ICD 10: What to Expect

1. ICD 10: What to Expect George A. Hill, MD Director, Nashville Fertility Center Nashville, TN 37203

2. LEARNING OBJECTIVES At the conclusion of this presentation, participants should be able to: • Understand ICD-10 background and history, description, and future • Comprehend the key distinctions between ICD-9-CM and ICD-10-CM • Understand what physicians need to do now to prepare • Understand the actions that practices need to take to implement the change to ICD -10-CM on a timely basis

3. DISCLOSURE • Committee Member: United Healthcare Women’s Health Scientific Advisory Board • Grant Recipient: EMD Serono Inc

4. Disclaimer • ICD-10 codes included in this presentation are not valid prior to the implementation date of October 1, 2014 • ICD-10 codes included in this presentation may be revised prior to implementation • ICD-9 codes should continue to be used until transition date of October 1, 2014

5. Why the Change? • ICD-9-CM is 30 years old, out of date and running out of space! • ICD-10 is the international standard and has been for a number of years • ICD is important to Health Information Technology (HIT) and the change is needed to fully implement HIT

6. ICD-10 and HIT Importance of a better coding classification system: • Integral to HIT Strategy - especially the Electronic Health Record (EHR) • Improved clinical specificity = improved patient safety • Improves understanding of disease / costs and allows providers and others to improve on their delivery • International Disease Surveillance

7. ICD-10: Current Status • Some current opposition to implementation • Per CMS, no delay or schedule change is pending (except!) (postponed from 10/1/2013 to 10/1/2014) • Physicians need to be prepared for the change in order to prevent a revenue flow interruption on 10/1/2014

8. Understanding ICD • ICD is part of the World Health Organization’s (WHO) system of classification • ICD-CM (clinical modification) used to track morbidity • ICD used to report mortality • In the United States, we (ASRM/ACOG Coding Committees) work through the National Center for Health Statistics to implement changes/updates

9. History of ICD-10 • ICD-10 adopted by WHO in 1990 • First modification in 1998 • U.S. only industrialized nation that has not yet implemented ICD-10 or a modification in some format • U.S. first began exploring idea in 1994 • Draft versions available 2002, 2007, 2009, 2010, 2011 • Implementation Date: October 1, 2014!

10. Key Differences: ICD-9-CM to ICD-10-CM • ICD-10-CM consists of 21 chapters compared to 17 in ICD-9-CM • Chapters divided into “blocks” of codes with additional subcategories • V and E code supplemental classifications incorporated into main classifications • Conditions of sense organs separated from nervous system

11. Key Differences: ICD-9-CM to ICD-10-CM • Certain diseases reclassified to reflect current medical knowledge • ICD-10 classifies injuries by specific site then by type vs. ICD-9 classification by type • Postoperative complications moved to procedure specific system chapters (complications of GU surgery in GU chapter)

12. Key Differences: ICD-9-CM to ICD-10-CM • ICD-10-CM codes are alphanumeric and up to 7 characters ICD-9-CM are 3-5 characters in length (mostly numeric) • ICD-10-CM includes full code titles vs. references to common 4th -5th digits • Addition of 6th characters for some • Addition of code extensions (7th digit) • Addition of dummy placeholder “X”

13. New Features in ICD-10-CM • Combination codes for conditions and common symptoms/manifestations • Combination codes for poisoning and external causes • Added laterality for some codes (right vs. left)

14. Key Changes for Reproductive Endocrinology/Infertility • Inclusion of trimesters in obstetric codes • Separate codes to indicate gestational week • Elimination of episodes of care for obstetric codes • Changes in time frames: • Abortion vs. Fetal death ( 20 weeks) • Early vs. Late pregnancy (20 weeks) • Extensions to denote specific fetus • New GU codes and notes including category title changes

15. Structure and Format of ICD-10-CM • First character is always alphabetic letter • Chapter 14 Diseases of the GU system (N00-N99) • Chapter 15 Pregnancy, Childbirth and Puerperium (O00-O9A) • Second character is always a number • Characters 3-7 alpha or numeric • O9A.311: Physical abuse complicating pregnancy, first trimester

16. Structure and Format of ICD-10-CM • Alphabetic Index: Alphabetic Listing of Terms and Codes • Index to Diseases and Injury • Index to External Causes of Injury • Neoplasm Table • Table of Drugs and Chemicals • Tabular List: Chronological list divided into chapters based on body system or condition

17. Structure and Format of ICD-10-CM • Code Format: XXX.XXX X • XXX= Category • XXX= Etiology, anatomic site, severity • X= Extension • Placeholder Character X • Used with certain codes for potential future expansion • When placeholder exists, must use X in that location for valid code

18. Structure and Format of ICD-10-CM • Labor and delivery complicated by cord around neck, without compression: O69.81X2 • O69:Labor and delivery complicated by umbilical cord complications • 81:Cord around neck, without compression • X: Placeholder • 2: Fetus 2

19. General Coding Guidelines • Locate code in Alphabetic Index and confirm in Tabular list • Report the highest number of characters available • Signs and symptoms are acceptable if diagnosis has not been confirmed by provider (Chapter 18 contains many but not all)

20. General Coding Guidelines • Combination codes should be reported when code fully describes condition • Combination code is single code that describes: • Two diagnoses • Diagnosis with an associated secondary process (manifestation) • Diagnosis with an associated complication

21. 2012 ICD-10-CM Codes Applicable to RE/I • C00-D99 Neoplasms • E00-E89 Endocrine, nutritional and metabolic diseases • N00-N99 Diseases of the genitourinary system • O00-09A Pregnancy, childbirth, and the puerperium • Q00-Q99 Congenital Malformation, deformations, and chromosomal abnormalities • R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

22. N00-N99 Diseases of the Genitourinary Sytem • N70-N77 Inflammatory diseases of female pelvic organs • N80-N98 Noninflammatory disorders of female genital tract • N99-N99 Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified

23. N80-N98 Noninflammatory disorders of female genital tract • N80 Endometriosis • N83 Noninflammatory disorders of ovary, fallopian tube, and broad ligament • N84 Polyp of female genital tract • N92 Excessive, frequent, and irregular menstruation • N96 Recurrent Pregnancy Loss • N97 Female Infertility • N98 Complications associated with artificial fertilization

24. Some Diagnoses will be Straight Crosswalks

25. N80 Endometriosis

26. N97 Female Infertility

27. N97 Female Infertility—What are Excludes? • Type 1 Excludes • Female infertility associated with: • Hypopituitarism (E23.0_) • Stein Leventhal Syndrome (E28.2_) • Type 2 Excludes • Incompetence of cervix uteri (N88.3_)

28. Type 1 Excludes • A type 1 excludes note is a pure excludes. It means “not coded here” • A type 1 excludes note indicates that the code excluded should never be used at the same time as (N97) • Used when 2 conditions cannot occur together

29. Type 2 Excludes • A type 2 excludes note represents “not included here” • A type 2 excludes note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time • When a type 2 excluded note appears under a code it is acceptable to use both the code (N97) and the excluded code together

30. N97 Female Infertility • Type 1 Excludes • Female infertility associated with: • Hypopituitarism (E23.0_) • Stein Leventhal Syndrome (E28.2_) • Type 2 Excludes • Incompetence of cervix uteri (N88.3_)

31. N96 Recurrent Pregnancy Loss • Type 1 Excludes • Recurrent pregnancy loss with current pregnancy (O26.2-) • O26.20 …unspecified • O26.21 …first trimester • O26.22 …second trimester • O26.23 …third trimester

32. Some Codes may be less specific

33. O00 Ectopic Pregnancy

34. Some codes may have the same specificity

35. O02 Other abnormal products of conception • O02.81 Inappropriate change in quantitative human chorionic gonadotropin (hCG) in early pregnancy • Currently in ICD-9-CM: 631.0

36. Some codes may be more specific

37. O30 Multiple Gestation

38. Some codes will replace multiple codes, some will be new

39. N98 Complications associated with artificial fertilization N98.1 Hyperstimulation of ovaries (620.8, 256.1, E932.4) N98.3 Complications of attempted introduction of embryo in embryo transfer

40. What about Fibroids?

41. Neoplasms (C00-D49) • (D10-D36) Benign neoplasms, except benign neuroendocrine tumors • D25 Leiomyoma of Uterus

42. D25 Leiomyoma of Uterus

43. Z31 Encounter for Procreative Management • Z31.41 Encounter for fertility testing (V26.21)

44. Z32 Encounter for pregnancy test and childbirth and childcare instruction

45. Summary • Greatly increased number of codes in ICD-10, butRE/I will still only routinely use a small subset of the new code set • Due to greater specificity, ICD-10 often allows the use of fewer codes than ICD-9 to adequately capture specific patient conditions • The general coding principles/diagnosis code selection processes that apply to ICD-9-CM will also apply to ICD-10-CM

46. Summary • System changes will be necessary to accommodate increased digits and character changes • May require changes in medical record documentation to support increased specificity • Education will be necessary for staff and providers

47. What to Do Now • Assess the quality of medical record documentation • Consider conducting a documentation assessment audit • Implement documentation improvement strategies if necessary based on audit results • Monitor the impact of any documentation improvement strategies • Reassess and refine • DO NOT PANIC!!

48. Planning for the Transition • Verify with software vendors plans for testing and implementation • Assign internal implementation team • Include physicians and other providers • Clinical staff (nursing, lab, etc) • Administrative staff • Coding/ Billing staff

49. Planning for the Transition • Assess current uses and users of ICD-9 in practice • Assess skills and understanding of ICD • Determine who needs ICD-10 training • Evaluate training options • Evaluate current documentation practices • Plan for changes to charge capture documents

50. ACOG: ICD-10-CM Resources • ICD-10 page on ACOG website • Monthly Subscription Listserv (contains latest ICD-10 news, updates and links)