ICD-10 Are You Ready to S.W.A.P.

Presented byKathy A. Montoya

Senior Provider Relations Representative

Agenda Background Volumes

ICD 10 CM ICD 10 PCS

General Equivalence Mappings Reimbursement Mappings Preparation Steps

Training Objectives Increase knowledge Identify obstacles Get on track for implementation

October, 1 2014

Health Insurance Portability and Accountability Act (HIPAA) Administrative simplification provides

standards for Electronic transmission of claims Provider identifiers Privacy Code set

Why The Change ICD-9

Adopted by CMS April 1, 1989 Produces limited data

Patients’ medical conditions Hospital inpatient procedures

30 years old and outdated Limits new code creation

ICD-10-CM/PCS Incorporates greater specificity and clinical

information Improves health care service measurement Helps with refining groupings and

reimbursement methodologies

ICD-10-CM/PCS Enhances ability to do public health

surveillance Decreases need for claims supporting

documentation Updates medical terminology and

classification of diseases

ICD-10-CM/PCS Provides better data for

Claims processing Making clinical decisions Identifying fraud and abuse Conducting research Comparison of mortality and morbidity

ICD 10 Department of Health and Human Services

Final regulation January 15, 2009 October 1, 2014

Guidance available on http://www.cms.gov/ICD10/

ICD-9 It’s Not Over Yet Worker’s compensation Auto insurance

Not required to convert Not planning to change

ICD 10 Developed by

World Health Organization (WHO) http://www.who.int/classifications/icd/en/.

Utilized in other countries Mandated for use in U.S.

October 1, 2014

ICD-10 In use in U.S.

Individual states Report cause of death on certificates

ICD 10 CM National Center for Health Statistics

(NCHS) Developed ICD 10 Clinical Modification (CM) for

U.S. In conjunction with advisory group and

physicians Still in DRAFT

ICD-10General Information

ICD-10 Part 1 ICD-10-CM for diagnosis coding

All U.S. health care setting 3 – 7 digit alphanumeric codes 68,069 ICD-10-CM codes

Increased from 14,025 ICD-9-CM

Provider ClaimsCompliance A Must No delays or grace period ICD-9-CM for dates of service < October 1,

2014 ICD-10 for dates of service ≥ October 1,

2014 Still use CPT and HCPCS

ICD-10 Code Structure

AXX.XXXX

3Categories

Code

4Subcategory

Code

5/6SubclassificationCode/Placeholder

7Extention

Code

ICD-10-CM Structure 3 – 7 characters

1st = alpha 2nd = numeric 3rd – 7th = alpha or numeric Decimal after 3rd character

ICD-10-CM Structure Character “X”

5th or 6th position “Placeholder”

Future expansion “Fill In”

Empty characters

7th Character One use is encounter type

A = Initial encounter D = Subsequent encounter S = Sequela

7th Character R40.2 Coma

Coma NOSUnconsciousness NOS

The appropriate 7th character is to be added to each code from subcategory R40.21-, R40.22-, R40.23-

0 Unspecified time1 In the field [EMT or ambulance]2 At arrival to emergency department3 At hospital admission4 24 hours or more after hospital admission

ICD Codes Describe medical necessity Facilitate payment Evaluate utilization patterns Study appropriateness of health care costs

Incorrect Coding Lead to investigations of fraud and abuse Must be correct Must be consistent

Comparison ICD-9 CM

Groups by type of injury Maximum 5 characters Most codes numeric 17 chapters

ICD-10 CM Groups by site of injury Maximum 7 characters Codes are alpha-

numeric 21 chapters

Changes Found In ICD-10 CM Addition information for ambulatory and

managed care encounters Expanded injury codes Combination codes Reclassification of diseases

Changes Found In ICD-10 CM New code definitions “E” and “V” codes incorporated in main

classifications Category restructuring and code

reorgaization

ICD-10 CM Format Introduction Official Guidelines for Coding and

Reporting Alphabetic Index to Diseases and Injuries Neoplasm Table

ICD-10 CM Format Table of Drugs and Chemicals Index of External Causes Tabular List of Diseases and Injuries

Official Guidelines forCoding and Reporting ICD-9 and ICD-101. Conventions, general coding guidelines

and chapter specific guidelines2. Selection of Principle Diagnosis3. Reporting Additional Diagnosis4. Diagnostic Coding and Reporting

Guidelines for Outpatient Services

Official Guidelines forCoding and Reporting ICD-10

Chapters 3, 7, 8 and 11 Not completed Specialty society involved in creation

Official Guidelines forCoding and Reporting Examples

Chapter 15 Chapter 15 codes have sequencing priority over

codes from other chapters Chapter 15 codes are to e used only on maternal

record, not on newborn

Alphabetic Index ICD-9

Diseases Illness Injury Other reasons for

encounters Table of Drugs and

Chemicals External Causes of Injury

and Poisoning

ICD-10 Diseases Illness Injury Other reasons for

encounters

Neoplasm Table ICD-9

In alpha index Malignant

Primary Secondary Ca in situ

Benign Uncertain Behavior Unspecified

ICD-10 Separate section Malignant Primary Malignant Secondary Malignant Ca in situ Benign Uncertain Unspecified Behavior

Table of Drugs andChemicals ICD-9

Under Alphabetic Index Poisoning Accident Therapeutic Use Suicide Attempt Assault Undetermined

ICD-10 Accidental

(unintentional) Intentional Self-Harm Assault Undetermined Adverse Effect Underdosing

Index of External Causes ICD-9

Under Alphabetic Index Cause of injury Adverse effects

ICD-10 Alphabetic by main

term indicating the event

Tabular List of Diseasesand Injuries ICD-9

17 chapters Based on diseases

2 Supplementary Classification

ICD-10 21 chapters

Based on body system or nature of injury and disease

Chapter ComparisonChapter ICD-9 CM ICD-10 CM

1 Infectious and Parasitic Diseases

Certain Infectious and Parasitic Diseases

2 Neoplasms Malignant Neoplasms

3Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders

Disease of the Blood and Blood-Forming Organs and certain Disorders involving Immune Mechanism

4 Disease of the Blood and Blood-Forming Organs

Endocrine, Nutritional and Metabolic Diseases

Chapter ComparisonChapter ICD-9 CM ICD-10 CM

5 Mental DisordersMental and Behavioral Disorders

6 Diseases of the Nervous System and Sense Organs

Diseases of the Nervous System

7 Diseases of the Circulatory System

Diseases of the Eye and Adnexa

8 Diseases of the Respiratory System

Diseases of the Ear and Mastoid Process

Chapter ComparisonChapter ICD-9 CM ICD-10 CM

9 Diseases of Digestive System

Diseases of the Circulatory System

10 Diseases of the Genitourinary System

Diseases of the Respiratory

11Complications of Pregnancy, Childbirth, and the Puerperium

Diseases of the Digestive System

12 Diseases of the Skin and Subcutaneous Tissue

Diseases of the Skin and Subcutaneous Tissue

Chapter ComparisonChapter ICD-9 CM ICD-10 CM

13Diseases of the Musculoskeletal System and Connective Tissue

Diseases of the Musculoskeletal System and Connective Tissue

14 Congenital Anomalies Diseases of the Genitourinary System

15Certain Conditions Originating in the Perinatal Period

Pregnancy, Childbirth and the Puerperium

Chapter ComparisonChapter ICD-9 CM ICD-10 CM

16 Symptoms, Signs and Ill-Defined Conditions

Certain Conditions Originating in the Newborn (Perinatal) Period

17 Injury and PoisoningCongenital Malformations, Deformations and Chromosomal Abnormalities

18 N/A

Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

Chapter ComparisonChapter ICD-9 CM ICD-10 CM

19 N/AInjury, Poisoning and Certain Other Consequences of External Causes

20 N/A External Causes of Morbidity

21 N/AFactors Influencing Health Status and Contact with Health Services

Chapter ComparisonChapter ICD-9 CM ICD-10 CM

Supplementary Classification

Classification of Factors Influencing Health Status and Contact with Health Services (V Codes)

N/A

Supplementary Classification

Classification of External Cause of Injury and Poisoning (E Codes)

N/A

ICD-10-CM Code Examples F03 Unspecified dementia L60.0 Ingrowing nail J09.12 Influenza due to identified novel

H1N1 influenza virus with other respiratory manifestations

M71.061 Abscess of bursa, right knee T21.31xa Burn of third degree of chest

wall

ICD-10-CM Terminologyand New Feature Laterality

Right = character 1 Left = character 2 Bilateral = character 3 Unspecified = character 0 or 9

ICD-10-CM Terminologyand New Feature

Laterality Examples M54.31 – Sciatica, right side

ICD-10-CM Terminologyand New Feature Combination codes

Diagnosis with associated sign or symptom Diagnosis with associated complication Diagnosis with cause

ICD-10-CM Terminologyand New Feature Combination code example

Conditions with symptoms and manifestations K27.2 – Acute peptic ulcer, site unspecified, with both

hemorrhage and perforation

ICD-10-CM Terminologyand New Feature Combination code example

Poisoning and external cause T51.0x2 – Toxic effect of ethanol, intentional, self-

harm

ICD-10-CM New Features Obstetric codes identify trimester

1 = 1st trimester < 14 weeks, 0 days 2 = 2nd trimester 14 weeks, 0 days to < 28

weeks, 0 days 3 = 3rd trimester 28 weeks, 0 days to delivery 0 or 9 = unspecified

Obstetric Codes Ex: O26.02

Excessive weight gain in pregnancy, second trimester

ICD-10-CM Excluded Indications Codes that should not be reported

together

Separately identifiable conditions Excluded condition not part of reported

condition Can have both condition at same time

Example 1 E11 – Type 2 diabetes

(Excludes1: Gestational diabetes (O24.4-); type 1 diabetes (E10.-)

Example 2 I10 – Essential (primary) Hypertension

Includes: High blood pressure hypertension (arterial) (benigh) (essential) (malignant) (primary) (systemic).

(Excludes 2: Essential (primary) hypertension involving vessels of brain (I60-I69); Essential (Primary) hypertension involving vessels of eye (H35.0)

ICD-10-CM Includes Clinical Concepts

Underdosing Blood type Blood alcohol level Encounter type Indication of healing

ICD-10-CMExpanded Codes Significant expansion of codes

Diabetes Substance abuse Postoperative complications

Distinction made between intraoperative complication and postprocedural disorders

Diabetes Increase from 40 to 122 codes Example

E08.321 – Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema

ICD -10 Terminology Granularity

Level of hierarchy Increased description information

ICD -10 Terminology Morbidity

Rate of disease in population Mortality

Rate of death in population

ICD -10 Terminology Principal or First-listed Diagnosis

Primary reason for encounter

Inpatient setting First code on medical record Principal diagnosis

Other health care settings First-listed code

ICD -10 Terminology Rubric

Group of similar conditions Three character category or four character

subcategory

Steps To Code Correctly Identify diagnosis or reason for encounter Locate in Alphabetic Index Verify in Tabular List Read and interpret notes

Steps To Code Correctly Choose tentative code Find highest level of specificity Consult prompts Assign a code

ICD 10 PCS

ICD-10 Part 2 ICD-10-PCS for inpatient procedure

coding All U.S. Inpatient hospital settings only 7 alpha-numeric digits 72,589 ICD-10-PCS

Increased from 3,824 ICD-9-CM procedure codes

Facility Claims Compliance A Must No delays or grace period ICD-9-CM for dates of discharge < October

1, 2014 ICD-10 for dates of discharge ≥ October 1,

2014 ICD-10-PCS for dates of discharge ≥

October 1, 2014

Structure Differences Codes are longer Greater clinical detail and specificity Updated terminology and classifications

ICD-10-PCS Structure 7 digits Each digit is either alpha or numeric

Alpha digits are not case sensitive Letters O and I are not used to avoid confusion

with numbers 0 and 1 Each character has a

value/meaning/option

ICD-10-PCSCode Examples 0FB03ZX – Excision of liver, percutaneous

approach, diagnostic; and 0DQ10ZZ – Repair upper esophagus, open

approach.

ICD-10-PCS Structure First character specifies the section or

type of procedure 0 = Medical and surgical 1 = Obstetrics 2 = Placement 3 = Administration 4 = Measurement and monitoring

ICD-10-PCS Structure First character continued

5 = Extracorporeal Assistance and Performance

6 = Extracorporeal Therapies 7 = Osteopathic 8 = Other Procedures 9 = Chiropractic

ICD-10-PCS Structure First character continued

B = Imaging C = Nuclear Medicine D = Radiation Oncology F = Physical Rehabilitation and Diagnostic

Audiology G = Mental Health H = Substance Abuse Treatment

Medical and SurgicalFirst Character = “0”

Character Meaning

1 Section

2 Body System

3 Root Operation

4 Body Part

5 Approach

6 Device

7 Qualifier

ChiropracticFirst Character = “9”

Character Meaning

1 Section

2 Anatomical Region

3 Root Operation

4 Body Region

5 Approach

6 Method

7 Qualifier

Radiation OncologyFirst Character = “D”

Character Meaning

1 Section

2 Body System

3 Root Type

4 Body Part

5 Modality Qualifier

6 Isotope

7 Qualifier

Mental HealthFirst Character = “G”

Character Meaning

1 Section

2 Body System

3 Root Type

4 Type Qualifier

5 Qualifier

6 Qualifier

7 Qualifier

ICD-10-PCS Structure Second through seventh characters

Same meanings within a section Different meanings per section Third character = general type of procedure

performed See chart in workbook

Parts of ICD-10-PCS Index

Alphabetic lookup Tables

Different organization than ICD-9 List of codes

Listing of unique procedure codes

ICD-10-PCS Table Example0 Medical and Surgical 2 Heart and Great Vessels 7 Dilation: Expanding an orifice or the lumen of a tubular body part

Body Part Approach Device Qualifier

0 = Coronary Artery, One site

1 = Coronary Arteries, Two Sites

2 = Coronary Arteries, Three Sites

3 = Coronary Arteries, Four or More Sites

0 = Open

3 = Percutaneous

4 = Percutaneous Endoscopic

4 = Drug=eluting Intraluminal Device

D = Intraluminal Device

T = Radioactive Intraluminal Device

Z = No Device

6 = Bifurcation

Z = No Qualifier

List of Codes - Example Code descriptions for dilation of one

coronary artery (0270) 027004Z Dilation of Coronary Artery, One Site with

Drug-eluting Intraluminal Device, Open Approach 02700DZ Dilation of Coronary Artery, One Site with

Intraluminal Device, Open Approach 02700TZ Dilation of Coronary Artery, One Site with

Radioactive Intraluminal Device,

ICD-10-PCS Character Meanings http://www.cms.gov/ICD10/Downloads/

pcs_final_report2010.pdf

General Equivalence Mappings (GEMs)

Proper Coding GEMs are not a substitute Select codes base on

Patient’s encounter Medical record documentation

GEMs As A Tool Forward mapping

ICD-9 to ICD-10-CM and PCS Backward mapping

ICD-10-CM or PCS to ICD-9 Convert databases such as

Track quality, record morbidity/mortality, calculate reimbursement

GEMs All ICD-10- CM codes

ICD-10-CM to ICD-9-CM GEM All ICD-9-CM diagnosis codes

ICD-9-CM to ICD-10-CM GEM All ICD-10-PCS codes

ICD-10-PCS to ICD-9-CM GEM All ICD-9-CM procedure codes

ICD-9-CM to ICD-10-PCS GEM

Three Steps To Use GEMs Extract

Select all rows containing code Analyze

Note and understand flags on code Refine

Select rows that meet applied mapping requirements

GEM Resources http://www.cms.gov/

ICD10/12_2010_ICD_10_CM.asp#TopOfPage

http://www.cms.gov/ICD10/13_2010_ICD10PCS.asp#TopOfPage

GEM Details One ICD-9-CM diagnosis code represented

by multiple ICD-10-CMs 82002 represented by

S72031A S72031G S72032A S72032G Other codes from GEMs

GEM Details One ICD-10-CM diagnosis code

represented by multiple ICD-9-CMs E11341 represented by

25050 36206 36207

GEM Details Some ICD-10-CM have no ICD-9-CMs

T500x6A T501x6A T502x6A T503x6A T504x6A Others found in GEMs

GEM Details One ICD-9-CM procedure code captured by

multiple ICD-10-PCSs 8659 captured by

JQ10ZZ JQ13ZZ JQ40ZZ JQ43ZZ Others found in GEMs

GEM Formatting Three columns

ICD-10-CM Source system code is on the left side

ICD-9-CM Target system code is in the middle Flags are on the right

GEM Mapping ExampleICD-10 Source

CodeICD-9 Target

CodeFlags

T1500xA 9300 10111

T1500xA E914 10112

T1500xD 9300 10111

T1500xD E914 10112

T1500xS 9085 10000

GEM Mapping Example

T1500xA Foreign body in cornea, unspecified eye, initial encounter

9300 Corneal foreign bodyE914 Foreign body accidentally entering eye and adnexa

T1500xD Foreign body in cornea, unspecified eye, subsequent encounter

9300 Corneal foreign bodyE914 Foreign body accidentally entering eye and adnexa

T1500xS Foreign body in cornea, unspecified eye, sequela

9085 Late effect of foreign body in orifice

GEM Flags 5 digit code (Ex: 10111) First position

1 = translation is approximate match T1500xA 9300 10111 T1500xA E914 10112

0 = translation is identical match 41411 12542 00000

GEM Flags Second position

1 = no plausible translation No Description Found (NODX) 0 = at least one plausible translation

Examples T500x6A NODX 11000 T500x6A NODX 11000 T500x6S NODX 11000

GEM Flags Third position

1 = code maps to more than one code 0 = code maps to single code

T1500xA 9300 10111

T1500xA E914 10112

T1500xD 9300 10111

T1500xD E914 10112

T1500xS 9085 10000

Reasons For No One-To-One Match ICD-10 New concepts not in ICD-9-CM No matching code exist in GEMs Multiple ICD-9-CM codes exist for a single

ICD-10 code Multiple ICD-10 codes exist for a single

ICD-9-CM code

GEM Updates Posted in January Updated annually Access updated GEMs for diagnoses

http://www.cms.gov/ICD10/12_2010_ICD_10_CM.asp

Access updated GEMs for procedures http://www.cms.gov/

ICD10/13_2010_ICD10PCS.asp

Reimbursement Mappings

Reimbursement Mappings CMS developed One-to-one reimbursement crosswalk

Temporary mechanism Codes submitted ≥ October 1, 2014 ICD-10-CM/PSC to reimbursement equivalent

ICD-9-CM codes Utilized GEMs

Reimbursement Mappings Two crosswalks

ICD-10-CM to ICD-9-CM diagnosis code(s) Ex: K50012 crosswalks to 555.0 and 560.9

ICD-10-PCS to ICD-9-CM procedure code Ex: 037544Z crosswalks to DX 395.0 and Procedure

and Intervention codes 00.40, 00.55 and 00.45

Reimbursement Mapping FormatPosition Length Contents

1 8 I-10 code

9 1 Number of I-9 codes this I-10 code maps to. Values 1 through 5.

10 6 First I-9 code

16 6 Second I-9 code

22 6 Third I-9 code

28 6 Fourth I-9 code

34 6 Fifth I-9 code

Reimbursement Mapping Resource ICD-10-CM-PCS to ICD-9 Reimbursement

Mapping Documentation and User Guide http://www.cms.gov/

ICD10/08a_Payer_Resources.asp#TopOfPage.

Reimbursement Mapping Example

00160K6 - Bypass Cerebral Ventricle to Peritoneal Cavity with Nonautologous

Tissue Substitute, Open Approach

03754DZ Dilation of Right Axillary Artery with Intraluminal Device, Percutaneous Endoscopic Approach

Reimbursement Mapping Example

Converting MS-DRGs to ICD-10-CM and ICD-10-PCS CMS Project Convert ICD-9-CM Medicare Severity –

Diagnosis Related Groups (MS-DRGs), version 26.0, to ICD-10-CM and ICD-10-PCS (ICD-10-CM/PCS) codes

Information available at: http://www.cms.gov/

ICD10/17_ICD10_MS_DRG_Conversion_Project.asp#TopOfPage.

Preparation Steps

Other Countries Experiences Problems with implementation

1. Clinical documentation2. IT: space, time and money3. Productivity

ICD-10Are You Ready To S.W.A.P. S = Schedule Training W = Work With Staff A = Adjust Work Processes P = Prepare Now

Basic Steps to Prepare forVersion 5010/ICD 10

Identify system and work processes that use ICD-9 Where are ICD-9 codes used

Identify potential changes

Basic Steps to Prepare forVersion 5010/ICD 10 Assess staff training needs

Find training opportunities Train the trainer

Train on Codes Anatomy, physiology, pathophysiology,

pharmacology Medical terminology

Test YourKnowledge of Anatomy Ulna Proximal phalanges Vomer Basal Ganglia Thymus Tibial nerve

ICD-10

6

4

3

2

5

1

Basic Steps to Prepare forVersion 5010/ICD 10 Contact practice management system

vendor Readiness for 5010 Needed upgrades to hardware/software Costs Implementation dates Training and customer support

Basic Steps to Prepare forVersion 5010/ICD 10 Contact clearinghouses, billing services

About 5010 and ICD-10 compliance Timeframe for transitions

Contact payers ICD-10 affects on contracts, payment

schedules, or reimbursement Timeframe for transitions

Basic Steps to Prepare forVersion 5010/ICD 10 Budget time and costs

ICD-10 implementation System changes Resource materials Training Money in case of implementation problems

Basic Steps to Prepare forVersion 5010/ICD 10 Conduct testing

Payers and clearinghouses Allow time for approval

New Draft1500 Claim Form

New Draft1500 Claim Form

Room for 12ICD-10 CM Codes

New CMS Guidelines Beginning July 1, 2012 Medicare contractors shall not accept new

direct submitter using HIPAA Version 4010A1

All new direct submitters will be required to enroll using HIPAA Version 5010 transactions

Resources American Medical Association www.ama-assn.org/go/5010

Fact Sheets 5010 Checklist Project Plan Template – Helping Practices

Prepare for the New HIPAA Standards 7 Steps

Resources The Centers for Medicare & Medicaid

Services (CMS) Web site www.cms.gov/ICD10

CMS sponsored calls http://www.cms.gov/

ICD10/02c_CMS_Sponsored_Calls.asp#TopOfPage

Resources American Academy of Professional Coders

(AAPC) Countdown to implementation Training Monthly articles Code translator

Resources GEMs and User’s Guides

http://www.cms.gov/ICD1013_2010_ICD10PCS.asp

Workgroup for Electronic Data Interchange (WEDI) http://www.wedi.org

Resources Health Information and Management

Systems Society (HIMSS) http://www.himss.org/icd10

American Health Information Management Association (AHIMA) http://www.ahima.org/ICD10/

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