ICD-10-CM/PCS Implementation in Physician Education

1. UHS, Inc. ICD-10-CM/PCS Physician Education Internal Medicine and Family Practice

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 Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and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 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] • Acuity • With acute exacerbation • With status asthmaticus • Type / Form • Childhood • Exercise induced • Extrinsic allergenic • Late onset • Tobacco Exposure • Exposure to environmental tobacco smoke • History of tobacco use • Occupational exposure to tobacco smoke

18. ICD-10 Documentation Tips COPD • 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 Diabetes - include the type or cause of diabetes • Type I • Type II • Due to drugs and chemicals • Due to underlying condition • Other specified diabetes • Link any manifestations to the diabetes • Circulatory, renal, neurological, ophthalmic, skin, other Use of Insulin – long term, current Example: • E08 - Diabetes mellitus due to underlying condition • E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma • E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma • E11 - Type 2 diabetes mellitus • E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema • E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular edema

20. ICD-10 Documentation Tips Encephalopathy • Acuity – acute, subacute, chronic • Severity – with or without coma • Type • Alcoholic • Hepatic • Hypertensive • Metabolic • Septic • Toxic • Due to disease classified elsewhere • Due to influenza, syphilis, hydrocephalus, neoplastic disease, etc… • Link altered mental status to encephalopathy with the specific type

21. ICD-10 Documentation Tips Heart Failure • Specify acuity • Acute • Chronic • Acute on chronic • Identify type • Systolic • Diastolic • Combined systolic and diastolic • List relationship of hypertension to heart failure or heart disease • Identify underlying cause • Example - Exacerbation of stable heart failure due to fluid overload or due to missed dialysis

22. ICD-10 Documentation Tips Kidney Disease • Specify acuity • Acute, Chronic, Acute on chronic • Identify stage • Stage I – GFR > 90 • Stage II – GFR 60 – 89 • Stage III – GFR 30 – 59 • Stage IV – GFR 15 – 29 • Stage V – GFR < 15 • List relationship of hypertension &/ or diabetes • Document as due to or with • Example – Type 2 DM with diabetic CKD stage 5 • Transplant Status – has the patient had a transplant or is a transplant candidate

23. ICD-10 Documentation Tips Otitis Media • Type • Serous • Sanguinous • Suppurative • Allergic • Mucoid • Infectious Agent • Strep • Staph • Influenza • Measles, Mumps • Laterality – left, right, both • Note whether tympanic membrane is ruptured

24. ICD-10 Documentation Tips Malnutrition • Specify acuity – mild, moderate, severe • Specify type • Protein calorie • Protein energy • Marasmus • Nutritional deficiency • At least 2 of the following are required to help identify malnutrition: • Insufficient energy intake • Weight loss • Loss of muscle mass • Loss of subcutaneous fat • Localized / generalized fluid accumulation • Diminished functional status as measure by hand grip strength

25. ICD-10 Documentation Tips Weight-related diagnoses and BMI

26. ICD-10 Documentation Tips Pneumonia • 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 • 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)

27. ICD-10 Documentation Tips Pressure Ulcers • Site – specific ulcer location • Ankle, back, buttock, coccyx, elbow, face, head, heel, hip, sacral region, other site • Laterality – left, right, both • Stage • 1 – pre-ulcer skin changes limited to persistent focal edema • 2 – abrasion, blister, partial thickness skin loss involving epidermis &/or dermis • 3 – full thickness skin loss involving damage or necrosis of subcutaneous tissue • 4 – necrosis of soft tissue through to underlying muscle, tendon or bone • Unspecified – not documented • Unstageable – full thickness tissue loss, covered with slough or eschar • Note whether the pressure ulcer was present on admission

28. 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 • Respiratory distress and respiratory insufficiency are NOT respiratory failure

29. ICD-10 Documentation Tips Respiratory Failure Criteria

30. ICD-10 Documentation Tips Sepsis • Acuity – sepsis, severe sepsis, septic shock, SIRS • Organism due to / suspected • Streptococcus (A or B) • Staphylococcus aureus • MSSA • MRSA • Hemophilus influenzae • Gram-negative organism • E Coli • Serratia • Enterococcus • Manifestations • With acute organ dysfunction • With multiple organ dysfunction • SIRS due to infectious process with organ dysfunction • Shock • Note the term urosepsis is NOT synonymous with sepsis

31. ICD-10 Documentation Tips Sepsis Criteria • Altered mental status • Heart rate > 90 beats per minute • Hypoxemia • PaCO2 < 32mmHg • Respiratory rate > 20 breaths per minute • Temperature > 100.9 F or < 96.8 F • WBC > 12,000 cells/mm3; < 4,000 cells/mm3; and/or > 10% immature band • Blood cultures do not need to be positive to support the diagnosis of sepsis – the physician may clinically diagnose based on signs and symptoms

32. ICD-10 Documentation Tips Strokes – dominant vs. non-dominant side • Specify the location or source of the hemorrhage and laterality • Document other causes – thrombosis, embolism, occlusion, stenosis • Sites – precerebral or cerebral arteries • Laterality • Document dominant verses non-dominant side for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesis and for residual effects Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.

33. ICD-10 Documentation Tips Drug and Alcohol Use • Expanded code set to classify cause-and-effect indicators • Documentation requirements include: • Specific aspects of the effects • Example – abuse and dependence • Specify the aspects of use • Example – withdrawal state • Identify manifestations • Example – hallucinations, delusions

34. 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

35. 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

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

37. 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