UHS, Inc. ICD-10-CM/PCS Physician Education Pulmonology and Respiratory

1. UHS, Inc. ICD-10-CM/PCS Physician Education Pulmonology and Respiratory

2. ICD-10 Implementation • October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) • Ambulatory and physician services provided on or after 10/1/15 • Inpatient discharges occurring on or after 10/1/15 • ICD-10-CM (diagnoses) will be used by all providers in every health care setting • ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures • ICD-10-PCS will not be used on physician claims, even those for inpatient visits

3. Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and detail to support: • Accurate anatomical positions • Differentiation of risk & severity • Key parameters to differentiate disease manifestations

4. Diagnosis Code Structure

5. ICD-10-CM Diagnosis Code Format

6. Comparison: ICD-9 to ICD-10-CM

7. Procedure Code Structure

8. ICD-10-PCS Code Format

9. ICD-10 Changes Everything! • ICD-10 is a Business Function Change, not just another code set change. • ICD-10 Implementation will impact everyone: • Registration, Nurses, Managers, Lab, Clinical Areas, Billing, Physicians, and Coding • How is ICD-10 going to change what you do?

10. ICD-10-CM/PCS Documentation Tips

11. ICD-10 Provider Impact • Clinical documentation is the foundation of successful ICD-10 Implementation • Golden Rule of Documentation • If it isn’t documented by the physician, it didn’t happen • If it didn’t happen, it can’t be billed • The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient • what services were rendered and what is the severity of illness • The key word is SPECIFICITY • Granularity • Laterality • Complete and concise documentation allows for accurate coding and reimbursement

12. Gold Standard Documentation Practices • Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms • Document diagnoses, rather that descriptors • Indicate acuity/severity of all diagnoses • Link all diseases/diagnoses to their underlying cause • Indicate “suspected”, “possible”, or “likely” when treating a condition empirically • Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers • Clarify diagnoses that are present on admission • Clearly indicate what has been ruled out • Avoid the use of arrows and symbols • Clarify the significance of diagnostic tests

13. ICD-10 Provider Impact The 7 Key Documentation Elements: • Acuity – acute versus chronic • Site – be as specific as possible • Laterality – right, left, bilateral for paired organs and anatomic sites • Etiology – causative disease or contributory drug, chemical, or non-medicinal substance • Manifestations – any other associated conditions • External Cause of Injury – circumstances of the injury or accident and the place of occurrence • Signs & Symptoms – clarify if related to a specific condition or disease process

14. ICD-10 Documentation Tips Do not use symbols to indicate a disease. For example “↑lipids” means that a laboratory result indicates the lipids are elevated • or “↑BP” means that a blood pressure reading is high These are not the same as hyperlipidemia or hypertension

15. ICD-10 Documentation Tips Site and Laterality – right versus left • bilateral body parts or paired organs Example – frontal sinusitis Stage of disease • Acute, Chronic • Intermittent, Recurrent, Transient • Primary, Secondary • Stage I, II, III, IV Example – stage of pressure ulcer: • L89.011 Pressure ulcer of right elbow, stage 1 • L89.021 Pressure ulcer of left elbow, stage 1

16. ICD-10 Documentation Tips Asthma • Specificity • Intermittent [less than or equal to two times per week] • Mild persistent [more than two times per week] • Moderate persistent [daily-may restrict physical activity] • Severe persistent [throughout the day-frequent severe attacks that limit the ability to breathe] • Type / Form • Childhood • Exercise induced • Extrinsic allergenic • Late onset • Allergic • Allergic bronchitis • Allergic rhinitis w/ asthma • Atopic asthma • Extrinsic allergic asthma • Intrinsic non-allergic asthma • Idiosyncratic asthma

17. ICD-10 Documentation Tips Asthma continued • Acuity • With acute exacerbation • With status asthmaticus • Tobacco Exposure • Exposure to environmental tobacco smoke • History of tobacco use • Occupational exposure to tobacco smoke • Cause and Effect – environmental • Detergent • Coal workers • Miners • Wood

18. ICD-10 Documentation Tips COPD • Type • Chronic obstructive bronchitis • Chronic bronchitis with airway obstruction • Chronic bronchitis with emphysema • Chronic obstructive tracheobronchitis • Acuity • With acute exacerbation • With acute lower respiratory infection • Specificity • With asthma • With bronchitis • With emphysema • Tobacco Exposure • Exposure to environmental tobacco smoke • History of tobacco use • Occupational exposure to tobacco smoke

19. ICD-10 Documentation Tips Influenza • Organism, document as known or suspected • Avian influenza • H1N1 influenza • Link associated conditions / manifestations • Influenza with secondary gram negative pneumonia • Laryngitis • Pleural effusion • Influenzal encephalopathy • Influenzal myocarditis • Influenzal otitis media

20. ICD-10 Documentation Tips Lung Cancer • Location • Detailed location of lesion site • Left, Right, Bilateral • Morphology • Malignant, Benign • Primary , Secondary • In situ • Uncertain behavior, Unspecified behavior • Histology • Identified by cytology, histology or pathology findings • Stage / Metastatic • Different, distinct locations • Different primaries • Metastatic sites

21. ICD-10 Documentation Tips Lung Cancer continued • Is patient being admitted for treatment of the neoplasm or an adverse reaction / complication? • Treatment - surgery, chemotherapy, immunotherapy, radiation • Adverse reaction of treatment – neutropenic fever secondary to chemo • Complication of the disease – anemia due to malignancy • Document if a complication is part of the disease process or an adverse effect of treatment • Anemia due to malignancy or due to chemotherapy • History of • Malignancies previously removed and no longer receiving active treatment • Clearly document for follow-up and medical surveillance

22. ICD-10 Documentation Tips Pneumonia • Type – bacterial, viral, fungal, aspiration, drug-induced • Organism, document as known or suspected • Viral – adenoviral, respiratory syncytial, parainfluenza, human metapneumovirus, viral unspecified • Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas, staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified • Link associated conditions / underlying conditions • Influenza with secondary gram negative pneumonia • Sepsis due to pneumonia • Acute respiratory failure due to pneumonia • Aspiration • Due to solids or liquids • Due to anesthesia during L/D or procedure • Due to anesthesia during puerperium • Laterality of lung involvement – left, right, both • Note whether ventilator associated (VAP)

23. ICD-10 Documentation Tips Respiratory Failure • Acuity - acute, chronic, acute on chronic • Specificity – with hypoxia or hypercapnia • Tobacco Use • Exposure to environmental tobacco smoke • History of tobacco use • Occupational exposure to tobacco • Does the patient require continuous home oxygen or is dependent on home oxygen • Differentiate pulmonary collapse from therapeutic collapse • Respiratory distress and respiratory insufficiency are NOT respiratory failure

24. ICD-10 Documentation Tips Respiratory Failure Criteria

25. ICD-10 Documentation Tips Drug Under-dosing is a new code in ICD-10-CM. • It identifies situations in which a patient has taken less of a medication than prescribed by the physician. • Intentional versus unintentional • Documentation requirements include: • The medical condition • The patient’s reason for not taking the medication • example – financial reason • Z91.120 – Patient’s intentional underdosing of medication due to financial hardship

26. ICD-10 Documentation Tips Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post-procedural disorders • The provider must clearly document the relationship between the condition and the procedure • Example: • D78.01 –Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen • D78.21 –Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen

27. ICD-10 Documentation Tips

28. ICD-10 Documentation Tips ICD-10-PCS does not allow for unspecified procedures, clearly document: • Body System • general physiological system / anatomic region • Root Operation • objective of the procedure • Body Part • specific anatomical site • Approach • technique used to reach the site of the procedure • Device • Devices left at the operative site

29. ICD-10 Documentation Tips Most Common Root Operations:

30. ICD-10 Documentation Tips Most Common Device Types:

31. Summary The 7 Key Documentation Elements: • Acuity – acute versus chronic • Site – be as specific as possible • Laterality – right, left, bilateral for paired organs and anatomic sites • Etiology – causative disease or contributory drug, chemical, or non-medicinal substance • Manifestations – any other associated conditions • External Cause of Injury – circumstances of the injury or accident and the place of occurrence • Signs & Symptoms – clarify if related to a specific condition or disease process