10/12/2014. Presented by: Connie Eckenrodt, RHIT, CHCA, CHC

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1 Presented by: Connie Eckenrodt, RHIT, CHCA, CHC Every reasonable effort has been taken to ensure that the educational information provided in this presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation. A thorough individual review of the information is recommended and to establish individual facility guidelines. Presenter makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. Presenter has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this presentation. Presenter makes no guarantee that the use of this presentation material will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. 2 With 20 years in health information management, Ms. Eckenrodt s focus has been on outpatient coding in the hospital and ambulatory settings, with particular emphasis on professional fee coding and documentation improvement. Consulting has been provided in myriad settings, from small practices to large multi-specialty medical and surgical groups. Areas of expertise include: New provider coding orientations Individual and group coding education for providers and professional fee coders Pre-bill and retrospective coding audits Risk assessment and focus review audits for internal compliance initiatives and compliance initiatives pursuant to federal investigations Ms. Eckenrodt received her A.A.S. in Health Information Management from Portland Community College. Dedicated to excellence in coding compliance, quality education and health care auditing, Ms. Eckenrodt is a certified professional with the American Health Information Management Association (AHIMA), the Health Care Compliance Association (HCCA) and the Association of Health Care Auditors and Educators (AHCAE). Ms. Eckenrodt is also a member of the American Academy of Professional Coders (AAPC). 1

2 Discuss history of ICD code set Review fundamental differences between ICD-9-CM and ICD-10-CM Review what PAs need to do now to prepare Understand actions practices need to take to implement on time History ICD-9-CM CM Based on World Health Organization s (WHO) Ninth Revision Main purpose morbidity and mortality reporting Made single classification system for hospitals in January 1979 Physicians required to submit diagnosis codes for Medicare reimbursement since April

3 January 2009 Final Rule requiring replacement of ICD-9 with ICD-10 Compliance date set for October 1, Department of Health and Human Services (DHHS) announced a 1-yr delay Implementation pushed back to October 1, 2014 April 1, 2014 Language inserted into Protecting Access to Medicare Act delayed implementation to no sooner than October 1, 2015 August 4, 2014 DHHS sets new compliance date of October 1, 2015 ICD CM will be used by all healthcare providers in all settings to assign and/or interpret diagnoses HIPAA Transaction Code Set -Principal or First-Listed diagnosis -Secondary diagnoses 8 ICD-9-CM CM Outdated terminology does not reflect current medical practice Lack of adequate space to add new codes Lack of detail Inability to capture new and emerging technologies 3

4 Provide anatomically specific clinical data More detailed information on Condition Severity Comorbidities Complications Location Introduction to ICD-10-CM Comparison - Format and Structure ICD 9-CM Approx.14,000 codes ICD 10-CM Over 68,000 codes 17 chapters 21 chapters Codes have 3 to 5 characters 1 st character is numeric or alpha (E or V) Second character is always numeric Third, fourth, and fifth characters are always numeric Shorter code descriptions because of lack of specificity; abbreviated code titles Codes have 3 to 7 characters 1 st character is alpha (all letters except U) Second character is always numeric Third, fourth, fifth, sixth, and seventh characters can be alpha or numeric Longer code descriptions because of greater clinical detail and specificity; full code titles 34,250 (50%) are related to the musculoskeletal system 17,045 (25%) are related to fractures ~25,000 (36%) distinguish right vs. left Small percentage of codes will be used by most providers 4

5 ICD-10-CM code book retains same format Index: Alphabetical list of terms and corresponding codes Indented sub-terms under main terms Same structure Alpha Index of Diseases and Injuries Alpha Index of External Causes Table of Neoplasms Table of Drugs & Chemicals Tabular: Sequential list of codes divided into chapters based on body system or condition Same hierarchical structure Codes are looked up the same way! Alphabetic Index Example: 5

6 Tabular List Example: EXCLUDES 1 note Pure excludes note, means NOT CODED HERE! Indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. Used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 EXCLUDES 1 note 6

7 EXCLUDES 2 note Represents Not included here Indicates that the condition excluded isnot part of the condition represented by the code, and a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 EXCLUDES 2 note Placeholder X Provides for future expansion Two uses: As 5 th character for certain 6-character codes. Example: T36.0x5A Penicillin adverse effect, initial encounter When code has less than 6 characters and 7 th character extension is required. Example: S01.02xA Laceration with foreign body of scalp, initial encounter 7

8 7 th th Character Certain codes have 7 characters Obstetrics, injuries, external causes of injuries Can be number or letter Must always be the 7th character If the code is not 6 characters a placeholder X must be used Example: O65.0xx1 Obstructed labor due to deformed pelvis, fetus 1 7 th Character Fractures- A Initial encounter for closed fracture B Initial encounter for open fracture D Subsequent encounter for fracture with routine healing G Subsequent encounter for fracture with delayed healing K Subsequent encounter for fracture with nonunion P Subsequent encounter for fracture with malunion S Sequela Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 Combination Codes Single code used to classify: Two diagnoses A diagnosis with an associated secondary process or manifestation A diagnosis with an associated complication Example: Pressure ulcer, site, stage L Pressure ulcer of right buttock, stage 2 8

9 Laterality For bilateral sites, the final character of the code indicates laterality If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side Unspecified side is also provided should the side not be identified in the documentation ICD-9-CM CM Codes Pressure ulcer codes 9 codes Codes: Pressure ulcer unspecified site elbow upper back lower back hip buttock ankle heel other site ICD CM Codes Pressure ulcer codes 125 codes L89.0-L89.94 Code Examples: L Pressure ulcer of right lower back, stage I L Pressure ulcer of right lower back, stage II L Pressure ulcer of right lower back, stage III L Pressure ulcer of right lower back, stage IV L Pressure ulcer of right lower back, unspecified stage L Pressure ulcer of left lower back, stage I L Pressure ulcer of left lower back, stage II L Pressure ulcer of left lower back, stage III L Pressure ulcer of left lower back, stage IV L Pressure ulcer of left lower back, unspecified stage L Pressure ulcer of sacral region, stage I L Pressure ulcer of sacral region, stage II L89.90 Pressure ulcer of unspecified site, unspecified stage Borderline Diagnosis If provider documents borderline diagnosis, code as confirmed unless classification provides a specific entry (e.g., borderline diabetes). Not considered uncertain, so ok to code in outpatient setting 9

10 Evaluation, treatment and monitoring of patient health Communication and continuity of care Accurate and timely claims review and payment Utilization review and quality of care Collection of data for research and education ~1995/1997 CMS Documentation Guidelines Poor quality documentation impacts Billing accuracy Quality measures Risk management Healthcare analytics Patient care 10

11 Detailed diagnosis codes require clinical documentation that supports the code selection Risk for refunding payments if negative audit findings Unspecified codes still available, however benefits of new code set not fully realized if used Inclusion of clinical concepts that do not exist in ICD-9-CM No need to learn over 68,000 codes! Focus on the clinical concepts and the codes will fall into place Type Description of the condition, type of Type II diabetes or pathological fracture Temporal Factors Time parameter associated with the condition Acute, chronic, paroxysmal, recurrent Caused by/contributing Factors Relates the cause of a condition to another condition, due to Drugs, alcohol, physical or mental disease 11

12 Symptoms/Findings/Manifestations Localization/Laterality Proximal or distal, right side or left side Anatomical location Associated with Severity Acuity of the condition Mild, moderate, severe Episode Single, recurrent; initial encounter, subsequent encounter Remission status Partial, full History of Morphology Complicated by External Cause Activity Place of Occurrence Level of Consciousness Substance Number of Gestations Outcome of Delivery BMI 12

13 Primarily used in inpatient setting Clinical indicators used to identify missed diagnoses or under-documented conditions that may impact reimbursement Coders may query the physician regarding the condition to determine if the condition should be reported or whether the condition might be better reported with a more specific code Inadequate Documentation S: 23 month-old male brought to ED after pt witnessed to have a seizure. Parents indicate pt has had cough and congestion x 2 days. O: T: 105.4, BP: 76/52, HR 116. Breath sounds decreased in the left base and scattered rales and wheezes present throughout. Blood drawn for CBC and blood cultures. Chest x-ray shows infiltrates. A: Acute pneumonia. P: Admit to PICU for antibiotic therapy. Adequate Documentation S: 23 month-old male brought to ED after suffering a seizureat home. Parents indicate pt has had cough and congestion x 2 days. This morning pt was witnessed to have a generalized motor seizure. O: T: 105.4, BP: 76/52, HR 116. Breath sounds decreased in the left base and scattered rales and wheezes present throughout. Blood drawn for CBC and blood cultures. Chest x-ray shows left lower lobe infiltrates. Blood test positive for Pseudomonas. A: Acute pneumonia due to H. influenza, febrile seizure. P: Admit to PICU for antibiotic therapy. J15.1 Pneumonia due to Pseudomonas R56.00 Simple febrile convulsions J18.9 Pneumonia, unspecified Discharge diagnosis = Pneumonia Sputum cultures, medications administered indicate bacterial infection as cause Codes cannot be assigned based on coder s interpretation of lab results query! Codes assigned solely on physician documentation Discharge diagnosis = Pneumonia due to Pseudomonas 13

14 ICD-10 CLINICAL CONCEPTS Examples Identify: Associated with Acute lower respiratory infection Acute exacerbation Environmental factor Exposure to tobacco smoke History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Inadequate Documentation S: 40 year-old woman here for follow-up of her COPD. She is experiencing more SOB O: Vital signs stable today. CV: RRR, No murmurs. Lungs: distinct breath sounds with no wheezes. A: COPD P: Change to Combivent inhaler 2 puffs QID. RTC 2 weeks. Adequate Documentation S: 40 year-old woman here for follow-up of her COPD. She is experiencing more SOB with exertionsince her last visit. She is c/o a new feeling of compression in her chest. She has been eating larger meals later at night and this seems to coincide with her symptoms. O: Vital signs stable today. CV: RRR, No murmurs. Lungs: distinct breath sounds with no wheezes. A: Chest pain and COPD with acute exacerbation. P: Refrain from eating 2-3 hours prior to sleeping and eat smaller meals. If chest pain symptoms continue RTC immediately. COPD exacerbated recently. Change to Combivent inhaler 2 puffs QID. RTC 2 weeks. J44.1Chronic obstructive pulmonary disease with (acute) exacerbation R07.9Chest pain, unspecified J44.9 Chronic obstructive pulmonary 14

15 Identify: Severity/type, if known Mild intermittent Mild persistent Moderate persistent Severe persistent Other specified type Exercise induced bronchospasm Cough variant Complications Uncomplicated With acute exacerbation With status asthmaticus Environmental factors Exposure to tobacco smoke History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Inadequate Documentation S: 55 year-old black female presents with acute asthma episode. O: She is SOB and very anxious. Wheezing can be heard without stethoscope. O2 sat was 92% on RA but increased to 95% after initiation of O2 4L/m via NC. Nebulizer treatment given. A: Asthma P: Admit for overnight breathing treatments and IV steroids. J Unspecified asthma with (acute) exacerbation Adequate Documentation S: 55 year-old black female presents with acute asthma episode. Pt has had dx of asthma since childhood. Allergic triggers include cold weather, pollen and mold. She uses oral and inhaled steroids extensively. O: She is SOB and very anxious. Wheezing can be heard without stethoscope. O2 sat was 92% on RA but increased to 95% after initiation of O2 4L/m via NC. Nebulizer treatment given. Chest x-ray r/o pneumonia. A: Moderate persistent asthma with acute exacerbation most likely due to weather change. P: Admit for overnight breathing treatments and IV steroids. J45.41Moderate persistent asthma with (acute) exacerbation Z79.51 Long term (current) use of inhaled steroids Z79.52 Long term (current) use of systemic steroids 15

16 Identify: Type Type (no longer benign, malignant, or unspecified) Essential hypertension Hypertensive heart disease Also document: With heart failure Without heart failure Hypertensive chronic kidney disease Hypertensive heart and chronic kidney disease Also document: With heart failure Without heart failure With chronic kidney disease, include Stage 1-4 or unspecified Stage 5 or end stage CKD Environmental factor Exposure to tobacco smoke Tobacco dependence Tobacco use ICD-9-CM CM Code/Documentation Essential hypertension, malignant Essential hypertension, benign Essential hypertension, unspecified ICD CM Code/Documentation I10 Essential hypertension 16

17 Inadequate Documentation S: 30 year-old patient seen in follow-up for high blood pressure. Pt home BP readings are consistently above 140/90. Pt is not taking any medications at this time. O: BP today 156/98, HR 82. A: High blood pressure P: Start Cozaar 25mg qd. RTC 1 month with BP readings. Adequate Documentation S: 30 year-old patient seen in follow-up for hypertension. Pt home BP readings are consistently above 140/90. Pt is not taking any medications at this time. Pt is a long time cigarette smoker. O: BP today 156/98, HR 82. Pt is counseled on long term effects of hypertensionand risks of not treating. Pt also counseled on quitting smoking. Pt is unwilling to try now. A: Hypertension. Nicotine dependence. P: Start Cozaar 25mg qd. RTC 1 month with BP readings. R03.0 Elevated blood-pressure reading, without diagnosis of hypertension I10 Essential hypertension F17.200Nicotine dependence, unspecified, uncomplicated Identify: Type Type 1 Type 2 Secondary diabetes - Drug or chemical induced - Due to underlying condition - Other specified Body system affected/manifestations Circulatory complications Hyperglycemia Hypoglycemia Ketoacidosis Kidney complications Neurological complications Ophthalmic complications - Diabetic retinopathy 17

18 With Diabetic retinopathy, identify severity Mild Moderate Severe Proliferative Unspecified With Diabetic retinopathy, include With macular edema Without macular edema Inadequate Documentation S: 56 year-old female here for follow-up of diabetes. She checks her BS faithfully and all are between She has had no episodes of hypoglycemia. O: Wt. 151 lb, Ht. 66 in, BMI 26kg/m2. Sensory function and pulses of lower extremities diminished. Last HbA1C = 6.2 (3 weeks ago). A: Diabetes mellitus. Neuropathy. P: Continue current meds. Add Gabapentin for neuropathy. RTC in 1 month. Fasting labs 1 week prior to appointment. Adequate Documentation S: 56 year-old female here for follow-up of diabetes type 2. She checks her BS faithfully and all are between She has had no episodes of hypoglycemia. She does complain on neuropathy in both feet. The pain is worse at night. O: Wt. 151 lb, Ht. 66 in. Sensory function and pulses of lower extremities diminished. Last HbA1C = 6.2 (3 weeks ago). A: Type II diabetes mellitus with diabetic peripheral neuropathy. P: Continue current meds. Add Gabapentin for neuropathy. RTC in 1 month. Fasting labs 1 week prior to appointment. E11.40Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.9 Type 2 diabetes mellitus Identify: Condition With current pathological fracture Without current pathological fracture Type Age-related Localized Other 18

19 Site Shoulder Humerus Forearm Hand Femur Lower leg Ankle/foot Vertebrae Episode of care Initial encounter Subsequent encounter - With routine healing - With delayed healing - With nonunion - With malunion Sequela Encounter Type: Initial Encounter patient is receiving active treatment for injury (surgical, emergency department, evaluation and treatment by new physician) Subsequent Encounter patient is no longer receiving active treatment of injury, and receiving routine care during healing or recovery phase 57 19

20 Inadequate Documentation S: 80 year-old female with senile osteoporosis here complaining of severe back pain. No history of trauma or falls. O: Vital signs stable. Lumbar vertebra palpitation causes severe pain reaction from patient. Pt reports pain is 8 on a scale of A: Senile osteoporosis. P: PT for strengthening exercises. Bone density testing is overdue. M81.0 Age related osteoporosis without current pathological fracture Adequate Documentation S: 80 year-old female with senile osteoporosis here complaining of severe back pain. No history of trauma or falls. O: Vital signs stable. Lumbar vertebra palpitation causes severe pain reaction from patient. Pt reports pain is 8 on a scale of X-rays reveal pathological compression fracture of several lumbar vertebrae. A: Pathological fracture of vertebrae due to osteoporosis. P: PT for strengthening exercises. Bone density testing is overdue. M80.08XAAge related osteoporosis with current pathological fracture, vertebrae, initial encounter for fracture Pathological Fractures documentation will require: Exact location of fracture with laterality Etiology of the fracture: Due to osteoporosis or neoplastic disease or other specified disease Encounter type Physician MUST make connection between a fall and a fracture due to osteoporosis 59 Identify: Type Acute Generalized Localized Localization/Laterality Right upper quadrant, left lower quadrant, etc. Epigastric Periumbilic 20

21 ICD-9-CM CM Code/Documentation Abdominal pain, unspecified site ICD CM Code/Documentation R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant, pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.2 Pelvic and perineal pain R10.30 lower abdominal pain, unspecified R10.31 Right lower quadrant pain R10.32 Left lower quadrant pain R10.33 Periumbilical pain Inadequate Documentation S: 70 year-old female c/o abdominal pain and indigestion. The pain is described as a dull constant pain. Nausea accompanies the pain and is worsened by eating. On a 10 point pain scale the patient rates the pain a 7. O: T: 99.2, BP 125/80, HR 70. Normal bowel sounds. Abdominal discomfort was felt on palpitation. Liver and spleen not enlarged. A: Abdominal pain suggestive of gall stone disease. P: Obtain abdominal ultrasound, lab tests and EKG. R10.9 Unspecified abdominal pain Adequate Documentation S: 70 year-old female c/o abdominal pain and indigestion. The pain is described as a dull constant pain in the RUQ. Nausea accompanies the pain and is worsened by eating. On a 10 point pain scale the patient rates the pain a 7. O: T: 99.2, BP 125/80, HR 70. Normal bowel sounds. Abdominal discomfort was felt on palpitation in the RUQ. Liver and spleen not enlarged. Family history positive for gallbladder disease and MI. A: RUQ abdominal pain suggestive of gall stone disease. P: Obtain abdominal ultrasound, lab tests and EKG. R10.11 Right upper quadrant abdominal pain Z83.79 Family history of other diseases of the digestive system Z82.49 Family history of cardiovascular disease The requirements for good documentation haven t changed ICD-10-CM is BUILT BETTER for coding clinical concepts that more fully describe the patient s condition Documentation of the clinical concepts is integral to good patient care and better reporting of healthcare data 21

22 QUESTIONS? Connie Eckenrodt, RHIT, CHCA, CHC Director, Physician Coding & Compliance On the Web: ICD-10-CM Official Coding Guidelines ICD-10-CM PDF Format Addenda List of Codes and Descriptions General Equivalence Mapping (GEM) files :// pdate ICD-10-CM Official Coding Guidelines ICD-10-CM Coder Training Manual-AHIMA ICD-10-CM Official Guidelines for Coding and Reporting 2013 ICD-10-CM Documentation: A How-To Guide for Coders, Physicians, and Healthcare Facilities 2014, Contexo Media Final Rule: hcsp?ddocname=bok3_ pdf