Introduction to ICD-10 and
what you need to know
for a Successful Transition
Sheila Goethel, RHIT, CCS
Coding Consultant
AHIMA ICD-10-CM/PCS Certified Trainer
May 2011
Objectives
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Introduction of ICD
Brief overview of major changes
Who is impacted by the conversion
What are affects of ineffective preparation
How you can be instrumental within the
change
• What’s being done at local and state levels
ICD Background
• The INTERNATIONAL CLASSIFICATION OF
DISEASES is the medical classification system
used in the US – and world wide – in the
collection of information regarding disease and
injury.
• Diagnosis and procedures are converted into
CODES that have an international definition for
each condition/injury
• Effective means to classify and retrieve diseases
and operations
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ICD Use
• ICD Codes are reported on the hospital/physician
claim form
– Claim form data is collected and maintained nationally
• Insurer is able to apply the benefits
• Purposeful to monitor the incidence and prevalence
of diseases,
• Basis for information retrieval for clinical and quality
purposes
• Serve as the major basis to compile national
mortality and morbidity statistics
ICD-9 transition to ICD-10
• US is the only industrialized nation that hasn’t
yet adopted the ICD-10 system
• ICD-9 was developed in 1979
– Running out of numbers/extensions to
accommodate updates
• Today’s use focus on reimbursement, quality, &
safety rather than research and retrievability
• HIPAA 5010
ICD-10 Implementation
• ICD-9-CM codes will not be accepted for
services provided on or after October 1, 2013
• Single implementation date for all users
• ICD-9-CM claims for services prior to
implementation date will continue to flow
through systems for a period of time
• No grace period
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Benefits of ICD-10
• Up-to-date classification will provide:
– Increased coding detail and specificity
– Enhanced information for measuring quality,
safety and efficiency
– Recognition of advances in medicine and
technology
– Space to accommodate future expansion
– Alignment with other systems nationwide and
ability to track and respond to international public
health issues
ICD-10
ICD-10-CM
• Diagnoses codes
• Used for hospital inpatient
and outpatients
• Used for ALL providers
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ICD-10-PCS
• Procedure codes
• Used for inpatient
encounters only
– CPT will be maintained as
procedure code choice for
outpatient
MD clinics
SNF
Home Health
Free standing clinics
ICD-9 vs ICD-10
ICD-9
ICD-10
# Characters
3-5
7
# DX Codes
14,315
69,099
# Procedure Codes
3,838
71,957
Capacity for new codes
Limited - New proc
codes are in different
system chapters
Flexibility to add new
codes in any category
Data analysis capability
Limited - Difficult to
analyze due to generic
or unavailable code
sets
Greater specificity will
improve richness of data
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Differences in Structure
ICD-10-PCS
X
X
X
X
X
X
X
Secti
on
Body
syste
m
Root
operati
on
Body
Part
Appro
ach
Device
Exten
sion
General Equivalent Mappings
• Tool to assist with conversion of ICD-9-CM codes to ICD-10-CM
codes and back to ICD-9-CM codes
• They are reference “Mappings” and not actual “Crosswalks”.
• GEMs are comprehensive translation dictionary to use to
translate ICD-9-CM-based data
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Tracking quality
Recording morbidity/mortality
Calculating reimbursement
Converting any ICD-9-CM based application to ICD-10-CM
GEMs Uses
• GEMS used by anyone to convert coded data. Possible
users:
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All payers
All providers
Medical researchers
Informatics professionals
Coding professionals – to convert large data sets
Software vendors – to use within their own products
Organizations – to make mappings suit internal purposes or
based on own historical data
– Others who use coded data
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Mapping Types
• Forward mapping – Translate existing coded
data to their counterparts in the new code set
• Backward mapping – Track newly coded data
back to what they may have been in the
previous code set
Method used to reconcile the difference may
depend purpose of mapping task (i.e.
research, claims adjudication, MSDRG
reimbursement, strategic planning)
CMS MSDRG Conversion Project
• CMS illustrated use of GEMs by developing
ICD-10 version of MS DRGs
• Stage 1 began with digestive MS-DRGs, Major
Diagnostic Category (MDC 06)
• Yearly, we have revised codes and updated
CCs and MCCs
• MSDRG Version 28 I-10 MS Grouper software
is available
http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp#
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HIPAA 5010 – Effective 1-1-12
• Code modifications require EDI Version 5010
– Allows expansion in fields to accommodate ICD-10-CM
and ICD-10-PCS (procedure codes only used for hospital
inpatients)
– Required by all payers
– Require changes to software, systems, and procedures for
billing Medicare and other payers
– Accommodates up to 25 ICD diagnosis codes (not in
current Version 4010)
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Who will these changes affect
External Stakeholders
• Vendors
• Payers
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CMS
Medicaid
MA
Insurers
Work Comp
• Clearinghouses
• Other business partners
Internal Key Individuals
• Physicians
• HIM/Coding
• IT/IS
• QI
• UR/Case managers
• CFO/Finance
• Ancillary
• Nursing
HIPAA 5010 and ICD-10 Preparation
(1-1-12)
(10-1-13)
Vendor
Does your license
include upgrades – will
there be additional costs
When can we test
internally
When can we test
externally
Payer
When can we test 5010
externally
Will ICD-10 affect our
contract
(are/will we paid on
MSDRG)
Hospital
Maintain 5010 timelines
and payer contracts
Internal readiness
(forms, P/P, education,
budgets)
Are they working with
GEMs to prepare for
conversion
NEED TO BE 5010
COMPLIANT BY 1-1-12
Are they working with
MSDRG conversions (if
paid on DRG
Support for dual
systems
When can we test for
MSDRG compatibility
ICD-10 Education
Documentation
expectations
Vendor Readiness
• Assess readiness for Compliance January 1, 2012
• Does your license include regulation updates? What are the
additional cost?
• Training for conversion – Customer Support opportunities
• Install upgrade and test functionality in 2011. Identify process
and timeline for testing submission of data under 5010. Assure
well before 1/1/2012 (suggest by September/October).
• All transactions must test compliant with Errata Version 5010
before being allowed into ‘production.’
• Modified logic to accommodate 2 sets of systems
simultaneously
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Payer(S) Readiness
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Will ICD-10 affect payer contract
Schedule (external) 5010 test
GEMs - Mapping protocols acknowledged
System logic and edits accommodate
– new extensions (initial, subsequent)
– 2 sets of code systems for transition period
• MSDRG conversion
• Appropriate Reimbursement
Hospital Readiness
• Ensure Vendor and Payers are ready!
• Maintain 5010 timelines
• Steering Committee to develop and maintain project
schedules
– IT Lead
– HIM Lead
• Identify affected systems, applications and uses of ICD-9
• Assess impact on work and process flow
Hospital Readiness
• Education
• Hospital Staff
• Physicians
• Coders
• ID forms/reports that need modification
• ID P/P that will need modification
• ID impact on external reporting
• Core Measures, P4P, CA reporting, WHAIC
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Assess and Plan for the impact on coding productivity
ID affect on decreased productivity will have on AR days/$
Estimate budget and resources necessary
Assess documentation expectations and improvement measures
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Implementation Challenges
Payers
Finance
Acct Recv
Vendors
ICD codes
Hospital Staff
Physicians &
Documentation
ICD Codes are the language of healthcare and will impact virtually
ALL areas of healthcare
Risks or Poor Preparation
Vendor
Payers
Coders
• Delay in creating and submitting claim
• Increase in claim rejection/denials
• Increased AR days and dollars
• Decreased revenues
• Inability to apply benefits to your claim
• Delay in acknowledging/payment of your claim(s)
• Error in payment application
• Coding Backlog
• Inaccurate MSDRG payment
• Distorted data which results in poor representation about your patient
care delivery
• Affect Core Measure data extraction and P4P payments
• Publically displayed data may negatively influence potential customers
TIMELINES - RECAP
Following timelines for required implementation
– January 1, 2011 + : Payers and providers begin external testing of
Version 5010 for electronic claims with trading partners. Begin
accepting new 5010/D.0 versions.
Version 4010 claims continue to be accepted
– December 31, 2011: External testing of Version 5010 must be
complete dual process testing to achieve Level II compliance
– January 1, 2012: All electronic claims must use Version 5010; Version
4010 claims no longer accepted. ICD-9-CM codes for medical
diagnosis and inpatient procedures continue.
– October 1, 2013: Claims for services provided on or after this date
must use ICD-10 codes for medical diagnosis and inpatient procedures;
CPT codes will continue to be used for outpatient services
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State and Local Support
• WHA ICD-10 Task Force
http://www.wha.org/financeanddata/icd_10.aspx
• WHIMA ICD-10 Task Force – (WI Health
Information Management Association)
http://www.whima.org/ICD10/ICD10.html
• RWHC ICD-10 Task Force
ICD-10 Countdown….
• Develop an I-10 Steering Committee with give
them necessary authority to make necessary
changes
• Provide adequate tools and resources to
affected positions and processes
• Support process(es) changes
• Support established deadlines
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Links
• http://www.cms.gov/ICD10/01_Overview.asp
#TopOfPage
• http://www.cdc.gov/nchs/icd/icd10cm.htm
• http://www.ahima.org/icd10/default.aspx
• http://www.aapc.com/ICD-10/training.aspx
• http://www.who.int/classifications/icd/en/
QUESTIONS?
Thank You!
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