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ICD-10 High Level Overview For Practice Managers

OPAOctober 6th, 2013

Presented byMargie Scalley Vaught

CPC, CPC-H, CPC-I, CCS-P, MCS-P, CCP, ACS-OR, ACS-EMscalley123@aol.com

Disclaimer• The purpose of these handouts is to accompany the presentation

conducted by Margie Scalley Vaught, and sponsored by MGMA OPA. It is only a supplemental workbook and is not a substitute for the CPT-4 or the ICD-9-CM coding manuals. There is no guarantee that the use of this publication will prevent differences of opinion with providers or carriers in reimbursement disputes. Margie S Vaught, or any third-party sponsor provide nor implied or expressed warranty regarding the content of this publication or seminar due to constant changing regulations, laws and policies. It is further noted that any and all liability arising from the use of materials or information in this publication and/or presented at a seminar is the sole responsibility of the participant, and their respective employers, who by his or her purchase of this publication and/or attendance at a seminar evidences agreement to hold harmless the aforementioned parties, their employees and affiliates. The intent of this publication is to be used as a teaching “tool” accompanying the oral presentation only.

• 2013Edition

• ©All rights reserved. No part of this publication may be reproduced in any form or by any means without the express written permission of the publisher. Seminars and their material are protected by copyright. 2

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Objective• During this session we will help practice leaders identify

areas needing attention as we prepare for ICD-10 usage. • Such areas discussed will be the work flow situation

– Who will be responsible to make sure the correct ICD-10 code(s) get selected for the encounter;

– Can superbills/encounter forms/cheat sheets be helpful and if so tips on putting these together for the Orthopedic Practice;

• We will also discuss how to get the physicians on board using their specialty society AAOS as a pressure point!

• Last but not least, how can you start TODAY to get this ICD-10 transfer to go smoothly and without as much drama and pain as some are stating.

ICD-10 IMPLEMENTATION

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Basic Info Practice Managers Need to know

ICD-10 Introduction

• In January 2009, the federal government determined the U.S. would upgrade to the 10th revision of the ICD as of October 1, 2014.– ICD-10-CM (Clinical Modification)

• Used to assign diagnosis codes• A clinical modification of ICD-10 developed by the

National Center for Health Statistics (NCHS), a division of the Centers for Disease Control and Prevention (CDC)

– ICD-10-PCS (Procedural Coding System)• Unique to the US and independent of ICD-10, but

designed to complement the structure of ICD-10• Developed by the Centers for Medicare and Medicaid

Services (CMS) with 3M’s health information systems division

• Used to assign procedure codes for the inpatient setting

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Delay until 2014

• CMS has confirmed that ICD-10 will take effect October 1, 2014

• No more delays

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ICD-10 Implementation

• No Grace Period– Providers will NOT be able to report

ICD-9-CM codes• For services on or after October 1, 2014

• No Delays– No delays in the implementation date

for ICD-10

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Benefits to ICD-10-CM/PCS

• Reduced ambiguity• Enhanced system flexibility

for adding new codes• Better reflection of current

medical terminology and technology

• Expanded detail relevant to ambulatory and managed care encounters

• Data transparency for reimbursement and compliance efforts

• Incorporation of recommended revisions to ICD-9-CM that could not be accommodated

• HIPAA criteria for code set standards are met (5010)

• Improved collection and tracking of new diseases and technologies

• Space to accommodate future expansion 9

ICD-10 Implementation

• ICD-10 vs. ICD-9 Codes– Provide greater diagnoses and

procedures description details– Greater number of ICD-10 codes than

ICD-9 codes– Longer and use more alpha characters– Requires system changes to

accommodate new codes

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ICD-10 Implementation

• ICD-9-CM– 3-5 characters

• 1 – Alpha or Numeric• 2-5 – Numeric• Always 3 characters• Decimal after 3rd

character

• ICD-10-CM– 3-7 characters

• 1 – Alpha (‘U’ NOT used)

• 2 – Numeric• 3-7 – Alpha or

Numeric• Decimal after 3rd

character• Dummy placeholder

‘X’• Alpha characters

NOT case-sensitive

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ICD-9-CM ICD-10-CM ICD-10 (WHO) ICD-9-CM ICD-10-PCS ICD-10 (WHO)0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Diagnosis

Procedure

ICD-10-CM/PCS Growth of Codes

Diagnosis Procedure

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Why So Many Diagnosis Codes?

Greater specificity and detail:– 34,250 (50%) of all ICD-10-CM codes are

related to the musculoskeletal system.– 17,045 (25%) of all ICD-10-CM codes are

related to fractures.– 10,582 (62%) of fracture codes

distinguish right from left.– 25,000 (36%) of all ICD-10-CM codes

distinguish right from left.

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ICD-10 Implementation

• Version Updates– Annual updates of ICD-10-CM & ICD-10-

PCS posted on the ICD-10 website• www.cms.gov/ICD10

– Maintenance and updates of ICD-9-CM and ICD-10 are discussed at the ICD-9-CM Coordination and Maintenance (C&M) Committee meeting• www.cms.gov/ICD9ProviderDiagnostic Code

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ICD-10 Implementation

• General Equivalence Mappings (GEMs)– Assist in converting data from ICD-9-CM to

ICD-10– Forward and backward mappings

• Information on GEMs and their use– www.cms.gov/ICD10

• Description of MS-DRG Conversion Project– www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp

– GEMs NOT a substitute for learning how to code with ICD-10

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ICD-10 Implementation

• Affordable Care Act– Section 10109(c) requires the Secretary

of HHS to task C&M Committee to obtain input regarding GEMs• Make appropriate revisions to GEMs• GEM updates discussed at the September

15, 2010 C&M Meeting– www.cms.gov/ICD9ProviderDiagnosticCodes/03_m

eetings.asp

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ICD-10 Implementation

• Available Updates– ICD-10-CM– ICD-10-PCS– GEMs– Reimbursement Mappings• www.cms.gov/ICD10

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ICD-10 Implementation

• Training Timeline– Intensive coder training should not be

provided until 6-9 months prior to implementation

– Two full days of ICD-10-CM training will likely be • For most coders• Proficient ICD-9-CM coders may not need

that much

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ICD-10 Implementation

• Recommendations– Be ready by Jan 1, 2014 for

implementation preparation• Complete tasks identified during Impact

Assessment: Implement Systems Changes • Modify or develop

– Policies/procedures– Reports– Forms

• Provide education to users – Other than intensive coder education

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How Can You Prepare?• Begin adding the following to physician

documentation templates and queries:– Side of dominance

• Left, right, or ambidextrous (defaults to right)

– Laterality • All paired organs or structures

– Ordinality• Is this the initial visit or a subsequent visit for the

complaint? • Are these symptoms the sequela of the initial

event?

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General Considerations• What policies and procedures will need

revision?– ICD-10-CM/PCS will have new Coding Clinic

advice– How will you address decreased

productivity during the transition?

• What templates will need revision?– Operative reports– History and physicals– Query forms

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References/Resources• CMS ICD-10 Web site: http://www.cms.gov/icd10

• Medicare Fee-for-Service Provider Resources: http://www.cms.gov/ICD10/06_MedicareFeeforServiceProviderResources.asp

• Association of Clinical Documentation Improvement Specialists Web site: http://www.hcpro.com/acdis/

• NHLBI’s National Asthma Education and Prevention Program: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

• Open Fracture: Gustilo Classification: http://www.eatonhand.com/clf/clf256.htm

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Help with Implementation

• Documentation Issues - NOW• Cheat sheets• Encounter forms• EMR/EHR• AAOS products• Physician buy in

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Documentation Issue Now

• How is your group set up?– Do you have billers/coders assigned to a

specific provider?– Do you have billers/coders assigned to

alphabet of patients?– Who is currently selecting the diagnosis

codes?– Do you review the documentation for EM

services BEFORE you bill the claim?– Do you review the documentation for the

Operative notes BEFORE you bill?

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Billing Staff assigned to given provider

• Option One – • Assigning Billing Staff to a given

provider– Example – Mary is in charge of Dr. Sam’s

coding and billing. Dr. Sam does mainly shoulders

– Example – Mary is also in charge of Dr. Tom’s coding and billing. Dr. Tom does mainly hips

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Option One in more Detail

• Using the example – If Mary is in charge of two providers – one doing shoulders and one doing hips – Mary can now focus on those ICD-10 codes

• Working with those providers on their current ICD-9 usages

• Checking to see if these providers are documenting appropriately– Are they stating right and left in follow-up visits– Are they being specific and not just saying “seeing back

postop” or “patient is here in follow up from surgery”– Checking this documentation NOW before ICD-10 comes

on board will help smooth the process – and will be better to handle provider-wise

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Downside Option One

• Billers/Coders must be aware of ALL contacted payers/carrier policies and guidelines

• Need to have ongoing tracking and checking of contract/reimbursement changes and medical necessity issue changes again for ALL payers

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Option Two

• Billing staff is assigned based on contracted payer/carrier– Example – Mary does all BCBS; Susan

does all Medicaid; Cindy does all Worker’s Comp; Tiffany does all Medicare; etc

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Option Two in more Detail

• Option Two is a great option for two reasons– One – It means that one or two people are

always up on the policies/updates for that contracted payer. Very important for reimbursement issues and especially medical necessity issues (LCDs)

– Two – Less chance of leaving $$ on the table as those billers/coders MUST always know when changes take place and not find out 3-6 months later after getting denials

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Downside Option Two

• In option two, there would be less one- on-one contact with the given provider – but if providers know that Tiffany does the Medicare patients, they would know who to go to.

• Cross training – there would have to be cross training just in case Mary goes out sick. – Otherwise, who is back up that knows BCBS

or where to even look?

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Option Three

• Billing staff not assigned to a given provider but just does the bills as they come in

• If this is your arrangement, you might want to see if you can change to Option One or Two without too much fuss

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Downside Option Three

• Since no one takes responsibility for a given payer/carrier, this can leave practice open to lost revenue

• Physicians could end up getting different answers to the same question regarding policy/procedures for a given payer.

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Do you have MA, PA, etc?

• In addition to the billing/coding staff do you have other staff members?

• Are the MA, PA, etc assigned to a given provider?

• Example– Sarah MA is assigned to Dr. Sam and Dr.

Tom – therefore Sarah MA might be the one assigning the diagnosis codes

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More Documentation Issues

• Need in EVERY service note being billed:– Right or Left– Specific anatomic location– What kind of injury– What kind of fracture– What kind of trauma– What stage - initial, subsequent, etc.– What is happening – normal healing,

delayed healing, nonunion, malunion, sequela

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Documentation Summary

• Any of the Four options can be used to start this ICD-10 transition and really does not involve the physician YET!!

• The more we can get in place before bringing physicians on full board will be better

• Need to start reviewing these notes NOW…

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Cheat Sheets

• Staff as well as Physicians will need help to get used to these new codes.

• Having workable ‘cheat sheets’ will go a long way in helping the process

• Remember, Orthopedic Surgeons are Specialists, so codes need to be HIGHEST specificity – NOT unspecified

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7th Character Cheat Sheet is a Must

• Under ICD-10 any fractures or injuries are going to continue to be coded with the acute code and the 7th character will change

• Some examples of laminated cheat sheets – front and back

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Injury 7th Characters

• A – Initial encounter• D – Subsequent encounter• S – Sequela• Examples– Dislocations, Injury to nerves, muscle,

tendons, blood vessels, crush injury, open wounds, etc.

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Fracture 7th Character

• A – Initial encounter for closed fracture• B – Initial encounter for open fracture type I or II• C – Initial encounter for open fracture type IIIA, IIIB,

or IIIC• D – Subsequent encounter for routine healing• E – Subsequent encounter for open fracture type I or II

with routine healing• F – Subsequent encounter for open fracture type IIIA, IIIB,

or IIIC• G – Subsequent encounter for fracture with delayed

healing• H – Subsequent encounter for open fracture type I or II

with delayed healing

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Continued Fracture 7th • J – Subsequent encounter for open fracture type IIIA, IIIB, or

IIIC with delayed healing• K – Subsequent encounter for closed fracture with nonunion• M – Subsequent encounter for open fracture open fracture

type IIIA, IIIB, or IIIC• N – Subsequent encounter for open fracture type IIA, IIIB, or

IIIC with nonunion• P – Subsequent encounter for closed fracture with malunion• Q – Subsequent encounter for open fracture type I or type II

with malunion• R – Subsequent encounter for open fracture type IIIA, IIIB,

or IIIC with malunion• S - Sequela

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Confusing part on fracture 7th character….

• Not all 7th character will apply to all fracture codes.

• Example – – S52 – Fracture Forearm uses all A-S– Exception S52.01X Torus fracture of upper end

ulna uses A, D, G, K, P, S– Exception S52.11X Torus fracture of upper end

radius A, D, G, K, P, S

Example

• Non-traumatic– Slipped acute upper femoral epiphysis right

hip – M93.001

• Traumatic– Acute or chronic slipped capital femoral

epiphysis, traumatic right hip – Initial visit – S79.011A– Subsequent visit normal healing – S79.011D– Subsequent visit delayed healing – S79.011G– Nonunion subsequent visit – S79.011K

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Aftercare Coding issues

• A patient has a displaced, closed fracture of the greater trochanter of the right femur (S72.111). The following codes would be assigned for this case: – Patient seen in the ER, admitted, and surgery

performed: S72.111A, Initial encounter for closed fracture

– Seen in the office two weeks after surgery - S72.111D, Subsequent encounter for closed fracture with routine healing

– Patient to physician office for follow-up visit and now PRN: S72.111D, Subsequent encounter for closed fracture with routine healing

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Late Effects… Use the “S”

• Extension S, sequela, is used for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequela of the burn. When using extension S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code.

• The S extension identifies the injury responsible for the sequela. The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code. Sequela is the new terminology in ICD-10-CM for late effects in ICD-9-CM and using the sequela extension replaces the late effects categories (905–909) in ICD-9-CM.

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Using Cheat Sheets

• Can you see where the different Options might work better with these 7th character issues?

• If the coder/biller/MA/PA is working just with the Hand surgeon they would need to know the open fracture Type I-IIIC – Most of these open types are for the forearms– The Gustilo open fracture classification for

extremities classifies open fractures into three major categories (types) depending on the mechanism of the injury, soft tissue damage, and degree of skeletal involvement

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Gustilo Classifications

Open fractures have been classified by Gustilo as follows, with higher numbers indicating more severe injuries:

I Low energy wound less than 1 cmII Wound greater than 1 cm with moderate soft

tissue damage

III High energy wound greater than 1 cm with extensive soft tissue damage

IIIA Adequate soft tissue cover

IIIB Inadequate soft tissue cover

IIIC Associated with arterial injury

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Will your documentation be ready for ICD-10

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Encounter Forms/EMR/EHR

• How to get ICD-10 to work in your office today– Paper office• Encounter forms• Billing slips

– EMR/EHR office• Linkage• Codes loaded appropriately

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Encounter form

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Placing ICD-10 on forms

• With more codes available in ICD-10, it will be hard to place all like on the following slide.

• Here is an example of shorter ways to get what you need– Shoulder– Hip– Knee

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Pelvic/Hip CodeLocation Scapula Fracture Code Location Humerus Cont. Code Location

Sacrum Zone 1 Fx S32.11XX   Body, displaced S42.11XX RT/LT Shaft obliq nondisp S42.33XX RT/LT

Sacrum Zone II Fx S32.12XX   Body, Nondisplaced S42.11XX RT/LTShaft spiral displace S42.34XX RT/LT

Anterior Wall Acetab S32.41XX RT/LT Acromial process, displaced S42.12XX RT/LT Shaft spiral nondisp S42.34XX RT/LT

Post. Wall Acetab S32.42XX RT/LT Acromial process, nondispl S42.12XX RT/LTShaft comm displace S42.35XX RT/LT

Ant. Column Acetab S32.43XX RT/LT Coracoid process, displaced S42.13XX RT/LTShaft comm nondisp S42.35XX RT/LT

Post. Column Acetab S32.44XX RT/LT Coracoid process, nondispl S42.13XX RT/LT Shaft segment disp S42.36XX RT/LT

Pubis superior rim S32.51XX RT/LT Glenoid cavity, displaced S42.14XX RT/LTShaft segment nond S42.36XX RT/LT

Ischium avulsion S32.61XX RT/LT Glenoid cavity, nondispl S42.14XX RT/LTCondyle lat, displace S42.45XX RT/LT

Shoulder     Neck, displaced S42.15XX RT/LTCondyle lat, nondisp S42.45XX RT/LT

Contusion, Shoulder S40.01XX RT/LT Neck, nondisplaced S42.15XX RT/LT Condyle med, displ S42.46XX RT/LT

Open wnd w/FB S41.02XX RT/LTShoulder sprain/strain/tear    

Condyle med, nondis S42.46XX RT/LT

Open wnd w/o FB S41.01XX RT/LT CH ligament S43.41XX RT/LTTranscond, displaced S42.47XX RT/LT

Dislocation     Rotator cuff capsule S43.42XX RT/LT Transcond, nondisp S42.47XX RT/LTAnterior, shoulder S43.01XX RT/LT Glenoid Labrum S43.43XX RT/LT Torus lower end S42.48XX RT/LT

Posterior, shoulder S43.02XX RT/LT Other ligament shoulder S43.49XX RT/LTHumerus supracond    

Inferior, shoulder S43.03XX RT/LT AC joint sprain S43.5XXX RT/LTSimple w/o inter disp S42.41XX RT/LT

AC jt subluxation S43.11XX RT/LT SC joint sprain S43.6XXX RT/LTSimple w/o inter non S42.41XX RT/LT

AC jt 100-200% disp S43.12XX RT/LT Humerus    Comm w/o inter disp S42.42XX RT/LT

AC jt > 200% disp S43.13XX RT/LT Surg. neck 2-pt, disp S42.22XX RT/LTComm w/o inter non S42.42XX RT/LT

AC jt inferior S43.14XX RT/LT Surg. Neck 2pt,nond S42.22XX RT/LTHumerus epicondylar    

AC jt posterior S43.15XX RT/LT Surg. Neck 3part disp S42.23XX RT/LT Lateral displaced S42.43XX RT/LT

SC jt anterior S43.21XX RT/LT Surg.neck 3part, non S42.23XX RT/LTLateral nondisplaced S42.43XX RT/LT

SC jt posterior S43.22XX RT/LT Surg.neck 4part, disp S42.24XX RT/LT Medial displaced S42.44XX RT/LT

Scapula sublux S43.31XX RT/LT Surg.neck 4part, non S42.24XX RT/LTMedial nondisplaced S42.44XX RT/LT

Scapula dislocation S43.31XX RT/LT Greater troch displ S42.25XX RT/LT      Clavicle Fracture     Greater troch nond S42.25XX RT/LT      Sternal, ant displ. S42.01XX RT/LT Lesser troch displ S42.26XX RT/LT      Sternal, post displ. S42.01XX RT/LT Lesser troch nond S42.26XX RT/LT      Sternal nondispl. S42.01XX RT/LT Torus upper end S42.27XX RT/LT      Shaft, displaced S42.02XX RT/LT Shaft greenstick S42.31XX RT/LT      Shaft, nondispl S42.02XX RT/LT Shaft trans. Displac S42.32XX RT/LT      Lateral end, displ S42.03XX RT/LT Shaft trans. Nondis S42.32XX RT/LT      Lateral end, nond S42.03XX RT/LT Shaft obliq displace S42.33XX RT/LT      

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Forms

• As you can see, the forms can be made for specific body parts

• But all options (besides unspecified) should be available for selection.

• Can use ‘other specified’ but try to avoid ‘unspecified’

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Medical Necessity Issues• Even more important that you know your

contracted payers/carriers policies• For Ortho those are:– Trigger points– Total hips and total knees– Spinal Procedures– Intra-articular injections

• Synvisc, etc.

– Spinal Injections• Facet• Transforaminal• SI joint• Epidural

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AAOS help

• CodeX 2013– Started putting ICD-10 codes to help– “Your 2013 Orthopaedic Code X program will

include CPT to ICD – 9 x-refs and CPT to ICD – 10 x-refs. You will be fully prepared to change coding systems on the October 1, 2014 effective date.”

• CPT/ICD-9/ICD-10 linkage• Articles• Webinars – Annual Meeting

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AAOE CodeX 2013 screens

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Now the Physician Piece

• Be pro-active• Start reviewing EM notes NOW– First encounters usually are good– Follow ups are BAD..

• Hard to get right/left – • Hard to get original injury once surgery done

• Start reviewing OP notes NOW• Let Physicians know that there is no longer

aftercare healing codes or late effects codes – will always use the original injury/fracture code all the way through.

Example

• Patient returns one year after total left knee arthroplasty – no complaints

• Z47.1 Aftercare following joint replacement surgery

• Z96.652 Presence of left artificial knee joint– Use additional code to identify the joint

(Z96.6-)

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Example

• Removal of hardware– Z47.2 Encounter for removal of internal fixation

device– Excludes1 –

• Encounter for adjustment of internal fixation device for fracture treatment, code to fracture with appropriate 7th character.

• Encounter for removal of external fixation device – code to fracture with 7th character D

• Infection or inflammatory reaction to internal fixation device (T84.6-)

• Mechanical complication of internal fixation device (T84.1-)

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Summary

• Auditing notes NOW– Get a base level – then start education– Re-audit after capturing a teaching point

• Example audit reveals they are not saying right and left on subsequent encounters – Educate they must – Re-audit 2 months later

• Work through with software vender– Is there a clickable option so provider can remember to

check that diagnosis with appropriate 6th and 7th characters

• Do monthly newsletters, meetings taking ICD-10 issues piece by piece– Start small – don’t overwhelm – better to do bit by bit

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Summary Tips

• Vendor Questions - See form at end of presentation

• Conduct a business impact and assess the impact on future reimbursement

• Identify, pursue and collaborate with providers who generate the highest volume of claims

• Involve Decision Support staff early to assist with analysis and reporting

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Additional Tips

• Start updating physician query forms/templates NOW and make sure you have a tracking process for queries.

• Remind physicians - ICD-10-CM is similar to ICD-9-CM, but with greater expansion and specificity.

• Clinical data is needed and used throughout healthcare for pay for performance, quality, legal aspects, regulatory, reimbursement, research and outcomes.

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Resources

• AAOS CodeX 2013• ICD-10 guidelines• http://www.ahima.org/ICD10/

icd10toolkit.aspx• Samples of encounter forms

ICD-10 Guidelines

• Guideline Resources– The Official ICD-10-CM coding guidelines

• www.cdc.gov/nchs/icd/icd10cm.htm

– Addenda • ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications

/ICD10CM/2011/

– Some other great resources:• www.findacode.com/icd-10-cm/icd-10-cm-diagnosis-code

s-S-group.html• www.findacode.com/code-set.php?set=ICD10CM• www.findacode.com/icd-10-cm/icd-10-cm-diagnosis-code

s-M-group.html

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Question

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