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RSM’s Senior Living Health Care Connection: Prepared for ICD-10?

CMS thinks you are


As a follow up to our April 21, 2015, article, ICD-10 is coming, we wanted to make sure you are really ready for ICD-10-CM diagnosis coding to go live on October 1, 2015. The ICD-10-CM/PCS overview will give you more detail regarding the transition. Have you taken the following steps to ensure a smooth transition to ICD-10?

  • Training your staff, including the entire interdisciplinary team
  • Testing your software to make sure the ICD-10 codes are accurate
  • Visiting with your software vendor to establish responsibility for the transition to ICD-10 from ICD-9
  • Revisiting the management of the coding process, including responsibility for:
    • Entering the admission diagnosis
    • Reviewing accuracy of the codes used on the minimum data set (MDS) billing claims and related documentation
    • Monitoring  the coding throughout the stay
    • Managing the discharge process and related documentation

For questions or further information regarding training, please contact Joan McCarthy at 312.634.3479 or any other member of your RSM health care team.

ICD-10-CM/PCS overview

  • International Classification of Diseases, 10th revision, Clinical Modification ICD-10-CM is the new diagnosis coding system that was developed as a replacement for ICD-9-CM, Volume 1 and 2. International Classification of Diseases, 10th revision, Procedure Coding System ICD-10-PCS is the new procedure coding system that was developed as a replacement for ICD-9-CM, Volume 3.
  • ICD-10-CM/PCS consists of two parts:
    • ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all United States health care treatment settings. Diagnosis coding under this system uses 3–7 alphanumeric digits and full code titles, but the format is very much the same as ICD-9-CM.
    • ICD-10-CS – The procedure classification system developed by the Centers for Medicare & Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings only. The new procedure coding system uses 7 alphanumeric digits, while the ICD-9-CM coding system uses 3 or 4 numeric digits.
  • The compliance date for ICD-10-CM for diagnoses use by Skilled Nursing Facilities and other health care providers and ICD-10-PCS for inpatient hospital procedures is October 1, 2015.
  • All Health Insurance Portability and Accountability Act (HIPAA)-covered entities must implement the new code sets with dates of service, or date of discharge for inpatients, that occur on or after October 1, 2015.
  • Because ICD-9-CM will no longer be maintained after ICD-10-CM/PCS is implemented, it is in noncovered entities’ (such as workers’ compensation) best interest to use the new coding system. The increased detail in ICD-10-CM/PCS is of significant value to noncovered entities. The CMS will work with noncovered entities to encourage their use of ICD-10-CM/PCS.
  • HIPAA requires the development of one official list of national medical code sets. The CMS will work with state Medicaid programs to ensure that ICD-10-CM/PCS is implemented on time.
  • ICD-10-CM and ICD-10-PCS code books are available and are of a manageable size (one publisher’s book is 2 inches thick). The use of ICD-10-CM/PCS is not predicated on the use of electronic hardware and software, so the resources do not comply with any specific software structure.
  • As with ICD-9-CM, ICD-10-CM/PCS codes should be based on medical record documentation. While documentation supporting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use when documentation doesn’t support a higher level of specificity. The American Hospital Association and the American Health Information Management Association performed field testing studies and reviews that allowed the removal of rarely used codes and the crosswalking of common codes from ICD-9-CM to ICD-10-CM. Crosswalking can be found in the General Equivalence Mappings (GEMs).
  • The GEMs were not developed to provide help in coding medical records. Code books are used for this purpose. Mapping is not the same as coding:
    • Mapping links concepts in two code sets without consideration of patient medical record information
    • Coding involves the assignment of the most appropriate code based on medical record documentation and applicable coding rules and guidelines. The GEMs can be used to convert the following databases from ICD-9-CM to ICD-10-CM/PCS: payment systems, payment and coverage edits, risk adjustment logic
  • The GEMs are a crosswalk tool that was developed by CMS and CDC for the use of all providers, payers and data users. The mappings are free of charge and are in the public domain.
  • As with ICD-9-CM, ICD-10-CM codes are derived from documentation in the medical record. Therefore, if a diagnosis has not yet been established, you should code the condition to its highest degree of certainty (which may be a sign or symptom) when using both coding systems. In fact, ICD-10-CM contains many more codes for signs and symptoms than ICD-9-CM, and it is better designed for use in ambulatory encounters when definitive diagnoses are often not yet known. Nonspecific codes are still available in ICD-10-CM/PCS for use when more detailed clinical information is not known.
  • The Alphabetic Index and electronic coding tools are available to help you select the proper code. It is anticipated that the improved structure and specificity of ICD-10-CM/PCS will assist in developing increasingly sophisticated electronic coding tools that will help you more quickly select codes. Because ICD-10-CM/PCS is much more specific, is more clinically accurate and uses a more logical structure, it is much easier to use than ICD-9-CM.
  • ICD-9-CM diagnoses codes:
    • 3–5 digits
    • First digit is alpha (E or V) or numeric
    • Digits 2–5 are numeric
    • Decimal is after third digit
  • Examples:
    • 496 – Chronic airway obstruction, Not Elsewhere Classified (NEC)
    • 511.9 – Unspecified pleural effusion
    • V02.61 – Hepatitis B carrier
  • ICD-10-CM diagnoses codes:
    • 3–7 digits
    • Digit 1 is alpha
    • Digit 2 is numeric
    • Digits 3–7 are alpha or numeric (alpha digits are not case-sensitive)
    • Decimal is after third digit
  • Examples:
    • A78 – Q fever
  • The new classification system provides significant improvements through greater detail.
  • ICD-9-CM Pressure ulcer codes
    • 9 location codes (707.00 – 707.09). Show broad location, but not depth (stage)
  • ICD-10-CM Pressure ulcer codes
    • Codes show more specific location, as well as depth, including:
      • L89.131 – Pressure ulcer of right lower back, stage 1
      • L89.132 – Pressure ulcer of right lower back, stage 2
      • L89.133 – Pressure ulcer of right lower back, stage 3
      • L89.134 – Pressure ulcer of right lower back, stage 4
      • L89.139 – Pressure ulcer of right lower back, unspecified stage
      • L89.141 – Pressure ulcer of left lower back, stage 1
      • L89.142 – Pressure ulcer of left lower back, stage 2
      • L89.143 – Pressure ulcer of left lower back, stage 3
      • L89.144 – Pressure ulcer of left lower back, stage 4
      • L89.149 – Pressure ulcer of left lower back, unspecified stage
      • L89.151 – Pressure ulcer of sacral region, stage 1
      • L89.152 – Pressure ulcer of sacral region, stage 2
  • In both ICD-9-CM and ICD-10-CM, sign and symptom and unspecified codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs and symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. Each health care encounter should be coded to the level of certainty known for that encounter.
  • If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined, but the specific type has not been determined). In fact, unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter

Continued use of CPT codes

When ICD-10-CM/PCS is implemented on October 1, 2015, it will not affect the use of Current Procedural Terminology (CPT) codes on Medicare fee-for-service claims. Providers should continue to use CPT codes to report these services. So, Part B reporting will continue to use the CPT codes to document therapy.

For more information, contact Joan McCarthy at 312.634.3479.

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