CPMA

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CPMA April 11, 2015 Phill Ward, DPM President,
APMA

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Whats new for 2015

• CPT 20600
• (Descriptor change)
• Arthrocentesis, aspiration and/or injection,
  small joint or bursa (e.g., fingers, toes)
  without ultrasound guidance

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Whats new for 2015

• CPT 20604
• (New Code)
• Arthrocentesis, aspiration and/or injection,
  small joint or bursa (e.g., fingers, toes) with
  ultrasound guidance with permanent recording and
  reporting

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Whats new for 2015

• CPT 20605
• (Descriptor change)
• Arthrocentesis, aspiration and/or injection,
  intermediate joint or bursa (e.g., ankle, wrist,
  elbow) without ultrasound guidance

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Whats new for 2015

• CPT 20606
• (New Code)
• Arthrocentesis, aspiration and/or injection,
  intermediate joint or bursa (e.g., ankle, wrist,
  elbow) with ultrasound guidance with permanent
  recording and reporting

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Whats new for 2015

• CPT 97605
• (descriptor change)
• Negative pressure wound therapy (e.g. vacuum
  assisted drainage collection) utilizing durable
  medical equipment (DME), including topical
  application(s), wound assessment, and
  instruction(s) for ongoing care, per session
  total wound(s) surface area less than or equal to
  50 square centimeters
• Example KCI wound vac

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Whats new for 2015

• CPT 97606
• (New code)
• Negative pressure wound therapy (e.g. vacuum
  assisted drainage collection) utilizing durable
  medical equipment (DME), including topical
  application(s), wound assessment, and
  instruction(s) for ongoing care, per session
  total wound(s) surface area greater than or equal
  to 50 square centimeters
• Example KCI wound vac

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Whats new for 2015

• CPT 97607
• (New code)
• Negative pressure wound therapy (e.g. vacuum
  assisted drainage collection) utilizing
  non-durable medical equipment including
  provision of exudate management collection
  system, topical application(s), wound assessment,
  and instruction(s) for ongoing care, per session
  total wound(s) surface area less than or equal to
  50 square centimeters
• Example Snap

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Whats new for 2015

• CPT 97608
• (New code)
• Negative pressure wound therapy (e.g. vacuum
  assisted drainage collection) utilizing
  non-durable medical equipment including
  provision of exudate management collection
  system, topical application(s), wound assessment,
  and instruction(s) for ongoing care, per session
  total wound(s) surface area greater to 50 square
  centimeters
• Example Snap

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Whats new for 2015

• -59 modifier change (only for CMS so far)
• -XE (separate encounter)
• -XS (separate structure)
• -XP (separate practitioner)
• -XU (unusual overlapping service)
• CMS has been less than clear in their notices
  about how/when to use these modifiers
• MLN article dated Feb 2015 still doesnt clarify
  the usage of these modifiers

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Whats new for 2015

• Examples
• -XE
• Patient was seen in the morning and returned in
  the afternoon for another service
• -XS
• Services were provided on nails and lesions or
  bunion and hammertoe

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Whats new for 2015

• Examples
• -XP
• Bone graft harvested by 1 surgeon and used by
  another surgeon on the same patient in the same
  encounter
• -XU
• 2 lesions present in the same code set and are
  excised separately

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Ongoing Controversy

• Nerve injections
• Other peripheral nerve 64450
• Neuroma Steroid 64455
• Neuroma Sclerosing 64632
• Other sclerosing 64640
• Other misc nerve 64999

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What About Globals?

• 10 day global
• 2017
• 90 day global
• 2019
• CPT Assistant March 2015 revision of global
  package definition/interpretation

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Meaningful ? Use

• 50 of eligible providers did not attest for
  Stage I
• 4 eligible providers successfully attested for
  Stage II in 2014

• Congressional (in)action
• Flex It Bill Rep Elmers
• Jan 30, 2015 CMS comments

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Sustainable Growth Rate andMedicare Fee Schedule
Reform

• House passed SGR reform 3/25
• Senate refused to act before Easter vacation
• /-21 decrease on April 1, 2015
• Senate is supposed to act soon

• Multiple payment models proposals to replace Fee
  For Service model
• No decisions made yet, likely a testing period
  before implementation

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• If you dont want to use ICD-10
• then dont
• ?
• have a nice day

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Postponement?

• It is possible that Congress will once again
  postpone ICD-10 implementation
• Are you willing to bet your practice on it?

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The Train has left station!!

• So what has APMA done to prepare you for ICD-10?

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APMA News Articles

• link http//www.apma.org/YourPractice/content.
  cfm?ItemNumber1413
• There have been more than 20 ICD-10 articles in
  the APMA News
• All are available for download on the APMA
  website

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Webinar Series

• There has been a series of ICD-10 webinars
  presented and recorded and archived on the APMA
  website

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Coding Resource Center

• The CRC has been updated with a crossover
  capability to translate ICD-9 codes to ICD-10
  codes

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ICD-10 Potential negative impacts

• Decreased productivity
• Interrupted cash flow
• Increased amount of rejections
• Incompatible systems
• Increased volumes of work
• Incorrect mapping
• Increased risk of payer audits
• Having to run 2 diagnosis coding systems at the
  same time

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ICD-10 Potential positive impacts

• Better specificity
• Better data collection

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ICD-10 Rules

• SYMBOLS and CONVENTIONS To get started with any
  new system, one must first understand the rules.
  This webinar will now address the symbols and
  conventions next.
• Never code from the Alphabetic Index because
  important instructional notes will surely be
  missed.
• 1) In the text a ? colored dot cautions you to
  make sure you use additional digit(s) to ensure
  greatest specificity.
• 2) Unspecified The Square before a code
  indicates there are more specific codes without
  the symbol. It is still a valid first line code
  but if possible look for the code with highest
  specificity.
• 3) OGCR This symbol indicates there is
  Official Guidelines for Coding and Reporting.
  The passage is usually placed near the codes in a
  colored box.

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 4) CC Indicates complications and
  comorbidities. MCC indicates Major
  Complications and comorbidities. Published in the
  Federal register these two codes address
  Inpatient Prospective Payment System (IPPS).
• 5) Z codes that have a number 1 inside a circle
  before them means the code must be listed first.
• 6) The ½ symbol inside a circle before a Z code
  indicates this code may be the first or second
  listed code.
• 7) The number 2 inside a circle before Z codes
  means it is listed as a secondary code.

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 8) The Excludes 1 is when two conditions can
  not occur together.
• 9) The Excludes 2 means not included here. This
  is the case where it is acceptable to use both
  the code and the excluded code together.
• 10) The Code first/Use additional code means when
  there are multiple body system manifestations you
  code the underlying condition first and the
  manifestation second.

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 11) In diseases classified elsewhere these
  codes are never permitted to be used as first
  line codes. These codes must be listed after the
  underlying condition.
• 12) Code also means two codes may be required
  but the sequencing of the codes is discretionary.
  
• 13) 7th characters means the applicable 7th
  character must always be used and placeholder x
  used as a 5th character and/or 6th character
  codes to allow for future expansion.
• 14) and This word is interpreted as either
  and or or.

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 15) Includes in a colored box further defines
  or gives examples of the content. This notation
  appears immediately under a code title.
• 16) Abbreviations NECNot Elsewhere
  Classifiable this is another specified code,
  used when a more specific code is not available.
  NOS Not otherwise specified, this indicates
  an unspecified code.
• 17) Each ICD-10-CM diagnosis codes are to be
  reported ONCE for an encounter. When bilateral
  conditions exist, this one listed code counts
  when no distinct code for laterality or two
  different conditions are classified.

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 18) Documentation for BMI should only report as
  secondary diagnosis codes.
• 19) The instruction see acts as a cross
  reference and directs the user to look elsewhere.
  This instruction is often found when the term or
  condition may not be the appropriate term. This
  is a mandatory instruction and must be followed
  for proper code selection.
• 20) See also is a reference instruction note to
  refer to a specific category, subcategory, or
  classification before making a code selection if
  you cannot find the diagnosis listed under a term
  in Volume 2.

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 21) Laterality. An unspecified side code is also
  provided should the side not be identified in the
  medical record. The unspecified side is either
  ends with a character 0 or 9 depending on whether
  it is a fifth or sixth character.
• 22) Dummy Place holders using the character
  x. The x is used as fifth or sixth character
  placeholder to allow for future expansion. Some
  codes in ICD-10-CM require either 6th or 7th
  characters in the code. If the code, for example,
  had 5 characters and a seventh character was
  required based on the instructional notes, dummy
  placeholder would be used in sixth character
  position to allow for the seventh character to be
  reported

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 23) Brackets are used in the index and to
  identify manifestation codes.
• 24) ( ) Parentheses are used in both the Index
  and Tabular List to enclose supplemental words
  that do NOT affect the code number. The terms
  within the parentheses are referred to as
  nonessential modifiers.
• 25) Colon is used after an incomplete term that
  needs one or more of the modifiers that allow it
  assignable to a given category.

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ICD-10 Rules

• SYMBOLS and CONVENTIONS Continued
• 26) Dash at the end of a code indicates
  additional digits are required to complete the
  diagnostic term.
• 27) , Comma words following a comma are
  essential modifiers. The term in the inclusion
  note must be present in the diagnostic statement
  to qualify the code.

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ICD-10 Structure

• Same as ICD-9
• Chapters
• 22 Chapters identifying categories
• Blocks
• Subchapters
• Etiology, anatomical site, severity
• Rubrics
• Identify closely related conditions
• Extensions

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ICD-10 Chapters

• Chapter 1 A00-B99 Infectious and Parasitic
  diseases
• Chapter 2 C00-D49 Neoplasms
• Chapter 3 D50-D89 Hematological and Immune
  Systems
• Chapter 4 E00-E90 Endocrine, Nutritional and
  Metabolic Diseases
• Chapter 5 F01-F99 Mental and Behavioral
  Disorders
• Chapter 6 G00-G99 Diseases of the Nervous System
• Chapter 7 H00-H59 Diseases of the Eye and Adnexa

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ICD-10 Chapters

• Chapter 8 H-60-H95 Diseases of the Ear and
  Mastoid
• Chapter 9 I01-I99 Diseases of the
  Circulatory System
• Chapter 10 J00-J99 Diseases of the Respiratory
  System
• Chapter 11 K00-K94 Diseases of the Digestive
  System
• Chapter 12 L00-L99 Diseases of the Skin and
• 
  Subcutaneous Tissue
• Chapter 13 M00-M99 Disease of the
  Musculoskeletal
  System and Connective Tissue
• Chapter 14 N00-N99 Diseases of the Genitourinary
  System

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ICD-10 Chapters

• Chapter 15 O00-O99 Pregnancy, Childbirth and
  Puerperium
• Chapter 16 P00-P96 Certain Conditions
  Originating in the Perinatal Period
• Chapter 17 Q00-Q99 Congenital Malformations,
  Deformations and Chromosomal Abnormalities
• Chapter 18 R00-R99 Symptoms, Signs and Abnormal
  Clinical and Laboratory findings, not
  classified elsewhere
• Chapter 19 S00-T88 Injury, Poisoning and Certain
  other Consequences of External Causes
• Chapter 20 V00-Y98 External Causes of Disease or
  Morbidity
• Chapter 21 Z00-Z99 Factors Influencing Health
  Status and Contact with Health Services
• Chapter 22 Special Purposes

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How Detailed is ICD-10?

• Decacodaphobia
• Definition Fear of ICD-10
• Z23.670

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ICD-9-CM vs. ICD-10-CM

• ICD-9-CM

• ICD-10-CM

• Numeric characters (with exception of some codes
  beginning with V, E, M)
• 3-5 in length
• About 13,000 codes

• Alphanumeric characters always begin with an
  alpha character
• 3-7 characters in length
• About 68,000 codes

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ICD-9-CM ICD-10-CM

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Other ICD-10 to ICD-9 Differences

• Laterality (side of the body affected
  right/left) has been added to relevant codes
• Injuries grouped by anatomic site rather than
  type of injury
• Expanded use of combination codes
• Certain conditions and associated common symptoms
  or manifestations
• Poisonings and associated external causes

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Format differences
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Combination Code Examples

• E11.52 Type 2 diabetes mellitus with diabetic
  
• peripheral angiopathy with gangrene
• E11.621 Type 2 diabetes mellitus with foot ulcer
  Use additional code to identify site of ulcer
  L97.4-,L97.5-
• I69.144 Monoplegia of lower limb following
• nontraumatic intracerebral hemorrhage
  affecting
• left non-dominant side
• I70.235 Atherosclerosis of native arteries of
  right
• leg with ulceration of other part of
  foot

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ICD-9-CM ICD-10-CM

• V49.71 - Lower limb
• amputation status,
• great toe

• Z89 Acquired absence of limb
• Z89.4 Acquired absence of toe(s), foot, ankle
• Z89.41 Acquired absence of great toe
• Z89.411 - Acquired
• absence of right great
• toe

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ICD-10-CM Structure - Format

• 3-7 character examples
• L84 Corn and callosities
• B95.5 Staphylococcus aureus as the cause of
  diseases classified elsewhere
• M20.11 Hallux valgus (acquired), right foot
• T78.01D Anaphylactic shock due to peanuts
  (subsequent encounter)
• S98.111A Complete traumatic amputation of right
  great toe (initial encounter)

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ICD-10-CM

• Fracture codes require a 7th character The
  fracture extensions are
• A - Initial encounter for closed fracture
• B - Initial encounter for open fracture
• D - Subsequent encounter for fracture with
  routine healing
• G - Subsequent encounter for fracture with
  delayed healing
• K - Subsequent encounter for fracture with
  nonunion
• P - Subsequent encounter for fracture with
  malunion
• S - Sequelae

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2015 , ready to retire?

• ICD-10 training and implementation
• PQRS penalties take effect this year
• MU2 can you get 5 of your patients to request
  info ?
• E-Prescribing
• HIPAA Drs. offices now being looked at
• Affordable Care Act higher deductibles and
  copays
• Have you got your line of credit yet?

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BtwObamacare too
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ICD-9-CM ICD-10-CM

• Both ICD-9 and ICD-10 Alphabetic Indexes
• Recommend beginning your code search in Volume 2
  (alphabetic), then verifying the code in Volume 1
  which is much more detailed
• (Most EHR will do this automatically after you
  type in an alpha search term)

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Alphabetic Index (ICD Volume 2)

• ICD-9 Alphabetic Index

• ICD-10 Alphabetic Index

• Hallux 735.9
• limitus 735.8
• malleus (acquired) 735.3
• rigidus (acquired) 735.2
• congenital 755.66
• late effects of rickets 268.1
• valgus (acquired) 735.0
• congenital 755.66
• varus (acquired) 735.1
• congenital 755.66

• Hallux
• deformity (acquired) NEC M20.5x
• limitus M20.5x
• malleus (acquired) NEC M20.3-
• rigidus (acquired) M20.2-
• congenital Q74.2
• sequelae (late effect) of rickets E64.3
• valgus (acquired) M20.1-
• congenital Q66.6
• varus (acquired) M20.3-
• congenital Q66.3

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Tabular List (ICD Volume 1)

• ICD-9 Tabular Index

• ICD-10 Tabular Index

• 735 Acquired deformities of toe
• Excludes congenital (754.60 - 754.69, 755.65 -
  755.66)
• 735.0 Hallux valgus (acquired)
• 735.1 Hallux varus (acquired)
• 735.2 Hallux rigidus
• 735.3 Hallux malleus

• M20.1- Hallux valgus (acquired)
• Bunion
• M20.10 Hallux valgus (acquired),
  unspecified foot
• M20.11 Hallux valgus (acquired), right
  foot
• M20.12 Hallux valgus (acquired), left foot
• M20.2- Hallux rigidus
• M20.20 Hallux rigidus, unspecified foot
• M20.21 Hallux rigidus, right foot
• M20.22 Hallux rigidus, left foot
• M20.3- Hallux varus (acquired)
• M20.30 Hallux varus (acquired),
  unspecified foot
• M20.31 Hallux varus (acquired), right foot
• M20.32 Hallux varus (acquired), left foot

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Start with Index

• START WITH INDEX
• There is a period after the 3rd character and
  often a dash
• Example Pain
• M79.
• NEXT TO TABULAR - Define the site, etiology,
  manifestation or state of the disease or
  condition
• Example Pain
• M79. -

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ICD-9-CM ICD-10-CM

• Both ICD-9 and ICD-10 Alphabetic Indexes include
• the Index of Diseases and Injury
• the Index of External Causes of Injury
• The Tables of Neoplasm and
• The Table of Drugs and Chemicals
• Both ICD-9 and ICD-10 use an indented format
• Hallux 735.9
• rigidus (acquired) 735.2
• congenital 755.66

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ICD Guidelines

• Example Volume 2
• hallux valgus (acquired)

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ICD Guidelines

• Example Volume 1
• M20.1 Hallux valgus (acquired)

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ICD 10 Changes APMA Submitted for Change 10/1/2015

• M21.6 Other acquired deformities of foot
• Excludes deformities of toe (acquired)
• (M20.1-M20.6)
• M21.6x Other acquired deformities of foot
• M21.6x1 Other acquired deformities of right
  foot
• M21.6x2 Other acquired deformities of left
  foot
• M21.6x9 Other acquired deformities of
  unspecified foot
• M21.61 Bunion
• M21.610 Bunion deformity, unspecified
• M21.611 Bunion deformity, right foot
• M21.612 Bunion deformity, left foot
• M21.62 Bunionette
• M21.620 Bunionette deformity, unspecified
• M21.621 Bunionette deformity, right foot
• M21.622 Bunionette deformity, left foot

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The X, dummy

• Dummy 5th Character
• Just to confuse you even more ?
• To allow for further expansion some codes have a
  dummy 5th place character so that the 6
  character structure will not be disrupted when
  changes are added
• Report these codes as they are in the book
  including the dummy5th character x

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DEFINITION Unspecified

• Codes in the Tabular Listing that include
  unspecified in their description are to be used
  when the information in the medical record is
  insufficient to assign a more specific code.
• M20.10 hallux valgus (acquired), unspecified
  foot
• In other words, in the hallux valgus example,
  the medical record failed to distinguish which
  foot had the hallux valgus deformity.
• The Alphabetic Index uses NOS not otherwise
  specified for the same designation.

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DEFINITION Other Unspecified or Other

• Codes that include other or other specified
  in their description are found in the Tabular
  Listing.
• Other or other specified codes are to be used
  when the medical record documents a condition for
  which no specific ICD code exists.
• The corresponding term in the Alphabetic Index
  is NEC (not elsewhere classified).

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Next

• 4th Character
• Define the site, etiology, manifestation or state
  of the disease or condition
• Numeric
• Example Pain
• M79. -
• M79.6 pain in limb, hand, foot, fingers, toes

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5

• 5th Character
• 5th character identifies a level of specificity
• Letter or Number (0-9)
• Example
• M79. Pain
• M79.6 pain in limb, hand, foot, fingers, toes
• M79.60 Pain in limb

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6

• 6th character is even more specific
• Numeric (0-9)
• Describes specific location or cause
• For laterality
• 1 is right
• 2 is left
• 3 is unspecified
• Example Pain
• M79.-
• M79.6 pain in limb, hand, foot, fingers, toes
• M79.60 Pain in limb unspecified
• M79.671 Pain in right foot

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7th

• 7th Character
• Some codes have a so-called character extension
• Typically letters, that describe
  conditions/timing of the visit
• Used to give more information about the events
  related to the reason for the visit or service

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Non-fracture care A- initial encounter D- subsequent encounter S- sequela Fracture care A- initial encounter (for closed fracture) B initial encounter for open fracture D- subsequent encounter for normal healing fracture G- subsequent encounter for delayed healing fracture K- subsequent encounter for fracture with non-union P- subsequent encounter for fracture with mal-union S- sequela of fracture
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ICD-10 Look-Up Example

• Stage III decubitus ulcer of left heel
• Step 1 - Look up main term in Alphabetic Index
• Ulcer, ulcerated, ulcerating, ulceration
• See ulcer by site
• lower limb (atrophic) (chronic) (neurogenic)
  (perforating) (pyogenic) (trophic)
  (topical)
• pressure (pressure area) L89-
• heel L89.6-

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ICD-10-CM Look-Up Example

• Stage III decubitus ulcer of left heel
• Step 2 - Verify in Tabular
• L89.6- Pressure ulcer of heel
• L89.62- Pressure ulcer of left heel
• L89.623 Pressure ulcer of left heel,
  stage III

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More ICD Guidelines

• Brackets in the Tabular List enclose
  synonyms, alternative wording, or explanatory
  phrases
• M21.4 Flat foot pes planus (acquired)
• Brackets in the Alphabetic Index are used
  to identify manifestation codes
• Disease, diseased skin L98.9
• due to metabolic disorder NEC E88.9 L99

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Code First Use Additional Code

• An ICD sequencing example
• Diabetic (type I) heel ulcer
• Is the underlying condition

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Code First Use Additional Code

• The ICD sequencing instruction is to list
• the underlying condition code first
• L97 is a
• manifestation
• code

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ICD Guidelines

• Manifestation code L97.411
• It is coded after the underlying condition code,
  E10.621 diabetic (type I) heel ulcer

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At Risk Care and ICD-10

• ICD- 9

• ICD- 10

• 703.8 (onychauxis)

• L60.2 onychogryphosis, hypertrophic nails
• L60.3 nail dystrophy
• L60.8 other nail disorders
• L60.9 nail disorder, unspecified
• Q84.5 onychauxis, enlarged nails
• Q84.6 other cong. Nail dz

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Lets add PVD

• ICD-9

• ICD-10

• 443.9 PVD, unspecified

• I70.2- ASO of native arteries of extremities
• (IMPORTANT!!)
• The hyphen denotes additional characters required
  specific for ASO disease
• Need to be SPECIFIC unlike in ICD 9

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AndDiabetes

• ICD 9

• ICD 10

• 250.60
• Diabetes with neurological manifestations

• E10.4- type 1 DM with neuro complications
• E11.4- type 2 DM with neuro
• Z79.4- with insulin use
• E13.4- other specific DM with neuro comps.
• 13.61- other specified DM with diabetic
  arthropathy and Z79.4- for insulin use

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Oh yeah, thick nails

• ICD 9

• ICD 10

• 110.1
• onychomycosis

• B35.1 onychomycosis

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Lets add a keratoma

• ICD 9

• ICD 10

• 701.1 keratoderma

• L85.1
• L85.2

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Impact analysis

• Determine any area in the practice that currently
  utilizes an ICD-9-CM code
• Ask for input from the various departments
  (clinical and clerical) to ensure that nothing is
  overlooked
• How are performance measures captured
• Prior authorizations
• Research
• Tracking and trending

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Impact analysis

• Create a flow chart to
• Demonstrate how the action of each individual
  impacts the entire process
• Identify areas of weakness and quickly create a
  process to strengthen it
• Clearly illustrates the need for interaction
  between clinical or business areas
• Generate ownership of each process
• Provides a clear picture of how things work today
  and can outline how things should work in the
  future

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• Strategies for Success
• The first place to begin in preparing for ICD-10
  implementation is with communication
• Keep everyone updated on what is happening
• No delay expected, we need to continue to prepare
  for the transition
• If you take it seriously, so will the people you
  are leading
• What form of communication will be most effective
  in your office/institution

84
Build an action plan

• Build an action plan based on the results of the
  impact analysis
• Create a preliminary needs assessment
• Establish timeline parameters to create a roadmap
• Adhere to the timeline, but be open-minded to
  allow for unexpected circumstances
• Begin discussion early with vendors to understand
  their timelines

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Measure productivity

• Understand where productivity is at prior to the
  implementation of ICD-10
• Use this as a goal to get back to after the
  official implementation date
• Canada indicates that their productivity has not
  recovered since implementation
• Different reimbursement system
• Implemented EMR at same time as ICD-10
• Went from DOS system to a windows based claims
  world

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Questions for Consideration

• Is your EHR and billing system ICD-10 compatible
• Are you sure?
• Has it been tested?
• Have you tested it?

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Your take home message isDont be a dinosaur
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Things that will effect your income in 2015

• ACA implications
• Rise of deductibles
• Decrease in malpractice premiums
• ICD-10
• ACOs

• Retail clinics
• PCPs, NPs, Pas
• MU moves from carrot to stick
• PQRS penalties
• Reporting payments to physicians

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QUESTIONS?peward_at_apma.orgTwitter
_at_APMApresident
www.apma.org