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ICD-10 Provider Education. Developmental Disabilities Provider Association. Cathy Munn, MPH RHIA CPHQ Sr. Consultant. Agenda. Overview of ICD-10 Transition Industry Update Impact of the Change Providers Payers  Provider Preparation Translation Examples

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icd 10 provider education

ICD-10 Provider Education

Developmental Disabilities Provider Association


Sr. Consultant

  • Overview of ICD-10 Transition
    • Industry Update
  • Impact of the Change
    • Providers
    • Payers
  •  Provider Preparation
    • Translation Examples
  • Arkansas DHS Preparation & Planning
  • Next Steps & Resources
before we begin
Before We Begin…..
  • The change to ICD-10 only applies to Medicaid….
  • The implementation date for ICD-10 is 10/1/2014…
  • CPT codes will be replaced with ICD-10 codes…
  • The ICD-10 code composition will now be alphanumeric….
  • ICD-10 is just like any other annual coding update…
icd 10 cm pcs
  • ICD-9-CM: International Classification of Diseases, 9th revision, Clinical Modification
    • US transitioned from ICD-8 to ICD-9 in 1979
    • Annual updates
  • ICD-10: Developed by the World Health Organization as the nomenclature for all countries
    • ICD-10-CM: International Classification of Diseases, 10th revision, Clinical Modification – US only
    • ICD-10-PCS: International Classification of Diseases, 10th revision, Procedure Classification System – US only
federal mandate
Federal Mandate
  • Final Rule Originally Published by HHS on January 16, 2009 requiring the adoption of ICD-10 on October 1, 2013


    • Dates of Service (outpatient) After 10/1/2013
    • Dates of Discharge (Inpatient) After 10/1/2013
  • Federal Mandate Updated Timeline:
    • February 14, 2012 – CMS announces they will “reexamine the pace” of implementing ICD-10
    • May 17, 2012 – All comments due to HHS for consideration prior to publication of the final rule
    • August 27, 2012 – Revised compliance date announced by CMS stating a one-year extension would be granted
    • October 1, 2014 is the revised ICD-10 Implementation Compliance Date
things to remember
Things to Remember
  • ICD-10-CM (diagnoses) will be used by all providers in every health care setting
  • ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures
  • No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes
  • CPT and HCPCS will continue to be used for physician and ambulatory services including physician inpatient hospital visits
  • Release of DSM-V codes occurred in May 2013; however DSM-V is not HIPAA compliant for claims or transactions
important information
Important Information
  • Systems will have to utilize both ICD-9-CM and ICD-10-CM for overlap e.g. claims backlog, Arkansas Medicaid allows providers 365 days to submit a claim.
  • Inpatient discharges occurring on or after 10-1-2014 will use ICD-10-CM and ICD-10-PCS codes regardless of date of admission.
  • Outpatient dates of service occurring on or after 10-1-2014 will use ICD-10-CM codes
  • There will be period of time when payers will be processing claims in both ICD-9 and ICD-10
a few icd 10 benefits
A Few ICD-10 Benefits
  • Better data will be available for:
    • Measuring the quality, safety, and efficacy of care
    • Designing payment systems and processing claims for reimbursement
    • Conducting research, epidemiological studies, and clinical trials
    • Setting health policy
    • Operational and strategic planning and designing healthcare delivery systems
    • Monitoring resource utilization
    • Improving clinical, financial, and administrative performance
    • Preventing and detecting healthcare fraud and abuse
    • Tracking public health and risks
icd 9 vs icd 10 diagnosis codes
ICD-9 vs. ICD-10 Diagnosis Codes

E codes reference External Causes of Injury & Poisoning in ICD-9.

E references the Endocrine system in ICD-10

V codes reference Health Status & Contact with Health Services in ICD-9

V – Y codes reference External Causes of Morbidity in ICD-10

structure and seventh character
Structure and Seventh Character

2 Numeric

3-7 Numeric or Alpha

Additional Characters


(Except U)




















Superficial injury of

knee & lower leg

Etiology, anatomic

site, severity:

Other superficial injuries of knee

1 – Right; 2 – Left; 9 – Unspecified

Added 7th character for obstetrics, injuries, and external causes of injury

Abrasion of the right knee, initial encounter

3–7 Characters

icd 9 procedure vs icd 10 pcs
ICD-9 Procedure vs. ICD-10-PCS

The increase in the number of procedure codes is driven by the increased specificity, granularity & laterality contained within the ICD-10 codes.

patient flow impact
Patient Flow Impact

Providers change coding practices based on ICD-10

Revise for ICD-10 reporting

Update data repositories to accommodate new coding

Update practice management system

Claim priced based on revised fee schedules

Update claims submission process

Revise authorization process

Update system to accept claims

Update benefit logic

& edits

impact on providers
Impact on Providers
  • Systems
  • Operations and Processes
  • Clinical Documentation
system impacts
System Impacts
  • Identify your current systems and work processes that use ICD-9 codes. This could include:
    • Clinical Documentation
    • Encounter Forms and Superbills
    • Practice Management Systems
    • Electronic Medical Record Systems
    • Contracts and Fees Schedules
    • Public Health and Quality Reporting Protocols & Reports
  • A good rule of thumb: Wherever ICD-9 codes appear today, ICD-10 codes will need to replace them in the future
system impacts1
System Impacts
  • Talk with your practice management system vendor about accommodations for both ICD-9 and ICD-10 codes
    • Will your current system require upgrades?
    • Is the vendor planning system updates for accommodation of ICD-10 codes?
    • When will they be ready to install/update?
    • Are the upgrades included in your current contract?
  • Discuss readiness and remediation plans with any clearinghouses or billing services you may use
system operational impacts
System & Operational Impacts
  • Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition
  • Be proactive; don’t wait for vendors to contact you
  • Ask about their plans for ICD-10 compliance and when they will be ready to collaboratively test their systems
  • Ask to see their Remediation Roadmap that supports their claims of “readiness”
  • Utilize CMS checklists and resources as a guide
operational impacts
Operational Impacts
  • Talk with your payers about how ICD-10 implementation might impact your contracts. Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, fee schedules or reimbursement methodologies
  • Understand your metrics:
    • Coding Productivity
    • Coding Accuracy
    • Financial Stability
      • Days in A/R
      • Cash on hand
operational impacts1
Operational Impacts
  • Identify potential changes to work flow and business processes
  • Consider changes to existing processes including:
    • Clinical documentation – viewed as an increasing area of vulnerability & concern in the industry
    • Prior authorization
    • Encounter forms and Superbills
    • Quality and Public Health reporting
    • Involvement in any Care Management or community outreach initiatives
operational impacts2
Operational Impacts
  • Identify the staff in your office who code, or have a need to know the new codes….anticipate that everyonein your office will require some level of awareness training
  • Don’t forget the physicians in the awareness training
  • There are a wide variety of training opportunities and materials available through a variety of resources:
    • Professional Coding Associations – AAPC, AHIMA
    • Online Courses – ICD10 Monitor, Contexo University, Precyse, Nuance
    • Webinars – ICD10 Monitor, HCPro
    • Onsite Training – Train-the-Trainer approach, Coding Boot Camp
    • Non-Traditional - Partner with the HIM Department at a nearby hospital
operational impacts3
Operational Impacts
  • Budget for time and costs related to ICD-10 implementation including:
    • Expenses for system changes and software updates
    • Resource materials
    • Training
    • Modifications to forms and Superbills
  • Other budgetary considerations:
    • Unanticipated payment delays, appeals & denials
    • Understand your operational metrics – benchmark for efficiency
    • Establish a line of credit……
  • Anticipate something you didn’t plan for or expect….
superbills how will they change
Superbills - How Will They Change?
  • Increased size
  • Increased specificity
  • Examples can be found at www.ahima.org/icd10

along with other valuable ICD-10-CM resources

clinical documentation
Clinical Documentation
  • If it’s not documented….it’s not done
    • Outcome Data
    • Liability
    • Reimbursement
clinical documentation practices
Clinical Documentation Practices
  • Clinical documentation improvement “best practices” provide an opportunity for accurate coding and richer clinical data.
  • Accurate data will allow us to better understand our patients; their compliance with care management initiatives and which treatments lead to better outcomes.
  • Complete clinical documentation will promote accurate coding thus leading to more accurate payment that could legitimately look different than it does today.
clinical scenario
Clinical Scenario

Patient presents to the ER for severe right lower leg pain with an

open leg wound following a fall from a ladder. The physician

documented that the patient had an open transverse fracture of the

shafts of the tibia & fibula.

ICD-9-CM code:

  • 823.32, Open fracture of shaft, fibula with tibia
  • E881.0 Accidental fall from ladder

ICD-10-CM codes:

  • S82.221B Displaced transverse fracture of shaft of right tibia, initial encounter for open fracture NOS
  • S82.421B Displaced transverse fracture of shaft of right fibula, initial encounter for open fracture NOS
  • W11.XXXA Fall on and from ladder, initial encounter
changes to e v codes in icd 10
Changes to E & V Codes in ICD-10
  • E codes reference External Causes of Injury & Poisoning in ICD-9
    • E code references the Endocrine system in ICD-10
      • Thyroid gland disorders: E00 – E07
      • Diabetes codes: E08 – E13
      • Disorders of glucose regulation & pancreatic internal secretion: E15 – E16
  • V codes reference Health Status & Contact with Health Services in ICD-9
    • Z codes reference Health Status & Contact with Health Services in ICD-10
  • V – Y codes reference External Causes of Morbidity in ICD-10
other resources reminders
Other Resources & Reminders

Additional information & resources you might find helpful….

arkansas dhs current state
Arkansas DHS Current State
  • Arkansas Medicaid has been working on ICD-10 for over two years
  • Progress to date:
    • Operational assessment complete
    • Remediation of Medical Policy, Edits and Audits complete
    • Remediation of Pharmacy Policy & edits nearing completion
    • Provider Manuals currently under review
    • Systems requirements obtained – HP/MMIS, Xerox/ACS & other integrated & stand alone systems
    • Arkansas DHS reports, forms, and brochures currently under review
    • Ongoing Provider Outreach
      • Meetings/Webcasts
      • Provider Bulletins
      • Newsletters
      • ICD-10 Website www.humanservices.Arkansas.gov/ICD10
  • Internal & external testing scenarios are under development
  • Per CMS; external testing should begin October, 2013
communication planning
Communication & Planning
  • Engage the support of leadership
  • Define your strategy & approach to ensure success
  • Understand the financial implications of non-compliance
  • Ensure everyone understands the impact of ICD-10
    • Receptionist
    • Nursing Staff
    • Physicians
    • Coders
    • Billing Staff
    • CFO/COO
    • Senior Practice Management Staff
  • Share regular updates & communication briefings with staff
operational assessment
Operational Assessment
  • Understand which systems & processes will be impacted
  • Understand the impact that the transition will have on people, process & technology; both internal & external to the practice
    • Staff & providers
      • Education & awareness
      • Training – just in time
    • Workflows
      • Office through-put
      • Clinical documentation
      • Code utilization within the practice – Superbill assessment
      • Coding & billing turn-around-time/cash flow
      • Denials & resubmission of claims
    • Systems upgrades/enhancements
      • Practice management systems
      • Billing transmissions – EDI
      • Vendor readiness
documentation assessment
Documentation Assessment
  • Provider practices and specialty departments should examine their patient population in terms of:
    • High volume/high cost
    • Patient demographic & payer mix: Medicare, Medicaid, Commercial insurance
    • Diagnoses that lead to the highest denial, physician query and re-bill rates; and
    • Areas related to quality reporting, improvement initiatives and published RAC reviews
documentation assessment1
Documentation Assessment
  • Evaluate your current documentation
    • Does it specify right vs. left?
    • Does it provide the specificity needed to accurately assign an ICD-10 code?
  • Conduct a sample audit to evaluate clinical documentation
    • Review claims coded in ICD-9 and code them in ICD-10
    • Is the documentation sufficient?
  • Share the audit results with the providers
    • Understanding of the future documentation needs will reduce queries, pended claims & denials post 10/1/2013
  • Largest testing effort in the history of healthcare
  • Not a routine upgrade with minimal testing before implementation
  • Recommended that you employ end to end testing with vendors, providers & payers to include:
    • Creation of the claim
    • Submission to payer/EDI vendor/clearinghouse via 837
    • Adjudication of claim
    • Reporting back to the provider via EOP/835
    • Adjustments/denials/resubmissions
    • Report creation
    • Denial tracking & analysis

Monitor the AR ICD-10 Website for information regarding testing

industry web site resources
Industry Web Site Resources
  • www.CMS.gov/ICD10
  • www.CMS.gov/NPC
  • www.AHIMA.org
  • www.ICD10watch.com
  • www.AAPC.com
  • http://www.cms.gov/Medicare/Coding/ICD-10/Downloads/ICD10SmallandMediumPractices508.pdf
  • http://www.himss.org/ASP/topics_icd10playbook.asp
  • www.WEDI.org
  • www.humanservices.Arkansas.gov/ICD10
for more icd 10 information
For More ICD-10 Information
  • White Papers (including but not limited to)
    • ICD-10 A Primer
    • ICD-10 Clinical Documentation
    • ICD-10 Physician Impact
    • ICD-10 Advantages
    • ICD-10 Specified or Unspecified


  • Checklists published by CMS for providers (small, medium and large) at:
    • http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html