ICD-10Getting There…..

Medicine

What Physicians Need To Know

• Claims for ambulatory and physician services provided on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• CPT Codes will continue to be used for physician inpatient and outpatient services and for hospital outpatient procedures.

• ICD-10-PCS – a NEW procedure coding classification system, must be used to code all inpatient procedures on Facility Claims for discharges on or after 10/1/15.

• ICD-9-CM codes must continue to be used for all dates of services on or before 9/30/2015.

• Further delays are not likely.

ICD-9 vs ICD-10 Diagnosis Codes

ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

3 to 5 digits 7 digits

Alpha “E” & “V” – 1st Character Alpha or numeric for any character

No place holder characters Include place holder characters (“x”)

Terminology Similar

Index and Tabular Structure Similar

Coding Guidelines Somewhat similar

Approximately 14,000 codes Approximately 69,000 codes

Severity parameters limited Extensive severity parameters

Does not include laterality Common definition of laterality

Combination codes limited Combination codes common

Number of Codes by Clinical Area

Clinical Area ICD-9 Codes ICD-10 Codes

Fractures 747 17,099

Poisoning and Toxic Effects 244 4,662

Pregnancy Related Conditions 1,104 2,155

Brain Injury 292 574

Diabetes 69 239

Migraine 40 44

Bleeding Disorders 26 29

Mood Related Disorders 78 71

Hypertensive Disease 33 14

End Stage Renal Disease 11 5

Chronic Respiratory Failure 7 4

Right vs. left

accounts for nearly ½

the increase in the #

of codes.

The Importance of Good Documentation

• The role of the provider is to accurately and specifically document the nature of the patient’s condition and treatment.

• The role of the Clinical Documentation Specialist is to query the provider for clarification, ensuring the documentation accurately reflects the severity of illness and risk of mortality.

• The role of the coder is to ensure that coding is consistent with the documentation.

• Good documentation….• Supports proper payment and reduces denials• Assures accurate measures of quality and efficiency• Captures the level of risk and severity• Supports clinical research• Enhances communication with hospital and other providers• It’s just good care!

Inadequate vs. Adequate Documentation Example 1: Acute Myocardial Infarction

Inadequate Documentation Required ICD-10 Documentation

Received in transfer from Medical Center A with AMI. Hx tobacco use and obesity.

Received Alteplase prior to transfer.Coded upon arrival.

Received in transfer from Medical Center A with LAD STEMI. Hx tobacco dependence with cessation x 6 months, morbid obesity d/t excess calories, BMI of 42.5.

Received Alteplase 6 hrs prior to transfer.Cardiac arrest on arrival secondary to MI.

Needed improvements:

Site, clot buster

administration, contributory

history, type, cause, and

complication(s).

Inadequate vs. Adequate Documentation Example 2: AIDS/HIV

Inadequate Documentation Required ICD-10 Documentation

38-year-old male with pneumonia and Kaposi’s sarcoma.

38-year-old male with P. carinii pneumonia & biopsy proven papular cutaneous Kaposi’s sarcoma both secondary to AIDS. HIV positive for 1 year.

Needed improvements:

HIV status, manifestation(s),

and linkage to secondary

condition(s).

Inadequate Documentation Required ICD-10 Documentation

42-year-old with chronic kidney disease, HTN, & diabetes.

Hbg & Hct decreased, transfuse 2 units PRBCs.

42-year-old on transplant list with ESRD on dialysis, HTN, IDDM type 2 with nephropathy & neuropathy.

Chronic kidney disease related iron deficiency anemia, transfuse 2 units PRBCs.

Inadequate vs. Adequate Documentation Example 3: Chronic Kidney Disease

Needed improvements: Stage, transplant status, and

related or contributing disease.

E11.21 Type 2 diabetes mellitus with diabetic nephropathyI112.0 Hypertensive End Stage Renal DiseaseN18.6 Chronic Kidney Disease requiring chronic dialysisZ99.2 Dependence on Renal DialysisE11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecifiedD63.1 Anemia in chronic kidney diseaseZ76.82 Awaiting Organ Transplant Status

I12.9 Hypertensive Chronic Kidney Disease, NOSE11.9 Type 2 Diabetes Mellitus Without ComplicationsN18.9 Chronic Kidney Disease, Unspecified (Stage)

Inadequate Documentation Required ICD-10 Documentation

BRIEF HISTORY:

43 year old positive for tobacco use and markedly positive family history of coronary artery disease. EKG showing old MI and atrial flutter. He has had episodes of angina and coronary angiography has been recommended.

BRIEF HISTORY:

43 year old with chewing tobacco dependence currently having withdrawal and markedly positive family history of coronary artery disease. EKG showing old anterior septal MI and atypical atrial flutter. He has had episodes of unstable angina and coronary angiography has been recommended.

Inadequate vs. Adequate Documentation Example 4: Dysrhythmias

Needed improvements:

Site, type, and tobacco

status.

Key Requirements for Documentation

• The acuity of the disease (e.g., acute, chronic)

• Disease specificity and granularity (e.g., contact dermatitis due to a detergent)

• The cause-and-effect relationship (e.g., hypertensive heart disease, diabetic retinopathy)

• The specific location/laterality (e.g., right lower lobe)

• The site of the manifestation (e.g. the specific coronary vessel affected by atherosclerosis and whether or not a bypass or stent has occurred at this site in the past.)

• The infectious agent (e.g. Streptococcus, Trichomoniasis)

• Alcohol, tobacco, or drug use, abuse, or dependence and their impact on other disease processes that are being treated.

With ICD-10, the need for specific and accurate documentation is increased significantly.

Using Sign/Symptom and Unspecified Codes

• Sign/symptom and “unspecified” codes have acceptable, even necessary, uses.

• If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs and/or symptoms in lieu of a definitive diagnosis.

• When sufficient clinical information is not known or available about a particular health condition, it is acceptable to report the appropriate “unspecified” code.

• It is inappropriate to select a SPECIFIC code that is not supported by the medical record documentation.

Training for Physicians

Dates Method Content

Nov 2014 – Jan 2015 Department Meetings

Introduction/Overview

Jan 2015 – Mar 2015 Web-based OverviewService Specific DocumentationFuture Order EntryDiagnosis Assistant

Mar 2015 – Jun 2015 Classroom Documenting for ICD10 using the Electronic Health Record

Jun 2015 – Sep 2015 Web-based OverviewDocumenting Operative and Procedure Notes for ICD-10-PCS

Future Orders & Diagnosis Assistant

Demonstration