ICD-10: Tackling The New System - CPT , ICD-10, HCPCS .

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ICD-10:Tackling the New SystemLeesa A. Israel, BA, CPC, CUC, CMBSExecutive Editor, The Coding InstituteManager, TCI Consulting & Revenue Cycle Solutionsleesai@codinginstitute.comSuzanne Leder, BA, M. Phil., CPC, COBGCExecutive Editor, The Coding InstituteManager, Supercoder.com’s Specialty Content Productssuzannel@codinginstitute.com

Take The Transition Seriously!If your practice fails to successfully migrate toICD-10, you potentially face:Delayed or reduced paymentsAudits from multiple regulatory agenciesDamaged relationship with your business partners,including vendors and payersProductivity declines for your coding, billing,and clinical staff.04/25/112

Look Beyond the CodingICD-10 is much more than a coding update -- It is anentirely new system!You’ll need to make changes to: Your coding Your billing system Your electronic health recordEMR) system Your superbill And more!04/25/113

Version 5010 Purpose: The current version — version 4010/4010A1 —does not accommodate the ICD-10 code set. Therefore, inpreparation for the use of ICD-10, CMS has introduced itsnew HIPAA 5010 Version D.0 Scope: Required to be used by all HIPAA-covered entities(i.e., providers, health plans, clearinghouses, and theirbusiness associates, including billing agents). Implementation Deadline: Jan. 1, 2012 Keep in mind that CMS will begin accepting 5010 formseffective Jan. 1, 2011, and use of the form will be required asof Jan. 1, 2012. The ICD-10 codes will take effect on Oct. 1,Timeline 2013.04/25/114

5010 Diagnosis ReportingImprovements1. Maximum number of diagnosis codes you can2. on a claim increases from eight to 12Increases the field size for ICD codes from 5 to 7Adds a version indicator to the ICD code to indicateversion 9 versus 10Distinguishes between principal diagnosis,admitting diagnosis, external cause of injury, andpatient reason for visit codesHas an indicator on institutional claims for“present on admission” conditions5

5010 and ICD-10 TimelineJanuary 1,2010 5010 internaltesting beganJanuary 1,2011 5010 externaltesting began Version 40101still acceptedJanuary 1,2012 All electronicclaims mustuse Version5010October 1,2013 Claims withdate of serviceafter thisdate must useICD-10 Version 40101no longeraccepted04/25/116

Dual Claims ProcessingBilling hurdle: For some span of time you’ll besubmitting both ICD-9 and ICD-10 codes on claims For testing purposes Because some payers won’t be on board by the 2013deadlinePointer: ICD-10 is a visit date activation, which means that you’llsubmit any services with visit date prior to Oct. 1, 2013 using ICD9 codes.04/25/117

Dual Claims Processing ExampleClaim SubmissionDate: Oct. 2, 201304/25/11Claim SubmissionDate: Oct. 2, 2013An office visit yourphysicianperformed onOct. 1A surgicalprocedure yourphysicianperformed onSept. 22Submit usingICD-10diagnosis codesSubmit usingICD-9diagnosis codes8

Technology ConsiderationsCommunicate with your vendors1.Pull all your contracts and evaluate how the each system andvendor will impact ICD-10 implementation in your practice.2.Check to see if you have anything written in the contract thatstates government mandates are covered.3.Contact your vendors and assess their ICD-10 readiness. Askwhat their plans are and set up timelines to get your practice’ssystem ready.4.Find out if the vendor has plans to upgrade systemsby the compliance date.04/25/119

Technology ConsiderationsCommunicate with your vendorsStart by asking: Is the vendor prepared for the move to ICD-10 on Oct. 1, 2013?Will the vendor be ready for version 5010 compliance by Jan. 1,2012?What costs will be involved with the transition?What are the vendor’s implementation plans?Will your practice need new or enhanced software/hardware?Bottom line: If your vendor is unable to offeryou solutions at this time you should beginlooking for a new vendor.04/25/1110

ICD-10 and EMRAn electronic medical record (EMR) system is notmandatory for ICD-10 implementation. But ifyour practice has been on the fence aboutwhether to implement an EMR, now is the time tolook into it. Your practice needs to assess whetheran EMR will benefit the practice.There are many benefits of 5010 and ICD-10but many will only be realized in theelectronic format.04/25/1111

ICD-10 Billing Benefits1. accurately report a patient’s diagnosis or condition with greaterspecificityFewer repayment requests, incorrect payments, and even denials dueto fewer erroneous, rejected, and exaggerated claimsFinancial benefits due to less lost reimbursementShorter claim cycle and faster paymentsBetter appeals supportPayers able to auto-adjudicate more claimsImproved national and local coverage determinations (NCDs andLCDs)A more efficient reimbursement process and therefore loweradministrative costsBonus: Improved quality measurements and patientsafety04/25/1112

GEMSGeneral Equivalence Mappings (GEMs)According to CMS, GEMs are “a tool to assist with the conversion of ICD-9-CMcodes to ICD-10 and the conversion of ICD-10 codes back to ICD-9-CM.The GEMs are forward and backward mappingsTRUEbetween the ICD-9-CM and ICD-10 coding systems.”CROSSWALKWatch out: Although you’ll see the term “crosswalk,”this can be deceiving. Not all codes have a directmatch, so you should think of the GEM file as merely a guideline.Source: General Equivalence Mappings FAQs04/25/1113

0-CMBackwardMappingToICD-9-CMSource: General Equivalence Mappings FAQs04/25/1114

GEMSHow They WorkThe GEM file is a “flat file,” meaning this is a record with no structuralrelationships. (You can download it here:http://www.cms.gov/ICD10/11b1 2011 ICD10CM and GEMs.asp#TopOfPage)Example 1: 62130 N8500 00000Translation: 621.30 (Endometrial hyperplasia, unspecified) maps directly toN8500 (Endometrial hyperplasia, unspecified).How do we know this? Let’s focus on “00000.”04/25/1115

GEMSApproximateFlagNo Map FlagOne-to-Many:Combo FlagScenario0 Off0 IdenticalMatch1 Approximatematch (Majorityof alternativesare consideredapproximate)0 At least oneplausibletranslation1-9 In a combo entry,0 Code maps to this is a collection ofa single codecodes from the targetsystem containing the1 No plausible1 Code maps to necessary codes thattranslation for the more than onecombined as directedsource symptom codewill satisfy thecodeequivalent meaning ofa code in the sourcesystem.Choice0 Off1-9 In a combinationentry, this is a list of one ormore codes in the targetsystem from which onecode must be chosen tosatisfy the equivalentmeaning of a code in thesource systemExample of Column 2 flag of “1”:T500x6A NODX 1100004/25/1116

GEMSApproximateFlagNo MapFlagOne-to-Many:Combo FlagScenarioChoiceSINGLEOn or OffN/AOff00COMBOOnN/AOn1-91-9Therefore, “00000” means that 621.30 and N8500 are direct matches.Example 2:R6521 99592 10111R6521 78552 10112Translation: This means that ICD-10-CM code R65.21 (Severe sepsiswith septic shock) matches to both 995.92 (Severe sepsis) and785.52 (Septic shock).04/25/1117

GEMSWhy do I have to know this?It’s up to you to find inconsistencies.Tactic: Start with the top 25 diagnoses in your practice. Look into your systemto see if they map correctly from I-9 to I-10. Then contact your vendor tomake any corrections.Threat: Inaccurate coding will result inincreased denials and delayed payments.04/25/1118

ICD-10 ExamplesScenario: Suppose a 30 year old female patient is in the 36th week ofpregnancy and presents to the emergency room with a hemorrhage due toplacenta previa. The ob-gyn performs a c-section with a live birth. How would youcode this using ICD-10?Solution: When your diagnosis coding changes in 2013, you should reportO44.13 and Z37.0. Notice how that first code features the letter “O” and not thenumber “0.” You would link these codes to 59514. If you’re on the facility side, youwould report 10D00Z0.Currently, you would use ICD-9 codes 641.11 and V27.0. You would link thesecodes to 59514. If you’re on the facility side, you would report 74.99.04/25/1119

ICD-10 ExamplesScenario: A patient comes in for an annual exam. Right now, you should attachV72.31 to an annual visit code (99384-99386 for new patients, or 99394-99396for established patients).ICD-10 difference: Instead of relying on one code, V72.31 will expand into twooptions. They are Z01.411 and Z01.419.Instead of relying on V72.31 as your catch-all annual visit diagnosis, you’ll needto examine your physician’s documentation. In other words, you will be looking atthe examination part of the visit and what the ob-gyn notes for the appearance ofthe external genitalia, vagina, uterus, and so on. If the ob-gyn does describe anabnormality, you’ll report Z01.411. If not, you’ll report Z01.419.Remember, if your physician does document an abnormal finding, you’ll mostlikely include that finding on your ICD-10 claim as well.04/25/1120

ICD-10 ExampleUreteral stonewith procedure such as 52353 (Cystourethroscopy, with ureteroscopy and/orpyeloscopy; with lithotripsy [ureteral catheterization is included]) ICD-9: 592.1 — Calculus of ureter ICD-10: N13.2 — Hydronephrosis with renal and ureteral calculusobstruction N13.6 — Pyonephrosis, conditions in N13.0-N13.5 withinfection N20.1 — Calculus of ureter N20.2 — Calculus of kidney with calculus of ureter.CPT 2011 American Medical Association. All rights reserved.CPT is a registered trademark of the American Medical Association. All rights reserved.04/25/1121

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Coming in March HCPCS 2011 ChangesRegister at SuperCoder.com/conference/04/25/1123

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

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