Mastering the ICD-10 Transition for your Organization!

Mastering the ICD-10 Transition for
Your Organization
Presentation to: GAMES/GRTC Winter Meeting
Presented by:
Camillia Harris, ICD-10 Communications Lead
Erica Baker, ICD-10 Communications Consultant
February 4, 2014
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Topics for Discussion
ICD-10 Overview
– ICD-10 Facts
– ICD-10 Reminders
Your ICD-10 Responsibility
ICD-10 Documentation
GEMs Mapping Tool
DCH – GA Medicaid Transition and Testing
Benefits & Rewards of ICD-10
Helpful Resources
ICD-10 is Real
239 days until ICD-10 is here!
ICD-10 Facts
Why the Change
• ICD-9 is outdated –
limited capacity, capability, can’t serve future needs
- The transition to ICD-10 is occurring because ICD-9 produces limited data about
patients’ medical conditions and hospital inpatient procedures
- ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical
• Moving from 9 to 10 – U.S. is last industrialized nation to adopt ICD-10
- By transitioning to ICD-10, providers will have:
• Improved operational processes
• Detailed information on condition, severity, complications and locations
• Detailed health reporting and analytics such as cost, utilization and outcome
• Transitioning to ICD-10 is not optional
- Federal compliance date is October 1, 2014 (firm and not subject to change)
- National impact, mandatory for all HIPAA-covered entities
• If you use ICD-9 codes TODAY, you will have to migrate to ICD-10 codes
More ICD-10 Facts
New ICD-10-CM and ICD-10-PCS code sets
– Replaces ICD-9-CM (Volumes 1, 2, and 3)
ICD-10 has no direct impact on Current Procedural Terminology (CPT) and
Healthcare Common Procedure Coding System (HCPCS)
Claims that are submitted with non-compliant codes will be rejected
Reminders About ICD-10
• For dates of services rendered on or after October 1, 2014
– All claims must use ICD-10 codes
– All claims using ICD-9 codes will NOT be accepted
• For dates of services rendered before October 1, 2014
– All claims must use ICD-9 codes
• Systems must accommodate BOTH ICD-9 and ICD-10 codes
– Effective with the October 1, 2014 compliance date
• Significant Code Increase from ICD-9
– Increasing from 13,000 to approximately 68,000 ICD-10-CM codes
– Increasing from 3,000 to approximately 87,000 ICD-10-PCS codes
– ICD-10 has more than nine times the codes in ICD-9
More ICD-10 Reminders
• Please keep the following in mind:
• There is no transition period to use either ICD-9 or ICD-10 codes
- If the claim contains ICD-9 codes for a date of service BEFORE October 1, 2014,
the claim will be accepted for payment. If the claim contains ICD-9 codes for a
date of service ON or AFTER October 1, 2014, the claim will be rejected.
• It is mandatory that you wait until October 1, 2014, to start using ICD-10 codes
- Providers, trading partners, and clearinghouses will not be able to process claims
using ICD-10 codes until the compliance date of October 1, 2014.
Your ICD-10 Responsibility
If you are a physician or other health care professional, you are responsible
for using the correct ICD-10 codes on your claims.
If you carry out the physician’s or other health care professional’s orders,
you are responsible for obtaining the correct ICD-10 codes from the health
care professional before filing your claims.
Billers/Coders do not determine the most appropriate ICD-10 codes.
Documentation is Key
ICD-10 and Patient Care
Transitioning to ICD-10
– Is more than an administrative burden placed on your medical claims reimbursement
– Should not affect the way you provide patient care
Specificity and Documentation are vital in ICD-10
– Look at the codes used most often in your practice
– Most of the information needed for documentation is likely shared by the patient during
your visit with them
– Improving how you document your clinical services will help you become accustomed to
the specific, detailed clinical documentation needed to assign ICD-10 codes
– Work with your coding staff to determine if the documentation would be detailed and
specific enough to select the best ICD-10 codes
– Identify and obtain the training needed for you and others in your practice
– Good documentation will help to reduce the need to follow-up on submitted claims –
saving you time and money
The GEMs Mapping Tool
GEMs – General Equivalence Mappings
– A tool used to convert data from ICD-9-CM to ICD-10-CM and ICD-10-PCS and vice
– Also known as crosswalks providing important information linking codes of one system
with codes in the other system
– A comprehensive translation dictionary used to assist in translating any ICD-9-CMbased data, including data for:
Tracking quality
Recording morbidity/mortality
Calculating reimbursement
Converting any ICD-9-CM-based application to ICD-10-CM/PCS such as:
Payment systems
Payment and coverage edits
Risk adjustment logic
Quality measures and a variety of research applications involving trend data
GEMs vs. Coding Manual
GEMs are not a substitute for learning how to use ICD-10-CM and ICD-10PCS.
Not all codes map in GEMs.
Providers’ coding staff will assign codes describing the patients’ encounters from the ICD-10-CM
and ICD-10-PCS code books or encoder systems.
In coding individual claims, it will be more efficient and accurate to work from the medical record
documentation and then select the appropriate code(s) from the coding book or encoder system.
GEMs is a tool to assist with converting larger International Classification of Diseases, 9th Edition,
Clinical Modification (ICD-9-CM) databases to ICD-10-CM and ICD-10-PCS.
Example: ICD-9-CM code 707.25 (pressure ulcer, unstageable)
Does not map to any ICD-10-CM code because ICD-10-CM classifies pressure ulcers by site and
ICD-10-CM does include codes for unstageable pressure ulcers (l89.-), but ICD-9-CM does not
include any site designation. As a result, the GEMs cannot pick a close match.
Coders cannot map to added specificity when the original information is
GEMs – Both Directions
From ICD-9-CM to ICD-10 and ICD-10 back to ICD-9-CM
- GEMs are designed to be used like a bi-directional translation dictionary. They go in
both directions so that you can look up a code to find out what it means according to
the concept and structure used by the other coding system.
- The bi-directional GEMS dictionaries are NOT a mirror image of each other.
- The translation alternatives are based on the meaning of the code you are looking up.
• GEMs Update
CMS and CDC made a commitment to update the GEMs annually along with the
updates to ICD-10-CM/PCS during the transition period prior to ICD-10 implementation.
GEMs will be maintained for at least 3 years beyond October 1, 2014, which is the
compliance date for implementation of ICD-10-CM/PCS for all Health Insurance
Portability and Accountability Act (HIPAA)-covered entities.
Code Translator Examples
• The following slides are code translator examples. Note…
– The ICD-10 code online translator tool allows you to compare many
ICD-9 to ICD-10 codes.
– Keep in mind that while many codes in ICD-9-CM map directly to codes
in ICD-10, in some cases, a clinical analysis may be required to
determine which code or codes should be selected for your mapping.
– The most accurate coding is accomplished using the ICD-10
coding manuals.
– Link provided for viewing:
Why do the GEMs go in both directions?
Why do the GEMs go in both directions?
Why do the GEMs go in both directions?
ICD-10 Transition & Testing
Georgia Medicaid -- DCH
DCH and the Transition to ICD-10
• DCH is on track for October 1, 2014, compliance
– Phases of implementation
• Awareness, Assessment, Remediation, Testing, Transition
– Status as of January 2014
• Awareness – ongoing
• Assessment – completed
• Remediation – necessary changes to our impacted policies, processes
and systems are underway
• Testing – verifying and validating the ICD-10 changes as completed in
• Transition – not started
DCH ICD-10 Testing Status
• DCH Readiness for Beta Testing with External Partners
– DCH is nearing completion of our ICD-10 system enhancements for beta
testing with our external partners.
– Due to the additional impact from the ICD-10-PCS codes, inpatient hospital
claims may require additional internal testing time within DCH.
– DCH and HP Enterprise Services* (our fiscal agent) are preparing security
measures for assurance of protected health information. Additional information
will be provided shortly.
*Hewlett-Packard Enterprise Services
ICD-10 Testing Reminders
• Please keep the following in mind:
– Beta testing will involve simulating an ICD-10 effective date which will be prior
to the true effective date of October 1, 2014. This date will need to be
coordinated with other testing that is occurring within our testing environment.
– We anticipate beta testing to begin Q1 2014 for Providers and for Trading
Partners/Clearinghouses/Billing Agents and Care Management Organizations.
DCH ICD-10 Testing Schedule
• DCH and Georgia Medicaid are preparing for the external testing
phase of our system’s remediation
• Trading Partners (Clearinghouses, Billing Services)
- Beta testing is anticipated to begin Q1 of 2014
• Providers
- Beta testing is anticipated to begin late Q1 of 2014
What You Need to Know…
Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?
No. The switch to ICD-10 does not affect CPT coding for outpatient procedures.
Is there a transition period when we can use either ICD-9 or ICD-10 codes?
– No. If the date of service on a claim is before October 1, 2014, and contains ICD-9
codes, then the claim will be accepted for payment. If the date of service is on or after
October 1, 2014, and uses ICD-9 codes, then this claim will be rejected. All claims that
contain a date of service on or after the federally mandated compliance date of October
1, 2014, MUST use ICD-10 codes to be accepted for payment. If a practice continues to
use ICD-9 codes on claims with dates of service after the compliance date, the practice
may be subject to penalties established by CMS.
Do we have to wait until October 1, 2014, to start using ICD-10 codes?
– Yes. Providers, payers, trading partners and clearinghouses will not be able to process
claims using ICD-10 codes until the mandated compliance date of October 1, 2014.
However, DCH strongly recommends that you conduct both internal and external
testing with your trading partners and payers using ICD-10 code sets before the
October 1, 2014, compliance date
What You Need to Know…
If I order a 2014 ICD-10 coding book now, will it be updated to another version
– The Georgia Department of Community Health does not have any input on ICD-10
coding publications. It is up to the provider to contact the resource directly for the final
version of their coding books.
What is the appropriate timeline to start ICD-10 training?
– The ICD-10 Project Team recommends that you should begin your staff’s ICD-10
training as soon as possible. The transition to ICD-10 is a major undertaking for
providers, payers, and vendors. The transition to ICD-10 will drive business and system
changes throughout the health care industry, from large national health plans to small
provider offices, laboratories, medical testing centers, hospitals, and more.
– Training needs will vary for different organizations.
More ICD-10 FAQs
Will DCH do any ICD-10 training prior to October 1, 2014?
– No. DCH will not conduct any ICD-10 training. However, there are numerous resources
for self-development training on ICD-10. There are companies that may report their
expertise of ICD-10 codes and offer training, but for a cost. Like any purchase of
software applications, equipment, trainers, course materials, etc., evaluate the
credibility of the product, the people/company and their purpose. DCH does not offer
any recommendations of ICD-10 training companies.
Will there be changes to ICD-9 codes for 2014?
– CMS is limiting the number of changes to the ICD-9 codes since the focus is now on the
ICD-10 codes.
More ICD-10 FAQs
Are there certain ICD-10 codes that Medicaid anticipates not accepting?
– There are some ICD-10 diagnosis codes that may not be accepted by Georgia
Medicaid, i.e., certain unspecified codes, when there is a more specific ICD-10
diagnosis code that can be billed. With the increased specificity and number of
available ICD-10 codes, the physicians’ documentation would need to support the ICD10 diagnosis coding.
Does the new ICD-10 code change affect current Medicaid rates?
– No changes are anticipated at this time by Georgia Medicaid nor has CMS provided any
reimbursement rules or rate changes for the ICD-10-CM or ICD-10-PCS codes.
Benefits and Rewards of ICD-10
Benefits of ICD-10
• ICD-10 will play a critical role in aligning the
definitions of services and care rendered
• ICD-10 will help prevent fraud and abuse
- More effective detection and investigation of potential fraud or abuse
and proof of intentional fraud.
- Modify edits to support correct coding with greater sensitivity and
specificity to help prevent fraud and abuse.
• ICD-10 is easier and more flexible for future updates
• ICD-10 enhances coding accuracy and specificity to
classify anatomic site, etiology and severity
• ICD-10 provides better analyses for disease patterns
and response to public health outbreaks
Rewards of Compliance with ICD-10
• Continued cash flows with claims processed and paid
• Financial statement stability, credit worthiness
• Increased efficiencies in administrative, billing and
reimbursement processes
• Reduced coding errors due to increased specificity
• Improvement in patient care management
• Increased health care IT system ROI and value,
increased productivity
• Increased capability to prevent and detect health care
fraud and abuse
CMS ICD-10 Checklists
• CMS has created ICD-10 Checklists to assist your organization
with overall ICD-10 compliance.
Large Practices
Small and Medium Practices
Small Hospitals
ICD-10 Training Resources
ICD-10 Resources
Centers for Medicare & Medicaid Services (CMS)
CMS Overview
- CMS ICD-10 Implementation Planning Guides/Checklist
- HHS, CMS ICD-10 Final Rule
- CMS, HHS Complete list of code sets for ICD-10-CM and ICD-10-PCS; Final
Rule and Official ICD-10-CM Guidelines
World Health Organization (WHO) ICD-10 Page
More ICD-10 Resources
DCH Resources
– DCH Website for ICD-10 Webinars/Downloads
– DCH ICD-10 FAQs & Fact Sheet
– DCH Provider Resources
HP Enterprise Services Statewide Workshops
– Check Georgia for future ICD-10 workshops
Upcoming ICD-10 Webinars
Register Now
February 11, 2014: ICD-10 Resource Review/ Resource Walkthrough
February 27, 2014: HCBS Waiver (Home - and Community - Based Service Providers)
March 11, 2014: Behavioral Health Services …Open Discussion
March 27, 2014: ICD-10 Clinical and Policy Update
April 8, 2014: Surviving ICD-10 Tools and Tips for Transitioning
April 24, 2014: ICD-10 Case Studies
June 10, 2014: Repeat Roadmap ICD-10 Emergency Tool Kit and Open Discussion
June 26, 2014: ICD-10 Essentials
To register for the above webinars: Visit
Each webinar is scheduled for up to one hour, 10:30 – 11:30 a.m. ET.
Unless otherwise noted, all webinars are targeted to Providers and Trading Partners.
Please be advised that webinar dates and times are subject to change.
Thank You!
• Join us as an ICD-10 Beta Test Site, email us at:
– [email protected]
• Join our mailing list at:
– [email protected] for ICD-10 events and updates
• We welcome your questions and comments at:
– [email protected]
Questions & Comments

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