Sponsored by: INOVA August 19, Presented by: Teri Romano, RN, MBA, CPC, CMDP CONNECT WITH US AT

Transcription

1 Sponsored by: INOVA August 19, 2015 Presented by: Teri Romano, RN, MBA, CPC, CMDP CONNECT WITH US AT 2 1

2 FOCUS Documentation! Diagnosis codes that get paid. Diagnosis codes that accurately portray your patient population. 3 ICD 9 is out of date and running out of space for new codes. ICD 10 is the international standard to report and monitor disease and mortality USA must adopt for reporting and surveillance. ICD codes are core elements of many health information technology systems making the conversion to ICD 10 CM necessary to fully realize benefits of HIT adoption. It is mandated by CMS for all HIPAA covered entities. 4 2

3 Today payors use diagnosis codes to: Deny payment based on a lack of medical necessity/wrong ICD 10 code. Build payment policies based on specific diagnosis codes. Today and future payors will use diagnosis codes to Establish reimbursement in risk based contracting models. Determine payment in ACO ( shared savings) and bundled payment models. Determine patient complexity to justify inpatient status and establish postop visit benchmarks. Source: Downloads/ICD 10 guidance.pdf 5 ICD 9 CM 3 5 characters in length Approximately 14,000 codes Limited space for adding new codes Lacks detail vs. ICD 10 CM 3 7 characters in length Approximately 69,000 codes Flexibility for adding new codes Very specific 6 3

4 ICD 9 CM Code Structure ICD 10 CM Code Structure 7 Chapters First Pertinent to Character Breast Surgery C, D Neoplasms N Genitourinary (Breast) N R Z Symptoms/Signs Other Reasons for Health Care Category Etiology, Anatomic Site, Severity Extension 8 4

5 ICD 10 says: Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Examples: You send the patient to their cardiologist for a pre op evaluation for co existing cardiac conditions. The patient has ESRD and you request clearance by his physician. 9 Action: Code the primary reason for the visit (breast cancer) and the underlying conditions if they affect your treatment/surgical plan. Why? Accurately portray the complexity of your patient population. Patient complexity will impact payment models, risk based contracting, ACOs, and bundled payments. Patient complexity also impacts inpatient status, number of postop visits and more. 10 5

6 Asthma Kidney Disease Nicotine Dependence Diabetes Obesity/BMI COPD HTN/Angina/Heart Disease Alcohol Abuse/ Dependence/Use Other? Personal History of Other or Other Specified Use when information in the medical record provides needed detail, but a specific code does not exist. Examples: N64.89 Other specified disorders of the breast Galactocele 12 6

7 13 Unspecified Use when the information in the medical record is insufficient to assign a more specific code. Beware of unspecified codes! Denial risk! Example: K64.9 Disorder of breast, Unspecified 13 Laterality of one of the biggest changes in coding for disorders of the breast For example: C Malignant neoplasm of lower inner quadrant of right female breast C Malignant neoplasm of lower inner quadrant of left female breast Tip: For laterality often a 1 in a code will indicate right, a 2 will indicate left. Tip: No bilateral code exists. If the diagnosis is bilateral, use both the right and left codes. 14 7

8 Utilize technology to facilitate finding the right code! EMR, and more! 15 CHAPTER 18: SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS 16 8

9 Chapter Organization R00 R99 R Category Etiology, Anatomic Site, Severity Extension 17 Do code signs and symptoms if a definitive diagnosis is not known. You see a patient with abnormal mammogram prior to a biopsy. Do not code signs and symptoms if a more definitive diagnosis is known. For example, don t code abnormal mammogram if the biopsy shows cancer. 18 9

10 Abnormal Mammogram ICD 9 ICD Abnormal mammogram, R92.0 Mammographic microcalcification unspecified found on diagnostic imaging of breast Mammographic R92.1 Mammographic calcification found on microcalcification diagnostic imaging of breast Inconclusive mammogram R92.2 Inconclusive mammogram Other (abnormal) findings on R92.8 Other abnormal and inconclusive radiological examination of findings on diagnostic imaging of breast breast 19 Abnormal Mammogram Do NOT Say: Abnormal mammogram DO Say: Microcalcification found on mammogram 20 10

11 CHAPTER 14: DISEASES OF THE GENITOURINARY (INCLUDES BREAST) 21 Chapter Organization N00 N99 N Category Etiology, Anatomic Site, Severity Extension 22 11

12 Breast Disorders ICD 9 ICD Lump or mass in breast N63 Unspecified lump in breast Inflammatory disorder of breast N61 Inflammatory disorder of breast 23 Breast Cyst (N60. ) ICD Solitary cyst of breast ICD 10 N60.01 Solitary cyst of right breast N60.02 Solitary cyst of leftbreast N60.09 Solitary cyst of unspecified breast 24 12

13 Cyst in Breast Do NOT Say: Breast cyst (N60.09, unspecified) DO Say: Cyst right breast (N60.01) 25 Diffuse Cystic Mastopathy (N60. ) ICD Diffuse cystic mastopathy ICD 10 N60.11 Diffuse cystic mastopathy right breast N60.12 Diffuse cystic mastopathy of left breast N60.19 Diffuse cystic mastopathy cyst of unspecified breast Cystic breast, fibrocystic disease of breast

14 Other Breast Disorders ICD 9 ICD Hypertrophy of breast N62 Hypertrophy of breast Fissure of nipple N60.02 Fissure and fistula of breast Fat necrosis of breast N64.1 Fat necrosis of breast Atrophy of breast N64.2 Atrophy of breast Galactocele N64.8 Other disorders of the breast Other signs and symptoms in breast N64.51 N64.52 N64.53 N64.59 Induration Nipple discharge Retraction of nipple Other 27 Fibroadenosis of Breast ICD Fibroadenosis of breast ICD 10 N60.21 Fibroadenosis of right breast N60.22 Fibroadenosis of left breast N60.29 Fibroadenosis of unspecified breast 28 14

15 CHAPTER 2: NEOPLASMS 29 Chapter Organization C00 D49 C or D Category Etiology, Anatomic Site, Severity Extension Image source:

16 Most significant changes in ICD 10 Laterality. Now codes for right or left breast Male breast cancer codes expanded. Mirror female anatomic sites and laterality 31 Category of Neoplasm Type of Neoplasm Malignant, primary Malignant, secondary Carcinoma in situ Benign Uncertain behavior Unspecified Information Cancer, first site Metastatic site The risk of transforming to cancer is high Non cancer Histologic diagnosis made by pathologist, morphology of tumor is uncertain The pathology is unknown at the time of encounter 32 16

17 Overlapping sites should be classified to a.8 code unless a combination code exists. Example: C50.8. Malignant neoplasm of overlapping sites of breast 33 Primary Malignancies With overlapping site boundaries Without overlapping boundaries A primary malignancy that overlaps two or more contiguous sites should be For multiple neoplasms that are not classified to the subcategory.8 contiguous code for each site overlapping lesions, unless there is a combination code. Example: Malignant neoplasm of overlapping sites of left female breast C Example: Breast areola C50.9 Breast lower outer quadrant C

18 History of vs. Active neoplasms codes No further treatment no further treatment then use a Z85. code Example: Z85.3 Personal history of malignant neoplasm of breast [Follow up visit 3 years post surgical resection with no evidence of disease] 35 Breast Neoplasms Location Malignant Primary Malignant Secondary Ca in situ Benign Uncertain Behavior Unspecified Connective tissue, C50.9 C79.81 D05. D24. D48.6 D49.3 glandular soft parts Areola C50.0 C79.81 D05. D24. D48.6 D49.3 Axillary tail C50.6 C79.81 D05. D24. D48.6 D49.3 Central portion C50.1 C79.81 D05. D24. D48.6 D49.3 Inner C50.8 C79.81 D05. D24. D48.6 D49.3 Lower C50.8 C79.81 D05. D24. D48.6 D49.3 Lower inner C50.3 C79.81 D05. D24. D48.6 D49.3 Lower outer C50.5 C79.81 D05. D24. D48.6 D49.3 (More by site) 36 18

19 C50.2 C50.21 C50.22 Malignant neoplasm of upper inner quadrant of breast Malignant neoplasm of upper inner quadrant of female breast C Malignant neoplasm of upper inner quadrant of right female breast C Malignant neoplasm of upper inner quadrant of left female breast C Malignant neoplasm of upper inner quadrant of unspecified female breast Malignant neoplasm of upper inner quadrant of male breast C Malignant neoplasm of upper inner quadrant of right male breast C Malignant neoplasm of upper inner quadrant of left male breast C Malignant neoplasm of upper inner quadrant of unspecified male breast 37 Breast Cancer Do NOT Say: Breast cancer (C50.919, unspecified) DO Say: Breast cancer in the lower inner quadrant, right breast (C50.311) 38 19

20 This code category has been expanded to include more specific types of carcinoma in situ. ICD 9 CM (1code) Carcinoma in situ of breast ICD 10 CM (12 codes) D05.00 Lobular carcinoma in situ of unspecified breast D05.01 Lobular carcinoma in situ of right breast D05.02 Lobular carcinoma in situ of left breast D05.10 Intraductal carcinoma in situ of unspecified breast D05.11 Intraductal carcinoma in situ of right breast D05.12 Intraductal carcinoma in situ of left breast D05.80 Other type of carcinoma in situ of unspecified breast D05.81 Other specified type of carcinoma in situ of right breast D05.82 Other specified type of carcinoma in situ of left breast D05.90 Unspecified type of carcinoma in situ of unspecified breast D05.91 Unspecified type of carcinoma in situ of right breast D05.92 Unspecified type of carcinoma in situ of left breast 39 Breast Cancer Do NOT Say: Cancer in situ, breast ( D50.90, unspecified) DO Say: Lobular carcinoma in situ, left breast (C50.02) 40 20

21 These codes have equivalent mapping with ICD 9 CM. Personal hx of malignant neoplasm of breast V10.3 = Z85.3 Family hx of malignant neoplasm of breast V16.3 = Z ICD 9 CM V82.71 Screening for genetic disease carrier status ICD 10 CM Z13.71 Encounter for non procreative screening for genetic disease carrier status Z13.79 Encounter for other screening for genetic and chromosomal anomalies 42 21

22 43 ICD 10 CM Descriptor ICD 9 CM Descriptor N99.61 Intraoperative hemorrhage and hematoma of a genitourinary system structure complicating a genitourinary system procedure Intraoperative hemorrhage and N99.62 hematoma of a genitourinary system structure complicating other procedure N99.71 Accidental puncture and laceration of a genitourinary system system structure during a genitourinary system procedure N99.72 Accidental puncture and laceration of a genitourinary system structure during other procedure N99.81 Other intraoperative complications and disorders of genitourinary system Hemorrhage complicating a procedure Hematoma complicating a procedure Hemorrhage complicating a procedure Hematoma complicating a procedure Accidental puncture or laceration during a procedure, not elsewhere classified ICD 10 CM Descriptor ICD 9 CM Descriptor Postprocedural hemorrhage and Hemorrhage complicating a hematoma of a genitourinary procedure N system structure following a Hematoma complicating a genitourinary system procedure procedure Postprocedural hemorrhage and hematoma of a genitourinary N system structure following other procedure N99.89 Other postprocedural complications and disorders of the genitourinary system Hemorrhage complicating a procedure Hematoma complicating a procedure Complications affecting other specified body systems, not elsewhere classified 44 22

23 WHAT NOW?? NEXT STEPS. 45 IDENTIFY YOUR TOP PRIMARY ICD 9 CODES 46 23

24 47 The Books CMS Your EHR/practice management information system. Content Types/ICD 10 Logo.jpg assn.org/store/catalog/productdetail.jsp?product_id=prod &navaction=push coding.html 47 ICD 9 Code ICD 10 Code and Description Potential Documentation Gaps 48 24

25 EHR develop favorite pick list Cheat sheets: create reference guides by physician 49 AKA: Prospective Gap Analysis DUAL CODE: ICD 9 CM AND ICD 10 CM 50 25

26 USING YOUR EMR AND OTHER TECHNOLOGY UNDERSTAND THE LIMITATIONS!! 51 THANK YOU Teri Romano RN, MBA, CPC, karenzupkoandassociates 26