1. ICD-10-CM Everything You Need to Know … For Now
2009 Codes
The single most significant coding change in 30 years is before us – the conversion from ICD-9 to ICD-10
The change will impact virtually all facets of your clinical practice and research. Major changes will have to occur to our business processes and our information systems. Countless hours will need to be spent education our faculty and the vast majority of our staff.

2. Main Objective Create an awareness of ICD-10-CM.
Start to consider the impact the conversion to ICD-10 will have on your operations.
Participants can help spread the “word” throughout the University.

3. What is ICD-10-CM and When is it Coming?

4. What is ICD and ICD-10?
ICD is the World Health Organization's International Classification of Diseases and Related Health Problems and is the international standard diagnostic classification system.
ICD-10 is the abbreviated term used to refer to the 10th revision of the ICD.
From which ICD-9 and ICD-10 are derived
ICD-10 was endorsed by the World Health Assemble in May 1990 and came into use in WHO Member States in 1994

5. What is ICD-10-CM and ICD-10-PCS?
The U.S. clinical modification (CM) of the WHO’s ICD-10, maintained by the NCHS.
Includes diagnoses which will be used by all providers in every health care setting.
ICD-10-PCS:
The procedural coding system developed under contract by the CMS.
Includes procedure codes which will only by used for hospitals claims for inpatient hospital procedures.

6. Implementation Date – October 1, 2013
On January 16, 2009, the Department of Health and Human Services published a Final Rule for the adoption of ICD-10-CM and ICD-10-PCS code sets.
All HIPAA covered entities must be ICD-10 compliant on October 1, 2013.
The compliance date is firm and not subject to change:
There will be no delay.
There will be no grace period for implementation.
There will be no impact on CPT and HCPCS codes.
Coding class 1993 – WHO adopting ICD-10 in 1994
ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013.
"Unfortunately, I believe some speakers in the industry talk about maybe this being delayed or postponed or double coding, but let me make very, very clear to you that the HIPAA final rule states that this is a firm implementation date of Oct. 1, 2013." - Pat Brooks, RHIA - Senior technical adviser, Center for Medicare Management, CMS

7. ICD-9-CM vs. ICD-10-CM

8. Why is ICD-9 Being Replaced?
ICD-9-CM is out of date and running out of space for new codes.
Lacks specificity and detail
No longer reflects current medical practice
ICD-10 is the international standard to report and monitor diseases and mortality, making it important for the U.S. to adopt ICD-10 based classifications for reporting and surveillance.
ICD codes are the core elements of HIT systems, conversion to ICD-10 is necessary to fully realize benefits of HIT adoption.
1) ICD-9-CM is not sufficiently robust to serve health care needs of the future.
2) The US is the only developed country that has not yet implemented ICD-10
3) limited structural design cannot accommodate advances in medicine and medical technology and the growing need for quality data

9. Coding Process Remains the Same
ICD-10-CM code book retains the same traditional format
Index
Tabular
Process of coding is similar
Look up a condition in the Index
Confirm the code in the Tabular

10. Major Differences Between ICD-9-CM and ICD-10-CM
13,600 codes
69,000 codes
Code book contains 17 chapters
Code book contains 21 chapters
Consists of 3 to 5 characters
Consists of 3 to 7 characters
1st character is alpha or numeric
1st character is alpha
Only utilizes letters E and V
Utilizes all letters (except U)
Second, third, fourth, and fifth
characters are always numeric
Second character
is always numeric
Third, fourth, fifth, sixth, and seventh
characters can be alpha or numeric
Shorter code descriptions because
of lack of specificity and
abbreviated code titles
Longer code descriptions because of greater clinical detail and specificity
and full code titles
5x more codes in ICD-10, than ICD-9
ICD-10 code book contains more chapters
Split some I-9 chapters in to two – nervous and sense organs
v and e codes were supplementary chapters in I-9, now own chapters
3) I-9 3 to 5, I
4)10 key pad, much easier to make errors reading letters
1st digit is alpha – letters A-Z, except U
V codes are now Z codes
Codes #s will be different

11. Comparison of ICD-9-CM and ICD-10-CM
ICD-9-CM Code
Icd-10-CM code
A - Category of code
B - Etiology, anatomical site, and manifestation
A - Category of code
B - Etiology, anatomical site, and/or severity
C - Extension
7th character for obstetrics, injuries, and external causes of injury A B A B C

12. Comparison of ICD-9-CM and ICD-10-CM
ICD-9-CM Codes
ICD-10-CM Codes
Pressure ulcer codes
9 codes –
125 codes
L89.0-L89.94
Codes:
707.0 Pressure ulcer
unspecified site
elbow
upper back
lower back
hip
buttock
ankle
heel
other site
Code Examples:
L – Pressure ulcer of right lower back, stage I
L – Pressure ulcer of right lower back, stage II
L – Pressure ulcer of right lower back, stage III
L – Pressure ulcer of right lower back, stage IV
L – Pressure ulcer of right lower back,
unspecified stage
L – Pressure ulcer of left lower back, stage I
L – Pressure ulcer of left lower back, stage II
L – Pressure ulcer of left lower back, stage III
L – Pressure ulcer of left lower back, stage IV
L – Pressure ulcer of left lower back,
L – Pressure ulcer of sacral region, stage I
L – Pressure ulcer of sacral region, stage II …
L89.90 – Pressure ulcer of unspecified site, unspecified stage
The codes on the right are only a small set of the 125 potential pressure ulcer codes offered in ICD-10
Pressure ulcer stages 707.2x separate codes (6 codes) , difficult to match up if more than one pressure ulcer

13. New Features of ICD-10-CM
Combination codes for conditions and common symptoms or manifestations
Combination codes for poisonings and external causes
Added laterality
Expanded codes: injury, diabetes, alcohol/substance abuse, postoperative complications

14. New Features of ICD-10-CM
Added extensions for episode of care
Inclusion of trimester in obstetrics codes and elimination of fifth digits for episode of care
Expanded detail relevant to ambulatory and managed care encounters
Inclusion of clinical concepts that do not exist in ICD-9-CM
Changes in timeframes specified in certain codes 1)
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
2) Delivered, Antepartum or Postpartum is replaced with the trimester
3) No info
4) Underdosing
5) Acute MI is 8 weeks in ICD-9, 4 weeks in ICD-10

15. Examples – ICD-10-CM Codes
I10, Essential (primary) hypertension
A69.21, Meningitis due to Lyme Disease
O9A.311, Physical abuse complicating pregnancy, first trimester
S52.131A, Displaced fracture of neck of right radius, initial encounter for closed fracture

16. Examples - Combination Codes
Combination codes for conditions and common associated symptoms and manifestations
I25.110, Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris
K50.013, Crohn’s disease of small intestine with fistula
Combination codes for poisonings and their associated external cause
T42.3X2S, Poisoning by barbiturates, intentional self –harm, sequela
In ICD-9 these codes would require multiple code assignments
ICD-10 has combo codes for ASHD with angina. When using one of these combo codes it is not necessary to use an additional code for the angina pectoris. A casual relationship can be assumed in a pt with both atherosclerosis and angina pectoris unless the documentation indicates the angina is due to something other than atheroslerosis.
ICD-10 provides combo codes for complications commonly associated with Crohn’s dz.

17. Examples – Combination Codes
Diabetes Codes in ICD-9
Diabetes Codes in ICD-10
Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled
Diabetic gangrene
Diabetic peripheral angiopathy
E Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
Diabetes with other coma, type I, not stated as uncontrolled
E Type 1 diabetes mellitus with ketoacidosis with coma
Diabetes with neurological manifestations, type II or unspecified, not stated as uncontrolled
Mononeuritis of unspecified site
E Type 2 diabetes mellitus with diabetic mononeuropathy
Secondary diabetes mellitus with renal manifestations , not stated as uncontrolled
Chronic kidney disease, unspecified
E Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease
ICD-10 diabetes mellitus codes are combination codes that include:
the type of diabetes mellitus
The body system affected
The complication affecting that body system
ICD-10 DM is no longer classified as controlled and uncontrolled

18. Examples – Added Laterality
C50.212, Malignant neoplasm of upper-inner quadrant of left female breast
H16.013, Central corneal ulcer, bilateral
L89.213, Pressure ulcer of right hip, stage III
H61.20, Impacted cerumen, unspecified, ear
H61.21, Impacted cerumen, right ear
H61.22, Impacted cerumen, left ear
H61.23, Impacted cerumen, bilateral
Reduction in claim denials

19. Examples – Obstetrics and New Clinical Concepts
Obstetric codes identify trimester instead of episode of care
O26.02, Excessive weight gain in pregnancy, second trimester
Inclusion of clinical concepts that do not exist in ICD-9-CM
T45.526D, Underdosing of antithrombotic drugs, subsequent encounter
Z67.40, Type O blood, Rh positive

20. New Official Guidelines and Coding Clinic
The AHA Central Office serves as the clearinghouse for issues related to the use of ICD-9-CM.
With the transfer to ICD-10, a new office will be developed called AHA Central Office on ICD-10-CM
Creation of new official guidelines
Development of the AHA Coding Clinic for ICD-10 (similar to the Coding Clinic for ICD-9 but will require a major overhaul)
Maintains integrity of the classification system
Recommends revisions and modifications to current and future revisions of ICD
Develops education material and programs on I-9
Answers questions from providers related to I-9
Publishes AHA Coding Clinic

21. General Equivalence Mappings

22. What are GEMs? “GEMs” stands for General Equivalence Mappings
The CMS and the CDC created GEMs to ensure consistent national data when the U.S. adopts ICD-10.
The GEMs will act as a translation dictionary to bridge the “language gap” between the two code sets and can be used to map an ICD-9 code to an ICD-10 code and vice versa.
Mappings between ICD-9-CM and ICD-10-CM will play a critical role in the successful transition to ICD-10. The CMS and the CDC created the GEMs to ensure consistent national data when the US makes the transition.

23. Purpose of GEMs
Designed to give all sectors of the healthcare industry that use coded data the tools to:
Convert large databases and test system applications
Link data in long-term clinical studies
Develop application-specific mappings
Analyze data collected before and after the transition to ICD-10-CM
They are public domain, general purpose reference mappings designed to give all sectors of the healthcare industry that use coded data the tools to:

24. Not a Substitute for Coding
The GEMs should not be used as a substitute for learning how to use the ICD-10-CM code sets.
“GEMs are not a substitute for learning ICD-10-PCS and ICD-10-CM coding. They’ll help you convert large data sets.”
Mapping simply links concepts in the two code sets, without consideration of context of specific patient information, whereas coding involves assigning the most appropriate code based on documentation and applicable coding guidelines.
They were created to serve a specific, limited, short-term need – primarily for translation purposes.
Compare GEMs to a Spanish to English dictionary, where both languages can be found and speakers can go back and for the to translate from one to the other.
Pat Brooks, senior technical advisor, CMS stresses that the GEMs are not substitute for learning ICD-10. A GEM should NEVER be used as a way to code in ICD-10. GEMs were not developed act as a substitution for learning to code in ICD-10.

25. Why a GEM Won’t Always Work
A clear one-to-one correspondence between an ICD-9 or ICD-10 code is the exception rather than the rule.
ICD-9 codes: Coronary atherosclerosis of native coronary artery and Intermediate coronary syndrome (unstable angina)
ICD-10 code :I Atherosclerotic heart disease of native coronary artery with unstable angina
There are situations when a code in the target system does not exist
T503x6A Underdosing of electrolytic, caloric and water-balance agents, initial encounter
Not all ICD-9 codes are used in ICD-10, Not all ICD-10 codes have comparative codes in ICD-9

26. Forward and Backward Mapping
Forward Mapping
ICD-9 Code
Description
(Source)
820.8
Fracture of unspecified part of neck of femur, closed
ICD-10 Code
Description
(Target)
S72.009A
Fracture of unspecified part of neck of femur, initial encounter for closed fracture
Backward Mapping
ICD-9 Code
Description
(Target)
820.8
Fracture of unspecified part of neck of femur, closed
ICD-10 Code
Description
(Source)
S72.001A
S72.002A
S72.009A
Fracture of unspecified part of neck of right femur, initial encounter for closed fracture
Fracture of unspecified part of neck of left femur, initial encounter for closed fracture
Fracture of unspecified part of neck of femur, initial encounter for closed fracture
In the backwards mapping example, all three ICD-10 codes would map onto Even though the ICD-10 codes are specific to a side of the body, the ICD-9 codes does not contain any specificity – so all three codes correlate with In the forward mapping example, the same does not apply. Because you are taking a code with no specificity regarding side, it maps onto S72.009A – which is an ICD-10 code that is more generic. The codes S72.001A and S72.002A would not appear as options because they specifiy “left femur” and “right femur.”

27. Preparing for ICD-10

28. ICD-10 Implementation Plan
Checklist:
Year
2009/ 2010
2011
2012
2013
Phase I
Awareness and
Impact Assessment
Phase II
Preparing for Implementation
We encourage that you start now to get ready for ICD-10 implementation.
The phases of an Implementation plan are included here. AHIMA’s ICD-10 Preparation Checklist includes greater details for each phase, and this document is a great resource to get you started.
Phase 1 – Impact Assessment
Phase 2 – Preparing for Implementation
Is the next step and this also includes making the change to 5010 as well
Phase 3 – Go Live Preparation
This phase will be focused on testing and training – a very busy time period.
Post-implementation
And of course we won’t be done on the first of October 2013, careful data review and analysis and impact assessment will start all over again.
Phase III
Go Live Preparation
Phase IV
Post –
Implementation

29. ICD-10-CM Preparation Create awareness among faculty and staff.
Identify your current systems and work processes, whether electronic or manual, in which you use ICD-9.
Identify potential changes to existing practice workflow and business processes.
Although the implementation date is years away, it is not too early to begin planning for the transition, and even putting some of those plans in motion.
Among the systems and work processes you should
review for possible modification or upgrade:
Billing process
Encounter Forms/Fee Tickets
Coding
Charge Entry
Electronic Health Record
Databases
Department specific software applications
Clinical documentation
Contracts (payer)
2. Inventory of all systems that require modification to support ICD-10. Consider hardware and software needs.

30. ICD-10-CM Preparation
Assess status of business associates and vendors ICD-10 readiness.
Budget for implementation costs.
Conduct a detailed assessment of education needs.
4. Are our products and vendors ICD-10 ready? Can the vendor prove it?
5. Hardware and Software costs 6.

31. Assessment of Educational Needs
Identify who will require education:
Coding professionals
Providers
Billing personnel
Clinical personnel
Administrative staff and Management
Researchers
Determine what type and level of education they will need.
Assess the current level of coder education and experience.
Assess the level of knowledge necessary per person/role based on job responsibilities.
Determine the best method of education.
The bulks of the costs of implementing ICD-10 will be the training of personnel

32. Coder Training and Education
Build awareness to understand the impact of the code set change and the differences between the code sets
Develop pre-requisite skills where needed, for example, in the biomedical sciences
Educate on the foundational concepts on the structure and organization of the code sets
Role-based application “just in time”
3 – 9 months prior to implementation
AHIMA has developed
AHA/AHIMA recommends 6 - 9

33. Coder Training and Education
The DHHS recommends inpatient/hospital coders receive 50 hours of training and outpatient coders receive 10 hours of training.
AHA/AHIMA anticipates that a maximum of 16 hours of training may be sufficient for experienced coding professionals on ICD-10-CM only.
6 hours learning the fundamentals (structure, coding conventions, guidelines and how ICD-10 is different)
6 hours in more intensive training applying the conventions and guidelines
4 hours practicing applying codes to typical encounters
Presumes that coding professionals already possess the required knowledge in biomedical sciences.
However, based on feedback from a field testing project sponsored by AHIMA and the American Hospital Association, it is anticipated that one to two days of training will be necessary for coders only needing to learn ICD-10- CM and not ICD-10-PCS. Since ICD-10-CM has the same hierarchical structure, the same basic organization, and many of the same conventions as ICD-9-CM, experienced coding professionals will not require the level of extensive training that would be necessary for an entirely new coding system. They will primarily need education on the changes and in the classification itself as well as guidelines and definitions.

34. Education Requirements - AHIMA
AHIMA Certified Professionals are required to participate in a predetermined number of mandatory baseline educational experiences specific to ICD-10-CM.
RHIT – 6 CEUs
RHIA – 6 CEUs
CCS-P – 12 CEUs
CCS – 18 CEUs
CCA – 18 CEUs

35. Proficiency Test - AAPC
AAPC members holding a credential will have two years to pass a proficiency test:
You will be given two (2) years to pass the exam, beginning October 1, 2012 (one year before implementation of ICD-10) and ending September 30, 2014 (one year after implementation)
The test will consist of 75 questions
The test will be open-book, online and un-proctored
Coders will be allowed two (2) attempts to pass for the $60 administration fee

36. Clinical Documentation
The increased specificity of the ICD-10 codes requires more detailed clinical documentation in order to code some diagnoses to the highest level of specificity.
There are “unspecified” codes in ICD-10-CM for those instances when medical record documentation is not available to support more specific codes.
The benefits of ICD-10 can not be realized if non-specific codes are used rather than taking advantage of the specificity ICD-10 offers.
1) The test results found that ICD-10-CM codes can be applied to today’s medical records in a variety of health care settings without having to change documentation practices, although improved documentation would result in higher coding specificity and, therefore higher data quality in some cases.
2) Field study only about 12% of the codes assigned were unspecified even though no changes to documentation were made as part of the study.

37. Improving Documentation
Conduct medical record documentation assessments
Evaluate records to determine adequacy of documentation to support the required level of detail in new coding systems
Implement a documentation improvement program to address deficiencies identified during the review process
Educate providers about documentation requirements for the new coding system through specific examples
Emphasize the value of more concise data capture for optimal results and better data quality
Asthma –
Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent

38. Physician Training
DHHS agrees that some physicians will want intensive training on ICD-10 but some will seek “awareness training”.
Nolan study estimates 8 hours of intensive physician training
Nachimson Advisors, LLC study predicts 12 hours of physician training in both the code set and documentation procedures.
AHIMA believes most physicians would want no more than 4 hours of training.
11 medical organizations (MGMA, AAD, AAPC, AANS, AAOS, AMA among others) retained Nachimson (knockamosin) advisors to assess the cost impact on the ICD-10 mandate.

39. Fee Tickets
AHIMA/AHA study found the process of converting fee tickets to ICD-10-CM is not difficult, time consuming, or expensive. Most can be converted to ICD-10 in just a few hours and they are no longer in length than existing fee tickets.
Making the “fee ticket” more manageable:
Electronic fee ticket
Hybrid coding
Context-specific fee tickets
Limit specificity/code options
List 7th character separate

40. Coder Proficiency
AHA/AHIMA field test demonstrated that people with previous ICD-9-CM experience can learn ICD-10-CM easily.
Proficiency in use of the system will be dependent on a number of factors, including level of coder education and experience.
It is anticipated that most coders will have a high level of proficiency within 6 months of use.
In the AHA/AHIMA ICD-10-CM Field Testing Project , 76% of the participants stated that ICD-10-CM is an improvement over ICD-9
A 2003 field testing study conducted by AHIMA and the AHA demonstrated that people with previous ICD-9-CM experience can learn ICD-10-CM easily. For someone familiar with ICD-9, ICD-10-CM is not difficult to learn.

41. ICD-10 Web Resources
2010 versions of ICD-10-CM, GEMs and the Official Guidelines are all available on-line.
CMS, AHA, AHIMA and NCHS/CDC all have ICD-10 resource centers.
AHIMA has a free monthly ICD-10 Newsletter

42. Conclusion
While it is too early to start learning how to code utilizing the ICD-10-CM code set, it is never to early to start planning/preparing for the transition.