ICD-10 Presentation Handout

ICD-10
Provider Education
Antonietta Sculimbrene, MD MHA
October 2015
Avoid claims processing errors=denials or claim
rejections for providers, by fostering an
understanding of the process of and reasoning
behind Palmetto’s development of ICD-10 LCD
code sets
 Review
high level differences between
ICD-9 and ICD-10
 Communicate principles used to convert
JM LCD and article coding to ICD-10
 Explain process by which providers can
convey feedback regarding the updated
LCD’s to Palmetto GBA
A coding improvement or
apocalypse now?
WARNING!
The ICD-10 code sets are not a simple
update of the ICD-9 code set.
The ICD-10 code sets have fundamental
changes in structure and concepts that
make them very different from ICD-9.
ICD-9-CM
3-5
ICD-10-CM
characters in length
Approx. 13,000
codes
3-7
characters in length
Approx. 68,000
codes
Digit
1 may be alpha
(E or V) or numeric;
digits 2-5 are numeric;
Lacks
laterality
available
Digit
1 is alpha; digits 2
and 3 are numeric; digits
4-6 are alpha or numeric
Has
laterality (i.e. codes
identifying right v. left)
Approximately a 6 fold increase in the number of codes!
ICD-9-PCS
 3-4
numbers in
length
 Approximately
3000 codes
ICD-10-PCS
7
alpha numeric
digits
 Approximately
87,000 codes
Anatomical Laterality (or specificity)
For example, if a patient is seen for treatment of a burn on the right arm, the ICD9 diagnosis code does not distinguish that the burn is on the right arm. If the
patient is seen a few weeks later for another burn on the left arm, the same ICD-9
diagnosis code would be reported.
943.21 Blisters with epidermal loss due to burn (second degree) of forearm
Additional documentation would likely be required for a claim for the treatment to
explain that the burn treated at this time is a different burn from the one that was
treated previously. In the ICD-10 diagnosis code set, characters in the code
identify right versus left, initial encounter versus subsequent encounter, and
other clinical information.
T22.211A Burn of second degree of right forearm, initial encounter
T22.212A Burn of second degree of left forearm, initial encounter
T22.219A Burn of second degree of unspecified forearm, initial encounter
T22.611A Corrosion of second degree of right forearm, initial encounter
T22.612A Corrosion of second degree of left forearm, initial encounter
T22.619A Corrosion of second degree of unspecified forearm, initial encounter
Ok, is it a burn (thermal) or a corrosion (chemical)? And that’s just for the initial
encounter!
What are the implications of laterality for
Medicare LCD and Medicare edit coding?
When a code subset
includes complete
anatomic specificity
such as right leg vs.
left leg or specific
digits (left index
finger, right ring
finger)the code for
leg, unspecified or
finger, unspecified
will not be accepted.
A claim containing
such a code will be
denied.
EPISODES OF CARE
X94.2XXA Assault by machine gun, initial encounter
X94.2XXD Assault by machine gun, subsequent encounter
X94.2XXS Assault by machine gun, sequelae
The above examples are unlikely events. In all probability, the only time that
you would survive an assault by machine gun and have a subsequent
encounter or sequelae is if Mr. T were doing the shooting. In multiple seasons
of the “A Team” he shot thousands of rounds and never hit anyone!
Mr. T’s response…I pity the fool because…
You will learn to use ICD-10
or I’ll bust your elbow!
Which leads us to:
S52.021A Displaced fracture of olecranon process without intraarticular
extension of right ulna, initial encounter for closed fracture
S52.022A Displaced fracture of olecranon process without intraarticular
extension of left ulna, initial encounter for closed fracture
S52.023A Displaced fracture of olecranon process without intraarticular
extension of unspecified ulna, initial encounter for closed fracture
(don’t use this one or we might have to bust your elbow)
Oh, but then it gets worse…
S52.021A Displaced fracture of olecranon process without
intraarticular extension of right ulna, initial encounter for closed
fracture
S52.024A Nondisplaced fracture of olecranon process without
intraarticular extension of right ulna, initial encounter for closed
fracture
S52.031A Displaced fracture of olecranon process with intraarticular
extension of right ulna, initial encounter for closed fracture
S52.034A Nondisplaced fracture of olecranon process with
intraarticular extension of right ulna, initial encounter for closed
fracture
BUT THIS IS ONLY THE BEGINNING…
S52.021A Displaced fracture of olecranon process without intraarticular extension
of right ulna, initial encounter for closed fracture
S52.021B Displaced fracture of olecranon process without intraarticular extension
of right ulna, initial encounter for open fracture type I or II
S52.021C Displaced fracture of olecranon process without intraarticular extension
of right ulna, initial encounter for open fracture type IIIA, IIIB, or IIIC
S52.021D Displaced fracture of olecranon process without intraarticular extension
of right ulna, subsequent encounter for closed fracture with routine healing
S52.021E Displaced fracture of olecranon process without intraarticular extension
of right ulna, subsequent encounter for open fracture type I or II with routine
healing
S52.021F Displaced fracture of olecranon process without intraarticular extension
of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
routine healing
S52.021G Displaced fracture of olecranon process without intraarticular extension
of right ulna, subsequent encounter for closed fracture with delayed healing
S52.021H Displaced fracture of olecranon process without intraarticular extension
of right ulna, subsequent encounter for open fracture type I or II with delayed
healing
S52.021J Displaced fracture of olecranon process without intraarticular extension
of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
delayed healing
AND THE BEAT GOES ON…
S52.021K Displaced fracture of olecranon process without intraarticular
extension of right ulna, subsequent encounter for closed fracture with
nonunion
S52.021M Displaced fracture of olecranon process without intraarticular
extension of right ulna, subsequent encounter for open fracture type I or II
with nonunion
S52.021N Displaced fracture of olecranon process without intraarticular
extension of right ulna, subsequent encounter for open fracture type IIIA,
IIIB, or IIIC with nonunion
S52.021P Displaced fracture of olecranon process without intraarticular
extension of right ulna, subsequent encounter for closed fracture with
malunion
S52.021Q Displaced fracture of olecranon process without intraarticular
extension of right ulna, subsequent encounter for open fracture type I or II
with malunion
S52.021R Displaced fracture of olecranon process without intraarticular
extension of right ulna, subsequent encounter for open fracture type IIIA,
IIIB, or IIIC with malunion
S52.021S Displaced fracture of olecranon process without intraarticular
extension of right ulna, sequelae
There are several thousand new
codes in ICD-10 that describe
fractures.
There are more than 2000 new
codes for fracture of femur alone!
This fact will have a significant
impact on level of documentation
required for emergency services,
orthopedics, therapy services, etc.
Important Tips:
Some less specific codes have been retained in the LCD’s and claims
processing edits because it is acknowledged that this level of detail in
documentation may take some time to achieve, but it is expected, in
general, that claims be coded to the highest level of specificity
possible.
When the code set encompasses all standard anatomic
possibilities: i.e. right eye, left eye, bilateral eyes; the code
for unspecified eye has been deleted as a payable code.
If you are a Cyclops, you are just out of luck, as there is no
code for middle eye…
For services involving physical therapy, occupational therapy, and
speech-language pathology services only the “S” codes for sequelae
have been retained in the payable code set. This is part of the ICD-10
coding instruction as therapy is considered a service rendered for a
sequelae of a brain injury, stroke, fracture, trauma, etc. and not direct
treatment for such a diagnosis. However, there may be some instances
were “A” and “D” codes are appropriate.
Manage some poorly controlled diabetics for which
you need frequent A1c measurements?
In ICD-9 this code would pay as per the LCD:
250.42 Diabetes with renal manifestations, type II or unspecified type,
uncontrolled OR
250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
In ICD-10 it’s a whole different story.
You would need to code:
E11.21 Type 2 diabetes mellitus with diabetic nephropathy OR
E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
AND/OR
E11.65 Type 2 diabetes mellitus with hyperglycemia
Another example of where ICD-10 is less specific than ICD-9:
Cardiac Rehabilitation: Post MI episodes of careICD-9 to ICD-10 Translations
Old ICD-9 “V” codes don’t exist as V codes in ICD-10**
ICD-9: V20.0 Foundling
ICD-10:V20.0XXA Motorcycle driver injured
in collision with pedestrian or animal in
nontraffic accident, initial encounter*
*Please keep this in mind when driving your Harley
on a sidewalk or through a zoo
** Hint-most are “Z” codes now
ICD-10 is supposed to allow for an
unprecedented new level of granularity …
WELL NOT ALWAYS!
Remember back in slide 3 we said there were
fundamental changes in structure?!?
Here are some examples:
ICD-9: V04.5 Need for prophylactic
vaccination and inoculation against certain
viral diseases; rabies
ICD-10: Z23 Encounter for immunization
YES all immunizations all map to Z23 in ICD-10! You will need to
add a second code to specify the circumstances such as Z20.3 Contact
with and (suspected) exposure to rabies, as Medicare only covers certain
types of immunizations and Z23 coded alone will cause the claim to deny.
OCTOBER 1, 2015
HALLOWEEN COMES EARLY THIS YEAR
ICD-10 PCS CODES ARE SCARY
ICD-9 PCS codes went from 00.01 Therapeutic
ultrasound of vessels of head and neck to 99.99 Other,
leech therapy, in numerical order.
ICD-10 PCS codes have an “unlucky 7” characters:
1) Section-medical surgical, osteopathic, placement
2) Body System-Central nervous system, eye, pregnancy
3) Operation-Assistance, atmospheric control, hypnosis
4) Body Part-Upper artery, lumbar, rib cage
5) Approach- Open, percutaneous, percutaneous endo
6) Device-selection depends on the operation
7) Qualifier-Diagnostic, no qualifier
Here are sample PCS codes:
0B9330Z
0-Medical and Surgical
B-Respiratory System
9-Drainage
3-Main Bronchus, Right
3-Percutaneous
0-Drainage Device
Z-no qualifier
5A15223
5-Extracorporeal Assistance and Performance
A-Physiological Systems
1-Performance
5-Circulatory
2-Continuous
2-Oxygenation
3-Membrane
Other Burning Questions:
How do we code claims for services performed prior to October 1, 2015 but
submitted after October 1, 2015?
For any DOS prior to October 1, 2015 the claim must still be coded with ICD-9
diagnosis and procedure codes even if submitted after October 1, 2015.
What if it is a hospital stay that spans dates from September 2015 to October 1
2015 or beyond?
These claims would be submitted with ICD-10 diagnosis and procedure codes.
Anesthesia procedures that begin on 9/30/15 but end on 10/1/15 are to be billed
with ICD-9 diagnosis codes and use 9/30/15 as both the FROM and THROUGH
date.
Help is on the way!
Let your fingers do the walking (you certainly wouldn’t want to ride in this!) …
CMS resources for the ICD-10 Transition:
http://www.cms.gov/Medicare/Coding/ICD10
or
http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources
How to view the JM LCD’s with ICD-10 code sets:
TIP
LCDs coded with ICD-10 have new LCD numbers in the Medicare Coverage
Database (different from the ICD-9 versions). The ICD-10 versions of the
LCDs contain links to the old ICD-9 versions.
Some LCD’s have been retired due to coding crossover
issues which will require redrafting the LCD. These will
begin to be re-issued in 2016.
On the ICD-10 page under either JM Part A or
JM Part B you will find a link to:
ICD-10 Local Coverage Determination (LCD) Mailbox
Or the direct e-mail address for this new mailbox is:
[email protected]
Please direct all inquiries regarding CODING questions and
suggestions to this mailbox. Inquiries prior to October 1, 2015
will not be treated as formal reconsideration requests but all
input will receive consideration for potential revisions to the
code sets. All other policy questions should continue to be
directed through the existing Part A and Part B policy
mailboxes.