ICD-10-CM & ICD-10 PCS: Getting Started

Transcription

1 ICD-10-CM & ICD-10 PCS: Getting Started Audio Seminar January 07, 2013 Practical Tools for Seminar Learning Copyright 2012 American Health Information Management Association. All rights reserved.

2 By accessing, purchasing, or registering for any AHIMA audio seminar or webinar, you agree to the terms and conditions outlined in the AHIMA Audio Seminar/Webinar Terms of Use Agreement. AHIMA Audio Seminar/Webinar Terms of Use Agreement If you do not accept and abide by this Agreement, you may not download, access, or attend AHIMA audio seminars or webinars. Nothing in this Agreement shall be deemed to confer any third party rights or benefits. Description of Service. AHIMA audio seminars and webinars are live or recorded events available via phone, Web, download, or Audio CD at a fee. AHIMA (American Health Information Management Association) reserves the right to modify, suspend or discontinue the product with or without notice at any time and without any liability to you. An executed registration or order form constitutes binding agreement between the parties. Personal Use. AHIMA audio seminars and webinars are made available to you for personal or single office (e.g. a conference room) use only and may not be rebroadcast, retransmitted, shared or disseminated without the express written permission of AHIMA. In addition, AHIMA component state associations (CSA) and local chapters or other groups of individuals representing multiple companies or separate offices within a single facility do not constitute a single office and may not share an audio seminar or webinar. If a registrant needs the ability to share audio seminar or webinar content outside his or her single office or facility, a multiple registration license is required. Unauthorized sharing of AHIMA audio seminar and webinar content through the sharing of user names and passwords or via alternative media (including, but not limited to ipod, CD-ROM and Flash Drive) through the sharing of said media, or via patching phone lines is restricted by law and may subject the copyright infringer to substantial civil damages. AHIMA reserves the right to refuse service to anyone at any time without notice for any reason. AHIMA audio seminar and webinar content may be available for licensed use for larger organizations and other uses under separate licensing arrangements made through AHIMA s business development team. You agree not to sell, reproduce, distribute, modify, display, publicly perform, prepare derivative works based on, or otherwise use, the AHIMA Programs in any way for any public or commercial purpose. Except as specifically agreed to by the parties in writing, you may not distribute, license, transfer or assign the AHIMA programs to any 3rd party. Proper Use. AHIMA reserves the right, but shall have no obligation, to investigate your use of the Product in order to determine whether a violation of the Agreement has occurred. Intellectual Property Rights. You acknowledge that AHIMA owns all right, title and interest in and to the Product content, except where stated otherwise, including without limitation all intellectual property rights (the "AHIMA Rights") specific to content, and such AHIMA Rights are protected by U.S. and international intellectual property laws. Accordingly, you agree that you will not copy, reproduce, alter, modify, or create derivative works from the Service. Disclaimers. AHIMA programs and services are provided on an "as is" and "as available" basis, with all faults. Neither AHIMA nor any person associated with AHIMA makes any warranty or representation with respect to the quality, accuracy or availability of the AHIMA programs or programs and services. Except as expressly stated herein, AHIMA disclaims all warranties, conditions, representations, indemnities and guarantees with respect to the AHIMA programs and programs and services, all components thereof whether express or implied, arising by law, custom or prior oral or written statements made by AHIMA, its representatives, third parties or otherwise, including but not limited to, the warranties or merchantability and fitness for a particular purpose. Further, the warranties stated above will not apply to the extent that there has been (A) use of the AHIMA programs in a manner for which it was not intended; or (B) modification of the AHIMA programs by anyone other than AHIMA. AHIMA does not warrant uninterrupted or error-free operation of the AHIMA programs, that AHIMA will correct all defects or that installation or operation of the AHIMA programs will not affect other software of systems of the user. Limitation of Liability. Except with respect to obligations under the indemnification section of this agreement, neither party will not be liable for any consequential, exemplary, incidental, indirect, or special damages or costs including, but not limited to, lost profits or loss of goodwill, resulting from any claim or cause of action based upon breach of warranty, breach of contract, negligence, strict liability, product liability, or any other legal theory, even if advised or should have known of the possibility thereof. Each party s maximum liability for direct damages is limited to the total fees paid and payable to AHIMA under this agreement during the then current term during which the incident that gave rise to the claim occurred. i

3 Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. CPT five digit codes, nomenclature, and other data are copyright 2012 by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. As a provider of continuing education the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: (1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation; (2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and (3) if the presentation will include discussion of investigational or unlabeled uses of a product. The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments. This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner. The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation. AHIMA 2012 Audio Seminar Series American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois ii

4 Disclaimer Document Usage Rights This document is exclusively for use by individuals attending the associated audio seminar or webinar (named on the first page of this document), in conjunction with their attendance of the live or recorded version of the presentation. All material herein is copyright 2012 American Health Information Management Association (AHIMA), except where otherwise noted. It may not be redistributed without prior written permission from AHIMA. AHIMA 2012 Audio Seminar Series American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois iii

5 Faculty Tammy R. Love, RHIA, CDIP, CCS, is manager of Inpatient Coding and Clinical Documentation Improvement at UAMS Medical Center in Little Rock, AR. Ms. Love has over 18 years experience in HIM in numerous coding management, compliance, and operational positions with emphasis on coding quality as it relates to compliant coding and capturing complete and accurate data for quality reporting purposes. She is also an AHIMA-approved ICD- 10-CM/PCS trainer AHIMA 2012 Audio Seminar Series American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois iv

6 Table of Contents AHIMA Audio Seminar/Webinar Terms of Use Agreement... i Disclaimer... ii Document Usage Rights... iii ICD-10-CM and ICD-10-PCS: Getting Started... 1 The New Coding Systems... 1 Regulatory Requirements... 2 Uses of Coded Data Evolving Healthcare data Needs... 3 Why Replace ICD-9-CM?... 4 Benefits of Adoption of New Coding Systems... 4 ICD-10-CM/PCS Significant Improvements... 5 ICD-10-CM/PCS Designed for the 21 st Century... 5 Applicable Code Sets 10/1/ ICD-10:CM and PCS... 6 Code Set Freeze... 7 What is ICD-10-CM?... 7 ICD-9-CM Structure - Format... 8 ICD-10-CM Structure - Format... 8 ICD-10-CM: Similarities to ICD-9-CM ICD-10-CM: Differences to ICD-9-CM ICD-10-CM New Features Combination Codes - Examples ICD-10-CM Laterality Examples ICD-10-CM Injury Changes ICD-10-CM: Differences to ICD-9-CM ICD-10-CM 7 th Character: Injuries & External Causes ICD-10-CM 7 th Character: Fractures Diagnosis Code Comparison What is ICD-10-PCS? Procedure Code Structure ICD-10-PCS System Attributes ICD-10-PCS Code Structure ICD-10-PCS General Principles Building an ICD-10-PCS Code Procedure Code Comparison Who Must Be Compliant? Non Covered Entities ICD-10-13\PCS Facts vs. Myths Healthcare Impact The Impact Impact of Coding System Change (CONTINUED) AHIMA 2012 Audio Seminar Series American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois v

7 Table of Contents Impact Inpatient Facilities What Processes Will Be Impacted? System Impact Staff Impact Financial Impact Documentation Impact Documentation Impact ICD-10-CM Documentation Impact ICD-10-PCS Clinical Documentation Improvement (CDI) Impact Provider Impact Physician Impact Physician Impact Office Physician Impact Hospital Impact Other Healthcare Providers Health Information Management Impact HIM Impact Data Impact Data Trending Challenges Data Concept Differences Terminology Differences ICD-10-CM Terminology Differences ICD-10-PCS Reports Inventory and Conversion General Equivalence Mapping (GEMs) What are GEMs? ICD-9-CM and ICD-10-CM/PCS are Different Languages Mapping Facts Direct Conversion ICD-10 GEMs Why Do We Need GEMs? Direct Conversion versus Applied Mappings Applied Mappings Transition Plan Transition Opportunities and Challenges Consequences of Poor Preparation Advance Preparation Websites Resources Available Resources & References Free ICD JAHIMA and e-newsletters Publications (CONTINUED) AHIMA 2012 Audio Seminar Series vi American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois

8 Table of Contents e-learning and e-assessments (AHIMA Distance Education) Thank You Thank You/Evaluation Form and CE Certificate (Web Address) Appendix CE Certificate Instructions AHIMA 2012 Audio Seminar Series American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois vii

9 ICD-10-CM and ICD-10-PCS: Getting Started THE NEW CODING SYSTEMS AHIMA 2012 Audio Seminar Series 1

10 Regulatory Requirements In 2000, HIPAA established electronic transaction and code set standards ICD-9-CM the current standard January, 2009 Final Rule August, 2012 One year delay ICD-10-CM and ICD-10-PCS are replacing the ICD-9-CM code set, effective Uses of Coded Data Measuring quality, safety, efficacy of care Designing payment systems Processing claims for reimbursement Conducting research, epidemiological studies, clinical trials Setting health policy Monitoring resource utilization 4 AHIMA 2012 Audio Seminar Series 2

11 Uses of Coded Data Operational and strategic planning Designing healthcare delivery systems Improving clinical, financial, and administrative performance Preventing and detecting healthcare fraud and abuse Tracking public health and risks 5 Evolving Healthcare Data Needs Greater demand for more specific data since ICD-9-CM implementation Coded data are used in multiple healthcare settings Coded data are essential component of multiple reimbursement systems 6 AHIMA 2012 Audio Seminar Series 3

12 Why Replace ICD-9-CM? Does not support today s healthcare needs No longer fits 21 st century healthcare Does not fulfill the need for accurate and complete healthcare data 7 Benefits of Adoption of New Coding Systems Improvements in: Data quality Consistency of coding Ability to trend and analyze healthcare costs Quality, safety, and efficacy of patient care Public health and bioterrorism surveillance Health policy decision-making 8 AHIMA 2012 Audio Seminar Series 4

13 ICD-10-CM/PCS Significant Improvements Greater specificity and clinical detail Enhanced system flexibility Better reflection of current medical knowledge Incorporation of recommended revisions to ICD-9-CM that could not be accommodated 9 ICD-10-CM/PCS Designed for the 21 st Century ICD-10-CM and PCS are more amenable to the use of computer technology in all areas Electronic health records Computer-assisted coding Electronic claims processing Data exchange Data analysis 10 AHIMA 2012 Audio Seminar Series 5

14 Applicable Code Sets 10/1/2014 Physician ICD-10-CM CPT / HCPCS All Others ICD-10-CM CPT / HCPCS Hospital Inpatient ICD-10-CM ICD-10-PCS Outpatient ICD-10-CM CPT / HCPCS Long Term Healthcare ICD-10-CM CPT / HCPCS Behavioral Health ICD-10-CM CPT / HCPCS Laboratory ICD-10-CM CPT / HCPCS 11 ICD-10: CM and PCS ICD-9 Diagnosis Codes (CM) ICD-10 ICD-9 Procedure Codes (PCS) ICD-10 71, AHIMA 2012 Audio Seminar Series 6

15 Code Set Freeze 10/1/11 Last regular annual updates ICD-9-CM and ICD-10-CM/PCS 10/1/12 Limited code updates ICD-9- CM and ICD-10-CM/PCS New technologies and diseases 10/1/13 Limited code updates ICD-9- CM and ICD-10-CM/PCS New technologies and diseases 10/1/14 10/1/15 Limited code updates ICD-10- CM/PCS New technologies and diseases Regular updates to ICD-10- CM/PCS 13 What is ICD-10-CM? Based on ICD-10 published by the World Health Organization (WHO) used for mortality coding in the U.S. NCHS developed ICD-10-CM and guidelines ICD-10-CM is used for morbidity classification ICD-10-CM in public domain, however cannot be altered except through the Coordination and Maintenance Committee process 14 AHIMA 2012 Audio Seminar Series 7

16 ICD-9-CM Structure Format Numeric or Alpha (E or V) Numeric X V4 5E X1 X4. X0 X0 Category Etiology, anatomic site, manifestation 3 5 Characters 15 ICD-10-CM Structure Format Alpha (Except U) 2 Always Numeric 3-7 Numeric or Alpha Additional Characters. XAMS X3 X2. X0 X1 X0 XA Category Etiology, anatomic site, severity 3 7 Characters Added code extensions (7 th character) for obstetrics, injuries, and external causes of injury 16 AHIMA 2012 Audio Seminar Series 8

17 ICD-10-CM: Similarities to ICD-9-CM Format Tabular List and Index Chapters in Tabular structured similarly to ICD-9-CM, with minor exceptions A few chapters have been restructured Sense organs (eye and ear) separated from Nervous System chapter and moved to their own chapters Index structured the same as ICD-9-CM Alphabetic Index of Diseases and Injuries Alphabetic Index of External Causes Table of Neoplasms Table of Drugs and Chemicals 17 ICD-10-CM: Similarities to ICD-9-CM Divided into Alphabetic Index and Tabular List Structure and format are the same Index is alphabetical list of terms and their corresponding codes Alphabetic Index lists main terms in alphabetical order with indented subterms under main terms Index is divided into 2 parts: Index to Diseases and Injuries and Index to External Causes 18 AHIMA 2012 Audio Seminar Series 9

18 ICD-10-CM: Similarities to ICD-9-CM Tabular List is a chronological list of codes divided into chapters based on body system or condition Tabular List is presented in code number order Same hierarchical structure Codes are invalid if they are missing an applicable character Codes are looked up the same way Look up diagnostic terms in Alphabetic Index Then verify code number in Tabular List 19 ICD-10-CM: Similarities to ICD-9-CM Many conventions have same meaning Abbreviations, punctuation, symbols, notes such as code first and use additional code Non-specific codes ( unspecified or not otherwise specified ) are available to use when detailed documentation to support more specific code is not available 20 AHIMA 2012 Audio Seminar Series 10

19 ICD-10-CM: Similarities to ICD-9-CM ICD-10-CM Official Guidelines for Coding and Reporting accompany and complement ICD-10-CM conventions and instructions Adherence to the official coding guidelines in all healthcare settings is required under HIPAA 21 ICD-10-CM: Differences from ICD-9-CM All codes are alphanumeric (not casesensitive) Codes can be up to 7 characters in length Some chapters restructured Certain diseases reclassified to reflect current medical knowledge Specificity and detail significantly expanded 22 AHIMA 2012 Audio Seminar Series 11

20 ICD-10-CM: Differences from ICD-9-CM Code titles are more complete (no need to refer back to a category, subcategory, or subclassification level to determine complete meaning of code) New features added 23 ICD-10-CM New Features Combination codes for conditions and common symptoms or manifestations Combination codes for poisonings and external causes Added laterality Expanded codes (injury, diabetes, alcohol/substance abuse, postoperative complications) Injuries grouped by anatomical site rather than injury category 24 AHIMA 2012 Audio Seminar Series 12

21 Combination Codes Examples I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema K71.51 Toxic liver disease with chronic active hepatitis with ascites K Crohn s disease of small intestine with intestinal obstruction 25 ICD-10-CM Laterality Examples C Malignant neoplasm of lower-outer quadrant of right female breast C Malignant neoplasm of lower-outer quadrant of left female breast C Malignant neoplasm of lower-outer quadrant of unspecified female breast 26 AHIMA 2012 Audio Seminar Series 13

22 ICD-10-CM Injury Changes ICD-9-CM Fractures ( ) Dislocations ( ) Sprains and strains ( ) ICD-10-CM Injuries to the head (S00-S09) Injuries to the neck (S10-S19) Injuries to the thorax (S20-S29) 27 ICD-10-CM: Differences from ICD-9-CM Addition of 7 th character Used in certain chapters to provide information about the characteristic of the encounter Must always be used in the 7 th character position If a code has an applicable 7 th character, the code must be reported with an appropriate 7 th character value in order to be valid 28 AHIMA 2012 Audio Seminar Series 14

23 ICD-10-CM 7 th Character: Injuries & External Causes A Initial encounter D Subsequent encounter S Sequela Note: For aftercare of an injury, assign acute injury code with 7 th character D 29 ICD-10-CM 7 th Character: Fractures A Initial encounter for closed fracture B Initial encounter for open fracture D Subsequent encounter for fracture with routine healing G Subsequent encounter for fracture with delayed healing K Subsequent encounter for fracture with nonunion P Subsequent encounter for fracture with malunion S Sequela 30 AHIMA 2012 Audio Seminar Series 15

24 Diagnosis Code Comparison ICD-9-CM ICD-10-CM Consists of 3 to 5 digits Consists of 3 to 7 characters 1st digit is numeric or alpha, using E or V 1 st character is alpha, using all letters except U 2 nd digit is numeric 2 nd Character is numeric 3 rd, 4 th, and 5 th digits are numeric Always at least 3 digits Decimal place after the first 3 digits Alpha characters are not case sensitive 3 rd to 7 th Characters can be alpha or numeric Always at least 3 characters Decimal place after the first 3 characters Alpha characters are not case sensitive 31 What is ICD-10-PCS? ICD-10 (international version) does not contain a procedure coding system CMS awarded a contract to 3M Health Information Systems to develop a new procedure coding system The new system is intended to replace ICD-9-CM Volume 3 for reporting inpatient procedures CPT and HCPCS will still be used where currently in place 32 AHIMA 2012 Audio Seminar Series 16

25 Procedure Code Structure ICD-9-CM Procedures ICD-10-PCS D B 5 8 Z X 33 ICD-10-PCS System Attributes Completeness All substantially different procedures have a unique code Expandability The structure of the system allow incorporation of new procedures as unique codes 34 AHIMA 2012 Audio Seminar Series 17

26 ICD-10-PCS System Attributes Standardized terminology Includes definitions of the terminology used (Definitions may vary from common usage) Multiaxial structure Each character has the same meaning within a section and across sections to the extent possible 35 ICD-10-PCS Code Structure Codes comprised of seven components, called characters Individual units for each character have a letter or number assigned as a value 34 possible values: Digits 0-9 Letters A-H, J-N, and P-Z No I or O 36 AHIMA 2012 Audio Seminar Series 18

27 ICD-10-PCS Code Structure Section Root Operation Approach Qualifier Body System Body Part Device 37 ICD-10-PCS General Principles Diagnostic information not included in code description Device value has an other value to allow for new devices and substances Not Elsewhere Classified options limited 38 AHIMA 2012 Audio Seminar Series 19

28 Building an ICD-10-PCS Code Index provides first 3 characters of code, associated with a code table Table is referenced to build the last 4 characters of the code Table arranged in rows to allow only valid character combinations 39 Building an ICD-10-PCS Code Resection of nasal turbinate 09TL7ZZ 40 AHIMA 2012 Audio Seminar Series 20

29 Procedure Code Comparison ICD-9-CM Procedures ICD-10-PCS 3-4 digits All digits are numerical Numerical by body system Decimal after 2 digits 7 characters Characters are both numerical and alpha Each character has a specific value. A character (0) in a different position has a different value/meaning No decimals 41 Who Must be Compliant? Hospitals Medical Devices Physicians HIE/RHIO Outpatient Facilities CDC ICD-10 CM /PCS Compliant Home Health Agencies State Medicaid Programs Home Medical Equip. Health plans & payors Reference Labs 42 AHIMA 2012 Audio Seminar Series 21

30 Non-Covered Entities Workers Compensation Auto Insurance Disability Insurance plans Quality Measures Reporting National Quality Forum (NQF) National Committee for Quality Assurance (NCQA) HEDIS 43 ICD-10-CM/PCS Facts vs. Myths Myth: The Oct. 1, 2014 date for implementation should be considered a flexible date Fact: All HIPAA covered entities MUST implement the new code sets with dates of service, or date of discharge for inpatients, that occur on or after Oct. 1, AHIMA 2012 Audio Seminar Series 22

31 ICD-10-CM/PCS Facts vs. Myths Myth: There will be no hard-copy code books and all coding will need to be performed electronically. Fact: ICD-10-CM and ICD-10-PCS code books are already available and are a manageable size. The use of ICD-10-CM is not predicated on the use of electronic hardware and software. 45 ICD-10-CM/PCS Facts vs. Myths Myth: Unnecessarily detailed medical record documentation will be required. Fact: As with ICD-9-CM, ICD-10 codes should be based on medical record documentation. While documentation supporting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use when documentation doesn t support a higher level of specificity. As demonstrated by the American Hospital Association/AHIMA field testing study, much of the detail contained in ICD-10-CM is already in medical record documentation but is not currently needed for ICD-9-CM coding. 46 AHIMA 2012 Audio Seminar Series 23

32 ICD-10-CM/PCS Facts vs. Myths Myth: The increased number of codes will make ICD-10-CM/PCS impossible to use. Fact #1: Just as the size of a dictionary doesn t make it more difficult to use, a higher number of codes doesn t necessarily increase the complexity of the coding system in fact, it makes it easier to find the right code. Fact #2: Greater specificity and clinical accuracy make ICD- 10-CM/PCS easier to use than ICD-9-CM. Fact #3: Because ICD-10-CM/PCS is much more specific, is more clinically accurate, and uses a more logical structure, it is much easier to use than ICD-9-CM. 47 ICD-10-CM/PCS Facts vs. Myths Myth: The increased number of codes will make ICD-10-CM/PCS impossible to use. Fact #4 : Just as it isn t necessary to search the entire list of ICD-9-CM codes for the proper code, it is also not necessary to conduct searches of the entire list of ICD-10 codes. Fact #5: The Alphabetic Index and electronic coding tools will continue to facilitate proper code selection. Fact #6: It is anticipated that the improved structure and specificity of ICD-10-CM/PCS will facilitate the development of increasingly sophisticated electronic coding tools that will assist in faster code selection. 48 AHIMA 2012 Audio Seminar Series 24

33 HEALTHCARE IMPACT 49 The Impact Diagnosis and procedure codes impact virtually every system and business process in the provider organization, with potentially significant impacts on reimbursement Competing initiatives with similar timeframes make prioritizing far more difficult 50 AHIMA 2012 Audio Seminar Series 25

34 Impact of Coding System Change Coded data are more widely used than when the US transitioned to ICD-9-CM Variety of data users requires varying levels of system training More sophisticated computer-assisted coding technologies will revolutionize the coding process 51 Impact of Coding System Change Increased detail in new coding systems will allow improved coding specificity, BUT this depends on: Coding professionals possessing a greater understanding of anatomy and physiology than is necessary for ICD-9- CM coding High-quality medical record documentation 52 AHIMA 2012 Audio Seminar Series 26

35 Impact of Coding System Change Detailed medical record documentation means: higher coding specificity higher data quality BUT Non-specific codes can still be assigned when detailed documentation is not available 53 Impact of Coding System Change Presents both opportunities and challenges Scope and complexity of changes are significant ICD-10-CM/PCS transition affects many systems, processes, and people 54 AHIMA 2012 Audio Seminar Series 27

36 Impact Inpatient Facilities Required to use ICD-10-CM and ICD-10-PCS Potentially have the most system changes Will, however, see added detail: to identify severity to identify new technologies and medical procedures that currently can only be identified in a claims attachment or other post-billing communication Will not experience an immediate change to CMS payment systems 55 What Processes will be Impacted? DRG conversion Conversion of other payment methodologies dependent on diagnosis/procedure codes National and local coverage determinations System logic and edits (e.g., medical necessity) Provider profiling Quality measurement Utilization management Disease management Fraud management Aggregate data reporting 56 AHIMA 2012 Audio Seminar Series 28

37 Systems Impact All systems using ICD-10-CM and PCS Field lengths (codes and descriptions) Alphanumeric characters Processing logic Ability to accommodate both ICD-9-CM and ICD-10-CM/PCS simultaneously Don t forget clinical technology 57 Staffing Impact Need for workflow and process analysis staff to complete the transition Need for additional coders during and after transition Training of coding professionals and other users Current coding professionals Students in HIM and coding programs Users other than coding professionals 58 AHIMA 2012 Audio Seminar Series 29

38 Financial Impact Transition costs Hardware upgrades Software upgrades Training costs $ Hundreds per provider $ Thousands per coder Reimbursement unknowns MS-DRGs changes 59 DOCUMENTATION IMPACT 60 AHIMA 2012 Audio Seminar Series 30

39 Documentation Impact ICD-10-CM Clinical documentation will need greater specificity Not more, just more detail Link complication to specific disease process Laterality and detailed locations Episode of care for all injuries Gustilo Classification for open fractures (specified on lower leg, forearm, and femur only) Trimester for Obstetrics Unspecified categories may impact reimbursement 61 Documentation Impact ICD-10-PCS Documentation specificity Type of device using PCS categories Genetic source of all grafts and transplants Contrast type on all imaging procedures Exact venous location of blood transfusion Very few unspecified codes Detail required for even the most common procedures 62 AHIMA 2012 Audio Seminar Series 31

40 Clinical Documentation Improvement (CDI) Impact Strong CDI program will ease the transition A mature program will: Reduce the stress on staff and providers Mitigate risk of poor audit outcomes Easily implement identified improvement needs Strengthen a weak program If no current program, start now 63 PROVIDER IMPACT 64 AHIMA 2012 Audio Seminar Series 32

41 Physician Impact ICD-10-CM includes current clinical groupings: Epilepsy Diabetes Asthma Myocardial infarction Arteries instead of heart walls Provide meaningful data on patient care and severity 65 Physician Impact - Office Learning changes to commonly used codes will ease transition Common ICD-9-CM code categories remain Create new superbill or EMR pick list of ICD-10-CM codes in same categories Complete training of staff Expect some increased documentation time Assure IT readiness to convert 66 AHIMA 2012 Audio Seminar Series 33

42 Physician Impact - Hospital ICD-10-CM Documentation must support coding Work with CDI staff and/or HIM coders View queries as learning opportunities Ask for EHR template or paper form changes, if necessary Volunteer to share clinical knowledge with the CDI and coding team 67 Physician Impact - Hospital ICD-10-PCS Documentation supports facility coding of procedures (CPT/HCPCS still in use for professional fee and hospital outpatient reimbursement) Coders faced with completely new terminology Coders need to know HOW it was done System organized and specific Will see more queries for ICD-10-PCS than with ICD-9-CM procedures 68 AHIMA 2012 Audio Seminar Series 34

43 Impact Other Healthcare Providers Other non-inpatient organizations will only use ICD-10-CM, NOT ICD-10-PCS Independent laboratories Independent radiology Therapy providers Long term care Home care CPT will continue to be used for Part B providers where it is used now 69 HEALTH INFORMATION MANAGEMENT IMPACT 70 AHIMA 2012 Audio Seminar Series 35

44 HIM Impact Recognize uncertainty about the changes and training plans Communicate, communicate. Informed workforce works toward a common goal 71 HIM Impact Decrease in productivity is a reality Not all people learn alike - flexible training methods may be necessary Visual style Auditory style Kinesthetic style 72 AHIMA 2012 Audio Seminar Series 36

45 HIM Impact Super-coders as internal Go-To s Job Enrichment Subject specialists Possible need for cross-trained coders Procedure knowledge of CPT very helpful in learning PCS Coders may want to change or increase their roles 73 HIM Impact Seize the opportunity to build a bridge with physicians: Reciprocity of knowledge Coders need increased clinical knowledge Physicians need to understand PCS terminology Data requests based on new terminology Not required to use terminology in documentation but need to know concepts 74 AHIMA 2012 Audio Seminar Series 37

46 HIM Impact More denials until both providers and payers are proficient in new system Reimbursement impact said to be neutral at first but no guarantees Specificity in principal diagnosis, MCC, CC or procedures could change MS-DRG grouping or the severity level 75 DATA IMPACT 76 AHIMA 2012 Audio Seminar Series 38

47 Data Impact Changes to multiple information systems and applications Increased system storage capacity Redesign of reports and forms Modification of patient assessment data sets Data trending challenges 77 Data Trending Challenges Differences in code sets go beyond changes in code titles or level of specificity Terminology, definitions, meaning of code, or instructions for code assignment may have changed When linking coded data, differences need to be reconciled Method used to reconcile differences may vary Flawed decisions may be made due to reliance on distorted, inaccurate, or misinterpreted data or comparability problems Caution should be exercised when interpreting data across transition 78 AHIMA 2012 Audio Seminar Series 39

48 Data Concept Differences Myocardial Infarction Abortion vs. Fetal Death Obstetrics 8 weeks, episode of care (ICD-9-CM) 4 weeks, no episode of care (ICD-10-CM) 22 weeks (ICD-9-CM) 20 weeks (ICD-10-CM) Episode of care (ICD-9-CM) Trimester (ICD-10-CM) 79 Terminology Differences ICD-10-CM 80 AHIMA 2012 Audio Seminar Series 40

49 Terminology Differences ICD-10-CM ICD-9-CM Fractures: open; closed ICD-10-CM Open; closed; Salter-Harris Types I, II, III, and IV; LeFort I, II, and III; avulsion; wedge compression; stable and unstable burst; Zone I, II, and III; Barton s; Smith s; greenstick; transverse; oblique; spiral; comminuted; segmental; torus; Maisonneuve s; open fracture types I, II, IIIA, IIIB, IIIC; with delayed healing Asthma: extrinsic; intrinsic; chronic obstructive asthma; with status asthmaticus; with (acute) exacerbation; exercise induced bronchospasm; cough variant asthma Mild intermittent; mild persistent; moderate persistent; severe persistent; with status asthmaticus; with (acute) exacerbation; exercise induced bronchospasm; cough variant asthma (chronic obstructive asthma classified to COPD) 81 Terminology Differences ICD-10-PCS Same Terms May Have Different Meaning ICD-9-CM Replacement Excision ICD-10-PCS Insertion + Removal, Replacement, Revision Excision, Destruction, Resection Resection Excision, Resection, Resection + Bypass Incision Repair Drainage, Extirpation, Insertion, Inspection, Removal, Revision Dilation, Reattachment, Release, Repair, Replacement, Reposition, Restriction, Revision, Supplement 82 AHIMA 2012 Audio Seminar Series 41

50 Reports Inventory and Conversion Internal Patient Care Quality & UR Registries Billing & Reimbursement Research Regulatory External Core measures Benchmarking Registries Regulatory HIE State Reporting 83 GENERAL EQUIVALENCE MAPS (GEMS) 84 AHIMA 2012 Audio Seminar Series 42

51 What are GEMs? GEMs General Equivalence Maps Attempt to find equivalent codes between two code sets Relationship is not always that easy to establish Not a simple crosswalk 85 ICD-9-CM and ICD-10-CM/ PCS are Different Languages Codes are language of healthcare ICD-9-CM and ICD-10-CM/PCS are different languages 30-year generation gap between ICD-9-CM and ICD-10-CM/PCS ICD-10-CM/PCS reflect the current understanding and practice of medicine General Equivalence Mappings (GEMs) bridge the language gap between ICD-9- CM and ICD-10-CM/PCS 86 AHIMA 2012 Audio Seminar Series 43

52 Mapping Facts GEMs developed as a general purpose translation tool For use by all providers, payers, and data users Created by CDC and CMS to ensure that consistency in national data is maintained after transition Free of charge and in public domain 87 Mapping Facts Mapping not the same as coding Mapping links concepts in 2 code sets without consideration of patient medical record information Coding involves assignment of most appropriate code Based on medical record documentation Applicable coding GEMs should not be used for coding medical records rules/guidelines 88 AHIMA 2012 Audio Seminar Series 44

53 Mapping Facts GEMs designed as a starting point foundation upon which applied mappings can be built Impossible to produce a one size fits all map GEMs can be refined based on use case of map to develop applied mappings Applied mappings can resolve mapping conflicts and narrow the possible choices in target code set by implementing set of userdefined criteria 89 Mapping Facts GEMs designed to aid in converting applications and systems from ICD-9-CM to ICD-10-CM/PCS GEMs can be used to convert multiple databases from ICD-9-CM to ICD-10-CM/PCS, including: Payment systems Payment and coverage edits Risk adjustment logic Quality measures Disease management programs Financial modeling Variety of research applications involving trend data 90 AHIMA 2012 Audio Seminar Series 45

54 Direct Conversion Large - reimbursement system GEMs can be used in any size and type of conversion project Not all conversions require use of GEMs Medium - lengthy, complex document containing multiple references to ICD-9- CM codes Small - single research study 91 ICD-10 GEMs Consists of four GEM files with documentation and annual updates at the end of the year Source Target A.K.A. From ICD-9-CM To ICD-10-CM Forward mapping From ICD-10-CM To ICD-9-CM Backward mapping 92 AHIMA 2012 Audio Seminar Series 46

55 Why do we need GEMs? To navigate multiple translation alternatives There may be multiple translation alternatives for a source system code, all of which are equally plausible Some translation projects require that you pick one best alternative 93 Why do we need GEMs? To manage complex translations Some concepts expressed by one ICD-10-CM/ PCS code need more than one ICD-9-CM code for complete translation And vice versa some concepts expressed by one ICD-9-CM code need more than one ICD-10- CM/ PCS code for complete translation 94 AHIMA 2012 Audio Seminar Series 47

56 Why do we need GEMs? To identify untranslatable ICD-10-CM/ PCS codes ICD-10-CM/PCS capture types of information not translatable to ICD-9-CM 95 Direct Conversion versus Applied Mappings Direct Conversion No direct link Can benefit from GEMs Applied Mapping Direct link GEMs used in development 96 AHIMA 2012 Audio Seminar Series 48

57 Applied Mapping Single one-to-one mapping cannot serve all purposes Applied mappings use GEMs as starting point Goal is to produce best one-to-one translation for a specific purpose One listed mapping alternative does not mean linked codes have identical meanings Might be useful in Revenue cycle impact analysis Quality measurement Claims adjudication Utilization review policy assessments 97 Applied Mappings GEMs vs. Reimbursement Mappings GEMs are a comprehensive, bidirectional translation dictionary Reimbursement map is an applied map developed in response to non-medicare industry requests for standard one-to-one reimbursement crosswalk 98 AHIMA 2012 Audio Seminar Series 49

58 Applied Mappings GEMs vs. Reimbursement Mappings Temporary mechanism for mapping ICD- 10-CM/PCS codes back to reimbursement equivalent in ICD-9-CM codes CMS not currently using Reimbursement Mappings for any purpose CMS provides a Reimbursement Mapping Guide at: ads/2011_reimbursement_mapping_user_guide.pdf 99 TRANSITION PLANNING 100 AHIMA 2012 Audio Seminar Series 50

59 Transition Opportunities and Challenges Scope and complexity are significant More widespread use of coded data than when US last transitioned (to ICD-9-CM) Data trending challenges likely 101 Consequences of Poor Preparation Increased claims rejections and denials Increased delays in processing authorizations and reimbursement claims Improper claims payment Coding backlogs Compliance issues Decisions based on inaccurate data 102 AHIMA 2012 Audio Seminar Series 51

60 Advance Preparation Potential problems during initial transition period can be mitigated with proper advance preparation Impact analysis Implementation planning Thorough training 103 Websites AHIMA ICD-10 Preparation Checklist Role Based Training Plans Implementation Planning Audio Presentations Centers for Medicare and Medicaid Services Overview National Center for Health Statistics CDC ICD-10-CM AHIMA 2012 Audio Seminar Series 52

61 Websites CMS HIPAA Website ICD-10 and HIPAA Federal Register Notices Workforce for Electronic Data Exchange ICD10 Watch 3M RESOURCES AVAILABLE 106 AHIMA 2012 Audio Seminar Series 53

62 Resources & References Butler, Rhonda. The ICD-10 General Equivalence Mappings: Bridging the Translation Gap for ICD-9. Journal of AHIMA 78, no. 9 (October 2007): CMS Fact Sheet, General Equivalence Mappings, (May 2009). ICD-10: A Roadmap for Success; Caroline R. Piselli, RN, MBA, FACHE, HIMSS Virtual Conference, 11/3/ Resources & References American Medical Association ICD-10 Checklist: assn.org/ama1/pub/upload/mm/399/icd10- checklist.pdf American Medical Association Implementation Project Plan Template assn.org/ama1/pub/upload/mm/399/icd-10- project-plan-template.xls 108 AHIMA 2012 Audio Seminar Series 54

63 Free ICD-10 Tools for Planning and Impact Analysis ICD-10 Readiness Assessment and Prioritization Tool ICD-10-CM/PCS Transition: Planning & Preparation Checklist ICD-10 Top Ten List: Phase 1 ICD-10 Vendor Questionnaire Clinical Documentation Improvement Toolkit Role-based Training Model for ICD-10 Implementation 109 Free ICD-10 Practical Guidance available in the AHIMA Body of Knowledge Planning Organizational Transition to ICD-10-CM/PCS 5010 and ICD-10 Planning & Implementation Survey Results Putting the ICD-10-CM/PCS GEMs into Practice ICD-10's Impact on Noncovered Entities Guidance for Clinical Documentation Improvement Programs Transitioning to ICD-10-CM/PCS An Academic Timeline EXTENSIVE RESOURCES AVAILABLE ON ICD-10-CM/PCS web_assets/ bok_home.hcsp 110 AHIMA 2012 Audio Seminar Series 55

64 JAHIMA and e-newsletters JAHIMA ICD-TEN Newsletter CodeWrite Advantage AHIMA Resources Publications Pocket Guide of ICD-10-CM and ICD-10-PCS Implementing ICD-10-CM/PCS for Hospitals: A Project Guide and Toolkit ICD-10-CM/PCS Preview Exercises Root Operations: Key to Procedure Coding in ICD- 10-PCS ICD-10-CM and ICD-10-PCS Coder Training Manuals AHIMA 2012 Audio Seminar Series 56

65 Publications Clinical Documentation Improvement: Achieving Excellence Transitioning to ICD-10-CM/PCS: The Essential Guide to GEMS Basic ICD-9-CM Coding (transitioning to ICD-10) ICD-10-PCS: An Applied Approach e-learning and e-assessments Distance Education Refreshing & Assessing A&P Skills Coding Basics: A&P*, Medical Terminology*, Pharmacology* Preparing for ICD-10 A&P Focus courses: Musculoskeletal, Nervous System, Cardiovascular, OB, Neoplasms, and Diseases of Respiratory System Clinical Concepts for Coders *College credit 114 AHIMA 2012 Audio Seminar Series 57

66 e-learning and e-assessments Distance Education ICD-10-CM/PCS Assessments ICD-10-CM/PCS Fundamentals of GEMS Deciphering the Code: ICD-10-CM and ICD- 10-PCS Clinical Documentation Improvement in Preparation for ICD-10-CM/PCS Audio seminars on ICD-10-CM/PCS Thank you! American Health Information Management Association 233 N. Michigan Ave, 21 st Floor Chicago, Illinois AHIMA 2012 Audio Seminar Series 58

67 Appendix CE Certificate Instructions AHIMA 2012 Audio Seminar Series 59

68 To receive your CE Certificate Please go to the AHIMA Web site click on the link to Sign In and Complete Online Evaluation listed for this seminar. You will be automatically linked to the CE certificate for this seminar after completing the evaluation. Each person seeking CE credit must complete the mandatory self-assessment which can be found in the appendix of the resource materials, as well as complete the sign-in form and evaluation to view and print their CE certificate.