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Presentation on theme: "PROPRIETARY AND CONFIDENTIAL ICD-10 ANSWERS AND UNDERSTANDING SURGERY CENTER COALITION Eileen Hummel, CPC March 19, 2014."— Presentation transcript:


2 Introduction ICD-10 was endorsed in 1990 by WHO (World Health Organization). The full version was released in 1994. On October 1, 2014 the transition to ICD-10 CM/PCS will be a defining moment for healthcare in the United States. A successful transition to ICD-10 will depend on how well you plan. ICD-10 will affect every facet of the healthcare industry. To ensure a smooth transition and minimize reductions in reimbursement, it is urgent that everyone receive training.

3 International Communication Over ten (10) countries are currently using ICD-10, such as: Australia – (1998) Canada – (2001) France – (1997) Germany – (2000) United Kingdom (1995)

4 Reasons for Change  ICD-9 is not detailed enough to describe patient diagnosis and modern medical services and procedures.  ICD-9 is over 30 years old and uses codes that produce inaccurate and limited patient data. It also reflects a healthcare landscape no longer relevant (smoking in hospitals and on airplanes!)  ICD-9 uses antiquated terminology.  ICD-9 cannot expand for additional disease classification and advances in the medical field.

5 Top 10 Reasons For ICD-10 1.Incorporates greater specificity and clinical information on a patient. 2.Improves ability to measure healthcare outcomes. 3.Includes updated medical terminology and classification of diseases. 4.Reduces burden to providers to produce additional clinical documentation. 4.Provides codes to allow comparison of mortality and morbidity data. 5.Provides better data for claims processing and designing payment models. 6.Improves clinical decision support. 7.Supports clinical research initiatives. 8.Identifies fraud and abuse. 9.Enhances public health trending. 10.Improves interoperability and data sharing.

6 Who Is Affected By ICD-10 *EVERYONE IS AFFECTED* ICD-10 will affect everyone covered by the Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare claims. Will introduce nine additional electronic transaction standards under HIPAA known as 5010. The change to ICD-10 DOES NOT affect CPT coding for outpatient procedures.

7 Who Is Affected By ICD-10 Cont. Source: AAPC

8 Code Structure ICD-10 includes full code titles for all codes. (No references, back to common 4 th or 5 th digits). V and E codes are no longer supplemental classifications. Sense organs have been separated from nervous system disorders. Injuries are grouped by anatomical site rather than injury category. Post-operative complications have been moved to procedure specific body system chapters.

9 Code Structure Comparisons ICD-9-CM 24,000 Codes 2 Volume Set 19 Chapters DOES NOT support laterality. Does NOT support interoperability because they are not recognized in other countries. ICD-10-CM Over 69,000 codes with the ability to expand to over 155,000 codes. 3 Volume Set 21 Chapters SUPPORTS laterality. DOES support interoperability and the exchange of healthcare information between the United States and other countries.

10 Code Structure Comparisons Cont. Code Structure of ICD-10-CM vs. ICD-9-CM ICD-10-CM codes may consist up to seven digits, with the seventh digit extensions representing visit encounter or sequela for injuries and external causes. ICD-9-CM Code Format ICD-9-CM may have and alpha (E or V) or numeric first digit, with numeric digits from the 2 nd through the 5 th digits. ICD-10-CM Code Format ICD-10-CM has only an alpha 1 st digit, 2 nd and 3 rd digits are numeric, and digits 4 – 7 are alpha or numeric.

11 Place Holders ICD-10-CM utilizes dummy placeholder characters (“X”). The “X” is used at the 5th or 6th digit placeholder in certain 6 or 7 character codes to permit future expansion. Example: – Postmenopausal osteoporosis with current pathological fracture, vertebra, initial encounter for fracture. Report Code: M80.08XA. – Since the code is only 5 characters long and it requires a 7th character, the placeholder “X” is needed in 6th character position. The 7th character “A” would be used to state the “initial encounter for fracture”, which is one of the following fracture extensions.

12 Fracture Extensions 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 non-union. P - Subsequent encounter for fracture with mal-union. S – Sequela.

13 GEM’s General Equivalent Mapping GEMS assist in converting data from ICD-9 to ICD-10. GEMS are not exact “crosswalks” from ICD-9 to ICD-10. A mapping that only shows each single ICD-9 code mapped to the more detailed ICD-10 code defeats the purpose of upgrading to ICD- 10. This would eliminate the benefits from the improvement in data quality that ICD-10 offers.

14 GEM’s Cont. Instead of a simple crosswalk, the GEM files attempt to organize those differences in a meaningful way. By linking a code to all valid alternatives in the other code set from which choices can be made. Forward mapping from ICD-9 to ICD-10. Backward mapping from ICD-10 to ICD-9. They are for TESTING ONLY NOT CODING!

15 Coding Tips ICD-10 is divided into the Alphabetic Index, which is an alphabetic list of terms and corresponding codes, and the Tabular List, a numerical list of codes divided by chapter, according to condition or body system. Become familiar with chapter specific guidelines to know when the seventh character is needed. NEVER code from the index or default codes! TWO types of “excludes notes” in ICD-10: Type I excludes note means “NOT CODED HERE”!!!!! Type II excludes note means “NOT INCLUDED HERE”!!!!

16 Coding Tips Cont. If anticipated treatment is NOT carried out due to unforeseen circumstances, the principal diagnosis/first listed code remains the condition or diagnosis that the provider planned to treat. Use of “and” represents and/or. NEVER code from the index, ALWAYS code from the tabular.

17 Coding Tips Cont. “‘Impending” or “threatened” condition at time of discharge should be coded as follows: If it DID occur, code as confirmed diagnosis. If it did NOT occur, see the Alphabetical Index to determine if the condition is a subentry term for “impending” or “threatened”. Also, reference main term entries for “impending” and for “threatened”. If the sub-terms are listed, assign the given code. If the sub-terms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.

18 ICD-10 Implementation Planning Communications & Awareness Transition Operational Implementation Testing Assessment

19 Project Plan Establish a team for ICD-10 implementation: Must understand ICD-10 and have accountability for the project. Must be a team player and can provide direction and resolve issues. Define clear goals and objectives. Establish governance – rules of engagement of project and resources. Identify your project tasks and milestones. Plan to communicate with external partners. Establish timelines for tasks and milestones. This sets off what is and what is not part of the implementation plan. Identify what are your possible risks, contingency measures are, and how issues will be addressed.

20 Communication & Awareness Develop a communication plan for your organization. It can be short and sweet. Identify the ICD-10 team members, roles and responsibilities. Outline how issues will be communicated and define your resolution process. How often meetings will take place, and how written communications will be disseminated. Who and how often? Assess training needs and develop a training plan. Meet with all staff to discuss the project and all of the pertinent details of the plan.

21 Assessment (Business) Perform a business and policy impact analysis. Assess workflow in all areas that may be impacted. Establish a budget (must have a reserve for cash flow disruption). Training Health plan contract modifications Super bill and EHR template modifications Process and procedure modifications Health information technology Increased documentation Evaluate information management uses (data, extracts, reports, etc.) What policies and procedures need to change? What contracts or linkages affected your external partners?

22 Contracts The level of specificity is essential in ICD-10 and should allow providers to describe complex patient conditions in much greater detail. Review your contracts and speak to payers about possible changes in reimbursement. Learn to use your data to negotiate higher reimbursement. Get paid for performance.

23 Assessment (Technology) Do you know when your system will be upgraded? What system training is your vendor providing? Will your EHR templates need to be changed? If so, who will make these modifications and when? How are ICD-9 codes used in each information system? How are codes entered? Manually or imported from another system or software? Can your current system handle both ICD-9 and ICD-10 Will you be able to map forward from ICD-9 to ICD-10 and backward from ICD-10 to ICD-9 to keep historical data in your organization? How do applications and systems interface? What are the impacts? Who will manage modifications, testing, go-live and support?

24 Electronic Transactions Transactions that will be affected: Claims Remittance Claims status inquiry/response Eligibility inquiry/response Functional acknowledgement Transaction acknowledgment Any transaction that currently accesses ICD-9

25 Training Develop your training plan with specific roles in mind. Anyone that ICD-9 impacts is on the list: Billing Physicians Clinical staff Administration Everyone will require different levels of training based on their functions.

26 Testing Testing is an evaluation by the users that systems and operations are working. Don’t wing it! Quality assurance - “Do all of the changes made provide the expected outcome?” User acceptance. Monitoring revenue cycle (A/R, rejection rates, practice productivity, and reimbursement dollars). Integration and system performance testing. End-to-end testing (operational and claim lifecycle).

27 What Is ICD-10 Compliance ICD-10 compliance means that you have to implement and start using ICD-10 codes effective October 1, 2014. Failure to convert to ICD-10 will result in total disruption of your revenue cycle and business operations. Your claims will not be processed and... NO CLAIMS MEANS NO MONEY!

28 Compliance and Clinical Documentation Documentation will have the largest impact on ICD-10 implementation. Being that ICD-10 is more robust and has up to seven (7) characters of specificity. You should verify that the current documentation in the medical record can support ICD-10. IMPORTANT element of compliance is auditing for appropriate documentation and coding. Auditors should have a deep knowledge of ICD-10 codes and guidelines. Ensure that providers are documenting a COMPLETE diagnosis to accommodate the higher level of specificity of ICD-10. Auditing for ICD-10 is somewhat different from the typical medical record documentation and coding audit. The auditor will need to assess the documentation to determine risks and re-training efforts.

29 Compliance and Clinical Documentation Cont. Laboratory and radiology procedures will be affected. Assess the level of specificity is documented and coded correctly or it will result in the claim being returned. Advanced Beneficiary Notices (ABNs) will need to be updated to allow for more specificity for services performed and can no longer state “medically unnecessary” or its equivalent. Any performance measure tied to a diagnosis code will need to be revised. Once the audit has been conducted and analyzed, you will have a good assessment of documentation deficiencies. Develop a priority list of diagnoses requiring more detail. Implement a documentation improvement program within your organization and implement monitoring controls.

30 Conclusion If you haven’t started planning, do not delay! Bring the team together and begin your planning process. Start identifying how this will impact your business (all areas). Assess workflow, training, and technology impacts. Billing and Coding will undergo a significant impact with ICD-10 implementation. Every process in this area must undergo review. If the provider is determining the diagnosis code selection, comprehensive education and training will be necessary.

31 Questions? Eileen Hummel, CPC Principal Consultant Billing and Financial Services Health Informatics Consulting, LLC Phone: 609-925-9008


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