Laurie Aloi, CHC, CHPC, CPCDirector of Billing & ComplianceMedSafeOctober 21, 2013

ICD-10 OverviewNext Steps to ICD-10

AgendaUnderstanding what’s coming

Timeline and history Delay in ImplementationWhat is ICD-10? Side by Side examplesReview of Coding GuidelinesPlanning for a Successful Transition

When?The Department of Health and Human Services (HHS) originally announced the plan for ICD-10-CM implementation.In August 2009, CMS announced the implementation date would be October 1, 2011The date was pushed back in January 2009 after MGMA and AAPC appealed to CMS that the training and software transition would be a burden to the medical professionPractices have had 4 years to prepare and should be learning about-What ICD-10 isWhat will need to be done to prepare

And Now?On February 16, 2012 HHS Secretary Kathleen Sebelius has announced that the October 1, 2013 date for implementation of ICD-10 has been pushed back indefinitely“ICD-10 codes are important to many positive improvements in our health care system. We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead.  We are committing to work through the rulemaking process, with the provider community, to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

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New Implementation DateOn April 9, 2012, CMS announced that the new implementation date will be October 1, 2014

The extra year will give medical practices more time to shift from the demands of Meaningful Use and Quality, to the issues of training and implementing ICD-10

Why change from ICD-9?ICD-9-CM has several problems. After 30

years, it is no longer useful. It is out of room.  Because the classification

is organized scientifically, each three-digit category can have only 10 subcategories. Most numbers in most categories have been assigned diagnoses. Medical science keeps making new discoveries, and there are no numbers to assign these  diagnoses. ICD-10 expands to 7 digits.

Computer science, combined with new, more detailed codes of ICD-10-CM, will allow for better analysis of disease patterns and treatment outcomes that can advance medical care provided.

These same details will streamline claims submissions, since these details will make the initial claim much easier for payers to understand. 

A large share of the world is using ICD-10 since it was introduced in

1992 • United Kingdom (1995) • Nordic countries (Denmark, Finland, Iceland,

Norway, Sweden) (1994 – 1997) • France (1997) • Australia (1998) • Belgium (1999) • Germany (2000) • Canada (2001)

Reimbursement and Quality problems with ICD-9

Example – fracture of wristPatient fractures left wrist

A month later, fractures right wrist– ICD-9-CM does not identify left versus right

–• requires additional documentation

– ICD-10-CM describes• Left versus right• Initial encounter, subsequent encounter• Routine healing, delayed healing, nonunion, or

malunion

ICD-10 Changes everything

From this…..

To this

ICD-10 Major ModificationsAdded trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used) Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be used) Expanded codes (e.g., injury, diabetes) Added code extensions for injuries and external causes of injuries

Laterality- Left versus Right - C50.1 Malignant neoplasm, of central portion of breast – C50.111 Malignant neoplasm of central

portion of right female breast – C50.112 Malignant neoplasm of central

portion of left female breast

Structural Differences ICD-9

ICD-9-CM has 3 – 5 digits Chapters 1 – 17: all characters are numeric Supplemental chapters: first digit is alpha (E or V), remainder are numeric Examples: – 496 Chronic airway obstruction not

elsewhere classified (NEC) – 511.9 Unspecified pleural effusion – V02.61 Hepatitis B carrier

Structural Differences ICD-10

ICD-10-CM has 3 – 7 digits Digit 1 is alpha (A – Z, not case sensitive) Digit 2 is numeric Digit 3 is alpha (not case sensitive) or numeric Digits 4 – 7 are alpha (not case sensitive) or numeric A66 Yaws A69.20 Lyme disease, unspecified O9A.311 Physical abuse complicating

pregnancy, first trimester S42.001A Fracture of unspecified part of

right clavicle, initial encounter for closed fracture

Format and Guidelines

ICD-10-CM Organization Introduction How to Use Official GuidelinesAlphabetic IndexNeoplasm TableTable of Drugs and ChemicalIndex to External Causes

Format and GuidelinesICD-10-CM OrganizationTabularChaptersICD-10-CM has 21 ChaptersBlocks

ExampleChapter 8 – Diseases of the Ear and Mastoid Process

is divided into 5 blocks H60-62 Diseases of the external ear, H65-75 Diseases of the middle ear and mastoid, H80-83, Diseases of the inner ear, H90-94 Other disorders of the ear, H95 Intraoperative/postprocedural complications

Comparison of Code SetsICD-9 ICD-10

3-5 characters 3-7 charactersMore than 17,000 codes More than 155,000 codes

68,000 are for ICD 10- CM

First digit may be alpha or numeric (E or V only), digits are 2-5 are always numeric

First digit is alpha; digits 2 & 3 are numeric; digits 4-7 are alpha or numeric

Limited space for adding new codes

Flexible, new format allows for expansion

Lacks detail Very specific

Lacks laterality Includes a specific field to identify laterality (right vs. left)

Structural DifferencesICD-9 Diagnosis Code ICD-10 Diagnosis Code382.9 Acute Otitis Media B01.2 Varicella pneumonia540.9 Acute Appendicitis K21.0 GERD with esophagitis780.01 Coma O30.003 Twin Pregnancy,

unspecified, third trimester

In the ICD-10 diagnosis code set, the alpha characters are not case sensitive. These examples show a comparison of the formats of the ICD-9 and ICD-10 diagnosis codes. You can see the use of alpha characters and longer codes in ICD-10

ICD-10 StructureThe expanced number of characters of the

ICD-10 diagnosis codes provides greater specificity to identify disease etiology, anatomic site, and severity

Characters 1-3 - CategoryCharacters 4-6 - Etiology, anatomic site,

severity, or other clinical detailCharacter 7 – Extension (example-

episode of care or other clinical detail)

Detailed ExampleS52 Fracture of ForearmS52.5 Fracture of lower end of radiusS52.52 Torus fracture of lower end of radiusS52.521 Torus fracture of lower end of right radiusS52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture

Side by side example #1Severe, unremitting left lower leg painICD-9 – 729.5 Pain, lower extremityICD-10 M79.662 Pain in left lower legICD-10 Coding StructureM79 Other and unspecified soft tissue disorders, not specified elsewhereM79.6 Pain in limb, hand, foot, fingers and toesM79.66 Pain in Lower LegM79.662 Pain in left lower extremity

Side by side example #2Sprain of the deltoid ligament of right ankleICD-9 – 845.01 Sprain, deltoid lligament of ankleICD-10 S93.421 sprain of the deltoid ligament of right ankleICD-10 Coding StructureS93 Subluxation and dislocation of the ankle jointS93.4 Sprain of ankleS93.42 Sprain of the deltoid ligamentS93.421 Sprain of the deltoid ligament of the right ankleS93.421A Sprain of the deltoid ligament of the right ankle, Initial Encounter

Similarities

Index abbreviations (NEC)Tabular abbreviations (NOS)“and” means “and/or”“other specified” and “unspecified” are the sameIncludes notesExample:I70.24 Atherosclerosis of native arteries of

left leg with ulceration Includes any condition classifiable to I70.212 and I70.222

SimilaritiesUse additional code….’, ‘Code first’ and ‘Code also’ notesExample:

G47.3 Sleep apneaCode also any associated underlying condition

Inclusion termsOfficial coding guidelinesCMSNCHSAHAAHIMA

Differences

ICD-10-CM codes are all alphanumericFirst character is always an alpha characterSubsequent characters may be alpha or numericExample:I82.a11 Acute embolism and thrombosis of

right axillary veinCodes may be 3, 4, 5, 6 or 7 characters in lengthCode Descriptions are listed in full

A Place for everything, everything in its place- Benjamin Franklin

The fact that the codes are up to seven characters in length is a major difference that brings two new considerations: seventh character extenders and dummy placeholders.

The seventh character extenders are usually a letter, and are used to identify the encounter type. The most common seventh character extenders used in ICD-10-CM are:

A-Initial Encounter for closed fractureB- Initial encounter for open fractureD- Subsequent Encounter for fracture with

routine healingG- Subsequent encounter for fracture with

delayed healingK- Subsequent encounter for fracture with

nonunionP- Subsequent encounter for fracture with

malunionS- Sequela

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A unique twist- the “Placeholder”

Some codes are 7 characters, but no 4th, 5th or 6th place is necessary, so “x” is a placeholderT68.xxxA - Hypothermia

The appropriate 7th character is to be added to code T68A – initial encounterD – Subsequent encounterS – sequela

Body Systems• Blood and Blood

Forming• Organs• Immune System• Endocrine System• Nervous System• Eye and Adnexa• Ear and Mastoid

Process• Circulatory System

• Respiratory System• Digestive System• Integumentary

System• Musculoskeletal

System• Genitourinary

System• Pregnancy,

Childbirth, and Puerperium

Diseases of the Circulatory System

ICD-9 Description ICD-10 Description401.1 Essential

hypertension (benign)

I1ØEssential (primary) hypertension

414.01 Coronary atherosclerosis of native coronary artery (CAD)

I25.1Ø

Atherosclerotic heart disease of native coronary artery without angina pectoris

427.31 Atrial fibrillation I48.Ø Atrial

fibrillation428.0 Congestive

heart failure I5Ø.9 Heart failure, unspecified

Diseases of the Respiratory SystemDescription ICD-9 ICD-10

Laryngitis 464.0 J04.0Croup 464.4 J05.0Respiratory Syncytial Virus (RSV

466.11 J04.11

Pneumonia 481 J13 pneumonia due to StrepJ18.1 Lobar pneumonia, unspecified organism

Influenza 488.0 JØ9.Ø19 Influenza due to identified avian influenza virus with unspecified type of pneumonia

COPD 496 J44.9

Signs and SymptomsDescription ICD-9 ICD-10 ICD-10

Description786.05 Shortness of

breath RØ6.Ø2 Shortness of breath

786.50 Chest painRØ7.9 Chest pain,

unspecified786.51 Precordial Pain RØ7.2 Precordial pain786.59 Chest Pain

NEC* RØ7.82

R07.89

Intercostal pain

Other Chest pain

790.93 Elevated PSA

R97.2Elevated prostate specific antigen [PSA]

Diseases of the Respiratory System

3311/12/12

Description ICD-9 ICD-10 ICD-10 Description

Asthma 493.00J45.2Ø

Mild intermittent asthma, uncomplicated

Bronchitis 490J4Ø

Bronchitis, not specified as acute or chronic

Pneumoconiosis 505 J64 Unspecified pneumoconiosis

Empyema (pus in lung)

510.9J86.9 Pyothorax without

fistula

Pneumothorax 512J93.Ø

Spontaneous tension pneumothorax

Interstitial Lung Disease

770.1 Fetal and newborn aspiration

P28.9Respiratory condition of newborn, unspecified

Diseases of the Respiratory System

3411/12/12

Description ICD-9 ICD-10 ICD-10 Description

Pulmonary Edema

518.4J81.Ø Acute pulmonary edema

Screening:

Personal history

V12.60Z87.Ø9

Personal history of other diseases of the respiratory system

Family history

V17.5 Z82.5Family history of asthma and other chronic lower respiratory diseases

Screenings V72.50 ZØ1.89Encounter for other specified special examinations

Common OB Gyn ConditionsICD-9 Description ICD-10 Description620.2 Ovarian Cyst N83.20

N83.29

Unspecified Ovarian CystOther ovarian Cysts

174.8 Malignant neoplasm breast

C50.819 Malignant neoplasm of overlapping sites of unspecified female breast

625.6 Stress incontinence, female

N39.3 Stress incontinence (female) (male)

625.4 Premenstrual tension syndromes

N94.3 Premenstrual tension syndrome

625.3 Dysmenorrhea N94.3 Dysmenorrhea, unspecified

628.3 Infertility, uterine (female)

N97.2 Female infertility of uterine origin

V Codes will be Z CodesICD-9 Description ICD-10 DescriptionV72.5 Z01.41

Z01.411

Encounter for gynecological examination..with abnormal findings

V22.0

V22.1

Supervision of normal first pregnancy…..other normal pregnancy

Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester

V25.0 Z30.8 Encounter for contraceptive management

V72.4V72.40V72.41V72.42

Pregnancy test……unconfirmed……negative……positive

Z32.3Z32.00Z32.01Z32.02

Pregnancy examination or test……unconfirmed……negative……positive

Diseases of the Musculoskeletal System

Description ICD-9 ICD-10 ICD-10 Description

715.11 Primary localized osteoarthritis, shoulder region

M19.Ø19Primary osteoarthritis, unspecified shoulder

M19.012 Primary Osteoarthritis, left shoulder

M19.011Primary Osteoarthritis, right shoulder

715.15 Primary localized osteoarthritis, pelvic region and thigh

M16.1ØUnilateral primary osteoarthritis, unspecified hip

M16.11 Unilateral Primary osteoarthritis, right hip

M16.12Unilateral primary osteoarthritis, left hip

Diseases of the Musculoskeletal System

Description ICD-9 ICD-10 ICD-10 Description

717.2 Derangement of posterior horn of medial meniscus M23.229

Derangement of posterior horn of medial meniscus due to old tear or injury, unspecified knee

M23.329

Other meniscus derangements, posterior horn of medial meniscus, unspecified knee

M23.221Derangement of posterior horn of medial meniscus due to old tear or injury, right knee

M23.222Derangement of posterior horn of medial meniscus due to old tear or injury, left knee

Diseases of the Musculoskeletal System

Description ICD-9 ICD-10 ICD-10 Description

719.41 Pain in joint, shoulder region

M25.519Pain in unspecified shoulder

M25.511 Pain in right shoulder M25.512 Pain in left

shoulder

719.45 Pain in joint, pelvic region and thigh

M25.559 Pain in unspecified hip

M25.551 Pain in right hip M25.552 Pain in left

hip

Diseases of the Musculoskeletal System

Description ICD-9 ICD-10 ICD-10 Description

721.0 Cervical spondylosis without myelopathy

M47.812

Spondylosis without myelopathy or radiculopathy, cervical region

721.3 Lumbosacral spondylosis without myelopathy

M47.817

Spondylosis without myelopathy or radiculopathy, lumbosacral region

722.0 Displacement of cervical intervertebral disc without myelopathy

M5Ø.2ØOther cervical disc displacement, unspecified cervical region

722.10 Lumbar intervertebral disc without myelopathy

M51.26(M51.27 for lumbsosacral)

Other intervertebral disc displacement, lumbar region

Diseases of the Musculoskeletal System

Description ICD-9 ICD-10 ICD-10 Description

727.03 Trigger finger (acquired) M65.3Ø

Trigger finger, unspecified finger

727.61 Complete rupture of rotator cuff M75.1Ø

Rotator cuff syndrome, unspecified shoulder

354.0 Carpal tunnel syndrome G56.ØØ

Carpal tunnel syndrome, unspecified upper limb

Anatomy and Pathophysiology

Higher level of specificity found in the new codesIn order to assign them correctly we have to first understand themFor example – the musculoskeletal system comprises 60% of the codes found in ICD-10206 bones in the body80 are Axial– head, facial, hyloid, auditory, trunk, ribs,

and sternum126 are Appendicular– arms, shoulders, wrists, hands, legs, hips,

ankles and feet

Types of FracturesDisplaced fracturesNon-displaced fracturesClosed fractureOpen fractureGreenstick FractureTransverse fractureSpiral fractureOblique fractureCompression fracture

Anatomy and Pathophysiology -

Musculoskeletal systemClassification is needed for open fractures using the “Gustilo Open fracture classification system”This system identifies fractures as Type I, II, IIIA, IIIB and IIICI – Low energy, wound less than 1 cmII – Wound greater than 1 cm with moderate soft tissue damageIII – High energy wound greater than 1 cm with extensive soft tissue damageIIIA – Adequate soft tissue coverIIIB – Inadequate soft tissue coverIIIC – Associated with arterial injury

Diseases of the Musculoskeletal System

Description

ICD-9 ICD-10 ICD-10 Description

813.42 Other fractures of distal end of radius (alone) S52.5Ø9A

Unspecified fracture of the lower end of unspecified radius, initial encounter for closed fracture

820.21 Intertrochanteric fracture, closed S72.143A

Displaced intertrochanteric fracture of unspecified femur, initial encounter for closed fracture

S72.146A

Nondisplaced intertrochanteric fracture of unspecified femur, initial encounter for closed fracture

NeoplasmDescription ICD-9 ICD-10 ICD-10

Description185 Malignant

neoplasm of prostate

C61Malignant neoplasm of prostate

188.9 Malignant neoplasm of bladder, unspecified part

C67.9Malignant neoplasm of bladder, unspecified

Comparison of ICD-9 Chapters to ICD-10 Chapters

ICD-9There are 17 Chapters, plus 2 supplementary chapters of V codes and E Codes*see spreadsheet

ICD-10There are 22 Chapters in ICD-10

Eye and AdnexaEar and mastoid ProcessExternal causes of morbidity and mortality

(separate from injury and poisoning)Codes for Special Purposes

GuidelinesIt is essential for a coder to review the chapter guidelines in the front of the ICD-10 manualChapter changes are summarized belowMany chapter guidelines are the same as ICD-9

Blood and Blood Forming Organs

SepsisComplication of infection outside the blood

streamBlood stream carries bacteria or other

organism through blood to other sitesSepsis vs. bacteremia vs. septicemia

Bacteremia - presence of bacteria in the bloodSepticemia - presence of bacteria in the blood (bacteremia)Sepsis - a serious condition characterized by a whole-body inflammatory state (systemic inflammatory response) with the presence of suspected or known infection

Chapter 15 Guidelines-Pregnancy, Childbirth, and the puerperium (O00-O099)a. General Rules for Obstetric Cases– 1) codes from chapter 15 have sequencing

priority over codes from other chapters.– Should the provider document the

pregnancy is incidental to the encounter, code Z33.1 pregnant state, incidental, in place of any chapter 15 codes. (condition not affecting pregnancy)

– 2) Chapter 15 codes are used only on the maternal record and never on the newborn record

– 3) final character for trimester

6 digit exampleFinal character for trimester– O23.51 Infections of the genital tract

in pregnancy• O23.511 infections of cervix in

pregnancy, first trimester• O23.512 …………………………….second

trimester• O23.513……………………………….third

trimester• O23.519…………………………unspecified

trimester

TrainingWe know there will need to be significant education and training for physicians, coders and other healthcare personnel. No one needs to panic. Please do not jump to individual training as its difficult to remember in 1 yearswhat you were trained on today.You have year to have a plan in place to provide all you'll need to effectively implement ICD-10.

TrainingConsider offering training to your billing and coding staff – Medical Terminology– Anatomy– Pathophysiology– Use Video’s such as “Anatomy for

Beginners”• Purchase DVD or download from Youtube free of

charge• Excellent modules to advance your coding and

billing staff’s clinical knowledge

Attain CertificationConsider sending your billing manager, coders and others in you practice to become CPC certified in preparation for ICD-10. Don’t wait until the implementation date, learning CPT, HCPCS and ICD-9 will be an excellent foundationContinuing education is a must!

Maintain CertificationCertified coders (CPC, CPC-A and other coding credentials from AAPC) will require ongoing a proficiency Assessment75 QuestionsOpen book, online, unproctored, use any resource availableTwo attempts to pass over a two year windowScheduled to be available Oct 1, 2013 – Sept 30, 2015

October 1, 2014Implementation ComplianceClaims will require the new ICD-10 CodesContinue Training2-3 days of training will be requiredAHIMA estimates 16 hours or less of training– Have a certified coder on hand to support

the physicians and staff as they use the new code sets, or system, “live” for the first time

– Anticipate some disruption, consider ways to support your practice during this time

Helpful web sitesNational Center for Health Statistics

http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

CMShttp://www.cms.hhs.gov/ICD10/

AHIMAhttp://www.ahima.org/icd10

MGMAwww.mgma.com

Ingenixwww.ingenix.com/caretracker

AAPCwww.aapc.com

AMAhttp://www.ama-assn.org/ama1/pub/upload/mm/399/

icd10-icd9-differences-fact-sheet.pdf

About The Presenter…Laurie Aloi is the Director of Billing and Compliance for Medsafe: The Total Compliance Solution.

Laurie oversees the billing compliance auditing and educational programs offered by Medsafe. A certified coder/physician chart auditor with over 25 years experience in the industry, Laurie directs the daily operations of the billing compliance division.

About The Company…For 20 years MedSafe has established the industry’s best practice standards for quality, and regulatory compliance services for healthcare practices. Through their onsite, and online programs MedSafe assures that physicians and their businesses are actively in compliance with the latest government regulations including HIPAA/HITECH, Corporate/Billing Compliance, OSHA, and more.

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