icd-10-cm update presented by: janet smith, rhit, cpc ahima approved icd-10 trainer the tennessee...

ICD-10-CM Update

Presented by:Janet Smith, RHIT, CPC

AHIMA Approved ICD-10 Trainer

The Tennessee Pediatric Society Foundation 1

Brief History

● ICD-10 was adopted by the World Health Organization (WHO) in 1990

● Following the publication of ICD-10, many countries performed analysis to determine if the WHO classification system would meet their needs

● The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the United States’ clinical modification to the World Health Organization’s version of ICD-10


Brief History

Countries Using ICD-10 For Reimbursement or Case Mix:

● United Kingdom - 1995● Nordic countries (Denmark, Finland,

Iceland, Norway, Sweden) - 1994 –1997● France - 1997● Australia - 1998● Belgium - 1999● Germany - 2000● Canada - 2001


Brief History

● The United States remains the only industrialized nation that has not yet implemented ICD-10 or a clinical modification for diseases or causes of illness typically coded in a healthcare facility

● Since 1999, however, the United States has used ICD-10 for mortality reporting (for death certificates)


Why do we need ICD-10?

● ICD-9 is 30 years old –medicine and technology has changed

● Many categories full● Not descriptive enough● Implementing ICD-10-CM will maintain data

comparability internationally and between mortality and morbidity data in the United States

● Would enhance accurate payment for services rendered


Benefits of ICD-10-CM

Greater clinical detail More specificity, laterality, external causes of

injuries, combination codes for diagnoses and symptoms

Reflects advances in medicine and medical technology

Measuring the quality, safety, and efficacy of care Reducing the need for attachments to explain

patient’s condition Improving clinical, financial, and administrative

performance Tracking public health and risks


When will ICD-10 be implemented?

In January 2009, the Department of Health and Human Services published the final rule for adoption of ICD-10-CM and ICD-10-PCS, setting a compliance date of October 1, 2013

On April 9, 2012, HHS released a proposed rule that calls for a one-year delay for the ICD-10 compliance date from October 1, 2013 to October 1, 2014.

On April 17, 2012 the announcement for the ICD-10 delay was published in the Federal Register. A 30-day comment period was granted on the proposed rule and is now closed.

Public comments are being reviewed and analyzed, and the Department will issue a final rule as expeditiously as possible


Reasons behind the delay● There was no one group that spurred CMS to

propose the delay

● The industry’s ongoing struggle to implement HIPAA Version 5010 (a precursor to ICD-10) that was effective January 2012 but has seen enforcement delayed twice because many physicians have had technical trouble implementing the version update

● Physician concern regarding the ICD-10 timeline

● A one-year delay reflects the industry’s need for a quick resolution and providers’ need for additional time to implement, and will not likely penalize those on track with the original deadline


What to Expect with ICD-10? ICD-10-CM (Clinical Modification) will replace ICD-9-CM

diagnosis codes rendered in all healthcare settings.

ICD-10-PCS (Procedural Coding System) will replace the ICD-9-CM procedure codes rendered in the hospital/inpatient setting.

CPT and HCPCS Level II will remain the coding system for physician and professional services and procedures performed in the outpatient setting.

After the implementation of the ICD-10 code set, inpatient reimbursement for Medicare patients will be based on Medicare DRGs using the ICD-10 coding system not ICD-9

Payer and office systems and processes must be able to support both ICD-9 and ICD-10 code sets on the implementation date


ICD-10 Practice Impact Plan for budgeting

Revenue flow problems Productivity Software/System upgrades

Staffing changes/additions Education for providers and staff

Audit for increased specificity in documentation

(Stages of healing, episode of care, laterality) Code set training Operate under dual coding system

Health Plans Contracts Coverage policies


Cost Estimate – 5 Physician Practice (Two Years)

Information Systems

Practice Management Upgrade - $5,000 EMR Upgrade (if applicable) - $5,000 IT and Consulting - $5,000

Audit/Review/Consulting

General Consulting/Audit Year 1 @ $500/provider twice a year - $3,000

General Consulting Year 2 - $3,000 Review of System Process - $3,000 Crosswalking - $1,500


Cost Estimate – 5 Physician Practice (Two Years) Education and Training

5 physicians - $3,500 1 coder/biller - $1,600 2 nurses/MA - $3,000 2 ancillary staff - $1,000 Management - $500

Staff and Overtime

Coders - $2,000 Ancillary Staff - $400 Productivity Loss - $18,400

TOTAL Estimated Cost = $59,500


How is ICD-10 structured?

● The “look-up” process will be very similar to ICD-9

● The same hierarchical structure is used as ICD-9

● The ICD-10 system will be alphanumeric and contain up to 7 characters

● ICD-10 has approximately 68,000 codes vs. 14,000 in ICD-9

● Code composition and level of detail are the major differences


ICD-10- CM Structure 21 Chapters 2 New Chapters

Diseases of the Eye and Adnexa (Ch 7) Diseases of the Ear and Mastoid Process (Ch 8)

Certain Diseases were re-classified and are now found in new chapters Immune Mechanism (Immunity) was moved from

Chapter 4 (Endocrine) to Chapter 3 (Blood Disorders) Injuries (Ch19) are now arranged by body part and

not by injury Mental Disorders (Ch 5), Injury and Poisonings (Ch

19), and External Causes (Ch 20) were all re-organized


ICD-10- CM Structure Codes have 3 to 7 alphanumeric characters (vs 5

numeric in ICD-9) Character 1 is always alpha – letters A-Z, except U Character 2 is numeric Character 3-7 can be alpha or numeric Decimal placed after the first three characters Alpha characters are not case-sensitive

A78 – Fever J04.0 – Acute laryngitis S41.111 – Laceration w/o foreign body of right upper arm S63.280A – Dislocation of proximal interphalangeal

joint of right index finger, initial encounter


ICD-10- CM Structure Character 4 represents a subcategory that further

defines the site, etiology and manifestation or state of the disease

Character 5 and 6 identify the most accurate level of specificity

Character 7 – Extension

Some codes require 7 characters If a code requires a 7th character and there is no 5th or 6th

character, a placeholder “X” must be used All placeholders of an applicable code must be reported

Example: T16.XXA – Foreign body in right ear, initial encounter


ICD-10- CM Structure

S60 – Superficial injury of wrist, hand and fingers

S60.4 – Other superficial injuries of other fingers

S60.45 – Superficial foreign body [splinter] of fingers

S60.451 – Superficial foreign body [splinter] of left index finger

S60.451A – Superficial foreign body [splinter] of left index finger, initial encounter


Translation of Codes

The Tennessee Pediatric Society Foundation

ICD-9-CM TO ICD-10-CM

003.21 Salmonella meningitis = A02.21 Salmonella meningitis

ICD-9-CM TO ICD-10-CM

307.46 Sleep Arousal Disorder ≠ F51.3 Sleepwalking

ICD-9-CM ICD-10-CM

010.90 Primary tuberculosis infection, unspecified examination010.91 Primary tuberculosis infection, bacteriological/histological exam not done010.92 Primary tuberculosis infection, bacteriological/histological exam unknown (at present)

≠ A15.7 Primary respiratory tuberculosis

18

External Causes

Chapter 20 - Codes for external causes V, W, X and Y are the 1st characters Are never used as primary code Are never reported alone


Z Codes are the New “V” Codes

Chapter 21 – Factors influencing health status and contact with health services

Encounter for healthcare exams Are part of the ICD-10-CM code set and must be

recognized by payers May be used as primary diagnosis


Preventive Care

Z00.129 Routine child health checkZ00.121 Routine child health check with abnormal

findings Z00.110 Health supervision (health check) for

newborn under 8 daysZ00.111 Health supervision (health check) for

newborn 8 to 28 days

Z23 Encounter for immunizations


Other Health Visits

Z01.818 Pre-operative examinationZ02.0 School physicalsZ02.5 Sports physicalsZ02.82 Pre-adoption examZ48.02 Suture removalZ71.0 Parent (family) conferenceZ71.3 Diet management (for obesity)Z76.81 Parents pre-birth or pre-adoption

visit


Documentation

Use appropriate terminology Document highest level of specificity Indicate right versus left Indicate specific body area Specify episode of care (initial, recurrent)


Reimbursement and Quality Problems With ICD-9-CM

● Example –Fracture of Wrist● Patient fractures left wrist● A month later, fractures right wrist● ICD-9-CM does not identify left versus right –

requires additional documentation● ICD-10-CM describes left versus right ● Initial encounter, subsequent encounter● Routine healing, delayed healing, nonunion,

or malunion


Example

If provider documents: OM (otitis media)

Code = H66.90 otitis media, unspecified, unspecified

ear


Possible Codes

Acute suppurative otitis media without spontaneous rupture of ear drum

H66.001, right earH66.002, left earH66.003, bilateralH66.004, recurrent, right earH66.005, recurrent, left earH66.006, recurrent, bilateralH66.007, recurrent, unspecified earH66.009, unspecified ear


Example

If provider documents: Reactive Airway Disease

Code = J45.909 Unspecified asthma, uncomplicated

If provider documents: Respiratory Distress

Code – R06.89 Other abnormalities of breathing


Possible Codes

J98.01 Acute bronchospasm

J45.990 Exercise induced bronchospasm

J45.991 Cough variant asthma


Other Possible Asthma Codes

AsthmaJ45.20 Mild intermittent, uncomplicatedJ45.21 Mild intermittent, with (acute) exacerbationJ45.22 Mild intermittent with status asthmaticusJ45.30 Mild persistent, uncomplicatedJ45.31 Mild persistent, with (acute) exacerbationJ45.32 Mild persistent, with status asthmaticusJ45.40 Moderate persistent, uncomplicatedJ45.41 Moderate persistent, with (acute) exacerbation


What to do now?

● Maintain momentum● Identify current systems and processes that

use ICD-9 codes● Talk with vendors about accommodations

for ICD-10● Take the time to improve clinical

documentation● Evaluation staff training needs● Ask payers how ICD-10 changes may affect

contracts, payment schedules and reimbursement


Informational Links

http://www.cdc.gov/nchs/icd/icd10cm.htm

http://www.cms.hhs.gov/ICD10

http://www.ahima.org/icd10/







Questions?


Thank You!

Contact information:

Janet SmithCoding [email protected] 615-672-1355


mailto:[email protected]

icd-10-cm update presented by: janet smith, rhit, cpc ahima approved icd-10 trainer the tennessee...

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