Slide 1
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Slide 2 Learning Objectives
• Identify the similarities and differences between ICD-9 and ICD-10.
• How to determine the correct ICD-10 codes.• Describe a mapping of ICD-9 to ICD-10 for
common conditions seen by physical therapists.• Recognize strategies and resources, and adapt
practice procedures for transition to ICD-10.• Identify timelines associated with ICD-10
adoption.
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Slide 3 Speakers• Joseph Nichols, MD, is a board certified Orthopedic Surgeon with a long history in health
information technology. He has a wide range of experiences in healthcare information technology on the provider, payer, government and vendor side of healthcare business. He has served in positions in executive management, system design, logical database architecture, product management, consulting and healthcare value measurement for the last 18 of his 35 years in the healthcare industry. He has given over 100 presentations nationally related to ICD-10 over the past 3 years on behalf of CMS, payers, providers, integrated delivery systems, consulting groups, universities, government entities, vendors and trade associations. He co-chairs the WEDI (Workgroup on Electronic Data Interchange) translation and coding sub-workgroup and has received WEDI merit awards 3 years in succession. He is also an AHIMA approved ICD-10 coding trainer. He is currently providing consulting services as the President of Health Data Consulting, Inc.
• Janet Albanese, PT, MPT, MHA, is presently an owner of Access Physical Therapy & Wellness and has served as the Compliance Officer and Director of the billing department for its 19 locations over the past 11 years. She oversees all training and transition related to compliance and billing and is in charge of the current ICD-10 transition. Janet also serves on the payment policy committee for Private Practice Section of the APTA. Janet has over 16 years' experience in the field of Physical Therapy. She earned both her Physical Therapy degree and Health Care Administration degrees from Springfield College.
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Slide 4
ICD-10Impacts and Opportunities
Presented by: Joe Nichols MDDate: March 27, 2014
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Slide 5
ICD-10 Basics
Key coding changes
Coding Challenge
ICD-10 documentation structure – Finding Codes
Mapping the good, the bad and the ugly
Implementation – Getting there in a timely manner
Testing – What, Why, Who and When
Available resources
Source: Health Data Consulting
5
Agenda
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Slide 6
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ICD-10 Compliance Date
The compliance date for ICD-10-CM and PCS is October 1, 2014
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Slide 7 The Road to 10: The Small Physician Practice's Route to ICD-10
7The Road to 10: The Small Physician Practice's Route to ICD-10. http://www.roadto10.org
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Slide 8
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Road to 10: Provider Preparation
Plan Your JourneyTo get you started, it is important to understand where you are on the road to ICD-10 compliance. The action plan provides a pictorial road map and the steps you may find helpful when pinpointing where diagnosis codes are used in your practice, identifying the transition team, preparing a budget for the transition to ICD-10, and arranging for training.
Train Your TeamYour support staff will be a big part of your success. The action plan contains guidelines to get your team started on the path to compliance. The website also highlights additional training resources that may be helpful to your practice.
Update Your ProcessesReviewing current clinical documentation practices and identifying gaps related to ICD-10 is an important step in your transition. The action plan walks you through the steps to update your policies, procedures, forms, and templates.
Engage Your Vendors & PayersCollaboration with technology vendors and payers is key. The action plan contains steps to help ensure system updates, set-up tasks, and compliance risks can be addressed.
Test Your Systems and ProcessesTesting is a critical component of the ICD-10 transition. The action plan walks you through the process of preparing test cases, performing internal and external testing, practicing coding in ICD-10, and validating clinical documentation processes.
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Slide 9
ICD-10 Basics
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Slide 10
ICD-10 international version– Adopted by WHO in 1990– Most countries other than the US currently use ICD-10– ICD-10 (International version) ~ 12,500 diagnostic codes– ICD-10 used for mortality reporting in the US - 1999
ICD-10-CM (US version) – ~ 69,000 diagnostic codes– Final rule published – 2009– Compliance date – October 1, 2014
ICD-10-PCS– ~72,000 codes– Not part of an international standard– Inpatient procedures only– Compliance date – October 1, 2014
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ICD10 Quick Facts
Source: Health Data Consulting
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Slide 11
ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes
3 to 5 digitsAlpha “E” and “V” on 1st
characterNo place holder characters
TerminologyIndex and Tabular Structure
Coding GuidelinesApproximately 14,000 codesSeverity parameters limited
Does not include lateralityCombination codes limited
7 digitsAlpha or numeric for any character
Include place holder characters (‘x’)
SimilarSimilarSome what similarApproximately 69,000 codesExtensive severity parametersCommon definition of lateralityCombination codes common
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ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes)
Source: Health Data Consulting
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Slide 12
September 2014 October 2014
ICD-9 ICD-1082111:Open fracture of Shaft of Femur
S72351C:Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
All codes for femur fractures = 16 All codes for femur fractures = 1530
Source: Health Data Consulting
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Same Condition – Different CodesWhat’s the Difference?
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Slide 13
Key Coding Changes
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Slide 14 ICD-10 StructureIndex Structure (Volume II)
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Slide 15
1 Certain infectious and parasitic diseases2 Neoplasms
3Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
4 Endocrine nutritional and metabolic diseases5 Mental and behavioral disorders6 Diseases of the nervous system7 Diseases of the eye and adnexa8 Diseases of the ear and mastoid process9 Diseases of the circulatory system10 Diseases of the respiratory system11 Diseases of the digestive system12 Diseases of the skin and subcutaneous tissue13 Diseases of the musculoskeletal system and connective tissue14 Diseases of the genitourinary system15 Pregnancy childbirth and the puerperium16 Certain conditions originating in the perinatal period17 Congenital malformations deformations and chromosomal abnormalities18 Symptoms signs and abnormal clinical and laboratory findings not elsewhere classified19 Injury poisoning and certain other consequences of external causes20 External causes of morbidity21 Factors influencing health status and contact with health services
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ICD-10 StructureTabular Structure – Level 1 (Chapters)
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Slide 16
13.1 Infectious arthropathies13.2 Inflammatory polyarthropathies13.3 Osteoarthritis13.4 Other joint disorders13.5 Dentofacial anomalies [including malocclusion] and other disorders of jaw13.6 Systemic connective tissue disorders13.7 Deforming dorsopathies13.8 Spondylopathies13.9 Other dorsopathies13.10 Disorders of muscles13.11 Disorders of synovium and tendon13.12 Other soft tissue disorders13.13 Disorders of bone density and structure13.14 Other osteopathies13.15 Chondropathies13.16 Other disorders of the musculoskeletal system and connective tissue
13.17 Intraoperative and postprocedural complications and disorders of musculoskeletal system not elsewhere classified
13.18 Biomechanical lesions not elsewhere classified
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ICD-10 StructureTabular Structure – Level 2 (Blocks)
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Slide 17
M15 Polyosteoarthritis
M16 Osteoarthritis of hip
M17 Osteoarthritis of knee
M18 Osteoarthritis of first carpometacarpal joint
M19 Other and unspecified osteoarthritis
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ICD-10 StructureTabular Structure – Level 3 (1st 3 Character Categories)
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Slide 18
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ICD-10 StructureTabular Structure (Volume I)
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Slide 19
2466 codes for fractures of the
femur
Source: Health Data Consulting
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Lots of Codes, Lots of Repetition
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Slide 20
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ICD-10 StructureTabular Structure (Volume I)
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Slide 21
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ICD-10 StructureTabular Structure (Volume I)
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Slide 22
Initial EncounterThe intent is to represent an encounter which is the first encounter for the clinician for a problem. The definition of “active treatment” is somewhat of a grey area.
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Coding ICD-10 CMGuidelines
Source: Health Data Consulting
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Slide 23
Subsequent EncounterThe intent is to represent an encounter for ongoing management and follow up of an initially treated condition.
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Coding ICD-10 CMGuidelines
Source: Health Data Consulting
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Slide 24 Coding: The Prime Directive
The goal of coding is to reflect as accurately as possible key parameters of the patient health condition and/or the
procedures done to maintain or improve that condition.
Coding focused on maximizing payment over accurate definition of the condition begins to cross the boundary of
fraud and abuse.
24 Source: Health Data Consulting
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Slide 25
Coding Challenge
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Slide 26
Example look up for “Coronary Artery Disease” + “Angina”
Source: Health Data Consulting
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Coding ICD-10-CM – ChallengesGetting There
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Slide 27
Distribution of codes related to “Arthritis” at the chapter level
*44% of codes are outside of Inflammatory Arthritis or Osteoarthritis categories
Chapter Description Count
Chapter1 Certain infectious and parasitic diseases 12
Chapter3Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 1
Chapter4 Endocrine nutritional and metabolic diseases 13
Chapter6 Diseases of the nervous system 1
Chapter12 Diseases of the skin and subcutaneous tissue 5
Chapter13 Diseases of the musculoskeletal system and connective tissue 920
Chapter14 Diseases of the genitourinary system 4
Chapter17 Congenital malformations deformations and chromosomal abnormalities 1
Chapter19 Injury poisoning and certain other consequences of external causes 3
Chapter21 Factors influencing health status and contact with health services 2
Source: Health Data Consulting 27
ICD-10 StructureVarying Distributions Across the Tabular Structure
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Slide 28
"If you don't find it in the index, look very carefully through the entire catalogue."
-- Unknown
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Coding ICD-10 CM – ChallengesRelevant Quote
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Slide 29
History
Physical Exam
Internal Record Review
External Record Review
Assessment/Diagnosis
Studies
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Clinical Documentation – The Patient InterfaceWhere It All Begins
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Slide 30
Supports proper payment and reduces denials
Assures accurate measures of quality and efficiency
Addresses the issue of accountability and transparency
Creates a competitive advantage
Provides better business intelligence
Supports clinical research
Supports interoperable sharing of data
It’s just good care!
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DocumentationWhy Is It Important?
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Slide 31
Source: Health Data Consulting
GEMGeneral Equivalency Mapping
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Slide 32
The best match between an ICD-9 and ICD-10 code results in the loss of some concepts in translation or the assumption of some concepts that may or may not be true.
ICD9 (82011):FRACTURE OF EPIPHYSIS (SEPARATION)
(UPPER) OF NECK OF FEMUR OPEN
ICD10 (S72023H):Displaced fracture of epiphysis (separation)
(upper) of unspecified femur, subsequent encounter for open fracture type I or II with delayed healing
Fracture Epiphyseal injury Proximal Femur Open Neck
Fracture Epiphyseal injury Proximal Femur Open Neck Subsequent encounter Type 1 or 2 Delayed Healing
Assumed Concepts
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Code Matching QualityAssumed Concepts
Source: Health Data Consulting
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Slide 33
ICD9 (80084):OPEN FRACTURE OF VAULT OF SKULL WITH OTHER
AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH PROLONGED (MORE THAN 24 HOURS)LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL
ICD10 (S020xxB): Fracture of vault of skull, initial encounter for open
fracture
Fracture Open Vault-Skull Head and Neck Region
Intracranial Hemorrhage Prolonged Loss of consciousness Return to conscious level
Fracture Open Vault-Skull Head and Neck Region Initial encounter Assumed
Concept
Lost Concepts
Source: Health Data Consulting
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Code Matching QualityLost and Assumed Concepts
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Slide 34
Matching can result in a significant distortion of the facts
ICD-10 Procedure Code
ICD-10 Procedure Term
0X6N0Z0 Detachment at Right Index Finger, Complete, Open Approach
0X6N0Z1 Detachment at Right Index Finger, High, Open Approach
0X6N0Z2 Detachment at Right Index Finger, Mid, Open Approach
0X6N0Z3 Detachment at Right Index Finger, Low, Open Approach
0X6P0Z0 Detachment at Left Index Finger, Complete, Open Approach
0X6P0Z1 Detachment at Left Index Finger, High, Open Approach
0X6P0Z2 Detachment at Left Index Finger, Mid, Open Approach
0X6P0Z3 Detachment at Left Index Finger, Low, Open Approach
0X6Q0Z0 Detachment at Right Middle Finger, Complete, Open Approach
0X6Q0Z1 Detachment at Right Middle Finger, High, Open Approach
0X6Q0Z2 Detachment at Right Middle Finger, Mid, Open Approach
0X6Q0Z3 Detachment at Right Middle Finger, Low, Open Approach
…
ICD-9 Procedure Code
ICD-9 Procedure Term
84.01 Finger Amputation
Source: Health Data Consulting
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Code Matching QualityProblematic Match
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Slide 35
Native ICD-9 definition [3] Codes[1 code related specifically to Median nerve injury][2 codes for review related to potential injury]
GEM Bidirectional Map = [15]*
Native ICD-10 definition [33] Codes[27 codes related specifically to median nerve injury][6 codes related to potential injury (Carpal Tunnel/Median nerve lesion)]
Source: Health Data Consulting
35
Code Aggregation ExampleMedian Nerve Injury
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Slide 36
Native ICD-9 definition [33] Codes[2 codes for Colles’ fracture][2 codes for Torus fracture of the Radius][1 codes for Pathologic fracture of the Radius][6 codes for fracture of the Forearm][22 codes for other fractures of the Radius]
GEM Bidirectional Map = [336]*
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Code Aggregation ExampleFracture of the Radius
Source: Health Data Consulting
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Slide 37
Native ICD-10 definition [1818] Codes[48 codes for Colles’ fracture][48 codes for Barton’s fracture][48 codes for Smith’s fracture][48 codes for Radial Styloid fracture][48 codes for Galeazzi’s fracture] [36 codes for Torus fracture of the Radius][18 codes for Stress fracture of the Radius][18 codes for Greenstick fracture of the Radius][90 codes for Pathologic fracture of the Radius][45 codes for Bent Bone fracture of the Radius][216 codes for Growth Plate fracture of the Radius][663 codes for other fractures of the Radius]
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Code Aggregation ExampleFracture of the Radius
Source: Health Data Consulting
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Slide 38
ImplementationGetting your ducks in a row
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Slide 39
Short term goals with a long term vision– What solution do I need today?– Will that solution extend to tomorrows needs?
Awareness of touch points with other initiatives– Overlap and conflicts
Down stream impacts– What works well for one business area, may not work well
for another business area
Positioning for competitive advantage– Can you predict risk better than you competitor?– Are you perceived as a supporter and facilitator of the ICD-
10 transition?– Can you manage the “burden of illness” of your population
better than your competitors?
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Implementation Strategy
Source: Health Data Consulting
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Slide 40
1. Assessment – Creating an inventory of impacted systems and processes– Identifying risk
2. Analysis/Planning– Prioritizing focus– Establishing business area specific approaches– Creating specifications for mapping to support implementation
3. Implementation and Operations– Translating codes from ICD-9 to ICD-10 and from ICD-10 to ICD-9 using
crosswalks– Changing analytic models to support both codes– Operationalizing coding to ICD-10 from source information– Changing processing logic to operate directly from ICD-10 codes
4. Leveraging ICD-10 capabilities– Using the enhanced information within ICD-10 codes to improve processing and
analysis based on improved concepts within the ICD-10 codes
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Phases of Transition
Source: Health Data Consulting
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Slide 41
The Scenario:– The identification of some event or condition that we are
familiar with today
– Recreating that event virtually through some verbal or data representation
– Defining a variety of assumptions and variables around this virtual representation
Applying one or more of these scenarios in a Reference Implementation Model (RIM).– Walk through current systems or processes using these
scenarios with varying assumptions and variables to determine if expected results can be achieved and identifying the required changes to achieve those expected results.
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Scenario-Based TestingWhat Is It?
Source: Health Data Consulting
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Slide 42 Leveraging ICD-10Other General Indicators of Severity and Risk
Co-morbidities
Manifestations
Etiology/causation
Complications
Detailed anatomical location
Sequelae
Functional impairment
Biologic and chemical agents
Phase/stage
Lymph node involvement
Lateralization and localization
Procedure or implant related
42 42Source: Health Data Consulting
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Slide 43
Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated
processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support
population risk management More accurate measures of quality and efficiency
4343
Leveraging ICD-10A Changing World of Cost Containment
Source: Health Data Consulting
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Slide 44
ICD-10 will be a substantial change in the standard for defining the patient’s health state and the institutional procedures performed to maintain or improve that health state.
There are significant impacts and changes to both the clinical and business side of the practice.
Coding accuracy and productivity will be substantially impacted during the transition and will impact both cost and revenue.
There are significant new opportunities to leverage ICD-10 in a new payment environment (ACO).
4444
SummaryKey Points
Source: Health Data Consulting
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Slide 45
Establish awareness across members of your organization
Clearly define strategic goals
Identify internal and external dependencies
Identify and prioritize key risks
Clearly define all business requirements and implementation tasks
Create a realistic project plan and support it as a priority
Test early and often
Get started now!!
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SummaryAction Items
Source: Health Data Consulting
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Slide 46
ICD-10 Resources
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Slide 47 ICD-10 Resources
• http://www.cms.gov/ICD-10
ICD-10 Website
• www.roadto10.org
Provider Portal
• GEMs Crosswalk documents• http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
• GEMs 2014 General Equivalence Mappings (Technical Document (zip file)• http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html
Mapping (GEMs)
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Slide 48 ICD-10 Resources (cont’d)
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html?redirect=/mlngeninfo
Medicare Learning Network Articles
• http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html
ICD-10 National Provider Calls
• http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
National Coverage Determinations (NCDs)
• Materials and associated CRs available free on CMS web site for selected NCDs
Medicare Learning Network
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Slide 49 ICD-10 Resources (cont’d)
• 2014 Reimbursement Mappings – Diagnosis Codes and Guides http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
• 2014 Reimbursement Mappings – Procedure Codes and Guides http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html
• Links to ordering the ICD-10 Pilot Version 31.0 Mainframe and PC version of the ICD-10 MS-DRGs and Medicare Code Editor (FY 2014 version) from NTIS have been placed on the CMS website under the Related Links section at http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html
•http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html?redirect=/mlngeninfo
Medicare Reimbursement Mappings
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7492.pdf
Medicare Claims Processing Guidance for ICD-10
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Slide 50 ICD-10 Resources (cont’d)
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8458.pdf
Home Health Agency
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1409.pdf
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8465.pdf
Medicare Testing Week
• http://www.cms.gov/Medicare/Coding/ICD10/Downloads/CMSReleasesICD-10-PCSFiles.pdf
Unspecified Codes
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Slide 51
51
ICD-10 - A Look Inside
Presented by: Janet Albanese, PT, MSPT, MHA
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Slide 52
• Take a practical look at ICD-10 as it relates to us in Physical Therapy– How to look up a PT related diagnosis in the
ICD-10 system– A look into what we, as a PT practice, are
doing to prepare for implementation– Key impacts ICD-10 will have within your
practice
Objectives
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Slide 53 APTA Web Site: www.APTA.org/icd10
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Slide 54 CMS link to Index and Tabs
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Slide 55 CMS WinZip File
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Slide 56
• Injury Sustained• Right Knee• Instability
Clinical Example
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Slide 57 Step 1: Look up term in
alphabetic index
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Slide 58 Step 1: Look up term in
alphabetic index “Instability”
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Slide 59 Step 1: Look up term in
alphabetic index
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Slide 60 Step 2: Verify code in
tabular list
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Slide 61 Step 2: Verify code in
tabular list
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Slide 62 Step 2: Verify code in
tabular list
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Slide 63 Step 3: Is there a 7th Character?
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Slide 64
Other instability, right knee
Category (first character always
alpha, second character numeric)
Category, anatomic site,
severity
Extension (initial encounter, subsequent
encounter, sequela)
2M 35 6 1
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Slide 65 Side Note…If there was a 7th
Character
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Slide 66 Patient Example:ICD-9 vs ICD-10
ICD 9
ICD 10M25.361 Other instability, right knee
718.86 Other joint derangement, not elsewhere classified of lower leg
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Slide 67 Use Caution in Coding
Instability search yields many options:
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Slide 68
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Slide 69
How does your organization work?
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Slide 70 Reality???
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Slide 71
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Slide 72
• Identify where diagnosis codes are used today: – Documentation– Electronic systems– Submitting claims for payment– Identifying patient eligibility– Getting prior authorization from a payer/ABNs– Reporting and Analysis
ICD-10: Key Practice Impacts
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Slide 73
• Documentation– Specificity– Severity– Other Underlying/Complicating Conditions– Support for Reported Quality Data – Support for Medical Necessity Required for
Coverage in Payer Policies– Auditing for Compliance
ICD-10: Documentation
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Slide 74
• Vendors: Communicate with all vendors to determine readiness – EMR system– Clearinghouse
• Payers: Be prepared for possible delays in cash flow and increased follow-up required
• Policies and Procedure: Updated to reflect changes
• ICD-9 to ICD-10 mapping: Review currently used codes and map them in ICD-10
ICD-10: Areas to Consider
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Slide 75
• Staff Training: All staff that work with the current ICD-9 system must be trained on the ICD-10– Who? – clinicians, coders & billers, front desk,
others– What? – GEMs mapping, knowledge of system– When? – Now vs Later and ongoing….
• Test Competence: Develop further training needed and identify key “champions” that can assist in training
ICD-10: Staff Training
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Slide 76
• APTA– State Chapters– Specific Sections
• CMS• Clearinghouse• Others
– Internally within your organization
ICD-10: Know Your Resources
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Slide 77 APTA Web Site
www.APTA.org/Payment/Coding/ICD10
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Slide 78 Get in on NEXT!
What’s happening at NEXT…• Forward-thinking educational sessions• Engaging opportunities to network with
professional peers• The prestigious Mary McMillan Lecture
Registration is open!
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Slide 79
QUESTIONS
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