Transcript Castro County Hospital District

THA Annual Conference
February 2nd & 3rd, 2011
Presented by: Janice K Neal, RN, CCS
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On October 1, 2013, medical coding in U.S. health care
settings will change from ICD-9-CM to ICD-10. The
transition will require business and systems changes
throughout the health care industry. Everyone who is
covered by the Health Insurance Portability and
Accountability Act (HIPAA) must make the transition, not
just those who submit Medicare or Medicaid claims. The
compliance dates are firm and not subject to change. If
you are not ready, your claims will not be paid. Preparing
now can help you avoid potential reimbursement issues.
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On October 1, 2013, the Centers for Medicare &
Medicaid Services (CMS) will implement the ICD-10-CM
(diagnoses) and ICD-10-PCS (inpatient procedures),
replacing the ICD-9-CM diagnosis and procedure code
sets.
ICD-10-CM diagnoses codes will be used by all
providers in every health care setting.
ICD-10-PCS procedure codes will be used only for
hospital claims for inpatient hospital procedures.
Physician reporting and outpatient services will continue
to report CPT codes.
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The differences between the ICD-10 code sets and the ICD-9 code
sets are primarily in the overall number of codes, their organization
and structure, code composition, and level of detail. There are
approximately 70,000 ICD-10-CM codes compared to approximately
14,000 ICD-9-CM diagnosis codes, and approximately 70,000 ICD10-PCS codes compared to approximately 4,000 ICD-9-CM
procedure codes.
In addition, ICD-10 codes are longer and use more alpha
characters, which enable them to provide greater clinical detail and
specificity in describing diagnoses and procedures. Also,
terminology and disease classification have been updated to be
consistent with current clinical practice.
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Comparing ICD-9-CM and ICD-10-CM
ICD-10-CM differs from ICD-9-CM in its organization and
structure, code composition, and level of detail.
ICD-9-CM
ICD-10-CM

Consists of three to five
characters

Consists of three to seven
characters

First digit is numeric or alpha
(E or V)

First digit is alpha

All letters used except U

Second and third digits are
numeric

Fourth, fifth, sixth, and
seventh digits can be alpha
or numeric

Decimal placed after the
first three characters

Second, third, fourth, and
fifth digits are numeric

Always at least three digits

Decimal placed after the first
three characters
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Code Structure of ICD-10-CM versus ICD-9-CM
ICD-10-CM codes may consist of up to seven digits, with the
seventh digit extensions representing visit encounter or
sequelae for injuries and external causes.
ICD-9-CM Code Format
ICD-10-CM Code Format
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ICD-10-CM has numerous new features allowing for a greater level
of specificity and clinical detail. These include:
Combination codes for conditions and common symptoms or
manifestations
Combination codes for poisonings and external causes
Added laterality
Added extensions for episode of care
Expanded codes (injury, diabetes, alcohol/substance abuse,
postoperative complications)
Inclusion of trimester in obstetrics codes and elimination of fifth
digits for episode of care
Expanded detail relevant to ambulatory and managed care
encounters
Changes in timeframes specified in certain codes
External cause codes no longer a supplementary classification
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ICD-10-CM consists of new features and greater specificity.
Sample ICD-10-CM codes are outlined below to illustrate this
increased detail.
Combination Codes for Conditions and Common Symptoms
I25.110, Arteriosclerotic heart disease of native coronary artery with
unstable angina pectoris
K50.013, Crohn’s disease of small intestine with fistula
K71.51, Toxic liver disease with chronic active hepatitis with ascites
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Combination Codes for Poisonings and the External
Cause
T39.011, Poisoning by aspirin, accidental (unintentional)
T39.012, Poisoning by aspirin, intentional self harm
T39.013, Poisoning by aspirin, assault
T39.014, Poisoning by aspirin, undetermined
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Laterality
C50.212, Malignant neoplasm of upper-inner quadrant of
left female breast
I80.01, Phlebitis and thrombophlebitis of superficial
vessels of right lower extremity
L89.213, Pressure ulcer of right hip, stage III
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Addition of dummy placeholder “X” is used in certain
codes to:
–Allow for future expansion
–Fill out empty characters when a code contains fewer
than 6 characters and a 7thcharacter applies
When placeholder character applies, it must be used
in order for the code to be considered valid
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Due to lack of space in ICD-9 we are currently
unable to report and collect data on new conditions
and new technology
Potential cost savings through more accurate trend
and cost analysis using the increased specificity of
ICD-10
ICD-10 was published in 1993 by the WHO. In
order to report healthcare data globally for
outcome studies and research the US must convert.
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Estimates for training coders range from 16 to as
much as 80 hours. There is wide agreement
among coding professionals that coders will need
an understanding of anatomy and physiology not
required by the current system.
With less training experts believe that productivity
will suffer for more than 6 months and re-work will
increase significantly.
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If productivity is to be maintained, some experts
believe that additional coders will be needed to
assist facilities through the transition period.
Some have suggested a permanent loss of
productivity in the range of 10 to 25 percent.
In an Ingenix audio seminar, the presenter told
participants to expect a 25% decline in coder
productivity and to begin making provisions 6-9
months in advance for the coding changes.
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Based on the report from the Robert E. Nolan
Management Consulting Company titled
“Replacing ICD-9-CM with ICD-10-CM and
ICD-10-PCS the costs of transitioning to
ICD-10 range from $6-$14 billion during the
2-3 year implementation period.
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Beginning on January 1, 2012 a federal mandate
requires all covered entities to begin using the new
HIPAA 5010 transaction standards. Medicare has
begun to implement some of the require changes
as of January 2011. The two areas affected include
the expansion of the number of diagnoses and
procedure codes allowed on the claim form. Also
changes to POA indicators were made as of this
date. These changes are in anticipation of the
change over to the 5010 data set.
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Affected health care providers will need to upgrade
and test their claims management software
systems to accommodate these changes.
Coding software systems, interfaces, physician
practice management software, clearing houses,
super bills and policy and procedures based on
diagnosis information will need to be updated to
allow for the use of ICD-10-CM and PCS. Providers
will need to inventory their systems in order to
determine what ones will be impacted by the
change.
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Facilities will need to determine the costs of
updating all of these systems to allow for the use
of the new code sets. To avoid disruptions
facilities will need to evaluate readiness, test and
validate your EDI transactions for compliance and
correct mapping with the multiple systems and
interfaces.
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All contracts that are based on the ICD-9
code definitions and associated
reimbursement rates will need to be renegotiated.
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It is not too soon to begin planning for the transition at your
facility. A transition team with appropriate members should
be developed. At the very least someone from HIM, IT,
business office, financial services and the medical staff
should be involved.
A transition budget and plan for decreased productivity
during the switch over should be developed.
The facility will need to determine how training will be
provided for the coding staff. Will the training be done
outside or by someone from inside the facility?
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“Replacing ICD-9-CM with ICD-10-CM and ICD-10-PCS,
Challenges, Estimated Costs and Potential Benefits”, prepared
by the Robert E. Nolan Company, October 2003
“ICD-10 Wediwhitepaper”, printed October 2003
“ICD-10-CM Field Testing Project”, AHA and AHIMA,
September 23, 2003
“Implementing ICD-10”, by Lori Becks, RHIA and Sheri Poe
Bernard, CPC, published by Ingenix, 2003
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Jan Neal, RN, CCS,
Parrish, Moody & Fikes, p.c.
7901 Woodway Dr., Ste. 100
Waco, TX 76712
(214) 673-9604
[email protected]
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