NFPRHA National Conference 2012

Preparing for ICD-10-CM: What’s the reality behind the Urban Myth ?

Dan Rode, MBA, CHPS, FHFMA Vice President, Advocacy and Policy American Health Information Management Association ICD-10-CM/PCS Preparing for ICD-10-CM: What’s the reality behind the Urban Myth ?

We are going to cover: • Terms • AHIMA • ICD History • ICD-9-CM v ICD-10-CM • The Advent of ICD-10 and the delay • Preparing for ICD-10-CM • Resources • Questions Preparing for ICD-10-CM: Terms • CAC: Computer Assisted Coding • CM: Clinical Modification (US designation) • CPT:® Common Procedure Terminology (AMA) • EHI: electronic health information • EHR: electronic health records • HIE: health information exchange • HIM: health information management [profession] • HIPAA: Health Insurance Portability and Accountability Act of 1996 • ICD: International Classification of Diseases • NPRM: Notice of Proposed Rulemaking • PCS: Procedure Coding System (US/inpatient only) • PPS: Prospective Payment System • WHO: World Health Organization Preparing for ICD-10-CM: AHIMA

• Founded in 1928 – spun off American College of Surgeons • 64,000+ members – health information managers • all segments of the healthcare industry: providers, health plans, research, public health, etc. • 40 various employers / 120 various functions • Formal education programs: (~300) community college associates to university masters graduates • 8 certifications (4 in coding) • 52 “state” associations, plus local associations • Serve as Cooperating Party (1 of 4) ICD-9-CM and ICD-10-CM/PCS – work directly with WHO-FIC • www.ahima.org Preparing for ICD-10-CM: AHIMA Principles:

The Individual

Data Data Integrity Privacy Preparing for ICD-10-CM: AHIMA Issues: • ICD-10-CM/PCS implementation and compliance • Clinical data and documentation integrity • Data Governance • Terminologies, Classifications, and Meta data • Enterprise data and legality • Confidentiality, Privacy, and Security • EHRs, HIEs, and Meaningful Use • Implementation and data flows • Real meaningful use • “Day-to-day issues” • RAC Audits and audits in general • Management issues • Coding

Preparing for ICD-10-CM: ICD HISTORY: • ~1975: ICD-9-CM developed from ICD-9 • 1979: ICD-9-CM implemented in US • ICD-9-CM, Volumes 1&2: Diseases • ICD-9-CM, Volume 3: Inpatient procedures • 1982: ICD-9-CM integrated into Medicare IP-PPS • 1990: WHO develops & adopts ICD-10 from ICD-9-CM • 1998: US prepared to implement ICD-10-CM/PCS • 1999: US adopts ICD-10 for mortality reporting • 1998-2012: US maintains but does not adopt CM/PCS • 2008: NPRM for ICD-10-CM/PCS – X12 5010 • 2009: Final rule 3/17/2009 • ANSI X12 5010 & NCPDP D.0 due 1/1/2012 • ICD-10-CM/PCS due 10/1/2013

Preparing for ICD-10-CM: ICD HISTORY (continued): • 2009: ARRA-HITECH passed in February: “Meaningful Use” Incentives • 2010 Accountable Care Act passed in March • 2005-2012: various other legislation aimed at value- based purchasing, accountable care organizations, etc. • 2012: X12 Version 5010 “delays” and “penalty extensions • 2011-2012: “hardship” complaints continue • 2012: Secretary “studies ICD-10-CM/PCS Delay • 2012: April 17: Delay NPRM Comments due 5/17 Preparing for ICD-10-CM: Dan’s Disclaimer

I am not a coder! Preparing for ICD-10-CM: 5010 v ICD-10-CM/PCS • X12 Standard (v4010) developed in 1990s • 1999 HHS adopts (v4010) for HIPAA transactions; also adopts ICD-9-CM not ICD-10-CM/PCS • 2000-2003: Version 4010 implemented • 2004: X12 adopts v5010 • 2009: HHS adopts v 5010 • 2012: v5010 not quite adopted

• Newer versions of X12 Standards can “understand” older versions – allows for some flexibility • Classification codes must have a cut-off date – can’t have two classifications of the same thing simultaneously Preparing for ICD-10-CM/PCS: Differences • ICD-10-CM • Disease diagnosis • Developed for ICD-10 plus US (CDC-NCHS) modifications (developed mainly by physicians) • All HIPAA covered entities • ? Use by other payers

• ICD-10-PCS • Procedures and devices • Developed by US (HCFA/CMS & 3-M) • Inpatient / facility only • ? Use by other payers

Preparing for ICD-10-CM: Structure Differences

ICD-9-CM ICD-10-CM • 3-5 characters • 3-7 characters • First character is • Character 1 is alpha numeric or alpha (E or V) • All letters except U • Characters 2-5 are • Characters 2-7 are alpha numeric or numeric • Always at least 3 • Always at least 3 characters characters • Use of decimal after 3 • characters Use of decimal after 3 characters Preparing for ICD-10-CM: Structure Differences

Numeric or Alpha (E or V) Numeric VXE45 X1 X4 . X0 X0

Category Etiology, anatomic site, manifestation 3 – 5 Characters Preparing for ICD-10-CM: Structure Differences

Alpha 2 - 7 Numeric or Alpha Additional (Except U) Characters MXAS X3 X2 . X0 X1 X0 XA

Added code extensions (7th Category Etiology, anatomic character) for obstetrics, injuries, and external causes site, severity of injury

3 – 7 Characters Preparing for ICD-10-CM: Structure Differences

• Alphanumeric (alpha characters are not case-sensitive)

• Addition of a 6th character

• Added 7th character for obstetrics, injuries, and external causes of injury

• Addition of dummy place holder (“x”)

• Certain diseases have been reclassified to reflect current medical knowledge

• Specificity and detail have been significantly expanded – non-specific codes are still available when detailed documentation is unavailable Preparing for ICD-10-CM: Structure Differences ICD-9-CM v ICD-10-CM Sample Codes

ICD-9-CM ICD-10-CM • 707.05 Pressure ulcer buttock • L89.111 Decubitus ulcer of right • 707.22 Pressure ulcer stage II buttock limited to breakdown of the • 707.24 Pressure ulcer stage IV skin • L89.124 Decubitus ulcer of left buttock with necrosis of bone OR • L89.121 Decubitus ulcer of left buttock limited to breakdown of the skin • L89.114 Decubitus ulcer of right buttock with necrosis of bone

Preparing for ICD-10-CM: Structure Differences ICD-9-CM Mechanical Complication of Other Vascular Device, Implant and Graft: one code (996.1)

ICD-10-CM Mechanical Complication of Other Vascular Grafts: 156 codes Type Device Episode of Care Breakdown Graft, Aorta Initial encounter Leakage Graft, Carotid artery Subsequent encounter Displacement Graft, Femoral artery Sequela (late effect of injury) Other (e.g., Obstruction) Dialysis catheter Arteriovenous fistula Arteriovenous shunt Counterpulsation balloon Infusion catheter Umbrella device Preparing for ICD-10-CM/PCS: Why?

• Needed to represent 21st Century medical knowledge, practice, and technology • Need detail for electronic health records and better care: • internal decision support • clinical interaction across point of care • support secondary uses (besides reimbursement) such as research, public health, quality measurement • evolution toward computer based terminologies • evolution toward value-based healthcare selection and reimbursement • International exchange of health data Preparing for ICD-10-CM: Who? HIPAA? Providers: • Hospitals • Physicians/Practices • Outpatient Clinics • Post-acute care providers (home health agencies, skilled nursing facilities, and so forth) • Public health clinics, HRSA, and similar facilities

Health Plans or Payers • Third party administrators

Clearinghouses /Billing Companies

Others? Preparing for ICD-10-CM: Who? HIPAA?

● Others ● Laboratories ● Free standing ancillaries ● Researchers ● Public health agencies et al. ● Data collection agencies/organizations (registries) ● Vendors ● Clearinghouses ● Business associates and partners

● Patients Preparing for ICD-10-CM/PCS: CM Only!

● Non-inpatient facilities including physician offices will only use ICD-10-CM, NOT ICD-10-PCS

● CPT® will continue to be used by Part B providers to describe procedures Preparing for ICD-10-CM: Implementation

• Systems: • EHR systems – ancillary systems (all) • Billing systems – internal or external • Business process – paper flow or other manual systems • Data warehouses or registries • Potential cross-over with “Meaningful Use” acquisitions • Interface with other systems including third parties or “trading partners” • Gap analysis • Testing with internal and external systems

Preparing for ICD-10-CM: Implementation

• People: • Information management and IT staff • Coders • Billing or other administrative staff • Clinical staff • Impacted by other HIT projects • Impacted by 3rd parties

Preparing for ICD-10-CM: Implementation

• Build a Team Representing: • Information systems staff • Coders • Billing • Clinic administration sponsor • Clinical staff represented

• Who else in your organization? Preparing for ICD-10-CM: Implementation

• Team: • What gap analysis is needed? What systems have ICD-9-CM embedded? • The more complex the system the harder the task • Computer systems v “superbills” • Status of EHR in clinic • Team review of systems with applicable staff

• How will the clinic deal with longitudinal data in records? What is needed and to what extent? • Mapping requirements?

Preparing for ICD-10-CM: Implementation

• Team: • What is the systems vendor status on ICD-10-CM? • What best fits immediate v long-term need: paper “superbill” v system? Clearinghouse? • What amount of time are needed to build the new system including gap analysis, system selection and implementation, data flow changes and coder training, training of others, etc? • Team assignments • Vendors/Consultants? Preparing for ICD-10-CM: Training /Testing

• Coder Trainer: • Size of organization? Train the trainer options. • Coder trainer – keep close to system readiness and compliance date • Consultants, AHIMA state association training, national training, on line training, etc.

• Training in ICD-10-CM • Training on the organization “system”

• Testing of data internally and with trading partners Preparing for ICD-10-CM: Delay? • Delay NPRM: April 17, 2012 Federal Register (Vol. 77; No. 74; Page 22950) • Comments Due: May 17, 2012 • Implementation should continue or if not started; start!!! • X12 HIPAA administrative transactions can handle both ICD-9-CM and ICD-10-CM – implementation is not the same as use (parallel data?) • “Interfaces take time to identify and address – the more electronic the more to address • Many payers ready to test soon (October 2012) Preparing for ICD-10-CM: Delay One Year? • Longer delays mean more expensive implementation • Overlap with Meaningful Use Incentive Requirements • Current MU-Stage 2 Certification Requirements NPRM calls for inclusion of ICD-10-CM/PCS and SNOMED-CT® terminology, plus… • Longer delay impacts federal Medicare and Medicaid programs including value-based reimbursement • Longer delay significantly increases the cost for those organizations that plan to be ready in 2013. • Longer delay leads many to shift resources elsewhere. Preparing for ICD-10-CM: Options • Options depend on the size and “electronic” status and resources in your organization • New or replacement electronic system(s) • New system and MU Incentives • How much needs to be replaced and which systems are effected? • Paper-based (right now?) – use of “superbills” • Use of clearinghouses or billing services • Others?

Whatever you do, don’t sign a contract without thinking ICD-10-CM! Preparing for ICD-10-CM: Steps

 Develop strategy and approach  Communicate !!!  Assess readiness  Inventory process and systems impact

 Plan Systems Implementation, Training and Testing  Develop metrics to document improvement  Develop budget Preparing for ICD-10-CM: Strategy and Approach

● Develop organizational strategy: ● Establish sponsors! (Who for what?) ● Establish a multi-disciplinary planning team and designate leader(s) ● Develop internal timeline, including resources required (and contacts) ● Develop organization-wide implementation plan ● Watch for HITECH-HIPAA Security Rules Preparing for ICD-10-CM: Communication

● Communication management strategies ● Minimize “fear of change” and fear from rumors ● Establish on-going communications with all affected groups ● Ensure external communication liaisons are appointed and recognized

Preparing for ICD-10-CM: Communications ● Build Awareness ● Orient key personnel ● Basic familiarity with structure, organization, and unique features of new systems (on-going) ● Provide understanding of how the new classifications fit into internal and external transitions including electronic health records, health information exchange, and health reform. ● Provide an understanding of how your strategy fits with the environment at your institution. Preparing for ICD-10-CM: Assessment and Inventory

Based on desired strategies: • Status of current systems using ICD-9-CM and ability to convert to ICD-10-CM • Status of data in data warehouse or registries • Status of IT systems development • Status of vendors, health plans or payers and other agencies with whom you must work • Resources available internal or external • Anticipated time table (including training and testing) Preparing for ICD-10-CM: Mapping

• Mapping is a tool to use between terminologies and classifications and with each other (cross walks) • General equivalence maps (GEMs) have been designed between ICD-10-CM and ICD-10-CM/PCS • Gems are not a crosswalk for coding.

ICD-9-CM GEMs Maps ICD0-10-CM via CMS/NCHS web sites Preparing for ICD-10-CM: Planning Implementation • Implementation of work process and electronic systems changes with associated guidelines, etc. • Coder training • Plenty of time to train (ICD-10-CM) and practice; but not so early as to lose effectiveness • Internal training • Web based • Community College or local AHIMA Association • Others • Training of other ICD-10-CM users • Training on use of ICD-10-CM and new internal systems Preparing for ICD-10-CM: Planning Implementation (continued) • Train lead coder to assist in implementation • Testing: • integral workflows and systems • Internal systems to each other • GEMs (?) • With external systems Preparing for ICD-10-CM: Metrics

• Develop Metrics to Document System Improvements • Internal metrics • System or workflow metrics • Coder metrics • Internal feedback systems or decision statistics • External • Testing • Data feedback – integrity • Learning measures Preparing for ICD-10-CM: Budget

• Capital improvements • New software – free or incremental cost • Potential revenue (e.g. MU Incentives) • Internal or consultant time • Internal implementation staff time on project – all player • Testing staff • Training • Improvements / Savings Preparing for ICD-10-CM: Resources

 National Center for Health Statistics – CDC ICD-10-CM www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

 Centers for Medicare and Medicaid Services ICD-10-PCS www.cms.hhs.gov/ICD10

 ICD-10 and HIPAA Federal Register Notices www.access.gpo.gov/su_docs/fedreg/a080822c.html

 CMS HIPAA Website www.cms.hhs.gov/HIPAA GenInfo

Preparing for ICD-10-CM: Resources

 AHIMA ICD-Ten Webpage www.ahima.org/icd10

 ICD Ten Newsletter (electronic) Questions?