The implementation date for ICD-10-CM has been pushed back one year to October 1, 2014, but it doesn’t mean you have a lot of time. If you have not assessed, through a Gap Analysis, the impact of ICD-10 on your organization, you should be planning that event…soon. There is a lot to do.
Consider organizing an ICD-10 Transition Team. That team should have a project leader.
One of the first tasks of the team is to conduct an overview of ICD-10, identify the differences between ICD-9 and ICD-10, as well as the changes soon to come.
The ICD-10-CM Manual is available in both a print and an electronic version. It will provide the classification system that identifies diagnoses and injuries. Acute care procedures are not included in ICD-10-CM as they have been provided in a separate classification system called ICD-10 PC, so they are not a focus of home care.
The Transition Team needs to understand that all entities covered by HIPAA, per the American Recovery and Reinvestment Act (ARRA) who conduct healthcare transactions must comply with ICD- 10 requirements.
Per CMS, every day it pays 4.4 million claims totaling $1.5 B. Each month, Medicare receives 19,000 provider enrollment applications. Each year, Medicare pays over $430 B for 45 million beneficiaries. Each year, Medicaid nationally pays 2.5 billion claims for 54 million beneficiaries in 56 states and territories. ICD-10 is expected to assist in cost savings as well impacting fraud and abuse. Because of the specificity of ICD-10, more sophisticated algorithms are designed to hone in on questionable combinations of codes coupled with OASIS answers to spot potential fraud.
What is the rationale for ICD-10?
- ICD- 9 is 30 years old and no longer has code space for new diagnoses or new conditions and treatments.
- ICD-9 is not always precise or unambiguous.
- US mortality data is being reported in ICD-10
thus making international comparison of mortality and morbidity difficult.
We need more coding specificity!
- Accountable Care Organizations, Patient Centered Medical Models, Guided Coaches, etc will require more discreet data.
- Benchmarking and quality measurement require more detailed codes
- Reimbursement will require detailed documentation reflected by codes that portray accurate patient conditions
- Increased specificity in data means more robust design of algorithms to predict outcomes and care
- Increased coding detail offers the capability to find previously unrecognized relationships in
disease as well as variables
- Increased capability to measure healthcare quality, safety, and efficiency
- Space to accommodate future advances and expansion
- Improved capability to determine disease severity for audit risk and adjustment
The primary physician or specialist must establish a patient’s diagnosis. A nurse or therapist will document all pertinent diagnoses on the OASIS-C and the Home Health Certification and Plan of Care (Form CMS-485). New or additional diagnoses that the clinician identifies at the assessment must be verified by the physician before the diagnoses may be added to the patient’s medical record. For ICD-10, nothing changes other than greater detail availability via codes.
At first glance, trying to use the ICD-10-CM Manual may seem overwhelming. In ICD-9-CM, there were approximately 14,000 choices for codes. In ICD-10-CM, there are approximately 68,000 choices. Codes exist for so many injuries, including W61.11XA biting by a macaw, initial encounter or W61.11XD biting, subsequent encounter or codes for bites by a parrot, a goose, a turkey, or a chicken. All in all nine codes for each animal and there are a total of 312 animals. There are even separate codes for a turtle as one may be “bit by a turtle” or “struck by a turtle.” Humor aside, there are now the precise combination codes to more clearly depict the true presenting picture of the patient and their needs.
ICD-10 CM may now have 68,000 codes but acute care procedure codes, ICD-10 PC, have increased from 3,000 to 87,000 codes. That is a phenomenal increase, but necessary, given the medical advances these past 30 years. There are expected organizational benefits from ICD-10 including administrative efficiencies, cost containment, capability for more accurate trend and cost analysis, along with improved coding accuracy and productivity.
CMS believes that the impact on reimbursement expected, includes increased accuracy, fairer reimbursement, improved justification for medical necessity, fewer errors and rejected claims (after the initial learning curve), and reduced opportunities for fraud.
ICD-10-CM codes may have up to 7 digits and digits 2 and 3 are numeric, digits 4-7 are alpha or numerical. The greater the specificity, the greater the number of characters required.
A Bit of Humor
There are so many codes including injuries incurred while sewing, ironing, playing a brass instrument, even while crocheting. There is even a code, V91.07XA, for burns due to water skis on fire. Really, quite the vision and subsequent to…what, one might ask.
Because of the precise specificity, ICD-10 requires expertise in anatomy and physiology, pathophysiology, and diagnostics. The specificity is far greater than ICD-9 and the need to better understand finite A&P as well as diagnostics is vital. Injuries are grouped by anatomical site rather than type of injury. Another change includes sequelae instead of after effects.
CMS plans to have a draft grouper ready by April, 2013.
New features in ICD-10 include combination codes for a large variety of conditions, commonly seen symptoms, and manifestations. An example of a combination code includes:
E13.331 Diabetic Retinopathy with Macular Edema- other specified diabetes Mellitus with moderate non-proliferative diabetic retinopathy with macular edema.
There are a number of expanded codes for diseases and conditions, such as diabetes, substance abuse, and injuries. Codes for post operative complications have also been expanded with a distinction between intraoperative complications and post procedural disorders.
There will be an impact on many home health departments. In our next article, let’s discuss what preparation will be needed and the specifics needed for the Gap Analysis.
Next article: What do we do to prepare for ICD-10: Developing the Gap Analysis