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Title: Long Tern C Author: kandersen Last modified by: Karrie Created Date: 4/10/2013 6:56:47 PM Document presentation format: On-screen Show (4:3) Company – PowerPoint PPT presentation

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Title: ICD10-CM/PCS

  • The What, When, Why and Who
  • Presenter Linda Parks MA RHIT CCS CTR
  • Assistant Professor, DSU HIM Programs

  • International Classification of Diseases
  • ICD is the international, standard diagnostic
    classification for all general epidemiological
    and health management purposes.
  • The World Health Organization owns and publishes
    the international version of the ICD
    classification system.

  • The United States remains the only industrialized
    nation that has not yet implemented ICD-10.

What ICD-10-CM
  • ICD-10-CM is the U.S. clinical modification of
    the World Health Organizations ICD-10
    classification system developed by the National
    Center for Health Statistics.
  • ICD-10-CM will replace ICD-9-CM.
  • ICD-9-CM - 14, 025 codes
  • ICD-10-CM 68,069 codes

What ICD-10-CM
  • ICD-10-CM will be used in all healthcare
    settings for diagnosis coding.

  • ICD-9-CM
  • 3 5 characters in length
  • First digit is numeric or alpha
  • Second, third, fourth, and fifth digits are
  • Always at least 3 digits
  • Decimal placed after the first three characters
  • Alpha characters are not case-sensitive
  • ICD-10-CM
  • 3-7 characters in length
  • First character is alpha
  • All letters except U
  • Second character is numeric
  • Characters 3-7 can be alpha or numeric
  • Decimal placed after the first three characters
  • Alpha characters are not case-sensitive

Another View
  • I10 Hypertension
  • J45.909 Asthma
  • K21.9 GERD
  • S52.319A Greenstick fracture of shaft
    radius left arm, initial encounter

What ICD-10-PCS
  • Developed in the US by CMS to replace the ICD-9
    CM procedural coding system
  • Not derived from an international coding system
    or used in other countries
  • Used only for facility reporting of hospital
    inpatient services
  • ICD-9-CM 3, 824 codes
  • ICD-10-PCS 72, 589 codes

What ICD-10-PCS
  • Incorporation of four essential attributes
  • Completeness A unique code for each
    substantially different procedure
  • Expandability Structure should allow for
  • Standardized Terminology Definitions are well
    defined, with no multiple meanings, and each term
    assigned a specific meaning
  • Multi-axial Structure Should contain
    independent characters, and an individual axis
    that maintains its meaning across ranges of codes

ICD-10-PCS Code Structure
  • Individual values rather than lists of fixed
    codes and text descriptions
  • Seven character alphanumeric code
  • Index and tables

  • Section 0 Medical and Surgical
  • Body System D Gastrointestinal System
  • Operation T Resection cutting out or off,
    without replacement, all of a body part

Body part Approach Device qualifier
1 esophagus, upper 2 esophagus, middle 3 esophagus, lower 4 esophagogastric junction 5. esophagus
6. Stomach 7 stomach, pylorus 8 small intestine 9 duodenum
A jejunum B ileum C ileocecal valve E large intestine F large intestine, right G Large intestine, left H Cecum I Appendix 0 open 4 percutaneous endoscopic 7 via natural/artificial opening 8 via natural/artificial opening endoscopic Z no device Z no device

Examples of ICD-10 PCS
  • Percutaneous needle core biopsy (diagnostic) of
    left kidney pelvis - 0TB43ZX
  • Right shoulder arthroscopy with coracoacromial
    ligament release - 0MN14ZZ
  • CABG of three coronary arteries using left
    autologous greater saphenous vein, harvested
    endoscopically - 021209W, 06BQ4ZZ
  • Ultrasonography, aortic arch, without contrast -
  • Lumbar epidural injection of steroid and local
    anesthetic - 3E1U38Z

  • ICD-9-CM
  • Terminology and classifications are outdated
  • Not able to accommodate addition of new codes
  • Lacks clinical detail to describe severity or
    complexity of diagnoses

  • ICD-10-CM
  • Greater specificity and clinical detail
  • Improvement in quality and usefulness of coded
  • Medical terminology and classification of
    diseases are consistent with current clinical
  • Greater flexibility in addition/revisions
    necessitated by medical advances
  • More amenable to computer assisted coding
    technology, which will reduce administrative
    costs associated with labor-intensive manual
    coding process
  • With adoption of the electronic health record, a
    standard code set is crucial
  • Offers providers and payers better data to
    improve performance, create efficiencies, and
    contain costs

  • Up to date classification systems will provide
    better data for
  • Measuring the quality, safety and efficacy of
  • Designing payment systems and processing claims
    for reimbursement
  • Conducting research, epidemiological studies, and
    clinical trials
  • Setting health policy
  • Operational and strategic planning and designing
    healthcare delivery systems
  • Monitoring resource utilization
  • Improving clinical, financial, and administrative
  • Preventing and detecting healthcare fraud and
  • Tracking public health risks

  • Effective with encounter and discharge dates on
    or after October 1, 2014.
  • Single implementation date for all users
  • No delays, no grace periods
  • Date of discharge for inpatient settings
  • Date of service for ambulatory and physician

General Equivalence Mappings (GEMS)
  • GEMS
  • Tool developed to assist with the translation of
    ICD-9-CM codes to ICD-10-CM/PCS and vice versa
  • Bidirectional (forward and backward) mappings
    developed between the ICD-9-CM diagnosis codes
    and ICD-10-CM
  • More complex than a simple one-to-one crosswalk

Examples of GEMS crosswalks
  • Nondisplaced fracture of the anterior wall of the
    acetabulum, left side, subsequent encounter for
    fracture with routine healing
  • S32.415D
  • Aftercare for healing traumatic fracture of the
  • V54.13
  • Atherosclerotic heart disease of native coronary
    artery with unstable angina
  • Combination code ICD-9-CM 414.01 411.1
  • ICD-10-CM I25.110

General Equivalence Mappings (GEMS)
  • Who will use GEMS?
  • Payers, providers, HIM professionals,
    Researchers, Informatics Professionals,
    Utilization Managers, Quality Managers,
    Developers of of Quality Measures, Software
  • How will GEMS be used?
  • -Convert large databases and test system
  • -Link data in long-term clinical studies
  • -Develop application-specific mappings
  • -Analyze data collected before and after the
    transition to ICD-10-CM/PCS
  • -Comparing data across the transition period for
    various reasons including calculating costs and
    institutional financial measurements

  • Detailed GEM user guides and further information
  • Websites
  • CMS
  • National Center for Health Statistics
  • Pocket Guide of ICD-10-CM and PCS (AHIMA)

Phases of Implementation
  • Phase 1 Impact Assessment
  • Involves assessing the impact of change to new
    coding systems and identifying key tasks and
  • Major tasks include
  • Creating an interdisciplinary implementation
    planning team
  • Identifying and budgeting for required IT changes
  • Assessing, budgeting, and implementing clinician
    and code set user education

Phases of Implementation
  • Phase 2 Overall Implementation
  • Involves 3 major tasks
  • Implementation of required IT changes
  • Follow-up assessment of documentation practices
  • Increasing education of the organizations coding
  • Items carried over from Phase 1

Phases of Implementation
  • Phase 3 Go-Live Preparation
  • This phase includes the following tasks
  • Finalization of system changes
  • Testing of claims transactions with payers
  • Intensive education of the organizations coding
  • Monitoring coding accuracy and reimbursement with
    prospective payment systems results (including
    DRG assignment)
  • Items carried over from Phase 2

Are YOU going to be affected by ICD-10?
  • More than likely the answer is YES!!!!
  • Areas affected by ICD-10 include
  • Health Information Management (Coding)
  • Information Technology (CPOE)
  • Utilization Management
  • Quality
  • Decision Support (Case Mix)
  • Billing
  • Clinical Applications
  • Compliance
  • Accounting
  • Registration/Scheduling
  • Physician Documentation
  • Contract Management
  • Any application where diagnoses are currently
    used today

Implications of ICD-10
  • Coding
  • ICD-10 CM will be used in ALL setting.
  • ICD-10 PCS is for inpatient procedure coding
  • Note CPT coding will have no impact with ICD-10
  • Productivity Decreases
  • Decrease if 50 in the beginning, gradually
    increasing over 3-6 months
  • never returning to pre-implementation
    productivity levels

Implications of ICD-10 for Coders
  • Training/Education
  • Inpatient Coder (experienced) 50 hours
  • Anatomy/Physiology/Medical Terminology
    re-education is in addition to these hours
  • Outpatient Coder 16 hours
  • Average Coder needs
  • 16 hours of ICD-10-CM
  • 24 hours of ICD-10-PCS
  • 10 hours of additional practice

Education Requirements for AHIMA Certified
  • CEU requirements in ICD-10-CM/PCS by credential
    are shown below
  • CHPS 1 CEU
  • CHDA 6 CEUs
  • RHIT 6 CEUs
  • RHIA 6 CEUs
  • CCS-P- 12 CEUs
  • CCS 18 CEUs
  • CCA 18 CEUs
  • Note Professionals who hold more than 1
    credential will only report the highest number of
    CEUs from among all credentials.
  • (RHIA, CCS will need 18 CEUs in ICD-10)

Anatomy and Physiology Review for ICD-10-CM/PCS
  • Dakota State University
  • Online 30 modules
  • CE units available

Implications of ICD-10
  • Information Technology
  • Version 5010
  • X12 standards consist of software that permits
    electronic data interchange (EDI)
  • One of those changes allows the X12 standards to
    recognize different versions of the diagnostic
    and procedures codes so that once in place the
    software can identify ICD-9-CM from ICD-10-CM 

Implications of ICD-10
  • Information Technology
  • ICD-9 and ICD-10 will need to be supported by the
  • Changes in multiple systems/applications to
    support the new code format ( 7 characters
  • Increases to storage capacity
  • Reporting
  • Edits (medical necessity)
  • CPOE
  • Scheduling
  • Encoding software
  • Provider Profiling
  • Project Planning/Timelines

Implications of ICD-10
  • Physicians
  • Need for improved and more specific documentation
  • Purpose of ICD-10 and more specific diagnoses
  • Measure quality and safety of care
  • Design of reimbursement systems
  • Conducting research and clinical trials
  • Operational/Strategic planning
  • Tracking public health risks
  • More specific documentation better clinical data

Implications of ICD-10
  • Documentation Issues
  • Capturing new information
  • Updating information
  • Expanding documentation
  • Example S52.319A
  • unspecified

Frequently Asked Questions
  • Where can I find resources on ICD-10?
  • CMS website
  • http//www.cms.gov/ICD10/
  • AHIMA website
  • http//www.ahima.org/icd10/
  • NCHS website http//www.cdc.gov/nchs/icd/icd10cm.h

Frequently Asked Questions
  • Will ALL AHIMA credentials have to comply with
  • Yes
  • Is ICD-10 CM only for Inpatient Hospitals?
  • No, It will be used in all settings that
    currently use ICD-9 CM Classification

Frequently Asked Questions
  • Will all providers and payers begin using
    ICD-10-CM/PCS at the same time?
  • Yes
  • Will there be a phase-in time period where
    providers can use either ICD-9-CM or
  • No

  • Who maintains ICD-10-PCS?
  • CMS develops and maintains ICD-10-PCS
  • Will ICD-10-PCS be used in Physician Office
  • No, PCS will only be used for Inpatient hospital
  • How will the implementation of ICD-10-CM/PCS
    change the Medicare Prospective Payment System?
  • CMS indicates that initially PPS case mix groups
    may not fundamentally change

Preparation Plans
  • Establish an ICD-10 Steering Committee
  • AHIMA ICD-10 Checklist
  • http//www.ahima.org/downloads/pdfs/resources/chec
  • Impact Assessment
  • Systems Review
  • Readiness Awareness/Education
  • Clinical Documentation Review
  • Training of Anatomy/Physiology


  • Pocket Guide of ICD-CM and ICD-10-PCS , Zeisset
    Bowman, AHIMA, 2010
  • Rode, Dan. "Why 5010 Is Needed." Journal of
    AHIMA 81, no.2 (February 2010) 52-53.
  • Dimick, Chris, Top Documentation Issues for
    ICD10, Journal of AHIMA, (April 2011),online
  • Dimick, Chris, CMS Readies for 5010, ICD10,
    Journal of AHIMA, (May 2011) online
  • Moynihan, Jim. "Preparing for 5010 Internal
    testing of HIPAA Transaction Upgrades recommended
    by December 31." Journal of AHIMA 81, no.1
    (January 2010) 22-26.
  • AHIMA e-HIM Workgroup on the Transition to
    ICD-10-CM/PCS. "Planning Organizational
    Transition to ICD-10-CM/PCS." Journal of
    AHIMA 80, no.10 (October 2009) 72-77.
  • Faye Browns ICD-9-CM Coding Handbook 2011,
    Leon-Chisen, AHA 2010
  • Zeisset, Ann. "ICD-10-CM Enhancements A Look at
    the Features That Will Improve Coding
    Accuracy" Journal of AHIMA 80, no.2 (February
    2009) 55-58.
  • Barta, Ann et al.. "ICD-10-CM Primer." Journal
    of AHIMA 79, no.5 (May 2008) 64-66.
  • www.cms.gov

Understanding the Change for Long Term Care
  • By
  • Kathy Andersen, RHIT, CCS,CPAT,CCAT
  • SDHIMA Director of Education
  • Revenue Cycle Management Rapid City Regional

Long Term Care Hospitals (LTCHs) Prospective
Payment System High Cost Outlier
  • LLTCHs are certified under Medicare as
    short-term acute care hospitals. LTCHs treat
    patients with multiple
  • comorbidities requiring long-stay hospital-level
    of care. For Medicare purposes, they use the
    average Length of Stay (LOS) greater then 25
    days. A Higher Cost Outlier is an adjustment to
    the Federal payment rate for LTCH stays that
    exceed the typical cost for a Medicare Severity
    Long Term Care Diagnosis Related Group

Document, Document!
  • LTCH PPS Final Rule
  • This rule emphasizes that proper coding is
    essential for correct diagnosis and procedure
  • ICD-10 Office Guidelines are to be followed
  • October 1 ,2013 will be the last major update to
    ICD-9, ICD-10 will be effective October 2014
  • Coding guidelines will have little change, but
    the detail of documentation needed to code a
    record for reimbursement will

Reporting Guidelines for LTC
V57.89, Multiple therapies, V54.13 Aftercare for
healing fracture (Repaired with ORIF), 332.0
Parkinson's disease
  • Principal Diagnosis and Guidance
  • Definition
  • Principal Diagnosis indicates the principal,
    primary and first listed diagnosis for each
  • Reason for Skilled Services
  • Condition established after study to be chiefly
    responsible for occasioning the admission of the
    hospital care.
  • Example
  • A resident was initially admitted to a LTC
    Facility to receive physical and occupational
    therapy services due to aftercare for a healing
    hip fracture. The resident remains in the
    facility because of his Parkinsons disease.
  • How would you code this?

Continued Stay Codes
  • Code 332.0 Parkinsons disease becomes the
    principal/primary diagnosis, as it is the reason
    for the continued stay.
  • If a year later the resident is transferred to
    the hospital for treatment of pneumonia and
    returns to the nursing facility after a three-day
    hospital stay. We would use 332.0, 486
    (Pneumonia) with the order for multiple therapies.

Medical Reviews
  • Pre and Post Payment Reviews by CERT/ADR/RAC
  • Key Components
  • Education
  • Training
  • Evaluation of Staff
  • responsibilities
  • Internal Audits
  • Review Billing
  • Cost reporting
  • Compliance Program
  • Guidance for Nursing Facilities is imperative
  • Review-LTC Facilities
  • Process
  • Polices
  • Procedures
  • Prevention

Preparing for ICD-10
Credentialed HIM Professionals Knowledge and
Expertise Industry Preparedness for
ICD-10 Accurate Coding Data Documentation
Improvement Electronic Medical Record Internal
and External Auditing Monitor Denials and Appeal
when necessary
  • Stages of Appeal
  • Redetermination
  • Reconsideration
  • Administrative Law Judge (ALJ)
  • Court/Hearing

Audit and Quality Monitoring
  • Critically important for all LTC Facilities

Implement an effective audit process Review Rebil
l Reimbursement Revenge
Comparing Roles
  • Coders
  • Clinicians
  • Coders new role
  • Computer-Assisted Coding (CAC)
  • Documentation Improvement
  • HIM Proactive role with Quality Improvement
    process to ensure data reporting
  • Clinicians new role
  • Clinical Documentation Improvement (CDI)
  • Utilization Review
  • Quality Review
  • Quality Improvement

  • Knowing where and when to start is the key to
    your success

Knowing where to find the right resources you need
  • Review-AHIMAs LTC Health Information Practice
  • AHIMA Certified Trainers
  • Certified Coders
  • Internal Medical Auditors
  • www.AHIMA.ORG
  • www.SDHIMA.org
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