Transcript Presentation Style Guide

ICD-10 Clinical Documentation
Improvement for Facilities
OrHIMA 2013 Fall Meeting
September 27, 2013
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Presenter:
• Laura Legg, RHIT, CCS AHIMA approved ICD10 Trainer
• Experienced as a leader, consultant, coding
expert, speaker, trainer and auditor for acute
care and critical access hospitals and major
health systems
• [email protected]
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Objectives
1. To gain an awareness of the complexity of
ICD-10 and the challenges of implementation
2. Identify chapter by chapter challenges in
documentation specificity for ICD-10
3. Identify diagnosis-specific sample queries for
ICD-10
4. Questions/Answers
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ICD-10-CM/PCS-Introduction
• US Department of Health and Human Services
announced change January 16, 2009 with a
compliance date of October 1, 2013
• 2012 delay til October 2014
• Biggest change to healthcare in the last 20
years!
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History of ICD-10
• US department of Health and Human Services
announced the change:
1988
1/19/2009
10/1/2013
10/1/2014
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History
More than 200 countries have adopted ICD-10
• Nordic countries-1997
• UK-1995
• France-1997
• Australia-1998
• Germany-2000
• Canada-2001
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If ICD-10 were a game what
game would it be?
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7/16/2015
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If ICD-10 were a game what
game would it be?
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7/16/2015
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If ICD-10 were a game what
game would it be?
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7/16/2015
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Now is a time to learn everything we can-
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Ask questions
Learn what testing reveals
Be proactive using what we are learning
Continue learning up until the time of
implementation
• Go-live planning
• Plan for after go live
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ICD-10 Testing Revealed:
• Earlier misconceptions
-DRG variance 2-6%
-MDC shifts not expected
• Expected results
-Coder productivity decrease
-If you are not proficient now you won’t be
proficient using ICD-10
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Testing Revealed:
DRG variances much higher than expected
Example:
DRG variance in the Nervous System
Expected 8%
Actual 27%
DRG variance in the Digestive System
Expected 8%
Actual 20%
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Testing Revealed:
• MDC shifts did occur
• Time-to-code IP claims decreased from 3-5 per
hour to 1-2 per hour
• Coding errors included:
-invalid codes
-decimals in incorrect places
-coding not following coding conventions
This caused increased rejected and pended claims
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ICD-10 Humor
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What should we do?
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The answer “DOCUMENTATION”
Back to the Basics
Look at Processes and Workflow now
Staff adjustments
Dual coding
Peer review
Physician queries
Go From ICD-9 to ICD-10
Think about this:
Remember:
• If it was not working that
well for ICD-9-CM/PCS it
won’t work for ICD 10 CM!
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Focus your efforts:
• Top 10 common clinical diagnoses
• If physicians are motivated or conditioned to
include specificity in these top clinical
diagnoses then the road to a successful
transition to clinical documentation under
ICD-10 can be established
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Tailor your CDI program:
• Run a report of the top 20 MS DRGs for the
last fiscal year
• Review diagnoses
• Tailor ICD-10 training for the common clinical
diagnoses that your physicians manage
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ICD-10 Clinical documentation
 Greater specificity
Increase accuracy in documentation
Increase accuracy in billing and
reimbursement
Improved statistical analysis which means:
-improved disease management
-better understanding of health care
outcomes
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Review Query forms
• Revise query forms and focus on some specific
areas:
 Asthma
 Coma
 Fracture
 Stroke
 Cardiac-hypertension, CAD, CHF
 Diabetes
 OB
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Chapter 1: Infectious and Parasitic diseases
• Queries will be mandatory for the diagnosis
“urosepsis” in ICD-10-CM
• More specific documentation is needed when
reporting sepsis. Septicemia is no longer
synonymous with sepsis
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Chapter 2: Neoplasms
• When an admission is solely for anemia
associated with a malignancy, the appropriate
malignancy code is sequenced as the principal
diagnosis followed by the code for anemia in
neoplastic disease. D63.0
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Chapter 3: Blood and blood forming organs
• Anemia appears in code categories D50-D64.
• ICD-10 also identifies anemia according to type,
but the categories rely on different language
-nutritional (iron deficiency in ICD-9)
-Hemolytic (e.g., sickle cell)
-Aplastic and other anemia, which include acute
blood loss anemia and anemia of chronic disease.
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Chapter 4: Endocrine, Nutritional, and Metabolic
• In ICD-9-CM diabetes mellitus was classified as
to type 1, type 2, or secondary
• The 5th digit indicates the type of diabetes
mellitus or unspecified diabetes and also
indicates if the diabetes is controlled or
uncontrolled
• In ICD-10-CM diabetes mellitus is not
classified as controlled or uncontrolled
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Chapter 4: Endocrine, Nutritional and Metabolic
E08-Diabetes mellitus due to an underlying
condition (code first the underlying condition)
E09-Drug or chemical-induced diabetes
mellitus.
E10-Type I diabetes mellitus
E11-Type 2 or diabetes NOS
E13-Other specified diabetes mellitus
(diabetes due to pancreatectomy)
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Sequencing has changed with “code first”
notes
Combination codes
Encourage physicians to document mild,
moderate or severe for the added specificity
in ICD-10 diabetes mellitus codes
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ICD-10 Humor
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Chapter 5: Mental and behavioral disorders
Drug and alcohol-related disorders
Assignment is based on type of substance and
whether the person abuses the substance or is
dependent on it
When documentation identifies that the
patient has use, abuse, and dependence the
most severe state is coded
Hierarchy is use---abuse----dependence lowest
to high severity
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Chapter 6: Nervous System/Sense Organs
• Encourage neurologists and other providers to
review ICD-10-CM code descriptions for
seizures and epilepsy and to document
accordingly.
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Chapter 6: Nervous System/Sense Organs
• Terminology for epilepsy has been updated to
include terms such as:
– Epilepsy, juvenile myoclonic
– Epilepsy, generalized, idiopathic
– Epilepsy, generalized, idiopathic, intractable,
without status epilepticus
• Code assignment will depend on specific
documentation (documentation opportunity)
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Chapter 6: Nervous system/Sense Organs
Other key documentation elements for the
Nervous system are:
• Dominant vs. nondominant side
• Laterality
• Episode of care for injuries and other external
causes-initial, subsequent, sequela
• Loss of consciousness time duration
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Chapter 7: Eye and Adnexa
• Codes have been expanded to increase anatomic
specificity and add the concept of laterality
• Many codes include right, left, bilateral, and
unspecified eye
• If the option of bilateral is not available and the
condition is present in both eyes, assign the code
for right and left
• If a code for bilateral exists it should be assigned
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Chapter 8: Ear and Mastoid
• Codes have been expanded to increase
anatomic specificity and add the concept of
laterality
• New instructional notes have been added
• A note at the beginning of the chapter states
to use an external cause code following the
code for the ear condition, if applicable, to
identify the cause of the ear condition
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Chapter 9: Circulatory system
• Acute myocardial infarction must be identified
as initial or subsequent
• Embolism, thrombosis, phlebitis and
thrombophlebitis of veins require
identification of laterality and the specific
lower extremity vein
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Chapter 9: Circulatory System
Documentation for coding CVAs in ICD-10-CM
• To make the correct code for CVAs the
documentation must reflect the
location/source and laterality
• If bilateral sites are indicated, codes should be
assigned for each side as there is no bilateral
option in this series
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Chapter 10: Respiratory System
• When assigning codes for patients with COPD
with asthma it is necessary to assign two
codes.
• A code from category J44 is assigned for the
COPD and is accompanied by a second code
from J45 to identify the severity and status of
the asthma.
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Chapter 10: Respiratory System
• Key Documentation elements:
Asthma must be documented as mild,
moderate or severe
Mild asthma must be documented as
intermittent or persistent
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Chapter 11: Digestive System
Documentation Note:
The term “hemorrhage” is used when referring
to ulcers, and the term “bleeding” is used when
classifying gastritis, duodenitis, diverticulosis,
and diverticulitis
• K25.0, Acute gastric ulcer with hemorrhage
• K29.01, Acute gastritis with bleeding
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ICD-10 Humor
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Chapter 12: Skin/Subcu Tissue
Coding Pressure Ulcers:
• In ICD-9-CM coders assigned 2 codes for pressure
ulcers-one from category707.0x (location) and
one from 707.2x (stage of the ulcer)
• In ICD-10-CM pressure ulcers appear in code
category L89.• Code L89.001 stage 1 pressure ulcer of the right
elbow (note location and stage in one code)
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Chapter 13: Musculoskeletal System
Fracture codes include greater specificity in:
• Type of fracture
• Specific anatomic site
• Displaced or nondisplaced
• Laterality
• Routine vs. delayed healing
• Non union and malnunion
• Fracture 7th character value
• Gustilo open fracture classification
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Chapter 13: Pathological fractures
Pathologic fracture documentation:
Exact location of the fracture site with
laterality
Etiology of the fracture-osteoporosis,
neoplasm, other specified
Encounter type-initial, subsequent with
routine healing, subsequent with delayed
healing, malunion and nonunion or sequelae
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Chapter 13: Musculoskeletal System
Gustilo classification
• Type I-clean wound < 1 cm long
• Type II-wound > 1 cm without extensive soft tissue
damage
• Type IIIA-extensive soft tissue lacerations (>10 cm) but
maintain adequate soft tissue coverage of bone
• Type IIIB-extensive soft tissue loss with periosteal
stripping and bony exposure, usually massive
contamination
• Type IIIC- with arterial injury that requires repair
regardless of size of wound
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Chapter 13: Musculoskeletal System
How do you prepare?
• Work with clinicians and physicians where
terminologies and specificity is required
• Work with CDI team to assist regarding
documentation requirements
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Chapter 14: Genitourinary System
Chronic Kidney disease and Kidney Transplant Status
• Patient who have undergone kidney transplant may still
have some form of CKD, because the kidney transplant may
not fully restore kidney function. Therefore, the presence
of CKD alone does not constitute a transplant complication.
• Assign the appropriate N18 code for the patient’s stage of
CKD and code Z94.0 Kidney transplant status.
• If a transplant complication such as failure or rejection or
other transplant complication is documented see section
I.C.19.g for information on coding complications of a kidney
transplant.
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Chapter 15: Pregnancy/Childbirth
• The final character in the code will indicate
the trimester
• Antepartum, postpartum and whether a
deliver has occurred are not used.
• Final character assignment should be based
on provider’s documentation
• Gestational diabetes needs specification of
diet controlled or insulin controlled
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Chapter 16: Newborn
• When both birth weight and gestational age of
the newborn are available both should be
coded with birth weight sequenced before
gestational age
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Chapter 17: Congenital Malformations
• Modifications have been made to specific
categories to update terminology
• Example:
Q61 Cystic kidney disease
Q61.0 Congenital renal cyst
Q61.1 Polycystic kidney, infantile type
Q61.2 Polycystic kidney, adult type
• Patau’s syndrome updated to Trisomy 13
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Chapter 18: Signs and Symptoms
Glasgow Coma ScaleThe Glasgow coma scale codes (R40.2-) can be used in
conjunction with traumatic brain injury codes, acute
cerebrovascular disease or sequelae of cerebrovascular
disease codes. The codes are primarily for use by trauma
registries, but they may be used in any setting where this
information is collected. The coma scale codes should be
sequenced after the diagnosis codes.
At a minimum report the initial score documented on
presentation at the facility. This may be a score from the
emergency medicine technician or the ER department. If
desired a facility may choose to capture several scores.
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Chapter 19: Injury/poisoning
UnderdosingUnderdosing refers to taking less of a medication
than is prescribed by a provider or a
manufacturer’s instruction. For underdosing
assign the code from categories T36-T50 (fifth or
sixth character6) Codes for underdosing should
never be assigned as principal or first-listed
codes. If a patient has a relapse or exacerbation
of the medical condition for which the drug is
prescribed because of the reduction in dose, then
the medical condition itself should be coded.
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Chapter 21: Factors Influencing Health
• Personal and family history codes have been
expanded in ICD-10 CM
• New codes to identify the patient’s blood type
• Category V57 Care involving use of
rehabilitation procedures no longer existsreport instead the underlying condition for
which the therapy is being provided with the
7th character indicating subsequent encounter
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It’s brand new!
• ICD-10-PCS presents a totally new model
• Drastically different from its ICD-9 counterpart
• Entirely new coding logic and will be new
territory for coders
• The changes in the meaning of characters may
be confusing
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Benefits of ICD-10 CM/PCS
• Improve the accuracy and efficiency of
procedure coding
• Replace ICD-9 CM with a more logical system
• Improve communication with physicians by
developing a code system that aligns more
with the clinical aspects of various procedures
• Allow coders to construct accurate codes with
minimal effort
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Procedure code comparison
Characteristic
ICD-9-CM volume 3
ICD-10-PCS
Field length
3-4 characters
7 alphanumeric characters
Available codes
3,000
72,081
Available space for new
codes
Limited
Flexible
Overall detail embedded in
codes
Ambiguous
Precise definition regarding
anatomic site, approach,
device used, and qualifying
information
Laterality
Code does not identify
right vs. left
Code identifies right vs. left
Terminology for body parts
Generic description
Detailed description
Procedure description
Lacks description of
procedure approach
Detailed description of
approach.
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Procedure code comparison, cont..
Characteristic
ICD-9-CM vol. 3
ICD-10-PCS
Character position within
code
N/A
16 PCS sections identify
procedures in a variety of
classifications (e.g. medical
surgical, mental health).
Among these sections
there may be variations in
the meaning of various
character positions, though
the meaning is consistent
within each section.
Example code
39.24 Aorta-renal bypass
04104J3 bypass abdominal
aorta to right renal artery
with synthetic substitute,
percutaneous endoscopic
approach
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PCS:
• All codes in PCS are seven characters
• Letters O and I not used in PCS
– Numbers 0 and 1 used
• Each character has a meaning
• Meanings change by sections
• Section provides first character value
• Sections of ICD-10-PCS listed in manual
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Root Operations:
Third character of the procedure code
--Defines the objective of the procedure
-New terminology used to define the different
types of root operations
-Physician does not have to document root
operation terms; coders will translate
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Root Operations:
Examples of Root operations:
• Bypass
• Drainage
• Reattachment
• Resection
• Inspection
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Anticipate Queries for ICD-10 PCS
• Root Operation
• Body Part
• Body System
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Current Documentation issues
Physicians
• How well do they already document?
• Have you already started education?
• Do you have buy in?
• Educate physicians by giving specific facts by
specialty
• Educate surgeons on the details of PCS
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Anticipate query increase
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Additional queries-guaranteed
Not just diagnoses but procedure queries
Think laterality
Muscle/vessel specificity
Think joints and fractures
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New Queries
• Queries need to be rewritten
• CDI staff educated on changes and anticipate
the rework of queries
• Physician educated on the new queries and
the new code structure
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New scales
National heart, lung and blood institute
asthma severity classification scale of
intermittent, mild persistent, moderate and
severe persistent
Glasgow Coma Scale
Gustilo Open Fracture Classification
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CDI specialists productivity
• Anticipate loss of productivity for a short time
• Education should be diagnosis & procedurespecific
• Focus on top DRGs
• Due to physician education, more queries,
more time spent reviewing charts
• Lay the groundwork now
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Focus
• Learn new code structure ICD-10 CM/PCS
• Review the ICD-10-CM/PCS Official Coding
Guidelines
• Re-audit documentation, query forms, make
revisions and improvements
• Educate physicians
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Physician buy-in
• Let your physicians know that ICD-10 will report
severity and make profiling more accurate
• Research will be improved with specificity of
clinical data
• Clearer reimbursement guidelines
• Fewer claim denials
• New technology and new terminology is reflected
in ICD-10
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What about you? Are you ready?
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Review the ICD-10-CM/PCS Guidelines
Compare to the ICD-9-CM Guidelines
Review Current Documentation
Have a positive outlook
Expect the unexpected
Physician Education needed now
• Do you have buy in?
• Physicians want to document correctly
• Educate physicians by giving specific facts by
specialty
• Educate surgeons on the details of PCS
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New queries
• Queries need to be rewritten
• CDI staff educated on changes and anticipate
the rework of queries
• Physician educated on the new queries and
the new code structure
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Productivity for coders and others
• Anticipate loss of productivity for a short time
• Canada had a 50% reduction in productivity
• Due to physician education, more queries,
more time spent reviewing charts
• Lay the groundwork now
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What to do?
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Become familiar with ICD-10 CM/PCS codes
Review the Official Coding Guidelines
Work with the physicians
Re-audit documentation, query forms, make
revisions and improvements
• Assess your ICD-10 needs
• Increase your clinical knowledge
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In the coming months
More will be learned about ICD-10
More clinical documentation issues will be
brought forward
BE prepared
The key to successful ICD-10 implementation
is improving your clinical documentation now!
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Leap into ICD-10
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Questions?
• Laura Legg, RHIT, CCS
• HIM Director for Healthcare Resource Group
• [email protected]
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References:
• http://www.nlm.nih.gov/medlineplus/ency/article/001214.htm
• ICD-10 CM official coding guidelines @
www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf
• ICD-10-CM Coder Training Manual-AHIMA
• Gustilo classificationhttp://eoriff.com/general/Open%20Fx%20Class.html
• Salter-Harris classification-http://www.bridgeport.edu/gwl/salterharrisclassification/htm
• AHA Coding Guidelines-October 1, 2012
• ICD-10-CM the complete draft code set
2012http://www.cms.hhs.gove/ICD10
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