Preparing for ICD-10 for Physicians

Preparing for ICD-10 for Physicians May 2011

Notices These coding suggestions and coverage guidelines do not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. See NCD 20.8 for Medicare covered indications for pacemakers and NCD 20.4 for Medicare covered indications for defibrillators. 2

CEUs for Coders A survey will be sent out to all registered participants a few days after the session. The CEU certificates will be included in the survey as attachments for those who listened to the entire session. AAPC This program has the prior approval of the American Academy of Professional Coders (AAPC) for 1 continuing education hour. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor. AAPC Index# MTI0322110521A. AHIMA This program has been approved for 1 continuing education unit for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). 3

Topics Preparing for ICD-10 An Introduction to ICD-10 for Cardiovascular Background ICD-10-CM Diagnosis Codes Other Impact ICD-10-PCS Procedure Codes DRGs under ICD-10 Appendix 4

Background 5

Components of ICD-10 ICD-10 has two main components: ICD-10-CM is for diagnosis codes and includes a tabular list, an index, and tables for drugs and neoplasms. ICD-10-PCS is for procedure codes and includes code tables and an index. There are other materials that are also officially part of the classification system, including: General Equivalence Mappings (GEMs) Official Guidelines for Coding and Reporting 6

This Is Going to Happen ICD-10 was adopted as the national standard under HIPAA and its use is mandatory (Federal Register, January 16, 2009, pp.3328-3362) Which components of ICD-10 must be used depends on the type of provider: Provider Setting Diagnoses Procedures Hospitals Inpatient ICD-10-CM ICD-10-PCS Hospitals Outpatient ICD-10-CM CPT ASCs Outpatient ICD-10-CM CPT Physicians Facility/Office ICD-10-CM CPT The effective date for implementation is October 1, 2013 7

ICD-10 Freeze Starting October 1, 2011, all codes in ICD-10 will be frozen for 3 years. The ICD-10 Coordination and Maintenance Committee announced the freeze to allow a period of stability for programming, publishing, and training prior to implementation of ICD-10. Limited updates may take place on October 1, 2012 and October 1, 2013 for new technologies and new diseases The deadline for submitting change requests prior to the freeze has already passed Regular annual updates will resume on October 1, 2014 8

Coding Updates Revisions and updates to ICD-10 are the responsibility of the ICD-10 Coordination and Maintenance Committee. CDC and CMS jointly chair the committee. Diagnosis codes are maintained and updated by CDC. Procedure codes are maintained and updated by CMS. The C&M Committee will continue to meet during the freeze to consider requests for code changes after the freeze is lifted. 9

GEMS The General Equivalence Mappings are a very useful tool for translating between ICD-9-CM and ICD-10. The forward GEM converts current ICD-9-CM codes to their equivalent ICD-10 codes The backward GEM converts ICD-10 codes back to ICD-9-CM codes While very handy, GEMS are not a substitute for learning ICD-10. They re intended for use in converting large databases, not for coding individual cases. 10

Limits of GEMS Because ICD-10 has greater specificity, many ICD-9-CM codes convert to more than one ICD-10 code. Example: 426.2, left bundle branch hemiblock There are other limits in GEMs conversion of ICD-9-CM codes to ICD-10: ICD-9-CM ICD-10-PCS 4262 I444 4262 I445 4262 I4460 4262 I4469 Some conversions are theoretically possible but unlikely Some codes convert to a cluster rather than one-for-one Some codes don t convert directly to ICD-10 at all In making the transition to ICD-10, the best way to use the GEMs is either as a starting place or for confirmation. 11

ICD-10-CM Diagnosis Codes 12

Format of ICD-10-CM Diagnosis Codes The format of ICD-10-CM has several new features: Codes can be from 3 to 7 characters long The first digit is always a letter (only U is not used) The second and third digits are always numbers The fourth to seventh digits can be letters or numbers A decimal is placed after the third digit Examples I11.0 Hypertensive heart disease with heart failure R55 Syncope T82.120A Displacement of cardiac electrode, initial encounter 13

Greater Specificity ICD-10-CM has far more diagnosis codes than ICD-9-CM. System # Diagnosis Codes ICD-9-CM 14,025 ICD-10-CM 68,069 The majority of new codes involve: Greater specificity for injuries, including site, type, and encounter Laterality (left, right, bilateral) Specificity for device complications, including encounter 14

Heart Block The heart block codes in ICD-10-CM are quite similar to those in ICD-9-CM. Complete heart block, a pacemaker indication, retains a distinct code ICD-10-CM doesn t make a distinction between Mobitz and other second degree blocks I44 Atrioventricular and left bundle-branch block I44.0 Atrioventricular block, first degree I44.1 Atrioventricular block, second degree Atrioventricular block, type I and II Mobitz block, type I and II Second degree block, type I and II Wenckebach's block I44.2 Atrioventricular block, complete Complete heart block NOS Third degree block 15

Other Conduction Disorders Other codes for pacemaker and defibrillator indications related to conduction are located in I45. Codes for bifascicular and trifascicular blocks were actually simplified; the codes reflect pacemaker indications and also remain CCs Long QT syndrome retains a distinct code, as needed to reflect the defibrillator indication I45 Other conduction disorders I45.2 Bifascicular block I45.3 Trifascicular block I45.6 Pre-excitation syndrome Lown-Ganong-Levine syndrome Wolff-Parkinson-White syndrome I45.8 Other specified conduction disorders I45.81 Long QT syndrome I45.89 Other specified conduction disorders Atrioventricular dissociation Interference dissociation Nonparoxysmal AV nodal tachycardia 16

Paroxysmal Tachycardia VT is an indication for defibrillators and retains its own code Re-entry ventricular arrhythmia has its own code Note that I47.0 and I47.1 are not assigned for AVNRT (atrioventricular nodal reentrant tachycardia) I47 Paroxysmal tachycardia I47.0 Re-entry ventricular arrhythmia I47.1 Supraventricular tachycardia Atrial paroxysmal tachycardia Atrioventricular paroxysmal tachycardia Junctional paroxysmal tachycardia Nodal paroxysmal tachycardia I47.2 Ventricular tachycardia I47.9 Paroxysmal tachycardia unspecified Tachycardia not documented as supraventricular, ventricular or paroxysmal is assigned to a symptom code. 17

Atrial Fibrillation and Flutter Like ICD-9-CM, the current version of ICD-10-CM has just two codes for atrial fibrillation and flutter. I48 Atrial fibrillation and flutter I48.0 Atrial fibrillation I48.1 Atrial flutter However, it is likely that this will be expanded on October 1, 2011 to capture more detail. WHO is updating the international version of ICD-10 for these codes and the US must maintain compatibility. A proposal was recently presented before the C&M Committee to create specific codes within I48 for atrial fibrillation documented as: First episode Paroxysmal Persistent Permanent PAF http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm March 9-10, 2011 proposals, pages 48-50 18

Other Cardiac Arrhythmias VF and SSS retain distinct codes, as needed for defibrillator and pacemaker indications The depolarization codes are new According to the ICD-10 Index, AVNRT is assigned to I49.8 I49 Ventricular fibrillation and flutter I49.0 Ventricular fibrillation and flutter I49.01 Ventricular fibrillation I49.02 Ventricular flutter I49.1 Atrial premature beats I49.2 Junctional premature depolarization I49.3 Ventricular premature depolarization I49.5 Sick sinus syndrome Tachycardia-bradycardia syndrome I49.8 Other specified cardiac arrhythmias I49.9 Cardiac arrhythmia unspecified 19

Heart Failure ICD-10-CM codes for heart failure are essentially the same as the ICD-9-CM codes. This is actually by intent. The main differences are: ICD-10-CM has no code for congestive heart failure per se; it s included in I50.9 for unspecified heart failure Congestive is a non-essential term for heart failure When any form of pulmonary edema (acute, chronic, unspecified) is present with heart failure, L50.1 for left ventricular failure is assigned 20

Heart Failure Code Structure For code assignment, it doesn t matter if the term congestive is documented or not I50 Heart failure I50.1 Left ventricular failure I50.2 Systolic (congestive) heart failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.3 Diastolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.4 Combined systolic (congestive) and diastolic (congestive) heart failure I50.40 Unspecified combined (congestive) heart failure I50.41 Acute combined (congestive) heart failure I50.42 Chronic combined (congestive) heart failure I50.43 Acute on chronic combined (congestive) heart failure I50.9 Heart failure, unspecified 21

Heart Failure Due to Hypertension ICD-10-CM also maintains the current coding practices for heart failure due to hypertension. An additional code is used from I50 to show the type of heart failure ICD-10-CM does not differentiate between benign, malignant, and unspecified hypertensive disease I11 Hypertensive heart disease I11.0 Hypertensive heart disease with heart failure Hypertensive heart failure Use additional code to identify type of heart failure (I50.-) I11.9 Hypertensive heart disease without heart failure ICD-10-CM has similar codes for hypertensive heart and chronic kidney disease. 22

Heart Failure Documentation Heart failure has a major impact on hospital DRG assignment as a secondary diagnosis for CCs and MCCs. Because heart failure is an indication for defibrillators and bi-ventricular devices, it also has a major impact as principal diagnosis. Physicians should avoid use of the abbreviation CHF For all heart failure, physician documentation should specify: diastolic or systolic or combined acute or chronic or acute on chronic For patients admitted for insertion of a defibrillator, CRT-P or CRT-D, the admitting documentation must clearly identify the role of heart failure in leading to the admission 23

Chest Pain Chest pain codes are both reorganized and expanded. ICD-10-CM more clearly differentiates anterior chest wall pain from types of respiratoryrelated pain According to the index, code R07.89 also classifies chest pressure, tightness, and discomfort R07 Pain in throat and chest R07.0 Pain in throat R07.1 Chest pain on breathing Painful respiration R07.2 Precordial pain R07.8 Other chest pain R07.81 Pleurodynia R07.82 Intercostal pain R07.89 Other chest pain Anterior chest wall pain R07.9 Chest pain unspecified 24

Coronary Artery Disease There are over 35 codes for CAD, reflecting different types of vessels as well as combination codes for CAD with angina. Category I25.1 is for CAD of native coronary vessels Category I25.7 is CAD of other coronary vessels with angina Subcategory Vessel Type I25.70 Coronary artery bypass graft(s), unspecified type I25.71 Coronary artery bypass graft(s), autologous vein I25.72 Coronary artery bypass graft(s), autologous artery I25.73 Coronary artery bypass graft(s), nonautologous biological I25.75 Coronary artery, native, transplanted heart I25.76 Coronary artery bypass graft(s), transplanted heart I25.79 Coronary artery bypass graft(s), other type Category I25.8 is CAD of other coronary vessels without angina 25

CAD of Native Coronary Arteries Subcategory I25.11 shows the basic structure for the combination codes for CAD with angina. I25.1 Atherosclerotic heart disease of native coronary artery Coronary artery disease I25.10 ASHD of native coronary artery without angina pectoris I25.11 ASHD of native coronary artery with angina pectoris I25.110 ASHD of native coronary artery with unstable angina pectoris I25.111 ASHD of native coronary artery with angina pectoris with documented spasm I25.112 ASHD of native coronary artery with other forms of angina pectoris I25.119 ASHD of native coronary artery with unspecified angina pectoris ICD-10-CM assumes a causal relationship between angina and atherosclerosis. 26

Acute Myocardial Infarction The ICD-10-CM AMI codes have several key differences from the AMI codes in ICD-9-CM. ICD-10-CM differentiates primarily between anterior wall and inferior wall, then by the coronary artery involved ICD-10-CM does not differentiate by episode of care Rather than 8 weeks, acute MI is defined as a duration of 4 weeks (28 days) or less from onset ICD-10-CM has distinct categories for the initial MI and for subsequent re-infarction 27

Initial Infarction Codes in I21 are used for the initial infarction. I21 ST elevation (STEMI) and non-st elevation (NSTEMI) myocardial infarction I21.0 STEMI of anterior wall I21.01 STEMI involving left main coronary artery I21.02 STEMI involving left anterior descending coronary artery I21.09 STEMI involving other coronary artery Transmural (Q wave) infarction (acute) (of) anterior (wall) NOS I21.1 STEMI of inferior wall I21.11 STEMI involving right coronary artery I21.19 STEMI involving other coronary artery Transmural (Q wave) infarction (acute) (of) inferior (wall) NOS I21.2 STEMI of other sites I21.21 STEMI involving left circumflex coronary artery I21.29 STEMI involving other sites I21.3 STEMI of unspecified site I21.4 NSTEMI For initial infarction, physician documentation should identify the specific wall and coronary artery involved 28

Subsequent Infarction Codes in I22 are used for a repeat infarction within 4 weeks (28 days) of a previous AMI, regardless of site. I22 Subsequent STEMI and NSTEMI myocardial infarction I22.0 Subsequent STEMI of anterior wall I22.1 Subsequent STEMI of inferior wall I22.2 Subsequent NSTEMI I22.8 Subsequent STEMI of other sites I22.9 Subsequent STEMI of unspecified site Codes in I22 are never used alone; they are always used with a code from I21 The I22 code is used first if the repeat AMI leads to a second admission, or is used after the I21 code if it occurs during the same admission as the initial AMI 29

Cardiomyopathy Cardiomyopathy, an indication for defibrillators, has expanded codes for greater specificity. Ischemic cardiomyopathy has its own code, distinct from other forms of chronic ischemic heart disease Congestive, restrictive and non-obstructive hypertrophic cardiomyopathy have their own codes I25.5 Ischemic cardiomyopathy I42 Cardiomyopathy I42.0 Dilated cardiomyopathy Congestive cardiomyopathy I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy Non-obstructive I42.5 Other restrictive cardiomyopathy I42.8 Other cardiomyopathies I42.9 Cardiomyopathy unspecified Specify the type 30

Non-Rheumatic Valve Disorders In ICD-10-CM, each valve has its own code category. Within each category, there are distinct codes for each specific type of valve disorder Category I34 I35 I36 I37 Valve Mitral Aortic Tricuspid Pulmonary I35 Non-rheumatic aortic valve disorders I35.0 Non-rheumatic aortic (valve) stenosis I35.1 Non-rheumatic aortic (valve) insufficiency Non-rheumatic aortic (valve) incompetence Non-rheumatic aortic (valve) regurgitation I35.2 Non-rheumatic aortic (valve) stenosis with insufficiency I35.8 Other non-rheumatic aortic valve disorders I35.9 Non-rheumatic aortic valve disorder unspecified 31

Historical Conditions As with ICD-9-CM, historical conditions which are indications for defibrillators are distinctly identified in ICD-10-CM. Old Myocardial Infarction This has its own code in chronic ischemic heart disease I25.2 Old myocardial infarction History of SCD Family and personal history are separately identified Z82.41 Family history of sudden cardiac death Z86.74 Personal history of sudden cardiac arrest Personal history of sudden cardiac death successfully resuscitated 32

Attention to Cardiac Device Like ICD-9-CM, ICD-10-CM has specific codes for use when the encounter focuses on attention to a device rather than the underlying condition, as in: Routine device replacement, eg. end-of-battery life Encounter for device interrogation or programming Z45.0 Encounter for adjustment and management of cardiac device Z45.01 Encounter for adjustment/management of cardiac pacemaker Z45.010 Encounter for checking and testing pacemaker pulse generator Encounter for replacing cardiac pacemaker pulse generator [battery] Z45.018 Encounter for adj/mgt of other part of cardiac pacemaker Z45.02 Encounter for adj/mgt of automatic implantable cardiac defibrillator Z45.09 Encounter for adj/mgt of other cardiac device 33

Device Complications ICD-10-CM continues to classify device complications as mechanical, infection, and other (non-mechanical). Definitions are the same as ICD-9-CM for mechanical (eg. breakdown) and other non-mechanical (eg. pain) Mechanical complication codes are defined as electrode vs generator, rather than by the type of device The nature of the mechanical complication is more specific, eg. breakdown, displacement or other complication The nature of the non-mechanical complication is also more specific, eg. embolism, hemorrhage 34

Device Complication Code Structure All codes require a 7 th digit for episode of care: A initial encounter D subsequent encounter S sequela T82.1 Mechanical complication of cardiac electronic device T82.11 Breakdown (mechanical) of cardiac electronic device T82.110 Breakdown of cardiac electrode T82.111 Breakdown of cardiac pulse generator T82.118 Breakdown of other cardiac electronic device T82.12 Displacement of cardiac electronic device T82.120 Displacement of cardiac electrode T82.121 Displacement of cardiac pulse generator T82.128 Displacement of other cardiac electronic device T82.7 Infection/inflammatory reaction to other cardiac devices. T82.8 Other specified complications of cardiac/vascular devices T82.84 Pain from cardiac and vascular devices T82.847 Pain from cardiac devices, implants and grafts T82.848 Pain from vascular devices, implants and grafts.. 35

ICD-10-CM Coding Guidelines Codes aren t complete without uniform guidelines on usage. As with ICD-9-CM, there is a set of ICD-10-CM Official Guidelines for Coding and Reporting Use of the Official Guidelines is mandatory under HIPAA The Official Guidelines are still in draft form but will be finalized prior to October 1, 2013 The quarterly journal Coding Clinic will also continue Coding Clinic will begin addressing ICD-10 guidance in advance of the 2013 implementation date 36

Learning ICD-10-CM ICD-10-CM reflects an evolution from ICD-9-CM. Once the user adjusts to its new code formats and additional digits, ICD-10-CM begins to seem reasonably familiar. CMS has estimated that professional coders will need about 10 hours of training to learn ICD-10-CM. 37

Other Impact of ICD-10 38

ICD-10-PCS Procedure Codes Procedure coding in ICD-10-PCS is completely unlike that in ICD-9-CM or CPT. Examples 0JH60P5 027034Z Insertion of CRT-D Pulse Generator into Subcutaneous Tissue/Fascia, Chest, Open Approach Dilation of Coronary Artery, One Site, with Drug-Eluting Intraluminal Device, Percutaneous Approach Each character in the code represents a specific element All terms have standard definitions There are very few defaults Codes are not assigned per se, they are built characterby-character from tables of values 39

Example: Insertion of CRDM Generator Pacemaker: 0JH60P2 Defibrillator: 0JH60P4 CRT-P (BiV): 0JH60P3 CRT-D (BiV): 0JH60P5 40

Example: PTCA and Stent PTCA with drug-eluting stent 027034Z Dilation of Coronary Artery, One Site, with Drug-Eluting Intraluminal Device, Percutaneous Approach PTCA with non-drug-eluting (bare metal) stent 02703DZ Dilation of Coronary Artery, One Site, with Intraluminal Device, Percutaneous Approach 41

Greater Specificity ICD-10-PCS has far more procedure codes than ICD-9-CM. System # Procedure Codes ICD-9-CM 3,824 ICD-10-PCS 72,589 The sheer volume of codes can be daunting at first but some constructs are far less likely than others. The structure of ICD-10-PCS has key consequences in: ease of expansion for new procedures and technologies greater depth of clinical documentation required to assign codes 42

Procedure Documentation Especially since it has minimal defaults, ICD-10-PCS requires greater detail and precision in documentation. Examples Physicians must specify the exact site of the generator pocket Because a site is not equivalent to a single coronary artery, physicians must document if the interventions took place in a continuous lesion or at discrete lesions within the same vessel For coding, LV refers to a lead within the chamber; coronary vein refers to a lead inserted via the CS overlying the LV 43

Terminology in Documentation Operations in ICD-10-PCS have standard definitions, which may or may not reflect physician usage of the term. It is the coder s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query. Example (See the Appendix for the link) Physicians commonly document removing a device and implanting another as a replacement or a revision. ICD-10-PCS has other meanings for these terms. This scenario is coded as insertion plus removal. 44

MS-DRG Conversion CMS s stated objective in the MS-DRG conversion is: for data coded in ICD-10, the ICD-10 MS-DRGs would assign the same MS-DRG had the same case been coded using ICD-9-CM codes (See the Appendix for the link) In other words, CMS is not taking advantage of the ICD-10 transition to make changes to MS-DRG assignments. DRG titles are unchanged Logic of DRG assignment is unchanged CCs and MCCs are the same 45

DRG Examples: CRT-D Implant Example 1 I47.2 ventricular tachycardia I50.22 chronic systolic (congestive) heart failure I42.0 dilated cardiomyopathy 0JH60P5 insrtn CRT-D generator 02H63ME insertion RA lead 02HK3ME insertion RV lead 02H43ME insertion LV (CS) lead MS-DRG 227 $29,002 Cardiac defibrillator implant WO cardiac cath WO MCC Example 2 I50.22 chronic systolic (congestive) heart failure I47.2 ventricular tachycardia I42.0 dilated cardiomyopathy 0JH60P5 insrtn CRT-D generator 02H63ME insertion RA lead 02HK3ME insertion RV lead 02H43ME insertion LV (CS) lead 4A023N7 left heart cath MS-DRG 223 $35,878 Cardiac defib implant W cardiac cath W AMI/HF/Shock WO MCC 46

Appendix 47

Key Websites The CDC and CMS have a wealth of educational materials and resources available on-line, both for implementation of ICD-10 and the MS-DRG conversion. ICD-10-CM Diagnosis Codes http://www.cdc.gov/nchs/icd/icd10cm.htm draft ICD-10-CM coding guidelines ICD-10-CM tabular and index diagnosis code GEMS 48

Key Websites ICD-10-PCS Procedure Codes http://www.cms.gov/icd10/11b_2011_icd10pcs.asp#topofpage ICD-10-PCS tables and index ICD-10-PCS Reference Manual procedure code GEMS 49

Key Websites DRGs http://www.cms.gov/icd10/17_icd10_ms_drg_conversion_project. asp#topofpage Hospital payment impact analysis MS-DRG Grouper in ICD-10 (manual) 50 MS-DRG Grouper in ICD-10 (pilot software)

Documentation CMS received numerous comments that, because of its focus on specificity, ICD-10 requires more documentation in the medical record for both diagnoses and procedures. CMS s response is worth noting: A poorly documented medical record can be problematic for a number of reasons but such deficient medical records are an issue of and by themselves, and not contingent upon whether the code assigned is an ICD-9-CM or an ICD-10 code. We view any potential improvements in medical record documentation as a positive outcome of the move to ICD-10-CM and ICD-10-PCS. With better and more accurate data, patient care can only be improved. Federal Register, January 16, 2009, p.3348 51

Future Updates This is the first in a series of educational programs designed to educate hospitals and physicians about ICD-10. The Basics of ICD-10 for Hospitals May 2011 and Physician Practices The Process of ICD-10 Implementation 2012 for Hospitals and Physicians What Clinicians Need to Know 2013 about ICD-10 To ensure you receive advance notification of these events, it is very easy to register at: www.medtronic.com/crdmreimbursement 52

Coding Hotlines You can contact Medtronic for assistance with coding and reimbursement issues. Cardiac Rhythm Disease Management (866) 877-4102, option 1 Vascular (877) 347-9662 Structural Heart (866) 616-8400 53

Question Time 54

Thanks for Participating! We hope this was informative. If you have any comments or questions, please send us an email at: rs.healthcareeconomics@medtronic.com Medtronic Inc. Minneapolis, MN www.medtronic.com