Laurie Aloi, CHC, CHPC, CPCDirector of Billing & ComplianceMedSafeOctober 21, 2013
ICD-10 OverviewNext Steps to ICD-10
AgendaUnderstanding what’s coming
Timeline and history Delay in ImplementationWhat is ICD-10? Side by Side examplesReview of Coding GuidelinesPlanning for a Successful Transition
When?The Department of Health and Human Services (HHS) originally announced the plan for ICD-10-CM implementation.In August 2009, CMS announced the implementation date would be October 1, 2011The date was pushed back in January 2009 after MGMA and AAPC appealed to CMS that the training and software transition would be a burden to the medical professionPractices have had 4 years to prepare and should be learning about-What ICD-10 isWhat will need to be done to prepare
And Now?On February 16, 2012 HHS Secretary Kathleen Sebelius has announced that the October 1, 2013 date for implementation of ICD-10 has been pushed back indefinitely“ICD-10 codes are important to many positive improvements in our health care system. We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work through the rulemaking process, with the provider community, to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”
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New Implementation DateOn April 9, 2012, CMS announced that the new implementation date will be October 1, 2014
The extra year will give medical practices more time to shift from the demands of Meaningful Use and Quality, to the issues of training and implementing ICD-10
Why change from ICD-9?ICD-9-CM has several problems. After 30
years, it is no longer useful. It is out of room. Because the classification
is organized scientifically, each three-digit category can have only 10 subcategories. Most numbers in most categories have been assigned diagnoses. Medical science keeps making new discoveries, and there are no numbers to assign these diagnoses. ICD-10 expands to 7 digits.
Computer science, combined with new, more detailed codes of ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care provided.
These same details will streamline claims submissions, since these details will make the initial claim much easier for payers to understand.
A large share of the world is using ICD-10 since it was introduced in
1992 • United Kingdom (1995) • Nordic countries (Denmark, Finland, Iceland,
Norway, Sweden) (1994 – 1997) • France (1997) • Australia (1998) • Belgium (1999) • Germany (2000)
• Canada (2001)
Reimbursement and Quality problems with ICD-9
Example – fracture of wristPatient fractures left wrist
A month later, fractures right wrist– ICD-9-CM does not identify left versus right
–• requires additional documentation
– ICD-10-CM describes• Left versus right• Initial encounter, subsequent encounter• Routine healing, delayed healing, nonunion, or
malunion
ICD-10 Changes everything
From this…..
To this
ICD-10 Major ModificationsAdded trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used) Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be used) Expanded codes (e.g., injury, diabetes) Added code extensions for injuries and external causes of injuries
Laterality- Left versus Right - C50.1 Malignant neoplasm, of central portion of breast – C50.111 Malignant neoplasm of central
portion of right female breast – C50.112 Malignant neoplasm of central
portion of left female breast
Structural Differences ICD-9
ICD-9-CM has 3 – 5 digits Chapters 1 – 17: all characters are numeric Supplemental chapters: first digit is alpha (E or V), remainder are numeric Examples: – 496 Chronic airway obstruction not
elsewhere classified (NEC) – 511.9 Unspecified pleural effusion – V02.61 Hepatitis B carrier
Structural Differences ICD-10
ICD-10-CM has 3 – 7 digits Digit 1 is alpha (A – Z, not case sensitive) Digit 2 is numeric Digit 3 is alpha (not case sensitive) or numeric Digits 4 – 7 are alpha (not case sensitive) or numeric A66 Yaws A69.20 Lyme disease, unspecified O9A.311 Physical abuse complicating
pregnancy, first trimester S42.001A Fracture of unspecified part of
right clavicle, initial encounter for closed fracture
Format and Guidelines
ICD-10-CM Organization Introduction How to Use Official GuidelinesAlphabetic IndexNeoplasm TableTable of Drugs and ChemicalIndex to External Causes
Format and Guidelines
ICD-10-CM OrganizationTabularChaptersICD-10-CM has 21 ChaptersBlocks
ExampleChapter 8 – Diseases of the Ear and Mastoid Process
is divided into 5 blocks H60-62 Diseases of the external ear, H65-75 Diseases of the middle ear and mastoid, H80-83, Diseases of the inner ear, H90-94 Other disorders of the ear, H95 Intraoperative/postprocedural complications
Comparison of Code SetsICD-9 ICD-10
3-5 characters 3-7 characters
More than 17,000 codes More than 155,000 codes68,000 are for ICD 10- CM
First digit may be alpha or numeric (E or V only), digits are 2-5 are always numeric
First digit is alpha; digits 2 & 3 are numeric; digits 4-7 are alpha or numeric
Limited space for adding new codes
Flexible, new format allows for expansion
Lacks detail Very specific
Lacks laterality Includes a specific field to identify laterality (right vs. left)
Structural DifferencesICD-9 Diagnosis Code ICD-10 Diagnosis Code
382.9 Acute Otitis Media B01.2 Varicella pneumonia
540.9 Acute Appendicitis K21.0 GERD with esophagitis
780.01 Coma O30.003 Twin Pregnancy, unspecified, third trimester
In the ICD-10 diagnosis code set, the alpha characters are not case sensitive. These examples show a comparison of the formats of the ICD-9 and ICD-10 diagnosis codes. You can see the use of alpha characters and longer codes in ICD-10
ICD-10 StructureThe expanced number of characters of the
ICD-10 diagnosis codes provides greater specificity to identify disease etiology, anatomic site, and severity
Characters 1-3 - CategoryCharacters 4-6 - Etiology, anatomic site,
severity, or other clinical detailCharacter 7 – Extension (example-
episode of care or other clinical detail)
Detailed ExampleS52 Fracture of ForearmS52.5 Fracture of lower end of radiusS52.52 Torus fracture of lower end of radiusS52.521 Torus fracture of lower end of right radiusS52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture
Side by side example #1Severe, unremitting left lower leg pain
ICD-9 – 729.5 Pain, lower extremity
ICD-10 M79.662 Pain in left lower leg
ICD-10 Coding Structure
M79 Other and unspecified soft tissue disorders, not specified elsewhere
M79.6 Pain in limb, hand, foot, fingers and toes
M79.66 Pain in Lower Leg
M79.662 Pain in left lower extremity
Side by side example #2Sprain of the deltoid ligament of right ankleICD-9 – 845.01 Sprain, deltoid lligament of ankle
ICD-10 S93.421 sprain of the deltoid ligament of right ankle
ICD-10 Coding Structure
S93 Subluxation and dislocation of the ankle joint
S93.4 Sprain of ankle
S93.42 Sprain of the deltoid ligament
S93.421 Sprain of the deltoid ligament of the right ankle
S93.421A Sprain of the deltoid ligament of the right ankle, Initial Encounter
Similarities
Index abbreviations (NEC)Tabular abbreviations (NOS)“and” means “and/or”“other specified” and “unspecified” are the sameIncludes notesExample:I70.24 Atherosclerosis of native arteries of
left leg with ulceration Includes any condition classifiable to I70.212 and I70.222
SimilaritiesUse additional code….’, ‘Code first’ and ‘Code also’ notesExample:
G47.3 Sleep apneaCode also any associated underlying condition
Inclusion termsOfficial coding guidelinesCMSNCHSAHAAHIMA
Differences
ICD-10-CM codes are all alphanumericFirst character is always an alpha characterSubsequent characters may be alpha or numericExample:I82.a11 Acute embolism and thrombosis of
right axillary veinCodes may be 3, 4, 5, 6 or 7 characters in lengthCode Descriptions are listed in full
A Place for everything, everything in its place- Benjamin Franklin
The fact that the codes are up to seven characters in length is a major difference that brings two new considerations: seventh character extenders and dummy placeholders.
The seventh character extenders are usually a letter, and are used to identify the encounter type. The most common seventh character extenders used in ICD-10-CM are:
A-Initial Encounter for closed fractureB- Initial encounter for open fractureD- Subsequent Encounter for fracture with
routine healingG- Subsequent encounter for fracture with
delayed healingK- Subsequent encounter for fracture with
nonunionP- Subsequent encounter for fracture with
malunionS- Sequela
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A unique twist- the “Placeholder”
Some codes are 7 characters, but no 4th, 5th or 6th place is necessary, so “x” is a placeholder
T68.xxxA - Hypothermia
The appropriate 7th character is to be added to code T68A – initial encounterD – Subsequent encounterS – sequela
Body Systems• Blood and Blood
Forming• Organs• Immune System• Endocrine System• Nervous System• Eye and Adnexa• Ear and Mastoid
Process• Circulatory System
• Respiratory System• Digestive System• Integumentary
System• Musculoskeletal
System• Genitourinary
System• Pregnancy,
Childbirth, and Puerperium
Diseases of the Circulatory System
ICD-9 Description ICD-10 Description
401.1 Essential hypertension (benign)
I1ØEssential (primary) hypertension
414.01 Coronary atherosclerosis of native coronary artery (CAD)
I25.1Ø
Atherosclerotic heart disease of native coronary artery without angina pectoris
427.31 Atrial fibrillation I48.Ø
Atrial fibrillation
428.0 Congestive heart failure I5Ø.9
Heart failure, unspecified
Diseases of the Respiratory System
Description ICD-9 ICD-10
Laryngitis 464.0 J04.0
Croup 464.4 J05.0
Respiratory Syncytial Virus (RSV
466.11 J04.11
Pneumonia 481 J13 pneumonia due to StrepJ18.1 Lobar pneumonia, unspecified organism
Influenza 488.0 JØ9.Ø19 Influenza due to identified avian influenza virus with unspecified type of pneumonia
COPD 496 J44.9
Signs and SymptomsDescription ICD-9 ICD-10 ICD-10
Description
786.05 Shortness of breath RØ6.Ø2
Shortness of breath
786.50 Chest painRØ7.9
Chest pain, unspecified
786.51 Precordial Pain RØ7.2 Precordial pain
786.59 Chest Pain NEC* RØ7.82
R07.89
Intercostal pain
Other Chest pain
790.93 Elevated PSA
R97.2
Elevated prostate specific antigen [PSA]
Diseases of the Respiratory System
3311/12/12
Description ICD-9 ICD-10 ICD-10 Description
Asthma 493.00J45.2Ø
Mild intermittent asthma, uncomplicated
Bronchitis 490J4Ø
Bronchitis, not specified as acute or chronic
Pneumoconiosis 505J64
Unspecified pneumoconiosis
Empyema (pus in lung)
510.9J86.9
Pyothorax without fistula
Pneumothorax 512J93.Ø
Spontaneous tension pneumothorax
Interstitial Lung Disease
770.1 Fetal and newborn aspiration
P28.9
Respiratory condition of newborn, unspecified
Diseases of the Respiratory System
3411/12/12
Description ICD-9 ICD-10 ICD-10 Description
Pulmonary Edema
518.4J81.Ø Acute pulmonary edema
Screening:
Personal history
V12.60Z87.Ø9
Personal history of other diseases of the respiratory system
Family history
V17.5Z82.5
Family history of asthma and other chronic lower respiratory diseases
Screenings V72.50ZØ1.89
Encounter for other specified special examinations
Common OB Gyn ConditionsICD-9 Description ICD-10 Description
620.2 Ovarian Cyst N83.20
N83.29
Unspecified Ovarian CystOther ovarian Cysts
174.8 Malignant neoplasm breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
625.6 Stress incontinence, female
N39.3 Stress incontinence (female) (male)
625.4 Premenstrual tension syndromes
N94.3 Premenstrual tension syndrome
625.3 Dysmenorrhea N94.3 Dysmenorrhea, unspecified
628.3 Infertility, uterine (female)
N97.2 Female infertility of uterine origin
V Codes will be Z CodesICD-9 Description ICD-10 Description
V72.5 Z01.41
Z01.411
Encounter for gynecological examination..with abnormal findings
V22.0
V22.1
Supervision of normal first pregnancy…..other normal pregnancy
Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester
V25.0 Z30.8 Encounter for contraceptive management
V72.4V72.40V72.41V72.42
Pregnancy test……unconfirmed……negative……positive
Z32.3Z32.00Z32.01Z32.02
Pregnancy examination or test……unconfirmed……negative……positive
Diseases of the Musculoskeletal System
Description ICD-9 ICD-10 ICD-10 Description
715.11 Primary localized osteoarthritis, shoulder region
M19.Ø19
Primary osteoarthritis, unspecified shoulder
M19.012 Primary Osteoarthritis, left shoulder
M19.011Primary Osteoarthritis, right shoulder
715.15 Primary localized osteoarthritis, pelvic region and thigh
M16.1Ø
Unilateral primary osteoarthritis, unspecified hip
M16.11 Unilateral Primary osteoarthritis, right hip
M16.12
Unilateral primary osteoarthritis, left hip
Diseases of the Musculoskeletal System
Description ICD-9 ICD-10 ICD-10 Description
717.2 Derangement of posterior horn of medial meniscus M23.229
Derangement of posterior horn of medial meniscus due to old tear or injury, unspecified knee
M23.329
Other meniscus derangements, posterior horn of medial meniscus, unspecified knee
M23.221
Derangement of posterior horn of medial meniscus due to old tear or injury, right knee
M23.222Derangement of posterior horn of medial meniscus due to old tear or injury, left knee
Diseases of the Musculoskeletal System
Description ICD-9 ICD-10 ICD-10 Description
719.41 Pain in joint, shoulder region
M25.519Pain in unspecified shoulder
M25.511 Pain in right shoulder M25.512 Pain in left
shoulder
719.45 Pain in joint, pelvic region and thigh
M25.559Pain in unspecified hip
M25.551 Pain in right hip M25.552 Pain in left
hip
Diseases of the Musculoskeletal System
Description ICD-9 ICD-10 ICD-10 Description
721.0 Cervical spondylosis without myelopathy
M47.812
Spondylosis without myelopathy or radiculopathy, cervical region
721.3 Lumbosacral spondylosis without myelopathy
M47.817
Spondylosis without myelopathy or radiculopathy, lumbosacral region
722.0 Displacement of cervical intervertebral disc without myelopathy
M5Ø.2Ø
Other cervical disc displacement, unspecified cervical region
722.10 Lumbar intervertebral disc without myelopathy
M51.26(M51.27 for lumbsosacral)
Other intervertebral disc displacement, lumbar region
Diseases of the Musculoskeletal System
Description ICD-9 ICD-10 ICD-10 Description
727.03 Trigger finger (acquired) M65.3Ø
Trigger finger, unspecified finger
727.61 Complete rupture of rotator cuff M75.1Ø
Rotator cuff syndrome, unspecified shoulder
354.0 Carpal tunnel syndrome
G56.ØØ
Carpal tunnel syndrome, unspecified upper limb
Anatomy and Pathophysiology
Higher level of specificity found in the new codesIn order to assign them correctly we have to first understand themFor example – the musculoskeletal system comprises 60% of the codes found in ICD-10
206 bones in the body80 are Axial– head, facial, hyloid, auditory, trunk, ribs,
and sternum
126 are Appendicular– arms, shoulders, wrists, hands, legs, hips,
ankles and feet
Types of FracturesDisplaced fracturesNon-displaced fracturesClosed fractureOpen fractureGreenstick FractureTransverse fractureSpiral fractureOblique fractureCompression fracture
Anatomy and Pathophysiology -
Musculoskeletal systemClassification is needed for open fractures using the “Gustilo Open fracture classification system”This system identifies fractures as Type I, II, IIIA, IIIB and IIICI – Low energy, wound less than 1 cmII – Wound greater than 1 cm with moderate soft tissue damageIII – High energy wound greater than 1 cm with extensive soft tissue damageIIIA – Adequate soft tissue coverIIIB – Inadequate soft tissue coverIIIC – Associated with arterial injury
Diseases of the Musculoskeletal System
Description
ICD-9 ICD-10 ICD-10 Description
813.42 Other fractures of distal end of radius (alone) S52.5Ø9A
Unspecified fracture of the lower end of unspecified radius, initial encounter for closed fracture
820.21 Intertrochanteric fracture, closed
S72.143A
Displaced intertrochanteric fracture of unspecified femur, initial encounter for closed fracture
S72.146A
Nondisplaced intertrochanteric fracture of unspecified femur, initial encounter for closed fracture
NeoplasmDescription ICD-9 ICD-10 ICD-10
Description
185 Malignant neoplasm of prostate
C61Malignant neoplasm of prostate
188.9 Malignant neoplasm of bladder, unspecified part
C67.9
Malignant neoplasm of bladder, unspecified
Comparison of ICD-9 Chapters to ICD-10 Chapters
ICD-9There are 17 Chapters, plus 2 supplementary chapters of V codes and E Codes*see spreadsheet
ICD-10There are 22 Chapters in ICD-10
Eye and AdnexaEar and mastoid ProcessExternal causes of morbidity and mortality
(separate from injury and poisoning)Codes for Special Purposes
GuidelinesIt is essential for a coder to review the chapter guidelines in the front of the ICD-10 manualChapter changes are summarized belowMany chapter guidelines are the same as ICD-9
Blood and Blood Forming Organs
SepsisComplication of infection outside the blood
streamBlood stream carries bacteria or other
organism through blood to other sitesSepsis vs. bacteremia vs. septicemia
Bacteremia - presence of bacteria in the bloodSepticemia - presence of bacteria in the blood (bacteremia)Sepsis - a serious condition characterized by a whole-body inflammatory state (systemic inflammatory response) with the presence of suspected or known infection
Chapter 15 Guidelines-Pregnancy, Childbirth, and the puerperium (O00-O099)a. General Rules for Obstetric Cases– 1) codes from chapter 15 have sequencing
priority over codes from other chapters.– Should the provider document the
pregnancy is incidental to the encounter, code Z33.1 pregnant state, incidental, in place of any chapter 15 codes. (condition not affecting pregnancy)
– 2) Chapter 15 codes are used only on the maternal record and never on the newborn record
– 3) final character for trimester
6 digit exampleFinal character for trimester– O23.51 Infections of the genital tract
in pregnancy• O23.511 infections of cervix in
pregnancy, first trimester• O23.512 …………………………….second
trimester• O23.513……………………………….third
trimester• O23.519…………………………unspecified
trimester
TrainingWe know there will need to be significant education and training for physicians, coders and other healthcare personnel. No one needs to panic. Please do not jump to individual training as its difficult to remember in 1 yearswhat you were trained on today.You have year to have a plan in place to provide all you'll need to effectively implement ICD-10.
TrainingConsider offering training to your billing and coding staff – Medical Terminology– Anatomy– Pathophysiology– Use Video’s such as “Anatomy for
Beginners”• Purchase DVD or download from Youtube free of
charge• Excellent modules to advance your coding and
billing staff’s clinical knowledge
Attain CertificationConsider sending your billing manager, coders and others in you practice to become CPC certified in preparation for ICD-10. Don’t wait until the implementation date, learning CPT, HCPCS and ICD-9 will be an excellent foundationContinuing education is a must!
Maintain CertificationCertified coders (CPC, CPC-A and other coding credentials from AAPC) will require ongoing a proficiency Assessment75 QuestionsOpen book, online, unproctored, use any resource availableTwo attempts to pass over a two year windowScheduled to be available Oct 1, 2013 – Sept 30, 2015
October 1, 2014Implementation ComplianceClaims will require the new ICD-10 CodesContinue Training2-3 days of training will be requiredAHIMA estimates 16 hours or less of training– Have a certified coder on hand to support
the physicians and staff as they use the new code sets, or system, “live” for the first time
– Anticipate some disruption, consider ways to support your practice during this time
Helpful web sitesNational Center for Health Statistics
http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm
CMShttp://www.cms.hhs.gov/ICD10/
AHIMAhttp://www.ahima.org/icd10
MGMAwww.mgma.com
Ingenixwww.ingenix.com/caretracker
AAPCwww.aapc.com
AMAhttp://www.ama-assn.org/ama1/pub/upload/mm/399/
icd10-icd9-differences-fact-sheet.pdf
About The Presenter…Laurie Aloi is the Director of Billing and Compliance for Medsafe: The Total Compliance Solution.
Laurie oversees the billing compliance auditing and educational programs offered by Medsafe. A certified coder/physician chart auditor with over 25 years experience in the industry, Laurie directs the daily operations of the billing compliance division.
About The Company…For 20 years MedSafe has established the industry’s best practice standards for quality, and regulatory compliance services for healthcare practices. Through their onsite, and online programs MedSafe assures that physicians and their businesses are actively in compliance with the latest government regulations including HIPAA/HITECH, Corporate/Billing Compliance, OSHA, and more.
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