UHS, Inc. ICD-10-CM/PCS Physician Education Neurology and Neurosurgery

1. UHS, Inc. ICD-10-CM/PCS Physician Education Neurology and Neurosurgery

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 Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and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 Signs & Symptoms – document underlying cause / conditions

16. ICD-10 Documentation Tips Site and Laterality – right versus left • bilateral body parts or paired organs Example – cellulitis of right upper arm 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

17. ICD-10 Documentation Tips Alzheimer’s Disease • Onset classification • Early onset • Late onset • Link manifestations / related conditions • Delirium • Dementia • Senile dementia • Behavioral disturbances • Senile degeneration

18. ICD-10 Documentation Tips Cerebrovascular Disease – non-traumatic • Type • Hemorrhage • Subarachnoid • Intracerebral • Intracranial • Occlusion / Stenosis without cerebral infarction • Cerebral infarction • Sequela of cerebrovascular disease • Laterality– right, left, bilateral • Tobacco Exposure • Exposure to environmental tobacco smoke • History of tobacco use • Tobacco use or dependence • Occupational exposure to tobacco smoke • Alcohol abuse or dependence

19. ICD-10 Documentation Tips Cerebrovascular Disease – non-traumatic continued • Location for brain hemorrhage – be as specific as possible • Subarachnoid • Middle cerebral artery • Basilar artery • Vertebral artery • Intracerebral • Brain stem • Cerebellum • Intraventricular • Intracranial • Subdural • Acute, subacute, chronic

20. ICD-10 Documentation Tips Cerebral Artery Infarction / Stroke Specify the location or source of the hemorrhage and laterality • Document cause – thrombosis, embolism, stenosis • Sites – be as specific as possible • Precerebral – right and left vertebral, basilar, right and left carotid • Cerebral – right and left middle, right and left anterior, right and left posterior, right and left cerebellar • Laterality– right, left, bilateral

21. ICD-10 Documentation Tips Cerebral Artery Infarction / Stroke • Document dominant verses non-dominant side • for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesisand for residual effects Example: previous cerebral infarction 6 months ago with residual left-sided hemiparesis on his nondominant side. • Did the patient receive tPA at a different facility within the 24 hours prior to admission?

22. ICD-10 Documentation Tips Epilepsy • Epilepsy Type • Idiopathic or symptomatic • Simple or complex partial seizures • Generalized • If intractable, include clarification • Poorly controlled • Pharmacoresistant • Treatment resistant • Refractory • Document with or without status epilepticus • Seizure - classify as • Febrile, convulsions, new onset, single or hysterical

23. ICD-10 Documentation Tips Parkinson’s Disease • Type – primary versus secondary • If secondary, specify underlying cause • Malignant neuroleptic • Neuroleptic-induced • Postencephalitic • Vascular • Syphilis • Drug-induced, specify drug • Link manifestations • Dementia • Behavioral disturbance

24. ICD-10 Documentation Tips Polyneuropathy • Type • Hereditary • Idiopathic • Inflammatory • Sequelae • Document underlying cause • Diabetes • Amyloidosis • Radiation-induced • Drug-induced, specify the drug • Alcohol-induced

25. ICD-10 Documentation Tips Glasgow Coma • ICD-10-CM coding will need the score from each of the assessment areas • Eye opening • Verbal response • Motor response • R40.211 Coma scale, eyes open never • R40.212 Coma scale, eyes open to pain • R40.213 Coma scale, eyes open to sound • R40.214 Coma scale, eyes open spontaneously • Report the Glasgow coma scale total score • R40.241 Glasgow coma scale score 13 – 15 • R40.242 Glasgow coma scale score 9 - 12 • R40.243 Glasgow coma scale score 3 – 8

26. ICD-10 Documentation Tips Glasgow Coma Scale

27. 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

28. 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

29. ICD-10 Documentation Tips

30. 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

31. ICD-10 Documentation Tips Example – spinal fusion • Root Operation • Fusion • Body Part • Thoracic vertebral joints 2 - 7 • Approach • Open (anterior/posterior) and Column (anterior/posterior) • Device • Autologous tissue substitute

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

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

34. 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