ICD-10 Getting There….. Urology

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: Genital Prolapse Inadequate DocumentationRequired ICD-10 Documentation Uterine prolapse with rectocele. Fecal difficulties. Third degree uterovaginal prolapse with rectocele. Fecal urgency. Needed improvements: Type, severity, and complication(s).

Inadequate vs. Adequate Documentation Example 2: Erectile Dysfunction Inadequate DocumentationRequired ICD-10 Documentation 67-year-old male with erectile dysfunction here to discuss pharmacologic vs. non-pharmacologic interventions. 67-year-old male with erectile dysfunction secondary to radical prostatectomy here to discuss pharmacologic vs. non-pharmacologic interventions. Needed improvements: Type and underlying cause.

Inadequate DocumentationRequired ICD-10 Documentation Multiple urinary problems. Rectal exam reveals an enlarged prostate. Urinary frequency, hesitancy, straining, and decreased flow. Rectal exam reveals an enlarged prostate. Inadequate vs. Adequate Documentation Example 3: Enlarged Prostate Needed improvements: Presence or absence of specific associated symptom(s).

Inadequate DocumentationRequired ICD-10 Documentation Complains of urinary frequency & dysuria. Urine culture shows urinary tract infection. Complains of urinary frequency & dysuria. Urine culture shows E. Coli. Acute cystitis with hematuria. Inadequate vs. Adequate Documentation Example 4: UTIs Needed improvements: Site, infectious agent, and presence of hematuria.

Key Requirements for Documenting Urology Disorders List right, left, or bilateral. Specify the location of calculi when applicable. Identify the underlying cause or state “undetermined” (e.g., nephritis secondary to gout). Document any associated medication or drug use if applicable (e.g., Sildenafil- induced priapism). Documentation should identify the significance of signs and symptoms in relation to associated conditions (e.g., dysuria, urinary incontinence). Identify the significance of a related diagnosis to test results and findings (e.g., invasive adenocarcinoma seminal vesicle from pathology report). Document any residual condition (e.g., erectile dysfunction (ED) following simple prostatectomy). 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