Transition to ICD-10-CM HMSA Long Term Services and Supports August 12, 2015

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1 Transition to ICD-10-CM HMSA Long Term Services and Supports August 12, 2015 PRESENTED BY: ESSIE WHITE, CPC, COC, CGSC, CPC-I, CPMA 1

2 Disclaimer The information presented herein contains the views of the presenter and does not imply a formal endorsement or consultation engagement on the part of Healthcare Coding Consultants of Hawaii. Attendees are cautioned that information contained in this presentation is not a substitute for informed medical coding judgment. Healthcare Coding Consultants of Hawaii and the presenter disclaim all responsibility for any use made of such information. 2

3 Course Objectives Examine and familiarize yourself with the ICD-10-CM book Examine organizational changes to ICD-10 3

4 ICD-10 Transition: Five Phases 1. Engage and Educate Staff 2. Assess Current Readiness and Impact 3. Create a Timeline and Transition Plan 4. Implement your Transition Plan 5. Conduct Post Transition Analysis and Reporting 4

5 Documentation & Transition Documentation is the cornerstone for ICD-10 transition success Accurate documentation is the primary responsibility physicians and other clinical providers have in the move to ICD-10 Providers should focus on documentation elements and not the overwhelming number of new codes It s important to engage your referral sources in providing accurate clinical information to support medical necessity 5

6 Introduction ICD-10-CM OVERVIEW 6

7 ICD-10 Background Information Published by WHO in 1990 U.S. last industrialized nation to implement ICD-10 Two parts: ICD-10-CM and ICD-10-PCS ICD-10-CM - Diagnosis 3 7 alpha/numeric characters ICD-10-PCS Inpatient Procedure (only) 7 alpha/numeric characters for -PCS 7

8 Official Guidelines Developed by the Cooperating Parties: American Hospital Association (AHA) American Health Information management Association (AHIMA) Centers for Medicare and Medicaid Services (CMS) National Center for Health Statistics (NCHS) 8

9 Overall Coding Process is the Same! 1. Capture the required encounter documentation 2. Choose the correct code Alphabetic Index Tabular List Read instructional notations 9

10 ICD-9-CM and ICD-10-CM Differences ICD-9-CM diagnosis codes ICD-10-CM diagnosis codes 3-5 numeric digits in length 3-7 Alpha-Numeric characters in length First digit may be alpha (E or V) or numeric; Digits 2-5 are numeric Character one is alpha Character two is numeric Characters 3-7 are alpha or numeric Lacks detail Very specific Lacks laterality Has laterality Approximately 14,000 codes Approximately 69,000 available codes

11 ICD-10 Format ICD-10 codes are alpha numeric All letters of the alphabet except U V codes are now in the Z section E codes are now V,W,X,Y codes Second through seventh characters are a combination of letters and numbers O is not an 0... I is not a 1 11

12 ICD-10-CM vs. ICD-9 Code Structure ICD-10-CM Code Format ICD-9-CM Code Format Ex: Unspecified Hearing loss, right ear ICD-10 H91.91 ICD

13 Code Structure Most, but not all, categories are further subdivided into 4 or 5 character subcategories If a category is not further subdivided it is considered to be a valid code Fourth character 8 is used to indicate other specified Fourth character 9 is used to indicate unspecified 13

14 Compare Codes H54.41 Blindness right eye, normal vision left eye S42.311K Greenstick fracture of shaft of humerus, right arm, Subsequent encounter for fx with nonunion Blindness one eye Nonunion of Fracture T45.2X5A Adverse effect of vitamins, Initial encounter E933.5 Vitamins, not elsewhere classified, causing adverse effects in therapeutic use 14

15 NEW Placeholder Character Provides for future expansion as 5 th character for certain 6 character codes without disturbing the 6 th character structure Assign for all characters less than 6 in order to meet requirement of coding when 7 th character is required 15

16 Placeholder Character What is the use of the X placeholder in subcategory M84.40? M84.40XA - Placeholder in 6 th What is the use of the X placeholder(s) in category X78? X78.9XXA Placeholder in 5 th and 6 th 16

17 General Coding Guidelines No change in guidelines from ICD-9 Code to highest level of specificity Code signs and symptoms in the absence of a definitive diagnosis Do not code signs and symptoms that are an integral part of a disease process Code signs and symptoms that are not an integral part of a disease process 17

18 NEW Laterality Right Left Bilateral If no bilateral code is provided, code both right and left If the side is not indicated in the documentation, code unspecified 18

19 NEW Laterality H Swimmer s ear, left ear S63.511A Sprain of carpal joint of right wrist, initial encounter H65.06 Acute serous otitis media, recurrent, bilateral 19

20 NEW Laterality Right Left Neoplasm codes now include laterality as well as specific site If the side is not indicated in the documentation, code unspecified Examples: breast, ovary, cornea, lung, limb 20

21 Organization and Classification Diabetes and malnutrition have their own subchapters and code titles revised Diabetes now has five categories (E08 E13) NO E12 Controlled/uncontrolled is not a factor in code selection See index - Diabetes 21

22 Diabetes Mellitus Type of DM Combination codes include Body system affected Complications affecting that body system 22

23 Diabetes Mellitus Use as many codes as necessary to identify all of the associated conditions Type 2 DM is default if type is not documented Z79.4 Long term (current) use of insulin Use only with Type 2 DM as appropriate Do not use if insulin is given temporarily 23

24 Mental, Behavioral, and Neurodevelopmental Disorders (F01- F99) CHAPTER 5 24

25 Organization and Classification Unique codes for alcohol and drug use, abuse, and dependence Continuous or episodic no longer classified Combination codes 25

26 Pain Disorders F45.41 Pain exclusively related to psychological disorders F45.42 Pain disorders with related psychological factors + code from category G89 26

27 Remission Selection of codes for in remission for categories F10-F19 requires the provider s clinical judgment. The appropriate codes for in remission are assigned on the basis of provider documentation 27

28 Dementia Do not use category F02 Dementia in other diseases classified elsewhere as primary diagnosis Use category F01 if dementia is a result of cerebral infarction Use category F03 for unspecified Dementia Use category G30 for Alzheimer s 28

29 Dementia Symptoms common among people living with advanced dementia: Pain Agitation Nutritional concerns Infections Delirium 29

30 Mental Health Examples F70 Mild intellectual disabilities F71 Moderate intellectual disabilities F72 F73 F78 F79 Severe intellectual disabilities Profound intellectual disabilities Other intellectual disabilities Unspecified intellectual disabilities F80.1 Expressive language disorder F80.4 Speech and language development delay DUE to hearing loss 30

31 Diseases of the Nervous System (G00 G99) CHAPTER 6 31

32 Organization and Classification Sleep disorders have been moved from signs and symptoms (ICD-9) to nervous system Sleep apnea has its own subcategory with greater specificity to identify type Diseases of the sense organs are no longer contained in the same chapter as the nervous system 32

33 NEW Dominant v. Non-Dominant Document - Dominant/Non-dominant in addition to Left or Right If dominant side is not documented use the following default guidelines: For ambidextrous patients, the default should be dominant. If the left side is affected, the default is nondominant. If the right side is affected, the default is dominant. 33

34 Pain Category G89 May be used in conjunction with other codes to provide more detail Acute or Chronic Neoplasm-related Post procedural, Post-thoracotomy or Posttraumatic Do not use category G89 if pain is not specified as one of the above 34

35 Sequencing Pain Category G89 Primary Pain control/pain management is the reason for encounter Neurostimulator is inserted for pain Secondary Encounter is for any other reason except pain control/management 35

36 Category G40 (Epilepsy and Recurrent Seizures) and G43 (Migraine) 36

37 Hemiplegia and Hemiparesis Category G81 Hemiplegia, G82 Paraplegia and quadriplegia, G83 Other paralytic syndromes Use only when listed conditions are reported without further specification or are stated to be old or longstanding, with unspecified cause Paralytic sequelae of infarct/stroke are in Chapter 9 37

38 Cerebral Palsy G80.0 G80.1 G80.2 G80.3 G80.4 G80.8 G80.9 Spastic quadriplegic cerebral palsy Spastic diplegic cerebral palsy Spastic hemiplegic cerebral palsy Athetoid cerebral palsy Ataxic cerebral palsy Other cerebral palsy Cerebral palsy, unspecified 38

39 Left-sided hemiplegia G81.94 Hemiplegia. Review Tabular for complete code assignment. Rationale: Under the term Hemiplegia in the index, the only code option for this diagnosis is G Review the Tabular under G81.9-, which offers five code choices. Coding Guideline I.C.6.a states Should the affected side be documented, but not specified as dominant or nondominant and the classification system does not indicate a default, code selection is as follows: If the left side is affected the default is nondominant. 39

40 Diseases of the Eye and Adnexa (H00 H59) CHAPTER 7 40

41 NEW Organization and Classification Entirely new chapter Different organization than ICD-9 Structure still by site but order differs Title changes to some categories to reflect current terminology Expansion of characters to provide for anatomic specificity and laterality 41

42 Disease of the Ear and Mastoid Process (H60-H95) CHAPTER 8 42

43 NEW Organization and Classification New chapter in ICD-10-CM Diseases have been arranged into blocks for easier identification: External ear Middle ear and mastoid Inner ear Other disorders of the ear Intraoperative and postprocedural complications 43

44 Official Guidelines There are no official guidelines at this time except for those contained in the Chapter and subchapter headings i.e. Use add t code for perforated tympanic membrane, H72.- i.e. Use add t code to identify tobacco 44

45 Eyes/Ears Examples H54.0 Blindness, both eyes H54.12 Blindness left eye normal rt H54.8 Legal blindness, as defined in USA H90.0 Conductive hearing loss,bilateral H91.03 Ototoxic hearing loss, bilateral H91.3 Deaf nonspeaking, not elsewhere classified 45

46 Diseases of the Circulatory System (I00-I99) CHAPTER 9 46

47 Organization and Classification Terminology was revised to reflect more current medical practice Hypertension is no longer classified as benign, malignant or unspecified 47

48 More than just I10 Hypertension HTN with Heart Disease requires documentation causal relationship Heart disease due to hypertension Hypertensive heart disease HTN with CKD Presumes cause-and-effect Read guidelines carefully 48

49 Sequelae of Cerebrovascular Disease (CVD) (Category I69) Sequelae of conditions classifiable to I60 I67 May be present at onset or anytime after the onset Use same guidelines for dominant vs. non-dominant as Chapter 6 Use I69 if patient has current CVD with deficits from old CVD 49

50 Diseases of the Respiratory System (J00-J99) CHAPTER 10 50

51 Organization and Classification Organized similarly to ICD-9-CM; however, diseases have been rearranged. Terminology changes Example: Asthma classified as mild persistent, moderate persistent, and severe persistent Classification changes that provide greater specificity Manifestations are reflected in the code 51

52 Chapter 10 - Guidelines When assigning any code from this chapter, use an additional code to identify any tobacco dependence, use, or exposure J10 Influenza contains a note to use an additional code to identify the virus J44 and J45 distinguish between uncomplicated cases vs. acute exacerbation 52

53 NEW Stages of Asthma Asthma Severity Intermittent Mild Persistent Moderate Persistent Severe Persistent Frequency of Daytime Symptoms Less than or equal to 2 times per week More than 2 times per week Daily. May restrict physical activity Throughout the day. Frequent severe attacks limiting ability to breathe. Source: Worldallergy.org 53

54 Coding Scenario The patient has increasing shortness of breath, weakness, and ineffective cough. Treatment included oxygen therapy. Diagnoses listed as acute respiratory insufficiency due to acute exacerbation of COPD and tobacco dependence. What diagnosis codes are assigned? 54

55 J44.1 Disease, diseased, pulmonary, chronic obstructive, with exacerbation (acute) F Dependence (on) (syndrome), tobacco see dependence, drug, nicotine Z99.81 Dependence, oxygen (long-term) (supplemental) Rationale: The acute respiratory insufficiency is a symptom that is an integral part of the COPD and is not coded. 55

56 Diseases of the Digestive System (K00-K95) CHAPTER 11 56

57 Organization and Classification New subchapters have been added Example: Diseases of the liver Terminology changes Hemorrhage is used for ulcers Bleeding is used for gastritis, duodenitis, diverticulosis, and diverticulitis Identification of obstruction is no longer a part of the ulcer code structure 57

58 Diseases of the Skin and Subcutaneous Tissue (L00-L99) CHAPTER 12 58

59 Organization and Classification Complete restructuring Brings together groups of diseases that are related Greater specificity has been added Title changes to reflect current terminology Note: Dermatitis and eczema are used synonymously and interchangeably 59

60 Pressure Ulcers Pressure ulcer codes are combination codes that identify site, laterality and stage of the ulcer Assignment of pressure ulcer stage is guided by clinical documentation of terms found in the Alphabetic Index Terms not found in the index or no documentation, the provider should be queried 60

61 Pressure Ulcers, cont. Unstageable is NOT unspecified Based on the clinical documentation May be documented by nurse No code is assigned if the ulcer is healed Healing ulcers are coded based on the stage documented in the medical record 61

62 Non-Pressure Ulcers Category L89 require: Site Laterality Severity Code first any associated underlying condition (gangrene, atherosclerosis, diabetic ulcer, etc.) 62

63 Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) CHAPTER 13 63

64 Organization and Classification Almost every code in Chapter 13 of ICD-10-CM has been expanded Greater specificity of sites Laterality Many codes moved from various chapter in ICD-9-CM to Chapter 13 in ICD-10-CM Gout moved from Endocrine Osteomalacia moved from Endocrine 64

65 Organization and Classification Recurrent and conditions related to a healed injury are usually found in Chapter 13 Current, acute, new injuries are found in Chapter 19 Osteoporosis with the site of a current pathological fracture is now one code 65

66 Sub-Categories Organized by Site and Laterality Bone Joint Muscle Multiple If no multiple code exists, assign a code for each site Right Left Bilateral If no bilateral code exists, assign a code for each side 66

67 Coding Scenario Julia is an 80-year-old female with senile osteoporosis. She complains of severe back pain with no history of trauma. X-rays revealed pathological compression fractures of several lumbar vertebrae. 67

68 M80.08XD Fracture, pathological (pathologic), due to osteoporosis, specified cause NEC see Osteoporosis, specified type NEC, with pathological fracture. Osteoporosis (female) (male), senile see Osteoporosis, age-related, with current pathologic fracture, vertebra(e) Rationale: In ICD-10-CM, a combination code is utilized to report osteoporosis with an associated pathological fracture. When identifying senile osteoporosis, the code book directs the coder to agerelated osteoporosis. 68

69 Diseases of the Genitourinary System (N00-N99) CHAPTER 14 69

70 Chapter 14 - Guidelines No changes in Chronic Kidney Disease guidelines from ICD-9 to ICD-10 70

71 Additional Codes Required N17.- N18.- N30.- N31.- N33 Code also underlying condition Code first etiology Additional code infectious agent Additional code urinary incontinence Code first underlying disease 71

72 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC (R00-R99) CHAPTER 18 72

73 Organization and Classification General signs and symptoms follow those related specifically to a body system or other relevant grouping Some codes have been moved to a chapter more specific to the symptom Hematuria now includes various types Hematuria, idiopathic N02.9 Hematuria, unspecified R31.9 Dyspepsia, functional K30 Epigastric pain (Dyspepsia) R

74 Category R00 R99 No more specific diagnosis can be made even after all facts have been investigated Signs or symptoms existing at time of initial encounter transient and causes not determined Provisional diagnosis in patient failing to return 74

75 Category R00 R99 cont. Referred elsewhere before diagnosis is made More precise diagnosis not available Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right 75

76 Chapter 18 - Guidelines Extensive Excludes 1 notes 76

77 NEW Repeated Falls R Use for encounter regarding a current fall Z91.81 History of falling 77

78 Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) CHAPTER 19 78

79 Organization and Classification Encompasses 2 alpha characters: S = Injuries related to body region T = Injuries to unspecified region, Poisonings, external causes Note that codes within T section that include the external cause do not require an additional external cause code. Use secondary codes(s) from Chapter 20 to indicate cause of injury 79

80 Wounds and Superficial Injuries Instructions for open wounds have changed Complicated wound in ICD-9 meant with infection ICD-10 instructs user to code also any associated wound infection Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site 80

81 Poisoning, Adverse Effect, Poisoning Underdose Overdose of substances Wrong substance given Taken in error Adverse effect - Hypersensitivity, Reaction, of correct substance properly administered Underdosing - Taking less of medication than is prescribed or instructed by manufacturer either inadvertently or deliberately 81

82 Poisoning, Adverse Effect, Underdosing ICD-9-CM = & E-Codes Accidental Therapeutic Suicide Assault Additional documentation required ICD-10-CM = T Codes Cause of poisoning and manifestation(s) Accidental Intentional Self Harm Assault Undetermined Cause of adverse effect and manifestation(s) Underdosing Failure in dosing during medical / surgical care Patient s underdosing of medication regime Episode of care 82

83 Poisoning, Adverse Effect, Underdose Combination codes for poisonings/ external cause (accidental, intentional self-harm, assault, undetermined) Table of Drugs and Chemicals groups all poisoning columns together Followed by adverse effect and underdosing When no intent of poisoning is indicated, code to accidental Undetermined intent is only for use when there is specific documentation in record that intent cannot be determined 83

84 Alcohol and Nicotine Alcohol and tobacco use or exposure is required to be coded with many other conditions, including but not limited to: Malignant neoplasms Cardiovascular conditions Respiratory conditions Note: History of anything (nicotine dependence, neoplasm, alcoholism, etc.) should always mean in the past

85 Abuse, Neglect, Maltreatment Sequence first code from categories T74 if confirmed or T76 if suspected If ruled out during encounter code Z04.71 or Z04.72; use Z04.41 or Z04.42 for sexual abuse Add external cause code (X92-Y08) to confirmed cases Use Y07 when perpetrator is known 85

86 Complications of Care Use additional from category G89 to identify acute or chronic pain due to presence of device, implant or graft Combination codes that include external cause do not require additional code Complications of care codes within the body system chapters should be sequenced first 86

87 External Causes of Morbidity (V00-Y99) CHAPTER 20 87

88 Organization and Classification No longer a supplemental classification No one-to-one relationship exists for ICD- 9-CM E-Codes to ICD-10-CM E-codes have been disseminated to Chapters 19 (combination codes) 20 88

89 Organization and Classification Most applicable to injuries, also valid for other use i.e., infections or heart attack occurring during strenuous physical activity External cause code may be used with any code in range A00.0-T88.9, Z00-Z99, that is health condition due to external cause 89

90 Organization and Classification Encompasses alpha characters V, W, X, and Y Assign external cause code, with appropriate seventh character for each encounter for which injury or condition is being treated Initial encounter Subsequent encounter Sequela 90

91 External Cause Guidelines Use for the length of treatment Cause Intent Use only on initial encounter Place of occurrence Activity (if applicable) Patient status 91

92 External Cause Guidelines Assign as many codes as necessary Never a principal (first listed) diagnosis Assign combination external cause codes to identify sequential events corresponding to the sequence of events No external cause code needed for combination codes from another chapter that include cause and intent 92

93 Category Y92 Place of Occurrence Use with activity code Only on initial encounter Only one Y92 code on record Do not use Y92.9 if place not stated 93

94 Category Y93 Activity Use with Y92 and Y99 Only on initial encounter Only one Y93 code on record Do not use Y93.9 if activity not stated Not applicable to poisonings, adverse effects, misadventures, or late effects 94

95 Category Y99- Assign Y99, External cause status, to indicate work status Civilian activity done for income or pay Military activity An individual including a student or volunteer was involved in a non-work activity 95

96 Transport Note Use additional code to identify Airbag injury (W22.1) Type of street, road, Hwy (Y92.4-) Use of cellular telephone at time of transport accident (Y93.C2) 96

97 Factors Influencing Health Status and Contact with Health Services (Z00-Z99) CHAPTER 21 97

98 Organization and Classification Some categories have rephrased titles Some conditions no longer have the specificity they did in ICD-9-CM Example: In ICD-10, Code Z23, Encounter for immunization is not further classified. In ICD-9, category codes V03 through V06 are used to identify the types of immunizations. 98

99 Z Codes- Reason for Visit When person who may or may not be sick encounters health services for some specific purpose i.e. to receive limited care or service for current condition, donate an organ or tissue, receive prophylactic vaccination, discuss problem Corresponding procedure code must accompany Z code if procedure is performed When some circumstance or problem is present which influences person s health status but is not a current illness or injury 99

100 Use of Z Codes Can be used in any healthcare setting May be used as either primary or secondary code, depending on the circumstances Certain Z codes may only be used as primary Corresponding procedure code must accompany the Z code 100

101 Z Code Examples Z64.- Problems related to certain psychosocial circumstances Z65.- Problems related to other psychosocial circumstances Z73.6 Limitation of activities due to disability Z74- Problems related to care provider dependency Z74.01 Reduced mobility Bed confinement status 101

102 Aftercare When the initial treatment has been performed and patient requires care during the healing or recovery phase, or for the long-term consequences of the disease Generally, first-listed (primary) code Certain aftercare Z code categories need a secondary code 102

103 Examples Z51.89 Encounter for other specified aftercare (Physical therapy) Z Encounter for surgical aftercare following surgery on specified body systems Z93.0 Status tracheostomy Z43.- Encounter for attention to artificial openings i.e. Trach/colostomy Z99.11 Dependence Ventilator status 103

104 Tools for Success 104

105 Tools for Success: GEMs Translation GEMs=General Equivalence Mapping: A mapping tool that attempts to include all valid relationships between the codes in ICD-9-CM and ICD-10-CM An excellent training tool to be used to familiarize differences between ICD 9 and ICD-10 and may also be used to select the correct ICD-10 code. The mapping identifies one-to-one and one-to-many code relationships Only 5% of ICD-9 to ICD-10 are a direct match 105

106 Selecting an ICD-10 GEMs Transition Software Should allow search by code and description Should be bi-directional: ICD-9 to ICD-10 and vice versa Look for the ability to perform code searches and store frequently used codes ( Cheat Sheet ) Have a print function to enable creation of training tools May be a stand alone or integrated product 106

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110 ICD 10: Next (or first) Steps Evaluate internal processes: Conduct a practice impact assessment (internal as well as business partners) Update ICD 10 coding resources (manual, encoder or online lookups) Perform a chart review to identify areas for CDI Provide documentation feedback for physicians (immediate and ongoing) 110

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112 49 Days 112

113 Thank You! Questions, Comments or Feedback? Please call or us 113

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