1. Rhonda Anderson, RHIA Anderson Health Information Systems, Inc. 1

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

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

4.  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 4

5.  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 5

6.  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. 6

7.  HIM personnel  Nurse managers  MDS nurses  Nursing unit staff/clerks  Case managers  Administration  Therapy personnel (PT/OT/ST)  Billing/admitting personnel 7

8.  Medical Directors/Providers  Corporate Office personnel  Compliance Office personnel working with ICD coding  Corporate administrative departments 8

9.  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 9

10.  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. 10

11.  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  Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services 11

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 12

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. 13

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. 14

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 15

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 16

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.) 17

18.  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 18

19.  For bilateral sites, the final character of the codes in ICD-10 indicates laterality:  C50.212 Malignant Neoplasm of upper-inner quadrant of left female breast  H02.835 Dermatochalasis of left lower eyelid  I80.01 Phlebitis and Thrombophlebitis of superficial vessels of right lower extremity  L89.213 Pressure Ulcer of right hip, Stage 3 *an unspecified site code is also provided should the site not be identified. 19

20.  Expanded Codes (injury, diabetes, alcohol/substance abuse, postoperative complications)  E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease 20

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  More combined codes, i.e. Diabetic retinopathy is one code 21

22.  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 22

23.  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 23

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 24

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 25

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  K = subsequent encounter for fracture with nonunion  P = subsequent encounter for fracture with mal-union  S = sequela 26

27.  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_ 27

28.  Fracture of lst lumbar vertebrae – S32.01__  Wedge compression, stable burst, unstable burst, other, or unspecified?  What type of fx is it? 28

29.  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. 29

30.  ICD-10 Code Format 30 ICD-9-CM Code FormatICD-10-CM Code Format

31.  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  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! 31

32.  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 32

33.  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  Review for Medicare must be more specific 33

34.  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. 34

35.  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 35

36.  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 36

37.  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 37

38.  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 38

39.  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 39

40.  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 40

41.  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 41

42.  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 42

43.  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 43

44.  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 44

45.  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 45

46.  Listen to ICD-10 webcasts  Have coding staff take medical terminology and Anatomy and Physiology courses (from local college or online) 46

47.  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 47

48.  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 48

49.  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 49

50.  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 50

51.  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 51

52.  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 52

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