ICD-10-CM 101 9/19/2016

Transcription

1 Presented by Cathy Jennings, BS, CPC, CPC-I, CEDC, CHONC AHIMA Approved ICD-10-CM/PCS Trainer Managing Consultant October 5, 2016 Disclaimer The speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by law. Attendees are advised to reference payer specific provider manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices. 2 Agenda Brief history of ICD-10-CM Change process and annual updates Why are diagnosis codes important? How do I find a code? Misunderstood guidelines 3 1

2 History 1893 International List of Causes of Death, was adopted by the International Statistical Institute rd World Health Assembly adopted ICD International Statistical Classification of Diseases, 10 th Revision was released by World Health Organization (WHO) 1998 First modification ICD-10-AM (Australian modification) 1999 US implements ICD-10-CM for mortality, but remains only industrialized nation not to use for morbidity 2015 US implements ICD-10-CM and ICD-10-PCS 2018 WHO is scheduled to release ICD-11 For more information Change Process & Annual Updates ICD-10-CM codes are updated annually. New codes go into effect on October 1st of each year (based on date of service) Anyone can submit proposals for updates to the code set ICD-10-CM was developed following evaluation by a Technical Advisory Panel and consultation with physician groups, clinical coders, and others Updates are managed by the ICD-10 Coordination and Maintenance Committee through a process of proposals and public meetings Documentation on proposals and meeting notes can be found on the CDC website along with rationale for updates and proposed updates Go to for more information regarding proposing updates and public meetings Why are diagnosis codes important? Misconception Providers are not paid based on diagnosis codes Fact Diagnosis codes trigger denials or improper payments based on medical necessity Fact Providers are scored based on the information on a claim. Incorrect or unspecified codes can lead to incorrect scoring Fact Payment methodologies are shifting. Diagnosis codes will play a role in provider reimbursement Fact Data used to determine new payment methodologies comes from claims submitted now 6 2

3 Why are diagnosis codes important? Diagnosis codes that do not correlate with medical necessity edits result in denials More payors are denying unspecified codes Incorrect diagnosis codes could result in improper payments and increase a provider s chance for audit by government and commercial payors As diagnosis codes become part of payment methodology in the near future, the more payors will scrutinize accuracy under review and audit 7 How do I find a code? Diagnosis coding guidelines must be followed Adhere to the instructional notes listed with the code Do not rely on codes from the index (section) of the book Cannot limit code selection to the tabular listing in the book Word searches in software often fail in finding the code 8 How do I find a code? EMR Pitfalls Many use a word search to find codes Some allow users to change the description of the code resulting in inaccuracy No instructional notes to assist the user No information regarding coding guidelines Some are missing information on sequencing of codes 9 3

4 How do I find a code? 1. Start with the index 10 How do I find a code? 2. Look up the code in the tabular listing 11 Where do I find the guidelines? The front section of each current ICD-10-CM book contains a full set of guidelines In coding software On the web GEMs.html 12 4

5 The ICD-10-CM coding guidelines- Provide instruction on how to look up codes Clarify the correct use of placeholders Define abbreviations and punctuation characters Explain the use of the word and 13 Guideline I.A.9 5

6 Guideline I.A.12 Excludes 1 versus Excludes 2 - Example Guideline I.A.13 6

7 Guidelines I.B.4 I.B.6 Examples Patient presents with tachycardia. Patient has a history of hyperthyroidism. Due to the severity of the tachycardia, the provider sends the patient out for an echocardiogram. Patient presents with runny nose and fever. Provider diagnoses URI. 21 7

8 Guidelines I.B.8, I.B.13, and I.B.15 Example Patient is diagnosed with acute and chronic bronchitis. Patient s place of employment exposes her to tobacco smoke. J20.9 Acute bronchitis, unspecified J42 Unspecified chronic bronchitis Z57.31 Occupational exposure to environmental tobacco smoke

9 Guideline I.B.17 Guideline I.C.1.c 9

10 Guideline I.C.2.m 10

11 Guideline I.C.4.a Diabetes Categories E08 Diabetes mellitus due to underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type 1 diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus 33 11

12 Guideline I.C.6.a Guideline I.C.6.a.1 12

13 Examples Diagnosis CHF and hypertension I50.9 Heart failure, unspecified I10 Essential (primary) hypertension Diagnosis CHF due to hypertension I11.0 Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified Guideline I.C.6.a.2 Examples Diagnosis hypertension and stage III chronic kidney failure 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) Diagnosis stage III hypertensive chronic kidney failure 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) 13

14 Guideline I.C.6.a.3 Examples Diagnosis Hypertensive heart disease and stage 1 chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease N18.1 Chronic kidney disease, stage 1 Guideline I.C.13.a 14

15 Beware Despite what the guideline says, there are not multiple site codes for all types of osteoarthritis. For example, the codes for primary osteoarthritis include the following. Hip, right, left, and bilateral Knee, right, left, and bilateral Carpometacarpal joint, right, left, and bilateral Shoulder, right and left Elbow, right and left Wrist, right and left Hand, right and left Ankle and foot, right and left Unspecified site Guideline I.C.13.b This guideline will create an increased number of queries. There are some defaults in the index, but to code these musculoskeletal conditions accurately, documentation needs to specify whether the patient is being seen for an acute traumatic injury or and old/chronic condition. 15

16 Guideline I.C.18.d Guideline I.C.19.a 16

17 Guideline I.C.20 17

18 QUESTIONS Cathy Jennings, BS, CPC, CPC-I, CEDC, CHONC AHIMA Approved ICD-10-CM/PCS Trainer 18