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• Now is the time to prepare for ICD-10!• The differences are critical – not just another coding change.• Define facility or practice specific needs and PLAN• Assessment will provide outline for achievement of goals• Prepare tasks / activities for implementation
– Designate “owner” for completion of all required tasks– Staff members, payors, vendors, physicians
• Lead!• Manage progress, and “re-group” when necessary• Reach ICD-10 “readiness” by September 30, 2015!• Use September 1 – 30 for “contingency” planning
• ICD-10 is the updated version of the ICD-9 codes:– Diagnoses for all providers (ICD-10-CM)– Inpatient hospital procedures (ICD-10-PCS)– In addition to coding – ICD-10 in the US will determine
reimbursement!• ICD-10-CM originated with the World Health Organization
(WHO).• Several countries have taken this code set and modified it for
use in their medical systems. • The US, through the National Center for Health Statistics, has
developed the ICD-10-CM (or clinical modification) of the code set for use in this country.
• The Centers for Medicare and Medicaid Services has created a new code set, ICD-10-PCS, for use with inpatients.
• These code sets are considered classification code sets.
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 IL89.132 – Pressure ulcer of right lower back, stage IIL89.133 – Pressure ulcer of right lower back, stage IIIL89.134 – Pressure ulcer of right lower back, stage IVL89.139 – Pressure ulcer of right lower back, unspecified stageL89.141 – Pressure ulcer of left lower back, stage I……
– M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture
• The appropriate 7th character is to be added to each code from category M80:
A - initial encounter for fractureD - subsequent encounter for fracture with routine healingG - subsequent encounter for fracture with delayed healingK - subsequent encounter for fracture with nonunionP - subsequent encounter for fracture with malunionS - sequela
• Requires changes to almost all clinical and administrative systems
• Requires changes to business processes• The updated code sets will allow, and in fact will require,
significant changes in the way services are reimbursed, and in the way that coverage (medical necessity ) is determined for services.– National Coverage Determinants (NCD’s) and Local
Coverage Determinants (LCD’s) are not slated to be published until sometime in the spring.
• Will enable significant improvements in patient care management, public health reporting, research, and quality measurement
• Let’s now turn our attention to the ICD-10-PCS procedure code set.
• This is a new code set developed in the United States by the Centers for Medicare and Medicaid Services (CMS). – It is not used outside of this country.– It is not related to the ICD-10-CM code set.
• This code set will only be used to report procedures on inpatient hospital claims.
Here is an example of an ICD-10-PCS code and how it differs from ICD-9.• The new code for Laparoscopic appendectomy uses the 7
position structure, with each position having a specific meaning. • A code for a similar removal of a different body part should
change only in the 4th position.• ICD-9-CM (sample code) – 47.01 Laparoscopic appendectomy• ICD-10-PCS (sample code) – Laparoscopic appendectomy
0DTJ4ZZ– 0 - Medical and Surgical Section– D - Gastrointestinal system– T - Resection (root operation)– J - Appendix (body part)– 4 - Percutaneous endoscopic (approach)– Z - No device– Z - No qualifier
• The practice of medicine has changed dramatically since ICD-9 was published
– Many new medical conditions discovered– Many new treatments developed– Many new types of medical devices have been placed into service– Has run out of room to allow for code expansion
• The ICD-9 code set was not designed to capture all of these changes, and has become bogged down with many types of modifications to attempt to capture information.
• There is an increased emphasis on the use of reported medical information for a multitude of tasks. We look to manage individual care, to place patients in special targeted programs, to track population disease patterns, and identify biological threats.• We are changing the way we look at providers, attempting to measure not only cost of care, but quality of care in an attempt to manage health care expenditures. • Payors are asking providers to justify increasing health care costs by showing improved outcomes and improved health of patient populations.
– ICD-10-CM/PCS allows for greater transparency to satisfy all of our reporting requirements and scrutiny outlined above.
• Systems used to document clinical findings will be modified or replaced to accommodate new coding language
• Any treating provider who documents in your legal medical record will impacted, required to document to the highest degree of specificity
• Any treating provider who refers to your facility will be impacted, required to document to the highest degree of specificity all orders and referrals– Failure to be specific will result in costly rework and
• Claims for all outpatient and physician services, and hospital inpatient procedures provided on or after October 1, 2015, must use ICD-10-CM diagnosis and inpatient procedure (ICD-10-PCS) codes. Claims that do not use ICD-10 diagnosis and inpatient
procedure codes cannot be processed and paid!• It is important to note, however, that claims for services and
inpatient procedures provided before October 1, 2015, must use ICD-9 codes even if they are submitted after the compliance date.
• Consider the need to start dual coding ICD-9 and ICD-10 in June – July 2015.
implementation process (this committee is responsible for overseeing all of the steps in the ICD-10 transition process, but may designate other individuals to complete specific tasks).
Interviews of clinical and financial leadersSurveys of team members who perform processesFacility walkthroughsDocumentation ReviewIT System inventory and review
• Formulate transition strategies and identify goals. • Develop organization’s ICD-10 implementation strategy and
identify actions, persons responsible, and deadlines for the various tasks required to complete the transition.
• Develop communication plan for business associates and other external entities.
• Software modifications (costs for in‐house as well as vendor system changes)– Education (both coding staff as well as other staff members
needing education)– Hardware/software upgrades– Testing related costs– Staff time
• Temporary or contract staffing to assist with increased work resulting from the transition, such as coding/billing backlogs, IT support, or coding accuracy review– Consulting services to assist with transition– Report redesign (and development of new reports)– Reprinting of paper forms
To get a facility or physician practice started on ICD-10 Preparation – conduct a detailed “patient flow” Impact Assessment –
• Follow a patient through an outpatient service / visit
Identify each revenue cycle process that utilizes a diagnosis
code
Admissions and Scheduling (Patient Access)• Pre-patient scheduling• Physician order receipt and review • Insurance verification, authorization, medical
• 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.• Unspecified codes = lower payments• May not meet medical necessity for services
• 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.
• 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
• The DHHS recommends inpatient/hospital coders receive 50 hours of training and outpatient coders receive 10 hours of training.
• AHA/AHIMA anticipates that a maximum of 16 hours of training may be sufficient for experienced coding professionals on ICD-10-CM only.– 6 hours learning the fundamentals (structure, coding
conventions, guidelines and how ICD-10 is different)– 6 hours in more intensive training applying the conventions
and guidelines– 4 hours practicing applying codes to typical encounters
Provider Impacts• We rely on providers to accurately code claims so that
processing decisions can be made. • First, providers must learn the new code set. • The first step to accurate coding is for the documentation to
reflect what the provider has observed or provided. • Coding must be supported by medical documentation. • Studies of the required documentation have indicated that
more documentation is required to support the increased specificity of the code set.
• We should expect providers to have to spend about 15% more time on asking questions, observing, and documenting their findings to support the ICD-10-CM code set.
• Even with increased documentation, we can expect, with better coding, an increase in denials or pending claims, and the need for providers to submit additional documentation to support the codes.
• As we replace ICD-9 codes with ICD-10 codes, health plans (Medicare and Medicaid State included) will be revising coverage policies, medical review procedures, and plan design and reimbursement schedules to take advantage of the better information being collected.
• It is expected that providers will need to change their processes to adapt to the changes, and that there may even be a need to discuss treatment changes with patients.
• For example, certain conditions may not be covered to the same extent if they can be better identified in terms of specificity.
• Documentation of diagnoses and procedures– Codes must be supported by medical documentation– ICD-10-CM codes are more specific– Requires more documentation to support codes– Expect a 15% increase in documentation time (per AAPC)– Revenue Impacts of specificity
o Denialso Additional Documentation
• Coverage and Payment– New coding system will mean new coverage policies, new
medical review edits, new reimbursement schedules– Changes will be made to accommodate increased specificity– May need to discuss changes with patients
• Billing and Eligibility Transactions– Updated transactions include support for ICD-10– New codes mean more specificity– How smooth is the transition?– Expect increased reject, denials, and pends as both
plans and providers get used to new codes• Laboratory and Pharmacy
– Will need specific ICD-10-CM codes for laboratory orders
– Expect coverage changes– Need to support the tests/drugs ordered– Transition issues for prior authorizations
• There is an additional transition issue for prior authorization or prescription refills.
• If the original order or prescription was done with an ICD-9 code (prior to Oct 1, 2015), it must be updated for any service delivered on or after Oct 1, 2015.
• The lab or pharmacy must be able to submit an ICD-10 code once a service is provided on or after Oct 1, 2015.
• Quality Measures / Pay for Performance (P4P)• New measures need to be determined based on ICD-10-CM
codes– Must renegotiate with provider groups– Difficult to measure impact of change – Is it because of code set
Implementation and Operational Steps• Training – not just coders
– Program staff– Administrative staff– Systems staff
• Business Process Analysis– Where do you use diagnoses/inpatient hospital procedures?– What are the interfaces that may need to be changed?– What databases need to be changed?
• This is a long-term project, which will consume considerable resources. – Planning is critical. – Initial estimates say that it will take all of the time between
now and Oct 1, 2015, to effectively implement ICD-10. – A structured Work Plan is critical.
• More precise coding and documentation, including signs, symptoms, and risk factors, that will permit tracking of many new diagnoses and procedures and result in fewer rejected claims for reimbursement
• Opportunities for improved benchmarking to allow Mayo Clinic compare itself to other providers and health care institutions in the areas of quality, safety, value, and service
• Detailed data availability that enhances quality metrics, patient safety and compliance
• Improved disease epidemiology that will directly impact public health
• Better data mining to improve predictive accuracy • Organizational monitoring and performance that supports
determination of episodes of care and high-risk-pool patients.
• Diagnoses and procedure codes impact virtually every system and business process in plan and provider organizations, with significant impacts on reimbursements