The ICD-10 Implementation Challenge

(International Classification of Diseases, Tenth Edition)

EHR & MU for HIM Professionals

Presenter

Janice Chase, RHITOffice of Information Technology - Tucson

Objectives

• Provide an overview of ICD history and the need to migrate to ICD-10

• Provide an overview of the ICD-10 implementation planning for the I/T/U community

• Provide a coding comparison of ICD-9 and ICD-10• Provide a high level overview of the impact to

clinical and financial work flows and next steps

The ICD–10 Challenge

• With ICD-10, the American health care industry is facing a change that will surpass Y2K in scope and complexity

• ICD-10 conversion will have major impacts on multiple systems and business processes including clinical documentation, clinical coding, and reimbursement

• I/T/U electronic systems and staff must be ready to use ICD-10 by Q4, 2013 (two years from now)

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IHS ICD-10 Implementation TimelinesActivity Target Date Status

High-Level Planning Ongoing Ongoing

Awareness and Communication Ongoing Ongoing

Detail Planning: Develop Tools, Processes to facilitate activities June 2012 In Progress

Requirements Analysis September 2011 In Progress

Requirements Freeze Date January 2012 Not Started

Design Complete March 2012 Not Started

Develop Training Approach February 2013 Ongoing

All Development Complete May 1, 2013 Not Started

All Testing (internal modular, internal integration, alpha, beta,) Complete

May 31, 2013 Not Started

All Software Deployable June 2013 Not Started

Implementation October 1, 2013 Not Started

ICD-10 Prerequisite – HIPAA 5010 • The HIPAA Transaction Set refers to the

standards used for electronic submission of claims. 5010 accommodates the ICD-10 code sets.

• The current version – 4010 – will be obsolete after this year.

• Version 5010 must be used for all electronic claims starting January 1, 2012.

• IHS has done most of the work required for HIPAA 5010 and will be compliant by CY2012.

• Areas will need to identify testing needs with payers

ICD – Making People CountWorld Health Organization

ICD is a common framework and language to report, compile, use and compare health information. • The meaning of classification • Standard grouping of diseases by a set of

principles is called classification, and it allows: • easy storage, retrieval and analysis of data • comparison and transmission of data between hospitals,

service units/tribes, states/areas and countries

Why ICD-10 CM/PCS?• ICD – 8 developed 1970’s• ICD – 9 is obsolete (30 years old)• ICD – 10 accurately describes diagnosis & procedures• ICD – 10 supports today’s healthcare needs (robots, etc.)• U.S. is the only developed country that has not implemented

ICD-10 for morbidity purposes• Since 1999, the U.S. uses ICD-10 only for mortality data• ICD-10 enhances ability to track and respond to international

public health threats – H1N1 – Supports HIE/NHIN• ICD – 11 is coming in 2015

ICD-10-CM and ICD-10-PCS

• ICD-10-Clinical Modification (Diagnoses)• Replaces Volumes I and II of ICD-9• Both inpatient and outpatient diagnoses – all care

settings

• ICD-10-Procedure Coding System (Procedures)• Replaces Volume III of ICD-9-CM• Inpatient Procedures Only • CPT codes will still be used for outpatient procedures

Comparison: ICD-9-CM and ICD-10-CMCharacteristic ICD-9-CM ICD-10-CM

Character Type Numeric, only V & E used

Alphanumeric

Code length 5 digit max 3-7 character max

# of Codes 13,500 68,000 +

Supplementary codes V & E Codes None (incorporated in main code book)

Laterality (left v. right) No Yes

Trimester No Yes (1st,2nd,3rd)

Structure of injuries Wound TypeLaceration, etc

Body part

How is Diabetes Described in ICD–9 & ICD–10–CM ?

ICD–9DM 250.00 controlled

DM 250.02 uncontrolled

Nephropathy 250.4 (583.81)

Neuropathy 250.6_ (357.2)

Retinopathy 250.5 (362.01)

ICD–10DM E08-E13

DM 11.9 Type 2 Diabetes Mellitus w/o complications

with diabetic…

Nephropathy E11.21

Neuropathy E11.40

Retinopathy E11.319

The Same Injury in ICD-9 and ICD-10

ICD-9-CM• 813.21 Fracture of shaft

of radius, closed• 813=Fx of radius and

ulna.2=shaft, closed1=radius (alone)

ICD-10-CM• S52.302

Closed fracture of shaft of left radius

• S52=Fracture of forearm.3=shaft of radius

0=closed fracture

2=left radius

Procedure Codes – Even More Different:ICD-9-CM Procedure and ICD-10-PCS

Characteristic ICD-9-CM Procedures ICD-10 PCS

Character Type Numeric codes Alphanumeric codes

Code Length 4 digit max 7 character max

# of Codes 4000+ codes 87,000+ codes

Code Structure • Letters O and I not used• 16 Sections• Expandable

System Structure: Sixteen Sections - PCS

0: Medical and Surgical1: Obstetrics2: Placement3: Administration4: Measurement & Monitoring5: Extracorporeal Assistance

and Performance6: Extracorporeal Therapies7: Osteopathic

8: Other Procedures

9: ChiropracticB: ImagingC: Nuclear MedicineD: Radiation OncologyF: Physical Rehabilitation and

Diagnostic AudiologyG: Mental HealthH: Substance Abuse Treatment

0: Medical and Surgical SectionD Gastrointestinal SystemB: EXCISION: Cutting out or off, without replacement, a portion of a body part.

Body Part Approach Device Qualifier

1 Esophagus, Upper2 Esophagus, Middle3 Esophagus, Lower4 EsophagogastricJunction5 Esophagus6 Stomach7 Stomach, Pylorus8 Small Intestine9 DuodenumA JejunumB IleumC Ileocecal ValveE Large IntestineF Large Intestine, RightG Large Intestine, LeftH CecumJ AppendixK Ascending ColonL Transverse ColonM Descending ColonN Sigmoid ColonP Rectum

0 Open2 Open Endoscopic3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening8 Via Natural or Artificial Opening Endoscopic

Z No Device

X DiagnosticZ No Qualifier

Example ICD-10 and Esophageal Surgery ICD-10-PCS Code: 0DB10ZZ

AAPC - ICD-10 Quick Facts155,00 codes

ICD-9-CM ICD-10-CM ICD-10 (WHO) ICD-9-CM ICD-10-CM ICD-10 (WHO)0

10000

20000

30000

40000

50000

60000

70000

80000

DiagnosisProcedure

Diagnosis Procedure

* Source: AAPC Presentation; ICD-10 will Change Everything; Deborah Grider, President & CEO AAPC

ICD-10 Fact

Many to 1 relationship• Only 20% of ICD-9 codes have a precise 1:1

mapping to ICD-10• No straightforward crosswalk fix • Example: Fracture of the Radius

• ICD-9 = 33 codes• ICD-10 = 1818 codes

How is IHS Approaching ICD-10?• Established an ICD-10 Steering Committee

• Building organizational awareness and commitment• Identified key stakeholders (HIM, IT, Business Office & Revenue

Cycle, Clinical) • Evaluating systems and interfaces where codes are captured,

exchanged, and reported • Assessing areas of risk• Identifying all systems that assign, utilize or store diagnosis

codes• Identifying all processes/policies that utilize diagnosis codes • Identifying all contractors and business partners that rely on

diagnosis codes • Obtaining vendor commitment for readiness • Evaluating interface engine support of ICD-10

• Developing a plan and beginning implementation activities18

ICD – 10 Steering Committee Launched November 2010

OIT Practice Management

Clinical Rep – Peter Ziegler, MD

Area Director – Dorothy Dupree

Executive Officer – Bernard DeAsis

Tribal Rep – Skip Leader

Urban – Cynthia Perez

CHS – Terri Schmidt

OIT Technical Staff

ORAP – Kris Kirk, John Rael, Carl Harper

HIM – Kelly Stewart, Angela Kihega

NBOC – Deanna Dennis

Statistical – Kirk Greenway

NIPRS – Chris Schiano

Plan, Eval – Diane Leach

CHR – Cathy Stueckemann

Six Sub-Groups

ICD 10 – Sub-groups/Co-ChairsBusiness & Revenue Cycle: Kris Housh, Adrian Lujan

Clinical Documentation Improvement: Volunteers

Data Management: Larry Layne, Chris Schiano

Outreach & Awareness: Janice Chase, Barry Dickman

Technical Development: Floyd Dennis, Jeannette Kompkoff

Training: Janice Chase, Deanna Dennis

Changes to RPMS for ICD-10

• 64 applications contain ICD-9 Codes• Assessing file structure changes• Field size changes, longer code descriptions• Numeric vs. alpha characters• Logic changes due to the revised code structure• Role of mapping codes being assessed• Interfaced systems with ICD-9 touch points

- I/T/U will have to assess any COTS products

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ICD – 10 & ICD – 9 FactsBoth ICD – 9 and ICD – 10 will have to be maintained/used for a period of time• Non-covered entities, like worker’s compensation and

auto insurances claims may still use ICD-9 well after the compliance date of 10/1/2013

• Coding and billing backlogs, CMS eligibility changes• Reporting, trending, comparison

• MU Core Measures (i.e., hypertension)

ICD-10 FactSubject Matter Experts (ICD-10) are essential in the migration to ICD-10• Critical to an accurate conversion• Industry wide demand for ICD-10 resources – already

short supply• IHS has none (that we know of)

• Efficient use of ICD-10 SME• Developing ICD-10 training opportunities with ORAP

Clinical and Business Process Changes• Understand this is not just an IT or HIM Project• Organization – wide initiative that impacts

• Information Systems – EHR Templates, Pick-lists• Provider Documentation

• Clinical Documentation Improvement Program• Coding and Billing

• Physician Query Process• Revenue Cycle Management• Contracting, HR, Finance• Quality Improvement, Data Extracts, etc.

Areas (I/T/U) recommended to conduct an assessment

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Business and Financial Impact

• Productivity impacts can be expected – coding and clinical

• Coders are looking for more information in the record

• Learning curve for at least first six months• Some productivity impacts may be permanent

(based on experience in Canada)

Sample Canada Coding Productivity

Pre and Post ICD-10 Implementation(Charts Completed Per Hour – percent of baseline)

Service ICD-9April 2002

Start ICD-10July 2002

ICD-10April 2003

Inpatient 4.62 2.15 (47%) 3.75 (81%)

Day Surgery 10.68 3.82 (36%) 8.53 (80%)

Emergency 10.37 6.49 (63%) 8.83 (85%)

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Source: HIMSS, Data taken from Humber River Regional Hospital; Ontario, Canada

Investment in training to minimize the impactInvest in Coding Staff Retention and Recruitment

Who Needs ICD-10 Training?• Providers

• Doctors, Nurses, Ancillary, etc.• Coders• Billing Staff• Quality Management and Utilization Review• EHR expands the staff that need to understand

codes and coding principles

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Specificity looks like this…..

ICD-10-CM

Many possible codes

S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture

S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture

S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture

S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture

S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture

S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture

S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture

S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture

S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture

S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture

S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture

S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture

S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

ICD-9-CM

821.01 Fracture of femur, shaft,

closed

Source: 3M

Industry Recommended Training Timeline

Training activities that should occur now:• Awareness training to Administrators,

Stakeholders, and users of ICD codes• Begin to address ICD–10 coding competency

• Anatomy & Physiology• Medical Terminology• Pharmacology, and other biosciences

• Attend training to gain organizational knowledge• IHS ICD-10 Website• IHS ICD-10 Listserv

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Intensive Training Recommended

Intensive Training to begin January – March 2013• Use of ICD-10 CM and PCS Coding Books

• Encoder

• Use Actual Case Studies• Review Coding for Accuracy – Identify Further

Education Need – Post Implementation Monitoring

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Steering Committee & Sub-Group Activity• 18 Awareness Presentations Provided• Area ICD-10 Coordinator Request from CMO

• Address Area Implementation, Awareness, Communication to I/T/U

• Develop In-House ICD-10 Trainer - sustainability• Identify staff that could train within each Area• Most cost-effective • ORAP Funding – Applications due 9-30-11

• Questionnaire on ICD-10 Awareness • Material for IHS ICD-10 Website

• Four-phased approach/resources

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Summary of Key Challenges• Resource Constraints (Financial and Staffing)• Competing Priorities

• Meaningful Use• Health Care Reform• Other Internal and External HIT Mandates

• Risk of Trading Partner 5010/ICD-10 Implementation Readiness

• Develop ICD-10 Expertise – Address internal needs and training

• Comprehensive Enterprise Preparedness as a result of many of the I/T/U remote locations    

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What Are Next Steps for Areas I/T/U’s?

• Designate an Area/local ICD-10 Coordinator• Develop Area/local ICD-10 expertise to assist with

implementation• Assess ICD-10 impact on IT systems

• Local modifications; COTS- vendor readiness; Testing with Payers

• Assess ICD-10 impact on coding competencies; plan for subsequent training in the bio sciences

• Begin/continue Awareness Training• Develop contingency plan to minimize impact on Revenue

Cycle Management (clinical documentation improvement, etc)

• Begin to identify a two-year budget for implementing ICD-10 and related training

• Begin to address recruitment and retention of coding staff

To Communicate is To Win

• The ICD-10 initiative is far reaching into every aspect of patient care and the need for the Steering Committee and sub-groups to do the hands-on tasks that have been identified is critical.

• Communication is essential in a project of this magnitude as not one group can affectively address the complex implementation issues of ICD-10 – tasks are cross-cutting to all groups.

• Continued communication and leadership must be demonstrated to our ICD-10 I/T/U stakeholders• ICD-10 Conferences should be considered• Use of the ICD-10 ListServ and Website • Area ICD-10 Coordinators - HIM key to local success

Area ICD-10 Coordinators

Aberdeen: Kathaleen Gordon

Alaska: Kenneth Gilfort

Albuquerque: Jacque Candelaria

Bemidji: Barbara Fairbanks

Billings: Deanna Dennis

California: Michelle Martinez

Nashville: Kristina Rogers

Navajo: Beverly Becenti

Oklahoma: TBD

Phoenix: Maria Strom; Luane Brien

Portland: Leslie Dye

Tucson: Bernard DeAsis

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Questions & Discussion