ICD-10-CM An Introduction 2013

Bobbi Buell, MBAonPoint Oncology LLC800-795-2633bbuell@onpointoncology.cim

Inspire panic---this is not that far away.

Create an awareness of ICD-10-CM.Start to consider the impact the

conversion to ICD-10 will have on your operations.

Start to understand what it means and does not mean in Oncology.

Latest UpdateThis is happening 10/1/2014

CMS intimated that the deadline would not be postponed.

The AMA still vehemently opposes this deadline.

Hospitals have spent millions on it.

You be the judge.

Implications of the Transition – Who?

ProvidersHospitalsPhysiciansOutpatient facilitiesPost-acute providers (home health agencies,

skilled nursing facilities, etc.)

Health Plans or PayersThird party administrators Employers

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Implications of the Transition – Who?

Others LaboratoriesFree standing ancillaries Researchers Public health agencies et alData collection agencies/organizations (tumor

registries) Vendors ClearinghousesBusiness associates and partners

Patients

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ICD-9-CM vs. ICD-10-CM

1) ICD-9-CM is out of date and running out of space for new codes on the procedural side.

• Lacks specificity and detail• No longer reflects current medical practice

2) ICD-10 is the international standard to report and monitor diseases and mortality, making it important for the U.S. to adopt ICD-10 based classifications for reporting and surveillance.

3) ICD codes are the core elements of HIT systems, conversion to ICD-10 is necessary to fully realize benefits of HIT adoption.

Reimbursement Issues With ICD-9?

Example: Fracture of WristSkateboarder fractures right wrist

A month later, fractures left wristICD-9 would require additional documentation to find

out which wrist was fractured ICD-10-CM describes in fracture codes

Left versus rightInitial or subsequent encounterRoutine healing , delayed healing, nonunion or

malunion

There Are Benefits of ICD-10

Reflects more emerging technologies, particularly PCS

Captures the details of EMRs

Might reduce ADRs from payers due to more specificity

Statistical outcomes will be more measurable and specific

May support better epidemiological trending

What is ICD-10-CM?CM = Clinical modification to ICD-10 used

around the world

Consultation withPhysician groupsClinical codersOther users of ICD-9-CM

Who Runs The Show?National Center for Health Statistics (NCHS) is

the federal agency that is responsible for maintaining the diagnostic coding systems in the U.S.

CMS partners with them to oversee publicly available coding systems

WHO oversees ICD-10 without the –CM

The American Health Information Management Association (AHIMA) oversees education and training

ICD-10-CM code book retains the same traditional format Index

Tabular

Process of coding is similarLook up a condition in the Index

Confirm the code in the Tabular

ICD – 9-CM ICD – 10-CM

13,600 codes 69,000 codes

Code book contains 17 chapters Code book contains 21 chapters

Consists of 3 to 5 characters Consists of 3 to 7 characters

1st character is alpha or numeric 1st character is alpha

Only utilizes letters E and V Utilizes all letters (except U)

Second, third, fourth, and fifth characters are always numeric

Second characteris always numeric

Third, fourth, fifth, sixth, and seventh

characters can be alpha or numeric

Shorter code descriptions because of lack of specificity and abbreviated code titles

Longer code descriptions because of greater clinical detail and

specificity and full code titles

Character ChangesICD-9-CM ICD-9-CM

ChapterICD-10-CM ICD-10-CM

Chapter

001-139 Chapter 1 Infectious or Parasitic Disease

A0-B99

140-239 Chapter 1 Neoplasms C00-D49

320-389 Chapter 6 Diseases of the Nervous System

G00-G99

Chapter 7 Diseases of the Eye and Adnexa

H00-H59

Chapter 8 Diseases of the Ear and Mastoid

H60-H95

ICD-9-CM CODE

A - Category of code

B - Etiology, anatomical site, and manifestation

ICD-10-CM CODE

A - Category of code

B - Etiology, anatomical site, and/or severity

C - Extension 7th character for obstetrics,

injuries, and external causes of injuryA B

A B C

XX .

ICD-9-CM Structure – Format

XX XX XX XX55EE 1 4 0 0.VV

Category Etiology, Anatomic Site, Manifestation

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Numeric or Alpha

(E or V) Numeric

3 – 5 Characters

XX XX XX XX

Category

.Etiology, Anatomic

Site, Severity

Added code extensions (7th character) for obstetrics, injuries, and external causes of injury

ICD-10-CM Structure – Format

XX XX XXAAMMS 3 2 0. 1 0 A

Additional Characters

Alpha (Except U)

2 - 7 Numeric or Alpha

3 – 7 Characters

Characteristics of ICD-10-CMICD-10-CM far exceeds its predecessors in the

number of concepts and codes provided

The disease classification has been greatly expanded to include health-related conditions and to provide greater specificity at the sixth digit level and with the seventh digit extension

By the way, the 6th and 7th digit extensions ARE NOT optional for the codes where they are present

Arrangement of Volumes of ICD-10

Volume 1: Main classifications

Volume 2: Instruction/ Guidance to users

Volume 3: Alphabetical Index

ICD-10 has 21 chapters against 17 Chapters in ICD-9

Chapters of ICD-10Chapters I to XVII: Diseases and other morbid

conditions

Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.

Chapter XIX: Injuries, poisoning and certain other consequences of external causes.

Chapter XX: External causes of morbidity and mortality,

Chapter XXI: Factors influencing health status and contact with health services.

What You Should Worry About

The codes you most frequently use Can you run a report from your PM or EMR system

that shows you all ICD-9’s that you have billed more than 50-100 times over the past 2-3 years? Your limits will depend upon your size.

These are the codes you need to know and translate.

You do not need to know 69,000 codes

But, physicians need to access to non-cancer codes to use when they are evaluating and/or managing patients

General Equivalence Mappings

ICD-9 Code

Description (Source)

820.8 Fracture of unspecified part of neck of femur, closed

ICD-9 Code

Description(Target)

820.8 Fracture of unspecified part of neck of femur, closed

Forward Mapping

Backward Mapping

GEMS Example #1

GEMS Example #2

GEMS #3

GEMS Example #4

Other Major Differences With ICD-10

Use additional codes

Sequelae

Combination codes

Differences in anemia

Mandatory 6th and 7th digits

Cancer DifferencesLaterality

Mandatory’ use additional’ codes—look at lung cancer

6th digits (check out skin and breast cancers)

Much more detail and confusion surrounding lymphoma

More detail in myeloid leukemia

Help with CUP

And this must be documented….

Preparing for ICD-10

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Checklist: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht

2011 2012 2013 2014

Awareness and Impact

Assessment Preparing for

Implementation

Go Live Preparati

on

Post – Implementation

Phase I

Phase II

Phase III

Phase IV

Year

Where to Start?

Diagnostic codes are everywhere – used by every person, every process, every system….– Superbills– Payments/EOBs/ERAs– Referrals– Contracts– EMRs

But, again, this is limited to codes you actually use

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Diagnostic Codes are Ubiquitous

Solo Practitioner Or Small Group (2-10) Practice Implementation Planning

1. Organize Implementation Effort2. Establish Communication Plan3. Conduct Impact Analysis4. Contact System Vendors5. Estimate Budget6. Implementation Planning7. Develop Training Plan8. Analyze Business Processes9. Education and Training 10.Policy Change Development 11.Deployment of Code12.Implementation Compliance

35Source: AAPC

2013 Plan

Organize Implementation Effort

Enlist staff person (coder, biller, manager) to oversee effort who will be key point person― Prepare information to share with other providers

and staff― Identify work and scope for implementation

Should be a team effort involving all medical practice staff and the staff needs to believe that this will actually happen.

If everyone is not signed on to this, your effort will not work long term

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Organize Implementation Effort

Examine the level of coding you have in your practice—who is certified? Who has experienced a change before, e.g. E/M, admin codes? Who is equipped to deal with this?

Look at all areas that will impact practice and identify each one that will be affected― List of codes― Practice management system― Electronic Medical Record (EMR), if applicable― Superbills― Clinical areas and pharmacy

Schedule regular meetings to share information with physicians and discuss progress and barriers of implementation.

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Establish Communication Plan

How will point person communicate with all staff?Most practices communicate via meetings or

memos No need to change method of communications Develop regular schedule for ICD-10 progress efforts

Monthly until 6 months prior to implementation Bi-weekly thereafter

Include information, publications, and articles

Document all meetings and what was discussed herein and make sure you are tracking with your plan.

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Conduct Impact Analysis

• Take this step prior to development of budget• In depth look at resources required for

implementation• Maybe check for a little process improvement

• Helps determine what costs might be involved as well as work processes

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Potential Areas that will be Impacted!

Clinical Area- Patient Coverage- Superbills- ABN’s

PhysiciansDocumentationCode SpecificityProblem lists

• Nurses– Forms– Documentation– Prior Authorization

• Managers– Policies & Procedures– Vendor/Payer Contracts– Budgets– Training Plan

Potential Areas that will be Impacted!For those that can’t read the small print…

Source: AAPC 2012

LabDocumentationReporting

Billing Policies & ProceduresTraining

Pharmacy

Infusion Room

• Coding– Code Set– Clinical

Knowledge– Concurrent Use

• Front Desk– Referrals/ History

codes– Systems

Potential Areas that will be Impacted!

Source: AAPC 2012

List Every Area That Uses Codes

Geographical

Technological

Processes

Vendors

Payers

Paper

Etc

What It Looks like

Source: AMA ICD-10 Project

Conduct Impact AnalysisDevelop reasonable timeline that can be

accomplished in your practice―Map out a project plan on a simple Excel

spreadsheet with benchmarks and status of completion

Managers and/or coders should get physician approval for the project plan and its impact on the practice. Make sure you show and tell them the level of work it will take.

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From Impact Analysis Develop a plan for

ProcessesDepartmentsTraining

Then, go to the next step…

Vendor Readiness

Contact System Vendors

• Will they be able to accommodate the need to move to ICD-10? Really? Were they ready for 5010?

• What plans do they have in place for implementation?

• Will they have new tools in place to help you with ICD-10? Will these have a cost? Will they create savings? How long will they run parallel coding?

• When will they have software available for testing?

• Will we need new hardware or is current hardware sufficient?

• What is the cost?

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Estimate BudgetBudget considerations should include

Hardware costsSoftware costs and licensingTrainingParallel codingPhysician QueryProductivity losses Jeopardy to cash flow

Some notable budget estimates follow this slide…

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Develop BudgetDevelop Budget

Cost Breakdown Example Education $ 2,500 Process Analysis $ 7,000 Changes to Super bills $ 3,000 IT Costs $ 7,500 Increased Documentation $44,000 Cash Flow Disruption $20,000

TOTAL $84,000

ICD-10 Implementation $: AMA

53(c) onPoint Oncology LLC

ICD-10 Implementation $$: MGMA

54(c) onPoint Oncology LLC

Ask Yourself

How much did 5010 really cost your practice?

2014

Implementation Planning

Break down planning into stages that fit your size and structure…Training for a very small practice does not need to

begin until 6 months prior to implementation

Review superbills or chargemaster or order entry charges and remove rarely used codes

Crosswalk common codes from ICD-9-CM to ICD-10-CMLook up codes in ICD-10-CM book and use GEMs, if

necessary, but this is a very general and not necessarily accurate way of coding.

Some vendors now have side-by-side coding, which facilitates the learning process.

You should parallel codes for some period

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Develop Training Plan

Who needs training?PhysiciansCodersBilling staffAdministrative staffNurses, MAs, Pharmacy

Required number of hours depends on their role and coding interface

What resources are available in your area?

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Develop Training PlanMany organizations will have several mechanisms

for trainingDistance learningWorkshopsConferencesAudio ConferencesWebinarsBooks

Establish training schedule or just “Train the Trainer”, but this must be a trusted coding person who also can communicate necessary information to clinicians.

Having systems that facilitate clinicians and coders to be around the codes in 2014 are helpful.

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Develop Training Plan

Determine if temporary staff or overtime will be necessary during training period

What materials will the office need for ongoing support after training?BooksSoftware (code look up programs)Other

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Analyze Payer Processes

Identify all payer systems and processes that currently use ICD-9-CM

Review existing medical policies related to ICD-9-CM

Which contracts tied to reimbursement are tied to a particular diagnosis? Which payers have policies for cancer drugs that are tied to ICD-9? How will this be impacted?

Modify any contract agreements with health plans

Ascertain their timelines for testing ICD-10 acceptance

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Policy Change/ Payment Impact

After health plans complete and change medical policy for procedures and services a specialty providesReview new payment policies Identify opportunities to improve coding processesCommunicate policy changes to applicable staffFind out the policy switch-over date (might not be

10/1/2014)

How long will they accept ICD-9-CM claims?

Good news: many payers have ICD-10 right on their sites right now!!! Check it out!!!

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Education and Training

• Formal education should begin approximately 6-8 months prior to implementation

• Large practices may need to begin earlier to accommodate all staff who need training

• Use various methods of training: on-line, distance, “Boot Camps”

• Training time depends on their role

• Physicians and coders/billers will need more training time than administrative staff

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Deployment of Code Should receive all updated software no later

than 7/31/2014 for implementation of your charge documents. And, that is cutting it mighty close…

Vendor delivers software update with ICD-10-CM, but you should also know how long ICD-9 will be on-line.

Vendors shouldTest system Integrate software into your systemsMake internal customizationsTest systems with clearinghouses, payers,

electronic claims transmission (end to end)Ensure that the vendor will maintain updates to

code during transition period 64

Testing of CodeDoes your PM system transmit ICD-10 codes?

What does your clearinghouse do?

Is your coding translated to incentive programs, PQRS? EHR?

Does the process from documentation to billing work?

Where are the snafus?

Implementation Compliance

Compliance date for implementation – October 1, 2014

Ensure you are staffed for the change.

Make sure lines of credit are in place.

Monitor compliance activities to identify any problems.

QA chart to billing coding and do this until it looks clean.

Pursue vendor and payer problems as necessary.

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Other Considerations

Consider use of electronic tools to facilitate coding process–Could reduce costs and claims rejections–Could increase productivity and coding accuracy

Don’t convert superbills/charge documents too early– Things can change and you don’t want to up your

costs

– Assign ICD-10-CM codes directly, not by applying ICD-9-CM to ICD-10-CM map—it’s good practice’!!

ResourcesResourcesICD-10-CM Online

http://www.cdc.gov/nchs/icd/icd10cm.htm

GEMs Mapping Files

ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2011/

Preparation Check List

http://www.ahima.org/downloads/pdfs/resources/checklist.pdf

CMS ICD-10 Information

https://www.cms.gov/ICD10/

Basic Education SitesNCHS – Basic ICD-10-CM Information

http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

CMS – ICD-10-PCS Informationhttp://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp

AHIMA - ICD-10 Educationhttp://www.ahima.org/icd10/index.asp

WEDI – ICD-10 Implementationwww.wedi.org

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CDC’s Web ResourcesGeneral ICD-10 information

http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

ICD-10-CM files, information, and General Equivalence Mappings (GEM) between ICD-10-CM and ICD-9-CMhttp://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

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AHA’s Resources• Regulatory member advisories

• Presentations and articles

• ICD-10 audio seminar series

• Central Office on ICD-9-CM

http://www.ahacentraloffice.org

• AHA Central Office ICD-10 Resource Center

http://www.ahacentraloffice.org/ICD-10

In Summary… The time to start is YESTERDAY

The first thing you need to do is determine where change needs to happen and how much it will cost. Physicians may have no idea that this will be a line item.

Hospitals are way ahead of practices. They are doing dual coding right now! So, do not count on delays!

Physicians need to be trained---do not let them off the hook---documentation is very different under ICD-10-CM.

Check out your payer polcies---some are already translated!

What did you learn from 5010 that will help you with this?

Marshall the resources that are available at no charge and there are a lot.

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CAN Web SiteThe latest newsFormsRegulationsNewslettersPresentationshttp://can.communityoncology.org

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Contactbbuell@covad.netbobbibuell1@yahoo.com800-795-2633

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