Objectives Tonya Mitchell, RHIT July 17, 2015 Review the History of ICD 10 Discuss the Myths and Facts of ICD 10 Discuss General Documentation ti Concepts Review ICD 10 Documentation Concepts Analyze Documentation for Top Diagnosis in ICD 10 WHY CHANGE FROM ICD 9 TO ICD 10? ICD 9 was developed in the 1970s and cannot support current health information needs There is no room for expansion in ICD 9 which is used for more purposes than originally i intended d Putting your fears at ease ICD 9 lacks sufficient specificity The United States is the almost the last industrialized nation to adopt ICD 10 making an integrated world wide medical records system impossible 1
MYTHS AND FACTS MYTH There was no clinical input into ICD 10. FACT (CMS) Although this often seems to be the case, a number of medical societies provided input. MYTH No hard copy code books will be available. FACT (CMS) ICD 10 books are already available. FACT (WSR) Medical professionals and staff love dead trees despite the push to computerize everything. MYTHS AND FACTS Shh! MYTH There are only specific codes in ICD 10. FACT (CMS) Nonspecific codes are still available in ICD 10. FACT (WSR) Don t tell your doctors this little l tidbit. MYTH ICD 10 PCS will replace current CPT codes. FACT (CMS) Only inpatient procedures will use ICD 10 PCS. CPT codes will still be used for officebased procedures. ICD 10 MYTHS AND FACTS (cont.) MYTH Unnecessary medical testing will be needed to assign ICD 10 codes FACTS ICD 10 contains many more codes for signs and symptoms than ICD 9 It is better designed for use in ambulatory settings when definitive diagnoses may not be known. Proper documentation is the key GENERAL DOCUMENTATION TIPS Acceptable to use unable to rule out, probable, possible, or suspected on inpatient documentation Once a condition i has been ruled out it can no longer be coded Avoid using abbreviations: HypoK+ CANNOT be assumed to mean hypokalemia The same rule applies to disorders of sodium, calcium, etc. 7 2
GENERAL DOCUMENTATION TIPS (cont.) Coders cannot assume linkage Examples: Acceptable: CVA due to right carotid stenosis Unacceptable: CVA, carotid disease The same rule applies to infection, anemia, renal failure, encephalopathy, diabetic complications, etc. When in doubt write it out! OVERVIEW OF ICD 10 Implementation date: ***********************OCTOBER 1, 2015*********************** ICD 10 PCS for coding procedures does NOT replace CPT coding for E/M services ICD 10 codes provide: Greater specificity More clinical information Information relevant to ambulatory and managed care encounters Information used for data tracking (example: substance disorders including tobacco) TOP INPATIENT DIAGNOSES CHF COPD Pneumonia DM with complications UTI with altered mental status CKD Anemia CONGESTIVE HEART FAILURE Document acuity: Acute Chronic Acute on chronic Compensated vs. exacerbation Document type: Systolic Diastolic Combined systolic and diastolic Always document EF if known 3
CONGESTIVE HEART FAILURE (cont.) Document if due to or associated with: Hypertension Valvular disease Cardiac or other surgery Rheumatic heart disease Endocarditis Pericarditis Myocarditis PNEUMONIA SPECIFICITY Document type/organism: Bacterial (gram negative, gram positive, anaerobic) Viral Fungal Interstitial Community acquired or healthcare associated pneumonia cannot be coded Document mechanism: Aspiration food, liquid, chemicals Post obstructive Ventilator associated Radiation induced PNEUMONIA (cont.) Document any associated illness: Respiratory failure Sepsis Underlying lung disease Malignancy COPD Specify with or without exacerbation Document if associated with: Asthma Bronchiectasis Bronchitis (acute or chronic) Document tobacco use: Present or past 4
DIABETES MELLITUS Document type: Type I or type II Drug/chemical induced Due to underlying condition Other specified type Specify if patient is on insulin Document control: Inadequate control Out of control/poorly controlled Hypoglycemia Hyperglycemia DIABETES MELLITUS (cont.) Document manifestations/complications: Circulatory complications Hyperosmolarity With or without coma Renal complications Neurological complications Ophthalmic complications Oral complications Skin complications Arthropathy DIABETES MELLITUS (cont.) Always link complications and manifestations to DM Examples: Acceptable: The patient has uncontrolled type II diabetes with diabetic nephropathy, retinopathy, and neuropathy as well as a stage 2 diabetic ulcer on the right foot. Unacceptable: Insulin dependent diabetes, neuropathy, foot wound Insulin and non insulin dependent cannot be coded ANEMIA SPECIFICITY Clarify the type/cause Blood loss acute, chronic, expected postoperative Chronic disease renal disease, malignancy, etc. Deficiency B12, iron Medication related And many more 5
URINARY TRACT INFECTION Specify and link to organism Specify site: Pyelonephritis Cystitis Specify if sepsis is present Acceptable: Sepsis secondary to E. coli UTI Unacceptable: Urosepsis Urosepsis codes to basic UTI CKD SPECIFICITY Stage GFR I >90 II III IV V 60 89 30 59 15 29 <15 (and pt is not on dialysis) ALTERED MENTAL STATUS AMS is a non specific term along with: Confusion Delirium Mental status changes Unresponsiveness Encephalopathy is the preferred term Document type/cause Document any associated diagnosis/conditions ENCEPHALOPATHY Specify type/cause: Alcoholic Anoxic/hypoxic CVA late effect Hepatic Hypertensive Hypoglycemic Metabolic/septic Post ictal Toxic/drug induced (specify drug) Traumatic If reason is unclear then toxic/metabolic is your default 6
DOCUMENTATION EXAMPLES UNABLE TO CODE ACCURATELY ABLE TO CODE ACCURATELY MSOF, multi-system organ failure Liver failure, acute respiratory failure Urosepsis Sepsis secondary to UTI Severe respiratory distress Respiratory failure acute, chronic, combined Hemodynamically unstable Hypotension, CHF, cardiogenic shock KEY ICD 10 DOCUMENTATION CONCEPTS CONCEPT EXAMPLE (CONDITION) Causal agent/ Biliary stone, meds Age, smoking, steroids, S. pneumonia, rhinovirus, tumor, Excess calories, Cushing s disease, condition (specify), alcohol, high other meds (specify) medications (specify) medications (specify) triglycerides (Osteoporosis) (Fever) (Obesity specifybmi and if morbidly obese) (Acute/chronic pancreatitis) Laterality Left Right Bilateral (CHF, stroke, DJD, kidney stone, cancer) (CHF, stroke, DJD, kidney stone, cancer) (Injury, pneumonia, hydronephrosis, DJD) Complication/ Abscess, Hemiparesis, dysarthria, Nephropathy, foot ulcer, neuropathy Abscess, perforation, hemorrhage manifestation lymphangitis dysphagia (Diabetes mellitus type I or type II) (Acute diverticulitis) (Cellulitis) (Acute stroke) Will rehydrate Dehydration, hypovolemia Acuity Acute (Otitis media, renal failure, systolic CHF, cystitis, hypoxic respiratory failure, stroke, diverticulitis) Chronic (Atrial fib, diastolic CHF, sinusitis, bronchitis, respiratory failure) Acute on chronic (Systolic/diastolic CHF, sinusitis, hypercapnic respiratory failure, bronchitis) Rhythm stable today Ventricular tachycardia, atrial flutter Unable to void Urinary retention due to (name the cause) K+ 2.0, will give KCL Hypokalemia LLL infiltrates, will give IV antibiotics LLL pneumonia (viral, bacterial, fungal, aspiration, etc.) Hgb 5.2, will transfuse Acute or chronic blood loss anemia due to... Frequency Encounter Episode Substance disorder Injury Intermittent/paroxysmal (Asthma, claudication) First (Initial visit for a condition) Initial (First occurrence of a condition) Substance (Tobacco, heroin, marijuana, meth, cocaine, alcohol) Bite (Open wound) State (Active, in remission) Laceration (Open wound) Persistent (Asthma, atrial fib, angina) Subsequent (F/U visit for the same condition) Recurrent (Condition recurs despite treatment) Type (Dependence,use, abuse) Puncture (Open wound) **Recurrent conditions are not the same as chronic conditions** Delivery method (Cigarettes, chewing tobacco, cigars, inhalation, injection) Fracture Strain (Bone, joint) (Bone, joint) Emaciated, total protein/albumin low nutrition supplements started Severe protein calorie malnutrition Soft tissue involvement Fascia (Right plantar, left quadriceps) Tendon (Left Achilles) Ligament (Right ACL) Muscle (Left hamstring, right bicep, bilateral quadriceps) R46.1 Bizarre personal appearance Laughter is always the best medicine (or( there is a code for that) t) Art by Chelsea Wittenbaugh. Struck by Orca. 2013 7
V61.6xxD Passenger in heavy transport vehicle injured in collision with pedal cycle in traffic accident, subsequent encounter W56.22xA Struck by orca, initial encounter Art by Sarah Sandock. Struck by Orca. 2013 Art by Ellery Addington-White. Struck by Orca. 2013 W61.62 Struck by duck, sequela What you need to know to survive Art by Alex Connelly. Struck by Orca. 2013. 8
Z73.4 Inadequate social skills, not elsewhere classified Physicians don t like change so your lives will be miserable for awhile. TAKE IT DAY BY DAY Art by Erica Samlowski. Struck by Orca. 2013 DON T STRESS YOURSELF OUT Z73.1 Type A behavior pattern Remember that ICD 9 was once new, and we all adapted to it. Art by Erica Samlowski. Struck by Orca. 2013 YOU DON T HAVE TO GO IT ALONE Z89.419 Acquired absence of unspecified great toe Please let us know if there is anything we can do to assist you. Art by Alex Connelly. Struck by Orca. 2013. Y93.D1 Activity, knitting and crocheting Enjoy your upcoming weekend but be careful! 9
TEST YOUR KNOWLEDGE Is urosepsis an acceptable term? No sepsis due to urinary tract infection Is diabetic foot wound acceptable documentation? No foot ulcer secondary to uncontrolled type II DM and diabetic nephropathy Wound = injury due to being stabbed Is mass interchangeable with neoplasm? No pancreatic neoplasm with peritoneal carcinomatosis Is insulin dependent diabetes acceptable? No type I DM or type II DM REFERENCES & ADDITIONAL RESOURCES References http://go.cms.gov/ MLNProducts, ICD 10 CM/PCS Myths and Facts, April 2013 Advisory Board Company, handouts and presentations, 2012 2015 Additional Resources http://go.cms.gov www.ahima.org www.icd10watch.com 38 Questions and Discussion CONTACT INFORMATION Tonya Mitchell, RHIT Team Leader, Clinical Documentation Improvement Program tmitchell@mbhs.org Office: 601 292 4691 Whitney Raju, MD Physician Advisor, Clinical Documentation Improvement Program wraju@mbhs.org Office: 601 968 4673 10