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

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

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

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

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

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”

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”

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”

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”

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

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

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

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

What About Globals? 10 day global 90 day global 2017 90 day global 2019 CPT Assistant March 2015 revision of global package definition/interpretation

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

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

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

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

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

APMA News Articles link: http://www.apma.org/YourPractice/content.cfm?ItemNumber=1413 There have been more than 20 ICD-10 articles in the APMA News All are available for download on the APMA website

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

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

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

ICD-10 Potential positive impacts Better specificity Better data collection

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.

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.

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.

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”.

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.

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.

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

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.

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.

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

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

ICD-10 Chapters Chapter 8 H-60-H95 Diseases of the Ear and Mastoid Chapter 9 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

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

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

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

ICD-9-CM ICD-10-CM

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

Format differences

Combination Code Examples E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.621 Type 2 diabetes mellitus with foot ulcer [Use additional code to identify site of ulcer L97.4-,L97.5-] I69.144 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot

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 Z89.411 - Acquired absence of right great toe

ICD-10-CM Structure - Format 3-7 character examples L84 Corn and callosities B95.5 Staphylococcus aureus as the cause of diseases classified elsewhere M20.11 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)

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

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?

Btw…Obamacare too

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)

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 755.66 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

Tabular List (ICD Volume 1) ICD-9 Tabular Index ICD-10 Tabular Index 735 Acquired deformities of toe Excludes: congenital (754.60 - 754.69, 755.65 - 755.66) 735.0 Hallux valgus (acquired) 735.1 Hallux varus (acquired) 735.2 Hallux rigidus 735.3 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

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. -

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 755.66

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

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

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 M21.61 Bunion M21.610 Bunion deformity, unspecified M21.611 Bunion deformity, right foot M21.612 Bunion deformity, left foot M21.62 Bunionette M21.620 Bunionette deformity, unspecified M21.621 Bunionette deformity, right foot M21.622 Bunionette deformity, left foot

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”

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.

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).

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

#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

#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 M79.671 Pain in right foot

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

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

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-

ICD-10-CM “Look-Up” Example Stage III decubitus ulcer of left heel Step 2 - Verify in Tabular: L89.6- Pressure ulcer of heel L89.62- Pressure ulcer of left heel L89.623 Pressure ulcer of left heel, stage III

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]

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

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

ICD Guidelines Manifestation code: L97.411 It is coded after the underlying condition code, E10.621 diabetic (type I) heel ulcer

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

Let’s add PVD ICD-9 ICD-10 443.9 PVD, unspecified I70.2- 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

And…Diabetes ICD 9 ICD 10 250.60 Diabetes with neurological manifestations E10.4- 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. 13.61- other specified DM with diabetic arthropathy and Z79.4- for insulin use

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

Let’s add a keratoma ICD 9 ICD 10 701.1 keratoderma L85.1 L85.2

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

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

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

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

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

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?

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

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

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