ICD-10 Clinical Documentation Improvement for Facilities OrHIMA 2013 Fall Meeting

1. ICD-10 Clinical Documentation Improvement for Facilities OrHIMA 2013 Fall Meeting September 27, 2013

2. Presenter: • Laura Legg, RHIT, CCS AHIMA approved ICD-10 Trainer • Experienced as a leader, consultant, coding expert, speaker, trainer and auditor for acute care and critical access hospitals and major health systems • llegg@hrgpros.com

3. Objectives • To gain an awareness of the complexity of ICD-10 and the challenges of implementation • Identify chapter by chapter challenges in documentation specificity for ICD-10 • Identify diagnosis-specific sample queries for ICD-10 4. Questions/Answers

4. ICD-10-CM/PCS-Introduction • US Department of Health and Human Services announced change January 16, 2009 with a compliance date of October 1, 2013 • 2012 delay til October 2014 • Biggest change to healthcare in the last 20 years!

5. History of ICD-10 • US department of Health and Human Services announced the change: • 1988 • 1/19/2009 • 10/1/2013 • 10/1/2014

6. History More than 200 countries have adopted ICD-10 • Nordic countries-1997 • UK-1995 • France-1997 • Australia-1998 • Germany-2000 • Canada-2001

7. If ICD-10 were a game what game would it be? 8/25/2014 7

8. If ICD-10 were a game what game would it be? 8/25/2014 8

9. If ICD-10 were a game what game would it be? 8/25/2014 9

10. Now is a time to learn everything we can- • Ask questions • Learn what testing reveals • Be proactive using what we are learning • Continue learning up until the time of implementation • Go-live planning • Plan for after go live

11. ICD-10 Testing Revealed: • Earlier misconceptions -DRG variance 2-6% -MDC shifts not expected • Expected results -Coder productivity decrease -If you are not proficient now you won’t be proficient using ICD-10

12. Testing Revealed: DRG variances much higher than expected Example: DRG variance in the Nervous System Expected 8% Actual 27% DRG variance in the Digestive System Expected 8% Actual 20%

13. Testing Revealed: • MDC shifts did occur • Time-to-code IP claims decreased from 3-5 per hour to 1-2 per hour • Coding errors included: -invalid codes -decimals in incorrect places -coding not following coding conventions This caused increased rejected and pended claims

14. ICD-10 Humor

15. What should we do? • The answer “DOCUMENTATION” • Back to the Basics • Look at Processes and Workflow now • Staff adjustments • Dual coding • Peer review • Physician queries

16. Go From ICD-9 to ICD-10 Remember: If it was not working that well for ICD-9-CM/PCS it won’t work for ICD 10 CM! Think about this:

17. Focus your efforts: • Top 10 common clinical diagnoses • If physicians are motivated or conditioned to include specificity in these top clinical diagnoses then the road to a successful transition to clinical documentation under ICD-10 can be established

18. Tailor your CDI program: • Run a report of the top 20 MS DRGs for the last fiscal year • Review diagnoses • Tailor ICD-10 training for the common clinical diagnoses that your physicians manage

19. ICD-10 Clinical documentation • Greater specificity • Increase accuracy in documentation • Increase accuracy in billing and reimbursement • Improved statistical analysis which means: -improved disease management -better understanding of health care outcomes

20. Review Query forms • Revise query forms and focus on some specific areas: • Asthma • Coma • Fracture • Stroke • Cardiac-hypertension, CAD, CHF • Diabetes • OB

21. Chapter 1: Infectious and Parasitic diseases • Queries will be mandatory for the diagnosis “urosepsis” in ICD-10-CM • More specific documentation is needed when reporting sepsis. Septicemia is no longer synonymous with sepsis

22. Chapter 2: Neoplasms • When an admission is solely for anemia associated with a malignancy, the appropriate malignancy code is sequenced as the principal diagnosis followed by the code for anemia in neoplastic disease. D63.0

23. Chapter 3: Blood and blood forming organs • Anemia appears in code categories D50-D64. • ICD-10 also identifies anemia according to type, but the categories rely on different language -nutritional (iron deficiency in ICD-9) -Hemolytic (e.g., sickle cell) -Aplastic and other anemia, which include acute blood loss anemia and anemia of chronic disease.

24. Chapter 4: Endocrine, Nutritional, and Metabolic • In ICD-9-CM diabetes mellitus was classified as to type 1, type 2, or secondary • The 5th digit indicates the type of diabetes mellitus or unspecified diabetes and also indicates if the diabetes is controlled or uncontrolled • In ICD-10-CM diabetes mellitus is not classified as controlled or uncontrolled

25. Chapter 4: Endocrine, Nutritional and Metabolic • E08-Diabetes mellitus due to an underlying condition (code first the underlying condition) • E09-Drug or chemical-induced diabetes mellitus. • E10-Type I diabetes mellitus • E11-Type 2 or diabetes NOS • E13-Other specified diabetes mellitus (diabetes due to pancreatectomy)

26. Sequencing has changed with “code first” notes • Combination codes • Encourage physicians to document mild, moderate or severe for the added specificity in ICD-10 diabetes mellitus codes

27. ICD-10 Humor

28. Chapter 5: Mental and behavioral disorders Drug and alcohol-related disorders Assignment is based on type of substance and whether the person abuses the substance or is dependent on it • When documentation identifies that the patient has use, abuse, and dependence the most severe state is coded • Hierarchy is use---abuse----dependence lowest to high severity

29. Chapter 6: Nervous System/Sense Organs • Encourage neurologists and other providers to review ICD-10-CM code descriptions for seizures and epilepsy and to document accordingly.

30. Chapter 6: Nervous System/Sense Organs • Terminology for epilepsy has been updated to include terms such as: • Epilepsy, juvenile myoclonic • Epilepsy, generalized, idiopathic • Epilepsy, generalized, idiopathic, intractable, without status epilepticus • Code assignment will depend on specific documentation (documentation opportunity)

31. Chapter 6: Nervous system/Sense Organs Other key documentation elements for the Nervous system are: • Dominant vs. nondominant side • Laterality • Episode of care for injuries and other external causes-initial, subsequent, sequela • Loss of consciousness time duration

32. Chapter 7: Eye and Adnexa • Codes have been expanded to increase anatomic specificity and add the concept of laterality • Many codes include right, left, bilateral, and unspecified eye • If the option of bilateral is not available and the condition is present in both eyes, assign the code for right and left • If a code for bilateral exists it should be assigned

33. Chapter 8: Ear and Mastoid • Codes have been expanded to increase anatomic specificity and add the concept of laterality • New instructional notes have been added • A note at the beginning of the chapter states to use an external cause code following the code for the ear condition, if applicable, to identify the cause of the ear condition

34. Chapter 9: Circulatory system • Acute myocardial infarction must be identified as initial or subsequent • Embolism, thrombosis, phlebitis and thrombophlebitis of veins require identification of laterality and the specific lower extremity vein

35. Chapter 9: Circulatory System Documentation for coding CVAs in ICD-10-CM • To make the correct code for CVAs the documentation must reflect the location/source and laterality • If bilateral sites are indicated, codes should be assigned for each side as there is no bilateral option in this series

36. Chapter 10: Respiratory System • When assigning codes for patients with COPD with asthma it is necessary to assign two codes. • A code from category J44 is assigned for the COPD and is accompanied by a second code from J45 to identify the severity and status of the asthma.

37. Chapter 10: Respiratory System • Key Documentation elements: • Asthma must be documented as mild, moderate or severe • Mild asthma must be documented as intermittent or persistent

38. Chapter 11: Digestive System Documentation Note: The term “hemorrhage” is used when referring to ulcers, and the term “bleeding” is used when classifying gastritis, duodenitis, diverticulosis, and diverticulitis • K25.0, Acute gastric ulcer with hemorrhage • K29.01, Acute gastritis with bleeding

39. ICD-10 Humor

40. Chapter 12: Skin/Subcu Tissue Coding Pressure Ulcers: • In ICD-9-CM coders assigned 2 codes for pressure ulcers-one from category707.0x (location) and one from 707.2x (stage of the ulcer) • In ICD-10-CM pressure ulcers appear in code category L89.- • Code L89.001 stage 1 pressure ulcer of the right elbow (note location and stage in one code)

41. Chapter 13: Musculoskeletal System Fracture codes include greater specificity in: • Type of fracture • Specific anatomic site • Displaced or nondisplaced • Laterality • Routine vs. delayed healing • Non union and malnunion • Fracture 7th character value • Gustilo open fracture classification

42. Chapter 13: Pathological fractures Pathologic fracture documentation: • Exact location of the fracture site with laterality • Etiology of the fracture-osteoporosis, neoplasm, other specified • Encounter type-initial, subsequent with routine healing, subsequent with delayed healing, malunion and nonunion or sequelae

43. Chapter 13: Musculoskeletal System Gustilo classification • Type I-clean wound < 1 cm long • Type II-wound > 1 cm without extensive soft tissue damage • Type IIIA-extensive soft tissue lacerations (>10 cm) but maintain adequate soft tissue coverage of bone • Type IIIB-extensive soft tissue loss with periosteal stripping and bony exposure, usually massive contamination • Type IIIC- with arterial injury that requires repair regardless of size of wound

44. Chapter 13: Musculoskeletal System How do you prepare? • Work with clinicians and physicians where terminologies and specificity is required • Work with CDI team to assist regarding documentation requirements

45. Chapter 14: Genitourinary System Chronic Kidney disease and Kidney Transplant Status • Patient who have undergone kidney transplant may still have some form of CKD, because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. • Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0 Kidney transplant status. • If a transplant complication such as failure or rejection or other transplant complication is documented see section I.C.19.g for information on coding complications of a kidney transplant.

46. Chapter 15: Pregnancy/Childbirth • The final character in the code will indicate the trimester • Antepartum, postpartum and whether a deliver has occurred are not used. • Final character assignment should be based on provider’s documentation • Gestational diabetes needs specification of diet controlled or insulin controlled

47. Chapter 16: Newborn • When both birth weight and gestational age of the newborn are available both should be coded with birth weight sequenced before gestational age

48. Chapter 17: Congenital Malformations • Modifications have been made to specific categories to update terminology • Example: Q61 Cystic kidney disease Q61.0 Congenital renal cyst Q61.1 Polycystic kidney, infantile type Q61.2 Polycystic kidney, adult type • Patau’s syndrome updated to Trisomy 13

49. Chapter 18: Signs and Symptoms Glasgow Coma Scale- The Glasgow coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. The codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis codes. At a minimum report the initial score documented on presentation at the facility. This may be a score from the emergency medicine technician or the ER department. If desired a facility may choose to capture several scores.

50. Chapter 19: Injury/poisoning Underdosing- Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing assign the code from categories T36-T50 (fifth or sixth character6) Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.