ICD-10 Conversion Awareness Training

Transcription

1 ICD-10 Conversion Awareness Training Presenters Dr. Nina Jo Muse Mirsa Douglass Steve Eichner 05/30/12 The term ICD-10 used throughout this presentation refers to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure ) codes. It does not include the ICD-10 set of codes used for mortality statistics.

2 Disclosure to Participants Requirements for Successful Completion of Continuing Education Activity Requires: 1. Completing the registration form, 2. Signing the Sign in Sheet, 3. Attending the entire educational activity, Disclosure to Participants 4. Participating in education activities instructed, and 5. Completing the participant evaluation. Commercial Support: This educational activity received no commercial support. Disclosure of Conflict of Interest The speakers and planning committee have disclosed no conflict of interest. Non-Endorsement Statement Accredited status does not imply endorsement by Department of State Health Services, Continuing Education Service Program of America Nurses Credentialing Center of any commercial product displayed in conjunction with this activity. Off-Label Use The speakers did not disclose the use of products for a purpose other than what it had been approved for by the Food and Drug Administration. Expiration Date for Awarding Contact Hours Complete the attendance sheet and evaluation by the end of the conference. 2

3 ICD-10 Awareness Training Objectives Describe the intent of the federal mandate related to ICD-10 and identify who the mandate applies to. Briefly describe the difference between ICD-9 coding and ICD-10 coding. Explain the connection between HIPAA and the federal mandate for ICD-10 conversion. Describe important operational impacts resulting from the hard switch conversion. Describe how the ICD-10 conversion may impact your specific work area. 3

4 ICD-10 Federal Mandate January 16, A final rule from the US DHHS Centers for Medicare and Medicaid Services (CMS) mandates the use of ICD-10 code sets for HIPAA standard transactions. Who does the rule apply to? Applies to covered entities (i.e., health plans, health care clearinghouses, and health care providers ) who transmit health information in electronic form in connection with HIPAA standard transactions. This includes providers and payers who do not deal with Medicaid and Medicare claims. 4

5 Health Insurance Portability Accountability Act (HIPAA) of 1996 HIPAA encompasses many regulations with some illustrated below.. Privacy Rule A patient information privacy rule (i.e., privacy rights) Security Rule - An electronic patient information security rule Electronic Data Interchange Rule transaction standards law so that healthcare companies may exchange medical, billing and patient information more efficiently. 5

6 Data Interchange Rule-Health Insurance Portability Accountability Act (HIPAA) of 1996 Before HIPAA, entities used different systems to process patient bills and other administrative information. Considerable time was spent to ensure claims had proper formats, codes and other details required by different insurers and payers. The HIPAA Electronic Data Interchange Rule (EDI Rule) allowed for the adoption of national standards for electronic health care transactions. (Keep in mind this pertains to HIPAA transactions.) National standards provide a common language for exchanging electronic data and a common coding structure for classifying diagnosis and procedures. 6

7 HIPAA Standard Transaction Defined HIPAA standard transaction defined simply means these transactions are transmitted using standard formats specified in HIPAA regulations. HIPAA regulations mostly specify standards developed by the Accredited Standards Committee (ASC) X12N (Insurance Subcommittee). 7

8 NOTE: Above is a sample of HIPAA standard transactions. The complete list is included in the HIPAA EDI Rule. 8

9 ASC X12 Standards and ICD Codes ASC X12 are standards used for formatting information for the electronic transmission of healthcare transactions. The ASC X12 standards incorporate coding sets (i.e., ICD-9, ICD-10-CM, and ICD-10-PCS which are common languages used to identify diagnosis and procedures). 9

10 What About 5010?? 5010 is simply describing a version of X12 HIPAA standard transactions. The version upgrade to 5010 was necessary so that HIPAA standard transactions could accommodate the more complex ICD-10 code set. Remember, the ICD-10 code sets are incorporated in the ASC X12 transaction standard. 10

11 Healthcare Clearinghouses and HIPAA Transactions Sends response reports Secure transmission of transaction responses in ASC X12 format Healthcare Related Entity Healthcare Clearinghouse Insurance Carrier or Payer DSHS Contractors Sends billing files with claim info Secure transmission of transactions in ASC X12 format TMHP HMO MCO, etc Not necessarily HIPAA Standard Transactions HIPAA Standard Transactions 11

12 Coding Standards Background Diagnostic and medical procedure information is captured during patient encounters to track clinical progress. Initially, diagnostic and procedural information is captured in narrative form. In general, coding translates words into numbers or alphanumeric strings, e.g. 1AB3E47. Coding facilitates the classification of diagnosis and procedures to: Determine eligibility File claims for payment Conduct research Track diseases Measure population health Describe cause of death Standardized coding makes data collection and data analysis easier. ICD is a coding standard. 12

13 Major Coding Standards International Classification of Diseases (ICD) ICD-9 managed by World Health Organization (WHO) ICD-9-CM (diagnostic codes) ICD-9-PCS (procedure codes) managed by managed by Centers for Medicare & Medicaid Services (CMS) National Center for Health Statistics (NCHS) Current Procedural Terminology (CPT) CPT-4 managed by American Medical Association (AMA) Diagnostic & Statistical Manual of Mental Disorders (DSM) DSM-IV American Psychiatric Association (APA) managed by 13

14 Common Procedure Terminology (CPT) CPT and ICD are two different coding sets used in different circumstances. Separate coding system Developed by a separate organization Designed to be used for a separate provider type Developed by the American Medical Association. Created by doctors, to be used by doctors Used for physician services whether inpatient or outpatient. CPT is not impacted by ICD-10 conversion. IMPORTANT: The final rule for ICD-10 conversion does not affect CPT coding. This is because CPT is devised for coding services not covered under ICD-10-PCS. 14

15 Diagnostic and Statistical Manual of Mental Disorders (DSM) Current version is DSM-IV. Developed by American Psychiatric Association. To provide a more detailed evidence-based diagnostic system than what was originally provided by ICD. Used only in the United States by behavioral health professionals for diagnosis coding. The APA and the DSM committee had input into the formation of ICD-10. ICD-10 behavioral health coding was based on DSM-IV. DSM-IV code are ICD-9 codes (from Chapter 5-Mental disorders) 15

16 International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) ICD-9 (WHO) Volume 1 & 2 (CMS) ICD-9-CM Clinical Modification For use in the US Volume 3 (NHCS) Used internationally Devised as a mortality coding tool Most of the world currently uses the latest version, ICD-10 Diagnosis codes Used by physicians and other individual providers Procedure codes Used by hospitals, not individual physicians or providers Referred to as ICD-9-PCS 16

17 ICD-9 to ICD-10 17

18 Example from Chapter 5- Mental Disorders All diagnoses related to alcohol ICD-9 11 Codes (22 DSM IV Diagnoses) ICD Codes 18

19 ICD-9-CM Coding Structure 3 5 character All characters are numeric (Chapters 1-17) Other chapters: first character is letter (E or V), remainder are numeric Decimal after the first three characters (xxx.) 19

20 ICD-10 Coding Structure 3 7 characters First character is always a letter (U is not used) Second and third characters are numeric Decimal placed after the first three characters Fourth, fifth, sixth and seventh characters may be letters or numeric Seven th Digit Extension Visit encounter (initial: A; subsequent: D) Sequelae = S injuries and external causes 20

21 Coding ICD-9 CM Code: (Chapters 1-17) ICD-10 Code: = Number = Letter = Alphanumeric Category F Category Manifestation, Etiology, Anatomic Site Severity, Etiology, Anatomic Site Extension 21

22 Mapping Between ICD-9 and ICD-10 95% of ICD-10 diagnosis codes will not map exactly to ICD-9 codes 75% of all ICD-9 diagnosis codes will not map exactly to ICD-10 codes All other diagnosis mappings will either lose information or make assumptions. Imperfect mapping will impact revenue, costs, risks and relationships 22

23 General Equivalency Mappings (GEMS) Does not resolve the one to many scenarios Over 30% of transactions reviewed have codes that include one-to-many mapping options Does not provide mappings for all Codes Only 52% of codes have the same relationships both directions 23

24 ICD-9 ICD-10 Mappings No Mapping Many: 1 Combination Complexity of mappings will determine risk of inaccurate processing Risk 1: Many Both (Single and Combination)c 1: Many Combination 1: Many Single High Risk Very High Risk 1:1 Approximate 1:1 Exact Moderate Risk Low Risk Risk Undetermined Code Missing (Requires Research) 24

25 ICD-9 ICD-10 Mappings Exact Match Minimizes Risk Complexity of mappings will determine risk of inaccurate processing Risk No exact matches in alcohol-related diagnoses in Chapter 5 1:1 Exact Low Risk Exact match indicates matching definitions 25

26 ICD-9 ICD-10 Mappings Moderate Risk Complexity of mappings will determine risk of inaccurate processing Risk Alcohol withdrawal with perceptual disturbance Alcohol dependence with withdrawal with perceptual disturbance F :1 Approximate Moderate Risk Matching clinical meanings with differing language 26

27 Complexity of mappings will determine risk of inaccurate processing ICD-9 ICD-10 Mappings High Risk Alcohol Use, Unspecified with Alcohol-Induced Mood Disorder F10.94 Alcohol Abuse with Alcohol-Induced Mood Disorder F10.14 Risk Alcohol-Induced Mood Disorder Alcohol Dependence with Alcohol- Induced Mood Disorder F : Many Single High Risk Several options for a similar clinical meaning with increased specificity. Choose 1

28 ICD-9 ICD-10 Mappings Very High Risk Complexity of mappings will determine risk of inaccurate processing No examples in alcohol-related diagnoses in Chapter 5 Risk 1: Many Both (Single and Combination) Very High Risk An ICD-9 code maps to 2 or more ICD-10 codes in combination in order to maintain clinical parity 28

29 ICD-9 ICD-10 Mappings Very High Risk Alcohol Intoxication Delirium Complexity of mappings will determine risk of inaccurate processing Risk Alcohol Abuse Alcohol Abuse with Intoxication Delirium F Many: 1 Combination 2 or more ICD-9 codes map to a single ICD-10 code 29

30 ICD-9 ICD-10 Mappings Very High Risk Complexity of mappings will determine risk of inaccurate processing Risk Alcohol Dependence on Agonist Therapy No Mapping Very High Risk 30

31 Impact on DSHS and Providers What does the final rule compliance mean? Required use of ICD-10-CM (diagnosis) and ICD- 10-PCS (procedures) in HIPAA standard transactions. ICD-10-CM (diagnosis) will be used by all providers in every health care setting. ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures. ICD-10-PCS will not be used on physician claims, even those for inpatient settings. 31

32 IMPORTANT: There is no grace period for ICD-10 conversion. There is no phased-in approach. It is a hard switch from ICD-9 to ICD-10. IMPORTANT: For a period of time, both ICD-9 and ICD-10 will be in play. Claims will be based on the date of service or date of discharge, not the date of transmission. Claims for services or discharge performed before October 1, 201X, but submitted on or after it, should be submitted, processed, and adjudicated using ICD-9. Services/discharges performed October 1 or later should be submitted and processed using ICD

33 Types of Impacts Business Aspects (Policy and Processes) Technical Aspects ICD Conversion Outreach Training 33

34 Business Impacts Reviewing policies, written and unwritten Codes, regulations, etc. Mapping ICD-9 codes to ICD-10 codes (DSHS function) Mapping for clinical intent Mapping for cost neutrality for reimbursements Developing strategies for delayed reimbursement (setting aside funds, additional human resources to manage activity) Updating documentation and forms w/icd-10 Reviewing changes on reports (i.e., trending) Updating contracts Outreach to stakeholders Training clinicians and coders 34

35 Technical Impacts Information systems handling ICD-9 codes and ICD-10 codes simultaneously. Updating information systems to accommodate new code structure. Meeting processing and storage capacity requirements to house increased volume of codes. Testing information systems and processes with all partners. 35

36 Partner Outreach & Training Impacts In general, ICD-10 code sets contain more specificity & acuity (level of detail) than ICD-9. Physicians must include more details in narrative notes about diagnosis and procedures for patients for coders to identify the proper ICD-10 code. Coders must have greater knowledge in anatomy & medicine overall to accurately code. Partners must be aware of DSHS policy changes, Expectations and timing of claims testing, for both ICD-9 and ICD-10, Monitoring demands of ensuring compliance of current or future EMR, EHR and/or practice management vendors 36

37 ICD-10 Conversion Enterprise Effort HHSC ICD-10 Project Manager Don Rau HHSC ICD-10 Coordinator HHSC ICD-10 Policy Workgroup DSHS ICD-10 Coordinator Mirsa Douglass DARS ICD-10 Coordinator DFPS ICD-10 (Foster Care Health Passport) HHSC ICD-10 Outreach Workgroup HHSC ICD-10 Data Mgmt Workgroup Other Workgroups DADS ICD-10 Coordinator 37

38 DSHS Project Team 38

39 Industry Resources Offered by American Association of Professional Coding and Navicure, the site includes timelines, white papers, and related news stories. The American Health Information Management Association site is filled with training materials for coders and other staff. The official CMS site. 39

40 Thank You MHSA Contact Information Project Coordinator - Steve Eichner steve.eichner@dshs.state.tx.us, (512) Business Lead - Valerie Shown valerie.shown@dshs.state.tx.us, (512) Business Lead - Nina Jo Muse ninajo.muse@dshs.state.tx.us, (512)