ready or not here comes icd-10 presented by valerie milot, bs, ccs, ahima approved icd-10 cm/pcs...

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Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Page 1: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Ready or Not Here Comes ICD-

10Presented by

Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer

Page 2: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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DISCLAIMER

This material is designed and provided to communicate information about the implementation of ICD-10.

The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding which will help to reduce reimbursement delays & denials when ICD-10 goes live.

Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful.

Page 3: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Objectives

The five W’s

Dual Coding

Changes & Future Reimbursement Implications

Comparisons

Page 4: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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WHY are we doing this now?

The United States is the ONLY industrialized country that is not using ICD-10 for our coding & reporting of diseases, illnesses, & injuries.

Many Countries have been using ICD-10 for their case mix for decades.

Canada was the last country & they have been using ICD-10 for their case mix since 2001.

By changing to ICD-10-CM/PCS, the US healthcare system’s will be able to more accurately gauge healthcare services, improve the monitoring and surveillance of diseases, and produce quality healthcare data to improve patient outcomes.

Page 5: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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When do we have to

As of today- the implementation date is…. OCTOBER 1, 2015-

JUST 321 more days

Page 6: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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WHERE The entire country will start using ICD-10 when submitting

health claims when the implementation date comes

A few exceptions to the mandate for using ICD-10 are:

Worker’s Compensation Carriers may choose to continue to use ICD-9

Dentists may or may not be required to use ICD-10 when submitting their electronic claims (In combination with their CDT (current dental terminology) codes

Although required, some State Medicaid systems will not be ready

Page 7: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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What’s the Difference?

Diagnosis

ICD-9-CM 3-5 Digits or characters

1st character is numeric (with exception of E & V codes)

2nd-5th characters are numeric

Decimal is placed after the first 3 characters

17 chapters and the “V & E” codes are supplemental

Approximately 14,000 diagnosis codes

ICD-10-CM 3-7 Digits or characters

1st character is alpha (all letters are used except the “u”)

2nd-7th characters can be alpha and/or numeric

Decimal is placed after the first 3 characters

21 chapters and the “V & E” codes are NOT supplemental

Approximately 69,000 diagnosis codes

Page 8: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Diagnosis ExampleICD-9-CM

Pressure ulcer codes 9 location codes

(707.00 – 707.09) Shows broad location, but not depth (stage)

ICD-10-CM Pressure ulcer codes 150 codes Show more specific location as well as depth, including:

L89.131 – Pressure ulcer of right lower back, stage 1

L89.132 – Pressure ulcer of right lower back, stage 2

L89.133 – Pressure ulcer of right lower back, stage 3

L89.134 – Pressure ulcer of right lower back, stage 4

L89.139 – Pressure ulcer of right lower back, unspecified stage

L89.141 – Pressure ulcer of left lower back, stage 1

L89.142 – Pressure ulcer of left lower back, stage 2 L89.143 – Pressure ulcer of left lower back, stage 3 L89.144 – Pressure ulcer of left lower back, stage 4 L89.149 – Pressure ulcer of left lower back, unspecified stage L89.151 – Pressure ulcer of sacral region, stage 1 L89.152 – Pressure ulcer of sacral region, stage 2

Page 9: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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What’s the Difference?

ProcedureICD-9-CM (Volume 3)

Minimum characters is 3

Maximum characters is 4

**Numeric format **

Decimal point

Approximately 3,000 procedure Codes

ICD-10-PCS Minimum characters is 7

Maximum characters is 7

**Alphanumeric format **

NO Decimal point

Approximately 71,920 procedure Codes

Page 10: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Procedure Example

ICD-9-CM (Procedure) 86.04, Other incision with

drainage of skin and subcutaneous tissue

Doesn’t differentiate between skin or subcutaneous tissue

Doesn’t specify site (scalp, left arm, abdomen, buttocks)

ICD-10_PCS OH96XOZ, Drainage of back skin, with

drainage device, external approach

OH96XZZ, Drainage of back skin, external approach

PLUS- an additional 264 other codes specifying location (back, left arm, genitalia, etc.) the depth (skin or subcutaneous) the approach (external, open, percutaneous, percutaneous endoscopic) and drainage device.

Page 11: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Who will be Ready

Providers

Hospitals

Payers

Vendors

It will depend on where you are at with implementation this time. October 1st will be here very soon

Page 12: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Dual Coding When do you start- It’s never too soon! How often- Depends on the type of Facility/Provider

At a minimum recommendation is monthly, bimonthly for at least one day.

By starting earlier- will minimize some of the back log on the Health Care Organization as

staff will be comfortable & ready for the “Go Live” date

Starts identifying needs of coding, provider, & system risks/issues

Make sure you are logging any concerns, issues, risks identified-

Track your information on spreadsheets then sort to identify patterns of areas to determine the system, the condition(s), or the providers so education and corrections can be done BEFORE the implementation date

Clinical Documentation Improvement Specialist is crucial for success

Page 13: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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How long will dual coding/billing be needed

Within the Industry, you will hear a variety of timelines. There is the potential the dual coding & dual systems may be indefinite

Majority of Medical claims: minimum is potentially up to two years, depending on filing limits of the various carriers

HOWEVER- because of various Regulatory agencies such as the RAC’s, MAC’s, & even the OIG reviews, it may be longer because of appeals on denials & take backs

If Worker’s Carriers chose not to make the transition, the dual coding & it’s costs to manage two systems may be indefinite

Page 14: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Estimated Costs of Implementation

CMS estimates the costs to the private sector to exceed $130 million

System upgrades throughout the organization may be needed For example- dietary, pharmacy, management, OR systems all

may use diagnosis and/or codes to perform their duties

Reduction in productivity in coding & billing AHIMA suggests after ICD-10 coders will be 50% slower for the

first 3 months.

Various figures have indicated even after staff have become comfortable with new processes, volumes will not return to ICD-9 numbers

Expect a 50 percent increase in provider queries

AAPC agrees & indicates that with current documentation, only 50 percent of encounters could be coded under ICD-10

Page 15: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Hidden Costs with Implementation

Education & Training

Staff throughout the organization (not just coding)

Providers

Vendors may not be able or ready to accept ICD-10 which will delay reimbursements

Creating/revising current Query processes because the volume will be very high once implementation has occurred

Potential impact to Case Mix Index

Staffing shortages & overtime

Will work need to be Outsourced

Page 16: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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How soon will we start seeing changes in Reimbursement

Time after implementation will truly define how much reimbursement will change

If you spend the time now to determine the areas needed for improvement, it will minimize- The volume of queries to providers Reduce delays in completing visits (aka- DNFB) Reduce denials from Carriers

CMS has already been providing information on what the DRG (as well as CC and MCC’s) will be on specific final diagnosis

Page 17: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Comparisons Following industries recommendations is strongly

suggested. You will need to review your top ten (or twenty if possible) current DRG’s. Have them dual coded to determine: Potential impact with the new coding structure If current documentation supports the necessary

information needed to code to the highest level of coding accuracy

Current processes such as forms, query processes and policies will support the new structure

Let’s take a look at a couple of examples on the differences….

Page 18: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Example 1: Pressure ulcer of buttock stage III with gangrene (both present on admission) (ICD-10-CM guidelines specify a sequencing change that changes the principal Dx and the MS-DRG)

ICD-9 707.05 Pressure ulcer, buttock

707.23 Pressure ulcer, stage III (MCC)

785.4 Gangrene (CC)

MS-DRG 592 Skin Ulcers W MCC

RW 1.4753

ICD-10 I96 Gangrene, NEC

L89.303 Pressure ulcer of unspecified buttock, stage III (MCC)

MS-DRG 299 Peripheral vascular disorders W MCC

RW 1.4072

Page 19: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Example 2: Pneumonia patient with NSTEMI MI two weeks ago (treated during the inpatient stay) (ICD-10-CM defines AMIs as 4 weeks, and classifies them differently, resulting in an MCC for this example) ICD-9 486 Pneumonia

410.72 subendocardial infarction, subsequent episode of care

MS DRG 195 Simple pneumonia w/o CC/MCC

RW 0.7096

ICD-10 J18.9 Pneumonia

I21.4 Non-ST elevation (NSTEMI) myocardial infarction (MCC)

MS DRG 193 Simple pneumonia w MCC

RW 1.4796

Page 20: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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QUESTIONS?

So who has a headache now

Will it really happen

If it does- Will you be ready

Does anyone have any questions

Page 21: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Helpful Resources/Links from CMS http://cms.gov/Medicare/Coding/ICD10/index.html

http://www.roadto10.org/quick-references/

http://cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html

http://cms.gov/Medicare/Coding/ICD10/Medicare-Fee-For-Service-Provider-Resources.html

http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10Overview.pdf

http://www.roadto10.org/action-plan/phase-2-train/common-codes-family-practice/

http://www.cms.gov/Medicare/Coding/ICD10/index.html

http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-For-Service-Provider-Resources.html

http://cms.gov/Medicare/Coding/ICD10/CMSImplementationPlanning.html

http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_Pathways_Provider_Specific_Booklet.pdf

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049750.hcsp?dDocName=bok1_049750

Page 22: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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Contact Information

Presentation by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer, Director of Physician Services

Tel: (603) 530-1459Medical Reimbursement Specialists, LLC Codeaid LLC

PO Box 486266A Summer StBristol, NH 03222

Main Office Tel: 603-217-0006FAX: (603)-947-1458

www.mrsnh.com 

 

 

 

Page 23: Ready or Not Here Comes ICD-10 Presented by Valerie Milot, BS, CCS, AHIMA Approved ICD-10 CM/PCS Trainer 1

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References American Academy of Professional Coders, https://www.aapc.com/

American Health Information Management Association, http://www.ahima.org/icd10/

California Health Information Management Association, June 2014 presentation obtained at http://californiahia.org/sites/californiahia.org/files/docs/events/handouts/convention/mon-red-100.pdf

Center for Medicare and Medicaid Services, see the previous ‘resources’ slide for various sites/documents used for this presentation

UASI, Stanfill, Jan 2012, obtained at http://www.uasi-qc.com/insights-education/news/article/power-10-reimbursement-impact-icd-10