ICD-10 OVERVIEW

Agenda

ICD-10 CM ICD-10 PCS Prior Auth Guidelines Claims Processing

ICD – 10 goes live

All HIPAA-covered entities, including health plans, clearinghouses, and healthcare providers must adopt ICD-10-CM and ICD-10-PCS* code sets by October 1, 2015.

ICD-9 vs. ICD-10

ICD-9 ICD-10

• Produces limited data about patients’ medical conditions and hospital inpatient procedures.

• Limits number of new codes that can be created.

• Many categories are full.

• Includes outdated terms (30 years old).

• Is inconsistent with current medical practice.

• Offers greater detail on the member’s condition including:

• Severity

• Complexity

• Co-morbidities

• Complications • Helps match healthcare needs to

the appropriate level of care.

• Assists in obtaining timely referrals to appropriate specialists.

ICD-9 vs ICD-10 code characteristics ICD-9 • Approx. 13,600 • 17 Chapters • Mostly numeric codes

except E and V codes

• Valid codes have three, four, or five digits

• No mapping required for code set

ICD-10 • Approx. 69,000 • 21 Chapters • All codes alphanumeric • Valid codes have three,

four, five, six, or seven digits

• Added a placeholder X

ICD-9 vs ICD-10 Format

Code Extensions

Code extensions (7th character) have been added for injuries and external causes to identify the encounter

Common code extensions: ◦ A = Initial encounter ◦ D = Subsequent encounter ◦ S = Sequelae

Character “X”

Character “X” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion

Or to fill in empty characters when a code that is less than 6 characters requires a 7th character ◦ T15.02XD: Foreign body in cornea, left eye,

subsequent encounter

ICD-10 vs. ICD-9: comparison scenarios

scenario 1: major depressive disorder ICD-9 ICD-10

296.32 F33.1 major depressive disorder,

major depressive disorder,

recurrent recurrent

Moderate severity

Moderate severity

Should document: Status of current episode Level of severity

60-year-old female.

Office Visit

• Here today for

medication refill • Diminished interest

or pleasure • Difficulty staying

asleep

Patient History

• Recently became widowed • Long term use of

Fluoxetine

Provider Assessment

• Recurrent Major Depression Moderate Severity

• Continue Fluoxetine 20 mg

• Referred to psychiatrist

Major depressive disorder ICD-9 Diagnosis: 296.2x - Major Depressive Disorder,

Single Episode

296.3x - Major Depressive Disorder, Recurrent Episode

ICD-10 Diagnosis: F32.x - Major Depressive Disorder,

Single Episode

F33.x - Major Depressive Disorder, Recurrent Episode

Fourth Digit 0 = Mild 1 = Moderate 2 = Severe w/o psychotic behavior 3 = Severe w/ psychotic behavior 4 = In partial or unspecified

remission 5 = Full remission 8 = Other 9 = Unspecified

Fifth Digit 0 = Unspecified 1 = Mild 2 = Moderate 3 = Severe w/o psychotic behavior 4 = Severe w/ psychotic behavior 5 = In partial or unspecified

remission 6= Full remission

scenario 2: diabetes mellitus

65-year-old male.

Office Visit

• Known peripheral

artery disease (manifestation of diabetes)

• Provider quickly performs ABI test: results are lower than normal

Patient History

• Diabetic PVD • Hypertension • CKD IV

Provider Assessment

• A/P: “Diabetic Peripheral Artery Disease - getting worse, referred to cardiologist

• Hypertension – stable, renew Lisinopril

• CKD IV – stable, labs ordered, diet counseling

ICD-9 ICD-10 250.70 Diabetic peripheral arterial disease, type 2 or unspecified

E11.51 Type 2 Diabetes with diabetic peripheral angiopathy without gangrene

443.9 – Peripheral vascular disease

585.4 CKD, stage IV

N18.4 CKD, stage IV

403.90 Hypertensive CKD with stage 1 through 4, or unspecified CKD

I12.9 Hypertensive CKD with stage 1 through 4, or unspecified CKD

scenario 3: diabetes mellitus w/ulcer

45-year-old male.

Office Visit

• Here today for his

follow-up exam • His labs look good and

he reports being well

Patient History

• Type 1 Diabetes • Diabetic left foot ulcer

Provider Assessment

• A/P: Type 1 Diabetes – stable, continue Metformin

• Diabetic left foot ulcer-following up with neurologist

ICD-9 ICD -10 250.81 Diabetic foot ulcer, type 1 or unspecified

E10.621 Type 1 Diabetes mellitus with left foot ulcer

707.15 Ulcer of other part of foot

L97.521 Non pressure chronic ulcer of other part of left foot limited to breakdown of skin

• Out of control, poorly controlled, and inadequately controlled are coded to diabetes, by type, with hyperglycemia.

• Use additional code to identify any use of insulin (Z79.4).

• Do not assign insulin code (Z79.4) with Type I cases because insulin is required to sustain life.

scenario 4: active neoplasm

65-year-old female.

Office Visit

• Patient presents for follow-up of left breast cancer

Patient History

• Patient had mastectomy done 2 years ago and refused chemo-therapy

• Now being treated with Tamoxifen

Patient Assessment

• Left breast cancer of the upper-inner quadrant. Continue Tamoxifen for 2 years.

ICD-9 ICD-10 174.2 Malignant neoplasm of the breast, upper-inner quadrant

C50.212 Malignant neoplasm of upper-inner quadrant of left female breast

• Code active cancer even when the primary malignancy has been excised but further treatment is directed to that site.

Scenario 5 - pregnancy

30-year-old female.

Office Visit

• Patient presents for follow-up for antepartum care

Patient History

• Patient is pregnant with her 2nd child

• No complications with 1st child

Patient Assessment

• 24 weeks pregnant with 2nd child

• Obesity complicating pregnancy

ICD-9 ICD -10 278.01 Morbid obesity

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

V22.1 Supervision of other normal pregnancy

Z34.82 Encounter for supervision of other normal pregnancy, second trimester

V Codes = Z Codes Factors influencing health status and contact

with health services V22.1 = Encounter for supervision of other

normal pregnancy, now translated in ICD-10 to: ◦ Z34.80: unspecified trimester ◦ Z34.81: 1st trimester ◦ Z34.82: 2nd trimester ◦ Z34.83: 3rd trimester ◦ Z34.90: unspecified, unspecified trimester ◦ Z34.91: unspecified, 1st trimester ◦ Z34.92: unspecified, 2nd trimester ◦ Z34.93: unspecified, 3rd trimester

ICD-10 CM Categories/Codes

ICD -10 PCS

UB Claims: ICD-10 also affect procedure codes (located in field 74)

ICD-9 vs ICD-10 Procedure Structure (UB)

ICD-9 Has 3 – 4 characters All characters are

numeric All codes have at

least 3 characters

ICD-10-PCS Has 7 characters Either alpha or

numeric Numbers 0-9, letters

A-H, J-N, P-Z

Procedure Codes

ICD-9 35.21 – Open and other

replacement of aortic valve w/tissue graft

37.22 – Left heart cardiac catheterization

88.72 – Diagnostic ultrasound of heart

ICD-10 02R – Replacement /

heart and great valves

4A0 – Measurement / Physiological systems

B24 – Ultrasonography / Heart

*These are not coded to specificity

Claims Processing – What’s Changed?

Prior Auth Guidelines

Authorization requests submitted on or before 9/30/15 are submitted with ICD-9 codes

Authorization requests submitted on or after 10/1/15 are submitted with ICD-10 codes

Claim Submission Rules Beginning with dates of service 10/1/15 and after claims must

be submitted with ICD-10 codes For Inpatient UB claims, with discharge dates 10/1/15 and

after, claims must be submitted with ICD-10 codes Submission guidelines for claims that span across 10/1: ◦ UB04 Inpatient claims with dates of service than span across

10/1 are submitted with ICD-10 codes ◦ UB04 Outpatient claims must be split to submit separate claims

with service dates 9/30/15 and prior with ICD-9 codes and services dates 10/1/15 and after with ICD-10 codes

◦ CMS1500 claims must be split to submit separate services with dates of service 9/30/15 and prior with ICD-9 codes and services with dates of service 10/1/15 and after with ICD-10

ICD-10 Resources

American Health Information Management Association (AHIMA) http://www.ahima.org/topics/icd10

American Academy of Professional Coding (AAPC) https://www.aapc.com/icd-10/

CMS link: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1408.pdf