Successful Surgical Coding and Compliance
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9/27/2015 DISCLOSURE ICD-10-CM IS HERE: Kim Pollock, RN, MBA, CPC, CMDP ARE YOU • Employee of KarenZupko & Associates, Inc., a physician practice management consulting company READY?! that helps physicians with practice management issues including improving revenue, decreasing Sponsored by: Presented by: SOHN’s 39th Annual Congress and Nursing Symposium Kim Pollock expenses, streamlining processes and reducing risk. “ORL Nursing: The New Frontier” RN, MBA, CPC, CMDP Dallas, Texas • Does not receive compensation for sales of KZA Tuesday, September 29, 2015 products or any recommended products/services. 2 CONNECT WITH US AT WWW.KARENZUPKO.COM We thought ICD-10 would be pushed back. karenzupkoandassociates @KarenZupkoAssoc [email protected] 3 4 2015_SOHN ICD–10–CM Are You Ready (KP)_092615 1 9/27/2015 WHEN TO USE WHICH CODES • Do not BILL ICD-10 Codes for a date of service prior to October 1, 2015. • Do PRECERT ICD-10 codes for a date of service October 1, 2015 and later. • Do not BILL ICD-9 codes for a date of service after September 30, 2015 (unless payer does not accept ICD-10). • ALERT: Claims cannot contain both ICD-9 codes and ICD-10 codes. • E/M inpatient care crossing September 30-October 1? Split the claims so the services prior to October 1, 2015 are billed with ICD-9 codes are on a separate claim. 5 6 WHAT IS ICD-10-CM? WHY ARE WE CHANGING? • International Classification of Diseases, 10th • ICD-9-CM is out of date and running out Revision, Clinical Modification. of space for new codes. • We are currently using ICD-9-CM. • ICD-10-CM is the international standard to • Codes are used to calculate MS-DRG payments. report and monitor disease and mortality – USA must adopt for reporting and • Compile statistics. surveillance. • Already being used in 138 countries for • ICD codes are core elements of many health mortality reporting, 99 countries for morbidity. information technology systems making the US implemented for mortality on 1/1/99. conversion to ICD-10-CM necessary to fully • Other countries use ICD-10 for reimbursement realize benefits of HIT adoption. or case mix: UK, Denmark, Finland, Iceland, ICD-10-CM Norway, Sweden, France, Australia, Belgium, IMPLEMENTATION DATE: • It’s mandated by CMS for all HIPAA-covered Germany, Canada. OCT 1, 2015 entities!! 7 8 2015_SOHN ICD–10–CM Are You Ready (KP)_092615 2 9/27/2015 POPULAR IN 1979… FORMAT OF ICD-9-CM VS. ICD-10-CM •9 Sony introduced the Sony Walkman costing $200. ICD-9-CM ICD-10-CM • Atari 400, one of the earliest 3-5 characters in length 3-7 characters in length home computer systems, was high tech. 1st digit may be alpha, but is usually Character 1 is alpha; character 2 is always numeric; characters 3-7 can are either • Record players were all the rage. numeric; 2nd-5th is numeric alpha or numeric • Gloria Gaynor topped the Approximately 14,000 codes Approximately 69,000 codes charts with “I Will Survive”. Limited space for adding new codes Flexible for adding new codes Lacks laterality Has laterality Sources: http://www.thepeoplehistory.com/1979.html http://en.wikipedia.org/wiki/File:WalkmanTPS-L2.jpg http://en.wikipedia.org/wiki/File:Atari-400-Comp.jpg http://en.wikipedia.org/wiki/File:Romanian_pickup1.jpg http://en.wikipedia.org/wiki/File:I_Will_Survive_Gloria_Gaynor.jpg 9 10 FORMAT OF ICD-9-CM VS. ICD-10-CM FORMAT OF ICD-9-CM VS. ICD-10-CM Major Differences between ICD-9-CM and ICD-10-CM ICD-9-CM Code Structure ICD-10-CM Code Structure • Laterality (right, left, bilateral) for many diagnoses • Combination codes for certain conditions, common associated symptoms, poisonings and associated external cause • Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character). • Inclusion of clinical concepts that did not exist in ICD-9-CM. • Codes expanded (e.g., injuries, postoperative complications). • Injuries grouped by anatomical site rather than type of injury. 11 12 2015_SOHN ICD–10–CM Are You Ready (KP)_092615 3 9/27/2015 ICD-10: 3 VOLUMES PLACEHOLDER “X” 13 ICD-10 has Three Volumes (but two types of codes) “X” placeholder is used I: Tabular List of ICD-10-CM is a structured list of codes divided to provide room for into chapters based on body system or condition. future expansion II: Alphabetic Index of ICD-10-CM is an alphabetical list of terms and their corresponding code. This volume is actually listed first in the book. “X” placeholder is used to keep III. Procedures (ICD-10-PCS) applicable 7th character in the 7th • Physicians will not use this code set for professional claims; hospitals and facilities use these codes to describe position when the code is less than procedures performed. 6 characters long. 13 14 PLACEHOLDER “X” FOR FUTURE PLACEHOLDER “X” EXPANSION 15 • H66.3X- Other chronic suppurative otitis media “X” placeholder is used to provide room for future o H66.3X1 Right ear expansion. o H66.3X2 Left ear o H66.3X3 Bilateral o H66.3X9 Unspecified ear “X” placeholder is used to keep applicable 7th character in the 7th position when the code is less than 6 characters long. 15 16 2015_SOHN ICD–10–CM Are You Ready (KP)_092615 4 9/27/2015 7TH CHARACTER EXTENSION AND 7TH CHARACTER EXTENSION AND “X” PLACEHOLDER “X” PLACEHOLDER The Tabular List will note how many characters are required for a code to be Some codes require a 7th character to be added valid. √ 7th T17.220 Food in pharynx causing asphyxiation for a complete, valid code. When seeing this √ 7th character notation, the applicable seventh character options will be at the code category level and must be appended to report a valid code. Remember not all codes are seven characters. Seventh character extensions are not the same for all code categories as There are valid three, four, five and six character codes. noted by the two examples below. T17 Foreign Body In Respiratory Tract Pertinent codes for otolaryngology that require a seventh The appropriate 7th character is to be added to each code from category T17. character mainly fall into injury categories including: A = initial encounter D = subsequent encounter open wounds, fractures, foreign bodies and certain S = sequela complications. T17.220A Food in pharynx causing asphyxiation, initial encounter 17 18 7TH CHARACTER EXTENSION AND 7TH CHARACTER EXTENSION AND “X” PLACEHOLDER “X” PLACEHOLDER However, fractures (S02.-) have 6 options for the 7th The 7th character must always be the 7th character in the character. data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty S02 Fracture of Skull and Facial Bones characters. T16 Foreign Body in Ear The appropriate 7th character is to be added to each code from category S02. The appropriate 7th character is to be added to each code from category T16. A = initial encounter for closed fracture A = initial encounter B = initial encounter for open fracture D = subsequent encounter D = subsequent encounter for fracture with routine healing S = sequela G = subsequent encounter for fracture with delayed healing √ x 7th T16.1 Foreign body in right ear K = subsequent encounter for fracture with nonunion S = sequela Incorrect code assignment: T16.1A Correct code assignment: T16.1XXA 19 20 2015_SOHN ICD–10–CM Are You Ready (KP)_092615 5 9/27/2015 7TH CHARACTER EXTENSION: 7TH CHARACTER DEFINITIONS INITIAL-SUBSEQUENT-SEQUELA • The healing process guides the extension Initial Encounter = A, B selection, not chronology of the visits. The 7th character for an initial encounter is used • While the patient may be seen by a new or while the patient is receiving active treatment for the condition. different provider over the course of treatment for an injury, assignment of the 7th character is Examples include: Surgical treatment, emergency department encounter, and evaluation based on whether the patient is undergoing and continuing treatment by the same or active treatment and not whether the provider a different physician. This extension is is seeing the patient for the first time. used when the patient is receiving active treatment for the condition. 21 22 7TH CHARACTER DEFINITIONS 7TH CHARACTER DEFINITIONS Subsequent Encounter = D, G, K Sequela = S The 7th character for a subsequent encounter, is used for • ICD-10-CM no longer has late effect codes. encounters after the patient has received active treatment • To indicate a condition is the result of a previous injury, the 7th of the condition and is receiving routine care for the character extension “S” is used on the active injury code. A code for condition during the healing or recovery phase. the current condition is also used. • The 7th character “S” sequela is used when there is a residual effect Examples include: Cast change or removal, an x-ray to check (condition produced) after the acute phase of an illness or injury has healing status of fracture, removal of external or terminated. internal fixation device, medication adjustment, • There is no time limit on when a sequela code can be used. other aftercare and follow up visits following treatment of the injury. Examples include: Scar formation resulting from a burn, deviated septum due to a nasal fracture, Subsequent encounter does not equal established patient (E/M code 9921x). and infertility due to tubal occlusion from old tuberculosis 23 24 2015_SOHN ICD–10–CM Are You Ready (KP)_092615 6 9/27/2015 OTHER CODING CONVENTIONS AND 7TH CHARACTER DEFINITIONS GUIDELINES Sequela = S “Other” Codes “Other” and “other specified” are used when the medical record gives Example: Scar resulting from a previous laceration.