IMPLEMENTATION OF ICD-10 JOINING THE REST OF THE WORLD IN CODING Jill Young - CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, Michigan 1.

IMPLEMENTATION OF ICD-10JOINING THE REST OF THE WORLD IN CODINGJill Young - CPC, CEDC, CIMC

Young Medical Consulting, LLC

East Lansing, Michigan

1

This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion

Disclaimer2

International Classification ofDiseases

ICD3

Purpose of ICD

Transforming documentation into numeric or alphanumeric designations Diseases Injuries Procedures

Designations are grouped into manageable categories

4

Purpose of ICD

A variety of healthcare reporting functions Not just for reimbursement purposes Intended as a tool to study outcomes and

improve patient care CDC uses data ** Need accuracy**

National Hospital Discharge Survey National Ambulatory Medical Care Survey External Causes of Injury statistics

(international)

5

ICD in Statistical Reporting The CDC uses clinical information for

many of their studies: Leading cause of deaths for males is heart

disease – 28.7% (2001) In 2003 health care expenditures for heart

disease and stroke was projected to be $209 billion

Information for consumers and physicians Most prevalent diseases Average length of stay Widely used treatments

6

ICD-9 is obsolete

Developed in early 1970s and has been in use since 1979

Many of the clinical and procedure concepts no longer meet today’s healthcare needs

The U.S. is the only developed country that has yet to adopt ICD-10 for morbidity/mortality classification

No longer supported by the WHO and therefore cannot be significantly modified

7

More bad news for ICD-9

The system does not comply with: HIPAA code set standardization BIPA (Benefits Improvement and Protection

Act of 2000) that outlines new services and technology that must be acknowledged in CMS payment systems

8

Details of Implementation9

Comparison

ICD‐9‐CM

3‐5 digits

Digits 2-5 are numeric

Alpha V and E codes

Lacks laterality

ICD‐10‐CM

3‐7 digits

Digit 1 is Alpha

Digit 2 and 3 are numeric

Digit 5‐7 are alpha or numeric

10

The Need for ICD-10

Billing and reimbursement specificity more manageable

No room for new codes Shortage of rubrics Diagnostic and statistical Manual of Mental

Disorders DSM IV

Chapter 2 (Neoplasms) and morphology codes correspond to ICD-O-2 Cancer registry programs have used since 1995

Misclassifications

11

Misclassifications - Urosepsis Dorland’s - a term used imprecisely to

denote infection ranging from urinary tract infection to generalized sepsis which may result from such infection

Providers – UTI with sepsis ICD-9 code- without clarification codes to

UTI ICD-10 – “code to condition”

12

ICD-10-CM Guidelines 2013

Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).

The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.

13

ICD-10-CM Guidelines 2013

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.

These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported.

14

1995 & 1997 E&M Guidelines If not documented, the rationale for ordering

diagnostic and other ancillary services should be easily inferred.

Appropriate health risk factors should be identified.

The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

15

1995 E&M

For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to

change as expected.

Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.

16

ICD-10-CM Guidelines 2013

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.

17

Poor Preparation Consequences

Increased delays in processing authorizations and reimbursement claims

Improper claims payment Coding backlogs Compliance issues Decisions based on inaccurate data Problems can be mitigated with proper

advance preparation

18

Other Concerns

Claims processing Will there be a significant increase in

rejections, pended or appealed claims Laboratory & other testing

What specificity is needed on order General symptoms vs specific symptoms

Patient concerns Change in covered benefits due to policy

changes Perceived change in coverage Is cause the coding system’s specificity?

19

The Rand Report

Implementation costs include: Training Lost productivity during this period System upgrades and changes

Future benefits include: More accurate payment for new procedures Fewer miscoded, rejected, and improperly

reimbursed claims Better understanding of the value of new

procedures and outcomes Improved disease management

20

21

AHIMA STUDY COMMENTS

Physicians need 5 hours of training to become proficient in ICD-10

AGREE DISAGREE

22

ICD-10-CM Myths or Misnomers

Physicians will need to learn new system of documentation which may change the way they practice

Coding and billing staff need to start code set training in 2014 Now

ICD-10 only works with an Electronic Medical Record system

Practices will need additional staff to handle the workload during and after the transition

23

ICD-10: Breaking it Down

Disease classifications expanded Health-related conditions Greater specificity to 6 digits with 7th digit

extension 21 chapters

Additional special group chapters 2 new chapters not in ICD-9

Diseases of the eye and adnexa Disorders of the ear

24

ICD-10: Breaking it down

Alphabetical Index Organized in the same manner as ICD-9 Codes listed by “main term” Cross-references and notes appear

Define terms Provide direction Provide coding instructions

3 sections Section I- Index to diseases and nature of injury Section II- External causes Section III- Table of drugs and chemicals

25

ICD-10: Breaking it Down

Chapters are further divided into subchapters or “blocks” Contain rubrics identifying closely related

conditions Each chapter contains a summary

subchapter that gives an overview of each block

26

New Concepts

Excludes1 Not coded here

Excludes2 Not included here

27

Fourth Digit Classification

The 4th digit defines site, etiology, manifestation, or state of the disease or condition Right, left, bilateral Viral vs. bacterial Controlled vs. uncontrolled Primary vs. secondary Malignant vs. benign Congenital vs. acquired

28

Fifth & Sixth Digit Classifications Adverse effect, Poisoning or Reaction to

improper use of medication, Toxic effect Accidental Intentional self harm Assault Undetermined

29

Example

A 32 y.o. hiker was bit by a venomous spider while hiking through the woods. He began experiencing muscle weakness and syncope and was rushed to the ED by a fellow hiker, where he was diagnosed with spider venom toxicity.

30

Example

T63.39 Toxic effect of venom of other spider T63.391 Toxic effect of venom of other

spider, accidental (unintentional) T63.392 Toxic effect of venom of other

spider, intentional self-harm T63.393 Toxic effect of venom of other

spider, assault T63.394 Toxic effect of venom of other

spider, undetermined

31

New Concepts

Placeholder character “X” Used as 5th and 6th character to allow for future

expansion

Seventh character alpha Burns

Initial vs subsequent vs sequela Fractures

Initial vs subsequent Healing vs malunion or non union

32

A Seventh character?

A seventh character indicates: A- the initial encounter

First encounter for treatment of the injury D- subsequent encounter

May be used for as long as the patient is receiving treatment for an injury

S- sequelae Complication or condition arising as a result of

the injury

33

7th Character Example

A 25 y.o. male presented to the emergency room after accidentally slashing his right arm with a sharp knife while cleaning a fish he caught during a Key West deep sea fishing trip. The Dx reported by the ED is laceration of the ulnar artery at the forearm, right arm

How to code the dx?

34

Laceration of Ulnar Artery at Forearm Level Laceration - see also Wound open by site

No other specific listing

Wound Artery – see injury, blood vessel, by site

Ulnar (artery) (vein) 903.3

903. Injury to blood vessels of upper extremity 903.3 Ulnar blood vessels

35

7th Character Example

S55 Injury of blood vessels at forearm level Code also any associated open wound (S51.-)Excludes2: injury of blood vessels at wrist and hand level (S65.-) injury of brachial vessels (S45.1-S45.2)

The appropriate 7th character is to be added to each code from category S55 A - initial encounterD - subsequent encounterS - sequela injury of ulnar artery at forearm level, unspecified arm

36

Example

S55.0 Injury of ulnar artery at forearm level S55.00 Unspecified injury of ulnar artery at forearm level

S55.001 Unspecified injury of ulnar artery at forearm level, right arm

S55.002 Unspecified injury of ulnar artery at forearm level, left arm S55.009 Unspecified injury of ulnar artery at forearm level,

unspecified arm

S55.01 Laceration of ulnar artery at forearm level S55.011 Laceration of ulnar artery at forearm level, right arm S55.012 Laceration of ulnar artery at forearm level, left arm S55.019 Laceration of ulnar artery at forearm level, unspecified arm

S55.09 Other specified injury of ulnar artery at forearm level S55.091 Other specified injury of ulnar artery at forearm level, right

arm S55.092 Other specified injury of ulnar artery at forearm level, left

arm S55.099 Other specified injury of ulnar artery at forearm level,

unspecified arm

37

ICD-10-CM Table of Neoplasms

Codes listed with a dash - following the code have a required 5th character for laterality or other location specificity.

The tabular list must be reviewed for the complete code.

38

Notes In Chapter Listing

The chapter uses the S-section for coding different types of injuries related to single body regions

T-section to covers injuries to multiple or unspecified body regions as well as poisoning and certain other consequences of external causes

39

Insect Bite – ICD-9

Insect Bite Non-venomous

See injury, superficial, by site

919.4 Insect bite non-venomous, without mention of infection

919.5 Insect bite, non-venonomous, infected

40

Insect Bite – ICD-10

S00.06A Insect bite of scalp; Initial encounterS00.06D Insect bite of scalp; Subsequent encounterS00.269A Insect bite of unspecified eyelid and periocular area; Initial encounterS00.269D Insect bite of unspecified eyelid and periocular area; Subsequent encounterS00.36A Insect bite of nose; Initial encounterS00.36D Insect bite of nose; Subsequent encounterS00.469A Insect bite of unspecified ear; Initial encounterS00.469D Insect bite of unspecified ear; Subsequent encounterS00.561A Insect bite of lip; Initial encounterS00.561D Insect bite of lip; Subsequent encounterS00.562A Insect bite of oral cavity; Initial encounterS00.562D Insect bite of oral cavity; Subsequent encounterS10.16A Insect bite of throat; Initial encounterS10.16D Insect bite of throat; Subsequent encounter

41

Insect Bite – ICD-10 S10.86A Insect bite of other part of neck; Initial encounter

S10.86S Insect bite of other part of necks; subsequent encounterS10.96A Insect bite of unspecified part of neck; Initial encounterS10.96D Insect bite of unspecified part of neck; Subsequent encounterS20.161A Insect bite of breast, right breast; Initial encounterS20.161D Insect bite of breast, right breast; Subsequent encounterS20.162A Insect bite of breast, left breast; Initial encounterS20.162D Insect bite of breast, left breast; Subsequent encounterS20.169A Insect bite of breast, unspecified breast; Initial encounterS20.169D Insect bite of breast, unspecified breast; Subsequent encounterS20.361A Insect bite of right front wall of thorax; Initial encounterS20.361D Insect bite of right front wall of thorax; Subsequent encounterS20.361S Insect bite of right front wall of thorax; Subsequent encounterS20.362A Insect bite of left front wall of thorax; Initial encounterS20.362D Insect bite of left front wall of thorax; Subsequent encounterS20.369A Insect bite of unspecified front wall of thorax; Initial encounterS20.369D Insect bite of unspecified front wall of thorax; Subsequent encounter

42

Insect Bite – ICD-10 S20.461A Insect bite of right back wall of thorax; Initial encounter

S20.461D Insect bite of right back wall of thorax; Subsequent encounterS20.462A Insect bite of left back wall of thorax; Initial encounterS20.462D Insect bite of left back wall of thorax; Subsequent encounterS20.469A Insect bite of unspecified back wall of thorax; Initial encounterS20.469D Insect bite of unspecified back wall of thorax; Subsequent encounterS20.96A Insect bite of unspecified parts of thorax; Initial encounterS20.96D Insect bite of unspecified parts of thorax; Subsequent encounterS30.860A Insect bite of lower back and pelvis; Initial encounterS30.860D Insect bite of lower back and pelvis; Subsequent encounterS30.861A Insect bite of abdominal wall; Initial encounterS30.861D Insect bite of abdominal wall; Subsequent encounterS30.862A Insect bite of penis; Initial encounterS30.862D Insect bite of penis; Subsequent encounterS30.863A Insect bite of scrotum and testes; Initial encounterS30.863D Insect bite of scrotum and testes; Subsequent encounterS30.864A Insect bite of vagina and vulva; Initial encounterS30.864D Insect bite of vagina and vulva; Subsequent encounterS30.865A Insect bite of unspecified external genital organs, male; Initial encounterS30.865D Insect bite of unspecified external genital organs, male; Subsequent encounterS30.866A Insect bite of unspecified external genital organs, female; Initial encounterS30.866D Insect bite of unspecified external genital organs, female; Subsequent encounter

43

Insect Bite – ICD-10

S30.867A Insect bite of anus; Initial encounterS30.867D Insect bite of anus; Subsequent encounterS40.269A Insect bite of unspecified shoulder; Initial encounterS40.269D Insect bite of unspecified shoulder; Subsequent encounterS40.869A Insect bite of unspecified upper arm; Initial encounterS40.869D Insect bite of unspecified upper arm; Subsequent encounterS50.369A Insect bite of unspecified elbow; Initial encounterS50.369D Insect bite of unspecified elbow; Subsequent encounterS50.869A Insect bite of unspecified forearm; Initial encounterS50.869D Insect bite of unspecified forearm; Subsequent encounterS60.369A Insect bite of unspecified thumb; Initial encounterS60.369D Insect bite of unspecified thumb; Subsequent encounterS60.468A Insect bite of other finger; Initial encounterS60.468D Insect bite of other finger; Subsequent encounterS60.469A Insect bite of unspecified finger; Initial encounterS60.469D Insect bite of unspecified finger; Subsequent encounterS60.569A Insect bite of unspecified hand; Initial encounterS60.569D Insect bite of unspecified hand; Subsequent encounter

44

Insect Bite – ICD-10

S60.869A Insect bite of unspecified wrist; Initial encounterS60.869D Insect bite of unspecified wrist; Subsequent encounterS70.269A Insect bite, unspecified hip; Initial encounterS70.269D Insect bite, unspecified hip; Subsequent encounterS70.369A Insect bite, unspecified thigh; Initial encounterS70.369D Insect bite, unspecified thigh; Subsequent encounterS80.269A Insect bite, unspecified knee; Initial encounterS80.269D Insect bite, unspecified knee; Subsequent encounterS90.463A Insect bite, unspecified great toe; Initial encounterS90.463D Insect bite, unspecified great toe; Subsequent encounterS90.466A Insect bite, unspecified lesser toe(s); Initial encounterS90.466D Insect bite, unspecified lesser toe(s); Subsequent encounterS90.569A Insect bite, unspecified ankle; Initial encounterS90.569D Insect bite, unspecified ankle; Subsequent encounterS90.869A Insect bite, unspecified foot; Initial encounterS90.869D Insect bite, unspecified foot; Subsequent encounter

45

Insect Bite – ICD-1046

Diabetes

E08 – Diabetes due to underlying condition E09 – Drug or chemical induced diabetes

mellitus E10 – Insulin dependent diabetes mellitus E11 – Non-insulin dependent diabetes

mellitus E12 – Malnutrition related diabetes E13 – Other specified diabetes mellitus

47

Diabetes Guidelines

The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.

As many codes within a particular category as are necessary to describe all of the complications of the disease may be used.

They should be sequenced based on the reason for a particular encounter.

48

Diabetes Guidelines

If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned.

Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.

Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.

49

Diabetes Specificity

.0 With coma .1 With ketoacidosis .2 With renal complications .3 With ophthalmic complications .4 With neurological complications .5 With peripheral circulatory

complications .6 With other specified complications .7 With multiple complications .8 With unspecified complications .9 Without complications

50

A 30 year old Type I patient has presented with a right foot ulcer due to diabetic atherosclerosis 250.81-Diabetes with other specified

manifestations, Type I, not stated as uncontrolled “use additional code to identify

manifestation” 440.23-Artherosclerosis of the extremities with

ulceration 707.14-Ulcer, except decubitus, of the heel and

mid-foot

Example51

Type I diabetic with right foot ulcer due to diabetic atherosclerosisE10.621 Type I diabetes mellitus with foot ulcer

Use additional code to identify site of ulcer

I70.234 Arteriosclerosis of native arteries of right leg with ulceration of heel and mid foot (other locations) Use additional code to identify severity of ulcer Use additional code to identify

Exposure to smoke Tobacco dependence Tobacco use History of tobacco use Occupational exposure to environmental tobacco

smoke

52

707.14 - Ulcer heel and mid-foot Diabetes Atherosclerosis

250.01 – Diabetes without mention of complication; Type I, [juvenile type], not stated as uncontrolled

440.20 – Atherosclerosis of extremities, unspecified

ALTERNATIVE CODES 440.23 – Atherosclerosis of

extremities with ulceration Use additional code for any

associated ulceration 250.81-Diabetes with

other specified manifestations, Type I, not stated as uncontrolled “use additional code to identify manifestation”

Example

A 30 year old Type I diabetic patient who also has atherosclerosis of the right leg extremity, presents with a foot ulcer (causal relationship not stated)

53

Complications of Care - Guidelines Not all conditions that occur during or

following medical care or surgery are classified as complications. There must be a cause-and-effect relationship

between the care provided and the condition, and an indication in the documentation that it is a complication.

Query the provider for clarification, if the complication is not clearly documented.

Guideline extends to any complications of care, regardless of the chapter the code is located in

54

Cause & Effect Relationship

Sepsis Based on provider’s documentation of the

relationship between the infection and the procedure.

55

Cause & Effect Relationship

Presume relationship Chronic kidney disease with hypertension

as hypertensive chronic kidney disease. Atherosclerosis and angina pectoris

Unless the documentation indicates the angina is due to something else

56

Acute Exacerbation of Chronic Obstructive Bronchitis & Asthma

The codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation.

An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

The codes for chronic obstructive bronchitis and asthma distinguish between uncomplicated cases and those in acute exacerbation.

An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

ICD-10 ICD-9

57

58

Asthma

√ 5th - J45.2 Mild Intermittent asthma

J45.20 Mild intermittent asthma, uncomplicated

Mild intermittent asthma NOS

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild Intermittent asthma with status asthmaticus

√ 5th - J45.3 Mild persistent asthma

J45.30 Mild persistent asthma, uncomplicated

Mild persistent asthma NOS

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild persistent asthma with status asthmaticus

59

Asthma

√ 5th - J45.4 Moderate persistent asthma J45.40 Moderate persistent asthma, uncomplicated

Moderate persistent asthma NOS J45.41 Moderate persistent asthma with (acute)

exacerbation J45.42 Moderate persistent asthma with status

asthmaticus

√ 5th - J45.5 Severe persistent asthma J45.50 Severe persistent asthma, uncomplicated

Severe persistent asthma NOS J45.51 Severe persistent asthma with (acute)

exacerbation J45.52 Severe persistent asthma with status asthmaticus

J45.9 Other and unspecified asthma

60

Crohn’s Disease

ICD-9 559.x – Regional enteritis

Large, small, combined, unspecified intestine ICD-10

Rubric contains 28 separate codes Site Complications of fistula Obstruction Bleeding Abscess Other None

61

62

Converting from ICD-9 to 10 A MUST DO

Getting everyone “on board” Physicians, nurses, billing/coding and

administration Education and training is key

63

AHIMA Preparation

Create implementation committee

Budget planning

Timeline for Implementation

Identify training needs

Information Management System upgrades and review

64

Challenges per AHIMA

Coders & Billers

Learn “new” system

Forget “old” system”

Must understand Coding Guidelines

Getting adequate information

Physicians

Need to understand coding world

Need to understand specificity needed

Need to write legibly

Need to give “better” documentation

65

What is your office’s GAP?

Conduct gap analysis of coding professionals’ knowledge and skills

Assess coding professionals’ knowledge in sciences (anatomy and physiology, pathophysiology), medical terminology, and pharmacology

Refresh coding staff knowledge as needed on basis of assessment results

66

Assess Quality of Medical Record Documentation Evaluate samples of various types of medical

records to determine whether documentation supports level of detail found in ICD-10-CM/PCS

Sampling techniques could include random samples, most frequent diagnoses or procedures, or diagnostic or procedural categories known to represent documentation problems with ICD-9-CM

Implement documentation improvement strategies where needed

67

Determine a Training Plan

Who will need education? What type and level of education will

they need? How will the education be delivered? When will training be needed?

68

Determine Business Associate Readiness

When will upgrades or replacement systems be available for testing and implementation?

What customer support and training will they provide?

How will their products/services accommodate both ICD-9 and ICD-10?

How long will their products accommodate both code sets?

69

QUESTIONS???QUESTIONS???

Thank you !

[email protected]