ICD-10 Implementation	
 Pat Brooks, RHIA
 Patricia.brooks2@cms.hhs.gov 
 Senior Technical Advisor
 Hospital and Ambulatory Policy Group, CMM, CMS

ICD-10 Final Rule
 Published January 16, 2009 
 CMS-0013-F
 http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf 
 October 1, 2013 implementation
 ICD-10-CM
 ICD-10-PCS

ICD-10 Final Rule Issues
 Implementation date October 1, 2013
 Single date for all users
 Date of service for ambulatory & physician reporting
 Date of discharge for inpatient settings
 ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013
 ICD-9-CM claims for services prior to implementation date will continue to flow through systems for a period of time

ICD-10 Final Rule Issues
 Outreach and education
 CMS worked collaboratively with AHA, AHIMA, and CDC (Cooperating Parties) on outreach materials
 Educational resources at http://www.cms.hhs.gov/ICD10/05_Educational_Resources.asp#TopOfPage 

ICD-10 Final Rule Issues
 Outreach and education
 Series of ICD-10 Outreach calls prior to final rule
 Information on calls posted at http://www.cms.hhs.gov/ICD10/07_Sponsored_Calls.asp#TopOfPage
 Transcripts of each call
 Slides used in calls

ICD-10 Final Rule Issues
 Outreach and education
 Plan additional outreach efforts through collaboration with Cooperating Parties
 Information on future educational outreach will be posted at http://www.cms.hhs.gov/ICD10/05_Educational_Resources.asp#TopOfPage 
 AHA, AHIMA, and others will also provide more detailed outreach and education resources

ICD-10 Final Rule Issues
 ICD-10 annual updates
 Coordination & Maintenance Committee will continue to discuss updates to ICD-9-CM, ICD-10-CM, & 
ICD-10-PCS
 Annual updates on CMS & CDC homepages
 Number of total codes changes with updates

ICD-10 Final Rule Issues
 ICD-10 annual updates
 New name  ICD-10 Coordination & Maintenance Committee upon implementation
 Need to discuss any need to freeze coding systems prior to implementation
 Will be agenda item for September 16-17, 2009
 Should ICD-10 and/or ICD-9-CM be frozen prior to implementation?
 When should the freeze begin?

ICD-10 Final Rule Issues
 Resources available on CMS & CDC websites
 Complete ICD-10-CM and PCS systems including guidelines
 General Equivalence Mappings (GEMs) between ICD-9-CM and ICD-10 (both ways)
 Users guide for GEMS
 Abbreviated Reimbursement Mappings 
 Development of ICD-10 version of MS-DRGs

Complete versions of ICD-10
 ICD-10-CM (diagnoses)
 http://www.cms.hhs.gov/ICD10/02m_2009_ICD_10_CM.asp#TopOfPage 
 ICD-10-PCS (procedures)
 http://www.cms.hhs.gov/ICD10/01m_2009_ICD10PCS.asp#TopOfPage 

ICD-9-CM Users
 ICD-9-CM Diagnoses  used by all types of providers
 ICD-10-CM will replace
 ICD-9-CM Procedures  used only by inpatient hospitals
 ICD-10-PCS will replace
 Current Procedural Terminology (CPT) & HCPCS used for all ambulatory and physician procedure reporting
 Not being replaced by ICD-10

ICD-9-CM is Outdated
 30 years old  technology has changed
 Many categories full
 Not descriptive enough

Countries Using ICD-10 For Reimbursement or Case Mix
 United Kingdom (1995)
 Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) (1994  1997)
 France (1997)
 Australia (1998)
 Belgium (1999)
 Germany (2000)
 Canada (2001)

Structural Differences - Diagnoses
 ICD-9-CM has 3  5 digits
 Chapters 1  17: all characters are numeric
 Supplemental chapters: first digit is alpha (E or V), remainder are numeric
 Examples: 
 496  Chronic airway obstruction not elsewhere classified (NEC)
 511.9  Unspecified pleural effusion
 V02.61  Hepatitis B carrier

Structural Differences - Diagnoses
 ICD-10-CM has 3  7 digits
 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
 A66  Yaws
 A69.20  Lyme disease, unspecified
 O9A.311  Physical abuse complicating pregnancy, first trimester
 S42.001A  Fracture of unspecified part of right clavicle, initial encounter for closed fracture

Structural Differences - Procedures
 ICD-9-CM has 3  4 digits
 All 4 digits are numeric
 43.5  Partial gastrectomy with anastomosis to esophagus
 44.42  Suture of duodenal ulcer site

Structural Differences - Procedures
 ICD-10-PCS has 7 digits
 Each can be either alpha (not case sensitive) or numeric
 Numbers 0  9 are used
 Letters O and I are not used to avoid confusion with numbers 0 and 1
 Examples
 OFB03ZX Excision of liver, percutaneous approach, diagnostic
 0DQ10ZZ  Repair, upper esophagus, open approach

Number of Codes  2009
 Diagnoses 
 ICD-9-CM		14,025
 ICD-10-CM		68,069

 Procedures
 ICD-9-CM		 3,824
 ICD-10-PCS		72,589	
ICD-9/ICD-10 Code Mappings

 General equivalence mappings (GEMS)
 Designed to aid in converting applications and systems from I-9 to I-10
 Bi-directional mappings
 For finding and replacing codes or lists of codes

Bi-directional Mappings
Use of GEMs to convert payment system
 CMS illustrated use of GEMS by developing ICD-10 version of MS-DRGs
 Began with digestive MS-DRGs, Major Diagnostic Category (MDC 6)
 Presented results at September 24, 2008 ICD-9-CM Coordination & Maintenance Committee meeting
 Will complete all MS-DRGS by October 1, 2009

MS-DRG Conversion Goals
 Coded in I-9 or I-10, the same patient is assigned to the same MS-DRG 
 Clinically equivalent
 Definitions manual has familiar look and feel

MDC 6, DISEASES & DISORDERS OF THE DIGESTIVE SYSTEM

A00* Cholera (3 codes)
A020 Salmonella enteritis
A03* Shigellosis (6 codes)
A04* Other bacterial intestinal infections (10 codes)
A050 Foodborne staphylococcal intoxication
A052 Foodborne Clostridium perfringens [Clostridium welchii] intoxication
A053 Foodborne Vibrio parahaemolyticus intoxication
A054 Foodborne Bacillus cereus intoxication
A055 Foodborne Vibrio vulnificus intoxication
A058 Other specified bacterial foodborne intoxications
A059 Bacterial foodborne intoxication, unspecified

Find and Replace
Diagnosis Codes
DRG385 INFLAMMATORY BOWEL DISEASE W MCC
DRG386 INFLAMMATORY BOWEL DISEASE W CC
DRG387 INFLAMMATORY BOWEL DISEASE W/O CC/MCC

PRINCIPAL DIAGNOSIS
5550 Reg enteritis, sm intest
5551 Reg enteritis, lg intest
5552 Reg enterit sm/lg intest
5559 Regional enteritis NOS
DRG 385 Inflammatory bowel disease w MCC
DRG 386 Inflammatory bowel disease w CC
DRG 387 Inflammatory bowel disease w/o CC/MCC

Principal Diagnosis
K5000 Crohn's disease of small intestine without complications
K50011 Crohn's disease of small intestine with rectal bleeding
K50012 Crohn's disease of small intestine with intestinal obstruction
K50013 Crohn's disease of small intestine with fistula
K50014 Crohn's disease of small intestine with abscess
K50018 Crohn's disease of small intestine with other complication
K50019 Crohn's disease of small intestine with unspecified complications
K5010 Crohn's disease of large intestine without complications
K50111 Crohn's disease of large intestine with rectal bleeding
K50112 Crohn's disease of large intestine with intestinal obstruction
K50113 Crohn's disease of large intestine with fistula
K50114 Crohn's disease of large intestine with abscess
K50118 Crohn's disease of large intestine with other complication
K50119 Crohn's disease of large intestine with unspecified complications
K5080 Crohn's disease of both small and large intestine without complications
K50811 Crohn's disease of both small and large intestine with rectal bleeding
K50812 Crohn's disease of both small and large intestine with intestinal obstruction
K50813 Crohn's disease of both small and large intestine with fistula
K50814 Crohn's disease of both small and large intestine with abscess
K50818 Crohn's disease of both small and large intestine with other complication

Find and Replace
Procedure Codes
DRG335 PERITONEAL ADHESIOLYSIS W MCC
DRG336 PERITONEAL ADHESIOLYSIS W CC
DRG337 PERITONEAL ADHESIOLYSIS W/O CC/MCC

OPERATING ROOM PROCEDURES
5451 Lap periton adhesiolysis
5459 Oth periton adhesiolysis
DRG 335 Peritoneal adhesiolysis w MCC
DRG 336 Peritoneal adhesiolysis w CC
DRG 337 Peritoneal adhesiolysis w/o CC/MCC

Operating Room Procedures: lysis
0DN80ZZ Release Small Intestine, Open Approach
0DN82ZZ Release Small Intestine, Open Endoscopic Approach
0DN83ZZ Release Small Intestine, Percutaneous Approach
0DN84ZZ Release Small Intestine, Percutaneous Endoscopic Approach
0DN90ZZ Release Duodenum, Open Approach
0DN92ZZ Release Duodenum, Open Endoscopic Approach
0DN93ZZ Release Duodenum, Percutaneous Approach
0DN94ZZ Release Duodenum, Percutaneous Endoscopic Approach
0DNA0ZZ Release Jejunum, Open Approach
0DNA2ZZ Release Jejunum, Open Endoscopic Approach
0DNA3ZZ Release Jejunum, Percutaneous Approach
0DNA4ZZ Release Jejunum, Percutaneous Endoscopic Approach
0DNB0ZZ Release Ileum, Open Approach
0DNB2ZZ Release Ileum, Open Endoscopic Approach
0DNB3ZZ Release Ileum, Percutaneous Approach
0DNB4ZZ Release Ileum, Percutaneous Endoscopic Approach
0DNE0ZZ Release Large Intestine, Open Approach
0DNE2ZZ Release Large Intestine, Open Endoscopic Approach

MS-DRGs Conversion Summary
 The GEMs produce 95% of the MDC 6 mapping without any need for review
 The remaining 5% is based on MDC 6
 Need for review of the remaining MDCs is expected to steadily decrease
 As the rules derived for MDC 6 are applied to the remaining MDCs, fewer codes will need clinical review

Overly Broad I-9 Procedure Codes
 ~200 overly broad I-9 procedure codes identified
 Should an I-9 procedure code be replaced with all associated PCS codes everywhere an I-9 code is listed?

Examples of 
Overly Broad I-9 Codes

I-9		Description
92.27	Radioactive elem implant
86.09	Skin & subq incision NEC
83.82	Muscle or fascia graft
81.96	Other repair of joint
80.19	Other arthrotomy NEC 
77.19	Bone incis w/o div NEC 
39.50	Angio oth non-coronary
39.31	Suture of artery
39.29	Vasc shunt & bypass NEC
38.21	Blood vessel biopsy
01.24	Other craniotomy
04.04	Peripheral nerve incis NEC

Solution for I-9 Overly Broad Procedure Codes
 Limit the assignment of PCS codes associated with overly broad I-9 codes to anatomic sites corresponding to each MDC

MDC 6 Example: 
DRGs 356, 357, 358 Other Digestive System O.R. Procedures 
92.27 Implantation or Insertion of Radioactive Elements 
 For procedure 92.27, only 10 of the 261 PCS codes are assigned to MDC 6
I-9 Code Conflicts 
Conflict: Where an I-10 code is assigned to more than one I-9 code and the I-9 codes are assigned to different MS-DRGs

I09.89 Other specified 	rheumatic heart 	diseases
		Rheumatic disease of 	pulmonary valve

398.99 	Other rheumatic heart 	diseases
	in MDC 5 DRG 314,315,316 
	Other circulatory system diagnoses 
397.1 	Rheumatic diseases of pulmonary valve
	in MDC 5 DRG 306,307 
	Cardiac congenital & valvular disorders

Use of GEMs to convert payment system
 Will discuss progress at future C&M meetings
 September 16, 17, 2009
 Register for C&M at http://www.cms.hhs.gov/apps/events/ 
 Complete ICD-10 Grouper by October 2009, post by the end of 2009 on ICD-10 website
 Final Grouper logic subject to rulemaking

The GEMs and 
the Reimbursement Mapping
 The GEMs are designed to aid in converting applications and systems from I-9 to I-10
 Some payers found the detail daunting
 Developed streamlined Reimbursement Mapping (one to one best map) 
 The reimbursement mappings would assist in a more simple conversion of codes for reimbursement purposes

Development of 
Reimbursement Mapping
 Start with the I-10 to I-9 GEM
 Where an I-10 code is translated to one I-9 code, no additional review is necessary
 95% percent of the I-10 codes is translated to a single I-9 code
 Many 1-10 codes are translated to the same I-9 code
 Where an I-10 code is translated to more than one I-9 code, historical I-9 code frequency data are used to determine the most commonly used I-9 code among the I-9 code alternatives
 Medpar and California (for newborn and OB codes) data were used
 In the vast majority of cases there is a clear dominant code in terms of frequency
 In rare cases, clinical review is needed to make the final choice

Use of Mappings	
 The GEMs and Reimbursement mappings were designed to be used by all providers, payers, and data users
 They are tools to assist in converting data
 They are publicly available on the CMS & CDC websites
 We will continue to update and maintain the mappings

ICD-10 Updates
 Posted on CMS ICD-10 website http://www.cms.hhs.gov/ICD10/ 
 2009 Diagnosis GEMs and user guide
 2009 Procedure GEMs and user guide
 2009 Reimbursement mapping 
 ICD-10 Digestive System MS-DRGs
 2009 version of ICD-10-CM and PCS codes and official coding guidelines


