Transcript Orthopaedics - South Texas Health System

UHS, Inc.
ICD-10-CM/PCS
Physician Education
Orthopaedics
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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– Outdated: 30 years old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 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 vs. chronic vs. acute on chronic
Example – stage of pressure ulcer:
– L89.011 Pressure ulcer of right elbow, stage 1
– L89.021 Pressure ulcer of left elbow, stage 1
Episode of care – initial, subsequent, and sequelae
Example - lower leg fracture:
–
–
–
–
–
A initial encounter for closed fracture
B initial encounter for open fracture type I or II
C initial encounter for open fracture type IIIA, IIIB, or IIIC
D subsequent encounter for closed fracture with routine healing
H subsequent encounter for open fracture type I or II with delayed
healing
– K subsequent encounter for closed fracture with nonunion
– S sequelae
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ICD-10 Documentation Tips
Fractures – clearly document all aspects
– Cause – traumatic, stress, pathological
– Location – which bone, where on the bone, laterality
– Type – compound, delayed, union, depressed, elevated,
greenstick, impacted, oblique, etc.
• If open – use Gustilo classification
– Displacement – displaced or non-displaced
– Encounter – initial, subsequent, sequelae
• Healing process – routine aftercare, delayed, nonunion, malunion
– External cause – how the fractured occurred and the activity
• Example - Fall while skiing
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ICD-10 Documentation Tips
Open fractures - Please specify the severity using the
Gustilo-Anderson Open Fracture Classification system for
forearm, femur, and lower leg
–
Type I: The wound is smaller than 1 cm, clean, and generally caused by a
fracture fragment that pierces the skin (i.e., inside-out injury).
–
Type II: The wound is longer than 1 cm, not contaminated, and without major
soft tissue damage or defect. This is also a low-energy injury.
–
Type III: The wound is longer than 1 cm, with significant soft tissue disruption.
The mechanism often involves high-energy trauma, resulting in a severely
unstable fracture with varying degrees of fragmentation.
–
Type III fractures are further divided into
• III A: Soft tissue coverage of the fractured bone is adequate.
• III B: Disruption of the soft tissue is extensive, that local or distant flap
coverage is necessary.
• III C: Any open fracture that is associated with an arterial injury that a
physician must repair, regardless of the degree of soft tissue injury.
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ICD-10 Documentation Tips
Pathologic (non-traumatic) fractures:
– Exact location of fracture –
• Bone, part of the bone, and laterality
– Etiology of the fracture –
• osteoporosis, neoplastic disease, drug induced
– Encounter type –
• initial encounter, subsequent encounter with routine
healing, subsequent encounter with delayed healing,
malunion, nonunion, or sequelae
– Healing status –
• Routine, delayed, nonunion, malunion
• Any past history of healed pathological fractures
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ICD-10 Documentation Tips
Arthropathies
•Type
–Traumatic
–Infectious – document specific organism
•Site – include laterality (right, left, bilateral)
•Link underlying or associated conditions
–Bone changes related to DM
•Examples:
–Traumatic arthropathy, left shoulder
–Arthropathy following intestinal bypass, left shoulder
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ICD-10 Documentation Tips
Bursa Disorders
•Type
–Bursitis
–Bursopathy
• Abscess of bursa
• Infective bursitis
• Synovial cyst
• Bursal cyst
• Calcium deposit
•Site – bursa affected and laterality (right, left, bilateral)
•Link underlying or associated conditions
–Activity causing the disorder
–Related to use, overuse, pressure, post-procedural complication
–Rupture of synovial or bursa cyst
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ICD-10 Documentation Tips
Osteomyelitis
•Site – include laterality (right, left, bilateral)
•Severity / Type
–Acute, chronic, subacute
–Hematogenous
•Link underlying or associated conditions
–Multifocal osteomyelitis
–With or without draining sinus
–Chronic hematogenous
–Major osseous defect
•Document if any associated injury is current or old
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ICD-10 Documentation Tips
Osteoarthritis
•Site – joint affected
– include laterality (right, left, bilateral)
•Severity / Type
–Acute, chronic, subacute
–Hematogenous
•Link underlying or associated conditions
–Presence or absence of hip dysplasia
–Polyosteoarthritis
•Document if any associated injury is current or old
–Primary, secondary, or post-traumatic
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ICD-10 Documentation Tips
Rheumatoid Arthritis
•Site
•Laterality
•Link manifestations
–With or without Rheumatoid Factor
–Felt’s syndrome
–Rheumatoid lung disease
–Rheumatoid vasculitis
–Rheumatoid heart disease
–Rheumatoid polyneuropathy
–With involvement of other organs or systems
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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
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ICD-10 Documentation Tips
Cause of Injury
– Mechanism
• How it happened
– Place of occurrence
• Where it happened
– Activity
• What was the patient doing
– External Cause
• Work-related, leisure
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ICD-10 Documentation Tips
Glasgow Coma
- ICD-10-CM coding will need the score from
each of the
assessment areas
– Eye opening
– Verbal response
– Motor response
»
»
»
»
R40.211 Coma scale, eyes open never
R40.212 Coma scale, eyes open to pain
R40.213 Coma scale, eyes open to sound
R40.214 Coma scale, eyes open spontaneously
–Report the Glasgow coma scale total score
» R40.241 Glasgow coma scale score 13 – 15
» R40.242 Glasgow coma scale score 9 - 12
» R40.243 Glasgow coma scale score 3 – 8
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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:
Detachment – cutting
off all or part of the
upper or lower
extremity
Fusion – joining
together portions of
an articular body
part, rendering the
body part immobile
Replacement –
putting in or on a
biological or
synthetic material
that takes the place
&/or function
Transfer – moving,
without taking out,
all of a portion of a
body part to another
location
Division – cutting into
a body part without
draining fluids &/or
gases in order to
separate / transect
the body part
Reattachment –
Reposition – moving to its normal location
putting back in or on or other suitable location a body part
all or a portion of a
separated body part
Drainage – taking or Repair – restoring,
Supplement – putting in or on biological or
letting out fluids &/or to the extent
synthetic material that physically
gases
possible, a body part reinforces &/or augments function
to its normal
function
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ICD-10 Documentation Tips
Approaches:
External
Via Natural or Artificial
Opening
Open
Via Natural or Artificial
Opening Endoscopic
Percutaneous
Via Natural or Artificial
Opening Endoscopic with
Percutaneous Endoscopic
Assistance
Percutaneous Endoscopic
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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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