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ICD10-CM/PCS

ICD10-CM/PCS. The “What”, “When”, “Why” and “Who” Presenter: Linda Parks MA RHIT CCS CTR Assistant Professor, DSU HIM Programs. International Classification of Diseases ICD is the international, standard diagnostic classification for all general epidemiological and health management purposes.

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ICD10-CM/PCS

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  1. ICD10-CM/PCS The “What”, “When”, “Why” and “Who” Presenter: Linda Parks MA RHIT CCS CTR Assistant Professor, DSU HIM Programs

  2. International Classification of Diseases • ICD is the international, standard diagnostic classification for all general epidemiological and health management purposes. • The World Health Organization owns and publishes the international version of the ICD classification system. What:

  3. The United States remains the only industrialized nation that has not yet implemented ICD-10. ICD-10-CM/PCS

  4. What: ICD-10-CM • ICD-10-CM is the U.S. clinical modification of the World Health Organization’s ICD-10 classification system; developed by the National Center for Health Statistics. • ICD-10-CM will replace ICD-9-CM. ICD-9-CM - 14, 025 codes ICD-10-CM – 68,069 codes

  5. What: ICD-10-CM ICD-10-CM will be used in all healthcare settings for diagnosis coding.

  6. Differences ICD-9-CM • 3 – 5 characters in length • First digit is numeric or alpha • Second, third, fourth, and fifth digits are numeric • Always at least 3 digits • Decimal placed after the first three characters • Alpha characters are not case-sensitive ICD-10-CM • 3-7 characters in length • First character is alpha • All letters except U • Second character is numeric • Characters 3-7 can be alpha or numeric • Decimal placed after the first three characters • Alpha characters are not case-sensitive

  7. Differences

  8. I10 Hypertension • J45.909 Asthma • K21.9 GERD • S52.319A Greenstick fracture of shaft radius left arm, initial encounter Another View

  9. Developed in the US by CMS to replace the ICD-9 –CM procedural coding system Not derived from an international coding system or used in other countries Used only for facility reporting of hospital inpatient services ICD-9-CM = 3, 824 codes ICD-10-PCS = 72, 589 codes What: ICD-10-PCS

  10. What: ICD-10-PCS Incorporation of four essential attributes: • Completeness – A unique code for each substantially different procedure • Expandability – Structure should allow for expansion • Standardized Terminology – Definitions are well defined, with no multiple meanings, and each term assigned a specific meaning • Multi-axial Structure – Should contain independent characters, and an individual axis that maintains its meaning across ranges of codes

  11. Individual values rather than lists of fixed codes and text descriptions • Seven character alphanumeric code • Index and tables ICD-10-PCS Code Structure

  12. Section 0 Medical and Surgical Body System D Gastrointestinal System Operation T Resection: cutting out or off, without replacement, all of a body part

  13. Percutaneous needle core biopsy (diagnostic) of left kidney pelvis - 0TB43ZX • Right shoulder arthroscopy with coracoacromial ligament release - 0MN14ZZ • CABG of three coronary arteries using left autologous greater saphenous vein, harvested endoscopically - 021209W, 06BQ4ZZ • Ultrasonography, aortic arch, without contrast - B24BZZZ • Lumbar epidural injection of steroid and local anesthetic - 3E1U38Z Examples of ICD-10 PCS

  14. ICD-9-CM • Terminology and classifications are outdated • Not able to accommodate addition of new codes • Lacks clinical detail to describe severity or complexity of diagnoses Why?

  15. ICD-10-CM • Greater specificity and clinical detail • Improvement in quality and usefulness of coded data • Medical terminology and classification of diseases are consistent with current clinical practice • Greater flexibility in addition/revisions necessitated by medical advances • More amenable to computer assisted coding technology, which will reduce administrative costs associated with labor-intensive manual coding process • With adoption of the electronic health record, a standard code set is crucial • Offers providers and payers better data to improve performance, create efficiencies, and contain costs Why?

  16. Up to date classification systems will provide better data for: • Measuring the quality, safety and efficacy of care • Designing payment systems and processing claims for reimbursement • Conducting research, epidemiological studies, and clinical trials • Setting health policy • Operational and strategic planning and designing healthcare delivery systems • Monitoring resource utilization • Improving clinical, financial, and administrative performance • Preventing and detecting healthcare fraud and abuse • Tracking public health risks Why?

  17. Effective with encounter and discharge dates on or after October 1, 2014. • Single implementation date for all users • No delays, no grace periods • Date of discharge for inpatient settings • Date of service for ambulatory and physician reporting When:

  18. GEMS • Tool developed to assist with the translation of ICD-9-CM codes to ICD-10-CM/PCS and vice versa • Bidirectional (forward and backward) mappings developed between the ICD-9-CM diagnosis codes and ICD-10-CM • More complex than a simple one-to-one crosswalk General Equivalence Mappings (GEMS)

  19. Nondisplaced fracture of the anterior wall of the acetabulum, left side, subsequent encounter for fracture with routine healing • S32.415D • Aftercare for healing traumatic fracture of the hip • V54.13 • Atherosclerotic heart disease of native coronary artery with unstable angina • Combination code : ICD-9-CM 414.01 & 411.1 • ICD-10-CM: I25.110 Examples of GEMS crosswalks

  20. Who will use GEMS? • Payers, providers, HIM professionals, Researchers, Informatics Professionals, Utilization Managers, Quality Managers, Developers of of Quality Measures, Software Vendors How will GEMS be used? -Convert large databases and test system applications -Link data in long-term clinical studies -Develop application-specific mappings -Analyze data collected before and after the transition to ICD-10-CM/PCS -Comparing data across the transition period for various reasons including calculating costs and institutional financial measurements General Equivalence Mappings (GEMS)

  21. Detailed GEM user guides and further information: Websites: • CMS • AHIMA • National Center for Health Statistics • Pocket Guide of ICD-10-CM and PCS (AHIMA)

  22. Phase 1 – Impact Assessment Involves assessing the impact of change to new coding systems and identifying key tasks and objectives. Major tasks include: • Creating an interdisciplinary implementation planning team • Identifying and budgeting for required IT changes • Assessing, budgeting, and implementing clinician and code set user education Phases of Implementation

  23. Phase 2 – Overall Implementation Involves 3 major tasks: • Implementation of required IT changes • Follow-up assessment of documentation practices • Increasing education of the organization’s coding professionals • Items carried over from Phase 1 Phases of Implementation

  24. Phase 3 – Go-Live Preparation This phase includes the following tasks: • Finalization of system changes • Testing of claims transactions with payers • Intensive education of the organization’s coding professionals • Monitoring coding accuracy and reimbursement with prospective payment systems results (including DRG assignment) • Items carried over from Phase 2 Phases of Implementation

  25. Timeline

  26. More than likely the answer is YES!!!! • Areas affected by ICD-10 include: • Health Information Management (Coding) • Information Technology (CPOE) • Utilization Management • Quality • Decision Support (Case Mix) • Billing • Clinical Applications • Compliance • Accounting • Registration/Scheduling • Physician Documentation • Contract Management • Any application where diagnoses are currently used today Are YOU going to be affected by ICD-10?

  27. Coding • ICD-10 CM will be used in ALL setting. • ICD-10 PCS is for inpatient procedure coding • Note: CPT coding will have no impact with ICD-10 implementation • Productivity Decreases • Decrease if 50% in the beginning, gradually increasing over 3-6 months • never returning to pre-implementation productivity levels Implications of ICD-10

  28. Training/Education • Inpatient Coder (experienced): 50 hours • Anatomy/Physiology/Medical Terminology re-education is in addition to these hours • Outpatient Coder: 16 hours Average Coder needs: • 16 hours of ICD-10-CM • 24 hours of ICD-10-PCS • 10 hours of additional practice Implications of ICD-10 for Coders

  29. CEU requirements in ICD-10-CM/PCS by credential are shown below: • CHPS – 1 CEU • CHDA – 6 CEU’s • RHIT – 6 CEU’s • RHIA – 6 CEU’s • CCS-P- 12 CEU’s • CCS – 18 CEU’s • CCA – 18 CEU’s Note: Professionals who hold more than 1 credential will only report the highest number of CEU’s from among all credentials. (RHIA, CCS will need 18 CEU’s in ICD-10) Education Requirements for AHIMA Certified Professionals

  30. Dakota State University Online – 30 modules CE units available Anatomy and Physiology Review for ICD-10-CM/PCS

  31. Information Technology • Version 5010 • X12 standards consist of software that permits electronic data interchange (EDI) • One of those changes allows the X12 standards to recognize different versions of the diagnostic and procedures codes so that once in place the software can identify ICD-9-CM from ICD-10-CM  Implications of ICD-10

  32. Information Technology • ICD-9 and ICD-10 will need to be supported by the system • Changes in multiple systems/applications to support the new code format ( 7 characters alpha-numeric) • Increases to storage capacity • Reporting • Edits (medical necessity) • CPOE • Scheduling • Encoding software • Provider Profiling • Project Planning/Timelines Implications of ICD-10

  33. Physicians • Need for improved and more specific documentation Purpose of ICD-10 and more specific diagnoses: • Measure quality and safety of care • Design of reimbursement systems • Conducting research and clinical trials • Operational/Strategic planning • Tracking public health &risks More specific documentation = better clinical data Implications of ICD-10

  34. Documentation Issues • Capturing new information • Updating information • Expanding documentation • Example: S52.319A • “unspecified” Implications of ICD-10

  35. Where can I find resources on ICD-10? • CMS website http://www.cms.gov/ICD10/ • AHIMA website http://www.ahima.org/icd10/ • NCHS website http://www.cdc.gov/nchs/icd/icd10cm.htm Frequently Asked Questions…

  36. Will ALL AHIMA credentials have to comply with requirements? Yes Is ICD-10 CM only for Inpatient Hospitals? No, It will be used in all settings that currently use ICD-9 CM Classification Frequently Asked Questions…

  37. Will all providers and payers begin using ICD-10-CM/PCS at the same time? Yes Will there be a phase-in time period where providers can use either ICD-9-CM or ICD-10-CM/PCS? No Frequently Asked Questions…

  38. Who maintains ICD-10-PCS? CMS develops and maintains ICD-10-PCS Will ICD-10-PCS be used in Physician Office settings? No, PCS will only be used for Inpatient hospital settings How will the implementation of ICD-10-CM/PCS change the Medicare Prospective Payment System? CMS indicates that initially PPS case mix groups may not fundamentally change

  39. Establish an ICD-10 Steering Committee • AHIMA ICD-10 Checklist • http://www.ahima.org/downloads/pdfs/resources/checklist.pdf • Impact Assessment • Systems Review • Readiness Awareness/Education • Clinical Documentation Review • Training of Anatomy/Physiology Preparation Plans…

  40. QUESTIONS?

  41. Pocket Guide of ICD-CM and ICD-10-PCS , Zeisset & Bowman, AHIMA, 2010 • Rode, Dan. "Why 5010 Is Needed." Journal of AHIMA 81, no.2 (February 2010): 52-53. • Dimick, Chris, “Top Documentation Issues for ICD10”, Journal of AHIMA, (April 2011),online • Dimick, Chris, “CMS Readies for 5010, ICD10”, Journal of AHIMA, (May 2011) online • Moynihan, Jim. "Preparing for 5010: Internal testing of HIPAA Transaction Upgrades recommended by December 31." Journal of AHIMA 81, no.1 (January 2010): 22-26. • AHIMA e-HIM Workgroup on the Transition to ICD-10-CM/PCS. "Planning Organizational Transition to ICD-10-CM/PCS." Journal of AHIMA 80, no.10 (October 2009): 72-77. • Faye Brown’s ICD-9-CM Coding Handbook 2011, Leon-Chisen, AHA 2010 • Zeisset, Ann. "ICD-10-CM Enhancements: A Look at the Features That Will Improve Coding Accuracy" Journal of AHIMA 80, no.2 (February 2009): 55-58. • Barta, Ann; et al.. "ICD-10-CM Primer." Journal of AHIMA 79, no.5 (May 2008): 64-66. • www.cms.gov References

  42. Understanding the ChangeforLong Term Care Hospitals By Kathy Andersen, RHIT, CCS,CPAT,CCAT SDHIMA Director of Education Revenue Cycle Management~ Rapid City Regional Hospital

  43. Long Term Care Hospitals (LTCH’s)Prospective Payment System: High Cost Outlier LLTCH’s are certified under Medicare as short-term acute care hospitals. LTCH’s treat patients with multiple comorbidities requiring long-stay hospital-level of care. For Medicare purposes, they use the average Length of Stay (LOS) greater then 25 days. A Higher Cost Outlier is an adjustment to the Federal payment rate for LTCH stays that exceed the typical cost for a Medicare Severity Long Term Care Diagnosis Related Group (MS-LTC-DRG)

  44. LTCH –PPS Final Rule • This rule emphasizes that proper coding is essential for correct diagnosis and procedure reporting. • ICD-10 Office Guidelines are to be followed • October 1 ,2013 will be the last major update to ICD-9, ICD-10 will be effective October 2014 • **Coding guidelines will have little change, but the detail of documentation needed to code a record for reimbursement will** CUEU6241 Document, Document!

  45. Reporting Guidelines for LTC

  46. Principal Diagnosis and Guidance Definition: Principal Diagnosis: indicates the principal, primary and first listed diagnosis for each patient. Reason for Skilled Services Condition established after study to be chiefly responsible for occasioning the admission of the hospital care. • Example: • A resident was initially admitted to a LTC Facility to receive physical and occupational therapy services due to aftercare for a healing hip fracture. The resident remains in the facility because of his Parkinson’s disease. • How would you code this? V57.89, Multiple therapies, V54.13 Aftercare for healing fracture (Repaired with ORIF), 332.0 Parkinson's disease

  47. Code 332.0 Parkinson’s disease becomes the principal/primary diagnosis, as it is the reason for the continued stay. If a year later the resident is transferred to the hospital for treatment of pneumonia and returns to the nursing facility after a three-day hospital stay. We would use 332.0, 486 (Pneumonia) with the order for multiple therapies. Continued Stay Codes

  48. Pre and Post Payment Reviews by ~CERT/ADR/RAC~ Key Components • Compliance Program • Guidance for Nursing Facilities is imperative • Review-LTC Facilities • Process • Polices • Procedures • Prevention • Education • Training • Evaluation of Staff responsibilities • Internal Audits • Review Billing • Cost reporting Medical Reviews

  49. Preparing for ICD-10

  50. Credentialed HIM ProfessionalsKnowledge and ExpertiseIndustry Preparedness for ICD-10Accurate Coding DataDocumentation Improvement Electronic Medical RecordInternal and External AuditingMonitor Denials and Appeal when necessary

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