ICD-10 Getting There….. Otolaryngology

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: Hearing Loss Inadequate DocumentationRequired ICD-10 Documentation Hearing loss. Currently receiving high doses of IV antibiotics. Bilat hearing loss. Currently receiving high doses of IV Gentamicin. Hearing loss secondary to Gentamicin. Needed improvements: Type, laterality, and causal agent(s).

Inadequate vs. Adequate Documentation Example 2: Otitis Media Inadequate DocumentationRequired ICD-10 Documentation 2 y.o. male, unilateral otitis media with ruptured tympanic membrane. 2 y.o. male, acute serous otitis media (L) ear with spontaneous 30% central tympanic rupture. Needed improvements: Type, laterality, and complicating factor(s).

Inadequate DocumentationRequired ICD-10 Documentation DIAGNOSTIC IMPRESSION: 1.Hyperthyroidism. 2.Goiter DIAGNOSTIC IMPRESSION: 1.Hyperthyroidism with thyrotoxic crisis. 2. Multinodular goiter Inadequate vs. Adequate Documentation Example 3: Hyperthyroidism Needed improvements: Goiter type and presence or absence of thyrotoxic crisis or storm.

Inadequate DocumentationRequired ICD-10 Documentation IMPRESSION: 1.Adenotonsillitis 2.Dysphagia 3.Laryngitis 4.Obesity IMPRESSION: 1.Chronic adenotonsillitis with adenotonsillary hypertrophy. 2.Oropharyngeal dysphagia 3.Acute obstructive laryngitis. 4.Morbid obesity with alveolar hypoventilation. Inadequate vs. Adequate Documentation Example 4: Adenotonsillitis Needed improvements: Acuity, phase, type, presence of hypertrophy, and underlying condition(s).

Key Requirements for Documentation Specify laterality (e.g., right, left, bilateral). State acute, subacute, chronic, and recurrent as applicable. Indicate when there are differences in hearing restrictions in each ear (e.g., conductive hearing loss in the right ear with unrestricted hearing loss in left ear). Document any underlying disease (e.g., otitis media secondary to maxillary sinusitis). List the circumstance of injury, medical misadventure, or other mishap, (e.g., accidental perforation of the eardrum with a cotton swab). List any tobacco use or exposure to tobacco smoke. 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