Preparing for ICD-10 What you need to know Robert Janowitz, MD - - PowerPoint PPT Presentation
Preparing for ICD-10 What you need to know Robert Janowitz, MD Medical Director, Illinois Local Markets BCBSIL July 17, 2015 Illinois Public Health Association A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an
Robert Janowitz, MD Medical Director, Illinois Local Markets BCBSIL
July 17, 2015 Illinois Public Health Association
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
ICD-9 ICD-10
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create information in health care
ICD + other coding attributes
BCBSIL have systems that derive (1) benefits, (2) medical policies, and (3) pricing from a combination
Congressional action
hold
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Patient Attributes
Revenue Codes
Treatment Settings
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ICD-10-CM Structure: 3- to 6-position code with leading alpha (+ extension)
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Category Etiology, anatomic site, severity Extension
ICD-10-PCS Structure: 7-position alphanumeric code
Section Body System Root Operation Body System Approach Device Qualifier
ICD-10-PCS Structure: 7-position alphanumeric code
Section Body System Root Operation Body System Approach Device Qualifier
Section Body System Root Operation Body System Approach Device Qualifier
ICD-10-CM Structure ICD-10-PCS Structure
Part
Hospitals Only!
transactions nationally
claims, small practices, etc.)
Prior authorizations, referrals, orders, and prescriptions written before 10/1/15 for services to be
provided on 10/1/15 and later should contain ICD-10 where ICD is required
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Use ICD-9* Use ICD-10* O/P and Professional - Date of service 9/30/15 or earlier For E/R and O/P Observation – treatment starts 23:59 or earlier on 9/30/15 O/P and Professional - Date of service 10/1/15 or later For E/R and O/P Observation – treatment starts 00:00 or later on 10/1/15 O/P and Professional with from-through dates that cross 10/1/15 – split the record, request, or claim For I/P Institutional – Date of Discharge 9/30/15 or earlier For I/P Institutional – Date of Discharge 10/1/15 or later
Makes richer data sets available Helps research and public health surveillance – information on subsets of patients can be more easily aggregated for large-scale population health analysis New payment methodologies more practical The ability to capture greater detail and differentiation in acuity/severity will make complex outcome-based and risk-adjusted payment models more mainstream Drives health systems innovation Innovations will better reflect the intensity of patient needs than is currently possible
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ICD-10 will provide better information to accelerate the meaningful use of health data
More specific coding – Detail often lost with ICD-9, physicians
had a hard time conveying to payers how sick their patients really are
Finding a diagnosis gets easier – Physicians and coders will find it
easier to look up unusual diagnoses, signs, and symptoms. New AHIMA study shows conversion costs range from $1,960 to $5,900 for small practices
Avoid audits and future payment delays – Claims are often
suspended for review or denied due to non-specific information, which the detail in ICD-10 can help eliminate
Makes ICD-9 limitations a thing of the past – ICD-9 increasingly
fragmented and contained archaic medical terminology, contributed to coding errors and delayed/inaccurate payments
More meaningful management of physician patient populations –
Are you currently tracking a population of diabetic or asthmatic patients in your practice?
ICD-10 will provide better information about patients’
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Link to Video – Internet connection required
02:46 min - Right click on link, select “Open Hyperlink” A new browser window will open, maximize window for best viewing, click “Play” button
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As a practicing physician, Dr. Martinez offers his insights about the benefits of ICD-10 and four key points to help physicians with their transition to ICD-10.
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Focus of today’s presentation
at primary Dx
to diabetes)
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ICD-10 requires the following scales into documentation:
More instructions to code tobacco use/exposure
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Risk Stratification – The varying degrees of asthma severity will make it easier to identify high risk populations in health care data sets; more identification of patients who smoke/exposed to tobacco smoke ICD-9-CM ICD-10-CM
493.22 chronic
status asthmaticus J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus Z72.0 Tobacco use
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highly impacted by the switch to ICD-10 depending on the type of encounter Health Status Factors and & “History of” codes represent a wide range of reasons for healthcare encounters for circumstances other than a current disease or injury, and can include contraindications to care
ICD-9-CM ICD-10-CM
Often referred to as “V" codes, because most of them started with the letter “V” Equivalent and more detailed codes have been dispersed throughout section “Z"
Example of Health Status Factor: Post heart surgery
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Annual physical exams and entrance exams for school, work, or sports participation Inoculations and vaccinations Routine exams to measure developmental progress in children
Routine hearing, vision and dental exams
Routine screenings when no symptoms are present, such as:
smears
Observation of a suspected condition that has been ruled out (no symptoms are present), such as
with no harmful effects
Contact/Exposure with a communicable disease or other health hazard (but showing no symptoms) Counseling for purposes such as genetic counseling, childcare instruction, and victim services Disease and condition screenings, for at-risk patients such as diabetes, heart disease, anemia, & genetic disorders
Donor screenings of blood, tissues,
such as autologous blood)
ICD-9-CM Examples ICD-10-CM Examples
V71.31 Routine gynecological examination visit V73.81 Special screening examination for Human papillomavirus (HPV) V76.47 Special screening for malignant neoplasms of vagina V04.81 Vaccination and inoculation; influenza Note: there is no ICD-9 code to indicate if the exam was normal
Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings Z11.51 Screening for human papillomavirus Z12.72 Screening vaginal pap smear Z23 Encounter for Vaccination (prophylactic) Note: the vaccine code does not indicate the type of vaccine administered, this information can be found in the procedure coded for this service V70.3 Other general medical examination for administrative purposes Z02.0 Encounter for examination for admission to educational institution (Note added specificity available for reason for exam)
V71.82 Observation and evaluation for suspected exposure to anthrax Z03.810 Encounter for observation for suspected exposure to anthrax ruled out
New information needed in ICD-10 for Exams by physician which are not well documented in many physician office records today: 3 categories of routine exams, divided further by nature of findings
Specific reasons needed for administrative exams (e.g. “screening physicals”)
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Risk Stratification – Can better identify abnormal vs normal screening exams in a population of patients ICD-9-CM ICD-10-CM
V20.2 Routine infant
794.15 Nonspecific abnormal auditory function studies Z00.121 Encounter for routine child health examination with abnormal findings R94.120 Abnormal auditory function study
Visits for screening tests are coded similarly as they were in ICD-9, but with more specificity
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Risk Stratification – Use ICD-10 to track screening exams in a population of patients ICD-9-CM ICD-10-CM
V72.42 Pregnancy examination or test, positive result Z32.01 Encounter for pregnancy test, result positive V74.5 Screening examination for venereal disease Z11.3* Encounter for screening for infections with a predominantly sexual mode of transmission Excludes: Encounter for screening for human immunodeficiency virus [HIV] (Z11.4) Encounter for screening for human papillomavirus (Z11.51) V77.1 Screening examination; diabetes mellitus Z13.1* Encounter for screening for diabetes mellitus
*Z00-Z13 Notes: Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94
R99, or signs and symptoms classified in the body system chapters
An example of where ICD-10-CM is less specific than ICD-9
Procedure code (rather than diagnosis) identifies
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Risk Stratification – Can no longer rely on Dx to identify type of vaccine given, must look to CPT/HCPCS code for most records CPT Procedure ICD-9-CM Diagnosis ICD-10-CM Diagnosis
90700 DTaP (6 weeks - 6 years old) V06.1 Vaccination; diphtheria-tetanus- pertussis, combined [DTP] [DTaP] Z23 Encounter for immunization Code First: any routine childhood examination 90649 GARDASIL (9 years
V04.89 Vaccination and inoculation;
Z23 Encounter for immunization Code First: any routine childhood examination
Is your patient underimmunized? Yes – code it: What if you can’t administer a vaccine using Z23, can you bill for the visit? Yes - use one of these codes:
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Risk Stratification – Use ICD to help manage immunization status of your patient populations
Z28.01 Immunization not carried out because of acute illness of patient Z28.02 Immunization not carried out because chronic illness or condition of patient Z28.03 Immunization not carried out because immune compromised state of patient Z28.04 Immunization not carried out because patient allergy to vaccine or component Z28.09 Immunization not carried out because of other contraindication Z28.1 Immunization not carried out because of patient belief or group pressure Z28.20 Immunization not carried out because patient decision for unspecified reason Z28.21 Immunization not carried out because of patient refusal Z28.29 Immunization not carried out because patient decision for other reason Z28.81 Immunization not carried out due to patient having had the disease Z28.82 Immunization not carried out because of caregiver refusal Z28.89 Immunization not carried out for other reason Z28.3 UnderImmunization status
Mom and Baby records must be coded separately, not combined Maternal Records
part of ICD-10-CM (but this information is captured in ICD- 10-PCS for OB procedures)
O00-O9A) are never for use on the newborn record.
fetus in multiple pregnancies
pregnancy, the week can be coded in ICD-10
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Risk Stratification – new ability to track conditions by trimester, weeks of pregnancy, and fetus affected in multiple pregnancies
ICD-9 ICD-10
650 Normal delivery V27.0 Outcome of delivery, single liveborn O80 Encounter for full- term uncomplicated delivery Z37.0 - Single live birth
ICD-9
Persons Encountering Health Services in Circumstances related to reproduction/development (V20-V29) V23 Supervision of high-risk pregnancy (section heading)
history of pre-term labor Vague condition in ICD-9:
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ICD-10
Pregnancy, childbirth and the puerperium (O00-O9A)
the puerperium (F53), obstetrical tetanus (A34), postpartum necrosis of pituitary gland, (E23.0) puerperal osteomalacia (M83.0)
gestation, to identify the specific week of the pregnancy O09 Supervision of high risk pregnancy (Section heading)
reproductive or obstetric history
pregnancy loss (O26.2-)
pre-term labor
history of pre-term labor, 1st trimester
history of pre-term labor, 2nd trimester
history of pre-term labor, 3rd trimester
history of pre-term labor, unsp trimester
Another example
+ Z3A.38 - 38 weeks gestation ?
ICD-10-CM ICD-9-CM
Infant Records
in the Perinatal Period - P00-P96) are never for use
diagnoses: Congenital Defects
patient if the condition is still present
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Risk Stratification – congenital defect conditions may appear on more records in a population of patients due to the new guideline to code conditions throughout the life of the patient
ICD-9 ICD-10
V30.00 Single liveborn, born in hospital, delivered without mention of cesarean section *Z38.0 Single liveborn infant, delivered vaginally, born in birthing center or other health care facility *New note - Not to be used on the mother’s record
ICD-9 ICD-10
760.75 Cocaine affecting fetus or newborn via placenta or breast milk P04.41 - Newborn (suspected to be) affected by maternal use of cocaine 'Crack baby‘ Can only be used on newborn record
Link to Video – Internet connection required
05:24 min - Right click on link, select “Open Hyperlink” A new browser window will open, maximize window for best viewing, click “Play” button
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“The current transfer of information is still way too dependent on electronic means that were good 30 years ago… we need to start looking at how we’re going to get better information and data transfer to providers to get back to taking care of our patients better.”
16 Sections
Medical/Surgical Obstetrics Placement Administration Measurement & Monitoring Extracorporeal Assist Extracorporeal Therapy Osteopathic Other Procedures Chiropractic Imaging Nuclear Medicine Radiation Oncology Phys Rehab & Diag Audiology Mental Health Substance Abuse Tx
Over 35 Body Systems
Central nervous system Peripheral nervous system Heart and Great vessels Upper arteries Lower arteries Upper veins Lower veins Lymphatic and Hemic system Eye Ear, Nose, Sinus Respiratory System Mouth and Throat Gastrointestinal system Hepatobiliary System & Pancreas Endocrine system Skin and Breast Subcutaneous tissue Muscles Tendons Bursae and Ligaments Head and Facial bones Upper bones Lower bones Upper joints Lower joints Urinary system Female reproductive system Male reproductive system Anatomical regions, General Anatomical regions, Upper extremities Anatomical regions, Lower extremities Pregnancy Anatomical Orifices Indwelling Device
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Excision Resection Destruction Extraction Drainage Extirpation Fragmentation Division Release Transplantation Reattachment Transfer Reposition Restriction Occlusion Dilation Bypass Insertion Replacement Supplement Change Removal Revision Inspection Map Repair Control Fusion Alteration Creation
Thousands
Parts
(Examples)
Abdominal Sympathetic Nerve Anterior Tibial Artery, Left Cephalic Vein, Right Cerebral Meninges Esophagus, Lower External Carotid Artery, Right Internal Mammary Artery, Left Lumbar Plexus Phrenic nerve Scapula, Left Shoulder Bursa Spleen Subcutaneous Tissue and Fascia, Left Lower Arm Ventricle, Right Upper Leg Muscle, Right Uterine Supporting Structure
Six Approaches
Open Percutaneous Percutaneous endoscopic Via Natural or artificial
Via Natural or artificial
Via Natural or artificial
percutaneous endoscopic assistance External
Hundreds of Devices
(Examples)
Graft (e.g. synthetic, autologous, nonautologous) Prosthesis Intraluminal Leads Implants Fixation Devices Mechanical appliances Electronic appliances Z = NONE
Intermittent Qualifiers
(Examples)
Diagnostic Temporary Cemented Allogeneic Zooplastic Multiple Type of Substance Source of tissue used for bypass or graft Z = NONE
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Values for each position are not interchangeable among sections, body systems, and root operations Only valid combinations can be coded using carefully organized tables
1 2 3 4 5 6 7
Medical/Surgical Section
Operation: Cesarean section delivery of twins One procedure, coded as follows: Rationale: Note that the diagnosis, not procedure, will explain the number of newborns, outcome of delivery, trimester of delivery, number of weeks gestation (if premature), birth weight, any complications in one of the newborns, and which newborn had each complication No diagnostic information is included in ICD-10-PCS
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Section Obstetrics 1 Body System Pregnancy Root Operation Extraction D Body Part Products of Conception Approach Open Device No Device Z Qualifier Low Cervical 1
Extraction of Products of Conception, Low Cervical, Open Approach
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VENDORS When do you plan to have your ICD-10 Services / Software available to customers?
From the Workgroup for Electronic Data Interchange (WEDI), largest industry ICD-10 surveyor with support from CMS, Feb 2015 Survey – 1,174 participants (68% providers, 17% health plans, 15% vendors)
HEALTH PLANS What is your estimated date to begin external testing? PROVIDERS What is your expected date to begin external testing?
Available Now 60% By Q2/Q3 2015 25% Unknown 15% Have Started 50% By Q1/Q2 2015 40% Unknown 10%
Have Started 30%
By Q2/Q3 2015 30% Unknown 40%
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Acute Respiratory Infections Acute Serous Otitis Media ICD-9 ICD-10 ICD-9 ICD-10
462 Acute pharyngitis 465.9 Acute upper respiratory infection, unspecified 466.0 Acute bronchitis
J02.0 - Streptococcal pharyngitis J02.8 Acute pharyngitis due to other specified organisms J02.9 Acute pharyngitis, unspecified J06.9 Acute upper respiratory infection, unspecified J20.0 Acute bronchitis due to Mycoplasma pneumoniae J20.1 due to Hemophilus influenzae J20.2 due to streptococcus J20.3 due to coxsackievirus J20.4 due to parainfluenza virus J20.5 due to respiratory syncytial virus J20.6 due to rhinovirus J20.7 due to echovirus J20.8 due to other specified organisms
381.01 Acute serous otitis media H65.01 Acute serous otitis media, right ear H65.02 left ear H65.03 bilateral H65.04 recurrent, right ear H65.05 recurrent, left ear H65.06 recurrent, bilateral
Find your common diagnoses in ICD-9, look them up in ICD-10 Notice that many, but not all, have more specific variations in ICD-10 than existed in ICD-9
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Orders/Referrals:
Labs Imaging Rx Billing & Practice Management Medical Coding Front Desk Scheduling Exam Rooms EMR
Chart
Scheduling & Front Desk:
alpha/numeric format
authorizations
Exam Rooms:
(advance beneficiary notices)
EMR or Chart:
Medical coding:
Billing & Practice Management:
associated with a disease/condition
Orders/Referrals:
have the right Dx for future dates of service (consider standing orders)
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Plan & Assess Remediate Test & Validate Educate
Create a Project Team Baseline Budget Formulation Internal Impact Assessment – talk to your staff External Impact Assessment – talk to your vendors Internal system changes Vendor system changes Business Process Changes Internal Testing & Validation External Testing & Validation Medical Coder Training Physician Training Office staff, Report writers, & Analytics staff Key Metrics Review Comparison Studies
Review & Assess
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BCBSIL is hosting ICD-10 Testing Readiness Webinars through July!
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Industry Resources
Centers for Medicare & Medicaid Services
CMS regulates ICD-10. Not just for Medicare, CMS oversees ICD-10 for the entire US, including all covered entities like health plans, clearinghouses, vendors and providers. Part of HIPAA regulations. CMS ICD-10 Main Page
http://www.cms.gov/Medicare/Coding/ICD10/index.html Available at this site:
http://www.medscape.org/viewarticle/820612_2 - 21 minutes, 0.5 CMEs
ICD-10 Resource Page
http://www.bcbsil.com/provider/standards/icd_10.html On our Provider Portal
Start Here Start Here
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Other Key Industry Associations
American Health Information Management Association
Healthcare Information Management Systems Society
program?navItemNumber=13477 Note: program is co-sponsored by WEDI
Workgroup for Electronic Data Interchange
including standards like ICD-10
American Association of Professional Coders
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icd@bcbsil.com
Or talk to your BCBSIL Provider Network Consultant