2. Post-Implementation Getting to ICD-10 is only the tip of the iceberg; the real challenge is ensuring the ability to evolve along with it.

3. Agenda for Today ICD-10 Coding Refresher Documentation for Specificity Post ICD-10 Implementation-Who, What, Why and When?

4. Why Did We Need a New Coding System? Reimbursement Flexibility Quality Would enhance accurate payment for services rendered To quickly incorporate emerging diagnoses and procedures Would facilitate evaluation of medical processes and outcomes Exactness Identify diagnoses and procedures precisely

5. ICD-10 Changes

6. ICD-10-CM Codes Compared to ICD-9-CM Codes ICD-9 034.0 Streptococcal sore throat ICD-10 J03.00 Acute streptococcal tonsillitis, unspecified ICD-9 465.9 ICD-10 J06.9 Acute upper respiratory infection, unspecified

7. CODING CONVENTIONS AND GUIDELINES

8. ICD-10-CM Codes 2016 ICD-10-CM is available at: http://www.cdc.gov/nchs/icd/icd10cm.htm or https://www.cms.gov/Medicare/Coding/ICD10/index.html 2015 Coding Manual Where do I find the codes?

10. ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Narrative changes appear in bold text Items underlined have been moved within the guidelines since the FY 2014 version Italics are used to indicate revisions to heading changes

11. ICD-10-CM – Chapter Overview First Character(s)ChapterTitle A and B1 C and D(49)2 D3 E4 F5 G6 H (H1-H59)7 H (60-95)8 I9 J10 K11 L12 M13 N14 O15 P16 Q17 R18 S-T19 V-Y20 Z21

12. First Character(s)ChapterTitleCheat Name A and B1Infectious and Parasitic DiseasesAntibodies/Bacteria/Bugs C and D(49)2NeoplasmsCancer D3Diseases of Blood/ Immune MechanismDracula E4Endocrine, Nutritional and Metabolic DiseasesEndocrine F5Mental, Behavior and neurodevelopmental disorders Flaky, frightened, fitful, fearful G6Diseases of Nervous SystemGanglia, gray matter H (H1-H59)7Diseases of Eye and AdnexaHeadlight H (60-95)8Diseases of the Ear and Mastoid ProcessHearing I9Diseases of Circulatory SystemIn motion, J10Disease of the Respiratory SystemJR (from Dallas) J=Respiratory K11Diseases of Digestive SystemKaopectate “Krohn’s”, “Kolitis” L12Diseases of Skin and Subcutaneous TissueLesions, Lotion M13Diseases of Musculoskeletal System and Connective Tissue Muscles N14Diseases of Genitourinary SystemNeed to pee O15Pregnancy, Childbirth and the PuerperiumOB P16Conditions Originating in Perinatal PeriodPerinatal Q17Congenital Malformations, Deformations, and Chromosomal Abnormalities Quirky, quandary R18Symptoms, Signs and Abnormal Clinical and Laboratory Findings Revelations. Review and Ratios S-T19Injury, Poisoning and Certain Consequences of External Causes Situations, Traumas V-Y20External Causes of MorbidityVehicles, walking, eXposure, Z21Factors Influencing Health Status and Contact with Health Services Zombie ICD-10-CM – Chapter Overview First Character(s)ChapterTitle A and B1Infectious and Parasitic Diseases C and D(49)2Neoplasms D3Diseases of Blood/ Immune Mechanism E4Endocrine, Nutritional and Metabolic Diseases F5Mental, Behavior and neurodevelopmental disorders G6Diseases of Nervous System H (H1-H59)7Diseases of Eye and Adnexa H (60-95)8Diseases of the Ear and Mastoid Process I9Diseases of Circulatory System J10Disease of the Respiratory System K11Diseases of Digestive System L12Diseases of Skin and Subcutaneous Tissue M13Diseases of Musculoskeletal System and Connective Tissue N14Diseases of Genitourinary System O15Pregnancy, Childbirth and the Puerperium P16Conditions Originating in Perinatal Period Q17Congenital Malformations, Deformations, and Chromosomal Abnormalities R18Symptoms, Signs and Abnormal Clinical and Laboratory Findings S-T19Injury, Poisoning and Certain Consequences of External Causes V-Y20External Causes of Morbidity Z21Factors Influencing Health Status and Contact with Health Services

13. ICD-10 Hierarchy

15. ICD-10-CM Structure

16. This example of an ICD-10-CM code is for the ‘injury of digital nerve of right index finger, initial encounter’. This one code shows laterality, anatomic site, encounter type, and the specific underlying disease.

17. Differences from ICD-9-CM Injuries grouped by anatomical site rather than type of injury Laterality (side of the body affected) has been added to relevant codes Expanded use of combination codes Poisonings and associated external cause Certain conditions and associated common symptoms or manifestations Expanded detail and specificity Excludes 2 note which means “NOT INCLUDED HERE”.

18. Addition of 7 th Character 7th character used in certain chapters (e.g., Obstetrics, Injury, Musculoskeletal, and External Cause chapters) Different meaning depending on section where it is being used Must always be used in the 7th character position When 7th character applies, codes missing 7th character are invalid Placeholder “X” Addition of dummy placeholder “X” (or “x”) is used in certain codes to: Allow for future expansion Fill out empty characters when a code contains fewer than 6 characters and a 7th character applies S50.01XA Contusion of R elbow

19. Unspecified Codes Each healthcare encounter should be coded to the level of certainty known for that encounter Unspecified codes should be reported when they most accurately reflect what is known about the patient’s condition at the time of that particular encounter Unspecified codes should need to be selected less often due to greater number of code choices in ICD-10-CM

21. Routine Well-Child Exams Routine Checks Z00.121 Encounter for routine child health examination with abnormal findings Use additional code to identify abnormal findings Z00.129 Encounter for routine child health examination without abnormal findings

22. Immunizations ICD-9 CM V04.81 Need for prophylactic vaccination and inoculation, influenza ICD-10 CM Z23 Encounter for immunization Code first any routine childhood examination Unlike ICD-9, ICD-10 does not have separate codes for types of immunization Unlike ICD-9, ICD-10 does not have separate codes for types of immunization

23. Upper Respiratory Infections ICD-9 CM 465.9 Acute upper respiratory infections of unspecified site ICD-10 CM J06.9 Acute upper respiratory infection, unspecified Excludes 1 Note = “Not coded here!” Use 1 code only Acute respiratory infections NOS (J22) Influenza virus (J09-J11) Streptococcal pharygitis (J02.0)

24. Acute Pharyngitis ICD-9 CM 462 Acute pharyngitis ICD-10 CM J02.8 Acute pharyngitis due to other specified organisms Use additional code B95-B97 to identify infectious agent ICD-10 CM J02.9 Acute pharyngitis, unspecified Sore throat NOS Pharyngitis (acute) NOS Etc. OR

25. Tobacco Exposure Is required to be coded with many conditions, including but not limited to: Otitis Media Respiratory conditions Cardiovascular conditions Z77.22 Exposure to environmental tobacco smoke Z72.0 Tobacco use

27. Documentation Drives the Process Documentation - Continuity of Care - Basis for code assignment Coding - Based on documentation - Directly affects cash flow Reimbursement - Paid or delayed?

28. Axis of Classification Possible 7-character codes Laterality Trimester Specificity Drug and Alcohol Code Expansion 7th Character Expansion Codes Complication Codes Combination Codes Increased Specificity Here are some of the major effects of the changes within ICD-10-CM that impacts provider documentation and the coding of the medical record.

29. Clinical Documentation Tips 21 Clinical Concepts Type Temporal Factors Severity Caused By/Contributing Factors Symptoms/Manifestations Associated with Complicated by Localization/Laterality Anatomy Remission Status History of External Cause Activity Place of Occurrence Episode Number of Gestations Outcome of Delivery BMI Morphology Loss of Consciousness Substance

32. ● Tobacco use or exposure, or nicotine dependence (additional code required)

34. Z68.

36. INJURIES ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins. When documenting injuries, include the following: 1.Episode of Caree.g. Initial, subsequent, sequelae 2.Injury SiteBe as specific as possible 3.EtiologyHow was the injury sustained (e.g. sports, pedestrian, slip and fall, environmental exposure, etc.)? 4.Place of Occurrencee.g. School, work, etc. Initial encounters may also require, where appropriate: 1.Intente.g. Unintentional or accidental, self-harm, etc.

38. Strep Throat Scenario 1: A 14 year-old boy presents with a sore throat, fever, difficulty swallowing. He has a fever of 102.8, otherwise his vitals are normal. His tonsils are enlarged and red. This is his second visit for the same symptoms. His rapid stress test is positive and a 10 day course of antibiotics is prescribed.

39. Strep Throat Summary of ICD-10-CM Impacts 1.If confirmed as strep throat, must be documented as streptococcal pharyngitis and/or streptococcal tonsillitis, not sore throat. 2.Must specify if recurrent or not. If it is recurrent, specify date or timeframe of recurrence. If not specified as recurrent, the default is unspecified. 3.All respiratory conditions should include documentation related to tobacco smoke exposure, history of tobacco use, tobacco use, or tobacco dependence

40. Strep Throat What if we use these codes? ICD-9-CM Diagnosis Codes 034.0Streptococcal sore throat NA How does the documentation need to be improved? ICD-10-CM Diagnosis Codes J03.01 Acute recurrent streptococcal tonsillitis Z77.22 Contact with and exposure to environmental tobacco smoke

41. Strep Throat Chief Complaint Sore throat HPI 14 year old boy presents with sore throat, fever, difficulty swallowing. This is his second visit for the same symptoms _______________________________________________________________ ________________________________________________________________ Medications None, except for Tylenol to reduce fever Exam Vitals: T 102.8°F, otherwise normal. Tonsils are enlarged and red Assessment and Plan Rapid strep test is positive ____________________________________________ 10 day course of antibiotics is prescribed In the last 2 months, diagnosed as strep before His father is a smoker. for streptococcal tonsillitis

42. Otitis Media Scenario 2: A 16 year-old patient complaining of ear pain, from which he awoke during the night. He states this is the third time this year he has had earaches. He received amoxicillin for previous episodes which resolved w/o problems. His TMs are deep red, dull, full and landmarks obscured. He is diagnosed with Otitis Media and given a prescription of Augmentin x 10 days, f/u appt. in 2 weeks.

43. Otitis Media Summary of ICD-10-CM (and other coding) Impacts-Otitis Media 1.Document laterality 2.Coding note: Use additional code to identify exposure to environmental tobacco smoke 3.Document type 4.Document contributing factors 5.Document temporal aspect of disease

44. ICD-9-CM Diagnosis Codes 381.10 Chronic serous otitis media, simple or unspecified NA What if we use these codes? How does the documentation need to be improved? ICD-10-CM Diagnosis Codes H65.23 Chronic serous otitis media, bilateral Z77.22 Contact with and exposure to environmental tobacco smoke

45. Chief Complaint Ear Pain HPI 13 year-old patient complaining of ear pain, from which he awoke during the night. His mom states this is the third time this year he has had earaches. He received amoxicillin for previous episodes which resolved w/o problems No upper respiratory symptoms, no recent head trauma, no history of allergies _______________________________________________________________ ________________________________________________( exposure to tobacco smoke) Medications None Exam Vitals: HT: 69” WT: 109, BP 110/60, T 99.2°F, HR 70, R 16 TMs deep red, dull, landmarks obscured, full ______________ (laterality) Post auricular and submandibular nodes on left are palpable and slightly tender Assessment and Plan ____________ (temporal) _____________ (type) Otitis Media, ___________ (laterality) Prescription for Augmentin x 10 days, follow-up appointment in 2 weeks Mother and father are non-smokers, however his grandfather, whom he stays with after school, is. bilaterally Serous Chronicbilateral

46. Scenario 3: A 17-year-old established patient seen for “check-up” and initiation of contraception; Menses are regular; no complaints; She reports that her mother had breast cancer. Sexual debut 6 months ago; 2 lifetime partners; she admits to smoking about ½ pack of cigarettes daily. Vitals checked. Vaginal swab for SDTs; Given prescription for Ortho-Evra patch.

47. What if we use these codes? How does the documentation need to be improved? ICD-9-CM Diagnosis Codes V25.02 General counseling on initiation of other contraceptive measures V74.5 Screening examination for venereal disease V37.88 (V37.98) Special screening examination for other specified (or unspecified) chlamydial diseases V16.3 Family history of malignant neoplasm of breast V69.8 Other problems related to lifestyle ICD-10-CM Diagnosis Codes Z30.018Encounter for initial prescription of other contraceptives Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.8 Encounter for screening for other infectious and parasitic diseases Z80.3 Family history of malignant neoplasm of breast Z72.0Tobacco use

48. Summary of ICD-10-CM (and other coding) Impacts- Family Planning 1.Document encounter type Be sure to include a billable encounter type that can be coded 2.For screenings – document screening type Important for many quality initiatives 3.Document any high-risk sexual behavior ICD-10 requires type: homosexual, heterosexual or bisexual

49. Chief Complaint Wants contraceptives HPI A 17-year-old established patient seen for “check-up” and initiation of contraception Menses are regular; no complaints She reports that her mother had breast cancer. Sexual debut 6 months ago; 2 lifetime partners Medications None Exam Vitals: HT: 66” WT: 156, BP 112/70, T 97.8°F, HR 70, R 16 Assessment and Plan Vaginal swab done for STDs ________________________________________ Given prescription for Ortho-Evra patch Does more need to be documented to determine risk? : Gonorrhea; Chlamydia

51. Post-Implementation Survey What grade would you give your organization’s ICD-10 implementation? How many of you believe that your ICD-10 billing will negatively impact your revenue? For how long? How many of you believe that coding/billing productivity has suffered?

52. One Clinic’s Experience 1. So much for the CMS grace period. CMS promised a year of accepting ICD-10 claims as long as the code is in the "right family" but other insurers have not followed suit. There is no promise there that commercial plans won't require specificity for paying us. For the most part, in order to ensure being paid, we must code to the highest level of specificity right from the beginning. I heard many doctors adding more than 1 hour a day just to enter correct ICD-10 codes.CMS 6. Personnel. While IT systems may have been prepared for ICD-10, the industry personnel not so much. One of my billers was calling about a previously denied claim and was told she needed to resubmit it in ICD-10 format. No, this visit was 3 months ago and it does not apply. Many reps could not answer ICD-10 related questions. 5. Wait times. One of my billers spent three hours on-hold with an insurance company. 4. Eligibility checks. Some insurance websites were unavailable for the first 2 days. We were not able to check eligibility on some patients. We may or may not be paid for these visits and according to our insurance contracts, we are not allowed to bill the patient. Any patients I saw on the first 2 days of October who we were unable to verify their insurance was treated for free and there's nothing I can do about it. 3. Referrals. As a primary care physician, I do many referrals. My largest payer requires on-line referral submissions. Yet, on October 1, their site did not allow ICD-10 codes to be submitted. They no longer allow paper referrals and I was unable to do any for 3 days. Patients sometimes need urgent referrals. 2. Clearinghouses. My clearinghouse kicked out all unspecified codes and will not submit them to any insurance carrier.

53. Post Implementation-Why? Revenue Impact - Immediate Denied claims Loss of productivity Revenue Impact - Future Denied claims Quality and impact on Value-based Payment Systems

54. Post Implementation-Who? Providers Billers and Coders Admin

55. Post-Implementation Team Administration Provider Billing/Coding Quality Coordinators

56. Post Implementation-What? Denial management strategy Continuing education Documentation audits Quality and coding integration strategy

57. Denial Management Strategy Ins Co. Patient ID# Charge Amount CPT Date of Service Diagnosis/ ICD-10 Code Reason for Denial Action Taken IF ICD error- corrected code Date Sent F/U Formal process to track denied claims, based on incorrect or invalid code

58. Documentation Audits Rule #1: Select charts randomly Pull every 5th chart until reaching 10 charts Rule #2: Use the same rules as the auditors Requires understanding of both ICD-10-CM and E/M coding and documentation requirements Rule #3: Keep coding audits results professional and educational Rule #4: Work at correcting errors

59. Audit Worksheet Provider Name: Reviewer: DatePatient ID Documented Diagnosis CPT Code(s) ICD-10 Code(s)CPT Notes Documentation Notes 10/2/2015 Jody Smith Gastroesophageal reflux (GERD) 99212 K21.9Based on History and MDM-should be 99213 To meet higher specificity for ICD- 10, the documentation needs to indicate with or w/o esophagitis

60. Queries Date: ______________________ Client Name: __________________________________ Client Record Number: __________________ CDI Program Reviewer: __________________ Clinician Name: ____________________ A review of the health record found a need for documentation clarification. There are clinical indicators in the client record of a missed and/or incomplete diagnosis. The relevant information is provided below. Clinical Indicator/Medical Evidence Please add/or consider one of the diagnoses commonly associated with the clinical indicators that can be captured by coding. I disagree with the need for additional documentation.

61. Post-Implementation- When? Determine Timeline Develop priorities Delegate responsibility and authority 0-3 Form post-implementation team Create denial mgmt. strategy Assess productivity 3-12 Documentation & coding audits Continuing training and education 1-5 Review Quality Data Continue audits

62. Post-Implementation: 0-3 Months Review education opportunities Develop and implement denial management strategy Review coder productivity Days to bill Days to payment Revenue Cycle Impact

63. Post Implementation: 3-12 Months Review training/education needs and develop continuing education plan Identify quality reporting and data integrity challenges Meaningful Use Quality scoring Population management Review/mitigate revenue cycle impacts Begin documentation and coding audits

64. Implementation 1-5 Years Review and gap analysis Continuing training and education Expand audits Review impact on value-based payment reform

66. http://michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546_42552_42696-256928--,00.html Helpful ICD-10 Web Resources

67. CMS ICD-10 overview page: http://www.cms.gov/ICD10/http://www.cms.gov/ICD10/ AHIMA ICD-10 Information: http://www.ahima.org/ICD10/default.aspxhttp://www.ahima.org/ICD10/default.aspx AAPC ICD-10 Information: http://www.aapc.com/icd-10/index.aspxhttp://www.aapc.com/icd-10/index.aspx HIMSS Playbook: http://www.himss.org/asp/topics_icd10playbook.asphttp://www.himss.org/asp/topics_icd10playbook.asp

68. Helpful ICD-10 Web Resources Road to 10: The Small Physician Practice's Route to ICD-10 http://www.roadto10.org/

69. Helpful ICD-10: Free or Inexpensive Resources - Converters Resource Name OrganizationSummaryDelivery Type CostResource location 2015 ICD- 10 Medical Coding Website ICD10Data Listing of ICD-10 Diagnosis Codes, Index, and conversion between ICD-9 and ICD-10 codes WebFreehttp://www.icd10data.com/ ICD-10 Code Translator AAPC Allows for comparison between ICD-9 and ICD-10 codes. WebFree http://www.aapc.com/ICD- 10/codes/index.aspx MTBC ICD9-10 MTBC Converts ICD-9 codes to their respective ICD-10 codes Mobile APP Free App store or Google Play

70. Helpful ICD-10: Free or Inexpensive Resources- Training Resource Name OrganizationSummaryDelivery Type CostResource location ICD-10 Interactive Self Learning Tool World Health Organization The WHO Electronic ICD-10 training tool is designed for self- learning and is built on a modular structure. WebFree http://apps.who.int/classifications/a pps/icd/ICD10Training/

71. AAPC- top 50 codes in 23 specialties mapped from ICD-9 to ICD-10 in a laminated document $20.00 for AAPC members $25.00 for non-members https://www.aapc.com/icd- 10/crosswalks/ Helpful ICD-10: Free or Inexpensive Resources- Crosswalks

72. Helpful ICD-10: Free or Inexpensive Resources- Clinical Documentation Resource NameOrganizationSummaryDelivery Type CostResource location ICD-10 Documentation Tips AHIMA A large library of documentation tips for a given diagnosis, condition or disease WebFree http://bok.ahima.org/PdfView? oid=300621 ICD-10 Doc Guide Precyse University Documentation tips and strategies to document the medical record with the specificity required for ICD-10 Mobile App Free Apple App Store or Google Pay

73. Cindy Buege AHIMA Ambassador, AHIMA Approved ICD-10 Trainer cbuege@mphi.org