ACR PRACTICE MANAGEMENT 2014

Countdown to ICD-10: Fact or FictionChicago Rheumatism Society

May 29, 2014

Antanya Chung, CPC, CPC-I,CRHC, CCPDirector, Practice Management

American College of Rheumatology

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Countdown to ICD-10

This session will include:

• ICD-10 Overview• Prepare for working with denials and claims edits• Prepare for the associated impact to charting and coding• Operational Impact• Resources

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Countdown to ICD-10

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Countdown to ICD-10

On March 31, Congress passed the ProtectingAccess to Medicare Act of 2014, mainly creates a temporary “fix” to the Medicare sustainable growthrate (SGR).

The bill states that the Department of Health and Human Services (HHS) cannot adopt the ICD–10 code set as the standard until at least October 1, 2015.

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Countdown to ICD-10

“The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.” - Albert Einstein

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Overview

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Countdown to ICD-10

What is ICD-10?

• ICD-10 is a new set of diagnosis codes which will replace ICD-9. It was implemented to allow additional codes to be added to different categories.

• New codes are being added constantly as ICD-9 can no longer support the additional codes.

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ICD-10 is the classification system currently being used by the majority of the world to identify medical diagnosis.

The US is the only industrialized nation not using an ICD-10-based classification system.

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Two reasons the transition to ICD-10-CM is pushed:

1. Payers cannot pay claims fairly using ICD-9-CM since the classification system does not accurately reflect current technology and medical treatment.

2. The healthcare industry cannot accurately measure quality of care using ICD-9-CM. It is difficult to evaluate the outcome of new procedures and emerging health care conditions when there are not precise codes.

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The code sets are expanding from an approximate total of14,000 in ICD-9 to approximately 68,000 in ICD-10 — almost an eight-fold increase.

Because of the magnitude of the difference in the number of codes in the sets, for many codes there will be no “crosswalks” with a one-to-one match. The EDI transactions associated with the claims cycle will need to be revised and tested.

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The improved code specificity of ICD-10 will eliminate some of the ambiguity that exists with the lack of specificity in ICD-9.

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DX Specificity Drives Data & Public Reporting

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Documentation &

Severity of Illness

ICD-11

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Countdown to ICD-10

Why move to ICD-10, if ICD-11 is on the horizon?

ICD-10 is the pathway to ICD-11 While other countries use ICD to classify and document

information, healthcare organizations in this country face a challenge in adopting newer versions of ICD to fit current HIPAA laws and billing codes.

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ICD-10

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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

ICD-10-CM Diagnosis Codes

3-7 characters in length Approximately 68,069 codes Alphanumeric throughout 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

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ICD-10 Structure

Categories

• alphanumeric• 3 characters

Subcategories

• 4-5 characters• digits or letters

Codes

• 7th character extension

• digit or letter

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ICD-10 Format

M05 – rheumatoid arthritis with rheumatoid factorM05.2 - rheumatoid vasculitis with rheumatoid arthritisM19.072 – primary osteoarthritis, left ankle and footM1a.0110 – idiopathic chronic gout, right shoulder, without tophus (tophi)M1a.08X0 – idiopathic chronic gout, vertebra, without tophus (tophi)

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M00-M02 Infectious arthropathiesM05-M14 Inflammatory polyarthropathiesM15-M19 OsteoarthritisM20-M25 Other joint disordersM26-M27 Dentofacial anomalies [including malocclusion] and other disorders of jawM30-M36 Systemic connective tissue disordersM40-M43 Deforming dorsopathiesM45-M49 SpondylopathiesM50-M54 Other dorsopathies M60-M63 Disorders of musclesM65-M67 Disorders of synovium and tendonM70-M79 Other soft tissue disorders

Chapter 13 Diseases of the Musculoskeletal System And Connective Tissue (M00-M99) 

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M80-M85 Disorders of bone density and structureM86-M90 Other osteopathiesM91-M94 ChondropathiesM95-M99 Other disorders of the musculoskeletal system and connective tissue

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Three Character Category List:

Chapter 14 Diseases of the Genitourinary System (N00-N99)Chapter 15 Pregnancy, Childbirth and the Puerperium (O00-O9A)Chapter 16 Certain Conditions Originating in the Perinatal Period (P00-P96) Chapter 17 Congenital Malformations, Deformations and Chromosomal

Abnormalities (Q00-Q99)Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)Chapter 19 Injury, Poisoning and Certain Other Consequences of External Cause (S00-T88)Chapter 20 External Causes of Morbidity (V00-Y99)Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99)  

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(M00-M99)Arthritis and osteoarthritis have both site and laterality designations inICD-10-CM

Example 1: A 65 year old female patient was seen for primary osteoarthritis of the left knee. She complains that pain is severe at night. The rheumatologist prescribes an NSAID to relieve the pain.

What is the code?M17.12

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(M00-M99)Rheumatoid arthritis is broken down by site, laterality complication, and withor without rheumatoid factor.

Examples:A. Patient has rheumatoid arthritis without rheumatoid factor, right elbow.

B. Patient has juvenile rheumatoid arthritis with systemic onset, left knee.

How are these coded?M06.021M08.262

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(M00-M99)Site and lateralityMost of the codes in Chapter 13 of the ICD-10-CM have site and laterality assignments. This is one of the big changes from ICD-9-CM to ICD-10-CM. - The right side will be coded with “1”

- The left side will be codes with “2”

Bone versus jointFor some conditions, the bone may affect the upper and lower end. Although, the part of the bone affected may be at the joint, the site description will be for the bone and not the joint.

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Key Coding Guidelines of ICD-10:

External Cause – These can be used with any codes in the range of A00.0 – T88.99 and Z00 – Z99.– These codes should be coded for the length of the treatment.– Assign as many external codes as needed.– External can never be the first diagnosis.– No external code is to be used is the primary diagnosis already

includes the cause of the injury in the diagnosis. 

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External Cause Codes Example:

Z21 Asymptomatic human immunodeficiency virus (HIV) infection status Z87.891 Personal history of nicotine dependence (past)

F17.21 Nicotine dependence, cigarettes (current) Z79.1 Long term (current) use of (NSAID) Z79.52 Long term (current) use of use of systemic steroids Z68.- Body mass index (categorized by age)

E66.01 Morbid (severe) obesity

Drug induced gout (M10.2-) use additional code for adverse effect T36 –T50

FYI Personal alcohol dependence F10.2-

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Obesity – If this condition is documented and coded; then the body mass index must also be documented and coded from the Z68.- section.

 Osteoporosis – There must be documentation if it is with or without a pathological fracture. – A patient with osteoporosis and without current pathological fracture

should be coded from category M81.-. Use Z87.310 for a history of osteoporosis pathological fractures.

– A patient with osteoporosis with current pathological fractures should be coded from category M80.-.

 Pregnancy – If a patient is pregnant and the physician documents that the pregnancy is incidental to visit; then Z33.1 must be coded along with the primary diagnosis.

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  Signs and Symptoms – It is only acceptable to code a sign or symptoms until a

definitive diagnosis is established. Once a definitive diagnosis is made do not code the sign and symptoms.

  Unspecified codes – Codes titled “unspecified” are for use when the

information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified.

HIV/AIDS – Code B20 for symptomatic HIV patients if they have any infections associated with HIV(AIDS). Code Z21 for asymptomatic HIV infection status –

Sequencing – If any HIV positive patient is treated for an unrelated condition; then code the unrelated condition first then code the HIV Z21.

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Signs and Symptoms Code Examples: R10.1- Pain localized to upper abdomen R11.1 Nausea (without vomiting) R53.83 Other fatigue R76.0 Raised antibody titer R79.1 Abnormal coagulation profile (PT, PTT) R79.82 Elevated C-reactive protein (CRP) R79.89 Other Specified abnormal finding of blood chemistry

(Positive ANA) R82.5 Elevated urine levels of drugs, medication and biological

substances

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Character Categories• Four character category example

• M79.7 Fibromyalgia• Fifth character category example

• M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement

• Sixth character category example• M08.461 Pauciarticular juvenile rheumatoid arthritis, right knee

• Seventh character category example• M1a.0710 Idiopathic chronic gout, right ankle and foot without tophus

(tophi)• Dummy place holder example

• M1a.08X0 Idiopathic chronic gout, vertebrae without tophus (tophi)

Implementation Preparation

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Countdown to ICD-10

Implementation Preparation• Physicians

• Documentation must change.• Coding and Billing Staff

• Must be allowed to query the physicians. • Vendors/Payers

• What are your vendors/payers doing to demonstrate they are ready?• Trainers

• Who will train the rest of your staff?

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Begin the Process

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Documentation

When it comes to ICD-10 implementation efforts, clinical documentation improvement (CDI) continues to be one of the most pressing concerns.

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Documentation

ICD-10 is not just a “coder” problem Industry analysts have predicted 50-70%

productivity losses due to ICD-10 The development of complete and accurate CDI

program will be critical to smooth transition.

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DocumentationWith the increased level of specificity due to ICD-10, provider documentation will need to accurately pinpoint elements such as: severity of illness, laterality, complications, symptom etiology

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Coding and Documentation

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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DocumentationA CDI program will need to:Promote medical necessity documentation to support

therapies, treatments and procedures.Ensure accurate and complete documentation for

accurate coding and reimbursement, reduced compliance risk, and the correct identification of the principal and/or secondary diagnoses

Support evidence-based care for quality reporting measures

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Billing and CollectionsPatient/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.

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Claims and reimbursements may be delayed or rejected due to several reasons by insurers:

differences in the codes sets that cannot be accounted for because of unavoidable compromises in the conversion,

efforts to take advantage of the more precise ICD-10 code set

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Timing

The time factor can play a crucial role in deciphering the codes.

This might mean longer waiting periods for reimbursements and more number crunching.

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Issues to Focus on Now

Some documentation issues will require physicians to capture new information; others involve updated, modified, and otherwise expanded documentation needs.

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A Warning against “Unspecified”

Physicians, coders and billers may be tempted to take the easy road and code “unspecified” if documentation doesn’t support more specific codes.

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Post Compliance Challenges

initial productivity lossdisruptions to claims flowincrease in claims rejection rateprovider-payer relationspatient experience with provider Preparation and a well-developed plan are key

to addressing challenges

Operational Impact

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Countdown to ICD-10

Running the Practice• Documentation must change/or continue the trend• Billing will slow down• Reimbursement slowdown• Increase of rejections• Patients visits will be longer

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The price tag?

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Training Timeline

Staff Timeframe

Coders 6-9 months

Physicians/health professionals

4-6 moths

Ancillary Staff 2-3 months

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Training Timeline

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Budget resources

Cost of training sessions and materials Time for staff members to learn. Cost of staff or temp workers who cover while your

people are in training sessions Cost of outsourcing medical coding while staff

coders are in training sessions

Final Thought

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Teamwork

• Joint Effort• How to be Successful?

• Understand each person’s skill set• Be patient

• There will be a learning curve

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ICD-10 implementation requires a methodical approach consisting, in part, of the following steps:

Evaluating all clinical, financial and business systems that currently use ICD-9 codes;

Collaborating with practice management vendors, billing services and payers to ensure that ICD-10 implementation is a priority for them, and

Drafting a budget that adequately covers changes to business processes, changes to software systems and staff training

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Additional areas for review:

Work flow redesignPolicy and procedureEHR modificationsStanding orders/prior authorizationsCross AuditingTESTING!!!!!

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Let’s Get Started

Identify your most common diagnoses and procedures and pull a sample of medical records by physician.

Conduct an ICD-10 documentation gap analysis.: Are you getting the level of specificity you currently need to

code ICD-10?  What are the gaps and documentation trends you see by

diagnosis and/or procedure?

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Keep in mind with the expansion of the codes and new categories, paper superbills/charge tickets might no longer be useful to any medical practice

Tools, such as an automated superbill or the use of the electronic health record may be the only answer

This is a critical business process that needs a high level of attention

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The ACR is committed to assisted practices with education and other helpful resources.

But help us help you…..

Countdown to ICD-10

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The ACR is committed to assisted practices with education and other helpful resources.

- Online Training- Online assessment testing- Superbill- Crosswalk

ICD-10:Ready or Not....It's Still Coming!

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