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ICD-10-CM Update Presented by: Janet Smith, RHIT, CPC AHIMA Approved ICD-10 Trainer The Tennessee Pediatric Society Foundation1.

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Presentation on theme: "ICD-10-CM Update Presented by: Janet Smith, RHIT, CPC AHIMA Approved ICD-10 Trainer The Tennessee Pediatric Society Foundation1."— Presentation transcript:

1 ICD-10-CM Update Presented by: Janet Smith, RHIT, CPC AHIMA Approved ICD-10 Trainer The Tennessee Pediatric Society Foundation1

2 Brief History ● ICD-10 was adopted by the World Health Organization (WHO) in 1990 ● Following the publication of ICD-10, many countries performed analysis to determine if the WHO classification system would meet their needs ● The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10- CM) is the United States’ clinical modification to the World Health Organization’s version of ICD-10 The Tennessee Pediatric Society Foundation2

3 Brief History Countries Using ICD-10 For Reimbursement or Case Mix: ● United Kingdom ● Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) –1997 ● France ● Australia ● Belgium ● Germany ● Canada The Tennessee Pediatric Society Foundation3

4 Brief History ● The United States remains the only industrialized nation that has not yet implemented ICD-10 or a clinical modification for diseases or causes of illness typically coded in a healthcare facility ● Since 1999, however, the United States has used ICD-10 for mortality reporting (for death certificates) The Tennessee Pediatric Society Foundation4

5 Why do we need ICD-10? ● ICD-9 is 30 years old –medicine and technology has changed ● Many categories full ● Not descriptive enough ● Implementing ICD-10-CM will maintain data comparability internationally and between mortality and morbidity data in the United States ● Would enhance accurate payment for services rendered The Tennessee Pediatric Society Foundation5

6 Benefits of ICD-10-CM Greater clinical detail More specificity, laterality, external causes of injuries, combination codes for diagnoses and symptoms Reflects advances in medicine and medical technology Measuring the quality, safety, and efficacy of care Reducing the need for attachments to explain patient’s condition Improving clinical, financial, and administrative performance Tracking public health and risks The Tennessee Pediatric Society Foundation6

7 When will ICD-10 be implemented? In January 2009, the Department of Health and Human Services published the final rule for adoption of ICD-10- CM and ICD-10-PCS, setting a compliance date of October 1, 2013 On April 9, 2012, HHS released a proposed rule that calls for a one-year delay for the ICD-10 compliance date from October 1, 2013 to October 1, On April 17, 2012 the announcement for the ICD-10 delay was published in the Federal Register. A 30-day comment period was granted on the proposed rule and is now closed. Public comments are being reviewed and analyzed, and the Department will issue a final rule as expeditiously as possible The Tennessee Pediatric Society Foundation7

8 Reasons behind the delay ● There was no one group that spurred CMS to propose the delay ● The industry’s ongoing struggle to implement HIPAA Version 5010 (a precursor to ICD-10) that was effective January 2012 but has seen enforcement delayed twice because many physicians have had technical trouble implementing the version update ● Physician concern regarding the ICD-10 timeline ● A one-year delay reflects the industry’s need for a quick resolution and providers’ need for additional time to implement, and will not likely penalize those on track with the original deadline The Tennessee Pediatric Society Foundation8

9 What to Expect with ICD-10? ICD-10-CM (Clinical Modification) will replace ICD-9-CM diagnosis codes rendered in all healthcare settings. ICD-10-PCS (Procedural Coding System) will replace the ICD- 9-CM procedure codes rendered in the hospital/inpatient setting. CPT and HCPCS Level II will remain the coding system for physician and professional services and procedures performed in the outpatient setting. After the implementation of the ICD-10 code set, inpatient reimbursement for Medicare patients will be based on Medicare DRGs using the ICD-10 coding system not ICD-9 Payer and office systems and processes must be able to support both ICD-9 and ICD-10 code sets on the implementation date The Tennessee Pediatric Society Foundation9

10 ICD-10 Practice Impact Plan for budgeting  Revenue flow problems  Productivity  Software/System upgrades Staffing changes/additions Education for providers and staff  Audit for increased specificity in documentation (Stages of healing, episode of care, laterality)  Code set training  Operate under dual coding system Health Plans  Contracts  Coverage policies The Tennessee Pediatric Society Foundation10

11 Cost Estimate – 5 Physician Practice (Two Years) Information Systems Practice Management Upgrade - $5,000 EMR Upgrade (if applicable) - $5,000 IT and Consulting - $5,000 Audit/Review/Consulting General Consulting/Audit Year $500/provider twice a year - $3,000 General Consulting Year 2 - $3,000 Review of System Process - $3,000 Crosswalking - $1,500 The Tennessee Pediatric Society Foundation11

12 Cost Estimate – 5 Physician Practice (Two Years) Education and Training 5 physicians - $3,500 1 coder/biller - $1,600 2 nurses/MA - $3,000 2 ancillary staff - $1,000 Management - $500 Staff and Overtime Coders - $2,000 Ancillary Staff - $400 Productivity Loss - $18,400 TOTAL Estimated Cost = $59,500 The Tennessee Pediatric Society Foundation12

13 How is ICD-10 structured? ● The “look-up” process will be very similar to ICD-9 ● The same hierarchical structure is used as ICD-9 ● The ICD-10 system will be alphanumeric and contain up to 7 characters ● ICD-10 has approximately 68,000 codes vs. 14,000 in ICD-9 ● Code composition and level of detail are the major differences The Tennessee Pediatric Society Foundation13

14 ICD-10- CM Structure 21 Chapters 2 New Chapters  Diseases of the Eye and Adnexa (Ch 7)  Diseases of the Ear and Mastoid Process (Ch 8) Certain Diseases were re-classified and are now found in new chapters  Immune Mechanism (Immunity) was moved from Chapter 4 (Endocrine) to Chapter 3 (Blood Disorders) Injuries (Ch19) are now arranged by body part and not by injury Mental Disorders (Ch 5), Injury and Poisonings (Ch 19), and External Causes (Ch 20) were all re-organized The Tennessee Pediatric Society Foundation14

15 ICD-10- CM Structure Codes have 3 to 7 alphanumeric characters (vs 5 numeric in ICD-9) Character 1 is always alpha – letters A-Z, except U Character 2 is numeric Character 3-7 can be alpha or numeric Decimal placed after the first three characters Alpha characters are not case-sensitive  A78 – Fever  J04.0 – Acute laryngitis  S – Laceration w/o foreign body of right upper arm  S63.280A – Dislocation of proximal interphalangeal joint of right index finger, initial encounter The Tennessee Pediatric Society Foundation15

16 ICD-10- CM Structure Character 4 represents a subcategory that further defines the site, etiology and manifestation or state of the disease Character 5 and 6 identify the most accurate level of specificity Character 7 – Extension  Some codes require 7 characters  If a code requires a 7 th character and there is no 5 th or 6 th character, a placeholder “X” must be used  All placeholders of an applicable code must be reported Example: T16.XXA – Foreign body in right ear, initial encounter The Tennessee Pediatric Society Foundation16

17 ICD-10- CM Structure  S60 – Superficial injury of wrist, hand and fingers  S60.4 – Other superficial injuries of other fingers  S60.45 – Superficial foreign body [splinter] of fingers  S – Superficial foreign body [splinter] of left index finger  S60.451A – Superficial foreign body [splinter] of left index finger, initial encounter The Tennessee Pediatric Society Foundation17

18 Translation of Codes The Tennessee Pediatric Society Foundation ICD-9-CMTOICD-10-CM Salmonella meningitis = A02.21 Salmonella meningitis ICD-9-CMTOICD-10-CM Sleep Arousal Disorder ≠ F51.3 Sleepwalking ICD-9-CMICD-10-CM Primary tuberculosis infection, unspecified examination Primary tuberculosis infection, bacteriological/histological exam not done Primary tuberculosis infection, bacteriological/histological exam unknown (at present) ≠ A15.7 Primary respiratory tuberculo sis 18

19 External Causes Chapter 20 - Codes for external causes  V, W, X and Y are the 1 st characters  Are never used as primary code  Are never reported alone The Tennessee Pediatric Society Foundation19

20 Z Codes are the New “V” Codes Chapter 21 – Factors influencing health status and contact with health services  Encounter for healthcare exams  Are part of the ICD-10-CM code set and must be recognized by payers  May be used as primary diagnosis The Tennessee Pediatric Society Foundation20

21 Preventive Care Z Routine child health check Z Routine child health check with abnormal findings Z Health supervision (health check) for newborn under 8 days Z Health supervision (health check) for newborn 8 to 28 days Z23 Encounter for immunizations The Tennessee Pediatric Society Foundation21

22 Other Health Visits Z01.818Pre-operative examination Z02.0School physicals Z02.5Sports physicals Z02.82Pre-adoption exam Z48.02Suture removal Z71.0Parent (family) conference Z71.3Diet management (for obesity) Z76.81Parents pre-birth or pre-adoption visit The Tennessee Pediatric Society Foundation22

23 Documentation Use appropriate terminology Document highest level of specificity Indicate right versus left Indicate specific body area Specify episode of care (initial, recurrent) The Tennessee Pediatric Society Foundation23

24 Reimbursement and Quality Problems With ICD-9-CM ● Example –Fracture of Wrist ● Patient fractures left wrist ● A month later, fractures right wrist ● ICD-9-CM does not identify left versus right – requires additional documentation ● ICD-10-CM describes left versus right ● Initial encounter, subsequent encounter ● Routine healing, delayed healing, nonunion, or malunion The Tennessee Pediatric Society Foundation24

25 Example If provider documents: OM (otitis media) Code =H66.90 otitis media, unspecified, unspecified ear The Tennessee Pediatric Society Foundation25

26 Possible Codes Acute suppurative otitis media without spontaneous rupture of ear drum H66.001, right ear H66.002, left ear H66.003, bilateral H66.004, recurrent, right ear H66.005, recurrent, left ear H66.006, recurrent, bilateral H66.007, recurrent, unspecified ear H66.009, unspecified ear The Tennessee Pediatric Society Foundation26

27 Example If provider documents: Reactive Airway Disease Code = J Unspecified asthma, uncomplicated If provider documents: Respiratory Distress Code – R06.89 Other abnormalities of breathing The Tennessee Pediatric Society Foundation27

28 Possible Codes J98.01Acute bronchospasm J45.990Exercise induced bronchospasm J Cough variant asthma The Tennessee Pediatric Society Foundation28

29 Other Possible Asthma Codes Asthma J45.20 Mild intermittent, uncomplicated J45.21 Mild intermittent, with (acute) exacerbation J45.22 Mild intermittent with status asthmaticus J45.30 Mild persistent, uncomplicated J45.31 Mild persistent, with (acute) exacerbation J45.32 Mild persistent, with status asthmaticus J45.40 Moderate persistent, uncomplicated J45.41 Moderate persistent, with (acute) exacerbation The Tennessee Pediatric Society Foundation29

30 What to do now? ● Maintain momentum ● Identify current systems and processes that use ICD-9 codes ● Talk with vendors about accommodations for ICD-10 ● Take the time to improve clinical documentation ● Evaluation staff training needs ● Ask payers how ICD-10 changes may affect contracts, payment schedules and reimbursement The Tennessee Pediatric Society Foundation30

31 Informational Links  m.htm m.htm   The Tennessee Pediatric Society Foundation31

32 Questions? The Tennessee Pediatric Society Foundation32

33 Thank You! Contact information: Janet Smith Coding Educator The Tennessee Pediatric Society Foundation33


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