Where Are You on the ICD-10-CM Radar Screen? Presented to the Indiana Medical Group Management Association

Transcription

1 Where Are You on the ICD-10-CM Radar Screen? Presented to the Indiana Medical Group Management Association

2 ICD-10 Final Rule On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released the final rule mandating that everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) implement ICD-10 for medical coding.

3 Deadline for ICD-10 Allows Health Care Industry Ample Time to Prepare For Change On July 31st, 2014, The U.S. Department of Health and Human Services (HHS) issued a rule finalizing October 1, 2015 as the new compliance date. The U.S. Department of Health and Human Services (HHS) has issued a rule finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. This new deadline gives providers, insurance companies, and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015.

4 Benefits of ICD-10-CM Up-to-date classification systems will provide much better data for: Measuring the quality, safety, and efficacy of care Designing payment systems and processing claims for reimbursement Conducting research, epidemiological studies, and clinical trials

5 Setting health policy Operational and strategic planning and designing healthcare delivery systems Monitoring resource utilization

6 Improving clinical, financial, and administrative performance Preventing and detecting healthcare fraud and abuse Tracking public health and risks Decreases fraud, waste, and abuse

7 Only a very small percentage of the codes will be used by most providers. Dispelling Myths Too Many Codes 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10-CM codes are related to fractures ~25,000(36%) of all ICD-10-CM codes to distinguish right vs. left

8 Testing Special acknowledgement testing weeks give submitters access to real-time help desk support and allows CMS to analyze testing data. Registration is not required. Mark your calendar and watch your Part B bulletins for information: March 2 through 6, 2015 June 1 through 5, 2015

9 This is different from end-to-end testing. Watch the CMS website asking for volunteers to perform end-to-end testing.

10 ICD-10-CM-and-GEMs.html

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13 The Anatomy of ICD-10 structure Alpha (not U) Numeric <Can be any combination of alpha or numeric characters> 1 st characte r 2 nd characte r 3 rd characte r 4 th characte r 5 th characte r 6 th characte r 7 th characte r Category Etiology, Anatomical Site, Severity Extension 3 character codes ONLY if not further subdivided Codes without all required characters are invalid Alpha characters are NOT case specific (e.g., s93.401a) 13

14 By Disease ICD-9 Codes ICD-10 Codes Fractures Poisoning and toxic effects Pregnancy related conditions Brain Injury Diabetes Migraine Bleeding disorders Mood related disorders Hypertensive Disease 33 14

15 Specialty ICD-9 ICD-10 Hypertension, unspec I10 Hyperlipidemia E78.5 Diabetes E11.9 Hypertension, benign I10 Hypothyroidism E03.9 Fatigue R53.83 GERD K21.9 Anxiety F41.9 Depression 311 F32.9 Well adult exam V70.0 Z00.01

16 Diabetes found at E08 thru E13 E08 Diabetes mellitus due to underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type 1 diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus

17 Additional diabetes codes are found in the OB Chapter 15 with; Pre-existing diabetes at O (Type 1 and Type 2) Gestational Diabetes O24.41-

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19 E Diabetes mellitus due to underlying condition with foot ulcer E Drug or chemical induced diabetes mellitus with foot ulcer E Type 1 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with foot ulcer E Other specified diabetes mellitus with foot ulcer

20 Specialty ICD-9 ICD-10 Well child exam V20.2 Z00.1 URI J06.9 Fever R50.9 Otitis, unspec H66.90 Acute resp failure J96.00* Dermatitis, unspec L30.9 Allergic rhinitis J30.9 ADHD F90.1 Need for Vaccination, pneumonia V03.82 Z23** Asthma, unspecified J45.909

21 *perinatal/newborn acute respiratory failure is P28.5 (first 28 days of life) **one vaccination diagnosis code for all of ICD-10-CM regardless of vaccine

22 Asthma Severity (Mild) intermittent asthma Mild persistent asthma Frequency of Daytime Symptoms Symptoms less than twice weekly and the patient is otherwise asymptomatic. Pulmonary function studies are normal except during periods of disease and exacerbations are brief and easily treated. Symptoms more than twice a week but less than daily. The symptoms are severe enough to interfere with daily activities and may interrupt sleep up to twice a month. Pulmonary function studies are normal or show mild airflow obstruction which is reversible with the inhalation of a bronchodilator. Moderate persistent asthma Symptoms occur daily, and the disease severity warrants regular use of medications for control. Patients are constantly aware of their disease, require medications on a daily basis, have their sleep interrupted at least weekly, and have to accommodate their life style to the disease. Pulmonary function is moderately abnormal, with the FEV1 being 60-80% of the predicted value. Severe persistent asthma Continuous symptoms despite the correct use of medications. The severity of the disease limits physical activities and is associated with frequent exacerbations and sleep interruption. Treatment requires combinations of medications on a constant basis. Pulmonary function tests are severely affected with the FEV1 being <60% of predicted.

23 J45. Asthma [ ] intermittent [ ] mild persistent [ ] moderate persistent [ ] severe persistent Check one of the following: [ ] uncomplicated [ ] exacerbation [ ] status asthmaticus [ ] exposure to environmental tobacco smoke (Z77.22) [ ] exposure to tobacco smoke in the perinatal period (P96.81) [ ] history of tobacco use (Z87.891) [ ] occupational exposure to environmental tobacco smoke (Z57.31) [ ] tobacco dependence (F17.-) [ ] tobacco use (Z72.0)

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27 AVOIDING UNSPECIFIED WHENEVER POSSIBLE

28 Early onset delivery before 37 weeks O60.1 X **** Specialty ICD-9 ICD-10 Single, Live born infant V27.0 Z37. * 2 Routine Gynecological Exam V72.31 Z Spontaneous vaginal delivery 650 O8Ø First degree perineal laceration, delivered O7Ø.Ø Previous c-section delivery, delivered O34.21 Supervision of other normal pregnancy V22.1 Z34.Ø ** Cord entanglement w/o compression O69.8 XØ*** Second degree perineal laceration, deliv O7Ø.1 Menorrhagia N92.Ø

29 *Various combinations of 4th and some 5th character spaces. 2 Secondary code only ** 5th character space is for trimester ***Different choices in position character space 5 for with or without compression **** 5th character space for trimester and 7th character for affected fetus

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31 These code categories all require the 7th character: O31, O32, O33, O35, O36, O4Ø, O41, O6Ø.1-, O60.2-, O64, O69 Ø not applicable or unspecified 1 fetus 1 2 fetus fetus 3 4 fetus 4 5 fetus 5 9 other fetus

32 O6Ø.1 x Preterm labor with preterm delivery [ ] trimester circle one [ ] 7th character fetus circle one below:

33 Specialty ICD-9 ICD-10* Osteoarthritis, unspec., knee M17.9 Knee joint pain M Osteoarthritis, localized, knee M17.9 Shoulder joint pain M Carpal tunnel syndrome G56.00 Complete rupture rotator cuff M Osteoarthritis, localized, hip M16.9 Hip joint pain M Old derangement medial meniscus M Fracture, lower end, unspec, femur S th & 7th character**

34 *The majority of these codes are not an exact match ** 6th character +left or right, 7th character see sample: The appropriate 7th character is to be added to all codes from category S72 A - Initial encounter for closed fracture B - Initial encounter for open fracture type I or II initial encounter for open fracture NOS C - Initial encounter for open fracture type IIIA, IIIB, or IIIC D - Subsequent encounter for closed fracture with routine healing E - Subsequent encounter for open fracture type I or II with routine healing F - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - Subsequent encounter for closed fracture with delayed healing H - Subsequent encounter for open fracture type I or II with delayed healing J - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - Subsequent encounter for closed fracture with nonunion M - Subsequent encounter for open fracture type I or II with nonunion N - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - Subsequent encounter for closed fracture with malunion Q - Subsequent encounter for open fracture type I or II with malunion R - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - Sequela

35 Traumatic Fracture codes will always have 3 rd character space of 2 and always have a 7 th character: S12, S22, S32, S42, S52, S62, S72, S82, S92 Some fracture codes will need x placeholders: S32.2xx Fracture of coccyx This code category is not tracking any information in the 5 th or 6 th position but does require a 7 th character. Quick sheet: M25.5 Pain, joint location [ ]right [ ]left M24.4 Effusion, joint, location [ ]right [ ]left

36 Specialty ICD-9 ICD-10 ASHD native coronary artery I25.10 Hypertension, benign I10 Atrial fibrillation I48.91 Chest pain R07.9 Abnormal EKG R94.31 Angina pectoris I20.8 / I20.9 Hypercholesterolemia E78.0 Hyperlipidemia E78.4 Palpitations R00.2 Unstable angina I20.0

37 Acute MI codes changed from 8 weeks to 4 weeks or less duration in category I21 A code from category I22 subsequent MI must be used in conjunction with a code from category I21 MI when the subsequent MI occurs within 28 days of the original MI. Combination codes for ASHD of native coronary artery, bypass grafts (autologous or nonautologous vein or artery) with unstable angina, angina pectoris, documented spasm *********************

38 To find NCD s that may affect your practice with ICD- 10-CM codes go to: eninfo/icd10.html

39 Additional free resources: Visit: Download your action plan

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