Preparing Now For ICD-10-CM

Preparing Now For ICD-10-CM
Tennessee Orthopaedic Society
September 27, 2014
Prepared for Tennessee Orthopaedic Society
September 27, 2014 Page 0

Learning Objectives
• Transition and impact of ICD-10
• ICD-10: Visualized
• High-level review of what’s new in
ICD-10-CM coding conventions and
guidelines
• Review common diagnoses and
documentation requirements in ICD-
10
• Project management approach to
ICD-10 operational considerations

Transition and Impact

What’s new?
NEW compliance date for ICD-10:
October 15, 2015
• The ICD-10 delay is forcing organizations to
reassess their timelines and budgets for
complying with the code change.
• CMS is offering multiple
in-person educational options as their
well as web-based education.

Making the Transition is
Not Optional
• All “covered entities” as defined by the Health
Insurance Portability and Accountability Act of 1996
(HIPAA) are required to adopt ICD-10 codes for use
in all HIPAA transactions.
• ICD-10 codes are the foundation for reimbursement
and will represent most or a large portion of the
data points for healthcare analytics.
• Electronic data interchange (EDI) is the transport
tool for claims.
• Lack of operational readiness – systems and staff
training – could negatively impact practice business.

Two Sets of Codes
are Being Replaced
ICD-10-CM
• Diagnosis Coding System – Used to
report the patient’s condition (i.e., what’s
wrong with the patient)
• Direct replacement for ICD-9-CM
Volumes 1 & 2
• Will be used in all settings – hospital
inpatient, hospital outpatient, physician
office, etc.
• Like ICD-9-CM, developed and
maintained by the World Health
Organization (WHO) and the National
Center for Health Statistics within the
Centers for Disease Control
ICD-10-PCS
• Procedure Coding System – Used to
report surgical procedures performed
• Direct replacement for ICD-9-CM
Volume 3
• Only used in a hospital inpatient setting
(and only for reporting facility services)
• Like ICD-9-CM Volume 3, ICD-10-PCS
was developed and is maintained by
CMS

Who is Impacted by ICD-10?
Everyone!
• Staffing Effectiveness
• Assessment of Revenue
Impact
• Process Improvement
• Decision Support Reporting
Impact
• Documentation Analysis
• ICD-10 Education
• Process Improvement
• Monitoring
• Physician Documentation
• Physician Integration
• Physician Performance
Physician
Office
Post Acute
Services
• Front – Scheduling, Access Areas
• Middle – Coding, CDI, Case
Management
• Back – Billing, Reimbursement
Health
Information
Management
ICD-10
Revenue
Process
Physician
Operational
Planning
Information
Technology
• IT Systems
• Capability, Communication
• Functionality
• Vendor Preparedness

What Does ICD-10-CM
Look Like?

ICD-9 vs. ICD-10
Issue ICD-9-CM ICD-10-CM
Volume of codes Approximately 13,600 Approximately 69,000
Composition of codes Mostly numeric, with E and V codes
alphanumeric.
Valid codes of three, four, or five
digits.
Duplication of code sets Currently, only ICD-9-CM codes are
required. No mapping is necessary.
Source: http://www.aapc.com/icd-10/faq.aspx#why
All codes are alphanumeric, beginning
with a letter and with a mix of numbers
and letters thereafter. Valid codes may
have three, four, five, six or seven digits.
For a period of up to two years, systems
will need to access both ICD-9-CM codes
and ICD-10-CM codes as the country
transitions from ICD-9-CM to ICD-10-CM.
Mapping will be necessary so that
equivalent codes can be found for issues
of disease tracking, medical necessity
edits, and outcomes studies.

ICD-10-CM Organization
The CM Manual divided into three main parts:
Index to Diseases
and Injuries
Official Guidelines
Tabular List of
Diseases and
Injuries
21 Chapters
Expanded injury
codes grouped
by site vs. type
of injury
Laterality (left
and right)
V and E codes
incorporated into
main
classification
Added a
placeholder X

Anatomy of an ICD-10-CM Code
3-7 Alphanumeric characters (digits)
X X X . X X X X
1st character –
Alpha (A-Z)
2nd character -
Numeric
3rd - 7th
characters –
Alpha or
Numeric
Decimal
placed after
the first 3
characters
• All letters but U are used
• The letters I & O are used only in the 1st character position
• Each letter is associated with a particular chapter (Except C&D
Neoplasms)

ICD-10-CM Characters and Extensions
.
MAS X X 0 X 2 X6 X5 Xx A
X
Category
Etiology, anatomic
site, severity
Added code
extensions (7th
character) for
obstetrics,
injuries, and
external causes
of injury
Alpha
(Except U)
2 - 7 Numeric or
Alpha
Additional
Characters

Crosswalk
• Partial solution: these are tools to
convert ICD-9 to ICD-10 and vice
versa.
• To assist with the transition,
cross-walking between the code
sets will assist you with identifying
the differences between ICD-9
and ICD-10.
• Not a high percentage of accuracy
(very few one-to-one matches)
due to increased specificity of
ICD-10 versus ICD-9.

GEMs
GEMs (General Equivalence Mappings) are a comprehensive translation
dictionary that can be used to accurately and effectively translate any ICD-9-CM-based
data, including data for:
– Tracking quality
– Recording morbidity/mortality
– Calculating reimbursement
– Converting any ICD-9-CM-based application to ICD-10-CM/PCS
The GEMs are not a substitute for learning how to use the ICD-10 codes.
More information about GEMs and their use can be found on the CMS website at:
http://www.cms.gov/Medicare/Coding/ICD10/index.html
(select from the left side of the web page ICD-10-CM to find the most recent GEMs)

How Does the Mapping Work?
ICD-9-CM
• 719.46 Pain in joint,
lower leg
ICD-10-CM
• M25.561 Pain in right
knee
• M25.562 Pain in left
knee
• M25.569 Pain in
unspecified knee

Percentages of Types of Matches
Mapping
Categories
No Match 1.2% 3.0%
1-to-1 Exact Match 5.0% 24.2%
1-to-1 Approximate Match with 1 Choice 82.6% 49.1%
1-to-1 Approximate match with Multiple Choices 4.3% 18.7%
1-to-Many Matches with 1 Scenario 6.6% 2.1%
1-to-Many Matches with Multiple Scenarios 0.2% 2.9%
Source: http://www.ama-assn.org/ama1/pub/upload/mm/399/crosswalking-between-icd-9-and-icd-10.pdf
ICD-10 to
ICD-9
ICD-9 to
ICD-10

High-Level Review of ICD-10
Coding Conventions and
Guidelines

Placeholder Character
Marks the Spot
• ICD-10-CM uses a placeholder character “X”
which allows for future code expansion.
• Where indicated as a placeholder the X must
be used in order for the code to be valid. (The X
is not case sensitive).
• A dash (-) at the end of an Index entry indicates
that additional characters are required; review
the tabular section for selection.

Place an X in the 5th and 6th digit
ICD-10-CM utilizes a placeholder: Character “X” is used as
a 5th character placeholder in certain 6 character codes
• To fill in other empty characters (e.g., character 5 and/or 6)
when a code that is less than 6 characters in length requires
a 7th character
Examples:
• S72.8x1A – Other fracture of right femur, initial encounter
• M48.8x6 – Other specified spondylopathies, lumbar region
• S03.4xxA – Sprain of jaw, initial encounter

Sequela – Late Effect
• A sequela is the residual effect (condition produced) after the
acute phase of an illness or injury has terminated.
• There is no time limit on when a sequela code can be used.
The residual may be apparent early, such as in cerebral
infarction, or it may occur months or years later, such as that
due to a previous injury.
• Coding of sequela generally requires two codes sequenced
in the following order:
– The condition or nature of the sequela is sequenced first.
– The sequela code is sequenced second.

Laterality
• Some ICD-10-CM codes indicate laterality, specifying
whether the condition occurs on the left, right, or bilateral.
• If no bilateral code is provided and the condition is
bilateral, assign separate codes for both the left and right
side.
• If the side is not identified in the medical record, assign
the code for the unspecified side.
Examples:
– M24.412 – Recurrent dislocation, left shoulder
– M65.321 – Trigger finger, right index finger
– L89.012 – Pressure ulcer of right elbow, stage II

More Information Reported, Higher
Level of Detail in Coding

Greater Specificity and Detail in
Orthopedic Coding:
• 34,250 of all ICD-10-CM codes are related to
the musculoskeletal system.
• 17,045 of all ICD-10-CM codes are related to
fractures.
• 10,582 of fracture codes distinguish right from
left.
• 25,000 of all ICD-10-CM codes distinguish
right from left.

Musculoskeletal
• There are several changes and expansion to the
musculoskeletal code system in ICD-10.
• Most codes in this section require additional
documentation to correctly code site and laterality to
the highest level of specificity, which include:
– Documentation of site and laterality
– More specific information for fractures and injuries
– Identification of episode of care
– Additional coding instructions surrounding
osteoporosis
– Reorganization of codes

Fracture Specificity
Fractures Require Greater Specificity:
• Type of fracture
• Specific anatomical site
• Displaced vs nondisplaced
• Laterality
• Routine vs delayed healing
• Nonunion
• Malunion
• Type of encounter
– Initial
– Subsequent
– Sequela

Episode of Care – Fractures
Assigning episode of care 7th characters for
fractures is a bit more complicated because the
episode of care provides additional information
about the fracture including:
• Whether the fracture is open or closed.
• Whether healing is routine or with
complications such as delayed healing,
nonunion, or malunion.

Episode of Care – Fractures
7th Characters
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
 If the fracture is not documented as open or closed, it is coded to closed.
 Additionally, if the fracture is not documented as displaced or not displaced, it
should be coded as displaced.

Episode of Care –Open Fractures
The open fracture designations are based on the Gustilo open fracture classification
• initial encounter for open fracture
type I or II initial encounter for
open fracture NOS
• subsequent encounter for open
fracture type IIIA, IIIB, or IIIC with
delayed healing
J
fracture type I or II with nonunion M
nonunion
N
fracture type I or II with malunion Q
fracture type IIIA, IIIB, or IIIC
with malunion
R
B
• initial encounter for open fracture
type IIIA, IIIB, or IIIC C
fracture type I or II with routine
healing
E
routine healing
F
fracture type I or II with delayed
healing
H

Resources Available
• http://www.cms.gov/Medicare/Coding/ICD10/index.html
• http://www.ahima.org/icd10/
• http://www.aapc.com/icd-10/index.aspx
• http://www.cdc.gov/nchs/icd/icd10.htm
• http://www.who.int/classifications/icd/en/

Project Management

ICD-10 Project Overview
Successful Go-Live
Training
Testing
Communications
Planning

Updated ICD-10 Timeline
2014 2015
PYA
May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Planning
Identify resources
Create project team
Assess effects
Create project plan
Secure budget
Communications
Inform staff
Contact vendors
Contact payers
Monitor vendor prep
Monitor payer prep
Testing
High-level training for
test team
Level 1: internal
Level 2: external1
Comprehensive Training
Documentation
Coding
2October 1, 2015 is the NEW compliance date for ICD-10.
G
O
L
I
V
E
Confirm ongoing practice schedule to correspond with
new "go live"2 date
1Monitor external testing periods - go to http://www.cahabagba.com/news/icd-10-volunteer-testing/ to apply for volunteer testing opportunity - DEADLINE 10/3/14.

Planning: Major Activities
Assess
effects
Identify
resources
Create
project plan
and team
Secure
budget

Planning:
Sample Activities
• Assess practice pre-authorization form and/or
templates for code changes needed.
• Review pre-authorization workflow processes
and affected staff for ICD-10 training needs.

Planning
• Review all National Coverage Determination
(NCD) and Local Coverage Determination (LCD)
policies used in the practice for updated code
sets from ICD-9 to -10.
http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html
• Review any practice internal codes for denials or
quality training that are tied to ICD-9 and create
an ICD-10 migration plan for these codes to be
updated.

Planning
• Determine the best superbill solution for the
practice specialty; is an electronic solution an
option?
• Assess current superbill process based on
potential list of ICD-10 codes for the practice.

Planning
• Communicate with the ICD-10 leadership team
at each facility - whether hospital, ASC, or
nursing home - where practice physicians are
working. They should be informed about the
ICD-10 training process requirements for the
practice physicians.
• Compile a top 10 list of the current practice
denials relating to diagnosis codes, then create
ICD-10 training materials around these codes.

Planning
• Review all customized reports for reference to
ICD-9 and make sure updates are made for ICD-
10. (e.g. billing, quality reporting, clinical trials,
etc.)
• Review all monthly management reports for
physicians, and referrals which may contain a
filter or data field relating to ICD-9. Be sure the
data field is set to accommodate ICD-10.

Planning
• Create a troubleshooting plan “decision tree”
for denials issues (like disaster plan). Who
does what, when, based on the problem?
When in danger, or in doubt, run in circles, scream and shout.
- Infantry Journal, Vol. 35, (1929), p. 369.

Communication: Major Activities
Inform
staff
Monitor
vendors
and payers
Contact
vendors
and payers

Communications:
Sample Activities
• Create a checklist by payer regarding their ICD-
10 readiness and claims filing timeline
requirements; monitor and update in the months
leading up to the new deadline.
• Create a checklist by payer for pre-authorization
coding transition dates to ensure compliance;
monitor and update in the months leading up to
the new deadline.

Communications
• Verify payer timing requirements for ICD-10 use
in pre-certification and pre-authorization
processes (i.e., pre-cert work completed prior to
ICD-10 'go-live' date may need to be done in
ICD-10 codes for visits after 'go-live' date).
• Review any commercial payer quality reporting
processes to be sure any ICD-9 linked data is
updated to ICD-10.

Testing: Major Activities
Train the
Testing
Team
Internal
Testing
External
Testing

Testing
• Testing Team
– Identify members
– Assign duties and focus
• Who will test the PM/EHR system(s)?
• Who will test with the clearinghouse(s)?
• Who will test with the payers?
– Develop feedback form, timeline, and follow-up
steps

Testing: What to test?
• Internally:
– Provider/staff process for selecting ICD-10 codes
in PM/EHR system
– Within the system screens, are the ICD-9/10
fields big enough for the new code format?
– Run reports which contain ICD-9/10 codes
• Are all digits showing?
• If the code description is included, is it
understandable?

Training: Major Activities
Coding
Documentation

Training
• Create an ICD-9 workflow map throughout the
office: moving to each work area examine
processes – daily, weekly, monthly, random-use
– for ICD-9 involvement in order to develop
appropriate staff training and focus areas.
• Prepare ICD-10 training based on job-type
group, i.e., clinicians, front desk staff, billing, etc.
and tailor content based on job duties
associated with ICD-9.

Training
• If you determine that an outside vendor will be
hired for training assistance, allow 2-3 months
prior to training for decision making and
contracting. However, keep in mind that vendors
and trainers will start filling up as the deadline
nears.

Project Management
Making the
difference

Thank you!
Linda ClenDening
Consulting Manager
Pershing Yoakley & Associates, P.C.
(865) 684-2735
lclendening@pyapc.com
www.pyapc.com

Preparing Now For ICD-10-CM

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