Revenue Cycle Solutions Consulting & Management Services. Why Words Matter. Through a Psychiatry Lens The Advisory Board Company advisory.

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1 Revenue Cycle Solutions Consulting & Management Services Why Words Matter Through a Psychiatry Lens 2014 The Advisory Board Company advisory.com

2 Key Objectives for Today s Session 1. Develop understanding of the role documentation plays in determining patient severity of illness (SOI), risk of mortality (ROM) and physician quality scores 2. Understand definition and key terminology changes in ICD-10-CM and ICD-10- PCS 3. Understand the concepts of linking conditions and manifestations for more accurate depiction of patient s clinical status 2

3 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Concepts Drive Documentation Requirements 3 Examples of Psychiatry Diagnoses in ICD-10-CM 3

4 The Evolution of Clinical Documentation What was once a tool for communication between providers and clinicians is now the primary data source to determine quality of patient care. Market forces are leading to Increase in documentation scrutiny. Who is the audience for your notes? Self Care Team State Government Insurance Companies Other Doctors Patients Federal Government 4

5 Increased Transparency For Patients MyCigna.com HealthGrades- all material and images are sourced from (accessed on 6/18/2012) Leapfrog- all material and images are sourced from (accessed on 6/18/2012) 5

6 Transition from ICD-9-CM to ICD-10-CM/PCS Per Bill H.R. 4302, The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD 10-CM/PCS code sets. Benefits and Goals of ICD-10-CM/PCS Provides better detail, a more accurate depiction, and improved communication of patients clinical status Allows for more accurate payment for new procedures Improves capture of morbidity and mortality data Reduces the number of miscoded, rejected and improper claims for reimbursement 2011, The Clinical documentation Improvement Specialist's Guide to ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS. 6

7 ICD-9-CM vs. ICD-10-CM/PCS: A Comparison 69,000 72,000 Why so many new codes? The main difference between ICD-9-CM and ICD-10-CM/PCS codes, outside of structural changes, is the SPECIFICITY of the code. 14,000 4,000 ICD-9 Diagnosis Codes ICD-10 Procedure Codes ICD-10-CM/PCS codes specify several components not found ICD-9-CM, such as causal agent, type, laterality, approach, episode of care, root operation, etc. 1) Code Volume Expansion in ICD-10-CM/PCS Source: Nichols, J.C. (2011). ICD-10 Physician impacts. Advisory Board Applications and Technologies Collaborative; CMS (2013). ICD-10 Implementation guide for small hospitals 7

8 Introduction to ICD-10-CM Diagnosis Coding Structure ICD-10-CM Codes will Contain 3-7 Alphanumeric Characters with the Following Structure α # α/# α/# α/# α/# α/# Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality, Complication) Extension (3-16 options depending on category) Key ICD-10-CM Documentation Concepts Specific anatomical location Type (primary, secondary, unspecified) Acuity (acute, subacute, chronic, acute on chronic, or unspecified ) Trimester (1,2,3,unspecified) Degree (mild, moderate, severe, or unspecified; total/complete vs. partial/incomplete) Episode of Care (Initial, Subsequent, Sequelae) Laterality (Right, Left, bilateral, or unspecified) Number of fetus (1-5, other) 8

9 Introduction to ICD-10-PCS Coding Structure In this exercise, we will dissect the structure of an ICD-10-PCS code α/# α/# α/# α/# α/# α/# α/# Section Body System Root Operation Body Part Approach Device Qualifier 1. Section 16 options identifying the general type of procedure. Example: Medical/Surgical Section represents the vast majority of procedures reported in an inpatient setting 2. Body System - e.g. circulatory system, respiratory system 3. Root Operation - 31 options, based on the objective of the procedure 4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve 5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic 6. Device - 4 basic groups: Grafts/prostheses, implants, simple or mechanical appliances, and electronic appliance 7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full thickness burn Physician documentation required: Type and intent of procedure (root operation) Specific anatomic sites treated Approach Specific type of device used Validate surgical complications Diagnoses that support inpatient medical necessity Source: AHIMA; The Advisory Board Company research 9

10 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Key Concepts To Capture in Your Documentation 3 Examples of Psychiatry Diagnoses in ICD-10 10

11 Remember: Signs, Symptoms & Test Results Must Be Linked to Related Diagnoses While important pieces of the medical record, signs, symptoms and test results are not sufficient for coders to assign a diagnosis. Linking signs and symptoms to diagnoses may increase SOI and ROM in the inpatient setting. (The terms probable, likely, or suspected are all acceptable on the inpatient record) In the ambulatory setting, documentation regarding patient condition should be to the highest level known, treated or evaluated Abnormal findings (laboratory, x-ray, pathology and other diagnostic test results) cannot be coded and reported unless the clinical significance is identified by the treating provider ICD-10-CM Official Coding Guidelines III.B Reminder: The attending physician is responsible for: Documenting all conditions in the progress notes and discharge summary Resolving conflicts in the documentation 11

12 Linking Conditions Critical to Capturing Patient Severity There is a significant increase in the number of combination codes available in the ICD-10-CM/PCS code set. These codes can help capture the highest level of complexity and acuity in the public eye. Linking clinically relevant conditions, where appropriate, is the key takeaway for physicians. Coders cannot assume clinical relationships. Examples: Linking Diseases Hypertension with heart disease Endocarditis due to staph aureus Right heart failure due to primary pulmonary hypertension Use terms like due to or with Note: Lists, commas, and the word and do not link conditions 12

13 Severity of Illness (SOI) and Risk of Mortality (ROM) Documentation drives SOI and ROM level assignment. These levels are used to measure patient acuity, and therefore drive expected patient LOS and mortality rate. Breakdown of SOI/ROM and their Implication on Quality Measures Four mutually exclusive SOI/ROM categories exist (1-4), and are determined based on a number of factors including primary and secondary diagnoses, comorbidities, demographics, patient history, treatment/procedure delivered, etc. Level Assigned SOI/ROM Category Minor 1 Moderate 2 Major 3 Extreme 4 13

14 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Key Concepts To Capture in Your Documentation 3 Examples of Psychiatry Diagnoses in ICD-10 14

15 ICD-10-CM/PCS Psychiatric Diagnoses & Procedures Covered Today Let s move on to these procedures to help explain what documentation will be like in ICD-10-CM/PCS 1 Alzheimer s Disease 2 Mood Disorders 3 Alcohol / Substance Abuse 4 Poisonings 15

16 Alzheimer s Disease A new concept in ICD-10-CM/PCS is to clarify the onset of the Alzheimer s disease as: Early onset Late onset Continue to document any associated: Delirium Dementia with behavioral disturbances Behavioral disturbances include those which are aggressive, combative, violent or wandering Dementia without behavioral disturbances Documentation Tip Clarify in the medical record why the patient requires restraints, a sitter, special room, or use of as needed sedatives or antipsychotic medications 16

17 Mood Disorders Documentation Requirements Specify the Type of Mood Disorder 1. Manic Episode 2. Bipolar Disorder 3. Major Depressive Disorder Single episode Recurrent Other 4. Unspecified Mood Disorders (e.g. depression, depressive disorder and major depression) 17

18 Mood Disorders Documentation Concepts Required for Documenting Mood Disorders 1. Remission status Partial remission Full remission 2. Severity Mild Moderate Severe 3. Associated manifestations With psychotic features Without psychotic features 18

19 Bipolar Disorder Bipolar Disorder Documentation Concepts Type Degree Hypomanic Manic with psychotic features Manic without psychotic features Mixed Depressed Mild Moderate Severe Unspecified Episode of Care Current episode In Remission (partial, full, unspecified) 19

20 Bipolar Disorder Bipolar disorder, current episode manic without manic psychotic features, moderate F Mood Disorders Episode of Care Current episode manic without psychotic features Degree Unspecified Mood Disorders (Bipolar) Current episode manic severe Current episode depressed, mild or moderate severity Current episode mixed Mild Moderate Severe Currently in remission Other Unspecified 20

21 Psychosis There are many conditions causing psychosis, and accurate reflection of the patient s severity of illness requires the clarification of these conditions. Clarify Type of Psychosis Hysterical Psychosis Alcoholic Psychosis Confusional Psychosis Clarify type of conversion disorders: (e.g. motor symptoms, seizures, sensory symptoms or deficits, etc.) Clarify as: With abuse With anxiety disorder With delirium tremens The following conditions are further classified as with abuse or dependence Delusions Hallucinosis Mood disorders Paranoia Clarify as: Acute or subacute Synonymous with sundowning, delirium superimposed on dementia, delirium of mixed etiology, acute or subacute infective psychosis, acute confusional state Reactive is considered a brief psychotic disorder, or a paranoid reaction Additional opportunities include: Drug Induced, Due to addiction, Epileptic, Exhaustive, Hallucinatory (include type of hallucinations), Mixed schizophrenic, Infective, Korsakoff s, or Manic Key Takeaway: Acute psychosis is defined as transient in ICD-10-CM Document the underlying cause/etiology of the psychosis Terms such as suspected, probably, or likely are also appropriate. 21

22 Substance Abuse Disorders Alcohol & Other Substances Specify the name of the substance (e.g. alcohol, cocaine, opioids, hallucinogens) Type of Use Use (e.g. smoked a cigarette today) Dependence new terminology, was previously called Addiction Is the patient dependent on the substance If yes, patient s SOI is higher = Comorbid condition (CC) Abuse (e.g. occasional drug user or binge drinker) Current status In remission with intoxication or with withdrawal Document any behavior disorders associated with the substance problem (e.g. anxiety disorder, delirium. hallucinations, sleep disorders etc.) Documentation Tip Physician will want to document Blood Alcohol Level (BAL) 22

23 Poisoning Documentation Definition: Exposure to toxins, reactions to improper use of medication, interaction between drugs, alcohol or illegal or herbal substances Poisonings include: Overdose Wrong dose or given/taken in error Wrong route of administration Specify in Your Documentation: Name of drug/chemical Describe all manifestations Describe intent Accidental Intentional self-harm Assault Investigated but undetermined ICD-10-CM/PCS Table of Drugs and Chemicals (55 pages) Based on: Substance Poisoning, Accidental Poisoning, Intentional Self-harm Poisoning, Assault Poisoning, Undetermined Adverse Effect Underdosing Encounter: Initial, Subsequent or Sequelae Documentation Example: Acute toxic encephalopathy with coma d/t accidental overdose of stolen oxycodone, initial visit 1) Source: The Advisory Board Company research; Health Data Consulting 23

24 Summary of Best Practice Documentation Teaching Points Key Documentation Concepts Conflicting, incomplete, or ambiguous documentation will lead to a query Carry all documentation from diagnostic test into progress notes to ensure it will be captured Documentation of tobacco exposure is crucial Sign, symptoms and test results do not contribute to SOI unless their significance is documented or they are linked to a named disease Clarify the onset of Alzheimer s disease Document type, acuity, episode and any associated psychotic features with mood disorders Clarify substance abuse disorders by agent and any associated physical or psychological conditions Document associated blood alcohol levels Clarify remission status 24

25 Appendix 25

26 Circling Back: Concepts Drive the Majority of Changes Key Considerations for Psychiatry: ICD-10-CM Infection Site Additional Symptom Acuity Causal Agent Type of Substance Disorder Causal Condition Laterality Complication Type of Mental Disorder The size of the circles indicates the relative frequency in which the concepts appear in the claims of a population of industry hospitals 26

27 Circling Back: Concepts Drive the Majority of Changes Key Considerations for Psychiatry: ICD-10-PCS Type of Imaging Root Operation Insertion Site Approach Laterality Type of Contrast Excision Site Quantity Type of Device The size of the circles indicates the relative frequency in which the concepts appear in the claims of a population of industry hospitals 27

28 Degenerative Disease of the Nervous System Other specified degenerative disease of the nervous system with mild cognitive impairment G Other degenerative diseases of the nervous system Type Mild cognitive impairment Other degenerative disease of the nervous system Interstitial Alpers disease Leigh s disease Dementia with Lewy bodies 28

29 Substance Abuse Cocaine abuse with intoxication with delirium F Mental & behavioral disorders d/t psychoactive substance use Type of Use Behavioral disorder Abuse Intoxication, uncomplicated unspecified Cocaine Dependence Intoxication with delirium Use Intoxication with perceptual disturbance 29

30 Documenting Pain in ICD-10-CM ICD-10-CM Documentation Requirements Documentation Concepts 1. Clarify etiology and acuity 2. If the pain is related to a psychological disorder, only the psychological disorder is captured 3. Clarify acuity for pain with a psychological component to capture SOI. 4. Is a spinal neurostimulator or intrathecal infusion pump or other methods being used to treat the patient? If so, clarify in your documentation. 30

31 Pain disorder w/ Psychological factors Document if associated with acute or chronic pain F Anxiety, dissociative, stress-related, somatoform & other nonpsychotic mental disorders Psychological factors Pain disorders related to psychological factors Exclusively related to psychological factors Psychological Factors (Code also associated with acute or chronic pain) 31

32 Electroconvulsive Therapy G Z B 3 Z Z Z Section Mental Health Body System None Root Type Electroconvulsive therapy Type Qualifier Bilateral Multiple Seizure Qualifier Qualifier Qualifier None None None Root Type: Psychological tests Crisis intervention Medication Management Individual psychotherapy Counseling Family psychotherapy Biofeedback Hypnosis Norcosynthesis Group therapy Light therapy Type Qualifier Options: Unilateral-single seizure Unilateral-multiple seizure Bilateral-single seizure Other ECT 32

33 Medication Management G Z 3 Z Z Z Z Section Mental Health Body System None Root Type Medication management Type Qualifier None Qualifier Qualifier Qualifier None None None Root Type: Psychological tests Crisis intervention Individual psychotherapy Counseling Family psychotherapy Electroconvulsive therapy Biofeedback Hypnosis Norcosynthesis Group therapy Light therapy 33

34 Outpatient Procedures & ICD-10-PCS Three Key Considerations When Documenting Procedures in the Outpatient or Ambulatory Setting 1. ICD-10-PCS is only used on inpatient procedures 2. If you do an outpatient procedure on a patient who is admitted within 3 days, then that procedure is rolled into the inpatient admission if the admission is for a related diagnosis 3. Physicians should document outpatient procedures to satisfy ICD-10-PCS, HCPCS and CPT requirements in case the patient is admitted Ensure documentation supports the severity of the patient s illness and use of resources to manage the patient. Patient status such as use, abuse, dependence and remission are determined by the physician s documentation within the medical record. 34