How to Avoid an Office Meltdown: Find Out the Facts about ICD-10-CM. Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix

Size: px

Start display at page:

Download "How to Avoid an Office Meltdown: Find Out the Facts about ICD-10-CM. Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix"

Brendan Watkins
5 years ago
Views:

1 How to Avoid an Office Meltdown: Find Out the Facts about ICD-10-CM

2 Table of Contents Chapter 1 Why Is ICD-9 Being Replaced?... 3 How Is ICD-10-CM Different?... 4 How Does the New Format Compare?....5 Struck By a Turtle?... 6 How Does Mapping Work?...7 Chapter 2 Assessing Software Vendor Readiness Chapter 3 Costs to Convert Chapter 4 Selecting an Experienced ICD-10-CM Partner Coding and Documentation...15 Create a Safe Environment to Learn and Test Chapter 5 Getting Started is Critical Appendix Resources Footnotes

3 CD-9 ICD-10 From IC-9 to ICD-10 Why Is ICD-9 Being Replaced?... 3 How Is ICD-10-CM Different?... 4 How Does the New Format Compare? Struck By a Turtle? How Does Mapping Work?... 7

4 Why is ICD-9 Being Replaced? The ICD-9 coding system currently being used to report medical diagnoses and inpatient procedures is more than 30 years old. It has outdated terms, produces limited data about medical conditions and inpatient procedures, and is inconsistent with new medical practices. Perhaps most importantly, the structure of ICD-9 restricts the number of new codes that can be created and many ICD-9 categories are full. 1 ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) is made up of two parts: ICD-10-CM ICD-10-CM is for diagnosis coding in all U.S. healthcare settings. Although diagnosis coding under ICD-10-CM relies on 3 to 7 digits to provide greater detail and specificity as opposed to the 3 to 5 digits used with ICD-9-CM the format of the two code sets is similar. ICD-10 Deadline: October 1, 2014 ICD-10-PCS ICD-10-PCS will be used for U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits, instead of the 3 or 4 numeric digits used in current ICD-9-CM procedure coding. ICD-10-PCS coding is much more specific and substantially different from ICD-9-CM procedure coding. The United States Department of Health and Human Services (HHS) announced in August 2012 that the deadline for compliance with the new ICD-10 medical coding system would be postponed one year, to Oct. 1, The delay came in response to concerns expressed by some payers and providers about meeting the Oct. 1, 2013 deadline. Because simultaneous adoption of ICD-10 across the industry is critical to success, HHS extended the deadline to give organizations more time for system preparation and testing. 2, Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix 3

5 How is ICD-10-CM Different? In many respects, ICD-10-CM is comparable to ICD-9-CM. The guidelines, conventions, and rules are similar, as is the code organization. 4 One of the biggest differences, however, is the level of specificity that can be achieved. A major concern with ICD-9-CM has been the lack of detail conveyed in the codes. For example, if a patient is seen for treatment of a burn on the right arm, the ICD-9-CM diagnosis code does not distinguish that the burn is on the right arm. If the patient is seen a few weeks later for another burn on the left arm, the same ICD-9-CM diagnosis code would be reported. Additional documentation would likely be required for a treatment claim to explain that the burn treated at this time was different from the one treated previously. Yet with the ICD-10-CM diagnosis code set, characters in the code identify right versus left, initial encounter versus subsequent encounter, and other granular, clinical information. 5 Specifically, the expanded number of characters of the ICD-10-CM diagnosis codes allows for identification of the disease etiology, anatomic site, and severity. ICD-10-CM Mandatory Payer Position Characters 1-3: CATEGORY Characters 4-6: ETIOLOGY, ANATOMIC SITE, SEVERITY, OR OTHER CLINICAL DETAIL Character 7: EXTENSION S52 Fracture of forearm S52.5 Fracture of lower end of radius S52.52 Torus fracture of lower end of radius S Torus fracture of lower end of right radius Torus fracture of lower end of right radius, S52.521A initial encounter for closed fracture The transition to ICD-10 is mandatory for all payers providers and other organizations covered by the Health Insurance Portability and Accountability Act (HIPAA). Payers are legally and financially responsible not only for adhering to ICD-10 but also administering regulations among their providers. 6 Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix 4

6 How Does the New Format Compare? As previously indicated, one of the primary identified benefits for the transition from ICD-9 to ICD-10 in the United States is the increased level of specificity offered by the ICD-10 code format. This specificity will benefit patients and doctors (by giving more detailed diagnosis and treatment information), payers (by more accurately defining services) and international organizations that monitor worldwide disease. However, all of this increased specificity comes at a price the codes are becoming more complex. In ICD-9-CM, codes are three to five digits. The first digit is either numeric or alpha (the letters E or V only) and all other digits are numeric. In ICD-10-CM, however, codes can be up to seven digits. The first digit is always alpha (it can be any letter except U), the second digit is always numeric, and the remaining five digits can be any combination. The following example shows an ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus. The corresponding ICD-9-CM code would have been , which only indicates gouty arthropathy. As you can see, the ICD-10-CM code contains much more information. 7 M What about ICD-10-PCS? ICD-10-CM ICD-9-CM Numeric or Alpha (E or V) Alpha (every letter except U) Numeric Numeric or Alpha (every letter except U) CATEGORY 1 A CATEGORY (Chronic Gout) CATEGORY Numeric CATEGORY, ANATOMIC SITE, SEVERITY CATEGORY, ANATOMIC SITE, SEVERITY ETIOLOGY LATERALITY (Renal Impairment) (Left Shoulder) LOCATION (Shoulder) ICD-10-PCS is a code set for inpatient procedure reporting. ICD-10-PCS has nearly 79,000 seven-digit alpha-numeric codes. Codes are selected from complex grids, based on the type of procedure performed, the approach, body part, and other characteristics. The code system does not use medical terminology based on Latin or eponyms. 8 EXTENSION EXTENSION (without tophus) Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix 5

7 Struck by a Turtle? The level of specificity conveyed with ICD-10-CM offers significant advantages, but it may also present challenges. From a clinical perspective, ICD-10-CM allows doctors to describe precisely what bone was broken or which artery received a stent. The challenge is ensuring the appropriate code is selected. For example, a pain in the limb is coded as with ICD-9-CM. But in ICD-10-CM, there are more than 30 code choices. Moreover, because of the complex grid system used to generate the ICD-10-CM codes, less common and arguably unlikely scenarios can be accounted for in the coding matrix. For instance, codes exist for injuries received while sewing, ironing, playing a brass instrument, crocheting, knitting, and doing handcrafts, as well as burn due to water-skis on fire, and more than 300 codes involving injuries related to animals. 9 (See the CMS ICD-10-CM coding example below. 10 ) Overutilization of Unspecified Codes CODE W5921XA W5921XD W5921XS W5922XA W5922XD W5922XS W5929XA W5929XD W5929XS DESCRIPTION Bitten by turtle, initial encounter Bitten by turtle, subsequent encounter Bitten by turtle, sequela Struck by turtle, initial encounter Struck by turtle, subsequent encounter Struck by turtle, sequela Other contact with turtle, initial encounter Other contact with turtle, subsequent encounter Other contact with turtle, sequela The unspecified field has been a part of the ICD-9-CM coding protocol and will continue with ICD-10-CM. Codes entitled unspecified are used when the information in the medical record is insufficient to assign a more specific code. In a busy practice, physicians and coders may be tempted to use unspecified codes, rather than locate the more accurate and appropriate code. However, unspecified codes can raise red flags for auditors and payers when reported frequently. The repeated use of the unspecified field also will undermine the greater specificity that ICD-10-CM was designed to provide. 11 That s why physicians should become familiar with the ICD-10-CM codes associated with frequent diagnoses, and be educated to provide new levels of detail (specific anatomy, laterality, severity, etc.) when providing documentation to coders. 12 Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix 6

8 How Does the Mapping Work? According to the American Academy of Professional Coders, certain ICD-9-CM codes map to ICD-10-CM in a simple one-to-one conversion. For example, the ICD-9-CM code (Tietze s Syndrome) maps directly to the ICD-10-CM code M94.0. (An exact map does not always mean the codes match in detail.) 13 1:1 MAPPING Other codes will require additional information to map for possible solutions. For instance, the ICD-9-CM code (spotting complicating pregnancy) requires information about weeks in pregnancy to map. There are three options: O (spotting complicating pregnancy, first trimester), O (spotting complicating pregnancy, second trimester), and O (spotting complicating pregnancy, third trimester). 14 1:3 MAPPING International Classification of Diseases, tenth Revision (ICD-10) ICD-9-CM (Tietze s Syndrome) ICD-9-CM (spotting complications during pregnancy) ICD-10-CM M94.0 (Tietze s Syndrome) ICD-10-CM O (spotting complications during pregnancy, first trimester) O (spotting complications during pregnancy, second trimester) O (spotting complications during pregnancy, third trimester) The International classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics. Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix 7

9 More on mapping And some codes require significantly more specificity and map into many more ICD-10-CM code set selections. For example, the ICD-9-CM code (poisoning by hormones and synthetic substitutes) has sixteen corresponding ICD-10-CM codes, requiring information about both the cause of the poisoning and the type of encounter. 15 1:16 MAPPING ICD-9-CM (poisoning by hormones and synthetic substitutes) T38.801A T38.802A T38.803A T38.804A T38.891A T38.892A T38.893A T38.894A ICD-10-CM T38.901A T38.902A T38.903A T38.904A T38.991A T38.992A T38.993A T38.994A Percentages of the different types of matches between ICD-10 and ICD-9 MATCHING CATEGORIES 16 ICD-10 TO ICD-9 ICD-9 TO ICD-10 NO MATCH 1.2% 3.0% 1-TO1 EXACT MATCH 5.0% 24.2% 1-TO-1 APPROXIMATE MATCH WITH 1 CHOICE 82.6% 49.1% 1-TO-1 APPROXIMATE MATCH WITH MULTIPLE CHOICES 4.3% 18.7% 1-TO-MANY MATCH WITH 1 SCENARIO 6.6% 2.1% 1-TO-MANY MATCH WITH MULTIPLE SCENARIOS 0.2% 2.9% Only 24.2% of ICD-9 codes have an exact match to ICD-10 codes. Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Appendix 8

10 Assessing Software Vendor Readiness

11 Assessing Software Vendor Readiness Proactively assessing a software vendor s readiness to accommodate the ICD-10 system is an important step for providers. Providers should not assume that vendors are or will be ready for the October 2014 deadline. It is important to determine in advance the extent and nature of the vendor s preparations. For current software vendors, key questions include: 17 Is this product ICD-10 compliant? Will this product ever be ICD-10 compliant? What is the timetable for making your product(s) ICD-10 compliant? Other important questions for current software vendors include: When do you plan to start and complete your ICD-10 internal testing? When do you plan to start and complete customer review and/or beta testing? What is the product version of your software that will be ICD-10 compliant? When do you plan to start and complete customer training on these updates? What is your estimated release date for customer use/installation? 18 Is Computer- Assisted Coding Software the Answer? Computer-assisted coding (CAC) has the potential to boost productivity in the face of the inevitable coding challenges that will surround the ICD-10 transition. Yet it is not a panacea and ultimately, a successful transition 19, 20 will be as much, or more, dependent on people who are knowledgeable about the ICD-10 regime for: Selecting the right codes Ensuring that those codes are justified Interfacing coded data correctly to billing systems Educating billing teams about appropriate codes Providing documentation feedback and education to physicians 10

12 What Will It Cost????$?

13 Costs to Convert A consortium of professional medical societies and organizations, including the Medical Group Management Association, in 2008 retained a consulting firm to assess the cost impact of the ICD-10 mandate on three different-sized provider practices. The assessment defined a small practice as comprising of three physicians and two administrative staff; a medium practice as consisting of ten physicians, one full-time coder and six administrative staff; and a large provider as consisting of one hundred physicians, sixty-four coding staff and fifty-four medical records staff. 21 PROJECTED TOTAL COST OF THE ICD-10 MANDATE $83,290 TYPICAL SMALL PRACTICE Spike in Returned Claims $285,195 TYPICAL MEDIUM PRACTICE $2.7 million TYPICAL LARGE PRACTICE SIX KEY EXPENSE AREAS Increased documentation costs, staff education and training Business process analysis of health plan contracts, coverage determinations and documentation Changes to super-bills Information technology system changes Cash flow disruption As a result of increased claims follow-up and longer durations of account resolution, the Department of Health and Human Services (HHS) anticipates that the percentage of returned claims following the ICD-10 implementation will more than double the amount typically associated with annual ICD-9 updates. This is based on analysis of thirty-six months of Medicare returned claims data following annual ICD-9 updates

14 We Can Help Selecting an Experienced ICD-10-CM Partner Coding and Documentation Create a Safe Environment to Learn and Test... 16

15 Selecting an Experienced ICD-10 Partner With more than 500 certified, phyisician-only coders and experience in almost every medical specialty, McKesson has developed a comprehensive approach to help providers, administrators and staff successfully and efficiently make the transition to the ICD-10-CM coding system in ICD-10 EDUCATION AND PLANNING Multiple one- and two-hour educational webinars on ICD-10-CM related topics are available, along with onsite education for larger groups. Customized webinars can be tailored to individual group requirements. The objective is to help groups plan and prepare for the transition and to foster physician, executive and staff buy-in. EXAMPLE EDUCATION TOPICS Introduction to ICD-10-CM ICD-10-CM Readiness Planning Specialty Specific ICD-10-CM Impact Planning Starts Now Mitigate your risk. A successful transition from ICD-9-CM codes to ICD-10-CM codes on October 1, 2014, will require significant advance planning. TRAIN clinical and administrative staff on new code sets, fraud and abuse regulations and compliance. AUDIT the coding of your top diagnoses in order to assess the potential gaps between ICD-9-CM and ICD-10-CM for individual or multiple specialties EDUCATE physicians to make sure that clinical documentation procedures capture the increased level of detail required for ICD-10-CM CONTRACT with an outside entity to translate codes well in advance of the deadline in order to help staff manage current workloads without a high level of disruption 14

16 Coding and Documentation McKesson helps you get a head start on the transition by helping you recognize the ICD-10-CM coding and clinical documentation gaps specific to your providers and then getting the necessary recommendations and education to make required improvements. ICD-10 GAP ANALYSIS Identify a practice s top 50 most utilized diagnoses codes Conduct ICD-10-CM coding and documentation audits Evaluate where additional documentation will be required for the new code set Map out modifications necessary to achieve appropriate reimbursement Update charge tickets, super-bills and other revenue cycle tools We can also analyze the estimated impact on claims processing that the transition to ICD-10-CM will have based on a group s current specialty, coding staff and historical claims volume. Major ICD-10 Transition Risks 23 SHORT-TERM LOSS OF REVENUE 60% of leaders expect short-term cash flow to be negatively impacted LOSS OF CODING PRODUCTIVITY Productivity losses anticipated to be 50%-70% ERROR RATES Error rates may rise to 6-10% compared with the typical 3% due to the annual ICD-9 updates 15

17 Create a Safe Environment to Learn and Test ICD-10 CODE FIRST McKesson offers coding services to help mitigate risk through early adoption of ICD-10. By simulating the world under ICD-10-CM in advance of the deadline, a safe testing ground is put in place before the cutoff date. The objective is to help prevent and reduce the difficulties and cash flow disruptions that could arise in offices not prepared for ICD 10. The ICD-10 Code First program is simple and effective. McKesson certified coders begin coding in ICD-10-CM from the start. We take out the middle step and the additional time needed to translate ICD-9-CM into ICD-10-CM and then back again. With ICD-10 Code First, normal claims processing continues while advance testing and documentation improvements are being put in place building up to a successful transition. McKesson coders take the documentation, such as surgical or patient notes, and then translate the information into the ICD-10-CM code. In this way, documentation deficiencies can be quickly identified. Gaps are noted along with any additional specificity detail required to support the most appropriate level of reimbursement. Helps You Improve Documentation and Minimize Disruption The ICD-10 Code First program combines our coding expertise with a proprietary ICD-10 coding engine. Clients gain the benefit of both our experience and resources to improve documentation, adhere to coding requirements and minimize disruption. The program is designed to work with a number of certified electronic health record and billing software systems for processing. ICD-10 Code First Advantages Prevent office disruption Create a safe testing ground for staff and physicians Quickly identify documentation deficiencies Make adjustments required to support appropriate reimbursement levels Accelerate learning curve while processing in ICD-9 continues until the deadline 16

18 Get Started

19 Getting Started is Critical Whether you work with McKesson or other coding experts, it is essential that you get started on the ICD-10-CM transition sooner rather than later. We invite you to call or us for more information at the following phone number or address: About Us ICD-10 Readiness Help Line McKesson Business Performance Services, a part of McKesson Corporation, currently ranked 14th on the FORTUNE 500, is a leading provider of coding, medical billing and practice management services. From education and assessment to coding and compliance services, McKesson has over 500 certified coders working with customers nationwide, across multiple specialties. McKesson supports McKesson s Better Health 2020 strategy which is focused on providing the capabilities needed to reduce costs, improve financial performance and successfully manage complex payment models. For more information, visit 18

20 Appendix Resources Footnotes... 21

21 Resources 2009 ICD-10 Final Rule: ICD-10 Final Rule: Centers for Medicare & Medicaid Services ICD-10 Website: CMS ICD-10 Implementation Guide for Small and Medium Practices: American Academy of Professional Coders FAQ: 20

22 Footnotes 1 The ICD-10 Transition: An Introduction, CMS ICD-10 Industry Resources, 2 New Health Care Standards to Save Up to $6 Billion, CMS Press Release, 24. Aug. 2012, aspcounter=4444&intnumperpage=10&checkdate=&checkkey=&srchtype=1&numdays=3500&srchopt=0&srchdata=&keywordtype=all&chknewstype=1%2c+2%2c+3%2c +4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date 3 HHS Proposed One-Year Delay of ICD-10 Compliance Date, CMS Fact Sheet, 9 April 2012, wordtype=all&chknewstype=6&intpage=&showall=1&pyear=&year=0&desc=&cboorder=date 4 ICD-10 FAQ, American Academy of Professional Coders, 5 The Differences Between ICD-9 and ICD-10, American Medical Association Fact Sheet, 6 ICD-10 Basics for Payers, Industry Resources for the ICD-10 Transition, CMS, 7 ICD-10 Conversion and Mapping, American Academy of Professional Coders, 8 ICD-10 FAQ, American Academy of Professional Coders, 9 Walked Into a Lamppost? Hurt While Crocheting? Help Is On the Way, The Wall Street Journal, 11 Sept 2011, 10 A Code for What Ails You, The Wall Street Journal, 11 A little-known potentially large ICD-10 loophole, ICD10 Watch, 8 Sept. 2010, 12 Know How Unspecified ICD-9-CM Diagnosis Codes Could Hurt Your Practices Bottom Line, Getting Paid blog, Kareo, 13 Sept. 2012, 13 ICD-10 Conversion and Mapping, American Academy of Professional Coders, 14 ibid. 15 ibid. 16 Crosswalking Between ICD-9 and ICD-10, American Medical Association, Fact Sheet 7, 25 Sept 2012, 17 ICD-10 Impact Assessments: How ready are you to assess vendor readiness? ICD10 Watch, 30 May 2012, 18 ibid. 19 Why CAC can t solve all your ICD-10 problems, ICD10 Watch, 22 Jan 2013, 20 CAC & ICD-10: How to evaluate what CAC can do for healthcare providers, ICD10 Watch, 7 Sept 2011, 21 New ICD-10 study confirms CMS underestimates costs and time required to implement complex new code set, Fact Sheet, Medical Group Management Association, October HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS Final Rule, Federal Register, p. 3346, 16 Jan 2009, 23 ICD-10 Puts Revenue at Risk, Intelligence Report, Health Leaders; July 2011; Health and Human Services, Federal Register Volume 73, #64 21

23 McKesson Business Performance Services McKesson Alpharetta, GA betterrevcycle.com ICD-10 Readiness Help Line Copyright 2013 McKesson Corporation and/or one of its subsidiaries. McKesson Business Performance Services is a trademark of McKesson Corporation and/ or one of its subsidiaries. All product or company names mentioned may be trademarks, service marks or registered trademarks of their respective companies. 04/2013-HAOM

ICD 10 Transition: What You Don t Already Know and How to Prepare for It!

ICD 10 Transition: What You Don t Already Know and How to Prepare for It! Jennifer Keiser, B.S., A.L.M. General Manager, Alternate Care Solutions Mediware Information Systems, Inc. Cranston, RI CE Credit