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ICD-10Getting There…..
Otolaryngology
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: Hearing Loss
Inadequate Documentation Required ICD-10 Documentation
Hearing loss.
Currently receiving high doses of IV antibiotics.
Bilat hearing loss.
Currently receiving high doses of IV Gentamicin. Hearing loss secondary to Gentamicin.
Needed improvements:
Type, laterality, and causal
agent(s).
Inadequate vs. Adequate Documentation Example 2: Otitis Media
Inadequate Documentation Required ICD-10 Documentation
2 y.o. male, unilateral otitis media with ruptured tympanic membrane.
2 y.o. male, acute serous otitis media (L) ear with spontaneous 30% central tympanic rupture.
Needed improvements:
Type, laterality, and
complicating factor(s).
Inadequate Documentation Required ICD-10 Documentation
DIAGNOSTIC IMPRESSION:
1. Hyperthyroidism.
2. Goiter
DIAGNOSTIC IMPRESSION:
1. Hyperthyroidism with thyrotoxic crisis.
2. Multinodular goiter
Inadequate vs. Adequate Documentation Example 3: Hyperthyroidism
Needed improvements:
Goiter type and presence or
absence of thyrotoxic crisis
or storm.
Inadequate Documentation Required ICD-10 Documentation
IMPRESSION:
1. Adenotonsillitis2. Dysphagia3. Laryngitis4. Obesity
IMPRESSION:
1. Chronic adenotonsillitis with adenotonsillary hypertrophy.
2. Oropharyngeal dysphagia3. Acute obstructive laryngitis.4. Morbid obesity with alveolar
hypoventilation.
Inadequate vs. Adequate Documentation Example 4: Adenotonsillitis
Needed improvements:
Acuity, phase, type, presence
of hypertrophy, and
underlying condition(s).
Key Requirements for Documentation
• Specify laterality (e.g., right, left, bilateral).
• State acute, subacute, chronic, and recurrent as applicable.
• Indicate when there are differences in hearing restrictions in each ear (e.g., conductive hearing loss in the right ear with unrestricted hearing loss in left ear).
• Document any underlying disease (e.g., otitis media secondary to maxillary sinusitis).
• List the circumstance of injury, medical misadventure, or other mishap, (e.g., accidental perforation of the eardrum with a cotton swab).
• List any tobacco use or exposure to tobacco smoke.
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