ICD-10-CM An Introduction 2012

Bobbi Buell, MBAonPoint Oncology LLC800-795-2633bbuell@onpointoncology.cim

Create an awareness of ICD-10-CM.Start to consider the impact the

conversion to ICD-10 will have on your operations.

Start to understand what it means and does not mean in Oncology.

Latest UpdateThe AMA asked HHS to postpone or cancel ICD-

10.

CMS intimated that the deadline would be postponed.

HHS is in the process of making a rule as to how the postponement will work.

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

1) ICD-9-CM is out of date and running out of space for new codes.

• Lacks specificity and detail• No longer reflects current medical practice

2) ICD-10 is the international standard to report and monitor diseases and mortality, making it important for the U.S. to adopt ICD-10 based classifications for reporting and surveillance.

3) ICD codes are the core elements of HIT systems, conversion to ICD-10 is necessary to fully realize benefits of HIT adoption.

ICD-10-CM code book retains the same traditional format Index

Tabular

Process of coding is similarLook up a condition in the Index

Confirm the code in the Tabular

ICD – 9-CM ICD – 10-CM

13,600 codes 69,000 codes

Code book contains 17 chapters Code book contains 21 chapters

Consists of 3 to 5 characters Consists of 3 to 7 characters

1st character is alpha or numeric 1st character is alpha

Only utilizes letters E and V Utilizes all letters (except U)

Second, third, fourth, and fifth characters are always numeric

Second characteris always numeric

Third, fourth, fifth, sixth, and seventh

characters can be alpha or numeric

Shorter code descriptions because of lack of specificity and abbreviated code titles

Longer code descriptions because of greater clinical detail and

specificity and full code titles

ICD-9-CM CODE

A - Category of code

B - Etiology, anatomical site, and manifestation

ICD-10-CM CODE

A - Category of code

B - Etiology, anatomical site, and/or severity

C - Extension 7th character for obstetrics,

injuries, and external causes of injuryA B

A B C

XX .

ICD-9-CM Structure – Format

XX XX XX XX55EE 1 4 0 0.VV

Category Etiology, Anatomic Site, Manifestation

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Numeric or Alpha

(E or V) Numeric

3 – 5 Characters

XX XX XX XX

Category

.Etiology, Anatomic

Site, Severity

Added code extensions (7th character) for obstetrics, injuries, and external causes of injury

ICD-10-CM Structure – Format

XX XX XXAAMMS 3 2 0. 1 0 A

Additional Characters

Alpha (Except U)

2 - 7 Numeric or Alpha

3 – 7 Characters

ICD-9-CM Codes ICD-10-CM Codes

Pressure ulcer codes 9 codes

707.00 – 707.09

Pressure ulcer codes 125 codes

L89.0-L89.94

Codes:707.0 Pressure ulcer 707.00 - unspecified site 707.01 - elbow 707.02 - upper back 707.03 - lower back 707.04 - hip 707.05 - buttock 707.06 - ankle 707.07 - heel 707.09 - other site

Code Examples:L89.131 – Pressure ulcer of right lower back, stage IL89.132 – Pressure ulcer of right lower back, stage IIL89.133 – Pressure ulcer of right lower back, stage IIIL89.134 – Pressure ulcer of right lower back, stage IVL89.139 – Pressure ulcer of right lower back, unspecified stageL89.141 – Pressure ulcer of left lower back, stage IL89.142 – Pressure ulcer of left lower back, stage IIL89.143 – Pressure ulcer of left lower back, stage IIIL89.144 – Pressure ulcer of left lower back, stage IVL89.149 – Pressure ulcer of left lower back, unspecified stageL89.151 – Pressure ulcer of sacral region, stage IL89.152 – Pressure ulcer of sacral region, stage II…L89.90 – Pressure ulcer of unspecified site, unspecified stage

Combination codes for conditions and common symptoms or manifestations

Combination codes for poisonings and external causes

Added laterality

Expanded codes: injury, diabetes, alcohol/substance abuse, postoperative complications

Added extensions for episode of care

Inclusion of trimester in obstetrics codes and elimination of fifth digits for episode of care

Expanded detail relevant to ambulatory and managed care encounters

Inclusion of clinical concepts that do not exist in ICD-9-CM

Changes in timeframes specified in certain codes

Useful in Cancer??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

Useful In Cancer???ICD-9-CM

143 Malignant neoplasm of gum 143.0 Upper gum 143.1 Lower gum

ICD-10-CM C03 Malignant neoplasm of gum

C03.0 Malignant neoplasm of upper gumC03.1 Malignant neoplasm of lower gum

Arrangement of Volumes of ICD-10

Volume 1: Main classifications

Volume 2: Instruction/ Guidance to users

Volume 3: Alphabetical Index

ICD-10 has 21 chapters against 17 Chapters in ICD-9

Chapters of ICD-10Chapters I to XVII: Diseases and other morbid

conditions

Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.

Chapter XIX: Injuries, poisoning and certain other consequences of external causes.

Chapter XX: External causes of morbidity and mortality,

Chapter XXI: Factors influencing health status and contact with health services.

General Equivalence Mappings

“GEMs” stands for General Equivalence Mappings

The CMS and the CDC created GEMs to ensure consistent national data when the U.S. adopts ICD-10.

The GEMs will act as a translation dictionary to bridge the “language gap” between the two code sets and can be used to map an ICD-9 code to an ICD-10 code and vice versa.

Designed to give all sectors of the healthcare industry that use coded data the tools to:Convert large databases and test system applicationsLink data in long-term clinical studiesDevelop application-specific mappingsAnalyze data collected before and after the transition

to ICD-10-CM

• The GEMs should not be used as a substitute for learning how to use the ICD-10-CM code sets.• “GEMs are not a substitute for learning ICD-

10-PCS and ICD-10-CM coding. They’ll help you convert large data sets.”

• Mapping simply links concepts in the two code sets, without consideration of context of specific patient information, whereas coding involves assigning the most appropriate code based on documentation and applicable coding guidelines.

• A clear one-to-one correspondence between an ICD-9 or ICD-10 code is the exception rather than the rule.• ICD-9 codes: 414.01 Coronary atherosclerosis of

native coronary artery and 411.1 Intermediate coronary syndrome (unstable angina)

• ICD-10 code :I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina

• There are situations when a code in the target system does not exist• T503x6A Underdosing of electrolytic, caloric and

water-balance agents, initial encounter

ICD-9 Code

Description (Source)

820.8 Fracture of unspecified part of neck of femur, closed

ICD-9 Code

Description(Target)

820.8 Fracture of unspecified part of neck of femur, closed

Forward Mapping

Backward Mapping

GEMS Example #1

GEMS Example #2

GEMS #3

GEMS Example #4

Neoplasm Guidelines

Neoplasm GuidelinesMany guidelines are the same, but there are

differences. We try to cover those today.

To properly code a neoplasm, it is necessary to determine (not too different) whether: It is benign, malignant, benign, in situ or of uncertain

behavior; If the malignant, any secondary or metastatic sites

should be identified.

To code properly the Index Neoplasm Table should be accessed EXCEPT: If the histology is mentioned in the code descriptor, e.g.

adenoma or sarcoma

Neoplasm GuidelinesAgain, if the encounter is strictly for chemo,

immunotherapy, or Radiation, those codes should be coded as the principal diagnosis with the neoplasm as a secondary. No big change from today.

The secondary neoplasm should be designated as the primary, if treatment is directed there.

Neoplasm ComplicationsAnemia associated with malignancy is coded with

the malignancy sequenced first and anemia second. This is a major departure---we shall see what payers do with this.

Anemia associated with chemo or immunotherapy is coded with the adverse event code first and anemia second, then the malignancy.

Management of anemia associated with radiation is coded with anemia first, malignancy second, and Y84.2 third which is radiation causing an abnormal reaction in the patient.

Neoplasm ComplicationsDehydration is coded first with the neoplasm

second.

And, then of course, there is the confusing “HISTORY OF” guideline---which is not changed in ICD-10.

Signs, symptoms, and abnormal findings cannot be used to replace malignancies as primary diagnosis, except as noted.

More Neoplasm GuidelinesMalignancies of two or more contiguous sites

should not be coded as one or the other without asking the physician.

For disseminated neoplasms with no known PRIMARY or SECONDARY sites are coded to C80.0. This should not be used if either is known.

Cancer of unknown primary (CUP): CO80.1 Malignant (primary) neoplasm, unspecified, equates to Cancer unspecified. This code should only be used when the primary cannot be determined.

More Neoplasm Guidelineshttp://www.cdc.gov/nchs/icd/icdcm.htm

Preparing for ICD-10

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Checklist: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht

2009/ 2010 2011 2012 2013

Awareness and Impact

Assessment Preparing for Implementation

Go Live Preparati

on

Post – Implementation

Phase I

Phase II

Phase III

Phase IV

Year

• The increased specificity of the ICD-10 codes requires more detailed clinical documentation in order to code some diagnoses to the highest level of specificity.

• There are “unspecified” codes in ICD-10-CM for those instances when medical record documentation is not available to support more specific codes.

• The benefits of ICD-10 can not be realized if non-specific codes are used rather than taking advantage of the specificity ICD-10 offers.

Conduct medical record documentation assessmentsEvaluate records to determine adequacy of

documentation to support the required level of detail in new coding systems

Implement a documentation improvement program to address deficiencies identified during the review processEducate providers about documentation

requirements for the new coding system through specific examples

Emphasize the value of more concise data capture for optimal results and better data quality

DHHS agrees that some physicians will want intensive training on ICD-10 but some will seek “awareness training”. Nolan study estimates 8 hours of intensive physician

training

Nachimson Advisors, LLC study predicts 12 hours of physician training in both the code set and documentation procedures.

AHIMA believes most physicians would want no more than 4 hours of training.

Solo Practitioner Or Small Group (2-10) Practice Implementation Planning

1. Organize Implementation Effort2. Establish Communication Plan3. Conduct Impact Analysis4. Contact System Vendors5. Estimate Budget6. Implementation Planning7. Develop Training Plan8. Analyze Business Processes9. Education and Training 10.Policy Change Development 11.Deployment of Code12.Implementation Compliance

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Organize Implementation Effort

Enlist staff person (coder, biller, manager) to oversee effort who will be key point person― Prepare information to share with other providers

and staff― Identify work and scope for implementation

Should be a team effort involving all medical practice staff and the staff needs to believe that this will actually happen.

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Organize Implementation Effort

Examine the level of coding you have in your practice—who is certified? Who has experienced a change before, e.g. E/M, admin codes? Who is equipped to deal with this?

Look at all areas that will impact practice and identify each one that will be affected― Practice management system― Electronic Medical Record (EMR), if applicable― Superbills― Clinical areas and pharmacy

Schedule regular meetings to share information with physicians and discuss progress and barriers of implementation.

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Establish Communication Plan

How will point person communicate with all staff?Most practices communicate via meetings or

memos No need to change method of communications Develop regular schedule for ICD-10 progress efforts

Monthly until 6 months prior to implementation Bi-weekly thereafter

Include information, publications, and articles

Document all meetings and what was discussed herein and make sure you are tracking with your plan.

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Conduct Impact Analysis• Take this step prior to development of budget

• In depth look at resources required for implementation• Maybe check for a little process improvement

• Helps determine what costs might be involved as well as work processes

• What systems will be affected?• Practice management• Coding look up programs (if applicable)/CDMs/Superbills• EMR• Remittance systems• Hardware space

• What are the potential costs involved?

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Conduct Impact AnalysisDevelop reasonable timeline that can be

accomplished in your practice―Map out a project plan on a simple Excel

spreadsheet with benchmarks and status of completion

Managers and/or coders should get physician approval for the project plan and its impact on the practice. Make sure you show and tell them the level of work it will take.

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Conduct Impact Analysis

Coding and documentation go hand in hand ICD-10 is based on complete and accurate

documentation, even where it comes to right and left or episode of care.

ICD-10 should impact documentation as physicians are required to support medical necessity using appropriate diagnosis code—this is not an easy situation, so physicians need to know from the outset that they need training.

Will not change the way a physician practices medicine

Complete and accurate documentation will continue to be important in 2013 (or whenever) as it is today

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Contact System Vendors

• Will they be able to accommodate the need to move to ICD-10? Really? Were they ready for 5010?

• What plans do they have in place for implementation?

• Will they have new tools in place to help you with ICD-10? Will these have a cost? Will they create savings?

• When will they have software available for testing?

• Will we need new hardware or is current hardware sufficient?

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Estimate BudgetBudget considerations should include

Hardware costsSoftware costs and licensingTrainingPhysician QueryProductivity losses Jeopardy to cash flow

Some notable budget estimates follow this slide…

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ICD-10 Implementation $: AMA

49(c) onPoint Oncology LLC

ICD-10 Implementation $$: MGMA

50(c) onPoint Oncology LLC

Implementation Planning

Begin Steps 1-5 (reviewed up until this point) in 2012, but save others until 2013 or whenever.

Break down planning into stagesTraining for a small practice does not need to begin

until 6 months prior to implementation

Review superbills and remove rarely used codes

Crosswalk common codes from ICD-9-CM to ICD-10-CMLook up codes in ICD-10-CM book and use GEMs, if

necessary, but this is a very general and not necessarily accurate way of coding.

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Crosswalk Example Iron Deficiency Anemia

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ICD-9-CM ICD-10-CM

280 Iron deficiency anemia D50 Iron deficiency anemia

280.0 Secondary to blood loss D50.0 Secondary to blood Loss

280.1 Secondary to inadequate dietary

intake

D50.8 Other iron deficiency anemias

280.8 Other specified iron deficiency

anemias

D50.1 Sideropenic dysphagia

D50.8 Other iron deficiency anemias

280.9 Iron deficiency anemia, unspecified D50.9 Iron deficiency anemia

unspecified

Develop Training Plan

Who needs training?PhysiciansCodersBilling staffAdministrative staffNurses, MAs, Pharmacy

Required number of hours depends on their role and coding interface

What resources are available in your area?

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Develop Training PlanMany organizations will have several mechanisms

for trainingDistance learningWorkshopsConferencesAudio ConferencesWebinarsBooks

Establish training schedule or just “Train the Trainer”, but this must be a trusted coding person who also can communicate necessary information to clinicians.

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Develop Training Plan

Determine if temporary staff or overtime will be necessary during training period

What materials will the office need for ongoing support after training?BooksSoftware (code look up programs)Other

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Analyze Business Processes

Identify all systems and processes that currently use ICD-9-CM

Review existing medical policies related to ICD-9-CM

Which contracts tied to reimbursement are tied to a particular diagnosis? Which payers have policies for cancer drugs that are tied to ICD-9? How will this be impacted?

Modify any contract agreements with health plans

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Education and Training

• Education should begin approximately 6 months prior to implementation

• Large practices may need to begin earlier to accommodate all staff who need training

• Use various methods of training: on-line, distance, “Boot Camps”

• Training time depends on their role

• Physicians and coders/billers will need more training time than administrative staff

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Policy Change/ Payment Impact

After health plans complete and change medical policy for procedures and services a specialty providesReview new payment policies Identify opportunities to improve coding processesCommunicate policy changes to applicable staff

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Deployment of Code Should receive all updated software no later

than 7/31/2013 for implementation of your charge documents.

Vendor delivers software update with ICD-10-CM, but you should also know how long ICD-9 will be on-line.

Vendors shouldTest system Integrate software into your systemsMake internal customizationsTest systems with clearinghouses, payers,

electronic claims transmission (end to end)Ensure that the vendor will maintain updates to

code during transition period

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Implementation Compliance

Compliance date for implementation – October 1, 2013

Ensure you are staffed for the change.

Make sure lines of credit are in place.

Monitor compliance activities to identify any problems.

Pursue vendor and payer problems as necessary.

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Other Considerations

Consider use of electronic tools to facilitate coding process–Could reduce costs and claims rejections–Could increase productivity and coding accuracy

Don’t convert superbills/charge documents too early–Currently, ICD-10-CM is still updated annually– 6 –12 months prior to implementation or after code

set has been “frozen”– Assign ICD-10-CM codes directly, not by applying

ICD-9-CM to ICD-10-CM map—it’s good practice’!!

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CDC’s Web ResourcesGeneral ICD-10 information

http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

ICD-10-CM files, information, and General Equivalence Mappings (GEM) between ICD-10-CM and ICD-9-CM

http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

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AHA’s Resources• Regulatory member advisories

• Presentations and articles

• ICD-10 audio seminar series

• Central Office on ICD-9-CM

http://www.ahacentraloffice.org

• AHA Central Office ICD-10 Resource Center

http://www.ahacentraloffice.org/ICD-10

In Summary… While ICD-10 might be postponed, it probably will not be

postponed forever. You will need to be in the planning process.

The first thing you need to do is determine where change needs to happen and how much it will cost. Physicians have no idea that this will be a line item.

Hospitals are way ahead of practices. They may push for this to be sooner rather than later.

What did you learn from 5010 that will help you with this?

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CAN Web SiteThe latest newsFormsRegulationsNewslettersPresentationshttp://can.communityoncology.org

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Contactbbuell@covad.netbobbibuell1@yahoo.com800-795-2633

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