ICD-10 Overview
Jacqueline L. Candelaria
Program Analyst
April 25, 2012
History of ICD-9-CM
• World Health Organization (WHO) developed ICD-9 for use
worldwide
• ICD-9 implemented in the US in 1979
• Expanded number of diagnosis codes
• Developed procedure coding system
ICD-9-CM Users
• ICD-9-CM Diagnoses –used by all types of providers
• ICD-9-CM Procedures –used only by inpatient hospitals
• Current Procedural Terminology (CPT) –used for all
ambulatory and physician procedure reporting
What is ICD-9-CM Used for
• Calculate payment –Medicare Severity-Diagnosis
Related Groups (MS-DRGs)
• Adjudicate coverage –diagnosis codes for all settings
• Compile statistics
• Assess quality
Why move from ICD-9 to ICD-10CM
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ICD-9-CM is outdated
30 years old-technology has changed
Many categories are full
Not descriptive enough
Why does we need a New Coding
System
• Quality–would facilitate evaluation of medical processes
and outcomes
• Reimbursement–would enhance accurate payment for
services rendered
Benefits of Adopting a New Coding
System
• Incorporates much greater
specificity and clinical information,
which results in:
• Improved ability to measure health care services
• Increased sensitivity when refining grouping and
reimbursement methodologies
• Enhanced ability to conduct public health surveillance
• Decreased need to include supporting documentation with
claims
Specific changes
• Diagnosis Codes (ICD-9 to ICD-10-CM)
• From 5 positions (first one alphanumeric, others numeric) to 7
positions, all alphanumeric
• From 13,000 existing codes to 68,000 codes
• Much greater specificity
• Full description and consistency within the code set
• Uses modern terminology for descriptions
• Creation of combination diagnosis/symptom codes to reduce
the number of codes needed to fully describe a condition
Structure of ICD-10
ICD-9-CM verses ICD-10-CM
ICD-9-CM codes
• Dental cariesunspecified-521.00
• Dental caries limited to
enamel-521.01
• Dental caries extending
into dentine-521.02
• Dental caries extending
into pulp-521.03
• Arrested dental caries521.04
ICD-10-CM codes
• Dental Caries-unspecifiedK02.9
• •localized destruction of
calcified tissue initiated on the
tooth surface by decalcification
of the enamel of the teeth,
followed by enzymatic lysis of
organic structures, leading to
cavity formation that, if left
untreated penetrates the
enamel and dentin and may
reach the pulp.
• •The decay of a tooth, in which
it becomes softened,
discolored, and/or porous.
ICD-9-CM codes verses 1CD-10-CM
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521 Diseases of hard tissues of teeth
521.0 Dental caries
521.00 Dental caries, unspecified
521.01 Dental caries limited to enamel
Initial caries
White spot lesion
521.02 Dental caries extending into dentine
521.03 Dental caries extending into pulp
521.04 Arrested dental caries
521.05 Odontoclasia
Infantile melanodontia
Melanodontoclasia
Excludes:
internal and external resorption of teeth
(521.40-521.49)
521.06 Dental caries pit and fissure
Primary dental caries, pit and fissure origin
521.07 Dental caries of smooth surface
Primary dental caries, smooth surface origin
521.08 Dental caries of root surface
Primary dental caries, root surface
521.09 Other dental caries
• 13 ICD-9- CM codes
• 20 ICD-10 CM codes
• ICD-10 codes are
descriptive
• ICD-9 codes a vague
and not as descriptive
How is IHS Approaching ICD-10
• Established an ICD-10 Steering Committee
• Building organizational awareness and commitment
• Identified key stakeholders (HIM, IT, Business Office & Revenue
Cycle, Clinical)
• Evaluating systems and interfaces where codes are captured,
exchanged, and reported
• Assessing areas of risk
• Identifying all systems that assign, utilize or store diagnosis codes
• Identifying all processes/policies that utilize diagnosis codes
• Identifying all contractors and business partners that rely on
diagnosis codes
• Obtaining vendor commitment for readiness
• Evaluating interface engine support of ICD-10
• Developing a plan and beginning implementation activities
ICD-10 – Subgroups
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Business & Revenue Cycle:
Clinical Documentation Improvement:
Data Management:
Outreach & Awareness:
Technical Development:
Training:
Changes to RPMS for ICD-10
• 64 applications contain ICD-9 Codes
• Assessing file structure changes
• Field size changes, longer code descriptions
• Numeric vs. alpha characters
• Logic changes due to the revised code structure
• Role of mapping codes being assessed
• Interfaced systems with ICD-9 touch points
- I/T/U will have to assess any COTS products
ICD-10 & ICD-9 FACTS
• Both ICD – 9 and ICD – 10 will have to be maintained/used
for a period of time
• Non-covered entities, like worker’s compensation and auto
insurances claims may still use ICD-9 well after the compliance
date of 10/1/2013
• Coding and billing backlogs, CMS eligibility changes
• Reporting, trending, comparison
• MU Core Measures (i.e., hypertension)
Clinical and Business Process
Changes
• Understand this is not just an IT or HIM Project
• Organization – wide initiative that impacts
• Information Systems – EHR Templates, Pick-lists
• Provider Documentation
• Clinical Documentation Improvement Program
• Coding and Billing
• Physician Query Process
• Revenue Cycle Management
• Contracting, HR, Finance
• Quality Improvement, Data Extracts, etc.
Areas (I/T/U) recommended to conduct an assessment
What are the Next Steps for Areas
I/T/U’s
Designate an Area/local ICD-10 Coordinator
• Develop Area/local ICD-10 expertise to assist with
implementation
• Assess ICD-10 impact on IT systems
• Local modifications; COTS- vendor readiness; Testing with
Payers
• Assess ICD-10 impact on coding competencies; plan for
subsequent training in the bio sciences
• Begin/continue Awareness Training
• Develop contingency plan to minimize impact on Revenue
Cycle Management (clinical documentation improvement, etc.)
• Begin to identify a two-year budget for implementing ICD-10
and related training
• Begin to address recruitment and retention of coding staff
Resources
• Join the ICD-10 List Serve:
http://www.ihs.gov/listserver/index.cfm?module=signUpForm
&list_id=201
• IHS ICD – 10 Website: http://www.ihs.gov/icd10
Summary
• ICD-10 Implementation-10/01/2013 with a CMS Proposed
delay of 10/01/2014
• ICD-10 affects Providers, Nurses, Ancillary staff, coders, billing
staff, HIM, QM, UR, Program Planning, Statistician, Sanitation,
etc.
• Outreach and Awareness, communication, training, impact
and awareness should be occurring now
• Intensive training to begin January-March 2013, possibly in
2014 when actual delay date is announced.