CPMAApril 11, 2015

Phill Ward, DPMPresident, APMA

CPMAApril 11, 2015

Phill Ward, DPMPresident, APMA

What’s new for 2015

• CPT 20600– (Descriptor change)– Arthrocentesis, aspiration and/or

injection, small joint or bursa (e.g., fingers, toes) without ultrasound guidance

What’s new for 2015

• CPT 20604– (New Code)– Arthrocentesis, aspiration and/or

injection, small joint or bursa (e.g., fingers, toes) with ultrasound guidance with permanent recording and reporting

What’s new for 2015

• CPT 20605– (Descriptor change)– Arthrocentesis, aspiration and/or

injection, intermediate joint or bursa (e.g., ankle, wrist, elbow) without ultrasound guidance

What’s new for 2015

• CPT 20606– (New Code)– Arthrocentesis, aspiration and/or

injection, intermediate joint or bursa (e.g., ankle, wrist, elbow) with ultrasound guidance with permanent recording and reporting

What’s new for 2015

• CPT 97605– (descriptor change)– Negative pressure wound therapy (e.g.

vacuum assisted drainage collection) utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

– Example “KCI wound vac”

What’s new for 2015

• CPT 97606– (New code)– Negative pressure wound therapy (e.g.

vacuum assisted drainage collection) utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than or equal to 50 square centimeters

– Example “KCI wound vac”

What’s new for 2015

• CPT 97607– (New code)– Negative pressure wound therapy (e.g.

vacuum assisted drainage collection) utilizing non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

– Example “Snap”

What’s new for 2015

• CPT 97608– (New code)– Negative pressure wound therapy (e.g.

vacuum assisted drainage collection) utilizing non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater to 50 square centimeters

– Example “Snap”

What’s new for 2015

• -59 modifier change (only for CMS so far)• -XE (separate encounter)• -XS (separate structure)• -XP (separate practitioner)• -XU (unusual overlapping service)

• CMS has been less than clear in their notices about how/when to use these modifiers

• MLN article dated Feb 2015 still doesn’t clarify the usage of these modifiers

What’s new for 2015

• Examples• -XE

– Patient was seen in the morning and returned in the afternoon for another service

• -XS– Services were provided on nails and

lesions or bunion and hammertoe

What’s new for 2015

• Examples• -XP

– Bone graft harvested by 1 surgeon and used by another surgeon on the same patient in the same encounter

• -XU– 2 lesions present in the same code set

and are excised separately

Ongoing Controversy

• Nerve injections– Other peripheral nerve 64450– Neuroma Steroid 64455– Neuroma Sclerosing 64632– Other sclerosing 64640– Other misc nerve 64999

What About Globals?

• 10 day global– 2017

• 90 day global– 2019

• CPT Assistant March 2015 revision of global package definition/interpretation

Meaningful ? Use

• 50% of eligible providers did not attest for Stage I

• 4% eligible providers successfully attested for Stage II in 2014

• Congressional (in)action

• Flex It Bill – Rep Elmers

• Jan 30, 2015 CMS comments

Sustainable Growth Rate andMedicare Fee Schedule Reform

• House passed SGR reform 3/25

• Senate refused to act before Easter vacation

• +/-21% decrease on April 1, 2015

• Senate is supposed to act “soon”

• Multiple payment models proposals to replace “Fee For Service” model

• No decisions made yet, likely a testing period before implementation

If you don’t want to use ICD-10…

…then don’t

have a nice day

Postponement?

• It is possible that Congress will once again postpone ICD-10 implementation

• Are you willing to bet your practice on it?

The Train has left station!!

• So what has APMA done to prepare you for ICD-10?

• link: http://www.apma.org/YourPractice/content.cfm?ItemNumber=1413

• There have been more than 20 ICD-10 articles in the APMA News• All are available for download on the

APMA website

APMA News Articles

Webinar Series

• There has been a series of ICD-10 webinars presented and recorded and archived on the APMA website

Coding Resource Center

• The CRC has been updated with a crossover capability to translate ICD-9 codes to ICD-10 codes

ICD-10 Potential negative impacts

• Decreased productivity• Interrupted cash flow• Increased amount of rejections• Incompatible systems • Increased volumes of work • Incorrect mapping• Increased risk of payer audits• Having to run 2 diagnosis coding

systems at the same time

ICD-10 Potential positive impacts

• Better specificity• Better data collection

ICD-10 Structure

• Same as ICD-9• Chapters

– 22 Chapters identifying categories• Blocks

– Subchapters – Etiology, anatomical site, severity

• Rubrics – Identify closely related conditions– Extensions

ICD-10 Chapters• Chapter 1 A00-B99 Infectious and Parasitic diseases• Chapter 2 C00-D49 Neoplasms• Chapter 3 D50-D89 Hematological and Immune

Systems• Chapter 4 E00-E90 Endocrine, Nutritional and

Metabolic Diseases• Chapter 5 F01-F99 Mental and Behavioral Disorders• Chapter 6 G00-G99 Diseases of the Nervous System• Chapter 7 H00-H59 Diseases of the Eye and Adnexa

ICD-10 Chapters

• Chapter 8 H-60-H95 Diseases of the Ear and Mastoid • Chapter 9 I01-I99 Diseases of the Circulatory

System• Chapter 10 J00-J99 Diseases of the Respiratory System• Chapter 11 K00-K94 Diseases of the Digestive System• Chapter 12 L00-L99 Diseases of the Skin and Subcutaneous Tissue• Chapter 13 M00-M99 Disease of the Musculoskeletal

System and Connective Tissue

• Chapter 14 N00-N99 Diseases of the Genitourinary System

ICD-10 Chapters

• Chapter 15 O00-O99 Pregnancy, Childbirth and Puerperium• Chapter 16 P00-P96 Certain Conditions Originating in the

Perinatal Period• Chapter 17 Q00-Q99 Congenital Malformations, Deformations

and Chromosomal Abnormalities• Chapter 18 R00-R99 Symptoms, Signs and Abnormal

Clinical and Laboratory findings, not classified elsewhere

• Chapter 19 S00-T88 Injury, Poisoning and Certain other Consequences of External Causes

• Chapter 20 V00-Y98 External Causes of Disease or Morbidity• Chapter 21 Z00-Z99 Factors Influencing Health Status and

Contact with Health Services• Chapter 22 – Special Purposes

How Detailed is ICD-10?

DecacodaphobiaDefinition = Fear of ICD-10

Z23.670

ICD-9-CM vs. ICD-10-CM

ICD-9-CM• Numeric characters

(with exception of some codes beginning with V, E, M)

• 3-5 in length• About 13,000

codes

ICD-10-CM

• Alphanumeric characters; always begin with an alpha character

• 3-7 characters in length

• About 68,000 codes

ICD-9-CM ICD-10-CM

Other ICD-10 to ICD-9 Differences

• Laterality (side of the body affected – right/left) has been added to relevant codes

• Injuries grouped by anatomic site rather than type of injury

• Expanded use of combination codes– Certain conditions and associated

common symptoms or manifestations– Poisonings and associated external

causes

Format differences

Combination Code Examples• E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene• E11.621 Type 2 diabetes mellitus with foot ulcer

[Use additional code to identify site of ulcer L97.4-,L97.5-]

• I69.144 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting

left non-dominant side• I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot

ICD-9-CM ICD-10-CM

V49.71 - Lower limbamputation status,great toe

Z89 – Acquired absence of limb

Z89.4 – Acquired absence of toe(s), foot, & ankle

Z89.41 – Acquired absence of great toe

Z89.411 - Acquiredabsence of right greattoe

ICD-10-CM Structure - Format

3-7 character examples

L84 Corn and callositiesB95.5 Staphylococcus aureus as the cause of

diseases classified elsewhereM20.11 Hallux valgus (acquired), right foot T78.01D Anaphylactic shock due to peanuts

(subsequent encounter)S98.111A Complete traumatic amputation of

right great toe (initial encounter)

ICD-10-CM

Fracture codes require a 7th character 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

ICD-9-CM & ICD-10-CM

Both ICD-9 and ICD-10 Alphabetic Indexes • Recommend beginning your code search

in Volume 2 (alphabetic), then verifying the code in Volume 1 which is much more detailed

(Most EHR will do this automatically after you type in an alpha search term)

Alphabetic Index (ICD Volume 2)

ICD-9 Alphabetic Index

Hallux 735.9limitus 735.8

malleus (acquired) 735.3rigidus (acquired) 735.2

congenital 755.66late effects of rickets

268.1valgus (acquired) 735.0

congenital 755.66varus (acquired) 735.1

congenital 755.66

ICD-10 Alphabetic IndexHallux

deformity (acquired) NEC M20.5xlimitus M20.5xmalleus (acquired) NEC M20.3-rigidus (acquired) M20.2-

congenital Q74.2sequelae (late effect) of

rickets E64.3valgus (acquired) M20.1-

congenital Q66.6varus (acquired) M20.3-

congenital Q66.3

Tabular List (ICD Volume 1)

ICD-9 Tabular Index

735 Acquired deformities of toeExcludes: congenital (754.60 - 754.69, 755.65 - 755.66)

735.0 Hallux valgus (acquired)

735.1 Hallux varus (acquired)735.2 Hallux rigidus735.3 Hallux malleus

ICD-10 Tabular IndexM20.1- Hallux valgus (acquired)

Bunion M20.10 Hallux valgus (acquired),

unspecified foot M20.11 Hallux valgus (acquired), right foot M20.12 Hallux valgus (acquired), left foot

M20.2- Hallux rigidus M20.20 Hallux rigidus, unspecified foot M20.21 Hallux rigidus, right foot M20.22 Hallux rigidus, left foot

M20.3- Hallux varus (acquired) M20.30 Hallux varus (acquired), unspecified foot M20.31 Hallux varus (acquired), right foot M20.32 Hallux varus (acquired), left foot

Start with Index

• START WITH INDEX• There is a period after the 3rd character and

often a dash• Example Pain

– M79. –

• NEXT TO TABULAR NEXT TO TABULAR - Define the site, - Define the site, etiology, manifestation or state of the disease etiology, manifestation or state of the disease or conditionor condition

• Example PainExample Pain– M79. - M79. -

ICD-9-CM & ICD-10-CM

Both ICD-9 and ICD-10 Alphabetic Indexes include • the Index of Diseases and Injury• the Index of External Causes of Injury• The Tables of Neoplasm; and• The Table of Drugs and Chemicals

Both ICD-9 and ICD-10 use an indented format

Hallux 735.9 rigidus (acquired) 735.2 congenital 755.66

ICD Guidelines Example: Volume 2

hallux valgus (acquired)

ICD Guidelines Example: Volume 1

M20.1 Hallux valgus (acquired)

ICD 10 Changes APMA Submitted for Change

10/1/2015• M21.6 Other acquired deformities of foot• Excludes: deformities of toe (acquired)• (M20.1-M20.6)• M21.6x Other acquired deformities of foot• M21.6x1 Other acquired deformities of right foot• M21.6x2 Other acquired deformities of left foot• M21.6x9 Other acquired deformities of unspecified foot• M21.61 Bunion

M21.610 Bunion deformity, unspecified• M21.611 Bunion deformity, right foot• M21.612 Bunion deformity, left foot• M21.62 Bunionette• M21.620 Bunionette deformity, unspecified• M21.621 Bunionette deformity, right foot• M21.622 Bunionette deformity, left foot

DEFINITION: Unspecified

Codes in the Tabular Listing that include “unspecified” in their description are to be used when the information in the medical record is insufficient to assign a more specific code.

M20.10 hallux valgus (acquired), unspecified foot

In other words, in the “hallux valgus” example, the medical record failed to distinguish which foot had the hallux valgus deformity.

The Alphabetic Index uses “NOS” – not otherwise specified – for the same designation.

DEFINITION: “Other Unspecified” or “Other”Codes that include “other” or “other specified” in

their description are found in the Tabular Listing.

“Other” or “other specified” codes are to be used when the medical record documents a condition for which no specific ICD code exists.

The corresponding term in the Alphabetic Index is “NEC” (not elsewhere classified).

Next…

• 4th Character

• Define the site, etiology, manifestation or state of the disease or condition

• Numeric

• Example Pain– M79. -

• M79.6 pain in limb, hand, foot, fingers, toes

#5

• 5th Character

• 5th character identifies a level of specificity• Letter or Number (0-9)• Example

– M79. Pain• M79.6 pain in limb, hand, foot, fingers,

toes–M79.60 Pain in limb

#6

• 6th character is even more specific• Numeric (0-9)

– Describes specific location or cause– For laterality

• 1 is right • 2 is left• 3 is unspecified

– Example Pain– M79.-

• M79.6 pain in limb, hand, foot, fingers, toes– M79.60 Pain in limb unspecified

• M79.671 Pain in right foot

7th…

• 7th Character

• Some codes have a so-called character extension

• Typically letters, that describe conditions/timing of the visit

• Used to give more information about the events related to the reason for the visit or service

• Non-fracture care• A- initial

encounter • D- subsequent

encounter• S- sequela

Fracture care• A- initial encounter (for

closed fracture)• B – initial encounter for

open fracture• D- subsequent

encounter for normal healing fracture

• G- subsequent encounter for delayed healing fracture

• K- subsequent encounter for fracture with non-union

• P- subsequent encounter for fracture with mal-union

• S- sequela of fracture

ICD-10 “Look-Up” Example

Stage III decubitus ulcer of left heelStep 1 - Look up main term in

Alphabetic Index

Ulcer, ulcerated, ulcerating, ulcerationSee ulcer by site

lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic)

(topical)pressure (pressure area) L89-

heel L89.6-

ICD-10-CM “Look-Up” Example

Stage III decubitus ulcer of left heel Step 2 - Verify in Tabular:

L89.6- Pressure ulcer of heel

L89.62- Pressure ulcer of left heel

L89.623 Pressure ulcer of left heel, stage III

More ICD Guidelines[ ] Brackets in the Tabular List enclose synonyms, alternative wording, or explanatory phrases

M21.4 Flat foot [pes planus] (acquired)

[ ] Brackets in the Alphabetic Index are used to identify manifestation codes

Disease, diseased skin L98.9

due to metabolic disorder NEC E88.9 [L99]

“Code First” & “Use Additional Code”

An ICD sequencing example

Diabetic (type I) heel ulcer

Is the underlying condition

“Code First” & “Use Additional

Code”The ICD sequencing instruction is to list

the underlying condition code first

L97 is a

manifestation code

ICD Guidelines

Manifestation code: L97.411

It is coded after the underlying condition code, E10.621 diabetic (type I) heel ulcer

At Risk Care and ICD-10

ICD- 9

• 703.8 (onychauxis)

ICD- 10• L60.2 onychogryphosis,

hypertrophic nails• L60.3 nail dystrophy• L60.8 other nail

disorders• L60.9 nail disorder,

unspecified• Q84.5 onychauxis,

enlarged nails• Q84.6 other cong. Nail

dz

Let’s add PVD

ICD-9• 443.9 PVD,

unspecified

ICD-10• I70.2- ASO of native

arteries of extremities• (IMPORTANT!!:)• The hyphen denotes

additional characters required specific for ASO disease

• Need to be SPECIFIC unlike in ICD 9

And…Diabetes

ICD 9• 250.60• Diabetes with

neurological manifestations

ICD 10• E10.4- type 1 DM with

neuro complications• E11.4- type 2 DM with

neuro• Z79.4- with insulin use• E13.4- other specific DM

with neuro comps.• 13.61- other specified

DM with diabetic arthropathy and Z79.4- for insulin use

Oh yeah, “thick nails”

ICD 9• 110.1• onychomycosis

ICD 10• B35.1 onychomycosis

Let’s add a keratoma

ICD 9• 701.1 keratoderma

ICD 10• L85.1• L85.2

Impact analysis

• Determine any area in the practice that currently utilizes an ICD-9-CM code

• Ask for input from the various departments (clinical and clerical) to ensure that nothing is overlooked

• How are performance measures captured• Prior authorizations• Research • Tracking and trending

Strategies for Success

• The first place to begin in preparing for ICD-10 implementation is with communication

• Keep everyone updated on what is happening• No delay expected, we need to continue to

prepare for the transition• If you take it seriously, so will the people you

are leading• What form of communication will be most

effective in your office/institution

Measure productivity

• Understand where productivity is at prior to the implementation of ICD-10

• Use this as a “goal” to get back to after the official implementation date

• Canada indicates that their productivity has not recovered since implementation– Different reimbursement system– Implemented EMR at same time as ICD-10– Went from DOS system to a windows based

claims world

Questions for Consideration:

– Is your EHR and billing system ICD-10 compatible

–Are you sure?

–Has it been tested?

–Have you tested it?

Your take home message is“Don’t be a dinosaur”

Things that will effect your income in 2015

• ACA implications

• Rise of deductibles

• Decrease in malpractice premiums

• ICD-10

• ACOs

• Retail clinics

• PCPs, NPs, Pas

• MU moves from carrot to stick

• PQRS penalties

• Reporting payments to physicians

QUESTIONS?PEWARD@APMA.ORGTWITTER: @APMAPRESIDENT

www.apma.org