ICD-10 Overview Program Integrity Code Structure & Definition GEMS, Translation & Dual Processing Claims Management Provider Communications Analytics & IT Infrastructure ICD-10 Testing Post Implementation Impacts & Opportunities Mapping & Policy Remediation ICD-10 for Provider Administrative Staff ICD-10 for Clinicians ICD-10 for Clinicians January 27-30, 2015 Puerto Rico ICD- 10 Implementation Assistance Site Visit Training segments to assist Puerto Rico with ICD-10 transition
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ICD-10 for Clinicians January 27-30, 2015 Puerto Rico ICD-10 Implementation Assistance Site Visit Training segments to assist Puerto Rico with ICD-10 transition.
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ICD-10 Overview
Program Integrity
Code Structure & Definition
GEMS, Translation & Dual Processing
Claims Management
Provider Communications
Analytics & IT Infrastructure
ICD-10 Testing
Post Implementation Impacts & Opportunities
Mapping & Policy Remediation
ICD-10 for Provider Administrative Staff
ICD-10 for Clinicians
ICD-10 for Clinicians
January 27-30, 2015
Puerto Rico ICD-10 Implementation Assistance Site VisitTraining segments to assist Puerto Rico with ICD-10 transition
2
Agenda
Health care data in a changing environment ICD-10 basics Clinical documentation – the key to data and good care Getting specific Clinical case examples Measuring coding patterns Reducing the burden of data capture
Source: Health Affairs
Japan – 8.5% of the GDP (2008)US – 16% of the GDP (2008)
Healthcare ExpendituresUnsustainable
Japa
n
Ital
y
Spai
n
U.K
.
Aus
tral
ia
Swed
en
Bel
gium
Fran
ce
Ger
man
y
Aus
tria
Net
herlan
ds
Can
ada
Switz
erla
nd
Nor
way
U.S
.A.
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$2,729 $2,870 $2,902$3,129
$3,353 $3,470$3,677 $3,696 $3,737
$3,970 $4,063 $4,079
$4,627$5,003
$7,538
Total Health Expenditure per Capita, U.S. and Selected Countries, 2008
Per
Cap
ita S
pen
din
g -
PPP A
dju
sted
Source: Organisation for Economic Co-operation and Development (2013), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2013).
Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.
• US 38th in life expectancy• Japan 1st in life expectancy
• US infant mortality is approximately 3 times Japan
ICD-10 international version– Adopted by WHO in 1990– Most countries other than the US currently use ICD-10– ICD-10 (International version) ~ 12,500 diagnostic codes– ICD-10 used for mortality reporting in the US - 1999
ICD-10-CM (US version) – ~ 69,000 diagnostic codes– Final rule published – 2009– Compliance date – Oct 1, 2015
ICD-10-PCS– ~72,000 codes– Not part of an international standard– Inpatient procedures only– Compliance date – Oct 1, 2015
Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
All codes for femur fractures = 16 All codes for femur fractures = 1530
Source: Health Data Consulting
Source: Health Data Consulting
Nature of the ChangesDiagnosis Codes – Clinical Example
10
A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].
ICD9 Code Description
42979Certain sequelae of myocardial infarction, not elsewhere
classified, other
ICD10 Code Description
I233Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Source: Health Data Consulting
Nature of the ChangesDiagnosis Codes – Clinical Example
11
A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].
ICD9 Code Description
42979Certain sequelae of myocardial infarction, not elsewhere
classified, other
ICD10 Code Description
I233Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Source: Health Data Consulting
Why are there so many diagnosis codes?
34,250 (45%) 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
~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’
Clinical / Business/Coding RelationshipsCreating a new working relationship
1. The role of the clinician is to document as accurately as possible the nature of the patient conditions and services done to maintain or improve those conditions.
2. The role of the coding professional is to assure that coding is consistent with the documentation
3. The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts.
If there is sufficient information available to more accurately define the condition
For basic concepts such as:– Laterality (Right, Left, Bilateral, Unilateral)– Anatomical locations– Trimester– Type of diabetes– Known complications or comorbidities – Description of severity, acute or chronic or other known parameters…
Where care is implemented that demands a more specific level of detail
At specialty level that should be able to define the detail required
Suspected, probable, likely and other condition qualifiers
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Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
The use of terms like “suspected”, “probable”, “likely” and other qualifications of conditions have different guidelines for coding in the inpatient vs. the outpatient setting.
Medical Scenario: A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s fracture] on the [right] that was exposed through an [open wound] with [minimal opening and minimal tissue damage]. The fracture has [not healed after 6 months].Though not explicitly stated in this scenario certain expressions imply other concepts:“Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extra-
articular], [displaced]
“minimal opening and minimal tissue damage” >> [Gustilo classification I]
Smoking– Exposure to environmental tobacco smoke– History of tobacco use– Occupational exposure to environmental tobacco smoke– Tobacco dependence– Tobacco use