ICD-10-CM/PCS What does it mean to us?

1. ICD-10-CM/PCSWhat does it mean to us? Lynda Starbuck, MS, RHIA, C-CDI AHIMA Approved ICD-10-CM/PCS Trainer

2. ICD-10 Timeline • October 1, 2011 - Last full update to ICD-9-CM and ICD-10 (revised with implementation delay) • January 1, 2012 - 5010 electronic claims submission • October 1, 2014 - ICD-10 codes required on all discharges (NEW DATE)

3. ICD-10-CM/PCS What is it? ICD-10-CM US clinical modification of the World Health Organization’s ICD-10 Diagnostic coding system (no procedure codes) ICD-10-PCS Developed under contract by CMS specifically to replace the ICD-9-CM procedural coding system

4. ICD-10-CM Code Structure • Alphanumeric • Up to 7 characters • Place holders of “x” are used when code is 5 characters and needs a seventh character code extension • 21 chapters and codes are dispersed differently • V and E codes are incorporated into the main code

5. ICD-10-CM Code Extensions CODE MEANING S73.011A– Posterior subluxation, right hip, initial encounter 064.0XX1- Obstructed labor due to incomplete rotation of fetal head, fetus 1 of multiple Initial encounter, subsequent encounter, sequela Fetus number

6. ICD-9-CMFull Code Titles ICD-9-CM ICD-10-CM 802. Fracture malar, maxillary and zygoma bones - 802.4 Closed - 802.5 Open S02.4 - S02.40 – Fracture of malar, maxillary, and zygoma bones, unspecified - S02.400 Malar Fracture, unspec. - S02.401 Maxillary Fracture, unspecified - S02.402 Zygomatic fracture, unspecified - S02.41 LeFort fracture - S02.411 LeFort I fracture - S02.412 LeFort II fracture - S02.413 LeFort III fracture

7. 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) • Impending/threatening condition codes • Injuries grouped by anatomical site rather than injury category

8. Official Coding Guidelines Chapter Specific • Infectious Disease - Urosepsis is a non-specific term – no reference in the alpha index - Post-procedural infection by procedure • Mental and Behavioral Disorders - Added disorders due to psychoactive substance use • Nervous System and Sense Organs - Hemiplegia/hemiparesis – new rule for dominant vs. non-dominant sides

9. Chapter Specific Guidelines continued… • Circulatory System - MI timeframes reduced to 4 weeks vs. 8 - Causal relationship assumed between CAD and Angina • Obstetrics - Trimester indicated in code (or weeks of gestation) - Fetal extension – used to distinguish to which fetus complication applies

10. Chapter Specific Guidelines continued… • Injuries - Code extensions used to indicate what phase of care the patient is receiving (initial, subsequent, or sequela) • Adverse effects / Poisonings - Includes under-dosing - Codes indicate how the adverse effect occurred

11. ICD-10-PCSCode Structure 1st character is the Section 2nd character is the Body System 3rd character is the Root Operation 4th character is the Body Part  5th character is the Approach 6th character is the Device 7th character is the Qualifier

12. ICD-10-PCS Code Example • PTCA with Stent RCA - Root Term – Dilation = Dilation - Artery >> Coronary >> Four or more sites 0273 >> One site 0270 >> Three sites 0272 >> Two sites 0271

13. ICD-10-PCS Code Example… 027 table

14. ICD-10-PCS Obstetric Delivery- Forceps • Extraction –pulling or stripping out or off all or a portion of a body part (10D) - Products of Conception (10DO) - Via Natural or Artificial Opening (10DO7) - No Device (10D07Z) >> Qualifier – Mid Forceps-4 ICD-10-PCS Code 10D07Z4

15. Impact of ICD-10-CM/PCSHospitals Potentially have the most system changes Advantage in added detail (to identify severity and reduced billing paperwork) Large learning curve for coders (no Coding Clinic guidance as of Oct.,2013) More physician specificity required – thus more queries DRG ‘s / CC’s / MCC’s – have not been formulated for ICD-10 codes.

16. IMPACTHealthcare Providers Non-inpatient facilities including physician offices will only use ICD-10-CM, not ICD-10-PCS CPT will continue to be used by Part B providers to describe procedures (all outpatient claims) Physicians will be asked to document specificity and detail Physicians offices will have to learn ICD-10-CM (diagnosis only) Training and new materials cost Revising Super Bills

17. Staff Training and Preparation • Limited knowledge to Business office, Registration staff, Radiology, Lab, Unit secretaries, and IT staff who support coding software. • Intermediate knowledge to Hospital Administration, Physicians, Finance, Rehabs, Home Health, Hospice, Case Management, and Outpatient Diagnostic coders • High levels of knowledge to Inpatient coders, Outpatient Surgical Coders, Quality, Chief Medical Officer, Educators, Documentation Improvement Managers, and CDI Staff/Nurses.

18. What should we be doing now? • Conduct an ICD-10 update once a month in RAC/UR Committee • CDI Chart Reviews – early identification of high-impact areas • Creation of Queries for ICD-10 in relation to top 10-15 DRG’s

19. Impact of ICD 10 CM Acute Care Hospitals • Required to use ICD-10-CM and ICD-10-PCS • Potentially have the most system changes • Advantage in added detail (to identify severity and reduce billing paperwork) • Coder productivity is predicted to decrease by 1/3 for potentially up to 2 years. • Medical Staff will be required to document more accurately

20. IMPACT continued… • Coding System Changes - Data trending challenges include maintenance of crosswalks among coding systems for longitudinal data analysis and the potential for faulty decisions due to distorted, inaccurate, or misinterpreted data • Other Healthcare Providers -Non-inpatient facilities including physician offices will only use ICD-10-CM, not ICD-10-PCS -CPT will continue to be used by Part B providers to describe procedures (outpatient claims)

21. Why ICD 10 Is Worth The Trouble Moving to the new code sets will permit improved efficiencies and lower administrative costs due to replacement of a dysfunctional classification system. This in turn allows: • Increased use of automated tools to facilitate the coding process • Decreased claims submission or claims adjudication costs • Fewer rejected and improper reimbursement claims • Greater interoperability • Decreased need for manual review of health records to meet the information needs of payers, researchers, and other data mining purposes • Decreased need for large research organizations to maintain dual classification systems (one for reimbursement and one for research) • Reduced coding errors • Reduced labor costs and increased productivity • Increased ability to prevent and detect healthcare fraud and abuse

22. ICD 10 Training Proposal • ICD 10 Introduction • Explanation of ICD 10, Benefits/Goals, Expectations, Deadlines (We suggest that All attend) • Location: Webinar or on-site. • Time expectation: 45 minute to 1 hour plus 15 min for test. • Up to 3 separate sessions to allow for time constraints of attendees.

23. Track 1: • ICD History; ICD 10 basics; Comparison to ICD 9; ICD 10 structure and format; Conventions and Guidelines. • Medical Terminology • Basic Anatomy and Physiology • Advanced Anatomy and Physiology

24. Track 2: • ICD History; ICD 10 basics; Comparison to ICD 9; ICD 10 structure and format; Conventions and Guidelines. • Advanced Anatomy and Physiology

25. Track 3: • ICD History; ICD 10 basics; Comparison to ICD 9; ICD 10 structure and format; Conventions and Guidelines. • CDI: What’s in it for me? Provider and facility profiling; Value based purchasing of Healthcare • CDI : What is CDI and the requirements under ICD 10 • CDI: OP and IP documentation Tips under ICD 10 • CDI: Comparison of documentation of common diagnoses under ICD 19 and ICD 10

26. Track 4: • ICD History; ICD 10 basics; Comparison to ICD 9; ICD 10 structure and format; Conventions and Guidelines. • Financial Implications and Reimbursement under ICD 10 • Assess ICD 10 impact on claims processing and productivity • Identifying front-end edits based on the new ICD 10 code logic • Develop action plans for post implementation payment issues (includes cross-walking both coding systems) • Assess ICD 10 impact on both the inpatient and outpatient revenue cycles • Update medical necessity coverage determination policies

27. Track 5: • ICD History; ICD 10 basics; Comparison to ICD 9; ICD 10 structure and format; Conventions and Guidelines. • Coding Essentials for ICD 10 • Assess ICD 10 impact on both internal and external review criteria • Assess impact on Trauma Registries, Tumor Registries, and other clinical research provided to external agencies. • Training clinic staff and coders in basic ICD-10-CM coding (ICD-10-PCS if necessary)

28. WHO SHOULD ATTEND WHICH TRACK? (Suggestions only) • ICD 10 Introduction: Hospital/Clinic Staff wide attendance • Track 1: Nurses, coders, Transcriptionists, Radiology, Lab, Case management, Utilization Review • Track 2: Nurses, coders, Transcriptionists, Radiology, Lab, Case management, Utilization Review • Track 3: Physicians, Nurses, Case Management, Utilization Review Committee , HIM Staff • Track 4: HIM Staff, Case Management, Utilization Review, Business office/Finance, Administration • Track 5: HIM staff, UR committee, Coders, Business Office • Note: There will be a short test after every session for every topic in each track.

29. Webinars and on-site training sessions will be presented by: • Terrance Govender MD, MBBCh, CHBC, C-CDI HCCS - Director of Medical Consulting • Lynda Starbuck MS, RHIA, C-CDI AHIMA Certified ICD-10 Trainer HCCS -VP Coding Services

30. References • ICD-10-CM/PCS – The Complete Official Draft Code Set, Draft 2011 • MLN Matters/CMS • CDI: Improve Documentation Now for Effective Transition Later – HCPro, Inc. • "Why ICD-10 Is Worth the Trouble." Journal of AHIMA 79, no.3 (March 2008): 24-29. • AHIMA ICD-10-CM/PCS Update (April, 2011) • Journal of AHIMA (2011 and 2012)