requirement to use these codes, but voluntary
reporting is encouraged
Y92 Place of occurrence should be listed after other codes, used only once an initial encounter, in conjunction with Y93
Y93 Activity code should be used only once, at initial encounter
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V, W, X, Y CodesFor Fun
•Bus Occupant V79.9(collision with) Animal in traffic being ridden
•Bus Occupant V70.3(collision with) animal, non-traffic
•Bus Occupant V70.4(collision with) animal, while boarding or alighting
E Codes in ICD-9 Expanded
•External Cause Codes•Do you use them?
E844.8•Sucked up into a jet without damage to the airplane; ground crew
ICD-10-CM Increased Specificity
Updated Code V97.33Sucked into a jet without damage to the airplane
Chapter 6: Nervous System
Site Specifics in Certain Codes
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Z63.1--Problems in relationship with in-laws
This Just In!
Say What??
•G44.82 Headache associated with sexual activity
•W22.01xD Walked into wall, subsequent encounter
•Y34 Unspecified event, undetermined intent
•R45.2 Unhappiness
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Case Example
•While playing tennis in a tournament at the Clay Court Country Club, a male player sprained his right wrist and was treated by his Chiropractor close to the courts.•S63.501A Unspecified sprain of right wrist, initial
encounter•Y93.73 Activity, racquet and hand sports•Y92.312 Tennis Court (place of occurrence for
external cause)
Case 1 Answers and Rationale
• S33.6xxA Sprain of the SI joint•M47.819 Spondylosis without myelopathy or radiculopathy,
site unspecified –• Rationale: We don’t know from the notes that it is Lumbar
(M47.816) or Lumbosacral (M47.817)•M62.50 Muscle wasting and atrophy, NEC, Unspecified site
• Rationale: We don’t know from the notes where it is so we can’t use M62.58 Muscle wasting and atrophy, NEC, other site OR M62.59 Muscle wasting and atrophy, NEC, multiple sites
•M99.05 Segmental and somatic dysfunction of pelvic region•W00.0xxA Fall on same level due to ice and snow, initial
encounter• Y92.007 Garden or yard in unspecified residence as place of
occurrence
Case 2-Answers and Rationale
•M50.12 Cervical Disc Disorder with radiculopathy, mid cervical region •G54.2 Cervical Root disorder, NEC not used because of
Excludes1 noted
•S13.8xxA Sprain of joints and ligaments of other parts of neck•M62.838 Muscle Spasm, other•We are unsure about whether or not “back” = “neck” and
hope to seek further clarification..i.e.-M62.830 may have applied as well
•Y93.B3 Activity, free weights•Y92.39 Other specified sports and athletic area as the
place of occurrence of the external cause (gymnasium)
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Case 3-Answers and Rationale
•G43.019 Migraine Without Aura, Intractable, Without Status Migrainosus
•M50.31 Other Cervical Disc Degeneration, High Cervical Region
•G43.A1 Cyclical vomiting, intractable
Case 4 Answers and Rationale
•M51.15 Intervertebral Disc Disorder with radiculopathy, Thoracolumbar Region •Would not use M54.15 Radiculopathy, Thoracolumbar
Region because of the Excludes1)
•R26.2 Difficulty walking, not otherwise classified
•Y93.H2 Activity, gardening and landscaping
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Case 5-Answers and Rationale
•M51.16 Intervertebral Disc Disorder with radiculopathy, Lumbar Region• Would not use M54.32 Sciatica, left side because of the
Excludes1
•M62.830 Muscle Spasm of the Back
What to Do Now: Forge Ahead What Should I Do Now?
•Concentrate on perfecting documentation•Learn the subtle nuances in your current diagnosis protocols•Begin to discern what each means to you
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Brainstorm Operational Impact
•Computers, software, memory, other IT concerns•Upgrades to software
and testing for billing-both paper and electronic•Super Bills, Diagnosis
Sheets, Existing SOP and Training Materials
Super CAs will Contribute at a High Level
Brainstorm Operational Impact
Know the IT Impact You’ll Face
• What changes will need to be made?
• Do they have available upgrades?
• When will the upgrades be available?
• Upgrade and your maintenance agreement
• Will they continue to provide support?
• Parallel coding?
• How long will my system be down?
ICD-10 Organization
•Address and prioritize tasks•Date software vendors
will be compatible•Upgrade schedules•Readiness and testing
schedules •Training schedules for
• Physicians• Office Staff
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Managed Care Contracts
•Identify all your payers
•Review the policies related to ICD-9
•Reimbursements tied to diagnosis
•Modify agreements
•Determine their timelines for testing
Managed Care Contracts
•Payer policy changes = Payment impact•Review new payment
policies• Improve coding and
documentation•Communicate changes
to staff•Dual coding•Know important dates
ICD-10 in My Practice
•Medicare: Free training•Chirocode.com: free
email alerts and webinars, more training, memberships, chart audits, and coding tools• FindACode.com:
Crosswalks and other advanced tools• ICD10Moinitor.com: Free
Articles•AAPC.com and
AHIMA.org
Recommended Tools
FindACode.com
www.findacode.com
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The Finish Line Looks Good From Here!