UHS, Inc. ICD-10-CM/PCS Physician Education Cardiology and Cardiovascular

1. UHS, Inc. ICD-10-CM/PCS Physician Education Cardiology and Cardiovascular

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 Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and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 • 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 Documentation should always include: • Patient’s BMI • Current of past history of tobacco use or dependence • Exposure to environmental or occupational tobacco smoke • History of previous MI • Administration of tPA at a different facility within 24 hours prior to admission to current facility

17. ICD-10 Documentation Tips Atherosclerosis • Specify type of vessel: • Native artery • CABG or Transplanted heart artery • Specify CABG graft type: • Autologous vein • Autologous artery • Non-autologous biological • Native coronary artery or transplanted heart • Specify CABG and transplanted heart to include: • With and without angina pectoris • Unstable angina • Documented spasm • Other forms of angina pectoris

18. 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

19. ICD-10 Documentation Tips Disorders of the Heart Valves • Specify Site • Mitral • Aortic • Tricuspid • Pulmonary • Specify Type • Rheumatic • Nonrheumatic • Congenital • Specify Severity – acute versus chronic • If rheumatic, classify with or without heart involvement • Subclassifications • Insufficiency • Incompetence • Regurgitation • Prolapse • Stenosis

20. ICD-10 Documentation Tips Ischemic Heart Disease • Specify occlusion as: • Total, partial • Specify the presence of: • Angina pectoris, unstable angina, any spasm of a coronary vessel • Identify the type and underlying cause of angina • if not related to heart disease • Identify ischemic heart disease as: • Atherosclerosis • Arteriosclerotic coronary artery disease • Arteriosclerotic heart disease • Coronary artery disease • Coronary arteriosclerosis • Coronary heart disease • Coronary ischemia

21. ICD-10 Documentation Tips Type of MI along with Myocardium involved • Specify the type – ST elevation, non ST elevation • Specify the location/site affected • anterior wall, anterolateral wall, interior wall • left anterior descending coronary artery • left main coronary artery, right coronary artery • Timeframe • Clearly indicate date of recent acute MIs within 28 days prior to current admission • History of MI (older than 28 days) • tPA • Was tPA administered within the last 24 hours of admission at a different facility?

22. 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 • Link any manifestations / complications to the diabetes • Circulatory, renal, neurological, ophthalmic, skin, other Examples: • 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

23. 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.

24. 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

25. ICD-10 Documentation Tips

26. 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

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

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

29. 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