iiccddicd- icd ---10 preparation for non10 preparation for ... - wallace.pdfall icd-10-cm/pcs codes...
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ICDICDICDICD----10 Preparation for Non10 Preparation for Non10 Preparation for Non10 Preparation for Non----Coders in the Revenue Coders in the Revenue Coders in the Revenue Coders in the Revenue CycleCycleCycleCycle
September 24, 2015
Arkansas HFMA Revenue Cycle Seminar
Susan Wallace, MEd, RHIA, CCS, CCDS, CDIP, FAHIMA
Program ObjectivesProgram ObjectivesProgram ObjectivesProgram Objectives
�Explain the impact of the ICD-10 code set to hospital operations.
�List examples of new features and requirements to assure reporting accuracy.
�Demonstrate an increased understanding of the impact of ICD-10 changes on their role within the healthcare facility.
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HowHowHowHow is coded is coded is coded is coded ddddata ata ata ata uuuused?sed?sed?sed?
�Public Report Cards
�Research
�Epidemiology
�Outcomes
� Statistical Analysis
� Financial and Strategic Planning
�Evaluation of Quality of Care
�Communication to Support Patient’s Treatment
� Insurance Coverage Determination
�Reimbursement
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Payment for Inpatient StaysPayment for Inpatient StaysPayment for Inpatient StaysPayment for Inpatient Stays
Physician Documentation: Pneumonia
Diagnoses & Procedures Coded
Codes on Claim Submitted
MS-DRG 179 Pneumonia
without CC / MCC
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Coding and Documentation Is The Key To:Coding and Documentation Is The Key To:Coding and Documentation Is The Key To:Coding and Documentation Is The Key To:
Coded Data
Payment
Public Reports
Quality Reports
VBP
HAC
NCHS / WHO
Hospital Wide ReadmissionHospital Wide ReadmissionHospital Wide ReadmissionHospital Wide ReadmissionHospital CompareHospital CompareHospital CompareHospital Compare 7/1/11 7/1/11 7/1/11 7/1/11 –––– 6/30/146/30/146/30/146/30/14
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RiskRiskRiskRisk----Standardized Mortality RatesStandardized Mortality RatesStandardized Mortality RatesStandardized Mortality Rates
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Medicare Hospital Quality Chartbook (Sept ‘14)
Hospital ValueHospital ValueHospital ValueHospital Value----Based PurchasingBased PurchasingBased PurchasingBased PurchasingDomain WeightsDomain WeightsDomain WeightsDomain Weights
25% 25% 25%
25% 25% 25%
40%
10%
30% 25%
20%25%
0%
20%
40%
60%
80%
100%
FY16 FY17 FY18
Experience Efficiency Outcomes Process Clinical Care Safety
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Coded Claims Data / Risk Adjustment
Affects All Domains Except Experience
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Hospital ValueHospital ValueHospital ValueHospital Value----Based PurchasingBased PurchasingBased PurchasingBased PurchasingBaseline vs Performance PeriodsBaseline vs Performance PeriodsBaseline vs Performance PeriodsBaseline vs Performance Periods
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Program Year 2017 2018 2019Baseline Period
Performance Period
2011 2012 2013 2014 2015 2016
FY17
FY18
FY19
FY20
FY21
2010
WhatWhatWhatWhat is changing?is changing?is changing?is changing?
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WhenWhenWhenWhen is is is is iiiit t t t cccchanging?hanging?hanging?hanging?
� Inpatient Discharges as of 10/1/15
�Outpatient dates of service 10/1/15
�See billing instructions for claims spanning implementation date
WhyWhyWhyWhy is it changing?is it changing?is it changing?is it changing?
� ICD-9 Insufficient detail
� Insufficient room for expansion
� Provide greater clinical detail and specificity in describing diagnoses and procedures
� Lack of current terminology / technology (1979)
� Updated to be consistent with current clinical practice
�Worldwide morbidity reporting
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Who Remembers 1979?Who Remembers 1979?Who Remembers 1979?Who Remembers 1979?
1979 Trivia1979 Trivia1979 Trivia1979 Trivia
�Age 65+ Avg LOS 10.8 days
�OB Avg LOS “only 3.7 days”
�% Pts w/ >1 diagnosis 48%
�Top volume IP Procedures (exclude delivery)� Biopsy� Digestive system endoscopy� D&C
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Prevalence of ICDPrevalence of ICDPrevalence of ICDPrevalence of ICD----10101010106 countries use for morbidity; 106 countries use for morbidity; 106 countries use for morbidity; 106 countries use for morbidity; 11 11 11 11 use for reimbursement / case mixuse for reimbursement / case mixuse for reimbursement / case mixuse for reimbursement / case mix
� Created by WHO (World Health Organization) in 1994
Canada
• Began
adopting in
2001
• Over a 5-year
implementatio
n
• Only use
diagnosis
codes
• Use for
statistical
purposes, not
billing
Brazil
• Adopted in 1998
South Africa
• Adopted in 1996
United Kingdom
• Adopted in 1995
Germany
• Adopted in
1998
• Use ICD-10-
AM for
morbidity
• Implementatio
n took 3 years
Australia
• Adopted in
1998
• Implementation
took 2 years
Countries who have adopted ICD-10
China
• Adopted in 2002
Russia
• Adopted in 1999
Netherlands
• Adopted in
2013
ICDICDICDICD----10 Benefits10 Benefits10 Benefits10 BenefitsCMS MLN Matters SE 1239CMS MLN Matters SE 1239CMS MLN Matters SE 1239CMS MLN Matters SE 1239
�Measure quality, safety, and efficacy of care
�Reduce need for attachments to explain patient’s condition
�Design payment systems and process claims for reimbursement
�Conduct research, epidemiological studies, and clinical trials
�Set health policy
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HowHowHowHow is it changing?is it changing?is it changing?is it changing?
Diagnoses
14,567 ICD-9-CM
69,823
ICD-10-CM
Procedures
3,882
ICD-9-CM
71,974
ICD-10-PCS
Biggest Changes Biggest Changes Biggest Changes Biggest Changes –––– ICDICDICDICD----10101010----CMCMCMCM
Category
Injury / Poisoning
External causes of morbidity / mortality
Musculoskeletal System / Connective Tissue
Pregnancy, Childbirth, Puerperium
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Reasons for Reasons for Reasons for Reasons for CCCChangehangehangehange
�Added codes for laterality (1/3 of changes)
� Right, left, bilateral
�Added codes for episode of care for select conditions (25%)
� Initial vs subsequent episode or sequela (late effect)
�Distinguish between acute and chronic conditions
Payer OptionsPayer OptionsPayer OptionsPayer Options
Accept ICD-10 Codes
Map back to ICD-9
“equivalent”
Apply based on ICD-9
methodology
Accept ICD-10 Codes
based on increased ICD-10 specificity
CMS ICD-10 MS-DRG /NCD/
LCD policies
Require ICD-9 Codes
per current methodology
Non-HIPAA entities
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ICDICDICDICD----10 Impact to Future Inpatient Reimbursement10 Impact to Future Inpatient Reimbursement10 Impact to Future Inpatient Reimbursement10 Impact to Future Inpatient Reimbursement
�“After CMS has gathered sufficient coded ICD-10-CM/PCS data to make adjustments based on the increased specificity of the ICD-10-CM/PCS codes, CMS would propose updates to the ICD-10-CM/PCS version of the MS-DRGs.”
CMS
Unspecified Codes May Result In…Unspecified Codes May Result In…Unspecified Codes May Result In…Unspecified Codes May Result In…
�Payers questioning “unspecified” diagnosis codes
�Delays in prior approval:
� Laboratory and imaging tests
� Referrals
� Elective surgeries
�More claim rejections and appeals
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CMS / AMA AgreementCMS / AMA AgreementCMS / AMA AgreementCMS / AMA AgreementPosted July 5Posted July 5Posted July 5Posted July 5----6, 20156, 20156, 20156, 2015
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�“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 denyphysician or other practitioner claims billed under the Part B physician fee schedule….”
�“However, a valid ICD-10 code will be required on all claims starting on October 1, 2015.”
CMS / AMA Agreement Q&ACMS / AMA Agreement Q&ACMS / AMA Agreement Q&ACMS / AMA Agreement Q&APublished July 27, 2015Published July 27, 2015Published July 27, 2015Published July 27, 2015
� “…Guidance only applies to Medicare fee-for-service claims from physician
or other practitioner claims billed under the Medicare Fee-for-Service Part
B physician fee schedule.”
� “…the recent Guidance does not change the coding specificity required by
the NCDs and LCDs.”
� “…submitters will know that it was rejected because it was not a valid code
versus a denial for lack of specificity required for a NCD or LCD or other
claim edit.”
� “…the audit and quality program flexibilities only pertain to post payment
reviews.”24
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ICD-10-CM Diagnosis Code Structure
1 2 3 4 5 6 7
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um
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Category Subcategory Exte
nsio
nExpanded Field Lengths for Codes and DescriptionsExpanded Field Lengths for Codes and DescriptionsExpanded Field Lengths for Codes and DescriptionsExpanded Field Lengths for Codes and DescriptionsAlphanumericAlphanumericAlphanumericAlphanumeric
ICD-10-CM Diagnoses (69,823)
�3 to 7 Characters
�Decimal after 3rd Character
� I50.9
�HIPAA required for all health claim diagnoses
ICD-10-PCS Procedures (71,974)
�7 Characters, No Decimal
� Letters I and O not used
�HIPAA required for inpatient procedures
� Will hospital use for internal reporting of outpatient procedures?
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New Features: New Features: New Features: New Features: More More More More Info in CodeInfo in CodeInfo in CodeInfo in Code
�K57.21 – Diverticulitis of large intestine with perforation and abscess with bleeding
�E11.341 – Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
�I25.110 – Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
Coding ExampleCoding ExampleCoding ExampleCoding Example---- ICDICDICDICD----10101010----CM:CM:CM:CM:Increased Length of Code DescriptionsIncreased Length of Code DescriptionsIncreased Length of Code DescriptionsIncreased Length of Code Descriptions
�S72.461A Displaced supracondylar fracture with intracondylar extension of lower end of right femur, initial encounter, closed fracture
�S72.391H Other fracture of shaft of right femur, subsequent encounter for open fracture type I or II with delayed healing
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ICDICDICDICD----10101010----PCS Procedure Codes PCS Procedure Codes PCS Procedure Codes PCS Procedure Codes Only for Hospital IP ClaimsOnly for Hospital IP ClaimsOnly for Hospital IP ClaimsOnly for Hospital IP Claims
0
•S
ect
ion
L•
Bo
dy S
yste
mB
•R
oo
t O
pe
rati
on
5
•B
od
y P
art
0
•A
pp
roa
ch
Z
•D
evic
e
Z
•Q
ua
lifi
er
ICDICDICDICD----10101010----PCS IllustrationsPCS IllustrationsPCS IllustrationsPCS Illustrations
�0FB03ZX - Excision of liver, percutaneous approach, diagnostic
�0DQ10ZZ - Repair, upper esophagus, open approach
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GEMs UsesGEMs UsesGEMs UsesGEMs Uses
�Translation of data for:
� Tracking quality
� Recording morbidity / mortality
� Calculating reimbursement
� Converting ICD-9 based application to ICD-10
�NOT substitute for assigning ICD-10 codes
Free CMS ResourcesFree CMS ResourcesFree CMS ResourcesFree CMS Resourceswww.CMS.gov/ICD10www.CMS.gov/ICD10www.CMS.gov/ICD10www.CMS.gov/ICD10
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Good ResourceGood ResourceGood ResourceGood Resourcewww.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10
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ICDICDICDICD----10 Reimbursement Mappings10 Reimbursement Mappings10 Reimbursement Mappings10 Reimbursement Mappingswww.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10www.cms.gov/ICD10
� Identify best matching ICD-9-CM code that can be used for reimbursement purposes for
each ICD-10 code.
� All ICD-10-CM/PCS codes are in the “ICD-10 Reimbursement Mappings”; however, all
ICD-9-CM codes are not included.
� Consists of two crosswalks:
� ICD-10-CM to ICD-9-CM for diagnosis codes; and
� ICD-10-PCS to ICD-9-CM for procedure codes.
� CMS is not using the “ICD-10 Reimbursement Mappings” for any purpose. We are
converting our systems and applications to acceptICD-10-CM/PCS codes directly.
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Planning for the TransitionPlanning for the TransitionPlanning for the TransitionPlanning for the Transition
�Will report request forms require revision?
�What happens when requestor is unfamiliar with ICD-10 codesets?
�How will requests that span 10/1/15 (such as 2015 calendar year requests) be handled?� Jan-Sept per ICD-9 and Oct-Dec per ICD-10?
� Use GEMS to translate?
35
DRGDRGDRGDRG----Based ReportsBased ReportsBased ReportsBased Reports
� ICD-10 codes occasionally map to different DRG than ICD-9 counterpart!
�Should any DRG-based report include a parenthetical notation that notes the ICD-10 implementation date?
� i.e. calendar year DRG report requests
�Will Case-Mix Index (CMI) reports flag the transition date?
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WhatWhatWhatWhat is reportable?is reportable?is reportable?is reportable?Whose documentation is used for coding?Whose documentation is used for coding?Whose documentation is used for coding?Whose documentation is used for coding?
�Any physician involved in the care and treatment of the patient, including documentation by consultants, anesthesiologists, as long as there is nothing conflicting from the attending physician.
� NOT diagnostic test results, i.e. pathology or radiology reports, echocardiogram, rhythm strips, etc.
�Nurse practitioners and physician assistants if they are considered legally accountable for establishing a diagnosis.
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ICDICDICDICD----10101010----CM CM CM CM Outpatient Coding GuidelineOutpatient Coding GuidelineOutpatient Coding GuidelineOutpatient Coding Guideline
� J. Code all documented conditions that coexist at time of visit and require or affect patient care treatment or management.
�Do not report conditions previously treated that no longer exist.
�“History” codes may be used if the historical condition or family history has an impact on current care or influences treatment.
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Medical NecessityMedical NecessityMedical NecessityMedical Necessity
�National Coverage Determinations (NCD)
�Local Coverage Determinations (LCD)
�List of CPT codes and corresponding diagnosis codes that establishes “medical necessity” for the procedure
�NCDs and LCDs for ICD-10 have been published to the appropriate websites
Local Coverage DeterminationsLocal Coverage DeterminationsLocal Coverage DeterminationsLocal Coverage DeterminationsMLN Matters MM8348 MLN Matters MM8348 MLN Matters MM8348 MLN Matters MM8348
�All ICD-10 LCDs and associated ICD-10 articles will be published on the Medicare Coverage Database (MCD) no later than April 10, 2014.
�All LCDs and Articles will receive a new LCD/Article ID number.
� i.e., LCD ID 1234 might become LCD ID 4567
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New for ICDNew for ICDNew for ICDNew for ICD----10101010----CMCMCMCM
�Combination codes for atherosclerotic heart disease with angina pectoris.
� NOT necessary to use additional code for angina
CAD
Angina
CAD w/ Angina
Angina OptionsAngina OptionsAngina OptionsAngina Options
�I20.1, Angina pectoris with documented spasm
�I20.8, Other forms of angina pectoris
�I20.9, Unspecified angina pectoris
�I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris
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Cardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab Programs
�Medicare Coverage with these Conditions:
�Acute MI within past 12 months; or
�Coronary artery bypass surgery; or
�Current stable angina pectoris; or
�Heart valve repair or replacement; or
�PTCA or coronary stenting; or
�Heart or heart-lung transplant; or
�Stable, chronic heart failure
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NCD
ALERT
Cardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab Programs
413.0 Angina decubitus I20.8
Other forms of angina
pectoris
413.1 Prinzmetal angina I20.1
Angina pectoris with
documented spasm
413.9
Other and unspecified
angina pectoris I20.8
Other forms of angina
pectoris
413.9
Other and unspecified
angina pectoris I20.9
Angina pectoris,
unspecified
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NCD
ALERT
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Cardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab ProgramsCardiac Rehab Programs
�What about Combination Codes for Coronary Artery Disease with Stable Angina??
�I25.1XX
�I25.7XX
http://acsteam.net
NCD
ALERT
Errors? Edits? ASK A CODERErrors? Edits? ASK A CODERErrors? Edits? ASK A CODERErrors? Edits? ASK A CODER
�115 pages of ICD-10-CM diagnosis coding guidelines
�15 pages of ICD-10-PCS procedure coding guidelines
�123,336 new codes!
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CMS Claims Processing Instructions IssuedCMS Claims Processing Instructions IssuedCMS Claims Processing Instructions IssuedCMS Claims Processing Instructions Issued
�Billing and Payment FAQs
�MLN Matters SE1325 Institutional Services Split Claims Billing Instructions for Medicare FFS Claims that Span the ICD-10 Implementation Date
�MLN Matters SE1408 Medicare FFS Claims Processing Guidance for Implementing ICD-10
�MLN Matters SE1410 Special Instructions for ICD-10 Coding on Home Health Episodes that Span October 1, 2015
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CMS Billing FAQCMS Billing FAQCMS Billing FAQCMS Billing FAQOP Date of Service / IP DischargeOP Date of Service / IP DischargeOP Date of Service / IP DischargeOP Date of Service / IP Discharge
9/30/15• ICD-9-CM Dx ONLY
• ICD-9 / CPT Procedures
10/1/15
• ICD-10-CM Dx ONLY
• ICD-10-PCS / CPT Procedures
Otherwise Returned / Rejected
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OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15
�Services prior to 10/1/15: bill separately with ICD-9
�Keep all charges within same LIDOS � Line item date of service
�Do NOT split single item services whose timeframes cross midnight 9/30/15. Use “from” date� ED = date patient enters ED
� OBS = date observation care begins
OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15Emergency DepartmentEmergency DepartmentEmergency DepartmentEmergency Department
�Arrives ED 9/30/15 @ 1900, discharged 10/1/15 @ 0100
� LIDOS = 9/30/15 ICD-9 codes 1st claim
� 10/1/15 charges ICD-10 codes, 2nd claim
�No services actually provided 10/1/15?
� Only 1 claim ICD-9 codes
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OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP Encounter Spans 10/1/15OP ObservationOP ObservationOP ObservationOP Observation
�Admit to OBS 9/29/15 @ 1400, discharged 10/1/15 @ 0800
� LIDOS = 9/28-29/15 ICD-9 codes, 1st claim
� 10/1/15 charges ICD-10 codes, 2nd claim
Encounter Spans 10/1/15Encounter Spans 10/1/15Encounter Spans 10/1/15Encounter Spans 10/1/15Admit within 3 Day Payment WindowAdmit within 3 Day Payment WindowAdmit within 3 Day Payment WindowAdmit within 3 Day Payment Window
�OP Surgery 9/29/15 @ 1400, admitted as IP 9/30/15 @ 1000, with discharge 10/2/15 @ 0800
� Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient bill if rendered within three days of admission, the claim must be billed with ICD-10 for those bundled outpatient services
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IP Encounter Spans 10/1/15IP Encounter Spans 10/1/15IP Encounter Spans 10/1/15IP Encounter Spans 10/1/15
�Admitted as IP 9/28/15
�Discharged Home 10/2/15
�All billed based on 10/2/15 discharge
� ICD-10 codes
PostPostPostPost----Implementation ActivityImplementation ActivityImplementation ActivityImplementation Activity
�Tracking initial ICD-10 charts coded
� Determine volume per each service type
Coding
Claim
Remit