Sherry Thomas, CCP, CCP-AS CEO/Director of Education

Sherry Thomas, CCP, CCP-AS CEO/Director of Education
ICD-10-CM: What You Need To Know Sherry Thomas, CCP, CCP-AS CEO/Director of Education

ICD-10-CM Guidelines Coding Structure Documentation Issues Auditing

To achieve accurate submission of claims…
Joint effort between the healthcare provider and the coder Consistent AND complete documentation in the medical record is IMPERATIVE! FOR CODING ACCURACY: ICD-10-CM suggests the “entire record” be reviewed to determine the specific “reason for the visit” AND the “condition(s) treated”. ©2010 PHIA/Medical Staff SOS,. Inc

Implementation date… October 1, 2013
Based on the process for adoption of standard under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). FINAL RULE for adoption of: ICD-10-CM (physician/out-pt) ICD-10-PCS (hospital) January 16, 2009 Federal Registry: 45 CFR part 162 [CMS-0013-F] ©2010 PHIA/Medical Staff SOS,. Inc

Per CMS… Effective Date of the regulation: March 17, Level I Compliance by: December 31, Level II Compliance by: December 31, 2011 All covered entities have to be fully compliant on: January 1, 2012 Level I compliance means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing.“ Level II compliance means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards." ©2010 PHIA/Medical Staff SOS,. Inc

Improvements include:
Addition of information relevant to ambulatory and managed care encounters Expanded injury codes Creation of combination diagnosis/symptom codes Reducing the number of codes needed to fully describe a condition Addition of 6th and 7th characters Providing greater specificity in code assignment ©2010 PHIA/Medical Staff SOS,. Inc

FORMAT 2 Main Parts: Index = Alphabetical list of terms
Index to Diseases and Injuries Index to External Causes of Injury Neoplasm Table Table of Drugs and Chemicals Tabular = Based on body system and condition Categories, subcategories, and valid codes ©2010 PHIA/Medical Staff SOS,. Inc

Guidelines organized into 4 Sections
Section1: General guidelines, structure and conventions Section 2: Guidelines for selection of principal diagnosis for “non-outpatient” settings Section 3: Guidelines for reporting additional diagnoses in “non-outpatient” settings Section 4: Outpatient coding and reporting ©2010 PHIA/Medical Staff SOS,. Inc

The term… Encounter = used for ALL settings including hospital admissions. Provider = physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. ©2010 PHIA/Medical Staff SOS,. Inc

New Guidelines: Chapter 18 Symptoms, signs, and abnormal clinical and laboratory findings, NEC
Codes R00 – R99 Use ONLY when NO definitive diagnosis is available. Code “in addition to” definitive diagnosis ONLY if “the sign/symptom is NOT routinely associated with that definitive diagnosis”. Code the definitive diagnosis first Then code the sign/symptom ©2010 PHIA/Medical Staff SOS,. Inc

If a “combination” definitive/sign & symptom code is billed do NOT bill a separate code for the sign/symptom. Repeat Falls: R29.6 = Repeated Falls use for encounters when patient has “recently fallen” and the reason for the fall is being investigated. Z91.81 = H/O falling use for encounters when patient has “fallen in the past” and is at risk for future falls. * R29.6 and Z91.81 can be coded together. Documentation must support both codes. ©2010 PHIA/Medical Staff SOS,. Inc

Codes S00 – T88 (previously E codes)
New Guidelines: Chapter 19 Injury, poisoning, and certain other consequences of external causes Codes S00 – T (previously E codes) Most categories in this chapter have 3 extensions A = initial encounter D = subsequent encounter S = sequela ©2010 PHIA/Medical Staff SOS,. Inc

ICD-10-CM Codes L20 Q10.0 3 – 7 characters in length Alpha-numeric code 1st digit of 3 digit code = Alpha 2nd and 3rd digit = Number 4th, 5th, 6th digit = Subcategory May be a Number or Alpha 7th digit - Alpha N99.520 M22.42 T46.995A ©2010 PHIA/Medical Staff SOS,. Inc

7th digit - Alpha S91.001D Applies to certain categories
Required when noted in the tabular Must ALWAYS be the last character If code is NOT a full 6 digit code: Place-holder “X” must be used Place in the 5th position within code ©2010 PHIA/Medical Staff SOS,. Inc

S91 Open Wound of ankle, foot and toes Code also any associated wound infection Excludes 1: open fracture of ankle, foot and toes (S92.- with 7th character B) traumatic amputation of ankle and foot (S98. -) The appropriate 7th character is to be added to each code from category S91 A initial encounter D subsequent encounter S sequela S91.0 Open wound of ankle S91.00 Unspecified open wound of ankle S Unspecified open wound, right ankle S Unspecified open wound, left ankle S Unspecified open wound, unspecified ankle

What does the 7th character represent?
A initial encounter D subsequent encounter S sequela

A = Initial encounter Use “while” patient is receiving “active”
treatment for the injury Examples: Surgical treatment Emergency department encounter Evaluation and treatment by a new physician ©2010 PHIA/Medical Staff SOS,. Inc

D = Subsequent encounter
Use “after” the patient has received active treatment of the injury and receiving “routine care” for the injury during the healing or recovery phase Examples: Cast change or removal Removal of external or internal fixation device Medication adjustment Other aftercare* and follow up visits following injury treatment ©2010 PHIA/Medical Staff SOS,. Inc

S = Sequela Use for complications or conditions that arise as a direct result of an injury Example: scar formation after a burn Use both the injury code (that precipitated the sequela) AND the code for the sequela “S” is ONLY added to the sequela code, NOT the injury code List the sequela code first AND the injury code second ©2010 PHIA/Medical Staff SOS,. Inc

Additional extensions for fractures
G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture with malunion

M80.0 Age-related osteoporosis with current
pathological fracture M81 Osteoporosis without current pathological fracture M83 Adult osteomalacia M84 Disorder of continuity of bone M85 Other disorders of bone density and structure M86 Osteomyelitis M87 Osteonecrosis M88 Osteitits deformans (Paget’s disease of bone) M89 Other disorders of bone and the list goes on and on ……….

“X” What does this represent?
“Filler” or “place holder” character  Use as 5th digit for certain 6 character codes  Allows for expansion of code in future T47.0x1 ©2010 PHIA/Medical Staff SOS,. Inc

T47 Poisoning by, adverse effect of an underdosing of agents primarily affecting the gastrointestinal system The appropriate 7th character is to be added to each code from category T47 A initial encounter D subsequent encounter S sequela T47.0 Poisoning by, adverse effect of and underdosing of histamine H2-receptor blockers T47.0x Poisoning by, adverse effect of and underdosing of histamine H2-receptor blockers T47.0x1 Poisoning by histamine H2-receptor blockers, accidental (unintentional) T47.0x2 Poisoning by histamine H2-receptor blockers, accidental (intentional-self harm) T47.0x3 Poisoning by histamine H2-receptor blockers, accidental (assault)

X00 Exposure to uncontrolled fire in building or structure Includes: Conflagration in building or structure Code first any associated cataclysm Excludes 2: Exposure to ignition or melting of nightwear (X05) Exposure to ignition or melting of other clothing and apparel (X06-) Exposure to other specified smoke, fire and flames (X08.-) The appropriate 7th character is to be added to each code from category X00 A initial encounter D subsequent encounter S sequela X00.0 Exposure to flames in uncontrolled fire in building or structure X00.1 Exposure to smoke in uncontrolled fire in building or structure X00.2 Injury due to collapse of burning building or structure in uncontrolled fire X00.3 Fall from burning building or structure in uncontrolled fire X00.4 Hit by object from burning building or structure in uncontrolled fire X00.5 Jump from burning building or structure in uncontrolled fire X00.8 Other exposure to uncontrolled fire in building or structure

Default Codes 3 digit code = Heading of a Category
Indicates this condition is the “most commonly associated” code with the main term or it’s “unspecified” Take back to provider for more specific documentation Diagnosis codes are suppose to be used and reported at their “highest number of digits” available! ©2010 PHIA/Medical Staff SOS,. Inc

DASH ( - ) M13.12- Will be listed at end of code
Indicates additional characters are REQUIRED Even if code does not indicate ( - ) at the end of the code be sure to check the Tabular listing as it may be indicated there. ©2010 PHIA/Medical Staff SOS,. Inc

Coding for bilateral sites
Final character of code indicates side Unspecified side codes available Take back to provider for additional information If there is NO bilateral code available Assign separate codes for both the left and right ©2010 PHIA/Medical Staff SOS,. Inc

Index indicates: Monoarthritis, elbow M13.12 -
M13 Other arthritis Excludes 1: arthrosis (M15 – M19) osteoarthritis (M15 – M19) M Polyarthritis, unspecified M Monoarthritis, not elsewhere classified M Monoarthritis, not elsewhere classified, unspecified site M Monoarthritis, not elsewhere classified, shoulder M Monoarthritis, not elsewhere classified, right shoulder M Monoarthritis, not elsewhere classified, left shoulder M Monoarthritis, not elsewhere classified, unspec. shoulder M Monoarthritis, not elsewhere classified, elbow M Monoarthritis, not elsewhere classified, right elbow M Monoarthritis, not elsewhere classified, left elbow M Monoarthritis, not elsewhere classified, unspec. elbow

Punctuation [ ] Brackets ( ) Parentheses : Colon
In the Tabular = Used to enclose synonyms, alternative wording or explanatory phrases. In the Index = used to identify “manifestation” codes. ( ) Parentheses In Tabular and Index Used to enclose supplementary words without affecting the code assignment. : Colon In Tabular Used for incomplete term ©2010 PHIA/Medical Staff SOS,. Inc

Abbreviations NEC = “Not Elsewhere Classifiable”
Indicates “other specified” in ICD-10-CM Index entry = directs you to “other specified” in Tabular Codes listed as “Other” or “Other Specified” in Tabular are used when a “more specific code” does not exist Will find in codes with a: 4th or 6th character of “8 or Z” AND 5th digit character of “9” ©2010 PHIA/Medical Staff SOS,. Inc

Abbreviations NOS = “Not Otherwise Specified”
Indicates “unspecified” in the Tabular Codes listed as “Unspecified” in Tabular are used when documentation lacks specific information needed to obtain better code. Take back to provider. Will find in codes with a: 4th or 6th character of “9” AND 5th digit character of “0” ©2010 PHIA/Medical Staff SOS,. Inc

Includes Notes Appears directly under the category name
Further defines, clarifies, or gives examples Inclusion terms listed: Indicates “some” of the condition that may be associated with that code NOT an “all inclusive” list ©2010 PHIA/Medical Staff SOS,. Inc

Excludes Notes 2 Types: Excludes 1 and 2
Considered a “pure” exclude NOT CODED HERE! Mutually exclusive codes: two codes that can NOT be coded together ©2010 PHIA/Medical Staff SOS,. Inc

EXCLUDES 2: NOT included here
Indicates “although the excluded condition is NOT part of the condition it is excluded from, a patient may have both conditions at the same time” May be acceptable to use both the code AND the “excluded code together (if documentation can support both). ©2010 PHIA/Medical Staff SOS,. Inc

CHAPTER 10 – Diseases of the respiratory system (J00 – J99) Note: When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40). Use additional code, where applicable, to identify: exposure to enviromental tobacco smoke (Z58.7) exposure to tobacco smoke in the perinatal period (P96.81) history of tobacco use (Z87.82) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0) Excludes 2: certain conditions originating in the perinatal period (P04 – P96) certain infectious and parasitic diseases (A00 – B99) complications of pregnancy, childbirth and the puerperium (O00 – O00) congenital malformations, deformations and chromosomal abnormalities (Q00 – Q99) endocrine, nutritional and metabolic diseases (E00 – E90) injury, poisoning and certain other consequences of external causes (E00 – T98) neoplasms (C00 – D48) smoke inhalation (T59.81-) symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00 – R94)

ACUTE UPPER RESPIRATORY INFECTIONS (J00 – J06) J00 Acute nasopharyngitis [common cold] Includes: acute rhinitis coryza (acute) infective nasopharyngitis NOS infective rhinitis nasal catarrh, acute nasopharyngitis NOS Excludes 1: acute pharyngitis (J02.-) acute sore throat NOS (J02.9) pharyngitis NOS (J02.9) rhinitis NOS (J31.0) sore throat NOS (J02.9) Excludes 2: allergic rhinitis (J30.1-J30.9) chronic pharyngitis (J31.2) chronic rhinitis (J31.0) chronic sore throat (J31.2) nasopharyngitis, chronic (J31.1) vasomotor rhinitis (J30.0)

J02 Acute pharyngitis Includes: acute sore throat Excludes 1: acute laryngopharyngitis (J06.0) peritonsillar abscess (J36) pharyngeal abscess (J39.1) pharyngitis due to coxsackie virus (B08.5) pharyngitis due to gonococcus (A54.5) retropharyngeal abscess (J39.0) Excludes 2: chronic pharyngitis (J31.2) J02.0 Streptococcal pharyngitis Septic pharyngitis Streptococcal sore throat Excludes 1: scarlet fever (A38.-) J02.8 Acute pharyngitis due to other specified organisms Use additional code (B95 – B97) to identify infectious agent Excludes 1: acute pharyngitis due to herpes [simplex] virus (B00.2) acute pharyngitis due to infectious monomucleosis (B27.-) acute pharyngitis due to influenza virus (J10.1) enteroviral vesicular pharyngitis (B08.5)

CODE ALSO AND 2 codes may be required to fully describe condition
Sequencing depends on “reason for visit” and “severity of condition(s)” AND Implied as “and/or” ©2010 PHIA/Medical Staff SOS,. Inc

WITH/WITHOUT When both are options for the final character, the default is ALWAYS “without” 5 character codes 0 in the 5th position = without 1 in the 5th position = with 6 character codes 9 in the 6th position = without 1 in the 6th position = with ©2010 PHIA/Medical Staff SOS,. Inc

Z Codes in relationship to injuries
Z codes = Factors influencing health status Should NOT be used for aftercare relating to “injuries” For aftercare of an injury Assign the acute injury code with the 7th character “D” (subsequent encounter) ©2010 PHIA/Medical Staff SOS,. Inc

TOP 6 ICD-9 Coding and Documentation Mistakes
Sherry Thomas, CCP, CCP-AS CEO/Director of Education

Mistake #1 Past Diagnoses
Previously reported diagnoses that no longer exist, should not be reported for the current date of service. Mistake # 1 Reporting previous diagnoses that no longer exist. Previously reported diagnoses that no longer exist, should not be reported for the current date of service. The only reportable diagnoses are those affecting the patient at the time of the encounter. If a condition has resolved, it should no longer be reported. History codes (V10-V19) may be reported as secondary codes if the historical condition or family history has an impact on the patient’s current care or treatment. For example, if the patient has a history of cancer, this is important to report as this could determine the test(s) the provider wants to order for follow up. Our goal is to show medical necessity for billing the test(s). ©2010 PHIA/Medical Staff SOS, Inc.

Mr. Johnson is being seen for fever, headache and nasal congestion.
Example 1 Mr. Johnson is being seen for fever, headache and nasal congestion. Acute sinusitis and acute tonsillitis documented in assessment. Fee ticket lists otitis media and otitis externa (from previous diagnoses). Let’s look at the first example. Mr. Johnson is being seen for fever, headache and nasal congestion. After examining the patient, the physician documents in the assessment the patient has acute sinusitis and acute tonsillitis. However, the patient’s fee ticket generated for this date of service has listed otitis media and otitis externa as previous diagnoses. Some computer systems automatically print the previous diagnoses on the fee ticket for quick reference for the physician. That does not mean these diagnoses are to be reported EVERYTIME the patient is seen. The only reportable diagnosis are the ones listed in the assessment for today's visit and addressed in the history. ©2010 PHIA/Medical Staff SOS, Inc.

Sinusitis ICD-9……………currently 23 codes ICD-10…………..going to 34 codes
New term with acute sinusitis: “recurrent” Must have location of sinusitis documented ethmoidal, frontal, maxillary, pansinusitis, sphenoidal, also one for “involving more than one sinus”

Tonsilitis ICD-9……………currently 10 codes ICD-10…………..going to 15 codes
New term with tonsilitis: “recurrent”  Must list organism when documented

Example 2 Ms. Baker is seen today for knee pain resulting from a fall. She was last seen in January with chest congestion, which has since resolved. After completing the remainder of the SOAP note, the physician documents knee pain in the assessment. ICD - 9 = Look at the next example, Ms. Baker is seen today for knee pain resulting from a fall. She was last seen in January with chest congestion, which has since resolved. After completing the remainder of the SOAP note, the physician documents knee pain in the assessment. The only reportable diagnosis for this example is knee pain however the fall (which would be represented by an E code in ICD-9) is important as well as it tells the story of why the patient has the knee pain. Be sure to check with the patient’s insurance carrier to see if they accept E codes. The “resolved” issue would not be reported because this issue no longer exists and was not addressed today. It would be important to educate the provider regarding indicating left and right within the diagnosis as ICD-10 is much more specific in the code descriptor. ICD-10 Example next 2 slides for knee pain and fall ©2010 PHIA/Medical Staff SOS, Inc.

ICD-10 Code Knee pain = M25.56 – * Excludes 2: pain in hand (M79.65-)
pain in fingers (M79.64-) pain in foot (M79.67-) pain in limb (M79.6-) pain in toes (M79.67-) M Pain in knee M Pain in right knee M Pain in left knee M Pain in unspecified knee Will reiterate what’s listed on the slide. Point out the “excludes 2” note and remind them they can select one of these codes in addition to M25.56 – as long as the documentation can support both codes. * Also tell them there are other conditions excluded from the M25 category and they should always go back to the 3 digit category to review this information. If a 7th character is required for this category it will be listed there as well. However Category M25 does not require a 7th character. Remind them the diagnosis codes are suppose to be used and reported at their “highest number of digits” available, which in this case 6 characters. Would recommend taking the documentation back to the provider (before billing the claim) to educate them on specificity and have them amend the record to reflect left/right so they aren’t submitting an “unspecified code”. ©2010 PHIA/Medical Staff SOS, Inc.

ICD-10 Code Unspecified fall - W19 Includes: accidental fall NOS
Requires a 7th character of A, D, or S Code W19XXXA In ICD-10 the code for an unspecified fall is W19 Point out the “includes” note. Remind them they should always go back to the 3 digit category to review the information listed under it. If a 7th character is required for this category it will be listed here. The 3 digit category Code W19 does require a 7th character of A, D, or S. Since the code is only 3 characters in length a “placeholder X” will need to be added to the code along with the 7th character of A,D or S. According to the convention guidelines in ICD-10 a “placeholder X” would need to inserted into the 4th, 5th & 6th position (as a filler) in order for the code to be correct. ©2010 PHIA/Medical Staff SOS, Inc.

Mistake #2 Correct Order
Diagnoses should be billed as they appear in the assessment. Mistake # 2 Choosing the order in which to bill the diagnoses that are documented. Diagnoses should be reported or billed as they are documented in the assessment. Sequenced in the order in which they are documented in the assessment or impression. The Official Guidelines for Coding and Reporting outpatient diagnoses state to list first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided. Then, list additional codes that describe any coexisting conditions. Therefore, in the assessment, the physician should be documenting the reason for the encounter as the first diagnosis. Other problems or diagnoses affecting the patient during this encounter should be additionally documented and submitted on the claim if they were discussed in the history. Even though the guideline appears to put the responsibility on to the physician’s documentation, it is also your responsibility as a coder to educate your physician. It is essential that you have an open line of communication with your physician. You need to be able to explain to the physician, “you need to list first the reason the patient is being seen, then the other diagnoses in the order of their importance”. If not, the documentation is incorrect, and ultimately, you have billed it incorrectly. You should ALWAYS be able to go to your physician with any coding related questions. It is imperative that the coder and physician communicate daily. This ensures that everyone is on the same page when it comes to documentation, coding, billing, and ultimately reimbursement, which is what we are all concerned with. ©2010 PHIA/Medical Staff SOS, Inc.

Example 1 1. COPD 2. Benign HTN, controlled 3. DM II, controlled
The assessment is documented as: 1. COPD 2. Benign HTN, controlled 3. DM II, controlled 4. H/O bladder cancer The physician writes on the fee ticket: Bladder cancer, DM II, and circles COPD and HTN. Let’s look at the first example for Mistake #2: The assessment is documented as: 1. COPD 2. Benign HTN, controlled 3. DM II, controlled 4. History of bladder cancer However, the physician writes on the fee ticket : Bladder cancer, DM II, and circles COPD and HTN but does not indicate which order they should be listed on the claim. The employee in charge with data entry of information for the claim typically is not reviewing the documentation and does not know how the assessment reads in the patient’s medical record for the DOS in question. The perfect scenario would be for the biller/coder to review the documentation before the claim is submitted however in reality this is rarely done. Therefore it’s important for you to audit encounters for each provider and educate them to let them know how to properly document the patient’s diagnosis on the fee ticket. The diagnosis should be submitted in the order they appear within the assessment therefore educate your providers and let them know to indicate the order on the fee ticket by inserting 1,2,3, 4 besides the diagnosis. In doing so the diagnosis being submitted on the claim will mirror the documentation in the patient’s medical record for the DOS in question. ©2010 PHIA/Medical Staff SOS, Inc.

Example 2 Mr. Simpson presents for hip and knee pain and this is documented as the chief complaint. During the visit the physician also documents the patient to have a skin lesion on his right arm. The diagnosis is listed in the assessment as skin lesion rt arm, knee and hip osteoarthritis. Example 2 Mr. Simpson presents for hip and knee pain. During the visit the physician also documents the patient to have a skin lesion on his right arm. The diagnosis is listed in the assessment as skin lesion right arm, knee and hip osteoarthritis however the reason for the visit was the hip/knee pain therefore this should be listed first in the assessment and the skin lesion should be listed next (as long this was discussed in the history). ©2010 PHIA/Medical Staff SOS, Inc.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
knee and hip osteoarthritis ICD-9 = approx. 12 codes  site specific  generalized  localized (idiopathic, primary, secondary) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ICD-10 = approx. 63 codes site specific generalized (erosive, primary, specified) post traumatic (primary, secondary)

Mistake #3 Billing Chronic Conditions
Ongoing, chronic conditions that are NOT documented for this date of service should NOT be reported. Mistake #3 Billing Chronic Conditions that were Not Documented During the current Encounter Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and/or care for the conditions(s). However, the condition must be discussed and documented during the current encounter. Documentation of diabetes on a previous encounter does not warrant reporting unless it is also documented and address during the current DOS. Any chronic conditions documented as part of the patient’s history or review of systems may be reported as long as the patient is still receiving treatment and/or care for that condition. If they are no longer receiving treatment or care for the chronic condition and was not addressed during today’s visit, there is no reason to report it. ©2010 PHIA/Medical Staff SOS, Inc.

Example 1 Ms. Johnson presents today for a follow-up of her high blood pressure. She has been closely followed for benign hypertension and diabetes mellitus, which are both under control at this time. Her history includes stable emphysema and a history of colon cancer 12 years ago. After completing the exam, the physician documents HTN, DM II, emphysema, CHF, gout, and H/O colon CA. Look at the first example for mistake #3: Ms. Johnson presents today for a follow-up of her high blood pressure. She has been closely followed for benign hypertension and Diabetes, which are both under control at this time. Her history includes stable emphysema and a history of colon cancer 12 years ago. After completing the exam, the physician documents HTN, DM II, emphysema, CHF, gout, and history of colon CA. The first diagnosis in the assessment should reflect the reason for the visit which is HTN, and this was done correctly. The provider also addressed the patient’s DM, emphysema and H/O colon CA however they have also listed “CHF and gout”. These 2 diagnosis were not discussed in the history and therefore should not be listed in the assessment as part of today’s visit. It is important to educate the provider to let them know they should only list the diagnosis they are dealing with today. They may have discussed the CHF and gout issues during the visit however they did not document this in the history therefore they should not be listed in the assessment. ©2010 PHIA/Medical Staff SOS, Inc.

ICD-10 Code History of………. Z codes
Personal or Family Personal = condition no longer exists and not receiving any treatment Family = patient may be at risk for said condition/disease Used in conjunction with screening codes Z codes Used to indicate medical necessity for ordering/performing test(s) and/or procedure(s) Will reiterate what’s listed on the slide H/O codes are important as they tell the story as to why the patient is being seen in follow up and shows medical necessity for ordering test(s). ©2010 PHIA/Medical Staff SOS, Inc.

Example 2 diabetes mellitus.
The provider documented on 1/1/10 new onset diabetes mellitus. On 2/5/10 the patient is seen again in the office. For this encounter the physician documents chest pain, abnormal EKG, and hyperlipidemia in the assessment. Example 2 The physician documented on 1/1/10 new onset diabetes mellitus. On 2/5/10 the patient is again seen in the office. For this encounter the physician documents chest pain, abnormal EKG, and hyperlipidemia in the assessment portion of the SOAP note. While the patient is a newly diagnosis diabetic we would only submit this diagnosis if it was addressed and documented in the history for the DOS in question. As it stands the provider has not listed this in the assessment therefore it would be incorrect to submit the DM code. ©2010 PHIA/Medical Staff SOS, Inc.

Etiology/Manifestation Codes
ICD-10 Manifestation codes include the phrase: “in diseases classified elsewhere” Indicates this is a “manifestation” code NEVER billed as “primary” diagnosis Use “in conjunction with” the underlying condition ©2010 PHIA/Medical Staff SOS,. Inc

Diabetes, diabetic (mellitus) (familial) (sugar) E11
Diabetes, diabetic (mellitus) (familial) (sugar) E11.9 (Type 2 diabetes mellitus without complications) with ………………………………… due to drug or chemical E09.9 due to underlying condition E08.9 Gestational diabetes Specified type NEC E13.9 With ……………………………….. Type 1 E10.9 Type 2 E11.9  Combination codes  Sequence based on the “reason” for a particular encounter  Assign as many codes as needed from E08 – E13 to identify all associated conditions  If type of diabetes is not documented then E11.-, Type 2 is the DEFAULT code

Example 2 The provider documents foot ulcer in the assessment portion of the SOAP note. On the encounter form the provider writes diabetic foot ulcer. The ICD-9 codes are incorrectly reported as and The correct code to report is: Example #2 The provider documents foot ulcer in the assessment portion of the SOAP note. However, on the fee ticket the provider writes diabetic foot ulcer. The codes are incorrectly reported as and The correct code to report is: This is the only reportable diagnosis because the physician failed to document that the ulcer was a diabetic ulcer in the patient’s medical record. ©2010 PHIA/Medical Staff SOS, Inc.

Example 2 con’t. The provider documents foot ulcer in the assessment portion of the SOAP note. On the encounter form the provider writes diabetic foot ulcer. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ The correct ICD-10 code(s) to report: E or E10.621? Example #2 The provider documents foot ulcer in the assessment portion of the SOAP note. However, on the fee ticket the provider writes diabetic foot ulcer. The codes are incorrectly reported as and The correct code to report is: This is the only reportable diagnosis because the physician failed to document that the ulcer was a diabetic ulcer in the patient’s medical record. ©2010 PHIA/Medical Staff SOS, Inc.

ICD-10 Code E11 Type 2 diabetes mellitus diabetes NOS
Includes: diabetes (mellitus) due to insulin secretory defect diabetes NOS insulin resistant diabetes (mellitus) Use additional code to identify any insulin use (Z79.4) Excludes 1: diabetes mellitus due to underlying condition (E08.-) drug or chemical induced diabetes mellitus (E09.-) gestational diabetes (O24.4-) Type 1 diabetes mellitus (E10.-) ICD-10 Code ICD-10 DM Example. will reiterate the following: Even though the previous scenario did not indicate the type of DM, for educational purposes let’s say the patient has Type II DM. Point out the “includes” note. Point out the “excludes 1” note and remind them they can not select one of these codes in addition to a code from the E11 category. If the documented assessment indicates the patient has “DM, Type 2 and a diabetic foot ulcer” then a code from the 3 digit category E11 that represented these two issues would be selected. This 3 digit category does not indicate a 7th character is required. Move to next slide ©2010 PHIA/Medical Staff SOS, Inc.

ICD-10 Code E Type 2 diabetes mellitus with foot ulcer Use additional code to identify site of ulcer (L97.4- – L97.5-) L97.4 Non-pressure chronic ulcer of heel and midfoot Non-pressure chronic ulcer of plantar surface of midfoot L97.5 Non-pressure chronic ulcer of other part of foot Non-pressure chronic ulcer of toe Code E represents a type 2 DM patient who has a foot ulcer. Under the code descriptor in the tabular it indicates an additional code from L97.4 or L97.5 is needed to identify the site of the ulcer on the foot. Each code is site specific, therefore in order to select one the documentation will have to support it. When you review these 2 codes there are approximately 31 codes to choose from. Move to next slide ©2010 PHIA/Medical Staff SOS, Inc.

L97.4- and L97.5- Specified Site  right heel and midfoot  left heel and midfoot  unspecified heel and midfoot  other part of foot (toes) Specified Degree of Ulcer  limited to breakdown of skin  fat layer exposed  necrosis of muscle  necrosis of bone  unspecified severity As previously stated there are approximately 31 codes to choose from within codes L97.4- and L97.5-. Each of these codes extend to a 6 character code but do not require a 7th character. However, in order to select one of these codes the documentation must support it. The codes are broken down by site and under each site the codes are further described by the degree of the ulcer. While unspecified codes are available it would be important to educate the provider on the types of codes available so the documentation can be more specific and show the true level of severity of illness for the patient. This in turn will show medical necessity for any test(s) or procedure(s) ordered or performed. ©2010 PHIA/Medical Staff SOS, Inc.

Mistake #4 Proper Linkage
CPT and ICD-9 codes MUST be properly linked on the claim form to prove medical necessity. Mistake #4 is incorrectly linking the ICD-9 and CPT codes on the claim form. Properly linking the CPT and ICD-9 codes is essential when proving medical necessity. We all know that it doesn’t make sense to report strep throat with an ankle x-ray, but you would be surprised as to how many times it actually happen. Often CPT and ICD-9 codes are not properly linked on the claim form. This mostly occurs when multiple diagnoses are being reported with multiple procedures or services. Many times the diagnoses are reported in the same order for every line item listed on the claim form. ©2010 PHIA/Medical Staff SOS, Inc.

Example 1 The provider marks the encounter form as: 99213, (AP chest x-ray) The diagnosis codes listed for this encounter are: 1) ) ) ) Look at the first example for mistake #4 The physician marks on the encounter form: and 71010 The diagnosis codes for this encounter are 1) ) 3) ) (for chest pain, shortness of air, headache and diabetes) For this example we will assume all of the diagnosis listed were addressed in the history and are appropriate for this encounter. To properly link the diagnosis code to the CPT code you will need to determine which ones reflect the service. The diagnosis codes linked to the E/M should reflect all the of the conditions listed in the assessment because all were addressed in the history and part of today’s visit. ©2010 PHIA/Medical Staff SOS, Inc.

786.50 784.0 250.00 786.05 99213 1,2,3,4 1, 2 71010 In the diagnosis indicator box E you would link the diagnosis that indicates medical necessary for performing the service or test(s). As we discussed on the previous slide all 4 of the diagnosis listed should be linked to the E/M service as all the of the conditions listed in the assessment were addressed in the history and part of the E/M service. However X-ray code should only be linked to the ICD-9 code(s) that reflect medical necessary for ordering and performing it. Which in this example would be the chest pain and SOA. Before submitting the claim you would need to check the LCD to make sure these codes are approved for this test. If the ICD-9 code you have listed does not appear on the LCD you will need to take the documentation back to the provider and discuss this with them. You should not alter the documentation “just to get paid”, it should accurately reflect the reason for ordering the test(s). Linking a diagnosis code, that is not listed in the LCD, to the CPT service would result in a rejected claim as it would be deemed medically unnecessary. ©2010 PHIA/Medical Staff SOS, Inc.

Mistake #5 Reporting diagnoses written on the fee ticket
The diagnosis or sign/symptom that is documented in the assessment should be reported. NOT what is written on the encounter form/fee ticket. Mistake #5 Reporting diagnoses written on the encounter form Do not automatically report the diagnosis that is written on the fee ticket. As we briefly discussed earlier, only diagnoses documented in the assessment portion of the SOAP note should be reported. Diagnoses written or circled on the fee ticket should only be reported if they have been clearly documented in the assessment. During the audit you should review the fee ticket and claim to determine if the codes were submitted correctly according to the documentation. The diagnosis listed in the assessment should be mirrored on to the fee ticket so that it is mirrored on the claim. All 3 pieces of information should match. No matter what diagnoses are written on the encounter form, if the diagnosis codes billed for that date of service do not match the diagnoses documented in the assessment, this could be considered fraud and/or abuse. If you find this to be an issue during the auditing process it would be an excellent time for you to sit and educate your provider. ©2010 PHIA/Medical Staff SOS, Inc.

Example 1 The physician documents strep throat, pneumonia, and high blood pressure in the assessment On the encounter form the physician writes pneumonia and HTN. The codes are incorrectly reported as 486 and The correct codes to report are: 034.0, 486, and 796.2 For example: The physician documents strep throat, pneumonia, and high blood pressure in the assessment. However, on the encounter form the physician writes pneumonia and hypertension. The codes are incorrectly reported as 486 and The correct codes to report are: , 486, and Again, the problem is many billers/coders do not see the actual documentation in the health record. They see what is written on the fee ticket as the patient checks out, or even after the patient has already left the office. As previously stated, you are not only a coder, but an educator in documentation. Help the provider understand that it is imperative they write the same diagnosis on the fee that they document and dictate. ©2010 PHIA/Medical Staff SOS, Inc.

Example 2 The provider documents chronic interstitial cystitis and urethritis in the assessment. The provider circles UTI on the fee ticket. Code is incorrectly reported. The correct ICD-9 codes to report are: and One more example for this mistake: The provider documents interstitial cystitis and urethritis in the assessment portion of the SOAP note. However, this office utilizes a pre-printed fee ticket that requires the provider to choose a diagnosis listed on the form. The provider will then bubble in the chosen diagnosis and the form is reviewed by the staff and they enter the information as listed, generating the claim. For this encounter the provider chooses UTI, because it is the most closely related diagnosis listed on the encounter form. Therefore the interstitial cystitis condition is incorrectly reported as a UTI. In order to accurately reflect the IC and urethritis diagnosis listed in the patient’s medical record the correct codes should be reported as: and I understand that ICD-9 codes were originally placed on fee tickets to minimize the providers work load however this can also cause problems. I discourage having the diagnosis codes pre-printed on the fee ticket in order to encourage the provider to write what they actually document or dictate instead of simply choosing the closest diagnosis available on the form. The goal of the ICD-9 code is to tell a story to the insurance company and to indicate to them the true level of severity of illness of the patient’s condition and to show medical necessity for billing the services and/or test(s) listed on the claim form. When the ICD-9 code does not reflect the patient’s true condition, they are being labeled with something they do not have and in some cases, a wrong diagnosis can affect the patient’s health or life insurance policy. ©2010 PHIA/Medical Staff SOS, Inc.

Example 2 con’t. The provider documents chronic interstitial cystitis and urethritis in the assessment. The provider circles UTI on the fee ticket. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ The correct ICD-10 codes to report are: N30.10 and N34.2 One more example for this mistake: The provider documents interstitial cystitis and urethritis in the assessment portion of the SOAP note. However, this office utilizes a pre-printed fee ticket that requires the provider to choose a diagnosis listed on the form. The provider will then bubble in the chosen diagnosis and the form is reviewed by the staff and they enter the information as listed, generating the claim. For this encounter the provider chooses UTI, because it is the most closely related diagnosis listed on the encounter form. Therefore the interstitial cystitis condition is incorrectly reported as a UTI. In order to accurately reflect the IC and urethritis diagnosis listed in the patient’s medical record the correct codes should be reported as: and I understand that ICD-9 codes were originally placed on fee tickets to minimize the providers work load however this can also cause problems. I discourage having the diagnosis codes pre-printed on the fee ticket in order to encourage the provider to write what they actually document or dictate instead of simply choosing the closest diagnosis available on the form. The goal of the ICD-9 code is to tell a story to the insurance company and to indicate to them the true level of severity of illness of the patient’s condition and to show medical necessity for billing the services and/or test(s) listed on the claim form. When the ICD-9 code does not reflect the patient’s true condition, they are being labeled with something they do not have and in some cases, a wrong diagnosis can affect the patient’s health or life insurance policy. ©2010 PHIA/Medical Staff SOS, Inc.

Mistake # 6 Not using an LCD
Always reference the LCD! Determine the diagnosis you are reporting is an approved diagnosis by Medicare. This also substantiates medical necessity. Last but not least, mistake # 6 – Not using the LCD The Local Coverage Determination(LCD) manual is an administrative and educational tool that is used to assist providers and suppliers in submitting correct claims for payment. These policies are developed by a Carrier Advisory Committee (CAC), which consists of physicians representing different medical specialties, a beneficiary representative, and representatives from other medical organizations. These policies are developed and enforced on a state-by-state basis. Each procedure listed in CPT has a corresponding LCD showing each ICD-9 code that is approved by Medicare and supports medical necessity. Claims that are submitted without a code that is listed in the LCD will be denied. The patient’s medical record documentation must fully support the medical necessity for reporting the ICD-9 code found in the LCD. A physical copy of LCD’s can be obtained from the hospital the physician most closely works with or you can review the electronic file on the CMS website. ©2010 PHIA/Medical Staff SOS, Inc.

 Always report current diagnoses only.
 Choose the correct order to report the diagnoses.  Do not bill a chronic condition if it is not documented for this date of service.  Properly link CPT and ICD-9 codes to clearly show medical necessity.  Report what is documented in the assessment, not what is written on the fee ticket.  Use the LCD! RE-CAP importance of each and the importance of obtaining further education for yourself and encourage your providers to obtain further education as well in ICD-10 so everyone will be prepared for the change in October 2013. ©2010 PHIA/Medical Staff SOS, Inc.

Additional Resources www.ncvhs.hhs.gov/070730p4.pdf
TransactionsandCodeSetsRegulations.asp ©2010 PHIA/Medical Staff SOS,. Inc

Medical Staff SOS, Inc./PHIA
Sherry Thomas, CEO/ Director of Education Certified Coding Professional (CCP) Certified Coding Professional – Audit Specialist (CCP-AS) 30 years experience in healthcare Clinical, Administrative, Education Services includes: Chart Auditing Healthcare Seminars/Workshops Qualified IRO - Integrity Agreements National Credentialing Organization ONLINE Coding/Billing Courses (Certification/Diploma) Provider/Staff Education ©2010 PHIA/Medical Staff SOS,. Inc

Thank you for joining me today!
For additional information please contact: SHERRY THOMAS, CCP, CCP-AS CEO/Director of Education Medical Staff SOS, Inc./ PHIA ©2010 PHIA/Medical Staff SOS,. Inc

Sherry Thomas, CCP, CCP-AS CEO/Director of Education

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