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ICD-10-CM An Introduction 2013 Bobbi Buell, MBA onPoint Oncology LLC 800-795-2633

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Presentation on theme: "ICD-10-CM An Introduction 2013 Bobbi Buell, MBA onPoint Oncology LLC 800-795-2633"— Presentation transcript:

1 ICD-10-CM An Introduction 2013 Bobbi Buell, MBA onPoint Oncology LLC

2 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 4

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 5

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

7  ICD-9-CM is out of date and running out of space for new codes on the procedural side.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.

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 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 ICD – 9-CMICD – 10-CM 13,600 codes69,000 codes Code book contains 17 chaptersCode book contains 21 chapters Consists of 3 to 5 charactersConsists of 3 to 7 characters 1 st character is alpha or numeric1 st character is alpha Only utilizes letters E and VUtilizes 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

14 Character Changes ICD-9-CMICD-9-CM Chapter ICD-10-CMICD-10-CM Chapter Chapter 1Infectious or Parasitic Disease A0-B Chapter 1NeoplasmsC00-D Chapter 6Diseases of the Nervous System G00-G99 Chapter 7Diseases of the Eye and Adnexa H00-H59 Chapter 8Diseases of the Ear and Mastoid H60-H95

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

16 X. ICD-9-CM Structure – Format XXXX5E1400. V Category Etiology, Anatomic Site, Manifestation 4 Numeric or Alpha (E or V) Numeric 3 – 5 Characters

17 XXXX Category. Etiology, Anatomic Site, Severity Added code extensions (7 th character) for obstetrics, injuries, and external causes of injury ICD-10-CM Structure – Format XXX AMS A Additional Characters Alpha (Except U) Numeric or Alpha 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 6 th and 7 th 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 ICD-9 Code Description (Source) 820.8Fracture of unspecified part of neck of femur, closed ICD-10 Code Description (Target) S72.009AFracture of unspecified part of neck of femur, initial encounter for closed fracture ICD-9 Code Description (Target) 820.8Fracture of unspecified part of neck of femur, closed ICD-10 Code Description (Source) S A S A S A 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 Forward Mapping Backward Mapping

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 6 th and 7 th digits

29 Cancer Differences Laterality Mandatory’ use additional’ codes—look at lung cancer 6 th 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 32 Checklist: Awareness and Impact Assessment Preparing for Implementation Go Live Preparation Post – Implementation Phase I Phase II Phase III Phase IV Year

33 Where to Start?

34 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 34 Diagnostic Codes are Ubiquitous

35 Solo Practitioner Or Small Group (2-10) Practice Implementation Planning 1. Organize Implementation Effort 2. Establish Communication Plan 3. Conduct Impact Analysis 4. Contact System Vendors 5. Estimate Budget 6. Implementation Planning 7. Develop Training Plan 8. Analyze Business Processes 9. Education and Training 10. Policy Change Development 11. Deployment of Code 12. Implementation Compliance 35 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 37

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. 38

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. 39

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 40

41 Potential Areas that will be Impacted!

42 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 Potential Areas that will be Impacted! For those that can’t read the small print… Source: AAPC 2012

43 Lab Documentation Reporting Billing Policies & Procedures Training Pharmacy Infusion Room Coding – Code Set – Clinical Knowledge – Concurrent Use Front Desk – Referrals/ History codes – Systems Potential Areas that will be Impacted! 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 ProjectSource: 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. 46

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

48

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? 50

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… 51

52 Develop Budget Cost Breakdown Example 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

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

54 ICD-10 Implementation $$: MGMA 54 (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 57

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? 58

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. 59

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 60

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 61

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!!! 62

63 Education and Training Formal education should begin approximately 6- 8 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 63

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 64

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. 66

67 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’!!

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 https://www.cms.gov/ICD10/

69 Basic Education Sites NCHS – Basic ICD-10-CM Information tm CMS – ICD-10-PCS Information AHIMA - ICD-10 Education WEDI – ICD-10 Implementation

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

71 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. 72

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

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


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