Moving Toward
Compliance
October 2014
Community Care Network of
Virginia, Inc.
Objectives
 Discuss ICD-10-CM Coding Purpose and Format
 Look at New Features of ICD-10-CM Codes
 View examples of ICD-10-CM Codes
 Stress the Importance of Transition planning
 Discuss Training Needs
October 2014
Community Care Network of Virginia, Inc.
2
Why Do We Need a New Diagnosis
Coding System?
 ICD-9 is 30 years old
 Technology has changed/is changing
 Many categories full
 Not descriptive enough
 Need multiple codes to define a diagnosis
 Needs modifiers to note Left or Right
 Need further documentation sent when there are
subsequent occurrences of same diagnoses
October 2014
Community Care Network of Virginia, Inc.
3
Benefits of ICD-10-CM
 Measuring the quality, safety, and efficacy of care
 Conducting research, epidemiological studies, and
clinical trials
 Setting health policy
 Improving clinical, financial, and administrative
performance
 Preventing and detecting healthcare fraud and abuse
 Tracking public health and risks
October 2014
Community Care Network of Virginia, Inc.
4
Benefits of ICD-10-CM
 Recognition of advances in medicine and technology
 Improved efficiencies and lower costs
 Reduced coding errors
 Greater achievement of the benefits of an electronic
health record
October 2014
Community Care Network of Virginia, Inc.
5
What is the Compliance Date for the
ICD-10 Coding System?
October 1, 2015
 President Obama signed legislation on Tuesday,
April 1, 2014.
 Bill HR 4302 was signed that included the provision to
delay ICD-10 Implementation by at least a year
 Compliance date for implementation of ICD-10-CM
(diagnoses) and ICD-10-PCS (procedures)
October 2014
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6
ICD-10 Coding System
 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,
even those for inpatient visits
October 2014
Community Care Network of Virginia, Inc.
7
CPT & HCPCS
 No impact on Current Procedural Terminology (CPT) and
Healthcare Common Procedure Coding System (HCPCS)
codes
 CPT and HCPCPS will continue to be used for physician
and ambulatory services including physician visits to
inpatients
 Annual updates to these manuals will continue through the
ICD-10 transition
October 2014
Community Care Network of Virginia, Inc.
8
Diagnosis Code Comparisons
ICD-9-CM
ICD-10-CM
Approximately 14,500 codes
Approximately 69,000 codes
Limited space for new codes
Flexible for adding new codes
Lacks detail
Very specific (initial/subsequent encounter,
routine/delayed healing,
nonunion/malunion)
Lacks laterality
Has laterality (key point)*
17 Chapters with 2 additional
supplementary classifications (V and E
codes)
21 Chapters with no supplementary
classifications (V codes = Z codes & E
codes = V-Y codes)
Difficult to analyze data due to non-specific
codes
Specificity improves coding accuracy &
depth of data for analysis
Non-specific codes do not adequately
define diagnoses needed for medical
research
Detail improves the accuracy of data used
in medical research
October 2014
Community Care Network of Virginia, Inc.
9
Structural Differences
ICD-9-CM
ICD-10-CM
3 -5 characters
3 -7 characters
First character is numeric or alpha (E
or V)
Character 1 is alpha (all letters except U
are used –holding “U” for unknown)
Characters 2-5 are numeric
Character 2 is numeric
Characters 3 -7 are alpha or numeric
Always at least 3 characters
Always at least 3 characters
Use of decimal after 3 characters
Use of decimal after 3 characters
Use of dummy placeholder “x”
Alpha characters are not case-sensitive
October 2014
Community Care Network of Virginia, Inc.
10
Format Differences
ICD – 9 Code Format:
X
X
X
X
X
4th Digit
Category
X
4th & 5th Digit
ICD – 10 Format:
X
X
Category
October 2014
X
X
X
X
4th – 6th Digits
Community Care Network of Virginia, Inc.
X
7th Digit
11
New Features
Combination codes for conditions
& common
symptoms/manifestations
Expanded codes for injury,
diabetes, alcohol/substance
abuse
Combination codes for poisonings
& external causes
Inclusion of trimester in OB codes
& elimination of fifth digits for
episode of care
Laterality code choices
Extensions for episode of care
(Initial encounter, Subsequent
encounter, Sequelae, etc.)
October 2014
Changes in timeframes specified in
certain codes
External cause codes no longer a
supplementary classification
Community Care Network of Virginia, Inc.
12
ICD-10-CM New Features
 ICD-9 classifies injuries by type.
 Fracture
 Body Area
 ICD-10 will classify injuries first by specific site and
then by type of injury.
 Body Area
 Fracture
October 2014
Community Care Network of Virginia, Inc.
13
ICD-10-CM New Features
Full Code Titles
ICD-9-CM
 143 Malignant neoplasm of gum
 143.0 Upper gum
 143.1 Lower gum
ICD-10-CM
 C03 Malignant neoplasm of gum
 C03.0 Malignant neoplasm of upper gum
 C03.1 Malignant neoplasm of lower gum
October 2014
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14
ICD-10-CM New Features
Placeholder “X”
Addition of placeholder “X” (or “x”) is used in certain
codes to:
 Allow for future expansion
 Fill out empty characters (4th, 5th and/or 6th) when a
code contains fewer than 6 characters and a 7th
character applies
 When placeholder character applies, it must be used in
order for the code to be valid
October 2014
Community Care Network of Virginia, Inc.
15
ICD-10-CM New Features
Placeholder “X”
Example
S01.01xA: Laceration, without foreign body, of scalp, initial
encounter
 S01.0 = Open wound of scalp
 S01.01x = Laceration, without foreign body, of scalp

X must hold the 6th character because there is a 7th character
required
 S01.01xA = Laceration, without foreign body, of scalp, initial
encounter
October 2014
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“X” is also a Category of ICD-10-CM
(External Causes of Morbidity)
CAUTION!
 Not about lower case or capitalization of
the letter “x”
 Its about the placement of the “x” within the
code

The “X” will begin the code if it is a specific category


October 2014
External Causes of Morbidity
The “x” will be in the 4th, 5th, and/or 6th character if it
is used as a placeholder
Community Care Network of Virginia, Inc.
17
“X” is also a Category of ICD-10-CM
 Exposure to smoke, fire and flames
 Example:

X02.0xxA
 “Exposure to flames in controlled fire in
building or structure, initial encounter”
 X = Category – begins the code
 xx = placeholders – within the code
October 2014
Community Care Network of Virginia, Inc.
18
ICD-10-CM New Features
Addition of 7th Character
 7th character used in certain chapters (e.g., Obstetrics,
Injury, Musculoskeletal, and External Cause chapters)
 Different meaning depending on section where it is
being used
 When 7th character applies, codes missing 7th
character are invalid
October 2014
Community Care Network of Virginia, Inc.
19
ICD-10-CM New Features
7th Character Describing Encounter
 Initial encounter: As long as patient is receiving active
treatment for the condition.
 Examples of active treatment are: evaluation and treatment
by a new physician.
 Subsequent encounter: After patient has received active
treatment of the condition and is receiving routine care for
the condition during the healing or recovery phase.
 Examples of subsequent care are: cast change or removal,
medication adjustment, other aftercare and follow up visits
following treatment of the injury or condition.
October 2014
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20
ICD-10-CM New Features
7th Character Describing Encounter
 Sequela: Complications or conditions that arise as a direct
result of a condition (e.g., scar formation after a burn).
 Note: For aftercare of injury, assign acute injury code with 7th
character for subsequent encounter.
October 2014
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21
ICD-10-CM New Features
7th Character – Fractures
A
B
D
G
K
P
S
Initial encounter for closed fracture
Initial encounter for open fracture
Subsequent encounter for fracture with routine
healing
Subsequent encounter for fracture with delayed
healing
Subsequent encounter for fracture with nonunion
Subsequent encounter for fracture with malunion
Sequela
October 2014
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22
ICD-10-CM New Features
7th Character – Injury
Example
S01.01xA: Laceration, without foreign body, of scalp, initial
encounter
 S01.0 = Open wound of scalp
 S01.01x = Laceration, without foreign body, of scalp

X must hold the 6th character because there is a 7th character
required
 S01.01xA = Laceration, without foreign body, of scalp, initial
encounter
October 2014
Community Care Network of Virginia, Inc.
23
ICD-10-CM New Features
Lateral/Bilateral Sites
For bilateral sites, a final character in the codes in which
ICD-10 specifies the side or both sides as follows:
Anatomic Detail
Right side
Left side
Bilateral
October 2014
Character Digit
1
2
3
Community Care Network of Virginia, Inc.
24
ICD-10-CM New Features
Lateral/Bilateral
H66.9x - Otitis media, unspecified (includes otitis media
NOS, acute otitis media NOS, chronic otitis media NOS)
Highest Degree of Specificity
 H66.91 Otitis media, unspecified, right ear
 H66.92 Otitis media, unspecified, left ear
 H66.93 Otitis media, unspecified, bilateral
October 2014
Community Care Network of Virginia, Inc.
25
ICD-10-CM New Features
Lateral/Bilateral
H66.9x - Otitis media, unspecified (includes otitis
media NOS, acute otitis media NOS, chronic otitis media
NOS)
Lowest Degree of Specificity
 H66.90 Otitis media, unspecified, unspecified ear
 Assessment should note which ear(s) is/are involved
 Avoid using unspecified codes as much as possible
October 2014
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26
Laterality Example #2
 A physician sees a patient for a follow-up visit in which
she examines an abscess of a bursa on the right wrist.
 You should report M71.031 (abscess of a bursa, right
wrist).
 Notice how the last digit is "1."
 If this was for the left wrist, you would report M71.032.
October 2014
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27
External Causes of Morbidity
No national requirement for mandatory ICD-10-CM
external cause code reporting
 Reporting of ICD-10-CM codes in Chapter 20, External
Causes of Morbidity, is only required for providers
subject to a state-based external cause code reporting
mandate or payer requirements
 In the absence of a mandatory reporting requirement,
providers are encouraged to voluntarily report external
cause codes
October 2014
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28
What is The Value of Reporting
External Cause of Injury Codes?
 Provide valuable data for injury research and
evaluation of injury prevention strategies
 External cause of injury data are used at the national,
state, and local levels to identify high-risk populations,
set priorities, and plan and evaluate injury prevention
programs and policies, and are potentially useful for
evaluating emergency medical services (EMS) and
trauma care systems
October 2014
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29
External Cause Code Example
 Injury sustained from falling down ice-covered steps, initial
encounter
 W00.1 Fall from stairs and steps due to ice and snow
 The appropriate 7th character is to be added to each code from category
W00



A - initial encounter
D - subsequent encounter
S – sequela
Code Assignment: W00.1xxA
October 2014
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30
Diabetes: Big Changes
Codes are expanded to include the classification of the
diabetes and the manifestation
 No longer classified as controlled/uncontrolled
 E08 – DM due to underlying conditions (20 diagnosis)
 E09 – Drug or chemical induced DM (20 diagnosis)
 Assign a “Z” code for any type of insulin use (not just long term
use)
 E10 – Type 1 DM – must be assigned by provider
 not age or insulin dependent
October 2014
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31
Diabetes: Big Changes
Codes are expanded to include the classification of the
diabetes and the manifestation
 No longer classified as controlled/uncontrolled
 E11 – Type 2 DM
 Assign a “Z” code for any type of insulin use (not just long term
use)
 E13 – Other specified DM
October 2014
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32
Diagnosis Code Structure
Comparison
ICD-9-CM Code: Category 250 {Diabetes
Mellitus-(DM)}

250.4 – Subcategory (DM with renal
manifestations)


October 2014
250.42 - Code Title (DM with renal manifestations –
type II or unspecified, uncontrolled).
Must also assign additional code to identify the
manifestation: i.e. – nephropathy NOS (538.81)
Community Care Network of Virginia, Inc.
33
Diagnosis Code Structure
Comparison
ICD-10-CM Code: Category E11 (Type II DM)


E11.2 –Subcategory (Type II DM with kidney
complications)
E11.21 – Code Title (Type II DM with diabetic
nephropathy)

October 2014
Use additional code to identify any Insulin use
(Z79.4)
Community Care Network of Virginia, Inc.
34
ICD-9 to ICD-10-CM Conversion Example
Physician documents Hypertension:
ICD-9-CM category choice:
401 (includes high blood pressure, hyperpiesia,
hyperpiesis, hypertension (arterial) (essential)
(primary) (systemic), hypertensive vascular:
degeneration, disease)



October 2014
401.0 – Essential Hypertension, malignant
401.1 - Essential Hypertension, benign
401.9 – Essential Hypertension, unspecified (most
common choice)
Community Care Network of Virginia, Inc.
35
ICD-9 to ICD-10-CM Conversion Example
Physician documents Hypertension:
ICD-10-CM choice:
 I10: Essential (primary) hypertension
Includes: high blood pressure
 hypertension (arterial) (benign) (essential) (malignant)
(primary) (systemic)
 R03.0 – Incidental reading w/o diagnosis of HTN

** Note the upper case letter I as the beginning character, it is
not the number 1.
October 2014
Community Care Network of Virginia, Inc.
36
ICD-9 to ICD-10-CM Conversion Example
Physician documents Depression:
ICD-10-CM choice:
 If no other documentation is present:

F32.9 – Major depressive disorder, single episode, unspecified
 Depression NOS
 Other documentation that will increase specificity is:


Single episode or recurrent
Mild, moderate, severe without psychotic features, severe with
psychotic features
 F32.0 – F32.9
October 2014
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37
Fracture Scenario With ICD-9-CM
Example –Fracture of wrist - NOS
 In December 2014, patient fractures left wrist

Claim is submitted with diagnosis code 814.00 (Closed
fracture of carpal bones, NOS)
 In January 2015, patient fractures right wrist

October 2014
Claim is submitted with diagnosis code 814.00 (Closed
fracture of carpal bones, NOS)
Community Care Network of Virginia, Inc.
38
Fracture Scenario With ICD-9-CM
 Third party payer could deny for duplication of service or and/or
request additional information (modifiers, provider notes, etc).
 ICD-9-CM code alone does not identify left vs. right, initial vs.
subsequent fracture, healing status –requires modifiers and/or
additional documentation
October 2014
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39
Same Scenario with ICD-10-CM
Example –Fracture of Wrist - NOS
 In December, patient fractures left wrist
 Claim is submitted with S62.102A (Fracture of
unspecified carpal bone, left wrist, closed fracture,
initial encounter)
 In January, patient fractures right wrist
 Claim is submitted with S62.101A (Fracture of
unspecified carpal bone, right wrist, closed fracture,
initial encounter)
(Documentation needs to support the code)
October 2014
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40
Continued
Scenario with ICD-10-CM
Example –Fracture of Wrist - NOS
 Patient returns for follow-up visit for both
fractures in February with routine healing in left
wrist & non-routine healing in right wrist:


Claim is submitted with diagnosis codes:
S62.102D (Fracture of unspecified carpal bone, left
wrist, closed fracture, subsequent encounter, routine
healing)
S62.101G (Fracture of unspecified carpal bone, right
wrist, closed fracture, subsequent encounter, delayed
healing) (Documentation needs to support the code)
October 2014
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41
Tools in Converting Codes
 General Equivalence Mappings (GEMs) assist in
converting data from ICD-9-CM to ICD-10
 Forward and backward mappings
 Information on GEMs and their use –
http://www.cms.gov/ICD10 (click on ICD-10-CM to find
most recent GEMs)
October 2014
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Converting Codes
 GEMs are not a substitute for learning how to code with
ICD-10
 For some small conversion projects it may well be quicker
and more accurate to use ICD-10 code books instead of
GEMs
 2013 Information re: ICD-10-CM GEMs:
http://www.cms.gov/Medicare/Coding/ICD10/downloads/GEMsCrosswalksBasicFAQ.pdf
 AAPC: ICD-10 Code Translator - http://www.aapc.com/ICD10/resources.aspx
October 2014
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Reference:
http://www.aapc
.com/ICD10/resources.as
px
October 2014
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44
ICD-10-CM Code Assignment
IMO Problem IT
 Intelligent Medical Objects, Inc.
 Available additional software for purchase on a yearly basis
 Each Center AR will need to download software for each
licensed eCW provider wanting the software.
 Code Search tool compatible with eCW
 Established partnerships with eCW®, Epic®, Cerner®,
Meditech®, Allscripts®, NextGen®, Greenway™,
PatientKeeper®, CPSI® and others
October 2014
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45
ICD-10-CM Code Assignment
IMO Problem IT
 Searches with layman’s terms to find correct diagnoses
 Gives multiple choices to ensure most accurate ICD-10-CM
code is assigned
 Achieved through drop down boxes that address laterality,
encounter status, healing status, etc.
 Is currently available for ICD-9-CM codes as well.
October 2014
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Moving Forward…
Planning for ICD-10
 Not just a coding/billing issue
 Strategic planning is crucial to CCNV and
Health Center operations
 Refer to Office Lay-out document titled: “ ICD10 will change everything…Will you be ready?”
from the AAPC
 Revenue stream will depend on successful
implementation
October 2014
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What is the Impact of this
Transition?
 Moving from a fee-for-service mindset to a value-
based purchasing mindset of healthcare services
 Better identify those complex conditions being treated
and managed
 More detailed information in the ICD-10-CM code
choices that could reduce delays in payment.
October 2014
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Increasing Demand for High-Quality
Documentation
Better clinical documentation promotes better patient
care and more accurate capture of acuity and severity
 Quality measures
 Reimbursement
 Severity-level profiles
October 2014
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Increasing Demand for High-Quality
Documentation
High-quality documentation can help to:
 Avoid misinterpretation by third parties (auditors,
payers, attorneys, etc.)
 Justify medical necessity
October 2014
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Documentation Gap Analysis
Assess quality of medical record documentation to
identify improvement opportunities
 Documentation to support ICD-10-CM detail may be
better than expected
Medical record sampling techniques could include:
 Random samples
 Sampling by clinical specialty
 Top diagnoses
October 2014
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Clinical Documentation
Improvement Strategies
 Identify documentation improvement opportunities
that could impact multiple initiatives – don’t focus
solely on ICD-10-CM
 Determine best solution for addressing each
documentation gap – one size doesn’t fit all
 Examples:





October 2014
Modifications to form or template
EHR documentation template
System prompts
Education
Workflow or operational process changes
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ICD-10 Details that Could be Added to
Electronic Health Record (EHR) Templates
 Laterality
 Encounter type (initial, subsequent, sequela, routine
healing, delayed healing)
 Anatomic details
 Severity (worsening, improving, stable)
October 2014
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Clinical Documentation Gaps
A physician treats a patient for a lower back pressure
ulcer
ICD-9: You should report 707.03 (Pressure ulcer; lower
back) and an additional code from 707.20-707.25
(Pressure ulcer stages ...) to identify the pressure ulcer
stage.
October 2014
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Clinical Documentation Gaps
A physician treats a patient for a lower back pressure
ulcer
ICD-10 Changes:
 The example does not include enough information. You
need to know whether the ulcer is on the left or right, the
stage of the ulcer.
 You'll report a single code. Some options will be (but are
not limited to): L89.131 (Pressure ulcer of right lower back,
stage I) L89.141 (Pressure ulcer of left lower back, stage I).
October 2014
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ICD-10 Payment & Coverage
Policies
 CMS and other payers will announce how specific
payment and coverage policies will be converted to
ICD-10 codes
 CMS will undergo formal rulemaking to announce final
decisions for specific payment policies
 All Payers will continue to make independent
judgments about how unspecified codes should be
handled under a payment or coverage policy
October 2014
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How Do We Get There?
Start Now!
 CCNV has developed a 9 Step-
by-Step Implementation Plan
- currently being revised
based on the NEW deadline.
 Plan is based on the American
Academy of Professional
Coders (AAPC) Model for
Small/Medium Sized
Practices
October 2014
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Internal Training
 Developing an Internal Training Schedule
 Physician specific documentation review

CCNV can provide education sessions and auditing services
 Overview ICD-10-CM for administrative staff
 Lunch and Learns
 Coding Blasts – Did you Know?
 Outside training opportunities
October 2014
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CPC’s
Must Take Proficiency Exam
 Required for all AAPC credential holders (excluding
CPPM®, CPCO™, and CIRCC®), recommended for all others
working with the new code set
 Two (2) years to take and pass the assessment, beginning
October 1, 2013 (one year before implementation of ICD-10)
and ending September 30, 2016 (one year after
implementation)
 75 questions, 3.5 hours, open-book, online, unproctored,
use any resource available
October 2014
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CPC’s
Must Take Proficiency Exam
 Coders will have two (2) attempts at passing (must have
80%+ score)
 $60 administration fee
 ICD-10-CM only
 (ICD-10-PCS will not be covered in the assessment)
 No CEUs given
October 2014
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ICD-10-CM Implementation – Network
Shareholders
 Provide scheduled conference calls with Center
Contact Person(s)
 Develop Diagnosis Auditing Tool to assess
provider documentation:
 Offering ICD-10 documentation readiness audits:
 Does current documentation support the most specific ICD-10
code(s)
 What additional information is crucial to ICD-10 code assignment
October 2014
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ICD-10-CM Implementation – Network
Shareholders
 Resources to help with educating various levels of
staff members
 Providers: Discuss areas of documentation that need
additional details

October 2014
AAPC – 3 hour online provider education training based on
specialty
 Self-paced, 3 CME’s upon completion
 CCNV to help with administration of the log-ons/passwords
 $295/provider
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Do You Think It’s a
Coincidence?
The ICD-10-CM Code for
Hypertension
Is….
October 2014
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October 2014
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Reduce F43.0
Acute
Stress
Reaction
October 2014
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We will get there!
One Step
at a Time…
October 2014
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Questions?
October 2014
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Contact Information
Stephanie Anderson, CPC
Director of Network Compliance
Community Care Network of
Virginia, Inc.
3831 Westerre Parkway
Henrico, VA 23233-1330
Phone: (804) 237-7686 x1204
E-mail: sanderson@ccnva.com
October 2014
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October 2014
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CMS ICD-10 Website
 The CMS ICD-10 website http://www.cms.gov/icd10
provides the latest ICD-10 information and links to
resources for providers to prepare for ICD-10
implementation in a 5010 environment.
 The CMS Sponsored ICD-10 Teleconferences web page at
http://www.cms.gov/ICD10/Tel10/list.asp provides
information on upcoming and previous CMS national
provider ICD-10 teleconferences , including registration,
presentation materials, written transcripts and audio
recordings.
October 2014
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CMS ICD-10 Website
 Medicare Fee-for-Service Provider Resources
http://www.cms.gov/ICD10/06_MedicareFeeforServiceProv
iderResources.asp
 Provider Resources (for all providers)
http://www.cms.gov/ICD10/05a_ProviderResources.asp
web pages provide links to a variety of related educational
resources and information
October 2014
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Resources:
Complete Versions of ICD-10-CM
 Annual updates of each system are posted on the ICD-10
website at http://www.cms.gov/ICD10
 Maintenance and updates of ICD-9-CM and ICD-10 are
discussed at the ICD-9-CM Coordination and Maintenance
(C&M) Committee meeting
http://www.cms.gov/ICD9ProviderDiagnosticCodes/03_m
eetings.asp
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Community Care Network of Virginia, Inc.
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Disclaimer
CCNV produces this education session for information and
guidance purposes only. It is produced in good faith and
with the goal of providing useful information obtained from
a variety of sources. CCNV has made every effort to
ensure that the information is correct and up-to-date. The
information presented is not designed to be a substitute for
professional and legal advice for specific situations. If
specific advice is required, it is recommended that you
contact professional services relating to the area of
concern.
October 2014
Community Care Network of Virginia, Inc.
73