ICD 10 Readiness analysis

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1 Case Study ICD 10 Readiness analysis

2 Introduction Physician documentation for ICD-10-CM will need to be more specific and detailed than is required for ICD-9- CM. The codes will change in many ways involving longer code structure, use of laterality, combination codes and types of encounters. For Radiologists, this transition from ICD-9- to ICD-10 may mean capturing new that the radiologist never documented before. Physicians with good documentation habits will find the transition much easier than those who use abbreviations or other shortcuts or do not use specificity while documenting the diagnosis. Radiologists would need to capture more detailed diagnosis information from referring physician orders. However, one thing remains constant the golden rule of coding if it is not documented, it did not happen, and should not be coded. No document is ever considered complete unless it is documented to the highest degree of specificity. As a good head start, we reviewed the diagnosis reporting currently being received from the radiologists for MEDEX against the new standards. Five hundred reports were analyzed to evaluate documentation readiness and identify the required changes for the successful ICD-10-CM transition. Methodology Used Five hundred reports were randomly picked from February Identified top 10 frequently occurring ICD-9-CM codes and performed a gap analysis based on the documentation. Mapped these ICD-9-CM Codes to GEMS and determined if they were 1:1 match or if they were complex. Also identified codes that required higher specificity in documentation laterality and encounter (fracture, pain, unspecified codes) and analyzed the documentation sufficiency for reporting such complex conditions. Based upon the mapping and the analysis of the reports, evaluated the readiness of MEDEX documentation for ICD-10-CM transition and identified areas of weakness and improvement across rendering physicians. Majority of the reports pertained to Dr. Gary D. Grossman (439 reports). A few reports pertained to Dr. Srinivas Bonthu (51 reports) and Dr. Jeffrey A. Kobak (7 reports). Assessment Results A total of 174 different ICD-9-CM codes were documented across the 500 reports that were picked for the ICD-10-CM readiness assessment. Of the 174 different diagnoses, identified top 10 frequently occurring codes topped the list followed by lumbar stenosis, and lumbar disc disease. screening mammograms Limb Pain / Abdominal Pain / Chest Pain /Unspecified Codes Although, ICD-10 allows for reporting unspecified codes for limb pain, it would be important to identify on which limb, where on the limb, and whether on the right or the left limb. Insurance companies will eventually not pay for unspecified codes and will request more specific information before paying a claim. There were a few documents which did not specify the region of the abdominal pain (which is essential for ICD-10-CM coding) and the laterality and the exact region of the limb pain. Chest pain The documentation was always unspecified chest pain. ICD-10-CM has classified chest pain between R07.1 R07.9. More specificity should be provided as to the region of the pain. Fractures Fractures, to include wedge compression fractures of the spine (site specific), were well documented. Laterality, type of fracture (displaced vs nondisplaced), and encounter type was also documented. Injury and Poisoning region and the laterality. physicians to include the Overall with the exception of pain codes and a few unspecified conditions/diagnoses documented, the rest of the documentation seemed to support ICD-10-CM transformation. Top 10 Diagnoses Documented

3 Diagnosis ICD-9-CM ICD-10-CM Screening mammogram V76.12 Z lumbar stenosis M lumnar disc disease M low back pain M breast nodule R cervical stenosis M breast mass N63 15 cough R05 15 chest pain R neck pain M Diagnosis (charts) Top 10 Diagnoses Documented Screening mammogram V76.12 Z12.31 lumbar stenosis M48.06 lumnar disc disease M51.36 low back pain M54.5 breast nodule R92.8 cervical stenosis M48.02 breast mass N63 cough R05 chest pain R07.9 neck pain M54.2

4 Documentation Analysis - Fracture Probably the biggest change providers will have to make is stating the side (right or left) on which the injury or diagnosis occurred. In ICD-10-CM close to 5,000 codes have a right and left distinction including joint pain, joint effusion, injury, fractures, sprains, tears of the meniscus and cruciate ligament, dislocations, arthritis, cerebral infarctions, extremity atherosclerosis, pressure ulcers, cancers, and neoplasms (breast, lung, bones, etc). The region, the side and the type of fracture was specified in the documentation. Also the type of encounter (initial vs. subsequent with routine healing or delayed healing, etc) was also documented. Fracture Documenation Analysis Dignosis ICD-9-CM ICD-10-CM Ocurrence Region Latrality Wedge compression fracture lumbar M48.56XA 2 a NA Wedge compression fracture thoracic M48.54XA 3 a NA Fracture distal right radius S52.501A 1 a a Capitate nondisplaced fracture left wrist S62.135A 1 a a Distal tibia and fibular buckle fracture left S82.302A 2 a a Fracture along the proximal medial femoral cortex extending to the neck of the prosthesis T84.011A 1 a a Healing nondisplaced hairline fracture of the distal first promixal phalanx right v54.16 S92.414D 1 a a Occurrence - Fracture wedge compression fracture lumbar M48.56XA wedge compression fracture thoracic M48.54XA fracture distal right radius S52.501A Capitate nondisplaced fracture left wrist S62.135A distal tibia and fibular buckle fracture left S82.302A fracture along the proximal medial femoral cortex extending to the neck of the prosthesis T84.011A Healing nondisplaced hairline fracture of the distal first promixal phalanx right v54.16 S92.414D Documentation Analysis Diagnosis of Tear

5 As far as documenting the diagnosis of tear, the laterality and site of the tear was specified in the documentation. Documentaiton Analysis - Diagnosis of Tear Diagnosis ICD-9-CM ICD-10-CM Occurrence Region Laterality Posterior medial meniscus tear right S83.241A 3 a a Posterior medial meniscus tear right S83.242A 3 a a Full thickness tear supraspinatus tendon left S43.82XA 3 a a Tear supraspinatus tear right S43.81XA 2 a a Medial patella retinaculum tear left knee S83.82XA 1 a a Occurrence Posterior medial meniscus tear right S83.241A Posterior medial meniscus tear right S83.242A Full thickness tear supraspinatus tendon left S43.82XA Tear supraspinatus tear right S43.81XA Medial patella retinaculum tear left knee S83.82XA Documentation Analysis Abdominal Pain

6 Unspecified abdominal pain was highly documented. ICD-10-CM has codes for both acute abdomen pain and diagnoses classification pertaining to pain localized to the upper abdomen and pain localized to the other parts of the lower abdomen. There were 9 reports in which only unspecified abdominal pain was documented. Specificity was missing in these cases and hence unspecified abdominal pain (R10.9) was mapped and coded. Abdominal Pain Specificity Documentation Diagnosis ICD-9-CM ICD-10-CM Frequency of Occurrence Region Specificity abdominal pain R a X right upper quadrant pain R a a epigastric pain R a a pelvic pain R a a Occurrence abdominal pain R10.9 right upper quadrant pain R10.11 epigastric pain R10.13 pelvic pain R10.30 Documentation Analysis Extremity Pain There were a few cases wherein the side of the pain was not documented. Only documenting the region and

7 thumb pain, hand pain. It is imperative to document both the region and the side of the pain in ICD-10-CM. Highest specificity should be provided wherever necessary as per the guidelines. Extremity Pain Documentation Analysis Diagnosis ICD-9-CM ICD-10-CM Occurrence Region Laterality left calf pain M a a right lower extremity pain M a a left lower extremity pain M a a lower extremity pain M a x hand pain right M a a left foot pain M a a right foot pain M a a right thigh pain M a a right heel pain M a a hand pain M a x thumb pain M a x Occurrence left calf pain M right lower extremity pain M left lower extremity pain M lower extremity pain M hand pain right M left foot pain M right foot pain M right thigh pain M right heel pain M hand pain M thumb pain M Documentation Analysis Other Joint Pain Upper and Lower Extremities The region and the side of pain (right / left) were documented in all reports.

8 Documentation Analysis - Other Joint Pain Diagnosis ICD-9-CM ICD-10-CM Occurrence Region Laterality right shoulder pain M a a left shoulder pain M a a left elbow pain M a a left wrist pain M a a right wrist pain M a a right hip pain M a a sacroiliac joint pain M NA NA right knee pain M a a right ankle pain M a a left ankle pain M a a Occurrence right shoulder pain M left shoulder pain M left elbow pain M left wrist pain M right wrist pain M right hip pain M sacroiliac joint pain M53.3 right knee pain M right ankle pain M left ankle pain M25.572

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