1. Presented by: Janet Smith, RHIT, CPC AHIMA Approved ICD-10 Trainer
ICD-10-CM Update
Presented by: Janet Smith, RHIT, CPC AHIMA Approved ICD-10 Trainer
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2. Brief History
ICD-10 was adopted by the World Health Organization (WHO) in 1990
Following the publication of ICD-10, many countries performed analysis to determine if the WHO classification system would meet their needs
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the United States’ clinical modification to the World Health Organization’s version of ICD-10
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3. Brief History Countries Using ICD-10 For Reimbursement or Case Mix:
United Kingdom
Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) –1997
France
Australia
Belgium
Germany
Canada
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4. Brief History
The United States remains the only industrialized nation that has not yet implemented ICD-10 or a clinical modification for diseases or causes of illness typically coded in a healthcare facility
Since 1999, however, the United States has used ICD-10 for mortality reporting (for death certificates)
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5. Why do we need ICD-10?
ICD-9 is 30 years old –medicine and technology has changed
Many categories full
Not descriptive enough
Implementing ICD-10-CM will maintain data comparability internationally and between mortality and morbidity data in the United States
Would enhance accurate payment for services rendered
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6. Benefits of ICD-10-CM Greater clinical detail
More specificity, laterality, external causes of injuries, combination codes for diagnoses and symptoms
Reflects advances in medicine and medical technology
Measuring the quality, safety, and efficacy of care
Reducing the need for attachments to explain patient’s condition
Improving clinical, financial, and administrative performance
Tracking public health and risks
So why do we need a new system?
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7. When will ICD-10 be implemented?
In January 2009, the Department of Health and Human Services published the final rule for adoption of ICD-10-CM and ICD-10-PCS, setting a compliance date of October 1, 2013
On April 9, 2012, HHS released a proposed rule that calls for a one-year delay for the ICD-10 compliance date from October 1, 2013 to October 1, 2014.
On April 17, 2012 the announcement for the ICD-10 delay was published in the Federal Register. A 30-day comment period was granted on the proposed rule and is now closed.
Public comments are being reviewed and analyzed, and the Department will issue a final rule as expeditiously as possible
As of today, a final rule has not been announced.
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8. Reasons behind the delay
There was no one group that spurred CMS to propose the delay
The industry’s ongoing struggle to implement HIPAA Version 5010 (a precursor to ICD-10) that was effective January 2012 but has seen enforcement delayed twice because many physicians have had technical trouble implementing the version update
Physician concern regarding the ICD-10 timeline
A one-year delay reflects the industry’s need for a quick resolution and providers’ need for additional time to implement, and will not likely penalize those on track with the original deadline
The American Health Information Management Association (AHIMA) recommended that the 2013 implementation deadline remain, stating that a majority of the healthcare industry is on track and that those who have worked hard to meet the original deadline should not be punished with the costs that will come with a delay.
According to the online publication, Journal of AHIMA – ICD-10 Summit Coverage - April 18, 2012, “Not all providers are for a delay. Dr. Jeff Linzer, with the American Academy of Pediatrics, said his organization is against any delay, stating that physicians have had adequate time to prepare for ICD-10 and that the code set, largely created by physicians, can only improve care.
The primary reason for the proposed delay, according to CMS, was the industry’s ongoing struggle to implement HIPAA Version 5010, which was a prerequisite for ICD-10. HIPPA Version 5010 has already seen delays because of technical trouble with the version update. Many provider groups and health care entities have also expressed serious concerns about their ability to meet the October 1, 2013 compliance date.
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9. What to Expect with ICD-10?
ICD-10-CM (Clinical Modification) will replace ICD-9-CM diagnosis codes rendered in all healthcare settings.
ICD-10-PCS (Procedural Coding System) will replace the ICD-9-CM procedure codes rendered in the hospital/inpatient setting.
CPT and HCPCS Level II will remain the coding system for physician and professional services and procedures performed in the outpatient setting.
After the implementation of the ICD-10 code set, inpatient reimbursement for Medicare patients will be based on Medicare DRGs using the ICD-10 coding system not ICD-9
Payer and office systems and processes must be able to support both ICD-9 and ICD-10 code sets on the implementation date
There will be no change to the current CPT and HCPS system. Physicians will still report the E/M and procedure codes for services in the outpatient setting and for evaluation and management services in the hospital setting. In order to continue to process claims, adjust or appeal claims for dates of service prior to implementation date, systems will have to support both coding systems for completing claims transactions.
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10. ICD-10 Practice Impact Plan for budgeting Staffing changes/additions
Revenue flow problems
Productivity
Software/System upgrades
Staffing changes/additions
Education for providers and staff
Audit for increased specificity in documentation
(Stages of healing, episode of care, laterality)
Code set training
Operate under dual coding system
Health Plans
Contracts
Coverage policies
All areas of healthcare will be affected. Will health plans be ready and how will ICD-10 affect contracts and coverage policies? Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, payment schedules, or reimbursement
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11. Cost Estimate – 5 Physician Practice (Two Years)
Information Systems
Practice Management Upgrade - $5,000
EMR Upgrade (if applicable) - $5,000
IT and Consulting - $5,000
Audit/Review/Consulting
General Consulting/Audit Year $500/provider twice a year - $3,000
General Consulting Year 2 - $3,000
Review of System Process - $3,000
Crosswalking - $1,500
These figures are from the American Academy of Professional Coders and give an estimated cost of ICD-10 implementation, training and education
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12. Cost Estimate – 5 Physician Practice (Two Years)
Education and Training
5 physicians - $3,500
1 coder/biller - $1,600
2 nurses/MA - $3,000
2 ancillary staff - $1,000
Management - $500
Staff and Overtime
Coders - $2,000
Ancillary Staff - $400
Productivity Loss - $18,400
TOTAL Estimated Cost = $59,500
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13. How is ICD-10 structured?
The “look-up” process will be very similar to ICD-9
The same hierarchical structure is used as ICD-9
The ICD-10 system will be alphanumeric and contain up to 7 characters
ICD-10 has approximately 68,000 codes vs. 14,000 in ICD-9
Code composition and level of detail are the major differences
You will look up codes from the tabular section just as you would in ICD-9. The more digits, the greater the specificity
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14. ICD-10- CM Structure 21 Chapters 2 New Chapters
Diseases of the Eye and Adnexa (Ch 7)
Diseases of the Ear and Mastoid Process (Ch 8)
Certain Diseases were re-classified and are now found in new chapters
Immune Mechanism (Immunity) was moved from Chapter 4 (Endocrine) to Chapter 3 (Blood Disorders)
Injuries (Ch19) are now arranged by body part and not by injury
Mental Disorders (Ch 5), Injury and Poisonings (Ch 19), and External Causes (Ch 20) were all
re-organized
Diseases of the eye and ear have been separated from the nervous system and these conditions have their own chapters. Injuries will be grouped by specific site (head, arm, leg) and then by type of injury (fracture, open wound). Many changes are seen in the Mental Disorders chapter to reflect updated terminology and include expanded codes for tobacco, drug and alcohol use and dependence.
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15. ICD-10- CM Structure
Codes have 3 to 7 alphanumeric characters (vs 5 numeric in ICD-9)
Character 1 is always alpha – letters A-Z, except U
Character 2 is numeric
Character 3-7 can be alpha or numeric
Decimal placed after the first three characters
Alpha characters are not case-sensitive
A78 – Fever
J04.0 – Acute laryngitis
S – Laceration w/o foreign body of right upper arm
S63.280A – Dislocation of proximal interphalangeal joint of right index finger, initial encounter
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16. ICD-10- CM Structure
Character 4 represents a subcategory that further defines the site, etiology and manifestation or state of the disease
Character 5 and 6 identify the most accurate level of specificity
Character 7 – Extension
Some codes require 7 characters
If a code requires a 7th character and there is no 5th or 6th character, a placeholder “X” must be used
All placeholders of an applicable code must be reported
Example: T16.XXA – Foreign body in right ear, initial encounter
The greatest specificity ends after the third character, but a 7 character is required to describe the episode of care so two place holders are reported in the 5th and 6th spot. The 7th character extender A indicates that this is the initial encounter
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17. ICD-10- CM Structure
S60 – Superficial injury of wrist, hand and fingers
S60.4 – Other superficial injuries of other fingers
S60.45 – Superficial foreign body [splinter] of fingers
S – Superficial foreign body [splinter] of left index finger
S60.451A – Superficial foreign body [splinter] of left index finger, initial encounter
So a 7 character code may look like this.
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18. Translation of Codes ICD-9-CM TO ICD-10-CM = ICD-9-CM TO ICD-10-CM ≠
Salmonella meningitis =
A Salmonella meningitis
ICD-9-CM TO
ICD-10-CM
Sleep Arousal Disorder ≠
F51.3 Sleepwalking
ICD-9-CM
ICD-10-CM
Primary tuberculosis infection, unspecified examination
Primary tuberculosis infection, bacteriological/histological exam not done
Primary tuberculosis infection, bacteriological/histological exam unknown (at present) ≠
A15.7 Primary respiratory tuberculosis
Some codes may have the same wording but different codes, some wording may not translate exactly due to increased specificity. Some codes in ICD9 may have certain specificities that do not translate to ICD-10
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19. External Causes Chapter 20 - Codes for external causes
V, W, X and Y are the 1st characters
Are never used as primary code
Are never reported alone
Chapter 20 contains codes for external causes related to place of occurrence or activity code, where and what the patient was doing when the injury occurred. These codes are used like E codes in ICD-9
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20. Z Codes are the New “V” Codes
Chapter 21 – Factors influencing health status and contact with health services
Encounter for healthcare exams
Are part of the ICD-10-CM code set and must be recognized by payers
May be used as primary diagnosis
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21. Preventive Care
Z Routine child health check Z Routine child health check with abnormal findings Z Health supervision (health check) for newborn under 8 days Z Health supervision (health check) for newborn 8 to 28 days Z23 Encounter for immunizations
With ICD-10 there will only be one code for immunizations.
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22. Other Health Visits
Z Pre-operative examination Z02.0 School physicals Z02.5 Sports physicals Z02.82 Pre-adoption exam Z48.02 Suture removal Z71.0 Parent (family) conference Z71.3 Diet management (for obesity) Z76.81 Parents pre-birth or pre-adoption visit
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23. Documentation Use appropriate terminology
Document highest level of specificity
Indicate right versus left
Indicate specific body area
Specify episode of care (initial, recurrent)
Documentation is going to be extremely important because of the increase in level of specificity. Practices should begin to audit their documentation to ensure specificity.
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24. Reimbursement and Quality Problems With ICD-9-CM
Example –Fracture of Wrist
Patient fractures left wrist
A month later, fractures right wrist
ICD-9-CM does not identify left versus right –requires additional documentation
ICD-10-CM describes left versus right
Initial encounter, subsequent encounter
Routine healing, delayed healing, nonunion, or malunion
Eliminates the need to submit additional documentation to explain circumstances.
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25. Example
If provider documents: OM (otitis media) Code = H66.90 otitis media, unspecified, unspecified ear
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26. Possible Codes
Acute suppurative otitis media without spontaneous rupture of ear drum
H66.001, right ear
H66.002, left ear
H66.003, bilateral
H66.004, recurrent, right ear
H66.005, recurrent, left ear
H66.006, recurrent, bilateral
H66.007, recurrent, unspecified ear
H66.009, unspecified ear
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27. Example
If provider documents: Reactive Airway Disease Code = J Unspecified asthma, uncomplicated Respiratory Distress Code – R06.89 Other abnormalities of breathing
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28. Possible Codes
J98.01 Acute bronchospasm J Exercise induced bronchospasm J Cough variant asthma
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29. Other Possible Asthma Codes
Asthma J45.20 Mild intermittent, uncomplicated J45.21 Mild intermittent, with (acute) exacerbation J45.22 Mild intermittent with status asthmaticus J45.30 Mild persistent, uncomplicated J45.31 Mild persistent, with (acute) exacerbation J45.32 Mild persistent, with status asthmaticus J45.40 Moderate persistent, uncomplicated J45.41 Moderate persistent, with (acute) exacerbation
You get the jist
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30. What to do now? Maintain momentum
Identify current systems and processes that use ICD-9 codes
Talk with vendors about accommodations for ICD-10
Take the time to improve clinical documentation
Evaluation staff training needs
Ask payers how ICD-10 changes may affect contracts, payment schedules and reimbursement
Forget that ICD-10 may be delayed. Treat it as a priority and use this time to plan. Improving clinical documentation will help with the new specificity of code selection. TNAAP plans to offer ICD-10 training for practices. The details and timing for training will be forthcoming and will depend largely on the final rule as to when to begin the training. It is anticipated that the trainings will be an all day workshop and held regionally. We are also looking at the possibility of on-line webinars.
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31. Informational Links http://www.cdc.gov/nchs/icd/icd10cm.htm
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32. Questions?
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33. Thank You!
Contact information: Janet Smith Coding Educator
Remember TNAAP offers many educational trainings and support for your office. If you would like to request further education or an in-office training for your staff, please contact me. Also if you have EPSDT or coding questions, please visit our website or me directly at or feel free to call me
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