ICD-10 Implementation: What Physicians Need to Know

1. ICD-10 Implementation: What Physicians Need to Know Nancy Spector, BSN, MSC Director, Electronic Medical Systems Organization of State Medical Association Presidents Meeting November 11, 2011

2. Overview • Background on ICD-9 and ICD-10 • ICD-10-CM • ICD-10-PCS • AMA Advocacy on ICD-10 • Impact on the Physicians • Implementation • Documentation • Financial • Crosswalking • Resources

3. ICD-9 vs. ICD-10 • ICD-9 • International Classification of Diseases, Ninth Revision, Clinical Modification • ICD-9-CM Volumes 1 and 2 – diagnosis code sets • ICD-9-CM Volume 3 – procedure coding system • ICD-10 • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) • Diagnosis code set • International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) • Procedure code set

4. ICD-9 • Was developed by the WHO • U.S. developed its clinical modification to ICD-9 • ICD-9-CM Volumes 1 and 2 – diagnosis code sets • ICD-9-CM Volume 3 – procedure coding system • ICD-9 implemented in the U.S. in 1979 • Named in 2000 as a HIPAA code set to be used in HIPAA electronic transactions

5. ICD-10 • Developed by the WHO in 1989 and released in 1994 • U.S. implemented for mortality reporting on January 1, 1999 • NCHS developed the U.S. clinical modification for diagnoses – ICD-10-CM • CMS developed a procedure code set – ICD-10-PCS

6. Use of ICD-10-CM • Reporting diagnoses • Will be used in all clinical settings • Inpatient • Outpatient

7. Use of ICD-10-PCS • Reporting inpatient hospital procedures only • Does not replace CPT or HCPCS

8. ICD-9 vs. ICD-10: Diagnosis Codes

9. ICD-9 vs. ICD-10: Diagnosis Codes • ICD-9 diagnosis codes • 382.9 Acute otitis media • 540.9 Acute appendicitis • 780.01 Coma • ICD-10 diagnosis codes • B01.2 Varicella pneumonia • K21.0 Gastro-esophageal reflux disease with esophagitis • O30.003 Twin pregnancy, unspecified, third trimester

10. ICD-10-CM Structure • Characters 1-3 – Category • Characters 4-6 – Etiology, anatomic site, severity, or other clinical detail • Characters 7 – Extension Example: S52 Fracture of forearm S52.5 Fracture of lower end of radius S52.52 Torus fracture of lower end of radius S52.521 Torus fracture of lower end of right radius S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture

11. ICD-10-CM Benefits • Flexible – can more quickly incorporate emerging diagnoses • More specificity for precise diagnosis • Improved ability to measure health care services • Supports improved public health surveillance • Reflects advances in medicine and medical technology • Uses current medical terminology

12. ICD-9 vs. ICD-10: Procedure Codes

13. ICD-9 vs. ICD-10: Procedure Codes • ICD-9 procedure codes • 39.50 Angioplasty • 39.31 Suture of artery • 47.01 Laparoscopic appendectomy • ICD-10 procedure codes • 0DN90ZZ Release of duodenum, open approach • 0FB03ZX Excision of liver, percutaneous approach, diagnostic • 02PS0CZ Removal, extraluminal device from pulmonary vein, right, open

14. ICD-10-PCS Structure Code structure in Medical and Surgical Section

15. ICD-10-PCS Structure Example: Right knee joint replacement = 0SRC0JZ 0 = Medical and Surgical Section S = Lower Joints R = Replacement D = Knee Joint, Right 0 = Open J = Synthetic Substitute Z = No Qualifier

16. ICD-10-PCS Benefits • Provides greater detail to describe complex medical procedures • Describes precisely what is done to the patient • Plenty of space to add new procedures • Follows a logical structure • Uses standardized terminology • Uses current medical terminology

17. How ICD-10 in Other Countries Differs from U.S. Implementation • No procedure code set • Not used for reimbursement • Government funding helped pay for implementation • Went from no coding standard to ICD-10 • Rolled out in phases across country • Implemented for inpatient facilities only • Less codes than U.S. modification

18. AMA Policy Related to ICD-10 • D-70.960 Implementation of ICD-10-CM - Our AMA will work for delayed implementation of a simplified, modified ICD-10-CM coding system which is less burdensome on practicing physicians, hospitals, and the health insurance industry. (Res. 719, A-06) • D-70.954 Transition to ICD-10 Code Sets - Our American Medical Association will develop systems to help physicians transition to the ICD-10 coding system. (Res. 810, I-09)

19. AMA Advocacy on ICD-10 • 2002 • Testimony to NCVHS against ICD-10 • Letters to HHS and GAO against ICD-10 • 2003 • Letters to Congressional leaders and NCVHS against ICD-10 • Get ICD-10 removed from a House Bill • Testimony to ICD-9 Coordination and Maintenance Committee on concerns of costs to implement ICD-10

20. AMA Advocacy on ICD-10 (cont.) • 2005 • Lobbying efforts on House Bill to maintain CPT for outpatient procedures • 2006 • Joined multi-stakeholder coalition advocating for sensible transition timeframe • 2008 • Letter to OMB expressing concerns of rapid adoption • Proposed rule released calling for October 1, 2011 compliance date • Letter to CMS advocating for longer implementation period

21. ICD-10 Regulation • “Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS” • Published January 16, 2009 • Compliance date is October 1, 2013 • AMA successful in getting date delayed 2 years • Names ICD-10 to replace ICD-9-CM • Maintains CPT for outpatient procedures

22. Compliance Date: October 1, 2013 • All services on or after October 1, 2013 must use ICD-10 • All discharges on or after October 1, 2013 must use ICD-10 • ICD-9 will not be accepted for services and discharges on or after this date • ICD-10 will not be accepted prior to this date

23. ICD-10 Impact on the Practice • Implementation • Documentation • Financial

24. Implementation Steps • Step 1 – Conduct impact analysis • Step 2 – Contact your software vendors • Step 3 – Contact your clearinghouses and/or billing service • Step 4 – Contact your payers • Step 5 – Undergo installation of system upgrades • Step 6 – Conduct internal testing • Step 7 – Update internal processes • Step 8 – Conduct staff training • Step 9 – Conduct external testing with trading partners • Step 10 – Make the switch to ICD-10

25. Practice Assessment • Where do you use diagnosis codes in your practice? • What process is involved in these activities? • Via HIPAA transaction • Via phone • Via web portal • Via paper form • What systems are involved in these activities? • Who are the people that work with the codes?

26. Pre-visit Activity • Patient schedules an appointment • Do you need to check eligibility? • Do you need a referral? • Do you need prior authorization? • Do you use a patient problem list? • Do you maintain a disease registry? • Ask: • How do you obtain this information? • What system is used? • Who does this work?

27. Patient Visit • Patient seen by clinician • Do you use an encounter form or superbill? • How do you document the encounter? • Do you write orders? • Do you write referrals? • Do you provide certificates for medical necessity? • Ask: • How do you do these activities? • What system is used? • Who does this work?

28. Post-visit Activity • Clinical activities after the patient is seen • Do you create consultation reports? • How do you update patient problem lists? • How do you update the disease registry? • Do you do public health reporting? • Do you do quality reporting? • Do you do research? • Ask: • How do you do these activities? • What system is used? • Who does this work?

29. Billing Activity • Bill for patient visit • How do you determine the diagnosis code? • Do you use any coding tools? • Are there other billing-related activities that use diagnosis codes? • Do you perform chart audits? • Ask: • How do you do these activities? • What system is used? • Who does this work?

30. Documentation • Documentation in the patient’s chart must support the diagnosis code submitted on the claim • Higher level of detail in ICD-10 may require more detailed documentation • Greater detail about patient’s condition • Factors related to condition, injury, or cause of injury • Information about initial treatment or follow-up care • Changes in clinical concepts in ICD-10

31. ICD-9 Asthma Diagnosis Codes • 49300 Extrinsic asthma without mention of status asthmaticus • 49310 Intrinsic asthma without mention of status asthmaticus • 49312 Intrinsic asthma with acute exacerbation • 49302 Extrinsic asthma with acute exacerbation • 49301 Extrinsic asthma with status asthmaticus • 49311 Intrinsic asthma with status asthmaticus • 49392 Asthma, unspecified type, with acute exacerbation • 49391 Asthma, unspecified type, with status asthmaticus • 49390 Asthma, unspecified type, without mention of status asthmaticus • 49381 Exercise induced bronchospasm • 49382 Cough variant asthma

32. ICD-10 Asthma Diagnosis Codes • J4520 Mild intermittent asthma, uncomplicated • J4521 Mild intermittent asthma with (acute) exacerbation • J4522 Mild intermittent asthma with status asthmaticus • J4530 Mild persistent asthma, uncomplicated • J4531 Mild persistent asthma with (acute) exacerbation • J4532 Mild persistent asthma with status asthmaticus • J4540 Moderate persistent, uncomplicated • J4541 Moderate persistent with (acute) exacerbation • J4542 Moderate persistent with status asthmaticus • J4550 Severe persistent, uncomplicated • J4551 Severe persistent with (acute) exacerbation • J4552 Severe persistent with status asthmaticus • J45901 Unspecified asthma with (acute) exacerbation • J45902 Unspecified asthma with status asthmaticus • J45909 Unspecified asthma, uncomplicated • J45990 Exercise induced bronchospasm • J45991 Cough variant asthma • J45998 Other asthma

33. Learning the ICD-10 Codes • Identify top 10, 20, or 30 codes used in your practice • Look at the ICD-10 codes for these diagnoses • Identify documentation needs for coding • Identify impact to your practice • Base type and amount of training on the person’s use of diagnosis codes • Use coding resources

34. Financial • Costs • Updates to systems • Replacement of forms • Training • Coding tools – books, software programs, etc. • Downtime • Decrease in productivity • Other administrative costs

35. Financial • Reimbursement • Payers will be updating their payment policies • Payer contracts have fee schedules and reimbursement rates tied to diagnosis codes • “Financial neutrality”

36. Talk to Your Payers • Ask: • Do you plan to change your reimbursement rates or fee schedule with ICD-10? • Do you plan to re-negotiate your contracts for ICD-10? • If so, are you going to re-negotiate the contracts when they are up for renewal or prior to that date? • What impacts will ICD-10 have on your fee schedule? • What impacts will ICD-10 have on your medical review, auditing, and coverage?

37. Crosswalking ICD-9 and ICD-10 • Lots of discussions about how to crosswalk • Forward from ICD-9 to ICD-10 and • Backward from ICD-10 to ICD-9 • There is no single “crosswalk” • NCHS and CMS have developed the General Equivalency Mappings (GEMs) • Available for free on NCHS and CMS websites • CMS has developed reimbursements map • Available on their website

38. Issues with Crosswalking • There is no ability to have a 1:1 map between ICD-9 and ICD-10 • Mappings can be 1:1, 1:many, many:1, 1: none • Some concepts changed between ICD-9 and ICD-10 • If concept is new in ICD-10, then it can’t be mapped to an ICD-9 code • Can lose details when crosswalking • Example – Displaced Rolando’s fracture, left, hand subsequent encounter for fracture with malunion (S62.222P) = Malunion of fracture (733.81)

39. AMA Resources • www.ama-assn.org/go/ICD-10 • Updated web content • Educational resources • ICD-10 FAQs • Article – “Preparing for the Conversion from ICD-9 to ICD-10: What You Need to Be Doing Today” • ICD-10 Fact Sheets Series • ICD-10 Project Plan Template • ICD-10 Checklist

40. Other Resources • CMS – www.cms.gov/ICD10 • National Center for Health Statistics – www.cdc.gov/nchs/icd.htm • American Academy of Professional Coders (AAPC) – www.aapc.com • American Hospital Association (AHA) – www.aha.org • American Health Information Management Association (AHIMA) – www.ahima.org • Workgroup for Electronic Data Interchange (WEDI) – www.wedi.org