ICD-10 OVERVIEW
Agenda ICD-10 CM ICD-10 PCS Prior Auth Guidelines Claims Processing
ICD 10 goes live All HIPAA-covered entities, including health plans, clearinghouses, and healthcare providers must adopt ICD-10-CM and ICD-10-PCS* code sets by October 1, 2015.
ICD-9 Produces limited data about patients medical conditions and hospital inpatient procedures. Limits number of new codes that can be created. Many categories are full. Includes outdated terms (30 years old). Is inconsistent with current medical practice. ICD-10 Offers greater detail on the member s condition including: Severity Complexity Co-morbidities Complications Helps match healthcare needs to the appropriate level of care. Assists in obtaining timely referrals to appropriate specialists. ICD-9 vs. ICD-10
ICD-9 vs ICD-10 code characteristics ICD-9 Approx. 13,600 17 Chapters Mostly numeric codes except E and V codes Valid codes have three, four, or five digits No mapping required for code set ICD-10 Approx. 69,000 21 Chapters All codes alphanumeric Valid codes have three, four, five, six, or seven digits Added a placeholder X
ICD-9 vs ICD-10 Format
Code Extensions Code extensions (7 th character) have been added for injuries and external causes to identify the encounter Common code extensions: A = Initial encounter D = Subsequent encounter S = Sequelae
Character X Character X is used as a 5 th character placeholder in certain 6 character codes to allow for future expansion Or to fill in empty characters when a code that is less than 6 characters requires a 7 th character T15.02XD: Foreign body in cornea, left eye, subsequent encounter
ICD-10 vs. ICD-9: comparison scenarios
scenario 1: major depressive disorder ICD-9 ICD-10 60-year-old female. Office Visit Here today for medication refill Diminished interest or pleasure Difficulty staying asleep 296.32 F33.1 major depressive disorder, major depressive disorder, recurrent recurrent Patient History Recently became widowed Long term use of Fluoxetine Moderate severity Moderate severity Should document: Status of current episode Level of severity Provider Assessment Recurrent Major Depression Moderate Severity Continue Fluoxetine 20 mg Referred to psychiatrist
Major depressive disorder ICD-9 Diagnosis: 296.2x - Major Depressive Disorder, Single Episode 296.3x - Major Depressive Disorder, Recurrent Episode ICD-10 Diagnosis: F32.x - Major Depressive Disorder, Single Episode F33.x - Major Depressive Disorder, Recurrent Episode Fifth Digit 0 = Unspecified 1 = Mild 2 = Moderate 3 = Severe w/o psychotic behavior 4 = Severe w/ psychotic behavior 5 = In partial or unspecified remission 6= Full remission Fourth Digit 0 = Mild 1 = Moderate 2 = Severe w/o psychotic behavior 3 = Severe w/ psychotic behavior 4 = In partial or unspecified remission 5 = Full remission 8 = Other 9 = Unspecified
scenario 2: diabetes mellitus 65-year-old male. Office Visit Patient History Provider Assessment Known peripheral artery disease (manifestation of diabetes) Provider quickly performs ABI test: results are lower than normal Diabetic PVD Hypertension CKD IV A/P: Diabetic Peripheral Artery Disease - getting worse, referred to cardiologist Hypertension stable, renew Lisinopril CKD IV stable, labs ordered, diet counseling ICD-9 250.70 Diabetic peripheral arterial disease, type 2 or unspecified 443.9 Peripheral vascular disease 585.4 CKD, stage IV 403.90 Hypertensive CKD with stage 1 through 4, or unspecified CKD ICD-10 E11.51 Type 2 Diabetes with diabetic peripheral angiopathy without gangrene N18.4 CKD, stage IV I12.9 Hypertensive CKD with stage 1 through 4, or unspecified CKD
scenario 3: diabetes mellitus w/ulcer 45-yearold male. Office Visit Patient History Provider Assessment Here today for his follow-up exam His labs look good and he reports being well Type 1 Diabetes Diabetic left foot ulcer A/P: Type 1 Diabetes stable, continue Metformin Diabetic left foot ulcerfollowing up with neurologist ICD-9 ICD -10 250.81 Diabetic foot ulcer, type 1 or unspecified 707.15 Ulcer of other part of foot E10.621 Type 1 Diabetes mellitus with left foot ulcer L97.521 Non pressure chronic ulcer of other part of left foot limited to breakdown of skin Out of control, poorly controlled, and inadequately controlled are coded to diabetes, by type, with hyperglycemia. Use additional code to identify any use of insulin (Z79.4). Do not assign insulin code (Z79.4) with Type I cases because insulin is required to sustain life.
scenario 4: active neoplasm 65-year-old female. Office Visit Patient Assessment Patient History Patient presents for follow-up of left breast cancer Patient had mastectomy done 2 years ago and refused chemo-therapy Now being treated with Tamoxifen Left breast cancer of the upper-inner quadrant. Continue Tamoxifen for 2 years. ICD-9 174.2 Malignant neoplasm of the breast, upper-inner quadrant ICD-10 C50.212 Malignant neoplasm of upper-inner quadrant of left female breast Code active cancer even when the primary malignancy has been excised but further treatment is directed to that site.
Scenario 5 - pregnancy 30-year-old female. Office Visit Patient presents for follow-up for antepartum care ICD-9 ICD -10 278.01 Morbid obesity E66.01 Morbid (severe) obesity due to excess calories Patient History Patient is pregnant with her 2 nd child No complications with 1 st child V22.1 Supervision of other normal pregnancy Z34.82 Encounter for supervision of other normal pregnancy, second trimester Patient Assessment 24 weeks pregnant with 2 nd child Obesity complicating pregnancy
V Codes = Z Codes Factors influencing health status and contact with health services V22.1 = Encounter for supervision of other normal pregnancy, now translated in ICD-10 to: Z34.80: unspecified trimester Z34.81: 1 st trimester Z34.82: 2 nd trimester Z34.83: 3 rd trimester Z34.90: unspecified, unspecified trimester Z34.91: unspecified, 1st trimester Z34.92: unspecified, 2 nd trimester Z34.93: unspecified, 3 rd trimester
ICD-10 CM Categories/Codes
ICD -10 PCS UB Claims: ICD-10 also affect procedure codes (located in field 74)
ICD-9 vs ICD-10 Procedure Structure (UB) ICD-9 Has 3 4 characters All characters are numeric All codes have at least 3 characters ICD-10-PCS Has 7 characters Either alpha or numeric Numbers 0-9, letters A-H, J-N, P-Z
Procedure Codes ICD-9 35.21 Open and other replacement of aortic valve w/tissue graft 37.22 Left heart cardiac catheterization 88.72 Diagnostic ultrasound of heart ICD-10 02R Replacement / heart and great valves 4A0 Measurement / Physiological systems B24 Ultrasonography / Heart *These are not coded to specificity
Claims Processing What s Changed?
Prior Auth Guidelines Authorization requests submitted on or before 9/30/15 are submitted with ICD-9 codes Authorization requests submitted on or after 10/1/15 are submitted with ICD-10 codes
Claim Submission Rules Beginning with dates of service 10/1/15 and after claims must be submitted with ICD-10 codes For Inpatient UB claims, with discharge dates 10/1/15 and after, claims must be submitted with ICD-10 codes Submission guidelines for claims that span across 10/1: UB04 Inpatient claims with dates of service than span across 10/1 are submitted with ICD-10 codes UB04 Outpatient claims must be split to submit separate claims with service dates 9/30/15 and prior with ICD-9 codes and services dates 10/1/15 and after with ICD-10 codes CMS1500 claims must be split to submit separate services with dates of service 9/30/15 and prior with ICD-9 codes and services with dates of service 10/1/15 and after with ICD-10
ICD-10 Resources American Health Information Management Association (AHIMA) http://www.ahima.org/topics/icd10 American Academy of Professional Coding (AAPC) https://www.aapc.com/icd-10/ CMS link: http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1408.pdf