Ten Tips for ICD-10. September 17, Theresa Marshall, Sr. Director Compliance Data Experian Health

Transcription

1 Ten Tips for ICD-10 September 17, 2015 Theresa Marshall, Sr. Director Compliance Data Experian Health Experian and the marks used herein are service marks or registered trademarks of Experian Information Solutions, Inc. Other product and company names mentioned herein are the trademarks of their respective owners. No part of this copyrighted work may be reproduced, modified, or distributed in any form or manner without the prior written permission of Experian.

2 Ten Tips for ICD-10 ICD-9 The clock is ticking down to Oct. 1 when the health care industry transitions, ready or not, to new diagnostic codes that bring the language of disease into modern times. The transition, from ICD-9 to ICD-10, modernizes and expands the roster of codes used to diagnose disease and injury and to help bill patients and insurance providers. This is the 10th iteration of ICD, the International Classification of Diseases and Related Health Problems. With two weeks left until Oct. 1, there is still time review of your checklists, ICD-10 information and processes for any gaps. 2

3 Tip 1. Centralize and Organize Questions and Responses for ICD-10 Know where to refer any questions for ICD-10 within your organization Have central point of contact and a central line of communication after implementation Create a type of coding command center hotline telephone number for those who will be performing the actual ICD-10 coding for the first few weeks of October. Consider having a uniformly staffed call center for eight hours a day, Monday through Friday at a minimum, with more hours and more days added depending on your workforce needs and operational structure. Using a toll-free number is one of the easiest to arrange. Once this is created, you ll want to be sure to communicate the number and the purpose of the coding command center to your coding workforce and management teams so they can utilize it easily. 3

4 Tip 1. continued Centralize and Organize Questions & Responses The purpose of the coding command center is to centralize the reporting of coding issues, problems, and questions. This provides an organizational structure that can be used to create a master list of all reported ICD-10 issues within your practice or organization. In addition, tracking the coding issues by type and with recommended actions or resolutions will allow for quick identification of any systemic issues and/or when and where an issue needs to be raised to a higher level of attention within your management or organization. Also, having the same responses and resolutions to the same coding issues and questions promotes quality. Priority (high, medium, low) categories and expected response times for each category should also be decided. Periodic summary review of inquiries can be insightful for trends, future education, and also shed light on any overlooked processes. 4

5 Tip 2. Review Diagnoses found on Electronic and Manual Forms Conduct a review of all ordering electronic and manual forms Create electronic superbills There may be forms, both electronic and manual that have been overlooked and need to be updated for ICD-10 implementation. Now is also a good time to take a last review at processes when different forms are utilized. For example, diagnoses on Standing Orders, Referrals and Laboratory Non- Patient Specimen requests may have been overlooked. In any software systems, if there are recurring accounts associated with ICD-9-CM, what are the steps to change the diagnoses from ICD-9 to ICD-10? Also, be aware of any new requirements for both patient information and diagnoses for Reference Laboratories. Accurate and complete ICD codes are necessary for proper processing, and of course, claim payment. 5

6 Tip 2. continued Review Diagnosis Review electronic systems for ICD-9 diagnoses that remain. Many systems have Diagnosis Favorites, Predefined Diagnoses or Pick Lists. If these are still in ICD-9, now is a great time to review and prepare to update to ICD-10. Collaborating with the medical coding staff to standardize these will save time as many coding professionals have been submitting dual codes (ICD-9and ICD-10) since Lastly, if any software systems are interfaced, if you haven t already done so, validate that when ICD-10 is electronically passed it is processed and filed correctly throughout the system. Additional types of patient information will generally need to be submitted for reference laboratories. For specific conditions, requirements will vary; some examples for common conditions include: Asthma: intermittent, mild persistent, moderate persistent, severe persistent? Fractures: Gustilo classification, type of fracture? Seizures: General or focal, what type, intractability? Pregnancy: Which trimester? Poisoning or toxic effect: Which substance? Ulcers: Which stage 6

7 Tip 3. Fine Tune ICD-10-CM Diagnosis Code Selection Process Leverage any coding tools for ICD-10 code selection How are your systems providing diagnoses for use for daily responsibilities? While some tasks, such as Eligibility, do not require diagnoses, you will need coded diagnoses to screen for medical necessity. Most organizations have focused on coder training and the requisite 7

8 Tip 3. Fine Tune ICD-10-CM Diagnosis Code Selection Process If you have an ICD-9 code, and you would like review ICD-10 options for it, there are coding cards that can be purchased, or any crosswalks provided by the coding staff. If you have access to an ICD-9 to ICD-10 translator tool that also can be very fast, helpful and easy to use. The code input must be at the highest level of specificity for successful translation Be aware also that not every ICD-9-CM is translated by the CMS GEMS; there are 425 ICD-9-CM codes listed in the GEMS that have no equivalent in ICD-10-CM and 669 ICD-10-CM codes that have no equivalent in ICD-9-CM. Granularity of ICD-10- Are there tools and queries that the patient access staff can leverage that follow the guidelines for coding and compliance within the organization? 8

9 Here s a view from a Code Translator used in some software products such as Medical Necessity Screening & Price Estimators 9

10 There may be other ways to locate an ICD-10 diagnosis as well such as a narrative look-up in your software. Most software will flag an ICD code that is not at the highest level of specificity, but check where and how this is displayed in any automation you may use. For some familiar products for many user in this region, a Clinical Condition to ICD-10 code look-up will be available as well on Oct 1. This allows entry of a Sign, Symptom or Disease to find ICD-10 diagnosis code: 10

11 Tip 4. ICD-10-CM Diagnosis codes are not all 7 characters long Many diagnosis codes are 3-5 characters in length; the key is if a code is the most specific code. To be valid, ICD-10-CM Diagnosis codes must be coded to the full number of characters for that code The coding process for assigning a diagnosis code for ICD- 10 is not any different than ICD-9; the diagnostic term is reviewed in the Alphabetic Index and then the code is validated in the Tabular index. Review a complete list of ICD- 10-CM codes and titles to determine that if an additional 4 th, 5 th, 6 th or 7 th character is needed. 11

12 Tip 4. continued they re not all 7 characters! For example I10 (hypertension) is the most specific code present; however, a review of I11 shows that would not be the most specific code as in the complete ICD list there is I11.0 and I11.9 I11 is not the most specific code as there are 4 digit codes available to select I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure Another example would be E11.6 E11.6 is not the most specific code as there are 5 digit codes available to select: E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication 12

13 Tip 5. Unspecified Codes Still Necessary These codes contain word the unspecified in the diagnosis description They remain not only acceptable for submission, but necessary Frequently confused with code specificity Documentation in the medical record must be present to support code selection beyond unspecified. Examples of some commonly diagnoses described as Unspecified: Anemia: ICD-9: Anemia, unspecified ICD-10: D64.9 Anemia, unspecified 13

14 Tip 5. continued unspecific still necessary Abdominal Pain: ICD-9: Abdominal pain, unspecified site ICD-10: R10.9 Unspecified abdominal pain Stroke: ICD-9: Cerebral Artery Occlusion unspecified with cerebral infarction ICD-10: I63.9 Cerebral infarction, unspecified Angina: ICD-9: Other and unspecified angina pectoris ICD-10 I20.9 Angina pectoris, unspecified 14

15 Tip 6. Placeholders in ICD-10- Letter x is really part of the Code Placeholders have been integrated into the diagnosis code for future expansion The letter x is used as a fifth-character placeholder Letter x is also used to fill in other empty characters (e.g. character 5 or 6) when a code is les than 6 characters long and requires a 7th character 7 th character may be needed for ICD-10 codes beginning with M,O, R, S, T, V, W, X, Y The 7 th character is a significant change from ICD-9 as it captures information and details not found in ICD-9. For injury, poisoning and other consequence of external injury, the 7 th character provides information about the episode of care. For pregnancy and childbirth, the 7 th digit provides information about the fetus. 15

16 Tip 6. Placeholders in ICD-10- Letter x is really part of the Code Episode of Care Designates the episode of care as initial, subsequent or a sequela for injuries, poisonings and in certain instances, provides more information about the injury A= Initial Encounter D= Subsequent encounter S = Sequela Example: T36.0x1D: Poisoning by penicillin's, accidental, unintentional, subsequent encounter 16

17 Tip 6. Placeholders in ICD-10- Letter x is really part of the Code Fetus: Used for certain complications of pregnancy, with multiple gestation to identify to describe which fetus(es) is (are) affected by the conditions described The 7 th character for Obstetrics is numbers 0-9 for multiple gestations. Examples: O31.8x35 Other complications specific to multiple gestations, third trimester, fetus 5 O32.1xx1 Maternal Care for breech presentation, fetus 1 17

18 ICD-10 codes nomenclature: Digit 1 is alpha; All letters except U are used Digit 2 is numeric Digit 3-7 are alpha or numeric (alpha characters are not case sensitive) Decimal is used after third character 18

19 7. New Features: ICD-10-CM Diagnoses and New Items of Interest Trimester description is available for Pregnancy; 1st Trimester is less than 14 days, 2nd trimester is 14 weeks to less than 28 weeks, 0 days, 3rd trimester over 28.0 weeks to delivery Prematurity of an infant must be document by a physician Acute Myocardial Infarction is now 4 weeks/28 days; > 4 weeks is now considered old myocardial infarction Anytime a tobacco situation exists, this is added as a secondary code. The code should be added as applicable Exposure to environmental smoke (Z77.22) Exposure to tobacco smoke in the perinatal period (P96.81 this is the code for the baby, not Mom) History of tobacco use/dependence (Z87.891) Tobacco use (Z72.0) 19

20 7. New Features: ICD-10-CM Diagnoses and New Items of Interest History of Nicotine, alcohol or drug dependence is coded as in remission. Nicotine dependence, cigarettes, in remission, F17.11 Anemia Associated with Malignancy has changed; when the encounter is for the management of the anemia associated with a malignancy, and the treatment is only for the anemia, the appropriate code for the malignancy is sequenced as the principal diagnosis or first-listed diagnosis followed by D63.0, anemia in neoplastic disease. Note: Selection of principal diagnosis relates only to inpatient settings and is not applied to outpatient visits Anemia due to an adverse effect of chemotherapy, immunotherapy or radiotherapy and the only treatment is for the anemia, the adverse effect code is sequenced as principal followed by the codes for the anemia and neoplasm. Hypertension code classification no longer needs documentation benign, malignant or unspecified 20

21 7. Continued - New Features: ICD-10-CM Diagnoses and New Items of Interest Laterality: Certain codes will need documentation of which side is affected: left, right, bilateral or unspecified: H Central Corneal Ulcer, bilateral S Insect bite of right thumb New Concepts not found in ICD-9 included in ICD-10: underdosing, blood types, and blood alcohol level T45.526D Underdosing of antithrombotic drugs, subsequent encounter Z67.40 Type O blood, RH positive Y90.6 Blood alcohol level of mg/100 ml 21

22 7. Continued - New Features: ICD-10-CM Diagnoses and New Items of Interest Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and postprocedural disorders: D78.01 Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen D78.21 Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen 22

23 Tip 8. continued - ICD-10-PCS Procedures Codes Always 7 characters long Will be used only for Hospital claims for inpatient hospital procedures; will not be used on physician claims, even those with inpatient visits Current Procedural Terminology (CPT ) and Healthcare Common Procedural Terminology are not affected by the transition to ICD-10 If you are are not using the ICD-9 procedure codes today, then, your procedure coding system will not change Diagnoses are used to determine coverage, not to determine amount of payment by CMS 23

24 Tip 8. ICD-10-PCS Procedures Codes Always 7 characters long ICD-10-PCS differ from the ICD-9-CM procedure codes in that they have 7 characters that can be either alpha (non case sensitive) or numeric. The numbers 0-9 are used (letters O and I are not used to avoid confusion with the numbers 0 and 1) and they do not contain decimals 24

25 25

26 ICD-PCS Structure Characters (Med/Surg) 26

27 Tip 8. ICD-10-PCS Procedures Codes Always 7 characters long Each character, as with the diagnoses, has a specific meaning. For example, Character 1 identifies the section or Type of procedure Chest X-Ray is in the Imaging Section Biopsy is in the Med/Surg section Crisis intervention is in the Mental Health Section Character 2 is body system Cardiovascular is divided into 5 body areas Character 3 is the Root Operation; this is the objective of the procedure. There are 31 different root operation values 27

28 Tip 8. ICD-10-PCS Procedures Codes Always 7 characters long Below are some example of Removal, ICD-9-PCS and ICD-10-PCS to demonstrate the procedure/root difference ICD-9 Testes Pacemaker Calculus Blood Clot ICD-10 Resection testes - Cutting out or off, without replacement Removal Pacemaker - Taking out or off a device from a body part Extirpation calculus - Taking or cutting out solid matter or material from a body part Extirpation blood clot 28

29 Tip 8. ICD-10-PCS Procedures Codes Always 7 characters long The second through 7 th characters can have different meaning for each section as the procedure code is built by the coder. Operationally, the Medicare Administrative Contractors (MACs) will use ICD-10-CM and ICD-10-PCS codes to assign discharges to appropriate DRG s. Remember that Date of Service determines which code set to use (ICD- 9 or ICD-10); for inpatient facility date of service = Discharge date. For outpatient and physician reporting, dates of services after Oct 1, 2015 must be coded in ICD-10-CM. Dates of services prior to Oct 1, 2015 must be coded in ICD-9-CM. 29

30 Tip 9. CMS and ICD-10 Submission Flexibility Consistency with LCD/NCD still required Medicare will process a valid ICD-10 code if from the correct family of codes CMS has stated that for 12 months after ICD-10 implementation, if a valid ICD-10 diagnosis Code from the right family is submitted, Medicare will process and not audit these valid ICD-10-CM codes. However, the claim may still be denied, if the code(s) submitted are not consistent with the Local Coverage Decisions or National Coverage Decisions. The reference to the Family of Codes, is the same as the ICD-10 three-digit character. As we know, these codes are all clinically related, and provide differences specifically for that type of condition. The flexibility are for physicians and other practitioners whose claims are billed under the Part B physician fee schedules 30

31 Tip 10. Claim Submission - Remember Date of Service Determines ICD-9 or ICD-10 Inpatient Claims Use ICD code set based on through/discharge date. For span dated claims, use ICD-10 Inpatient Claims having a principle (first-listed) ICD-10-CM in the range V00-Y99 (external causes of morbidity) will be returned as unprocessible. Outpatient claims Use ICD code set based on the From date of service Medicare claims cannot contain both ICD-9 and ICD-10 codes CMS is not accepting dual processing Claims for CMS that do not meet the above standards will be returned to provider (institutional claims) or returned as unprocessible (professional/supplier claims) 31

32 There are 13 days left to work on your go-live process But only 9 of them are not on a weekend 32

33 Theresa Marshall, Sr. Director Compliance Data, Experian Health