The Nuts and Bolts of ICD-­‐‑10
Dr. Kelly Kerksick, OD
About Your Presenter
• OD Advisor for Revolution EHR
• Group practice in Southern
Illinois near St. Louis
• Cards Fan!
• Mom of two boys
From My City to Yours
Discussion Points
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ICD Overview
“Crosswalking”
General Equivalence Mapping
Choosing ICD-10 Codes in Clinical Care
5 step process to prepare for October 1
Overview of ICD
International Classification of Diseases
World Health Organization (WHO)
Started in 1900 with ICD-1
ICD-9 is the disease/problem/condition code for US
provider claims through September 30, 2015
• ICD-10 is the updated coding & documentation system
that will be used for US provider claims on October 1,
2015
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ICD-­‐‑9
• Almost 14,000 codes
• Used in US since 1979
• No documentation
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Laterality
Pertinent negatives
Context
• 3-5 characters
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Always three characters minimum, with two optional after decimal
ICD-­‐‑10
• Over 68,000 diagnosis codes
• ICD-10-CM (Clinical Modification) has 21 chapters, about 10
have codes that relate to eye care delivery
• Up to 7 characters, 3-7 alpha-numeric
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First character alpha, 2nd numeric, not case sensitive
Documentation of:
• Laterality
• Pertinent negatives
• Context (e.g. MVA, on a residential street, texting while
driving, fighting with in-laws)
• State of care (initial, subsequent, sequela)
ICD-­‐‑11, up next…
• WHO undertaking development with plan for final
endorsement in 2015 and release in 2017
• Will align with SNOMED coding
• Expanded multilinguality
• Enhanced “Content Model” will guide users
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Each disease will have definitions that give key descriptions and guidance on
the meaning of the code in human readable terms
ICD-­‐‑10 Implementation
• CMS will pay claims with ICD-10 for services rendered
on and after October 1, 2015
• Testing is underway in 2015
• End-to-end testing is only necessary for those who do
not use an electronic clearinghouse
• Your practice’s clearinghouse must confirm successful
CMS ICD-10 submissions
Crosswalking
• Called General Equivalence Mapping (GEM)
• Identifies the 1-to-n mapping from ICD-9 to -10
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No match: 3%
1-to-1 match: 24%
1-to-1 approximate match with 1 choice: 49%
1-to-1 approximate match with Mult choices: 19%
1-to-many match with 1 or many scenarios: 5%
General Equivalence Mappings
• The purpose is to:
create a useful, practical, code to code translation reference dictionary
for both code sets
o Offer acceptable translation alternatives wherever possible
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• Mappings from specific concepts to more general
concepts are possible
• It is not possible to use mappings to add specificity
when the original information is general
ICD-­‐‑10 Peculiarity
• 39,000 codes for injury and poisoning
• Multiple codes due to laterality
• NOTE: some codes do not have laterality
• AMD, POAG, Diabetic Retinopathy, Presbyopia
• O is only in the first position
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All other round figures are zeroes
• X is a placeholder or allows for future expansion
• 7th position codes for trauma
• A = Initial encounter
• D = Subsequent encounter
• S = Sequela (resulting from)
Anatomy of the ICD-­‐‑10 code
Anatomy of ICD-­‐‑10
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3-7 alpha-numeric
First character alpha (not case sensitive)
Second character numeric
Truly considered clinical documentation
Example: Primary Open Angle Glaucoma
H40.11X1
Glaucoma
Open Angle
Mild Stage
Primary
Placeholder
Choosing ICD-­‐‑10 in Clinical Care
• Identify the disease and consider the context
• Laterality when appropriate:
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1 in the last position = Right Eye
2 in the last position = Left Eye
3 in the last position = Bilateral
• Pertinent negative, with/without:
o 1 in the sixth position means “with”: E11.321 – T2D, mild NPDR,
with DME
o 9 in the sixth position “without”: E11.329 – T2D, mild NPDR,
without DME
ICD-­‐‑10 for Eyes
• H00-H59: Diseases of eye and adnexa
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H00-H05
H10-H11
H15-H22
H25-H28
H30-H36
H40-H42
H43-H44
Eyelid, lacrimal system, orbit
Conjunctiva
Sclera, cornea, iris, ciliary body
Crystalline lens
Choroid, retina
Glaucoma
Vitreous body, globe
ICD-­‐‑10 for Eyes
• H00-H59: Diseases of eye and adnexa
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H46-H47 Optic nerve, visual pathways
H49-H52 Muscles, binocular movement, accommodation, refractive error
H53-H54 Visual disturbances, blindness
H55-H57 Nystagmus, Other disorders
H59 Intraoperative and post-procedural complications/disorders of eye and
adnexa, not elsewhere classified
Example Patient 1: ICD-­‐‑9 MPL
Patient 1: Conversion View
Patient 1: Vitreous Lookup View
Patient 1: ICD-­‐‑10 MPL
Example Patient 2: ICD-­‐‑9 MPL
Patient 2: Conversion View
Patient 2: ICD-­‐‑10 MPL
ICD-­‐‑9 to ICD-­‐‑10 Conversions
Example Conversion Display
Patient 1 – Before Conversion
Patient 1 – Conversion
Patient 1 – After Conversion
Patient 2 – Before Conversion
Patient 2 – GLC Conversion
Patient 2 – DM Conversion
Patient 2 – Bleph Conversion
Patient 2 – After Conversion
ICD-­‐‑10 Assessments
ICD-­‐‑10 Plans
ICD-­‐‑10 Plan Tracking to ICD-­‐‑9
Choosing ICD-­‐‑10: Eyelids
• All eyelid conditions reference the location:
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1 in
2 in
4 in
5 in
the last position:
the last position:
the last position:
the last position:
right upper eyelid
right lower eyelid
left upper eyelid
left lower eyelid
HCPCS modifiers for CPT coding are the same:
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E1 – left upper
E2 – left lower
E3 – right upper
E4 – right lower
Choosing ICD-­‐‑10: Refractive Error
• H52.11 – Myopia, right eye
• H52.12 – Myopia, left eye
• H52.13 – Myopia, bilateral
• H52.0 – Hypermetropia
• H52.2 – Astigmatism (5th digit for unspecified, irregular,
regular
• H52.4 – Presbyopia (no laterality)
ICD-­9: 367.1, 367.0, 367.2, 367.4
Choosing ICD-­‐‑10: Dry Eye
• H04.121 – Dry eye syndrome,
right lacrimal gland
• H04.122 – Dry eye syndrome,
left lacrimal gland
• H04.123 – Dry eye syndrome,
bilateral lacrimal glands
• Coding H04.121 and H04.122 together is EQUAL to
H04.123
ICD-­9: 375.15
Choosing ICD-­‐‑10: Nuclear Cataract
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H25.11 – Age-related nuclear cataract, right eye
H25.12 – Age-related nuclear cataract, left eye
H25.13 – Age-related nuclear cataract, bilateral
H26.03 – Infantile and juvenile nuclear cataract
Q12.0 – Congenital cataract (nuclear embryonal)
ICD-­9: 366.16
Choosing ICD-­‐‑10: Dry AMD
• H35.31 – Non-exudative/atrophic AMD
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NO LATERALITY
H35.32 – Exudative AMD
With 6th digit for right/left/bilateral:
NO LATERALITY
H35.35 – Cystoid macular degeneration
H35.36 – Drusen (degenerative) of macula
ICD-­9: 362.51
Choosing ICD-­‐‑10: Glaucoma (POAG)
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H40.11x0 – POAG, stage unspecified
H40.11x1 – POAG, mild stage
H40.11x2 – POAG, moderate stage
H40.11x3 – POAG, severe stage
H40.11x4 – POAG, indeterminate stage
NO LATERALITY
• H40.2- – Primary angle-closure glaucoma
• H40.13 – Pigmentary glaucoma
WITH LATERALITY
ICD-­9: 365.11 + stage
Choosing ICD-­‐‑10: Diabetes with DR
• E11.321 – T2D, mild NPDR, with DME
• E11.329 – T2D, mild NPDR, without DME
NO LATERALITY
5th position = mild/moderate/severe NPDR or Proliferative retinopathy
E11.339 – moderate NPDR, (-­)DME
E11.349 – severe NPDR, (-­)DME
E11.359 – proliferative DR, (-­)DME
• E11.9 – T2D without complications
• E10 codes represent T1D
ICD-­9: 250.52 + 362.04
Choosing ICD-­‐‑10: Medical Mgmt.
• Patient on long-term medication who have no findings
– code the underlying medical condition
• L93.0 – Lupus
• M06.09 – Rheumatoid Arthritis
• Example for plaquenil retinal assessment:
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H35.381 – Toxic maculopathy, right eye
H35.382 – Toxic maculopathy, left eye
H35.383 – Toxic maculopathy, bilateral
Z79.899 – Other long term (current) drug therapy
ICD-­9 (Lupus + Plaquenil): 695.4 + V58.69
Common Concerns
• What happens if I use the wrong ICD-10 code? Will
my claim be denied?
o Correct level of specificity is the goal
o Medicare review contractors will not deny physician or other practitioner
claims billed based solely on errors relating to specificity of the ICD-10
code for 12 months
• Can I use ICD-9 codes at all after October 1st?
o No
o Unless you don’t want to be paid.
Preparing for October 1
• If you are not using an electronic clearinghouse,
review CMS resources to participate in testing claim
submission from EHR to CMS
• If you use an electronic clearinghouse:
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They test submission from clearinghouse to CMS (back-end testing)
Front-end testing is done by the practice or the EHR vendor, to affirm that
claims sent to the clearinghouse “pass”
Preparing for October 1, cont.
• EHR will likely dictate coding that can be applied to
claims based upon the Oct. 1 date
o ICD-9 only paid through Sept. 30
o ICD-10 required for payment on/after Oct. 1
• Filters at the clearinghouse may help identify mistakes
on claims
o Consider use of Revenue Cycle Management resources for claims filing and
processing
Preparing for October 1, Internally
• Billing team and doctor must manage:
o Master Problem (Diagnosis) List
o Same-day Encounter Coding
• If you have filtered down to limited ICD-9 codes, you
will have more effort to deal with the specificity of ICD10
o Unspecified codes in ICD-10 will be targets for rejections
Action Plan
• Confirm that your EHR has been updated to support
the new code set, or will be by late summer
• Train staff on ICD-10 code structure
• Review documentation from CMS, major insurers, and
AOA
• Develop plan for ICD-10 selection
• Practice ICD-10 selection on fictitious patients
Let’s recap!
Steps Needed to Be Prepared
• Step 1: Make a Plan!
• Obtain Access to ICD10 Codes
• cms.gov/ICD10 to
download code tables
and index
• Other references:
Step 2: Training
• Training for staff and
doctors
• Clinical application and
Billing/Coding
application
• Focus on documentation
of new clinical concepts
captured in ICD-10
• Identify top codes and
code current cases in
ICD-10 to test your
knowledge
Step 3:
Update Your Processes
• Make sure that you
have the correct CMS
1500 forms
• Be sure you have the
2012 version for paper
claims submissions
• Know how the new
ICD-10 codes will be
linked to your CPT
codes. This is important
for claims submission
Step 4
Talk To Your Vendors
• Is YOUR electronic health records system going
to be ready?
• Is YOUR clearinghouse going to be ready?
• Find out if they are doing the leg work for you
• Confirm that these things have been tested
Step 5:
Test Your Systems and Processes
• Verify that you can
generate claims with
ICD-10
• Testing is needed
with health plans,
clearinghouses, and
vendors
Conclusions
• Plan for some denials, challenging office morale and
possibly cash flow
• EHR Diagnosis lists in ICD-9 will undergo some
conversion to ICD-10, but you will have some effort
• Find references to assist when you code medical
conditions not commonly referenced, and when
treating uncommon conditions (trauma)
Contact Information & Resources
CMS:
http://www.cms.gov/Medicare/Coding/ICD10/ProviderResourc
es.html
MGMA: http://www.mgma.com/icd-10-5010-implementation