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ICD-10-CM Overview & Implementation Update

ICD-10-CM Overview & Implementation Update. MVLTCA – February 25, 2014 Cathryn J. Moore, BS, RHIA, RAC-CT . OBJECTIVES. 1. Regulations which mandate implementation of ICD-10-CM 2. Updates that have occurred for conversion to the non-acute arena

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ICD-10-CM Overview & Implementation Update

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  1. ICD-10-CM Overview & Implementation Update MVLTCA – February 25, 2014 CathrynJ. Moore, BS, RHIA, RAC-CT

  2. OBJECTIVES 1. Regulations which mandate implementation of ICD-10-CM 2. Updates that have occurred for conversion to the non-acute arena 3. Major differences from ICD-9 to ICD-10 4. Implementation Plan to facilitate a smooth transition to the new system

  3. Regulations which mandate implementation of ICD-10-CM

  4. Implementation Date: October 1, 2014 Final Rule: August 24, 2012 Available at http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html

  5. HISTORY • ICD-10 was created by the World Health Organization in1990 • Since 2001, most of the world has adopted it • U.S. modified it and added CM (Clinical Modification) • Review more information at: • http://www.who/int/classifications/icd/implementation/en/index.html

  6. ICD-10-CM CODES 2014 ICD-10-CM is available at http://www.cdc.gov/nchs/icd/icd10cm.htm or http://www.cms.hhs.gov/ICD10 • 2014 ICD-10-CM Index to Diseases and Injuries • 2014 ICD-10-CM Tabular List of Diseases and Injuries • Instructional Notations • 2014 Official Guidelines for Coding and Reporting • 2014 Table of Drugs and Chemicals • 2014 Neoplasm Table • 2014 Index to External Causes • 2014 Mapping ICD-9-CM to ICD-10-CM and ICD-10-CM to ICD-9-CM

  7. Help with Converting Codes • GEMs (General Equivalence Mappings) are a tool that can be used to convert data from ICD-9-CM to ICD-10-CM and vice versa. • Mapping from 10 to 9 is referred to as backward mapping while 9 to 10 is referred to as forward mapping • GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM based data

  8. Help with Converting Codes • GEMs (General Equivalence Mappings) can be used by anyone who wants to convert coded data, including: • All payers • All providers • Medical researchers • Informatics professionals • Coding professionals • Software vendors • Organizations • Others who use coded data

  9. Help with Converting Codes • GEMs (General Equivalence Mappings) are not a substitute for learning how to use the ICD-10 codes. • More information about GEMs and their use can be found on the CMS website at: http://www.cms.gov/Medicare/Coding/ICD10/index.html • Select from left side of web page to find most recent GEMs

  10. October 1, 2014 • Medical Coding in U.S. health care settings will change from ICD-9-CM to ICD-10 • Compliance date is firm (no grace period, no delays) • ICD-10-CM diagnoses codes will be used by all providers in every health care setting • ICD-10-PCS procedure codes will be used only for hospital claims for inpatient hospital procedures • ICD-9-CM codes will not be accepted for services provided on or after 10-1-14

  11. Check Your Understanding of Implementation Compliance Date

  12. Important!! • ICD-10-CM codes will not be accepted for services prior to October 1, 2014 • Providers must begin using ICD-10-CM codes to report diagnoses from all ambulatory and physician services on claims with dates of service on or after October 1, 2014, and for all diagnoses on claims for inpatient settings with dates of discharge that occur on or after October 1, 2014 • ICD-10-PCS (procedure codes) must be used for all hospital claims for inpatient procedures on claims with dates of discharge that occur on or after 10-1-2014

  13. Benefits of ICD-10 Coding System • New Classification system will provide better data needed to: • Measure the quality, safety, and efficacy of care • Reduce the need for attachments to explain the patient’s condition • Design payment systems and process claims for reimbursement • Conduct research, epidemiological studies, and clinical trials

  14. Benefits of ICD-10 Coding System • New Classification system will provide better data needed to: • Set health policy • Support operational and strategic planning • Design health care delivery systems • Monitor resource utilization • Improve clinical, financial, and administrative performance • Prevent and detect health care fraud and abuse • Track public health and risks

  15. Differences from ICD-9-CM to ICD-10-CM • Overall number of codes is significantly increased from approximately 14,000 in ICD-9-CM to approximately 70,000 in ICD-10-CM • ICD-10-PCS codes increased from approximately 4,000 in ICD-9-CM to approximately 70,000 • ICD-10 codes are longer and use more alpha characters

  16. Differences from ICD-9-CM to ICD-10-CM • Codes allow greater clinical detail and specificity in describing diagnoses and procedures • Terminology and disease classification have been updated to be consistent with current clinical practice • Last but not least is that system changes are required to accommodate the ICD-10 codes

  17. ICD-9-CM Code Format Numeric or (E or V) Numeric . . X X A M X 4 1 4 X 0 0 Category Etiology, anatomic site, manifestation 3–5 Characters

  18. ICD-10-CM Code Format Additional Characters 2-7 Numeric or Alpha Alpha (Except U) . . X X X A A M X S 0 X 2 X X 6 5 x Added 7th character for obstetrics, injuries, and external causes of injury Category Etiology, anatomic site, severity 3–7 Characters

  19. Examples of ICD-10-CM Codes compared to ICD-9-CM Codes Cerebral Vascular Accident with Hemiplegia ICD-9-CM ICD-10-CM 438.20 I69.959

  20. Examples of ICD-10-CM Codes compared to ICD-9-CM Codes Fracture of the left hip ICD-9-CM ICD-10-CM V54.13 S72.002D

  21. Examples of ICD-10-CM Codes compared to ICD-9-CM Codes Diabetes mellitus with retinopathy ICD-9-CM ICD-10-CM 250.50 E11.319 362.01

  22. ICD-10-CM NEW FEATURES • Combination codes for conditions and common symptoms or manifestations • Combination codes for poisonings and external causes • Added laterality • Expanded codes (injury, diabetes, alcohol/substance abuse, postoperative complications) • Injuries grouped by anatomical site rather than injury category

  23. Combination Codes • I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris • E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema • K50.012 Crohn’s disease of small intestine with intestinal obstruction • N41.01 Acute prostatitis with hematuria • T57.0X4A Toxic effect of arsenic and its compounds, assault

  24. Laterality • C50.511 Malignant neoplasm of lower-outer quadrant of right female breast • C50.512 Malignant neoplasm of lower-outer quadrant of left female breast • C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast • C50.521 Malignancy neoplasm of lower-outer quadrant male breast

  25. Increased Specificity • S72.044G Nondisplaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing • I69.351 Sequelae of cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side • Z47.81 Encounter for orthopedic aftercare following surgical amputation • Z48.21 Encounter for aftercare following heart transplant

  26. 7th Character Addition of 7th character : • Used in certain chapters to provide information about the characteristic of the encounter • Must always be used in the 7th character position • If a code has an applicable 7th character, the complete code must be reported with an appropriate 7th character value in order to be valid

  27. Character “X” • Character “x” is used as a 5 character placeholder in certain 6 character codes to allow for further expansion and to fill in other empty characters when a code that is less than 6 characters in length requires a 7thcharacter • T46.1x5A - Adverse effect of calcium channel blockers, initial encounter • T15.02xD – Foreign body in cornea, left eye, subsequent encounter

  28. Two Types of Excludes Notes • Excludes 1 – Indicates that the condition excluded should never be used with the code noted in the note (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 (both codes can be used to capture both conditions)

  29. Example of Excludes • R22.2 Localized swelling, mass and lump, trunk Excludes 1: intra-abdominal or pelvic mass and lump (R19.0-) Excludes 2: breast mass and lump (N63)

  30. Inclusion and Code Expansion • Inclusion of clinical concepts that do not exist in ICD-9-CM (e.g., underdosing, blood type, blood alcohol level) • A number of codes have been significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications)

  31. Examples of Expanded Codes • T45.526D – Underdosing of antithrombotic drugs, subsequent encounter • Z67.40 – Type O blood, Rh positive • Y90.6 – Blood alcohol level of 120-199 mg/100 ml

  32. Examples of Expanded Codes • E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy • F10.182 – Alcohol abuse with alcohol-induced sleep disorder • T82.02xA – Displacement of heart valve prosthesis, initial encounter

  33. Category restructuring and Code Reorganization • Injuries are grouped by anatomical site rather than by type of injury • Category restructuring and code reorganization have occurred in a number of chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM

  34. Category restructuring and Code Reorganization • Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge • New code definitions (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8 weeks) • The V codes and E codes are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM

  35. ESSENTIAL DEFINITIONS • The Uniform Hospital Discharge Data Set (UHDDS) provides definitions for primary and secondary diagnoses. • Adapted to fit all non-inpatient settings (post-acute) such as home healthcare, hospice, nursing facilities, and rehab facilities. • In determining principal diagnosis/primary diagnosis, the coding conventions (instructional notes incorporated in the codes) take precedence over the Tabular and Alphabetic Index guidelines.

  36. Primary Diagnosis • The condition that caused the admission for services. • That condition most relevant to the plan of care. • That diagnosis which represents the most acute condition and will require the most intensive services.

  37. Secondary Diagnosis • Co-Morbidities • Additional Diagnoses used in coding guidelines. • All conditions that coexist during the episode of care that may affect the plan of care or which developed subsequently and affect the treatment or care of the patient. • Entered on the OASIS C (OASIS C-1) in the order by the degree of which they will impact the plan of care and the need for homecare services. • Entered on the MDS only if active diagnoses and impact the plan of care.

  38. Case-mix Diagnosis • A diagnosis related to the prospective payment system; may involve manifestation coding. • Medical record documentation must support the diagnosis reported on the OASIS-C and 485 and the MDS Assessment.

  39. Hospital or Referral Diagnosis • The condition treated by the inpatient facility or by the physician in an outpatient setting relevant within the past 14 days.

  40. Historical Diagnosis • Any condition that is resolved and is no longer being treated. • Appropriate for the OASIS C assessment but not the plan of care. • Not appropriate for MDS assessment.

  41. LTC CODING SCENARIO • A resident was admitted to the nursing facility following foot amputation due to diabetic peripheral vascular disease. PT and OT was ordered with the plan for the resident to return home. Staff is to change dressings and report any suture site breakdown to the physician. Other diagnoses include gastroparesis due to type 2 diabetes (receiving insulin), mitral valve regurgitation with aortic stenosis, inguinal hernia, generalized DJD and COPD. Assign Codes.

  42. LTC CODING SCENARIO • A resident was admitted to the nursing facility following foot amputation due to diabetic peripheral vascular disease. PT and OT was ordered with the plan for the resident to return home. Staff is to change dressings and report any suture site breakdown to the physician. Other diagnoses include gastroparesis due to type 2 diabetes (receiving insulin), mitral valve regurgitation with aortic stenosis, inguinal hernia, generalized DJD and COPD. Assign Codes.

  43. LTC CODING SCENARIO • Z47.81 Aftercare, following surgery (for) (on), amputation • E11.51 Diabetes, diabetic (mellitus) (sugar) Type 2, with peripheral angiopathy • E11.43 Diabetes, diabetic (mellitus) (sugar) Type 2, with gastroparesis • I80.0 Regurgitation, mitral (valve) – see Insufficiency, mitral. Insufficiency, insufficient, mitral (valve), with aortic valve disease

  44. LTC CODING SCENARIO • K40.90 Hernia, hernial (acquired) (recurrent), inguinal (direct) (external) (funicular) (indirect) (internal) (oblique) (scrotal) (sliding) • M15.9 Disease, diseased, joint, degenerative—see Osteoarthritis. Osteoarthritis generalized • J44.9 Disease, diseased, pulmonary, chronic, obstructive

  45. LTC CODING SCENARIO • Z79.4 Long-term (current) (prophylactic) • Z89.439 Absence (of) (organ or part) (complete or partial), foot (acquired)

  46. HOME HEALTH CODING SCENARIO • LTC resident returns home with orders for home health care..... • E11.51 DM with PVD • E11.43 DM with gastroparesis • M15.9 OA (debility affecting ADL/IADL) • J44.9 COPD (debility affecting ADL/IADL) • I80.0 Mitral valve regurgitation with aortic stenosis: monitor signs/symptoms • Z48.01 Change of surgical dressing: • Z79.4 LT insulin use • G54.6 Phantom Limb Syndrome, with pain **** must be documented by physician

  47. HOME HEALTH Patient has hypertension. He continues to experience elevated BP while taking BP medication. While assessing the patient, the nurse discovers he was taking his medication once daily instead of twice (as ordered) because of the cost of the drug. • I10 Essential HTN • T46.5x6D Underdosing of other anti-hypertensive drug, subsequent encounter • Z59.8 Other problems related to housing and economic circumstances

  48. How to Prepare for Implementation • Learn about the structure, organization, and unique feature of ICD-10-CM • Learn about the system impact and 5010 • Identify areas of strength/weakness in medical terminology and medical record documentation • Review and train to improve knowledge of medical terminology as needed

  49. How to Prepare for Implementation • Provide intensive coder training approximately 3-6 months prior to implementation • Contact vendors to determine their state of readiness for implementation • Provide additional training to refresh or expand knowledge in the biomedical sciences (anatomy, physiology, pathophysiology, pharmacology, and medical terminology)

  50. How to Prepare for Implementation • Communicate with all staff who will be impacted by the change to keep them updated and to make sure they understand their role in the transition • Work with physicians to make sure they understand some of the changes that will need to be made in documentation to allow for greater specificity in coding with ICD-10

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