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Issue #33 - March 13, 2013

AAPC ICD-10 Tips and Resources


Featured Article
In the News
Coding Snapshot
ICD-10 Strategies
ICD-10 Resource


Boot Camps:

Miami, FL 3/14
Cleveland, OH 3/21
Nashville, TN 3/28
Denver, CO 4/4
San Francisco, CA 4/11
San Antonio, TX 4/25

Implementation Boot Camps

Anatomy & Pathophysiology Online

Code Set Training


ICD-10: To Test or Not to Test? – Is that the Question?
Testing is a controversial topic within the ICD-10 world. There are many types of testing, including quality assurance, user acceptance, integration, regression, performance, end to end, and many entities that providers will want and need to test with, such as payers, practice management systems, billing companies, and clearinghouses. Knowing where to begin can be challenging. But even with all the variables, testing is the best way to minimize negative impact post implementation and ensure that provider practices are operationally ready for October 1, 2014.

Two major categories: Internal and External

Internal testing encompasses testing internal systems, business procedures, and operational workflows to ensure ICD-10 codes can be successfully processed. Thorough internal testing allows an organization to identify and resolve systems, process, or workflow issues before the compliance mandate to allow for necessary remediation and avoid issues such as cash flow disruption post implementation.

External testing includes testing with external business partners such as payers, clearinghouses, and third party billing services. The end goal of external testing is similar to internal—identification and remediation of issues to avoid disruption to the claims process.

Often providers are uncertain of with whom they should be testing or how far in advance to begin testing. In the best case scenario, providers will test with every entity that they transact ICD-10 data, as far in advance of the compliance date as possible. Given implementation timelines and budgetary limitations, this may not be the most feasible approach. We suggest that providers use the Pareto Principle, commonly referred to as the 80-20 rule. In this case it would be applied as 80% of practice revenue is derived from 20% of business partners. In other words, providers should prioritize testing to include the entities that make up the largest portion of their practice revenue.

Significant time and resources will be required to complete thorough internal and external testing. Ideally practices will allow one full year for testing. The American Medical Association (AMA) recommends two to three months for internal and six to nine months for external testing. Do not wait until the last minute! Many entities are beginning test planning and strategizing now. Savvy physician practices will begin discussions with vendors, payers, and clearinghouses as soon as possible to determine where they can fit into existing test schedules.

Testing is the question. Yes is the answer!


Coordination and Maintenance Committee Meeting
Representatives from the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention's National Center for Health Statistics hosted their biannual ICD-9-CM Coordination and Maintenance Committee Meeting on Tuesday, March 5. This meeting covered a variety of ICD-10 topics, including implementation announcements, MS-DRG v30 mainframe and PC software, ICD-10 conversions of national coverage determinations, new formatting for ICD-10-PCS addenda, revisions to ICD-10-CM code set for Salter-Harris fractures and other physeal fractures, reaction to gluten and gluten sensitivity, and injuries involving the spinal cord in the lumbar and sacral regions. Review the meeting agenda and handouts.


CHIEF COMPLAINT: "I got a lot of stress and I have suicidal thoughts."
HISTORY OF PRESENT ILLNESS: Male patient had been seeing his primary care physician for anxiety and depression since 2001. This began with job related stress; he was a supervisor and was on 24-hour call. The patient became increasingly depressed and began isolating himself and staying in bed on his day off. The patient has depressive symptoms of crying, insomnia, anorexia with recent 20-pound weight loss, decreased concentration, psychomotor retardation, and suicidal ideation with plan. In addition, the patient has auditory hallucinations and hears vague voices talking to him. He will sometimes hear his wife call him when she is not present. At the present time, the patient has been taking Wellbutrin 150 milligrams daily, Lexapro 20 milligrams daily, and Xanax 1 milligram three times a day. He also uses a Combivent inhaler. He has been to the emergency room on several occasions for panic and anxiety attacks and he was treated symptomatically and released.
PAST PSYCHIATRIC HISTORY: See above. There is no evidence of physical, emotional, or sexual abuse as a child and there is no evidence of substance abuse. He denies any family history of emotional illness.
MEDICAL AND SURGICAL HISTORY: At work, the patient was moving a chlorine tank, which ruptured, and he inhaled chlorine gas and was hospitalized for a week. He also has asthma and sinus problems.
FAMILY HISTORY: His wife has bipolar disorder. One son has problems with anger management and is currently disabled because of this.
SOCIAL HISTORY: The patient has a high school education. He worked for 38 years before he was disabled. He feels that he gets along well with people. His marriage is solid but his wife's mental problems, which have been going on for five or seven years, cause him stress.
HEENT - Non-contributory.
Cardiorespiratory - Patient has shortness of breath.
Gastrointestinal - Non-contributory.
Genitourinary - Non-contributory.
Musculoskeletal - Non-contributory.
MENTAL STATUS EXAM: Patient is a well-nourished, well-developed white man in moderate to marked distress. He is tearful during the initial interview. His mood is depressed and his affect is appropriate for the situation. Stream of mental activity is unremarkable; there is no evidence of delusions or ideas of reference. He does have auditory hallucinations. He appears to be of average intellectual functioning. His memory is good for remote and recent events. His general knowledge is good. Insight and judgment are fair.
INVENTORY OF STRENGTHS AND WEAKNESSES: Patient's primary strength is his recognition of illness and willingness to accept help. Weaknesses include difficulty in dealing with stressful situations and difficulty in controlling impulses at times.
1. Major depressive illness, recurrent with suicidal ideation and plan and psychotic features.
2. Panic/Anxiety disorder without agoraphobia.
TREATMENT PLAN: Patient will have individual and group therapy. His Wellbutrin will be increased and he will be started on low doses of Seroquel, which will be increased if psychotic symptoms are not abated.
PROBLEM SUMMARIES AND RECOMMENDATIONS; This 58-year-old married white male is admitted for treatment of depression with suicidal ideation and psychotic features secondary to multiple stressors as noted in history and physical.
PROGNOSIS: Fair to good.
DISCHARGE CRITERIA: Resolution of depression, suicidal ideation and auditory hallucinations, follow-up treatment plan in place.

ICD-10-CM Codes:
F33.3 Major Depressive disorder, recurrent, severe with psychotic symptoms
R45.851 Suicidal ideations
F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia

Rationale: In ICD-10-CM, codes for depressive disorders are broken down by type of depression (major, organic, etc.), temporal factors (recurrent or single), severity (mild, moderate, or severe), and any associated symptoms or manifestations (psychotic symptoms). In our example above, the patient has a major depressive disorder with psychotic features. Because depression codes are combination codes, we can report the code F33.3 that reports the type, temporal factors, severity, and the associated symptoms. This patient also suffers from related co-morbid conditions which should also be reported.


We will be sharing a number of strategies to help your practice successfully implement ICD-10-CM. Please remember to track your progress in your ICD-10 Implementation Tracker on AAPC's website.

Re-evaluate Progress
At this point no matter what size of practice you're in, you should be in the preparation and training phase of the timeline. You should have begun the process of creating staff training materials or determining where and from whom to obtain that training. The key step in this process is identifying the best training methods for your practice and staff. Consideration should be made about beginning clinical documentation assessments and developing targeted training based on these assessments for clinical staff.

Coders and non-clinical staff should begin or continue medical terminology, anatomy, and pathophysiology training. Training for coders should be sought covering general and specialty code sets, including ICD-10-PCS (if required).

All internal policies should be updated such as the use of ABNs, referrals, pharmacy, lab orders, new LCDs and NCDs, etc. This also includes creating flow charts for new procedures and processes for ICD-10. Modify as needed until ICD-10 is supported in all processes and flows.

You should take the opportunity to develop improved operations, performance, and quality assessments for your planned updates. Remember that being compliant is sufficient but now is the time to make sure all systems are updated to carry you well beyond the implementation date.


ICD-10 Reference Guides
Last month we premiered one of our newest ICD-10 resources that provides additional information about non-pressure chronic ulcers. This month we would like to introduce you to our reference guides page on the AAPC website. This is the page where we will continue to provide resources to assist you with some of the complex coding issues related to ICD-10-CM. In addition to the non-pressure chronic ulcer resource, we have downloadable resources for fractures and OB/GYN coding.

Reference Guides

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