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©2014 The Advisory Board Company • advisory.com What You Need to Know About ICD-10 Documentation in an ICD-10-CM/PCS World A Physician Practice Perspective Revenue Cycle Solutions Consulting & Management Services

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©2014 The Advisory Board Company • advisory.com

What You Need to Know About ICD-10 Documentation in an ICD-10-CM/PCS World

A Physician Practice Perspective

Revenue Cycle Solutions Consulting & Management Services

©2014 The Advisory Board Company advisory.com 2

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About Today’s Speaker

Shamim Noorani, MPH

• Project Lead for The Valley Hospital’s ICD-10 Implementation Initiative

• Has partnered with large health systems and community hospitals to improve

revenue cycle performance

• Works with multiple Advisory Board members on ensuring a successful

transition from ICD-9 to ICD-10

• Other areas of concentration include strategic planning, market analysis, and

revenue cycle optimization

Shamim Noorani, MPH

Associate Director

202.568.7147

[email protected]

For more information, contact:

©2014 The Advisory Board Company advisory.com

Our Firm in Brief

RESEARCH

AND INSIGHTS

• Dedicated to the most

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based care, revenue cycle

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6

©2014 The Advisory Board Company advisory.com 7

The Valley Hospital’s ICD-10 Physician Education Approach

A Three Phased Approach

1

Better indication of

Severity of Illness

(SOI) and Risk of

Mortality (ROM)

January-March 2014

• Distribute high-level physician awareness

• Begin ICD-10-related messaging in Med Staff

Bulletin

• Launch Physician Champion Intensive

• Schedule specialty specific education sessions

April – September 2014

• Initiate specialty specific physician education

• Provide tip sheets to physicians by specialty

• Host on-site sessions and offsite webinars for select focus areas

• ICD-10 case study examples and focused messages

October- December 2014

• Ongoing education and support

• Reinforcement of ICD-10 concepts

• Sustainability plan

What is in it for ME?

2

3

4

Better information to

support and drive

quality of care

Greater specificity

provides insight for

patients and other

providers

Greater opportunities

for advanced medical

research

5

Completion of the

ICD-10 specialty

specific training

curriculum will

provide CME credits

Phase 2 Phase 3 Phase 1

Protect your bottom

line

6

©2014 The Advisory Board Company advisory.com

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Road Map for Discussion

8

Impact on Physician Practices

Documentation Best Practices

Resources and Q&A

ICD-10-CM/PCS: What Changes?

©2014 The Advisory Board Company advisory.com 9

ICD-10-CM/PCS: What Changes?

ICD-9 Deconstructed

Understanding where we are…

History of ICD-9

• World Health Organization (WHO) endorsed ICD-9

codes for use worldwide

• U.S. developed clinical modification (ICD-9-CM) in

1979

• Expanded number of diagnosis codes; developed

inpatient procedure coding system

ICD-9 Uses Today

• Calculate Payment: Medicare Severity-Diagnosis

Related Groups (MS-DRGs)

• Adjudicate Coverage: diagnosis codes for all settings

• Compile statistics

• Assess quality

Current ICD-9 Users

• ICD-9-CM Diagnoses: used by all types of providers

• ICD-9-CM Procedures: used only by inpatient

hospitals

• Current Procedural Terminology (CPT): used for all

ambulatory and physician procedure reporting

Why a New System?

• ICD-9 cannot accurately describe the diagnoses and

inpatient procedures of care delivered in the 21st

century

©2014 The Advisory Board Company advisory.com 10

ICD-10-CM/PCS: What Changes?

ICD-10-CM/PCS Quick Facts

…to understand where we’re going…

Source: Nichols, J.C. (2011). ICD-10 – A primer. Advisory Board

Applications and Technologies Collaborative.

ICD-10 Regulatory Requirements

• All HIPAA transactions will require the use of ICD-10-CM/PCS codes

• The compliance deadline is October 1, 2014

• Institutional, outpatient and professional services claims submitted with a date of service or

discharge on or after the compliance deadline must contain ICD-10-CM (diagnosis) codes

• ICD-10-PCS (procedure) codes will also be required for inpatient institutional services only

• CPT codes remain unchanged as a means to define procedures conducted in the clinic and

physician practice settings

Significant Changes on the Horizon

This migration from the current ICD-9 standard to the ICD-10 standard will represent one

of the greatest changes in health care information in many years.

Joseph C. Nichols, MD

©2014 The Advisory Board Company advisory.com 11

ICD-10-CM/PCS: What Changes?

October 1, 2014 Transition from ICD-9-CM/PCS to ICD-10-CM/PCS

Add Source: 2011, The Clinical documentation Improvement

Specialist's Guide to ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS,

CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS.

Benefits and Goals of ICD-10-CM/PCS

• Provides better detail and a more accurate depiction of patient

severity

• Improves care management of patients

• Obtains reliable and robust clinical data that can be used to make

intelligent, data-driven decisions related to all aspects of health care

• Allows for more accurate payment for new procedures

• Improves disease management through capture of morbidity and

mortality data

• Offers a better understanding of the value of new medical procedures

• Provides more specific data to address global disease emergencies

• Reduces the number of miscoded, rejected and improper claims for

reimbursement

• Provides comprehensive data for improved fraud and abuse

monitoring

©2014 The Advisory Board Company advisory.com 12

ICD-10-CM/PCS: What Changes?

ICD-10 Substantially Increases Code Volumes

~14K

~68K

~4K

~87K

ICD-9 ICD-10

Diagnosis Codes Procedure Codes

ICD-10 Code Set Characteristics

Increase in Codes from ICD-9 to ICD-10

Percentage of ICD-10

codes related to

musculoskeletal conditions

Percentage of ICD-10

codes related to fractures

Percentage of ICD-10-CM

codes that are different

due to distinguishing

between “right” vs “left”

>50%

~25%

36%

©2014 The Advisory Board Company advisory.com 13

ICD-10-CM/PCS: What Changes?

ICD-10-CM Captures More Information

New codes are more descriptive

Characteristic ICD-9-CM Diagnosis Codes (Vol. 1 & 2) ICD-10-CM Diagnosis Codes

Field Length 3-5 characters (except for the 1st character for

“E” and “V” codes) 3-7 characters

Acuity Capture Limited inclusion of co-morbidities,

complications, severity, manifestation, and, risk

Includes many of these parameters within

codes

Laterality Does not distinguish laterality (left vs. right vs.

bilateral)

Usually includes laterality where

appropriate

Encounter Does not define initial vs. subsequent

encounters Includes these concepts

Available Space for New Codes Expansion ability is limited

Alphanumeric support and place holder

characters provide significant ability to

expand the codes sets

Consistency of Terms Consistency of terms and definition has been a

challenge

Consistency for terms and concepts has

been improved

Code Combination Combination codes are limited

Combination codes are frequent, with

multiple distinct medical concepts per

code

©2014 The Advisory Board Company advisory.com 14

Introduction to ICD-10-CM Diagnosis Coding Structure

ICD-10-CM codes will contain 3-7 alphanumeric characters with the following structure

α # α/#

α/# α/# α/#

Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality,

Complication)

Extension

(3-16 options

depending on

category)

α/#

Key ICD-10-CM Documentation Concepts

Specific anatomical location

Degree (mild, moderate, severe, or

unspecified; total/complete vs

partial/incomplete)

Type (primary, secondary, unspecified) Episode of Care (Initial, Subsequent,

Sequelae)

Acuity (acute, subacute, chronic, acute on

chronic, or unspecified ) Laterality (Right, Left, bilateral, or unspecified)

Trimester (1,2,3,unspecified) Number of fetus (1-5, other)

©2014 The Advisory Board Company advisory.com 15

ICD-10-CM/PCS: What Changes?

More Specific Codes Requires More Specific Documentation

Physician documentation drives successful ICD-10-CM coding

A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius]

with [intra-articular extension] and a [minimal opening] with [minimal tissue damage]

ICD-10 Code Description

S52571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture

type I or II with nonunion

ICD-9 Code Description

813.52 Other Open Fracture of Distal End of Radius (Alone)

For all codes related to fractures of the radius:

• Volume of ICD-9-CM codes = 33

• Volume of ICD-10-CM codes = 1,818

©2014 The Advisory Board Company advisory.com 16

ICD-10-CM/PCS: What Changes?

All Codes Change

No Familiar Favorites to Choose From

ICD-9-CM ICD-10-CM

250.02

Diabetes mellitus without

mention of complication, type II

or unspecified type, uncontrolled

E11.65

Type 2 diabetes mellitus with

hyperglycemia

250.43

Diabetes with renal

manifestations, type I [juvenile

type], uncontrolled

E10.21

Type I diabetes mellitus with

diabetic nephropathy

AND

E10.65

Type I diabetes mellitus with

hyperglycemia

Well… Not Exactly…

Required ICD-10 Concepts: Type, Clinical details of disease manifestation or complications

Not much will change. I use 250.0x for diabetes in my office now. In the future, I will still use 250.0x. I will just need to add more information in the record to support it.

VPMA

300+ bed facility

©2014 The Advisory Board Company advisory.com

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Road Map for Discussion

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Impact on Physician Practices

Documentation Best Practices

Resources and Q&A

ICD-10-CM/PCS: What Changes?

©2014 The Advisory Board Company advisory.com 18

Impact on Physician Practices

Impact Spans Acute and Ambulatory Settings

Addressing documentation and query impacts

Documentation

• Additional clinical details must be noted.

Queries

• Additional requests from coders attempting to enter procedures and diagnoses

into information systems.

• Additional requests from documentation improvement staff.

Hospital:

Coding Challenges

Potential physician workflow disruptions

derive from new documentation

requirements and increased query

volumes that may exist to facilitate code

assignment.

©2014 The Advisory Board Company advisory.com 19

Impact on Physician Practices

Challenges in the Physician Practice Area

Coding challenges yield operational and financial impacts

Drivers of Coding Challenges

• Insufficient physician documentation

• Code structure, number, detail,

rules, sequencing, definitions, and

relationships

• Paper encounter form

Physician documents

patient and

procedure details

Coder tries to

crosswalk codes

Increase in denied

claims from payer

Coding Challenges Operational Challenges Financial Challenges

What it Affects

• Practice management system

• Encounter form

• Staff training

©2014 The Advisory Board Company advisory.com 20

Impact on Physician Practices

Impact on Day-to-Day Operations

ICD-10-CM creates structural challenges in the physician office

Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory

Board Applications and Technologies Collaborative.

Drivers of Operational Challenges

• Workflow disruptions

• Training time

• Coding productivity

• Updates to electronic health record

systems

• Redesign of the encounter form

Create and Implement Strategies Early

to Prevent Workflow Crisis

Traditional Paper Encounter May be an

Ineffective Coding Tool

What it Affects

• Patient flow in the office

• Coding efficiency

• Public health reporting

• Clinical and quality reporting

• Encounter forms

• Practice management system

• EMR

Coding Challenges Operational Challenges Financial Challenges

©2014 The Advisory Board Company advisory.com 21

Impact on Physician Practices

How Practice Finances are Impacted

ICD-10 will impact physician practice revenue

Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory

Board Applications and Technologies Collaborative.

Drivers of Financial Impact

• 10-20% estimated increase in denials

• Processing rules

• Remediation of medical policies

• Crosswalk complications

• Differences in authorization and

referral triggers

• Increased scrutiny of documentation

to prevent fraud and abuse

What it Affects

• Conversations with vendors

• Conversations with payers

• Budget for new or updated technology

• Revenue from lost productivity and increase

in denials

Physicians Discuss ICD-10 with Vendors

Coding Challenges Operational Challenges Financial Challenges

©2014 The Advisory Board Company advisory.com

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Road Map for Discussion

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Impact on Physician Practices

Documentation Best Practices

Resources and Q&A

ICD-10-CM/PCS: What Changes?

©2014 The Advisory Board Company advisory.com 23

Documentation Best Practices

Understand Coding the Medical Record

Coders rely primarily on physician documentation

Unable to code from: Able to Code/Capture:

ED Physician Notes

History and Physical

Progress Notes

Consultation

MD Orders

Discharge Summary

Operative / Procedure Note

× Nursing Notes

× Pathology Report

× Lab

× X-rays (exception: can be utilized for laterality

and specific type or site. Example: # of rib

fractures and site specificity)

× Ancillary documentation (exception:

stage of pressure ulcers and BMI can be

captured from ancillary documentation if there is

a corresponding diagnosis by the physician)

Attending Physicians

Surgeons

Anesthesiologists

Consulting Physicians

Only the documentation of a credentialed, treating provider can be used

for hospital coding. Examples include:

Interventional Radiologists

Residents

Nurse Practitioners

Physician Assistants

A “provider” is defined as any physician or health care practitioner who is legally accountable for

establishing the patient’s diagnosis. (Official Coding Guidelines October 2012).

©2014 The Advisory Board Company advisory.com 24

Documentation Best Practices

Specific Items for Consideration

What does more robust documentation look like?

Coders Unable to Assume Documentation Intention

Robust H&P, D/C

summary, past

vs. current

conditions

Secondary

diagnoses,

comorbid

conditions

Clinical

indicators

Modifiers matter!

(POA, resolving,

suspected,

severity,

relationships, etc.)

©2014 The Advisory Board Company advisory.com 25

Documentation Best Practices

Defining Detailed Documentation

Will Rehydrate Dehydration

Unable to Void Urinary Retention

Shortness of Breath Acute Respiratory Failure

Pulmonary infiltrate Suspected Pneumonia (type)

The above represent descriptors, lab

values or other test results

The above represent clearer

diagnostic statements

The following diagnoses are detailed

documentation with no changes required:

Elevated Creatinine Acute Kidney Injury or Acute Renal Failure

The following phrases elude data assignment

and additional information is required:

©2014 The Advisory Board Company advisory.com 26

Diagnoses in the Outpatient and Clinic Setting

Unspecific Diagnoses Examples

• Diabetes: not clearly noted to be controlled or uncontrolled, type 1 or 2 or whether there were complications

related to DM (i.e., neuropathy).

• Carcinoma: often described as “history of carcinoma” while the patient is actually still under treatment for

carcinoma; diagnosis frequently lacks specificity around malignant vs. benign, type, and/or site

• Fracture: often unclear whether the patient is suffering from an acute fracture or aftercare for a fracture that

has occurred previously vs. nonunion vs. malunion

• Acute/Chronic/or Further Described: many diagnoses (i.e., bronchitis, sinusitis, conjunctivitis, hepatitis, otitis

media) lack this specificity

The most common and problematic documentation issue in the Outpatient and Clinic

Settings is the lack of specificity of diagnoses documented.

!

©2014 The Advisory Board Company advisory.com 27

Documentation Best Practices

ICD-10-CM Documentation Concepts

Important to capture dysfunction

Source: Advisory Board Research

A routine patient evaluation reveals presence of congestive heart failure [systolic] or [diastolic].

Bottom Line: Specific physician documentation will be necessary to capture

the specificity between the two most commonly encountered types of heart

failure, given two different treatment options.

ICD-10 Code Description

150.21 Acute combined systolic (congestive) and diastolic

ICD-9 Code Description

428.21 Congestive heart failure, unspecified

©2014 The Advisory Board Company advisory.com 28

Documentation Best Practices

ICD-10 Documentation Concepts

Important to capture history and type

Source: Health Data Consulting

A provider sees a patient in an outpatient setting for a [past] dependency of [tobacco] use.

ICD-10 Code Description

F17.211

F17.213

Nicotine dependence, cigarettes, in remission

Nicotine dependence, cigarettes, with withdrawal

ICD-9 Code Description

305.1 Tobacco use disorder

Bottom Line: Additional, specific physician documentation will be necessary to capture the history

of tobacco dependence and type (cigarette, chewing tobacco, etc.) In ICD-10.

©2014 The Advisory Board Company advisory.com 29

Documentation Best Practices

ICD-10 Documentation Concepts

Important to capture disease origin

Source: Health Data Consulting

A routine patient evaluation reveals presence of a respiratory infection.

ICD-10 Code Description

J20.2 Acute bronchitis due to streptococcus

ICD-9 Code Description

466.0 Acute bronchitis

Bottom Line: Additional, specific physician documentation will be necessary to capture the cause of

the bronchitis.

©2014 The Advisory Board Company advisory.com 30

Documentation Best Practices

ICD-10 Documentation Concepts

Important to capture cause of disease

Source: Health Data Consulting

A routine patient evaluation reveals reason for a patient’s obesity.

ICD-10 Code Description

E66.09 Other obesity due to excess calories

ICD-9 Code Description

278.00 Obesity, Unspecified

Bottom Line: Additional, specific physician documentation will be necessary to capture the origin of

obesity.

©2014 The Advisory Board Company advisory.com 31

Documentation Best Practices

ICD-10-CM Documentation Tips

Details Matter

• Specify acuity: acute, chronic, or acute on chronic

• Specify level of severity: mild, moderate, severe or profound

• Link causal agents to specific diagnosis(es): i.e., constipation due to dehydration; otitis

media due to strep pneumonia

©2014 The Advisory Board Company advisory.com 32

Ten Ways to Improve Documentation Now

Below are the elements most commonly missed in clinical documentation. Often times the intent of the physician to

capture these elements can be construed, but the clarity and specificity needed by the coding professionals is not

present. The list below is not in any ranked order.

Top 10 Considerations for Improvement

1. Document the reason for admission 6. Prevent conflicting documentation between

different caregivers (i.e.: attending vs. consulting)

2. Clearly document whether diagnosis was

Present on Admission (POA)

7. Document the clinical significance (diagnosis)

for each abnormal lab value and all diagnostic

test results

3. Link symptoms to diagnosis 8. Avoid symbols and non-approved

abbreviations as shorthand

4. If patient is empirically treated prior to

confirming a diagnosis, describe such a

diagnoses as “probable,” “likely,” “presumed,”

“can’t rule out,” etc. in progress notes and

discharge summary. Clearly document any

diagnoses that have been resolved or ruled out

9. Link associated diagnoses with

manifestations, indwelling devices, and/or

medications

5. Capture all specificity

10. Include all clinically significant diagnoses,

findings, procedures, and treatment provided in

the discharge summary

©2014 The Advisory Board Company advisory.com

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Road Map for Discussion

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Impact on Physician Practices

Documentation Best Practices

Resources and Q&A

ICD-10-CM/PCS: What Changes?

©2014 The Advisory Board Company advisory.com 34

ICD-10 Apps

• There are numerous mobile apps dedicated to providing tips and strategies for proper

documentation in ICD-10

• Apps allow the user to enter a disease or condition of interest and view any relevant ICD-10

information

• Most apps are free and available on iPhone, Android and other mobile devices

©2014 The Advisory Board Company advisory.com 35

ICD-10 Apps

• Diseases Codes ICD-10 - Trofo Systems

• ICD 10 Lite 2012 - iPremiumApps

• Find-A-Code ICD10/ICD9 +GEMs - Find A

Code, LLC

• ICD-10 Search - Queo Sistemas

• Medisoft ICD-10 Medical -

www.MedicalBilllingSoftware.com

• ICD 10 Codes 2012 Free - JTO Dev Team

• ICD 10 - appgroup lab

• ICD 10 Professional - AppHouse Software

• ICD 10 HD 2012 - iPremiumApps

• ICD-10-CM - Webpatient.net

• ICD-10 Doc Guide - Precyse

And many more!

Android Apps: iPhone Apps:

• ICD 10 On the Go Medical Codes - VLR

Software

• HCPCS Pro - 2011 Codes – SvmSoft

• ICD10 Codes - Black Knight Lab

• ICD-10 Virtual Code Book – Precyse University

• STAT ICD-10 Coder - Austin Physician

Productivity, LLC

• AHIMA’s ICD-10 PCS Flash Cards – AHIMA

• ICD 10 HD 2013 – Eslam Farhat

• ICD 10 Reference – Grupo CRM

• ICD-10 Search – The Coding Institute

• ICD 10 – Nirmala T V

• ICD 10 Mobile – SvmSoft

And many more!

©2014 The Advisory Board Company advisory.com

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ICD-10 Resources

• Develop custom action plans to help prepare for ICD-10 implementation

• Library of references for all ICD-10: From clinical documentation to vendors

• Template library to augment your action plan

• http://www.roadto10.org/

©2014 The Advisory Board Company advisory.com

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ICD-10 Resources

• Implementation roadmaps available for different providers

• Readiness assessments including prioritization tools and vendor questionnaires

• http://www.ahima.org/topics/icd10

©2014 The Advisory Board Company advisory.com 38

The Valley Hospital’s Physician Portal

©2014 The Advisory Board Company advisory.com 39

The Valley Hospital’s Physician Portal

More information on how you can access

this information will come from the Office

Manager Advisory Board.

!

©2014 The Advisory Board Company advisory.com 40

The Engagement Team

Paul Gallo

Senior Project Consultant

[email protected]

202-266-5511

Ben Beadle-Ryby

Associate Director

[email protected]

202-266-5323

Nick Tanner

Project Consultant

[email protected]

202-568-7065

James Green, MBA

Senior Partner

[email protected]

202-266-5443

Samantha Hauger

Partner

[email protected]

202-266-6679

Shamim Noorani

Associate Director

[email protected]

202-568-7147

Emeric Palmer, MD

Medical Consultant

[email protected]

202-266-5600