www. TheNationalCouncil. org ICD-10-CM An overview of changes relevant to behavioral health Presented by: Donna Pickett - CDC/OPHS/NCHS Joe Nichols - MD Date: January 24, 2014
Agenda www. TheNationalCouncil. org Overview ICD-10, the basic facts How is ICD-10-CM different? Clinical documentation - What s needed to support proper coding in ICD-10-CM? What s changed for behavioral health What are the business impacts? What do I need to do to prepare? 2
Source: Health Data Consulting ICD-10-CM Overview 3
ICD10 Quick Facts ICD-10 international version Adopted by WHO in 1990 Most countries other than the US currently use ICD-10 ICD-10 (International version) ~ 12,500 diagnostic codes Source: Health Data Consulting ICD-10 used for mortality reporting in the US - 1999 ICD-10-CM (US version) ~ 69,000 diagnostic codes Final rule published 2012 Compliance date Oct 1, 2014 Source: Health Data Consulting 4
ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes) ICD-9-CM Diagnosis Codes 3 to 5 digits Alpha E and V on 1 st character No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality Combination codes limited ICD-10-CM Diagnosis Codes 7 digits Alpha or numeric for any character Include place holder characters ( x ) Similar Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common Source: Health Data Consulting 5
ICD9 Comparison to ICD10-CM Diagnosis Codes Clinical Example A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug]. ICD9 Code Description 29285 Drug induced sleep disorders ICD10 Code F13282 Description Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder Source: Health Data Consulting 6
ICD9 Comparison to ICD10-CM Diagnosis Codes Clinical Example A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug]. ICD9 Code Description 29285 Drug induced sleep disorders ICD10 Code F13282 Description Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder Source: Health Data Consulting 7
There are too many Codes There are lots of words in the dictionary, but that doesn t seem to trouble authors 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10CM codes are related to fractures ~25,000(36%) of all ICD-10-CM codes to distinguish right vs. left Only a very small percentage of the codes will be used most providers Source: Health Data Consulting 8
Current Distribution of ICD-9 diagnosis codes 3 Years of Data - All claims - All lines of business - 1million Lives 80.0% Total Charges by Code 3years - $10 Bill 70.0% 60.0% 50.0% 40.0% Charge % 30.0% 20.0% 10.0% 0.0% 5% next 5% Source: Health Data Consulting 9
Varying Code Volume By Clinical Area Clinical Area ICD-9 Codes ICD-10 Codes Fractures 747 17099 Poisoning and toxic effects 244 4662 Pregnancy related conditions 1104 2155 Brain Injury 292 574 Diabetes 69 239 Anxiety Disorders 27 47 Autism Spectrum Disorders 6 4 Mood related disorders 75 71 Schizophrenia 56 11 Hypertensive Disease 33 14 End stage renal disease 11 5 Source: Health Data Consulting 10
Documentation It could be better Incomplete clinical documentation is bad for Payers, Providers and Patients. Billing accuracy Quality measures Population management Risk management Healthcare analytics Patient Care Bad Mojo is not a diagnosis 11
Good Clinical Documentation is Not a New Requirement The number and type of new concepts required for ICD-10 are not foreign to clinicians The focus of documentation is good patient care Patients deserve to have accurate and complete documentation of their conditions If other industries understand the value of accurate and complete documentation of data about encounters; shouldn t we? Source: Health Data Consulting 12
Documentation Why is it important? Supports proper payment reduced denials Assures accurate measures of quality and efficiency Assures accountability and transparency Captures the level of risk and severity Provides better business intelligence Supports clinical research Enhances communication with hospital and other providers It s just good care! Source: Health Data Consulting 13
Coding The Patient Interface Where it all begins History Physical Exam Internal Record Review External Record Review Studies Assessment/Diagnosis 14
Getting to the Code A Necessary Step Back-office Coding The Super Bill Back to the Doctor? 15
The Super Bill Not That Super Really [Note] For all codes related to fractures of the radius: ICD-9 codes = 32 ICD-10 codes = 1731 16
New concepts supported by ICD-10 Drug use vs dependence vs abuse Bipolar II Recurrent depressive disorder Mood disorder related to physiologic condition Adjustment insomnia Adjustment reaction with withdrawal Asperger's syndrome Rett's syndrome Distinguishes between current episode and most recent episode for bipolar disorders Source: Health Data Consulting 17
Removed concepts from ICD-9 Substance dependence o o continuous episodic Amphetamine o o Dependence Abuse Bipolar I Passive-aggressive personality Pervasive Disorders o o current or active state residual state Source: Health Data Consulting 18
Removed concepts from ICD-9 Schizophrenia o o o o o o o Latent Simple type Subchronic Chronic Subchronic with acute exacerbation Chronic with acute exacerbation In remission Source: Health Data Consulting 19
Source: Health Data Consulting ICD-10-CM Key coding changes relevant to behavioral health 20
Changes in detail and content Code Examples Substance related sleep disorders: ICD-9 Code Description 29285 Drug induced sleep disorders More Codes ICD-10 Code F11182 F11982 F11282 F14182 F14282 F14982 F13182 Description Opioid abuse with opioid-induced sleep disorder Opioid use, unspecified with opioid-induced sleep disorder Opioid dependence with opioid-induced sleep disorder Cocaine abuse with cocaine-induced sleep disorder Cocaine dependence with cocaine-induced sleep disorder Cocaine use, unspecified with cocaine-induced sleep disorder Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder Multiple other substances Source: Health Data Consulting 21
ICD-9 Code Changes in detail and content Code Examples Substance related abuse: Description 30550 (Non-dependent) Opioid abuse, unspecified More Codes ICD-10 Code F1110 F11120 F11121 F11122 F1114 F11150 F11151 F11181 F11182 F11188 F1119 Description Opioid abuse, uncomplicated Opioid abuse with intoxication, uncomplicated Opioid abuse with intoxication delirium Opioid abuse with intoxication with perceptual disturbance Opioid abuse with opioid-induced mood disorder Opioid abuse with opioid-induced psychotic disorder with delusions Opioid abuse with opioid-induced psychotic disorder with hallucinations Opioid abuse with opioid-induced sexual dysfunction Opioid abuse with opioid-induced sleep disorder Opioid abuse with other opioid-induced disorder Opioid abuse with unspecified opioid-induced disorder Source: Health Data Consulting 22
Changes in detail and content Code Examples Schizophrenia: Less Codes ICD-9 Code Description 29530 Paranoid type schizophrenia, unspecified 29531 Paranoid type schizophrenia, subchronic 29532 Paranoid type schizophrenia, chronic 29533 Paranoid type schizophrenia, subchronic with acute exacerbation 29534 Paranoid type schizophrenia, chronic with acute exacerbation 29535 Paranoid type schizophrenia, in remission ICD-10 Code F200 Description Paranoid schizophrenia Source: Health Data Consulting 23
Changes in detail and content Code Examples Schizoaffective disorder: ICD-9 Code Description 29570 Schizoaffective disorder, unspecified More Codes ICD-10 Code F250 F251 F258 F259 Description Schizoaffective disorder, bipolar type Schizoaffective disorder, depressive type Other schizoaffective disorders Schizoaffective disorder, unspecified Health Data Consulting 2013 24
Changes in detail and content Code Examples Post traumatic Stress Disorder: More Codes ICD-9 Code Description 30981 Posttraumatic stress disorder ICD-10 Code F4310 F4311 F4312 Description Post-traumatic stress disorder, unspecified Post-traumatic stress disorder, acute Post-traumatic stress disorder, chronic Health Data Consulting 2013 25
Changes in detail and content Code Examples Childhood Emotional Disorders: Less Codes ICD-9 Code Description 3130 Overanxious disorder specific to childhood and adolescence 3131 Misery and unhappiness disorder specific to childhood and adolescence 31321 Shyness disorder of childhood 31322 Introverted disorder of childhood 3133 Relationship problems specific to childhood and adolescence 31382 Identity disorder of childhood or adolescence 31383 Academic underachievement disorder of childhood or adolescence 31389 Other emotional disturbances of childhood or adolescence 3139 Unspecified emotional disturbance of childhood or adolescence ICD-10 Code F930 F938 F939 Source: Health Data Consulting Description Separation anxiety disorder of childhood Other childhood emotional disorders Childhood emotional disorder, unspecified 26
Changes in detail and content Code Examples Conversion Disorders: More Codes ICD-9 Code Description 30011 Conversion disorder ICD-10 Code F444 F445 F446 F447 F4489 F449 Description Conversion disorder with motor symptom or deficit Conversion disorder with seizures or convulsions Conversion disorder with sensory symptom or deficit Conversion disorder with mixed symptom presentation Other dissociative and conversion disorders Dissociative and conversion disorder, unspecified Source: Health Data Consulting 27
Changes in detail and content Code Examples Other substance abuse: ICD-9 Code Description 30592 Other, mixed, or unspecified drug abuse, episodic More Codes ICD-10 Code F550 F551 F552 F553 F554 F558 Description Abuse of antacids Abuse of herbal or folk remedies Abuse of laxatives Abuse of steroids or hormones Abuse of vitamins Abuse of other non-psychoactive substances Health Data Consulting 2013 28
Changes in detail and content Code Examples Attention Deficit Disorders: ICD-9 Code Description 31400 Attention deficit disorder without mention of hyperactivity 31401 Attention deficit disorder with hyperactivity More Codes ICD-10 Code F900 F901 F902 F908 F909 Description Attention-deficit hyperactivity disorder, predominantly inattentive type Attention-deficit hyperactivity disorder, predominantly hyperactive type Attention-deficit hyperactivity disorder, combined type Attention-deficit hyperactivity disorder, other type Attention-deficit hyperactivity disorder, unspecified type Source: Health Data Consulting 29
Business Impacts 30
Business Impacts Coding EHR updates Super Bill??? Training Coding software Contracting Billing Scope of services Case rates Carve outs Billing code updates Charge masters Billing Edits Benefits and coverage determinations Health Data Consulting 2013 31
Business Impacts (Cont.) Compliance HIPAA Reporting National State Regional Initiatives Contract requirement Accreditation Reimbursement Audits Pay for performance POA, never events, re-admissions, HACs, tiered payment models Network inclusion Denials RAC Fraud and abuse Coding Health Data Consulting 2013 32
ICD diagnosis codes are irrelevant to my business. ICD-9 codes factor into: Payer processing rules The determination of appropriateness Measures of quality (pay for performance) Compliance (meaningful use) Contracting decisions Risk adjustments Fraud waste and abuse Audits Authorizations Health Data Consulting 2013 33
ICD diagnosis codes are irrelevant to my business. ICD-10 codes are likely to factor into: Changes in reimbursement based on both what was done and why Managing financial risks for contracted populations (ACO s) Changes in reimbursement based on more robust models of payment adjusted for risk and severity More sophisticated weighting of payments based on DRGs, episodes or other groupers of care. Health Data Consulting 2013 34
Business Impacts Compliance HIPAA Reporting o o o National State Regional Initiatives Contract Accreditation Reimbursement Audits Pay for performance POA, Never Events, Tier Models Network inclusion Denials RAC Fraud and abuse Coding 35
Cash Flow Impacts inbound and outbound Lack of Provider Preparation Payment Delays Increased Cost 36
Cash Flow Impacts inbound and outbound Source: CMS 37
Implementation Getting your ducks in a row 38
Implementation Strategy Short term goals with a long term visions What solution do I need today? Will that solution extend to tomorrows needs? Awareness of touch points with other initiatives Overlap and conflicts Down Stream Impacts What works well for one business area, may bring another business area to it s knees Positioning for competitive advantage Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator for the transition challenge to providers and other stakeholders? Can you manage the burden of illness of your population better than your competitors? 39
Phases of Transition 1. Assessment Inventory of impacted systems and processes Identifying risk 2. Analysis/Planning Prioritizing focus Establishing business area specific approaches Creating specifications for mapping to support implementation 3. Implementation and Operations Translating codes from 9 to 10 and from 10 to 9 using crosswalks Changing analytic models to support both codes Operationalization of coding to ICD-10 from source information Changing processing logic to operate directly from ICD-10 codes 4. Leveraging ICD10 capabilities Using the enhanced information within ICD-10 codes to improve processing and analysis based on improved concepts buried within the ICD-10 codes 40
Scenario-Based Testing What is it? The scenario: The identification of some event or condition that we are familiar with today Recreating that event virtually through some verbal or data representation Defining a variety of assumptions and variables around this virtual representation Applying one or more of these scenarios in a Reference Implementation Model (RIM). Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results. 41
Leveraging ICD-10 A changing world of cost containment Accurate and complete documentation and coding provides opportunities to support the transition into a value-based, accountable care reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support population risk management More accurate measures of quality and efficiency 42
Q&A Review of Q&A from Attendees If you have a question that has not been addressed, please send it to us at the ICD-10 Questions Mailbox: icd10questions@noblis.org 43
Online Resources Review of Q&A from Attendees CMS - https://www.cms.gov/icd10/ Coding Documentation (Indexes, Coding Guidelines, Code Files): http://www.cms.gov/medicare/coding/icd10/index.html General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) GEMs Crosswalk documents: http://cms.hhs.gov/medicare/coding/icd10/2014-icd-10-cm-and- GEMs.html GEMs 2014 General Equivalence Mappings: http://cms.hhs.gov/medicare/coding/icd10/2014-icd-10-pcs.html Medicare Learning Network Articles: http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNGenInfo/index.html?redirect=/mlngeninfo Implementation Guides: https://implementicd10.noblis.org 44
Online Resources Review of Q&A from Attendees CMS - https://www.cms.gov/icd10/ (Continued) Implementation Guides: https://implementicd10.noblis.org ICD-10 National Provider Calls: http://www.cms.gov/medicare/coding/icd10/cms-sponsored-icd-10- Teleconferences.html National Coverage Determinations (NCDs): http://www.cms.gov/medicare-coverage-database/overview-and-quicksearch.aspx Medicare Testing Week: http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8465.pdf Medicare Claims Processing Guidance for ICD-10: http://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNMattersArticles/downloads/MM7492.pdf 45
Online Resources Review of Q&A from Attendees CMS - https://www.cms.gov/icd10/ (Continued) Medicare Reimbursement Mappings 2014 Reimbursement Mappings Diagnosis Codes and Guides http://cms.hhs.gov/medicare/coding/icd10/2014-icd-10-cm-and-gems.html 2014 Reimbursement Mappings Procedure Codes and Guides http://cms.hhs.gov/medicare/coding/icd10/2014-icd-10-pcs.html Links to ordering the ICD-10 Pilot Version 31.0 Mainframe and PC version of the ICD-10 MS-DRGs and Medicare Code Editor (FY 2014 version) from NTIS have been placed on the CMS website under the Related Links section at http://cms.hhs.gov/medicare/coding/icd10/icd-10-ms-drg-conversion- Project.html http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNGenInfo/index.html?redirect=/mlngeninfo FAQ, Coordination and maintenance Committee minutes 46
Online Resources Review of Q&A from Attendees CDC - http://www.cdc.gov/nchs/icd/icd10cm.htm ICD-10-CM files (Alphabetic Indexes, Tabular List, Coding Guidelines, Codes and Descriptions Files, FY2014 Addenda) General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) GEMs Crosswalk documents: GEMs 2014 General Equivalence Mappings: Detailed List of Codes Exempt from Diagnosis Present on Admission Requirements Public Health Transition to ICD-10-CM/PCS http://www.cdc.gov/nchs/icd/icd10cm_pcs.htm 47
Online Resources Review of Q&A from Attendees WEDI - http://www.wedi.org/ List serves Workgroups White papers Implementation forums Industry advocacy and issue Access to standards leaders AHIMA - http://ahima.org/ Training and certification Extensive documentation libraries Bookstore Communities of practices ICD-10 focused conferences 48
Online Resources Review of Q&A from Attendees HIMSS - http://www.himss.org/ White papers Bookstore Webinars Vendors Consulting Organization Online news Blogs 49
Online Resources Review of Q&A from Attendees Health Data Consulting white papers: ICD-10 A Primer ICD-10 Physician Impacts Scenario Based Testing ICD-10 The Case for Moving Forward ICD-10 Clinical Documentation The Role of the Clinician in Capturing Accurate Data ICD-10 Specified or Unspecified? http://healthdataconsulting.com/resources/white-papers/ 50