Slide 1 Three ways to find the right ICD-10 code

Transcription

1 Slide 1 Three ways to find the right ICD-10 code Presented by Wyn L Staheli Director of Research & Editing 1 ICD-10 can be overwhelming, but, with some strategizing and planning it can be managed. In this presentation we will look at a few ICD-10 fundamentals, then familiarize ourselves with three methods for finding the right ICD-10 code. Each one is a different path, but all lead to the same destination: the right code. Slide 2 2 You may remember that there were some who thought the world would end on December 21, 2012 (because that was the end of the Mayan calendar). When that date passed, some thought that maybe it would be the next year, or the one after that. Many physicians feel that ICD-10 could be the end too. But that date keeps passing us by with no end in sight. It looks like 2015 will finally be the year. Don t worry though, with the right plan and the right tools, you will make it through the ICD-10-ocolypse.

2 Slide 3 Education Wyn L Staheli Bachelor s of Science, Management Information Systems (MIS) Experience Office Manager for an Infectious Disease specialist and behavioral health group Computer Programmer for a large insurance carrier as well as a California hospital system Writer and editor of medical resource books Founder of InstaCodeInstitute (which has been serving the medical community since 1996) Cofounder of FindACode.com Just in case you are wondering about who I am, here s my background. I ve played on both sides of the insurance game. 3 Slide 4 Why can t we keep using ICD-9? A common question, especially from providers, is: Why can t we just keep using ICD-9? It works fine. ICD-9 14,567 codes ICD-10 69,832 codes 4 The truth is that if you drop ICD-9 and ICD-10 into a ring together, ICD-10 will win every time. Not only is it much bigger, it is better. The codes are more detailed, more logical, and better organized. Sure, ICD-10 is a bigger code set, but as CMS recently stated in an alert about ICD-10: You don t have to use 68,000 codes. Your practice does not use all 13,000 diagnosis codes available in ICD-9. Nor will it be required to use the 68,000 codes that ICD-10 offers. As you do now, your practice will use a very small subset of the codes. Because ICD-10 is more logical, detailed and better organized, sticking with ICD-9 is like sticking with a type writer when you could be using Microsoft Word.

3 Slide 5 ICD-10 examples In ICD-9: E844.8 Sucked into jet without accident to aircraft; ground crew To illustrate to you just how detailed ICD-10 can be, we will take this ICD-9 code and translate it so that you can see how much information can be conveyed in the new codes. This really is an actual ICD-9 code. 5 Slide 6 ICD-10 examples In ICD-10: V97.3 Person on ground injured in air transport accident; Here we see the first four characters of the ICD-10 equivalent. Not much new yet. 6

4 Slide 7 ICD-10 examples In ICD-10: V97.33 Person on ground injured in air transport accident; sucked into jet engine As we add the fifth character we see some detail, but the code does not really offer anything that the ICD-9 equivalent did not. 7 Slide 8 ICD-10 examples In ICD-10: V97.33& Person on ground injured in air transport accident; sucked into jet engine, male; Now it gets interesting. The ampersand symbol offers the gender of the patient. 8 Slide 9 ICD-10 examples In ICD-10: V97.33&µ Person on ground injured in air transport accident; sucked into jet engine, male; under 5 5 in height; The greek letter, mew, describes the patient s vertical stature. 9

5 Slide 10 ICD-10 examples In ICD-10: V97.33&µ# Person on ground injured in air transport accident; sucked into jet engine, male; under 5 5 in height; slightly bald; The hashtag identifies the patient s hair status 10 Slide 11 ICD-10 examples In ICD-10: V97.33&µ#$ Person on ground injured in air transport accident; sucked into jet engine, male; under 5 5 in height; slightly bald; wearing a jump suit; The dollar sign describes his or her fashion choice. 11 Slide 12 ICD-10 examples In ICD-10: V97.33&µ#$ Person on ground injured in air transport accident; sucked into jet engine, male; under 5 5 in height; slightly bald; wearing a jump suit; during a full moon 12 And the euro symbol identifies the phase of the moon at the time of the incident. So, if you have not already guessed, most of this is made up. Symbols are not used in ICD-10, just letters and numbers. And the codes can be up to seven characters long, not ten, like this silly code. However, the characters and description you see in blue, V97.33 are all part of a real code. Some ICD-10 naysayers suggest that

6 the codes are useless because they provide detail that is not necessary. However, as you will see, much of the detail in real codes can actually be quite helpful in communicating the medical necessity of a claim to a third party payer. Slide 13 ICD-10 examples ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus. Note: there are 11 gout codes in ICD-9 and 365 in ICD Here is a real code that clearly demonstrates the additional detail available in ICD-10. The first three characters (M1A) represent the category, which is a group of related conditions. This one is chronic gout. The other gout category is M10 and it contains acute gout. The fourth character identifies the cause or etiology for this case of gout. There are actually six different digits that could go here, but we have selected the 3 for renal impairment for this example. The fifth character identifies the location. Even though gout usually occurs in the big toe, there are ten choices for this character, each one a different joint where gout could occur. The sixth character is a 1 for right, 2 for left, or 9 for unspecified. This is one of the new features of ICD- 10 that ICD-9 lacked: laterality. This category is one that offers a seventh character extension. It is a 0 or a 1 for without and with

7 tophus, which is an accumulation of uric acid crystals in the joint. You can see that this seven character code tells quite the story. A third party is less likely to ask for documentation when all this detail appears on the claim form. It is interesting to note that there are 11 codes for gout in ICD-9, but 365 in ICD-10, just because of all of the extra detail available. Slide 14 Tabular list layout Chapter Block 21 of them from A to Z Ranges of Categories categories Subcategories 3 characters 4 th or 5 th Codes characters 6 th or 7 th characters Note: Codes may be complete with fewer than 6 characters. Some codes only have Before we learn how to select the right codes, you need to know how the tabular list is organized. If you open up the tabular list of a code book, the first major subdivision you will find is chapters. There are 21 in ICD-10, which is up from 17 (plus 2) in ICD-9. They run from A to Z. The next subdivision of a chapter is a block. These cover ranges of categories, such as I70-I79 Diseases of arteries, arterioles, and capillaries. Blocks can be broken down to the three digit categories, such as I70 Atherosclerosis. Next, you add fourth and fifth characters, which are considered subcategories. Once you get down to sixth and seventh characters, those are just called codes. But note that codes may be complete with fewer than six characters. Some only have three characters, such as R42 Dizziness and

8 giddiness. In the book I am using as an example, complete codes will always be in bold, so it is easy to know if you have enough characters. Slide 15 Tabular List Chapter: 13, Diseases of the Musculoskeletal System and Connective Tissue (M00 M99) (always white font in a black box) Let s see how this looks in a coding manual. This is the beginning of chapter 13, which covers diseases of the musculoskeletal system. 15 Every code in this chapter begins with the letter M. It spans the range of M00 to M99. Notice all of the rules listed under the chapter heading. Just like ICD-9, these guidelines apply to every code in this chapter, so it is important to come back to them from time to time to make sure your code is the right one.

9 Slide 16 Tabular List A chapter is divided into blocks, or a range of three digit categories. Block: Deforming Dorsopathies (M40 M43) (Always bold CAPS, lined above and below) 16 This one is deforming dorsopathies. If there were guidelines that pertained to the whole block, they would appear under this heading. The formatting here makes it easy to see when a new block begins. Slide 17 Tabular List Category: M43-Other Deforming Dorsopathies (Always all CAPS, with a line above) 17 Blocks are divided into three digit categories. This one, M43-, is for other deforming dorsopathies. The use of the word other is diagnosis coding just means that the diagnosis can t be found in one of the other nearby categories. Notice that the formatting here makes it easy to spot when you are at the beginning of a new category because of the line above the three character heading. Also notice that M43- is followed by a hyphen, which indicates that this is not a complete code. All of the complete codes on this page lack a hyphen and they are in bold. Some have four, and some have five characters.

10 Slide 18 Tabular List Subcategory: M43.1- Spondylolisthesis 18 Once you add a fourth or fifth character you have entered a subcategory. This one is spondylolisthesis (spän-də-lō-lis-ˈthēsəs), which is a condition where the front part of a vertebra separates from the back part and slips forward. Notice that the subcategory is not a complete code because it is not in bold and it has a hyphen, which tips off the reader that he or she needs to keep adding characters. However, there are some instructions below this subcategory heading, and they apply to all codes which contain these four characters. The fifth character adds detail about the specific anatomic level in the spine. We will come back and visit this code category in a minute. Slide 19 Finding the ICD-10 code Now that we have covered some basic tabular list orientation, we are ready to actually learn how to find the right code. Translating from ICD-9 to ICD-10 is a lot like translating from English to French. You can t just take a sentence and translate each word one at a time. You have to consider the rules of grammar, such as proper sentence structure and grammar rules. The same is true in ICD-10. Some codes translate as an exact match. These are convenient, but few and far between. Some ICD-9 codes translate into multiple ICD-10 codes. These are called scenarios. Since there are five times as many

11 ICD-10 codes as there are ICD-9 codes, some can only be mapped backwards from ICD-10. Likewise there may be words in French that do not really have an English equivalent. You need to learn more than just a simple forwards translation to figure out how to use these new words (or codes) In some cases multiple ICD-9 codes can be combined into a single ICD- 10 code. But frequently, we find that the match is only approximate. Slide 20 Finding the ICD-10 code Three methods using the InstaCodeICD-10 book: 1. Commonly used code list (but don t stop there!) 2. GEMs code map (don t stop here either!) 3. Alphabetic index (still not safe!) Always confirm the code using the Tabular List 20 Finally, we are where the rubber meets the road. Here are the three strategies for finding the right ICD-10 code. They are [see above]. But the truth is that these methods are just step one of a slightly bigger process. Let s say that you walk into the supermarket, looking for grape juice. You might ask a clerk where to find it and he could point you to aisle 3. Once you get there you might find exactly what you are looking for on the end cap. Or, you might have to wander up and down the aisle until you spot it. Then you might want to compare brands, or nutritional content, or look for the best price. In fact, you might realize that you really need apple-grape juice, or, after searching for a while, you decide you really wanted chocolate milk all along. These three strategies all get you to aisle 3. But often you have to do some investigating before you can be certain that you have chosen the right

12 product (or code). You do this by digging through the Tabular List. Slide Common Codes 21 This is an example of a common codes list. This one is for spinal conditions in the lumbar region. It can be helpful because the provider won t need to search through all 70,000 ICD-10 codes. He or she can just browse this much shorter list, specific to the anatomical region of interest, and the provider s specialty. Unfortunately, using common code lists are a little misleading because ICD-10 has not yet been used in the US, so no one really knows which codes are truly common. These lists are being produced by specialty associations and coding book publishers, but at this point in time, they are really just best guesses. Hence, they cannot be relied upon completely. Whatever path they lead us down (like the aisle in the grocery store), we must confirm with the tabular list.

13 Slide GEMs General Equivalence Mappings (GEMs) o Created by the National Center for Health Statistics, part of the CDC o Forward maps from ICD-9 to ICD-10 o Backward maps from ICD-10 to ICD-9 o Approximations only 22 Many providers will say, Here is my old code. Just translate to the new one. That is what GEMs does. GEMs is a government database that allows us to crosswalk from ICD-9 to ICD-10, or from ICD-10 to ICD-9. It seems like it could eliminate all the concern about finding the right code, but, unfortunately, it does not work like that. We have been warned by CMS that GEMs are only approximations and they should not be used to code. Codes should only be selected based on the key terms found in the provider documentation. Nonetheless, GEMs can be helpful in identifying good prospects. Since GEMs was created by the government, it is in the public domain. You can obtain it for free, such as with the FindACode smart phone app. Slide GEMs Here is an example of a printed crosswalk based on GEMs forward mapping from ICD-9 to ICD-10. The ICD-9 codes are listed in numeric order in the left hand column and the ICD-10 equivalents are on the right. 23 Many times there is only one ICD-10 code listed, but sometimes multiple options are offered. Unfortunately, as we ll see in a moment, GEMs frequently crosses to unspecified codes because the original ICD-9 code was not very specific. Unspecified codes are expected to be denied, or lead to delayed payment if more detail could have been reported.

14 In this customized crosswalk, you ll notice that unspecified codes do not appear. Rather, code categories and subcategories are provided. They are not in bold and end with a hyphen to encourage the reader to go to the Tabular List to research the detail needed to complete the code. If a complete code is available, it is bolded. Slide Alphabetic index 24 The third, and best, strategy for finding the right ICD-10 code is the alphabetic index. This is the method that CMS recommends. For this approach, you do not need to know what the ICD-9 code was. You just need to read the provider documentation, pick out the key terms, and look them up in the index. Sometimes the index will take you right to a complete code, which will be in bold (in this book anyway), but often it only provides the first three or four characters of a code. This is indicated by a hyphen (and no bold), which means that the reader needs to seek out the rest of the code in the Tabular List. However, it is very important to then review the Tabular List before making the final code selection. There are often specific guidelines that should be considered before making the final code decision.

15 Slide 25 Example A 32 year old female presents with low back pain at L4/L5. The pain worsens with extension and with exercise. The patient complains of tight hamstrings and pain in the low back. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2015, the diagnosis is Acquired Spondylolisthesis. On October 1, 2015, it is: Here is an example of a case. We will use all three methods to seek out the appropriate ICD-10 code, then confirm using the tabular list. [read the example] 25 Note that, at this time, we have been instructed to report ICD-9 codes for dates of service that occur prior to October 1. There is no testing or dual reporting period. But there has been some movement among some healthcare provider s organizations to create a sort of transitionary period where both codes could be accepted. Slide Common Codes 26 This common codes list contains musculoskeletal diagnoses for the lumbar spine. It is simply listed in alphanumeric order, so the only way to try to find our new code is to browse the list until we see something we like. Highlighted in the bottom left corner, you can see two possible codes under the heading for spondylolisthesis. One is for the lumbar region, M43.16, and the other is lumbosacral. Since the note said L4, we can stick with M This could be the right code, and we might be done with our search. However, we should use the other two strategies, then confirm with the Tabular List, just to be sure.

16 Slide GEMs 27 This is a GEMs based crosswalk or code map. As we scan the ICD-9 column, we come to 738.4, which is the code we are starting with. This is a one-to-two map. Upon examination, we ll see that that only one of the ICD- 10 codes matches the wording from the provider documentation, M43.1- Spondylolisthesis. However, we were only given the subcategory, not the complete code. We ll have to go to the Tabular List to see how many more characters we need to code to the highest level of specificity. The official GEMs crosswalk points to an unspecified code, but this list omits those codes and replaces them with an unbold, hyphenated subcategory, forcing the user to dig deeper, rather than default to the undesirable unspecified code. Before we go to the Tabular List, let s use the third strategy. Slide Alphabetic index 28 As we look up the key term, spondylolisthesis in the alphabetic index, we are led to a few options. The first code suggested is M43.10, and it might just be the one we are looking for. But, a little closer inspection will lead us to M43.16 which is specific to the lumbar region. Sometimes the alpha index does not offer a complete code, but we know it does in this case because the code is in bold. Now we need to go take a look at the Tabular list and see if M43.10 or

17 M43.16 is a better choice. Slide 29 The three strategies have all led us here, to the Tabular List. 29 The first option we found, using a commonly codes list, was M This was also suggested by the Alphabetic Index. It looks pretty good. We now see that M43.10 was the unspecified code, so it should be avoided if we have information to choose a better code. M43.1- is just the subcategory. It is not bold, so it is incomplete, but it does help us to identify some guidelines that apply to the code(s) we are interested in. Excludes1 means that these other codes are mutually exclusive and cannot be coded along with any M43.1- codes. For example, a patient can either have congenital spondylolisthesis, or acquired spondylolisthesis, but not both. Within the Tabular List, we should always trace back to the beginning of the category to see if there are any other important guidelines. On the

18 left of this page, we see that M43- has list of Excludes1 notes. We should look over that list to see if any of those diagnoses provide a better option. Notice that there are some rules on the bottom left, under M43.0- as well. Those rules do not apply to the M43.1- subcategory, so we can ignore them. Slide 30 Example A 32 year old female presents with low back pain at L4/L5. The pain worsens with extension and with exercise. The patient complains of tight hamstrings and pain in the low back. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2015, the diagnosis is Acquired Spondylolisthesis. On October 1, 2015, it is: M43.16 Spondylolisthesis, lumbar region Note: Common codes lists are just an expert guess GEMs is often unspecified Alphabetic Index often gives incomplete or multiple options 30 If we go back to our example, we can choose our code. We went down to aisle 3, we compared all the grape juice and we found the one that meets our needs. M It really is not that different from the ICD-9 code that we started with, except that it offers the specific anatomical region. Note that the common codes list gave two options, each with a different anatomical region. We had to know our anatomy in order to select the right code. The code map did not give us a complete code, and the alpha index gave a few options too. However, it was only in the Tabular List where we found the detail we needed to confidently choose the correct code.

19 Slide 31 Example 2 68 year old Hispanic female with Type 2 DM, controlled with insulin, with mild nonproliferativediabetic retinopathy without macular edema. On September 30, 2015, the diagnosis is DM Type 2, insulin dependent with ophthalmic manifestations, controlled. On October 1, 2015, it is: Example 2 is an example of a common coding situation diabetes. 31 Slide Common Codes 32 This sample of commonly used codes from a professional organization shows Type 2 diabetes codes. It is simply listed in alphanumeric order, so the only way to try to find our new code is to browse the list until we see something we like. One possible code is highlighted. This could be the right code, and we might be done with our search. However, we should use the other two strategies, then confirm with the Tabular List, just to be sure. Slide GEMs 33 Using a GEMs based crosswalk or code map we can scan the ICD-9 column, we come to , which is the code we are familiar with. This is a one-tomany map. Upon examination, we ll see that that only one of the ICD-10 codes matches the wording from the provider documentation, E11.3-Type 2 Diabetes Mellitus with ophthalmic manifestations. However, we were only given the subcategory, not the complete code. There is on information in the ICD-10-

20 CM column about not stated as uncontrolled. We ll have to go to the Tabular List to see how many more characters we need to code to the highest level of specificity. The official GEMs crosswalk points to an unspecified code, but this list omits those codes and replaces them with an unbold, hyphenated subcategory, forcing the user to dig deeper, rather than default to the undesirable unspecified code. Before we go to the Tabular List, let s use the third strategy. Slide Alphabetic index 34 As we look up the key terms, diabetes, type 2 with retinopathy in the alphabetic index, we are led to a few options. The first code shown is E11.319, however, it does not include all the required elements of our coding example. By continuing the same as we have become accustomed to with ICD-9 indexes, we find E which includes all the elements of our coding example. Sometimes the alpha index does not offer a complete code, but we know it does in this case because the code is in bold. Now we need to go take a look at the Tabular list to make sure that there are no exclusions or guidelines which might reveal a better code choice.

21 Slide 35 All three strategies have all led us here, to the Tabular List. 35 There are no guidelines associated with this code, however, just like ICD- 9, we should always trace back to the beginning of the category to see if there are any other relevant guidelines. On the left of this page, we see that E11- has list of Excludes1 notes. It is important to look over that list to see if any of those diagnoses provide a better option. In our example, none are applicable. However, there is an important use additional code guideline that applies. With ICD-10, insulin use is documented with it s own code, in this case Z79.4. Remember, an Excludes1 guideline means that these other codes are mutually exclusive and cannot be coded along with any E11- codes. For example, if the patient s diabetes is due to an underlying condition, you cannot use an E11- code. Finally, take a look at the highlighted See Guidelines notation. That is a unique InstaCode Institute helpful tool which lets you know that there are official guidelines regarding the coding of Type 2 Diabetes Mellitus. It also tells the user WHERE to look in the guidelines to find those instructions. Very handy!

22 Slide 36 The next step for converting to ICD Go to the Tabular List o Look at the following: 1. Notes 2. Includes and alternative wording 3. Excludes1 4. Excludes2 5. Code Also, Code First, Use Additional 6. Seventh character extensions 2. Repeat at the level of the code, then the subcategory, category, block, and chapter 3. Reverse map for confirmation if necessary 36 We don t have time to go through all of the ICD-10 conventions and guidelines, but be sure to get educated on these rules so that you can become fluent in ICD-10. Just like you need to study French in order to become fluent, you need to get familiar with the rules of grammar in ICD-10 coding so that you can speak with the natives, or rather avoid interruptions to your reimbursement. Slide 37 In many cases, ICD-10 requires that provider documentation meet new standards in order to properly select codes. But with all the changes, this might seem a little daunting. 37 To assist healthcare providers with this issue, InstaCode Institute created Provider Documentation Guides which are part of our ICD-10 books. There are 3-5 Examples of these documentation guides in each book. These guides are great to use for 10 minute training sessions to prepare providers for the new ICD-10 requirements. This slide shows a PDG for Type 2 Diabetes Mellitus using the example we just used. The What to Document section becomes the healthcare provider s documentation cheat sheet. It lets them know what information a coder needs to know and helps prompt them to include additional information where required.

23 Slide 38 Here is a continuation of the Provider Documentation Guide (PDG) showing the remaining character options. 38 This standard can be used for other commonly used codes for your specialty. Look at your codes and review your provider documentation and see where you need to beef up your documentation. Create your own PDGs to begin proper documentation right now. Slide 39 The examples shown today were from InstaCode Institute s ICD-10 specialty books. There are 24 different specialties, each with their own customized ICD-10 code listings, training and Provider Documentation Guides. Come to our booth to see some examples and get a flyer. We have special pricing available for those who wish to order one today.