ICD-9 to ICD-10: What and Why It’s Being Implemented 0 ICD-9 to ICD-10: What and Why It’s Being Implemented This primer is intended to be a concise overview of the conversion from ICD-9 to ICD-10 codes. Throughout this primer, ICD-9 and ICD-10 are the terms used to refer generally to the two different code sets. It should be noted that both code sets were developed by the World Health Organization (WHO). ICD-9 In 2003, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 named ICD-9 as the code set for reporting diagnoses and procedures in the electronic administrative transactions (HIPAA 4010A1 transactions – 270/271, 276/277, 278, 820, 824, 834, 835, 837 D/I/P). “ICD-9” is the abbreviated term for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). ICD-9-CM is the U.S. version developed by the Center for Medicare and Medicaid Services (CMS) of the World Health Organization’s (WHO) ninth revision of the International Classification of Diseases. The code set is designed for the classification of morbidity (sickness) and mortality (death) information for statistical purposes. ICD-9-CM consists of three (3) volumes. Volumes 1 and 2 contain the codes for reporting diagnoses and symptoms. Volume 3 contains the codes for reporting surgical and nonsurgical procedures in hospital settings. The Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) are the code sets for reporting services and procedures in outpatient and office settings. ICD-10 ICD-10 is the abbreviated term used to refer to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). ICD-10-CM is the diagnosis code set that replaces ICD-9-CM Volumes 1 and 2. ICD-10-PCS is the code set of hospital procedures that replaces ICD-9-CM Volume 3. CMS awarded a contract to 3M Health Information Systems to develop a new Procedure Coding System (PCS) o Development History: 1995 - 1996: First draft of ICD-10-PCS completed 1996 - 1997: Training program developed and Informal testing conducted ICD-10-PCS revised o 1997 - 1998: Independent formal testing conducted ICD-10-PCS revised Final draft completed o 1998-present ICD-10-PCS updated annually o The new system is intended to replace ICD-9-CM Volume 3 for reporting procedures Since January 1, 1999, ICD-10 has been the standard for hospital reporting of the cause of death by U.S. hospitals. ICD-10 has not yet been implemented in the U.S., nor is it required to be used for other data reporting requirements until October 1, 2013. 1 Experis - All Rights Reserved. The U.S., through CMS, has created ICD-10-PCS, since a procedure code set was not developed by WHO. CMS is also responsible for the on-going maintenance of ICD-10-PCS. More information on ICD-10-PCS is available at: www.cms.gov/ICD10/. The National Center for Health Statistics (NCHS) under the Centers for Disease Control and Prevention (CDC) is responsible for the development and maintenance of ICD-10-CM. Additional information on ICD-10-CM can be found on the NCHS website at: www.cdc.gov/nchs/icd/icd10cm.htm. Regulation Requiring the Implementation of ICD-10 On January 16, 2009, the Department of Health and Human Services (HHS) published a regulation requiring: The replacement of ICD-9 with ICD-10 as of October 1, 2013. All encounters and discharges on or after October 1, 2013 must use the ICD-10 codes. Transactions submitted with ICD-9 codes will be rejected after October 1, 2013. The regulation names ICD-10-CM for reporting diagnoses in all clinical situations and ICD-10-PCS for hospital procedures only. CPT and HCPCS will continue to be the code sets for reporting procedures in outpatient and office settings. ICD-10 is replacing ICD-9 as part of the HIPAA-named code set; therefore, covered entities, defined in HIPAA as health care providers, including physicians, payers, and clearinghouses, are required to comply with this regulation. Although HIPAA requirements specifically apply to the HIPAA-named electronic transactions, payers are expected to require ICD-10 codes on transactions submitted using other methods, such as on paper (e.g., 1500 claim form), through a dedicated fax machine, or via the phone. CMS is the agency within HHS that is responsible for oversight of the implementation and compliance with the regulation. Additional resources are available on the CMS website. The general consensus of opinion is that ICD-9 has become too outdated and is no longer workable for treatment, reporting, and payment processes. ICD-9 has been used widely in the U.S. since 1978. The WHO endorsed ICD10 in 1990 and many countries have adopted versions of it, except for the U.S. Solely from the age of ICD-9 means that it does not accurately reflect all advances in medical technology, knowledge and usage. The original structure of the ICD-9 diagnosis codes are divided into chapters based on the body as we knew it in the early 1970s. During the years of maintaining and expanding the codes within chapters, the more complex body systems have run out of codes. Consequently, new codes are being assigned in chapters of other body systems. The rearranging of codes makes finding the correct code more complicated. Another factor in replacing ICD-9 is the increased specificity of ICD-10. More specific data will provide better information for identifying diagnosis, trends, public health needs, epidemic outbreaks, and bio-terrorism events. More precise codes also have the potential benefit for fewer rejected claims, enhanced benchmarking of data, better quality, improved care management, and advanced public health reporting. 2 Experis - All Rights Reserved. Migration Plan Successful migration plans for ICD-10 implementation will address the requirements in an integrated, enterprise-wide fashion. The overall plan will: Balance industry deadlines, internal business requirements, trading partner readiness and vendor schedules. o The critical path may not address every contingency, but will reflect business priorities and resource availability. Be phased in over time in a structured set of manageable releases that can be effectively implemented by the organization. This approach recognizes that many applications, systems and processes will be effected by the implementation. o Grouping the migration activities into a predictable set of manageable releases leverages organizational testing and training resources and helps to minimize operational and financial disruptions. Include the use of appropriate automation for testing and configuration management to ensure the synchronization of changes and adjustments over the entire scope of the implementation. With a partner’s vendor agnostic, independent thought leadership, it is important to look at what is not being said about ICD-10. Y2K spurred the healthcare industry to update technology solutions and implement electronic medical/health record systems. Many organizations moved from index card-based systems to paperless files. The implementation left health information offices neat and tidy, while providers pulled their hair out struggling to make the operational changes. ICD-10 implementations are no different, requiring the inclusion of operational changes for clinical staff throughout each organization. Vendors need to consider these operational changes when implementing technologies to accommodate ICD-10. Clinical Documentation Improvement (CDI) programs are efforts to educate providers on how to improve the clinical quality of their documentation upfront rather than retrospectively replying to coding queries. Improving clinical data quality is an ongoing effort and a necessity of the more expansive and specific ICD-10 data set. These CDI programs will become a staple to the management of electronic data in the ICD-10 era. In addition, pressure to appropriately code diagnoses and procedures based on the patient’s clinical record will require adequate exposure and practice coding medical charts in the ICD-10 format. Clinical documents will need to meet the expanded language in order for the appropriate code to be assigned and finalized. Finally, claim rejections are expected to rise, either as a result of technology or as a result of coding errors. Expecting to deliver technology updated to meet the regulatory requirements alone will not suffice for a comprehensive implementation. Operational change management practices may be added to existing implementation plans. Below are some of the generic steps with their definition: Assessment: Identifying operational impact areas is a standard practice for any project; however, the results may not naturally be shared with the technology vendor’s project team. Work closely with your clients to review the acknowledged impact areas and confirm that the findings include a CDI program. Gap Analysis: If a client does not currently have a CDI program in place, work with clients that do to develop a standard template and methodology you can share. Sample industry tool kits and reference information are also available through associations such as AHIMA. Good clinical data is fundamental to the ICD-10 coding practices, potentially expanding the vocabulary of existing clinical templates and dictation practices. Once a CDI program is in place, it should become an ongoing and indefinite improvement effort. 3 Experis - All Rights Reserved. Implementation and Testing: Client testing will be crucial because of the significance of this technology change. Testing will require active participation from both the vendor and client. Unlike other implementations, ICD-10 will require product knowledge as well as ICD-10 coding knowledge. Due to the nuances in moving from ICD-9 to ICD-10, both the vendor and client will make business decisions regarding application and coding practices. A testing strategy for each organization should include a review of business decisions that create technology or operational rules. These business decisions, made by either the vendor or the client, can alter testing outcomes. The collective knowledge of the product changes, as well as the coding changes, will prove useful when diagnosing a technology issue. These additional decisions should be included in a test plan to comprehensively cover the test planning process: Resources: Clients will need to identify the physical location, technology, and staff to use during the testing and validation processes. Vendors will also need to plan staffing to support the end-user testing and validation efforts. Assigning a team of resources from both sides to work through the testing phase will reduce communication barriers. Scheduling: Work with each client to schedule time dedicated to testing and validation, and to track the results and progress made towards completing the entire process. This time is reserved for the client to discuss testing results, brainstorm issues, or ask questions about product functionality. As testing demand increases, the schedule of these meetings may need to be altered. Keep a dedicated time to regularly provide the client the opportunity to discuss questions outside of the standard support services arrangement. Methodology: Develop a set of test scripts for each product that includes a description of the test activity, expected results, and space for collected results and enduser identification. Test results should be shared during the scheduled meetings. As test results show opportunities for documentation improvements, incorporate the CDI program into the testing process. The ICD-10 implementation is manageable if work is planned and executed thoughtfully, while keeping an eye on the looming deadline. Encouraging clients to begin CDI programs, and assisting along the way, will not only improve data processed, stored and referenced within applications; it will also provide clients with an opportunity to gain additional exposure to the code set. Vendor and client collaborating throughout the implementation will effectively incorporate product functionality as well as improve clinical documentation. The more production like exposure both vendor and client have to the code set prior to the productive use; the better the data will be on October 1, 2013. 4 Experis - All Rights Reserved. A good partner will address the future of chaos brought on by ICD-10. Specifically, a good partner will aide your organization in dealing with exploding data volumes, skyrocketing demands, and shrinking staff, while delivering continuous improvement in outcomes. Health care reform, rising costs and ever-exploding data volumes, combined with shrinking analyst and IT staffs are making it increasingly difficult for health care system executives and other key decision makers to effectively manage better outcomes, whether they are clinical, operational or financial. A good partner’s strategic approach will focus on the dilemma we all face in implementing ICD-10. They will cover effective strategies to consider, including the use of technologies. Conclusion The implementation of ICD-10 will pose a significant burden on physicians and the health care industry as a whole. There will be benefits gained as a result of the more detailed information contained within the ICD-10 codes, but the implementation will require significant changes to clinical and administrative systems that capture and report these codes, as well as extensive training for all staff. For more information, contact [email protected] Experis is the global leader in professional resourcing and project-based solutions. Our healthcare focus leverages the expertise of the entire Experis organization, bringing solutions to the payer, provider and pharmaceutical sectors. Experis is a dedicated business unit of ManpowerGroup. 5 Experis - All Rights Reserved.
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