1. ICD-10
Getting There…..
Pulmonary Medicine

2. 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.
What Physicians Need To Know

3. 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
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
ICD-9 vs ICD-10 Diagnosis Codes

4. Number of Codes by 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.
Number of Codes by Clinical Area

5. 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!
The Importance of Good Documentation

6. Inadequate vs. Adequate Documentation Example 1: Pneumothorax
Inadequate Documentation
Required ICD-10 Documentation
Patient received via ambulance, multi stab wounds torso & hands. Stabbed repeatedly by husband at school.
Hemopneumothorax & subcutaneous emphysema. Chest tube placement.
Stabilized to OR.
Patient received via ambulance, multi stab wounds bilateral anterior & posterior torso & both hands. Stabbed repeatedly with hunting knife by husband at school where she worked.
Bilateral hemopneumothorax & subcutaneous emphysema. Bilateral chest tube placement.
Stabilized, to OR.
Needed improvements:
Location, laterality, injury and encounter specifics.
Inadequate vs. Adequate Documentation Example 1: Pneumothorax

7. Inadequate vs. Adequate Documentation Example 2: Pulmonary Embolism
Inadequate Documentation
Required ICD-10 Documentation
38-year-old female presented with fever, dyspnea, toothache & chest pain. Oral exam reveals significant periodontal disease.
Elevated C-reactive protein & WBC. CT demonstrates large PE.
Dx: Pulmonary Embolism
Dx: Acute septic pulmonary embolism secondary to cytomegalovirus. No cor pulmonale.
Needed improvements:
Acuity, type, presence or absence of cor pulmonale, and underlying infection.
Inadequate vs. Adequate Documentation Example 2: Pulmonary Embolism

8. Inadequate vs. Adequate Documentation Example 3: Respiratory Failure
Inadequate Documentation
Required ICD-10 Documentation
78-year-old male admitted with respiratory failure. ABGs showed respiratory acidosis. Long-standing history of COPD & asthma with exacerbation. Hx tobacco abuse. O2 use.
Found to be in atrial flutter.
78-year-old male admitted with acute on chronic respiratory failure. ABGs showed hypoxia & hypercapnia. Long-standing history of COPD & moderate persistent asthma with exacerbation of both. Nicotine dependent, smokes 3 PPD despite O2 use.
Found to be in atypical atrial flutter.
Needed improvements:
Acuity, presence of hypoxia or hypercapnia, underlying condition(s), type, complication(s) and tobacco status.
Inadequate vs. Adequate Documentation Example 3: Respiratory Failure

9. Causal organism, severity, complication(s), linkage, and onset.
Inadequate Documentation
Required ICD-10 Documentation
Admit for left total knee replacement. Pneumonia. Now septic. Blood cultures positive.
Adult respiratory distress syndrome requiring vent support with increased PEEP.
B/P down to 73/45, Swan placed.
Admit for left total knee replacement. Post op day #6. Staph aureus pneumonia. Now septic with shock. Blood cultures positive for Staph aureus.
Adult respiratory distress syndrome secondary to sepsis requiring vent support with increased PEEP.
Needed improvements:
Causal organism, severity, complication(s), linkage, and onset.
Inadequate vs. Adequate Documentation Example 4: Sepsis

10. Stage, transplant status, and related or contributing disease.
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.
I Hypertensive Chronic Kidney Disease, NOS
E Type 2 Diabetes Mellitus Without Complications
N Chronic Kidney Disease, Unspecified (Stage)
Needed improvements:
Stage, transplant status, and related or contributing disease.
E Type 2 diabetes mellitus with diabetic nephropathy
I Hypertensive End Stage Renal Disease
N Chronic Kidney Disease requiring chronic dialysis
Z Dependence on Renal Dialysis
E Type 2 diabetes mellitus with diabetic neuropathy, unspecified
D Anemia in chronic kidney disease
Z Awaiting Organ Transplant Status
Inadequate vs. Adequate Documentation Example 5: Chronic Kidney Disease

11. 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.
Using Sign/Symptom and Unspecified Codes

12. Training for Physicians
Dates
Method
Content
Nov 2014 – Feb 2015
Dept. Meetings
ICD-10 Introduction/Overview
Feb 2015 – Mar 2015
On-line/Classroom
Future Order Entry
Diagnosis Assistant
Feb 2015 – Jul 2015
Web-based
ICD-10-CM Overview &
Service Specific Documentation
Mar 2015 – Jun 2015
Classroom
Physician Playbooks/
Documenting for ICD10 using the Electronic Health Record
Jul 2015 – Sep 2015
Documenting Operative and Procedure Notes for ICD-10-PCS
Training for Physicians

13. Future Orders & Diagnosis Assistant
Demonstration
Future Orders & Diagnosis Assistant