ICD-10: It s Time to Dive In

Transcription

1 Presented by: Shelly Cronin, Director ICD-10 Training

2 Format and Structure Differences from ICD-9-CM include: Some chapters have been rearranged Some titles have changed Conditions have been regrouped ICD-10 has almost twice as many categories as ICD-9 Minor changes have been made in the coding rules for mortality

3 Format and Structure ICD-10-CM consists of: Tabular lists containing cause-of-death titles and codes (Volume 1) Inclusion and exclusion terms for cause-of-death titles (Volume 1) Alphabetical index to diseases and nature of injury External causes of injury Table of drugs and chemicals (Volume 3) Description, guidelines, and coding rules (Volume 2)

4 Key Terms Combination Codes Granularity Laterality Morbidity Mortality Principal or First-listed diagnosis code Rubric

5 Laterality Example M12.15 Kaschin-Beck disease hip M Kaschin-Beck disease, right hip M Kaschin-Beck disease, left hip M Kaschin-Beck disease, unspecified hip

6 Code Structure All categories are three characters The first character of a category is a letter. The second and third characters are usually numbers Each level of subdivision after a category is a subcategory. The final level of subdivision is a code Codes may be 3, 4, 5, 6 or 7 characters Characters 4, 5, 6 or 7 may be either numbers or letters

7 Three Character Categories Each chapter begins with three character categories Chapter 1 Certain Infectious and Parasitic Diseases (A00 B99) A00 A09 Intestinal infectious diseases B15 B19 Viral hepatitis Chapter 2 Neoplasms (C00 D49) C00 C14 Lip, oral cavity and pharynx C51 C58 Female genital organs Chapter 4 Endocrine, Nutritional and Metabolic Diseases (E00 E90) E08 E13 Diabetes mellitus E65 E68 Obesity and other hyperalimentation

8 Four Character Categories The four character categories further define the site, etiology, and manifestation or state of the disease or condition Example: C15.- Malignant neoplasm of the esophagus C15.3 Malignant neoplasm of upper third of esophagus C15.4 Malignant neoplasm of middle third of esophagus C15.5 Malignant neoplasm of lower third of esophagus C15.8 Malignant neoplasm of overlapping lesion of esophagus C15.9 Malignant neoplasm of esophagus, unspecified

9 Five-Six Character Classification In ICD-10-CM, a 5th or 6th six character subclassifications represents the most accurate level of specificity Example: J10.8- Influenza due to other influenza virus with other manifestations J10.81 Influenzal gastroenteritis J10.89 Influenza with other manifestations Influenzal encephalopathy Influenzal myocarditis

10 Seventh Character Extension Certain ICD-10-CM categories have applicable seven characters The applicable seventh character is required for all codes within the category, or as the notes in the Tabular List instruct The seventh character must always be the seventh character in the data field If code is not 6 characters long, use a placeholder X

11 Seventh Character Extension ICD-10-CM utilizes a placeholder character X The X is used as a fifth or sixth character placeholder in certain codes to allow for future expansion in those sections Example: T16.1XXA Foreign body in right ear, initial encounter T16.2XXA Foreign body in left ear, initial encounter T16.9XXA Foreign body in unspecified ear, initial encounter

12 Locating a Code Locate Code in Index Verify Code in Tabular List Assign codes based on coding conventions

13 Diabetes Mellitus Diabetes mellitus is located in Chapter 3, Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders in ICD-9-CM Diabetes mellitus is located in Chapter 4, Endocrine, Nutritional and Metabolic Disorders in ICD-10-CM (E00-E89) in ICD-10-CM

14 Diabetes Mellitus There are five (5) Diabetes Mellitus categories in the ICD-10-CM to reflect the current clinical classifications of diabetes. They are: E08 Diabetes Mellitus due to an underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type I diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus

15 Diabetes Mellitus ICD-9-CM has fifth digits subclassifications that state the type of diabetes (including unspecified) and whether the diabetes is uncontrolled or not stated as uncontrolled Diabetes without mention of complication, NOS, not stated as uncontrolled ICD-10-CM has no stated unspecified code, so the default is type II and no longer classified as uncontrolled/controlled E10.11 Type 1 diabetes mellitus with ketoacidosis with coma

16 Diabetes Mellitus Combination codes are used in ICD-10-CM for diabetes The three character category shows the type of diabetes The fourth character shows the underlying conditions with specified complications The fifth character defines the specific manifestation

17 Diabetes Mellitus Examples of diabetes combination codes E08.22 Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy

18 Diabetes Mellitus In ICD-10-CM there is a code, Z79.4 long-term current use of insulin, that is used the same way we currently use V58.67 in ICD-9-CM This code is not to be added to type I diabetic patients (E10 category) or gestational diabetic patients (O24.4 subcategory)

19 Diabetes Mellitus Type II diabetic patient presents to the physician s office for a follow up visit. She has diabetic dermatitis on her left calf that will not resolve. She had recently been started on Humulin N for better diabetes control. At today s visit the doctor decides to continue the patient on insulin for another month and gives her a prescription for steroids for the skin condition. E Type 2 diabetes mellitus with diabetic dermatitis Z79.4 Long term current use of insulin

20 Neoplasms A patient may have a malignancy in two or more sites in the same organ, which may represent different primaries or metastatic disease The ICD-10-CM guidelines state to query the provider for the status of each tumor so that the correct codes can be assigned Reference: ICD-10-CM Official Draft Guideline C.2.i

21 Neoplasms A patient is found to have two distinct malignant tumors one in his right lower lobe and one in his right upper lobe C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

22 Neoplasms Laterality is also addressed in ICD-10-CM, unlike ICD-9-CM Examples: D30.02 Benign neoplasm of left kidney D04.11 Carcinoma in situ of skin of right eyelid, including canthus C40.31 Malignant neoplasm of short bones of right lower limb

23 Neoplasm Changes Malignant neoplasm breast 54 choices for male/female breast Documentation must include: Laterality Location Use of an additional code to identify estrogen receptor status (if known) C malignant neoplasm of upper-outer quadrant of the left male breast

24 Neoplasm Changes Malignant neoplasm of large and small intestine 26 choices available Specific anatomic site Example: C18.5 Malignant neoplasm of splenic flexure

25 Tobacco.. Use, History of, Dependence.. Tobacco abuse/addiction 20 choices in ICD-10-CM for nicotine dependence Documentation must include: Uncomplicated In remission With withdrawal With other nicotine induced disorders

26 Migraines Migraines with aura 32 choices available Documentation must include Intractable, not intractable, with/without status migrainosus, with vomiting, ophthalmologic, menstrual etc G Chronic migraine without aura, not intractable, with status migrainosus

27 Obstetrics At the beginning of chapter 15 the trimesters are identified as follows: 1 st trimester less than 14 weeks 0 days 2 nd trimester 14 weeks 0 days to less than 28 weeks 0 days 3 rd trimester 28 weeks 0 days until delivery The trimesters are counted from the first day of the last menstrual period.

28 Obstetrics In 2012, codes were added to indicate the weeks of gestation of the pregnancy Codes in category Z3A, weeks of gestation are added to provide additional information about the pregnancy

29 Obstetrics 7 th character fetal extensions are used in certain subcategories 0 not applicable or unspecified 1 fetus 1 2 fetus 2 3 fetus 3 4 fetus 4 5 fetus 5 9 other fetus

30 Obstetrics A 40 year-old pregnant patient comes in for a consultation for possible chromosomal abnormalities to the fetus. She is carrying a single pregnancy. O35.1xx0 Maternal care for (suspected) chromosomal abnormality in fetus, not applicable or unspecified

31 Obstetrics A pregnant patient presents to the office for a visit. She is 19 weeks, 3 days, and is diagnosed with a bladder infection caused by E. coli. The doctor told the patient to drink more water and prescribes cephalexin. She is to return in 10 days for a recheck. O23.12 Infections of bladder in pregnancy, second trimester B96.2 Escherichia coli (E. coli) as the cause of diseases classified elsewhere Z3A weeks gestation of pregnancy

32 Traumatic Fractures Chapter 19 Seventh character extenders Most include three (except for fractures) A Initial encounter D Subsequent encounter S Sequela

33 Initial vs. Subsequent Initial encounter is while receiving active treatment Surgical treatment Emergency treatment E/M by a new provider Those who seek delay for treatment of a nonunion or fracture

34 Initial vs. Subsequent Subsequent Encounter Patient has completed active care and is receiving routine fracture care during healing or recovery phase. Cast change or removal, removal of external or internal fixation devices, medication adjustment, follow up visits

35 Additional 7 th Characters Complication of fractures Nonunions K, M, N Malunions P, Q, R

36 Fractures A 14 year-old boy is at a movie theater and running in a parking lot when he was hit by a car. He was diagnosed with a nondisplaced fracture of the medial condyle of the lower end of the left femur. The leg was placed in a long leg splint and no further intervention was required. S72.435A Nondisplaced fracture of medial condyle of left femur, initial encounter for closed fracture

37 Fracture Clavicle 24 choices available Documentation must include: Laterality Example Displaced/nondisplaced Location: sternal end, shaft, lateral end, unspecified S42.011B Anterior displaced fracture of the sternal end of the right clavicle initial encounter open fracture

38 Injuries A patient presents to the emergency department after receiving a second degree burn to his left upper arm. He receives treatment and is told to follow up with his family physician. T22.232A Burn of second degree of left upper arm, initial encounter

39 Injuries A patient presents for a follow up visit. She had tried to stop her two cats from fighting. One of the cats bit her left hand and thumb without nail damage. The wound was washed and she was started on antibiotics. She presents today for a dressing change and wound check. S61.052D Open bite of left thumb without damage to nail, subsequent encounter S61.452D Open bite of left hand, subsequent encounter W55.01XD Bitten by cat

40 External Causes External cause code with appropriate 7 th character extender is used for each encounter for which the injury or condition is being treated.

41 Place of Occurrence Secondary codes for use after other external cause codes to identify the location of the patient at the time of the injury. Only used once Do not use Y92.9 (unspecified) if not stated or not applicable

42 Activity Code Describes the activity of the patient at the time of the injury Used only once at the initial encounter Do not use Y93.9, unspecified if activity is not stated

43 External Cause Status Used to indicate the work status Used only once at the initial encounter Not used for poisonings, adverse effects, misadventures or late effects Do not use Y99.9, unspecified, if not known

44 Initial Encounter Coding Initial encounters generally require four codes External cause codes Used for length of treatment Utilizes 7 th character extender Place of Occurrence Used only at initial encounter Activity code Used only once at the initial encounter External cause status Used only once at the initial encounter

45 Clinical Documentation Challenges and Training Considerations

46 Benefits of Proper Documentation Improves compliance Improves patient care Improves clinical data for research and education Protects the legal interest of the patient, facility and physician Enables proper reimbursement for services performed Achieves accurate case mix index by correctly coding from proper documentation

47 Context Look in all aspects of the medical record How does documentation tie in? Coding/billing Quality reporting Compliance

48 Documentation Challenges - Clinical Area Faces the biggest changes Coding to the highest level of specificity is needed for better data Allows you to spell out the complete condition of the patient Damage can be done to the practice long term if not accurately coded Could disrupt revenue stream, quality reporting, denials etc. Correct coding allows for immediate adjudication without additional submission of attachments

49 How to Prepare - Clinical Area Begin working with current documentation Is there enough contained to code in ICD- 10-CM Remember, ICD-10-CM has new concepts Approximately 51 different clinical concepts

50 Example HPI: 64 YO male here last 3 weeks ago for wheezing and cough. The MDI and Prednisone worked great while on the meds, the first week was great, he is sleeping now through the night. He says he is better but not like he felt when on the Prednisone. He feels the Prednisone is the only thing making him feel better over the last several months. History: Patient is a former smoker Assessment and Plan: Asthma, refills given on meds and patient educated on triggers. Pt to return following PFT or sooner if not any better. Singular 10 mg 1 po qd; Proair HFA 108 (90 bse) mcg/ac 2 puffs q4h prn; Orders: pulmonary function test

51 Example ICD-10-CM J Unspecified asthma, uncomplicated Need additional code to identify Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke in perinatal period (P96.81) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17-) Tobacco use (Z72.0)

52 J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J Unspecified asthma with (acute) exacerbation J Unspecified asthma with status asthmaticus J Exercise induced bronchospasm J Cough variant asthma J Other asthma

53 Intermittent Mild Persistent Moderate Persistent Severe Persistent Symptoms 2 or less days per week More than 2 days per week Daily Throughout the day Nighttime Awakenings 2 X s per month or less 3-4 X s per month More than once per week but not nightly Nightly Rescue Inhaler Use 2 or less days per week More than 2 days per week but not daily Daily Several times per day Interference with Normal activity None Minor limitation Some limitation Extremely limited Lung Function FEV1 >80% predicted and normal between exacerbations FEV1 >80% predicted FEV % predicted FEV1 less than 60% predicted

54 Subjective CC: Patient presents with c/o cough HPI: 34 year-old female patient presents for establishment, moved here from another state. She states that for 2 weeks she has had a productive cough of yellow/green phlegm. She states that her chest hurts when she cough but denies fever/chills. She does report that "both ears hurt" also. Diabetes. Type 2 diabetes with neuropathy. 7 8 years Patient feeling well. Taking medication as prescribed, see flow sheet. Inconsistently following recommended diet. Patient is exercising sporadically. Patient is taking Ace Inhibitor. Glucose Monitoring: Yes. Patient uses once a day Hypoglycemic Episodes: Occasional. Patient checks feet regularly. Patient reports on her last eye exam that the physician noted some macular edema and this is confirmed via her medical records. Last flu shot was given: December, Personal Habits: Cigarette Use: Current Cigarette Smoker cigarettes daily for 20 years. Alcohol: Denies alcohol use. Drug Use: Denies Drug Use. Objective: Example BP: 130/82 Pulse: 72 T; 96 9 Ht: 62" 5'2" WT: 212lb BMI: 38.8

55 Exam: Const: Appears well and comfortable. Appears to be stable in weight although morbidly obese. No signs of apparent distress present. ENMT: Auditory canals normal. Tympanic membranes: effusion. Nasal mucosa is pink and moist. Dentition is in good repair. Posterior pharynx shows irritation, but no exudate or redness. Neck: Palpation reveals left anterior lymphadenopathy No masses appreciated. Thyroid exhibits no thyromegaly. Musculo: Walks with a normal gait. Skin: Skin is warm and dry Assessment #1: Diabetes Mellitus W/o Complications Type II with retinopathy Plan: HIS MICROALBUMIN.IS ELEVATED.WILL RECK IN 6MO AND THEN EVAL. IF STILL UP. CONT TO WATCH DIET AND WEIGHT. MOD. DAILY EXCERCISE WOULD HELP. Med Current: Onetouch Ultra Test Strips bgm bid dx: dm ii Glyburide 5 mg 1 po bid Aetas 45 mg 1 PO qd, Metformin 1,000 mg 1 po bid Immunizations: Administered: H1N1 Vaccine Administration Administered: Influenza Virus Split 3 Yrs And Above For Intramuscular Use Administered: Pneumococcal Vaccine 2Yrs Or Older Assessment #2: Upper Respiratory Infections Acute, viral

56 Documentation Evaluations Identify most frequently used ICD-9-CM codes now Pull charts and begin to evaluate documentation Can you assign a code? Provide education and guidance Outsource if no internal resources-but don t skip!

57 Areas Impacted by Change.

58 Policies and procedures Disease management tracking Physician Quality Reporting System (PQRS) Working with vendors System upgrades Coordinating education Workflow changes Manager s office Assess Practice Management Systems for compatibility

59 Hardware/Software upgrades Mapping Timelines Testing Information Technology Ensure providers have tools to simplify the code selection process

60 Budgets System upgrades Education/Training Finance

61 Clinical areas Nurses Documentation in medical records Advanced Beneficiary Notices (ABN) Ordering tests Changes to charge tickets (superbills, encounter forms)

62 Documentation in the medical record Increased level of specificity Ordering tests Providers Code selection in an EMR Identify the elements required to allow for precise selection of code(s)

63 Billers/Coders Anatomy and Pathophysiology Code set Guidelines Payer policies Local Coverage Determinations (LCD) National Coverage Determinations (NCD) Prior authorizations Worker s Compensation/Auto carriers

64 Front desk Upgrades to systems First contact with patients so education will be required to assist patients in understanding: Changes in deductibles Why the change is taking place What will happen if the payer is not ready Think about how confused the patients will be in trying to understand these changes

65 Importance of preparing Even though the date of implementation was delayed until October 1, 2014 A practice may put themselves at risk by waiting to prepare for the transition to ICD-10 Small inefficiencies will be magnified with the implementation of ICD-10 if they are not identified and corrected prior to the transition

66 Potential negative impacts Decreased productivity Interrupted cash flow Increased amount of rejections Incompatible systems Increased volumes of work Incorrect mapping Increased risk of payer audits

67 Champions of Change Make sure providers and staff are aware of potential risks Communication is key Try to keep the conversations about ICD- 10 positive Providers will not feel an immediate benefit from using more precise codes Be empathetic!

68 Strategies for Success The first place to begin in preparing for ICD-10 implementation is with communication Keep everyone updated on what is happening If you take it seriously, so will the people you are leading What form of communication will be most effective in your office/institution Complete an Impact analysis Build an action plan Measure productivity

69 Together We Can Do It!