Transcript ICD-10 - Care Share Health Alliance

ICD-10
Innovation & Impact
Tammy Norville
Rural Health Operations Specialist
NC DHHS – Office of Rural Health and Community Care
September 23, 2014
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Road Map
• ORHCC
o Who we are
o What we do
• ICD-10 General Overview
o What – What are the code sets?
o Why – Why is this important?
o Who – All provider types
o When – Not before October 1, 2015
o How – How might this impact my job?
• Resources & Conclusion
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The Mission Of The N.C.
Department Of Health And
Human Services Is, In
Collaboration With Our
Partners, To Protect The
Health And Safety Of All North
Carolinians And Provide
Essential Human Services.
“Culture of
Accountability”
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Chatuge Family Practice
Hayesville, NC
The Office Of Rural
Health And Community
Care Assists Underserved
Communities And
Populations To Develop
Innovative Strategies For
Equal Access, Quality,
And Cost-effectiveness Of
Health Care For All.
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ORHCC in NC
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Works with communities to meet the health needs of all underserved residents
Fosters state and local partnerships with ownership vested in communities
Provides in-depth technical assistance on an on-going basis
Assures clear and measurable accountability
Seeks to eliminate health disparities
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Tammy Norville
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With ORHCC since April 2003
Rural Health Operations Specialist
2011 National Organization of State
Offices of Rural Health (NOSORH)
Recognition Award winner
Registered Medical Coder
Registered Medical Manager
Certificates in ICD-10 Management,
Non-Provider Clinical, Billing and Coding
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ICD-10 General Overview
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What is a code set?
Under HIPAA, a "code set" is any set of codes used for
encoding data elements, such as tables of terms, medical
concepts, medical diagnosis codes, or medical procedure
codes. Medical data code sets used in the health care
industry include coding systems for diseases,
impairments, other health related problems, and their
manifestations; causes of injury, disease, impairment, or
other health-related problems; actions taken to prevent,
diagnose, treat, or manage diseases, injuries, and
impairments; and any substances, equipment, supplies, or
other items used to perform these actions. Code sets for
medical data are required for data elements in the
administrative and financial health care transaction
standards adopted under HIPAA for diagnoses,
procedures, and drugs.
(http://aspe.hhs.gov/admnsimp/faqcode.htm)
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HCPCS Codes
The acronym HCPCS originally stood for HCFA Common
Procedure Coding System, as the Centers for Medicare
and Medicaid (CMS) was previously (before 2001) known
as the Health Care Financing Administration (HCFA). The
Healthcare Common Procedure Coding System (HCPCS)
was established in 1978 to provide a standardized coding
system for describing the specific items and services
provided in the delivery of health care. Such coding is
necessary for Medicare, Medicaid, and other health
insurance programs to ensure that insurance claims are
processed in an orderly and consistent manner. Initially,
use of the codes was voluntary, but with the
implementation of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) use of the HCPCS for
transactions involving health care information became
mandatory.
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HCPCS Codes
HCPCS includes three levels of codes:
 Level I consists of the American Medical Association's
Current Procedural Terminology (CPT) and is numeric.
 Level II codes are alphanumeric and primarily include
non-physician services such as ambulance services
and prosthetic devices,[2] and represent items and
supplies and non-physician services, not covered by
CPT-4 codes (Level I).
 Level III codes, also called local codes, were developed
by state Medicaid agencies, Medicare contractors, and
private insurers for use in specific programs and
jurisdictions. The use of Level III codes was
discontinued on December 31, 2003, in order to adhere
to consistent coding standards.[3]
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CPT Codes
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The Current Procedural Terminology (CPT) code set is a medical
code set maintained by the American Medical Association through
the CPT Editorial Panel.[1] The CPT code set (copyright protected by
the AMA) describes medical, surgical, and diagnostic services and is
designed to communicate uniform information about medical
services and procedures among physicians, coders, patients,
accreditation organizations, and payers for administrative, financial,
and analytical purposes.
New editions are released each October.[2] The current version is the
CPT 2014. It is available in both a standard edition and a
professional edition.[3][4]
CPT coding is similar to ICD-9 and ICD-10 coding, except that it
identifies the services rendered rather than the diagnosis on the
claim. ICD code sets also contain procedure codes but these are
only used in the inpatient setting.[5]
CPT is currently identified by the Centers for Medicare and Medicaid
Services (CMS)[6] as Level 1 of the Health Care Procedure Coding
System.
The Current Procedural Terminology (CPT) was developed by the
American Medical Association (AMA).[6]
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CPT and HCPCS
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 visits to inpatients
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ICD-9 Codes
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International Classification of Diseases, Clinical Modification
(ICD-9-CM) is an adaption created by the U.S. National
Center for Health Statistics (NCHS) and used in assigning
diagnostic and procedure codes associated with inpatient,
outpatient, and physician office utilization in the United
States. The ICD-9-CM is based on the ICD-9 but provides for
additional morbidity detail. It is updated annually on October
1.[14][15]
It consists of two or three volumes:
Volumes 1 and 2 contain diagnosis codes. (Volume 1 is a
tabular listing, and volume 2 is an index.) Extended for ICD-9CM
Volume 3 contains procedure codes. ICD-9-CM only
The NCHS and the Centers for Medicare and Medicaid
Services are the U.S. governmental agencies responsible for
overseeing all changes and modifications to the ICD-9-CM.
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ICD-10 Codes
Work on ICD-10 began in 1983, and the new revision was endorsed by the
Forty-third World Health Assembly in May 1990. The latest version came into
use in WHO Member States starting in 1994.[16] The classification system
allows more than 155,000 different codes and permits tracking of many new
diagnoses and procedures, a significant expansion on the 17,000 codes
available in ICD-9.[17] Adoption was relatively swift in most of the world.
Several materials are made available online by WHO to facilitate its use,
including a manual, training guidelines, a browser, and files for download.[3]
Some countries have adapted the international standard, such as the "ICD10-AM" published in Australia in 1998 (also used in New Zealand),[18] and the
"ICD-10-CA" introduced in Canada in 2000.[19]
 Adoption of ICD-10-CM has been slow in the United States. Since 1979, the
USA had required ICD-9-CM codes[20] for Medicare and Medicaid claims, and
most of the rest of the American medical industry followed suit. On 1 January
1999 the ICD-10 (without clinical extensions) was adopted for reporting
mortality, but ICD-9-CM was still used for morbidity. Meanwhile, NCHS
received permission from the WHO to create a clinical modification of the
ICD-10, and has production of all these systems:
 ICD-10-CM, for diagnosis codes, is intended to replace volumes 1 and 2.
Annual updates are provided.
 ICD-10-PCS, for procedure codes, is intended to replace volume 3. Annual
updates are provided.
(Source: http://en.wikipedia.org/wiki/ICD-9#ICD-9)
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ICD-10 Codes Continued
On August 21, 2008, the US Department of Health and
Human Services (HHS) proposed new code sets to be
used for reporting diagnoses and procedures on health
care transactions. Under the proposal, the ICD-9-CM code
sets would be replaced with the ICD-10-CM code sets,
effective October 1, 2013. On April 17, 2012 the
Department of Health and Human Services (HHS)
published a proposed rule that would delay, from October
1, 2013 to October 1, 2014,the compliance date for the
ICD-10-CM and PCS.[21] Once again, Congress delayed
implementation date to October 1, 2015, after it was
inserted into "Doc Fix" Bill without debate over objections
of many.
(Source: http://en.wikipedia.org/wiki/ICD-9#ICD-9)
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ICD-10 Similarities to ICD-9-CM
• Tabular List Chronological list of codes
divided into chapters based on body
system or condition
• Same hierarchical structure
• Chapters in Tabular structured similarly to
ICD-9-CM, with minor exceptions A few
chapters have been restructured
• Sense organs (eye and ear) separated
from Nervous System chapter and moved
to their own chapters
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ICD-10 Similarities to ICD-9-CM
• Index Alphabetical list of terms and their
corresponding codes
• Indented subterms appear under main
terms
• Same structure as ICD-9-CM Alphabetic
Index of Diseases and Injuries
• Alphabetic Index of External Causes
• Table of Neoplasms
• Table of Drugs and Chemicals
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ICD-10 Similarities to ICD-9-CM
• Nonspecific codes (“unspecified” or “not
otherwise specified”) are available to use
when detailed documentation to support
more specific code is not available
• Many conventions have same meaning
Abbreviations, punctuation, symbols, notes
such as “code first” and “use additional code”
• Codes are looked up the same way Look up
diagnostic terms in Alphabetic Index, then
• Verify code number in Tabular List
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Why is ICD-10 important?
WAIT A MINUTE!!!
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Areas Impacted by ICD-10
Information Technology
◦ Systems currently impacted
◦ Current system readiness
◦ Current vendor readiness
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Areas Impacted by ICD-10
Operations
• Revenue cycle
• Clinical processes
• Stakeholders
• Process impacts
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Areas Impacted by ICD-10
Operations (cont.)
• Clinical Documentation
• Coding
• Education
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Areas Impacted by ICD-10
Finance
◦ Risk mitigation
◦ Contingency planning
◦ Contracts
◦ Revenue cycle & cash flow impact
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Benefits of ICD-10-CM
• 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
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Benefits of ICD-10-CM
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Recognition of advances in medicine and
technology
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Tracking public health and risks
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Improved efficiencies and lower costs
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Reduced coding errors
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Greater achievement of the benefits of
an electronic health record
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ICD-10-CM Structure
ICD-9-CM
• 3-5 characters
• First character is
numeric or alpha (E or
V)
• Characters 2-5 are
numeric
• Always at least 3
characters
• Use of decimal after 3
characters
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ICD-10-CM
3-7 characters •1st
character is alpha (all
letters except U are used)
2nd character is numeric
Characters 3-7 are alpha
or numeric •Use of
decimal after 3 characters
Alpha characters are not
case-sensitive (e.g., Right
ankle sprain, initial
encounter: S93.401A,
S93.401a, s93.401A,
s93.401a)
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Code Structure Comparison
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Who will be impacted?
ALL PROVIDERS
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Who is impacted?
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Health care practitioners
Hospitals
Health Insurers and 3rd party payers
Electronic Clearinghouses
Hardware & Software vendors
Billing & PM service providers
Health care admin and oversight
agencies
Public and Private research institutions
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When is implementation?
WAITING GAME
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Other Useful Information and Resources
On April 1st, 2014 the President signed the Protecting
Access to Medicare Act of 2014 that eliminates for
one year scheduled cuts to the Medicare Physician
Fee Schedule (PFS) associated with the sustainable
growth rate (SGR). The formula known as the SGR
determines how much physicians and other providers
are paid when they see Medicare patients. Without
this law, the SGR cut would have taken effect and
reduced the payment for services paid under the PFS
by approximately 24% for all services after April 1,
2014.
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Other Useful Information and Resources
ICD-10: This provision delays until October 1, 2015 the
transition from ICD-9 to ICD-10. The International
Statistical Classification of Diseases (ICD) is used to code
services in order to bill for patient treatment. ICD-10 is a
major revision and expansion of the code set. This change
was previously scheduled to happen October 1, 2014.
This delay will change the training and testing schedule
for hospitals, clinics, and other providers. This may help
providers who weren’t ready for the change, but could
increase costs for the ones already gearing up for the
transition. CMS will be issuing further guidance on ICD-10
implementation. When it is finally implemented, all
providers will have to use ICD-10 in order to be paid by
Medicare (and most other insurance companies).
(Source: Office of Rural Health Policy/HRSA via email 4/10/2014)
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How might this impact my job?
RELEVANCE!
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QUESTIONS!!
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How do you see ICD-10 impacting
your organization overall?
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How do you see ICD-10 impacting
your job?
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How do you see ICD-10 impacting the
way your organization provides patient
care?
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Injuries – Chapter 19
QUICK CODING CLASS &
NEW DOCUMENTATION
REQUIREMENTS
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Injuries (Chapter 19)
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Expanded category using the 7th
character extension to identify the
encounter type or Episode of Care:
• “A” for the initial encounter
• “D” for the subsequent encounter for
fracture with routine healing
• “G” for the subsequent encounter for
fracture with delayed healing
• “S” for sequela of fracture (late effects)
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Injuries (Chapter 19)
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Size and depth of injury
Cause of the injury and
Place of injury
A fracture not indicated as displaced
or nondisplaced should be coded to
displaced, and
A fracture not designated as open or
closed should be coded to closed.
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Opportunity is Knocking
The delay in ICD-10 implementation is
an opportunity to help our providers
improve documentation specificity
which will lead to improved patient care.
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ICD-10 Changes the way we Document
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If it isn’t documented, it did not happen and
cannot be coded or billed.
New information will be required to code for
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claims
Research indicates that in many cases, the
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medical records may contain the information,
but it not currently used in coding the
diagnosis
Some cases may require new and expanded
documentation
Laterality
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Association between conditions
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Importance of Clinical Documentation
ICD-10 code set requires a much higher level of
specificity than the current ICD-9 standard
 Redesign clinical documentation practices
 Documentation will drive practice coding, a
cornerstone to billing revenue.
 Failing to prepare for ICD-10 documentation
requirements can drastically impact your
revenue—missing information may prevent claims
from even being submitted.
 Taking steps now to improve documentation will be
foundational in helping your practice get paid faster
and experience fewer delays and denials during
the changeover.
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More on Documentation
Under ICD-10, providers will need to
document the following in order to be
able to assign a code:
 Laterality
 Stages of healing
 Trimester of pregnancy
 Episode of care
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Immediate Documentation
Areas of Focus
Begin adding the following to physician
documentation:
• Side of dominance
• Left, right, or ambidextrous (defaults to right)
• Laterality
• All paired organs or structures
• Is this the initial visit or a subsequent visit for
the complaint?
• Are these symptoms the sequela of the initial
event?
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What do we do now?
RESOURCES FOR A
SMOOTH TRANSITION
(AKA, CMS ROCKS!)
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CMS ICD-10 Implementation Guide
for Small and Medium Practices
The CMS ICD-10 Implementation Guide for Small and
Medium Practices groups the milestones and tasks into
the following six phases:
 Planning
 Communication and Awareness
 Assessment
 Operational Implementation
 Testing
 Transition
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Figure 1 (next slide) shows these recommended ICD10 implementation phases and high-level steps. More
detailed tasks are referenced on the ICD-10
Implementation Timeline.
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Source: CMS ICD-10 Implementation Guide for Small and Medium Practices, Page 8
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Three Words
ROAD TO TEN…
http://www.roadto10.org/
Awesome ICD-10 implementation
website and it’s FREE!!
(Thank you, CMS!!)
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Resources and Contact Information
CONCLUSION
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Resources
Centers for Medicare and Medicaid Services
http://www.cms.gov/Medicare/Coding/ICD10/index.html
Road to 10
http://www.roadto10.org/
The North Carolina Healthcare Information and
Communications Alliance, Inc. (NCHICA)
http://nchica.org/HIPAAResources/icd10.htm
Workgroup for Electronic Data Interchange (WEDI)
https://www.wedi.org/topics/icd-10
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Resources (con’t)
The American Health Information Management
Association (AHIMA)
http://www.ahima.org/topics/icd10
NC Tracks (Medicaid) information
https://www.nctracks.nc.gov/content/public/providers/ICD10.html
Monthly NC Medicaid Bulletins
http://www.ncdhhs.gov/dma/bulletin/
National Rural Health Resource Center
http://www.ruralcenter.org/rural-hit-networkdevelopment/resources/icd-10-implementation-toolkit
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Contact Information
Tammy Norville
Rural Health Operations Specialist
Office: 919.527.6476
[email protected]
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