Countdown to ICD-10-CM: Three Months to Go. Presented by: Rhonda Granja, BS, CMA, CMC, CPC, CMIS, CMOM

Transcription

1 Countdown to ICD-10-CM: Three Months to Go Presented by: Rhonda Granja, BS, CMA, CMC, CPC, CMIS, CMOM

2 Overview Setting the Stage ICD-10-CM Coding System Overview Planning Your ICD-10 Transition Assessing the Impact of ICD-10 on your organization Operations, Budgeting, Education and Training Documentation, Documentation, Documentation!! Testing GOING LIVE!!! Post-Implementation 2

3 Setting the Stage On October 1, 2015, the U.S. Healthcare system is set to transition to a new diagnostic system Who will be affected by the change to ICD-10-CM? ANSWER: Now is the time for all members of your healthcare organization to start building the base of knowledge for the mandated conversion to ICD-10 Coding professionals Providers Other healthcare professionals 3

4 So Why Are We Switching Over to ICD-10? Greater coding accuracy and specificity Higher quality information for measuring healthcare service quality, safety, and efficiency Improved efficiencies and lower costs Reduced coding errors Greater achievement of the benefits of an electronic health record Recognition of advances in medicine and technology Alignment of the US with coding systems worldwide Improved ability to track and respond to international public health threats Enhanced ability to meet HIPAA electronic transaction/code set requirements 4

5 ICD-10-CM Review of Chapters CODING SYSTEM CONSISTS OF 21 CHAPTERS: CHAPTER 1: (A00-B99) Certain Infectious And Parasitic Diseases CHAPTER 2: (C00-D48) Neoplasms CHAPTER 3: (D50-D89) Diseases Of Blood/Blood-Forming Organs & Certain Disorders Involving Immune Mechanism CHAPTER 4: (E00-E90) Endocrine, Nutritional, And Metabolic Diseases CHAPTER 5: (F01-F99) Mental And Behavioral Disorders CHAPTER 6: (G00-G99) Diseases Of The Nervous System CHAPTER 7: (HOO-H59) Diseases Of The Eye And Adnexa (New) CHAPTER 8: (H60-H95) Diseases Of The Ear And Mastoid Process (New) CHAPTER 9: (I00-I97) Diseases Of The Circulatory System CHAPTER 10: (J00-J99) Diseases Of The Respiratory System CHAPTER 11: (K00-K93) Diseases Of The Digestive System CHAPTER 12: (L00-L99) Diseases Of Skin And Subcutaneous Tissue 5

6 CHAPTER 13: (M00-M99) CHAPTER 14: (N00-N99) CHAPTER 15: (O00-O99) CHAPTER 16: (P04-P94) CHAPTER 17: (Q00-Q94) CHAPTER 18: (R00-R99) CHAPTER 19: (SOO-T98) CHAPTER 20: (V01-Y87) CHAPTER 21: (Z00-Z99) Diseases Of Musculoskeletal System/ Connective System Diseases Of The Genitourinary System Pregnancy, Childbirth, And The Puerperium Certain Conditions Originating In The Perinatal Period Congenital Malformations, Deformations, & Chromosomal Abnormalities Symptoms, Signs, Abnormal Clinical/Laboratory Findings, NEC Injury, Poisoning Certain Other Consequences Of External Causes External Causes Of Morbidity Factors Influencing Health Status/Contact w/health Services 6

7 The Differences Alphanumeric codes Expanded injury code, grouped according to site rather than type of injury Combination of diagnosis/symptom codes Addition of a sixth character with some codes extended out to the seventh character Laterality (left and right specified where applicable) V and E codes incorporated into the main classification Obstetric codes that identify trimester Diabetes category that differentiates between Type 1 and Type II diabetes, drug or chemical induced diabetes, and diabetes due an underlying condition. The additions of ambulatory and managed care encounter information Postoperative complications are expanded and located within the individual chapters. 7

8 ICD-10-CM Code Format ICD-10-CM Code Format X X X X X X X category etiology, anatomical site, severity extension Consist of up to seven digits: The 1 st digit is always alpha The 2 nd digit is always numeric The remaining five digits can be any combination 8

9 Improvements Between 9 and 10 ICD-9 & ICD-10 Comparison ICD-9-CM ICD-10-CM 3-5 Digits Approximately 13,000 Codes First digit may be alpha (E or V) or numeric, digits 2-5 are numeric Limited space for adding new codes Lacks detail - Ambiguous Lacks laterality Difficult to analyze data due to non-specific codes Codes are non-specific and do not adequately define diagnosis needed for medical research Does not support interoperability because it is not used by other countries 3-7 Digits Approximately 68,000 codes Digit 1 is alpha; Digits 2 is numeric;. However, Digits 4-7 can be alpha or numeric (alpha digits are not case sensitive) Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy & richness of data for analysis Detail improves the accuracy of data used for medical research Supports interoperability & the exchange of health data between other countries & the U.S. 9

10 Locating Codes in ICD-10-CM: The Details Alphabetic Index Volume II Divided into two parts: The Index to Disease and Injury The Index to External Causes of Injury Within the Index of Diseases and Injury, there is: Neoplasm Table Table of Drugs and Chemicals Index to External Causes Tabular List Volume I 10

11 Code Expansion E08.33 Diabetes mellitus due to an underlying condition with moderate nonproliferative diabetic retinopathy E Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema 11

12 T Adhesions due to foreign body accidentally left in body following aspiration, puncture or other catherization T Obstruction due to foreign body accidentally left in body following endoscopic examination T Perforation due to foreign body accidentally left in body following surgical operation T Perforation due to foreign body accidentally left in body following heart catherization 12

13 In ICD-10-CM Two Types of Excludes Notes Added definitions for two types of Excludes notes Excludes 1 not coded here never used with the code (Same as the Excludes note in 9 ) Example: B06 Rubella has an Excludes 1 of congenital rubella (P35.0). Excludes 2 not included here not part of the condition; it is acceptable to use both codes together if patient has both conditions Example: T81.59 Other complications of foreign body accidentally left in body following procedure Excludes 2: obstruction or perforation due to prosthetic devices and implants intentionally left in body (T82.0-T82.5, T83.0-T83.4, T83.7, T84.0-T84.4, T85.0-T85.6) 13

14 Code Extensions 7 th character code extensions have been added for injuries and external causes: A D S Initial encounter Subsequent encounter Sequelae Example: S31.623A Laceration with foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity, initial encounter. Shows an extension used with a laceration code. 14

15 7 th Character Describing Encounter A - Initial encounter: As long as patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter and evaluation and treatment by a new physician. D - Subsequent encounter: After patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent treatment are: cast change or removal, removal of external or internal fixations device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition. S - Sequela: Complications or conditions that arise as a direct result of a condition (e.g., scar, formation after a burn). 15

16 Fracture Codes 7 TH Character identifies if the fx is open or closed for an initial encounter or if a subsequent encounter is for routine healing, delayed healing, nonunion, malunion, or sequelae. The extensions are: A B D G K P S Initial encounter for closed fx Initial encounter for open fx Subsequent encounter for fx with routine healing Subsequent encounter for fx with delayed healing Subsequent encounter for fx with nonunion Subsequent encounter for fx with malunion Sequelae Example: S42.321A Displaced transverse fx of shaft of humerus, right arm, initial encounter for closed fx 16

17 10 Shows Laterality Laterality C Malignant neoplasm of upper-inner quadrant of right female breast C Malignant neoplasm of upper-inner quadrant of left female breast L Pressure ulcer of right hip, stage III 17

18 Inclusion of Trimester O23.52 Salpingo-oophoritis in pregnancy Oophoritis in pregnancy Salpingitis in pregnancy O Salpingo-oophoritis in pregnancy, first trimester O Salpingo-oophoritis in pregnancy, second trimester O Salpingo-oophoritis in pregnancy, third trimester O Salpingo-oophoritis in pregancy, unspecified trimester 18

19 Combination Codes for Conditions and Common Symptoms I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris I Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm 19

20 Combination Codes for Poisoning and External Cause T Poisoning by aspirin, accidental (unintentional) T Poisoning by aspirin, intentional self-harm T Poisoning by aspirin, assault T Poisoning by aspirin, undetermined T Adverse effect of aspirin T Underdosing of aspirin 20

21 Status of V and E Codes V and E codes are no longer supplementary classifications. V codes, which currently describe health status and contact with health services are now being classified as Z codes. External Causes of Injury ( E) codes are now included in Chapter 20, External causes of morbidity in the ICD-10 coding system. 21

22 Chapter 20: External Causes Morbidity (V00-Y99) Examples V03 Pedestrian injured in collision with car, pick-up truck or van The appropriate 7th character is to be added to each code from category V03 A - initial encounter D - subsequent encounter S sequela V03.0 Pedestrian injured in collision with car, pick-up truck or van in nontraffic accident V03.00 Pedestrian on foot injured in collision with car, pick-up truck or van in nontraffic accident Pedestrian NOS injured in collision with car, pick-up truck or van in nontraffic accident V03.01 Pedestrian on roller-skates injured in collision with car, pick-up truck or van in nontraffic accident V03.02 Pedestrian on skateboard injured in collision with car, pick-up truck or van in nontraffic accident V03.09 Pedestrian with other conveyance injured in collision with car, pick-up truck or van in nontraffic accident Pedestrian with baby stroller injured in collision with car, pick-up truck or van in 22 nontraffic accident

23 Index to External Causes Status of external cause Y99.9 Child assisting in compensated work for family Y99.8 Civilian activity done for financial or other compensation Y99.0 Civilian activity done for income or pay Y99.0 Family member assisting in compensated work for other family member Y99.8 Hobby not done for income Y99.8 Leisure activity Y99.8 Military activity Y99.1 Off-duty activity of military personnel Y99.8 Specified NEC Y99.8 Student activity Y99.8 Volunteer activity Y99.2 Tabular List: Y99.8 Other external cause status Code: Y99.8 Reminder: Status of external cause status codes do not require 7 th character extension and are only placed on the initial episode of care. 23

24 Index to External Causes Place of occurrence: Institutional Y92.10 Tabular: Prison Y Bathroom Y Cell Y Courtyard Y Dining room Y Kitchen Y Specified NEC Y Swimming pool Y Y Other place in prison as the place of occurrence of the external cause Reminder: Place of occurrence codes do not require a 7 th character extension and are only used on the initial episode of care. 24

25 Index to External Causes Place of occurrence: Football field Y Tabular List Y Football field as place of occurrence of the external cause Code: Y NOTE -- the Official Guidelines state that there can be only one Place of Occurrence Code on the patient's medical record for the injury. Therefore, in this instance the "specified place at the residential institution (prison) is more specific as to where the injury occurred and should be coded as the Place of Occurrence. The Place of Occurrence - Football field - would not be coded. 25

26 Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. (a) When a person who may or may not be sick encounters the health service for some specific purpose (limited care, donate an organ or tissue, immunization) (b) When some circumstances or problem is present which influences the person s health status a current illness or injury Z00-Z13 Persons encountering health services for examinations Z14-Z15 Genetic carrier and genetic susceptibility to disease 26

27 General Equivalence Mappings (GEMs) In the GEMs, there are three flags: 1. Approximate indicates that the entry is not considered equivalent 2. No Map indicates that a code in the source system is not linked to any code in the target system 3. Combination indicates that more than one code in the target system is required to satisfy the full equivalent meaning of a code in the source system 27

28 Planning Your ICD-10 Transition: Important Skills Needed for ICD-10 Implementation Ability to break through assumptions To look at the big picture Ability to thrive on change Ability to gather data and improve processes based on these results Ability to collaborate towards working solutions 28

29 Assessing the Impact of ICD-10 on Your Healthcare Organization Conducting an Impact Analysis Diagnosis codes are used in virtually every aspect of health care operations Each organization will need to determine the impact of this coding change This allows organizations to identify gaps in operational and technical capabilities, current readiness and potential risks 29

30 Managing Resistance to the Change Ensuring that all staff and external partners are on board. Resource distribution will be difficult as the staff may not spend extra time Mandatory EHR implementation will reduce productivity of clinicians, coders, and billers Coders need to probe deep into medical records and query the provider for the specificity in the documentation Educating providers about the ICD-10 documentation requirements and getting them on board with documenting more clearly for medical necessity. 30

31 Impact Focus Area: Operations Education Business Process Analysis Changes to Superbills IT Costs Increased Documentation Costs Increases in Claim Inquiries/denials and Reduction in Cash Flow 31

32 Impact Focus Area: Budgeting for the Transition Build a Project Budget Examples of Direct Costs Software and hardware Education and training Payer integration planning and modeling Testing-related costs Staff time needed Temporary staff to assist with extra work Consulting services Forms and reports Data conversion Dual coding Indirect costs are the factors that can reduce cash flow and revenues 32

33 Impact Focus Area: Education & Training Developing Training Plans: Staff would learn about the new coding system to understand the differences in the code sets and specific impacts on their organizations Detailed training will have to be provided to specific staff involved in: documentation of patient activities coding of medical records administrative records information technology health plan relations contracts. 33

34 Assessing Staff Training Needs Not all coding staff will require the same type or amount of ICD-10 education Training for coding staff in specialty area or specialty clinic should focus on the code categories most applicable to particular patient mix. Estimates indicate that coding staff working in outpatient settings will require 16 hours of ICD-10 education Determine staff competence and skill gaps, and how to customize trainings to individuals. 34

35 Consider best approach training methods for your practice: webinars certification courses onsite training Assess staff for ICD-10 proficiency after training and provide feedback Provide additional training, if needed, to bring staff up to competency expectations Include time for practice by dual coding select cases Continue training well into post-implementation phase 35

36 Impact Focus Area: Documentation ICD-10 implementation will affect the clinical documentation your organization provides to payer organizations. Accurate, detailed, and consistent data will greatly improve clinical decision-making, performance reporting, managed care contracting and financial analysis used for improving patients health and the nation s health care system. 36

37 Increased code detail contained in ICD-10- CM means required documentation will change substantially. Incomplete documentation leads to a lack of data integrity. The importance of documentation can not be overstated!!! 37

38 Run a practice management report that extracts your top diagnosis codes. Perform documentation audit on previous coded and documented charts. Map current ICD-9 codes to an ICD-10 code selection. Review ICD-10-CM Official Guidelines for Coding and Reporting for new levels of specificity. 38

39 WHAT HAPPENS IF I USE THE WRONG ICD-10 CODE? While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting on October 1, It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor. 39

40 ICD-10-CM Training Resources Training and Education Resources - Road to 10. ICD-10 training for Coders, Auditors, Physicians, Practice Choose Your Path to ICD-10www.ahima.org ICD-10 Coding Running a Practice ACP Practice Management Institute - Medical Staff Training and 40

41 Impact Focus Area: Testing and Transition Developing a Testing Plan Starting the Conversation with your Vendors Internal Testing (Level 1) External Testing (Level II) Which Transactions Should I Test? Which Business Partners Should Be Included in External Testing? Error Testing 41

42 Testing Plan An important step in preparing for the change to ICD-10 is to have conversations with your software vendors, clearinghouses, or billing services you use to ensure they are ready to provide the support you need. 42

43 What Questions Do I Ask My Vendor? Points to consider discussing with your vendors include: System upgrades/replacements to accommodate ICD-10 Costs involved and whether upgrades will be covered with existing contracts When will these upgrades be available? Customer support and training that will be provided How will their products and services accommodate both ICD-9 and ICD-10 for services provided before and after the transition deadline. 43

44 INTERNAL TESTING (Level 1) Internal testing allows you to identify and address any potential issues that may arise in advance of testing with external business partners. Identify cases to test, most frequently-used codes Testing can coincide with evaluating any workflow processes related to the assignment of diagnosis codes. After testing, make any necessary adjustments 44

45 External Testing (Level 2) After successful completion of internal testing, you can begin sending test data to your external business partners. Which transactions should I test? Claims Eligibility determinations Remittances Referral authorizations 45

46 Which Business Partners should be included in External Testing? Vendors Payers Hospitals Health Information Exchanges Outsourced billing/coding Government entities Testing may result in errors. Correcting the errors before go-live date is the goal of the testing phase. 46

47 Going Live!!! Finalize systems changes and complete testing of these changes. Complete pre-implementation testing of claims transactions with payers. Complete intensive coding professional education and education of other users previously identified as requiring education. Assess potential reimbursement impact of new coding systems. Review and modify the detailed schedule leading up to the point golive in order to clearly articulate all key stakeholders role and responsibilities during the last two weeks prior to the implementation deadline. Keep staff informed as appropriate through frequent updates regarding progress, next steps, and issue identification and resolution. 47

48 Post-Implementation Evaluating the Success of the Project Post-Implementation Audit Processes and Procedures Software Upgrades Quality Improvements Comparative Assessments Organization Adaptations Cash Flow Reduce Waste Better documentation Better financial and administrative performance Better patient care Better policies and decisions 48

49 ICD-10-CM RESOURCES Live Webinar & Classroom training events Crash course for Distance Learners Online Proficiency Test for prove your knowledge of ICD-10-CM coding 49

50 ICD-10-CM RESOURCES 50

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