Learning Objectives. Slide 1. Slide 2. Slide 3 Speakers

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1 Slide 1 Slide 2 Learning Objectives Identify the similarities and differences between ICD-9 and ICD-10. How to determine the correct ICD-10 codes. Describe a mapping of ICD-9 to ICD-10 for common conditions seen by physical therapists. Recognize strategies and resources, and adapt practice procedures for transition to ICD-10. Identify timelines associated with ICD-10 adoption. Slide 3 Speakers Joseph Nichols, MD, is a board certified Orthopedic Surgeon with a long history in health information technology. He has a wide range of experiences in healthcare information technology on the provider, payer, government and vendor side of healthcare business. He has served in positions in executive management, system design, logical database architecture, product management, consulting and healthcare value measurement for the last 18 of his 35 years in the healthcare industry. He has given over 100 presentations nationally related to ICD-10 over the past 3 years on behalf of CMS, payers, providers, integrated delivery systems, consulting groups, universities, government entities, vendors and trade associations. He co-chairs the WEDI (Workgroup on Electronic Data Interchange) translation and coding sub-workgroup and has received WEDI merit awards 3 years in succession. He is also an AHIMA approved ICD-10 coding trainer. He is currently providing consulting services as the President of Health Data, Inc. Janet Albanese, PT, MPT, MHA, is presently an owner of Access Physical Therapy & Wellness and has served as the Compliance Officer and Director of the billing department for its 19 locations over the past 11 years. She oversees all training and transition related to compliance and billing and is in charge of the current ICD-10 transition. Janet also serves on the payment policy committee for Private Practice Section of the APTA. Janet has over 16 years' experience in the field of Physical Therapy. She earned both her Physical Therapy degree and Health Care Administration degrees from Springfield College.

2 Slide 4 ICD-10 Impacts and Opportunities Presented by: Joe Nichols MD Date: March 27, 2014 Slide 5 ICD-10 Basics Key coding changes Agenda Coding Challenge ICD-10 documentation structure Finding Codes Mapping the good, the bad and the ugly Implementation Getting there in a timely manner Testing What, Why, Who and When Available resources 5 5 Slide 6 ICD-10 Compliance Date The compliance date for ICD-10-CM and PCS is October 1,

3 Slide 7 The Road to 10: The Small Physician Practice's Route to ICD-10 The Road to 10: The Small Physician Practice's Route to ICD Slide 8 Road to 10: Provider Preparation Plan Your Journey To get you started, it is important to understand where you are on the road to ICD-10 compliance. The action plan provides a pictorial road map and the steps you may find helpful when pinpointing where diagnosis codes are used in your practice, identifying the transition team, preparing a budget for the transition to ICD-10, and arranging for training. Train Your Team Your support staff will be a big part of your success. The action plan contains guidelines to get your team started on the path to compliance. The website also highlights additional training resources that may be helpful to your practice. Update Your Processes Reviewing current clinical documentation practices and identifying gaps related to ICD-10 is an important step in your transition. The action plan walks you through the steps to update your policies, procedures, forms, and templates. 4 5 Engage Your Vendors & Payers Collaboration with technology vendors and payers is key. The action plan contains steps to help ensure system updates, set-up tasks, and compliance risks can be addressed. Test Your Systems and Processes Testing is a critical component of the ICD-10 transition. The action plan walks you through the process of preparing test cases, performing internal and external testing, practicing coding in ICD-10, and validating clinical documentation processes. 8 Slide 9 ICD-10 Basics 9

4 Slide 10 ICD10 Quick Facts ICD-10 international version Adopted by WHO in 1990 Most countries other than the US currently use ICD-10 ICD-10 (International version) ~ 12,500 diagnostic codes ICD-10 used for mortality reporting in the US ICD-10-CM (US version) ~ 69,000 diagnostic codes Final rule published 2009 Compliance date October 1, 2014 ICD-10-PCS ~72,000 codes Not part of an international standard Inpatient procedures only Compliance date October 1, Slide 11 ICD-9 Diagnosis Codes vs. ICD-10- CM (Diagnosis Codes) ICD-9-CM Diagnosis Codes 3 to 5 digits Alpha E and V on 1 st character No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality Combination codes limited ICD-10-CM Diagnosis Codes 7 digits Alpha or numeric for any character Include place holder characters ( x ) Similar Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common 11 Slide 12 Same Condition Different Codes What s the Difference? September 2014 October 2014 ICD : Open fracture of Shaft of Femur ICD-10 S72351C: Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC All codes for femur fractures = 16 All codes for femur fractures =

5 Slide 13 Key Coding Changes 13 Slide 14 ICD-10 Structure Index Structure (Volume II) 14 Slide 15 ICD-10 Structure Tabular Structure Level 1 (Chapters) 1 Certain infectious and parasitic diseases 2 Neoplasms Diseases of the blood and blood-forming organs and certain disorders involving the immune 3 mechanism 4 Endocrine nutritional and metabolic diseases 5 Mental and behavioral disorders 6 Diseases of the nervous system 7 Diseases of the eye and adnexa 8 Diseases of the ear and mastoid process 9 Diseases of the circulatory system 10 Diseases of the respiratory system 11 Diseases of the digestive system 12 Diseases of the skin and subcutaneous tissue 13 Diseases of the musculoskeletal system and connective tissue 14 Diseases of the genitourinary system 15 Pregnancy childbirth and the puerperium 16 Certain conditions originating in the perinatal period 17 Congenital malformations deformations and chromosomal abnormalities 18 Symptoms signs and abnormal clinical and laboratory findings not elsewhere classified 19 Injury poisoning and certain other consequences of external causes 20 External causes of morbidity 21 Factors influencing health status and contact with health services 15

6 Slide 16 ICD-10 Structure Tabular Structure Level 2 (Blocks) 13.1 Infectious arthropathies 13.2 Inflammatory polyarthropathies 13.3 Osteoarthritis 13.4 Other joint disorders 13.5 Dentofacial anomalies [including malocclusion] and other disorders of jaw 13.6 Systemic connective tissue disorders 13.7 Deforming dorsopathies 13.8 Spondylopathies 13.9 Other dorsopathies Disorders of muscles Disorders of synovium and tendon Other soft tissue disorders Disorders of bone density and structure Other osteopathies Chondropathies Other disorders of the musculoskeletal system and connective tissue Intraoperative and postprocedural complications and disorders of musculoskeletal system not elsewhere classified Biomechanical lesions not elsewhere classified 16 Slide 17 ICD-10 Structure Tabular Structure Level 3 (1 st 3 Character Categories) M15 Polyosteoarthritis M16 Osteoarthritis of hip M17 Osteoarthritis of knee M18 Osteoarthritis of first carpometacarpal joint M19 Other and unspecified osteoarthritis 17 Slide 18 ICD-10 Structure Tabular Structure (Volume I) 18

7 Slide 19 Lots of Codes, Lots of Repetition 2466 codes for fractures of the femur 19 Slide 20 ICD-10 Structure Tabular Structure (Volume I) 20 Slide 21 ICD-10 Structure Tabular Structure (Volume I) 21

8 Slide 22 Coding ICD-10 CM Guidelines Initial Encounter The intent is to represent an encounter which is the first encounter for the clinician for a problem. The definition of active treatment is somewhat of a grey area. 22 Slide 23 Coding ICD-10 CM Guidelines Subsequent Encounter The intent is to represent an encounter for ongoing management and follow up of an initially treated condition. 23 Slide 24 Coding: The Prime Directive The goal of coding is to reflect as accurately as possible key parameters of the patient health condition and/or the procedures done to maintain or improve that condition. Coding focused on maximizing payment over accurate definition of the condition begins to cross the boundary of fraud and abuse. 24

9 Slide 25 Coding Challenge 25 Slide 26 Coding ICD-10-CM Challenges Getting There Example look up for Coronary Artery Disease + Angina 26 Slide 27 ICD-10 Structure Varying Distributions Across the Tabular Structure Distribution of codes related to Arthritis at the chapter level Chapter Description Count Chapter1 Certain infectious and parasitic diseases 12 Chapter3 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 1 Chapter4 Endocrine nutritional and metabolic diseases 13 Chapter6 Diseases of the nervous system 1 Chapter12 Diseases of the skin and subcutaneous tissue 5 Chapter13 Diseases of the musculoskeletal system and connective tissue 920 Chapter14 Diseases of the genitourinary system 4 Chapter17 Congenital malformations deformations and chromosomal abnormalities 1 Chapter19 Injury poisoning and certain other consequences of external causes 3 Chapter21 Factors influencing health status and contact with health services 2 *44% of codes are outside of Inflammatory Arthritis or Osteoarthritis categories 27

10 Slide 28 Coding ICD-10 CM Challenges Relevant Quote "If you don't find it in the index, look very carefully through the entire catalogue." -- Unknown 28 Slide 29 Clinical Documentation The Patient Interface Where It All Begins External Record Review History Physical Exam Internal Record Review Studies Assessment/Diagnosis 29 Slide 30 Documentation Why Is It Important? Supports proper payment and reduces denials Assures accurate measures of quality and efficiency Addresses the issue of accountability and transparency Creates a competitive advantage Provides better business intelligence Supports clinical research Supports interoperable sharing of data It s just good care! 30 30

11 Slide 31 GEM General Equivalency Mapping 31 Slide 32 The best match between an ICD-9 and ICD-10 code results in the loss of some concepts in translation or the assumption of some concepts that may or may not be true. ICD9 (82011): FRACTURE OF EPIPHYSIS (SEPARATION) (UPPER) OF NECK OF FEMUR OPEN Fracture Epiphyseal injury Proximal Femur Open Neck Code Matching Quality Assumed Concepts ICD10 (S72023H): Displaced fracture of epiphysis (separation) (upper) of unspecified femur, subsequent encounter for open fracture type I or II with delayed healing Fracture Epiphyseal injury Proximal Femur Open Neck Subsequent encounter Type 1 or 2 Delayed Healing Assumed Concepts 32 Slide 33 Code Matching Quality Lost and Assumed Concepts ICD9 (80084): OPEN FRACTURE OF VAULT OF SKULL WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH PROLONGED (MORE THAN 24 HOURS)LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL Fracture Open Vault-Skull Head and Neck Region Intracranial Hemorrhage Prolonged Loss of consciousness Return to conscious level Lost Concepts ICD10 (S020xxB): Fracture of vault of skull, initial encounter for open fracture Fracture Open Vault-Skull Head and Neck Region Initial encounter Assumed Concept 33

12 Slide 34 Matching can result in a significant distortion of the facts ICD-9 Procedure Code Finger Amputation ICD-10 Procedure ICD-10 Procedure Term Code 0X6N0Z0 0X6N0Z1 0X6N0Z2 0X6N0Z3 0X6P0Z0 0X6P0Z1 0X6P0Z2 0X6P0Z3 0X6Q0Z0 0X6Q0Z1 0X6Q0Z2 0X6Q0Z3 Code Matching Quality Problematic Match ICD-9 Procedure Term Detachment at Right Index Finger, Complete, Open Approach Detachment at Right Index Finger, High, Open Approach Detachment at Right Index Finger, Mid, Open Approach Detachment at Right Index Finger, Low, Open Approach Detachment at Left Index Finger, Complete, Open Approach Detachment at Left Index Finger, High, Open Approach Detachment at Left Index Finger, Mid, Open Approach Detachment at Left Index Finger, Low, Open Approach Detachment at Right Middle Finger, Complete, Open Approach Detachment at Right Middle Finger, High, Open Approach Detachment at Right Middle Finger, Mid, Open Approach Detachment at Right Middle Finger, Low, Open Approach 34 Slide 35 Code Aggregation Example Median Nerve Injury Native ICD-9 definition [3] Codes [1 code related specifically to Median nerve injury] [2 codes for review related to potential injury] GEM Bidirectional Map = [15]* Native ICD-10 definition [33] Codes [27 codes related specifically to median nerve injury] [6 codes related to potential injury (Carpal Tunnel/Median nerve lesion)] 35 Slide 36 Code Aggregation Example Fracture of the Radius Native ICD-9 definition [33] Codes [2 codes for Colles fracture] [2 codes for Torus fracture of the Radius] [1 codes for Pathologic fracture of the Radius] [6 codes for fracture of the Forearm] [22 codes for other fractures of the Radius] GEM Bidirectional Map = [336]* 36

13 Slide 37 Code Aggregation Example Fracture of the Radius Native ICD-10 definition [1818] Codes [48 codes for Colles fracture] [48 codes for Barton s fracture] [48 codes for Smith s fracture] [48 codes for Radial Styloid fracture] [48 codes for Galeazzi s fracture] [36 codes for Torus fracture of the Radius] [18 codes for Stress fracture of the Radius] [18 codes for Greenstick fracture of the Radius] [90 codes for Pathologic fracture of the Radius] [45 codes for Bent Bone fracture of the Radius] [216 codes for Growth Plate fracture of the Radius] [663 codes for other fractures of the Radius] 37 Slide 38 Implementation Getting your ducks in a row 38 Slide 39 Implementation Strategy Short term goals with a long term vision What solution do I need today? Will that solution extend to tomorrows needs? Awareness of touch points with other initiatives Overlap and conflicts Down stream impacts What works well for one business area, may not work well for another business area Positioning for competitive advantage Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator of the ICD- 10 transition? Can you manage the burden of illness of your population better than your competitors? 39

14 Slide Assessment Creating an inventory of impacted systems and processes Identifying risk 2. Analysis/Planning Prioritizing focus Phases of Transition Establishing business area specific approaches Creating specifications for mapping to support implementation 3. Implementation and Operations Translating codes from ICD-9 to ICD-10 and from ICD-10 to ICD-9 using crosswalks Changing analytic models to support both codes Operationalizing coding to ICD-10 from source information Changing processing logic to operate directly from ICD-10 codes 4. Leveraging ICD-10 capabilities Using the enhanced information within ICD-10 codes to improve processing and analysis based on improved concepts within the ICD-10 codes Slide 41 Scenario-Based Testing What Is It? The Scenario: The identification of some event or condition that we are familiar with today Recreating that event virtually through some verbal or data representation Defining a variety of assumptions and variables around this virtual representation Applying one or more of these scenarios in a Reference Implementation Model (RIM). Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and identifying the required changes to achieve those expected results. 41 Slide 42 Leveraging ICD-10 Other General Indicators of Severity and Risk Co-morbidities Manifestations Etiology/causation Complications Detailed anatomical location Sequelae Functional impairment Biologic and chemical agents Phase/stage Lymph node involvement Lateralization and localization Procedure or implant related 42 42

15 Slide 43 Leveraging ICD-10 A Changing World of Cost Containment Accurate and complete documentation and coding provides opportunities to support the transition into a value-based, accountable care reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support population risk management More accurate measures of quality and efficiency Slide 44 Summary Key Points ICD-10 will be a substantial change in the standard for defining the patient s health state and the institutional procedures performed to maintain or improve that health state. There are significant impacts and changes to both the clinical and business side of the practice. Coding accuracy and productivity will be substantially impacted during the transition and will impact both cost and revenue. There are significant new opportunities to leverage ICD-10 in a new payment environment (ACO) Slide 45 Summary Action Items Establish awareness across members of your organization Clearly define strategic goals Identify internal and external dependencies Identify and prioritize key risks Clearly define all business requirements and implementation tasks Create a realistic project plan and support it as a priority Test early and often Get started now!! 45 45

16 Slide 46 ICD-10 Resources 46 Slide 47 ICD-10 Website Provider Portal ICD-10 Resources Mapping (GEMs) GEMs Crosswalk documents GEMs 2014 General Equivalence Mappings (Technical Document (zip file) 47 Slide 48 ICD-10 Resources (cont d) Medicare Learning Network Articles MLN/MLNGenInfo/index.html?redirect=/mlngeninfo ICD-10 National Provider Calls Teleconferences.html National Coverage Determinations (NCDs) Medicare Learning Network Materials and associated CRs available free on CMS web site for selected NCDs 48

17 Slide 49 ICD-10 Resources (cont d) Medicare Reimbursement Mappings 2014 Reimbursement Mappings Diagnosis Codes and Guides ICD-10-CM-and-GEMs.html 2014 Reimbursement Mappings Procedure Codes and Guides Links to ordering the ICD-10 Pilot Version 31.0 Mainframe and PC version of the ICD-10 MS-DRGs and Medicare Code Editor (FY 2014 version) from NTIS have been placed on the CMS website under the Related Links section at MLN/MLNGenInfo/index.html?redirect=/mlngeninfo Medicare Claims Processing Guidance for ICD-10 Learning-Network- MLN/MLNMattersArticles/downloads/MM7492.pdf 49 Slide 50 ICD-10 Resources (cont d) Home Health Agency MLN/MLNMattersArticles/downloads/MM8458.pdf Medicare Testing Week MLN/MLNMattersArticles/Downloads/SE1409.pdf MLN/MLNMattersArticles/Downloads/MM8465.pdf Unspecified Codes 50 Slide 51 ICD-10 - A Look Inside Presented by: Janet Albanese, PT, MSPT, MHA 51

18 Slide 52 Objectives Take a practical look at ICD-10 as it relates to us in Physical Therapy How to look up a PT related diagnosis in the ICD-10 system A look into what we, as a PT practice, are doing to prepare for implementation Key impacts ICD-10 will have within your practice Slide 53 APTA Web Site: Slide 54 CMS link to Index and Tabs

19 Slide 55 CMS WinZip File Slide 56 Injury Sustained Right Knee Instability Clinical Example Slide 57 Step 1: Look up term in alphabetic index

20 Slide 58 Step 1: Look up term in alphabetic index Instability Slide 59 Step 1: Look up term in alphabetic index Slide 60 Step 2: Verify code in tabular list

21 Slide 61 Step 2: Verify code in tabular list Slide 62 Step 2: Verify code in tabular list Slide 63 Step 3: Is there a 7th Character?

22 Slide 64 Other instability, right knee M Category (first character always alpha, second character numeric) Category, anatomic site, severity Extension (initial encounter, subsequent encounter, sequela) Slide 65 Side Note If there was a 7 th Character Slide 66 ICD Other joint derangement, not elsewhere classified of lower leg Patient Example: ICD-9 vs ICD-10 ICD 10 M Other instability, right knee

23 Slide 67 Use Caution in Coding Instability search yields many options: Slide 68 Slide 69 How does your organization work?

24 Slide 70 Reality??? Slide 71 Slide 72 ICD-10: Key Practice Impacts Identify where diagnosis codes are used today: Documentation Electronic systems Submitting claims for payment Identifying patient eligibility Getting prior authorization from a payer/abns Reporting and Analysis

25 Slide 73 ICD-10: Documentation Documentation Specificity Severity Other Underlying/Complicating Conditions Support for Reported Quality Data Support for Medical Necessity Required for Coverage in Payer Policies Auditing for Compliance Slide 74 ICD-10: Areas to Consider Vendors: Communicate with all vendors to determine readiness EMR system Clearinghouse Payers: Be prepared for possible delays in cash flow and increased follow-up required Policies and Procedure: Updated to reflect changes ICD-9 to ICD-10 mapping: Review currently used codes and map them in ICD-10 Slide 75 ICD-10: Staff Training Staff Training: All staff that work with the current ICD-9 system must be trained on the ICD-10 Who? clinicians, coders & billers, front desk, others What? GEMs mapping, knowledge of system When? Now vs Later and ongoing. Test Competence: Develop further training needed and identify key champions that can assist in training

26 Slide 76 ICD-10: Know Your Resources APTA State Chapters Specific Sections CMS Clearinghouse Others Internally within your organization Slide 77 APTA Web Site Slide 78 Get in on NEXT! What s happening at NEXT Forward-thinking educational sessions Engaging opportunities to network with professional peers The prestigious Mary McMillan Lecture Registration is open!

27 Slide 79 QUESTIONS