The Aftershocks of ICD-10 MAOFP Presented by Traci Cook, CPC Affiliated Medical Billing, LLC January 22, 2016 Alma | Ann Arbor | Flint | Greater Detroit | Kalamazoo | Lansing | Midland | Saginaw (866) 493-9830 | www.yeoandyeo.com Topics . The Benefits of ICD-10 . Glitches & How We Detect Them . Where Do You Go for Help for ICD-10 Related Issues? The Benefits of ICD-10 Benefits The American Health Information Management Association reported that…. “The mountain of new data that will be generated by ICD- 10 can also be mined for the greater good of public health, allowing the U.S. to track and respond to global health threats faster and compare best practices with the international community.” Benefits Replacing ICD-9-CM with ICD-10-CM provides higher quality information for measuring healthcare service, quality, safety, and efficacy. This in turn provides better data for: • Quality measurement and medical error reduction (patient safety) • Outcomes measurement • Clinical research • Clinical, financial, and administrative performance measurement • Health policy planning • Operational and strategic planning and healthcare delivery system design • Payment systems design and claims processing • Reporting on use and effects of new medical technology • Provider profiling Benefits • Refinements to current reimbursement systems, such as severity- adjusted DRG systems • Pay-for-performance programs • Public health and bioterrorism monitoring • Managing care and disease processes • Educating consumers on costs and outcomes of treatment options Benefits- Laterality . Laterality in the diagnostic codes can explain that the treatment provided is for the contralateral side. Laterality in the diagnostic codes may help to define that treatment today is not related to treatment provided in the global period. • Example: In ICD-9 Carpal Tunnel Syndrome was 3540. In ICD-10 Carpal Tunnel Syndrome is G5601 for right and G5602 for left. • If a patient is in the post-op period for Right CTS surgery and is now being treated for Left CTS, it is now obvious that current treatment is not related to previous treatment. Benefits- Combination Codes ICD-10 contains many combination codes • A combination code is a single code used to classify two diagnoses. Using a combination code will save some time- time normally needed to code a diagnosis with an associated complication or a diagnosis with an associated sign or symptom. Benefits- Combination Codes . Combination codes are available making reporting more efficient. Examples: 1. Diabetes mellitus. ICD-10 combination codes include both the diabetic manifestation as well as the diabetes itself. For example, say a physician provides a diagnostic statement of “type 1 diabetes complicated by gastroparesis.” In ICD-9, coders assign two codes 250.61 (diabetes with neurological manifestations) and 536.3 (gastroparesis). In ICD-10, one single combination code, E10.43 (Type 1 Diabetes mellitus with diabetic autonomic [poly]neuropathy), captures the entire encounter. Benefits- Combination Codes Examples Continued: 2. Conditions due to drugs, medicaments, and biological substances. ICD-10 combination codes denote whether the patient has experienced a poisoning, adverse effect, or underdosing as well as the specific substance responsible for the outcome. For example, say a patient presents with an accidental heroin overdose. In ICD-9, coders assign two codes- 965.01 (poisoning by heroin) and E850.0 (accidental poisoning by heroin). In ICD-10, one single combination code (T40.1X1A, poisoning by heroin, accidental [unintentional]) captures the entire encounter. Benefits- Combination Codes Examples Continued: 3. ICD-10 code A69.23 (arthritis due to Lyme disease). In ICD-9, coders must report both 088.81 (Lyme disease) and 711.89 (arthropathy associated other infectious and parasitic diseases) to denote this condition. Benefits- Combination Codes ICD-10 contains many combination codes 5. Acute cystitis with hematuria was coded separately in ICD-9 as 59970 and 5950 in ICD-10 it is N3001. 5. Osteoporosis unspecified with current pathological fracture of the neck of the femur was coded with two codes 73300 and 73314. In ICD-10 it is M80051D if it is the right hip and M80052D if it is the left hip, both being the subsequent encounter (D). Benefits We are encouraged to report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies. Benefits The improvements in external cause codes have important implications for the ability to rate the severity of injuries, for which ICD-9-CM was inadequate. ICD-10-CM will bring the US closer toward a universal classification of injuries, which could be used to more adequately describe the nature of the injury and its severity, both in terms of mortality risk and probability of residual impairment. Benefits External cause of injury codes are also much more detailed in ICD-10-CM than in ICD-9-CM. This coding provides a framework for systematically collecting population-based information needed to fully describe and document how and where injuries occur. The codes are important for injury surveillance and for designing, implementing, and monitoring injury prevention and control programs. Benefits Moving to the new code sets will also permit improved efficiencies and lower administrative costs due to replacement of dysfunctional classification system. This in turn allows: • Increased use of automated tools to facilitate the coding process • Decreased claims submission or claims adjudication costs • Fewer rejected and improper reimbursement claims • Greater interoperability • Decreased need for manual review of health records to meet the information needs of payers, researchers, and other data mining purposes • Decreased need for large research organization to maintain dual class classification systems • Reduced coding errors • Reduced labor costs and increased productivity • Increased ability to prevent and detect healthcare fraud and abuse Benefits The more accurate clinical terms in ICD-10 and the more specific code descriptions give reason to believe that coding error rates will eventually drop their current level under ICD-9-CM. It is anticipated that ICD-10 will likely result in fewer fraudulent and exaggerated claims, which drive up the cost of medical care and health insurance premiums for all. The National Health Care Anti-Fraud Association estimates that the financial losses due to healthcare fraud are in the tens of billions of dollars each year. Glitches & How We Detect Them . Glitches & How We Detect Them In the May 2014 issue of the AAPC Healthcare Business Monthly, Dr. David Dunn wrote about the “day after” ICD- 10 implementation. He compared ICD-10 to an earthquake- an earthquake being a geological seismic adjustment…ICD-10 is essentially an adjustment. Glitches & How We Detect Them When an earthquake happens, it is not just the area where it occurs that’s affected. There are aftershocks, spreading out like ripples on a pond from a thrown rock. In many ways, ICD-10 will have similar implications- aftershocks, adjustments and adjustments to adjustments. The aftershocks that will be the most difficult to manage are the ones that blindside us, the ones we do not anticipate. Thank you Dr. Dunn for that analogy!! Glitches Before implementing ICD-10 the healthcare industry advocates predicted that practices would face a short-term spike in delayed claims or denied claims stemming from insufficient documentation, coding errors and heightened payer scrutiny of claims. Internal Glitches Medicare has extended flexibilities regarding submission of ICD-10 codes. For the first 12 months they will relax auditing and rejecting of claims that lack specificity as long as the ICD-10 codes are in the correct “Family of codes.” Internal Glitches Michigan Medicaid (MDHHS) has not agreed to this flexibility guidance. The flexibility guidance will NOT apply to either Medicaid primary or secondary claims. Internal Glitches Blue Cross and Blue Shield of Michigan has not made any statement regarding any flexibility in coding. Internal Glitches External Causes Codes There is no national requirement for mandatory ICD-10-CM external cause code reporting. There could be a payer mandate to report these codes from Chapter 20 of the ICD-10 book. Internal Glitches If you are reporting an injury code of any kind to the Veterans Administration, you must report an external cause code or your claim will be rejected. Internal Glitches Excludes1 and Excludes2 notes Take extra notice when coding, if an Exclude note appears. Excludes 1- Means not coded here. It indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. Excludes 2: Represents not included here. An Excludes 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears it is acceptable to use both the code and the excluded code. Internal Glitches Use Caution with Preventative Visits and Lab Orders Z0189 Encounter for other specified special exam This codes has been used by labs for reporting preventative type lab services resulting in rejections, causing the patient to receive the bills. Z000 Encounter for general adult medical examination Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations. Excludes1 encounter for examination of sign or symptom- code to