ARE YOU READY FOR ICD-10-CM?
PALMETTO HEALTH
Carolyn Todd Mahon, PhD, MSN-NP, MBA
Medical Business Institute
Dallas, Texas
DISCLOSURE
I have no relevant financial
relationships with any commercial
interests related to the content
of this activity –
Carolyn Todd Mahon, PhD, MSN-NP, MBA
Medical Business Institute
Dallas, Texas
DISCLAIMER
• While all information in this document is
believed to be correct at the time of writing, this
document is for educational purposes only and
does not purport to provide legal advice. All
models, methodologies and guidelines are
undergoing continuous improvement and
modification by NHIC, Corp. and the Centers for
Medicare & Medicaid Services (CMS). The most
current edition of the information contained in
this release can be found on the NHIC, Corp.
web site at www.medicarenhic.comand the
CMS web site at www.cms.gov.
ICD-10-CM WHERE DO I
START?
1.
2.
3.
4.
Overview
Structure and Use
Actions and Timeline
Tools and Resource
4
ICD-10-CM OVERVIEW
• ICD is one of the code sets used in medical
billing along with others such as CPT
• The ICD system is the code set for identifying
diagnoses to support services and/or
procedures (identified by the CPT code sets)
rendered by healthcare providers
• ICD-10-CM is the abbreviation for the
International Classification of Diseases,
Tenth Revision, Clinical Modification
OVERVIEW OF ICD-10-CM
• No longer October 1, 2013 but a future date
to be announced by HHS, medical coding in
U.S. health care settings will change from
ICD-9 to ICD-10. The transition will require
business and systems changes throughout
the health care industry. Everyone who is
covered by the Health Insurance Portability
and Accountability Act (HIPAA) must make
the transition, not just those who submit
Medicare or Medicaid claims.
OVERVIEW OF ICD-10
• On January 1, 2012, standards for
electronic health transactions change
to Version 5010. Version 5010
accommodates the ICD-10 code
structure. This change occurs before
the ICD-10 implementation date to
allow adequate testing and
implementation time.
What’s In IT For You?
• Benefits
– Claims Acknowledgement
– 5010 is more specific about required data
– Supports new ICD-10 codes
– 5010 contains significant improvements
for the reporting of clinical data
– 5010 supports increased use of EDI
between covered entities
– 5010 supports E-Health initiatives now
and in the future
5010 Changes
Some 5010 changes
• Prohibits use of P.O. Box
addresses for billing provider
(different from pay to address)
• Expands size of diagnosis code
field
• Expansion of the number of
diagnosis codes to 12
• Immediate assignment of a claim
number allows easier follow-up
WHEN DOES ICD-10
ACTUALLY HAPPEN?
• A date to be announced by HHS
• “I believe we are looking at a minimum of 1
year. They will need to announce a delay
from October 1, 2013 to at least October 1,
2014 because of CMS fiscal planning
calendars.”
When the new compliance date is set it will
still be true that if you are not ready, your
claims will not be paid. Preparing now can
help you avoid potential reimbursement
issues
History of ICD-9-CM
• World Health Organization (WHO)
developed ICD-9 for use worldwide
– The National Center for Health Statistics
developed clinical modification (ICD-9-CM)
Implemented in 1979 in U.S.
– Expanded number of diagnosis codes
– Developed procedure coding system
– DESIGNED TO LAST 10 YEARS
WHAT IS ICD-10?
• 1990 –Endorsed by World Health Assembly
(diagnosis only)
• 1994 –Release of full ICD-10 by WHO
• HIPAA Mandate- 1996
• 2002 (October) –ICD-10 published in 42
languages (including 6 official WHO languages)
• January 1, 1999 –U.S. implemented for mortality
(death certificates)
WHY ARE WE MOVING TO ICD-10?
• ICD-9-CM is Outdated
– 30 years old –technology has changed
– Many categories full
– Not descriptive enough
WHY ARE WE MOVING TO ICD-10?
– Reimbursement–would enhance accurate
payment for services rendered
– Quality–would facilitate evaluation of
medical processes and outcomes
– What Characteristics Are Needed in a
Coding System?
• Flexible enough to quickly incorporate
emerging diagnoses and procedures
• Exact enough to identify diagnoses and
procedures precisely
ICD-9-CM is too old to be either of these
Reimbursement and Quality
Problems With ICD-9-CM
• 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
Reimbursement and Quality
Problems With ICD-9-CM
Ex: Ovary - ICD-9= 1 code vs. ICD-10= 4 codes
• ICD-10-CM describes Left versus right
• Initial encounter, subsequent encounter
Reimbursement and Quality
Problems With ICD-9-CM
Example –combination defibrillator pacemaker device
– Codes for this device are not in the cardiovascular
chapter of ICD-9-CM with other defibrillator and
pacemaker devices
– Coders and researchers have trouble finding these
codes with this type of erratic code assignment
– ICD-10-PCS provides distinct codes for all these types
of devices, in an orderly manner that is easy to find
ICD-10
1. ICD Structure and Use
2. Actions and Timeline
3. Tools and Resource
18
Structural Differences –ICD-9-CM
Diagnoses
•
•
•
•
ICD-9 HAS TWO VOLUMES
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-9/10-CM
Diagnoses
ICD-10-CM – diagnosis coding
• Change in structure and volume
• ICD-9-CM 2010 - 14,315 codes
• ICD-10-CM 2010 – 69,099 codes
• Both code sets currently being
updated
• Added specificity & added complexity
• Electronic “crosswalk” created and
free from CMS
Structural Differences ICD-10-CM
Diagnoses
• ICD-10 HAS THREE VOLUMES
• ICD-10-CM has 3 –7 digits
• •Digit 1 is alpha (A –Z, not case sensitive)
• •Digit 2 is numeric
• •Digit 3-7 is ALPHA (not case sensitive) or NUMERIC
– 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
ICD-10-CM Tabular List
1.
2.
3.
Certain Infectious and Parasitic Diseases
Neoplasms
Diseases of the Blood and Blood-forming Organs and
Certain Disorders Involving the Immune Mechanism
4. Endocrine, Nutritional, and Metabolic Diseases
5. Mental and Behavioral Disorders
6. Diseases of the Nervous System
7. Diseases of the Eye and Adnexa
8. Diseases of the Ear and Mastoid Process
9. Diseases of the Circulatory System
10. Diseases of the Respiratory System
ICD-10-CM Tabular List
11. Diseases of the Digestive System
12. Diseases of the Skin and Subcutaneous System
13. Diseases of the Musculoskeletal System and Connective Tissue
14. Diseases of the Genitourinary System
15. Pregnancy, Childbirth and the Puerperium
16. Certain Conditions Originating in the Perinatal Period
17. Congenital Malformations, Deformations and Chromosomal
Abnormalities
18. Symptoms, Signs and Abnormal Clinical and Laboratory Findings,
not elsewhere classifiable
19. Injury, Poisonings, and Certain Other Consequences of External
Causes
20. External Causes of Morbidity
21. Factors Influencing Health Status and Contact with Health
Services
ICD-10 Structure & Use
The patient is in the office for the first visit because
of
closed greenstick fracture of the right radial shaft.
ICD-9
813.21
Fracture of radius and ulna; shaft,
closed radius (alone)
S52.311A
ICD-10
Greenstick fracture of shaft of radius,
right arm, initial encounter for closed
fracture
24
Diagnosis Code Structure
S52.311A
Greenstick fracture of shaft of radius, right arm, initial
encounter for closed fracture
Root
Root
Root
Site
Severity
Etiology Extension
S
5
2
3
1
1
A
Injury,
poisoning and
certain other
consequences
of external
causes
Injuries
to the
elbow
and
forearm
Fracture
of
Forearm
Radial
Shaft
Greenstick
Right
Initial
Encounter
25
SPECIFICITY/LATERALTY
ICD-10 CODE STRUCTURE
Characters 1-3= Category
Characters 4-6= Etiology, anatomic site, severity or other
clinical detail
Character 7
= Extension
Example code: S52.521A
S52
Fracture of the 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 right radius, initial encounter
for closed fracture
Code extensions
(seventh character)
• Code extensions (seventh character) have been added
for injuries and external causes to identify the
encounter: initial, subsequent, or sequela. The
extensions are:
• A Initial encounter
• D Subsequent encounter
• S Sequelae
• For example, ICD-10-CM code S31.623A, Laceration
with foreign body of abdominal wall, right lower quadrant
with penetration into peritoneal cavity, initial encounter,
shows an extension used with a laceration code. Note
that in ICD-10-CM, the entire code description is written
out.
Code extensions
(seventh character)
• Fracture codes require a seventh character that identifies if the
fracture is open or closed for an initial encounter or if a subsequent
encounter is for routine healing, delayed healing, nonunion,
malunion, or sequelae. 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
• An example is code S42.321A, Displaced transverse fracture of
shaft of humerus, right arm, initial encounter for closed fracture.
Diabetes mellitus
• Diabetes mellitus codes are expanded to include the
classification of the diabetes and the manifestation. The
category for diabetes mellitus has been updated to
reflect the current clinical classification of diabetes and
is 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
Complications of foreign body
• ICD-10-CM provides 50 different codes for
“complications of foreign body accidently left in body
following a procedure,” compared to only one code in
ICD-9-CM. Examples include:
• T81.535, Perforation due to foreign body accidently left
in body following heart catheterization
• T81.530, Perforation due to foreign body accidently left
in body following surgical operation
• T81.524, Obstruction due to foreign body accidently left
in body following endoscopic examination
• T81.516, Adhesions due to foreign body accidently left
in body following aspiration, puncture or other
catheterization
MAPPING WITH GEMS
• What are the General Equivalence Mappings?
• The GEMs are a tool that can be used to convert data from ICD9-CM to ICD-10-CM and PCS
• and vice versa. Mapping from ICD-10-CM and PCS codes back
to ICD-9-CM codes is referred to
• as backward mapping. Mapping from ICD-9-CM codes to ICD10-CM and PCS codes is referred to
• as forward mapping. The GEMs are a comprehensive
translation dictionary that can be used to
• accurately and effectively translate any ICD-9-CM-based data,
including data for:
➤ Tracking quality;
➤ Recording morbidity/mortality;
➤ Calculating reimbursement; or
➤ Converting any ICD-9-CM-based application to ICD-10CM/PCS.
(CDC)
MAPPING WITH GEMs
• The GEMs are complete in their description
of all the mapping possibilities as well as
when there are new concepts in ICD-10 that
are not found in ICD-9-CM. All ICD-9-CM
codes and all ICD-10-CM/PCS codes are
included in the collective GEMs:
➤ All ICD-10-CM codes are in the ICD-10-CM to
ICD-9-CM GEM;
➤ All ICD-9-CM Diagnosis Codes are in the ICD9CM to ICD-10-CM GEM;
Why Do We Need the General
Equivalence Mappings?
• ICD-10 is much more specific:
– For diagnoses, there are 14,025 ICD-9-CM
codes and 68,069 ICD-10-CM codes; and
– For procedures, there are 3,824 ICD-9-CM
codes and 72,589 ICD-10-PCS codes (in
the 2009 versions of ICD-9-CM, ICD-10-CM,
and ICD-10-PCS).
Why Do We Need the General
Equivalence Mappings? Cont’d
One ICD-9-CM Diagnosis Code is represented by
multiple ICD-10-CM codes:
82002 Fracture of midcervical section of femur, closed
– From S72031A
• Displaced midcervical fracture of right femur, initial encounter
for closed fracture
– From S72031G
• Displaced midcervical fracture of right femur, subsequent
encounter for closed fracture with delayed healing
– From S72032A
• Displaced midcervical fracture of left femur, initial encounter
for closed fracture
– From S72032G
• Displaced midcervical fracture of left femur, subsequent
encounter for closed fracture with delayed healing
– And other codes from the GEMs
Why Do We Need the General
Equivalence Mappings? Cont’d
• One ICD-10-CM Diagnosis Code is
represented by multiple ICD-9-CM Codes:
– E11341 Type 2 diabetes mellitus with severe
nonproliferative diabetic retinopathy with macular
edema
• To ICD-9 Cluster:
– 250.50 Diabetes with ophthalmic
manisfestations, type II or specified type, not
stated as uncontrolled
– 362.06 Severe nonproliferative diabetic
retinopathy
– 362.07 Diabetic macular edema
Why Do We Need the General
Equivalence Mappings? Cont’d
➤ A few ICD-10-CM codes have no predecessor ICD-9CM codes:
– T500x6A Under dosing of mineral corticoids and their
–
–
–
–
–
antagonists, initial encounter
T501x6A Under dosing of loop [high-ceiling] diuretics,
initial encounter
T502x6A Under dosing of carbonic-anhydrase inhibitors,
benzothiadiazides and other diuretics, initial encounter
T503x6A Under dosing of electrolytic, caloric and waterbalance agents, initial encounter
T504x6A Under dosing of drugs affecting uric acid
metabolism, initial encounter
And others found in the GEMs
How are the GEM Files Formatted?
• Here is an example from the ICD-10-CM diagnosis
mapping:
➤ ICD-10-CM Source system code is on the left side;
➤ ICD-9-CM Target system code is in the middle; and
➤ Flags are on the right.
ICD-10 CM
ICD-9 CM
Source Code
Target Code
Flags
T1500xA
9300
10111
T1500xA
E914
10112
T1500xD
9300
10111
T1500xD
E914
10112
T1500xS
908.5
10000
How are the GEM Files Formatted?
•
T1500xA
Foreign body in cornea, unspecified
eye, initial encounter
– To ICD-9 cluster:
• 9300 Corneal foreign body
• E914 Foreign body accidentally entering eye and
adnexa
•
T1500xD
Foreign body in cornea, unspecified eye,
subsequent encounter
– To ICD-9 cluster:
• 9300 Corneal foreign body
• E914 Foreign body accidentally entering eye and
adnexa
•
T1500xS Foreign body in cornea, unspecified
eye, sequela
– To 908.5 Late effect of foreign body in orifice
How are the GEM Files Formatted?
• There are three different flags:
– “Approximate” is Flag 1, which is in column 1 of
the flags:
• 1 means the translation is an Approximate match
Example of Diagnosis Approximate match (1),
not Identical match
– T1500xA
9300
10111
– T1500xA
E914
10112
– Each of these codes is an Approximate match
• 0 means the translation is an Identical match
Example of diagnosis Identical match (0)
– 41411
12542
00000
– ICD-9-CM code 414.11 is an Identical match to
ICD-10-CM code 12542
How are the GEM Files Formatted?
• “No Map” is Flag 2, which is in column 2 of
the flags:
– 1 means there is no plausible translation for the
source system code
– 0 means there is at least one plausible translation
for the source system code
– Notice the NODX “No Description Found” entry
instead of a code number in middle column
• T500x6A
• T500x6D
• T500x6S
NODX
NODX
NODX
11000
11000
11000
How are the GEM Files Formatted?
• “Combination” is Flag 3, the scenario and
choice list flags:
– 1 means code maps to more than one code
– 0 means the code maps to a single code
– Flags 4 and 5 further clarify combination entries
(See the User’s Guides for complete information
on these flags)
•
•
•
•
T1500xA
T1500xA
T1500xD
T1500xD
9300
E914
9300
E914
10111
10112
10111
10112
How are the GEM Files Formatted
Example:
T1500xA Foreign body in cornea, unspecified
eye, initial encounter
— To ICD-9 cluster (Flag 3 is 1)
— 9300 Corneal foreign body
— E914 Foreign body accidentally entering
eye and adnexa
— T1500xD Foreign body in cornea, unspecified
eye, subsequent encounter
— To ICD-9 cluster (Flag 3 is 1)
— 9300 Corneal foreign body
— E914 Foreign body accidentally entering
eye and adnexa
— T1500xS Foreign body in cornea, unspecified
eye, sequela (Flag 3 is 0)
— To 9085 Late effect of foreign body in orifice
Why is There No One-to-One Match
Between ICD-9-CM and ICD-10?
• There is not a one-to-one match between
ICD-9-CM and ICD-10, for which there are a
variety of reasons including:
– There are new concepts in ICD-10 that are not
present in ICD-9-CM;
– For a small number of codes, there is no
matching code in the GEMs;
– There may be multiple ICD-9-CM codes for a
single ICD-10 code; and
– There may be multiple ICD-10 codes for a single
ICD-9-CM code.
Action Overview
•
•
•
•
•
•
•
•
•
ICD-10 Awareness
Budget Strategy
Business Assessment
Internal System assessment
External (Vendor) System assessment
Implementation
Education
Testing
Maintenance and Ongoing Support
44
WHERE DO I START?
• Learn about the structure, organization
and unique features of ICD-10-CM all
provider types
• Understand system impact and 5010
• Identify areas of strength/weakness in
medical terminology and medical
record documentation
ICD-10 Preparedness
•
•
•
•
•
•
Provide information on ICD usage and
format
Identify why you need ICD-10
Determine what needs to be done
Identify who needs to be involved
Discuss a time line for maximum benefit
Collect needed tools and resources
46
Benefits and Challenges
•
•
•
•
•
•
•
•
•
Mandatory
Will cost – time and money
Learning something different
Documentation requirements
Improve business practices
Improve reporting
Reduce costs
Increase efficiency
Improve timely claim processing
47
Education
Who should receive ICD-10-CM training
in your office?
• Coders
• System users
• Business users
• Management
• Physicians
48
CODER EDUCATION??
• Plan to provide intensive coder training
approximately 6-9 months prior to
implementation –allocating 16 hours of
ICD-10-CM training will likely be
adequate for most coders
• Providers should have at least 4-6
hours of ICD-10-CM training
• Other staff receiving training will
determine number of hours by
individual practice needs
Business Impact Assessment
•
•
•
•
•
•
Operational processes
Reports
Procedures
Charge Master or Super bills
Pre-authorizations
Coding changes
50
Business Impact Assessment
•
•
•
•
•
•
Budget impact
Cash flow
Contract revisions
Fee schedule changes/revisions
Pay for performance initiatives
Productivity losses
51
Internal System Implementation
•
•
•
•
•
Data structure differences
Field structure
Programs
Maintain both ICD-9 and ICD-10 data
Implement and test systems changes.
52
External System Impact Assessment
•
•
•
•
•
•
Vendor Readiness
Vendor Timeline
Interfaces
Cost
System changes/upgrades
Testing
53
HOW DOES THIS HELP YOU?
• Improved ability to measure health care services
• Decreased need to include supporting
documentation with claims
• Updated medical terminology and classification of
diseases
• Codes allow comparison of mortality and morbidity
data
• Better data for:
–
–
–
–
–
Measuring care furnished to patients
Processing claims
Making clinical decisions
Tracking public health issues
Conducting research
http://www.cms.gov/ICD10/05a_ProviderResources.asp#TopOf
Page
LET’S REVIEW
• Basic Steps to Prepare for Version
5010/ICD-10
• Begin preparing now for the ICD-10
transition to make sure you are ready
by the compliance deadline. The
following quick checklist will assist
you with preliminary planning steps.
LET’S REVIEW
• Identify your current systems and work
processes that use ICD-9 codes. This
could include clinical documentation,
encounter forms/superbills, practice
management system, electronic health
record system, contracts, and public
health and quality reporting protocols.
It is likely that wherever ICD-9 codes
now appear, ICD-10 codes will take
their place.
LET’S REVIEW
• Talk with your practice management system
vendor about accommodations for both
Version 5010 and ICD-10 codes. Contact
your vendor and ask what updates they are
planning to your practice management
system for both Version 5010 and ICD-10,
and when they expect to have it ready to
install. Check your contract to see if
upgrades are included as part of your
agreement. If you are in the process of
making a practice management or related
system purchase, ask if it is Version 5010
and ICD-10 ready.
LET’S REVIEW
• Discuss implementation plans with all
your clearinghouses, billing services,
and payers to ensure a smooth
transition. Be proactive, don't wait.
Contact your payers, clearinghouse,
billing service with whom you conduct
business, ask about their plans for the
Version 5010 and ICD-10 compliance,
and when they will be ready to test
their systems for both transitions
LET’S REVIEW
• Talk with your payers about how ICD10 implementation might affect your
contracts. Because ICD-10 codes are
much more specific than ICD-9 codes,
payers may modify terms of contracts,
payment schedules, or reimbursement.
LET’S REVIEW
• Identify potential changes to work flow
and business processes. Consider
changes to existing processes
including clinical documentation,
encounter forms, and quality and
public health reporting.
LET’S REVIEW
• Assess staff training needs. Identify the staff
in your office who code, or have a need to
know the new codes. There are a wide
variety of training opportunities and
materials available through professional
associations, online courses, webinars, and
onsite training. If you have a small practice,
think about teaming up with other local
providers. You might be able, for example, to
provide training for a staff person from one
practice, who can in turn train staff members
in other practices. MBI recommends that
training take place approximately 6 months
prior to the compliance date
LET’S REVIEW
• Budget for time and costs related to
ICD-10 implementation, including
expenses for system changes,
resource materials, and training.
Assess the costs of any necessary
software updates, reprinting of super
bills, training and related expenses.
THANK YOU VERY MUCH!