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1 ICD 10 Documentation Preparation and Leveraging Documentation Templates and Coding Queries Shatondra Surulere, MBA, RHIA, CCS, CCS P, CHTS PW, AHIMA Approved Trainer and Ambassador Senior Consultant, Revenue Cycle Consulting 1 Presentation Objectives Identify ICD-10 documentation requirements for hospitals and physician practices Gain an understanding of today s documentation challenges Review key ICD-10 documentation requirements Review ICD-10 documentation improvement strategies 2

2 IF IT ISN T DOCUMENTED, IT CANNOT BE CODED 3 In a Perfect World All clinical documentation would be: Legible Complete Clear Consistent Precise 4

3 The Real World Clinical Documentation Practices VS. Coding Documentation Needs 5 The Role of Clinical Documentation Clinical information for patient care Quality/core measures Hospital profiling Physician profiling Disease reporting Compliance Government and payor reviews Others 6

4 The Connection to Coding Clinical documentation paints a picture Patient s acute condition Complicating condition(s) Clinical, therapeutic and/or diagnostic treatment and patient responses to treatment Translates to codes o Billing o Incentive payments 7 The Relationship to Reimbursement 1. Billing and AR 2. Quality incentives 3. Discharged Not Final Billed (DNFB) 4. Patient status (inpatient, outpatient, observation) 5. APDRG/APRDRG/MS-DRG reimbursement 6. Compliance 8

5 The Reality For Many Health Information Management Departments Accountability Responsibility Tools Documentation Tools Documentation Coding Benchmarks Coding Benchmarks 9 Polling Question In your opinion, does your facility do a good job holding physicians accountable for the quality of their documentation? A. Yes B. No C. Not sure 10

6 From the Provider s Point of View 11 Overwhelming Documentation Requirements Basic Clinical Documentation + Quality Requirements + Meaningful Use + Regulatory and Compliance Initiatives + Operational Challenges + EHR Template Requirements + ICD-10 Initiatives 12

7 Inconsistent Tools and Requirements Incomplete and inconsistent documentation tools Physician query questions could be addressed in current tools Inconsistent physician query questions between clinical documentation improvement and/or coding staff Quality, Joint Commission, infection control, and other requirements are often not incorporated in documentation tools 13 ICD-10 Documentation Requirements 14

8 The Importance of Specificity Specificity in documentation is key, because, in ICD-10, fewer unspecified codes exist Specific documentation benefits Reduces physician queries and AR delays Reduces denials/request for medical records More accurate quality and infection control reporting Your documentation is, the less queries you will receive from the CDI specialist and the coders 15 ICD 10 A Refresher in Documentation Requirements Below are some general documentation tips that you can begin using now to create a seamless transition to the new system: Specific diagnosis o Document the diagnosis to the greatest level of specificity Specific anatomy o Document the exact body location Document ALL conditions identified and treated during the encounter o Secondary diagnosis ARE IMPORTANT 16

9 ICD 10 A Refresher in Documentation Requirements Laterality Document which side of the body- right or left o Note: approximately 5,000+ codes have a right and left distinction Dominant verses non-dominant side Document dominant verses non-dominant side for all paralytic syndrome conditions Initial verses recurrent Document whether the condition is initial or recurrent Combination codes for conditions and common symptoms or manifestations o Secondary diagnosis ARE IMPORTANT 17 Cardiovascular Example CAD (coronary arteriosclerosis) is specified as of native vessel, bypass graft, or transplanted heart. Combination codes to include CAD with angina (unstable, with spasm, other) as well as CAD with ischemic chest pain. Document exact date of MI New/initial MI: Occurred or diagnosed within the past four weeks but not previously treated Old MI: Report a "healed or old MI" whether the patient is currently experiencing problems or not Subsequent MI: subsequent, new MI occurring within the four-week timeframe of the initial MI Document type of MI STEMI vs. NSTEMI 18

10 Cardiovascular Documentation Examples Physician office documentation: reports history of CAD, HTN, MI, and angioplasty o Need additional documentation CAD is present after angioplasty of a native artery (I25.10) or of the bypass (I25.810) o Documentation regarding the date and specifies of the MI will be required Inpatient physician documentation: patient has history of ESRD, CHF, and high blood pressure and past MI o There is conflicting documentation on this chart from another physician, stating that the patient has HTN. HBP and HTN are coded differently, and, if the patient truly has HTN (I10), it should be documented as such, not as HBP (R03.0). o Documentation regarding the date and specifies of the MI will be required 19 Laterality Documentation Examples For all body parts that can be defined as left, right, or bilateral side(s), the specific side must be documented Physician office documentation patient complains of hearing loss (right); large right cerumen impaction good example of laterality documentation (H61.21 impacted cerumen, right ear) Physician office documentation patient presents with glaucoma and senile cataract This would need specification for the glaucoma and cataract(s), are they right, left, or bilateral? 20

11 Fracture Documentation Requirements More information will be required to accurately code fractures in ICD-10 type of fracture specific anatomical site whether the fracture is displaced or not laterality routine versus delayed healing nonunion and malunions 21 Injury Documentation Requirements Documentation for injuries should include the encounter type Initial encounter Subsequent encounter for fracture with routine healing Subsequent encounter for fracture with delayed healing Sequela of fracture 22

12 Pregnancy/Obstetrics Documentation All diagnoses related to a patient s pregnancy should have the trimester in which the problem began documented (1 st trimester up to 13 weeks, 6 days; 2 nd trimester 14 weeks 0 days to 27 weeks 6 days; 3 rd trimester 28 weeks 0 days to delivery) Inpatient physician documentation: H&P patient is 29 weeks pregnant, presents with new onset of malnutrition, low weight gain since week 20, and edema of the legs which is new. This is an example of good documentation regarding obstetrics. The codes for this patient would be: o O25.13 malnutrition in pregnancy, 3 rd trimester o O12.03 gestational edema, 3 rd trimester o O26.12 low weight gain in pregnancy, second trimester 23 Tobacco Use/Exposure Documentation The medical record documentation should include information regarding the patient s history impact to current encounter and treatment Tobacco use/abuse codes now specify what type of tobacco (cigarettes, chewing tobacco, etc.) Any patient with a respiratory diagnosis and/or cardiac diagnosis should have documentation of current and/or past tobacco smoke exposure/abuse Physician office documentation current tobacco use. This example of documentation would need more clarification. o Is patient tobacco dependent? o Does patient smoke cigarettes (F172.10), cigars/other (F172.90), or use chewing tobacco (F172.20)? 24

13 Procedure Documentation Standard terminology Example, in ICD-9, excision can mean different things, depending on the body site/procedure being done. In ICD-10, excision means cutting out or off, without replacement, a portion of a body part Expandability to accommodate new procedures and technologies Specificity specify approach, body part and devises Example, in ICD-9, means suture of an artery. In ICD-10, specific codes exist for each artery

14 Step 1: Develop The Plan Identify the team Develop a detailed plan Specific steps and timelines Milestones Testing Monitoring Accountability 27 Collaboration is Required! 28

15 Build a Collaborative Team ICD-10 governance structure Clinical documentation work group Physician champions Coding specialists (hospital and physician practice) Administration Information technology Physician practice management 29 Step 2: Understand Current State Communication is Key! 30

16 Understand the Physician Environment Evaluate physician perception of documentation work flow, requirements, and concerns Identify opportunities to develop and/or expand physician champion strategy Develop physician champion strategy Physician champion roles and responsibilities Engage physician leaders By specialty Consider physician feedback strategies Engage physician practice managers 31 Start with the Documentation Identify your most common diagnoses and procedures and pull a sample of medical records by physician. Conduct an ICD-10 documentation gap analysis. Identify gaps and trends By disease Specialty Physician 32

17 Step 3: Work Flow Optimization Consider work flow re-design sessions Evaluate dashboards Documentation issues by disease Physician query trends A/R delays due to non-specific and/or missing documentation Identify opportunities to utilize technology Enhance tracking, trending and reporting to capture trends and delays 33 Step 4: Develop Future State Tools A successful conversion to ICD-10 will require a review of current tools to identify enhancements to facilitate capture documentation required for code assignment CPOE Templates EHR Templates Physician Query Forms Identify ICD-10 specific documentation requirements Engage Physicians to identify opportunities to enhance compliance and acceptance A few things to consider Work flow re-design sessions Utilizing an ICD-10 Approved Trainer Start NOW! 34

18 ICD 10 Mitral Valve Disorder Code Revisions Mitral Valve Disorders Documentation Specificity Required for Code Assignment ICD-9 Code ICD-9 Descriptions ICD-10 Code ICD-10 Description Mitral Valve Disorders I34.0 I34.8 Nonrheumatic mitral (valve) insufficiency Other nonrheumatic mitral valve disorders 35 Problem List/CPOE Templates Sample Problem List and Physician Order Specificity for Reporting Cardiac Ischemia Problem Hypertension, heart disease, kidney disease Hypertension, heart disease, kidney disease, CHF MI or Not? Non-Specific Documentation 1) HTN; 2) CAD; 3) CKD 1) CHF; 2) CAD; 3) CKD; 4) HTN ACS Specific Documentation Hypertensive heart and CKD, stage 4, w/out heart failure Hypertensive heart disease; Stage 3 CKD; Primary essential hypertension; Acute/Chronic systolic heart failure Atherosclerotic heart disease of native coronary artery with unstable angina pectoris MI NQWMI NSTEMI MI STEMI STEMI involving left circumflex coronary artery 36

19 EHR Documentation Templates Review documentation templates by disease Identify ICD-10 documentation needs Develop future state tables and prompts to support ICD-10 documentation requirements Coordinate physician practice and hospital templates for like diseases Engage vendors to identify timelines and upgrade requirements 37 EHR Documentation Templates Obstetrics Obstetrics Specify trimester for which condition occurs o 1 st trimester less than 14 weeks, 0 days o 2 nd trimester 14 weeks, 0 days to less than 28 weeks, 0 days o 3 rd trimester- 28 weeks, 0 days until delivery Specify # weeks of pregnancy Specify pre-existing or pregnancy induced Complications affecting pregnancy 38

20 EHR Documentation Templates MI/CABG Acute Myocardial Infarction (MI) MI episode of care o Initial refers to initial episode of care for an acute MI o Subsequent refers to care for a subsequent, new Acute MI occurring within the 4 week time frame Type of MI o STEMI o NSTEMI Site and artery (if known) Complications of the MI CABG Aorta to coronary artery (aortocoronary) Coronary artery to coronary artery Coronary vein to coronary artery (percutaneous only) Left internal mammary (LIMA) to coronary artery Right internal mammary (RIMA) to coronary artery Abdominal to coronary artery (gastroepiploic anastomosis) Thoracic to coronary artery 39 EHR Documentation Templates MI/CABG (Continued) Body Part Coronary Artery, One Site Coronary Artery, Two Site Coronary Artery, Three Site Coronary Artery, Four or More Sites Device No Device (direct anastomosis) Autologous Arterial Tissue Autologous Venous Tissue Nonautologous Tissue Substitute 40

21 EHR Documentation Templates Diabetes Type Diabetes mellitus due to underlying condition Drug or chemical induced diabetes mellitus Type 1 diabetes mellitus Type 2 diabetes mellitus Other specified diabetes mellitus Control ICD-10 no longer recognizes uncontrolled Poorly controlled, out of control, or inadequately controlled are coded to diabetes by type with hyperglycemia Complications of Diabetes 41 EHR Documentation Templates Acute Respiratory Failure/Asthma/Bronchitis/COPD Respiratory Failure Acuity Hypercapnic/Hypoxic Tobacco usage/exposure/history 42

22 EHR Documentation Templates Acute Respiratory Failure/Asthma/Bronchitis/COPD (Continued) Asthma/Bronchitis/ COPD Identify the type of asthma o Allergic extrinsic, childhood, chronic obstructive, exerciseinduced, hay fever, persistent, due to other agents Identify the type of bronchitis o Allergic, asthmatic, chemical, chronic obstructive, smoker s, viral, due to other agents Identify the type of COPD o Chronic bronchitis with tracheobronchitis, emphysema, decompensated, due to other agents Acuity Tobacco usage/exposure/history 43 EHR Documentation Templates Traumatic Fracture Site Laterality Open Gustilo classification for long bone fractures Closed Episode of care Initial (active phase of treatment) Subsequent (after active phase) o With delayed healing o With malunion o With nonunion o With routine healing or aftercare Sequela/late effect 44

23 EHR Documentation Templates Sepsis Document if sepsis was present on admission Document underlying local infection Pneumonia, UTI, and post operative infections are examples Urosepsis-MUST specify sepsis with UTI, versus UTI only o Urosepsis is not recognized in ICD-10 Specify causal relationship to local infection and/or procedure Identify causative organism Severity With septic shock Without septic shock Associated organ dysfunction when documenting severe sepsis 45 EHR Documentation Templates PICC/CVC Placement Location of insertion Atrium, right Inferior vena cava (IVC) Innominate vein Subclavian vein (e.g., midline cath) Superior vena cava (SVC) Approach Open Percutaneous Percutaneous endoscopic Radiological guidance *No guidance performed ECG (electrocardiography) Fluoroscopic Ultrasonic Contrast Used None High osmolar Low osmolar Other contrast 46

24 EHR Templates Obstetrics 47 EHR Templates Obstetrics 48

25 EHR Templates PICC Line 49 EHR Templates Orthopedics 50

26 Template Case Study 51 Polling Question Do you have a clinical documentation improvement program? A. Yes B. No C. Not sure 52

27 Physician Query Redesign Review Trends Physician response rate Most common queries by disease Evaluate process and identify opportunities for improvement Re-design physician query forms (standard vs. free text) Be clearly and concisely written Contain precise language Present the facts but not lead the clinician 53 Physician Query Redesign Include ICD-10 specific documentation needed for diagnoses o Sepsis, urosepsis o Obstetrics ICD-10 specific documentation needed for procedures o PICC/CVC insertion o Transfusions 54

28 Physician Education Recommendations ICD-10 documentation changes Emphasis on physician specialty Specificity in documentation of diagnoses Specificity in documentation of procedures Importance of coding secondary diagnoses More than four diagnoses (physician office) 55 Coder Education Recommendations ICD-10 Official Coding Guidelines for Coding and Reporting Chapters specific changes Specificity in the coding of diagnoses Specificity in the coding of procedures Emphasis on secondary diagnosis coding ICD-10 Coding Clinics ICD-10 documentation and physician query guidelines 56

29 Step 5: Implement the Plan Develop a Roll Out Schedule Physician queries o By disease o In conjunction with physician, coding, and/or CDI education Floor coaching Hospital Physician practice Hotline and ongoing assistance Monitoring and reporting 57 Step 6: Hardwiring Solution New physician and/or staff orientation Documentation tools maintenance Control Re-design Testing 58

30 59 Thanks for Attending! Intended for internal guidance only, and not as recommendations for specific situations. Readers should consult a qualified attorney for specific legal guidance. 60