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  • ICD-10-CM/PCS: Coding and Clinical Documentation Changes

    Surgery

    Presented by:

    Angie Audler, MBA, RHIT, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer

    Copyright c 2015 Confidential and Proprietary Information

  • Disclaimer

    This PowerPoint presentation is an education tool to provide basic information for coding. The information is the sole view of the author and was put together based on experience, research and expertise in the coding profession. It is not intended to be an exhaustive review and should not be considered a substitution for Coding Guidelines. The presenter does not accept any responsibility or liability with regard to errors, omissions misinterpretations or misuse by the audience.

    Copyright c 2015

    Confidential and Proprietary Information

  • Todays Topics

    Brief Overview of ICD-10-CM/PCS

    How does ICD-10 Impact you as a Provider

    Common Surgery ICD-10 Codes

    Clinical Documentation Awareness Tips for ICD-10

    Copyright 2015 Confidential and Proprietary Information

  • Compliance Date

    October 1, 2015 Date of service on or after 10/01/2015 for office and

    other outpatient services (including Hospital Observation)

    ED and Observation services prior to 10/1 with overlap on or after 10/1 will use ICD9 codes for reporting

    Discharge date on or after 10/01/2015 for hospital inpatient discharges

    Claims for services prior to 10/1/2015 will continue to flow through systems utilizing ICD-9-CM diagnosis and ICD-9-CM Vol. 3 procedure codes (for facilities) for a period of time

    4

  • CMS Concession Source: Healthcare IT News 7/6/2015

    CMS has indicated that "a valid ICD-10 code will be required on all claims starting Oct. 1, 2015. 1. Claims denials. "While diagnosis coding to the

    correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family," CMS officials wrote in a guidance document.

    Copyright c 2015 Confidential and Proprietary Information

  • CMS Concession Source: Healthcare IT News 7/6/2015

    2. Quality reporting and other penalties. "For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes," CMS explained. "Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes."

    Copyright c 2015 Confidential and Proprietary Information

  • CMS Concession Source: Healthcare IT News 7/6/2015

    3. Payment disruptions. If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians, AMA president Steven Stack, MD, noted on the groups website.

    Copyright c 2015 Confidential and Proprietary Information

  • CMS Concession Source: Healthcare IT News 7/6/2015

    4. Navigating transition problems. CMS intends to create a communication center of sorts, including an ICD-10 Ombudsman, "to help receive and triage physician and provider issues." The center will also "identify and initiate resolution of issues caused by the new code sets, officials added.

    Copyright c 2015 Confidential and Proprietary Information

  • Brief Overview of ICD-10-CM/PCS

    ICD-10 is composed of two parts:

    ICD-10-CM (clinical modification)

    ICD-10-PCS (procedural coding system)

    Copyright c 2015 Confidential and Proprietary Information

  • The Difference Between ICD-10-CM/PCS

    ICD-10-CM Replaces ICD-9-CM Vol. 1 & 2 Codes

    ICD-10-CM will be used to identify diagnosis codes in all health

    care settings

    ICD-10-PCS Replaces ICD-9 Vol. 3 Procedure Codes (facility use

    only)

    ICD-10PCS will be used by facilities to report procedures in the

    hospital inpatient setting

    Physicians and Other Healthcare Professionals will continue to use

    CPT and HCPCS (Level II) codes to report office and other

    procedures and services

    Hospital Outpatient Departments/OPSurgery and Ambulatory

    Surgery Centers will also continue to use CPT and HCPCS (Level II)

    codes for reporting outpatient procedures and ancillary services

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    Confidential and Proprietary Information

  • ICD-10-PCS

    Under ICD-10, new and cutting-edge technology that have been problematic to code in ICD-9 will be assigned based on surgeons documentation in the operative note Type of surgery Body system Root operation Body part Approach Device Qualifiers (e.g. biopsy, second site, etc.)

    Copyright c 2015 Confidential and Proprietary Information

  • Overview of ICD-10-CM

    The transition to ICD-10 affects all HIPAA-covered entities hospitals, physicians, allied health professionals, home health, skilled nursing, etc.; as well as payers, business associates billing companies, vendors, clearinghouses

    Non-covered entities (e.g. automobile insurance and workers compensation programs are not required to transition to ICD-10), although it is recommended

    Copyright 2015

    Confidential and Proprietary Information

  • ICD-10-CM Changes

    There are three main categories of changes in ICD-10-CM

    - Definition Changes

    - Differences in Terminology

    - Increased Documentation Specificity

    ICD-10 doesnt affect coding only; it involves physician reporting, billing, information technology, and revenue management

    Copyright 2015

    Confidential and Proprietary Information

  • Comparison

    14

  • ICD-10-CM

    Although there are approximately 70,000 codes in ICD-10, specialists will use only a small subset of those codes

    You will be surprised at how much of this work you are already doing

    Over 1/3 of the expansion codes are due to laterality (physicians are already documenting right, left, bilateral)

    If bilateral and there is no specific code for bilateral, you code both right and left sides

    15

  • Overview of ICD-10-CM

    ICD-9 codes will no longer be maintained once ICD-10 is implemented

    A claim cannot contain both ICD-9-CM and ICD-10-CM (CMS Transmittal 950, effective 10/1/2013)

    16

  • Risk Mitigation

    Denials can run high for not medically necessary reasons

    In the beginning there is risk of payers not fully mapping procedures with new allowed diagnosis reasons

    Be prepared for short term reduced revenues

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  • Louisiana Medicaid Source: Modern Healthcare, 9/4/2015

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    Four State Medicaid Programs will NOT Transition to ICD-10 by 10/1

    CMS will allow four states - California, Louisiana, Maryland and Montana - to use a "crosswalk technique" to continue using the older code sets for Medicaid fee-for-service programs because their claims processing systems in these four states are unable to use the new ICD-10 codes.

    Under the crosswalk technique, the Medicaid programs will convert claims using the ICD10 system into ICD-9 codes to calculate payments

    Some provider groups and healthIT experts say the use of such a technique could result in payment delays and other issues.

    It was not stated whether this applies to straight Medicaid and/or the Medicaid Bayou Plans.

    Stay tuned for additional information to be released

  • Administrative Considerations

    Reimbursement Potential effect of delays, initial decrease in coder

    productivity

    (Industry estimates 20-30% reduction in coder productivity due to additional specificity; physician queries; loss of memorized codes; learning curve.)

    Decrease in physician/provider productivity due to additional specificity needed in charting; additional specificity needed for orders; additional specificity for authorizations; answering queries; increased selection on charge tickets and/or order sets

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  • ICD-10-CM Structure

    20

  • ICD-10-CM Structure

    The seventh character represents a visit encounter or sequelae (condition resulting from a previous disease; also known as Late Effects) for injuries and external causes. The seventh character extender must always be the seventh character of a code.

    A hyphen - at the end of an ICD-10 code in the Alphabetic Index indicates that

    additional characters are required. Placeholder: An x is used as a fifth character in certain six

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