1. CPMA
April 11, 2015
Phill Ward, DPM
President, APMA

2. What’s new for 2015 CPT 20600 (Descriptor change)
Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes) without ultrasound guidance

3. What’s new for 2015 CPT 20604 (New Code)
Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes) with ultrasound guidance with permanent recording and reporting

4. What’s new for 2015 CPT 20605 (Descriptor change)
Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., ankle, wrist, elbow) without ultrasound guidance

5. What’s new for 2015 CPT 20606 (New Code)
Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., ankle, wrist, elbow) with ultrasound guidance with permanent recording and reporting

6. What’s new for 2015 CPT 97605 (descriptor change)
Negative pressure wound therapy (e.g. vacuum assisted drainage collection) utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
Example “KCI wound vac”

7. What’s new for 2015 CPT 97606 (New code)
Negative pressure wound therapy (e.g. vacuum assisted drainage collection) utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than or equal to 50 square centimeters
Example “KCI wound vac”

8. What’s new for 2015 CPT 97607 (New code)
Negative pressure wound therapy (e.g. vacuum assisted drainage collection) utilizing non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
Example “Snap”

9. What’s new for 2015 CPT 97608 (New code)
Negative pressure wound therapy (e.g. vacuum assisted drainage collection) utilizing non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater to 50 square centimeters
Example “Snap”

10. What’s new for 2015 -59 modifier change (only for CMS so far)
-XE (separate encounter)
-XS (separate structure)
-XP (separate practitioner)
-XU (unusual overlapping service)
CMS has been less than clear in their notices about how/when to use these modifiers
MLN article dated Feb 2015 still doesn’t clarify the usage of these modifiers

11. What’s new for 2015 Examples -XE -XS
Patient was seen in the morning and returned in the afternoon for another service
-XS
Services were provided on nails and lesions or bunion and hammertoe

12. What’s new for 2015 Examples -XP -XU
Bone graft harvested by 1 surgeon and used by another surgeon on the same patient in the same encounter
-XU
2 lesions present in the same code set and are excised separately

13. Ongoing Controversy Nerve injections Other peripheral nerve 64450
Neuroma Steroid 64455
Neuroma Sclerosing 64632
Other sclerosing 64640
Other misc nerve 64999

14. What About Globals? 10 day global 90 day global
2017
90 day global
2019
CPT Assistant March revision of global package definition/interpretation

15. Meaningful ? Use 50% of eligible providers did not attest for Stage I
4% eligible providers successfully attested for Stage II in 2014
Congressional (in)action
Flex It Bill – Rep Elmers
Jan 30, 2015 CMS comments

16. Sustainable Growth Rate and Medicare Fee Schedule Reform
House passed SGR reform 3/25
Senate refused to act before Easter vacation
+/-21% decrease on April 1, 2015
Senate is supposed to act “soon”
Multiple payment models proposals to replace “Fee For Service” model
No decisions made yet, likely a testing period before implementation

18. If you don’t want to use ICD-10…
…then don’t 
have a nice day

19. Postponement?
It is possible that Congress will once again postpone ICD-10 implementation
Are you willing to bet your practice on it?

20. The Train has left station!!
So what has APMA done to prepare you for ICD-10?

21. APMA News Articles
link:
There have been more than 20 ICD-10 articles in the APMA News
All are available for download on the APMA website

22. Webinar Series
There has been a series of ICD-10 webinars presented and recorded and archived on the APMA website

23. Coding Resource Center
The CRC has been updated with a crossover capability to translate ICD-9 codes to ICD-10 codes

24. ICD-10 Potential negative impacts
Decreased productivity
Interrupted cash flow
Increased amount of rejections
Incompatible systems
Increased volumes of work
Incorrect mapping
Increased risk of payer audits
Having to run 2 diagnosis coding systems at the same time

25. ICD-10 Potential positive impacts
Better specificity
Better data collection

26. ICD-10 Rules
“SYMBOLS and CONVENTIONS” To get started with any new system, one must first understand the rules. This webinar will now address the symbols and conventions next.
Never code from the Alphabetic Index because important instructional notes will surely be missed.
1) In the text a ● colored dot cautions you to make sure you use additional digit(s) to ensure greatest specificity.
2) ■ “Unspecified” The Square before a code indicates there are more specific codes without the symbol. It is still a valid first line code but if possible look for the code with highest specificity.
3) “OGCR” This symbol indicates there is “Official Guidelines for Coding and Reporting”. The passage is usually placed near the codes in a colored box.

27. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
4) “CC” Indicates complications and comorbidities. “MCC” indicates Major Complications and comorbidities. Published in the Federal register these two codes address Inpatient Prospective Payment System (IPPS).
5) Z codes that have a number 1 inside a circle before them means the code must be listed first.
6) The ½ symbol inside a circle before a Z code indicates this code may be the first or second listed code.
7) The number 2 inside a circle before Z codes means it is listed as a secondary code.

28. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
8) The “Excludes 1” is when two conditions can not occur together.
9) The “Excludes 2” means not included here. This is the case where it is acceptable to use both the code and the excluded code together.
10) The Code first/Use additional code means when there are multiple body system manifestations you code the underlying condition first and the manifestation second.

29. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
11) “In diseases classified elsewhere” these codes are never permitted to be used as first line codes. These codes must be listed after the underlying condition.
12) “Code also” means two codes may be required but the sequencing of the codes is discretionary.
13) “7th characters” means the applicable 7th character must always be used and placeholder “x” used as a 5th character and/or 6th character codes to allow for future expansion.
14) “and” This word is interpreted as either “and” or “or”.

30. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
15) “Includes” in a colored box further defines or gives examples of the content. This notation appears immediately under a code title.
16) Abbreviations: “NEC”=”Not Elsewhere Classifiable” this is another specified code, used when a more specific code is not available. “NOS” = “Not otherwise specified”, this indicates an unspecified code.
17) Each ICD-10-CM diagnosis codes are to be reported ONCE for an encounter. When bilateral conditions exist, this one listed code counts when no distinct code for laterality or two different conditions are classified.

31. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
18) Documentation for BMI should only report as secondary diagnosis codes.
19) The instruction “see” acts as a cross reference and directs the user to look elsewhere. This instruction is often found when the term or condition may not be the appropriate term. This is a mandatory instruction and must be followed for proper code selection.
20) “See also” is a reference instruction note to refer to a specific category, subcategory, or classification before making a code selection if you cannot find the diagnosis listed under a term in Volume 2.

32. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
21) Laterality. An unspecified side code is also provided should the side not be identified in the medical record. The unspecified side is either ends with a character 0 or 9 depending on whether it is a fifth or sixth character.
22) Dummy Place holders – using the character “x”. The “x” is used as fifth or sixth character placeholder to allow for future expansion. Some codes in ICD-10-CM require either 6th or 7th characters in the code. If the code, for example, had 5 characters and a seventh character was required based on the instructional notes, dummy placeholder would be used in sixth character position to allow for the seventh character to be reported

33. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
23) [ ] Brackets are used in the index and to identify manifestation codes.
24) ( ) Parentheses are used in both the Index and Tabular List to enclose supplemental words that do NOT affect the code number. The terms within the parentheses are referred to as nonessential modifiers.
25) : Colon is used after an incomplete term that needs one or more of the modifiers that allow it assignable to a given category.

34. ICD-10 Rules “SYMBOLS and CONVENTIONS Continued”
26) – Dash at the end of a code indicates additional digits are required to complete the diagnostic term.
27) , Comma – words following a comma are essential modifiers. The term in the inclusion note must be present in the diagnostic statement to qualify the code.

35. ICD-10 Structure Same as ICD-9 Chapters
22 Chapters identifying categories
Blocks
Subchapters
Etiology, anatomical site, severity
Rubrics
Identify closely related conditions
Extensions

36. ICD-10 Chapters Chapter 1 A00-B99 Infectious and Parasitic diseases
Chapter 2 C00-D49 Neoplasms
Chapter 3 D50-D89 Hematological and Immune Systems
Chapter 4 E00-E90 Endocrine, Nutritional and Metabolic Diseases
Chapter 5 F01-F99 Mental and Behavioral Disorders
Chapter 6 G00-G99 Diseases of the Nervous System
Chapter 7 H00-H59 Diseases of the Eye and Adnexa

37. ICD-10 Chapters Chapter 8 H-60-H95 Diseases of the Ear and Mastoid
Chapter I01-I99 Diseases of the Circulatory System
Chapter 10 J00-J99 Diseases of the Respiratory System
Chapter 11 K00-K94 Diseases of the Digestive System
Chapter 12 L00-L99 Diseases of the Skin and
Subcutaneous Tissue
Chapter 13 M00-M99 Disease of the Musculoskeletal System and Connective Tissue
Chapter 14 N00-N99 Diseases of the Genitourinary System

38. ICD-10 Chapters
Chapter 15 O00-O99 Pregnancy, Childbirth and Puerperium
Chapter 16 P00-P96 Certain Conditions Originating in the Perinatal Period
Chapter 17 Q00-Q99 Congenital Malformations, Deformations and Chromosomal Abnormalities
Chapter 18 R00-R99 Symptoms, Signs and Abnormal Clinical and Laboratory findings, not classified elsewhere
Chapter 19 S00-T88 Injury, Poisoning and Certain other Consequences of External Causes
Chapter 20 V00-Y98 External Causes of Disease or Morbidity
Chapter 21 Z00-Z99 Factors Influencing Health Status and Contact with Health Services
Chapter 22 – Special Purposes

39. Decacodaphobia Definition = Fear of ICD-10 Z23.670
How Detailed is ICD-10?
Decacodaphobia
Definition = Fear of ICD-10
Z23.670

41. ICD-9-CM vs. ICD-10-CM ICD-9-CM ICD-10-CM
Numeric characters (with exception of some codes beginning with V, E, M)
3-5 in length
About 13,000 codes
Alphanumeric characters; always begin with an alpha character
3-7 characters in length
About 68,000 codes

42. ICD-9-CM ICD-10-CM

43. Other ICD-10 to ICD-9 Differences
Laterality (side of the body affected – right/left) has been added to relevant codes
Injuries grouped by anatomic site rather than type of injury
Expanded use of combination codes
Certain conditions and associated common symptoms or manifestations
Poisonings and associated external causes

44. Format differences

45. Combination Code Examples
E Type 2 diabetes mellitus with diabetic
peripheral angiopathy with gangrene
E Type 2 diabetes mellitus with foot ulcer [Use additional code to identify site of ulcer L97.4-,L97.5-]
I Monoplegia of lower limb following
nontraumatic intracerebral hemorrhage affecting
left non-dominant side
I Atherosclerosis of native arteries of right
leg with ulceration of other part of foot

46. ICD-9-CM ICD-10-CM V49.71 - Lower limb amputation status, great toe
Z89 – Acquired absence of limb Z89.4 – Acquired absence of toe(s), foot, & ankle Z89.41 – Acquired absence of great toe Z Acquired absence of right great toe

47. ICD-10-CM Structure - Format
3-7 character examples
L84 Corn and callosities
B95.5 Staphylococcus aureus as the cause of diseases classified elsewhere
M Hallux valgus (acquired), right foot
T78.01D Anaphylactic shock due to peanuts (subsequent encounter)
S98.111A Complete traumatic amputation of right great toe (initial encounter)

48. ICD-10-CM
Fracture codes require a 7th character The fracture extensions are:
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 nonunion
P - Subsequent encounter for fracture with malunion
S - Sequelae

49. 2015 , ready to retire? ICD-10 – training and implementation
PQRS – penalties take effect this year
MU2 – can you get 5% of your patients to request info ?
E-Prescribing
HIPAA – Drs. offices now being looked at
Affordable Care Act – higher deductibles and copays
Have you got your line of credit yet?

50. Btw…Obamacare too

51. ICD-9-CM & ICD-10-CM Both ICD-9 and ICD-10 Alphabetic Indexes
Recommend beginning your code search in Volume 2 (alphabetic), then verifying the code in Volume 1 which is much more detailed
(Most EHR will do this automatically after you type in an alpha search term)

52. Alphabetic Index (ICD Volume 2)
ICD-9 Alphabetic Index
ICD-10 Alphabetic Index
Hallux 735.9
limitus 735.8
malleus (acquired) 735.3
rigidus (acquired) 735.2
congenital
late effects of rickets 268.1
valgus (acquired) 735.0
varus (acquired) 735.1
Hallux
deformity (acquired) NEC M20.5x
limitus M20.5x
malleus (acquired) NEC M20.3-
rigidus (acquired) M20.2-
congenital Q74.2
sequelae (late effect) of rickets E64.3
valgus (acquired) M20.1-
congenital Q66.6
varus (acquired) M20.3-
congenital Q66.3

53. Tabular List (ICD Volume 1)
ICD-9 Tabular Index
ICD-10 Tabular Index
735 Acquired deformities of toe Excludes: congenital ( , ) Hallux valgus (acquired) Hallux varus (acquired) Hallux rigidus Hallux malleus
M20.1- Hallux valgus (acquired) Bunion M20.10 Hallux valgus (acquired), unspecified foot M20.11 Hallux valgus (acquired), right foot M20.12 Hallux valgus (acquired), left foot M20.2- Hallux rigidus M20.20 Hallux rigidus, unspecified foot M20.21 Hallux rigidus, right foot M20.22 Hallux rigidus, left foot M20.3- Hallux varus (acquired) M20.30 Hallux varus (acquired), unspecified foot M20.31 Hallux varus (acquired), right foot M20.32 Hallux varus (acquired), left foot

54. Start with Index START WITH INDEX
There is a period after the 3rd character and often a dash
Example Pain
M79. –
NEXT TO TABULAR - Define the site, etiology, manifestation or state of the disease or condition
M79. -

55. ICD-9-CM & ICD-10-CM Both ICD-9 and ICD-10 Alphabetic Indexes include
the Index of Diseases and Injury
the Index of External Causes of Injury
The Tables of Neoplasm; and
The Table of Drugs and Chemicals
Both ICD-9 and ICD-10 use an indented format
Hallux 735.9
rigidus (acquired) 735.2
congenital

56. hallux valgus (acquired)
ICD Guidelines
Example: Volume 2
hallux valgus (acquired)

57. M20.1 Hallux valgus (acquired)
ICD Guidelines
Example: Volume 1
M20.1 Hallux valgus (acquired)

58. ICD 10 Changes APMA Submitted for Change 10/1/2015
M21.6 Other acquired deformities of foot
Excludes: deformities of toe (acquired)
(M20.1-M20.6)
M21.6x Other acquired deformities of foot
M21.6x1 Other acquired deformities of right foot
M21.6x2 Other acquired deformities of left foot
M21.6x9 Other acquired deformities of unspecified foot
M Bunion
M Bunion deformity, unspecified
M Bunion deformity, right foot
M Bunion deformity, left foot
M Bunionette
M Bunionette deformity, unspecified
M Bunionette deformity, right foot
M Bunionette deformity, left foot

59. The X, “dummy” Dummy 5th Character Just to confuse you even more 
To allow for further expansion some codes have a “dummy” 5th place character so that the 6 character structure will not be disrupted when changes are added
Report these codes as they are in the book including the “dummy”5th character “x”

60. DEFINITION: Unspecified
Codes in the Tabular Listing that include “unspecified” in their description are to be used when the information in the medical record is insufficient to assign a more specific code. M20.10 hallux valgus (acquired), unspecified foot In other words, in the “hallux valgus” example, the medical record failed to distinguish which foot had the hallux valgus deformity. The Alphabetic Index uses “NOS” – not otherwise specified – for the same designation.

61. DEFINITION: “Other Unspecified” or “Other”
Codes that include “other” or “other specified” in their description are found in the Tabular Listing.
“Other” or “other specified” codes are to be used when the medical record documents a condition for which no specific ICD code exists.
The corresponding term in the Alphabetic Index is “NEC” (not elsewhere classified).

62. Next…
4th Character
Define the site, etiology, manifestation or state of the disease or condition
Numeric
Example Pain
M79. -
M79.6 pain in limb, hand, foot, fingers, toes

63. #5 5th Character 5th character identifies a level of specificity
Letter or Number (0-9)
Example
M79. Pain
M79.6 pain in limb, hand, foot, fingers, toes
M79.60 Pain in limb

64. #6 Numeric (0-9) 6th character is even more specific
Describes specific location or cause
For laterality
1 is right
2 is left
3 is unspecified
Example Pain
M79.-
M79.6 pain in limb, hand, foot, fingers, toes
M79.60 Pain in limb unspecified
M Pain in right foot

65. 7th… 7th Character Some codes have a so-called character extension
Typically letters, that describe conditions/timing of the visit
Used to give more information about the events related to the reason for the visit or service

66. Non-fracture care A- initial encounter D- subsequent encounter
S- sequela
Fracture care
A- initial encounter (for closed fracture)
B – initial encounter for open fracture
D- subsequent encounter for normal healing fracture
G- subsequent encounter for delayed healing fracture
K- subsequent encounter for fracture with non-union
P- subsequent encounter for fracture with mal-union
S- sequela of fracture

67. ICD-10 “Look-Up” Example
Stage III decubitus ulcer of left heel
Step 1 - Look up main term in Alphabetic Index
Ulcer, ulcerated, ulcerating, ulceration
See ulcer by site
lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic) (topical)
pressure (pressure area) L89-
heel L89.6-

68. ICD-10-CM “Look-Up” Example
Stage III decubitus ulcer of left heel
Step 2 - Verify in Tabular:
L Pressure ulcer of heel
L Pressure ulcer of left heel
L Pressure ulcer of left heel, stage III

69. More ICD Guidelines
[ ] Brackets in the Tabular List enclose synonyms, alternative wording, or explanatory phrases
M21.4 Flat foot [pes planus] (acquired)
[ ] Brackets in the Alphabetic Index are used to identify manifestation codes
Disease, diseased skin L98.9
due to metabolic disorder NEC E88.9 [L99]

70. “Code First” & “Use Additional Code”
An ICD sequencing example
Diabetic (type I) heel ulcer
Is the underlying condition

71. “Code First” & “Use Additional Code”
The ICD sequencing instruction is to list
the underlying condition code first
L97 is a
manifestation
code

72. ICD Guidelines Manifestation code: L97.411
It is coded after the underlying condition code, E diabetic (type I) heel ulcer

73. At Risk Care and ICD-10 ICD- 10 703.8 (onychauxis)
L60.2 onychogryphosis, hypertrophic nails
L60.3 nail dystrophy
L60.8 other nail disorders
L60.9 nail disorder, unspecified
Q84.5 onychauxis, enlarged nails
Q84.6 other cong. Nail dz

74. Let’s add PVD ICD-9 ICD-10 443.9 PVD, unspecified
I ASO of native arteries of extremities
(IMPORTANT!!:)
The hyphen denotes additional characters required specific for ASO disease
Need to be SPECIFIC unlike in ICD 9

75. And…Diabetes
ICD 9
ICD 10
250.60
Diabetes with neurological manifestations
E type 1 DM with neuro complications
E11.4- type 2 DM with neuro
Z79.4- with insulin use
E13.4- other specific DM with neuro comps.
other specified DM with diabetic arthropathy and Z79.4- for insulin use

76. Oh yeah, “thick nails” ICD 9 ICD 10 110.1 onychomycosis
B35.1 onychomycosis

77. Let’s add a keratoma
ICD 9
ICD 10
keratoderma
L85.1
L85.2

81. Impact analysis
Determine any area in the practice that currently utilizes an ICD-9-CM code
Ask for input from the various departments (clinical and clerical) to ensure that nothing is overlooked
How are performance measures captured
Prior authorizations
Research
Tracking and trending

82. Impact analysis
Create a flow chart to:
Demonstrate how the action of each individual impacts the entire process
Identify areas of weakness and quickly create a process to strengthen it
Clearly illustrates the need for interaction between clinical or business areas
Generate ownership of each process
Provides a clear picture of how things work today and can outline how things should work in the future

83. Strategies for Success
The first place to begin in preparing for ICD-10 implementation is with communication
Keep everyone updated on what is happening
No delay expected, we need to continue to prepare for the transition
If you take it seriously, so will the people you are leading
What form of communication will be most effective in your office/institution

84. Build an action plan
Build an action plan based on the results of the impact analysis
Create a preliminary needs assessment
Establish timeline parameters to create a roadmap
Adhere to the timeline, but be open-minded to allow for unexpected circumstances
Begin discussion early with vendors to understand their timelines

85. Measure productivity Different reimbursement system
Understand where productivity is at prior to the implementation of ICD-10
Use this as a “goal” to get back to after the official implementation date
Canada indicates that their productivity has not recovered since implementation
Different reimbursement system
Implemented EMR at same time as ICD-10
Went from DOS system to a windows based claims world

86. Is your EHR and billing system ICD-10 compatible
Questions for Consideration:
Is your EHR and billing system ICD-10 compatible
Are you sure?
Has it been tested?
Have you tested it?

87. Your take home message is “Don’t be a dinosaur”

88. Things that will effect your income in 2015
ACA implications
Rise of deductibles
Decrease in malpractice premiums
ICD-10
ACOs
Retail clinics
PCPs, NPs, Pas
MU moves from carrot to stick
PQRS penalties
Reporting payments to physicians

89. QUESTIONS? peward@apma.org Twitter: @APMApresident
QUESTIONS? Twitter: @APMApresident