Introduction to ICD-10-CM and PCS. ICD Background. ICD Use ICD Codes are reported on the hospital/physician claim form

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1 Introduction to ICD-10-CM and PCS Sheila Goethel, RHIT, CCS Coding Consultant and AHIMA ICD-10 Certified Trainer Rural Wisconsin Health Cooperative June 2011 ICD Background The INTERNATIONAL CLASSIFICATION OF DISEASES is the medical classification system used in the US and world wide in the collection of information regarding disease and injury. Diagnosis and procedures are converted into CODES that have an international definition for each condition/injury Effective means to classify and retrieve diseases and operations ICD Use ICD Codes are reported on the hospital/physician claim form Claim form data is collected and maintained nationally Insurer is able to apply the benefits Purposeful to monitor the incidence and prevalence of diseases, Basis for information retrieval for clinical and quality purposes Serves as major basis for national mortality and morbidity statistics 1

2 ICD-9-CM has been in use since 1979 ICD-9-CM Volume I and 2 contains tabular and alphabetical listing of diagnoses codes Volume 3 contains procedure codes for inpatient hospital use Yearly updates have allowed for advancements in medical technology (procedures) as well as medical conditions ICD-9 used for more purposes today than when it was developed Many codes have run out of extension opportunities or information needs. ICD-10 Implementation ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013 Single implementation date for all users ICD-9-CM claims for services prior to implementation date will continue to flow through systems for a period of time No grace period ICD-10 ICD-10-CM Diagnosescodes Used for hospital inpatient and outpatients Used for ALL providers MD clinics SNF Home Health Free standing clinics ICD-10-PCS Procedurecodes Used for inpatient encounters only CPT will be maintained as procedure code choice for outpatient 2

3 ICD-9 vs ICD-10 ICD-9 ICD-10 # Characters # DX Codes 14,315 69,099 # Procedure Codes 3,838 71,957 Capacity for new codes Data analysis capability Limited-Newproc codes are in different system chapters Limited -Difficultto analyze due to generic or unavailable code sets Flexibility to add new codes in any category Greater specificity will improve richness of data Asthma with acute exacerbation ICD-9-CM Asthma, unspecified with acute exacerbation ICD-10-CM J Mild intermittent asthma with (acute) exacerbation J Mild persistent asthma with (acute) exacerbation J Moderate persistent asthma with (acute) exacerbation J Severe persistent asthma with (acute) exacerbation HIPAA 5010 Code modifications require EDI Version 5010 Allows expansion in fields to accommodate ICD-10-CM and ICD-10-PCS (procedure codes only used for hospital inpatients) Accommodates up to 25 ICD diagnosis codes (not in current Version 4010) Required by all payers Require changes to software, systems, and procedures for billing Medicare and other payers Effective date January 1,

4 ICD-10-CM/PCM timeline Jan 1, 2011 Medicare FFS begin accepting 5010 (external testing) ICD-10 Assessments and Preparations Jan 1, electronic data interchange effective obsolete. Continue ICD-10 Preparation tasks. Start ICD-10 education. January 2013 ICD-10 EDUCATION EDUCATION EDUCATION October 1, 2013 ICD-10-CM implementation 10andVersion5010ComplianceTimelines.asp Who will these changes affect External Stakeholders Vendors Payers CMS Medicaid MA Insurers Work Comp Clearinghouses Other business partners Internal Key Individuals Physicians HIM/Coding IT/IS QI UR/Case managers CFO/Finance Ancillary Nursing Implementation functions Identify stakeholders Develop Steering Committee to plan and oversee entire transition project Develop and support project plan Identify KEY tasks, roles, objectives and timelines Set and maintain responsibilities and goals 4

5 Assess Impact on Process Identify affected systems, applications and uses of ICD-9 Assess impact on documentation, work, and process flow ID forms/reports that need modification ID P/P that will need modification ID impact on external reporting core measures, CA reporting, DHS Assess and Plan for the impact on coding productivity ID affect on decreased productivity will have on AR days/$ Estimate budget and resources necessary Assess documentation improvement measures Assess Educational Needs Become ICD-10 Literate Assess Education needs Hospital staff who, what, how much, and when Plan for and Educate Hospital Team Coding HIM department Physicians UR nurses, QI, billing, Dept managers Assess Impact on Technology Determine Vendor Readiness Costs involved with upgrades or covered in existing contracts Timelines for testing Training and Customer support Accommodate 2 sets ICD-9 and ICD-10 for? period of time Will Vendor upgrades be prudent to consider Assess BA readiness (contracts with all payers) 5010 timelines and accountability for implementation 5

6 Risks or Poor Preparation Vendor Delay in creating and submitting claim Increase in claim rejection/denials Increased AR days and dollars Decreased revenues Payers Inability to apply benefits to your claim Delay in acknowledging/payment of your claim(s) Error in payment application Hospital Coding Backlog Insufficient documentation to support increased specificity Inaccurate reimbursement rates (MSDRG & coverage applications) Distorted data which results in poor representation about your patient care delivery (Outcome and Process Measures affected) Publically displayed data may negatively influence potential customers Implementation Challenges Payers Vendors ICD codes Finance Acct Recv Hospital Staff Physicians & Documentation ICD Codes are the language of healthcare and will impact virtually ALL areas of healthcare ICD-10 Countdown. A dedicated implementation plan is crucial for successful ICD-10 transition Keep your physicians involved with the process!! They are vital stakeholders 6

7 ICD-10 Countdown. Develop an I-10 Steering Committee with give them necessary authority to make necessary changes Provide adequate tools and resources to affected positions and processes Support process(es) changes Support established deadlines Get Ready for the road ahead CMS _5010D0.asp#TopOfPage NHDS Good Luck on the ICD-10 Journey! 7