1. CHIA Coding and Data Quality Committee 2011
ICD
CHIA
Coding and Data Quality Committee
2011
Developed October 2011

2. Presenter Instructions…
The following ICD-10 slides and content was prepared by the CHIA Coding and Data Quality Committee as a tool and resource for the CHIA membership.
The use of this ICD material can be beyond that of HIM and Coding and this is encouraged.
Having an ICD information tool and document will help to promote awareness of implementation as well as promote consistency with messaging. (This slide would be deleted from the actual presentation)

3. Introduction
WHO (World Health Organization) owns & publishes ICD (International Classification of Diseases).
WHO endorsed ICD-10 in 1990; members began using ICD- 10 or modifications in 1994.
U.S. is only industrialized country not using ICD-10, for morbidity reporting (coding diseases, illnesses, injuries in a healthcare setting).
The U.S. has used ICD-10 for mortality reporting (coding of death certificates by Vital Statistics offices) since 1999.
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is a clinical modification of the World Health Organization’s (WHO) ICD-10, which consists of a diagnostic classification system.

4. Introduction
The Final Rule for ICD-10 implementation in the Unites States was published in January 2009, giving a five year readiness timeline.
ICD-10-CM (Diagnosis code set) includes the level of detail needed for morbidity classification and diagnostic specificity in the United States. It also provides code titles and language that complement accepted clinical practice in the United States.
The Centers for Medicare & Medicaid Services (CMS) is driving the industry to upgrade core HIPAA transactions (5010) as well as diagnosis and procedure coding standards (ICD-10-CM/PCS)
PCS represents the procedural coding system to be used for hospital inpatient records

5. Introduction: Version 5010
New version of the HIPAA standards - Version includes:
Technical
Data content improvements
The updated version is more specific in requiring the data that is needed, collected, and transmitted in a transaction; its adoption will reduce ambiguities
Version 5010 addresses currently unmet business needs, including, for example, providing on institutional claims an indicator for conditions that were “present on admission” 
Most important:
Version 5010 also accommodates the use of the ICD-10 code sets, which are not supported by Version 4010/4010A1
Second final rule adopts updated versions of the standards for certain electronic health care transactions, under the authority of HIPAA (5010/D.0 final rule
Updated versions replace the current versions of the standards and will promote greater use of electronic transactions
Version 5010 of the X12 standard
is essential to the use of ICD-10 codes because the current X12 standard (Version 4010/4010A1), cannot accommodate the use of the greatly expanded ICD-10 code sets. 
Effective date January 1, 2012 5

6. Today’s Uses of ICD-9-CM
In addition to HIM and Coding the ICD-9 code set today is used in and for many others:
Reimbursement by payers
Medical necessity screening
Quality of care indicators
Outcome measurements
Medical care review
Method to index medical records
Storage and retrieval of dx data
Utilization patterns and review by payers
Research data
Statistics
Reasons for Denials
Monitoring and analyzing the incidence of disease and other health problems
Identify health care trends and Future health care needs
Non HIM users……

7. Benefits to ICD-10 Enhanced system flexibility
Better reflection of current medical terminology
Expanded detail relevant to ambulatory and managed care encounters
Incorporation of recommended revisions to ICD-9-CM that could not be accommodated
HIPAA criteria for code set standards are met
Improved collection and tracking of new diseases and technologies
Space to accommodate future expansion
The value of this transition will be broad and far-reaching throughout the healthcare industry, and will result in:
• Greater coding accuracy and specificity
• Higher quality information for measuring healthcare service quality, safety, and efficiency
• Improved efficiencies and lower costs
• Greater achievement of the benefits of an electronic health record
• Recognition of advances in medicine and technology
• Alignment of the US with coding systems worldwide

8. Important ICD-10 Compliance Timeline
January 1, 2010 Payers and providers should begin internal testing of Version 5010 standards for electronic claims
December 31, 2010 Internal testing of Version 5010 must be complete to achieve Level I Version compliance
January 1,2011 Payers and providers should begin external testing of Version 5010 for electronic claims
CMS begins accepting Version 5010 claims
Version 4010 claims continue to be accepted
December 31, 2011 External testing of Version 5010 must be complete to achieve Level II compliance
January 1, 2012 All electronic claims must use Version Version 4010 claims are no longer accepted
October 1, 2013 Claims for services provided on or after this date must use ICD-10-CM/PCS codes for medical diagnoses and inpatient procedures
ICD-10 Compliance Timeline – Important
January 1, 2010 Payers and providers should begin internal testing of Version 5010 standards for electronic claims
December 31, 2010 Internal testing of Version 5010 must be complete to achieve Level I Version compliance
January 1,2011 Payers and providers should begin external testing of Version 5010 for electronic claims
CMS begins accepting Version5010 claims
Version 4010 claims continue to be accepted
December 31, 2011 External testing of Version 5010 must be complete to achieve Level II compliance
January 1, 2012 All electronic claims must use Version Version 4010 claims are no longer accepted
October 1, 2013 Claims for services provided on or after this date must use ICD-10-CM/PCS codes for medical diagnoses and inpatient procedures

9. ICD-9-CM & ICD-10 Code Freeze
Vendors, system maintainers, payers, and educators requested a code freeze
Last regular, annual updates to both ICD-9-CM and ICD-10 will be made on October 1, 2011
On October 1, 2012 there will be only limited code updates to both ICD-9-CM & ICD-10 code sets to capture new technology and new diseases.
On October 1, 2013 there will be only limited code updates to ICD- 10 code sets to capture new technology and new diseases.
You’ve heard about the halt to the annual code changes……..here is the overview of that decision, referred to as the Code Freeze”
ICD-9-CM & ICD-10 Code Freeze, because …… Annual ICD-9-CM and ICD-10 code updates make transition planning difficult

10. ICD-10 Code Freeze (con’t)
There will be no updates to ICD-9-CM on October 1, 2013 as the system will no longer be a HIPAA standard.
On October 1, 2014 regular updates to ICD-10 will begin
The ICD-9-CM Coordination & Maintenance Committee will continue to meet twice a year during the freeze
The public will comment on whether new codes should be created during the freeze
Any codes that do not meet the criteria of being a new technology or new disease will be held for consideration of inclusion in ICD-10 after the freeze ends
There will be no updates to ICD-9-CM on October 1, 2013 as the system will no longer be a HIPAA standard.
On October 1, 2014 regular updates to ICD-10 will begin
The ICD-9-CM Coordination & Maintenance Committee will continue to meet twice a year during the freeze
The public will comment on whether new codes should be created during the freeze
Any codes that do not meet the criteria of being a new technology or new disease will be held for consideration of inclusion in ICD-10 after the freeze ends

11. ICD-10 Growth
Diagnosis
Procedure 11

12. Some Differences: Diagnosis Coding & Data
ICD-9-CM* ICD-10-CM*
-3–5 characters in length -3–7 characters in length
-14,315 diagnosis codes ,101 diagnosis codes -Only V codes and E codes -ALL codes start with a letter
start with a letter
-Limited space for adding new codes -Flexible for adding new codes
-Cannot identify laterality -Can identify laterality
* Based on the 2010 versions of ICD-9-CM and ICD-10-CM.
Although the ICD-10-CM diagnosis codes will replace the ICD-9-CM diagnosis codes, they will be used in the same capacity as ICD-9-CM.
Here you see some of the differences:
ICD-10-CM will be used in all healthcare settings

13. Etiology, Anatomical site, Severity
ICD-10 CM Format
X X X
X X X X
Category
Etiology, Anatomical site, Severity
Extension
“Code first”
Underlying etiology and multiple body system manifestations due to underlying etiology
“Use additional code”
Convention that identifies another code is required to report the manifestation
“In diseases classified elsewhere”
Component of the etiology/manifestation convention
Never permitted as first listed diagnosis
When referencing Alphabetic Index
Manifestation codes in brackets always reported secondarily
ICD-10-CM code structure differs from ICD‑9-CM in that it consists of three to seven characters, the first digit being an alpha character and second and third digits are numeric; the fourth and fifth digits may be alpha (not case sensitive) or numeric with a decimal after the third character. 13

14. Why so Many Codes?
Greater specificity and detail in all diagnosis codes:
34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system
17,045 (25%) of all ICD-10-CM codes are related to fractures
10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’
25,000 (36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’

15. Some Differences: Procedure Coding & Data
ICD-9-CM* ICD-10-PCS*
-3–4 digits alphanumeric characters
-3,838 procedure codes -71,957 procedure codes
-Lacks detail -Very specific
-Limited space for adding new codes -Flexible for adding new codes
-Generic terms for body parts -Specific terms for body parts
Based on the 2010 versions of ICD-9-CM and ICD-10-PCS.
To be used only for hospital inpatient medical records.
Here are some of the
common differences between ICD-9-CM Volume 3 and ICD-10-PCS:

16. Format of ICD-10 PCS
As you can see, the position designates a specific meaning. This is consistent throughout the entire code set. For any ICD-10-PCS code, the 4th position, for example, always refers to the body part involved in the procedure.
The procedure coding system for ICD-10-PCS will be used only on inpatient hospital stays. Outpatient surgery and physician outpatient coding will continue to use Current Procedural Terminology® (CPT) for procedure coding.
There are seven characters in each ICD‑10‑PCS (Procedural Coding System). In each section of PCS, the characters have slightly different meanings to relate to that particular section.

17. Why so Many Codes? Seven Character Alphanumeric Code:
All procedure codes will be seven characters long
“I” and “O” (letters) are never used
34 possible values for each character
Digits 0 – 9
Letters A-H, J-N, P-Z
A character is a stable, standardized code component
Holds a fixed place in the code
Retains its meaning across a range of codes
A value is an individual unit defined for each character:
Section Body Root Body Approach
Device Qualifier System Operation Part

18. ICD-10 Impact People and Business
Communications with both internal and external key stakeholders
Regarding preparation activities
Human resource strategy, change management, organizational research and communication should come together.
Process and Technology
Address and align technology and employee behavior with business needs.
Monitor vendor readiness and compliance
Analyze end-to-end information and data flow
Impact all aspects of healthcare business and all settings:
Assessed
Changed
Tested and made ready

19. Implementation and Planning for ICD-10
Establish an ICD-10 Steering Committee
Members should be multidisciplinary and are key stakeholders
Establish a leader for implementation. HIM and IT may want to co-lead the Steering Committee
The plan should have a charter with goals, objectives, deliverables and timelines.
Preparation is key!
The biggest
change to happen in Health
Information Management and Revenue
Cycle in more than 30 years.
Preparation is the KEY!
Will you be ready?

20. Key Stakeholders Physicians HIMIT
PFS/Billing
Case Mgmt. and UR
Decision Support
Contracting
Educators
Compliance
Physicians
Clinical Documentation Improvement (CDI) staff
Payers
Vendors
Revenue Cycle/Finance
 Beyond the coders…
 PFS leadership as payers may reject based on ICD -10
coding and medical necessary codes.
 PFS leadership and contracting to ensure contracts can
accept both ICD-9 and ICD-10 on the UBs post go live.
 UR and all care mgt as payers will need to be able to do
pre-certifications and concurrent review with ICD-10.
 Decision support and all areas using ICD-9/10 coding for
tracking, reporting, etc. (Trauma registry, outcome
comparisons, contracting, etc.).
 IT leadership must be involved to ensure all impacted
areas are ready.

21. ICD-10 System Readiness
Making sure that ALL systems that touch or use ICD-9- CM codes today are ready for ICD-10 is critical.
Have an inventory of all systems
IT will lead the communicate with external users, vendors and payers in assessing their readiness
Testing of systems prior to 10/1/2013 should be built into the implementation plan.
Inventory of reports (digital and analog), and reporting to outside agencies and registries.

22. Education and Training
Education and Training is large component to ICD-10 implementation.
Although HIM and Coding staff are the main target for Education and training due to the impact of ICD-10 to their work, others will also need education and training.
Use “role based” education and training
Consider conducting an assessment in the core areas for preparation of ICD-10.
This should have occurred by now (2011)
The four core health science competency areas for ICD-10 are:
Medical Terminology
Anatomy & Physiology
Pathophys or Disease Process
Pharmacology
Inpatient coder
•Outpatient coder
•Managers of data
•Tasks for 5010 &
•ICD-10-CM/PCS compliance
•Educators
•Current students
•Prospective students

23. Education and Training
Provide education in the four core competency areas based upon the assessment findings.
Actual ICD-10 training should be delivery in
AHIMA estimates approximately 16 hours of coding training is needed for outpatient coders and 50 hours for inpatient coders.
Go-live and post go-live plans should also be in place as education and training will be needed.
Allow time for practice, practice, practice (key!)
 Down time during training and practice time.

24. AHIMA
AHIMA Certified Professionals are required by CCHIIM (Commission on Certification for Health Informatics and Information Management) to participate in a predetermined number of mandatory baseline educational experiences specific to ICD-10-CM/PCS. These ICD-10- CM/PCS specific CEUs will count as part of all AHIMA certificants’ total CEU requirements for the purpose of recertification. Stated differently, the following CEU requirements will be included as part of each certificants’ total, required CEUs, by credential, per CEU Cycle.
The total number of ICD-10-CM/PCS continuing education units (CEUs) required, by AHIMA credential, is as follows:
CHPS – 1 CEU CHDA – 6 CEUs
RHIT – 6 CEUs RHIA – 6 CEUs
CCS-P – 12 CEUs CCS – 18 CEUs
CCA – 18 CEUs
Certificants who hold more than one AHIMA credential will only report the highest number of CEUs from among all credentials held. For example, if a certificant has both an RHIA and CCS, the certificant would normally report 40 (30 CEUs for RHIA and an additional 10 CEUs for CCS) CEUs per recertification cycle, and 18 of these CEUs will be required to cover ICD-10- CM/PCS.
Source: AHIMA ICD-10 website
CCHIIM recognizes that AHIMA Certified Professionals have different levels of required competency regarding ICD-10-CM/PCS. These levels may be as follows:
• Awareness of ICD-10-CM/PCS which may include general structure of the systems, potential impact to workflow processes in order to prepare for the systems;
• Use of ICD-10-CM/PCS which may include analysis, trending or providing information that involves coded data but not actually apply the codes in their daily jobs and requires more in-depth knowledge of the systems; and
• Application of ICD-10-CM/PCS which includes assigning codes on a routine bases for various purposes and requires a more extensive knowledge of the systems.
Therefore, all certificants are encouraged to tailor their education specific to their job role. For example, if you are an RHIT and perform coding as a large percentage of your daily routine , you are encouraged to follow the requirements set forth for those specialized coding credentials. For further role based information to tailor your educational requirements see:  
Timeline for Accumulating ICD-10-CM/PCS CEUs
AHIMA Certified Professionals can begin earning ICD-10-CM/PCS specific CEUs during the period of January 1, 2011 thru December 31, 2013.
Additional information regarding reporting these CEUs and the types of recommended training areas/educational activities will be released no later than September 30, 2010.
__________________ Source:  AHIMA (2010) CCHIIM ICD-10 Continuing Education Requirements for AHIMA Certified Professionals, from: 
Page 24

25. Documentation Assessment
Clinical documentation is critical today and will continue with ICD- 10, thus engage Physicians and other clinicians is important to successful implementation
A documentation assessment will be helpful
Conduct a review of actual medical records
Identify gaps (ie nonspecific diagnostic or procedure terms)
Remember: Coders are required to code to the highest degree of specificity, but the quality of the physician documentation HAS to be there in the medical record before coding can be achieved.
Expect an increase in the # of physician queries that will be generated from ICD-10.
Existing physician queries will most likely have to be updated as you will be asking for different documentation to capture “specificity”.
Begin providing them education now so that they
are fully prepared on what will be required for
appropriate documentation for correct ICD-10
code assignment and MS-DRG assignment.
 Customize the training for physicians based on
their medical specialty.
 Do not just focus on inpatient diagnoses and/or
procedures but also on outpatient diagnoses as
this will require ‘beefed’ up documentation from
your docs as well to support the codes.

26. Budgeting Consider the following: Coding/HIM Assessment
Coding/HIM Prerequisite coursework
ICD-10 coding education/training
Coverage for coding staff while in education/training
Productivity decrease and coverage
IT assessment
Documentation assessment

27. Use the CMS ICD-10 Website

28. Appendix ICD-10 Myths & Facts
Myth: The Oct. 1, 2013 date for implementation should be considered a flexible date.
Fact: All HIPAA covered entities MUST implement the new code sets with dates of service, or date of discharge for inpatients, that occur on or after Oct. 1, 2013.
Myth: Implementation planning should be undertaken with the assumption that HHS will grant an extension.
Fact: HHS has no plans to extend compliance date for implementation of ICD-10-CM/PCS; covered entities should plan to complete steps required to implement on Oct. 1, 2013.

29. Appendix ICD-10 Myths & Facts (con’t)
Myth: There will be no hard-copy code books and all coding will need to be performed electronically. Fact: ICD-10-CM and ICD-10-PCS code books are already available and are a manageable size. The use of ICD-10-CM is not predicated on the use of electronic hardware and software.

30. Appendix ICD-10 Myths & Facts (con’t)
Myth: The increased number of codes will make ICD-10- CM/PCS impossible to use. Fact: Just as the size of a dictionary doesn’t make it more difficult to use, a higher number of codes doesn’t necessarily increase the complexity of the coding system –in fact, it makes it easier to find the right code. Fact: Greater specificity and clinical accuracy make ICD-10 easier to use than ICD-9-CM. Fact: Because ICD-10-CM/PCS is much more specific, is more clinically accurate, and uses a more logical structure, it is much easier to use than ICD-9-CM.

31. Appendix ICD-10 Myths & Facts (con’t)
Myth: The increased number of codes will make ICD-10- CM/PCS impossible to use (con’t). Fact: Just as it isn’t necessary to search the entire list of ICD-9-CM codes for the proper code, it is also not necessary to conduct searches of the entire list of ICD- 10 codes. Fact: The Alphabetic Index and electronic coding tools will continue to facilitate proper code selection. Fact: It is anticipated that the improved structure and specificity of ICD-10-CM/PCS will facilitate the development of increasingly sophisticated electronic coding tools that will assist in faster code selection.

32. Appendix ICD-10 Myths & Facts (con’t)
Myth: ICD-10-CM/PCS was developed without clinical input. Fact: The development of ICD-10-CM/PCS involved significant clinical input. A number of medical specialty societies contributed to the development of the coding systems.

33. Appendix ICD-10 Myths & Facts (con’t)
Myth: ICD-10-CM-based super bills will be too long or too complex to be of much use. Fact: Practices may continue to create super bills that contain the most common diagnosis codes used in their practice. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM- based super bills. Neither currently-used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions.

34. ICD-10 Web Resources

35. www.AHIMA.org www.CaliforniaHIA.org
Other Resources

36. Acknowledgement
We wish to acknowledge and thank the California Health Information Management Association Coding and Data Quality Committee. Especially Monica Leisch, Chantel Susztar, Gloryanne Bryant and Elaine Lips for their input and assistance in developing this ICD presentation.