1. ICD-10-CM, SKILLED NURSING FACILITIES, AND LAB SERVICES

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1 1. ICD-10-CM, SKILLED NURSING FACILITIES, AND LAB SERVICES 1.1 ICD-10-CM, SKILLED NURSING FACILITIES, AND LAB SERVICES Welcome to the ICD-10-CM, Skilled Nursing Facilities, and Lab Services training. Please take a moment to adjust the audio volume on your device. Audio is strongly recommended, but not required. Closed captioning will appear to the left of the screen throughout the majority of the course. When you are ready to begin, please click "Get Started!"

2 1.2 COURSE AGENDA Welcome to the course agenda. Click on the link for Lesson One to enter the course content. Each time you complete a lesson, you will be directed back to this page. Just click on the next lesson. Once you have completed all six lessons, you will be able to exit the course.

3 2. LESSON ONE 2.1 LESSON 1: INTRODUCTION

4 2.2 COURSE OBJECTIVES Once you have completed this course, you should understand the role of ICD-10-CM in Skilled Nursing Facilities, recognize the importance of documentation, understand Medicare requirements, and identify the documentation requirements for ICD-10-CM.

5 2.3 SKILLED NURSING FACILITY CHALLENGES A challenge skilled nursing facilities encounter when providing services is ensuring all diagnoses and services are documented appropriately. This documentation, including diagnoses, is not optional. Without the required documentation, there can be financial and regulatory compliance consequences.

6 3. LESSON TWO 3.1 LESSON 2: ICD-10-CM IN SKILLED NURSING FACILITIES

7 3.2 SKILLED NURSING FACILITY DOCUMENTATION Documentation must include detailed records proving the level of care provided by the skilled nursing facility is necessary. ICD-10-CM requires detailed patient diagnostic and assessment information.

8 3.3 DOCUMENTATION KNOWLEDGE In this course, we will discuss the reasons why ICD-10-CM requires a deeper and more complete knowledge of anatomy and physiology. ICD-10-CM codes are more logical, specific, and provide a better clinical picture. With ICD-10 codes, the amount of information required from the physician increases dramatically.

9 4. LESSON THREE 4.1 LESSON 3: DOCUMENTATION

10 4.2 DOCUMENTATION PURPOSES Documentation provided regarding a patient encounter is very important as it affects data entry of diagnostic orders and Current Procedural Terminology (CPT) equivalents of tests provided. This is critical for quality of care and reimbursement for all providers. Orders, Medical Necessity, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Advanced Beneficiary Notices of Non-Coverage (ABNs) are intertwined with ICD-10.

11 4.3 PHYSICIAN ORDERS Lab services must be ordered by physicians. They may be ordered in one of three ways: written document, electronic transmission, or by telephone.

12 4.4 PHYSICIAN ORDERS For a physician order to be valid, it must include a diagnosis and adequate information for the type of test needed. If these requirements are not met, the lab must hold the order until a compliant reason for the test is submitted by the physician.

13 4.5 PHYSICIAN ORDERS A missing diagnosis (proof of medical necessity) may cause care to be delayed or could result in inappropriate care. Claims may result in rejection, payment denial, or payment reduction.

14 4.6 DOCUMENTATION ADEQUACY A current issue with ICD-9 is inadequate documentation. The new challenge with ICD- 10 is the increased specificity needed for accurate coding. Changes will require providers to document new information as well as expand on information currently captured. ICD-10 takes health care to a higher level of standardization in communication to improve quality of care and accuracy of services provided.

15 4.7 MEDICAL NECESSITY Many times the diagnosis or reason for the service is missing from lab orders. Medical necessity is critical to insurer coverage and payment. Without necessary clinical documentation to prove medical necessity, claims are often denied and compliance concerns occur.

16 5. LESSON FOUR 5.1 LESSON 4: MEDICARE

17 5.2 NCDS & LCDS Insurers have documents that outline their coverage requirements and medical necessity criteria. For Medicare, the documents are National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Review this page to identify the differences in the two document types.

18 5.3 MEDICARE COVERAGE DATABASE The Centers for Medicare and Medicaid Services (CMS) is the government agency which oversees Medicare. You can find all of Medicare's NCDs and LCDs housed in the Medicare Coverage Database. You may access this database by clicking on the 'Welcome to Medicare Coverage Database' banner on this page. Link:

19 5.4 LOCAL COVERAGE DETERMINATION Medicare Administrative Contractors (MACs) process claims for Medicare. Therefore, MACs use NCDs and LCDs when determining coverage for a claim. You can see an example of a Local Coverage Determination for a Prostate Specific Antigen (PSA) test on this page.

20 5.5 ADVANCED BENEFICIARY NOTICE If a service is not expected to be paid through Medicare as it is not likely to be deemed a medically necessary procedure, the provider must present an Advanced Beneficiary Notice of Non-Coverage (ABN). This allows the beneficiary to make an educated decision regarding his or her healthcare keeping in mind he or she may be responsible for the full cost of the procedure.

21 5.6 ADVANCED BENEFICIARY NOTICE There are specific guidelines that must be followed when issuing ABNs. Look over this page to become more familiar with these guidelines. You will have the opportunity to explore the Advanced Beneficiary Notice of Non-coverage on the next page.

22 5.7 ADVANCED BENEFICIARY NOTICE

23

24 Take some time to review the ABN form on this page.

25 5.8 ICD-10 and ABNS It is expected that with the introduction of ICD-10-CM, the use of Advanced Beneficiary Notices will increase.

26 6. LESSON FIVE 6.1 Lesson 5: ICD-10-CM

27 6.2 WHY IS ICD-10-CM DIFFERENT? A brief history lesson on the International Classification of Diseases (ICD) before we get started reviewing the changes for ICD-10. ICD-9-CM was written in As you are aware, health care and technology have both advanced greatly since then. Unfortunately, ICD-9 was not created with these things in mind. ICD-10-CM, on the other hand, takes into account that both health care and technology are always changing.

28 6.3 ICD-9-CM VERSUS ICD-10-CM Here you can see a side by side comparison of ICD-9 and ICD-10 for the same condition, gout.

29 6.4 ICD-9-CM VERSUS ICD-10-CM Here is another comparison which details the information ICD-10-CM provides and is required.

30 6.5 AXIS OF CLASSIFICATION ICD-10-CM is a multiaxial system, meaning there are multiple components that comprise the code. The main axis is anatomy. Other axes include etiology, disease site, type of disease, and morphology.

31 6.6 EXAMPLES OF THE AXES Many diseases are organized based on multiple axes. You can review some examples of these diseases on this page.

32 6.7 SEVEN-CHARACTER CODES ICD-10 codes can be up to seven characters in length. The initial three character codes work the same as ICD-9. In a few cases, these three characters are enough. Usually, they are considered category codes which lead to the need for 4th, 5th, 6th, and sometimes 7th characters. You can review the codes for an acute embolism and thrombosis of deep veins of the lower extremities to see how these codes work.

33 6.8 SEVEN-CHARACTER CODES Beginning with the fourth character in ICD-10 codes, subcategories are added. These define the axis of classification by describing granular details, such as site, etiology, and the treatment level for the disease. Each subcategory requires specific documentation regarding the disease process to support the corresponding character. Review this slide to become more familiar with the 5 th, 6 th, and 7 th characters of ICD-10 codes before you move on to the next page to review a detailed example.

34 6.9 SEVEN-CHARACTER CODES Review this chart to see how the 5 th, 6 th, and 7 th characters add details to the ICD code.

35 6.10 LATERALITY Laterality within ICD-10 allows the health care provider to identify which side or sides are affected. Not all conditions that could encompass a left, right, or bilateral site will require laterality to be identified. Conditions that will require laterality include fractures, burns, neoplasms, and pressure ulcers. Using unspecified codes may result in claims pending or even being rejected.

36 6.11 LATERALITY Review this chart and the use of laterality in the ICD-10 coding.

37 6.12 SITE The anatomical site is required when documenting for ICD-10 as it provides optimal support of disease severity, medical necessity, and diagnostic options.

38 6.13 SITE Review these examples in which the anatomical site is crucial for laboratory orders.

39 6.14 TYPE The specific type of a patient's disease or manifestation has significant effect on treatment and supports medical necessity for the services provided. Using an unspecified code due to lacking documentation may eliminate the reporting of a diagnosis which qualifies as a complication or co-morbidity (CC) or major complication or co-morbidity (MCC). This has negative effects not only on data collection but also reimbursement.

40 6.15 TYPE Here is a comparison between ICD-9 and ICD-10. While the general terms may have been sufficient with ICD-9, ICD-10 will require the use of more specific terms. Review this page to identify and become more familiar with the specific terms listed for these conditions.

41 6.16 INCREASED SPECIFICITY Review these additional examples of changes within ICD-10.

42 6.17 SEVENTH-CHARACTER The seventh-character conveys level of care and severity. It helps expedite billing and provides a clearer picture of services and treatment provided. In the following code examples, notice the level of specificity and the documentation detail required for fractures, including the type of encounter, the type of fracture, the type of healing, and the fracture classification.

43 6.18 COMPLICATIONS Skilled nursing facilities often serve patients with postoperative complications. Coding guidelines for these complications has expanded and moved to support site-specific complications. ICD-10 codes make a distinction between intraoperative complications and post procedural disorders. Codes for complications of care can only be assigned when a provider clearly documents the relationship between the condition and the procedure.

44 6.19 COMPLICATIONS Provider documentation for complications of care must identify the relationship between the condition and the care or procedure. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Review this chart for examples of codes in ICD-10 for complications.

45 6.20 COMBINATION CODES With ICD-10 comes the addition of combination codes. These can represent two diagnoses that often occur together, a diagnosis with a commonly associated manifestation, a diagnosis with a commonly associated complication, or a diagnosis with a more accurate biomedical description and specificity.

46 6.21 COMBINATION CODES Review this page for examples of ICD-10 combination codes.

47 6.22 UNDERLYING AND ASSOCIATED CONDITIONS It is important to include information regarding common conditions associated with the effects of disease progression. Underlying and associated conditions often affect many body systems.

48 6.23 UNDERLYING AND ASSOCIATED CONDITIONS Review this slide for common diseases and their potential associated conditions.

49 7. LESSON SIX 7.1 LESSON 6: CONCLUSION

50 7.2 IN CONCLUSION We have reviewed the ICD-10-CM classification system. We have discovered the major ICD-10-CM documentation changes, and their impacts on the overall specificity required for SNF documentation. The specificity of this system supports improved quality of care, communication, and reimbursement accuracy. Many diseases have been expanded to include recent advances in diagnostics, treatments, and disease prognosis.

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