Christina Janus, MBA, RHIA, CHAM Associate Director, ICD-10 The MetroHealth System Cleveland, Ohio

On to the Next Chapter of ICD…

2015

October 1, 2015 – USA medical systems will change from ICD-9-CM to ICD-10-CM/PCS

ICD-10-CM: Diagnosis coding

Used for inpatient and outpatient

Used by providers, coding and other clinical/operations staff

ICD-10-PCS: Procedure coding

Used for inpatient only

Used primarily by coding

CPT© codes will continue to be used for outpatient procedure coding

USA is the last developed nation to comply with the WHO system

Global use of ICD-10: Catching up with the industrialized world

Poland

Thailand

United States

Iceland

Denmark

Brazil

New Zealand

Argentina

Austria

Norway

Australia

Finland

Singapore

Canada

Sweden

China

Japan

Venezuela

Germany

Switzerland

Colombia

UK Ireland

Czech Republic The Netherlands

France

Costa Rica

Source: 3M Mission 13 Powerpoint

Greater coding accuracy and specificity

Higher quality information for measuring healthcare service quality, safety, and efficiency

Improved efficiencies and lower costs in the long run with more specific data

Reduced coding errors

Greater achievement of the benefits of an electronic health record

Recognition of advances in medicine and technology

Alignment of the USA with coding systems worldwide

Improved ability to track and respond to international public health threats

Enhanced ability to meet HIPAA electronic transaction/code set requirements

Increased value in the US investment in the SNOMED-CT

Space to accommodate future expansion

ICD-10 incorporates much greater specificity and clinical information to improve capture of healthcare information, which has the following benefits:

Universal Benefits of ICD-10 Why are we doing this?

Source: HFMA, Strategically Approaching the ICD-10 Transition Presentation

Source HIMSS Virtual Event 2011

ICD-10 Impact for Physician Office Operations

ICD-9-CM Diagnoses ICD-10-CM Diagnoses

1st char alphanumeric (only E and V

codes)

1st char alphanumeric (all letters except

U)

3 to 5 characters 3 to 7 characters

ICD-9-CM Procedures ICD-10-PCS Procedures

Numeric Alphanumeric

Codes 3 to 4 characters All codes 7 characters

ICD-9 General ICD-10 General

Space is limited for new codes Easily expandable for new codes

Lacks significant detail More specific. For example, identifies:

• Laterality

• Trimester

Source: 3M Mission 13 Powerpoint

Laterality Common clinical guidance scales

Increased granularity of

disease manifestation

Expansion of injury codes

Specific disease pathophysiology

7th character and timing of

encounters

X placeholders Post-procedural disorders

Acuity Identification of trimesters

Alcohol and drug dependence effects of use

Underlying or Associated Conditions

10

Source: HIMSS Virtual Event 2011

Allow for coding more specific content Laterality

Severity

Anatomic site

Etiology

Pregnancy trimesters

Expandable codes (i.e., injury, diabetes)

One-to-Twenty-Four Mapping

ICD-9-CM

821.01

(Fracture, femur, shaft,

closed)

ICD-10-CM

S72.301A

S72.301G

S72.302A

S72.302G

S72.309A

S72.309G

S72.321A

S72.321G

S72.322A

S72.322G

S72.323A

S72.323G

S72.324A

S72.324G

S72.325A

S72.325G

S72.326A

S72.326G

S72.331A

S72.331G

S72.332A

S72.332G

S72.333A

S72.333G

S72.326A Nondisplaced transverse

fracture of shaft of unspecified

femur, initial encounter for closed

fracture

S72.326G Nondisplaced

transverse fracture of shaft of

unspecified femur, subsequent

encounter for closed fracture with

delayed healing

Fracture of Forearm (813.00)

S52 Fracture of forearm

S52.5 Fracture of lower end of radius

S52.52 Torus fracture of lower end of radius

S52.521 Torus fracture of lower end of right

radius

S52.521A Torus facture of lower end of

right radius, initial encounter for closed

fracture

Acute Asthma Exacerbation (93.92)

Multiple options in ICD-10

J45.21 Mild, intermittent, w/acute exacerbation

J45.41 Moderate, persistent, w/acute exacerbation

J45.51 Severe, persistent, w/acute exacerbation

Right Ankle Sprain (845.00)

S93.401Sprain of unspecified ligament of right ankle

S93.411Sprain of calcaneofibular ligament of right ankle

S93.421Sprain of deltoid ligament of right ankle

S93.431Sprain of tibiofibular ligament of right ankle

S93.49 Sprain of other ligament of ankle

16

J02 Acute pharyngitis

J02.0 Streptococcal pharyngitis

J02.8 Acute pharyngitis due to other specified organisms

J02.9 Acute pharyngitis, unspecified

J03 Acute tonsillitis

J03.0 Streptococcal tonsillitis

J03.00 Acute streptococcal tonsillitis, unspecified

J03.01 Acute recurrent streptococcal tonsillitis

J03.8 Acute tonsillitis due to other specified organisms

J03.80 Acute tonsillitis due to other specified organisms

J03.81 Acute recurrent tonsillitis due to other specified organisms

J03.9 Acute tonsillitis, unspecified

J03.90 Acute tonsillitis, unspecified

J03.91 Acute recurrent tonsillitis, unspecified

17

E66 Overweight and obesity

E66.0 Obesity due to excess calories

E66.01 Morbid (severe) obesity due to excess calories

E66.09 Other obesity due to excess calories

E66.1 Drug-induced obesity

E66.2 Morbid (severe) obesity with alveolar hypoventilation

E66.3 Overweight

E66.8 Other obesity

E66.9 Obesity, unspecified

18

F90 Attention-deficit hyperactivity disorders

F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type

F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type

F90.2 Attention-deficit hyperactivity disorder, combined type

F90.8 Attention-deficit hyperactivity disorder, other type

F90.9 Attention-deficit hyperactivity disorder, unspecified type

19

R10 Abdominal and pelvic pain

R10.0 Acute abdomen

R10.1 Pain localized to upper abdomen

R10.10 Upper abdominal pain, unspecified

R10.11 Right upper quadrant pain

R10.12 Left upper quadrant pain

R10.13 Epigastric pain

R10.2 Pelvic and perineal pain

R10.3 Pain localized to other parts of lower abdomen

R10.30 Lower abdominal pain, unspecified

R10.31 Right lower quadrant pain

R10.32 Left lower quadrant pain

R10.33 Periumbilical pain

R10.8 Other abdominal pain

R10.81 Abdominal tenderness

R10.811 Right upper quadrant abdominal tenderness

R10.812 Left upper quadrant abdominal tenderness

R10.813 Right lower quadrant abdominal tenderness

R10.814 Left lower quadrant abdominal tenderness

R10.815 Periumbilic abdominal tenderness

R10.816 Epigastric abdominal tenderness

R10.817 Generalized abdominal tenderness

R10.819 …… unspecified site

R10.82 Rebound abdominal tenderness

R10.821 Right upper quadrant rebound abdominal tenderness

R10.822 Left upper quadrant rebound abdominal tenderness

R10.823 Right lower quadrant rebound abdominal tenderness

R10.824 Left lower quadrant rebound abdominal tenderness

R10.825 Periumbilic rebound abdominal tenderness

R10.826 Epigastric rebound abdominal tenderness

R10.827 Generalized rebound abdominal tenderness

R10.829 …… unspecified site

R10.83 Colic

R10.84 Generalized abdominal pain

R10.9 Unspecified abdominal pain

Source: HIMSS Virtual Event 2011

Angioplasty Code (39.50)

1,170 ICD-10-PCS angioplasty codes specifying body part, approach and device, including:

- 047K04Z Dilation of right femoral artery with drug-eluting intraluminar device, open approach

- 047K0DZ Dilation of right femoral artery with intraluminal device, open approach

- 047K0ZZ Dilation of right femoral artery, open approach

- 047K24Z Dilation of right femoral artery with drug-eluting intraluminal device, open endoscopic approach

- 047K2DZ Dilation of right femoral artery with intraluminal device, open endoscopic approach

Left Knee Replacement (81.54) - 0SRD Knee Joint, Left

- 0SRD0 Open

- 0SRD07 Autologous Tissue Substitute

- 0SRD07Z Replacement of Left Knee Joint with Autologous Tissue Substitute, Open Approach

- 0SRD0K Nonautologous Tissue Substitute

- 0SRD0KZ Replacement of Left Knee Joint with Nonautologous Tissue Substitute, Open Approach

- 0SRD0J Synthetic Substitute

- 0SRD0J9 Replacement of Left Knee Joint with Synthetic Substitute, Cemented, Open Approach

- 0SRD0JA Replacement of Left Knee Joint with Synthetic Substitute, Uncemented, Open Approach

- 0SRD0JZ Replacement of Left Knee Joint with Synthetic Substitute, Open Approach

Accuracy of medical records more critical Codes must be supported by medical documentation

Codes are more specific than previous coding

Expect coverage changes Will need specific ICD-10-CM codes for orders such as labs

Documentation will need to support tests ordered and justify the medical necessity of the patient

Expected increase in rejections, denials and pended claims while plans and providers get used to new codes

Need to expand “superbills” or “smart sets” to cover all options for diagnoses

Receipt of Physician Orders

Pre-Registration/Scheduling

Insurance Verification

Patient Check-in/Consent

Patient Discharge

Receipt of Physician Orders Request for service drives the encounter, the subsequent data needed to support the service delivered, and the level of care provided

Adequate physician documentation is required to support medical necessity for compliant delivery of medical service requested

The need for data accuracy and clinical knowledge of the impact of ICD-10 on requested services

Scripts used for ICD-9 need to be updated to accommodate ICD-10 granularity and specificity to be compliant

Pre-Registration / Scheduling Data for each patient is entered into a system where the diagnosis and code is impacted by ICD-10 code specificity

Compliance checker may be used for principal diagnosis

Incorrect diagnostic and procedural data can effect the patient’s stay throughout the encounter and cause payment denial

Due to increased number of ICD-10 codes, national and local coverage policies will look different than they do for ICD-9

It is likely that payers will no longer accept unspecified codes but will require the providers to use more specific codes

Providers will have to query physicians who do not submit complete diagnostic information

Bypassing this important step can create claim denial or rejection causing re-work later in the revenue cycle

Insurance Verification Understand local and national coverage determination to include changes related to ICD-10 specificity

Diagnosis specificity will impact the patient’s eligibility for diagnosis, pre-certification, medical necessity review, and ABNs

Ensure workflow surrounding verification captures accurate and specific diagnosis and procedure data to avoid delays and failure to acquire authorization

Understand updated system business rules to capture ICD-10 codes, templates and dictionaries. Understand the differences for ICD-10

Patient Check-in / Consent ABN is issued if patient is scheduled for tests/procedures not covered by insurance

Understand the relationship of ICD-10 codes to the compliance checker and guidelines for medical necessity

Ensure scripts are modified for ICD-10 and communication with clinicians concerning the order entry of new ICD-10 diagnosis codes and meanings

Patient Discharge Ensuring accurate data to close the encounter, i.e., date, time, discharge disposition

Patient’s type of insurance reviewed and diagnosis is verified. Collection of co-pay based on discharge diagnosis as appropriate

Ensure correct patient type, i.e. inpatient, outpatient, emergency, observation, etc.

Ensure correct discharge disposition, i.,e., SNF, LTAC, Home Health, etc.

Incorrect discharge data causes delay revenue cycle processes and potential denials due to improper medical necessity data

Payment can be denied or delayed by payer due to missing or inaccurate data

Items to Consider:

Ensure all impacted professionals are educated on ICD-10 code changes and documentation specificity

Successfully complete all systems and integrated testing where ICD-10 impact exists

Understand any changes to payer websites for ICD-10 code entry screens and processes typically performed by Patient Access professionals

Eliminate revenue cycle backlogs (coding, claims processing, denials, pre-authorization, referrals, etc)

Establish revised performance management system (key indicators, productivity, quality)

Establish ICD-10 training & education plan post Go-Live

Conduct follow-up assessments (Plan-Do-Check-Act)

AAPC (American Academy of Professional Coders) http://www.aapc.com

AHIMA (American Health Information Management Association) http://www.ahima.org

CMS (Centers for Medicare & Medicaid Services) http://www.cms.gov

HFMA (Healthcare Financial Management Association) https://www.hfma.org

HIMSS (Healthcare Information & Management Systems Society) http://www.himss.org