With the upcoming transition date of October 1, 2015 from ICD-9 to ICD-10 quickly approaching, it is important to note the coding changes from ICD-9 to ICD-10. Specific areas of this transition will impact skilled nursing facilities and the coding of both the short and long term population in the facility.
ICD-9 has been utilized for over 30 years for a number of uses in the American Healthcare system. These uses include reimbursement, payer contracts and coverage determinations, assessment of provider performance with disease management, and monitoring utilization patterns. It has also been utilized for providing criteria for inpatient care vs. outpatient services, tracking the severity of illness data including mortality and complications, as well as public health tracking
So why transition to ICD-10? The current ICD-9 system lacks room for expansion for new diagnoses, includes outdated language, a lack of specificity and has an inability to provide details necessary to measure the acuity level of patients or their continuum of care. Specifically, the system requires multiple codes for some diseases and manifestations with no ability to show relationships or co-morbidities impacting care.
As of October 1, 2015, all HIPAA entities must implement the new code set. With the implementation of ICD-10 providers will see combination diagnosis/symptom codes that reduce the number of codes needed to describe a condition. ICD-10 also includes expanded injury codes, an incorporation of common 4th and 5th digit sub-classifications as well as an additional 6th and 7th character. ICD-10 will allow providers increased specificity in code assignment and will have the potential for further expansion that was not possible with ICD-9.
There are multiple goals with the transition from ICD-9 to ICD-10. The increased specificity will allow monitoring of resource utilization across the continuum of care, it will reduce the number of claims miscoded, rejected, or improperly reimbursed and will assist in identifying and preventing fraud and abuse. ICD-10 also aims to improve clinical, financial, and administrative performance, and allow data review and comparison to be expanded outside of the United States to include international data.
How does it work? ICD-10 has 37 digits compared to a maximum of 5 digits with ICD-9. The first three digits identify the disease major category, the next three digits represent the etiology, anatomic site and severity of the condition. The last digit is the extension code used to identify information pertaining to the episode of care.
Codes will include the following format:
- Digit 1 is alpha (A-Z, not case sensitive)
- Digit 2 is numeric
- Digit 3 is alpha (not case sensitive) or numeric
- Digits 4-7 are alpha (not case sensitive) or numeric
- “X” is used a placeholder for codes that contain fewer than 6 characters and a 7th character is required
How will this new coding system impact the skilled nursing facility? ICD-10 will eliminate a vast majority of common coding practices currently utilized, including the utilization of the V-Code to identify encounters for therapy, the 18 aftercare codes for fractures, the “late effects” codes and the Hypertension table. It will add the “X” placeholder and change the timeframe in the reporting of a Myocardial Infarct.
ICD-10 eliminates the use of the V-Codes due to the fact that they provide no clinical information about the patient other than the fact that therapy services are being provided. ICD-10 will require much more specificity related to the medical condition resulting in the need for the therapy encounter. Skilled Nursing Facilities will no longer use aftercare codes when coding fractures, but instead will utilize the specific acute fracture code followed by the appropriate 7th digit extension to indicate a Subsequent Episode of Care. For therapy delivery, the specific medical diagnosis should be coded in combination with any applicable treatment diagnosis.
Under ICD-10, “late effects” codes (such as the late effects of a CVA previously coded under ICD-9 in the 438.XX category) will be replaced by the use of the sequelae codes utilizing the I69 category. Under ICD-9 coding, the late effects category includes neurological deficits that persisted after the initial onset of conditions. With ICD-10, the documentation should clearly indicate whether the neurologic deficits were present from the onset or were identified at any time after the onset of the primary neurological condition. In some cases, when coding the sequelae of cerebrovascular disease, it will be necessary to also include an additional code to identify the type of sequelae. With the I69 codes for dysphagia following a CVA, an additional code should also be included from R13.19 to identify the specific type of dysphagia.
To assist providers in the transition from ICD-9 to ICD-10, General Equivalence Mappings (GEMs) were developed over several years by the National Center for Health Statistics, Centers for Medicare and Medicaid Services, AHIMA, the American Hospital Association, and 3M Health Information Systems. Unfortunately, there are no perfect crosswalks to convert from ICD-9 to ICD-10. GEMs provide plausible conversions, not equivalent conversions. When forward mapping from ICD-9 to ICD-10, only about 5% of all codes will accurately map 1:1. GEMs do not provide an exact match and in most cases translation may require the selection of the best alternative code from among all plausible coding options.
The following is an example of forward mapping:
- When coding pressure ulcers under ICD-9, there are 9 possible coding options that identify the location but not stage (707.00 – 707.99). In order to identify the stage a second code would need to be used to from the 707.20 – 707.25 series
- Under ICD-10 there are 125 possible coding options for pressure ulcers (L89.000 – L89.95)
- One ICD-10 code is used to provide all pertinent additional information related to the depth, severity, and occurrence of the ulcer.
If you need help with transitioning from ICD-9 to ICD-10 or would like on-site training, please click here to contact Harmony Healthcare International or call us at (800) 530-4413.