ICD-10 Provider Education
Developmental Disabilities Provider Association
Cathy Munn, MPH RHIA CPHQ
Sr. Consultant
1
Agenda
• Overview of ICD-10 Transition
– Industry Update
• Impact of the Change
– Providers
– Payers
• Provider Preparation
– Translation Examples
• Arkansas DHS Preparation & Planning
• Next Steps & Resources
2
Before We Begin…..
•
•
•
•
The change to ICD-10 only applies to Medicaid….
The implementation date for ICD-10 is 10/1/2014…
CPT codes will be replaced with ICD-10 codes…
The ICD-10 code composition will now be
alphanumeric….
• ICD-10 is just like any other annual coding update…
3
ICD-10-CM/PCS
• ICD-9-CM: International Classification of Diseases,
9th revision, Clinical Modification
– US transitioned from ICD-8 to ICD-9 in 1979
– Annual updates
• ICD-10: Developed by the World Health Organization
as the nomenclature for all countries
– ICD-10-CM: International Classification of Diseases, 10th
revision, Clinical Modification – US only
– ICD-10-PCS: International Classification of Diseases, 10th
revision, Procedure Classification System – US only
4
Federal Mandate
• Final Rule Originally Published by HHS on January 16, 2009
requiring the adoption of ICD-10 on October 1, 2013
NO GRACE PERIOD
– Dates of Service (outpatient) After 10/1/2013
– Dates of Discharge (Inpatient) After 10/1/2013
• Federal Mandate Updated Timeline:
– February 14, 2012 – CMS announces they will “reexamine the pace” of
implementing ICD-10
– May 17, 2012 – All comments due to HHS for consideration prior to
publication of the final rule
– August 27, 2012 – Revised compliance date announced by CMS stating a
one-year extension would be granted
– October 1, 2014 is the revised ICD-10 Implementation Compliance Date
5
Things to Remember
• ICD-10-CM (diagnoses) will be used by all providers
in every health care setting
• ICD-10-PCS (procedures) will be used only for
hospital claims for inpatient hospital procedures
• No impact on Current Procedural Terminology (CPT)
and Healthcare Common Procedure Coding System
(HCPCS) codes
• CPT and HCPCS will continue to be used for physician
and ambulatory services including physician inpatient
hospital visits
• Release of DSM-V codes occurred in May 2013;
however DSM-V is not HIPAA compliant for claims
or transactions
6
Important Information
• Systems will have to utilize both ICD-9-CM and ICD10-CM for overlap e.g. claims backlog, Arkansas
Medicaid allows providers 365 days to submit a claim.
• Inpatient discharges occurring on or after 10-1-2014
will use ICD-10-CM and ICD-10-PCS codes regardless
of date of admission.
• Outpatient dates of service occurring on or after
10-1-2014 will use ICD-10-CM codes
• There will be period of time when payers will be
processing claims in both ICD-9 and ICD-10
7
ICD-9 Current State
ICD-9 lacks the specificity
& granularity needed to
accurately reflect care
provided
Technology & practice
patterns have changed
dramatically in 30 years
ICD-9 has run out of codes
to accurately capture current
medical practice
8
ICD-10 Future State
Updates terminology &
disease classification
consistent w/current practice
Expands flexibility for
future updates based on
technical advances
Enhances research &
outcomes data capture &
quality measure reporting
9
A Few ICD-10 Benefits
• Better data will be available for:
– Measuring the quality, safety, and efficacy of care
– Designing payment systems and processing claims for
reimbursement
– Conducting research, epidemiological studies, and clinical trials
– Setting health policy
– Operational and strategic planning and designing healthcare
delivery systems
– Monitoring resource utilization
– Improving clinical, financial, and administrative performance
– Preventing and detecting healthcare fraud and abuse
– Tracking public health and risks
10
Other Competing Priorities
ACOs/ Patient
Centered
Medical
Home
Public
Reporting &
Quality
Measures
ICD-10: Key
to the success
of each
initiative
EHR/
Meaningful
Use
Value Based
Purchasing
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ICD-10 Chapter Headings
Alpha Character
A and B
Narrative Description
Certain infectious and parasitic diseases.
C00 to D48
Neoplasms.
D50 to D89
Diseases of the blood and blood-forming organs and certain
disorders involving the immune mechanism.
E
Endocrine, nutritional and metabolic diseases.
F
Mental and behavioral disorders.
G
Diseases of the nervous system.
H00 to H59
Diseases of the eye and adnexa.
H60 to H95
Diseases of the ear and mastoid process.
12
ICD-9 vs. ICD-10 Diagnosis Codes
ICD-9 Diagnosis Codes – 13,000
ICD-10 Diagnosis Codes – 68,000
3-5 Characters
3-7 Characters
First character is numeric or alpha (E or First character is alpha
V)
Use of decimal after 3rd character
Use of decimal after 3rd character
Characters 2-7 are alpha or numeric –
letter U is not used
Use of dummy placeholder “X” for
future code expansion
E codes reference External Causes of Injury & Poisoning in ICD-9.
E references the Endocrine system in ICD-10
V codes reference Health Status & Contact with Health Services in ICD-9
V – Y codes reference External Causes of Morbidity in ICD-10
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Structure and Seventh Character
Alpha
(Except U)
2 Numeric
3-7 Numeric or Alpha
S X
8 X
0
M
X
A
Category:
Superficial injury of
knee & lower leg
.
Additional
Characters
X
2 X
1 X
1
A
X
Etiology, anatomic
site, severity:
Added 7th character for
obstetrics, injuries, and
external causes of injury
Other superficial injuries of knee
1 – Right; 2 – Left; 9 – Unspecified
Abrasion of the right
knee, initial encounter
3–7 Characters
14
ICD-9 Procedure vs. ICD-10-PCS
ICD-9 Procedure Codes – 4,000
ICD-10 Procedure Codes – 87,000
3-4 Digits
7 Digits
All digits are numeric
Alpha or numeric composition
• Numbers 0 - 9
• Letters O & I are omitted
Example: Artery suture has 1 code
Example: Artery suture – 195 coding
options
The increase in the number of procedure codes is driven by the
increased specificity, granularity & laterality contained within the
ICD-10 codes.
15
ICD-10 Procedure Code Structure
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ECT Code Translation
FY2013 ICD-9CM procedure Source Code Title
FY2013 ICDSource 10-PCS
Status procedure
94.27
Other electroshock therapy
GZB0ZZZ
94.27
Other electroshock therapy
GZB1ZZZ
94.27
Other electroshock therapy
GZB2ZZZ
94.27
Other electroshock therapy
GZB3ZZZ
94.27
Other electroshock therapy
GZB4ZZZ
Target Code
Title
Electroconvulsive
Therapy, UnilateralSingle Seizure
Electroconvulsive
Therapy, UnilateralMultiple Seizure
Electroconvulsive
Therapy, BilateralSingle Seizure
Electroconvulsive
Therapy, BilateralMultiple Seizure
Other
Electroconvulsive
Therapy
17
Patient Flow Impact
Start Patient
Encounter
Revise for ICD10 reporting
Update data repositories
to accommodate new
coding
Claim priced based
on revised fee
schedules
Revise
authorization
process
Back end
processes
Providers change
coding practices based
on ICD-10
Diagnose
Patient
Payment &
Remit
Code Claim
Update practice
management
system
Submit
Claim
Price
Claim
Update claims
submission
process
Check
Auth
Receive Claim
Select
provider &
contract
Update benefit logic
& edits
Begin
Adjudication
Determine
Benefits
Update system to
accept claims
Check
Eligibility
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Impact on Providers
•Systems
•Operations and Processes
•Clinical Documentation
19
System Impacts
• Identify your current systems and work processes that use
ICD-9 codes. This could include:
–
–
–
–
–
–
Clinical Documentation
Encounter Forms and Superbills
Practice Management Systems
Electronic Medical Record Systems
Contracts and Fees Schedules
Public Health and Quality Reporting Protocols & Reports
• A good rule of thumb: Wherever ICD-9 codes appear
today, ICD-10 codes will need to replace them in the future
20
System Impacts
• Talk with your practice management system vendor
about accommodations for both ICD-9 and ICD-10
codes
– Will your current system require upgrades?
– Is the vendor planning system updates for accommodation of
ICD-10 codes?
– When will they be ready to install/update?
– Are the upgrades included in your current contract?
• Discuss readiness and remediation plans with any
clearinghouses or billing services you may use
21
System & Operational Impacts
• Discuss implementation plans with all your
clearinghouses, billing services, and payers to ensure a
smooth transition
• Be proactive; don’t wait for vendors to contact you
• Ask about their plans for ICD-10 compliance and when
they will be ready to collaboratively test their systems
• Ask to see their Remediation Roadmap that supports
their claims of “readiness”
• Utilize CMS checklists and resources as a guide
22
Operational Impacts
• Talk with your payers about how ICD-10
implementation might impact your contracts. Because
ICD-10 codes are much more specific than ICD-9
codes, payers may modify terms of contracts, fee
schedules or reimbursement methodologies
• Understand your metrics:
– Coding Productivity
– Coding Accuracy
– Financial Stability
• Days in A/R
• Cash on hand
23
Operational Impacts
• Identify potential changes to work flow and business
processes
• Consider changes to existing processes including:
– Clinical documentation – viewed as an increasing area of
vulnerability & concern in the industry
– Prior authorization
– Encounter forms and Superbills
– Quality and Public Health reporting
– Involvement in any Care Management or community
outreach initiatives
24
Operational Impacts
• Identify the staff in your office who code, or have a
need to know the new codes….anticipate that everyone
in your office will require some level of awareness
training
• Don’t forget the physicians in the awareness training
• There are a wide variety of training opportunities and
materials available through a variety of resources:
– Professional Coding Associations – AAPC, AHIMA
– Online Courses – ICD10 Monitor, Contexo University, Precyse,
Nuance
– Webinars – ICD10 Monitor, HCPro
– Onsite Training – Train-the-Trainer approach, Coding Boot Camp
– Non-Traditional - Partner with the HIM Department at a nearby
hospital
25
Operational Impacts
• Budget for time and costs related to ICD-10
implementation including:
–
–
–
–
Expenses for system changes and software updates
Resource materials
Training
Modifications to forms and Superbills
• Other budgetary considerations:
– Unanticipated payment delays, appeals & denials
– Understand your operational metrics – benchmark for efficiency
– Establish a line of credit……
• Anticipate something you didn’t plan for or expect….
26
Superbills - How Will They Change?
• Increased size
• Increased specificity
• Examples can be found at www.ahima.org/icd10
along with other valuable ICD-10-CM resources
27
Pervasive Developmental Disorders
FY2013 ICD-9-CM
Diagnosis
Source Code Title
299.00
299.01
299.10
299.11
Autistic disorder, current or
active state
FY2013 ICD-10CM Diagnosis
Target Code Title
F84.0
Autistic disorder, residual state F84.0
Childhood disintegrative
disorder, current or active state F84.3
Childhood disintegrative
disorder, residual state
F84.3
Autistic disorder
Autistic disorder
Other childhood
disintegrative disorder
Other childhood
disintegrative disorder
28
Pervasive Developmental Disorders Cont.
FY2013 ICD-9-CM
Diagnosis
Source Code Title
299.80
299.80
299.81
299.81
299.90
299.91
Other specified pervasive
developmental disorders,
current or active state
Other specified pervasive
developmental disorders,
current or active state
Other specified pervasive
developmental disorders,
residual state
Other specified pervasive
developmental disorders,
residual state
Unspecified pervasive
developmental disorder,
current or active state
Unspecified pervasive
developmental disorder,
residual state
FY2013 ICD-10CM Diagnosis
Target Code Title
F84.5
Asperger's syndrome
F84.8
Other pervasive
developmental disorders
F84.5
Asperger's syndrome
F84.8
Other pervasive
developmental disorders
F84.9
Pervasive developmental
disorder, unspecified
F84.9
Pervasive developmental
disorder, unspecified
29
Intellectual Disabilities
FY2013 ICD-9-CM
Diagnosis
Source Code Title
315.9
315.9
317
318.0
318.1
318.2
319
319
Unspecified delay in
development
Unspecified delay in
development
Mild intellectual
disabilities
Moderate intellectual
disabilities
Severe intellectual
disabilities
Profound intellectual
disabilities
Unspecified intellectual
disabilities
Unspecified intellectual
disabilities
FY2013 ICD-10-CM
Diagnosis
Target Code Title
F81.9
F89
F70
F71
F72
F73
F78
F79
Developmental disorder
of scholastic skills,
unspecified
Unspecified disorder of
psychological
development
Mild intellectual
disabilities
Moderate intellectual
disabilities
Severe intellectual
disabilities
Profound intellectual
disabilities
Other intellectual
disabilities
Unspecified intellectual
disabilities
30
Intellectual Disabilities
ICD-10 Code
Definition
IQ Level
F70
Mild Intellectual Disabilities
IQ level 50 – 55 to
approximately 70
Mild mental subnormality
F71
Moderate Intellectual Disabilities
IQ level 35 – 40 to 50 – 55
Moderate mental subnormality
F72
Severe Intellectual Disabilities
IQ level 20 – 25 to 35 – 40
Severe mental subnormality
F73
Profound Intellectual Disabilities
IQ level 20 – 25
Profound mental subnormality
NOTE – Borderline intellectual
functioning with IQ level above 70
– 84 is coded R41.83
31
Developmental Delays
FY2013 ICD-9-CM
Diagnosis
Source Code Title
FY2013 ICD-10CM Diagnosis
783.40
Lack of normal
physiological development,
unspecified
R62.50
783.40
Lack of normal
physiological development,
unspecified
R62.59
Target Code Title
Unspecified lack of
expected normal
physiological
development in
childhood
Other lack of expected
normal physiological
development in
childhood
32
Cerebral Palsy
FY2013 ICD-9-CM
Diagnosis
Source Code Title
FY2013 ICD-10Target Code Title
CM Diagnosis
343.2
Congenital quadriplegia
G80.0
343.0
Congenital diplegia
G80.1
343.1
Congenital hemiplegia
G80.2
Spastic quadriplegic
cerebral palsy
Spastic diplegic cerebral
palsy
Spastic hemiplegic cerebral
palsy
333.71
Athetoid cerebral palsy
Other specified infantile
cerebral palsy
G80.3
Athetoid cerebral palsy
G80.4
Ataxic cerebral palsy
Congenital monoplegia
Other specified infantile
cerebral palsy
Infantile cerebral palsy,
unspecified
G80.8
Other cerebral palsy
G80.8
Other cerebral palsy
G80.9
Cerebral palsy, unspecified
343.8
343.3
343.8
343.9
33
Down’s Syndrome
FY2013 ICD-9-CM
Diagnosis
Source Code Title
FY2013 ICD-10-CM
Diagnosis
Target Code Title
758.0
Down's syndrome
Q90.0
758.0
Down's syndrome
Q90.1
758.0
Down's syndrome
Q90.2
758.0
Down's syndrome
Q90.9
Trisomy 21,
nonmosaicism (meiotic
nondisjunction)
Trisomy 21, mosaicism
(mitotic nondisjunction)
Trisomy 21, translocation
Down syndrome,
unspecified
34
Clinical Documentation
• If it’s not documented….it’s not done
– Outcome Data
– Liability
– Reimbursement
35
Clinical Documentation Practices
• Clinical documentation improvement “best practices”
provide an opportunity for accurate coding and richer
clinical data.
• Accurate data will allow us to better understand our
patients; their compliance with care management
initiatives and which treatments lead to better
outcomes.
• Complete clinical documentation will promote accurate
coding thus leading to more accurate payment that
could legitimately look different than it does today.
36
Clinical Scenario
Patient presents to the ER for severe right lower leg pain with an
open leg wound following a fall from a ladder. The physician
documented that the patient had an open transverse fracture of the
shafts of the tibia & fibula.
ICD-9-CM code:
• 823.32, Open fracture of shaft, fibula with tibia
•
E881.0 Accidental fall from ladder
ICD-10-CM codes:
• S82.221B Displaced transverse fracture of shaft of right tibia, initial
encounter for open fracture NOS
• S82.421B Displaced transverse fracture of shaft of right fibula, initial
encounter for open fracture NOS
• W11.XXXA Fall on and from ladder, initial encounter
37
Changes to E & V Codes in ICD-10
• E codes reference External Causes of Injury & Poisoning
in ICD-9
– E code references the Endocrine system in ICD-10
• Thyroid gland disorders: E00 – E07
• Diabetes codes: E08 – E13
• Disorders of glucose regulation & pancreatic internal secretion: E15 –
E16
• V codes reference Health Status & Contact with Health
Services in ICD-9
– Z codes reference Health Status & Contact with Health Services
in ICD-10
• V – Y codes reference External Causes of Morbidity in
ICD-10
38
Other Resources & Reminders
Additional information & resources you might find
helpful….
39
CMS Resources
40
CMS Resources
41
42
Arkansas DHS Current State
• Arkansas Medicaid has been working on ICD-10 for over two years
• Progress to date:
–
–
–
–
–
Operational assessment complete
Remediation of Medical Policy, Edits and Audits complete
Remediation of Pharmacy Policy & edits nearing completion
Provider Manuals currently under review
Systems requirements obtained – HP/MMIS, Xerox/ACS & other integrated &
stand alone systems
– Arkansas DHS reports, forms, and brochures currently under review
– Ongoing Provider Outreach
•
•
•
•
Meetings/Webcasts
Provider Bulletins
Newsletters
ICD-10 Website www.humanservices.Arkansas.gov/ICD10
• Internal & external testing scenarios are under development
• Per CMS; external testing should begin October, 2013
43
Now What?
44
Communication & Planning
•
•
•
•
Engage the support of leadership
Define your strategy & approach to ensure success
Understand the financial implications of non-compliance
Ensure everyone understands the impact of ICD-10
–
–
–
–
–
–
–
Receptionist
Nursing Staff
Physicians
Coders
Billing Staff
CFO/COO
Senior Practice Management Staff
• Share regular updates & communication briefings with staff
45
Operational Assessment
•
Understand which systems & processes will be impacted
•
Understand the impact that the transition will have on people, process &
technology; both internal & external to the practice
– Staff & providers
• Education & awareness
• Training – just in time
– Workflows
• Office through-put
• Clinical documentation
• Code utilization within the practice – Superbill assessment
• Coding & billing turn-around-time/cash flow
• Denials & resubmission of claims
– Systems upgrades/enhancements
• Practice management systems
• Billing transmissions – EDI
• Vendor readiness
46
Documentation Assessment
• Provider practices and specialty departments should
examine their patient population in terms of:
– High volume/high cost
– Patient demographic & payer mix: Medicare, Medicaid,
Commercial insurance
– Diagnoses that lead to the highest denial, physician query and
re-bill rates; and
– Areas related to quality reporting, improvement
initiatives and published RAC reviews
47
Documentation Assessment
• Evaluate your current documentation
– Does it specify right vs. left?
– Does it provide the specificity needed to accurately assign an
ICD-10 code?
• Conduct a sample audit to evaluate clinical
documentation
– Review claims coded in ICD-9 and code them in ICD-10
– Is the documentation sufficient?
• Share the audit results with the providers
– Understanding of the future documentation needs will reduce
queries, pended claims & denials post 10/1/2013
48
Testing
• Largest testing effort in the history of healthcare
• Not a routine upgrade with minimal testing before implementation
• Recommended that you employ end to end testing with vendors,
providers & payers to include:
–
–
–
–
–
–
–
Creation of the claim
Submission to payer/EDI vendor/clearinghouse via 837
Adjudication of claim
Reporting back to the provider via EOP/835
Adjustments/denials/resubmissions
Report creation
Denial tracking & analysis
Monitor the AR ICD-10 Website for information regarding testing
49
Industry Web Site Resources
•
•
•
•
•
•
www.CMS.gov/ICD10
www.CMS.gov/NPC
www.AHIMA.org
www.ICD10watch.com
www.AAPC.com
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10SmallandMediumPractices508.pdf
• http://www.himss.org/ASP/topics_icd10playbook.asp
• www.WEDI.org
• www.humanservices.Arkansas.gov/ICD10
50
CMS Resources
51
For More ICD-10 Information
• White Papers (including but not limited to)
– ICD-10 A Primer
– ICD-10 Clinical Documentation
– ICD-10 Physician Impact
– ICD-10 Advantages
– ICD-10 Specified or Unspecified
http://healthdataconsulting.com/
• Checklists published by CMS for providers (small, medium and
large) at:
– http://www.cms.gov/Medicare/Coding/ICD10/ICD10ImplementationTimelines.html
52
AR Medicaid ICD-10 Website
53
Questions & Comments
54