ICD-10-CM Update
Presented by:
Janet Smith, RHIT, CPC
AHIMA Approved ICD-10 Trainer
The Tennessee Pediatric Society Foundation
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Brief History
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ICD-10 was adopted by the World Health
Organization (WHO) in 1990
Following the publication of ICD-10, many
countries performed analysis to determine if
the WHO classification system would meet
their needs
The International Classification of Diseases,
Tenth Revision, Clinical Modification (ICD-10CM) is the United States’ clinical modification
to the World Health Organization’s version of
ICD-10
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Brief History
Countries Using ICD-10 For Reimbursement
or Case Mix:
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United Kingdom - 1995
Nordic countries (Denmark, Finland,
Iceland, Norway, Sweden) - 1994 –1997
France - 1997
Australia - 1998
Belgium - 1999
Germany - 2000
Canada - 2001
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Brief History
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The United States remains the only
industrialized nation that has not yet
implemented ICD-10 or a clinical
modification for diseases or causes of illness
typically coded in a healthcare facility
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Since 1999, however, the United States has
used ICD-10 for mortality reporting (for
death certificates)
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Why do we need ICD-10?
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ICD-9 is 30 years old –medicine and
technology has changed
Many categories full
Not descriptive enough
Implementing ICD-10-CM will maintain
data comparability internationally and
between mortality and morbidity data in
the United States
Would enhance accurate payment for
services rendered
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Benefits of ICD-10-CM
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Greater clinical detail
More specificity, laterality, external causes of
injuries, combination codes for diagnoses and
symptoms
Reflects advances in medicine and medical
technology
Measuring the quality, safety, and efficacy of care
Reducing the need for attachments to explain
patient’s condition
Improving clinical, financial, and administrative
performance
Tracking public health and risks
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When will ICD-10 be implemented?
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In January 2009, the Department of Health and Human
Services published the final rule for adoption of ICD-10CM and ICD-10-PCS, setting a compliance date of October
1, 2013
On April 9, 2012, HHS released a proposed rule that calls
for a one-year delay for the ICD-10 compliance date from
October 1, 2013 to October 1, 2014.
On April 17, 2012 the announcement for the ICD-10 delay
was published in the Federal Register. A 30-day comment
period was granted on the proposed rule and is now
closed.
Public comments are being reviewed and analyzed, and
the Department will issue a final rule as expeditiously as
possible
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Reasons behind the delay
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There was no one group that spurred CMS to
propose the delay
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The industry’s ongoing struggle to implement HIPAA
Version 5010 (a precursor to ICD-10) that was
effective January 2012 but has seen enforcement
delayed twice because many physicians have had
technical trouble implementing the version update
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Physician concern regarding the ICD-10 timeline
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A one-year delay reflects the industry’s need for a
quick resolution and providers’ need for additional
time to implement, and will not likely penalize those
on track with the original deadline
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What to Expect with ICD-10?
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ICD-10-CM (Clinical Modification) will replace ICD-9-CM
diagnosis codes rendered in all healthcare settings.
ICD-10-PCS (Procedural Coding System) will replace the ICD9-CM procedure codes rendered in the hospital/inpatient
setting.
CPT and HCPCS Level II will remain the coding system for
physician and professional services and procedures performed
in the outpatient setting.
After the implementation of the ICD-10 code set, inpatient
reimbursement for Medicare patients will be based on
Medicare DRGs using the ICD-10 coding system not ICD-9
Payer and office systems and processes must be able to
support both ICD-9 and ICD-10 code sets on the
implementation date
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ICD-10 Practice Impact
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Plan for budgeting
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Staffing changes/additions
Education for providers and staff
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Revenue flow problems
Productivity
Software/System upgrades
Audit for increased specificity in documentation
(Stages of healing, episode of care, laterality)
Code set training
Operate under dual coding system
Health Plans
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Contracts
Coverage policies
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Cost Estimate – 5 Physician
Practice (Two Years)
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Information Systems
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Practice Management Upgrade - $5,000
EMR Upgrade (if applicable) - $5,000
IT and Consulting - $5,000
Audit/Review/Consulting
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General Consulting/Audit Year 1 @ $500/provider twice a
year - $3,000
General Consulting Year 2 - $3,000
Review of System Process - $3,000
Crosswalking - $1,500
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Cost Estimate – 5 Physician
Practice (Two Years)
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Education and Training
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5 physicians - $3,500
1 coder/biller - $1,600
2 nurses/MA - $3,000
2 ancillary staff - $1,000
Management - $500
Staff and Overtime
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Coders - $2,000
Ancillary Staff - $400
Productivity Loss - $18,400
TOTAL Estimated Cost = $59,500
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How is ICD-10 structured?
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The “look-up” process will be very similar
to ICD-9
The same hierarchical structure is used as
ICD-9
The ICD-10 system will be alphanumeric
and contain up to 7 characters
ICD-10 has approximately 68,000 codes vs.
14,000 in ICD-9
Code composition and level of detail are the
major differences
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ICD-10- CM Structure
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21 Chapters
2 New Chapters
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Certain Diseases were re-classified and are now
found in new chapters
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Diseases of the Eye and Adnexa (Ch 7)
Diseases of the Ear and Mastoid Process (Ch 8)
Immune Mechanism (Immunity) was moved from
Chapter 4 (Endocrine) to Chapter 3 (Blood Disorders)
Injuries (Ch19) are now arranged by body part and
not by injury
Mental Disorders (Ch 5), Injury and Poisonings (Ch
19), and External Causes (Ch 20) were all
re-organized
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ICD-10- CM Structure
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Codes have 3 to 7 alphanumeric characters (vs 5
numeric in ICD-9)
Character 1 is always alpha – letters A-Z, except U
Character 2 is numeric
Character 3-7 can be alpha or numeric
Decimal placed after the first three characters
Alpha characters are not case-sensitive
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A78 – Fever
J04.0 – Acute laryngitis
S41.111 – Laceration w/o foreign body of right upper arm
S63.280A – Dislocation of proximal interphalangeal
joint of right index finger, initial encounter
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ICD-10- CM Structure
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Character 4 represents a subcategory that further
defines the site, etiology and manifestation or state of
the disease
Character 5 and 6 identify the most accurate level of
specificity
Character 7 – Extension
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Some codes require 7 characters
If a code requires a 7th character and there is no 5th or 6th
character, a placeholder “X” must be used
All placeholders of an applicable code must be reported
Example: T16.XXA – Foreign body in right ear, initial encounter
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ICD-10- CM Structure
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S60 – Superficial injury of wrist, hand and fingers
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S60.4 – Other superficial injuries of other fingers
S60.45 – Superficial foreign body [splinter] of
fingers
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S60.451 – Superficial foreign body [splinter] of
left index finger
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S60.451A – Superficial foreign body
[splinter] of left index finger, initial encounter
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Translation of Codes
ICD-9-CM
TO
ICD-10-CM
003.21 Salmonella meningitis
=
A02.21 Salmonella meningitis
ICD-9-CM
TO
ICD-10-CM
307.46 Sleep Arousal
Disorder
≠
F51.3 Sleepwalking
ICD-9-CM
ICD-10-CM
010.90 Primary tuberculosis
infection, unspecified examination
010.91 Primary tuberculosis
infection, bacteriological/histological
exam not done
010.92 Primary tuberculosis
infection, bacteriological/histological
exam unknown (at present)
≠
A15.7 Primary
respiratory tuberculosis
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External Causes
Chapter 20 - Codes for external causes
 V, W, X and Y are the 1st characters
 Are never used as primary code
 Are never reported alone
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Z Codes are the New “V” Codes
Chapter 21 – Factors influencing health status and
contact with health services
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Encounter for healthcare exams
Are part of the ICD-10-CM code set and must be
recognized by payers
May be used as primary diagnosis
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Preventive Care
Z00.129 Routine child health check
Z00.121 Routine child health check with abnormal
findings
Z00.110 Health supervision (health check) for
newborn under 8 days
Z00.111 Health supervision (health check) for
newborn 8 to 28 days
Z23
Encounter for immunizations
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Other Health Visits
Z01.818
Z02.0
Z02.5
Z02.82
Z48.02
Z71.0
Z71.3
Z76.81
Pre-operative examination
School physicals
Sports physicals
Pre-adoption exam
Suture removal
Parent (family) conference
Diet management (for obesity)
Parents pre-birth or pre-adoption
visit
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Documentation
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Use appropriate terminology
Document highest level of specificity
Indicate right versus left
Indicate specific body area
Specify episode of care (initial, recurrent)
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Reimbursement and Quality Problems
With ICD-9-CM
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Example –Fracture of Wrist
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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
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Example
If provider documents:
OM (otitis media)
Code =
H66.90 otitis media,
unspecified, unspecified ear
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Possible Codes
Acute suppurative otitis media without
spontaneous rupture of ear drum
H66.001,
H66.002,
H66.003,
H66.004,
H66.005,
H66.006,
H66.007,
H66.009,
right ear
left ear
bilateral
recurrent, right ear
recurrent, left ear
recurrent, bilateral
recurrent, unspecified ear
unspecified ear
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Example
If provider documents:
Reactive Airway Disease
Code = J45.909 Unspecified asthma,
uncomplicated
If provider documents:
Respiratory Distress
Code – R06.89 Other abnormalities of
breathing
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Possible Codes
J98.01
Acute bronchospasm
J45.990
Exercise induced
bronchospasm
J45.991
Cough variant asthma
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Other Possible Asthma Codes
Asthma
J45.20
J45.21
J45.22
J45.30
J45.31
J45.32
J45.40
J45.41
Mild intermittent, uncomplicated
Mild intermittent, with (acute) exacerbation
Mild intermittent with status asthmaticus
Mild persistent, uncomplicated
Mild persistent, with (acute) exacerbation
Mild persistent, with status asthmaticus
Moderate persistent, uncomplicated
Moderate persistent, with (acute) exacerbation
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What to do now?
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Maintain momentum
Identify current systems and processes that
use ICD-9 codes
Talk with vendors about accommodations
for ICD-10
Take the time to improve clinical
documentation
Evaluation staff training needs
Ask payers how ICD-10 changes may affect
contracts, payment schedules and
reimbursement
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Informational Links
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http://www.cdc.gov/nchs/icd/icd10c
m.htm
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http://www.cms.hhs.gov/ICD10
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http://www.ahima.org/icd10/
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Questions?
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Thank You!
Contact information:
Janet Smith
Coding Educator
janet.smith@tnaap.org
615-672-1355
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Foundation
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