1. 3/9/2011
ICD-
ICD-10 IS Coming…
Are YOU Prepared?
Brenda Edwards, CPC, CPMA, CPC‐I, CEMC
3/9/2011 Kansas Medical Mutual Insurance Company 1
Agenda
• 5010 Implementation
• Resources
• Responsibilities and Impacts ICD-10-CM may
be referred to
as ICD-10,
• Code Check
Code Check ICD10, I-10 or
– Format of ICD‐10‐CM simply I10
– External causes
– Examples
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5010 Implementation
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5010 Implementation
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Vendor Discussion
• CORNERSTONE of implementation planning
– If you haven’t had this discussion yet, you are BEHIND!
– The sooner the better for your practice!
• Questions to ask:
1.Project lead and contact information
2.Is the 5010 update part of existing contract or additional $$ to become
compliant?
3.When will they be 5010 compliant?
h ll h b l ?
4.Will they be ready by 1/1/2012?
5.How can you test with them?
6. Any side user impacts to systems?
– If so, will training be included at no additional cost
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5010 Implementation
• ALL HIPAA covered entities MUST be compliant by 1/1/2012
• Over 850 changes and benefits (process improvement)
• Clarity in identifying information (provider fields)
• Improved tracking to match patient to payer
• ICD‐10 support
• 45 new “Service Type” codes
– Benefits where physician and hospital events are covered by different
insurers
– Query to a payer would require response of both hospital and physician
service types if covered
service types if covered
• Reduced “syntax errors” denials (program language problem with patient name)
• COB improvements‐identify to payers primary vs. secondary
• Build in time for unexpected delays and setbacks
• No regulatory extension‐fines after HIPAA mandated change
– Minimum $100 per transaction up to $50,000 annually!
• Not “just a software update”
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3. 3/9/2011
ICD-
ICD-10 Resources
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CDC
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AAPC
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5. 3/9/2011
CMS
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BCBS of KS
New tools coming soon!
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AHIMA
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6. 3/9/2011
Compliance
Responsibilities
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Compliance Responsibilities
• Are you involved in a planning, steering or implementation committee?
• Valuable input from regulatory standpoint
– Learn all you can about ICD‐10
• www.cms.hhs.gov/ICD10
• www.cdc.gov/nchs/icd/icd10cm.htm
• www.aapc.com/icd‐10
• Compliance auditors
Compliance auditors
– Compare current documentation to what will be required
• Improve documentation
– Provider and staff education
• Maintain compliance after implementation date
• ? New medical necessity edits new code set?
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Impact
Anything related to the diagnosis or
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medical necessity will change 18
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7. 3/9/2011
Effects of Implementation
• What if I’m not ready by the compliance deadline?
Any ICD‐9 codes used in transactions for services or discharges on or after
October 1, 2013 will be rejected as non‐compliant and the transactions will
not be processed. You will have disruptions in your transactions being
processed and receipt of your payments. Physicians are urged to set up a
line of credit to mitigate any cash flow interruptions that may occur.
– www.ama‐assn.org/go/ICD‐10
• Cash flow problems for provider
• Increased denied claims
• Temporary increase of physician coding errors
• Decreased coder productivity
• Increased claims re‐billing
– Federal Register, Vol. 74, No. 11, 1/16/09
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Impact to Providers $$$
Anything related to the diagnosis or medical necessity will change
• Documentation must support the code
• New coverage policies, edits, fee schedules
• Greater specificity
• Explanations to patients
• Payer contracts
• Testing orders
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Impact to Administrative Staff
Anything related to the diagnosis or medical necessity will change
• Increased phone calls and
• Confusion from every direction (physicians,
questions from patients
patients, providers, plans)
• ABNs
• Delay in payments, increased denials and
rebilling • Budget
• Health plan contract changes • Training
• Transition period using ICD‐9 and ICD‐10‐CM • System upgrades
• Privacy concerns‐ more specificity and detail – Hardware
– Software
– Interface
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8. 3/9/2011
http://www.cms.gov/ICD10/Downloads/Jan122011_ICD10_Call.pdf
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http://www.cms.gov/ICD10/Downloads/Jan122011_ICD10_Call.pdf
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Impact on Health Plans
Anything related to the diagnosis or medical necessity will change
• Plan structures
• Statistical reports
• Actuarial projections
• New or revised contracts with providers
• Coverage and payment determinations
• Medical review policies
• Fraud and abuse monitoring
• Quality measurements
• Testing
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Benefits of Implementation
• Greater detail to describe new diseases
• Greater specificity in coding
• New understanding of diseases due to increased detail
• Reduction in error rates
• Reduction in false claims
• Reduction in returned claims, refunds
• 1 in 5 claims paid without additional documentation or questions!
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What About…
• Inpatient hospital admission with a date prior to October 1,
2013 and discharge date after October 1, 2013???
– “Use ICD‐10‐CM codes for all diagnoses on claims for
inpatient settings with dates of discharge that occur on or
after October 1, 2013. (MLN Matters SE1019)
after October 1 2013 ” (MLN Matters SE1019)
• My coding credential?
• Training?
• Superbills/encounter forms?
• What questions haven’t we thought about?
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Code Check
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10. 3/9/2011
ICD-10-CM is Better…REALLY!
ICD‐9‐CM ICD‐10‐CM
3‐5 characters Length of code 3‐7 characters
Nearly 15,000 codes Number of codes 69,000 codes and growing
1st‐alpha or numeric Alpha or numeric digits 1‐alpha,
2‐5 numeric 2&3‐numeric,
4‐7 alpha or numeric
No room for new codes
No room for new codes Space Flexible for adding
Flexible for adding
Lacks detail Detail/Specificity Very specific
Lacks laterality Laterality Has laterality (rt/lt)
Non‐specific and Accuracy More accurately reported
inadequate codes conditions due to level of detail
Not used by other Operability Supports interoperability between
countries U.S. and other countries
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ICD-10-CM and ICD-10-PCS
ICD‐10‐CM ICD‐10‐PCS
Clinical modification of World Health •Procedural coding system (PCS) developed for
Organization’s (WHO) diagnostic system for the reporting hospital procedural services
United States •PCS has no relationship with WHO
•Linked to ICD‐10‐CM‐both systems are
components of DRG system which pays hospitals
components of DRG system which pays hospitals
for Medicare services
After implementation, physicians will still report Hospitals who provide the operating rooms,
their services with CPT® codes and diagnoses with nursing services and hospital beds for patients
ICD‐10‐CM will report the procedures under ICD‐10‐PCS
In some instances, ICD‐10‐CM is referred to as The name of ICD‐10‐PCS may be shortened to
simply ICD‐10, ICD10, or just I‐10 “PCS.”
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Need to Know
• There is NOT a crosswalk from ICD‐9‐CM to ICD‐10‐CM
– Mapping and conversion tools are available
– You HAVE to use the coding book in addition to a mapping tool
• Tool may say 380.4 = H61.23
• 380.4 Cerumen impaction = H61.2Ø unspecified ear
H61.21 right ear
H61.22 left ear
H61.23 bilateral
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Random Tidbits
• There are over 200 codes for Diabetes Mellitus alone!
• Diagnoses may have single or multiple codes in ICD‐10‐CM
OR there may not be a code! Example
– Endometrial thickening does not have a specific code in
ICD‐10‐CM
• ICD‐9‐CM
– 793.5 nonspecific findings on radiological exam, genitourinary
• ICD‐10‐CM
– R93.4 Abnormal findings on diagnostic imaging of urinary organs
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ICD-10-CM is Better…REALLY!
• Nearly twice as many categories as ICD‐9
• First three digits have common traits
– Each additional digit adds more specificity
• Injuries and post‐op complications grouped by anatomical site
not by type of injury/wound
• Diseases are arranged according to
– Etiology
– Anatomy
– Severity
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ICD-10-CM is Better…REALLY!
• Laterality
• “x” placeholder (a.k.a “dummy placeholder”)
– Used as 5th character and certain 6th character
• Allows for future expansion without disturbing 6 character structure
• Example T45.7x2 Poisoning by anticoagulant antagonists, vitamin K,
g , ( )
and other coagulants, accidental (unintentional)
• Alpha extensions specify encounter status for episode of care
or identify status of current condition under care
– A Initial encounter
– D Subsequent encounter
– S Sequela (late effect)
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Alpha
ICD-10-CM Format Alpha
Numeric Alpha or Numeric (when present)
xxx ●
xxx
“block”
“S” and “T” codes
Category Injuries and poisonings
and external causes
5th and 6th Character
4th Character Most accurate level of
Site, etiology, manifestation or specificity regarding
state of disease/condition diagnosis or condition
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ICD-10-CM Layout
Chapter
Number and Disease Chapter 19 (SØØ‐T88)
Categories
Single disease or
Defines content S55
related conditions
Subcategory
4th or 5th character with
S55. Ø12
4,5, or 6 digit level of specificity
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Chapter
Category
Don’t forget !
Subcategory
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ICD-10-CM Categories
Begin to think in Chapters
Category Chapter Heading Category Chapter Heading
A00‐B99 1 Infectious disease & L00‐L99 12 Skin disease
parasites
M00‐ M99 13 Musculoskeletal (including
C00‐D48 2 Neoplasm Dental)
D50‐D89 3 Blood diseases N00‐N99 14 Genitourinary system
E00‐E90 4 Metabolic & nutritional O00‐O99 15 Pregnancy and child birth
diseases
F01‐F99 5 Mental health P00‐P96 16 Newborn
G00‐G99 6 Nervous & sensory systems Q00‐Q99 17 Congenital, deformations,
chromosomal abnormalities
H00‐H59 7 Eye disease R00‐R99 18 Signs, symptoms, & abnormal lab
H60‐H95 8 Ear disease S00‐T88 19 Injury, poisoning, complications,
fractures, & other external causes
I00‐I99 9 Circulatory system V01‐Y95 20 External causes of morbidity
(“E” codes)
J00‐J99 10 Respiratory system Z00‐Z99 21 Health status/contact with health
services (“V” codes)
K00‐K93 11 Digestive system
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Anatomy of a Code
Laceration of ulnar artery at forearm level, left arm, initial encounter
Third digit (Category)
S55 Injury of blood vessels at forearm level Alpha /numeric
Outline the chapters
Fourth digit
S55.Ø Injury of ulnar artery at forearm Defines site, etiology, manifestation or
state of disease/condition
Fifth digit
S55. Ø1 Laceration of ulnar artery at forearm Most precise level of specificity
level
Sixth digit
S55. Ø12 Laceration of ulnar artery at forearm Defines more specificity
level, left arm
Seventh digit
S55. Ø12A Laceration of ulnar artery at forearm Codes for injuries and poisonings and
level, left arm, initial encounter other external causes
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Chapter 20
External Causes
V00‐Y95 20 External causes of morbidity
(“E” codes)
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14. 3/9/2011
Chapter 20-External Causes of Morbidity (V01-Y95)
• External causes of morbidity and health status/contact with health
services (“V” and “E” codes) will be incorporated into main
classification
• Are not specified as optional in ICD‐10‐CM (are required)
– Identify intent of circumstance
• Unintentional (accidental)
• Intentional (self‐harm or assault)
• Place of occurrence
• Activity
– Secondary codes to be used for single‐condition coding, only provides
supplemental information
– Used only one time per patient encounter on initial
encounter for treatment
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Chapter 20-External Causes of Morbidity (V01-Y95)
• Sequencing multiple external cause codes will depend of the
sequence of events leading up to injury
• Sequencing priority
– Child and adult abuse
– Terrorism has priority over all other external causes except above
p y p
– Cataclysmic events take sequence over all except the two above
– Transport take sequence over all other external causes except those
listed above
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Chapter 20-External Causes of Morbidity (V01-Y95)
• Place of occurrence and activity codes are sequenced after the
primary external cause code
– How it happened
– What activity
– Where it occurred
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Chapter 20-External Causes of Morbidity (V01-Y95)
• Extensions
– V00‐Y35 require extension to indicate the encounter
• A Initial encounter
• D Subsequent encounter
• S Sequela (late effect)
• Accidental injuries
j
– Default for external cause is unintentional
– No documentation of intent of injury=unintentional
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Chapter 20-External Causes of Morbidity (V01-Y95)
• Activity Code “what” (Y93) new with ICD‐10‐CM
– Always used with a place of occurrence code (Y92)
– 7th character extension is used on primary code
• 1 non‐work related
• 2 work related activity done for income
• 3 student activity
• 4 activity performed while a student, not for income
• 5 Military activity
– Y93 is used with
• Conditions due to long term, cumulative effects (Chapter 13)
• Used for acute injuries (Chapter 19)
• External cause codes if the activity adds additional
information on the event (Y99)
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External Cause Codes
• Place of Occurrence Code “where” (Y92)
– Location of the patient at the time of injury
– Used with activity code (Y93)
– Not necessary for poisonings, toxic effects, adverse effects, or under
dosing codes
– Sequenced after main external‐cause code
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16. 3/9/2011
Real Life Examples
ICD‐9‐CM Brenda was playing in a softball game and tripped and fell while running to second ICD‐10‐CM
base. She has contusions to both knees.
Contusion of unspecified knee, initial
encounter, right knee S8Ø.Ø1xA
left knee S8Ø.Ø2xA
924.11 Contusion of knee
Fell on same level from tripping
Fell on same level from tripping WØ1. ØxxA
WØ1 ØxxA
Place of occurrence‐ball field Y92.32Ø
Activity code‐while playing softball game Y93.64
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Real Life Examples
ICD‐9‐CM Brenda presented at prompt care following an attack by her domestic cat ICD‐10‐CM
while she was watching tv in bed in her 2 story home. She suffered a
superficial cat bite to the left hand. The doctor prescribed antibiotics and
cleaned the hand and sent her home.
882.0 Open wound of hand except finger(s) Other superficial bite of left hand
alone without mention of complication Initial encounter S6Ø.572A
Bitten by cat W55. Ø1
Activity code‐watching tv Y93.89
Place of occurrence‐bedroom of Y92. Ø13
Ø
a single family house
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Dyspnea and shortness of breath with
intercostal pain in let-sided rib cage
ICD‐9‐CM ICD‐10‐CM
• 786.05 Dyspnea • RØ6.Ø2 Dyspnea
• 786.09 Shortness of breath • RØ6. ØØ Shortness of
• 786.50 Intercostal pain breath
– No code for intercostal, have
to use rib pain which is found • RØ7.82 Intercostal pain
RØ7 82 Intercostal pain
under unspecified chest pain
Intercostal pain is located in the ribs and muscles
between the ribs. Increased pain when
coughing, breathing or sneezing.
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Twin pregnancy, 35 weeks, with premature rupture of
membranes (ROM) and mal-presentation; twin A in breech
position, twin B in transverse presentation.
ICD‐9‐CM ICD‐10‐CM
• 658.11 Premature ROM, • 042.913 Preterm ROM, unspecified as to
delivered length of time between rupture and onset
• 651.01 Twin pregnancy, delivered of labor, third trimester
w/w‐out mention of antepartum • 032.1x1 Breech, twin A,
condition
• 032.2x1 Transverse, twin B
,
• 652.21 Breech, twin A, delivered
• 652.31 Transverse, twin B, • 03Ø. ØØ3 Twin pregnancy, unspecified,
delivered third trimester
• V27.2 Twins, both liveborn • Z37.2 Twins, both liveborn (outcome of
(outcome of delivery) delivery)
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Stress incontinence (female) with intrinsic
sphincteric deficiency
ICD‐9‐CM ICD‐10‐CM
• 625.6 Stress incontinence, • N39.3 Stress incontinence
female (male or female)
• 599.82 Intrinsic (urethral) • N36.42 Intrinsic sphincter
sphincter deficiency deficiency
– U
Use additional code to
dditi l d t
– Use additional code to
identify urinary incontinence
identify associated urinary
(625.6, 788.30‐788.39)
stress incontinence (N39.3)
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Slipped and fell in parking lot while walking to car.
The parking lot looked wet but was actually black
ice. Fracture to left ankle and left wrist.
ICD‐9‐CM ICD‐10‐CM
• 824.6 Closed fracture • S82.855A Nondisplaced trimalleolar
trimalleolar fracture of left lower leg, initial encounter
• 814.00 Closed fracture wrist • S62.1Ø2A Fracture unspecified carpal
bone, left wrist, initial encounter
• E885.9 Fall from slipping,
tripping, or stumbling
bl • WØØ Ø A F ll
WØØ. ØxxA Fall on same level due to
l ld t
ice and snow, initial encounter
• Y92.481 Parking lot (place of occurrence)
• Y93.89 other activity (activity code)
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18. 3/9/2011
Takeaway Points
• Embrace the change ‐ its coming with you or without you
• Huge book – small subset per specialty
• Develop crosswalks that are easy to use
• Plant seeds early ‐ train later
• Provide general training and move to specific training
• It s not quite time to learn the new code sets because of annual
It’s not quite time to learn the new code sets because of annual
changes!
• Begin implementation NOW!
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Thank you!
bedwards@kammco.com
KaMMCO
AAPCCA Board of Directors
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