rhonda anderson, rhia anderson health information systems, inc. 1

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Rhonda Anderson, RHIAAnderson Health Information Systems, Inc.

ICD-10 ORIENTATION IN SNF’S

OBJECTIVES

Participants will identify: Dates for New ICD-10 Documentation support New terms encounter principal diagnosis

re-defined Some general coding guidelines

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FINAL REGULATION

January 15, 2009 Final Regulation Released

EXCHANGE the ICD-9 for the ICD-10 on October, 1, 2014

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ICD-10 “HAS TWO PARTS”

ICD-10-CM = Clinical Modification, ICD-10 CM – applies to SNF, Intermediate Care, Physician’s Offices, Clinics, Dialysis, Home Health, other health care settings who bill Medicare, MediCal or Private Ins.

ICD-10 PCS = Procedural Code System (used for Acute Hospital procedures, operations

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HIPAA

Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)

HIPAA has evolved from 1996 to HITECH which relates to security and breaches

HIPAA Transactions 5010 went into effect October 2011

HITECH – HIPAA Privacy and Security final rule was released January 2013

WHO IS AFFECTED??

All inpatient and outpatient facility visits as well as freestanding providers and ancillary services “that means all of us really” who provide services and bill for them under Medicare, Medi-Cal and private insurances.

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VARIOUS ROLES THAT ARE AFFECTED HIM personnel Nurse managers MDS nurses Nursing unit staff/clerks Case managers Administration Therapy personnel (PT/OT/ST) Billing/admitting personnel

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MORE AFFECTED ROLES...

Medical Directors/Providers Corporate Office personnel Compliance Office personnel working

with ICD coding Corporate administrative departments

BENEFITS

More specific coding system Reflects medical advancements Standardization, UK implemented in

1995, used worldwide The United States is the only

industrialized nation that has not yet implemented ICD-10

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WHAT DOES THIS MEAN??

The guidelines in the ICD-10 manual 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.

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KEY HIGHLIGHTS

ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings

Current Procedural Terminology (CPT) is still used for the Physician, and some services, but they must have a diagnosis that is ICD-10 compliant

Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services

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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

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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.

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ICD-10 CM 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.

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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

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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

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ICD-10-CM DIAGNOSIS CODES – FORMAT & STRUCTURE -2

Codes that have applicable 7th character is considered invalid without the 7th character.

Expanded codes Flexible for adding new codes Addition of placeholder “X” Has laterality (right, left, lower, upper,

outer, etc.)

EXAMPLE OF PLACEHOLDER “X”

ICD-10 utilizes a placeholder character “x”

The “x” is used as a placeholder at certain codes to allow for expansion Categories T36-T50, poisoning and injury

codes T36.8X1D Also, Pathological vertebral fracture due to

age-related osteoporosis, subsequent encounter with delayed healing M80.08XG

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EXAMPLE OF LATERALITY

For bilateral sites, the final character of the codes in ICD-10 indicates laterality: C50.212 Malignant Neoplasm of upper-

inner quadrant of left female breast H02.835 Dermatochalasis of left lower

eyelid I80.01 Phlebitis and Thrombophlebitis of

superficial vessels of right lower extremity L89.213 Pressure Ulcer of right hip, Stage 3*an unspecified site code is also provided should the site not be identified. 19

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

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ICD-10-CM STRUCTURE

Requires “use” of proper coding guidelines Relies on the use of the guidelines and in

our case Skilled/ICF/IRF rules ICD-10-CM Index – disease, injury and

external causes of Injury More combined codes, i.e. Diabetic

retinopathy is one code

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ICD-10-CM STRUCTURE -2

More specificity, i.e. Alzheimer’s disease with specific details of early or late onset:

G30.0 Alzheimer’s with early onset G30.1 Alzheimer’s with late onset G30.8 Other Alzheimer’s disease G30.9 Alzheimer’s disease, unspecified

CONVENTIONS FOR THE ICD-10-CM

General rules for use of the classification independent of the guidelines Alphabetic Index and Tabular List

Alphabetic Index – List of terms and their corresponding code

Tabular List – chronological list of codes divided into chapters based on body system/condition

General coding guidelines are similar to ICD-9 with one additional guideline - laterality 23

CONVENTIONS FOR THE ICD-10-CM -2

General rules for use of the classification independent of the guidelines Format and Structure

First character is always alpha Three character category that has no further

subdivision is equivalent to a code Subcategories are either 4 or 5 characters Codes may be 3, 4, 5, 6 or 7 characters

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CONVENTIONS FOR THE ICD-10-CM -3

General rules for use of the classification independent of the guidelines 7th Characters

Certain ICD-10-CM categories have applicable 7th characters

Required for all codes within the category or as instructed by the notes in the Tabular List

Must always be the 7th character in the data field

If a code that requires a7th character is not 6 characters, a placeholder X must be used to fill in the empty characters

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EXAMPLES OF 7TH CHARACTER

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

mal-union S = sequela

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FRACTURE

Fracture Traumatic (abduction, adduction, separation)

Acetabulum – anterior, displaced, illopubic S32.43__ or non-displaced S32.436_

Acetabulum – dome (displaced) S32.48__

Fracture, lumbar vertebrae - (NOS) S32.009_

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FRACTURE -2

Fracture of lst lumbar vertebrae – S32.01__ Wedge compression, stable burst,

unstable burst, other, or unspecified? What type of fx is it?

ICD-10-CM DIAGNOSIS CODES -4

Specificity improves coding accuracy and depth of data for analysis

Detail improves the accuracy of data used in medical research

Supports interoperability and the exchange of health care data between other countries and the U.S.

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CODE FORMAT

ICD-10 Code Format

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ICD-9-CM Code Format ICD-10-CM Code Format

GEM FILES

Before we go further- do not despair…your vendor should prepare as much crosswalk as possible. There are “GEM” files.

General Equivalence Mappings (GEM) translation dictionary for diagnoses

There is NOT a one-to-one match between ICD-9 and ICD-10 codes

We will talk about GEMS later and how to use them. Key to early review! 31

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WHAT DOES THAT MEAN TO ME?

Identify your most common diagnoses. Determine in advance some of the

documentation issues that you will have with the nurses and the physicians

Discuss the specificity at the QA/PI meetings

Keep staff informed as we progress

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WHAT DOES THIS MEAN TO ME?

The organization will need to know for all facilities or your facility what the most common diagnoses that are admitted and focus on those first

Focus on the documentation to support those

Focus on review of Acute Hospital Records more closely – Impact Inquiries

Review for Medicare must be more specific

ICD-10 & ICD-9 DIFFERENCES

Organization Structure Code composition Level of detail May consist of 3 to 7 digits, with the

seventh digit extensions representing visit encounter or sequel, as stated above.

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ICD-10 & ICD-9 DIFFERENCES -2

Includes full code titles for all codes (no reference back to common 4th and 5th digits)

V and E codes are no longer supplemental classifications, as stated previously

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INSTRUCTIONAL NOTES

Inclusion notes further define, or give examples of the content of the category

Exclusion notes – Excludes1 vs. Excludes2 Excludes1 means “not coded here” Excludes2 means “not included here” may

need to use both the code and the excluded code together if patient has both conditions

Code first and Use additional code notes are similar to ICD-9 36

GENERAL CODING GUIDELINES

Locating a code in the ICD-10-CM Level of detail coding Code/codes from A00.0 through Z99.8 Signs and symptoms are acceptable for

reporting purposes when a related diagnosis has not been established

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CHAPTER 20 – EXTERNAL CAUSES OF MORBIDITY (V00-Y99)

These codes are secondary codes for use in any health care setting

These codes capture how the injury happened (cause) or the intent

Assign the external cause code with the appropriate 7th character for each encounter for which the injury or condition is being treated (initial, subsequent or sequela)

What happened? V03 pedestrian injured in collision with car, pick-up truck or van

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ICD-10-CM READINESS

Identify Corporate/Facility Steering Committees

Identify who needs education/pretest

Knowledge is a key step in successful implementation

Separate roles into two groups Group that primarily assigns codes Group that primarily does NOT assign

codes

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DIFFERENT KNOWLEDGE LEVELS DEFINED A general knowledge of the code

system and important differences between ICD-9 and ICD-10

Use and/or knowledge level for an individual who uses coded data but is typically not assigning codes daily

Application of the code set would be for those individuals who are routinely applying codes

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EDUCATION TIME

An employee with experience in coding (who was trained on the job) is estimated to need 18 hours of cumulative education for ICD-10

Education varies based upon the needs of each individuals skill level

Intense coding education should NOT be initiated until three to six months before implementation

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STEPS TO TAKE NOW

Educational Tasks/Phase I Learn about the structure, organization,

and unique features of ICD-10 Create an educational plan for all roles

which require education at various levels Network with peers, access resources, and

read literature to identify transition issues and best practices

Take advantage of education opportunities

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GENERAL IMPLEMENTATION TASK/PHASE I Develop an implementation plan

Identify steps to prepare for implementation

Identify who should be involved in preparation

Develop time frames for implementation phases

• Develop a budget • Identify current systems that input, store

and utilize ICD data • Identify who is currently performing coding

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GENERAL IMPLEMENTATION -2

Review current workflow to identify areas of impact and analyze opportunities for improvement (data in MDS, health record, and claim form)

Common workflow examples are diagnostic tests (laboratory, radiology, therapy diagnoses and billing)

Document improvement processes

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EDUCATIONAL IMPLEMENTATION TASKS/PHASE I

Conduct detailed assessment of staff educational needs

Assess knowledge of ICD-9 of current staff so that basic education can be obtained

Assess areas of strength/weakness of coding staff in the biomedical sciences

Evaluate barriers to preparing coding staff

Communicate the ICD-10 prep activities throughout the organization

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EDUCATIONAL RESOURCES

Listen to ICD-10 webcasts Have coding staff take medical

terminology and Anatomy and Physiology courses (from local college or online)

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IMPROVEMENT PROCESSES

Analyze current documentation practices, physician, nursing and therapy, to identify areas in need of improvement

Identify current processes that may lead to poor data quality due to inadequate or outdated documentation practices

Conduct detailed assessment of staff educational needs r/t documentation

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GENERAL IMPLEMENTATION TASKS / PHASE 2

Talk with vendors and other business associates regarding their ability to be prepared to accept ICD-10 codes

Determine the date of installation of facilities ICD-10 database software (must be utilized in a parallel manner with current ICD-9 code library)

Do NOT uninstall ICD-9 database

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GENERAL IMPLEMENTATION -2

Continue to address impact of code change such as required system changes and report modifications

Address legacy data issues in regards to how ICD-9 coded data is currently used

Evaluate barriers or potential barriers to preparing staff for ICD-10

Address timeline to begin coding current residents’ dx

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EDUCATIONAL TASKS/PHASE 2

Create an educational plan Provide education on the fundamentals

of the ICD-10 systems Provide opportunity for coders to

refresh knowledge of anatomy and physiology concepts

Continue to have educational sessions with clinical staff in the facility to learn more about commonly reported conditions and dx r/t LTC facilities

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GENERAL IMPLEMENTATION TASKS / PHASE 3

Install ICD-10 vendor software into the system to prepare for transition/perform software system testing

ICD-9 legacy data must be maintained and available

Closely monitor productivity and quality measures for issues r/t implementation of new code sets

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EDUCATIONAL TASKS/PHASE 3

Continue educational plan, including intensive education for roles who primarily assign codes

Practice ICD-10 coding of current records

Implement process for parallel coding of current residents with ICD-10 to facilitate future data entry

Provide more intensive educational and consultative support to coders and users of coded data

THANKS FOR ATTENDING!!

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