Special Thanks. What is ICD-10-CM? CDQ Education Department. Coding on the River Executive Committee. Seth Canterbury Stacey Dingman Wanda Brown

Transcription

1 Special Thanks CDQ Education Department Seth Canterbury Stacey Dingman Wanda Brown Coding on the River Executive Committee Virginia Outlaw What is ICD-10-CM? Clinical modification of the WHO s ICD-10 morbidity/mortality data set Used primarily to identify reasons for healthcare encounters Four cooperating bodies: NCHS, CMS, AHA, AHIMA Replaces ICD-9-CM Implementation date: October 1,

2 Why Make the Switch? Measures the quality, safety, and efficacy of care Reduces the need for attachments to explain the patient s condition Assists in conducting research/studies/trials ICD-10-CM: Improves clinical, financial, and administrative performance Helps to prevent and detect fraud, waste, and abuse Assists in tracking public health and risks Other Considerations ICD-9-CM has reached the limits of its usefulness Several clinical definitions in ICD-9-CM are outdated No more room to expand in ICD-9-CM USA is the ONLY developed country that has not implemented ICD-10-CM codes for morbidity Facets to Implementation Strategic Planning Identify team/clinic champion Formulate communication plan Conduct an impact analysis Budget for the change IS/software updates Hard copy updates (superbills/charge tickets) EDUCATION!!! 2

3 Education Who should be trained? Coders, physicians, managers, office staff How should they be trained? Online vs. in-house courses, on-site consultants, books from reputable vendors To what extent? Coders vs. physicians vs. managers Certification impact Use Free Resources Available! CMS: AHIMA: AAPC: General Equivalency Mappings (GEMs) Published by CMS Attempt to map ICD-10-CM codes to ICD- 9-CM codes and vice versa Do not attempt to use these mappings to code! CMS published disclaimer on following slide 3

4 The GEMs are not a substitute for learning how to use the ICD-10-CM and ICD-10-PCS. Providers coding staff will assign codes describing the patients encounters from the ICD- 10-CM and ICD-10-PCS code books or encoder systems. In coding individual claims, it will be more efficient and accurate to work from the medical record documentation and then select the appropriate code(s) from the coding book or encoder system. The GEMs are a tool to assist with converting larger International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) databases to ICD-10-CM and ICD-10- PCS. AAPC Code Translator Found at 10/codes/index.aspx Based on CMS GEMs Forward and backward translating Do not attempt to use this tool to code! AAPC published disclaimer on following slide This tool is based on the General Equivalency Mapping files published by CMS, and is not intended to be used as an ICD10 conversion or crosswalk tool. Keep in mind that while many codes in ICD- 9-CM map directly to codes in ICD-10, in some cases, a clinical analysis may be required to determine which code or codes should be selected for your mapping. Always review mapping results before applying them. 4

5 What We ve Learned So Far from the GEMs 5% of codes are a direct 1:1 match 83% of codes were found to be an approximate match 4% of the time, the codes were an approximate match with multiple choices 7% of the time, the ICD-10 code mapped to many ICD-9 codes 1% of the time, there was no way to map to an ICD-9 code ICD-10-CM Details About 70K codes ICD-10-CM code set will still be available in printed form Each code is 3-7 characters in length 1 st character is alpha character 2 nd character is numeric Characters 3-7 can be either alpha or numeric, with decimal after 3 rd character (as with ICD-9-CM) Book Structure/Layout Dominated by 2 main components: Alphabetic Index Tabular List All components in order: Preface/introductory section Official Guidelines for Coding and Reporting Volume II/Alphabetic Index Volume I/Tabular List No appendices in draft versions now available 5

6 Volume II The Alphabetic Index Index to Diseases (AKA the Main Index ) still appears 1st Index to External Cause codes still last Tables appear in-between above indeces Neoplasm table has been extracted from the Index to Diseases and placed after it Table of Drugs and Chemicals appears next NO more Hypertension table! Volume I The Tabular List 21 chapters of codes listed in numerical order (vs. 17 chapters + 2 additional classifications [E and V-codes] in ICD-9- CM) Chapters still largely categorized by body system with some exceptions Codes that replace E and V-codes assigned Chapters 20 and 21 Volume I The Tabular List Code titles more complete In ICD-9-CM: 821 Fx of other/unspec. parts of femur Shaft or unspecified part, closed Shaft 6

7 In ICD-10-CM: Volume I The Tabular List S72 Fx of femur S72.3 Fx of shaft of femur S72.39 Other fx of shaft of femur S Other fx of shaft of unspec. (whether rt. or lt) femur Coding Conventions Many similarities/carry-overs from ICD-9-CM: Abbreviations Punctuations Definitions of And/With, See also Etiology/Manifestation coding Other/unspecified codes still available! Myth regarding other and unspecified codes on following slide Myth: Unnecessarily detailed medical record documentation will be required when ICD-10- CM/PCS is implemented. FACT: As with ICD-9-CM, ICD-10-CM/PCS codes should be based on medical record documentation. While documentation supporting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use when documentation doesn t support a higher level of specificity. As demonstrated by the American Hospital Association/American Health Information Management Association field testing study, much of the detail contained in ICD-10-CM is already in medical record documentation but is not currently needed for ICD-9-CM coding. 7

8 Coding Conventions Some key differences: Placeholder X New Excludes notes New Code also notes Coding for syndromes The Placeholder X Used in the 5 th place of some 6 character codes to allow for future expansion S06.1 Traumatic cerebral edema Diffuse traumatic cerebral edema Focal traumatic cerebral edema S06.1x Traumatic cerebral edema S06.1x0 Traumatic cerebral edema w/o LOC The Placeholder X Used in places 5 and 6 as necessary to fill in empty spaces for codes requiring a 7 th digit The appropriate 7 th character is to be added to each code from category S07 A initial encounter D subsequent encounter S sequela X7th S07.0 Crushing injury of face 8

9 Excludes Notes An Excludes note indicates that terms excluded from the code are to be coded elsewhere ICD-9-CM has a single type of Excludes note used for all situations ICD-10-CM differentiates between the two types of situations for which Excludes notes may apply Excludes 1 Note Used to indicate that the code excluded should never be used at the same time as the code above the Excludes 1 note M48.4 Fatigue fracture of vertebra EXCLUDES 1 pathological fracture NOS (M84.4-) Excludes 2 Note Used to advise that the condition described in the Excludes note has its own separate code and is not represented by the code found, BUT it is possible for both conditions to exist S59 Other/unspecified injuries of elbow and forearm EXCLUDES 2 Other/unspecified injuries of wrist and hand (S69.-) 9

10 Code Also Note Must 1 st review carryover (from ICD-9-CM) Code first and Use additional code notes to fully understand new Code also note Code first attached to manifestation code to indicate underlying condition should be coded first Use add l code attached to underlying condition code to indicate manifestations should be coded if present Code Also Note Code first and Use add l code notes also attached to other codes when two codes are needed to fully describe a condition and sequencing rules apply New-for-ICD-10-CM Code also note used when two codes are needed to fully describe a condition but when no certain sequence is required Coding for Syndromes If syndrome is listed in the Main Index (either under the name of the syndrome or as a subterm under Syndrome ), follow index guidance Battered baby syndrome: see Maltreatment, child, physical, abuse Syndrome, Alder s: D

11 Coding for Syndromes If syndrome is NOT listed in the Main Index (either under the name of the syndrome or as a subterm under Syndrome ), code separately the manifestations of the syndrome Coding Guidelines Many similarities/carry-overs from ICD-9-CM: Method for locating a code Look up main term in Main Index, verify suggested code in Tabular List Not coding conditions integral to a disease Coding acute and chronic conditions Coding late effects Coding to the level of detail required Key difference: Coding Guidelines New Laterality concept 11

12 Laterality Concept Many ICD-10-CM code categories have the ability to capture which side of the body the condition affects Last digit always used to convey laterality Categories that include the laterality concept will have an unspecified code if laterality not indicated in record Laterality Concept Some categories that include laterality concept will have a right side code, a left side code, an unspecified laterality code, and a bilateral code H57.1 Ocular pain H57.10 Ocular pain, unsp. eye H57.11 Ocular pain, rt. eye H57.12 Ocular pain, left eye H57.13 Ocular pain, bilateral Laterality Concept Other categories that include laterality concept will only have a right side code, a left side code, and an unspecified laterality code NOT a bilateral code S80.21 Abrasion of knee S Abrasion, right knee S Abrasion, left knee S Abrasion, unspecified knee 12

13 Laterality Concept For these categories use BOTH the right side code and the left side code if the condition is bilateral S80.21 Abrasion of knee S Abrasion, right knee S Abrasion, left knee S Abrasion, unspecified knee Laterality Concept If a code category does NOT include the laterality concept, do NOT attempt to convey that a condition is present on both sides of the body by using a single ICD-10-CM code twice on the same claim Q13.1 Absence of iris Use above code only once even if both eyes have no iris Final Recommendations Check to see if an implementation committee and plan exists at your organization Find out how your organization plans to train staff on ICD-10-CM coding Download Draft ICD-10-CM Official Guidelines from NCHS site Check out the free resources available on the web sites of CMS, AHIMA, and AAPC 13

14 QUESTIONS? 14