www.TheNationalCouncil.org
ICD-10-CM An overview of changes relevant to behavioral health Presented by: Donna Pickett - CDC/OPHS/NCHS Joe Nichols - MD Date: January 24, 2014 Contact:
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Agenda www.TheNationalCouncil.org
• Overview – ICD-10, the basic facts – How is ICD-10-CM different?
• Clinical documentation - What’s needed to support proper coding in ICD-10-CM? • What’s changed for behavioral health • What are the business impacts? • What do I need to do to prepare? Contact:
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ICD-10-CM Overview Contact:
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ICD10 Quick Facts • ICD-10 international version – Adopted by WHO in 1990 – Most countries other than the US currently use ICD-10 – ICD-10 (International version) ~ 12,500 diagnostic Source: Health Data Consulting codes – ICD-10 used for mortality reporting in the US - 1999 • ICD-10-CM (US version) – ~ 69,000 diagnostic codes – Final rule published – 2012 – Compliance date – Oct 1, 2014 Source: Health Data Consulting Contact:
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ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes) ICD-9-CM Diagnosis Codes 3 to 5 digits Alpha “E” and “V” on 1st character No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality Combination codes limited
ICD-10-CM Diagnosis Codes 7 digits Alpha or numeric for any character Include place holder characters (‘x’) Similar Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common
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ICD9 Comparison to ICD10-CM Diagnosis Codes – Clinical Example
A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug]. ICD9 Code
Description Drug induced sleep disorders
29285 ICD10 Code F13282
Description Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
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ICD9 Comparison to ICD10-CM Diagnosis Codes – Clinical Example
A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug].
ICD9 Code
Description Drug induced sleep disorders
29285 ICD10 Code F13282
Description Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder
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“There are too many Codes” • There are lots of words in the dictionary, but that doesn’t seem to trouble authors… • 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system
• 17,045 (25%) of all ICD-10CM codes are related to fractures
• ~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’
• Only a very small percentage of the codes will be used most providers Source: Health Data Consulting Contact:
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Current Distribution of ICD-9 diagnosis codes 3 Years of Data - All claims - All lines of business - 1million Lives
Total Charges by Code 3years - $10 Bill
80.0% 70.0% 60.0% 50.0% 40.0% Charge % 30.0% 20.0% 10.0% 0.0% 5%
next 5%
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Varying Code Volume By Clinical Area
Clinical Area Fractures Poisoning and toxic effects Pregnancy related conditions Brain Injury Diabetes Anxiety Disorders Autism Spectrum Disorders Mood related disorders Schizophrenia Hypertensive Disease End stage renal disease
ICD-9 Codes 747 244 1104 292 69 27 6 75 56 33 11
ICD-10 Codes 17099 4662 2155 574 239 47 4 71 11 14 5
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Documentation It could be better…
Bad Mojo
is not a diagnosis • Incomplete clinical documentation is bad for Payers, Providers and Patients.
Billing accuracy Quality measures Population management Risk management Healthcare analytics Patient Care
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Good Clinical Documentation is Not a New Requirement
• The number and type of new concepts required for ICD-10 are not foreign to clinicians
• The focus of documentation is good patient care • Patients deserve to have accurate and complete documentation of their conditions
• If other industries understand the value of accurate and complete documentation of data about encounters; shouldn’t we? Source: Health Data Consulting Contact:
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Documentation Why is it important?
• Supports proper payment reduced denials • Assures accurate measures of quality and efficiency • Assures accountability and transparency • Captures the level of risk and severity • Provides better business intelligence • Supports clinical research • Enhances communication with hospital and other providers • It’s just good care! Source: Health Data Consulting Contact:
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Coding – The Patient Interface Where it all begins
Physical Exam Internal Record Review
History
External Record Review Studies
Assessment/Diagnosis Contact:
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Getting to the Code A Necessary Step
Back-office Coding
The “Super Bill” Contact:
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Back to the Doctor? 15
The Super Bill Not That Super Really…
[Note] For all codes related to fractures of the radius: •ICD-9 codes = 32 •ICD-10 codes = 1731 Contact:
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New concepts supported by ICD-10
• • • • • • • • •
Drug “use” vs “dependence” vs “abuse” Bipolar II Recurrent depressive disorder Mood disorder related to physiologic condition Adjustment insomnia Adjustment reaction with withdrawal Asperger's syndrome Rett's syndrome Distinguishes between current episode and most recent episode for bipolar disorders
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Removed concepts from ICD-9
• Substance dependence o o
continuous episodic
• Amphetamine o o
Dependence Abuse
• Bipolar I • Passive-aggressive personality • Pervasive Disorders o o
current or active state residual state
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Removed concepts from ICD-9
• Schizophrenia o o o o o o o
Latent Simple type Subchronic Chronic Subchronic with acute exacerbation Chronic with acute exacerbation In remission
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ICD-10-CM Key coding changes relevant to behavioral health Contact:
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Changes in detail and content Code Examples – Substance related sleep disorders:
More Codes ICD-9 Code 29285
Description Drug induced sleep disorders
ICD-10 Code
Description
F11182
Opioid abuse with opioid-induced sleep disorder
F11982
Opioid use, unspecified with opioid-induced sleep disorder
F11282
Opioid dependence with opioid-induced sleep disorder
F14182
Cocaine abuse with cocaine-induced sleep disorder
F14282
Cocaine dependence with cocaine-induced sleep disorder
F14982
Cocaine use, unspecified with cocaine-induced sleep disorder
F13182
Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder
…
Multiple other substances
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Changes in detail and content Code Examples – Substance related abuse:
More Codes ICD-9 Code 30550
Description (Non-dependent) Opioid abuse, unspecified
ICD-10 Code
Description
F1110
Opioid abuse, uncomplicated
F11120
Opioid abuse with intoxication, uncomplicated
F11121
Opioid abuse with intoxication delirium
F11122
Opioid abuse with intoxication with perceptual disturbance
F1114
Opioid abuse with opioid-induced mood disorder
F11150
Opioid abuse with opioid-induced psychotic disorder with delusions
F11151
Opioid abuse with opioid-induced psychotic disorder with hallucinations
F11181
Opioid abuse with opioid-induced sexual dysfunction
F11182
Opioid abuse with opioid-induced sleep disorder
F11188
Opioid abuse with other opioid-induced disorder
F1119
Opioid abuse with unspecified opioid-induced disorder
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Changes in detail and content Code Examples – Schizophrenia:
Less Codes ICD-9 Code
Description
29530
Paranoid type schizophrenia, unspecified
29531
Paranoid type schizophrenia, subchronic
29532
Paranoid type schizophrenia, chronic
29533
Paranoid type schizophrenia, subchronic with acute exacerbation
29534
Paranoid type schizophrenia, chronic with acute exacerbation
29535
Paranoid type schizophrenia, in remission
ICD-10 Code
Description
F200
Paranoid schizophrenia
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Changes in detail and content Code Examples – Schizoaffective disorder:
More Codes ICD-9 Code
Description
29570
Schizoaffective disorder, unspecified
ICD-10 Code
Description
F250
Schizoaffective disorder, bipolar type
F251
Schizoaffective disorder, depressive type
F258
Other schizoaffective disorders
F259
Schizoaffective disorder, unspecified
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Changes in detail and content Code Examples – Post traumatic Stress Disorder:
More Codes ICD-9 Code
Description
30981
Posttraumatic stress disorder
ICD-10 Code
Description
F4310
Post-traumatic stress disorder, unspecified
F4311
Post-traumatic stress disorder, acute
F4312
Post-traumatic stress disorder, chronic
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Changes in detail and content Code Examples – Childhood Emotional Disorders:
Less Codes ICD-9 Code
Description
3130
Overanxious disorder specific to childhood and adolescence
3131
Misery and unhappiness disorder specific to childhood and adolescence
31321
Shyness disorder of childhood
31322
Introverted disorder of childhood
3133
Relationship problems specific to childhood and adolescence
31382
Identity disorder of childhood or adolescence
31383
Academic underachievement disorder of childhood or adolescence
31389
Other emotional disturbances of childhood or adolescence
3139
Unspecified emotional disturbance of childhood or adolescence
ICD-10 Code F930 F938 F939
Description Separation anxiety disorder of childhood Other childhood emotional disorders Childhood emotional disorder, unspecified
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Changes in detail and content Code Examples – Conversion Disorders:
More Codes ICD-9 Code
Description
30011
Conversion disorder
ICD-10 Code
Description
F444
Conversion disorder with motor symptom or deficit
F445
Conversion disorder with seizures or convulsions
F446
Conversion disorder with sensory symptom or deficit
F447
Conversion disorder with mixed symptom presentation
F4489
Other dissociative and conversion disorders
F449
Dissociative and conversion disorder, unspecified
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Changes in detail and content Code Examples – Other substance abuse:
More Codes ICD-9 Code
Description
30592
Other, mixed, or unspecified drug abuse, episodic
ICD-10 Code
Description
F550
Abuse of antacids
F551
Abuse of herbal or folk remedies
F552
Abuse of laxatives
F553
Abuse of steroids or hormones
F554
Abuse of vitamins
F558
Abuse of other non-psychoactive substances
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Changes in detail and content Code Examples – Attention Deficit Disorders:
More Codes ICD-9 Code
Description
31400
Attention deficit disorder without mention of hyperactivity
31401
Attention deficit disorder with hyperactivity
ICD-10 Code
Description
F900
Attention-deficit hyperactivity disorder, predominantly inattentive type
F901
Attention-deficit hyperactivity disorder, predominantly hyperactive type
F902
Attention-deficit hyperactivity disorder, combined type
F908
Attention-deficit hyperactivity disorder, other type
F909
Attention-deficit hyperactivity disorder, unspecified type
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Business Impacts Contact:
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Business Impacts •
Coding
•
Contracting
•
Scope of services Case rates Carve outs
Billing
•
EHR updates Super Bill??? Training Coding software
Billing code updates Charge masters Billing Edits
Benefits and coverage determinations
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Business Impacts (Cont.) • Compliance
HIPAA Reporting
National State Regional Initiatives
Contract requirement Accreditation
• Reimbursement
Pay for performance POA, “never events”, re-admissions, HACs, tiered payment models Network inclusion Denials
• Audits
RAC Fraud and abuse Coding
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“ICD diagnosis codes are irrelevant to my business.”
•
ICD-9 codes factor into:
Payer processing rules
The determination of appropriateness
Measures of quality (pay for performance)
Compliance (meaningful use)
Contracting decisions
Risk adjustments
Fraud waste and abuse
Audits
Authorizations
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“ICD diagnosis codes are irrelevant to my business.”
•
ICD-10 codes are likely to factor into:
Changes in reimbursement based on both “what” was done and “why”
Managing financial risks for contracted populations (ACO’s)
Changes in reimbursement based on more robust models of payment adjusted for risk and severity
More sophisticated weighting of payments based on DRGs, episodes or other groupers of care.
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Business Impacts •
Compliance
HIPAA Reporting o o o
•
Contract Accreditation
Reimbursement
•
National State Regional Initiatives
Pay for performance POA, “Never Events”, Tier Models Network inclusion Denials
Audits
RAC Fraud and abuse Coding
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Cash Flow
Impacts inbound and outbound
Lack of Provider Preparation
Payment Delays
Increased Cost Contact:
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Cash Flow
Impacts inbound and outbound
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Implementation Getting your ducks in a row Contact:
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Implementation Strategy
• Short term goals with a long term visions
What solution do I need today? Will that solution extend to tomorrows needs?
• Awareness of touch points with other initiatives
Overlap and conflicts
• Down Stream Impacts
What works well for one business area, may bring another business area to it’s knees
• Positioning for competitive advantage
Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator for the transition challenge to providers and other stakeholders? Can you manage the “burden of illness” of your population better than your competitors?
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Phases of Transition 1. Assessment
Inventory of impacted systems and processes Identifying risk
2. Analysis/Planning
Prioritizing focus Establishing business area specific approaches Creating specifications for mapping to support implementation
3. Implementation and Operations
Translating codes from 9 to 10 and from 10 to 9 using crosswalks Changing analytic models to support both codes Operationalization of coding to ICD-10 from source information Changing processing logic to operate directly from ICD-10 codes
4. Leveraging ICD10 capabilities
Using the enhanced information within ICD-10 codes to improve processing and analysis based on improved concepts buried within the ICD-10 codes
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Scenario-Based Testing What is it?
• The scenario:
The identification of some event or condition that we are familiar with today
Recreating that event virtually through some verbal or data representation
Defining a variety of assumptions and variables around this virtual representation
• Applying one or more of these scenarios in a Reference Implementation Model (RIM).
Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results.
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Leveraging ICD-10
A changing world of cost containment
Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment.
• Better representation of severity and risk • Recognition of varying levels of complexity • Better claim information to support automated processing and more rapid reimbursement
• Opportunities to reduce audit risk exposure • Improved business intelligence to support population risk management
• More accurate measures of quality and efficiency Contact:
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Q&A
Review of Q&A from Attendees
If you have a question that has not been addressed, please send it to us at the ICD-10 Questions Mailbox:
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Online Resources Review of Q&A from Attendees
• CMS - https://www.cms.gov/ICD10/ Coding Documentation (Indexes, Coding Guidelines, Code Files): http://www.cms.gov/Medicare/Coding/ICD10/index.html
General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) GEMs Crosswalk documents: http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-andGEMs.html GEMs 2014 General Equivalence Mappings: http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html
Medicare Learning Network Articles: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNGenInfo/index.html?redirect=/mlngeninfo
Implementation Guides: https://implementicd10.noblis.org
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Online Resources Review of Q&A from Attendees
• CMS - https://www.cms.gov/ICD10/ (Continued)
Implementation Guides: https://implementicd10.noblis.org ICD-10 National Provider Calls: http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10Teleconferences.html National Coverage Determinations (NCDs): http://www.cms.gov/medicare-coverage-database/overview-and-quicksearch.aspx Medicare Testing Week: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8465.pdf Medicare Claims Processing Guidance for ICD-10: http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/MM7492.pdf
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Online Resources Review of Q&A from Attendees
• CMS - https://www.cms.gov/ICD10/ (Continued)
Medicare Reimbursement Mappings 2014 Reimbursement Mappings – Diagnosis Codes and Guides http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html 2014 Reimbursement Mappings – Procedure Codes and Guides http://cms.hhs.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html Links to ordering the ICD-10 Pilot Version 31.0 Mainframe and PC version of the ICD-10 MS-DRGs and Medicare Code Editor (FY 2014 version) from NTIS have been placed on the CMS website under the Related Links section at http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-ConversionProject.html http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNGenInfo/index.html?redirect=/mlngeninfo FAQ, Coordination and maintenance Committee minutes
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Online Resources Review of Q&A from Attendees
• CDC - http://www.cdc.gov/nchs/icd/icd10cm.htm ICD-10-CM files (Alphabetic Indexes, Tabular List, Coding Guidelines, Codes and Descriptions Files, FY2014 Addenda)
General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) GEMs Crosswalk documents: GEMs 2014 General Equivalence Mappings:
Detailed List of Codes Exempt from Diagnosis Present on Admission Requirements
Public Health Transition to ICD-10-CM/PCS http://www.cdc.gov/nchs/icd/icd10cm_pcs.htm
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Online Resources Review of Q&A from Attendees
• WEDI - http://www.wedi.org/
List serves Workgroups White papers Implementation forums Industry advocacy and issue Access to standards leaders
• AHIMA - http://ahima.org/
Training and certification Extensive documentation libraries Bookstore Communities of practices ICD-10 focused conferences
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Online Resources Review of Q&A from Attendees
• HIMSS - http://www.himss.org/
White papers Bookstore Webinars
• Vendors • Consulting Organization • Online news
• Blogs
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Online Resources Review of Q&A from Attendees
• Health Data Consulting white papers:
ICD-10 A Primer ICD-10 Physician Impacts Scenario Based Testing ICD-10 The Case for Moving Forward ICD-10 Clinical Documentation – The Role of the Clinician in Capturing Accurate Data ICD-10 – Specified or Unspecified?
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