ICD-10-CM An Introduction 2012

1. ICD-10-CM An Introduction 2012 Bobbi Buell, MBA onPoint Oncology LLC 800-795-2633 bbuell@onpointoncology.cim

2. Main Objective • Create an awareness of ICD-10-CM. • Start to consider the impact the conversion to ICD-10 will have on your operations. • Start to understand what it means and does not mean in Oncology.

3. Latest Update • The AMA asked HHS to postpone or cancel ICD-10. • CMS intimated that the deadline would be postponed. • HHS is in the process of making a rule as to how the postponement will work.

4. ICD-9-CM vs. ICD-10-CM

5. Why is ICD-9 Being Replaced? • ICD-9-CM is out of date and running out of space for new codes. • Lacks specificity and detail • No longer reflects current medical practice • ICD-10 is the international standard to report and monitor diseases and mortality, making it important for the U.S. to adopt ICD-10 based classifications for reporting and surveillance. • ICD codes are the core elements of HIT systems, conversion to ICD-10 is necessary to fully realize benefits of HIT adoption.

6. Coding Process Remains the Same • ICD-10-CM code book retains the same traditional format • Index • Tabular • Process of coding is similar • Look up a condition in the Index • Confirm the code in the Tabular

7. Major Differences Between ICD-9-CM and ICD-10-CM

8. Comparison of ICD-9-CM and ICD-10-CM ICD-9-CM CODE ICD-10-CM CODE A - Category of code B - Etiology, anatomical site, and/or severity C - Extension 7th character for obstetrics, injuries, and external causes of injury • A - Category of code • B - Etiology, anatomical site, and manifestation A A B C B

9. ICD-9-CM Structure – Format Numeric or Alpha (E or V) Numeric X V 5 E 4 X 1 X 4 X 0 0 X . . Category Etiology, Anatomic Site, Manifestation 3 – 5 Characters

10. ICD-10-CM Structure – Format Alpha (Except U) Additional Characters 2 - 7 Numeric or Alpha . . X X X A M A X S 3 X 2 X X 0 1 0 Added code extensions (7th character) for obstetrics, injuries, and external causes of injury Category Etiology, Anatomic Site, Severity 3 – 7 Characters

11. Comparison of ICD-9-CM and ICD-10-CM Codes: 707.0 Pressure ulcer 707.00 - unspecified site 707.01 - elbow 707.02 - upper back 707.03 - lower back 707.04 - hip 707.05 - buttock 707.06 - ankle 707.07 - heel 707.09 - other site Code Examples: L89.131 – Pressure ulcer of right lower back, stage I L89.132 – Pressure ulcer of right lower back, stage II L89.133 – Pressure ulcer of right lower back, stage III L89.134 – Pressure ulcer of right lower back, stage IV L89.139 – Pressure ulcer of right lower back, unspecified stage L89.141 – Pressure ulcer of left lower back, stage I L89.142 – Pressure ulcer of left lower back, stage II L89.143 – Pressure ulcer of left lower back, stage III L89.144 – Pressure ulcer of left lower back, stage IV L89.149 – Pressure ulcer of left lower back, unspecified stage L89.151 – Pressure ulcer of sacral region, stage I L89.152 – Pressure ulcer of sacral region, stage II … L89.90 – Pressure ulcer of unspecified site, unspecified stage

12. New Features of ICD-10-CM • 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

13. New Features of ICD-10-CM • Added extensions for episode of care • Inclusion of trimester in obstetrics codes and elimination of fifth digits for episode of care • Expanded detail relevant to ambulatory and managed care encounters • Inclusion of clinical concepts that do not exist in ICD-9-CM • Changes in timeframes specified in certain codes

14. Useful in Cancer?? • Laterality – Left Versus Right • C50.1 Malignant neoplasm, of central portion of breast • C50.111 Malignant neoplasm of central portion of right female breast • C50.112 Malignant neoplasm of central portion of left female breast

15. Useful In Cancer??? • ICD-9-CM • 143 Malignant neoplasm of gum • 143.0 Upper gum • 143.1 Lower gum • ICD-10-CM • C03 Malignant neoplasm of gum • C03.0 Malignant neoplasm of upper gum • C03.1 Malignant neoplasm of lower gum

16. Arrangement of Volumes of ICD-10 • Volume 1: Main classifications • Volume 2: Instruction/ Guidance to users • Volume 3: Alphabetical Index • ICD-10 has 21 chapters against 17 Chapters in ICD-9

17. Chapters of ICD-10 • Chapters I to XVII: Diseases and other morbid conditions • Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified. • Chapter XIX: Injuries, poisoning and certain other consequences of external causes. • Chapter XX: External causes of morbidity and mortality, • Chapter XXI: Factors influencing health status and contact with health services.

18. General Equivalence Mappings

19. What are GEMs? • “GEMs” stands for General Equivalence Mappings • The CMS and the CDC created GEMs to ensure consistent national data when the U.S. adopts ICD-10. • The GEMs will act as a translation dictionary to bridge the “language gap” between the two code sets and can be used to map an ICD-9 code to an ICD-10 code and vice versa.

20. Purpose of GEMs • Designed to give all sectors of the healthcare industry that use coded data the tools to: • 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

21. Not a Substitute for Coding • The GEMs should not be used as a substitute for learning how to use the ICD-10-CM code sets. • “GEMs are not a substitute for learning ICD-10-PCS and ICD-10-CM coding. They’ll help you convert large data sets.” • Mapping simply links concepts in the two code sets, without consideration of context of specific patient information, whereas coding involves assigning the most appropriate code based on documentation and applicable coding guidelines.

22. Why a GEM Won’t Always Work • A clear one-to-one correspondence between an ICD-9 or ICD-10 code is the exception rather than the rule. • ICD-9 codes: 414.01 Coronary atherosclerosis of native coronary artery and 411.1 Intermediate coronary syndrome (unstable angina) • ICD-10 code :I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina • There are situations when a code in the target system does not exist • T503x6A Underdosing of electrolytic, caloric and water-balance agents, initial encounter

23. Forward and Backward Mapping Forward Mapping Backward Mapping

24. GEMS Example #1

25. GEMS Example #2

26. GEMS #3

27. GEMS Example #4

28. Neoplasm Guidelines

29. Neoplasm Guidelines • Many guidelines are the same, but there are differences. We try to cover those today. • To properly code a neoplasm, it is necessary to determine (not too different) whether: • It is benign, malignant, benign, in situ or of uncertain behavior; • If the malignant, any secondary or metastatic sites should be identified. • To code properly the Index Neoplasm Table should be accessed EXCEPT: • If the histology is mentioned in the code descriptor, e.g. adenoma or sarcoma

30. Neoplasm Guidelines • Again, if the encounter is strictly for chemo, immunotherapy, or Radiation, those codes should be coded as the principal diagnosis with the neoplasm as a secondary. No big change from today. • The secondary neoplasm should be designated as the primary, if treatment is directed there.

31. Neoplasm Complications • Anemia associated with malignancy is coded with the malignancy sequenced first and anemia second. This is a major departure---we shall see what payers do with this. • Anemia associated with chemo or immunotherapy is coded with the adverse event code first and anemia second, then the malignancy. • Management of anemia associated with radiation is coded with anemia first, malignancy second, and Y84.2 third which is radiation causing an abnormal reaction in the patient.

32. Neoplasm Complications • Dehydration is coded first with the neoplasm second. • And, then of course, there is the confusing “HISTORY OF” guideline---which is not changed in ICD-10. • Signs, symptoms, and abnormal findings cannot be used to replace malignancies as primary diagnosis, except as noted.

33. More Neoplasm Guidelines • Malignancies of two or more contiguous sites should not be coded as one or the other without asking the physician. • For disseminated neoplasms with no known PRIMARY or SECONDARY sites are coded to C80.0. This should not be used if either is known. • Cancer of unknown primary (CUP): CO80.1 Malignant (primary) neoplasm, unspecified, equates to Cancer unspecified. This code should only be used when the primary cannot be determined.

34. More Neoplasm Guidelines • http://www.cdc.gov/nchs/icd/icdcm.htm

35. Preparing for ICD-10

36. ICD-10 Implementation Plan Checklist: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht Year 2009/ 2010 2011 2012 2013 Phase I Awareness and ImpactAssessment Phase II Preparing for Implementation Phase III Go Live Preparation Phase IV Post – Implementation

37. Clinical Documentation • The increased specificity of the ICD-10 codes requires more detailed clinical documentation in order to code some diagnoses to the highest level of specificity. • There are “unspecified” codes in ICD-10-CM for those instances when medical record documentation is not available to support more specific codes. • The benefits of ICD-10 can not be realized if non-specific codes are used rather than taking advantage of the specificity ICD-10 offers.

38. Improving Documentation • Conduct medical record documentation assessments • Evaluate records to determine adequacy of documentation to support the required level of detail in new coding systems • Implement a documentation improvement program to address deficiencies identified during the review process • Educate providers about documentation requirements for the new coding system through specific examples • Emphasize the value of more concise data capture for optimal results and better data quality

39. Physician Training • DHHS agrees that some physicians will want intensive training on ICD-10 but some will seek “awareness training”. • Nolan study estimates 8 hours of intensive physician training • Nachimson Advisors, LLC study predicts 12 hours of physician training in both the code set and documentation procedures. • AHIMA believes most physicians would want no more than 4 hours of training.

40. Solo Practitioner Or Small Group (2-10) Practice Implementation Planning • Organize Implementation Effort • Establish Communication Plan • Conduct Impact Analysis • Contact System Vendors • Estimate Budget • Implementation Planning • Develop Training Plan • Analyze Business Processes • Education and Training • Policy Change Development • Deployment of Code • Implementation Compliance

41. Organize Implementation Effort • Enlist staff person (coder, biller, manager) to oversee effort who will be key point person • Prepare information to share with other providers and staff • Identify work and scope for implementation • Should be a team effort involving all medical practice staff and the staff needs to believe that this will actually happen.

42. Organize Implementation Effort • Examine the level of coding you have in your practice—who is certified? Who has experienced a change before, e.g. E/M, admin codes? Who is equipped to deal with this? • Look at all areas that will impact practice and identify each one that will be affected • Practice management system • Electronic Medical Record (EMR), if applicable • Superbills • Clinical areas and pharmacy • Schedule regular meetings to share information with physicians and discuss progress and barriers of implementation.

43. Establish Communication Plan • How will point person communicate with all staff? • Most practices communicate via meetings or memos • No need to change method of communications • Develop regular schedule for ICD-10 progress efforts • Monthly until 6 months prior to implementation • Bi-weekly thereafter • Include information, publications, and articles • Document all meetings and what was discussed herein and make sure you are tracking with your plan.

44. Conduct Impact Analysis • Take this step prior to development of budget • In depth look at resources required for implementation • Maybe check for a little process improvement • Helps determine what costs might be involved as well as work processes • What systems will be affected? • Practice management • Coding look up programs (if applicable)/CDMs/Superbills • EMR • Remittance systems • Hardware space • What are the potential costs involved?

45. Conduct Impact Analysis • Develop reasonable timeline that can be accomplished in your practice • Map out a project plan on a simple Excel spreadsheet with benchmarks and status of completion • Managers and/or coders should get physician approval for the project plan and its impact on the practice. Make sure you show and tell them the level of work it will take.

46. Conduct Impact Analysis • Coding and documentation go hand in hand • ICD-10 is based on complete and accurate documentation, even where it comes to right and left or episode of care. • ICD-10 should impact documentation as physicians are required to support medical necessity using appropriate diagnosis code—this is not an easy situation, so physicians need to know from the outset that they need training. • Will not change the way a physician practices medicine • Complete and accurate documentation will continue to be important in 2013 (or whenever) as it is today

47. Contact System Vendors • Will they be able to accommodate the need to move to ICD-10? Really? Were they ready for 5010? • What plans do they have in place for implementation? • Will they have new tools in place to help you with ICD-10? Will these have a cost? Will they create savings? • When will they have software available for testing? • Will we need new hardware or is current hardware sufficient?

48. Estimate Budget • Budget considerations should include • Hardware costs • Software costs and licensing • Training • Physician Query • Productivity losses • Jeopardy to cash flow • Some notable budget estimates follow this slide…

49. ICD-10 Implementation $: AMA (c) onPoint Oncology LLC

50. ICD-10 Implementation $$: MGMA (c) onPoint Oncology LLC