Our Goals 10/2/2013. ICD-10 Transition: Five Phases. Hot Topics in Billing and Coding: Transitioning to ICD-10

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1 Hot Topics in Billing and Coding: Transitioning to ICD-10 HCCA HAWAII 2013 REGIONAL CONFERENCE Jeri Leong, RN, CPC, CPC-H, CPC-I, CPMA Healthcare Coding Consultants of Hawaii LLC 1 Our Goals Introduce ICD-10 Engage your organization for the ICD-10 transition Identify potential compliance risks Discuss tools that may assist with your transition 2 ICD-10 Transition: Five Phases 1. Engage and Educate Physicians and Staff 2. Assess Current Readiness and Impact 3. Create a Timeline and Transition Plan 4. Implement a Transition Plan 5. Conduct Post Transition Analysis and Reporting Most Physician Practices are in Phase 1 3 1

2 ICD-9 and ICD-10: Background Evolved from earlier versions of ICD ICD-9 code set published for billing purposes in 1990 U.S. last industrialized nation to implement ICD-10 ICD-9-CM is outdated: Over 30 years old Many categories are at capacity No longer descriptive enough Two parts: ICD-10-CM and ICD-10-PCS ICD-10-CM 69,000 codes, ICD-9-CM 14,000 codes Implementation date of October 1, ICD 10: Getting Started Learn the important differences between ICD-10 and ICD 9 codes Discover how to use an ICD-10 mapping system to achieve what s needed for documentation and selection of codes Determine what documentation changes need to occur to comply with increased code specificity Embrace the benefits and opportunities of ICD-10-CM 5 ICD-9-CM and ICD-10-CM ICD-9-CM ICD numeric digits in length 3-7 Alpha-Numeric characters in length First digit may be alpha (E or V) or numeric; Digits 2-5 are numeric Lacks detail Lacks laterality Character one is alpha; charactertwo is numeric; characters 3-7 are alpha or numeric Very specific Has laterality Approximately 14,000 codes Approximately 69,000 available codes 6 2

3 ICD-10-CM vs. ICD-9 Code Structure ICD-10-CM Code Format ICD-9-CM Code Format Ex: Epilepsy, unspecified, intractable, without status epilepticus ICD ICD-10 G ICD-10 Format Codes are alpha numeric All letters of the alphabet except U V codes are now Z codes E codes are now V,W,X,Y codes Second through seventh characters are a combination of letters and numbers O is not an Clinician Coding Workflow Code Volume 14,000 to 69,000 Some code descriptions are completely different ICD-9 -Congenital bowleg deformity ICD-10 Congenital bowing of long bones of leg ICD-9 - Posttraumatic stress disorder ICD-10 - Post-traumatic stress disorder Description length increases an average of 25 to 45 characters 9 3

4 7 th Character Extenders Certain ICD-10 codes have applicable seven characters Seventh character is required for these codes and must always be in the 7 th position If a code does not have six characters, a placeholder must be used to fill the character space 10 7 th Character Extenders M80.08xAAge related osteoporosis with current pathological fracture, vertebra(e), initial encounter S61.421D Laceration with foreign body of right hand, subsequent encounter T21.31xS Burn of third degree of chest, sequela 11 Trimesters Episode of care (delivered, antepartum, postpartum) is no longer applicable Most codes have a final character identifying the trimester of pregnancy in which the condition occurred Some conditions or complications occur during certain trimesters, thus not all conditions include codes for all three trimesters Weeks of gestation code also appended 12 4

5 OB/ Weeks of Gestation Example: O Abscess of breast associated with pregnancy, 2 nd trimester Z3A weeks of gestation pregnancy 13 Health Maintenance Z23 is for an encounter for inoculations and vaccinations Z codes also describe encounters for routine examinations Some codes distinguish exams with and without abnormal findings Other Z codes describe special exams such as WWE, pre-op, etc. 14 Laterality ICD-10 includes codes for laterality Codes for left side, right side and bilateral are available in some chapters H Swimmer s ear, left ear H65.06Acute serous otitis media, recurrent, bilateral S63.511ASprain of carpal joint of rightwrist, initial encounter 15 5

6 Unspecified Codes Similar to ICD-9, ICD-10 does contain unspecified codes Coding guidelines advise use of unspecified in circumstances where the medical record does not contain sufficient information required to assign a more specific code 16 Unspecified = Claim Delay? Physicians may be ICD-10 compliant, but if they abuse the other or unspecified codes, payment will not occur if a more specific alternative exists. David Winkler Michigan Blue Cross Director of Technical Program Management Justifying the medical necessity of your services and procedures depends on the accuracy and specificity of diagnostic coding! 17 Documentation: The KEYto Success HCCH recommends chart reviews to determine if current documentation is sufficient for assigning ICD-10 codes Identify your top 20 billed ICD-9 codes Compare your current documentation with the increased specificity of ICD-10 Is there sufficient documentation for the assignment of an equivalent ICD-10 code (manual or electronic)? 18 6

7 Tools for Success: GEMs Translation GEMs=General Equivalence Mapping: Amapping tool that attempts to include all valid relationships between the codes in ICD-9-CM and ICD-10-CM An excellent training tool to be used to familiarize differences between ICD 9 and ICD-10 and may also be used to select the correct ICD-10 code. The mapping identifies one-to-one and one-to-many code relationships 19 ICD-10 GEMs Transition Software You ll want to search by code and description It should be bi-directional: ICD-9 to ICD-10 and vice versa Look for the ability to perform code searches and store frequently used codes ( Favorites or Cheat Sheet ) Make sure you have a print function so you can create training tools Can be a stand alone or integrated product

8 How Will You Use acrosswalk? Quick lookup for commonly used codes Performance Measure reporting Administrative purposes: Evaluating insurance contracts, pre-authorizations, surgery scheduling; updating referral slips Clinical documentation improvement Transitioning to ICD-10: Next Steps 24 8

9 ICD-10 Transition: Impact Assessment The impact assessment should evaluate: Physician office process and workflow Referrals and pre-authorizations Payers and business partners Budget and productivity Billing software and EHR readiness Claims running dual systems until?? 25 ICD-10: Billing Staff- Productivity Up to 40 % increase in keystrokes -full keyboard Code lookups books and EHR may have completely different wording for some codes GEMS should not be your sole resource may pose a compliance risk if documentation does not support assigned codes An unspecified ICD-9 code will crosswalk to unspecified ICD-10;documentation must support the use of a more specified code ICD-10 Transition: Training Work with your organization to: Identify those who code, or have a need to know the codes Develop staff training -not all staff require the same level of training(role based training) Professional Coding Associations recommend: Providers 6 12 hours Coders 16 hours (for outpatient coders) Other Staff 2-8 hours (depending on involvement) 27 9

10 ICD-10: Worker s Comp and Auto Workers Comp and Auto insurance are HIPAA exempt, therefore may not change to ICD-10 A claim submitted to payer --benefit limit may be reached or TPL is changed; Charges will need to be resubmitted to private insurance with ICD-10; reverse may be true for private insurance identified as WC or auto May be difficult to crosswalk due to specificity of ICD ICD 10: Readiness Checklist Evaluate internal processes: 1. Conduct a practice impact assessment 2. Update ICD 10 coding resources (manual, encoder or online lookups) 3. Perform chart audits to identify areas for CDI 4. Provide ongoing documentation feedback for physicians 5. Evaluate transition software 29 ICD-10: Benefits More specific diagnoses = reduced denials Describing higher diagnostic complexity may support a higher complexity procedure or service payment Better data with which to justify payment, including pay-for-performance or diagnosis-based reimbursement (e.g., PCMH or ACO models) 30 10

11 Other Benefits of ICD-10-CM More patient information can be recorded, especially in the EHR environment Better describe new diseases Reduced requests for additional information Improved tracking and reporting for public health surveillance and risk management Increased information that can justify quality and outcomes assessment 31 Mahalo! (808) 947-CODE ( ) 32 11