5/29/2014. Common diagnosis used in Family Practice. What documentation will be required to accurately code services
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1 Documentation for ICD-10 Robin Gulick, CPC Billing Compliance Manager University of Oklahoma- Tulsa Introduction- Common diagnosis used in Family Practice What documentation will be required to accurately code services Basic changes ICD9-CM 3-5 Characters Approx. 14,000 codes Limited space for new codes Lacks detail Difficult to analyse Non-spec / Doesn t adequately define dx Doesn t support interoperability ICD10-CM 3-7 Characters Over 70,000 codes Flexible for adding new codes Specificity improves accuracy/ analysis Detail improves data used in research Supports interoperability 1
2 Basic changes- Higher specificity More granularity (mild, moderate, severe) Laterality (LT, RT, Bilateral, Unspec) Anatomical location Manifestations/ ns/ complications Combination codes Cause Episode of care (Initial, Subsequent, Sequela) Coding Rules Official Guidelines for Coding and Reporting- Found in the front of your ICD- book Used by hospitals and for physician services Remain basically the same for ICD-10 NOS, NEC, Code Also, See Also, Excludes Alpha- numeric X- 7 th digit place holder Combination codes Hypertension: Benign- Malignant- Unspecified Will be coded as: I10 Unless the patient has Chronic Heart Ds, Chronic Kidney Ds, Heart and Kidney or Hypertensive Cerebrovascular Ds. The causal relationship must be stated with heart disease. It is assumed with kidney disease 2
3 Hypertension: Hypertensive Heart Disease With heart failure Code also Type of heart failure Hypertensive Heart Disease Without heart failure Example: I11.0 Hypertensive heart disease with heart failure Code also: I50.31Acute diastolic congestive heart failure Hypertension: Hypertensive Chronic Kidney Disease With Stage 5 or ESRD With Stage 1-4 or unspecified Code also Stage for CKD Example: I12.0 Hypertensive chronic kidney ds with stage 5 CKD or End stage renal ds Also code: N18.2 CKD, stage 2 Diabetes: Coding will be based on Type Body system affected Specific complication/ manifestation Controlled / Uncontrolled no longer apply With complications Without complications 3
4 Diabetes: Type Drug or chemical induced (E09) Due to an underlying condition (E08) Type 1 (E10) Type 11 (E11) Other specified DM (E13) Also will code insulin use (Z79.4) Combination codes Diabetes: Body system affected Circulatory Hyperosmolarity Kidney Neurological Ophthalmic Other- Arthropathy Dermatitis Hyperglycaemia Hypoglycaemia Oral Skin ulcer Unspecified Without Asthma: Documentation requirements are different Type- Mild (Intermittent or Persistent) Moderate Persistent Severe Persistent Other spec type (Exercise induced, Cough variant, Other) Identify complications Uncomplicated With acute exacerbation With status asthmaticus 4
5 Asthma: Symptoms Night-time awakening Rescue Inhaler Use Interference w/ Normal Activity Lung function Intermittent 2 or less days per week 2 X s per month or less 2 or less days per week None FEV1>80% predicted & normal between exacerbation Mild Persistent >2 days per week 3-4 X s per month > 2 days per week, not daily Minor limitations FEV1> 80% predicted Moderate Persistent Daily > Once per week / not nightly Daily Some limitations FEV % predicted Severe Persistent Throughout the day Nightly Several times per day Extremely limited FEV1 < 60% predicted Asthma: Code also- Exposure to environmental tobacco smoke Exposure to tobacco smoke in the perinatal period History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Example: J45.21Mild intermittent asthma with acute exacerbation Code also: Z77.22 Exposure to environmental tobacco smoke Routine examinations Identify by age Adult Child Newborn Under 8 days 8-28 days Identify if abnormalities found With abnormal findings Without abnormal findings Code also abnormal findings 5
6 Otitis Media First identify: Nonsuppurative, suppurative/ unspecified Then identify: Acute, chronic, unspecified Then identify: Left, Right, Bilateral, Unspecified Code also any associated perforation Code also exposure to tobacco Example: H Acute suppurative OM without spontaneous rupture of ear drum, right ear Pharyngitis/ Tonsillitis Location- Pharynx Tonsils Acute, Chronic, Acute recurrent Organism Streptococcus Other- specify (code this) Example: J0301Acute recurrent streptococcal tonsillitis Obesity vs Overweight Overweight= BMI 25.0 to 29.9 Obesity= BMI 30.0 and above Identify if patient is Overweight or Obese If Obese is it due to: Drug induced Due to excess calories Do they also have alveolar hypoventilation Code also BMI If drug induced- code adverse affect of drug 6
7 Cough: Symptom of cough (R05) If cough is manifestation of influenza (J11.1) Smokers Cough (J41.0) Tobacco use You will notice the hierarchy of coding in these codes and other similar diagnosis Use vs Abuse vs Dependence For tobacco use, the type must be specified Cigarettes, chewing tobacco, other product Also- uncomplicated or in remission Example: F Nicotine dependence, cigarettes, uncomplicated. Sinusitis: Acute (J32) vs Chronic (J01) Location- Maxillary Frontal Ethmoidal Sphenoidal Pansinusitis (New) Unspec Is it recurrent? You can now code this. Use additional code for organism if known Example: J01.01 Acute recurrent frontal sinusitis 7
8 Bronchitis and Bronchiolitis: Acute/ Subacute Bronchitis (J20-J21) Combination codes will be used to identity the organism Chronic Bronchitis (J40-J42) J Also code tobacco smoke exposure Acute Bronchiolitis Due to RSV Due to Human metapneumovirus Example: J21.0 Acute bronchiolitis due to RSV Back Pain: Radiculopathy (M54.1X) by locations Cervicalgia (M54.2) Sciatica (M54.3X) LT, RT, Unspecified Lumbago w/sciatica (M54.4X) LT, RT, Unspec Low back pain (M54.5) Example: M54.40 Lumbago with sciatica, right side Limb Pain Under ICD-9 pain in the leg, arm, finger, foot, or toe was coded as ICD-10 defines these codes by location and laterality (M79.6XX) 5 th digit will show- upper arm, forearm, hand/fingers, thigh, lower leg, foot/toes 6 th digit will show- RT, LT, Unspecified Example: M Pain in right lower leg Joint pain will be similar 8
9 Fractures: The largest percentage of change to ICD-10 comes from the musculoskeletal section. All of the following must be documented Cause Type of fracture Laterality Manifestations Anatomical location Episode of care Fractures Cause: Trauma Pathological Stress/ Fatigue Issues occurring due to placement of device, implant or graft Fractures Type- open vs closed Greenstick Spiral Comminuted Segmental Transverse Oblique Open- soft tissue involvement or contamination 9
10 Fractures Pathological must include the underlying cause: Osteoporosis Cysts Neoplasm Paget s Disease Osteomyelitis Osteonecrosis Laterality- LT, RT, Unspecified Fractures- Anatomical location Shaft Surgical neck Greater tuberosity Lesser tuberosity Supracondylar Intercondylar Epicondylar Medical condylar Transcondylar Fractures: Episode of Care Fractures: Episode of Care Initial Subsequent With routine healing With delayed healing With nonunion With malunion Sequela Sprains/ strains, dislocations will also have episode of care as 7 th digit Example: S59.221A Salter Harris Type II physeal fracture of lower end of radius, right arm, initial encounter for closed fracture 10
11 Anemia- Type and cause must be specified A coder can t report a specified code without physician specific documentation They can t go by the results of a test. Classified as: Deficiency Anemia Hemolytic anemia Aplastic/ bone marrow failure Acute post-hemorrhagic Due to radiation/ external agents Red cell aplasia Sideroblastic anemia Pregnancy- Supervision of normal, first trimester Code by trimester (Z34.0X) Supervision of other normal pregnancy Code by trimester (Z34.8X) Encounter nter for other normal preg, unspec Coe by trimester (Z34.9X) Conditions related to/ aggravated by pregnancy are coded from Ch.15 (OØØ- OØ9A) Also code gestational weeks (Z3A. ØX) Contraception Really hasn t changed much (Z30.XXX) Encounter for initial Rx of contraception 6 th digit- Pills, emergency, injectable, IUD Encounter for surveillance of contraception (Z30.4X) Pills-repeat Rx, injectable (Z30.43X) IUD- insertion, checking, removal, removal and reinsertion. 11
12 Vaccines: ICD-9 V02.61 Hep B V03.82 Pneumonia V04.81 Influenza V04.82 RSV V06.8 Combination V06.4 MMR ICD-10 Z23 Fever Is the same (R50. XX) Drug induced Also code Adverse effect Fever presenting with other conditions Post-procedural fever Post-vaccination fever Febrile non-hemolytic transfusion reaction Recommendations Review your charge ticket- build a crosswalk Review your documentation- Adit Audit your records Is it enough to code ICD-10 Build requirements in your templates Training 12
13 Resources AAFP- AAPC- AHIMA- CMS- index.html ICD10 monitor- Publishers like Optum, Contexo, PMI, and Coding Institute Contact Info Robin Gulick, CPC 13
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