1. ICD-10
Getting There…..
Surgery

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. Inadequate Documentation
Required ICD-10 Documentation
74-year-old female with anemia & dehydration. S/P surgical treatment for pancreatic cancer per Path report.
Bone cancer arm & spine.
Previous cancer treatment.
74-year-old female with anemia & dehydration secondary to Fluorouracil. S/P surgical treatment for stage IV primary cancer of pancreatic head per Path report.
Bone metastasis left arm & spine.
Previous radiation therapy.
Needed improvements:
Location, stage, pathology, metastasis, reason for/focus of treatment, and complication(s) with linkage.
Inadequate vs. Adequate Documentation Diagnosis Coding Example 1: Pancreatic Cancer

6. Location, complication(s), or manifestation(s).
Inadequate Documentation
Required ICD-10 Documentation
UGI series shows exacerbation regional enteritis.
Colonoscopy scheduled for tomorrow.
UGI series shows Crohn’s disease of the large intestine with rectal bleeding.
Needed improvements:
Location, complication(s), or manifestation(s).
Inadequate vs. Adequate Documentation Diagnosis Coding Example 2: Crohn’s Disease

7. 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
Diagnosis Coding Example 3: Chronic Kidney Disease

8. Four Key Elements of Documentation Detail
to Build an Accurate PCS Code 1.
STATE THE INTENTION 2.
DESCRIBE THE APPROACH 3.
DETAIL OUTCOMES 4.
LIST MEDICAL DEVICES
List the procedure objective (e.g., incision and drainage, excision)
Identify the site of the planned procedure – body part and laterality (e.g., right thyroid gland, ascending colon)
Techniques and methods (e.g., percutaneous, endoscopic)
Conversions (e.g., laparoscopic to open)
Total versus partial thyroidectomy
Repair of an accidental bladder perforation
Devices and implants (e.g., mesh, stimulator lead)

9. Inadequate Documentation
Required ICD-10 Documentation
Operative Procedure:
Hysterectomy.
Resection of intestine due to dense adhesions. Nicked bladder.
Partial, laparoscopic hysterectomy converted to open.
Resection of jejunum with side-to-end anastomosis due to dense adhesions. Incidental bladder laceration repaired.
Portion removed, original objective of the procedure, any changes to the objective, approach, additional work performed, and complications.
Inadequate vs. Adequate Documentation Procedure Coding Example 1: Surgical Outcomes

10. Inadequate Documentation
Required ICD-10 Documentation
Operative Procedure:
Removal breast mass.
Removal of breast tumor with minimal blood loss. Procedure tolerated well.
Biopsy, right breast mass, upper-inner quadrant.
Excisional biopsy of right breast tumor with minimal blood loss. Specimen sent to lab. Procedure tolerated well.
Operative intent, location of the tumor, and laterality of the body part.
Inadequate vs. Adequate Documentation Procedure Coding Example 2: Breast Mass

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 – Jan 2015
Department Meetings
Introduction/Overview
Jan 2015 – Mar 2015
Web-based
Overview
Service Specific Documentation
Future Order Entry
Diagnosis Assistant
Mar 2015 – Jun 2015
Classroom
Documenting for ICD10 using the Electronic Health Record
Jun 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