ICD-10 –CM and the Impact on Physician

Practices

1450 Winter VAR ConferenceFebruary 3, 2012

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Denisha M. Torres-Lich, MS, RHIA, LHRMPresidentTorres-Lich & Associates, Inc.

Over 30 years old Codes are insufficient Lack specificity and detail Limits the ability of payers and others Do not provide the level of detail

Current System Limitations

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ICD-10 Final Rule CMS-0013-F◦ http://edocket.access.gpo.gov/

2009/pdf/E9-743.pdf ◦ Published January 16, 2009

Compliance Date for Implementation◦ October 1, 2013

First implement the “Version 5010” electronic health care transaction standards◦ January 1, 2012

The Beginning: ICD-10

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Improve operational processes Update the terminology and disease

classifications Increase flexibility Enhance coding accuracy and specificity Support refined reimbursement models

Benefits

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Allows for greater automation = fewer payer-physician inquiries

Provides more detailed data Greater diagnostic specificity Provides for more effective detection and

investigation of potential fraud or abuse

Benefits

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Standard coding convention that:◦ flexible ◦ provides unique codes ◦ allows new procedures and diagnoses to be easily

incorporated Two Components

◦ ICD-10 – CM Diagnosis classification system

◦ ICD-10-PCS Procedure classification system for inpatient hospital

use

Characteristics of ICD-10

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Both components can improve:◦ quality measurements◦ patient safety ◦ evaluation of medical processes and outcomes.

ICD–10–PCS ◦ can readily expand and capture new procedures

and technologies

Characteristics ICD-10

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ICD-9 ICD- 10

17 Chapters 21 Chapters

3 – 5 Digits 3 – 7 Digits

Supplemental Chapters 1st Digit is alpha (E & V) = all other Numeric

1st Digit is alpha2nd Digit is numeric3rd – 7th Digit is alpha

Approx. 14,500 Approx. 70,000

Antiquated terminology Current terminology

Complications of Medical Care in 1 Chapter Complications have been moved to procedure specific body system chapters

Partial code titles Full code titles

Code extensions for specificity and laterality

Dummy place holder

813.15, Open fracture of head of radius S52123C, Displaced fracture of head of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC

Structural Difference between – ICD-9-CM and ICD-10- CM

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Table of Contents◦ 1 Certain infectious and parasitic diseases (A00-B99)

◦ 2 Neoplasms (C00-D49)◦ 3 Diseases of the blood and blood-forming organs

and certain disorders involving the immune mechanism (D50-D89)

◦ 4 Endocrine, nutritional and metabolic diseases (E00-E89)

◦ 12 Diseases of the skin and subcutaneous tissue (L00-L99)

◦ 13 Diseases of the musculoskeletal system and connective tissue (M00-M99)

◦ 14 Diseases of the genitourinary system (N00-N99)

ICD-10-CM TABULAR LIST of DISEASES and INJURIES

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ICD-9 ICD- 10

3 – 4 Digits 3 – 7 Digits

Codes are numeric Codes are alphanumeric

Approx. 3,000+ Approx. 72,000

Antiquated terminology Current terminology

Does not have laterality Has laterality

Generic details of body parts Full detail of body part

Detail of methodology and approach

Flexible

48.36 [Endoscopic] polypectomy of rectum 0DBP8ZZ Excision of Rectum, Via Natural or Artificial Opening Endoscopic

Structural Difference between – ICD-9-CM Vol 3 and ICD-10- PCS

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0 D B 6 8 X Z Med/Surg

Gastrointestinal

Excision

Stomach

Transorifice Intraluminal Endoscopic

None

Diagnostic

SectionBody

SystemRoot

OperationBodyPart Approach Device Qualifier

Example of ICD-10-PCS

network of relationships between the two code sets ◦ ICD-9-CM to ICD-10-CM (forward mapping)◦ ICD-10-CM to ICD-9-CM (backward mapping)

“…a series of possible compromises rather than the mirror image of one code in the other code set.”

General Equivalence Mappings -(GEMS)

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Challenges with Mapping

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Diagnosis Codes and Differences in Classification ◦ For example:

I-9 code description - “complicated open wound” Delayed healing, delayed treatment, foreign body or

infection I-10 categorizes open wounds

wound type -laceration or puncture wound, and whether a foreign body is present

depending on the documentation in the record, the correct correspondence between and I-9 and I-10 code could be one of several.

Challenges with Mapping

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Diagnosis Codes and Levels of Specificity codes. ◦ i.e. in I-9, category 733, Other disorders of bone

and cartilage, contains the codes: 733.93 Stress fracture of tibia or fibula 733.94 Stress fracture of the metatarsals 733.95 Stress fracture of other bone 733.96 Stress fracture of femoral neck 733.97 Stress fracture of shaft of femur 733.98 Stress fracture of pelvis

in many instances I-10 provides specific codes for all likely sites of a stress fracture, including more specificity for the bones of the extremities, the pelvis and the vertebra. Stress fracture data coded in I-10 possesses a consistent level of specificity.

Challenges with Mapping

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73395 M4840XA 1000073395 M4841XA 1000073395 M4842XA 1000073395 M4843XA 1000073395 M4844XA 1000073395 M4845XA 1000073395 M4846XA 1000073395 M4847XA 1000073395 M4848XA 1000073395 M8430XA 1000073395 M84319A 1000073395 M84329A 1000073395 M84339A 1000073395 M84343A 1000073395 M84373A 1000073395 M8438XA 10000

Example of I-9 to I-10 GEM

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Diagnosis Codes in Combination i.e.

I – 9 code 115.11Histoplasma duboisii meningitis = I – 10 codes B39.5 Histoplasmosis duboisii

AND G02 Meningitis in other infectious and parasitic diseases classified elsewhere

Challenges with Mapping

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ICD-10-CM

Many possible codes

Specificity looks like this…

S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture

S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture

S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture

S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture

S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture

S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture

S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture

S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture

S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture

S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture

S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture

S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture

S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing

S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing

S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing

ICD-9-CM

821.01 Fracture of femur, shaft,

closed

Impact

Hospitals Health care

practitioners & institutions

Health insurers & other third-party payers

Electronic-transaction clearinghouses

Hardware & software manufacturers & vendors

Billing & practice-management service providers

Health care administrative & oversight agencies

Public & private health care research institutions

All reporting/billing health care providers • ICD-10-CM

– Hospitals, physicians, clinics, laboratory, radiology, psychiatric, rehab, nursing homes etc. All diagnosis codes

• ICD-10-PCS– Procedures for Hospital InpatientsCPT/HCPCS– Procedures for Hospital Outpatients,

Physician, Laboratory and Radiology Outpatients

Users

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- Electronic Health Records- Practice Management Systems- Billing- Accounts Receivable- Productivity Loss

Impact on Physician Practices

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Physician Perception Impact on Practice Management Impact on reimbursement Physician practice changes

Challenges of Engaging Physicians

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Six phases: ◦ Planning ◦ Communication and Awareness ◦ Assessment ◦ Operational Implementation ◦ Testing ◦ Transition

Milestones & Tasks

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Quality vs. Quantity More stringent

documentation◦ i.e. Myocardial Infarction ICD-

10 documentation will need to include: Type of Infarction Age of Infarction Specific Site of Myocardium

involved Coronary Artery Involved Information regarding initial or

subsequent MI within 4 weeks

Impact on Coding and Documentation

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Work toward better documentation to◦ Avoid misinterpretation by third parties (auditors,

payers, attorneys, etc.)◦ Justify medical necessity ◦ Provide a more accurate clinical picture of quality

of care provided

Coding and Documentation

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Speech Recognition◦ Back End◦ Front End

Computer Assisted Physician Documentation

Computerized Assisted Coding◦ reduce costs and claims rejections ◦ improve productivity and accuracy

Electronic Tools to Facilitate Coding & Documentation Process

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2012 ICD-10◦ http://www.cdc.gov/nchs/icd/icd10cm.htm◦ http://www.cms.hhs.gov/ICD10

AHIMA ICD-10 Resources◦ http://www.ahima.org/ICD10/default.aspx

Provider Resources◦ http://

www.cms.gov/ICD10/05a_ProviderResources.asp

Web Resources

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Questions

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Denisha M. Torres-Lich, MS, RHIA,LHRMPresident

Torres-Lich & Associates, Inc.(727) 515-2355

Denisha@Torres-Lich.com

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