ICD-10 Implementation and Documentation Tips for Mental Health and Substance Abuse

1. UHS, Inc. ICD-10-CM/PCS Physician Education Mental Health and Substance Abuse

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 Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and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 – cellulitis of right upper arm Stage of disease • Acute, Chronic • Intermittent, Recurrent, Transient, Persistent • Primary, Secondary • Stage I, II, III, IV

16. ICD-10 Documentation Tips Status of disease • Mild • Moderate • Severe • Major • In remission, Not in remission • Single episode, Recurrent major Link manifestations with a mental or behavioral disorder • Speech impediment with autism Identify disease related to behavioral disorder • Alzheimer’s with aggressive behavior

17. ICD-10 Documentation Tips Mental disorders due to physiologic condition • Document associated conditions • Personality and behavior disorders due to physiological condition • Specify the physiological condition • List underlying physiological condition • Specify if dementia is with / in underlying condition • Clearly identify any associated alcohol or psychoactive substance use / disorders • Any behavior disturbances?

18. ICD-10 Documentation Tips Mood Disorders • Most recent episode • Depressed • Manic • Mixed • Acuity • Mild • Moderate • Severe • Status • Partial remission • Full remission • Episode of care • Single or recurrent

19. ICD-10 Documentation Tips Non-Psychotic Mental Disorders • Type • Anxiety • Dissociative • Stress-related • Somatoform • Acuity • Mild, Moderate, Severe • Status • With or without panic attacks • Conversion disorders • List symptoms – seizures, motor deficit

20. ICD-10 Documentation Tips Non-Psychotic Mental Disorders continued • Somatoform • Specify disorder – hypochondriacal disorders, pain disorders • Specify type of phobia • PTSD – acute or chronic • OCD specificity • Obsessive-compulsive personality depression • Obsessive compulsive disorder • Schizophrenia • Link and manifestations or related conditions • Depressed mood • Conduct disturbance • Mixed emotion disturbance

21. ICD-10 Documentation Tips Physical Factors • Type • Eating disorder • Sleep disorder • Sexual dysfunction • Postpartum depression • Specify type – be as specific as possible • Eating Disorder • Specify type and binge eating / purging • Document any associated mental or adjustment disorder

22. ICD-10 Documentation Tips Intellectual Disability • Specify the Type • Acuity • Mild • Moderate • Severe • Profound • Document associated physical or developmental disorders

23. ICD-10 Documentation Tips Schizophrenia • Type • Schizophrenia • Schizoaffective disorder • Schizophrenic reaction • Schizotypal disorder • Document associated conditions • Asperger’s • Epilepsy • Brain disease • Alcoholism • Identify any: • Acute schizophrenic-like psychotic disorders • Post –schizophrenic depression

24. ICD-10 Documentation Tips Childhood / Adolescent • Type of conduct disorder • Childhood-onset • Adolescent-onset • Confined to family context • Oppositional defiant disorder • Type of social functioning disorder • Selective mutism • Reactive attachment disorder • Disinherited attachment disorder • Type of ADHD • Inactive • Hyperactive • Combined

25. ICD-10 Documentation Tips Childhood / Adolescent continued • Manifestations / related conditions • ADHD • Mood disorders • Emotional disorders • Pervasive developmental disorders • Schizophrenia • Separation anxiety • Failure to thrive • Growth retardation • Asperger’s syndrome • Tic disorders with specific type

26. ICD-10 Documentation Tips Adult Personality Disorders • Type • Paranoid • Schizoid • Antisocial • Borderline • Histrionic • Obsessive-compulsive • Avoidant • Dependent • Narcissistic • Manifestations / related conditions • Other mental disorders • Alcohol or substance use • Impulse disorders

27. ICD-10 Documentation Tips Drug and Alcohol Use • Expanded code set to classify cause-and-effect indicators • Specify drug used • Document intoxication and blood alcohol levels • Documentation requirements include: • Specific aspects of the effects • Example – use, abuse, or dependence • Specify the aspects of use • Example – withdrawal state, in remission • Identify manifestations / alcohol or drug-induced disorders • See next slide for examples

28. ICD-10 Documentation Tips Drug and Alcohol Use • Conditions associated with Withdrawal Syndromes • Delirium • Tremors • Mood or psychotic disorder • Perceptual disturbance • Amnesic disorder or dementia • Anxiety • Sleep disorder • Conditions associated with Alcohol & Drug-induced psychotic disorder • Delusions • Hallucinations • Anxiety • Sexual dysfunction • Sleep disorder

29. 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

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 Most Common Root Operations:

32. 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