Transcript Hematology and Oncology - South Texas Health System

UHS, Inc.
ICD-10-CM/PCS
Physician Education
Hematology and Oncology
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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– Outdated: 30 years old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)
Neutropenic fever
Neutropenic sepsis
Pain
Underlying condition (due to)
•Neoplasm
•Other cause
Treatments – pain pumps, intrathecal
treatments, etc.
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
Stage of disease
–Acute, Chronic
–Intermittent, Recurrent, Transient
–Primary, Secondary
–Stage I, II, III, IV
Disease Status
–Current disease, in treatment
–History of disease, treatment complete
–Also include family history
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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
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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
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ICD-10 Documentation Tips
Breast Neoplasm
– in addition to information on previous slides, also
include:
– Location
• Must include the quadrant of the breast
– Gender
• Specify clearly if patient is a male or female
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ICD-10 Documentation Tips
Leukemia
– Acuity
• Acute, chronic
– Type
•
•
•
•
Acute lymphoblastic
Chronic lymphocytic
Hairy cell
Adult T-cell
– Disease Status
• Remission not achieved
• In remission
• In relapse
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ICD-10 Documentation Tips
Lymphoma
– Classify based on histiologic type with lymph node,
extranodal and solid organ involvement
– Hodgkin examples
• Nodular lymphocytic predominat
• Mixed cellularity classical
• Lymphocytic-rich classical
– Follicular examples
• Grade I – IIIb
• Cutaneous follicle center
• Diffuse follicle center
– Non-follicular examples
• Small B-cell
• Diffuse large B-cell
• Lymphoblastic
– Mature T/NK-Cell
• Mycosis fungoides
• Anaplastic large cell, ALK-
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ICD-10 Documentation Tips
Anemia
– Type
• Nutritional – iron deficiency, vitamin B12 deficiency
• Hemolytic – enzyme disorder, thalassemia
– Acquired versus hereditary
• Aplastic – drug induced, idiopathic
– Cause / Underlying disease
•
•
•
•
Post hemorrhagic
Drug induced
Malignancy
Manifestation of adverse effect or poisoning
– Example – neoplasm, kidney disease
– Document if part of the disease process, or an adverse
effect of treatment
• Anemia due to malignancy or chemotherpay
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ICD-10 Documentation Tips
Sickle Cell Anemia
– Type
•
•
•
•
Hb-SS
Thalassemia
HB-C
Trait
– Sickle-cell crisis
• Specify with or without crisis
• If in crisis, document manifestations
– Acute chest syndrome
– Splenic sequestration
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ICD-10 Documentation Tips
Coagulation
– Type
• Hemorrhagic Disorder
• Coagulation defect
– Cause
• Hereditary
• Acquired
– Document underlying or associated disease
– Specify medications or drug use affiliated with
manifestations
• Hematuria due to Coumadin
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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
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:
Bypass – altering the route Excision – cutting out or off,
of passage of the contents without replacement a
of a tubular body part
portion of a body part
Reposition – moving to its
normal location all or a
portion of a body part
Control – stopping or
attempting to stop, postprocedural bleeding
Release – freeing a body part
from an abnormal physical
constraint
Resection – cutting out or off,
without replacement, all of a
body part
Division – cutting into a
body part without draining
fluids &/or gases in order
to separate or transect the
body part
Repair – restoring, to the
extent possible, a body part
to its normal anatomic
structure & function
Restriction – partially closing
an orifice or the lumen of a
tubular body part
Drainage – taking or letting Replacement – putting in or on a biological or synthetic
out fluids &/or gases from material that physically takes the place and/or function of all
a body part
or a portion of a body part
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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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