Transition to ICD-10

1. Transition to ICD-10 Don’t Panic….. PREPARE!!! Tabitha Harris, PT, DPT, OCS Steven Spinks, DPT, COMT

2. OBJECTIVES • Understand the history of ICD-10 • Understand and describe the primary differences between ICD-9 and ICD-10 • Understand how to report and bill ICD-10 codes appropriately (outpatient specific) • Ability to apply appropriate documentation principles to support ICD-10 codes • Identify when a 7th character is required in ICD-10 coding • Define initial & subsequent encounter and sequela • Ability to apply correct ICD-10 coding concepts to PT, OT and SLP (outpatient specific) • Ability to identify, find and utilize appropriate resources for ICD-10 coding

3. HISTORY of Coding • 1948: ICD-6 • 1955: ICD-7 • 1965: ICD-8 • 1977: ICD-9 • 1990: ICD-10 • What happened between 1990 and the present?

4. HISTORY of Coding • W.H.O. began working on 10th edition of ICD coding system > 30 years ago (1983) • Endorsed by the World Health Assembly 1990 • Ready for use 1994 • Several countries quickly adopted the system – including Australia, France, Canada, Dubai… • United States?? A little late to the party, but we are getting there!

5. So Why Change Now? • ICD-9 is outdated • Technology changes • Lacks flexibility and accuracy • Unable to incorporate emerging diagnoses and procedures • U.S. one of few developed countries that has not transitioned: • complex healthcare system • highly influential special interest groups who control decision making • Repeated extension of transition deadlines

6. So Why Change Now? • 2009 – Final rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) – Administrative Simplification with Modifications to the medical data code sets • ICD-10 would be the “standard” coding set as of October 1, 2013 • 2012 – September final rule moved implementation date back to October 1, 2014 • 2014 – “Protecting Access to Medicare Act of 2014” delayed implementation to “at least” October 1, 2015

7. So Why Change Now? July 31, 2014 – US Department of Health & Human Services (HHS) issued ruling finalizing October 1, 2015 as new compliance date for “healthcare providers”

8. Who has to transition? • Rule applies to “Healthcare providers” covered by HIPAA. This includes: • Medicare • Medicaid • Third Party Insurance providers • Some Worker’s Comp providers • Some Auto insurance providers • Some Work Comp and auto insurance providers are not HIPAA covered entities • It is possible that some of these providers will not transition to ICD-10 and will continue to use ICD-9 diagnosis codes.

9. ICD-10-CM vs ICD-10-PCS • ICD-10-CM • Used for outpatient services (including therapy) • CM stands for clinical modification – US has “modified” ICD-10 as created by the W. H. O. • ICD-10-PCS • Used for inpatient claims only • PCS stands for procedure coding system • Hospitals and inpatient facilities should train/transition facility wide

10. Benefits of ICD-10 transition? • Increased specificity – approx. 70,000 ICD-10 codes! • Improved sensitivity when modifying grouping for reimbursement methodologies • Improved measurement of quality, efficacy and safety of care • Assists in design of payment systems and claims processing • Allows improved Public Health surveillance

11. Benefits of ICD-10 transition? • Allows greater detail in reporting on: • Laterality • Preventive health measures • Lifestyle related problems • Socioeconomic factors • Comorbidities – contributing factors

12. ICD-9 vs ICD-10: Major Differences ICD-9 ICD-10 3-7 characters 1st character always alpha 2nd character always numeric 3-7th characters alpha or numeric Decimal occurs after 3rd character Has laterality of affected side Approximately 70,000 diagnosis codes May use placeholder (X) • 3-5 characters • 1st character numeric or alpha • 2-5th characters always numeric • Decimal occurs after 3rd character • No laterality of affected side • Just over 14,000 diagnosis codes • No place holders used

13. ICD-10 “Placeholder” • ICD-10 uses a placeholder character. 2 uses: • Allows future expansion of the code set • If a code has fewer than 6 characters and a 7th character is required • Placeholder character is always “X” • The X is assigned to all characters fewer than 6 in order to meet coding requirement to 7 characters

14. ICD-10-CM “7th” Character • Used primarily when coding injury caused by trauma, or the “cause” of traumatic injury (CMS tabular Index Chapters 15, 19 and 20) • Choose one of three choices for 7th character: • “A” = Initial Encounter • “D” = Subsequent Encounter • “S” = Sequela (Exception: Fractures have additional 7th characters)

15. ICD-10-CM “7th” Character – A • Initial Encounter • Used the FIRST time a patient is being seen for a condition • Emergency room visit • Evaluation by new physician or first time physician visit • Unusual for therapists to use this character • Direct access visit – seen by therapist prior to any other medical professional • In hospital – could be used if therapist evaluating in emergency dept. or under observation in hospital

16. ICD-10-CM “7th” Character – D • Subsequent encounter • Used for encounters after the patient has received treatment for a condition • While receiving routine care for condition • During healing/recovery phase • Most common character used in therapies

17. ICD-10-CM “7th” Character – S • Sequela • Used for conditions or complications that have arisen as a direct result of a condition • Ataxia as a result of CVA • Scar formation as a result of a burn • Must code both the injury and the sequela • S character identifies the injury responsible for the sequela (i.e. burn = injury, scar = sequela)

18. Implementation of ICD-10 • Impact on CPT Codes? • CPT codes and HCPCS codes will not change • CPT codes will be used for billing the same as they were for ICD-9 • It may be more difficult for payers to create lists of “reimbursable” codes • Claim form changes? • CMS has a revised version (paper form) of the 1500 claim form – allows up to 12 diagnosis codes on the form • Submitting on paper form – had to begin using revised form for DOS 4-01-14 • Electronic version of 1500 form (837P) allows for 9 diagnosis codes • Electronic version of UB-04 (837I) allows for up to 27 diagnosis codes

19. Implementation of ICD-10 • CMS requirements • Cannot accept claims with ICD-9 codes after September 30 • Cannot accept claims with both ICD-9 and ICD-10 codes • ICD-10-CM (primarily outpatient facilities) • Date of service is the date service is provided, NOT the date of the claim • ICD-10-PCS (inpatient facilities) • Date of service defined as the date of discharge. • Patient admitted 9/05, DC 10/02: must use ICD-10 codes

20. Documentation for ICD-10 • ICD-10 coding requires supporting documentation • Tell each patient’s complete “story” • Include details to support codes • Type of injury • Location of injury or symptoms (laterality) • Description of symptoms • Description of functional limitations • Comorbidities (other existing medical diagnoses) • External cause – including description of trauma, accident, what forces or machinery was involved.

21. Documentation for ICD-10: Example • Trauma Example: Patient is a [dominance, age, and gender] referred to [physical/occupational/speech] therapy for a [insert injury here, detailed as to laterality, anatomical location and characteristics] due to [exactly what happened]. Patient has [level of pain] and [joint stiffness? edema?] in her [affected joint/s].

22. Documentation for ICD-10: Example • Entrapment Neuropathy Example: Patient is a [dominance, age, and gender] referred to [physical/occupational/speech] therapy for [specific entrapment neuropathy, detailed as to laterality and nerve involved]. Patient complains of [pain, stiffness, atrophy, etc.] of the [specific body part].

23. Documentation for ICD-10: Example • TBI Example: Patient is a [dominance, age, and gender] referred to [physical/occupational/speech] following a [describe specific type of brain injury and details about length of loss of consciousness]. Patient presents with [-paresis or -plegia and type, laterality, and dominance] and [gait pattern? joint contracture? pain?].

24. Documentation for ICD-10: Example • Additional neurological information…

25. Documentation for ICD-10: Example • Non-traumatic musculoskeletal Example: Patient is a [dominance, age, and gender] referred to [physical/occupational/ speech] for complaints of [specific complaints—pain? stiffness? swelling?] of her [specific body part] following [type of activity or event that precipitated symptoms]. Patient was diagnosed with [specific diagnosis] and referred to [PT/OT/ST] to allow her to return to [e.g. pain free use of body part during a specific activity].

26. Coding Tools ICD-10 Coding Books Cross Walks And Cross Mapping Guides (GEMs) General Equivalency Mappings (CMS resources)

27. Coding Guidelines • General Guidelines – Follow 1-2-3 format • 1. Code what you treat – always list treating diagnosis (es) first on claim form • 2. Code medical diagnoses – comorbidities, other medical conditions • 3. Code Injury and External causes of injury – last on claim form but important in telling patient story

28. Coding Guidelines • GEMs – Alphabetical and Tabular Index • 1st order of business: Download Indices: • Cms.gov > Medicare (top left) > ICD-10 (mid page under Coding) > 2015 ICD-10 CM and GEMs > 2015 Code Tables and Index (ZIP file) • Right click on “Index” PDF file, select copy, then paste onto desktop. Do the same for the “Tabular” PDF file.

29. Coding Guidelines www.cms.gov

30. Coding Guidelines

31. Coding Guidelines Right click on the Adobe PDF version of the index, select copy, then paste onto your desktop. Repeat with the Adobe PDF version of the tabular.

32. Coding Guidelines – ABC Index • Search ABC Index first • Gives initial characters of your code • Dash (-) at the end of a code indicates more characters needed • Find complete code in Tabular Index (always verify in tabular) • Search ABC Index using one-word terms if possible • Go to first letter of the word you are searching before you begin the search • i.e. “Pain” – go to “P” then open search field “Sprain” – go to “S” then open search field

33. Coding Guidelines – ABC Index

34. Coding Guidelines – ABC Index

35. Coding Guidelines – Tabular Index • Selection of complete codes - only done in tabular • Include laterality • No bilateral codes (use both left and right codes) • Avoid “unspecified” codes for laterality • Include 7th character (when applicable) • Look at group heading to see if 7th character needed • Required for traumatic injuries and external causes

36. Coding Guidelines – Tabular Index • Divided by “Chapters” • There is a table of contents at beginning of index • Each “chapter” has an additional table of contents

37. Coding Guidelines – Tabular Index • Common “therapy” chapters • E (Ch. 4): Endocrine, metabolic diseases • G (Ch. 6): Neurological conditions • M (Ch. 13): Musculoskeletal conditions • R (Ch. 18): Symptoms, signs, abnormal clinical findings (i.e. abnml gait, ataxia, abnml posture, dizziness, speech symptoms, etc…) • S/T (Ch. 19): Traumatic injuries (due to external causes – 7th char.) • V-Y (Ch. 20): External causes, tell how injury occurred (7th char.)

38. Coding Guidelines – Tabular Index • Chapter 4 (E) - Endocrine, nutritional and metabolic diseases (E00-E89) • Diabetes Mellitus – (E08-E13) • Obesity, overweight, hyperalimentation – (E65-E68) • Specificity of coding co-morbidities • Code only what you know • i.e. DM with or without complications: do not assume complications if they are undiagnosed or unclear.

39. Coding Guidelines – Tabular Index • Chapter 6 (G): Diseases of the Nervous System (G00-G99) • G10-G14: Systemic atrophies primarily affecting central nervous system (i.e. Huntington’s, ALS, post polio) • G20-G26: Extrapyramidal and movement disorders (i.e. Parkinson’s disease, Dystonia, Spasmodic Torticollis) • G30-G37: Other degenerative diseases, demyelinating diseases of CNS (i.e. Alzheimer’s, Dementia, Multiple Sclerosis) • G50-G59: Nerve, nerve root and plexus disorders (i.e. facial/cranial nerve disorders, Bell’s palsy, carpal tunnel syndrome, nerve lesions) • G80-G83: Cerebral palsy and other paralytic syndromes (i.e. CP, hemiplegia, monoplegia, paraplegia, quadriplegia)

40. Coding Guidelines – Tabular Index • Chapter 13 (M): Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) • M00-M19: arthropathies, inflammatory joint conditions, arthritis (inflammatory/ bacterial arthritis, joint infections, RA/JRA, gout, OA, etc…) • M40-M54: Dorsopathies, spondylopathies(i.e. kyphosis, scoliosis, spondylosis, ankylosing spondylitis, spinal stenosis, intervertebral disc disorders, etc…) • M60-M67: Disorders of muscles, synovium and tendon (i.e. Myositis, non-traumatic tears/ruptures of muscle, contractures, muscle wasting/atrophy, synovitis, etc…)

41. Coding Guidelines – Tabular Index • Chapter 13 (M): Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) • M70-M79: Other soft tissue disorders (“itis” conditions - i.e. bursitis, tendonitis, overuse disorders, adhesive capsulitis, IT Band syndrome, etc..) • M80-M85: Disorders of bone density and structure (i.e. osteoporosis with and without fractures, osteomalacia, etc…) • M96: Intraoperative and post-procedural complications and disorders of musculoskeletal system

42. Coding Guidelines – Tabular Index • Chapter 18 (R): Symptoms, signs, abnormal clinical and laboratory findings (R00-R99) • R25-R29: Sx’s/signs involving nervous and musculoskeletal system (i.e. abnormality of gait, ataxia, difficulty walking, abnormal posture, dizziness, speech symptoms, etc…) • R40-R46: Sx’s/signs involving cognition, perception, emotional state, behavior (i.e. Coma scales, senility, dizziness, attention/concentration deficits, etc..) • R47-R49: Sx’s/signs involving speech and voice (i.e. dysarthria, apraxia, dysphasia, aphasia, etc…) • R50-R69: General symptoms and signs (i.e. headache, malaise/fatigue, delayed developmental milestones, etc…)

43. Coding Guidelines – Tabular Index • Chapter 19 (S/T): Injury, poisoning and certain other consequences of external causes (S00-T88) • Sprains, strains, dislocations, fractures, burns, ligament disruptions, etc… • Current, acute or traumatic injury codes (not chronic or recurrent) • Multiple injuries or fractures – code each separately • Fracture • Displaced vs non-displaced? Code displaced • Open vs closed? Code closed • 7th character required for injury codes

44. Coding Guidelines – Tabular Index • Chapter 20 (V00-Y99): External causes of morbidity • Tells how injury occurred • Codes from this Chapter will always be used secondary to a code from another chapter • Slips/trips, falls, transportation accidents, assault, exposure to animate/inanimate forces, complications of med/surg care, etc… • Helps insurance companies understand how injury occurred and why they need therapy • 7thcharacter required

45. Coding Guidelines – Tabular Index • Searching Tabular Index • Open search field in index (Ctrl + F) • Enter the characters found in the ABC index to take you to appropriate diagnosis “group” • Once in the right area, you can do additional search • Ankle sprain (right CFL) – Example: • ABC > “S” > search “Sprain” > look for “ankle” > S93.40 – • Tabular search field > enter S93.40 • Locate correct code (S93.411)

46. Coding Guidelines – Tabular Index

47. Coding Guidelines – Tabular Index • Go to top of the section to see if 7th character is required (Sprain is an injury – 7th character should be expected)

48. Coding Guidelines – Tabular Index • Direct search in Tabular Index • Open appropriate “chapter” in tabular before beginning search • i.e. Ch. 6 (G) to search for neurological disorders (CP, hemiplegia…) • Use search field once in correct chapter (Ctrl + F) • Search key words rather than entire diagnosis • “Tab” through search results or further define search

49. Coding Guidelines – Tabular Index

50. Coding Guidelines – Tabular Index • Injury codes: Can search directly in tabular • Ch. 19 (S00-T88): Injury, poisoning and other consequences… • Use search field once in correct chapter (Ctrl + F) • Search specific injury • Fracture of (bone), sprain of (ligament), dislocation of (joint), etc… • “Tab” through search results or further define search • 7th character required on traumatic injury codes