"ICD-10 For Clinical Staff" February 21, 2014 by Paula Digby, CPC, CCS, CPCI, AHIMA Approved ICD-10-CM/PCS Instructor. Disclaimer

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1 Slide 1 1 Slide 2 Disclaimer The information contained in this presentation is provided to assist the attendee in understanding the reimbursement process. It is intended to assist healthcare providers in accurately obtaining reimbursement for health care services. It is not intended to increase or maximize reimbursement inappropriately by any payer. It is strongly recommended that attendees consult their payer organizations with regard to local reimbursement policies. The information contained in the presentation is provided for information purposes only and represents no statement, promise or guarantee concerning levels of reimbursement, payment or charge. The material is designed to provide accurate information on the subject matter covered and is for guidance and reference purposes only. Although prepared for use by professionals, the presentation information should not be utilized as a substitute for professional services in specific situations. If legal advice is required, the services of a professional should be sought. All CPT codes discussed are used with permission of the American Medical Association. CPT is a trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. 2

2 Slide 3 ICD-10 for Clinical Staff Just tell me what to say! Paula Digby, CPC, CCS, CPCI, AHIMA Approved ICD-10-CM/PCS Instructor

3 Slide 4 Agenda Why should I listen to this presentation? Just how much more do we have to say in the medical record when ICD-10 is implemented? Detailed discussion of documentation improvement focus and techniques needed under ICD-10.

4 Slide 5 Start With Why All this reimbursement talk makes me ill. Tell me what you want to hear! You are keeping me from the important work of helping the patient. I AM BEING SPECIFIC!! Just tell me what to say!

5 Slide 6 Documentation: How Much More ICD-10 contains approximately five times more codes than ICD-9. Many of the changes should already be in the medical record. EX: The addition of laterality.

6 Slide 7 New ICD-10 features Combination codes for conditions and common symptoms or manifestations EX: E10.43 Type I diabetes mellitus with diabetic neuropathy EX: K Crohn s disease of large intestine with intestinal obstruction Combination codes for poisonings and external causes EX: T36.0x1D Poisoning by penicillin's, accidental (unintentional), subsequent encounter EX: T42.4x5A Adverse effect of benzodiazepines, initial encounter Added laterality EX: H Swimmer s ear, left ear EX. C Malignant neoplasm of lower-outer quadrant of right female breast

7 Slide 8 New ICD-10 features Added seventh-character extensions for episode of care EX: S06.0x1A Concussion with loss of consciousness of 30 minutes or less, initial encounter EX: M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture Expanded codes (injuries, diabetes, alcohol and substances abuse, postoperative complications) F Cocaine dependence with intoxication delirium K91.71 Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure

8 Slide 9 New ICD-10 features Inclusion of trimesters in obstetrics codes (and elimination of fifth digits for episode of care) O Pre-existing essential hypertension complicating pregnancy, second trimester Changes in timeframes specified in certain codes Acute myocardial infarction-time period changes from 8 weeks to 4 weeks Abortion vs fetal death from 22 to 20 weeks

9 Slide 10 Connecting the Dots The clinical staff must clearly draw the line between the diagnoses /symptoms /complications. Relationship cannot be inferred or assumed by the coder, it must be established in the medical record State the obvious

10 Slide 11 Diabetes Mellitus the type of diabetes mellitus, the body system affected, and the complications affecting that body system. secondary dm linked to underlying disorder

11 Slide 12 Cerebral Infarctions: Type of stroke should be stated in the medical record Episode of care Relationship to other conditions (Sequela)

12 Slide 13 Documentation of Complications of Care based on the provider s documentation of the relationship between the condition and the care or procedure not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship and an indication in the documentation that it is a complication. ICD-10-CM Official Guidelines for Coding and Reporting

13 Slide 14 Specificity Episode of care now required Exact diagnosis CHF is not exact! Exact anatomical location pain in left ankle bilateral *** in kidney

14 Slide 15

15 Slide 16 Injuries size and depth of injury cause of injury episode of care exact anatomical site fractures burns

16 Slide 17 Drug Underdosing Intent (non compliance or complication of care) if known Underlying condition

17 Slide 18

18 Slide 19 Acute Myocardial Infarction: Age definition New 4 weeks Laterality as well as site (coronary artery involved) should be documented An AMI is documented as nontransmural or subendocardial, should include site. Encounter type should be documented (initial vs. subsequent)

19 Slide diagnosed on ECG, but presenting no symptoms I healed or old I intraoperative during cardiac surgery I during other surgery I non-q wave I non-st elevation (NSTEMI) I subsequent I nontransmural I past (diagnosed on ECG or other investigation, but currently presenting no symptoms) I postprocedural following cardiac surgery I following other surgery I Q wave (see also, Infarct, myocardium, by site) I ST elevation (STEMI) I anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) I subsequent I inferior (diaphragmatic) (inferolateral) (inferoposterior) (wall)nec I subsequent I inferoposterior transmural (Q wave) I involving coronary artery of anterior wall NEC I coronary artery of inferior wall NEC I diagonal coronary artery I left anterior descending coronary artery I left circumflex coronary artery I left main coronary artery I oblique marginal coronary artery I right coronary artery I lateral (apical-lateral) (basal-lateral) (high) I21.29

20 Slide 21 Neoplasms Whether the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior Some malignancies will require documentation of stage and depth The site of the malignancy Any secondary site if malignant Histological type when applicable Laterality For neoplasms of the breast, sex should be documented

21 Slide 22

22 Slide 23

23 Slide 24 Pregnancy Documentation of trimester now required. Reason for the obstructed Identify specific fetus (1-5) affected by obstetric condition

24 Slide 25 Documentation Improvement It is imperative that the most specific codes be reported to provide the most accurate ability to provide meaningful data on patient care and severity.

25 Slide 26 Documentation Improvement Current documentation practices should be assessed and a plan developed to improve health record documentation, thereby minimizing the use of vague or nonspecific codes.

26 Slide 27 Documentation Improvement What are the gaps in documentation? What are the trends in documentation by diagnosis, procedure, physician, etc. Analyze the impact that the gaps in documentation will have on reimbursement.

27 Slide 28 The Bottom Line With accurate documentation facilities may see greater reimbursement and better patient care. Remember if it isn't documented it wasn t done and cannot be coded or billed.

28 Slide 29 Documentation Improvement Review documentation regularly to ensure accuracy when ICD-10 is implemented CHANGE QUERIES NOW

29 Slide 30 Review CLINICAL DOCUMENTATION IMPROVEMENT: ICD-10-CM contains multiple combination codes so the documentation must reflect the association between conditions. Laterality, site, position etc. needs to be documented Stages of healing Episode of care Trimester of Pregnancy Greater Specificity will be required! is

30 Slide 31 AHIMAS Top Clinical Documentation Problem Areas Diabetes mellitus Injuries Drug underdosing Cerebral infarctions AMI Neoplasms Musculoskeletal conditions Pregnancy Respiratory/vents

31 Slide 34 34

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