1. ICD-10
Getting There…..
Neurosurgery

2. 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.
What Physicians Need To Know

3. ICD-9 vs ICD-10 Diagnosis Codes
ICD-9-CM Diagnosis Codes
ICD-10-CM Diagnosis Codes
3 to 5 digits
7 digits
Alpha “E” & “V” – 1st Character
Alpha or numeric for any character
No place holder characters
Include place holder characters (“x”)
Terminology
Similar
Index and Tabular Structure
Coding Guidelines
Somewhat similar
Approximately 14,000 codes
Approximately 69,000 codes
Severity parameters limited
Extensive severity parameters
Does not include laterality
Common definition of laterality
Combination codes limited
Combination codes common
ICD-9 vs ICD-10 Diagnosis Codes

4. Number of Codes by Clinical Area
ICD-9 Codes
ICD-10 Codes
Fractures
747
17,099
Poisoning and Toxic Effects
244
4,662
Pregnancy Related Conditions
1,104
2,155
Brain Injury
292
574
Diabetes 69
239
Migraine 40 44
Bleeding Disorders 26 29
Mood Related Disorders 78 71
Hypertensive Disease 33 14
End Stage Renal Disease 11 5
Chronic Respiratory Failure 7 4
Right vs. left accounts for nearly ½ the increase in the # of codes.
Number of Codes by Clinical Area

5. 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!
The Importance of Good Documentation

6. Inadequate vs. Adequate Documentation Example 1: Spina Bifida
Inadequate Documentation
Required ICD-10 Documentation
Spina bifida with paralysis.
Previous ventriculoperitoneal shunt placement.
Lumbar spina bifida cystica, bilateral lower limb paralysis and hydrocephalus with previous ventriculoperitoneal shunt placement.
Needed improvements:
Location, type, and presence of complicating factors.
Inadequate vs. Adequate Documentation Example 1: Spina Bifida

7. Inadequate vs. Adequate Documentation Example 2: Spondylopathies
Inadequate Documentation
Required ICD-10 Documentation
Disc disease and stenosis with spondylolisthesis. Spinal curvature and Schmorl’s node present.
Anterior lumbar interbody fusion scheduled for Tuesday.
Degenerative disc disease and spinal stenosis with lumbar spondylolisthesis. Lumbar scoliotic curve secondary to disc disease. Schmorl’s L3.
Anterior lumbar interbody fusion L2 – L3 and L3 – L4 scheduled for Tuesday.
Needed improvements:
Location, complicating factor(s), and underlying disease(s).
Inadequate vs. Adequate Documentation Example 2: Spondylopathies

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

9. Inadequate vs. Adequate Documentation Example 4: Pain
Inadequate Documentation
Required 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.
Needed improvements:
Encounter reason, pain location, acute vs. chronic, underlying cause, and related psychological factors.
Inadequate vs. Adequate Documentation Example 4: Pain

10. Stage, transplant status, and related or contributing disease.
Inadequate Documentation
Required ICD-10 Documentation
42-year-old with chronic kidney disease, HTN, & diabetes.
Hbg & Hct decreased, transfuse 2 units PRBCs.
42-year-old on transplant list with ESRD on dialysis, HTN, IDDM type 2 with nephropathy & neuropathy.
Chronic kidney disease related iron deficiency anemia, transfuse 2 units PRBCs.
I Hypertensive Chronic Kidney Disease, NOS
E Type 2 Diabetes Mellitus Without Complications
N Chronic Kidney Disease, Unspecified (Stage)
Needed improvements:
Stage, transplant status, and related or contributing disease.
E Type 2 diabetes mellitus with diabetic nephropathy
I Hypertensive End Stage Renal Disease
N Chronic Kidney Disease requiring chronic dialysis
Z Dependence on Renal Dialysis
E Type 2 diabetes mellitus with diabetic neuropathy, unspecified
D Anemia in chronic kidney disease
Z Awaiting Organ Transplant Status
Inadequate vs. Adequate Documentation Example 5: Chronic Kidney Disease

11. 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.
Using Sign/Symptom and Unspecified Codes

12. Training for Physicians
Dates
Method
Content
Nov 2014 – Feb 2015
Dept. Meetings
ICD-10 Introduction/Overview
Feb 2015 – Mar 2015
On-line/Classroom
Future Order Entry
Diagnosis Assistant
Feb 2015 – Jul 2015
Web-based
ICD-10-CM Overview &
Service Specific Documentation
Mar 2015 – Jun 2015
Classroom
Physician Playbooks/
Documenting for ICD10 using the Electronic Health Record
Jul 2015 – Sep 2015
Documenting Operative and Procedure Notes for ICD-10-PCS
Training for Physicians

13. Future Orders & Diagnosis Assistant
Demonstration
Future Orders & Diagnosis Assistant