ICD-10-CM Boot Camp

1. ICD-10-CM Boot Camp Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. 2014

2. ICD-10 Changes Everything! It’s on our doorstep! The biggest change to happen in Health Information Management and the Revenue Cycle in more than 30 years! Preparation is the key. Will you be ready?

3. ICD-10 • WHO (World Health Organization) owns & publishes ‘ICD’ (International Classification of Diseases). • WHO endorsed ICD-10 in 1990; members began using ICD-10 or modifications in 1994. • United States is the only industrialized country not using ICD-10 for our coding & reporting of diseases, illnesses, and injuries. Why? What makes us so different?

4. Countries Using ICD-10 For Case Mix • United Kingdom (1995) • Denmark, Finland, Iceland, Norway, Sweden (1994 – 1997) • France (1997) • Australia (1998) • Belgium (1999) • Germany (2000) • Canada (2001) • U.S. (2015) (Reimbursement + Case Mix)

5. But What’s Wrong With ICD-9? If it’s not broken, why fix it?

6. What’s Wrong With ICD-9? • Bottom line…We have run out of space and cannot capture any new diseases and/or procedures. • Does not capture ‘specificity’ as ICD-10 does. • In 1979, the year ICD-9 was implemented, the Nobel Prize was awarded for the CT scanner. Just think about how far we have come in healthcare since then, while our codes have remained in ICD-9!

7. Who Will Be Impacted By ICD-10? We all know that ICD-10 will impact the coder, but who else?

8. Non-HIM Impact Areas • CDM – Hardcoded RT/LT needs to match with the soft coded RT/LT ICD-10 diagnosis code • Trauma Registry – Translation of codes • All IT Systems Within The Organization • Decision Support & Utilization Patterns – Will need to be translated • Revise Forms To Include New ICD-10 Codes • Lab Requisitions • Physician encounter forms • EMR • CPOE • Scheduling – Pre-certs, eligibility • Don’t forget Medicaid! • Medical Necessity CPT Codes – software, manual processes, cheat sheets • Recurring Accounts – Will need new pre-certs & re-coded after October 1, 2015 • Payer Acceptance of new ICD-10 codes PLUS ICD-9 codes – 2 batches • Payer Contract Language – Dx codes • Payer Remark Codes/Denial Codes

9. Payer Readiness - Letters With Timelines To Get Started, Test, Dialogue • UB submissions with ICD-9 and ICD-10 - conversion dates • Denials with new reasons – as ICD-10 is far more specific • Contract language that addresses ICD-10 inclusions/exclusions • Claim scrubbers/payer scrubbers – ABN issues (LCD/NDC dx codes), ‘if’ rules, edits • Pre-authorization process/coverage • WC and Liability are not subject to HIPAA standard transactions. Will they convert? What does this really mean?

10. Exploring New Partnerships With Provider Offices • Physician dictates ► hospital coders code ► UB is created. • New! Why not share the codes with the providers who are attached to the account? Why repeat the same coding process in the physician office? • New! Brown bag coding luncheons with the provider offices. Office brings samples to code, hospital coders code while teaching ICD-10 concepts. • New! Hospital becomes the outsourcing company to assist small practices with coding.

11. So…what is ICD-10?

12. What is ICD-10-CM/PCS? • Department of Health and Human Services (HHS) mandated that HIPAA covered entities must update medical coding sets,effective October 1, 2015 (1 year delay). • Diagnosis code set changes from ICD-9-CM to ICD-10-CM. • Hospital inpatientprocedure code set changes from ICD-9-CM (Volume 3) to ICD-10-PCS. • No impact on CPT and/or HCPCS codes. Yeah! We will still report CPT codes for all outpatient procedures/services & physician hospital visits to Observation and Inpatients (E&Ms).

13. ICD-10 Impact • ICD-10-CM (Diagnoses) • Will be used byallhospitals, providers, clinics, lab, radiology, psych, rehab, nursing homes, etc. • ICD-10-PCS (Procedures) • Will be used only for hospital claims for inpatienthospital procedures • CPT/HCPCS – No change! • Procedures for Hospital Outpatients, Physician Visits, Lab and Radiology Outpatients, etc.

14. When is Implementation? • October 1, 2015– Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures). • CMS initially stated that there would be nograce period. Then why the 1 year delay? And now another year?

15. ICD-10 Implementation Span Date • CMS clarified policy for processing split claims for hospital encounters that span the ICD-10 implementation date. • MLN (Medical Learning Network) Matters Number: SE1325 • Split Claims • Require providers split the claim so all ICD-9 codesremain on one claim with Date of Service (DOS) through September30, 2015, and all ICD-10 codes placed on the other claim with DOS beginning October 1, 2015 and later. • Same guidance for Inpatient and Outpatient encounters!

16. Diagnosis Coding (ICD-10-CM)

17. ICD-9-CM vs. ICD-10-CM ICD-10-CM • 3 - 7 digits or characters • 1st character is alpha (all letters used except “U”) • 2nd – 7th characters can be alpha and/or numeric • Decimal placed after the first 3 characters (the same!) • 21 Chapters and “V” & “E” codes are ‘not’supplemental • 69,000+ diagnosis codes ICD-9-CM • 3 - 5 digits or characters • 1st character is numeric oralpha (E or V codes) • 2nd – 5th characters are numeric • Decimal placed after the first 3 characters • 17 Chapters and “V” & “E” codes are ‘supplemental’ • 14,000 diagnosis codes

18. ICD-10-CM Format X X XX X XX

19. What Does ICD-10-CM Have To Offer? • Provides many,many more categories for diseases and other health-related conditions • Higher level of “specificity” • Combined etiology and manifestations, poisoning and external causes, or diagnosis and symptoms into a single code Did you know that ICD-11 is already in draft format?

20. Why Are There So Many Diagnosis Codes? • Greater “specificity and detail” in all diagnosis codes! • But…is there supporting physician documentation in the medical record? • 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system • 17,045 (25%) of all ICD-10-CM codes are related to fractures • 10,582 fracture codes will distinguish ‘right’ vs. ‘left’ • 25,000 (36%) of all ICD-10-CM diagnosis codes will now distinguish right vs. left

21. Level of Detail Example • ICD-9-CM (Irregular Astigmatism) (367.22) • Only 1 code in ICD-9-CM • ICD-10-CM (Irregular Astigmatism) • Will have 4 code choices: • H52.211 (Irregular astigmatism, right eye) • H52.212 (Irregular astigmatism, left eye) • H52.213 (Irregular astigmatism, bilateral) • H52.219 (Irregular astigmatism, unspecified eye) • Physicians are likely documenting “laterality” now, but coders aren’t looking for it. • One easy place to look for documentation improvement!

22. New Features to ICD-10-CM • Combination codes for conditions and common symptoms or manifestations • E10.21 Type 1 diabetes mellitus with diabetic nephropathy • Added laterality (left vs. right) • M94.211 Chrondromalacia, right shoulder • Added 7th character extensions for episode of care • S06.01xA Concussion with loss of consciousness of 30 minutes or less, initial encounter • Expanded codes (injuries, diabetes, alcohol & substance abuse, postoperative complications) • F14.221 Cocaine dependence with intoxication delirium

23. More New Stuff! • Injuries are grouped by anatomical site rather than by the type of injury • Diseases of the sense organs (eyes & ears) have their own chapters, no longer part of the Nervous System chapter • Inclusion of trimesters in obstetric codes and elimination of 5th digits for episode of care • O99.013 Anemia complicating pregnancy, third trimester • Change in timeframes specified in certain codes • Acute myocardial infarction – time period changed from 8 weeks to 4weeks • Full code titles for all codes (no reference back to common fourth and fifth digits) • Post-op complications have been moved to procedure-specific body system chapters

24. Not Everything Will Change In ICD-10-CM! • We tend to focus on the ways ICD-10-CM is different, such as: • Number of codes (69,000+) • Length of the codes • The “look” of the codes • Level of specificity • Increased documentation requirements • But wait! The indexes will be structured very much the same as in ICD-9-CM.

25. Format of ICD-10-CM • Two main parts: Alphabetic Index & Tabular List • Alphabetic Index • Alphabetical list of terms and their corresponding codes • Index to Diseases and Injury • Neoplasm Table • Table of Drugs and Chemicals • Index to External Causes of Injury Coding Tip: The “-” at the end of an index entry indicates that additional characters are required – need to look further!

26. Tabular List • Chronological list of codes divided into chapters (21) based on body system and/or condition. Further divided into categories and subcategories which may be either letters or numbers. • For some chapters, the body or organ system is the axis of the classification. • Diseases/conditions of the sense organs (eyes and ears) have been separated from the Nervous System diseases/conditions and have their own chapters in ICD-10-CM. • Certain diseases have been reclassified (or reassigned) to a more appropriate chapter in ICD-10-CM.

27. More on Tabular List… • The final character in a code may be either a letter or a number. • Utilizes dummy place holders, always letter “x”. • Is not case-sensitive (upper/lower case) • A dummy “x” is used as a 5th character place holder for certain 6 character codes to allow for future expansion. • Certain categories have 7th character extensions (fractures/injuries/obstetrics). The extension is required for all codes within the category, or as the notes in the tabular instruct.

28. Episode of Care (7th Character Extensions) • Found predominately in 2 chapters: • Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes) • Chapter 15 (Pregnancy, Childbirth and the Puerperium) • Injuries/Poisonings: • Episode of Care: Designates the episode of care as initial, subsequent or sequela • Pregnancy/Childbirth/Puerperium: • Provides additional information about the fetus: • Used to identify certain complications of pregnancy with multiple gestation to identify which fetus(es) is(are) affected by the condition indicated by the code.

29. Injuries & Poisonings • ALL diagnoses within this category will require a 7th character (episode of care). • Tabular list will identify which diagnosis codes will need this final character in the code. • Provides a shaded boxto let you know the applicable 7th characters for the code. • Have to “build” the characters to get to the final spot in the code (7th character).

30. ICD-10-CM (Injury and External Cause Extensions) AInitial encounter DSubsequent encounter SSequela (disease progression/late effect) • Coders will need to look for the episode of care. Is this the patient’s 1st visit for treatment or is it for routine follow-up? Is it clearly documented in the medical record?

31. “Initial” Encounter (A) • Period when a patient is receiving ‘active’ treatment for an injury, poisoning or other consequences of an external cause. • “A” may be assigned on more than 1 claim. • Patient is seen in the ER for a head injury that first is evaluated by the ER physician. If the ER physician requests a CT scan that is subsequently read by a radiologist and/or neurologist, the 7th character “A” for initial is used by all 3 physicians and also reported on the ER claim by the hospital.

32. “Subsequent” Encounter (D) • Occurs after the active phase of treatment, when patient is receiving routine care during a period of healing or recovery. • Examples of “subsequent” care: • Cast change or removal • External or internal fixation removal • Medication adjustment • Follow-up visits following fracture treatment

33. Coding Change! • Today we code the ‘after care’ code as the principal diagnosis, i.e., V57.1 (physical therapy), etc. • In ICD-10-CM we will have to report the acuteinjury code with the correct 7th character, i.e., “D”, etc. to identify that it is a ‘subsequent’ encounter. • What is on your order today? Injury diagnosis or just order for PT?

34. “Sequela” Encounter (S) • Assigned for complications or conditions that arise as a direct result of an injury. • Example: Scar resulting from a burn • When using extension “S”, you will code boththe injury that precipitated the sequela and the sequela itself. • There is no time limit on when a sequela code can be used. • Coding Tip!Sequence the specific type of sequela, i.e., scar first, followed by the injury code, i.e., burn as the secondary diagnosis.

35. Fracture Coding

36. What Do We Need? • Coders will need the following to code a fracture in ICD-10-CM: • Displaced or non-displaced • Open or closed • Laterality (left vs. right vs. bilateral) • Specific bone and location of the bone • Distal, proximal, mid-shaft, etc. • Encounter • Initial, subsequent, sequela

37. Fracture Diagnosis Codes Have Their Own 7th Characters • Identifies if the fracture is open or closed for an initial encounter, or if a subsequent encounter is for routine healing, delayed healing, nonunion, malunion, and/or sequela. • Fracture extensions: • A (Initial encounter for closed fracture) • B (Initial encounter for open fracture) • D (Subsequent encounter for fx with routine healing) • G (Subsequent encounter for fx with delayed healing) • K (Subsequent encounter for fx with nonunion) • P (Subsequent encounter for fx with malunion) • S (Sequela)

38. Fracture 7th Character Extensions • Initial encounter for closed and open fractures • Use while the patient is receiving “active” treatment for the fracture • 7th Character Extensions: • A ► Closed fracture • B ► Open fracture type I (one) or II (two) or unspecified • C ► Open fracture type III (three) • Examples of “active” treatment: • Surgical treatment • Emergency Department encounter • Evaluation & treatment by a new physician

39. “Fracture” Subsequent Encounter • Subsequent encounter for open and closed fractures: • Used for encounters afteractive fracture treatment has been completed and the patient is receiving routine care during the healing or recovery period. • Closed Fracture 7th Character Extensions: • D ► Routine healing or aftercare • G ► Delayed healing • K ► Nonunion • P ► Malunion

40. What is Gustilo-Anderson Scale? • Gustilo-Anderson classification identifies the energy, soft-tissue damage, and the degree of contamination in “open” fractures – may be new to coders and orthopedic physicians. • Type I: Wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (low energy injury) • Type II: Wound is longer than 1 cm, not contaminated, and w/o major soft tissue damage or defect (low energy injury) • Type III: Wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.

41. More Information… • Purpose of the fracture classification system in the clinical setting is to allow communication that infers fracture morphology and treatment parameters. • Important to educate providers on the use of this scale for the specific documentation necessary in ICD-10-CM. • Make sure to look at each 7th character box in the fracture section, as not all categories utilize the Gustilo classification because it is not for all bones or all types of fractures.

42. Additional Fracture Note! • There are no combination codes for fractures involving both the radius and ulna in ICD-10-CM. • Each fracture will be coded separately.

43. Clavicle Fracture • 24 choices for fracture of clavicle (only 1 in ICD-9-CM) • Documentation must include: • Laterality • Displaced (anterior or posterior displacements) • Nondisplaced • Location: sternal end, shaft, lateral end, unspecified • 7th character extension • Example: S42.011B (Anterior displaced fracture of sternal end of right clavicle initial encounter open fracture)

44. Examples of ICD-10-CMEmergency Room • I10 Essential (primary) hypertension • S01.02xA Laceration with foreign body of scalp, initialencounter • S01.02xD Laceration with foreign body of scalp, subsequent encounter • S02.2xxA Fracture of nasal bones, initial encounter for closed fracture • H65.01 Acute serous otitis media, right ear • H65.02 Acute serous otitis media, left ear • H65.03 Acute serous otitis media, bilateral

45. Quirky ICD-10-CM Codes On any given day, anything can happen! • W17.82xA Fall from (out of) grocery cart, initial encounter • V94.4xxA Injury to barefoot water-skier, initial encounter • W61.43xA Pecked by turkey, initial encounter • Y93.C2 Activity, handheld interactive electronic device, i.e., cellular phone

46. Cross Walking - GEMs • CMS has created GEMs (General Equivalence Mappings) to assist hospitals with cross walking ICD-9-CM ►ICD-10-CM/PCS “forward mapping” & ICD-10-CM/PCS ◄ ICD-9-CM “backward mapping”. The correlation between the 2 code sets for some codes is fairly close, but not a straight correlation for others, i.e. OB, etc. • Not always 1 to 1 crosswalk from ICD-9-CM to ICD-10-CM (www.cms.gov/ICD10/11b15_2013_ICD10PCS.asp) • Available on CMS’s website

47. GEMs

48. ICD-10-CM Code Structure

49. ICD-10-CM Code Structure • 1st character is always an alphabetic letter. All the letters of the alphabet are used except for the letter “U” which has been reserved for the provisional assignment of new diseases & uncertain etiology (U00-U49) & for bacterial agents resistant to antibiotics (U80-U89). • ICD-10-CM codes may consist of up to seven characters, with the 7th character extensions representing ‘visit’ encounter or sequela for injuries and external causes.

50. ICD-10-CM Format X X XX X XX