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ICD-10 Basics MLN Connects™ Call 08/22/13

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.


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