1. ICD-9-CM ICD-10-CM Preparing for the Conversion
Implementing ICD-10-CM
Preparing for the Conversion
Long Term and Post Acute Care Practice Council

2. Background ICD-9-CM Current coding classification system
Introduced 30 years ago
No longer fits with 21st century health system
ICD-10-CM
International standard
Track, report & compare morbidity & mortality
Transition to ICD-10 required by federal regulations (HIPAA standards)

3. Background ICD-10 Available since 1992
Approximately 100 countries use ICD-10 including Canada, Australia, and the United Kingdom
United States: Only industrialized nation not using ICD-10
United States: ICD-10 go-live date was October 1, 2013 NOW revised to be implemented October 1, 2014

4. Global Use of ICD-10

5. The WHO - What – Why ??? ICD-9 Developed by the WHO
ICD-9-CM Overview
ICD-9 Developed by the WHO
(World Health Organization)
1979 U.S. developed the Clinical Modification to ICD-9-CM
2000 HIPAA transaction and code set:
ICD-9 -CM for electronic transactions
Now updated for ICD-10-CM

6. Where - How – When ???
ICD-10-CM All health care settings as well as other industries which utilize the ICD system, e.g. Insurance Providers
ICD-10-PCS for inpatient hospital)
A single implementation date for all providers
Current Implementation Date: October 1, 2014

7. Code Freeze
Last regular, annual updates to both ICD-9 and ICD-10 was Oct. 1, 2011
Oct. 1, there will be only limited code updates to both code sets
Oct. 1, 2014 there will be only limited updates to ICD 10 code set
Limited updates will capture new technology or new diseases only
Oct. 1, 2015 regular annual updates to ICD-10 will begin, ending the freeze

8. ICD-10-CM Significant improvement for reporting clinical data
Measuring the quality, safety, and efficacy of care
Conducting clinical trials, epidemiological studies, research
Setting health policy
Tracking public health and risks

9. ICD-10-CM Significant Improvements
Strategic planning and designing healthcare delivery systems
Monitoring resource utilization
Improving clinical, financial, and administrative performance
Detecting and preventing healthcare fraud and abuse

10. ICD-10-CM Significant Improvements
Fewer miscoded, rejected & improperly reimbursed claims
Improved disease management
Increased Specificity
Data comparability internationally

11. What remains the same? Use of code books or encoder
Tabular List Chapters similar to
ICD-9-CM with some exceptions
Main Term, indented sub term
Alphabetic Index of External Causes
Table of Neoplasms
Table of Drugs and Chemicals

12. What remains the same?
Conventions – abbreviations, punctuation, symbols, code first, use additional code, includes, excludes
Code to highest level of specificity
Adherence to HIPAA and official guidelines (ICD-10-CM)
Nonspecific codes still available

13. What remains the same?
Inconsistent, missing, conflicting, documentation must still be resolved by the Provider—both today under ICD-9-CM, as well as in the future with ICD-10-CM

14. Coding and Documentation
The goal is always to work toward better documentation for the following reasons:
Avoid misinterpretation by third parties (such as auditors, payers, attorneys)
Justify medical necessity
Provide a more accurate clinical picture of the quality of care provided
Support current & future initiatives aimed at improving quality and reducing costs, such as value-based purchasing

15. ICD-10-CM Differences Increase codes: 14,000 to 68,000
Flexible – Incorporate emerging diagnoses, advances in medicine and medical technology
Uses current medical terminology
Codes are Alphanumeric
all codes begin with a letter
Uses all letters of the alphabet except the letter U

16. ICD-10-CM Differences Expanded length 3-7 characters vs. 3-5
Increased precision in diagnosis code
Full diagnostic titles for each code
Added Laterality (right/left, bilateral)
Code extensions for injuries and external causes of injuries
Combination codes for etiology & manifestations
Episode of Care designation

17. ICD-10 Differences EXCLUDE NOTES Excludes 1: not coded here
The 2 conditions contradict each other
Acquired condition vs. congenital
Codes cannot be reported together
Excludes 2: not included here
The condition excluded is not a part of the condition represented by the code
Both codes can be reported together

18. ICD-10 Difference Acute MI – Time Frame Change ICD – 9 8 weeks or less
Hemiplegia / Monoplegia
Dominant vs. Nondominant
Example:
G Hemiplegia, unspecified affecting right dominant side

19. Difference & Similarities
Hypertension Table eliminated
Only 1 hypertension code in ICD-10
Same rules apply in ICD-10 as in ICD-9 for combining Hypertension codes with heart disease and chronic kidney disease.

20. Hypertension ICD-9-CM ICD-10-CM I10 Essential Primary Hypertension
401.0 Essential Hypertension, Malignant
401.1 Essential Hypertension Benign
401.9 Essential Hypertension Unspecified
I10 Essential
Primary
Hypertension

21. Asthma with Acute Exacerbation
ICD-9-CM
ICD-10-CM
– Asthma, unspecified with acute exacerbation
J Mild intermittent asthma with acute
exacerbation
J Mild persistent asthma with acute exacerbation
J Moderate persistent asthma with acute exacerbation
J Severe persistent asthma with acute exacerbation

22. Etiology, anatomic site,
ICD-10-CM Code Format . X X X X X X X
Category
Etiology, anatomic site,
severity
Extension

23. ICD-10 Placeholder “X”
Addition of dummy placeholder “X” is used in certain codes to:
Allow for future expansion
Fill out empty characters when a code contains fewer than 6 characters and a 7th character is required
When placeholder character applies, it must be used in order for the code to be considered valid
Example: S32.9XXD Fx Pelvis d/t fall, routine healing, subsequent episode of care

24. SIGNIFICANT DIFFERENCE
Coding Fractures
No longer will we use Aftercare codes for healing fractures
V Aftercare for healing traumatic fracture of hip
Will use the acute fracture code followed by an appropriate 7th character extension to indicate subsequent episode of care

25. Closed Fracture 7th character extensions:
A – Initial encounter for closed fracture hospital, ER, clinic
D – Subsequent encounter for fracture routine healing
G – Subsequent encounter for fracture delayed healing
K – Subsequent encounter for fracture nonunion
P – Subsequent encounter for fracture malunion

26. CODING GUIDELINES

27. Coding Guidelines
A Fracture not indicated as displaced or nondisplaced should be coded to displaced.
A fracture not indicated whether open or closed should be coded to closed

28. Coding Guidelines Initial vs. subsequent encounter for fractures:
Initial care involves active treatment
Subsequent care occurs after active treatment and receiving routine care during the healing or recovery phase
Sequela – complications or conditions that arise as a direct result of an injury (previously called ‘late effect’)

29. ICD 10 Structure FRACTURES S72 Fracture Femur
S Pertrochanteric fx femur
S Intertrochanteric fx femur
S Displaced Intertrochanteric fracture of right femur
S72.141D Displaced Intertrochanteric Fx of right femur, subsequent encounter for closed fx with routine healing

30. Closed fracture of the greater trochanter of the right femur (hip fracture)
S72.111A - Initial encounter for closed fracture: Patient admitted for initial treatment in ER and hospital with resulting surgical repair
S72.111D - Subsequent encounter for closed fracture with routine healing: Admission to long-term care (LTC) for rehabilitation after hip replacement

31. Examples: Subsequent Encounter
S72.111D, Subsequent encounter for closed fracture with routine healing: Discharged from LTC Home Health for continued PT
S72.111D, Subsequent encounter for closed fracture with routine healing: Patient visits hospital radiology department for X-ray
S72.111D, Subsequent encounter for closed fracture with routine healing: Patient to physician office for follow-up visit

32. ICD-10-CM ‘Snapshot’ Diabetes mellitus 59 to ~ 200+
Pressure ulcer to ~ 125
Path. fracture to ~ 150
Under dosing NEW section

33. ICD-10-CM ‘Snapshot’ Z43.1 Attention to gastrostomy
Z Aftercare following surgery on digestive system (cholecystectomy)
F Unspecified Dementia, w/o behavior
L Pressure ulcer right heel, stage III

34. ICD-10-CM ‘Snapshot’ E11.40 Type II DM with neuropathy
Z Long Term use of insulin
J COPD
Z Oxygen dependent
Z Prednisone dependent

35. MI – Myocardial Infarction
Time frame for coding acute myocardial infarctions changes with ICD-10
ICD weeks
ICD weeks
As long as treatment is required, regardless of care setting

36. MI – Myocardial Infarction
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
Use acute code for 4 weeks regardless of treatment facility
I25.2 Old myocardial infarction
After initial episode of 4 weeks, then use “healed / old MI” code

37. Residual Effects of Cerebrovascular Disease
ICD-10-CM
Hemiplegia following nontraumatic subarachnoid hemorrhage
Hemiplegia following nontramatic intracerebral hemorrhage
Hemiplegia following other intracranial hemorrhage

38. Residual Effects of Cerebrovascular Disease
ICD-10-CM
Hemiplegia following cerebral infarction
Hemiplegia following other cerebrovascular disease
Hemiplegia following unspecified cerebrovascular disease

39. Hemiparesis following CVA
ICD-9-CM
ICD-10-CM
Hemiplegia following CVA affecting dominant side
I Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side
I Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side

40. CVAs Terminology “Late Effects” is eliminated from ICD-10
Sequela is the new term for Late Effects
Sequela of cerebral hemorrhage
Sequela of cerebral infarct
Sequela of cerebrovascular disease

41. CVAs I69.0 – I69.298 Sequela of hemorrhages I69.3 – I69.398
Sequel of cerebral infarction
Occlusion of artery
Default for “stroke”
I69.8 – I69.998
Sequela of cerebrovascular disease

42. CVAs
Coder will have to pay close attention to the type of CVA which occurred to obtain the correct code
No more flipping to the 438 section and looking for your code!
Flipping to I69 will only confuse you more!
Use alphabetic index to look up what is documented in the record.

43. ICD-10-CM Project Planning
Resources:
Coding Manuals
Coding Instruction Resources
Training costs (Biomedical science & ICD-10)

44. ICD-10-CM Transition Budget $$$ Considerations
Hardware/software system upgrade, maintenance fees
Data Conversion
Clinical & financial
Forms redesign & reprinting
Consultant Fees
Outsourcing

45. ICD-10-CM Transition Budget Considerations
Temporary staff needed to assist during transition period
Lost productivity during training & implementation phase
Increased coding time
with ICD-10

46. ICD-10 Project Planning
Clearinghouses, outside billing service, health Insurance payers
When will upgrades be completed?
When can claims with ICD-10-CM codes be transmitted for testing?
Re-negotiate provider contracts or electronic data interchange agreements (EDI)

47. ICD-10-CM Project Planning
Who Assigns or Uses ICD-9-CM Codes:
Health Information Management (Medical Record Staff)
Nursing, MDS Coordinators
Admissions
Billing
Therapy
Lab, X-ray

48. Early Preparation
A well-planned, well-managed implementation process will increase the changes of a smooth, successful transition
Experience in other countries has shown that early preparation is the key to success & earlier realization of benefits
An early start allows for resource allocation, such as costs for systems changes and education, process evaluation and change, as well as staff time devoted to implementation processes to be spread over several years

49. Inadequate Preparation
Potential Consequences
Decreased coding accuracy
Decreased coding productivity
Increased compliance risks
Increased claims rejection
An adverse impact on patient care and administrative decision-making
Decrease in key staff morale

50. Preparation – When to Start.
Don’t Delay!
Get Started Today!

52. Methods of Training Current in-house SNF on-line Education System
Online self-study courses including AHIMA
Webinars/WebEx

53. Methods of Training Videos on specific body systems Seminars/workshops
Local Educational Institutions
ICD-10-CM Workbooks (self learn)

54. Methods of Training Local hospital educational programs ICD-10-CM ONLY
NOT ICD-10-PCS)
Qualified HIM Professionals / HIM Consultants (e.g. AHIMA Approved)

55. Coder Preparation
Intensive Training: Not until 6 – 9 months prior to implementation 10/1/2014
LTC Coders: 16 hours (ICD-10-CM only for current trained coders)
(Check with our timeline for consistency)

56. Coder Preparation
Obtain ‘refresher’ training for biomedical sciences
Anatomy and Physiology
Medical Terminology
Pathophysiology
Pharmacology

57. Transitioning from ICD-9 to ICD-10 LTC
1st Quarter 2014 (January – March)
Formal training for staff followed by “hands-on practice”
Determine if coders have been using ICD-9-CM code lists (e.g. ‘cheat’ sheets). These will require updating if processes are appropriate. (e.g. list of codes for unit clerks for lab requisitions)
Determine if there are any forms which will need to be revised to allow for 7 characters
Determine whether software is compatible with ICD-10-CM

58. Transitioning from ICD-9 to ICD-10 LTC
2nd Quarter 2014 (April – June)
Begin using ICD 9 codes with clear diagnostic descriptions, similar to those used in ICD 10 for ease in re-coding.
Print diagnosis lists of current residents and code diagnoses with ICD-10-CM (Take sample number each week) for practice
Maintain ICD-10-CM coded diagnosis lists (in case resident remains in facility)
Continue to practice, practice, practice!!

59. Transitioning ICD-9 to ICD-10 LTC
3rd Quarter 2014 (July – September)
Dual code using both ICD-9 & ICD-10
By July 1, 2014
Determine if your software will be available and capable of dual coding
All new admissions,
hospital returns, and
continued stay
PLEASE NOTE: ICD-10-CM CONVERSION DOES NOT APPLY IN WORKMEN’S COMP CASES
Continue updating diagnosis lists and codes according to MDS schedule until all residents’ diagnosis lists have been updated.

60. Transitioning from ICD-9 to ICD-10 LTC
4th Quarter 2014 (Oct. – December)
Apply ICD-10-CM codes for all diagnoses for all admissions and MDSs starting October 1, 2014.
Maintain Legacy ICD-9-CM Coding System
Monitor claims & denials for coding errors and vendor problems

61. Billing Claims
CMS working to address claims that overlap from September 30, 2014 into October 2014 (SNFs)
All Claims submitted for services on or before September 30, 2014 will use ICD-9 codes
ICD-10 codes will not be recognized/accepted on claims BEFORE

62. Billing Claims
All claims submitted for services provided on or after October 1, 2014 will use ICD 10 codes
Claims cannot contain BOTH ICD-9 codes and ICD-10 codes
Claims using ICD-9-CM after 10/1/14 will be rejected

63. Billing Claims Facilities behind in billing Medicare?
Use added transition time to get caught up with billing.
Be current on go-live date

64. RESOURCES
American Health Information Management Association
American Association of Professional Coders
Centers for Medicare and Medicaid Services
Centers for Disease Control

69. Special Thanks to the AHIMA 2012 LTPAC Practice Council Coding & Reimbursement Strategy Team
Nancy Benson, RHIA Molly Cahill, RHIA Michelle Dick, RHIA Deborah Johnson, RHIT, CHP Leslie Joyner, RHIT Kathie McClary, RHIT Tamela McQuiston, RHIT, RAC-CT Renae Spohn, RHIA Monica Tormey, RHIA Carol Young, RHIT