Basic Information regarding ICD 10 codes, implementation and some of the CMS guidance as of Sep 25, 2015.

1. ICD 10 Basics
Taino Consultants Inc.
Dr. Jose I. Delgado

2. Battered
by child:
E96.794
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3. Grandma
got run
over by a
reindeer:
V06.00xA
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4. Problems in
relationship
with in
laws: Z63.1
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5. Uncongenial
work
environment
: Z63.1
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6. Crushed by Alligator: W5803XA
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7. What Is ICD-10?
 ICD-10 is the updated version of codes used for
coding:
• Diagnoses for all providers (ICD-10-CM)
• Inpatient hospital 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
 These are “classification” code sets
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8. Major Changes from ICD-9 to ICD-10
 Not just the usual annual update
 ICD-10 markedly different from ICD-9
 Requires changes to almost all clinical and
administrative systems
 Requires changes to business processes
 Changes to reimbursement and coverage
 Will enable significant improvements in care
management, public health reporting, research, and
quality measurement
 Why?
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9. Specific Changes
 Diagnosis Codes (ICD-9 to ICD-10-CM)
• From 5 positions (first one alphanumeric, others
numeric) to 7 positions, all alphanumeric
• From 13,000 existing codes to 68,000 codes
• 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
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10. Specific Changes
 Enables laterality (right vs. left designations)
• It makes a difference whether the right or left limb
is the subject of the problem
 Restructures reporting of obstetric diagnoses
• In ICD-9-CM, the patient is classified by diagnosis in
relation to the episode of care.
• In ICD-10-CM, the patient is classified by diagnosis
in relation to the patient’s stage of pregnancy
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11. Difference in Organization
 The ICD-10 codes are organized differently than the
ICD-9 codes
 Example:
• Sense organs have been separated from nervous
system disorders
• Injuries are grouped by anatomical site rather than
injury category
• Postoperative complications have been moved to
procedure-specific body system chapter
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12. Examples of ICD-10-CM Specificity
 Sports injuries now coded with sport and reason
for injury
• ICD-9 code - Striking against or struck accidentally
in sports without subsequent fall (E917.0)
• 24 ICD-10-CM Detail Codes
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13. Examples of ICD-10 Specificity
V43.51
Car driver injured in collision with sport utility vehicle in
traffic accident
V43.61
Car passenger injured in collision with sport utility
vehicle in traffic accident
V43.53
Car driver injured in collision with pick-up truck in traffic
accident
V43.63
Car passenger injured in collision with pick-up truck in
traffic accident
V55.5
Driver of pick-up truck or van injured in collision
with railway train or railway vehicle in traffic accident
V55.6
Passenger in pick-up truck or van injured in collision
with railway train or railway vehicle in traffic accident
V73.6
Passenger on bus injured in collision with car, pick-up
truck or van in traffic accident
Notes:
• On above remember to add 7th digit character:
A – initial encounter, D – subsequent encounter or S – sequel
• Also remember placeholders when needed (i.e.: V43.51xA)
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14. Place of Occurrence Specificity
Y92 Place of occurrence of the external cause
• More specificity in rooms of home or public place
Y92.0 Non-institutional (private) residence
Y92.010 Kitchen
Y92.011 Dining room
Y92.012 Bathroom
Y92.013 Bedroom
Y92.014 Private driveway
Y92.015 Private garage
Y92.016 Swimming-pool
Y92.017 Garden or yard
Y92.02 Mobile home as the place of occurrence
Y92.03 Apartment as the place of occurrence
(Condominium or Co-op apartment)
Y92.12 Nursing home as the place of occurrence of the external cause
Y92.14 Prison as the place of occurrence of the external cause
Y92.143 Cell of prison as the place of occurrence of the external cause
Y92.147 Courtyard of prison as the place of occurrence of the external cause
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15. New Concepts
• Timeline changes for postpartum and other conditions
o 072.3 Postpartum coagulation defects
o 090.4 Postpartum acute kidney failure
o 090.6 Postpartum mood disturbance
• New concepts such as coding trimester & fetus number
• New concept such as underdosing that is not seen in ICD-9
• New chapters for both eyes & ears, which are currently in the
Nervous Systems & Sense Organs chapter
• Many codes in ICD-10-CM include site & laterality (i.e. Chapter
13)
o M25.511 Pain in right shoulder
o M25.512 Pain in left shoulder
• Combination codes that are new in ICD-10-CM
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16. New Concepts
• Postoperative & intraoperative complications are now found at
the end of each body system chapter
o K91.7- Accidental puncture and laceration of a digestive system
organ or structure during a procedure
 K91.71 Accidental puncture and laceration of a digestive system
organ or structure during a digestive system procedure
 K91.72 Accidental puncture and laceration of a digestive system
organ or structure during other procedure
Note: that K91.7 may not be used without additional characters.
• Seven digit extensions to indicate encounter & healing such as
nonunion & malunion fractures:
• Seventh digit K - subsequent encounter for fracture with
nonunion
• Seventh digit P - subsequent encounter for fracture with
malunion
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17. Examples
718.86Knee Instability Lower Leg M23.50
Chronic instability of knee, unspecified
knee
M23.8X9
Other internal derangements of unspecified
knee
M23.51 Chronic instability of knee, right knee
M23.52 Chronic instability of knee, left knee
M25.261 Flail joint, right knee
M25.262 Flail joint, left knee
M25.269 Flail joint, unspecified knee
M25.361 Other instability, right knee
M25.362 Other instability, left knee
M25.369 Other instability, unspecified knee
719.41Shoulder Pain Generalized M25.519 Pain in unspecified shoulder
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
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18. Structure of ICD-10 PCS
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19. • Documentation of diagnoses and procedures
● Codes must be supported by medical documentation
● ICD-10-CM codes are more specific
● Requires more documentation to support codes
● Expect a 15% increase in documentation time (per
American Academy of Professional Coders)
● Revenue Impacts of specificity
▫ Denials
▫ Additional Documentation
Provider Impacts
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20. • Coverage and Payment
o New coding system will mean new coverage policies, new medical
review edits, new reimbursement schedules
o Changes will be made to accommodate increased specificity
o May need to discuss changes with patients
Provider Impacts
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21. • Relationship with Plans
● Coding more specific and includes severity
● Changes will be based on new coding, coverage,
and reimbursement
● Difficult to measure what the changes will mean
to overall reimbursement
Provider Impacts
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22. • Billing and Eligibility Transactions
o Updated transactions include support for ICD-10
o New codes mean more specificity
o Expect increased reject, denials, and pendings as
both plans and providers get used to new codes
Provider Impacts
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23. EXCEPTION AND CHALLENGES TO ICD-10
 Workers Compensation and Auto carriers
are excluded from conversion to ICD-10
 How will workers compensation claims be
submitted?
 How will health plans handle in subrogation?
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24. ICD-10-CM MYTHS
 Providers will need to change how they practice medicine
 Documentation is critical as the same must support the ICD 10 code.
In other words, high probability of an increase in time to complete
paperwork and collect information from each patient
 Providers and coders need to start learning the new code set
now
 Too late. Now is time to cram!!!
 They must implement an Electronic Medical Record with
ICD-10-CM
 Electronic records are not required. Paper records are still allowed.
 They must hire additional staff to handle the workload
 Potentially as there is a high probability of an increase in paperwork,
coding and billing process
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25. ICD-10-CM MYTHS
 ICD-10 is not currently used in the US
No. It has been used to classify causes of death
 ICD-10 is replacing CPT
No. CPT is the service provided ICD is the reason
plus other circumstances related to the cause
 Providers do not need to know about – PCS
Hospital services requires ICD 10 PCS coding
 CMS will change the deadline
 Dates are firm; no delays; no grace period
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26. Latest Guidance
as of Sep 24, 2015
• While diagnosis coding to the correct level of specificity is the
goal for all claims, for 12 months after ICD-10 implementation,
if a valid ICD- 10 code from the right family is submitted,
Medicare fee-for-service will process such code and not audit
Example
o Right Code:
• G43.711 (Chronic migraine without aura, intractable, with status
migrainosus).
o Right Family:
• G43.701 (Chronic migraine without aura) or
• G43.719 (Chronic migraine without aura, intractable without status
migrainosus)
Under the audit flexibilities, occurring till Oct 1, 2016, there is no need to audit
since they are all in the same family of codes.
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27. Family of Codes
• “Family of codes” is the same as the ICD-10 three-
character category.
Example: K50 Crohn’s disease
o K50.00 Crohn's disease of small intestine without
complications
o K50.012 Crohn's disease of small intestine with intestinal
obstruction
o K50.90 Crohn's disease, unspecified, without complications
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28. Reminder
Medicare review contractors will not deny
physician or other practitioner claims billed
under the Part B physician fee schedule
through either automated medical review or
complex medical record review based solely
on the specificity of the ICD-10 diagnosis code
as long as the physician/ practitioner uses a
valid code from the right family of codes.
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29. REFERENCES
http://icd10crosswords.com/whats_new.htm
CMS ICD 10, ICD-10 Planning and Assessment
Presentation
ICD-10 will be here before you know it…Are you Ready?,
Gianni Gonzalez, HealthCare Management
Solutions, LLC
A complete list of the 2016 ICD-10-CM valid codes
and code titles is posted on the CMS website at
http://www.cms.gov/Medicare/Coding/ICD10/2016-
ICD-10-CM-and-GEMs.html.
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30. Dr. Jose I Delgado
Tel 904-794-7830
DrDelgado@Tainoconsultants.c
om
www.tainoconsultants.com