Laurie Aloi, CHC, CHPC, CPC Director of Billing & Compliance MedSafe October 21, 2013

1. ICD-10 OverviewNext Steps to ICD-10 Laurie Aloi, CHC, CHPC, CPC Director of Billing & Compliance MedSafe October 21, 2013

2. Agenda • Understanding what’s coming • Timeline and history • Delay in Implementation • What is ICD-10? • Side by Side examples • Review of Coding Guidelines • Planning for a Successful Transition

3. When? • The Department of Health and Human Services (HHS) originally announced the plan for ICD-10-CM implementation. • In August 2009, CMS announced the implementation date would be October 1, 2011 • The date was pushed back in January 2009 after MGMA and AAPC appealed to CMS that the training and software transition would be a burden to the medical profession • Practices have had 4 years to prepare and should be learning about- • What ICD-10 is • What will need to be done to prepare

4. And Now? On February 16, 2012 HHS Secretary Kathleen Sebelius has announced that the October 1, 2013 date for implementation of ICD-10 has been pushed back indefinitely “ICD-10 codes are important to many positive improvements in our health care system. We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead.  We are committing to work through the rulemaking process, with the provider community, to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.” 5

5. New Implementation Date On April 9, 2012, CMS announced that the new implementation date will be October 1, 2014 The extra year will give medical practices more time to shift from the demands of Meaningful Use and Quality, to the issues of training and implementing ICD-10

6. Why change from ICD-9? • ICD-9-CM has several problems. After 30 years, it is no longer useful. • It is out of room.  Because the classification is organized scientifically, each three-digit category can have only 10 subcategories. Most numbers in most categories have been assigned diagnoses. Medical science keeps making new discoveries, and there are no numbers to assign these  diagnoses. ICD-10 expands to 7 digits. • Computer science, combined with new, more detailed codes of ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care provided. • These same details will streamline claims submissions, since these details will make the initial claim much easier for payers to understand.

7. A large share of the world is using ICD-10 since it was introduced in 1992 • United Kingdom (1995) • Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) (1994 – 1997) • France (1997) • Australia (1998) • Belgium (1999) • Germany (2000) • Canada (2001)

8. Reimbursement and Quality problems with ICD-9 Example – fracture of wrist Patient fractures left wrist A month later, fractures right wrist • ICD-9-CM does not identify left versus right – • requires additional documentation • ICD-10-CM describes • Left versus right • Initial encounter, subsequent encounter • Routine healing, delayed healing, nonunion, or malunion

9. ICD-10 Changes everything

10. From this…..

11. To this

12. ICD-10 Major Modifications Added trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used) Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be used) Expanded codes (e.g., injury, diabetes) Added code extensions for injuries and external causes of injuries

13. Laterality- Left versus Right - C50.1 Malignant neoplasm, of central portion of breast • C50.111 Malignant neoplasm of central portion of right female breast • C50.112 Malignant neoplasm of central portion of left female breast

14. Structural Differences ICD-9 ICD-9-CM has 3 – 5 digits Chapters 1 – 17: all characters are numeric Supplemental chapters: first digit is alpha (E or V), remainder are numeric Examples: • 496 Chronic airway obstruction not elsewhere classified (NEC) • 511.9 Unspecified pleural effusion • V02.61 Hepatitis B carrier

15. Structural Differences ICD-10 • ICD-10-CM has 3 – 7 digits • Digit 1 is alpha (A – Z, not case sensitive) • Digit 2 is numeric • Digit 3 is alpha (not case sensitive) or numeric • Digits 4 – 7 are alpha (not case sensitive) or numeric • A66 Yaws • A69.20 Lyme disease, unspecified • O9A.311 Physical abuse complicating pregnancy, first trimester • S42.001A Fracture of unspecified part of right clavicle, initial encounter for closed fracture

16. Format and Guidelines • ICD-10-CM Organization • Introduction • How to Use • Official Guidelines • Alphabetic Index • Neoplasm Table • Table of Drugs and Chemical • Index to External Causes

17. Format and Guidelines • ICD-10-CM Organization • Tabular • Chapters • ICD-10-CM has 21 Chapters • Blocks • Example • Chapter 8 – Diseases of the Ear and Mastoid Process is divided into 5 blocks • H60-62 Diseases of the external ear, • H65-75 Diseases of the middle ear and mastoid, • H80-83, Diseases of the inner ear, • H90-94 Other disorders of the ear, • H95 Intraoperative/postprocedural complications

18. Comparison of Code Sets

19. Structural Differences In the ICD-10 diagnosis code set, the alpha characters are not case sensitive. These examples show a comparison of the formats of the ICD-9 and ICD-10 diagnosis codes. You can see the use of alpha characters and longer codes in ICD-10

20. ICD-10 Structure • The expanced number of characters of the ICD-10 diagnosis codes provides greater specificity to identify disease etiology, anatomic site, and severity • Characters 1-3 - Category • Characters 4-6 - Etiology, anatomic site, severity, or other clinical detail • Character 7 – Extension (example- episode of care or other clinical detail)

21. Detailed Example S52 Fracture of Forearm S52.5 Fracture of lower end of radius S52.52 Torus fracture of lower end of radius S52.521 Torus fracture of lower end of right radius S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture

22. Side by side example #1

23. Side by side example #2

24. Similarities • Index abbreviations (NEC) • Tabular abbreviations (NOS) • “and” means “and/or” • “other specified” and “unspecified” are the same • Includes notes • Example: • I70.24 Atherosclerosis of native arteries of left leg with ulceration Includes any condition classifiable to I70.212 and I70.222

25. Similarities • Use additional code….’, ‘Code first’ and ‘Code also’ notes • Example: • G47.3 Sleep apnea • Code also any associated underlying condition • Inclusion terms • Official coding guidelines • CMS • NCHS • AHA • AHIMA

26. Differences • ICD-10-CM codes are all alphanumeric • First character is always an alpha character • Subsequent characters may be alpha or numeric • Example: • I82.a11 Acute embolism and thrombosis of right axillary vein • Codes may be 3, 4, 5, 6 or 7 characters in length • Code Descriptions are listed in full

27. A Place for everything, everything in its place- Benjamin Franklin The fact that the codes are up to seven characters in length is a major difference that brings two new considerations: seventh character extenders and dummy placeholders. The seventh character extenders are usually a letter, and are used to identify the encounter type. The most common seventh character extenders used in ICD-10-CM are: A-Initial Encounter for closed fracture B- Initial encounter for open fracture D- Subsequent Encounter for fracture with routine healing G- Subsequent encounter for fracture with delayed healing K- Subsequent encounter for fracture with nonunion P- Subsequent encounter for fracture with malunion S- Sequela 27

28. A unique twist- the “Placeholder” • Some codes are 7 characters, but no 4th, 5th or 6th place is necessary, so “x” is a placeholder • T68.xxxA - Hypothermia • The appropriate 7th character is to be added to code T68 • A – initial encounter • D – Subsequent encounter • S – sequela

29. Body Systems • Blood and Blood Forming • Organs • Immune System • Endocrine System • Nervous System • Eye and Adnexa • Ear and Mastoid Process • Circulatory System • Respiratory System • Digestive System • Integumentary System • Musculoskeletal System • Genitourinary System • Pregnancy, Childbirth, and Puerperium

30. Diseases of the Circulatory System

31. Diseases of the Respiratory System

32. Signs and Symptoms

33. Diseases of the Respiratory System 11/12/12 33

34. Diseases of the Respiratory System 11/12/12 34

35. Common OB Gyn Conditions

36. V Codes will be Z Codes

37. Diseases of the Musculoskeletal System

38. Diseases of the Musculoskeletal System

39. Diseases of the Musculoskeletal System

40. Diseases of the Musculoskeletal System

41. Diseases of the Musculoskeletal System

42. Anatomy and Pathophysiology Higher level of specificity found in the new codes In order to assign them correctly we have to first understand them For example – the musculoskeletal system comprises 60% of the codes found in ICD-10 206 bones in the body 80 are Axial • head, facial, hyloid, auditory, trunk, ribs, and sternum 126 are Appendicular • arms, shoulders, wrists, hands, legs, hips, ankles and feet

43. Types of Fractures Displaced fractures Non-displaced fractures Closed fracture Open fracture Greenstick Fracture Transverse fracture Spiral fracture Oblique fracture Compression fracture

44. Anatomy and Pathophysiology - Musculoskeletal system Classification is needed for open fractures using the “Gustilo Open fracture classification system” This system identifies fractures as Type I, II, IIIA, IIIB and IIIC I – Low energy, wound less than 1 cm II – Wound greater than 1 cm with moderate soft tissue damage III – High energy wound greater than 1 cm with extensive soft tissue damage IIIA – Adequate soft tissue cover IIIB – Inadequate soft tissue cover IIIC – Associated with arterial injury

45. Diseases of the Musculoskeletal System

46. Neoplasm

47. Comparison of ICD-9 Chapters to ICD-10 Chapters • ICD-9 • There are 17 Chapters, plus 2 supplementary chapters of V codes and E Codes • *see spreadsheet • ICD-10 • There are 22 Chapters in ICD-10 • Eye and Adnexa • Ear and mastoid Process • External causes of morbidity and mortality (separate from injury and poisoning) • Codes for Special Purposes

48. Guidelines It is essential for a coder to review the chapter guidelines in the front of the ICD-10 manual Chapter changes are summarized below Many chapter guidelines are the same as ICD-9

49. Blood and Blood Forming Organs • Sepsis • Complication of infection outside the blood stream • Blood stream carries bacteria or other organism through blood to other sites • Sepsis vs. bacteremia vs. septicemia • Bacteremia - presence of bacteria in the blood • Septicemia - presence of bacteria in the blood (bacteremia) • Sepsis - a serious condition characterized by a whole-body inflammatory state (systemic inflammatory response) with the presence of suspected or known infection

50. Chapter 15 Guidelines- Pregnancy, Childbirth, and the puerperium (O00-O099) a. General Rules for Obstetric Cases • 1) codes from chapter 15 have sequencing priority over codes from other chapters. • Should the provider document the pregnancy is incidental to the encounter, code Z33.1 pregnant state, incidental, in place of any chapter 15 codes. (condition not affecting pregnancy) • 2) Chapter 15 codes are used only on the maternal record and never on the newborn record • 3) final character for trimester