Are you ready for ICD-10 implementation?
New system delayed until Oct. 1, 2015
Executive Summary
Implementation of ICD-10 has been postponed until Oct. 1, 2015, and all claims submitted after that point must use the new coding system.
• The biggest change from ICD-9 is the level of detail the new coding system requires.
• Case managers need to understand basic concepts of ICD-10 and the specificity it requires.
• They need to work with physicians to make sure that all documentation is complete and detailed.
The implementation of ICD-10 has been postponed until Oct. 1, 2015, but case managers still need to familiarize themselves with the new coding system and make sure that all documentation in the medical record is complete and detailed.
All claims submitted on or after Oct. 1, 2015, to any payer covered by the Health Insurance Portability and Accountability Act (HIPAA) for services provided in all healthcare settings must use the ICD-10 codes for medical diagnoses and inpatient procedures. Otherwise, the claims may be rejected and providers will have to resubmit them using the ICD-10 codes.
While case managers don’t need training on specific codes, they do need to understand the basic concept and the level of documentation specificity required by ICD-10, especially if they are involved in documentation improvement, says Tom Ormondroyd, BS, MBA, vice president and general manager of Precyse Learning Solutions, based in Wayne, PA.
"Case managers may not need to know as much as the clinical documentation specialist, but they do need to understand the documentation requirements so they can educate physicians on the level of specificity required. They are in the records and work closely with physicians, so they are in a good position to ensure that the documentation contains the level of detail needed for the hospital to be reimbursed for all the conditions treated and services provided," he says. Ormondroyd recommends that the unit nurses go through ICD-10 training as well. "The coder can’t code based solely on the nurses’ documentation. However, providers review nurses’ documentation, and if the documentation contains needed specificity, it may prompt providers to include that level of specificity in their documentation," he says.
ICD-10 represents a substantial change from ICD-9, he adds. ICD-9 was published more than 30 years ago as a research-based system and was later used for reimbursement. ICD-10 is based on clinical specificity, he says.
While ICD-9 uses five-digit numeric codes, ICD-10 is a seven-digit alpha-numeric coding system. The expanded fields make it possible to track much more detailed information about the patient’s condition.
"The need for more detailed documentation is the biggest change in IDC-10. That’s likely to be the challenge for case managers who will have to make sure providers document as specifically as possible. Whether it’s a disease state, a type of fracture, the manifestation or complications of disease, the ICD-10 system requires a lot more specificity," he says.
For instance, ICD-9 has a specific assigned code for a coronary artery bypass graft (CABG), but in ICD-10, the coders have to build the code based on information that is unique to that patient. "Assigned codes are the same for each patient that has a similar procedure. The codes in ICD-10 are like a fingerprint and are unique to each procedure," he says.
ICD-10 has 70,000 diagnosis and procedure codes, compared to 17,000 codes in ICD-9, he points out. "But 25% of the new codes are to show laterality. Providers can no longer just say a patient has a pressure ulcer on the knee. They have to document whether it’s the right, left, or bilateral," he says.
The documentation also needs to give details on the acuity of the disease. For instance, is the patient’s asthma chronic, acute, or intermittent? If the patient has alcohol, drug, or tobacco dependence and the physician knows it, that also should be documented.
The silver lining in the shift to ICD-10 is that the level of documentation required will put hospitals in a good position when it comes to dealing with the Recovery Auditors and payer reimbursement requirements, Ormondroyd points out. More specific documentation can affect the DRG assignment and gives case managers a better understanding of the conditions affecting discharge, he says.
"ICD-10 finally gives case managers the ability to show the true severity of illness that will demonstrate the medical necessity for the level of care and intensity of services provided. If the record is poorly documented, it doesn’t show how sick the patient really is and the claim is likely to be denied," he says.
The requirements of ICD-10 go hand in hand with payers’ emphasis on quality, he points out. "How well hospitals demonstrate the severity of illness and mortality already affects their performance on quality reports and reimbursement. ICD-10 just ratchets up the process," Ormondroyd says.
