hfma 1-21-11 on 5010 and icd-10

A Winning Offense for Tomorrow’s Challenges Preparing for ICD-10 and

5010

Friday, January 21, 2011Gillette Stadium Clubhouse

Cynthia TrappCHFP, CMPE, CPCO, CPC, CPC-I, CCS-P, CHC, PCA

A Winning Offense for Tomorrow’s Challenges

The Latest …….

• Final Rule issued January 16, 2009– HHS in 45 CFR Part 162 issued the FINAL Rule

effective March 17, 2009

• Two parts:– Replace ICD-9-CM code sets with ICD-10 code

sets• Compliance date – October 1, 2013

– Implement HIPAA 5010 standards for electronic transactions

• Compliance date – January 1, 2012

*Federal Register / Vol. 74, No. 11 / Friday, January 16, 2009 / Rules and Regulations


5010


Compliance Dates

• Effective Date – March 1, 2009• Level I Compliance – December 31, 2010

– "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."

• Level II Compliance – December 31, 2011– "that a covered entity has completed end-to-end testing

with each of its trading partners, and is able to operate in production mode with the new versions of the standards."

• Fully Compliant – January 1, 2012 – Exception:

• Small Health plans for Medicaid – January 1, 2013

*Federal Register / Vol. 74, No. 11 / Friday, January 16, 2009 / Rules and Regulations


Compliance Dates

A Winning Offense for Tomorrow’s Challenges What and Why HIPAA

5010?• Current version 4010/4010A1

– Is outdated– Lacks necessary functionality– Does not support ICD-10

• New Version 5010/DO– Contains structural, technical, and data

content improvements– Allows for more specific data– Supports ICD-10 – Supports Pharmacy Standards


What are the Versions?

• Version 5010 – New version of X12 Standards for HIPAA transactions

• Version DO – New version of the National Council for Prescription Drug Program (NCPDP) standards for pharmacy and supplier transactions

• Version 3.0 – New NCPDP standard for Medicaid pharmacy subrogation

A Winning Offense for Tomorrow’s Challenges What are HIPAA

Transactions?HIPAA Act of 1996 required a standard format

for Electronic Data Interchange (EDI) of health care data for covered entities

• Claims and encounter information• Payment and remittance advice• Claims status• Eligibility• Enrollment and disenrollment• Referrals and authorizations• Premium payment

A Winning Offense for Tomorrow’s Challenges Who are the covered

entities?

• Health plans• Health care clearinghouses• Health care providers

A Winning Offense for Tomorrow’s Challenges 5010 Readiness

Assessment• Side by Side Comparison 4010 vs. 5010

– http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

– Claims, Claim Status, Remittances, Eligibility

• Software modification to meet new standards

• Testing with external vendors, payers, NOW…..Target date – January, 2011– Errata testing target date – April, 2011

• Contact MAC early for testing!


Side by Side Comparison

http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp



http://www.cms.gov/ElectronicBillingEDITrans/Downloads/NCPDP51toD0.pdf



http://www.cms.gov/ElectronicBillingEDITrans/Downloads/NCPDP51toD0.pdf

• Identify differences requiring change

A Winning Offense for Tomorrow’s Challenges Checklist for Level I

Testing

http://www.cms.gov/Versions5010andD0/Downloads/w5010PrepChklst.pdf


EDI Resource Guide

http://www.cms.gov/MLNProducts/downloads/5010EDI_RefCard_ICN904284.pdf

A Winning Offense for Tomorrow’s Challenges Provider Action Checklist

http://www.cms.gov/Versions5010andD0/Downloads/w5010PvdrActionChklst.pdf

A Winning Offense for Tomorrow’s Challenges Why change ICD-9-CM?

ICD-9-CM is obsolete– No longer supported by WHO– Over 30 Years old– Does not meet guidelines for

• HIPAA Code standards• Benefits Improvement and Protection Act of 2000 (BIPA)• 1993 coding system outlined by NCVHS

– Can not describe today’s diseases– Inaccurate data for making healthcare decisions– Unable to track international public health issues– Unable to compare costs and outcomes of modern

technology


ICD-10 CM/PCS


October 1, 2013


Why move to ICD-10?

ICD-10-CM has better data for:– Measuring Quality and Safety– Pay-for-performance initiatives– Public Health Reporting (e.g. SARS, West Nile

Virus)– Bioterrorism Monitoring– Reimbursement Rates– Medical Necessity– Research and Clinical Trials– Mapping from SNOMED – CT®– Meeting HIPAA requirements (5010,D.0 version)


Why not SNOMED-CT®?

• SNOMED-CT®– Systematized Nomenclature of Medicine -

Clinical Terms– Input system

• Designed for documentation of clinical care• Can only be used with EHR

• ICD-9-CM, ICD-10-CM, ICD-10-PCS– Output systems

• Designed for reporting and/or aggregation of data• Designed for paper or EHR systems• Not used for documentation of clinical care

A Winning Offense for Tomorrow’s Challenges Characteristics of ICD-10-

CM• Changed Titles• Conditions re-grouped • 7 digits for higher specificity• Diagnostic codes more precise/complete• Code combinations to reduce use of

multiple coding• Includes full code titles for all codes • Injury coding expanded• Room for future expansion• Structured by blocks


CM

• 7 digits for higher specificity• Alphanumeric Codes

– Character 1 is always Alpha– Character 2 is always Numeric– Character 3-7 can be either Alpha or Numeric– All letters used except “U”

• Decimal after the 1st three characters• Alpha characters are not case sensitive• Uses Zeros and Ones as well as I’s and O’s


Other differences…

• Injury classified by site then type rather than by type

• Post op complications moved to procedure specific body systems

• V-codes and E-codes are incorporated into main classification

• Eyes and Ears have their own chapters• Addition of sixth character in some chapters• Some chapters will have placeholder “x” where

there is no 6th character


Other differences cont…

• Obstetrics, Injuries, and external causes of injuries will have 7th character extensions

• All codes must go out to the 7th digit “if” there is a need for a seventh character extension

• Combination codes for common symptoms or manifestations

• Combination codes for poisonings and external causes

• 7th Character for episode of care (initial, subsequent)• Expanded diabetes, injuries, alcohol and substance

abuse, post op complications• Trimesters in OB and eliminate 5th digit for episode

of care


Other differences cont…

• Morphology codes are no longer in included• Changes in timeframes of codes

– Acute Myocardial Infarction from 8 wks to 4 wks– Abortion vs. fetal death from 22 wks to 20 wks

• Addition of Standard definitions for Excludes notes– Excludes 1 = Not coded here

• The two conditions can not be coded together– Excludes 2 = Not included here

• The condition is not included in this code so can be coded together


PCSProcedural coding system to replace the current

inpatient procedural coding system (Volume 3 of ICD-9-CM) for the DRG code assignment.

• Alphanumeric Codes• 7 digits for higher specificity• It is expandable and multi-axial• Standardized Terminology• Unique code for each substantially different

procedure• Uses Zero’s and One’s but not I’s and O’s• New “Look and Feel” to code selection


PCSICD-10-CM/PCS

Diagnoses • 21 Chapters

• No supplements• 7 characters• Alpha-numeric categories• Alpha-numeric codes• 69,101 Codes• 2,033 Code categoriesProcedures• ICD-10-PCS• 71,957 Procedure codes• 7 Alpha-numeric

Characters

ICD-9-CMDiagnoses• 17 Chapters

– 2 supplements• 3-5 characters• Numeric categories• Numeric codes• 13,000 Diagnosis

codes• 855 Code categoriesProcedures• Volume 3• 4,000 Procedure codes• 4 Numeric Characters


Chapter Changes


Basic Structure of ICD-10

• Volume I– Tabular Lists containing cause-of-death titles and

codes– Inclusion and exclusion terms for cause-of-death titles

• Volume II– Alphabetic index to diseases and nature of injury– External causes of injury– Descriptions, guidelines, and coding rules

• Volume III– Table of drugs and chemicals

A Winning Offense for Tomorrow’s Challenges What is the ICD-10-CM

Change?ICD-10-CM Structure -- Format

X X X X X X X

Extension

Etiology, anatomic site,

severityCategory


Basic Structure of ICD-10

Third Character Block– Example: Tuberculosis A15 – A19

• A15 Respiratory Tuberculosis• A17 Tuberculosis of Nervous System• A18 Tuberculosis of Other Organs• A19 Miliary Tuberculosis

*“The Future of Coding: 10 Strategies for Successful Implementation of ICD-10-CM”, © Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, EMS


Structure of ICD-10-CM

• Fourth Character– Site, etiology, manifestation or state of the disease

or condition– Example:

• C15 Malignant Neoplasm of the Esophagus– C15.3 Malignant neoplasm of upper third of esophagus– C15.4 Malignant neoplasm of middle third of esophagus– C15.5 Malignant neoplasm of lower third of esophagus– C15.8 Malignant neoplasm of overlapping lesion of

esophagus– C15.9 Malignant neoplasm of esophagus, unspecified




• Fifth – Sixth Character– Higher specificity of patient’s condition or

diagnosis– Example:

• F50.0 Anorexia Nervosa– F50.00 Anorexia Nervosa, unspecified– F50.01 Anorexia Nervosa, restrictive type– F50.02 Anorexia Nervosa, binge eating/purging type




• Seventh Character– Most precise level of specificity of patient’s condition or

diagnosis– Example:

• S42.215 Fracture (abduction) (adduction) (separation) Upper end Surgical neck (displaced) Non-displaced Left

– 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– J subsequent encounter for fracture with nonunion– M subsequent encounter for fracture with malunion– Q sequela

• If A fracture not designated as open or closed should be coded to closed


A Winning Offense for Tomorrow’s Challenges Change as a new Alpha-

number Example: Malignancy of Uterus

ICD-9-CM ICD-10-CM

179Malignancy of uterus

C55Malignancy of uterus

•179 Malignant neoplasm of the uterus, part unspecified

•C55 Malignant neoplasm of the uterus, part unspecified

A Winning Offense for Tomorrow’s Challenges Example: ICD-9-CM vs. ICD-10-

CM

ICD-9-CM ICD-10-CM

786.50Chest pain: NOS

R07.9Chest pain: NOS

Diagnosis: Chest Pain


CM

ICD-9-CM ICD-10-CM

997.09CSF

G97.0CSF

•997.01 Cerebrospinal Fluid Leak from spinal puncture

•G96.0 Cerebrospinal Fluid Leak from spinal puncture

Diagnosis: Cerebrospinal Fluid Leak (CSF)


CM

ICD-9-CM ICD-10-CM

401.9Hypertension unspecified

I11.◊Hypertension

•401.9 Hypertension, unspecified

•I11.0 Hypertensive heart disease with heart failure•I00.1 Hypertensive heart disease w/o heart failure

A Winning Offense for Tomorrow’s Challenges Organizational

Adjustments

ICD-9-CM ICD-10-CM274Gout

M10Gout

•274 Gout(Moved from Chapter 3)

Endocrine, Nutritional, Metabolic & Immunity Disorders

•M10 Gout(Moved to Chapter 13)

Disease of the Musculoskeletal System & Connective Tissue


Adjustments

ICD-9-CM ICD-10-CM

729.81Swelling of Limb

M79.89Swelling of Limb

•729.81 Swelling of Limb

Swelling of limb has been deleted in ICD-10

•M79.8 Other specified soft tissue disorders


AdjustmentsOsteoporosis with pathological fracture M80.0 Postmenopausal osteoporosis with pathological fractureM80.1 Post-oophorectomy osteoporosis with pathological

fractureM80.2 Osteoporosis of disuse with pathological fractureM80.3 Post-surgical malabsorption osteoporosis with

pathological fractureM80.4 Drug-induced osteoporosis with pathological fractureM80.5 Idiopathic osteoporosis with pathological fractureM80.8 Other osteoporosis with current pathological fracture

A Winning Offense for Tomorrow’s Challenges Greater Specificity in ICD-

10ICD-9-CM ICD-10-CM

565.0 ANAL FISSURE

K60.◊ ANAL FISSURE

•565.0 ANAL FISSURE •K60.0 ANAL FISSURE acute•K60.1 ANAL FISSURE chronic •K60.2 ANAL FISSURE unspecified


Example: ICD-9-CM vs. ICD-10-CM

ICD-9-CM ICD-10-CM143

Malignant Neoplasm of Gum

C03Malignant Neoplasm of

Gum•143.0 Upper Gum•143.1 Lower Gum

•C03.0 Malignant Neoplasm of Upper Gum•C03.1 Malignant Neoplasm of Lower Gum



ICD-9-CM ICD-10-CM413.9Angina

I20.◊◊Angina

•I20.0 Angina, unstable•I20.1 Angina pectoris with documented spasm•I20.8 Angina pectoris, other forms•I20.9 Angina pectoris, unspecified



ICD-9-CM ICD-10-CM

427.89Bradycardia

I49.◊Bradycardia

•I49.5 Sick sinus syndrome•I49.8 Other specified cardiac arrythmias•I49.9 Cardiac arrhythmia, unspecified



ICD-9-CM ICD-10-CM

427.9Arrhythmia

I47.◊Arrhythmia

•I47.0 Re-entry Ventricular arrhythmia•I47.1 Supraventricular tachycardia•I47.2 Ventricular tachycardia•I47.9 Paroxysmal tachycardia



493.92 Asthma

Acute Exacerbation

J45.◊1Asthma

Acute Exacerbation•493.92 Asthma, Acute Exacerbation

•J45.21 Mild, intermittent w/acute exacerbation•J45.41 Moderate, persistent w/acute exacerbation •J45.51 Severe, persistent w/acute exacerbation



424.1Aortic Valve Disorders

NOS, except rheumatic

I35.0Nonrheumatic Aortic Valve Disorders

•I35.0 Nonrheumatic aortic valve stenosis •I35.1 Nonrheumatic aortic valve insufficiency•I35.2 Nonrheumatic aortic valve stenosis•I35.8 Other nonrheumatic aortic valve disorders• I35.9 Nonrheumatic aortic valve disorder, unspecified



425.4Cardiomyopathy

I42.Cardiomyopathy

•I42.0 Dilated or congestive cardiomyopathy•I42.1 Obstructive hypertrophic cardiomyopathy•I49.2 Other hypertrophic cardiomyopathy•I49.3 Endomyocardial (consinophilic) disease•I49.4 Endocardial fibroelastosis•I49.5 Other restrictive cardiomyopathy•I49.6 Alcoholic cardiomyopathy•I49.7 Cardiomyopathy due to drugs and external agent•I49.8 Other cardiomyopathy•I49.9 Cardiomyopathy, unspecified



433.10Occlusion and

stenosis of pre-cerebral arteries

I65.2◊ Occlusion and stenosis of pre-

cerebral arteries

•433.10 Occlusion and stenosis of carotid artery without mention of cerebral infarction

•I65.21 Occlusion and stenosis of right carotid artery not resulting in cerebral infarction•I65.22 Occlusion and stenosis of left carotid artery not resulting in cerebral infarction•I65.23 Occlusion and stenosis of bilateral carotid artery not resulting in cerebral infarction



535.5Unspecified Gastritis

and Duodenitis

K29.◊0Gastritis and Duodenitis

•535.50 Unspecified Gastritis and Duodenitis without mention of hemorrhage

•K29.70 Unspecified gastritis w/o bleeding•K29.90 Unspecified gastroduodenitis w/o bleeding



555.9Regional enteritis

K50.90Regional enteritis

•555.9 Regional enteritis, unspecified site

•K50.90 Crohn’s Disease – unspecified, without complications

Additional 27 choices for Crohn’s Disease based on site and complications



365.83Aqueous

Misdirection

H40.83Aqueous Misdirection

•H40.831 Aqueous Misdirection, right eye•H40.832 Aqueous Misdirection, left eye•H40.833 Aqueous Misdirection, bilateral•H40.839 Aqueous Misdirection, Unspecified eye



883.0 Thumb laceration

S61.01◊a Thumb laceration

•883.0 Thumb laceration w/o mention of complication(needs modifier for left or right thumb)

•S61.011a* Laceration w/o FB, RT Thumb, w/o nail damage, initial encounter•S61.012a* Laceration w/o FB, LT Thumb, w/o nail damage, initial encounter(*a = initial encounter)

A Winning Offense for Tomorrow’s Challenges Hemorrhoids

ICD-9-CM = 10 codes ~ ICD-10-CM = 32 codes

ICD-9-CM ICD-10-CM455.2

Internal Hemorrhoids with other

complication

I84.11Internal Hemorrhoids with

other complication

•455.2 Internal Hemorrhoids with other complication

•I84.111 Internal Bleeding •Hemorrhoids•I84.112 Internal Prolapsed Hemorrhoids•I84.113 Internal Strangulated Hemorrhoids•I84.114 Internal Ulcerated Hemorrhoids


New for 2010! Example: ICD-9-CM vs. ICD-10-

CM

ICD-9-CM ICD-10-CM307.8

Pain disorders related to psychological factors

F45.4 Pain disorder related to psychological

factors

•307.80 Psychogenic pain, site unspecified

•F45.41 Pain disorder exclusively related to psychological factors Somatoform pain disorder (persistent) •F45.42 Pain disorder with related psychological factors Code also associated acute or chronic pain (G89.-)

Pain disorders related to psychological factors


ICD-9-CM ICD-10-CM•V70.0 Routine general medical examination at a healthcare facility•240.9 Goiter, nontoxic, unspecified

•Z00.011 Encounter for general medical examination with abnormal findings•E04.9 Nontoxic goiter, unspecified

45-year-old established patient presented to her physician’s office for a routine physical exam. During the examination the physician identified an enlarged thyroid. The physician ordered a laboratory test and requested to see the patient in two weeks.

Example: ICD-9-CM vs. ICD-10-CM Physician Office – Routine Exam

**From V Codes to Z Codes: Transitioning to ICD-10 by Karen M. Kostick, RHIIT, CCS,


Patient sees MD for follow-up for Rheumatoid Arthritis. MD documents in medical record “Rheumatoid Polyneuropathy with Rheumatoid arthritis of the right ankle and foot.”


ICD-9-CM ICD-10-CM•714.0 Rheumatoid Arthritis•357.1 Polyneuropathy in collagen vascular disease

•M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot


Asymptomatic 67-year-old female patient presents to the outpatient radiology department for a bilateral mammogram. The physician’s order documented breast cancer screening. The radiology report notes clusters of microcalcification in the left breast.

Example: ICD-9-CM vs. ICD-10-CM Outpatient Facility – Screening Scenario


ICD-9-CM ICD-10-CM•V76.12 Other screening mammogram •793.81 Mammographic microcalcification

•Z12.31 Encounter for screening mammogram for malignancy of breast•R92.0 Mammographic micro-calcification found on diagnostic imaging of breast


74-year-old patient fell at home and sustained a subtrochanteric fracture of the left femur and was discharged home. Physician ordered physical therapy for difficulty in walking and exercise three times a week for one month.

Example: ICD-9-CM vs. ICD-10-CM Home Health – Aftercare visit


ICD-9-CM ICD-10-CM•V57.1 Other physical •719.7 Difficulty in walking•V54.13 Aftercare for healing traumatic fracture of hip

•S72.22xd Displaced subtrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing•R26.2 Difficulty in walking, not elsewhere classified


A 54-year-old male is admitted into the hospital with a principal diagnosis of surgical site infection secondary to a recent right side below the knee amputation. Patient is a type I diabetic with diabetic peripheral vascular disease and congestive heart failure. The patient sought treatment when the wound began to exude purulent drainage. On the second day of his hospitalization he had developed nausea, uncontrolled diabetes, and ketoacidosis.Moist saline dressings were applied twice daily to the wound. Wound culture tested positive for Staphylococcus aureus and was resistant to flucloxacillin. Ciprofloxacin effectively treated the infection. Diabetic ketoacidosis managed well and blood glucose was brought under control. Patient was discharged to a rehabilitation facility for continued wound management.


Inpatient – Acute Care




Inpatient – Acute Care cont…


ICD-9-CM ICD-10-CM•997.62 Amputation stump infection•041.11 Staphylococcus aureus•V09.0 Infection with microorganisms resistant to penicillin's •250.13 Diabetes with ketoacidosis•250.73 Diabetes uncontrolled with peripheral circulatory disorders•443.81 Peripheral angiopathy in diseases classified elsewhere•428.0 Congestive heart failure, unspecified

•T87.43 Infection of amputation stump, right lower extremity•B95.6 Staphylococcus aureus as the cause of diseases classified elsewhere•Z16 Infection with drug-resistant microorganisms•E10.10 Type 1 diabetes mellitus with ketoacidosis without coma•E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene•I50.9 Congestive heart failure, NOS

A Winning Offense for Tomorrow’s Challenges A bit about ICD-10-

PCS?


Procedural coding system to replace the current inpatient procedural coding system

(Volume 3 of ICD-9-CM) for the DRG code assignment.

• 71,957 codes• Alphanumeric Codes• 7 digits for higher specificity• It is expandable and multi-axial• Standardized Terminology• Unique code for each substantially different

procedure• Uses Zero’s and One’s but not I’s and O’s• New “Look and Feel” to code selection

A Winning Offense for Tomorrow’s Challenges Structure of ICD-10-

PCS


• Multi-axial Definition: Multiple characters in the code string make up the complete code description

1Section

2Body

System

3Root

Operation

4Body Part

5Approac

h

6Devic

e

7Qualifie

r


ICD-10-PCS Code 2010 Totals, By Section2010 Release Summary


• Medical and Surgical 62,123 • Obstetric 338 • Placement 864 • Administration 1,435 • Measurement and Monitoring 326 • Extracorporeal Assistance and Performance 43 • Extracorporeal Therapies

42 • Osteopathic 100 • Other Procedures 60 • Chiropractic 90 • Imaging 2,673 • Nuclear Medicine 463 • Radiation Oncology 1,929 • Rehabilitation and Diagnostic Audiology 1,382 • Mental Health 30 • Substance Abuse Treatment 59 • Total 71,957

A Winning Offense for Tomorrow’s Challenges Medical and Surgical Section

Body Systems (Character 2)


Central NervousPeripheral NervousHeart and Great VesselsUpper ArteriesLower ArteriesUpper VeinsLower VeinsLymphatic and Hemic EyeEar, Nose, SinusRespiratoryMouth and ThroatGastrointestinalHepatobiliary and PancreasEndocrineSkin and Breast

Subcutaneous Tissue and FasciaMusclesTendonsBursae and LigamentsHead and Facial BonesUpper Bones Lower BonesUpper JointsLower JointsUrinaryFemale ReproductiveMale ReproductiveAnatomical Regions, GeneralAnatomical Regions, Upper

ExtremitiesAnatomical Regions, Lower

Extremities


Root Operations (Character 3)

AlterationBypassChangeControlCreationDestructionDetachmentDilationDivisionExcisionExtirpationExtractionFragmentation

FusionInsertionInspection MapOcclusionReleaseRemovalRepairReplacementRepositionResectionRestrictionRevisionTransfer


Body Part (Character 4)

• Defines the specific anatomical site where the procedure is performed

• 34 possible body part values for each body system value


Approach (Character 5)

• Defines the technique used to reach the site of the procedure

• 8 different approach values

– Open– Open Endoscopic– Percutaneous– Percutaneous Endoscopic– Open with percutaneous endoscopic assistance– Via natural or artificial opening– Via Natural or artificial opening endoscopic


Device (Character 6)

• The term “device” includes only devices that remain after the procedure is completed

• Instruments used to perform the procedure are not specified in the device character– Instruments for visualization are specified in the

approach character

• Materials incidental to a procedure such as clips and sutures are not considered devices


Qualifier (Character 7)

• Defines an additional attribute of the procedure performed, if applicable

• May have a unique meaning, depending on the root operation, body system, or body part

• Examples of qualifiers include:

Diagnostic and Stereotactic


Example: ICD-10-PCS

Percutaneous placement of pacemaker lead into the left atrium

0 2 H 7 3 M A

1

Section

2

Body System

3

Root Operation

4

Body Part

5

Approach

6

Device

7

Qualifier


Example of ICD-10-PCS cont…

0 2 H 7 3 M A

• 1 – Section (Medical/Surgical) 0• 2 – Body System (Heart and Great

Vessels) 2• 3 – Root Operation (Insertion) H• 4 – Body Part (Atrium, left) 7• 5 – Approach (Percutaneous) 3• 6 – Device (Cardiac Lead) M• 7 – Qualifier (Pacemaker Lead) A


Example: ICD-9-CM vs. ICD-10-PCS

Repair of fracture, radius w/internal fixation device

1Section

2Body

System

3Root

Operation

4Body Part

5Approac

h

6Devic

e

7Qualifier

ICD-9-CM ICD-10-PCS

79.32 0PQJ04Z

0 P Q J 0 4 Z

A Winning Offense for Tomorrow’s Challenges Example of ICD-10-PCS

cont…

• 1 – Section (Medical/Surgical) 0• 2 – Body System (Upper Bones) P• 3 – Root Operation (Repair) Q• 4 – Body Part (Left Radius) J• 5 – Approach (Open) 0• 6 – Device (Internal Fixation Device)

4• 7 – Qualifier (None) Z


Example: ICD-9-CM vs. ICD-10-PCS

*Percutaneous Transluminal Coronary Angioplasty with Stent

1Section

2Body

System

3Root

Operation

4Body Part

5Approac

h

6Devic

e

7Qualifier

0 2 7 0 3 D Z

ICD-9-CM ICD-10-PCS

00.6636.06

02703DZ

A Winning Offense for Tomorrow’s Challenges Example of ICD-10-PCS

cont…

• 1 – Section (Medical/Surgical) 0• 2 – Body System (Heart and Great

Vessels) 2• 3 – Root Operation (Dilation) 7• 4 – Body Part (Coronary Artery) 0• 5 – Approach (Percutaneous) 3• 6 – Device (Intraluminal) D• 7 – Qualifier (None) Z

A Winning Offense for Tomorrow’s Challenges Varying Specificity

Approaches Unique to Pituitary Gland

ICD-9-CM ICD-10-CM

07.◊◊Excision of Pituitary

Gland

0GT00ZZExcision of Pituitary

Gland•07.64 – Total excision of pituitary gland, transfrontal approach•07.65 – Total excision of pituitary gland, transsphenoidal approach•07.68 – Total excision of pituitary gland, other specific approach•07.69 – Total excision of pituitary gland, unspecified approach

•0GT00ZZ – Resection of Pituitary Gland, Open Approach


What are GEMS?


What are GEMS?

General Equivalence Mapping

“The Centers for Medicare and Medicaid Services (CMS) and the and the Centers for

Disease Control and Prevention (CDC) created the General Equivalence Mappings created GEMs to ensure consistent national

data when the US makes the transition, October 1, 2013”.

AHIMA “Putting the ICD-10-CM?PCS GEMs into Practice.” Journal of AHIMA 81,no.3 (March 201): 46-52


General Equivalence Mapping ICD-9 to ICD-10 - ICD-10 to ICD-9

• GEMs are more complex than a simple one-to-one crosswalk

• Convert large databases and test system applications

• Link data in long-term clinical studies• Develop application-specific mappings• Analyze data collected before and after the

transition to ICD-10-CM/PCS• Created to fill a specific, limited, short-term need

© AHIMA “Putting the ICD-10-CM?PCS GEMs into Practice.” Journal of AHIMA 81,no.3 (March 201): 46-52


General Equivalence Mapping ICD-9 to ICD-10 - ICD-10 to ICD-9

• Difficult to find two corresponding descriptions that are identical in level of specificity and terminology used

• Method used to reconcile those differences may vary, depending on whether the data is used for research, claims adjudication, or analyzing coding patterns between the two code sets

• Some areas of the classification translating between the codes is straightforward (infectious disease, neoplasm, eye, and ear)

• In other areas whole chapters are organized along a different axis of classification (obstetrics)

A Winning Offense for Tomorrow’s Challenges General Equivalence Mapping

(GEM)No Mirror Image

ICD-9-CM

ICD-10-CM

820.8 Fracture of unspecified part of neck of femur, closed

links to–––> (forward

S72.009A Fracture of unspecified part of neck of right femur, initial encounter for closed fracture

ICD-9-CM

ICD-10-CM


links from<––– (backward

S72.001AOr

S72.002AOr

S72.009A

Fracture of unspecified part of neck of right femur, initial encounter for closed fractureFracture of unspecified part of neck of left femur, initial encounter for closed fractureFracture of unspecified part of neck of femur, initial encounter for closed fracture





ICD-9-CM ICD-10-CM


links to–––> (forward

S72.009A Fracture of unspecified part of neck of right femur, initial encounter for closed fracture

“In the table’s GEM forward –––> example, ICD-9-CM code 820.8 does not map to ICD-10-CM codes S72.001A or S72002A because the ICD-9-CM code does not included information about which side of the body the fracture occurred, and this information is needed in order to link to these ICD-10-CM codes”.




ICD-9-CM

ICD-10-CM


links from<––– (backward

S72.001AOr

S72.002AOr

S72.009A

Fracture of unspecified part of neck of right femur, initial encounter for closed fractureFracture of unspecified part of neck of left femur, initial encounter for closed fractureFracture of unspecified part of neck of femur, initial encounter for closed fracture

However, in the <––– backward GEM CD-10-CM codes S72.001A and S72.002A map do map back to ICD-9-CM code 820.8 because laterally is not specified in ICD-9-CM and therefore both the left and right sides are included in this ICD-9-CM code.


Who should use GEMs?

Users include…• Payers • Providers • HIM professionals • Researchers • Informatics professionals • Utilization managers • Quality managers • Developers of quality measures • Software vendors



Number of Translation Alternatives in each GEM

Backward GEMs

ICD-10-CM codes with one ICD-9-CM translation alternative: 64,961

ICD-10-CM codes with more than one ICD-9-CM alternative: 4,140 (5%)

ICD-10-CM codes with no translation in ICD-9-CM: 593ICD-10-PCS codes with only one ICD-9-CM alternative: 67,126 ICD-10-PCS codes with more than one ICD-9-CM alternative: 4,831 (6%) ICD-10-PCS codes with no translation in ICD-9-CM: 0



Number of Translation Alternatives in each GEM

Forward GEMs

ICD-9-CM diagnosis codes with only one ICD-10-CM alternative: 11,344ICD-9-CM diagnosis codes with more than one ICD-10-CM alternative:

2,971 (20%) ICD-9-CM codes with no translation in ICD-10-CM: 416ICD-9-CM procedure codes with only one ICD-10-PCS alternative: 352 ICD-9-CM procedure codes with more than one ICD-10-PCS alternative:

3,486 (90%)ICD-9-CM procedure codes with no translation in ICD-10-PCS: 209



Glossary of Terms

• Applied mapping: distillation of a reference mapping to conform to the needs of a particular application (e.g., data quality, reimbursement, research).

• Backward mapping: mapping from a newer code set to an older code set.• Cluster: a combination of codes in the target system that represent a single

translation alternative.• Entry: the relationship between a code in the source system and possible

equivalents in the target system.• Forward mapping: mapping from an older code set to a newer code set.• Reference mapping: mapping that includes all possible valid relationships

between a source system and a target system.• Reverse lookup: the process of looking up a target system code in a GEM to

see all the source system codes that translate to it.• Source system: the code set of origin in the mapping; the set being mapped

from.• Target system: the destination code set in the mapping; the set being

mapped to GEMs.



Example of ICD-10-CM mapping

CMS Downloads General Equivalence Mappings and User’s Guides May 2009

ICD-10-CMSource Code

ICD-9-CM Target Code

Flags

T1500xA 9300 10111

T1500xA E914 10112

T1500xD 9300 10111

T1500xD E914 10112

T1500xS 9085 10000


Why do they go in both directionICD-9 to ICD-10 and ICD-10 to ICD-

9?• GEMs are designed to be used like a bi-directional

translation dictionary • Look up a code according to the concepts and

structure• Similar to Spanish-English and English-Spanish

dictionary design• Neither are a mirror image of each other • Translation alternatives are based on the meaning of

the code you are looking up• Based on index entries, tabular instruction, and

applicable Coding Clinic adviceCMS FAQ Published 03/26/2009 10:35 AM/Updated

03/30/2010/Answer ID 9663


Why do they go in both directionICD-9 to ICD-10 and ICD-10 to ICD-

9?• A "reverse lookup" of the backward mappings can be

used to convert payment logic or coverage decisions • Could be used in examining trend data over multiple

years• In 2013 going backwards it will be possible to

compare how frequencies changed for a specific condition using an ICD-10 code compared to prior years using ICD-9-CM codes

• Forward mapping (ICD-9-CM to ICD-10-CM/PCS GEMs) can be used to convert ICD-9-CM-based edits and can be used for analysis or conversion projects

CMS FAQ Published 03/26/2009 10:35 AM/Updated 03/30/2010/Answer ID 9663


GEMs consists of three basic steps

• Step 1: EXTRACT – Select all rows containing the code in the

source system.• Step 2: ANALYZE

– Note any flags applied to the code and understand what they convey about the entry.

• Step 3: REFINE – Select the row (s) of an entry that meet

the requirements of the applied mapping.2010 release of the National Center for Health Statistics (NCHS) public domain diagnosis code reference mappings


So Now What???

• What is affected by this change?• What does this mean to practices?• What does this mean to physicians?• What do our organizations need to do?• What can you do?

2010 release of the National Center for Health Statistics (NCHS) public domain diagnosis code reference mappings

A Winning Offense for Tomorrow’s Challenges What will be affected by ICD-

10?

• All computer systems that use ICD-9– Billing, coding, lab, pharmacy, EMR, etc…

• All Vendors that supply or support ICD-9 products• All Interfaces from system to system that pass ICD-9• All staff, MD’s, coders, billers, etc…• All diagnostic tests ordered/all orders placed• All claims/charges processed• All reports generated with ICD codes• Compliance efforts/Budgets/Training• Other projects/timelines

A Winning Offense for Tomorrow’s Challenges What must be

considered?IT Readiness

Physician/Clinician Adoption

Vendor Readiness

Coder / Staff Training

Payer ReadinessQuality, Compliance and

Audit Readiness

Reporting Readiness

Strategic Planning

Financial Impact

Senior Leadership Support

A Winning Offense for Tomorrow’s Challenges What do organizations need to

do?

• Analyze and plan for costs and budget implications• Analyze and plan for revenue and productivity

impact• Update all computer systems• Update all interfaces• Manage competing projects/timelines• Perform testing with Vendors and internal systems • Perform testing with payers• Plan for migration of diagnostic tests and orders

placed

A Winning Offense for Tomorrow’s Challenges What do organizations need to

do?

• Communicate to all physicians and leaders– Managers, Directors, Finance liaisons, coders, billers,

etc.

• Train all staff, MD’s, coders, billers, etc…• Migrate diagnostic tests orders placed• Update all encounter forms and other forms• Plan to manage claims/charges through

transition and after on both ICD-9 and ICD-10• Plan a transition of all reports generated with

ICD codes• Anticipate Compliance issues

A Winning Offense for Tomorrow’s Challenges Who needs to be

involved?

Any one else who touches ICD-9 today, HIM, Reporting, etc…

Administrative Staff, Nursing Staff

Quality, Compliance, Audit

Registration and Scheduling Staff, Pre-cert Staff

Finance and Billing

All Ancillary System Administrators, Vendors, Payers

Coding, Finance, and Billing

Information Services and Technology

Physicians and Clinical Staff

Senior Leadership

A Winning Offense for Tomorrow’s Challenges What are the Cost

Implications?• System transitions• Interface transitions• Training• Testing, Support• Dual Coding efforts• Productivity• Revenue impact (potential loss due to rejections)• Revenue cost due to re-work• Compliance impact (medical necessity)

A Winning Offense for Tomorrow’s Challenges Strategic decisions to

consider….

Will you use ICD-10 in your strategy Initiatives?• To improve reporting with external entities• To enhance disease wellness and management• To support initiatives to improve quality • To reduce cost of care • To enhance incentive based contracts with payers• To leverage cost savings/payments


Prepare Readiness Chart

Strategic Planning

Education IT Readiness

Vendor Integration

Payer Integration

Lahey Readiness

Awareness

Timeline

Budget

Staffing

Needs Assessment

Tools Assessment

Gap Analysis

Competing Projects

Gap Analysis

Vendor Readiness

Payer Analysis

Contract Negotiation

Granularity to our advantage

Internal Readiness

Strategic Support


What is your Code Impact?

• What is your volume of codes used?• How often is each code used?• How many in the first position?• Through what systems?• How many will change?• How many will require more complex

documentation?

A Winning Offense for Tomorrow’s Challenges What can you do to

prepare?• Start to communicate and plan for change• Educate your MD’s on the importance of being

specific in documentation• Review all systems that need to change• Update all encounter forms • Help establish a timeframe for implementation• Identify training needs in your organization• Review potential expenses and budget

Get ready for October 1, 2013

A Winning Offense for Tomorrow’s Challenges Updating Encounter

FormsICD-9-CM ICD-10-CM

• 211.3 Colon polyp• 564.00 Constipation• 555.9 Crohn's disease• 787.91 Diarrhea: NOS• 536.9 Digestive disorder• 536.8 Dyspepsia• 787.20 Dysphagia, unspecified• 790.5 Enzyme levels, abnormal• 530.10 Esophagitis• V16.0 Family history of GI cancer• 535.50 Gastritis: NOS

• K63.5 Colon polyp• K59.00 Constipation• K50.90 Crohn's disease• R19.7 Diarrhea: NOS• K92.9 Digestive disorder• K30 Dyspepsia• R47.02 Dysphagia, unspecified• R74.9 Enzyme levels, abnormal• K20.9 Esophagitis• Z83.7 Family history of GI cancer• K29.70 Gastritis: NOS

A Winning Offense for Tomorrow’s Challenges Updating Encounter

FormsICD-9-CM ICD-10-CM

• 272.4 Hyperlipidemia: NOS• 401.9 Hypertension unspecified• 401.1 Hypertension, benign• 401.0 Hypertension, malignant• 412. MI, old• 424.0 Mitral valve prolapse• 785.2 Murmur• 785.1 Palpitations• 782.3 Pedal edema• 423.9 Pericarditis• 443.9 Peripheral vascular disease• 443.0 Raynaud's syndrome• 396.3 Regurgitation / mitral• 780.2 Syncope & collapse• 785.0 Tachycardia• 435.9 TIA

• E78.2 Hyperlipidemia: NOS• I11.9 Hypertension unspecified• I10 Hypertension, benign• I10x Hypertension, malignant • I25.2 MI, old• I05.1 Mitral valve prolapse• R01.1 Murmur• R00.2 Palpitations• R60.0 Pedal edema• I31.9 Pericarditis• I73.9 Peripheral vascular dis• I73.0 Raynaud's syndrome• Q23.3 Regurgitation / mitral• R55 Syncope & collapse• R00.0 Tachycardia • G45.9 TIA

A Winning Offense for Tomorrow’s Challenges Biggest change…we need

to….

•THINK…Documentation

•THINK…Specificity

A Winning Offense for Tomorrow’s Challenges Biggest change…we need

to….

“Documentation is the Cornerstone to Successful

Implementation”

Deborah GriderPresident, AAPC



?


• Centers for Medicare and Medicaid– http://www.cms.hhs.gov – http://www.cms.gov/ElectronicBillingEDITrans/18_5010D

0.asp– http://www.cms.gov/Versions5010andD0/– http://www.cms.gov/Versions5010andD0/10_backgroun

d.asp#TopOfPage– http://www.cms.gov/MLNProducts/downloads/5010EDI_R

efCard_ICN904284.pdf– http://www.cms.gov/Versions5010andD0/Downloads/w5

010PrepChklst.pdf– http://www.cms.gov/Versions5010andD0/Downloads/w5

010PvdrActionChklst.pdf– https://questions.cms.hhs.gov/app/answers/list/kw/5010

Useful Websites for 5010


• National Center for Vital and Health Statistics– http://www.cdc.gov/nchs/about/otheract/icd9/

abticd10.htm• World Health Organization (WHO)

– http://www.who.int/aboutwho/en/mission.html• Centers for Medicare and Medicaid

– http://www.cms.hhs.gov/paymentsystems/icd9/icd10.asp

– http://www.cms.hhs.gov/medlearn/icd9code.asp

Useful Websites for ICD-10


• Health and Human Services– http://www.hhs.gov/agencies/

• Ingenix Online:– http://www.ingenixonline.com/content/

icd10/resources.asp• WHO 2010 Version of ICD-10

– http://www.who.int/classifications/apps/icd/icd10online/

Useful Websites for ICD-10


• National Center for Vital and Health Statistics• World Health Organization (WHO)• Centers for Medicare and Medicaid• Health and Human Services• “About the International Classification of Diseases, Tenth

Revision, Clinical Modification (ICD-10-CM), CDC, http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

• “July 2010 Release* International Classification of Diseases, Tenth Revision (ICD-10), CDC, http://www.cdc.gov/nchs/about/otheract/icd10cm.htm

• “International Classification of Diseases, Tenth Revision (ICD-10), CDC, http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

• “Transition to ICD-10”, Ingenix, Inc. © 2005

Sources of Information


• “The Future of Coding: 10 Strategies for Successful Implementation of ICD-10-CM”, © Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, EMS

• “Why ICD-9-CM Needs to be replaced”, AHIMA, http://www.ahima.org/icd10/icd9.asp

• “US must adopt and implement ICD-10-CM and ICD-10-PCS”, July 2007 AHIMA, www.ahima.org/icd10

• “The Regulatory Journey to Destination 10: Understanding the Process for Adoption of ICD-10-CM and ICD-10-PCS”, Giannangelo, RHIA, CCS, AHIMA, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_023199.hcsp?dDoc

• “Destination 10: Healthcare Organization Preparation for ICD-10-CM and ICD-10-PCS”, AHIMA Practice Brief, Journal of AHIMA 75, no.3 (March 2004): 56A-D.



• “ICD-10 Made Easy”, © Medicode, Inc.• “HIT Legislation – It’s Still the Data”, AHIMA• “AHIMA’s Advocacy Effort”, AHIMA,

http://www.ahima.org/icd10/advocacy.asp• “Understanding ICD-10 ”, AHIMA,

http://www.ahima.org/icd10/understand.asp• “ICD-10 Regulatory Process”, AHIMA,

http://www.ahima.org/icd10/regulatory.asp• “Relationship of Classifications and Terminologies ”, AHIMA,

http://www.ahima.org/icd10/relationship.asp• “Preparing for ICD-10”, AHIMA,

http://www.ahima.org/icd10/prepare.asp• “ICD-10: Essential Components of the 21st Century Healthcare

System”, AHIMA, http://www.ahima.org/icd10/index.asp



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Disclaimer


Cynthia A. TrappCHFP, CMPE, CPCO, CPC, CPC-I, CCS-P, CHC, PCA

[email protected]

Contact Information

hfma 1-21-11 on 5010 and icd-10

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