Preparing for ICD-10-CM

Preparing for ICD-10-CM

Mary Pat Johnson, COMT, CPC, COE, CPMA Senior Consultant

Corcoran Consulting Group

Financial Disclosure

Mary Pat Johnson is a Senior Consultant at Corcoran Consulting Group and acknowledges a financial interest in the subject matter of this presentation.

Key Points in Code Selection

? ICD-10 is more specific than ICD-9 ? Attention to detail ? Consider primary diagnosis, cause and/or related

conditions

ICD-10-CM Changes Everything

Who is Impacted?

? Physicians ? Administrators ? Coders / Billers ? Technicians ? Receptionists ? IT Staff ? Billing companies

How does ICD-10 Impact?

? Payer policies ? Pre-authorizations ? PQRS ? Tracking of services ? Marketing ? Forms ? Practice management system

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History of ICD-10-CM

? International Classification of Diseases, 10th Revision, Clinical Modification

? Developed by U.S. National Center for Health Statistics (NCHS) in 1993

? ICD-10 copywritten by the World Health Organization (WHO)

? ICD-10-CM replaces ICD-9-CM, volumes 1 and 2 ? United States is one of last countries to adopt ICD-

10

Why Replace ICD-9 ! ?

? ICD-9 is >30 years old, outdated, obsolete terminology

? Outdated codes producing inaccurate and limited data

? Inconsistent with current medical practice ? Does not provide enough detail

ICD-10-CM

? Much greater specificity and clinical information ? Use of most specific code(s) is not optional ? Provides better data to:

? Measure care ? Process claims ? Track public health ? Identify fraud and abuse ? Conduct research

ICD-10-CM

? Codes that allow comparison of mortality and morbidity data

? Increased number of concepts and codes provided ? Disease classifications include health related

conditions

Benefits of ICD-10

? More accurate payment for new procedures ? Fewer rejected claims ? Fewer improper claims ? Better understanding of new procedures ? Improved disease management

Deadline

? Final rule for adoption of ICD-10-CM ? Published in January 16, 2009 Federal Register (45

CFR part 162) ? Compliance date is October 1, 2013 ? Initial delay to October 1, 2014

Source: Federal Register, Vol. 74, No. 11 1/16/09

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ICD-10 Delayed Again...

? March 31, 2014 - HR 4302 signed by President Obama ? SGR formula ? temporary fix ? ICD-10 delayed ... "The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard code sets under section 1173(c) of the SSA and section 162.1001 of 45CFR"

Compare and Contrast

ICD-9 ? 17 Chapters ? 14,000 codes ? 3-5 digits ? First digit is numeric or

alpha (E or V) ? Digits 2-5 are numeric

ICD-10 ? 21 Chapters ? ~ 69,000 codes ? 3-7 digits ? Digit 1 is alpha ? Digit 2 is numeric ? Digits 3-7 are alpha or

numeric (alpha digits are not case sensitive)

Compare and Contrast

ICD-9

Example: ? Central corneal ulcer ?

370.03

ICD-10

Example:

? Central corneal ulcer right ? H16.011

? Central corneal ulcer left ? H16.012

? Central corneal ulcer bilateral ? H16.013

? Central corneal ulcer unspecified ? H16.019

"GEM"

? General Equivalence Mappings ? No "simple" crosswalk contained in this file ? GEM file is NOT a crosswalk, it is a mapping ? Expect annual update of files ? Eye codes translation is fairly straightforward

"GEM" Files

? Two sets of files ? ICD-9 to ICD-10 ? ICD-10 to ICD-9

? Each file contains "code pairs" ? one from each set

"GEM" Files

? No decimal point in the codes ? Three columns ? Third column describes additional attributes

? Flags (approximate, no map, combination) ? Combination entry ? 1 indicates "on" (Approximate) ? 0 indicates "off" (Direct hit, but verify)

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GEM File Layout

Senile Cataract Example

I-9

36610 36611 36612 36613 36614 36615 36616 36617 36618 36619 36619

I-10 + Flags

H259 H2589 H25099 H25039 H25049 H25019 H2510 H2589 H2520 H25819 H2589

00000 10000 10000 10000 10000 10000 10000 10000 10000 10000 10000

"1" in the first position in flag column = approximate

Organization of ICD-10-CM

? Introduction ? Conventions and Guidelines ? Alphabetic Index to Diseases ? Neoplasm Table ? Table of Drugs and Chemicals ? Index to External Causes ? Tabular List of Diseases

"GEM" Files

? Use GEMS ? Translating lists of codes ? Converting a system or application ? To study differences in meaning between two systems

? Use Code Books ? Translating short list of codes ? Access to medical record

Conventions for the ICD-10-CM Format

1. Alphabetic Index ? Index of Diseases and Injury ? Index of External Causes of Injury ? Table of Neoplasms ? Table of Drugs and Chemicals

2. Tabular List ? Categories ? Subcategories ? Codes

Alphabetic Index Notes

? Define terms ? Provide direction

? Wound, superficial (see also specified injury type)

? Provide coding instructions ? Trichiasis (eyelid) ? H02.059 ? with entropion ? see Entropion

Tabular List

? Categories ? 3 characters ? Chapter 7 ? Disorder of the Eye and Adnexa (H00-H59)

? Subcategories ? 4th character further defines site, etiology, manifestation or state of disease or condition ? 5th & 6th character increases specificity

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Tabular List

? 7th Character Extension ? Some categories have applicable 7th characters ? Last character ? If code is not six digits, use "x" as placeholder

? "x" as placeholder ? For when characters are needed for expansion

7th Character Extension

? A initial encounter ? D subsequent encounter ? S sequela

Example

Corneal Abrasion

Example

Corneal Abrasion

? Category ? Chapter 19 ? Injury, Poisoning . . .

S05 ? Injury of eye and orbit ? Subcategory ? 5th S05.0 ? Injury of conjunctiva and

corneal abrasion without foreign body ? Specificity ? x 7th S05.01 ? Injury of conjunctiva

and corneal abrasion without foreign body right eye

? Valid code ? S05.01xA -- Injury of conjunctiva and corneal abrasion without foreign body right eye; initial encounter

7th Character Extension

For glaucoma staging, 7th denotes severity of disease

? 1 = mild

0 = unspecified

? 2 = moderate

4 = indeterminate

? 3 = severe

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Example: Glaucoma Staging

7th character "is to be assigned to each code in subcategory H40.12 to designate the stage of glaucoma" ? Low-tension Glaucoma

? H40.12 ? Low-tension Glaucoma, bilateral (cannot stop here!)

? H40.123 ? Low-tension Glaucoma, right eye, moderate stage

? H40.1212 ? Low-tension Glaucoma, left eye, severe stage

? H40.1223

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