2013 Webinar Series #1 –
Pathway through the ICD-10 Maze
March 19, 2013
*
2013 Webinar Series #1 –
Pathway through the ICD-10 Maze
ICD-10 Background
Presented by
Jeff Hinson
Regional Administrator
Centers for Medicare & Medicaid Services
Denver Regional Office
*What is ICD-10?
*Refers to diagnosis and procedure code sets
*Replaces ICD-9 code sets and includes updated medical
terminology and classification of diseases.
*Does not impact other medical coding sets (CPT-4, HCPS,
NDC)
*What’s Required?
*ICD-10 must be used for transactions with dates of
service/date of discharge on or after October 1, 2014
*ICD-9 will no longer be accepted.
*Deadline is firm.
*Who Is Affected?
Anyone who is
covered by HIPAA:
Health care providers
that conduct electronic
transactions
Payers including
Medicaid and Medicare
Clearinghouses
*Who Is Affected?
Some non-HIPAA covered
entities that use ICD-9 codes:
Vendors and business
associates of covered
entities
Worker’s compensation
programs
Life insurance
companies
*Why the change?
ICD-10 Provides More Specific Data
*
*
Better reflects current medical practice
Structure accommodates addition of new codes
• The current coding system is running out of
capacity and cannot accommodate future state
of health care
*Benefit:
• More accurate payments for new procedures
• Fewer miscoded, rejected and improper
reimbursed claims
* Why the change?
ICD-10 Allows for Expanded Data Capture
•
•
•
•
•
Quality measurement
Better analysis of disease patterns
Track and respond to public health outbreaks
Make claim submission more efficient
Identify fraud and abuse
*Benefit: Improved ability to measure healthcare services
•
•
Increased sensitivity when refining grouping &
reimbursement methodologies
Decreased need to include supporting documentation
with claims
*ICD-10 Resources
Website
Implementation Handbooks
www.cms.gov/icd10
Fact Sheets
Email Updates
*Thank you!
*
2013 Webinar Series #1 –
Pathway through the ICD10 Maze
* ICD-10 Basics
Presented by
Rebekah S. Gatti, CCS-P, CPC, CPC-I, CEDC, CPMA
R.T. Welter and Associates, Inc.
*ICD-10 Basics
• ICD-10-CM is similar to ICD-9CM as far as format and basic
guideline information
• Total number of codes
expands from about 14,000
ICD-9-CM codes to well over
68,000 in ICD-10-CM (the
majority of additions lie in the
musculoskeletal codes,
accounting for about 37,000
of the additional codes)
• ICD-10 Uses full code titles in
the code description, while
ICD-9 does not
• ICD-10-CM was designed
with better capability for
expansion
* ICD-10-CM TABULAR LIST
of DISEASES and INJURIES
*ICD-9 to ICD-10
Structural Differences
*ICD-10-CM Structure
Alphanumeric
* Characters 1-3 – Category
* Characters 4-6 – Etiology, anatomic site, severity,
or other clinical detail
* Character 7 – Extension (may indicate encounter
information, trimester, fetus number, etc.)
*ICD-10-CM Structure
ICD-10 Structure 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
Code can’t be completed until all information as to type of
fracture, site (lower end of radius), healing type and encounter
are specified.
*A Few ICD-10-CM Conventions
*A Few ICD-10-CM Conventions
ICD-9-CM has minimal instruction to it’s 9 conventions
ICD-10-CM has twice as many conventions (18) and additional detail and
guidance for correct use and interpretation
Excludes 1 - Example
*A Few ICD-10-CM Conventions
Excludes 2 - Example
*A Few ICD-10-CM Conventions
*A Few ICD-10-CM Conventions
General Coding Guidelines – Example
ICD-10-CM 2013 Release is now available and
can be accessed at:
Download the 113 page document at:
www.cdc.gov/nchs/icd/icd10cm.ht
m
*
2013 Webinar Series #1 –
Pathway through the ICD10 Maze
* Code by example
Rebekah S. Gatti, CCS-P, CPC, CPC-I, CEDC, CPMA
R.T. Welter and Associates, Inc.
*Choices
The number of codes has increased dramatically
*What may have been a single code in ICD-9 may now
have several hundred code choices due to the
specificity of ICD-10-CM
*Code choices require more information
*More specificity may require better documentation
* Example 1:
*
*
Diabetes
Significant Change to Diabetes Mellitus
Six Diabetes Mellitus categories in the ICD-10-CM.
1.
2.
3.
4.
5.
6.
E08
E09
E10
E11
E13
E14
Diabetes Mellitus due to an underlying condition
Drug or chemical induced diabetes mellitus
Type I diabetes mellitus
Type 2 diabetes mellitus
Other specified diabetes mellitus
Unspecified diabetes mellitus
Example: Type II Diabetes with heel ulcer
ICD-9 250.80 707.14
ICD-10 E11.621
L97.401 thru L97.429
(fifteen codes defining level of breakdown,
right heel, left heel, or unspecified heel)
* Diabetes
*
*
*
Expanded to include the classification of the diabetes and
the manifestation.
Category updated to reflect the current clinical
classification of diabetes.
No longer classified as controlled/uncontrolled.
E08.22, Diabetes mellitus due to an underlying condition with
diabetic chronic kidney disease
E09.52, Drug or chemical induced diabetes mellitus with
diabetic peripheral angiopathy with gangrene
E10.11, Type 1 diabetes mellitus with ketoacidosis with coma
E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy
* Example 2: Gout
*
Gout: ICD-9 has 36 codes describing gout/gouty conditions
Unspecified 274.9
*
ICD-10 currently has 239 codes to describe gout/gouty
conditions (primary, secondary, drug induced, due to renal
impairment, body area, right, left, unspecified, lead
induced, idiopathic etc., etc.)
*
Chronic Gout Unspecified M1a.9 (requires 7th digit)
M1a.9xx1 or M1a.9xx0
*Example 3:
Fractures
Fracture codes require seventh character to identify if
fracture is closed or open.
•The fracture extensions 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 Sequelae
* Fractures
Example:
- ICD-9-CM code 813.42 – Other closed fracture of distal
end of radius (alone)
- ICD-10-CM: 210 possible corresponding codes
Information needed to accurately code in ICD-10:
Fracture type (e.g. displaced/non-displaced, intraarticular/extra-articular, Salters-Harris Type 1 to Type 4
etc.), which part of radius (styloid process), healing
type (routine healing, delayed healing, mal-union, nonunion), laterality, and encounter.
ICD-10-CM example: S52.511G – Displaced fracture of
right radial styloid process, subsequent encounter for
closed fracture with delayed healing
*
2013 Webinar Series #1 –
Pathway through the ICD-10 Maze
Presented by
Denny Flint
President
Complete Practice Resources
*Additional ICD-10 Points
*Increased specificity requires more
detailed documentation
*Providers are therefore the
cornerstone for the success of your
ICD-10 transition
*Unspecified = Unpaid
*Increase in Codes?
Here’s the Real Story
* Gastroenterologists: 596 ICD-9 codes - 706 codes in ICD-10
(+110)
* Pulmonologists: 255 codes in ICD-9 - 336 codes in ICD-10
(+81)
* Urologists: 389 codes in ICD-9 - 591 codes in ICD-10 (+202)
* Endocrinologists: 335 codes in ICD-9 - 675 codes in ICD-10
(+340)*
* Neurologists: 459 codes in ICD-9 - 591 codes in ICD-10 (+132)
* Pediatricians: 702 codes in ICD-9 down to 591 codes in ICD-10 (111)
* Infectious disease: 1,270 in ICD-9 down to 1,056 in ICD-10 (-214)
A few hundred new codes = a few dozen new documentation elements
* ICD-10-CM includes more combination codes containing co-morbidities and
associated conditions. Example - Diabetes
© 2011 MedLearn /
35
© 2011 MedLearn /
36
Fracture of the Patella
ICD-9-CM
2 codes
ICD-10-CM 480 codes
Watch what happens to the number of ICD-10
codes when we add only 3 additional
documentation elements
© 2011 MedLearn /
38
© 2011 MedLearn /
39
© 2011 MedLearn /
40
*Problem/Solution
*Fracture of Patella
*2 ICD-9 codes translate to a seemingly absurd
number of ICD-10 Codes
*But only 5 new documentation elements!
It’s not about the thousands of new codes,
it’s about the dozen or so new
documentation elements!
* Documentation needs and
Responsibility for ICD-10 Success
*Create documentation awareness now!
*Physician Documentation is the cornerstone
for ICD-10 Transition success
*This is the primary responsibility physicians
have in the move to ICD-10
*But doctors want to doctor
*So…create easy reference tools.
Here’s an example - Asthma
Asthma
Quick Reference Documentation Guide
*Mild, Moderate, or Severe?
*Intermittent or Persistent?
*Tobacco use or exposure?
If you create one of these for your top 50
most frequently used diagnoses, and
introduce one every two weeks, you will be
ready.
Gauge current documentation’s
ability to support ICD-10
Easy-to-perform Chart Audit
*Convert top 20 ICD-9 codes using Transition Software
*Analyze required ICD-10 documentation
*Select 5 charts per provider for each ICD-9 code
*Assess current chart documentation ability to
support new, more specific ICD-10 codes
*Give the docs a report card
Excellent technique to get your providers educated
and engaged for the ICD-10 Transition
Why is this so important?
“Physicians may be ICD-10 compliant,
but if they abuse the “other” or
“unspecified” codes, payment will not
occur if a more specific alternative
exists.”
David Winkler
Director of Technical Program Management
Blue Cross of Michigan
Justifying medically necessary procedures and
services depends on specificity of diagnoses
coding!
Doctors need to know…
*Current Insurance Reimbursement Issues will
carry over to ICD-10
*Medical Necessity Denials
*Unspecified = Unpaid?
*Delayed payment – requests for additional
information
*(Broken Record) Documentation is the key to
ICD-10 Transition success
…And you need their support.
*At the end of the day, it’s
all about the patients
*Richer acuity level databases =
better care (metal hip prostheses,
asthma)
*Patient advocates in the insurance
arena
*Better data should equate to better
reimbursement
*Working for you!
*Thank you!