About Your Faculty. National Alliance of Medical Auditing Specialists (NAMAS) ICD-10-CM CM Introduction. Take a Deep Breath!

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1 National Alliance of Medical Auditing Specialists (NAMAS) ICD-10-CM CM Introduction Presented by: John Burns, CPC, CPMA, CPC-I, CEMC Approved NAMAS Instructor ICD-10 Ambassador & AHIMA Approved ICD-10 PCS/CM Trainer Senior Consultant DoctorsManagement, LLC About Your Faculty BS Health Science- SUNY Cortland (1995) Consultant, Doctors Management, LLC 2013 present President- Modern Conventions in Compliance, Inc Senior Consultant- Medical Management Institute CPC (2000), CPC-I (2004), CEMC (2009), CPMA (2013) AHIMA Approved ICD-10 Ambassador/Trainer (2013) Take a Deep Breath! The sky is not falling I swear it s really not!! While ICD-10 (CM and PCS) does pose numerous challenges to all constituents of the healthcare industry but many of the general concepts utilized to successfully select ICD-9 codes may be applied to ICD-10. The major challenge lies with understanding the concepts described in ICD-10-CM and ICD-10-PCS and how they translate from the codes we have become accustomed to ICD-10 will impact all aspects of the revenue cycle and requires: -complete provider documentation -increase appeals in the short-term 1

2 HHS Confirms Final Implementation Date for ICD-10 for the Last Time The primary reasons for the delay were stated to be issues with 5010 implementation and the need to carefully develop testing plans On August 24, 2012 HHS announced the one year delay would move the implementation one year to October 1, 2014 for printing in the Federal Register on September 5, Did you know: ICD has not been clinically modified since 1977? ICD-11? Codes Will Change Between Now and Implementation The last annual update to ICD-9-CM was made on October 1, On October 1, 2013 there were only limited code updates to both the ICD-9-CM and ICD-10 code sets On October 1, 2014, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L There will be no updates to ICD-9-CM, as it will no longer be used for reporting On October 1, 2015, regular updates to ICD-10 will begin. ICD-10-CM Training Before Go-Live Various parties have estimated that approximately 16 hours of coding training are likely needed for each coding manager to learn ICD-10-CM. More is required for those actively involved in coding each day Estimate at least 2-3 hours of in-depth education for each specialty section We haven t received any billing guidance yet which will require far more education and training for everyone in many areas of the revenue cycle All affected parties will need to refresh or expand on coders knowledge in the biomedical sciences (anatomy, physiology, pharmacology, and medical terminology) 2

3 Some Enhancements Of ICD-10-CM Expanded injury codes, grouped by anatomic site(s) rather than injury category (E-codes are no longer) Combination diagnosis/symptom or manifestation codes to reduce number of codes needed to fully describe conditions Combination codes for poisonings and external causes Additions of 6 th and 7 th characters- 7 th digit to describe visit encounter or sequelae for injuries and external causes Laterality (right, left, bilateral, unspecified etc.) Full code titles for 4 th and 5 th digits no more need to refer back to common 4 th /5 th digits for full code description V-Codes and E-Codes are no longer supplemental classifications (placed in applicable sections) Excerpts From Official ICD-10 Guidelines A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Approach, laterality, encounter (initial, subsequent, sequela), etc Orders should contain specific information. Do not utilize R/O or suspected conditions Section I: C. Chapter Specific Coding Guidelines Chapter 1: Infectious and Parasitic Disease (A00-B99) Chapter 2: Neoplasms (C00-D49) Chapter 3: Diseases of Blood and Blood Forming Organs (D50-D89) Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89) Diabetes is located in this section (E08-E13) Chapter 5: Mental and Behavioral Disorders (F01-F99) Chapter 6: Diseases of the Nervous System and Sense Organs (G00-G99) Chapter 7: Diseases of the Eye and Adnexa (H00-H59) Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) Chapter 9: Disease of the Circulatory System (I00-I99) Hypertension is located in this section (I10-I15), R03.0 for elevated BP (ICD-9 code 796.2) Chapter 10: Diseases of the Respiratory System (J00-J99) Chapter 11: Diseases of the Digestive System (K00-K94) Chapter 12: Diseases of Skin and Subcutaneous Tissue (L00-L99) Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) 3

4 Section I: C. Chapter Specific Coding Guidelines Chapter 14: Diseases of the Genitourinary System (N00-N99) Chapter 15: Pregnancy, Childbirth, Pueperium (O00-O9A) OB, Delivery and Postpartum Services Chapter 16: Newborn (Perinatal) Guidelines (P00-P96) Newborn services and reporting stillborns Chapter 17: Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99) Q99) Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) Chapter 20: External Causes of Morbidity (V01-Y99) Chapter 21: Factors Influencing Health Status and Contact With Health Services (Z00-Z99) Official ICD-10 Guidelines The Official Guidelines are broken down in to sections: Section I: A. Conventions of ICD-10 Conventions of ICD-10-CM Alphabetic Indexing and Tabular Listings Format and Structure Use of Codes for Reporting Purposes Placeholder ld X 7 th Digit s Abbreviations (Index and Tabular) Punctuation Use of And, With, See Also, Code Also Unspecified Codes, Includes and Excludes Etiology/Manifestation Conventions (e.g., code first, use additional code, in diseases classified elsewhere Default codes and Syndromes Incorrect True True or False? Many ICD-10-CM codes will require a 4 th, 5 th, and/or 6 th character that is not listed specifically. In these cases, the coder/auditor will simply insert a Z as a placeholder. Correct False Reset Questions 4

5 The Dummy Placeholder ICD-10 instructs coders to place an x in the 4 th, 5 th and/or 6 th places when a 7 th digit is available and the 4 th, 5 th and/or 6 th characters do not exist. This convention allows for future code expansion if necessary The dummy placeholder is very prevalent in Chapter 15 (ICD-10- CM) Pregnancy, Childbirth & Puerperium Example: O41.90X1- Disorder of amniotic fluid and membranes, unspecified, first trimester Introduction-Where Did It Come From? Health Insurance Portability and Accountability Act (HIPAA) of 1996 includes provisions for the standardization of health care information Transaction and Code Set Standards (TCS) The National Center for Health Statistics ti ti (NCHS) developed ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) To assist in the classification of morbidity, mortality, indexing medical records, medical care review, as well as for basic health statistics ICD-10 has only been used in the USA for mortality (death certificates) since 1999 New for ICD-10-CM: Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used Coding of sequela generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. SOURCE: 2013 ICD-10-CM Coding Guidelines 5

6 Biggest Challenges to Providers General Equivalence Mapping (GEM) - Conversion of ICD-9 codes to ICD-10 codes Require more specificity of documentation (e.g., LT/RT) Many providers have never really mastered ICD-9 coding principles major challenge for ICD-10 GEMs can be accessed at CMS website: CrosswalksTechnicalFAQ.pdf Its important to mention that though some ICD-9-CM codes can be mapped one to one many ICD-9-CM codes will map to a multitude of ICD-10 listings and vice versa ICD-10-CM Basics ICD-10-CM coding guidelines will only impact those constituents of the healthcare industry who currently use ICD-9-CM (Volumes 1 and 2) to report diagnostic codes identifying signs, symptoms, established acute or chronic conditions, etc. documented by qualified care providers Physicians and other care professionals will continue to use the CPT and HCPCS-II codes to report the services that they perform Hospitals reporting to Medicare Part A and other payors for their assorted daily inpatient/facility services will not use ICD-10-CM for payment purposes, rather they will use ICD-10-PCS (replaces Vol. III) Limitations of ICD-9-CM Code set is greater than 30 years old and does not speak to the current medical practice Current 3-5 numeric (except V-codes and E-codes) characters do not allow for expansion Lack anatomic descriptions Lack of specificity and severity descriptions Not specific to laterality No flexibility for future expansion (6 th and 7 th digits) Example: ICD-9-CM Open fracture of head of radius ICD-10-CM S52123C Displaced fracture of head of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC 13,000 ICD-9-CM codes versus 68,000 ICD-10-CM codes 6

7 True or False? One major difference between ICD-9-CM and ICD-10-CM is that rule out conditions are to be reported when reasonably suspected. Incorrect True Correct False Reset Questions What Will Not Change With ICD-10-CM Code reason for visit first Code to the highest level of known specificity/certainty This means the user is to report signs/symptoms in absence of definitive dx Don t code probable, suspected, questionable or rule out Code chronic diseases as often and as long as the patient receives treatment for them Code coexisting conditions affecting patient care at the time of the visit Comparison of Clinical Modifications ICD-9-CM Three to five characters First digit is numeric but can be alpha (E or V) ICD-10-CM Three to seven characters First character always alpha 2-5 are numeric All letters used except U Always at least three digits Decimal placed after the first three characters (or with E codes, placed after the first four characters) Alpha characters are not case-sensitive 2 always numeric: 3-7 can be alpha or numeric Always at least three digits and the decimal placed after the first three characters Alpha characters are not case-sensitive 7

8 Locating An ICD-10-CM Code First, locate the term in the Alphabetic Index Alphabetical list of terms (e.g., fracture, pain, etc.) Next, verify the code in the Tabular List Chapters based on body systems or conditions 1) Index of diseases, 2) External Causes,3) Neoplasms, 4) Drugs and Chemicals This should come by no surprise it s what we have always done with ICD-9 Always consult the instructional notations that appear in both the Index and the Tabular List ICD-10-CM Index to Diseases and Injuries The index is arranged A-Z Unlike ICD-9-CM, Neoplasms are not located within the alphabetic index but follows letter z There are vertical lines used to assist in using the index: Pain(s) limb M lower M toe M Never code directly from index Alphabetic index, Neoplasm table, Table of Drugs and Chemicals, External Causes, Places of occurrence The Tabular List Categories (3 characters) [M16] Osteoarthritis of hip Subcategories [M16.1] unilateral primary osteoarthritis of hip Codes [M16.10 (unspecified), M16.11 (RT hip), M16.12 (LT hip) All Categories are 3 characters (decimal follows) A 3-character category without 4 th /5 th is a reportable code M25 (Other joint disorder, not elsewhere classified) A code with an applicable 7 th character is invalid without the 7 th character X is used as placeholder if 5 th /6 th characters are not applicable M (Collapsed vertebra) 5 th character describes the vertebral region, 6 th character x, 7 th character describes type of encounter [A-initial, D/G-subsequent, S-sequela] 8

9 A Initial receiving active treatment Example of a 7 th Digit and a Dummy Placeholder ( X for 6 th character) Collapsed Vertebra M D Subsequent fracture with routine healing G Delayed healing S Sequela EXAMPLE M Collapsed vertebra 5 th character defines vertebral region (e.g., thoracic) 6 th character is x 7 th character described by one of the alpha characters listed 1 st - Alpha (Except U) 2 nd Numeric Code Structure: ICD-10-CM 3-7 Numeric or Alpha XAM X4 X8. X 5 X 4 X XA Base code 5 th character describes vertebra (4 = thoracic) Added code extensions (7 th character) for injuries, and external causes of injury (A = Initial Encounter) Watch for the dummy placeholder for the 5 th and/or 6 th characters Excludes 1 Versus Excludes 2 Excludes 1: Used when 2 codes cannot occur together (e.g., congenital versus acquired) M79.A Nontraumatic compartment syndrome Excludes 1- fibromyalgia (M79.7) Excludes 2 - used when 2 codes may occur together but separate documentation is required of each condition M80 Osteoporosis with current pathological fracture Excludes 2- personal history of (healed) osteoporosis fracture (Z87.310) 9

10 Etiology/Manifestation Codes Certain conditions have both an underlying etiology (cause or origination of disease) and manifestations (symptom resulting from disease) In ICD-10-CM, the etiology (underlying condition) is to be reported primary with the manifestation being sequenced second In diseases classified elsewhere codes are never to be first listed or as principal diagnosis codes In the Alphabetic Index, etiology code is listed first with the manifestation in [brackets]; the code in brackets is always to be sequenced second. Specific ICD-10-CM Reporting Parameters Osteoarthritis (Categories M15-M19) Unlike ICD-9-CM, Osteoarthritis is provided a unique category for each anatomic structure: Polyosteoarthritis (M15.0 M15.9) Primary osteoarthritis of: Bilateral Hip (M16.0) Unilateral l Hip (M16.1-) 1 5 Bilateral Knee (M17.0) th character 0 unspecified Unilateral Knee (M17.1-) 1 right 2 - left Bilateral First Carpometacarpal Joint (M18.0) Unilateral First Carpometacarpal Joint (M18.1-) As you can see, bilateral codes are 4 character codes while unilateral codes are 5 character codes. Never use 2 codes when 1 tells the story Osteoarthritis of other joints is reported using M19.- codes ICD-10-CM Reporting Other Joint Disorders Similar coding instructions apply to other joint disorders Instability of joint (M25.3--) Effusion of joint (M25.4--) Pain in joint (M25.5--) Crosswalk on next slide Pain in Limb coded has been codes but will require a 6 th digit in ICD-10 to demonstrate the limb and laterality documentation will be critical! Stiffness of joint (M25.6--) Each of these code sets require a 5 th digit to identify the joint and a 6 th digit to demonstrate laterality (e.g., right, left, unspecified) Bilateral codes do not apply so 2 codes may be required (RT/LT) 10

11 ICD-9-CM Pain in 5 th digit Joint Joint X 1 Shoulder 2 Upper arm 3 Forearm 4 Hand 5 Pelvis/hip 6 Lower leg 7 Ankle/foot 8 Other specified 9 Unspecified ICD-10-CM Pain in Laterality Joint Joint M25.51 X 1, 2, 9 Shoulder M25.52 X 1, 2, 9 Elbow M25.53 X 1, 2, 9 Wrist M25.55 X 1, 2, 9 Hip M25.56 X 1, 2, 9 Knee M25.57 X 1, 2, 9 Ankle and Foot 1=Right 2=Left 9=UNSPEC ICD-9-CM to ICD-10-CM Mapping Lumbago M54.5 Low back pain Thoracic or lumbosacral neuritis or radiculitis, unspecified M51.14-Intervertebral disc disorders with radiculopathy, thoracic region M51.15-thoracolumbar region M51.16-lumbar M51.17-lumbosacral M54.14-Radiculopathy, thoracic M54.15-thoracolumbar M54.16-lumbar M54.17-lumbosacral M sacral and sacrococccygeal Cervicalgia M54.2 -Cervicalgia Other ICD-10-CM Reporting Parameters Osteoporosis (Categories M80-M81) Unlike ICD-9-CM, Osteoporosis is now reported based on being with (M ) or without (M81.-) pathological fracture: M (Osteoporosis with pathologic fracture) Requires 7 th character: A initial encounter for fracture D subsequent encounter for fracture with normal healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S sequela M80.1- (Osteoporosis without pathologic fracture) Only requires a 4 th character (age-related, localized, other) 11

12 Osteoporosis: ICD-9-CM to ICD-10-CM Mapping Unspecified osteoporosis M Age-related osteoporosis without current pathological fracture Disorder of bone and cartilage, unspecified M Disorder of bone density and structure, unspecified M Disorder of bone, unspecified M Disorder of cartilage, unspecified Other ICD-10-CM Reporting Parameters Fractures (Pathologic versus Traumatic) Stress Fractures (M ) & Pathologic Fractures (M ): Indexing: Fracture, pathological or stress, specify location Requires 7 th characters: A initial encounter for fracture D subsequent encounter for fracture with normal healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S sequela Traumatic Fractures (S02.0XX- through S92.919): Indexing: Fracture, traumatic, specify location (now structured anatomically) Located in Chapter 19, Injury, Poisoning & Consequences of External Causes Do not report directly from the index; always refer back to Tabular ICD-10-PCS: Medical-Surgical Code Structure 1 Section 2 Body System 3 Root Operation Body Part Approach Device Qualifier Objective of procedure 31 Root operations Arranged by similar attributes Multiple codes CAUTION: They are easily confused and may differ from the documentation! Root Operations Examples: Bypass Drainage Extirpation Resection Inspection Removal 12

13 SOURCE: Centers for Medicare and Medicaid Services ICD-10 Public Presentation on August 3, 2011 available at CMS.gov) Main References History of the development of the ICD, World Health Organization website, ICD-10-CM Official Guidelines for Coding and Reporting-Centers for Disease Control (CDC), National Center for Health Statistics Centers for Medicare & Medicaid Services ICD-10 page: 0 Assorted guidelines and concepts created and/or approved by the official ICD- 10 Cooperating Parties: American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and National Center of Health Statistics (NCHS) John F. Burns, CPC, CPMA, CPC I, CEMC jburns@drsmgmt.com 13