ICD-10 Getting There….. Family Medicine

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: Acute Myocardial Infarction Inadequate DocumentationRequired ICD-10 Documentation Received in transfer from Medical Center A with AMI. Hx tobacco use and obesity. Received Alteplase prior to transfer. Coded upon arrival. Received in transfer from Medical Center A with LAD STEMI. Hx tobacco dependence with cessation x 6 months, morbid obesity d/t excess calories, BMI of Received Alteplase 6 hrs prior to transfer. Cardiac arrest on arrival secondary to MI. Needed improvements: Site, clot buster administration, contributory history, type, cause, and complication(s).

Inadequate vs. Adequate Documentation Example 2: Asthma Inadequate DocumentationRequired ICD-10 Documentation Seven-year-old female with asthma presents to ER in resp distress. Tachycardic and tachypneic, audible in and out wheeze, O2 sat 63% on room air. Mother reports home inhaler and nebulizers used but didn’t help. Seven-year-old female with moderate, persistent asthma presents to ER in resp distress d/t status asthmaticus. Tachycardic and tachypneic, audible in and out wheeze, O2 sat 63% on room air. Mother reports home inhaler and nebulizers used but didn’t help. Dad smokes near child. Needed improvements: Type, severity, exacerbation(s), complication(s), and precipitating factor(s).

Inadequate DocumentationRequired ICD-10 Documentation Critically ill, diabetes requiring insulin x 40 years, diabetic ketoacidosis. Renal failure requiring hemodialysis 3 x week. Ulcer noted on toe. Critically ill, Type I diabetes requiring insulin x 40 years, diabetic ketoacidosis with coma since yesterday. End stage renal failure, secondary to diabetes, requiring hemodialysis 3 x week. Chronic diabetic ulcer noted on right big toe with muscle necrosis. Inadequate vs. Adequate Documentation Example 3: Diabetes Needed improvements: Type, complication(s), and underlying disease.

Inadequate DocumentationRequired ICD-10 Documentation 67-year-old female with HTN, kidney disease requiring dialysis, positive for tobacco, and CHF here for pre op. 67-year-old female current smoker with chronic systolic CHF due to HTN, chronic stage 4 kidney disease requiring dialysis here for pre op. Inadequate vs. Adequate Documentation Example 4: Hypertension Needed improvements: Stage, cause-and-effect relationship(s), and tobacco experience.

Key Requirements for Documentation The acuity of the disease (e.g., acute, chronic) Disease specificity and granularity (e.g., contact dermatitis due to a detergent) The cause-and-effect relationship (e.g., hypertensive heart disease, diabetic retinopathy) The specific location/laterality (e.g., right lower lobe) The site of the manifestation (e.g. the specific coronary vessel affected by atherosclerosis and whether or not a bypass or stent has occurred at this site in the past.) The infectious agent (e.g. Streptococcus, Trichomoniasis) Alcohol, tobacco, or drug use, abuse, or dependence and their impact on other disease processes that are being treated. 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