2015 PCC Optimization Workshop

ICD-10It Takes a Village!

Presented by: Shawn Philabaum, Clinical & Revenue Cycle Specialist

philabaum@hwco.comKelsey Damroze, Software Education & Implementation

damroze@hwco.com

Of course, ICD-10 will impact some staff roles more than others, but even those folks who might not be directly impacted still play an important role in your clinic’s preparations, so you definitely want to get your whole staff involved.

• Nursing- Medications, lab, x-ray will continue to need diagnosis

• MDS and therapy how will they communicate diagnosis that impact billing

• Billers

• Medical records (coders)

• Admission Coordinators – pre review of the medical record to ensure specific diagnosis information is provided

Train Your Staff

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• Utilize your PCC hot list as most commonly used list

• Provide specific ICD10 diagnosis most commonly used in your facility population

• Update as new diagnosis that are identified not on the list (Identify the staff member responsible)

• Meet with the therapist to identify Fx codes that will be utilized for Medicare admission

• Create a Medicare B referral assessment that allows the diagnosis and reason for therapy to be documented and reviewed prior to the therapy evaluation to support medical necessity

• Create a Diagnosis UDA for physician signatures every 60 days to ensure that the diagnosis are documented as active and meet the RAI guidelines

• Print the diagnosis sheets with the ICD9 to ICD10 conversion and have the physician sign prior to 10/01/2015

• Create a pre-admission form that will allow the Medicare Diagnosis to be identified prior to admission

How PCC Can Help

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INTRODUCTION• You will need to enable the ability to begin converting diagnoses from the Diagnosis

Configuration link within setup in Clinical. Once enabled, this feature cannot be disabled.

PROCEDURE• Select Diagnosis Configuration from the Clinical Setup screen.• At Enable ICD-10 Conversion select Yes.• Select Save.

HINTS AND TIPS• You also have an option to Allow future dated diagnosis sheets. This configuration option will

be set to No by default but when set to yes will allow users to create a diagnosis sheet with an effective date in the future. Choosing to do this during your ICD-9 to ICD-10 transition may be helpful in that it will allow more time to create the necessary Diagnosis Sheets in time for October Billing.

• ICD-9 Diagnosis codes will only populate on diagnosis sheets with an effective date prior to the ICD-10 Implementation Date (October 1, 2015) and ICD-10 Diagnosis codes will only populate Diagnosis Sheets with an effective date on or after the ICD-10 Implementation Date (October 1, 2015).

Medical Diagnosis, ICD-9 to ICD-10 Conversion, Configuration

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• Point Click Care provides a utility to assist in assigning ICD-10 codes to resident records based on the General Equivalence Mapping (GEMs) provided by CMS. This tool enables users to quickly view ICD-10 codes that are mapped by CMS to the older ICD-9 codes. While the GEMs provided by CMS are technically correct and matched codes, they may be codes recommended for use in acute care settings. Therefore, it is recommended that users completing conversion be educated on ICD-10 coding and review to determine that the suggested mapping is the best code for your setting.

• If the GEM mapping is a 1:1 conversion (meaning there is only one suggested ICD-10 code for the given ICD-9 code), the mapped ICD-10 code will automatically populate in the conversion pop-up.

• Review your diagnosis with the conversion the majority of the ICD9 diagnosis are non specific and need to be reviewed and revised to be more specific.

Definition:• The Principal/Primary Diagnosis is the condition established after study to be chiefly

responsible for occasioning the admission of the patient to the hospital for care. Since the Principal/Primary Diagnosis represents the reason for the patient's stay, it may not necessarily be the diagnosis which represents the greatest length of stay, the greatest consumption of hospital resources, or the most life-threatening condition. Since the Principal/Primary Diagnosis reflects clinical findings discovered during the patient's stay, it may differ from Admitting Diagnosis. After care codes will need modified and updated

Converting Existing Codes

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Ultimately, CMS will review its flexible, 12-month timeline and adjust it based on the success of ICD-10 adoption. And don’t forget: Just because providers have some wiggle room when it comes to coding for complexity, it doesn’t mean they’re totally off the hook. The ultimate goal is to submit the most complete and accurate code—the first time, every time.

Flexible Review • CMS and the AMA want physicians and other practitioners (therapists included) to make a successful

transition to ICD-10. So, they recently announced a 12-month period during which, according to CMS, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” So, what does that mean?

Are providers off the hook for coding mistakes? • The short answer is “no,” because:

– You still must document ICD-10 codes for dates of service on or after October 1.– You can’t submit both ICD-9 and ICD-10 codes on the same claim.– You still have to make your best effort to code to the highest level of specificity.– However, if your claim doesn’t contain any errors other than those related to code specificity—

and you’ve used a valid code from the correct family of codes—your claim won’t be denied within that 12-month period

Converting Existing Codes (continued)

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ICD-10 Ombudsman

• The ICD-10 Ombud—what? According to my handy-dandy online dictionary, an ombudsman is “a person (such as a government official or an employee) who investigates complaints and tries to deal with problems fairly.” And as part of this announcement, CMS described its plans to designate an ICD-10 ombudsman to investigate and help providers with their ICD-10 troubles during the transition. CMS hasn’t released many details about this resource other than the fact that the ombudsman will work closely with regional Medicare offices to better assist providers. As October 1 approaches, CMS will release more details on how you can contact the ombudsman for ICD-10 assistance.

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Converting Existing Codes (continued)

While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when “unspecified” codes are the best choices for accurately reflecting the understanding of the patient’s health state at the time of the encounter. Coding on health transactions should reflect this level of understanding. In both ICD 9 and ICD‐ ‐10, “unspecified” codes have acceptable, even necessary, uses.

If reasonable confidence in a working diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a more definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Managed Care ConsiderationsThis ICD 10 TIPS applies to both fee for service and managed‐ ‐ ‐

• Note: Reviewing hospital records for diagnosis prior to admission will provide more specific information. On admission clarifications from the MD maybe needed for more specific diagnosis.

Ohio Department of Medicaid

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Diabetes Mellitus (DM) Case Study 1 62 y.o. Mr. X has DM with insulin in use, DM Neuropathy and DM Renal insufficiency. Receives Lantus 25 units sq every HS. E11.22 Type 2 DM with Diabetic Chronic Kidney Disease E11.40 Type 2 DM with Diabetic Neuropathy, unspecified N18.9 Chronic Renal Insufficiency Z79.4 Long term (current) use of insulin‐

Diabetes Mellitus (DM)The DM codes include: Type of diabetes mellitusCombination The body system affectedCodes The complications affecting that body system Assign as many codes from categories E08 – E13 as needed to identify all of the associated conditions that the patient has.

Case Study 1

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• DIABETES MELLITUS (DM) (E08 E13)‐• E08 Diabetes mellitus due to underlying condition • E09 Drug or chemical induced diabetes mellitus • E10 Type 1 diabetes mellitus• E11 Type 2 diabetes mellitus• E12 Other specified diabetes mellitus Diabetes, diabetic• Inadequately controlled code to Diabetes, by type with hyperglycemia‐• Includes out of control code to Diabetes, by type, with hyperglycemia‐• Poorly controlled code to Diabetes, by type, with hyperglycemia‐

Case Study 1 (continued)

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Chapter 19 Injury, Poisoning and certain other consequences of external causes (S00 T88)‐• 7th Character “D”• The Aftercare Z Codes• Coding Traumatic Fractures• Subsequent encounter is used for receiving routine care for the condition during the healing

or recovery phase.• Examples (subsequent care):• Cast change/removal o X ray to check healing status of fracture,…,‐• medication adjustment, other aftercare…• Should not be used for aftercare for conditions such as injuries or poisonings, where 7th

characters are provided to identify subsequent care.• Example• Aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent

encounter).– Fractures (Fx) of specified sites are coded individually by site in accordance with:

• categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92• Level of detail furnished by medical record content.

– Fx not indicated as open or closed should be coded to closed.– Fx not indicated whether displaced or not displaced should be coded to displaced.

• Multiple Fx are sequenced in accordance with the severity of the fracture.

Case Study 2

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• 7th Character “D”• The Aftercare Z Codes• Coding Traumatic Fractures• Subsequent encounter is used for receiving routine care for the condition during

the healing or recovery phase.• Examples (subsequent care):

– Cast change/removal o X ray to check healing status of fracture,…,‐– medication adjustment, other aftercare…– Should not be used for aftercare for conditions such as injuries or poisonings,

where 7th characters are provided to identify subsequent care.• Example

– Aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).

– Fractures (Fx) of specified sites are coded individually by site in accordance with:

– categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92– Level of detail furnished by medical record content.

Case Study 2 (continued)

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Reminders when coding Injury

• “D” represents the aftercare (healing or recovery phase) represented at the 7th character.

• Aftercare Z codes are not used for aftercare following injuries or fractures.

• For aftercare of an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter).

Case Study 2 (continued)

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• Require Medical Necessity For Treatment, Identified By A Medical Diagnosis• Section IV In The Official Guidelines Not USED in LTC• LTC Resident Receiving Part B Therapy Services UB 04‐• Medical diagnosis that identifies the reason for the Part B therapy• Listed on the MDS after the reason for the continued stay.• Outpatient diagnoses are not used for Part B therapy services for residents in LTC

facilities• Nursing homes are identified as a non outpatient setting in section II.‐• Chronic conditions that affect the resident’s progress may also be reported to

support therapy services• Specific line items for therapy services• Appropriate Medical & Tx• Medical condition that required the treatment are used when there is no code

representing the treatment.• Accurate & Complete health record will support appropriate reimbursement for

Medicare Part B services

Medicare Part B Therapy Services

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S72 Fracture of Femur• NOTE• A fracture not indicated as displaced or nondisplaced should be coded to

displaced. The open fracture designations are based on the Gustilo open fracture classification.

• A fracture not indicated as open or closed should be coded to closed.

• EXCLUDES 1

• EXCLUDES 2• traumatic amputation of hip and thigh (78. )‐• fracture of lower leg and ankle (S82. )‐• fracture of foot (S92.)• periprosthetic fracture of prosthetic implant of hip (T84.040,T84.041)

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Case Study Three

• S72.0 Fracture of head and neck of • 5th• femur

• EXCLUDES 2• Fracture of upper end of femur (S79.0)• S72.00 Fracture of unspecified part of neck of femur • Fracture of hip NOS Fracture of neck of femur NOS• S72.001 Fracture of unspecified part of neck of ‐ right femur• S72.002 Fracture of unspecified part of neck of ‐ left femur• S72.009 Fracture of unspecified part of neck of ‐ unspecified femur• S72.001 Right Fx of the Femur Neck‐

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Case Study Three (continued)

7thS72 Fracture of Femur• A initial encounter for closed fracture• B initial encounter for open fracture type I or II• C initial encounter for open fracture type IIIA, IIIB, or IIIC• D Subsequent encounter for closed fracture with routine healing• E subsequent encounter for open fracture type I or II with routine healing• F subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing• G Subsequent encounter for closed fracture with delayed healing• H subsequent encounter for open fracture type I or II with delayed healing• J subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing• K Subsequent encounter for fracture with nonunion• M subsequent encounter for open fracture type I or I with nonunion• N subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion• P Subsequent encounter for closed fracture with malunion• Q subsequent encounter for open fracture with type I or II with malunion• R subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion• S sequela• The appropriate 7th character is to be added to all codes from category S72 [unless otherwise

indicated].

• ICD 10 CM Coding ‐ ‐

Case Study Three (continued)

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• Review configuration• Set up hot list• Educate Staff on new coding• Set up assessments to push pull so that all departments

can review for consistency• Identify procedure to review Admission • Start the conversion with each MDS and all new

Admissions• Print the Diagnosis list with the 9 & 10 and have physician

review and sign• Meet with therapy and review

Conclusion

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Ohio Medicaid’s ICD 10 Webpage‐http://medicaid.ohio.gov/providers/billing/icd10.aspx

General ICD 10 Questions‐http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10

E-mail questions to:ICD10questions@medicaid.ohio.gov

Other informational sites:ICD-10 Guide for Physical Therapistswww.ICD10forPT.com

AHIMA ICD-10 CM Coding Guidance for Long-Term Care Facilitieshttp://bok.ahima.org/doc?oid=107574

Resources

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23240 Chagrin Blvd., Suite 700Cleveland, OH 44122P. 216.831.1200F. 216.831.1842

460 Polaris Parkway, Suite 300Westerville, OH 43082P. 614.794.8710F. 614.794.8712

8800 Tyler Blvd.Mentor, OH 44060P: 440.951.1777

F: 440.951.2143

www.hwco.com877.FOR.HWCO

Thank You!

Shawn PhilabaumClinical & Revenue Cycle Specialist

Kelsey DamrozeSoftware Education & Implementation

This educational offering has been reviewed by the National Continuing Education Review Service (NCERS) of the National Association of Long Term Care Administrator Boards (NAB) and approved for 8.75 clock hours and 5.50 participant hours. Program Approval Number: 3072015-8.75-14852-in. For comments please email cecomments@habweb.org.

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