Preparing for ICD-10 What you need to know Robert Janowitz, MD Medical Director, Illinois Local Markets BCBSIL July 17, 2015 Illinois Public Health Association A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
Agenda What is ICD-10? Why does ICD-10 Matter? What is Changing? How do I get ready for ICD-10? How are we helping you prepare for ICD-10? ICD-9 ICD-10 2
What is ICD-10?
What is ICD-10? Regulatory mandate from the US Dept. of Health & Human Services beginning 2009 • Applies to all health care organizations • Implementation date postponed 3 times, most recently in 2014 due to Congressional action • Current compliance date is 10/1/2015 – all indications say this date will hold ICD is an important building block for health data Treatment • ICD works with other code sets to create information in health care • Healthcare services are defined by Revenue Settings ICD + other coding attributes Codes • Most payers like Medicare and ICD-10 BCBSIL have systems that derive Patient (1) benefits, (2) medical policies, and (3) pricing from a combination Attributes of codes, including ICD 4
What is ICD-10? Diagnoses: Procedures/Treatments: ICD-10-CM ICD-10-PCS • • Will be used by all providers For inpatient facility billing only • • Replaces ICD-9-CM Volumes 1 & 2 Replaces ICD-9-CM Volume 3 • • Distributed by CDC and CMS Distributed by CMS • • No license fees, free to use No license fees, free to use • • >5 x increase in volume of codes >8 x increase in volume of codes 71,974 codes 69,823 codes Hospitals only! You will use a fraction of these! 5
What is ICD-10? Up to seven characters – all alphanumeric ICD-10-CM Structure ICD-10-PCS Structure ICD-10-CM Structure: ICD-10-PCS Structure: ICD-10-PCS Structure: 3- to 6-position code with leading alpha (+ extension) 7-position alphanumeric code 7-position alphanumeric code 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 X X X X X X X . Root Root Root Section Section Section Approach Approach Approach Qualifier Qualifier Qualifier Operation Operation Operation Category Etiology, anatomic Body Body Body Body Body Body site, severity Device Device Device System System System System System System Part Extension Hospitals Only! 6
Why does ICD-10 Matter?
ICD-10: Why does it matter? It’s a Federal Mandate! • DHHS final rule under HIPAA – new ICD standard • Becomes effective 10/1/2015 – required for all HIPAA-covered transactions nationally • Effective date or Implementation date means date of service or date of discharge • No opting out – There are no provisions allowing opt out (e.g. paper claims, small practices, etc.) • Same implementation date for everyone: Use ICD-9* Use ICD-10* O/P and Professional - Date of service 9/30/15 or earlier O/P and Professional - Date of service 10/1/15 or later For E/R and O/P Observation – treatment starts 23:59 or For E/R and O/P Observation – treatment starts 00:00 or earlier on 9/30/15 later on 10/1/15 O/P and Professional with from-through dates that cross 10/1/15 – split the record, request, or claim For I/P Institutional – Date of Discharge 9/30/15 or earlier For I/P Institutional – Date of Discharge 10/1/15 or later Prior authorizations, referrals, orders, and prescriptions written before 10/1/15 for services to be provided on 10/1/15 and later should contain ICD-10 where ICD is required 8
ICD-10: Why does it matter? Industry Benefits of the transition to ICD-10 Makes richer data sets available Helps research and public health surveillance – information on subsets of patients can be more easily aggregated for large-scale population health analysis New payment methodologies more practical The ability to capture greater detail and differentiation in acuity/severity will make complex outcome-based and risk-adjusted payment models more mainstream Drives health systems innovation Innovations will better reflect the intensity of patient needs than is currently possible ICD-10 will provide better information to accelerate the meaningful use of health data 9
ICD-10: Why does it matter? Benefits to You More specific coding – Detail often lost with ICD-9, physicians had a hard time conveying to payers how sick their patients really are Finding a diagnosis gets easier – Physicians and coders will find it easier to look up unusual diagnoses, signs, and symptoms. New AHIMA study shows conversion costs range from $1,960 to $5,900 for small practices Avoid audits and future payment delays – Claims are often suspended for review or denied due to non-specific information, which the detail in ICD-10 can help eliminate Makes ICD-9 limitations a thing of the past – ICD-9 increasingly fragmented and contained archaic medical terminology, contributed to coding errors and delayed/inaccurate payments More meaningful management of physician patient populations – Are you currently tracking a population of diabetic or asthmatic patients in your practice? ICD- 10 will provide better information about patients’ overall health, aiding in clinical decision support 10
Let’s Hear From A Physician Champion at CMS As a practicing physician, Dr. Martinez offers his insights about the benefits of ICD-10 and four key points to help physicians with their transition to ICD-10. Link to Video – Internet connection required 02:46 min - Right click on link, select “Open H yperlink” A new browser window will open, maximize window for best viewing, click “Play” button 11
What is Changing?
ICD-10-CM New and Different Diagnoses Major Areas of Change • Abnormal Test Findings & Borderline Diagnoses • Acute Myocardial Infarction • Adverse Effects, Dosing, & Poisoning • Atherosclerosis, Angina & Hypertension • Coma • Diabetes Mellitus • Kidney Disease & Urosepsis • OB, Pregnancy, & Newborns • Oncology & Neoplasms • Orthopedics, Musculoskeletal, Injuries & Fractures • Routine Exams / Screening Tests • Vaccines / Immunizations Focus of today’s presentation 13
ICD-10-CM New and Different Diagnoses New Terminology and Concepts, some examples: • STEMI and Non- STEMI instead of “Heart Attack” or “AMI” • Underdosing and more Borderline conditions can be coded • New scales for Asthma (4 levels), Diabetes (5 levels), Coma, and other conditions • Episode of care indicators • Pregnancy coded in trimesters • Only 1 code to use for vaccinations • Routine exams split into “with” and “without findings” categories Data will behave differently, some examples: • Fewer heart attacks (coded for 4 weeks following infarct instead of 8 in ICD-9) • More cancer cases (anemia coded 2 nd in ICD-10 after cancer, ICD-9 rule was opposite) when looking at primary Dx • No V codes for rehab visits, instead this is part of the episode of care digit • Pregnancies include new code for weeks gestation • More combination codes will cause some conditions harder to locate in queries (e.g. kidney failure due to diabetes) • Abnormal test findings will appear in more records • Smokers and patients exposed to tobacco smoke will appear more often 14
ICD-10 Diagnosis Changes Asthma ICD-10 requires the following scales into documentation: Mild intermittent Mild persistent Moderate persistent Severe persistent More instructions to code tobacco use/exposure ICD-9-CM ICD-10-CM 493.22 chronic J44.1 Chronic obstructive obstructive asthma, with pulmonary disease with status asthmaticus (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus Z72.0 Tobacco use Risk Stratification – The varying degrees of asthma severity will make it easier to identify high risk populations in health care data sets; more identification of patients who smoke/exposed to tobacco smoke 15
ICD-10 Diagnosis Changes Health Status Factors & “History of” condition codes are moderately to highly impacted by the switch to ICD-10 depending on the type of encounter Health Status Factors and & “History of” codes represent a wide range of reasons for healthcare encounters for circumstances other than a current disease or injury, and can include contraindications to care ICD-9-CM ICD-10-CM Example of Often referred to as Equivalent and more Health Status Factor: Post heart surgery “V" codes, because detailed codes have most of them started been dispersed with the letter “V” throughout section “Z" V = Z 16
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