Implementing ICD-10-CM Preparing for the Conversion

Transcription

1 ICD-9-CM ICD-10-CM Implementing ICD-10-CM Preparing for the Conversion AHIMA Long Term and Post Acute Care Practice Council 1 Users are encouraged to adapt these slides as long as they in no way suggest their use or adaptation is endorsed by AHIMA. You do not need permission from AHIMA to adapt for your use.

2 Background ICD-9-CM Current coding classification system Introduced 30 years ago No longer fits with 21 st century health system ICD-10-CM International standard Track, report & compare morbidity & mortality Transition to ICD-10 required by federal regulations (HIPAA standards) 2

3 Background ICD-10 Available since 1992 Approximately 100 countries use ICD-10 including Canada, Australia, and the United Kingdom United States: Only industrialized nation not using ICD-10 United States: ICD-10 go-live date was October 1, 2013 NOW revised to be implemented October 1,

4 Global Use of ICD-10 4

5 The WHO - What Why??? ICD-9-CM Overview ICD-9 Developed by the WHO (World Health Organization) 1979 U.S. developed the Clinical Modification to ICD-9-CM 2000 HIPAA transaction and code set: ICD-9 -CM for electronic transactions Now updated for ICD-10-CM 5

6 Where - How When??? ICD-10-CM All health care settings as well as other industries which utilize the ICD system, e.g. Insurance Providers ICD-10-PCS for inpatient hospital) A single implementation date for all providers Current Implementation Date: October 1,

7 Code Freeze Last regular, annual updates to both ICD-9 and ICD-10 was Oct. 1, 2011 Oct. 1, there will be only limited code updates to both code sets Oct. 1, 2014 there will be only limited updates to ICD 10 code set Limited updates will capture new technology or new diseases only Oct. 1, 2015 regular annual updates to ICD- 10 will begin, ending the freeze 7

8 ICD-10-CM Significant improvement for reporting clinical data Measuring the quality, safety, and efficacy of care Conducting clinical trials, epidemiological studies, research Setting health policy Tracking public health and risks 8

9 ICD-10-CM Significant Improvements Strategic planning and designing healthcare delivery systems Monitoring resource utilization Improving clinical, financial, and administrative performance Detecting and preventing healthcare fraud and abuse 9

10 ICD-10-CM Significant Improvements Fewer miscoded, rejected & improperly reimbursed claims Improved disease management Increased Specificity Data comparability internationally 10

11 What remains the same? Use of code books or encoder Tabular List Chapters similar to ICD-9-CM with some exceptions Main Term, indented sub term Alphabetic Index of External Causes Table of Neoplasms Table of Drugs and Chemicals 11

12 What remains the same? Conventions abbreviations, punctuation, symbols, code first, use additional code, includes, excludes Code to highest level of specificity Adherence to HIPAA and official guidelines (ICD-10-CM) Nonspecific codes still available 12

13 What remains the same? Inconsistent, missing, conflicting, documentation must still be resolved by the Provider both today under ICD-9-CM, as well as in the future with ICD-10-CM 13

14 Coding and Documentation The goal is always to work toward better documentation for the following reasons: Avoid misinterpretation by third parties (such as auditors, payers, attorneys) Justify medical necessity Provide a more accurate clinical picture of the quality of care provided Support current & future initiatives aimed at improving quality and reducing costs, such as value-based purchasing 14

15 ICD-10-CM Differences Increase codes: 14,000 to 68,000 Flexible Incorporate emerging diagnoses, advances in medicine and medical technology Uses current medical terminology Codes are Alphanumeric all codes begin with a letter Uses all letters of the alphabet except the letter U 15

16 ICD-10-CM Differences Expanded length 3-7 characters vs. 3-5 Increased precision in diagnosis code Full diagnostic titles for each code Added Laterality (right/left, bilateral) Code extensions for injuries and external causes of injuries Combination codes for etiology & manifestations Episode of Care designation 16

17 ICD-10 Differences EXCLUDE NOTES Excludes 1: not coded here The 2 conditions contradict each other Acquired condition vs. congenital Codes cannot be reported together Excludes 2: not included here The condition excluded is not a part of the condition represented by the code Both codes can be reported together 17

18 ICD-10 Difference Acute MI Time Frame Change ICD 9 8 weeks or less ICD 10 4 weeks or less Hemiplegia / Monoplegia Dominant vs. Nondominant Example: G81.91 Hemiplegia, unspecified affecting right dominant side 18

19 Difference & Similarities Hypertension Table eliminated Only 1 hypertension code in ICD-10 Same rules apply in ICD-10 as in ICD-9 for combining Hypertension codes with heart disease and chronic kidney disease. 19

20 2013 American Health Information Management Association Hypertension ICD-9-CM Essential Hypertension, Malignant Essential Hypertension Benign Essential Hypertension Unspecified ICD-10-CM I10 Essential Primary Hypertension 20

21 2013 American Health Information Management Association Asthma with Acute Exacerbation ICD-9-CM Asthma, unspecified with acute exacerbation ICD-10-CM J Mild intermittent asthma with acute exacerbation J Mild persistent asthma with acute exacerbation J Moderate persistent asthma with acute exacerbation J Severe persistent asthma with acute exacerbation 21

22 2013 American Health Information Management Association ICD-10-CM Code Format. X X X X X X X Category Etiology, anatomic site, severity Extension 22

23 ICD-10 Placeholder X Addition of dummy placeholder X is used in certain codes to: Allow for future expansion Fill out empty characters when a code contains fewer than 6 characters and a 7 th character is required When placeholder character applies, it must be used in order for the code to be considered valid Example: S32.9XXD Fx Pelvis d/t fall, routine healing, subsequent episode of care 23

24 SIGNIFICANT DIFFERENCE Coding Fractures No longer will we use Aftercare codes for healing fractures V54.13 Aftercare for healing traumatic fracture of hip Will use the acute fracture code followed by an appropriate 7 th character extension to indicate subsequent episode of care 24

25 Closed Fracture 7th character extensions: A Initial encounter for closed fracture hospital, ER, clinic D Subsequent encounter for fracture routine healing G Subsequent encounter for fracture delayed healing K Subsequent encounter for fracture nonunion P Subsequent encounter for fracture malunion 25

26 CODING GUIDELINES 26

27 Coding Guidelines A Fracture not indicated as displaced or nondisplaced should be coded to displaced. A fracture not indicated whether open or closed should be coded to closed 27

28 Coding Guidelines Initial vs. subsequent encounter for fractures: Initial care involves active treatment Subsequent care occurs after active treatment and receiving routine care during the healing or recovery phase Sequela complications or conditions that arise as a direct result of an injury (previously called late effect ) 28

29 FRACTURES S72 S72.1 S72.14 S ICD 10 Structure Fracture Femur Pertrochanteric fx femur Intertrochanteric fx femur Displaced Intertrochanteric fracture of right femur S72.141D Displaced Intertrochanteric Fx of right femur, subsequent encounter for closed fx with routine healing 29

30 Closed fracture of the greater trochanter of the right femur (hip fracture) S72.111A - Initial encounter for closed fracture: Patient admitted for initial treatment in ER and hospital with resulting surgical repair S72.111D - Subsequent encounter for closed fracture with routine healing: Admission to long-term care (LTC) for rehabilitation after hip replacement 30

31 Examples: Subsequent Encounter S72.111D, Subsequent encounter for closed fracture with routine healing: Discharged from LTC Home Health for continued PT S72.111D, Subsequent encounter for closed fracture with routine healing: Patient visits hospital radiology department for X-ray S72.111D, Subsequent encounter for closed fracture with routine healing: Patient to physician office for follow-up visit 31

32 ICD-10-CM Snapshot Diabetes mellitus 59 to ~ 200+ Pressure ulcer 9 to ~ 125 Path. fracture 8 to ~ 150 Under dosing NEW section 32

33 ICD-10-CM Snapshot Z43.1 Z F03.90 L Attention to gastrostomy Aftercare following surgery on digestive system (cholecystectomy) Unspecified Dementia, w/o behavior Pressure ulcer right heel, stage III 33

34 ICD-10-CM Snapshot E11.40 Type II DM with neuropathy Z79.4 Long Term use of insulin J44.9 COPD Z99.81 Oxygen dependent Z79.52 Prednisone dependent 34

35 MI Myocardial Infarction Time frame for coding acute myocardial infarctions changes with ICD-10 ICD-9 ICD-10 8 weeks 4 weeks As long as treatment is required, regardless of care setting 35

36 MI Myocardial Infarction I21.4 Non-ST elevation (NSTEMI) myocardial infarction Use acute code for 4 weeks regardless of treatment facility I25.2 Old myocardial infarction After initial episode of 4 weeks, then use healed / old MI code 36

37 Residual Effects of Cerebrovascular Disease ICD-10-CM Hemiplegia following nontraumatic subarachnoid hemorrhage Hemiplegia following nontramatic intracerebral hemorrhage Hemiplegia following other intracranial hemorrhage 37

38 Residual Effects of Cerebrovascular Disease ICD-10-CM Hemiplegia following cerebral infarction Hemiplegia following other cerebrovascular disease Hemiplegia following unspecified cerebrovascular disease 38

39 Hemiparesis following CVA ICD-9-CM Hemiplegia following CVA affecting dominant side ICD-10-CM I Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side I Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side 39

40 CVAs Terminology Late Effects is eliminated from ICD-10 Sequela is the new term for Late Effects Sequela of cerebral hemorrhage Sequela of cerebral infarct Sequela of cerebrovascular disease 40

41 CVAs I69.0 I Sequela of hemorrhages I69.3 I Sequel of cerebral infarction Occlusion of artery Default for stroke I69.8 I Sequela of cerebrovascular disease 41

42 CVAs Coder will have to pay close attention to the type of CVA which occurred to obtain the correct code No more flipping to the 438 section and looking for your code! Flipping to I69 will only confuse you more! Use alphabetic index to look up what is documented in the record. 42

43 ICD-10-CM Project Planning Resources: Coding Manuals Coding Instruction Resources Training costs (Biomedical science & ICD-10) 43

44 ICD-10-CM Transition Budget $$$ Considerations Hardware/software system upgrade, maintenance fees Data Conversion Clinical & financial Forms redesign & reprinting Consultant Fees Outsourcing 44

45 ICD-10-CM Transition Budget Considerations Temporary staff needed to assist during transition period Lost productivity during training & implementation phase Increased coding time with ICD-10 45

46 ICD-10 Project Planning Clearinghouses, outside billing service, health Insurance payers When will upgrades be completed? When can claims with ICD-10-CM codes be transmitted for testing? Re-negotiate provider contracts or electronic data interchange agreements (EDI) 46

47 ICD-10-CM Project Planning Who Assigns or Uses ICD-9-CM Codes: Health Information Management (Medical Record Staff) Nursing, MDS Coordinators Admissions Billing Therapy Lab, X-ray 47

48 Early Preparation A well-planned, well-managed implementation process will increase the changes of a smooth, successful transition Experience in other countries has shown that early preparation is the key to success & earlier realization of benefits An early start allows for resource allocation, such as costs for systems changes and education, process evaluation and change, as well as staff time devoted to implementation processes to be spread over several years 48

49 Inadequate Preparation Potential Consequences Decreased coding accuracy Decreased coding productivity Increased compliance risks Increased claims rejection An adverse impact on patient care and administrative decision-making Decrease in key staff morale 49

50 Preparation When to Start. 50

51 2013 American Health Information Management Association 51

52 Methods of Training Current in-house SNF on-line Education System Online self-study courses including AHIMA Webinars/WebEx 52

53 Methods of Training Videos on specific body systems Seminars/workshops Local Educational Institutions ICD-10-CM Workbooks (self learn) 53

54 Methods of Training Local hospital educational programs ICD-10-CM ONLY NOT ICD-10-PCS) Qualified HIM Professionals / HIM Consultants (e.g. AHIMA Approved) 54

55 Coder Preparation Intensive Training: Not until 6 9 months prior to implementation 10/1/2014 LTC Coders: 16 hours (ICD-10-CM only for current trained coders) (Check with our timeline for consistency) 55

56 Coder Preparation Obtain refresher training for biomedical sciences Anatomy and Physiology Medical Terminology Pathophysiology Pharmacology 56

57 Transitioning from ICD-9 to ICD-10 LTC 1st Quarter 2014 (January March) Formal training for staff followed by hands-on practice Determine if coders have been using ICD-9- CM code lists (e.g. cheat sheets). These will require updating if processes are appropriate. (e.g. list of codes for unit clerks for lab requisitions) Determine if there are any forms which will need to be revised to allow for 7 characters Determine whether software is compatible with ICD-10-CM 57

58 Transitioning from ICD-9 to ICD-10 LTC 2nd Quarter 2014 (April June) Begin using ICD 9 codes with clear diagnostic descriptions, similar to those used in ICD 10 for ease in re-coding. Print diagnosis lists of current residents and code diagnoses with ICD-10-CM (Take sample number each week) for practice Maintain ICD-10-CM coded diagnosis lists (in case resident remains in facility) Continue to practice, practice, practice!! 58

59 Transitioning ICD-9 to ICD-10 LTC 3rd Quarter 2014 (July September) Dual code using both ICD-9 & ICD-10 By July 1, 2014 Determine if your software will be available and capable of dual coding All new admissions, hospital returns, and continued stay PLEASE NOTE: ICD-10-CM CONVERSION DOES NOT APPLY IN WORKMEN S COMP CASES Continue updating diagnosis lists and codes according to MDS schedule until all residents diagnosis lists have been updated. 59

60 Transitioning from ICD-9 to ICD-10 LTC 4th Quarter 2014 (Oct. December) Apply ICD-10-CM codes for all diagnoses for all admissions and MDSs starting October 1, Maintain Legacy ICD-9-CM Coding System Monitor claims & denials for coding errors and vendor problems 60

61 Billing Claims CMS working to address claims that overlap from September 30, 2014 into October 2014 (SNFs) All Claims submitted for services on or before September 30, 2014 will use ICD-9 codes ICD-10 codes will not be recognized/accepted on claims BEFORE

62 Billing Claims All claims submitted for services provided on or after October 1, 2014 will use ICD 10 codes Claims cannot contain BOTH ICD-9 codes and ICD-10 codes Claims using ICD-9-CM after 10/1/14 will be rejected 62

63 Billing Claims Facilities behind in billing Medicare? Use added transition time to get caught up with billing. Be current on go-live date 63

64 RESOURCES American Health Information Management Association American Association of Professional Coders Centers for Medicare and Medicaid Services ationplanning.html ces.html Centers for Disease Control 64

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69 2013 American Health Information Management Association Special Thanks to the AHIMA 2012 LTPAC Practice Council Coding & Reimbursement Strategy Team Nancy Benson, RHIA Molly Cahill, RHIA Michelle Dick, RHIA Deborah Johnson, RHIT, CHP Leslie Joyner, RHIT Kathie McClary, RHIT Tamela McQuiston, RHIT, RAC-CT Renae Spohn, RHIA Monica Tormey, RHIA Carol Young, RHIT 69