UHS, Inc. ICD-10-CM/PCS Physician Education Obstetrics and Gynecology

1. UHS, Inc. ICD-10-CM/PCS Physician Education Obstetrics and Gynecology

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 Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and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

16. ICD-10 Documentation Tips Female Reproductive • Inflammatory Disease • Examples - Salpingitis, Oophoritis, PID • Severity – acute, subacute, chronic • Manifestation / cause / underlying condition • Pelvic adhesions causing the disorder or exacerbating • Current or past antineoplastic therapy or radiological procedures • Non-inflammatory Disease • Examples – Endometriosis, Prolapse, Dysplasia • Post-surgical state • Post-surgical complication • Location • Acuity – mild, moderate, severe • Origin of infertility • Tubal, uterine, other

17. ICD-10 Documentation Tips Female Reproductive continued • Prolapse • Classification • Urethrocele • Cystocele • Rectocele • Vaginal enterocele • Location – lateral or midline • Severity • Incomplete / First degree • Incomplete / Second degree • Complete / Third degree

18. ICD-10 Documentation Tips Neoplasm • Location • Detailed location • Left, Right, Bilateral • Morphology • Malignant, Benign • Primary , Secondary • In situ • Uncertain behavior, Unspecified behavior • Histology • Identified by cytology, histology or pathology findings • Stage / Metastatic • Different, distinct locations • Different primaries • Metastatic sites

19. ICD-10 Documentation Tips Neoplasm continued • Is patient being admitted for treatment of the neoplasm or an adverse reaction / complication? • Treatment - surgery, chemotherapy, immunotherapy, radiation • Adverse reaction of treatment – neutropenic fever secondary to chemo • Complication of the disease – anemia due to malignancy • Document if a complication is part of the disease process or an adverse effect of treatment • Anemia due to malignancy or due to chemotherapy • History of • Malignancies previously removed and no longer receiving active treatment • Clearly document for follow-up and medical surveillance

20. ICD-10 Documentation Tips Pregnancy ICD-10-CM definitions of trimesters: • First trimester = less than 14 weeks, 0 days • Second trimester = 14 weeks, 0 days to less than 28 weeks, 0 days • Third trimester = 28 weeks until delivery • Documentation of conditions/complications of pregnancy will need to specify the trimester in which the condition occurred. • If the condition develops prior to admission, assign the trimester at the time of admission.

21. ICD-10 Documentation Tips Pregnancy continued • Past infertility / poor reproductive history • Abortive outcomes • Ectopic • Hydatidiform mole • Abnormal products of conception (e.g. - blighted ovum) • Spontaneous abortion • Induced termination of pregnancy • Specify abortive agent or method used • Failed attempted termination of pregnancy • Incomplete abortion • Pre-term labor • Pregnancy induced conditions • Pregnancy induced hypertension • document acuity of pre-eclampsia (mild, moderate or severe) • Gestational diabetes • needs specification of diet controlled or insulin controlled

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 • 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

23. ICD-10 Documentation Tips Pregnancy continued • High risk pregnancy • History of infertility • Ectopic or molar pregnancy • Substance abuse • Insufficient care • Specify any pre-existing condition, infection or disorder • HIV • Smoking • Anemia • Hypertension

24. ICD-10 Documentation Tips Labor and Delivery • Labor is categorized by weeks of gestation • Pre-term = before 37 weeks gestation • Post-term = over 40 weeks but less than 42 weeks gestation • Prolonged = over 42 weeks gestation • Document specifics of delivery • Outcome of delivery • List method of delivery • Specify instrumentation used • Severity of any perineal laceration and level of repair • Method of labor induction if applicable • Malposition, malpresentation • Include if obstructed or non-obstructed • If obstructed, what is the condition causing the obstruction of labor • Large fetus, locked twins, etc.

25. ICD-10 Documentation Tips Labor and Delivery continued • Reason for C-section, if performed • List past history of C-section, when applicable • Complications of anesthesia • Aspiration pneumonitis • Pressure collapse of lung • Cardiac complication • CNS complication • Toxic reaction to local anesthesia • Spinal / epidural headache • Failed or difficult intubation

26. ICD-10 Documentation Tips Fetal Anomalies • Multiples • Number of fetuses (numeric designation of 1 -9) • include number of placenta and number of amniotic sacs • Identify fetus with complication with assigned number • Fetal conditions • Central nervous system malformation • Chromosomal abnormality • Hereditary disease • Damage to fetus due to viral disease, alcohol, drugs, radiation, medical procedure • Isoimmunization – Rh, ABO, other

27. ICD-10 Documentation Tips Puerperium • Retained placenta • With or without membranes • Infection • Cesarean wound infection • UTI • Endometritis • Other conditions requiring treatment • Disruption of obstetric wound • Postpartum mood disturbance • Post-delivery anemia • Abscess of the breast • Mastitis • Retracted or cracked nipple

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

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 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

31. ICD-10 Documentation Tips

32. 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

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

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