Christina Janus, MBA, RHIA, CHAM Associate Director, ICD-10 The MetroHealth System Cleveland, Ohio
On to the Next Chapter of ICD…
2015
October 1, 2015 – USA medical systems will change from ICD-9-CM to ICD-10-CM/PCS
ICD-10-CM: Diagnosis coding
Used for inpatient and outpatient
Used by providers, coding and other clinical/operations staff
ICD-10-PCS: Procedure coding
Used for inpatient only
Used primarily by coding
CPT© codes will continue to be used for outpatient procedure coding
USA is the last developed nation to comply with the WHO system
Global use of ICD-10: Catching up with the industrialized world
Poland
Thailand
United States
Iceland
Denmark
Brazil
New Zealand
Argentina
Austria
Norway
Australia
Finland
Singapore
Canada
Sweden
China
Japan
Venezuela
Germany
Switzerland
Colombia
UK Ireland
Czech Republic The Netherlands
France
Costa Rica
Source: 3M Mission 13 Powerpoint
Greater coding accuracy and specificity
Higher quality information for measuring healthcare service quality, safety, and efficiency
Improved efficiencies and lower costs in the long run with more specific data
Reduced coding errors
Greater achievement of the benefits of an electronic health record
Recognition of advances in medicine and technology
Alignment of the USA with coding systems worldwide
Improved ability to track and respond to international public health threats
Enhanced ability to meet HIPAA electronic transaction/code set requirements
Increased value in the US investment in the SNOMED-CT
Space to accommodate future expansion
ICD-10 incorporates much greater specificity and clinical information to improve capture of healthcare information, which has the following benefits:
Universal Benefits of ICD-10 Why are we doing this?
Source: HFMA, Strategically Approaching the ICD-10 Transition Presentation
Source HIMSS Virtual Event 2011
ICD-10 Impact for Physician Office Operations
ICD-9-CM Diagnoses ICD-10-CM Diagnoses
1st char alphanumeric (only E and V
codes)
1st char alphanumeric (all letters except
U)
3 to 5 characters 3 to 7 characters
ICD-9-CM Procedures ICD-10-PCS Procedures
Numeric Alphanumeric
Codes 3 to 4 characters All codes 7 characters
ICD-9 General ICD-10 General
Space is limited for new codes Easily expandable for new codes
Lacks significant detail More specific. For example, identifies:
• Laterality
• Trimester
Source: 3M Mission 13 Powerpoint
Laterality Common clinical guidance scales
Increased granularity of
disease manifestation
Expansion of injury codes
Specific disease pathophysiology
7th character and timing of
encounters
X placeholders Post-procedural disorders
Acuity Identification of trimesters
Alcohol and drug dependence effects of use
Underlying or Associated Conditions
10
Source: HIMSS Virtual Event 2011
Allow for coding more specific content Laterality
Severity
Anatomic site
Etiology
Pregnancy trimesters
Expandable codes (i.e., injury, diabetes)
One-to-Twenty-Four Mapping
ICD-9-CM
821.01
(Fracture, femur, shaft,
closed)
ICD-10-CM
S72.301A
S72.301G
S72.302A
S72.302G
S72.309A
S72.309G
S72.321A
S72.321G
S72.322A
S72.322G
S72.323A
S72.323G
S72.324A
S72.324G
S72.325A
S72.325G
S72.326A
S72.326G
S72.331A
S72.331G
S72.332A
S72.332G
S72.333A
S72.333G
S72.326A Nondisplaced transverse
fracture of shaft of unspecified
femur, initial encounter for closed
fracture
S72.326G Nondisplaced
transverse fracture of shaft of
unspecified femur, subsequent
encounter for closed fracture with
delayed healing
Fracture of Forearm (813.00)
S52 Fracture of forearm
S52.5 Fracture of lower end of radius
S52.52 Torus fracture of lower end of radius
S52.521 Torus fracture of lower end of right
radius
S52.521A Torus facture of lower end of
right radius, initial encounter for closed
fracture
Acute Asthma Exacerbation (93.92)
Multiple options in ICD-10
J45.21 Mild, intermittent, w/acute exacerbation
J45.41 Moderate, persistent, w/acute exacerbation
J45.51 Severe, persistent, w/acute exacerbation
Right Ankle Sprain (845.00)
S93.401Sprain of unspecified ligament of right ankle
S93.411Sprain of calcaneofibular ligament of right ankle
S93.421Sprain of deltoid ligament of right ankle
S93.431Sprain of tibiofibular ligament of right ankle
S93.49 Sprain of other ligament of ankle
16
J02 Acute pharyngitis
J02.0 Streptococcal pharyngitis
J02.8 Acute pharyngitis due to other specified organisms
J02.9 Acute pharyngitis, unspecified
J03 Acute tonsillitis
J03.0 Streptococcal tonsillitis
J03.00 Acute streptococcal tonsillitis, unspecified
J03.01 Acute recurrent streptococcal tonsillitis
J03.8 Acute tonsillitis due to other specified organisms
J03.80 Acute tonsillitis due to other specified organisms
J03.81 Acute recurrent tonsillitis due to other specified organisms
J03.9 Acute tonsillitis, unspecified
J03.90 Acute tonsillitis, unspecified
J03.91 Acute recurrent tonsillitis, unspecified
17
E66 Overweight and obesity
E66.0 Obesity due to excess calories
E66.01 Morbid (severe) obesity due to excess calories
E66.09 Other obesity due to excess calories
E66.1 Drug-induced obesity
E66.2 Morbid (severe) obesity with alveolar hypoventilation
E66.3 Overweight
E66.8 Other obesity
E66.9 Obesity, unspecified
18
F90 Attention-deficit hyperactivity disorders
F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
F90.2 Attention-deficit hyperactivity disorder, combined type
F90.8 Attention-deficit hyperactivity disorder, other type
F90.9 Attention-deficit hyperactivity disorder, unspecified type
19
R10 Abdominal and pelvic pain
R10.0 Acute abdomen
R10.1 Pain localized to upper abdomen
R10.10 Upper abdominal pain, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.2 Pelvic and perineal pain
R10.3 Pain localized to other parts of lower abdomen
R10.30 Lower abdominal pain, unspecified
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.8 Other abdominal pain
R10.81 Abdominal tenderness
R10.811 Right upper quadrant abdominal tenderness
R10.812 Left upper quadrant abdominal tenderness
R10.813 Right lower quadrant abdominal tenderness
R10.814 Left lower quadrant abdominal tenderness
R10.815 Periumbilic abdominal tenderness
R10.816 Epigastric abdominal tenderness
R10.817 Generalized abdominal tenderness
R10.819 …… unspecified site
R10.82 Rebound abdominal tenderness
R10.821 Right upper quadrant rebound abdominal tenderness
R10.822 Left upper quadrant rebound abdominal tenderness
R10.823 Right lower quadrant rebound abdominal tenderness
R10.824 Left lower quadrant rebound abdominal tenderness
R10.825 Periumbilic rebound abdominal tenderness
R10.826 Epigastric rebound abdominal tenderness
R10.827 Generalized rebound abdominal tenderness
R10.829 …… unspecified site
R10.83 Colic
R10.84 Generalized abdominal pain
R10.9 Unspecified abdominal pain
Source: HIMSS Virtual Event 2011
Angioplasty Code (39.50)
1,170 ICD-10-PCS angioplasty codes specifying body part, approach and device, including:
- 047K04Z Dilation of right femoral artery with drug-eluting intraluminar device, open approach
- 047K0DZ Dilation of right femoral artery with intraluminal device, open approach
- 047K0ZZ Dilation of right femoral artery, open approach
- 047K24Z Dilation of right femoral artery with drug-eluting intraluminal device, open endoscopic approach
- 047K2DZ Dilation of right femoral artery with intraluminal device, open endoscopic approach
Left Knee Replacement (81.54) - 0SRD Knee Joint, Left
- 0SRD0 Open
- 0SRD07 Autologous Tissue Substitute
- 0SRD07Z Replacement of Left Knee Joint with Autologous Tissue Substitute, Open Approach
- 0SRD0K Nonautologous Tissue Substitute
- 0SRD0KZ Replacement of Left Knee Joint with Nonautologous Tissue Substitute, Open Approach
- 0SRD0J Synthetic Substitute
- 0SRD0J9 Replacement of Left Knee Joint with Synthetic Substitute, Cemented, Open Approach
- 0SRD0JA Replacement of Left Knee Joint with Synthetic Substitute, Uncemented, Open Approach
- 0SRD0JZ Replacement of Left Knee Joint with Synthetic Substitute, Open Approach
Accuracy of medical records more critical Codes must be supported by medical documentation
Codes are more specific than previous coding
Expect coverage changes Will need specific ICD-10-CM codes for orders such as labs
Documentation will need to support tests ordered and justify the medical necessity of the patient
Expected increase in rejections, denials and pended claims while plans and providers get used to new codes
Need to expand “superbills” or “smart sets” to cover all options for diagnoses
Receipt of Physician Orders
Pre-Registration/Scheduling
Insurance Verification
Patient Check-in/Consent
Patient Discharge
Receipt of Physician Orders Request for service drives the encounter, the subsequent data needed to support the service delivered, and the level of care provided
Adequate physician documentation is required to support medical necessity for compliant delivery of medical service requested
The need for data accuracy and clinical knowledge of the impact of ICD-10 on requested services
Scripts used for ICD-9 need to be updated to accommodate ICD-10 granularity and specificity to be compliant
Pre-Registration / Scheduling Data for each patient is entered into a system where the diagnosis and code is impacted by ICD-10 code specificity
Compliance checker may be used for principal diagnosis
Incorrect diagnostic and procedural data can effect the patient’s stay throughout the encounter and cause payment denial
Due to increased number of ICD-10 codes, national and local coverage policies will look different than they do for ICD-9
It is likely that payers will no longer accept unspecified codes but will require the providers to use more specific codes
Providers will have to query physicians who do not submit complete diagnostic information
Bypassing this important step can create claim denial or rejection causing re-work later in the revenue cycle
Insurance Verification Understand local and national coverage determination to include changes related to ICD-10 specificity
Diagnosis specificity will impact the patient’s eligibility for diagnosis, pre-certification, medical necessity review, and ABNs
Ensure workflow surrounding verification captures accurate and specific diagnosis and procedure data to avoid delays and failure to acquire authorization
Understand updated system business rules to capture ICD-10 codes, templates and dictionaries. Understand the differences for ICD-10
Patient Check-in / Consent ABN is issued if patient is scheduled for tests/procedures not covered by insurance
Understand the relationship of ICD-10 codes to the compliance checker and guidelines for medical necessity
Ensure scripts are modified for ICD-10 and communication with clinicians concerning the order entry of new ICD-10 diagnosis codes and meanings
Patient Discharge Ensuring accurate data to close the encounter, i.e., date, time, discharge disposition
Patient’s type of insurance reviewed and diagnosis is verified. Collection of co-pay based on discharge diagnosis as appropriate
Ensure correct patient type, i.e. inpatient, outpatient, emergency, observation, etc.
Ensure correct discharge disposition, i.,e., SNF, LTAC, Home Health, etc.
Incorrect discharge data causes delay revenue cycle processes and potential denials due to improper medical necessity data
Payment can be denied or delayed by payer due to missing or inaccurate data
Items to Consider:
Ensure all impacted professionals are educated on ICD-10 code changes and documentation specificity
Successfully complete all systems and integrated testing where ICD-10 impact exists
Understand any changes to payer websites for ICD-10 code entry screens and processes typically performed by Patient Access professionals
Eliminate revenue cycle backlogs (coding, claims processing, denials, pre-authorization, referrals, etc)
Establish revised performance management system (key indicators, productivity, quality)
Establish ICD-10 training & education plan post Go-Live
Conduct follow-up assessments (Plan-Do-Check-Act)
AAPC (American Academy of Professional Coders) http://www.aapc.com
AHIMA (American Health Information Management Association) http://www.ahima.org
CMS (Centers for Medicare & Medicaid Services) http://www.cms.gov
HFMA (Healthcare Financial Management Association) https://www.hfma.org
HIMSS (Healthcare Information & Management Systems Society) http://www.himss.org