1. What’s Up with ICD-10? Identifying the Impact on your Program
Kim Wedel, Robin Nelson and Maureen Greer
Improving Data, Improving Outcomes
September 17, 2013

2. Overview of Session Background Information on ICD-10
How does ICD-10 differ from ICD-9?
What are the impacts on your program?
Eligibility
Billing
Data/billing systems
Data analysis and reporting

3. What is the ICD-10? International Classification of Diseases
ICD-10 is the updated version of codes used for coding:
Diagnoses for all providers (ICD-10-CM)
Hospital inpatient procedures (ICD-10-PCS)
ICD-10-CM is the US “clinical modification” of the WHO ICD-10 code set
ICD-10-PCS is a U.S. creation
release of full ICD-10 by WHO
2002 – published ICD-10 in 42 languages
ICD-10 is an updated version of the ICD-9 code sets. The ICD-10 code set was originally developed by the World Health Organization. Several countries have taken this code set and modified it for use in their medical systems. The United States, through the National Center for Health Statistics, has developed the ICD-10-CM (or clinical modification) of the code set for use in this country. The Centers for Medicare and Medicaid Services has created a new code set, ICD-10-PCS, for use.
ICD-10, 14,000 codes
ICD-10-CM, 68,000

4. Codes NOT Affected by ICD-10-CM
CPT Codes
Common Procedure Terminology
CPT -
used for all outpatient/ambulatory and physician procedure reporting
set of codes, descriptions, and guidelines that describe
procedures and services performed by physicians and other qualified health care providers
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).
HCPCS Codes
Healthcare Common Procedure Coding System

5. ICD-10-CM Compliance Deadline
October 1, 2014
Based on DATE OF SERVICE, not date of transaction or claim submission
Use ICD-9-CM dx code if date of service is before October 1, 2014
Use ICD-10-CM dx code if date of service is on or after October 1, 2014
NO transition period
The transition to ICD-10 is required for everyone covered by HIPAA.
ICD-10 compliance means that a HIPAA-covered entity uses ICD-10 codes for health care services provided on or after October 1, 2014.
You may not be able to use ICD-9 and ICD-10 codes on the same claim based on your payers' instructions. This may mean splitting services that would typically be captured on one claim into two claims: one claim with ICD-9 diagnosis codes for services provided before October 1, 2014, and another claim with ICD10 diagnosis codes for services provided on or after October 1, 2014.

6. Benefits of ICD-10-CM
Incorporates much greater specificity and clinical information, which results in improved ability to measure health care services
Increased sensitivity when refining grouping and reimbursement methodologies
Enhanced ability to conduct public health surveillance
ICD-9-CM running out of codes
Not compatible with DSM-IV. ICD-11 will be compatible with DSM-V

7. Major Changes from ICD-9 to ICD-10
ICD-9-CM
ICD-10-CM
3 to 5 positions
First position is numeric or alpha (V or E)
Positions 2 to 5 are numeric
13,000 codes
3 to 7 positions
Position 1 is alpha, not case sensitive
Position 2 is numeric
Positions 3 to 7 are alpha or numeric (alpha are not case sensitive)
68,000 codes
US went crazy with clinical modification to arrive at 68,000 codes, compared to 14,000 codes for the rest of the world using plain old ICD-10 diagnoses

8. Structure of ICD-10-CM Diagnosis Codes
Each position has a specific meaning
Tabular List contains categories, subcategories and codes.
All categories are 3 characters. A 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.
A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.

9. Examples of ICD-10-CM Codes
R62.51 – Failure to thrive (excludes child under 28 days old)
E70.0 – Classical phenylketonuria (PKU)
Q04.0 – Congenital malformation of corpus callosum
Q – Congenital shortening of right upper limb
R45.2 – Unhappiness
R45.2 – Worries
R45.4 – Irritability and anger

10. More Specific Changes Much greater specificity
Full description and consistency within the code set
Uses modern terminology for descriptions
Creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition
Enables laterality (right vs. left designations)
The new code set provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code.
The terminology has been modernized and has been made consistent throughout the code set.
There are codes that are a combination of diagnoses and symptoms, so that fewer codes need to be reported to fully describe a condition.
It makes a difference whether the right or left limb is the subject of the problem
The ICD-10 code set has also been organized somewhat differently than ICD-9, primarily to bring it up to date with modern medicine and the requirements of the industry to clearly identify particular conditions. The tabular lists, which represent the major “Chapters”, are not that different.
Some examples of this are that sense organs are now separate from nervous system disorders; injuries are grouped by anatomical site (e.g., injuries of the head, injuries of the leg) instead of an injury category (fracture, bruise); and postoperative complications are now part of the specific body system chapter.
Some codes also specify initial vs. subsequent encounter

11. Examples of ICD-10-CM Specificity
W21.00 Struck by hit or thrown ball, unspecified type
W21.01 Struck by football
W21.02 Struck by soccer ball
W21.03 Struck by baseball
W21.04 Struck by golf ball
W21.05 Struck by basketball
W21.06 Struck by volleyball
W21.07 Struck by softball
W21.09 Struck by other hit or
thrown ball
W21.31 Struck by shoe cleats
Stepped on by shoe cleats
W21.32 Struck by skate blades
Skated over by skate blades
W21.39 Struck by other sports
foot wear
W21.4 Striking against diving board
W21.11 Struck by baseball bat
W21.12 Struck by tennis racquet
W21.13 Struck by golf club
W21.19 Struck by other bat, racquet or club
W Struck by ice hockey stick
W Struck by field hockey stick
W Struck by ice hockey puck
W Struck by field hockey puck
W21.81 Striking against or struck by football helmet
W21.89 Striking against or struck by other sports equipment
W21.9 Striking against or struck by unspecified sports equipment
For comic relief

12. General Equivalence Mappings (GEMs)
Tools you can use to convert data from ICD-9-CM to ICD-10-CM, and 10 to 9 (crosswalks)
Mapping is bi-directional
ICD-9 to ICD-10 is called forward mapping
ICD-10 to ICD-9 is called backward mapping
May be multiple translation alternatives for a code being looked up, all of which are equally plausible
Not a substitute for learning how to use ICD-10-CM
Designed to be used to convert coded data.
To both create and maintain the GEMs, all reasonable code translation alternatives are included in its respective GEM, based on the complete meaning of the code being looked up.
May not need GEMs when a small number of ICD-9-CM codes are being converted to ICD-10-CM .

13. Issue: No Clear Mapping
Not always an exact, one-to-one conversion
Could be one to many, many to one or many to many
GEMS
Not always a clear map
Have flags for exact vs. approximate
Not just data conversion
Need clinical review/decision- making
GEMS – 9 to 10, and 10 to 9
One of the major issues (and something we will discuss in detail in a later session) is that there is no “easy” mapping or translation from ICD-9 to ICD-10 codes. There are some one-to-one correspondences, but often there are one-to-many, many-to-one, many-to-many, or no correspondence at all. This will be a major implementation consideration. There are some tables that have been published, but much more study needs to be done to determine how coding will change.
ICD-10 consistent with DSM-IV, but not DSM V
ICD-11 is consistent with DSM V, but if US as slow to adopt 11 as it was

14. Conversion of ICD-9-CM code 741.00 to ICD-10-CM
Spina bifida with hydrocephalus, unspecified region
Converts approximately to:
ICD-10-CM Q05.4 Unspecified spina bifida with hydrocephalus
Or:
ICD-10-CM Q07.01 Arnold-Chiari syndrome with spina bifida
ICD-10-CM Q07.02 Arnold-Chiari syndrome with hydrocephalus
ICD-10-CM Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus
Show tools/web sites that “convert” 9 to 10

15. Specific Impacts on EI AND ECSE
Eligibility
Billing and Related Business Processes
Electronic Data and/or Billing Systems
Data Analysis and Reporting
NECTAC/ECO/WRRC 2012

16. Provider Impacts
Changes to clinical and administrative systems, including documentation
Changes in business processes
Changes to IT systems (client and billing), and testing
Changes to data analyses
Training – not just coders
program, admin and systems staff
Not just business as usual, e.g., with “normal” annual updates to code sets
The first step to accurate coding is for the documentation to reflect what the provider has observed. Coding must be supported by medical documentation. Studies of the required documentation have indicated that more documentation is required to support the increased specificity of the code set. We should expect providers to have to spend about 15% more time on asking questions, observing, and documenting their findings to support the ICD-10-CM code set. Even with increased documentation, we can expect, with better coding, an increase in denials or pending claims, and the need for providers to submit additional documentation to support the codes.
Where do you use diagnoses/inpatient hospital procedures?
What are the interfaces that may need to be changed?
What databases need to be changed?
Be sure to test claims and transactions well in advance, both within your organization and with your payers and other business partners, e.g., clearinghouses or third-party billing services
American Health Information Management Association (AHIMA) recommends training begin no more than six to nine months before the October 1, 2014, compliance deadline. Training needs will vary for different organizations, but it is projected to take 16 hours for outpatient coders

17. Provider Impacts
New coding system will likely mean new coverage policies, new medical review edits, new reimbursement schedules
Expect increased reject, denials, and pends as both plans and providers get used to new codes (CMS)
Revenue impacts of specificity
Denials
Additional documentation
Not just business as usual, e.g., with “normal” annual updates to code sets
The first step to accurate coding is for the documentation to reflect what the provider has observed. Coding must be supported by medical documentation. Studies of the required documentation have indicated that more documentation is required to support the increased specificity of the code set. We should expect providers to have to spend about 15% more time on asking questions, observing, and documenting their findings to support the ICD-10-CM code set. Even with increased documentation, we can expect, with better coding, an increase in denials or pending claims, and the need for providers to submit additional documentation to support the codes.
Plan contracts (or Medicaid coverage policies) will be changed. Providers will adjust, but it will be difficult for them to measure exactly what the changes will mean to their overall reimbursement. This will make for a very challenging first year or two for providers as they move to ICD-10.
Be sure to test claims and transactions well in advance, both within your organization and with your payers and other business partners, e.g., clearinghouses or third-party billing services
American Health Information Management Association (AHIMA) recommends training begin no more than six to nine months before the October 1, 2014, compliance deadline. Training needs will vary for different organizations, but it is projected to take 16 hours for outpatient coders

18. Medicaid Plan Impacts Coverage determinations Payment determinations
Medical review policies
Plan structures
Statistical reporting
Actuarial projections
Fraud and abuse monitoring
Quality measurements

19. Impact on Eligibility
If you use a list of diagnoses, via ICD-9 codes, to specify eligible established conditions:
What will the list look like using ICD-10 codes?
How will you “convert” ICD-9 codes to ICD-10 codes?
What level of specificity will it have?
What impact will the level of specificity have on communications with physicians, family members, other referral sources
Examples

20. EI Example: Down Syndrome
ICD-9-CM
ICD-10-CM
758.0
Q90 – use additional codes to identify any associated physical conditions and degree of intellectual disabilities
Q90.0 Trisomy 21, nonmosaicism
Q90.1 Trisomy 21, mosaicism
Q90.2 Trisomy, translocation
Q90.9 Down Syndrome, unspecified

21. EI Example: Cleft Lip/Palate
ICD-9-CM
ICD-10-CM
Cleft palate
Cleft lip
Cleft palate with cleft lip
Unspecified
Unilateral, complete
Unilateral, incomplete
Bilateral, complete
Bilateral, incomplete
Q35 Cleft palate
Q35.1 Cleft hard palate
Q35.3 Cleft soft palate
Q Cleft hard palate with cleft soft palate
Q Cleft uvula
Q Cleft palate, unspecified
Q36 Cleft lip
Q Cleft lip, bilateral
Q Cleft lip, median
Q Cleft lip, unilateral
.00
.01
.02
.03
.04

22. EI Example: Cleft Lip/Palate
ICD-9-CM
ICD-10-CM
Cleft palate
Cleft lip
Cleft palate with
cleft lip
Q37 Cleft palate with cleft lip
Q Cleft hp with bilateral cleft lip
Q Cleft hp with unilateral cleft lip
Q Cleft sp with bilateral cleft lip
Q Cleft sp with unilateral cleft lip
Q Cleft hard & soft, bilateral
Q Cleft hard & soft, unilateral
Q Unspecified cp with bilateral
Q Unspecified cp with unilateral

23. Impact on Billing Understand payer processes/practices
Business rules
Medical policies
Coding guidelines for ICD-10-CM
Related processes, e.g., forms and documentation
All categories are 3 characters. A 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.
A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
A three-character code is to be used only if it is not further subdivided.

24. Examples of Billing Codes
ICD-9-CM
ICD-10-CM
Unspecified Delay in Development
– Mixed receptive- expressive language disorder
– Spasm of muscle
F Developmental disorder of scholastic skills, unspecified
F89 - Unspecified disorder of psychological development
F80.2 – Mixed receptive- expressive language disorder
H Central auditory processing disorder
M62.4xx – More than 20 codes
Contracture of muscle – right upper arm, left upper arm, right forearm, right thigh, right lower leg, etc.

25. Impact on Data System Design
ICD-9-CM Drop-downs
By name/condition and by ICD-9 code
Search by text string and/or by code
Options for ICD-10-CM
Arrange alphabetically or by code
Follow tabular (chapter) organization
Level of specificity
May depend on relationship to billing processes

26. If working with a vendor, ask:
When will your ICD-10 compliant system be ready?
Are there any additional costs involved for upgrades or ongoing maintenance?
What is the basis of your crosswalk or mapping strategy?
Will your product support dual coding?
What is your external testing strategy?
Do you have a contingency plan if you’re not ready by October 2014?
Especially for billing

27. Impact on Data Analysis and Reporting
Depends on the level of specificity of the data you collect
Depends on your desired level of specificity for reporting
Depends on your audience
Existing data (9 codes) vs. new data (10 codes)

28. Sample Report Using Categories
Condition
Percent
Chromosomal Anomalies 22
Symptoms and Ill-Defined Conditions 15
Diseases of the Nervous System 13
Congenital Anomalies--Brain/Spinal Cord 12
Congenital Anomalies--Musculoskeletal & Other
Conditions Originating in Perinatal Period 8
Congenital Anomalies--Facial Clefts 6
Congenital Anomalies - Other 4
Autism Spectrum Disorders
Endocrine, Nutritional and Metabolic Diseases 2
Other

29. Sample Report Using Individual Dx
Most Prevalent Qualifying Diagnoses
Down Syndrome
Failure to Thrive
Plagiocephaly
Seizure Disorders
Microcephaly
Hydrocephalus
Spina Bifida
Autism

30. CMS Web Resources: Basic Education
CMS – ICD-10-CM
CD10/index.html
Introduction fact sheet
FAQs
Updates from CMS

31. Web Resources: Basic Education
NCHS/CDC – Basic ICD-10-CM Information
AHIMA - ICD-10-CM Education
WEDI – ICD-10-CM Implementation
Two major, national coding organizations:
American Health Information Management Association – Health Information Mgmt
Advancing the Business of Health Care -- provide education and professional certification to physician-based medical coders

32. More Web Resources General Equivalence Mappings (GEMS)
Lists of Codes and Descriptions
Training Resources (AHIMA and AAPC)