ICD-10-CM Chapter 21 Navigating New Concepts and Guidelines for Factors Influencing Health Status & Contact with Health Services. September 23, 2015

Transcription

1 ICD-10-CM Chapter 21 Navigating New Concepts and Guidelines for Factors Influencing Health Status & Contact with Health Services September 23, 2015

2 This presentation is brought to you by G2N We work to ensure America s healthcare providers have honest & healthy bottom lines in order to continue to fulfill their mission of improving community health. 2

3 Rosie Donovan, RHIA, CCS-P Client Partner for G2N, Inc. G2N provides coding, reimbursement and documentation audits, charge master, and other revenue cycle consulting services. 3

4 Rosie Donovan, RHIA, CCS-P 25+ years of physician practice experience in both multispecialty, independent and RHC ambulatory medical groups Focus on documentation, coding, acquisition audits, compliance, and reimbursement B.S. from Saint Louis University RHIA, CCS-P credentialed by AHIMA AHIMA-Approved ICD-10-CM/PCS Trainer Joined G2N in

5 Disclaimer The examples and discussion are not meant to be used as coding advice. This presentation will discuss basic diagnosis coding concepts for Chapter 21 and ICD-10 coding scenarios. This session will focus on Physicians and Non-Physicians, diagnosis coding. Hospital, Facility and/or ASC diagnosis coding will not be discussed. 5

6 Agenda ICD-10-CM Chapter 21 Overview and Guidelines Z code Categories Practice Cases Documentation Reminders 6

7 Good Documentation Good documentation isn t about the code set. It s about patient care. Physicians shouldn t be documenting for payment. They should be telling the patient s story. 7

8 Documentation Suggestions Eliminate abbreviations- spell it out Just a few extra words to explain It s not about volume it s about content In coding we are not allowed to, assume, or guess, or suppose. If the physician didn t document it, we can t code it, OR BILL IT. 8

9 Documentation Suggestions If diagnosis is not established, document signs or symptoms Always document a rule out or probable or possible diagnoses, but never code them Document all diagnoses, or problems that you are managing or must consider at the current encounter/service Document status of condition: resolved, unresolved, stable, unstable, controlled, uncontrolled The Diagnoses or problems, signs or symptoms must be documented in every note each note stands alone When the encounter is for other than an illness or injury use the Z codes from Chapter 21 Note: When a patient is currently being treated/managed for a specific condition the problem is current. DO NOT indicate history of. 9

10 Polling Question 1 Have you looked at your clinical documentation to determine what needs to be added to code in ICD10CM? a. Yes b. No c. I m not sure 10 10

11 Chapter 21 Overview & Guidelines 11

12 Overview of ICD-10-CM Chapter 21 Brief Overview of Chapter 21 - Codes Z00-Z99 Z codes represent Reasons for Encounters: Encounters other than a disease, injury or external cause When a person who may or may not be sick encounters the health services for some specific purpose, i.e. To receive limited care or service for current condition Donate an organ or tissue Receive prophylactic vaccinations Discuss problem When some circumstance or problem is present which influences person s health status but is not a current illness or injury 12

13 Overview of ICD-10-CM Chapter 21 Brief Overview of Chapter 21 - Codes Z00-Z99 Codes have been moved from other chapters in ICD-9 to Chapter 21: Elective, legal, or therapeutic abortions have been moved from Ch.11 in ICD-9 Complications of Pregnancy, Childbirth and Puerperium Codes have been expanded in ICD-10 Chapter 21: Personal and family history codes have expanded Body mass index (BMI) is now divided into adult and pediatric codes Code concepts that existed in ICD-9 no longer exist in ICD-10: There are no comparable codes for the category V57- Care involving use of rehabilitation procedures. Instructional Notes have been added to the different categories to explain how codes should be assigned. See NOTE in the Tabular List. 13

14 Chapter 21- Guidelines Guideline I.C.21.a. Z codes can be used in any health care setting. May be used as either a first-listed or secondary diagnosis code. Only certain Z codes may be used as first-listed diagnosis codes. Guideline I.C.21. b. A Z code is not a procedure code. 14

15 Chapter 21 Guidelines Guideline I.C.21.c.16 First-Listed Diagnosis Z codes that may only be first-listed diagnosis The following slide lists those Z codes/categories that may only be reported as the first-listed diagnosis Exception: when there are multiple encounters on the same day and the medical records or the encounters are combined. 15

16 First-Listed Diagnosis- review The first listed diagnosis in the assessment and on claim form should be the diagnosis, condition, or other reason for the encounter/service. The 1 st listed should indicate the condition that is chiefly responsible for the encounter/service that day. 16

17 First-Listed Diagnosis - ONLY Z00 general exam Z01 special exam Z02 administrative exam Z03 suspected problem, ruled out Z04 exam, other reasons Z31.81 male factor infertility in female patient Z31.82 Rh incompatibility status Z31.83 assisted reproductive fertility procedure cycle Z31.84 fertility preservation procedure Z33.2 elective termination of pregnancy Z34 supervision NL pregnancy Z38 live born infant Z39 post partum care Z42 plastic surgery following procedure or injury Z51.0 antineoplastic radiation therapy Z antineoplastic chemotherapy & immunotherapy Z52 donor organ/tissue Z76.1 care of foundling Z76.2 care healthy infant/child Z99.12 ventilator dependence during power failure 17

18 Common Index Main Terms Admission (encounter) Encounter for Aftercare Examination Attention to Exposure Boarder Fitting (of) Care (of) Follow-up Carrier (suspected) of Healthy Checking History (personal) of Chemotherapy Maintenance Contact Maladjustment Contraception, Newborn contraceptives Observation Counseling Outcome of delivery Dependence Pregnancy Dialysis Problem Donor Prophylactic Replacement by artificial or mechanical device or prosthesis of Resistance, Resistant Screening Status (post) Supervision (of) Test(s) Therapy Transplant(ed) Unavailability of medical facilities Vaccination 18

19 Aftercare as a Main Term Coding note for Aftercare Z codes: After patient received active treatment for the condition and receiving routine care during healing or recovery phase Cast change or removal An x-ray to check the healing status of fracture Removal of external or internal fixation device Medication adjustment Other aftercare and follow-up visits following injury treatment Aftercare Z codes should not be used for aftercare for conditions such as injuries and poisonings, where 7 th characters are provided to identify subsequent care. 19

20 Categories of Z codes 20

21 Chapter 21 - Categories Guideline I.C.21.c. Category of Z codes 15 Categories of Z Codes Which are then further subdivided Categories can be used as a main term to find the correct Z code in the Index 21

22 1) Contact/Exposure Contact/Exposure Category Z20 contact with and suspected exposure to communicable disease. Use these codes for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by an infected individual, or are in an epidemic area. Category Z77 contact with and (suspected) exposures hazardous to health. May be used as first-listed to explain encounter for testing, or more commonly as a secondary code to identify potential risk. 22

23 2) Inoculations/Vaccinations Inoculations/Vaccinations Category Z23 encounters for inoculations and vaccinations. Use these codes when a patient is being seen to receive a prophylactic inoculation against a disease. Remember the CPT/HCPCS codes to identify the actual injection and supply. May be used as a secondary code if the inoculation is given as part of routine preventative health care, e.g. well child check. 23

24 3) Status Multiple status codes. Status Do not use these codes with a diagnosis code from one of the other chapters, if the diagnosis code includes information provided by the status code. Z94.1 heart transplant status vs. T86.2 complication of heart transplant. Guideline: Encounter for weaning from ventilator; Assign J96.1 Chronic respiratory failure and Z99.11 dependence on ventilator status. 24

25 3) Status Multiple status codes. Status Use these codes when patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such thing as the presence of devices. Status codes may affect the course of treatment and its outcome. Status code is distinct from a history code. The history codes indicate the patient no longer has the condition. 25

26 3) Status Z14 Genetic carrier Z67 Blood type Z15 Genetic Susceptibility to disease Z68 Body Mass Index Z74.01 Bed confinement Z16 Resistance to antimicrobial drugs status Z76.82 Awaiting organ Z17 Estrogen receptor status transplant status Z78 Other specified health status Z18 Retained foreign body fragment Z21 Asymptomatic HIV Infection status Z22 Carrier of Infectious disease Z28.3 Under immunization status Z33.1 Pregnant state, incidental Z66 Do not resuscitate Z79 Long term (current) drug therapy Z88 Allergy status to drugs, other substances Z89 Acquired absence of limb Z90 Acquired absence of organs, NEC Z91.0 Allergy status, other than drugs, and biological substance Z92.82 S/P administration of tpa in different facility w/in last 24 hrs. prior to current admission Z93 Artificial opening status Z94 Transplanted organ/tissue status Z95 Presence of cardiac/vascular implants/grafts Z96 Presence of other implants Z97 Presence of other devices Z98 Other post procedural status Z99 Dependence on enabling machines and devises, NEC 26

27 4) History (of) Categories for Personal and Family Histories History (of) Personal history codes; Z85 Z92 Personal history codes explain a patient s past medical condition that no longer exists and is not receiving treatment, but may need continued monitoring in case it reoccurs. Family history codes; Z80 Z84 Family history codes are for use when a patient has a family member who has had a particular disease that causes the patient to be at a higher risk of contracting the disease. A history of diagnosis is important information that may alter the treatment/management of the patient. 27

28 5) Screening -Screening is testing for a disease in a well individual. -May be the first-listed code if the reason for the encounter is specifically for a screening service. Screening -The Z code indicates that a screening service is planned. (Additional procedure codes may apply) Code categories; Z11 Z13, Z36 Should a condition be discovered during the screening then the code for the condition is assigned as an additional diagnosis. 28

29 6) Observation Two (2) Observation Categories: Observation Z03 - Observation for suspected disease ruled out. Z04 - Observation for exam/observation, other reason. These Z codes are for use in limited circumstances. If there is a injury/illness, or sign/symptom then use the more specified injury/illness, or sign/symptom code. Do not use Z03.7 code for encounters for antenatal screening of moms. Use additional diagnosis codes only if unrelated to the suspected condition. 29

30 7) Aftercare Multiple aftercare codes. Aftercare These Z codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during healing/recovery, or for long term consequence of disease. Do Not Use for aftercare of acute injury/illness. Code categories; Z42 Z49, Z51 Multiple Z51 codes can be used together should a patient receive multiple antineoplastic therapies during the same encounter. 30

31 8) Follow-up Multiple follow-up codes. Follow-up Z08- Follow-up exam after completed treatment of malignant neoplasm. Z09- Follow-up exam after completed treatment of condition (other than malignant neoplasm). Z39- Follow-up exam for maternal postpartum care. These Z codes are used to explain continuing surveillance following completed treatment of a disease, condition or injury. 31

32 9) Donor Z52 Donor Donor These Z codes are used for donors of organs/tissue by living individual who are donating organs/tissue to others (not for self-donation). Do Not Use for Cadaver donations. 32

33 10) Counseling Multiple counseling codes. Counseling These Z codes are used when a patient or family member receives assistance in the aftermath of an illness/injury or when support is required in coping with family/social problems. Code Categories; Z30.0-, Z31.5-Z31.6-, Z32.2, Z32.3, Z69-Z71, Z76.81 Do not use in conjunction with a diagnosis code when the counseling component of care is considered integral to the standard treatment. 33

34 11) Encounter for OB & Reproductive Services Multiple OB & Reproductive Services codes. OB & Reproductive Services These Z codes are used in those circumstances when none of the problems/complications included in codes from OB chapter exist (e.g. Encounter for normal pregnancy). Code Categories; Z30-Z34, Z36, Z3A, Z37, Z39, Z76.81 See Section I.C.15, Pregnancy, Childbirth, and the Puerperium, for further instruction on the use of these codes. 34

35 12) Newborns and Infants Newborns & Infants Multiple newborn & infants codes. Z76.1- Encounter for supervision and care of foundling. Z00.1- Encounter for routine child health examination. Z38- Live born infants according to place of birth and type of delivery. See Section I.C.16, Newborn (Perinatal) Guidelines, for further instruction on the use of these codes. 35

36 13) Routine and Administrative Exams Routine & Administrative Exams Multiple Routine & Admin. Exam codes These Z codes allow for the description of encounters for routine exams, such as, general check-up, or an exam for administrative purposes, such as, pre-employment physical. Code Categories; Z00 Z02, Z32.0 Do Not Use if there is a diagnosis, if a condition is suspected, or for treatment purpose. Pre-operative exam and pre-procedure laboratory exams Z codes are for use only in those situations when patient is being cleared for a procedure/surgery and NO treatment is given. 36

37 14) Miscellaneous Z codes Miscellaneous Z codes Multiple miscellaneous codes. These Z codes capture a number of other health care encounters that do not fall into other categories. Use them with additional codes to provide useful information on circumstances that may affect a patient s care or treatment. 37

38 14) Miscellaneous Z Codes Z28 Immunization not carried out Z40 Prophylactic surgery Z41 Procedures other than remedying health Z53 Procedures and treatment not carried out Z55 Related to education and literacy Z56 Related to employment and unemployment Z57 Occupational exposure to risk factor Z58 Related to physical environment. Z59 Related to housing and economic circumstances Z60 Related to social environment Z62 Related to Upbringing Z63 Related to primary support group Z64 Related to certain psychosocial circumstances Z65 Related to other psychosocial circumstances Z72 Related to lifestyle Z73 Related to life management difficulty Z74 Related to care provider dependency Z75 Related to medical facilities, other healthcare Z76.0 Issues of repeated Rx Z76.3 Accompany sick person Z76.4 Boarder to healthcare facility Z76.5 Malingerer Z91.1- Noncompliance with medical treatment Z91.83 Wandering in disease classified elsewhere Z91.89 Other personal risk factors, NEC 38

39 15) Nonspecific Z codes Nonspecific Z codes Multiple nonspecific codes. These Z codes are so nonspecific, and/or redundant there can be little justification for their use in the inpatient setting. For the outpatient setting, they should be used in those instance when there is no further documentation to permit a more precise code. If there is a sign or symptom or other reason for the visit and it can be captured by another code, by all means use the more SPECIFIC code. 39

40 15) Nonspecific Z codes Z02.9 administrative exam, unspecified Z04.9 exam and observation, unspecified reason Z13.9 screening, unspecified Z41.9 encounter for procedure, for purpose other than remedying health state, unspecified Z52.9 donor of unspecified organ/tissue Z86.59 personal hx. Of mental & behavioral disorders Z88.9 Allergy status, to unspec. drug, etc. substance status Z92.0 personal history of contraception 40

41 16) First-listed diagnosis Guideline I.C.21.c.16. First-listed diagnosis Z codes that may only be first-listed diagnosis. See slide

42 Polling Question 2 Do you have a clinical documentation improvement program? If yes, which healthcare providers are included? a) Physicians b) Non-physician Practitioners (NPP) c) Both Physicians & NPP d) My physician practice does not have a CDI program 42 42

43 Case Examples 43

44 Case Example #1 Patient with middle lobe lung cancer admitted for initiation of chemotherapy What is the correct diagnosis code(s)? Z51.11 Encounter for antineoplastic chemotherapy C34.2 Malignant neoplasm of middle lobe, bronchus or lung Explanation: A Z code can be used as first listed in this situation based on the guideline I. C. 21.a-Use of Z codes and I.C.21.c.16-First-listed diagnosis. See chapter 2 for Neoplasm coding guidelines. 44

45 Case Example #2 Patient has chronic lymphocytic leukemia for which the patient had previous chemotherapy and is now in remission. What is the correct diagnosis code? C91.11 Chronic lymphocytic leukemia of B-cell type in remission Z92.21 Personal history of antineoplastic chemotherapy Explanation: The personal history Z code is used to describe a secondary diagnosis to identify that this patient has had chemotherapy in the past. Guideline I. C. 21. c. 4.-History of. 45

46 Case Example #3 Prostate screening for healthy 50 year old male patient; PSA noted to be elevated but normal digital rectal exam. What is the correct diagnosis code(s)? Z12.5 Encounter for screening for malignant neoplasm of prostate R97.2 Elevated prostate specific antigen (PSA) Explanation: the patient had no signs or symptoms of any prostate-related illness prior to coming in for the screening. The screening code is appropriately used as the first-listed code to signify that this was for a routine screening. The elevated PSA is reported as a secondary diagnosis to reflect that an abnormal lab value was found as a result of the screening procedure(s). Guideline I.C.21.c.5.-Screening. 46

47 Case Example #4 Follow-up for patient several months after completing a regime of IV antibiotics for recurrent pneumonia; lungs are clear and pneumonia is resolved. What is the correct diagnosis code(s)? Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z87.01 Personal history of pneumonia (recurrent) Explanation: Code Z09 identifies the follow-up visit as being unrelated to a malignant neoplasm, and code Z87 describes the condition that now has resolved. Guideline I.C.21.c.8-Follow-up. 47

48 Case Example #5 The patient is seen several months after completing a regime of IV antibiotics for recurrent pneumonia; pneumonia has reoccurred, and a new antibiotic regimen has been prescribed. What is the correct diagnosis code? J18.9 Pneumonia, unspecified organism Explanation Since the follow-up exam for pneumonia determined that the pneumonia was not resolved and had reoccurred, code Z09 no longer applies. Instead the first-listed code describes the pneumonia, or the result of the evaluation at the current encounter. 48

49 Case Example #6 12 month old boy comes in for well child visit; Pediatrician notices some eczema on the child s scalp and back of knees. What is the correct diagnosis code? Z Encounter for routine child health examination with abnormal findings L30.9 Dermatitis, unspecified Explanation: The Z code identifying that this is a routine well child visit is reported first. Because an abnormal finding (eczema) was documented, a code for this condition may also be appended. Guideline I.C.21.c.13- Routine and administrative examinations. 49

50 Case Example #7 Female patient seen at 32 weeks gestation to check the progress of her first pregnancy. What is the correct diagnosis code? Z34.03 Encounter for supervision of normal first pregnancy, third trimester Z3A weeks gestation of pregnancy Explanation: Category Z34 is appropriate as the first-listed diagnosis, routine or normal prenatal care. Category Z3A helps to clarify at which point in the pregnancy the patient was provided care or supervision. Guideline I.C.21.c.11-Encounters for OB and reproductive services. 50

51 Case Example #8 Patient who is HIV positive but does not have any symptoms. correct diagnosis code? What is the Z21 Asymptomatic human immunodeficiency virus (HIV) infection status Explanation: A status code is not a history code, a history code indicates that the patient no longer has the condition. Guideline I.C.21.c.3-Status. 51

52 References 2015 ICD-10-CM Coding Guidelines DeVault, K., Barta, A., & Endicott, M. (2014). ICD-10- CM Coder Training Manual. Chicago, IL: AHIMA ICD-10-CM The Complete Official Draft Code Set, 2015 Optum Book 52

53 Polling Question 3 What are your current feelings towards ICD-10-CM implementation? a. I am ready and willing. b. Oh no, it s here already. c. I truly thought they would delay it

54 Transition Steps Several officials such as Sue Bowman from the American Health Information Management Association and Nelly Leon-Chisen from the American Hospital Association, offered the following transition steps: -If claim is submitted after Oct. 1 for date of service in September, use ICD-9 codes; -No claim can contain both ICD-9 and 10 codes; -There is no dual code reporting; -Determination of which code set to use is driven by date of service, not billing date; -The date of service is the date of discharge; or date of service (face to face) for physicians -Claims for dates of service on and after October 1, 2015 must be coded in ICD-10; -Claims for dates of service prior to October 1, must be coded in ICD-9; -Any claims for dates of service after October 1, that contain ICD-9 codes will be rejected; -The process for determining the correct code is same as ICD-9: Look up the diagnostic term in Alphabetic Index, then verify the code number in Tabular List; -To be valid, ICD-10-CM diagnosis codes must be coded to the full number of characters required for that code; While documentation supporting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use when documentation doesn't support a higher level of specificity; When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code; It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing to determine a more specific code. 54

55 CMMS - Ombudsman William Rogers, MD, Director of the Physicians Regulatory Issues Team at the Centers for Medicare and Medicaid Services, will act as ICD-10 ombudsman Rogers can be reached at ICD10_ombudsman@CMS.HHS.gov. The Medicare Ombudsman helps you with Medicare-related complaints, grievances, and information requests. 55

56 ICD-10-CM ICD-10-CM Implementation date is October 1, Click on the Link below to access FREE downloads of the 2016 ICD-10-CM/PCS files: GEMs.html 56

57 CMS Claims submission ICD-10-CM Implementation date is October 1, Click on the link below to see latest article from CMS for Claim Submission Alternatives: MLN/MLNMattersArticles/Downloads/SE1522.pdf 57

58 I leave you with W58.03XA DO NOT let yourself feel like you are being Crushed by an Alligator 58

59 Questions? 59

60 For More Information Rosie Donovan, RHIA, CCS-P G2N, Inc