This information was current at the time of publication and/or presentation.
Medicare and commercial payer policies change frequently so source documents
have been provided within the presentation for your reference.
This presentation was prepared as a tool to assist providers and is not intended
to grant rights or impose obligations. Although every reasonable effort has been
made to assure the accuracy of the information within these pages, the ultimate
responsibility for the correct submission of claims and response to any remittance
advice lies with the provider of services. VEI Consulting, ICDExpert.net
employees, agents, and staff make no guarantee that this information is error-free
and bears no liability or responsibility for any results or consequences resulting
from the use of this information. Medical practitioners are responsible for the day
to day implementation and compliance with applicable state and federal laws and
regulations. Attendees should contact their own counsel or advisors for further
legal opinion.
Disclaimer
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Objectives
• Compliance Deadline
• Where we are today
• Structural Differences
• Planning Phase
• Steps to preparedness
• Resources
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WHERE WE ARE TODAY
• ICD-10 Mandatory Compliance Deadline: • October 1, 2014
• Industry Challenges
• It is not just about coding – It is about clinical
documentation of records to support accurate coding
• Better information leads to better care
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What is ICD-10?
International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM)
• The diagnosis code set that will replace ICD-9-CM Volumes 1 and 2
• Reports diagnosis in all clinical settings
International Classification of Diseases, Tenth Revision, Procedure
Coding System (ICD-10-PCS)
• The procedure code set that will replace ICD-9-PCS Volume 3
• Reports hospital inpatient procedures only
ICD-10-PCS will NOT replace CPT
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Why Convert to ICD-10-CM?
ICD-9-CM is outdated
• 30 years old – technology has changed
• Many of the categories are full
• Not descriptive enough
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Why Convert to ICD-10-CM?
Benefits of ICD-10
•Detailed health reporting and analytics
•Detailed information on condition, severity,
comorbidities, complications, and locations
•Expanded coding flexibility
•Improved operational processes 8
STAKEHOLDERS
• HIM
• Coding Processes
• CDI Processes
• IT
• System Compliance
• FINANCE
• Payer Contracts
• Account resolution
• PHYSICIANS/PRACTITIONERS
• Documentation specificity
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ASSESSMENTS
Organization
• Needs and Functions of all Departments
Coder/Biller/Staff
• Anatomy and Physiology
• Medical Terminology
• Official Coding Guidelines
Documentation Assessment
• Specificity and quality of clinical documentation
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Structural Differences
ICD-9-CM
3 to 5 digit codes
Letters V and E
14,315+ ICD-9-CM and 3,824 ICD-9-PCS
ICD-10-CM
3 to 7 alpha numeric characters
All letters except U
69,099 + ICD-10-CM
71,957+ ICD-10-PCS
Greater specificity 11
ORGANIZATIONAL & STUCTURAL CHANGES
ICD-9-CM
17 CHAPTERS
Letters V and E
Injuries classified by type
ICD-10-CM
21 CHAPTERS
Eye and Ear have their own chapter
All letters except U
Postoperative Complications moved to procedure specific body system chapter
Reclassifications
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CODE STRUCTURE
Code structure of ICD-10-CM versus ICD-9-CM
ICD-9-CM codes are three to five digits while ICD-10-CM codes can be from three to
seven characters, with the seventh character extensions representing visit encounter,
subsequent, or sequelae for injuries and external causes, etc.
ICD-9-CM Code Format ICD-10-CM Code Format
●
category etiology,
anatomic site,
manifestation
●
category etiology extension
anatomic site,
severity
3 3 2 8 S 4 2 3 1 1 K 7
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Tabular List – Structural Differences:
•Certain diseases have been reclassified to a more
appropriate chapter in ICD-10-CM to reflect current
medical knowledge
•Ex: Gout reclassified from the endocrine chapter
in ICD-9-CM to the musculoskeletal chapter in ICD-
10-CM
•Postoperative complications have been moved to
procedure-specific body system chapters
Structural Differences
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New for physicians and coders
• Laterality – need to know which side was affected
• Encounter – need to know if it was an initial encounter,
subsequent encounter or sequela
• Activity – need to know what the patient was doing when
the injury occurred
• Place of Occurrence – need to know where the patient was
when the injury occurred
Structural Differences
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Index – structured the same as ICD-9-CM
• Alphabetic Index of Diseases and Injuries
• Alphabetic Index of External Causes
• Table of Neoplasm
• Table of Drugs and Chemicals
Structural Differences
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Many conventions have same meaning
• Abbreviations
• Punctuations
• Symbols
• Notes such as “code first” and “use
additional code”
Structural Differences
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ICD-10-PCS allows identification of:
• Body system
• Root operation
• Body part
• Approach
• Device involved in the procedure
Structural Differences
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New for physicians and coders
•Added clinical concepts
•Ex: underdosing, blood type, coma scale, etc
•Obstetric codes identify trimester
•Changes in some code definitions
•Ex: acute myocardial infarction has changed from 8
weeks to 4 weeks
Structural Differences
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ICD-9 codes
• 14,315 CM diagnosis codes
• 3,824 PCS procedure codes
ICD-10 codes
• 69,099 CM diagnosis codes
• 71,957 PCS procedure codes
Change in character length requires system upgrades to
expand data fields for the longer codes
Structural Differences
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General Equivalence Mapping (GEM)
• Created by Centers for Medicare & Medicaid Services (CMS)
and Centers for Disease Control and Prevention (CDC) as a
general purpose translation tool
• Ensure that consistency in national data is maintained
• Updated annually
• NOT a substitute for learning how to use the ICD-10-CM and
ICD-10-PCS code books
• GEM and User Guides are found at CMS website
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Coding Snapshot - Fracture
ICD-9-CM Diagnostic Statement : Orbital fracture
• Assign ICD-9: 802.8 Other facial bones, closed
•Orbit
•NOS
•Part other than roof or floor
•Coder’s query to physician should include:
•Bone?
•Open or Closed?
•Physician updates diagnostic statement in medical record as
follows:
•802.6 orbital floor (blow out), closed
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Coding Snapshot- Fracture
ICD-10-CM Diagnostic Statement: Initial encounter
closed orbital floor fracture, batter hit by baseball in a
public park
•Assign ICD-10-CM:
•S02.3xxA fracture of orbital floor, initial encounter
for closed fracture
•W21.03xA struck by baseball, initial encounter
•Y92.320 baseball field as the place of occurrence of
the external cause
•Y92.830 public park as the place of occurrence of
the external cause
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Planning Phase
•Assign overall responsibility and decision-making
authority for managing the transition
•Ensure top leadership understands the breadth and
significance of the ICD-10 change
•Ensure involvement and commitment of all internal and
external stakeholders
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Planning Phase
• Impact/GAP Analysis
• Assessments
• Adhere to a well-defined timeline
• Plan a comprehensive and realistic budget
• What you don’t know today will hurt your organization
tomorrow!
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Steps to Preparation
#1: Identify Current Systems and Work Processes
Impact Assessment
• Where are you using ICD-9?
• Electronic or manual
• Clinical documentation
• Encounter Forms or Superbills
• Practice Management System
• Electronic Health Record (EHR/EMR) System
• Quality Reporting
• Public Health Reporting
• Contracts
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#2: Communicate with Practice Management System Vendor
• Review your contract to determine if regulatory updates are included in your maintenance
• Ask your vendor the following questions:
• Can my current system accommodate the data format changes for the ICD-10 codes?
• Will you be upgrading my current system to accommodate the ICD-10 codes?
• Will there be a charge for the upgrade?
• When will the upgrades be available for installation?
• When will the upgrades to my system be completed?
Steps to Preparation
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Steps to Preparation
#3: Communicate with Your Billing Service,
Clearinghouse and Payers
• Ask your billing service and clearinghouse the following
questions:
• Will you be upgrading your systems to accommodate the
ICD-10 codes?
• When will your upgrades be complete?
• When can I send claims and other transactions with ICD-10
codes to you so you can test that they will be accepted?
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Steps to Preparation
#4: Communicate with Your Payers About Your
Contracts
• Payers may modify the terms of their contracts for billing
• Medical policies and local coverage determinations may
require highest specificity be reported
• Payment schedules may be altered and reimbursed
differently for higher vs. less specific codes
• More detailed ICD-10 may impact payer medical review,
auditing, and coverage
• Negotiate extended timely filing limits and appeals time
limits
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Steps to Preparation
#5: Identify Changes to Practice Work Flow and
Business Processes
• Clinical documentation
• Encounter Forms or Superbills
• Quality Reporting
• Public Health Reporting
• The biggest disruption in workflow will occur
when the information needed for coding just isn’t
there!
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Steps to Preparation
#6: Identify Staff Training Needs
• Critical step is ensuring that staff are knowledgeable about the
ICD-10 code set
• Staff may require different training based on their involvement
with diagnosis codes
• Clinical staff will need to understand how their documentation
will impact the ability to code and bill
• Coding staff will need the most training to learn how to use the
new code set and capture the diagnosis using ICD-10
• Focus on learning the ICD-10 code set and work flow changes
• The most important thing to do TODAY is to ensure that
documentation is sufficient
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Steps to Preparation
#6: Identify Staff Training Needs
Ask the following questions:
• Which ICD-10 codes sets do we need to receive training: ICD-10-CM, ICD-10-PCS, or both?
• Who needs to be trained?
• How long will it take to train?
• What training format will work best?
• Where can we obtain training?
• What is the cost of training?
• What resources will be needed to support the staff after training?
• When should training be completed?
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Steps to Preparation
#7: Test – Test – Test!
Trading partners
• Organizations with which you exchange various transactions
Ask the following questions:
• Which transactions should I test with the ICD-10 codes?
• It’s not just about claims!
• Which trading partners should I test with?
• When should I begin testing?
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Steps to Preparation
#8: Budget for Implementation Costs
Include expenses for:
• System changes
• Practice business process changes
• Resource materials
• Training
• Continued education
• ICD-9 focused review of current documentation
• ICD-10 focused review of medical records
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Steps to Preparation
Transition Phase
How do you actually make the jump into transition
and what things do you need to look for while you are
making the transition?
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Steps to Preparation
Transition Phase – Where are you today?
Don’t be stuck between a rock and hard place
There is a code for that!
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References
• Centers for Medicare and Medicaid Services (CMS)
http://www.cms.gov/ICD10/
• American Medical Association www.ama-assn.org
• ICD-10 Final Rule Federal Register published January 16, 2009
http://edocket.access.gpo.gov
• ICD-10 Final Rule Federal Register published September 5, 2012
http://edocket.access.gpo.gov
• American Academy of Professional Coders www.aapc.com
• American Health Information Management Association www.ahima.org
• Assess Your Skills:
• Medical Terminology/Anatomy/Physiology:
http://www.dmu.edu/medterms/
• Human Anatomy and Physiology:
http://www.lrn.org/index.html?wwparam=1327609974
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Questions
Questions about this presentation can be emailed to
VEI Consulting Services
7330 Shadeland Station, Suite 200
Indianapolis, IN 45256-3985
www.veicorp.com/consulting
E-mail: [email protected]
Office: (317) 621-7197 Fax: (317) 355-8738
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