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: [email protected]
202.684.7457
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: [email protected]
202.684.7457
2
Source: Health Data Consulting
ICD-10-CM
Overview
Contact: [email protected]
202.684.7457
3
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: [email protected]
202.684.7457
4
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
5
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
6
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
7
“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: [email protected]
202.684.7457
8
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%
…
…
…
…
Contact: [email protected]
202.684.7457
…
…
…
…
…
…
Source: Health Data Consulting
…
…
…
…
…
…
…
…
9
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
10
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
Contact: [email protected]
202.684.7457
11
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: [email protected]
202.684.7457
12
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: [email protected]
202.684.7457
13
Coding – The Patient Interface
Where it all begins
Physical Exam
Internal Record Review
History
External Record Review
Studies
Assessment/Diagnosis
Contact: [email protected]
202.684.7457
14
Getting to the Code
A Necessary Step
Back-office Coding
The “Super Bill”
Contact: [email protected]
202.684.7457
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: [email protected]
202.684.7457
16
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
17
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
18
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
19
Source: Health Data Consulting
ICD-10-CM
Key coding changes relevant to behavioral health
Contact: [email protected]
202.684.7457
20
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
21
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
22
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
23
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
Contact: [email protected]
202.684.7457
Health Data Consulting © 2013
24
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
Contact: [email protected]
202.684.7457
Health Data Consulting © 2013
25
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
26
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
27
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
Contact: [email protected]
202.684.7457
Health Data Consulting © 2013
28
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
Source: Health Data Consulting
Contact: [email protected]
202.684.7457
29
Business Impacts
Contact: [email protected]
202.684.7457
30
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
Contact: [email protected]
202.684.7457
Health Data Consulting © 2013
31
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
Contact: [email protected]
202.684.7457
Health Data Consulting © 2013
32
“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
Contact: [email protected]
202.684.7457
Health Data Consulting © 2013
33
“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.
Contact: [email protected]
202.684.7457
Health Data Consulting © 2013
34
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
Contact: [email protected]
202.684.7457
35
Cash Flow
Impacts inbound and outbound
Lack of Provider
Preparation
Payment Delays
Increased Cost
Contact: [email protected]
202.684.7457
36
Cash Flow
Impacts inbound and outbound
Source: CMS
Contact: [email protected]
202.684.7457
37
Implementation
Getting your ducks in a row
Contact: [email protected]
202.684.7457
38
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?
Contact: [email protected]
202.684.7457
39
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
Contact: [email protected]
202.684.7457
40
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.
Contact: [email protected]
202.684.7457
41
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: [email protected]
202.684.7457
42
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: [email protected]
Contact: [email protected]
202.684.7457
43
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
Contact: [email protected]
202.684.7457
44
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
Contact: [email protected]
202.684.7457
45
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
Contact: [email protected]
202.684.7457
46
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
Contact: [email protected]
202.684.7457
47
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
Contact: [email protected]
202.684.7457
48
Online Resources
Review of Q&A from Attendees
• HIMSS - http://www.himss.org/



White papers
Bookstore
Webinars
• Vendors
• Consulting Organization
• Online news
• Blogs
Contact: [email protected]
202.684.7457
49
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?
http://healthdataconsulting.com/resources/white-papers/
Contact: [email protected]
202.684.7457
50