ICD-10 ORIENTATION IN SNF’S Rhonda Anderson, RHIA Anderson Health Information Systems, Inc.

ICD-10 ORIENTATION IN SNF’S

Rhonda Anderson, RHIA

Anderson Health Information Systems, Inc.

• Participants will identify:– Dates for New ICD-10– Documentation support– New terms encounter principal diagnosis re-

defined– Some general coding guidelines

Objectives

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• January 15, 2009 Final Regulation Released

• EXCHANGE the ICD-9 for the ICD-10 on October, 1, 2014

Final Regulation

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• ICD-10-CM = Clinical Modification, ICD-10 CM – applies to SNF, Intermediate Care, Physician’s Offices, Clinics, Dialysis, Home Health, other health care settings who bill Medicare, MediCal or Private Ins.

• ICD-10 PCS = Procedural Code System (used for Acute Hospital procedures, operations

ICD-10 “Has Two Parts”

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• Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)

• HIPAA has evolved from 1996 to HITECH which relates to security and breaches

• HIPAA Transactions 5010 went into effect October 2011

• HITECH – HIPAA Privacy and Security final rule was released January 2013

HIPAA

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• All inpatient and outpatient facility visits as well as freestanding providers and ancillary services “that means all of us really” who provide services and bill for them under Medicare, Medi-Cal and private insurances.

Who Is Affected??

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• HIM personnel• Nurse managers• MDS nurses• Nursing unit staff/clerks• Case managers• Administration• Therapy personnel (PT/OT/ST)• Billing/admitting personnel• Medical Directors/Providers

Various roles that are affected

• Corporate Office personnel• Compliance Office personnel working with

ICD coding• Corporate administrative departments

More affected roles...

• More specific coding system• Reflects medical advancements• Standardization, UK implemented in 1995,

used worldwide• The United States is the only industrialized

nation that has not yet implemented ICD-10

Benefits

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• The guidelines in the ICD-10 manual developed for the provider and the coder….(person who may review the documentation and determine if code is accurate.

• Consistent, complete documentation in the medical record is a major emphasis.

What Does This Mean??

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• ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings

• Current Procedural Terminology (CPT) is still used for the Physician, and some services, but they must have a diagnosis that is ICD-10 compliant

Key Highlights

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• Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services.

Key Highlights -2

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• 3-5 characters in length• Approximately 14,000 codes• First digit may be alpha or numeric• Digits 2-5 are numeric• Always at least three digits• Decimal placed after the first three

characters• Limited space for new codes

ICD-9-CM Diagnosis Codes

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• Lacks detail• Lacks laterality, difficult to analyze, dated,

non-specific and does not adequately define diagnoses needed for medical research

• Does not support interoperability because it is not used in other countries.

ICD-9-CM Diagnosis Codes -2

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• Index and Tabular list have the same hierarchical structure as ICD-9

• ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list.

ICD-10 CM Structure

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• ICD-9 V and E code supplemental classifications are incorporated into the main classification in ICD-10

• ICD-9 V codes are now Z codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services

• Postoperative complications have been moved to procedure-specific body system chapters

ICD-10 CM Structure -2

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• 3-7 characters in length and alphanumeric• 21 chapters (compared to 17 in ICD-9)• Approximately 68,000 codes• Digit 1 is always alpha, digit 2 is numeric;

digits 3-7 can be alpha or numeric• Decimal placed after the first 3 characters

ICD-10-CM Diagnosis Codes – Format & Structure

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• Codes that have applicable 7th character is considered invalid without the 7th character.

• Expanded codes• Flexible for adding new codes• Addition of placeholder “X”• Has laterality (right, left, lower, upper,

outer, etc.)

ICD-10-CM Diagnosis Codes – Format & Structure

• ICD-10 utilizes a placeholder character “x”• The “x” is used as a placeholder at certain

codes to allow for expansion– Categories T36-T50, poisoning and injury

codes T36.8X1D– Also, Pathological vertebral fracture due to

age-related osteoporosis, subsequent encounter with delayed healing M80.08XG

Example Of Placeholder “X”

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• For bilateral sites, the final character of the codes in ICD-10 indicates laterality:– C50.212 Malignant Neoplasm of upper-inner

quadrant of left female breast– H02.835 Dermatochalasis of left lower eyelid– I80.01 Phlebitis and Thrombophlebitis of

superficial vessels of right lower extremity– L89.213 Pressure Ulcer of right hip, Stage 3

*an unspecified site code is also provided should the site not be identified.

Example Of Laterality

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• Expanded Codes (injury, diabetes, alcohol/substance abuse, postoperative complications)

• E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease

Example Of Expanded Codes

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• Requires “use” of proper coding guidelines– Relies on the use of the guidelines and in our

case Skilled/ICF/IRF rules– ICD-10-CM Index – disease, injury and

external causes of Injury

ICD-10-CM Structure -

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– More combined codes, i.e. Diabetic retinopathy is one code

– More specificity, i.e. Alzheimer’s disease with specific details of early or late onset:

G30.0 Alzheimer’s with early onset

G30.1 Alzheimer’s with late onset

G30.8 Other Alzheimer’s disease

G30.9 Alzheimer’s disease, unspecified

ICD-10-CM Structure

• General rules for use of the classification independent of the guidelines– Alphabetic Index and Tabular List

• Alphabetic Index – List of terms and their corresponding code

• Tabular List – chronological list of codes divided into chapters based on body system/condition

• General coding guidelines are similar to ICD-9 with one additional guideline - laterality

Conventions For The ICD-10-CM

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• General rules for use of the classification independent of the guidelines– Format and Structure

• First character is always alpha• Three character category that has no further

subdivision is equivalent to a code• Subcategories are either 4 or 5 characters• Codes may be 3, 4, 5, 6 or 7 characters

Conventions For The ICD-10-CM -2

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• General rules for use of the classification independent of the guidelines– 7th Characters

• Certain ICD-10-CM categories have applicable 7th characters

• Required for all codes within the category or as instructed by the notes in the Tabular List

• Must always be the 7th character in the data field• If a code that requires a7th character is not 6

characters, a placeholder X must be used to fill in the empty characters

Conventions For TheICD-10-CM -3

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• Seventh character for a fracture– A = initial encounter for fracture– D = subsequent encounter for fracture with

routine healing– G = subsequent encounter for fracture with

delayed healing

Examples Of 7th Character

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– K = subsequent encounter for fracture with nonunion

– P = subsequent encounter for fracture with mal-union

– S = sequela

Examples of 7th Character

• Fracture Traumatic (abduction, adduction, separation)

• Acetabulum – anterior, displaced, illopubic S32.43__ or non-displaced S32.436_

• Acetabulum – dome (displaced) S32.48__• Fracture, lumbar vertebrae - (NOS)

S32.009_

FRACTURE

• Fracture of lst lumbar vertebrae – S32.01__–Wedge compression, stable burst,

unstable burst, other, or unspecified?–What type of fx is it?

FRACTURE

• Specificity improves coding accuracy and depth of data for analysis

• Detail improves the accuracy of data used in medical research

• Supports interoperability and the exchange of health care data between other countries and the U.S.

ICD-10-CM Diagnosis Codes -4

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• ICD-10 Code Format

Code Format

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ICD-9-CM Code Format ICD-10-CM Code Format

• Before we go further- do not despair…your vendor should prepare as much crosswalk as possible. There are “GEM” files.

• General Equivalence Mappings (GEM) – translation dictionary for diagnoses

GEM Files

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• There is NOT a one-to-one match between ICD-9 and ICD-10 codes

• We will talk about GEMS later and how to use them. Key to early review!

GEM FILES

• Identify your most common diagnoses.• Determine in advance some of the

documentation issues that you will have with the nurses and the physicians

• Discuss the specificity at the QA/PI meetings

• Keep staff informed as we progress

WHAT DOES THAT MEAN TO ME?

• The organization will need to know for all facilities or your facility what the most common diagnoses that are admitted and focus on those first

• Focus on the documentation to support those

• Focus on review of Acute Hospital Records more closely – Impact Inquiries

WHAT DOES THIS MEAN TO ME?

• Review for Medicare must be more specific

WHAT DOES THIS MEAN TO ME?

• Organization• Structure• Code composition• Level of detail• May consist of 3 to 7 digits, with the

seventh digit extensions representing visit encounter or sequel, as stated above.

ICD-10 & ICD-9 Differences

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• Includes full code titles for all codes (no reference back to common 4th and 5th digits)

• V and E codes are no longer supplemental classifications, as stated previously

ICD-10 & ICD-9 Differences -2

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• Inclusion notes further define, or give examples of the content of the category

• Exclusion notes – Excludes1 vs. Excludes2– Excludes1 means “not coded here”– Excludes2 means “not included here” may

need to use both the code and the excluded code together if patient has both conditions

• Code first and Use additional code notes are similar to ICD-9

Instructional Notes

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• Locating a code in the ICD-10-CM• Level of detail coding• Code/codes from A00.0 through Z99.8• Signs and symptoms are acceptable for

reporting purposes when a related diagnosis has not been established

General Coding Guidelines

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• These codes are secondary codes for use in any health care setting

• These codes capture how the injury happened (cause) or the intent

• Assign the external cause code with the appropriate 7th character for each encounter for which the injury or condition is being treated (initial, subsequent or sequela)

• What happened? V03 pedestrian injured in collision with car, pick-up truck or van

Chapter 20 – External Causes of Morbidity (V00-Y99)

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• Identify Corporate/Facility Steering Committees

• Identify who needs education/pretest• Knowledge is a key step in successful

implementation• Separate roles into two groups

– Group that primarily assigns codes – Group that primarily does NOT assign codes

ICD-10-CM Readiness

• A general knowledge of the code system and important differences between ICD-9 and ICD-10

• Use and/or knowledge level for an individual who uses coded data but is typically not assigning codes daily

• Application of the code set would be for those individuals who are routinely applying codes

Different knowledge levels defined as:

• An employee with experience in coding (who was trained on the job) is estimated to need 18 hours of cumulative education for ICD-10

• Education varies based upon the needs of each individuals skill level

• Intense coding education should NOT be initiated until three to six months before implementation

Education time

• Educational Tasks/Phase I– Learn about the structure, organization, and

unique features of ICD-10– Create an educational plan for all roles which

require education at various levels– Network with peers, access resources, and

read literature to identify transition issues and best practices

– Take advantage of education opportunities

Steps to take now

• Develop an implementation plan – Identify steps to prepare for implementation– Identify who should be involved in preparation– Develop time frames for implementation

phases• Develop a budget • Identify current systems that input, store and

utilize ICD data • Identify who is currently performing coding

General Implementation Task/Phase I

• Review current workflow to identify areas of impact and analyze opportunities for improvement (data in MDS, health record, and claim form)

• Common workflow examples are diagnostic tests (laboratory, radiology, therapy diagnoses and billing)

• Document improvement processes

General Implementation - 2

• Conduct detailed assessment of staff educational needs

• Assess knowledge of ICD-9 of current staff so that basic education can be obtained

• Assess areas of strength/weakness of coding staff in the biomedical sciences

• Evaluate barriers to preparing coding staff • Communicate the ICD-10 prep activities

throughout the organization

Educational Implementation Tasks/Phase I

• Listen to ICD-10 webcasts• Have coding staff take medical

terminology and Anatomy and Physiology courses (from local college or online)

Educational Resources

• Analyze current documentation practices, physician, nursing and therapy, to identify areas in need of improvement

• Identify current processes that may lead to poor data quality due to inadequate or outdated documentation practices

• Conduct detailed assessment of staff educational needs r/t documentation

Improvement Processes

• Talk with vendors and other business associates regarding their ability to be prepared to accept ICD-10 codes

• Determine the date of installation of facilities ICD-10 database software (must be utilized in a parallel manner with current ICD-9 code library)

• Do NOT uninstall ICD-9 database

General Implementation Tasks/Phase 2

• Continue to address impact of code change such as required system changes and report modifications

• Address legacy data issues in regards to how ICD-9 coded data is currently used

• Evaluate barriers or potential barriers to preparing staff for ICD-10

• Address timeline to begin coding current residents’ dx

General Implementation - 2

• Create an educational plan• Provide education on the fundamentals of

the ICD-10 systems• Provide opportunity for coders to refresh

knowledge of anatomy and physiology concepts

• Continue to have educational sessions with clinical staff in the facility to learn more about commonly reported conditions and dx r/t LTC facilities

Educational Tasks/Phase 2

• Install ICD-10 vendor software into the system to prepare for transition/perform software system testing

• ICD-9 legacy data must be maintained and available

• Closely monitor productivity and quality measures for issues r/t implementation of new code sets

General Implementation Tasks/Phase 3

• Continue educational plan, including intensive education for roles who primarily assign codes

• Practice ICD-10 coding of current records • Implement process for parallel coding of

current residents with ICD-10 to facilitate future data entry

• Provide more intensive educational and consultative support to coders and users of coded data

Educational Tasks/Phase 3

Thanks for attending!!

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