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