1. ICD-10 ORIENTATION & “YOUR FACILITY PLAN”
ICD-10 Facility Admin Orientation 1hr

2. Presenters
Rhonda Anderson, RHIA, President Khaleelah Wagner, RHIA, Staci LePage, RHIT Anderson Health Info. Systems, Inc. 940 W. 17th Street, Suite B Santa Ana, CA Tel Fax

3. Objectives Participants will identify: Dates for New ICD-10
Administrative Support Needed
Documentation support
Some general coding guidelines, a glance
Facility Work plan – Key timelines

4. Final Regulation Final Regulations were released in January 2009
Implementation Date is October 1, 2014
All billing using ICD-10 begins 10/1/2014
ICD-10 for billing purposes as far as ability to accept the code known as “5010” was required by October, 2012 is in compliance

5. Facility ICD-10 Project Team
Steering Committee
Support Team
Regional Resource Team
Facility Level Team

6. ICD-10 “Has Two Parts”
ICD-10 CM – Clinical Modification – Skilled Nursing will use “CM”
ICD-10 PCS – Procedural Code System (used for procedures, operations within the hospital inpatient setting)

7. What Does ICD-10 Compliance Means?
ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD- 10 codes
All Billing Claims will be denied if not ICD-10 by OCTOBER 1, 2014

8. Who Is Affected?? Freestanding providers
Ancillary services – “that means all of us really” who provide services and bill for them under Medicare, Medicaid/Cal and private insurances
Therapy Providers

9. Who Is Affected?? -2
Developed for the provider and the coder….(person who may review the documentation and determine if code is accurate)
Consistent, complete documentation in the medical record is a major emphasis

10. State Medicaid Program Needs To Transition To ICD-10
Like everyone else covered by HIPAA, state Medicaid programs must comply with ICD-10

11. Review Your Role No you will NOT code!
Leadership needs some information about the importance
To know resources – and resources needed
Identify Facility Project Team – initiated now
Obtain assurance from the computer system
To know that coding is correct – in future to have a system to assure accuracy of coding, billing, documentation

12. Codes Change Every Year
ICD-10 codes will be updated every year
Not in 2014 unless new technologies and new diseases
IN 2015 – regular updates (affects training and also purchase of manuals – computer alone is not enough

13. ICD-10 Differences Organization – Two volumes
Structure – Alphanumeric categories rather than numeric categories.(has “includes and excludes notes:
Categories are three digits
Chapters – re-arranged
Titles have Changed – examples on following slides

14. Diseases of the Eye and Adnexa
ICD-10 Differences -2
CHAPTER*
ICD-9-CM
ICD-10-CM* 1
Infectious and Parasitic Diseases
Certain Infectious and Parasitic Diseases -A00-B99 2
Neoplasms
Malignant Neoplasms 6
Diseases of the Nervous System and Sense Organs
Diseases of the Nervous System 7
Disease of the Circulatory System
Diseases of the Eye and Adnexa
ICD-10 Facility Admin Orientation 1hr

15. Diseases of the Ear and Mastoid Process H60-H95
ICD-10 Differences -3
CHAPTER*
ICD-9-CM
ICD-10-CM* 8
Diseases of the Respiratory System
Diseases of the Ear and Mastoid Process H60-H95 9
Diseases of the Digestive System
Diseases of the Circulatory System 10
Diseases of the Genitourinary System
ICD-10 Facility Admin Orientation 1hr

16. ICD-10 Differences -4 CHAPTER ICD-9-CM ICD-10-CM 13
Diseases of the Musculoskeletal System and Connective Tissue 14
Congenital Anomalies
Disease of the Genitourinary System
ICD-10 Facility Admin Orientation 1hr

17. ICD-10 Code composition – increased Specificity Level of detail
May consist of up to 7 digits with the seventh digit extensions representing visit encounter or sequelae as stated above
Includes full code titles and no reference back to common 4th and 5th digits)
V and E codes are no longer supplemental

18. ICD-10-CM Diagnosis Codes – Format & Structure
3-7 characters in length
Approximately 68,000 codes
Digit 1 is alpha, digit 2 and 3 are numeric; digit 4-7 are alpha or numeric
Decimal placed after the first 3 characters,
All letters used except “U”
Flexible for adding new codes
Very specific
Has laterality

19. Five-Six Character Subdivision
Way too much detail…but it looks like this!!
J10.8 – Influenza due to other influenza virus with other manifestations
J10.81 – Influenza gastroenteritis
J10.89 – Influenza with other manifestations:
Influenzal encephalopathy
Influenzal myocarditis
ANOTHER EXAMPLE – WITH SPECIFICITY AND LATERALITY:
S Laceration of ulnar artery at forearm level, right arm

20. Mapping Tools
Mapping from ICD-9 to 10 tools are available, General Equivalence Mappings (GEMS) – translation dictionary for diagnoses
Called “GEMS” – general equivalence mappings
CM – GEMS available
PCS – GEMS just available last of September (acute hospital mostly)

21. GEM Files
Do not despair…you vendor should prepare as much of a crosswalk as possible
NOTE: will require some conversion for long term resident’s diagnoses by the effective date of ICD-10
Later TRAINING and how to use them…Key to early review!!!

22. Key Highlights
ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings
ICD-10 PCS (Procedural Code System) – replaces ICD-9 CM in the inpatient hospital setting
Current Procedural Terminology (CPT) is still used for the Physician and some services, but they must have a diagnosis that is ICD- 10 compliant

23. Key Highlights -2
Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services
ICD-10 CM/PCS – Increased level of detail required for medicine advancements in technology, $$, improved data quality for clinical and financial decision making, to support value based purchasing and facilitate quality reporting

24. ICD-9-CM Diagnosis Codes
3-5 characters in length
Approximately 14,000 codes
First digit may be alpha or numeric
Digits 2-5 are numeric
Always at least three digits
Decimal placed after the first three characters
Limited space for new codes

25. ICD-9-CM Diagnosis Codes -2
Lacks detail
Lacks laterality, difficult to analyze, dated, non-specific and does not adequately define diagnoses needed for medical research
Does not support interoperability because it is not used in other countries

26. ICD-10 Structure
Index and Tabular list have the same hierarchical structure as ICD-9
ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list

27. ICD-10 CM Structure -2
ICD-9 V and E code supplemental classifications are incorporated into the main classification in ICD-10
ICD-9 V codes are now Z codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services
Postoperative complications have been moved to procedure-specific body system chapters

28. ICD-10-CM Diagnosis Codes – Format & Structure
3-7 characters in length and alphanumeric
21 chapters (compared to 17 in ICD-9)
Approximately 68,000 codes
Digit 1 is always alpha, digit 2 is numeric; digits 3-7 can be alpha or numeric
Decimal placed after the first 3 characters
Expanded codes
Flexible for adding new codes
Addition of placeholder “X”
Has laterality

29. Example Of Placeholder
ICD-10 utilizes a placeholder character “x”
The “x” is used as a placeholder at certain codes to allow for expansion
See categories T36-T50, poisoning codes T36.8X1
Also, Pathological vertebral fracture due to age- related osteoporosis, subsequent encounter with delayed healing M80.08XG

30. Example Of Laterality
For bilateral sites, the final character of the codes in ICD-10 indicates laterality.
C Malignant Neoplasm of upper-inner quadrant of left female breast
H Dermatochalasis of left lower eyelid
I80.01 Phlebitis and Thrombophlebitis of superficial vessels of right lower extremity
L Pressure Ulcer of right hip, Stage 3 An unspecified site code is also provided should the site not be identified.

31. Example Of Expanded Codes
Expanded Codes (injury, diabetes, alcohol/substance abuse, postoperative complications)
E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease

32. Examples Of 7th Characters
Seventh character for a fracture
A = initial encounter for 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 = sequela

33. Principal Diagnosis
Two or more interrelated conditions with each potentially meeting the definition:
Such as diseases in the same ICD-10-CM or manifestations characteristically associated with a certain disease potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise

34. Principal Diagnosis -2
Two or more interrelated conditions that equally meet the definition (cont.):
When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the code book does NOT provide sequencing direction, any one of the diagnoses may be sequenced first

35. Other Diagnoses Two or more comparative or contrasting conditions:
When two or more diagnoses are documented as “either/or”, they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission
Either diagnosis may be sequenced first
When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first
These should never be principal diagnoses

36. Signs, Symptoms, Ill-defined Conditions
Codes for symptoms, signs, and ill-defined conditions – are NOT to be used as a principal diagnosis when a definitive diagnosis has been established

37. Uncertain Diagnoses Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed/established
Applicable only to inpatient admissions to short- term, acute, long-term care & psychiatric hospitals

38. Sequencing Of Codes
Sequencing of codes is determined by the reason for admission/encounter, with the highest acuity diagnoses sequenced 1st

39. Specificity Of Coding
With added laterality, need greater documentation from your MD’s
Hypertensive Retinopathy H35.03
H right eye
H left eye
H bilateral
H unspecified (this would be a ?? for billing most likely!!)
Code also any associated hypertension (I10)

40. Chapter 2 – Neoplasms C00-d49
The neoplasm table should be referenced first
Anemia asso w/malignancy
If encounter is for mgmt of anemia asso w/malignancy, and tx is only for anemia, principal dx = malignancy code, followed by anemia code D63.0
Anemia asso w/chemotherapy
Encounter for mgmt of anemia asso w/adverse effect of chemo or tx, code anemia 1st, followed by neoplasm code and adverse effect

41. Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89
Diabetes Mellitus
Combination codes
Includes the body system affected and complications affecting the body system
Many codes particular category as are necessary to describe all of the complications of the disease may be used
Sequenced base on the reason for a particular encounter

42. Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89 -2
E08 Diabetes d/t underlying condition
E09 Drug or chemical induced diabetes
Secondary diabetes is always caused by another condition or event
E10 Type I Diabetes
E11 Type II Diabetes
Z79.4 long-term use of insulin
Not used when insulin is being used temporarily

43. Chapter 5 – Mental And Behavioral Disorders F01-f99
Vascular Dementia
Dementia in other diseases classified elsewhere
Unspecified Dementia
All of above are coded:
With behavioral disturbance, or
Without behavioral disturbance

44. Chapter 6 – Diseases of the Nervous System G00-G99
Chronic pain syndrome G89.4 vs. chronic pain G89.2
Provider must specifically document which condition
Hemiplegia - Dominant/nondominant side G81
For ambidextrous patients, the default should be dominant
Left side affected, the default is non-dominant
Right side affected, the default is dominant

45. Chapter 6 – Diseases of the Nervous System G00-G99 -2
Pain – category G89
Used in conjunction with codes from other categories to provide more detail about pain i.e., acute or chronic, neoplasm, or post-procedural
Can be listed as principal diagnosis
When pain control or pain mgmt. is reason for admit, the underlying cause and site of pain should be reported as additional dx, if known
If encounter is for any other reason, and dx has not been established, assign the code for the site of pain 1st, followed by code from G89

46. Chapter 7 – Diseases of Eye and Adnexa H00-H59
Assigning glaucoma codes:
Assign as many codes from category H40, as needed, to identify the type of glaucoma, the affected eye, and the glaucoma stage

47. Chapter 9 – Diseases of the Circulatory System I00-I99
Combination Codes for Conditions and Common Symptoms or Manifestations
I – Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris

48. Right Hip Replacement Now: Then:
V54.81 Aftercare following joint replacement
V43.64 Joint replacement, hip
Then:
Z47.1 Aftercare following joint replacement surgery
*only use above code for OA, not injury
Z Presence of right artificial hip joint

49. THE WORKPLAN TRANSITION TO ICD-10

50. Work Plan to Facilities
Steering Committee – Coordinating Dates
1. February – Brief Orientation ( Webinar) Feb 6 and Feb 7
2. March – 2 hours Webinar – 2 Sessions
March 18 and 20
3. April /May/June/July – “Live Trainings”
4. July /August– Each Facility will transition all Long Term residents to ICD-10.
5. September All facilities ready ….Dual Coding ICD 9 and ICD-10

51. ICD-10 Project Plan Determine who/how many staff needs training:
Facility Level ICD- 10 Team/ Attendees:
Administrator
DON
Medical Records
Diagnosis Coder – Nursing Supervisor
Biller
MDS
Admissions
Medical Director/ UR Doctors

52. Improve Documentation Now
All of the information that is required to code according to ICD-10 is information that is necessary to an individual’s care and is already documented in the medical record
What we will ask is “how does your documentation in your facility compare to what is needed to code accurately using ICD- 10?
???? Your evaluation early of the “medical record”
ICD-10 Facility Admin Orientation 1hr

53. ICD-10 Codes Require Clear focus to better documentation
Absolutely critical to the success of ICD-10
Good resident care –focused on documentation:
Affect so many facets of health care downstream
Quality measures to analytics, research, payment and surveillance
Must be as accurately documented, coded and billed

54. ICD-10 Codes Require -2 Good resident care (cont.) Recognition of:
Requires i.e., physician, nursing, therapy– efforts to provide good documentation
?? To Ask
What are you documenting today?
Evaluate documentation “best practices” to increase quality/quantity as needed
Recognition of:
Impact of ICD-10 (not new but = new focus
medical, financial, even regulatory ramifications

55. Develop The Relationship Between Clinicians
Clinicians Director of Nursing (DON) do not need to understand all of the intricacies of coding, and coders do not need to understand all of the medical – but the 2 must work together to ensure optimal accuracy
Increase questions from coders as there is a need to understand basic anatomy and pathophysiology
Crowded slide
ICD-10 Facility Admin Orientation 1hr

56. Strategies For Training
Leadership are those individuals who are responsible for moving things through the organization:
Understand what the impact of ICD-10 will be
What challenges are anticipated

57. Strategies For Training -2
Training Medical Record, MDS/PPS, DON, Business Office, Inquiry Staff, Medical Director:
Have training
Parallel coding taking the same cases and coding them accurate to ICD-9 and ICD-10
Parallel training and testing
Start in early 2014

58. Strategies For Training -3
Leadership should understand enough about the coding changes to understand the implications:
Documentation
Business practices
MDS / Medicare PPS
$$ impact for training, implementation and billing

59. Resources HIM Consultant – ICD-10 Certified and Specialized Training
Corporate/Facility Team members who have been to training will be “ Trainer” resource
DCR’s / Medical Records Consultant will assist in Training Facilities

60. Why Prepare Now? Major understanding for providers, payers and vendors
Will drive business and systems changes, hospital, SNF, Physicians, Outpatient, et’l, from large national health plans to small provider offices, laboratories, medical testing centers
Staff time – start looking at who is affected now and what they need to know
Financial resources
Options for ICD-10 transition

61. ICD-10 Project Plan -2 Evaluate current documentation
Identify most commonly used diagnoses by checking out:
Reports – past coding Medicare coverage issues “ADR”
Documentation to support those diagnoses
Medical staff / Medical Director support
Clinical documentation improvements
ICD-10 Facility Admin Orientation 1hr

62. Too Much Information??
Just A Few Examples – For Some, More Than You Need To Know!!!
Ongoing impacts your admission, billing clinical staff from prior to admission to discharge and beyond – physicians, Medical Directors responsibility, billing final reconciliation of billing, Medicare/Medicaid/MediCal, et’l

63. Specific Information Needed To Accurately Code
Diabetes Mellitus (example)
Type of diabetes
Body system affected
Complication or manifestation
If type 2 diabetes, long-term insulin use

64. Specific Information Needed To Accurately Code -2
Fractures
Site
Laterality
Type
Location

65. Review Changes In Documentation Requirements
Injuries
External cause – cause of the injury, more applicable to op
Place of occurrence – home, at work, in the car, etc.
More related to op we will have some references
Resident Activity level code
External code status – indicate if the injury was related to military, work, or other

66. Transition & Testing Jan/Feb, 2014 – September 15, 2014
Conduct high level training on ICD-10 for clinicians
Codes to prepare for testing
Clinical documentation review
Determine dual coding dates and record reviews

67. Complete Transition / Full Compliance
Corporate/Facility Compliance date
CMS Compliance date – October 1, 2014
Complete ICD-10 transition for full compliance
ICD-9 codes continue to be used for services provided before October 1, 2014
ICD-10 diagnosis and inpatient procedure codes required for services provided on or after October 1, Monitor systems correct errors if needed.

68. More Than You Need To Know???
The next several slides are provided as a glimpse of some Chapter example. More details will follow in future training sessions.

69. Chapter 9 – Diseases Of Circulatory System I00-I99
Sequelae of cerebrovascular disease I69 - used to indicate conditions in I60-I67 as the cause of sequelae. The “sequelae” include conditions specified as such or as residuals which m occur at any time after the onset of the causal condition.

70. Chapter 9 – Diseases Of Circulatory System I00-I99 -2
Hypertension with Heart Disease I11
Heart conditions classified to I50 or I51.4-I51.9 are also assigned to, a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive)
Use an additional code from category I50
Hypertensive chronic kidney disease/CKD I12
Cause and effect relationship is presumed
Need add’l code to identify the stage of CKD
Hypertensive heart and CKD I13
Causal relationship for HTN and heart dx must be doc’d

71. Chapter 9 – Acute Myocardial Infarction (AMI)
I21 For encounters occurring while the AMI is equal to, or less tan, four weeks old, including transfers to another acute setting or another acute setting or a postacute setting and pt requires continued care for the AMI
Subsequent acute MI
When a pt who has suffered an AMI has a new AMI within the 4 wk time frame of the initial AMI, code I22 in conjunction with I21 code

72. Chapter 10 – Diseases Of Respiratory System J00-J99
Chronic Obstructive Pulmonary Disease (COPD) and Asthma
Acute exacerbation of chronic obstructive bronchitis and asthma
J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation
Acute exacerbation is a worsening or a decompensation of a chronic condition

73. Chapter 12 – Diseases Of Skin & Subcutaneous Tissue L00-L99
L89 codes for Pressure Ulcer are combination codes that identify the site as well as the stage of the ulcer
Assignment of the pressure ulcer stage should be guided by clinical documentation of the stage
Assign code for the highest stage reported for that site

74. Chapter 14 – Diseases Of Genitourinary N00-N99
Stages of chronic kidney disease (CKD)
If both a stage of CKD and ESRD are documented, then assign code N18.6 only
Patients who have had kidney transplant may still have some form of CKD, because the transplant may not fully restore kidney function. Therefore, presence of CKD alone does NOT constitute a transplant complication.

75. Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab Findings R00-R99
A41.9 Sepsis, unspecified organism – Septicemia, unspecified (Chapter 1 Infectious & Parasitic Diseases)
Severe Sepsis – R65.20 – code first underlying infection, and use additional code to identify specific organ
Urosepsis – cannot code, code to condition

76. Chapter 18 – Symptoms, Signs & Abnormal … R00-R99 -2
Septic Shock
Circulatory failure associated with severe sepsis; represents a type of acute organ dysfunction. Underlying infection sequenced first, followed by code R Severe sepsis with septic shock. Add additional codes for other acute organ dysfunction
ICD-10 Facility Admin Orientation 1hr

77. Chapter 18 – Symptoms, Signs & Abnormal … R00-R99 -3
Use of symptom codes are acceptable for use when a related diagnosis has NOT been established by the provider
Use a symptom code with a diagnosis code may be reported when the sign or symptom is NOT routinely associated with that diagnosis
Signs or symptoms that are associated routinely with a disease process should NOT be assigned as additional codes

78. Chapter 18 – Symptoms, Signs & Abnormal … R00-R99 -4
R29.6 Repeated falls is used when a patient has recently fallen and reason for the fall is being investigated.
Z91.81 Hx falls is used when a pt has fallen in the past and is at right for future falls
When appropriate, both of the above codes may be assigned together

79. Chapter 18 – Functional Quadriplegia
R53.2 is the lack of ability to use one’s limbs or to ambulate d/t extreme debility.
It is NOT associated with neurologic deficit or injury, code R53.2 should NOT be used for cases of neurologic quadriplegia.
It should only be assigned if functional quadriplegia is specifically documented in the medical record

80. Chapter 19 – Injury, Poisoning & Certain Other Consequences of External Causes (S00-T88)
An example – S42.321D. Displaced transverse fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing
This means more specific documentation from the physician (the initial encounter of treatment is usually in the Emergency room)

81. Chapter 19 – Injury, Poisoning & Certain Other … (S00-T88) -2
A fracture not indicated as open or closed should be coded to closed
A fracture not indicated whether displaced or not should be coded to displaced

82. Chapter 19 – Drug Toxicity
When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the code for the adverse effect of the drug (T36-T50)
The code for the drug should have a 5th or 6th character “S”
ICD-10 Facility Admin Orientation 1hr

83. Chapter 19 – Poisoning
When coding a poisoning or reaction to the improper use of a medication, i.e. overdose, wrong substance given or taken in error, assign the appropriate code from categories T36-T50
The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined)

84. Chapter 21 – Factors Influencing Health Status and Contact with Health Services (Z00-Z99)
For use in any healthcare setting
May be used as either a principal diagnosis or secondary code
Certain Z-codes may only be used as principal diagnosis

85. Chapter 21 – Factors Influencing Health Status … (Z00-Z99) -2
Z code should not be used if treatment is directed at a current acute disease
Exceptions
First listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy Z51.0
Code also condition requiring care

86. Chapter 21 – Z Codes Former V codes are now Z codes
Provided for occasions when circumstances other than a dx, injury or external cause are recorded
Several codes have been expanded, i.e. personal and family hx
Now have a code for patients blood type, i.e. Z67

87. Chapter 21 – Z Codes -2 No longer have V57 codes
Code the underlying condition, i.e. injury, etc. with the appropriate 7th character for subsequent encounter
Z68 BMI is divided into adult and pediatric codes (Adults = age 21 or older)
RD in facility can assist with documenting the BMI

88. Chapter 21 – Z Codes -3
Code Z92.82 when tsf facility has admin tPA within 24 hrs prior to admit (usually with new dx of MI or CVD)
Aftercare Z codes should NOT be used for aftercare of fractures
For aftercare of fractures, assign fracture code with 7th character D for subsequent encounter

89. THANKS FOR ATTENDING ICD-10 Project Team In coordination with
Rhonda Anderson, RHIA, President
Khaleelah Wagner, RHIA, Staci LePage, RHIT
Anderson Health Information Systems, Inc.
940 W. 17th Street, Suite B
Santa Ana, CA 92706
Mobile Office
ICD-10 Facility Admin Orientation 1hr