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Presented by Jeff Hinson Regional Administrator Centers for Medicare & Medicaid Services Denver Regional Office.

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Presentation on theme: "Presented by Jeff Hinson Regional Administrator Centers for Medicare & Medicaid Services Denver Regional Office."— Presentation transcript:

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3 Presented by Jeff Hinson Regional Administrator Centers for Medicare & Medicaid Services Denver Regional Office

4 * Refers to diagnosis and procedure code sets * Replaces ICD-9 code sets and includes updated medical terminology and classification of diseases. * Does not impact other medical coding sets (CPT-4, HCPS, NDC)

5 * What’s Required? * ICD-10 must be used for transactions with dates of service/date of discharge on or after October 1, 2014 * ICD-9 will no longer be accepted. * Deadline is firm.

6 * Who Is Affected?

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9 * Better reflects current medical practice * Structure accommodates addition of new codes The current coding system is running out of capacity and cannot accommodate future state of health care * Benefit: More accurate payments for new procedures Fewer miscoded, rejected and improper reimbursed claims

10 Quality measurement Better analysis of disease patterns Track and respond to public health outbreaks Make claim submission more efficient Identify fraud and abuse * Benefit : Improved ability to measure healthcare services Increased sensitivity when refining grouping & reimbursement methodologies Decreased need to include supporting documentation with claims

11 Website Updates Fact Sheets Implementation Handbooks

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13 Presented by Rebekah S. Gatti, CCS-P, CPC, CPC-I, CEDC, CPMA R.T. Welter and Associates, Inc.

14 ICD-10-CM is similar to ICD-9- CM as far as format and basic guideline information * ICD-10 Basics Total number of codes expands from about 14,000 ICD-9-CM codes to well over 68,000 in ICD-10-CM (the majority of additions lie in the musculoskeletal codes, accounting for about 37,000 of the additional codes) ICD-10 Uses full code titles in the code description, while ICD-9 does not ICD-10-CM was designed with better capability for expansion

15 * ICD-10-CM TABULAR LIST of DISEASES and INJURIES

16 *ICD-9 to ICD-10 Structural Differences

17 Alphanumeric * Characters 1-3 – Category * Characters 4-6 – Etiology, anatomic site, severity, or other clinical detail * Character 7 – Extension (may indicate encounter information, trimester, fetus number, etc.)

18 ICD-10 Structure Example S52.5 Fracture of lower end of radius S52.52 Torus fracture of lower end of radius S Torus fracture of lower end of right radius S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture Code can’t be completed until all information as to type of fracture, site (lower end of radius), healing type and encounter are specified. S52 Fracture of forearm

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20 ICD-9-CM has minimal instruction to it’s 9 conventions ICD-10-CM has twice as many conventions (18) and additional detail and guidance for correct use and interpretation Excludes 1 - Example

21 Excludes 2 - Example

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23 General Coding Guidelines – Example

24 Download the 113 page document at: m ICD-10-CM 2013 Release is now available and can be accessed at:

25 Rebekah S. Gatti, CCS-P, CPC, CPC-I, CEDC, CPMA R.T. Welter and Associates, Inc.

26 The number of codes has increased dramatically * What may have been a single code in ICD-9 may now have several hundred code choices due to the specificity of ICD-10-CM * Code choices require more information * More specificity may require better documentation

27 * Significant Change to Diabetes Mellitus * Six Diabetes Mellitus categories in the ICD-10-CM. 1. E08 Diabetes Mellitus due to an underlying condition 2. E09 Drug or chemical induced diabetes mellitus 3. E10 Type I diabetes mellitus 4. E11 Type 2 diabetes mellitus 5. E13 Other specified diabetes mellitus 6. E14 Unspecified diabetes mellitus Example: Type II Diabetes with heel ulcer ICD ICD-10 E L thru L (fifteen codes defining level of breakdown, right heel, left heel, or unspecified heel)

28 * Expanded to include the classification of the diabetes and the manifestation. * Category updated to reflect the current clinical classification of diabetes. * No longer classified as controlled/uncontrolled. E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.11, Type 1 diabetes mellitus with ketoacidosis with coma E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy

29 * Gout: ICD-9 has 36 codes describing gout/gouty conditions Unspecified * ICD-10 currently has 239 codes to describe gout/gouty conditions (primary, secondary, drug induced, due to renal impairment, body area, right, left, unspecified, lead induced, idiopathic etc., etc.) * Chronic Gout Unspecified M1a.9 (requires 7 th digit) M1a.9xx1 or M1a.9xx0

30 Fracture codes require seventh character to identify if fracture is closed or open. The fracture extensions are: 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

31 Example: - ICD-9-CM code – Other closed fracture of distal end of radius (alone) - ICD-10-CM: 210 possible corresponding codes Information needed to accurately code in ICD-10: Fracture type (e.g. displaced/non-displaced, intra- articular/extra-articular, Salters-Harris Type 1 to Type 4 etc.), which part of radius (styloid process), healing type (routine healing, delayed healing, mal-union, non- union), laterality, and encounter. ICD-10-CM example: S52.511G – Displaced fracture of right radial styloid process, subsequent encounter for closed fracture with delayed healing

32 Presented by Denny Flint President Complete Practice Resources

33 * Increased specificity requires more detailed documentation * Providers are therefore the cornerstone for the success of your ICD-10 transition * Unspecified = Unpaid

34 * Gastroenterologists: 596 ICD-9 codes codes in ICD-10 (+110) * Pulmonologists: 255 codes in ICD codes in ICD-10 (+81) * Urologists: 389 codes in ICD codes in ICD-10 (+202) * Endocrinologists: 335 codes in ICD codes in ICD-10 (+340)* * Neurologists: 459 codes in ICD codes in ICD-10 (+132) * Pediatricians: 702 codes in ICD-9 down to 591 codes in ICD-10 (- 111) * Infectious disease: 1,270 in ICD-9 down to 1,056 in ICD-10 (-214) A few hundred new codes = a few dozen new documentation elements * ICD-10-CM includes more combination codes containing co-morbidities and associated conditions. Example - Diabetes

35 35© 2011 MedLearn / SLIDE

36 36© 2011 MedLearn / SLIDE

37 ICD-9-CM2 codes ICD-10-CM480 codes Watch what happens to the number of ICD-10 codes when we add only 3 additional documentation elements

38 38© 2011 MedLearn / SLIDE

39 39© 2011 MedLearn / SLIDE

40 40© 2011 MedLearn / SLIDE

41 * Fracture of Patella * 2 ICD-9 codes translate to a seemingly absurd number of ICD-10 Codes * But only 5 new documentation elements! It’s not about the thousands of new codes, it’s about the dozen or so new documentation elements!

42 * Create documentation awareness now! * Physician Documentation is the cornerstone for ICD-10 Transition success * This is the primary responsibility physicians have in the move to ICD-10 * But doctors want to doctor * So…create easy reference tools. Here’s an example - Asthma

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45 * Mild, Moderate, or Severe? * Intermittent or Persistent? * Tobacco use or exposure? If you create one of these for your top 50 most frequently used diagnoses, and introduce one every two weeks, you will be ready.

46 Easy-to-perform Chart A udit * Convert top 20 ICD-9 codes using Transition Software * Analyze required ICD-10 documentation * Select 5 charts per provider for each ICD-9 code * Assess current chart documentation ability to support new, more specific ICD-10 codes * Give the docs a report card Excellent technique to get your providers educated and engaged for the ICD-10 Transition

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48 “Physicians may be ICD-10 compliant, but if they abuse the “other” or “unspecified” codes, payment will not occur if a more specific alternative exists.” David Winkler Director of Technical Program Management Blue Cross of Michigan Justifying medically necessary procedures and services depends on specificity of diagnoses coding!

49 * Current Insurance Reimbursement Issues will carry over to ICD-10 * Medical Necessity Denials * Unspecified = Unpaid? * Delayed payment – requests for additional information * (Broken Record) Documentation is the key to ICD-10 Transition success … And you need their support.

50 * Richer acuity level databases = better care (metal hip prostheses, asthma) * Patient advocates in the insurance arena * Better data should equate to better reimbursement

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