Scott + White Healthcare System. International Classification of Diseases 10 th Edition Clinical Modification

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1 Presented by: Christi Gonzales, CCS Data Quality Coding Manager AHIMA ICD-10-CM/PCS Trainer 1 ICD-10 CM International Classification of Diseases 10 th Edition Clinical Modification ICD-10 PCS International Classification of Diseases 10 th Edition Procedure Coding System 2 1

2 ICD-9 was implemented in 1979 and is outdated and inconsistent with current medical practice. ICD-9 is not able to expand enumeration due to physical numbering constraints. ICD-9 has vague and imprecise codes. 3 Effective with encounters and discharge dates on or after October 1, Every application and database in which diagnosis or procedure codes are captured, stored, analyzed, or reported will use the new classification system. Number of Codes ICD-9 ICD-10 Diagnoses 14,025 68,069 Procedures 3,824 86,

3 More accurate payment for inpatient procedures Improved coding compliance Clearer understanding of outcomes including risk and severity adjustments Enhanced disease management Improved documentation Greater flexibility for expansion of new codes 5 Completeness: with substantially unique codes Expandability: allows for easy incorporation of new procedures and diagnoses Standardized methodology: unique definitions for the terms used 6 3

4 7 Codes are the language of healthcare and will impact virtually all areas of healthcare. 8 4

5 Where are we currently using ICD-9 codes? 3M All rights reserved. ICD-10-CM: Diagnosis coding Used for inpatient and outpatient ICD-10-PCS: Procedure coding Used for inpatient only CPT codes will continue to be used for outpatient procedure coding 10 5

6 On September 30, 2014: I m calling to preauthorize the admission of Mr. Smith who has been diagnosed with Crohn s disease, diagnosis code 555.0, Regional enteritis of the small intestine. On October 1, 2014: I m calling to pre-authorize the admission of Mr. Smith who has been diagnosed with Crohn s disease of the small intestine with abscess, diagnosis code K The principal changes in ICD-10 CM are in the: organization and structure code composition level of detail and specificity 12 6

7 Minimum number of digits/characters Maximum number of digits/characters Feature ICD-9-CM ICD-10 CM Number of chapters Supplemental classification V codes and E codes X,Y, and Z codes Laterality No Yes Alphanumeric versus numeric Numeric, except for V codes and E codes Alphanumeric Dummy placeholders No Yes X 13 Fracture of second cervical vertebra, anterior displaced Type II, initial encounter S12.110A Category: S12 (fracture second cervical vertebra) Etiology: 110 (anterior displaced Type II) Extension: A (initial encounter) S A 14 7

8 Acute gastritis with hemorrhage K29.01 Category: Etiology: Extension: K29 (acute gastritis) 01 (with hemorrhage) None K Codes must be used to the highest number of characters available. Filler X is used for each spot in between the 1st character to the 7 th character if required to complete the code. T56.0x2S, toxic effect of lead, intentional self-harm, sequelae S17.0xxA, laceration with foreign body of scalp, initial encounter 16 8

9 ICD-10 CM is very specific with the main classifications of disease processes. Examples of variations of specificity. Otitis media = 97 codes Fever = 288 codes 17 I II III IIIA IIIB IIIC low energy, wound less than 1 cm wound greater than 1 cm with moderate soft tissue damage high energy wound greater than 1 cm with extensive soft tissue damage adequate soft tissue cover inadequate soft tissue cover associated with arterial injury 18 9

10 Specificity looks like this ICD-9-CM Fracture of femur, shaft, closed S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing ICD-10-CM S72322A Displaced transverse fracture S72326A Nondisplaced transverse of shaft of left femur, initial encounter for fracture of shaft of unspecified femur, closed fracture initial encounter for closed fracture S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing Many possible codes And this.. W56.21 Bitten by an orca W15.xxD Fall from cliff, subsequent encounter W59.22xA Struck by a turtle T17.1xxS Foreign body in the nose 20 10

11 ICD-9 Late effects Senile Urosepsis Diabetes uncontrolled Bilateral MI acute for 8 weeks Accelerated or malignant HTN AIDS & HIV Weeks for abortion in Texas is 20 weeks ICD-10 Sequelae Age related No default to UTI Diabetes with hyperglycemia Laterality MI acute for 4 weeks HTN AIDS Standardized weeks for abortion for all States is 20 weeks 21 Combination codes for conditions and common symptoms or manifestations. E10.21, Type 1 DM with diabetic nephropathy I25.110, CAD of native coronary artery with unstable angina pectoris K50.112, Crohn s disease of large intestine with intestinal obstruction 22 11

12 Laterality H60.332,swimmer s ear, left ear C50.912, left breast cancer Extensions - Added 7 th characters for episode of care. M80.051A, age related osteoporosis with current pathological fracture, right femur, initial encounter for fracture 23 Let s roll into PCS

13 ICD-9-CM Procedure Codes ICD-10 PCS Procedure Codes 3 4 numbers in length 7 alphanumeric characters in length Based upon outdated technology Lacks laterality Approximately 3,824 Lacks detail Lacks description of methodology and approach Lacks precision to adequately define procedures Limited space for adding new codes Generic terms for body parts Reflects current usage of medical terminology Has laterality (right and left) Approximately 86,000 codes Very specific Provides detailed descriptions of methodology and approach Precisely defines procedures and includes detail on body part, approach, and devices used Flexible for adding new codes Detailed descriptions for body parts 25 All ICD-10 PCS codes have an alphanumeric structure with no decimal points and seven characters. The letters O and I are not used in PCS so as not to be confused with the numbers 0 and 1. There is a unique code for each procedure. Structure allows for easy expansion

14 There are 16 sections of PCS. The largest section is the Medical and Surgical section. There is a separate section for Obstetrics and Abortions. Each of the seven characters is an axis of classification that represents an aspect of the procedure. 27 Each procedure code consists of: Character 1 - Section Character 2 - Body system Character 3 - Root operation Character 4 - Body part Character 5 - Approach Character 6 - Device Character 7 - Qualifier Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation Body Part Approach Device Qualifier 28 14

15 0FT34ZZ Total laparoscopic cholecystectomy Section Body System Operation 0 Medical and Surgical F Hepatobiliary System and Pancreas T Resection Body Part Approach Device Qualifier 0 Liver 1 Liver, right lobe 2 Liver, left lobe 3 Gallbladder 4 Pancreas 0 Open 4 Percutaneous Endoscopic Z No Device Z No Qualifier 29 Central nervous system Peripheral nervous system Heart and great vessels Upper arteries Lower veins Ear, nose, sinus Muscles Respiratory system Skin and breast Subcutaneous tissue and fascia Lower bones Male reproductive system Head and facial bones 30 15

16 Character 1: Section Defines the general type of procedure. There are 16 sections in PCS with the number 0 representing the Medical and Surgical Section which is the largest section. Others Include: Obstetrics Placement Administration Measurement Osteopathic Extracorporeal Assistance Chiropractic Imaging Extracorporeal Therapies Nuclear Med Rehabilitation Radiation Oncology Mental Health Substance Abuse 31 Character 2: Body System This character indicates the general physiological system on which the procedure is performed or anatomical region involved. PCS uses 31 body systems. The diaphragm is used as the frame of reference for body system classifications for the upper and lower anatomical regions

17 Character 3: Root Operation Refers to the objective of the procedure. Mastering the definitions of the root operations is the key to building a code in PCS. The physician is not expected to use the exact terms used in PCS code descriptions. Instead, it is the coder s responsibility to determine what the documentation in the medical record equates to the PCS definition. 33 Root Operation Excision Resection Detachment Destruction Extraction Drainage Extirpation Fragmentation Breast lumpectomy Liver biopsy Total mastectomy Total resection of the cecum Examples Above the knee amputation Traumatic amputation of the ear Ablation of endometriosis Cautery of nosebleed C-section Liposuction Thoracentesis Incision and drainage of perianal abscess Thrombectomy Removal of foreign body from the nose Lithotripsy Thoracotomy with crushing of pericardial calcifications 34 17

18 Root Operation Division Release Transplantation Reattachment Transfer Reposition Restriction Occlusion Spinal cordotomy Episiotomy Examples Arthroscopy with ligament release Adhesiolysis Heart transplant Lung transplant Reattachment of severed finger Replantation of avulsed scalp Scalp advancement to temple region Nerve transfer ORIF Reposition of undescended testicle Cervical cerclage Clipping of a cerebral aneurysm Embolization of uterine artery using coils Tubal ligation 35 Root Operation Dilation Bypass Insertion Replacement Supplement Change Removal Revision PTCA Dilation of common bile duct CABG Formation of a colostomy Insertion of PICC Cochlear implant Total hip replacement Aortic valve replacement Examples Hernia repair with mesh Exchange of a liner in femoral component of previous hip replacement Exchange of tracheostomy tube G-tube change Removal of external fixation device Cystoscopy with retrieval of ureteral stent Revision of knee replacement Adjustment of a pacemaker lead 36 18

19 Inspection Map Control Repair Fusion Alteration Creation Root Operation Diagnostic cystoscopy Digital rectal exam Examples Heart catheterization with cardiac mapping Brain mapping via craniotomy Control of post tonsillectomy hemorrhage Ligation of postop arterial bleeder Hernia repair without mesh Closure of chest wall stab wound Spinal fusion Ankle arthrodesis Face lift Cosmetic rhinoplasty Creation of a penis in a female patient Creation of a vagina in a male patient 37 Examples: Open Percutaneous Percutaneous endoscopic Via artificial or natural opening Via artificial or natural opening endoscopic External 38 19

20 Character 7: Qualifier A qualifier has a unique meaning within individual procedures and is used to provide additional information. Examples: Diagnostic biopsy Donor organ from a cadaver Heart bypass 39 0H0V0JZ - Bilateral breast augmentation with silicone implants, open approach 0 Medical and Surgical H Skin and Breast 0 Alteration Body Part Approach Device Qualifier T Breast, right U Breast, left V Breast, bilateral 0 Open 3 Percutaneous X External 7 Autologous tissue J Synthetic substitute K Nonautologous tissue Z No device Z No qualifier 40 20

21 0PSC0ZZ Open fracture reduction, displaced fracture of right humeral head 0 Medical and Surgical P Upper Bones S Reposition Body Part Approach Device Qualifier C Humeral head, right D Humeral head, left F Humeral shaft, right G Humeral shaft, left H Radius, left J Radius, right 0 Open 3 Percutaneous 4 Percutaneous endoscopic 4 Internal fixation device 5 External fixation device 6 Intramedullary B Monoplanar C Ring D Hybrid Z No device Z No qualifier 41 ICD , pressure ulcer of hip 785.4, gangrene , pressure ulcer, stage 3 MS DRG 592, Skin ulcer with MCC CMI Reimbursement $9,007 ICD-10 I96, gangrene L89.203, pressure ulcer, hip, stage 3 MS DRG 299, Peripheral vascular disease with MCC CMI Reimbursement $8,

22 ICD , pressure ulcer of hip 785.4, gangrene , pressure ulcer, stage 3 Procedure 86.22, Excisional debridement MS DRG 570, Skin debridement with MCC CMI Reimbursement $15,198 ICD-10 I96, gangrene L89.203, pressure ulcer, hip, stage 3 Procedure 0JBC0ZZ, Excision subcutaneous tissue, open approach MS DRG 264, Other circulatory system OR Procedures CMI Reimbursement $16, ICD-9 V57.89, Care involving rehabilitation V54.13, Aftercare for healing traumatic hip fracture MS DRG 946, Rehabilitation without CC/MCC CMI Reimbursement $7,713 ICD-10 S72.041D, Displaced fracture neck of femur, right, subsequent episode of care MS DRG 536, Fracture of hip and pelvis without MCC CMI Reimbursement $4,

23 ICD-9 V45.71, Acquired absence of breast V10.31, History of breast cancer 85.43, Unilateral simple mastectomy (general surgeon) 85.73, TRAM (plastic surgeon) MS DRG 583, Mastectomy for malignancy without CC/MCC CMI Reimbursement $5,535 ICD-10 Z90.11, Acquired absence of breast Z85.3, History of breast cancer 0HRT076, TRAM, open approach (plastic surgeon) MS DRG 583, Mastectomy for malignancy without CC/MCC CMI Reimbursement $5, HACs POAs Medical Necessity 46 23

24 Preparation and Strategy 47 Training Staff will need differing levels of education on ICD-10 to determine transition approach and opportunities related to more detailed information Clinicians will need training to know that: ICD-10 requires more detailed documentation ICD-10 also impacts their office billing, pre-certification, and medical necessity Resources The change to ICD-10 adds to employees responsibilities, so additional FTEs, consulting help, outsourcing, etc. may be needed Budgeting Planning for the potential costs of new hardware, software, adding new employees, consulting, training, etc

25 Payer contracts Many payer contracts have ICD-9 codes in them and will need to be changed and renegotiated Adapt to new reimbursement policies Documentation is critical to maintain same MS-DRG assignment, CMI, and payment Potential slow down in dropping claims Testing and training can reduce HIM slow-down during learning curve, software issues, payers not being ready, etc. If we do this right, little impact on cash flow! 49 Record Type ICD-9 Minutes ICD-10 Minutes Acute Care Day Surgery LTAC Rehabilitation Observation

26 Documentation improvement Continue documentation improvement now for ICD-9 and phase in ICD-10 programs More specific codes require accurate, detailed documentation Collaboration with medical staff will be crucial Coder/Coach training Coders/coaches will rely on detailed training Training rolled out in January 2013 for diagnoses and procedures 51 Paper Cut W45.1xxA Sleep Deprivation Z Slipped on Banana W01.0xxA Seasickness T75.1 Bitten by Horse W55.11xA Sunburn L

27 Any Questions? 53 27