An Introduction 2012
Bobbi Buell, MBA
onPoint Oncology LLC
 Create an awareness of ICD-10-CM.
 Start to consider the impact the
conversion to ICD-10 will have on your
 Start to understand what it means and
does not mean in Oncology.
Latest Update
 The AMA asked HHS to postpone or cancel ICD-10.
 CMS intimated that the deadline would be postponed.
 HHS is in the process of making a rule as to how the
postponement will work.
ICD-9-CM vs. ICD-10-CM
1) ICD-9-CM is out of date and running out of space
for new codes.
Lacks specificity and detail
No longer reflects current medical practice
2) ICD-10 is the international standard to report and
monitor diseases and mortality, making it important
for the U.S. to adopt ICD-10 based classifications
for reporting and surveillance.
3) ICD codes are the core elements of HIT systems,
conversion to ICD-10 is necessary to fully realize
benefits of HIT adoption.
 ICD-10-CM code book retains the same
traditional format
 Index
 Tabular
 Process of coding is similar
 Look up a condition in the Index
 Confirm the code in the Tabular
ICD – 9-CM
ICD – 10-CM
13,600 codes
69,000 codes
Code book contains 17 chapters
Code book contains 21 chapters
Consists of 3 to 5 characters
Consists of 3 to 7 characters
1st character is alpha or numeric
1st character is alpha
Only utilizes letters E and V
Utilizes all letters (except U)
Second, third, fourth, and fifth
characters are always numeric
Second character
is always numeric
Third, fourth, fifth, sixth, and seventh
characters can be alpha or numeric
Shorter code descriptions because
of lack of specificity and
abbreviated code titles
Longer code descriptions because of
greater clinical detail and specificity
and full code titles
 A - Category of code
 A - Category of code
 B - Etiology,
 B - Etiology,
anatomical site, and
anatomical site,
and/or severity
 C - Extension
 7th character for obstetrics,
injuries, and external causes of
ICD-9-CM Structure – Format
Numeric or
(E or V)
Etiology, Anatomic
Site, Manifestation
3 – 5 Characters
ICD-10-CM Structure – Format
(Except U)
3 X
2 - 7 Numeric or Alpha
0 X
1 X
Etiology, Anatomic
Site, Severity
Added code extensions
(7th character) for
obstetrics, injuries, and
external causes of injury
3 – 7 Characters
ICD-9-CM Codes
ICD-10-CM Codes
Pressure ulcer codes
9 codes
707.00 – 707.09
Pressure ulcer codes
125 codes
707.0 Pressure ulcer
707.00 - unspecified site
707.01 - elbow
707.02 - upper back
707.03 - lower back
707.04 - hip
707.05 - buttock
707.06 - ankle
707.07 - heel
707.09 - other site
Code Examples:
L89.131 – Pressure ulcer of right lower back, stage I
L89.132 – Pressure ulcer of right lower back, stage II
L89.133 – Pressure ulcer of right lower back, stage III
L89.134 – Pressure ulcer of right lower back, stage IV
L89.139 – Pressure ulcer of right lower back,
unspecified stage
L89.141 – Pressure ulcer of left lower back, stage I
L89.142 – Pressure ulcer of left lower back, stage II
L89.143 – Pressure ulcer of left lower back, stage III
L89.144 – Pressure ulcer of left lower back, stage IV
L89.149 – Pressure ulcer of left lower back,
unspecified stage
L89.151 – Pressure ulcer of sacral region, stage I
L89.152 – Pressure ulcer of sacral region, stage II
L89.90 – Pressure ulcer of unspecified site,
unspecified stage
 Combination codes for conditions and common symptoms
or manifestations
 Combination codes for poisonings and external causes
 Added laterality
 Expanded codes: injury, diabetes, alcohol/substance
abuse, postoperative complications
 Added extensions for episode of care
 Inclusion of trimester in obstetrics codes and elimination of
fifth digits for episode of care
 Expanded detail relevant to ambulatory and managed care
 Inclusion of clinical concepts that do not exist in ICD-9-CM
 Changes in timeframes specified in certain codes
Useful in Cancer??
 Laterality – Left Versus Right
 C50.1 Malignant neoplasm, of central portion of breast
 C50.111 Malignant neoplasm of central portion of right
female breast
 C50.112 Malignant neoplasm of central portion of left
female breast
Useful In Cancer???
 ICD-9-CM
 143 Malignant neoplasm of gum
 143.0 Upper gum
 143.1 Lower gum
 ICD-10-CM
 C03 Malignant neoplasm of gum
 C03.0 Malignant neoplasm of upper gum
 C03.1 Malignant neoplasm of lower gum
Arrangement of Volumes of
 Volume 1: Main classifications
 Volume 2: Instruction/ Guidance to users
 Volume 3: Alphabetical Index
 ICD-10 has 21 chapters against 17 Chapters in ICD-9
Chapters of ICD-10
 Chapters I to XVII: Diseases and other morbid
 Chapter XVIII: Symptoms, signs and abnormal
clinical and laboratory findings, not elsewhere
 Chapter XIX: Injuries, poisoning and certain
other consequences of external causes.
 Chapter XX: External causes of morbidity and
 Chapter XXI: Factors influencing health status
and contact with health services.
General Equivalence
 “GEMs” stands for General Equivalence Mappings
 The CMS and the CDC created GEMs to ensure
consistent national data when the U.S. adopts ICD-10.
 The GEMs will act as a translation dictionary to bridge the
“language gap” between the two code sets and can be
used to map an ICD-9 code to an ICD-10 code and vice
 Designed to give all sectors of the healthcare industry that
use coded data the tools to:
 Convert large databases and test system applications
 Link data in long-term clinical studies
 Develop application-specific mappings
 Analyze data collected before and after the transition to ICD10-CM
• The GEMs should not be used as a substitute
for learning how to use the ICD-10-CM code
• “GEMs are not a substitute for learning ICD-10-PCS
and ICD-10-CM coding.
large data sets.”
They’ll help you convert
• Mapping simply links concepts in the two code
sets, without consideration of context of
specific patient information, whereas coding
involves assigning the most appropriate code
based on documentation and applicable coding
• A clear one-to-one correspondence between an ICD-9
or ICD-10 code is the exception rather than the rule.
• ICD-9 codes: 414.01 Coronary atherosclerosis of native
coronary artery and 411.1 Intermediate coronary syndrome
(unstable angina)
• ICD-10 code :I25.110 Atherosclerotic heart disease of native
coronary artery with unstable angina
• There are situations when a code in the target
system does not exist
• T503x6A Underdosing of electrolytic, caloric and waterbalance agents, initial encounter
Forward Mapping
Fracture of unspecified part of
neck of femur, closed
Fracture of unspecified part of
neck of femur, initial encounter
for closed fracture
Backward Mapping
Fracture of unspecified part of
neck of femur, closed
Fracture of unspecified part of
neck of right femur, initial
encounter for closed fracture
Fracture of unspecified part of
neck of left femur, initial
encounter for closed fracture
Fracture of unspecified part of
neck of femur, initial encounter
for closed fracture
GEMS Example #1
GEMS Example #2
GEMS Example #4
Neoplasm Guidelines
Neoplasm Guidelines
 Many guidelines are the same, but there are
differences. We try to cover those today.
 To properly code a neoplasm, it is necessary to
determine (not too different) whether:
 It is benign, malignant, benign, in situ or of uncertain
 If the malignant, any secondary or metastatic sites should
be identified.
 To code properly the Index Neoplasm Table should be
accessed EXCEPT:
 If the histology is mentioned in the code descriptor, e.g.
adenoma or sarcoma
Neoplasm Guidelines
 Again, if the encounter is strictly for chemo,
immunotherapy, or Radiation, those codes should be
coded as the principal diagnosis with the neoplasm as
a secondary. No big change from today.
 The secondary neoplasm should be designated as the
primary, if treatment is directed there.
Neoplasm Complications
 Anemia associated with malignancy is coded with the
malignancy sequenced first and anemia second. This
is a major departure---we shall see what payers do with
 Anemia associated with chemo or immunotherapy is
coded with the adverse event code first and anemia
second, then the malignancy.
 Management of anemia associated with radiation is
coded with anemia first, malignancy second, and Y84.2
third which is radiation causing an abnormal reaction in
the patient.
Neoplasm Complications
 Dehydration is coded first with the neoplasm second.
 And, then of course, there is the confusing “HISTORY
OF” guideline---which is not changed in ICD-10.
 Signs, symptoms, and abnormal findings cannot be
used to replace malignancies as primary diagnosis,
except as noted.
More Neoplasm Guidelines
 Malignancies of two or more contiguous sites should
not be coded as one or the other without asking the
 For disseminated neoplasms with no known PRIMARY
or SECONDARY sites are coded to C80.0. This should
not be used if either is known.
 Cancer of unknown primary (CUP): CO80.1 Malignant
(primary) neoplasm, unspecified, equates to Cancer
unspecified. This code should only be used when the
primary cannot be determined.
More Neoplasm Guidelines
 http://www.cdc.gov/nchs/icd/icdcm.htm
Preparing for ICD-10
Checklist: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht
Phase I
Phase II
Phase III
Phase IV
2009/ 2010
Awareness and
Impact Assessment
Preparing for Implementation
Go Live
Post –
• The increased specificity of the ICD-10 codes
requires more detailed clinical documentation in
order to code some diagnoses to the highest level
of specificity.
• There are “unspecified” codes in ICD-10-CM for
those instances when medical record
documentation is not available to support more
specific codes.
• The benefits of ICD-10 can not be realized if nonspecific codes are used rather than taking
advantage of the specificity ICD-10 offers.
 Conduct medical record documentation
 Evaluate records to determine adequacy of
documentation to support the required level of
detail in new coding systems
 Implement a documentation improvement
program to address deficiencies identified
during the review process
 Educate providers about documentation
requirements for the new coding system through
specific examples
 Emphasize the value of more concise data capture
for optimal results and better data quality
 DHHS agrees that some physicians will want intensive
training on ICD-10 but some will seek “awareness
 Nolan study estimates 8 hours of intensive physician training
 Nachimson Advisors, LLC study predicts 12 hours of
physician training in both the code set and documentation
 AHIMA believes most physicians would want no more than
4 hours of training.
Solo Practitioner Or Small Group (2-10)
Practice Implementation Planning
1. Organize Implementation Effort
2. Establish Communication Plan
3. Conduct Impact Analysis
4. Contact System Vendors
5. Estimate Budget
6. Implementation Planning
7. Develop Training Plan
8. Analyze Business Processes
9. Education and Training
10. Policy Change Development
11. Deployment of Code
12. Implementation Compliance
Organize Implementation Effort
 Enlist staff person (coder, biller, manager) to oversee
effort who will be key point person
― Prepare information to share with other providers and staff
― Identify work and scope for implementation
 Should be a team effort involving all medical practice staff
and the staff needs to believe that this will actually
Organize Implementation Effort
 Examine the level of coding you have in your practice—who is
certified? Who has experienced a change before, e.g. E/M, admin
codes? Who is equipped to deal with this?
 Look at all areas that will impact practice and identify each one that
will be affected
― Practice management system
― Electronic Medical Record (EMR), if applicable
― Superbills
― Clinical areas and pharmacy
 Schedule regular meetings to share information with
physicians and discuss progress and barriers of
Establish Communication Plan
 How will point person communicate with all staff?
 Most practices communicate via meetings or memos
 No need to change method of communications
 Develop regular schedule for ICD-10 progress efforts
 Monthly until 6 months prior to implementation
 Bi-weekly thereafter
 Include information, publications, and articles
 Document all meetings and what was discussed herein
and make sure you are tracking with your plan.
Conduct Impact Analysis
• Take this step prior to development of budget
• In depth look at resources required for implementation
• Maybe check for a little process improvement
• Helps determine what costs might be involved as well as
work processes
• What systems will be affected?
Practice management
Coding look up programs (if applicable)/CDMs/Superbills
Remittance systems
Hardware space
• What are the potential costs involved?
Conduct Impact Analysis
 Develop reasonable timeline that can be accomplished
in your practice
― Map out a project plan on a simple Excel spreadsheet with
benchmarks and status of completion
 Managers and/or coders should get physician approval
for the project plan and its impact on the practice. Make
sure you show and tell them the level of work it will take.
Conduct Impact Analysis
 Coding and documentation go hand in hand
 ICD-10 is based on complete and accurate
documentation, even where it comes to right and left
or episode of care.
 ICD-10 should impact documentation as physicians
are required to support medical necessity using
appropriate diagnosis code—this is not an easy
situation, so physicians need to know from the outset
that they need training.
 Will not change the way a physician practices
 Complete and accurate documentation will continue to
be important in 2013 (or whenever) as it is today
Contact System Vendors
• Will they be able to accommodate the need to move to
ICD-10? Really? Were they ready for 5010?
• What plans do they have in place for implementation?
• Will they have new tools in place to help you with ICD10? Will these have a cost? Will they create savings?
• When will they have software available for testing?
• Will we need new hardware or is current hardware
Estimate Budget
 Budget considerations should include
Hardware costs
Software costs and licensing
Physician Query
Productivity losses
Jeopardy to cash flow
 Some notable budget estimates follow this slide…
ICD-10 Implementation $:
(c) onPoint Oncology LLC
ICD-10 Implementation $$:
(c) onPoint Oncology LLC
Implementation Planning
 Begin Steps 1-5 (reviewed up until this point) in 2012, but
save others until 2013 or whenever.
 Break down planning into stages
 Training for a small practice does not need to begin until 6
months prior to implementation
 Review superbills and remove rarely used codes
 Crosswalk common codes from ICD-9-CM to ICD-10-CM
 Look up codes in ICD-10-CM book and use GEMs, if
necessary, but this is a very general and not necessarily
accurate way of coding.
Crosswalk Example
Iron Deficiency Anemia
Iron deficiency anemia
Iron deficiency anemia
280.0 Secondary to blood loss
D50.0 Secondary to blood Loss
280.1 Secondary to inadequate dietary
D50.8 Other iron deficiency anemias
280.8 Other specified iron deficiency
D50.1 Sideropenic dysphagia
D50.8 Other iron deficiency anemias
280.9 Iron deficiency anemia, unspecified
D50.9 Iron deficiency anemia
Develop Training Plan
 Who needs training?
Billing staff
Administrative staff
 Nurses, MAs, Pharmacy
 Required number of hours depends on their role
and coding interface
 What resources are available in your area?
Develop Training Plan
 Many organizations will have several mechanisms for
 Distance learning
 Workshops
 Conferences
 Audio Conferences
 Webinars
 Books
 Establish training schedule or just “Train the Trainer”, but
this must be a trusted coding person who also can
communicate necessary information to clinicians.
Develop Training Plan
 Determine if temporary staff or overtime will be
necessary during training period
 What materials will the office need for ongoing support
after training?
 Books
 Software (code look up programs)
 Other
Analyze Business Processes
 Identify all systems and processes that currently use
 Review existing medical policies related to ICD-9-CM
 Which contracts tied to reimbursement are tied to a
particular diagnosis? Which payers have policies for
cancer drugs that are tied to ICD-9? How will this be
 Modify any contract agreements with health plans
Education and Training
• Education should begin approximately 6 months
prior to implementation
• Large practices may need to begin earlier to
accommodate all staff who need training
• Use various methods of training: on-line,
distance, “Boot Camps”
• Training time depends on their role
• Physicians and coders/billers will need more
training time than administrative staff
Policy Change/ Payment Impact
 After health plans complete and change medical policy
for procedures and services a specialty provides
 Review new payment policies
 Identify opportunities to improve coding processes
 Communicate policy changes to applicable staff
Deployment of Code
 Should receive all updated software no later than
7/31/2013 for implementation of your charge
 Vendor delivers software update with ICD-10-CM,
but you should also know how long ICD-9 will be online.
 Vendors should
Test system
Integrate software into your systems
Make internal customizations
Test systems with clearinghouses, payers, electronic
claims transmission (end to end)
 Ensure that the vendor will maintain updates to code during
transition period
Implementation Compliance
 Compliance date for implementation – October 1, 2013
 Ensure you are staffed for the change.
 Make sure lines of credit are in place.
 Monitor compliance activities to identify any problems.
 Pursue vendor and payer problems as necessary.
Other Considerations
Consider use of electronic tools to facilitate coding
– Could reduce costs and claims rejections
– Could increase productivity and coding accuracy
Don’t convert superbills/charge documents too early
– Currently, ICD-10-CM is still updated annually
– 6 –12 months prior to implementation or after code set
has been “frozen”
– Assign ICD-10-CM codes directly, not by applying ICD-9CM to ICD-10-CM map—it’s good practice’!!
CDC’s Web Resources
 General ICD-10 information
 ICD-10-CM files, information, and General
Equivalence Mappings (GEM) between ICD-10-CM
and ICD-9-CM
AHA’s Resources
Regulatory member advisories
Presentations and articles
ICD-10 audio seminar series
Central Office on ICD-9-CM
• AHA Central Office ICD-10 Resource Center
In Summary…
 While ICD-10 might be postponed, it probably will not be
postponed forever. You will need to be in the planning process.
 The first thing you need to do is determine where change needs
to happen and how much it will cost. Physicians have no idea
that this will be a line item.
 Hospitals are way ahead of practices. They may push for this to
be sooner rather than later.
 What did you learn from 5010 that will help you with this?
 CAN Web Site
 The latest news
 Forms
 Regulations
 Newsletters
 Presentations
 http://can.communityoncology.org
 Contact
 bbuell@covad.net
 bobbibuell1@yahoo.com
 800-795-2633
 Newsletter is free!
 Send all RAC information to me at the ABOVE E-mails
or FAX to 650-618-8621
 Go to our website: http://www.onpointoncology.com

ICD-10-CM – Everything You Need to Know … For Now