1. Director, Nashville Fertility Center
ICD 10: What to Expect
George A. Hill, MD
Director, Nashville Fertility Center
Nashville, TN 37203

2. LEARNING OBJECTIVES
At the conclusion of this presentation, participants should be able to:
Understand ICD-10 background and history, description, and future
Comprehend the key distinctions between ICD-9-CM and ICD-10-CM
Understand what physicians need to do now to prepare
Understand the actions that practices need to take to implement the change to ICD -10-CM on a timely basis

3. DISCLOSURE
Committee Member: United Healthcare Women’s Health Scientific Advisory Board
Grant Recipient: EMD Serono Inc

4. Disclaimer
ICD-10 codes included in this presentation are not valid prior to the implementation date of October 1, 2014
ICD-10 codes included in this presentation may be revised prior to implementation
ICD-9 codes should continue to be used until transition date of October 1, 2014

5. Why the Change?
ICD-9-CM is 30 years old, out of date and running out of space!
ICD-10 is the international standard and has been for a number of years
ICD is important to Health Information Technology (HIT) and the change is needed to fully implement HIT

6. ICD-10 and HIT
Importance of a better coding classification system:
Integral to HIT Strategy - especially the Electronic Health Record (EHR)
Improved clinical specificity = improved patient safety
Improves understanding of disease / costs and allows providers and others to improve on their delivery
International Disease Surveillance

7. ICD-10: Current Status Some current opposition to implementation
Per CMS, no delay or schedule change is pending (except!) (postponed from 10/1/2013 to 10/1/2014)
Physicians need to be prepared for the change in order to prevent a revenue flow interruption on 10/1/2014

8. Understanding ICD
ICD is part of the World Health Organization’s (WHO) system of classification
ICD-CM (clinical modification) used to track morbidity
ICD used to report mortality
In the United States, we (ASRM/ACOG Coding Committees) work through the National Center for Health Statistics to implement changes/updates

9. History of ICD-10 ICD-10 adopted by WHO in 1990
First modification in 1998
U.S. only industrialized nation that has not yet implemented ICD-10 or a modification in some format
U.S. first began exploring idea in 1994
Draft versions available 2002, 2007, 2009, 2010, 2011
Implementation Date: October 1, 2014!

10. Key Differences: ICD-9-CM to ICD-10-CM
ICD-10-CM consists of 21 chapters compared to 17 in ICD-9-CM
Chapters divided into “blocks” of codes with additional subcategories
V and E code supplemental classifications incorporated into main classifications
Conditions of sense organs separated from nervous system

11. Key Differences: ICD-9-CM to ICD-10-CM
Certain diseases reclassified to reflect current medical knowledge
ICD-10 classifies injuries by specific site then by type vs. ICD-9 classification by type
Postoperative complications moved to procedure specific system chapters (complications of GU surgery in GU chapter)

12. Key Differences: ICD-9-CM to ICD-10-CM
ICD-10-CM codes are alphanumeric and up to 7 characters ICD-9-CM are 3-5 characters in length (mostly numeric)
ICD-10-CM includes full code titles vs. references to common 4th -5th digits
Addition of 6th characters for some
Addition of code extensions (7th digit)
Addition of dummy placeholder “X”

13. New Features in ICD-10-CM
Combination codes for conditions and common symptoms/manifestations
Combination codes for poisoning and external causes
Added laterality for some codes (right vs. left)

14. Key Changes for Reproductive Endocrinology/Infertility
Inclusion of trimesters in obstetric codes
Separate codes to indicate gestational week
Elimination of episodes of care for obstetric codes
Changes in time frames:
Abortion vs. Fetal death ( 20 weeks)
Early vs. Late pregnancy (20 weeks)
Extensions to denote specific fetus
New GU codes and notes including category title changes

15. Structure and Format of ICD-10-CM
First character is always alphabetic letter
Chapter 14 Diseases of the GU system (N00-N99)
Chapter 15 Pregnancy, Childbirth and Puerperium (O00-O9A)
Second character is always a number
Characters 3-7 alpha or numeric
O9A.311: Physical abuse complicating pregnancy, first trimester

16. Structure and Format of ICD-10-CM
Alphabetic Index: Alphabetic Listing of Terms and Codes
Index to Diseases and Injury
Index to External Causes of Injury
Neoplasm Table
Table of Drugs and Chemicals
Tabular List: Chronological list divided into chapters based on body system or condition

17. Structure and Format of ICD-10-CM
Code Format: XXX.XXX X
XXX= Category
XXX= Etiology, anatomic site, severity
X= Extension
Placeholder Character X
Used with certain codes for potential future expansion
When placeholder exists, must use X in that location for valid code

18. Structure and Format of ICD-10-CM
Labor and delivery complicated by cord around neck, without compression: O69.81X2
O69:Labor and delivery complicated by umbilical cord complications
81:Cord around neck, without compression
X: Placeholder
2: Fetus 2

19. General Coding Guidelines
Locate code in Alphabetic Index and confirm in Tabular list
Report the highest number of characters available
Signs and symptoms are acceptable if diagnosis has not been confirmed by provider (Chapter 18 contains many but not all)

20. General Coding Guidelines
Combination codes should be reported when code fully describes condition
Combination code is single code that describes:
Two diagnoses
Diagnosis with an associated secondary process (manifestation)
Diagnosis with an associated complication

21. 2012 ICD-10-CM Codes Applicable to RE/I
C00-D99 Neoplasms
E00-E89 Endocrine, nutritional and metabolic diseases
N00-N99 Diseases of the genitourinary system
O00-09A Pregnancy, childbirth, and the puerperium
Q00-Q99 Congenital Malformation, deformations, and chromosomal abnormalities
R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

22. N00-N99 Diseases of the Genitourinary Sytem
N70-N77 Inflammatory diseases of female pelvic organs
N80-N98 Noninflammatory disorders of female genital tract
N99-N99 Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified

23. N80-N98 Noninflammatory disorders of female genital tract
N80 Endometriosis
N83 Noninflammatory disorders of ovary, fallopian tube, and broad ligament
N84 Polyp of female genital tract
N92 Excessive, frequent, and irregular menstruation
N96 Recurrent Pregnancy Loss
N97 Female Infertility
N98 Complications associated with artificial fertilization

24. Some Diagnoses will be Straight Crosswalks

25. N80 Endometriosis ICD-9-CM Description ICD-10-CM 617.0
Endometriosis of uterus
N80.0
617.1
Endometriosis of ovary
N80.1
617.3
Endometriosis of pelvic peritoneum
N80.3
617.5
Endometriosis of intestine
N80.5

26. N97 Female Infertility ICD-9-CM Description ICD-10-CM 628.0
Female Infertility associated with anovulation
N97.0
628.2
Female Infertility of tubal origin
N97.1
628.3
Female Infertility of uterine origin
N97.2
628.8
Female Infertility of other origin
N97.8
628.9
Female Infertility, unspecified
N97.9

27. N97 Female Infertility—What are Excludes?
Type 1 Excludes
Female infertility associated with:
Hypopituitarism (E23.0_)
Stein Leventhal Syndrome (E28.2_)
Type 2 Excludes
Incompetence of cervix uteri (N88.3_)

28. Type 1 Excludes
A type 1 excludes note is a pure excludes. It means “not coded here”
A type 1 excludes note indicates that the code excluded should never be used at the same time as (N97)
Used when 2 conditions cannot occur together

29. Type 2 Excludes A type 2 excludes note represents “not included here”
A type 2 excludes note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time
When a type 2 excluded note appears under a code it is acceptable to use both the code (N97) and the excluded code together

30. N97 Female Infertility Type 1 Excludes Type 2 Excludes
Female infertility associated with:
Hypopituitarism (E23.0_)
Stein Leventhal Syndrome (E28.2_)
Type 2 Excludes
Incompetence of cervix uteri (N88.3_)

31. N96 Recurrent Pregnancy Loss
Type 1 Excludes
Recurrent pregnancy loss with current pregnancy (O26.2-)
O26.20 …unspecified
O26.21 …first trimester
O26.22 …second trimester
O26.23 …third trimester

32. Some Codes may be less specific

33. O00 Ectopic Pregnancy ICD-9-CM Description ICD-10-CM 633.0
Abdominal pregnancy
O00.0
633.1
Tubal pregnancy
O00.1
633.10
without intrauterine pregnancy
633.11
with intrauterine pregnancy
633.2
Ovarian pregnancy
O00.2
633.8
Other ectopic pregnancy
O00.8
633.9
Ectopic pregnancy, unspecified
O00.9

34. Some codes may have the same specificity

35. O02 Other abnormal products of conception
O02.81 Inappropriate change in quantitative human chorionic gonadotropin (hCG) in early pregnancy
Currently in ICD-9-CM:

36. Some codes may be more specific

37. O30 Multiple Gestation ICD-9-CM Description ICD-10-CM 651.0_
Twin pregnancy
O30.0
V91.02
Twin pregnancy, monochorionic/diamniotic
O30.03
…first trimester
O30.031
V91.03
Twin pregnancy, dichorionic/diamniotic
O30.04
O30.041
651.1_
Triplet pregnancy
O30.1
V91.11
Triplet pregnancy with 2 or more monochorionic fetuses
O30.11
O30.111

38. Some codes will replace multiple codes, some will be new

39. N98 Complications associated with artificial fertilization
N98.1 Hyperstimulation of ovaries (620.8, 256.1, E932.4)
N98.3 Complications of attempted introduction of embryo in embryo transfer

40. What about Fibroids?

41. Neoplasms (C00-D49)
(D10-D36) Benign neoplasms, except benign neuroendocrine tumors
D25 Leiomyoma of Uterus

42. D25 Leiomyoma of Uterus ICD-9-CM Description ICD-10-CM 218.0
Submucous leiomyoma of uterus
D25.0
218.1
Intramural leiomyoma of uterus
D25.1
218.2
Subserous leiomyoma of uterus
D25.2
218.9
Leiomyoma of uterus, unspecified
D25.9

43. Z31 Encounter for Procreative Management
Z31.41 Encounter for fertility testing (V26.21)

44. Z32. Encounter for pregnancy test and childbirth
Z32 Encounter for pregnancy test and childbirth and childcare instruction
ICD-9-CM
Description
ICD-10-CM
V72.4
Encounter for pregnancy test
Z32.0
V72.40
…result unknown
Z32.00
V72.42
…result positive
Z32.01
V72.41
…result negative
Z32.02

45. Summary
Greatly increased number of codes in ICD-10, but RE/I will still only routinely use a small subset of the new code set
Due to greater specificity, ICD-10 often allows the use of fewer codes than ICD-9 to adequately capture specific patient conditions
The general coding principles/diagnosis code selection processes that apply to ICD-9-CM will also apply to ICD-10-CM

46. Summary
System changes will be necessary to accommodate increased digits and character changes
May require changes in medical record documentation to support increased specificity
Education will be necessary for staff and providers

47. What to Do Now DO NOT PANIC!!
Assess the quality of medical record documentation
Consider conducting a documentation assessment audit
Implement documentation improvement strategies if necessary based on audit results
Monitor the impact of any documentation improvement strategies
Reassess and refine
DO NOT PANIC!!

48. Planning for the Transition
Verify with software vendors plans for testing and implementation
Assign internal implementation team
Include physicians and other providers
Clinical staff (nursing, lab, etc)
Administrative staff
Coding/ Billing staff

49. Planning for the Transition
Assess current uses and users of ICD-9 in practice
Assess skills and understanding of ICD
Determine who needs ICD-10 training
Evaluate training options
Evaluate current documentation practices
Plan for changes to charge capture documents

50. ACOG: ICD-10-CM Resources
ICD-10 page on ACOG website
Monthly Subscription Listserv (contains latest ICD-10 news, updates and links)

51. ACOG: ICD-10-CM Resources
ICD Training Plan
2013
Increased number of Coding Workshops (14)
All Workshops presented using only ICD-10 codes
ICD-10 to ICD-9 / ICD-9 to ICD-10 Crosswalks included for each Workshop module
Each Workshop attendee will receive a draft copy of the current ICD-10 code set
Separate (1/2 day) ICD-10 only training modules
Focused exercises using the new code set
Staff may attend alone

52. ACOG: ICD-10-CM Resources
Separate (1 page) ICD-10 and CPT Encounter Forms and Quick Reference Sheets in 2013
Coding Publications
Essential Guide, Frequently Asked Questions, (all coding publications with ICD info) will be updated to include ICD-10 content

53. What will ASRM do? Coding courses at the Annual Clinical Meeting
Information in the Coding Corner of the Website
Communicate with the ASRM Coding Committee any ideas you have that would be beneficial in helping our members implement ICD-10-CM

54. ICD-10-CM Resources CMS NCHS (CDC) AHIMA AAPC http://www.cms.gov/ICD10
AHIMA
AAPC

55. ICD10Data.com ICD-10-CM Resources
The best web site I have found to help with looking up ICD-10-CM codes:
ICD10Data.com

56. ICD Future ICD -11 is on the horizon internationally:
Tweaked version of ICD-10, not a huge change from 10 to 11
ICD-11 initial version made available for public review - May 2011
WHO plans to present ICD-11 to the World Health Assembly in 2015

57. Other Important Codes in ICD-10
W61.11XA: Bitten by macaw, initial encounter
W61.11XD: Bitten by macaw, subsequent encounter
W61.11XS: Bitten by macaw, sequela
W61.12XA: Struck by macaw, initial encounter
W61.12XD: Struck by macaw, subsequent encounter
W61.12XS: Struck by macaw, sequela
W61.19XA: Other contact with macaw, initial encounter
W61.19XD: Other contact with macaw, subsequent encounter
W61.19XS: Other contact with macaw, sequela

58. Important Codes in ICD-10
V90.27XA: Drowning and submersion due to falling or jumping from burning water-skis, initial encounter
V90.27XD: Drowning and submersion due to falling or jumping from burning water-skis, subsequent encounter
V90.27XS: Drowning and submersion due to falling or jumping from burning water-skis, sequela
V90.37XA: Drowning and submersion due to falling or jumping from crushed water-skis, initial encounter
V90.37XD: Drowning and submersion due to falling or jumping from crushed water-skis, subsequent encounter
V90.37XS: Drowning and submersion due to falling or jumping from crushed water-skis, sequela
V90.87XA: Drowning and submersion due to other accident to water-skis, initial encounter
V90.87XD: Drowning and submersion due to other accident to water-skis, subsequent encounter
V90.87XS: Drowning and submersion due to other accident to water-skis, sequela
V91.07XA: Burn due to water-skis on fire, initial encounter
V91.07XD: Burn due to water-skis on fire, subsequent encounter
V92.07XA: Drowning and submersion due to fall off water-skis, initial encounter
V92.07XD: Drowning and submersion due to fall off water-skis, subsequent encounter
V92.07XS: Drowning and submersion due to fall off water-skis, sequela
V92.27XA: Drowning and submersion due to being washed overboard from water-skis, initial encounter
V92.27XD: Drowning and submersion due to being washed overboard from water-skis, subsequent encounter
V92.27XS: Drowning and submersion due to being washed overboard from water-skis, sequela
V93.87XA: Other injury due to other accident on board water-skis, initial encounter
V93.87XD: Other injury due to other accident on board water-skis

59. September 2014 rolls around, You haven’t prepared!
TIME TO PANIC!!

60. QUESTIONS?