10/12/2014 1 Presented by: Connie Eckenrodt, RHIT, CHCA, CHC Every reasonable effort has been taken to ensure that the educational information provided in this presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation. A thorough individual review of the information is recommended and to establish individual facility guidelines. Presenter makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. Presenter has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this presentation. Presenter makes no guarantee that the use of this presentation material will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. 2 With 20 years in health information management, Ms. Eckenrodt’s focus has been on outpatient coding in the hospital and ambulatory settings, with particular emphasis on professional fee coding and documentation improvement. Consulting has been provided in myriad settings, from small practices to large multi-specialty medical and surgical groups. Areas of expertise include: New provider coding orientations Individual and group coding education for providers and professional fee coders Pre-bill and retrospective coding audits Risk assessment and focus review audits for internal compliance initiatives and compliance initiatives pursuant to federal investigations Ms. Eckenrodt received her A.A.S. in Health Information Management from Portland Community College. Dedicated to excellence in coding compliance, quality education and health care auditing, Ms. Eckenrodt is a certified professional with the American Health Information Management Association (AHIMA), the Health Care Compliance Association (HCCA) and the Association of Health Care Auditors and Educators (AHCAE). Ms. Eckenrodt is also a member of the American Academy of Professional Coders (AAPC).
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10/12/2014
1
Presented by:Connie Eckenrodt, RHIT, CHCA, CHC
Every reasonable effort has been taken to ensure that the educational information provided in this presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation. A thorough individual
review of the information is recommended and to establish individual facility guidelines.
Presenter makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied
guarantee of suitability for any specific purpose. Presenter has no liability or responsibility to any person or entity with respect to any
loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this presentation. Presenter makes no guarantee that the
use of this presentation material will prevent differences of opinion or disputes with Medicare or other third party payers as to
the amount that will be paid to providers of service.
2
With 20 years in health information management, Ms. Eckenrodt’s focus has been on outpatient coding in the hospital and ambulatory settings, with particular emphasis on professional fee coding and documentation improvement. Consulting has been provided in myriad settings, from small practices to large multi-specialty medical and surgical groups. Areas of expertise include: � New provider coding orientations
� Individual and group coding education for providers and professional fee coders
� Pre-bill and retrospective coding audits
� Risk assessment and focus review audits for internal compliance initiatives and compliance initiatives pursuant to federal investigations
Ms. Eckenrodt received her A.A.S. in Health Information Management from Portland Community College. Dedicated to excellence in coding compliance, quality education and health care auditing, Ms. Eckenrodt is a certified professional with the American Health Information Management Association (AHIMA), the Health Care Compliance Association (HCCA) and the Association of Health Care Auditors and Educators (AHCAE). Ms. Eckenrodt is also a member of the American Academy of Professional Coders (AAPC).
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� Discuss history of ICD code set
� Review fundamental differences between ICD-9-CM and ICD-10-CM
� Review what PAs need to do now to prepare
� Understand actions practices need to take to implement on time
HistoryHistoryHistoryHistory
ICDICDICDICD----9999----CMCMCMCM• Based on World Health Organization’s (WHO) Ninth
Revision
• Main purpose morbidity and mortality reporting
• Made single classification system for hospitals in January 1979
• Physicians required to submit diagnosis codes for Medicare reimbursement since April 1989
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• January 2009 –• Final Rule requiring replacement of ICD-9 with ICD-10• Compliance date set for October 1, 2013
• 2012 –• Department of Health and Human Services (DHHS)
announced a 1-yr delay• Implementation pushed back to October 1, 2014• April 1, 2014 –• Language inserted into Protecting Access to Medicare Act
delayed implementation to no sooner than October 1, 2015
• August 4, 2014 –• DHHS sets new compliance date of October 1, 2015
� ICDICDICDICD----10101010----CM CM CM CM will be used by all healthcare providers in all settings to assign and/or interpret diagnoses
� HIPAA Transaction Code Set
-Principal or First-Listed diagnosis
-Secondary diagnoses
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ICDICDICDICD----9999----CMCMCMCM
� Outdated – terminology does not reflect current medical practice
� Lack of adequate space to add new codes
� Lack of detail
� Inability to capture new and emerging technologies
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� Provide anatomically specific clinical dataProvide anatomically specific clinical dataProvide anatomically specific clinical dataProvide anatomically specific clinical data
� More detailed information More detailed information More detailed information More detailed information on ◦ Condition
S01.02xA Laceration with foreign body of S01.02xA Laceration with foreign body of S01.02xA Laceration with foreign body of S01.02xA Laceration with foreign body of scalp, scalp, scalp, scalp, initial encounterinitial encounterinitial encounterinitial encounter
◦ Obstetrics, injuries, external causes of injuries
� Can be number or letter
� Must always be the 7th character
� If the code is not 6 characters a placeholder X must be used
Example: Example: Example: Example:
O65.0xx1 Obstructed labor due to deformed O65.0xx1 Obstructed labor due to deformed O65.0xx1 Obstructed labor due to deformed O65.0xx1 Obstructed labor due to deformed pelvis, pelvis, pelvis, pelvis, fetus 1fetus 1fetus 1fetus 1
7777 thththth Character FracturesCharacter FracturesCharacter FracturesCharacter Fractures----• A Initial encounter for closed fracture • B Initial encounter for open fracture • D Subsequent encounter for fracture with routine
healing • G Subsequent encounter for fracture with delayed
healing • K Subsequent encounter for fracture with
nonunion • P Subsequent encounter for fracture with
malunion • S Sequela
Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 2013 2013 2013
Single code used to classify:Single code used to classify:Single code used to classify:Single code used to classify:
� Two diagnoses
� A diagnosis with an associated secondary process or manifestation
� A diagnosis with an associated complication Example: Example: Example: Example: Pressure ulcer, site, stagePressure ulcer, site, stagePressure ulcer, site, stagePressure ulcer, site, stageL89.312 Pressure ulcer of right buttock, stage L89.312 Pressure ulcer of right buttock, stage L89.312 Pressure ulcer of right buttock, stage L89.312 Pressure ulcer of right buttock, stage
2222
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Laterality Laterality Laterality Laterality ◦ For bilateral sites, the final character of the code
indicates laterality
◦ If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side
◦ Unspecified side is also provided should the side not be identified in the documentation
Code Examples:L89.131 – Pressure ulcer of right lower back, stage I
L89.132 – Pressure ulcer of right lower back, stage IIL89.133 – Pressure ulcer of right lower back, stage IIIL89.134 – Pressure ulcer of right lower back, stage IVL89.139 – Pressure ulcer of right lower back,
unspecified stageL89.141 – Pressure ulcer of left lower back, stage IL89.142 – Pressure ulcer of left lower back, stage IIL89.143 – Pressure ulcer of left lower back, stage III
L89.144 – Pressure ulcer of left lower back, stage IVL89.149 – Pressure ulcer of left lower back, unspecified stageL89.151 – Pressure ulcer of sacral region, stage I
L89.152 – Pressure ulcer of sacral region, stage II…L89.90 – Pressure ulcer of unspecified site,
unspecified stage
Borderline DiagnosisBorderline DiagnosisBorderline DiagnosisBorderline Diagnosis◦ If provider documents “borderline” diagnosis,
code as confirmed unless classification provides a specific entry (e.g., borderline diabetes).
◦ Not considered “uncertain,” so ok to code in outpatient setting
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� Evaluation, treatment and monitoring of patient health
◦ Patient carePatient carePatient carePatient care
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� Detailed diagnosis codes require clinical documentation that supports the code selection
� Risk for refunding payments if negative audit findings
� “Unspecified” codes still available, however benefits of new code set not fully realized if used
� Inclusion of clinical concepts that do not exist in ICD-9-CM
No need to learn over 68,000 No need to learn over 68,000 No need to learn over 68,000 No need to learn over 68,000 codes!codes!codes!codes!
Focus on the clinical concepts and the codes
will fall into place…
� Type Type Type Type ◦ Description of the condition, “type of”
� Type II diabetes or pathological fracture
� Temporal FactorsTemporal FactorsTemporal FactorsTemporal Factors◦ Time parameter associated with the condition
� Acute, chronic, paroxysmal, recurrent
� Caused by/Contributing FactorsCaused by/Contributing FactorsCaused by/Contributing FactorsCaused by/Contributing Factors◦ Relates the cause of a condition to another
� Associated withAssociated withAssociated withAssociated with
� SeveritySeveritySeveritySeverity◦ Acuity of the condition
� Mild, moderate, severe
� EpisodeEpisodeEpisodeEpisode� Single, recurrent; initial encounter, subsequent
encounter
� Remission statusRemission statusRemission statusRemission status� Partial, full
� History ofHistory ofHistory ofHistory of
� MorphologyMorphologyMorphologyMorphology
� Complicated byComplicated byComplicated byComplicated by
� External CauseExternal CauseExternal CauseExternal Cause
� ActivityActivityActivityActivity
� Place of OccurrencePlace of OccurrencePlace of OccurrencePlace of Occurrence
� Level of ConsciousnessLevel of ConsciousnessLevel of ConsciousnessLevel of Consciousness
� SubstanceSubstanceSubstanceSubstance
� Number of GestationsNumber of GestationsNumber of GestationsNumber of Gestations
� Outcome of DeliveryOutcome of DeliveryOutcome of DeliveryOutcome of Delivery
� BMIBMIBMIBMI
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� Primarily used in inpatient setting
� Clinical indicators used to identify missed diagnoses or under-documented conditions that may impact reimbursement
� Coders may query the physician regarding the condition to determine if the condition should be reported or whether the condition might be better reported with a more specific code
Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 23 month-old male brought to
ED after pt witnessed to have a seizure. Parents indicate pt has had cough and congestion x 2 days.
O: T: 105.4, BP: 76/52, HR 116. Breath sounds decreased in the left base and scattered rales and wheezes present throughout. Blood drawn for CBC and blood cultures. Chest x-ray shows infiltr ates.
� Occupational exposure to environmental tobacco smoke
� Tobacco dependence
� Tobacco use
Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 55 year-old black female
presents with acuteacuteacuteacute asthma episode.
O: She is SOB and very anxious. Wheezing can be heard without stethoscope. O2 sat was 92% on RA but increased to 95% after initiation of O2 4L/m via NC. Nebulizer tr eatment given.
A: Asthma
P: Admit for overnight breathing tr eatments and IV steroids.
J45.901 J45.901 J45.901 J45.901 Unspecified asthma with (acute) exacerbation
Adequate DocumentationS: 55 year-old black female presents with acute asthma
episode. Pt has had dx of asthma since childhood.
Allergic triggers include cold weather, pollen and mold.
She uses oral and inhaled steroids extensively.
O: She is SOB and very anxious. Wheezing can be heard
without stethoscope. O2 sat was 92% on RA but
increased to 95% after initiation of O2 4L/m via NC.
P : Admit for overnight breathing treatments and IV
steroids.
J45.41 Moderate persistent asthma with (acute)
exacerbation
Z79.51 Long term (current) use of inhaled steroids
Z79.52 Long term (current) use of systemic steroids
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Identify:Identify:Identify:Identify:
Type Type Type Type (no longer benign, malignant, or unspecified)(no longer benign, malignant, or unspecified)(no longer benign, malignant, or unspecified)(no longer benign, malignant, or unspecified)
� Essential hypertension
� Hypertensive heart disease
Also document:
With heart failureWith heart failureWith heart failureWith heart failure
Without heart failureWithout heart failureWithout heart failureWithout heart failure
� Hypertensive chronic kidney disease
� Hypertensive heart and chronic kidney disease
Also document:
With heart failureWith heart failureWith heart failureWith heart failure
Without heart failureWithout heart failureWithout heart failureWithout heart failure
With chronic kidney disease, includeWith chronic kidney disease, includeWith chronic kidney disease, includeWith chronic kidney disease, include
pain and indigestion. The pain is descr ibed as a dull constant pain.Nausea accompanies the pain and is worsened by eating. On a 10 point pain scale the patient r ates the pain a 7.
O: T: 99.2, BP 125/80, HR 70. Normal bowel sounds. Abdominal discomfor t was felt on palpitation. Liver and spleen not enlarged. . . .
A: Abdominal pain suggestive of gall stone disease.
P: Obtain abdominal ultrasound, lab tests and EKG.
R10.9R10.9R10.9R10.9 Unspecified abdominal pain
Adequate DocumentationS: 70 year-old female c/o abdominal pain and
indigestion. The pain is described as a dull constant
pain in the RUQ. Nausea accompanies the pain and is
worsened by eating. On a 10 point pain scale the
patient rates the pain a 7.
O: T: 99.2, BP 125/80, HR 70. Normal bowel sounds.
Abdominal discomfort was felt on palpitation in the
RUQ. Liver and spleen not enlarged. Family history
positive for gallbladder disease and MI.
A: RUQ abdominal pain suggestive of gall stone
disease.
P : Obtain abdominal ultrasound, lab tests and EKG.
R10.11 Right upper quadrant abdominal pain
Z83.79 Family history of other diseases of the
digestive system
Z82.49 Family history of cardiovascular disease
� The requirements for good documentation haven’t changed
� ICD-10-CM is BUILT BETTER for coding clinical concepts that more fully describe the patient’s condition
� Documentation of the clinical concepts is integral to good patient care and better reporting of healthcare data