Transcript ICD-10 Are You Ready to S.W.A.P.

ICD-10 Are You Ready
to S.W.A.P.
Presented by
Kathy A. Montoya
Senior Provider Relations
Representative
Agenda
Background
 Volumes



ICD 10 CM
ICD 10 PCS
General Equivalence Mappings
 Reimbursement Mappings
 Preparation Steps

Training Objectives
Increase knowledge
 Identify obstacles
 Get on track for implementation
October, 1 2014

Health Insurance Portability and
Accountability Act (HIPAA)

Administrative simplification provides
standards for




Electronic transmission of claims
Provider identifiers
Privacy
Code set
Why The Change

ICD-9


Adopted by CMS April 1, 1989
Produces limited data




Patients’ medical conditions
Hospital inpatient procedures
30 years old and outdated
Limits new code creation
ICD-10-CM/PCS

Incorporates greater specificity and clinical
information


Improves health care service measurement
Helps with refining groupings and
reimbursement methodologies
ICD-10-CM/PCS



Enhances ability to do public health
surveillance
Decreases need for claims supporting
documentation
Updates medical terminology and
classification of diseases
ICD-10-CM/PCS

Provides better data for





Claims processing
Making clinical decisions
Identifying fraud and abuse
Conducting research
Comparison of mortality and morbidity
ICD 10

Department of Health and Human Services



Final regulation January 15, 2009
October 1, 2014
Guidance available on

http://www.cms.gov/ICD10/
ICD-9 It’s Not Over Yet
Worker’s compensation
 Auto insurance

Not required to convert
 Not planning to change

ICD 10

Developed by

World Health Organization (WHO)



http://www.who.int/classifications/icd/en/.
Utilized in other countries
Mandated for use in U.S.

October 1, 2014
ICD-10

In use in U.S.


Individual states
Report cause of death on certificates
ICD 10 CM

National Center for Health Statistics
(NCHS)



Developed ICD 10 Clinical Modification (CM)
for U.S.
In conjunction with advisory group and
physicians
Still in DRAFT
ICD-10
General Information
ICD-10 Part 1

ICD-10-CM for diagnosis coding



All U.S. health care setting
3 – 7 digit alphanumeric codes
68,069 ICD-10-CM codes
 Increased from 14,025 ICD-9-CM
Provider Claims
Compliance A Must
No delays or grace period
 ICD-9-CM for dates of service < October
1, 2014
 ICD-10 for dates of service ≥ October 1,
2014
 Still use CPT and HCPCS

ICD-10 Code Structure
AXX.XXXX
3 45/67
Categories
Subclassification
Subcategory
Extention
Code/Placeholder
Code
Code
Code
ICD-10-CM Structure

3 – 7 characters




1st = alpha
2nd = numeric
3rd – 7th = alpha or numeric
Decimal after 3rd character
ICD-10-CM Structure

Character “X”


5th or 6th position
“Placeholder”


Future expansion
“Fill In”

Empty characters
7th Character

One use is encounter type



A = Initial encounter
D = Subsequent encounter
S = Sequela
7th Character

R40.2
Coma
Coma NOS
Unconsciousness NOS
The appropriate 7th character is to be added to each code from
subcategory R40.21-, R40.22-, R40.230 Unspecified time
1 In the field [EMT or ambulance]
2 At arrival to emergency department
3 At hospital admission
4 24 hours or more after hospital admission
ICD Codes
Describe medical necessity
 Facilitate payment
 Evaluate utilization patterns
 Study appropriateness of health care costs

Incorrect Coding
Lead to investigations of fraud and abuse
 Must be correct
 Must be consistent

Comparison

ICD-9 CM




Groups by type of
injury
Maximum 5 characters
Most codes numeric
17 chapters

ICD-10 CM




Groups by site of injury
Maximum 7 characters
Codes are alphanumeric
21 chapters
Changes Found In ICD-10 CM
Addition information for ambulatory and
managed care encounters
 Expanded injury codes
 Combination codes
 Reclassification of diseases

Changes Found In ICD-10 CM
New code definitions
 “E” and “V” codes incorporated in main
classifications
 Category restructuring and code
reorgaization

ICD-10 CM Format
Introduction
 Official Guidelines for Coding and
Reporting
 Alphabetic Index to Diseases and Injuries
 Neoplasm Table

ICD-10 CM Format
Table of Drugs and Chemicals
 Index of External Causes
 Tabular List of Diseases and Injuries

Official Guidelines for
Coding and Reporting

1.
2.
3.
4.
ICD-9 and ICD-10
Conventions, general coding guidelines
and chapter specific guidelines
Selection of Principle Diagnosis
Reporting Additional Diagnosis
Diagnostic Coding and Reporting
Guidelines for Outpatient Services
Official Guidelines for
Coding and Reporting

ICD-10



Chapters 3, 7, 8 and 11
Not completed
Specialty society involved in creation
Official Guidelines for
Coding and Reporting

Examples

Chapter 15


Chapter 15 codes have sequencing priority over
codes from other chapters
Chapter 15 codes are to e used only on maternal
record, not on newborn
Alphabetic Index

ICD-9






Diseases
Illness
Injury
Other reasons for
encounters
Table of Drugs and
Chemicals
External Causes of Injury
and Poisoning

ICD-10




Diseases
Illness
Injury
Other reasons for
encounters
Neoplasm Table

ICD-9


In alpha index
Malignant







Primary
Secondary
Ca in situ
Benign
Uncertain Behavior
Unspecified
ICD-10








Separate section
Malignant Primary
Malignant Secondary
Malignant
Ca in situ
Benign
Uncertain
Unspecified Behavior
Table of Drugs and
Chemicals

ICD-9

Under Alphabetic Index






Poisoning
Accident
Therapeutic Use
Suicide Attempt
Assault
Undetermined

ICD-10


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Accidental
(unintentional)
Intentional Self-Harm
Assault
Undetermined
Adverse Effect
Underdosing
Index of External Causes

ICD-9

Under Alphabetic Index


Cause of injury
Adverse effects

ICD-10

Alphabetic by main
term indicating the
event
Tabular List of Diseases
and Injuries

ICD-9

17 chapters


Based on diseases
2 Supplementary
Classification

ICD-10

21 chapters

Based on body system
or nature of injury and
disease
Chapter Comparison
Chapter
ICD-9 CM
ICD-10 CM
1
Infectious and Parasitic
Diseases
Certain Infectious and
Parasitic Diseases
2
Neoplasms
Malignant Neoplasms
3
Endocrine, Nutritional and
Metabolic Diseases, and
Immunity Disorders
Disease of the Blood and
Blood-Forming Organs and
certain Disorders involving
Immune Mechanism
4
Disease of the Blood and
Blood-Forming Organs
Endocrine, Nutritional and
Metabolic Diseases
Chapter Comparison
Chapter
ICD-9 CM
ICD-10 CM
5
Mental Disorders
Mental and Behavioral
Disorders
6
Diseases of the Nervous
System and Sense Organs
Diseases of the Nervous
System
7
Diseases of the Circulatory
System
Diseases of the Eye and
Adnexa
8
Diseases of the Respiratory Diseases of the Ear and
System
Mastoid Process
Chapter Comparison
Chapter
ICD-9 CM
ICD-10 CM
9
Diseases of Digestive
System
Diseases of the Circulatory
System
10
Diseases of the
Genitourinary System
Diseases of the Respiratory
11
Complications of
Pregnancy, Childbirth, and
the Puerperium
Diseases of the Digestive
System
12
Diseases of the Skin and
Subcutaneous Tissue
Diseases of the Skin and
Subcutaneous Tissue
Chapter Comparison
Chapter
ICD-9 CM
ICD-10 CM
13
Diseases of the
Musculoskeletal System and
Connective Tissue
Diseases of the
Musculoskeletal System
and Connective Tissue
14
Congenital Anomalies
Diseases of the
Genitourinary System
15
Certain Conditions
Originating in the Perinatal
Period
Pregnancy, Childbirth and
the Puerperium
Chapter Comparison
ICD-9 CM
Chapter
16
17
18
ICD-10 CM
Symptoms, Signs and
Ill-Defined Conditions
Certain Conditions Originating
in the Newborn (Perinatal)
Period
Injury and Poisoning
Congenital Malformations,
Deformations and
Chromosomal Abnormalities
N/A
Symptoms, Signs and Abnormal
Clinical and Laboratory
Findings, Not Elsewhere
Classified
Chapter Comparison
ICD-9 CM
Chapter
ICD-10 CM
19
N/A
Injury, Poisoning and Certain
Other Consequences of External
Causes
20
N/A
External Causes of Morbidity
N/A
Factors Influencing Health
Status and Contact with Health
Services
21
Chapter Comparison
Chapter
Supplementary
Classification
Supplementary
Classification
ICD-9 CM
ICD-10 CM
Classification of Factors
Influencing Health Status
and Contact with Health
Services (V Codes)
N/A
Classification of External
Cause of Injury and
Poisoning (E Codes)
N/A
ICD-10-CM Code Examples



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
F03
L60.0
J09.12
M71.061
T21.31xa
Unspecified dementia
Ingrowing nail
Influenza due to identified novel
H1N1 influenza virus with other
respiratory manifestations
Abscess of bursa, right knee
Burn of third degree of chest
wall
ICD-10-CM Terminology
and New Feature

Laterality




Right = character 1
Left = character 2
Bilateral = character 3
Unspecified = character 0 or 9
ICD-10-CM Terminology
and New Feature

Laterality Examples

M54.31 – Sciatica, right side
ICD-10-CM Terminology
and New Feature

Combination codes



Diagnosis with associated sign or symptom
Diagnosis with associated complication
Diagnosis with cause
ICD-10-CM Terminology
and New Feature

Combination code example

Conditions with symptoms and manifestations

K27.2 – Acute peptic ulcer, site unspecified, with
both hemorrhage and perforation
ICD-10-CM Terminology
and New Feature

Combination code example

Poisoning and external cause

T51.0x2 – Toxic effect of ethanol, intentional, selfharm
ICD-10-CM New Features

Obstetric codes identify trimester




1 = 1st trimester < 14 weeks, 0 days
2 = 2nd trimester 14 weeks, 0 days to < 28
weeks, 0 days
3 = 3rd trimester 28 weeks, 0 days to delivery
0 or 9 = unspecified
Obstetric Codes

Ex: O26.02

Excessive weight gain in pregnancy, second
trimester
ICD-10-CM Excluded
Indications

Codes that should not be reported
together

Separately identifiable conditions


Excluded condition not part of reported
condition
Can have both condition at same time
Example 1

E11 – Type 2 diabetes

(Excludes1: Gestational diabetes (O24.4-); type 1
diabetes (E10.-)
Example 2

I10 – Essential (primary) Hypertension
Includes: High blood pressure
hypertension (arterial) (benigh)
(essential) (malignant) (primary)
(systemic).

(Excludes 2: Essential (primary)
hypertension involving vessels of brain (I60I69); Essential (Primary) hypertension
involving vessels of eye (H35.0)
ICD-10-CM Includes Clinical
Concepts
Underdosing
 Blood type
 Blood alcohol level
 Encounter type
 Indication of healing

ICD-10-CM
Expanded Codes

Significant expansion of codes



Diabetes
Substance abuse
Postoperative complications

Distinction made between intraoperative complication
and postprocedural disorders
Diabetes
Increase from 40 to 122 codes
 Example


E08.321 – Diabetes mellitus due to underlying
condition with mild nonproliferative diabetic
retinopathy without macular edema
ICD -10 Terminology

Granularity


Level of hierarchy
Increased description information
ICD -10 Terminology

Morbidity


Rate of disease in population
Mortality

Rate of death in population
ICD -10 Terminology

Principal or First-listed Diagnosis

Primary reason for encounter

Inpatient setting



First code on medical record
Principal diagnosis
Other health care settings

First-listed code
ICD -10 Terminology

Rubric


Group of similar conditions
Three character category or four character
subcategory
Steps To Code Correctly
Identify diagnosis or reason for encounter
 Locate in Alphabetic Index
 Verify in Tabular List
 Read and interpret notes

Steps To Code Correctly
Choose tentative code
 Find highest level of specificity
 Consult prompts
 Assign a code

ICD 10 PCS
ICD-10 Part 2

ICD-10-PCS for inpatient procedure
coding



All U.S. Inpatient hospital settings only
7 alpha-numeric digits
72,589 ICD-10-PCS
 Increased from 3,824 ICD-9-CM
procedure codes
Facility Claims
Compliance A Must
No delays or grace period
 ICD-9-CM for dates of discharge <
October 1, 2014
 ICD-10 for dates of discharge ≥ October
1, 2014
 ICD-10-PCS for dates of discharge ≥
October 1, 2014

Structure Differences
Codes are longer
 Greater clinical detail and specificity
 Updated terminology and classifications

ICD-10-PCS Structure
7 digits
 Each digit is either alpha or numeric




Alpha digits are not case sensitive
Letters O and I are not used to avoid confusion
with numbers 0 and 1
Each character has a
value/meaning/option
ICD-10-PCS
Code Examples
0FB03ZX – Excision of liver, percutaneous
approach, diagnostic; and
 0DQ10ZZ – Repair upper esophagus, open
approach.

ICD-10-PCS Structure

First character specifies the section or
type of procedure





0
1
2
3
4
=
=
=
=
=
Medical and surgical
Obstetrics
Placement
Administration
Measurement and monitoring
ICD-10-PCS Structure

First character continued





5 = Extracorporeal Assistance and
Performance
6 = Extracorporeal Therapies
7 = Osteopathic
8 = Other Procedures
9 = Chiropractic
ICD-10-PCS Structure

First character continued






B = Imaging
C = Nuclear Medicine
D = Radiation Oncology
F = Physical Rehabilitation and Diagnostic
Audiology
G = Mental Health
H = Substance Abuse Treatment
Medical and Surgical
First Character = “0”
Character
Meaning
1
Section
2
Body System
3
Root Operation
4
Body Part
5
Approach
6
Device
7
Qualifier
Chiropractic
First Character = “9”
Character
Meaning
1
Section
2
Anatomical Region
3
Root Operation
4
Body Region
5
Approach
6
Method
7
Qualifier
Radiation Oncology
First Character = “D”
Character
Meaning
1
Section
2
Body System
3
Root Type
4
Body Part
5
Modality Qualifier
6
Isotope
7
Qualifier
Mental Health
First Character = “G”
Character
Meaning
1
Section
2
Body System
3
Root Type
4
Type Qualifier
5
Qualifier
6
Qualifier
7
Qualifier
ICD-10-PCS Structure

Second through seventh characters




Same meanings within a section
Different meanings per section
Third character = general type of procedure
performed
See chart in workbook
Parts of ICD-10-PCS

Index


Tables


Alphabetic lookup
Different organization than ICD-9
List of codes

Listing of unique procedure codes
ICD-10-PCS Table Example
0 Medical and Surgical
2 Heart and Great Vessels
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
2 = Coronary Arteries,
Three Sites
3 = Coronary Arteries,
Four or More Sites
Qualifier
4 = Drug=eluting
Intraluminal Device
0 = Coronary Artery, One
site
1 = Coronary Arteries, Two
Sites
Device
0 = Open
D = Intraluminal Device
3 = Percutaneous
T = Radioactive
Intraluminal Device
4 = Percutaneous
Endoscopic
6 = Bifurcation
Z = No Device
Z = No Qualifier
List of Codes - Example

Code descriptions for dilation of one
coronary artery (0270)



027004Z Dilation of Coronary Artery, One Site with
Drug-eluting Intraluminal Device, Open Approach
02700DZ Dilation of Coronary Artery, One Site with
Intraluminal Device, Open Approach
02700TZ Dilation of Coronary Artery, One Site with
Radioactive Intraluminal Device,
ICD-10-PCS Character
Meanings

http://www.cms.gov/ICD10/Downloads/pc
s_final_report2010.pdf
General Equivalence Mappings
(GEMs)
Proper Coding
GEMs are not a substitute
 Select codes base on



Patient’s encounter
Medical record documentation
GEMs As A Tool

Forward mapping


Backward mapping


ICD-9 to ICD-10-CM and PCS
ICD-10-CM or PCS to ICD-9
Convert databases such as

Track quality, record morbidity/mortality,
calculate reimbursement
GEMs

All ICD-10- CM codes


All ICD-9-CM diagnosis codes


ICD-9-CM to ICD-10-CM GEM
All ICD-10-PCS codes


ICD-10-CM to ICD-9-CM GEM
ICD-10-PCS to ICD-9-CM GEM
All ICD-9-CM procedure codes

ICD-9-CM to ICD-10-PCS GEM
Three Steps To Use GEMs

Extract


Analyze


Select all rows containing code
Note and understand flags on code
Refine

Select rows that meet applied mapping
requirements
GEM Resources

http://www.cms.gov/ICD10/12_2010_ICD
_10_CM.asp#TopOfPage

http://www.cms.gov/ICD10/13_2010_ICD
10PCS.asp#TopOfPage
GEM Details

One ICD-9-CM diagnosis code represented
by multiple ICD-10-CMs

82002 represented by





S72031A
S72031G
S72032A
S72032G
Other codes from GEMs
GEM Details

One ICD-10-CM diagnosis code
represented by multiple ICD-9-CMs

E11341 represented by



25050
36206
36207
GEM Details

Some ICD-10-CM have no ICD-9-CMs






T500x6A
T501x6A
T502x6A
T503x6A
T504x6A
Others found in GEMs
GEM Details

One ICD-9-CM procedure code captured
by multiple ICD-10-PCSs

8659 captured by





JQ10ZZ
JQ13ZZ
JQ40ZZ
JQ43ZZ
Others found in GEMs
GEM Formatting

Three columns



ICD-10-CM Source system code is on the left
side
ICD-9-CM Target system code is in the middle
Flags are on the right
GEM Mapping Example
ICD-10 Source
Code
ICD-9 Target
Code
Flags
T1500xA
9300
10111
T1500xA
E914
10112
T1500xD
9300
10111
T1500xD
E914
10112
T1500xS
9085
10000
GEM Mapping Example
T1500xA
Foreign body in
cornea, unspecified eye, initial
encounter
T1500xD
Foreign body in
cornea, unspecified eye,
subsequent encounter
T1500xS
Foreign body in
cornea, unspecified eye,
sequela
9300
Corneal foreign body
E914 Foreign body accidentally
entering eye and adnexa
9300
Corneal foreign body
E914 Foreign body accidentally
entering eye and adnexa
9085
Late effect of foreign body
in orifice
GEM Flags
5 digit code (Ex: 10111)
 First position


1 = translation is approximate match



T1500xA
T1500xA
9300
E914
10111
10112
0 = translation is identical match

41411
12542
00000
GEM Flags

Second position

1 = no plausible translation



No Description Found (NODX)
0 = at least one plausible translation
Examples



T500x6A
T500x6A
T500x6S
NODX
NODX
NODX
11000
11000
11000
GEM Flags

Third position


1 = code maps to more than one code
0 = code maps to single code
T1500xA
9300
10111
T1500xA
E914
10112
T1500xD
9300
10111
T1500xD
E914
10112
T1500xS
9085
10000
Reasons For
No One-To-One Match
ICD-10 New concepts not in ICD-9-CM
 No matching code exist in GEMs
 Multiple ICD-9-CM codes exist for a single
ICD-10 code
 Multiple ICD-10 codes exist for a single
ICD-9-CM code

GEM Updates
Posted in January
 Updated annually
 Access updated GEMs for diagnoses



http://www.cms.gov/ICD10/12_2010_ICD_10
_CM.asp
Access updated GEMs for procedures

http://www.cms.gov/ICD10/13_2010_ICD10P
CS.asp
Reimbursement Mappings
Reimbursement Mappings
CMS developed
 One-to-one reimbursement crosswalk





Temporary mechanism
Codes submitted ≥ October 1, 2014
ICD-10-CM/PSC to reimbursement equivalent
ICD-9-CM codes
Utilized GEMs
Reimbursement Mappings

Two crosswalks

ICD-10-CM to ICD-9-CM diagnosis code(s)


Ex: K50012 crosswalks to 555.0 and 560.9
ICD-10-PCS to ICD-9-CM procedure code

Ex: 037544Z crosswalks to DX 395.0 and Procedure
and Intervention codes 00.40, 00.55 and 00.45
Reimbursement Mapping
Format
Position
Length
Contents
1
8
I-10 code
9
1
Number of I-9 codes this I-10 code maps to.
Values 1 through 5.
10
6
First I-9 code
16
6
Second I-9 code
22
6
Third I-9 code
28
6
Fourth I-9 code
34
6
Fifth I-9 code
Reimbursement Mapping
Resource

ICD-10-CM-PCS to ICD-9 Reimbursement
Mapping Documentation and User Guide

http://www.cms.gov/ICD10/08a_Payer_Resour
ces.asp#TopOfPage.
Reimbursement Mapping Example
00160K6 - Bypass Cerebral Ventricle to
Peritoneal Cavity with Nonautologous
Tissue Substitute, Open Approach
Reimbursement Mapping
Example
03754DZ Dilation of Right Axillary Artery
with Intraluminal Device, Percutaneous
Endoscopic Approach
Converting MS-DRGs to ICD-10CM and ICD-10-PCS
CMS Project
 Convert ICD-9-CM Medicare Severity –
Diagnosis Related Groups (MS-DRGs),
version 26.0, to ICD-10-CM and ICD-10PCS (ICD-10-CM/PCS) codes
 Information available at:


http://www.cms.gov/ICD10/17_ICD10_MS_DR
G_Conversion_Project.asp#TopOfPage.
Preparation Steps
Other Countries Experiences
Problems with implementation

1.
2.
3.
Clinical documentation
IT: space, time and money
Productivity
ICD-10
Are You Ready To S.W.A.P.
S = Schedule Training
 W = Work With Staff
 A = Adjust Work Processes
 P = Prepare Now

Basic Steps to Prepare for
Version 5010/ICD 10

Identify system and work processes that use
ICD-9


Where are ICD-9 codes used
Identify potential changes
Basic Steps to Prepare for
Version 5010/ICD 10

Assess staff training needs



Find training opportunities
Train the trainer
Train on



Codes
Anatomy, physiology, pathophysiology,
pharmacology
Medical terminology
Test Your
Knowledge of Anatomy






Ulna
Proximal phalanges
Vomer
Basal Ganglia
Thymus
Tibial nerve
2
5
6
1
4
ICD-10
3
Basic Steps to Prepare for
Version 5010/ICD 10

Contact practice management system
vendor





Readiness for 5010
Needed upgrades to hardware/software
Costs
Implementation dates
Training and customer support
Basic Steps to Prepare for
Version 5010/ICD 10

Contact clearinghouses, billing services



About 5010 and ICD-10 compliance
Timeframe for transitions
Contact payers


ICD-10 affects on contracts, payment
schedules, or reimbursement
Timeframe for transitions
Basic Steps to Prepare for
Version 5010/ICD 10

Budget time and costs

ICD-10 implementation




System changes
Resource materials
Training
Money in case of implementation problems
Basic Steps to Prepare for
Version 5010/ICD 10

Conduct testing


Payers and clearinghouses
Allow time for approval
New Draft
1500 Claim Form
New Draft
1500 Claim Form
Room for 12
ICD-10 CM Codes
New CMS Guidelines
Beginning July 1, 2012
 Medicare contractors shall not accept new
direct submitter using HIPAA Version
4010A1
 All new direct submitters will be required
to enroll using HIPAA Version 5010
transactions

Resources
American Medical Association
 www.ama-assn.org/go/5010





Fact Sheets
5010 Checklist
Project Plan Template – Helping Practices
Prepare for the New HIPAA Standards
7 Steps
Resources

The Centers for Medicare & Medicaid
Services (CMS) Web site


www.cms.gov/ICD10
CMS sponsored calls

http://www.cms.gov/ICD10/02c_CMS_Sponsor
ed_Calls.asp#TopOfPage
Resources

American Academy of Professional Coders
(AAPC)




Countdown to implementation
Training
Monthly articles
Code translator
Resources

GEMs and User’s Guides


http://www.cms.gov/ICD1013_2010_ICD10PC
S.asp
Workgroup for Electronic Data
Interchange (WEDI)

http://www.wedi.org
Resources

Health Information and Management
Systems Society (HIMSS)


http://www.himss.org/icd10
American Health Information Management
Association (AHIMA)

http://www.ahima.org/ICD10/
Questions?
Complete Evaluations