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ICD-10-CM Making a Successful, Timely Transition. Presented by Jerry Bridge President LifeWorks Education Healthcare Collections & Training. Purpose. To provide the knowledge, tools & resources in order to make a successful, timely transition to ICD- 10 . . Objectives.

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icd 10 cm making a successful timely transition

ICD-10-CMMaking a Successful, Timely Transition

Presented by Jerry Bridge

President LifeWorks Education

Healthcare Collections & Training


To provide the knowledge, tools & resources in order to make a successful, timely transition to ICD-10.

  • Know the regulatory mandate and background for ICD-10
  • Know pervasive impacts on revenue, reimbursement, productivity and work flow
  • Know how to make a project plan; budget, training, vendor management
  • Take away tools & resources to help you get there!
what have you heard
What have you heard?
  • What have you heard, assume or know about ICD-10?
  • Have you started to transition?
  • What have you done to prepare?
how can providers benefit from icd 10
How Can Providers' Benefit from ICD-10?
  • Determine severity of illness and prove medical necessity consistently
  • Improved care with better documentation
  • Address technology and healthcare reform initiatives
  • Reduce the hassle of audits
reimbursement benefits
Reimbursement Benefits
  • Reduced coding error rates = reduced denials
  • Describing higher complexity justifies higher complexity procedure/service payment
  • Better data with which to justify better payment for physicians and pay-for-performance metrics
  • Levels the insurance company tactics “playing field”
why do we need icd 10
Why Do We Need ICD-10?
  • ICD-9-CM is outdated:
    • Over 30 years old
    • Many categories full
    • Not descriptive enough
  • A coding system needs to be:
    • Flexible to quickly incorporate emerging diagnoses
    • Exact enough to precisely identify diagnoses
an outdated coding system
An outdated coding system

A patient is diagnosed with acute tonsillitis, his second diagnoses within 6 months. In ICD-9, acute tonsillitis is reported using ICD-9-CM code 463.

  • There is no fourth or fifth digit to report the acute condition or the specific organism causing it.
  • In ICD-10-CM, the code set for tonsillitis is expanded to a fourth character extension to identify whether the acute condition is recurrent and the causative organism, if known.
the bottom line on icd 9
The bottom line on ICD-9

Any ICD-9 codes used in transactions for services or discharges on or after October 1, 2014 will be rejected as non-compliant and the transactions will not be processed.

icd background information
ICD Background Information
  • Published by WHO in 1990
  • U.S. last industrialized nation to implement ICD-10
  • Two parts: ICD-10-CM and ICD-10-PCS
  • ICD-10-CM – 69,000 codes, ICD-9-CM – 14,000 codes
  • 3–7 alpha and numeric characters for ICD-10-CM
myth or fact
Myth or Fact?

Non-covered entities (those not covered by HIPAA) such as Worker’s Compensation, may choose not to implement ICD-10.


Workers’ Compensation and auto insurance companies are noncovered entities under HIPAA and are not “required” to comply with the October 1, 2014 deadline. However, ICD-9 will no longer be maintained and it will be in the noncovered entities’ best interest to use the new coding system.



Your clinic will need to maintain the ability to submit both ICD-9-CM and ICD-10-CM!

(i.e…..software, hardware capacity and coding capability needed for both code sets)

myth or fact1
Myth or Fact?

State Medicaid Programs will not be required to update their systems in order to utilize ICD-10 codes.


State Medicaid Programs are all covered entities under HIPAA; therefore must comply with the October 1, 2014 deadline.

myth or fact2
Myth or Fact?

Physicians who choose their own codes will not have to worry about training as their EHR will do this for them.


Although EHRs are starting to do some great things in regards to prompts, problem lists, and other assistive tools for ICD-10, they do not take the place of required education for those physicians selecting their own codes.

myth or fact3
Myth or Fact?

ICD-10-CM is a reimbursement system not built for physicians


ICD-10 started its origins at the WHO through the efforts of a team of physicians, clinicians, coders, and other healthcare professionals and then further modified by the United States again by a team of clinicians and other healthcare professionals. ICD-10 is far more rooted in current clinical thought and practice than the ICD-9 system.

icd 10 cm vs icd 9 code structure
ICD-10-CM vs. ICD-9 Code Structure

ICD-10-CM Code Format

Ex: Unspecified asthma with acute exacerbation


ICD-10             J45.901

(Etiology means “cause or origin”)

ICD-9-CM Code Format

icd 10 code set websites
ICD-10 Code Set Websites
  • CMS: http://www.cms.gov/Medicare/Coding/ICD10/
  • AMA: http://www.ama-assn.org
  • AHIMA: http://www.ahima.org/icd10/
  • AAPC:http://www.aapc.com/icd-10/
more is better
More is Better!

Just as an increase in the number of words in a dictionary doesn’tmake it more difficult to use, the greater number of codes in ICD-10-CM, the easier it is for you to find the rightcode!

increase in codes the real story
Increase in Codes: The Real Story
  • Gastroenterologists: 596 ICD-9 codes and 706 codes in ICD-10 (+110)
  • Pulmonologists: 255 codes in ICD-9 and 336 codes in ICD-10 (+81)
  • Urologists: 389 codes in ICD-9 and 591 codes in ICD-10 (+202)
  • Endocrinologists: 335 codes in ICD-9 and 675 codes in ICD-10 (+340)*
  • Neurologists: 459 codes in ICD-9 and 591 codes in ICD-10 (+132)
  • Pediatricians: 702 codes in ICD-9 down to 591 codes in ICD-10 (-111)
  • Infectious disease: 1,270 in ICD-9 down to 1,056 in ICD-10 (-214)

A few hundred new codes =

a few dozen new documentation elements

* ICD-10-CM includes more combination codes containing co-morbidities and associated conditions. (e.g.- Diabetes)

overall coding process is the same
Overall Coding Process Is The Same!
  • Capture the required encounter documentation
  • Choose the correct code
  • Make sure you have the medical necessity to justify the procedure or service
examples of icd 10 cm codes
Examples of ICD-10-CM Codes
  • I10 - Hypertension (Seriously? I10?)
  • H90.3 - Sensorineural hearing loss bilateral
  • K80.63Calculus of gallbladder and bile duct with acute cholecystitis with obstruction
  • Fracture of Patella (GEMs)
unspecified unpaid
“Unspecified” = “Unpaid”

“Physicians may be ICD-10 compliant, but if they abuse the “other” or “unspecified” codes, payment will not occur if a more specific alternative exists.”

David Winkler

Michigan Blue Cross’ Director of Technical Program Management

Justifying medically necessary procedures and services depends on specificity of diagnoses coding!

unspecified codes
Unspecified Codes
  • Use of signs, symptoms, and unspecified codes is “acceptable, even necessary” in both ICD-9-CM and ICD-10-CM, says CMS.
  • For example, if the physician has not determined a definitive diagnosis by the end of the encounter, codes for sign(s) and/or symptom(s) may be reported.
unspecified codes1
Unspecified Codes
  • When a more specific code can’t be assigned because the clinical information provided isn’t sufficient, the appropriate unspecified code may be used (such as when a physician determines a diagnosis of pneumonia but not the specific type). 
  • Always remember that, in all cases, the medical record documentation must support the code choice!
documentation the key to icd 10 success
Documentation: The KEYto ICD-10 Success

With increased dx coding specificity comes a requirement for detailed documentation.

Jeri Leong, President, Healthcare Coding Consultants of Hawaii:

“…(for current audits), 40% of the time we were unable to assign a specific ICD-10-CM code based on current documentation.”

How good is YOUR current documentation?

example patient is seen for asthma with status asthmaticus
Example:Patient is seen for Asthma with Status Asthmaticus

ICD-9-CM = 493.91

  • Extrinsic vs. intrinsic
  • Chronic obstructive asthma
  • With status asthmaticus
  • With exacerbation
  • Exercise induced bronchospasm
  • Cough variant asthma

 Additional documentation required

ICD-10-CM = J45.902

  • Mild intermittent 
  • Mild persistent 
  • Moderate persistent 
  • Severe persistent 
  • With status asthmaticus
  • With exacerbation
  • Exercise induced bronchospasm
  • Cough variant asthma
  • Tobacco use or exposure 
  • Excludes chronic obstructive asthma *
combination codes
Combination Codes
  • Multiple conditions that may include common symptoms or manifestations
  • 250.50 Diabetes with ophthalmic manifestations
  • Sequencing errors reduced

A patient is being treated by his physician for moderate nonproliferative diabetic retinopathy. The physician documents Type II diabetes with macular edema.

how can you prepare
How Can You Prepare?
  • Don’t focus on 69,000 Codes
  • Convert your codes!!!
  • Engage your providers
  • Practice coding in I 10 -Now!
gems translation and training tool
GEMs Translation and Training Tool

GEMs=General Equivalence Mapping:

  • a reference mapping tool that attempts to include all valid relationships between the codes in ICD-9-CM and ICD-10-CM
  • an excellent training tool to be used to familiarize differences between ICD 9 and ICD-10 and to be able to select the correct ICD-10 code.
  • The mapping identifies one-to-one and one-to-many code relationships
characteristics of a good gems tool
Characteristics of a Good GEMs Tool
  • Outpatient setting
  • Search by code and description
  • Bi-directional: ICD-9 to ICD-10 and vice versa
  • Multiple code lookups at one time
  • Store most frequently used codes (“Favorites”)
  • “Print” function: easily create training tools
practical uses of gems
Practical Uses of GEMs
  • Create immediate awareness
  • Engage providers and staff
  • Facilitate chart audits to analyze current documentation
  • Assess managed care contracts
  • Facilitates EMR templates updates
  • Helps identify “role based” training
  • Saves time over manual conversion
engage the entire team
Engage the Entire Team!
  • Promote benefits of ICD-10
  • Make a plan
  • Provide real world tools

If all else fails, show them the really fun codes they’ll miss out on if they don’t go ICD-10!

w18 12x

Fall from or off toilet with subsequent striking against an object

W18.12XA Initial Encounter

W18.12XD Subsequent Encounter

W18.12XS Sequela

y04 1xxa

Assault by Human Bite, Initial Encounter

w22 09zd

Striking against other stationary object,

Subsequent Encounter


Two fish were swimming along

and ran into a cement wall.

One looked at the other and said, “Dam.”

ok we don t really treat fis h unless they have really good insurance
Ok, we don’t really treat fish…(Unless they have really good insurance!)


Striking against other stationary object, Subsequent Encounter

How about this one…

y93 k2

Activity, Milking an animal

if the milking goes badly
(If the milking goes badly)

…the related W55.22XS

Struck by cow, Sequela

v91 07xd

Burn due to water-skis on fire, subsequent encounter

v91 07xd1

Ok…so I looked everywhere.

I could not find a single burning water skis picture.

But I DID find incidents involving SNOW SKIS

v98 3xxa

Accident to, on, or involving Ski Lift, initial encounter

t68 xxxa

Unfortunately, upon rescue our intrepid skier suffered from…


Initial Encounter

w61 91xa

Bitten by other birds, Initial Encounter

please note separate codes for
Please Note Separate Codes For:

Being bitten or struck by…

Turkey, chicken, macaw, parrot, other psittacines, goose, duck, mouse, rodent, rat, squirrel, sea lion, orca, horse, cow, pig, raccoon, lizard, snake, alligator or crocodile.

and the ever popular r46 1
And….the ever popular:R46.1

Bizarre Personal Appearance

do now physician s documentation a chart audit
Do Now: Physician’s Documentation: A Chart Audit
  • Per Doctor: list top 25 diagnoses (by revenue, frequency)
  • Use GEMS to translate ICD-9 to ICD-10
  • Pull patient charts containing those ICD- 9 diagnoses
  • Assess current documentation as sufficient or not
  • Create report for providers
  • Customize training by provider
  • Continue to monitor documentation
do now create documentation coding tools
Do Now:Create Documentation Coding Tools
  • Make a list of your practice’s top 100 most frequently used ICD-9-CM diagnosis codes
  • Use the GEMs mapping tool to translate the ICD-9 codes to ICD-10
  • For each ICD-10-CM code, highlight unique documentation and coding requirements
  • Create flash cards, one per code, for your providers

If providers start now and learn the unique documentation and coding requirements for 1 or 2 diagnoses codes per week, they will be prepared for ICD-10-CM when the Oct. 1, 2014 deadline arrives.

asthma documentation quick reference guide
ASTHMA Documentation Quick Reference Guide

J45 (ICD-10-CM Root Code) – Asthma

Required Documentation Elements

  • Mild Intermittent
  • Mild Persistent
  • Moderate Persistent
  • Severe Persistent
  • Tobacco Use or Exposure
impacts to your organization
Impacts to Your Organization
  • Documentation
  • Reporting
  • Office processes
  • Referrals
  • Payers and business partners
  • Budget and productivity
  • Claims and other electronic transactions
  • PM and EMR software

The AAFP conducted a study by converting the most common dx codes in the family practice environment

In ICD-10 the superbill/encounter form would expand on average to 9 pages!

work flow impacts
Work Flow Impacts
  • Diagnostic Orders (Lab, Radiology, etc)
  • Other service requests: PT, OT, DME
  • Referrals
  • Home Health Treatment Plans
work flow impacts1
Work Flow Impacts
  • Pharmacy
  • Admin services: Insurance verification, pre-authorization and surgery scheduling
  • Retrospective reporting
payer and business partner
Payer and Business Partner
  • Begin a dialogue with your payers about:
    • testing
    • ICD-10 implementation plan
    • provider contracts
    • coverage and reimbursement policies

Start asking the important questions NOW!

Delaying until the last minute could have a devastating effect on cash flow!

  • Identify the staff in your office who code, or have a need to know the codes
  • Not all staff require the same level of training.
  • Role Based training is essential
  • Professional Coding Associations recommend:
    • Providers 6 – 12 hours
    • Coders 16 hours (for outpatient coders)
    • Other Staff 2-8 hours (depending on involvement)
time frame
Time Frame

When the training will be delivered?

  • ICD-10 Awareness-Immediately!
  • Workflow/Process/Coding 6-9 months prior to the go live date.
  • Code Training- Suggested start for coding training is 6-12 months prior to go live date.
  • You may need to schedule ‘refresher’ trainings as needed.
hardware software
  • Talk with your practice management software vendor about accommodations for both version 5010 and ICD-10 codes
  • Discuss implementation plans with your clearinghouses, billing services, and payers to ensure a smooth transition
  • Conduct test transactions using version 5010 and ICD-10 codes with your payers and clearinghouses
hardware software cont
Hardware/Software (cont.)
  • Confirm systems upgrades are covered by existing contracts and if not, budget for them.
  • Confirm vendor will provide support and training
  • Confirm PM/EMR services will accommodate both ICD-9 and ICD-10 as you work with claims for services provided before and after the transition deadline
  • Confirm current hardware resources are sufficient to handle the increased load
  • Create budget for H/W, S/W purchase and possible IS personnel additional workload
  • ICD-10-CM adds coding, documenting and work process complications.
  • EMR is an excellent way to mitigate current and ongoing challenges due to the new transition.
  • Government incentives to transition to EMR make NOW the perfect time to do so.
icd 10 readiness checklist
ICD 10 Readiness Checklist


  • Are top-revenue-producing insurance plans going to ICD 10? _____
  • When? (Will they meet the Oct. 1, 2014 deadline? _____
  • Have contract negotiations been completed for plans tying reimbursement to ICD 10? _____
icd 10 readiness checklist1
ICD 10 Readiness Checklist

Internal Processes

  • Impact assessed for everywhere ICD 10 touches?
  • ICD 10 coding resources (manual, encoder or online lookups) updated?
  • Chart audit Completed?
  • Documentation training for physicians completed?
  • GEMs available and in use?
icd 10 summary
ICD-10 Summary

Early, effective preparation can turn the ICD-10-CM transition from a predicament to a significant opportunity for your practice.

  • Reimbursement
  • Productivity
  • Accuracy
  • Software and hardware upgrades
  • Training
  • Administrative functions
  • EMR adoption that enhances the ICD-10 transition
tools you will need
Tools You Will Need
  • ICD-10 Transition Software – saves valuable conversion time
  • Documentation and Coding Training Guides
  • Do-it-yourself ICD-10 Implementation Tool Kits - Impact Assessment/Planning Guide
  • Chart Documentation Reviews
  • Role Based Training Plan
  • Budget- Money and time!
the icd 10 transition practice manager planning guide
The ICD-10 Transition “Practice Manager-Planning Guide”

Organized and designed specifically for practice-project managers

responsible for ICD-10-CM implementation.

Your ICD-10 Planning Guide includes:

The 4 critical action steps you should be taking now!

‘Project Planner’: broken down by quarter with action steps!

Training & Budget Planner

‘Vendor Tracker & Query Forms’ keep your vendors on track! CD-ROM

Recommendations and resources on how to conduct End to End testing!

ICD-10 Planning Guide $399

With Code Translation Software: Convert ICD-9 codes to ICD-10 in seconds! Features multiple code

lookups, print capabilities, ability to save favorites and create flash cards. Create training tools for your entire staff, accessible anywhere, from any computer!

Planning Guide with Code Translation Software, Only $599

thank you
Thank You!

Questions, Comments or Feedback?

Please call or email:

Jerry Bridge