Page 1 March 21, 2013 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues March 21, 2013 ICD-10 Transition Update: What Health Lawyers Need to Know
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ICD-10 Transition Update: What Health Lawyers Need to Know
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Page 1March 21, 2013
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
American Health Lawyers AssociationInstitute on Medicare and Medicaid Payment Issues
March 21, 2013
ICD-10 Transition Update: What Health Lawyers Need to Know
Page 2March 21, 2013
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
• What is ICD‐10 and why is it important to the healthcare community?
• What is the current regulatory status of ICD‐10?
• Organizational Impact – Operational and Finance
• Readiness and Implementation Strategies
Learning Objectives
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What Are ICD Codes?• The International Classification of Disease (ICD) codes
are the international classifications for all diseases and many other health problems for purposes of health management, including:– Analysis of the general health of population groups,
– Monitoring of the incidence and prevalence of diseases;
– Monitoring other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, and quality. http://www.who.int/classifications/icd/en/
• ICD codes are now recorded on many types of health records and is a key component in reimbursement, quality and utilization review and other data management activities
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ICD History
19901977196519551948
ICD-6
ICD-7
ICD-8 ICD-10
ICD-9
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• Replaces ICD-9 - Not a revised version of ICD-9
• ICD-10 represents a complete change from one coding system to a new one structured in an entirely new way
• Like all medical coding systems, it provides a way to condense textual clinical information into “codes” that can be used for billing and other data-based applications
What is ICD-10?
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There is no relationship between the two code sets – they have completely different structures and uses
ICD-10 Is Really Two DifferentCode Sets
ICD-10-CM• International
Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS• International
Classification of Diseases, 10th Revision, Procedure Coding System
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What’s ICD-10-CM?
ICD-10-CM• Diagnosis Coding System – Used to report the patient’s
condition (i.e., what’s wrong with the patient)
• Direct replacement for ICD-9-CM Volumes 1 & 2
• Will be used in all settings – hospital inpatient, hospital outpatient, physician office, etc.
• Like ICD-9-CM, developed and maintained by the World Health Organization (WHO) and the National Center for Health Statistics within the Centers for Disease Control
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The ICD-10-CM “Official Guidelines”
• As with ICD-9-CM, ICD-10-CM is supplemented by a set of “Official Guidelines” that are designated as part of the ICD-10-CM code set by the HIPAA “medical data code set” regulations (45 CFR § 162.1002(C)(2))
• The Official Guidelines provide detailed guidance on the use of the ICD-10-CM code set
• The 2013 ICD-10-CM Official Guidelines are available from http://www.cdc.gov/nchs/icd/icd10cm.htm#10update
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ICD-10-CM Example
Page 10March 21, 2013
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What’s ICD-10-PCS?
ICD-10-PCS• Procedure Coding System – Used to report surgical
procedures performed
• Direct replacement for ICD-9-CM Volume 3
• Only used in a hospital inpatient setting (and only for reporting facility services)
• Like ICD-9-CM Volume 3, ICD-10-PCS was developed and is maintained by CMS
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The ICD-10-PCS “Official Guidelines”
• CMS has released a set of “Official Guidelines” for ICD-10-PCS
• Like the ICD-10-CM Official Guidelines, the ICD-10-PCS Official Guidelines are designated as part of the ICD-10-PCS code set by the HIPAA “medical data code set” regulations (45 CFR § 162.1002(C)(3))
• The 2013 ICD-10-PCS Official Guidelines are available from https://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html
ICD-9-CM: 50.24 Percutaneous ablation of liver lesion or tissue
ICD-10-PCS GEM: 0F503ZZ Destruction of Liver, Percutaneous Approach
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How Big Could It Be?ICD-9-CM
Diagnosis: 14,025
Procedures: 3,824
820.02, Fracture of midcervical section of femur, closed
ICD-10-CM & ICD-10-PCS
Diagnosis: 68,069
Procedures: 72,589
S72031A, Displaced midcervical fracture of right femur, initial encounter for closed fracture
S72031G: Displaced midcervical fracture of right femur, subsequent encounter for closed fracture with delayed healing
S72032A: Displaced midcervical fracture of left femur, initial encounter for closed fracture
S72032G: Displaced midcervical fracture of left femur; subsequent encounter for closed fracture with delayed healing
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When is it official?
January 1, 2010
• Payers and providers should begin internal testing of Version 5010 standards for electronic claims
December 31, 2010
• Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance
• Providers should form ICD-10 sponsorship team
January 1, 2011
• Payers and providers should begin external testing of Version 5010 for electronic claims
• CMS begins accepting Version 5010 claims
• Version 4010 claims continue to be accepted
December 31, 2011
• External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance
January 1, 2012
• All electronic claims must use Version 5010
• Version 4010 claims are no longer accepted
October 1, 2014
• Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures
• CPT codes will continue to be used for outpatient services
Per the Department of Health and Human Services, the compliance date for implementation of ICD-10-CM and
ICD-10-PCS is October 1, 2014.
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Why is ICD-9 being replaced?B
arrie
rs: • ICD-9 is outdated
• Developed in 1970s, based on medicine and technology that is outdated and no longer used
• Lack of detail for payment for today’s medicine
• No space for new codes
Ben
efits
: • ICD-10 allows greater detail for laterality, primary encounters, external causes of injury, preventative health, as well as socioeconomic, family relationships, lifestyle related problems
• More space to accommodate evolving technology
• Supports exchange of health data with other countries (think of AIDS, SARS, H1N1)
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ICD-10 Global perspective
ICD-9 code set is no longer maintained by the WHO
The USA is the only developed nation still using ICD-9. All other G-7 nations have transitioned to ICD-10
As of 2002, 99 countries have adopted ICD-10 or a clinical modification for coding and reporting morbidity data
As of 2002, 138 countries have adopted ICD-10 for coding and reporting mortality data
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Implications of ICD-10 TransitionICD-10 presents both extensive opportunities and challenges
• ICD-10 code sets will allow for accurate description of diagnoses and procedures that is critical for health care utilization, health policy, and cost containment.
• ICD-10 will provide for specific diagnosis and treatment information that can improve quality measurements and patient safety, as well as better evaluation of medical processes and outcomes.
• Accuracy will facilitate better payment in pay-for-performance (P4P) programs, more accurate health grades, and again, improved quality of care.
• Scope and complexity of transition is significant!
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ICD-10 Impact and Implementation
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ICD-10 ImpactScope
• All HIPAA covered providers and entities
– Includes, payers, health plans, DME, pharmacy, vendors
• Other Code Sets
– Current Procedural Terminology (CPT) Codes
– Healthcare Common Procedure Codes (HCPCS)
– No impact
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