American Health Information Management Association
2012
Table of Contents
Introduction
Background of ICD
ICD-9-CM Outdated
Development of ICD-10
Development of ICD-10-CM/PCS
Reasons for ICD-10-CM/PCS Implementation
Rulemaking Process and HIPAA
ICD-10-CM/PCS Uses
Implementation Issues
Implementation Strategy
Communication
Impact Assessment and Initiate Resolutions
Budgetary Issues
Process/System Impact
Vendor/Payer Contractual Issues
Training
Documentation Improvement
Reimbursement/Productivity/Accuracy Issues
Mapping and Legacy Data
Maps and How They Are Used
General Equivalence Mappings
Applied Mappings
Reimbursement Mappings
Data Analysis and Trending Challenges
Summary
References
Appendix A
Appendix B
Appendix C: Implementation Tools
Planning and Preparation
Clinical Documentation Improvement
Authors and Contributors
Acknowledgments
The scope and complexity of the transition to ICD-10-CM/PCS (ICD-10) by healthcare providers in the United States are significant. The conversion to a modified version of the classification system already in use by the rest of the world will be a transformational effort in the U.S. affecting many systems, processes, and people. It will have a tremendous and widespread impact on every operational process across healthcare. Ready access to pertinent information about ICD-10-CM/PCS is an important aspect of effective and efficient transition preparation.
This ICD-10-CM/PCS Implementation Toolkit provides many of the necessary tools and documents needed for successfully implementing ICD-10-CM/PCS. While the information contained in this toolkit is comprehensive, it is by no means inclusive of all the possible sources of information. The resources were current at the time of publication, but website addresses change frequently. If the specific URL is nonfunctioning, an Internet search can be conducted for the referenced item.
This toolkit will be useful to all healthcare professionals involved in the implementation of ICD-10-CM/PCS as well as those who may eventually be working with ICD-10-CM/PCS. The resources included in this toolkit are relevant to physicians, acute care hospitals, long term care (LTC) organizations, home health providers, and other similar settings. The following resources are classified under general headings further delineated by key terms to enable searching and the source URL to facilitate its use.
Note: In February 2012, the Department of Health and Human Services (HHS) announced its intent to modify the ICD-10 implementation timeline but gave no detail on its plans. Once HHS's plans are known, the deadlines in this kit will be updated.
The ICD-9-CM code set is the U.S. clinical modification of the World Health Organization's (WHO) International Classification of Diseases 9th Revision (ICD-9) diagnosis classification system. The purpose of ICD is to permit the systematic recording, analysis, interpretation, and comparison of mortality and morbidity data collected in different countries. ICD-9-CM includes both diagnosis and procedural codes. The inclusion of a procedure coding system that complements the diagnosis system is unique to the U.S. The ICD-9-CM coding system was developed and implemented in the U.S. in 1979.
The original function for ICD data collection was for statistics and research, but there has been an increase in the uses of data since its implementation. Some of these increased uses are:
- Setting healthcare policy
- Storing and retrieving data
- Designing payment systems
- Monitoring resource utilization
- Tracking public health and risks
- Designing healthcare delivery systems
- Analyzing payments for health services
- Implementing operational and strategic plans
- Measuring quality, safety, and efficacy of care
- Preventing and detecting healthcare fraud and abuse
ICD-9-CM terminology and classifications are outdated and inconsistent with current medical practice. In addition, the ICD-9-CM classification system has run out of space to accommodate new codes that address advances in medical knowledge, new technology, or newly identified diseases. Because of limited space, ICD-9-CM codes lack sufficient clinical detail to describe the severity or complexity of diagnoses. An updated classification system will allow the ability to perform the following:
- Measure quality of care
- Initiate pay-for-performance
- Evaluate resource utilization
- Track public health threats, such as avian flu
- Identify medical errors and patient safety issues
- Exchange meaningful health data with other organizations and government agencies
WHO owns and publishes the international version of the ICD classification system, and ICD has become an international diagnostic classification system used for all general epidemiological and healthcare purposes. In 1992 WHO published the tenth revision of the ICD system (ICD-10), which represents the broadest scope of any ICD revision to date.
The goal of the tenth revision was to expand the content, purpose, and scope of the system. It was designed to include ambulatory care services, increase clinical detail, capture risk factors in primary care, identify emergent diseases, and develop group diagnoses for epidemiological purposes. ICD-10 provides more categories for disease and health-related conditions than previous revisions through its alphanumeric coding system. Currently the ICD-10 classification system is used by many countries to record both mortality and morbidity data. Although the U.S. won't fully implement its ICD-10 based classification systems until October 1, 2014, the U.S. has used the WHO ICD-10 classification to report mortality data since 1999.
As noted, ICD-10-CM is the U.S. clinical modification of the WHO's ICD-10 classification system. All revisions or enhancements to the U.S. system must conform to the international ICD-10 conventions. As owner and publisher of ICD-10, WHO promotes the development of any adaptations that will expand the usefulness and comparability of health statistics and has authorized an adaptation of ICD-10 for use in the U.S. Both the WHO version of ICD-10 and the U.S. ICD-10-CM version contain diagnostic codes, but neither contains procedure codes.
ICD-10-CM was developed by the National Center for Health Statistics (NCHS), a division of the Centers for Disease Control and Prevention (CDC). NCHS worked closely with many organizations to address clinical needs particular to the U.S. ICD-10-CM incorporates the level of detail needed for morbidity classification and provides code titles using language that complements accepted U.S. clinical practices.
ICD-10-PCS was developed under contract by the Centers for Medicare and Medicaid (CMS) with 3M Health Information Systems to replace the outdated ICD-9-CM procedural coding system. Neither ICD-9-CM procedure codes nor ICD-10 PCS were derived from an international coding system; however ICD-10-PCS is designed to reflect current and future technology.
The objectives of ICD-10-PCS were to improve the accuracy and efficiency of procedural coding through greater specificity, reduce training efforts through standardization, and improve communication with physicians through the use of language reflecting current medical practices. The development of ICD-10-PCS was designed to incorporate four essential attributes: completeness, expandability, standardized terminology, and a multi-axial structure.
ICD-10-CM/PCS represents a significant improvement over ICD-9-CM. Both ICD-10-CM and ICD-10-PCS were designed to overcome issues and limitations of the ICD-9-CM system, updating healthcare coding in the U.S. by providing unambiguous codes for conditions and procedures while providing more flexibility in adding new codes.
The new code sets incorporate greater specificity and clinical detail resulting in major improvements in the quality and usefulness of coded data. Furthermore, medical terminology and the classification of diseases have been updated to be consistent with current clinical practice. Both ICD-10-CM and ICD-10-PCS have an improved structure and capacity for capturing technological advances. These systems are more flexible and able to accommodate revisions necessitated by medical advances.
On August 22, 2008, the U.S. Department of Health and Human Services (HHS) published a notice of proposed rulemaking for the adoption of ICD-10-CM/PCS code sets to replace the currently used ICD-9-CM code sets under rules 45 CFR Parts 160 and 162 of HIPAA. On January 16, 2009, HHS published the final rule adopting ICD-10-CM/PCS as replacements for the ICD-9-CM code set. The final compliance date is October 1, 2014.
Effective with encounter and discharge dates on or after October 1, 2014, the ICD-9-CM diagnosis code set will be replaced with ICD-10-CM (including the ICD-10-CM Official Guidelines for Coding and Reporting) for coding diseases, injuries, impairments, other health problems and their manifestations. The ICD-9-CM procedure code set will be replaced with ICD-10-PCS (including the ICD-10-PCS Official Guidelines for Coding and Reporting) for coding procedures on hospital inpatients reported by hospitals.
ICD-10-CM will be used in all healthcare settings, both inpatient and outpatient, and by all types of providers for the reporting of diagnoses. ICD-10-PCS, which will be used for procedural coding, will only be used by facilities for the reporting of hospital inpatient services.
CPT® and HCPCS Level II codes will continue to be used for the reporting of physician and other professional services as well as procedures performed in the outpatient setting (e.g., hospital observation services, clinic settings, physician office setting, home health, etc.).
The transition to ICD-10-CM/PCS represents much more than just an increase in codes and field sizes. The scope and complexity of the transition are significant and should not be underestimated. A smooth, successful transition requires a well-planned and well-managed implementation process. Proper planning and preparation throughout the continuum of the timeline are critical so that organizations can manage each step of the process to successfully move towards full implementation by the October 1, 2014 deadline.
The ICD-10 implementation planning and preparation process should be accomplished in the phased approach suggested below:
Phase
|
Action
|
Date
|
|
1
|
Implementation plan development and potential impact assessments
|
first quarter 2009 –
second quarter 2012
|
|
2
|
Implementation preparation
|
first quarter 2011 –
second quarter 2014
|
|
3
|
"Go live" preparation
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first quarter 2014 –
third quarter 2014
|
|
4
|
Post-implementation follow-up
|
fourth quarter 2014 –
fourth quarter 2015
|
One of the first steps in moving toward successful implementation is to establish an interdisciplinary steering committee to guide the transition process. Since the transition impacts almost every department in the organization, it is important that the steering committee includes representation from all key stakeholders.
Key stakeholders may include health information department leadership, revenue cycle management, executive leadership, physician leadership, and information technology. The primary duty of the committee is to develop, plan, coordinate, implement, and test all strategies, actions, and deadlines included in the transition plan.
The implementation of the ICD-10-CM/PCS classification system will be an enormous undertaking requiring extensive coordination among a variety of departments within the organization as well as with external business associates. A comprehensive communication plan is vital to success. The steering committee should develop clear, consistent, and concise messages. The development of an organization-wide ICD-10-CM/PCS awareness campaign targeting all key stakeholders is an essential step in the implementation process.
The communication plan should also include regularly scheduled communication between the organization and its business associates to determine their readiness and timelines. Deviations from the original implementation timelines should be communicated immediately to the steering committee to allow for modifications to the implementation plan.
One of the most significant parts of the first implementation phase is to complete an organization-wide impact assessment. The purpose of this assessment is to anticipate who or what will be affected by the transition to ICD-10-CM/PCS while determining the degree of impact. All operations within the organization must be examined to identify the potential ramifications of the transition to ICD-10-CM/PCS.
The assessment involves an analysis of all processes to identify their readiness for applying, accepting, processing, or translating coded data in the new ICD-10-CM/PCS formats. Delayed completion of impact assessments will jeopardize an organization's ability to complete all ICD-10 implementation tasks by the compliance date, risking claim rejections and payment delays.
An implementation budget must be created to address the costs associated with upgrading technology and training as well as the potential loss of productivity, which can delay remittance. All ICD-10-CM/PCS transition expenses should be identified and a plan developed to allocate the costs over several years.
The cost will depend on the size and complexity of the organization and the amount of outside technical assistance it requires. This is driven by the numbers of systems, applications, and interfaces that need to be updated or modified. An organization's largest estimated expenses are anticipated to be systems upgrades and education.
A systems inventory is necessary to identify those systems requiring modifications or replacement to process the new coded data, especially if the systems rely on collaboration with external business partners. All processes and systems that pertain to ICD codes need to be analyzed and modified to accommodate the expanded alpha-numeric code structure of ICD-10.
The number of systems involved may be extensive, and hardware and software changes will need to be identified and completed while working with vendors. The transition also may have an impact on business processes, affecting workflows, reports, forms, and policies and procedures. Existing items may require revision and new items may need development.
Part of organizational planning is identifying the impact from vendors and payer contracts. Organizations must consider vendor readiness and timelines for upgrading systems and software. The costs and timing of this work requires planning.
Frequent communication is needed with all payers to find out when testing will begin, what issues, if any, were identified, and when testing will be completed. Consideration should be given to the ICD-10 transition during contract renewals with vendors, payers and providers.
Training is a major component of a successful implementation. There are multiple categories of users of healthcare coded data who will require various types and levels of ICD-10-CM/PCS education. A detailed training plan should be created to address the needs of each population of user from those who casually interact with coded data to those who assign the codes or verify the assignment of data codes.
This role-based training model will guide the organization in providing the right training to the right audience at the right time. For example, the training of coder training requires a delicate balance in timing and implementation. If coders are trained too early, they may not retain the coding knowledge. In contrast, if coders are trained too late, this may result in productivity issues that negatively impact the revenue cycle.
As previously mentioned there needs to be organization-wide training regarding ICD-10-CM/PCS. Awareness training is probably appropriate for the casual user of coded data to provide an overall framework of the changes in the appearance of coded data as well as how the organization will be impacted during the transition. More intense training regarding the specifics of the two new classification systems will be required for those who use coded data for the purpose of reimbursement, statistics, and/or research.
Those who apply the new ICD-10-CM/PCS codes will require extensive training. A gap analysis can provide an organization with valuable information regarding the current skill level of the coding staff and what it will take to obtain proficiency with the new code set. Coders who assign diagnosis codes will require training on the guidelines, definitions, and the correct method to assign codes in ICD-10-CM. Coders who are tasked with assigning inpatient acute care procedure codes will require training pertinent to ICD-10-PCS. In addition, coding will be more difficult if the documentation is not available to support the more detailed code set.
ICD-10-CM and ICD-10-PCS offer much more specificity because of the expansion of codes. While it is still possible to assign nonspecific codes, it is imperative that the most specific code be reported to maximize ICD-10-CM/PCS's ability to provide meaningful data on patient care and severity.
Current documentation practices should be assessed and a plan developed to improve health record documentation, thereby minimizing the use of vague or nonspecific codes. A gap analysis can be conducted to examine how the most frequently used ICD-9-CM codes will translate into ICD-10-CM/PCS codes to allow for focused training.
As the planning and implementation strategies move into the next phase of implementation, an organization should start evaluating potential reimbursement changes. Although healthcare providers are required to submit claims using ICD-10-CM/PCS for encounters on or after October 1, 2014, there is no rule that requires all payers to remit payment based on the MS-DRG associated with the ICD-10-CM/PCS codes.
Some payers who reimburse based on MS-DRGs might translate the ICD-10-CM/PCS codes into ICD-9-CM codes resulting in a MS-DRG assignment that may or may not be equivalent to a MS-DRG based directly on ICD-10-CM/PCS codes.
During the transition, a decrease in coding productivity and accuracy may be expected; it is necessary for the organization to develop strategies to minimize these risks. The amount and level of preparation and the extent of education, credentials and knowledge of coding professionals will be an important consideration. The quality of medical record documentation will also contribute to a successful outcome.
The transition to new code sets means that data encoded in either the old (ICD-9-CM) or new (ICD-10-CM/PCS) code set will need to be converted or translated to the other code set to preserve the informational value of healthcare data, regardless of whether it was collected before or after the transition to ICD-10-CM/PCS. Maps are an integral component of this data conversion process.
Mapping is the process of creating one-way links between concepts and terms for specific purposes with the result being a universal cross-reference map accounting for all concepts and terms.
Maps are created for many purposes, including exchange of data for patient care purposes, access to longitudinal data, reimbursement, epidemiology, public health data reporting, and reporting to regulators and state data organizations. Correct mapping requires a complete understanding of how data will be used.
Authoritative, detailed bidirectional mappings, referred to as General Equivalence Mappings (GEMs), allow identification of potential corresponding codes between ICD-9-CM and their counterparts in ICD-10-CM/PCS. The mappings are bidirectional because they include both backward and forward mappings.
When the initial code is in ICD-9-CM and the user wants to find the corresponding ICD-10-CM/PCS code(s) this is referred to as forward mapping. When the initial code is in ICD-10-CM/PCS and the user wants to find the corresponding ICD-9-CM code(s) this is referred to as backwards mapping.
These mappings were developed with stakeholder input and discussed at public meetings of the ICD-9-CM Coordination and Maintenance Committee. The GEMs will continue to be updated through the normal update process. The maps were developed by the NCHS (ICD-10-CM) and CMS (ICD-10-PCS).
The GEMs were created to ensure consistency in national data and to serve as a conversion tool between ICD-9-CM codes and ICD-10-CM/PCS codes. Since the GEMs need to support all uses of coded healthcare data, they were designed as a starting point, presenting all plausible translation alternatives. They are to be used during the implementation process and will be maintained for three years beyond the October 1, 2014, compliance date.
It is important to note that the GEMs are not direct crosswalks, because there is not a one-to-one correlation between ICD-9-CM and the more complex ICD-10-CM/PCS. Some of the reasons that limit the likelihood of an exact match between an ICD-9-CM and ICD-10-CM or ICD-10-PCS code include:
- For a small number of codes, there is no matching code in the GEMs.
- A single ICD-9-CM code may map to multiple ICD-10-CM/PCS codes.
- There are new concepts in ICD-10-CM/PCS that are not present in ICD-9-CM.
- More than one ICD-9-CM may be a possible translation of a given ICD-10-CM/PCS code.
- More than one ICD-9-CM code may be required to convey the complete meaning of a given ICD-10-CM/PCS code.
Due to the many uses of coded healthcare data it would not be possible to produce one set of mappings that could be used by all, because mapping is heavily dependent on its purpose. For example, a map for reimbursement uses different rules and contains different entries than a map for research. The GEMs are not applied mappings, but they are the foundation upon which mappings for a specific outcome can be readily built.
Reimbursement mappings were developed by CMS in response to non-Medicare industry requests for a "standard one-to-one reimbursement crosswalk." This will be a temporary mechanism for mapping ICD-10-CM/PCS codes submitted on or after October 1, 2014, back to "reimbursement equivalent" ICD-9-CM codes. The use of reimbursement mappings does not allow users to take advantage of the increased detail available within ICD-10-CM/PCS. Whenever possible, use of the GEMs for mapping purposes is preferable.
CMS is not using the ICD-10-CM/PCS reimbursement mappings for any purpose. They are converting their systems and applications to accept ICD-10-CM/PCS codes directly. The reimbursement mappings offer a single recommended mapping of each ICD-10-CM/PCS code to a single ICD-9-CM alternative. Part of a successful implementation plan would include a gap analysis using the ICD-10-CM/PCS reimbursement mappings to identify any potential changes in revenue by payer.
Even though standardized mappings will facilitate the process of translating between the old and new code sets, there will still be challenges connecting data coded under ICD-9-CM to data coded under ICD-10-CM/PCS due to the differences in the code sets. This will impact reports that compile statistical data for trend analysis.
Any activity involving comparisons of historical and current data, such as retrospective audits, is likely to be impacted. Caution should be exercised when interpreting longitudinal data, as diagnoses and procedures may be classified differently within each code set, which could lead to distorted, inaccurate, or misinterpreted findings.
Although the transition to ICD-10-CM/PCS may seem overwhelming, early planning is a must for all organizations impacted by ICD-10-CM and/or ICD-10-PCS. There is no time to delay. The size and complexity of the implementation plan will vary by organization, but the important thing is to proactively identify the impact of ICD-10-CM/PCS.
The tools provided in the appendixes will help organizations assess the impact, form an implementation plan, and prepare staff for using the new code sets.
Bowman, Sue E., and Ann M. Zeisset. "ICD-10-CM/PCS Transition: Planning and Preparation Checklist." 2011. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048737.pdf.
Zeisset, Ann M., and Sue E. Bowman. Pocket Guide of ICD-10-CM and ICD-10-PCS. Chicago, IL: AHIMA Press, 2010.
Listing of ICD-10-CM and ICD-10-PCS Resources (Excel spreadsheet)
Listing of Resources for Physician Practices and Users of Only ICD10CM (Excel spreadsheet)
Anita Archer, CPC
Danita G. Arrowood, RHIT,CCS
Judy A. Bielby, MBA, RHIA, CPHQ, CCS
June Bronnert, RHIA, CCS, CCS-P
Gloryanne Bryant, RHIA, CCS, CCDS
Janice Crocker, MSA, RHIA, CCS, CHP, FAHIMA
Cheryl A. D'Amato, RHIT,CCS
Kathryn DeVault, RHIA, CCS, CCS-P
Cheryl Ericson, MS, RN
Cheryl Gregg Fahrenholz, RHIA, CCS-P
Lisa Hart, MPA, RHIA
Mack Henderson, RHIT, CCS-P, PhD
Robin R Holmes, RN, MSN
Crystal M. Isom, RHIA, CCS
Laurie M. Johnson, MS, RHIA, CPC-H
Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA
Kim S. Murphy, RN, BSN
Theresa A. Rihanek, RHIA, CCS
Sharlene A. Scott, CPC, CPC-H, CCS-P, PMCC, CCP-P, CPMA
Cortnie R. Simmons, MHA, RHIA, CCS
Tamika S. Smith, RHIA
Ann Zeisset, RHIT, CCS, CCS-P
Wendy Zumar, MA, RHIA, CCS
Kathy Arner, RHIT, CCS
Cecilia Backman, MBA, RHIA, CPHQ
Jan Barsophy, RHIT
Sara Bible, RHIA
Sheila Bowlds, MBA, RHIA
Linda Darvill, RHIT
Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P
MeShawn Foster, BS, RHIT
Lesly Kadlec, MA, RHIA
Priscilla Komara, RHIA, CCS-P, CPC
Carole Liebner, RHIT, CCS
Melissa Martin, RHIA, CCS
Maria A. Muscarella, RHIA
Pam Petz, RHIA, CHC
Rayna Scott, MS, RHIT, CHDA
Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR