ICD-10-CM Making a Successful, Timely Transition

1. ICD-10-CMMaking a Successful, Timely Transition Presented by Jerry Bridge President LifeWorks Education Healthcare Collections & Training

2. Purpose To provide the knowledge, tools & resources in order to make a successful, timely transition to ICD-10.

3. Objectives • Know the regulatory mandate and background for ICD-10 • Know pervasive impacts on revenue, reimbursement, productivity and work flow • Know how to make a project plan; budget, training, vendor management • Take away tools & resources to help you get there!

4. What have you heard? • What have you heard, assume or know about ICD-10? • Have you started to transition? • What have you done to prepare?

5. How Can Providers' Benefit from ICD-10? • Determine severity of illness and prove medical necessity consistently • Improved care with better documentation • Address technology and healthcare reform initiatives • Reduce the hassle of audits

6. Reimbursement Benefits • Reduced coding error rates = reduced denials • Describing higher complexity justifies higher complexity procedure/service payment • Better data with which to justify better payment for physicians and pay-for-performance metrics • Levels the insurance company tactics “playing field”

7. Why Do We Need ICD-10? • ICD-9-CM is outdated: • Over 30 years old • Many categories full • Not descriptive enough • A coding system needs to be: • Flexible to quickly incorporate emerging diagnoses • Exact enough to precisely identify diagnoses

8. An outdated coding system A patient is diagnosed with acute tonsillitis, his second diagnoses within 6 months. In ICD-9, acute tonsillitis is reported using ICD-9-CM code 463. • There is no fourth or fifth digit to report the acute condition or the specific organism causing it. • In ICD-10-CM, the code set for tonsillitis is expanded to a fourth character extension to identify whether the acute condition is recurrent and the causative organism, if known.

9. The bottom line on ICD-9 Any ICD-9 codes used in transactions for services or discharges on or after October 1, 2014 will be rejected as non-compliant and the transactions will not be processed.

10. ICD Background Information • Published by WHO in 1990 • U.S. last industrialized nation to implement ICD-10 • Two parts: ICD-10-CM and ICD-10-PCS • ICD-10-CM – 69,000 codes, ICD-9-CM – 14,000 codes • 3–7 alpha and numeric characters for ICD-10-CM

11. Myth or Fact? Non-covered entities (those not covered by HIPAA) such as Worker’s Compensation, may choose not to implement ICD-10. Fact Workers’ Compensation and auto insurance companies are noncovered entities under HIPAA and are not “required” to comply with the October 1, 2014 deadline. However, ICD-9 will no longer be maintained and it will be in the noncovered entities’ best interest to use the new coding system.

12. Therefore….. Your clinic will need to maintain the ability to submit both ICD-9-CM and ICD-10-CM! (i.e…..software, hardware capacity and coding capability needed for both code sets)

13. Myth or Fact? State Medicaid Programs will not be required to update their systems in order to utilize ICD-10 codes. Fact State Medicaid Programs are all covered entities under HIPAA; therefore must comply with the October 1, 2014 deadline.

14. Myth or Fact? Physicians who choose their own codes will not have to worry about training as their EHR will do this for them. Fact Although EHRs are starting to do some great things in regards to prompts, problem lists, and other assistive tools for ICD-10, they do not take the place of required education for those physicians selecting their own codes.

15. Myth or Fact? ICD-10-CM is a reimbursement system not built for physicians Fact ICD-10 started its origins at the WHO through the efforts of a team of physicians, clinicians, coders, and other healthcare professionals and then further modified by the United States again by a team of clinicians and other healthcare professionals. ICD-10 is far more rooted in current clinical thought and practice than the ICD-9 system.

16. ICD-10-CM vs. ICD-9 Code Structure ICD-10-CM Code Format Ex: Unspecified asthma with acute exacerbation ICD-9493.92 ICD-10             J45.901 (Etiology means “cause or origin”) ICD-9-CM Code Format

17. ICD-10 Code Set Websites • CMS: http://www.cms.gov/Medicare/Coding/ICD10/ • AMA: http://www.ama-assn.org • AHIMA: http://www.ahima.org/icd10/ • AAPC:http://www.aapc.com/icd-10/

18. More is Better! Just as an increase in the number of words in a dictionary doesn’tmake it more difficult to use, the greater number of codes in ICD-10-CM, the easier it is for you to find the rightcode!

19. Increase in Codes: The Real Story • Gastroenterologists: 596 ICD-9 codes and 706 codes in ICD-10 (+110) • Pulmonologists: 255 codes in ICD-9 and 336 codes in ICD-10 (+81) • Urologists: 389 codes in ICD-9 and 591 codes in ICD-10 (+202) • Endocrinologists: 335 codes in ICD-9 and 675 codes in ICD-10 (+340)* • Neurologists: 459 codes in ICD-9 and 591 codes in ICD-10 (+132) • Pediatricians: 702 codes in ICD-9 down to 591 codes in ICD-10 (-111) • Infectious disease: 1,270 in ICD-9 down to 1,056 in ICD-10 (-214) A few hundred new codes = a few dozen new documentation elements * ICD-10-CM includes more combination codes containing co-morbidities and associated conditions. (e.g.- Diabetes)

20. Overall Coding Process Is The Same! • Capture the required encounter documentation • Choose the correct code • Make sure you have the medical necessity to justify the procedure or service

21. Examples of ICD-10-CM Codes • I10 - Hypertension (Seriously? I10?) • H90.3 - Sensorineural hearing loss bilateral • K80.63Calculus of gallbladder and bile duct with acute cholecystitis with obstruction • Fracture of Patella (GEMs)

22. “Unspecified” = “Unpaid” “Physicians may be ICD-10 compliant, but if they abuse the “other” or “unspecified” codes, payment will not occur if a more specific alternative exists.” David Winkler Michigan Blue Cross’ Director of Technical Program Management Justifying medically necessary procedures and services depends on specificity of diagnoses coding!

23. Unspecified Codes • Use of signs, symptoms, and unspecified codes is “acceptable, even necessary” in both ICD-9-CM and ICD-10-CM, says CMS. • For example, if the physician has not determined a definitive diagnosis by the end of the encounter, codes for sign(s) and/or symptom(s) may be reported.

24. Unspecified Codes • When a more specific code can’t be assigned because the clinical information provided isn’t sufficient, the appropriate unspecified code may be used (such as when a physician determines a diagnosis of pneumonia but not the specific type).  • Always remember that, in all cases, the medical record documentation must support the code choice!

25. Documentation: The KEYto ICD-10 Success With increased dx coding specificity comes a requirement for detailed documentation. Jeri Leong, President, Healthcare Coding Consultants of Hawaii: “…(for current audits), 40% of the time we were unable to assign a specific ICD-10-CM code based on current documentation.” How good is YOUR current documentation?

26. Example:Patient is seen for Asthma with Status Asthmaticus ICD-9-CM = 493.91 • Extrinsic vs. intrinsic • Chronic obstructive asthma • With status asthmaticus • With exacerbation • Exercise induced bronchospasm • Cough variant asthma  Additional documentation required ICD-10-CM = J45.902 • Mild intermittent  • Mild persistent  • Moderate persistent  • Severe persistent  • With status asthmaticus • With exacerbation • Exercise induced bronchospasm • Cough variant asthma • Tobacco use or exposure  • Excludes chronic obstructive asthma *

27. Combination Codes • Multiple conditions that may include common symptoms or manifestations • 250.50 Diabetes with ophthalmic manifestations • Sequencing errors reduced

28. A patient is being treated by his physician for moderate nonproliferative diabetic retinopathy. The physician documents Type II diabetes with macular edema.

29. How Can You Prepare? • Don’t focus on 69,000 Codes • Convert your codes!!! • Engage your providers • Practice coding in I 10 -Now!

30. GEMs Translation and Training Tool GEMs=General Equivalence Mapping: • a reference mapping tool that attempts to include all valid relationships between the codes in ICD-9-CM and ICD-10-CM • an excellent training tool to be used to familiarize differences between ICD 9 and ICD-10 and to be able to select the correct ICD-10 code. • The mapping identifies one-to-one and one-to-many code relationships

31. Characteristics of a Good GEMs Tool • Outpatient setting • Search by code and description • Bi-directional: ICD-9 to ICD-10 and vice versa • Multiple code lookups at one time • Store most frequently used codes (“Favorites”) • “Print” function: easily create training tools

32. Practical Uses of GEMs • Create immediate awareness • Engage providers and staff • Facilitate chart audits to analyze current documentation • Assess managed care contracts • Facilitates EMR templates updates • Helps identify “role based” training • Saves time over manual conversion

33. Fracture of Patella

34. Fracture of Patella in ICD-10?

35. Elements of Documentation

36. Elements of documentation

37. Flash Cards

38. Engage the Entire Team! • Promote benefits of ICD-10 • Make a plan • Provide real world tools If all else fails, show them the really fun codes they’ll miss out on if they don’t go ICD-10!

39. W18.12X Fall from or off toilet with subsequent striking against an object W18.12XA Initial Encounter W18.12XD Subsequent Encounter W18.12XS Sequela

40. Y04.1XXA Assault by Human Bite, Initial Encounter

42. W22.09ZD Striking against other stationary object, Subsequent Encounter

43. Two fish were swimming along and ran into a cement wall. One looked at the other and said, “Dam.”

44. Ok, we don’t really treat fish…(Unless they have really good insurance!) W22.09ZD Striking against other stationary object, Subsequent Encounter How about this one…

46. Y93.K2 Activity, Milking an animal

48. (If the milking goes badly) …the related W55.22XS Struck by cow, Sequela

50. V91.07XD Burn due to water-skis on fire, subsequent encounter