2. January 29, 2014 ICD-10 ORIENTATION AND YOUR “PLAN”

3. PRESENTED BY AMERICAN HEALTH TECH In Coordination With Rhonda Anderson, RHIA, President Anderson Health Info. Systems, Inc. 940 W. 17 th Street, Suite B Santa Ana, CA 92706 Tel. 714-558-3887Fax 714-558-1302 Office@ahis.net 2

4. OBJECTIVES Participants will identify: –Dates for New ICD-10 –Documentation support –Some general coding guidelines –YOUR Work plan – Key timelines 3

5. ICD—10 “HAS TWO PARTS” ICD-10 CM – Clinical Modification – Skilled Nursing will use “CM” ICD-10 PCS – Procedural Code System (used for procedures, operations within the hospital inpatient setting) 4

6. HIPAA Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA), latest update January 23, 2013 5

7. FINAL REGULATION January 15, 2009 Final Regulation Released EXCHANGE the ICD-9 for the ICD-10 by October 1 (originally 2013, changed to 2014) ICD-10 for billing purposes as far as ability to accept the code known as “5010” was required by October, 2012 6

8. WHAT DOES ICD-10 COMPLIANCE MEANS? ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD-10 codes 7

9. WHO IS AFFECTED?? Freestanding providers Ancillary services – “that means all of us really” who provide services and bill for them under Medicare, Medicaid/Cal and private insurances Therapy Providers 8

10. WHO IS AFFECTED?? -2 Developed for the provider and the coder….(person who may review the documentation and determine if code is accurate) Consistent, complete documentation in the medical record is a major emphasis 9

11. WHO IS AFFECTED?? -3 More specific in documentation to support the ICD-10 diagnostic code convention, general and specific coding guidelines in the front of the ICD-10 Coding Manual –”Official Guidelines for Coding and Reporting 10

12. REVIEW OF FEW DETAILS No you will NOT code! You will need –To provide your Board of Directors with some information about the importance know your resources –To know your resources –Identify your own key staff –Obtain assurance from the computer system –To know that coding is correct 11

13. WHY ICD-10 IS HAPPENING? Increased level of detailICD-10 CM/PCS – Increased level of detail –Required for medicine advancements in technology –$$, improved data quality for clinical and financial decision making –To support value based purchasing and facilitate quality reporting 12

14. WHY ICD-10 IS HAPPENING? -2 ICD-9 codes have limited data about resident’s medical condition & hospital inpatient procedures ICD-9 is 30 years old Has outdate and obsolete terms Inconsistent with current medical practices 13

15. STATE MEDICAID PROG. NEED TO TRANSITION TO ICD-10 Like everyone else covered by HIPAA, state Medicaid programs must comply with ICD-10 14

16. CODES CHANGE EVERY YEAR ICD-10 codes will be updated every year Not in 2014 unless new technologies and new diseases IN 2015 – regular updates (affects training and also purchase of manuals – computer alone is not enough. On line ICD-10 as a resource?? 15

17. ICD-10 DIFFERENCES Organization – Two volumes Structure – Alphanumeric categories rather than numeric categories.(has “includes and excludes notes: –Categories are three digits –Chapters – re-arranged –Titles have Changed – examples on following slides 16

18. ICD-10 DIFFERENCES -2 CHAPTER * ICD-9-CMICD-10-CM* 1Infectious and Parasitic Diseases Certain Infectious and Parasitic Diseases A00-B99 2NeoplasmsMalignant Neoplasms C00-D49 3Diseases of Blood and Blood Forming Organs Diseases of Blood and Blood forming Organs 17

19. ICD-10 DIFFERENCES -2 CHAPTER * ICD-9-CMICD-10-CM* 4Endocrine and Nutritional, Metabolic Diseases Endocrine and Nutritional Metabolic Diseases E00-E89 6Diseases of the Nervous System and Sense Organs Diseases of the Nervous System G00-G99 7Disease of the Circulatory System Diseases of the Eye and Adnexa H00-H59 18

20. ICD-10 DIFFERENCES -3 CHAPTER * ICD-9-CMICD-10-CM* 8Diseases of the Respiratory System Diseases of the Ear and Mastoid Process H60-H95 9Diseases of the Digestive System Diseases of the Circulatory System I00-I99 10Diseases of the Genitourinary System Diseases of the Respiratory System J00-J99 19

21. ICD-10 DIFFERENCES -4 CHAPTERICD-9-CMICD-10-CM 13Diseases of the Musculoskeletal System and Connective Tissue Musculo skeletal M00-M99 Diseases of the Musculoskeletal System and Connective Tissue Disease of Genitourinary N00-N99 14Congenital Anomalies Disease of the Genitourinary System 20 THERE ARE Additions (not all included)– example, Chapter 21 Factor Influencing Health Status – 00-Z99

22. ICD-9 DIFFERENCES Lacks detail Lacks laterality Difficult to analyze dated due to non-specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries 21

23. ICD-10 Code composition – increased specificity Level of detail May consist of up to 7 digits with the seventh digit extensions representing visit encounter or sequelae as stated above Includes full code titles and no reference back to common 4 th and 5 th digits) V and E codes are no longer supplemental 22

24. ICD-9-CM DIAGNOSIS CODES – FORMAT & STRUCTURE 3-5 characters in length Approximately 14,000 codes First digit may be alpha (E or V) or numeric Digits 2-5 are numeric Always at least three digits, Decimal placed after the first three characters Limited space for new codes 23

25. ICD-10-CM DIAGNOSIS CODES – FORMAT & STRUCTURE 3-7 characters in length Approximately 68,000 codes Digit 1 is alpha, digit 2 and 3 are numeric; digit 4-7 are alpha or numeric Decimal placed after the first 3 characters, All letters used except “U” Flexible for adding new codes Very specific Has laterality 24

26. CODE FORMAT ICD-9-CM Code FormatICD-10-CM Code Format 25

27. FIVE-SIX CHARACTER SUBDIVISION Way too much detail…but it looks like this!! –J10.8 – Influenza due to other influenza virus with other manifestations –J10.81 – Influenza gastroenteritis –J10.89 – Influenza with other manifestations: Influenzal encephalopathy Influenzal myocarditis 26

28. FIVE-SIX CHARACTER SUBDIVISION -2 Way too much detail…but it looks like this!! –ANOTHER EXAMPLE – WITH SPECIFICITY AND LATERALITY: S55.011 Laceration of ulnar artery at forearm level, right arm 27

29. ICD-10 STRUCTURE Index and Tabular list similar to ICD-9 ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list Z =codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services (NEW)…Former V=codes are now Z =codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services (NEW)… 28

30. ICD-10-CM DIAGNOSIS CODES Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data between other countries and the U.S. 29

31. MAPPING TOOLS Mapping from ICD-9 to 10 tools are available, General Equivalence Mappings (GEMS) – translation dictionary for diagnoses Called “GEMS” – general equivalence mappings CM – GEMS available PCS – GEMS just available last of September (acute hospital mostly) 30

32. GEM FILES Do not despair…you vendor should prepare as much of a crosswalk as possible NOTE: will require some conversion for long term resident’s diagnoses by the effective date of ICD-10 TRAININGLater TRAINING and how to use them…Key to early review!!! 31

33. THE WORKPLAN TRANSITION TO ICD-10 32

34. IMPLEMENTATING ICD-10 Notification to Board –Click here for HO #1 (ICD-10 for Governing Body)Click here for HO #1 (ICD-10 for Governing Body) 33

35. IMPROVE DOCUMENTATION NOW All of the information that is required to code according to ICD-10 is information that is necessary to an individual’s care and is already documented in the medical record ???? Your evaluation early of the “medical record” 34

36. ICD-10 CODES REQUIRE Clear focus to better documentation Absolutely critical to the success of ICD- 10 Good resident care: –Affect so many facets of health care downstream –Quality measures to analytics, research, payment and surveillance –Must be as accurate as possible 35

37. ICD-10 CODES REQUIRE -2 Good resident care (cont.) –Accurate coding require physician’s efforts to provide good documentation as well as nursing –No reason to delay implementation of good documentation practices –Information that is required to code according to ICD-10 is information necessary to resident and is already documented in the medical record 36

38. ICD-10 CODES REQUIRE -3 Good resident care (cont.) –What are you documenting today? –Ways more appropriately document? –Failure to fully properly document has medical, financial, and even regulatory ramifications 37

39. DEVELOP THE RELATIONSHIP BETWEEN CLINICIANS Clinicians Director of Nursing (DON) do not need to understand all of the intricacies of coding, and coders do not need to understand all of medicine – but the 2 must work together to ensure optimal accuracy Whoever codes need to understand basic anatomy and pathophysiology increase in questions from coders 38

40. STRATEGIES FOR TRAINING Leadership those individuals who are responsible for moving things through the organization: –Understand what the impact of ICD-10 will be –What challenges anticipated 39

41. STRATEGIES FOR TRAINING -2 Training Medical Record, MDS/PPS, DON, Business Office, Inquiry Staff, Medical Director: –Have training –Parallel coding taking the same cases and coding them accurate to ICD-9 and ICD-10 –Parallel training and testing –Start in early 2014 40

42. STRATEGIES FOR TRAINING -3 Leadership should understand enough about the coding changes to understand the implications: –Documentation –Business practices –MDS / Medicare PPS –$$ impact for training, implementation and billing 41

43. RESOURCES HIM Consultant – Be sure ICD-10 Certified or Specialized Training Centers for Medicare & Medicaid Services (CMS) Includes official codes and guidelines 42

44. ICD-10 CODE SETS www.cms.gov/ICD10 43

45. WHY PREPARE NOW? Major understanding for providers, payers and vendors Will drive business and systems changes, hospital, SNF, Physicians, Outpatient, et’l, from large national health plans to small provider offices, laboratories, medical testing centers Staff time – start looking who affects now and what they need to know Financial resources Also option for ICD-10 transition 44

46. TYPES OF TRAINING – PROVIDERS / STAFF Six months before the compliance deadline Projected to take 16 hours for coders to 25 > hours ICD-10 resources and training materials available: –Professional associations, societies, software/system vendors, HIM Consultants –Some resources on CMS 45

47. ICD-10 PROJECT PLAN Develop and complete an ICD-10 project plan: –Identify each task, deadline and who is responsible –Develop plan for communicating with staff and business parts about ICD-10 –Estimate and secure budget 46

48. ICD-10 PROJECT PLAN -2 Check with: –HIM Consultants, –Payers, –Software/systems vendors –Clearinghouses –Billing services –Labs –Physicians 47

49. ICD-10 PROJECT PLAN -3 Check out: –Systems changes –A timeline –Costs –Testing plans –Determine who and how many staff need training and at what level –?how many orientations? –?how many on site training or webinar? 48

50. ICD-10 PROJECT PLAN -4 Evaluate current documentation Identify most commonly used diagnoses by checking out: –Reports – past coding Medicare coverage issues “ADR” –Documentation to support those diagnoses –Medical staff / Medical Director support –Clinical documentation improvements 49

51. ICD-10 PROJECT PLAN -5 Look at pol/procedures, all operations and who you receive clinical information from Set a time frame: –# orientations –# onsite training –# offsite training –other tasks 50

52. SPECIFIC INFO. NEEDED TO ACCURATELY CODE Diabetes Mellitus –Type of diabetes –Body system affected –Complication or manifestation –If type 2 diabetes, long-term insulin use 51

53. SPECIFIC INFO. NEEDED TO ACCURATELY CODE -2 Fractures –Site –Laterality –Type –Location 52

54. REVIEW CHANGES IN DOC. REQUIREMENTS Injuries –External cause – cause of the injury, more applicable to op –Place of occurrence – home, at work, in the car, etc. More related to op we will have some references –Activity code –External code status – indicate if the injury was related to military, work, or other 53

55. LOOK AT SAMPLES IN BACK OF POWERPOINT 54

56. TRANSITION & TESTING Jan/Feb, 2014 – September 15, 2014 –Conduct high level training on ICD-10 for clinicians –Codes to prepare for testing –Clinical documentation review –Determine dual coding dates and record reviews 55

57. COMPLETE TRANSITION / FULL COMPLIANCE October 1, 2014 Complete ICD-10 transition for full compliance –ICD-9 codes continue to be used for services provided before October 1, 2014 –ICD-10 diagnosis and inpatient procedure codes required for services provided on or after October 1, 2014 –Monitor systems correct errors if needed 56

58. PRINCIPAL DIAGNOSIS Circumstances of inpatient admission always govern the selection of PRINCIPAL DIAGNOSIS: –“that condition established after study to be chiefly responsible for occasioning the admission of the resident to the hospital (facility) care” 57

59. PRINCIPAL DIAGNOSIS -2 The references and correct coding guidelines HAVE BEEN USED IN THE PAST – NOW THERE ARE NEW CODING GUIDELINES – TAKE PRECEDENCE IN ICD-10 58

60. PRINCIPAL DIAGNOSIS -3 TEACH THE NEW GUIDELINES!!!TEACH THE NEW GUIDELINES!!! The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is difficult!!The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is difficult!! 59

61. QUESTIONS & ANSWERS 60

62. SOME EXAMPLES Reference ONLY Slides from here to end of ppt. on coding – sample references 61

63. ICD-10 NEW FEATURES Combination Codes for Condition s and Common Symptom or ManifestationsCombination Codes for Condition s and Common Symptom or Manifestations – specify…This example reflects specificity down to the type of artery – and would related to post follow up care but the Dx. Given at the hospital would carry, too. I25.110 – Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris 62

64. ICD-10 NEW FEATURES -2 Added Laterality – EXAMPLES –C50.212 Malignant neoplasm of upper-inner quadrant of left female breast superficial vessels of right lower extremity –I80.01, Phlebitis and thrombophlebitis of superficial vessels of right lower extremity right hip, Stage III –L80.213, Pressure Ulcer of right hip, Stage III 63

65. A FEW CODES YOU WILL LEARN Added examples of specificity:Added examples of specificity: –A41.9 Sepsis without cause organism –A41.9 Sepsis without cause organism – Sepsis, unspecified –Severe Sepsis – A41.9 Sepsis unspecified for the infection. Additional code for organ must be identified –UROSEPSIS is not allowed as a dx 64

66. A FEW CODES YOU WILL LEARN -2 Septic Shock – EXAMPLE OF SPECIFICITY R65.21 Severe sepsis with septic shock. Add additional codes for other acute organ dysfunction. –Circulatory failure associated with severe sepsis; represents a type of acute organ dysfunction. Underlying infection sequenced first, followed by code R65.21 Severe sepsis with septic shock. Add additional codes for other acute organ dysfunction. New guidelines for sequencing Severe Sepsis Must be clear if it is present on admission 65

67. ICD-10 NEW FEATURES -3 Expanded CodesExpanded Codes (injury, diabetes alcohol/substance abuse, postoperative complications) Diabetes –E08.22 Diabetes due to underlying condition with diabetic chronic kidney disease 66

68. CHAPTER 4 – E00-E89 Endocrine, nutritional and metabolic diseases –Diabetes Mellitus Combination codesCombination codes Includes the body system affected and complications affecting the body system Many codes particular category as are necessary to describe all of the complications of the disease may be used Sequenced base on the reason for a particular encounter 67

69. CHAPTER 4 – ENDOCRINE, NUTRITIONAL…(E00-E89) Endocrine, nutritional and metabolic diseases – SPECIFICITY –Secondary Diabetes Mellitus: Category E08 due to underlying condition Category E09 for drug/chemical induced Use code Z79.4 for residents who routinely use insulin; also assigned for long-term (current) use 68

70. CHAPTER 9 – DISEASES OF CIRCULATORY SYS. (I00-I99) Hypertension with Heart Disease –Heart conditions classified to I50 or I51.4- I51.9 are assigned to, a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive) –Use an additional code from category I50 69

71. CHAPTER 10 – DISEASES OF RESPIRATORY SYS. (J00-J99) Chronic Obstructive Pulmonary Disease (COPD) and Asthma –Acute exacerbation of chronic obstructive bronchitis and asthma –J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation Acute Respiratory Failure –Principle diagnosis when it is the condition established after study to be chiefly responsible 70

72. CHAPTER 13 – DISEASE OF MUSCULOSKELETAL (M00-M99) Site and laterality:Site and laterality: –Designations –Represents the bone, joint or the muscle –Where more than one bone, joint or muscle is involved, such as osteoarthritis, use the assigned “multiple sites” code; if not available, use multiple codes to indicate the sites –Bone vs. Joint – Certain conditions where the bone may be affected at the upper & lower end; site designation will be the bone, not the joint 71

73. LET’S SEE SOME CODES Sequencing of codes is determined by the reason for admission/encounter - Hypertensive RetinopathySequencing of codes is determined by the reason for admission/encounter - Hypertensive Retinopathy –H35.03 Hypertensive Retinopathy, –031 – Right eye, 032, left eye, 033, bilateral, –039 – Unspecified (and this would be a ?? For billing most likely)!! –I10 – Essential Primary Hypertension. 72

74. ICD-10 NEW FEATURES An example S42.321A Displaced transverse fracture of shaft of humerus, right arm, initial encounter for closed fracture This means more specific documentation from the physician (the initial encounter may not have been in your setting) 73

75. REPEATED FALLS Code R29.6 Repeated fallsCode R29.6 Repeated falls for use for encounters when a resident has recently fallen and the reason for the fall is being investigated. Code Z91.81, History of falling, is for use when a resident has fallen in the past is at risk for future falls. Both codes may be assigned 74

76. CODING OF TRAUMATIC FRACTURES Fractures of specified sites are coded individually by siteFractures of specified sites are coded individually by site S-codes…need to pay attention to level of detail furnished by medical record content Fracture not indicated as open or closed, displaced, initial vs. subsequent encounter for fractures. (use 7 th character extension for initial encounter (A.B.C) There are specific instructions related to this area (#18) 75

77. AFTERCARE Aftercare codes cover situations when the initial treatment of a disease has been performed and the resident requires continued care during the healing or recovery phase or the long term consequences of the disease Z code should not be used if treatment is directed at a current acute disease 76

78. REMINDER MAKE YOUR LIST OF DUTIES YOU SEE IMPORTANT WHEN YOU RETURN TO YOUR FACILITYMAKE YOUR LIST OF DUTIES YOU SEE IMPORTANT WHEN YOU RETURN TO YOUR FACILITY 77

79. THANKS FOR ATTENDING Rhonda Anderson, RHIA President Anderson Health Information Systems, Inc. 940 W. 17 th Street, Suite B Santa Ana, CA 92706 714-558-3887 office@ahis.net 78