ACR PRACTICE MANAGEMENT 2014Countdown to ICD-10: Fact or FictionChicago Rheumatism SocietyMay 29, 2014 Antanya Chung, CPC, CPC-I,CRHC, CCP Director, Practice Management American College of Rheumatology
Countdown to ICD-10 This session will include: • ICD-10 Overview • Prepare for working with denials and claims edits • Prepare for the associated impact to charting and coding • Operational Impact • Resources
Countdown to ICD-10 DELAYED
Countdown to ICD-10 • On March 31, Congress passed the Protecting • Access to Medicare Act of 2014, mainly creates a • temporary “fix” to the Medicare sustainable growth • rate (SGR). • The bill states that the Department of Health and • Human Services (HHS) cannot adopt the ICD–10 • code set as the standard until at least October 1, • 2015.
Countdown to ICD-10 • “The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.” - Albert Einstein
Countdown to ICD-10 Overview .
Countdown to ICD-10 • What is ICD-10? • ICD-10 is a new set of diagnosis codes which will replace ICD-9. It was implemented to allow additional codes to be added to different categories. • New codes are being added constantly as ICD-9 can no longer support the additional codes.
Countdown to ICD-10 ICD-10 is the classification system currently being used by the majority of the worldto identify medical diagnosis. The US is the only industrialized nation not using an ICD-10-based classification system.
Countdown to ICD-10 • Two reasons the transition to ICD-10-CM is pushed: • Payers cannot pay claims fairly using ICD-9-CM since the classification system does not accurately reflect current technology and medical treatment. • The healthcare industry cannot accurately measure quality of care using ICD-9-CM. It is difficult to evaluate the outcome of new procedures and emerging health care conditions when there are not precise codes.
Countdown to ICD-10 • The code sets are expanding from an approximate total of • 14,000 in ICD-9 to approximately 68,000 in ICD-10 — • almost an eight-fold increase. • Because of the magnitude of the difference in the number • of codes in the sets, for many codes there will be no • “crosswalks” with a one-to-one match. The EDI • transactions associated with the claims cycle will need to • be revised and tested.
Countdown to ICD-10 • The improved code specificity of ICD-10 will eliminate • some of the ambiguity that exists with the lack of specificity • in ICD-9.
DX Specificity Drives Data & Public Reporting Documentation & Severity of Illness
Countdown to ICD-10 ICD-11 .
Countdown to ICD-10 • Why move to ICD-10, if ICD-11 is on the horizon? • ICD-10 is the pathway to ICD-11 • While other countries use ICD to classify and document information, healthcare organizations in this country face a challenge in adopting newer versions of ICD to fit current HIPAA laws and billing codes.
Countdown to ICD-10 ICD-10 .
Countdown to ICD-10 • ICD-9-CM Diagnosis Codes • 3-5 characters in length • Approximately 14,025 codes • First digit may be alpha (E or V) or numeric. Digits 2-5 are numeric • Limited space for new codes • Lacks detail • Lacks laterality • Difficult to analyze data due to non-specific codes • Codes are non-specific and do not adequately define diagnoses needed for medical research • Does not support interoperability • ICD-10-CM Diagnosis Codes • 3-7 characters in length • Approximately 68,069 codes • Alphanumeric throughout • Flexible for adding new codes • Very specific • Has laterality • Specificity improves coding accuracy and depth of data for analysis • Detail improves the accuracy of data used in medical research • Supports interoperability and the exchange of health care data between other countries and the United States
Countdown to ICD-10 Categories • alphanumeric • 3 characters Subcategories • 4-5 characters • digits or letters Codes • 7th character extension • digit or letter • ICD-10 Structure
Countdown to ICD-10 ICD-10 Format M05 – rheumatoid arthritis with rheumatoid factor M05.2 - rheumatoid vasculitis with rheumatoid arthritis M19.072 – primary osteoarthritis, left ankle and foot M1a.0110 – idiopathic chronic gout, right shoulder, without tophus (tophi) M1a.08X0 – idiopathic chronic gout, vertebra, without tophus (tophi)
Countdown to ICD-10 Chapter 13 Diseases of the Musculoskeletal System And Connective Tissue (M00-M99) M00-M02 Infectious arthropathies M05-M14 Inflammatory polyarthropathies M15-M19 Osteoarthritis M20-M25 Other joint disorders M26-M27 Dentofacial anomalies [including malocclusion] and other disorders of jaw M30-M36 Systemic connective tissue disorders M40-M43 Deforming dorsopathies M45-M49 Spondylopathies M50-M54 Other dorsopathies M60-M63 Disorders of muscles M65-M67 Disorders of synovium and tendon M70-M79 Other soft tissue disorders
Countdown to ICD-10 M80-M85 Disorders of bone density and structure M86-M90 Other osteopathies M91-M94 Chondropathies M95-M99 Other disorders of the musculoskeletal system and connective tissue
Countdown to ICD-10 • Three Character Category List: • Chapter 14 Diseases of the Genitourinary System (N00-N99) • Chapter 15 Pregnancy, Childbirth and the Puerperium (O00-O9A) • Chapter 16 Certain Conditions Originating in the Perinatal Period (P00-P96) • Chapter 17 Congenital Malformations, Deformations and Chromosomal • Abnormalities (Q00-Q99) • Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory • Findings, Not Elsewhere Classified (R00-R99) • Chapter 19 Injury, Poisoning and Certain Other Consequences of External • Cause (S00-T88) • Chapter 20 External Causes of Morbidity (V00-Y99) • Chapter 21 Factors Influencing Health Status and Contact with Health • Services (Z00-Z99)
Countdown to ICD-10 (M00-M99) Arthritis and osteoarthritis have both site and laterality designations in ICD-10-CM Example 1: A 65 year old female patient was seen for primary osteoarthritis of the left knee. She complains that pain is severe at night. The rheumatologist prescribes an NSAID to relieve the pain. What is the code? M17.12
Countdown to ICD-10 (M00-M99) Rheumatoid arthritis is broken down by site, laterality complication, and with or without rheumatoid factor. Examples: Patient has rheumatoid arthritis without rheumatoid factor, right elbow. Patient has juvenile rheumatoid arthritis with systemic onset, left knee. How are these coded? M06.021 M08.262
Countdown to ICD-10 (M00-M99) Site and laterality Most of the codes in Chapter 13 of the ICD-10-CM have site and laterality assignments. This is one of the big changes from ICD-9-CM to ICD-10-CM. - The right side will be coded with “1” - The left side will be codes with “2” Bone versus joint For some conditions, the bone may affect the upper and lower end. Although, the part of the bone affected may be at the joint, the site description will be for the bone and not the joint.
Countdown to ICD-10 • Key Coding Guidelines of ICD-10: • External Cause – These can be used with any codes in the range of A00.0 – T88.99 and Z00 – Z99. • These codes should be coded for the length of the treatment. • Assign as many external codes as needed. • External can never be the first diagnosis. • No external code is to be used is the primary diagnosis already includes the cause of the injury in the diagnosis.
Countdown to ICD-10 • External Cause Codes Example: • Z21 Asymptomatic human immunodeficiency virus (HIV) infection status • Z87.891 Personal history of nicotine dependence (past) • F17.21 Nicotine dependence, cigarettes (current) • Z79.1 Long term (current) use of (NSAID) • Z79.52 Long term (current) use of use of systemic steroids • Z68.- Body mass index (categorized by age) • E66.01 Morbid (severe) obesity Drug induced gout (M10.2-) use additional code for adverse effect T36 –T50 FYI Personal alcohol dependence F10.2-
Countdown to ICD-10 • Obesity– If this condition is documented and coded; then the body mass index must also be documented and coded from the Z68.- section. • Osteoporosis – There must be documentation if it is with or without a pathological fracture. • A patient with osteoporosis and without current pathological fracture should be coded from category M81.-. Use Z87.310 for a history of osteoporosis pathological fractures. • A patient with osteoporosis with current pathological fractures should be coded from category M80.-. • Pregnancy – If a patient is pregnant and the physician documents that the pregnancy is incidental to visit; then Z33.1 must be coded along with the primary diagnosis.
Countdown to ICD-10 • Signs and Symptoms – It is only acceptable to code a sign or symptoms until a definitive diagnosis is established. Once a definitive diagnosis is made do not code the sign and symptoms. • Unspecified codes – Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified. • HIV/AIDS – Code B20 for symptomatic HIV patients if they have any infections associated with HIV(AIDS). • Code Z21 for asymptomatic HIV infection status – • Sequencing – If any HIV positive patient is treated for an unrelated condition; then code the unrelated condition first then code the HIV Z21.
Countdown to ICD-10 • Signs and Symptoms Code Examples: • R10.1- Pain localized to upper abdomen • R11.1 Nausea (without vomiting) • R53.83 Other fatigue • R76.0 Raised antibody titer • R79.1 Abnormal coagulation profile (PT, PTT) • R79.82 Elevated C-reactive protein (CRP) • R79.89 Other Specified abnormal finding of blood chemistry • (Positive ANA) • R82.5 Elevated urine levels of drugs, medication and biological substances
Countdown to ICD-10 • Character Categories • Four character category example • M79.7 Fibromyalgia • Fifth character category example • M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement • Sixth character category example • M08.461 Pauciarticular juvenile rheumatoid arthritis, right knee • Seventh character category example • M1a.0710 Idiopathic chronic gout, right ankle and foot without tophus (tophi) • Dummy place holder example • M1a.08X0 Idiopathic chronic gout, vertebrae without tophus (tophi)
Countdown to ICD-10 Implementation Preparation .
Countdown to ICD-10 • Implementation Preparation • Physicians • Documentation must change. • Coding and Billing Staff • Must be allowed to query the physicians. • Vendors/Payers • What are your vendors/payers doing to demonstrate they are ready? • Trainers • Who will train the rest of your staff?
Countdown to ICD-10 • Begin the Process
Countdown to ICD-10 • Documentation • When it comes to ICD-10 implementation efforts, clinical documentation improvement (CDI) continues to be one of the most pressing concerns.
Countdown to ICD-10 • Documentation • ICD-10 is not just a “coder” problem • Industry analysts have predicted 50-70% productivity losses due to ICD-10 • The development of complete and accurate CDI program will be critical to smooth transition.
Countdown to ICD-10 • Documentation • With the increased level of specificity due to ICD-10, provider documentation will need to accurately pinpoint elements such as: • severity of illness, • laterality, • complications, • symptom etiology
Countdown to ICD-10 • Coding and Documentation • Issues related to inconsistent, missing, conflicting, or unclear documentation must still be resolved by the provider—both today under ICD-9-CM, as well as in the future with ICD-10-CM • If providers are not documenting concisely for reimbursement today… • They are putting themselves at unnecessary risk for not supporting medical necessity
Countdown to ICD-10 • Documentation • A CDI program will need to: • Promote medical necessity documentation to support therapies, treatments and procedures. • Ensure accurate and complete documentation for accurate coding and reimbursement, reduced compliance risk, and the correct identification of the principal and/or secondary diagnoses • Support evidence-based care for quality reporting measures
Countdown to ICD-10 • Billing and Collections • Patient/Provider/Plan Confusion • increase in denials? • patient misunderstanding of changes in coverage • provider questions • Older debt versus newer services • using ICD-9 codes versus ICD-10 for rebilling • Privacy concerns • new codes contain significantly more detail, how much can be shared • .
Countdown to ICD-10 • Claims and reimbursements may be delayed or rejected due to several reasons by insurers: • differences in the codes sets that cannot be accounted for because of unavoidable compromises in the conversion, • efforts to take advantage of the more precise ICD-10 code set
Countdown to ICD-10 • Timing • The time factor can play a crucial role in deciphering the codes. • This might mean longer waiting periods for reimbursements and more number crunching.
Countdown to ICD-10 • Issues to Focus on Now • Some documentation issues will require physicians to capture new information; others involve updated, modified, and otherwise expanded documentation needs.
Countdown to ICD-10 • A Warning against “Unspecified” • Physicians, coders and billers may be tempted to take the easy road and code “unspecified” if documentation doesn’t support more specific codes.
Countdown to ICD-10 • Post Compliance Challenges • initial productivity loss • disruptions to claims flow • increase in claims rejection rate • provider-payer relations • patient experience with provider • Preparation and a well-developed plan are key to addressing challenges
Countdown to ICD-10 Operational Impact .
Countdown to ICD-10 • Running the Practice • Documentation must change/or continue the trend • Billing will slow down • Reimbursement slowdown • Increase of rejections • Patients visits will be longer
Countdown to ICD-10 • The price tag?