1. Mastering the ICD-10 Transition for Your Organization
Presentation to: GAMES/GRTC Winter Meeting
Presented by: Camillia Harris, ICD-10 Communications Lead
Erica Baker, ICD-10 Communications Consultant
February 4, 2014

2. We are dedicated to A Healthy Georgia.
Mission
We will provide Georgians with access to affordable, quality health care through effective planning, purchasing and oversight.
We are dedicated to A Healthy Georgia.

3. Topics for Discussion ICD-10 Overview ICD-10 Facts ICD-10 Reminders
Your ICD-10 Responsibility
ICD-10 Documentation
GEMs Mapping Tool
DCH – GA Medicaid Transition and Testing
ICD-10 FAQs
Benefits & Rewards of ICD-10
Helpful Resources
Q&A
Closing

4. ICD-10 is Real
239 days until ICD-10 is here!

5. ICD-10 Facts

6. Why the Change
ICD-9 is outdated – limited capacity, capability, can’t serve future needs
The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures
ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice
Moving from 9 to 10 – U.S. is last industrialized nation to adopt ICD-10
By transitioning to ICD-10, providers will have:
Improved operational processes
Detailed information on condition, severity, complications and locations
Detailed health reporting and analytics such as cost, utilization and outcome
Transitioning to ICD-10 is not optional
Federal compliance date is October 1, 2014 (firm and not subject to change)
National impact, mandatory for all HIPAA-covered entities
If you use ICD-9 codes TODAY, you will have to migrate to ICD-10 codes

7. More ICD-10 Facts NO MORE EXTENSIONS
New ICD-10-CM and ICD-10-PCS code sets
Replaces ICD-9-CM (Volumes 1, 2, and 3)
ICD-10 has no direct impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS)
Claims that are submitted with non-compliant codes will be rejected

8. Reminders About ICD-10
For dates of services rendered on or after October 1, 2014
All claims must use ICD-10 codes
All claims using ICD-9 codes will NOT be accepted
For dates of services rendered before October 1, 2014
All claims must use ICD-9 codes
Systems must accommodate BOTH ICD-9 and ICD-10 codes
Effective with the October 1, 2014 compliance date
Significant Code Increase from ICD-9
Increasing from 13,000 to approximately 68,000 ICD-10-CM codes
Increasing from 3,000 to approximately 87,000 ICD-10-PCS codes
ICD-10 has more than nine times the codes in ICD-9

9. More ICD-10 Reminders Please keep the following in mind:
There is no transition period to use either ICD-9 or ICD-10 codes
If the claim contains ICD-9 codes for a date of service BEFORE October 1, 2014, the claim will be accepted for payment. If the claim contains ICD-9 codes for a date of service ON or AFTER October 1, 2014, the claim will be rejected.
It is mandatory that you wait until October 1, 2014, to start using ICD-10 codes
Providers, trading partners, and clearinghouses will not be able to process claims using ICD-10 codes until the compliance date of October 1, 2014.

10. Your ICD-10 Responsibility
If you are a physician or other health care professional, you are responsible for using the correct ICD-10 codes on your claims.
If you carry out the physician’s or other health care professional’s orders, you are responsible for obtaining the correct ICD-10 codes from the health care professional before filing your claims.
Billers/Coders do not determine the most appropriate ICD-10 codes.

11. Documentation is Key

12. ICD-10 and Patient Care Transitioning to ICD-10
Is more than an administrative burden placed on your medical claims reimbursement process/people
Should not affect the way you provide patient care
Specificity and Documentation are vital in ICD-10
Look at the codes used most often in your practice
Most of the information needed for documentation is likely shared by the patient during your visit with them
Improving how you document your clinical services will help you become accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes
Work with your coding staff to determine if the documentation would be detailed and specific enough to select the best ICD-10 codes
Identify and obtain the training needed for you and others in your practice
Good documentation will help to reduce the need to follow-up on submitted claims – saving you time and money

13. The GEMs Mapping Tool

14. GEMs GEMs – General Equivalence Mappings
A tool used to convert data from ICD-9-CM to ICD-10-CM and ICD-10-PCS and vice versa
Also known as crosswalks providing important information linking codes of one system with codes in the other system
A comprehensive translation dictionary used to assist in translating any ICD-9-CM-based data, including data for:
Tracking quality
Recording morbidity/mortality
Calculating reimbursement
Converting any ICD-9-CM-based application to ICD-10-CM/PCS such as:
Payment systems
Payment and coverage edits
Risk adjustment logic
Quality measures and a variety of research applications involving trend data
Sources:

15. GEMs vs. Coding Manual
GEMs are not a substitute for learning how to use ICD-10-CM and ICD-10-PCS.
Providers’ coding staff will assign codes describing the patients’ encounters from the ICD-10-CM and ICD-10-PCS code books or encoder systems.
In coding individual claims, it will be more efficient and accurate to work from the medical record documentation and then select the appropriate code(s) from the coding book or encoder system.
GEMs is a tool to assist with converting larger International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) databases to ICD-10-CM and ICD-10-PCS.
Not all codes map in GEMs.
Example: ICD-9-CM code (pressure ulcer, unstageable)
Does not map to any ICD-10-CM code because ICD-10-CM classifies pressure ulcers by site and stage.
ICD-10-CM does include codes for unstageable pressure ulcers (l89.-), but ICD-9-CM does not include any site designation. As a result, the GEMs cannot pick a close match.
Coders cannot map to added specificity when the original information is general.

16. GEMs – Both Directions
From ICD-9-CM to ICD-10 and ICD-10 back to ICD-9-CM
GEMs are designed to be used like a bi-directional translation dictionary. They go in both directions so that you can look up a code to find out what it means according to the concept and structure used by the other coding system.
The bi-directional GEMS dictionaries are NOT a mirror image of each other.
The translation alternatives are based on the meaning of the code you are looking up.
GEMs Update
CMS and CDC made a commitment to update the GEMs annually along with the updates to ICD-10-CM/PCS during the transition period prior to ICD-10 implementation.
GEMs will be maintained for at least 3 years beyond October 1, 2014, which is the compliance date for implementation of ICD-10-CM/PCS for all Health Insurance Portability and Accountability Act (HIPAA)-covered entities.
Sources:

17. Code Translator Examples
The following slides are code translator examples. Note…
The ICD-10 code online translator tool allows you to compare many ICD-9 to ICD-10 codes.
Keep in mind that while many codes in ICD-9-CM map directly to codes in ICD-10, in some cases, a clinical analysis may be required to determine which code or codes should be selected for your mapping.
The most accurate coding is accomplished using the ICD-10 coding manuals.
Link provided for viewing:

18. Why do the GEMs go in both directions?

19. Why do the GEMs go in both directions?

20. Why do the GEMs go in both directions?

21. ICD-10 Transition & Testing Georgia Medicaid -- DCH

22. DCH and the Transition to ICD-10
DCH is on track for October 1, 2014, compliance
Phases of implementation
Awareness, Assessment, Remediation, Testing, Transition
Status as of January 2014
Awareness – ongoing
Assessment – completed
Remediation – necessary changes to our impacted policies, processes and systems are underway
Testing – verifying and validating the ICD-10 changes as completed in Remediation…underway
Transition – not started

23. DCH ICD-10 Testing Status
DCH Readiness for Beta Testing with External Partners
DCH is nearing completion of our ICD-10 system enhancements for beta testing with our external partners.
Due to the additional impact from the ICD-10-PCS codes, inpatient hospital claims may require additional internal testing time within DCH.
DCH and HP Enterprise Services* (our fiscal agent) are preparing security measures for assurance of protected health information. Additional information will be provided shortly.
*Hewlett-Packard Enterprise Services

24. ICD-10 Testing Reminders
Please keep the following in mind:
Beta testing will involve simulating an ICD-10 effective date which will be prior to the true effective date of October 1, 2014. This date will need to be coordinated with other testing that is occurring within our testing environment.
We anticipate beta testing to begin Q for Providers and for Trading Partners/Clearinghouses/Billing Agents and Care Management Organizations.

25. DCH ICD-10 Testing Schedule
DCH and Georgia Medicaid are preparing for the external testing phase of our system’s remediation
Trading Partners (Clearinghouses, Billing Services)
Beta testing is anticipated to begin Q1 of 2014
Providers
Beta testing is anticipated to begin late Q1 of 2014

26. ICD-10 FAQs

27. What You Need to Know…
Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?
No. The switch to ICD-10 does not affect CPT coding for outpatient procedures.
Is there a transition period when we can use either ICD-9 or ICD-10 codes?
No. If the date of service on a claim is before October 1, 2014, and contains ICD-9 codes, then the claim will be accepted for payment. If the date of service is on or after October 1, 2014, and uses ICD-9 codes, then this claim will be rejected. All claims that contain a date of service on or after the federally mandated compliance date of October 1, 2014, MUST use ICD-10 codes to be accepted for payment. If a practice continues to use ICD-9 codes on claims with dates of service after the compliance date, the practice may be subject to penalties established by CMS.
Do we have to wait until October 1, 2014, to start using ICD-10 codes?
Yes. Providers, payers, trading partners and clearinghouses will not be able to process claims using ICD-10 codes until the mandated compliance date of October 1, However, DCH strongly recommends that you conduct both internal and external testing with your trading partners and payers using ICD-10 code sets before the October 1, 2014, compliance date

28. What You Need to Know…
If I order a 2014 ICD-10 coding book now, will it be updated to another version later?
The Georgia Department of Community Health does not have any input on ICD-10 coding publications. It is up to the provider to contact the resource directly for the final version of their coding books.
What is the appropriate timeline to start ICD-10 training?
The ICD-10 Project Team recommends that you should begin your staff’s ICD-10 training as soon as possible. The transition to ICD-10 is a major undertaking for providers, payers, and vendors. The transition to ICD-10 will drive business and system changes throughout the health care industry, from large national health plans to small provider offices, laboratories, medical testing centers, hospitals, and more.
Training needs will vary for different organizations.

29. More ICD-10 FAQs
Will DCH do any ICD-10 training prior to October 1, 2014?
No. DCH will not conduct any ICD-10 training. However, there are numerous resources for self-development training on ICD-10. There are companies that may report their expertise of ICD-10 codes and offer training, but for a cost. Like any purchase of software applications, equipment, trainers, course materials, etc., evaluate the credibility of the product, the people/company and their purpose. DCH does not offer any recommendations of ICD-10 training companies.
Will there be changes to ICD-9 codes for 2014?
CMS is limiting the number of changes to the ICD-9 codes since the focus is now on the ICD-10 codes.

30. More ICD-10 FAQs
Are there certain ICD-10 codes that Medicaid anticipates not accepting?
There are some ICD-10 diagnosis codes that may not be accepted by Georgia Medicaid, i.e., certain unspecified codes, when there is a more specific ICD-10 diagnosis code that can be billed. With the increased specificity and number of available ICD-10 codes, the physicians’ documentation would need to support the ICD-10 diagnosis coding.
Does the new ICD-10 code change affect current Medicaid rates?
No changes are anticipated at this time by Georgia Medicaid nor has CMS provided any reimbursement rules or rate changes for the ICD-10-CM or ICD-10-PCS codes.

31. Benefits and Rewards of ICD-10

32. Benefits of ICD-10
ICD-10 will play a critical role in aligning the definitions of services and care rendered
ICD-10 will help prevent fraud and abuse
More effective detection and investigation of potential fraud or abuse and proof of intentional fraud.
Modify edits to support correct coding with greater sensitivity and specificity to help prevent fraud and abuse.
ICD-10 is easier and more flexible for future updates
ICD-10 enhances coding accuracy and specificity to classify anatomic site, etiology and severity
ICD-10 provides better analyses for disease patterns and response to public health outbreaks
Sources:

33. Rewards of Compliance with ICD-10
Continued cash flows with claims processed and paid
Financial statement stability, credit worthiness
Increased efficiencies in administrative, billing and reimbursement processes
Reduced coding errors due to increased specificity
Improvement in patient care management
Increased health care IT system ROI and value, increased productivity
Increased capability to prevent and detect health care fraud and abuse
Sources:

34. Resources

35. CMS ICD-10 Checklists
CMS has created ICD-10 Checklists to assist your organization with overall ICD-10 compliance.
Large Practices
Small and Medium Practices
Small Hospitals
Payers

36. ICD-10 Training Resources

37. ICD-10 Resources Centers for Medicare & Medicaid Services (CMS)
CMS Overview
CMS ICD-10 Implementation Planning Guides/Checklist
HHS, CMS ICD-10 Final Rule
CMS, HHS Complete list of code sets for ICD-10-CM and ICD-10-PCS; Final Rule and Official ICD-10-CM Guidelines
World Health Organization (WHO) ICD-10 Page

38. More ICD-10 Resources DCH Resources
DCH Website for ICD-10 Webinars/Downloads
DCH ICD-10 FAQs & Fact Sheet
DCH Provider Resources
HP Enterprise Services Statewide Workshops
Check Georgia for future ICD-10 workshops

39. Upcoming ICD-10 Webinars
Register Now
February 11, 2014: ICD-10 Resource Review/ Resource Walkthrough
February 27, 2014: HCBS Waiver (Home - and Community - Based Service Providers)
March 11, 2014: Behavioral Health Services …Open Discussion
March 27, 2014: ICD-10 Clinical and Policy Update
April 8, 2014: Surviving ICD-10 Tools and Tips for Transitioning
April 24, 2014: ICD-10 Case Studies
June 10, 2014: Repeat Roadmap ICD-10 Emergency Tool Kit and Open Discussion
June 26, 2014: ICD-10 Essentials
To register for the above webinars: Visit
Each webinar is scheduled for up to one hour, 10:30 – 11:30 a.m. ET.
Unless otherwise noted, all webinars are targeted to Providers and Trading Partners.
Please be advised that webinar dates and times are subject to change.

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41. Questions & Comments