Director, Nashville Fertility Center ICD 10: What to Expect George A. Hill, MD Director, Nashville Fertility Center Nashville, TN 37203

LEARNING OBJECTIVES At the conclusion of this presentation, participants should be able to: Understand ICD-10 background and history, description, and future Comprehend the key distinctions between ICD-9-CM and ICD-10-CM Understand what physicians need to do now to prepare Understand the actions that practices need to take to implement the change to ICD -10-CM on a timely basis

DISCLOSURE Committee Member: United Healthcare Women’s Health Scientific Advisory Board Grant Recipient: EMD Serono Inc

Disclaimer ICD-10 codes included in this presentation are not valid prior to the implementation date of October 1, 2014 ICD-10 codes included in this presentation may be revised prior to implementation ICD-9 codes should continue to be used until transition date of October 1, 2014

Why the Change? ICD-9-CM is 30 years old, out of date and running out of space! ICD-10 is the international standard and has been for a number of years ICD is important to Health Information Technology (HIT) and the change is needed to fully implement HIT

ICD-10 and HIT Importance of a better coding classification system: Integral to HIT Strategy - especially the Electronic Health Record (EHR) Improved clinical specificity = improved patient safety Improves understanding of disease / costs and allows providers and others to improve on their delivery International Disease Surveillance

ICD-10: Current Status Some current opposition to implementation Per CMS, no delay or schedule change is pending (except!) (postponed from 10/1/2013 to 10/1/2014) Physicians need to be prepared for the change in order to prevent a revenue flow interruption on 10/1/2014

Understanding ICD ICD is part of the World Health Organization’s (WHO) system of classification ICD-CM (clinical modification) used to track morbidity ICD used to report mortality In the United States, we (ASRM/ACOG Coding Committees) work through the National Center for Health Statistics to implement changes/updates

History of ICD-10 ICD-10 adopted by WHO in 1990 First modification in 1998 U.S. only industrialized nation that has not yet implemented ICD-10 or a modification in some format U.S. first began exploring idea in 1994 Draft versions available 2002, 2007, 2009, 2010, 2011 Implementation Date: October 1, 2014!

Key Differences: ICD-9-CM to ICD-10-CM ICD-10-CM consists of 21 chapters compared to 17 in ICD-9-CM Chapters divided into “blocks” of codes with additional subcategories V and E code supplemental classifications incorporated into main classifications Conditions of sense organs separated from nervous system

Key Differences: ICD-9-CM to ICD-10-CM Certain diseases reclassified to reflect current medical knowledge ICD-10 classifies injuries by specific site then by type vs. ICD-9 classification by type Postoperative complications moved to procedure specific system chapters (complications of GU surgery in GU chapter)

Key Differences: ICD-9-CM to ICD-10-CM ICD-10-CM codes are alphanumeric and up to 7 characters ICD-9-CM are 3-5 characters in length (mostly numeric) ICD-10-CM includes full code titles vs. references to common 4th -5th digits Addition of 6th characters for some Addition of code extensions (7th digit) Addition of dummy placeholder “X”

New Features in ICD-10-CM Combination codes for conditions and common symptoms/manifestations Combination codes for poisoning and external causes Added laterality for some codes (right vs. left)

Key Changes for Reproductive Endocrinology/Infertility Inclusion of trimesters in obstetric codes Separate codes to indicate gestational week Elimination of episodes of care for obstetric codes Changes in time frames: Abortion vs. Fetal death ( 20 weeks) Early vs. Late pregnancy (20 weeks) Extensions to denote specific fetus New GU codes and notes including category title changes

Structure and Format of ICD-10-CM First character is always alphabetic letter Chapter 14 Diseases of the GU system (N00-N99) Chapter 15 Pregnancy, Childbirth and Puerperium (O00-O9A) Second character is always a number Characters 3-7 alpha or numeric O9A.311: Physical abuse complicating pregnancy, first trimester

Structure and Format of ICD-10-CM Alphabetic Index: Alphabetic Listing of Terms and Codes Index to Diseases and Injury Index to External Causes of Injury Neoplasm Table Table of Drugs and Chemicals Tabular List: Chronological list divided into chapters based on body system or condition

Structure and Format of ICD-10-CM Code Format: XXX.XXX X XXX= Category XXX= Etiology, anatomic site, severity X= Extension Placeholder Character X Used with certain codes for potential future expansion When placeholder exists, must use X in that location for valid code

Structure and Format of ICD-10-CM Labor and delivery complicated by cord around neck, without compression: O69.81X2 O69:Labor and delivery complicated by umbilical cord complications 81:Cord around neck, without compression X: Placeholder 2: Fetus 2

General Coding Guidelines Locate code in Alphabetic Index and confirm in Tabular list Report the highest number of characters available Signs and symptoms are acceptable if diagnosis has not been confirmed by provider (Chapter 18 contains many but not all)

General Coding Guidelines Combination codes should be reported when code fully describes condition Combination code is single code that describes: Two diagnoses Diagnosis with an associated secondary process (manifestation) Diagnosis with an associated complication

2012 ICD-10-CM Codes Applicable to RE/I C00-D99 Neoplasms E00-E89 Endocrine, nutritional and metabolic diseases N00-N99 Diseases of the genitourinary system O00-09A Pregnancy, childbirth, and the puerperium Q00-Q99 Congenital Malformation, deformations, and chromosomal abnormalities R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

N00-N99 Diseases of the Genitourinary Sytem N70-N77 Inflammatory diseases of female pelvic organs N80-N98 Noninflammatory disorders of female genital tract N99-N99 Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified

N80-N98 Noninflammatory disorders of female genital tract N80 Endometriosis N83 Noninflammatory disorders of ovary, fallopian tube, and broad ligament N84 Polyp of female genital tract N92 Excessive, frequent, and irregular menstruation N96 Recurrent Pregnancy Loss N97 Female Infertility N98 Complications associated with artificial fertilization

Some Diagnoses will be Straight Crosswalks

N80 Endometriosis ICD-9-CM Description ICD-10-CM 617.0 Endometriosis of uterus N80.0 617.1 Endometriosis of ovary N80.1 617.3 Endometriosis of pelvic peritoneum N80.3 617.5 Endometriosis of intestine N80.5

N97 Female Infertility ICD-9-CM Description ICD-10-CM 628.0 Female Infertility associated with anovulation N97.0 628.2 Female Infertility of tubal origin N97.1 628.3 Female Infertility of uterine origin N97.2 628.8 Female Infertility of other origin N97.8 628.9 Female Infertility, unspecified N97.9

N97 Female Infertility—What are Excludes? Type 1 Excludes Female infertility associated with: Hypopituitarism (E23.0_) Stein Leventhal Syndrome (E28.2_) Type 2 Excludes Incompetence of cervix uteri (N88.3_)

Type 1 Excludes A type 1 excludes note is a pure excludes. It means “not coded here” A type 1 excludes note indicates that the code excluded should never be used at the same time as (N97) Used when 2 conditions cannot occur together

Type 2 Excludes A type 2 excludes note represents “not included here” A type 2 excludes note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time When a type 2 excluded note appears under a code it is acceptable to use both the code (N97) and the excluded code together

N97 Female Infertility Type 1 Excludes Type 2 Excludes Female infertility associated with: Hypopituitarism (E23.0_) Stein Leventhal Syndrome (E28.2_) Type 2 Excludes Incompetence of cervix uteri (N88.3_)

N96 Recurrent Pregnancy Loss Type 1 Excludes Recurrent pregnancy loss with current pregnancy (O26.2-) O26.20 …unspecified O26.21 …first trimester O26.22 …second trimester O26.23 …third trimester

Some Codes may be less specific

O00 Ectopic Pregnancy ICD-9-CM Description ICD-10-CM 633.0 Abdominal pregnancy O00.0 633.1 Tubal pregnancy O00.1 633.10 without intrauterine pregnancy 633.11 with intrauterine pregnancy 633.2 Ovarian pregnancy O00.2 633.8 Other ectopic pregnancy O00.8 633.9 Ectopic pregnancy, unspecified O00.9

Some codes may have the same specificity

O02 Other abnormal products of conception O02.81 Inappropriate change in quantitative human chorionic gonadotropin (hCG) in early pregnancy Currently in ICD-9-CM: 631.0

Some codes may be more specific

O30 Multiple Gestation ICD-9-CM Description ICD-10-CM 651.0_ Twin pregnancy O30.0 V91.02 Twin pregnancy, monochorionic/diamniotic O30.03 …first trimester O30.031 V91.03 Twin pregnancy, dichorionic/diamniotic O30.04 O30.041 651.1_ Triplet pregnancy O30.1 V91.11 Triplet pregnancy with 2 or more monochorionic fetuses O30.11 O30.111

Some codes will replace multiple codes, some will be new

N98 Complications associated with artificial fertilization N98.1 Hyperstimulation of ovaries (620.8, 256.1, E932.4) N98.3 Complications of attempted introduction of embryo in embryo transfer

What about Fibroids?

Neoplasms (C00-D49) (D10-D36) Benign neoplasms, except benign neuroendocrine tumors D25 Leiomyoma of Uterus

D25 Leiomyoma of Uterus ICD-9-CM Description ICD-10-CM 218.0 Submucous leiomyoma of uterus D25.0 218.1 Intramural leiomyoma of uterus D25.1 218.2 Subserous leiomyoma of uterus D25.2 218.9 Leiomyoma of uterus, unspecified D25.9

Z31 Encounter for Procreative Management Z31.41 Encounter for fertility testing (V26.21)

Z32. Encounter for pregnancy test and childbirth Z32 Encounter for pregnancy test and childbirth and childcare instruction ICD-9-CM Description ICD-10-CM V72.4 Encounter for pregnancy test Z32.0 V72.40 …result unknown Z32.00 V72.42 …result positive Z32.01 V72.41 …result negative Z32.02

Summary Greatly increased number of codes in ICD-10, but RE/I will still only routinely use a small subset of the new code set Due to greater specificity, ICD-10 often allows the use of fewer codes than ICD-9 to adequately capture specific patient conditions The general coding principles/diagnosis code selection processes that apply to ICD-9-CM will also apply to ICD-10-CM

Summary System changes will be necessary to accommodate increased digits and character changes May require changes in medical record documentation to support increased specificity Education will be necessary for staff and providers

What to Do Now DO NOT PANIC!! Assess the quality of medical record documentation Consider conducting a documentation assessment audit Implement documentation improvement strategies if necessary based on audit results Monitor the impact of any documentation improvement strategies Reassess and refine DO NOT PANIC!!

Planning for the Transition Verify with software vendors plans for testing and implementation Assign internal implementation team Include physicians and other providers Clinical staff (nursing, lab, etc) Administrative staff Coding/ Billing staff

Planning for the Transition Assess current uses and users of ICD-9 in practice Assess skills and understanding of ICD Determine who needs ICD-10 training Evaluate training options Evaluate current documentation practices Plan for changes to charge capture documents

ACOG: ICD-10-CM Resources ICD-10 page on ACOG website Monthly Subscription Listserv (contains latest ICD-10 news, updates and links)

ACOG: ICD-10-CM Resources ICD Training Plan 2013 Increased number of Coding Workshops (14) All Workshops presented using only ICD-10 codes ICD-10 to ICD-9 / ICD-9 to ICD-10 Crosswalks included for each Workshop module Each Workshop attendee will receive a draft copy of the current ICD-10 code set Separate (1/2 day) ICD-10 only training modules Focused exercises using the new code set Staff may attend alone

ACOG: ICD-10-CM Resources Separate (1 page) ICD-10 and CPT Encounter Forms and Quick Reference Sheets in 2013 Coding Publications Essential Guide, Frequently Asked Questions, (all coding publications with ICD info) will be updated to include ICD-10 content

What will ASRM do? Coding courses at the Annual Clinical Meeting Information in the Coding Corner of the Website Communicate with the ASRM Coding Committee any ideas you have that would be beneficial in helping our members implement ICD-10-CM

ICD-10-CM Resources CMS NCHS (CDC) AHIMA AAPC http://www.cms.gov/ICD10 http://www.cdc.gov/nchs/icd/icd10.htm AHIMA http://www.ahima.org/icd10/ AAPC http://www.aapc.com/icd-10/

ICD10Data.com ICD-10-CM Resources The best web site I have found to help with looking up ICD-10-CM codes: ICD10Data.com

ICD Future ICD -11 is on the horizon internationally: Tweaked version of ICD-10, not a huge change from 10 to 11 ICD-11 initial version made available for public review - May 2011 WHO plans to present ICD-11 to the World Health Assembly in 2015

Other Important Codes in ICD-10 W61.11XA: Bitten by macaw, initial encounter W61.11XD: Bitten by macaw, subsequent encounter W61.11XS: Bitten by macaw, sequela W61.12XA: Struck by macaw, initial encounter W61.12XD: Struck by macaw, subsequent encounter W61.12XS: Struck by macaw, sequela W61.19XA: Other contact with macaw, initial encounter W61.19XD: Other contact with macaw, subsequent encounter W61.19XS: Other contact with macaw, sequela

Important Codes in ICD-10 V90.27XA: Drowning and submersion due to falling or jumping from burning water-skis, initial encounter V90.27XD: Drowning and submersion due to falling or jumping from burning water-skis, subsequent encounter V90.27XS: Drowning and submersion due to falling or jumping from burning water-skis, sequela V90.37XA: Drowning and submersion due to falling or jumping from crushed water-skis, initial encounter V90.37XD: Drowning and submersion due to falling or jumping from crushed water-skis, subsequent encounter V90.37XS: Drowning and submersion due to falling or jumping from crushed water-skis, sequela V90.87XA: Drowning and submersion due to other accident to water-skis, initial encounter V90.87XD: Drowning and submersion due to other accident to water-skis, subsequent encounter V90.87XS: Drowning and submersion due to other accident to water-skis, sequela V91.07XA: Burn due to water-skis on fire, initial encounter V91.07XD: Burn due to water-skis on fire, subsequent encounter V92.07XA: Drowning and submersion due to fall off water-skis, initial encounter V92.07XD: Drowning and submersion due to fall off water-skis, subsequent encounter V92.07XS: Drowning and submersion due to fall off water-skis, sequela V92.27XA: Drowning and submersion due to being washed overboard from water-skis, initial encounter V92.27XD: Drowning and submersion due to being washed overboard from water-skis, subsequent encounter V92.27XS: Drowning and submersion due to being washed overboard from water-skis, sequela V93.87XA: Other injury due to other accident on board water-skis, initial encounter V93.87XD: Other injury due to other accident on board water-skis

September 2014 rolls around, You haven’t prepared! TIME TO PANIC!!

QUESTIONS?