2/28/2013 ICD-10 AS MANDATED BY ACCME SPEAKERS ARE ASKED TO DISCLOSE ANY REAL OR APPARENT CONFLICT RELATED TO THE CONTENT OF THEIR PRESENTATION

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ICD-10

An Overview of the Code Sets with Emphasis on Documentation Requirements & Practice Readiness

UMMC Family Medicine Update March 5-8, 2013 Flowood, Mississippi Patty Harper, RHIA

AHIMA Approved ICD-CM/PCS Trainer AHIMA Ambassador

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AS MANDATED BY ACCME

SPEAKERS ARE ASKED TO

DISCLOSE ANY

REAL OR APPARENT CONFLICT

RELATED TO

THE CONTENT OF THEIR

PRESENTATION

TODAY’S SPEAKER HAS NO

DISCLOSURE TO MAKE

.

2

Today’s Objectives

• To provide an overview of ICD-10-CM and PCS • To discuss the structure and format of the code sets

• To discuss the importance of clinical documentation when assigning diagnosis codes

• To provide examples of ICD-10 Clinical Guidelines for code assignment • To provide tips for practice readiness

• To take questions from the participants

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What is ICD-10?

• The World Health Organization (WHO) publishes the International

Classification of Disease (ICD) code set, which defines diseases,

illnesses, sign & symptoms, complaints, abnormal findings as well

as external causes of injury or illness and social factors.

• ICD-10 is the tenth edition.

• NCHS is the federal agency responsible for adapting the WHO

version to a clinical modification (CM) for use in the United States.

• ICD-10-CM is mandatory for all entities covered under HIPAA.

• Version 5010 electronic health care transaction standards, also

mandated by HIPAA, must be implemented first.

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ICD-10 Timeline in the United States

1990 • World Health Organization authorizes Version 10.

1999 • United States begins using ICD-10 for mortality only. 2009 • HIPAA Simplification Act Rule pushed back Implementation from 10/1/2011 to 10/1/2013. 2011 • Original Implementation Date: 10/1/2011

2012 • 5010 Compliance Deadline & Delay; Final Rule postpones ICD-10 implementation to 10/1/2014. 2013

• Second Implementation Date : 10/1/2013 • Second Postponement through HHS Rule 2014 • Third Implementation Date: 10/1/2014

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ICD-10: Two Code Sets

 ICD-10- CM for Diagnosis Coding: This is the US Clinical Modification (CM) of the World Health Organization classification system or ICD-10-CM. ICD-10-CM will be used in ALL settings.

 ICD-10-PCS for Procedure Coding: In 1993, Centers for Medicare and Medicaid Services (CMS) commissioned 3M Health Information Systems to develop the new system. This is ICD-10-PCS. It will be used for Inpatient Procedures. CPT Codes will remain in use for all Physician Services

and Outpatient/Ambulatory Services. 

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What are the differences between

ICD-9 and ICD-10 diagnosis codes?

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Comparison of ICD-9 and ICD-10 Diagnosis Codes Diagnosis Coding Comparison

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Feature ICD-9-CM ICD-10-CM

# of Diagnosis Codes 16,000 68,000 Chapter in Code Set 17 21 Length of Codes 3-5 digits 3-7 characters Format of Code 1st_{digit is numeric or}

E of V; 2-5 are numeric. 1st_{character is} alpha; 2-3 is numeric; 4-7 can be alpha or numeric. Injury Codes By Type of Injury By site and then type

of injury Laterality Not required Specified in code Code extensions Not applicable Place holder of X to

allow 7th_{character for}

episode of care, severity, etc.

Diagnosis Code Structure Comparison

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ICD-9-CM ICD-10-CM

Codes can be 3-5 characters/positions in length. Decimal after the 3rd_character.

Codes can be 3-7 characters/positions in length. Decimal is after the 3rd_{character. Placeholders} “x” are used if an extension is required.

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Diagnosis Code Comparison

Diagnosis ICD-9 ICD-10

Hypertension, unspecified 401.9 I110 Sprain, left ankle

Fall from stairs Initial Treatment 845.00 E880.9 S93.402A W10.9xxA Diabetes mellitus

Type II, Not uncontrolled. 250.00 E11.9 Diabetes mellitus,

Unspecified, uncontrolled 250.02 E11.65 Full-term uncomplicated

delivery, single live birth

650 V27.0

O80 Z37.0

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Will more codes mean more

documentation?

Maybe...

Most Probably!

11 12 Documentation elements, probably already in the note, now become critical to code assignment. The challenge will be how to get that documentation to the claim.

What is already in your

note and what isn’t ?

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Documentation Requirements

Some of the documentation requirements include:

• Laterality (right, left, bilateral) • More specific anatomical site • Episode of care for injuries • Characteristics of disease • Complications • Contributing Factors • Patient History

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Laterality and Anatomical Direction

• Right, Left, Bilateral

• Anterior/Posterior

• Ventral/Dorsal

• Distal/Proximal

• Medial/Lateral

• Superior/Inferior

This will be common knowledge for the physician or provider. But, will the coder or biller understand this language?

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Acute Suppurative Otitis Media

ICD-10-CM The Code Assignment Requires:

Type of OM

+

Laterality

+

Status of Infection

+

With or W/0 rupture of eardrum

=

A Total of 16 possible codes

**Plus, additional code for exposure to environmental tobacco smoke.

ICD-9-CM 382.00: Acute suppurative Otitis Media without spontaneous rupture of eardrum

382.01: Acute suppurative Otitis Media with spontaneous rupture of eardrum

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Acute Suppurative Otitis Media

PLUS: Use Additional Codes: Exposure to tobacco smoke; in perinatal period; occupational; environmental.

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H66.001: w/o rupture of eardrum, right

ear

H66.002: w/o rupture of eardrum,

left ear H66.003:w/o rupture of eardrum,

bilateral

recurrent, rightear H66.005: w/o rupture of eardrum,

recurrent,left ear

H66.006: w/o rupture of eardrum,

recurrent, bilateral

H66.007: w/o rupture of eardrum, recurrent,unspecifiedear

unspecifiedear H66.011:w/rupture of eardrum, right

ear

H66.012:w/rupture of eardrum, left

ear H66.013: w/rupture of eardrum,

bilateral

H66.014: w/rupture of eardrum,

recurrent, rightear H66.015: w/rupture of eardrum,

recurrent, leftear

recurrent, bilateral

recurrent,unspecified ear.

H66.019:w/rupture of eardrum,

unspecifiedear.

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Injuries: Specific Anatomical Site

S63.6 Other and Unspecified

Sprain of Fingers

S63.621

Sprain of

interphalangeal

joint

of

right

thumb

S63.633

Sprain of

interphalangeal

joint

of

left

middle finger

S63.656

Sprain of

metacarpophalangea

l joint

of the

right

little finger

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More examples of Injury Codes

Injury codes are organized by site and then by type of injury. Secondary codes used to provider more information about cause of morbidity. Case #1: A 10 year old child is sting on the lip by a wasp while playing in a tree house.

T63.461 Toxic effect of venom of wasp, unintentional

Case #2: His sister receives a tick bite her rightthigh while playing in the same tree house.

S70.361A Insect bite (nonvenomous), right thigh, initial encounter for care W57.xxxA Bitten or stung by nonvenomous insect

Case #3: A 36 year old man is treated for a second degree burn on the back of his left hand during a welding accident. This is the second visit for this injury.

T23.262D Burn of second degree of back of left hand X18.xxxD Contact with other hot metals

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Clinical Data Elements Needed for

Code Assignment (Examples)

Element Description ICD-9-CM Code ICD-10-CM Code

Laterality Right knee pain 719.46: Pain in joint, lower leg

M25.561: Pain in rightknee Laterality Acute Atopic

Conjunctivitis, Bilateral 572.05: acute atopic conjunctivitis H10.13: Acute atopic conjunctivitis, bilateral Laterality Laceration, left hand 882.0: open wound

of hand without complication

S61.402A: Open wound, left hand,

initial care

Sequela Skin Contracture, right foot, resulting from 2nd

degree burn. 906.7; Late effect of burn 709.2: Cicatrix L90.5;Cicatrix T25.221S; 2nd_degree

burn foot, rightfoot,

late effect.

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Clinical Data Elements Needed for

Code Assignment (Examples)-

continued

Element Description ICD-9-CM Code ICD-10-CM Code

History & Factors Influencing Health Status

Chronic maxillary sinusitis in a patient with cigarette smoking in the home.

473.0, Chronic sinusitis, maxillary J32.0, Chronic maxillary sinusitis Code also: Z77.22, Exposure to second hand tobacco smoke History & Factors Influencing Health Status Malignant neoplasm of external upper lip in alcoholic patient who is also a smoker. 140.0, Malignant neoplasm of lip, vermilion border C00.0, Malignant neoplasm of external upper lip. Code also: F10.20, Alcohol dependence, uncomplicated Z72.0, Tobacco use 21

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Can you benefit from this specificity?

• Can the codes help you manage your panel better by more specifically identifying conditions, contributory factors, and complications?

• Or, are you just collecting data for researchers and third parties? • It’s a good question. The question can apply to both ICD-10 and

EHR implementation.

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Clinical Guidelines for Code

Assignment

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A few highlights...

Coding Diabetes Mellitus

ICD-10

E08 Diabetes Mellitus due to an underlying condition E09 Drug or chemical induced

diabetes mellitus E10 Type I diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes

mellitus

E14 Unspecified diabetes mellitus

• Combination codes under each category include manifestation; no need to code separately. ICD-9

249 Secondary DM

250 Diabetes Mellitus • 5th_{digit used to state type and}

whether in or out of control • Use additional code to identify

manifestation.

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Coding Case: Diabetes Mellitus

A 68 year old woman with poorly controlled DM II presents with an ulcer on her left foot (as illustrated). There is a significant breakdown of the skin. The patient is insulin dependent and has a history of non-compliance. Patient acknowledges that she is still not following her diet. Random blood glucose taken this office visit is 300 mg/dL. A1c = 9.0%.

ICD-10

E11.621 Type 2 diabetes mellitus with foot ulcer E11.65 Type 2 diabetes mellitus with hyperglycemia L97.522 Non-pressure chronic ulcer of other part of leftfoot Z79.4 Long term (current) use of Insulin

Z91.11 Patient’s noncompliance with dietary regimen

ICD-9

250.82 Diabetes with other specified manifestations 707.15 Ulcer of lower limbs, except pressure ulcer, ulcer of

other part of the foot V58.67 Long term use of insulin V15.81 Non-compliance with medical treatment

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ICD-10-CM Coding Guidelines:

Hypertension, Heart Disease & Kidney Disease

• Hypertension with Heart Disease – A causal relationship must be stated. – Additional code for heart failure by type. – Heart conditions not stated as due to hypertension are

coded separately.

I11.0 Hypertensive Heart Disease

I50.43 Acute on Chronic Combined systolic (congestive) and diastolic (congestive) heart failure • Hypertensive Chronic Kidney Disease

– ICD-10 presumes a cause and effect relationship even if not stated.

– Additional code for stage. – Additional code for acute renal failure.

I12.9 Hypertensive Chronic Kidney Disease (Stage 1-4) N18.4 Chronic Kidney Disease (Stage 4)

N17.9 Acute Kidney Failure, Unspecified

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Hypertension, Heart Disease & Kidney Disease

• Hypertensive Heart and CKD – New combination codes

– Hypertensive heart and hypertensive kidney disease must be stated in diagnosis.

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease or unspecified stage chronic kidney disease.

• Myocardial Infarctions – In ICD-9: 8 weeks – In ICD-10: 4 week

I121.01 ST Elevation (STEMI) myocardial infarction of anterior wall involving left main coronary artery. Also code, tobacco use or exposure or history of use.

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ICD-10-CM Coding

Examples/Guidelines

Pressure Ulcers: New combination codes that identify site and stage in one code; no code assigned if the pressure ulcer is documented as healed.

L89.212 Pressure Ulcer Right Hip, Stage 2 L89.143 Pressure Ulcer of Left Lower Back, Stage 3 L89.000 Pressure Ulcer of Unspecified Elbow, unstageable

Obstetric Care: The trimester of pregnancy is reflected in the last character of the diagnosis. Incidental encounters use Z33.1: Pregnant state, incidental

O23.91 Unspecified Genitourinary Tract Infection in Pregnancy, First Trimester O26.03 Excessive Weight Gain in Pregnancy, Third Trimester

O26.842 Uterine size – date discrepancy, Second Trimester

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ICD-10-CM Coding

Examples/Guidelines

Fractures: A 7th character extension is used to specify whether it is an initial or subsequent encounter during active treatment or if delayed treatment or nonunion occurred. Fractures are coded using Salter-Harris or Gustilo classifications, as applicable. The acute injury is coded each time the condition is treated.

S42.031A Displaced fracture of lateralend of the rightclavicle, initial care

S89.012G Salter-Harris Type I physeal fracture of the upper end of left

tibia with delayed healing.

S72.009C Fracture of unspecifiedpart of neck ofunspecifiedfemur,

initial encounter for open fracture type IIIA, IIIB, IIIC.

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ICD-10- PCS

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ICD-10- PCS: The other new code set

• Used only for inpatient settings

• CMS engaged 3M to create the code set • Not used outside the United States

• Replaces the ICD-9 procedure codes currently used for IP services • Will not apply to outpatient or physician services

• Hospitals may choose to code OP services this way for comparison purposes.

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What will the PCS codes look like?

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• The ICD-10/PCS is structured as a multi-axial, seven character alpha-numeric code. • Codes are “built” using a defined value for each position.

Codes are specific to each case. Knowledge of anatomy and physiology.

• Will require more detailed operative reports; increased queries; interpretation of terms to conform with new root

operation definitions.

Source of character diagram (rev.)

http://www.clinicalarchitecture.com/Portals/41958/images/ICD10PCS_small.jpg

Body System

Procedural Coding Comparison

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Getting There from Here

How does a practice transition from ICD-9 to

ICD-10?

34 Think about everywhere a code is created, used, or communicated! The entire revenue cycle from registration to final payment is changed by the codes we use. Diagram source: http://www.aapc.com/ICD-10/office-map/index.aspx 35

How to Transition to ICD-10

1. Determine how your practice will be effected (gap analysis). 2. Decide if you need help. Where to get help?

3. Identify your top diagnosis codes in ICD-9.

4. Map the current diagnosis codes to new ICD-10 codes to determine what the new requirements will be for documentation & code assignment.

5. Evaluate current practice management systems and EHR systems. 6. Contact vendors. Ask about ICD-10 and their products. Are implementation and

transition upgrades included in your current license or agreement.

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How to Transition to ICD-10

(continued)

6. Evaluate current clinical workflow. Can you capture information more efficiently?

7. Evaluate front & back office business processes. What will need to change? 8. Analyze clinic notes, office forms, orders, EHR templates. Will these need to be

redesigned to accommodate greater specificity? 9. Who will need to be trained in ICD-10? To what extent? 10. Consider adding a professional coder to your team.

11. Find out how your other business partners (payers, clearinghouses, your affiliated hospitals, outside service providers, labs) are going to make the change. How does what they do effect you?

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Additional Resources

• CDC Website for ICD-10

http://www.cdc.gov/nchs/icd/icd10cm.htm • ICD-10-CM Official Clinical Guidelines

http://www.cdc.gov/nchs/data/icd10/10cmguidelines_2013_final.pdf • CMS ICD-10 Implementation Guide for Small to Medium Practices http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD10SmallandMediumPractices508.pdf • CMS ICD-10 Implementation Guide for Large Practices

http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD10LargePractices508.pdf • AMA Resources for ICD-10

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing- insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page

• AAFP Resources for ICD-10

http://www.aafp.org/fpm/topicModules/viewTopicModule.htm?topicModuleId=79

• AAPC Resources for ICD-10

http://www.aapc.com/icd-10/index.aspx

• AHIMA Resources for ICD-10

http://www.aapc.com/icd-10/index.aspx

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Questions or Comments

?

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Contact Information

Patty Harper, CEO

RHIA

AHIMA-Approved ICD-10-CM/PCS Trainer HIT-IM HIT-CF 406 Frazier Road Ruston, LA 71270 pharper@inquiseek.com www.inquiseek.com 318-243-2687 40