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ICD-10 Innovation & Impact

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Presentation on theme: "ICD-10 Innovation & Impact"— Presentation transcript:

1 ICD-10 Innovation & Impact
Tammy Norville Rural Health Operations Specialist NC DHHS – Office of Rural Health and Community Care September 23, 2014

2 Road Map ORHCC ICD-10 General Overview Resources & Conclusion
Who we are What we do ICD-10 General Overview What – What are the code sets? Why – Why is this important? Who – All provider types When – Not before October 1, 2015 How – How might this impact my job? Resources & Conclusion

3 The Mission Of The N.C. Department Of Health And Human Services Is, In Collaboration With Our Partners, To Protect The Health And Safety Of All North Carolinians And Provide Essential Human Services. “Culture of Accountability”

4 The Office Of Rural Health And Community Care Assists Underserved Communities And Populations To Develop Innovative Strategies For Equal Access, Quality, And Cost-effectiveness Of Health Care For All. Chatuge Family Practice Hayesville, NC

5 ORHCC in NC Works with communities to meet the health needs of all underserved residents Fosters state and local partnerships with ownership vested in communities Provides in-depth technical assistance on an on-going basis Assures clear and measurable accountability Seeks to eliminate health disparities

6 Tammy Norville With ORHCC since April 2003
Rural Health Operations Specialist 2011 National Organization of State Offices of Rural Health (NOSORH) Recognition Award winner Registered Medical Coder Registered Medical Manager Certificates in ICD-10 Management, Non-Provider Clinical, Billing and Coding

7 ICD-10 General Overview

8 What is a code set? Under HIPAA, a "code set" is any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes. Medical data code sets used in the health care industry include coding systems for diseases, impairments, other health related problems, and their manifestations; causes of injury, disease, impairment, or other health-related problems; actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments; and any substances, equipment, supplies, or other items used to perform these actions. Code sets for medical data are required for data elements in the administrative and financial health care transaction standards adopted under HIPAA for diagnoses, procedures, and drugs. (

9 HCPCS Codes The acronym HCPCS originally stood for HCFA Common Procedure Coding System, as the Centers for Medicare and Medicaid (CMS) was previously (before 2001) known as the Health Care Financing Administration (HCFA). The Healthcare Common Procedure Coding System (HCPCS) was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care. Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.

10 HCPCS Codes HCPCS includes three levels of codes:
Level I consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices,[2] and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I). Level III codes, also called local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.[3]

11 CPT Codes The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel.[1] The CPT code set (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. New editions are released each October.[2] The current version is the CPT It is available in both a standard edition and a professional edition.[3][4] CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim. ICD code sets also contain procedure codes but these are only used in the inpatient setting.[5] CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS)[6] as Level 1 of the Health Care Procedure Coding System. The Current Procedural Terminology (CPT) was developed by the American Medical Association (AMA).[6]

12 CPT and HCPCS No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to inpatients

13 ICD-9 Codes International Classification of Diseases, Clinical Modification (ICD-9-CM) is an adaption created by the U.S. National Center for Health Statistics (NCHS) and used in assigning diagnostic and procedure codes associated with inpatient, outpatient, and physician office utilization in the United States. The ICD-9-CM is based on the ICD-9 but provides for additional morbidity detail. It is updated annually on October 1.[14][15] It consists of two or three volumes: Volumes 1 and 2 contain diagnosis codes. (Volume 1 is a tabular listing, and volume 2 is an index.) Extended for ICD-9- CM Volume 3 contains procedure codes. ICD-9-CM only The NCHS and the Centers for Medicare and Medicaid Services are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM.

14 (Source:
ICD-10 Codes Work on ICD-10 began in 1983, and the new revision was endorsed by the Forty-third World Health Assembly in May The latest version came into use in WHO Member States starting in 1994.[16] The classification system allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion on the 17,000 codes available in ICD-9.[17] Adoption was relatively swift in most of the world. Several materials are made available online by WHO to facilitate its use, including a manual, training guidelines, a browser, and files for download.[3] Some countries have adapted the international standard, such as the "ICD- 10-AM" published in Australia in 1998 (also used in New Zealand),[18] and the "ICD-10-CA" introduced in Canada in 2000.[19] Adoption of ICD-10-CM has been slow in the United States. Since 1979, the USA had required ICD-9-CM codes[20] for Medicare and Medicaid claims, and most of the rest of the American medical industry followed suit. On 1 January the ICD-10 (without clinical extensions) was adopted for reporting mortality, but ICD-9-CM was still used for morbidity. Meanwhile, NCHS received permission from the WHO to create a clinical modification of the ICD-10, and has production of all these systems: ICD-10-CM, for diagnosis codes, is intended to replace volumes 1 and 2. Annual updates are provided. ICD-10-PCS, for procedure codes, is intended to replace volume 3. Annual updates are provided. (Source:

15 (Source:
ICD-10 Codes Continued On August 21, 2008, the US Department of Health and Human Services (HHS) proposed new code sets to be used for reporting diagnoses and procedures on health care transactions. Under the proposal, the ICD-9-CM code sets would be replaced with the ICD-10-CM code sets, effective October 1, On April 17, 2012 the Department of Health and Human Services (HHS) published a proposed rule that would delay, from October 1, 2013 to October 1, 2014,the compliance date for the ICD-10-CM and PCS.[21] Once again, Congress delayed implementation date to October 1, 2015, after it was inserted into "Doc Fix" Bill without debate over objections of many. (Source:

16 ICD-10 Similarities to ICD-9-CM
Tabular List Chronological list of codes divided into chapters based on body system or condition Same hierarchical structure Chapters in Tabular structured similarly to ICD-9-CM, with minor exceptions A few chapters have been restructured Sense organs (eye and ear) separated from Nervous System chapter and moved to their own chapters

17 ICD-10 Similarities to ICD-9-CM
Index Alphabetical list of terms and their corresponding codes Indented subterms appear under main terms Same structure as ICD-9-CM Alphabetic Index of Diseases and Injuries Alphabetic Index of External Causes Table of Neoplasms Table of Drugs and Chemicals

18 ICD-10 Similarities to ICD-9-CM
Nonspecific codes (“unspecified” or “not otherwise specified”) are available to use when detailed documentation to support more specific code is not available Many conventions have same meaning Abbreviations, punctuation, symbols, notes such as “code first” and “use additional code” Codes are looked up the same way Look up diagnostic terms in Alphabetic Index, then Verify code number in Tabular List

19 Why is ICD-10 important? Wait a minute!!!


21 Areas Impacted by ICD-10 Information Technology
Systems currently impacted Current system readiness Current vendor readiness

22 Areas Impacted by ICD-10 Operations Revenue cycle Clinical processes
Stakeholders Process impacts

23 Areas Impacted by ICD-10 Operations (cont.) Clinical Documentation
Coding Education

24 Areas Impacted by ICD-10 Finance Risk mitigation Contingency planning
Contracts Revenue cycle & cash flow impact

25 Benefits of ICD-10-CM Better data will be available for: Measuring the quality, safety, and efficacy of care Designing payment systems and processing claims for reimbursement Conducting research, epidemiological studies, and clinical trials Setting health policy Operational and strategic planning and designing healthcare delivery systems Monitoring resource utilization Improving clinical, financial, and administrative performance Preventing and detecting healthcare fraud and abuse

26 Benefits of ICD-10-CM Recognition of advances in medicine and technology Tracking public health and risks Improved efficiencies and lower costs Reduced coding errors Greater achievement of the benefits of an electronic health record

27 ICD-10-CM Structure ICD-9-CM 3-5 characters
3-7 characters •1st character is alpha (all letters except U are used) 2nd character is numeric Characters 3-7 are alpha or numeric •Use of decimal after 3 characters Alpha characters are not case-sensitive (e.g., Right ankle sprain, initial encounter: S93.401A, S93.401a, s93.401A, s93.401a) ICD-9-CM 3-5 characters First character is numeric or alpha (E or V) Characters 2-5 are numeric Always at least 3 characters Use of decimal after 3 characters

28 Code Structure Comparison


30 Who will be impacted? All providers

31 Who is impacted? Health care practitioners Hospitals
Health Insurers and 3rd party payers Electronic Clearinghouses Hardware & Software vendors Billing & PM service providers Health care admin and oversight agencies Public and Private research institutions

32 When is implementation?
Waiting game

33 Other Useful Information and Resources
On April 1st, 2014 the President signed the Protecting Access to Medicare Act of 2014 that eliminates for one year scheduled cuts to the Medicare Physician Fee Schedule (PFS) associated with the sustainable growth rate (SGR). The formula known as the SGR determines how much physicians and other providers are paid when they see Medicare patients. Without this law, the SGR cut would have taken effect and reduced the payment for services paid under the PFS by approximately 24% for all services after April 1,

34 Other Useful Information and Resources
ICD-10: This provision delays until October 1, 2015 the transition from ICD-9 to ICD-10. The International Statistical Classification of Diseases (ICD) is used to code services in order to bill for patient treatment. ICD-10 is a major revision and expansion of the code set. This change was previously scheduled to happen October 1, This delay will change the training and testing schedule for hospitals, clinics, and other providers. This may help providers who weren’t ready for the change, but could increase costs for the ones already gearing up for the transition. CMS will be issuing further guidance on ICD-10 implementation. When it is finally implemented, all providers will have to use ICD-10 in order to be paid by Medicare (and most other insurance companies). (Source: Office of Rural Health Policy/HRSA via 4/10/2014)

35 How might this impact my job?

36 QUESTIONS!! How do you see ICD-10 impacting your organization overall?
How do you see ICD-10 impacting your job? How do you see ICD-10 impacting the way your organization provides patient care?

37 Quick Coding Class & New documentation requirements
Injuries – Chapter 19 Quick Coding Class & New documentation requirements

38 Injuries (Chapter 19) Expanded category using the 7th character extension to identify the encounter type or Episode of Care: “A” for the initial encounter “D” for the subsequent encounter for fracture with routine healing “G” for the subsequent encounter for fracture with delayed healing “S” for sequela of fracture (late effects)

39 Injuries (Chapter 19) Size and depth of injury Cause of the injury and
Place of injury A fracture not indicated as displaced or nondisplaced should be coded to displaced, and A fracture not designated as open or closed should be coded to closed.

40 Opportunity is Knocking
The delay in ICD-10 implementation is an opportunity to help our providers improve documentation specificity which will lead to improved patient care.

41 ICD-10 Changes the way we Document
If it isn’t documented, it did not happen and cannot be coded or billed. —New information will be required to code for claims —Research indicates that in many cases, the medical records may contain the information, but it not currently used in coding the diagnosis Some cases may require new and expanded documentation —Laterality —Association between conditions

42 Importance of Clinical Documentation
ICD-10 code set requires a much higher level of specificity than the current ICD-9 standard Redesign clinical documentation practices Documentation will drive practice coding, a cornerstone to billing revenue. Failing to prepare for ICD-10 documentation requirements can drastically impact your revenue—missing information may prevent claims from even being submitted. Taking steps now to improve documentation will be foundational in helping your practice get paid faster and experience fewer delays and denials during the changeover.

43 More on Documentation Under ICD-10, providers will need to document the following in order to be able to assign a code: Laterality Stages of healing Trimester of pregnancy Episode of care

44 Immediate Documentation Areas of Focus
Begin adding the following to physician documentation: Side of dominance Left, right, or ambidextrous (defaults to right) Laterality All paired organs or structures Is this the initial visit or a subsequent visit for the complaint? Are these symptoms the sequela of the initial event?

45 Resources for a smooth transition (aka, cms rocks!)
What do we do now? Resources for a smooth transition (aka, cms rocks!)

46 CMS ICD-10 Implementation Guide for Small and Medium Practices
The CMS ICD-10 Implementation Guide for Small and Medium Practices groups the milestones and tasks into the following six phases: Planning Communication and Awareness Assessment Operational Implementation Testing Transition Figure 1 (next slide) shows these recommended ICD- 10 implementation phases and high-level steps. More detailed tasks are referenced on the ICD-10 Implementation Timeline.

47 Source: CMS ICD-10 Implementation Guide for Small and Medium Practices, Page 8

48 Awesome ICD-10 implementation website and it’s FREE!!
Three Words ROAD TO TEN… Awesome ICD-10 implementation website and it’s FREE!! (Thank you, CMS!!)

49 Resources and Contact Information conclusion

50 Resources Centers for Medicare and Medicaid Services
Road to 10 The North Carolina Healthcare Information and Communications Alliance, Inc. (NCHICA) Workgroup for Electronic Data Interchange (WEDI)

51 Resources (con’t) The American Health Information Management Association (AHIMA) NC Tracks (Medicaid) information Monthly NC Medicaid Bulletins National Rural Health Resource Center development/resources/icd-10-implementation-toolkit

52 Contact Information Tammy Norville Rural Health Operations Specialist Office:

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