4/20/2011 - hitechanswers.net · •following the “excludes” and “includes” notes, ... or...
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4/20/2011
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INCREASING REVENUES IN THE BUSINESS OFFICE
Richard S. Blauvelt, BA, MHSM
President/CEO
PRO-DOC SOLUTIONS
ICD-10-CM: A Look at the Code Set
Betty Johnson, CPC, CPMA, CPC-I, CCS-P, CPC-H, CPCD, PCS, CCP, CIC, RMC Regional Director, Midwest
ICD
-10 FIN
AL R
ULE C
MS-0
01
3-F
• Published January 16, 2009
• October 1, 2013 – Compliance date for implementation of ICD-10-CM and
ICD-10-PCS (no delays)
• No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes
http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf
ICD
-10 F
INA
L RU
LE ISSUES
• Single implementation date for all users – Date of service for ambulatory and physician reporting
– Date of discharge for inpatient settings
• ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013
• ICD-9-CM claims for services prior to implementation date will continue to flow through systems for a period of time
• 4010 electronic transaction standard to 5010 – January 1, 2012
• THERE WILL BE NO DELAY!!!
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CO
DE S
ET CO
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AR
ISON
: DIA
GN
OSIS C
OD
ES
• ICD-9-CM Diagnosis Codes
• 3-5 characters in length
• Approximately 14,025 codes
• First digit may be alpha (E or V) or numeric. Digits 2-5 are numeric
• Limited space for new codes
• Lacks detail
• Lacks laterality
• Difficult to analyze data due to non-specific codes
• Codes are non-specific and do not adequately define diagnoses needed for medical research
• Does not support interoperability because it is not used in other countries
• ICD-10-CM Diagnosis Codes
• 3-7 characters in length
• Approximately 69,368 codes
• Digit 1 is alpha; digit 2 and 3 are numeric; digit 4-7 are alpha or numeric
• Flexible for adding new codes
• Very specific
• Has laterality
• Specificity improves coding accuracy and depth of data for analysis
• Detail improves the accuracy of data used in medical research
• Supports interoperability and the exchange of health care data between other countries and the United States
ICD-10 Impact
Staff Education and Training
IT System Changes
Impact to Documentation
Changes in Business Process
Changes to Super-Bills
Possibility of Cash Flow Disruption
ICD
-10
P
R
OV
I
DER
IMP
AC
T
PR
OV
IDER IM
PA
CTS
Documentation of diagnoses and procedures
▫ Codes must be supported by medical documentation
▫ ICD-10-CM codes are more specific
▫ Revenue Impacts of specificity
▫ Denials
▫ Additional Documentation 6
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PR
OV
IDER IM
PA
CTS
– Coverage and payment • New coding system will mean new coverage policies, new
medical review edits, new reimbursement schedules
• Changes will be made to accommodate increase specificity
• May need to discuss changes with patients
– Contracts with plans • Coding more specific and includes severity
• Renegotiations will be based on new coding, coverage, and reimbursement
• Difficult to measure what the changes will mean to overall reimbursement
PR
OV
IDER IM
PA
CTS
– Billing and eligibility transactions
– Updated transactions include support for ICD-10
– New codes mean more specificity
– How smooth the transition?
– Expect increased reject, denials, and pended claims as both plans and providers get used to new codes
– Laboratory orders
– Will need specific ICD-10-CM codes for laboratory orders
– Expect coverage changes
– Need to support the tests ordered
– Documentation challenges
CO
DIN
G A
ND
DO
CU
MEN
TATIO
N
• Issues related to inconsistent, missing, conflicting, or unclear documentation must still be resolved by the provider—both today under ICD-9-CM, as well as in the future with ICD-10-CM
• If providers are not documenting concisely for reimbursement today
– They are putting themselves at unnecessary risk for not supporting medical necessity
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LTH P
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IMP
AC
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• Contracting with providers and employers
• Coverage determinations
• Payment determinations
• Medical review policies
• Plan structures
• Statistical reporting
• Actuarial projections
• Fraud and abuse monitoring
• Quality measurements
BILLIN
G A
ND
CO
LLECTIO
NS
• Patient/Provider/Plan Confusion
– Increase in denials?
– Patient misunderstanding of changes in coverage
– Provider questions
• Older debt versus newer services
– Using ICD-9 codes versus ICD-10 for rebilling
• Privacy concerns
– New codes contain significantly more detail, how much can be shared
ICD
-10-C
M C
HA
NG
ES
• There are multiple changes in store for physicians/coders such as – the addition of information relevant to ambulatory and managed
care encounters
– expanded injury codes in which ICD-10-CM groups injuries by site of the injury, as opposed to grouping in ICD-9-CM by type of injury or type of wound
– creation of combination diagnosis/symptom codes, which reduces the number of codes needed to fully describe a condition
– greater specificity in code assignment (up to seven characters)
– V and E codes being incorporated into the main classification in ICD-10-CM
– ICD-10-CM codes being alphanumeric and including all letters except U
– the length of codes in ICD-10-CM being a maximum of seven characters, as opposed to five digits in ICD-9-CM
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ICD
-10 C
HA
NG
ES
From 14,125 codes to approximately 69,368 ICD-10--CM codes
All codes have full descriptions for both ICD-10-CM and ICD-10-PCS
ICD-9-CM
• 2011
• 14,125 codes
ICD-10-CM
• 2011
• 69,368
Categories
Alphanumeric
3 characters
Subcategories
4 or 5 characters
Codes
Up to 7 characters
ICD-10 CM Format
Extension Etiology, Anatomical site, Severity Category
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TH
REE C
HA
RA
CTER C
ATEG
OR
IES
• Following the “excludes” and “includes” notes, each chapter begins with a list of blocks—or subchapters—of three character categories
• A00–A09 Intestinal infectious diseases
• A15–A19 Tuberculosis
• A20–A28 Certain zoonotic bacterial diseases
• A30–A49 Other bacterial diseases
FO
UR C
HA
RA
CTER C
ATEG
OR
IES • The fourth character categories further define the
site, etiology, and manifestation or state of the disease or condition
• C15 Malignant Neoplasm of the Esophagus
• C15.3 Malignant neoplasm of upper third of esophagus
• C15.4 Malignant neoplasm of middle third of esophagus
• C15.5 Malignant neoplasm of lower third of esophagus
• C15.8 Malignant neoplasm of overlapping lesion of esophagus
• C15.9 Malignant neoplasm of esophagus, unspecified
FIV
E-SIX C
HA
RA
CTER C
ATEG
OR
Y
• In ICD-10-CM, a fifth or sixth six character sub-classifications represents the most accurate level of specificity
• S55.011 Laceration of ulnar artery at forearm level, right arm
• Plus we need a 7th character classification
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SEV
ENTH
CH
AR
AC
TER EX
TENSIO
N
• Certain ICD-10-CM categories have applicable 7
characters.
– The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct.
– The 7th character must always be the 7th character in the data field.
– If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
SEV
ENTH
CH
AR
AC
TER EX
TENSIO
N
• Certain ICD-10-CM categories have applicable 7 characters.
• S55.011 Laceration of ulnar artery at forearm level, right arm – A-Initial encounter
– D-subsequent encounter
– S-sequela
• Code selection is S55.011A – Extension “A”, initial encounter is used while the patient is
receiving active treatment for the injury
EX
AM
PLES
• T50.B96A Underdosing of other viral vaccines, initial encounter
• T50.B96D Underdosing of other viral vaccines, subsequent encounter
• T50.B96S Underdosing of other viral vaccines, sequela
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DU
MM
Y PLA
CEH
OLD
ERS
• The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a 5th character placeholder at certain 6 character codes to allow for future expansion
• Example:
– O33.5xx0 Maternal care for disproportion due to unusually large fetus, not applicable or unspecified
EX
AM
PLE
• A patient not wearing a seatbelt was involved in an automobile accident, hit the windshield was treated in the emergency room for a laceration to the scalp.
• First listed diagnosis: S01.01xA Laceration without foreign body of scalp
EX
CLU
DES N
OTES
• Two types of “excludes” notes are found although each indicates that codes excluded from each other are independent of each other.
– Excludes1—Indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. An Excludes1 is used for when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Conditions listed with Excludes1 are mutually exclusive.
• Example: E11 Type II diabetes
Excludes1: gestational diabetes type 1 diabetes
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EX
CLU
DES N
OTES
• Excludes1 instructs the user to go to another code for the excluded condition, so if the patient is pregnant code I10 is not assigned.
– Excludes2—Indicates that the condition excluded is not part of the condition represented by the code, but from a patient who may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together when both conditions exist.
• Example: J03 Acute tonsillitis
Excludes2: chronic tonsillitis
LA
TERA
LITY
• The right side is always character 1
• the left side character 2.
• In those cases where a bilateral code is provided the bilateral character is always 3
• The unspecified side is either a character 0 or 9 depending on whether it is a 5th or 6th character
EX
AM
PLES • C50.212-Malignant neoplasm of upper-inner
quadrant of left female breast
• H02.835-Dermatochalasis of left lower eyelid
• I80.01-Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
• L89.213-Pressure ulcer of right hip, stage III
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DIA
BETES M
ELLITUS
• Significant Change to Diabetes Mellitus
• There are five (5) Diabetes Mellitus categories in the ICD-10-CM. They are:
• E08 Diabetes Mellitus due to an underlying condition
• E09 Drug or chemical induced diabetes mellitus
• E10 Type I diabetes mellitus
• E11 Type 2 diabetes mellitus
• E13 Other specified diabetes mellitus
DIA
BETES M
ELLITUS
• Diabetes mellitus codes expanded to include the classification of the diabetes and the manifestation.
• Category for diabetes mellitus has been updated to reflect the current clinical classification of diabetes
• No longer classified as controlled/uncontrolled:
– E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease
– E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
– E10.11, Type 1 diabetes mellitus with ketoacidosis with coma
– E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy
EX
AM
PLE
• A 45-year-old type II patient returns to his physician’s office for a 3-month follow-up visit. The patient has been on insulin for the past eight month since the diabetes was not well controlled. After an expanded problem-focused history and physical examination, the physician documents in the medical record, “Type II diabetes mellitus currently maintaining good control with insulin, diet, and exercise. Patient will continue with same medication dosage, monitor glucose levels with home monitoring system, and return in 3 months for recheck We may consider discontinuing insulin if patient remains in good control.”
– E11.9-Type 2 diabetes mellitus without complication
– Z79.4, Long-term (current) use of insulin
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TION
CO
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• ICD-10-CM consists of greater specificity.
• Examples
– I25.110, Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris
– K50.013, Crohn’s disease of small intestine with fistula
– K71.51, Toxic liver disease with chronic active hepatitis with ascites
CO
MP
LICA
TION
EX
AM
PLE
• ICD-10-CM provides 50 different codes for “complications of foreign body accidently left in body following a procedure”
• Only one code in ICD-9-CM.
CO
MP
LICA
TION
EX
AM
PLE
• T81.535-Perforation due to foreign body accidently left in body following heart catheterization
• T81.530-Perforation due to foreign body accidently left in body following surgical operation
• T81.524-Obstruction due to foreign body accidently left in body following endoscopic examination
• T81.516-Adhesions due to foreign body accidently left in body following aspiration, puncture or other catheterization
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AN
OTH
ER EX
AM
PLE
• S31.623A-Laceration with foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity, initial encounter,
• Extension used with a laceration code. Note that in ICD-10-CM, the entire code description is written out
– A Initial encounter
– D Subsequent encounter
– S Sequelae
FR
AC
TUR
ES • Fracture codes require seventh character to identify if
fracture is open or closed
• Other fracture extensions are:
– A Initial encounter for closed fracture
– B Initial encounter for open fracture
– D Subsequent encounter for fracture with routine healing
– G Subsequent encounter for fracture with delayed healing
– K Subsequent encounter for fracture with nonunion
– P Subsequent encounter for fracture with malunion
– S Sequelae
• S42.022-Displaced fracture of shaft of left clavicle initial encounter for closed fracture
– Requires 7th character A for initial encounter
– S42.022A
FR
AC
TUR
E CO
DIN
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MP
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• A patient underwent surgery for an open burst fracture of the lumbar vertebra which became unstable.
• First listed diagnosis: S32.012B
– Seventh character “B” identifies the initial encounter for the open fracture.
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CA
SE EX
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CA
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CA
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RESO
UR
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http://www.aapc.com
• Valuable resources for all medical practices solo practitioners-large medical groups
• http://www.aapcps.com
• Valuable resources for all practices regarding ICD-10-CM implementation and education
• http://www.cms.hhs.gov/ICD10
• Complete list of code sets for ICD-10-CM and ICD-10 PCS; final rule and Official ICD-10-CM Guidelines
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QU
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S?
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THE C
OU
NTD
OW
N IS N
OW
!!!
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E-Mail: [email protected]
Phone: 866-200-4157 X 309
• For more information or to schedule implementation assistance go to: www.aapcps.com
• For more information or to schedule Curriculum Training go to: www.aapc.com
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AGENDA
• Agenda
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