Arkansas DMS: ICD-10 Provider Education Series

1. Arkansas DMS: ICD-10 Provider Education Series ICD-10 Preparation & Implementation Cathy Munn, MPH RHIA CPHQ Sr. Consultant

2. Agenda • Why ICD-10 & Why Now? • Industry Update • Key Points to Remember • Impact of the Change • Providers • Payers • Review of ICD-10 Codes & Changes • Arkansas DHS Preparation & Planning • Provider Preparation • Next Steps & Resources

3. Industry Update • Cutting Costly Codes Act of 2013 • A bill to prohibit the Secretary of Health and Human Services from replacing ICD-9 with ICD-10 in implementing the HIPAA code set standards. • AMA – remains opposed to ICD-10 • Best Practices for ICD-10-CM Documentation 2012 • Preparing for ICD-10-CM • CMS – continues to move forward with compliance date of October 1, 2014

4. ICD-10-CM/PCS • ICD-9-CM: International Classification of Diseases, 9th revision, Clinical Modification • ICD-10: Developed by the World Health Organization as the nomenclature for all countries • ICD-10-CM: International Classification of Diseases, 10th revision, Clinical Modification – US only • ICD-10-PCS: International Classification of Diseases, 10th revision, Procedure Classification System – US only

5. Federal Mandate Timeline • Final Rule Originally Published by HHS on January 16, 2009 requiring the adoption of ICD-10 on October 1, 2013 NO GRACE PERIOD • Dates of Service (outpatient) After 10/1/2013 • Dates of Discharge (Inpatient) After 10/1/2013 • Federal Mandate Updated Timeline: • February 14, 2012 – CMS announces they will “reexamine the pace” of implementing ICD-10 • May 17, 2012 – All comments due to HHS for consideration prior to publication of the final rule • August 27, 2012 – Revised compliance date announced by CMS stating a one-year extension would be granted • October 1, 2014 is the revised ICD-10 Implementation Compliance Date

6. Things to Remember • ICD-10-CM (diagnoses) will be used by all providers in every health care setting • ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures • ICD-10-PCS will not be used on physician claims • This has change has no impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes • CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to hospital inpatients • DSM-V codes have been released; however DSM-V is not HIPAA compliant for claims or transactions

7. Important Information • Inpatient discharges occurring on or after 10-1-2014 will use ICD-10-CM and ICD-10-PCS codes regardless of date of admission. • Outpatient dates of service occurring on or after 10-1-2014 will use ICD-10-CM codes • There will be period of time when payers will be processing both ICD-9 and ICD-10 claims due to claims backlogs, appeals, grievances, etc. • Systems will have to utilize both ICD-9-CM and ICD-10-CM for some period of time. Arkansas Medicaid allows providers 365 days to submit a claim.

8. A Few ICD-10 Benefits • Better data will be available for: • Measuring the quality, safety, and efficacy of care • Designing payment systems and processing claims for reimbursement • Conducting research, epidemiological studies, and clinical trials • Setting health policy • Operational and strategic planning and designing healthcare delivery systems • Monitoring resource utilization • Improving clinical, financial, and administrative performance • Preventing and detecting healthcare fraud and abuse • Tracking public health and risks

9. Current Competing Priorities

10. ICD-9 vs. ICD-10 Diagnosis Codes E codes reference External Causes of Injury & Poisoning in ICD-9. E references the Endocrine system in ICD-10 V codes reference Health Status & Contact with Health Services in ICD-9 V – Y codes reference External Causes of Morbidity in ICD-10

11. ICD-9 Procedure vs. ICD-10-PCS The increase in the number of procedure codes is driven by the increased specificity, granularity & laterality contained within the ICD-10 codes.

12. Patient Flow Impact Providers change coding practices based on ICD-10 Revise for ICD-10 reporting Update data repositories to accommodate new coding Update practice management system Claim priced based on revised fee schedules Update claims submission process Revise authorization process Update system to accept claims Update benefit logic & edits

13. Impact on Providers • First Things First: • Impact Assessment & Gap Analysis • Evaluate Vulnerabilities • Systems • Operations and Processes • Clinical Documentation

14. System Impacts • Identify your current systems and work processes that use ICD-9 codes. This could include: • Practice Management Systems • Reports • Electronic Medical Record Systems • Clinical Documentation • ICD-9 Code Assignment • Encounter Forms and Superbills • Public Health and Quality Reporting Protocols & Reports • A good rule of thumb: Wherever ICD-9 codes appear today, ICD-10 codes will need to replace them in the future

15. System Impacts • If applicable, talk with your practice management/EHR vendor(s) about accommodations for both ICD-9 and ICD-10 codes • Contact your vendor(s) and ask what updates they are planning for your practice management/EHR system and the anticipated install/update implementation date • Check your contract to see if upgrades are included or if there is an additional cost • Discuss implementation plans with any clearinghouses or billing services you may use

16. Operational Impacts

17. Operational Impacts • Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition • Be proactive, don’t wait for vendors to contact you • Ask about their plans for ICD-10 compliance and when they will be ready to collaboratively test their systems • Ask to see their roadmap that supports their claims of “ICD-10 Readiness” • Utilize CMS checklists and resources – new information is posted on www.CMS.org/ICD10

18. Operational Impacts • Talk with your payers about how ICD-10 implementation might affect your contracts. Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, fee schedules or reimbursement methodologies

19. Operational Impacts • Identify potential changes to work flow and business processes • Consider changes to existing processes including: • Clinical documentation • Prior authorization • Encounter forms and Superbills • Report generation • Operational • Quality and Public Health reporting • Involvement in any Care Management initiatives

20. Operational Impacts • Assess staff training needs – coders, billing staff, ancillary staff. Anticipate that everyonein your office will require some level of ICD-10 awareness training • There are many training options and materials available through a variety of resources & venues: • Professional Associations – AAPC, AHIMA • Online Courses – ICD10 Monitor, Contexo University • Webinars – ICD10 Monitor, HC Pro • Onsite Training – Train the Trainer • If you have a small practice, think about collaborating with other local providers

21. Operational Impacts • Budget for time and costs related to ICD-10 implementation including: • Expenses for system changes and software updates • Resource materials • Training • Modifications to forms and Superbills • Other budgetary considerations: • Unanticipated payment delays, appeals & denials • Understand your operational metrics – benchmark for efficiency • Establish a line of credit……

22. Superbills - How Will They Change? • Increased size • Increased specificity • Examples can be found at www.ahima.org/icd10 along with other valuable ICD-10-CM resources

23. Not so Super-Superbill?

24. The appropriate 7th character is to be added to each ICD-10-CM code:A – initial encounter D – Subsequent encounter S - Sequela

25. Continued…

26. Clinical Documentation Practices • If it’s not documented….it’s not done • Outcome Data • Reimbursement • Liability

27. Clinical Documentation Practices A frequent concern heard from providers is that the requirement for documentation to support ICD-10 coding is an “unnecessary administrative burden”. Is the inclusion of this information really an administrative burden? • Laterality – left, right, bilateral or unilateral • Trimester of pregnancy and weeks of gestation • Length of time a patient was unconscious • Which finger, and which level in a finger amputation • The type of surgical approach for procedures • The severity of seizures • The stage of a decubitus ulcer

28. Clinical Documentation Practices • Clinical documentation is the first step in reaching the ultimate goal of better disease and risk management outcomes and data integrity. • Clinical documentation improvement best practices provide accurate coding and clinical data. • Accurate documentation = accurate coding • Accurate coding = richer data & understanding patient needs • Ultimately leading us to better patient outcomes

29. Clinical Documentation Practices • Most of the new concepts introduced in ICD-10 codes are concepts that physicians should be documenting now. • Based on 125 clinical documentation engagements performed by 3M Consulting Services, it was found physician documentation does not support coding at the highest level of specificity 30 to 40 percent of the time. • Documentation requirements vary greatly by specialty or clinical domain. Codes related to ophthalmology have changed little in scope; however, codes related to the musculoskeletal system have increased dramatically. Over 50% of the ICD-10 codes are related to musculoskeletal conditions. Over 17,000 ICD-10 codes (~25%) are related to fractures.

30. Clinical Documentation Practices • AHIMA Online Education Physician Series • Clinical Documentation for ICD-10: Principles & Practice • Short, self-paced training modules • Case-based, real life examples • Provides more than 200 bite-sized, on-demand, specialty-specific training modules that can be accessed anytime or anywhere with a mobile device. (computer, tablet or smartphone) • Delivers 3-5 minute modules that cover physician’s 10 – 20 most billed diagnoses & conditions making learning targeted and relevant to their practice specialty. • www.ahima.org/physicianICD10

31. New Concepts and Features with ICD-10

32. ICD-10 Chapter Titles

33. ICD-10 Chapter Titles

34. Repeating Patterns • Of the 69,000 ICD-10 codes, over one third are the same with the exception of the concept of right vs. left. Considering that most of these codes also have an “unspecified side” option, the ratio is even higher. • For every acute fracture code there is a code for initial encounter, subsequent encounter or sequela. Each code x 3. • If the encounter is a subsequent encounter, then for each fracture there is a code for routine healing, delayed healing, malunion or nonunion. Each code x 4.

35. Understanding Code Patterns **Health Data Consulting

36. Individual Codes vs. Combination Codes • Combination codes for conditions and common symptoms or manifestations • E10.21 Type I diabetes mellitus with diabetic nephropathy • I23.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris • K50.112 Crohn’s Disease of large intestine with intestinal obstruction • Combination codes for Poisonings and External Causes • T36.0X1D Poisoning by penicillins, accidental (unintentional), subsequent encounter • T42.4X5A Adverse effect of benzodiazepines, initial encounter

37. Added Laterality • H60.332 Swimmer’s ear, left ear • M94.211 Chondromalacia, right shoulder • S40.251A Superficial foreign body of right shoulder, initial encounter About 25,000 (36%) of all ICD-10-CM codes are different only in that they distinguish right vs. left

38. The patient is receiving active treatment for the condition • Surgical treatment • Emergency Department encounter • Evaluation and treatment by a new physician

39. Added Seventh-Character for Episode of Care • M80.051A Age related osteoporosis with current pathological fracture, right femur, initial encounter for fracture • S06.0X1A Concussion with loss of consciousness of 30 minutes or less, initial encounter • S52.132A Displaced fracture of neck of left radius, initial encounter for open fracture Type I or II or initial encounter for open fracture NOS

40. After patient received active treatment for the condition and receiving routine care during healing or recovery phase • Cast change or removal • Removal of external or internal fixation device • Medication adjustment • Other aftercare and follow-up visits following injury treatment

41. Encounter Codes • M80.051A Age related osteoporosis with current pathological fracture, right femur, initialencounter for fracture • M80.051D Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing

42. Complications or conditions that arise as a direct result of a condition • Scar formation after burn • Use both the injury code that precipitated sequela and code for sequela • S added only to injury code, not sequela code • S identifies injury responsible for sequela • Specific type of sequela (like scar) sequenced first, followed by injury code

43. Encounter Codes • M80.051A Age related osteoporosis with current pathological fracture, right femur, initialencounter for fracture • M80.051D Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing • M80.051S Age-related osteoporosis with current pathological fracture, right femur, sequela

44. Pathological or Stress Fracture Seventh Characters

45. Fractures • Type of fracture • Specific anatomical site • Displaced vs. nondisplaced • Laterality – right vs. left • Routine vs. delayed healing • Nonunion • Malunion • Type of encounter • Initial • Subsequent • Sequela

46. Episode of Care Codes • M80.051D Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing • M80.051G Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with delayed healing • M80.051K Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with nonunion • M80.051P Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with malunion

47. Fractures • Some fracture categories provide for seventh characters to designate the specific type of open fracture based on the Gustilo open fracture classification • A fracture not indicated as displaced or nondisplaced should be coded as displaced • A fracture not designated as open or closed should be coded as closed

48. Gustilo Classification

49. Clinical Scenario Patient presents to the ER for severe right lower leg pain with an open leg wound following a fall from a ladder. The physician documented that the patient had an open transverse fracture of the shafts of the tibia & fibula. ICD-9-CM code: • 823.32, Open fracture of shaft, fibula with tibia • E881.0 Accidental fall from ladder ICD-10-CM codes: • S82.221B, Displaced transverse fracture of shaft of right tibia, initial encounter for open fracture NOS • S82.421B Displaced transverse fracture of shaft of right fibula, initial encounter for open fracture NOS • W11.XXXA Fall on and from ladder, initial encounter

50. Inclusion of Trimesters in Obstetrics Codes • O10.012 Pre-existing essential hypertension complicating pregnancy, second trimester • O99.013 Anemia complicating pregnancy, third trimester