June 3, 2015 Gloria Johnston, MBA, RN, RHIT

Clinical Documentation in ICD 10 June 3, 2015 Gloria Johnston, MBA, RN, RHIT 1

Are You In The Right Meeting? 2

Overview Agenda Overview of ICD 10 Clinical Documentation in ICD 10 ICD 10 Clinical Document Preparations and Analysis ICD 10 Clinical Documentation Resources Q&A Table of Contents Slide(s) Topic 6 ICD Timeline 7 Why We Need ICD 10 8 11 ICD 9 vs. ICD 10 12 ICD 10 Diagnosis Code Format 15 24 Key ICD 10 Clinical Documentation Concepts 25 26 OB Concepts 27 29 Cardiology Concepts 30 31 Orthopedics Concepts 32 35 Internal Medicine Concepts 36 37 Alcohol and Drug Use 39 44 Clinical Documentation Preparation and Analytics 46 47 ICD 10 Resources 49 Sources Used 3

ICD 10 CM 4

The Journey From ICD 9 to ICD 10 Cassette Tape 60 minute capacity ipod 64 MB 26,600 minute capacity Original concept by 3M 5

The ICD Timeline ICD 9 CM Live Work started on ICD 10 ICD 10 Endorsed By WHO ICD 10 CM Published ICD 10 Ruling By HHS ICD 10 CM Go Live ICD 11 Published ICD 11 CM Available 1979 1983 1990 1998 2009 2013 2017 2014 Est 2022 2015 6

Why We Need ICD 10 Research Value Based Reimbursement Globally Connect Health Data 7

ICD 9 vs. ICD 10 Diagnosis 2014 ICD 10 ICD 10 Chapter # ICD 10 Code Range # ICD 10 Codes ICD 10 Chapter Description ICD 9 Chapter # ICD 9 Code Range ICD 9 # of Codes 1 A00 B99 1,056 Certain Infectious and Parasitic Diseases 1 001 139 1,270 2 C00 D49 1,620 Neoplasms 2 140 239 988 3 D50 D89 238 Diseases Of The Blood and Blood Forming Organs and Certain Disorders Involving The Immune Mechanism 4 280 289 123 4 E00 E89 675 Endocrine, Nutritional and Metabolic Diseases 3 240 279 335 5 F01 F99 724 Mental, Behavioral and Neurodevelopmental Disorders 5 290 319 477 6 G00 G99 591 Diseases Of The Nervous System 6 320 359 412 7 H00 H59 2,452 Diseases Of The Eye and Adnexa 6 360 379 795 8 H60 H95 642 Diseases Of The Ear and Mastoid Process 6 380 389 192 9 I00 I99 1,254 Diseases Of The Circulatory System 7 390 459 474 10 J00 J99 336 Diseases Of The Respiratory System 8 460 519 255 11 K00 K95 706 Diseases Of The Digestive System 9 520 579 596 12 L00 L99 769 Diseases Of The Skin and Subcutaneous Tissue 12 680 709 204 13 M00 M99 6,339 Diseases Of The Musculoskeletal System and Connective Tissue 13 710 739 892 14 N00 N99 591 Diseases Of The Genitourinary System 10 580 629 389 15 O00 O9A 2,155 Pregnancy, Childbirth and The Puerperium 11 630 679 1104 16 P00 P96 417 Certain Conditions Originating In The Perinatal Period 15 760 779 281 17 Q00 Q99 790 Congenital Malformations, Deformations and Chromosomal Abnormalities 14 740 759 421 18 R00 R99 639 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified 16 780 799 372 19 S00 T88 39,869 Injury, Poisoning and Certain Other Consequences Of External Causes 17 800 999 2,587 20 V00 Y99 6,812 External Causes Of Morbidity 18 V01 V91 1,291 21 Z00 Z99 1,178 Factors Influencing Health Status and Contact With Health Services 19 E000 E999 1,109 69,853 14,567 14,567 68,953 Codes 8

ICD 9 vs. ICD 10 Femur Fracture ICD 9 821.11 Open fracture of shaft of femur 16 ICD 9 codes for femur fracture ICD 10 S72.351C Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 1530 ICD 10 codes for femur fracture Source: http://www.roadto10.org/whats different/ 11

Anatomy of an ICD 10 Diagnosis Code ICD 10 Diagnosis Codes are 3 7 Characters 1 Alpha [No U] 2 Numeric 3 7 Numeric or Alpha. AM XS X0 X2 X6 X5 Xx AX Category Etiology, anatomic site, severity Added 7 th character for obstetrics, injuries, and external causes of injury x serves as placeholder for future expansion 12

ICD 10 Overview Take Aways Moving to ICD 10 is necessary ICD 10 is not as complex as it may seem The majority of code volume increases are related to Laterality Episode of care Fractures Clinical documentation is key Coders are going to be just fine 13

Clinical Documentation in ICD 10 14

Key ICD 10 Clinical Documentation Concepts Laterality Episode of care Use of clinical scales Coma Gustilo fracture Trimesters and fetuses for OB Drug and Alcohol use Increased specificity Combination codes Complication codes Clinical terminology changes 15

Increased Specificity Disease acuity Gastritis Acute vs. chronic Osteomyelitis Acute, subacute, other Disease type Acute renal failure Tubular, acute cortical or medullary necrosis Hypothyroidism Post surgical, other Disease stage CKD Stage 1 V, ESRD Skin ulcers Stage/degree of tissue damage Site specificity UTI Cystitis, pyelonephritis, urethritis Chrohn s Large and/or small intestine Neoplasm Lobe of lung, laterality Intent and episode of encounter Complications 16

Increased Specificity Source: http://www.aapcps.com/services/icd 10 documentation example.aspx 17

Combination Codes A single code is used to report Two or more diagnoses A diagnosis with an associated secondary process A diagnosis with an associated complication All diagnostic conditions and modifying factors must be documented ICD 9 250.52 Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled 362.05 Moderate nonproliferative diabetic retinopathy 362.07 Diabetic macular edema ICD 10 E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema 18

Combination Codes ICD 9 ICD 10 707.03 707.22 Pressure ulcer, lower back Pressure ulcer, stage II L89.132 Or L89.142 Or L89.152 Pressure ulcer of right lower back, stage 2 Or Pressure ulcer of left lower back, stage 2 Or Pressure ulcer of sacral region, stage 2 19

Complication Codes The provider must document of the cause and effect relationship between the condition and the care or procedure and declare the condition is a complication Intraoperative and postprocedural complication codes have been relocated to within the body system chapter for the affected organ/system Complications are coded as secondary ICD 10 codes Some complications require assignment of an external cause code Pain due to medical devices also code acute or chronic pain due to the presence of the device, implant or graft (T ) Some complication codes include external cause therefore it is not necessary to also code an external cause code. 20

Laterality Left, right, bilateral, not specified ~23,844 laterality codes in 2015 ICD 10 Applies to conditions affecting Bones, joints, limbs Skin, tissues, breasts Muscles Organs kidneys, lungs, eyes, ears Nerves Veins, arteries Leverage ancillary personnel to capture laterality Use of laterality CPT modifiers 21

Episode of Care Episode of care is indicated in the 7 th position of the ICD 10 diagnosis code ~ 47181 EOC codes in ICD 10 2015 Other Than Fractures ^ Fractures * A D S Initial encounter Subsequent encounter Sequela ^Used primarily for injuries, poisonings and other consequences of external causes Note that x placeholder is used for codes less than 6 characters Leverage support staff to collect data elements A B D Initial encounter for closed fracture Initial encounter for open fracture Subsequent encounter for fracture with routine healing G Subsequent encounter for fracture with delayed healing K P S Subsequent encounter for fracture with nonunion Subsequent encounter for fracture with malunion Sequela * EOC/Gustilo Classification Integrated see next slide 22

Clinical Scales Gustilo Gustilo open B Initial fracture encounter for open classification fracture type I or II (~3251 C Initial encounter for open fracture type IIIA, IIIB, or IIIC codes in ICD 10) Type I, Type F Subsequent II, Type encounter IIIA, for Type open fracture IIIB, type IIIA, Type IIIB, or IIIC IIIC with routine healing Three factors H Subsequent considered encounter for open in fracture assigning type I or II with classification Mechanism of injury: Low energy vs. high energy impact J Subsequent encounter for open fracture type IIIA, IIIB, or Extent of soft tissue IIIC with damage: delayed healing Minimal, moderate, extensive M Degree of bone injury or involvement: (A) Simple transverse/short M Subsequent encounter for open fracture type I or II with oblique/minimally nonunion comminuted; (B) Those more complicated than listed in (A) 7 th character designation identifies Gusillo classification AND Q Subsequent encounter for open fracture type I or II with episode of care malunion Gustilo E N R Gustilo Classification 7 th Character Subsequent encounter for open fracture type I or II with routine healing delayed healing Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion 23

Clinical Scales Glasgow Coma Scale Physician must document initial (more frequently is OK) composite GCS or component scores Document time of assessment (7 th character) 0 Not specified 1 In the field [EMT/ambulance] 2 At arrival in ED 3 At admission to hospital 4 >=24 hours post admission 4 code groups (~78 codes) R40.21 Eye opening R40.22 Best motor response R40.23 Best verbal response R40.24 Composite score 24

OB Concepts Complications/conditions require documentation of the trimester (or weeks) 7 th character to identify the fetus in a multiple gestation that is affected by the condition being coded 0 not applicable or unspecified 1 fetus 1 2 fetus 2 3 fetus 3 Describe deliveries as they do today Level of assistance required With or without episiotomy With or without fetal manipulation Instrumentation Fetal presentation 4 fetus 4 5 fetus 5 9 other fetus Fetus count Full term, pre mature Vaginal, C section Spontaneous, induced Delivery outcome Newborn status 25

OB Concepts Obstructed delivery codes now include the reason for obstruction Example: O64.1xx2 Obstructed labor due to breech presentation, fetus 2 Late vomiting in pregnancy changed from 22 weeks in ICD 9 to 20 weeks in ICD 10 Missed abortion timing changed from 22 weeks in ICD 9 to 20 weeks in ICD 10 Abortion Elective abortion is now described as an elective termination of pregnancy Four spontaneous abortion definitions in ICD 10: Missed, threatened, incomplete, complete Complications of pregnancy describe complication, identify trimester when condition developed, establish causal relationship between pregnancy and complication Document use/non use of tobacco, alcohol and substance abuse along with the associated risk to the child 26

Cardiology Concepts Acute myocardial infarction Acute MI timeframe Reduced to 4 weeks in ICD 10 down from 8 weeks in in ICD 9 Subsequent MI now defined as a 2 nd MI during the acute period Provider must document Hypertension STEMI vs non STEMI Initial vs. subsequent MI Affected area of myocardium Specify involved coronary artery Tobacco status Benign vs. malignant no longer applicable Provider must document Type Essential, secondary Causal relationship Renal, pulmonary Comorbidities e.g. CHF 27

Cardiology Concepts Congestive heart failure No changes with ICD 10, #1 physician query reason today Acuity Acute, chronic, acute on chronic Type Systolic, diastolic Atherosclerotic heart disease with angina pectoris Cause Assumed to be atherosclerosis; notate if there is another cause Stability Stable, unstable Vessel Note artery (if known) Bypass graft Involvement, originating location and autologous or biological Cardiomyopathy Type Dilated/congestive, obstructive, nonobstructive hypertrophic, etc. Location Endocarditis, right ventricle, etc. Cause Congenital, alcohol, etc. List seen in other diseases such as gout, amyloidosis, etc. 28

Cardiology Concepts Heart valve disease Cause Rheumatic vs non rheumatic Type Prolapse, insufficiency, regurgitation, incompetence, stenosis, etc. Location Specify valve Arrhythmias Location Atrium, ventricle, subventricular, etc. Rhythm name Flutter, fibrillation, type 1 atrial flutter, long QT syndrome, sick sinus syndrome, etc. Acuity Acute, chronic, etc. Cause Hyperkalemia, hypertension, alcohol consumption, digoxin, amiodarone, verapamil HCl, etc. 29

Orthopedics Concepts Fractures Location Shaft, head, neck, distal, proximal, styloid Type Open, closed, pathological, neoplastic disease, stress Pattern Comminuted, oblique, segmental, spiral, transverse, etc. Displacement e.g. Displaced, non displaced Classification e.g. Gustilo Anderson, Salter Harris Etiology to document in the external cause codes Encounter of care Initial, subsequent, sequelae Healing status if subsequent encounter Normal healing, delayed healing, nonunion, malunion Complications, whether acute or delayed e.g. Direct result of trauma sustained Arthritis Type Localized vs. generalized; primary vs. secondary, subtype Location Affected bones, joints, laterality Other conditions Describe related underlying diseases or conditions 30

Orthopedics Concepts Injuries Episode of care initial, subsequent, sequelae Injury site Specific location including laterality Etiology of injury How was injury sustained Place of occurrence Where did injury happen Intent Unintentional/accidental, self harm, etc. Person status Civilian, military, etc 31

Internal Medicine Concepts Asthma Cause Exercise induced, cough variant, related to smoking, chemical, etc. Severity Mild, moderate, severe Temporal Factors Acute, chronic, intermittent, persistent, status asmaticus, acute exacerbation Diabetes Type Type 1, Type 2, drug/chemical induced, gestational, due to other condition Complications What other body organs/systems are affected by diabetes (e.g. foot ulcer) Treatment Diet controlled, insulin dependent Secondary diabetes is not long a concept in ICD 10 32

Internal Medicine Concepts Hypoglycemia, hyperglycemia It is now possible to code for these conditions without using Diabetes Mellitus. Document hypo/hyperglycemia and specify if due to a procedure or other cause Abdominal pain and tenderness Location Specify quadrant, periumbilical, etc Pain or tenderness type Colic, tenderness, rebound Acute respiratory failure Type Acute, chronic, acute and chronic With/without hypoxia, hypercapnia 33

Internal Medicine Concepts Anemia Type Iron deficiency, hereditary hemolytic, acquired, aplastic, etc. Causation if applicable e.g. blood loss, due to other stated condition Acute kidney/renal failure Acute kidney failure Causation e.g. toxic agents, renal ischemia following trauma, etc. Comorbidities e.g. tubular necrosis, Hyperlipidemia Type Pure, mixed, hyperchylomicronemia, etc. 34

Internal Medicine Concepts Hypothyroidism UTI Type Congenital, acquired Causation if acquired Post surgical, iodine, etc. Site Cystitis, urethritis, etc. With vs. without hematuria Identify causative organism if known Hyperlipidemia Type Pure, mixed, hyperchylomicronemia, etc. 35

Alcohol and Drug Use New concepts Alcohol/drug use Drug underdosing Combination codes for drug and alcohol use Blood alcohol codes Documentation required Involved substance Aspects of use (e.g. withdrawal, intoxication) Effects (e.g. abuse, dependence) Common manifestations (e.g. alcohol induced delirium, sleep disorders, psychosis) 36

Drug Underdosing Drug underdosing is a new concept in ICD 10 Patient has taken less of a medication than prescribed by their physician whether inadvertently or deliberately Providers must note What drug is underdosed The resulting clinical impact Contributing factors Episode of care (7 th characters A, D or S) Codes listed in this order: The medical condition is sequenced first The underdosing code is listed as the secondary The additional codes to explains why the patient is not taking the medication(s) such as Financial hardships and age related debilities 37

ICD 10 Clinical Document Preparations and Analysis 38

Preparing Documentation for ICD 10 Identify documentation deficiencies for top clinical conditions treated Conduct an analysis of current documentation practices compared to ICD 10 requirements Analyze ICD 9 diagnostic coding. Review clinical documentation templates associated with conditions frequently reported as unspecified Determine root causes Are EMR, dictation or paper based templates missing required documentation elements? Are physicians, coders, billers aware of the impact of unspecific codes? Is there an opportunity to intervene when unspecified codes are assigned prior to billing? Prioritize remediation efforts Educate providers and staff Providers: documentation, documentation, documentation Staff: (A) capturing required elements for common clinical conditions during the schedule and rooming process. (B) ICD 10 codes 39

ICD 9 Analytics A study executed by Dr. Joe Nicholas noted that 72.5% of all charges over a three year period were coded with only 5% of ICD 9 codes. 54% of codes used were unspecified or were symptoms only. Retrieved from: http://www.medscape.org/viewarticle/828929_2 40

ICD 9 Analytics 41

ICD 10 Analytics 42

ICD 10 Analytics 43

ICD 10 Clinical Documentation Take Aways Ensure clinical documentation sources are attuned for ICD 10 requirements Focus physician education on documentation that impacts their practice Leverage support staff to bring information into the record so that it is available to the provider for consideration and documentation Analysis of ICD 9 documentation and coding behaviors can narrow the focus for remediation and training 44

ICD 10 Resources 45

Resources To Assist with ICD 10 Readiness Scheduled Activities http://www.roadto10.org/ 46

There s An App for That 47

Gloria Johnston, MBA, RN, RHIT Chief Health Information Officer O: 888 507 2988 x102 E: gjohnston@healthadvanta.com 48

Sources Used CMS Road to ICD 10 http://www.roadto10.org/ http://www.medscape.org/viewarticle/828929_2 http://www.who.int/classifications/icd/revision/en/ http://www.codeitrightonline.com/ciri/understanding icd 10 cm episodeof care 7th character extensions.html http://www.amerihealth.com/pdfs/providers/claims_and_billing/icd_10/i cd_10_spotlight_ah.pdf http://www.ciproms.com/newsevents/tabid/65/entryid/62/examining ICD 10 CM Codes for Mental Behavioral and Neurodevelopmental Disorders Part 2.aspx 49