1 UHS, Inc. ICD-10-CM/PCS Physician Education Cardiology and Cardiovascular

ICD-10 Implementation October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) – Ambulatory and physician services provided on or after 10/1/15 – Inpatient discharges occurring on or after 10/1/15 ICD-10-CM (diagnoses) will be used by all providers in every health care setting ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures – ICD-10-PCS will not be used on physician claims, even those for inpatient visits 2

Why ICD-10 Current ICD-9 Code Set is: – Outdated: 30 years old – Current code structure limits amount of new codes that can be created – Has obsolete groupings of disease families – Lacks specificity and detail to support: Accurate anatomical positions Differentiation of risk & severity Key parameters to differentiate disease manifestations 3

Diagnosis Code Structure 4

ICD-10-CM Diagnosis Code Format 5

Comparison: ICD-9 to ICD-10-CM 6

Procedure Code Structure

ICD-10-PCS Code Format 8

ICD-10 Changes Everything! ICD-10 is a Business Function Change, not just another code set change. ICD-10 Implementation will impact everyone: – Registration, Nurses, Managers, Lab, Clinical Areas, Billing, Physicians, and Coding How is ICD-10 going to change what you do? 9

10 ICD-10-CM/PCS Documentation Tips

ICD-10 Provider Impact Clinical documentation is the foundation of successful ICD- 10 Implementation Golden Rule of Documentation – If it isn’t documented by the physician, it didn’t happen – If it didn’t happen, it can’t be billed The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient – what services were rendered and what is the severity of illness The key word is SPECIFICITY – Granularity – Laterality Complete and concise documentation allows for accurate coding and reimbursement 11

Gold Standard Documentation Practices 1.Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms 2.Document diagnoses, rather that descriptors 3.Indicate acuity/severity of all diagnoses 4.Link all diseases/diagnoses to their underlying cause 5.Indicate “suspected”, “possible”, or “likely” when treating a condition empirically 6.Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers 7.Clarify diagnoses that are present on admission 8.Clearly indicate what has been ruled out 9.Avoid the use of arrows and symbols 10.Clarify the significance of diagnostic tests 12

ICD-10 Provider Impact The 7 Key Documentation Elements: 1.Acuity – acute versus chronic 2.Site – be as specific as possible 3.Laterality – right, left, bilateral for paired organs and anatomic sites 4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance 5.Manifestations – any other associated conditions 6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence 7.Signs & Symptoms – clarify if related to a specific condition or disease process 13

ICD-10 Documentation Tips Do not use symbols to indicate a disease. For example “↑lipids” means that a laboratory result indicates the lipids are elevated – or “↑BP” means that a blood pressure reading is high These are not the same as hyperlipidemia or hypertension 14

ICD-10 Documentation Tips Site and Laterality – right versus left – bilateral body parts or paired organs Example – cellulitis of right upper arm Stage of disease – Acute, Chronic – Intermittent, Recurrent, Transient – Primary, Secondary – Stage I, II, III, IV Example – stage of pressure ulcer: – L Pressure ulcer of right elbow, stage 1 – L Pressure ulcer of left elbow, stage 1 15

ICD-10 Documentation Tips Documentation should always include: – Patient’s BMI – Current of past history of tobacco use or dependence – Exposure to environmental or occupational tobacco smoke – History of previous MI – Administration of tPA at a different facility within 24 hours prior to admission to current facility 16

ICD-10 Documentation Tips Atherosclerosis – Specify type of vessel: Native artery CABG or Transplanted heart artery – Specify CABG graft type: Autologous vein Autologous artery Non-autologous biological Native coronary artery or transplanted heart – Specify CABG and transplanted heart to include: With and without angina pectoris Unstable angina Documented spasm Other forms of angina pectoris 17

ICD-10 Documentation Tips Heart Failure – Specify acuity Acute Chronic Acute on chronic – Identify type Systolic Diastolic Combined systolic and diastolic – List relationship of hypertension to heart failure or heart disease – Identify underlying cause » Example - Exacerbation of stable heart failure due to fluid overload or due to missed dialysis 18

ICD-10 Documentation Tips Disorders of the Heart Valves – Specify Site Mitral Aortic Tricuspid Pulmonary – Specify Type Rheumatic Nonrheumatic Congenital – Specify Severity – acute versus chronic If rheumatic, classify with or without heart involvement – Subclassifications Insufficiency Incompetence Regurgitation Prolapse Stenosis 19

ICD-10 Documentation Tips Ischemic Heart Disease – Specify occlusion as: Total, partial – Specify the presence of: Angina pectoris, unstable angina, any spasm of a coronary vessel – Identify the type and underlying cause of angina » if not related to heart disease – Identify ischemic heart disease as: Atherosclerosis Arteriosclerotic coronary artery disease Arteriosclerotic heart disease Coronary artery disease Coronary arteriosclerosis Coronary heart disease Coronary ischemia 20

ICD-10 Documentation Tips Type of MI along with Myocardium involved – Specify the type – ST elevation, non ST elevation – Specify the location/site affected anterior wall, anterolateral wall, interior wall left anterior descending coronary artery left main coronary artery, right coronary artery – Timeframe Clearly indicate date of recent acute MIs within 28 days prior to current admission History of MI (older than 28 days) – tPA Was tPA administered within the last 24 hours of admission at a different facility? 21

ICD-10 Documentation Tips Diabetes - include the type or cause of diabetes – Type I – Type II – Due to drugs and chemicals – Due to underlying condition – Link any manifestations / complications to the diabetes Circulatory, renal, neurological, ophthalmic, skin, other Examples: E08 - Diabetes mellitus due to underlying condition – E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma – E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E11 - Type 2 diabetes mellitus – E Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema – E Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular edema 22

ICD-10 Documentation Tips Strokes – dominant vs. non-dominant side – Specify the location or source of the hemorrhage and laterality – Document other causes – thrombosis, embolism, occlusion, stenosis Sites – precerebral or cerebral arteries Laterality – Document dominant verses non-dominant side for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesis and for residual effects Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side. 23

ICD-10 Documentation Tips Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post- procedural disorders The provider must clearly document the relationship between the condition and the procedure – Example: D78.01 –Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen D78.21 –Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen 24

ICD-10 Documentation Tips 25 Intra-operativePost-procedural Accidental puncture / lacerationTiming: Post-procedure Late effect Same or different body systemClassify as: An expected post-procedural condition An unexpected post-procedural condition, related to the patient’s underlying medical comorbidities An unexpected post-procedural condition, unrelated to the procedure An unexpected post-procedural condition related to surgical care (a complication of care) Blood product Central venous catheter Drug: What adverse effect Drug name Correctly prescribed Properly administered Encounter: Initial Subsequent Sequelae

ICD-10 Documentation Tips ICD-10-PCS does not allow for unspecified procedures, clearly document: Body System – general physiological system / anatomic region Root Operation – objective of the procedure Body Part – specific anatomical site Approach – technique used to reach the site of the procedure Device – Devices left at the operative site

ICD-10 Documentation Tips Most Common Root Operations: 27 Bypass – altering the route of passage Drainage – taking or letting out fluids &/or gases Insertion – putting in a non-biological appliance Restriction – partially closing Control – stopping or attempting to stop bleeding Excision – cutting out or off Replacement – putting in a biological / synthetic material to replace or function as a body part Supplement – putting in a biological / synthetic to reinforce and / or augment function Dilation - expandingExtirpation – taking or cutting out solid matter Repair – restoring to its anatomic structure and function Transfer – moving a body part to another location Division – cutting into a body part to separate or transect Extraction – pulling or stripping out of off Resection – cutting out or off Transplantation – putting in a living body part from another individual or animal

ICD-10 Documentation Tips Most Common Device Types: 28 Cardiac LeadDrainage DeviceMonitoring Device Stimulator Lead Cardiac Rhythm Related Device Extraluminal Device Pacemaker, single or dual Tracheostomy Device Contractility Modulation Device Feeding DeviceRadioactive Element Vascular Access Device, Reservoir or pump DefibrillatorIntraluminal Device: Plain, Drug-Eluting or Radioactive Stimulator Generator

Summary The 7 Key Documentation Elements: 1.Acuity – acute versus chronic 2.Site – be as specific as possible 3.Laterality – right, left, bilateral for paired organs and anatomic sites 4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance 5.Manifestations – any other associated conditions 6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence 7.Signs & Symptoms – clarify if related to a specific condition or disease process 29