Transcript Neonatal and Pediatrics - South Texas Health System

UHS, Inc.
ICD-10-CM/PCS
Physician Education
Neonatal and Pediatrics
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ICD-10 Implementation
• October 1, 2015 – Compliance date for
implementation of ICD-10-CM (diagnoses) and
ICD-10-PCS (procedures)
– Ambulatory and physician services provided on or after
10/1/15
– Inpatient discharges occurring on or after 10/1/15
• ICD-10-CM (diagnoses) will be used by all
providers in every health care setting
• ICD-10-PCS (procedures) will be used only for
hospital claims for inpatient hospital procedures
– ICD-10-PCS will not be used on physician claims, even
those for inpatient visits
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Why ICD-10
Current ICD-9 Code Set is:
– Outdated: 30 years old
– Current code structure limits amount of
new codes that can be created
– Has obsolete groupings of disease
families
– Lacks specificity and detail to support:
• Accurate anatomical positions
• Differentiation of risk & severity
• Key parameters to differentiate disease
manifestations
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Diagnosis Code Structure
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ICD-10-CM Diagnosis Code Format
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Comparison: ICD-9 to ICD-10-CM
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Procedure Code Structure
ICD-10-PCS Code Format
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ICD-10 Changes Everything!
• ICD-10 is a Business Function Change, not just
another code set change.
• ICD-10 Implementation will impact everyone:
– Registration, Nurses, Managers, Lab, Clinical Areas,
Billing, Physicians, and Coding
• How is ICD-10 going to change what you do?
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ICD-10-CM/PCS
Documentation Tips
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ICD-10 Provider Impact
• Clinical documentation is the foundation of successful ICD10 Implementation
• Golden Rule of Documentation
– If it isn’t documented by the physician, it didn’t happen
– If it didn’t happen, it can’t be billed
• The purpose in documentation is to tell the story of what
was performed and what is diagnosed accurately and
thoroughly reflecting the condition of the patient
– what services were rendered and what is the severity of illness
• The key word is SPECIFICITY
– Granularity
– Laterality
• Complete and concise documentation allows for accurate
coding and reimbursement
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Gold Standard Documentation Practices
1.
Always document diagnoses that contributed to the reason for
admission, not just the presenting symptoms
2.
Document diagnoses, rather that descriptors
3.
Indicate acuity/severity of all diagnoses
4.
Link all diseases/diagnoses to their underlying cause
5.
Indicate “suspected”, “possible”, or “likely” when treating a
condition empirically
6.
Use supporting documentation from the dietician / wound care to
accurately document nutritional disorders and pressure ulcers
7.
Clarify diagnoses that are present on admission
8.
Clearly indicate what has been ruled out
9.
Avoid the use of arrows and symbols
10. Clarify the significance of diagnostic tests
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ICD-10 Provider Impact
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and
anatomic sites
4.Etiology – causative disease or contributory drug, chemical,
or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or
accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition
or disease process
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ICD-10 Provider Impact
Newborn Documentation:
1.Gestational age / prematurity
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Extreme immaturity – less than 28 weeks gestation
Preterm – 28 weeks or more but less than 37 weeks gestation
Post-term – 40 – 42 weeks gestation
Prolonged – more than 42 weeks gestation
2.Weight
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Extremely low birth weight – less than 999 grams
Low birth weight – 1000 – 2499 grams
Heavy – 4000 – 4499 grams
Exceptionally large – 4500 grams or more
3.Abnormalities in fetal size and health
4.Differentiate community-acquired versus conditions related
to the birthing process
5.Abnormal results from neonatal screenings
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ICD-10 Provider Impact
Newborn – birth to 28 days of life
Document any condition (even those that may impact
future healthcare needs) that requires:
1.
Further clinical evaluation
2.
Therapeutic treatment
3.
Diagnostic procedure
4.
An extended length of hospital stay
5.
Increase in nursing care and / or monitoring
Document maternal conditions that impact the
health of the baby
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ICD-10 Documentation Tips
Do not use symbols to indicate a disease.
For example “↑lipids” means that a laboratory result
indicates the lipids are elevated
– or “↑BP” means that a blood pressure reading is high
These are not the same as hyperlipidemia or hypertension
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ICD-10 Documentation Tips
Site and Laterality – right versus left
–bilateral body parts or paired organs
Example – cellulitis of right upper arm
Stage of disease
–Acute, Chronic
–Intermittent, Recurrent, Transient
–Primary, Secondary
–Stage I, II, III, IV
Example – stage of pressure ulcer:
– L89.011 Pressure ulcer of right elbow, stage 1
– L89.021 Pressure ulcer of left elbow, stage 1
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ICD-10 Documentation Tips
Birth Injury
–Site and type of trauma
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–
–
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Birth injury to facial nerve
Fractured clavicle due to birth process
Subdural hemorrhage related to birth injury
Erb’s palsy
–Contributing factors
– Scalp of facial bruising due to forceps
– Injury to scalp due to monitoring equipment
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ICD-10 Documentation Tips
Feeding Problems
– Specify related conditions and the feeding problem
– Vomiting
» bilious or other
– Regurgitation
– Rumination
– Slow feeding
– Underfeeding
– Overfeeding
– Difficulty with breast feeding
– Failure to thrive
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ICD-10 Documentation Tips
Neonatal Jaundice
– Specify cause
– Associated with preterm delivery
– Due to:
» Infection
» Polycythemia
» Swallowed maternal blood
» Drugs or toxins
» Excessive hemolysis
» Breast milk inhibitor
» Hepatocellular damage
– Document type of hepatitis, if applicable
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ICD-10 Documentation Tips
Noxious Influences
– Specify condition
• Withdrawal symptoms
• Alcoholic fetor
• Allergic reaction
– Specify substance
– Prescribed or illicit drugs
– Alcohol
– Smoking
– Specify exposure
– Via the placenta, maternal use
– Administered during labor and delivery
– Given directly to newborn
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ICD-10 Documentation Tips
Respiratory
– If disease if unknown, document the signs and symptoms
– If known, document the most specific disease
– Neonatal aspiration
» Meconium, amniotic fluid, mucus, blood
» Aspiration of mild or regurgitated food
– Respiratory Distress Syndrome
» Type I or Type II
– Respiratory Failure
– Respiratory Arrest
– Newborn apnea
» Primary obstructive, cyanotic attacks, apnea of
prematurity
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ICD-10 Provider Impact
Congenital Malformation Documentation:
1.Congenital and chromosomal anomalies that impact
throughout the patient’s life
2.Laterality
•Right, left, bilateral
3.Anatomical site and malformation, deformity, abnormality
4.Associated manifestations
5.Surgically corrected congenital malformation
•Document as history of
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ICD-10 Provider Impact
Chromosomal Abnormality Documentation:
1.Specific chromosome anomaly
•
Down syndrome, trisomy 18, Turner’s
2.Mosaic
•
Non-mosaicism, mosaicism, translocation
3.Associated physical conditions and degree of mental
retardation
4.Metabolic disorders
5.Associated duplications or deletions
•
Due to unbalanced translocations, inversions and insertions related
to complex rearrangements
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ICD-10 Documentation Tips
Codes for postoperative complications have been expanded and a
distinction made between intraoperative complications and postprocedural disorders
•The provider must clearly document the relationship between the
condition and the procedure
–
Example:
• D78.01 –Intraoperative hemorrhage and hematoma of spleen
complicating a procedure on the spleen
• D78.21 –Post-procedural hemorrhage and hematoma of spleen following
a procedure on the spleen
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ICD-10 Documentation Tips
Intra-operative
Post-procedural
Accidental puncture / laceration
Timing:
•Post-procedure
•Late effect
Same or different body system
Classify as:
•An expected post-procedural
condition
•An unexpected post-procedural
condition, related to the
patient’s underlying medical
comorbidities
•An unexpected post-procedural
condition, unrelated to the
procedure
•An unexpected post-procedural
condition related to surgical care
(a complication of care)
Blood product
Central venous catheter
Drug:
•What adverse effect
•Drug name
•Correctly prescribed
•Properly administered
Encounter:
•Initial
•Subsequent
•Sequelae
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ICD-10 Documentation Tips
ICD-10-PCS does not allow for unspecified
procedures, clearly document:
• Body System
– general physiological system / anatomic region
• Root Operation
– objective of the procedure
• Body Part
– specific anatomical site
• Approach
–
technique used to reach the site of the procedure
• Device
– Devices left at the operative site
ICD-10 Documentation Tips
Most Common Root Operations:
Destruction – physical eradication of all Excision – cutting out or off, without
or a portion of a body part by direct use replacement, a portion of a body part
of energy, force, or destructive agent
Drainage – taking or letting out fluids
&/or gases from a body part
Repair – restoring, to the extent possible, a
body part to its normal anatomic structure
& function
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Summary
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and
anatomic sites
4.Etiology – causative disease or contributory drug, chemical,
or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or
accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition
or disease process
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