ICD-10 ORIENTATION IN SNF’S Rhonda Anderson, RHIA Anderson Health Information Systems, Inc.

Participants will identify: –Dates for New ICD-10 –Documentation support –New terms encounter principal diagnosis re- defined –Some general coding guidelines Objectives 2

January 15, 2009 Final Regulation Released EXCHANGE the ICD-9 for the ICD-10 on October, 1, 2014 Final Regulation 3

ICD-10-CM = Clinical Modification, ICD-10 CM – applies to SNF, Intermediate Care, Physician’s Offices, Clinics, Dialysis, Home Health, other health care settings who bill Medicare, MediCal or Private Ins. ICD-10 PCS = Procedural Code System (used for Acute Hospital procedures, operations ICD-10 “Has Two Parts” 4

Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA) HIPAA has evolved from 1996 to HITECH which relates to security and breaches HIPAA Transactions 5010 went into effect October 2011 HITECH – HIPAA Privacy and Security final rule was released January 2013 HIPAA 5

All inpatient and outpatient facility visits as well as freestanding providers and ancillary services “that means all of us really” who provide services and bill for them under Medicare, Medi-Cal and private insurances. Who Is Affected?? 6

HIM personnel Nurse managers MDS nurses Nursing unit staff/clerks Case managers Administration Therapy personnel (PT/OT/ST) Billing/admitting personnel Medical Directors/Providers Various roles that are affected

Corporate Office personnel Compliance Office personnel working with ICD coding Corporate administrative departments More affected roles...

More specific coding system Reflects medical advancements Standardization, UK implemented in 1995, used worldwide The United States is the only industrialized nation that has not yet implemented ICD- 10 Benefits 9

The guidelines in the ICD-10 manual developed for the provider and the coder….(person who may review the documentation and determine if code is accurate. Consistent, complete documentation in the medical record is a major emphasis. What Does This Mean?? 10

ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings Current Procedural Terminology (CPT) is still used for the Physician, and some services, but they must have a diagnosis that is ICD-10 compliant Key Highlights 11

Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services. Key Highlights -2 12

3-5 characters in length Approximately 14,000 codes First digit may be alpha or numeric Digits 2-5 are numeric Always at least three digits Decimal placed after the first three characters Limited space for new codes ICD-9-CM Diagnosis Codes 13

Lacks detail Lacks laterality, difficult to analyze, dated, non-specific and does not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries. ICD-9-CM Diagnosis Codes -2 14

Index and Tabular list have the same hierarchical structure as ICD-9 ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list. ICD-10 CM Structure 15

ICD-9 V and E code supplemental classifications are incorporated into the main classification in ICD-10 ICD-9 V codes are now Z codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services Postoperative complications have been moved to procedure-specific body system chapters ICD-10 CM Structure -2 16

3-7 characters in length and alphanumeric 21 chapters (compared to 17 in ICD-9) Approximately 68,000 codes Digit 1 is always alpha, digit 2 is numeric; digits 3-7 can be alpha or numeric Decimal placed after the first 3 characters ICD-10-CM Diagnosis Codes – Format & Structure 17

Codes that have applicable 7 th character is considered invalid without the 7 th character. Expanded codes Flexible for adding new codes Addition of placeholder “X” Has laterality (right, left, lower, upper, outer, etc.) ICD-10-CM Diagnosis Codes – Format & Structure

ICD-10 utilizes a placeholder character “x” The “x” is used as a placeholder at certain codes to allow for expansion –Categories T36-T50, poisoning and injury codes T36.8X1D –Also, Pathological vertebral fracture due to age-related osteoporosis, subsequent encounter with delayed healing M80.08XG Example Of Placeholder “X” 19

For bilateral sites, the final character of the codes in ICD-10 indicates laterality: –C Malignant Neoplasm of upper-inner quadrant of left female breast –H Dermatochalasis of left lower eyelid –I80.01 Phlebitis and Thrombophlebitis of superficial vessels of right lower extremity –L Pressure Ulcer of right hip, Stage 3 *an unspecified site code is also provided should the site not be identified. Example Of Laterality 20

Expanded Codes (injury, diabetes, alcohol/substance abuse, postoperative complications) E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease Example Of Expanded Codes 21

Requires “use” of proper coding guidelines –Relies on the use of the guidelines and in our case Skilled/ICF/IRF rules –ICD-10-CM Index – disease, injury and external causes of Injury ICD-10-CM Structure - 22

–More combined codes, i.e. Diabetic retinopathy is one code –More specificity, i.e. Alzheimer’s disease with specific details of early or late onset: G30.0 Alzheimer’s with early onset G30.1 Alzheimer’s with late onset G30.8 Other Alzheimer’s disease G30.9 Alzheimer’s disease, unspecified ICD-10-CM Structure

General rules for use of the classification independent of the guidelines –Alphabetic Index and Tabular List Alphabetic Index – List of terms and their corresponding code Tabular List – chronological list of codes divided into chapters based on body system/condition General coding guidelines are similar to ICD-9 with one additional guideline - laterality Conventions For The ICD-10-CM 24

General rules for use of the classification independent of the guidelines –Format and Structure First character is always alpha Three character category that has no further subdivision is equivalent to a code Subcategories are either 4 or 5 characters Codes may be 3, 4, 5, 6 or 7 characters Conventions For The ICD-10-CM -2 25

General rules for use of the classification independent of the guidelines –7th Characters Certain ICD-10-CM categories have applicable 7th characters Required for all codes within the category or as instructed by the notes in the Tabular List Must always be the 7th character in the data field If a code that requires a7th character is not 6 characters, a placeholder X must be used to fill in the empty characters Conventions For The ICD-10-CM -3 26

Seventh character for a fracture –A = initial encounter for fracture –D = subsequent encounter for fracture with routine healing –G = subsequent encounter for fracture with delayed healing Examples Of 7th Character 27

–K = subsequent encounter for fracture with nonunion –P = subsequent encounter for fracture with mal-union –S = sequela Examples of 7 th Character

Fracture Traumatic (abduction, adduction, separation) Acetabulum – anterior, displaced, illopubic S32.43__ or non-displaced S32.436_ Acetabulum – dome (displaced) S32.48__ Fracture, lumbar vertebrae - (NOS) S32.009_ FRACTURE

Fracture of lst lumbar vertebrae – S32.01__ –Wedge compression, stable burst, unstable burst, other, or unspecified? –What type of fx is it? FRACTURE

Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data between other countries and the U.S. ICD-10-CM Diagnosis Codes -4 31

ICD-10 Code Format Code Format 32 ICD-9-CM Code FormatICD-10-CM Code Format

Before we go further- do not despair…your vendor should prepare as much crosswalk as possible. There are “GEM” files. General Equivalence Mappings (GEM) –translation dictionary for diagnoses GEM Files 33

There is NOT a one-to-one match between ICD-9 and ICD-10 codes We will talk about GEMS later and how to use them. Key to early review! GEM FILES

Identify your most common diagnoses. Determine in advance some of the documentation issues that you will have with the nurses and the physicians Discuss the specificity at the QA/PI meetings Keep staff informed as we progress WHAT DOES THAT MEAN TO ME?

The organization will need to know for all facilities or your facility what the most common diagnoses that are admitted and focus on those first Focus on the documentation to support those Focus on review of Acute Hospital Records more closely – Impact Inquiries WHAT DOES THIS MEAN TO ME?

Review for Medicare must be more specific WHAT DOES THIS MEAN TO ME?

Organization Structure Code composition Level of detail May consist of 3 to 7 digits, with the seventh digit extensions representing visit encounter or sequel, as stated above. ICD-10 & ICD-9 Differences 38

Includes full code titles for all codes (no reference back to common 4th and 5th digits) V and E codes are no longer supplemental classifications, as stated previously ICD-10 & ICD-9 Differences -2 39

Inclusion notes further define, or give examples of the content of the category Exclusion notes – Excludes1 vs. Excludes2 –Excludes1 means “not coded here” –Excludes2 means “not included here” may need to use both the code and the excluded code together if patient has both conditions Code first and Use additional code notes are similar to ICD-9 Instructional Notes 40

Locating a code in the ICD-10-CM Level of detail coding Code/codes from A00.0 through Z99.8 Signs and symptoms are acceptable for reporting purposes when a related diagnosis has not been established General Coding Guidelines 41

These codes are secondary codes for use in any health care setting These codes capture how the injury happened (cause) or the intent Assign the external cause code with the appropriate 7th character for each encounter for which the injury or condition is being treated (initial, subsequent or sequela) What happened? V03 pedestrian injured in collision with car, pick-up truck or van Chapter 20 – External Causes of Morbidity (V00-Y99) 42

Identify Corporate/Facility Steering Committees Identify who needs education/pretest Knowledge is a key step in successful implementation Separate roles into two groups –Group that primarily assigns codes –Group that primarily does NOT assign codes ICD-10-CM Readiness

A general knowledge of the code system and important differences between ICD-9 and ICD-10 Use and/or knowledge level for an individual who uses coded data but is typically not assigning codes daily Application of the code set would be for those individuals who are routinely applying codes Different knowledge levels defined as:

An employee with experience in coding (who was trained on the job) is estimated to need 18 hours of cumulative education for ICD-10 Education varies based upon the needs of each individuals skill level Intense coding education should NOT be initiated until three to six months before implementation Education time

Educational Tasks/Phase I –Learn about the structure, organization, and unique features of ICD-10 –Create an educational plan for all roles which require education at various levels –Network with peers, access resources, and read literature to identify transition issues and best practices –Take advantage of education opportunities Steps to take now

Develop an implementation plan –Identify steps to prepare for implementation –Identify who should be involved in preparation –Develop time frames for implementation phases Develop a budget Identify current systems that input, store and utilize ICD data Identify who is currently performing coding General Implementation Task/Phase I

Review current workflow to identify areas of impact and analyze opportunities for improvement (data in MDS, health record, and claim form) Common workflow examples are diagnostic tests (laboratory, radiology, therapy diagnoses and billing) Document improvement processes General Implementation - 2

Conduct detailed assessment of staff educational needs Assess knowledge of ICD-9 of current staff so that basic education can be obtained Assess areas of strength/weakness of coding staff in the biomedical sciences Evaluate barriers to preparing coding staff Communicate the ICD-10 prep activities throughout the organization Educational Implementation Tasks/Phase I

Listen to ICD-10 webcasts Have coding staff take medical terminology and Anatomy and Physiology courses (from local college or online) Educational Resources

Analyze current documentation practices, physician, nursing and therapy, to identify areas in need of improvement Identify current processes that may lead to poor data quality due to inadequate or outdated documentation practices Conduct detailed assessment of staff educational needs r/t documentation Improvement Processes

Talk with vendors and other business associates regarding their ability to be prepared to accept ICD-10 codes Determine the date of installation of facilities ICD-10 database software (must be utilized in a parallel manner with current ICD-9 code library) Do NOT uninstall ICD-9 database General Implementation Tasks/Phase 2

Continue to address impact of code change such as required system changes and report modifications Address legacy data issues in regards to how ICD-9 coded data is currently used Evaluate barriers or potential barriers to preparing staff for ICD-10 Address timeline to begin coding current residents’ dx General Implementation - 2

Create an educational plan Provide education on the fundamentals of the ICD-10 systems Provide opportunity for coders to refresh knowledge of anatomy and physiology concepts Continue to have educational sessions with clinical staff in the facility to learn more about commonly reported conditions and dx r/t LTC facilities Educational Tasks/Phase 2

Install ICD-10 vendor software into the system to prepare for transition/perform software system testing ICD-9 legacy data must be maintained and available Closely monitor productivity and quality measures for issues r/t implementation of new code sets General Implementation Tasks/Phase 3

Continue educational plan, including intensive education for roles who primarily assign codes Practice ICD-10 coding of current records Implement process for parallel coding of current residents with ICD-10 to facilitate future data entry Provide more intensive educational and consultative support to coders and users of coded data Educational Tasks/Phase 3

Thanks for attending!! 57