Preparing for ICD-10-CM

Transcription

1 Financial Disclosure Preparing for ICD-10-CM Mary Pat Johnson is a Senior Consultant at Corcoran Consulting Group and acknowledges a financial interest in the subject matter of this presentation. Mary Pat Johnson, COMT, CPC, COE, CPMA Senior Consultant Corcoran Consulting Group Key Points in Code Selection ICD-10-CM Changes Everything ICD-10 is more specific than ICD-9 Attention to detail Consider primary diagnosis, cause and/or related conditions Physicians Administrators Coders / Billers Technicians Receptionists IT Staff Billing companies Who is Impacted? How does ICD-10 Impact? Payer policies Pre-authorizations PQRS Tracking of services Marketing Forms Practice management system

2 History of ICD-10-CM International Classification of Diseases, 10 th Revision, Clinical Modification Developed by U.S. National Center for Health Statistics (NCHS) in 1993 ICD-10 copywritten by the World Health Organization (WHO) ICD-10-CM replaces ICD-9-CM, volumes 1 and 2 United States is one of last countries to adopt ICD- 10 Why Replace ICD-9!? ICD-9 is >30 years old, outdated, obsolete terminology Outdated codes producing inaccurate and limited data Inconsistent with current medical practice Does not provide enough detail ICD-10-CM Much greater specificity and clinical information Use of most specific code(s) is not optional Provides better data to: Measure care Process claims Track public health Identify fraud and abuse Conduct research ICD-10-CM Codes that allow comparison of mortality and morbidity data Increased number of concepts and codes provided Disease classifications include health related conditions Benefits of ICD-10 More accurate payment for new procedures Fewer rejected claims Fewer improper claims Better understanding of new procedures Improved disease management Deadline Final rule for adoption of ICD-10-CM Published in January 16, 2009 Federal Register (45 CFR part 162) Compliance date is October 1, 2013 Initial delay to October 1, 2014 Source: Federal Register, Vol. 74, No. 11 1/16/09

3 ICD-10 Delayed Again Compare and Contrast March 31, HR 4302 signed by President Obama SGR formula temporary fix ICD-10 delayed The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard code sets under section 1173(c) of the SSA and section of 45CFR ICD-9 17 Chapters 14,000 codes 3-5 digits First digit is numeric or alpha (E or V) Digits 2-5 are numeric ICD Chapters ~ 69,000 codes 3-7 digits Digit 1 is alpha Digit 2 is numeric Digits 3-7 are alpha or numeric (alpha digits are not case sensitive) Compare and Contrast GEM ICD-9 Example: Central corneal ulcer ICD-10 Example: Central corneal ulcer right H Central corneal ulcer left H Central corneal ulcer bilateral H Central corneal ulcer unspecified H General Equivalence Mappings No simple crosswalk contained in this file GEM file is NOT a crosswalk, it is a mapping Expect annual update of files Eye codes translation is fairly straightforward GEM Files Two sets of files ICD-9 to ICD-10 ICD-10 to ICD-9 Each file contains code pairs one from each set GEM Files No decimal point in the codes Three columns Third column describes additional attributes Flags (approximate, no map, combination) Combination entry 1 indicates on (Approximate) 0 indicates off (Direct hit, but verify)

4 GEM File Layout Senile Cataract Example I-9 I-10 + Flags H H H H H H H H H H H GEM Files Use GEMS Translating lists of codes Converting a system or application To study differences in meaning between two systems Use Code Books Translating short list of codes Access to medical record 1 in the first position in flag column = approximate Organization of ICD-10-CM Introduction Conventions and Guidelines Alphabetic Index to Diseases Neoplasm Table Table of Drugs and Chemicals Index to External Causes Tabular List of Diseases Conventions for the ICD-10-CM Format 1. Alphabetic Index Index of Diseases and Injury Index of External Causes of Injury Table of Neoplasms Table of Drugs and Chemicals 2. Tabular List Categories Subcategories Codes Alphabetic Index Notes Define terms Provide direction Wound, superficial (see also specified injury type) Provide coding instructions Trichiasis (eyelid) H with entropion see Entropion Tabular List Categories 3 characters Chapter 7 Disorder of the Eye and Adnexa (H00-H59) Subcategories 4 th character further defines site, etiology, manifestation or state of disease or condition 5 th & 6 th character increases specificity

5 Tabular List 7 th Character Extension Some categories have applicable 7 th characters Last character If code is not six digits, use x as placeholder x as placeholder For when characters are needed for expansion A D S 7 th Character Extension initial encounter subsequent encounter sequela Example Corneal Abrasion Example Corneal Abrasion Category Chapter 19 Injury, Poisoning... S05 Injury of eye and orbit Subcategory 5 th S05.0 Injury of conjunctiva and corneal abrasion without foreign body Specificity x 7 th S05.01 Injury of conjunctiva and corneal abrasion without foreign body right eye Valid code S05.01xA -- Injury of conjunctiva and corneal abrasion without foreign body right eye; initial encounter 7 th Character Extension For glaucoma staging, 7 th denotes severity of disease 1 = mild 0 = unspecified 2 = moderate 4 = indeterminate 3 = severe Example: Glaucoma Staging 7th character is to be assigned to each code in subcategory H40.12 to designate the stage of glaucoma Low-tension Glaucoma H40.12 Low-tension Glaucoma, bilateral (cannot stop here!) H Low-tension Glaucoma, right eye, moderate stage H Low-tension Glaucoma, left eye, severe stage H

6 Laterality Terminology Laterality Right and left designation 1 = right 2 = left 3 = bilateral 0 or 9 = unspecified Example H25.11 Age-related nuclear cataract, right eye H25.12 Age-related nuclear cataract, left eye H25.13 Age-related nuclear cataract, bilateral H25.10 Age-related nuclear cataract, unspecified eye Terminology Laterality Terminology Combination Code Exception example (diseases of eyelids) H Cicatricial entropion of right upper eyelid H Cicatricial entropion of right lower eyelid H Cicatricial entropion of right eye, unspecified eyelid H Cicatricial entropion of left upper eyelid H Cicatricial entropion of left lower eyelid H Cicatricial entropion of left eye, unspecified eyelid H Cicatricial entropion of unspecified eye, unspecified eyelid Single code used to classify two diagnoses 1. Diagnosis with an associated manifestation 2. Diagnosis with an associated complication Examples E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema H Cystoid macular edema following cataract surgery, left eye Other Conventions Terminology Code Also Instructs that two codes may be required to fully describe a condition; sequencing depends on severity of conditions and reason for the encounter. Example H18.03 Corneal deposits in metabolic disorders Code also associated metabolic disorder

7 Terminology See and See Also Terminology Code First / Use Additional Code See follows a main term in the index indicating that it is necessary to go to that term to locate the correct code. Examples Lesion eyelid see Disorder, eyelid Etiology / manifestation rule; the underlying condition is listed first with the manifestation listed second. Example H42 Glaucoma in diseases classified elsewhere Code first underlying condition, such as: aniridia (Q13.1) See Also follows a main term in the index indicating that another term may also be useful. Retinochoroiditis (see also Inflammation, chorioretinal) Code first will be listed at the etiology code; Use additional code will be listed at the manifestation code. Q13.1 Absence of iris Aniridia Use additional code for associated glaucoma (H42) Terminology Excludes Terminology and Excludes 1 excluded code should never be used at the same time as the code above excludes 1 note. Excludes 2 represents Not included here ; Condition excluded not part of condition represented by the code; patient may have both conditions at the same time; may use both codes when appropriate. Examples H01.0 Blepharitis Excludes 1 blepharoconjunctivitis (H10.5-) H00.1 Chalazion Meibomian (gland) cyst Excludes 2 infected meibomian gland (H00.02-) When the term and is used in a narrative statement, it represents and / or. Example T26.11 Burn of cornea and conjunctival sac, right eye Abbreviations How to find a code NEC Not elsewhere classifiable Represents other specified Detail for which a specific code does not exist NOS Not otherwise specified Represents unspecified For when a more specific code cannot be assigned

8 General Guidelines Diagnosis codes are to be used and reported to the highest number of characters available. Signs and symptoms are acceptable when a definitive diagnosis has not been established by the provider. Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis or other similar terms indicating uncertainty. General Guidelines Multiple codes may be required for a single condition that affects multiple body systems. Principal diagnosis should be based on the condition that prompted the visit and was the primary focus of treatment. Code all documented conditions that coexist at the time of the visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. How to Use the ICD-10-CM 1. Look up the main term in the Alphabetical Index, scan subterm entries if needed. Review continued lines / additional subterms. 2. Note parenthetical terms that help with code selection but do not affect code assignment How to Use the ICD-10-CM (continued) 3. Pay attention to the following index instructions in the Alphabetical Index see, see also, and see category crossreferences with and without notes omit code notes due to subterms other instructions found in note boxes, such as code by site 4. Do not code from the Alphabetical Index without verifying the accuracy of the code from the Tabular List How to Use the ICD-10-CM (continued) 5. Read all instructional material in Tabular Index, including includes and excludes notes use additional code and code first underlying disease code also fourth-, fifth-, sixth-, and seventh- digit requirements 6. Consult the ICD-10-CM guidelines for use of specific codes 7. Confirm and assign the correct code Cataract Example CC: cataracts, OU, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Schedule phaco IOL OD ICD-9: Nuclear Sclerotic Cataract What is the appropriate ICD-10 code?

9 Cataract Step 1: Alpha Index: Search cataract Cataract (cortical) (immature) (incipient) H26.9 Step 2: Under cataract search nuclear sclerotic - nuclear - - sclerosis see Cataract, senile, nuclear Cataract Step 3: See Cataract Senile Nuclear - senile H brunescens see Cataract, senile, nuclear - - combined forms H coronary see Cataract, senile, incipient - - cortical H hypermature see Cataract, senile, morgagnian type - - incipient (mature) (total) H cortical see Cataract, senile, cortical subcapsular see Cataract, senile, subcapsular - - morgagnian type (hypermature) H nuclear (sclerosis) H25.1- Cataract Step 4: Go to H25.1- in Tabular List H25.1 Age-related nuclear cataract Cataracta brunescens Nuclear sclerosis cataract H25.10 Age-related nuclear cataract, unspecified eye H25.11 Age-related nuclear cataract, right eye H25.12 Age-related nuclear cataract, left eye H25.13 Age-related nuclear cataract, bilateral Step 5: No additional instructions in tabular list Step 6: No additional guidelines Step 7: Assign code CC: Cataracts, OD, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Phaco IOL OD H25.13 NS, Cataract, OU Cataract Chapters 1. Certain Infectious and Parasitic Diseases (A00- B99) 2. Neoplasms (C00-D49) 3. Diseases of the Blood and Blood-forming Organs (D50-D89) 4. Endocrine, Nutritional and Metabolic Diseases (E00-E90) 5. Mental and Behavioral Disorders (F01-F99) 6. Diseases of Nervous System (G00-G99) 7. Diseases of Eye and Adnexa (H00-H59) Chapters 8. Diseases of Ear and Mastoid Process (H60-H95) 9. Diseases of Circulatory System (I00-I99) 10.Diseases of Respiratory System (J00-J99) 11.Diseases of Digestive System (K00-K94) 12.Diseases of Skin and Subcutaneous Tissue (L00- L99) 13.Diseases of the Musculoskeletal System and connective Tissue (M00-M99) 14.Diseases of Genitourinary System (N00-N99)

10 Chapters 15.Pregnancy, Childbirth, and the Puerperium (O00- O99) 16.Newborn (Perinatal) Guidelines (P00-P96) 17.Congenital Malformations, Deformations, and chromosomal Abnormalities (Q00-Q99) 18.Symptoms, Signs, and Abnormal Clinical and Lab Findings, NEC (R00-R99) Chapters 19.Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) 20.External Causes of Morbidity (V01-Y99) 21.Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Ch. 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) Diabetes mellitus Combination codes that include Type of diabetes mellitus Body system affected Complications affecting body system Sequenced based on reason for encounter Diabetes Mellitus Five diabetes mellitus categories E08 Diabetes mellitus due to an underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type 1 diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus *Use E11 if record does not indicate type of DM, but does indicate insulin use. Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines Diabetes Mellitus Insulin use All categories except E10 (Type 1 DM) require use of additional code to indentify any insulin use Z79.4 Long term (current) use of insulin Diabetes Mellitus Examples E11.9 Type 2 DM without complications E Type 1 DM with moderate NPDR without macular edema E Z79.4 Type 2 DM with mild NPDR with macular edema & Long-term current use of insulin (if documented) Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines

11 Case Study While sitting at the 10 th tee box, your patient is struck in the left eye with a golf ball causing a traumatic hyphema. Code this encounter with ICD-10 codes. Chapters 19.Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) 20.External Causes of Morbidity (V01-Y99) 21.Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Case Study ICD-10 Codes S05.12xA Contusion of eyeball and orbital tissues, left eye, initial encounter V86.59xA Driver of golf cart injured in nontraffic accident W21.04xA Struck by golf ball Y92.39 Golf course as place of occurrence Y93.53 Activity, golf Documentation Considerations Laterality Is your assessment specific to which eye or eyelid? Etiology / Manifestation Does your chart note list both the disease and the associated manifestation? Specificity Is the impression as specific as possible for a particular condition? Documentation Considerations History ROS Documentation Considerations History HPI & PFSH Old Diabetic Cataract OD from injury Hypertension Shingles HIV positive New Type II diabetes on insulin Cataract OD caused by driver side airbag Hypertension; history of tobacco use Shingles w/ear infection Asymptomatic HIV Old Eyelid laceration FB sensation OD, poor blink 3 days Elevated IOP; seen at health fair New Laceration right eyelid from contact with a chisel (workbench tool) FB sensation OD, poor blink 3 days; recent dx of Bell s palsy Family history of glaucoma

12 Documentation Considerations Impression Documentation Considerations Impression Old Chalazion OS BDR OU Iritis OU Hyphema OD No maculopathy New Chalazion LLL Type II diabetes with mild NPDR w/out macula edema; taking insulin Chronic iritis OU Traumatic hyphema OD RA taking plaquenil; no ocular disease Old Myopia CME Ptosis Complex cataract New Myopia OU; regular astigmatism OD CME OD after cataract sx Mechanical ptosis OU NS cataract OD, floppy iris syndrome, adverse effect of Tamsulosin Common Patient Syndromes Key Points in Preparation R46.0 Low level of personal hygiene R19.6 Halitosis (bad breath) History and Timeline Gather resources Assess and Improve Documentation Practice, Practice, Practice One Step at a Time Begin Using ICD-10 Codes Practice early, practice often! You are asking people to change habits or patterns This takes time and practice Continue reporting ICD-9 for claims submission Double code a few of claims with ICD-10 codes Compare your answers with each other Use for training and glossary most common codes Begin Using ICD-10 Codes Divide tasks in to workable segments refractive error and cataract codes glaucoma cornea and external eye codes (plastics) retina and diabetes code Injuries and infections Use this time to assess tools available to you Apps, websites etc Use this time to educate staff History taking, documentation, anatomy

13 Resources Resource Links Useful Aids Apps Apple iphone Android World Health Organization AAPC Code Translator Others More help For additional assistance or confidential consultation, please contact us at: (800) or

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15 APPENDIX

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17 How To SEARCH For A Code Within ICD 10 CM General guidelines: 1. ALPHABETIC index a place to START 2. TABULAR List is most specific code from here! 3. Report HIGHEST number of characters possible Specific guidelines: 1. Identify reason for visit/encounter a. Diagnoses b. Problems c. Complaints d. Signs and symptoms i. Used for reporting when no related definitive diagnosis is established e. Conditions i. Report those that are an integral part of a disease process 1. Do not use additional codes ii. Conditions that are not an integral part of a disease process 1. Code when present (see below if multiple conditions ) 2. Multiple coding for a single condition a. Required for i. Any condition with a use additional code note b. May be needed for i. Fully describing a condition, such as ii. Late effects iii. Complication codes iv. Obstetric codes 3. Acute and chronic conditions a. If both are present i. Code both ii. Sequence acute code first 560 E. Hospitality Lane Suite 360 San Bernardino, California Telephone: (800) FAX (909)

18 4. Combination code a. Single code to classify either i. Two diagnoses ii. Diagnosis with associated secondary process iii. Diagnosis with associated complication b. Do not use multiple codes if combination code identifies all elements 5. Late effects (sequelae) a. Residual effect after acute phase of injury/illness b. No time limit c. Condition code sequenced first, late effect code sequenced second d. Do not use with acute injury code 6. Impending or threatened condition a. If condition did occur, code as diagnosis b. If condition did not occur, reference impending, threatened i. If subentry terms for impending or threatened are listed: 1. Assign the appropriate code ii. Are not listed: 1. Code existing underlying conditions c. Do not code the impending/threatening condition 7. Reporting same diagnosis code more than once a. Each code may be used once per encounter 8. Laterality a. For codes that can have bilateral sites b. Final character of code indicates laterality (0 or 9, 1, 2, 3) c. If no bilateral code is provided, assign separate codes for right and left sides 9. RARE for Ophthalmology: Documentation for BMI and pressure ulcer stages a. May be based on documentation from clinicians who are not the patient s provider b. Associated diagnosis must be documented by patient s provider c. BMI codes are always secondary diagnoses 560 E. Hospitality Lane Suite 360 San Bernardino, California Telephone: (800) FAX (909)