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 11 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 13 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 16 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 18 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