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What Do I Need to Know Now about ICD-10?

ICD-10 Delay

Delay could cost between $1 and $6 billion

Prepared? Relax and refresh in time for 2015

Not prepared? Be proactive now Review and adjustment

documentation quality Delay allows for attention to coding

and billing procedures

Haven’t We Been Here Before?

Per CMS Acting Administrator, Merilyn Tavenner

Feb. 6, 2013: “We will not abandon ICD-10” Too much work has already

been done to turn back now

The old system won’t work with new technologies

That would penalize innovators

It is necessary for health care reform

Why in the World Do We Have to Change?

WHO says so!

US is the only civilized country NOT on ICD-10

Too much complaining about costs and time

What’s Wrong with ICD-9?

ICD-9 is 30 years old

ICD-9 lacks specificity

ICD-9 does not reflect new services

ICD-9 doe not compare costs and outcomes

ICD-9 is limited (13,000 codes)

What Can I Expect with ICD-10?

ICD-10 will encompass more precise documentation

ICD-10 will allow for more accuracy when determining medical necessity for the services rendered

ICD-10 will allow providers to code more accurately which will contribute to the health care quality improvement initiatives

ICD-9 vs. ICD-10

ICD-9-CM diagnosis codes, 3-5 digits –14,000 total

ICD-10-CM diagnosis codes, 3-7 digits –68,000 total

Similarities? Not!

3-7 characters in length – each added digit adds specificity to the code

7th character can represent visit encounters (initial, subsequent or sequelae for injuries and external causes

7th character is used only for certain sections (e.g. musculoskeletal, injuries and external causes of injury)

Some codes will use “x” as a place holder for characters 4-6 weeks when needed

How are ICD-9 and ICD-10 Different?

ICD-10

ICD-9

Let’s Compare

Myths or Fact?

ICD-10 will replace CPT

The number of codes make ICD-10 impossible to use

ICD-10 is already out of date

Workers comp and Auto insurance will still use ICD-9

Workers Comp

ICD-10 Coding and Documentation

Site

Laterality 5th or 6th digit - Sciatica

Left – M54.31

Right – M54.32

Episodes of care 7th digit

A D S

Injuries

The 7th Character

A – Initial encounter, while patient is receiving active treatment such as surgery, ER, or evaluation and treatment by a new physician.

D – Subsequent encounter, routine care during the healing or recovery phase, such a cast change, medication adjustment, aftercare and follow up.

S – Sequela, complications or conditions that arise as a direct result of a condition, such as a degenerative disc disease a year after a neck sprain. Sequela code (i.e. DDD) is first, then the injury code.

Placeholder “x” character

Placeholder character “x” in positions 4, 5, and/or 6 in certain codes to allow for future expansion.

7th Characters

The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder “x” must be used to fill in the empty characters

For Example

ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus.

NOTE: there are 11 gout codes in ICD-9 and 365 in ICD-10

Important Definitions Carry Over

“Includes”This note appears immediately under a three-digit code title to further define, clarify, or give examples of the content of a code category.

“And”The word “and” should be interpreted to mean either “and” or “or” when it appears in a title… “either or”

NEC “Not elsewhere classified”Used when the information in the medical record provides detail for which specific code does not exist

NOS “Not otherwise “specified” or “unspecified”Used when the information in the medical record is insufficient to assign a more specific code.

ICD-9 and ICD-10 Similarities

[ ] Brackets are use in the tabular list to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Index to identify manifestation codes

( ) Parentheses are used in both the Index and Tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers

Sequencing

“Code First/Use additional code”

Provides instructions on how to “sequence” the codes. Signals that that an additional code should be reported to provide a more complete picture of the diagnosis

“Code Also”

Alerts the coder that more than one code may be required to fully describe the condition. The sequencing of the codes depends on the severity and/or the reason for the encounter

So What is “Excludes 1” or “Excludes 2”?

Similar to Correct Coding Initiative Edits for CPT Codes

Dictates when certain codes can be used together and when not

The explanation will be helpful in the long run

Remember the CCI Edits?

Excludes 1 - is used when two conditions cannot occur together or “NOT CODED HERE!” Mutually exclusive codes; two conditions that cannot be reported together

(A condition may be acquired OR congenital but not both!)

Remember the CCI Edits?Excludes 2 – Indicates “NOT INCLUDED HERE.” Although the excluded condition is not part of condition, it is excluded from, a patient may have both conditions at the same time. The excluded code and the code above the excludes can be used together if the documentation supports them.

HIPAA Electronic Transaction Standards

The new version of the standard for electronic health care transactions (Version5010) is essential to the use of ICD-10 codes because the current standard (Version 4010/4010A1), cannot accommodate the use of the greatly expanded ICD-10 code set.

CMS-1500 Claim Form Revision 02/12

Changed to match the electronic format (5010) and ICD-10 codes

Adds space for eight more diagnosis codes in box 21

Jan 6th, 2014 – Health plans and clearing houses must accept the form.

April 1st, 2014 – Providers must use the new form

Chapter 6: Guidelines for diseases of the nervous system (G00-G99)

Dominant or non-dominant side in hemiplegia (G81):

For ambidextrous patients, default is dominant

If the left side is affected, default is non-dominant

If the right side is affected, default is dominant

Pain (G89 pain, not elsewhere classified)

For generalized acute, chronic, post-thoracotomy, post-procedural, or neoplasm related.

Localized pain codes are found in other chapters (i.e. M54.9, back pain)

G89 can be the principal diagnosis when it is reason for visit

Migraines: 44 Choices

Documentation must include: With or without aura

Intractable or not intractable

With or without status migrainosus

Persistent or chronic

With or without vomiting

With or without opthalmoplegic, menstrual, etc.

Induced by ICD-10 training

Chapter 13-Diseases of the Musculoskeletal System and Soft Tissue

Our Wheelhouse

M-00 through M-99 series

General Coding Guidelines

If the condition is bilateral and there is no bilateral code, then you have to list the left and right code separately

List unspecified if laterality is not described

Examples of Common Codes

CervicobrachialSyndrome

M53.1

(excludes 2: cervical disc disorder)

CervicocranialSyndrome

M53.0

Posterior cervical sympathetic syndrome

Coccygodynia

M53.3

Defined as Sacrococcygeal disorders, not elsewhere classified

In the neighborhood with Spinal Instabilities M53.2X2-Spinal instabilities, cervical

region

Talk About Detail!

Take 847.0 Cervical Sprain

Could be S13.4xxA

Could be S13.8xxA

Much more detail is possible in ICD-10

Item one: sprain of ligaments of the cervical spine

Item two: sprain of joints and ligaments of other parts of the neck

Remember 728.85?

Pes Planus—Now a Code!!

Kissing Spine-Comparison

ICD-9

Kissing

Osteophyte 721.5

Spine 721.5

Vertebra 721.5

ICD-10

Kissing Spine, unspecified M48.20

Occipito-atlanto region M48.21

Cervical region M48.22

Cervicothoracic region M48.23

Thoracic region M48.24

Thoracolumbar region M48.25

Lumbar region M48.26

Lumbosacral region M48.27

Case Study

Sixty one year old female present to your office with ongoing right hip pain and stiffness. Patient stated she had a soft tissue injury to her right hip six years ago following a bicycle accident. X-rays at the time negative for fracture.

Tenderness to the palpation in the right hip, with a positive Patrick’s test on the right reproducing the hip symptoms. X-rays of the left hip were unremarkable, however, the right hip showed sclerosis of the superior aspect of the acetabulum.

DX: Post-traumatic osteoarthritis of the right hip

ICD-10:M99.06 Segmental and somatic dysfunction of the lower extremity

M16.51 Unilateral post-traumatic osteoarthritis, right hip

Coding Symptoms

Chapter 18: Guidelines for symptom signs, and abnormal clinical findings, not elsewhere classified

Use of symptom codes

Acceptable when a definitive diagnosis has not been established by the provider

With a definitive diagnosis

Only when the symptom is not routinely associated with the diagnosis

In a combination code

Don’t code the symptom separately if it is part of a combination code.

General coding guidelines

Use codes that describe symptoms and signs ONLY if that is the highest level of diagnostic certainty documented by the doctor.

Use if other diagnosis has been established (confirmed) by the provider. (see R00 to R99)

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Additional signs and symptoms that are not routinely associated with a disease may be reported.

How do I Find the ICD-10 Code?

Can We Just Crosswalk from ICD-9?

General Equivalence Mappings (GEMs)

Some pointing based on the initial set up

Three possible ways to define subluxation: M99.01, M99.11, or S13.11

Time will tell

ChiroCode ICD-10

Three Methods using the ChiroCode ICD-10 book:

1. Commonly used code list

2. GEMs code map

3. Alphabetic index

4. Always confirm the code using the Tabular list

One-to-one Mapping

723.1 Cervicalgia

M54.2 Cervicalgia

One-to-Five Mapping 724.4 Thoracic or lumbosacral

neuritis (radicular syndrome of the lower limbs)

•ICD-10 – M54.14, M54.15, M54.16, M54.17, M54.18 Radiculopathy

What We Have Now: 729.2

Combination Mapping724.3 Sciatica

M54.30 Sciatica, unspecified side

M54.31 Sciatica, right side

M54.32 Sciatica, left side

OR

M54.40 Sciatica with lumbago, unspecified

M54.41 Sciatica with lumbago, right side

M54.42 Sciatica with lumbago, left side

Coding Whiplash

Sprain VS. Strain 847.0: Sprain of Neck (Includes

strain of joint capsule, ligament, muscle, tendon)

S13.4 _ _ _ Sprain of ligaments of the cervical spine

S16.1xxA STRAIN of muscle, fascia and tendon at neck level, initial encounter

Sprain Vs. Strain“Exam findings are consistent with the strain and sprain of the ligaments and muscles of the cervical spine and acute traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with another motor vehicle on the interstate. He was not treated at the scene.”

S13.4xxA Sprain of ligaments of the cervical spine, initial encounter S16.1xxA Strain of muscles, fascia and tendon at neck level, initial

encounter G44.311 Acute post-traumatic headache, intractable V49.40xA Driver injured in collision with unspecified motor vehicle,

traffic accident, initial encounter Y92.411 Interstate as place of occurrence external cause

Headaches

In ICD-9, the codes might be: 339.21 Acute post-traumatic headache

GEMs suggest: G44.319 Acute post-traumatic headache, not intractable

NOTE: in the index, G44.319 is next to G44.311 which is the intractable version of this condition.

Intractable means “hard to control or deal with”

This must be documented in order to select the correct code

For Example

S30.0xxD-Contusion of lower back and pelvis, subsequent encounter

We will have to wait to see whether this will be required throughout the episode of care, or only on first visit using “A”

V – Y Codes

Chapter 20: Guidelines for external causes of morbidity (V00-Y99) Never sequenced first

Provide data about the cause, intent, place, activity, or status of the accident or patient

No national requirement to use these codes, but voluntary reporting is encouraged

Y92 Place of occurrence should be listed after other codes, used only once an initial encounter, in conjunction with Y93

Y93 Activity code should be used only once, at initial encounter

V, W, X, Y CodesFor Fun

Bus Occupant V79.9

(collision with) Animal in traffic being ridden

Bus Occupant V70.3

(collision with) animal, non-traffic

Bus Occupant V70.4

(collision with) animal, while boarding or alighting

E Codes in ICD-9 Expanded

External Cause Codes

Do you use them?

E844.8Sucked up into a jet

without damage to the airplane; ground crew

ICD-10-CM Increased Specificity

Updated Code V97.33

Sucked into a jet without damage to the airplane

V91.07XA

V95.43XA

Spacecraft collision injuring occupant

Z63.1--Problems in relationship with in-laws

Say What??

G44.82 Headache associated with sexual activity

W22.01xD Walked into wall, subsequent encounter

Y34 Unspecified event, undetermined intent

R45.2 Unhappiness

Case Example

While playing tennis in a tournament at the Clay Court Country Club, a male player sprained his right wrist and was treated by his Chiropractor close to the courts.

S63.5001A Unspecified sprain of right wrist, initial encounter

Y93.73 Activity, racquet and hand sports

Y92.312 Tennis Court (place of occurrence for external cause)

What Should I Do Now?

Concentrate on perfecting documentation

Learn the subtle nuances in your current diagnosis protocols

Begin to discern what each means to you

What Does the Documentation Look Like?

Codes must be supported by the documentation in patient record

The AAPC estimates an increase in docuemtation time of 15%

The AAPC also found that 65% of physician notes were not specific

What the Does Documentation Look Like?

Examples of details not necessary in ICD-9:

Side of dominance

Trimesters

Stages of healing

Laterality

Ordinality

External causes

What Does the Documentation Look Like?S: Mrs. Finley presents today after having a new cabinet fall on her last week suffering a concussion, as well as some cervicalgia. She was cooking at diner at the home she shares with her husband. She did not seek treatment at all that time. She states that the people put in the cabinet in her kitchen missed the stud by about two inches. Her husband, who was home with her at the time told her she was “out cold” for about two minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius.

O: Her weight is 188 which is up 5 pounds from the last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear.

A: Status post concussion with acute persistent headaches

Cervicalgia

Cervical somatic dysfunction

P: The pain at this time is to send her for physical therapy, three times a week for four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month. Sooner if needed

Know the IT Impact You’ll Face

What changes will need to be made?

Do they have available upgrades?

When will the upgrades be available?

Upgrade and your maintenance agreement

Will they continue to provide support?

Parallel coding?

How long will my system be down?

Cross Walk Exercise

Make a list of the 10 most common DX codes you tend to use

Can you list 10 more?

Run the list from your computer

Practicum Exercise!

It’s a Peek!!

ICD-10 in My Practice

Medicare: Free training

Chirocode.com: free email alerts and webinars, more training, memberships, chart audits, and coding tools

FindACode.com: Crosswalks and other advanced tools

ICD10Moinitor.com: Free Articles

AAPC.com and AHIMA.org

Recommended Tools

FindACode.com