1. Conquering the ICD-10 Documentation Challenge Barbara Oviatt, CPC, CCS-P

2. Purpose Develop a transition process to prepare clinicians to document in an ICD-10 environment

3. Objectives Evaluate the documentation impact of ICD-10 Review significant coding guideline variations between ICD-9 and ICD-10 Demonstrate effective use of GEMs Develop an effective chart review strategy

4. Documentation Matters!

5. Provider’s responsibility Facilitates continuity of care Supports the claim – Diagnosis codes – CPT codes – Modifiers Will be impacted by ICD-10 Begin awareness campaign and chart reviews now

6. Chart Review Process Establish review team members Identify goals and objectives Determine the sample Conduct the chart review Educate Re-review

7. Chart Review Process Determine the sample Frequently reported ICD-9 codes Identify top 20 diagnosis – Generate code lists by specialty – Analyze and adjust the list as needed Establish sample size – Include all providers who code or whose documentation is the basis for code assignment – Number of codes per provider – Number of charts per code / provider

8. Analyze Your Top 20 Identify the top 20 codes for each specialty and / or provider Review the GEMs mapping for each code – Review the additional codes in the category – Note the necessary documentation elements – Note any pertinent coding guidelines Adjust code selections and revise list as necessary

9. What is GEMs? General Equivalency Mappings Developed by CMS Not a crosswalk! Attempts to find corresponding diagnosis codes between I-9 and I-10 Often maps to an unspecified code

10. GEMs Example

11. Avoid the Unspecified Trap GEMs often leads to unspecified code maps – Unspecified can lead to unpaid – Denied for medical necessity – Denied because you should know if it was the left or right – Look for specific alternatives within the code category

12. Asthma GEMs Map: Unspecified to unspecified; search the category for a better alternative.

13. CATEGORYSEARCHCATEGORYSEARCH

14. Asthma ICD-9-CM = 493.90 Extrinsic vs. intrinsic Chronic obstructive asthma With status asthmaticus With exacerbation Exercise induced bronchospasm Cough variant asthma  Additional documentation required ICD-10-CM = J45.909 Mild intermittent  Mild persistent  Moderate persistent  Severe persistent  With status asthmaticus With exacerbation Exercise induced bronchospasm Cough variant asthma Tobacco use or exposure (additional code required)  Notes: Excludes chronic obstructive asthma

15. Tobacco Use and Exposure Numerous instructions to use additional code identifying tobacco use or exposure, if applicable Exposure Z77.22 - Environmental Z57.31 - Occupational P96.81 - Perinatal Use O99.33 – Complicating pregnancy Z72.0 - Nondependent Z87.891 - History Nicotine Dependence Category F17 Cigarettes, chewing tobacco, other Remission, withdrawal, other disorder

16. Hypertension GEMs mappings:

17. CATEGORYSEARCHCATEGORYSEARCH

18. Hypertension Gems mappings:

19. PARTIAL CATEGORY SEARCH - I1

20. Hypertension ICD-9: 401.X – 404.x Benign Malignant Hypertensive heart disease Hypertensive CKD Hypertensive heart and CKD Secondary hypertension – Renovascular Indicate as appropriate – With / without heart failure – Type of heart failure – Stage of CKD  Additional documentation required ICD-10: I10 – I15.x Essential (without comorbidities) Comorbidities Present – Hypertensive heart disease – Hypertensive CKD – Hypertensive heart and CKD – Secondary hypertension Renovascular, endocrine Underlying condition – Indicate as appropriate With / without heart failure Type of heart failure Stage of CKD History of use, current use of, or exposure to tobacco  Distinguish between hypertension and high blood pressure without diagnosis of HTN (coded with R03.0)

21. Other Common Features Significant expansion of combination codes that will require documented specificity of conditions – E20.21 Type I diabetes mellitus with diabetic nephropathy – I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris – K50.112 Crohn’s disease of large intestine with intestinal obstruction

22. Other Common Features Placeholder character – T42.4x5A Adverse effect of benzodiazepines, initial encounter Always the letter “x” Used to keep other characters in their place 5 th digit is a place holder 6 th digit indicates external cause 7 th digit indicates episode of care

23. Other Common Features Episode of care is associated with various injuries throughout ICD-10 – M80.08A Age related osteoporosis with current pathological fracture, vertebra(e), initial encounter – S61.421D Laceration with foreign body of right hand, subsequent encounter – T21.31xS Burn of third degree of chest, sequela There are 16 episode of care extensions associated with fractures

24. W56.02XA Struck by a Dolphin, Initial Encounter

25. Other Common Features Codes reflect laterality when appropriate: – H60.332 Swimmer’s ear, left ear – S63.411A Sprain of carpal joint of right wrist, initial encounter – H65.06 Acute serous otitis media, recurrent, bilateral

26. Conduct the Chart Review Assess the documentation – Potential ICD-10 code assignment – Note strengths and weaknesses – Identify educational needs – Identify process issues

27. Chart Review Follow Up Educate – Deliver positive feedback to providers – Be prepared and stay focused Use effective methodology – Lunch and learn meetings – Contests – Flashcards – Diagnosis of the week campaign Address needs – Template revisions, etc.

28. Chart Review Follow Up Monitor on established timeline – Re-review for improvement – Re-educate as necessary – Evaluate effectiveness of strategy Repeat – Select the next code or re-review – Educate – Address needs – Monitor

29. EvaluateReviewAnalyzeEducate Re- review Chart Review Recap

30. Questions…

31. Thank you! boviatt@cpticdpros.com 855-ICD-10CM/855-423-1026