Better Late than Never: How to catch up with ICD-10-CM/PCS

Better Late than Never: How to
catch up with ICD-10-CM/PCS
in 2012
Or BGYBIG
What Does it Really Take?
Prepared by: Rose T. Dunn, RHIA, MBA, CPA, FACHE, FHFMA, FAHIMA
©2012
© 2010
Disclaimer
• Information contained in this presentation has
been presented at VHA, HFMA, AHIMA, and
other professional and healthcare organization
meetings.
2
© 2010
AGENDA
• Brief overview of 5010 and its ties to ICD-10
• ICD-9cm vs. ICD-10cm
• Department/Function Impacts and
Considerations
• What you need to do
• Resources
3
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Where Are You?
1. Identified sponsor(s) and/or steering
committee
2. Conducted awareness education
3. Started/completed system and other
inventories
4. Vendor discussions underway
5. Testing upgrades for ICD-10
6. Initiated a new job search
4
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What You Need to Do
1. Champion/Steering Committee
a) Senior leader(s) who will make organization
wide decision
b) Senior leader(s) who will remove roadblocks
2. Project Team
a) YOU CAN’T DO IT ALL YOURSELF
b) IT, HIM, CDI, PFS, CM, MD, Decision Support
5
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Another Federal Mandate Effective
10/1/2013
6
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Effective 10/1/2013
• Not dead, not going to die: Going full steam
ahead
– Well until Valentine’s Day came
– AMA Spoke Up
7
© 2010
HHS Proposed Rule Published 4/9/12
• Buried in a Proposed Rule that includes:
– Unique Health Plan Identifier and Other Entity Identifiers
– Expanding the National Provider Identifier Requirements
• Identifies that the delay will serve certain providers
including physicians, small hospitals, trading partners,
and vendors
• Acknowledges that larger hospitals and payers have
incurred costs to be prepared
• Recognizes that the delay will cost providers, payers,
and others estimated up to $6.5 billion
© 2010
Whenever It’s Effective
• Affects any provider who uses
ICD-9 codes for billing or
reimbursement purposes
• All health plans must accept ICD-10 codes
– Some may accept earlier
9
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For Purposes of This Session:
ICD-10 Will Be
Effective 10/1/2013
• Use any extra time to refine your processes
© 2010
Significant Change
• 33 years
• 18 years
• Failure to comply by 10/1/2013 may cause
cash flow interruption or no reimbursement
• Coding granularity
• Major change in documentation requirements
• Direct Tie to 5010
11
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5010 was Effective 1/1/12
• What is 5010?
– The electronic data standards that allow healthcare
organizations and health plans communicate with
one another electronically
12
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5010’s Benefits &Tie to ICD-10
850+ changes
 Accommodates the attributes of ICD-10
codes
• Allows for 25 diagnoses (up from 9
diagnoses) and 25 procedures (up from 6
procedures)
– Severity and Complexity
– Distinguish your care and
outcomes from others

13
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What You Need To Do
• Validate that your payers are accepting the 25/25
• Confirm your HIM coding team is taking
advantage of the 25/25
• When: NOW
© 2010
Healthcare
Reform
Other Internal Competing Projects
Source: HIMSS
15
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Fiscal Contraints, Demand for the
Same Labor, Competing Priorities will
Stretch Your Existing Resources
© 2010
What You Need To Do
• Hold on to your existing resources
• Staff upIt’s temporary; Attrition
• Spice up your recruitment process
• When: Now and through 2014
© 2010
Comparing ICD-9 & ICD-10
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ICD-9cm vs. ICD-10cm
• International Classification of Diseases, 9
Edition, Clinically Modified for the United
States (I-9)
• I-9 since January 1979
– What’s the problem?
33
• Space limitations for new codes
• Lack of detail
• Inability to compare data internationally
19
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ICD-9cm vs. ICD-10cm/PCS
• International Classification of Diseases 10th
Edition (developed by WHO)
– Clinically Modified for the US (I-10cm) and
• Updated annually by National Center for Health
Statistics
– Clinically modified: Includes additional subsections
– ICD-10CM = Diagnosis Coding System
– Procedural Coding System (I-10 PCS)
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ICD-9cm vs. ICD-10cm/PCS
• I-10 since 1994
– For Morbidity-99 countries and Mortality-138
countries
– For Reimbursement/Case Mix: United Kingdom,
Norway, Belgium, Finland, Iceland, Denmark,
Sweden, France, Canada, Australia and Germany
• US-Only industrialized country not using I-10
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ICD-9cm vs. ICD-10cm
• 3 Volumes
– Diagnosis
– Procedure (v.3)
– Index
• Diagnosis
– ~13,700 codes
– Up to 5 characters
– Alpha-Numeric
• 3 Volumes
– Diagnosis
– Rules and Guidelines
– Index
• Diagnosis
– ~70,000 codes
1:5
– Up to 7 characters
– Alpha-Numeric
• Not case sensitive
– Placeholder “x”
Source: MLN SE0832
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ICD-10cm
ICD-9cm
Comparing Attributes
•496 – Chronic airway obstruction not
elsewhere classified (NEC)
•511.9 – Unspecified pleural effusion
•V02.61 – Hepatitis B carrier
•O9A●311 – Physical abuse complicating
pregnancy, first trimester
•S42.001A – Fracture of unspecified part of right
clavicle, initial encounter for closed fracture
Source: AHA I-10 Overview
© 2010
One for All of Us
•Z63.1:
– Problems in relationships with In-Laws!
•Z59.2:
24
– Problems in relationships with neighbors
© 2010
What You Need To Do
• Inventory reports
– Customized
•
•
•
•
Field length for ICD-10 descriptions
50250
Not high on the priority list
When: April-June 2013
– System edits
• Alpha characters throughout the code
• When: During Testing (December 2012-August 2013
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Structure
3% to
30%
• ICD-10 CM
–
–
–
–
–
Category (3)
Etiology
Anatomic Site
Severity
Extension
• Pros
• Cons
ICD-9
ICD-10
26
© 2010
What You Need To Do
• Ask the question!
• When: NOW
• Consider:
–
–
–
–
Contracts
Retention Bonuses
Recruitment
Grow your own
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Where Do You Find Those To Grow?
•
•
•
•
•
Permanent Light Duty Clinical Staff
Military Medics
Outpatient Coders
Transcriptionists
HIM Program Students
• Assign to HR
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Specificity
HAC or Potentially Preventable Condition/Event
• 50 different codes for “complications of foreign
body accidently left in body following a
procedure”
– ICD-9: only one code
• Who is interested in this?
Source: AHIMA ICD-10 Primer
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HAC/PPC-E Identification-20 Categories
• Misadventures to patients during surgical and medical
care (Y62-Y69) 6 (not 8) categories
• Y62:
care
• Y63:
• Y64:
• Y65:
• Y66:
• Y69:
Failure of sterile precautions during surgical and medical
Failure in dosage during surgical and medical care
Contaminated medical or biological substances
Other misadventures during surgical and medical care
Non-administration of surgical and medical care
Unspecified misadventure during surgical and medical care
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Detail of Category Y62
Y62Failure of sterile precautions during surgical and
medical care
•
•
•
•
•
•
•
Y62.0 Failure of sterile precautions during surgical operation
Y62.1 Failure of sterile precautions during infusion or transfusion
Y62.2 Failure of sterile precautions during kidney dialysis and other perfusion
Y62.3 Failure of sterile precautions during injection or immunization
Y62.4 Failure of sterile precautions during endoscopic examination
Y62.5 Failure of sterile precautions during heart catheterization
Y62.6 Failure of sterile precautions during aspiration, puncture and other
catheterization
• Y62.8 Failure of sterile precautions during other surgical and medical care
• Y62.9 Failure of sterile precautions during unspecified surgical and medical
care
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Detail of Category Y63
Y63Failure in dosage during surgical and medical care
• Y63.0 Excessive amount of blood or other fluid given during transfusion or
infusion
• Y63.1 Incorrect dilution of fluid used during infusion
• Y63.2 Overdose of radiation given during therapy
• Y63.3 Inadvertent exposure of patient to radiation during medical care
• Y63.4 Failure in dosage in electroshock or insulin-shock therapy
• Y63.5 Inappropriate temperature in local application and packing
• Y63.6 Underdosing and non-administration of necessary drug,
medicament or biological substance
– Y63.61 Underdosing of necessary drug, medicament or biological substance
– Y63.62 Nonadministration of necessary drug, medicament or biological
substance
– Y63.8 Failure in dosage during other surgical and medical care
– Y63.9 Failure in dosage during unspecified surgical and medical care
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Detail of Category Y65
• Y65 Other misadventures during surgical and medical
care
–
–
–
–
Y65.0 Mismatched blood used in transfusion
Y65.1 Wrong fluid used in infusion
Y65.2 Failure in suture or ligature during surgical operation
Y65.3 Endotracheal tube wrongly placed during anesthetic
procedure
– Y65.4 Failure to introduce or to remove other tube or instrument
– Y65.5 Performance of inappropriate operation
– Y65.8 Other specified misadventures during surgical and medical
care
33
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HAC/PPC-E Identification-20 Categories
– Y70-Y82: Breakdown or
malfunctioning of medical
device (during procedure)
(after implantation) (ongoing
use)
– Y83-Y84: Surgical and
medical procedures as the
cause of abnormal reaction of
the patient, without mention of
misadventure at the time of
the procedure
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~115 codes in 20 categories
© 2010
HAC/PPC-E Identification-20 Categories
Y70-Y82: Breakdown or malfunctioning of medical device (during
procedure) (after implantation) (ongoing use)
• Y70 Anesthesiology devices associated with adverse incidents
• Y71 Cardiovascular devices associated with adverse incidents
• Y72 Otorhinolaryngological devices associated with adverse incidents
• Y73 Gastroenterology and urology devices associated with adverse
incidents
• Y74 General hospital and personal-use devices associated with adverse
incidents
• Y75 Neurological devices associated with adverse incidents
• Y76 Obstetric and gynecological devices associated with adverse incidents
• Y77 Ophthalmic devices associated with adverse incidents
• Y78 Radiological devices associated with adverse incidents
• Y79 Orthopedic devices associated with adverse incidents
• Y80 Physical medicine devices associated with adverse incidents
• Y81 General- and plastic-surgery devices associated with adverse incidents
35
• Y82 Other and unspecified medical devices associated with adverse
incidents
© 2010
What Do You Need To Do
• Look back at your existing experience
• Expect an expansion of HACs from all payers
– Lower Reimbursement
•
•
•
•
High Transparency
Anticipate the Ambulance Chasers
Consider a financial reserve
When: August 2012-October 2012 (Budget)
© 2010
What You Need to Do
1. Risk Management and Clinical Teams need to
address exposure
2. Revenue impact needs to be addressed
• Steering Committee or Sub Committee
3. How will coders obtain information
4. Compliance involvement?
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General Equivalence Mappings
(GEMS)
• ICD-9 to ICD-10
• ICD-10 to ICD-9
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© 2010
GEM Excerpt 1-1
ICD-9
•
•
•
•
•
•
•
•
•
•
•
•
2229
2230
2231
2232
2233
22381
22389
2239
2240
2241
2242
2243
ICD-10
D299
D3000
D3010
D3020
D303
D304
D307
D309
D3140
D3160
D3150
D3100
ICD-9 to ICD-10
Source: http://www.cms.hhs.gov/ICD10/
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One to One
Source: CMS GEMS
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© 2010
ICD-9 to ICD-10
GEMS 1 to Many
•
•
•
•
•
•
•
•
•
•
•
•
ICD-9
24950
24950
24950
24950
24950
24950
24950
24950
24950
24950
24950
24950
ICD-10
E09311
E09349
E0939
E0936
E09359
E09351
E09341
E09339
E09331
E09329
E09319
E09321
•
•
•
•
•
•
•
•
•
•
•
•
ICD-9
24951
24951
24951
24951
24951
24951
24951
24951
24951
24951
24951
24951
Source: http://www.cms.hhs.gov/ICD10/
ICD-10
E09341
E09351
E0939
E09359
E09349
E09331
E09329
E09311
E09321
E0936
E09319
E09339
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Specificity -- Cause
• ICD-9-CM: Aphasia due to previous CVA. 438.11
• ICD-10-CM codes:
– I69.020…Aphasia following non-traumatic subarachnoid
hemorrhage
– I69.120…Aphasia following non-traumatic intra-cerebral
hemorrhage
– I69.220…Aphasia following other non-traumatic intra-cranial
hemorrhage
– I69.320…Aphasia following cerebral infarct
– I69.820…Aphasia following other cerebro-vascular disease
– I69.920…Aphasia following unspecified cerebro-vascular disease
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© 2010
Example – One-to-Many; Laterality
Fracture of femur…
ICD-9-CM
ICD-10-CM
S72.001A – Fracture of unspecified part of
neck of right femur, initial encounter for
closed fracture
820.8 – Fracture of unspecified part of
neck of femur, closed
S72.002A - Fracture of unspecified part of
neck of left femur, initial encounter for
closed fracture
S72.009A - Fracture of unspecified part of
neck of femur [unspecified], initial
encounter for closed fracture
Unspecified exists in ICD-10
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© 2010
Examples – Combination Codes
Diabetes Codes in ICD-9
Diabetes Codes in ICD-10
249.70 - Secondary diabetes mellitus with
peripheral circulatory disorders, not stated
as uncontrolled
785.4 - Diabetic gangrene
443.81 - Diabetic peripheral angiopathy
E09.52 - Drug or chemical induced diabetes
mellitus with diabetic peripheral angiopathy
with gangrene
250.60 - Diabetes with neurological
manifestations, type II or unspecified, not
stated as uncontrolled
355.9 - Mononeuritis of unspecified site
E11.41 - Type 2 diabetes mellitus with
diabetic mononeuropathy
249.40 - Secondary diabetes mellitus with
renal manifestations , not stated as
uncontrolled
585.9 - Chronic kidney disease, unspecified
E08.22 - Diabetes mellitus due to an
underlying condition with diabetic chronic
kidney disease
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_038084.hcsp?dDocName=bok1_038084
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GEMS Fog
ICD-10
J869
J90
J90
J910
J918
J920
ICD-9
ICD-10 to ICD-9
5109
5119
51189
51181
5119
5110
http://www.cms.hhs.gov/ICD10/
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© 2010
New Clinical Concepts
 Inclusion of clinical concepts that do not exist in ICD9-CM
 T45.526D, Underdosing of antithrombotic drugs, subsequent
encounter
 Z67.40, Type O blood, Rh positive
 Trimesters rather than episodes of care
 NO MATCH
 Recognize the limitations
46
© 2010
When Will You Use the GEMS?
• Transitional
–
–
–
–
Trended Data
Preparing for Managed Care Contract Negotiations
Converting Forms with ICD-9 codes
Identifying Documentation Opportunities
• When: Now through 2014
47
© 2010
Start Your Internal
Comparison
Mapping between I-9 and I-10
www.cdc.gov/nchs/about/otheract/ICD9/ICD10CM.h
tm
CM
http://www.cms.gov/ICD10/11b14_2012_ICD10C
M_and_GEMs.asp#TopOfPage
PCS
http://www.cms.gov/ICD10/11b15_2012_ICD10PC
S.asp#TopOfPage
48
© 2010
What You Need to Do
1. Look at top 10-30 conditions by patient care
area or physician practice (map to ICD-10)
a) Define the documentation requirements
b) Assess documentation weaknesses
i.
Case review
c) Address through documentation improvement
2. When: June 2012-August 2012 (templates)
49
© 2010
What You Need to Do:
Physician Offices
• Look at your superbills for your common
Diagnoses
• Update the superbills
– Examples at AHIMA.org/ICD10
– Assume 2 pages
• When: July 2013-August 2013 (training)
50
© 2010
NCPD Recommendation
• National Coalition of Pharmaceutical
Distributors
– Effective 3/1/2013
– E-Prescriptions sent to Retail Pharmacies
• Include an ICD-10 Code
51
© 2010
What You Need to Do
• Ask your pharmacist to do some research
• Check with your e-prescribing application
vendors
• Figure out how you’re going to be I-10 Ready 7
months before you need to be!
• When: Now….until?
52
© 2010
ICD-10cm-PCS
Procedure Coding System
• Procedure
– Up to 4 digits
– Numeric
– ~3,800 codes
• ICD for Inpatient
Procedures
• CPT for Outpatient and
Physician Services
• Procedure
– Up to 7 characters
– Alpha Numeric
• Not case sensitive
1:18
– ~72,000 codes
• ICD-PCS for Inpatient
Procedures
• CPT for Outpatient and
Physician Services
53
© 2010
Comparing Attributes
ICD-9 V. 3 • 43.5 – Partial gastrectomy with anastomosis
to esophagus
• 44.42 – Suture of duodenal ulcer site
• 0FB03ZX – Excision of liver, percutaneous
ICD-10 PCS
approach, diagnostic
• 0DQ107Z – Repair, esophagus, upper,
open with autograft
• No decimal point
54
Source: AHA ICD-10 Overview
© 2010
Structure
 ICD-10-PCS-Each position of the code has a
specific meaning
›
›
›
›
›
›
›
Section
Body System
Root Operation
Body Part
Approach
Device
Qualifier
55
© 2010
Documentation
• Procedure specificity
– Operative Reports
Source: Ann Zeisset 2010
56
© 2010
Specificity Comparison
Source: AHA ICD-10 Overview
57
© 2010
What You Need to Do
1. Identify top 10-30 surgeries (Map to ICD-10)
a) Define the documentation requirements
b) Assess documentation weaknesses
i.
Case review
c) Address through documentation improvement
2. When: June-August 2012
58
© 2010
What You Need to Do
1. Review reports (customized)
a)
b)
c)
d)
Size of field
System edits for decimal point
System edits for alpha numeric characters
Testing plan
2. When: April-June 2013
59
© 2010
What Do We Need To Do
•
•
•
•
Identify sources of documentation
Link to other documents
Auto-populate
Physician authentication
• When: June-August 2012 (templates)
60
© 2010
What and Where
Hospital Inpatient
Outpatient (Hospital/Office)
ICD-10 CM for diagnoses
ICD-10 CM for diagnoses
ICD-10 PCS for procedures
CPT-4 for procedures
DSM IVDSM5 for Behavioral Health
DSM IVDSM5 for Behavioral Health
ICD-O for Cancer Registry
ICD-O for Cancer Registry
Source: First Class Solutions
61
© 2010
Resources
• Complete Versions of ICD-10-CM and ICD-10PCS
• Available at: www.cms.gov/ICD10
62
© 2010
Are There Any Benefits?
 Increased granularity
› Improve cost analyses within organization
› Improved resource utilization management
› Enhances ability to compare to others
 Volume
 Cost
 Morbidity/Mortality
› Facilitates identifying quality improvement opportunities
› Improved revenue stream as a result of documentation
improvement
› Enhances disease management and development of protocols
› Supports Meaningful Use CQMs
› Facilitates strategic positioning and contracting value
discussions (innovative contracting)
63
› Facilitates epidemiological and bio-surveillance activities
© 2010
What You Need to Do
1. Direct the Steering Committee to evaluate
impact and how to collect and utilize the data
effectively
2. When: Now until…..
64
© 2010
Education across the organization
•
•
•
•
•
•
•
•
•
•
•
Coders (hosp./phys. Off.)
Other HIM staff
Case Management
Clinicians
MDS Coordinators
Senior Management
Information Systems
QM/PI
Utilization Review
Accounting
Patient Financial Services
• Clinical Department Managers
• Documentation Improvement
Professionals
• Data Analysts
• Home Health
• Researchers
• Epidemiologists
• Software Vendors
• RM and Compliance
• Data Quality/Security
• Decision Support
• Access/Ancillary Registrars
Source: Adapted from AHIMA 2007: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht
65
© 2010
Education….but when?
• Physicians—documentation: Sooner than later
• Case Managers and CDI Specialists: Sooner than
later
• Coders:
– Refresher coursework: 2012 (all year)
– ICD-10 Specific EducationLate 2012/early 2013
• Ideal if both codes can be captured in system
• Give some history in your decision support data bases
• Role-based: One size does not fit all
66
© 2010
Coder (CDI, Some Physician
Office Staff, Others) Education
• First: Refresher courses: Anatomy, Physiology,
Pharmacology, Pathophysiology, Surgical
Procedures, Surgical Devices
• Then: ICD-10: 6-10 days for experienced coders (for
both I-10cm and PCS)
• For understanding the structure
• Coder learning curve (6+ months)
• DNFB
• Loss of coders
• Contract coders
67
© 2010
What You Need to Do
1. Conduct a Skills Assessment
– When: Yesterday
2. Consider refresher training needed
a)
b)
c)
d)
e)
A&P
Pharmacology
Pathophysiology
Medical terminology
Surgeries/Surgical Devices
a) When: 12 months Now-March 2013
68
© 2010
What You Need to Do
3. Consider training options
a) Using internal staffs (Pharmacist, Surgeons/OR team,
Educator)
b) Using You Tube
c) Community colleges/technical schools
d) Apprentice programs
e) College
f) On-line programs
g) State/professional associations
h) Professional journals
i) Sharepoint/websites
j) Surgical supply firms
69
© 2010
What You Need to Do
4. Consider direct training hours and backfill
a)
b)
c)
d)
e)
Basic: Awareness ~2 hours
Moderate: 4 hours
Detailed: 40 hours
GEMs: 8-10 hours
Physician: 4 hours
 How best to do physician training
 One on One?
 Groups or Medical Staff Meeting? NOT
70
© 2010
Coding Time/Productivity
• Additional labor time projected by CMS-up to
2 minutes additional for each encounter
• 24 inpts/day to 22 inpts/day
• However…………..
Just the facts
71
© 2010
AHA/AHIMA’s Productivity Study
Record Type
ICD-9cm Minutes
ICD-10cm Minutes
Short-term Acute Care Inpatient
8.99
15.99
Short-term Acute Care Outpatient
4.18
9.03
Clinic/Community Health Center
2.42
5.05
Physician Practice
3.04
6.70
Free Standing Ambulatory Surgery Center
2.22
4.62
Home Health/Hospice
10.76
13.31
Nursing Home
6.71
12.99
Long-term Care Hospital Inpatient
18.22
28.74
Rehabilitation Facility
4.97
10.94
Behavioral Health Inpatient
6.33
12.89
Behavioral Health Outpatient
3.08
9.71
“ICD-10-Field Testing Project. Report on Findings: Perceptions, Ideas and Recommendations from Coding
Professionals Across the Nation”
72
© 2010
Lessons Learned from Canada
Source: ICD-10 Lessons Learned
from Canada 12/09 ICD-10 Task Force
73
© 2010
What You Need To Do
• Ensure Coders Practice
• Evaluate other coding productivity enhancement
tools: CAC, Get rid of the non-coding duties
• Identify other physician documentation
enhancement tools: Slang translators, Intelligent
Dictation, etc.
• When: July 2012 until….
© 2010
It’s All About the Data
• Meaningful Use, PQRI, CQMs
• ICD-10 data will drive clarity in
outcome definitions
• ACOs-Outcomes-Value based
purchasing
• ICD-10 coding is dependent
upon physician documentation
75
© 2010
Documentation: Baseline Assessment
• What condition is your documentation in
today?
• Share findings with clinicians
– Physician champion and coding leadership address
findings with clinical service meetings
• Monitor efforts to change documentation
practices
76
© 2010
Assess Documentation
• Which diagnoses now are source of queries
• Identify top 30 diagnoses and top 30 procedures
• Convert (Map) diagnoses and procedures to ICD-10 and
identify the details required
• Create drop-down ladders to accurately define the top
diagnoses and procedures using EHR’s drop downs
• Review documentation to determine if documentation supports
ICD-10 diagnoses/procedures (all fields)
• Segregate issues by physician and specialty
• Physician champion and coding leadership address findings
with clinical service meetings
• When: August 2012---until
77
© 2010
Queries
• The Medical Staff will:
– Experience more queries for clarification
• Helpful Options:
– Short form documents (H&Ps and Discharge Summaries)
discontinued?
– Dictated reports (increased expense)
– Templated documents will require more qualifying
components (drop down selections)
• ADR invitations
78
© 2010
Today vs. Tomorrow
Today
House
Tomorrow
Two story house with
Rough sawn cedar siding
3500 square feet
All electric
Source: First Class Solutions, Inc.
79
© 2010
Staffing
• Alert Human Resources
– More staff in certain areas: Case Management,
Clinical Documentation Improvement, Coding,
Access, Physician Offices, IT, PFS
• Temporarily? Permanently?
• Consider light duty staff
80
© 2010
What You Need to Do
• Decide when new staff will be added
– JIT
• Will they exist
• September 2012….
• Recognize your competition
– Other Providers --Payers
– Vendors
--Others
• Contracts/Retention Bonuses
– When: Now (Lock ‘em in)
• Apprentice Program
– When: Now (12-16 months)
81
© 2010
Payers
• Same HIPAA Mandate
– By 10/1/2013
• 5010 by 1/1/2012
– More detailed data on all providers
– Profiles will be more specific
• Including quality evaluations (P4P)
82
© 2010
Healthcare Reform
Source: HFMA 3/31/10
83
© 2010
Payers
• System changes
– Phase In
– Testing
• Adjudication challenges
– Two coding systems in use during transition for
claims “before” and “after”
• “Potential” reduction of “attachments”
• Facilitate validating “medical necessity”
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Payers
• Will Medicaid be ready?
• Not Required to use I-10
– Workers Compensation
– Automobile Insurance (no fault)
• 8-12 month overlap period for claims to clear your
system
• How many coding databases will be required to be
maintained?
– Consider complexity of claim edits
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What You Need To Do
• Inventory and Contact Payers
– When will they be ready for ICD-10?
– When will you be able to test their readiness?
– How will they pay you when you submit ICD-10
codes? (reverse map)
– When will new Advisories and LCDs/NCDs be
issued
– Will Medicaid be ready
– Will state Workers Comp accept 5010/ICD-10
• When: April 2012-June 2012
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Managed Care Contracts
• Contracts:
– Any based on DRGs?
– Any fee schedules based on I-9 codes?
• Need to map DRGs/Codes and align
healthcare costs to ICD-10
– Anticipate educating Provider Relations Contract
staff
– Start re-negotiating no later than 1Q2013.
• Need data
• Dual coding in 2012/2013
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What You Need to Do
1. Understand your managed care contracts
a) Inventory the contracts
i. Understand the basis for payment
ii. Define renegotiation activity required
b) Prepare for potential mapping efforts
2. When: May 2012-July 2012
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MS-DRG Conversion Project
• HHS MS-DRGs conversion to I-10cm
– http://www.cms.gov/ICD9ProviderDiagnosticCodes/
03_meetings.asp#TopOfPage
– http://www.cms.gov/ICD10/17_ICD10_MS_DRG_
Conversion_Project.asp
• Which diagnosis to choose
to trigger principle diagnosis
Which Dx/Px?
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MS-DRGs mapped to ICD-10
ICD-10 MS-DRG conversion project website -- new information now available
• The ICD-10 Medicare Code Editor v27 and a text version of the ICD-10-CM/PCS Medicare
Severity-Diagnosis Related Group (MS-DRG) v28 Definitions Manual are now posted on the
Centers for Medicare & Medicaid Services (CMS) website at
http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp in the
“Downloads” section. There are also links to order the MS Grouper with Medicare Code
Editor ICD-10 Pilot Software Version 28 on CD-ROM from National Technical Information
Service (NTIS) in the “Related Links Outside CMS” section of the Web page.
• This update is part of the ICD-10 MS-DRG conversion project. In the conversion project,
CMS is using the General Equivalence Mappings (GEMs) to convert CMS payment systems.
CMS is sharing information learned from this project with other organizations facing similar
conversion projects. Please note that the final ICD-10 MS-DRGs will be subject to formal
rulemaking.
•
3/17/11 First Coast
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Contract Management Software
• Is vendor/application ready to accept new codes?
• Allow more than 1 contract per payer for
different years and store ICD-9 and ICD-10
codes?
• Staffing efforts required to ensure payments are
made correctly after new codes are initiated
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Physicians/Other Providers
• ICD-10cm ONLY
• Continue to use CPT for services
• Revise Superbills/Encounter Forms
– http://www.ahima.org/icd10
• Coding Education
– Billing
– ABNs
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Physicians/Other Providers
• More SPECIFICITY in coding
– Enhance profile/severity index
– Profiles will be more specific and transparent
• Including quality evaluations (P4P)
– Facilitates research
– Facilitates “medical necessity” checking
• 5010 may help on physician office denials
– If they document and code the cases
• Documentation education
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What You Need To Do
• Assess Physician Office Documentation
– Identify 25 most common diagnoses
– Map to ICD-10
– Assess whether documentation would support
complete coding
– Address findings with practitioners
• One on one
• When: June-July 2012 (templates)
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Physicians/Other Providers
• Practice Management Software updates (all
installed?)
• Clearinghouse readiness
• Less demand for attachments--Later
• Fee schedule changes-minimal
– (CPT driven)
• Reimbursement changes-?major--Profile
• Report changes
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What You Need To Do
1. Find out if your owned physician practices have
updated their software
2. Contact software vendor for readiness
3. Contact clearinghouse for readiness
4. Schedule upgrades
5. Schedule testing
6. Update superbills/encounter forms and requisitions
7. Schedule training for physician office staff
a) Your cost or theirs?
8. Buy educational resources for the office
–
When: Throughout 2012
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Access/Patient Financial Services
• Forms
– Facesheet fields
• ABNs
– Education (Access, Lab, Cardiology,
Radiology)
– Updated LCDs/NCDs
• Clearinghouse readiness
– Claim transaction sets
• UB-04 and CMS-1500
– Already incorporated larger fields and
indicator for I-9 vs. I-10
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Access/Patient Financial Services
• Access or Scheduling’s use of I-10 to validate eligibility,
pre-certs/auths, and verification
• Anticipate delayed or lost payments
• Contract management system changes
– Accommodate both coding systems
• Billing system modifications (larger and alpha numeric
fields)
• Impact on A/R due to “attachments” and potential lack of
readiness by the Payers
• CDM (embedded ICD-9 Procedure Codes)
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Decision Support and
Information Technology
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Decision Support/IT
• Assessment and Inventory
House of Y2K
– Which systems capture, store, use:
• ICD codes
• ICD descriptions
–
–
–
–
Databases
Standalone
Research
Interfaces
When: April 2012July 2012….
• EHR (does it use ICD-9 to trigger alerts, rules,
reminders etc.)
• Credentialing data modifications
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Don’t Forget
• Third party products integrated in your
information system
– ABN applications
When: AprilJuly 2012
• Web-based applications
– Code Look Ups
– Eligibility
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Decision Support/IT
• Updates will require coordination with:
– Application/System vendors
– Payers
• Parallel systems to accommodate phasing in of Payer
Modifications
– External Data Exchange Entities
• Field sizes (Character Attributes)
– Printed reports
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Decision Support/IT
• Management Reports-Mapping
–
–
–
–
Top 25 DRGs
Cost Reports-Analytics
Cancer Registry
Managed Care, Grant, Registry Analyses
• Mapping effort [When: 2013-2014]
– Between various systems
– Between historical records using I-9
• Data repositories
– Use a dual-code strategy
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Information Systems
• IT Can’t Do “It” Alone:
– Need an organization wide approach
– Need a cross-functional team
• Prioritize and Test system upgrades
• Modify Interfaces
• When: December 2012-August 2013
– Build test environment October 2012-December 2012
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Information Systems
• Consider I-10’s impact on any new systems or
applications being considered
– Add question to capital request process
– Query vendors
– Delay new applications?
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Systems Likely to be Affected
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Encoders
Case mix
Medical record abstracting
Billing systems
DRG/HHRG/Rehab grouper
Scrubbers
Registration and scheduling systems
Advance Beneficiary Notice software
Financial applications
Claim submission
Decision support
Clinical Applications
Utilization Management
Quality Management
Pharmacy
Clinical Documentation Integrity
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cost accounting
Case management
Clinical protocols
Test ordering
Clinical reminder
Performance measurement
Disease management
Provider profiling
Compliance checking
Aggregate data reporting
Registries-State and Internal
State reporting UHDDS
Managed Care Eligibility
Patient assessment data sets (e.g.
MDS, PAI, OASIS)
Managed Care reporting (HEDIS)
Adapted from: AHIMA 2007 Checklist www.AHIMA.org/ICD10
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Vendor Assessment
• Check with vendor on their readiness (See AHIMA
website for sample Vendor Letter)
– When: May 2012….until they answer!
• Will the update be part of the standard maintenance
contract? (regulatory change)
– When: Now
• Renewing contracts
– Price tags for updates
– Timetable for testing
• Will there be any charges for interface changes or testing?
• Will vendor offer any education?
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Don’t Forget!
• Trading partners (external data exchange entities-EDEEs)
– Send data to:
– Receive data from:
•
•
•
•
•
•
•
Registries
Providers’ billing services
Contract coders/registrars
Reference laboratory
State DOH
Physician offices
Etc…….
• Interface changes/costs
• Testing
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Information Technology
Considerations
• Additional staff for:
–
–
–
–
–
–
Inventory effort
Implementation/Updating efforts
Multiple systems -- parallel period
Testing
Mapping
???
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Next Phase of IT
Mega-Expenditures
• I-10
• ARRA-EHR Incentives
2009-2013
2011-2015
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Next Phase of IT
Mega-Expenditures
• I-10
• ARRA-EHR Incentives
2009-2013
2011-2015
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What will this cost you?
• Look at Your Y2K History
– AHA est. $8.2 Billion in 1999 for Y2K
Source: www.milbank.org/reports/990725y2k.html
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What will this cost you?
• Human
–
–
–
–
–
–
–
–
–
Steering committee
Inventory/Investigation
Implementation team
Vendor management
System modification
Parallel testing/Validation
Conversion team
Education
Back up resources-Coding,
Access, IT, PFS, Documentation
Improvement, Case Mgmt
– Data conversion
– Consultant Services
• Non-Human
– New interfaces
– New modules/updates (not covered
by contract)
– More robust hardware
– Replacement of systems no longer
supported
– DNFB/Cashflow
– Mis-adjudication efforts-delayed
payments
– Books/reference materials
– Reprinting of superbills, LCDs,
NCDs
– Encoders (if non-existed)
– Bugs….
See AHIMA & HIMSS Resource too
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What will it cost?
• HayGroup White Paper (10/12/06) by Thomas Wildsmith
– 400+ beds
$500,000-$2,000,000
– 200-400 beds
$250,000-$1,000,000
– 100-200 beds
$150,000-$500,000
– <100 beds
$ 35,000-$150,000
==================================================
– 21+ Physician Group
$50,000-$100,000
– 11-20 Physician Group
$20,000-$40,000
– 6-10 Physician Group
$10,000-20,000
– 3-5 Physician Group
$ 5,000-$10,000
– 1-2 Physician Group
$ 2,000-$8,000
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At the Physician Office
2008 http://nachimsonadvisors.com/Documents/ICD-10%20Impacts%20on%20Providers.pdf
115
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Owned Practices
•Will you adjust physician contracts to address the
extra effort?
© 2010
Monitor Impacts
• Baseline 10/1/12 or 1 Year Prior--Document:
–
–
–
–
–
–
Coding productivity
DNFB Average
Days in A/R
CMI
Days in Cash On Hand
Denials
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Insurers
•
•
•
•
Small plans (<1M members):
Medium Plans:
Large Plans(>5M members):
Per Member:
$99 million
$293 million
$1.3 billion
– Small Plans: $38/per member
– Large Plans: $11/per member
• Cost will trickle back to all of us in premium
increases
Source: www.ahip.org/SurveyICD-10CostsSept2010/
118
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What We’re Hearing
• $1-$2 million for every 100 beds
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Budgeting
• Time to inventory systems, interfaces, trading
partners (the initial gap analysis)
• Time and Cost to Build Test System
• Time to Install and Test System upgrades
• Time/Cost to Modify and Test Interfaces
• Cost of upgrades
• Implementation fees
• Additional Staff and Backfill
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Budgeting
•
•
•
•
•
Integrated Testing
Replacement Systems
Modifying Reports
Coder assessment and refresher education
ICD-10 Education
– Role based
• Initial ICD-10 system glitches
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Budgeting
•
•
•
•
•
•
•
Loss of staff/Developing new staff
Physician training
Update and Reprint Superbills
Encoder upgrade
Consider CAC
Documentation Reviews
DRG Shift Analysis
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Budgeting
•
•
•
•
•
Denials, HACs, PPC-Es
DNFB
Days in A/R
Increased litigation
Increased labor
–
–
–
–
Attachments
Verifying payments
Edits/rejections
Coding
123
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AHIMA/HIMSS Tools
124
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HIMSS/AHIMA Tools
125
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Entire Organization
Make A
“To-Do”
List!
126
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What You Need to Do
• Appoint Steering Committee
• Appoint Project Team
• Provide General Awareness Education
– To whom?
• _________________________
• _________________________
• _________________________
• Communication Plan
– PR
• Medical Staff
• Employees
127
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What You Need to Do
•
•
•
•
•
Evaluate maintenance contracts
Evaluate managed care contracts
Itemize upgrades (system and interfaces)
Itemize system replacements/terminations
Delegate!
– Contact Vendors
– Contact Payers
– Contact Trading Partners
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Entire Organization Impacted
• Checklist (Resources)
• Budget
• Anticipate some chaos
– Work disruptions
• Fees for updates and/or mapping applications
• Conversion resources
– Staff for installing updates
– Staff for testing updates
– Labor to maintain parallel systems
129
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Entire Organization Impacted
• Billing/Clearinghouse rejections
– DNFB/Accounts Receivable
• Education costs and time
• HHS anticipates significant short-term
productivity losses during the first 6 months of
implementation
– DNFB/Accounts Receivable
130
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ICD-10
– 532 days (+?365)
131
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On the horizonICD-11
• ~2015-2019 worldwide
• US clinical modifications
– ~2020
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Fast Forward
• If the delay doesn’t occur
– Use the AHIMA-HIMSS Document
• If the delay does occur…….
© 2010
To Do: 2012
• Implement coding apprentice
program (Grow Your Own)
• Refresher education for coders
• Study CAC
• Build your test environment
– Populate with upgrades when
available
• Vendor and payer readiness defined
134
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To Do: 2012
• Modify maintenance contracts
• Modify managed care contracts
– Do mapping efforts (different DRGs)
• Analyze your DRG exposure
– Intensify your documentation improvement efforts (ALL
payers)
– Modify templates, drop downs to ease documentation
pressures
– Acquire HLI, IMO and other physician friendly
documentation software
• Use of IMO (cross links vocabularies) and HLI (Health
Language-mapping of SNOMED to ICD codes) to assist
physicians to select the correct code
135
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To Do: 2013
• Continue to monitor Payer, Vendor, & Trading
Partner readiness
• Modify interfaces and test
• Schedule your upgrades and tests with vendor
– Sooner than later
• Schedule your tests with payers
– Sooner than later
© 2010
To Do: 2013
• Obtain LCDs from Medicare and Advisories from
Commercials
– Assess your exposure for outpatient denials
• Validate Medicaid’s readiness
– Develop plan for Medicaid’s non-readiness
• Develop plan for Workers Comp and Motor Vehicle
Insurers
• Assess readiness for CAC
– Install if appropriate
• Evaluate Intelligent Dictation Systems
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To Do: 2013-2014
• Acquire additional coding staff (employed/contracted)
• Late 2013: Trading partner readiness defined
– Schedule testing in 2013 with trading partners
• Late 2013: Install latest grouper and software in Encoders
– ICD-10 ready?
– Training
– Bookshelf resources (anatomy, devices, drugs, etc.)
• Late 2013 or early 2014
– ICD-10 Education for Coders and CDI
– Practice Coding
• Coders to code 5 records per week using ICD-10
• Mid 2014: ICD-10 Education for others (Access,
Scheduling, etc.)
138
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To Do: 2014
• Reassess readiness for CAC and Intelligent Dication
Systems…and….implement if indicated
• Continue adding any new upgrades and testing
• Test interfaces between systems and with trading partners
• Testing with payers
• Update contract management system
• Educate PFS on revised managed care contracts
• Ready by 8/1/14!
• Go Live 10/1/14!
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Questions
Check out the resources >>
© 2010
Resources
• Preparing for ICD-10 Checklist:
http://library.ahima.org/xpedio/groups/public/documents/ahima/bo
k1_048737.pdf
• Medicare Learning Network (MLN) Matters-SE 0832, 10/3/08,
CMS
• ICD-10 Overview, CMS
http://www.cms.hhs.gov/ContractorLearningResources/Downloads
/ICD-10_Overview_Presentation.pdf
• ICD-10 Implementation-What’s Next, AHIMA
http://www.ahima.org/icd10/documents/Implementation.pdf
• Webinar-AHIMA http://www.ahima.org/icd10/index.asp
• AHIMA Study
http://www.ahima.org/icd10/documents/FinalStudy_000.pdf.
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Resources
• Barta, A., et al. “ICD-10 Primer.” Journal of AHIMA 79, no.5
(May 2008): 64-66.
• Where to look for ICD-10 Guidance & Info.:
– AHIMA
• http://www.ahima.org/icd10/index.html
– AHA
• http://www.ahacentraloffice.com/ahacentraloffice_app/I
CD-10/ICD-10.jsp
• HIPAA Code Set Rule: ICD-10 Implementation (An
Executive Briefing)
– HIMSS (ICD-10 and 5010)-Budget Thoughts
• http://www.himss.org/ASP/topics_FocusDynamic.asp?f
aid=220
• Training Recommendations
– http://www.ahima.org/icd10/role-based-model.html
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ICD-9cm vs. ICD-10cm Resources
• Medicare dedicated webpage to ICD-10:
– http://www.cms.gov/ICD10
• Medicare’s training manual
– http://www.cms.gov/ICD9ProviderDiagnosticCodes/08_IC
D10.asp
• AHA and AHIMA have dedicate webpages as well
– www.AHIMA.org/ICD10
– www.AHAcentraloffice.org
• Clinical Modifications: http://www.cdc.gov/nchs/icd9.htm
143
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Speaker Information
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, FAHIMA
[email protected]m
First Class Solutions, Inc.
St. Louis, MO
(800) 274-1214
144
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