ICD-10 : The Basics for Health Plans and Payers Congratulations! You are a forward thinker. You are concerned with the future. The knowledge you receive today will provide you with the opportunity to become a leader and a change agent. 2 1
Goal This presentation will provide an overview of ICD-10 CM and ICD-10-PCS and assist in you determining the impact that these codes will have to your business area. It s not to soon to prepare for ICD-10!! 3 Outline Diagnosis i and Procedure Coding ICD-10-CM and ICD-10-PCS Next steps for YOU!! 4 2
Proposed Rule for the Adoption of ICD-10-CM /PCS Proposed rule was published August 2008 Proposed ICD-10 implementation October 1, 2011 AAPC, AMA, Medical Societies and others aggressively pushed back the proposed date. 5 Final Rule for the Adoption of ICD-10- CM & ICD-10-PCS -CMS-0013-F January 15, 2009 HHS released the final regulation The final rule was expected to undergo Congressional review until March 16, 2009 Compliance Date - October 1, 2013(no delay!!) 6 3
ICD-10 Final Rule CMS-0013-F X12 Version 5010 & NCPDP Version D.0 transactions Compliance date is January 1, 2012 No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes http://edocket.access.gpo.gov/2009/pdf/e9-743.pdf 7 ICD-10 Final Rule Issues Single implementation date for all users Date of service for ambulatory and physician reporting Date of discharge for inpatient settings ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013 ICD-9-CM claims for services prior to implementation date will continue to flow through systems for a period of time 4010 electronic transaction standard to 5010 January 1, 2012 8 4
ICD - What is It? Acronym - International Classification of Disease ICD is a standard used throughout the world for: Classification of causes of mortality (death records) For morbidity statistics Setting medical policy Records and Surveys Health Care Claims As the basis for some prospective payment systems 9 ICD in the United States We currently use the ICD-9-CM system in the US International Classification of Diseases, Ninth Edition, Clinical Modification Two main divisions ICD-9-CM Diagnosis Codes ICD-9-CM Procedure Codes 10 5
ICD-9-CM - What Is It? ICD-9-CM CM Diagnosis Codes are used to: Identify symptoms, conditions, problems, complaints or other reasons for the medical service or procedure being provided Translates written information in the patient's chart into a form that can be submitted electronically for reimbursement Hypertension = 401.xx 11 ICD-9-CM - What Is It? ICD-9-CM CM Procedure codes are used to: Identify procedures and services being provided Translates written information in the patient's chart into a form that can be submitted electronically for reimbursement Appendectomy = 47.01 12 6
Why Does ICD- 9 CM Need to Be Replaced? 30 years old Terminology and classification of some conditions are outdated and obsolete Running out of room Increasing lack of specificity Outdated codes produce inaccurate and limited data 13 Why Does ICD- 9 CM Need to be Replaced? Anticipate full benefits of the Electronic Health Record (EHR) can not be achieved without transitioning to ICD-10 Comparison with international data is hindered 14 7
Timeline for ICD-10 4 Phases of Development July 2000, W.H.O. authorized publication of ICD- 10 in 37 languages About 100 countries have implemented ICD-10 UK 1995 France 1997 Australia 1998 Germany 2000 Canada 2001 15 Timeline for ICD-10 USA October 1, 2013 16 8
Organization of ICD-10 CM Comprised of 21 chapters Chapters classify diseases by Organ System Additional special group chapters have been added Diseases of the Eye and Adnexa Diseases of the Ear 17 18 Features of ICD-10 Structural Changes - Chapters Chapter 1 - Infectious Disease Chapter 2 - Neoplasms Chapter 3 - Diseases of the Blood Chapter 4 - Endocrine Chapter 5 - Mental and Behavioral Disorders Chapter 6 - Diseases of the Nervous System Chapter 7 - Diseases of the Eye Chapter 8 - Diseases of the Ear Chapter 9 - Diseases of the Circulatory System Chapter 10 - Diseases of the Respiratory System Chapter 11 - Diseases of the Digestive System Chapter 12 - Diseases of the Skin Chapter 13 - Diseases of the Musculoskeletal System Chapter 14 - Diseases of the Genitourinary System Chapter 15 - Pregnancy Chapter 16 - Conditions of the Perinatal Period Chapter 17 - Congenital Malformations Chapter 18 - Signs, Symptoms and Abnormal Findings Chapter 19 - Injury and Poisonings Chapter 20 - External Causes of Morbidity and Mortality Chapter 21 - Factors Influencing Health Status 9
ICD-9 CM vs. ICD-10 CM Similarities Same hierarchical structure Same conventions/notes/instructions Availability of not otherwise specified and not elsewhere classified options Differences Structural changes Organizational revisions New features 19 ICD-10 CM Format X X X X X X X Category Etiology, Anatomical site, Severity Extension 20 10
Code Set Comparison: Diagnosis Codes ICD-9-CM Diagnosis Codes 3-5 characters in length Approximately 14,000 codes First digit may be alpha (E or V) or numeric. Digits 2-5 are numeric Limited space for new codes Lacks detail Lacks laterality Difficult to analyze data due to nonspecific codes Codes are non-specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries ICD-10-CM Diagnosis Codes 3-7 characters in length Approximately 68,000 codes Digit 1 is alpha; digit 2 and 3 are numeric; digit 4-7 are alpha or numeric Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data between other countries and the United States 21 Example of Greater Specificity Chapter 12 - L00-L99 Diseases of the Skin and Subcutaneous Tissue and Other Diseases of the Skin and Subcutaneous Tissue L89 Decubitus ulcer L89.2 Decubitus ulcer with necrosis of the muscle L89.3 Decubitus ulcer with necrosis of the bone L97.01 Ulcer of the lower limb limited to breakdown L97.12 Ulcer of the lower limb with fat layer exposed, left limb L97.21 Ulcer of the lower limb with necrosis, right limb L98.42 Chronic ulcer of the skin with fat layer exposed L98.44 Chronic ulcer of the skin with necrosis of the bone 22 11
Example of ICD-10 CM Laterality 23 ICD-9 CM 880 Open wound of shoulder and upper arm 880.0 Without mention of complication 880.1 Complicated 880.2 With tendon involvement ICD-10 CM S41.0 Open wound of shoulder S41.01X Laceration without foreign body of shoulder S41.02X Laceration with foreign body of shoulder Final character of the codes indicates laterality Right side is always 1 Left side is always 2 Bilateral is always 3 ICD-10-PCS 24 12
ICD-10-PCS Smart codes: each character in a given code string represents a separate data description set with a specific meaning, and provides additional information Each character can be reported on separately The complete and final code description will have multiple subdescriptions in its final and complete form 1 2 3 4 5 6 7 Section Body System Root Operation Body Part Approach Device Qualifier 25 Code Set Comparison: Procedure Codes ICD-9-CM Procedure Codes 3-5 numbers in length Approximately 3,000 codes Codes are all numeric Based on outdate technology Limited space for new codes Lacks detail Lacks laterality Generic terms of anatomy Lacks description of methodology and approach for procedures Limits DRG assignment Lacks precision to adequately define procedures ICD-10-PCS Procedure Codes 7 alpha numeric characters in length Approximately 87,000 codes Codes are alpha numeric (no use of I and O) Reflects current usage of medical terminology Flexible for adding new codes Very specific Has laterality Detailed anatomical descriptions Provides detailed descriptions of methodology and approaches for surgical procedures Allows DRG definitions to better recognize new technologies and devices Precisely defines procedures with detail regarding body part, approach, any device used and qualifying information 26 13
Example of ICD-10 PCS Code Insertion of a tissue expander vs. Insertion of a tissue expander in the right breast, open approach ICD-9 Procedure Code 85.95 ICD-10-PCS 0HHT0NZ 27 ICD-10-PCS Example: Repair of a fracture, radius w/ internal fixation device ICD-9-CM 79.32 ICD-10-PCS ØPQJØ4Z 1 (Ø) 2 (P) 3 (Q) 4 (J) 5 (Ø) 6 (4) 7 (Z) 28 14
ICD-10-PCS Here is a breakdown of the multi-axial code assignment for the previous example using the code: ØPQJØ4Z 1 Section (such as Medical/Surgical - Ø) 2 Body System (Upper Bones - P) 3 Root Operation (Repair - Q) 4 Body Part (Left Radius - J) 5 Approach (Open - Ø) 6 Device (Internal Fixation Device - 4) 7 Qualifier-(none - Z) 29 Mappings How can we cheat and get from ICD-9 to ICD-10 and from ICD-10 to ICD-9? 30 15
GEMs Files GEMs General Equivalence Mappings Coordinated effort spanning several years and involving the National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS), AHIMA, the American Hospital Association, and 3M Health Information Systems Public domain reference mapping designed to give all sectors of the healthcare industry that use coded data a tool to convert and test systems, link data in long-term clinical studies, develop application- specific mappings, and analyze data collected during the transition period and beyond 31 Sample of ICD-9 to ICD-10 Mapping - 1:1 ICD 9 CM 003.21 Salmonella meningitis ICD 10 CM A02.21 Salmonella meningitis 32 16
Sample of ICD-9 to ICD-10 Mapping ICD 9 CM 250.XX Diabetes mellitus 4 th digit indicates the complication 5 th digit indicates juvenile or adult onset ICD10 CM E08 Diabetes due to an underlying disease E09 Drug or chemical induced Diabetes E10 Type 1 Diabetes E11Type II Diabetes E13 Other specified diabetes mellitus E14 Unspecified 33 Sample of ICD-9 to ICD-10 Mapping ICD 9 CM 010.00 Primary TB infection unspecified exam 010.01 Primary TB infection bacteriological /histological exam not done 010.02 Primary TB infection bacteriological/ histological exam unknown (at the present time) 010.03 Primary TB infection found by microscopy 010.0404 Primary TB infection found by bacterial culture 010.05 Primary TB infection confirmed histologically 010.06 Primary TB infection confirmed by other methods ICD10 CM A15.7 Primary respiratory TB 34 17
Sample of ICD-10 with no ICD-9 Equivalent Mapping ICD 9 CM NA ICD10 CM Z72. 3 Lack of Physical Exercise Z72.4 Inappropriate diet and eating habits Z73.1 Type A behavior pattern Z73.2 Lack of relaxation and leisure 35 HIPAA ICD-10 / ANSI 5010 Overview Today: 4010 Current HIPAA Standard Procedure and Diagnosis Codes Electronic Transaction Version Not capable of handling ICD-10 Today: ICD-9 ICD-9-CM (Diagnosis) 5 digits (e.g. 821.01 Closed Fracture of shaft of femur) ~13,000 unique codes Tomorrow: 5010 Allows for ICD-10 Procedure and Diagnosis Codes in HIPAA Standard d Electronic Transactions Tomorrow: ICD-10 ICD-10-CM (Diagnosis) 6 alphanumeric with qualifier (e.g. S72.344 Displaced spiral fracture of shaft of right femur) ~68,000 unique codes ICD-9-CM (Procedure) 3-5 digits (e.g. 47.01 Laparoscopic appendectomy) ~3,000 unique codes ICD-10 PCS (Procedure) 7 alphanumeric (e.g. ODTJ4ZZ Laparoscopic appendectomy) ~87,000 unique codes 36 18
Timeline for 5010 and ICD-10 01/2008 1/2009 01/2010 01/2011 01/2012 1/2013 10/2013 Implementation Period Testing Period 5010 Timeline NPRM Awareness Final Rule Requirements Assessment System Changes Testing ICD-10 Timeline 37 ICD-10 Overview Key Drivers for Conversion ICD-9 code system is outdated and incapable of sustaining continuous advances in medical knowledge leading to inaccurate, illogical and/or lack of appropriate coding ICD-10 is used in many other countries and there is pressure from the World Health Organization for US to convert Current codes do not capture data relating to factors other than disease affecting health especially important for academic/government researchers Increased specificity could generate better data on procedure and diagnosis trends resulting in improved patient care 38 ICD-10 Industry Implementation Cost Estimate: $$$$$ Five Cost Categories: System Implementation Training Productivity Loss Rework Contract Negotiation Key Impact Points : ICD-10 represents the broadest scope of any ICD revision to date All major business processes will be impacted Potential significant overhaul of IT architecture Industry experts state it is the most significant overhaul of the medical coding system since the advent of computers and could surpass entire HIPAA Transaction and Code Set implementation ICD-10 planning and implementation effort being forecasted to take multiple years Key Potential Benefits: More precise reimbursement Improved benchmarking and quality management Enhanced P4P initiatives Improved public health reporting and health services research 19
AAPC ICD-10 Resources Looking toward the future, the American Academy of Professional Coders (AAPC) is committed to providing you with the tools you need to prepare for this exciting change 39 AAPC ICD-10 Resources Currently under development Reasonable priced training - right training at the right time Health plan and payer webinar on the Organizational Implementation of ICD-10 for Health Plans and Payers A 30,000 ft view outlining implementation steps health plans and payers need to focus on and in what time period for successful implementation of ICD-10CM/PCS by October 2013 40 20
AAPC ICD-10 Resources January 2010 June 2013 3 Day Onsite Implementation Training Content-sequential planning from awareness to deployment, business area assessments, education, budget and communication planning, system design and post compliance monitoring. Distance elearning Implementation Training Content-sequential planning from awareness to deployment, business area assessments, education, budget and communication planning, system design and post compliance monitoring 41 AAPC s ICD-10 Resources 2011-2013 for Health Plans and Payers AAPC National Conference (Nashville) in 2010 2 sessions focused on ICD-10 AAPC National Conference in 2011 4 sessions focused on ICD-10 AAPC National Conference in 2012 and 2013 5 sessions focused on ICD-10 Eight Regional Conferences will be held throughout the country and all sessions will focus on ICD-10-CM and ICD-10-PCS in 2013 42 21
AAPC s ICD-10 Plan For Our Certified Coders ICD-10-CM proficiency testing will begin October 1, 2012 and end September 30, 2014 Every certified coder must take and pass a proficiency i examination on ICD-10-CM to maintain certification Open book 75 question test. Coder may use any resource available to complete examination May take the examination up to two times for a cost of $60.0000 Test is taken on line and is a timed test 43 Resources http://www.aapc.com Valuable resources for health plans and payers http://www.cms.hhs.gov/icd10 Complete list of code sets for ICD-10-CM and ICD-10 PCS; final rule and Official ICD-10-CM Guidelines 44 22
ICD-10 QUESTIONS? 45 23