ICD-10 I m Back October 1, 2015 in 10 min. or less. AAOS Specialty Day 2015 William Beach, MD

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2 ICD-10 I m Back October 1, 2015 in 10 min. or less AAOS Specialty Day 2015 William Beach, MD

3 Conflict of Interest Statement Fellowship Grants Smith Nephew Arthrex Synthes Mitek Share Holder Tuckahoe Surgery Center & St. Mary s ASC Comp Recovery AANA Board of Directors AAOS Coding, Coverage and Reimbursement Committee

4 ICD 10 Just the Facts Determine how and how much $ will it effect you? Establish why we need it? Describe when we need to use it? Understand the logic and it becomes obvious! (maybe not easy)

5 1 2/10/2015

6 Slide 5 1 Advanced Beneficiary Notice of Noncoverage William Beach, 3/18/2013

7 2/10/2015

8 ICD 9 > 10 Why ICD 9 is out of numbers! The 5 digit ICD 9, all numeric system can no longer accommodate new diagnoses! The desire for more detail, a more granular system has lead to the creation of ICD 10. CM = Clinical Modification

9 When Do Surgeons Need ICD? ICD Legitimizes/Substantiates Every CPT Codes S (Traumatic bucket handle tear of the right medial meniscus) or similar code, substantiates/allows PAYMENT for Need an ICD code to support E&M 99203, NO/Incorrect ICD with CPT = NO REIMBURSEMENT!

10 Contrasting ICD 9 & 10 ICD9-CM ICD10-CM Dxs: Vols 1&2 ~14,000 Procs: Vol 3 ~ 4,000 Dx Codes 3-5 digits max Only numeric No placeholder Specificity No laterality Injuries grouped by type of injury Only open vs closed fracture Dxs: ICD10-CM ~68,000 Procs: ICD10-PCS ~87,000 Dx Codes 3-7 digits max Alphanumeric x serves as placeholder at 5 th (and 6 th ) positions Specificity Laterality Injuries grouped by anatomical site Gustilo open fracture type Expanded combination codes

11 ICD 10 = 7 Characters 7 digits for higher specificity Alphanumeric Codes Character 1 is always Alpha Character 2 is always Numeric Character 3-7 can be either Alpha or Numeric All letters are used except U 7 th digit for orthopedics = letter Decimal after the 1st three characters

12 S83.211A = bucket handle tear R med. men

13 Logic of ICD 10 (Orthopedics) A new and better ICD system would ask/answer: Chronic/degenerative (M chapter 13 ) vs. acute/traumatic (S chapter 19) Right vs. left (6 th digit) (usually 1 or 2) Natural history of a condition (7 th digit)

14 Logic of ICD 10 First Character = Chapter M or S The next 4 digits have to learn Diagnosis codes to describe a specific condition. For example a traumatic rotator cuff tear is S46.01 The 6 th digit describes laterality S is a traumatic right rotator cuff strain and S is a traumatic left rotator cuff strain S46.02 = laceration (S = R)

15 Logic of ICD 10-7 th Digit = Natural History: Non- Fracture A = initial visit/evaluation of a condition D = subsequent (follow-up) visit for the same condition S = sequelae of that condition S46.021A= R RCT (acute)(initial eval)

16 ICD 10 Reality of Orthopedics Be comfortable with 2 Chapters M and S The degenerative conditions of orthopedics are found in the M Chapter Those conditions have the first character M Derangement of posterior horn of medial meniscus due to old tear or injury, right knee = M The traumatic or acute conditions are found in the S Chapter Those conditions have the first character S Peripheral tear of medial meniscus, current injury, right knee = S83.221

17 How to Find an ICD-10 Code? Helpful Resources AAOS Code-X Has pick lists and key word searches for ICD-10 GET CODE-X from the AAOS!!!! Will allow knee- >meniscus->bucket- >R/L->7 th digit 7 th = initial(a), subsequent(d) and sequelae(s)

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19 How to Find an ICD-10 Code? Helpful Resources ICD-10 Complete Official Code Set from the AMA

20 ICD 10 Example 18 year old football player injures his right knee. He is seen in your office, for the first time with an MRI that shows bucket handle tear medial meniscus

21 Using the AMA Code Book Go to INDEX (Alphabetical list) and look up condition Tear acute (pg. 315 = S Chapter) Derangement chronic (pg. 95 = M Chapter) Provides 5 digits

22 Code Book Go to corresponding TABULAR List CHAPTER - S Get the specifics/lateralit y S (or 2)

23 Final Code - Add 7 th Character A = Initial Encounter D = Subsequent Encounter S = Sequelae S83.211A = bucket handle tear R med. Men S83.212A = bucket handle tear L med. Men

24 Fracture ICD 10 = Logical Confusion You must know the Gustillo Classification All S codes = Traumatic/Acute First character = S Next 4 are diagnosis specific Code X Cheat Sheet 7 th character = Letter = History = 16 options 1. Initial encounter 2. Routine healing 3. Delayed healing 4. Non-union 5. Mal-union 6. Sequelae

25 ICD 10 7 th Digit: Fractures = Gustilo Classification A = initial encounter for a closed fracture B = initial encounter for an open grade I or II C = initial encounter for and open grade III (A,B,C) D = subsequent encounter for a closed fracture with routine healing E = subsequent encounter for an open grade I or II with routine healing F = subsequent encounter for an open grade III (A,B,C) with routine healing

26 ICD 10 7 th Digit: Fractures = Gustilo Classification G = subsequent encounter for a closed fracture with delayed healing; H = subsequent encounter for an open grade I or II with delayed healing; There is no letter I. J = subsequent encounter for an open grade III (A,B,C) with delayed healing

27 ICD 10 7 th Digit: Fractures = Gustilo Classification K = subsequent encounter for a closed fracture non-union; There is no letter L. M = subsequent encounter for an open grade I or II with a non-union; N = subsequent encounter for an open grade III (A,B,C) with a non-union There is no letter O.

28 ICD 10 7 th Digit: Fractures = Gustilo Classification P = subsequent encounter for a closed fracture with a mal-union; Q = subsequent encounter for an open grade I or II with a mal-union R = subsequent encounter for an open grade III (A,B,C) S = sequelae

29 Closed Fracture 7 th character (5 options) A = initial encounter for a closed fracture D = subsequent encounter for a closed fracture with routine healing G = subsequent encounter for a closed fracture with delayed healing K = subsequent encounter for a closed fracture non-union; P = subsequent encounter for a closed fracture with a mal-union;

30 Open Fracture Grade I or II 7 th Character (5 options) B = initial encounter for an open grade I or II E = subsequent encounter for an open grade I or II with routine healing H = subsequent encounter for an open grade I or II with delayed healing M = subsequent encounter for an open grade I or II with a non-union Q = subsequent encounter for an open grade I or II with a mal-union;

31 Open Fracture Grade III 7 th Character (5 options) C = initial encounter for and open grade III (A,B,C) F = subsequent encounter for an open grade III (A,B,C) with routine healing J = subsequent encounter for an open grade III (A,B,C) with delayed healing N = subsequent encounter for an open grade III (A,B,C) with a non-union R = subsequent encounter for an open grade III (A,B,C)

32 Keys Get Started! Organize the implementation (10 months) Analyze the impact on your practice Contact systems vendors - KEY Budget for costs training, IT, outsourced coding Contact trading partners Implement system/software upgrades

33 Create a Time Table Conduct internal testing Update internal processes Conduct staff training Conduct external testing of transactions wit ICD-10 codes Implement (Up to 22 months!!) Monitor (3-6 months!)

34 Implement Action Items Run ICD-9 Frequency Report for the top 25 OFFICE codes Pull OP notes for the top 10 PROCEDURES and evaluate for ability to code ICD-10 By end of first quarter of 2015, goal is to code in both systems Check with vendors for resources and support

35 Coordinate with Payors/Vendors Check with top ten payers for their ICD- 10 status and medical necessity guidelines-check websites Plan test by April-May (2015)? to see if system is working well enough to generate payments

36 Choices Consider reserving cash, establishing Line of Credit for cash flow problems Get Educated! Get a Plan! NOW! Get your vendors onboard! Consider Scribes = Front End Coders

37 Remember ONE Thing!!! 2014 We are recommending to our clients that they get a line of credit now and they should be prepared to cover overhead for 6 months Margi Maley (Karen Zepko) We reference many articles just like the one below to support our recommendation. ws/cash-hand-youll-need-it-icd-10?page=0

38 References CDC & HCHS for general information ICD-10-CM files, information and 9-CM and 10-CM GEMs Official guidelines df CMS AHIMA