Planning Our Way for Planning Our Way for ICD 10-CMICD 10-CM

Virginia Long, RN, LHRM, CPCPresident, Advanced Medical ServicesCurrent President of Clearwater AAPC

Chapter

ICD 10 goes into effect

OCTOBER 1, 2013OCTOBER 1, 2013

World Health Organization

WHO publishes the International Classification of Diseases (ICD) code set which defines diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. The WHO authorized a US adaptation of the code set for Clinical Modification (CM).

Currently the United States uses the ICD ninth edition originally published in 1977.– ICD-9-CM (Clinical Modification), used in all

health care settings– ICD-9-PCS (Procedure Coding System), used only

in inpatient hospital settings.

In 1990, the WHO updated to the ICD-10. Other countries began using ICD-10 in 1994 but the United States only partially adopted ICD-10 in 1999 for mortality reporting.

Some Major Countries Utilizing ICD-10

Country ICD – 10 Implementation

United Kingdom 1995

France 1997

Australia 1998

Belgium 1999

Germany 2000

Canada 2001

Productivity

Productivity was reported to drop when ICD-10 was implemented. Some countries reported a drop from normal to 60%.

The ICD-10 codes will be increasing from approx. 15,000 ICD-9 codes to 150,000 ICD-10 codes.

Thus proper planning, training, and implementation are essential to protect the business entity.

October 1, 2013!Why are we hearing so much now? Why are there so many seminars and webinars to train us as time seems to be of the essence? This change does not occur for 2 years.

We will discuss the following:

• Significant Dates and Suggested Timeline• Why Are Changes Needed?• What Changes Occur with ICD 10?• What System Changes are Needed?• What Training is Needed?• When is Training Needed? • What are the Financial Impacts and Risks?

Significant DatesDecember 31, 2011 External Testing for 5010 must be complete

January 1 , 2012 All electronic claims must use 5010

January 2012 – December 2013 Develop implementation strategy that includes 1. An assessment of the impact on your organization2. A detailed timeline3. A budget4. Revised and new policies and procedures

January 2012 – October 1, 2012 Staff and physician training on concepts and overview of changes required for ICD 10

October 1, 2012 – October 1, 2014

ICD codes FROZEN until October 1, 2014

October 1, 2013 Services on or after Oct. 1, 2013 require ICD 10 codes. Billing for services prior to 10/1/2013 continue to use ICD 9

Why Change?

ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. The modern classification system will provide much better data needed for:Measuring the quality, safety, and efficacy of care;Reducing the need for attachments to explain the patient’s condition

Designing payment systems and processing claims for reimbursement;

Conducting research, epidemiological studies, and clinical trials;

Setting health policy;Operational and strategic planning;Designing health care delivery systems;Monitoring resource utilization;Improving clinical, financial, and

administrative performance;

Preventing and detecting health care fraud and abuse; and

Tracking public health and risks.

What Changes Occur with ICD 10?

ICD – CM 9 ICD-CM 10

3-5 Digits; 3-7 Digits;

First digit is alpha (E or V) or numeric (alpha characters are not case sensitive);

Digit 1 is alpha; Digit 2 is numeric;

Digits 2-5 are numeric; and Digits 3-7 are alpha or numeric (alpha characters are not case sensitive); and

Decimal is used after third character Decimal is used after third character

14,400 Codes 69,368 Codes

3,800 Procedure Codes 72,000 Procedure Codes

Format and Structure

• Categories– Alphanumeric 3 characters

• Subcategories– 4 or 5 characters

• Codes– Up to 7 characters

New Features in ICD-10-CM

1. Laterality (left, right, bilateral)2. Combination codes for certain conditions and

common associated symptoms and manifestations.

3. Combination codes for poisonings and their associated external cause.

4. Obstetric codes identify trimester instead of episode of care.

5. Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and 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.

6. Two types of Excludes notes Excludes 1 – Indicates that the code excluded should

never be used with the code where the note is located (do not report both codes).

Excludes 2 – Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together.

7. Inclusion of clinical concepts that do not exist in ICD-9-CM.

8. A number of codes have been significantly expanded.

9. Codes for postoperative complications have been expanded and a distribution made between intraoperative complications and post procedural disorders.

Additional Changes Found In ICD-10-CM

1. Injuries are grouped by anatomical site rather than by type of injury;

2. Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM;

3. Certain diseases have been reclassified to different chapters or sections in order to refelct current medical knowledge;

4. New code definitions (e.g. definition of acute myocardial infarction is now 4 weeks rather than 8 weeks.)

5. The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM.

ICD-9-CM verses ICD-10-CM

• The ICD-10-CM code range for diabetes mellitus has over 210 codes. In order to code diabetes mellitus in ICD-10-CM the following is necessary:– Type of diabetes– Body system affected– Use of insulin– Complications– Manifestations– Reason for secondary diabetes mellitus

Code Mapping

General Equivalency Mappings (GEMs) attempt to include all valid relationships between the codes in the ICD-9-CM diagnosis classification and the ICD-10-CM diagnosis classification. The tool allows coders to look up an ICD-9 code and be provided with the most appropriate ICD-10 matches and vice versa. GEMs are not a crosswalk but merely a guide. Many errors have already been found in the GEMs.

Mapping ExamplesICD – 9-CM ICD-10-CM

381.81 Acute Serous Otitis Media H65.00 Acute Serous Otitis Media Unspecified Ear

H65.01 Acute serous Otitis Media Right Ear

H65.02 Acute Serous Otitis Media Left Ear

H65.03 Acute Serous Otitis Media Bilateral

H65.04 Acute Serous Otitis Media recurrent Right Ear

H65.05 Acute Serous Otitis Media recurrent Left Ear

H65.06 Acute Serous Otitis Media recurrent Bilateral

H65.07 Acute Serous Otitis Media recurrent UNS Ear

What System Changes are Needed?

• All software to submit claims must be the 5010 version as of January 1, 2012.

• October 1, 2013 software must be able to utilize both ICD-9-CM codes and ICD-10-CM codes. It will be important to verify in advance that your clearinghouse and the insurance companies you transmit to have these abilities.

• Superbills must be updated and in place as of Oct. 1, 2013 if the provider used superbills with common diagnosis codes listed to choose from.

• Your software must have the ability to transmit both ICD-9 and ICD-10 effective October 1, 2013. ICD 9 codes will continue to be entered and processed for dates of service prior to Oct. 1, 2013.

• The clearinghouses and insurance companies must be able to receive and process both ICD 9 and ICD 10 codes.

• Policies and Procedures must be in place for the new coding rules. These should include how to manage claim rejections.

• P & P s should include how to educate the provider of rejections and needed steps to prevent rejections in the future. Detailed documentation is increasingly important .

• Extra staffing of coders, auditors, and billers should be in place. Productivity is expected to drop by 60%.

What Training is Needed?

• Train your planning and implementation team of changes that will occur and deadlines for changes. When? – NOW.

• Train IT, Auditors, Coders, Billing Staff, Office Managers, and Providers of upcoming changes. When? – Oct. 2011 through Oct. 2012. Increase training and test for knowledge of Anatomy and Physiology. An excellent knowledge of Anatomy and Physiology will be necessary to code and audit.

• Train new ICD-10-CM codes and rules October 2012 through September 30, 2013.

What are the Financial Impacts and Risks?

• Cost of 5010 Conversion– Cost of software– Cost of rebilling and follow-up– Cost of cash flow delay

• Cost of Training– Cost of Development of Training– Cost of Materials– Cost of Labor for Trainers and Attendees. Also

replacement labor while attendee in training.

• Cost to Financial Department– Budgeting is essential and should include the cost

of additional• Accounting staff both in the planning and

implementation phase will require additional FTEs.• An increase in staffing for Accounts Receivable Staff,

Coders, and Auditors. This increase may be up to 40% for several months following the conversion.• (Note that other countries have experienced a

decrease in Productivity to 60% when ICD-10 was implemented.)• An increase in clearinghouse charges due to re-filing

and rejections of claims. • Due to expected cash flow decrease, some providers

will need to secure a loan to cover the transition period.

www.cms.gov › Medicare › ICD-10

Summary

• The U.S. will implement ICD-10-CM Oct. 1, 2013.

• It is important to have an implementation plan and a financial budget to prepare for decreased productivity and a high number of claim rejections.