Hello, and welcome to this CME/CE certified presentation,
"ICD-10: Small Practice Guide to a Smooth Transition."
I'm Dr. Joe Nichols.
I'm working on behalf of CMS as a contractor with Noblis,
the project management office contractor
responsible for implementing ICD-10.
I'm the Principal Health Data Consulting
and a Board-certified orthopedic surgeon by training,
currently involved full time
in health care information technology.
The goals of this program are
to share an understanding of ICD-10 transition
and what it means specifically for small clinical practices;
to discuss the requirements and timelines
for implementation of ICD-10,
as well as a framework for implementation;
and to describe resources and offer recommendations
that will kick-start the process and facilitate smooth process
towards conversion by the October 1, 2014, deadline.
Providers have many questions.
Many have concerns that the conversion of ICD-10
will be complicated, expensive, or time-consuming.
So let's take a look at some of those questions
that are commonly raised about ICD-10.
What is it?
Well, ICD-10 represents the current international standard
as established by the World Health Organization
for the definition of patient health conditions,
providing a highly specific picture
of each clinical encounter.
ICD-10-CM represents the U.S.-mandated standard.
So, who's affected by ICD-10?
Well, virtually everyone who works in health care
or with health care organizations,
as required by HIPAA, will be affected by ICD-10,
including payers, providers, vendors,
clearinghouses, or any other covered entities.
So if you deliver health care services in the United States
or U.S. territories, this affects you.
While there are a few exceptions of noncovered entities,
such as auto or casualty, workers' compensation
insurers that may not technically come under HIPAA,
for most of these entities,
they're going to convert to ICD-10
simply because they cannot do business
with major players in the market if they don't.
So why do we move to ICD-10?
Well, ICD-9 is now over 30 years old
and cannot support
the current state of health care information.
The rest of the world has moved to ICD-10,
and our ability to compare data internationally
is compromised if we continue to use ICD-9.
ICD-10 allows for the capture
of some key parameters of health conditions
and inpatient procedures that provide a much greater insight
into severity, risk, complexity;
complications, manifestations, sequelae;
comorbidities, etiologies, a variety of external factors;
and allow us to classify diseases and stages
in a much better way.
When does the transition occur?
Well, the compliance date for ICD-10 is October 1, 2014.
That means ICD-10 codes must be used
in claims and other transactions for services
provided on or after the October 1, 2014, deadline.
Hospital claims with dates of discharge on or after that date
must also use ICD-10 codes.
There is no grace period.
Even though we'll be using 9 and 10 codes
based on date of services,
the discharge date is a hard cutoff,
and all entities will be required
to submit ICD-10 codes for those services.
So, what about CPT as compared to ICD-10?
A common misconception is that ICD-10 will replace CPT,
and that's really not true.
CPT will continue to be used
to code outpatient services and procedures.
ICD-10-CM will be used for diagnosis only.
Inpatient procedures and services will be coded
with ICD-10 PCS.
Resources for answers --
a good place for answers is the CMS website.
There's lots of information out there.
Simply go to CMS.gov/ICD10,
and there's more than enough information
to keep you busy for a long period of time.
Resources that are tailored
to specific practice size and setting,
as well as specific questions/concerns
are also on the CMS website.
Other resources, including trade and medical associations
that may offer materials, training, and guidance
are also available, and many, if not most of them,
are for free on their websites.
Why are there so many codes?
ICD-10 represents a substantial increase in the number of codes
compared to ICD-9 --
approximately 14,000, going up to 69,000.
Historically, however, we have only used
a small percentage of these codes.
5% of the ICD-9 codes account for about 70%
of the volume submitted on claims.
Remember, just because you have a bigger dictionary
doesn't mean you have to use all the words in the dictionary.
In practice, providers may only use
a small portion of the codes,
depending on the nature of the conditions they manage.
In addition, the large number of codes in ICD-10
is related to the fact that we are using combination codes.
In other words, we combine a number of concepts
into a single code.
Over one-third of the codes are exactly the same,
except for right or left.
So, for every right side, we need to have a code,
and for every left side.
Recurring concepts occur in multiple other areas
and cause us to have an increase in the number of codes,
simply because we have to have a code that says,
for any given condition, whether it's an initial
or subsequent encounter or sequelae;
whether it's acute or chronic;
whether it's right or left;
whether it's normal healing, delayed healing,
nonunion, or malunion.
It's really these repeating concepts
that result in a significant increase in the number of codes.
However, those concepts are rather finite,
and when you really factor it down to common issues,
there isn't a substantial increase.
So how does ICD-10 better reflect
current advances in science and medicine?
Well, we are going to look at an example of that,
to look at the nature of distinctions
related to Down syndrome, as an example,
because we can now better understand,
with ICD-10 code data,
what the differences are in the different types of Down's
and how those differences might impact information that we see.
In this particular slide, what we see is
today's code for Down syndrome.
There's a single code -- Down syndrome.
When we move to ICD-10,
we've now added three additional codes.
So we have a code, Down syndrome, unspecified,
but we also have codes for trisomy 21, nonmosaicism;
trisomy 21, mosaicism;
trisomy 21, translocation.
These different aspects of Down syndrome
are really important in terms of understanding
data related to patients with Down syndrome,
and capturing that level of granularity
will certainly add to our knowledge
when we are looking at data across enterprises.
So let's look at another clinical example -- asthma.
The following simple example illustrates how ICD-10
better supports the capture of key clinical concepts,
compared with ICD-9.
In this example, the options for codes to represent a patient
presenting with an acute exacerbation of asthma
allow for a much better description
of the nature and severity of the asthmatic attack.
As we can see in this slide, if a patient presented today
with acute asthma, an acute exacerbation of asthma,
we would have this particular ICD-9 code
that states, "extrinsic asthma with acute exacerbation."
In ICD-10, however, we can capture whether this was
a mild intermittent-type asthma,
whether it was mild persistent,
whether it was a severe persistent type of asthma.
So we are able to distinguish
between the different forms and severity of asthma,
that we really couldn't do in ICD-9.
There's a lot of questions about EHR systems
and how do we verify software capabilities?
One of the questions that came in was,
"We recently made the switch
to the use of electronic health records.
Won't that facilitate the transition to ICD-10?
Isn't ICD-10 functionality built into the newest EHR system?"
And this is really a good question
to illustrate why it's important
to establish two-way conversations with your vendor,
because it's not just a matter
of whether your system will capture ICD-10.
The question is, will your system help you
define and capture the key concepts that are necessary
in order to be able to document
in a way that supports ICD-10 and proper coding?
The only real way to tell that is to actually test the system
with some common scenarios that you see
and see how well it works for you.
Another big question that comes in is,
"Why don't we just wait for ICD-11,
for the next ICD change?"
The thought is, if we just wait for ICD-11,
that we will be able to skip the ICD-10 implementation.
But ICD-11 won't be available for a very long time.
In addition, it takes us a very long time to implement
from the time it comes out.
Another question -- "Is a formal course of special training
necessary for ICD-10?"
And certainly, while special training would be very helpful
and is highly recommended,
today, the reality is that a lot of small practices
really have not had formal or certified training in ICD-9.
So the first step for your practice is really
to look at the new ICD-10 code book.
A lot of information can be gleaned from that,
simply looking at the codes that are relevant
to your particular practice,
selecting the ones that seem to make the most sense,
and then looking at how your practice would handle that.
If the process looks reasonable
when you try and walk through an implementation,
then you may not need a formal course;
however, if you find that looking at the new codes
is not working for you
and that you really need additional training,
there are plenty of training sources available.
AHIMA, AAPC, or any other coding organization
has lots of courses, either online or on site,
that can really be very helpful if you should need that.
Let's talk a minute just about general equivalency mapping.
So there are many ways you and your staff
can learn about ICD-10,
so one way you can do that is look at what's called
the general equivalency maps.
Now, these are a set of maps that have been put together
by CMS, in cooperation with 3M,
that look at how one set of 9 codes might be reflected
in a similar set of 10 codes and vice versa --
how a single 10 code might be reflected in a 9 code.
And while these tools are helpful
in understanding some of the codes in ICD-10
that may be related to codes in ICD-9,
providers are instructed to code directly into ICD-10.
In other words, we need to speak the ICD-10 language.
We need to identify, based off the documentation,
and identify the ICD-10 code as accurately as possible
that represents the patient condition,
based off the published standard and guidelines
available on the CMS website.
So, again, translation, crosswalks, mappings
are all very helpful as part of the work to understand things.
But the bottom line is, you need to pick the code in ICD-10
that most accurately represents the patient condition.
Coders have a number of options for formal training in ICD-10.
Many trade and medical associations offer courses,
and several hours of guided training can be helpful.
Those who are interested may also consider
more in-depth study of anatomy and physiology
to become more familiar with appropriate terminology.
Again, a formal course is not absolutely necessary.
Coders should begin to familiarize themselves
with ICD-10 codes
in the current and readily available ICD-10 code books
to see whether they are going to need some additional training.
Now, there's been a lot said about all these unusual
or what they call silly codes out there,
and you'll hear people talk
about these codes like "hit by a spacecraft"
or "suicide by paintball gun."
Seems kind of silly; however, those aren't new ICD-10 codes.
Those codes have been in ICD-9 for many years.
So we've had a lot of codes out there
that no one will probably ever use,
but then again, if you're working on injury cases
for NASA employees, the code "hit by a spacecraft"
might make some sense in analyzing on-the-job injuries.
So these are kind of special codes;
they seem kind of silly out of context,
but they may have some important purpose
for those in those particular areas.
The bottom line is, you won't have to use codes
that don't make sense in your practice
or don't accurately represent your patient's condition.
So the other question is,
"Are different specialties affected in different ways?"
There certainly are substantial differences
in how different specialty or clinical areas
use diagnostic codes.
The impact of coding changes may vary.
Therefore, depending on the size,
type, and specialty of a practice,
we may see substantial differences.
For example, a specialty that deals with a variety
of musculoskeletal conditions and fractures
will potentially need to select many new diagnostic codes.
In contrast, a provider who treats a patient
with hypertension or end-stage renal disease
may actually use fewer codes in ICD-10 than in ICD-9.
Codes related to musculoskeletal care
account for about 50% of the ICD-10 codes,
largely because of these recurring concepts
of right versus left, or types of fractures,
or healing levels.
Close to one-third of the codes are related to fractures alone.
The following table illustrates the differences
in numbers of codes between ICD-9 and ICD-10
for different clinical areas.
In some clinical areas, there are more codes,
and in some clinical areas, there are actually fewer codes.
So this slide shows you some of those clinical areas.
As you can see, fractures, for example,
have a substantial increase in the number of codes,
from 747 codes for fractures in ICD-9
to nearly 17,000 codes in ICD-10.
Similarly, things like poisoning and toxic effects
have had substantial increases.
There's been substantial increases
in codes related to pregnancy, for example,
because now we capture whether it's first trimester,
second trimester, or third trimester,
which multiplies a lot of the codes that we have today.
In some areas, there's been minor changes.
For example, in the area
of coding around migraine headaches,
we've added four codes.
In some other areas, we've actually found less codes.
Mood-related disorders have gone from 78 codes down to 71 codes.
Hypertensive disease is about half the number of codes,
as is end-stage renal disease and chronic respiratory failure.
So some areas have gone up, some areas have gone down.
It all depends on which clinical area you're dealing with,
as to whether you're going to see a substantial increase
or perhaps even a decrease in the number of codes.
"So how will the transition to ICD-10 affect my practice?"
Well, certainly, ICD-10 may result in some changes
to the business- and data- related process of health care.
You may need to look at different templates.
You may need to look
at different billing and reporting requirements
that may require updates.
Is your billing handling internally
or by a third-party billing service?
Where do you use ICD-9 codes?
What do you need to do to update or be able to use ICD-10?
Will your vendor confirm
that software is appropriately updated?
Payers will be updating their rules for authorization
in coverage decisions.
If you code correctly, CMS and other payers
should still pay correctly.
But again, you need to have that dialogue with your payers
to make sure that you are all on the same page.
"What other facts should I be aware of?"
As with any substantial change, there is the potential
for increased time and resources.
Take into consideration
the financial and human resource effects
potentially related to this change.
System changes, processes and software,
resource materials, superbills, templates,
other materials that you might have
for capturing information in your office.
Training -- could potentially cause increase
in training-related expenses,
but, again, this will vary by office
and by specialty and by practice type.
The most important thing to remember is,
the primary goal of good coding a patient's condition
is all about good patient data,
which is all about good patient care.
To have good patient data, we require three things --
observation of all the objective and subjective facts
relevant to the patient condition,
documentation of all the key medical concepts
relevant to the patient care currently and in the future,
and coding that includes all of the key medical concepts
supported by the coding standard and guidelines.
Without good observation of the patient,
good documentation of that observation,
and good coding, we really cannot rely on our data.
So let's talk a little bit about implementation,
or moving towards a successful transition.
First, you need to understand your current practice
and how it may be affected by ICD-10.
You need to define the task and create a checklist
that includes system readiness,
assessment of your current
clinical documentation practices,
some familiarization with the coding.
You're going to have to prioritize.
You may not be able to get everything done,
and if you can't, you want to do the most important things
or give that the highest priority.
There are plenty of resources.
You can gather and use resources from CMS
as well as a variety of other professional groups
to help give you training and understanding
of this may mean to you in terms of an implementation.
And finally, you've got to implement
and then test to make sure your implementation worked.
The key is, get started and keep moving.
So, in conclusion, you might ask yourself,
will you be able to submit claims?
Will you be able to complete medical records?
Can your EHR capture ICD-10 codes?
How will you code your claims under ICD-10?
You need to build sufficient time into your overall plan
for testing systems and coders, external partners, payers.
I would like to thank you for participating in this activity.
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