Transcript ICD-10 101 - California Health Information Association

CHIA
Coding and Data Quality Committee
2011
Developed October 2011
Presenter Instructions…
• The following ICD-10 slides and content was prepared by
the CHIA Coding and Data Quality Committee as a tool
and resource for the CHIA membership.
• The use of this ICD-10 101 material can be beyond that
of HIM and Coding and this is encouraged.
• Having an ICD-10 101 information tool and document
will help to promote awareness of implementation as
well as promote consistency with messaging. (This slide
would be deleted from the actual presentation)
Introduction
• WHO (World Health Organization) owns & publishes ICD
(International Classification of Diseases).
• WHO endorsed ICD-10 in 1990; members began using ICD10 or modifications in 1994.
• U.S. is only industrialized country not using ICD-10, for
morbidity reporting (coding diseases, illnesses, injuries in a
healthcare setting).
• The U.S. has used ICD-10 for mortality reporting (coding of
death certificates by Vital Statistics offices) since 1999.
• International Classification of Diseases, 10th Revision,
Clinical Modification (ICD-10-CM) is a clinical modification
of the World Health Organization’s (WHO) ICD-10, which
consists of a diagnostic classification system.
Introduction
• The Final Rule for ICD-10 implementation in the Unites
States was published in January 2009, giving a five year
readiness timeline.
• ICD-10-CM (Diagnosis code set) includes the level of detail
needed for morbidity classification and diagnostic specificity
in the United States. It also provides code titles and language
that complement accepted clinical practice in the United
States.
• The Centers for Medicare & Medicaid Services (CMS) is
driving the industry to upgrade core HIPAA transactions
(5010) as well as diagnosis and procedure coding standards
(ICD-10-CM/PCS)
▫ PCS represents the procedural coding system to be used for hospital
inpatient records
Introduction: Version 5010
 New version of the HIPAA standards - Version 5010
includes:
 Technical
 Data content improvements
 The updated version is more specific in requiring the data that is
needed, collected, and transmitted in a transaction; its adoption
will reduce ambiguities
 Version 5010 addresses currently unmet business needs,
including, for example, providing on institutional claims an
indicator for conditions that were “present on admission”
 Most important:
 Version 5010 also accommodates the use of the ICD-10 code sets,
which are not supported by Version 4010/4010A1
Today’s Uses of ICD-9-CM
• In addition to HIM and Coding the ICD-9 code set today
is used in and for many others:
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Reimbursement by payers
Medical necessity screening
Quality of care indicators
Outcome measurements
Medical care review
Method to index medical records
Storage and retrieval of dx data
Utilization patterns and review by payers
Research data
Statistics
Reasons for Denials
Monitoring and analyzing the incidence of disease and other
health problems
▫ Identify health care trends and Future health care needs
Benefits to ICD-10
• Enhanced system flexibility
• Better reflection of current
medical terminology
• Expanded detail relevant to
ambulatory and managed
care encounters
• Incorporation of
recommended revisions to
ICD-9-CM that could not be
accommodated
• HIPAA criteria for code set
standards are met
• Improved collection and
tracking of new diseases
and technologies
• Space to accommodate
future expansion
Important ICD-10 Compliance Timeline
• January 1, 2010
Payers and providers should begin internal
testing of Version 5010 standards for
electronic claims
• December 31, 2010 Internal testing of Version 5010 must be
complete to achieve Level I Version 5010
compliance
• January 1,2011
Payers and providers should begin external
testing of Version 5010 for electronic claims
CMS begins accepting Version 5010 claims
Version 4010 claims continue to be accepted
• December 31, 2011 External testing of Version 5010 must be
complete to achieve Level II compliance
• January 1, 2012
All electronic claims must use Version 5010
Version 4010 claims are no longer
accepted
• October 1, 2013
Claims for services provided on or after this
date must use ICD-10-CM/PCS codes for medical
diagnoses and inpatient procedures
ICD-9-CM & ICD-10 Code Freeze
• Vendors, system maintainers, payers, and educators requested a
code freeze
• Last regular, annual updates to both ICD-9-CM and ICD-10 will be
made on October 1, 2011
• On October 1, 2012 there will be only limited code updates to both
ICD-9-CM & ICD-10 code sets to capture new technology and new
diseases.
• On October 1, 2013 there will be only limited code updates to ICD10 code sets to capture new technology and new diseases.
ICD-10 Code Freeze (con’t)
• There will be no updates to ICD-9-CM on October 1, 2013 as the
system will no longer be a HIPAA standard.
• On October 1, 2014 regular updates to ICD-10 will begin
• The ICD-9-CM Coordination & Maintenance Committee will
continue to meet twice a year during the freeze
• The public will comment on whether new codes should be created
during the freeze
• Any codes that do not meet the criteria of being a new technology or
new disease will be held for consideration of inclusion in ICD-10
after the freeze ends
ICD-10 Growth
Diagnosis
80,000
Procedure
70,000
60,000
50,000
Diagnosis
40,000
Procedure
30,000
20,000
10,000
0
ICD-9-CM
ICD-10-CM
ICD-10 (WHO)
ICD-9-CM
ICD-10-PCS
ICD-10 (WHO)
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Some Differences:
Diagnosis Coding & Data
ICD-9-CM*
-3–5 characters in length
-14,315 diagnosis codes
-Only V codes and E codes
start with a letter
-Limited space for adding new codes
-Cannot identify laterality
ICD-10-CM*
-3–7 characters in length
-69,101 diagnosis codes
-ALL codes start with a letter
-Flexible for adding new codes
-Can identify laterality
* Based on the 2010 versions of ICD-9-CM and ICD-10-CM.
ICD-10-CM will be used in all healthcare settings
ICD-10 CM Format
X
X
Category
X
X X X
Etiology, Anatomical site, Severity
X
Extension
ICD-10-CM code structure differs from ICD-9-CM in that it consists of three to
seven characters, the first digit being an alpha character and second and third
digits are numeric; the fourth and fifth digits may be alpha (not case sensitive) or
numeric with a decimal after the third character.
Why so Many Codes?
• Greater specificity and detail in all diagnosis codes:
▫ 34,250 (50%) of all ICD-10-CM codes are related to the
musculoskeletal system
▫ 17,045 (25%) of all ICD-10-CM codes are related to
fractures
▫ 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’
▫ 25,000 (36%) of all ICD-10-CM codes to distinguish ‘right’
vs. ‘left’
Some Differences:
Procedure Coding & Data
ICD-9-CM*
-3–4 digits
-3,838 procedure codes
-Lacks detail
-Limited space for adding new codes
-Generic terms for body parts
ICD-10-PCS*
-7 alphanumeric characters
-71,957 procedure codes
-Very specific
-Flexible for adding new codes
-Specific terms for body parts
• Based on the 2010 versions of ICD-9-CM and ICD-10-PCS.
• To be used only for hospital inpatient medical records.
Format of ICD-10 PCS
The procedure coding system for ICD-10-PCS will be used only on inpatient
hospital stays. Outpatient surgery and physician outpatient coding will
continue to use Current Procedural Terminology® (CPT) for procedure coding.
There are seven characters in each ICD-10-PCS (Procedural Coding System). In
each section of PCS, the characters have slightly different meanings to relate to
that particular section.
Why so Many Codes?
• Seven Character Alphanumeric Code:
▫ All procedure codes will be seven characters long
▫ “I” and “O” (letters) are never used
• 34 possible values for each character
▫ Digits 0 – 9
▫ Letters A-H, J-N, P-Z
• A character is a stable, standardized code component
▫ Holds a fixed place in the code
▫ Retains its meaning across a range of codes
• A value is an individual unit defined for each character:
▫ Section Body Root Body Approach
▫ Device Qualifier System Operation Part
ICD-10 Impact
• People and Business
• Communications with both
internal and external key
stakeholders
▫ Regarding preparation activities
• Human resource strategy,
change management,
organizational research and
communication should come
together.
• Process and Technology
• Address and align
technology and employee
behavior with business
needs.
• Monitor vendor readiness
and compliance
• Analyze end-to-end
information and data flow
• Impact all aspects of
healthcare business and all
settings:
▫ Assessed
▫ Changed
▫ Tested and made ready
Implementation and Planning for ICD-10
• Establish an ICD-10 Steering Committee
• Members should be multidisciplinary and are key
stakeholders
• Establish a leader for implementation. HIM and IT
may want to co-lead the Steering Committee
• The plan should have a charter with goals,
objectives, deliverables and timelines.
• Preparation is key!
Key Stakeholders
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HIM
IT
PFS/Billing
Case Mgmt. and UR
Decision Support
Contracting
Educators
Compliance
• Physicians
• Clinical
Documentation
Improvement (CDI)
staff
• Payers
• Vendors
• Revenue Cycle/Finance
ICD-10 System Readiness
• Making sure that ALL systems that touch or use ICD-9CM codes today are ready for ICD-10 is critical.
• Have an inventory of all systems
• IT will lead the communicate with external users,
vendors and payers in assessing their readiness
• Testing of systems prior to 10/1/2013 should be built
into the implementation plan.
• Inventory of reports (digital and analog), and reporting
to outside agencies and registries.
Education and Training
• Education and Training is large component to ICD-10
implementation.
• Although HIM and Coding staff are the main target for Education
and training due to the impact of ICD-10 to their work, others will
also need education and training.
• Use “role based” education and training
• Consider conducting an assessment in the core areas for preparation
of ICD-10.
▫ This should have occurred by now (2011)
• The four core health science competency areas for ICD-10 are:
▫ Medical Terminology
▫ Anatomy & Physiology
▫ Pathophys or Disease Process
▫ Pharmacology
Education and Training
• Provide education in the four core competency
areas based upon the assessment findings.
• Actual ICD-10 training should be delivery in
2013.
▫ AHIMA estimates approximately 16 hours of coding
training is needed for outpatient coders and 50 hours
for inpatient coders.
• Go-live and post go-live plans should also be in
place as education and training will be needed.
AHIMA
AHIMA Certified Professionals are required by CCHIIM (Commission on Certification for
Health Informatics and Information Management) to participate in a predetermined number of
mandatory baseline educational experiences specific to ICD-10-CM/PCS. These ICD-10CM/PCS specific CEUs will count as part of all AHIMA certificants’ total CEU requirements for
the purpose of recertification. Stated differently, the following CEU requirements will be
included as part of each certificants’ total, required CEUs, by credential, per CEU
Cycle.
The total number of ICD-10-CM/PCS continuing education units (CEUs) required, by AHIMA
credential, is as follows:
 CHPS – 1 CEU
CHDA – 6 CEUs
 RHIT – 6 CEUs
RHIA – 6 CEUs
 CCS-P – 12 CEUs
CCS – 18 CEUs
 CCA – 18 CEUs
Certificants who hold more than one AHIMA credential will only report the highest number of
CEUs from among all credentials held. For example, if a certificant has both an RHIA and CCS,
the certificant would normally report 40 (30 CEUs for RHIA and an additional 10 CEUs for
CCS) CEUs per recertification cycle, and 18 of these CEUs will be required to cover ICD-10CM/PCS.
Source: AHIMA ICD-10 website
Page 24
Documentation Assessment
• Clinical documentation is critical today and will continue with ICD10, thus engage Physicians and other clinicians is important to
successful implementation
• A documentation assessment will be helpful
▫ Conduct a review of actual medical records
▫ Identify gaps (ie nonspecific diagnostic or procedure terms)
• Remember: Coders are required to code to the highest degree of
specificity, but the quality of the physician documentation HAS to
be there in the medical record before coding can be achieved.
• Expect an increase in the # of physician queries that will be
generated from ICD-10.
• Existing physician queries will most likely have to be updated as you
will be asking for different documentation to capture “specificity”.
Budgeting
Consider the following:
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Coding/HIM Assessment
Coding/HIM Prerequisite coursework
ICD-10 coding education/training
Coverage for coding staff while in education/training
Productivity decrease and coverage
IT assessment
Documentation assessment
Use the CMS ICD-10 Website
Appendix
ICD-10 Myths & Facts
Myth: The Oct. 1, 2013 date for implementation should be
considered a flexible date.
Fact: All HIPAA covered entities MUST implement the
new code sets with dates of service, or date of discharge
for inpatients, that occur on or after Oct. 1, 2013.
Myth: Implementation planning should be undertaken
with the assumption that HHS will grant an extension.
Fact: HHS has no plans to extend compliance date for
implementation of ICD-10-CM/PCS; covered entities
should plan to complete steps required to implement on
Oct. 1, 2013.
Appendix
ICD-10 Myths & Facts (con’t)
Myth: There will be no hard-copy code books and all
coding will need to be performed electronically.
Fact: ICD-10-CM and ICD-10-PCS code books are
already available and are a manageable size. The use of
ICD-10-CM is not predicated on the use of electronic
hardware and software.
Appendix
ICD-10 Myths & Facts (con’t)
Myth: The increased number of codes will make ICD-10CM/PCS impossible to use.
Fact: Just as the size of a dictionary doesn’t make it more
difficult to use, a higher number of codes doesn’t
necessarily increase the complexity of the coding system
–in fact, it makes it easier to find the right code.
Fact: Greater specificity and clinical accuracy make
ICD-10 easier to use than ICD-9-CM.
Fact: Because ICD-10-CM/PCS is much more specific, is
more clinically accurate, and uses a more logical
structure, it is much easier to use than ICD-9-CM.
Appendix
ICD-10 Myths & Facts (con’t)
Myth: The increased number of codes will make ICD-10CM/PCS impossible to use (con’t).
Fact: Just as it isn’t necessary to search the entire list of
ICD-9-CM codes for the proper code, it is also not
necessary to conduct searches of the entire list of ICD10 codes.
Fact: The Alphabetic Index and electronic coding tools
will continue to facilitate proper code selection.
Fact: It is anticipated that the improved structure and
specificity of ICD-10-CM/PCS will facilitate the
development of increasingly sophisticated electronic
coding tools that will assist in faster code selection.
Appendix
ICD-10 Myths & Facts (con’t)
Myth: ICD-10-CM/PCS was developed without clinical
input.
Fact: The development of ICD-10-CM/PCS involved
significant clinical input. A number of medical specialty
societies contributed to the development of the coding
systems.
Appendix
ICD-10 Myths & Facts (con’t)
Myth: ICD-10-CM-based super bills will be too long or too
complex to be of much use.
Fact: Practices may continue to create super bills that
contain the most common diagnosis codes used in their
practice. ICD-10-CM-based super bills will not
necessarily be longer or more complex than ICD-9-CMbased super bills. Neither currently-used super bills nor
ICD-10-CM-based super bills provide all possible code
options for many conditions.
ICD-10 Web Resources
http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf
http://www.cms.hhs.gov/apps/media/fact_sheets.asp
http://www.cms.hhs.gov/ICD10/01_Overview.asp
http://www.cms.hhs.gov/ICD10/03_ICD_10_CM.asp#
http://www.hhs.gov/news/press/2008pres/2008.html
http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm
http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm
http://www.ahacentraloffice.org/ICD-10
Other Resources
www.AHIMA.org
www.CaliforniaHIA.org
Acknowledgement
We wish to acknowledge and thank the California
Health Information Management Association
Coding and Data Quality Committee. Especially
Monica Leisch, Chantel Susztar, Gloryanne Bryant
and Elaine Lips for their input and assistance in
developing this ICD-10 101 presentation.