ICD 10: The Road Forward - Molina Healthcare

Puerto RicoICD 10: The Road Forward

Agenda ICD-10 OverviewICD-10 DocumentationExamplesImplementationPutting into PracticeResources2

Overview

Final Rule Issued On July 31st, 2014, The U.S. Department ofHealth and Human Services (HHS) issued arule finalizing Oct. 1, 2015 as the newcompliance date.4

Now is the Time to PrepareCompliance Date – Oct. 1, 2015ICD-10 Go LiveOctober 1, 2015Jan 2015End-to-End TestingJul 1 – Dec 31, 2014Build and MaintainMomentumJul2014AugSepOctNovApr 2015End-to-End TestingJul 2015End-to-End TestingOct 1, 2015 – Feb 29, 5FebMarAprMayJul 1, 2014 – Sep 30, 2015Acknowledgement Testingwith StakeholdersJunJulAugApr 1 – Sep 30, 2015Operational Readiness5SepOctNovDecJan2016Feb

ICD10 Quick Facts ICD-10 international version– Adopted by WHO in 1990– Most countries other than the US currently use ICD10– ICD-10 (International version) 12,500 diagnosticcodes– ICD-10 used for mortality reporting in the US - 1999 ICD-10-CM (US version)– 69,000 diagnostic codes– Final rule published – 2009ICD-10-PCS– 72,000 codes– Not part of an international standard– Inpatient procedures only6

The “Anatomy” of ICD-10structureAlpha (notU)Numeric1stcharacter2ndcharacter Can be any combination of alpha or numericcharacters racterEtiology, Anatomical Site, Severity 3 character codes ONLY if not further subdivided Codes without all required characters are invalid Alpha characters are NOT case specific (e.g., s93.401A)77thcharacterExtension

ICD-10 codes have UP TO 7charactersThe following are examples of the many possible alphaand numeric characters that are used in the 7thcharacter position:7th character A Initial EncounterD Subsequent EncounterS Sequelae3 Fetus #3 in multiplegestation, complication ofOften seen in: Obstetrics, Musculoskeletal conditions suchas fractures, injuries, and many others8

ICD9 Comparison to ICD10-CMDiagnosis Codes – Clinical ExampleA patient is seen in the emergency room with an acuteexacerbation of her severe persistent asthma.ICD-9 only captures part of the information available forthis patient.ICD9 Code49312DescriptionIntrinsic asthma with (acute) exacerbation9

ICD9 Comparison to ICD10-CMDiagnosis Codes – Clinical ExampleA patient is seen in the emergency room with an acuteexacerbation of her severe persistent asthma.ICD-10 provides a more complete description of thispatient’s condition compared to the limited informationavailable in ICD-9ICD10 CodeJ4551DescriptionSevere persistent asthma with (acute) exacerbationICD9 Code49312DescriptionIntrinsic asthma with (acute) exacerbation10

Each Physician Will Use aSmall Subset of ICD-10 Codes 34,250 (50%) of all ICD-10-CM codes are related tothe musculoskeletal system 17,045 (25%) of all ICD-10-CM codes are related tofractures 25,000(36%) of all ICD-10-CM codes to distinguish‘right’ vs. ‘left’ Only a very small percentage of the codes willbe used by most providersSource: Health Data Consulting11

Varying Code VolumeBy Clinical AreaClinical AreaICD-9 CodesICD-10 CodesFractures74717099Poisoning and toxic effects2444662Pregnancy related conditions11042155Brain Injury292574Diabetes69239Migraine4044Bleeding disorders2629Mood related disorders7871Hypertensive Disease3314End stage renal disease115Chronic respiratory failure74Source: Health Data Consulting12

Current Distribution ofICD-9 Diagnosis Codes3 Years of Data – All claims – 1 Million Lives Over 72% of all chargesinvolve only 5% of codesTotal Charges by Code3 years - 10 Bill Almost 85% of all chargesare covered by 10% ofcodes80.0%70.0%60.0%50.0%40.0%Charge %30.0%20.0%10.0%13 5%next 5%0.0% Over 95% of all chargesare covered by 15% ofcodes Similar results areexpected with ICD-10codes

Coding SpecificityNo Place for “Unspecified” Codes If there is sufficient information available to moreaccurately define the condition For basic concepts such as:––––––Laterality (Right, Left, Bilateral, Unilateral)Anatomical locationsSource: Health Data ConsultingTrimesterType of diabetesKnown complications or comorbiditiesDescription of severity, acute or chronic or other known parameters Where care is implemented that demands a morespecific level of detail At specialty level that should be able to define the detailrequired14

Coding SpecificityA place for “Unspecified” Codes Sometimes unspecified makes sense – The patient may be early in the course ofevaluation– The claim may be coming from a provider whois not directly related to diagnosing the patient’scondition and unfamiliar with all the details– The clinician seeing the patient may be more ofa generalist and not able to define the conditionat a level of detail expected by a specialist15

Leveraging ICD10Better Information Greater detail Enhanced categorization models Greater severity and risk definition Greater precision of definition Greater forward flexibility Greater ability to integrate clinical information16

ICD-10 Documentation

ICD-10 Clinical DocumentationImpactsTiming ofTimingofcarecareCombination codeswith Symptomsand/or ManifestationsAnatomical sitespecificityComplicationsLateralityStatus codes, personaland family historycodesDisease acuityGeneral – BMI, tobaccouse/smoking exposure,health status18

Clinical DocumentationKnow Your Role The role of the clinician is to document asaccurately as possible the nature of the patient’sconditions and services provide to maintain orimprove those conditions The role of the coding professional is to assure thatcoding is consistent with the documentation The role of the business manager is to assure thatall billing is accurately coded and supported by thedocumented facts19

Clinical Documentation –The Patient InterfaceWhere It All BeginsPhysical ExamHistoryInternal Record ReviewExternal Record ReviewStudiesAssessment/Diagnosis20

Good Patient DataIt’s all About Good Patient Care Observation of all objective and subjective factsrelevant to the patient condition Documentation of all of the key medicalconcepts relevant to patient care currently and inthe future Coding that includes all of the key medicalconcepts supported by the coding standard andguidelines21

Clinical DocumentationWhat They Taught Us in Medical School Type of Condition Onset Etiology / Cause Anatomical Location Laterality Severity Environmental Factors Time Parameters22 Comorbidities Complications Manifestations Healing Level Findings & Symptoms External Causes Type of Encounter

DocumentationWhy Is It Important? Supports proper payment and reduces denialsAssures accurate measures of quality and efficiencyAddresses the issue of accountability and transparencyCreates a competitive advantageProvides better business intelligenceSupports clinical researchSupports interoperable sharing of dataIt’s just good care!23

How documentation Impacts The PracticeA Changing World of Cost ContainmentAccurate and complete documentation and coding providesopportunities to support the transition into a “value-based”,“accountable care” reimbursement environment. Better representation of severity and risk Opportunities to reduce audit risk exposure More accurate measures of quality and efficiencyRecognition of varying levels of complexityBetter claim information to support automatedprocessing and more rapid reimbursementImproved business intelligence to support population riskmanagement24

Examples

Exercise 1AsthmaCurrent History8 year old female here for follow up to ER visit 2 days ago for shortness of breath.The patient was discharged with a diagnosis of asthma and Albuterol inhalerprescription. Patient is stable on inhaler.History Patient has seasonal allergies with rhinorrhea and a history of wheezing duringphysical exertion. Last episode occurred during PE at school and the patientwas taken to the ER for assessment and treatment. Patient has been exposed to second hand cigarette smoke since infancy; fatheris a pack-a-day smoke The patient has a history of moderately severe episodes of awakening at nightapproximately 2 times a week requiring the use of an inhaler.Assessment Moderate persistent asthma Seasonal allergic rhinitis Second hand smoke exposure26

Answer 1AsthmaCODINGICD-9-CM Diagnosis Codes493.02 – Asthma, extrinsic, acute exacerbation477.0 – Allergic rhinitis, due to pollenANALYSIS ICD-10-CM Diagnosis CodesJ45.41– Moderate persistent asthma with(acute) exacerbationJ30.1 – Allergic rhinitis, due to pollenZ77.22 – Contact with and (suspected)exposure to environmental tobacco smoke(acute) (chronic)ICD-10 does not include the concept of extrinsic, but does include whether asthma is mildintermittent or persistent or moderate and severe persistent.ICD-10 guidelines now require the use of an additional code to indicate if a patient is exposedto tobacco smoke.Moderate Persistent AsthmaSymptoms occur daily, and the disease severity warrants regular use of medications forcontrol.Patients are constantly aware of their disease, require medications on a daily basis, havetheir sleep interrupted at least weekly, and have to accommodate their life style to thedisease.27Pulmonary function is moderately abnormal, with the FEV1 being 60-80

Exercise 2Breast Cancer with Chemotherapy Induced AnemiaCurrent History:The patient is a 44 year old female with Estrogen positive, Stage IIinvasive ductal carcinoma in the lower inner quadrant of the left breast.She has been receiving chemotherapy and complains of extreme fatigue,headaches, dizziness and rapid heart rate. Hematology studies indicateaplastic anemia consistent with chemotherapy treatment.History Patient has completed first round of chemotherapy.Assessment Malignancy left breast; estrogen positive Drug induced aplastic anemia28

Exercise 2 AnswerBreast Cancer with Chemotherapy InducedAnemiaCODINGICD-9-CM Diagnosis Codes284.89 – Other specified aplastic anemiasICD-10-CM Diagnosis CodesD61.1 - Drug-induced aplastic anemiaE933.1 Therapeutic use of Antineoplasticagents174.3 – Malignant neoplasm of female breast,lower-inner quadrantV86.0 Estrogen receptor positiveT45.1X5D - Adverse effect of antineoplasticand immunosuppressive drugsC50.312 - Malignant neoplasm of lower-innerquadrant of left female breastZ17.0 - Estrogen receptor positive status[ER ]ANALYSIS ICD-10 includes a new guideline that requires the reporting of an adverse effect codewhen anemia is associated with chemotherapy. ICD-10 has codes for Estrogen receptor positive or negative status codes. Adverse effect codes are found in the Table of Drugs and Chemicals in ICD-10-CM.29

Exercise 3MusculoskeletalCurrent HistoryPatient’s neck hurts and I have a tingling pain sensation going down my right arm.History Patient is a 68 year-old male with history of neck pain that has been worseningover the last two years. Recently, he has experienced some numbness and apainful tingling sensation in his right arm going down to his thumb. No othersymptoms or pertinent medical history.Assessment Review of systems is negative except for the neck pain and sensations in hisright arm described above. No history of acute injury to neck or arm. Physical exam is normal except for neurological exam of the right upperextremity, which reveals slight decrease to sensation in the thumb andforefinger region of the hand in the C6 nerve root distribution. No evidence ofweakness in the muscles of the arm or hand. MRI scan of the neck shows degenerative changes of the C5-6 disc with lateralprotrusion of disc material. No other abnormalities noted. Cervical transforaminal injection at C5-6.30