Tuesday, May 17, 2011, 9:30 AM Scottish Rite Auditorium

Transcription

1 Practice Administrator Meeting Tuesday, May 17, 2011, 9:30 AM Scottish Rite Auditorium I. Physicians Alliance 9:30 9:35 II. IDC 10 Overview 9:35 10: 40 Valerie Rock, Gates-Moore III. MOC Program 10:40 10:45 IV. Physician meeting Attendance 10:45 10:55 V. Spring POD Meetings 10:55 11:05 VI. Patient Satisfaction Survey 11:05 11:10 VII. Benchmarking 11:10 11:15 VIII. Round Table Discussion 11:15 11:30 IX. WellCare 11:30 11:40 Ashley Hereford X. Payor Update (hand out) NO MEETING IN JUNE OR JULY Next PA Meeting August 16, 2011, Scottish Rite Auditorium

2 Pediatric ICD-10 Mapping Examples Notes: I added two codes to the list provided to show how the code you start with impacts the codes recommended. Unspecified codes may map to other unspecified codes. So, if a more specific ICD-9 is appropriate, a more specific ICD-10 would be appropriate. These are examples which may be updated prior to 2013, therefore we do not recommend utilizing these codes on practice forms until confirmed in 2013.

3 Mapping ICD-9-CM 462 Acute Pharyngitis ICD-10-CM J02.8 Acute Pharyngitis due to other spec organisms J02.9 Acute Pharyngitis unspecified

4 Mapping ICD-9-CM Unspecified Otitis Media ICD-10-CM H66.90 Otitis Media Unspecified Unspecified Ear H66.91 Otitis Media Unspecified Right Ear H66.90 Otitis Media Unspecified Left Ear H66.90 Otitis Media Unspecified Bilateral

5 Mapping ICD-9-CM Streptococcal Sore Throat ICD-10-CM J02.0 Streptococcal Pharyngitis J03.00 Acute Streptococcal Tonsillitis Unspecified J03.01 Acute Recurrent Streptococcal Tonsillitis

6 Mapping Cough ICD-9-CM R05 Cough ICD-10-CM

7 Mapping ICD-9-CM Fever Unspecified ICD-10-CM R50.9 Fever Unspecified R50.2 Drug Induced Fever (combined code)

8 Mapping ICD-9-CM Feeding Problems in Newborn ICD-10-CM P92.8 Other Feeding Problems of Newborn

9 Mapping ICD-9-CM Abdominal Pain, Unspecified Site ICD-10-CM R10.0 Acute Abdomen R10.9 Unspecified Abdominal Pain

10 Mapping Example of More Specific ICD-9 Leading to More Specific ICD-10 ICD-9-CM Abdominal Pain Right Upper Quadrant ICD-10-CM R10.11 Right Upper Quadrant Pain

11 Mapping ICD-9-CM Acute Bronchiolitis Due Oth Infectious Organisms ICD-10-CM J21.1 Acute Bronchiolitis Due To Human Metapneumovirus J21.8 Acute Bronchiolitis Due To Other Spec Organisms J21.9 Acute Bronchiolitis Unspecified

12 Mapping Example of Less Specific ICD-9 Leading to More Specific ICD-10 ICD-9-CM ICD-10-CM Acute Bronchiolitis J20.0 Acute Bronchiolitis Due To Mycoplasma Pneumoniae J20.1 Acute Bronchiolitis Due To Hemophilus Influenzae J20.2 Acute Bronchiolitis Due To Streptococcus J20.3 Acute Bronchiolitis Due To Coxsackievirus J20.4 Acute Bronchiolitis Due To Parainfluenza Virus J20.5 Acute Bronchiolitis D/T Respiratory Syncytial Virus J20.6 Acute Bronchiolitis Due To Rhinovirus J20.7 Acute Bronchiolitis Due To Echovirus J20.8 Acute Bronchiolitis Due To Other Spec Organisms J20.9 Acute Bronchiolitis Unspecified

13 Contact: Valerie G Rock, CPC, ACS-EM GatesMoore vrock@gatesmoore.com Source: ICD-10-CM Mappings: Linking ICD-9-CM to all valid ICD-10-CM Alternatives, 2010, Ingenix

14 Kids Health First Pediatric Alliance Atlanta, GA May 17, 2011 Presented by Valerie G Rock, CPC, ASC-EM ICD-10 Background Reasoning Structural Differences Planning GatesMoore 1

15 October 1, 2013 May surpass Y2K and original HIPAA Transactions and code sets in size and complexity! ICD-10 is a diagnostic coding system implemented by the World Health Organization (WHO) in 1993 Replaces ICD-9, which was developed by WHO in the 1970s. ICD-10 is in almost every country in the world, except the United States. GatesMoore 2

16 Several countries use ICD-10 or a clinical modification in casemix and reimbursement systems United Kingdom [1995] Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) [ ] France [1997] Australia [1998] Belgium [1999] Germany [2000] Canada [2001] ICD-9-CM has several problems. It is out of room. Because the classification is organized scientifically, each three-digit category can have only 10 subcategories. Most numbers in most categories have been assigned diagnoses. Medical science keeps making new discoveries, and there are no numbers to assign these diagnoses. Computer science, combined with new, more detailed codes of ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care. Streamline claims submissions Details will make the initial claim much easier for payers to understand. GatesMoore 3

17 Diagnosis coding: ICD-10-CM replacing ICD-9-CM CM: Clinical Modification Inpatient Procedure Coding: ICD-10-PCS replacing ICD-9-CM Vol 3 PCS: Procedural Coding System The last regular annual update to both ICD-9 and ICD- 10 code sets will be made on October 1, On October 1, 2012 there will be only limited code updates to both ICD-9- CM and ICD- 10 code sets to capture new technology and new diseases. On October 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses. There will be no updates to ICD-9 -CM on October 1, 2013 as the system will no longer be a HIPAA standard. Source: GatesMoore 4

18 CPT & HCPCS will remain in effect No changes in physician procedure, supply, and visit coding HIPAA rules require adoption of ICD-10 for all provider services (1/09) Much more specific than even enhanced ICD-9 ICD-10-CM Diagnoses will increase from 13,500 to 69,000! ICD-10-PCS (procedure codes for inpatient services) will increase from 4,000 to 200,000! Change from a 3-5 numeric code to a seven position alphanumeric code GatesMoore 5

19 Systems will need to be modified to reflect where ICD-9 is currently being used relative to: Policies Care plans Contracts Forms Training Will be required for various users Should not require extensive coder retraining Coding rules and conventions remain basically the same Some short-term loss of productivity is expected during the learning curve Will require changes in data retrieval/analysis Will require changes to data systems GatesMoore 6

20 The CMS Medicare Fee-for-Service schedule is: Level I April 1, 2010 through December 31, 2010 Level II January 1, 2011 through December 31, 2011 Fully compliant on January 1, 2012 Level I compliance means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing." Level II compliance means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards." Contact your vendor and/or clearinghouse to ensure products and processes are updated (e.g. license includes regulation updates, and will the upgrade include acknowledgement transactions 277A & 999). GatesMoore 7

21 HP Enterprise Services and Georgia Department of Community Health will begin accepting fee for service v5010 X12 837P and 837I Health Insurance Portability and Accountability Act transactions on Friday April 1, During this time, we will still accept all v4010 transactions. All Trading Partners are encouraged to test their formatted 5010 transactions using the Georgia Ramp Manager system before submitting Electronic Data Information (EDI) files to HP Enterprise Services. Ramp Manager can be located at the following link: Georgia Specific companion guides for the 837P and 837I fee for service transactions can be downloaded from the Companion Guide page located within the EDI menu at Important Dates (5010 Transition Schedule): Wednesday March 2, 2011: Companion Guides Available Monday March 7, 2011: Begin testing using Ramp Manager Friday April 1, 2011: Submit fee for service v5010 HIPAA 837P and 837I production files to HP Enterprise Services Issue ICD-9-CM ICD-10-CM Volume of codes approximately 13,600 approximately 69,000 Composition of codes Mostly numeric, with E and V codes alphanumeric. Valid codes of three, four, or five digits. All codes are alphanumeric, beginning with a letter and with a mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits. Duplication of code sets Currently, only ICD-9-CM codes are required. No mapping is necessary. For a period of up to two years, systems will need to access both ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD- 9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits and outcomes studies. GatesMoore 8

22 2011 Analyze impact, budget, develop training plan, contact system vendors Implementation planning 5010 testing 2012 Process analysis Begin training 5010 only 2013 Policy changes Contract discussions May 2013 Deployment of codes by vendors to customers October 1, 2013 Compliance GatesMoore 9

23 PMS 5010 Compliance EHR Look for products to include drop down menus and selection edits Need appropriate granularity to accurately capture correct code Partial solution Not a high percentage of accuracy due to increased complexity of ICD-10 versus ICD-9 GatesMoore 10

24 ICD-10-CM has 3 7 digits Digit 1 is alpha (A Z, not case sensitive) Digit 2 is numeric Digit 3 is alpha (not case sensitive) or numeric Digits 4 7 are alpha (not case sensitive) or numeric A69.20 Lyme disease, unspecified O9A.311 Physical abuse complicating pregnancy, first trimester S42.001A Fracture of unspecified part of right clavicle, initial encounter for closed fracture Codes are divided into chapters based on body system or condition Chapter 1 Certain Infectious and Parasitic Diseases (A00-B99) Chapter 2 Neoplasms (C00-D49) Etc. GatesMoore 11

25 Laterality (left, right, bilateral) Examples: C Malignant neoplasm of lower outer quadrant of right female breast H Central corneal ulcer, bilateral L Pressure ulcer of right elbow, stage II Combination codes for certain conditions and common associated symptoms and manifestations Examples: K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris Combination codes for poisonings and their associated external cause Example: T42.3x2S Poisoning by barbiturates, intentional self-harm, sequela GatesMoore 12

26 Character x is used as a 5th character placeholder in certain 6 character codes allows for future expansion to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character Examples: T46.1x5A Adverse effect of calcium-channel blockers, initial encounter T15.02xD Foreign body in cornea, left eye, subsequent encounter Excludes 1 Indicates that the code excluded should never be used with the code where the note is located (do not report both codes). Example: Q03 Congenital hydrocephalus Excludes 1: Acquired hydrocephalus (G91.-) Excludes 2 Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together (both codes can be reported to capture both conditions). Example: L27.2 Dermatitis due to ingested food. Excludes 2: Dermatitis due to food in contact with skin (L23.6, L24.6, L25.4). GatesMoore 13

27 Inclusion of clinical concepts that do not exist in ICD-9-CM (e.g., underdosing, blood type, blood alcohol level) Examples: T45.526D Underdosing of antithrombotic drugs, subsequent encounter Z67.40 Type O blood, Rh positive Y90.6 Blood alcohol level of mg/100 ml A number of codes have been significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications) Examples: E Type 1 diabetes mellitus with diabetic neuropathic arthropathy F Alcohol abuse with alcohol-induced sleep disorder T82.02xA Displacement of heart valve prosthesis, initial encounter GatesMoore 14

28 Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and postprocedural disorders Examples: D78.01 Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen D78.21 Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen Buy the ICD-10-CM effective October 1, 2013 when released ~May Make sure all of your systems are up-to-date. Billing should have access to both code sets to properly handle new and old claims. Consider an encoder or mapping resource if EHR or PM does not have mapping options. Update superbill with most used diagnosis codes. GatesMoore 15

29 Workgroup for Electronic Data Interchange CMS ICD-10 General Information World Health Organization on-line ICD-10 AAPC GATESMOORE Monarch Tower, Suite Peachtree Road, N.E. Atlanta, Georgia (404) GatesMoore 16

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