Transcript Obstetrics and Gynecology - South Texas Health System

UHS, Inc.
ICD-10-CM/PCS
Physician Education
Obstetrics and Gynecology
1
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
2
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– Outdated: 30 years old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
3
Diagnosis Code Structure
4
ICD-10-CM Diagnosis Code Format
5
Comparison: ICD-9 to ICD-10-CM
6
Procedure Code Structure
ICD-10-PCS Code Format
8
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?
9
ICD-10-CM/PCS
Documentation Tips
10
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
11
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
12
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
13
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
14
ICD-10 Documentation Tips
Site and Laterality – right versus left
–bilateral body parts or paired organs
Example – right fallopian tube
Stage of disease
–Acute, Chronic
–Intermittent, Recurrent, Transient
–Primary, Secondary
–Stage I, II, III, IV
Example – chronic kidney disease, stage II
15
ICD-10 Documentation Tips
Female Reproductive
– Inflammatory Disease
• Examples - Salpingitis, Oophoritis, PID
•
•
•
•
Severity – acute, subacute, chronic
Manifestation / cause / underlying condition
Pelvic adhesions causing the disorder or exacerbating
Current or past antineoplastic therapy or radiological procedures
– Non-inflammatory Disease
•
•
•
•
•
–
Examples – Endometriosis, Prolapse, Dysplasia
Post-surgical state
Post-surgical complication
Location
Acuity – mild, moderate, severe
Origin of infertility
• Tubal, uterine, other
16
ICD-10 Documentation Tips
Female Reproductive continued
– Prolapse
• Classification
– Urethrocele
– Cystocele
– Rectocele
– Vaginal enterocele
• Location – lateral or midline
• Severity
– Incomplete / First degree
– Incomplete / Second degree
– Complete / Third degree
17
ICD-10 Documentation Tips
Neoplasm
– Location
• Detailed location
• Left, Right, Bilateral
– Morphology
•
•
•
•
Malignant, Benign
Primary , Secondary
In situ
Uncertain behavior, Unspecified behavior
– Histology
• Identified by cytology, histology or pathology findings
– Stage / Metastatic
• Different, distinct locations
– Different primaries
– Metastatic sites
18
ICD-10 Documentation Tips
Neoplasm continued
– Is patient being admitted for treatment of the
neoplasm or an adverse reaction / complication?
• Treatment - surgery, chemotherapy, immunotherapy, radiation
• Adverse reaction of treatment – neutropenic fever secondary to
chemo
• Complication of the disease – anemia due to malignancy
– Document if a complication is part of the disease
process or an adverse effect of treatment
• Anemia due to malignancy or due to chemotherapy
– History of
• Malignancies previously removed and no longer receiving active
treatment
• Clearly document for follow-up and medical surveillance
19
ICD-10 Documentation Tips
Pregnancy
ICD-10-CM definitions of trimesters:
• First trimester = less than 14 weeks, 0 days
• Second trimester = 14 weeks, 0 days to less than 28
weeks, 0 days
• Third trimester = 28 weeks until delivery
– Documentation of conditions/complications of pregnancy
will need to specify the trimester in which the condition
occurred.
• If the condition develops prior to admission, assign the trimester at the
time of admission.
20
ICD-10 Documentation Tips
Pregnancy continued
– Past infertility / poor reproductive history
• Abortive outcomes
– Ectopic
– Hydatidiform mole
– Abnormal products of conception (e.g. - blighted ovum)
– Spontaneous abortion
– Induced termination of pregnancy
» Specify abortive agent or method used
– Failed attempted termination of pregnancy
– Incomplete abortion
• Pre-term labor
– Pregnancy induced conditions
• Pregnancy induced hypertension
– document acuity of pre-eclampsia (mild, moderate or severe)
• Gestational diabetes
– needs specification of diet controlled or insulin controlled
21
ICD-10 Documentation Tips
Diabetes - include the type or cause of diabetes
–
–
–
–
–
–
Type I
Type II
Due to drugs and chemicals
Due to underlying condition
Other specified diabetes
Link any manifestations to the diabetes
•
Circulatory, renal, neurological, ophthalmic, skin, other
Use of Insulin – long term, current
Example:
•E08 - Diabetes mellitus due to underlying condition
–
–
E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
22
ICD-10 Documentation Tips
Pregnancy continued
– High risk pregnancy
•
•
•
•
History of infertility
Ectopic or molar pregnancy
Substance abuse
Insufficient care
– Specify any pre-existing condition, infection or
disorder
•
•
•
•
HIV
Smoking
Anemia
Hypertension
23
ICD-10 Documentation Tips
Labor and Delivery
– Labor is categorized by weeks of gestation
• Pre-term = before 37 weeks gestation
• Post-term = over 40 weeks but less than 42 weeks gestation
• Prolonged = over 42 weeks gestation
– Document specifics of delivery
• Outcome of delivery
• List method of delivery
– Specify instrumentation used
– Severity of any perineal laceration and level of repair
• Method of labor induction if applicable
• Malposition, malpresentation
– Include if obstructed or non-obstructed
– If obstructed, what is the condition causing the obstruction of
labor
» Large fetus, locked twins, etc.
24
ICD-10 Documentation Tips
Labor and Delivery continued
– Reason for C-section, if performed
• List past history of C-section, when applicable
– Complications of anesthesia
•
•
•
•
•
•
•
Aspiration pneumonitis
Pressure collapse of lung
Cardiac complication
CNS complication
Toxic reaction to local anesthesia
Spinal / epidural headache
Failed or difficult intubation
25
ICD-10 Documentation Tips
Fetal Anomalies
– Multiples
• Number of fetuses (numeric designation of 1 -9)
– include number of placenta and number of amniotic sacs
• Identify fetus with complication with assigned number
– Fetal conditions
•
•
•
•
Central nervous system malformation
Chromosomal abnormality
Hereditary disease
Damage to fetus due to viral disease, alcohol, drugs, radiation,
medical procedure
• Isoimmunization – Rh, ABO, other
26
ICD-10 Documentation Tips
Puerperium
– Retained placenta
• With or without membranes
– Infection
• Cesarean wound infection
• UTI
• Endometritis
– Other conditions requiring treatment
•
•
•
•
•
•
Disruption of obstetric wound
Postpartum mood disturbance
Post-delivery anemia
Abscess of the breast
Mastitis
Retracted or cracked nipple
27
ICD-10 Documentation Tips
Weight-related diagnoses and BMI
BMI < 19
BMI > 40
• For malnutrition, specify type
(e.g. - protein-calorie
malnutrition) and severity
(indicate mild, moderate,
severe)
• Overweight versus obesity,
specify if severe or morbid
• Link to the cause
• Document if drug-induced and
provide the specific drug
• Document “starvation” in abuse
cases
• Bariatric procedures performed
• Link other illnesses
• Associated conditions (example
– obesity hypoventilation
syndrome)
28
ICD-10 Documentation Tips
Drug Under-dosing
is a new code in ICD-10-CM.
– It identifies situations in which a patient has taken less of a
medication than prescribed by the physician.
• Intentional versus unintentional
– Documentation requirements include:
• The medical condition
• The patient’s reason for not taking the medication
– example – financial reason
– Z91.120 – Patient’s intentional underdosing of
medication due to financial hardship
29
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
30
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
31
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:
Abortion – artificially Excision – cutting out
terminating a
or off, without
pregnancy
replacement a portion
of a body part
Resection – cutting Restriction –
out or off, without partially closing an
replacement, all of orifice
a body part
Delivery – assisting
the passage of
products of
conception from the
birth canal
Extraction – pulling or
stripping out or off all
or a portion of a body
part
Reposition – moving to its normal
location/other location all or portion of a
body part
Dilation – expanding
an orifice
Occlusion – completely Supplement – putting in biological or
closing an orifice
synthetic material that physically
reinforces &/or augments the function
Drainage – taking or
letting out fluids
&/or gases from a
body part
Repair – restoring, to
Transplantation – putting in all or a
the extent possible, a
portion of a living body part taken from
body part to its normal another individual or animal
anatomic structure &
function
33
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
34