ICD-10 Overview
Next Steps to ICD-10
Laurie Aloi, CHC, CHPC, CPC
Director of Billing & Compliance
MedSafe
October 21, 2013
Agenda

Understanding what’s coming

Timeline and history
Delay in Implementation
What is ICD-10?
 Side by Side examples
Review of Coding Guidelines
Planning for a Successful Transition

When?
The Department of Health and Human Services
(HHS) originally announced the plan for ICD-10-CM
implementation.
In August 2009, CMS announced the implementation
date would be October 1, 2011
The date was pushed back in January 2009 after
MGMA and AAPC appealed to CMS that the training
and software transition would be a burden to the
medical profession
Practices have had 4 years to prepare and should be
learning about


What ICD-10 is
What will need to be done to prepare
And Now?
On February 16, 2012 HHS Secretary Kathleen
Sebelius has announced that the October 1, 2013 date for
implementation of ICD-10 has been pushed back
indefinitely
“ICD-10 codes are important to many positive improvements in our
health care system. We have heard from many in the provider
community who have concerns about the administrative burdens they
face in the years ahead. We are committing to work through the
rulemaking process, with the provider community, to reexamine the
pace at which HHS and the nation implement these important
improvements to our health care system.”
5
New Implementation Date
On April 9, 2012, CMS announced that the new
implementation date will be October 1, 2014
The extra year will give medical practices more time to
shift from the demands of Meaningful Use and Quality, to
the issues of training and implementing ICD-10
Why change from ICD-9?




ICD-9-CM has several problems. After 30 years, it is no
longer useful.
It is out of room. Because the classification is organized
scientifically, each three-digit category can have only 10
subcategories. Most numbers in most categories have been
assigned diagnoses. Medical science keeps making new
discoveries, and there are no numbers to assign
these diagnoses. ICD-10 expands to 7 digits.
Computer science, combined with new, more detailed codes
of ICD-10-CM, will allow for better analysis of disease
patterns and treatment outcomes that can advance medical
care provided.
These same details will streamline claims submissions, since
these details will make the initial claim much easier for
payers to understand.
A large share of the world is using ICD-10
since it was introduced in 1992
• United Kingdom (1995)
• Nordic countries (Denmark, Finland, Iceland, Norway,
Sweden) (1994 – 1997)
• France (1997)
• Australia (1998)
• Belgium (1999)
• Germany (2000)
• Canada (2001)
Reimbursement and Quality problems
with ICD-9
Example – fracture of wrist
Patient fractures left wrist
A month later, fractures right wrist
– ICD-9-CM does not identify left versus right –
• requires additional documentation
– ICD-10-CM describes
• Left versus right
• Initial encounter, subsequent encounter
• Routine healing, delayed healing, nonunion, or malunion
ICD-10 Changes everything
From this…..
To this
ICD-10 Major Modifications
Added trimesters to obstetrical codes (5th digits from
ICD-9-CM will not be used)
Revised diabetes mellitus codes (5th digits from ICD-9CM will not be used)
Expanded codes (e.g., injury, diabetes)
Added code extensions for injuries and external causes of
injuries
Laterality- Left versus Right
- C50.1 Malignant neoplasm, of central portion of
breast
– C50.111 Malignant neoplasm of central portion of right
female breast
– C50.112 Malignant neoplasm of central portion of left
female breast
Structural Differences ICD-9
ICD-9-CM has 3 – 5 digits
Chapters 1 – 17: all characters are numeric
Supplemental chapters: first digit is alpha (E or V),
remainder are numeric
Examples:
– 496 Chronic airway obstruction not elsewhere classified
(NEC)
– 511.9 Unspecified pleural effusion
– V02.61 Hepatitis B carrier
Structural Differences ICD-10
ICD-10-CM has 3 – 7 digits
Digit 1 is alpha (A – Z, not case sensitive)
Digit 2 is numeric
Digit 3 is alpha (not case sensitive) or numeric
Digits 4 – 7 are alpha (not case sensitive) or numeric





A66 Yaws
A69.20 Lyme disease, unspecified
O9A.311 Physical abuse complicating pregnancy, first
trimester
S42.001A Fracture of unspecified part of right clavicle,
initial encounter for closed fracture
Format and Guidelines








ICD-10-CM Organization
Introduction
How to Use
Official Guidelines
Alphabetic Index
Neoplasm Table
Table of Drugs and Chemical
Index to External Causes
Format and Guidelines
ICD-10-CM Organization
Tabular
Chapters
ICD-10-CM has 21 Chapters
Blocks



Example
Chapter 8 – Diseases of the Ear and Mastoid Process is divided into 5
blocks





H60-62 Diseases of the external ear,
H65-75 Diseases of the middle ear and mastoid,
H80-83, Diseases of the inner ear,
H90-94 Other disorders of the ear,
H95 Intraoperative/postprocedural complications
Comparison of Code Sets
ICD-9
ICD-10
3-5 characters
3-7 characters
More than 17,000 codes
More than 155,000 codes
68,000 are for ICD 10- CM
First digit may be alpha or numeric (E or V First digit is alpha; digits 2 & 3 are
only), digits are 2-5 are always numeric
numeric; digits 4-7 are alpha or numeric
Limited space for adding new codes
Flexible, new format allows for expansion
Lacks detail
Very specific
Lacks laterality
Includes a specific field to identify
laterality (right vs. left)
Structural Differences
ICD-9 Diagnosis Code
ICD-10 Diagnosis Code
382.9 Acute Otitis Media
B01.2 Varicella pneumonia
540.9 Acute Appendicitis
K21.0 GERD with esophagitis
780.01 Coma
O30.003 Twin Pregnancy, unspecified, third
trimester
In the ICD-10 diagnosis code set, the alpha characters are
not case sensitive. These examples show a comparison of
the formats of the ICD-9 and ICD-10 diagnosis codes. You
can see the use of alpha characters and longer codes in
ICD-10
ICD-10 Structure




The expanced number of characters of the ICD-10
diagnosis codes provides greater specificity to identify
disease etiology, anatomic site, and severity
Characters 1-3 - Category
Characters 4-6 - Etiology, anatomic site, severity, or
other clinical detail
Character 7 – Extension (example- episode of care or
other clinical detail)
Detailed Example
S52 Fracture of Forearm
S52.5 Fracture of lower end of radius
S52.52 Torus fracture of lower end of radius
S52.521 Torus fracture of lower end of right radius
S52.521A Torus fracture of lower end of right radius,
initial encounter for closed fracture
Side by side example #1
Severe, unremitting left lower leg pain
ICD-9 – 729.5 Pain, lower extremity
ICD-10 M79.662 Pain in left lower leg
ICD-10 Coding Structure
M79 Other and unspecified soft tissue disorders, not specified elsewhere
M79.6 Pain in limb, hand, foot, fingers and toes
M79.66 Pain in Lower Leg
M79.662 Pain in left lower extremity
Side by side example #2
Sprain of the deltoid ligament of right ankle
ICD-9 – 845.01 Sprain, deltoid lligament of ankle
ICD-10 S93.421 sprain of the deltoid ligament of right ankle
ICD-10 Coding Structure
S93 Subluxation and dislocation of the ankle joint
S93.4 Sprain of ankle
S93.42 Sprain of the deltoid ligament
S93.421 Sprain of the deltoid ligament of the right ankle
S93.421A Sprain of the deltoid ligament of the right ankle, Initial Encounter
Similarities
Index abbreviations (NEC)
Tabular abbreviations (NOS)
“and” means “and/or”
“other specified” and “unspecified” are the same
Includes notes

Example:
 I70.24 Atherosclerosis of native arteries of left leg with
ulceration Includes any condition classifiable to I70.212 and
I70.222

Similarities

Use additional code….’, ‘Code first’ and ‘Code also’ notes

Example:


G47.3 Sleep apnea
Code also any associated underlying condition
Inclusion terms
Official coding guidelines

CMS
 NCHS
 AHA
 AHIMA

Differences
ICD-10-CM codes are all alphanumeric
First character is always an alpha character
Subsequent characters may be alpha or numeric
Example:


I82.a11 Acute embolism and thrombosis of right axillary
vein
Codes may be 3, 4, 5, 6 or 7 characters in length
Code Descriptions are listed in full

A Place for everything, everything in its placeBenjamin Franklin
The fact that the codes are up to seven characters in length is a major difference
that brings two new considerations: seventh character extenders and dummy
placeholders.
The seventh character extenders are usually a letter, and are used to identify the
encounter type. The most common seventh character extenders used in ICD-10CM are:
A-Initial Encounter for closed fracture
B- Initial encounter for open fracture
D- Subsequent Encounter for fracture with routine healing
G- Subsequent encounter for fracture with delayed healing
K- Subsequent encounter for fracture with nonunion
P- Subsequent encounter for fracture with malunion
S- Sequela
27
A unique twist- the “Placeholder”
Some codes are 7 characters, but no 4th, 5th or 6th place is
necessary, so “x” is a placeholder


T68.xxxA - Hypothermia
The appropriate 7th character is to be added to code T68
A – initial encounter
D – Subsequent encounter
S – sequela

Body Systems
• Blood and Blood Forming
• Respiratory System
• Organs
• Digestive System
• Immune System
• Integumentary System
• Endocrine System
• Musculoskeletal System
• Nervous System
• Genitourinary System
• Eye and Adnexa
• Pregnancy, Childbirth, and
• Ear and Mastoid Process
• Circulatory System
Puerperium
Diseases of the Circulatory System
ICD-9
Description
401.1
Essential
hypertension
(benign)
414.01
Coronary
atherosclerosis of
native coronary
artery (CAD)
427.31
Atrial fibrillation
428.0
Congestive heart
failure
ICD-10
Description
I1Ø
Essential
(primary)
hypertension
I25.1Ø
Atherosclerotic
heart disease
of native
coronary artery
without angina
pectoris
I48.Ø
Atrial
fibrillation
I5Ø.9
Heart failure,
unspecified
Diseases of the Respiratory System
Description
ICD-9
ICD-10
Laryngitis
464.0
J04.0
Croup
464.4
J05.0
Respiratory Syncytial Virus
(RSV
466.11
J04.11
Pneumonia
481
J13 pneumonia due to Strep
J18.1 Lobar pneumonia,
unspecified organism
Influenza
488.0
JØ9.Ø19 Influenza due to
identified avian influenza virus
with unspecified type of
pneumonia
COPD
496
J44.9
Signs and Symptoms
Description
ICD-9
786.05
Shortness of breath
786.50
Chest pain
786.51
Precordial Pain
786.59
Chest Pain NEC*
790.93
ICD-10
ICD-10
Description
RØ6.Ø2
Shortness of
breath
RØ7.9
Chest pain,
unspecified
RØ7.2
Precordial pain
RØ7.82
Intercostal
pain
R07.89
Other Chest
pain
R97.2
Elevated
prostate
specific antigen
[PSA]
Elevated PSA
Diseases of the Respiratory System
Description
ICD-9
Asthma
493.00
Bronchitis
490
Pneumoconiosis
505
Empyema
lung)
510.9
(pus in
Pneumothorax
512
Interstitial Lung
Disease
770.1 Fetal and
newborn aspiration
11/12/12
ICD-10
ICD-10
Description
J45.2Ø
Mild intermittent
asthma,
uncomplicated
J4Ø
Bronchitis, not
specified as acute or
chronic
J64
Unspecified
pneumoconiosis
J86.9
Pyothorax without
fistula
J93.Ø
Spontaneous
tension
pneumothorax
P28.9
Respiratory condition
of newborn,
unspecified
33
Diseases of the Respiratory System
Description
ICD-9
Pulmonary
Edema
518.4
ICD-10
ICD-10 Description
J81.Ø
Acute pulmonary edema
Z87.Ø9
Personal history of other
diseases of the respiratory
system
Z82.5
Family history of asthma
and other chronic lower
respiratory diseases
ZØ1.89
Encounter for other
specified special
examinations
Screening:
Personal history
V12.60
Family history
V17.5
Screenings
V72.50
11/12/12
34
Common OB Gyn Conditions
ICD-9
Description
ICD-10
Description
620.2
Ovarian Cyst
N83.20
Unspecified Ovarian
Cyst
Other ovarian Cysts
N83.29
174.8
Malignant neoplasm
breast
C50.819
Malignant neoplasm
of overlapping sites
of unspecified female
breast
625.6
Stress incontinence,
female
N39.3
Stress incontinence
(female) (male)
625.4
Premenstrual tension N94.3
syndromes
Premenstrual tension
syndrome
625.3
Dysmenorrhea
N94.3
Dysmenorrhea,
unspecified
628.3
Infertility, uterine
(female)
N97.2
Female infertility of
uterine origin
V Codes will be Z Codes
ICD-9
Description
V72.5
ICD-10
Description
Z01.41
Encounter for gynecological
examination
..with abnormal findings
Z01.411
V22.0
V22.1
Supervision of normal first
pregnancy
…..other normal pregnancy
V25.0
V72.4
V72.40
V72.41
V72.42
Pregnancy test
……unconfirmed
……negative
……positive
Z34.00
Encounter for supervision of
normal first pregnancy,
unspecified trimester
Z30.8
Encounter for contraceptive
management
Z32.3
Z32.00
Z32.01
Z32.02
Pregnancy examination or test
……unconfirmed
……negative
……positive
Diseases of the Musculoskeletal System
Description
ICD-9
715.11
Primary
localized
osteoarthritis,
shoulder region
M19.012
Primary
Osteoarthritis, left
shoulder
715.15
Primary
localized
osteoarthritis,
pelvic region
and thigh
M16.11
Unilateral Primary
osteoarthritis, right
hip
ICD-10
ICD-10
Description
M19.Ø19
Primary
osteoarthritis,
unspecified
shoulder
M19.011
Primary
Osteoarthritis, right
shoulder
M16.1Ø
Unilateral
primary
osteoarthritis,
unspecified hip
M16.12
Unilateral primary
osteoarthritis, left
hip
Diseases of the Musculoskeletal System
Description
ICD-9
717.2
Derangement of
posterior horn of
medial meniscus
M23.221
Derangement of
posterior horn of
medial meniscus due
to old tear or injury,
right knee
ICD-10
ICD-10
Description
M23.229
Derangement of
posterior horn of
medial meniscus
due to old tear
or injury,
unspecified knee
M23.329
Other meniscus
derangements,
posterior horn of
medial meniscus,
unspecified knee
M23.222
Derangement of
posterior horn of
medial meniscus due to
old tear or injury, left
knee
Diseases of the Musculoskeletal System
Description
ICD-9
719.41
Pain in joint,
shoulder region
M25.511
Pain in right shoulder
719.45
M25.551
ICD-10
ICD-10
Description
M25.519
Pain in
unspecified
shoulder
M25.512
Pain in left shoulder
Pain in joint, pelvic
region and thigh
M25.559
Pain in
unspecified hip
Pain in right hip
M25.552
Pain in left hip
Diseases of the Musculoskeletal System
Description
ICD-9
721.0
Cervical spondylosis
without myelopathy
721.3
722.0
722.10
Lumbosacral
spondylosis without
myelopathy
Displacement of
cervical
intervertebral disc
without myelopathy
Lumbar
intervertebral disc
without myelopathy
ICD-10
ICD-10
Description
M47.812
Spondylosis
without
myelopathy or
radiculopathy,
cervical region
M47.817
Spondylosis
without
myelopathy or
radiculopathy,
lumbosacral
region
M5Ø.2Ø
Other cervical disc
displacement,
unspecified
cervical region
M51.26
(M51.27 for
lumbsosacral)
Other
intervertebral disc
displacement,
lumbar region
Diseases of the Musculoskeletal System
Description
ICD-9
727.03
Trigger finger
(acquired)
727.61
354.0
Complete
rupture of
rotator cuff
Carpal tunnel
syndrome
ICD-10
ICD-10
Description
M65.3Ø
Trigger finger,
unspecified
finger
M75.1Ø
Rotator cuff
syndrome,
unspecified
shoulder
G56.ØØ
Carpal tunnel
syndrome,
unspecified
upper limb
Anatomy and Pathophysiology
Higher level of specificity found in the new codes
In order to assign them correctly we have to first
understand them
For example – the musculoskeletal system comprises 60%
of the codes found in ICD-10
206 bones in the body
80 are Axial
– head, facial, hyloid, auditory, trunk, ribs, and sternum
126 are Appendicular
– arms, shoulders, wrists, hands, legs, hips, ankles and feet
Types of Fractures
Displaced fractures
Non-displaced fractures
Closed fracture
Open fracture
Greenstick Fracture
Transverse fracture
Spiral fracture
Oblique fracture
Compression fracture
Anatomy and Pathophysiology Musculoskeletal system
Classification is needed for open fractures using the “Gustilo
Open fracture classification system”
This system identifies fractures as Type I, II, IIIA, IIIB and IIIC
I – Low energy, wound less than 1 cm
II – Wound greater than 1 cm with moderate soft tissue damage
III – High energy wound greater than 1 cm with extensive soft
tissue damage
IIIA – Adequate soft tissue cover
IIIB – Inadequate soft tissue cover
IIIC – Associated with arterial injury
Diseases of the Musculoskeletal System
Description
ICD-9
813.42
Other fractures
of distal end of
radius (alone)
820.21
Intertrochanteric
fracture, closed
ICD-10
ICD-10 Description
S52.5Ø9A
Unspecified fracture of the
lower end of unspecified
radius, initial encounter for
closed fracture
S72.143A
Displaced intertrochanteric
fracture of unspecified
femur, initial encounter for
closed fracture
S72.146A
Nondisplaced
intertrochanteric fracture of
unspecified femur, initial
encounter for closed
fracture
Neoplasm
Description
ICD-9
185
Malignant
neoplasm of
prostate
188.9
Malignant
neoplasm of
bladder,
unspecified part
ICD-10
ICD-10
Description
C61
Malignant
neoplasm of
prostate
C67.9
Malignant
neoplasm of
bladder,
unspecified
Comparison of ICD-9 Chapters to ICD-10
Chapters
ICD-9
There are 17 Chapters, plus 2 supplementary chapters of V
codes and E Codes
*see spreadsheet

ICD-10
There are 22 Chapters in ICD-10





Eye and Adnexa
Ear and mastoid Process
External causes of morbidity and mortality (separate from injury
and poisoning)
Codes for Special Purposes
Guidelines
It is essential for a coder to review the chapter guidelines
in the front of the ICD-10 manual
Chapter changes are summarized below
Many chapter guidelines are the same as ICD-9
Blood and Blood Forming Organs

Sepsis
Complication of infection outside the blood stream
 Blood stream carries bacteria or other organism through
blood to other sites
 Sepsis vs. bacteremia vs. septicemia

Bacteremia - presence of bacteria in the blood
Septicemia - presence of bacteria in the blood
(bacteremia)
Sepsis - a serious condition characterized by a whole-body
inflammatory state (systemic inflammatory response) with
the presence of suspected or known
infection

Chapter 15 GuidelinesPregnancy, Childbirth, and the puerperium (O00-O099)
a. General Rules for Obstetric Cases
– 1) codes from chapter 15 have sequencing priority over
codes from other chapters.
– Should the provider document the pregnancy is incidental
to the encounter, code Z33.1 pregnant state, incidental, in
place of any chapter 15 codes. (condition not affecting
pregnancy)
– 2) Chapter 15 codes are used only on the maternal record
and never on the newborn record
– 3) final character for trimester
6 digit example
Final character for trimester
– O23.51 Infections of the genital tract in
pregnancy
• O23.511 infections of cervix in pregnancy, first
trimester
• O23.512 …………………………….second
trimester
• O23.513……………………………….third trimester
• O23.519…………………………unspecified
trimester
Training
We know there will need to be significant
education and training for physicians, coders and
other healthcare personnel. No one needs to
panic.
Please do not jump to individual training as its
difficult to remember in 1 yearswhat you were
trained on today.
You have year to have a plan in place to provide all
you'll need to effectively implement ICD-10.
Training
Consider offering training to your billing and coding staff
–
–
–
–
Medical Terminology
Anatomy
Pathophysiology
Use Video’s such as “Anatomy for Beginners”
• Purchase DVD or download from Youtube free of charge
• Excellent modules to advance your coding and billing staff ’s
clinical knowledge
Attain Certification
Consider sending your billing manager, coders and others
in you practice to become CPC certified in preparation for
ICD-10.
Don’t wait until the implementation date, learning CPT,
HCPCS and ICD-9 will be an excellent foundation
Continuing education is a must!
Maintain Certification
Certified coders (CPC, CPC-A and other coding credentials
from AAPC) will require ongoing a proficiency Assessment
75 Questions
Open book, online, unproctored, use any resource available
Two attempts to pass over a two year window
Scheduled to be available Oct 1, 2013 – Sept 30, 2015
October 1, 2014
Implementation Compliance
Claims will require the new ICD-10 Codes
Continue Training
2-3 days of training will be required
AHIMA estimates 16 hours or less of training
– Have a certified coder on hand to support the physicians
and staff as they use the new code sets, or system, “live”
for the first time
– Anticipate some disruption, consider ways to support
your practice during this time
Helpful web sites

National Center for Health Statistics


CMS


www.ingenix.com/caretracker
AAPC


www.mgma.com
Ingenix


http://www.ahima.org/icd10
MGMA


http://www.cms.hhs.gov/ICD10/
AHIMA


http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm
www.aapc.com
AMA

http://www.ama-assn.org/ama1/pub/upload/mm/399/icd10-icd9differences-fact-sheet.pdf
About The Company…
For 20 years MedSafe has established the industry’s best practice
standards for quality, and regulatory compliance services for
healthcare practices. Through their onsite, and online programs
MedSafe assures that physicians and their businesses are actively in
compliance with the latest government regulations including
HIPAA/HITECH, Corporate/Billing Compliance, OSHA, and more.
About The Presenter…
Laurie Aloi is the Director of Billing and Compliance for
Medsafe: The Total Compliance Solution.
Laurie oversees the billing compliance auditing and
educational programs offered by Medsafe. A certified
coder/physician chart auditor with over 25 years
experience in the industry, Laurie directs the daily
operations of the billing compliance division.
59