A Venture of Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD 10 CM/PCS Trainer Clinical Documentation Program Manager for ezdi HIPAA Code Sets HIPAA legislation required use of the International Classification of Diseases, 9th Edition, Clinical Modification, (ICD 9 CM), Volumes 1 and 2 as updated and distributed by the Department of Health and Human Services (HHS), for the following conditions: Diseases. Injuries. Impairments. Other health related problems and their manifestations. Causes of injury, disease, impairment, or other healthrelated problems. 2 1
HIPAA Code Sets Section 1104 of the Patient Protection and Affordable Care Act (Affordable Care Act) established new requirements for administrative transactions Migration from ICD 9 CM to ICD 10 CM/PCS originally scheduled for October 1, 2013 delayed until October 1, 2015 Both ICD 9 CM and ICD 10 CM/PCS have been in a code freeze since 2011 As a result there have been essentially no updates to either ICD 9 CM or ICD 10 CM/PCS except for those associated with technology 3 ICD 10 CM The ICD stands for the International Classification of Diseases, which was developed by the World Health Organization (WHO) for international use in regards to classifying health conditions for the purpose of morbidity and mortality The 10 represents the code set as the 10 th revision of ICD, which was initially adopted by WHO members in 1994 WHO plans to release the 11 th revision in 2017 The CM denotes that the version used in the U.S. is clinically modified for use in the U.S. so it varies from that used by other nations 4 2
Cooperating Parties In order to adapt the ICD code set for use in the United States, Health and Human Services enlisted the services of the following organizations, who serve as the cooperating parties The American Health Information Management Association (AHIMA) The American Hospital Association (AHA) The Centers for Medicare and Medicaid (CMS) The National Center for Health Statistics (NCHS) The guidelines state, Only this set of guidelines, approved by the Cooperating Parties, is official. ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 1 of 115 5 Cooperating Parties Not only do the cooperating parties influence modifications to the code sets, but they also are able to set professional standards within the industry as it relates to coded data AHIMA issues practice briefs on a variety of topics on HIM topics that include coding and querying AHA issues Coding Clinic, a publication that provide advice to promote consistent coding practices by answering questions from professionals as well as providing education regarding the use of new and/or revised codes as they are introduced 6 3
AHA Coding Clinic Although the mechanics of coding will remain the same under ICD 10 CM the nuances of coding under the new system has yet to be fully explored due to limited opportunities to perform dual coding by many organizations Coding Clinic is a publication by the American Hospital Association (AHA), who is a cooperating party, for the purpose of promoting accurate and consistent code assignment through providing advice about use of ICD 10 CM/PCS Various Coding Clinics are used routinely by coders when applying codes and sequencing diagnoses 7 General Coding Guidelines The official guidelines for coding and reporting (OCG) are a set of rules developed to accompany and complement the official coding conventions and instructions of the ICD code set They expand and clarify the coding and sequencing instructions found within the code manual Adherence to these guidelines when assigning ICD 10 CM/PCS codes is REQUIRED by HIPAA In regards to hospice services, CMS accepts only HIPAA approved ICD 10 CM/PCS codes (depending on the date of service) Medicare Claims Processing Manual Chapter 11: Processing Hospice Claims 8 4
FY 2016 ICD 10 CM/PCS http://www.cms.gov/medicare/coding/icd10/2016 ICD 10 PCS and GEMs.html 9 2016 Conventions for ICD 10 CM 10 5
Hospice Guidelines Understanding the coding conventions is important because the Medicare Claims Process Manual for Processing Hospice Claims states, Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD 10 CM Coding Guidelines or require further compliance with various ICD 10 CM coding conventions, such as those that have principal diagnosis code sequencing guidelines. Medicare Claims Processing Manual Chapter 11: Processing Hospice Claims Key Coding Conventions The conventions for the ICD 10 CM are the general rules for use of the classification independent of the guidelines These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD 10 CM as instructional notes The ICD 10 CM is divided into The Alphabetic Index, an alphabetical list of terms and their corresponding code, The Tabular List, a structured list of codes divided into chapters based on body system or condition. ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 7 of 115 12 6
ICD 10 CM Tabular List The Tabular List contains 21 chapters The axis of classification can be The body/organ system Circulatory system Respiratory system Etiology or nature of the disease process Infections and parasitic disease Location/Site (topography) Trauma/injuries Neoplasms 13 Body Systems Associated with Most Common Hospice Diagnoses The body system associated with the most common hospice diagnoses are: Neoplasm Nervous Mental, behavioral and neurodevelopmental diseases Circulatory Respiratory Digestive (hepatobiliary) Renal Signs, symptoms and ill defined conditions 7
Hospice Guidelines According to the Medicare Claims Processing Manual, the principal diagnosis listed for hospice services is the diagnosis most contributory to the terminal prognosis Hospices may not report ICD 10 CM Z codes as the principal diagnosis on hospice claims Z codes are used to identify factors influencing health status and contact with health services They are reported when circumstances other than a disease, injury or external cause classifiable to categories A00 Y89 are recorded as 'diagnoses' or 'problems Medicare Claims Processing Manual Chapter 11: Processing Hospice Claims ICD 10 CM Alphabetic Index Example The alphabetic index guides the coder to the correct location in the tabular list In the alphabetic index, terms are listed alphabetically for quick reference 8
Tabular List Example ICD 10 CM In the tabular list, terms are listed in alphanumeric order 17 Assigning a Neoplasm Code Neoplasm codes are assigned differently from other types of conditions because the neoplasm table located in the Alphabetic Index must be referenced The table for neoplasm gives the code numbers for neoplasms by anatomical site ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 25 of 115 18 9
Assigning a Neoplasm Code For each site there are six possible code numbers according to whether the neoplasm in question is Malignant The type most likely associated with a hospice patient Benign In situ Of uncertain behavior Of unspecified nature ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 25 of 115 19 The Histology of Neoplasms: Malignancy Malignancy is synonymous for cancer and/or neoplasm A term for diseases in which abnormal cells divide without control and can invade nearby tissues Malignant cells can also spread to other parts of the body through the blood and lymph systems Metastasis is the spread of cancer from one part of the body to another. A tumor formed by cells that have spread is called a metastatic tumor or a metastasis. The metastatic tumor contains cells that are like those in the original (primary) tumor http://www.cancer.gov/publications/dictionaries/cancer terms?expand=i 20 10
The Histology of Neoplasms: Malignancy There are several main types of malignancy Carcinoma is a malignancy that begins in the skin or in tissues that line or cover internal organs Sarcoma is a malignancy that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue Leukemia is a malignancy that starts in blood forming tissue, such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood Lymphoma and multiple myeloma are malignancies that begin in the cells of the immune system Central nervous system cancers are malignancies that begin in the tissues of the brain and spinal cord http://www.cancer.gov/publications/dictionaries/cancer terms?expand=i 21 Staging/Grading Cancer ICD 10 CM doesn t capture codes for the associated cancer stage, but metastasis can be captured Grading systems (as determined by a staging system) are different for each type of cancer The objective of a grading system is to provide information about the probable growth rate of the tumor and its tendency to spread They are used to help plan treatment and determine prognosis because staging describes the extent or severity of a person s cancer based on knowledge of how cancer progresses The severity of the patient s condition must be captured by reporting additional diagnoses 22 11
ICD 10 CM Diagnoses Codes ICD-10 CM codes consist of three to seven alphanumeric characters The first character is a letter (alpha) U is the only letter not currently in use O is used for Obstetrics (pregnancy, childbirth and the puerperium) and resembles a zero 0 I is used for circulatory and resembles a one 1 The second character is ALWAYS a number The remaining characters can be letters or numbers 23 ICD 10 CM Diagnoses Codes Diagnosis codes are to be used and reported at their highest number of characters available Diagnoses are preferred over symptoms when applicable Minimize use of unspecified codes ICD 10 CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters... A three character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 12 of 115 24 12
The Format of an ICD 10 CM Code ICD 10 CM codes can have a few as three and as many as seven characters Additional characters usually provide more specificity Hospices are required to use full diagnosis codes including all applicable digits... up to seven digits for ICD 10 CM Disease with basic location 5 th character added laterality 4 th character added complication of ulcer Medicare Claims Processing Manual Chapter 11: Processing Hospice Claims 6 th character refined location 25 ICD 10 CM Code Specificity: Laterality Much of the increase in the volume of codes for ICD 10 CM is due to the capture of laterality For bilateral body sites, the final character of the code usually indicates laterality 0 or 9 = unspecified 1 = right 2 = left A diagnosis code is only used once on a claim so if a bilateral code is not available the code for the right and the code for the left are used ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 15 of 115 26 13
Example of ICD 10 CM Laterality Codes The same number of characters can be assigned even if the laterality isn t specified because unspecified is usually an option in addition to left or right so the code can still be reported if the affect side is unknown 27 ICD 10 CM Specificity and Default Codes Precise documentation is required to assign the most accurate code (which is usually reflected as additional characters within the code) as many diagnosis codes are differentiated by Acuity Anatomical specificity Laterality The presence or absence of an associated manifestation A default code represents the condition most commonly associated with the main term or can be the unspecified code for the condition 28 14
ICD 10 CM Default Codes Default 29 Unspecified Diagnoses When sufficient clinical information isn t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (e.g., a diagnosis of pneumonia, but not the specific type), which may be the default code Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient s condition at the time of that particular encounter It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 16 of 115 30 15
Provider Education: Educate providers to always document in terms of ACUITY for all diagnoses to avoid the reporting of default codes Is it a new condition = acute Be aware the provider often use the term acute to equal severe It is unlikely a chronic condition is acute, but it could be acute on chronic or decompensated Documentation elements should include how the patient currently deviates from baseline Neither coding guidelines nor Coding Clinic define the term acute or subacute or chronic 31 Conventions: 7 th Character & Placeholder Certain ICD 10 CM categories have applicable 7th characters, but none of these are associated with the top hospice diagnoses The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct The 7th character must always be the 7th character in the data field If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 8 of 115 32 16
7 th Character Extension Characters in ICD 10 CM encounter specificity These codes are five characters so a valid code requires use of a placeholder in the sixth character location M48.40XA so the A represents an initial encounter 33 Words that Link Conditions Throughout the code set there are occasions where a relationship between two conditions needs to be established so a combination code can be reported Some times the relationship is loose where the conditions coexist The term with is sufficient to support this type of relationship Sometimes the relationship must demonstrate causeand effect where one condition lead to another condition The phrase due to or similar phrasing is necessary 34 17
Combination Codes A combination code is a single code used to classify: Two diagnoses Usually the word with is sufficient to support use of these types of combination codes A diagnosis with an associated secondary process (manifestation) Sometimes the word with will be sufficient and other times a cause and effect relationship will be required The alphabetic index alphabetic index can clarify what type of association is required A diagnosis with an associated complication A cause and effect relationship is required in or due to ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 14 of 116 35 Combination Codes Including a Symptom The alphabetic index has the following options with hepatitis: The alphabetic index includes the term with ascites 36 18
Late Effects Coding Guidelines A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated most often associated with a CVA/stroke There is no time limit when a late effect code can be used The residual may be apparent early, such as in cerebrovascular accident cases The residual effect may occur months or years later, such as that due to a previous injury The key is provider documentation linking the residual effect to its cause with as much specificity as possible in terms of the initial event for proper code assignment ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 14 of 116 37 Sequela (Late Effects) Coding of sequela generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first The sequela code is sequenced second The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect For the guidelines specific to cerebrovascular disease, see Section I.C.9. Sequelae of cerebrovascular disease ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 14 of 115 38 19
Late Effects of Cerebrovascular Disease Coding Guidelines Category I69 is used to indicate conditions classifiable to categories I60 I67 = acute cerebrovascular disease as the causes of sequelae (neurologic deficits) themselves classified elsewhere These late effects include neurologic deficits that persist after initial onset of cerebrovascular disease These deficits may be present from the onset or may arise at any time after the onset of the cerebrovascular condition ICD 10 CM Official Guidelines for Coding and Reporting FY 2016 Page 42 of 115 39 Sequela of Cerebrovascular Disease Require provider documentation to link 40 20
Top Hospice Diagnoses: LHIMA Alzheimer s Disease/dementia/senile degeneration of the brain Cancers Coronary artery disease (CAD) Cardiomyopathy Cirrhosis of the liver/liver failure Chronic pulmonary heart disease Chronic obstructive pulmonary disease (COPD) End stage renal disease (ESRD) Acute pericarditis Heart failure Heart disease, unspecified Malnutrition Stroke/hemiplegia/unspecified late effects Parkinson s Disease/essential and other specified form of tremor Medicare Hospice Data Trends: 1998 2008 The frequency of some hospice terminal diagnoses has changed over time Relatively fewer cancer patients as a percentage of total hospice patients Percentage of all Medicare hospice patients with a terminal diagnosis of cancer dropped from 52.8% in 1998 to 31.1% in 2008 Lung cancer has been recognized as the most common diagnosis among Medicare hospice patients every year since 1998 The percentage of Medicare hospice patients with lung cancer dropped from 16% in 1998 to 9% in 2008 Medicare_Hospice_Data_Top_20_2008.pdf 21
Medicare Hospice Data Trends: 1998 2008 The frequency of some hospice terminal diagnoses has changed over time In 2006 non Alzheimer s dementia became the most common diagnosis among Medicare hospice patients A notable increase in the number of neurologically based diagnoses Increase in non specific diagnoses such as Debility, Not Otherwise Specified, and Adult Failure to Thrive Non cancer diagnoses are associated with a longer LOS as the national average LOS has increased by 48% between 1998 and 2008 Medicare_Hospice_Data_Top_20_2008.pdf Hospice Guidelines Although non specific diagnoses were growing in frequency, they have since been addressed by the Medicare Claims Processing Manual As of the 11/2014 version Hospices may not report the following conditions as principal hospice diagnoses on the hospice claim: Debility Failure to thrive Dementia codes classified as unspecified Medicare Claims Processing Manual Chapter 11: Processing Hospice Claims 22
Summary The next presentation will address documentation requirements specific to those diagnoses common to the respondents of the LHIMA survey based on scenarios, if provided. Thank You Questions??? 23