ICD-10 Getting There….. Neurology

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 CodesICD-10-CM Diagnosis Codes 3 to 5 digits7 digits Alpha “E” & “V” – 1 st CharacterAlpha or numeric for any character No place holder charactersInclude place holder characters (“x”) TerminologySimilar Index and Tabular StructureSimilar Coding GuidelinesSomewhat similar Approximately 14,000 codesApproximately 69,000 codes Severity parameters limitedExtensive severity parameters Does not include lateralityCommon definition of laterality Combination codes limitedCombination codes common

Number of Codes by Clinical Area Clinical AreaICD-9 CodesICD-10 Codes Fractures74717,099 Poisoning and Toxic Effects2444,662 Pregnancy Related Conditions1,1042,155 Brain Injury Diabetes69239 Migraine4044 Bleeding Disorders2629 Mood Related Disorders7871 Hypertensive Disease3314 End Stage Renal Disease115 Chronic Respiratory Failure74 Right vs. left accounts for nearly ½ the increase in the # of codes.

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!

Inadequate vs. Adequate Documentation Example 1: Altered Mental Conditions Inadequate DocumentationRequired ICD-10 Documentation Unconscious and intubated on arrival to ER. Glasgow scores low. CT scan revealed fractures & hemorrhage. Unconscious and intubated on arrival to ER. Glasgow scores on ER Arrival: Eyes = 1 Verbal = 1 Motor = 2 CT scan revealed displaced fracture of left calvarium with left frontoparietal intraparenchymal hemorrhage. Needed improvements: Glascow coma scale responses, time obtained, type and sites.

Inadequate vs. Adequate Documentation Example 2: Alzheimer’s Inadequate DocumentationRequired ICD-10 Documentation Disoriented 48-year-old with Alzheimer’s here for eval right arm laceration. Husband reports she was outside and he saw her fall and hit her arm. 48-year-old with early onset Alzheimer’s & dementia here for eval right arm laceration. Husband reports she wandered off two hours ago and was found walking in a baseball field. He saw her fall against some metal bleachers and hit her arm. Needed improvements: Onset, complicating factors, behavioral disturbance(s), and injury specifics.

Inadequate DocumentationRequired ICD-10 Documentation IMPRESSION: Epilepsy. IMPRESSION: Well controlled, cryptogenic left temporal lobe epilepsy with complex partial seizures, no status epilepticus. Inadequate vs. Adequate Documentation Example 3: Epilepsy Needed improvements: Types, control status, and presence or abscence of status epilepticus.

Inadequate DocumentationRequired ICD-10 Documentation Admitted for psychiatric eval. Back pain. Psychosocial dysfunction. Depressed, agoraphobia, and reports sleeping difficulty. Admitted for psychiatric eval. Chronic low back pain due to lumbar spinal stenosis. Psychosocial dysfunction secondary to pain. Recurrent major depression with psychotic symptoms such as locking self in bedroom for weeks at a time, agoraphobia with frequent panic attacks, and reports difficulty falling asleep. Inadequate vs. Adequate Documentation Example 4: Pain Needed improvements: Encounter reason, pain location, acute vs. chronic, underlying cause, and related psychological factors.

Key Requirements for Documentation Detail laterality as right, left, bilateral. Document the significance of test results and findings related to diagnosis (e.g., abnormal EEG results to epilepsy) Include any residual conditions (e.g., chronic constipation secondary to Guillain- Barre´Syndrome). Document any underlying disease (e.g., septic encephalopathy ). Detail any associated medication or drug use, if applicable (e.g., drug- induced tremor secondary to Albuterol). Any related alcohol use, abuse, or dependence. With ICD-10, the need for specific and accurate documentation is increased significantly.

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 DatesMethodContent Nov 2014 – Jan 2015Department Meetings Introduction/Overview Jan 2015 – Mar 2015Web-basedOverview Service Specific Documentation Future Order Entry Diagnosis Assistant Mar 2015 – Jun 2015ClassroomDocumenting for ICD10 using the Electronic Health Record Jun 2015 – Sep 2015Web-basedOverview Documenting Operative and Procedure Notes for ICD-10-PCS

Future Orders & Diagnosis Assistant Demonstration