Transcript Notes 1 - Georgia Chiropractic Association

Revisiting ICD-10
May 21, 2016
ICD-10 at a glance
More codes
Longer codes –up to 7 alpha/numeric
Injury codes are grouped by anatomical site (rather than the category of injury).
More divisions (21 chapters).
Higher specificity; distinguishes between: Right and left
Initial encounter, subsequent encounter, sequela
↑coding specificity for statistical analysis & research.
Is there an easy equivalence map between 9 and 10?
NO one-to-one match. But there is a “crosswalk”–http://www.nber.org/gem/GEMsCrosswalksBasicFAQ.pdf
BEWARE:
“In coding individual claims, it will be more efficient and accurate to work
from the medical record documentation and then select the appropriate
code(s) from the coding book or encoder system.”
“The GEMs are not a substitute for learning how to use the ICD-10-CM.”
ICD Linkage to CPT
• ICD codes form a crucial partnership with CPT procedural codes.
The ICD codes indicate the reason why the CPT procedure or
service was performed. ICD codes can also indicate what level
CPT was performed and why.
• Diagnosis to procedure edits are among the most common type
of edits applied to claims.
• The selection of the primary diagnosis for a patient encounter is
usually “the reason the physician saw the patient that day” and
is not necessarily the patient’s most serious condition
Basic Coding Principles
• It is important that you are coding based upon what
you have documented in your patient’s records
• Code by subluxation first as mandated (ie. Medicare)
• Symptoms and ill-defined conditions can be used but
only in the absence of a definitive primary diagnosis
Basis Coding Principles cont…
• Injuries: When coding an injury, reference the condition, not just
the anatomical site.
• Choose specific diagnoses: Avoid codes for diagnoses that
include the words not otherwise specified or not elsewhere
classified (unless it is your only choice until more conclusive test
results are received)
• Select codes to their highest level of specificity
• Non-relevant conditions: Do not code conditions which are not
related to the current reason for the patient encounter
Coding Co-Morbidities
• Providers tend not to include Co-morbidities in the diagnoses.
However, if it can have a direct relation to the patient’s
progress and/or if it can “explain” the choice of care for the
patient, then it should be documented in the patient’s chart
and can be included as a diagnosis (depending on the carrier).
• Ie. Obesity, Diabetes, and Hypertension are just a few
examples of co-morbidities/complicating factors that can
have an affect on treatment
Updating/Changing your DX
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New Conditions/New Injury
Change in condition
Improvement
Exacerbation
It all goes back to documentation
Don’t forget to change your illness date! (side note: Medicare
says the illness date is the first date of the patient encounter)
ICD-10 Chapters: Chiropractic
1. Infectious
12. Diseases of Skin
2. Neoplasms Tissue
13. Disease of Musculoskeletal & Connective
3. Blood and Blood-forming
14. Disease of Genitourinary
4. Endocrine, Nutritional
15. Pregnancy
5. Mental Disorders
16. Perinatal
6. Diseases of Nervous system
17. Congenital
7. Diseases of the Eye
18. Symptoms, Signs & Abnormal Clinical & Lab
8. Diseases of the Ear
19. Injury and Poisoning
9. Diseases of Circulatory
20. External Causes of Morbidity
10. Diseases of Respiratory
21. Factors Influencing Health Status
11. Diseases of Digestive
ICD-10 Layout and Definitions
Includes and Excludes
-Includes: gives definitions and examples
ICD-10 Layout and Definitions
-Excludes 1: “not coded here” (when two
conditions cannot occur together).
ICD-10 Layout and Definitions
-Excludes 2: condition not included here
(need additional code if documentations
supports it).
Code also: two codes may be required to fully
describe a condition.
Non-essential modifiers
[ ] Brackets enclose alternative wording or
explanatory phrases.
( ) extra words present/absent that do not affect
the code number.
Non-essential modifiers
• AND : Either “and” or “or”
Example: A18.0 Tuberculosis of bones and joints.
• With: “associated with” or “due to”
ICD-10 Layout and Definitions
X = place holder
When the 7thcharacter is needed, but there is
no 6thcharacter, an X is used as a placeholder.
M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region
Signs and Symptoms (Chapter 18)
Codes that describe signs and symptoms are
acceptable for reporting IF a definitive diagnosis
has not been established (confirmed).
• Only use signs and symptoms if no definitive
Diagnosis is established
Signs and Symptoms (S & S)
Don’t use S & S if:
they are routinely associated with a disease.
Do use S&S if:
not routinely with a disease process.
Example: Person comes in with Brachial Neuritis. To include a
diagnosis of shoulder pain would be redundant.
Uncertain Diagnosis
Code to the highest degree of certainty for that encounter/visit.
Do NOT use a diagnosis without certainty/documentation.
Do not code:
“probable”
“suspected”
“questionable”
“rule out”
“working diagnosis”
Etiology (cause)/ Manifestation
Underlying condition –sequenced first
Manifestation second
Example: Parkinson’s disease (G20) with dementia
F02.80 or F02.81
Acute and Chronic
Acute conditions get listed before chronic
–if both are present.
Code all documented conditions that coexist
1) Code all documented conditions that require or affect patient care
treatment or management.
2) Do not code conditions that were previously treated and no longer
exist.
3) History codes (categories Z80-Z87) may be used if it impacts current
care or influences treatment.
Examples:
Z89.61 Acquired absence of leg above knee
Z82.62 Family history of osteoporosis
Z82.69 Family history of other diseases of the musculoskeletal
system and connective tissue
M codes (Chapter 13)
• “M” prefix –diseases of musculoskeletal or
connective.
• Diseases related to:
• Bone
• Joint
• Muscle
Example: Patient with Sciatica & LB Pain
• Find the GEM
• Read your exclusions
• Code specific to documentation
• The more specific – the more you increase the
necessity for service
Laterality
• Some ICD-10-CM codes indicate laterality, specifying whether the
condition occurs on the left, right or is bilateral. If no bilateral code is
provided and the condition is bilateral, assign separate characters (2
separate diagnosis) for both the left and right side.
• … 0 unspecified
• … 1 right
• … 2 left
• If the side is not identified in the medical record, assign the code for
the unspecified side.
Example: 724.4 Cervical Radiculitis
• Find the GEM
• Read your exclusions
• Code specific to documentation
• Note that for this one, it is specific to a level and not a
side
MUST have documentation!
• USE the most specific code that is SUPPORTED by your
documentation.
• More changes to the diagnosis
• LEGALLY responsible for EVERYTHING on the bill-on paper or
electronically.
Injury “S” Codes (Chapter 19)
Strains and Sprains
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S00-S09 Injuries to the head
S10-S19 Injuries to the neck
S20-S29 Injuries to the thorax
S30-S39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external
genitals
S40-S49 Injuries to the shoulder and upper arm
S50-S59 Injuries to the elbow and forearm
S60-S69 Injuries to the wrist, hand and fingers
S70-S79 Injuries to the hip and thigh
S80-S89 Injuries to the knee and lower leg
S90-S99 Injuries to the ankle and foot
For most of these blocks, the third character is the one that designates the type
of injury. The "3" is for sprains, while the "6" or "9" is for strains
Strains and Sprains
• It will help to remember the following information
when searching for Strains vs. Sprains:
• A strain is an injury found under
muscle/tendon/fascia
• A sprain is an injury found under
dislocation/ligament/joint
ICD 10 for Lumbar Strain
• Search for strain of the lumbar spine. Remember a STRAIN is a muscle, fascia and
tendon
• S- Injury, poisoning and certain other consequences of external causes
• S3- Injuries to the abdomen, lower back, lumbar spine, pelvis and external
genitals
• S39- Other and unspecified injuries of the abdomen, lower back, pelvis and
external genitals
• S39.0- Injury of muscle, fascia and tendon of the abdomen, lower back and pelvis
• S39.01- Strain of muscle, fascia and tendon of the abdomen, lower back and
pelvis
• S39.012_ Strain of muscle, fascia and tendon of lower back
• S39.012A Strain of muscle, fascia and tendon of lower back, initial encounter
ICD 10 for Cervical Sprain
• Take a look at a sprain of the neck. It should be clearly documented as a
sprain of the ligaments of the cervical spine in order to assign the correct
code. Remember a SPRAIN is found under dislocation/ligament/joint
• S- Injury, poisoning and certain other consequences of external causes
• S1- Injuries to the neck
• S13- Dislocation and sprain of joints and ligaments at neck level
• S13.4- Sprain of ligaments of cervical spine
• S13.4xxA Sprain of ligaments of cervical spine, initial encounter
• This code does not have a fifth or sixth character, so we are instructed to
drop in a couple of "x" placeholders. Also, do not confuse the “A” -Initial
Encounter for the Initial Visit. The initial encounter should be used during
the entire time the patient is receiving active treatment for the condition.
th
7
Character – A, D, S
• Medicare States:
•A
•D
•S
• Active Care
• Subsequent – Routine Care
• Sequela – Late Effect
• This is not a universal rule yet! You may find other payers who will want to
see “A” used for the first visit and “D” used for subsequent (not routine) – it’s
always best to ask the payer!
th
7
character - A, D, S
• While the patient may be seen by a new or different
provider over the course of treatment for an injury,
assignment of the 7th character is based on whether
the patient is undergoing active treatment and not
whether the provider is seeing the patient for the first
time.
HCFA Notes for ICD 10
• Decimal Point should not be showing up in your diagnosis
on your claim
• Punctuation should never show up on a claim form
• Your DX box should show a {0} indicating you are reporting
with ICD 10
Additional Notes…
• If you find that your ICD 10 claims are being rejected check
the following
• Did you use a valid ICD 10 code?
• Did you add characters that should not have been added?
• Did you use a non specific code?
• If all looks good on your end, call the Payer
• They may have changed their policies and what may
have once been considered a covered code, may no
longer be so
Physician Quality Reporting System
aka: PQRS
Physician Quality Reporting System
• The Physician Quality Reporting System (PQRS) is a reporting program
that uses a combination of incentive payments and payment
adjustments to promote reporting of quality information by eligible
professionals.
• 2015 brought a major change to PQRS
• There are no incentive to participate other than the avoidance of payment
cuts.
• If you haven’t been reporting – start now!
Physician Quality Reporting System
• In the past, it has been stated that failure to participate in PQRS
would result in fee cuts
• That day is here
• If you haven’t been participating in PQRS, your claims are already
being cut
Physician Quality Reporting System
• Check your Medicare Fee Schedule
• In particular if you are a Non Participating Provider
• Limiting Charge
• EHR Limiting Charge
• PQRS Limiting Charge
• EHR & PQRS Limiting Charge
Physician Quality Reporting System
• Starting in 2017, all physicians that participate in Fee-for-Service
Medicare will be affected by the Value Based Modifier
• Failure to have participated in PQRS in 2015 will result in the doctor
being assigned the lowest level Value-Based Modifier in 2017
Physician Quality Reporting System
• Chiropractors are listed as eligible professionals
• We have two measures that we can report
• Measure #131 Pain Assessment and Follow-Up
• Measure #182 Functional Outcome Assessment
Physician Quality Reporting System
• Measures consist of two major components
• A denominator that describes the eligible cases for a measure (the
eligible patient population associated with a measure’s numerator)
• A numerator that describes the clinical action required by the
measure for reporting and performance
• Each component is defined by specific codes described in each
measure specification along with reporting instructions and use of
modifiers
Physician Quality Reporting System
• Quality-Data Codes (QDC’s)
• QDC’s are non-payable Healthcare Common Procedure Coding System
(HCPCS) codes comprised of specified CPT Category II codes and/or Gcodes that describe the clinical action required by a measure’s
numerator
• Clinical actions can apply to more than one condition, and therefore,
can also apply to more than one measure
Physician Quality Reporting System
• There is no enrollment required to report PQRS measures
• There are three ways to report PQRS measures
• Direct reporting on claim forms
• Reporting through a Qualified Registry
• Reporting through EHR
Physician Quality Reporting System
• Unfortunately none of the measures that can be reported through
EHR are measures that chiropractors can report
• Also, currently there is no Qualified Registry that applies to
chiropractic
Physician Quality Reporting System
• The satisfactory reporting requirements are:
• Report at least 3 measures, OR,
• If less than 3 measures apply to the eligible professional, report 1 -2
measures; AND
• Report each measure for at least 50 percent of the eligible
professional’s Medicare Part B Fee For Service (FFS) patients seen
during the reporting period to which the measure applies
Physician Quality Reporting System
• Measures with a 0 percent performance rate will not be counted
• The reporting period is January 1, 2016 to December 31, 2016.
• Beginning in 2015 Measure #317 (Preventive Care and Screening:
Screening for High Blood Pressure and Follow-Up Documented) No
longer needs to be reported
Physician Quality Reporting System
• Measure #131: Pain Assessment and Follow-Up.
• This measure documents the use of standardized pain assessment
tools
• This is different from standardized outcomes assessment
questionnaires
PQRS Measure #131
• This measure identifies the percentage of patients aged 18 years and
older with documentation of a pain assessment through discussion
with the patient including the use of a standardized tool(s) on each
visit AND documentation of a follow-up plan when pain is present
PQRS Measure #131
• This measure is to be reported for each visit occurring during the
reporting period for patients seen during the reporting period
• There is no diagnosis associated with this measure
PQRS Measure #131
• This measure may be reported by eligible professionals who perform
the quality actions described in the measure based on the services
provided and the measure-specific denominator coding
PQRS Measure #131
• The documented follow up plan must be related to the presence of
pain
• For example:
• “Patient referred to pain management specialist for back pain”
• “Return in two weeks for re-assessment of pain”
PQRS Measure #131
• For chiropractors the following is suggested:
• “Patient will be evaluated at the next visit to determine the effect of
treatment on their current pain level”
PQRS Measure #131
• CPT codes and patient demographics are used to identify patients
who are included in the measure’s denominator
• G-codes are used to report the numerator of the measure
• When reporting the measure via claims, submit the listed CPT codes,
and the appropriate numerator G-code
PQRS Measure #131
• Pain Assessment – Documentation of a clinical assessment for the
presence or absence of pain using a standardized tool is required. A
multi-dimensional clinical assessment of pain using a standardized
tool may include characteristics of pain; such as: location, intensity,
description, and onset/duration.
PQRS Measure #131
• Standardized Tool – An assessment tool that has been appropriately
normalized and validated for the population in which it is used
• Examples of tools for pain assessment, include, but are not limited to:
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Brief Pain Inventory (BPI)
Faces Pain Scale (FPS)
McGill Pain Questionnaire (MPQ)
Multidimensional Pain Inventory (MPI)
Neuropathic Pain Scale (NPS)
Numeric Rating Scale (NRS)
PQRS Measure #131
• Further examples of tools for Pain Assessment:
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Oswestry Disability Index (ODI)
Roland Morris Disability Questionnaire (RMDQ)
Verbal Descriptor Scale (VDS)
Verbal Numeric Rating Scale (VNRS)
Visual Analog Scale (VAS)
PQRS Measure #131
• Follow-Up Plan – A documented outline of care for a positive pain
assessment is required. This must include a planned follow-up
appointment or a referral, a notification to other care providers as
applicable OR indicate the initial treatment plan is still in effect.
These plans may include pharmacologic and/or educational
interventions.
PQRS Measure #131
• Not Eligible – A patient is not eligible if one or more of the following
reason(s) exists:
• Severe mental and/or physical incapacity where the person is unable
to express himself/herself in a manner understood by others. For
example, cases where pain cannot be accurately assessed through
use of nationally recognized standardized pain assessment tools
• Patient is in an urgent or emergent situation where time is of the
essence and to delay treatment would jeopardize the patient’s health
status
PQRS Measure #131
• NUMERATOR NOTE: The standardized tool used to assess the
patient’s pain must be documented in the medical record (exception:
A provider may use a fraction such as 5/10 for Numeric Rating Scale
without documenting this actual tool name when assessing pain for
intensity)
PQRS Measure #131
• For chiropractors, the denominator is one of the codes 98940, 98941,
or 98942
• This is to be reported on all patient encounters for patients aged 18
years and over
PQRS Measure #131
• The numerators are in groups of two
• You choose which group is appropriate
• Then choose one of the two options with the group
• Numerator Quality Data Coding Options for Reporting Satisfactorily:
• G8730: Pain assessment documented as positive utilizing a standardized tool
AND a follow-up plan is documented. OR
• G8731: Pain assessment documented as negative, no follow-up plan required
PQRS Measure #131
• G8442: Pain assessment NOT documented as being performed,
documentation the patient is not eligible for a pain assessment using
a standardized tool. OR
• G8939: Pain assessment documented as positive, follow-up plan not
documented, documentation the patient not eligible
PQRS Measure #131
• G8732: No documentation of pain assessment, reason not given
OR
• G8509: Pain assessment documented as positive using a standardized
tool, follow-up plan not documented, reason not given.
Physician Quality Reporting System
• Measure #182 Functional Outcome Assessment
• This measure documents the use of standardized outcome
assessment questionnaires
PQRS Measure #182
• Percentage of patients aged 18 years and older with documentation
of a current functional outcome assessment using a standardized
functional outcome assessment tool on the date of the encounter
AND documentation of a care plan based on identified functional
outcome deficiencies on the date of the identified deficiencies.
PQRS Measure #182
• This measure is to be reported each visit for patients seen during the
12 month reporting period
• The functional outcome assessment is required to be current as
defined in the definition section
• This measure may be reported by eligible professionals who perform
the quality actions described in the measure based on the services
provided and the measure-specific denominator coding
PQRS Measure #182
• NOTE: A functional outcome assessment is multi-dimensional and
quantifies pain and neuromusculoskeletal capacity; therefore theuse
of a standardized tool assessing pain alone, such as the visual analog
scale (VAS), does not meet the criteria of a functional outcome
assessment standardized tool.
PQRS Measure #182
• The intent of the measure is for the functional outcome assessment
tool to be utilized at a minimum of every 30 days but reporting is
required each visit due to coding limitations
• Therefore, for visits occurring within 30 days of a previously
documented functional outcome assessment, the numerator qualitydata code G8942 should be used for reporting purposes
PQRS Measure #182
• Standardized Tool – An assessment tool that has been appropriately
normalized and validated
• Examples of tools for functional outcome assessment include, but are
not limited to:
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Oswestry Disability Index (ODI)
Roland Morris Disability/Activity Questionnaire (RM)
Neck Disability Index (NDI)
Patient-Reported Outcomes Measurement Information System (PROMIS)
Disabilities of the Arm, Shoulder, and Hand (DASH)
Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL)
PQRS Measure #182
• Functional Outcome Assessment – Patient completed questionnaires
designed to measure a patient’s physical limitations in performing the
usual human tasks of living and to directly quantify functional and
behavioral symptoms
PQRS Measure #182
• Current (Functional Outcome Assessment) – A patient having a
documented functional assessment utilizing a standardized tool and a
care plan if indicated within the previous 30 days
PQRS Measure #182
• Functional Outcome Deficiencies – Impairment or loss of physical
function related to musculoskeletal/neuromusculoskeletal capacity,
may include but are not limited to: restricted flexion, extension, and
rotation, back pain, neck pain, pain in the joints of the arms or legs,
and headaches.
PQRS Measure #182
• Care Plan – A care plan is an ordered assembly of expected/planned
activities or actionable elements based on identified deficiencies.
These may include observations, goals, services, appointments, and
procedures, usually organized in phases or sessions, which have the
objective of organizing and managing health care activity for the
patient, often focused on one or more of the patient’s health care
problems. Care plans may also be known as a treatment plan.
PQRS Measure #182
• Not Eligible – A patient is not eligible if the following reason(s) is
documented:
• Patient refuses to participate
• Patient unable to complete questionnaire
• Patient is in an urgent or emergent medical situation where time is of
the essence and to delay treatment would jeopardize the patient’s
health status
PQRS Measure #182
• CPT codes and patient demographics are used to identify patients
that are included in the measure’s denominator
• Quality-data codes (G-codes) are used to report the numerator of the
measure
• When reporting the measure via claims, submit the listed CPT codes,
and the appropriate numerator Quality-data code
PQRS Measure #182
• For chiropractors, the denominator is one of the codes 98940, 98941,
or 98942
• This is to be reported on all patient encounters for patients aged 18
years and over
PQRS Measure #182
• The numerators are in groups
• You choose which group is appropriate
• Then choose one of the options from within the group
• Numerator Quality-Data Coding Options for Reporting Satisfactorily
are:
PQRS Measure #182
• G8539: Functional outcome assessment documented as positive
using a standardized tool AND a care plan based on identified
deficiencies on the date of the functional outcome assessment, is
documented. OR
• G8542: Functional outcome assessment using a standardized tool is
documented; no functional deficiencies identified, care plan not
required. OR
• G8942: Functional outcome assessment using a standardized tool is
documented tool is documented within the previous 30 days and care
plan, based on identified deficiencies on the date of the functional
outcome assessment, is documented
PQRS Measure #182
• G8540: Functional Outcome Assessment NOT documented as being
performed, documentation the patient is not eligible for a functional
outcome assessment using a standardized tool. OR
• G9227: Functional Outcome Assessment documented, care plan not
documented, documentation the patient is not eligible for a care plan
PQRS Measure #182
• G8541: Functional Outcome Assessment using a standardized tool
not documented, reason not given. OR
• G8543: Documentation of a positive functional outcome assessment
using a standardized tool; care plan not documented, reason not
given.
PQRS Measure #182
• Functional Timeline
• At the initial assessment visit you administer an outcome assessment
questionnaire and find a functional deficiency
• From this you develop a treatment plan
• You would use G8539 for that visit
PQRS Measure #182
• For the next 30 days you follow the treatment plan with treatment
visits
• You would use G8942 for each of these visits
PQRS Measure #182
• At the end of the 30 days you would re-evaluate the patient at an
assessment visit
• You would administer another outcome assessment questionnaire,
find functional deficiencies and develop a new treatment plan
• You would use G8539 for this visit
PQRS Measure #182
• Standardized Outcome Assessments, questionnaires or tools are a
vital part of evidence-based practice.
• Despite the recognition of the importance of outcome assessments,
questionnaires, and tools, recent evidence suggests their use in
clinical practice is limited
PQRS Measure #182
• Selecting the most appropriate outcomes assessment, questionnaire
or tool enhances clinical practice by:
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(1) identifying and quantifying body function and structure limitations
(2) formulating the evaluation, diagnosis, and prognosis
(3) informing the plan of care; and
(4) helping to evaluate the success of chiropractic therapy interventions
Physician Quality Reporting System
• Both measure #131 and #182 specifically list the Oswestry Disability
Index (which is another name for the Oswestry Low Back Disability
Index) and the Roland Morris Questionnaire as acceptable
standardized tools
• You may be able to use the following to satisfy some of the
requirements for both measure #131 and #182
• Revised Oswestry Low Back Pain Disability Index Questionnaire
• Neck Disability Index
• Rowland-Morris Questionnaire
Physician Quality Reporting System
• These measures #131 and #182 are to be reported when you file your
claim
• It is important to place an entry in the charge field. $.01 is
recommended. It won’t be paid.
• Do: report measures on Medicare “AT” patients
• Don’t: report measure on Medicare replacement policies
Physician Quality Reporting System
• By participating in the PQRS you will avoid a 2% cut in your fees
starting in 2017
• You will also be establishing your Value Based Modifier (VBM)
• The VBM will be effective for chiropractors in 2017 and will be based
on your 2015 PQRS participation
Physician Quality Reporting System
• Not all of the G-codes are payable codes
• You should watch for a code N365 on the remittance advisories
• N365 reads: “This procedure code is not payable. It is for
reporting/information purposes only.”
• This code will indicate that the reporting code passed into the
national database
Summary of PQRS
• Reporting the PQRS measures is essential for two reasons
• To ensure that you are paid the maximum amount available from Medicare
• To build as accurate of a performance database as possible for chiropractic
procedures and for yourself
• Accurately reporting the PQRS measures will prove beneficial to both
you and the profession