Getting Ready for ICD-10
Part 1: The Basics
In the United States, on October 1, 2015 the ICD‐9 code set used to report medical diagnoses and inpatient procedures will be replaced by the International Classification of Disease, Tenth Edition (ICD‐10). This module will provide an overview of why the change to ICD‐ 10 is occurring and the impact of this change on healthcare documentation.
Introduction
After completion of this module the learner will be able to: 1. Discuss the need for the change from ICD‐9 to ICD‐10. 2. Distinguish between ICD‐10‐CM and ICD‐10‐PCS. 3. Describe key benefits to changing to ICD‐10 Coding for providers, patients and payers. 4. Define GEMS.
Objectives:
Directions:
Review the content of this module and complete the attached post‐ test. Successful completion of the post‐test is worth 0.5 PRMC educational credit and will be documented on your NetLearning transcript.What is ICD‐10?
• ICD‐10 is the updated version of medical codes used for coding patients’ medical treatments and care. It will replace the ICD‐9 codes (International Classification of Diseases, 9th edition). • ICD‐10 contains 2 “classification” code sets: 1. Diagnoses for all providers (ICD‐10‐CM) CM stands for Clinical Modifications 2. Inpatient hospital procedures (ICD‐10‐PCS) PCS stands for Procedure Coding SystemThe History of ICD‐10
•
In 1994, ICD‐10‐CM guidelines were published by the World Health Organization (WHO) and adopted world‐wide (except for the United States).•
Using the ICD‐10 CM guidelines published by WHO, ICD‐10‐CM
(Clinical Modifications) were developed and modified by the U.S. Centers for Disease Control and Prevention (CDC) with the input of physician specialty associations. The intent is to replace ICD‐9‐CM.•
The ICD‐10‐PCS
(Procedure Coding System) was developed and is maintained by the Centers for Medicare and Medicaid Services (CMS) and will replace the ICD‐9‐CM Volume 3 procedural codes.Why the Change from ICD‐9‐CM?
The change is being made from ICD‐9‐CM because ICD‐9‐CM: • Is 30+ years old. It is outdated, and includes obsolete classifications of diseases. • It does not allow for new technology unheard of 3 decades ago, for example – laparoscopy, endoscopy or thoracoscopy. • Produces limited data about patients’ medical conditions and hospital inpatient procedures. • Is out of capacity. Data to improve care is incomplete and lacks the necessary detail. • Does not allow the physician to see the whole scope of patients’ conditions.Why the Change to ICD‐10?
With the change to ICD‐10‐CM and ICD‐10‐PCS there will be: • Better exchange of health data between the U.S. and other countries. • Better data for the National Committee on Vital and Health Statistics (NCVHS); details on injuries, accidents, including what the patient was doing when injured, where injury occurred, what body part. • Improved public health reporting and tracking for: • Dangerous settings and products • Diseases • Injuries • Terrorism • Threats • Better examples to identify a public health concern for an entire community, or data for the CDC on the top 10 causes of death.Who Needs to Transition to ICD‐10?
The transition to ICD‐10 is required for every healthcare organization that is covered by the Health Insurance Portability Accountability Act, or HIPAA. This includes: – Health Care Providers – Payers (including Medicare) – Clearinghouses – Billing Services NOTE: Non‐Covered Entities are not required to transition to ICD‐10. See next slide.Who Are Non‐Covered Entities?
•
Property and casualty insurance health plans (auto insurers)•
Workers Compensation ProgramsHowever, non‐covered entities may still want to
transition to ICD‐10 coding . . .
If non‐covered entities choose to participate in ICD‐10 it will be to their benefit because:•
The expanded detail in injury codes in ICD‐10 will help automobile and Workers Compensation programs identify types of injuries.•
ICD‐9 will no longer be maintained.•
The use of ICD‐10 coding facilitates coordination of benefits.•
It will help non‐covered entities to be consistent with industry standards.What Improvements Come With ICD‐10?
ICD‐10‐CM and ICD‐10‐PCS will: • Better reflect current medical practices. • Capture more specific data from clinical documentation – much higher level of specificity. • Help facilitate patient care coordination across settings. • Link diseases. • Provide updated terminology with synonyms to make documentation easier. continued on next slideICD‐10‐CM and ICD‐10‐PCS will have: • More information per code. • Better support for care management. • Better support for quality measurement. • Better support for analytics – safety, reimbursement, value‐ based purchasing, research and policy. • Improved ability to understand risk and severity of condition. • Fraud prevention by being able to track a problem for multiple encounters or treatments.
What Improvements Come With ICD‐10?
Comparison of ICD‐9‐CM to ICD‐10
ICD-9
ICD-10
18,000 codes ‐ 14,000 diagnosis codes ‐ 4,000 procedure codes ‐ 1,592 MCCs (major comorbid conditions) ‐ 3,427 CCs (comorbid conditions) 155,000 codes ‐ 68,000 diagnosis codes ‐ 87,000 procedure codes ‐ 3,152 MCCs (major comorbid conditions) ‐ 13,594 CCs (comorbid conditions) • Little detail • Difficult to analyze data • High definition • Laterality, bilaterally dominance • Supports data analysis • Greater specificity • Full description and consistency within the code set • Uses modern terminology for descriptionsThe new structure of ICD‐10‐CM will be:
category etiology extension anatomic site
severity
X X X X X X X
ICD‐10‐CM replaces ICD‐9‐CM
for Diagnosis Coding:
The new structure of ICD‐10‐PCS will be:
Section Root Approach Qualifier Operation
Body Body Device System Part
1
2
3
4
5
6
7
ICD‐10‐PCS replaces ICD‐9‐CM
(Volume 3, Procedural Codes)• ICD‐10‐CM replaces ICD‐9‐CM for diagnosis coding: ICD‐10 CM diagnosis codes will be 3 to 7 digits • ICD‐10‐PCS replaces ICD‐9‐CM for inpatient procedure coding: ICD‐10‐PCS codes must be 7 alphanumeric digits Each position has a specific meaning. • ICD‐10 expands details for many conditions.
So to Review ICD‐10 Structure . . .
Please Note: The change to ICD‐10 does not affect Current Procedure Terminology (CPT) for outpatient procedures.What is GEMS?
General Equivalence Maps (GEMS), is located on the CMS website, and is a tool used to convert data from ICD‐9‐CM to ICD‐10‐CM and ICD‐10‐PCS and vice versa. Mappings between ICD‐9 and ICD‐10 attempts to find corresponding diagnosis codes between the two code sets, insofar as this is possible. This tool provides important information linking codes of one system with codes in the other system. GEMS is intended as a reference, but does not take the place of using the ICD‐10 Coding Manual.In making the conversion to ICD-10 you will see and hear the term “GEMS”.
NOTE: GEMS should not be used for coding medical records. Codes are not equivalent because some ICD‐9 codes have multiple ICD‐10 codes due to increased specificity in ICD‐10. GEMS is: • a crosswalk between ICD‐9‐CM to ICD‐10‐CM. • found on CMS and CDC/NCHS websites. (NOTE: Our geographic area is denoted as
JL
, this includes DC, DE, MD, NJ and PA.) • intended for use by payers as a temporary mechanism for Legacy® systems. • used for education and planningMore About GEMS?
The following ICD‐9‐CM Codes – 25050 Diabetes with ophthalmic manifestations, type II or specified type, not stated as uncontrolled – 36206 Severe nonproliferative diabetic retinopathy; – 36207 Diabetic macular edema Would crosswalk in ICD‐10‐CM as: (GEM) ‐ E11341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
An Example of a GEM
• The ICD‐10 code set differs significantly from ICD‐9. • The ICD‐10 code set conveys significantly more information and detail than ICD‐9. • The change in code sets has significant impact on healthcare providers, patients and payors. • GEMS will be a part of the transition from ICD‐9 to ICD‐10. • It is important for you to be aware of and understand the coding structure of ICD‐10 in order to support Patient Financial Services functions. No coding experience is needed, you are NOT required to become a coder.
