Leesa A. Israel, BA, CPC, CUC, CMBSExecutive Editor, The Coding Institute

Manager, TCI Consulting & Revenue Cycle Solutionsleesai@codinginstitute.com

Suzanne Leder, BA, M. Phil., CPC, COBGCExecutive Editor, The Coding Institute

Manager, Supercoder.com’s Specialty Content Productssuzannel@codinginstitute.com

ICD-10:

Tackling the New System

04/25/11

Take The Transition Seriously!If your practice fails to successfully migrate to

ICD-10, you potentially face:

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Delayed or reduced payments

Audits from multiple regulatory agencies

Damaged relationship with your business partners, including vendors and payers

Productivity declines for your coding, billing, and clinical staff.

Look Beyond the Coding

ICD-10 is much more than a coding update -- It is an entirely new system!

You’ll need to make changes to:

• Your coding

• Your billing system

• Your electronic health record EMR) system

• Your superbill

• And more!

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Version 5010 Purpose: The current version — version 4010/4010A1 —

does not accommodate the ICD-10 code set. Therefore, in preparation for the use of ICD-10, CMS has introduced its new HIPAA 5010 Version D.0

Scope: Required to be used by all HIPAA-covered entities (i.e., providers, health plans, clearinghouses, and their business associates, including billing agents).

Implementation Deadline: Jan. 1, 2012

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Timeline

• Keep in mind that CMS will begin accepting 5010 forms effective Jan. 1, 2011, and use of the form will be required as of Jan. 1, 2012. The ICD-10 codes will take effect on Oct. 1, 2013.

5010 Diagnosis Reporting

Improvements

1. Maximum number of diagnosis codes you can report on a claim increases from eight to 12

2. Increases the field size for ICD codes from 5 to 7

3. Adds a version indicator to the ICD code to indicate version 9 versus 10

4. Distinguishes between principal diagnosis, admitting diagnosis, external cause of injury, and patient reason for visit codes

5. Has an indicator on institutional claims for “present on admission” conditions

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5010 and ICD-10 Timeline

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January 1, 2010

• 5010 internal testing began

January 1, 2011

• 5010 external testing began

• Version 40101 still accepted

January 1, 2012

• All electronic claims must use Version 5010

• Version 40101 no longer accepted

October 1, 2013

• Claims with date of service after this date must use ICD-10

Dual Claims Processing

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Pointer: ICD-10 is a visit date activation, which means that you’ll

submit any services with visit date prior to Oct. 1, 2013 using ICD-

9 codes.

Billing hurdle: For some span of time you’ll be submitting both ICD-9 and ICD-10 codes on claims

• For testing purposes

• Because some payers won’t be on board by the 2013 deadline

Dual Claims Processing Example

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Claim Submission Date: Oct. 2, 2013

An office visit your physician

performed on Oct. 1

Submit using ICD-10

diagnosis codes

Claim Submission Date: Oct. 2, 2013

A surgical procedure your

physician performed on

Sept. 22

Submit using ICD-9

diagnosis codes

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Technology ConsiderationsCommunicate with your vendors

1. Pull all your contracts and evaluate how the each system and vendor will impact ICD-10 implementation in your practice.

2. Check to see if you have anything written in the contract that states government mandates are covered.

3. Contact your vendors and assess their ICD-10 readiness. Ask what their plans are and set up timelines to get your practice’s system ready.

4. Find out if the vendor has plans to upgrade systems by the compliance date.

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Technology Considerations

Communicate with your vendors

Start by asking:

Is the vendor prepared for the move to ICD-10 on Oct. 1, 2013?

Will the vendor be ready for version 5010 compliance by Jan. 1, 2012?

What costs will be involved with the transition?

What are the vendor’s implementation plans?

Will your practice need new or enhanced software/hardware?

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Bottom line: If your vendor is unable to offer

you solutions at this time you should begin

looking for a new vendor.

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ICD-10 and EMR

An electronic medical record (EMR) system is not mandatory for ICD-10 implementation. But if your practice has been on the fence about whether to implement an EMR, now is the time to look into it. Your practice needs to assess whether an EMR will benefit the practice.

There are many benefits of 5010 and ICD-10but many will only be realized in the

electronic format.

ICD-10 Billing Benefits1. More accurately report a patient’s diagnosis or condition with greater

specificity

2. Fewer repayment requests, incorrect payments, and even denials due to fewer erroneous, rejected, and exaggerated claims

3. Financial benefits due to less lost reimbursement

4. Shorter claim cycle and faster payments

5. Better appeals support

6. Payers able to auto-adjudicate more claims

7. Improved national and local coverage determinations (NCDs and LCDs)

8. A more efficient reimbursement process and therefore lower administrative costs

Bonus: Improved quality measurements and patient safety

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GEMS

General Equivalence Mappings (GEMs)

According to CMS, GEMs are “a tool to assist with the conversion of ICD-9-CM

codes to ICD-10 and the conversion of ICD-10 codes back to ICD-9-CM.

The GEMs are forward and backward mappings

between the ICD-9-CM and ICD-10 coding systems.”

Watch out: Although you’ll see the term “crosswalk,”

this can be deceiving. Not all codes have a direct

match, so you should think of the GEM file as merely a guideline.

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Source: General Equivalence Mappings FAQs

TRUE

CROSSWALK

GEMS

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Source: General Equivalence Mappings FAQs

From

ICD-9-CM

From

ICD-10-CM

To

ICD-9-CM

To

ICD-10-CMForward

Mapping

Backward

Mapping

GEMS

How They Work

The GEM file is a “flat file,” meaning this is a record with no structural

relationships. (You can download it here:

http://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp#TopOfPage)

Example 1: 62130 N8500 00000

Translation: 621.30 (Endometrial hyperplasia, unspecified) maps directly to

N8500 (Endometrial hyperplasia, unspecified).

How do we know this? Let’s focus on “00000.”

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GEMS

Example of Column 2 flag of “1”:

T500x6A NODX 11000

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Approximate

FlagNo Map Flag

One-to-Many:

Combo FlagScenario Choice

0=Identical

Match

1=Approximate

match (Majority

of alternatives

are considered

approximate)

0=At least one

plausible

translation

1=No plausible

translation for the

source symptom

code

0=Code maps to

a single code

1=Code maps to

more than one

code

0=Off

1-9=In a combo entry,

this is a collection of

codes from the target

system containing the

necessary codes that

combined as directed

will satisfy the

equivalent meaning of

a code in the source

system.

0=Off

1-9=In a combination

entry, this is a list of one or

more codes in the target

system from which one

code must be chosen to

satisfy the equivalent

meaning of a code in the

source system

GEMS

Therefore, “00000” means that 621.30 and N8500 are direct matches.

Example 2:

R6521 99592 10111

R6521 78552 10112

Translation: This means that ICD-10-CM code R65.21 (Severe sepsis

with septic shock) matches to both 995.92 (Severe sepsis) and

785.52 (Septic shock).

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Approximate

Flag

No Map

Flag

One-to-Many:

Combo FlagScenario Choice

SINGLE On or Off N/A Off 0 0

COMBO On N/A On 1-9 1-9

GEMS

Why do I have to know this?

It’s up to you to find inconsistencies.

Tactic: Start with the top 25 diagnoses in your practice. Look into your system

to see if they map correctly from I-9 to I-10. Then contact your vendor to

make any corrections.

Threat: Inaccurate coding will result in

increased denials and delayed payments.

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ICD-10 Examples

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Scenario: Suppose a 30 year old female patient is in the 36th week of

pregnancy and presents to the emergency room with a hemorrhage due to

placenta previa. The ob-gyn performs a c-section with a live birth. How would you

code this using ICD-10?

Solution: When your diagnosis coding changes in 2013, you should report

O44.13 and Z37.0. Notice how that first code features the letter “O” and not the

number “0.” You would link these codes to 59514. If you’re on the facility side, you

would report 10D00Z0.

Currently, you would use ICD-9 codes 641.11 and V27.0. You would link these

codes to 59514. If you’re on the facility side, you would report 74.99.

Scenario: A patient comes in for an annual exam. Right now, you should attach

V72.31 to an annual visit code (99384-99386 for new patients, or 99394-99396

for established patients).

ICD-10 difference: Instead of relying on one code, V72.31 will expand into two

options. They are Z01.411 and Z01.419.

Instead of relying on V72.31 as your catch-all annual visit diagnosis, you’ll need

to examine your physician’s documentation. In other words, you will be looking at

the examination part of the visit and what the ob-gyn notes for the appearance of

the external genitalia, vagina, uterus, and so on. If the ob-gyn does describe an

abnormality, you’ll report Z01.411. If not, you’ll report Z01.419.

Remember, if your physician does document an abnormal finding, you’ll most

likely include that finding on your ICD-10 claim as well.

ICD-10 Examples

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ICD-10 Example

CPT© 2011 American Medical Association. All rights reserved.

CPT® is a registered trademark of the American Medical Association. All rights reserved.

Ureteral stonewith procedure such as 52353 (Cystourethroscopy, with ureteroscopy and/or

pyeloscopy; with lithotripsy [ureteral catheterization is included])

• ICD-9: 592.1 — Calculus of ureter

• ICD-10:

• N13.2 — Hydronephrosis with renal and ureteral calculus

obstruction

• N13.6 — Pyonephrosis, conditions in N13.0-N13.5 with

infection

• N20.1 — Calculus of ureter

• N20.2 — Calculus of kidney with calculus of ureter.

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04/25/11

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