Implementation of ICD-10 Joining the Rest of the World in Coding

1. Implementation of ICD-10Joining the Rest of the World in Coding Jill Young - CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, Michigan

2. Disclaimer This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion

3. ICD International Classification of Diseases

4. Purpose of ICD • Transforming documentation into numeric or alphanumeric designations • Diseases • Injuries • Procedures • Designations are grouped into manageable categories

5. Purpose of ICD • A variety of healthcare reporting functions • Not just for reimbursement purposes • Intended as a tool to study outcomes and improve patient care • CDC uses data ** Need accuracy** • National Hospital Discharge Survey • National Ambulatory Medical Care Survey • External Causes of Injury statistics (international)

6. ICD in Statistical Reporting • The CDC uses clinical information for many of their studies: • Leading cause of deaths for males is heart disease – 28.7% (2001) • In 2003 health care expenditures for heart disease and stroke was projected to be $209 billion • Information for consumers and physicians • Most prevalent diseases • Average length of stay • Widely used treatments

7. ICD-9 is obsolete • Developed in early 1970s and has been in use since 1979 • Many of the clinical and procedure concepts no longer meet today’s healthcare needs • The U.S. is the only developed country that has yet to adopt ICD-10 for morbidity/mortality classification • No longer supported by the WHO and therefore cannot be significantly modified

8. More bad news for ICD-9 • The system does not comply with: • HIPAA code set standardization • BIPA (Benefits Improvement and Protection Act of 2000) that outlines new services and technology that must be acknowledged in CMS payment systems

9. Details of Implementation • October 1, 2013 October 1, 2014 • Exacting date for physician and ambulatory services • Date of discharge for inpatient setting • ICD-9-CM codes not accepted for new claims for dates of service * on or after October 1, 2013 October 1, 2014 • Except discharge as above • ICD-9-CM will still exist to allow claims completion • Unknown how long ICD-9 allowed

10. Comparison ICD‐9‐CM • 3‐5 digits • Digits 2-5 are numeric • Alpha V and E codes • Lacks laterality ICD‐10‐CM • 3‐7 digits • Digit 1 is Alpha • Digit 2 and 3 are numeric • Digit 5‐7 are alpha or numeric

11. The Need for ICD-10 • Billing and reimbursement specificity more manageable • No room for new codes • Shortage of rubrics • Diagnostic and statistical Manual of Mental Disorders • DSM IV • Chapter 2 (Neoplasms) and morphology codes correspond to ICD-O-2 • Cancer registry programs have used since 1995 • Misclassifications

12. Misclassifications - Urosepsis • Dorland’s - a term used imprecisely to denote infection ranging from urinary tract infection to generalized sepsis which may result from such infection • Providers – UTI with sepsis • ICD-9 code- without clarification codes to UTI • ICD-10 – “code to condition”

13. ICD-10-CM Guidelines 2013 • Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). • The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.

14. ICD-10-CM Guidelines 2013 • A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. • These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported.

15. 1995 & 1997 E&M Guidelines • If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. • Appropriate health risk factors should be identified. • The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented. • The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

16. 1995 E&M • For a presenting problem with an established diagnosis the record should reflect whether the problem is: • a) improved, well controlled, resolving or resolved; or, • b) inadequately controlled, worsening, or failing to change as expected. • Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.

17. ICD-10-CM Guidelines 2013 • The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.

18. Poor Preparation Consequences • Increased delays in processing authorizations and reimbursement claims • Improper claims payment • Coding backlogs • Compliance issues • Decisions based on inaccurate data • Problems can be mitigated with proper advance preparation

19. Other Concerns • Claims processing • Will there be a significant increase in rejections, pended or appealed claims • Laboratory & other testing • What specificity is needed on order • General symptoms vs specific symptoms • Patient concerns • Change in covered benefits due to policy changes • Perceived change in coverage • Is cause the coding system’s specificity?

20. The Rand Report • Implementation costs include: • Training • Lost productivity during this period • System upgrades and changes • Future benefits include: • More accurate payment for new procedures • Fewer miscoded, rejected, and improperly reimbursed claims • Better understanding of the value of new procedures and outcomes • Improved disease management

22. AHIMA STUDY COMMENTS • Physicians need 5 hours of training to become proficient in ICD-10 • AGREE  DISAGREE

23. ICD-10-CM Myths or Misnomers • Physicians will need to learn new system of documentation which may change the way they practice • Coding and billing staff need to start code set training • in 2014 • Now • ICD-10 only works with an Electronic Medical Record system • Practices will need additional staff to handle the workload during and after the transition

24. ICD-10: Breaking it Down • Disease classifications expanded • Health-related conditions • Greater specificity to 6 digits with 7th digit extension • 21 chapters • Additional special group chapters • 2 new chapters not in ICD-9 • Diseases of the eye and adnexa • Disorders of the ear

25. ICD-10: Breaking it down • Alphabetical Index • Organized in the same manner as ICD-9 • Codes listed by “main term” • Cross-references and notes appear • Define terms • Provide direction • Provide coding instructions • 3 sections • Section I- Index to diseases and nature of injury • Section II- External causes • Section III- Table of drugs and chemicals

26. ICD-10: Breaking it Down • Chapters are further divided into subchapters or “blocks” • Contain rubrics identifying closely related conditions • Each chapter contains a summary subchapter that gives an overview of each block

27. New Concepts • Excludes1 • Not coded here • Excludes2 • Not included here

28. Fourth Digit Classification • The 4th digit defines site, etiology, manifestation, or state of the disease or condition • Right, left, bilateral • Viral vs. bacterial • Controlled vs. uncontrolled • Primary vs. secondary • Malignant vs. benign • Congenital vs. acquired

29. Fifth & Sixth Digit Classifications • Adverse effect, Poisoning or Reaction to improper use of medication, Toxic effect • Accidental • Intentional self harm • Assault • Undetermined

30. Example • A 32 y.o. hiker was bit by a venomous spider while hiking through the woods. He began experiencing muscle weakness and syncope and was rushed to the ED by a fellow hiker, where he was diagnosed with spider venom toxicity.

31. Example T63.39 Toxic effect of venom of other spider • T63.391 Toxic effect of venom of other spider, accidental (unintentional) • T63.392 Toxic effect of venom of other spider, intentional self-harm • T63.393 Toxic effect of venom of other spider, assault • T63.394 Toxic effect of venom of other spider, undetermined

32. New Concepts • Placeholder character • “X” • Used as 5th and 6th character to allow for future expansion • Seventh character alpha • Burns • Initial vs subsequent vs sequela • Fractures • Initial vs subsequent • Healing vs malunion or non union

33. A Seventh character? • A seventh character indicates: • A- the initial encounter • First encounter for treatment of the injury • D- subsequent encounter • May be used for as long as the patient is receiving treatment for an injury • S- sequelae • Complication or condition arising as a result of the injury

34. 7th Character Example • A 25 y.o. male presented to the emergency room after accidentally slashing his right arm with a sharp knife while cleaning a fish he caught during a Key West deep sea fishing trip. The Dx reported by the ED is laceration of the ulnar artery at the forearm, right arm • How to code the dx?

35. Laceration of Ulnar Artery at Forearm Level • Laceration - see also Wound open by site • No other specific listing • Wound • Artery – see injury, blood vessel, by site • Ulnar (artery) (vein) 903.3 • 903. Injury to blood vessels of upper extremity • 903.3 Ulnar blood vessels

36. 7th Character Example • S55 Injury of blood vessels at forearm level Code also any associated open wound (S51.-) Excludes2: injury of blood vessels at wrist and hand level (S65.-) injury of brachial vessels (S45.1-S45.2) • The appropriate 7th character is to be added to each code from category S55 A - initial encounter D - subsequent encounter S - sequela injury of ulnar artery at forearm level, unspecified arm

37. Example S55.0 Injury of ulnar artery at forearm level • S55.00 Unspecified injury of ulnar artery at forearm level • S55.001 Unspecified injury of ulnar artery at forearm level, right arm • S55.002 Unspecified injury of ulnar artery at forearm level, left arm • S55.009 Unspecified injury of ulnar artery at forearm level, unspecified arm • S55.01 Laceration of ulnar artery at forearm level • S55.011 Laceration of ulnar artery at forearm level, right arm • S55.012 Laceration of ulnar artery at forearm level, left arm • S55.019 Laceration of ulnar artery at forearm level, unspecified arm • S55.09 Other specified injury of ulnar artery at forearm level • S55.091 Other specified injury of ulnar artery at forearm level, right arm • S55.092 Other specified injury of ulnar artery at forearm level, left arm • S55.099 Other specified injury of ulnar artery at forearm level, unspecified arm

38. ICD-10-CM Table of Neoplasms • Codes listed with a dash - following the code have a required 5th character for laterality or other location specificity. • The tabular list must be reviewed for the complete code.

39. Notes In Chapter Listing • The chapter uses the S-section for coding different types of injuries related to single body regions • T-section to covers injuries to multiple or unspecified body regions as well as poisoning and certain other consequences of external causes

40. Insect Bite – ICD-9 • Insect Bite • Non-venomous • See injury, superficial, by site • 919.4 Insect bite non-venomous, without mention of infection • 919.5 Insect bite, non-venonomous, infected

41. Insect Bite – ICD-10 S00.06A Insect bite of scalp; Initial encounterS00.06D Insect bite of scalp; Subsequent encounterS00.269A Insect bite of unspecified eyelid and periocular area; Initial encounterS00.269D Insect bite of unspecified eyelid and periocular area; Subsequent encounterS00.36A Insect bite of nose; Initial encounterS00.36D Insect bite of nose; Subsequent encounterS00.469A Insect bite of unspecified ear; Initial encounterS00.469D Insect bite of unspecified ear; Subsequent encounterS00.561A Insect bite of lip; Initial encounterS00.561D Insect bite of lip; Subsequent encounterS00.562A Insect bite of oral cavity; Initial encounterS00.562D Insect bite of oral cavity; Subsequent encounterS10.16A Insect bite of throat; Initial encounterS10.16D Insect bite of throat; Subsequent encounter

42. Insect Bite – ICD-10 • S10.86A Insect bite of other part of neck; Initial encounterS10.86S Insect bite of other part of necks; subsequent encounterS10.96A Insect bite of unspecified part of neck; Initial encounterS10.96D Insect bite of unspecified part of neck; Subsequent encounterS20.161A Insect bite of breast, right breast; Initial encounterS20.161D Insect bite of breast, right breast; Subsequent encounterS20.162A Insect bite of breast, left breast; Initial encounterS20.162D Insect bite of breast, left breast; Subsequent encounterS20.169A Insect bite of breast, unspecified breast; Initial encounterS20.169D Insect bite of breast, unspecified breast; Subsequent encounterS20.361A Insect bite of right front wall of thorax; Initial encounterS20.361D Insect bite of right front wall of thorax; Subsequent encounterS20.361S Insect bite of right front wall of thorax; Subsequent encounterS20.362A Insect bite of left front wall of thorax; Initial encounterS20.362D Insect bite of left front wall of thorax; Subsequent encounterS20.369A Insect bite of unspecified front wall of thorax; Initial encounterS20.369D Insect bite of unspecified front wall of thorax; Subsequent encounter

43. Insect Bite – ICD-10 • S20.461A Insect bite of right back wall of thorax; Initial encounterS20.461D Insect bite of right back wall of thorax; Subsequent encounterS20.462A Insect bite of left back wall of thorax; Initial encounterS20.462D Insect bite of left back wall of thorax; Subsequent encounterS20.469A Insect bite of unspecified back wall of thorax; Initial encounterS20.469D Insect bite of unspecified back wall of thorax; Subsequent encounterS20.96A Insect bite of unspecified parts of thorax; Initial encounterS20.96D Insect bite of unspecified parts of thorax; Subsequent encounterS30.860A Insect bite of lower back and pelvis; Initial encounterS30.860D Insect bite of lower back and pelvis; Subsequent encounterS30.861A Insect bite of abdominal wall; Initial encounterS30.861D Insect bite of abdominal wall; Subsequent encounterS30.862A Insect bite of penis; Initial encounterS30.862D Insect bite of penis; Subsequent encounterS30.863A Insect bite of scrotum and testes; Initial encounterS30.863D Insect bite of scrotum and testes; Subsequent encounterS30.864A Insect bite of vagina and vulva; Initial encounterS30.864D Insect bite of vagina and vulva; Subsequent encounterS30.865A Insect bite of unspecified external genital organs, male; Initial encounterS30.865D Insect bite of unspecified external genital organs, male; Subsequent encounterS30.866A Insect bite of unspecified external genital organs, female; Initial encounterS30.866D Insect bite of unspecified external genital organs, female; Subsequent encounter

44. Insect Bite – ICD-10 S30.867A Insect bite of anus; Initial encounterS30.867D Insect bite of anus; Subsequent encounterS40.269A Insect bite of unspecified shoulder; Initial encounterS40.269D Insect bite of unspecified shoulder; Subsequent encounterS40.869A Insect bite of unspecified upper arm; Initial encounterS40.869D Insect bite of unspecified upper arm; Subsequent encounterS50.369A Insect bite of unspecified elbow; Initial encounterS50.369D Insect bite of unspecified elbow; Subsequent encounterS50.869A Insect bite of unspecified forearm; Initial encounterS50.869D Insect bite of unspecified forearm; Subsequent encounterS60.369A Insect bite of unspecified thumb; Initial encounterS60.369D Insect bite of unspecified thumb; Subsequent encounterS60.468A Insect bite of other finger; Initial encounterS60.468D Insect bite of other finger; Subsequent encounterS60.469A Insect bite of unspecified finger; Initial encounterS60.469D Insect bite of unspecified finger; Subsequent encounterS60.569A Insect bite of unspecified hand; Initial encounterS60.569D Insect bite of unspecified hand; Subsequent encounter

45. Insect Bite – ICD-10 S60.869A Insect bite of unspecified wrist; Initial encounterS60.869D Insect bite of unspecified wrist; Subsequent encounterS70.269A Insect bite, unspecified hip; Initial encounterS70.269D Insect bite, unspecified hip; Subsequent encounterS70.369A Insect bite, unspecified thigh; Initial encounterS70.369D Insect bite, unspecified thigh; Subsequent encounterS80.269A Insect bite, unspecified knee; Initial encounterS80.269D Insect bite, unspecified knee; Subsequent encounterS90.463A Insect bite, unspecified great toe; Initial encounterS90.463D Insect bite, unspecified great toe; Subsequent encounterS90.466A Insect bite, unspecified lesser toe(s); Initial encounterS90.466D Insect bite, unspecified lesser toe(s); Subsequent encounterS90.569A Insect bite, unspecified ankle; Initial encounterS90.569D Insect bite, unspecified ankle; Subsequent encounterS90.869A Insect bite, unspecified foot; Initial encounterS90.869D Insect bite, unspecified foot; Subsequent encounter

46. Insect Bite – ICD-10

47. Diabetes • E08 – Diabetes due to underlying condition • E09 – Drug or chemical induced diabetes mellitus • E10 – Insulin dependent diabetes mellitus • E11 – Non-insulin dependent diabetes mellitus • E12 – Malnutrition related diabetes • E13 – Other specified diabetes mellitus

48. Diabetes Guidelines • The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. • As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. • They should be sequenced based on the reason for a particular encounter.

49. Diabetes Guidelines • If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned. • Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin. • Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.

50. Diabetes Specificity • .0 With coma • .1 With ketoacidosis • .2 With renal complications • .3 With ophthalmic complications • .4 With neurological complications • .5 With peripheral circulatory complications • .6 With other specified complications • .7 With multiple complications • .8 With unspecified complications • .9 Without complications