ICD-10 Provider Education Antonietta Sculimbrene, MD MHA October 20 - PowerPoint PPT Presentation

ICD-10 Provider Education Antonietta Sculimbrene, MD MHA October 20 15

Avoid claims processing errors=denials or claim rejections for providers, by fostering an understanding of the process of and reasoning behind Palmetto’s development of ICD-10 LCD code sets

 Review high level differences between ICD-9 and ICD-10  Communicate principles used to convert JM LCD and article coding to ICD-10  Explain process by which providers can convey feedback regarding the updated LCD’s to Palmetto GBA

A coding improvement or apocalypse now?

WARNING! The ICD-10 code sets are not a simple update of the ICD-9 code set. The ICD-10 code sets have fundamental changes in structure and concepts that make them very different from ICD-9.

ICD-9-CM ICD-10-CM  3-5 characters in length  3-7 characters in length  Approx. 13,000 codes  Approx. 68,000 available codes  Digit 1 is alpha; digits 2  Digit 1 may be alpha and 3 are numeric; digits (E or V) or numeric; 4-6 are alpha or numeric digits 2-5 are numeric;  Has laterality (i.e. codes  Lacks laterality identifying right v. left) Approximately a 6 fold increase in the number of codes!

ICD-9-PCS ICD-10-PCS  3-4 numbers in  7 alpha numeric length digits  Approximately  Approximately 3000 codes 87,000 codes

Anatomical Laterality (or specificity) For example, if a patient is seen for treatment of a burn on the right arm , the ICD- 9 diagnosis code does not distinguish that the burn is on the right arm . If the patient is seen a few weeks later for another burn on the left arm , the same ICD-9 diagnosis code would be reported. 943.21 Blisters with epidermal loss due to burn (second degree) of forearm Additional documentation would likely be required for a claim for the treatment to explain that the burn treated at this time is a different burn from the one that was treated previously. In the ICD-10 diagnosis code set, characters in the code identify right versus left , initial encounter versus subsequent encounter, and other clinical information. T22.211A Burn of second degree of right forearm, initial encounter T22.212A Burn of second degree of left forearm, initial encounter T22.219A Burn of second degree of unspecified forearm, initial encounter T22.611A Corrosion of second degree of right forearm, initial encounter T22.612A Corrosion of second degree of left forearm, initial encounter T22.619A Corrosion of second degree of unspecified forearm, initial encounter Ok, is it a burn (thermal) or a corrosion (chemical)? And that’s just for the initial encounter!

What are the implications of laterality for Medicare LCD and Medicare edit coding? When a code subset includes complete anatomic specificity such as right leg vs. left leg or specific digits (left index finger, right ring finger)the code for leg, unspecified or finger, unspecified will not be accepted. A claim containing such a code will be denied .

EPISODES OF CARE X94.2XXA Assault by machine gun, initial encounter X94.2XXD Assault by machine gun, subsequent encounter X94.2XXS Assault by machine gun, sequelae The above examples are unlikely events. In all probability, the only time that you would survive an assault by machine gun and have a subsequent encounter or sequelae is if Mr. T were doing the shooting. In multiple seasons of the “A Team” he shot thousands of rounds and never hit anyone! Mr. T’s response…I pity the fool because…

You will learn to use ICD-10 or I’ll bust your elbow! Which leads us to: S52.021A Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture S52.022A Displaced fracture of olecranon process without intraarticular extension of left ulna, initial encounter for closed fracture S52.023A Displaced fracture of olecranon process without intraarticular extension of unspecified ulna, initial encounter for closed fracture (don’t use this one or we might have to bust your elbow)

Oh, but then it gets worse… S52.021A Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture S52.024A Nondisplaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture S52.031A Displaced fracture of olecranon process with intraarticular extension of right ulna, initial encounter for closed fracture S52.034A Nondisplaced fracture of olecranon process with intraarticular extension of right ulna, initial encounter for closed fracture BUT THIS IS ONLY THE BEGINNING…

S52.021A Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture S52.021B Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for open fracture type I or II S52.021C Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for open fracture type IIIA, IIIB, or IIIC S52.021D Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed fracture with routine healing S52.021E Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type I or II with routine healing S52.021F Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing S52.021G Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed fracture with delayed healing S52.021H Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type I or II with delayed healing S52.021J Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

AND THE BEAT GOES ON… S52.021K Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed fracture with nonunion S52.021M Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type I or II with nonunion S52.021N Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion S52.021P Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed fracture with malunion S52.021Q Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type I or II with malunion S52.021R Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S52.021S Displaced fracture of olecranon process without intraarticular extension of right ulna, sequelae

 There are several thousand new codes in ICD-10 that describe fractures.  There are more than 2000 new codes for fracture of femur alone!  This fact will have a significant impact on level of documentation required for emergency services, orthopedics, therapy services, etc.

Important Tips: Some less specific codes have been retained in the LCD’s and claims processing edits because it is acknowledged that this level of detail in documentation may take some time to achieve, but it is expected, in general, that claims be coded to the highest level of specificity possible. When the code set encompasses all standard anatomic possibilities: i.e. right eye, left eye, bilateral eyes; the code for unspecified eye has been deleted as a payable code. If you are a Cyclops, you are just out of luck, as there is no code for middle eye… For services involving physical therapy, occupational therapy, and speech-language pathology services only the “S” codes for sequelae have been retained in the payable code set. This is part of the ICD-10 coding instruction as therapy is considered a service rendered for a sequelae of a brain injury, stroke, fracture, trauma, etc. and not direct treatment for such a diagnosis. However, there may be some instances were “A” and “D” codes are appropriate.

Manage some poorly controlled diabetics for which you need frequent A1c measurements? In ICD-9 this code would pay as per the LCD: 250.42 Diabetes with renal manifestations, type II or unspecified type, uncontrolled OR 250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled In ICD-10 it’s a whole different story. You would need to code: E11.21 Type 2 diabetes mellitus with diabetic nephropathy OR E11.29 Type 2 diabetes mellitus with other diabetic kidney complication AND/OR E11.65 Type 2 diabetes mellitus with hyperglycemia