Head Start to Implementation: Preparing Now for ICD-10 (Focus on PCS)
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1 Head Start to Implementation: Preparing Now for ICD-10 (Focus on PCS) 3M All rights reserved. Marc Berlinguet, MD, MPH, CSPQ- International Medical Manager, 3M HIS Spain, September 15 and 16, 2009
2 Head Start to Implementation: Preparing Now for ICD-10 Reasons for change Basic structure of ICD-10-CM and ICD-10-PCS Differences between ICD-9 and ICD-10 Preparing for implementation and change 2
3 Reasons to Switch to ICD-10 ICD-9-CM has been used in the U.S. since 1979 cannot keep up with medical technology does not allow new codes to be added as needed 3
4 ICD code set: 1001 uses Set healthcare policy Determine reimbursement Conduct research and clinical trials Measure quality of health care Evaluate health care providers Provide treatment options Track and manage health risk and disease process 4
5 ICD-10-CM Development With consideration of other code sets: DSM-IV NANDA (nursing classification) ICD-O-2 5
6 ICD-10-CM: Major Changes Alphanumeric codes Addition of a 6th digit classification with a seventh digit extension Combination diagnosis/symptom codes Expanded injury codes, grouped according to site rather than type of injury Laterality V and E codes incorporated into the main classification 6
7 ICD-10-CM: Major Changes Obstetric codes identify trimester Separate categories for Type I and Type II diabetes Addition of ambulatory and managed care encounter information Postoperative complications codes expanded and located within the individual chapters 7
8 ICD Structure: Overview ICD-9-CM Numeric 17 chapters V codes and E codes additional ICD-10-CM Alphanumeric and includes all letters except U 21 chapters V-codes and E-codes in main classification 8 E => V, W, X, Y V => Z
9 ICD Structure: Overview Retained some ICD-9 modifications Combination codes A02.21 Salmonella meningitis A02.22 Salmonella pneumonia Removed some ICD-9 modifications No 5th digit for episode of care I21 Acute myocardial infarction I22 Subsequent acute myocardial infarction 9
10 ICD-10-CM Structure: Codes Valid codes can be 3, 4, 5, 6 or 7 characters K23 Disorders of esophagus in diseases classified elsewhere K44.1 Diaphragmatic hernia with gangrene K29.01 Acute gastritis with bleeding K Crohn s disease of lg. intestine with abscess S20.112a Abrasion of breast, left breast, initial encounter Source: 3M Health Information Systems 10
11 ICD-10-CM Structure :Codes A00-B99 C00-D48 G00-G99 H00-H95 I00-I99 O00-O99 Infectious/Parasitic Disease Neoplasms Nervous System Sense Organs Circulatory System Pregnancy/Childbirth 11 First character always a letter Second and third characters always numbers Fourth and fifth characters either numbers or letters In some cases, fifth character uses lowercase x as place holder : T38.1x5 Systems Source: 3M Health Information
12 ICD-10-CM Example: Injury Seventh Character Extensions Expansion of injury codes S Abrasion of ear, right ear 5th digit defines type of injury 6th digit defines laterality 12
13 ICD-10-CM Example: Combination codes Combination codes for diagnosis and symptom I25.12 Atherosclerotic heart disease with unstable angina N41.01 Acute prostatitis with hematuria K71.51 Toxic liver disease with chronic active hepatitis with ascites 13
14 ICD-10-CM Example: Obstetrics ICD-10-CM O15.03 Eclampsia in pregnancy, third trimester: O15 = Eclampsia.0 = in pregnancy 3 = third trimester ICD-10 (WHO version) O15.0 Eclampsia in pregnancy 14
15 ICD-10-CM Example: Diabetes E Type 2 diabetes mellitus with foot ulcer E11 = Type 2 diabetes mellitus.6 = with other specified complications 2 = skin complications 1 = foot ulcer 15
16 ICD-10-CM: Field Testing Project National Committee on Vital and Health Statistics (NCVHS) called for ICD-10-CM coding study by Health and Human Services (HHS) Conducted June-August ,177 medical records coded ICD-10-CM seen as improvement Sixteen hours or less of training needed No time difference in coding 16
17 Development of ICD-10-PCS PCS Procedure Coding System Replacement for ICD-9-CM, procedures 1998 first version released by CMS Annual updates since that time Not in use at this time 17
18 I-10 PCS: Essential Characteristics Seven Character Alphanumeric Code Digits 0-9 Letters A-H, J-N, P-Z Source: 3M Health Information Systems 18
19 I-10 PCS: Essential Characteristics Completeness: unique code for every distinct procedure Expandability: easily adapts to changes in technology and clinical practice Standardized terminology: terms have a single precise meaning Multiaxial: fixed order, each character functions independently 19
20 PCS Character Assignment: Medical and Surgical Procedures 1st 2nd 3rd 4th 5th 6th 7th Section Root Operation Approach Qualifier Body System Body Part Device Source: 3M Health Information Systems 20
21 PCS Codes: Each Code Tells a Story Z Med/Surg Drainage Open None CNS Brain Drainage Device Source: 3M Health Information Systems 21
22 Section (1 st character) 1st 2nd 3rd 4th 5th 6th 7th 0 Medical and Surgical 9 Physical Rehabilitation and 1 Obstetrics Diagnostic Audiology 2 Placement B Extracorporeal 3 Administration Assistance and Performance 4 Measurement and Monitoring C Extracorporeal Therapies 5 Imaging D Laboratory 6 Nuclear Medicine F Mental Health 7 Radiation Oncology G Chiropractic 8 Osteopathic H Miscellaneous J Substance Abuse Treatment 22
23 Body System (2 nd character) 1st 2nd 3rd 4th 5th 6th 7th Identifies general area of procedure Examples: 1 Peripheral Nervous System 2 Heart and Great Vessels B Respiratory System C Mouth and Throat D Gastrointestinal System 23
24 Root Operation (3 rd character) 1st 2nd 3rd 4th 5th 6th 7th Identifies essential surgical action performed Examples in Medical/Surgical: 0 Alteration 4 Creation 1 Bypass 5 Destruction 2 Change 6 Detachment 3 Control 7 Dilation 24
25 Body Part (4 th character) 1st 2nd 3rd 4th 5th 6th 7th Describes specific body part on which the procedure was performed Body parts include lesions, polyps, etc. found in/on the body part Example: body system D, Gastrointestinal 0 Esophagus B Ileum 1 Esophagus, Upper J Appendix 5 Upper Intestine W Peritoneum 25
26 Approach (5 th character) 1st 2nd 3rd 4th 5th 6th 7th Indicates the method used to reach the body part 13 different approaches made up of three basic types, plus the external approach: Open => Open intraluminal Percutaneous=> Percutaneous intraluminal Transorifice=> Transorifice intraluminal 26
27 Device (6 th character) 1st 2nd 3rd 4th 5th 6th 7th Describes a device placed during the procedure Applies only to devices that remain after the procedure is completed Grafts and prostheses (skin graft, joint prosthesis) Implants (IUD, brachytherapy seeds) Simple/Mechanical Appliances (tracheostomy tube, VAD) Electronic Appliances (pacemakers, infusion pumps) 27
28 Qualifier (7 th character) 1st 2nd 3rd 4th 5th 6th 7th Unique meaning for different root operations Examples: Genetic compatibility of transplant Biopsy (diagnostic excision) Destination site for a bypass Original procedure being revised 28
29 Number of PCS codes by section= 86, Medical and Surgical 77,242 Obstetrics 331 Placement 864 Administration 1,401 Measurement and Monitoring 290 Extracorporeal Assistance and Performance 26 Extracorporeal Therapies 34 Osteopathic 100 Other Procedures 21 Chiropractic 90 Imaging 2,466 Nuclear Medicine 458 Radiation Oncology 1,823 Rehabilitation and Diagnostic Audiology 1,382 Mental Health 30 Substance Abuse Treatment 59
30 I-10-PCS Book Format Matrix and index Index provides first three or four characters Matrix must be used to build valid code No eponyms are included 30
31 0: Medical and Surgical Section D Gastrointestinal System B: EXCISION: Cutting out or off, without replacement, a portion of a body part. 1 Esophagus, upper 2 Esophagus, middle 3 Esophagus, lower 4 Esophagogastric junction 6 Stomach 7 Stomach, pylorus 9 Duodenum A Jejunum B Ileum C Ileocecal valve H Cecum J Appendix K Ascending Colon L Transverse Colon M Descending Colon N Sigmoid Colon P Rectum Q Anus R Anal Sphincter S Greater Omentum T Lesser Omentum V Mesentery W Peritoneum 0 Open 1 Open Intraluminal 2 Open Intraluminal Endoscopic 3 Percutaneous 4 Percutaneous Endoscopic 5 Percutaneous Intraluminal 6 Percutaneous Intraluminal Endoscopic 7 Transorifice Intraluminal 8 Transorifice Intraluminal Endoscopic 0 Open 1 Open Intraluminal 2 Open Intraluminal Endoscopic 3 Percutaneous 4 Percutaneous Endoscopic 5 Percutaneous Intraluminal 6 Percutaneous Intraluminal Endoscopic 7 Transorifice Intraluminal 8 Transorifice Intraluminal Endoscopic Z None 0 Open 3 Percutaneous 4 Percutaneous Endoscopic Z None Z None Z None X Diagnostic Z None X Diagnostic Z None X Diagnostic Z None 31
32 PCS Code Example: EGD with biopsy of stomach 0 D B 6 8 Z X Med/Surg Excision Transorifice Intraluminal Endoscopic Diagnostic Gastrointestinal Stomach None Source: 3M Health Information Systems 32
33 PCS Code Example: Drainage of liver, open 0 F Z Z Med/Surg Drainage Open None Hepatobiliary Liver None Source: 3M Health Information Systems 33
34 I-9-CM to I-10-PCS: Excisional debridement of skin ICD-9-CM CM ICD PCS Description HBJZZZ Excision, skin right upper leg HBLZZZ Excision, skin right lower leg HB9ZZZ Excision, skin buttock HBPZZ Excision, skin left foot 34 Source: 3M Health Information Systems
35 ICD-10: Implementation Issues Codes are the language of healthcare When the code set changes it will affect all healthcare providers and payers Areas of impact: Health Information Management (HIM) Patient Financial Services (PFS) Information Services (IS) 35
36 HIM: Implementation Issues Evaluate education needs: Expertise in medical terminology Detailed knowledge of anatomy Better comprehension of operative reports Increased collaboration with medical staff Comprehension, interpretation and application of ICD-10-PCS definitions Source: 3M Health Information Systems 36
37 HIM: Implementation Issues Consider alternative ways to increase the capabilities of coding staff Begin a mentor program ( train the trainer ) Cross train (assign leadership) Monthly education sessions (tracking, Q&A) 37
38 HIM: Implementation Issues Clinical Impact Physician Documentation Is the key to appropriate coding Has been a problem since 1900s Will need to meet expanded requirements 38
39 HIM: Implementation Issues Single most important step to take in determining weakness: Gap analysis of current documentation and coding practices Audit for weaknesses in: Coder knowledge of anatomy and surgical procedures Physician documentation Source: 3M Health Information Systems 39
40 Pay For Service: Implementation Issues Budgetary Impact Hospital Finance Inventory all reports containing procedure DRG information Determine source of reports Clinical Impact Reports should be inventoried By department, By user, By content Source: 3M Health Information Systems 40
41 Information Systems: Implementation Issues Retention of both ICD-9-CM and ICD-10 codes are based on the facility s needs for Research data Trending of clinical data and comprehensive clinical studies Case-mix analysis Financial information connected with DRGs Source: 3M Health Information Systems 41
42 ICD-10 Preparation Educate affected personnel HIM, Clinicians, Management, other departments Vendor preparation Contract renewals Communicate with regulatory agencies and payers Plan for transition Teams, staffing, training, going live Source: 3M Health Information Systems 42
43 ICD-10 Preparation Task Force members should include, but not be limited to: Health Information Management Patient Financial Services Information Services Medical Staff Affairs Physician liaisons Quality Management Hospital Finance 43
44 ICD-10-CM resources Access ICD-10-CM on the NCHS website: ICD-9-CM Coordination and Maintenance Meeting 44
45 ICD-10-PCS resources Access ICD-10-PCS on the CMS website: 3M 10.jhtml 45
46 Thank you! 46
47 ICD-10CM Resources Questions/Comments? Marc Berlinguet: Rachael D Andrea: [email protected] 47
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