ICD-10-CM: Working Through Documentation Kim Reid, CPC, CPC-I, CEMC, CPMA Introduction Basic Structure of ICD-10 Documentation Productivity Review actual notes 1
Basic Structure ICD-10-CM has many changes in store Chapters increase from 17 to 21 and have been rearranged Addition of eye/adnexa and ears Guidelines Some have stayed the same but very important to become familiar with them to be aware of changes Codes are three to seven characters in length Laterality has been added to provide greater specificity Basic Structure Codes must still be verified in the tabular section At this time, codes are not yet considered to be stable so the information used today is intended to be a GUIDE Dummy placeholders There are codes that may be less than six characters, but require a seventh digit to make the code complete In this case a dummy placeholder of X is used to extend the code 2
Documentation The notes today do not provide enough detail, how will this be handled in 2013? Will the EHR be the answer to these problems? Who will educate and will the providers listen? Most effective education plan will be to start early and discuss the changes so everyone is aware long before the changes take place Productivity With the transition to ICD-10-CM productivity will decrease Codes contain letters and numbers Can be up to seven characters What will happen to charge tickets (super bills)? H ill ddi i l i f i b b i d h i How will additional information be obtained that is not immediately available (charge can not be entered before patient leaves)? 3
What does all this mean? Coders are vital to a successful transition Communication MUST be open between coders and physicians (providers) The most successful transition will begin with education early on and continue beyond implementation Providers relyy on their coders to inform them of what the requirements are Let s do this TOGETHER!!! 4
ENT Note A patient comes in with an earache - the provider does a problem-focused history and exam the documentation states: Otitis media. Amoxicillin BID x 10 days. Follow-up in one week if no improvement The appropriate ICD-9-CM code is 382.9 otitis media, unspecified In ICD-10-CM CM there are many options for this diagnosis and the documentation should include the necessary information Otitis media H66.9 (requires 5 th digit) Otitis media, unspecified H66.90 - Otitis media, unspecified, unspecified ear H66.91 - Otitis media, unspecified, right ear H66.92 Otitis media, unspecified, left ear H66.93 Otitis media, unspecified, bilateral Insurance companies may question the integrity of a claim that is sent in with unspecified ear because such vital information should be indicated in the documentation 5
Otitis media H65- Nonsuppurative otitis media H65.0- Acute serous otitis media Acute, recurrent, laterality H65.1- Other acute nonsuppurative otitis media Acute, subacute, recurrent, laterality H65.2- Chronic serous otitis media Laterality H65.3- Chronic mucoid otitis media Laterality H65.4- Other chronic nonsuppurative otitis media Chronic allergic vs. other chronic, laterality H65.9- Unspecified nonsuppurative otitis media Laterality Otitis media H66- Suppurative and unspecified otitis media H66.0- Acute suppurative otitis media With or without spontaneous rupture of eardrum, acute, recurrent, laterality (16 codes) H66.1- Chronic tubotympanic suppurative otitis media H66.2- Chronic atticoantral suppurative otitis media H66.3- Other chronic suppurative otitis media H66.4- Suppurative otitis media H66.9- Otitis media, unspecified H67- Otitis media in diseases classified elsewhere 6
ENT PREOPERATIVE DIAGNOSIS: Profound deafness POSTOPERATIVE DIAGNOSIS: Profound deafness OPERATION: 1. Left cochlear implant 2.Operating microscope. DESCRIPTION OF OPERATION: After the establishment of general anesthesia and administration of appropriate IV antibiotics, the left ear was prepped and draped in the usual fashion. A 5 cm incision was made l cm behind the postauricular sulcus. The periosteal flap was then elevated and the mastoid was exposed. A pocket was created for his internal device using a tight packet technique.. ENT To find the diagnosis code, we would look under deafness: Deafness (acquired) (complete) (hereditary) (partial) H91.9 Profound deafness is not listed as an option, but specified type, not elsewhere classified is listed and states to see subcategory H91.8 H91.9 is listed as unspecified hearing loss H91.8 is listed as other specified hearing loss 7
ENT In our example, our diagnosis is listed as profound hearing loss so it is NOT unspecified. Because there is not a specific code for this, the appropriate p choice is other specified hearing loss H91.8X1 Other specified hearing loss, right ear H91.8X2 Other specified hearing loss, left ear H91.8X3 Other specified hearing loss, bilateral H91.8X9 Other specified hearing loss, unspecified ear Diabetes Six categories exist for Diabetes Mellitus in ICD-10-CM: E08 Diabetes Mellitus due to underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type I diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus E15 Unspecified diabetes mellitus 8
Diabetes Official ICD-10-CM Guidelines state: The diabetes mellitus codes are combination codes that include the type of DM, the body system affected, and the complications affecting that body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08 E13 as needed to identify all of the associated conditions that the patient has. Diabetes Guidelines If the documentation in the medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned for type 2 patients who routinely use insulin, code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient s blood sugar under control during an encounter. 9
Diabetes note Tom is a 50-year-old type II diabetic patient who returns to his physician for his 6-month follow-up. Tom has been on insulin for the past eight months as his diabetes was not well controlled. The physician i documents in the medical record, Type II diabetes mellitus currently maintaining good control with insulin, diet, and exercise. Patient will continue with same medication dosage, monitor glucose levels with home monitoring system, and return in 3 months for recheck We may consider discontinuing insulin if patient remains in good control. E11.9 -Type 2 diabetes mellitus without complication Z79.4 - Long-term (current) use of insulin Dermatology note Patient is 70-year-old female who presented to office with a left leg well differentiated squamous cell carcinoma. She had this lesion previously biopsied. After examining her, I informed her of the risks, benefits, indications, and alternatives of excision. I think she will be a good candidate for elliptical excision with margins. I marked 4 mm margins after informed consent and performed an excision and marked specimen short superior. Closed her with 3-0 Vicryl deep and 4-0 nylon interrupted. Placed a bandage. She tolerated the procedure well. I instructed her to follow up in one week for suture removal and pathology review. I gave her instructions to keep the leg elevated and also standard wound care protocol. 10
Dermatology note In ICD-10-CM the diagnosis would be looked up in the alphabetical index by: Neoplasm, skin, lower limb, malignant C44.7 C44.70- Malignant neoplasm of skin of lower limb, including hip, unspecified side C44.71- Malignant neoplasm of skin of right lower limb, including hip C44.72- Malignant neoplasm of skin of left lower limb, including cud hip Pressure ulcer Pressure ulcers require the following documentation to d t th hi h t l l f ifi it code to the highest level of specificity: Anatomical site Stage Laterality 11
Pressure ulcer INDICATIONS: This 26-year-old female has developed what appears to be a fairly classic pressure ulcer over the right trochanter after lipodissolve. She is here for debridement. POSTOPERATIVE DIAGNOSIS: Stage II pressure ulcer right trochanter ulcer right trochanter. Pressure ulcer This diagnosis code is found by looking in the index under: Ulcer Pressure (pressure area) L89.9 Stage II (healing) (abrasion, blister, partial thickness skin loss involving epidermis and/or dermis) Hip L89.2 12
Pressure ulcer L89.20 - Pressure ulcer of unspecified hip L89.21 - Pressure ulcer of right hip L89.22 - Pressure ulcer of left hip As you can see, there is a code for unspecified hip; however, overutilization i of this code will raise a red flag and increase the risk of an audit Pressure ulcer In our example, the diagnosis is documented as stage II pressure ulcer right trochanter: L89.210 Pressure ulcer of right hip, unstageable L89.211 Pressure ulcer of right hip, stage I L89.212 Pressure ulcer of right hip, stage II L89.213 Pressure ulcer of right hip, stage III L89.214 Pressure ulcer of right hip, stage IV L89.219 Pressure ulcer of right hip, unspecified stage 13
Well child visit This patient is a female of 14 years who presents for a first visit to us in need of a well-child exam. She is accompanied by her mom. Mother is concerned about high risk behavior (caught drinking alcohol) ASSESSMENT AND PLAN: 1. Well-child exam performed today on female of 14 Years. Anticipatory guidance was reviewed. Counseled regarding high risk behaviors. 2. Immunizations: HPV, Menactra 3. Return to clinic in one to two years for a well-child exam and as needed. Well child visit Index lookup: Examination, child (over 28 days old) Code description: Z001.129, Encounter for routine child health examination without abnormal findings Index lookup: Counseling, specified reason NEC Code description: Z71.89, Other specified counseling Index lookup: Vaccination, encounter for Code description: Z23., Encounter for immunization 14
Family medicine PHYSICAL EXAMINATION: Weight 241 #. BP 134/82. Pulse 68. Respiratory rate 16. Temperature 97. Eyes: anicteric. Ears: clear. Throat: normal. Neck: no JVD, no bruits. Extremities: no cyanosis, clubbing or edema. Shoulder reveals good ROM, some tenderness and spasm along the medial scapula on the left compared to the right. Distal neuro and vascular supply is grossly intact. ASSESSMENT: HTN, hypercholesterolemia, musculoskeletal strain and depression. PLAN; We will increase her Zoloft to 100 mg per pt request and have her stay on this for at least one year and wean off in the spring of next year. Today her lipids revealed LDL of 131, total cholesterol 220. We will continue with the Zocor given her two risk factors and her age. For HTN, continue Uniretic. Recommended heating pad for muscle strain. Pt will FU as needed. Family medicine Index look-up for hypertension: Hypertension, (accelerated)(benign)(essential)(idiopathic)(systemic) Code description: I10. - Essential (primary) hypertension Index look-up: Hypercholesterolemia (essential)(familial)(hereditary)(primary) Code description: E78.0 - Pure hypercholesterolemia Index look-up: Depression (acute)(mental) Code description: F32.9 - Major depressive disorder, single episode, unspecified 15
Family medicine Index look-up: Strain, muscle..see injury, muscle, by site, strain. Injury, muscle, shoulder Code Description: S46.902A Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, l left arm initial encounter Seventh character extensions: A= initial encounter D= subsequent encounter S= sequela Extensions Most categories in chapter 19 have 7 th character extensions that are required for each applicable code. Most categories in this chapter have three extensions (with the exception of fractures): A, D, S. Extension A, initial encounter is used while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, emergency department t encounter, and evaluation and treatment t t by a new physician. 16
Extensions Extension D, subsequent encounter, is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment. The aftercare Z codes should not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the 7 th character D (subsequent encounter). Extensions Extension S, Sequela, is for use for complications or conditions that arise as a direct result of an injury, such as a scar formation after a burn. When using extension S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S extension identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. 17
Contusion ASSESSMENT AND PLAN: The patient has recurrence of the hematoma. Unfortunately, the Dermabond has sealed the hematoma in. I would recommend that we repeat the incision and drainage. With that in mind the following procedure was done. PROCEDURE: Incision and drainage of right pinna hematoma. Hematoma, pinna (see contusion, ear) Contusion, ear S00.432A (Contusion, right ear, initial encounter) Fracture History Of Present Illness: A 12-year-old boy presenting with his mother who gives the history. He was playing football 2 days ago on August 7, 20xx, and as he was catching the football, he jammed his left fifth finger into the ball. He states that the ball was pumped up very tight and felt like a rock hitting his finger. He has had pain with movement or touching the finger. He identifies the area of maximal tenderness over the middle phalanx. He has been icing the area, but not regularly. He has no prior injury or fracture to that finger. He has no history of joint or bone disorders 18
Fracture Assessment and Plan: Patient has a nondisplaced traumatic fracture of the left fifth middle phalanx, not involving the growth plate. Treatment for this fracture includes stabilization for 3 weeks. He was given an aluminum splint which was placed with the finger extended through at the proximal and distal interphalangeal joint and flexed at the metacarpophalangeal joint. He is to ice the area several times a day for 20 to 30 minutes to reduce the swelling and also to have ibuprofen for the swelling. I would like to see him back in 1 week to examine the area once the swelling has been reduced. He is to avoid activities that would cause further injury. Fracture Index lookup: Fracture, finger, middle, proximal, phalanx, nondisplaced Code description: S62.643A,, Nondisplaced fracture of proximal phalanx of left middle finger Index lookup: Striking against, object, sports equipment Code description: W21.01XA, Struck by football, initial encounter Index lookup: Activity, football (American) NOS Code description: Y93.61, American tackle football 19
Fracture Fractures of the ulna and/or radius have 16 choices for a seventh character extension: 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 Fracture 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, 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, IIIC with nonunion P subsequent encounter for closed fracture with malunion 20
Fracture Q subsequent encounter for open fracture type I or II with malunion R subsequent encounter for open fracture type IIIA, IIIB, IIIC with malunion S sequela The guidelines state: A fracture not designated as open or closed should be coded to closed The open fracture designations are based on the Gustilo open fracture classification POSTOPERATIVE DIAGNOSIS: Displaced both-bone forearm fracture, right arm. OPERATIONS PERFORMED: Closed reduction and casting, right forearm fracture DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the operating table in the supine position. The arm was removed from the splint and placed into a fingertrap suspension. He was given some intravenous sedation, and seven pounds of traction was applied to the proximal arm. A closed reduction of the forearm fracture was accomplished. The adequacy of the reduction was checked with a mini C-arm, which showed good alignment of the fracture fragments to both AP and lateral views. A long-arm plaster cast was applied. After appropriate time was allowed for hardening, the patient was transferred back to stretcher and returned to the recovery room in satisfactory condition. He tolerated the procedure well. 21
Closed fracture Index look-up: Fracture, traumatic Forearm S52.9 Radius see Fracture, radius Ulna see Fracture, ulna The example does not specifically indicate where the fracture is on the forearm, we have to use an unspecified code: Code description: S52.91XA - Unspecified fracture of forearm, right forearm Complications INDICATIONS: The patient is a 17-year-old male who had a previous clavicle ORlF, now here for hardware removal from symptomatic problems Index lookup: Complication, fixation device, internal (orthopedic) Code description: T84.9XXS - Unspecified complication of internal orthopedic prosthetic device, implant and graft, sequela 22
Questions Change is inevitable - except from a vending machine. ~Robert C. Gallagher 23