Preparing for Radiology Coding Transition from ICD-9 to ICD-10: Understand the Changes and Develop Your Strategy

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SLIDE 1 _{Slide 1}

Preparing for Radiology

Coding Transition from

ICD-9 to ICD-10:

Understand the Changes and

Develop Your Strategy

Presented by

Donna J. Richmond, BA, RCC, CPC

Senior Healthcare Consultant

MedLearn, a Panacea Healthcare Solutions Co.

March 1, 2012

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SLIDE 2 _{Slide 2}_{Slide 2}

Disclaimer

 RAC Monitor, LLC has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user.

 RAC Monitor, LLC, its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or

consequences of the use of this material. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose.

 The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation.

Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

 CPT®_{is a trademark of the American Medical Association.}

– No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher

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•

They’re coming!

•

They aren’t going away. (Probably!)

•

You’re going to have to use them.

o

Outpatient, physician – date of service October

1, 2013

o

Inpatient – date of discharge October 1, 2013

•

That’s more than a year away – why worry now?

Especially if there is a delay?

•

What’s the difference in what we have now and

ICD-10?

(4)

•

International classification of diseases, 10th edition

•

ICD-10 is used in most of the rest of the world

o

Since US uses ICD-9-CM instead of ICD-10, it’s harder

to compare and track disease processes internationally

o

US uses ICD-10 for coding mortality data for death

certificates – which makes it difficult to compare death

certificate info with hospital info

•

Clinical Modification (CM) used in US for claims data

•

ICD-9-CM is running out of space

•

ICD-9-CM can not get to the detail needed in today’s

healthcare climate

(5)

•

International classification of diseases, 10th

edition, Procedure Coding System

•

ICD-9-CM procedure codes do not accurately

reflect current technology and medical treatment.

Since ICD-9-CM does not accurately describe

advancements in technologies, significantly

different procedures are assigned to a single

ICD-9-CM procedure code. Limitations in the coding

system translate directly into limitations in

coverage and reimbursement.

(6)

• ICD-10-CM incorporates much greater clinical detail and specificity

than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practice. The

modern classification system will provide much better data needed for:

– Measuring the quality, safety, and efficacy of care;

– Reducing the need for attachments to explain the patient’s

condition;

– Designing payment systems and processing claims for

reimbursement;

– Conducting research, epidemiological studies, and clinical

trials;

– Setting health policy;

– Operational and strategic planning;

– Designing health care delivery systems; – Monitoring resource utilization;

– Improving clinical, financial, and administrative performance; – Preventing and detecting health care fraud and abuse; and – Tracking public health and risks.

Benefits of ICD-10-CM

(7)

• Tabular lists – contains cause of morbidity

and diagnosis codes

o

Inclusion and exclusion terms

• Description, guidelines and coding rules

• Alphabetical index to disease and nature

of injury, external cause of injury, table of

drugs and chemicals

(8)

•

Myth: No hard-copy code books

•

Fact: Books are already available

•

Myth: All coding will need to be electronic

•

Fact: Electronic coding is not required for ICD-10-CM

although it is anticipated that the improved structure and

specificity will facilitate the development of increasingly

sophisticated electronic coding tools

•

Myth: Unnecessarily detailed medical record documentation

will be required

•

Fact: There will still be unspecified diagnosis codes, but

better documentation will result in higher-quality data

ICD-10-CM Myths

(9)

•

Identify the diagnosis or reason for visit in the

documentation

•

Locate the main term in the index

•

Verify the code in the tabular

•

Read and be guided by instructional notes in both

the index and tabular

•

It is important to use both the index and tabular in

code assignment

•

Assign the code

•

Diagnosis codes are to be used and reported at

their highest number of characters available

(10)

•

Alpha and numeric

•

1st character is always alpha

•

All letters except “U” are used

•

First 3 characters are the category

•

4-6 are anatomic site, etiology, severity, etc.

•

7 is extension

•

Period after the first 3 characters (when there are 4 or

more characters)

o

M1a.3120

 M1a – category – chronic gout  3 – etiology – renal impairment  1 – location – shoulder

 2 – laterality – left

 0 – additional info – without tophos

(11)

•

More detail

o

Approximately 140,000 codes vs. 17,000 now

o

8,000 categories vs. 4,000 now

o

Laterality is included in the code when appropriate

o

Combination codes for certain diseases and common

symptoms and manifestations

o

Combination codes for poisonings and external cause

o

Obstetric codes identify trimester

o

Clinical concepts not in ICD-9-CM

o

Surgical complications distinguish between

intra-operative and post-intra-operative

o

Change in code definitions

o

2 kinds of excludes notes

ICD-10-CM/PCS – Details,

Details

(12)

•

Combination codes for certain diseases and

common symptoms and manifestations

o

I25.110 – atherosclerotic heart disease of native

coronary artery with unstable angina pectoris

o

K71.51 – Toxic liver disease with chronic active hepatitis

with ascites

o

I83.202 – Varicose veins of unspecified lower extremity

with both ulcer of calf and inflammation

•

Combination codes for poisonings and external

cause

o

T42.3X2S – Poisoning by barbiturates, intentional

self-harm, sequela

(13)

• Obstetric codes identify trimester

o

O26.02 – Excessive weight gain in

pregnancy, second trimester

o

O26.841 – Uterine size-date discrepancy,

first trimester

• Clinical concepts not in ICD-9-CM

o

Z67.40 – Type 0 blood, Rh positive

o

Y90.6 – Blood alcohol level of 120-199

mg/100 ml

(14)

• Surgical complications distinguish between

intra-operative and post-operative

o

D78.01 – Intra-operative hemorrhage and

hematoma of spleen complicating a

procedure on the spleen

o

D78.21 – Post-procedural hemorrhage and

hematoma of spleen following a procedure

on the spleen

(15)

•

Change in code definitions

o

Definition of acute myocardial infarction is now 4 weeks

instead of 8

•

I21 ST elevation (STEMI) and non-ST

elevation (NSTEMI) myocardial infarction

o

Includes: cardiac infarction

o

coronary (artery) embolism

o

coronary (artery) occlusion

o

coronary (artery) rupture

o

coronary (artery) thrombosis

o

infarction of heart, myocardium, or ventricle

o

myocardial infarction specified as acute or with a stated

duration of 4 weeks (28 days) or less from onset

(16)

•

2 kinds of excludes notes

o

Excludes 1 – excluded code should never be reported

with the code where the note is located (2 conditions

cannot occur together)

o

Excludes 2 – excluded code is not part of the condition

represented by the code where the note appears so both

codes may be reported together as appropriate

Q03 – Congenital hydrocephalus

Excludes 1 – Acquired hydrocephalus (G91.-)

L27.2 – Dermatitis due to ingested food.

Excludes 2 – Dermatitis due to food in contact

with skin (L23.6, L24.6, L25.4)

(17)

• Laterality and type of encounter are now

included within the code

o

S52.134D – Nondisplaced fracture of neck

of right radius, subsequent encounter for

closed fracture with routine healing

(18)

•

This is a potential problem for radiology, and

something practices should begin to work toward

now. Most radiology claims are coded now with

non-specific diagnosis codes because complete

information is either not provided, or does not

make it through the system to the final dictated

report. While there will still be non-specific codes

available for use, the use of these non-specific

codes on a regular basis will negate the benefits

of CM. In addition, the advent of

ICD-10-CM may bring more specific medical policies. It is

possible that claims will be denied if a

non-specific diagnosis is coded.

(19)

•

Payers are also going to look for more

specificity regarding accident details. The

codes for external causes have increased

greatly.

o

Place of occurrence codes (Y92.x) now take up 4 +

pages



Y92.72 – Chicken coop (or Hen house)

o

How the injury happened can now be very specific



W61.32 – Struck by chicken



W61.33 – Pecked by chicken



W61.39 – Other contact with chicken (exposure to

chickens)

(20)

• Sometimes 1 to 1

• But often 1 ICD-9-CM code will map to

multiple ICD-10-CM codes

• For example – 649.53 (antepartum

spotting complication of pregnancy) maps

to 4 ICD-10-CM codes (one for each

trimester, one for unspecified trimester)

• Extreme example – 733.82 (nonunion of

fracture) corresponds to

2,530 ICD-10-CM codes

ICD-9-CM to ICD-10-CM

Mapping

(21)

•

814.01 Closed, navicular [scaphoid] of

wrist

•

814.11 Open, navicular [scaphoid] of

wrist

Fracture, Navicular Bone –

ICD-9-CM

(22)

• S62.00

Unspecified fracture of navicular

[scaphoid] bone of wrist

o

S62.001

Unspecified fracture of navicular

[scaphoid] bone of right wrist

o

S62.002

Unspecified fracture of navicular

[scaphoid] bone of left wrist

o

S62.009

Unspecified fracture of navicular

[scaphoid] bone of unspecified wrist

Fracture, Navicular Bone –

ICD-10-CM

(23)

•

S62.01 Fracture of distal pole of navicular

[scaphoid] bone of wrist

o Fracture of volar tuberosity of navicular [scaphoid] bone of

wrist

o S62.011 Displaced fracture of distal pole of navicular

[scaphoid] bone of right wrist

[scaphoid] bone of left wrist

[scaphoid] bone of unspecified wrist

o S62.014 Nondisplaced fracture of distal pole of navicular

Fracture, Navicular Bone –

ICD-10-CM

(24)

•

S62.02 Fracture of middle third of navicular

[scaphoid] bone of wrist

o S62.021 Displaced fracture of middle third of navicular

o S62.024 Nondisplaced fracture of middle third of navicular

S62.0 Fracture of Navicular

[Scaphoid] Bone of Wrist

(25)

•

WS62.03 Fracture of proximal third of navicular

[scaphoid] bone of wrist

o S62.031 Displaced fracture of proximal third of navicular

o S62.034 Nondisplaced fracture of proximal third of navicular

S62.0 Fracture of Navicular

[Scaphoid] Bone of Wrist

(26)

•

The appropriate 7

th

character is to be added to each code

from category S62

•

A fracture not designated as open or closed should be

coded to closed

o A initial encounter for closed fracture o B initial encounter for open fracture

o D subsequent encounter for fracture with routine healing o G subsequent encounter for fracture with delayed healing o K subsequent encounter for fracture with nonunion

o P subsequent encounter for fracture with malunion o S sequela

•

Displaced fracture, middle third of navicular bone of right

wrist, subsequent encounter for fracture with routine

healing

o S62.021D

S62.0 Fracture of Navicular

[Scaphoid] Bone of Wrist

(27)

•

Sometimes a category requires a 6

th

or 7

th

character but the base code doesn’t have that

many. In that case, we will use X as a

placeholder.

•

For example, the injury codes require a 7

th

character to indicate initial encounter,

subsequent encounter, etc. Yet, not all injury

codes have 6 characters, so X is used in place

of the “missing” character.

•

This gives the codes room to grow in future

years.

(28)

•

Category S43

•

The appropriate 7

th

character is to be added to each code

from category S43

o A initial encounter

o D subsequent encounter o S sequela

•

S43.5 Sprain of acromioclavicular joint

 Sprain of acromioclavicular ligament

o S43.50 Sprain of acromioclavicular joint, unspecified side

o S43.51 Sprain of right acromioclavicular joint o S43.52 Sprain of left acromioclavicular joint

•

Initial encounter for sprain of the right AC joint – S43.51xA

(29)

(30)

(31)

• 99% of Part A claims and 96% of Part B claims transactions are

received electronically

• Current versions of the transaction standards do not have the

functionality needed

• Allow for the 7 characters of ICD-10-CM

• Adds a one-digit version indicator to the ICD code to indicate 9 vs. 10 • Increases number of diagnosis codes allowed

• Distinguishes between principal diagnosis, admitting diagnosis,

external cause of injury, and patient reason for visit codes

• Supports monitoring of certain illness mortality rates, outcomes for

specific treatment options, some hospital length of stays, and clinical reasons for care

• Addresses currently unmet business needs, such as an indicator on

institutional claims for conditions that were “present on admission”

Electronic Transactions

Standard – 5010

(32)

•

What Changes Must Occur with Version 5010?

•

For Medicare, these HIPAA-mandated formats include

the following:

o Claims

o Remittance Advice

o Claim Status Inquiry/Response o Eligibility Inquiry/Response

•

Three additional formats, not mandated by HIPAA, will

also be adopted by Medicare Fee-for-Service (FFS).

These include:

o Transaction Acknowledgement o Functional Acknowledgement o Claims Acknowledgement

Electronic Transactions

Standard – 5010

(33)

• Implementation Timeline

• For all covered entities:

• Effective date of the regulation: March 17, 2009

• Level I compliance to begin by: December 31, 2010 • Level II compliance by: December 31, 2011 • Fully compliant on: January 1, 2012

• Level I compliance means “that a covered entity can demonstrably

create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing.” We

expect covered entities to be testing throughout calendar year 2011, and to schedule testing as early as possible, to ensure sufficient time for corrective actions and re-testing.

• Level II compliance means “that a covered entity has completed

end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards.”

Electronic Transactions

Standard -5010

(34)

•

Choose an ICD-10 Project Leader and team

•

Schedule regular meetings for follow-up

•

Monitor regulatory information

•

Staff involvement

o Physicians o Administration o Managers o Nurses o Coders o Billers o Registration o IT

(35)

• Perform a practice impact analysis

• Identify all areas within the practice that

ICD-10-CM will impact and create a plan

o

Assign tasks

o

Assign due dates

• Training needs

o

Internal vs. external

o

Type of training

o

Training schedule

o

Educational materials

(36)

•

Clinical documentation

o Front desk – are they getting complete diagnoses now?

o Physicians – are they dictating the diagnoses they are given? o Coders – are they coding specific diagnoses documented are

the non-specific diagnoses they remember?

•

Forms

o Order forms

o Charge tickets / superbills

•

Systems

o RIS

o Encoders

o Billing systems

o Registration systems

(37)

•

Payers

o

Contracts

o

Claims submission / acceptance

o

Provider’s manuals

o

Medical necessity policy

o

Preauthorization process

•

Vendors

o

Get a detailed plan from all your vendors (payers,

clearinghouses)

 Upgrades and revisions to your current system  Release dates

 Testing schedules

(38)

• Create a timeline for implementation

• Estimate a budget

(MGMA has estimated that a 3-physician

practice will have an average ICD-10-CM

implementation cost of $84,000)

• Anticipate decrease in productivity in

transition period

• Anticipate a decrease in cash-flow if

payers other than Medicare aren’t ready

on time

(39)

•

Hospital radiology departments, radiology practices,

and imaging centers should begin now to train (or

re-train) both clerical and clinical staff to make sure that

the most complete and appropriate clinical

information and/or diagnosis codes are obtained and

documented. Oftentimes, a complete diagnosis is

given at the outset, but does not make it through

from front-desk to coder. Or, for an inpatient, the

hospital system only allows the admitting diagnosis on

the ordering form. Practices should be looking at all

the points where diagnosis coding can be impacted

and begin now to work to improve the process.

(40)

•

Scheduling or other in-take personnel should ask for

additional information if a non-specific indication is

given.

•

If an uncertain diagnosis such as “rule-out

pneumonia” is given as the clinical indication,

radiology personnel should ask what symptoms the

patient has that is leading toward that possible

diagnosis.

•

Technologists may ask the patient for additional

information. As long as this is documented into the

medical record, it can be used for coding.

•

Radiologist should be responsible for dictating the

clinical indication in his report.

(41)

•

The final step in this process is the coder. Many coders have

a “cheat sheet” with common (and usually non-specific)

codes that they use and rarely open a diagnosis code book.

This will not be possible with ICD-10-CM and coders should

begin now to get used to looking up the more specific codes

that are available even now with ICD-9-CM. All coders

should be familiar with the Official Guidelines that are

revised and published each year on the NCHS website.

(http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.

htm) If possible, coders should also have access to “AHA

Coding Clinic For ICD-9-CM” and when the time comes the

ICD-10-CM publication. Coding Clinic is the official

publication for guidelines and advice concerning diagnosis

coding.

(42)

• The facility or physician who is billing for

the service is ultimately responsible for

the medical necessity of that service.

o

Work now with referring physicians and

radiology staff to make sure you are

getting appropriate information.

(43)

•

Don’t start memorizing yet!

•

Per CMS intensive coder training should not be

provided until 6-9 months prior to implementation

although certification requirements may require

earlier training

•

Additional training may be needed to refresh or

expand knowledge in anatomy, physiology,

terminology, and disease processes

•

Coders can start now learning about the structure,

organization, and new features of ICD-10-CM

•

Review / test on anatomy, physiology, terminology,

disease processes

(44)

•

AAPC

o Special online timed test o 75 questions

o $60 for 2 attempts (can pay $60 again if needed for more than

2 tries)

o October 1, 2012 – September 30, 2014

•

AHIMA

o Specific CEU requirements

o January 1, 2011 – December 31, 2013

(Academy for ICD-10 can be used even if taken before 1/1/2011)

o CHPS 1/30, CHDA 6/30, RHIT 6/30, RHIA 6/30 o CCS-P 12/20, CCS 18/20, CCA 18/20

•

RCC

o Specific CEU requirements

What About Our Coding

Credentials?

(45)

• CMS

o http://www.cms.gov/ICD10/01_Overview.asp#TopOfPage

• AAPC

o http://www.aapc.com/ICD-10/

• AHIMA

o http://www.ahima.org/icd10/default.aspx

• AHA Central Office

o http://www.ahacentraloffice.org/ahacentraloffice/shtml/ICD10over

view.shtml

• National Center for Health Statistics

o http://www.cdc.gov/nchs/icd/icd10cm.htm

(46)