Transcript Internal Medicine and Family Practice

UHS, Inc.
ICD-10-CM/PCS
Physician Education
Internal Medicine and Family Practice
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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– Outdated: 30 years old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
Signs & Symptoms – document underlying cause /
conditions
Admit with sign / symptom
Discharge with a Diagnosis
Fever
Underlying condition (due to)
Infection type (example: pneumonia)
Chest pain
Underlying condition (due to)
• GERD
• Atelectasis
• Costochondritis
• Pleurisy
• Cholecystitis
• AMI
Altered Mental Status
Underlying cause
• Encephalopathy
• UTI
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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
Asthma
–
Specificity
•
•
•
•
Intermittent [less than or equal to two times per week]
Mild persistent [more than two times per week]
Moderate persistent [daily-may restrict physical activity]
Severe persistent [throughout the day-frequent severe attacks that limit
the ability to breathe]
– Acuity
• With acute exacerbation
• With status asthmaticus
– Type / Form
•
•
•
•
Childhood
Exercise induced
Extrinsic allergenic
Late onset
– Tobacco Exposure
• Exposure to environmental tobacco smoke
• History of tobacco use
• Occupational exposure to tobacco smoke
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ICD-10 Documentation Tips
COPD
–
Acuity
• With acute exacerbation
• With acute lower respiratory infection
– Specificity
• With asthma
• With bronchitis
• With emphysema
– Tobacco Exposure
• Exposure to environmental tobacco smoke
• History of tobacco use
• Occupational exposure to tobacco smoke
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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
•E11 - Type 2 diabetes mellitus
–
–
E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema
E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular
edema
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ICD-10 Documentation Tips
Encephalopathy
– Acuity – acute, subacute, chronic
– Severity – with or without coma
– Type
•
•
•
•
•
•
•
Alcoholic
Hepatic
Hypertensive
Metabolic
Septic
Toxic
Due to disease classified elsewhere
– Due to influenza, syphilis, hydrocephalus, neoplastic disease, etc…
– Link altered mental status to encephalopathy with the
specific type
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ICD-10 Documentation Tips
Heart Failure
– Specify acuity
•
•
•
Acute
Chronic
Acute on chronic
– Identify type
•
•
•
Systolic
Diastolic
Combined systolic and diastolic
– List relationship of hypertension to heart failure or heart
disease
– Identify underlying cause
»
Example - Exacerbation of stable heart failure due to fluid overload or
due to missed dialysis
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ICD-10 Documentation Tips
Kidney Disease
– Specify acuity
•
Acute, Chronic, Acute on chronic
– Identify stage
•
•
•
•
•
Stage I – GFR > 90
Stage II – GFR 60 – 89
Stage III – GFR 30 – 59
Stage IV – GFR 15 – 29
Stage V – GFR < 15
– List relationship of hypertension &/ or diabetes
» Document as due to or with
»
Example – Type 2 DM with diabetic CKD stage 5
– Transplant Status – has the patient had a transplant or is a
transplant candidate
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ICD-10 Documentation Tips
Otitis Media
– Type
•
•
•
•
•
Serous
Sanguinous
Suppurative
Allergic
Mucoid
– Infectious Agent
•
•
•
•
Strep
Staph
Influenza
Measles, Mumps
– Laterality – left, right, both
– Note whether tympanic membrane is ruptured
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ICD-10 Documentation Tips
Malnutrition
– Specify acuity – mild, moderate, severe
– Specify type
•
•
•
•
Protein calorie
Protein energy
Marasmus
Nutritional deficiency
– At least 2 of the following are required to help identify
malnutrition:
•
•
•
•
•
•
Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized / generalized fluid accumulation
Diminished functional status as measure by hand grip strength
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ICD-10 Documentation Tips
Weight-related diagnoses and BMI
BMI < 19
BMI > 40
• For protein-calorie malnutrition, • Obesity, specify severe or
indicate mild, moderate, severe
morbid
• Document “starvation” in abuse • Link to the cause
cases
• Document if drug-induced and
• Link other illnesses
provide the specific drug
• Bariatric procedures performed
• Associated conditions (example
– obesity hypoventilation
syndrome)
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ICD-10 Documentation Tips
Pneumonia
– Organism, document as known or suspected
• Viral – adenoviral, respiratory syncytial, parainfluenza, human
metapneumovirus, viral unspecified
• Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas,
staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified
– Link associated conditions
• Influenza with secondary gram negative pneumonia
• Sepsis due to pneumonia
• Acute respiratory failure due to pneumonia
– Aspiration
• Due to solids or liquids
• Due to anesthesia during L/D or procedure
• Due to anesthesia during puerperium
– Laterality of lung involvement – left, right, both
– Note whether ventilator associated (VAP)
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ICD-10 Documentation Tips
Pressure Ulcers
– Site – specific ulcer location
• Ankle, back, buttock, coccyx, elbow, face, head, heel, hip, sacral region,
other site
– Laterality – left, right, both
– Stage
• 1 – pre-ulcer skin changes limited to persistent focal edema
• 2 – abrasion, blister, partial thickness skin loss involving epidermis &/or
dermis
• 3 – full thickness skin loss involving damage or necrosis of
subcutaneous tissue
• 4 – necrosis of soft tissue through to underlying muscle, tendon or
bone
• Unspecified – not documented
• Unstageable – full thickness tissue loss, covered with slough or eschar
– Note whether the pressure ulcer was present on
admission
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ICD-10 Documentation Tips
Respiratory Failure
– Acuity - acute, chronic, acute on chronic
– Specificity – with hypoxia or hypercapnia
– Tobacco Use
• Exposure to environmental tobacco smoke
• History of tobacco use
• Occupational exposure to tobacco
– Does the patient require continuous home oxygen or is
dependent on home oxygen
– Respiratory distress and respiratory insufficiency are NOT
respiratory failure
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ICD-10 Documentation Tips
Respiratory Failure Criteria
Acute
Chronic
Symptoms – difficulty breathing, shortness of
breath, dyspnea, tachypnea, respiratory
distress, labored breathing, use of accessory
muscles, cyanosis, unable to speak
Symptoms – severe COPD, chronic lung
disease such as cystic or pulmonary
fibrosis
Ph < 7.35 & pCO2 > 50 or pO2 < 55 & FIO2 >
28 %
pO2 < 55 or pCO2 > 50
Hypoxemia
Hypercapnia
pO2 < 60 mmHg
OR
pO2 / FIO2 ratio < 300 OR
10 mmHg decrease in baseline pO2
pCO2 > 50mmHg with pH < 7.35
OR
10 mmHg increase in baseline pCO2
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ICD-10 Documentation Tips
Sepsis
– Acuity – sepsis, severe sepsis, septic shock, SIRS
– Organism due to / suspected
•Streptococcus (A or B)
•Staphylococcus aureus
•MSSA
•MRSA
•Hemophilus influenzae
•Gram-negative organism
•E Coli
•Serratia
•Enterococcus
– Manifestations
•With acute organ dysfunction
•With multiple organ dysfunction
•SIRS due to infectious process with organ dysfunction
•Shock
– Note the term urosepsis is NOT synonymous with sepsis
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ICD-10 Documentation Tips
Sepsis Criteria
–Altered mental status
–Heart rate > 90 beats per minute
–Hypoxemia
–PaCO2 < 32mmHg
–Respiratory rate > 20 breaths per minute
–Temperature > 100.9 F or < 96.8 F
–WBC > 12,000 cells/mm3; < 4,000 cells/mm3; and/or >
10% immature band
–Blood cultures do not need to be positive to support
the diagnosis of sepsis – the physician may clinically
diagnose based on signs and symptoms
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ICD-10 Documentation Tips
Strokes – dominant vs. non-dominant side
– Specify the location or source of the hemorrhage and
laterality
– Document other causes – thrombosis, embolism, occlusion,
stenosis
• Sites – precerebral or cerebral arteries
• Laterality
– Document dominant verses non-dominant side for all
paralytic syndromes such as hemiplegia, monoplegia and
hemiparesis and for residual effects
Example: previous cerebrovascular infarction 6 months ago
with residual left-sided hemiparesis on his nondominant
side.
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ICD-10 Documentation Tips
Drug and Alcohol Use
– Expanded code set to classify cause-and-effect indicators
– Documentation requirements include:
• Specific aspects of the effects
– Example – abuse and dependence
• Specify the aspects of use
– Example – withdrawal state
• Identify manifestations
– Example – hallucinations, delusions
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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
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 of a portion of a body part
by direct use of energy, force or destructive agent
Drainage – taking or letting out fluids &/or gases from a body part
Excision – cutting out or off, without replacement, a portion of a
body part; diagnostic or therapeutic
Repair – restoring to the extent possible, a body part to its
anatomic structure and 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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