Objectives. ICD Background. Introduction to ICD-10 and what you need to know for a Successful Transition

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1 Introduction to ICD-10 and what you need to know for a Successful Transition Sheila Goethel, RHIT, CCS Coding Consultant AHIMA ICD-10-CM/PCS Certified Trainer May 2011 Objectives Introduction of ICD Brief overview of major changes Who is impacted by the conversion What are affects of ineffective preparation How you can be instrumental within the change What s being done at local and state levels ICD Background The INTERNATIONAL CLASSIFICATION OF DISEASES is the medical classification system used in the US and world wide in the collection of information regarding disease and injury. Diagnosis and procedures are converted into CODES that have an international definition for each condition/injury Effective means to classify and retrieve diseases and operations 1

2 ICD Use ICD Codes are reported on the hospital/physician claim form Claim form data is collected and maintained nationally Insurer is able to apply the benefits Purposeful to monitor the incidence and prevalence of diseases, Basis for information retrieval for clinical and quality purposes Serve as the major basis to compile national mortality and morbidity statistics ICD-9 transition to ICD-10 US is the only industrialized nation that hasn t yet adopted the ICD-10 system ICD-9 was developed in 1979 Running out of numbers/extensions to accommodate updates Today s use focus on reimbursement, quality, & safety rather than research and retrievability HIPAA 5010 ICD-10 Implementation ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013 Single implementation date for all users ICD-9-CM claims for services prior to implementation date will continue to flow through systems for a period of time No grace period 2

3 Benefits of ICD-10 Up-to-date classification will provide: Increased coding detail and specificity Enhanced information for measuring quality, safety and efficiency Recognition of advances in medicine and technology Space to accommodate future expansion Alignment with other systems nationwide and ability to track and respond to international public health issues ICD-10 ICD-10-CM Diagnosescodes Used for hospital inpatient and outpatients Used for ALL providers MD clinics SNF Home Health Free standing clinics ICD-10-PCS Procedurecodes Used for inpatient encounters only CPT will be maintained as procedure code choice for outpatient ICD-9 vs ICD-10 ICD-9 ICD-10 # Characters # DX Codes 14,315 69,099 # Procedure Codes 3,838 71,957 Capacity for new codes Data analysis capability Limited-Newproc codes are in different system chapters Limited -Difficultto analyze due to generic or unavailable code sets Flexibility to add new codes in any category Greater specificity will improve richness of data 3

4 Differences in Structure ICD-10-PCS X X X X X X X Secti on Body syste m Root operati on Body Part Appro ach Device Exten sion General Equivalent Mappings Tool to assist with conversion of ICD-9-CM codes to ICD-10-CM codes and back to ICD-9-CM codes They are reference Mappings and not actual Crosswalks. GEMs are comprehensive translation dictionary to use to translate ICD-9-CM-based data Tracking quality Recording morbidity/mortality Calculating reimbursement Converting any ICD-9-CM based application to ICD-10-CM GEMs Uses GEMS used by anyone to convert coded data. Possible users: All payers All providers Medical researchers Informatics professionals Coding professionals to convert large data sets Software vendors to use within their own products Organizations to make mappings suit internal purposes or based on own historical data Others who use coded data 4

5 Mapping Types Forward mapping Translate existing coded data to their counterparts in the new code set Backward mapping Track newly coded data back to what they may have been in the previous code set Method used to reconcile the difference may depend purpose of mapping task (i.e. research, claims adjudication, MSDRG reimbursement, strategic planning) CMS MSDRG Conversion Project CMS illustrated use of GEMs by developing ICD-10 version of MS DRGs Stage 1 began with digestive MS-DRGs, Major Diagnostic Category (MDC 06) Yearly, we have revised codes and updated CCs and MCCs MSDRG Version 28 I-10 MS Grouper software is available TopOfPage HIPAA 5010 Effective Code modifications require EDI Version 5010 Allows expansion in fields to accommodate ICD-10-CM and ICD-10-PCS (procedure codes only used for hospital inpatients) Required by all payers Require changes to software, systems, and procedures for billing Medicare and other payers Accommodates up to 25 ICD diagnosis codes (not in current Version 4010) 5

6 Who will these changes affect External Stakeholders Vendors Payers CMS Medicaid MA Insurers Work Comp Clearinghouses Other business partners Internal Key Individuals Physicians HIM/Coding IT/IS QI UR/Case managers CFO/Finance Ancillary Nursing HIPAA 5010 and ICD-10 Preparation (1-1-12) ( ) Vendor Payer Hospital Does your license include upgrades will there be additional costs When can we test 5010 externally Maintain 5010 timelines and payer contracts When can we test internally Will ICD-10 affect our contract (are/will we paid on MSDRG) Internal readiness (forms, P/P, education, budgets) When can we test externally NEED TO BE 5010 COMPLIANT BY Are they working with GEMs to prepare for conversion Are they working with MSDRG conversions (if paid on DRG ICD-10 Education Support for dual systems When can we test for MSDRG compatibility Documentation expectations Vendor Readiness Assess readiness for Compliance January 1, 2012 Does your license include regulation updates? What are the additional cost? Training for conversion Customer Support opportunities Install upgrade and test functionality in Identify process and timeline for testing submission of data under Assure well before 1/1/2012 (suggest by September/October). All transactions must test compliant with Errata Version 5010 before being allowed into production. Modified logic to accommodate 2 sets of systems simultaneously 6

7 Payer(S) Readiness Will ICD-10 affect payer contract Schedule (external) 5010 test GEMs - Mapping protocols acknowledged System logic and edits accommodate new extensions (initial, subsequent) 2 sets of code systems for transition period MSDRG conversion Appropriate Reimbursement Hospital Readiness Ensure Vendor and Payers are ready! Maintain 5010 timelines Steering Committee to develop and maintain project schedules IT Lead HIM Lead Identify affected systems, applications and uses of ICD-9 Assess impact on work and process flow Hospital Readiness Education Hospital Staff Physicians Coders ID forms/reports that need modification ID P/P that will need modification ID impact on external reporting Core Measures, P4P, CA reporting, WHAIC Assess and Plan for the impact on coding productivity ID affect on decreased productivity will have on AR days/$ Estimate budget and resources necessary Assess documentation expectations and improvement measures 7

8 Implementation Challenges Payers Vendors ICD codes Finance Acct Recv Hospital Staff Physicians & Documentation ICD Codes are the language of healthcare and will impact virtually ALL areas of healthcare Risks or Poor Preparation Vendor Delay in creating and submitting claim Increase in claim rejection/denials Increased AR days and dollars Decreased revenues Payers Inability to apply benefits to your claim Delay in acknowledging/payment of your claim(s) Error in payment application Coders Coding Backlog Inaccurate MSDRG payment Distorted data which results in poor representation about your patient care delivery Affect Core Measure data extraction and P4P payments Publically displayed data may negatively influence potential customers TIMELINES - RECAP Following timelines for required implementation January 1, : Payers and providers begin external testing of Version 5010 for electronic claims with trading partners. Begin accepting new 5010/D.0 versions. Version 4010 claims continue to be accepted December 31, 2011: External testing of Version 5010 must be complete dual process testing to achieve Level II compliance January 1, 2012: All electronic claims must use Version 5010; Version 4010 claims no longer accepted. ICD-9-CM codes for medical diagnosis and inpatient procedures continue. October 1, 2013: Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures; CPT codes will continue to be used for outpatient services 8

9 State and Local Support WHA ICD-10 Task Force WHIMA ICD-10 Task Force (WI Health Information Management Association) RWHC ICD-10 Task Force ICD-10 Countdown. Develop an I-10 Steering Committee with give them necessary authority to make necessary changes Provide adequate tools and resources to affected positions and processes Support process(es) changes Support established deadlines 9

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