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ICD-10 –CM and the Impact on Physician Practices

ICD-10 –CM and the Impact on Physician Practices. 1450 Winter VAR Conference February 3, 2012. Denisha M. Torres-Lich, MS, RHIA, LHRM President Torres-Lich & Associates, Inc. Current System Limitations. Over 30 years old Codes are insufficient Lack specificity and detail

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ICD-10 –CM and the Impact on Physician Practices

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  1. ICD-10 –CM and the Impact on Physician Practices 1450 Winter VAR Conference February 3, 2012 Denisha M. Torres-Lich, MS, RHIA, LHRM President Torres-Lich & Associates, Inc.

  2. Current System Limitations • Over 30 years old • Codes are insufficient • Lack specificity and detail • Limits the ability of payers and others • Do not provide the level of detail

  3. The Beginning: ICD-10 • ICD-10 Final Rule CMS-0013-F • http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf • Published January 16, 2009 • Compliance Date for Implementation • October 1, 2013 • First implement the “Version 5010” electronic health care transaction standards • January 1, 2012

  4. Benefits • Improve operational processes • Update the terminology and disease classifications • Increase flexibility • Enhance coding accuracy and specificity • Support refined reimbursement models

  5. Benefits • Allows for greater automation = fewer payer-physician inquiries • Provides more detailed data • Greater diagnostic specificity • Provides for more effective detection and investigation of potential fraud or abuse

  6. Characteristics of ICD-10 • Standard coding convention that: • flexible • provides unique codes • allows new procedures and diagnoses to be easily incorporated • Two Components • ICD-10 – CM • Diagnosis classification system • ICD-10-PCS • Procedure classification system for inpatient hospital use

  7. Characteristics ICD-10 • Both components can improve: • quality measurements • patient safety • evaluation of medical processes and outcomes. • ICD–10–PCS • can readily expand and capture new procedures and technologies

  8. Structural Difference between – ICD-9-CM and ICD-10- CM

  9. ICD-10-CM TABULAR LIST of DISEASES and INJURIES • Table of Contents • 1 Certain infectious and parasitic diseases (A00-B99) • 2 Neoplasms (C00-D49) • 3 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) • 4 Endocrine, nutritional and metabolic diseases (E00-E89) • 12 Diseases of the skin and subcutaneous tissue (L00-L99) • 13 Diseases of the musculoskeletal system and connective tissue (M00-M99) • 14 Diseases of the genitourinary system (N00-N99)

  10. Structural Difference between – ICD-9-CM Vol 3 and ICD-10- PCS

  11. Example of ICD-10-PCS Section Body System Root Operation Body Part Approach Device Qualifier 0DB68XZ Excision TransorificeIntraluminal Endoscopic Diagnostic Med/Surg Gastrointestinal Stomach None

  12. General Equivalence Mappings -(GEMS) • network of relationships between the two code sets • ICD-9-CM to ICD-10-CM (forward mapping) • ICD-10-CM to ICD-9-CM (backward mapping) “…a series of possible compromises rather than the mirror image of one code in the other code set.”

  13. Challenges with Mapping

  14. Challenges with Mapping • Diagnosis Codes and Differences in Classification • For example: • I-9 code description - “complicated open wound” • Delayed healing, delayed treatment, foreign body or infection • I-10 categorizes open wounds • wound type -laceration or puncture wound, and whether a foreign body is present • depending on the documentation in the record, the correct correspondence between and I-9 and I-10 code could be one of several.

  15. Challenges with Mapping • Diagnosis Codes and Levels of Specificity codes. • i.e. in I-9, category 733, Other disorders of bone and cartilage, contains the codes: • 733.93 Stress fracture of tibia or fibula • 733.94 Stress fracture of the metatarsals • 733.95 Stress fracture of other bone • 733.96 Stress fracture of femoral neck • 733.97 Stress fracture of shaft of femur • 733.98 Stress fracture of pelvis • in many instances I-10 provides specific codes for all likely sites of a stress fracture, including more specificity for the bones of the extremities, the pelvis and the vertebra. Stress fracture data coded in I-10 possesses a consistent level of specificity.

  16. Example of I-9 to I-10 GEM 73395 M4840XA 10000 73395 M4841XA 10000 73395 M4842XA 10000 73395 M4843XA 10000 73395 M4844XA 10000 73395 M4845XA 10000 73395 M4846XA 10000 73395 M4847XA 10000 73395 M4848XA 10000 73395 M8430XA 10000 73395 M84319A 10000 73395 M84329A 10000 73395 M84339A 10000 73395 M84343A 10000 73395 M84373A 10000 73395 M8438XA 10000

  17. Challenges with Mapping • Diagnosis Codes in Combination • i.e. I – 9 code 115.11Histoplasma duboisii meningitis = I – 10 codes B39.5 Histoplasmosis duboisii AND G02 Meningitis in other infectious and parasitic diseases classified elsewhere

  18. ICD-9-CM 821.01 Fracture of femur, shaft, closed ICD-10-CM Many possible codes Specificity looks like this…

  19. Impact • Hospitals • Health care practitioners & institutions • Health insurers & other third-party payers • Electronic-transaction clearinghouses • Hardware & software manufacturers & vendors • Billing & practice-management service providers • Health care administrative & oversight agencies • Public & private health care research institutions

  20. Users All reporting/billing health care providers • ICD-10-CM • Hospitals, physicians, clinics, laboratory, radiology, psychiatric, rehab, nursing homes etc. All diagnosis codes • ICD-10-PCS • Procedures for Hospital Inpatients CPT/HCPCS • Procedures for Hospital Outpatients, Physician, Laboratory and Radiology Outpatients

  21. Impact on Physician Practices • Electronic Health Records • Practice Management Systems • Billing • Accounts Receivable • Productivity Loss

  22. Challenges of Engaging Physicians • Physician Perception • Impact on Practice Management • Impact on reimbursement • Physician practice changes

  23. Milestones & Tasks • Six phases: • Planning • Communication and Awareness • Assessment • Operational Implementation • Testing • Transition

  24. Impact on Coding and Documentation • Quality vs. Quantity • More stringent documentation • i.e.Myocardial Infarction ICD-10 documentation will need to include: • Type of Infarction • Age of Infarction • Specific Site of Myocardium involved • Coronary Artery Involved • Information regarding initial or subsequent MI within 4 weeks

  25. Coding and Documentation • Work toward better documentation to • Avoid misinterpretation by third parties (auditors, payers, attorneys, etc.) • Justify medical necessity • Provide a more accurate clinical picture of quality of care provided

  26. Electronic Tools to Facilitate Coding & Documentation Process • Speech Recognition • Back End • Front End • Computer Assisted Physician Documentation • Computerized Assisted Coding • reduce costs and claims rejections • improve productivity and accuracy

  27. Web Resources • 2012 ICD-10 • http://www.cdc.gov/nchs/icd/icd10cm.htm • http://www.cms.hhs.gov/ICD10 • AHIMA ICD-10 Resources • http://www.ahima.org/ICD10/default.aspx • Provider Resources • http://www.cms.gov/ICD10/05a_ProviderResources.asp

  28. Questions

  29. Denisha M. Torres-Lich, MS, RHIA,LHRM President Torres-Lich & Associates, Inc. (727) 515-2355 Denisha@Torres-Lich.com

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