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A straw-poll vote by attendees at the Workgroup for Electronic Data Exchange (WEDI) ICD-10 Emergency Summit indicated favor for 2015 as the implementation date for the new code set.

July 9, 2013

Potholes in the ICD-10 Testing Road

By Maria Bounos, RN, MPH, CPC-H

ICD-10 testing has been a major topic of conversation recently, and understandably so. As a matter of timeline, all healthcare providers should be well into their implementation plans by now, but some areas of the industry may be experiencing more difficulties than others.

Senior Policy Advisor for Government Affairs of the Medical Group Management Association (MGMA) Robert Tennant presented findings of a recent research project to the National Center for Vital and Health Statistics Subcommittee on Standards in mid-June. The 1,195 respondents to the MGMA research survey described a bleak picture of their path down the road to ICD-10 implementation and testing.

When asked when their major health plan partners would be ready to perform ICD-10 testing, 71.2 percent of respondents said they had not heard from those partners. Some 60 percent also said they had not heard from their clearinghouses about when they plan to start ICD-10 testing. Those are some pretty hefty percentages.

The percentage of respondents that have not heard from their clearinghouses paints an even bleaker picture, however, when combined with the fact that more than 78 percent of the survey respondents said they use a clearinghouse for between 80 to 100 percent of the insurance claims they process. If the clearinghouses and the payers are not informing data trading partners about the expected date by which to submit test claims, it’s easy to see why the MGMA would be concerned about the potholes in the road ahead.

To complicate matters even more, many of the existing practice management systems and electronic health records in use in medical practices around the country will need to be upgraded or replaced to handle ICD-10-CM transactions. The respondents to the survey indicated that approximately 5 percent of their systems have been or will need to be replaced, and about 70 percent of the systems will need to be upgraded to accommodate such transactions. These upgrades and replacements will cost on average around $10,000 per provider, using a full-time equivalent (FTE) in the practice. The survey also showed that about half of respondents with upgrade/replacement needs do not have a specific date from their vendors regarding when they plan to finish implementing these upgrades and changes. It seems fairly obvious that it’s hard to test a system if you don’t have the new system in place yet!

Robert Tennant’s statements to the subcommittee also reflected concern over a recent statement by Palmetto GBA, a Medicare Administrative Contractor (MAC) that indicated that “Medicare does not plan to pursue testing of Medicare fee-for-service claims directly with providers for ICD-10 at this time.” A statement such as this seems to send the incorrect message that testing is not vitally important. Yet the Centers for Medicare & Medicaid Services’ (CMS’) own implementation handbooks for various organizations and payers provide clear instructions on the need for end-to-end testing. \MGMA was quick to point out how these mixed messages are creating uncertainty within the industry.

Yet MGMA offered some excellent recommendations to the U.S. Department of Health and Human Services (HHS) in the form of ways the department can support the industry during this transition. Specifically, MGMA called for a reversal of the policy not to test with external trading partners and called for the need to fully engage with the HIMSS-WEDI National Testing Pilot. In addition to these pointed recommendations, they also called for a ramp-up of education and the provision of resources directed to all stakeholders, with an emphasis on vendors and small, rural and safety-net providers who could see a large negative impact from any lack of a solid ICD-10 implementation and testing plan.

Based on the results of their research, MGMA also called for a focus on the role of the clearinghouse, given the large numbers of claims that are processed through these partners. Specifically, MGMA suggested leveraging the use of the Regional Extension Centers (RECs) to help reach smaller practices and the expansion of the REC mandate to include medical specialties other than primary care.

These recommendations place a clear focus on the need to use all available resources and involve all major players to ensure that the industry moves quickly to prepare for this impending change.

About the Author

Maria T. Bounos, RN, MPM, CPC-H, is the practice lead for coding and reimbursement software solutions for Wolters Kluwer.  Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

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So I have a question: what is it our Congress doesn’t get? How many years has the United States healthcare industry been trying to implement the ICD‐10 coding system for the simple reason that ICD‐9 is outdated?

After all, we already are well on our way in the implementation phases of converting to ICD‐10 by Oct. 1, 2014, which is not that far away. The resources we have poured into improving our health data system updates is mind-boggling! However, there still continue to be naysayers within Congress who continue to push back.

I was invited to appear with a group of ophthalmologists a few weeks ago to talk about documentation improvement in preparation for ICD‐10. We talked about the benefits of electronic medical record templates used to assist with documentation and improving reported medical condition codes today as well as following implementation of the new coding system. Yet I quickly was told that “ICD-10 was not going to happen,” and why. They heard directly from several of our U.S. senators not to worry about “this costly coding system.” They suggested I do a quick Google search for new bills in Congress. Talk about being a deer in the headlights: I was caught totally unaware of any legislation that had been introduced to stop the implementation of ICD‐10. I wanted to run to a computer right away.

And here’s what I found:

What: There are two bills on the floor of the U.S. House of Representatives and U.S. Senate, titled: H.R.1701: Cutting Costly Codes Act of 2013 (introduced April 24) and S.972 (introduced May 16), respectfully. There has not been any documented action on the bills ever since H.R. 1701 was referred to the House Subcommittee on Health and the Senate bill was referred to the Committee on Health, Education, Labor and Pensions.

Why: “To prohibit the Secretary of Health and Human Services replacing ICD‐9 with ICD‐10 in implementing the HIPAA code set standards.”

Who is supporting this move? From the House of Representatives there are 16 representatives (from Alabama, Florida, Tennessee and Texas), and from the Senate there are four (from Arkansas, Kentucky, Oklahoma and Wyoming).

Watch: U.S. Sen. Tom Coburn, R-Okla., has an amendment to the Farm Bill S. 954 to block the implementation of ICD‐10. It will be interesting to watch this particular bill, which is expected to be voted on by the Senate sometime this week. At the time of this writing I could not find any reference to the prohibition of ICD‐10 in the most current version to date, which started out with more than 1,000 pages. However, the aforementioned amendment was noted to be “in committee” as of May 16. It may well die in committee due to lack of merit; however, it is nonetheless interesting to witness how our government works on matters of such importance.

Action? Is it disbelief, or surprise, we will see on the faces of those who refuse to accept change? Is the sky falling? No, but I would bet that ICD‐10 is still coming – and moving forward, Oct. 1, 2014 will be coming up on us very fast. Don’t waste time! It continues to be a strong recommendation to stay the course and continue to be proactive regarding the implementation of ICD‐10.

About the Author

Gretchen Dixon, MBA, RN, is a consultant at Hayes Management Consulting. She is a Certified Healthcare Compliance Officer, Certified Coding Specialist and internal auditor with more than 20 years of experience in the healthcare industry with an emphasis on clinical documentation improvement, compliance, revenue cycle and coding.

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Citing a research study conducted by the American Hospital Association (AHA) reporting that nearly 95 percent of surveyed hospitals are on track to implement ICD-10 by the mandatory compliance date of October 2014, the AHA and Blue Cross and Blue Shield told Congress in a joint letter that they oppose any action to delay implementation of the new code set.

May 14, 2013

Payers Start to Get “Testy”

By John Wollman

Perhaps the most intellectually challenging aspect of ICD-10 implementation is trying to determine how, when, what, and with whom to test. Most ICD-10 teams spend a lot of time identifying test strategies and arduously planning various aspects of testing.

Testing is critical because it is quite apparent that ICD-10 could cause a major disruption to claims’ life cycles, resulting in claim rejections, claims being processed incorrectly, incorrect payments, etc., also causing cash flow disruption. In order to avoid this, it is imperative for payers to test with as many providers as possible (and for providers to test with as many payers as possible).

Many industry groups espouse a form of testing often referred to as scenario-based testing as an optimal way for providers and payers to test collaboratively. Scenario-based testing generally involves the development of medically relevant scenarios that are given to providers to code in ICD-10.

The scenarios are based on real-world claims that previously have been coded and adjudicated in ICD-9. The ICD-10-coded claims can be adjudicated and the results (Did the claim process properly? Did the claim wind up pending? How did the claim price?) can be compared to the ICD-9 adjudication results. Scenario-based testing provides several benefits, including:

Examples of actual data and real-world scenarios;

  • Streamlining of processes to allow providers and payers to collaborate;
  • An increase in the likelihood of trading partner engagement; and
  • The avoidance of risk associated with using PHI during testing.

Several of our payer clients are moving forward aggressively with scenario-based testing processes, and providers can expect to be recruited to participate in such processes in the coming months. For professional (non-facility) providers, you can expect to see invites to websites that will allow you to view one or more scenarios (based on specialty) that contain a series of narratives, with the narratives describing actual medical encounters. You will be asked to enter the appropriate ICD-10 code(s) for each narrative and to submit the entire scenario for processing. The payers then will run back-end processes to adjudicate the inputs and to determine the accuracy of your responses and impacts on pricing.

Facility providers likely will see a slightly different approach. For facilities, the payers will collaborate with their larger providers to agree on specific claims of mutual interest (based on volumes, cost, etc.). The facility providers will re-code the agreed-upon claims in ICD-10 using the existing medical records. The providers will use a website or file-transfer mechanism to upload the re-coded claims for processing and the payers will group the claims to determine any potential issues (pends/suspends/DRG shifts, etc.).

Providers should be prepared to participate in scenario-based testing as their payer trading partners start to engage with providers in the coming months. In the pursuit of revenue and operational neutrality, scenario-based testing should provide an accurate view of the potential impacts of ICD-10.

We would encourage providers to take these efforts seriously, and to allocate appropriate coding resources to code/re-code narratives and/or historic claims.

About the Author

John Wollman is the Executive Vice President of Healthcare for HighPoint Solutions, a Management and Information Technology consulting firm focused on Healthcare and Life Sciences.  John is responsible for HighPoint’s Healthcare industry group, catering to Payers and Providers.  John is a recognized expert in several healthcare business domains (Reform, HIPAA 5010, ICD-10, Platform Strategy) and technical domains (Master Data Management, Analytics).  Since graduating from Duke University, John has held executive level positions at consulting and technology companies over his 25 years in business.

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EDITOR’S NOTE: This is the second in a two-part series on ICD-10 testing by John Wollman.

Multiple recent ICD-10monitor articles have focused on testing, and in particular scenario-based testing. This concept was described in one prior article titled “Payers Start to Get Testy.” This follow-up article provides a case study of how Blue Cross Blue Shield of Michigan (BCBSM) is testing with its partners, both professional and facility providers.

Note that the testing described herein is not what some would call “end-to-end” testing. End-to-end testing is a form of testing wherein a “transaction” (a claim related to an encounter) is initiated by a provider from within the provider’s systems, then passes from the provider to the payer either directly or via an intermediary (a clearinghouse or some other value-added network). From there the transaction progresses through the payer’s systems, resulting in some form of response back to the provider. In addition to testing the business ramifications of ICD-10, end-to-end testing also tests the “plumbing” and connections between providers, clearinghouses (and other intermediaries) and payers.

At this point in time, BCBSM and the providers it works with are more interested in testing the business ramifications of ICD-10 rather than the plumbing. In fact, BCBSM refers its approach to scenario-based testing (SBT) as “content-based testing,” in that the content (ICD-10 codes and results) is all that needs to pass between trading partners.

The content-based testing approach enables providers and payers to communicate directly with each other regarding claims of interest in an unobtrusive, cost-effective and scalable manner. With providers and payers equally interested in understanding potential challenges to claims adjudication and pricing, this approach makes a lot of sense for testing with both professional and facility providers.

BCBSM’s original intent was to develop scenarios based on historic claims for all healthcare providers. As they began creating the professional scenarios, they realized that building generic, facility-based scenarios was quite work-intensive and couldn’t be completed in the requisite time frame. Therefore, BCBSM created separate approaches for professional and facility providers.

BCBSM intends to support testing with professional providers via a Web application. The application allows providers to view scenarios and narratives fully describing medical encounters and, based on their review and knowledge, provide the best ICD-10 code(s) for each encounter. Upon receipt of the ICD-10 codes from the provider, BCBSM will “catch” the information and append it on pre-formatted test claims, then run those claims through the back-end claim adjudication and pricing systems. The results, along with the original ICD-9 baseline results, will be compared, and differences and/or similarities will be returned to the provider via email. To maximize the value of the scenarios versus the effort expended to develop them, BCBSM concentrated on high-dollar, high-volume, highly complex claim examples.

BCBSM will make this available to all professional Michigan healthcare providers, but could make it available outside its service territory should an interest arise.

Content-based testing for facilities is different. Given the complexity associated with the creation of generic facility scenarios, BCBSM chose an approach in which they will meet with Michigan healthcare facilities face-to-face and, based on agreed-to medical scenarios of interest (high-dollar, high-cost, high complexity), identify claims to be re-coded by the facilities. Again, facilities only will enter the associated ICD-10 codes, and the same process as noted in the professional provider testing section will be followed, with one important exception: the comparison is between ICD-10 DRGs and ICD-9 DRGs. BCBSM will provide feedback in a similar way, via email, to the facility providers.

The results of the content-based testing initiative will allow BCBSM and the providers to visualize the impacts of coding claims with ICD-10 codes. Providers will be able to see potential issues with medical record documentation (whether there is not enough information to code in ICD-10, for example), understand the complexity involved with ICD-10, and get help with their transition. BCBSM will get an advanced look at what may be sent once ICD-10 is implemented, how it will affect claims processing, and perhaps how it can help them identify areas in which to focus their efforts for outreach and communication. All in all, the process yields a greater degree of information than testing “plumbing-based” transactions.

While the content-based testing approach specifically was targeted for the ICD-10 mandate, BCBSM firmly believes that the same approach will have applicability for future mandates that will require similar collaborative testing among trading partners.

Providers of all types should be prepared to participate in scenario-based testing as their payer trading partners (like BCBSM) start to engage them.

Content-based testing is one approach that can be used to provide a useful view of the potential impacts of implementing ICD-10.

About the Authors

John Wollman is the Executive Vice President of Healthcare for HighPoint Solutions, a Management and Information Technology consulting firm focused on Healthcare and Life Sciences.  John is responsible for HighPoint’s Healthcare industry group, catering to Payers and Providers.  John is a recognized expert in several healthcare business domains (Reform, HIPAA 5010, ICD-10, Platform Strategy) and technical domains (Master Data Management, Analytics).  Since graduating from Duke University, John has held executive level positions at consulting and technology companies over his 25 years in business.

Dennis Winkler is the Technical Program Director of Program Management and ICD-10 for Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan. He is responsible for ICD-10 program direction and is the IT business partner for Medicare Advantage. Dennis graduated with distinction from the University of Michigan's Ross School of Business. He spent his first 11 years of his career with Anderson Consulting (now Accenture); specializing in large, complex system development projects. Winkler joined BCBSM in 1998 and since has been responsible for leading major enterprise programs including HIPAA 4010 implementation, Social Security Number elimination and the National Provider Identifier initiative, among others. He has spoken at several national summits and seminars about ICD-10 since BCBSM began its ICD-10implementation.

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As we all annually make New Year’s resolutions such as losing weight, getting more exercise, spending more time with our families, etc., typically we have good intentions but fall short at the end of the year. ICD-10 is coming quickly this year, and you cannot afford to develop “good intentions” without achieving good results. So, what New Year’s resolution did you make relative to your ICD-10 Implementation process?

Have you started on implementation at all? If not, you already are far behind, and need to jump-start the process. Get your steering committee together to begin planning, and be sure to touch on the following steps:

  1. Conduct your impact assessment. Look at all processes, departments and workflows to get a true understanding of the “as is” state. Instead of sending out a survey, interview department directors, supervisors, etc. directly to determine how ICD-10 currently is being used in each department or practice.
  2. Put together an assessment analysis of the “as is” state and identify risks. By identifying risks you can determine what changes need to be made right now and what changes can wait for 2014.
  3. Build your training plan. Training services are at a premium right now, and if you are responsible for implementation or have a large staff, you need to begin training immediately so everyone can be appropriately prepared. First, decide what type of training each staff member needs (in-depth, overview, basic, etc.).
  4. Conduct an ICD-10 readiness audit, looking at top DRGs and utilization of diagnosis codes. Then contrast current documentation with what documentation needs to be evident with ICD-10.
  5. Using the ICD-10 readiness audit, you can determine what type of training each practitioner will need.
  6. Begin training practitioners either one-on-one or as a group, by specialty, on documentation requirements for ICD-10.
  7. Begin training coding managers and coders on the ICD-10-CM/PCS code sets. Keep in mind that we all need to begin dual-coding early in 2014, and training resources will dry up quickly.
  8. Make certain to keep in contact with your software vendors and business associates, and get dates and timelines for testing, which will be key in any successful implementation. If you cannot submit proper claims, revenue will be affected starting late in 2014.
  9. Keep your organization on target. Keep everyone motivated and actively moving forward.
  10. Take your impact assessment to the next level: develop the action plan. Be sure to ask: What changes need to be made to implement ICD-10 successfully?

By itemizing the tasks at hand and involving numerous staff and departments to help with ICD-10 implementation, the chances of success are greater than they’d be if you just sit back and wait to see what happens. You cannot afford to risk your organization’s financial health by waiting or hoping for another delay. Federal officials keep telling us that ICD-10 is “closer than it seems,” and that statement is so true.

So get up, get going and implement your ICD-10 resolutions – starting today.

About the Author

Ms. Grider, an AHIMA-approved ICD-10 trainer and an American Medical Association coding author, is a senior manager with her firm, possessing more than 30 years of experience in coding, reimbursement, practice management, billing compliance, accounts receivable, revenue cycle management and compliance across many specialties. Her specific areas of expertise include medical documentation reviews, accounts receivable analysis and coding and billing education.

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January 8, 2013

ICD-10-CM Coding for Latrogenic Blood Vessel Injuries

By Lauri Gray, RHIT, CPC

Some of the more common causes of blood vessel injury include gunshot wounds, stab wounds, blunt trauma (including blunt trauma with fracture or dislocation) and iatrogenic injuries. With more procedures being performed using intravascular techniques of late, the number of iatrogenic injuries to blood vessels has increased. Understanding the differences between ICD-9-CM and ICD-10-CM coding for blood vessel injuries occurring as a complication of a surgical procedure will help with correct code assignment when ICD-10-CM is implemented.

In ICD-9-CM, codes for iatrogenic injuries of blood vessels are found in Chapter 17, Injury and Poisoning. An injury to a blood vessel complicating a surgical procedure is reported with one of three nonspecific codes, as follows:

998.11 Hemorrhage complicating a procedure;

998.12 Hematoma complicating a procedure; and

998.2 Accidental puncture or laceration during a procedure.

It should be noted that no distinction is made in ICD-9-CM for intra-operative or postoperative hemorrhage or hematoma.

In ICD-10-CM, codes for intra-operative and post-procedural blood vessel injuries are found in Chapter 9, Diseases of the Circulatory System. ICD-10-CM classifies body system-specific, intra-operative and post-procedural complications within each body system chapter, rather than in Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes).

While ICD-10 codes for intra-operative and post-procedural complications affecting blood vessels are not specific to the site of the injury, they are specific to the body system affected, which in the case of blood vessel injuries is the circulatory system. Codes are also specific to the type of injury – hemorrhage and hematoma or puncture and laceration. Hemorrhage and hematoma codes are specific to whether the complication occurs during a surgical procedure or postoperatively, and these codes are also specific to some types of procedures (including cardiac catheterization, cardiac bypass, other circulatory system procedure or other procedure). Puncture and laceration codes are specific to whether the blood vessel injury occurred during a circulatory system procedure or during a procedure being performed on another body system.

For intra-operative hemorrhage and hematoma of a blood vessel or other circulatory system organs or structures, the following codes apply:

I97.410 – Use when the hemorrhage or hematoma complicates a cardiac catheterization procedure.

I97.411 – Use when the hemorrhage or hematoma complicates a cardiac bypass procedure.

I97.418 – Use when the hemorrhage or hematoma complicates another circulatory system procedure.

I97.42 – Use when the hemorrhage or hematoma complicates a procedure on a body system other than the circulatory system.

For post-procedural hemorrhage and hematoma of a blood vessel or other circulatory system organs or structures, the following codes apply:

I97.610 – Use when the hemorrhage or hematoma complicates a cardiac catheterization procedure.

I97.611 – Use when the hemorrhage or hematoma complicates a cardiac bypass procedure.

I97.618 – Use when the hemorrhage or hematoma complicates another circulatory system procedure.

I97.62 – Use when the hemorrhage or hematoma complicates a procedure on a body system other than the circulatory system.

For accidental puncture and laceration of a blood vessel or other circulatory system organ or structure, the following codes apply:

I97.51 – Use when the accidental puncture or laceration occurs during a circulatory system procedure.

I97.52 – Use when the accidental puncture or laceration occurs during a procedure on another body system.

About the Author

Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).

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EDITOR’S NOTE: This is the first in a two-part series

To be successful using ICD-10, payers, providers and vendors should follow six simple steps for management of code transition from ICD-9. It is critical that each organization apply a common mapping consistently in order to meet the compliance date.

Industry goals include compliance and business neutrality, as well as more accurate and detailed clinical and quality reporting, improvements to patient safety, better tracking of patient outcomes, improvements to the accuracy of claims processing, prevention of fraud and abuse, and the availability of richer sources of data for clinical research.

Here are the first three of those aforementioned six steps:

1. Design a mapping tool that is specific to the business needs of your organization.
To ensure consistency and transparency, each organization should select a mapping software application as the standard mapping application for all remediation work. Remediation is the process of translation from ICD-9 to ICD-10 for the hundreds of thousands of applicable business rules and codes. One such software application, HLI’s LEAP I-10, is embedded with the Centers for Medicare & Medicaid Services (CMS) General Equivalency Mappings (GEMs). From the GEMs file, the WellPoint Reference Map (WRM) was designed to meet the specific needs of businesses, and it is included in LEAP I10.

The WRM, simply put, is the GEMs offered with additional attributes such as laterality, chapter changes or the exclusion of notes. In addition, the WRM routinely is updated to include purpose-built maps (PBMs) – map changes that meet enterprise-wide business needs. This customized GEMs file allows clients to meet the unique and varied business needs of benefits, clinical, and pricing arenas, as well as those of other key business segments.

Each remediation team begins its map translation effort with the WRM as a primary source. Once the remediation work is complete, the WRM is moved to a reference data platform to allow for auto-configuration of all business rules. Auto-configuration allows for automated updates by replacing the hundreds of thousands of ICD-9 codes in business rules with their equivalent clinical and business ICD-10 codes, the goal being neutrality.

If a benefit is approved on an ICD-9 code, then the plan is that same benefit will be approved with the ICD-10 codes.

2. Select your highest-impact business units for initial mapping efforts.
The decision to select two initial claims platforms was based on large memberships and the fact that they are long-term target platforms. One of the claims platforms also had external dependencies, representing an additional reason. We also started with a third business unit, the clinical system, due to its direct impact on members engaged in critical medical services. Any issue could create friction, which must be avoided.

3. Include credentialed clinical coding experts in projects related to mapping.
The clinical coder skill set that a HIM coding consultant expert recently brought to a team of insurance experts during the process of remediation resulted in synergies that would not have been attained otherwise.

As a result of these remediation meetings, not only were insights related to mapping identified, but the team identified process and technical opportunities as well. For example, a rule designed to process a behavioral benefit for sexual dysfunction was evaluated by the remediation team. The sexual dysfunction codes are classified in the ICD-9 Mental Health chapter, and an unspecified sexual dysfunction code was identified in the Signs and Symptoms chapter.

To ensure correct processing and neutrality, this symptom code was added to the benefit rule to retain the business and clinical context. In a second example, it was determined by the HIM coding expert that there was an omission in annual code updates, specifically coming in the form of a missed update of the 249.xx diabetes codes introduced a few years ago. After much discussion, we arrived at a decision on how to remediate missed ICD-9 codes during the act of remediating the ICD-10 codes.

Another example of insights provided with the HIM coding expert included as part of the team is identifying potential computer limitations with field length. It was determined that one ICD-10 code was truncated. This resulted in an ICD-9 and an ICD-10 code reading the same as an alphanumeric value, but different as descriptors: V723 in ICD-9 is “gynecological exam,” which is truncated from its fifth digit, and V723 in ICD-10 is “unspecified occupant of bus injured in collision with two- or three-wheeled motor vehicle in non-traffic accident,” which is truncated from the sixth and seventh digits. In summary, process improvements, the annual code update, technical improvements and field limitation revisions are a result of synergy generated by a team effort.

The primary goal of the HIM coding expert is to assist the remediation team with forming accurate and appropriate ICD-9-to-ICD-10 map translations. In other words, the intent is to review all maps and identify any ICD-10 map(s) that do not match the clinical and business context of the business rule. Once such a map is not accepted, it becomes known as a derivation. For example, consider that a derivation is identified for case management. It is determined that the “traumatic subarachnoid hemorrhage with death” map needed to be disabled in order to avoid a case manager making contact with a surviving family member.

Another example is the “unspecified angina” code in ICD-9 that typically denies a benefit; we determined that for the business rule, to avoid denying the benefit for coronary artery disease, the ICD-10 combination code (“coronary artery disease with angina”) needed to be disabled. The derivations are documented in the LEAP I10 tool and laid out in an Excel spreadsheet called a Business Configuration Inventory (BCI). Any derivation from the WRM map is documented to differentiate the codes for manual configuration as well as for the purposes of control and traceability.

Following the key steps plus the three additional ones in the second part of this series will help focus your organization’s efforts on areas that will support these key goals.

About the Authors

Carol Spencer is the program director for WellPoint’s CodeSet Competency Center. Mike Younkman is the director of WellPoint’s ICD-10 execution.

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Click here to read Part 2 of this series

January 8, 2013

Dispelling Some Myths About ICD-10

By Thomas Ormondroyd, BS, MBA

The ability of any organization to transition to ICD-10 successfully will be dictated by both the specificity and adequacy of documentation – and whether that documentation will be detailed enough for coders to code accurately under ICD-10.

This will require a tremendous amount of training and education, not just for coders and clinical populations, but for every population within a healthcare organization that is part of the revenue cycle. But before planning the necessary training and education, we first must dispel some of the negative myths regarding the process.

Such myths can create a hopeless view of the ICD-10 transition and discourage utilization of training and education programs. If we expect colleagues to take the time out of their busy schedules to participate in these programs, then we need to clear the air and show them how the process will be a benefit to both them and the organization in which they practice or are employed.

Myth No. 1: The increase in documentation required by ICD-10 will demand a huge amount of content added to the medical record.

Reality: In most cases, ICD-10 will require just a few more words per documented condition.

The good news is that physicians already should know all this information as part of the clinical story gleaned from their encounters with patients (or the encounters reported to them by ancillary departments).

All physicians need to do is make sure they actually document this information. And physicians may be aware of the new terminology required already due to changes in clinical practice. A good example of this is asthma: Physicians already should be using clinical criteria to establish stage of asthma, as ICD-10 now allows documenting and coding of these stages.

Myth No. 2: All codes in ICD-10-CM will be complex, seven-character codes.

Reality: There are three character codes in ICD-10-CM, and the most common code length is four characters. Therefore, in many cases the ICD-10-CM code will actually be shorter than its ICD-9-CM counterpart.

Moreover, ICD-10-CM is a more logical system than ICD-9, because the first character of the code indicates the category of disease. This way, even a non-coder can look at a code and immediately tell under which disease family the code falls. In many cases it would take multiple ICD-9 codes to tell the same clinical story as just one ICD-10 code. The result is the increased detail level of ICD-10 reduces the chance of error and provides improved assurance that facilities will be reimbursed appropriately.

Myth No. 3: ICD-10 requires knowledge of unnecessary and unknown details of a patient’s illness or condition.

Reality: We all have read the amusing articles and stories about ICD-10 codes noting what a person was doing when he or she were injured. The infamous jet skis catching on fire has been a favorite one. However, while it is important that all impacted populations become familiar with ICD-10, it is not required that everyone know every code and dig up all unknown details of every encounter. Federal officials have compared ICD-10 to a phone book. Denise M. Buenning, MsM, acting deputy director of the Office of E-health Standards & Services (OESS) stated, “All the numbers are in there. Are you going to call all of the numbers? No. But the numbers you need are in there.”

Remember that ICD-10-CM/PCS will be used not only in all regions of the United States, but also at every military base, domestic and international, and even by NASA (that V95.41XD code of Spacecraft crash injuring occupant, subsequent encounter, makes a little more sense, considering). Is it a little over the top? Perhaps, but the key thing to remember is that if a patient’s jet skis did catch on fire, or if he or she was bitten by a parrot, you pretty much can bet this will be noted in the medical record.

Again, ICD-10 education is not meant to teach physicians or other clinicians how to find out a patient’s innermost secrets, but rather to teach them how to document what they are told in their normal discovery efforts – and to teach the coder how to find the code when it is documented.

About the Author

Thomas Ormondroyd, BS, MBA, is vice president and general manager of Precyse Learning Solutions. He oversees several business lines, including Precyse University, ICD-10 Consulting and Education, and Clinical Documentation Improvement Services. Tom and his team are responsible for building Precyse University.

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