ICD-10 CM Training. Orthopaedic

Transcription

1 ICD-10 CM Training Orthopaedic

2 ICD-10-CM Compliance Dates ICD-10-CM will be valid for dates of service on or after October 1, 2015 Outpatient dates of service of October 1, 2015 and beyond. Inpatient hospital service claims, is effective for dates of discharge after September 30, 2015

3 Covered and Non-Covered Entities Covered Entities Everyone covered by the Health Insurance Portability Accountability Act (HIPPA) Non-Covered Entities Worker s Compensation Auto Insurance Non covered HIPAA entities are exempt but are encouraged to adapt the new code set

4 ICD-10 Code Structure 21 Chapters Alpha-numeric codes; not case-sensitive Codes begin with Alpha letter, A-Z, excluding U Common errors I verses 1 O verses 0 X Placeholder 3 to 7 characters Decimal following 3 rd character

5 ICD-10 Code Structure Placeholder X Used for future expansion of a code Fills in empty characters when a 6 th and/or 7 th character apply The placeholder may be used in different scenarios but should never serve as the final character. Example: W19.XXXA Unspecified fall, Initial Encounter

6 ICD-10 Code Structure 7 th Character Provides specified information regarding the clinical visit Is required for certain categories and must be reported in the seventh position May be alpha or numeric Has different meanings depending on the coding category

7 ICD-10 Code Structure Laterality Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. OGCR section 1.B.13

8 ICD-10 Code Structure Other Codes Codes titled other or other specified are for use when the information in the medical record provides detail for which a specific code does not exist. Unspecified Codes Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. OGCR section 1.A.9.a.b

9 ICD-10 Structure Excludes Notes Excludes1 A type 1 Excludes note is a pure excludes note It means NOT CODED HERE The code excluded should never be used at the same time When two conditions cannot occur together Excludes2 Represents Not included here The condition excluded is not part of the condition represented by the code It is acceptable to use both the code and the excluded code together, when appropriate OGCR section 1.A.12.a.b

10 ICD-10 Code Structure Code First and Use Additional Code ICD-10 has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. These instructional notes indicate the proper sequencing order of the codes. OGCR section 1.A.13 The - indicates there are additional reporting options

11 Most Common Diagnosis Codes

12 Pain of Joint Category M25.5 Excludes1 Excludes2 Contracture of muscle without contracture of joint (M62.4-) Contracture of tendon (sheath) without contracture of joint (M62.4-) Dupuytren s contracture (M72.0) acquired deformities of limbs (M20-M21)

13 Pain, Shoulder ICD-9 Code ICD-10 Code Description M Pain, right shoulder M Pain, left shoulder M Pain, unspecified shoulder Pain, Elbow ICD-9 Code ICD-10 Code Description M Pain, right elbow M Pain, left elbow M Pain, unspecified elbow Pain, Wrist ICD-9 Code ICD-10 Code Description Pain, Hip ICD-9 Code ICD-10 Code Description M Pain, right hip M Pain, left hip M Pain, unspecified hip Pain, Knee ICD-9 Code ICD-10 Code Description M Pain, right knee M Pain, left knee M Pain, unspecified knee M Pain, right wrist M Pain, left wrist M Pain, unspecified wrist

14 Pain, Ankle and Foot ICD-9 Code ICD-10 Code Description M Pain, right ankle and foot M Pain, left ankle and foot M Pain, unspecified ankle and foot Pain, Unspecified Joint M25.50 Pain, unspecified joint Documentation Tips Site Laterality Right Left Unspecified Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.

15 Documentation Tips Bone versus joint For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.

16 Osteoarthritis of knee ICD-9 Code ICD-10 Code Description Excludes1 Excludes M17.9 Osteoarthritis of knee, unspecified There are more specific code choice selections below: N/A osteoarthritis of spine (M47.-) M17.0 Bilateral primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post-traumatic osteoarthritis of knee M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other bilateral secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee

17 Documentation Tips Identify Site Laterality Type Primary Post-traumatic Other secondary Unspecified

18 Osteoarthritis of hip ICD-9 Code ICD-10 Code Description Excludes1 Excludes M16.9 Osteoarthritis of hip, unspecified There are more specific code choice selections below: bilateral involvement of single joint (M16- M19) osteoarthritis of spine (M47.-) M16.0 Bilateral primary osteoarthritis of hip M16.10 Unilateral primary osteoarthritis, unspecified hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip M16.2 Bilateral osteoarthritis resulting from hip dysplasia M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4 Bilateral post-traumatic osteoarthritis of hip M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip M16.51 Unilateral post-traumatic osteoarthritis, right hip M16.52 Unilateral post-traumatic osteoarthritis, left hip M16.6 Other bilateral secondary osteoarthritis of hip M16.7 Other unilateral secondary osteoarthritis of hip

19 Documentation Tips Identify: Laterality Bone versus joint For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.

20 Cardiac murmur, unspecified ICD-9 Code ICD-10 Code Description Excludes1 Excludes M Incomplete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic There are more specific code choice selections below: Tear of rotator cuff, traumatic (S46.01-) Shoulder-hand syndrome (M89.0-) M Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic M Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic

21 Documentation Tips Note: Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition Identify: Laterality

22 Unspecified fracture of forearm ICD-9 Code ICD-10 Code Description Excludes1 Excludes S52.90xA Unspecified fracture of unspecified forearm There are more specific code choice selections below: Traumatic amputation of forearm (S58.-) Fracture of wrist and hand level (S62.-) S52.91x- S52.92x- Unspecified fracture of right forearm Unspecified fracture of left forearm The appropriate 7th character is to be added to all codes from category S52 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II initial encounter for open fracture NOS C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunion Q - subsequent encounter for open fracture type I or II with malunion R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - sequela

23 Documentation Tips A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced. The open fracture designations are based on the Gustilo open fracture classification Identify: Laterality

24 Low back pain ICD-9 Code ICD-10 Code Description Excludes1 Excludes M54.5 Low back pain Loin pain Lumbago NOS psychogenic dorsalgia (F45.41) low back strain (S39.012) lumbago due to intervertebral disc displacement (M51.2-) lumbago with sciatica (M54.4-) N/A

25 Low Back Pain Documentation Tips Document site and laterality Unspecified codes should be used only in rare circumstances With or without sciatica Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.

26 Trochanteric bursitis ICD-9 Code ICD-10 Code Description Excludes1 Excludes M70.60 Trochanteric bursitis, unspecified hip Applicable to: Trochanteric tendinitis M70.70 Other bursitis of hip, unspecified hip M76.10 Psoas tendinitis, unspecified hip M76.20 Iliac crest spur, unspecified hip There are more specific code choice selections below: bursitis NOS (M71.9-) bursitis of shoulder (M75.5) enthesopathies (M76- M77) pressure ulcer (pressure area) (L89.-) M70.60 Trochanteric bursitis, unspecified hip M70.61 Trochanteric bursitis, right hip M70.62 Trochanteric bursitis, left hip

27 Documentation Tips Identify: laterality

28 Carpal tunnel syndrome, unspecified upper limb ICD-9 Code ICD-10 Code G56.00 Carpal tunnel syndrome, unspecified upper limb Description Excludes1 Excludes2 There are more specific code choice selections below: current traumatic nerve disorder - see nerve injury by body region G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, leftt upper limb N/A

29 Documentation Tips Identify: Laterality

30 Unspecified intracapsular fracture of femur ICD-9 Code ICD-10 Code Description Excludes1 Excludes S72.019A Unspecified intracapsular fracture of femur Applicable to: Subcapital fracture of femur There are more specific code choice selections below: traumatic amputation of hip and thigh (S78.-) fracture of lower leg and ankle (S82.-) fracture of foot (S92.-) periprosthetic fracture of prosthetic implant of hip (T84.040, T84.041) S S Unspecified intracapsular fracture of right femur Unspecified intracapsular fracture of left femur The appropriate 7th character is to be added to all codes from category S72 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II initial encounter for open fracture NOS C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunion Q - subsequent encounter for open fracture type I or II with malunion R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - sequela

31 Documentation Tips A fracture not indicated as open or closed should be coded to closed The open fracture designations are based on the Gustilo open fracture classification Identify: Laterality Open or closed

32 Pain in limb ICD-9 Code ICD-10 Code Description Excludes1 Excludes M Pain in limb, unspecified psychogenic rheumatism (F45.8) soft tissue pain, psychogenic (F45.41) There are more specific code choice selections below: Pain in joint (M25.5-) M Pain in upper arm M Pain in forearm M Pain in hand and fingers M Pain in thigh M Pain in leg M Pain in foot and toes

33 Documentation Tips Site Laterality Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition

34 Sprain of unspecified rotator cuff capsule ICD-9 Code ICD-10 Code Description Excludes1 Excludes S43.429A Sprain of unspecified rotator cuff capsule, initial encounter S43.429D Sprain of unspecified rotator cuff capsule, subsequent encounter S43.429S Sprain of unspecified rotator cuff capsule, sequela Code also any associated open wound There are more specific code choice selections below: rotator cuff syndrome (complete) (incomplete), not specified as traumatic (M75.1-) strain of muscle, fascia and tendon of shoulder and upper arm (S46.-) injury of tendon of rotator cuff (S46.0-) S S S Sprain of right rotator cuff capsule Sprain of left rotator cuff capsule Sprain of unspecified rotator cuff capsule

35 Documentation Tips Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes. Identify: Laterality

36 Secondary osteoarthritis, shoulder ICD-9 Code ICD-10 Code Description Excludes1 Excludes M Secondary osteoarthritis, unspecified shoulder There are more specific code choice selections below: Polyarthritis (M15.1-) arthrosis of spine (M47.-) Hallux rigidus (M20.2) osteoarthritis of spine (M47.-) M Secondary osteoarthritis, right shoulder M Secondary osteoarthritis, left shoulder

37 Documentation Tips Identify: Laterality Primary, Secondary, Post-traumatic

38 Displaced intertrochanteric fracture of femur ICD-9 Code ICD-10 Code Description Excludes1 Excludes S Displaced intertrochanteric fracture of unspecified femur There are more specific code choice selections below: traumatic amputation of hip and thigh (S78.-) fracture of lower leg and ankle (S82.-) fracture of foot (S92.-) periprosthetic fracture of prosthetic implant of hip (T84.040, T84.041) S S Displaced intertrochanteric fracture of right femur Displaced intertrochanteric fracture of left femur The appropriate 7th character is to be added to all codes from category S72 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II initial encounter for open fracture NOS C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunion Q - subsequent encounter for open fracture type I or II with malunion R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - sequela

39 Documentation Tips A fracture not indicated as open or closed should be coded to closed The open fracture designations are based on the Gustilo open fracture classification Identify: Laterality

40 Other specified postprocedural states ICD-9 Code ICD-10 Code Description Excludes1 Excludes2 V45.89 Z98.89 Other specified postprocedural states Applicable To: Personal history of surgery, not elsewhere classified Code also any follow-up examination (Z08-Z09) N/A N/A

41 Documentation Tips Note: Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00- Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways: (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury. (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.

42 Monitor Claims On October 01, 2015 we will monitor claims for date of service rules Outpatient claims cannot have crossover dates Outpatient claims will be coded according to date of service Inpatient facility claims will be coded per date of discharge We will monitor claims to resolve any unanticipated problems with the submission process

43 Claim Denial and Management We will monitor for claim denials We will monitor editing trends for ICD-10 Coding guidelines We will provide feedback to the physicians regarding supporting documentation requirements We will monitor WC or Liability carriers for published rules on use of ICD-9 or ICD-10 code sets

44 Client Responsibilities Client will need to update Templates Order Sets Superbills Favorites Future Orders Remove ICD-9 code add ICD-10 code

45 Documentation Start Now All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection. Site specificity Document notation of qualifiers Exacerbation Manifestations Relapse Status Stages Indicate acute or chronic Indicate underlying or external cause factors Medication Smoke Accidents Mechanical failure Laterality Bilateral Right Left

46 Documentation Start Now Episode of Care for injuries, poisoning, external causes and other conditions Initial Encounter Use while the patient is receiving active treatment of the condition Active treatment includes surgical treatment, an emergency encounter, and evaluation and treatment by a new physician Subsequent Encounter Used on encounter after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Medication adjustments, aftercare, device adjustments, cast change Sequela Used for complications or conditions that arise as a direct result of a condition, late effect

47 Documentation Start Now Combination codes that capture Etiology and manifestation Related conditions Disease, injury or other medical condition and complications Disease or other medical conditions and common signs or symptoms Add ICD-10 Codes to patient Problem List

48 Questions Centers for Disease Control and Prevention (ICD-10-CM)