ICD-10 Will Change Everything - AAPC
9/21/2010ICD-10 Will Change EverythingDeborah Grider, CPC, CPC-I, CPC-H,CPC-P, CEMC, CPMA, COBGC, CPCD,CCS-PPresident & CEOAAPCAuthor of “ICD-10 ImplementationGuide,, Make the TransitionpManageable,” AMA Press, 2009ICD-10 Final Rule CMS-0013-F Published Januaryy 16, 2009 October 1, 2013 – Compliance date for implementation of ICD-10-CM andICD-10-PCS (no delays)No impact on Current Procedural Terminology(CPT ) and Healthcare Common ProcedureCoding System (HCPCS) .pdf1
9/21/2010ICD-10 Final Rule Issues Single implementation date for all usersooDate of service for ambulatory and physician reportingDate of discharge for inpatient settings ICD-9-CM codes will not be accepted for servicesprovided on or after October 1, 2013 ICD-9-CM claims for services prior toimplementation date will continue to flow throughtf a periodi d off timetisystemsfor 4010 electronic transaction standard to 5010 –January 1, 2012Version 5010 New version of the HIPAA standards - Version 5010 includes: Structuralfront matterTechnicalData content improvementsThe updated version is more specific in requiring the data that isneeded, collected, and transmitted in a transaction; its adoptionwill reduce ambiguitiesVersion 5010 addresses currently unmet business needs,including,example, providing on institutional claims anincluding for exampleindicator for conditions that were “present on admission”Version 5010 also accommodates the use of the ICD-10 codesets, which are not supported by Version 4010/4010A12
9/21/2010What Does 5010 Bring? Clarity and consistency in front matter Clarity in situational elements to minimize need for companionguides Changes in some segments and data elements to better representbusiness processes Example – change in use of subscriber loop in claims Enables use of ICD-10 Claims Enables use of POA indicator Separates diagnosis code reporting Clarifies use of NPI Required minutes for anesthesia as opposed to units or minutes Provides greater consistency between dental and professionalclaimsUse of Clinical Coding Data Benchmarking and quality management – to improve the quality and effectiveness of patientcareDecision-making (clinical, financial, funding,expansion, education)Healthcare policy and public health trackingReimbursementResearch3
9/21/2010ICD-10 Changes From 14,025 codes to approximately 68,000 ICD 10-CM codesAll codes haveICD-10ha e fullf ll descriptions for both ICD10CM and ICD-10-PCSICD-9-CM 2010 14,025 codesICD-10-CM 2010 69,101Provider ImpactsDocumentation of diagnoses and procedures Codes must be supported by medicaldocumentation ICD-10-CM codes are more specific Revenue Impacts of specificity Denials Additional Documentation4
9/21/2010Provider ImpactsooCoverage and payment New coding system will mean new coverage policies,new medical review edits, new reimbursementschedules Changes will be made to accommodate increasespecificity May need to discuss changes with patientsContracts with plansC di more specificifi andd iincludesl d severityit Coding Renegotiations will be based on new coding, coverage, andreimbursement Difficult to measure what the changes will mean to overallreimbursementProvider ImpactsooBilling and eligibility transactionso Updated transactions include support for ICD-10o New codes mean more specificityo How smooth the transition?o Expect increased reject, denials, and pended claimsas both plans and providers get used to new codesLaboratory orderso Will need specific ICDICD-10-CM10 CM codes for laboratoryorderso Expect coverage changeso Need to support the tests ordered5
9/21/2010Health Plan Impacts Contracting with providers and employersCoverage determinationsPayment determinationsMedical review policiesPlan structuresStatistical reportingActuarial projectionsFraud and abuse monitoringQuality measurementsConcerns for Billing and Collection Patient/Provider/Plan ConfusionoooIncrease in denials?Patient misunderstanding of changes in coverageProvider questions Older debt versus newer servicesoUsing ICD-9 codes versus ICD-10 for rebilling Privacy concernsoNew codes contain significantly more detail, howmuch can be shared6
9/21/2010Impacts of Other Changes High Deductible Health PlansooMajor increases in patient responsibilityNo requirement to spend HSA money on medicalexpense Real Time AdjudicationoooA near instantaneous responseto a pprovider claimspKnow patient responsibility immediatelyLess bad debt?Format and StructureCategoriesAlphanumeric3 charactersSubcategories4 or 5charactersCodesUp to 7characters7
9/21/2010ICD-10 CM FormatXXXCategoryX X XEtiology, Anatomical site, SeverityXExtensionICD-10-CM Structure ICD-10 consists of: Tabular list containing cause of death titles andcodes (Volume 1)Inclusion and exclusion terms for cause of deathtitles (Volume 1)Alphabetic index to diseases of injuryj yExternal causes of injuryDescriptions, guidelines and coding rules(Volume 2)Table of drugs and chemicals (Volume 3)168
9/21/2010Hierarchy Structure Differences in ICD-10-CMooooooooAlphanumeric StructureAddition of 6 and 7 digit extensions to provide a higher level ofspecificityMore specificityReorganizing and adding chaptersDiagnostic codes will be more preciseExpanded to include health-related conditionsCreation of combination diagnosis/symptom codes to reduceth numberb off codesd neededd d tot fullyf ll describedib a conditiondititheThe new structure will allow further expansion than waspossible with ICD-9-CMOrganization The ICD-10 codes are organized differently than the ICD-9ICD 9 codesExample:oooSense organs have been separated from nervoussystem disorderInjuries are grouped by anatomical site rather thaninjury categoryPostoperative complications have been moved toprocedure-specific body system chapter9
9/21/2010Chapters and Sub-Chapters Chapters further divided into subchapters or blocks(“Rubrics”) Rubrics Identify conditions closely related A summary of the subchapters is found in eachchapter Indicates overview of the classification structure19Organizational Changes Some Significant Changes:ooooooInjuriesCombined codesReassignment of existing codes to new categoriesAlpha extensionsExcludes note changesGuidelines10
9/21/2010Five-Six Character Subclassification In ICD-10-CM, a fifth or sixth six character sub classifications represents the most accuratelevel of specificityThis addition may identify more specificityregarding the patient’s condition or diagnosisLet’s Talk Differences Going from 14,02514 025 codes to over 6969,101101ooooRequires greater specificityLateralityStages of healingTrimesters in pregnancy11
9/21/2010Comparison ICD-10-CMICD-9-CMICD-10-CM Alphanumeric: Numeric exceptfor V and E codes Minimum: 3 digits Maximum: 5 digits Decimal point: yes, after thirddigit Dummy placeholder? No Lacks laterality 3-7 digitsDigit 1 is AlphaDigit 2 and 3 numericDigit 5-7 are alpha or numericMinimum: 3 digitsMaximum: 7 digits (somechapters have 7th characterextension Decimal point: yes, after thirddigit Dummy placeholder: “x” Laterality -Yes23ComparisonICD-9-CMICD9 CM 931 Foreign body inearICD-10-CMICD10 CM T16.1xxa Foreignbody in right ear, initialencounter T16.2xxd, Foreignbody in left ear,subsequent encounter T16.3xxq, Foreignbody in ear,unspecified ear,sequela2412
9/21/2010Laterality For bilateral sites Final character of the codes in the ICD-10CM indicates laterality Right side is always character 1Left side character 2In those cases where a bilateral code is providedBilateral character is always 3An unspecified side code is also provided should the sidenot be identified in the medical recordUnspecified side is either a character 0 or 9, depending onwhether it is a 5th or 6th character25Laterality Example: A patient is treated for cholesteaoma ofmastoid bilateral. H71.2 Cholesteatoma of mastoidooooH71.20 Cholesteatoma of mastoid, unspecified earH71.21 Cholesteatoma of mastoid, right earH71.22 Cholesteatoma of mastoid, left earH71.23 Cholesteatoma of mastoid, bilateral Correct code: H71.23 for this patient encounter2613
9/21/2010Excludes1 ExampleH61.3 Acquired stenosis of external ear canalExcludes1: postprocedural stenosis of external ear canal(H95.81-)27Excludes2 ExampleJ45 AsthmaExcludes2: asthma with chronic obstructive pulmonarydiseasechronic asthmatic (obstructive) bronchitischronic obstructive asthma2814
9/21/2010Etiology/Manifestation Convention “Code first”oUnderlyingandbodymanifestationsU d l i etiologyti ld multiplelti l bd systemtif t tidue to underlying etiology “Use additional code”oConvention that identifies another code is required to reportthe manifestation “In diseases classified elsewhere”ooComponent of the etiology/manifestation conventionNever permitted as first listed diagnosis When referencing Alphabetic IndexoManifestation codes in brackets always reported secondarily29Three Digit Categories The coding professional should note the following change in the fifthcharacters with regardgto code ICD-9-CM code 385.0,,Tympanosclerosis. Fifth digits in ICD-9-CM delineate the site oftympanosclerosis, but sixth characters in ICD-10-CM delineatelaterality. H74 other disorders of middle ear mastoidExcludes2: mastoiditis (H70.0-)H74.0 TympanosclerosisH74.01 Tympanosclerosis, right earH74.02 Tympanosclerosis, left earH74.03 Tympanosclerosis, bilateralH74.09 Tympanosclerosis, unspecified ear3015
9/21/2010Four Character Subcategory Four digit sub-categories define: the site etiology manifestation or state of the disease orcondition. The four-digit sub-category includes thethree-digit category plus decimal with anadditional digit to further identify thecondition to the highest level of specificity31Four Character Subcategory C15 Malignant Neoplasm of the Esophagus C15.3C153C15.4C15.5C15.8C15.9Malignant neoplasm of upper third of esophagusMalignant neoplasm of middle third of esophagusMalignant neoplasm of lower third of esophagusMalignant neoplasm of overlapping lesion of esophagusMalignant neoplasm of esophagus, unspecified3216
9/21/2010Five-Six Character SubclassificationICD-10-CM, a fifth or sixth six character In ICD-10-CM sub-classifications represents the mostaccurate level of specificityThis addition may identify more specificityregarding the patient’s condition or diagnosis33Expansions Most of the codes have been expanded to include fourth and,, in manyy cases,, fifth and sixthcharacters.For example, in ICD-9-CM, Acute nonsuppurativeotitis media, unspecified, is classified to 381.00.3417
9/21/2010Expansions ICD-10-CM, the codes are as follows:H65.1H65 65.117Other acute nonsuppurative otitis mediaAcute and subacute allergic otitis media (mucoid) (sanguinous) (serous)Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), right earAcute and subacute allergic otitis media (mucoid) (sanguinous) (serous), left earAcute and subacute allergic otitis media (mucoid) (sanguinous) serous), bilateralAcute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, right earAcute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, left earAcute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, bilateralAcute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent,unspecified earH65.119 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), unspecified ear35Category Split Nonsuppurative otitis media and Eustachian tubedisorders (ICD-9-CM category code 381) is only oneof several codes that has been split into two categorycodes in ICD-10-CM:o H65 Nonsuppurative otitis mediao H68 Eustachian salpingitis and obstruction3618
9/21/2010Diseases of the Ear and MastoidProcess (H60–H95) H60–H62H60 H62 H65–H75 H80–H83 H90–H95Diseases of external earDiseases of middle ear andmastoidDiseases of inner earOther disorders of ear37Perforation of Tympanic Membrane Perforation of tympanic membrane (ICD-9-CM code 384.2) is assigned to perforation of tympanicmembrane, category code H72 in ICD-10-CMThis category now has instructions to code first anyassociated otitis media:oooooooH65.—, Other acte nonsuppurative otitis mediaH66.1—, Acute suppurative otitis mediaH66.2H66.2—,, Chronic atticoantral suppurative otitis mediaH66.3—, Other chronic suppurative otitis mediaH66.4—, Suppurative otitis media, unspecifiedH66.9—, Otitis media, unspecifiedH67.—, Otitis media in diseases classified elsewhere3819
9/21/2010New Section ICD-10-CM contains a new section,Intraoperative and postproceduralpcomplicationsand disorders of ear andmastoid process, not elsewhere classified(H95)ooFurther divided into fourth-, fifth-, and even sixthcharacter codesCodes reflect conditions such as hemorrhage,hematoma accidental puncturehematoma,puncture, stenosisstenosis, and soon that would have generally been classified to thecomplications section of chapter 17 in ICD-9-CM39ExampleH95.111H95111 Chronic inflammation ofpostmastoidectomy cavity, right sideo H95.112 Chronic inflammation ofpostmastoidectomy cavity, left sideo H95.113 Chronic inflammation ofpostmastoidectomy cavitycavity, bilateralo H95119 Chronic inflammation ofpostmastoidectomy cavity, unspecifiedo20
9/21/2010Influenza The code for Influenza with involvement of ggastrointestinal tract,,has been expanded in ICD-10-CM to reflect the manifestationsof the influenza:J10.8 Influenza with other manifestationsJ10.81Influenzal gastroenteritisJ10.89Influenza with other manifestationsInfluenzal encephalopathyInfluenzal myocarditis41Acute TonsillitisJ03Acute tonsillitisJ03.0Streptococcal tonsillitisJ03.00 Acute streptococcal tonsillitis, unspecifiedJ03.01 Acute recurrent streptococcal tonsillitisJ03.8Acute tonsillitis due to other specified organismsJ03.80 Acute tonsillitis due to other specifiedorganismsJ03.81 Acute recurrent tonsillitis due to otherspecified organisms4221
9/21/2010Acute TonsillitisJ03Acute tonsillitis (continued)J03.9Acute tonsillitis, unspecifiedFollicular tonsillitis (acute)Gangrenous tonsillitis (acute)Infective tonsillitis (acute)Tonsillitis (acute) NOSUlcerative tonsillitis (acute)J03.90 Acute tonsillitis, unspecifiedJ03.91 Acute recurrent tonsillitis, unspecified43Respiratory System Acute pharyngitis has been expanded in ICD-10-CM todelineate the causative organismJ02Acute pharyngitisJ02.0 Streptococcal pharyngitisJ02.8 Acute pharyngitis due to other specifiedorganismJ02.9 Acute pharyngitis, unspecifiedf4422
9/21/2010Expansion ICD-9-CM does not have a specific code foracute recurrent sinusitis. ICD-10-CMincludes subcategories for this 91Acute recurrent maxillary sinusitisAcute recurrent frontal sinusitisAcute recurrent ethmoidal sinusitisAcute recurrent sphenoidal sinusitisAcute recurrent pansinusitisOther acute recurrent sinusitisAcute recurrent sinusitis, unspecified45Five-Six Character Subclassification ExampleReview category 493 (ICD-9-CM) in comparison with Category J45 (ICD-10-CM)ICD-9-CM493 Asthma493.0 Extrinsic asthma493.00 Extrinsic asthma, unspecified493.01 Extrinsic asthma with statusasthmaticus493.02 Extrinsic asthma, with((acute)t ) exacerbationb ti493.1 Intrinsic asthma493.10 Intrinsic asthma, unspecified493.11 Intrinsic asthma with statusasthmaticus493.12 Intrinsic asthma, with (acute)exacerbation493.20 Chronic obstructive asthma,unspecified493.21 Chronic obstructive asthmawith status asthmaticus493.22 Chronic obstructive asthma,with (acute) exacerbation493.8 Other forms of asthma493.81 Exercise inducedbronchospasm493.82 Cough variant asthma493.9 Unspecified asthma493.90 Asthma, unspecified,unspecified493.91 Unspecified asthma, withstatus asthmaticus493.92 Asthma, unspecified, with(acute) exacerbationICD-10-CMJ45 AsthmaJ45.2 Mild intermittent asthmaJ45.20 Mild intermittent asthma, uncomplicatedMild intermittent asthma NOSJ45.21 Mild intermittent asthma with (acute)exacerbationJ45.22 Mild intermittent asthma with statusasthmaticusJ45.3 Mild persistent asthmaJ45.30 Mild persistent asthma, uncomplicatedMild persistent asthma NOSJ45.31 Mild persistent asthma with (acute)exacerbationJ45.32 Mild persistent asthma with status asthmaticusJ45.4 Moderate persistentJ45.40 Moderate persistent, uncomplicatedModerate persistent asthma NOSJ45.41 Moderate persistent with (acute) exacerbationJ45.42 Moderate persistent with status asthmaticusJ45.5 Severe persistentJ45.50 Severe persistent, uncomplicatedSevere persistent asthma NOSJ45.51 Severe persistent with (acute) exacerbationJ45.52 Severe persistent with status asthmaticusJ45 9 Other and unspecified asthmaJ45.9J45.90 Unspecified asthmaNOS Late onset asthmaJ45.901 Unspecified asthma with (acute)exacerbationJ45.902 Unspecified asthma with statusasthmaticusJ45.909 Unspecified asthma, uncomplicatedAsthma NOSJ45.99 Other asthmaJ45.990 Exercise induced bronchospasmJ45.991 Cough variant asthmaJ45.998 Other asthma4623
9/21/2010Place-holding X T38.3x6- ((Underdosingg of insulin and oralhypoglycemic [antidiabetic] drugs) X should be assigned for all characters less than 6The 7th character must always be the 7th character ofa code47Diagnosis Code Set GeneralEquivalence Mapping May be more than one code that maps to anotherGems Files published by CMS map codes fromICD-9-CM to ICD-10-CM and backward fromICD-10-CM to ICD-9-CMoooUpdated in 2009Flat text filesContains list of code pairs to identify correspondencebetween source system code and target system code24
9/21/2010What is a GEMTo assist in the transition to ICD-10 for diagnosis codes andprocedure codes, CMS contracted with 3M to develop GEM files.GEMs are: A public domain reference mapping designed for health careindustry:o An initial mapping tool to be used to assist in converting and testingsystems Two-way translation dictionaries that:o Cannot be used in a legacy system in unaltered formo Include one-to-one correspondence as the exception rather thanthe ruleo Can be used to develop crosswalks for specific situations andpurposeso Assist users in making informed decisions about how to link thecodes in a way that meets their needsR i bt mappingsiReimbursementare: A temporary mechanism:o To be used for mapping records containing ICD-10 diagnoses andprocedures to “reimbursement equivalent” ICD-9 diagnoses andprocedureso So that while systems are being converted to process ICD-10claims directly, the claims may be processed by the legacy systemso To allow a claim to be priced using the rules written for ICD-9 codesGEMS GEM (General Equivalence Mapping) provides a first step in understanding the relationship of ICD-9 andICD-10 codes. It is an important piece of work and ishelpful in understanding mapping issuesIt is not a complete solution in moving the industry to adefinitive conversion to the use of ICD-10 codes as anormal part of businessoGEM is a mapping, not a crosswalkoOne-to-many or many-to-many maps are commonoy getg to a singleg ppp codeIt does not alwayspreferred mappedoIt does not define what was assumed or lost intranslationoThere is no weighting of the importance of one conceptover another25
9/21/2010MappingDefinition: find thepg diagnosisgcorrespondingbetween two code sets andfind correlation between both3-5 digits plus V and E Codesand approximately 13,500codes3-7 Alphanumeric codes ICD-9-CM ICD-10-CM 14,500 codes 69,101 codes51Diagnosis Code Set GeneralEquivalence Mapping May be more than one code that maps to anotherGems Files published by CMS map codes fromICD-9-CM to ICD-10-CM and backward fromICD-10-CM to ICD-9-CMoooUpdated in 2009Flat text filesContains list of code pairs to identify correspondencebetween source system code and target system code5226
9/21/2010Mapping from ICD-9-CM to ICD-10-CMICD-9-CMICD-10-CM010.00 Primary tubercu
ICD-10 Will Change Everything Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CEMC, CPMA, COBGC, CPCD, CCS-P President & CEO AAPC Author of “ICD-10 Impp,lementation Guide, Make the Transition Manageable,” AMA Press, 2009 ICD-10 Final Rule CMS-0013-F Published January 16, 2009 October 1, 2013 – Compliance date for implementation of ICD-10 .
ICD-9 724.02 ICD-10 M48.06 Spinal stenosis, lumbar region ICD-9 720.2 ICD-10 M46.1 Sacroiliitis, not elsewhere classified ICD-9 724.8 ICD-10 R29.898 Other symptoms and signs involving the ** musculoskeletal system ICD-9 721.42 ICD-10 M47.16 Other spondylosis with myelopathy, lumbar region ICD-9 723.1 ICD-10 M54.2 Cervicalgia ICD
More on ICD-10. ICD-10-PCS replaces ICD-9-CM inpatient procedure coding: ICD-9-CM procedure codes 3 to 4 numeric digits ICD-10-CM codes 7 alphanumeric digits ICD-10-PCS code format substantially different from ICD -9 Unlike ICD-9, ICD-10
ICD-10 Tips from PHCS The Road to ICD-10 Flyer AMA ICD-10 Project Plan Template Educational Tools Folder Precyse University ICD-10 Physician Office Solution Brochure Precyse Catalog of ICD-10 Courses ICD-10 Precyse Apps for Physicians Resources Folder Free Resources ICD-9 to ICD-10 Crosswalk of Most Common ICD-9 .
Dec 14, 2010 · ICD-9. ICD-10. ICD-9. ICD-10. Inactive. Active. Combined Code Set. Core Technologies. ICD-9 and ICD-10 code values are unique. Generally, the industry is taking one of two approaches as it relates to the ICD-10 transition: Remediation: Modify/expand all systems and processes to accommodate ICD-
ICD-10 to ICD-10-CM Based on FY2017 ICD-10-CM codes Category and subcategory codes are shaded in grey and marked with an Cells shaded in pink and marked with an *indicate the preferred code when a single code maps to multiple codes (see Introduction) Reportable Neoplasms . Type of Code ICD-10 Category Chapter II (Neoplasms) ICD-10 Term . ICD .
7/13/2015 1 Tonya Mitchell, RHIT July 17, 2015 Objectives Review the History of ICD‐10 Discuss the Myths and Facts of ICD‐10 Discuss GlGeneral DttiDocumentation CtConcepts Review ICD‐10 Documentation Concepts Analyze Documentation for Top Diagnosis in ICD‐10 WHY CHANGE FROM ICD‐9 TO ICD‐10? ICD‐9 was developed in the 1970s and cannot support current
of the previous ICD-9 coding system. The volume of ICD-10 codes as compared to ICD-9 codes is significant because in ICD-10, the code size has been expanded, code values and interpretations have been redefined and specificity has been further improved. Global ICD-10 adoption The current version of ICD is ICD-10, which was adopted by the World .
According to CMS, GEMs are “a tool to assist with the conversion of ICD-9-CM codes to ICD-10 and the conversion of ICD-10 codes back to ICD-9-CM. The GEMs are forward and backward mappings between the ICD-9-CM and ICD-10 coding systems.” Watch out: Although you’ll see the term “cr
