1. Thomas Weida, M.D. Professor, Penn State College of Medicine 12014, Thomas J. Weida, M.D. Thomas Weida, M.D., Professor, Penn State College of Medicine The Clock’s Ticking

2. I have nothing to disclose I have no conflicts of interest other than I am conflicted about ICD-10 2014, Thomas J. Weida, M.D.2

3. Objectives Describe the rationale for ICD-10 implementation. Describe the basics of ICD-10 coding. Demonstrate knowledge of specific must-have ICD-10 codes. 2014, Thomas J. Weida, M.D.3

4. Due Date: October 1, 2014 42014, Thomas J. Weida, M.D. http:// http://121clicks.com/inspirations/beautiful-photography-of-pregnant-woman-a-tribute-to- motherhood: Photo Credit : Alexandra Sophiehttp://121clicks.com/inspirations/beautiful-photography-of-pregnant-woman-a-tribute-to- motherhood 2015

5. Professional Society Positions Last Year AAFP –delay the implementation of ICD-10 for at least another year –boost Medicare funding for the creation of educational resources for physicians in smaller practices –provide money to Medicare administrative contractors to be used for physician education about the correct use of ICD-10 codes AMA –Reconsider implementation –If implemented, provide a 2-year period where payments cannot be denied base on lack of specificity of the ICD-10 code –Simplify claims so no additional information needed if most specific ICD-10 code used 2014, Thomas J. Weida, M.D.5

6. 6 ICD-9: 14,000 Diagnosis Codes

7. Why? Better definition of certain conditions Increased specificity Better support of research, population health and value-based payment Medicare shared savings uses acuity ICD-9 terms inconsistent with current clinical practice ICD-9 has run out of space for new codes SnoMed – clinical data for decision making ICD-10 – enables manageable categories for secondary data purposes 2014, Thomas J. Weida, M.D.7

8. How to Prepare 2014, Thomas J. Weida, M.D.8

9. 10 Steps 2014, Thomas J. Weida, M.D.9 1.Order the ICD-10 book –Although labeled draft, it’s the real thing –Download CDC general guidelines http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2 014.pdf http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2 014.pdf Useful for professional coders –Online tools may be very helpful http://www.icd10data.com/ http://cms.gov/Medicare/Coding/ICD10/2014-ICD-10- CM-and-GEMs.htmlhttp://cms.gov/Medicare/Coding/ICD10/2014-ICD-10- CM-and-GEMs.html http://www.aafp.org/fpm/2014/0100/p9.html Photo: today went fast forward by Gerrit Wenz

10. 10 Steps 2. Orient yourself to the code set –Codes are 3 to 7 characters long and start with a letter 2014, Thomas J. Weida, M.D.10

11. 10 Steps 3.Crosswalk ICD-9 codes to ICD-10 codes –Use online or EHR translation programs –Will bring up a list of ICD-10 codes from which to choose: GEMS (General Equivalence Mappings) –http://www.aapc.com/icd-10/codes/http://www.aapc.com/icd-10/codes/ –http://www.icd10data.com/ICD10CM/Codeshttp://www.icd10data.com/ICD10CM/Codes –Disclaimer: must use clinical judgment when picking code and have documentation to support choice 2014, Thomas J. Weida, M.D.11

12. 10 Steps 4.Start using more specific ICD-9 codes now –Example: ICD-9 for CHF, unspecified is 428.0, but there are 15 more specific CHF codes in ICD-9 which will crosswalk to specific ICD-10 codes 2014, Thomas J. Weida, M.D.12

13. 10 Steps 5.Do a Gap Analysis –Pick 50 of the most commonly used codes –Sort by system –Look at chart documentation for charts with these codes and try to identify a specific ICD-10 code based on the documentation –Example: CHF can be acute, chronic, acute on chronic, systolic, diastolic or combined –Hint: can use crosswalk tool to see which ICD-10 codes are available 2014, Thomas J. Weida, M.D.13 Photo from: http://traveltherockies.com/destinations/grand- canyon/grand-canyon-couples-favorite/#

14. 10 Steps 6.Educate Staff –One or two staff who function as billers or coders should have an ICD-10 course which includes coding cases. –Nurses may need training to match screening diagnosis with immunization performed. 2014, Thomas J. Weida, M.D.14

15. 10 Steps 7.Educate physicians, nurse practitioners and physician assistants –Use gap analysis –May need a day of training –Schedule training in summer –Schedule training follow up after October 1. 2014, Thomas J. Weida, M.D.15

16. 10 Steps 8.Talk with your EHR vendors –When will ICD-10 be installed? –Will new hardware be needed? –When can it be tested? –Will both ICD-9 and ICD- 10 work? –How much will it cost? 2014, Thomas J. Weida, M.D.16

17. 10 Steps 9.Have cash on hand –Payers may not be ready –May need 3-6 months of operating costs on hand or by line of credit 2014, Thomas J. Weida, M.D.17

18. 10 Steps 10.Decide on a “go live” process –Have someone available to answer coding question in real time. –EHR process should be easier than practices on paper –Paper cheat sheet won’t work well. –Might use online resource –Be part of a test group for Medicare and your private payers 2014, Thomas J. Weida, M.D.18

19. CMS Announces Readiness Testing 2,500 Volunteers to submit ICD-10 claims over 3 testing weeks. Nov. 17-21, 2014, March 2-6, 2015 June 1-5, 2015 Designed to generate awareness and interest in ICD-10 Designed to instill confidence that CMS and Medicare Contractors are ready for ICD-10 2014, Thomas J. Weida, M.D.19

20. Timeline: January-April 2015 Evaluate cash flow Impact on quality initiatives (should you report before Oct 1) Complete ICD-10 training Follow-up with EHR vendors –Upgrade schedule date –Additional training Claims testing opportunities Review insurance contracts for diagnosis- based payment impact Purchase Coding resources 2014, Thomas J. Weida, M.D.20

21. April-August 2015 Reevaluate cash flow Open line of credit to offset cash-flow disruptions Complete training Test matching ICD-10 codes to documentation Follow up with EHR –Complete Internal Testing –Start external testing –Get contact info for support services Review payer ICD-10 communications Watch for ICD-10 payment policy changes 2014, Thomas J. Weida, M.D.21

22. September 2015 Develop and assign workflow and processes for 10/1/ 2015 Verify testing completed successfully Consider direct-to-payer or other alternative claims submission if testing unsuccessful Monitor payer news regarding changes and readiness Order diazepam 2014, Thomas J. Weida, M.D.22

23. October 1, 2015 May want to have a lighter schedule for a few days till processes become familiar 2014, Thomas J. Weida, M.D.23

24. October 2, 2015 Order more diazepam Stock up on SSRI’s Hire coding expert (good luck) Retire Work to improve documentation and coding compliance with increased pay for value payment 2014, Thomas J. Weida, M.D.24

25. October 2015 and beyond Monitor claims acknowledgement (997) and acceptance/rejection (277) reports –Correct and resubmit rejected claims Evaluate post-implementation cash flow Evaluate contingency activities (overtime, credit line, consultants) Monitor payer news regarding issues Monitor reimbursement accuracy and timeliness of payment Conduct coding review for accuracy and compliance 2014, Thomas J. Weida, M.D.25

26. Timelines and Planning Help CMS Implementation Guide https://implementicd10.noblis.org/ 2014, Thomas J. Weida, M.D.26

27. The Codes – Two parts ICD-10 CM –Diagnosis Codes ICD-10 PCS –Procedure codes which will replace ICD-9 Volume 3 2014, Thomas J. Weida, M.D.27

28. Anatomy 3 to 7 Characters –3 Characters before decimal point, up to 4 after –1 st is alpha numeric (except no U) –2 nd is numeric –3-7 alpha numeric or numeric –Not case sensitive 2014, Thomas J. Weida, M.D.28

29. 2014 ICD-10-CM Codes (These links are active) A00-B99 Certain infectious and parasitic diseasesA00-B99 C00-D49 NeoplasmsC00-D49 D50-D89 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanismD50-D89 E00-E89 Endocrine, nutritional and metabolic diseasesE00-E89 F01-F99 Mental, Behavioral and Neurodevelopmental disordersF01-F99 G00-G99 Diseases of the nervous systemG00-G99 H00-H59 Diseases of the eye and adnexaH00-H59 H60-H95 Diseases of the ear and mastoid processH60-H95 I00-I99 Diseases of the circulatory systemI00-I99 J00-J99 Diseases of the respiratory systemJ00-J99 K00-K95 Diseases of the digestive systemK00-K95 L00-L99 Diseases of the skin and subcutaneous tissueL00-L99 M00-M99 Diseases of the musculoskeletal system and connective tissueM00-M99 N00-N99 Diseases of the genitourinary systemN00-N99 O00-O9A Pregnancy, childbirth and the puerperiumO00-O9A P00-P96 Certain conditions originating in the perinatal periodP00-P96 Q00-Q99 Congenital malformations, deformations and chromosomal abnormalitiesQ00-Q99 R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classifiedR00-R99 S00-T88 Injury, poisoning and certain other consequences of external causesS00-T88 V00-Y99 External causes of morbidityV00-Y99 Z00-Z99 Factors influencing health status and contact with health servicesZ00-Z99 2014, Thomas J. Weida, M.D.29 http://www.icd10data.com/IC D10CM/Codes

30. Major Changes Laterality Specific disease pathophysiology –Anterior cerebral artery syndrome, –Middle cerebral artery syndrome Combination codes –Crohn’s disease large intestine with rectal bleeding Common clinical guidance scales –Glasgow Coma Scale, Salter-Harris Fracture Scale, Gustilo-Anderson Classification of Open Fractures, Scale for Visual Acuity 7 th character and timing of encounters –Initial or Subsequent encounter or sequela of a previous injury 2014, Thomas J. Weida, M.D.30

31. ID of trimesters Increased granularity of disease manifestations –Acute bronchitis due to respiratory syncytial virus, drug induced folate deficiency anemia, Acute peptic ulcer with both hemorrhage and perforation. X-placeholders –When 7 th place used but 5 th and 6 th are not Alcohol and drug dependence effects –Effects of use with 4 th digit, aspects of use at 5 th digit and manifestations at the 6 th digit –Alcohol use with alcohol-induced sleep disorder, alcohol abuse with alcohol induced mood disorder Expansion of injury codes Post procedure disorders –Post procedure hypothyroidism 2014, Thomas J. Weida, M.D.31

32. Documentation Examples: Alzheimer’s disease Early onset (G30.0) Late onset (G30.1) Delirium (F05) Dementia (F02.80) Dementia with behavioral disturbances (F02.81) Senile dementia (F03) Senile degeneration of the brain NEC (G31.1) 2014, Thomas J. Weida, M.D.32

33. Hypertension 9 codes for Primary Hypertension 5 codes for Secondary Hypertension Reference to benign and malignant hypertension eliminated Be careful differentiating “I” from 1 in the codes as Hypertension spans from I10 to I15 (no I14). 2014, Thomas J. Weida, M.D.33 http://www.aafp.org/fpm/2014/0300/p5.html

34. Essential Hypertension - I10 I10 – Essential (primary) hypertension –No comorbid heart or kidney disease R03.0 – Elevated blood pressure without a diagnosis of hypertension 2014, Thomas J. Weida, M.D.34

35. Hypertension and Hypertensive Heart Disease - I11 I11.0 – Hypertensive heart disease with heart failure. Must then code type of heart failure –I50.2 Systolic CHF –I50.3 Diastolic CHF –I50.4 Combined systolic and diastolic CHF –I50.9 CHF, Unspecified –I50.1 Left ventricular failure (no EF on chart) I11.9 – Hypertensive heart disease without heart failure 2014, Thomas J. Weida, M.D.35 For these need 5 th digit specifying acuity 0 – Unspecified 1 – Acute 2 – Chronic 3 – Acute on Chronic

36. Hypertension and Chronic Kidney Disease – I12 If CKD first, use secondary HTN codes I12.0 – Hypertensive CKD with stage 5 CKD or end-stage renal disease I12.9 – Hypertensive CKD with stage 1-4 CKD or unspecified CKD 2014, Thomas J. Weida, M.D.36 But That’s not all. Need additional N18 code for stage of kidney disease: N18.1 CKD Stage 1 (GFR 90+, Positive urine findings) N18.2 CKD Stage 2 (GFR 60-89) N18.3 CKD Stage 3 (GFR 30-59) N18.4 CKD Stage 4 (GFR 15-29) N18.5 CKD Stage 5 (GFR <15) N18.6 End-stage renal disease (Dialysis) N18.9 CKD, unspecified But That’s not all. Need additional N18 code for stage of kidney disease: N18.1 CKD Stage 1 (GFR 90+, Positive urine findings) N18.2 CKD Stage 2 (GFR 60-89) N18.3 CKD Stage 3 (GFR 30-59) N18.4 CKD Stage 4 (GFR 15-29) N18.5 CKD Stage 5 (GFR <15) N18.6 End-stage renal disease (Dialysis) N18.9 CKD, unspecified

37. The Trifecta: Hypertension, Hypertensive Heart Disease (HHD) and Chronic Kidney Disease – I13 I13.0 – HHD and CKD with CHF with Stage 1-4 CKD, or unspecified CKD I13.10 – HHD and CKD without CHF with Stage 1-4 CKD or unspecified CKD I13.11 – HHD and CKD without CHF with Stage 5 CKD or end-stage renal disease I13.2 – HHD and CKD with CHF and with Stage 5 CKD or end-stage renal disease 2014, Thomas J. Weida, M.D.37 And you need the N18 series to ID the stage of CKD and the I50 series to ID the type and acuity of the CHF

38. We’re not done yet. Don’t forget Tobacco Use – the F codes F17 – Nicotine dependence F17.20 Unspecified F17.21 Cigarettes F17.22 Chewing tobacco F17.29 Other tobacco product 2014, Thomas J. Weida, M.D.38 And a Required 6 th digit needed: 0 – uncomplicated 1 – in remission 3 – with withdrawal 8 – with other specified nicotine-induced disorder 9 – with unspecified nicotine-induced disorder And a Required 6 th digit needed: 0 – uncomplicated 1 – in remission 3 – with withdrawal 8 – with other specified nicotine-induced disorder 9 – with unspecified nicotine-induced disorder But if patient is “Not dependent” on tobacco use, then code Z72.0 would apply And some more: Z57.31 Occupational exposure to environmental tobacco smoke Z72.0 Problems related to lifestyle, tobacco use Z77.22 Exposure to environmental tobacco smoke (2 nd hand smoke) Z87.891 Personal (past) history of nicotine dependence (on no aids to help) And some more: Z57.31 Occupational exposure to environmental tobacco smoke Z72.0 Problems related to lifestyle, tobacco use Z77.22 Exposure to environmental tobacco smoke (2 nd hand smoke) Z87.891 Personal (past) history of nicotine dependence (on no aids to help)

39. Secondary Hypertension - I15 I15.0 – Renovascular hypertension I15.1 – HTN secondary to other renal disorders I15.2 – HTN secondary to endocrine disorders I15.8 – Other secondary HTN I15.9 – Secondary HTN, unspecified 2014, Thomas J. Weida, M.D.39 And of course you also need to code the other underlying condition. If using I15.8, “Other” need to list the “Other” code first.

40. Just about makes your head explode 2014, Thomas J. Weida, M.D.40

41. 2014, Thomas J. Weida, M.D.41

42. CMS Reference Resource http://www.cms.gov/Medicare/Codin g/ICD10/index.html?redirect=/icd10http://www.cms.gov/Medicare/Codin g/ICD10/index.html?redirect=/icd10 Road to 10 – specialty specific and designed for small practices Very good site 2014, Thomas J. Weida, M.D.42

43. ICD-10 Coding Basics Video (30 min) http://www.youtube.com/watch ?v=kCV6aFlA- Sc&feature=youtu.behttp://www.youtube.com/watch ?v=kCV6aFlA- Sc&feature=youtu.be 2014, Thomas J. Weida, M.D.43

44. AAFP Resources – will need to log in Family Practice Management ICD-10 Topic Collection: http://www.aafp.org/fpm/icd10http://www.aafp.org/fpm/icd10 ICD-10 Coding for the Undiagnosed Problem: Http://www.aafp.org/fpm/2014/0500/p17.ht ml Http://www.aafp.org/fpm/2014/0500/p17.ht ml ICD-10 Simplifies Preventive Care Coding, Sort Of: –http://www.aafp.org/fpm/2014/0700/0a1. htmlhttp://www.aafp.org/fpm/2014/0700/0a1. html Coming attractions: Upper respiratory system, Lower respiratory system, Sprains, strains and automobile (accidents) 2014, Thomas J. Weida, M.D.44

45. Critical Codes to Remember for Family Physicians Dizziness R42 - hysterical F44.89 - psychogenic F45.8 Fatigue R53.83 - chronic R53.82 Mental Cruelty X58 2014, Thomas J. Weida, M.D.45

46. Critical Codes to Remember – It’s a ZOO out there Z00.00 Encounter for general adult medical exam without abnormal findings Z00.01 Encounter for general adult medical exam with abnormal findings 2014, Thomas J. Weida, M.D.46 www.tripadvisor.com

47. Critical Codes to Remember Discord (with) - boss Z56.4 - classmates Z55.4 - counselor Z64.4 - employer Z56.4 - family Z63.8 - fellow employees Z56.4 - in-laws Z63.1 - landlord Z59.2 - lodgers Z59.2 - neighbors Z59.2 - probation officer Z64.4 - social worker Z64.4 - teachers Z55.4 - workmates Z56.4 2014, Thomas J. Weida, M.D.47 Discord with ICD-10 XXX.XXXX This is the only condition for which there quite possibly is no code Discord with ICD-10 XXX.XXXX This is the only condition for which there quite possibly is no code

48. Codes to Die By http://www.youtube.com/watch ?v=kiZe8zs_6Twhttp://www.youtube.com/watch ?v=kiZe8zs_6Tw 2014, Thomas J. Weida, M.D.48

49. Crazy Codes V9542XA: Spacecraft crash injuring occupant, initial encounter. W5922XA: Struck by a turtle. Additionally, Justus looked to codes W5612XA: Struck by a sea lion, initial encounter, W5609XA: Other contact with dolphin, initial encounter W51.XXXA. “Accidental striking against or bumped into by another person, initial encounter,” V0001XD, or, ”Pedestrian on foot injured in collision with roller-skater, subsequent encounter.” V91.07XA – Burn due to water-skis on fire, initial encounter Y92250, or when a patient is injured in an art gallery. Y92029, or “unspecified place in mobile home as the place of occurrence of the external cause,” Y92146, or, “swimming pool of prison as the place of occurrence of the external cause. W6133XA, or being pecked by chicken, initial encounter; W5541XA, or being bitten by pig, initial encounter; and W5531XA, or being bitten by other hoof stock, initial encounter "T7501XD, or, shock due to being struck by lightning, subsequent encounter “Y34,. “Unspecified event, undetermined intent. Hurt at the opera: Y92253 Stabbed while crocheting: Y93D1 Walked into a lamppost: W2202XA Walked into a lamppost, subsequent encounter: W2202XD Submersion due to falling or jumping from crushed water skis: V9037XA 2014, Thomas J. Weida, M.D.49