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ICD-10 Introduction By: Aaron Weg ADL Data Systems, INC.
ICD History • ICD-1 1900-1909 • ICD-2 1910-1920 (1044 pages 30 lines) • ICD-3 1921-1929 (43 countries) • ICD-4 1930-1938 • ICD-5 1939-1948 (model for future versions) • ICD-6 1949-1957 (3 digit codes 800 total) • ICD-7 1958-1967 • ICD-8 1968-1978 (4 digit codes & E codes) • ICD-9 1979-1994 (5 digit codes, E &V codes) • ICD-10 1993-??? (in US 2014)
Reasons to switch to ICD-10 • Regulation • More detail in description • Standardized Terminology • Includes definitions of the terminology used • While the meaning of specific words can vary in common usage, ICD-10 defines a single meaning for each term used in the system. • Multi-Axial • Each character has the same meaning within a section and across sections to the extent possible • Expandability • Better patient care • More accurate records
ICD-9 Limitations • Follows a 1970s outdated medical coding system • Lacks clinical specificity to process claims and reimbursement accurately • Fails to capture detailed health care data analytics • Limits the characters available (3-5) to account for complexity and severity • The codes themselves lack specificity and detail to support the following • Accurate anatomical descriptions • Differentiation of risk and severity • Key parameters to differentiate disease manifestations
Benefits of ICD-10 • Improve operational processes across the health care industry by classifying detail within codes to accurately process payments and reimbursements • Update the terminology and disease classifications to be consistent with current clinical practice and medical and technological advances. • Increase flexibility for future updates as necessary. • Enhance coding accuracy and specificity to classify anatomic site, etiology, and severity
Comparison of ICD9CM to ICD10CM ICD-9 ICD-10 3-5 characters Approx 13,000 1 Alphanumeric and 4 numeric Limitted Ambiguous Does not identify Right vs Left 3-7 Characters Approx 68,000 1 Alpha, 1 numeric, 5- Alphanumeric Flexible Very specific (Allows description of comorbidities, manifestations, etiology/causation, complications, detailed anatomical location, sequelae, degree of functional impairment, biologic and chemical agents, phase/stage, lymph node involvement, lateralization and localization, procedure or implant related, age related, or joint involvement) Often identifies Right vs Left Field length Available codes Code composition Codes available Level of detail Laterality
Comparison of ICD9 to ICD10PCS ICD-9 ICD-10 3-4 characters Approx 3,000 Generic Description No Right vs Left Lacks description of procedure approach N/A 7 Alphanumeric Characters Approx 72,081 Detailed description Code identifies Right vs Left Detailed description of procedure approach. Precise definition of anatomic site, approach, device used, and qualifying information 16 PCS sections identify procedures in a variety of classifications (e.g., medical surgical, mental health, etc.). Among these sections, there may be variations in the meaning of various character positions, though the meaning is consistent within each section. I.e. for the Medical surgical section.1=Name of Section, 2=Body System, 3=Root Operation, 4=Body Part, 5=Approach, 6=Device, 7=Qualifier Field length Available codes Terminology for Body Parts Laterality Level of detail Character position within code
Things to note about ICD10 • Diagnosis may not be exactly the same as ICD9 • All procedure codes are 7 chars with “Z” fill • No spaces allowed in the middle of a diagnosis. Use an “X” • Not all diagnosis exist in both ICD9 and ICD10 • One may need several ICD10 diagnosis to be equivalent to one ICD9
ICD-10 Guidelines • Special cases / definitions • Sequence of diagnosis • and = and / or • Excludes 1 • Type 1 exclude – NOT CODED HERE • Excludes 2 • not included in this diagnosis • you may need this code and another • With = associated with or due to • Code Also = a second code may also be needed • There are chapter specific guidelines as well
ICD-10 Guidelines (cont) • Special cases (cont) • Etiology (cause or source) /manifestation convention • “code first” • “use additional code” • “in diseases classified elsewhere” • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires theunderlying condition be sequenced first followed by the manifestation • Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
ICD-10 Guidelines (cont 2) • Special cases (cont) • Etiology/manifestation convention (cont) • In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere." Codes with this title are a component of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. • "In diseases classified elsewhere" codes are never permitted to be used as first-listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. • See category F02, Dementia in other diseases classified elsewhere, for an example of this convention
ICD-10 coding scheme • 1st character Alpha A-Z • E-codes are now starting with “Y” • Characters 2-3 digits • Characters 4-7 alphanumeric • Depends on section • First 3 characters are the initial lookup • G80 Cerebral Palsey • G81 Hemiplegia and Hemiparesis • G82 Paraplegia (paraparesis) and Quadriplegia (quadriparesis)
ICD10-CM Primary groups I • Certain infectious and parasitic diseases (A00-B99) • Neoplasms (C00-D49) • Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) • Endocrine, nutritional and metabolic diseases (E00-E89) • Mental and behavioral disorders (F01-F99) • Diseases of the nervous system (G00-G99) • Diseases of the eye and adnexa (H00-H59) • Diseases of the ear and mastoid process (H60-H95) • Diseases of the circulatory system (I00-I99) • Diseases of the respiratory system (J00-J99) • Diseases of the digestive system (K00-K94)
ICD10-CM Primary Groups II • Diseases of the skin and subcutaneous tissue (L00-L99) • Diseases of the musculoskeletal system and connective tissue (M00-M99) • Diseases of the genitourinary system (N00-N99) • Pregnancy, childbirth and the puerperium (O00-O99) • Certain conditions originating in the perinatal period (P00-P96) • Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) • Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) • Injury, poisoning and certain other consequences of external causes (S00-T88) • External causes of morbidity (V00-Y99) • Factors influencing health status and contact with health services (Z00-Z99)
Mental and Behavioral Disorders (F01-F99) • F01-F09 Mental disorders due to known physiological conditions • F10-F19 Mental and behavioral disorders due to psychoactive substance use • F20-F29 Schizophrenia, schizotypal, delusional, and other non- mood psychotic disorders • F30-F39 Mood [affective] disorders • F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders • F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors • F60-F69 Disorders of adult personality and behavior • F70-F79 Mental retardation • F80-F89 Pervasive and specific developmental disorders • F90-F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence • F99 Unspecified mental disorder
Mental disorders due to known physiological conditions (F01-F09) • F01 Vascular dementia • F02 Dementia in other diseases classified elsewhere • F03 Unspecified dementia • F04 Amnestic disorder due to known physiological condition • F05 Delirium due to known physiological condition • F06 Other mental disorders due to known physiological condition • F07 Personality and behavioral disorders due to known physiological condition • F09 Unspecified mental disorder due to known physiological condition
Dementia in other diseases classified elsewhere(F02) Code first • the underlying physiological condition, such as: • Alzheimer's (G30.-) • cerebral lipidosis (E75.4) • Creutzfeldt-Jakob disease (A81.0-) • dementia with Lewy bodies (G31.83) • epilepsy and recurrent seizures (G40.-) • frontotemporal dementia (G31.09) • hepatolenticular degeneration (E83.0) • human immunodeficiency virus [HIV] disease (B20) • There are 13 more items in the list
Dementia in other diseases classified elsewhere(F02) • Excludes1: • dementia with Parkinsonism (G31.83) • Excludes2: • dementia in alcohol and psychoactive substance disorders (F10-F19, with .17, .27, .97) • vascular dementia (F01.5-)
Dementia in other diseases classified elsewhere(F02) • F02.8 Dementia in other diseases classified elsewhere • F02.80 Dementia in other diseases classified elsewhere, without behavioral disturbance • Dementia in other diseases classified elsewhere NOS • F02.81 Dementia in other diseases classified elsewhere, with behavioral disturbance • Dementia in other diseases classified elsewhere with aggressive behavior • Dementia in other diseases classified elsewhere with combative behavior • Dementia in other diseases classified elsewhere with violent behavior • Dementia in other diseases classified elsewhere with wandering off
GEMs (General Equivalence Mappings) Mappings between I-9 and I-10 attempt to find corresponding diagnosis codes between the two code sets, insofar as this is possible. In some areas of the classification the correlation between codes is fairly close, and since the two code sets share the conventions of organization and formatting common to both revisions of the International Classification of Diseases, translating between them is straightforward. Many infectious disease, neoplasm, eye, and ear codes are examples of fairly straightforward correspondence between the two code sets. In other areas—obstetrics, for example—whole chapters are organized along a different axis of classification. In such cases, translating between them the majority of the time can offer only a series of possible compromises rather than the mirror image of one code in the other code set.
GEMs examples • Equal Axis of Classification • Example 1 • A02.21 Salmonella meningitis • Translates to and from 003.21 Salmonella meningitis • Example 2 • C92.01 Acute myeloid leukemia, in remission • Translates to and from 205.01 Myeloid leukemia, acute, in remission
GEM Examples • Unequal Axis of Classification: Stage of Pregnancy vs. Episode of Care • Classified by stage of pregnancy: ICD-10-CM • O26.851 Spotting complicating pregnancy, first trimester • O26.852 Spotting complicating pregnancy, second trimester • O26.853 Spotting complicating pregnancy, third trimester • O26.859 Spotting complicating pregnancy, unspecified trimester • Classified by episode of care: ICD-9-CM • 649.50 Spotting complicating pregnancy, unspecified episode of care • 649.51 Spotting complicating pregnancy, delivered • 649.53 Spotting complicating pregnancy, antepartum
GEMs A sentence translated from English to Chinese may not be able to capture the full meaning of the original because of fundamental differences in the structure of the language. Likewise, a code set may not be able to seamlessly link the codes in one set to identical counterparts in the other code set. For these two diagnosis code sets, it is often difficult to find two corresponding descriptions that are identical in level of specificity and terminology used. This is understandable. Indeed, there would be little point in changing from the old system to the new system if the differences between the two, and the benefits available in the new system, were not significant.
GEMs For example, an I-9 code description containing the words “complicated open wound” does not have a simple one-to-one correspondent in I-10. The I-9 description identifies the clinical concept “complicated,” but according to the note at the beginning of the section, that one concept includes any of the following: delayed healing, delayed treatment, foreign body or infection. I-10 does not classify open wound codes based on the general concept “complicated.” It categorizes open wounds by wound type—laceration or puncture wound, for example—and then further classifies each type of open wound according to whether a foreign body is present. I-10 open wound codes do not mention delayed healing or delayed treatment, and instructional notes advise the coder to code any associated infection separately. Therefore, depending on the documentation in the record, the correct correspondence between and I-9 and I-10 code could be one of several.
GEMs - Purpose • Ease in transition • Not a “Cure All” • Most are approximate • Many cases are one to many and/or many to one • In many cases need to pick from a list • Not all codes are mapped
Types of GEMs • No ICD-10 mapping (425) • One to one (exact and approximate) (11000) • One to a choice (2520) • Over 1430 are simple choice of 2 • About 860 are between 3 and 5 selections • About 220 have 6 or more to select one from • One to a group of 2 ICD-10s (300) • One to a set of scenarios each with choices (359)
GEM table use • Find the ICD9-code • Verify that it is not NO MAP • If single entry – use ICD10 code • If multiple entry without combination • Set up a choice list to choose from • If multiple entry with combination and 1 scenario • If multiple entries in choice list • Choose from those choices for each choice list • If one entry • Choose that entry • If multiple scenarios • Repeat above for each of the scenarios • Should choose entries only from 1 scenario
Mapping Simple Entry One to Choice mapping One to Many mapping No Map Flag
Gem table structure • Flag 1 Approximate • 0 Exact match (one or more codes) • 1 Approximate match • Flag 2 No Map • 0 Mapping exists • 1 No mapping exists • Flag 3 Combination Flag • 0 Not a combination entry • 1 A combination entry • Flag 4 Scenario (0-9) • Flag 5 Choice list (0-9)
ADL’s Solution – GEM’s • Screens have 2 columns ICD and Gem • Must be enabled in security • Allow display • Allow update • Restrict regular diagnosis • One to one cases map automatically • Double click first time • All other cases need manual intervention • Double click and the selection screen comes up
Screens that have been modified • Medical • Basic (medical tab) • Discharge • Discharge DX • Medicare (DXs Tab)
Initial Gem Selection Double click in “Dx Gem” column Click Yes to automatically do simple GEMs
Initial GEM selection (cont) • Double-click in the GEM column for any entry that does not show to get the selection screen • We double click on the row 806.4 in the Dx Gem column
Gem selection screen • Select from one of the scenarios one diagnosis from each group
Gem Selection Screen (cont) • If we attempt to select entries from 2 scenarios we get the warning
GEMs placed in screen • Multiple lines are used as needed • When reselecting it removes the extra lines • For billing the duplicates are eliminated
GEM descriptions • Double-click in the Description column to switch between ICD description and the GEM description
GEM extreme simple choice • 533 choices • Less then 10 codes have more then 100 • Less then 50 codes have more then 12
ADL status • Gem selection is available now • Suggested implementation • Review existing diagnosis for accuracy • Slowly update records as diagnosis change • Do all new admissions when they occur
ICD10-PCS • Procedure codes • We will not map procedure GEMs • Slide show from CMS part of seminar documentation • Parts of it follow on the next set of slides
ICD-10-PCS Section Structure Medical & Surgical Sections • Character 1 = Section • Character 2 = Body System (31 systems) • Character 3 = Root Operation (31 root operations) • Character 4 = Body Part • Character 5 = Approach • Character 6 = Device • Character 7 = Qualifier • Letters I and O are never used to avoid confusion with 0 and 1
ICD10-PCS Principles • Composite Terms are not Root Operations • Colonoscopy • Appendectomy • The Root Operation is Based on the Objective of the Procedure • What was actually done, not what was intended • Combination procedures are coded separately • Vein Graft with Bypass surgery • Redo of Procedures are Coded to the Procedure Performed • I.e. redoing a Hip Replacement is coded as a Replacement, not Revision
ICD10-PCS Root Operation Terms • Each term clearly defined