Introduction to ICD-10Introduction to ICD-10

Kyle Miller, Todd Couts

CMS ICD-10 PMO

February, 2011

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Agenda

Overview of ICD-10

CMS’ ICD-10 Program and Activities to Date

Impact on ESRD at CMS

Additional Resources

The ICD-10 Regulation

Adopts ICD-10 code sets under HIPAA ICD-10 Clinical Modification (CM)

ICD-10 Procedure Coding System (PCS)

Diagnosis ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings

Procedures ICD-10 PCS replaces ICD-9 CM procedure codes for hospital

inpatient procedures

HCPCS and CPT-4 codes remain the official procedural coding systems for outpatient reporting

Applies to all HIPAA Covered Entities and electronic interactions between those entities

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Diagnosis and Procedure Codes

Single implementation date of October 1, 2013 for all users Date of service for ambulatory and

physician reportingAmbulatory services provided on or after 10-1-2013 will use ICD-10-CM diagnosis codes

Date of discharge for inpatient settings

Inpatient discharges occurring on or after 10-1-2013 will use ICD-10-CM and ICD-10-PCS codes

No delays

No grace period

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ICD-9 Volumes 1 and 2 Diagnosis CodesICD-9 Volumes 1 and 2 Diagnosis Codes

ICD-9 Volume 3 Procedure codesICD-9 Volume 3 Procedure codes

ICD-10 Clinical Modification (CM) – DIAGNOSIS CODES

ICD-10 Clinical Modification (CM) – DIAGNOSIS CODES

ICD-10 Procedure Coding System (PCS) – INPATIENT PROCEDURE CODES

ICD-10 Procedure Coding System (PCS) – INPATIENT PROCEDURE CODES

All Settings Inpatient

Why ICD-10 Now?

ICD-9-CM code set is outdated 30 years old ICD-9-CM codes cannot reflect current medical technologies Many code chapters are full, resulting in code placement in non-

related chapters Current codes are often not descriptive enough The rest of the world is already on ICD-10

ICD-10-CM and ICD-10-PCS provides these improvements More codes, greater specificity Greater flexibility to add new codes Reflects current use of medical technology

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ICD-10 Advantages for Physicians

Ability to report (inpatient) procedures exactly as performed (OP still CPT)Ability to describe complex and atypical patients Less staff time (less expensive) claims coding due to decreased ambiguity and better organizationBetter ability of payer to match payment to work involved

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ICD-10 is Different than Other HIPAA Implementations

Original HIPAA Implementation Code set standards were already de facto standards – ICD-9,

CPT, HCPCS Significant front-end translation to insulate systems from changes Heavy IT focus

ICD-10 Implementation Much more expansive than maintenance updates to ICD-9 codes First mandated industry wide implementation of a new medical

code set Reach extends into policies, business processes, and systems Requires broad business and systems focus

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ICD-10 is No Worse Than Other HIPAA Implementations for Most Providers

Software must be updated and

Staff must be trained but

Physicians only use a small section of codes regularly and

Diagnoses and procedures are all the same, just with clearer distinctions

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Changes in ICD-10

Structural Changes Expanded field lengths (diagnosis and procedure codes) Different field formats (procedure codes)

Clinical Content Differences New taxonomy for documenting

Diseases, injuries, impairments, cause of injury (diagnosis codes)

Specific procedures done to a patient (procedure codes) ICD-10 provides greater detail in describing diagnoses and

procedures

There are many more ICD-10 codes than ICD-9-CM codes

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Diagnosis Code Changes

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Diagnosis Code Example

ICD-10 Codes Provide Greater Specificity in Some Cases ICD-9 code - Striking against or struck accidentally in sports without

subsequent fall (E917.0) 24 ICD-10-CM Detail Codes

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Nephrology Diagnosis Codes:Consistent Organization

(N00-N08) Glomerular diseases

(N00) Acute nephritic syndrome

(N01) Rapidly progressive nephritic syndrome

(N02) Recurrent and persistent hematuria

(N03) Chronic nephritic syndrome

(N04) Nephrotic syndrome

Lipoid nephrosis

(N05) Unspecified nephritic syndrome

(N06) Isolated proteinuria with specified morphological lesion

(N07) Hereditary nephropathy, not elsewhere classified

(N08) Glomerular disorders in diseases classified elsewhere

Suffixes:

.0 Minor glomerular abnormality

.1 Focal and segmental glomerular lesions

.2 Diffuse membranous glomerulonephritis

.3 Diffuse mesangial proliferative glomerulonephritis

.4 Diffuse endocapillary proliferative glomerulonephritis

.5 Diffuse mesangiocapillary glomerulonephritis

.6 Dense deposit disease

.7 Diffuse crescentic glomerulonephritis

.8 Other

.9 Unspecified

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Procedure Code Changes

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Procedure Code Example - 2 ICD-9-CM Codes Replaced by 112 ICD-10-PCS Codes

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Nephrology Procedure Codes:Better Organization

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Example: Percutaneous Pyelostomy

New0T9330Z

Current Ambiguity55.03 Percutaneous NephrostomyOR 55.12 (Unspecified) Pyelostomy

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Better ability of payer to match payment to work involved

ICD-10 and 5010

5010 is short for Version 5010 of the ACS (Accredited Standards Committee) X12 standards for electronic transactions (e.g. claim submission)

5010 is a prerequisite for ICD-10 as 4010/4010A1 transactions cannot carry ICD-10 codes

5010 also enhances diagnosis reporting Separates principal diagnosis, admitting diagnosis,

external cause of injury and reason for visit

Increases number of ICD occurrences on 837 transactions (electronic claims)

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Tools and Implementation Strategies

Tools/Files General Equivalence Mappings (GEMs)

Reference mappings to help navigate between code sets. Bi-directional translation dictionaries (9 > 10 and 10 > 9)

All codes in one set that could be used to replace a code in the other

Reimbursement Mapping (9 > 10 and 10 > 9)To provide non CMS payers a temporary mechanism for mapping records containing ICD-10 codes to “reimbursement equivalent” ICD-9 codes

One code that most closely replaces the resources/costs of the other

Implementation Strategies Upgrade

Update the impacted systems to accept, use, and send ICD-10 codes natively

CrosswalkShield the impacted systems from accepting, using, or sending ICD-10 codes natively

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Fundamental Payer ICD-10 Strategy Choices

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Fundamental Provider ICD-10 Strategy Choices

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Physician Codes in ICD-9Physician Codes in ICD-10

Office Submits in ICD-10Office Submits in ICD-10

Staff Translates ICD-9 to 10

ICD-10 DiagnosisCodes

ICD-10 ProcedureCodes

ICD-10 DiagnosisCodes

ICD-10 ProcedureCodes

ICD-10 DiagnosisCodes

ICD-10 ProcedureCodes

ICD-10 DiagnosisCodes

ICD-10 ProcedureCodes

ICD-10 DiagnosisCodes

ICD-10 ProcedureCodes

Use GEMS to find new versions of your most commonly used codes.

Adds extra work, increases errors and loses the benefits of ICD-10.

All claims MUST be submitted in ICD-10For DOS after October 1, 2013

Upgrade Crosswalk

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CMS ICD-10 Program and Activities to Date

ICD-10 Program History and Current State

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ICD-10 Program Organization

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ICD-10 Implementation Projects

Project Structure

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High Level Implementation Timeline

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Key CMS Activities

Created GEMS and Reimbursement Mapping Tools

MS-DRG Update and Associated White Paper

October 2009 FFS JAD Session

Analysis CR

Detailed planning conference calls with MACs/Fis/Carriers and Shared System Maintainers

Educational materials and calls

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Impact on ESRD at CMS

Milestones for ESRD

• QE-0: Preliminary Analysis• QE-1: Policy Decision on How Facilities Will Report Assessment Data for Patients

Whose Stay Spans the ICD-10 Implementation Date• QE-2: Mapping/Crosswalk Implementation Strategy Approach Defined• QE-3: End-to-End Testing Strategies Defined• QE-4: CMS Staff and Quality Contractors Educated and Trained • QE-5.1: Form 2728 Updated• QE-5.2: VISION Updated• QE-5.3: REMIS Updated• QE-6.1: ESRD Activities End-to-End Testing Level 1 • QE-6.2: ESRD Activities End-to-End Testing Level 2• QE-7: Transition and Implement ESRD Activities Systems• QE-8: Providers, Contractor Provider Contact Centers, and QIOs Educated on the

Increased Granularity and Use of ICD-10 Code Set • QE-9: Education and Outreach Provided to External Vendors on ICD-9 to ICD- 10

Translations • QE-10: CROWNWeb Updated

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Additional Resources

CMS Resources

ICD-10 General Information

http://www.cms.gov/ICD10

MS-DRG Conversion Report http://www.cms.gov/ICD10/Downloads/MsdrgConversion.pdf

Central Version 5010 and D.0 web page on the CMS website http://www.cms.gov/Versions5010andD0/

The CMS ICD-10 website http://www.cms.gov/icd10/ provides the latest ICD-10 information and links to resources for providers to prepare for ICD-10 implementation in a 5010 environment.

CMS Sponsored Calls web page provides current information on CMS national provider conference calls focused on the implementation of ICD-10 http://www.cms.gov/ICD10/02c_CMS_Sponsored_Calls.asp#TopOfPage. You will find copies of call materials (presentations, written and audio transcripts, etc.). 

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Additional Resources

The following organizations offer providers and others ICD-10 resources WEDI (Workgroup for Electronic Data

Interchange)

http://www.wedi.org

HIMSS (Health Information and Management Systems Society)

http://www.himss.org/icd10

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