1. ICD-10-CM An Introduction 2013
2009 Codes
The single most significant coding change in 30 years is before us – the conversion from ICD-9 to ICD-10
The change will impact virtually all facets of your clinical practice and research. Major changes will have to occur to our business processes and our information systems. Countless hours will need to be spent education our faculty and the vast majority of our staff.
Bobbi Buell, MBA
onPoint Oncology LLC

2. Main Objective Inspire panic---this is not that far away.
Create an awareness of ICD-10-CM.
Start to consider the impact the conversion to ICD-10 will have on your operations.
Start to understand what it means and does not mean in Oncology.

3. Latest Update This is happening 10/1/2014
CMS intimated that the deadline would not be postponed.
The AMA still vehemently opposes this deadline.
Hospitals have spent millions on it.
You be the judge.

4. Implications of the Transition – Who?
Providers
Hospitals
Physicians
Outpatient facilities
Post-acute providers (home health agencies, skilled nursing facilities, etc.)
Health Plans or Payers
Third party administrators
Employers

5. Implications of the Transition – Who?
Others
Laboratories
Free standing ancillaries
Researchers
Public health agencies et al
Data collection agencies/organizations (tumor registries)
Vendors
Clearinghouses
Business associates and partners
Patients

6. ICD-9-CM vs. ICD-10-CM

7. Why is ICD-9 Being Replaced?
ICD-9-CM is out of date and running out of space for new codes on the procedural side.
Lacks specificity and detail
No longer reflects current medical practice
ICD-10 is the international standard to report and monitor diseases and mortality, making it important for the U.S. to adopt ICD-10 based classifications for reporting and surveillance.
ICD codes are the core elements of HIT systems, conversion to ICD-10 is necessary to fully realize benefits of HIT adoption.
1) ICD-9-CM is not sufficiently robust to serve health care needs of the future.
2) The US is the only developed country that has not yet implemented ICD-10
3) limited structural design cannot accommodate advances in medicine and medical technology and the growing need for quality data

8. Reimbursement Issues With ICD-9?
Example: Fracture of Wrist
Skateboarder fractures right wrist
A month later, fractures left wrist
ICD-9 would require additional documentation to find out which wrist was fractured
ICD-10-CM describes in fracture codes
Left versus right
Initial or subsequent encounter
Routine healing , delayed healing, nonunion or malunion

9. There Are Benefits of ICD-10
Reflects more emerging technologies, particularly PCS
Captures the details of EMRs
Might reduce ADRs from payers due to more specificity
Statistical outcomes will be more measurable and specific
May support better epidemiological trending

10. What is ICD-10-CM?
CM = Clinical modification to ICD-10 used around the world
Consultation with
Physician groups
Clinical coders
Other users of ICD-9-CM

11. Who Runs The Show?
National Center for Health Statistics (NCHS) is the federal agency that is responsible for maintaining the diagnostic coding systems in the U.S.
CMS partners with them to oversee publicly available coding systems
WHO oversees ICD-10 without the –CM
The American Health Information Management Association (AHIMA) oversees education and training

12. Coding Process Remains the Same
ICD-10-CM code book retains the same traditional format
Index
Tabular
Process of coding is similar
Look up a condition in the Index
Confirm the code in the Tabular

13. Major Differences Between ICD-9-CM and ICD-10-CM
13,600 codes
69,000 codes
Code book contains 17 chapters
Code book contains 21 chapters
Consists of 3 to 5 characters
Consists of 3 to 7 characters
1st character is alpha or numeric
1st character is alpha
Only utilizes letters E and V
Utilizes all letters (except U)
Second, third, fourth, and fifth
characters are always numeric
Second character
is always numeric
Third, fourth, fifth, sixth, and seventh
characters can be alpha or numeric
Shorter code descriptions because
of lack of specificity and
abbreviated code titles
Longer code descriptions because of greater clinical detail and specificity
and full code titles
5x more codes in ICD-10, than ICD-9
ICD-10 code book contains more chapters
Split some I-9 chapters in to two – nervous and sense organs
v and e codes were supplementary chapters in I-9, now own chapters
3) I-9 3 to 5, I
4)10 key pad, much easier to make errors reading letters
1st digit is alpha – letters A-Z, except U
V codes are now Z codes
Codes #s will be different

14. Character Changes ICD-9-CM ICD-9-CM Chapter ICD-10-CM
Chapter 1
Infectious or Parasitic Disease
A0-B99
Neoplasms
C00-D49
Chapter 6
Diseases of the Nervous System
G00-G99
Chapter 7
Diseases of the Eye and Adnexa
H00-H59
Chapter 8
Diseases of the Ear and Mastoid
H60-H95

15. Comparison of ICD-9-CM and ICD-10-CM
ICD-9-CM CODE
ICD-10-CM CODE
A - Category of code
B - Etiology, anatomical site, and manifestation
A - Category of code
B - Etiology, anatomical site, and/or severity
C - Extension
7th character for obstetrics, injuries, and external causes of injury A B A B C

16. ICD-9-CM Structure – Format
Numeric or Alpha
(E or V)
Numeric V X E 5 4 1 X 4 X . X X .
Category
Etiology, Anatomic
Site, Manifestation
3 – 5 Characters

17. ICD-10-CM Structure – Format
Alpha
(Except U)
2 - 7 Numeric or Alpha
Additional Characters . . X M A S 3 X 2 X X 1 X X A X
Category
Etiology, Anatomic
Site, Severity
Added code extensions (7th character) for obstetrics, injuries, and external causes of injury
3 – 7 Characters

18. Characteristics of ICD-10-CM
ICD-10-CM far exceeds its predecessors in the number of concepts and codes provided
The disease classification has been greatly expanded to include health-related conditions and to provide greater specificity at the sixth digit level and with the seventh digit extension
By the way, the 6th and 7th digit extensions ARE NOT optional for the codes where they are present

19. Arrangement of Volumes of ICD-10
Volume 1: Main classifications
Volume 2: Instruction/ Guidance to users
Volume 3: Alphabetical Index
ICD-10 has 21 chapters against 17 Chapters in ICD-9

20. Chapters of ICD-10
Chapters I to XVII: Diseases and other morbid conditions
Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.
Chapter XIX: Injuries, poisoning and certain other consequences of external causes.
Chapter XX: External causes of morbidity and mortality,
Chapter XXI: Factors influencing health status and contact with health services.

21. What You Should Worry About
The codes you most frequently use
Can you run a report from your PM or EMR system that shows you all ICD-9’s that you have billed more than times over the past 2-3 years? Your limits will depend upon your size.
These are the codes you need to know and translate.
You do not need to know 69,000 codes
But, physicians need to access to non-cancer codes to use when they are evaluating and/or managing patients

22. General Equivalence Mappings

23. Forward and Backward Mapping
Forward Mapping
ICD-9 Code
Description
(Source)
820.8
Fracture of unspecified part of neck of femur, closed
ICD-10 Code
Description
(Target)
S72.009A
Fracture of unspecified part of neck of femur, initial encounter for closed fracture
Backward Mapping
ICD-9 Code
Description
(Target)
820.8
Fracture of unspecified part of neck of femur, closed
ICD-10 Code
Description
(Source)
S72.001A
S72.002A
S72.009A
Fracture of unspecified part of neck of right femur, initial encounter for closed fracture
Fracture of unspecified part of neck of left femur, initial encounter for closed fracture
Fracture of unspecified part of neck of femur, initial encounter for closed fracture
In the backwards mapping example, all three ICD-10 codes would map onto Even though the ICD-10 codes are specific to a side of the body, the ICD-9 codes does not contain any specificity – so all three codes correlate with In the forward mapping example, the same does not apply. Because you are taking a code with no specificity regarding side, it maps onto S72.009A – which is an ICD-10 code that is more generic. The codes S72.001A and S72.002A would not appear as options because they specifiy “left femur” and “right femur.”

24. GEMS Example #1

25. GEMS Example #2

26. GEMS #3

27. GEMS Example #4

28. Other Major Differences With ICD-10
Use additional codes
Sequelae
Combination codes
Differences in anemia
Mandatory 6th and 7th digits

29. Cancer Differences Laterality
Mandatory’ use additional’ codes—look at lung cancer
6th digits (check out skin and breast cancers)
Much more detail and confusion surrounding lymphoma
More detail in myeloid leukemia
Help with CUP

30. And this must be documented….

31. Preparing for ICD-10

32. ICD-10 Implementation Plan
Checklist:
Year
2011
2012
2013
2014
Phase I
Awareness and
Impact Assessment
Phase II
Preparing for Implementation
We encourage that you start now to get ready for ICD-10 implementation.
The phases of an Implementation plan are included here. AHIMA’s ICD-10 Preparation Checklist includes greater details for each phase, and this document is a great resource to get you started.
Phase 1 – Impact Assessment
Phase 2 – Preparing for Implementation
Is the next step and this also includes making the change to 5010 as well
Phase 3 – Go Live Preparation
This phase will be focused on testing and training – a very busy time period.
Post-implementation
And of course we won’t be done on the first of October 2013, careful data review and analysis and impact assessment will start all over again.
Phase III
Go Live Preparation
Phase IV
Post –
Implementation

33. Where to Start?

34. Diagnostic Codes are Ubiquitous
Diagnostic codes are everywhere – used by every person, every process, every system….
Superbills
Payments/EOBs/ERAs
Referrals
Contracts
EMRs
But, again, this is limited to codes you actually use

35. Solo Practitioner Or Small Group (2-10) Practice Implementation Planning
Organize Implementation Effort
Establish Communication Plan
Conduct Impact Analysis
Contact System Vendors
Estimate Budget
Implementation Planning
Develop Training Plan
Analyze Business Processes
Education and Training
Policy Change Development
Deployment of Code
Implementation Compliance
Source: AAPC

36. 2013 Plan

37. Organize Implementation Effort
Enlist staff person (coder, biller, manager) to oversee effort who will be key point person
Prepare information to share with other providers and staff
Identify work and scope for implementation
Should be a team effort involving all medical practice staff and the staff needs to believe that this will actually happen.
If everyone is not signed on to this, your effort will not work long term

38. Organize Implementation Effort
Examine the level of coding you have in your practice—who is certified? Who has experienced a change before, e.g. E/M, admin codes? Who is equipped to deal with this?
Look at all areas that will impact practice and identify each one that will be affected
List of codes
Practice management system
Electronic Medical Record (EMR), if applicable
Superbills
Clinical areas and pharmacy
Schedule regular meetings to share information with physicians and discuss progress and barriers of implementation.

39. Establish Communication Plan
How will point person communicate with all staff?
Most practices communicate via meetings or memos
No need to change method of communications
Develop regular schedule for ICD-10 progress efforts
Monthly until 6 months prior to implementation
Bi-weekly thereafter
Include information, publications, and articles
Document all meetings and what was discussed herein and make sure you are tracking with your plan.

40. Conduct Impact Analysis
Take this step prior to development of budget
In depth look at resources required for implementation
Maybe check for a little process improvement
Helps determine what costs might be involved as well as work processes

41. Potential Areas that will be Impacted!

42. Potential Areas that will be Impacted!
For those that can’t read the small print…
Clinical Area
Patient Coverage
Superbills
ABN’s
Physicians
Documentation
Code Specificity
Problem lists
Nurses
Forms
Documentation
Prior Authorization
Managers
Policies & Procedures
Vendor/Payer Contracts
Budgets
Training Plan
Source: AAPC 2012

43. Potential Areas that will be Impacted!
Lab
Documentation
Reporting
Billing
Policies & Procedures
Training
Pharmacy
Infusion Room
Coding
Code Set
Clinical Knowledge
Concurrent Use
Front Desk
Referrals/ History codes
Systems
Source: AAPC 2012

44. List Every Area That Uses Codes
Geographical
Technological
Processes
Vendors
Payers
Paper
Etc

45. What It Looks like
Source: AMA ICD-10 Project

46. Conduct Impact Analysis
Develop reasonable timeline that can be accomplished in your practice
Map out a project plan on a simple Excel spreadsheet with benchmarks and status of completion
Managers and/or coders should get physician approval for the project plan and its impact on the practice. Make sure you show and tell them the level of work it will take.

47. From Impact Analysis Develop a plan for Then, go to the next step…
Processes
Departments
Training
Then, go to the next step…

49. Vendor Readiness

50. Contact System Vendors
Will they be able to accommodate the need to move to ICD-10? Really? Were they ready for 5010?
What plans do they have in place for implementation?
Will they have new tools in place to help you with ICD-10? Will these have a cost? Will they create savings? How long will they run parallel coding?
When will they have software available for testing?
Will we need new hardware or is current hardware sufficient?
What is the cost?

51. Estimate Budget Budget considerations should include
Hardware costs
Software costs and licensing
Training
Parallel coding
Physician Query
Productivity losses
Jeopardy to cash flow
Some notable budget estimates follow this slide…

52. Develop Budget Cost Breakdown Example TOTAL $84,000 Education $ 2,500
Process Analysis $ 7,000
Changes to Super bills $ 3,000
IT Costs $ 7,500
Increased Documentation $44,000
Cash Flow Disruption $20,000
TOTAL $84,000
Cash flow disruption due to errors, delays in processing, etc.
Important that vendor can demonstrate successful test files before deadline
Conducted in 2008

53. ICD-10 Implementation $: AMA
(c) onPoint Oncology LLC

54. ICD-10 Implementation $$: MGMA
(c) onPoint Oncology LLC

55. Ask Yourself
How much did 5010 really cost your practice?

56. 2014

57. Implementation Planning
Break down planning into stages that fit your size and structure…
Training for a very small practice does not need to begin until 6 months prior to implementation
Review superbills or chargemaster or order entry charges and remove rarely used codes
Crosswalk common codes from ICD-9-CM to ICD-10-CM
Look up codes in ICD-10-CM book and use GEMs, if necessary, but this is a very general and not necessarily accurate way of coding.
Some vendors now have side-by-side coding, which facilitates the learning process.
You should parallel codes for some period

58. Develop Training Plan Who needs training?
Physicians
Coders
Billing staff
Administrative staff
Nurses, MAs, Pharmacy
Required number of hours depends on their role and coding interface
What resources are available in your area?

59. Develop Training Plan
Many organizations will have several mechanisms for training
Distance learning
Workshops
Conferences
Audio Conferences
Webinars
Books
Establish training schedule or just “Train the Trainer”, but this must be a trusted coding person who also can communicate necessary information to clinicians.
Having systems that facilitate clinicians and coders to be around the codes in 2014 are helpful.

60. Develop Training Plan
Determine if temporary staff or overtime will be necessary during training period
What materials will the office need for ongoing support after training?
Books
Software (code look up programs)
Other

61. Analyze Payer Processes
Identify all payer systems and processes that currently use ICD-9-CM
Review existing medical policies related to ICD-9-CM
Which contracts tied to reimbursement are tied to a particular diagnosis? Which payers have policies for cancer drugs that are tied to ICD-9? How will this be impacted?
Modify any contract agreements with health plans
Ascertain their timelines for testing ICD-10 acceptance

62. Policy Change/ Payment Impact
After health plans complete and change medical policy for procedures and services a specialty provides
Review new payment policies
Identify opportunities to improve coding processes
Communicate policy changes to applicable staff
Find out the policy switch-over date (might not be 10/1/2014)
How long will they accept ICD-9-CM claims?
Good news: many payers have ICD-10 right on their sites right now!!! Check it out!!!

63. Education and Training
Formal education should begin approximately months prior to implementation
Large practices may need to begin earlier to accommodate all staff who need training
Use various methods of training: on-line, distance, “Boot Camps”
Training time depends on their role
Physicians and coders/billers will need more training time than administrative staff

64. Deployment of Code
Should receive all updated software no later than 7/31/2014 for implementation of your charge documents. And, that is cutting it mighty close…
Vendor delivers software update with ICD-10-CM, but you should also know how long ICD-9 will be on- line.
Vendors should
Test system
Integrate software into your systems
Make internal customizations
Test systems with clearinghouses, payers, electronic claims transmission (end to end)
Ensure that the vendor will maintain updates to code during transition period

65. Testing of Code Does your PM system transmit ICD-10 codes?
What does your clearinghouse do?
Is your coding translated to incentive programs, PQRS? EHR?
Does the process from documentation to billing work?
Where are the snafus?

66. Implementation Compliance
Compliance date for implementation – October 1, 2014
Ensure you are staffed for the change.
Make sure lines of credit are in place.
Monitor compliance activities to identify any problems.
QA chart to billing coding and do this until it looks clean.
Pursue vendor and payer problems as necessary.

67. Other Considerations
Consider use of electronic tools to facilitate coding process
Could reduce costs and claims rejections
Could increase productivity and coding accuracy
Don’t convert superbills/charge documents too early
Things can change and you don’t want to up your costs
Assign ICD-10-CM codes directly, not by applying ICD-9- CM to ICD-10-CM map—it’s good practice’!! 67

68. Resources
ICD-10-CM Online GEMs Mapping Files ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2011/ Preparation Check List CMS ICD-10 Information

69. Basic Education Sites NCHS – Basic ICD-10-CM Informationtm
CMS – ICD-10-PCS Information
AHIMA - ICD-10 Education
WEDI – ICD-10 Implementation
We have included some web sites that contain basic information on what ICD-10 is, how coding should be done, and some of the key implementation steps and issues. We urge you to monitor these web sites for continued information. Both local and national organizations are looking at this topic, and may have resources for you to take advantage of.

70. CDC’s Web Resources General ICD-10 information
ICD-10-CM files, information, and General Equivalence Mappings (GEM) between ICD-10-CM and ICD-9-CM

71. AHA’s Resources Regulatory member advisories
Presentations and articles
ICD-10 audio seminar series
Central Office on ICD-9-CM
AHA Central Office ICD-10 Resource Center

72. In Summary… The time to start is YESTERDAY
The first thing you need to do is determine where change needs to happen and how much it will cost. Physicians may have no idea that this will be a line item.
Hospitals are way ahead of practices. They are doing dual coding right now! So, do not count on delays!
Physicians need to be trained---do not let them off the hook--- documentation is very different under ICD-10-CM.
Check out your payer polcies---some are already translated!
What did you learn from 5010 that will help you with this?
Marshall the resources that are available at no charge and there are a lot.

73. CAN Web Site
The latest news
Forms
Regulations
Newsletters
Presentations

74. Contact Info
Contact
Newsletter is free!
Send all RAC information to me at the ABOVE s or FAX to
Go to our website: