ICD-10 Changes Everything in the Revenue Cycle Presented by: Day Egusquiza, President AR Systems, Inc. Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc.
ICD-10 Changes Everything! It’s on your doorstep! The biggest change to happen in Health Information Management and the Revenue Cycle in more than 30 years! Preparation is the key! Will YOU be ready?
ICD-10 • WHO (World Health Organization) owns & publishes ‘ICD’ (International Classification of Diseases). • WHO endorsed ICD-10 in 1990; members began using ICD-10 or modifications in 1994. • United States is the only industrialized country not using ICD-10 for our coding & reporting of diseases, illnesses, and injuries. Why? What makes us so different?
Countries Using ICD-10 For Case Mix • United Kingdom (1995) • Denmark, Finland, Iceland, Norway, Sweden (1994 – 1997) • France (1997) • Australia (1998) • Belgium (1999) • Germany (2000) • Canada (2001) • U.S. (2015) (Reimbursement+ Case Mix + HIPAA Standard Transaction Act 2003)
Why Should We Do ICD-10? • What is the benefit to the provider? • Dramatic improvement in the assignment of costs to procedures performed. • ICD-10 will allow us to develop meaningful estimates about what a disease state or a procedure costs us, while ICD-9 is limited in what it can do in this regard. • Identify opportunities to avoid cost & improve lives. • Additional information in an ICD-10 diagnosis code includes severity and specific comorbidity, but it can also include information about demographics and some of the underlying reasons for the diagnosis.
Additional Benefits… • Share higher-quality data with other health care providers. • ICD-10 increases the amount of “specific” information in every diagnosis code and makes this more valuable to other providers. • For example, ICD-9 has a code for laceration of an artery. • ICD-10 lets you know if that artery was in someone’s finger or in their heart.
Reimbursements will better align with activity & cost. • Payers will reimburse severe & complex cases better and simple cases at lower rates. • How? By the diagnosis codes!
Here’s an Example • Imagine you had a patient who was noncompliant with their medical therapy. • In ICD-9, the only code we have available is V15.81 (personal history of noncompliance with medical treatment). • Is the patient noncompliant because of their own personal reason? Or something else?
How Will it Look in ICD-10? • Z9111 (Patient’s noncompliance with dietary regimen) • Z91120 (Patient's intentional underdosing of medication regimen due to financial hardship) • Z91128 (Patient’s intentional underdosing of medication regimen for other reason) • Z91130 (Patient’s unintentional underdosing of medication regimen due to age-related debility) • Z91138 (Patient’s unintentional underdosing of medication regimen for other reason) Shows whether or not the patient’s noncompliance was intentional, but also identifies if the patient needs some form of assistance from social services, etc.
Non-HIM Uses For ICD-9-CM- Preparing for ICD-10-CM – as we move from 15,000 codes to over 70,000 codes
Ideas for Physician Engagement • Rollout ‘monthly dedicated specialty specific’ audit and training. • EX) May is ER month. Coders dual code an identified sample of ER claims. Identify ‘at risk’ documentation by provider. Turn into ‘easy to implement documentation. • EX) If the facility has a CDI team, work cooperatively with the coding team to ‘coach/que’ the ER providers thru their month. • EX) Do an month end dual coding – show improvement or challenges.
Exploring new partnerships with provider offices • Physician dictates, hospital coders code, UB is created. • NEW: Why not share the codes with the providers who are attached to the account? Why repeat the same coding process in the office? • NEW: Brown bag coding luncheons with the provider offices. Office brings samples to code, hospital coders code while teaching ICD 10 concepts. (TX: Lunch & Learn weekly) • NEW: Hospital becomes the outsourcing company to assist small practices with coding.
Non-HIM Impact Areas(HINT: Denial Busting) • 837/835 HIPAA transaction sets – new for ICD 10 locators • Quality of care indicators – translated • P4P indicators/Outcome Measures – translated • Decision Support, utilization patterns, benchmarking – translated • Medical care review – by provider, by dx, by LOS • New business plan research/future healthcare trends – translated • Monitoring and analyzing the incidence of disease & other health problems –translated & new • Embedded dx attached to CPT codes • Not case sensitive • Revise forms to include new ICD 10 codes. • Scheduling –precerts, eligibility. • Claims submission with scrubber –both ICD 9 and ICD 10 codes ( Min-1 yr ability to rebill, do duality with IT systems.) • Medical necessity CPT codes – software, manual processes, cheat sheets • Recurring accounts – will need new precerts & recoded after 10-1-2014 • Payer acceptance of new ICD 10 codes PLUS ICD 9 codes – 2 batches • Payer contract language – Dx codes • Payer remark codes/denial codes • CDM – Hardcoded RT/LT needs to match with the soft coded RT/LT ICD10 • Trauma/Tumor registry - translated • All IT systems within the organization
Who Needs to Understand ICD-10? • Beyond the coders… • PFS leadership as payers may reject based on ICD -10 coding and medical necessary codes & denial software. • PFS leadership and contracting to ensure contracts can accept both ICD-9 and ICD-10 on the UBs post go live. • UR and all care mgt as payers will need to be able to do pre-certifications and concurrent review with ICD-10. • Decision support and all areas using ICD-9/10 coding for tracking, reporting, etc. (Trauma registry, Tumor registry, outcome comparisons, contracting, etc.). • IT leadership must be involved to ensure all impacted areas are ready. A team leader or leaders are identified.
Payer Readiness - Letters with timelines to get started, test, dialogue • UB submissions with ICD-9 and ICD-10 - conversion dates • Denials with new reasons –as ICD-10 is far more specific • Contract language that addresses ICD-10 inclusions/exclusions • Claim scrubbers/payer scrubbers – ABN issues (LCD/NDC dx codes), ‘if ‘ rules, edits • Pre-authorization process/coverage • WC and Liability are not subject to HIPAA standard transactions. Will they convert?
More Payer Issues • Will they deny ‘unspecified” dx? • How many digits will they require to have a ‘pre authorization ‘ match? • Testing – test pt type, create claim, thru scrubber, to payer to payment. When start? • Post go live? Accept DOS with ICD 9 after go live? • If delayed, notify CMS/HIPAA Standard Transaction 2003. • Track and trend all payer issues – report to hospital association.
More On LCD/NCD Diagnosis Codes Under ICD-10 • The challenges… • What? For each Lab NCD, the ICD-9-CM codes and descriptions will have to be translated to ICD-10-CM versions. • When? • (A) Prepare preliminary versions of ICD-10-CM translations of Lab NCDs by end of January 2011 (for use in testing system functions). • (B) Prepare ICD-10-CM versions for full ICD-10-CM implementation in 2015 • HEY – look at MLN Matters MM8197 3-15-13 • “ICD conversion from ICD-9 to related code infrastructure of the Medicare shared systems as they relate to CMS’ NCDs.”
LCD/NCD Objectives and Goal • Translate all ICD-9-CM codes and descriptors in each Lab NCD’s table of covered codes to the ICD-10-CM equivalent(s). • Provide these translated tables to the CMS contractor, so that the tables can be incorporated into the ‘codelist spreadsheet’ which will be processed for use by the shared systems for claims processing (update 2/13 – NCDs available). • Goal: Allow consistent and “seamless” transition of claims for providers of laboratory test services. • (CONTINUE TO WATCH for payer updates)
Duality of Systems • Will payers, vendors (claim submission and scrubber) and other IT systems be able to handle ICD-9-CM as well as ICD-10-CM and ICD-10-PCS at the same time? • Rebills of pre-conversion, medical necessity software, scrubbers, ensuring all payers are ready to convert AND test with each payer = critical to the successful conversion. • P.S. Don’t forget all payers (Medicaid too!)
Hot Spots • Make a master list of all vendors who currently support any ICD-9 activity. (Think Y2K) • Look at all items /ordering tools where ICD-9 codes are present. Need reviewed and revised. • Lab requisitions • Online ordering of services that also requests ICD-9 codes • Physician super bills/encounter forms with pre-printed ICD-9 codes • Dept. specific ‘cheat sheets’ for covered dx. (Yep we know you have them!)
Example of 200 Bed Hospital IT List • Decision support • Scheduling software • All tied Medical Necessity software in different areas – main frame, bolt on software, individual areas screening • Infection Control software • Cardiology – EKG system • Itemized statements with dx as needed by the payer/pt • Clinical quality reporting software • Cheat sheets in each dept! • OR software • Occupational Med software • 3M or other encoder • Main frame /main IT system • Radiology-doc billing, radiology’s own system • Clearing house/claims • Hospital employed doctor’s software for billing • SNF/RUG software for grouper • HH/HHRG software for grouper • Lab – pathology doc billing, lab’s own system • Internal electronic medical record used for coding • Software used for Trauma & Tumor Registry
What is ICD-10-CM and ICD-10-PCS?
What is ICD-10-CM/PCS? • Department of Health and Human Services (HHS) mandated that HIPAA covered entities must update medical coding sets. • Diagnosis code set changes from ICD-9-CM to ICD-10-CM. • Hospital inpatientprocedure code set changes from ICD-9-CM (Volume 3) to ICD-10-PCS. • No impact on CPT and/or HCPCS codes. Yeah! We will still report CPT codes for all outpatient procedures/services & physician hospital visits to Observation and Inpatients (E&Ms).
The ICD-10Impact! • ICD-10-CM (Diagnoses) • Will be used byallhospitals, providers, clinics, lab, radiology, psych, rehab, nursing homes, etc. • ICD-10-PCS (Procedures) • Will be used only for hospital claims for inpatienthospital procedures • CPT/HCPCS – No change! • Procedures for Hospital Outpatients, Physician Visits, Lab and Radiology Outpatients, etc.
Another Year Delay… • Revised Date: October 1, 2015 • Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures).
ICD-10 Implementation Span Date • CMS clarifies policy for processing split claims for hospital encounters that span the ICD-10 implementation date. • MLN (Medical Learning Network) Matters Number: SE1325 • Split Claims • Require providers split the claim so all ICD-9 codes remain on one claim with Date of Service (DOS) through September30, 2015, and all ICD-10 codes placed on the other claim with DOS beginning October 1, 2015 and later. • Same guidance for Inpatient and Outpatient encounters!
Diagnosis Coding (ICD-10-CM)
ICD-9-CM vs. ICD-10-CM ICD-10-CM • 3 - 7 digits or characters • 1st character is alpha (all letters used except “U”) • 2nd – 7th characters can be alpha and/or numeric • Decimal placed after the first 3 characters (the same!) • 21 Chapters and “V” & “E” codes are ‘not’supplemental • 69,000+ diagnosis codes ICD-9-CM • 3 - 5 digits or characters • 1st character is numeric oralpha (E or V codes) • 2nd – 5th characters are numeric • Decimal placed after the first 3 characters • 17 Chapters and “V” & “E” codes are ‘supplemental’ • 14,000 diagnosis codes
ICD-10-CM Format X X XX X XX
Why Are There So Many Diagnosis Codes? • Greater “specificity and detail” in all diagnosis codes! • But…is there supporting physician documentation in the medical record? • 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system • 17,045 (25%) of all ICD-10-CM codes are related to fractures • 10,582 fracture codes will distinguish ‘right’ vs. ‘left’ • 25,000 (36%) of all ICD-10-CM diagnosis codes will now distinguish right vs. left
New Features to ICD-10-CM • Combination codes for conditions and common symptoms or manifestations • E10.21 Type 1 diabetes mellitus with diabetic nephropathy • Combination codes for poisonings and external causes • T42.4x5AAdverse effect of benzodiazepines, initial encounter • Added laterality (left vs. right) • M94.211 Chrondromalacia, right shoulder • Added 7th character extensions for episode of care • S06.01xA Concussion with loss of consciousness of 30 minutes or less, initial encounter
ICD-10-CM (Injury and External Cause Extensions) A Initial encounter D Subsequent encounter S Sequelae (disease progression) • Coders will need to look for the episode of care. Is this the patient’s 1st visit for treatment or is it for routine follow-up? Is it clearly documented in the medical record?
And a Bit More… • Examples of “Subsequent” care: • Cast change or removal • External or internal fixation removal • Medication adjustment • Follow-up visits following fracture treatment • For aftercare, the acute injury code with the 7th character ‘D’, ‘E’, or ‘F’ is assigned. • Do not assign the aftercare “Z” codes!
What is Gustilo-Anderson Scale? • Gustilo-Anderson classification identifies the ‘severityof soft tissue damage’ in open fractures – may be new to coders and physicians • Type I: Wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (low energy injury) • Type II: Wound is longer than 1 cm, not contaminated, and w/o major soft tissue damage or defect (low energy injury) • Type III: Wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.
Examples of ICD-10-CM *Emergency Room* • I10 Essential (primary) hypertension • S01.02xA Laceration with foreign body of scalp, initialencounter • S01.02xD Laceration with foreign body of scalp, subsequent encounter • S02.2xxA Fracture of nasal bones, initial encounter for closed fracture • H65.01 Acute serous otitis media, right ear • H65.02 Acute serous otitis media, left ear • H65.03 Acute serous otitis media, bilateral
Quirky ICD-10-CM Codes On any given day, anything can happen! • W17.82xA Fall from (out of) grocery cart, initial encounter • V94.4xxA Injury to barefoot water-skier, initial encounter • W61.43xA Pecked by turkey, initial encounter • Y93.C2 Activity, handheld interactive electronic device, i.e., cellular phone • Are we querying the provider for this level of detail? Who wants it? The payer? • Have internal discussions, contact payers, gather excellent data= Decide.
Cross Walking - GEMs • CMS has created GEMs (General Equivalence Mappings) to assist hospitals with cross walking ICD-9-CM ►ICD-10-CM/PCS “forward mapping” & ICD-10-CM/PCS ◄ ICD-9-CM “backward mapping”. The correlation between the 2 code sets for some codes is fairly close, but not a straight correlation for others, i.e. OB, etc. • Not always 1 to 1 crosswalk from ICD-9-CM to ICD-10-CM (www.cms.gov/ICD10/11b15_2013_ICD10PCS.asp) • Available on CMS’s website
Good News! We will still look up the diagnosis codes the same way as we do today. Yeah! • #1 - Look up diagnostic terms in the Alphabetic Index…and then • #2 - Verify the code number in the Tabular List That’s it!
ICD-9-CM vs. ICD-10-PCS • ICD-10-PCS (Procedures) • Min. characters: 7 • Max. characters: 7 • Alphanumeric format • No decimal point • 71,920 procedure codes • ICD-9-CM (Volume 3) (Procedures) • Min. characters: 3 • Max. characters: 4 • Numeric format • Decimal point • 3,000 procedure codes
ICD-10-PCS: Code Structure • Seven Character Alphanumeric Code • All procedure codes will be seven characters long • “I” and “O” (letters) are never used Can you guess why? • 34 possible values for each character • Digits 0 – 9 • Letters A-H, J-N, P-Z
ICD-10-PCS Characters(Medical and Surgical Section) Root SectionOperationApproachQualifier BodyBodyDevice System Part
ICD-10-PCS Characters Section: Identifies general type of procedure Body System: Identifies general body system Root Operation: Specifies objective of procedure Body Part: Identifies specific part of body system on which procedure is being performed Approach: Technique used to reach the site of the procedure Device: Identifies devices that remain after procedure is completed Qualifier: Provides additional information about a procedure, if necessary
ICD-10-PCS codes are assigned based on theintent of operation rather than the operation name as in ICD-9-CM. Can be a big difference! • Coders and CDI specialists will need to review surgical reports to identify root operations and surgical approaches and to also understand various eponyms for high-volume procedures.
Case # 1 Diagnostic Colonoscopy • 44-year-old male patient is known to have diverticulitis of the colon and has noticed melena occasionally for the past week. The initial impression was acute bleeding from diverticulitis. Patient was scheduled for colonoscopy. Colonoscopy identified the cause of the bleeding to be angiodysplasia of the ascending colon.
Case # 1ICD-10-CM (Diagnosis) Coding • K55.21 Angiodysplasia of colon with hemorrhage (569.85) • K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding (562.11)
Case # 1ICD-10-PCS (Procedure) Coding • 0DJD8ZZ Inspection of Lower Intestinal Tract, via Natural or Artificial Opening Endoscopic (45.23)
Case # 2 Inguinal Hernia Repair • Patient with hypertension and COPD is admitted for bilateral inguinal hernia repair. H&P states that the left side is recurrent. The operative report states that the surgeon repaired a left direct and right indirect inguinal hernias with mesh, via open approach.
Case # 2ICD-10-CM Coding • K40.2 Bilateral inguinal hernia without obstruction or gangrene(550.92) • I10 Essential (primary) hypertension (401.9) • J44.9 Chronic obstructive pulmonary disease, unspecified (496) Notice anything familiar to ICD-9-CM?