ICD-9-CMICD-10-CM Covered by pages 2.23-2.39 Section 2 Susan Vannoni 040314 10:45-11:30
Historical Background 24 • ICD-9-CM is an acronym for International Classification of Diseases-9th Revision-Clinical Modification. • ICD is a statistical classification system that has been published since 1900. It arranges diseases and injuries into groups according to established criteria. • Most ICD-9-CM codes are numeric and consist of three numbers followed by one or two decimals and a description.
NIB HISTORY OF ICD REVISION YEARS 1st 1900-1909 2nd 1910-1920 3rd 1921-1929 4th 1930-1938 5th 1939-1948 6th 1949-1957 7th 1958-1967 8th 1968-1978 9th (ICD-9) 1979-1998 10th (ICD-10) 1999-2014 11th (ICD-11) 2015
25 The final rule mandated that as of Oct.1, 2013 CMS would require ICD-10 to be used, but this date is now moved to Oct 1, 2015 the same year ICD-10 expires and ICD-11 becomes active!!!!.
26 To allow an Orderly Transition from ICD-9 to ICD-10 • October 1, 2011, CMS Set a 1 year freeze on any further updates to ICD-9 and ICD-10. • October 2012 a limited number of updates were allowed to both, but only for new technologies and diseases. • October 2013 only limited updates to ICD-10, but allow continued use of ICD-9 until October 2014. • October 2014 Regular updates will resume to ICD-10 • This schedule is STILL valid.
ICD-10 26 • Will/may be required for your practice in 18 months. • Will require massive changes in software, and staff training to use ICD-10 • ICD-10 has 120,000 codes in contrast to ICD-9 which has 12,000 codes • ICD-10 will happen some day , and your practice needs to be ready for it • You have a great deal of preparation necessary for this conversion.
Preparations for ICD-10 NIB • Identify commonly used ICD-9 codes and build a crosswalk to ICD-10 codes. We have this for you! • Identify and update all paper and electronic forms to accommodate the ICD -10 code structure. • Schedule ICD-10 training for clinicians, office staff, billers, coders, and any other key individuals. • Participate in all testing opportunities to identify weaknesses/risks in documentation. • Avail yourself of all opportunities to participate in provider based training programs in ICD-10. • You should start coding both in ICD-9 and ICD-10 to gain familiarity.
Cost Estimates of ICD-10 NIB • The conversion cost is estimated to range from $20,000 for a small practice to over $2,000,000 for a large multi specialty group practice. • The Feds will not cover the cost of conversion!! No Bonus money here. • Will your software handle ICD-10? • How much will the upgrade cost?
FORMAT OF ICD-10 26 • Divided into 22 chapters • Neoplasms, Chapter 2 • Blocks or Sections C00 to D48 • Malignant Neoplasms C00-C97 • Benign Neoplasms D10-D36 • Almost all have a decimal (C09.1 tonsillar pillar)
26 LOCATION AND LATERALITY • C50.11- Malignant neoplasm female breast, central portion • C50.111 Malignant neoplasm female breast, central portion, right breast. • C50.112 Malignant neoplasm female breast, central portion, left breast.
26 ICD-9 has 6 codes, ICD-10 has 18 codes
Additional ICD 10 codes 26 Exposure to environmental smoke..............Z77.22 History of tobacco use....................................Z87.891 Occupational exposure to smoke.................Z57.31 Tobacco dependence.......................................F17.- - Tobacco use......................................................Z72.0 Alcohol use/dependence................................F10.- - Right side........................................................XXX.XX1 Left side...........................................................XXX.XX2 Bilateral...........................................................XXX.XX3
ICD 10 September 30 October 1 NIB For dates of service on or after the October 1, 2015, deadline, you must use ICD10. You will not be able to use ICD-9 and ICD-10 codes on the same claim based on your payers' instructions. This may mean splitting services that would typically be captured on one claim into two claims: one claim with ICD-9 diagnosis codes for services provided before October 1, 2015, and another claim with ICD10 diagnosis codes for services provided on or after October 1, 2015.
WHY DO WE NEED ICD-10? 27 • Will eventually increase the number of available codes for diagnostic, medical, and treatment procedures by a factor of 10 • There just are not enough code numbers left in ICD-9 to cover the multitude of new procedures • Added codes are needed for the many new procedures, and the new ones to come in the future.
RADIATION ONCOLOGY PROCEDURE CODING SYSTEM 27 • Will this replace CPT?, probably not in the immediate future, but later?? • ICD-10, and later ICD-11 will have characters for the basic modes of radiation therapy used (external beam, Brachytherapy, stereotactic, other) • Further identify the type of radiation used ( photons, electrons, heavy particles, contact radiation, others)
Radiation Oncology Series D Codes 27 D-1 Use of radiation oncology. D-2 Body system involved. D-3 Root type. 0 External beam 1 Brachytherapy. 2 SRS,SBRT 4 Other types of radiation therapy. D-3 Specific Body part being treated. D-5 Modality, blocking, beam modifiers, etc.. D-6 Use of radioisotopes, all or part of treatment. D-7 Qualifiers, none for radiation oncology.
NIB Prediction • ICD-9 has been a requirement since 1989, conversion to ICD-10 will/may happen October 1 , 2015. • CPT has been in use for 48 years, much longer than most predicted it would last • After ICD-10 or ICD-11 has been in effect for a few years, procedure reporting using CPT will disappear, one specialty at a time, and be replaced with the enhanced features of diagnosis and treatment based reporting. 70/90
Applicability of ICD-9 and ICD-10 to Radiation Oncology 27 Over 1700 ICD-9 and ICD-10 codes that are most applicable to Radiation Oncology are covered in these tables. The tables are arranged by subject, followed by specific areas indicating the proper code to use See Table, Section 2
TABLES AT END OF SECTION 2 Primary Bone Tumors
Ovary-Prostate Prostate is still discriminated against
ICD-9 versus ICD-10 There are approximately 220 ICD-9 codes in the malignancy section of ICD-9 that we commonly utilize for radiation therapy. Some of these are broken down into subsets with the final number of approximate 396 individual ICD-9 code/narration that we commonly utilize. This conversion table has 1788 ICD-10 codes, almost 5 times as many codes to deal with.
DRG 26 HCFA contracted for the development of the first concepts of DRG (Diagnostic Related Groups) in the early 1980’s. This was a means of utilizing the coding system for procedures based on ICD-9 codes to ration payments to hospitals. This shifted the emphasis from the previously utilized CPT procedure based system to the ICD-9diagnostic based system.
Cancer of the prostate (185)cannot link to a female patient 29 Watch for obvious mistakes
29 Medicare requires the use of the appropriate ICD-9 code on all Medicare claims submitted for reimbursement. Absence of an ICD-9 diagnosis code will result in rejection of the claim and a delay in payment.
29 It is extremely important that the proper ICD-9 code for the course of therapy being delivered is used as the code for that course of therapy. The patient's primary cancer, which was previously treated, becomes the secondary code for this particular claim form. This is important not only from the aspect of Medicare coding, but also for statistical record keeping in your department, based upon diagnostic coding of treated patients.
30 Case examples with multiple diagnoses • Metastatic disease, known previous primary cancer • Metastatic disease with active primary cancer • Multiple primary cancers
Brain metastasis from primary carcinoma of the lung 30 Primary Lung, initially treated with SBRT 9 months later developed brain metastasis, treated with whole brain radiation.
30 Correct coding/billing for this case Present Brain Metastasis Previous Lung Primary
Skin cancer metastatic to lymph nodes in the Head and Neck area. 31 Primary Squamous cell skin cancer resected with positive margins, will treat this area with electrons. Parotid and Neck nodes to be treated with IMRT at the same time
31 In order to be paid as IMRT, this case must be coded as metastatic cancer to lymph nodes (196.0) as the first code, and list the Squamous cell skin primary as the secondary code (173.32). Treatment delivery is 77418.
ICD-10 Versus Carrier LCD 31 • The majority of the Medicare carriers now realize that the conversion to ICD-10 will increase the number of diagnosis codes utilized as restrictive payment policy in their LCD documents from hundreds of codes to thousands of codes. • These carriers will probably discontinue the LCD policy, which will remove code restrictions from the procedure payment policies. • This may eliminate the restrictions on the use of IMRT in certain anatomic areas. • However, this will certainly increase the close scrutiny and medical necessity of the use of IMRT and result in a higher rate of case denial for payment of IMRT.
Two Distinct Primary Cancer Diagnoses 32 Primary Carcinoma of the Larynx, started on treatment as the initial course of therapy Then found an unsuspected Adenocarcinoma of the lung, treat as a second primary site
Proper Coding for this Case 32 First course, Larynx is primary diagnosis, Lung is a secondary code. Second course, Lung is the primary diagnosis, Larynx is now secondary.
ICD-10 AND STAGING 33 • The 2010 AJC staging book uses ICD-9 and ICD-10 for all the diagnostic areas. • Many of new codes are used for histology modified staging not found in earlier versions • Numerous areas have been completely re done to take into account many of the new features of ICD-10
T-N-M Staging 33 • The AJCC has been developing staging methodology since 1950 • The AJCC 7th edition is far more comprehensive than previous editions. • T -Tumor size • N- Nodal status • M- Presence or absence of Metastatic disease
34 “V” Codes Two supplementary classifications included in the tabular list of ICD-9 are the V codes and the E codes. These are the so called encounter codes, one of which may be required by your carrier.
34 V58.0 Encounter for Radiation Therapy:This V code may still be required to be listed first on all Medicare claims for patients who receive radiation therapy treatment as part of the encounter. Use this code in addition to the ICD-9-CM diagnosis code. V67.1 Follow-up Examination:This is a follow-up code for use after a course of radiation therapy has been delivered. You may be required to use this code in addition to the ICD-9-CM diagnosis code. V-10 Personal History of Malignant Neoplasm:There is an entire section devoted to specific malignant neoplasms based upon the V-10 Codes. These are the codes to be utilized if the patient does not have an encounter for radiation therapy. CHECK YOUR LCD
35 Added IMRT “V” Code • Some GYN, Lymphoma, Metastatic lymph nodes, and Sarcomas will require a supplemental V code. • 179, 180.0-180.9, 182.0-182.9, 183.0-183.9, 184.0-184.9, 196.0, and 200.00-200.88 • Require V49.89, Other specified conditions influencing health status • IMRT will not be paid without this code.
37 Prophylactic Whole Brain Radiation • What code to use? • 198.3 brain metastasis not proven • 162.3 lung primary previously treated cancer, wrong anatomic area to treat (use as secondary) • V 10.2 history of respiratory tract cancer, or • V 07.8 other specified prophylactic measure, or • V10.11 history of lung cancer; are the possible codes to properly describe the problem END
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