ICD10 / 5010 – One providers prospective

1. By Chris Briggs PMP MSPM ICD10 / 5010 – One providers prospective

2. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (known as "ICD-10"). A medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Maintained by the World Health Organization (WHO). Work on ICD-10 began in 1983 and was completed in 1992. ICD-11 has been in development since 1992 with draft presented in July 2011 for WHO adoption by 2015. The U.S. is the second to the last industrialized nation in the world to adopt the standard. What is ICD-10

3. ICD-10 CM stands for “Clinical Modification” and is the code set adopted in the U.S. ICD-10 PCS stands for “Procedure Code System” and is only in use in the U.S. Both are subsets to what is commonly called ICD-10. CMS has mandated both be implemented by October 1st, 2013. What is icd-10 CM & PCs

4. What is HIPAA 5010 • HIPAA 5010 is a new file format for the electronic transmission of claims and eligibility data. • The 5010 format supports the migration to ICD-10. • CMS has mandated the new standard be implemented by January 1st, 2012.

5. The following code sets and their use will not change with ICD-10 conversion: • CPT Codes • HCPC Codes • Other Code Sets What’s not changing with ICD-10?

6. WHAT’S CHANGING WITH ICD-10? ICD-9-CM Diagnosis Codes ICD-10 Diagnosis Codes (CM) Current Future 14,000 diagnosis codes 69,000 diagnosis codes Uses 3 to 5 digit codes Uses 3 to 7 digit codes Chapters 1-17 uses all numeric characters; supplemental chapters use an alpha first digit (E or V) Digit 1 is alpha; Digit 2 and 3 are numeric; Digits 4 to 7 are alpha or numeric • Other New Features: • Laterality (Left, right etc.) • Symptoms and associated manifestations • Trimester • Type of visit • Preoperative conditions vs. post operative complications

7. What’s changing with ICD-10? ICD-9-CM Diagnosis Codes Current Future Example: 820.02 = Fracture of midcervical section of femur, closed ICD-10 Diagnosis Codes (CM) Example: S72.013A = Displaced midcervical section of right femur, initial encounter, for closed fracture S72.013G= Displaced midcervical section of right femur, subsequent encounter, for closed fracture, with delayed healing S72.012A= Displaced midcervical section of left femur, initial encounter, for closed fracture S72.012G= Displaced midcervical section of left femur, subsequent encounter, for closed fracture, with delayed healing

8. What’s changing with ICD-10? ICD-9 Vol. 3 Procedure Codes ICD-10 PCS Procedure Codes (PCS) Current Future 70,000 + codes > 4000 codes 7 Alpha or Numeric characters. No decimal 3-4 Numeric characters. Decimal after 2 digits • Other New Features : • Flexibility for adding new codes as procedures change or are improved • Identifies specific body parts • Encompasses all procedure detail in a single code • Provides very specific detail about the procedure changes (Benefits)

9. What’s changing with ICD-10? ICD-9- Vol.3 Procedure Codes Current Future Example: 86.59 = Suture of skin and subcutaneous tissue of other sites ICD-10 PCS Procedure Codes (PCS) Example: 0JQ10ZZ = Repair face subcutaneous tissue and fascia, Open Approach 0JQ13ZZ = Repair face subcutaneous tissue and fascia, Percutaneous Approach 0JQ40ZZ = Repair anterior neck subcutaneous tissue and fascia, Open Approach 0JQ43ZZ = Repair anterior neck subcutaneous tissue and fascia, Percutaneous Approach

10. Impacts: 5010 • All applications that send electronic claim information (claims, remits, and eligibility) will need be upgraded to the new 5010 format. • Almost entirely a “backend” effort not affecting clinical end users. • What can you do: • Identify all applications that generate electronic claims and eligibility. • Work with application vendors to upgrade applications. • Work with clearing houses to establish workarounds for applications not remediated.

11. ICD-10 Impacts: Application • All applications that currently utilize ICD-9 codes will need to be upgraded to accept the new ICD-10 code set. • The change is a structural change, not just the addition of new codes as with previous changes. • Often referred to as the “Y2K of Healthcare”. • What can you do: • Identify all applications that have ICD-9 codes and/or applications that generate electronic claims. • Assess application readiness and work with vendors to ensure applications are going to be remediated. • Ensure contracts for new applications include requirements for ICD-10 readiness and testing.

12. ICD-10 Impacts: User Training • All users who utilize ICD-9 codes in their current workflows will need to be trained in the new code set. • Workflows will need to be reviewed, and tools may need to be implemented, to ensure ICD-10 codes can be successful integrated. • What can you do: • Asses existing workflows to understand current use of ICD-9 codes. • Plan a training strategy to ensure clinicians are trained in documentation standards so coding professionals have the information required to code in an ICD-10 environment. (CDI). • Budget for impacts related to downtime and training costs.

13. ICD-10 Impacts: Interface and reporting • All existing reporting and interfaces will need to be upgraded to accept the new data format. • Data collected in an ICD-9 environment is not normalized to data in an ICD-10 environment. • One to many relationship on both sides of the spectrum. • What can you do: • Review current reporting and interfaces to assess impacts and develop a strategy for remediation. • Work to develop a strategy on how data will be tracked after implementation of the mandate.

14. ICD-10 Impacts: Revenue cycle • Claims not sent with the correct ICD-10codes may be rejected by payers. • Reimbursements tied to codes may differ from current reimbursements. • Generic codes will generally result in lower reimbursements by payers. • Increased demand on coders may increase AR cycle time impacting cash reserves. • Increased complexity of claim adjudication could delay AR cycle time at switch over.

15. ICD-10 Impacts: Revenue cycle Cont. • What can you do: • Ensure systems are in place to facilitate accurate coding. • Work with Clinical Documentation Improvement (CDI) program to ensure data is captured to support accurate coding. • Model claims in both the ICD-9 and ICD-10 environment to understand revenue impacts. • Develop strategies to mitigate impacts to coder productivity. • Ensure reserves or lines of credit exist to support delays in AR cycle time.

16. Mandate affects all healthcare entities through the entire continuum of care and claims processing (shared need). Looming deadlines require systemic changes to integrated systems throughout all of healthcare. The Need for Local Collaboration

17. Finding partners in change. • Many health systems share providers and have the need for common education. • Physician partners (OMA) have a need to ensure independent physicians understand and plan for mandated changes. • Payers, providers, and clearing houses have a common need to develop testing strategies. Local Collaboration – Partners

18. Share and review provider training strategies. Share and review common communication concerning ICD10 / 5010. Share and review industry updates concerning IDC10 / 5010. Share and review payer testing across providers, clearing houses, and payers. Leverage shared information to ensure applications are remediated, and where necessary escalating application issues across multiple health systems. Local Collaboration – Goals

19. ? Questions