ICD-10 An Introduction to the New Diagnosis Coding The Untold Story Charles Jarvis, Senior Manager Health Reform cjarvis@cokergroup.com 610-811-4015/848-992-0281
Agenda Brief Overview of ICD-10 ICD-10 Reality Check Where to Start The Technical ICD-10 Impact Making the Transition Contingency Planning Summary & Questions
Top 10 Signs You are Not Ready for ICD-10 1. Your office is still using ICD-4 2. Your coding books are 2 years behind 3. The practice management system is not modern 4. No EHR strategy 5. No formal compliance training program 6. High volume of coding denials 7. Not sending claims electronically 8. No checks and balances 9. No self-audits 10. Your coder is in jail! 3
Brief Overview 4
International Classification of Diseases (ICD) ICD-10 was endorsed by the 43rd World Health Assembly in May 1990 and came into use in WHO Member States as from 1994. The classification is the latest in a series which has its origins in the 1850s. The first edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893. 25 countries use ICD-10 for reimbursement and resource allocation in their health system A smooth, successful transition by the compliance date of October 1, 2015, requires a well-planned and well-managed implementation process Experience in other countries has shown that early preparation is the key to success. Organizations that start early can spread their resources across multiple years, rather than incurring a large budgetary investment at one time 5
Why Does IDC-10 Matter? Diagnoses and procedure codes impact virtually every system and business process in plan and provider organizations, with significant impacts on billing and reimbursement 6
Impacts of Other Changes High Deductible Health Plans Major increases in patient responsibility No requirement to spend HSA money on medical expense Real Time Adjudication Near instantaneous response to a provider claims Know patient responsibility immediately Less bad debt? 7
Why the change? The current system, ICD-9-CM, does not provide the necessary detail for patients medical conditions or the procedures and services performed on hospitalized patients. ICD-9-CM is 30 years old, Has outdated and obsolete terminology (no code for ebola as a stark example!), uses outdated codes that produce inaccurate and limited data, and is inconsistent with current medical practice. It cannot accurately describe the diagnoses and inpatient procedures of care delivered in the 21st century. http://www.cms.hhs.gov/icd10 8
Examples of ICD-10 Specificity W21.00 Struck by hit or thrown ball, unspecified type W21.01 Struck by football W21.02 Struck by soccer ball W21.03 Struck by baseball W21.04 Struck by golf ball W21.05 Struck by basketball W21.06 Struck by volleyball W21.07 Struck by softball W21.09 Struck by other hit or thrown ball W21.31 Struck by shoe cleats Stepped on by shoe cleats W21.32 Struck by skate blades Skated over by skate blades W21.39 Struck by other sports foot wear W21.4 Striking against diving board W21.11 Struck by baseball bat W21.12 Struck by tennis racquet W21.13 Struck by golf club W21.19 Struck by other bat, racquet or club W21.210 Struck by ice hockey stick W21.211 Struck by field hockey stick W21.220 Struck by ice hockey puck W21.221 Struck by field hockey puck W21.81 Striking against or struck by football helmet W21.89 Striking against or struck by other sports equipment W21.9 Striking against or struck by unspecified sports equipment 9
ICD-10CM vs. ICD-10PCS ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts: 1. ICD-10-CM for diagnosis coding 2. ICD-10-PCS for inpatient procedure coding ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD- 10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar. ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding. 10
ICD-9-CM vs. ICD-10-CM ICD-9-Clinical Modifications 3-5 characters in length 3-7 characters About 13,000 diagnosis codes Limited space for new codes Lacks detail Difficult to analyze data Limited ability to identify affected body parts or organs Inadequate diagnoses hamper medical research Not used by other countries ICD-10-Clinical Modifications About 68,000 codes Flexible for adding new codes Very specific Data are richer and more accurate Allows laterality and bilaterality More accurate diagnoses boost research Allows data exchange 11
Example of PCS Code ICD-9-PCS (sample code) 47.01 Laparoscopic appendectomy ICD-10-PCS (sample code) Laparoscopic appendectomy 0DTJ4ZZ 0 - Medical and Surgical Section D - Gastrointestinal system T - Resection (root operation) J - Appendix (body part) 4 - Percutaneous endoscopic (approach) Z - No device Z - No qualifier 12
Structure of ICD-10 PCS 13
Benefits and Challenges Mandatory Cost time and money Learning something different Documentation requirements Improve business practices Improve reporting Reduce costs Increase efficiency Improve timely claim processing 14
ICD-10 Reality Check There are a lot of rumors flying around the medical billing industry about the transition to ICD-10 codes and what it will mean for providers, payers and associated vendors. Here are a few FACTs. ICD-10 Codes far outnumber those in ICD-9: TRUE The ICD-10 manual lists 68,000 codes, versus the 13,000 codes represented in ICD-9: TRUE ICD-10 codes are different than ICD-9: TRUE ICD-10 codes have up to seven digits, in part because they are more detailed and include information on the type of encounter and laterality of the condition: TRUE Your vendor will be ICD-10 compliant by the deadline: Mostly TRUE Making sure your vendor is ICD-10 compliant is the only thing to worry about: FALSE 15
Vendor Readiness Interfacing Cross Walking Third Party Partners 16 Leadership Awareness Electronic Health Records Staff Training Payers Clearinghouses Policy Updates TESTING Impact Assessments Departments Upgrading IT systems
ICD-10 Timeline Now 2015 Source: Ingenix 17
Important ICD-10 Compliance Dates... Level 1 Compliance: Complete by December 31, 2010 You can create and receive compliant transactions and can process them WITHIN YOUR OWN SYSTEMS. Level 2 Compliance: Complete by December 31, 2011 You have completed end-to-end testing with each of your trading partners, and are able to completely process transactions with the new versions of the standards. Level 3 Compliance: Complete by October 2015 Must by 100% ICD-10 compliant or utilize a cross walking tool. Source:: Refer to Centers for Medicare and Medicaid Services (CMS); Information on 5010 / D.0 for exact wording. http://www1.cms.gov/electronicbillingeditrans/18_5010d0.asp 18
19 WHERE TO START..
5 Critical Success Factors 1. Leadership Awareness 2. Project Governance 3. Staff Education 4. Communication 5. Develop a plan 20
At a high level... both HIPAA 5010 and ICD-10 appear to be on track... The Vendor Level Communicating Clearinghouses Tools & Solutions Testing At the Industry level Documentation Standards Policies 21 But How Does all This Impact YOUR Practice.
In Reality HIPAA 5010 and ICD-10 impact the following... Processes People Technology Operations 22
The Internal Impact... Registration ABNs Medical Necessity Rules Billing Software Functionality Encoding tools Compliance Training Staff Billing Financial Systems Billing System Claims Submission Scrubbing tools Editing tool Clearinghouse Tracking and Reporting Administration Compliance Risk managements Staff Training Reporting Disease Management Registries Utilization Tracking Compliance Manage Care HEDIS Provider productivity Clinical Information Systems EHR PACS erx LIS Interfacing Supply chain IT infrastructure Software Upgrades Hardware Upgrades Testing Gap Solutions Etc
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External Impact... Your external trading partners and /or vendors must also comply Insurance companies EDI Vendors / Clearinghouse providers Billing Companies EHR / PM Vendors Coding Vendors Scrubbing Tools Hardware Auditing tools
The Technical Side of ICD-10: Cutting Through the Noise, Hype and Myths
Tech Side of ICD-10 This is NOT exclusive to just the I.T. dept. Every IT system in the institution needs to be part of the ICD10 assessment Any and all systems that captures, shares and stores codes and/or interfaces with accounting/billing/ehr/cpoe/lis/ris/rx are potentially affected. 27
Tech Side of ICD-10 Systems Potentially Impacted Financial Reporting Hospital IS Registration Support Systems Clinical Systems Billing Systems Provider Profiling DRG Grouper Scheduling Case Mix Clinical Protocols Financial Systems Quality Mgt. Encoding Software ABNs Utilization Mgt. Ordering Claims Submission Disease Mgt. Abstracting Systems Medical Necessity Quality Mgt. Reminders Scrubbing Software Registries Compliance Case Mgt. Disease Mgt. Determinations State Reporting Medical Necessity Performance Mgt. CPOE Fraud Mgt. EHR Patient Assessment LIS Data sets PACE Aggregate Data EKG Managed Care 28
Completing an Impact Assessment What to consider... Conduct an Assessment to determine the current state of effort applied toward achieving compliance for both HIPAA 5010 & ICD-10. Identify any gaps (i.e. Gap Analysis) that exist including, but not limited to: o Workflow, process, policy, and technology considerations o Readiness level o All related projects o Resource Allocation o Contingency considerations, etc. Starting having discussions and meetings with all your vendors and trading partners Identify documents needing updating (Charge slips, superbills, policies, training manuals, etc...) Develop a contingency plan 29
Summary ICD-10 goes beyond just coding policy changes The technical side will be significant Must allow time for testing and validation prior to the deadline Start discussions now with all your vendors/suppliers Get promises in writing Complete an impact assessment Leverage knowledge sharing within your trade association 30
Resources Coker Group http://www.cokergroup.com AHIMA http://www.ahima.org/icd10 AAPC http://www.aapc.com/icd-10 CMS http://www.cms.gov/icd10 WHO http://www.who.int/classifications/icd CDC http://www.cdc.gov/nchs/icd.htm AMA http://www.ama-assn.org HealthSystems http://www.healthsystems.net Email upgrades @ healthsystems.net 31