ICD-10 Diagnostic Coding for. Breast Reconstruction

Transcription

1 ICD-10 Diagnostic Coding for Webinar Hosted by: Breast Reconstruction December 5, 2013 Presented by: Kim Pollock, RN, MBA, CPC

2 Meet Kim Pollock RN, MBA, CPC Kim Pollock, RN, MBA, CPCspecializes in streamlining the operations of physician practices. For over fifteen years, Ms. Pollock has helped large group practices, as well as academic and solo practices, improve collections and efficiency. She teaches the coding courses for the American Society of Plastic Surgeons and is a nationally recognized expert in plastic surgery coding and documentation. Ms. Pollock is recognized across the country for her understanding of physician coding and reimbursement both from a clinical perspective and from a payor side. She is an expert in analyzing payments and denials and in reengineering practices for revenue cycle enhancement. 3

3 Webinar Policy Webinars are the property of KarenZupko& Associates, Inc. and are for personal use only. They may not be rebroadcast, retransmitted, shared, or disseminated without permission from KZA. 4

4 Learning Objectives 1. Chart a course for initiating an ICD-10-CM assessment in your practice. 2. Measure the impact of ICD-10-CM on your breast reconstruction practice by reviewing your current diagnosis coding data. 3. Analyze how current diagnosis coding translates to the new ICD-10-CM system. 4. Sharpen your understanding of how to use diagnosis codes for common breast reconstruction procedures including symmetry procedures. 5

5 What s ICD-10? International Classification of Diseases, 10 th Revision, Clinical Modification We are currently using ICD-9-CM. Codes are used to calculate MS-DRG payments. Compile statistics Already being used in 138 countries for mortality reporting, 99 countries for morbidity. US implemented for mortality on 1/1/99. Other countries use ICD-10 for reimbursement or case mix: UK, Denmark, Finland, Iceland, Norway, Sweden, France, Australia, Belgium, Germany, Canada. 6

6 Why Are We Changing? ICD-9 is out of date and running out of space for new codes. ICD-10 is the international standard to report and monitor disease and mortality USA must adopt for reporting and surveillance. ICD codes are core elements of many health information technology systems making the conversion to ICD-10-CM necessary to fully realize benefits of HIT adoption. 7

7 October st 1, 2014 Have you started planning for implementation? 8

8 I m late! I m late! Source: 9

9 ICD-10-CM Action Agenda December 2013 Assign due dates, deliverables and responsibilities now! January 2014 February

10 ICD CM Action Agenda 1. Inventory your practice Who uses diagnosis codes to perform their job functions? What documents need to be updated? Who will need ICD-10 education and at what level? 11

11 ICD-10-CM Action Agenda 2. Run an ICD-9-CM frequency report Top Most Used ICD-9-CM Codes Diagnosis Diagnosis Description Volume V51.0 Encounter for breast recon after mast 237 V45.71 Acquired absence of breast/nipple 202 V10.3 Personal history, breast cancer Deformity of reconstructed breast Breast cancer, central portion Disproportion of reconstructed breast 13 V16.3 Family history, breast cancer 7 V84.01 Genetic suseptibility breast cancer 4 12

12 Not every code is created equal. $ $ $ 13

13 Initial Steps to Implementation 3. Perform Gap Analysis Will current documentation support ICD-10-CM code assignment? Where does documentation improvement education need to be focused and who needs it the most? 14

14 ICD-10-CM Action Agenda 3. Gap Analysis: Compare ICD-9-CM to ICD-10-CM ICD-9-CM V45.71 Acquired absence of breast and nipple ICD-10-CM Z90.10 Acquired absence of unspecified breast and nipple Z90.11 Acquired absence of right breast and nipple Z90.12 Acquired absence of left breast and nipple Z90.13 Acquired absence of bilateral breasts and nipples 15

15 ICD-10-CM Action Agenda 4. Try Bilingual Coding ICD-9-CM ICD-10-CM 16

16 ICD-10-CM Action Agenda 17

17 Source:

18 CR 8348 instructs that all ICD-10 LCDs and associated ICD-10 articles will be published on the Medicare Coverage Database (MCD) no later than April 10, All other LCDs and articles (i.e., those LCDs and articles that do not contain ICD-10 information, or articles not attached to an LCD) will be published on the MCD no later than September 4, Source:

19 Source: 20

20 Anthem Policy: Breast Reconstruction Approved ICD-9-CM vs ICD-10-CM Codes 21

21 Queen Latifah Bilateral breast reduction or Source: 22

22 Anthem Policy: Breast Reduction Source: 23

23 ICD-9-CM vs ICD-10-CM Codes Covered Diagnoses Note: N64.81 excludes ptosis of native breast in relation to reconstructed breast (use N65.1). 24

24 6. Use the New Claim Form January 6, 2014 Payers begin processing January 6 March 31 Dual period April 1 Medicare will reject the old form 25

25 New Form Can Accept More Diagnosis Codes! 26

26 ICD-9-CM vs. ICD-10-CM 3-5 characters in length 3-7 characters in length 1st digit may be alpha; 2nd- 5th is numeric Character 1 is alpha; characters 2 & 3 are numeric; characters 4-6 can be either alpha or numeric Approximately 14,000 codes Approximately 69,000 codes Limited space for adding new codes Lacks detail Flexibility for adding new codes Very specific

27 ICD-9-CM cont. vs. ICD-10-CM cont. Lacks laterality Has laterality Difficult to analyze data due to non specific codes Codes are non-specific and do not adequately define diagnosis needed for medical research Does not support interoperability and not used by most other countries Specificity improves coding accuracy and richness of data for analysis Detail improves the accuracy of data used for medical research Supports interoperability and the exchange of health data between other countries & the U.S.

28 Code Structure and Format ICD-9-CM ICD-10-CM 29

29 Steps to Correct ICD-10-CM Coding 1. Review the Conventions and General Coding Guidelines sections of the guidelines. 2. Look up the main term and applicable subtermsin the Alphabetic Index and. Be careful some entries appear in the next column or on the next page! 3. Note all parenthetical terms that may help in code selection. 30

30 Steps to Correct ICD-10-CM Coding 4. Look carefully at the instructions: see, see also, and see category cross-references with / without notes omit code notes, due to subterms Other instructions found in note boxes, such as code by site 5. Find the code in the Tabular List and verify accuracy. Do not code just from Alphabetic List. 31

31 Steps to Correct ICD-10-CM Coding 6. Read all instructional material including: includes and excludes notes use additional code and code first underlying disease instructions code also more than one code may be required and represents and/or Fourth-, fifth-, and sixth-digit requirements and seventh-digit extension requirements 7. Confirm and assign the correct code. 32

32 ICD-10-CM Resources The book CMS Your EHR /practice management information system Proprietary mapping tools Sources:

33 GEMS 34

34 Example: Robust Mapping Software 35

35 ICD-10-CM Coding Conventions Other codes: use when the information in the medical record provides detail for which a specific code does not exist. Unspecified codes: Use when the information in the medical record is insufficient to assign a more specific code. 36

36 ICD-10-CM Coding Conventions Certain ICD-10-CM categories have applicable 7 th characters. The applicable 7 th character is required for all codes within the category, or as the notes in the Tabular List instruct. If a code requires a 7 th character and is not 6 characters in length, a placeholder x must be used to fill in the empty characters. 37

37 7 th Character Example T Leakage of breast prosthesis and implant T85.43xA T85.43xD T85.43xS initial encounter subsequent encounter sequela 38

38 What is a Sequela? ICD-10-CM Says about Late Effects (Sequela): The residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. 39

39 What is a Sequela? ICD-10-CM Says about Late Effects (Sequela): Example: A patient returns to see you ten years after breast reconstruction with a prosthesis and the implant is leaking. Codes: 1. N65.0 Deformity of reconstructed breast 2. T85.43xS Leakage of breast prosthesis and implant 40

40 General Coding Guidelines Laterality: Thefinal character of the code indicates laterality for bilateral sites. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. ICD-10-CM Z90.10 Acquired absence of unspecified breast and nipple Z90.11 Acquired absence of right breast and nipple Z90.12 Acquired absence of left breast and nipple Z90.13 Acquired absence of bilateral breasts and nipples Unspecified: The medical record is insufficient to assign a more specific code. 41

41 Breast Reconstruction Specific ICD-10-CM Coding 42

42 Using a Breast Cancer Diagnosis Code What disease are you treating? Use breast cancer diagnosis code for office visits premastectomy/resection. May also use as a secondary diagnosis for immediate reconstruction at same operative session as mastectomy. 43

43 Breast Cancer Diagnosis Codes Need to know: Area on breast nipple/areola, central, upper-inner quadrant, lower-inner quadrant, upper-outer quadrant, lower-outer quadrant, axillary tail, overlapping sites, unspecified site Sex of patient female (ICD-9-CM = 174.x, ICD-10-CM = C50.- 1), male (ICD-9-CM = 175.x, ICD-10-CM = C50.-2) Laterality right, left, unspecified 44

44 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, nipple and areola ICD-10-CM C Malignant neoplasm of nipple and areola, right female breast C Malignant neoplasm of nipple and areola, left female breast C Malignant neoplasm of nipple and areola, unspecified female breast 45

45 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, central portion ICD-10-CM C Malignant neoplasm of central portion of right female breast C Malignant neoplasm of central portion of left female breast C Malignant neoplasm of central portion of unspecified female breast 46

46 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, upper-inner quadrant ICD-10-CM C Malignant neoplasm of upper-inner quadrant of right female breast C Malignant neoplasm of upper-inner quadrant of left female breast C Malignant neoplasm of upper-inner quadrant of unspecified female breast 47

47 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, lower-inner quadrant ICD-10-CM C Malignant neoplasm of lower-inner quadrant of right female breast C Malignant neoplasm of lower-inner quadrant of left female breast C Malignant neoplasm of lower-inner quadrant of unspecified female breast 48

48 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, upper-outer quadrant ICD-10-CM C Malignant neoplasm of upper-outer quadrant of right female breast C Malignant neoplasm of upper-outer quadrant of left female breast C Malignant neoplasm of upper-outer quadrant of unspecified female breast 49

49 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, lower-outer quadrant ICD-10-CM C Malignant neoplasm of lower-outer quadrant of right female breast C Malignant neoplasm of lower-outer quadrant of left female breast C Malignant neoplasm of lower-outer quadrant of unspecified female breast 50

50 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, axillary tail ICD-10-CM C Malignant neoplasm of axillary tail of right female breast C Malignant neoplasm of axillary tail of left female breast C Malignant neoplasm of axillary tail of unspecified female breast 51

51 Breast Cancer Diagnosis Codes ICD-9-CM Other specified sites of female breast Ectopic sites Inner breast Lower breast Midline of breast Outer breast Upper breast Malignant neoplasm of contiguous or overlapping sites of breast whose point of origin cannot be determined ICD-10-CM C Malignant neoplasm of overlapping sites of right female breast C Malignant neoplasm of overlapping sites of left female breast C Malignant neoplasm of overlapping sites of unspecified female breast 52

52 Breast Cancer Diagnosis Codes ICD-9-CM Malignant neoplasm of female breast, unspecified ICD-10-CM C Malignant neoplasm of unspecified site of right female breast C Malignant neoplasm of unspecified site of left female breast C Malignant neoplasm of unspecified site of unspecified female breast 53

53 Post-Mastectomy Diagnosis Codes ICD-9-CM V45.71 Acquired absence of breast and nipple ICD-10-CM Z90.10 Acquired absence of unspecified breast and nipple Z90.11 Acquired absence of right breast and nipple Z90.12 Acquired absence of left breast and nipple Z90.13 Acquired absence of bilateral breasts and nipples 54

54 Post-Mastectomy Diagnosis Codes ICD-9-CM V10.3 Personal history of malignant neoplasm, breast ICD-10-CM Z85.3 Personal history of malignant neoplasm of breast Use when you are not treating the cancer 55

55 Other Diagnosis Codes ICD-9-CM V84.01 Genetic susceptibility to malignant neoplasm of breast ICD-10-CM Z15.01 Genetic susceptibility to malignant neoplasm of breast Code first, if applicable, any current malignant neoplasm (C00- C75, C81-C96). Use additional code, if applicable, for any personal history of malignant neoplasm (Z85-). 56

56 Other Diagnosis Codes ICD-9-CM Diagnosis Description ICD-10-CM Diagnosis Description V51.0 Aftercare involving the use of plastic surgery, Plastic surgery following healed injury or operation, Encounter for breast reconstruction after mastectomy Z42.1 Encounter for plastic and reconstructive surgery following medical procedure or healed injury, Encounter for breast reconstruction following mastectomy Codes is intended for use to indicate a reason for care. It may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state. Examples include: 1) tissue expander exchange to permanent implant, 2) revision of reconstructed breast, 3) nipple/areola reconstruction, 4) post-op reconstruction visits. Do not use for immediate reconstruction procedures. 57

57 Angelina Jolie Stage 1: Immediate bilateral breast reconstruction with tissue expanders after bilateral prophylactic mastectomies. CPT Codes/Modifiers Bundled Format Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Source: 58

58 Angelina Jolie ICD-9-CM V45.71 Acquired absence of breast and nipple V84.01 Genetic susceptibility to malignant neoplasm of breast ICD-10-CM Z90.13 Acquired absence of bilateral breasts and nipples Z15.01 Genetic susceptibility to malignant neoplasm of breast Source: 59

59 Claim Format for Use of Modifier 50 Payor Preference Claim Form Format Bundled Format Line-Item Format Placement of Code and Modifier Number of Units One line (though some payors may want 2) Two lines Billed Fee Double your unilateral fee Use your unilateral fee Expected Payment 150% of allowable 100% for first code 50% for second code 1 60

60 Angelina Jolie What if stage 1 was: Bilateral immediate breast reconstruction with tissue expanders with placement of biologic material CPT Codes/Modifiers Bundled Format Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code for primary procedure) Source: 61

61 Angelina Jolie CPT Codes/Modifiers Line-Item Format Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion (as above) Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code for primary procedure) (as above) Source: 62

62 Christina Applegate Bilateral mastectomy for early stage breast cancer in one breast and a prophylactic mastectomy due to being a carrier of the BRCA1 gene mutation with immediate breast reconstruction. Source: 63

63 Reconstruction Diagnosis Codes ICD-10-CM Z90.13 Acquired absence of bilateral breasts and nipples Z85.3 Personal history of malignant neoplasm of breast (note no laterality required) Z15.01 Genetic susceptibility to malignant neoplasm of breast (note no laterality required) Source: 64

64 Giuliana Rancic Assume immediate bilateral breast reconstruction with placement of permanent prostheses after mastectomies for cancer. CPT ICD-9-CM ICD-10-CM Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction V45.71 Acquired absence of breast and nipple V10.3 Personal history of malignant neoplasm, breast Z90.13 Acquired absence of bilateral breasts and nipples Z85.3 Personal history of malignant neoplasm of breast 65

65 Other Commonly Used Codes ICD-9-CM Description Deformity of reconstructed breast, Contour irregularity in reconstructed breast, Excess tissue in reconstructed breast, Misshapen reconstructed breast Disproportion of reconstructed breast, Breast asymmetry between native breast and reconstructed breast, Disproportion between native breast and reconstructed breast ICD-10-CM N65.0 N

66 Sharon Osbourne Assume bilateral revision of reconstructed breasts ( ) and bilateral nipple/areola reconstruction ( ). ICD-9-CM Description ICD-10-CM V50.1 Encounter for plastic and reconstructive surgery following mastectomy Z42.1 V45.71 Acquired absence of breast and nipple Z90.13 bilateral Deformity of reconstructed breast, Contour irregularity in reconstructed breast, Excess tissue in reconstructed breast, Misshapen reconstructed breast N65.0 V10.3 Personal history malignant neoplasm, breast Z85.3 Source: commons.wikimeida.org 67

67 Jewel Assume right immediate breast reconstruction and placement of permanent prosthesis after mastectomy for cancer and left breast mastopexy for symmetry. Codes Right Left CPT ICD-9-CM V45.71 V10.3 ICD-10-CM Z90.11 right Z85.3 V Z85.3 N65.1 Source: 68

68 Be Prepared for ICD-10-CM: Don t Pull a Scarlett I ll think about it tomorrow. Source: 69

69 Questions? 70

70 Thank You! Kim Pollock,RN, MBA, CPC 71