ICD-10 Provider Education Antonietta Sculimbrene, MD MHA October 20 - - PowerPoint PPT Presentation

October 20 15

ICD-10 Provider Education

Antonietta Sculimbrene, MD MHA

Avoid claims processing errors=denials or claim rejections for providers, by fostering an understanding of the process of and reasoning behind Palmetto’s development of ICD-10 LCD code sets

Review high level differences between

ICD-9 and ICD-10

Communicate principles used to convert

JM LCD and article coding to ICD-10

Explain process by which providers can

convey feedback regarding the updated LCD’s to Palmetto GBA

A coding improvement or apocalypse now?

The ICD-10 code sets are not a simple update of the ICD-9 code set. The ICD-10 code sets have fundamental changes in structure and concepts that make them very different from ICD-9.

WARNING!

ICD-9-CM

3-5 characters in length Approx. 13,000 codes Digit 1 may be alpha

(E or V) or numeric; digits 2-5 are numeric;

Lacks laterality

ICD-10-CM

3-7 characters in length Approx. 68,000 available

codes

Digit 1 is alpha; digits 2

and 3 are numeric; digits 4-6 are alpha or numeric

Has laterality (i.e. codes

identifying right v. left)

Approximately a 6 fold increase in the number of codes!

3-4 numbers in

length

Approximately

3000 codes

7 alpha numeric

digits

Approximately

87,000 codes

ICD-9-PCS ICD-10-PCS

Anatomical Laterality (or specificity)

For example, if a patient is seen for treatment of a burn on the right arm, the ICD- 9 diagnosis code does not distinguish that the burn is on the right arm. If the patient is seen a few weeks later for another burn on the left arm, the same ICD-9 diagnosis code would be reported. 943.21 Blisters with epidermal loss due to burn (second degree) of forearm Additional documentation would likely be required for a claim for the treatment to explain that the burn treated at this time is a different burn from the one that was treated previously. In the ICD-10 diagnosis code set, characters in the code identify right versus left, initial encounter versus subsequent encounter, and

• ther clinical information.

T22.211A Burn of second degree of right forearm, initial encounter T22.212A Burn of second degree of left forearm, initial encounter T22.219A Burn of second degree of unspecified forearm, initial encounter T22.611A Corrosion of second degree of right forearm, initial encounter T22.612A Corrosion of second degree of left forearm, initial encounter T22.619A Corrosion of second degree of unspecified forearm, initial encounter Ok, is it a burn (thermal) or a corrosion (chemical)? And that’s just for the initial encounter!

When a code subset includes complete anatomic specificity such as right leg vs. left leg or specific digits (left index finger, right ring finger)the code for leg, unspecified or finger, unspecified will not be accepted. A claim containing such a code will be denied.

What are the implications of laterality for Medicare LCD and Medicare edit coding?

X94.2XXA Assault by machine gun, initial encounter X94.2XXD Assault by machine gun, subsequent encounter X94.2XXS Assault by machine gun, sequelae

EPISODES OF CARE

The above examples are unlikely events. In all probability, the only time that you would survive an assault by machine gun and have a subsequent encounter or sequelae is if Mr. T were doing the shooting. In multiple seasons

• f the “A Team” he shot thousands of rounds and never hit anyone!
• Mr. T’s response…I pity the fool because…

You will learn to use ICD-10

• r I’ll bust your elbow!

Which leads us to: S52.021A Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture S52.022A Displaced fracture of olecranon process without intraarticular extension of left ulna, initial encounter for closed fracture S52.023A Displaced fracture of olecranon process without intraarticular extension of unspecified ulna, initial encounter for closed fracture (don’t use this one or we might have to bust your elbow)

Oh, but then it gets worse…

S52.021A Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture S52.024A Nondisplaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture

S52.031A Displaced fracture of olecranon process with intraarticular

extension of right ulna, initial encounter for closed fracture

S52.034A Nondisplaced fracture of olecranon process with

intraarticular extension of right ulna, initial encounter for closed fracture

BUT THIS IS ONLY THE BEGINNING…

S52.021A Displaced fracture of olecranon process without intraarticular extension

• f right ulna, initial encounter for closed fracture

S52.021B Displaced fracture of olecranon process without intraarticular extension

• f right ulna, initial encounter for open fracture type I or II

S52.021C Displaced fracture of olecranon process without intraarticular extension

• f right ulna, initial encounter for open fracture type IIIA, IIIB, or IIIC

S52.021D Displaced fracture of olecranon process without intraarticular extension

• f right ulna, subsequent encounter for closed fracture with routine healing

S52.021E Displaced fracture of olecranon process without intraarticular extension

• f right ulna, subsequent encounter for open fracture type I or II with routine

healing S52.021F Displaced fracture of olecranon process without intraarticular extension

• f right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with

routine healing S52.021G Displaced fracture of olecranon process without intraarticular extension

• f right ulna, subsequent encounter for closed fracture with delayed healing

S52.021H Displaced fracture of olecranon process without intraarticular extension

• f right ulna, subsequent encounter for open fracture type I or II with delayed

healing S52.021J Displaced fracture of olecranon process without intraarticular extension

• f right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with

delayed healing

S52.021K Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed fracture with nonunion S52.021M Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type I or II with nonunion S52.021N Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion S52.021P Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed fracture with malunion S52.021Q Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type I or II with malunion S52.021R Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S52.021S Displaced fracture of olecranon process without intraarticular extension of right ulna, sequelae

AND THE BEAT GOES ON…

• There are several thousand new

codes in ICD-10 that describe fractures.

• There are more than 2000 new

codes for fracture of femur alone!

• This fact will have a significant

impact on level of documentation required for emergency services,

• rthopedics, therapy services, etc.

Important Tips:

Some less specific codes have been retained in the LCD’s and claims processing edits because it is acknowledged that this level of detail in documentation may take some time to achieve, but it is expected, in general, that claims be coded to the highest level of specificity possible. When the code set encompasses all standard anatomic possibilities: i.e. right eye, left eye, bilateral eyes; the code for unspecified eye has been deleted as a payable code. If you are a Cyclops, you are just out of luck, as there is no code for middle eye… For services involving physical therapy, occupational therapy, and speech-language pathology services only the “S” codes for sequelae have been retained in the payable code set. This is part of the ICD-10 coding instruction as therapy is considered a service rendered for a sequelae of a brain injury, stroke, fracture, trauma, etc. and not direct treatment for such a diagnosis. However, there may be some instances were “A” and “D” codes are appropriate.

250.42 Diabetes with renal manifestations, type II or unspecified type, uncontrolled OR 250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled

In ICD-10 it’s a whole different story.

You would need to code: E11.21 Type 2 diabetes mellitus with diabetic nephropathy OR E11.29 Type 2 diabetes mellitus with other diabetic kidney complication AND/OR E11.65 Type 2 diabetes mellitus with hyperglycemia

Manage some poorly controlled diabetics for which you need frequent A1c measurements? In ICD-9 this code would pay as per the LCD:

Another example of where ICD-10 is less specific than ICD-9:

Cardiac Rehabilitation: Post MI episodes of care-

410.01

Acute myocardial infarction of anterolateral wall, initial episode of care

410.02

Acute myocardial infarction of anterolateral wall, subsequent episode

• f care

I21.09

ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I21.09

ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I22.0

Subsequent ST elevation (STEMI) myocardial infarction of anterior wall ICD-9 to ICD-10 Translations

Old ICD-9 “V” codes don’t exist as V codes in ICD-10**

ICD-9: V20.0 Foundling ICD-10:V20.0XXA Motorcycle driver injured in collision with pedestrian or animal in nontraffic accident, initial encounter* *Please keep this in mind when driving your Harley

• n a sidewalk or through a zoo

** Hint-most are “Z” codes now

ICD-10 is supposed to allow for an unprecedented new level of granularity … WELL NOT ALWAYS!

Remember back in slide 3 we said there were fundamental changes in structure?!?

Here are some examples: ICD-9: V04.5 Need for prophylactic vaccination and inoculation against certain viral diseases; rabies ICD-10: Z23 Encounter for immunization

YES all immunizations all map to Z23 in ICD-10! You will need to

add a second code to specify the circumstances such as Z20.3 Contact with and (suspected) exposure to rabies, as Medicare only covers certain types of immunizations and Z23 coded alone will cause the claim to deny.

OCTOBER 1, 2015 HALLOWEEN COMES EARLY THIS YEAR ICD-10 PCS CODES ARE SCARY ICD-9 PCS codes went from 00.01 Therapeutic ultrasound of vessels of head and neck to 99.99 Other, leech therapy, in numerical order. ICD-10 PCS codes have an “unlucky 7” characters: 1) Section-medical surgical, osteopathic, placement 2) Body System-Central nervous system, eye, pregnancy 3) Operation-Assistance, atmospheric control, hypnosis 4) Body Part-Upper artery, lumbar, rib cage 5) Approach- Open, percutaneous, percutaneous endo 6) Device-selection depends on the operation 7) Qualifier-Diagnostic, no qualifier

Here are sample PCS codes: 0B9330Z 0-Medical and Surgical B-Respiratory System 9-Drainage 3-Main Bronchus, Right 3-Percutaneous 0-Drainage Device Z-no qualifier 5A15223 5-Extracorporeal Assistance and Performance A-Physiological Systems 1-Performance 5-Circulatory 2-Continuous 2-Oxygenation 3-Membrane

Other Burning Questions:

How do we code claims for services performed prior to October 1, 2015 but submitted after October 1, 2015? For any DOS prior to October 1, 2015 the claim must still be coded with ICD-9 diagnosis and procedure codes even if submitted after October 1, 2015. What if it is a hospital stay that spans dates from September 2015 to October 1 2015 or beyond? These claims would be submitted with ICD-10 diagnosis and procedure codes. Anesthesia procedures that begin on 9/30/15 but end on 10/1/15 are to be billed with ICD-9 diagnosis codes and use 9/30/15 as both the FROM and THROUGH date.

Help is on the way!

CMS resources for the ICD-10 Transition:

Let your fingers do the walking (you certainly wouldn’t want to ride in this!) …

http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources http://www.cms.gov/Medicare/Coding/ICD10

• r

How to view the JM LCD’s with ICD-10 code sets:

TIP

LCDs coded with ICD-10 have new LCD numbers in the Medicare Coverage Database (different from the ICD-9 versions). The ICD-10 versions of the LCDs contain links to the old ICD-9 versions. Some LCD’s have been retired due to coding crossover issues which will require redrafting the LCD. These will begin to be re-issued in 2016.

ICD-10 Local Coverage Determination (LCD) Mailbox Or the direct e-mail address for this new mailbox is:

ICD10.POLICY@PALMETTOGBA.COM

On the ICD-10 page under either JM Part A or JM Part B you will find a link to:

Please direct all inquiries regarding CODING questions and suggestions to this mailbox. Inquiries prior to October 1, 2015 will not be treated as formal reconsideration requests but all input will receive consideration for potential revisions to the code sets. All other policy questions should continue to be directed through the existing Part A and Part B policy mailboxes.