Updated video, 26min w/o Q&A posted Jan 14, 2014 - click here to view on YouTube.
Published on Oct 31, 2013
Are you ready to transition to ICD-10 on October 1, 2014? During the August 22, 2013 MLN Connects National Provider Call, Sue Bowman from the American Health Information Management Association (AHIMA) gives a keynote presentation on ICD-10 basics.
0:13 Leah Nguyen: Welcome to this video slideshow presentation from the 0:16 ICD-10 Basics MLN Connects National Provider Call. This educational call 0:18 was hosted by the CMS Provider Communications Group within the Center 0:21 for Medicare on Thursday, August 22, 2012. 0:23 I am Leah Nguyen from the Provider Communications Group here at CMS, and 0:30 I am your moderator today. I would like to welcome you to this MLN 0:35 Connects National Provider Call on ICD-10 Basics. MLN Connects Calls are 0:39 part of the Medicare Learning Network. 0:41 Are you ready to transition to ICD-10 on October 1st, 2014? Thank you 0:46 for joining us today for a keynote presentation on ICD-10 basics by Sue 0:51 Bowman from the American Health Information Management Association, or 0:55 AHIMA, along with an implementation update by CMS. A question-and-answer 1:00 session will follow the presentation. At this time, I would like to turn 1:05 the call over to Pat Brooks from the Hospital and Ambulatory Policy 1:08 Group of the Center for Medicare for an ICD-10 update. 1:13 Pat Brooks: Thank you, Leah. 1:14 I would like to begin with slide 6, where we're going to discuss ICD-10 1:18 implementation. It's now a little over a year from when we will 1:23 implement ICD-10. October 1st, 2014, is the compliance date for the 1:28 implementation of ICD-10-CM for diagnoses and ICD10PCS for procedures. 1:36 There will be no more delays. 1:38 Those who have been postponing ICD-10 implementation planning thinking 1:43 there might be additional delays should really begin to plan 1:46 implementation now. There will be no more delays to the ICD-10 1:51 implementation date. 1:54 ICD-10-CM, the diagnosis, will be used by all providers in every health 2:00 care setting. We've asked Sue Bowman of AHIMA to give an overview of 2:05 this system since it is so important to all users. 2:09 After the teleconference, I would urge all of you to either go to a 2014 2:14 ICD-10-CM code book or you can look at our electronic files on the CMS 2:19 website and start using both the index and the tabular system to code a 2:25 few common diagnoses that you have in your systems. 2:29 ICD-10-PCS procedures will be used only for hospital claims and for 2:36 inpatient hospital procedures. ICD-10-PCS will not be used on physician 2:42 claims, even those for physician claims for inpatient visits. 2:46 I'll let you know that the last update to ICD-9-CM will occur on October 2:52 1st, 2013. There will be no other updates to ICD-9-CM because we are 2:59 moving to ICD-10. 3:02 Moving on to slide 7, we'll discuss the actual implementation date of 3:07 October 1st, 2014. This will be determined by the date of service for 3:13 ambulatory and physician reporting, and that is the ambulatory and 3:17 physician services provided on or after October 1st, 2014, you'll use 3:24 ICD-10-CM diagnosis codes. 3:27 For the date of discharge for hospital claims, that will be determined 3:33 when you will use ICD-10. So for inpatient discharges occurring on or 3:39 after October 1st, 2014, you will use ICD-10-CM and ICD-10-PCS codes. 3:48 On slide 8, you will see that there will be no impact on CPT or HCPCS 3:55 codes. Physicians and ambulatory services will continue to use both CPT 4:01 and HCPCS. 4:02 On slide 8, we discuss some ICD-10 MS-DRG updates. We now have posted on 4:11 our CMS website version 30 of the ICD-10 MS-DRGs. And that's the version 4:19 that mimics the ICD-9 version of the MS-DRGs currently used by 4:24 hospitals. 4:26 We have the definitions manual posted in both text and HTML versions. We 4:32 also have a document that shows changes made between version 29 and 4:37 version 30 of the ICD10 MS-DRGs. We also have the definitions of the 4:42 Medicare code edits. 4:45 The final fiscal year 2015 ICD-10 MS-DRGs version 32 will be subject to 4:53 formal rule making. 4:55 On slide 10, we show that we have available for order both the mainframe 5:01 and PC versions of the software for version 30 of the ICD-10 MS-DRG, and 5:08 we're making that available through NTIS, through the links we show on 5:13 slide 10. 5:15 On slide 11, we begin to share some MLN resources. At the top of slide 5:22 11, you'll see some MLN Matters articles that will be of great interest 5:26 to you if you have not seen them before some on the ICD-10 5:30 implementation, the partial code freeze, and what to do with claims that 5:35 span the implementation period. 5:39 At the bottom of slide 11, you'll see some links to four factsheets that 5:44 have been updated recently that cover important information about 5:49 ICD-10. You can go to these factsheets, print them out, and use them to 5:54 train others in your organization about ICD-10. 5:58 On slide 12, we provide information on how you can sign up for an ICD-10 6:04 Industry Email Update so that you'll get periodic information about 6:08 happenings with ICD-10 and help you prepare for ICD-10. 6:12 At the bottom of slide 12 is a link to the CMS-sponsored ICD-10 6:19 teleconferences like the one we're having today. You can go listen to 6:23 prior teleconferences and get important information if you've missed 6:27 some of these, and you can get information about future ones that are 6:30 planned, through that website. 6:35 On slide 13, we give a couple more important websites, the Medicare 6:40 Fee-for-Service Provider Resources and the Provider Resources. 6:45 At the bottom of slide 13, we give a link to the ICD-9-CM Coordination 6:51 and Maintenance Committee. This is the committee that discusses updates 6:55 to both the ICD-9 and ICD10 coding system. The next meeting of this 7:01 committee will be on September 18th through 19th, 2013, about a month 7:08 away, and we will be live streaming this committee meeting if you care 7:12 to listen to it over the Internet through your office or at home. This 7:18 committee will be renamed the ICD-10 Coordination and Maintenance 7:22 Committee beginning with our March 2014 meeting, because, as I stated 7:27 earlier, we're not going to be updating ICD9CM any more. And just 7:32 information to let you know that by listening to these Coordination and 7:36 Maintenance Committee, you can get free CEUs for some organizations, 7:40 such as through AHIMA. 7:41 The bottom of slide 14 shows two organizations that agreed to share 7:49 ICD-10 resources. If you're looking for some special software or 7:54 educational material or additional resources, you can look at these two 7:58 organizations' websites to see what's available. 8:01 And with that, I'll turn it over to Leah. 8:05 At this time, I would like to introduce our keynote speaker, Sue Bowman, 8:09 Senior Director of Coding Policy and Compliance, from AHIMA. Sue Bowman: 8:14 Thank you, Leah. 8:18 On slides 16 and 17, I've listed some of the benefits of ICD-10-CM. I'm 8:22 not going to read these all to you, but the important point to remember 8:28 that as you all prepare for the transition to ICD-10, keep in mind that 8:32 coding isn't just for reimbursement. And even within the realm of 8:37 reimbursement, future reimbursement models are likely to be quite 8:41 different from today's reimbursement systems and even more dependent on 8:47 health care data. 8:48 Current and emerging initiatives aimed at promoting value in health care 8:53 really can't be successful without good health care data. And a more 8:58 modern code set, like we're moving to with ICD-10, will permit a level 9:02 of precision that hasn't been possible in the past, enabling more 9:06 meaningful data and analytics and greater health intelligence. So on 9:13 slide 18, we will talk about the difference in the structure between 9:20 ICD-9 and ICD10. I won't go over the structure of ICD-9; I'm sure 9:25 you're all pretty familiar with that. 9:26 But ICD-10-CM has three to seven characters, and I'll go into more 9:31 detail on some of those later. The first character is alpha, and all of 9:37 the letters of the alphabet are used except for the letter U. The second 9:42 character is numeric, and characters three through seven can be either 9:46 alpha or numeric. There's a decimal after the third character, which is 9:52 the same as in ICD-9 today. 9:55 And it's important to keep in mind that the alpha characters are not 9:59 case sensitive. So what does that mean? If you see the example in the 10:04 parenthetical on slide 18, you'll see that the leading letter S and the 10:10 seventh character A can appear either as an uppercase or a lowercase 10:15 letter without affecting the code, and both ways of displaying the code 10:21 are valid. 10:24 On slide 19, we're going to talk a little bit about some of the 10:28 similarities to ICD9CM, and there's quite a few similarities. In the 10:34 tabular list, which is the list of code numbers, it's still a 10:38 chronological list of codes divided into chapters based on body system 10:42 or condition. It has the same hierarchical structure like ICD-9-CM has, 10:48 and most of the chapters are structured similarly to ICD-9-CM, with a 10:53 few exceptions. A few chapters have gone under some restructuring, and 10:57 the sense organs, the eye and ear, have been separated from the nervous 11:01 system chapter and moved to their own chapters. 11:05 On slide 20, the index is still an alphabetical list of terms with their 11:11 corresponding codes. Indented sub-terms appear under the main terms, and 11:17 for those of you who are coders, you'll understand what that means. And 11:22 the index is structured similarly to ICD9CM, with an alphabetic index 11:26 of diseases and injuries, an alphabetic index of external causes, a 11:30 table of neoplasms, and a table of drugs and chemicals. 11:36 On slide 21, many of the conventions used in ICD-9-CM are also used in 11:42 ICD10CM and have the same meanings. Some of the all the abbreviations, 11:48 punctuations, symbols, many of the notes, such as "code first" and "use 11:52 additional code" notes, are also used in ICD10CM and have the same 11:58 meaning. 11:59 Nonspecific codes or "unspecified" or "not otherwise specified" codes, 12:05 as they're called are still available to use when detailed documentation 12:09 to support more specific codes is not available. And we'll talk a little 12:13 bit more about that later. 12:16 And codes are looked up the same way. You still look up the diagnostic 12:19 term in the alphabetic index and then verify the code number in the 12:23 tabular list. And a little bit later, we'll walk through a few examples 12:28 to show how a code would be looked up in ICD10CM and then verified in 12:33 the tabular. 12:37 The codes are invalid if they're missing an applicable character, just 12:41 like they would be in ICD-9-CM. And there is a set of official 12:46 guidelines for coding and reporting for ICD10CM that's very similar to 12:51 ICD-9 with just some additional sections to address some of the 12:55 differences in ICD-10-CM. And on slide 22, there is a link to where you 13:01 can find those official coding guidelines. And just with as with ICD-9, 13:07 adherence to the official coding guidelines is required under HIPAA. 13:15 But, of course, there are some differences from ICD-9-CM, or there 13:19 wouldn't be much point in making the switch to a new coding system. So 13:23 on slide 23, we're going to start talking about some of the differences. 13:29 The biggest difference is the level of detail and specificity. For those 13:34 of you who have taken a look at ICD-10-CM, you know what I'm talking 13:37 about. There's a lot more detail, a lot more specificity. Laterality, 13:42 meaning the side of the body that's affected, has been added to relevant 13:47 codes. And there's a lot of combination codes to capture certain 13:53 conditions and their associated common symptoms or manifestations. 13:58 There's also some combination codes for poisonings and their associated 14:03 external cause. 14:06 On slide 24, one change in the ICD-10-CM system is that injuries are 14:12 grouped by anatomical site rather than the type of injury. And what do I 14:18 mean by that? Well, in ICD9CM, injuries are grouped by fractures, 14:22 dislocations, sprains and strains, and then within those categories, 14:26 they are grouped by anatomical site. 14:29 In ICD-10-CM, it starts off with structure by anatomical site, like 14:35 injuries to the head, injuries to the neck, thorax, and so forth. And 14:39 within those sections, it breaks it down by the type of injury to that 14:45 part of the body. 14:47 The codes in ICD-10-CM better reflect modern medicine and updated 14:52 medical terminology. And it's important to keep in mind that ICD-10-CM 14:56 has not remained static since it was originally developed. It's been 15:00 continually updated since its initial development, both to reflect 15:05 changes to the World Health Organization's ICD-10, as well as in 15:09 response to requests for modifications to the Coordination and 15:13 Maintenance Committee from groups within the U.S. 15:18 On slide 25, I provided a few examples of what some of the combination 15:23 codes look like. I won't read them to you, but you can see from looking 15:27 at these some of the kind of details that are put together with common 15:32 conditions and some of the manifestations they have, such as Crohn's 15:36 disease with obstruction, and diabetes with the relevant diabetic 15:42 manifestations. 15:45 On slide 26, one of the big changes in ICD-10-CM is the addition of a 15:52 seventh character, which isn't used in certain isn't used in every 15:56 chapter. It's used in certain chapters, including OB, injury, 16:00 musculoskeletal, and the external cause chapters. And it has a different 16:05 meaning depending on the section where it's being used. So within a 16:09 particular section, the meaning will be consistent, but across all of 16:14 the sections where it's used, the meaning will be different. It always 16:19 has to be used in the seventh character position. And when the seventh 16:24 character applies to a code, any code missing that seventh character is 16:29 considered an invalid code. 16:31 So on slide 27, here is a description of what some of the seventh 16:38 characters are used for. A very common use is to describe the type of 16:42 encounter. An initial encounter seventh character is when the patient is 16:49 continuing to receive active treatment for the condition. So, encounters 16:53 for things like surgical treatment, the emergency department encounter 16:58 after the injury occurred, going to see a new physician for evaluation 17:03 of the injury, such as primary care physician sending the patient to an 17:08 orthopedic specialist that is an example of how the initial encounter 17:12 would be used. 17:14 The subsequent encounter does not refer to a repeat incidence of the 17:18 same injury. It refers to the same injury as the initial encounter, but 17:24 it's referring to encounters after the patient has gotten the active 17:30 treatment and is now just continuing to receive routine care during the 17:34 healing or recovery phase. So, examples that I've listed there include 17:40 coming back for a cast change or removal, or removal of external or 17:44 internal fixation device, or after care. You know, we have we different 17:50 aftercare V-codes in ICD-9. In ICD-10-CM, if you return for after care of 17:59 an injury, you use the acute injury code with the seventh character 18:04 indicating subsequent encounter. So, that would be a very common use of 18:09 the seventh character for the subsequent encounter. 18:12 Sequela refers to complications or conditions that arise as a direct 18:18 result of a condition. And an example of that would be scar formation. 18:25 On slide 28 is an example of some of the seventh characters for 18:31 fractures. And you can see it breaks it down by the initial, subsequent, 18:35 and sequela that I just talked about. But it also has further division 18:40 to identify the open or closed fracture, and then fractures with routine 18:45 or delayed healing, or nonunion or malunion. 18:53 On slide 29, another new feature in ICD-10-CM is a dummy placeholder X, 19:01 which is used in certain codes to allow for future expansion of those 19:05 codes. And it's also used to fill out empty characters when a code 19:10 containing fewer than six characters has a seventh character applicable 19:16 to that code. So, as I mentioned earlier, the seventh character always 19:20 has to be in the seventh character position. So, if a particular code is 19:24 not six characters long, then you have to use the placeholder X to fill 19:30 up the empty spots in order for the seventh character to appear in the 19:34 seventh character position. And I'll give a couple of examples of that 19:39 later on. Some code book publishers are displaying the placeholder X in 19:45 the codes that require them in their code books so that you don't forget 19:49 to include it as part of the reported code. 19:53 Just like the other alpha characters in ICD-10-CM, the placeholder X is 19:59 not case-sensitive. So, it can be displayed as a lowercase or uppercase 20:06 X and it's still perfectly valid. And that's what we're showing on slide 20:11 30. 20:13 On slide 31, another new feature of ICD-10-CM is the distinction between 20:20 two different types of excludes notes. An excludes1 note means that the 20:26 code identified in the note and the code where the note appears cannot 20:30 be reported together because the two conditions can are mutually 20:33 exclusive and cannot occur together. 20:37 So, for in this example, for the same patient wouldn't have both type 1 20:42 and type2 diabetes. It would be one or the other. So under the category 20:47 for type 1 diabetes, there is an excludes1 note indicating that type 2 20:53 diabetes would not be coded here, and the two codes would not be 20:58 reported together. 21:01 The other type of excludes note is an excludes2 note, which appears on 21:05 slide 32. And that indicates that the condition identified in the note 21:10 is not part of the condition represented by the code where the note 21:14 appears. So both codes may be reported together if the patient has both 21:19 conditions. 21:21 So, the example here would be under the category for a pressure ulcer. A 21:25 patient could have a pressure ulcer and also other kinds of ulcers, such 21:30 as a diabetic ulcer or a varicose ulcer. So this is saying the pressure 21:35 ulcers don't pressure ulcer codes don't include these other kinds of 21:40 ulcers. If the patient also has these other type of ulcers, they should 21:45 be separately coded with different codes. 21:48 So this distinction between excludes1 and excludes2 notes is an 21:52 extremely helpful new feature in ICD-10-CM. ICD-9-CM doesn't have this 21:58 distinction, which has led to a lot of confusion and questions being 22:03 raised over the years as to the meaning of some of the excludes notes in 22:08 ICD-9, because an excludes note in ICD-9 could have either one of these 22:13 two meanings, and you don't know which it is because they are not 22:16 identified with this excludes1 and excludes2 distinction. So this is a 22:21 really great feature in ICD10. On slide 33, I've just provided you with 22:28 some examples of some of the expanded specificity that appears in the 22:34 ICD-10-CM codes so you have a flavor for what some of these codes look 22:39 like. 22:42 And on slide 34, I've provided some examples of the addition of 22:48 laterality to the codes to show the kinds of codes where that attribute 22:53 features in. Now, on slide 35 we're going to walk through a few coding 23:00 examples so that you can see the process of how you code in ICD-10-CM 23:07 and see how similar the process is to ICD9, even if the code you arrive 23:12 at is different than it would be in ICD-9. And I know not all of you are 23:17 coders, but this will give you a general idea of what the process is and 23:21 what's involved. 23:22 So, the first one is type 1 diabetes with diabetic nephropathy. Well, 23:28 you would look up the main term of "Diabetes" in the alphabetic index, 23:32 look at the indented entries underneath to see which one applies to your 23:37 particular situation that you're trying to code, and you will see "type 23:41 1" listed there with an indented term for "with nephropathy." 23:46 So then you would go to E10, and then E10.21, as mentioned in the index. 23:54 And the tabular part is shown on slide 36. And you will see that E10.21 23:59 is the code for type1 diabetes with diabetic nephropathy. 24:08 On slide 37, the diagnosis of acute cystitis with hematuria. So, you 24:15 would look up the main term of "Cystitis" in the alphabetic index, then 24:19 the indented entry for "acute" and then "with hematuria." And you'll see 24:24 N30.01 listed. 24:27 Note the default. And we will talk a little bit more about defaults a 24:31 little later. But, if you didn't know there wasif there was hematuria 24:34 or not, you can see the default takes you to N30.00, which I'll show you 24:41 in a second, is the code for without hematuria. So, it's important to 24:46 know that the classification does sometimes use these defaults when you 24:52 don't have the specific information to get you to the more specific 24:57 code. 24:58 So now you go to the N30 section of the tabular, and you find N30 and 25:04 then N30.01 (it's index-directed), and see that acute cystitis with 25:10 hematuria is correctly coded N30.01. Notice the "use additional code" 25:16 note under the category N30, indicating that you would use an additional 25:21 code to identify the infectious agent. So, if you knew the infectious 25:24 agent, you would code that as well. 25:29 On slide 39excuse me is an example for chronic obstructive pulmonary 25:34 disease. You would look up "Disease, pulmonary, chronic obstructive." 25:39 You'll see J44.9 listed. If you go to the tabular, look under the 25:45 category of J44and what's listed on J44 is split between slides 40 and 25:54 41. And then youon slide 41, you'll see that J44.9 is the code for 26:01 chronic obstructive lung disease not otherwise specified. 26:09 On slide 42, let's look at an injury example fracture of proximal third 26:16 of scaphoid bone, left wrist, initial encounter. So, look up the term in 26:22 the alphabetic index of "Fracture, scaphoid." It says to see also 26:27 "Fracture, carpal, navicular" because that's another term for the 26:31 scaphoid bone. So, then you look up "Fracture, carpal bone, navicular." 26:37 You'll see "proximal third, S62.03" listed. 26:43 And one point I'd like to make before we go any further on this 26:47 particular slide is, notice in the diagnosis, I did say "initial 26:51 encounter." Now, you might be wondering, does the physician have to 26:55 specifically document initial encounter in order for us to be coding 27:01 this particular diagnosis that way? And the answer is no. You would be 27:05 able to tell from the description of the patient's history whether this 27:09 is a new fracture presenting for initial evaluation and treatment, or 27:13 whether the encounter is for ongoing care of a previously treated 27:16 fracture. So the coder would use that information to determine whether 27:21 it should be coded as an initial encounter or a subsequent encounter 27:25 without the physician having to specifically state that. 27:31 So now we move on to S62 in the tabular to take a look at that. And you 27:37 will see two notes listed under S62. One says, "A fracture not indicated 27:43 as displaced or nondisplaced should be coded to displaced," and "A 27:48 fracture not indicated as open or closed should be coded to closed." And 27:52 you will notice in our diagnostic description, we did not it was not 27:57 specified whether it was displaced or nondisplaced or open or closed. 28:03 So, this provides you direction of how that should be coded in the 28:07 absence of that information. 28:11 And we also need to apply the appropriate seventh character, as shown on 28:15 slide 44. And we already know it's an initial encounter. It didn't say 28:21 open or closed, but we have the note that we just read that said that if 28:25 it's not specified as open or closed, it should be coded to closed. 28:31 So then, on the next slide the next two slides, slides 45 and 46, it 28:37 shows what the listing of codes look like under S62. And so the correct 28:47 code assignment for this diagnosis would be S62.032A, to indicate that 28:56 it's a displaced fracture because of our note that said if it doesn't 29:00 specify displaced or nondisplaced, you code as displaced. It's the 29:04 proximal third of the scaphoid bone of the left wrist, and the A is 29:11 showing that it's an initial encounter for a closed fracture. 29:15 So that was a little bit more complicated one. But you could still see 29:20 that the index entries and the instructional notes under the code number 29:25 guided you to the correct code. 29:29 So for our last example for this section, we'll take a look at a mental 29:34 health diagnosis of anxiety reaction. So, you will look up the main term 29:38 "Anxiety"and these terms on slide 47 should actually be a little bit 29:45 indented under Anxietyand you scroll down and you see "Anxiety 29:49 reaction," which is the diagnosis that you're coding, F41.1. So you go 29:56 to the tabular list and see that F41.1 is indeed the correct diagnosis, 30:04 because "Anxiety reaction" is listed as an inclusion term. All right. On 30:14 the next slide, slide 49, we're going to talk for a minute about the use 30:23 of unspecified codes. 30:25 The four cooperating parties responsible for the official ICD-10-CM 30:29 coding guidelinesCMS, the American Hospital Association, the American 30:34 Health Information Management Association, and the National Center for 30:38 Health Statistics recently approved a statement explaining the 30:43 appropriate use of unspecified codes, because there's been some 30:47 misinformation out there about if these will be allowed under ICD-10. 30:53 This official statement is available on all four of our organizations' 30:57 websites. 30:58 But basically, in the next couple of slides, I've highlighted the key 31:02 points here, which is that each health encounter should be coded to the 31:06 level of certainty known for that encounter. Unspecified codes, frankly, 31:13 should need to be selected less often due to a greater number of code 31:17 choices in ICD-10-CM. And that seems maybe a little counterintuitive, 31:21 but when you match up the documentation in the record with the more 31:27 specific code choices in ICD-10-CM, you may find that you actually don't 31:31 even need the unspecified codes that often. 31:34 But unspecified codes should be reported when they most accurately 31:38 reflect what is known about the patient's condition at the time of the 31:42 particular encounter. When sufficient clinical information isn't known 31:48 or available about a particular health condition to assign a more 31:52 specific code, it's totally acceptable to report the appropriate 31:55 unspecified code. It would not be appropriate to select the specific 32:00 code that's not supported by the medical record documentation, or 32:04 conduct medically unnecessary diagnostic testing just in order to 32:08 determine a more specific code. 32:12 But you need to keep in mind that while unspecified codes are available 32:16 in ICD10CM, the use of these codes impacts the completeness of coded 32:20 data and should only be used when no specific code is available or a 32:24 more specific diagnosis is not yet known. And as I showed in some of the 32:29 earlier coding examples, in addition to unspecified codes, sometimes 32:34 ICD-10-CM uses defaults for some conditions, which are indicated by 32:40 index entries or inclusion terms under the codes, such as the closed and 32:46 displaced fracture example that I presented a few minutes ago. 32:50 So let's look at an unspecified a couple of unspecified code examples, 32:55 starting on slide51. Let's look at the fracture of the left wrist that 33:01 we coded earlier, but assuming that we have less information than we had 33:05 before. We still know that it's traumatic. We're going to assume here 33:12 that it's traumatic, that we know that it's the initial encounter. But 33:15 we don't know the specific bone, the scaphoid bone that we knew before. 33:19 All we know is that it's the left wrist. So, we look up the main term of 33:23 "Fracture, wrist." It says, "carpalsee Fracture, carpal bone." 33:32 Then on the next slide, slide 52, you look at S62 in the tabular. You 33:38 see those same notes about displaced and closed fractures that we had 33:43 talked about earlier. We still have to pick our appropriate seventh 33:49 character on slide 53. And then on slide 54, we see the code of S62.10, 33:59 which has an inclusion term of "Fracture of wrist not otherwise 34:02 specified." 34:03 And then we see "S62.102, Fracture of unspecified carpal bone, left 34:09 wrist" because we do know it's the left wrist. And we would add the 34:13 seventh character of A for the initial encounter for closed fracture, 34:18 because, again, if you don't know if it's open of closed, the default in 34:22 ICD-10-CM is closed. So that's an example of how you would get to the 34:28 unspecified wrist fracture code. 34:31 Another example on slide 55 is pneumonia. Look up the main term of 34:37 "Pneumonia." It shows J18.9. You go to the tabular on slide 56. It shows 34:45 "Pneumonia, unspecified organism." This is what we're trying to code, so 34:50 the code assignment would be J18.9. 34:53 Notice the "code first" note under J18 for associated influenza. There 34:59 was no mention of influenza in our diagnosis example, so we 35:03 wouldn't this note doesn't apply. We wouldn't code the influenza in this 35:07 case. But, if influenza had also been documented, per this instructional 35:13 note, it would be coded first, and then the pneumonia code. On slide 57, 35:20 we're going to talk a little bit about external causes of morbidity 35:26 coding. The four cooperating parties that I mentioned earlier approved a 35:30 statement on the external cause codes in ICD-10-CM. And just like the 35:36 statement I mentioned earlier about the use of unspecified codes, this 35:40 statement is available on all four of our websites. 35:45 There is no national requirement for mandatory ICD-10-CM external cause 35:51 code reporting. There is no national requirement for external cause 35:55 coding under ICD9CM either. Reporting of ICD-10-CM codes in the 36:01 external cause chapter is only required for providers subject to a 36:07 State-based external cause code reporting mandate or a payer 36:12 requirement. Over the years, unrelated to the transition of ICD-10-CM, 36:19 the number of States requiring external cause code reporting has grown 36:23 because of the additional valuable information these codes provide about 36:27 how and where the injury occurred. 36:30 But, unless you are required by a payer in your State or by a State data 36:36 agency to report external cause codes, and you haven't been reporting 36:41 them in the past and aren't aware of any new requirement coming down the 36:44 pike in the future, then you are not required to report them under 36:49 ICD-10-CM either. Of course, in the absence of a mandatory reporting 36:55 requirement, providers are encouraged to voluntarily report these codes 37:00 because they do provide valuable additional information. 37:04 So why is external cause information useful? Well, on slide 58, I've 37:12 explained that they provide valuable data for injury research and 37:16 evaluation of injury prevention strategies. And these codes are used at 37:21 the national, State, and local levels to identify high-risk populations, 37:26 set priorities, and plan and evaluate injury prevention programs and 37:30 policies, and are potentially useful for evaluating emergency medical 37:36 services and trauma care systems. 37:40 Improving the availability of and access to high-quality external 37:44 codedcause-coded data can benefit auto insurance companies, disability 37:49 insurers, health insurance plans, public payers, health care purchasers, 37:54 employers, businesses, labor unions, schools, and other entities who are 37:59 interested in injury prevention and safety issues. So that's the role of 38:04 these codes. 38:06 On the next slide, I provide an example of how you would assign an 38:10 external cause code in ICD-10-CM. So we have an injury sustained from 38:15 falling down ice-covered steps, initial encounters. Like other codes in 38:21 ICD-10-CM, the process of assigning an external cause code is the same 38:25 as in ICD-9-CM. 38:27 And so you would look up the main term in the external cause index, this 38:32 time, of "Fall." And then you see indented entries of "from," "stairs," 38:39 and "due to ice or snow." These on this slide, it's not really showing 38:44 the indents properly the "stairs" should be indented under the "from" 38:47 line, and then the "due to ice or snow" should be indented a little bit 38:50 under "stairs." And you will see W00.1 listed. 38:57 If you go to the next slide, verifying the code in the tabular, you'll 39:03 look up "W00 Fall due to ice and snow." It does require a seventh 39:09 character that you'll see there. And it's indicating the initial 39:13 encounter, subsequent encounter, or sequela. And then you will see 39:18 "W00.1 Fall from stairs and steps due to ice and snow." 39:22 Now, you'll notice this is only a four-character code and you need a 39:29 seventh character. So, this is an example where you would need to use 39:32 the placeholder X. So you have W00.1, and then you have XX, and then A 40:03 for the initial encounter because the seventh character must appear in 40:10 the seventh character position. 40:11 And as I mentioned earlier, some code book publishers, also encoding 40:14 vendors and others, have added these Xs to the codes in their code books 40:17 where they're applicable so you don't forget to include them. So what is 40:20 the impact of the ICD-10 transition on medical record documentation? We 40:23 keep hearing that with all this specificity, so much more documentation 40:26 is going to be needed. 40:27 Well, as the Department of Health and Human Services noted in the 2009 40:30 ICD-10 final rule, improved medical record documentation is not 40:33 predicated on the change from ICD9CM to ICD-10-CM. Rather, improved 40:35 medical record documentation is being driven by initiatives such as 40:38 quality measurement reporting, value-based purchasing, and patient 40:41 safety. And any potential improvements in medical record documentation 40:45 is really just a positive outcome of the move to ICD-10, but not 40:51 required solely for ICD-10. With better and more accurate data, patient 40:57 care can only be improved. 41:00 So on slide 61, better clinical documentation promotes better patient 41:05 care and more accurate capture of acuity and severity that can be used 41:10 for quality measures, reimbursement, severity-level profiles, risk 41:15 adjustment profiles, present on admission reporting, hospital-acquired 41:19 conditions. On slide 62, high-quality documentation can also help to 41:26 avoid misinterpretation by third parties, payers, auditors, attorneys in 41:32 legal cases, and also justify medical necessity. So there's a lot of 41:38 reasons for documentation, and the increased specificity of ICD-10 is 41:43 just one of these many reasons. 41:49 So, on slide 63, you need to start off by assessing the quality of the 41:56 medical record documentation to identify improvement opportunities. You 42:01 can't just go out there and improve documentation if you don't know 42:04 what's wrong with it today or how it needs to be improved. And you might 42:09 be pleasantly surprised to find more documentation is available to 42:13 support the increased detail in ICD-10-CM than you expect. 42:17 A lot of clinical information documented today is being lost when it's 42:22 translated to ICD9CM codes for external reporting purposes because 42:27 many of the ambiguous or broad ICD-9-CM codes don't need some of the 42:32 details contained in the documentation. So the information is buried 42:36 there in the medical record, but it's just not represented in the vague 42:41 ICD-9-CM code that's coming out of the process. 42:45 So, as you do a documentation gap analysis, on slide 64, consider a 42:53 variety of different medical record sampling techniques a random sample, 42:58 sampling by clinical specialty, looking at your top diagnoses, top 43:04 service lines, high-volume diagnoses, and diagnoses known to represent 43:09 documentation problems today, because chances are if they're problematic 43:14 today, they are not going to go away when ICD-10-CM is implemented. 43:23 On slide 65, make sure you identify documentation improvement 43:28 opportunities that could impact multiple initiatives. Don't look solely 43:32 at the ICD-10-CM codes and what documentation is needed to support them, 43:38 but how could you improve documentation for Meaningful Use, 43:43 hospital-acquired conditions, value-based purchasing, State reporting 43:49 requirements? Where else could the documentation be improved? Because if 43:54 the documentation is better overall, then it's going to support all the 43:58 different things going on, not just ICD-10. 44:03 And try to determine the best solution for addressing each documentation 44:07 gap. Don't have one solution for everything because one size doesn't fit 44:13 all. So examples of some of the approaches to improving documentation 44:18 include modifications to forms or templates to capture the information, 44:25 adding things to EHR documentation templates or having EHR documentation 44:31 prompts, further education on different topics of where more detailed 44:38 documentation is needed, and workflow or operational process changes 44:44 might be something that needs to be done. 44:47 And don't try to bite off everything at once. Prioritize. Start with the 44:52 low-hanging fruit or issues that would have the greatest impact if the 44:58 documentation was improved. 45:02 On slide 66 are a few examples of ICD-10-related details that could be 45:08 added to EHR templates, like capturing laterality, making sure the 45:14 encounter type is clear. I think initial and subsequent is going to be 45:19 pretty clear from the patient history. But it may not be so clear 45:24 whether it's a routine healing or delayed healing, and that might be 45:28 information that needs to be captured. More specific anatomic details 45:33 could be added to EHR templates; severity, such as the stages of chronic 45:39 kidney disease, and relationships among diseases could be identified 45:45 through prompts, as well. And on slide 67, plan your educational 45:54 strategy for ICD-10-CM training. Who will need education? What type and 46:00 level of education will be needed? For example, only hospital inpatient 46:05 coders are going to need to learn ICD-10-PCS. 46:10 It's estimated, probably (at least in our experience at AHIMA) 3 to 4 46:15 days for coders to learn ICD-10-CM. But this is somewhat dependent on 46:20 the individual's level of ICD9CM knowledge and what formal background 46:26 they've had in coding education or the biomedical sciences already. 46:31 Additional training may be needed to refresh or expand people's 46:35 knowledge in the biomedical sciences. 46:38 And so, you should use assessment tools to identify coders' areas of 46:43 strengths and weaknesses, and then review and refresh the knowledge of 46:49 biomedical concepts as needed based on the assessment results. So don't 46:53 just give everyone throw a remedial training at anatomy and physiology 46:58 and pathophysiology at everyone, and figure they need it and they all 47:02 need the same amount. Really assess where people's gaps are and then 47:06 focus that additional training on covering that gap. 47:12 And keep in mind that training for coders working in a medical specialty 47:17 area can focus on code sections most applicable to that specialty. 47:22 Obviously, some of the general attributes I've talked about like how the 47:26 seventh characters work, and what the different conventions mean, and 47:29 what an excludes1 note and excludes2 note is, and a placeholder that's 47:34 something everyone needs to learn. But maybe if most of their coding is 47:39 focused in a particular specialty area, you can focus most of their 47:43 training on the coding issues related to that particular specialty. 47:50 And consider how education will be delivered, when should the education 47:55 be provided. It's typically recommended that intensive coder training 48:01 should be provided about 6 to 9months prior to implementation. That 48:06 sort of depends on how many coders you have, what else the coders are 48:10 helping with the ICD-10 implementation process where they might 48:14 need training earlier in order to help with those initiatives. 48:18 But, the idea behind the 6- to 9-month timeframe is that if you train 48:24 the coders too early and then they're continuing to work in ICD-9 up 48:29 until the implementation date, they've now forgotten what they have 48:33 learned, and now you have the added cost of some additional training to 48:38 refresh them when it's time to implement ICD-10. 48:44 Coder training is available from many, many sources not even all, you 48:49 know, represented on this slide, slide 69: professional associations, 48:54 medical specialty societies, State medical societies, commercial 48:58 entities, independent consultants. And there are many, many 49:02 formats online, both self-paced and instructor led; face-to-face, both 49:08 on site at your own organization or off site; and as many price points 49:14 as there are sources and formats. So there are a lot of training choices 49:20 and options out there. So before I conclude my presentation, let's just 49:27 have a brief word about the GEMs and the reimbursement mappings. I'm on 49:32 slide 70 now. 49:34 The General Equivalence Mappings, the GEMs, are designed to aid in 49:38 converting applications and systems from ICD-9-CM to ICD-10-CM and PCS. 49:45 And the reimbursement mappings are a temporary mechanism for mapping 49:49 claims containing ICD-10 codes to reimbursement-equivalent ICD-9 codes. 49:57 But a key point I really want everyone to take away from this session 50:01 today, on slide 71 and highlight this if you've printed the handout out. 50:08 But, the maps neither the GEMs nor the reimbursement mappings should be 50:13 used to assign codes to report on claims. The GEMs and the reimbursement 50:18 mappings are not a substitute for learning how to use the ICD-10 code 50:22 sets. 50:24 Mapping is not the same as coding. Mapping links concepts in two code 50:29 sets without any consideration of the context or medical record 50:34 documentation, whereas coding involves the assignment of the most 50:38 appropriate codes based on medical record documentation and applicable 50:43 coding rules and guidelines. I also wanted to touch on just a couple of 50:50 the most common questions that we get a lot, and that I'm sure CMS gets 50:56 as well. 50:57 And on slide 72, the first one is "Since ICD-10-CM has many more codes, 51:04 is it more difficult to use than ICD-9-CM?" 51:09 Well, the analogy I like to use is to compare it to using a dictionary 51:15 or a phone book. A dictionary or a phone book has a lot of terms or 51:21 numbers in it, but it doesn't really that doesn't really make it harder 51:25 to use. And when you add more words to the dictionary or add more phone 51:30 numbers to the phone book, it doesn't add to the complexity of using 51:36 that resource. 51:37 So just under the same concept, the more detail and clinical accuracy 51:44 and specificity in ICD-10-CM really make the system easier to use than 51:50 ICD-9-CM because instead of scratching your head about which of the 51:55 vague codes with the outdated clinical terminologies the right code for 52:02 this particular clinical situation, it's much more specific, and you can 52:07 immediately tie it to the documentation of the diagnosis that you're 52:12 talking about. Because ICD-10-CM is much more specific, more clinically 52:17 accurate, and uses a more logical structure, it's actually easier to use 52:21 than ICD-9-CM. 52:22 And the alphabetic index and electronic coding tools will continue to 52:28 facilitate proper code selection. Just as you don't search the entire 52:33 list of ICD-9 codes today, the search for the proper code that's not how 52:38 you look codes up on ICD-10 either, as I showed you with the coding 52:42 examples earlier. And it's anticipated that the improved structure and 52:47 specificity of ICD-10-CM will facilitate the development of increasingly 52:52 sophisticated electronic coding tools that will assist in even faster 52:57 and easier code selection. 53:00 Another question on slide 73: "Are ICD-10-CM code books currently 53:06 available?" 53:07 And yes, they are, from a variety of different code book publishers 53:11 already have ICD10CM code books out there. And ICD-10-CM is also 53:16 available free of charge in PDF and XML formats from the National Center 53:21 for Health Statistics, with the link listed there on slide 73. 53:28 And "Where can physician practices obtain a list of ICD-10-CM codes 53:32 applicable to their particular specialty?" 53:35 I would recommend contacting your medical specialty society because I 53:41 think a lot of them have started working on that. So, if you have a 53:49 specific ICD-10-CM coding question, how would you get that answered? 53:55 Well, the American Hospital Association Central Office serves as the 53:59 U.S. clearinghouse for issues related to the use of ICD-9-CM and 54:05 ICD-10-CM and PCS codes. And on slide 74, we've provided you with the 54:10 link to the online process for submitting coding questions to them. 54:16 These coding questions are reviewed by an editorial advisory board 54:22 comprised of a variety of coding experts and physicians, as well as the 54:27 four cooperating parties that I had mentioned earlier, who publicized 54:31 the official responses to these questions. So that's the process for 54:36 submitting questions. 54:38 And please submit a copy of the applicable the identified medical record 54:44 with the coding question. It's very difficult to respond to coding 54:49 questions without the medical record to refer to, just as you would find 54:54 it hard to code a case without having the medical record to review. 55:01 This coding clinic process does not respond to payment policy questions, 55:05 however. They just respond to coding questions. So for payment policy 55:10 questions, you should contact the relevant payer, such as your Medicare 55:15 contractor if it's a Medicare question, or the appropriate private 55:18 insurer if it's a non-Medicare question. 55:24 On slides 75 through 78, I've provided some of the resources that AHIMA 55:35 offers, including a link to our website. Many of these are free of 55:39 charge, such as our Planning and Preparation Checklist. A lot of 55:45 organizations, including CMS and many professional associations, offer a 55:49 wide array of free, very comprehensive materials that I really encourage 55:57 you to seek and use because a lot of them are just wonderful. And a lot 56:03 of other groups, commercial entities, offer tons of educational 56:07 materials and implementation resources, as well, to help you make this 56:13 transition. 56:15 And so now I will turn it back to Leah for the question-and-answer 56:20 session. Leah Nguyen: Thank you, Sue. 56:22 Before we start the question-and-answer session, we would like to make a 56:26 special announcement. 56:27 CMS will soon provide a new opportunity for Medicare-enrolled providers 56:30 and suppliers to give us your feedback about your experience with your 56:34 Medicare Administrative Contractor, or MAC, the contractor that 56:38 processes your Medicare claims. This new assessment tool is called the 56:43 Medicare Administrative Contractor Satisfaction Indicator, or MSI. Your 56:47 feedback will help CMS monitor MAC performance trends, improve 56:51 oversight, and increase efficiency for the Medicare Program. 56:55 Each year, CMS will randomly select its MSI administration sample from a 56:58 list of providers who register to become a participant. If you would 57:03 like to register to become an MSI participant or for more information, 57:07 please visit the website listed on slide 80. Thank you. Our 57:12 subject-matter experts will now take your questions about ICD-10. We 57:16 have had tremendous interest in this call and may not be able to address 57:19 every question today. 57:20 Operator: Your first question comes from Jill Young. 57:24 Jill Young: Good afternoon. My question is regard to the episode of 57:30 care, the A seventh digit. And it says it's for initial episode, but 57:36 then in the descriptor it goes on to describe additional surgery and 57:41 stuff like that. Are you going to clarify that any better? Because 57:44 initial to me means, like, the first one and that's it. But it goes on 57:48 to describe other events that would be included with that A. 57:51 Sue Bowman: This is Sue. I can answer that question. And yes, that's 57:56 actually an excellent question. I'm glad you raised that point. 58:01 The word "initial" does sort of imply that it's only the very first 58:05 time. But it actually is intended to be used as long as the patient is 58:13 really still in the active treatment phase. And the reason for that is a 58:18 lot of patients, they'll go to the ED with the injury, they'll be 58:21 referred to the orthopedist, who will then do the definitive surgery, 58:25 and so forth. And it doesn't really seem like the orthopedist, who's 58:30 actually repairing the fracture, is really a subsequent encounter just 58:34 because the patient happened to go to the ED first. 58:37 So, the intent is that it would be the initial encounter as long as the 58:44 injury is still undergoing active treatment and isn't like, sort of a 58:49 follow up kind of visit. 58:51 Jill Young: But it uses the words, I don't have it right in front 58:58 of me, and I do apologize"for removal of fixation," and sometimes, that 59:02 requires going back into the OR, and all of that's going to be 59:05 considered initial? 59:06 Sue Bowman: No. If they if they go back in for removal of the hardware, 59:11 that kind of thing, that could still be considered subsequent. It isn't 59:14 necessarily limited to just after care. But anything that would be 59:19 considered, really, the main focus of actively treating the injury to 59:25 begin with, that would still be considered initial. 59:29 Jill Young: Will we get any clarification? I hearI hear what you're 59:32 saying, but I also see the grey area starting to creep in. Will there be 59:36 any further clarification of that, perhaps from coding clinics or the 59:40 hospital clinics or somewhere there? 59:42 Sue Bowman: We can yes, I'm sure that there will be, probably, questions 59:47 coming in to coding clinic for different scenarios to clarify that. So, 59:52 yes. 59:53 Jill Young: OK. Great. 59:54 Sue Bowman: And if you have a specific case that you'd like to know 59:58 about, of course, you can submit it to coding clinic on that slide 74 60:01 that I referenced. 60:02 Jill Young: Great. Thank you very much. I appreciate it. 60:05 Operator: Your next question is from Maggie Jazvic. 60:07 Maggie Jazvic: Hello. Again, this is Maggie Jazvic. I work with 60:12 Cornerstone Prosthetics. My question is, is to try to get more 60:17 clarification on the seventh character. We are a DMEPOS provider. We do 60:23 a lot of cast changes after amputations, and bracing after fractures and 60:30 also after surgeries. So would we be using that seventh character? 60:36 Sue Bowman: Yes. If you're if you well, I you know, that would sort of 60:42 depend on the actual scenario. But if you're using the injury code, you 60:47 would be sort of the subsequent encounter, to follow up on the previous 60:53 caller's question. Yours would be a perfect example of what a subsequent 60:56 encounter would be because you're not, you know, actively reducing 60:59 or the fracture or anything like that. So . . . 61:02 Maggie Jazvic: Right. Right. We the primary or we would have a referring 61:07 physician sending the patient to us after the, say, fracture. We would 61:15 be giving them a brace. So then we would be coding with the seventh 61:18 character. 61:19 Sue Bowman: Right. 61:20 Maggie Jazvic: OK. Thank you. 61:23 Operator: Your next question is from Robert Zeman. 61:26 Robert Zeman: Yes, hi. This is Bob Zeman. I chair the Carrier Advisory 61:30 Network for the American College of Radiology. And my question isI was 61:34 glad to hear your comments about GEMs and mapping. As you know, for 61:37 radiology referrals, we don't always get the most specific codes 61:42 possible, and a lot of the local coverage determination policies that 61:46 the carriers use are kind of a reflection of that. 61:48 I'm kind of worried, and I guess I'd want to know, what's going to be 61:52 the process to make sure that the MACs are actually translating their 61:55 old LCDs that have a lot of the ICD-9 codes in them into the newer 62:00 policies with ICD-10 codes? Because, again, I'm concerned that there may 62:06 be inaccuracies, there may be change in intent to the policy without 62:09 vetting it through the Carrier Advisory Committee. So what's your take 62:15 on that? 62:16 Janet Brock: This is actually Janet Brock. 62:18 Robert Zeman: Yes. 62:19 Janet Brock: I work in the Coverage and Analysis Group. 62:21 Robert Zeman: Yes. 62:22 Janet Brock: And we help oversee the policy direction for the LCD 62:25 writers . . . 62:26 Robert Zeman: Yes. 62:27 Janet Brock: . . . here at CMS. Now, I cannot speak for the LCD writers 62:30 or MAC leadership, although we've talked extensively about the plans 62:35 that they have to translate their own policies. I believe that they 62:41 planand they're doing it now, actually to follow the same process that 62:45 we followed for national coverage determination, which is to primarily, 62:50 as the first step, use the GEMs, use the CTT tool developed by 3M, and 62:57 then use clinical oversight to find and take out those codes that maybe 63:03 are inappropriate according to the policy as written. 63:06 Robert Zeman: Yes. 63:07 Janet Brock: Because, of course, the policies are to be preserved. 63:09 Robert Zeman: Yes. 63:10 Janet Brock: There should be no change in coverage . . . 63:12 Robert Zeman: Right. 63:13 Janet Brock: . . . as part of this conversion. 63:15 Robert Zeman: Yes. 63:16 Janet Brock: If there were a need to change coverage, then the policy, 63:19 whether it be national or local, would have to be reopened. 63:22 Robert Zeman: Yes. 63:23 Janet Brock: So, from what I've heard from the LCD writers, this is what 63:26 they plan on doing. Because it is just like with national coverage, 63:29 because it is a conversion of present coding and not a change in policy, 63:33 there's no need to actually put it through an advisory body. We didn't 63:36 put ours through MEDCAC. We don't expect our local our local contractors 63:40 to put it through their CACs. 63:42 But just like national coverage, once it's published for you to see and 63:48 if you see something that you don't agree with, I believe that the local 63:52 contractors are looking for feedback, just like we're looking for 63:55 feedback at the national level. They're going to have their codes out in 63:59 front of the public 6 months in advance of them being active, you know, 64:05 for the for the transition to ICD-10 on October 1st, 2014. 64:08 Robert Zeman: Yes. 64:09 Janet Brock: There is time to make those changes . . . 64:11 Robert Zeman: Yes. 64:12 Janet Brock: . . . especially if a lot of people have something to say . 64:16 . . 64:16 Robert Zeman: Yes. 64:17 Janet Brock: . . . about the specific changes. So I would say keep an 64:21 eye open. I would say especially, talk to your MAC . . . 64:25 Robert Zeman: Yes. 64:26 Janet Brock: . . . if they happen to be a local jurisdiction. If you're 64:29 a national provider and you work with several MACs . . . 64:31 Robert Zeman: Yes. 64:32 Janet Brock: . . . usually, it's best to come through up here. You can 64:34 send ayou can send a note to me through our CAC inquiries mailbox . . . 64:39 Robert Zeman: Yes. 64:40 Janet Brock: . . . or directly to Pat Brooks through the link that was 64:45 given in thein the presentation today. And we can have our LCD 64:50 coordinator kind of help figure out what's going on there. There have 64:55 been a lot of questions about whether CACs should be involved. There's 64:59 benefits and also rather hefty expenses in having CACs involved. 65:04 Robert Zeman: Yes. 65:05 Janet Brock: And in this era of very constrained resources, we're having 65:08 to kind of, you know, do what we can with what we've got. 65:12 Robert Zeman: OK. But, that's great news, that actually there will be an 65:15 opportunity to take a look at those before we're dealing with denials, 65:18 basically. So that's great. 65:19 Janet Brock: Yes. I would say look for them starting in October. Most of 65:23 the MACsI think everyone has agreed to have them out byI'm sorry. I 65:27 said October and I meant April. 65:29 Robert Zeman: April. 65:30 Janet Brock: I'm looking at a calendar. I should never do that. 65:33 Robert Zeman: OK. Thank you. 65:34 Janet Brock: Start looking for them in April. You may see them sooner. 65:37 Robert Zeman: OK. Great. Thank you. 65:39 Operator: Your next question is from Joyce Quinn. 65:41 Joyce Quinn: Hi. My question isI'm thinking he it was kind of answered. 65:44 So, the local coverage determinations and the national coverage 65:49 determination are they available yet with the ICD-10 codes? Or is that 65:55 what you're saying they're not going to be available until April? 65:57 Janet Brock: They won't be available until April. They're actually in 66:01 the process of being translated now. 66:03 Joyce Quinn: OK. 66:04 Janet Brock: All the system changes are in place. That was necessary 66:07 for you know, for internal testing, things of that nature. So basically 66:12 what we're doing now is we're catching up with what you might call the 66:15 paperwork of it and making sure that the manuals and the coverage 66:19 policies reflect what's been done in the systems. 66:23 Wethe commitment that we have from our MACs is that they will put that 66:27 information out on their website and in our LCD database by April 1st, 66:29 2014. 66:30 Joyce Quinn: OK. Thank you so much. 66:32 Janet Brock: OK? 66:33 Joyce Quinn: Thanks. 66:34 Operator: Your next question is from Joan Criscitiello. 66:36 Joan Criscitiello: Yes. Hi. I work for a podiatrist in New York. And I 66:43 just have a couple of questions. The mappings and GEMscould you kindly 66:48 explain that to me? Because I am completely lost. 66:50 Pat Brooks: This is Pat Brooks. We post on our ICD-10 web page something 67:00 called "General Equivalence Mappings (GEMs) and Reimbursement Mappings." 67:04 If you're working in podiatry, you probably don't need to look at that 67:07 at all. We developed these mappings for people doing massive code 67:11 conversions, people like that are converting payments, like an insurer 67:16 like CMS. 67:17 Joan Criscitiello: Oh, I see. 67:18 Pat Brooks: If you're doing so, if you're doing massive things like 67:21 thatI don't even know that you want to go look at them, but you can 67:25 feel free to look at them on ICD10 website. I agree with what Sue 67:28 Bowman said. If you work in a specialty area and you want to know the 67:32 impact of a particular issue on you, I would open the code book or look 67:36 at those electronic files that are also on CMS's website. And I would 67:41 simply look up the codes for common conditions and see how they are 67:43 affected. 67:44 You don't need to learn about the GEMs or reimbursement mappings to do 67:48 what you need to do. You're probably much better off simply following 67:52 Sue's excellent direction of how to use the index to get to the tabular 67:56 and find your correct code. 67:57 Joan Criscitiello: That sounds perfect. Thank you. 67:59 Operator: Your next question is from Francine Tobin. 68:05 Francine Tobin: Yes. How can we find out if our State is using the 68:08 external cause chapter or not? And have they already designated whether 68:12 they are or they're not? The whole issue of training we may need to we 68:17 may be able to skip if our State isn't doing it. 68:20 Leah Nguyen: Could you hold on for a moment? 68:22 Sue Bowman: Well, this is Sue. And I can and CMS can jump in and help if 68:37 they want. But if you have not if you have not been reporting external 68:41 cause codes under ICD9 and haven't received any kind of notification 68:48 from a State agency or a particular payer that they're going to start 68:52 requiring them any time soon, then it probably does not apply to you. 69:01 Francine Tobin: OK. Thank you. 69:02 Operator: Your next question is from Kelly King. 69:08 Kelly King: Yes. I work for an ambulance company. We do both emergent 69:14 and non-emergent transports. Most of our patients we take just once, but 69:19 we do have a few patients that we do take more than once. How would that 69:23 seventh placement affect us between initial and subsequent encounters? 69:32 Sue Bowman: Well, if the it would it would pretty much work the same 69:37 way. If the injury is new and this is their first transport for the 69:42 injury, it would be the initial the initial encounter. If you're if 69:47 you're not sure later on, you just know that it's an older injury and 69:52 they're having repeated trips based on the information that you may 69:57 have, which may be somewhat limited, you may be using the subsequent 70:02 encounter because you wouldn't . . . 70:04 Kelly King: OK. 70:05 Sue Bowman: . . . necessarily know whether they were still getting 70:07 active treatment. But you would probably know that this either that this 70:11 injury just happened or this is an older injury. 70:15 Kelly King: OK. That's what we figured, but we just wanted to 70:18 double-check. Thank you. 70:19 Operator: Your next question is from Jackie Kravitz. 70:22 Jackie Kravitz: I'm so sorry. I had my microphone muted. This is Jackie 70:30 Kravitz, and my question is about unspecified codes. The question that I 70:35 have is, if I don't have enough information in the documentation, should 70:38 I try and find it out first? Is that an automatic red flag and won't be 70:43 payable? Or can I continue billing with that unspecified code? 70:53 Pat Brooks: This is Pat Brooks. That's a little difficult to respond to 70:58 because we don't know the issue. But what I would say to you is if you 71:02 work in a physician office now, and you know there is a payment edit on 71:06 a particular service for a CPT code that requires extremely specific 71:09 ICD-9 codes, then you can just assume that under ICD-10-CM, that they're 71:16 probably going to have extremely specific edits for ICD-10 codes. And so 71:21 you might need to get good information to document better. 71:25 If now, for the claims that you send in, you have more general diagnoses 71:30 like pneumonia, you haven't been putting down the bacteria type or 71:35 whatever and that's going through fine, then you can probably assume 71:39 there aren't going to be new payment edits from October 1st, 2014, for 71:45 pneumonia, and you might not need to ask your physician, "Are you going 71:49 to go do testing?" and things like that. Like Sue said, you code what 71:52 you know at the time. 71:54 And frequently in the physician's office, you're doing the first 71:56 encounter. Maybe all you know is a general diagnosis. And maybe at the 71:59 second encounter or later after testing, you might have more 72:02 information. 72:03 So you code what you know. You don't hold up plans waiting for special 72:09 tests to be run. But, you're aware that if there are payment edits for a 72:13 small percentage of your claims for a CPT code, then, you may need to 72:18 get more precise information on the diagnosis. 72:21 Sue, do you have anything else to add? That's the most generic advice I 72:26 can give. 72:27 Sue Bowman: No. I wouldI would agree. And I think it's important to 72:31 realize that, you know, there's while unspecified codes should be used 72:35 when they're appropriate, there are places today, even under ICD-9, 72:40 where ICDwhere unspecified codes are discouraged or not included in the 72:45 particular payment policy or an edit. 72:48 So I agree with Pat that you should just be aware of where those exist 72:54 today in ICD9 because a lot of those same areas is probably going to be 72:58 the same situation in ICD10, the areas where the payers are going to be 73:04 looking for greater specificity. And asand as Pat said, certainly, you 73:09 shouldn't be going out and doing additional testing or anything trying 73:13 to get to a more specific code. It should be what you know at the time 73:17 of that encounter. 73:18 Jackie Kravitz: Thank you. 73:19 Operator: Your next question is from Ana Servellon. 73:22 Ana Servellon: Hi. My name is Ana Servellon with Care & Rehabilitation. 73:28 We're an outpatient physical therapy office. And I was wondering, if we 73:33 have a patient that is attending physical therapy prior to 10/1, we 73:38 start reporting with an ICD-9, on 10/1 will we need to change it to an 73:44 ICD-10 code? 73:45 Sarah Shirey-Losso: Yes. This is Sarah Shirey with the Provider Billing 73:53 Group. And we have instructions. Since ICD-10 is based on date of 73:58 service, for services performed on or after 10/1/14, you would use your 74:03 ICD-10 code. 74:04 Ana Servellon: OK. Thank you. 74:05 Operator: Your next question is from Sue DeRosa. 74:11 Sue DeRosa: Yes, hi. I work for an optometric physician. Sometimes we 74:17 get referrals on same day from a primary care's office. Is he allowed to 74:23 do first encounter as well? 74:27 Sue Bowman: Yes. As long as you're both you know, as long as the injury 74:31 is still new and actively being treated and is often that's often the 74:37 case where multiple physicians are treating the injury at the same time. 74:42 They would all report initial encounter even if it's the same day. 74:46 Sue DeRosa: OK. And just one other quick question. Could you just go 74:49 over an inclusion term for me real quick? 74:53 Sue Bowman: An inclusion term in a couple of the examples I had, there 74:58 was it just refers to some examples of conditions that are classified to 75:04 that particular code. And it appears underneath the code number in the 75:11 tabular part of the of the coding system. So, it will just like in the 75:18 example I gave on slide 40, I think, on COPD, there was a bunch of terms 75:26 for chronic asthmatic bronchitis, chronic bronchitis with airway 75:29 obstructionit gave a whole long list of terms. 75:32 Sue DeRosa: Yes. 75:33 Sue Bowman: Those are called inclusion terms because they're just saying 75:35 thatthose terms are examples of the conditions that are classified to 75:42 that category or that code. 75:43 Sue DeRosa: OK. Thanks. I'm sorry. We don't have a computer up. We're 75:47 just doing phone. So, I just needed a slide to refer to, then. Thank 75:50 you. 75:51 Sue Bowman: Yes. 75:52 Operator: Your next question is from Sybil Kalish. 75:54 Sibyl Kalish: Good afternoon. Thank you very much. I'm an independent 76:00 medical educator. I'm still not clear about the initial encounter. As 76:08 long as the patient is receiving active treatment for the condition it's 76:12 not really clear what that is. The patient is being treated for a broken 76:16 leg. 76:19 Sue Bowman: So, as long as they are still receiving treatment for to 76:26 sort of repair or actively address the fracture, that would be 76:31 considered active treatment for the purpose of assigning the initial 76:36 encounter. If they are coming back to have hardware removed, to go to 76:44 physical therapy, to just have the physician do an X-ray and check the 76:51 status of the fracture to make sure it's healing OK, those would all 76:55 be or a cast change those would all be examples of the subsequent 77:01 encounter. 77:02 Sibyl Kalish: So, then, I can bill an initial encounter when the patient 77:06 comes in for surgical evaluation and as the diagnosis for the surgery. 77:12 Sue Bowman: Correct. 77:13 Sibyl Kalish: All right. That's where I was being tripped up a little 77:16 bit. 77:17 Sue Bowman: Yes. The initial encounter can be used multiple times by 77:21 multiple physicians, as long as they are still in the stage of their 77:27 injury where it's actively being evaluated and actively being treated as 77:32 opposed to being followed up or having hardware removed or, you know, 77:37 other things that are going on after all of the treatment part has been 77:40 done. 77:41 Sibyl Kalish: All right. Thank you for the clarification. I appreciate 77:44 it. 77:45 Leah Nguyen: Thank you. 77:46 Victoria, it looks like we have time for one final question. 77:50 Operator: Your final question comes from Kim Riggs. 77:52 Kim Riggs: Hi, this is Kim. The question I had and I'm not a coder, so I 77:58 may not be this may be a very quick answer. But, on page 59, it talks 78:03 about the external cause code. And in the example, you have both 78:09 "falling down on ice-covered steps"so, the "ice-covered" and the 78:13 "steps." But we only did "due to ice or snow""a fall due to ice or 78:19 snow." Is it not important to include the "steps" in there? Or, when 78:22 would you use one and not the other? 78:25 Sue Bowman: On that slide, the indentation did not show on the slide 78:30 quite correctly. The "ice-covered" part is indented under "steps" if you 78:36 actually look it up in the index. 78:37 Kim Riggs: Oh, OK. It's all inclusive? 78:39 Sue Bowman: So it's not it's not an either/or situation. 78:41 Kim Riggs: OK. 78:42 Sue Bowman: It's, you look at the steps, and then indented under that is 78:46 "due to ice." So, that's a 78:47 Kim Riggs: Oh, OK, great. All right. Thank you. That was it. Leah 78:50 Nguyen: Thank you. 78:51 Again, my name is Leah Nguyen. I would like to thank our presenters and 78:56 also thank you for participating in today's MLN Connects Call on ICD-10 79:01 basics. Have a great day, everyone. 79:03 Thank you for viewing this ICD-10 video slideshow presentation. The 79:09 information presented in this presentation was correct as of the date it 79:14 was recorded. This presentation is not a legal document. Official 79:17 Medicare program legal guidance is contained in the relevant statutes, 79:21 regulations, and rulings.