World Health Organization WHO publishes the International Classification of Diseases (ICD) code set which defines diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. The WHO authorized a US adaptation of the code set for Clinical Modification (CM).
Currently the United States uses the ICD ninth edition originally published in 1977. – ICD-9-CM (Clinical Modification), used in all health care settings – ICD-9-PCS (Procedure Coding System), used only in inpatient hospital settings. In 1990, the WHO updated to the ICD-10. Other countries began using ICD-10 in 1994 but the United States only partially adopted ICD-10 in 1999 for mortality reporting.
Some Major Countries Utilizing ICD-10 CountryICD – 10 Implementation United Kingdom1995 France1997 Australia1998 Belgium1999 Germany2000 Canada2001
Productivity Productivity was reported to drop when ICD-10 was implemented. Some countries reported a drop from normal to 60%. The ICD-10 codes will be increasing from approx. 15,000 ICD-9 codes to 150,000 ICD-10 codes. Thus proper planning, training, and implementation are essential to protect the business entity.
October 1, 2013! Why are we hearing so much now? Why are there so many seminars and webinars to train us as time seems to be of the essence? This change does not occur for 2 years. We will discuss the following: Significant Dates and Suggested Timeline Why Are Changes Needed? What Changes Occur with ICD 10? What System Changes are Needed? What Training is Needed? When is Training Needed? What are the Financial Impacts and Risks?
Significant Dates December 31, 2011External Testing for 5010 must be complete January 1, 2012All electronic claims must use 5010 January 2012 – December 2013Develop implementation strategy that includes 1. An assessment of the impact on your organization 2. A detailed timeline 3. A budget 4. Revised and new policies and procedures January 2012 – October 1, 2012Staff and physician training on concepts and overview of changes required for ICD 10 October 1, 2012 – October 1, 2014 ICD codes FROZEN until October 1, 2014 October 1, 2013Services on or after Oct. 1, 2013 require ICD 10 codes. Billing for services prior to 10/1/2013 continue to use ICD 9
Why Change? ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. The modern classification system will provide much better data needed for: Measuring the quality, safety, and efficacy of care; Reducing the need for attachments to explain the patient’s condition
Designing payment systems and processing claims for reimbursement; Conducting research, epidemiological studies, and clinical trials; Setting health policy; Operational and strategic planning; Designing health care delivery systems; Monitoring resource utilization; Improving clinical, financial, and administrative performance;
Preventing and detecting health care fraud and abuse; and Tracking public health and risks.
What Changes Occur with ICD 10? ICD – CM 9ICD-CM 10 3-5 Digits;3-7 Digits; First digit is alpha (E or V) or numeric (alpha characters are not case sensitive); Digit 1 is alpha; Digit 2 is numeric; Digits 2-5 are numeric; andDigits 3-7 are alpha or numeric (alpha characters are not case sensitive); and Decimal is used after third character 14,400 Codes69,368 Codes 3,800 Procedure Codes72,000 Procedure Codes
Format and Structure Categories – Alphanumeric 3 characters Subcategories – 4 or 5 characters Codes – Up to 7 characters
New Features in ICD-10-CM 1.Laterality (left, right, bilateral) 2.Combination codes for certain conditions and common associated symptoms and manifestations. 3.Combination codes for poisonings and their associated external cause. 4.Obstetric codes identify trimester instead of episode of care.
5.Character “x” is used as a 5 th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7 th character. 6.Two types of Excludes notes Excludes 1 – Indicates that the code excluded should never be used with the code where the note is located (do not report both codes). Excludes 2 – Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together.
7.Inclusion of clinical concepts that do not exist in ICD-9-CM. 8.A number of codes have been significantly expanded. 9.Codes for postoperative complications have been expanded and a distribution made between intraoperative complications and post procedural disorders.
Additional Changes Found In ICD-10- CM 1.Injuries are grouped by anatomical site rather than by type of injury; 2.Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM; 3.Certain diseases have been reclassified to different chapters or sections in order to refelct current medical knowledge;
4.New code definitions (e.g. definition of acute myocardial infarction is now 4 weeks rather than 8 weeks.) 5.The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM.
ICD-9-CM verses ICD-10-CM The ICD-10-CM code range for diabetes mellitus has over 210 codes. In order to code diabetes mellitus in ICD-10-CM the following is necessary: – Type of diabetes – Body system affected – Use of insulin – Complications – Manifestations – Reason for secondary diabetes mellitus
Code Mapping General Equivalency Mappings (GEMs) attempt to include all valid relationships between the codes in the ICD-9-CM diagnosis classification and the ICD-10-CM diagnosis classification. The tool allows coders to look up an ICD-9 code and be provided with the most appropriate ICD-10 matches and vice versa. GEMs are not a crosswalk but merely a guide. Many errors have already been found in the GEMs.
Mapping Examples ICD – 9-CMICD-10-CM 381.81 Acute Serous Otitis MediaH65.00 Acute Serous Otitis Media Unspecified Ear H65.01 Acute serous Otitis Media Right Ear H65.02 Acute Serous Otitis Media Left Ear H65.03 Acute Serous Otitis Media Bilateral H65.04 Acute Serous Otitis Media recurrent Right Ear H65.05 Acute Serous Otitis Media recurrent Left Ear H65.06 Acute Serous Otitis Media recurrent Bilateral H65.07 Acute Serous Otitis Media recurrent UNS Ear
What System Changes are Needed? All software to submit claims must be the 5010 version as of January 1, 2012. October 1, 2013 software must be able to utilize both ICD-9-CM codes and ICD-10-CM codes. It will be important to verify in advance that your clearinghouse and the insurance companies you transmit to have these abilities.
Superbills must be updated and in place as of Oct. 1, 2013 if the provider used superbills with common diagnosis codes listed to choose from. Your software must have the ability to transmit both ICD-9 and ICD-10 effective October 1, 2013. ICD 9 codes will continue to be entered and processed for dates of service prior to Oct. 1, 2013. The clearinghouses and insurance companies must be able to receive and process both ICD 9 and ICD 10 codes. Policies and Procedures must be in place for the new coding rules. These should include how to manage claim rejections. P & P s should include how to educate the provider of rejections and needed steps to prevent rejections in the future. Detailed documentation is increasingly important. Extra staffing of coders, auditors, and billers should be in place. Productivity is expected to drop by 60%.
What Training is Needed? Train your planning and implementation team of changes that will occur and deadlines for changes. When? – NOW. Train IT, Auditors, Coders, Billing Staff, Office Managers, and Providers of upcoming changes. When? – Oct. 2011 through Oct. 2012. Increase training and test for knowledge of Anatomy and Physiology. An excellent knowledge of Anatomy and Physiology will be necessary to code and audit. Train new ICD-10-CM codes and rules October 2012 through September 30, 2013.
What are the Financial Impacts and Risks? Cost of 5010 Conversion – Cost of software – Cost of rebilling and follow-up – Cost of cash flow delay Cost of Training – Cost of Development of Training – Cost of Materials – Cost of Labor for Trainers and Attendees. Also replacement labor while attendee in training.
Cost to Financial Department – Budgeting is essential and should include the cost of additional Accounting staff both in the planning and implementation phase will require additional FTEs. An increase in staffing for Accounts Receivable Staff, Coders, and Auditors. This increase may be up to 40% for several months following the conversion. (Note that other countries have experienced a decrease in Productivity to 60% when ICD-10 was implemented.) An increase in clearinghouse charges due to re-filing and rejections of claims. Due to expected cash flow decrease, some providers will need to secure a loan to cover the transition period.
Summary The U.S. will implement ICD-10-CM Oct. 1, 2013. It is important to have an implementation plan and a financial budget to prepare for decreased productivity and a high number of claim rejections.