ICD-10-CM: What Does Your Coder Really Need To Know Part I. Your Speaker A SHORT HISTORY LESSON

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1 ICD-10-CM: What Does Your Coder Really Need To Know Part I IAHHC 2014 ANNUAL COFERENCE Wednesday, May 7, :00 p.m.-2:30 p.m. Copyright 2014 FR&R Healthcare Consulting Inc. 1 Your Speaker Bonny Kohr, RN, CHCE, HCS-D AHIMA approved ICD-10 trainer Manager Clinical Services FR&R Healthcare Consulting, Inc. Frost, Ruttenberg & Rothblatt, P.C. 111 S. Pfingsten Road, Suite 300 Deerfield, IL Main: (847) or (888) Direct: (847) bkohr@frrcpas.com Copyright 2014 FR&R Healthcare Consulting Inc. 2 A SHORT HISTORY LESSON Copyright 2014 FR&R Healthcare Consulting Inc. 3 1

2 What is ICD-10 International classification for all general epidemiological, many health management purposes, and clinical use Published by the World Health Organization (WHO) 10 versions of ICD to date ICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification (U.S. modification to the WHO Classification of Diseases) Copyright 2014 FR&R Healthcare Consulting Inc. 4 Adopting ICD-10 January 16, 2009 HHS published a Final Rule adopting ICD-10-CM and ICD-10-PCS code sets Initial compliance date was October 1, 2013 Revised compliance date was October 1, 2014 New compliance date not before October 1, 2015 HIPAA transactions software was updated to accommodate the changes (X12 version 5010) Copyright 2014 FR&R Healthcare Consulting Inc. 5 Highlights of the ICD-10 Final Rule ICD-10-CM and ICD-10-PCS coding systems will replace the current ICD-9-CM coding system ICD-10-CM will replace the ICD-9-CM diagnosis codes in all settings ICD-10-PCS will replace the ICD-10-CM procedure codes in the hospital inpatient setting ICD-10-PCS will not replace CPT for reporting procedures and services in outpatient setting Copyright 2014 FR&R Healthcare Consulting Inc. 6 2

3 Rationale for Change ICD-9-CM coding system has outgrown its intended level of specificity ICD-9-CM has been in use since 1979, and no longer reflects advances in medical treatment ICD-9-CM lacks specificity and detail for reporting diagnoses Copyright 2014 FR&R Healthcare Consulting Inc. 7 Rationale for Change The US is the only industrialized nation that hasn t implemented ICD-10 for coding diseases or causes of illness US has been using ICD-10 on death certificates since 1999 so that we can compare data internationally This coding is typically done by a vital statistics office, not the healthcare provider Copyright 2014 FR&R Healthcare Consulting Inc. 8 Rationale for Change Some of the reasons we use coding data today is to: Support medical necessity Research and support clinical trials Set health policy Process claims for reimbursement Measure quality and efficacy of care Identify fraudulent practices Copyright 2014 FR&R Healthcare Consulting Inc. 9 3

4 Modifications to ICD-10-CM ICD-9-CM DIAGNOSIS CODES ICD-10-CM DIAGNOSIS CODES 3-5 characters in length 3-7 characters in length Approximately 14,000 codes Approximately 68,000 codes First digit may be alpha (E or V) or numeric. Digits 2-5 are numeric Limited space for new codes Lacks detail Lacks laterality Difficult to analyze data due to nonspecific codes Codes are non-specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries Character 1 is alpha; 2 is always numeric; digit 3-7 are alpha or numeric Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data between other countries and the United States Copyright 2014 FR&R Healthcare Consulting Inc. 10 ICD-10-CM RESOURCES AND REFERENCES Copyright 2014 FR&R Healthcare Consulting Inc ICD-10-CM Available at or ICD-10-CM Index to Diseases and Injuries 2014 ICD-10-CM Tabular List of Diseases and Injuries Instructional Notations 2014 Official Guidelines for Coding and Reporting 2014 Table of Drugs and Chemicals 2014 Neoplasm Table 2014 Index to External Causes 2014 Mapping ICD-9-CM to ICD-10-CM and ICD-10-CM to ICD-9-CM Copyright 2014 FR&R Healthcare Consulting Inc. 12 4

5 KEY DIFFERENCES Copyright 2014 FR&R Healthcare Consulting Inc. 13 Number of Codes Number of ICD codes increased to over 140,000 and the description for each code is significantly larger Copyright 2014 FR&R Healthcare Consulting Inc. 14 Number of Codes Increased Good news, you will not use all of these codes. Post acute providers will only use ICD CM (Diagnoses codes) Procedure codes will only be used by inpatient hospitals Each provider type uses only a small portion of codes Bad news, your software systems and manuals must house all of them Copyright 2014 FR&R Healthcare Consulting Inc. 15 5

6 New Characters Caution required First character is always alpha Second character is always a number 3-7 could be a challenge Is it a letter or is it a number? O versus 0 I (upper case i) versus l (lower case L) versus 1 Copyright 2014 FR&R Healthcare Consulting Inc. 16 Major Differences Codes related to musculoskeletal care make up >50% of ICD-10 codes Approximately one-third of the ICD-10 codes are related to fractures Increasing from 747 ICD-9 codes Never to be used by post acute care providers Increasing to ICD-10 codes which Will be used by post acute care providers Copyright 2014 FR&R Healthcare Consulting Inc. 17 Major Differences Diabetes codes increase from 69 ICD-9 codes to 239 ICD-10 codes Copyright 2014 FR&R Healthcare Consulting Inc. 18 6

7 ORGANIZATION AND STRUCTURE OF ICD-10-CM Copyright 2014 FR&R Healthcare Consulting Inc. 19 ICD-10-CM Alphabetic Index Still divided into two parts Index to disease and injuries, includes Neoplasm table Drugs and chemicals Index to external causes Morphology codes are no longer listed in the Alphabetic index and no longer have a separate appendix Copyright 2014 FR&R Healthcare Consulting Inc. 20 ICD-10-CM Tabular List Divided into 21 chapters instead of 17 Copyright 2014 FR&R Healthcare Consulting Inc. 21 7

8 21 Chapters 1. Certain infectious and parasitic diseases (A00-B99) 2. Neoplasms (C00-D49) 3. Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) 4. Endocrine, nutritional and metabolic disorders (E00-E89) 5. Mental, behavioral and neurodevelopmental disorders (F01-F99) 6. Diseases of the nervous system (G00-G99) 7. Diseases of the eye and adnexa (H00-H59) 8. Diseases of the ear and mastoid process (H60-H95) 9. Diseases of the circulatory system (I00-I99) 10. Diseases of the respiratory system (J00-J99) 11. Diseases of the digestive system (K00-K95) Copyright 2014 FR&R Healthcare Consulting Inc Chapters 12. Diseases of the skin and subcutaneous tissue (L00-L99) 13. Diseases of the musculoskeletal system and connective tissue (M00-M99) 14. Diseases of the genitourinary system (N00-N99) 15.Pregnancy, childbirth and the puerperium (O00-O9A) 16. Certain conditions originating in the perinatal period (P00-P96) 17. Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 18. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 19.Injury, poisoning and certain other consequences of external causes (S00- T88) 20. External causes of morbidity (V00-Y99) 21. Factors influencing health status and contact with health services (Z00-Z99) Copyright 2014 FR&R Healthcare Consulting Inc. 23 Subchapters Each chapter begins with a list of the subchapters (blocks) that contain the three character categories within the chapter Copyright 2014 FR&R Healthcare Consulting Inc. 24 8

9 Blocks Copyright 2014 FR&R Healthcare Consulting Inc. 25 Subcategories Most, but not all, categories are further subdivided into four or five character subcategories The fourth character 8 is used to indicate some other specified category The fourth character 9 is usually used for an unspecified condition Examples: K52.89, Other specified non-infective gastroenteritis and colitis K52.9, Non-infective gastroenteritis and colitis, unspecified Copyright 2014 FR&R Healthcare Consulting Inc. 26 ICD-10-CM Tabular List Diseases of the Nervous System and Sense Organs (eyes and ears) are three separate chapters V (aftercare, attention to, history, etc.) and E (external cause ) codes are included in the main classification Order of the chapters is different Copyright 2014 FR&R Healthcare Consulting Inc. 27 9

10 ICD-10-CM Tabular List Disorders of the immune mechanism are included in the blood and blood-forming organs Certain diseases have been reassigned to a more specific chapter (ex: gout) Copyright 2014 FR&R Healthcare Consulting Inc. 28 Other Differences ICD-10-CM groups injuries first by site (head, arm, leg) then by type (fracture, open wound) Postoperative complications have been moved to procedure-specific body system chapters ICD-10-CM includes full code titles (no reference back to common fourth and fifth digits- example: separate codes for cerebral occlusions with infarction versus without infarct) Copyright 2014 FR&R Healthcare Consulting Inc. 29 ICD-9 Fifth Digit Reference Example Copyright 2014 FR&R Healthcare Consulting Inc

11 ICD-10 Example Copyright 2014 FR&R Healthcare Consulting Inc. 31 Classification Changes ICD-10 reorganized the following chapters Chapter 5 Mental and Behavioral disorders Chapter 19 Injury and Poisoning Chapter 20 External causes of morbidity Copyright 2014 FR&R Healthcare Consulting Inc. 32 ICD-9 Chapter 5 Mental Disorders ICD-10-CM contains more subchapters, categories and subcategories and codes ICD-9-CM Chapter 5: Mental Disorders ( ) Chapter 5: Mental, behavioral and ICD-10-CM neurodevelopmental disorders (F01-F99) Copyright 2014 FR&R Healthcare Consulting Inc

12 ICD-9 Chapter 17 Injury and Poisoning In ICD-9-CM the type of injury is the axis of classification In ICD-10-CM specific types of injuries (S00- S99) are arranged by body region However burns, effects of foreign bodies etc. are by body region groups ICD-9-CM Chapter 17: Injury and Poisoning ( ) ICD-10-CM Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88) Copyright 2014 FR&R Healthcare Consulting Inc. 34 ICD-10- CM Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes EXAMPLES: S32.111A T22.151D S32.1 Fracture of Sacrum Minimally displaced Zone I fracture of sacrum, initial encounter for closed fracture T22.1 Burn of first degree Burn of first degree of right shoulder, subsequent encounter T45.516A T45 Poisoning by, adverse effect of and underdosing of primarily systemic and hemotological agents Underdosing of anticoagulant, initial encounter Copyright 2014 FR&R Healthcare Consulting Inc. 35 ICD-10 Chapter 20 External Causes of Morbidity Codes for external causes are no longer located in a supplemental classification The E codes from ICD-9 are found in Chapter 19: Injury, poisoning or Chapter 20: External cause in ICD-10-CM ICD-9-CM ICD-10-CM Supplementary Classification of External Causes of Injury and Poisoning (E800-E999) Chapter 20: External causes of morbidity (V00-Y99) Copyright 2014 FR&R Healthcare Consulting Inc

13 New Features Combination Codes Combination Codes for conditions and common symptoms or manifestations examples: E10.21, Type 1 diabetes mellitus with diabetic nephropathy ICD-9 = or Diabetes with renal manifestation type 1 not stated as uncontrolled or uncontrolled plus Nephropathy NOS I25.110, Atherosclerotic heart disease of native coronary artery with unstable angina pectoris ICD-9-CM requires two codes ASHD and Angina Copyright 2014 FR&R Healthcare Consulting Inc. 37 New Features Combination Codes Combination codes for poisonings and external causes examples: T36.0X1D, Poisoning by Penicillin, accidental (unintentional), subsequent encounter T42.4X5A, Adverse effect of benzodiazepines, initial encounter Copyright 2014 FR&R Healthcare Consulting Inc. 38 New Features Laterality ICD-10 L Ulcer, decubitus, stage 3, hip, right ICD Pressure, Ulcer Hip plus Pressure Ulcer, stage III Need to avoid this type of coding S40.259D, Superficial foreign body of unspecified shoulder, subsequent encounter Copyright 2014 FR&R Healthcare Consulting Inc

14 ICD-10 E11.341, Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema New Features Expanded Codes ICD or Diabetes with Opthalmic type II either uncontrolled or not stated as uncontrolled Severe nonproliferative diabetic retinopathy Diabetic macular edema Copyright 2014 FR&R Healthcare Consulting Inc. 40 New Features Increased Level of Detail Addition of sixth character in some chapters Addition of seventh characters for obstetrics, injuries, and external causes of injuries Addition of placeholder X character Changes in instructions related to specific conditions/diseases Copyright 2014 FR&R Healthcare Consulting Inc. 41 New Features Seventh Character Some categories require a seventh character for specificity It may a letter or number but it must always be in the seventh position May result in the need for placeholder characters SOS Copyright 2014 FR&R Healthcare Consulting Inc

15 New Features Seventh Character Episode of Care example: T17.220D Food in pharynx causing asphyxiation, subsequent encounter The D indicates subsequent encounter Copyright 2014 FR&R Healthcare Consulting Inc. 43 New Features Seventh Character Episode of Care plus Status example: M80.051D, Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter with routine healing D indicates subsequent encounter with routine healing S52.132H, Displaced fracture of neck of left radius, subsequent encounter for open fracture Type I or II with delayed healing H indicates type of fracture, subsequent encounter and delayed healing Copyright 2014 FR&R Healthcare Consulting Inc Alpha (Except U) Coding and Seventh Character 2 Numeric. 3-7 Numeric or Alpha Additional Characters S S Category Etiology, anatomic site, severity 3 7 Characters Added 7 th character for obstetrics, injuries, and external causes of injury 45 Copyright 2014 FR&R Healthcare Consulting Inc. 15

16 New Feature Placeholders Always an X and has two uses (X must be used to fill in for empty characters) As the fifth character for certain six character codes and for future expansion Example: T37.0X1D, Poisoning by sulfonamides, accidental (unintentional), subsequent encounter When a code has less than six characters and a seventh character is required. Example: S01.02XS, Laceration with foreign body of scalp, sequela Copyright 2014 FR&R Healthcare Consulting Inc. 46 General Equivalence Mappings (GEMs) Created as a conversion tool for national data Not a direct crosswalk There is no one-to-one correlation between ICD-9- CM and ICD-10-CM Some codes have no matching code One ICD-9-CM code may map to multiple ICD-10- CM codes New concepts in ICD10 that do not exist in ICD9 More than one ICD-9-CM code may be required to convey the meaning of a ICD-10-CM code Copyright 2014 FR&R Healthcare Consulting Inc. 47 ICD-9-CM to ICD-10-CM Mapping Examples Open fracture of upper end of the tibia maps to 72 codes in ICD-10-CM and only one of them is correct Closed fracture of upper end of tibia maps to 54 codes in ICD-10-CM CHF, NOS maps to 13 potential ICD-10- CM codes Copyright 2014 FR&R Healthcare Consulting Inc

17 ICD-10-CM CONVENTIONS AND CODING GUIDELINES Copyright 2014 FR&R Healthcare Consulting Inc. 49 ICD-10-CM Conventions Correct assignment is dependent upon certain conventions used in the classification system Similar to ICD-9-CM, abbreviations, punctuation, symbols, and notes are used as conventions These conventions have special meanings that affect code assignment Copyright 2014 FR&R Healthcare Consulting Inc. 50 Punctuate This Sentence Woman without her man is nothing Woman, without her man, is nothing Woman: without her, man is nothing Copyright 2014 FR&R Healthcare Consulting Inc

18 Punctuation Changes Similar to ICD-9, parentheses, brackets and colons are used Some symbols are no longer used in ICD-10 Lozenges Section mark Braces { } Copyright 2014 FR&R Healthcare Consulting Inc. 52 Punctuation Changes Dashes are used in both ICD-10-CM Alphabetic Indexes and Tabular list Index uses the dash at the end of a code number to indicate that it is incomplete Fracture, pathologic ankle M carpus M In the tabular list a dash preceded by a decimal point (.-) indicates an incomplete code J43 Excludes1: emphysematous Emphysema (obstructive) bronchitis (J44.-) Copyright 2014 FR&R Healthcare Consulting Inc. 53 Two Types of Exclude Codes Exclude 1 note not coded here The code being excluded is never used with the code The two conditions cannot occur together Hypertensive chronic kidney disease (I12) and Hypertension due to kidney disease (I15.0) Copyright 2014 FR&R Healthcare Consulting Inc

19 Two Types of Exclude Codes Exclude 2 note not included here The excluded condition is not part of the condition represented by the code Both codes may be used if appropriate I12 Hypertensive Chronic Kidney Disease N17 Acute Kidney Disease Copyright 2014 FR&R Healthcare Consulting Inc. 55 Code First Use Additional Code Similar to ICD-9-CM, some conditions have both an underlying etiology and multiple body system manifestations due to the etiology Must code the underlying condition first followed by manifestation G30 Alzheimer s Disease Use additional code to identify: Dementia without behavioral disturbance (F02.80) Dementia with behavioral disturbance (F02.81) F02 Dementia in other diseases classified elsewhere Code first the underlying conditions, such as Alzheimer s (G30.-) F02.80 Dementia in other diseases classified elsewhere, without behavioral disturbance F02.81 Dementia in other diseases classified elsewhere, with behavioral disturbance Copyright 2014 FR&R Healthcare Consulting Inc. 56 Changes in Time Frames Example: Acute myocardial infarction time period changed from 8 weeks to 4 weeks Time frame for abortion versus fetal death changes from 22 weeks to 20 weeks Copyright 2014 FR&R Healthcare Consulting Inc

20 Areas of Impact FINANCIAL Copyright 2014 FR&R Healthcare Consulting Inc. 58 Establish a Plan Fact 1 ICD 10 CM is coming????????????? Fact 2 ICD 9 CM codes will not be accepted on any claims for services provided on or after the implementation date Copyright 2014 FR&R Healthcare Consulting Inc. Inc. 59 ICD-9-CM HH PPS Grouper Refinements Effective January 2013 Payment diagnosis field restricted to only fracture diagnoses codes Fracture codes paired with specific aftercare codes appearing in primary or secondary diagnosis fields are awarded points Effective January 1, ICD-9-CM diagnosis codes removed from case mix assignment Codes too acute Did not result in increased resource utilization Copyright 2014 FR&R Healthcare Consulting Inc

21 ICD-10-CM HH PPS Grouper Diagnostic group assignment of ICD-10-CM codes replicates ICD-9-CM assignment as much as possible ICD-10 Diagnoses Group Contains 22 diagnostic groups with 14,404 ICD- 10-CM codes 12 NRS diagnoses groups with 1722 ICD-10-CM diagnoses Draft ICD-10-CM HH PPS grouper to be available on CMS web site on or before July 201? Copyright 2014 FR&R Healthcare Consulting Inc. 61 OASIS C-1 No longer need to use payment diagnosis field- all ICD-10-CM codes included in HH PPS grouper will be appropriate for reporting as a primary and other condition However, OASIS-C1 still includes M1025 (agencies may voluntarily choose to report diagnosis) and is a potential quality measure risk adjustment Appendix D will be retired Copyright 2014 FR&R Healthcare Consulting Inc. 62 New claim edits October 1, 2014 HH claims containing inappropriate principal or secondary diagnosis codes will be RTP More details on the edit to come however Mental, Behavioral and Neurodevelopment Disorders dementias was an example provided Copyright 2014 FR&R Healthcare Consulting Inc

22 Episodes Spanning ICD-10 Implementation Home Health Episodes RAPs with dates prior to October 1, 201? Submit ICD-9 code on RAP Corresponding final claim with dates of service on or after October 1, 201? must use ICD-10 codes PPS calculation based on ICD-9 grouper Copyright 2014 FR&R Healthcare Consulting Inc. 64 Episodes Spanning ICD-10 Implementation Guide Type of OASIS Assessment RAP From/Through Dates OASIS M0090 Date OASIS Version Claim Through Date Diagnosis Coding Used on OASIS Diagnosis Coding Used on RAP Diagnosis Coding Used on Claim SOC/ROC 9/28/2014 9/30/14 OASIS-C Recert 9/28/2014 9/25/14 OASIS-C 11/26/14 ICD-9-CM ICD-9-CM Mapped ICD-10-CM 11/26/14 ICD-9-CM ICD-9-CM Mapped ICD-10-CM SOC/ROC 9/28/ /2/14 OASIS-C1 11/26/14 ICD-10-CM Mapped ICD-9-CM ICD-10-CM Recert 10/2/2014 9/28/14 OASIS-C1 11/30/14 ICD-9-CM Mapped ICD-10-CM Mapped ICD-10-CM FR&R Healthcare Consulting, Inc 65 Risks PPS Incorrect calculations for billing Incorrect payments Incorrect ICD codes (9 vs 10) Copyright 2014 FR&R Healthcare Consulting Inc

23 Areas of Impact CLINICAL Copyright 2014 FR&R Healthcare Consulting Inc. 67 Clinical Areas Intake Diagnosis coding Clinical documentation Quality reporting Decision support systems Copyright 2014 FR&R Healthcare Consulting Inc. 68 Intake Intake staff should begin to ask for more information from the referral source Request for supporting documentation is more important with ICD-10-CM Ensure admitting staff have access to referral information at the SOC Decrease query time Copyright 2014 FR&R Healthcare Consulting Inc

24 Intake Consider revising your intake form/process to include more details What diagnoses were treated during this hospital stay (physician visit, SNF stay etc.)? What is the reason for the home health referral? Are there any co-morbidities that may impact the outcome of the home health plan and/or that have been treated recently? Add cues for the most frequently used diagnoses Copyright 2014 FR&R Healthcare Consulting Inc. 70 Diagnosis Coding ICD-10-CM Readiness assessment Start with your top10 ICD-9-CM codes Select patient records containing these codes Review the documentation available to determine if it is sufficient to code the equivalent ICD-10-CM code Copyright 2014 FR&R Healthcare Consulting Inc. 71 Diagnosis Coding Consider the Following Due to the specificity required in ICD-10-CM The word documentation is stated 72 times in the ICD-10-CM guidelines document* Querying for additional information is noted 23 times in the ICD-10-CM Guidelines* *Numbers are courtesy of Decision Health Copyright 2014 FR&R Healthcare Consulting Inc

25 Clinical Documentation CMS expects Congruency between documentation of the comprehensive assessment and the plan of care Accuracy and completeness of OASIS data (including diagnoses assignment) Coding practices to be appropriate and ensure integrity of diagnoses codes We will know the rules and follow the rules Copyright 2014 FR&R Healthcare Consulting Inc. 73 Clinical Documentation Documentation challenges just got tougher Specificity of code assignment in ICD-10-CM will be essential ICD-10-CM requires more information from clinician ICD-10 includes more code first and use additional codes requiring more detail Example: exposure to environmental or occupational tobacco smoke, history or current tobacco use, and dependence with diseases of the respiratory system Copyright 2014 FR&R Healthcare Consulting Inc. 74 Clinical Documentation ICD-10-CM requires more information from clinician continued ICD-10-CM requires coding of drugs associated with adverse effects, poisoning and underdosing Requires increased understanding of pharmacology related to drug categories Increased details and understanding of medical terminology Example: use of STEMI, NSTEMI, transmural, subendocardial terms in MI category may lead to need for refresher for some clinicians and coders Copyright 2014 FR&R Healthcare Consulting Inc

26 Clinical Documentation Increase Level of Detail Clinical documentation must capture detail needed to assign or support ICD-10 codes Fracture Example: Basic information (location and type) plus Initial or subsequent encounter Sequelae Which side Healing level (normal, delayed, malunion, nonunion) Copyright 2014 FR&R Healthcare Consulting Inc. 76 Clinical Documentation Work on Improvements Evaluate the quality of the current medical record documentation Work with clinicians on what details they include and how they document the details Work with physicians on methods to obtain more detailed information Use current query time to educate on ICD-10 Stop using unspecified ICD-9 codes NOW Copyright 2014 FR&R Healthcare Consulting Inc. 77 Quality Reporting Case Mix reports- Patient Characteristics Percent of patients per Acute and Chronic Conditions Monitoring reports Primary diagnosis Rehospitalization by diagnosis Therapy utilization by diagnosis Care Paths, tasks etc. Conversion of legacy data Copyright 2014 FR&R Healthcare Consulting Inc

27 Decision Support Systems Identify which forms and reports contain ICD codes Determine which of those reports are actually being used and require modification Will legacy data need to be converted? How will you compare moving forward? Determine who will be responsible for reformatting or revising the reports Copyright 2014 FR&R Healthcare Consulting Inc. 79 Areas of Impact COMPLIANCE Copyright 2014 FR&R Healthcare Consulting Inc. 80 Documentation Compliance OIG Report % of HHA claims were billed in error.. services were not medically necessary or claims were coded inaccurately, resulting in $432 million in improper Medicare payments coding comments included: Upcoding often resulted because HHAs assigned inappropriate diagnosis codes to the beneficiaries Although a beneficiary may be accurately diagnosed with a disease, it is appropriate to list it [the diagnosis] for payment purposes only when the plan of care addresses the condition Copyright 2014 FR&R Healthcare Consulting Inc

28 Compliance OIG Work Plan Home Health PPS We will review compliance with various aspects of the home health prospective payment system (PPS), including the documentation required in support of the claims paid by Medicare. We will determine whether home health claims were in paid in accordance with Federal laws and regulations. Context A prior OIG report found that one in four HHAs had questionable billing. Further, CMS designated newly enrolling HHAs as high-risk providers, citing their record of fraud, waste, and abuse. Since 2010, nearly $1 billion in improper Medicare payments and fraud has been identified relating to the home health benefit Copyright 2014 FR&R Healthcare Consulting Inc. 82 Compliance Work on Improvements Documentation and codes are interdependent It was difficult to get correct in ICD-9 and it will be more challenging with ICD-10 Copyright 2014 FR&R Healthcare Consulting Inc. 83 Compliance Review Assignment of the primary diagnosis based on the planned focus of care, including physician validation, F2F, and orders Assignment of co morbid (secondary) diagnoses based on ICD-CM guidance Review of the Plan of Care for congruency with the all of the above elements Copyright 2014 FR&R Healthcare Consulting Inc

29 LET S REVIEW Copyright 2014 FR&R Healthcare Consulting Inc. 85 Seventh Character 1. The ICD-10-CM code for electrocution is T75.4 and requires the use of a seventh character to identify the encounter. Which of the following is the correct code for an initial encounter to treat the electrocution? a.t75.4a b.t75.4xa c. T75.4XXA d.t75.4 Copyright 2014 FR&R Healthcare Consulting Inc. 3 Excludes Notes 2. True or false? When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together Copyright 2014 FR&R Healthcare Consulting Inc

30 ICD-10-CM Characters 3. The first character of an ICD-10-CM code is: a) Always a number b) Always a letter c) Either a number or letter Copyright 2014 FR&R Healthcare Consulting Inc. 88 Coding Guidelines 4. A note means not coded here Copyright 2014 FR&R Healthcare Consulting Inc. 89 Sequencing 5. True or False? In ICD-10-CM a code also note provides sequencing guidance to the coding professional Copyright 2014 FR&R Healthcare Consulting Inc

31 Episodes 6. When a patient seeks medical attention for an injury that occurred several days prior to the medical encounter, which is the appropriate seventh character to use? Copyright 2014 FR&R Healthcare Consulting Inc. 91 QUESTIONS Copyright 2014 FR&R Healthcare Consulting Inc