Transcript ICD-10 Background
2013 Webinar Series #1 – Pathway through the ICD-10 Maze March 19, 2013
*
2013 Webinar Series #1 – Pathway through the ICD-10 Maze
ICD-10 Background
Presented by
Jeff Hinson Regional Administrator
Centers for Medicare & Medicaid Services Denver Regional Office
*
What is ICD-10?
*
Refers to diagnosis and procedure code sets
*
Replaces ICD-9 code sets and includes updated medical terminology and classification of diseases.
*
Does not impact other medical coding sets (CPT-4, HCPS, NDC)
*
What’s Required?
*
ICD-10 must be used for transactions with dates of service/date of discharge on or after October 1, 2014
*
ICD-9 will no longer be accepted.
*
Deadline is firm.
*
Who Is Affected?
Anyone who is covered by HIPAA: Health care providers that conduct electronic transactions Payers including Medicaid and Medicare Clearinghouses
*
Who Is Affected?
Some non-HIPAA covered entities that use ICD-9 codes: Vendors and business associates of covered entities Worker’s compensation programs Life insurance companies
*
Why the change?
ICD-10 Provides More Specific Data
* *
Better reflects current medical practice Structure accommodates addition of new codes
•
The current coding system is running out of capacity and cannot accommodate future state of health care
*
Benefit:
•
More accurate payments for new procedures
•
Fewer miscoded, rejected and improper reimbursed claims
*
Why the change?
ICD-10 Allows for Expanded Data Capture
• • • • •
Quality measurement Better analysis of disease patterns Track and respond to public health outbreaks Make claim submission more efficient Identify fraud and abuse
• • *
Benefit : Improved ability to measure healthcare services Increased sensitivity when refining grouping & reimbursement methodologies Decreased need to include supporting documentation with claims
Website
*
ICD-10 Resources
Fact Sheets Implementation Handbooks www.cms.gov/icd10 Email Updates
*
Thank you!
*
2013 Webinar Series #1 – Pathway through the ICD 10 Maze
*
ICD-10 Basics
Presented by
Rebekah S. Gatti, CCS-P, CPC, CPC-I, CEDC, CPMA
R.T. Welter and Associates, Inc.
*
ICD-10 Basics
• • • • ICD-10-CM is similar to ICD-9 CM as far as format and basic guideline information Total number of codes expands from about 14,000 ICD-9-CM codes to well over 68,000 in ICD-10-CM (the majority of additions lie in the musculoskeletal codes, accounting for about 37,000 of the additional codes) ICD-10 Uses full code titles in the code description, while ICD-9 does not ICD-10-CM was designed with better capability for expansion
*
ICD-10-CM TABULAR LIST of DISEASES and INJURIES
*
ICD-9 to ICD-10 Structural Differences
*
ICD-10-CM Structure
Alphanumeric
* Characters 1-3 – Category * Characters 4-6 – Etiology, anatomic site, severity, or other clinical detail * Character 7 – Extension (may indicate encounter information, trimester, fetus number, etc.)
*
ICD-10-CM Structure
ICD-10 Structure Example S52 Fracture of forearm
S52.
5 Fracture of lower end of radius S52.5
2 Torus fracture of lower end of radius S52.52
1 Torus fracture of lower end of right S52.521
A Torus fracture of lower end of right radius, initial encounter for closed fracture radius Code can ’ t be completed until all information as to type of fracture, site (lower end of radius), healing type and encounter are specified.
*
A Few ICD-10-CM Conventions
*
A Few ICD-10-CM Conventions
ICD-9-CM has minimal instruction to it’s 9 conventions ICD-10-CM has twice as many conventions (18) and additional detail and guidance for correct use and interpretation Excludes 1 -
Example
*
A Few ICD-10-CM Conventions
Excludes 2 -
Example
*
A Few ICD-10-CM Conventions
*
A Few ICD-10-CM Conventions
General Coding Guidelines –
Example
ICD-10-CM 2013 Release is now available and can be accessed at:
Download the 113 page document at:
www.cdc.gov/nchs/icd/icd10cm.ht
m
*
2013 Webinar Series #1 – Pathway through the ICD 10 Maze
*
Code by example
Rebekah S. Gatti, CCS-P, CPC, CPC-I, CEDC, CPMA
R.T. Welter and Associates, Inc.
*
Choices
The number of codes has increased dramatically
* What may have been a single code in ICD-9 may now have several hundred code choices due to the specificity of ICD-10-CM * Code choices require more information * More specificity may require better documentation
*
Example 1: Diabetes
* * 1.
2.
3.
4.
5.
6.
Significant Change to Diabetes Mellitus Six Diabetes Mellitus categories in the ICD-10-CM.
E08 Diabetes Mellitus due to an underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type I diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus E14 Unspecified diabetes mellitus
Example:
Type II Diabetes with heel ulcer ICD-9 250.80 707.14
ICD-10 E11.621 L97.401 thru L97.429 (fifteen codes defining level of breakdown, right heel, left heel, or unspecified heel)
*
Diabetes
* * * Expanded to include the classification of the diabetes and the manifestation.
Category updated to reflect the current clinical classification of diabetes.
No longer classified as controlled/uncontrolled.
E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.11, Type 1 diabetes mellitus with ketoacidosis with coma E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy
*
Example 2: Gout
* Gout: ICD-9 has 36 codes Unspecified 274.9 describing gout/gouty conditions * ICD-10 currently has 239 codes induced, idiopathic etc., etc.) to describe gout/gouty conditions (primary, secondary, drug induced, due to renal impairment, body area, right, left, unspecified, lead * Chronic Gout Unspecified M1a.9 (requires 7 th M1a.9xx1 or M1a.9xx0
digit)
*
Example 3: Fractures
Fracture codes require seventh character to identify if fracture is closed or open.
• The fracture extensions are: A Initial encounter for closed fracture B Initial encounter for open 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 malunion S Sequelae
*
Fractures
Example:
- ICD-9-CM code 813.42 – Other closed fracture of distal end of radius (alone) - ICD-10-CM: 210 possible corresponding codes
Information needed to accurately code in ICD-10:
Fracture type (e.g. displaced/non-displaced, intra articular/extra-articular, Salters-Harris Type 1 to Type 4 etc.), which part of radius (styloid process), healing type (routine healing, delayed healing, mal-union, non union), laterality, and encounter. ICD-10-CM example: S52.511G – Displaced fracture of right radial styloid process, subsequent encounter for closed fracture with delayed healing
*
2013 Webinar Series #1 – Pathway through the ICD-10 Maze
Presented by
Denny Flint President
Complete Practice Resources
*
Additional ICD-10 Points
* Increased specificity requires more detailed documentation * Providers are therefore the cornerstone for the success of your ICD-10 transition * Unspecified = Unpaid
*
Increase in Codes?
Here’s the Real Story
* Gastroenterologists: 596 ICD-9 codes - 706 codes in ICD-10 (+110) * Pulmonologists: 255 codes in ICD-9 - 336 codes in ICD-10 (+81) * Urologists: 389 codes in ICD-9 - 591 codes in ICD-10 (+202) * Endocrinologists: 335 codes in ICD-9 - 675 codes in ICD-10 (+340)* * Neurologists: 459 codes in ICD-9 - 591 codes in ICD-10 (+132) * Pediatricians: 702 codes in ICD-9 down to 591 codes in ICD-10 ( 111) * Infectious disease: 1,270 in ICD-9 down to 1,056 in ICD-10 (-214)
A few hundred new codes = a few dozen new documentation elements
* ICD-10-CM includes more combination codes containing co-morbidities and associated conditions. Example - Diabetes
© 2011 MedLearn / SLIDE 35
© 2011 MedLearn / SLIDE 36
Fracture of the Patella
ICD-9-CM 2 codes ICD-10-CM 480 codes
Watch what happens to the number of ICD-10 codes when we add only 3 additional documentation elements
© 2011 MedLearn / SLIDE 38
© 2011 MedLearn / SLIDE 39
© 2011 MedLearn / SLIDE 40
*
Problem/Solution
* Fracture of Patella * 2 ICD-9 codes translate to a seemingly absurd number of ICD-10 Codes * But only 5 new documentation elements!
It
’
s not about the thousands of new codes, it
’
s about the dozen or so new documentation elements!
*
Documentation needs and Responsibility for ICD-10 Success
* Create documentation awareness now!
* Physician Documentation is the cornerstone for ICD-10 Transition success * This is the primary responsibility physicians have in the move to ICD-10 * But doctors want to doctor * So…create easy reference tools.
Here
’
s an example - Asthma
Asthma
Quick Reference Documentation Guide
* Mild, Moderate, or Severe?
* Intermittent or Persistent?
* Tobacco use or exposure?
If you create one of these for your top 50 most frequently used diagnoses, and introduce one every two weeks, you will be ready.
Gauge current documentation’s ability to support ICD-10 Easy-to-perform Chart A udit
* Convert top 20 ICD-9 codes using Transition Software * Analyze required ICD-10 documentation * Select 5 charts per provider for each ICD-9 code * Assess current chart documentation ability to support new, more specific ICD-10 codes * Give the docs a report card
Excellent technique to get your providers educated and engaged for the ICD-10 Transition
Why is this so important?
“
Physicians may be ICD-10 compliant, but if they abuse the
“
other
”
or
“
unspecified exists.
” ”
codes, payment will not occur if a more specific alternative
David Winkler Director of Technical Program Management Blue Cross of Michigan
Justifying medically necessary procedures and services depends on specificity of diagnoses coding!
Doctors need to know…
* Current Insurance Reimbursement Issues will carry over to ICD-10 * Medical Necessity Denials * Unspecified = Unpaid?
* Delayed payment – requests for additional information * (Broken Record) Documentation is the key to ICD-10 Transition success
…
And you need their support
.
*
At the end of the day, it’s all about the patients
* Richer acuity level databases = better care (metal hip prostheses, asthma) * Patient advocates in the insurance arena * Better data should equate to better reimbursement
*
Working for you!
*