ICD-10
Implementation
Merin McCabe
•
AAPC Certified Professional Coder (CPC)
•
AAPC Certified Coding Instructor (PMCC and ICD-10)
•
Coder/Biller
•
Independent Contractor
•
Medical Business Advocates, LLC
•
858-382-9853
WHAT
• CM=Patients
reason for
encountering
health care
• PCS = Procedures
(in-patient)
WHY
• More Informative
Codes
• Improved Quality
Reporting
• Improved Risk &
Severity
WHO
• All HIPAA
covered entities
• Auto-liability and
Workers
Compensation
exclusion
Cosmetic Changes
•
ICD-9-CM = 3-5 Characters
•
ICD-10-CM = 3-7 Characters
•
All codes are alphanumeric
Narrative
ICD-9-CM
ICD-10-CM
DM Type II, uncontrolled
with stage 4 kidney disease
250.42 – DM Type II,
uncontrolled w renal
manifestations
585.4 – Stage 4 CKD
E11.22 – DM 2 w CKD
N18.4 – Stage 4 CKD in Chronic Disease
E11.65 – DM2 w hyperglycemia
Asthma, moderate persistent
with acute exacerbation
493.92 – Asthma unspecified
with acute exacerbation
J45.41 – Moderate persistent asthma with
acute exacerbation
RULE: Code also tobacco use or exposure
CVA 2006, left arm weakness
438.89 Other late effects of
cerebrovascular disease
Sequela of cerebrovascular disease and need
the following additional information:
1) Non-traumatic Subarachnoid hemorrhage,
intracerebral hemorrhage; cerebral
infarction; other cerebrovascular disease
2) Left dominant/non-dominant or right
dominant/non-dominant
Hypertension
•
I10 = Essential (primary) hypertension. Includes hypertension (arterial)
(benign) (essential) (malignant) (primary) (systemic)
•
No longer separate Benign from Malignant
Behavioral/Mental Health
•
Added Behavioral and Neurodevelopmental Disorders to heading, was
Mental Health
•
Continuous and Episodic are removed
•
History of = Remission
•
Hierarchy: Use – Abuse – Dependence
•
ADD/ADHD = ADHD predominantly inattentive; predominantly
hyperactive; combined
Major ICD Concept Changes
•
# Weeks and Trimester for maternity care; from pre-post period
•
Acute Care timeline for MI changed from 8 weeks to 4 weeks
•
Fetal death now 20 weeks gestation not 22 weeks
•
Initial v Subsequent v Sequela Care for injuries, no longer late effects
•
Laterality – Right, Left, Bilateral
•
Underdosing and toxic effects codes
•
1 need for vaccination code
Social Determinants of Health
•
Environmental Factors
•
Socio-Economic Factors
•
Household Factors
•
Behavioral Factors
•
Social & Community Factors
•
Health System Factors
•
Psychological Factors
•
Biological Factors
Z73.- Life Management
•
Burn out
•
Type A Behavior Pattern
•
Lack of relaxation and leisure
•
Stress, NEC
•
Inadequate social skills
•
Social Role Conflict
PLAN
Impact Analysis:
High impact codes
& documentation
requirements
Where ICD touches
the program now
PREPARE
Train/educate
High impact
process changes
Process
improvements
IMPLEMENT
Test
Internal & External
Readiness
October 1,
2015
Dates of
Plan
A CHAMPION:
A PROVIDER OR ADMINISTRATOR WHO
UNDERSTANDS THE BREADTH AND SIGNIFICANCE OF THE
CHANGE; HOLDS OVERALL RESPONSIBIILTY AND DECISION
MAKING AUTHORITY; ENSURES INVOLVEMENT OF ALL
STAKEHOLDERS FROM PROVIDERS TO CLEARINGHOUSES AND
SOFTWARE VENDORS.
High Level Impact Analysis
HIGH IMPACT CODES
•
Highest revenue impact
•
Highest frequency
TOUCHES
Referrals and authorizations
Quality Improvements
Pay for Performance Programs
Billing Service
Clearinghouse
Software definitely – hardware too?
Impact Analysis – deeper dive
•
Which are your “High Revenue Codes” could be most common or higher reimbursement risk
•
Evaluate high revenue codes used over the past year. Exclude those codes that are not cross-walking (vaccines)
•
Evaluate ICD coding skills now. What are losses due to “Medical Necessity”?
•
How can other staff assist? Injury Details, pregnancy # weeks, episode of care
•
Look at business processes
•
Referrals, authorizations and pre-certifications
•
Patient scheduling
•
Provider orders
•
Public Health Reporting
•
Contracts linked to diagnoses; payment timeliness
External readiness
•
Software Vendors:
When can you use the codes for testing? Additional costs for the
update(s)? How will issues be managed? If a software upgrade is required, how will the
installation be handled (downtime)? Are there any hardware requirements associated with
this upgrade? Maintenance costs? How are you to report issues and what is the response
plan including timeliness?
•
Clearinghouse:
Check on their ICD-10 preparation and readiness; when and how can you
test; how will rejections be managed?
•
Billing service:
Have they obtained appropriate training? How will provider queries and
claim rejections be handed? What are compliance program updates for your contract?
•
Payers:
Ask payers if they are revising contracts or policies based on ICD-10 and if so do
you need to negotiate; Ask about testing plans
EMR Upgrades
•
Cost and Schedule
•
Downtime
•
Staff training absence
•
Impact to care and access
Skill in Business Office
•
What date of service are you billing for?
•
Are you following up on denials?
Formal Training & Education
•
Full training = 2.5-3 days
•
Provider documentation = ~1 day
•
Administration = 2-4 hours
•
Software changes = ??
•
Coding training – Who is providing the training? What qualifications do they
have to train you and what materials are they using and providing.
Code Set
•
Obtain ICD-10-CM Code books
•
Verify software capability
•
Look-up functionality in software or other resource
•
Code set available
•
Documentation Adequate
•
Staff trained to use correctly
•
Users are proficient
•
Dual Coding period (90days)
Documentation
•
Documentation requirements for ICD-10 should:
•
Support the diagnosis
•
Justify the treatment/procedure
•
Document the course of care
•
Identify treatment/test results
•
Promote continuity of care among healthcare providers
•
Payors are looking for:
•
Knowledge of severity of patient’s complaint or condition
Clinical Documentation
•
There are “Magic Words” that will correct high number of documentation
problems
(credit Dr. Jonathan Elion)
•
DUE TO
•
MANIFESTED BY
Internal Readiness - Software
•
Software functional
•
Templates prepared
•
Reports functional
Internal Testing
•
Policies and processes
•
Payer readiness
•
Test claim submission and remittance receipt (end-to-end)
•
Test verification of eligibility, referral and pre-authorizations
•
Test quality management reports
•
Test all existing processes to be sure none were negatively affected by
this update
End to End Testing,
next round
•
Sign up in April (CMS)
PREPARE FOR IMPACT
•
Provider productivity
•
Coding productivity
•
Coding accuracy
•
Vendor responsiveness
•
Payer preparedness
BEST RECOMMENDATIONS
•
Eliminate coding and billing backlogs a full 45 days prior to 10/01/2015
•
Prioritize medical records for coding
•
Provide refresher training to address productivity and accuracy issues
RESOURCES
•
http://www.cms.gov/Medicare/Coding/ICD10
•
https://www.aapc.com/icd-10/
•
http://www.ahima.org/topics/icd10
•
http://www.mgma.com/store/store-news/april-2015/icd-10-preparation-resources
Ask the Contractor Teleconference - ICD-10 - April 30, 2015
Join us at the upcoming Ask the Contractor Teleconference (ACT) for ICD-10 related questions or concerns.
Date: Thursday, April 30, 2015
Time: 1-2 p.m. PT
Toll Free Number: 800-260-0712
Noridian representatives from various departments including Appeals, Claims Processing, Electronic Data Interchange Support Services (EDISS),
Medical Review (MR), Provider Contact Center (PCC), Provider Enrollment, Provider Outreach and Education (POE), and System Support will be
available to address your questions.
No registration is required for this call
. Please call in ten minutes prior, the call will start promptly at the time
designated in the schedule listing. After placing the call, you will be asked for the following:
•
Conference Name
•
Facility Name
•
Location
•
Number of people in attendance
ACTs are designed to open communication between providers and Noridian, which allows for timely identification of problems, and sharing
information in an informal and interactive question and answer (Q&A) format.
No Personal Health Information (PHI) is allowed.
Noridian created
the "Ask the Contractor Teleconference Question Submission Form"
https://med.noridianmedicare.com/web/jeb/education/act
, which can be used
to submit questions up to five days prior to the ACT. Questions submitted using this form will be answered first during the ACT; lines will then be
opened as time allows.
Do not include any PHI or claim specific inquiries on this form. If you have claim specific questions, contact the Provider
Contact Center.
Providers will need to have Version 7 or higher of Adobe Reader to use this form. Q&As will be posted on the Noridian website at
Medi-Cal
•
FAQ Handout
•
Highlight
How is Medi-Cal addressing the implementation of ICD-10?
Medi-Cal will be using a crosswalk solution in the legacy California Medicaid Management
Information System (CA-MMIS). Medi-Cal has mapped all ICD-10 codes to corresponding
ICD-9 codes starting with the General Equivalence Mappings (GEMs) provided by the Centers
for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing
Medi-Cal policy. Claims will be run against the crosswalk to determine the ICD-9 value to
process through the system. The crosswalk will only be used temporarily for ICD-10 claim
adjudication while the implementation of our new MMIS system is being completed. Once the
new system is online, Medi-Cal will adjudicate all claims natively using ICD-10 and the
Cencal Health
Merin McCabe
•
AAPC Certified Professional Coder (CPC)
•
AAPC Certified Coding Instructor (PMCC and ICD-10)
•
Coder/Biller
•
Independent Contractor
•
Medical Business Advocates, LLC
•
858-382-9853
BE
GINNER
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» The ICD-10 Transition:
AN INTRODUCTION
he ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. This fact sheet provides background on the ICD-10 transition, general guidance on how to prepare for it, and resources for more information.
T
»
ICD-10
ICD-10 DEADLINE
BE
GINNER
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-2-About ICD-10
ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/ Procedure Coding System) consists of two parts:
The transition to ICD-10 is occurring because ICD-9 produces limited
data about patients’ medical conditions and hospital inpatient
procedures.
ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.Who Needs to Transition
ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The change to ICD-10 does not affect CPT coding for outpatient procedures.
Health care providers, payers, clearinghouses, and billing services must be prepared to comply with the transition to ICD-10, which means:
l All electronic transactions must use Version 5010 standards, which have
been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes.
l ICD-10 diagnosis codes must be used for all health care services provided in
the U.S., and ICD-10 procedure codes must be used for all hospital inpatient procedures. Claims with ICD-9 codes for services provided on or after the compliance deadline cannot be paid.
Health care
providers, payers,
clearinghouses, and
billing services must
be prepared to comply
with the transition to
ICD-10.
ICD-10-CM
for diagnosis
coding
ICD-10-PCS
for inpatient
procedure coding
ICD-10-CM is for use in all U.S. healthcare settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.
ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.
BE
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Last Updated: August 2014
Transitioning to ICD-10
It is important to prepare now for the ICD-10 transition. The following are steps you can take to get started:
l Providers – Develop an implementation strategy that includes an assessment of the
impact on your organization, a detailed timeline, and budget. Check with your billing service, clearinghouse, or practice management software vendor about their compliance plans. Providers who handle billing and software development internally should plan for medical records/coding, clinical, IT, and finance staff to coordinate on ICD-10 transition efforts.
l Payers – Review payment policies since the transition to ICD-10 will involve new
coding rules. Ask your software vendors about their readiness plans and timelines for product development, testing, availability, and training for ICD-10. You should have an implementation plan and transition budget in place.
l Software vendors, clearinghouses, and third-party billing services – Work with
customers to install and test ICD-10 ready products. Take a proactive role in assisting with the transition so your customers can get their claims paid. Products and services will be obsolete if steps are not taken to prepare.
ICD-10 Resources
There are many professional, clinical, and trade associations offering ICD-10
information, educational resources, and checklists. Call or check the websites of your associations and other industry groups to see what resources are available.
www.cms.gov/ICD10
The CMS website has official resources to help you prepare for ICD-10. CMS will continue to add new tools and information to the site throughout the course of the transition.
Sign up for ICD-10 Email Updates
ICD-10 Basics for
Medical Practices
The ICD-10 transition takes planning, preparation, and time, so medical practices should continue working toward compliance. The following quick checklist will assist you with preliminary planning steps.
Identify your current systems and work processes that use ICD-9 codes. This could include your clinical documentation, encounterforms/superbills, practice management system, electronic health record system, contracts, and public health and quality reporting protocols. It is likely that wherever ICD-9 codes now appear, ICD-10 codes will take their place.
Talk with your practice management system vendor about accommodations for ICD-10 codes.• Confirm with your vendor that your system has been upgraded to
Version 5010 standards, which have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes.
• Contact your vendor and ask what updates they are planning to make to your practice management system for ICD-10, and when they expect to have it ready to install.
• Check your contract to see if upgrades are included as part of your agreement.
• If you are in the process of making a practice management or related system purchase, ask if it is ICD-10 ready.
Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition. Beproactive, don’t wait. Contact organizations you conduct business with such as your payers, clearinghouse, or billing service. Ask about their plans for ICD-10 compliance and when they will be ready to test their systems for the transition.
Talk with your payers about how ICD-10 implementation might affect your contracts. Because ICD-10 codes are much more specificthan ICD-9 codes, payers may modify terms of contracts, payment schedules, or reimbursement.
Identify potential changes to work flow and business processes. Consider changes to existing processes includingclinical documentation, encounter forms, and quality and public health reporting.
Background
www.cms.gov/ICD10
Official CMS Industry Resources for the ICD-10 Transition
About ICD-10
ICD-10 CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/ Procedure Coding System) consists of two parts:
ICD-10-CM (diagnosis coding) was developed
by the Centers for Disease Control and Prevention for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.
ICD-10-PCS (inpatient procedure coding)
was developed by the Centers for Medicare & Medicaid Services (CMS) for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding. The transition to ICD-10-CM/PCS does not affect Current Procedural Terminology (CPT) codes, which will continue to be used for outpatient services.
Visit www.cms.gov/ICD10
for ICD-10 and Version 5010 resources from CMS.
ICD-10 DEADLINE
I061 Rheumatic aortic insufficiency
I062 Rheumatic aortic stenosis with insufficiency I068 Other rheumatic aortic valve diseases
I069 Rheumatic aortic valve disease, unspecified I070 Rheumatic tricuspid stenosis
I071 Rheumatic tricuspid insufficiency
I072 Rheumatic tricuspid stenosis and insufficiency I078 Other rheumatic tricuspid valve dis
Assess staff training needs. Identify the staff in your office who code, or have a need to know the newcodes. There are a wide variety of training opportunities and materials available through professional associations, online courses, webinars, and onsite training. If you have a small practice, think about teaming up with other local providers. For example, you might be able to provide training for a staff person from one practice, who can in turn train staff members in other practices. Coding professionals recommend that training take place approximately six months prior to the ICD-10 compliance deadline.
Budget for time and costs related to ICD-10 implementation, including expenses for system changes, resource materials, and training. Assess the costs of any necessary software updates,reprinting of superbills, trainings, and related expenses.
Conduct test transactions using ICD-10 codes with your payers and clearinghouses. Testing iscritical. You will need to test claims containing ICD-10 codes to make sure they are being successfully transmitted and received by your payers and billing service or clearinghouse. Check to see when they will begin testing, and the test days they have scheduled.
This fact sheet was prepared as a service to the health care industry and is not intended to grant rights or impose obligations. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.
www.cms.gov/ICD10
October 201 4 and ongoing September 201 4 Com plete betw een Januar
y – April 201
4
Com
plete betw
een
October – December 201
3
International Classification of Diseases
10th Revision
(ICD-10)
Are you ready?*The deadline for transitioning to ICD-10 is October 1, 2014. Don’t wait to start this important process.
*This timeline is a generalized resource for use in creating an individualized timeline specific to the needs of your practice. Successful ICD-10 transition may require different approaches based on practice size and resources.
Com
plete betw
een
April – A
ugus
t 201
4
Description Owner Start Date Due by Date Completed
Select internal Champion and/or committee. ______________________________ __________ __________ __________ Set a schedule for project meetings (hard and firm dates and times). ______________________________ __________ __________ __________ Identify and list all work processes and systems that utilize ICD-9 today. ______________________________ __________ __________ __________ Conduct inventory of current coding tools/resources. ______________________________ __________ __________ __________ Become familiar with ICD-10. ______________________________ __________ __________ __________ Obtain code set and guidelines (electronic files available from http://www.cdc.gov/nchs/icd/icd10cm.htm).
Research ICD-10 training. ______________________________ __________ __________ __________ Research training programs/resources (e.g., online courses, local or regional seminars).
Determine level of staff training needed by role (comprehensive, intermediate, or basic).
Review status of and impact to electronic systems (see AAFP ICD-10 Systems Checklist). ______________________________ __________ __________ __________ Appoint staff to act as primary/secondary contact with system vendors.
Cost for temporary help or overtime cost during training and go-live. ______________________________ __________ __________ __________ If using an outside source for coding and/or billing, learn vendor’s ICD-10
implementation plan. ______________________________ __________ __________ __________ Budget – Identify ICD-10 related internal costs (see AAFP Cost Calculator www.aafp.org/icd10).. ______________________________ __________ __________ __________ Introduce concept and plans for ICD-10 to staff. ______________________________ __________ __________ __________ Evaluate current cash flow (age of account balances, billing lag time). ______________________________ __________ __________ __________ Set goals and plan to correct and prevent recurring errors/issues and optimize cash flow.
Determine impact, if any, on quality initiatives (e.g., PQRS, EHR). ______________________________ __________ __________ __________ Should 2014 reporting be completed prior to system upgrades?
Complete ICD-10 training at all levels. ______________________________ __________ __________ __________ Follow-up with electronic system vendors. ______________________________ __________ __________ __________ Are upgrades completed or scheduled?
Is training on upgraded system necessary and if so, scheduled?
Note payer news regarding ICD-10 claims testing requirements/opportunities. ______________________________ __________ __________ __________ Review insurance contracts for diagnosis-based payment impact (if any). ______________________________ __________ __________ __________ Revise/develop/purchase internal coding resources (encounter forms, coding quick references). ______________________________ __________ __________ __________ Re-evaluate cash flow (Are goals met and current processes efficient?). ______________________________ __________ __________ __________ Review budget for any changes and accuracy. ______________________________ __________ __________ __________ Consider opening a line of credit to offset potential cash-flow disruption.
Review and ensure that physicians and coers have completed training. ______________________________ __________ __________ __________ Test ability to apply ICD-10 codes to documentation as a training exercise. ______________________________ __________ __________ __________ Do coding resources support efficient and accurate coding?
Follow up with system vendors and/or outsourced business partners. ______________________________ __________ __________ __________ Complete internal testing.
Investigate options for external testing with clearinghouse/payers. Review and update contact information for support services.
Review payer ICD-10 communications (include non-covered entities such as
worker’s compensation). ______________________________ __________ __________ __________ Watch for and disseminate ICD-10 changes in payment policies (e.g., Medicare local coverage decisions).
Develop and assign workflow and processes effective 10/01/14. ______________________________ __________ __________ __________ Verify that all testing was successfully completed.
Consider direct-to-payer or other alternative claims submission resources
(if testing has not been successful). ______________________________ __________ __________ __________ Monitor payer news regarding readiness and changes to payment policies. ______________________________ __________ __________ __________ Monitor all claims acknowledgement (997) and acceptance/rejection (277) reports. ______________________________ __________ __________ __________ Promptly correct and resubmit all rejected/denied claims.
Evaluate post-implementation cash flow until claims filed with ICD-10 are consistently paid.______________________________ __________ __________ __________ Evaluate need for contingency activities (e.g., overtime, consultant, credit line). ______________________________ __________ __________ __________ Monitor payer news regarding claims adjudication issues and resolutions. ______________________________ __________ __________ __________ Monitor reimbursement accuracy and timeliness of payer per contract. ______________________________ __________ __________ __________ Conduct coding review for accuracy and compliance. ______________________________ __________ __________ __________
2015
2015
2015
2015
BE
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» ICD-10 Fact Sheet:
BASICS FOR SMALL AND
RURAL PRACTICES
n October 1, 2015, the health care industry will transition from ICD-9 to ICD-10 codes for diagnoses and inpatient procedures. This means everyone covered by HIPAA must use ICD-10 codes for health care services provided on or after October 1, 2015.
O
»
ICD-10
October 1, 2014
ICD-10 DEADLINE
ICD-10 DEADLINE
OCT 1, 2015
-2-BE
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Will you be able to submit claims?
If you use an electronic system for any or all payers, you need to know if it will be able to submit ICD-10 codes. If your system uses Version 5010 for electronic transactions, you should be able to submit ICD-10 codes. However, check with your practice management system or software vendor to make sure.
Will you be able to complete medical records?
If you use any type of electronic health record (EHR) system in your office, you need to know if it will capture ICD-10 codes. Look at how you enter ICD-9 codes (e.g., do you type them in or select from a program) and talk to your EHR vendor about your system’s capabilities for ICD-10.
How will you code your claims under ICD-10?
If you want to keep coding the same way you are now, and you only use books to code, purchase an ICD-10 code book in early 2015. If your coder—or whoever is responsible for coding in your practice—cannot identify codes accurately using the code book or ‘look-up’ functionality in your software, explore their ICD-10 training options and determine if formal training is necessary. Then, take a look at the codes most commonly used in your office and practice coding over the summer in 2015.
Where do you use ICD-9 codes? Is there anywhere you use ICD-9 codes
other than claims submission or your EHR?
Talk to your colleagues and keep track of your own activities for a couple of weeks. Write down or use a sticky note to mark everywhere you see an ICD-9 code as you do your job. If the code is on paper, you will need new forms (e.g., patient encounter form). If you see the code on your computer, check with your EHR or practice management system vendor to see if your system will accept ICD-10 codes.
Are there ways to make coding more efficient?
For example, develop a list of your most commonly used ICD-10 codes, or invest in an inexpensive software program that helps small practices with coding. Also, think about ways to make sure the new coding does not delay payments. Look at your most common non-visit services—do any sometimes trigger reviews or denials related to medical necessity? It is important to understand how to code these services correctly under ICD-10.
The following is a list of important questions to address now
to help you prepare your practice for ICD-10.
Talk to your EHR
vendor about your
system’s capabilities
for ICD-10.
1
2
3
4
5
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Last Updated: August 2014
-3-ICD-10 Resources
Visit the CMS ICD-10 website for information and resources on ICD-10. The Provider Resources section of the website has helpful fact sheets, checklists, timelines, and other resources to help practices transition to ICD-10.
Also, be sure to check out ICD-10 resources and trainings available from your payers, vendors, and professional associations such as the American Academy of Professional Coders and the American Health Information Management Association.
Background
About ICD-10ICD-10 CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/ Procedure Coding System) consists of two parts:
ICD-10-CM (diagnosis coding) was developed by the Centers for Disease Control and Prevention for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.
ICD-10-PCS (inpatient procedure coding) was developed by the Centers for Medicare & Medicaid Services (CMS) for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.
The transition to ICD-10-CM/PCS does not affect Current Procedural Terminology (CPT) codes, which will continue to be used for outpatient services.
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
Small and Medium Practices
ICD-10 Transition Checklist
The following is a checklist of ICD-10 tasks, including estimated timeframes for each task. Depending on your organization, many of these tasks can be performed on a compressed timeline or performed at the same time as other tasks.
This checklist is designed to provide a viable path forward for organizations just beginning to prepare for ICD-10. CMS encourages those who are ahead of this schedule to continue their progress forward.
NOW
Planning, Communication, and Assessment
Actions to Take Immediately
To prepare for testing, make sure you have completed the following activities. If you have already completed these tasks, review the information to make sure you did not overlook an important step.
r r r r r r r r r r r r r
Review ICD-10 resources from CMS, trade associations, payers, and vendors Inform your staff/colleagues of upcoming changes (1 month)
Create an ICD-10 project team (1-2 days)
Identify how ICD-10 will affect your practice (1-2 months)
How will ICD-10 affect your people and processes? To find out, ask all staff members how/where they use/see ICD-9
Include ICD-10 as you plan for projects like meaningful use of electronic health records Develop and complete an ICD-10 project plan for your practice (1-2 weeks)
Identify each task, including deadline and who is responsible
Develop plan for communicating with staff and business partners about ICD-10
Estimate and secure budget (potential costs include updates to practice management systems, new coding guides and superbills, staff training) (2 months)
Ask your payers and vendors — software/systems, clearinghouses, billing services — about ICD-10 readiness (2 months)
Review trading partner agreements
Small and Medium Practices ICD-10 Transition Checklist
Complete Transition/Full Compliance
October 1, 2014
Complete ICD-10 transition for full compliance
ICD-9 codes continue to be used for services provided before October 1, 2014 ICD-10 codes required for services provided on or after October 1, 2014 Monitor systems and correct errors if needed
r r r r
CMS consulted resources from the American Medical Association (AMA), the American Health Information Management Association (AHIMA), the North Carolina Healthcare Information & Communications Alliance (NCHICA) and the Workgroup for Electronic Data Interchange (WEDI) in developing this timeline.
www.cms.gov/ICD10
Official CMS Industry Resources for the ICD-10 Transition
Ask when they will start testing, how long they will need, and how you and other clients will be involved Select/retain vendor(s)
r r r
Review changes in documentation requirements and educate staff by looking at frequently used ICD-9 codes and new ICD-10 codes (ongoing)
2014
Transition and Testing
March 2013 to September 2014
March 1, 2013 – December 31, 2013: Conduct high-level training on ICD-10 for clinicians and coders to prepare for testing (e.g., clinical documentation, software updates) (ongoing)
April – June 2013: Start testing ICD-10 codes and systems with your practice’s coding, billing, and clinical staff (9 months)
Use ICD-10 codes for diagnoses your practice sees most often Test data and reports for accuracy
Monitor vendor and payer preparedness, identify and address gaps (ongoing)
October 2013 – January 2014: Begin testing claims and other transactions using ICD-10 codes with business trading partners such as payers, clearinghouses, and billing services (10 months minimum)
January 1, 2014 – April 1, 2014: Review coder and clinician preparation; begin detailed ICD-10 coding training (6-9 months)
Work with vendors to complete transition to production-ready ICD-10 systems
r r r r r r r r JANUARY 2013 2013
NOW:
20152015
2016 2015 20152015
2015 2015ICD-10 Timeline for Small-Medium Practices at a Glance
2014 2013
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep + Oct Nov Dec
PLANNING
Identify resources Create project team Assess effects Create project plan Secure budget
COMMUNICATIONS
Inform staff Contact vendors Contact payers Monitor vendor prep Monitor payer prep
TESTING
High-level training for test team Level 1: internal Level 2: external
COMPREHENSIVE TRAINING
Documentation
Coding Ongoing practice before “go live”
Ongoing practice before “go live”
D E A D L I N E O C T 1 , 2 0 1 4 January 2013
2014
2015
r r r r r r r r r r r
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
Large Practices
ICD-10 Transition Checklist
The following is a checklist of ICD-10 tasks, including estimated timeframes for each task. Depending on your organization, many of these tasks can be performed on a compressed timeline or performed at the same time as other tasks.
This checklist is designed to provide a viable path forward for organizations just beginning to prepare for ICD-10. CMS encourages those who are ahead of this schedule to continue their progress forward.
NOW
Planning, Communication, and Assessment
Actions to Take Immediately
To prepare for testing, make sure you have completed the following activities. If you have already completed these tasks, review the information to make sure you did not overlook an important step.
r r
Review ICD-10 resources from CMS, trade associations, payers, and vendors
Inform your staff/colleagues of upcoming changes (1 month)
Create an ICD-10 project team (1 month)
Identify how ICD-10 will affect your practice (3 months)
How will ICD-10 affect your people and processes? To find out, ask all staff members how/where they use/see ICD-9
Include ICD-10 as you plan for projects like meaningful use of electronic health records
Develop and complete an ICD-10 project plan for your organization (1 month)
Identify each task, including deadline and who is responsible
Develop plan for communicating with staff and business partners about ICD-10
Estimate and secure budget (potential costs include updates to practice management systems, new
coding guides and superbills, staff training) (2 months)
Ask your payers and vendors — software/systems, clearinghouses, billing services — about ICD-10 readiness (2 months)
Ask about systems changes, a timeline, costs, and testing plans
Large Practices ICD-10 Transition Checklist
Review trading partner agreements Select/retain vendor(s)
r r
Review changes in documentation requirements and educate staff by looking at frequently used ICD-9
codes and new ICD-10 codes (ongoing)
r
2013
Transition and Testing
March 2013 to September 2014
March 1, 2013 – December 31, 2013: Conduct high-level training on ICD-10 for clinicians and coders to prepare for testing (e.g., clinical documentation, software updates) (ongoing)
April 1, 2013: Start testing ICD-10 codes and systems with your practice’s coding, billing, and clinical staff (9 months)
Use ICD-10 codes for diagnoses your practice sees most often Test data and reports for accuracy
Monitor vendor and payer preparedness, identify and address gaps (ongoing)
October 1, 2013: Begin testing claims and other transactions using ICD-10 codes with business trading partners such as payers, clearinghouses, and billing services (10 months minimum)
January 1, 2014 – April 1, 2014: Review coder and clinician preparation; begin detailed ICD-10 coding training (6-9 months)
r r
r r r
r Work with vendors to complete transition to production-ready ICD-10 systems
r r
Complete Transition/Full Compliance
2014
October 1, 2014
Complete ICD-10 transition for full compliance
ICD-9 codes continue to be used for services provided before October 1, 2014
ICD-10 codes required for services provided on or after October 1, 2014
Monitor systems and correct errors if needed
r r r r
CMS consulted resources from the American Medical Association (AMA), the American Health Information Management Association (AHIMA), the North Carolina Healthcare Information & Communications Alliance (NCHICA) and the Workgroup for Electronic Data Interchange (WEDI) in developing this timeline.
www.cms.gov/ICD10
Official CMS Industry Resources for the ICD-10 Transition JANUARY 2013
2014
2015
NOW
2015 2015 2015 20152015
2015 2015ICD-10 Timeline for Large Practices at a Glance
2013 2014
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep + Oct Nov Dec
PLANNING
Identify resources Create project team Assess effects Create project plan Secure budget
COMMUNICATIONS
Inform staff Contact vendors Contact payers Monitor vendor prep Monitor payer prep
TESTING
High-level training for test team Level 1: internal Level 2: external
COMPREHENSIVE TRAINING
Documentation Ongoing practice before “go live”
Coding Ongoing practice before “go live”
D E A D L I N E O C T 1 , 2 0 1 4 January 2013
2014
2015
News Updates
|
December 27, 2012
Simple Steps to Improve Clinical Documentation
On October 1, 2014, your practice and the clearinghouses, payers, and billing companies that you work with will need to use ICD-10 codes. One way to help your practice prepare for ICD-10 is to work on improving how you document your clinical services. This will help you and your coding staff become more
accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.
Take a look at documentation for the most often used codes in your practice, and work with your coding staff to determine if the documentation would be specific and detailed enough to select the best ICD-10 codes. For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information on which side of the body is affected (i.e., right, left, or
bilateral).
Below are additional examples of the specific information needed to accurately code the following common diagnoses:
Diabetes Mellitus: Type of diabetes Body system affected
Complication or manifestation
If type 2 diabetes, long-term insulin use Fractures:
Site Laterality Type Location
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This service is provided to you by the Office of E-Health Standards & Services, ICD-10. Injuries:
External cause – Provide the cause of the injury; when meeting with
patients, ask and document “how” the injury happened.
Place of occurrence – Document where the patient was when the injury
occurred; for example, include if the patient was at home, at work, in the car, etc.
Activity code – Describewhat the patient was doing at the time of the
injury; for example, was he or she playing a sport or using a tool?
External cause status – Indicate if the injury was related to military, work,
or other.
Remember, ICD-10 will not affect the way you provide patient care. It will just be important to make your documentation as detailed as possible since ICD-10 gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during your visit—it’s just a matter of recording it for your coding staff. Good documentation will also help reduce the need to follow-up on submitted claims—saving you time and money.
Keep Up to Date on ICD-10
Visit the CMS ICD-10 website for the latest news and resources to help you prepare.
For practical transition tips:
Read recent ICD-10 email update messages
Access the ICD-10 continuing medical education modules developed by CMS in partnership with Medscape
ICD-10
03
TIPS FOR MEDICAL PRACTICES
» Talking to Your Vendors About ICD-10:
Start the Conversation with
Your Vendors
October 1, 2015 is the
ICD-10 transition deadline.
Begin testing now.
1
Talk with your vendors now to be sure that you can count on them to:l Have fully functional, compliant products and services ready in plenty of time
to allow for thorough ICD-10 testing
l Help you avoid potential reimbursement issues and interruptions to workflow
2
Ask your vendors to establish acomprehensive approach that will
ICD-10
deliver compatible products whenyou need them. Points to consider
Resources
discussing with your vendors include:An important step in
The CMS website hasl System upgrades/replacements
preparing for the change
official resources to help you
needed to accommodate ICD-10
to ICD-10 is to talk with
prepare for ICD-10. CMS willl Costs involved and whether upgrades continue to add new tools
any software vendors,
will be covered by existing contracts
and information to the site
clearinghouses, or
l When upgrades or new systems will be throughout the course of the
billing services you
available for testing and implementation transition.
use to be sure they are
l Customer support and training thatthey will provide Official CMS Industry
ready to provide the
l How their products and services will Resources for the ICD-10
support you need.
accommodate both ICD-9 and TransitionICD-10 as you work with claims for
www.cms.gov/ICD10
services provided both before and after the transition deadline for code sets
ADV
AN
CED
Your vendors will need to have products and services on a
schedule that allows adequate time for you to conduct testing.
3
Talking to your vendors now about ICD-10 will help ensure that your transition goes smoothly.Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
Questions to Ask Your Systems
Vendors about ICD-10
As the health care industry embraces broader use of health IT, many providers are looking to purchase or upgrade their clinical and administrative health IT systems. ICD-10 should be a consideration when choosing either clinical or administrative health IT systems. ICD-10 is the next code set for diagnosis and inpatient procedure coding. The switch to the ICD-10 code set is mandated for October 1,
2015. The new codes will impact many parts of the health care process, from patient referrals to billing and payment. Asking the right questions about ICD-10 will help ensure that a new system will meet your practice’s health IT goals.
ICD-10 DEADLINE
OCT 1, 2015
Questions to Ask Your Practice Management Vendor
Your current health IT vendor may be planning to upgrade your practice management system to function with ICD-10. To check whether a practice management vendor’s ICD-10 upgrades or products will meet your needs, ask vendors these questions:
Will you install products well before the October 1, 2015, deadline, so I can begin testing them in 2014?
Will support for my current products be discontinued after the October 1, 2015, ICD-10 deadline?
When will you update my current products and applications for ICD-10?
Will you provide periodic updates for new products? Will there be a charge for these updates?
Will I need new hardware to accommodate ICD-10-related software changes?
What are the costs associated with maintaining new products?
Will you offer product support? If so, how long will the vendor support the application?
How do I report issues and how quickly will you respond?
Will you provide training on your software?
Will you offer support during and after internal ICD-10 testing?
Will you help me test my system with payers and other trading partners?
Does your product give me the ability to search for codes by the ICD-10 alphabetic and tabular indexes? By clinical concept?
Will your product allow for coding in both ICD-9 and ICD-10 to accommodate transactions with dates of service beforeI061 Rheumatic aortic insufficiency
I062 Rheumatic aortic stenosis with insufficiency I068 Other rheumatic aortic valve diseases
I069 Rheumatic aortic valve disease, unspecified I070 Rheumatic tricuspid stenosis
I071 Rheumatic tricuspid insufficiency
I072 Rheumatic tricuspid stenosis and insufficiency I078 Other rheumatic tricuspid valve dis
Questions to Ask Your EHR Vendor
Clinical health IT systems, such as electronic health records (EHRs), will also need to be compatible with ICD-10 in order to make the most of your health IT investment. When purchasing or upgrading an EHR system, be sure to ask the following questions about ICD-10:
Are your EHR products ICD-10 ready? If not, when will they be?
Can your products help me with the ICD-10 transition? For example, will the products suggest ICD-10 codes based onthe clinical data I enter about specific patients?
Do your products map SNOMED-CT to ICD-10 codes to help connect clinical and administrative data?Partner with Your Vendor
After assessing your vendors’ capabilities, continue to work with them throughout the ICD-10 transition. Ask your vendor to share strategies that other clients have used successfully.
For More Information
To learn more about working with vendors and other business partners, consult the ICD-10 resources available on the CMS ICD-10 website.
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
ICD‐10: FAQs MEDI‐CAL
The federal government has postponed the implementation of ICD‐10 codes in all billing activities pursuant to the Protecting Access
to Medicare Act of 2014, House Resolution 4302, Section 212, Delay in Transition from ICD‐9 to ICD‐10 Code Sets:
“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD‐10 code sets as the standard for code
sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal
Regulations.”
On July 31, 2014, the Centers for Medicare & Medicaid Services (CMS) released a final rule that will require ICD‐10 to be
implemented on October 1, 2015, and that will require HIPAA‐covered entities to continue to use ICD‐9 until September 30, 2015.
1. What does International Classification of Diseases, 10th Revision (ICD‐10) compliance mean?
ICD‐10 compliance means that all HIPAA‐covered entities are able to successfully conduct health care transactions on or after
October 1, 2015, using the ICD‐10 diagnosis and procedure codes. ICD‐9 diagnosis and procedure codes can no longer be used for
health care services provided on or after this date.
2. Why is the ICD‐10 transition necessary?
ICD‐10 is a provision of HIPAA, as regulated by the U.S. Department of Health and Human Services (HHS), Centers for Medicare &
Medicaid Services (CMS). This federal mandate pertains to all HIPAA‐covered entities.
The transition from ICD‐9 to ICD‐10 is occurring for the following reasons:
ICD‐9 codes have limited data about patient’s medical conditions and hospital inpatient procedures.
ICD‐9 codes use outdated and obsolete terms and are not consistent with current medical practices.
The structure of ICD‐9 limits the number of new codes that can be created, and many ICD‐9 categories are full. A successful
transition to ICD‐10 is vital to transforming our nation’s health care system.
3. Codes change every year, so why is the transition to ICD‐10 any different from the annual code changes?
ICD‐10 codes are different from ICD‐9 codes in several ways. Currently, ICD‐9 codes are for the most part numeric and have three to
five digits. ICD‐10 codes are alphanumeric and contain three to seven characters. ICD‐10 codes provide a higher level of description.
However, like ICD‐9 codes, ICD‐10 codes will be updated every year.
4. Will ICD‐10 replace Current Procedural Terminology (CPT) procedure coding?
No. The transition to ICD‐10 does not affect CPT coding for outpatient procedures. For hospital inpatient procedures, ICD‐9 codes
will be transitioned to ICD‐10‐PCS (Procedure Coding System).
5. What is the implementation date for ICD‐10?
On October 1, 2015, medical coding in U.S. health care settings will change from ICD‐9 code sets to ICD‐10 code sets.
6. After the October 1, 2015, implementation date, when do I use ICD‐9 versus ICD‐10 on my claim?
Please refer to the chart below, using the date specified in the date field, to determine the ICD code version to use. If the value of
the date field is before October 1, 2015, use ICD‐9 to code the diagnosis. If the value of the date field is on or after October 1, 2015,
use ICD‐10.
Claim Type Claims Date Field To Be Used For Determining ICD Code Version
1 Pharmacy Date of service
2 Long Term Care (LTC) Through date
3 Inpatient Through date
4 Outpatient From date
5 Medical From date
7. Will there be a grace period for converting to ICD‐10?
No.
8. How is Medi‐Cal addressing the implementation of ICD‐10?
Medi‐Cal will be using a crosswalk solution in the legacy California Medicaid Management Information System (CA‐MMIS). Medi‐Cal
has mapped all ICD‐10 codes to corresponding ICD‐9 codes starting with the General Equivalence Mappings (GEMs) provided by the
Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi‐Cal policy. Claims will be
run against the crosswalk to determine the ICD‐9 value to process through the system. The crosswalk will only be used temporarily
for ICD‐10 claim adjudication while the implementation of our new MMIS system is being completed. Once the new system is online,
Medi‐Cal will adjudicate all claims natively using ICD‐10 and the crosswalk will no longer be used.
9. What is a crosswalk solution?
Medi‐Cal has mapped all ICD‐10 codes to corresponding ICD‐9 codes starting with the General Equivalence Mappings (GEMs) and
Reimbursement Mappings provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align
with existing Medi‐Cal policy. Claims that are submitted with ICD‐10 starting October 1, 2015, will run against this crosswalk in order
to identify the appropriate ICD‐9 code that will be used to process the claim. The crosswalk will only be used temporarily for ICD‐10
claim adjudication while the implementation of our new MMIS system is being completed. Once the new system is online, Medi‐Cal
will adjudicate all claims natively using ICD‐10 and the crosswalk will no longer be used.
10. Will an ICD‐10 to ICD‐9 crosswalk be published?
Medi‐Cal will not publish the crosswalk. The crosswalk will not be published since there is already a process for appeal of claim
adjudication where there are disagreements between the amount paid and the amount submitted. However, the provider manuals
will be updated with the ICD‐10 codes as appropriate, allowing providers to refer to the manual for guidance.
11. Who is affected by the transition to ICD‐10? If I don’t deal with Medicare claims, will I have to transition?
Everyone covered by HIPAA must transition to ICD‐10. This includes providers and payers who do not deal with Medicare or
Medicaid claims.
12. What if I don’t make the transition to ICD‐10?
For HIPAA‐covered entities, transition to ICD‐10 is not an option. Claims for all services and hospital inpatient procedures performed
on or after the compliance deadline must use ICD‐10 diagnosis and inpatient procedure codes. This change does not apply to
Current Procedural Terminology (CPT) coding for outpatient procedures. Without ICD‐10, providers will experience delayed
payments or even non‐payments; increased rejected, denied or pending claims; reduced cash flows and ultimately lost revenues.
It is important to note, however, that claims for services and inpatient procedures provided before the compliance date must use
ICD‐9 codes.
13. Is Medi‐Cal policy going to change with ICD‐10?
Medi‐Cal will be updating the provider manuals to account for the change to ICD‐10 in 2015. However, due to the size of the ICD‐10
code set and limitations in the legacy MMIS, policy will not change.
14. Will Medi‐Cal accept claims with both ICD‐10 and ICD‐9 codes on the same claim form?
No. Medi‐Cal will accept claim forms containing only ICD‐9 or ICD‐10 codes.
15. If I transition early to ICD‐10, will Medi‐Cal be able to process my claims?
Pursuant to the CMS final rule issued on July 31, 2014: "This final rule implements section 212 of the Protecting Access to Medicare
Act of 2014 by changing the compliance date for the International Classification of Diseases, 10th Revision, Clinical Modification
(ICD‐10‐CM) for diagnosis coding, including the Official ICD‐10‐CM Guidelines for Coding and Reporting, and the International
Classification of Diseases, 10th Revision, Procedure Coding System (ICD‐10‐PCS) for inpatient hospital procedure coding, including
the Official ICD‐10‐PCS Guidelines for Coding and Reporting, from October 1, 2014 to October 1, 2015. It also requires the continued
use of the International Classification of Diseases, 9th Revision, Clinical Modification, Volumes 1 and 2 (diagnoses), and 3
(procedures) (ICD‐9‐CM), including the Official ICD‐9‐CM Guidelines for Coding and Reporting, through September 30, 2015."
Medi‐Cal will transition to the use of ICD‐10 on October 1, 2015, and early or late transitions will not be allowed.
16. Are paper claims affected by the transition to ICD‐10?
Yes. All claim transactions, whether paper or electronic, except dental claims, will be required to be submitted using ICD‐10 codes.
17. What type of training will providers and staff need for the ICD‐10 transition?
Medi‐Cal will be providing education about the use of ICD‐10 for submitting claims to Medi‐Cal. Providers are encouraged to visit the
Medi‐Cal website regularly throughout the course of the transition to access the latest information about education opportunities.
In addition, ICD‐10 resources and training materials may be available through the Centers for Medicare & Medicaid Services (CMS),
many professional associations and societies, and software/system vendors.
18. Do Treatment Authorization Requests (TARs) that have been approved prior to October 1, 2015 with approval extending past
October 1, 2015, need to be resubmitted with ICD‐10 codes?
No. All active TARs based on the submission of ICD‐9 on or before October 1, 2015, that span the ICD‐10 implementation date will
remain valid. Claims containing ICD‐10 in adherence with the ICD‐10 implementation rules will not be negatively impacted by the
ICD‐9 TAR approvals.
