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Countdown To ICD-10 ERICA LEEDS MIS, RHIA, CCS, CCS-P PROJECT LEAD ICD-10 INDIANA UNIVERSITY HEALTH Conflicts of Interest Disclosures NONE ICD-10 Implementation Date IP Services ~ Discharges on/after OP Services ~ Clinic Date of Service Professional Services ~ Clinic Date of Service October 1, 201? 3 What is ICD-10? A Brand New Coding System for diagnosis and procedure codes ICD-10 was developed by the World Health Organization as the next version of medical coding (after ICD-9) to internationally categorize, track, and report clinical diagnoses and hospital procedures. ICD-10 consists of: ICD-10-CM ~ Diagnosis Coding Used in all U.S. healthcare settings ICD-10-PCS ~ Procedure Coding Used in U.S. inpatient hospital settings only Codes reported by hospitals 4 Where is ICD-10-CM? Iceland Norway Sweden Finland Denmar Poland Ireland k Germany UK Czech Republic The Netherlands Austria France Switzerland Canada United States Japan China Thailand Costa Rica Venezuela Colombia The United States is the last industrialized nation to make the transition Reference: 3M Singapore Brazil Australia Argentina New Zealand Implementation Date Comparison United Kingdom – 1995 France – 1997 Australia – 1998 Germany – 2000 Canada – 2001 USA – 201? 5 Reasons to Transition to ICD-10 ICD-9 is 30 years old ICD-9 lacks the specificity required to adequately document today’s diagnoses and procedures ICD-9 lacks the capacity for continued growth of diagnosis and procedure codes as new diagnoses are discovered and new procedures are developed • ICD-9 is running out of space & cannot accommodate for the future state of healthcare 6 What Changes from ICD-9 to ICD-10? What Changes ~ • Code Structure • Up to 7 characters • Alpha Numeric Values • Code Volume • 24,000 up to 140,000 • Specificity • Laterality • Site • Type of Encounter What Stays the Same ~ • DRGs • CPT & HCPCS • Modifiers • Reimbursement methodology – awaiting finalization • Coders can only code what provider documents ICD-9 to ICD-10 Differences Diagnosis Code Structural Change Reference: CMS ICD-10 ICD-9 X X . X X X X Etiology, anatomic site, manifestation Category X X . X X X Etiology, anatomic site, manifestation Category X Extension Procedure Code Structural Change ICD-9 X X Body System or Site . X ICD-10 X Purpose or Technique X Section X X X X X X Body Root Body Approach Device Qualifier System Operation Part 8 ICD-10-CM Chapters A00-B99 Certain infectious and parasitic diseases C00-D49 Neoplasms D50-D89 Diseases of the Blood and blood-forming organs and certain disorders involving the immune mechanism E00-E90 Endocrine, nutritional and metabolic disorders F01-F99 Mental and behavioral disorders G00-G99 Diseases of the nervous system H00-H59 Diseases of the eye and adnexa H60-H95 Diseases of the ear and mastoid process I00-I99 Diseases of the circulatory system J00-J99 Diseases of the respiratory system K00-K94 Diseases of the digestive system L00-L99 Diseases of the skin and subcutaneous tissue M00-M99 Diseases of the musculoskeletal system and connective tissue N00-N99 Diseases of the genitourinary system O00-O9A Pregnancy, childbirth and the puerperium P00-P96 Certain conditions originating in the perinatal period Q00-Q99 Congenital malformations, deformations and chromosomal abnormalities R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, NEC S00-T88 Injury, poisoning and certain other consequences of external causes V01-Y99 External causes of morbidity Z00-Z99 Factors influencing health status and contact with health services 9 Medical Terminology ICD-10-CM Update: Asthma: Osteoporosis: 10 “Age-related” replaces “senile” Diabetes mellitus: No longer coded as “intrinsic or “extrinsic” No longer coded as “controlled” or “uncontrolled” Cardiovascular: “unstable angina” replaces “Intermediate coronary syndrome” Coding Comparison 11 ICD9 Code Description ICD-10 Code 401.9 Essential hypertension, unspecified benign or malignant 259.0 Delay in sexual development & puberty, NEC E30.0 Delayed puberty 054.13 Herpetic infection of penis A60.01 Herpes viral infection of penis 339.01 Episodic cluster headache G44.011 Episodic cluster headache, intractable 873.0 Open wound of scalp, uncomplicated S01.01XA 733.95 Stress fracture of other bone M84.311 D I10 Description Essential (primary) hypertension Laceration without foreign body of scalp, initial encounter Stress fracture, right shoulder, subsequent encounter with routine healing The table above illustrates changes in the code structure from ICD-9 to ICD-10 ICD-10-CM codes may contain: 3, 4, 5, 6 or 7 characters. 7/17/2015 ICD-10-PCS Format Character 1 Character 2 Character 3 Section Body System Root Operation Sally 12 Bought Root Character 4 Character 5 Body Part Approach Beer At Character 6 Character 7 Device Qualifier Dairy Queen ICD-10-PCS Code Breakdown 86% 4% 10% 13 GEMs General Equivalency Mappings Developed to facilitate the transition from one code set to another Maps codes from ICD-9-CM to ICD-10-CM (and vice versa) GEMs are available at: http://www.cdc.gov/nchs/icd/icd10cm.htm http://www.cms.hhs.gov/ICD10 14 Pros vs Cons of GEMs Pros: Some type of matching between ICD-9 and ICD10 codes. More matches going from ICD-10 back to ICD-9. 15 Cons: Only 5% 1:to:1 match 95% is 1:to:Many ranges Need documentation to code to level of specificity Lacks clinical interpretation More Precise Coding with ICD-10 ICD-10-CM 4 codes ICD-9 1 code Barrett’s Esophagus 530.85 Barrett’s esophagus w/o dysplasia – K22.70 Barrett’s esophagus w/low grade dysplasia – K22.710 Barrett’s esophagus w/high grade dysplasia – K22.711 Barrett’s esophagus w/dysplasia unspecified – K22.719 16 More Precise Coding with ICD-10 ICD-10-PCS Angioplasty 854 codes Specifying body part, approach, and device, including 047K04Z ICD-9-CM Angioplasty 1 code (39.50) Dilation of right femoral artery with Drug-eluting intraluminal device, open approach 047K0DZ Dilation of right femoral artery with Intraluminal device, open approach 047K0ZZ Dilation of right femoral artery, open approach 047K34Z Dilation of right femoral artery with Drug-eluting intraluminal device, percutaneous approach 047K3DZ Reference: CMS (…) 17 Superbill Conversion Sample ICD-9 Orthopedics Superbill 2 pages ICD-10 Orthopedics Superbill 49 pages 18 Benefits of ICD-10 Allows for expanded data capture: 19 More Precise Coding Improved Quality Measurement Improved Analysis of Disease Patterns and Outbreaks Improved Analysis of Disease Patterns, Accidents, Outbreaks Hospital Acquired Conditions Complications from Medical Devices External Causes and Places of Occurrence What? When? Where? External Status? Public Health Tracking 20 Examples of Increased Specificity W22.02XA, “walked into lamppost, initial encounter W22.02XD, “walked into lamppost, subsequent encounter” V91.07XA, “burn due to water-skis on fire” 21 7/17/2015 Quality ~ Combo Codes More combination codes: To report condition & common symptoms/manifestations Previously (with ICD-9) type II DM with mild nonproliferative diabetic retinopathy with macular edema was reported with (3) codes: 250.50; DM with opthalmic manifestations, type II or unspecified type, not stated as uncontrolled 362.04; mild non-proliferative diabetic retinopathy 362.07; diabetic macular edema With ICD-10 only (1) code is reported: E11.321 22 Quality: AMI Acute Myocardial Infarction Timeframe of reporting “Acute” Initial MI changed from 8 to 4 wks duration This time frame change will need to be considered when comparing ICD-10 measures to the previous ICD-9 data as differences in volume/outcomes are noted Situations like these will need to be evaluated for all quality measures to determine the possibility if there could be significant difference in the composition of the measure and whether these measures are even comparable 23 Quality: New OB Time Changes New OB Time Changes: Abortion vs. fetal death 20 weeks instead of 22 Early vs. late vomiting 20 weeks instead of 22 Preterm labor < 37 completed weeks of gestation 24 Quality: Pressure Ulcers Pressure Ulcers are used for public reporting of quality measures and as a healthcare-acquired condition with payment provisions Instead of reporting (2) codes (as with ICD-9), ICD-10 reports (1) combination code to identify both the location (including laterality) and the stage/severity of the ulcer ICD-9 codes: 707.02 (pressure ulcer, upper back), 707.23 (pressure ulcer, stage III) ICD-10 code: 25 L89.123 (pressure ulcer of left upper back, stage 3 Measures evaluating stage 3 & 4 pressure ulcers will need to incorporate all ICD-10-CM’s new location codes (specific laterality – i.e., left upper back, right upper back, left lower back, left upper back) identified as stage 3 & 4 Quality: Blood Transfusions ICD-9 Procedure Coding Blood transfusions have one possible code per blood product type. Examples: 99.04 Transfusion packed cells 99.05 Transfusion Platelets 26 ICD-10 Procedure Coding Separate codes depending on vein or artery used for transfusion. No unspecified options. Examples: 30233N1 Transfusion Nonautologous Red Blood Cells into Peripheral Vein, Percutaneous Approach 30243R1 Transfusion Nonautologous Platelets into Central Vein, Perc Approach Quality: BMI Why It Is Important: 1. A BMI of less than 19 or greater than 40 is considered a significant co-morbidity which may impact MS-DRG assignment when coded on an inpatient claim. 2. Some procedures (such as gastric bypass) require a BMI code from a particular range in order to be reimbursed for services. 27 What Needs To Be Documented: A diagnosis such as obesity, morbid obesity, underweight, malnutrition, etc. must be documented by the physician when appropriate. A BMI must be documented by a physician or other qualified healthcare provider (dietician or nurse). Coders cannot calculate the BMI. Patients age 2-20 should have their BMI documented in percentiles based on growth charts from the CDC. Quality: Shock Liver A syndrome often referred to as “shock liver” occurs after cardiac arrest, a period of significant hypovolemia /hypotension, or in the setting of severe CHF. Shock liver occurs when the blood supply to the liver is impaired (i.e. necrotic) resulting in elevated transaminases. 28 In ICD-9-CM, shock liver can be coded in the encoder by typing in ‘shock’ and then selecting ‘shock liver’. The resulting code is: In ICD-10-CM, there is no option in the encoder for looking up ‘shock liver’. To find the best code for this condition, you must start from the term ‘necrosis’ and then pick ’liver’ and then ’acute or subacute’. The resulting code is: High Risk Impact Multiple Delays – lack of push for implementation. Lack of documentation to assign specific codes. Learning Curve for everyone involved. ‘Big Bang’ across all 50 United States. Transitional period [working in new ICD-10 format and still working on ICD-9 run-off]. Support, QA, feedback and re-education of inaccurate coding. [after transition] Physician Support. 29 ICD-10 Preparations Educate stakeholders on changes and impact. Review measured data definitions, code set conversions and identify high risk impact areas. Prioritize most significant measured changes. Create data set for high-risk measures. Prepare assessment report for each measure. 30 Questions ? 31