Arkansas DMS: ICD-10 Provider Education Series
ICD-10 Preparation & Implementation
Cathy Munn, MPH RHIA CPHQ
Sr. Consultant
1
Agenda
• Why ICD-10 & Why Now?
– Industry Update
– Key Points to Remember
• Impact of the Change
– Providers
– Payers
•
•
•
•
Review of ICD-10 Codes & Changes
Arkansas DHS Preparation & Planning
Provider Preparation
Next Steps & Resources
2
Industry Update
• Cutting Costly Codes Act of 2013
– A bill to prohibit the Secretary of Health and Human Services
from replacing ICD-9 with ICD-10 in implementing the
HIPAA code set standards.
• AMA – remains opposed to ICD-10
– Best Practices for ICD-10-CM Documentation 2012
– Preparing for ICD-10-CM
• CMS – continues to move forward with compliance
date of October 1, 2014
3
ICD-10-CM/PCS
• ICD-9-CM: International Classification of Diseases,
9th revision, Clinical Modification
• 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 Timeline
• 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
• ICD-10-PCS will not be used on physician claims
• This has change has 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 visits to
hospital inpatients
• DSM-V codes have been released; however DSM-V is
not HIPAA compliant for claims or transactions
6
Important Information
• 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 10-12014 will use ICD-10-CM codes
• There will be period of time when payers will be
processing both ICD-9 and ICD-10 claims due to
claims backlogs, appeals, grievances, etc.
• Systems will have to utilize both ICD-9-CM and ICD10-CM for some period of time. Arkansas Medicaid
allows providers 365 days to submit a claim.
7
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
8
Current Competing Priorities
ACOs/
Patient
Centered
Medical
Home
Public
Reporting
& Quality
Measures
ICD-10: A
key
component
to success
EHR/
MU
Value
Based
vs.
Volume
9
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
10
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: Angioplasty has 3 codes
Example: Angioplasty – 1298 coding
combinations
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.
11
Patient Flow Impact
Revise for ICD10 reporting
Update data repositories
to accommodate new
coding
Claim priced based
on revised fee
schedules
Revise
authorization
process
Back end
processes
Start
Patient
Encounter
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
Providers change
coding practices based
on ICD-10
Diagnose
Patient
Begin
Adjudication
Determine
Benefits
Update system to
accept claims
Check
Eligibility
12
Impact on Providers
•First Things First:
•Impact Assessment & Gap Analysis
•Evaluate Vulnerabilities
•Systems
•Operations and Processes
•Clinical Documentation
13
System Impacts
• Identify your current systems and work processes that
use ICD-9 codes. This could include:
– Practice Management Systems
• Reports
– Electronic Medical Record Systems
• Clinical Documentation
• ICD-9 Code Assignment
– Encounter Forms and Superbills
– 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
14
System Impacts
• If applicable, talk with your practice management/EHR
vendor(s) about accommodations for both ICD-9 and
ICD-10 codes
• Contact your vendor(s) and ask what updates they are
planning for your practice management/EHR system
and the anticipated install/update implementation date
• Check your contract to see if upgrades are included or
if there is an additional cost
• Discuss implementation plans with any clearinghouses
or billing services you may use
15
Operational Impacts
16
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 roadmap that supports their claims of
“ICD-10 Readiness”
• Utilize CMS checklists and resources – new
information is posted on www.CMS.org/ICD10
17
Operational Impacts
• Talk with your payers about how ICD-10
implementation might affect 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
18
Operational Impacts
• Identify potential changes to work flow and business
processes
• Consider changes to existing processes including:
–
–
–
–
Clinical documentation
Prior authorization
Encounter forms and Superbills
Report generation
• Operational
• Quality and Public Health reporting
– Involvement in any Care Management initiatives
19
Operational Impacts
• Assess staff training needs – coders, billing staff,
ancillary staff. Anticipate that everyone in your office
will require some level of ICD-10 awareness training
• There are many training options and materials available
through a variety of resources & venues:
– Professional Associations – AAPC, AHIMA
– Online Courses – ICD10 Monitor, Contexo University
– Webinars – ICD10 Monitor, HC Pro
– Onsite Training – Train the Trainer
• If you have a small practice, think about collaborating with other
local providers
20
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……
21
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
22
Not so Super-Superbill?
ICD-9-CM
ICD-10-CM
454.1 Varicose veins of lower
extremities with inflammation
I83.10 Varicose veins of unspecified
lower extremity with inflammation
I83.11 Varicose veins of right lower
extremity with inflammation
I83.12 Varicose veins of left lower
extremity with inflammation
23
The appropriate 7th character is to be added to each
ICD-10-CM code:
A – initial encounter D – Subsequent encounter S - Sequela
ICD-9-CM
ICD-10-CM
845.09 Sprain and S86011x Strain of right Achilles tendon
strain of ankle
S86012x Strain of left Achilles tendon
and foot, other
S86019x Strain of unspecified Achilles tendon
S93491x Sprain of other ligament of right ankle
S93492x Sprain of other ligament of left ankle
S93499x Sprain of other ligament of unspecified ankle
S96111x Strain of muscle and tendon of long extensor muscle of
toe at ankle and foot level, right foot
S96112x Strain of muscle and tendon of long extensor muscle of
toe at ankle and foot level, left foot
S96119x Strain of muscle and tendon of long extensor muscle of
toe at ankle and foot level, unspecified foot
S96211x Strain of intrinsic muscle and tendon at right ankle and
foot level, right foot
S96212x Strain of intrinsic muscle and tendon at right ankle and
foot level, left foot
S96219x Strain of intrinsic muscle and tendon at right ankle and24
Continued…
ICD-9-CM
ICD-10-CM
845.09 Sprain
and strain of
ankle and foot,
other
S96911x Strain of unspecified muscle and tendon at ankle and
foot level, right foot
S96912x Strain of unspecified muscle and tendon at ankle and
foot level, left foot
S96919x Strain of unspecified muscle and tendon at ankle and
foot level, unspecified foot
25
Clinical Documentation Practices
• If it’s not documented….it’s not done
– Outcome Data
– Reimbursement
– Liability
26
Clinical Documentation Practices
A frequent concern heard from providers is that the requirement
for documentation to support ICD-10 coding is an “unnecessary
administrative burden”.
Is the inclusion of this information really an administrative
burden?
• Laterality – left, right, bilateral or unilateral
• Trimester of pregnancy and weeks of gestation
• Length of time a patient was unconscious
• Which finger, and which level in a finger amputation
• The type of surgical approach for procedures
• The severity of seizures
• The stage of a decubitus ulcer
27
Clinical Documentation Practices
• Clinical documentation is the first step in reaching the
ultimate goal of better disease and risk management
outcomes and data integrity.
• Clinical documentation improvement best practices
provide accurate coding and clinical data.
– Accurate documentation = accurate coding
– Accurate coding = richer data & understanding patient needs
– Ultimately leading us to better patient outcomes
28
Clinical Documentation Practices
• Most of the new concepts introduced in ICD-10 codes are
concepts that physicians should be documenting now.
• Based on 125 clinical documentation engagements performed by
3M Consulting Services, it was found physician documentation
does not support coding at the highest level of specificity 30 to
40 percent of the time.
• Documentation requirements vary greatly by specialty or clinical
domain. Codes related to ophthalmology have changed little in
scope; however, codes related to the musculoskeletal system
have increased dramatically. Over 50% of the ICD-10 codes are
related to musculoskeletal conditions. Over 17,000 ICD-10
codes (~25%) are related to fractures.
29
Clinical Documentation Practices
• AHIMA Online Education Physician Series
– Clinical Documentation for ICD-10: Principles & Practice
• Short, self-paced training modules
• Case-based, real life examples
– Provides more than 200 bite-sized, on-demand, specialtyspecific training modules that can be accessed anytime or
anywhere with a mobile device. (computer, tablet or
smartphone)
– Delivers 3-5 minute modules that cover physician’s 10 – 20
most billed diagnoses & conditions making learning targeted
and relevant to their practice specialty.
• www.ahima.org/physicianICD10
30
New Concepts and Features with ICD-10
31
ICD-10 Chapter Titles
Character
Chapter Title
A and B
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.
I
Diseases of the circulatory system.
J
Diseases of the respiratory system.
32
ICD-10 Chapter Titles
Character
Chapter Title
K
Diseases of the digestive system.
L
Diseases of the skin and subcutaneous tissue.
M
Diseases of the musculoskeletal system and connective tissue.
N
Diseases of the genitourinary system.
O
Pregnancy, childbirth and the puerperium.
P
Certain conditions originating in the perinatal period.
Q
Congenital malformations, deformations and chromosomal
abnormalities.
R
Symptoms, signs and abnormal clinical and laboratory findings, not
elsewhere classified.
S and T
Injury, poisoning and certain other consequences of external causes.
U
This letter is currently left vacant.
V, W, X and Y
External causes of morbidity and mortality.
33
Repeating Patterns
• Of the 69,000 ICD-10 codes, over one third are the
same with the exception of the concept of right vs. left.
Considering that most of these codes also have an
“unspecified side” option, the ratio is even higher.
• For every acute fracture code there is a code for initial
encounter, subsequent encounter or sequela. Each
code x 3.
• If the encounter is a subsequent encounter, then for
each fracture there is a code for routine healing,
delayed healing, malunion or nonunion. Each code x 4.
34
Understanding Code Patterns
Concept
Number of Codes Impacted
Acute or chronic
1764
Open or closed
Routine healing, delayed healing
Right or left
Initial encounter, subsequent encounter
or sequela
10,893
11,290
25,230
47,223
**Health Data Consulting
35
Individual Codes vs. Combination Codes
•Combination codes for conditions and common
symptoms or manifestations
–E10.21 Type I diabetes mellitus with diabetic nephropathy
–I23.110 Atherosclerotic heart disease of native coronary
artery with unstable angina pectoris
–K50.112 Crohn’s Disease of large intestine with intestinal
obstruction
•Combination codes for Poisonings and External Causes
–T36.0X1D Poisoning by penicillins, accidental
(unintentional), subsequent encounter
–T42.4X5A Adverse effect of benzodiazepines, initial
encounter
36
Added Laterality
• H60.332 Swimmer’s ear, left ear
• M94.211 Chondromalacia, right shoulder
• S40.251A Superficial foreign body of right shoulder,
initial encounter
About 25,000 (36%) of all
ICD-10-CM codes are different
only in that they distinguish
right vs. left
37
• The patient is receiving active
treatment for the condition
– Surgical treatment
– Emergency Department
encounter
– Evaluation and treatment
by a new physician
38
Added Seventh-Character for Episode of Care
• M80.051A Age related osteoporosis with current
pathological fracture, right femur, initial encounter for
fracture
• S06.0X1A Concussion with loss of consciousness of
30 minutes or less, initial encounter
• S52.132A Displaced fracture of neck of left radius,
initial encounter for open fracture Type I or II or initial
encounter for open fracture NOS
39
After patient received active
treatment for the condition
and receiving routine care
during healing or recovery
phase
– Cast change or removal
– Removal of external or internal
fixation device
– Medication adjustment
– Other aftercare and follow-up
visits following injury treatment
40
Encounter Codes
• M80.051A Age related osteoporosis with current
pathological fracture, right femur, initial encounter for
fracture
• M80.051D Age-related osteoporosis with current
pathological fracture, right femur, subsequent
encounter for fracture with routine healing
41
– Complications or conditions
that arise as a direct result of
a condition
• Scar formation after burn
– Use both the injury code that
precipitated sequela and code
for sequela
– S added only to injury code, not
sequela code
– S identifies injury responsible
for sequela
– Specific type of sequela (like scar)
sequenced first, followed by
injury code
42
Encounter Codes
• M80.051A Age related osteoporosis with current
pathological fracture, right femur, initial encounter for
fracture
• M80.051D Age-related osteoporosis with current
pathological fracture, right femur, subsequent
encounter for fracture with routine healing
• M80.051S Age-related osteoporosis with current
pathological fracture, right femur, sequela
43
Pathological or Stress
Fracture Seventh
Characters
A
• Initial encounter
D
• Subsequent – routine healing
G
• Subsequent – delayed healing
K
• Subsequent – nonunion
P
• Subsequent – malunion
S
• Sequela
44
Fractures
–
–
–
–
–
–
–
–
Type of fracture
Specific anatomical site
Displaced vs. nondisplaced
Laterality – right vs. left
Routine vs. delayed healing
Nonunion
Malunion
Type of encounter
• Initial
• Subsequent
• Sequela
45
Episode of Care Codes
• M80.051D Age-related osteoporosis with current
pathological fracture, right femur, subsequent
encounter for fracture with routine healing
– M80.051G Age-related osteoporosis with current
pathological fracture, right femur, subsequent encounter for
fracture with delayed healing
– M80.051K Age-related osteoporosis with current
pathological fracture, right femur, subsequent encounter for
fracture with nonunion
– M80.051P Age-related osteoporosis with current pathological
fracture, right femur, subsequent encounter for fracture with
malunion
46
Fractures
• Some fracture categories
provide for seventh characters
to designate the specific type
of open fracture based on
the Gustilo open fracture
classification
• A fracture not indicated as
displaced or nondisplaced
should be coded as displaced
• A fracture not designated as
open or closed should be coded
as closed
47
Gustilo Classification
I
II
III
IIIA
IIIB
IIIC
• Low energy, Wound less than 1 cm
• Greater than 1 cm with moderate soft tissue damage
• High energy wound greater than 1 cm with extensive soft tissue damage
• Adequate soft tissue cover
• Inadequate soft tissue cover
• Associated with arterial injury
48
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
49
Inclusion of Trimesters in Obstetrics Codes
• O10.012 Pre-existing essential hypertension
complicating pregnancy, second trimester
• O99.013 Anemia complicating pregnancy, third
trimester
50
• Trimester axis of
classification rather than
episode of care
Trimesters
1st
Less than 14 weeks 0 days
2nd
14 weeks 0 days to less than
28 weeks 0 days
3rd
28 weeks 0 days until delivery
– Not all conditions
include codes for all
three trimesters or
is N/A
– Counted from first day of
last menstrual period
51
52
Pregnancy Codes
• For example, ICD-10-CM code of O15.03 designates
“eclampsia in pregnancy, third trimester”
– ICD-9 code for same condition is 642.63 – “eclampsia;
antepartum condition not delivered during current episode of
care”
– Obstructed labor codes incorporate the reason for the
obstruction; code extensions are used to identify specific
fetus: (1-5) affected by obstetric condition
• e.g., ICD-10-CM code O64.1xx2 designates “obstructed labor due to
breech presentation, fetus 2”
53
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
54
Arkansas Frequently Used V Codes
• V22.0 Supervision of normal first pregnancy
– Translates to:
• Z3400 – Encounter for supervision of normal first pregnancy,
unspecified trimester
• V22.1 Supervision of other normal pregnancy
– Translates to:
• Z3480 – Encounter for supervision of other normal pregnancy,
unspecified trimester
• Z3490 – Encounter for supervision of normal pregnancy, unspecified,
unspecified trimester
• V30.00 Single liveborn; born in hospital w/o mention
of cesarean delivery
– Translates to:
• Z3800 - Single liveborn infant, delivered vaginally
55
Timeframe Specific Code Changes
• Time frame for abortion versus fetal death changed
from 22 weeks to 20 weeks
• Acute myocardial infarction – time period changed
from 8 weeks to 4 weeks
56
Acute Myocardial Infarction (AMI)
• Age definition for AMI has changed to four weeks
rather than eight weeks.
• New categories for subsequent AMI and for
complications within 28 days of AMI.
• Different terminology is used and laterality is included
– e.g., I21.02 designates “ST segment elevation
myocardial infarction [STEMI] involving left anterior
descending coronary artery”
57
Per the Official AHA Coding Guidelines:
“If an AMI is documented as nontransmural or
subendocardial, but the site is provided, it is still coded
as a subendocardial AMI.” The STEMI and NSTEMI
are treated differently. Generally, the STEMI is caused
by complete obstruction of the coronary artery, and
causes damage that involved the full thickness of the
heart muscle, while the NSTEMI is caused by a partial
obstruction and the damage does not involve the full
thickness of the heart wall.
58
CHF Specificity
• 428.0 Congestive heart failure, unspecified
–
–
–
–
–
–
–
–
–
–
–
–
–
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive)
heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart
failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart
failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive)
heart failure
I50.9 Heart failure, unspecified
59
Important Changes Beyond New Concepts
Additional information you need to know….
60
Pressure Ulcer Specificity – Combination Codes
ICD-10 pressure ulcer
codes are combination
codes that include:
●the site (lower back)
of the pressure ulcer;
●the location
(right/left) of the
pressure ulcer;
●the stage of the
pressure ulcer.
ICD-9-CM
ICD-10-CM
707.03 Pressure ulcer,
lower back
L89.132 Pressure ulcer
of right lower back,
stage 2
OR
L89.142 Pressure ulcer
of left lower back, stage
2
OR
L89.152 Pressure ulcer
of sacral region, stage
2*
(*episode of care
extension)
AND
707.22 Pressure ulcer
stage II
61
Pressure Ulcer Stages
• Stage 1: Pressure pre-ulcer skin changes limited to persistent focal
edema
• Stage 2: Pressure ulcer with abrasion, blister, partial thickness skin
loss involving epidermis and/or dermis
• Stage 3: Pressure ulcer with full thickness skin loss involving damage
or necrosis of subcutaneous tissue
• Stage 4: Pressure ulcer with necrosis of soft tissues through to
underlying muscle, tendon, or bone
• Unstageable: Based on clinical documentation pressure ulcers are
those “whose stage cannot be clinically determined (e.g., the ulcer is
covered by eschar or has been treated with a skin or muscle graft) and
pressure ulcers that are documented as deep tissue injury but not
documented as due to trauma.”
• Unspecified: The ICD-10-CM unspecified coding option is not
considered a part of the NPUAP staging but is provided for reporting
when the documentation is insufficient to assign a more specific code.
62
Diabetes Mellitus – Combination Codes
• ICD-10 diabetes mellitus codes are combination codes
that include:
– type of diabetes mellitus
– body system affected
– the complication/manifestation affecting the body system
ICD-9-CM
ICD-10-CM
250.52 Diabetes with ophthalmic
manifestations, type II or
unspecified type, uncontrolled
E11.331 Type 2 diabetes mellitus
with moderate nonproliferative
diabetic retinopathy with macular
edema
362.05 Moderate nonproliferative
diabetic retinopathy
362.07 Diabetic macular edema
63
Diabetes Codes & Insulin Use
• For type II diabetes, a secondary code for long-term
(current) use of insulin is required if the patient is using
insulin.
• For example,
– E11.42 Type 2 diabetes mellitus with diabetic
polyneuropathy and
– Z79.4 Long term (current) use of insulin
64
Asthma
• Asthma – 493 w/fourth digits for extrinsic, intrinsic,
chronic obstructive & unspecified.
– J45 – Asthma
•
•
•
•
•
J45.2X
J45.3X
J45.4X
J45.5X
J45.9X
Mild intermittent asthma
Mild persistent asthma
Moderate persistent asthma
Severe persistent asthma
Other & unspecified asthma
• Fifth digits reflect presence/absence of status asthmaticus or acute
exacerbation
For example, J45.51 would be assigned for a patient who has severe
persistent asthma with (acute) exacerbation.
65
Cerebral Infarctions
• Late effects of stroke are differentiated by type of
stroke.
• Combination codes for common
etiologies/manifestations are included
• ICD-10-CM code I63.012 designates “cerebral
infarction due to thrombosis of left vertebral artery”
66
This Isn’t Payer Versus Provider
• ICD-10 poses challenges for both payers and providers
– Readiness for payers and providers
• There is a potential for 1-2 years of uncertainty or “data
fog” after implementation for payers and providers
– Data integrity and comparability
• Readiness will yield financial advantages for those who
execute well
– Cash flow
67
CMS Resources
68
CMS Resources
69
70
DMS Remediation Progress
● Tasks completed
– Operational assessment
– Remediation of medical policy, edits & audits
• Code translations ICD-9 -> ICD-10
• 3M Code Translation Tool
– Compilation of system requirements
• HP – MMIS
• Xerox/ACS – Smart PA
• Arkansas DHS – all integrated & stand-alone systems
– Creation of Risk Remediation Plan
– Identification of impacted DMS reports, forms & brochures
71
DMS Remediation Progress
● Tasks nearing completion
–
–
–
–
–
Remediation of Pharmacy policy & edits
Remediation of Provider Manuals
Creation of internal & external clinical testing scenarios
Launch of testing environment – Q1 2014
Remediation of Episodes of Care
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Arkansas DMS Assistance
• Continued Provider outreach
– Provider outreach & training
• Face to face meetings
• Webinars
– Periodic Arkansas DMS updates via various messaging channels
• System updates/remediation efforts:
– HP – MMIS
– Xerox/ACS – SmartPA
– Arkansas DHS – all integrated & stand-alone systems
• Arkansas ICD-10 Website: www.humanservices.Arkansas.gov/ICD10
– Arkansas ICD-10 Frequently Asked Questions documents
– Recent updates from CMS & the industry
– ICD-10 mailbox established for submission of questions & comments
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Now What?
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Communication & Planning
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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
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Receptionist
Nursing Staff
Physicians
Coders
Billing Staff
CFO/COO
Senior Practice Management Staff
• Share regular updates & communication briefings with staff
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Impact Assessment
• 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
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Office through-put & documentation
Code utilization within the practice – Superbill assessment
Coding & billing turn-around-time/cash flow
Denials & resubmission of claims
– Systems upgrades/enhancements
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Practice management systems
EHRs
Billing transmissions – EDI
Vendor readiness
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Impact Assessment
• Facilities, provider practices and specialty providers
should examine their patient population in terms of:
– High volume/high cost
– Begin translating your codes from ICD-9 to ICD-10 based on volume
– Patient demographic; Medicare, Medicaid,
Commercial insurance
– Be in contact with your large volume payers to understand their
approach & strategy for ICD-10
– 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
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Testing
• DMS is working to deliver clinical scenarios via the AR
ICD-10 Website for providers & facilities to initiate testing
• DMS must employ end to end testing based on CMS
mandates. E2E testing should include:
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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
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Industry Web Site Resources
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www.CMS.gov/ICD10
https://implementicd10.noblis.org/
www.AHIMA.org
www.ICD10watch.com
www.AAPC.com
www.WEDI.org
www.humanservices.Arkansas.gov/ICD10
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10SmallandMediumPractices508.pdf
• http://www.himss.org/ASP/topics_icd10playbook.asp
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CMS Resources
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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
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AR Medicaid ICD-10 Icon
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Questions & Comments
We have brains in our head & feet in our shoes. Today is our day; our
(ICD-10) mountain is waiting so let’s get on our way….Dr. Seuss
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