ICD-10 ORIENTATION & “YOUR FACILITY PLAN”

Rhonda Anderson, RHIA, PresidentKhaleelah Wagner, RHIA, Staci LePage, RHIT

Anderson Health Info. Systems, Inc.940 W. 17th Street, Suite B

Santa Ana, CA 92706Tel. 714-558-3887 Fax 714-558-1302

Office@ahis.net

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Presenters

Participants will identify:◦Dates for New ICD-10◦Administrative Support Needed◦Documentation support◦Some general coding guidelines, a glance◦Facility Work plan – Key timelines

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Objectives

Final Regulations were released in January 2009

Implementation Date is October 1, 2014• All billing using ICD-10 begins 10/1/2014

ICD-10 for billing purposes as far as ability to accept the code known as “5010” was required by October, 2012 is in compliance

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Final Regulation

Steering Committee Support Team Regional Resource Team Facility Level Team

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Facility ICD-10 Project Team

ICD-10 CM – Clinical Modification – Skilled Nursing will use “CM”

ICD-10 PCS – Procedural Code System (used for procedures, operations within the hospital inpatient setting)

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ICD-10 “Has Two Parts”

ICD-10 compliance means that everyone covered by HIPAA is able to successfully conduct health care transactions using ICD-10 codes

All Billing Claims will be denied if not ICD-10 by OCTOBER 1, 2014

What Does ICD-10 Compliance Means?

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Freestanding providers Ancillary services – “that means all of us

really” who provide services and bill for them under Medicare, Medicaid/Cal and private insurances

Therapy Providers

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Who Is Affected??

Developed for the provider and the coder….(person who may review the documentation and determine if code is accurate)

Consistent, complete documentation in the medical record is a major emphasis

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Who Is Affected?? -2

Like everyone else covered by HIPAA, state Medicaid programs must comply with ICD-10

State Medicaid Program Needs To Transition To ICD-10

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No you will NOT code!◦ Leadership needs some information about the

importance◦To know resources – and resources needed◦ Identify Facility Project Team – initiated now◦Obtain assurance from the computer system◦To know that coding is correct – in future to

have a system to assure accuracy of coding, billing, documentation

Review Your Role

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ICD-10 codes will be updated every year Not in 2014 unless new technologies and

new diseases IN 2015 – regular updates (affects training

and also purchase of manuals – computer alone is not enough

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Codes Change Every Year

Organization – Two volumes Structure – Alphanumeric

categories rather than numeric categories.(has “includes and excludes notes:◦Categories are three digits◦Chapters – re-arranged◦Titles have Changed – examples on following

slides

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ICD-10 Differences

ICD-10 Differences -2

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CHAPTER* ICD-9-CM ICD-10-CM*

1 Infectious and Parasitic Diseases

Certain Infectious and Parasitic Diseases -

A00-B99

2 Neoplasms Malignant Neoplasms

6 Diseases of the Nervous System

and Sense Organs

Diseases of the Nervous System

7 Disease of the Circulatory System

Diseases of the Eye and Adnexa

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ICD-10 Differences -3

CHAPTER* ICD-9-CM ICD-10-CM*

8 Diseases of the Respiratory

System

Diseases of the Ear and Mastoid Process

H60-H95

9 Diseases of the Digestive System

Diseases of the Circulatory System

10 Diseases of the Genitourinary

System

Diseases of the Respiratory System

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ICD-10 Differences -4

CHAPTER ICD-9-CM ICD-10-CM

13 Diseases of the Musculoskeletal

System and Connective Tissue

Diseases of the Musculoskeletal

System and Connective Tissue

14 Congenital Anomalies

Disease of the Genitourinary System

Code composition – increased◦Specificity◦Level of detail◦May consist of up to 7 digits with the seventh

digit extensions representing visit encounter or sequelae as stated above

◦ Includes full code titles and no reference back to common 4th and 5th digits)

◦V and E codes are no longer supplemental

ICD-10

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3-7 characters in length Approximately 68,000 codes Digit 1 is alpha, digit 2 and 3 are numeric;

digit 4-7 are alpha or numeric Decimal placed after the first 3 characters, All letters used except “U” Flexible for adding new codes Very specific Has laterality

ICD-10-CM Diagnosis Codes – Format & Structure

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Way too much detail…but it looks like this!!◦J10.8 – Influenza due to other influenza virus with

other manifestations◦J10.81 – Influenza gastroenteritis◦J10.89 – Influenza with other manifestations:

Influenzal encephalopathy Influenzal myocarditis

◦ANOTHER EXAMPLE – WITH SPECIFICITY AND LATERALITY: S55.011 Laceration of ulnar artery at forearm level,

right arm

Five-Six Character Subdivision

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Mapping from ICD-9 to 10 tools are available, General Equivalence Mappings (GEMS) – translation dictionary for diagnoses

Called “GEMS” – general equivalence mappings

CM – GEMS available PCS – GEMS just available last of

September (acute hospital mostly)

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Mapping Tools

Do not despair…you vendor should prepare as much of a crosswalk as possible

NOTE: will require some conversion for long term resident’s diagnoses by the effective date of ICD-10

Later TRAINING and how to use them…Key to early review!!!

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GEM Files

ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings

ICD-10 PCS (Procedural Code System) – replaces ICD-9 CM in the inpatient hospital setting

Current Procedural Terminology (CPT) is still used for the Physician and some services, but they must have a diagnosis that is ICD-10 compliant

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Key Highlights

Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services

ICD-10 CM/PCS – Increased level of detail required for medicine advancements in technology, $$, improved data quality for clinical and financial decision making, to support value based purchasing and facilitate quality reporting

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Key Highlights -2

3-5 characters in length Approximately 14,000 codes First digit may be alpha or numeric Digits 2-5 are numeric Always at least three digits Decimal placed after the first three characters Limited space for new codes

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ICD-9-CM Diagnosis Codes

Lacks detail Lacks laterality, difficult to analyze, dated,

non-specific and does not adequately define diagnoses needed for medical research

Does not support interoperability because it is not used in other countries

ICD-9-CM Diagnosis Codes -2

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Index and Tabular list have the same hierarchical structure as ICD-9

ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list

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ICD-10 Structure

ICD-9 V and E code supplemental classifications are incorporated into the main classification in ICD-10

ICD-9 V codes are now Z codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services

Postoperative complications have been moved to procedure-specific body system chapters

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ICD-10 CM Structure -2

3-7 characters in length and alphanumeric 21 chapters (compared to 17 in ICD-9) Approximately 68,000 codes Digit 1 is always alpha, digit 2 is numeric; digits

3-7 can be alpha or numeric Decimal placed after the first 3 characters Expanded codes Flexible for adding new codes Addition of placeholder “X” Has laterality

ICD-10-CM Diagnosis Codes – Format & Structure

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ICD-10 utilizes a placeholder character “x” The “x” is used as a placeholder at certain

codes to allow for expansion◦See categories T36-T50, poisoning codes

T36.8X1◦Also, Pathological vertebral fracture due to age-

related osteoporosis, subsequent encounter with delayed healing M80.08XG

Example Of Placeholder

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For bilateral sites, the final character of the codes in ICD-10 indicates laterality.◦C50.212 Malignant Neoplasm of upper-inner

quadrant of left female breast◦H02.835 Dermatochalasis of left lower eyelid◦ I80.01 Phlebitis and Thrombophlebitis of

superficial vessels of right lower extremity◦L89.213 Pressure Ulcer of right hip, Stage 3

An unspecified site code is also provided should the site not be identified.

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Example Of Laterality

Expanded Codes (injury, diabetes, alcohol/substance abuse, postoperative complications)

E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease

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Example Of Expanded Codes

Seventh character for a fracture◦A = initial encounter for fracture◦D = subsequent encounter for fracture with routine

healing◦G = subsequent encounter for fracture with

delayed healing◦K = subsequent encounter for fracture with

nonunion◦P = subsequent encounter for fracture with

malunion◦S = sequela

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Examples Of 7th Characters

Principal Diagnosis

Two or more interrelated conditions with each potentially meeting the definition:◦Such as diseases in the same ICD-10-CM or

manifestations characteristically associated with a certain disease potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise

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Two or more interrelated conditions that equally meet the definition (cont.):◦When two or more diagnoses equally meet the

criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the code book does NOT provide sequencing direction, any one of the diagnoses may be sequenced first

Principal Diagnosis -2

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Other Diagnoses

Two or more comparative or contrasting conditions:◦When two or more diagnoses are documented as

“either/or”, they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission

◦Either diagnosis may be sequenced first◦When a symptom is followed by

contrasting/comparative diagnoses, the symptom code is sequenced first

◦These should never be principal diagnoses35

Codes for symptoms, signs, and ill-defined conditions – are NOT to be used as a principal diagnosis when a definitive diagnosis has been established

Signs, Symptoms, Ill-defined Conditions

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Uncertain Diagnosis◦ If the diagnosis documented at the time of

discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed/established

◦Applicable only to inpatient admissions to short-term, acute, long-term care & psychiatric hospitals

Uncertain Diagnoses

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Sequencing of codes is determined by the reason for admission/encounter, with the highest acuity diagnoses sequenced 1st

Sequencing Of Codes

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Specificity Of Coding

With added laterality, need greater documentation from your MD’s

Hypertensive Retinopathy H35.03◦H35.031 right eye◦H35.032 left eye◦H35.033 bilateral◦H35.039 unspecified (this would be a ?? for billing

most likely!!)◦Code also any associated hypertension (I10)

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The neoplasm table should be referenced first◦Anemia asso w/malignancy

If encounter is for mgmt of anemia asso w/malignancy, and tx is only for anemia, principal dx = malignancy code, followed by anemia code D63.0

◦Anemia asso w/chemotherapy Encounter for mgmt of anemia asso w/adverse effect of

chemo or tx, code anemia 1st, followed by neoplasm code and adverse effect

Chapter 2 – Neoplasms C00-d49

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Diabetes Mellitus◦Combination codes◦ Includes the body system affected and

complications affecting the body system◦Many codes particular category as are necessary

to describe all of the complications of the disease may be used

◦Sequenced base on the reason for a particular encounter

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89

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E08 Diabetes d/t underlying condition E09 Drug or chemical induced diabetes◦Secondary diabetes is always caused by another

condition or event E10 Type I Diabetes E11 Type II Diabetes Z79.4 long-term use of insulin◦Not used when insulin is being used temporarily

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89 -2

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Vascular Dementia Dementia in other diseases classified

elsewhere Unspecified Dementia All of above are coded:◦With behavioral disturbance, or◦Without behavioral disturbance

Chapter 5 – Mental And Behavioral Disorders F01-f99

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Chronic pain syndrome G89.4 vs. chronic pain G89.2◦Provider must specifically document

which condition Hemiplegia - Dominant/nondominant side

G81◦For ambidextrous patients, the default should be

dominant◦Left side affected, the default is non-dominant◦Right side affected, the default is dominant

Chapter 6 – Diseases of the Nervous System G00-G99

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Pain – category G89◦Used in conjunction with codes from other

categories to provide more detail about pain i.e., acute or chronic, neoplasm, or post-procedural

◦Can be listed as principal diagnosis◦When pain control or pain mgmt. is reason for

admit, the underlying cause and site of pain should be reported as additional dx, if known

◦ If encounter is for any other reason, and dx has not been established, assign the code for the site of pain 1st, followed by code from G89

Chapter 6 – Diseases of the Nervous System G00-G99 -2

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Assigning glaucoma codes:◦Assign as many codes from category H40, as

needed, to identify the type of glaucoma, the affected eye, and the glaucoma stage

Chapter 7 – Diseases of Eye and Adnexa H00-H59

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Combination Codes for Conditions and Common Symptoms or Manifestations

I25.110 – Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris

Chapter 9 – Diseases of the Circulatory System I00-I99

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Now:◦V54.81 Aftercare following joint replacement ◦V43.64 Joint replacement, hip

Then:◦Z47.1 Aftercare following joint replacement

surgery ◦*only use above code for OA, not injury◦Z96.641 Presence of right artificial hip joint

Right Hip Replacement

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THE WORKPLANTRANSITION TO ICD-10

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Steering Committee – Coordinating Dates◦1. February – Brief Orientation ( Webinar)

Feb 6 and Feb 7◦2. March – 2 hours Webinar – 2 Sessions◦ March 18 and 20 ◦3. April /May/June/July – “Live Trainings”◦4. July /August– Each Facility will transition all

Long Term residents to ICD-10.◦5. September 1 - All facilities ready ….Dual

Coding ICD 9 and ICD-10

Work Plan to Facilities

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Determine who/how many staff needs training: ◦Facility Level ICD- 10 Team/ Attendees: ◦Administrator◦DON◦Medical Records ◦Diagnosis Coder – Nursing Supervisor◦Biller ◦MDS◦Admissions◦Medical Director/ UR Doctors

ICD-10 Project Plan

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All of the information that is required to code according to ICD-10 is information that is necessary to an individual’s care and is already documented in the medical record

What we will ask is “how does your documentation in your facility compare to what is needed to code accurately using ICD-10?

Improve Documentation Now

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Clear focus to better documentation Absolutely critical to the success of

ICD-10 Good resident care –focused on

documentation:◦Affect so many facets of health care downstream◦Quality measures to analytics, research, payment

and surveillance◦Must be as accurately documented, coded

and billed

ICD-10 Codes Require

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Good resident care (cont.)◦Requires i.e., physician, nursing, therapy– efforts

to provide good documentation ◦?? To Ask◦What are you documenting today?◦Evaluate documentation “best practices” to

increase quality/quantity as needed Recognition of:◦ Impact of ICD-10 (not new but = new focus◦ medical, financial, even regulatory ramifications

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ICD-10 Codes Require -2

Clinicians Director of Nursing (DON) do not need to understand all of the intricacies of coding, and coders do not need to understand all of the medical – but the 2 must work together to ensure optimal accuracy

Increase questions from coders as there is a need to understand basic anatomy and pathophysiology

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Develop The Relationship Between Clinicians

Leadership are those individuals who are responsible for moving things through the organization:◦Understand what the impact of ICD-10 will be◦What challenges are anticipated

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Strategies For Training

Training Medical Record, MDS/PPS, DON, Business Office, Inquiry Staff, Medical Director:◦Have training◦Parallel coding taking the same cases and coding

them accurate to ICD-9 and ICD-10◦Parallel training and testing ◦Start in early 2014

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Strategies For Training -2

Leadership should understand enough about the coding changes to understand the implications:◦Documentation◦Business practices◦MDS / Medicare PPS◦$$ impact for training, implementation and billing

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Strategies For Training -3

HIM Consultant – ICD-10 Certified and Specialized Training

Corporate/Facility Team members who have been to training will be “ Trainer” resource

DCR’s / Medical Records Consultant will assist in Training Facilities

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Resources

Major understanding for providers, payers and vendors

Will drive business and systems changes, hospital, SNF, Physicians, Outpatient, et’l, from large national health plans to small provider offices, laboratories, medical testing centers

Staff time – start looking at who is affected now and what they need to know

Financial resources Options for ICD-10 transition

Why Prepare Now?

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Evaluate current documentation Identify most commonly used diagnoses by

checking out:◦Reports – past coding Medicare coverage issues

“ADR”◦Documentation to support those diagnoses◦Medical staff / Medical Director support◦Clinical documentation improvements

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ICD-10 Project Plan -2

Just A Few Examples – For Some, More Than You Need To Know!!!

Ongoing impacts your admission, billing clinical staff from prior to admission to discharge and beyond – physicians, Medical Directors responsibility, billing final reconciliation of billing, Medicare/Medicaid/MediCal, et’l

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Too Much Information??

Diabetes Mellitus (example)◦Type of diabetes◦Body system affected◦Complication or manifestation◦ If type 2 diabetes, long-term

insulin use

Specific Information Needed To Accurately Code

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Fractures◦Site◦Laterality◦Type◦Location

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Specific Information Needed To Accurately Code -2

Injuries◦External cause – cause of the injury, more

applicable to op◦Place of occurrence – home, at work, in the car,

etc. More related to op we will have some references

◦Resident Activity level code◦External code status – indicate if the injury was

related to military, work, or other

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Review Changes In Documentation Requirements

Jan/Feb, 2014 – September 15, 2014◦Conduct high level training on ICD-10 for clinicians◦Codes to prepare for testing◦Clinical documentation review◦Determine dual coding dates and record reviews

Transition & Testing

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Corporate/Facility Compliance date CMS Compliance date – October 1, 2014 Complete ICD-10 transition for full

compliance◦ ICD-9 codes continue to be used for services

provided before October 1, 2014◦ ICD-10 diagnosis and inpatient procedure codes

required for services provided on or after October 1, 2014. Monitor systems correct errors if needed.

Complete Transition / Full Compliance

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The next several slides are provided as a glimpse of some Chapter example. More details will follow in future training sessions.

More Than You Need To Know???

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Sequelae of cerebrovascular disease I69 - used to indicate conditions in I60-I67 as the cause of sequelae. The “sequelae” include conditions specified as such or as residuals which m occur at any time after the onset of the causal condition.

Chapter 9 – Diseases Of Circulatory System I00-I99

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Hypertension with Heart Disease I11◦Heart conditions classified to I50 or I51.4-I51.9 are also

assigned to, a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive)

◦Use an additional code from category I50 Hypertensive chronic kidney disease/CKD I12 ◦Cause and effect relationship is presumed◦Need add’l code to identify the stage of CKD

Hypertensive heart and CKD I13◦Causal relationship for HTN and heart dx must be doc’d

Chapter 9 – Diseases Of Circulatory System I00-I99 -2

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I21 For encounters occurring while the AMI is equal to, or less tan, four weeks old, including transfers to another acute setting or another acute setting or a postacute setting and pt requires continued care for the AMI

Subsequent acute MI◦When a pt who has suffered an AMI has a new

AMI within the 4 wk time frame of the initial AMI, code I22 in conjunction with I21 code

Chapter 9 – Acute Myocardial Infarction (AMI)

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Chronic Obstructive Pulmonary Disease (COPD) and Asthma◦Acute exacerbation of chronic obstructive

bronchitis and asthma◦J44 and J45 distinguish between uncomplicated

cases and those in acute exacerbation◦Acute exacerbation is a worsening or a

decompensation of a chronic condition

Chapter 10 – Diseases Of Respiratory System J00-J99

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L89 codes for Pressure Ulcer are combination codes that identify the site as well as the stage of the ulcer

Assignment of the pressure ulcer stage should be guided by clinical documentation of the stage

Assign code for the highest stage reported for that site

Chapter 12 – Diseases Of Skin & Subcutaneous Tissue L00-L99

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Stages of chronic kidney disease (CKD) If both a stage of CKD and ESRD are

documented, then assign code N18.6 only Patients who have had kidney transplant may

still have some form of CKD, because the transplant may not fully restore kidney function. Therefore, presence of CKD alone does NOT constitute a transplant complication.

Chapter 14 – Diseases Of Genitourinary N00-N99

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A41.9 Sepsis, unspecified organism –Septicemia, unspecified (Chapter 1 Infectious & Parasitic Diseases)

Severe Sepsis – R65.20 – code first underlying infection, and use additional code to identify specific organ

Urosepsis – cannot code, code to condition

Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab Findings R00-R99

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Septic Shock◦Circulatory failure associated with severe sepsis;

represents a type of acute organ dysfunction. Underlying infection sequenced first, followed by code R65.21 Severe sepsis with septic shock. Add additional codes for other acute organ dysfunction

Chapter 18 – Symptoms, Signs & Abnormal … R00-R99 -2

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Use of symptom codes are acceptable for use when a related diagnosis has NOT been established by the provider

Use a symptom code with a diagnosis code may be reported when the sign or symptom is NOT routinely associated with that diagnosis

Signs or symptoms that are associated routinely with a disease process should NOT be assigned as additional codes

Chapter 18 – Symptoms, Signs & Abnormal … R00-R99 -3

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Chapter 18 – Symptoms, Signs & Abnormal … R00-R99 -4

R29.6 Repeated falls is used when a patient has recently fallen and reason for the fall is being investigated.

Z91.81 Hx falls is used when a pt has fallen in the past and is at right for future falls

When appropriate, both of the above codes may be assigned together

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R53.2 is the lack of ability to use one’s limbs or to ambulate d/t extreme debility.

It is NOT associated with neurologic deficit or injury, code R53.2 should NOT be used for cases of neurologic quadriplegia.

It should only be assigned if functional quadriplegia is specifically documented in the medical record

Chapter 18 – Functional Quadriplegia

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An example – S42.321D. Displaced transverse fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing

This means more specific documentation from the physician (the initial encounter of treatment is usually in the Emergency room)

Chapter 19 – Injury, Poisoning & Certain Other Consequences of External Causes (S00-T88)

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

A fracture not indicated whether displaced or not should be coded to displaced

Chapter 19 – Injury, Poisoning & Certain Other … (S00-T88) -2

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When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the code for the adverse effect of the drug (T36-T50)

The code for the drug should have a 5th or 6th character “S”

Chapter 19 – Drug Toxicity

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Chapter 19 – Poisoning

When coding a poisoning or reactionto the improper use of a medication, i.e. overdose, wrong substance given or taken in error, assign the appropriate code from categories T36-T50

The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined)

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For use in any healthcare setting May be used as either a principal diagnosis

or secondary code Certain Z-codes may only be used as

principal diagnosis

Chapter 21 – Factors Influencing Health Status and Contact with Health Services (Z00-Z99)

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Chapter 21 – Factors Influencing Health Status … (Z00-Z99) -2

Z code should not be used if treatment is directed at a current acute disease

Exceptions◦First listed, followed by the diagnosis code when a

patient’s encounter is solely to receive radiation therapy Z51.0

◦Code also condition requiring care

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Former V codes are now Z codes Provided for occasions when circumstances

other than a dx, injury or external cause are recorded

Several codes have been expanded, i.e. personal and family hx

Now have a code for patients blood type, i.e. Z67

Chapter 21 – Z Codes

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Chapter 21 – Z Codes -2

No longer have V57 codes Code the underlying condition, i.e. injury, etc.

with the appropriate 7th character for subsequent encounter

Z68 BMI is divided into adult and pediatric codes (Adults = age 21 or older)

RD in facility can assist with documenting the BMI

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Chapter 21 – Z Codes -3

Code Z92.82 when tsf facility has admin tPA within 24 hrs prior to admit (usually with new dx of MI or CVD)

Aftercare Z codes should NOT be used for aftercare of fractures

For aftercare of fractures, assign fracture code with 7th character D for subsequent encounter

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ICD-10 Project TeamIn coordination with

Rhonda Anderson, RHIA, President Khaleelah Wagner, RHIA, Staci LePage, RHIT

Anderson Health Information Systems, Inc.940 W. 17th Street, Suite B

Santa Ana, CA 92706Mobile 714-299-0573 Office 714-558-3887

rhonda@ahis.net

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THANKS FOR ATTENDING