Transitioning to ICD-10

Transcription

1 Transitioning to ICD-10 Sponsored by: Society of Otorhinolaryngology and Head-Neck Nurses Vancouver, Canada September 29, 2013 Presented by: Kim Pollock, RN, MBA, CPC

2 Here s How To Reach Us Be sure to visit our website for useful practice management ideas and course information! KZA Disclaimer This manual is not intended to provide legal advice to physicians and their staffs. If you have specific questions regarding the permissibility of your billing or other practices, we recommend that you consult legal counsel directly for assistance in evaluating any legal, regulatory or compliance issues regarding these matters. In the event that you choose to consult with outside legal counsel, KZA is available to work with such counsel, as appropriate, to meet your needs. CPT five digit codes, nomenclature and other data are copyright 2012 American Medical Association.. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Kim Pollock, RN, MBA, CPC Consultant and Speaker For almost twenty years, Kim Pollock has been nationally recognized as an otolaryngology coding expert including all subspecialties. Additionally, she has demonstrated expertise in improving collections, decreasing expense, minimizing risk and enhancing efficiencies in large group practices, as well as academic and solo practices. She knows how to apply reimbursement principles to ensure otolaryngologists are paid accurately. She has over thirty years of healthcare experience working for and with otolaryngologists. Ms. Pollock understands the complexity of coding and reimbursement issues specific to otolaryngologists both from a clinical perspective and from a payor side. She is a nationally recognized authority in coding and analyzing chart documentation. She presents seminars and workshops for physicians and their staff on behalf of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF), the American Association of Neurological Surgeons and the American Society of Plastic Surgeons. Ms. Pollock has also conducted programs for the American Academy of Professional Coders, the North American Spine Society, the American Neurotology Society and the Congress of Neurological Surgeons. Based on her previous years of administrative experience, Ms. Pollock has a unique understanding of the challenges facing academic medicine both clinically and organizationally. She has served as the Administrator of the Department of Otorhinolaryngology, where she was a member of the Association of Otolaryngology Administrators, as well as Associate Vice President of Cancer Programs at the University of Texas Southwestern Medical Center in Dallas. Ms. Pollock was the representative for the AAO-HNS on the clinical practice expert panel-technical group (CPEP- TEG) convened by CMS (formerly HCFA) to redetermine the practice expense portion of RBRVS. She served two terms on the Board of Directors for the Society of Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN) and has served on the Board for the Ear, Nose and Throat Nursing Foundation. Ms. Pollock is the recipient of the prestigious Presidential Citation Award from the SOHN as well as an Honor Award from the AAO-HNSF. 2

3 What s ICD-10? International Classification of Diseases, 10 th Revision, Clinical Modification We are currently using ICD-9-CM Codes are used to calculate MS-DRG payments Compile statistics Already being used in 138 countries for mortality reporting, 99 countries for morbidity. US implemented for mortality on 1/1/99. Other countries use ICD-10 for reimbursement or case mix: UK, Denmark, Finland, Iceland, Norway, Sweden, France, Australia, Belgium, Germany, Canada Why Are We Changing? ICD-9 is out of date and running out of space for new codes ICD-10 is the international standard to report and monitor disease and mortality USA must adopt for reporting and surveillance ICD codes are core elements of many health information technology systems making the conversion to ICD-10-CM necessary to fully realize benefits of HIT adoption FIRM ICD-10 DEADLINE OCT 1,

4 Dirty Dozen ICD-10 Action Agenda 1. Run an ICD-9 frequency report from your practice management system for each doctor or provider for the last 12 months. Focus on the top 25 diagnosis codes. Diagnosis Code Top Most Used Frequency Codes Description Number of Charges Impacted cerumen Chronic rhinitis Chronic tubotympanic suppurative otitis media, Benign chronic suppurative otitis media (with anterior perforation of ear drum), 253 Chronic tubotympanic disease (with anterior perforation of ear drum) Hypertrophy of nasal turbinates Chronic laryngitis Dizziness and giddiness, Lightheadedness, Vertigo Epistaxis Sensorineural hearing loss, unspecified Chronic tonsillitis Deviated nasal septum 124 See if you can run this valuable data! Diagnosis Diagnosis Description Charges Total Insurance Payments Patient Payments Total Payments Charge Flag OSTEOARTHRITIS KNEE DJD 465, , , , , TENDINITIS/BURSITIS 94, , , , SHOULDER PAIN KNEE /PATELLOFEMORAL SYNDROME 53, , , , TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE, CURR 144, , , , LUMBAR SPRAIN AND STRAIN 45, , , , BURSITISITEND- 31, , , , HIP,TROCHANTERIC,LEG LOCALIZED OSTEOARTHROSIS 91, , , , NOT SPECIFIED WHETHER PRI SPRAIN AND STRAIN OF 23, , , , CALCANEOFIBULAR (LIGAMENT) UNSPECIFIED SITE OF ANKLE 15, , , , SPRAIN AND STRAIN SPRAIN/TEAR RUPTURE- WRIST.LIG.,AVN,MUSCLE 15, , , ,

5 Dirty Dozen ICD-10 Action Agenda Compare ICD-9 to ICD-10: Dr. A Top Codes ICD-9 ICD-9 Description ICD-10 ICD-10 Description Impacted cerumen H61.2Ø Impacted cerumen, unspecified ear H61.21 Impacted cerumen, right ear H62.22 Impacted cerumen, left ear Dizziness and giddiness, Lightheadedness, Vertigo H62.23 Impacted cerumen, bilateral R42 Compare ICD-9 to ICD-10: Dr. B Top Codes Dizziness and giddiness, Lightheadedness, Vertigo ICD-9 ICD-9 Description ICD-10 ICD-10 Description V50.1 Elective surgery plastic surgery Z411 Encounter for cosmetic surgery unacceptable cosmetic appearance Benign neoplasm skin face other D22.3Ø Melanocytic nevi of unspecified part of the face unspecified part D22.39 Melanocytic nevi of other parts of the face D23.3Ø Other benign neoplasm of skin of unspecified part of face D23.39 Other benign neoplasm of skin of other parts of face Open wound cheek, without mention of complication SØ1.4Ø1A Unspecified open wound of right cheek and temporomandibular area, initial encounter SØ1.4Ø2A Unspecified open wound of left cheek and temporomandibular area, initial encounter SØ1.4Ø9A Unspecified open wound of unspecified cheek and temporomandibular area, initial encounter *The appropriate 7th character SØ1.411A Laceration without foreign body of right cheek needs to be added to each code: and temporomandibular area, initial encounter SØ1.412A Laceration without foreign body of left cheek A = Initial encounter and temporomandibular area, initial encounter D = Subsequent encounter SØ1.419A Laceration without foreign body of unspecified S = Sequela cheek and temporomandibular area, initial encounter SØ1.431A Puncture wound without foreign body of right cheek and temporomandibular area, initial encounter SØ1.432A Puncture wound without foreign body of left cheek and temporomandibular area, initial encounter SØ1.439A Puncture wound without foreign body of unspecified cheek and temporomandibular area, initial encounter SØ1.451A Open bite of right cheek and temporomandibular area, initial encounter SØ1.452A Open bite of left cheek and temporomandibular area, initial encounter SØ1.459A Open bite of unspecified cheek and temporomandibular area, initial encounter 5

6 Dirty Dozen ICD-10 Action Agenda 2. Now, pull operative reports for the top FIVE procedures you do. See if using your present level of documentation staff can find an ICD-10 code. If they can t have them write a memo of what s missing for you. Budget two weeks for the five procedures. This is a retrospective gap analysis. It is based on YOUR practice reality. No one else s. Discuss at a partner s meeting or one-on-one sessions with each physician. Pay special attention to laterality, late effects and sequelae. Improve your dictation or documentation templates accordingly. Who will lead this effort? Now do the next five conditions and corresponding reports. You should be done with your top 25 by the end of Q1 or early Q2. 3. Armed with good technology, well educated staff should begin by the end of the first quarter coding at least 50% of your cases in both diagnosis coding systems. Practice makes perfect. Anatomy + Terminology + Physiology Training Helps in Accurate Coding! 4. Check what your software vendor has to offer in terms of resources and support. Check what the clearinghouse offers. 6

7 Dirty Dozen ICD-10 Action Agenda 5. Estimate what the transition is going to cost your practice. 6. Investigate revised, changed medical necessity guidelines for top five diagnoses for three payors ICD-10 Coding (Effective October 1, 2014) In preparation for the implementation of ICD-10 CM and ICD-10 PCS, we are updating medical policies and clinical UM guidelines on a quarterly basis to include proposed ICD-10 coding. The ICD-10 coding is available through either a hyperlinked Appendix or a listing of applicable ICD-10 codes within the Coding section. Please note that at this time, the ICD-10 code list may not be all inclusive and is subject to change as Position Statements may be updated. Feel free to send comments regarding the ICD-10 coding using the Contact Us link below. 7

8 Dirty Dozen ICD-10 Action Agenda Source: MLN/MLNMattersArticles/Downloads/MM8348.pdf 8. At the first available opportunity (6 to 9 months out) run some tests with your software and clearinghouse and biggest payers to see if it is all working correctly enough to generate payments. Whose job? 8

9 Dirty Dozen ICD-10 Action Agenda 9. Take advantage of resources for ICD-10. AAOHNS: KZA: Take advantage of webinars that are planned Sharpen practice collection skills. All sources are predicting cash flow slowdowns. If you are collecting at 87% functionality, that s not good enough and work now to improve. This is serious! 11. Delay bonuses! Reserve money, just in case. 12. Obtain a LOC. Shoot for 1 st quarter. ALERT Plan your schedule! To extent possible, schedule as much surgery and as many patients as possible in September as possible (unfortunately a historically low period for otolaryngologists!). Get those claims in ASAP so your cash flow is high. 9

10 New! 10

11 NUCC recommends April 1 implementation of new 1500 claim form The National Uniform Claim Committee (NUCC) approved a transition timeline for the version 02/ Health Insurance Claim Form (1500 claim form). The updated form accommodates ICD-10 reporting and aligns with additional requirements identified by the industry. MGMA serves on the NUCC. Changes incorporated into the new 1500 claim form include: An indicator in Item Number 21 to identify the version of the diagnosis code set being reported (i.e., ICD-9 or ICD-10). This indicator will be important during the implementation period for ICD-10. Expansion of the number of diagnosis codes that can be reported in Item Number 21, which was increased from 4 to 12. The ability to identify the role of the provider reported in Item Number 17 and the specific dates reported in Item Number 14. The NUCC approved the following 2014 transition timeline: Jan. 6: Payers begin receiving and processing paper claims submitted on the revised 1500 claim form (version 02/12). Jan. 6 through March 31: Dual use period during which payers continue to receive and process paper claims submitted on the old 1500 claim form (version 08/05). April 1: Payers receive and process paper claims submitted only on the revised 1500 claim form (version 02/12). Although the NUCC timeline is not binding on commercial health plans, it does align with Medicare's announced transition timeline. Medicare has indicated it will reject claims submitted on the old claim form after April 1. 11

12 ICD-9 vs. ICD-10 ICD-9- CM ICD-10- CM 3-5 characters in length 3-7 characters in length 1st digit may be alpha, but is usually numeric; 2nd-5th is numeric Character 1 is alpha; character s 2 & 3 are numeric; characters 4-6 can be either alpha or numeric Approximately 14,000 codes Approximately 69,000 codes Limited space for adding new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality Has laterality Difficult to analyze data due to nonspecific codes Specificity improves coding accuracy and richness of data for analysis Codes are non-specific and do not adequately define diagnosis needed for medical reesearch Does not support interoperatbility because it's not used by other countries Detail improves the accuracy of data used for medical research Supports interoperability and the exchange of health data between other countries & the U.S. 12

13 ICD-9 vs. ICD-10 13

14 ICD-10 CM Examples Ear Examples ICD-9-CM Other acute otitis externa 1:28 ratio! ICD-10-CM H6Ø.5Ø1 Unspecified acute noninfective otitis externa, right ear H6Ø.5Ø2 Unspecified acute noninfective otitis externa, left ear H6Ø.5Ø3 Unspecified acute noninfective otitis externa, bilateral H6Ø.5Ø9 Unspecified acute noninfective otitis externa, unspecified ear H6Ø.511 Acute actinic otitis externa, right ear H6Ø.512 Acute actinic otitis externa, left ear H6Ø.513 Acute actinic otitis externa, bilateral H6Ø.519 Acute actinic otitis externa, unspecified ear H6Ø.521 Acute chemical otitis externa, right ear H6Ø.522 Acute chemical otitis externa, left ear H6Ø.523 Acute chemical otitis externa, bilateral H6Ø.529 Acute chemical otitis externa, unspecified ear H6Ø.531 Acute contact otitis externa, right ear H6Ø.532 Acute contact otitis externa, left ear H6Ø.533 Acute contact otitis externa, bilateral H6Ø.539 Acute contact otitis externa, unspecified ear H6Ø.541 Acute eczematoid otitis externa, right ear H6Ø.542 Acute eczematoid otitis externa, left ear H6Ø.543 Acute eczematoid otitis externa, bilateral H6Ø.549 Acute eczematoid otitis externa, unspecified ear H6Ø.551 Acute reactive otitis externa, right ear H6Ø.552 Acute reactive otitis externa, left ear H6Ø.553 Acute reactive otitis externa, bilateral H6Ø.559 Acute reactive otitis externa, unspecified ear H6Ø.591 Other noninfective acute otitis externa, right ear H6Ø.592 Other noninfective acute otitis externa, left ear H6Ø.593 Other noninfective acute otitis externa, bilateral H6Ø.599 Other noninfective acute otitis externa, unspecified ear 14

15 ICD-10 CM Examples Ear Examples (continued) ICD-9-CM Acute swimmers ear 1:4 ratio! ICD-10-CM H6Ø.331 Swimmer's ear, right ear H6Ø.332 Swimmer's ear, left ear H6Ø.333 Swimmer's ear, bilateral H6Ø.339 Swimmer's ear, unspecified ear ICD-10-CM* H65.ØØ Acute serous otitis media, unspecified ear H65.Ø1 Acute serous otitis media, right ear H65.Ø2 Acute serous otitis media, left ear H65.Ø3 Acute serous otitis media, bilateral H65.Ø4 Acute serous otitis media, recurrent, right ear H65.Ø5 Acute serous otitis media, recurrent, left ear H65.Ø6 Acute serous otitis media, recurrent, bilateral H65.Ø7 Acute serous otitis media, recurrent, unspecified ear *For H65- and H66- codes: -Use additional code for any associated perforated tympanic membrane (H72-) -Use additional code to identify: exposure to environmental tobacco smoke (Z77.22) exposure to tobacco smoke in the perinatal period (P96.81) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17-) tobacco use (Z72.Ø) Nose ICD-9-CM ICD-10-CM Nasal airway obstruction J34.89 Nasal airway obstruction Chronic maxillary sinusitis J32.Ø Chronic maxillary sinusitis Chronic frontal sinusitis J32.1 Chronic frontal sinusitis Chronic ethmoidal sinusitis J32.2 Chronic ethmoidal sinusitis Chronic sphenoidal sinusitis J32.3 Chronic sphenoidal sinusitis Other chronic sinusitis (pansinusitis, chronic) J32.4 Chronic pansinusitis J32.8 Other chronic sinusitis sinusitis (chronic) involving more than one sinus but not pansinusitis 15

16 ICD-10 CM Examples ICD-9-CM ICD-10-CM 470 Deviated nasal septum J34.2 Deviated nasal septum Throat ICD-9-CM ICD-10-CM Dysphonia, Hoarseness R49.Ø Dysphonia, Hoarseness Dysphagia, unspecified R13.1Ø Dysphagia, unspecified Fractures ICD-10-CM SØ2.2xx- Fracture of nasal bones A initial encounter for closed fracture B initial encounter for open fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion S sequela Open vs. Closed Displaced vs. Nondisplaced Location of fracture on the bone (e.g., mandible condylar process, subcondylar process, coronoid process, ramus, angle, symphysis, alveolus) Episode of care (initial, subsequent, sequela). Dorland s Dictionary defines sequela as any lesion or affection following or caused by an attack of disease. 16

17 More on Fracture/Injuries Chapter 19 Chapter 20 Injury, Poisoning and Certain Other External Causes of Morbidity Consequences of External Cause SØØ-T88 Injuries, fractures, burns and corrosions, adverse effects, poisoning, underdosing and toxic effects Example: SØ2.2xxA Fracture of nasal bones, initial encounter for close fracture VØ1-Y98 Required: Example: 7 th character required: A D S Required: Vxx.xxxx (How it happened) VØØ.211A Fall from ice-skates Initial encounter Subsequent encounter Sequela Y92.xxx (Place it happened) Place of occurrence of the external cause Example: Y Ice skating rink (indoor) (outdoor) Fractures of skull and facial bones Required: Y93.xx 7 th character required: (Activity performed) Activity codes A Initial encounter for closed fracture B D G K S Initial encounter for open fracture Subsequent encounter for fracture with routine healing Subsequent encounter for fracture with delayed healing Subsequent encounter for fracture with nonunion Sequela Example: Y93.21 Activity, ice skating Required: External cause status Y99.x (Who patient is) External cause status Y99.Ø Civilian activity done for income or pay Y99.1 Military activity Y99.2 Volunteer activity Y99.8 Other external cause status Y99.9 Unspecified external cause status 17

18 Clarification on the Use of External Cause and Unspecified Codes in ICD-10-CM Approved by the four Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, which includes American Health Information Management Association, American Hospital Association, Centers for Medicare & Medicaid Services, and National Center for Health Statistics External Cause Codes Just as with ICD-9-CM, there is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not required. If a provider has not been reporting ICD-9-CM external cause codes, the provider will not be required to report ICD-10-CM codes in Chapter 20, unless a new state or payer-based requirement regarding the reporting of these codes is instituted. Such a requirement would be independent of ICD-10-CM implementation. In the absence of a mandatory reporting requirement, providers are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies. Sign/Symptom/Unspecified Codes In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. Source: Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, May

19 Notes 19

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