ICD-10: Addressing the Top Ten Documentation Issues

2. ICD-10: Addressing the Top Ten Documentation Issues Michael Powell, MD – Physician Consultant, 3M Health Information Systems Donna M. Smith, RHIA – Senior Consultant, 3M Health Information Systems

3. Key Documentation Education Opportunities • Top 10 documentation issues related to ICD-10 • Diabetes mellitus • Injuries • Drug underdosing • Cerebral infarctions • AMI • Neoplasms • Musculoskeletal conditions • Pregnancy • Respiratory/vents • ICD-10-PCS

4. Complete and Accurate Documentation and Coding: Example: Diabetes Mellitus ICD-9-CM Diabetes 59 codes (249-250) ICD-10-CM Diabetes 200+ codes (E08-E13) Including: E1121 Type 2 diabetes with diabetic nephropathy E1122 Type 2 diabetes with chronic kidney disease E1129 Type 2 diabetes with other kidney complications E11321 Type 2 diabetes with mild nonproliferative retinopathy with macular edema E11621 Type 2 diabetes with foot ulcer E11649 Type 2 diabetes with hypoglycemia without coma 4 • Diabetes documentation and coding will need to include: • Type or cause of diabetes • Type I • Type 2 • Due to drugs or chemicals • Due to other cause • Body system complications related to diabetes • Nephropathy • Neuropathy • Specific complication, such as: • Chronic kidney disease • Proliferative diabetic retinopathy with macular edema • Foot ulcer • Hypoglycemia without coma

5. Complete and Accurate Documentation and Coding: Example: Injuries • Injuries • Injuries have a 7th character extension to identify the encounter type, with “A” as initial encounter and “D” for subsequent encounter • Fractures • Fractures have a unique 7th character extension, which indicates open or closed fracture, initial or subsequent encounter with delayed healing, malunion or nonunion • Specificity – type of fracture • Oblique • Comminuted • Transverse • Displaced • Laterality • Lacerations/contusions (internal organs) • Minor – length and depth • Moderate – length and depth • Major – length and depth

6. Complete and Accurate Documentation and Coding: Example: Fractures ICD-10-CM Many possible codes ICD-9-CM 821.01 Fracture of femur, shaft, closed

7. Complete and Accurate Documentation and Coding: Example: Drug Underdosing • Underdosing – New to ICD-10 • Combination codes exist that can identify a situation where a patient has taken less of a medication than prescribed, as well as the specific drug. The medical condition is sequenced first with the underdosing code listed as a secondary diagnosis. • Intentional vs. unintentional. • Underdose of insulin due to an insulin pump failure – Mechanical compilation of other specified internal and external prosthetic devices, implants and grafts followed by underdosing conditions.

8. Complete and Accurate Documentation and Coding: Example: Cerebral Infarction • Cerebral infarction • Specificity related to: • Specific artery involvement • Vertebral artery • Carotid artery • Cerebellar artery • tPA (rtPA) given in a different facility within 24 hours • Glasgow Coma Scale • Laterality

9. Myocardial infarction documentation and coding will need to include: Type of infarction STEMI NSTEMI Age of infarction If within 4 weeks coded as initial If older than 4 weeks coded as “old” Specific site of myocardium involved Anterior wall Inferior wall Coronary artery involved Information regarding initial or subsequent MI within 4 weeks Complete and Accurate Documentation and Coding: Example: Myocardial Infarction ICD-9-CM Acute Myocardial Infarction 10 codes (410.01-410.91) ICD-10-CM Myocardial Infarction 9 codes for initial (I21) and 5 codes for subsequent (I22) Including: I21.01 STEMI myocardial infarction involving the anterior wall with left main coronary artery involvement I21.02 STEMI myocardial infarction involving the anterior wall with left anterior descending coronary artery involvement I21.09 STEMI myocardial infarction involving other coronary artery of anterior wall I22.0 Subsequent STEMI of anterior wall (within 4 weeks of initial MI)

10. Complete and Accurate Documentation and Coding: Example: Neoplasms • Neoplasms • Specificity related to: • Anemia due to Neoplasms – Anemia associated with malignancy is sequenced as a secondary diagnosis with the malignancy sequenced as principal • Pathological fractures due to neoplasms • Overlapping sites • Laterality

11. Complete and Accurate Documentation and Coding: Example: Pathologic Fracture ICD-9-CM Pathologic Fracture 8 codes (733.13-733.19) ICD-10-CM Pathologic Fracture 150 + codes (M80-M84) Including: M8008xA Age-related osteoporosis with current pathological fracture, vertebra, initial encounter for fracture M80051A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture M8458xA Pathological fracture in neoplastic disease, vertebra, initial encounter for fracture 11 • Pathologic fracture documentation and coding will need to include: • Exact location of fracture • Site • Laterality • Etiology of fracture • Osteoporosis • Neoplastic disease • Encounter type • Initial encounter for fracture • Subsequent encounter for fracture • Subsequent encounter for fracture with delayed healing

12. Complete and Accurate Documentation and Coding: Example: Musculoskeletal conditions • Osteoarthritis, gout, rheumatoid arthritis, osteonecrosis, etc., all need specificity of exact site and laterality • Linkage to cause of disease process • Gout due to renal impairment • Drug-induced gout • Post-traumatic osteoarthritis • Primary osteoarthritis • Specificity of other organ involvement • Rheumatoid lung with arthritis of right wrist

13. Complete and Accurate Documentation and Coding: Example: Pregnancy • Pregnancy • Specificity related to: • Trimester – Pregnancy codes have a final character indicating the trimester for the current encounter • 1st Trimester – less than 14 weeks, 0 days • 2nd Trimester – 14 weeks 0 days to less than 28 weeks 0 days • 3rd Trimester – 28 weeks 9 days until delivery • Gestational diabetes – documentation of diet controlled or insulin controlled is required to appropriately classify this condition • If both diet and insulin controlled, only insulin controlled will be used in the coding process • Only present in the second or third trimester • Puerperal sepsis • Causal organism should be documented • Documentation of severe sepsis and organ dysfunction is required (if present)

14. Complete and Accurate Documentation and Coding: Example: Respiratory/Ventilators • Respiratory/ventilators • Specificity related to: • Ventilators • Less than 24 consecutive hours • 24–96 consecutive hours • Greater than 96 consecutive hours • Pneumonia – Ventilator-associated pneumonia; requires additional reporting of type of pneumonia • Acute pulmonary insufficiency • Following thoracic surgery (MCC) • Following non-thoracic surgery (MCC) • Following shock or trauma (CC) • Respiratory insufficiency – just a symptom

15. ICD-10-PCS Impact: Procedure codes standardized/provide additional specificity Benefit: Ability to capture new medical advances and technology Each code tells a story: Section Body System Root Operation Body Part Approach Device Qualifier 0DB68Z X Excision Transorifice Intraluminal Endoscopic Diagnostic Med-Surg Gastrointestinal Stomach None • A character is a stable, standardized code component • Holds a fixed place in the code • Retains its meaning across a range of codes • A value is an individual unit defined for each character

16. Complete and Accurate Documentation and Coding: Example: Root Operations • Root operation examples • Excision: “Cutting out or off, without replacement, a portion of a body part” • Resection: “Cutting out or off, without replacement, all of a body part” • Dilation: “Expanding an orifice or the lumen of a tubular body part” • Extirpation: “Taking or cutting out solid matter from a body part” • Extraction: “Pulling or stripping out or off all or a portion of a body part by the use of force”

17. ICD-10 Physician Education • Physician education methodologies/timing • ICD-10 improvements • Current education • Who to educate • Who does the education • Timing • Venues • Teaching tools

18. ICD-10 Physician Education • ICD-10 improvements • Updated medical terminology more consistent with the 21st century: • More specific relative to anatomy and pathophysiology • More adaptable to IT • Increased specificity in clinical terminology also allows for improved medical necessity information and overall consistency and accuracy of data collection • Improved data allows for more accurate: • SOI and expected mortality reflections – profiling • Reimbursement for services provided

19. ICD-10 Physician Education • Physician education methodologies/timing • Current education • Complete and accurate documentation • Specificity required by ICD-10 will likely increase the volume of queries to achieve complete documentation • ICD-10 – raising the bar • Requires more stringent documentation

20. The Need Unable to code Able to code Multisystem organ failure Severe respiratory distress Hemodynamically unstable Will rehydrate Rhythm stable today Unable to void K + 2.0, will give KCL LLL infiltrate, will give IV ABX Hgb 5.2, transfuse Emaciated, total protein/albumin Low, nutrition supplements started Liver failure, renal failure Respiratory failure – acute, acute on chronic Hypotension, CHF, cardiogenic shock Dehydration, hypovolenia Ventricular tachycardia Urinary retention Hypokalemia LLL pneumonia Acute or chronic blood loss anemia Severe protein-calorie malnutrition

21. Secondary Diagnoses • For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring at least one of the following: • Clinical evaluation • Therapeutic treatment • Diagnostic procedures • Extended length of hospital stay • Increased nursing care and/or monitoring

22. Probable, Possible, Suspected, Clinical, or Unable to Rule Out • Inpatient application: • Code these conditions as though they exist – applies to hospital setting only • If condition is ruled out, it may not be coded • Outpatient application: • Must code signs/symptoms, not the suspected condition • Note: When ordering ancillary tests (EKG, radiology, anatomical pathology, etc.), use signs and symptoms to indicate medical necessity

23. GERD Gastritis MS-DRGs 391/392 RW = 1.0958 Biliary Colic MS-DRGs 444/445/446RW = 1.5055 Anxiety MS-DRG 880RW = 0.6191 Anterior CPPleuritic CPChest Wall PainMS-DRG 204 RW = 0.6472 Psychogenic Angina Pericarditis MS-DRGs 314/315/316RW = 1.7589 Costochondritis Tietze’s Disease MS-DRGs 205/206 RW = 1.2566 Chest Pain MS-DRG 313RW = 0.5404 Pleurisy MS-DRGs 193/194/195 RW = 1.4378 Pulmonary Embolism MS-DRGs 175/176 RW = 1.6121 Psychogenic Chest Pain MS-DRG 882 RW = 0.6676 Cardiac Arrhythmia MS-DRGs 308/309/310 RW = 1.2188 Shingles MS-DRGs 595/596RW = 1.7691 Angina MS-DRG 311RW = 0.5128 CAD MS-DRGs 302/303 RW = 0.9999 Chest Pain Alternatives Cardiac Cath MS-DRGs 286/287 RW = 1.9634

24. Specificity and Severity of Illness

25. ICD-10 Physician Education • Physician education methodologies/timing • Who to educate • CMO/leadership physicians/physician champion • Qualities: • Lends credibility and support to the program as an articulate opinion leader who influences other physicians via reputation or informal leadership qualities • May be invited, may emerge, or may be a convert, but has the courage to take a stand • Attending physicians • Resident physicians • Mid-level professionals

26. ICD-10 Physician Education • Physician education methodologies/timing • Who does the education • CDIS • Consultant • Physician champion • CMO • Department chair • Coder

27. ICD-10 Physician Education • Physician education methodologies/timing • Timing • Start now • Coordinate hospital-specific strategies for implementing the educational process • Begin specific queries for the increased specificity with ICD-10 coding system – a graduated approach

28. ICD-10 Physician Education • Physician education methodologies/timing • Venues • One-on-one • Department/medical staff meetings • Grand rounds • Off-site meetings with physicians

29. ICD-10 Physician Education • Physician education methodologies/timing • Teaching tools • Presentation • Queries • Diagnostic profiles – “pocket cards” • Newsletters • Documentation posters • Encoder • EHR

30. General Medical Diagnoses documented solely on diagnostic reports are not “codeable.” The physician must clinically correlate diagnoses in the body of the medical record with abnormal findings.

31. General Surgery Diagnoses documented solely on diagnostic reports are not “codeable.” The physician must clinically correlate diagnoses in the body of the medical record with abnormal findings.

32. Physician Documentation Guidelines—Pneumonia • Document type of pneumonia, if known (e.g., aspiration pneumonia, MRSA pneumonia, pneumonia due to Klebsiella, viral pneumonia). • Documentation of CAP, HAP, and HCAP can be further specified with the possible/probable causativeorganism, if known. • It is the physician’s responsibility, when cultures reveal the responsible pathogen, to document the relationship between the causative organism and the pneumonia (e.g., Klebsiella pneumonia, pneumonia due to Klebsiella). • Document “probable,” “suspected,” or “clinical” pneumonia if treating pneumonia as if present but cannot be confirmed. To reflect your patient’s true severity of illness, document all conditions you are treating, evaluating, or monitoring.

33. Summary • Transitioning to ICD-10 specificity will be challenging and will require more complete and accurate documentation by the physician as well as a more thorough knowledge of anatomy and pathophysiology by CDIS nurses and coders. • However, the benefits will include a more complete capture of patient data, which will lend support to medical necessity, more accurately reflect severity of illness and expected mortality, and facilitate appropriate reimbursement.

34. Questions?