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2 ICD- 10 Will it be here on October 1, 2013 Or NOT

3 DOCUMENTATION AND THE ELECTRONIC MEDICAL RECORD Objectives ICD-10-CM Regulatory Environment ICD-9-CM vs. ICD-10-CM ICD-10-CM Draft Guidelines for Coding and Reporting 2011 Documentation Challenges Electronic Medical Record (EMR) Failure to Implement Opportunities How To Prepare

4 ICD-9 TO ICD-10 NOW CH 1 Infectious and Parasitic Diseases 001-139 CH 2 Neoplasms 140-239 CH 3 Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders 240-279 CH 4 Diseases of the Blood and Blood-forming Organs 280-289 CH 5 Mental Disorders 290-319 CH 6 Diseases of Nervous System and Sense Organs 320-389 CH 7 Diseases of the Circulatory System 390-459 CH 8 Diseases of the Respiratory System 460-519 THEN Certain infectious and parasitic diseases A00-B99 Neoplasms C00-D499 Diseases of the Blood and Blood-forming Organs D50- D89 Endocrine, Nutritional and Metabolic Diseases E00-E89 Mental and Behavioral Disorders F01-F99 Diseases of the Nervous System G00-G99 Diseases of the Eye and Adnexa (new) H00-H59 Diseases of the Ear and Mastoid Process (new) H60-H95

5 ICD-9 TO ICD-10 NOW CH 9 Diseases of the Digestive System 520-579 CH 10 Diseases of the Genitourinary System 580-629 CH 11 Complications of Pregnancy, Childbirth and the Puerperium 630-679 CH 12 Diseases of the Skin and Subcutaneous Tissue 680-709 CH 13 Diseases of Musculoskeletal and Connective Tissue 710-739 CH 14 Congenital Anomalies 740-759 CH 15 Newborn (Perinatal) Guidelines 760-779 CH 16 Signs, Symptoms and ILL-Defined Conditions 780-799 THEN Diseases of the Circulatory System I00-I99 Diseases of the Respiratory System J00-J99 Diseases of the Digestive K00-K94 Diseases of the Skin and Subcutaneous Tissue L00- L99 Diseases of the Musculoskeletal System and Connective Tissue M00-M99 Diseases of the Genitourinary System N00-N99 Pregnancy, Childbirth and the Puerperium O00-O9a Certain Conditions Originating in the Perinatal Period P05-P96

6 ICD-9 TO ICD-10 NOW CH 17 Injury and Poisoning 800-999 CH 18 N/A – CH 19 N/A – CH 20 N/A – CH 21 N/A – Index Neoplasm Table Table of Drugs and Chemicals – Index to External Causes - Classification of Factors influencing Health Status and Contact with Health Service V01-V89 Supplemental Classification of External Causes of Injury and Poisoning E800-E999 THEN Congenital Malformations, Deformations and Chromosonal Abnormalities Q00-Q99 Symptoms, Signs and Abnormal Clinical and Laboratory Findings R00-R99 Injury, Poisoning and Certain Other Consequences of External Causes S00-T88 External Causes of Morbidity (new) V00-Y99 Factors Influencing Health Status and Contact with Health Services (new) Z00-Z99 Index Neoplasm Table - Table of Drugs and Chemicals Index to External Causes

7 ICD-9-CM VS ICD-10-CM ICD-9-CMICD-10-CM 17 Chapters21 Chapters E and V code Supplemental Classification All codes are alphanumeric Sense organ conditions in Nervous System Separate Chapters Outdated languageCurrent terminology Injuries by typeInjuries group by site, then type Complications of Medical care in 1 Chapter Complications have been categorized to procedure-specific body system chapters Maximum of 5 charactersMaximum of 7 characters Partial code titlesFull code titles Code extensors for specificity and laterality Dummy place holder (x)

8 ICD-10-CM STRUCTURAL CHANGES ICD-9-CMICD-10-CM 3-5 characters3- 7 characters First character is numeric or alpha (E or V) First character is alpha Characters 2-5 are numericAll letters except U Always at least 3 charactersCharacters 2-7 are alpha or numeric Use of decimal after 3 characters 13,000 codes72,000 codes (approximately)

9 S ICD-10-CM FORMAT 5. 7012 Category Chronic heart disease Atherosclerosis of coronary artery bypass graft(s), complication, manifestation Atherosclerosis of coronary bypass graft(s), unspecified, with angina pectoris with documented spasm I

10 GENERAL CODING GUIDELINES FOR 2011 For reporting purposes only codes are permissible not categories, subcategories. The 7 th character is applicable when required. Place holder “x” is used as a placeholder on certain codes to allow for future expansion of the code. Example: poisoning, adverse effect, and underdosing codes (T36-T50) may need a placeholder to be considered a valid code. 7 th Character – The 7 th character must always be the 7 th character in the data field. If a code that requires a 7 th character is not 6 characters, then a place holder must be used to fill in the empty characters. “NEC”- still represents not elsewhere classifiable in the Alphabetical Index. NOS – still represents not other wise specified and is the equivalent of unspecified in the Alphabetic Index. “NEC” still represents not elsewhere classifiable in the Tabular list. NOS still represents not otherwise specified and is the equivalent of unspecified in the Tabular List

11 GENERAL CODING GUIDELINES Locating a code- Locate a code in the Alphabetical Index and verify the code in the Tabular list. Apply instructional notes that appear in both the Alphabetical Index and the Tabular List. (same) Level of detail in Coding- Codes must be reported to the highest level of detail. Codes from A00 – T88.9, Z00-Z99 - must be used to identify diagnosis, symptoms conditions, problems, complaints, or other reason(s) for a encounter/visit. (same) Signs and symptoms – signs and symptoms must be reported when a related definitive diagnosis has not be established by the provider. (same) Conditions that are integral part of a disease process – signs and symptoms that are routinely associated with a disease process should not be coded, unless otherwise instructed by the classification. (same) Laterality – for bilateral sites the sites the final character of the code in ICD-10-CM indicates laterality. If no bilateral code is provided, and the condition is bilateral then assign separate codes for both the left and the right side (new). Combination code - is a single code used to classify: - Two diagnoses, or a diagnosis with an associated secondary process (manifestation - A diagnosis with an associated complication (new)

12 DIAGNOSTIC CODING AND REPORTING GUIDELINES FOR OUTPATIENT SERVICES Selection of first listed diagnosis – Coding conventions of ICD-10-CM as well as general disease specific guidelines take precedence over the outpatient guidelines. Codes from A00 – T88.9, Z00-Z99 - must be used to identify diagnosis, symptoms conditions, problems, complaints, or other reason(s) for a encounter/visit. Accurate reporting of ICD-10-CM diagnosis codes – Documentation should describe the patient’s condition using terminology which includes specific diagnoses as well as symptoms, problems, or reason for the encounter. Factors influencing health status – Z00- Z99 are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems. Level of detail in Coding – ICD-10-CM codes are 3,4,5,6 or 7 characters. Codes with three characters are head of a category codes. Subdivided by the use of fourth, fifth, sixth, or seventh characters to provide greater specificity. A code is not valid if it has not been coded to the full number of characters required for that code, including the 7 th character extension, if applicable.

13 ICD-9-CM VS ICD-10-CM ICD-9-CMICD-10-CM 305.0 Nondependent alcohol abuse 305.00 Nondependent alcohol abuse, unspecified drunkenness 305.1 Nondependent alcohol abuse, continuous drunkenness 305.2 Nondependent alcohol abuse, episodic drunkenness 305.03 Nondependent alcohol abuse, in remission F 10.12 Alcohol abuse with intoxication F10.120 Alcohol abuse with intoxication, uncomplicated F10.12 1 Alcohol abuse with intoxication delirium F10.129 Alcohol abuse with intoxication, unspecified

14 Y 90.0 Blood alcohol level less than 20mg/100ml Y90.1 Blood alcohol level of 20-39 mg/100ml Y90.2 Blood alcohol level of 40-59 mg/100 ml Y90.3 Blood alcohol level of 60-79 mg/100ml Y90.4 Blood alcohol level of 80-99 mg/100 ml Y 90.5 Blood alcohol level of 100- 119 mg/100ml Y90.6 Blood alcohol level of 120-199 mg/100ml Y90.7 Blood alcohol of 200-239 mg/100ml Y90.8 Blood alcohol level of 240 mg/100ml Y90.9 Presence of alcohol in blood, level not specified Y90.- Evidence of alcohol involvement determined by blood alcohol. Code first any associated alcohol related disorders. ICD-10-CM

15 DOCUMENTATION CHALLENGE Reason for visit : Follow-up- Nephrology Progress Note: __________is a 87 y.o. male who presents for follow-up of chronic kidney disease stage 3. It appears that he developed sudden onset of shortness of breath after seeing me and was hospitalized for a few days with CHF exacerbation and pneumonia. Since then he has been doing better. ROS (Review of Systems) Review of Systems Constitutional: Positive for malaise/fatigue. Negative for fever, chills and weight loss. Mostly on a wheel chair Eyes: Negative for blurred vision. Cardiovascular: Positive for leg swelling. Negative for chest pain and palpitations. Continues to have dyspnea on exertion Gastrointestinal: Negative for nausea, vomiting and diarrhea. Genitourinary: Negative for dysuria and hematuria. Skin: Negative for rash. Neurological: Negative for weakness and headaches. Psychiatric/Behavioral: The patient does not have insomnia. All other systems reviewed and are negative Physical Exam Nursing note and vitals reviewed. Constitutional: He is oriented to person, place, and time and well-developed, well-nourished, and in no distress. No distress. On a wheel chair and in no distress. Normal speech, on oxygen HENT: Mouth/Throat: Oropharynx is clear and moist. Eyes: Conjunctivae and EOM are normal. Neck:

16 DOCUMENTATION CHALLENGE Not able to assess JVD as he was sitting up in his wheel chair during the exam Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. Few crackles left lung base Abdominal: Soft. Bowel sounds are normal. He exhibits no mass. No tenderness. He has no rebound and no guarding. Musculoskeletal: Normal range of motion. He exhibits edema. He exhibits no tenderness. 1+ bilateral lower extremity edema Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. Gait normal. Skin: No rash noted. No erythema Assessment & Plan Chronic Kidney Disease stage 3 with episodes of AKI secondary to ischemic nephropathy and possibly hypertension. According to him his renal function was checked a month ago at his PCP's office and he was told it was better. I will check renal function again. No proteinuria or even microalbuminuria. Secondary hyperparathyroidism of renal origin. Patient is being treated with vitamin D. I will check PTH, phosphorus and calcium today. Anemia of chronic kidney disease. Hemoglobin has been was below the goal of 10 - 12 g/dL for CKD. I will check a CBC today. He may benefit from treatment with ESA. Blood pressure. Patients blood pressure ( 131/60 ) is within the desired goal of <130/80 for CKD. Volume status. The patient appears to be hypervolemic but better than his last visit. His lungs sounded better and edema is less. He is now on Bumetanide. I did not change the dose. Discussed health maintenance, including regular aerobic exercise, low fat/low salt diet, and periodic exams. Return to Clinic in 6 months and as needed. Patient has issues with transportation and stated that it costs him a lot of money to come and see me. I left the decision regarding future appointments.

17 DOCUMENTATION CHALLENGE Addendum: Hyperkalemia has resolved. No microalbuminuria, normal vitamin D level. PTH remains unchanged and not too high for degree of renal function. He remains anemic, but no indication for treatment with ESA. I suggest checking his iron stores. Visit Diagnoses and Associated Orders: Chronic kidney disease, stage III (moderate) [585.3] Secondary hyperparathyroidism (of renal origin) [588.81] Hypertensive kidney disease with chronic kidney disease stage III [403.90BK] Congestive heart failure, unspecified [428.0]

18 DOCUMENTATION CHALLENGE Chronic Kidney Disease, stage III Chronic kidney disease, stage III (N18.3) Secondary hyperparathyroidism Secondary hyperparathyroidism ( N25.81) Anemia of chronic diseaseHypertensive kidney disease with chronic kidney disease stage III ( I12.9) Congestive heart failure, (150.9) Documentation must validate the codes assigned Assessment & Plan Visit Diagnoses

19 DOCUMENTATION CHALLENGE Issues: The CHF was mentioned in the HPI, but was not documented and addressed in the Assessment and Plan. The CHF was not specified Anemia of chronic kidney disease is not listed in the visit diagnoses section in the EMR. Are the codes sequenced appropriately? Actions: Coding guidelines state that chronic conditions that are addressed during the encounter should be coded. Coding Professional (CP) should contact provider about clinical significance of CHF. Anemia of chronic kidney disease needs to be added to the list of visit diagnoses. Codes should be sequenced in accordance with coding guidelines.

20 DOCUMENTATION CHALLENGE Documentation issues are resolved: CP contacts the provider and CHF is added to the assessment and plan. The provider documents that the patient has chronic systolic heart failure. Anemia of chronic kidney disease is added to the visit diagnoses list Visit diagnoses for this encounter have been revised: 1.I12.9 – Hypertensive chronic kidney disease, with stage 1-4 chronic kidney disease, or unspec CKD 2.N18.3 – Chronic kidney disease, stage III (moderate) 3.I50.22 - Chronic systolic congestive heart failure 4.N25.1 - Hyperparathyroidism 5.D63.1 – Anemia in chronic kidney disease

21 FAILURE TO IMPLEMENT Failure to successfully implement ICD-10-CM :  Potential to create distorted or misinterpreted information about patient care  Impacts decisions to improve healthcare delivery  Creates coding and billing backlog  Increases in claims rejections/denials  Causes cash flow delays  Places payer contracts and/or market share arrangements at risk due to poor quality rating or higher costs

22 OPPORTUNITIES IT coupled with the adoption of ICD-10-CM can effect the quality, effectiveness, and delivery of health care services The classification requires front-end documentation improvement of medical information Significant shift in delivery and finance Development of EHR components

23 HOW TO PREPARE Assess ICD-10-CM readiness Evaluate documentation requirements Improve documentation

24 HOW TO PREPARE Centers for Disease Control and Prevention date Centers for Medicare and Medicaid sp



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