More Detailed Coding Requires More Specific Documentation

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3 More Detailed Coding Requires More Specific Documentation

4 Medical necessity demonstrated by the diagnosis code supports the need for treatment. It answers the questions: Why, why is the patient being seen TODAY? Why is the patient receiving this treatment or procedure? Why are your special skills needed?

5 S A S Chapter 19, Injury, Poisoning and Certain Other Consequences of External Causes S52 Fracture of forearm S52.5 Fracture of lower end of radius S52.52 Torus fracture of lower end of radius S Torus fracture of lower end of right radius S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture In the above example: S52 is the chapter and the category The fourth and fifth characters of 5 and 2 provide additional clinical detail and anatomic site The sixth character in this example indicates laterality, i.e., right radius The seventh character, A, is an extension that provides additional information, which means initial encounter for closed fracture

6 Location - Forearm Type of Fracture Displaced or Nondisplaced Laterality Episode of Care / Open or Closed Ulna unspecified Torus Displaced Right A - Initial encounter for closed fracture Ulna upper end Greenstick Nondisplaced Left Olecranon process w/o intraarticular extension Olecranon process w/ intraarticular extension Coronoid process Shaft of Ulna Lower end of ulna Ulna styloid process Radius unspecified Transverse Oblique Spiral Comminuted Segmental Monteggia Bent Bone Unspecified B - Initial encounter for open fracture type I or II (or open NOS or not otherwise specified) 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 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 Radius upper end Galeazzi K - Subsequent encounter for fracture with nonunion Head of Radius Neck of Radius Colles Smith s 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 Shaft of Radius Barton s P - Subsequent encounter for fracture with malunion Lower end of radius Radial styloid process Unspecified fracture of forearm Extraarticular Intraarticular 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

7 If applicable, always state laterality Detail anatomical locations and type of approaches (open, endoscopic, closed) State whether the patient is in the treatment (surgery, Emergency Department, etc.) or healing phase (most follow-up visits) or is this a late effect/sequela of an injury? Define the original injury to determine the injury code and define the late effect Example: Thigh pain due to a closed fracture of the shaft of the right femur in an MVA 5 years ago State acute or chronic, old injury, any descriptive conditions that help to illustrate the condition Acute duodenal ulcer with perforation State any due to or precipitating conditions Post-traumatic osteoarthritis, gout due to renal impairment Remember to include comorbid and complicating conditions that impact your decision making Document trimester for all pregnant patients and number of weeks gestation

8 Episode of care For many conditions, only the last character changes as the phases of treatment change Description A - Initial encounter while patient is receiving active treatment for the condition (Example: surgical treatment, emergency department encounter, evaluation and treatment by new physician) D Subsequent encounter after patient has received active treatment and is receiving routine care for condition during the healing or recovery phase (Example: cast change or removal, medication adjustment, aftercare following treatment) S - Sequela (late effect) is for complications or conditions that arise as a direct result of a condition. State causal relationship (Example: scar formation after a burn or pain following laceration of arm in MVA 5 years ago) Infection document infectious organism, if known Indicate any retained foreign bodies For sequela, list current condition in addition to the original injury External cause of injury (MVA, fall on stairs, sports, etc.)

9 We can now code for intraoperative and postprocedural complications Documentation of Complications of Care Code assignment is based on the provider s documentation of the relationship between the condition and the care or procedure The guideline extends to any complications of care Note: Not all conditions that occur during or following medical care or surgery are classified as complications There must be a cause-and-effect relationship between the care provided and the condition, and An indication in the documentation that it is a complication A condition that is normal and expected post-operatively is not a complication

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11 Audit Results of Documentation Challenges for ICD-10 Top Diagnosis Description I-9 I-10 Problem Information Needed Abdominal Pain R10.-- Missing information to code Right or left? Upper or lower, periumbilic, epigastric, or generalized? Is this a late effect of injury or condition? Abscess anal rectal region 566 K61.0- Missing information to code Anal, rectal, anorectal, ischiorectal, and intrashincteric? Acquired absence of breast V45.71 Z90.1- Missing information to code Laterality? Alcohol dependence F10.20 Additional information needed Use, abuse, or dependence of alcohol? Blood alcohol level if applicable? With other related disorders (withdrawal, intoxication, in remission, mood disorder, etc.)? Amputation Stump Complication T87.5- or T8781 Missing information to code Laterality? Necrosis or dehiscence? Anemia D64.9 Unspecified Code Appendicitis K35.-- Missing information to code Arthritis M19.90 Unspecified Code Aseptic necrosis of femur M Missing information to code Due to? Aplastic? Acute or Chronic? Type: Hemorrhagic, Idiopathic, Iron Deficiency, Nutritional, Blood Loss, etc. Acute, chronic or recurrent? With or without generalized or localized peritonitis? Type-infectious, juvenile, meaning osteoarthritis, rheumatoid, etc.? If meaning osteoarthritis, need if generalized, primary, secondary, or post-traumatic? Specific location? Directed to Idiopathic, osteonecrosis, due to drugs, previous trauma, secondary? Specific location of pelvis or femur? Laterality? Atrial fibrillation I48.91 Additional information needed Paroxysmal, persistent, or chronic? Atrial flutter I48.92 Additional information needed ICD-10 specific to persistent, typical, atypical or unspecified Barrett's esophagus K Additional information needed Presence or absence of dysplasia? Bipolar 1 disorder F31.9 Additional information needed Specific to recent episode, in remission, partial remission, or full remission. Bladder Cancer C67.9 Additional information needed Breast Cancer C50.91 Missing information to code Breech presentation O641XX0 Additional information needed CAD I25.10 Additional information needed Calculus of ureter N20.1 Additional information needed Kidney with ureter? Carotid Stenosis (Occlusion and stenosis) I65.2- Missing information to code Laterality? Specify site, trigone, dome, lateral wall, anterior or posterior wall, bladder neck, ureteric, overlapping site? Laterality? Specific location, quadrant, or overlapping site. Estrogen receptor status if known. The codes for breech presentation has additional classification on the basis of no. of gestation (fetus) Due to calcified lesion or lipid rich plaque? Use or exposure to smoking? With or without angina pectoris?

12 Audit Results of Documentation Challenges for ICD-10 Top Diagnosis Description I-9 I-10 Problem Information Needed x Cataract H26.9 Additional information needed Type (infantile/juvenile, drug induced, senile, anterior, diabetic, presenile, nuclear, traumatic, etc.)? Laterality? x Cesarean Delivery Additional information needed (single liveborn, twins, stillborn, etc.) Cesarean, Repeat O34.21 Additional information needed Requires weeks of gestation and outcome of delivery CVA I Additional information needed Codes are depended upon the artery involved in the infarction and laterality. Chalazion H Additional information needed Upper or lower eyelid? Cholecystitis K81.9 Additional information needed Acute, chronic or acute on chronic? With calculus, if so where? Cholelithiasis K80.20 Additional information needed With or without obstruction Chondromalacia M Additional information needed Laterality? Specific anatomical location? Chronic tonsillitis J35.01 Additional information needed Use or exposure to smoking? Colon cancer C18.9 Additional information needed Use, abuse, or dependence of alcohol? x Colon polyps D12.2 Additional information needed Site specific: cecum, ascending, transverse, descending sigmoid, etc. Complication of AV fistula T Specifics needed Embolism, Fibrosis, Hemorrhage, Pain, Stenosis, Thrombosis? Cardiac or Vascular device, implant, or graft? Episode of care: Initial or subsequent? Or Sequela? Complication of internal orthopedic device, implant, and graft, mechanical T Additional information needed What kind of device, implant, or graft? Breakdown, displacement, osteolysis, wear of articular bearing surface, Complication of vascular device T Missing information to code COPD 496 J44.9 Additional information needed Crohn's Disease, large intestine K50.10 Additional information needed CVA I Missing information to code Type of cardiovascular device, implant, or graft? Type of complication (breakdown, displacement, infection, embolism, etc.)? Episode of care: Initial or subsequent? Or Sequela? With respiratory infection, exacerbation? Does patient additionally have asthma? Use or exposure to tobacco? Specific to: with bleeding, with obstruction, with fistula, with abscess, with other complication, with or without unspecified complications Cystitis, interstitial, chronic N30.10 Additional information needed With or without hematuria? Codes are dependent on the artery involved in the infarction: Anterior cerebral artery, posterior or cerebellar artery. Also laterality?

13 x x Audit Results of Documentation Challenges for ICD-10 Top Diagnosis Description I-9 I-10 Problem Information Needed Delivery (Spontaneous) (Normal) (Vaginal) 650 O80 Additional information needed Needs additional descriptors for "full term", "uncomplicated", if applicable. Also, needs outcome of delivery (single liveborn, stillborn, twins, etc.) Acute /Chronic is not specified, based on the statement: "having failed conservative management" chronic ICD- 9/ICD-10 was selected. Episode of care is not documented Derangement of medial meniscus M Missing information to code Diabetes E11.9 Additional information needed Type? Additional manifestations? Insulin usage? Dislocation of prosthetic Requires right or left, and episode of care: Initial or joint T Missing information to code subsequent? Or Sequela? Diverticulosis K57.-- Missing information to code Small or large intestine? Where-Upper or Lower Extremity? Distal or Proximal? DVT I Unspecified Code Acute or Chronic? Right, Left, or Bilateral? Which vein? Dysfunction of Eustachian Complication of PE tubes? Laterality? Use or exposure to tube H69.8- Missing information to code tobacco? Weeks of gestation? Abdominal, with viable fetus? Tubal? Ovarian? Complicated by (infection, renal failure, sepsis, Ectopic pregnancy O00.9 Additional information needed hemorrhage, etc.)? Emphysema J43.9 Additional information needed Specify type? Eosinophilic? Use additional code to identify alcohol abuse Esophagitis K20.9 Unspecified Code and dependence x ESRD N18.6 Additional information needed Need additional information to identify dialysis status? Failed back syndrome (Postlaminectomy syndrome) M96.1 Somewhat difficult to find Failed induction of labor O61.9 Additional information needed Trimester? Failed spinal cord stimulator T85.192A Additional information needed Specific to breakdown, displacement, or other complication. Requires episode of care: Initial or subsequent encounter? Or Sequela? Codes for femur fracture are classified on the basis of following: Episode of care: Initial (treatment phase)/ subsequent (Routine healing/ Delayed healing, Non-union/ Malunion) Type of fracture: open or closed (Type I, II, IIIA, IIIB, IIIC for open fracture) Displaced or non-displaced Femur Fracture S72.92XA Missing information to code

14 Audit Results of Documentation Challenges for ICD-10 Top Diagnosis Description I-9 I-10 Problem Information Needed Foreign body Missing information to code With laceration or puncture wound? Causing acute reaction? Location? Complication of? Retained foreign body? Episode of care: x Fractures 816 S62.602A Episode of care not specified Codes for fractures are classified on the basis of following: Traumatic or Pathologic (+ underlying condition)? Specific anatomical information (which finger, which bone, proximal-shaftdistal, head, neck, etc.)? Type of fracture: open or closed (Type I, II, IIIA, IIIB, IIIC for open fracture) Displaced or non-displaced? Right, Left, or Bilateral? Episode of care: Initial (treatment phase)/ subsequent (Routine healing/ Delayed healing, Non-union/ Malunion) Initial or subsequent encounter? Or sequela (detail original injury)? Ganglion M67.4- Missing information to code Need specific anatomical site and laterality Gangrene I96 Additional information needed Laterality? Specific anatomic information? Due to diabetes, drug induced, atherosclerosis of native arteries or by-pass grafts (type of graft)? Gastritis K29.70 Unspecified Code Acute or Chronic? If Chronic - superficial or atrophic? Alcoholic? With or without bleeding? x GERD K21.9 Additional information needed With or without esophagitis? Type? Suspect, open angle (risk), ocular hypertension, pigmentary, Glaucoma H40.9 Unspecified Code capsular, acute, chronic, intermittent, residual, secondary to, etc.? Goiter E04.9 Additional information needed Iodine deficiency? Hardware What kind of complication-hemorrhage, pain, stenosis, embolism, etc.? complication T84.9XX- Missing information to code Episode of care: Initial or subsequent encounter? Or Sequela? Headaches R51 Additional information needed Type? If Migraine: Type, with or without aura, intractable, persistent, with or without status migrainosus? Herniated Occipito-atlanto-axial, cervical, cervicothoracic, thoracic, thoracolumbar, Nucleus Pulposus M51.2- Missing information to code lumbar, lumbosacral, sacral and sacrococcygeal, or multiple sites? Hip Dislocation 835 S73.004A Episode of care not specified Initial or subsequent encounter? Or Sequela? Humeral Supracondylar fracture S42.412A Missing information to code Laterality: LT/ RT. Episode or Care: Initial/ Subsequent/ Sequela. Nature of the fracture: Displaced/ Non-displaced Anatomical Location: There are separate codes for medial condyle/ lateral condyle of the humerus.

15 Audit Results of Documentation Challenges for ICD-10 Top Diagnosis Description I-9 I-10 Problem Information Needed Hydronephrosis 591 N13.30 Combination code available Also has a combination code for due to stricture or to calculous obstruction Infection due to nervous system device T85.79X- Missing information to code Episode of care: Initial or subsequent encounter? Or Sequela? Is type of infection known? x Inguinal hernia K40.90 Additional information needed With gangrene or obstruction? Unilateral or bilateral? Recurrent? Laterality? Specific anatomical information? Is this a late effect of Leg Pain M Missing information to code an injury (detail injury)? Cause? Lipoma D17.-- Missing information to code Anatomical location detail? Liver Cancer C22.9 Additional information needed Asks for additional code to identify alcohol abuse and/or dependence, hepatitis B or C. Lumbar DDD M51.3- Missing information to code Lumbar or lumbosacral? With or without mylopathy, neuritis, radiculopathy, radiculitis, or sciatica? Lumbar stenosis M48.06 Specific portion of lumbar region Thoracolumbar, lumbar, lumbosacral? Lumbosacral spondylosis M Missing information to code With or without myelopathy or radiculopathy? Lung Cancer C34.9- Missing information to code Laterality required. Specific to site: upper lobe, middle lobe, lower lobe, overlapping or unspecified. Asks for additional information regarding exposure to or history of tobacco use, occupational exposure to tobacco smoke, tobacco dependence or use Malfunctioning peritoneal dialysis catheter T85.611A Additional information needed Specific to mechanical breakdown, displacement, leakage or other Mechanical complication of internal orthopedic Laterality? Anatomical location? Breakdown, displacement, obstruction, perforation, protrusion? Episode of care: Initial or device, implant or graft T Missing information to code secondary? Sequela? Medial Meniscus Tear S Missing information to code Type of tear (bucket handle, peripheral, complex, or other)? Laterality? Episode of care: Initial or subsequent? Or Sequela? Morbid obesity E66.01 Additional information needed BMI needed. Any additional comorbid conditions or complications? Even for unspecified MVA you need the episode of care: Initial or MVA E819.9 V Missing information to code subsequent encounter? Or Sequela? Oropharynx cancer- lateraright side C10.2 Additional information needed Asks for additional code to identify exposure to tobacco smoke, history of tobacco use, occupational exposure to tobacco smoke, tobacco dependence, tobacco use Osteoarthritis of Hip M16.9 Unspecified Code Bilateral or Unilateral? Primary, Secondary, or resulting from hip dysplasia? Post-traumatic? Osteoarthritis of knee

16 Audit Results of Documentation Challenges for ICD-10 Top Diagnosis Description I-9 I-10 Problem Information Needed Osteomyelitis M86.9 Unspecified Code Acute, subacute, or Chronic? Specific anatomical location? Hematogenous? Otitis Media H66.90 Unspecified Acute, subacute, or Chronic? Serous, allergic, mucoid, suppurative or nonsuppurative? With or without rupture of eardrum? Any use or exposure to tobacco? Laterality and specific conditions for each ear, if applicable. Ovarian Cyst N83.20 or N83.29 Missing information to code Type? In pregnancy or childbirth? Unspecified or Other? Pancreatitis, acute biliary K85.1 Additional information needed Specify type: idiopathic, alcohol induced, drug induced, other or unspecified. Plica syndrome (Plica Knee) M67.5- Missing information to code Laterality? Post-op complication T Missing information to code Specific complication: Hemorrhage, seroma, stitch dehiscence, etc.? Intraoperative or post operative? Post-op pain G89.18 Unspecified Acute or chronic (G89.28)? Acute or chronic post-thorcotomy G89.12, G89.22? Prolapsed cord O69.01 Unspecified Trimester? Laterality required. Congenital, mechanical, myogenic, neurogenic, Ptosis H Missing information to code paralytic? PVD I73.9 Additional information needed In diabetes? Radiculopathy M54.1- Specific portion of spine Occipito-atlanto-axial, cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral, or sacral and sacrococcygeal? Respiratory distress R06.-- Missing information to code Adult, child, or newborn? Orthopnea, psychogenic, short of breath, apnea, tachypnea, dyspnea, stridor, wheezing, hyperventilation, mouth breathing? Respiratory failure J++.90 Missing information to code Acute or Chronic? With or without hypoxia or hypercapnia? Use or exposure to tobacco? Respiratory insufficiency J06.89 More specific codes available Dyspnea, periodic breathing, snoring, other abnormalities of breathing? Rotator Cuff Tear M Unspecified Code, not specified as traumatic (S If traumatic) Traumatic or Non-traumatic? Complete or Incomplete? Sepsis A41.9 Additional information needed Need specifics regarding with or without organ dysfunction or acute documented. Urosepsis is nonspecific term not synonymous with sepsis. Type or causal organism or cause (postprocedural infection, trauma, etc.) Extent (with or without septic shock)?

17 Audit Results of Documentation Challenges for ICD-10 Top Diagnosis Description I-9 I-10 Problem Information Needed Shoulder injury, upper arm S49.80X- Missing information to code Laterality? Type of injury? Muscle, tendon, fascia? Context of injury? Current or sequela (late effect)? Sinusitis, chronic J32.9 Additional information needed Site: maxillary, frontal, ethmoidal, sphenoidal, pansinusitis, unspecified x Synovitis, tenosynovitis M6-.-- Missing information to code Type? (Due to, crepitant, infective, transient, syphilitic, etc.) Specific location? Laterality? Spinal enthesopathy M46.00 Unspecified Occipito-atlanto-axial, cervical, cervidothoracic, thoracic, thoracolumbar, lumbar, lumbosacral, sacral and sacrococcygeal, or multiple sites? Squamous cell carcinoma - leg C Missing information to code Laterality? Subdural hemorrhage I62.01 Additional information needed Specific to non-traumatic: acute, birth injury, chronic,subacute Flexor or Extensor? Laterality? Traumatic or non-traumatic? Tendon rupture, biceps M66.30 Additional information needed Specific anatomical location? Trigger Finger M Missing information to code Laterality? Correct finger? Ulcer of skin of L Missing information to code Laterality? Specific anatomical location? With bone necrosis, exposed fat layer, muscle necrosis, or skin breakdown only? Umbilica hernia K42.- Missing information to code With or without obstruction or gangrene? Uterine Cancer 179 C55 Unspecified Malignant neoplasm of what segment: isthmus uteri, endometrium, myometrium, fundus uteri, overlapping sites, lower uterine segment? Uterine Fibroids (leiomyoma of uterus) D25.9 Unspecified Code Submucous, Intramural, Subserosal? Wrist sprain S Missing information to code Laterality? Specify site of sprain? Any associated open wounds? Episode of care: Initial or subsequent encounter? Or Sequela? The list will continue to expand as additional condition requirements come to light

18 Services before October 1, 2015 need to be completed and processed ASAP to limit disruptions and dual code timeframes Revisions of superbills, encounter forms/ehr templates (to reflect greater specificity) need to be completed Expect increased coder queries

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22 Questions? Ladonna Schaad, CCS-P, CPC, CANPC abeo Management Corporation Coding Compliance Manager Link: Extended Provider Overview recording