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ICD-9-CM ICD-10-CM

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ICD-9-CM ICD-10-CM
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  1. ICD-9-CMICD-10-CM Implementing ICD-10-CM Preparing for the Conversion Long Term and Post Acute Care Practice Council

  2. Background ICD-9-CM • Current coding classification system • Introduced 30 years ago • No longer fits with 21st century health system ICD-10-CM • International standard • Track, report & compare morbidity & mortality • Transition to ICD-10 required by federal regulations (HIPAA standards)

  3. Background ICD-10 • Available since 1992 • Approximately 100 countries use ICD-10 including Canada, Australia, and the United Kingdom • United States: Only industrialized nation not using ICD-10 • United States: ICD-10 go-live date was October 1, 2013 NOW revised to be implemented October 1, 2014

  4. Global Use of ICD-10

  5. The WHO - What – Why ??? ICD-9-CM Overview • ICD-9 Developed by the WHO (World Health Organization) • 1979 U.S. developed the Clinical Modification to ICD-9-CM • 2000 HIPAA transaction and code set: ICD-9 -CM for electronic transactions Now updated for ICD-10-CM

  6. Where - How – When ??? • ICD-10-CM All health care settings as well as other industries which utilize the ICD system, e.g. Insurance Providers ICD-10-PCSfor inpatient hospital) • A single implementation date for all providers • Current Implementation Date: October 1, 2014

  7. Code Freeze • Last regular, annual updates to both ICD-9 and ICD-10 was Oct. 1, 2011 • Oct. 1, 2012 - 2013 there will be only limited code updates to both code sets • Oct. 1, 2014 there will be only limited updates to ICD 10 code set • Limited updates will capture new technology or new diseases only • Oct. 1, 2015 regular annual updates to ICD-10 will begin, ending the freeze

  8. ICD-10-CM Significantimprovement for reporting clinical data • Measuring the quality, safety, and efficacy of care • Conducting clinical trials, epidemiological studies, research • Setting health policy • Tracking public health and risks

  9. ICD-10-CMSignificant Improvements • Strategic planning and designing healthcare delivery systems • Monitoring resource utilization • Improving clinical, financial, and administrative performance • Detecting and preventing healthcare fraud and abuse

  10. ICD-10-CMSignificant Improvements • Fewer miscoded, rejected & improperly reimbursed claims • Improved disease management • Increased Specificity • Data comparability internationally

  11. What remains the same? • Use of code books or encoder • Tabular List Chapters similar to ICD-9-CM with some exceptions • Main Term, indented sub term • Alphabetic Index of External Causes • Table of Neoplasms • Table of Drugs and Chemicals

  12. What remains the same? • Conventions – abbreviations, punctuation, symbols, code first, use additional code, includes, excludes • Code to highest level of specificity • Adherence to HIPAA and official guidelines (ICD-10-CM) • Nonspecific codes still available

  13. What remains the same? Inconsistent, missing, conflicting, documentation must still be resolved by the Provider—both today under ICD-9-CM, as well as in the future with ICD-10-CM

  14. Coding and Documentation • The goal is always to work toward better documentation for the following reasons: • Avoid misinterpretation by third parties (such as auditors, payers, attorneys) • Justify medical necessity • Provide a more accurate clinical picture of the quality of care provided • Support current & future initiatives aimed at improving quality and reducing costs, such as value-based purchasing

  15. ICD-10-CM Differences • Increase codes: 14,000 to 68,000 • Flexible– Incorporate emerging diagnoses, advancesin medicine and medical technology • Uses current medical terminology • Codes are Alphanumeric • all codes begin with a letter • Uses all letters of the alphabet except the letter U

  16. ICD-10-CM Differences • Expanded length 3-7 characters vs. 3-5 • Increased precision in diagnosis code • Full diagnostic titles for each code • Added Laterality (right/left, bilateral) • Code extensions for injuries and external causes of injuries • Combination codes for etiology & manifestations • Episode of Care designation

  17. ICD-10 Differences EXCLUDE NOTES • Excludes 1: not coded here • The 2 conditions contradict each other • Acquired condition vs. congenital • Codes cannot be reported together • Excludes 2: not included here • The condition excluded is not a part of the condition represented by the code • Both codes can be reported together

  18. ICD-10 Difference • Acute MI – Time Frame Change ICD – 9 8 weeks or less ICD – 10 4 weeks or less • Hemiplegia / Monoplegia Dominant vs. Nondominant • Example: • G81.91 Hemiplegia, unspecified affecting right dominant side

  19. Difference & Similarities • Hypertension Table eliminated • Only 1 hypertension code in ICD-10 • Same rules apply in ICD-10 as in ICD-9 for combining Hypertension codes with heart disease and chronic kidney disease.

  20. Hypertension ICD-9-CM ICD-10-CM I10 Essential Primary Hypertension • 401.0 Essential Hypertension, Malignant • 401.1 Essential Hypertension Benign • 401.9 Essential Hypertension Unspecified

  21. Asthma with Acute Exacerbation ICD-9-CM ICD-10-CM J45.21 - Mild intermittent asthma with acute exacerbation J45.31 - Mild persistent asthma with acute exacerbation J45.41 - Moderate persistent asthma with acute exacerbation J45.51 - Severe persistent asthma with acute exacerbation • 493.92 – Asthma, unspecified with acute exacerbation

  22. ICD-10-CM Code Format . X X X X X X X Category Etiology, anatomic site, severity Extension

  23. ICD-10 Placeholder “X” • Addition of dummy placeholder “X” is used in certain codes to: • Allow for future expansion • Fill out empty characters when a code contains fewer than 6 characters and a 7th character is required • When placeholder character applies, it must be used in order for the code to be considered valid • Example: S32.9XXD Fx Pelvis d/t fall, routine healing, subsequent episode of care

  24. SIGNIFICANT DIFFERENCE Coding Fractures • No longer will we use Aftercare codes for healing fractures • V54.13 Aftercare for healing traumatic fracture of hip • Will use the acute fracture code followed by an appropriate 7th character extension to indicate subsequent episode of care

  25. Closed Fracture 7th character extensions: • A – Initialencounter for closed fracture hospital, ER, clinic • D – Subsequent encounter for fracture routine healing • G – Subsequent encounter for fracture delayedhealing • K – Subsequent encounter for fracture nonunion • P – Subsequent encounter for fracture malunion

  26. CODING GUIDELINES

  27. Coding Guidelines • A Fracture not indicated as displaced or nondisplaced should be coded to displaced. • A fracture not indicated whether open or closed should be coded to closed

  28. Coding Guidelines Initial vs. subsequent encounter for fractures: • Initial care involves active treatment • Subsequent care occurs after active treatment and receiving routine care during the healing or recovery phase • Sequela – complications or conditions that arise as a direct result of an injury (previously called ‘late effect’)

  29. ICD 10 Structure FRACTURES • S72 FractureFemur • S72.1Pertrochanteric fxfemur • S72.14Intertrochanteric fxfemur • S72.141 Displaced Intertrochanteric fracture of right femur • S72.141D Displaced Intertrochanteric Fx of right femur, subsequent encounter for closed fx with routine healing

  30. Closed fracture of the greater trochanter of the right femur (hip fracture) • S72.111A- Initial encounter for closed fracture: Patient admitted for initial treatment in ER and hospital with resulting surgical repair • S72.111D - Subsequent encounter for closed fracture with routine healing: Admission to long-term care (LTC) for rehabilitation after hip replacement

  31. Examples: Subsequent Encounter • S72.111D, Subsequent encounter for closed fracture with routine healing: Discharged from LTC Home Health for continued PT • S72.111D, Subsequent encounter for closed fracture with routine healing: Patient visits hospital radiology department for X-ray • S72.111D, Subsequent encounter for closed fracture with routine healing: Patient to physician office for follow-up visit

  32. ICD-10-CM ‘Snapshot’ • Diabetes mellitus 59 to ~ 200+ • Pressure ulcer 9 to ~ 125 • Path. fracture 8 to ~ 150 • Under dosing NEW section

  33. ICD-10-CM ‘Snapshot’ • Z43.1 Attention to gastrostomy • Z48.815 Aftercare following surgery on digestive system (cholecystectomy) • F03.90 Unspecified Dementia, w/o behavior • L89.613 Pressure ulcer right heel, stage III

  34. ICD-10-CM ‘Snapshot’ • E11.40 Type II DM with neuropathy • Z79.4 Long Term use of insulin • J44.9 COPD • Z99.81 Oxygen dependent • Z79.52 Prednisone dependent

  35. MI – Myocardial Infarction • Time frame for coding acute myocardial infarctions changes with ICD-10 • ICD-9 8 weeks • ICD-10 4 weeks • As long as treatment is required, regardless of care setting

  36. MI – Myocardial Infarction • I21.4 Non-ST elevation (NSTEMI) myocardial infarction • Use acute code for 4 weeks regardless of treatment facility • I25.2 Old myocardial infarction • After initial episode of 4 weeks, then use “healed / old MI” code

  37. Residual Effects of Cerebrovascular Disease ICD-10-CM • Hemiplegia following nontraumaticsubarachnoid hemorrhage • Hemiplegia following nontramaticintracerebral hemorrhage • Hemiplegia following other intracranial hemorrhage

  38. Residual Effects of Cerebrovascular Disease ICD-10-CM • Hemiplegia following cerebral infarction • Hemiplegia following other cerebrovasculardisease • Hemiplegia following unspecified cerebrovasculardisease

  39. Hemiparesis following CVA

  40. CVAs • Terminology “Late Effects” is eliminated from ICD-10 • Sequelais the new term for Late Effects • Sequelaof cerebral hemorrhage • Sequelaof cerebral infarct • Sequelaof cerebrovasculardisease

  41. CVAs • I69.0 – I69.298 • Sequela of hemorrhages • I69.3 – I69.398 • Sequel of cerebral infarction • Occlusion of artery • Default for “stroke” • I69.8 – I69.998 • Sequelaof cerebrovascular disease

  42. CVAs • Coder will have to pay close attention to the type of CVA which occurred to obtain the correct code • No more flipping to the 438 section and looking for your code! • Flipping to I69 will only confuse you more! • Use alphabetic index to look up what is documented in the record.

  43. ICD-10-CM Project Planning • Resources: • Coding Manuals • Coding Instruction Resources • Training costs (Biomedical science & ICD-10)

  44. ICD-10-CM Transition Budget $$$Considerations • Hardware/software system upgrade, maintenance fees • Data Conversion • Clinical & financial • Forms redesign & reprinting • Consultant Fees • Outsourcing

  45. ICD-10-CM Transition Budget Considerations • Temporary staff needed to assist during transition period • Lost productivity during training & implementation phase • Increased coding time with ICD-10

  46. ICD-10 Project Planning • Clearinghouses, outside billing service, health Insurance payers • When will upgrades be completed? • When can claims with ICD-10-CM codes be transmitted for testing? • Re-negotiate provider contracts or electronic data interchange agreements (EDI)

  47. ICD-10-CM Project Planning • Who Assigns or Uses ICD-9-CM Codes: • Health Information Management (Medical Record Staff) • Nursing, MDS Coordinators • Admissions • Billing • Therapy • Lab, X-ray

  48. Early Preparation • A well-planned, well-managed implementation process will increase the changes of a smooth, successful transition • Experience in other countries has shown that early preparation is the key to success & earlier realization of benefits • An early start allows for resource allocation, such as costs for systems changes and education, process evaluation and change, as well as staff time devoted to implementation processes to be spread over several years

  49. Inadequate Preparation Potential Consequences • Decreased coding accuracy • Decreased coding productivity • Increased compliance risks • Increased claims rejection • An adverse impact on patient care and administrative decision-making • Decrease in key staff morale

  50. Preparation – When to Start . Don’t Delay! Get Started Today!