Transcript Title

Beginning the Transition to
ICD-10-CM/PCS
Sue Bowman, RHIA, CCS
Director, Coding Policy and Compliance
American Health Information Management Association
© 2009
Migrating to ICD-10 -- History
• ICDA-8
ICD-9-CM – 1979
• Prospective Payment – 1982-1983
• ICD-9
ICD-10 – WHO 1990s
• US Change – or lack thereof
• US Readiness
• HIPAA and HIPAA transactions
• Hearings – studies -- hearings
• 2008 Proposed Rules
• Today
2
© 2009
Migrating to ICD-10 -- Code Sets
• ICD-9-CM diagnosis coding system
–US clinical modification of WHO’s ICD-9
–ICD-9-CM diagnosis codes are used by all
providers
–Maintained by National Center for Health
Statistics
• ICD-9-CM procedure coding system
–developed by HCFA (now CMS)
–ICD-9-CM procedure codes are used by
hospitals for inpatient reporting
–Maintained by CMS
3
© 2009
Migrating to ICD-10 -- Code Sets
• ICD-10
– Diagnosis coding system developed by WHO as a
replacement for ICD-9
– Implemented for mortality coding in the US in
1999
• ICD-10-CM
– US clinical modification of the WHO’s ICD-10
– Diagnosis coding system (no procedure codes)
• ICD-10-PCS
– Developed by CMS to replace the ICD-9-CM
procedure coding system
4
© 2009
ICD-10-CM/PCS Final Regulation
• Compliance date of October 1, 2013 applies to:
– All HIPAA covered entities
– All claims received for encounters and discharges
occurring on or after this date
• It is in the best interest of non-covered
entities to transition to ICD-10-CM/PCS on
10/1/2013 as well
– ICD-9-CM will no longer be maintained
– Increased detail in ICD-10-CM/PCS is of significant
value to non-covered entities
5
© 2009
ICD-10-CM/PCS Final Regulation
• ICD-10-CM will be used in all healthcare
settings
• ICD-10-PCS will be used for facility reporting
of hospital inpatient services
• CPT® and HCPCS Level II will continue to be
used for:
– Reporting physician and other professional
services
– Procedures performed in physician practices,
hospital outpatient departments, and other
outpatient settings
6
© 2009
Changes: ICD-10-CM Structure
ICD-9-CM
ICD-10-CM
• 3-5 characters
• First character is
numeric or alpha
(E or V)
• Characters 2-5 are
numeric
• Always at least 3
characters
• Use of decimal after 3
characters
• Alpha characters are not
case-sensitive
•
•
•
•
7
•
•
•
•
3-7 characters
Character 1 is alpha
Character 2 is numeric
Characters 3-7 are alpha
or numeric
All letters except U
Always at least 3
characters
Use of decimal after 3
characters
Alpha characters are not
case-sensitive
© 2009
Changes – Classifications
ICD-9-CM Structured Format
Numeric or Alpha
(E or V)
V
X
E
4
5
Numeric
X
1
Category
X
4
.
X
0
X
0
Etiology, anatomic
site, manifestation
3 – 5 Characters
8
© 2009
Changes – Classifications
ICD-10-CM Structured Format
Alpha
(Except U)
3 - 7 Numeric or Alpha
Numeric
M
X X
A
S
3 X
2
Category
.
Additional
Characters
X
0 X
1 X
0
A
X
Etiology, anatomic
site, severity
Added code extensions (7th
character) for obstetrics,
injuries, and external
causes of injury
3 – 7 Characters
9
© 2009
How Does ICD-10-CM Differ From ICD-9-CM?
• Alphanumeric (alpha characters are not casesensitive)
• Addition of a 6th character
• Added 7th character for obstetrics, injuries, and
external causes
• Addition of dummy place holder (“x”)
• Certain diseases have been reclassified to reflect
current medical knowledge
• Specificity and detail have been significantly
expanded
– non-specific codes are still available when detailed
documentation is unavailable
10
© 2009
ICD-9-CM v ICD-10-CM Sample Codes
ICD-9-CM
ICD-10-CM
• 707.05 Pressure ulcer buttock
• 707.22 Pressure ulcer stage II
• 707.24 Pressure ulcer stage IV
• L89.111 Decubitus ulcer of right
buttock limited to breakdown of the
skin
• L89.124 Decubitus ulcer of left
buttock with necrosis of bone
OR
• L89.121 Decubitus ulcer of left
buttock limited to breakdown of the
skin
• L89.114 Decubitus ulcer of right
buttock with necrosis of bone
11
© 2009
ICD-9-CM vs. ICD-10-CM Sample
Codes
ICD-9-CM
• 996.09 Other mechanical
complication of cardiac device,
implant, and graft
• 909.3 Late effect of
complications of surgical and
medical care
ICD-10-CM
• T82.223A Leakage of biological
heart valve graft, initial encounter
OR
• T82.223D Leakage of biological
heart valve graft, subsequent
encounter
• T82.223S Leakage of biological
heart valve graft, sequela
12
© 2009
ICD-9-CM vs. ICD-10-CM Sample
Codes
ICD-9-CM
ICD-10-CM
• 414.01 Coronary
atherosclerosis of native
coronary artery
AND
• 411.1 Intermediate coronary
syndrome
• I25.110 Atherosclerotic heart
disease of native coronary artery
with unstable angina pectoris
13
© 2009
ICD-9-CM vs. ICD-10-CM Comparison
ICD-9-CM Mechanical Complication of Other Vascular Device,
Implant and Graft: one code (996.1)
ICD-10-CM Mechanical Complication of Other Vascular Grafts : 156
codes
Type
Device
Episode of Care
Breakdown
Graft, Aorta
Initial encounter
Leakage
Graft, Carotid artery
Subsequent encounter
Displacement
Graft, Femoral artery
Sequela (late effect of injury)
Other (e.g., Obstruction)
Dialysis catheter
Arteriovenous fistula
Arteriovenous shunt
Counterpulsation balloon
Infusion catheter
Umbrella device
14
© 2009
Changes Go Beyond the Codes ….
Myocardial
Infarction
Abortion vs.
Fetal Death
Obstetrics
15
• ICD-9-CM: 8 weeks, episode
of care
• ICD-10-CM: 4 weeks, no
episode of care
• ICD-9-CM: 22 weeks
• ICD-10-CM: 20 weeks
• ICD-9-CM: Episode of care
• ICD-10-CM: Trimester
© 2009
Changes: ICD-10-PCS – Structure
16
ICD-9-CM
ICD-10-PCS
• ICD-9-CM has 3-4
characters
• All characters are
numeric
• All codes have at least 3
characters
• ICD-10-PCS has 7
characters
• Each can be either alpha
or numeric
• Numbers 0-9; letters AH, J-N, P-Z
• Alpha characters are not
case-sensitive
• Each code must have 7
characters
© 2009
Change: ICD-10-PCS – Structured Format
ICD-9-CM
X
1
X
2
.
X
4
X
3
ICD-10-PCS
X
3 D
1
0
X
E
0 H
X
B
0 X
F
0 X
5
7 X
8
Z
0 X
3
Z
4
17
© 2009
Change: ICD-10-PCS – Structured Format
Characters (Medical/Surgical)
1
2
4
Root
Operation
Section
Body
System
18
3
5
6
Approach
Body Part
7
Qualifier
Device
© 2009
ICD-9-CM Suture of Artery: One code 39.31
ICD-10-PCS Repair of Artery: 195 codes
Approach
Body Part
0-Open
Abdominal Aorta
3-Percutaneous
Common Carotid Artery
4-Percutaneous Endoscopic
Radial Artery
…
…
…
…
…
19
65 Different Arteries
© 2009
ICD-9-CM Suture of Artery: one code (39.31), MSDRGs 252-254 (MDC 5)
ICD-10-PCS Repair of Artery: 195 codes, MS-DRGs
252-254, 237-238 (MDC 5)
Approach
Body Part
0-Open
Abdominal Aorta
3-Percutaneous
Common Carotid Artery
4-Percutaneous Endoscopic
Radial Artery
…
…
…
…
…
65 Different Arteries
20
© 2009
Implications of Transition
• Scope and complexity are significant
• More widespread use of coded data than when
the US last transitioned (to ICD-9-CM)
• Data trending challenges are likely
• Potential problems during initial transition
period (e.g., increased payment delays, high
coding error rates) can be mitigated with
proper advance preparation
21
© 2009
Implications of Transition
• Transition will permit:
– More accurate payment, improved patient safety, and
better patient outcomes due to higher-quality data
– Improved clinical documentation and coding
accuracy
– Improved administrative efficiencies and lowered
administrative costs
– Better detail to utilize standard electronic health
records and population health reporting including
facility comparisons
– Decrease in compliance risks
– Development of more sophisticated computerassisted coding technologies that will revolutionize
the coding process
22
© 2009
Implications of Transition – Who?
• Providers
–
–
–
–
Hospitals
Physicians
Outpatient facilities
Post-acute providers
(home health agencies,
skilled nursing facilities,
etc.)
• Health plans or payers
– Third party administrators
– Employers
• Others
–
–
–
–
–
Laboratories
Free standing ancillaries
Researchers
Public health agencies et al.
Data collection
agencies/organizations
(registries)
– Vendors
– Clearinghouses
– Business associates and
partners
• Patients
23
© 2009
Implications: Mapping Between Old
and New Systems
• General equivalence maps (GEMs) between ICD9-CM and ICD-10-CM/PCS have been developed
• Maps should NOT be used for coding medical
records
ICD-9-CM
ICD-9-CM
GEMs
24
GEMs Maps
GEMs Maps
=
ICD-10-PCS
via CMS web site
ICD-10-CM via CMS /NCHS web sites
Crosswalks
© 2009
Implications: Mapping Between Old
and New Systems
• GEMs were developed as a general purpose
translation tool for use by all providers, payers,
and data users
– Free of charge and in public domain
• GEMs are designed to aid in converting
applications and systems from ICD-9-CM to
ICD-10-CM/PCS
• Every conversion project won’t necessarily
need to use the GEMs
• GEMs were designed as a starting point – they
are the foundation upon which applied
mappings can be built
25
© 2009
Implications: Mapping Between Old
and New Systems
• Reimbursement map added to CMS web
site in 2009
–Intended for use by payers
–Temporary mechanism
–Allows claims processing by legacy
systems
26
© 2009
Implementation Phases
• Phase 1 – Impact Assessment
– Assessing impact of the change to ICD-10CM/PCS
code sets and identifying key tasks and objectives
– Conducting gap analysis
• Phase 2 – Preparing for Implementation
– Implementation of required information systems
changes
– Follow up assessment of documentation practices
– Increasing education of the organization’s coding
professionals
– Items carried over from Phase 1
27
© 2009
Implementation Phases
• Phase 3 – Go-Live Preparation
–
–
–
–
–
Finalization of system changes
Testing of claims transactions with payers
Intensive education of coding professionals
Monitoring of coding and reimbursement accuracy
Items carried over from Phase 2
• Phase 4 – Post-implementation
– Assessment of impact on operations, data quality,
reimbursement, coding productivity
– Additional education as needed
28
© 2009
Impact of Coding System Change:
7 Steps
1. Develop Strategy
2. Communicate
3. Assess Readiness
4. Inventory Process/ System Impact
5. Plan Training
6. Documentation Improvement
7. Develop Budget
29
© 2009
Impact Assessment: Develop Strategy
• Develop organizational
implementation strategy
–Establish a multi-disciplinary
implementation planning team and
designate leader
–Develop internal timeline, including
resources required
–Develop organization-wide
implementation plan
30
© 2009
Impact Assessment: Communication
• Communication management
strategies
–Minimize “fear of change” and fear from
rumors
–Establish on-going communications with
all affected groups
–Ensure external communication liaisons
are appointed and recognized
31
© 2009
Impact Assessment: Communication
• Build Awareness
– Orient key personnel
– Basic familiarity with structure, organization,
and unique features of new systems (on-going)
– Provide understanding of how the new
classifications fits into internal and external
transitions including electronic health records,
health information exchange, and health reform
– Provide an understanding of how your strategy
fits with the environment at your institution
32
© 2009
Impact Assessment: Assess Readiness
• Assess organizational readiness for HIPAA,
ICD, and other system, processes and data
changes – effects on:
– information systems using 4010/4010a and ICD-9CM (Where is ICD-9-CM?)
– documentation process and work flow
– data availability and use (Now v future?)
– staff: medical, clinical, and administrative
– current plans and acquisitions
– organizational and vendor capacities
33
© 2009
Impact Assessment: Inventory
• Assess what processes or systems will be
impacted:
– HIM/Coding Systems
– DRG grouper
– Encoding software
– Abstracting systems
– Compliance software
– Claims or billing systems
– Other systems
– Future systems (on order/considered)
34
© 2009
Implementation – Impact Assessment:
Inventory
Billing/ Financial
•
•
•
•
•
•
•
•
Reporting
DRG grouper
Conversion of other payment methodologies
National and local coverage determinations
System logic and edits
Billing systems
Financial systems
Claim submission systems
Compliance checking systems
• Provider profiling
• Quality measurement
• Utilization
management
• Disease management
registries
• Other registries
• State reporting systems
• Fraud management
• Aggregate data
reporting
• Clinical systems
• Patient assessment
data sets (e.g., MDS,
PAI, OASIS)
• Managed care
reporting system
(HEDIS)
HIM
•
•
•
•
•
DRG grouper
Encoding software
Abstract systems
Compliance software
Medical record abstracting
Clinical Systems
Registration
•
•
•
•
Registration and scheduling systems
Advance Beneficiary software
Performance measurement systems
Medical necessity edits
Support Systems
•
•
•
•
•
•
•
•
•
•
•
•
Clinical protocols
Test ordering systems
Clinical reminder systems
Medical necessity software
Disease management systems
Decision support systems
Clinical systems
Pharmacy systems
Case mix systems
Utilization management
Quality management
Case Management
© 2009
Impact Assessment: Inventory
• Orient IS/IT personnel on specifications of
code sets
• Perform comprehensive systems audit
– Inventory databases and systems
– Screens and input
– Map electronic data flow to inventory all reports
containing ICD-9-CM
– Detailed analysis of system changes needed
• Determine testing that will be needed
– Vendors
– Trading partners
36
© 2009
Impact Assessment: Inventory
Determine required software changes
• Field size expansion
• Alphanumeric
composition
• Use of decimals
• Redefinition of code
values
• Longer code
descriptions
37
• Edit and logic
changes
• Modification of table
structures
• Expansion of flat
files containing
diagnosis codes
• Systems interfaces
© 2009
Impact Assessment: Inventory
• Determine length of time for legacy and
new coding systems
• Determine which reports require
modification
• Forms redesign
• Budgetary implications –
hardware/software
• Vendor readiness and timelines
• Build flexibility for future upgrades
38
© 2009
Impact Assessment: Plan Training
• Assess educational needs and develop
budget plan
– Who will need education?
– What type and level of education will they need?
– How will the education be delivered? Timing of
education for what groups?
– Who will need early education for
implementation and training tasks?
• Multiple categories of users of coded data
will require varying levels of training
• All coders will not require the same level of
training
39
© 2009
Impact Assessment: Plan Training – Who?
•
Coders
•
Clinical department managers
•
Other HIM
•
Ancillary departments
•
Clinicians
•
Data analysts
•
Senior management
•
Researchers
•
Information systems
•
Epidemiologists
•
Quality management
•
Software vendors
•
Utilization management
•
Performance improvement
•
Accounting
•
Compliance
•
Business Office
•
Data quality management
•
Auditors and consultants
•
Data security
•
Patient access and registration
•
Data analysts
40
© 2009
Impact Assessment: Documentation
Improvement
• Conduct gap analysis of coding and
documentation practices
– Assess adequacy of staff knowledge
• Measure coding professionals’ baseline knowledge of
anatomy, physiology, pharmacology, and medical
terminology
• Identify areas of weakness and provide targeted education
if necessary
– Assess adequacy of medical record documentation
to support level of detail in new coding systems –
implement documentation improvement strategies
as needed
41
© 2009
Impact Assessment: Develop Budget
• Develop budget
– Departmental budget responsible for costs
• Systems, hardware, software, education
– Increased staffing?
• Impact on productivity and accuracy
– Short-term (during learning curve) and long-term
– More sophisticated computer-assisted coding technologies
and advances in mapping from clinical terminologies will
improve productivity and accuracy
• Consulting services
– Backlogs
– Monitoring coding accuracy
– Other support
– Allocate costs over multiple years
42
© 2009
“Lessons Learned” from Other
Countries
• Starting early is key to success
• Importance of planning and preparation
• Six-month learning curve
• Vendor readiness is extremely important
• Communication is critical
• Targeted significant ICD-9/ICD-10
comparability issues
43
© 2009
Expectations: Bottom Line on
Preparation (Goals)
• Maintain coding productivity
• Maintain coding accuracy
• Reduce claims rejections and denials
• Maintain account receivables
• Proper claims payment
• Reduce risk of compliance issues
• Decisions based on improved data
44
© 2009
Expectations: ICD-10-CM and ICD-10PCS in 2013
• Compliance deadlines were set per
public comments
• Federal government expects compliance
deadlines to be met – no extensions
• Initial payments will not reflect new
codes
• Codes will likely be “frozen” for some
period of time
• Success will depend on starting early!
45
© 2009
CMS Resources
• ICD-10 General Information
http://www.cms.hhs.gov/ICD10
• ICD-10 Educational Resources (fact sheets)
http://www.cms.hhs.gov/ICD10/05_Educational_Resources.as
p
• ICD-10-PCS files, information, and General
Equivalence Mappings (GEM) between ICD-10-PCS
and ICD-9-CM
http://www.cms.hhs.gov/ICD10/01m_2009_ICD10PCS.asp
• 2009 and 2008 ICD-10 CMS Sponsored Calls
http://www.cms.hhs.gov/ICD10/06a_2009_CMS_Sponsored_C
alls.asp
http://www.cms.hhs.gov/ICD10/07_Sponsored_Calls.asp
46
© 2009
CDC Resources
• General ICD-10 information
http://www.cdc.gov/nchs/about/major/dvs/icd10
des.htm
• ICD-10-CM files, information, and
General Equivalence Mappings
(GEM) between ICD-10-CM and ICD9-CM
http://www.cdc.gov/nchs/about/otheract/icd9/icd
10cm.htm
47
© 2009
AHIMA Resources
http://www.ahima.org/icd10
•
•
•
•
•
•
•
•
Practical guidance
Articles
Online courses
Proficiency assessments
Books
Webinars/Conferences
E-newsletter
Academy for ICD-10-CM/PCS
Trainers
• Frequently Asked Questions
―Submit questions for list
[email protected]
48
• New resources
– Practice briefs
– Implementing ICD-10CM/PCS for Hospitals
(book)
– Pocket Guide of ICD-10CM and ICD-10-PCS
(available by the end of
2009)
© 2009
Questions
Sue Bowman, RHIA, CCS
Director, Coding Policy and Compliance
American Health Information Management Association
233 North Michigan Avenue
Chicago, IL 60601
Telephone: (312) 233-1115
E-Mail: [email protected]
© 2009