are you ready for icd-10? - partners training academy€¦ · are you ready for icd-10? vince...
TRANSCRIPT
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Are You Ready for ICD-10?
Vince Joyce, CPHIMS, Member ASC X12
e3 Informatics LLC
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Objectives
• Teach participants about the format changesbetween ICD-9 and ICD-10
• Inform participants about the challenges ofcross walking DSM-V and ICD-9 to ICD-10
• Discuss software system changes that arerequired to accommodate ICD-10
• Suggest testing strategies to make sure claimsystems are ready for ICD-10
• Discuss some valuable ICD-10 resources
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Federal Mandate
• Beginning on October 1 2015, all health careclaims must use ICD-10 codes
• The number of codes will increase from14,000 to 68,000
• 837P and 837I formats were updated underversion 5010 to accommodate ICD-10diagnosis codes
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Federal Mandate
• Driven by Date of Service
– If the date of service is before October 1, 2015,you must use ICD-9 on the claim
– If the date of service is on or after October 1,2015, you must use ICD-10 on the claim
• Should not mix diagnosis types within theclaim
• Can mix diagnosis types within the 837 file
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Federal Mandate
• ICD-10-CM
– Diagnosis codes
– Major impact on us
• ICD-10-PCS
– Procedure codes
– Little or no impact on us; we use CPT, HCPCS andRevenue codes
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FORMAT CHANGES
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Format Changes
• ICD-9– Consists of three to five
characters
– First digit is numeric oralpha (E or V only)
– Second, third, fourth,and fifth digits arenumeric
– Decimal placed after thefirst three characters
• ICD-10– Consists of three to
seven characters
– First digit is always alpha
– Second and third digitsare numeric
– Fourth, fifth, sixth, andseventh digits can bealpha or numeric
– Decimal placed after thefirst three characters
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Format Change Examples
• ICD-9
– Oppositional defiantdisorder = 313.81
– Schizophrenia = 295.90
– Opioid use disorder,Moderate = 304.00
– Intellectual disability(intellectualdevelopmentaldisorder), Moderate =318.0
• ICD-10
– Oppositional defiantdisorder = F91.3
– Schizophrenia = F20.9
– Opioid use disorder,Moderate = F11.20
– Intellectual disability(intellectualdevelopmentaldisorder), Moderate =F71
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Format Change Examples
ICD-9
854.00
ICD-10
S06.890A
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Format Changes
10
ICD-9 Format
X X X . X X
Category Etiology,Anatomic Site,Manifestation
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Format Changes
11
ICD-10 Format
X X .
Sub-category
Etiology,Anatomic Site,Manifestation
X X X
EncounterExtension
X
Category
X
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Format ChangesLetter Categories
• A00–B99 = Certain infectious and parasiticdiseases
• C00–D48 = Neoplasms
• D50–D89 = Diseases of the blood and blood-forming organs and certain disorders involvingthe immune mechanism
• E00–E90 = Endocrine, nutritional andmetabolic diseases
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Format ChangesLetter Categories
• F00–F99 = Mental and behavioral disorders
• G00–G99 = Diseases of the nervous system(includes cerebral palsy)
• H00–H59 = Diseases of the eye and adnexa
• H60–H95 = Diseases of the ear and mastoidprocess
• I00–I99 = Diseases of the circulatory system
• J00–J99 = Diseases of the respiratory system
• K00–K93 = Diseases of the digestive system
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Format ChangesLetter Categories
• L00–L99 = Diseases of the skin andsubcutaneous tissue
• M00–M99 = Diseases of the musculoskeletalsystem and connective tissue
• N00–N99 = Diseases of the genitourinarysystem
• O00–O99 = Pregnancy, childbirth and thepuerperium
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Format ChangesLetter Categories
• P00–P96 = Certain conditions originating inthe perinatal period
• Q00–Q99 = Congenital malformations,deformations and chromosomal abnormalities(Prader Willi Syndrome)
• R00–R99 = Symptoms, signs and abnormalclinical and laboratory findings, not elsewhereclassified
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Format ChangesLetter Categories
• S00–T98 = Injury, poisoning and certain otherconsequences of external causes (TBI, someof these were E codes under ICD-9)
• V01–Y98 = External causes of morbidity andmortality
• Z00–Z99 = Factors influencing health statusand contact with health services (these wereV codes under ICD-9)
• U00–U99 = Codes for special purposes
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Format Changes
• Encounter Extension
– A = Initial encounter
– B = Initial encounter for open fracture
– D = Subsequent encounter
– G = Subsequent encounter for fracture with delayedhealing
– K = Subsequent encounter for fracture with nonunion
– P = Subsequent encounter for fracture with malunion
– S = Sequelae
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Format ChangesBehavioral Health Categories
• F01-F09 = Mental disorders due to knownphysiological conditions
• F10-F19 = Mental and behavioral disordersdue to psychoactive substance use
• F20-F29 = Schizophrenia, schizotypal,delusional, and other non-mood psychoticdisorders
• F30-F39 = Mood [affective] disorders
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Format ChangesBehavioral Health Categories
• F40-F48 = Anxiety, dissociative, stress-related,somatoform and other nonpsychotic mentaldisorders
• F50-F59 = Behavioral syndromes associatedwith physiological disturbances and physicalfactors
• F60-F69 = Disorders of adult personality andbehavior
• F70-F79 = Intellectual disabilities
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Format ChangesBehavioral Health Categories
• F80-F89 = Pervasive and specificdevelopmental disorders (includes autism,Asperger's syndrome, speech and languagedisorders and delays)
• F90-F98 = Behavioral and emotional disorderswith onset usually occurring in childhood andadolescence
• F99-F99 = Unspecified mental disorder
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Mental Disorders Due to KnownPhysiological Conditions
• F01 = Vascular dementia
• F02 = Dementia in other diseases classifiedelsewhere
• F03 = Unspecified dementia
• F04 = Amnestic disorder due to knownphysiological condition
• F05 = Delirium due to known physiologicalcondition
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Mental Disorders Due to KnownPhysiological Conditions
• F06 = Other mental disorders due to knownphysiological condition
• F07 = Personality and behavioral disordersdue to known physiological condition
• F09 = Unspecified mental disorder due toknown physiological condition
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Mental and Behavioral Disorders Due toPsychoactive Substance Use
• F10 = Alcohol related disorders
• F11 = Opioid related disorders
• F12 = Cannabis related disorders
• F13 = Sedative, hypnotic, or anxiolytic relateddisorders
• F14 = Cocaine related disorders
• F15 = Other stimulant related disorders
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Mental and Behavioral Disorders Due toPsychoactive Substance Use
• F16 = Hallucinogen related disorders
• F17 = Nicotine dependence
• F18 = Inhalant related disorders
• F19 = Other psychoactive substance relateddisorders
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Schizophrenia, Schizotypal, Delusional, andOther Non-Mood Psychotic Disorders
• F20 = Schizophrenia
• F21 = Schizotypal disorder
• F22 = Delusional disorders
• F23 = Brief psychotic disorder
• F24 = Shared psychotic disorder
• F25 = Schizoaffective disorders
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Schizophrenia, Schizotypal, Delusional, andOther Non-Mood Psychotic Disorders
• F28 = Other psychotic disorder not due to asubstance or known physiological condition
• F29 = Unspecified psychosis not due to asubstance or known physiological condition
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Mood [Affective] Disorders
• F30 = Manic episode
• F31 = Bipolar disorder
• F32 = Major depressive disorder, singleepisode
• F33 = Major depressive disorder, recurrent
• F34 = Persistent mood [affective] disorders
• F39 = Unspecified mood [affective] disorder
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Anxiety, Dissociative, Stress-related, Somatoform andOther Nonpsychotic Mental Disorders
• F40 = Phobic anxiety disorders
• F41 = Other anxiety disorders
• F42 = Obsessive-compulsive disorder
• F43 = Reaction to severe stress, andadjustment disorders
• F44 = Dissociative and conversion disorders
• F45 = Somatoform disorders
• F48 = Other nonpsychotic mental disorders
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Behavioral Syndromes Associated withPhysiological Disturbances and Physical Factors
• F50 = Eating disorders
• F51 = Sleep disorders not due to a substanceor known physiological condition
• F52 = Sexual dysfunction not due to asubstance or known physiological condition
• F53 = Puerperal psychosis
• F54 = Psychological and behavioral factorsassociated with disorders or diseases classifiedelsewhere
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Behavioral Syndromes Associated withPhysiological Disturbances and Physical Factors
• F55 = Abuse of non-psychoactive substances
• F59 = Unspecified behavioral syndromesassociated with physiological disturbances andphysical factors
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Disorders of Adult Personality and Behavior
• F60 = Specific personality disorders
• F63 = Impulse disorders
• F64 = Gender identity disorders
• F65 = Paraphilias
• F66 = Other sexual disorders
• F68 = Other disorders of adult personality andbehavior
• F69 = Unspecified disorder of adult personalityand behavior
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Intellectual Disabilities
• F70 = Mild intellectual disabilities
• F71 = Moderate intellectual disabilities
• F72 = Severe intellectual disabilities
• F73 = Profound intellectual disabilities
• F78 = Other intellectual disabilities
• F79 = Unspecified intellectual disabilities
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Pervasive and Specific Developmental Disorders
• F80 = Specific developmental disorders of speech andlanguage
• F81 = Specific developmental disorders of scholasticskills
• F82 = Specific developmental disorder of motorfunction
• F84 = Pervasive developmental disorders
• F88 = Other disorders of psychological development
• F89 = Unspecified disorder of psychologicaldevelopment
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Behavioral and Emotional Disorders with OnsetUsually Occurring in Childhood and Adolescence
• F90 = Attention-deficit hyperactivity disorders• F91 = Conduct disorders• F93 = Emotional disorders with onset specific to
childhood• F94 = Disorders of social functioning with onset
specific to childhood and adolescence• F95 = Tic disorder• F98 = Other behavioral and emotional disorders
with onset usually occurring in childhood andadolescence
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Unspecified Mental Disorder
• F99 = Mental disorder, not otherwisespecified
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Format Changes F43Reaction to Severe Stress, and Adjustment
Disorders
• F43.0 = Acute stress reaction
• F43.1 = Post-traumatic stress disorder (PTSD)
• F43.2 = Adjustment disorders
• F43.8 = Other reactions to severe stress
• F43.9 = Reaction to severe stress, unspecified
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Format Changes Adjustment DisordersF43.2
• F43.20 = Adjustment disorder, unspecified
• F43.21 = Adjustment disorder with depressedmood
• F43.22 = Adjustment disorder with anxiety
• F43.23 = Adjustment disorder with mixedanxiety and depressed mood
• F43.24 = Adjustment disorder withdisturbance of conduct
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Format Changes Adjustment DisordersF43.2
• F43.25 = Adjustment disorder with mixeddisturbance of emotions and conduct
• F43.29 = Adjustment disorder with othersymptoms
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Format ChangesOpioid Related Disorders F11
• F11.1 = Opioid abuse
• F11.2 = Opioid dependence
• F11.9 = Opioid use, unspecified
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Format Changes Opioid Abuse F11.1
• F11.10 = Opioid abuse uncomplicated• F11.12 = Opioid abuse with intoxication• F11.14 = Opioid abuse with opioid-induced
mood disorder• F11.15 = Opioid abuse with opioid-induced
psychotic disorder• F11.18 = Opioid abuse with other opioid-induced
disorder• F11.99 = Opioid abuse with unspecified opioid-
induced disorder
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Format ChangesOpioid Abuse with Intoxication F11.12
• F11.120 = Opioid abuse with intoxicationuncomplicated
• F11.121 = Opioid abuse with intoxicationdelirium
• F11.122 = Opioid abuse with intoxication withperceptual disturbance
• F11.129 = Opioid abuse with intoxicationunspecified
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Format ChangesIntellectual Disabilities
• F70 = Mild intellectual disabilities
• F71 = Moderate intellectual disabilities
• F72 = Severe intellectual disabilities
• F73 = Profound intellectual disabilities
• F78 = Other intellectual disabilities
• F79 = Unspecified intellectual disabilities
• No drill-downs
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Be Aware of Non-Billable Codes
• Non-Billable
– F43.2 = Adjustment disorders
– F11.12 = Opioid abuse with intoxication
• Billable
– F43.20 = Adjustment disorder, unspecified
– F11.120 = Opioid abuse with intoxication
uncomplicated
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CROSSWALKING DSM-V AND ICD9TO ICD-10
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Crosswalking to ICD-10
• ICD codes used on claims (HIPAA required)• DSM codes used by clinicians (State clinical policy,
service definitions)• ICD-9 and DSM shared most codes, although
code descriptions were often not exactly thesame
• Cross walking between ICD-9 and DSM wasrelatively easy
• Crosswalking between ICD-10 and DSM is muchmore difficult
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Crosswalking to ICD-10
• How will your system crosswalk codes???
• Who is responsible for selecting the ICD-10code that will go on the claim???
• Clinical and Finance must communicate andcoordinate efforts!!!
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Crosswalking to ICD-10
• No clear crosswalk between ICD-9 and DSM Vto ICD-10
– One to one crosswalks
– One to many crosswalks (Substance Abuse!)
– Many to one crosswalks
– No ICD-9 crosswalk to ICD-10
– No ICD-10 crosswalk to ICD-9
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Crosswalking to ICD-10One to One
• ICD-9 and DSM V
– Obsessive-compulsivedisorder= 300.3
– Borderline personalitydisorder = 301.83
– Adjustment disorder,With anxiety = 309.24
– Major depressivedisorder, Single episode,Moderate = 296.22
• ICD-10
– Obsessive-compulsivedisorder= F42
– Borderline personalitydisorder = F60.3
– Adjustment disorder,With anxiety = F43.22
– Major depressivedisorder, Single episode,Moderate = F32.1
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Crosswalking to ICD-10One to One
• ICD-9 and DSM V
– Intellectual disability(IDD), Mild = 317
– Intellectual disability(IDD), Moderate = 318.0
– Intellectual disability(IDD), Severe = 318.1
– Intellectual disability(IDD), Profound = 318.2
• ICD-10
– Mild intellectualdisabilities = F70
– Moderate intellectualdisabilities = F71
– Severe intellectualdisabilities = F72
– Profound intellectualdisabilities= F73
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V
– Alcohol-induced anxietydisorder = 291.89
• ICD-10
– Alcohol abuse withalcohol-induced mooddisorder = F10.14
– Alcohol abuse withalcohol-inducedpsychotic disorder,unspecified = F10.159
– Alcohol abuse withalcohol-induced anxietydisorder = F10.180
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V
– Alcohol-induced anxietydisorder = 291.89(continued)
• ICD-10
– Alcohol abuse withalcohol-induced sexualdysfunction = F10.181
– Alcohol abuse with otheralcohol-induced disorder= F10.188
– Alcohol dependencewith alcohol-inducedmood disorder = F10.24
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V
– Alcohol-induced anxietydisorder = 291.89(continued)
• ICD-10
– Alcohol dependence walcohol-induce psychoticdisorder, unspecified =F10.259
– Alcohol dependence withalcohol-induced anxietydisorder = F10.280
– Alcohol dependence withalcohol-induced sexualdysfunction = F10.281
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V
– Alcohol-induced anxietydisorder = 291.89(continued)
• ICD-10
– Alcohol dependence withother alcohol-induceddisorder = F10.288
– Alcohol use, unspecifiedwith alcohol-inducedpsychotic disorder,unspecified =F10.959
– Alcohol use, unspecifiedwith alcohol-inducedanxiety disorder = F10.980
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V
– Alcohol-induced anxietydisorder = 291.89(continued)
• ICD-10
– Alcohol use, unspecifiedwith alcohol-inducedsexual dysfunction =F10.981
– Alcohol use, unspecifiedwith other alcohol-induced disorder =F10.988
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V– Depressive disorder due to
another medical condition= 293.83
• ICD-10– Mood disorder due to
known physiologicalcondition, unspecified =F06.30
– Depressive disorder due toanother medical condition,With depressive features =F06.31
– Depressive disorder due toanother medical condition,With major depressive-likeepisode = F06.32
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V
– Depressive disorder dueto another medicalcondition = 293.83(continued)
• ICD-10
– Mood disorder due toknown physiologicalcondition with manicfeatures = F06.33
– Depressive disorder dueto another medicalcondition, With mixedfeatures = F06.34
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V– Other isolated or specific
phobia = 300.29
• ICD-10– Arachnophobia =
F40.210
– Other animal typephobia = F40.218
– Fear of thunderstorms =F40.220
– Other naturalenvironment typephobia = F40.228
– Fear of blood = F40.230
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V– Other isolated or specific
phobia = 300.29
• ICD-10– Fear of injections and
transfusions = F40.231
– Fear of other medicalcare = F40.232
– Fear of injury = F40.233
– Claustrophobia =F40.240
– Acrophobia = F40.241
– Fear of bridges =F40.242
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V
– Other isolated or specificphobia = 300.29
• ICD-10
– Fear of flying = F40.243
– Other situational typephobia = F40.248
– Androphobia = F40.290
– Gynephobia = F40.291
– Other specified phobia =F40.298
– Other phobic anxietydisorders = F40.8
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Crosswalking to ICD-10One to Many
• ICD-9
– Intracranial injury ofother and unspecifiednature without mentionof open intracranialwound, with no loss ofconsciousness = 854.01
• ICD-10
– Traumatic cerebraledema without loss ofconsciousness = S06.1X0
– Diffuse TBI without lossof consciousness =S06.2X0
– Unspecified focal TBIwithout loss ofconsciousness = S06.300
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Crosswalking to ICD-10One to Many
• ICD-9
– Intracranial injury of otherand unspecified naturewithout mention of openintracranial wound, withno loss of consciousness =854.01 (continued)
• ICD-10
– Injury of right internalcarotid artery, intracranialportion, not elsewhereclassified without loss ofconsciousness = S06.810
– Injury of left internalcarotid artery, intracranialportion, not elsewhereclassified without loss ofconsciousness= S06.820
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Crosswalking to ICD-10One to Many
• ICD-9
– Intracranial injury ofother and unspecifiednature without mentionof open intracranialwound, with no loss ofconsciousness = 854.01(continued)
• ICD-10
– Other specifiedintracranial injurywithout loss ofconsciousness= S06.890
– Unspecified intracranialinjury without loss ofconsciousness= S06.9X0
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Crosswalking to ICD-10One to Many
• ICD-9 and DSM V– Anorexia nervosa =
307.1
– Pica = 307.52
• ICD-10– Anorexia nervosa,
restricting type = F50.01
– Anorexia nervosa, bingeeating/purging type =F50.02
– Pica of infancy andchildhood = F98.3
– Other eating disorders =F50.8
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Crosswalking to ICD-10Many to One
• ICD-9
– Tuberculosis of lung,infiltrative, unspecified= 011.00
THROUGH
– Pulmonary tuberculosis,unspecified, unspecified= 011.90
63 Codes
• ICD-10
– Tuberculosis of lung =A15.0
1 Code
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Crosswalking to ICD-10ICD-9 Only
• ICD-9
– Mild stage glaucoma= 365.71
– Arthroscopic surgicalprocedure converted toopen procedure= V64.43
– Poisoning bytranquilizers and otherpsychotropic agents= E98.03
• ICD-10
– No equivalent
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Crosswalking to ICD-10ICD-10 Only
• ICD-9
– No equivalent
• ICD-10
– Other coma, withoutdocumented Glasgowcoma scale = R40.244
– Underdosing ofantiepileptic andsedative-hypnotic drugs,initial episode =T42.6X6A
– Type O blood, Rhnegative = Z67.41
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Crosswalking to ICD-10Other Important Codes
• ICD-9 and DSM V
– Observation forother suspectedmental condition =V71.09
• ICD-10
– Encounter forobservation for othersuspected diseasesand conditions ruledout = Z03.89
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Crosswalking to ICD-10Other Important Codes
• ICD-9 and DSM V
– Diagnosis deferred =799.99
• ICD-10
– Illness, unspecified =R69
– Ill-defined andunknown cause ofmortality = R99
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837 CHANGES
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Format Changes837P
• ICD-9
– Principal diagnosisqualifier = BK
– Additionaldiagnosis qualifier= BF
– 4 diagnoses
• ICD-10
– Principal diagnosisqualifier = ABK
– Additionaldiagnosis qualifier= ABF
– 12 diagnoses
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Format Changes837P
• ICD-9
HI*BK:29532*BF:2913*BF:29650*BF:2929~
• ICD-10
HI*ABK:F13239*ABF:F71*ABF:F4322*ABF:F1094*ABF:F1524*ABF:F3131*ABF:F603*ABF:F23*ABF:F12121*ABF:F14188*ABF:F607*ABF:F3173~
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Format Changes837I
• ICD-9– Principal diagnosis
qualifier = BK– Admitting diagnosis
= BJ– Additional
diagnosis qualifier= BF
– 12 additionaldiagnoses
• ICD-10– Principal diagnosis
qualifier = ABK– Admitting diagnosis
= ABJ– Additional
diagnosis qualifier= ABF
– 12 additionaldiagnoses
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Format Changes837I
• ICD-9HI*BK:29532~HI*BJ:29532~HI*BF:2913:::::::N*BF:30410:::::::N*BF:29650:::::::N*BF:2929:::::::N~
• ICD-10HI*ABK:F1524~HI*ABJ:F1524~HI*ABF:F23:::::::N*ABF:F13239:::::::N*ABF:F71:::::::N*ABF:F4322:::::::N*ABF:F1094:::::::N*ABF:F3131:::::::N*ABF:F603:::::::N*ABF:F12121:::::::N*ABF:F14188:::::::N*ABF:F607:::::::N*ABF:F10259:::::::N*ABF:F653:::::::N~
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SOFTWARE UPDATES AND TESTING
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Providers Must
• Talk to your software vendor, billing agency orclearinghouse
• Ask them if they have tested internally forformat and adjudication
• Format test with all of your payers:– Each MCO
– NC Tracks
– Medicare
– Insurance Companies
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MCOs Must
• Talk to your software vendor
• Develop a written ICD-10 Test Plan
• Develop specific test cases– Format test cases
– Adjudication test cases
• Develop a procedure for testing with providers
• Test with NC Tracks– Encounter
– State Funds
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Required Software Updates
• Must be able to accommodate up diagnosiscodes up to seven digits in length
• Must be able to recognize new diagnosisqualifiers in 837P and 837I
• Must be able to accommodate up to twelvediagnosis codes on professional claims and up to12 secondary diagnosis codes on inpatient claims
• Must group ICD-10 codes to correct MH, SA andIDD categories
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Software Testing
• 837 format tests– Mismatched diagnosis qualifiers and diagnosis
versions should fail, for example BK with ICD-10 orABK with ICD-9
– Correct diagnosis qualifiers and diagnosis versionsshould pass, for example ABK with ICD-10
– Test qualifiers at principal and secondary levels onthe 837P and 837I (BK/ABK, BF/ABF)
– Test qualifiers at admission level on the 837I(BJ/ABJ)
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Software Testing
• 837 format tests
– Test to make sure up to 12 secondary diagnosescan be accepted
– Test with and without decimals
– Test to make sure seven digit diagnosis codes areaccepted
– Claredi and Faciledi have been upgraded forformat testing
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Software Testing
• Adjudication testing
– Test mental health claims against mental healthdiagnosis groupings
– Test substance abuse claims against substance abusediagnosis groupings
– Test IDD claims against IDD diagnosis groupings
– Test mismatched groupings, for example substanceabuse claims against mental health diagnosisgroupings
– Test behavioral health claims with medical diagnoses
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Software Testing
• Adjudication testing
– Test outpatient claims
– Test inpatient claims
– Test emergency department claims (particularlywith medical diagnosis vs. behavioral healthdiagnosis)
– Test diagnosis pointer
– Test 837 electronic claims and direct data entryclaims
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Suggested 837 Format Test CasesTest ID Test Expected Result
1 Submit 837P with principaldiagnosis qualifier = BK and ICD-9principal diagnosis code.
File should be rejected.
2 Submit 837P with principaldiagnosis qualifier = BK and ICD-10 principal diagnosis code.
File should be rejected.
3 Submit 837P with principaldiagnosis qualifier = ABK and ICD-9 principal diagnosis code.
File should be rejected.
4 Submit 837P with principaldiagnosis qualifier = ABK and ICD-10 principal diagnosis code.
File should be accepted.
5 Submit 837P with principaldiagnosis qualifier = ABK and a 6digit ICD-10 principal diagnosiscode.
File should be accepted.
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Suggested 837 Format Test Cases
83
6 Submit 837P with principaldiagnosis qualifier = ABK, ICD-10 principal diagnosis code,secondary diagnosis qualifier =BF and ICD-9 secondarydiagnosis code.
File should be rejected.
7 Submit 837P with principaldiagnosis qualifier = ABK, ICD-10 principal diagnosis code,secondary diagnosis qualifier =BF and ICD-10 secondarydiagnosis code.
File should be rejected.
8 Submit 837P with principaldiagnosis qualifier = ABK, ICD-10 principal diagnosis code,secondary diagnosis qualifier =ABF and ICD-9 secondarydiagnosis code.
File should be rejected.
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Suggested 837 Format Test Cases9 Submit 837P with principal
diagnosis qualifier = ABK, ICD-10 principal diagnosis code,secondary diagnosis qualifier =ABF and ICD-10 secondarydiagnosis code.
File should be accepted.
10 Submit 837P with a principaldiagnosis qualifier = ABK andICD-10 principal diagnosis codeand 11 secondary diagnoseswith qualifiers = ABF and ICD-10secondary diagnosis codes.
File should be accepted.
11 Submit 837P with principaldiagnosis qualifier = ABK, ICD-10 principal diagnosis code withdecimal, secondary diagnosisqualifier = ABF and ICD-10secondary diagnosis code withdecimals.
File should be rejected.
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Suggested 837 Format Test Cases12 Submit 837I with principal
diagnosis qualifier = BK and ICD-9 principal diagnosis code.
File should be rejected.
13 Submit 837I with principaldiagnosis qualifier = BK and ICD-10 principal diagnosis code.
File should be rejected.
14 Submit 837I with principaldiagnosis qualifier = ABK andICD-9 principal diagnosis code.
File should be rejected.
15 Submit 837I with principaldiagnosis qualifier = ABK andICD-10 principal diagnosis code.
File should be accepted.
16 Submit 837I with principaldiagnosis qualifier = ABK and asix digit ICD-10 principaldiagnosis code.
File should be accepted.
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Suggested 837 Format Test Cases17 Submit 837I with principal
diagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier = BJand ICD-9 admitting diagnosiscode.
File should be rejected.
18 Submit 837I with principaldiagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier = BJand ICD-10 admitting diagnosiscode.
File should be rejected.
19 Submit 837I with principaldiagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ and ICD-9 admittingdiagnosis code.
File should be rejected.
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Suggested 837 Format Test Cases20 Submit 837I with principal
diagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ and ICD-10 admittingdiagnosis code.
File should be accepted.
21 Submit 837I with principaldiagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ, ICD-10 admitting diagnosiscode, secondary diagnosisqualifier = BF and ICD-9secondary diagnosis code.
File should be rejected.
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Suggested 837 Format Test Cases22 Submit 837I with principal
diagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ, ICD-10 admitting diagnosiscode, secondary diagnosisqualifier = BF and ICD-10secondary diagnosis code.
File should be rejected.
23 Submit 837I with principaldiagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ, ICD-10 admitting diagnosiscode, secondary diagnosisqualifier = ABF and ICD-9secondary diagnosis code.
File should be rejected.
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Suggested 837 Format Test Cases24 Submit 837I with principal
diagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ, ICD-10 admitting diagnosiscode, secondary diagnosisqualifier = ABF and ICD-10secondary diagnosis code.
File should be accepted.
25 Submit 837I with principaldiagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ, ICD-10 admitting diagnosiscode, 12 secondary diagnoseswith qualifiers = ABF and ICD-10secondary diagnosis codes.
File should be accepted.
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Suggested 837 Format Test Cases26 Submit 837I with principal
diagnosis qualifier = ABK, ICD-10principal diagnosis code,admitting diagnosis qualifier =ABJ, ICD-10 admitting diagnosiscode, secondary diagnosisqualifier = ABF and ICD-10secondary diagnosis code withdecimals.
File should be rejected.
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Suggested 837 Adjudication Test Cases27 Submit 837P with mental health
claim, principal ICD-10 mentalhealth diagnosis and diagnosispointer = 1.
Claim should adjudicate and pay.
28 Submit 837P with mental healthclaim, principal ICD-10 medicaldiagnosis and diagnosis pointer= 1.
Claim should adjudicate and deny.
29 Submit 837P with substanceabuse claim, principal ICD-10substance abuse diagnosis anddiagnosis pointer = 1.
Claim should adjudicate and pay.
30 Submit 837P with substanceabuse claim, principal ICD-10medical diagnosis and diagnosispointer = 1.
Claim should adjudicate and deny.
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Suggested 837 Adjudication Test Cases31 Submit 837P with IDD claim,
principal ICD-10 IDD diagnosisand diagnosis pointer = 1.
Claim should adjudicate and pay.
32 Submit 837P with IDD claim,principal ICD-10 medicaldiagnosis and diagnosis pointer= 1.
Claim should adjudicate and deny.
33 Submit 837P with substanceabuse specific claim, principalICD-10 mental health diagnosisand diagnosis pointer = 1.
Claim should adjudicate and deny.
34 Submit 837P with substanceabuse claim, principal ICD-10mental health diagnosis in firstposition, secondary ICD-10substance abuse diagnosis insecond position and diagnosispointer = 2.
Claim should adjudicate and pay.
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Suggested 837 Adjudication Test Cases
35 Submit 837I inpatient claim withprincipal ICD-10 mental healthdiagnosis.
Claim should adjudicate and pay.
36 Submit 837I inpatient claim withprincipal ICD-10 substance abusediagnosis.
Claim should adjudicate and pay.
37 Submit 837I inpatient claim withprincipal ICD-10 IDD diagnosis.
Claim should adjudicate and pay.
38 Submit 837I inpatient claim withprincipal ICD-10 medicaldiagnosis.
Claim should adjudicate and deny.
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Suggested 837 Adjudication Test Cases
39 Submit 837I emergencydepartment claim with principalICD-10 mental health diagnosis.
Claim should adjudicate and pay.
40 Submit 837I emergencydepartment claim with principalICD-10 substance abusediagnosis.
Claim should adjudicate and pay.
41 Submit 837I emergencydepartment claim with principalICD-10 IDD diagnosis.
Claim should adjudicate and pay.
42 Submit 837I emergencydepartment claim with principalICD-10 medical diagnosis.
Claim should adjudicate and deny.
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Suggested DDE Adjudication Test Cases
43 Direct data enter CMS-1500with mental health claim,principal ICD-10 mental healthdiagnosis and diagnosis pointer= 1.
Claim should adjudicate and pay.
44 Direct data enter CMS-1500with mental health claim,principal ICD-10 medicaldiagnosis and diagnosis pointer= 1.
Claim should adjudicate and deny.
45 Direct data enter CMS-1500with substance abuse claim,principal ICD-10 substanceabuse diagnosis and diagnosispointer = 1.
Claim should adjudicate and pay.
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Suggested DDE Adjudication Test Cases47 Direct data enter CMS-1500
with IDD claim, principal ICD-10IDD diagnosis and diagnosispointer = 1.
Claim should adjudicate and pay.
48 Direct data enter CMS-1500with IDD claim, principal ICD-10medical diagnosis and diagnosispointer = 1.
Claim should adjudicate and deny.
49 Direct data enter CMS-1500with substance abuse specificclaim, principal ICD-10 mentalhealth diagnosis and diagnosispointer = 1.
Claim should adjudicate and deny.
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Suggested DDE Adjudication Test Cases
50 Direct data enter CMS-1500 withsubstance abuse claim, principalICD-10 mental health diagnosisin first position, secondary ICD-10 substance abuse diagnosis insecond position and diagnosispointer = 2.
Claim should adjudicate and pay.
51 Direct data enter UB-04inpatient claim with principalICD-10 mental health diagnosis.
Claim should adjudicate and pay.
52 Direct data enter UB-04inpatient claim with principalICD-10 substance abusediagnosis.
Claim should adjudicate and pay.
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Suggested DDE Adjudication Test Cases53 Direct data enter UB-04
inpatient claim with principalICD-10 IDD diagnosis.
Claim should adjudicate and pay.
54 Direct data enter UB-04inpatient claim with principalICD-10 medical diagnosis.
Claim should adjudicate and deny.
55 Direct data enter UB-04emergency department claimwith principal ICD-10 mentalhealth diagnosis.
Claim should adjudicate and pay.
56 Direct data enter UB-04emergency department claimwith principal ICD-10 substanceabuse diagnosis.
Claim should adjudicate and pay.
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Suggested DDE Adjudication Test Cases
57 Direct data enter UB-04 emergencydepartment claim with principalICD-10 IDD diagnosis.
Claim should adjudicate and pay.
58 Direct data enter UB-04 emergencydepartment claim with principalICD-10 medical diagnosis.
Claim should adjudicate and deny.
59 Direct data enter UB-04 Level 3residential claim with principal ICD-10 mental health diagnosis.
Claim should adjudicate and pay.
60 Direct data enter UB-04 Level 3residential claim with principal ICD-10 medical diagnosis.
Claim should adjudicate and deny.
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Suggested DDE Adjudication Test Cases
61 Direct data enter UB-04 ICF-MRclaim with principal ICD-10 IDDdiagnosis.
Claim should adjudicate and pay.
62 Direct data enter UB-04 ICF-MRclaim with principal ICD-10medical diagnosis.
Claim should adjudicate and deny.
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VALUABLE RESOURCES
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Valuable Resources
• CMS General Equivalency Mappings (GEMs)
– Downloadable text files
– Downloadable layout document
– ICD-9 to ICD-10 crosswalks
– ICD-10 to ICD -9 crosswalks
– No crosswalk indicators
– Combination indicators
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Valuable Resources
• CMS General Equivalency Mappings (GEMs)
– Shows billable vs. non-billable codes
– Easily converted to Excel, Access, SQL
– Can query with Access or SQL
– Free!
– www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
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Valuable Resources
• DSM V Manual
– Behavioral health specific
– Valuable for clinicians and utilization management
– Contains crosswalks to ICD-10
• www.ICD10data.com
– Well organized ICD-10 code list
– Comprehensive
– Free!
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Valuable Resources
• www.dr-bob.org/tips/dsm5a.html
– Behavioral health specific
– Contains good crosswalks from DSM V to ICD-9and ICD-10
– Free!
• http://ncmmis.ncdhhs.gov/icdxwalk.asp
– NC Tracks ICD-9 to ICD-10 crosswalks tool
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ICD-10 Format Changes
ICD-9
• Consists of three to five characters
• First digit is numeric or alpha (E or V only)
• Second, third, fourth, and fifth digits are numeric
• Decimal placed after the first three characters
ICD-10
• Consists of three to seven characters
• First digit is always alpha • Second and third digits are
numeric • Fourth, fifth, sixth, and seventh
digits can be alpha or numeric • Decimal placed after the first
three characters
ICD-10 Format
X X X X X
Category
Etiology, Anatomic Site, Manifestation
ICD-9 Format
X X X X X X X
Category
Etiology, Anatomic Site, Manifestation
Sub Category
Extension
ICD-9
854.00
ICD-10
S06.890A
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• A00–B99 = Certain infectious and parasitic diseases • C00–D48 = Neoplasms • D50–D89 = Diseases of the blood and blood-forming organs and certain disorders involving the
immune mechanism • E00–E90 = Endocrine, nutritional and metabolic diseases • F00–F99 = Mental and behavioral disorders (see below) • G00–G99 = Diseases of the nervous system • H00–H59 = Diseases of the eye and adnexa • H60–H95 = Diseases of the ear and mastoid process • I00–I99 = Diseases of the circulatory system • J00–J99 = Diseases of the respiratory system • K00–K93 = Diseases of the digestive system • L00–L99 = Diseases of the skin and subcutaneous tissue • M00–M99 = Diseases of the musculoskeletal system and connective tissue • N00–N99 = Diseases of the genitourinary system • O00–O99 = Pregnancy, childbirth and the puerperium • P00–P96 = Certain conditions originating in the perinatal period • Q00–Q99 = Congenital malformations, deformations and chromosomal abnormalities • R00–R99 = Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified • S00–T98 = Injury, poisoning and certain other consequences of external causes (these were E
codes under ICD-9) • V01–Y98 = External causes of morbidity and mortality • Z00–Z99 = Factors influencing health status and contact with health services (these were V
codes under ICD-9) • U00–U99 = Codes for special purposes
• F01-F09 = Mental disorders due to known physiological conditions • F10-F19 = Mental and behavioral disorders due to psychoactive substance use • F20-F29 = Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders • F30-F39 = Mood [affective] disorders • F40-F48 = Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental
disorders • F50-F59 = Behavioral syndromes associated with physiological disturbances and physical factors • F60-F69 = Disorders of adult personality and behavior • F70-F79 = Intellectual disabilities • F80-F89 = Pervasive and specific developmental disorders • F90-F98 = Behavioral and emotional disorders with onset usually occurring in childhood and
adolescence • F99-F99 = Unspecified mental disorder
ICD-10 Format Changes Letter Categories
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• CMS General Equivalency Mappings (GEMs)
– Shows billable vs. non-billable codes
– Easily converted to Excel, Access, SQL
– Can query with Access or SQL
– Free!
– www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html
• www.ICD10data.com
– Well organized ICD-10 code list
– Comprehensive
– Free!
• www.dr-bob.org/tips/dsm5a.html
– Behavioral health specific
– Contains good crosswalks from DSM V to ICD-9 and ICD-10
– Free!
• http://ncmmis.ncdhhs.gov/icdxwalk.asp
– NC Tracks ICD-9 to ICD-10 crosswalks tool
– Free
• www.e3informatics.com (click on download page to download presentation and cross walk tool)
Valuable Resources