ICD-10 information documents

There is some extremely vital, important and excellent information on the Noridian website for ICD-10.

This information should be passed on to your HIM/coding department. CMS is making available several technical tables for ICD-10, for both the CM (diagnosis codes) and the PCS (procedure codes).

These include guides on how the new ICD-10 methodology compares to the old ICD-9 methodology for creating codes; actual tabular indexes for the CM and PCS codes, and GEMs (General Equivalence Mappings crosswalks between ICD-9 and ICD-10 codes).

It’s an excellent resource, especially if you are not getting this kind of detailed information in tables from your coding software or you haven’t subscribed to a service for that coding information.
The site is http://cms.hhs.gov/Medicare/Coding/ICD10 or you can touch on the following link:

ICD-10 coding guides

Once there, on the left side under the ICD10 menu, choose the two 2014 links to ICD-10 CM and PCS codes. Each of these two links contains the tables, indexes, maps and much more.

ICD-10 and documentation

Moving to ICD-10 coding shouldn’t actually change the providers documentation. It should only change the capability of capturing that documentation.

For example, the provider should always have documented things like whether this encounter was initial, a subsequent encounter or whether this was a sequelae or after effect of a disease. They should be documenting whether a condition is acute or chronic; whether the injury is effecting right or left; and whether in a fracture the healing is normal, delayed or if there was either a nonunion or malunion. If there was a bite or injury, what caused the injury?

The difference is that the old ICD-9 codes themselves couldn’t always capture this detail, but the new ICD-10 codes will capture the detail.

So you’ll want to take samples of some documentation from your physicians currently, and have the coder apply both ICD-9 and ICD-10 codes to see what the differences are. Then  show these to both the coders and the providers so they can understand how ICD-10 more clearly utilizes the depth of detail in the documentation.

Split Claims instructions for the ICD-10 Oct 1, 2014 implementation

Medicare has released a document regarding the exact instructions on how to split claims for those few patients who will be getting services in your facility over the night of Sept 30 and Oct 1, 2014 when ICD-10 diagnosis coding goes into effect.

Remember, there can be no ICD-9 diagnosis codes on any bills with a service date on or later than Oct 1, 2014 and, conversely, there can be no ICD-10 diagnosis codes on any bills with a service date prior to Oct 1, 2014.

This is one of those times when Medicare created a fantastic, succinct instruction sheet. I couldn’t have done it better myself. So I’ve attached it here and you can see this at CMS.  It includes:

  1. clear instructions
  2. examples of real world situations involving the ER and observation
  3. picture examples of what the correct UB-04 claims should look like (translate those to your 837I format)

Touch on the link split claims for ICD-10 implementation to see these great instructions.

Who will be impacted?

Your billing department needs to see this information. Since it’s a “one time only” issue, you shouldn’t make changes in your IT system. Billing will just have to manually split these bills in your IT system or in your electronic claims clearinghouse/scrubber software.

Your HIM department will need to apply the ICD-9 codes that are only applicable to the charges prior to Oct 1, 2014 and apply the ICD-10 codes that are only applicable to the charges on or after Oct 1, 2014. Again, this might be a manual process, working with the billing department since it may be difficult in your IT system.

Implementation suggestions

  • Preferably put an IT system hold on all patients with a discharge date OR charge dates of 10/1/2014
  • Review all these patients to see which were “overnighters” and need to be reviewed
  • HIM needs to work with billing to determine which ICD diagnosis codes are related to which dates of service
  • Take off the hold and release your claims
  • Do not transmit any claims from your electronic system/claims clearinghouse/scrubber system until they have been reviewed
  • Billing will split the appropriate “overnighter” claims, moving the appropriate diagnosis codes to each split upon HIM’s instructions

ICD-10 – working with your vendors

Noridian Medicare has an excellent half page, short and sweet, checklist for working with your ICD-10 vendors on the testing and transition to ICD-10.  Since I couldn’t come up with a better checklist, go to this link to see the short checklist. ICD-10 checklist for working with vendors.

Remember that your ICD-10 vendors are more than just your coding software (ie: 3M, Craneware, etc.). They are any software that has to include or encompass or use ICD-10 diagnosis codes.

This could be your clinic EMR, a separate software used in the ED for coding and charging levels, separate lab software that captures charges, any other unique department software, you claims clearinghouse or claims scrubber, your billing system, and any reporting system you might have for financial and statistical reporting that captures diagnosis codes.

Do not fool yourself into thinking this is one of those pesky ICD-10 things you can put off. Not being prepared for ICD-10 will result in stopping claims, and money. Remember, at this point, there is no “transition”. ICD-10 will be turned on at the given date.

ICD-10 End-to-End testing with CMS

CMS will be hosting some webinars on conducting end-to-end testing of the ICD-10 system which includes a checklist for testing. These would be very good to attend. You should have your currently assigned ICD-10 expert in your HIM department and someone in IT, billing or HIM that is familiar with the software(s) in your facility that will be using ICD-10. That could be your hospital EMR, your clinic EMR, and your claims scrubber or clearinghouse software.

The sessions are specifically geared towards separate provider types and there are two different dates for a session specifically for the Small Provider.  This means you won’t end up listening to large providers, payers and vendors asking their questions and addressing problems that aren’t targeted to the small hospital, wasting your time.

Go to the following link “end-to-end ICD-10 testing webinar to see the dates and times for small providers. Since these are specifically addressing your segment of the industry, this will not be a waste of time and should not be missed.

Start easing your providers into ICD-10

If you haven’t already started some practical applications of your ICD-10 education with your providers, you can start doing this in bits and pieces so it’s not quite so overwhelming.

Start practicing now with your providers (clinic, ER and admitting providers) on understanding the difference that ICD-10 will make for them. Here are some suggestions on how to do this.

Understand and communicate with your providers that they’re not going to be memorizing the ICD-10 codes anytime soon, just like they may not have had the ICD-9 codes memorized.

They may have always been documenting the specificity necessary for the new ICD-10 but were used to a current EMR system which they have their “favorite” codes they choose when the system gives them their options.  But they’re going to have to entirely forget these “favorites” and realize they will have to look more thoroughly at the new options give them by the EMR system and choose appropriately.

Code comparison

  • Identify the top 10 outpatient and inpatient diagnoses used at your facility
  • Have your HIM department use an ICD-9 to ICD-10 crosswalk (MediRegs, CMS ICD-10 resources, your current coding product) to determine the new ICD-10 codes or multiple replacement codes that would correspond to these two Top Ten lists
  • Create and print a document that shows the ICD-9 code and description and the replacement ICD-10 code(s) and descriptions side by side and give to the providers to show them what to expect

Here’s an example of a common presentation seen either in your clinic or your ED.

910.6 superficial FB (splinter) of face, neck, scalp except eye, w/o major open wounds or infection S00.05XA Superficial foreign body of scalp, initial encounter
S00.35XA Superficial foreign body of nose initial encounter
S00.451A Superficial foreign body of right ear initial encounter
S00.452A Superficial foreign body of left ear initial encounter
S00.459A Superficial foreign body of unspecified ear initial encounter
S00.551A Superficial foreign body of lip initial encounter
S00.552A Superficial foreign body of oral cavity initial encounter
S00.85XA Superficial foreign body of other part of head initial encounter
S00.95XA Superficial foreign body of unspecified part of head initial encounter
S10.15XA Superficial foreign body of throat initial encounter
S10.85XA Superficial foreign body of other specified part of neck initial encounter
S10.95XA Superficial foreign body of unspecified part of neck initial encounter

Mini-audits and feedback

Once a month, have your HIM staff gather 10 patients for each provider, and give the provider a report that shows the ICD-9(s) and description(s) for that patient presently, compared with what the ICD-10(s) and description(s) would be in the future.

Have HIM report on each patient whether there was sufficient documentation in the providers notes to substantiate any of the new ICD-10 codes and if there was not, specifically state what documentation or verbiage was lacking.

This can continually be a mechanism for the physicians to get used to the new specificity and documentation that will be required.

ICD-10 dates, what they mean, how to prepare

At this moment, here are some items from Medicare regarding dates and implementation of ICD-10, along with some suggestions for making these operational.

This is a lot of information but if you don’t figure out how to operationalize these issues, you could either lose cash permanently and never know it, or significantly hamper your cash flow.

Item: October 1, 2014 is a “hard” cutoff cate

This means that there is no period of easing into ICD-10 or a period when both codes are acceptable (like the annual changes in HCPCS codes between October and January).

Claims after 10/1/14 will not be accepted with ICD-9 diagnosis codes and claims prior to 10/1/14 will not be accepted with ICD-10 diagnosis codes.

Think about what this means – these are claim dates, not service dates or coding dates. This means that if you have a patient who has a date of service of 9/28/14 and your HIM staff is coding them with ICD-9 diagnosis codes, but the claim is not finalized/dropped until 10/1/14 and transmitted that day to CMS, it will be returned.

Conversely, If you have a patient who has a date of service of 9/28/14 and your HIM staff starts coding with the ICD-10 diagnosis codes in anticipation of the 10/1/14 date, but the claim is finalized/dropped on 9/30/14 with the ICD-10 codes and transmitted that day to CMS, it will not be accepted.

You’re going to have to coordinate your coding and billing/transmission efforts and probably have an internal “hold” period.

Operational Suggestion:

  • Determine 30 days prior to 10/1/14 what your average DNFB (discharge not final billed) days are. In other words, is it taking your HIM department 3 days to code and finalize bills after discharge? 7 days? 15 days?
  • If it’s taking your department 7 days to code and finalize, then on 9/24/14, start having them using all ICD-10 diagnosis codes
  • Have HIM or your technology system put a temporary hold on all claims to finalize/drop/create only after 10/1/14
  • On 10/1/14, take a quick peek at each claim on hold to make sure they are in the ICD-10 format
  • If any are in the ICD-9 format, have HIM change them
  • At least 30 days prior to 10/1/14, make sure your claims transmission or scrubber software has installed date sensitive, Medicare only edits for ICD-10 codes so that claims being transmitted after 10/1/14 with ICD-9 codes will be stopped in your system with an error
  • Once the claims on hold have ICD-10’s and your edits are in place, remove the temporary hold, have HIM finalized/drop/create your claims so they can be transmitted and accepted

Item: Claims cannot have a mix of ICD-9 and ICD-10 diagnosis codes

Make sure your HIM staff understand this completely. You cannot have any account/patient with a combination of both formats of diagnosis coding.

Operational suggestion:

You may have different staff that apply diagnosis codes to different portions of a patient chart. For example, a non-certified staff or trainee who applies diagnosis codes only to labs, xrays and EKGs and a more experienced or certified staff who applies diagnosis codes from dictation or documentation from the H&P, admit notes, ER notes, observation or inpatient admissions, procedure notes, etc.

Make sure that both of these staff understand when your facility is going to be entering ICD-10 diagnosis codes so one is not entering ICD-9 and the other is entering ICD-10, giving you a ‘mixed bag’ of diagnosis codes.

Item: Claims that span the date of Oct 1, 2014

If you have an outpatient (such as ER or observation) claim that spans the dates of 9/30/14 and 10/1/14, you will split the claims, using ICD-9 codes on the claim with the date of service 9/30/14 and a different claim with the date of service 10/1/14 using the ICD-10 codes.

For inpatient claims, you will use only the discharge or “through” date as your guide. If a patient is admitted on 9/30/14 and discharged on 10/2/14, you will use the 10/2/14 date as your guide and submit the entire claim using ICD-10 diagnosis codes.

Operational suggestion:

For inpatients, this would fall under the same suggestion as above with HIM holding all claims for a given period of time.

For outpatients, you may want to also look at your outpatient census (probably just ER and observation, although it could happen on a patient with a procedure) for 9/30/14 and you have at least a couple of choices.

  1. Have either registration or HIM (whomever is responsible for creating new accounts in your technology system) create a new account for these outpatients with the date of 10/1/14
  2. Make sure the charges for each date are entered appropriately on each separate account
  3. Make sure HIM applies the appropriate diagnosis codes, in the appropriate format, to each account. Remember that since these are outpatient claims and you can run into medical necessity issues (LCD and NCD), it’s important that the correct diagnosis codes are entered on the correct date of service/account
  1. If your claims submission/scrubber system is capable, your billers can manually “split” the claims in that system
  2. You’ll have to have the billers work with HIM to determine which charge line items and which diagnosis codes belong on each claim

Item: claims are RTP’d (Returned To Provider)

Claims that do not meet any of the ICD-10 criteria (dates, span or service dates, mixed coding formats) will be returned.

This means that you cannot simply go to the Medicare FISS system and correct these online causing a delay of only a day or two like other claim errors. They will be entirely returned and you’ll have to start all over again, causing significant delays in your payment.

Item: LCD’s and NCD’s

LCD’s (local coverage determinations) are basically medical necessity edits that are interpreted by the FI/Carrier/MAC (such as Noridian).  NCD’s are basically medical necessity edits that mandated by CMS for all FI/Carrier/MACs and for the most part, include the lab medical necessity edits (determining which diagnoses are covered for certain HCPCS codes).

Medicare states that they will be responsible for updating the NCD lists appropriately and on time.

However, the local FI/MAC/Carrier (such as Noridian) is responsible for updating the LCD lists appropriately and on time.

This means that if Noridian doesn’t have their act together, even though you have started using ICD-10 codes as of 10/1/14, if Noridian didn’t update properly all of their LCD’s in time, you could still end up getting medical necessity denials, because their LCD’s are looking for certain ICD-9 dx codes instead of your appropriate ICD-10 codes. The same could hold true for CMS on the NCD’s, although this is less likely.

Operational suggestion:

For at least 60-90 days after 10/1/14, review each and every medical necessity denial instead of posting it to a Medicare contractual and determine if it was appropriately denied, or if it was the fault of the ICD-10 conversion. You could bleed a lot of money away if either your IT system or your cash posters simply automatically continue to adjust off medical necessity denials when it could be that the MAC accidentally missed uploading some of the ICD-10 codes that were acceptable.

Watch for notifications from your MAC about whether they are on time for this segment of the ICD-10 conversion.

Also watch your MAC for published LCD’s lists. It may be that the published list is correct, but that in the upload process, a few diagnosis codes got left off and their technology denies the line item even though the published LCD shows that the ICD-10 is covered.


Great ICD-10 information for small hospitals

CMS has put out what is actually a really good document called the ICD-10 Implementation Guide for Small Hospitals. You can find it at the following link and then choose the guide for small hospitals. CMS ICD-10 Implementation Guide for Small Hospitals. 

It may look long, but it’s very detailed, specific and relevant. It can also be virtually used as a checklist so you don’t have to reinvent the wheel to get through ICD-10.

Need to know:

  • Don’t think you can ignore this
  • The required implementation date for CMS is October 2014
  • Some of your other payers may still require ICD-9 at that point so you should be ready for dual implementation
  • You cannot capture ICD-10 codes on bills if you’re not using the 5010 version of claims (5010 was implemented January 2012)
  • This has nothing to do with outpatient CPT and HCPCS codes, only ICD diagnosis and inpatient procedure codes

This entire document is really quite good and I’d recommend you read it all. But if you’re going to skimp and take a short cut, of special note would be:

  • Page 13,14 – the small hospital implementation timeline. This is a good checklist with target time periods
  • Page 20 – see the sections especially regarding the adverse short term impact on hospital revenue stream and the adverse impact on relationships with payers and patients
  • Page 26 – the self assessment questions on Training Preparation and Needs Assessment
  • Page 32,33 – the Hospital Business Impact – this is very important
  • Page 40 – Systems that require updating to ICD-10 – again a good checklist
  • Page 42-44 – New Documentation Requirements. This is crucially important to show your practitioners. If you currently have any issues with your practitioners dictating or documenting the bare minimum (and you do), it will be essential to show them this example. Don’t get hampered by the fact the example is fracture care if you don’t provide this.  It shows the new depth of detail that they’ll need to dictate/document to be even able to code an ICD-10 code. If their detail stays the same as it is, they’ll end up with a LOT MORE downtime spent sitting with your coders and billers asking for additional documentation and your cash flow will suffer severely.

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