1. Elaine Schmidt, CPC, CPO-C, OCS INTERNATION CLASSIFICATION OF DISEASES, 10 th Edition, Clinical Modification (ICD-10—CM) OVERVIEW 1

2. DISCLAIMER This information is current as to the time it was prepared and reasonable effort was made to assure accuracy. There is no guarantee of being completely error-free. This presentation is intended to be a tool to assist and guide understanding. 2

3. GOALS Basic understanding for implementation and use of ICD-10-CM as it pertains to our world of Optometric Healthcare Diagnosis codes ICD-10-PCS is for PROCEDURES and ONLY used for inpatient procedures in the United States 3

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5. What is ICD: International Classification of Diseases Came into use by the WHO-World Health Organization member states in 1994 Origins in the 1850s 1 st edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893 WHO took over the responsibility for ICD at its creation in 1948 when the 6 th revision, which included causes of morbidity for the first time 5

6. What is ICD: The World Health Assembly adopted the WHO nomenclature Regulations that stipulate the use of ICD in its most current revision for mortality and morbidity statistics by all member states in 1967 6

7. ICD-10 and HIPAA 5010 CONNECTION HIPAA (Health Portability and Accountability Act) 5010 was adopted to replace the version of X12 - 4010 standard that covered entities (health plans, health plan clearinghouses, and certain health care providers) conducting electronic transactions 5010 implementation was part of preparing for ICD-10 The 5010 submission standard will accommodate the increased size and complexity in ICD-10 codes 7

8. ICD-10-CM/PCS ICD -10 consists of 2 parts: ICD-10-CM – for diagnosis coding ICD-10-PCS – for inpatient procedure coding- Hospitals ONLY Implementation of I-10-CM does NOT change our use of CPT Coding set 8

9. ICD-10-CM Consists of: 3 Volumes: -Volume 1 – Tabular List: Alpha-numeric listing of diseases, disease groups and health related problems with inclusion & exclusion notes* and some coding rules -Volume 2 – Instruction Manual: Descriptions, guidelines/conventions, coding resources -Volume 3 – Alphabetical Index: Alphabetical list of codes from the Tabular List 9

10. Volumes & Confusion Volume 1, Tabular List, uses British spelling Volume 3, Alphabetical Index, uses American spelling Volumes 1 & 3 must be used together To code correctly, start with (Volume 3), the Alphabetical Index for the code, THEN confirm in the Tabular List (Volume 1) Remember, “List” is the Tabular; “Index” is the alphabetical 10

11. Order 1. Determine the condition/s to be coded from the documentation; site (cornea, retina, eyelid), laterality (right, left, OU), location (central, peripheral) 2. Begin with the Alphabetical Index (Vol 3) to find the condition and select a code 3. Confirm selected code in the Tabular List (Vol 1)-this must include reviewing the coding instructions 11

12. New Features Added laterality Expanded codes (injury, diabetes, alcohol/substance abuse, postoperative complications) Added extensions for episode of care Excludes 1 and Excludes 2 notes Combination codes for conditions and common symptoms or manifestations 12

13. New Features Combination codes for conditions and common symptoms or manifestations Ex: H40.10x Unspecified open angle GLC, stage x x will be assigned 0-4 showing stage of GLC Combination codes for poisonings and external causes External cause codes no longer a supplementary classification Changes in time frames specified in certain codes 13

14. Details are Important I’s can look like 1’s 0’s can look like O’s all O codes are OBG Placeholder x is lower case E10- Includes Type 1 diabetes mellitus diagnoses E11- Includes Type 2 diabetes mellitus diagnoses When doing a search, it is important to put ICD- 10-CM (as opposed to ICD-10), otherwise information for other countries may be shown 14

15. HIPAA “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)” A quote directly from the Official Coding Guidelines 15

16. Non-HIPAA Entities Non-HIPAA covered entities such as workers compensation, nursing homes, and home health agencies are not mandated to switch to the new code set being implemented October 1, 2014. However, the changing tide will sweep them along with the complex transition whether they like it or not. 16

17. Implementation Mandatory Implementation is October 1, 2014 Affected by anyone covered by HIPAA -Health care providers -Payers including Medicare & Medicaid -Clearinghouses -Some non-HIPAA covered entities: venders, business associates, worker’s comp programs, life insurance companies 17

18. Date of Service The date of service, NOT the date the claim is filed, determines use of ICD-9 or ICD-10. If the date of service is prior to October 1, 2014, the ICD-9 codes are to be used. If the date of service is October 1, 2014 or after, use ICD-10 18

19. NUMBERS: Diagnosis codes effectively increase from 14K in ICD-9-CM to more than 70K in ICD- 10-CM (and will continue to grow) ICD-10-CM-diagnosis coding in all health care settings ICD-10-PCS – procedure codes – do NOT apply to office or out-patient procedures 21 Chapters Chapter 7: Diseases of the Eye and Adnexa 19

20. INTERNATIONAL EMPHASIS Other countries have already implemented ICD-10 United Kingdom – 1995 France – 1997 Australia – 1998 Germany – 2000 Canada – 2001 United States - 2014 20

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22. OUTDATED Foremost, it is out of room-many I-9 categories are full ICD-9 was originally published in 1977 Over 34 years old; having outdated and obsolete terminology Uses outdated codes that produce inaccurate and limited data Inconsistent with current medical practice Cannot accurately describe the diagnoses for care provided in the 21 st century 22

23. BENEFITS OF I-10 Accommodates a host of new diagnoses and procedures Accurate anatomical descriptions Combination codes and laterality extensions allow for greater specificity Differentiation of risk and severity Key parameters to differentiate disease manifestations 23

24. MORE BENEFITS Improves operational processes -due to detail accuracy and fewer payer- physician inquiries thus decreasing delays Updated terminology Increases flexibility for updates Provides detailed data to analyze disease patterns Decreased need to include supporting documentation with claims- OR, end up sending documentation due to unclear information on the claim 24

25. STILL MORE BENEFITS Provides better data for: -measuring care furnished to patients -designing payment systems -processing claims -making clinical decisions -tracking public health -identifying fraud and abuse -conducting research 25

26. Foreign Language? I-9 had 3-5 characters I-10 has 3-7 characters; alpha and numeric digits: -digit 1 is alpha (all letters used except U); digits 2 & 3 are numeric; digits 4-7 are alpha (not case sensitive) OR numeric; and decimal is after the 3 rd digit Diagnosis Codes will be grouped by anatomical site, rather than by type of disease or injury Just the Official Guidelines to ICD-10-CM is 113 pages 26

27. MAYBE NOT SO FOREIGN In many ways, ICD-10 is similar to ICD-9 The guidelines, conventions, and rules are very similar Organization of the codes is similar Almost anyone who is qualified to code ICD-9 should be able to make the transition to coding ICD-10 27

28. DIFFERENCES The big difference between ICD-9 and ICD- 10 systems are differences that will affect information technology and software at your practice 28

29. IMPROVEMENTS A single code can report a disease and its current manifestation For example: type II diabetes with diabetic retinopathy Due to the increased number of diagnosis codes under ICD-10, a more precise code Some of the numbers growth is due to laterality 29

30. DM with DR E11.3- Type 2 Diabetes with ophthalmic complications E11.31- Type 2 DM with unspec retinopathy E11.311 Type 2 DM w unspec DR with ME E11.319 Type 2 DM w unspec DR w/o ME E11.32- Type 2 DM w mild non-proliferative DR E11.321 Type 2 DM w mild non-proliferative DR with ME E11.329 Type 2 DM w mild non-prolif w/o ME 30

31. DM with DR E11.33- Type 2 DM w moderate non-proliferative DR E11.33- Type 2 DM with mod. Non-proliferative DR E11.331 Type 2 w mod. nonproliferative DR w ME E11.339 Type 2 w mod. nonproliferative DR w/o ME E11.34- Type 2 DM w severe nonproliferative DR E11.35- Type 2 DM w proliferative DR E11.36 Type 2 DM with diabetic cataract note, no “-”, so complete code E11.39 Type 2 DM with other diabetic complication Use addtl code to identify manifestation (H40-H42) ME=Macular Edema 31

32. Retinopathy H35.0- Background retinopathy H35.00 unspecified background retinopathy central serous – see Chorioretinopathy, central serous (H35.71-)H35.7- separation of retinal layers diabetic – see Diabetes, retinopathy exudative H35.02- hypertensive H35.03- proliferative NEC H35.2- (other non-diabetic proliferative retinopathy) diabetic – see Diabetes, retinopathy, proliferative 32

33. H35.02-, H35.03- “-” means incomplete, so (in this example), a 1, 2, 3, or 9 is required for the 6 th digit 1= right eye 2= left eye 3= bilateral 9= unspecified 33

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35. Cautious Help - GEMs General Equivalence Mappings Crosswalk tool developed by CMS and CDC with input from the AHA and AHIMA for the use of ALL providers, payers, and data users. They are free of charge and are in the public domain Tool to “guide” I-9 codes to I-10 codes Assist with transitioning between code sets, identifying the differences 35

36. GEMS GEMS are not a substitute for learning how to use ICD-10 Designed as a general purpose translation tool to convert coded data The complete meaning of a coded includes: -tabular instruction, index entries, guidelines, and applicable coding clinic advice GEMS will be maintained for at least 3 years beyond October 1, 2014 36

37. CHANGES? GEMS can be helpful when used as a “guide” Some ICD-10 codes have no predecessor ICD-9 code If an unspecified I-9 Dx is translated to I-10, it will do so as an unspecified I-10 – when there is likely a more specific I-10 available: REMEMBER, we must code to the greatest specificity 37

38. Example: One ICD-10 is represented by multiple ICD-9 codes: E11.341 – Type 2 DM with severe nonproliferative diabetic retinopathy with macular edema: To ICD-9 cluster: (ie, translation) -250.50 - DM with ophthalmic manifestations, type II or specified type, not stated as uncontrolled -362.06 – Severe nonproliferative diabetic retinopathy -362.07 – Diabetic macular edema 38

39. Example I-9 to I-10 379.11 – Hordeolum could be: H00.011 Hordeolum, right upper lid H00.012 Hordeolum, right lower lid 373.2 – Chalazion could be: H00.011 Chalazion, right upper lid H00.012 Chalazion, right lower lid H00.013 rt eye, unspec lid, H00.014 lt upper lid, H00.015 lt lower lid, H00.016 lt, unspec lid H00.019 unspec eye, unspecified eyelid 39

40. Mapping & Conversion Available for free and can be downloaded at: www.cdc.gov/nchs/icd/icd10cm.htm GEMs files: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/ Publications/ICD10CM/2010 2010_DiagnosisGEMs.zip ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/ Publications/ICD10CM/2010 2010_DiagnosisGEMs.zip Another good source is: ICD10Data.com/convert 40

41. MATCH Per CMS, there is NOT a one-to-one match between ICD-9 and ICD-10 for the following reasons: -There are new concepts in ICD-10 that are not present in ICD-9 -For a small number of codes, there is not a matching code in the GEMS -There may be multiple ICD-9 codes for a single ICD-10 code -There may be multiple ICD-10 codes for a single ICD-9 code 41

42. GEMs-Words from the AMA -an “attempt to find corresponding….codes between the two code sets, insofar as this is possible.” NOT an exact crosswalk Information cam be lost or gained Crosswalking is NOT a substitute for learning and fully implementing ICD-10 into your practice 42

43. ACCESS For a period of two years or more, systems will need to access both ICD-9 and ICD-10 codes as the country transitions from ICD-9 to ICD-10 Mapping may be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits and outcomes studies 43

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45. Order of Chapter Groupings Information on diseases and conditions and causes are grouped in the following order: -Communicable diseases -General diseases that affect the whole body -Local diseases arranged by site -Developmental diseases -Injuries -External causes 45

46. Chapters 1. (A00-B99): Certain Infectious and Parasitic Diseases 2. (C00-D48): Neoplasms 3. (D50-D89): Diseases of the Blood and Blood- forming Organs and Certain Disorders Involving the Immune Mechanism 4. (E00-E90): Endocrine, Nutritional, and Metabolic Diseases 5. (F01-F99): Mental and Behavioral Disorders 6. (G00-G99): Diseases of the Nervous Systerm 46

47. Chapters 7. (H00-H59): Diseases of the Eye and Adnexa 8. (H60-H95): Diseases of the Ear and Mastoid Process 9. (I00-I97): Diseases of the Circulatory System 10. (J00-J99): Diseases of the Respiratory System 11. (K00-K93): Diseases of the Digestive System 12. (L00-L99): Diseases of the Skin and Subcutaneous Tissue 13. (M00-M99): Diseases of the Musculoskeltal System and Connective Tissue 47

48. Chapters 14. (N00-N99): Diseases of the Genitourinary System 15. (O00-O99): Pregnancy, Childbirth, and the Puerperium 16. (P04-P94): Certain Conditions Originating in the Perinatal Period 17. (Q00-Q94): Congenital Malformations, Deformations, and Chromosomal Abnormalities 18. (R00-R99): Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified 48

49. Chapters 19. (S00-T98): Injury, Poisoning, and Certain Other Consequences of External Causes 20. (V01-Y97): External Causes of Morbidity 21. (Z00-Z99): Factors Influencing Health Status and Contact with Health Services (former V codes are now Z codes contained in chapter 21) 49

50. Signs and Symptoms Codes that describe symptoms & signs, as opposed to diagnoses, are acceptable for reporting purposes when a related DEFINITIVE diagnosis has not been established by the provider. Chapter 18-Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0-R99) contains many but not all codes for symptoms. 50

51. CATEGORIES-TABULAR LIST- Vol 1 Categories all have 3 characters and are the 1 st 3 digits of the diagnosis code Subcategories are the next 4 or 5 characters defining the etiology, anatomic site, and severity The 7 th digit extensions would represent visit encounter or *sequela for injuries and external causes Diagnosis codes are to used and reported at their highest number of characters available; ie, greatest specificity 51

52. IMPORTANT LOOKUP REMINDER: Always consult the Alphabetic Index BEFORE turning to the Tabular List This is the most critical rule to begin a search Alpha Index will then direct you on where to go in the Tabular List to obtain the correct code 52

53. EXAMPLE Look up cataract in the alpha index Shows an extensive list of alpha-numeric codes Go to the tabular index to verify code selection H25.041 -following is the dissection of the I-10 code H25 – Age-related cataract (category) 04 – Posterior subcapsular polar 1 – Right eye 53

54. CODING CONVENTIONS There are many abbreviations/acronyms, and symbols that will be important to learn and understand with ICD-10 Some are like or similar to ICD-9 NEC = not elsewhere classifiable NOS = not otherwise specified 54

55. Punctuation Conventions [ ] In the tabular index, the bracket is used to enclose synonyms In the alpha index, to identify manifestation codes ( ) parentheses enclose supplementary words, aka, nonessential modifiers : colons are used after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category 55

56. Punctuation - dash A dash at the end of a code indicates the code is incomplete Additional characters are required 56

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58. Dummy Placeholder Character “x” always represents the dummy placeholder Used to provider future expansion Meet the requirement of coding the highest level of specificity T15.00XA – (ICD-9 was 930.0) Foreign body in cornea, unspecified eye, initial encounter T15.01XA – Rt eye, initial encounter T15.01XD – Rt eye, subsequent encounter (S as the 7 th digit would represent sequela) 58

59. Convention Words Use of “and” when used in a narrative statement represents and/or Codes titled “other” or “other unspecified” are for use only when the information in the medical record provides detail for which a specific code does not exist Alpha index entries with NEC in the line designate “other” codes in the Tabular list. Such entries represent specific disease entities for which no specific code exists 59

60. Unspecified “unspecified” or NOS- not otherwise specified, is used when the information in the medical record is insufficient to assign a more specific code. Those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified “We aren’t sure what’s wrong or the documentation is not specific” 60

61. Excludes Notes Excludes1: is a pure excludes note. It means “NOT CODED HERE!” It indicates that the code excluded should NEVER be used at the same time as the code above the Excludes1 note. Used when 2 conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. (patient could not both be born with a specific diagnosis, and also acquire/develop the same diagnosis later) 61

62. Excludes Notes Excludes2 represent “Not included here”. It indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. With an Excludes2 note, it is acceptable to use both the code and the excluded code together, when appropriate. 62

63. Excludes 2 example S05: Injury of eye and orbit In the tabular index, includes and excludes notes are shown; Includes: Open wound of eye and orbit Excludes 2: 2 nd cranial [optic] nerve injury (S04.0-) 3 rd cranial [oculomotor] nerve injury (S04-1-) open wound of eyelid and periocular area (S01.1-) orbital bone fracture (S02.1-,S02.3-,S02.8-) superficial injury of eyelid (S00.1-S00.2) 63

64. Other notes Like I-9, some codes require the underlying condition be sequenced 1 st, followed by the manifestation. Be observant of instructional notes: “use additional code” “code first” “see” and “see also” “code also” 64

65. Code 1 st, Instruction notes, Excludes, Use additional code Patient with glaucoma due to Lowe’s syndrome H42 Glaucoma in diseases classified elsewhere Code first underlying condition, such as: Lowe’s syndrome (E72.03) E72.03 Lowe’s syndrome Use additional code for associated glaucoma (H42) H42 has Excludes 1: glaucoma (in) *shows list of exclusions Principle Dx = E72.03, 2 nd Dx = H42 65

66. Specificity Diagnosis codes are to be used and reported at their highest number of characters available Combination Codes and laterality extensions allow for this greater specificity Signs and symptoms that are associated routinely with a disease process should NOT be assigned as additional codes, unless instructed by the classification Additional signs and symptoms NOT associated routinely with a disease SHOULD be coded when present 66

67. Chapter 7 Categories: H00-H59 Total of 12 defined H00-H05: Disorders of eyelid, lacrimal system and orbit H10-H11: Disorders of conjunctiva H15-H22: Disorders of sclera, cornea, iris and ciliary body H25-H28: Disorders of lens H30-H36: Disorders of choroid and retina 67

68. Chapter 7 Categories: H40-H42: Glaucoma H43-H44: Disorders of vitreous body and globe H46-H47: Disorders of optic nerve and visual pathways H49-H52: Disorders of ocular muscles, binocular movement, accommodation and refraction 68

69. Chapter 7 Categories: H53-H54: Visual disturbances and blindness H55-H57: Other disorders of eye and adnexa H59: Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified 69

70. OTHER CHAPTERS/CATEGORIES Chapter 7 was detailed to show Diseases of the Eye and Adnexa Other I-10 categories relevant to Eye Care -C69.xxx Malignant neoplasm Rxx.xxx Sign & Symptom codes (headache, weakness, malaise, etc R00.xxx Symptoms, signs and abnormal clinical findings Sxx.xxx S codes – injury, poisoning - external Txx.xxx T codes – FB in cornea T74.xxx Adult and child abuse, neglect & maltreatment T36-T50 Poisoning codes 70

71. Additional Categories X00.xxx Injury and Accident codes (initial, subsequent, and sequela –late effect) Y92.xxx Place of occurrence (replaces E codes) Y93.xxx Activity codes (replaces E codes) V01-V099 External causes of Morbidity Z00-Z99 Replace V codes for screenings and histories 71

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73. FEE DRIVEN TO QUALITY OF SERVICE Emphasis on service is going from a fee driven reimbursement to quality of service; CPT driven VS Dx driven Clinical documentation improvement National Coverage Determination (NCD) policies will be ready by year end 2013 Local Coverage Determination (NCD) by April 2014 73

74. DOCUMENTATION Better reporting, better documentation What ordered and why, along with interpretation and report If the final Dx is the RESULT of the signs & symptoms, just code the final Dx Co-morbidities: how do they affect services being done at a specific encounter? -then address them in the assessment & plan so additional diagnoses codes can be used 74

75. TIDBITS Uncertain does NOT = unspecified Concerning diabetes; wording of controlled and uncontrolled no longer used. Type 1 and Type 2 are used. Type 1, category E10, indicates the patient is not producing insulin Type 2 is category E11 Category E13 is OTHER specified diabetes mellitus (NOT the same as unspecified) 75

76. COMPLIANCE Implementation date of ICD-10-CM is October 1, 2014 No delays No grace period 76

77. CONSIDERATIONS Allow time to learn this new language Once we become familiar with it, the benefits will be readily experienced *Oh, and by the way, the I-10 diagnosis for hypertension (which we may now all have) is………… I10 One important benefit: we’ll be using our brain in a whole (not hole) new way; which will help stave off dementia (hopefully); or will contribute to or put us there 77