Presentation on theme: "Welcome Basic Introduction to ICD-10-CM/PCS"— Presentation transcript:
1Welcome Basic Introduction to ICD-10-CM/PCS What documentation changes are needed?Presented by:Christine Leiphart, RHIAAHIMA Approved ICD-10-CM/PCS TrainerHealth Information/Coding Supervisor – Ephrata Community Hospital1
2ICD-10-CM/PCS Facts: Effective 10/1/2013 ICD-10 -CM/PCS consists of two parts:ICD-10-CM for diagnosis coding in all health care settingsICD-10-PCS for inpatient procedure coding in hospital settings.There are approximately 18,000 codes in ICD-9, but there are over 171,000 codes in ICD-10CPT coding for outpatient and office procedures is not affected by the ICD-10 transition
3Why Change? ICD-10 provides more specific data than ICD-9 Better reflects current medical practicesUpdated medical terminologyImproved clinical accuracy in the definition/classification of diseasesMore logically organized, more detailed and specificStructure accommodates addition of new codesICD-9 is at capacity and cannot accommodate future coding demands in health careExpanded Data Capture for the reimbursement and data reporting
4AMA vs CMSOn November 10th, the AMA’s House of Delegates approved a policy opposing the implementation of ICD-10.CMS has already delayed ICD-10 numerous times, some of them because of the AMA’s influence, but CMS is stating that ICD-10 will not be delayed again.In response to the AMA action, a spokesperson for CMS says, “Implementation of this new coding system will mean better information to improve the quality of healthcare, and more accurate payments to providers. CMS is giving significant transition time and flexibility to providers to switch over, and we will continue to work with the healthcare community to ensure successful compliance.”
5New Features in ICD-10: Laterality (left, right, bilateral) L Pressure Ulcer of right elbow, stage IID27.0 Benign neoplasm of right ovaryI Cerebral infarction due to embolism of left middle cerebral arteryCombination codes for conditions and common associated symptoms/manifestationsI Atherosclerotic heart disease of native coronary artery with unstable angina pectorisE11.22 Type 2 DM with diabetic chronic kidney disease
6New Features: Combination codes for poisonings and associated causes T42.3x2S Poisoning by barbiturates, intentional self harm, sequelaOB codes identify trimester instead of weeks or episode of careO Excessive weight gain in pregnancy, 2nd trimesterInclusion of clinical concepts not found in ICD-9T45.526D Underdosing of antithrombotic drugs, subsequent encounterY Blood alcohol level of mg/100 ml
8Why does documentation need to change? Specificity in documentation is key, because in ICD-10, there are fewer “unspecified” codes, and even for those diagnoses that have an unspecified option, it is predicted that Medicare will not cover “unspecified” diagnosis codes.The more specific your documentation is, the less queries you will receive from the CDI Specialist and the Coders.There is no question that there will be an increased number of queries with the implementation of ICD-10, but we will try to limit them as much as possible.
9CerebrovascularCerebral Infarction documentation will need to include:Due to thrombosis, embolism, occlusion, stenosis of specific artery:I Cerebral infarction due to embolism of right carotid arteryI Cerebral infarction due to stenosis of left middle cerebralarteryIntracerebral hemorrhage documentation will need to include:Location of the hemorrhageSubcortical hemisphere, brain stem, cerebellum, etc.Residual conditions due to CVA must be specified as:Left or right/dominant or non-dominant side- I Hemiplegia/hemiparesis following cerebral infarction affecting right dominant side.
10Examples: Cerebrovascular Inpatient physician documentation:H&P – “acute CVA, probably in the left middle cerebral artery distribution.”D/C Summary – “probably multiple thrombotic CVAs… he underwent an MRI which showed acute watershed infarct in the left cerebellum involving the anterior and posterior circulation.This is excellent documentation for coding of a CVA. The code for this CVA would be I – Cerebral infarction due to thrombus of left cerebellar artery.
11CardiovascularCAD (coronary arteriosclerosis) is specified as of native vessel, bypass graft, or transplanted heart.Combination codes to include CAD with angina (unstable, with spasm, other) as well as CAD with ischemic chest pain.Myocardial infarction can be specified as current (within the last 4 weeks), diagnosed on EKG but with no presenting symptoms, healed/old; intraoperative, post-operative, or recurrent.If current, further specification by site (anterior, STEMI, Q wave, etc) is necessary.
12Examples for cardiovascular Physician office documentation:“reports history of CAD, HTN and angioplasty.”Need specification if the CAD is still present after angioplasty, and if so, is it of a native artery (I25.10) or of the bypass (I25.810).Inpatient physician documentation:“patient has history of ESRD, CHF and high blood pressure”.There is conflicting documentation on this chart from anotherphysician stating that the patient has HTN. HBP and HTNare coded differently, and if the patient truly has HTN (I10) itshould be documented as such, not as HBP (R03.0).
13LateralityFor all body parts that can be defined as left, right or bilateral side(s), the specific “side” must be documented.Examples:Hemiplegia/hemiparesisPressure UlcersPhlebitis or ThrombophlebitisVaricose VeinsPostphlebitic syndromeDVT lower extremities- Must also specify specific vein (femoral, iliac)
14Examples of laterality Physician office documentation“patient complains of hearing loss (right); large right cerumen impaction” – good example of laterality documentation (H61.21 – impacted cerumen, right ear)“patient presents with glaucoma and senile cataract” – This would need specification for the glaucoma and cataract(s), are they right, left, or bilateral?
15Fractures:More information will be required to accurately code fractures in ICD-10type of fracturespecific anatomical sitewhether the fracture is displaced or notlateralityroutine versus delayed healingnonunions and malunions
16Fractures:Seventh character extensions are assigned for fractures to indicate:fracture is the initial or subsequent encounter or sequelae/late effectthe type of fracture (open or closed)the type of healing (routine, delayed, malunion or nonunionExample: S52.521D: Torus fracture of lower end of right radius, subsequent encounter for closed fracture with routine healing. (see graphic above)
17Open Fractures:Some fracture categories provide for seventh character extensions to designate the specific type of open fracture (based on the Gustilo open fracture classification) The classification is as follows:I Low energy, wound less than 1 cmII Wound greater than 1 cm with moderate soft tissue damageHigh energy wound greater than 1 cm with extensive soft tissue damageIIIA Adequate soft tissue coverIIIB Inadequate soft tissue coverIIIC Associated with arterial injuryExample: S82.111N Displaced fracture of right tibial spine, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
18Other Musculoskeletal Diagnoses Osteoarthritis now divided into Primary, Secondary, Post-Traumatic, Generalized, etcMore specific categories for rheumatoid disease of organs with rheumatoid arthritis: lung, vasculitis, heart disease, myopathy, polyneuropathy, bursitis, nodule, etc.Documentation of pathological fractures will require the underlying cause of the fracture.
19Examples: Musculoskeletal Inpatient physician documentation:H&P – “DJD of the knee, scheduled for TKR”D/C Summary – “DJD of the left knee, status post TKR”.This example would need more clarification as to the type of DJD.Was it generalized (M15.9), post-traumatic (M17.32), primary (M17.12), secondary (M17.5), other/unspecified (M17.9)?H&P – “pathological fx of the right hip”D/C Summary – “pathological fx of the right hip, s/p pinning”.This example would need more clarification as to the cause of the pathological fracture.Was it a stress fracture (M84.359A)?Traumatic (S72.001A)?Due to neoplasm (M84.559A)?osteoporosis (code depends on type of osteoporosis as well, age related, drug induced, postmenopausal, etc)?other disease?Was it of a previous joint prosthesis (T84.010A)?
20Skin DisordersCellulitis (skin infection) and abscess (collection of pus) are now in separate categories, and the terms should not be used interchangeably.Codes for furuncle (painful boil caused by infection of hair follicle) and carbuncle (group of boils that have clustered together) are now separate categories with specific sites and lateralities. Terms should not be used interchangeably.Contact dermatitis should now be specified if it is allergic, irritant, or other with the cause specified. (makeup, plant, detergent, etc)
21Urosepsis:“Urosepsis” is not a term that can be coded in I-10. This will guarantee a query!Specify if the patient has a UTI, SIRS due to a UTI, or SepsisIndwelling catheter or –ostomy:The link between the UTI and catheter/device must be documentedE. Coli UTI: ICD-9 : ICD-10: N390B962
22Other Genitourinary disorders Cystitis – with or without hematuriaUrethral stricture – post-infection or post-traumaticProstatitis – acute or chronic, with or without hematuriaErectile dysfunction – needs underlying causeFistula of female genital tract – specific as to siteExcessive/frequent menstruation – with or without regular cycleChronic renal failure after a kidney transplant needs to be documented as a complication or expected result
23Examples: Other GU Disorders Inpatient physician documentation:“patient with prostatitis”This would need more clarification.Is it acute, chronic or subacute?Is there an organism causing it? (trichomonas, gonococcal, etc)Does patient also have hematuria due to the prostatitis?
24Anemia Anemia with Neoplasm – specify how it’s related Associated with/due to the malignancyAssociated with chemotherapyAssociated with immunotherapyAssociated with radiation therapyAnemia with underlying cause needs to be specifiedNutritional anemias: specify cause - inadequate dietary intake, malabsorption, adverse effect of medicationOther anemias – just like with ICD-9, we continue to need documentation of acute vs chronic blood loss, as well as anemias due to other chronic diseases.
25Examples: Anemia Inpatient physician documentation: H&P - “severe symptomatic anemia, likely due to upper GI bleed from gastritis or PUD”.D/C Summary – “Upper GI bleed in the setting of gastric ulcer, with symptomatic anemia secondary to #1.”In this case, the anemia needs to be further specified as to whether it is an acute blood loss (D62) or chronic blood loss (D50.0). “Symptomatic anemia due to GI bleed” is not specific enough to assume that the patient has acute blood loss anemia.
26Pregnancy/Obstetrics All diagnoses related to a patient’s pregnancy should have the trimester in which the problem began documented. (1st trimester up to 13 weeks, 6 days; 2nd trimester 14 weeks 0 days to 27 weeks 6 days; 3rd trimester 28 weeks 0 days to delivery)Example: O132, Gestational (pregnancy-induced) hypertension without significant proteinuria, second trimesterExpanded codes for more specific codes while pregnant (malnutrition, excessive/low weight gain, abnormal test findings on screenings, etc)
27Examples: Pregnancy/Obstetrics Inpatient physician documentation:H&P – “patient is 29 weeks pregnant, presents with new onset of malnutrition, low weight gain since week 20, and edema of the legs which is new.”This is an example of good documentation regarding obstetrics. The codes for this patient would be:O25.13 – malnutrition in pregnancy, 3rd trimesterO12.03 – gestational edema, 3rd trimesterO26.12 – low weight gain in pregnancy, second trimester
28Tobacco Use/ExposureTobacco use/abuse codes now specify what type of tobacco (cigarettes, chewing tobacco, etc).Also specific codes for types of second hand tobacco smoke (from parent, at work, perinatal, etc)Any patient with a respiratory diagnosis and/or cardiac diagnosis, should have documentation of current and/or past tobacco smoke exposure/abuse.
29Example: Tobacco UsePhysician office documentation – “Former smoker, pack years”.This is an example of good documentation and would be coded as ICD-10 F172.10Physician office documentation – “current tobacco use”.This example of documentation would need more clarification.Is patient tobacco dependent?Does patient smoke cigarettes (F172.10), cigars/other (F172.90), or use chewing tobacco (F172.20)?
30Asthma/Bronchitis/COPD Needs to be documented as mild, moderate or severe.Mild asthma must be documented as intermittent or persistent.Acute bronchitis – now has a combination code to show the organism responsible for the bronchitis.COPD – should be specified as to type (emphysema, chronic bronchitis/asthma, acute exacerbation, decompensated, due to organic dust, allergic, etc)
31Examples: COPD/Asthma Inpatient record, physician documented:“Patient smokes 1 pack per day since she was 17.”“Severe, acute bronchitis, probably underlying COPD”“Severe acute asthmatic bronchitis”“Acute ↑ of COPD”Smoking history documented appropriatelyShould not use ↑ to indicate exacerbation, must document exacerbation if that is what the arrow means. Must also clarify link between asthma/bronchitis and COPD if there is one.
32COPD Examples, continued When coding the previous example, if physician documents Acute exacerbation of COPD with bronchitis and asthma:J44.1 COPD with acute exacerbationJ44.0 COPD with acute lower respiratory infectionJ Unspecified asthma, uncomplicatedIf physician documents Acute asthmatic bronchitis, as exacerbation of COPD:J Unspecified asthma with acute exacerbation
33Diabetes Type of diabetes Due to underlying conditionDue to drug/chemicalType IType IIOtherManifestations are more specific, with more combination codesNo longer classified as controlled or uncontrolledInadequately, out of control or poorly controlled are coded by type (I or II) with hyperglycemia
34Examples: Diabetes Inpatient hospital physician documentation: H&P – 1. R leg cellulitis; possible osteomyelitis. 2. diabetes mellitus type Diabetic neuropathy.D/C Summary – R ankle osteomyelitis with MRSA and cellulitis secondary to diabetes mellitus and peripheral neuropathy.This is excellent documentation for diabetes with complications. The codes for this patient would be:M – other acute osteomyelitis, right ankleB95.6 – Staph aureus as the cause of diseases classified elsewhereZ16 – infection with drug resistant microorganismsL – cellulitis of right lower limbE11.40 – Type 2 diabetes mellitus with diabetic neuropathy, unspecified.
35Personal and Family Histories Expanded number codes for personal and family history of diseases.Personal historyAllergies, diseases/disorders, drug/alcohol dependence, malignancies, MI, non-compliance, surgeries, etcFamily historyDrug/alcohol abuse, arthritis, blindness, genetic disorders, chronic diseases, diabetes, malignancies, mental disorders, respiratory conditions, stroke, etc
36Examples of Histories Physician office documentation “personal history of chickenpox, mumps, tonsillectomy, lap band, tubal ligation, family history of diabetes, former tobacco use”“personal history of appendectomy, has never used tobacco, family history of CAD and stroke (father at 83 years old)These are examples of good documentation of a patient’s history.“Past, family and social history” left blank, or “denies”This would need more clarification. If the patient truly denies all histories, or refuses to give information, the documentation should state “patient refuses” or “patient denies history of any surgeries or medical problems, no significant family history”.
37Other diagnosis examples Physician office documentation:“Impression: Severe aortic stenosis, chronic diastolic CHF, iron deficiency anemia, DM, status post CVA with left-sided hemiparesis, lymphedema, DJD”On the encounter form for this patient, it states “anemia 285.9, AS , edema 782.3, DM ” (written by physician)The diagnoses in the patient’s notes differ from the codes/diagnoses listed on the encounter form. According to what is documented on the record, the diagnoses/codes should be: severe aortic stenosis 424.1, chronic diastolic CHF , iron deficiency anemia 280.9, DM , status post CVA with left-sided hemiparesis , lymphedema 457.1, DJDThis issue will be even more important with ICD-10 as there are so many more codes to choose from.ICD-10 codes for this patient:AS I35.0, CHF I50.32, fe def anemia D50.9, DM E11.9, s/p CVA with hemiparesis I693.54, lymphedema I89.0, DJD M19.90 – however, most of these codes are “unspecified”. In ICD-10, there are specific codes for the type/cause of most of these disorders. For example, for lymphedema, choices are hereditary, post-mastectomy, secondary, surgical, glandular, streptococcal, lymphangiectatic, congenital, etc.
38Procedures Standard terminology Example, in ICD-9, “excision” can mean different things depending on the body site/procedure being done. In ICD-10, excision means, “cutting out or off, without replacement, a portion of a body part.Expandability – to accommodate new procedures and technologiesSpecificityExample, in ICD-9, means suture of an artery. In ICD-10, there are specific codes for each artery.Code descriptions do not include eponyms or common procedure names. (Caldwell-Luc approach, Burch procedure, X-Stop, etc) All procedures should be documented as what was actually done, not the name of the device implanted, or the eponym commonly used for that procedure.