ICD-10Getting There…..

Surgery

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.

Inadequate vs. Adequate Documentation Diagnosis Coding Example 1: Pancreatic Cancer

Inadequate Documentation Required ICD-10 Documentation

74-year-old female with anemia & dehydration. S/P surgical treatment for pancreatic cancer per Path report.

Bone cancer arm & spine.

Previous cancer treatment.

74-year-old female with anemia & dehydration secondary to Fluorouracil. S/P surgical treatment for stage IV primary cancer of pancreatic head per Path report.

Bone metastasis left arm & spine.

Previous radiation therapy.

Needed improvements:

Location, stage, pathology,

metastasis, reason for/focus

of treatment, and

complication(s) with linkage.

Inadequate vs. Adequate Documentation Diagnosis Coding Example 2: Crohn’s Disease

Inadequate Documentation Required ICD-10 Documentation

UGI series shows exacerbation regional enteritis.

Colonoscopy scheduled for tomorrow.

UGI series shows Crohn’s disease of the large intestine with rectal bleeding.

Colonoscopy scheduled for tomorrow.

Needed improvements:

Location, complication(s), or

manifestation(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 Diagnosis Coding 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)

Four Key Elements of Documentation Detail to Build an Accurate PCS Code

1. STATE THE INTENTION

2. DESCRIBE THE

APPROACH

3. DETAIL

OUTCOMES

4. LIST MEDICAL

DEVICES

• List the procedure objective (e.g., incision and drainage, excision)

• Identify the site of the planned procedure – body part and laterality (e.g., right thyroid gland, ascending colon)

• Techniques and methods (e.g., percutaneous, endoscopic)

• Conversions (e.g., laparoscopic to open)

• Total versus partial thyroidectomy

• Repair of an accidental bladder perforation

• Devices and implants (e.g., mesh, stimulator lead)

Inadequate Documentation Required ICD-10 Documentation

Operative Procedure:Hysterectomy.

Resection of intestine due to dense adhesions. Nicked bladder.

Operative Procedure:Partial, laparoscopic hysterectomy converted to open.

Resection of jejunum with side-to-end anastomosis due to dense adhesions. Incidental bladder laceration repaired.

Inadequate vs. Adequate Documentation Procedure Coding Example 1: Surgical Outcomes

Portion removed, original

objective of the procedure,

any changes to the objective,

approach, additional work

performed, and

complications.

Inadequate Documentation Required ICD-10 Documentation

Operative Procedure:Removal breast mass.

Removal of breast tumor with minimal blood loss. Procedure tolerated well.

Operative Procedure:Biopsy, right breast mass, upper-inner quadrant.

Excisional biopsy of right breast tumor with minimal blood loss. Specimen sent to lab. Procedure tolerated well.

Inadequate vs. Adequate Documentation Procedure Coding Example 2: Breast Mass

Operative intent, location of the

tumor, and laterality of the body

part.

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