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ICD-10 Are You Ready to S.W.A.P.

ICD-10 Are You Ready to S.W.A.P. Presented by Kathy A. Montoya Senior Provider Relations Representative. Agenda. Background Volumes ICD 10 CM ICD 10 PCS General Equivalence Mappings Reimbursement Mappings Preparation Steps. Training Objectives. Increase knowledge Identify obstacles

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ICD-10 Are You Ready to S.W.A.P.

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  1. ICD-10 Are You Ready to S.W.A.P. Presented by Kathy A. Montoya Senior Provider Relations Representative

  2. Agenda • Background • Volumes • ICD 10 CM • ICD 10 PCS • General Equivalence Mappings • Reimbursement Mappings • Preparation Steps

  3. Training Objectives • Increase knowledge • Identify obstacles • Get on track for implementation October, 1 2014

  4. Health Insurance Portability and Accountability Act (HIPAA) • Administrative simplification provides standards for • Electronic transmission of claims • Provider identifiers • Privacy • Code set

  5. Why The Change • ICD-9 • Adopted by CMS April 1, 1989 • Produces limited data • Patients’ medical conditions • Hospital inpatient procedures • 30 years old and outdated • Limits new code creation

  6. ICD-10-CM/PCS • Incorporates greater specificity and clinical information • Improves health care service measurement • Helps with refining groupings and reimbursement methodologies

  7. ICD-10-CM/PCS • Enhances ability to do public health surveillance • Decreases need for claims supporting documentation • Updates medical terminology and classification of diseases

  8. ICD-10-CM/PCS • Provides better data for • Claims processing • Making clinical decisions • Identifying fraud and abuse • Conducting research • Comparison of mortality and morbidity

  9. ICD 10 • Department of Health and Human Services • Final regulation January 15, 2009 • October 1, 2014 • Guidance available on • http://www.cms.gov/ICD10/

  10. ICD-9 It’s Not Over Yet • Worker’s compensation • Auto insurance • Not required to convert • Not planning to change

  11. ICD 10 • Developed by • World Health Organization (WHO) • http://www.who.int/classifications/icd/en/. • Utilized in other countries • Mandated for use in U.S. • October 1, 2014

  12. ICD-10 • In use in U.S. • Individual states • Report cause of death on certificates

  13. ICD 10 CM • National Center for Health Statistics (NCHS) • Developed ICD 10 Clinical Modification (CM) for U.S. • In conjunction with advisory group and physicians • Still in DRAFT

  14. ICD-10 General Information

  15. ICD-10 Part 1 • ICD-10-CM for diagnosis coding • All U.S. health care setting • 3 – 7 digit alphanumeric codes • 68,069 ICD-10-CM codes • Increased from 14,025 ICD-9-CM

  16. Provider ClaimsCompliance A Must • No delays or grace period • ICD-9-CM for dates of service < October 1, 2014 • ICD-10 for dates of service ≥ October 1, 2014 • Still use CPT and HCPCS

  17. ICD-10 Code Structure AXX.XXXX 3 Categories Code 5/6 Subclassification Code/Placeholder 4 Subcategory Code 7 Extention Code

  18. ICD-10-CM Structure • 3 – 7 characters • 1st = alpha • 2nd = numeric • 3rd – 7th = alpha or numeric • Decimal after 3rd character

  19. ICD-10-CM Structure • Character “X” • 5th or 6th position • “Placeholder” • Future expansion • “Fill In” • Empty characters

  20. 7th Character • One use is encounter type • A = Initial encounter • D = Subsequent encounter • S = Sequela

  21. R40.2 Coma Coma NOS Unconsciousness NOS The appropriate 7th character is to be added to each code from subcategory R40.21-, R40.22-, R40.23- 0 Unspecified time 1 In the field [EMT or ambulance] 2 At arrival to emergency department 3 At hospital admission 4 24 hours or more after hospital admission 7th Character

  22. ICD Codes • Describe medical necessity • Facilitate payment • Evaluate utilization patterns • Study appropriateness of health care costs

  23. Incorrect Coding • Lead to investigations of fraud and abuse • Must be correct • Must be consistent

  24. ICD-9 CM Groups by type of injury Maximum 5 characters Most codes numeric 17 chapters ICD-10 CM Groups by site of injury Maximum 7 characters Codes are alpha-numeric 21 chapters Comparison

  25. Changes Found In ICD-10 CM • Addition information for ambulatory and managed care encounters • Expanded injury codes • Combination codes • Reclassification of diseases

  26. Changes Found In ICD-10 CM • New code definitions • “E” and “V” codes incorporated in main classifications • Category restructuring and code reorgaization

  27. ICD-10 CM Format • Introduction • Official Guidelines for Coding and Reporting • Alphabetic Index to Diseases and Injuries • Neoplasm Table

  28. ICD-10 CM Format • Table of Drugs and Chemicals • Index of External Causes • Tabular List of Diseases and Injuries

  29. Official Guidelines forCoding and Reporting • ICD-9 and ICD-10 • Conventions, general coding guidelines and chapter specific guidelines • Selection of Principle Diagnosis • Reporting Additional Diagnosis • Diagnostic Coding and Reporting Guidelines for Outpatient Services

  30. Official Guidelines forCoding and Reporting • ICD-10 • Chapters 3, 7, 8 and 11 • Not completed • Specialty society involved in creation

  31. Official Guidelines forCoding and Reporting • Examples • Chapter 15 • Chapter 15 codes have sequencing priority over codes from other chapters • Chapter 15 codes are to e used only on maternal record, not on newborn

  32. ICD-9 Diseases Illness Injury Other reasons for encounters Table of Drugs and Chemicals External Causes of Injury and Poisoning ICD-10 Diseases Illness Injury Other reasons for encounters Alphabetic Index

  33. ICD-9 In alpha index Malignant Primary Secondary Ca in situ Benign Uncertain Behavior Unspecified ICD-10 Separate section Malignant Primary Malignant Secondary Malignant Ca in situ Benign Uncertain Unspecified Behavior Neoplasm Table

  34. ICD-9 Under Alphabetic Index Poisoning Accident Therapeutic Use Suicide Attempt Assault Undetermined ICD-10 Accidental (unintentional) Intentional Self-Harm Assault Undetermined Adverse Effect Underdosing Table of Drugs andChemicals

  35. ICD-9 Under Alphabetic Index Cause of injury Adverse effects ICD-10 Alphabetic by main term indicating the event Index of External Causes

  36. ICD-9 17 chapters Based on diseases 2 Supplementary Classification ICD-10 21 chapters Based on body system or nature of injury and disease Tabular List of Diseasesand Injuries

  37. Chapter Comparison

  38. Chapter Comparison

  39. Chapter Comparison

  40. Chapter Comparison

  41. Chapter Comparison

  42. Chapter Comparison

  43. Chapter Comparison

  44. ICD-10-CM Code Examples • F03 Unspecified dementia • L60.0 Ingrowing nail • J09.12 Influenza due to identified novel H1N1 influenza virus with other respiratory manifestations • M71.061 Abscess of bursa, right knee • T21.31xa Burn of third degree of chest wall

  45. ICD-10-CM Terminologyand New Feature • Laterality • Right = character 1 • Left = character 2 • Bilateral = character 3 • Unspecified = character 0 or 9

  46. ICD-10-CM Terminologyand New Feature • Laterality Examples • M54.31 – Sciatica, right side

  47. ICD-10-CM Terminologyand New Feature • Combination codes • Diagnosis with associated sign or symptom • Diagnosis with associated complication • Diagnosis with cause

  48. ICD-10-CM Terminologyand New Feature • Combination code example • Conditions with symptoms and manifestations • K27.2 – Acute peptic ulcer, site unspecified, with both hemorrhage and perforation

  49. ICD-10-CM Terminologyand New Feature • Combination code example • Poisoning and external cause • T51.0x2 – Toxic effect of ethanol, intentional, self-harm

  50. ICD-10-CM New Features • Obstetric codes identify trimester • 1 = 1st trimester < 14 weeks, 0 days • 2 = 2nd trimester 14 weeks, 0 days to < 28 weeks, 0 days • 3 = 3rd trimester 28 weeks, 0 days to delivery • 0 or 9 = unspecified

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