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ICD-10-CM An Introduction 2012

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1 ICD-10-CM An Introduction 2012
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 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 The AMA asked HHS to postpone or cancel ICD-10.
CMS intimated that the deadline would be postponed. HHS is in the process of making a rule as to how the postponement will work.

4 ICD-9-CM vs. ICD-10-CM

5 Why is ICD-9 Being Replaced?
ICD-9-CM is out of date and running out of space for new codes. 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

6 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

7 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

8 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

9 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

10 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

11 Comparison of ICD-9-CM and ICD-10-CM
ICD-9-CM Codes ICD-10-CM Codes Pressure ulcer codes 9 codes 125 codes L89.0-L89.94 Codes: 707.0 Pressure ulcer unspecified site elbow upper back lower back hip buttock ankle heel other site Code Examples: L – Pressure ulcer of right lower back, stage I L – Pressure ulcer of right lower back, stage II L – Pressure ulcer of right lower back, stage III L – Pressure ulcer of right lower back, stage IV L – Pressure ulcer of right lower back, unspecified stage L – Pressure ulcer of left lower back, stage I L – Pressure ulcer of left lower back, stage II L – Pressure ulcer of left lower back, stage III L – Pressure ulcer of left lower back, stage IV L – Pressure ulcer of left lower back, L – Pressure ulcer of sacral region, stage I L – Pressure ulcer of sacral region, stage II L89.90 – Pressure ulcer of unspecified site, unspecified stage The codes on the right are only a small set of the 125 potential pressure ulcer codes offered in ICD-10 Pressure ulcer stages 707.2x separate codes (6 codes) , difficult to match up if more than one pressure ulcer

12 New Features of ICD-10-CM
Combination codes for conditions and common symptoms or manifestations Combination codes for poisonings and external causes Added laterality Expanded codes: injury, diabetes, alcohol/substance abuse, postoperative complications

13 New Features of ICD-10-CM
Added extensions for episode of care Inclusion of trimester in obstetrics codes and elimination of fifth digits for episode of care Expanded detail relevant to ambulatory and managed care encounters Inclusion of clinical concepts that do not exist in ICD-9-CM Changes in timeframes specified in certain codes 1) A Initial encounter for closed fracture B Initial encounter for open fracture D Subsequent encounter for fracture with routine healing G Subsequent encounter for fracture with delayed healing K Subsequent encounter for fracture with nonunion P Subsequent encounter for fracture with malunion S Sequelae 2) Delivered, Antepartum or Postpartum is replaced with the trimester 3) No info 4) Underdosing 5) Acute MI is 8 weeks in ICD-9, 4 weeks in ICD-10

14 Useful in Cancer?? Laterality – Left Versus Right
C50.1 Malignant neoplasm, of central portion of breast C Malignant neoplasm of central portion of right female breast C Malignant neoplasm of central portion of left female breast

15 Useful In Cancer??? ICD-9-CM ICD-10-CM 143 Malignant neoplasm of gum
143.0 Upper gum 143.1 Lower gum ICD-10-CM C03 Malignant neoplasm of gum C03.0 Malignant neoplasm of upper gum C03.1 Malignant neoplasm of lower gum

16 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

17 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.

18 General Equivalence Mappings

19 What are GEMs? “GEMs” stands for General Equivalence Mappings
The CMS and the CDC created GEMs to ensure consistent national data when the U.S. adopts ICD-10. The GEMs will act as a translation dictionary to bridge the “language gap” between the two code sets and can be used to map an ICD-9 code to an ICD-10 code and vice versa. Mappings between ICD-9-CM and ICD-10-CM will play a critical role in the successful transition to ICD-10. The CMS and the CDC created the GEMs to ensure consistent national data when the US makes the transition.

20 Purpose of GEMs Designed to give all sectors of the healthcare industry that use coded data the tools to: Convert large databases and test system applications Link data in long-term clinical studies Develop application-specific mappings Analyze data collected before and after the transition to ICD- 10-CM They are public domain, general purpose reference mappings designed to give all sectors of the healthcare industry that use coded data the tools to:

21 Not a Substitute for Coding
The GEMs should not be used as a substitute for learning how to use the ICD-10-CM code sets. “GEMs are not a substitute for learning ICD-10-PCS and ICD-10-CM coding. They’ll help you convert large data sets.” Mapping simply links concepts in the two code sets, without consideration of context of specific patient information, whereas coding involves assigning the most appropriate code based on documentation and applicable coding guidelines. They were created to serve a specific, limited, short-term need – primarily for translation purposes. Compare GEMs to a Spanish to English dictionary, where both languages can be found and speakers can go back and for the to translate from one to the other. Pat Brooks, senior technical advisor, CMS stresses that the GEMs are not substitute for learning ICD-10. A GEM should NEVER be used as a way to code in ICD-10. GEMs were not developed act as a substitution for learning to code in ICD-10.

22 Why a GEM Won’t Always Work
A clear one-to-one correspondence between an ICD-9 or ICD-10 code is the exception rather than the rule. ICD-9 codes: Coronary atherosclerosis of native coronary artery and Intermediate coronary syndrome (unstable angina) ICD-10 code :I Atherosclerotic heart disease of native coronary artery with unstable angina There are situations when a code in the target system does not exist T503x6A Underdosing of electrolytic, caloric and water- balance agents, initial encounter Not all ICD-9 codes are used in ICD-10, Not all ICD-10 codes have comparative codes in ICD-9

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 Neoplasm Guidelines

29 Neoplasm Guidelines Many guidelines are the same, but there are differences. We try to cover those today. To properly code a neoplasm, it is necessary to determine (not too different) whether: It is benign, malignant, benign, in situ or of uncertain behavior; If the malignant, any secondary or metastatic sites should be identified. To code properly the Index Neoplasm Table should be accessed EXCEPT: If the histology is mentioned in the code descriptor, e.g. adenoma or sarcoma

30 Neoplasm Guidelines Again, if the encounter is strictly for chemo, immunotherapy, or Radiation, those codes should be coded as the principal diagnosis with the neoplasm as a secondary. No big change from today. The secondary neoplasm should be designated as the primary, if treatment is directed there.

31 Neoplasm Complications
Anemia associated with malignancy is coded with the malignancy sequenced first and anemia second. This is a major departure---we shall see what payers do with this. Anemia associated with chemo or immunotherapy is coded with the adverse event code first and anemia second, then the malignancy. Management of anemia associated with radiation is coded with anemia first, malignancy second, and Y84.2 third which is radiation causing an abnormal reaction in the patient.

32 Neoplasm Complications
Dehydration is coded first with the neoplasm second. And, then of course, there is the confusing “HISTORY OF” guideline---which is not changed in ICD-10. Signs, symptoms, and abnormal findings cannot be used to replace malignancies as primary diagnosis, except as noted.

33 More Neoplasm Guidelines
Malignancies of two or more contiguous sites should not be coded as one or the other without asking the physician. For disseminated neoplasms with no known PRIMARY or SECONDARY sites are coded to C80.0. This should not be used if either is known. Cancer of unknown primary (CUP): CO80.1 Malignant (primary) neoplasm, unspecified, equates to Cancer unspecified. This code should only be used when the primary cannot be determined.

34 More Neoplasm Guidelines

35 Preparing for ICD-10

36 ICD-10 Implementation Plan
Checklist: Year 2009/ 2010 2011 2012 2013 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

37 Clinical Documentation
The increased specificity of the ICD-10 codes requires more detailed clinical documentation in order to code some diagnoses to the highest level of specificity. There are “unspecified” codes in ICD-10-CM for those instances when medical record documentation is not available to support more specific codes. The benefits of ICD-10 can not be realized if non- specific codes are used rather than taking advantage of the specificity ICD-10 offers. 1) The test results found that ICD-10-CM codes can be applied to today’s medical records in a variety of health care settings without having to change documentation practices, although improved documentation would result in higher coding specificity and, therefore higher data quality in some cases. 2) Field study only about 12% of the codes assigned were unspecified even though no changes to documentation were made as part of the study.

38 Improving Documentation
Conduct medical record documentation assessments Evaluate records to determine adequacy of documentation to support the required level of detail in new coding systems Implement a documentation improvement program to address deficiencies identified during the review process Educate providers about documentation requirements for the new coding system through specific examples Emphasize the value of more concise data capture for optimal results and better data quality Asthma – Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent

39 Physician Training DHHS agrees that some physicians will want intensive training on ICD-10 but some will seek “awareness training”. Nolan study estimates 8 hours of intensive physician training Nachimson Advisors, LLC study predicts 12 hours of physician training in both the code set and documentation procedures. AHIMA believes most physicians would want no more than 4 hours of training. 11 medical organizations (MGMA, AAD, AAPC, AANS, AAOS, AMA among others) retained Nachimson (knockamosin) advisors to assess the cost impact on the ICD-10 mandate.

40 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

41 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.

42 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 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.

43 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.

44 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 What systems will be affected? Practice management Coding look up programs (if applicable)/CDMs/Superbills EMR Remittance systems Hardware space What are the potential costs involved?

45 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 Conduct Impact Analysis
Coding and documentation go hand in hand ICD-10 is based on complete and accurate documentation, even where it comes to right and left or episode of care. ICD-10 should impact documentation as physicians are required to support medical necessity using appropriate diagnosis code—this is not an easy situation, so physicians need to know from the outset that they need training. Will not change the way a physician practices medicine Complete and accurate documentation will continue to be important in 2013 (or whenever) as it is today

47 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? When will they have software available for testing? Will we need new hardware or is current hardware sufficient?

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

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

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

51 Implementation Planning
Begin Steps 1-5 (reviewed up until this point) in 2012, but save others until 2013 or whenever. Break down planning into stages Training for a small practice does not need to begin until 6 months prior to implementation Review superbills 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.

52 Crosswalk Example Iron Deficiency Anemia
ICD-9-CM ICD-10-CM Iron deficiency anemia D Iron deficiency anemia Secondary to blood loss D50.0 Secondary to blood Loss Secondary to inadequate dietary intake D50.8 Other iron deficiency anemias Other specified iron deficiency anemias D50.1 Sideropenic dysphagia Iron deficiency anemia, unspecified D50.9 Iron deficiency anemia unspecified

53 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?

54 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.

55 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

56 Analyze Business Processes
Identify all 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

57 Education and Training
Education should begin approximately 6 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

58 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

59 Deployment of Code Should receive all updated software no later than 7/31/2013 for implementation of your charge documents. 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

60 Implementation Compliance
Compliance date for implementation – October 1, 2013 Ensure you are staffed for the change. Make sure lines of credit are in place. Monitor compliance activities to identify any problems. Pursue vendor and payer problems as necessary.

61 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 Currently, ICD-10-CM is still updated annually 6 –12 months prior to implementation or after code set has been “frozen” Assign ICD-10-CM codes directly, not by applying ICD-9- CM to ICD-10-CM map—it’s good practice’!! 61

62 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

63 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

64 In Summary… While ICD-10 might be postponed, it probably will not be postponed forever. You will need to be in the planning process. The first thing you need to do is determine where change needs to happen and how much it will cost. Physicians have no idea that this will be a line item. Hospitals are way ahead of practices. They may push for this to be sooner rather than later. What did you learn from 5010 that will help you with this?

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