2014 Intro to ICD-10-CM 1 Hour Part 1

Transcription

1 2014 Intro to ICD-10-CM 1 Hour Part 1 Presenter Name, Credential(s) Presenter Title Date

2 Can Help Make a Difference Introduction Optum collaborates with health care professionals and health plans towards improved health outcomes. Optum provides tools and support to assist providers in the early detection, ongoing assessment and accurate reporting of chronic conditions for Medicare and Medicaid patients. Optum applies technology and health intelligence solutions that help providers accurately document and code health care services while improving the overall quality of patient care. Propriety and Confidential. Do not distribute. 2

3 Course Disclaimer The information presented in this course complies with accepted coding practices and guidelines as defined in the ICD-9-CM and ICD- 10-CM coding books. It is the responsibility of the physician or other healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM and ICD-10-CM code(s) according to the guidelines. If the clinical information in the medical record does not support a given code, that code cannot be used. Propriety and Confidential. Do not distribute. 3

4 Bolding Legend Due to the updated, clinically revised CMS-HCC risk adjustment model for Payment Year 2014, the bolding of ICD-9-CM codes has been revised to reflect: Red = Risk adjusts in only the 2013 CMS-HCC model Black = Risk adjusts in both the 2013 CMS-HCC model and the 2014 CMS- HCC model Orange = Risk adjusts in only the 2014 CMS-HCC model Note: The 2014 Payment Year model is a blend of the 2013 CMS-HCC model (25%) and the 2014 CMS-HCC model (75%). Propriety and Confidential. Do not distribute.

5 Agenda CMS Directive Introduction to ICD-10-CM Documentation requirements Advantages of ICD-10-CM implementation Comparing the code sets ICD-10-CM relevance to documentation & coding ICD-10-CM code book usage (Index & Tabular) Coding Chronic Conditions with the Greatest Medicare Risk Adjustment Impact with ICD-9-CM and ICD-10-CM Comparison: Diabetes mellitus (DM) Preparing for ICD-10-CM: Clinical Documentation Improvement Propriety and Confidential. Do not distribute. 5

6 CMS The Directive The Mandate from CMS Any condition that is taken into account or affects patient care, treatment or management should be documented and ultimately coded. The listing of all pertinent diagnosis codes is important! The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), (2011, October). ICD-9-CM official guidelines for coding and reporting. Retrieved October 20, 2011, from Department of Health and Human Services (DHHS) Web site: Propriety and Confidential. Do not distribute. 6

7 CMS Chronic Conditions Outpatient Coding: Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care, treatment, or management. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), (2011, October). ICD-9-CM official guidelines for coding and reporting. Retrieved October 20, 2011, from Department of Health and Human Services (DHHS) Web site: Propriety and Confidential. Do not distribute. 7

8 Documentation Requirements Implementing documentation to the highest level of specificity today is key to a successful ICD-10-CM transition.

9 Why Documentation & Coding is Important Good documentation assures that all of the patient s medical conditions are addressed. It allows better communication between providers. It allows claims to be paid correctly. It is used in research and education. Accurate coding of conditions is needed for accurate and appropriate reimbursement for Risk Adjustment. Documentation is key if not documented, it cannot be coded. ICD-9-CM coding must be to the highest level of specificity. Avoid inappropriate and/or unnecessary use of unspecified codes. Propriety and Confidential. Do not distribute. 9

10 Clinical Specificity in Documentation Clinical specificity involves having a diagnosis fully documented in the source medical record instead of routinely defaulting to a general term or an unspecified diagnosis. Remember, the practice of specific documentation and coding of the diagnoses can have an impact on E/M and procedural reimbursement due to Medical Necessity. The following examples involve situations in which a physician uses the most common code for all forms of a disease or condition. Diabetes: Hypertension: Chronic Obstructive Pulmonary Disease: 496 CMS-Centers for Medicare & Medicaid Services, 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide. Leading Through Change, Inc Propriety and Confidential. Do not distribute. 10

11 A Joint Effort is Essential Communication with the provider is perhaps one of the key elements in improving documentation skills that allow for more specific coding. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and conditions treated. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), (2011, October). ICD-9-CM official guidelines for coding and reporting. Retrieved October 20, 2011, from Department of Health and Human Services (DHHS) Web site: Propriety and Confidential. Do not distribute. 11

12 Documentation Requirements Validates that services were provided Ensures continuity of care Verifies that services provided are reported with accuracy Both coding and documentation must be in sync on any day of service Document with clinical and legal implications Supports medical necessity Centers for Medicare & Medicaid Services, (1995) documentation guidelines for evaluation & management services. Retrieved from Propriety and Confidential. Do not distribute. 12

13 Medical Necessity Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. 1 Medical necessity can only be portrayed on the claim form by accurate and complete diagnostic coding. What is reported in diagnostic coding on the claim form must match exactly what is documented in the progress note. Failure to accurately report medical necessity on the claim form may result in claim delays, denials or even post-payment review recoupments. 2 1 Centers for Medicaid & Medicare Services. "Medicare Claims Processing Manual, Chapter 12." Physicians/Nonphysician Practitioners - Selection of Level of Evaluation and Management Service, (Rev. 1875, Effective: , Implementation: ), A. Use of CPT Codes) (2009): n. page. Print. 2 Health and Human Services. "HHS OIG Work Plan FY 2012: Part I: Medicare Part A and Part B."Evaluation and Management Services: Trends in Coding of Claims & Evaluation and Management Services: Potentially Inappropriate Payments (p 1-19); Medical Claims Review at Selected Providers (Pg. I-24). (2012): Print. B.pdf Propriety and Confidential. Do not distribute. 13

14 The Goal of Better Documentation 1 Keep in mind that nonspecific codes are still available when necessary. The goal here is not to eliminate the use of all unspecified codes. There are times when even the clinician doesn t have the information about the disease process necessary for assigning a more specific code. The goal, however, is to work toward better documentation in order to: avoid misinterpretation by third parties, justify the medical necessity of the services, provide a more accurate clinical picture of the quality of care provided, and support current and future initiatives aimed at improving quality and reducing cost. Any issues related to inconsistent, missing, conflicting, or unclear documentation will still have to be resolved by the provider, just as they are today. 1 Nguyen, Leah. ICD-10 Implementation Strategies and Planning." National Provider Teleconference. Centers for Medicare & Medicaid Services. November 17, 2011, 1:30 p.m. ET. Web Site: Propriety and Confidential. Do not distribute. 14

15 Use of Sign/Symptom/Unspecified Codes in ICD-10-CM In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the health care encounter. Each health care encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. ICD-10 News: CMS Releases ICD-10-PCS Files, Centers for Medicare & Medicaid Services cmslists@subscriptions.cms.hhs.gov, News Updates May 17, 2013 Propriety and Confidential. Do not distribute. 15

16 MEAT the Requirement To determine whether a chronic medical condition can be coded, does the documentation: Monitor the condition Functioning colostomy V44.3 (Z93.3) Evaluate the condition ESRD, noncompliant with dialysis 585.6, V45.12 (N18.6, Z91.15) Assess/Address the condition COPD stable on albuterol 496 (J44.9) Treat the condition Let s try OTC Advil for the LBP (M54.5) Propriety and Confidential. Do not distribute. 16

17 Documentation Be Specific The medical record must thoroughly document all conditions evaluated. Evaluative documentation would include statements such as: Stable on meds. Patient s depression is stable on Paxil Condition worsening; medication adjusted. Atrial fib has worsened; Lanoxin has been adjusted to Condition improving. s/p CVA with right-sided hemiparesis improving Tests ordered; documentation reviewed. Repeat GFR remains at 47 CKD Stage III 1 Centers for Medicare & Medicaid Services, (1995) documentation guidelines for evaluation & management services. Retrieved from Propriety and Confidential. Do not distribute. 17

18 Advantages of ICD-10-CM Implementation

19 Purpose and Benefits of ICD-10-CM Transition Greater specificity and enhanced clinical information (Granularity) Improves ability to measure research, statistics and other means of health care services This granularity is good for government researchers tracking disease in the United States, because such statistics can help drive health care reform, research, and other payment systems. Increases sensitivity when refining grouping and reimbursement methodologies Supports important payer decisions regarding the most effective course and appropriation of treatment Granularity Creates Enhances ability to conduct public health surveillance an Accurate Picture Aids in improvement of social programs and of Complexity appropriation of necessary funding by congress for such programs. Ingenix, Detailed Instruction for Appropriate ICD-10-CM Coding; An educational guide to the structure, conventions, and guidelines of ICD-10-CM coding. West Valley City, UT: OptumInsight, p Print. Propriety and Confidential. Do not distribute. 19

20 Comparing the Code Sets

21 Comparison: Diagnosis Code Sets ICD-9-CM vs. ICD-10-CM Code Sets Current Code Set Purpose New Code Set ICD-9-CM Volumes 1 & 2 ICD-9-CM Volume 3 Used for inpatient & outpatient diagnosis coding Used for inpatient procedures ICD-10-CM ICD-10-PCS Propriety and Confidential. Do not distribute. 21

22 ICD-10-CM: Introduction ICD-10-CM has been updated to reflect current clinical understanding and technological advancements of medicine. Code descriptors are designed to provide a more consistent level of detail This coding system contains more extensive vocabulary of: Clinical concepts Body part specificity Patient encounter information Other components from which codes are built American Academy of Professional Coders. Introduction to ICD-10-CM for Providers, Vol. 2. Salt Lake City, UT: AAPC, p Print. Propriety and Confidential. Do not distribute. 22

23 ICD-9-CM vs. ICD-10-CM: Some Basic Differences ICD-9-CM ICD-10-CM Outdated: Updated: Oct 1, chapters 14,000+ codes 2 supplementary chpts. (V & E codes) Numeric categories No placeholders No room for future expansion 21 chapters 68,000+ codes No supplementary chpts. (Incorporated within ICD-10-CM Tabular) Alphanumeric categories X placeholders To allow for future expansion of certain codes American Academy of Professional Coders. Introduction to ICD-10-CM for Providers, Vol. 2. Salt Lake City, UT: AAPC, p. 8. Print. Propriety and Confidential. Do not distribute. 23

24 ICD-9-CM vs. ICD-10-CM: Some basic differences ICD-9-CM Structure - With & Without Codes Without = 0 With = 1 Default = Without Structure ICD-10-CM - With & Without Codes 5-Character Codes Without = 0 With = 1 6-Character Codes Without = 9 With = 1 Default = Without American Academy of Professional Coders. Introduction to ICD-10-CM for Providers, Vol. 2. Salt Lake City, UT: AAPC, p. 8. Print. Propriety and Confidential. Do not distribute. 24

25 Comparison of ICD-9-CM vs. ICD-10-CM Feature ICD-9-CM ICD-10-CM Code Set ICD-9-CM (Vol. I & II) ICD-10-CM (Clinical Modification) Structure Minimum of 3 digits; maximum of 5 digits with a decimal point after the 3 rd digit. Numeric, except for supplementary codes - V & E codes Structure of injuries designated by wound type Minimum of 3 digits; maximum of 7 digits with a decimal point after the 3 rd digit. Alphanumeric with all codes using an alphabetic lead character (A-Z, except U). V & E codes have been eliminated and incorporated into the main code set. Structure of injuries designated by body part (location) No laterality (left vs. right) Laterality (left vs. right) X X X X X X X X X X X X Format Category Significant axis such as anatomical site Etiology or disease manifestations Sub-classification (e.g. mode of diagnosis; anatomical site) Category Etiology (i.e. cause) anatomic site, manifestation Extension: visit, encounter or sequelae for injuries & external causes Propriety and Confidential. Do not distribute. 25

26 ICD-10-CM Relevance to Documentation and Coding

27 ICD-10-CM Requires Improved Documentation Making the Transition to ICD-10-CM Means: Changing the language of medical documentation to a higher level of specificity Documentation improvement must reflect the growing need for quality data for: Improved patient safety Improved quality of care Improved public health monitoring Improved bio-terrorism monitoring Changing the coding of highly specified documentation to alpha-numeric digits that can be used for accurate and efficient billing Changing all systems and operational processes that utilize coding systems to accommodate the ICD-10-CM implementation transition American Academy of Professional Coders. Introduction to ICD-10-CM for Providers, Vol. 2. Salt Lake City, UT: AAPC, p. 8. Print. Propriety and Confidential. Do not distribute. 27

28 ICD-10-CM Coding - Expected Pitfalls Acute Asthma with Exacerbation (Unspecified) It is expected that ICD-10-CM codes will be defaulted to unspecified code assignment, and the clinical detail of ICD-10-CM will be ignored. There are several reasons for this: Unspecified as: - Mild Intermittent - Mild Persistent - Moderate Persistent - Severe Persistent J Changing old habits is difficult Standard assumptions that assigning unspecified codes carry little risk There is vague understanding with regard to Medicare Risk and resource allocation by documenting and assigning codes to a higher level of specificity Standard assumptions support no economic benefit to detailed documentation and coding American Academy of Professional Coders. Introduction to ICD-10-CM for Providers, Vol. 2. Salt Lake City, UT: AAPC, p Print. Propriety and Confidential. Do not distribute. 28

29 ICD-10-CM Coding - Expected Pitfalls Overutilization of unspecified codes does not wholly explain a Medicare Advantage member s legitimate increases in condition severity. From a clinical coding and compliance standpoint: Assignment of unspecified codes when greater specificity is warranted is inaccurate - and plays right into Medicare s viewpoint of the need for documentation and coding adjustment to promote changes in coding patterns that accurately reflect patient severity. 1, 2 1 Medicare Payment Advisory Commission, Centers for Medicare & Medicaid Services. (2009, June 29). Proposed fy2010 ms-drg documentation and coding adjustment to payments in the ipps (re: file code cms-1406-p) (CMS-1406-P). Department of Health & Human Services. 2 CMS-Centers for Medicare & Medicaid Services, 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide. Leading Through Change, Inc Propriety and Confidential. Do not distribute. 29

30 Specific Documentation: Laterality & Anatomic Site Term Chalazion Coding Component Documentation must specify laterality and anatomic site: Right upper eyelid Right lower eyelid Right eye, unspecified eyelid Left upper eyelid Left lower eyelid Left eye, unspecified eyelid Unspecified eye, unspecified Codes H00.11 Chalazion, right upper eyelid H00.12 Chalazion, right lower eyelid H00.13 Chalazion right eye, unspecified eyelid. H00.14 Chalazion, left upper eyelid H00.15 Chalazion, left lower eyelid H00.16 Chalazion left eye, unspecified eyelid. H00.17 Chalazion unspecified eye, unspecified Unfortunately, many will be tempted to assign the unspecified type codes, which may hinder the necessary specificity or granularity for placing Medicare Advantage members into the appropriate risk category for expected resource utilization. OptumInsight, Detailed Instruction for Appropriate ICD-10-CM Coding; An educational guide to the structure, conventions, and guidelines of ICD-10-CM coding. West Valley City, UT: OptumInsight, p Print. Propriety and Confidential. Do not distribute. 30

31 Specific Documentation: Anatomic Site & Manifestation Term Coding Component Codes Sarcoidosis Specify anatomic site and/or nature of manifestation: D86.0 Sarcoidosis of lung D86.1 Sarcoidosis of lymph D86.83 Sarcoid iridocyclitis D86.84 Sarcoid pyelonephritis nodes D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes D86.85 Sarcoid myocarditis D86.86 Sarcoid arthropathy D86.3 Sarcoidosis of skin D86.87 Sarcoid myositis D86.8 Sarcoidosis of other sites D86.89 Sarcoidosis of other sites D86.81 Sarcoid meningitis D86.9 Sarcoidosis, unspecified D86.82 Multiple cranial nerve palsies in sarcoidosis Unfortunately, many will be tempted to assign the unspecified type codes, which may hinder the necessary specificity or granularity for placing Medicare Advantage members into the appropriate risk category for expected resource utilization. OptumInsight, Detailed Instruction for Appropriate ICD-10-CM Coding; An educational guide to the structure, conventions, and guidelines of ICD-10-CM coding. West Valley City, UT: OptumInsight, p Print. Propriety and Confidential. Do not distribute. 31

32 Analyze Documentation With all of the attention around the increase specificity of ICD-10-CM codes, coders may be concerned that documentation will lack sufficient detail. What to do? Determine which conditions the providers at specific facilities or practice most often treat Evaluate the documentation to see what additional information providers will need to document with the added specificity. Identify the information that providers can document now in comparison with details needed for the current ICD-10-CM draft the additional information may not help now with ICD-9-CM; however, it will help prepare for such documentation details when ICD-10-CM is fully implemented. Avoid the unspecified type codes! Take the fear out of switch to ICD-10-CM. Just Coding. HCPro, Inc., 15 Nov Web. 5 Jan Propriety and Confidential. Do not distribute. 32

33 Encourage Documentation Specificity Some things that weren t important in ICD-9-CM will be needed in ICD-10-CM. Example: A patient presents with acute pancreatitis and is also a chronically dependent alcoholic. ICD-9-CM: Assign acute pancreatitis (577.0) and a code for other and unspecified chronic alcohol dependence (303.91) with no need to identify that the two conditions are interrelated. ICD-10-CM: Specificity is needed in this statement to describe that the two conditions (pancreatitis and alcohol dependence) are interrelated. This example could prompt a query to the provider because there is a more specific combination code that can be assigned to identify the conditions being related code K85.2 (Alcohol induced acute pancreatitis). See example next slide Take the fear out of switch to ICD-10-CM. Just Coding. HCPro, Inc., 15 Nov Web. 5 Jan Propriety and Confidential. Do not distribute. 33

34 Encourage Documentation Specificity Example: A patient presents with acute pancreatitis and is also a chronically dependent alcoholic. Note here that in ICD-10-CM, there are two possible ways this described pancreatitis can be coded. a. K providing that additional documentation identifies that the two conditions are interrelated Encourage Specific Documentation! b. K providing that no additional documentation supports that the two conditions are interrelated "Take the fear out of switch to ICD-10-CM." Just Coding. HCPro, Inc., 15 Nov Web. 5 Jan Propriety and Confidential. Do not distribute. 34

35 Documentation Specificity Challenges Physicians may not be accustomed to being asked for correlation of some conditions as exemplified here because in the past it wasn t relevant to appropriate code assignment. Know that the specificity is necessary in order to code many conditions in ICD-10-CM. ICD-10-CM Index For Comparison: ICD-9-CM: Coders were able to report certain conditions that were not specifically clear. Example: When providers document the diagnosis urosepsis, it is not clear as to whether they mean a UTI or sepsis of a urinary source. In a situation such as this, coders can simply look up urosepsis in the index and cross walk to the tabular code (599.0) for urosepsis, unspecified. ICD-10-CM: urosepsis will no longer have an unspecified default code in ICD-10-CM, which will prompt coders to go back to the providers for clarification of specific condition. "Take the fear out of switch to ICD-10-CM." Just Coding. HCPro, Inc., 15 Nov Web. 5 Jan Propriety and Confidential. Do not distribute. 35

36 ICD-10-CM Code Book Usage: The Index & Tabular

37 ICD-10-CM Index The Alphabetic Index (Volume 2) is organized in the same manner as ICD-9-CM. Punctuations are the same & codes are listed by: Condition (Anomalies, disorder, complications, disease, injury, fracture, etc.) Main Term (describing the disease and/or condition. Nonessential modifiers are found after the main term in parentheses) Subterm (Specific subclassification such as acute or chronic; indented 2 character spaced to the right under the main term) Specific Subterm (More specific subclassification such as CKD stage; indented 4 character spaced to the right under the main term) Carry Over Line (Use to complete a sentence or phrase; indented 2 character spaced to the right under the line above it) OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. Proprietary and Confidential. Do not distribute. 37

38 ICD-10-CM Index: New Features General Rules when Indexing Codes: Codes ending with a hyphen (-) In the Index, a (-) at the end of some entries indicates that additional characters are required, for example: Timing (e.g. Loss of consciousness 30 min, min, 1 hr to 5hrs 59 min, etc.) Hematoma, cerebrum, SØ6.36- Index Note: Even if a (-) is not included at an index entry, always refer to the Tabular List to verify that no extension is required. Trimester (e.g. 1 st, 2 nd, 3 rd, Unsp.) Cracked nipple, pregnancy, O Laterality (lt., rt., bilat., unsp.) Code descriptions with hyphens that represent laterality represent the following: The right side is always character 1, the left side is character 2, bilateral is character 3, unspecified is either a character 0 or 9. Tabular Propriety and Confidential. Do not distribute. 38

39 ICD-10-CM: Locating Codes Use both the Index and Tabular Listing Codes may be 3, 4, 5, 6 or even 7 characters Always code to the highest level of specificity Codes for disease, symptoms, conditions, problems, complaints, injuries, ill-defined conditions or other reasons for the encounter are A00.0 T88.9 and Z00 Z99.8 Propriety and Confidential. Do not distribute. 39

40 ICD-10-CM: Locating Codes Assign codes for Signs & Symptoms if a definitive diagnosis has not been established Do not assign codes for conditions that are an integral part of a disease process in most situations. Consider multiple coding for a single condition Code acute conditions Code all chronic conditions that are problem pertinent for each episode of care Consider combination codes Consider late effect codes Propriety and Confidential. Do not distribute. 40

41 ICD-10-CM: Chapters & Locating Codes Consider impending or threatened conditions Consider laterality with the selection of new ICD-10-CM codes Consider appropriate coding of two or more comparative or contrasting conditions Code complications of surgery and other medical care Do not code uncertain diagnoses (e.g. possible, probable, suspected, rule out or any working diagnosis) Code previous conditions (e.g. history of) Code abnormal findings Note: Always check special instructions (e.g. includes and excludes notes) at the beginning of each corresponding chapter when selecting codes from the Tabular Listing. Propriety and Confidential. Do not distribute. 41

42 Additional Conventions Additional digits required (Tabular List). 4 th 5 th 6 th 7 th x7 th This symbol indicates that the code requires a fourth digit. This symbol indicates that the code requires a fifth digit. This symbol indicates that the code requires a sixth digit. This symbol indicates that the code requires a seventh digit following the placeholder x. Codes less than six characters that require a seventh character must contain placeholder x to fill the missing digits. The seventh character must always be a valid seventh character for that code. Coders should also note that an ICD-10-CM code can start with an X (i.e., codes X00 X99 from Chapt 20). OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. p. vii Propriety and Confidential. Do not distribute. 42

43 ICD-10-CM Index: New Features General rules when indexing codes: x Placeholders In those cases, such as poisonings or injuries, coders will need to add a placeholder so the seventh character ends up in the correct position. The placeholder is reported as an x. Example: SØ6.2xØD Diffuse traumatic brain injury w/o loss of consciousness, subsequent visit Index Tabular Note: If the character isn t in the correct position, the code isn t valid. Note: the seven characters do not include the decimal point. means another alpha character is needed at the end (refer to listing in pink just under the complimentary code category) OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. Proprietary and Confidential. Do not distribute. 43

44 7 th Digit Examples with x Placeholders x7 th Example 1 Adverse effect of unspecified systemic antibiotic, initial encounter Code: T36.95xA Note: The Index entries for these conditions only end with the first 4 th or 5 th digits. Always crosswalk to the Tabular Listing for additional conventions. OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. Proprietary and Confidential. Do not distribute. 44

45 7 th Digit Examples with x Placeholders x7 th Example 2 Frostbite with tissue necrosis of the neck, subsequent encounter Code: T34.1xxD OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. Proprietary and Confidential. Do not distribute. 45

46 ICD-9-CM vs ICD-10-CM: Coding Convention Changes Use of the Index and Tabular are unchanged Except for Excludes Notes Exclude Notes have been subdivided into: Excludes 1 Not Coded Here Two conditions cannot occur together Excludes 2 Not Included Here It is acceptable to use both the listed code and excluded code together It is not mandatory to use both Proprietary and Confidential. Do not distribute. 46

47 ICD-10-CM: Excludes Notes There are two types of Excludes notes, although each indicates that codes excluded from each other are independent of each other: Excludes1: A type 1 excludes note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note: An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Condition listed with Excludes1 are mutually exclusive. Excludes2: A type 2 excludes note represents Not included here. Excludes1 Excludes2 An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code; however, a patient may have both conditions at the same time. When an Excludes2 note appears, it is acceptable to assign both the code in reference and the excluded code(s) together. OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. Propriety and Confidential. Do not distribute. 47

48 Coding Chronic Conditions: ICD-9-CM & ICD-10-CM Comparison

49 Diabetes Mellitus (DM) See Provider Toolbook

50 ICD-9-CM: Underlying Disease Diabetes Mellitus Complications of diabetes are under-reported is over-reported Diabetes Mellitus, code without mention of complication is appropriate at times. However, if complications exist, code to the specific complications and manifestations. Propriety and Confidential. Do not distribute. 50

51 ICD-9-CM: Underlying Disease Diabetes Mellitus Coding of Underlying Disease (Etiology) and Manifestation Document & code both the etiology (underlying disease) and the manifestation of the disease. The underlying disease is coded first. Both the underlying disease and the manifestation are in the present tense. ICD-9-CM states, "the most commonly used etiology/manifestation combinations are the codes for Diabetes Mellitus 250.XX [XXX.XX]. 1 The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), (2011, October). ICD-9-CM official guidelines for coding and reporting. Retrieved October 3, 2011, from Department of Health and Human Services (DHHS) Web site: Propriety and Confidential. Do not distribute. 51

52 ICD-9-CM: Underlying Disease Diabetes Mellitus The documentation MUST make the connection. Specific complications and manifestations reviewed and documented in the chart should be coded. In order to code a disease or condition as a manifestation of DM, it must be stated that the disease or condition is diabetic or due to diabetes. (The Coding Clinic, Third Quarter 1991, pages 7-8) Propriety and Confidential. Do not distribute. 52

53 Underlying Disease Diabetes Mellitus What System is being Affected? 250.4X 250.5X 250.6X 250.7X 250.8X 250.9X Diabetes with renal manifestations Diabetes with ophthalmic manifestations Diabetes with neurological manifestations Diabetes with peripheral circulatory disorders Diabetes with other specified manifestations Diabetes with unspecified complications The X reports the type of diabetes and the control status. Be sure to append V58.67 for long term (current) use of Insulin (except Type I). Propriety and Confidential. Do not distribute. 53

54 ICD-9-CM: Diabetes Documentation and Coding Evaluate every patient with diabetes, especially the senior patient, for manifestation(s) of the disease. Diabetic Nephropathy, OOC Diabetic CKD Stage III Diabetic Retinopathy Type I Diabetic Neuropathy, OOC and and and and Diabetic Peripheral Autonomic Neuropathy Diabetic Neuralgia Diabetic PVD Diabetic Ulcer and and and and Proprietary and Confidential. Do not distribute. 54

55 Underlying Disease Diabetes Mellitus A patient with Type II controlled Diabetes that has treatment for a manifestation of the disease should have both conditions coded: PVD due to Diabetes Mellitus Diabetes with peripheral circulatory disorders Peripheral angiopathy in diseases classified elsewhere The underlying disease is coded first, followed by the manifestation code. The linkage has been documented with due to and the 4 th digit is properly assigned on the 250.xx Propriety and Confidential. Do not distribute. 55

56 ICD-9-CM: Underlying Disease Diabetes Mellitus Be Specific If the same scenario was documented as: PVD and Diabetes Mellitus No cause and effect relationship established 1 Code Diabetes mellitus without mention of complication Code Peripheral vascular disease, unspecified With this example, there is nothing indicating that the PVD was due to the diabetes. The coding must be more generic in this case. ¹ According to the ICD-9-CM Index imperative, which takes precedence over all other coding literature reviews and advice, there is no automatic relationship here. Proprietary and Confidential. Do not distribute. 56

57 ICD-10-CM: Diabetes (EØ8-E13) Diabetes Mellitus (ICD-10-CM) The DM codes are combination codes that include: The type of diabetes The body system affected The complications affecting that body system. Diabetic Manifestations Many diabetes with manifestations are combined into a single code. There are a few exception where the manifestation must be coded separately (e.g., diabetic gastroparesis, diabetic ulcer, CKD due to diabetes) Diabetic manifestations are captured by the 4 th, 5 th, and 6 th characters Most conditions may be reported using only one code However, assignment of as many codes within a particular category as are necessary to describe all of the complications of the disease may be used Underlying Conditions and additional codes Code first underlying conditions responsible for DM (e.g., E08 category) Code in addition stage of chronic kidney disease for Diabetic CKD (N18.1-N18.6) Code in addition the site of associative diabetic ulcers (L97.1-L97.9, L98.41-L98.49) Propriety and Confidential. Do not distribute. 57

58 ICD-10-CM: Diabetes (EØ8-E13) Diabetes Mellitus (ICD-10-CM) Primary Diabetes Mellitus Type 1 diabetes is reported with codes in category E1Ø Type 2 diabetes is reported with codes in category E11 Secondary Diabetes Mellitus due to underlying condition is reported with codes in category EØ8 due to drug or chemical induced is reported with codes in category EØ9 due to other specified diabetes mellitus is reported with codes in category E13 such as:» Diabetes due to genetic defects» Diabetes due to pancreatectomy or other procedure» Secondary diabetes mellitus NEC Patient Use of Insulin For E08, E09, E11 and E13:» Use additional code to identify any long term (current) use of insulin Z79.4 Propriety and Confidential. Do not distribute. 58

59 ICD-10-CM: Diabetes Mellitus Type 1&2 E10 Type 1 diabetes mellitus (Categories) E10.2_ Type 1 diabetes mellitus with kidney complications E10.3_ Type 1 diabetes mellitus with ophthalmic complications E10.4_ Type 1 diabetes mellitus with neurological complications E10.5_ Type 1 diabetes mellitus with circulatory complications E10.6_ Type 1 diabetes mellitus with other specified complications E10.8_ Type 1 diabetes mellitus with unspecified complications E10.9_ Type 1 diabetes mellitus without complications E11 Type 2 diabetes mellitus (Categories) E11.2_ Type 2 diabetes mellitus with kidney complications E11.3_ Type 2 diabetes mellitus with ophthalmic complications E11.4_ Type 2 diabetes mellitus with neurological complications E11.5_ Type 2 diabetes mellitus with circulatory complications E11.6_ Type 2 diabetes mellitus with other specified complications E11.8_ Type 2 diabetes mellitus with unspecified complications E10.9_ Type 2 diabetes mellitus without complications Propriety and Confidential. Do not distribute. 59

60 ICD-10-CM: Diabetes Mellitus Index Diabetic cause and effect relationships using ICD-10-CM The cause and effect relationship between diabetes and its manifestation can be indexed using the word with. Example: Diabetes (II) with diabetic CKD = E11.22 Use additional code to identify stage of chronic kidney disease (N18.1-N18.6) Example: Diabetes (II) with diabetic nephropathy = E11.21 OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. Propriety and Confidential. Do not distribute. 60

61 ICD-10-CM: Diabetes Mellitus Control Status Diabetes Mellitus Deletion of 5 th digits controlled and uncontrolled within the specified DM categories. The terms: inadequately controlled out of control (uncontrolled) poorly controlled Now default code to Diabetes (by type) with hyperglycemia. OptumInsight. ICD-10-CM; The Complete Official Draft Code Set. Draft. St Paul, MN: Ingenix, Inc., Print. Propriety and Confidential. Do not distribute. 61

62 ICD-10-CM: Diabetes Mellitus Examples Some conditions cannot be captured by one code. Type 1 diabetic foot ulcer Requires a code E1Ø.621, Type 1 diabetes mellitus with foot ulcer, and a code from subcategory L97.4 or L97.5 to designate the exact location and severity of the foot ulcer Legal diabetic blindness, type 2 Requires a code E11.39, Type 2 diabetes mellitus with other diabetic ophthalmic complication, and a code from subcategory H54,8 legal blindness NOS (according to USA definition). Propriety and Confidential. Do not distribute. 62

63 ICD-10-CM: Coding Scenario Type 1 diabetic patient presents with osteomyelitis due to diabetes ICD-9-CM Diabetes with other specified manifestations, type I, not stated as uncontrolled Other bone involvement in diseases classified elsewhere Unspecified osteomyelitis, site unspecified ICD-10-CM E1Ø.69 Type I diabetes mellitus with other specified complication M9Ø.50 Osteonecrosis in diseases classified elsewhere, unspecified site M86.9 Osteomyelitis, unspecified Propriety and Confidential. Do not distribute. 63

64 Preparing for ICD-10-CM: Clinical Documentation Improvement (CDI)

65 CDI: DM Coding Diabetes in ICD-10-CM (I.C.4.a.): One of the biggest changes in the guidelines is in the area of diabetes mellitus, which will now include combination codes. Combination codes for diabetes mellitus include the type, the body system affected, and the complications. Assign as many codes from the appropriate diabetes mellitus category as needed to identify all associated conditions. It is important for providers to document: the type of diabetes the system affected the complications or manifestations The control status is reported as a separate code Propriety and Confidential. Do not distribute. 65

66 CDI: DM Example: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy and macular edema ICD-9-CM Diabetes with ophthalmic manifestations Diabetic macular edema Moderate nonproliferative diabetic retinopathy ICD-10-CM E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Propriety and Confidential. Do not distribute. 66

67 CDI: Combination Codes Combination Codes (I.B.9.): This guideline affects the number of codes assigned. A combination code is a single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation) or a diagnosis with an associated complication. Combination codes provide full identification of diagnostic conditions. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code as in the example on the next slide. Often the instructional notes in the Tabular will direct you: Code first Use additional code Code also Propriety and Confidential. Do not distribute. 67

68 CDI: Combination Codes Example: Hypertensive chronic kidney disease stage 3 ICD-9-CM Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, Stage III (moderate) ICD-10-CM I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease N18.3 Chronic kidney disease, stage 3 (moderate) Propriety and Confidential. Do not distribute. 68

69 CDI: Causal Language Hypertensive Diseases (I.C.9.a.1): This guideline includes documentation instruction for hypertension with heart disease. Example: Hypertensive congestive heart failure ICD-9-CM Hypertensive heart disease, unspecified, with heart failure Congestive heart failure, unspecified ICD-10-CM I11.0 Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified There is no assumed relationship between hypertension and heart disease or heart failure. It must be stated (due to hypertension) or implied (hypertensive). Propriety and Confidential. Do not distribute. 69

70 CDI: Laterality and Severity Laterality and Severity (I.B ): This guideline includes anatomically paired organ or site designations and may include right, left, or bilateral. Separate right and left codes may be reported if no bilateral code is provided. You would only assign an unspecified code if the site is not specified in the record. It is critical that providers get in the habit of documenting: Site Laterality Severity Propriety and Confidential. Do not distribute. 70

71 CDI: Site, Laterality and Severity Unspecified Example: Foot ulcer ICD-9-CM Ulcer of other part of foot (except pressure ulcer) ICD-10-CM L Non-pressure chronic ulcer of other part of unspecified foot limited to breakdown of skin L Non-pressure chronic ulcer of other part of unspecified foot with fat layer exposed L Non-pressure chronic ulcer of other part of unspecified foot with necrosis of muscle L Non-pressure chronic ulcer of other part of unspecified foot with necrosis of bone L Non-pressure chronic ulcer of other part of unspecified foot with unspecified severity Propriety and Confidential. Do not distribute. 71

72 CDI: Site, Laterality and Severity Right Example: Foot ulcer (right foot) ICD-9-CM Ulcer of other part of foot (except pressure ulcer) ICD-10-CM L Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin L Non-pressure chronic ulcer of other part of right foot with fat layer exposed L Non-pressure chronic ulcer of other part of right foot with necrosis of muscle L Non-pressure chronic ulcer of other part of right foot with necrosis of bone L Non-pressure chronic ulcer of other part of right foot with unspecified severity Propriety and Confidential. Do not distribute. 72

73 CDI: Site, Laterality and Severity Left Example: Foot ulcer (left foot) ICD-9-CM Ulcer of other part of foot (except pressure ulcer) ICD-10-CM L Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin L Non-pressure chronic ulcer of other part of left foot with fat layer exposed L Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L Non-pressure chronic ulcer of other part of left foot with necrosis of bone L Non-pressure chronic ulcer of other part of left foot with unspecified severity Propriety and Confidential. Do not distribute. 73

74 Chart Mechanics & Authentication Requirements

75 Chart Mechanics & Documentation Considerations 1,2,3 Identify patient (name) and date (of service) and one additional patient identifier (e.g., date of birth) on each page of the record Reported diagnoses must be supported with medical record documentation Acceptable documentation should be clear, concise, consistent, complete and legible Document and report co-existing diagnoses any that require or affect the care and treatment of the patient that day Use only standard abbreviations (acronyms and symbols) It is NOT appropriate to code a condition that is represented only by an up or down arrow in combination with a chemical symbol or lab abbreviation such as chol for hypercholesterolemia CMS requires that the documentation show evaluation, monitoring or treatment of the conditions documented The medical record must support all diagnoses coded for the date of service and must be able to stand alone for audit on those reported diagnosis codes 1 CMS-Centers for Medicare & Medicaid Services, 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide. Leading Through Change, Inc The Joint Commission, Standards. The Joint Commission, Web. 13 Dec < 3 World Health Organization, International Classification of Diseases, Ninth Revision, Clinical Modification, 6th Ed. National Center for Health Statistics Web. 15 Nov Propriety and Confidential. Do not distribute. 75

76 Authentication Requirements: Paper Record 1,2 Medicare documentation requirements state each patient encounter should include the date and legible identity of the provider. All dates of service must be signed (with credentials) and dated by the physician (provider) or an appropriate extender (non-physician practitioner) e.g., nurse practitioner Stamps of the provider s signature are not acceptable per CMS. The credentials for the provider of services must be somewhere on the medical record: next to the provider s signature, or pre-printed with the provider s name on the group practice s stationery The physician (provider) must authenticate at the end of each note for which services were provided with handwritten signature. The physician s signature and credentials must be on each chart entry as a condition of payment from CMS. Disclaimer: This is not an all-inclusive listing of CMS requirements and is only a reminder of certain chart mechanics and documentation guidelines. 1 CMS-Centers for Medicare & Medicaid Services, 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide. Leading Through Change, Inc The Joint Commission, Standards. The Joint Commission, Web. 13 Dec < Propriety and Confidential. Do not distribute. 76

77 Authentication Requirements: EMR 1,2 Medicare documentation requirements state each patient encounter should include the date and legible identity of the provider. The physician (provider) must authenticate at the end of each note for which services were provided with an electronic signature. Electronic signature, including credentials Requires authentication by the responsible provider for example, but not limited to, Approved by, Signed by, Electronically signed by, Authenticated by Must be password protected and used exclusively by the individual physician (provider) Disclaimer: This is not an all-inclusive listing of CMS requirements and is only a reminder of certain chart mechanics and documentation guidelines. 1 CMS-Centers for Medicare & Medicaid Services, 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide. Leading Through Change, Inc World Health Organization, International Classification of Diseases, Ninth Revision, Clinical Modification, 6th Ed. National Center for Health Statistics Web. 15 Nov Propriety and Confidential. Do not distribute. 77

78 Additional Steps in Making the Transition

79 A Three-Step Approach To ease the transition from ICD-9-CM to ICD-10-CM: Understand the specificity of the new code set Review the new guidelines and the code set Review your most frequently used codes translated into ICD-10-CM Look for key terms that differentiate the codes Document to the greatest degree of certainty State the causal relationships you know to exist (e.g. diabetic, hypertensive) Document in adjectives (e.g. type, site, laterality, severity) Allow query early Code to the highest specificity possible Follow the guidelines and instructional notes Translate your most frequently used codes from ICD-9-CM to ICD-10-CM Query the providers Propriety and Confidential. Do not distribute. 79

80 First Steps in Transition ICD-10-CM provides tremendous opportunities for disease tracking, but also creates enormous challenges. To ease the transition develop a solid foundation in understanding the coding conventions inherent in the ICD-10-CM text. The ICD-10-CM Official Guidelines for Coding and Reporting are updated regularly and are posted on the National Center for Health Statistics (NCHS) website at: A critical step in easing the transition from ICD-9-CM to ICD-10-CM is clinical documentation improvement. Understanding the specificity of the new code set will encourage providers to: document to the greatest degree of certainty based on their clinical judgment document in adjectives (e.g., laterality, severity, episode of care, type of diabetes and complications) Propriety and Confidential. Do not distribute. 80

81 Helpful Sites Visit the CMS ICD-10 website for the latest news and resources to help you prepare. ( For practical transition tips: Read recent ICD-10 update messages: 10_Industry_ _Updates.html Access the ICD-10 continuing medical education modules developed by CMS in partnership with Medscape vailableonicd10.pdf Utilize the CMS implementation timelines and checklists 10ImplementationTimelines.html Start converting your highest volume ICD-9-CM codes to ICD-10-CM by utilizing the General Equivalency Mappings (GEMs) posted on the NCHS website Propriety and Confidential. Do not distribute. 81

82 Available Resources from Optum Optum Can provide comprehensive trainings and tools to help providers and coders transition to ICD-10-CM. ICD-10-CM coding classes provide: Training on ICD-10-CM content, structure and key features of each chapter of the ICD-10-CM coding system Code translation examples that illustrate key contrasts and similarities between systems Knowledge assessments to help quantify understanding of the ICD-10- CM system For additional ICD-10-CM coding resources: Please contact your Optum Healthcare Advocate regarding ICD-10-CM resources and discounts that may be available. Propriety and Confidential. Do not distribute. 82

83 Coding Disclaimer This guidance is to be used for easy reference; however, the code book for the ICD-9- CM coding version used is the authoritative reference for correct coding guidelines. The information presented herein is for general informational purposes only. Neither Optum nor its affiliates warrant or represent that the information contained herein is complete, accurate or free from defects. Specific documentation is reflective of the thought process of the provider when treating patients. All conditions affecting the care, treatment or management of the patient should be documented with their status and treatment and coded to the highest level of specificity. Enhanced precision and accuracy in the codes selected is the ultimate goal. On 4/1/2013, CMS announced that they will implement the updated, clinically revised CMS-HCC risk adjustment model proposed in the Advance Notice with some differences from the proposed model. For more data, see: Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2014.pdf, Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2014.pdf and Optum and its respective marks, such as OptumInsight, are trademarks of Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owner. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer Optum. All Rights Reserved Codes Valid 10/01/13 to 9/30/14 Revised 01/16/2014 CP< > Proprietary and Confidential. Do not distribute. 83

84 Optum would like to Thank You for Your Participation! We hope you have found this presentation informative and useful. Any Questions? Propriety and Confidential. Do not distribute. 84