Technicians & Nurses Program

Transcription

1 ASCRS ASOA Symposium & Congress Technicians & Nurses Program May 6-10, 2016 New Orleans

2 ICD-10 Implementation: Tips and Pearls for Technicians Financial Disclosure The instructor acknowledges a financial interest in the subject matter of this presentation. Paul M. Larson, MBA, MMSc, COMT, CPE, CPC, CPMA Senior Consultant Corcoran Consulting Group I am a consultant for Corcoran Consulting Group. Executive Summary Compare and Contrast BEFORE & NOW ICD-9 vs ICD-10 Mapping issues Specificity and 7 th character use Documentation challenges Payment issues Grace period Payer policies Inappropriate denials PQRS and MU implications Changes to ICD-10 in the future ICD-9 17 Chapters 14,000 codes 3-5 digits First digit is numeric or alpha (E or V) Digits 2-5 are numeric We had a comfort level ICD Chapters ~ 69,000 codes 3-7 digits Digit 1 is alpha Digit 2 is numeric Digits 3-7 are alpha or numeric (alpha digits are not case sensitive) Some things illogical Will ICD-10 change again? Yes! Mapping Issues New codes - Effective on October 1, new diabetes combination codes for reporting manifestations Laterality for diabetic eye disease New diabetic eye disease options Laterality for AMD and Open-Angle Glaucoma Chapter 19 changes Source: Centers for Disease Control, Decision Health (Both on March 22, 2016) ICD-9 code = Under: Senile Cataract Nuclear sclerosis ICD-10: Right, Left, and Bilateral designations 1 = right 2= left 3 = bilateral 0 or 9 = unspecified Example: H25.11 Age-related nuclear cataract, right eye H25.12 Age-related nuclear cataract, left eye H25.13 Age-related nuclear cataract, bilateral H25.10 Age-related nuclear cataract, unspecified eye

3 H Cicatricial entropion of right eye, H Cicatricial entropion of right eye, H Cicatricial entropion of left upper eyelid H Cicatricial entropion of right eye, H Cicatricial entropion of left upper eyelid H Cicatricial entropion of left lower eyelid H Cicatricial entropion of right eye, H Cicatricial entropion of left upper eyelid H Cicatricial entropion of left lower eyelid H Cicatricial entropion of left eye,

4 Seventh (7 th ) Character Extension H Cicatricial entropion of right eye, H Cicatricial entropion of left upper eyelid H Cicatricial entropion of left lower eyelid H Cicatricial entropion of left eye, H Cicatricial entropion of unspecified eye, Seventh (7 th ) Character Extension 7 th Character Extension Some categories have applicable 7 th characters Last character If code is not six digits, use x as placeholder x as placeholder For when characters are needed for expansion 7 th Character Extension - A Initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, ER dep t encounter, E/M by a new physician 7 th Character Extension - D Subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent encounter are: cast change or removal, removal of external or internal fixation devices, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition. 7 th Character Extension S Sequela is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. When using 7 th character 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 sequela is sequenced first.

5 Example Open Globe with Prolapsed Iris Example Open Globe with Prolapsed Iris Category Chapter 19 Injury, Poisoning... S05 Injury of eye and orbit Example Open Globe with Prolapsed Iris Category Chapter 19 Injury, Poisoning... S05 Injury of eye and orbit Subcategory 5 th S05.2 Ocular laceration and rupture with prolapse or loss of intraocular tissue Example Open Globe with Prolapsed Iris Category Chapter 19 Injury, Poisoning... S05 Injury of eye and orbit Subcategory 5 th S05.2 Ocular laceration and rupture with prolapse or loss of intraocular tissue Specificity x 7 th S05.21 Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye Example Open Globe with Prolapsed Iris Category Chapter 19 Injury, Poisoning... S05 Injury of eye and orbit Subcategory 5 th S05.2 Ocular laceration and rupture with prolapse or loss of intraocular tissue Specificity x 7 th S05.21 Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye Valid code S05.21xA -- Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye; initial encounter 7 th Character Extension For glaucoma staging, 7 th denotes severity of disease 0 = unspecified (not noted in chart)

6 7 th Character Extension For glaucoma staging, 7 th denotes severity of disease 0 = unspecified (not noted in chart) 1 = mild 7 th Character Extension For glaucoma staging, 7 th denotes severity of disease 0 = unspecified (not noted in chart) 1 = mild 2 = moderate 7 th Character Extension For glaucoma staging, 7 th denotes severity of disease 0 = unspecified (not noted in chart) 1 = mild 2 = moderate 3 = severe 7 th Character Extension For glaucoma staging, 7 th denotes severity of disease 0 = unspecified (not noted in chart) 1 = mild 2 = moderate 3 = severe 4 = indeterminate (unknown) Example: Glaucoma Staging How would you code for moderate, low tension glaucoma, OD, and severe, low tension glaucoma, OS? Example: Glaucoma Staging 7th character is to be assigned to each code in subcategory H40.12 to designate the stage of glaucoma Low-tension Glaucoma H40.12

7 Example: Glaucoma Staging 7th character is to be assigned to each code in subcategory H40.12 to designate the stage of glaucoma Low-tension Glaucoma H40.12 Low-tension Glaucoma, right eye, moderate stage H Example: Glaucoma Staging 7th character is to be assigned to each code in subcategory H40.12 to designate the stage of glaucoma Low-tension Glaucoma H40.12 Low-tension Glaucoma, right eye, moderate stage H Low-tension Glaucoma, left eye, severe stage H Combination Codes Combination Codes Single code used to classify two or more diagnoses Diagnosis with an associated manifestation Examples: E Type 2 DM with severe nonproliferative diabetic retinopathy with macular edema Source: AAO Diabetes ICD-10 Tree Diabetes Mellitus Insulin use All categories except E10 (Type 1 DM) require use of additional code to indentify any insulin use Z79.4 Long term (current) use of insulin Excludes 1 excluded code should never be used at the same time as the code above excludes 1 note. Excludes Examples H01.0 Blepharitis Excludes 1 blepharoconjunctivitis (H10.5-)

8 : Excludes Excludes 1 excluded code should never be used at the same time as the code above excludes 1 note. Excludes 2 represents Not included here ; Condition excluded not part of condition represented by the code; patient may have both conditions at the same time; may use both codes when appropriate. Examples H33.- Retinal detachments and breaks Excludes 1 detachment of retinal pigment epithelium (H35.72 H35.73-) H31.1 Choroidal degeneration Excludes 2 angioid streaks of macula (H35.33) Source: ICD-10 Official Guidelines, Sect 1 A.12 External Causes Your patient was hit in the right eye by a paintball when a friend s paintball gun malfunctioned. Your eye doctor diagnoses RUL laceration, conjunctival hemorrhage, and traumatic hyphema OD. What ICD-10 code(s) apply at this visit? External Causes External Causes S01.111A Laceration of right eyelid w/o foreign body, initial encounter S01.111A S05.11xA Laceration of right eyelid w/o foreign body, initial encounter Contusion of eyeball and orbital tissues, right eye, initial encounter Traumatic hyphema External Causes External Causes S01.111A Laceration of right eyelid w/o foreign body, initial encounter S05.11xA Contusion of eyeball and orbital tissues, right eye, initial encounter Traumatic hyphema H11.31 Conjunctival hemorrhage, right eye S01.111A Laceration of right eyelid w/o foreign body, initial encounter S05.11xA Contusion of eyeball and orbital tissues, right eye, initial encounter Traumatic hyphema H11.31 Conjunctival hemorrhage, right eye W34.011A Accidental discharge of paintball gun; accidental injury, initial encounter Ch 20 codes (V, W, X, Y) are not required.

9 Executive Summary ICD-9 vs ICD-10 Mapping issues Specificity and 7 th character use Documentation challenges Documentation Considerations Laterality Is your assessment specific to which eye or eyelid? Etiology / Manifestation Does your chart note list both the disease and the associated manifestation? Specificity Is the impression as specific as possible for a particular condition? Documentation Considerations Possible ICD-10 Mistakes Old Eyelid laceration Cataract Diabetic Iritis Ptosis New Laceration LLL Combined forms of cataract, left eye Type II DM, mild NPDR w/ DME, takes insulin Chronic iritis, OU Myogenic ptosis, RUL, LUL Unable to code from chart notes Insufficient characters Too many digits Nonexistent or invented code Choosing laterality when inappropriate Incompatible codes Excludes1, Excludes2 Undesirable code use Unspecified or other nonspecific code used (Does not match chart specifics) Possible ICD-10 Omissions Missing required additional code Code Also, Code First Use Additional Code Missing pertinent co-morbidities Missing history of prior surgery Missing history of prior implant, graft Executive Summary ICD-9 vs ICD-10 Mapping issues Specificity and 7 th character use Documentation challenges Payment issues Grace period Payer policies Inappropriate denials

10 Coding Leniency? CMS has said it will not deny or audit claims just for specificity for one year after implementation of ICD- 10, as long as the ICD-10 code is from the appropriate family of codes CMS stated auditors will not deny a claim "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." Coding Leniency? Non-Medicare payers might not follow CMS lead If an LCD or NCD is present and valid: If it lists specific codes, you MUST code to greater specificity Less specific codes likely generate an invalid code denial of some sort Source: CMS ICD-10 Guidance, July 2015 Payer Policy Issues Payer s policies does not properly translate the ICD-9 codes to ICD-10 for coverage purposes Payer omits some codes in the new policy (CME) and (DME) both had ICD-9 coverage H omitted Diabetic retinopathy codes (E10, E11) ending in 1 (with ME) are omitted but the ending 9 (without ME) are included Be sure and check the new policies Enlist professional associations for assistance Executive Summary ICD-9 vs ICD-10 Mapping issues Specificity and 7 th character use Documentation challenges Payment issues Grace period Payer policies Inappropriate denials PQRS and MU implications PQRS and MU One year grace period with no denials based on specificity as long as ICD-10 code is from appropriate family of codes No penalty with quality programs (PQRS, VBM, MU) as long as appropriate family of codes is used PQRS and MU Your PM system must be able to count the measures and calculate the proper percentages Some systems might not count family of code selections Back-up plan: save and print your internally-generated report results in case of future questioning Source: guidance.pdf Source: guidance.pdf

11 Executive Summary ICD-10 Update? ICD-9 vs ICD-10 Mapping issues Specificity and 7 th character use Documentation challenges Payment issues Grace period Payer policies Inappropriate denials PQRS and MU implications Changes to ICD-10 in the future ICD-10 (Now) H35.31 (Dry AMD) H40.11x2 (Mod St OAG) E (Type II DM, Mild NPDR, no DME) ICD-10 (Proposed 10/01/16) H (Non-exudative AMD, intermediate stage, OD) H (Mod St OAG, OS) E (Type II DM, mild NPDR, no DME, bilateral) E (Type II DM, PDR, traction RD not involving macula, OS) Additional Assistance (800) Website: Mobile App: Corcoran 24/7 plarson@corcoranccg.com