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Agenda

• What is ICD-10?

• Benefits of ICD-10

• Early Implementation

Activities

• Timeline

• Next Steps

(3)

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Worldwide

ICO-10 Usage

The World Health Organization (WHO) adopted ICD-l0 in 1990. Since then

,

136 countries have adopted ICD-l0. The United States still uses ICD-9

.

Co·staRica- Venezuela

•

Columbia_ Argentina Legend

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The Basics: What is ICD-10?

In 1990, the WHO approved the

i

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v

C

l

assification of the International

Classification of Diseases (ICD)

,

which is known as ICD-l0.

-

What is ICO-10?

• One of several different coding

I

systems in health care

• ICD-l0 CM :Patient Diagnosis

(i.e., the patient's condition/

disease/injury) is referenced in

Volume 1 and 2and maintained

by National Centerfor Health

Statistics (NCHS) a division of the,

Centers for Disease Control and

Prevention (CDC)

• ICO-10 PCS: Procedures for

Inpatient Settings (i.e., the

action that a provider performs

on the patient) replaces Volume

3, maintained by CMS

Why Change?

• Federal regulation

?

- All HIPAA-covered entities must

use ICO-1Ocodes for information they transmit electronically

• ICO-9 is outdated (adopted in 1979)

• More information per code

• Better support for analysis

• Improved ability to look atrisk

and severity

• More consistent with the rest of

the world

,

.

_

,

/

~

-

Dates

••I' Published Final Regulation (45

CFR162.1002) : January16/ 2009

• Effective Date: March 17} 2009

• Compliance Date:

October I, 2013

'Outpatient services are

based on the Date of

Service

-Inpatient services are

based on the Date of

Discharge • Code Freeze Date:

(5)

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The Basics: ICO-10 Key Facts

Processing 5010 transactions is a prerequisite

to processing ICD-l0 claims as the current HIPAA

transaction standards (i.e

.

, 4010) cannot accommodate

the longer ICD-l0 code characters.

Coordina

ti

on is necessary between the 5010 and ICD-l0 projects to identify impacted transactions,

systems" trading partners" and data mapping

to

implement 5010 and ICD-l0 successfully.

5010

is a prerequisite to

ICO-l0

• X12 Version 4010/4010Al

transactions cannot carry ICD-l0 codes

• Only X12 Version 5010 can accommodate ICD-l0 codes

• 5010 also enhances diagnosis reporting

·Separates principal diagnosis, admitting diagnosis, external cause of injury and

reason for visit

• Increases number of ICDoccurrences on 837 claims

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Many HIT Initiatives have Direct

Dependencies with the ICD-10 Transition

• National Electronic Disease

Surveillance System (NEDSS)

• State Specific Quality

Improvement

Organizations

• Ex

t

ernal

Q

uali

t

y Revie

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Organizations

• Value Based Purchasing

• Implementation

of the American

Recovery and Reinvestment Act

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ICO-10 Impacts Across the Industry

Premium Paymen1s Patient/Member / Beneficiary Co-Payments Co-Insurance Providers

Employers Insurance Brokers

Intermediary for

Insurance Products

reo

Contract for Benefit Products, Enroll Employees,

Premium Payment

Treasury

_.

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Benefits and Rate

Negotiation leD

Financial Information

reo

Premium Payments & Claim Submissions

ico

Claims

Clinical & Financial Information

Outsourced Services (Business Associates &

Covered Entities) Claims Payments

reo

Claims Payments "C ::J C'tI •...C I.L. 0 .•..0-• c .•..• <II C

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<II » C'tI ~ a.no ~ a.

leD Healthcare Payers

Liommerciallnsur~rs~

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Medicare

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Claims

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Payments Banks ~

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Multiple Payment

Coordination

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Healthcare Payers )

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ICO-9 vs. ICO-10 Diagnosis Codes

ICD-9-CM Diagnosis Codes

ICD-lo-eM

Diagnosis Codes

3 to 5 digits Alpha ((E" and ((V" on

15

tcharacter only

No place holder characters Terminology Index and Tabular Structure Coding Guidelines

Approximately 14,000 codes

Severity parameters limited Does not include laterality (Right vs. Left)

Combination codes limited

7 digits

Alpha or numeric for any code character Include place holder characters ('x') Similar

Similar

Somewhat similar

Extensive inclusion of severity parameters Common definition of laterality

(9)

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Procedure Codes

ICO-9-CM Procedure Codes

ICO-10-PCS Procedure Codes

3 to 4 digits Not Structured

Chapter 3 of ICD-9-CM Diagnosis included NOS and NEC com man Uses eponyms and named procedures

Uses "combination" codes

7 digits

Structured (Complex)

Managed separately from ICD-10-PCS Diagnosis excluded

NOS and NEC uncommon

Avoids eponyms and named procedures Avoids "combination" codes

(10)

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Example Difference in Diagnosis Granularity

• ICD-9 code -

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or struck accidentally in sports wi

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subsequent

fall {E9l7.0}

• 24 ICD-lO-CM Detail Codes

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Example Difference in Diagnosis Granularity

• This new granularity

has positive and negative effects: besides offering

greater specificity for diagnoses and procedures, it is a real problem for

mapping old codes to new. A single ICD-9 code could be one of

several

ICD-10

codes.

• For example:

250.61 a diabetes mellitus patient, not stated as

uncontrolled,

with Type

1 neurological complications could now be coded

as:

El0.40 Type I diabetes mellitus with diabetic neuropathy,

unspecified

El0.41 Type I diabetes mellitus with diabetic mononeuropathy

El0.44 Type I diabetes mellitus with diabetic amyotrophy

(12)

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What is GEMs?

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CMS contracted with 3M to develop General Equivalency Mappings (GEMs)

files to assist in the translation

between ICO-10 and ICO-9.

GEMs are:

• A public domain reference mapping designed to give the health care

industry:

Bi-directional

mapping between ICD-9 and ICD-10 diagnosis and institutional

procedure codes

To provide a start in the process of identifying

codes that would represent as

accurately as possible the original intent of the ICD-9 or ICD-10 source code

for crosswalking purposes.

To provide a tool to identify the appropriate

set or group of codes in ICD-10

that would be equivalent

to the initial intent of a similar set or group of ICD-9

(13)

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Code Categorization Comparison for

Fracture of the Radius

ICO-9 Definition: 33 Codes for

Fracture of the Radius

2 codes for Calles' fracture

2 codes for Torus fracture of the Radius .1codes for Pathologic fracture of the

Radius

6 codes for fracture of the Forearm

"

-.'-22 codes for other fractures of the Radius

Fracture of the

Radius

ICO-I0 Definition: 1818 Codes for

Using GEMs

Fracture of the Radius

f

48 codes for Calles' fracture Mapping ICD-9 to ICD-10

48 codes for Barton's fracture • Results in 76 codes "

\ • Uses a forward map

48 codes for Smith's fracture ₁_. _•

where ICD-9 is the fl'

48 codes for Radial Styloid fracture source code -,

48 codes for Galeazzi's fracture

{ .Mapping ICD-l0 to ICO-9 1

36 codes for Torus fracture of the Radius _' _{• Results in 353 codes}

1

18 codes for Stress fracture of the Radius • Uses a backward map j

i

18 codes for Greenstick fracture of the where ICD-9 is the

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target code

Radius \

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90 codes for Pathologic fracture of the

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Radius

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45 codes for Bent Bone fracture of the 'j '1

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Radius 'j

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216 codes for Growth Plate fracture of the Radius

,

663 codes for other fractures of the Radius \

(14)

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ICO-10 Benefits and ICO-9-CM Limitations

• ICO-10 codes refine and improve SMA operational capabilities and processing

Detailed health reporting and analytics: cost, utilization, and outcomes Detailed information on condition, severity, co-morbidities, complications, and location

Expanded coding flexibility by increasing code length to seven characters Classifies code detail to process payments and reimbursements accurately Embedded detail informs healthcare providers and health plans of patient incidence and history, improving case management and care coordination

Supports greater analysis of risk and severity

• ICO-9-CM limits operations, reporting, and analytic processes

Follows a 1970s outdated medical coding system Lacks clinical specificity to process claims and

reimbursements accurately and effectively

Failsto capture detailed healthcare data analytics

Restricted to three to five characters, limiting the ability to account for complexity and severity

(15)

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ICO-10 Advantages lead to

SMAs' Business Advantages

ICO-10 advantages

.

• Detailed medical concepts

• Enhanced categorization

models

• Granularity in severity and risk definitions

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. Enhanced clinical information integration

ICO-10advantages

lead to SMA health plan

and business advantages

-Estabhshed Compliance Model -I mproved Contracting

-Enhanced Network Management

-Enhanced Fraud, Waste, Abuse Prevention and Detection -Enhanced ability to predict risk population

-lrnproved Claims Payment Accuracy and Efficiency

-Opportunity to Improve Coding Practices among Providers -More Accurate Understanding of Population Health

-Opportunity to Improve Precision and Accuracy of Payment Policies

-Opportunity to Improve Accuracy of Quality Measures -Opportunity to Improve Care and Disease Management

(16)

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ICO-10 Impacts People, Processes,

and Technology

Coordinate with vendors, providers and contractors/fiscal

agents to remediate ICD-10 impacts for

both business/policy and technology.

State Medicaid Agencies Vendors /,;, Providers Contractors and FiscalAgents