Presentation on theme: "ICD-10-CM An Introduction 2012"— Presentation transcript:
1 ICD-10-CM An Introduction 2012 2009 CodesThe single most significant coding change in 30 years is before us – the conversion from ICD-9 to ICD-10The 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, MBAonPoint 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.
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 ICD-9-CM is out of date and running out of space for new codes.Lacks specificity and detailNo longer reflects current medical practiceICD-10 is the international standard to report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-103) 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 formatIndexTabularProcess of coding is similarLook up a condition in the IndexConfirm the code in the Tabular
7 Major Differences Between ICD-9-CM and ICD-10-CM 13,600 codes69,000 codesCode book contains 17 chaptersCode book contains 21 chaptersConsists of 3 to 5 charactersConsists of 3 to 7 characters1st character is alpha or numeric1st character is alphaOnly utilizes letters E and VUtilizes all letters (except U)Second, third, fourth, and fifthcharacters are always numericSecond characteris always numericThird, fourth, fifth, sixth, and seventhcharacters can be alpha or numericShorter code descriptions becauseof lack of specificity andabbreviated code titlesLonger code descriptions because of greater clinical detail and specificityand full code titles5x more codes in ICD-10, than ICD-9ICD-10 code book contains more chaptersSplit some I-9 chapters in to two – nervous and sense organsv and e codes were supplementary chapters in I-9, now own chapters3) I-9 3 to 5, I4)10 key pad, much easier to make errors reading letters1st digit is alpha – letters A-Z, except UV codes are now Z codesCodes #s will be different
8 Comparison of ICD-9-CM and ICD-10-CM ICD-9-CM CODEICD-10-CM CODEA - Category of codeB - Etiology, anatomical site, and manifestationA - Category of codeB - Etiology, anatomical site, and/or severityC - Extension7th character for obstetrics, injuries, and external causes of injuryABABC
9 ICD-9-CM Structure – Format Numeric or Alpha(E or V)NumericVXE541X4X.XX.CategoryEtiology, AnatomicSite, Manifestation3 – 5 Characters
10 ICD-10-CM Structure – Format Alpha(Except U)2 - 7 Numeric or AlphaAdditional Characters..XMAS3X2XX1XXAXCategoryEtiology, AnatomicSite, SeverityAdded code extensions (7th character) for obstetrics, injuries, and external causes of injury3 – 7 Characters
11 Comparison of ICD-9-CM and ICD-10-CM ICD-9-CM CodesICD-10-CM CodesPressure ulcer codes9 codes–125 codesL89.0-L89.94Codes:707.0 Pressure ulcerunspecified siteelbowupper backlower backhipbuttockankleheelother siteCode Examples:L – Pressure ulcer of right lower back, stage IL – Pressure ulcer of right lower back, stage IIL – Pressure ulcer of right lower back, stage IIIL – Pressure ulcer of right lower back, stage IVL – Pressure ulcer of right lower back,unspecified stageL – Pressure ulcer of left lower back, stage IL – Pressure ulcer of left lower back, stage IIL – Pressure ulcer of left lower back, stage IIIL – Pressure ulcer of left lower back, stage IVL – Pressure ulcer of left lower back,L – Pressure ulcer of sacral region, stage IL – Pressure ulcer of sacral region, stage II…L89.90 – Pressure ulcer of unspecified site, unspecified stageThe codes on the right are only a small set of the 125 potential pressure ulcer codes offered in ICD-10Pressure 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 manifestationsCombination codes for poisonings and external causesAdded lateralityExpanded codes: injury, diabetes, alcohol/substance abuse, postoperative complications
13 New Features of ICD-10-CM Added extensions for episode of careInclusion of trimester in obstetrics codes and elimination of fifth digits for episode of careExpanded detail relevant to ambulatory and managed care encountersInclusion of clinical concepts that do not exist in ICD-9-CMChanges in timeframes specified in certain codes1)A Initial encounter for closed fractureB Initial encounter for open fractureD Subsequent encounter for fracture with routine healingG Subsequent encounter for fracture with delayed healingK Subsequent encounter for fracture with nonunionP Subsequent encounter for fracture with malunionS Sequelae2) Delivered, Antepartum or Postpartum is replaced with the trimester3) No info4) Underdosing5) 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 breastC Malignant neoplasm of central portion of right female breastC 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 gum143.1 Lower gumICD-10-CMC03 Malignant neoplasm of gumC03.0 Malignant neoplasm of upper gumC03.1 Malignant neoplasm of lower gum
16 Arrangement of Volumes of ICD-10 Volume 1: Main classificationsVolume 2: Instruction/ Guidance to usersVolume 3: Alphabetical IndexICD-10 has 21 chapters against 17 Chapters in ICD-9
17 Chapters of ICD-10Chapters I to XVII: Diseases and other morbid conditionsChapter 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.
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 GEMsDesigned to give all sectors of the healthcare industry that use coded data the tools to:Convert large databases and test system applicationsLink data in long-term clinical studiesDevelop application-specific mappingsAnalyze data collected before and after the transition to ICD- 10-CMThey 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 anginaThere are situations when a code in the target system does not existT503x6A Underdosing of electrolytic, caloric and water- balance agents, initial encounterNot 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 MappingICD-9 CodeDescription(Source)820.8Fracture of unspecified part of neck of femur, closedICD-10 CodeDescription(Target)S72.009AFracture of unspecified part of neck of femur, initial encounter for closed fractureBackward MappingICD-9 CodeDescription(Target)820.8Fracture of unspecified part of neck of femur, closedICD-10 CodeDescription(Source)S72.001AS72.002AS72.009AFracture of unspecified part of neck of right femur, initial encounter for closed fractureFracture of unspecified part of neck of left femur, initial encounter for closed fractureFracture of unspecified part of neck of femur, initial encounter for closed fractureIn 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.”
29 Neoplasm GuidelinesMany 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 GuidelinesAgain, 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.
36 ICD-10 Implementation Plan Checklist:Year2009/ 2010201120122013Phase IAwareness andImpact AssessmentPhase IIPreparing for ImplementationWe 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 AssessmentPhase 2 – Preparing for ImplementationIs the next step and this also includes making the change to 5010 as wellPhase 3 – Go Live PreparationThis phase will be focused on testing and training – a very busy time period.Post-implementationAnd 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 IIIGo Live PreparationPhase IVPost –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 assessmentsEvaluate records to determine adequacy of documentation to support the required level of detail in new coding systemsImplement a documentation improvement program to address deficiencies identified during the review processEducate providers about documentation requirements for the new coding system through specific examplesEmphasize the value of more concise data capture for optimal results and better data qualityAsthma –Mild IntermittentMild PersistentModerate PersistentSevere Persistent
39 Physician TrainingDHHS 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 trainingNachimson 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 EffortEstablish Communication PlanConduct Impact AnalysisContact System VendorsEstimate BudgetImplementation PlanningDevelop Training PlanAnalyze Business ProcessesEducation and TrainingPolicy Change DevelopmentDeployment of CodeImplementation Compliance
41 Organize Implementation Effort Enlist staff person (coder, biller, manager) to oversee effort who will be key point personPrepare information to share with other providers and staffIdentify work and scope for implementationShould 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 affectedPractice management systemElectronic Medical Record (EMR), if applicableSuperbillsClinical areas and pharmacySchedule 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 memosNo need to change method of communicationsDevelop regular schedule for ICD-10 progress effortsMonthly until 6 months prior to implementationBi-weekly thereafterInclude information, publications, and articlesDocument 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 budgetIn depth look at resources required for implementationMaybe check for a little process improvementHelps determine what costs might be involved as well as work processesWhat systems will be affected?Practice managementCoding look up programs (if applicable)/CDMs/SuperbillsEMRRemittance systemsHardware spaceWhat are the potential costs involved?
45 Conduct Impact Analysis Develop reasonable timeline that can be accomplished in your practiceMap out a project plan on a simple Excel spreadsheet with benchmarks and status of completionManagers 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 handICD-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 medicineComplete 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 costsSoftware costs and licensingTrainingPhysician QueryProductivity lossesJeopardy to cash flowSome notable budget estimates follow this slide…
49 ICD-10 Implementation $: AMA (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 stagesTraining for a small practice does not need to begin until 6 months prior to implementationReview superbills and remove rarely used codesCrosswalk common codes from ICD-9-CM to ICD-10-CMLook 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-CMICD-10-CMIron deficiency anemiaD Iron deficiency anemiaSecondary to blood lossD50.0 Secondary to blood LossSecondary to inadequate dietaryintakeD50.8 Other iron deficiency anemiasOther specified iron deficiencyanemiasD50.1 Sideropenic dysphagiaIron deficiency anemia, unspecifiedD50.9 Iron deficiency anemiaunspecified
53 Develop Training Plan Who needs training? PhysiciansCodersBilling staffAdministrative staffNurses, MAs, PharmacyRequired number of hours depends on their role and coding interfaceWhat resources are available in your area?
54 Develop Training PlanMany organizations will have several mechanisms for trainingDistance learningWorkshopsConferencesAudio ConferencesWebinarsBooksEstablish 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 PlanDetermine if temporary staff or overtime will be necessary during training periodWhat materials will the office need for ongoing support after training?BooksSoftware (code look up programs)Other
56 Analyze Business Processes Identify all systems and processes that currently use ICD-9-CMReview existing medical policies related to ICD-9-CMWhich 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 implementationLarge practices may need to begin earlier to accommodate all staff who need trainingUse various methods of training: on-line, distance, “Boot Camps”Training time depends on their rolePhysicians 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 providesReview new payment policiesIdentify opportunities to improve coding processesCommunicate policy changes to applicable staff
59 Deployment of CodeShould 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 shouldTest systemIntegrate software into your systemsMake internal customizationsTest 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, 2013Ensure 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 ConsiderationsConsider use of electronic tools to facilitate coding processCould reduce costs and claims rejectionsCould increase productivity and coding accuracyDon’t convert superbills/charge documents too earlyCurrently, ICD-10-CM is still updated annually6 –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 articlesICD-10 audio seminar seriesCentral Office on ICD-9-CMAHA 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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