1 UHS, Inc. ICD-10-CM/PCS Physician Education Pulmonology and Respiratory
Jan 12, 2016
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UHS, Inc.
ICD-10-CM/PCSPhysician Education
Pulmonology and Respiratory
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 visits2
Why ICD-10Why 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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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
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Diagnosis Code StructureDiagnosis Code Structure
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ICD-10-CM Diagnosis Code FormatICD-10-CM Diagnosis Code Format
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Comparison: ICD-9 to ICD-10-CMComparison: ICD-9 to ICD-10-CM
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Procedure Code Structure Procedure Code Structure
ICD-10-PCS Code FormatICD-10-PCS Code Format
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ICD-10 Changes Everything!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?
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ICD-10-CM/PCSDocumentation Tips
ICD-10 Provider ImpactICD-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
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Gold Standard Documentation PracticesGold Standard Documentation Practices
1. Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms
2. Document diagnoses, rather that descriptors
3. Indicate acuity/severity of all diagnoses
4. Link all diseases/diagnoses to their underlying cause
5. Indicate “suspected”, “possible”, or “likely” when treating a condition empirically
6. Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers
7. Clarify diagnoses that are present on admission
8. Clearly indicate what has been ruled out
9. Avoid the use of arrows and symbols
10. Clarify the significance of diagnostic tests12
ICD-10 Provider ImpactICD-10 Provider Impact
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and anatomic sites
4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition or disease process
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-10 Documentation Tips
Site and Laterality – right versus left–bilateral body parts or paired organs
Example – frontal sinusitis
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
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ICD-10 Documentation TipsICD-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]
– Type / Form• Childhood• Exercise induced• Extrinsic allergenic• Late onset• Allergic• Allergic bronchitis• Allergic rhinitis w/ asthma• Atopic asthma• Extrinsic allergic asthma• Intrinsic non-allergic asthma• Idiosyncratic asthma
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ICD-10 Documentation TipsICD-10 Documentation Tips
Asthma continued
– Acuity •With acute exacerbation•With status asthmaticus
– Tobacco Exposure •Exposure to environmental tobacco smoke•History of tobacco use•Occupational exposure to tobacco smoke
– Cause and Effect – environmental•Detergent•Coal workers•Miners•Wood
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ICD-10 Documentation TipsICD-10 Documentation Tips
COPD – Type
• Chronic obstructive bronchitis• Chronic bronchitis with airway obstruction• Chronic bronchitis with emphysema• Chronic obstructive tracheobronchitis
– 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
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ICD-10 Documentation TipsICD-10 Documentation Tips
Influenza– Organism, document as known or suspected
• Avian influenza• H1N1 influenza
– Link associated conditions / manifestations• Influenza with secondary gram negative pneumonia• Laryngitis• Pleural effusion• Influenzal encephalopathy• Influenzal myocarditis• Influenzal otitis media
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ICD-10 Documentation TipsICD-10 Documentation Tips
Lung Cancer
– Location• Detailed location of lesion site• 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
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ICD-10 Documentation TipsICD-10 Documentation Tips
Lung Cancer 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
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ICD-10 Documentation TipsICD-10 Documentation Tips
Pneumonia– Type – bacterial, viral, fungal, aspiration, drug-induced
– 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 / underlying 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)
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ICD-10 Documentation TipsICD-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
– Differentiate pulmonary collapse from therapeutic collapse
– Respiratory distress and respiratory insufficiency are NOT respiratory failure
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ICD-10 Documentation TipsICD-10 Documentation Tips
Respiratory Failure Criteria
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Acute Chronic
Symptoms – difficulty breathing, shortness of breath, dyspnea, tachypnea, respiratory distress, labored breathing, use of accessory muscles, cyanosis, unable to speak
Symptoms – severe COPD, chronic lung disease such as cystic or pulmonary fibrosis
Ph < 7.35 & pCO2 > 50 or pO2 < 55 & FIO2 > 28 %
pO2 < 55 or pCO2 > 50
Hypoxemia Hypercapnia
pO2 < 60 mmHg ORpO2 / FIO2 ratio < 300 OR10 mmHg decrease in baseline pO2
pCO2 > 50mmHg with pH < 7.35 OR10 mmHg increase in baseline pCO2
ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-10 Documentation Tips
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Intra-operative Post-procedural
Accidental puncture / laceration Timing:•Post-procedure•Late effect
Same or different body system Classify as:•An expected post-procedural condition•An unexpected post-procedural condition, related to the patient’s underlying medical comorbidities•An unexpected post-procedural condition, unrelated to the procedure•An unexpected post-procedural condition related to surgical care (a complication of care)
Blood product
Central venous catheter
Drug:•What adverse effect•Drug name•Correctly prescribed•Properly administered
Encounter:•Initial•Subsequent•Sequelae
ICD-10 Documentation TipsICD-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
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Root Operations:
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Control – stopping or attempting to stop
Excision – cutting out or off without replacement a portion of a body part
Repair – restoring, to the extent possible, a body part
Restriction – partially closing an orifice or lumen of a tubular body part
Dilation – expanding an orifice or the lumen of a tubular body part
Extirpation – taking or cutting out solid matter
Replacement – putting in a biological /synthetic material that takes the place or function
Supplement – putting in a biological/ synthetic material to reinforce / augment
Division – cutting into a body part to transect the body part
Insertion – putting in a non-biological appliance
Reposition – moving to its normal location
Transfer – moving, without taking out, all or a portion of a body part to another location
Drainage – taking or letting out fluids &/or gases
Release – freeing a body part from an abnormal physical constraint
Resection – cutting out or off without replacement all of a body part
Transplantation – putting in all or a portion of a living part from another individual or animal
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Device Types:
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Diaphragmatic pacemaker lead
Endobronchial valve Intraluminal device: plain, drug-eluting, or radioactive
Drainage device Endotracheal airway
Monitoring device Tracheostomy device
Extraluminal device Infusion device Radioactive element
SummarySummary
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and anatomic sites
4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition or disease process
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