Today s Presenter 4/22/2015. ICD-10-CM Documentation and Diagnosis: Behavioral Health. By Tammy Jones, CPC, COC

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1 ICD-10-CM Documentation and Diagnosis: Behavioral Health By Tammy Jones, CPC, COC Today s Presenter Tammy Jones, CPC, COC SVA Healthcare Services, LLC jonest@sva.com 1

2 ICD-10 Documentation Objectives Practitioner impact Common pitfalls Keys to successful documentation ICD-10 specific examples Review impact, pitfalls and successful documentation for each example ICD-10 Documentation Background Behavioral Health diagnoses identified by TNPCA Common and usual conditions Primary or secondary Typical for the FQHC environment 2

3 DSM or ICD DSM Established 1952 Created by APA Mental disorders only Diagnostic classification Diagnostic criteria Descriptive text ICD Established 1948 Created by WHO Covers health as a whole Diagnostic classification ICD Billing 3

4 DSM Diagnosing ICD-10 Concepts Type Temporal Severity Location/laterality/anatomy Caused by/complications/ manifestations Remission 4

BH vs Primary care documentation and ICD Behavioral Health Psychotherapy and/or medical care Psychotherapy notes separate Specificity in assessment stands alone (DSM-5 no Axis) Clinical judgment

5 BH vs Primary care documentation and ICD Behavioral Health Psychotherapy and/or medical care Psychotherapy notes separate Specificity in assessment stands alone (DSM-5 no Axis) Clinical judgment applies to diagnosis choice Diagnostic criteria Subjective Primary care Medical care and/or counseling All within legal medical record Specificity in assessment may be supported by subjective and/or exam documentation Clinical judgment may or may not apply to diagnosis choice Laterality Anatomical location Behavioral ICD-10 Chapter 5 F01-F99 Anxiety Depression Tobacco Addiction Substance Abuse 5

6 Anxiety ICD-9 Code range ; ; 300.4; ; 308.0; codes ICD-10 Code range F41.0-F41.9; F codes Impacts & Pitfalls Additional documentation Type (panic, general) Templates Missing specificity (assessment options) EHR diagnosis entry/superbill How to find the correct diagnosis? Is the right code on the superbill? 6

7 Anxiety Type TLCR Episodic paroxysmal Panic type Generalized Neurosis Reaction/state Abnormal separation, childhood Success Focus on TLCR contributing factors Key word(s) Small additions to documentation Mixed, panic Update templates/superbills Add common verbiage/codes 7

8 Examples Assessment: Anxiety What s missing? F41.9 Anxiety disorder, unspecified Examples Assessment: General anxiety Better F41.1 Generalized anxiety disorder 8

9 Anxiety Anxiety F41.9 Anxiety disorder, unspecified General anxiety F41.1 Generalized anxiety disorder Depression ICD-9 Code range ; ; 298.0; 300.4; ; codes ICD-10 Code range F32.0-F33.9; F34.1; F43.21; F codes 9

10 Impacts & Pitfalls Additional documentation Type Temporal (single episode) Severity (mild, severe) Complication (w or w/o psychosis) Remission (partial, full) Templates Missing specificity (assessment options) EHR diagnosis entry/superbill How to find the correct diagnosis? Is the right code on the superbill? Depression Temporal TLCR Single episode Recurrent 10

11 Depression Type/Severity (TLCR) Mild Moderate Severe Depression Complication TLCR With psychotic features Without psychotic features 11

12 Depression Remission Status - TLCR Partial Full Success Focus on TLCR contributing factors Key word(s) Small additions to documentation Recurrent, with psychosis, remission Update templates/superbills Add common verbiage/codes 12

13 Examples Assessment: Depression What s missing? F32.9 Major depressive disorder, single episode, unspecified Examples Assessment: Recurrent moderate depression Better Subjective indicates patient experiencing hallucinations of bugs Coding query to clarify severity & psychosis F33.1 Major depressive disorder, recurrent, moderate 13

14 Depression Recurrent moderate depression F33.1 Major depressive disorder, recurrent, moderate Recurrent severe depression w psychosis F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms Tobacco ICD-9 Code range 305.1; V15.82; V65.42 Includes counseling and history of 3 codes ICD-10 Code range F F17.299; Z57.31; Z71.6; Z72.0; Z77.22 Includes counseling and history of 24 codes 14

15 Impacts & Pitfalls Additional documentation Type (dependence, use, history) Complication (pregnancy) Remission (remission, withdrawal) Templates Missing specificity (assessment options) EHR diagnosis entry/superbill How to find the correct diagnosis? Is the right code on the superbill? Tobacco Type TLCE Dependence Use History of Exposure to 15

16 Tobacco Type TLCE Chewing Cigarettes Specified product Tobacco Remission Status - TLCR Uncomplicated In remission withdrawal 16

17 Tobacco Complication TLCE Pregnancy Success Focus on TLCR contributing factors Key word(s) Small additions to documentation Dependence, use, chewing tobacco Update templates/superbills Add common verbiage/codes 17

18 Examples Assessment: Smoker What s missing? Subjective documents 1pack of cigarettes per day for years F Nicotine dependence, cigarettes, uncomplicated Examples Assessment: Mild int asthma, tobacco exposure from work Good J45.20 Mild intermittent asthma, uncomplicated Z57.31 Occupational exposure to environmental tobacco smoke 18

19 Tobacco Tobacco dependence, cigarettes F Nicotine dependence, cigarettes, uncomplicated Tobacco exposure, work Z57.31 Occupational exposure to environmental tobacco smoke Substance Abuse ICD-9 Code range ; ; ; V65.42 Includes counseling 86 codes ICD-10 Code range F F19.99; F55.0-F55.8; Z71.41; Z71.51 Includes counseling 415 codes! New category of use New specificity of complications 19

20 Impacts & Pitfalls Additional documentation Type (abuse, dependence, use) Complication (anxiety, psychosis) Remission (remission, withdrawal) Templates Missing specificity (assessment options) EHR diagnosis entry/superbill How to find the correct diagnosis? Is the right code on the superbill? Substance Abuse Type TLCR Abuse Dependent Use 20

21 Substance Abuse Type TLCR Alcohol Antacids Cannabis Cocaine Hallucinogen Herbal Etc. Substance Abuse Complication TLCR Anxiety disorder Intoxication Psychosis Mood disorder Sexual dysfunction Sleep disorder Flashbacks Dementia 21

22 Substance Abuse Complication TLCR Delirium Delusions Hallucinations Perceptual disturbance Substance Abuse Remission Status - TLCR Uncomplicated Remission Withdrawal 22

23 Success Focus on TLCR contributing factors Key word(s) Small additions to documentation Dependence, use, abuse Update templates/superbills Add common verbiage/codes Examples Assessment: Cocaine abuse What s missing? F14.10 Cocaine abuse, uncomplicated 23

24 Examples Assessment: Laxative abuse F55.2 Abuse of laxatives Examples Assessment: alcohol intoxication What s missing? F Alcohol abuse with intoxication, unspecified Coding default is abuse 24

25 Substance abuse Alcohol dependence with dementia F10.27 Alcohol dependence with alcoholinduced persisting dementia Alcohol use with dementia F10.97 Alcohol use, unspecified with alcoholinduced persisting dementia Summary Coding concepts TLCR Key words & small additions Update templates & superbills Incorporate now 25

26 Q & A 29 References ICD-10-CM Official Guidelines nloads/icd10cm-guidelines-2015.pdf American Psychiatric Association 26

27 Thank You!! Contact Information Tammy Jones, CPC, COC SVA Healthcare Services, LLC

PerformCare Provider Network Scott Daubert PhD, VP Provider Network & Account Management. AD ICD-10-CM Frequently Asked Questions

Provider Notice To: From: PerformCare Provider Network Scott Daubert PhD, VP Provider Network & Account Management Date: April 23, 2015 Subject: AD 15 105 ICD-10-CM Frequently Asked Questions The Centers