ICD-10 CM Training. Internal Medicine

Transcription

1 ICD-10 CM Training Internal Medicine

2 ICD-10-CM Compliance Dates ICD-10-CM will be valid for dates of service on or after October 1, 2015 Outpatient dates of service of October 1, 2015 and beyond. Inpatient hospital service claims, is effective for dates of discharge after September 30, 2015

3 Covered and Non-Covered Entities Covered Entities Everyone covered by the Health Insurance Portability Accountability Act (HIPPA) Non-Covered Entities Worker s Compensation Auto Insurance Non covered HIPAA entities are exempt but are encouraged to adapt the new code set

4 ICD-10 Code Structure 21 Chapters Alpha-numeric codes; not case-sensitive Codes begin with Alpha letter, A-Z, excluding U Common errors I verses 1 O verses 0 X Placeholder 3 to 7 characters Decimal following 3 rd character

5 ICD-10 Code Structure Placeholder X Used for future expansion of a code Fills in empty characters when a 6 th and/or 7 th character apply The placeholder may be used in different scenarios but should never serve as the final character. Example: W19.XXXA Unspecified fall, Initial Encounter

6 ICD-10 Code Structure 7 th Character Provides specified information regarding the clinical visit Is required for certain categories and must be reported in the seventh position May be alpha or numeric Has different meanings depending on the coding category

7 ICD-10 Code Structure Laterality Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. OGCR section 1.B.13

8 ICD-10 Code Structure Other Codes Codes titled other or other specified are for use when the information in the medical record provides detail for which a specific code does not exist. Unspecified Codes Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. OGCR section 1.A.9.a.b

9 ICD-10 Structure Excludes Notes Excludes1 A type 1 Excludes note is a pure excludes note It means NOT CODED HERE The code excluded should never be used at the same time When two conditions cannot occur together Excludes2 Represents Not included here The condition excluded is not part of the condition represented by the code It is acceptable to use both the code and the excluded code together, when appropriate OGCR section 1.A.12.a.b

10 ICD-10 Code Structure Code First and Use Additional Code ICD-10 has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. These instructional notes indicate the proper sequencing order of the codes. OGCR section 1.A.13 The - indicates there are additional reporting options

11 Most Common Diagnosis Codes

12 Hypertension ICD-9 Code ICD-10 Code Description Excludes1 Excludes I10 Essential (Primary) Hypertension Includes: high blood pressure, Hypertension (arterial) (benign) (essential) (malignant) (systemic) Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16) Neonatal hypertension (P29.2) Primary pulmonary hypertension (I127.0) Essential (primary) hypertension involving vessels of brain (I60-I69) Essential (primary) hypertension involving vessels of eye (H35.0-) Hypertensive Diseases Categories (I10-I15) The use additional codes and Excludes1 codes apply for all categories. (I10-I15) Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0) Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11. O13-O16) Neonatal hypertension (P29.2) Primary Pulmonary hypertension (I27.0)

13 Hypertension cont. ICD-9 Code ICD-10 Code Description Excludes1 Excludes I11.0 Hypertensive Heart Disease with heart failure Use additional code to identify type of heart failure (I50.-) N/A N/A I11.9 Hypertensive Heart Disease without heart failure N/A N/A I12.0 Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or end stage renal disease. Use additional code to identify the stage of chronic kidney disease (N185.5, N18.6) Hypertension due to Kidney Disease (I15.0, I15.1) Renovascular Hypertension (I15.0) Secondary Hypertension (I115.-) Acute Kidney Failure (N17.-) I12.9 Hypertensive Chronic Kidney Disease with stage 1-4 Chronic Kidney Disease, or unspecified Chronic Kidney Disease. Use additional code to identify the stage of chronic kidney disease (N18.1-N18.9) Hypertension due to Kidney Disease (I15.0, I15.1) Renovascular Hypertension (I15.0) Secondary Hypertension (I115.-) Acute Kidney Failure (N17.-)

14 Hypertension cont. ICD-9 Code ICD-10 Code Description Excludes1 Excludes I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney disease Use additional code to identify type of heart failure (I50.-) Use additional code to identify stage of chronic kidney disease (N18.1-NN18.4, N18.9) N/A N/A I13.10 Hypertensive Heart and Chronic Kidney Disease without heart failure, with stage 1-4 chronic kidney disease, or unspecified chronic kidney disease. Use additional code to identify the stage of chronic kidney disease (N18.1-N18.4, N18.9) N/A N/A I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease. Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6) N/A N/A I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Use additional code to identify type of heart failure (I50.-) Use additional code to identify the stage of chronic kidney disease (N18.5. N18.6) N/A N/A

15 Hypertension cont. ICD-9 Code ICD-10 Code Description Excludes1 Excludes I15.0 Renovascular Hypertension Code also underlying condition I15.1 Hypertension secondary to other renal disorders Code also underlying condition I15.2 Hypertension secondary to endocrine disorders Code also underlying condition I15.8 Other secondary hypertension Code also underlying condition I15.9 Secondary hypertension, unspecified Code also underlying condition Postprocedural hypertension (I97.3) Postprocedural hypertension (I97.3) Postprocedural hypertension (I97.3) Postprocedural hypertension (I97.3) Postprocedural hypertension (I97.3) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-)

16 Hypertension Documentation Tips Hypertension is no longer classified as benign, malignant or unspecified. ICD-10 Codes have been grouped according to disease progression: I10 Essential Hypertension I11.- Hypertensive Heart Disease I12.- Hypertensive CKD» Further subdivided by stage of kidney disease I13.- Hypertensive Heart and CKD» Further subdivided by stage of kidney disease I15.- Secondary Hypertension Transient Hypertension A code for hypertension is NOT assigned unless the patient has a documented, established diagnosis of hypertension. R03.0 Elevated blood pressure reading without diagnosis of hypertension Document requirements Type Current Status Associated relationships

17 Diabetes ICD-9 Code ICD-10 Code Description Excludes1 Excludes E11.9 Type 2 Diabetes mellitus without complications Diabetes (mellitus) due to insulin secretory defect Diabetes (NOS) Insulin resistant diabetes (mellitus) Use additional code to identify any insulin use (Z79.4) E11.65 Type 2 diabetes mellitus with hyperglycemia Diabetes (mellitus) due to insulin secretory defect Diabetes (NOS) Insulin resistant diabetes (mellitus Use additional code to identify any insulin use (Z79.4) Diabetes mellitus due to underlying condition (E08.-) Drug or chemical induced diabetes mellitus (E09.1-) Gestational diabetes (O24.4-) Neonatal diabetes mellitus (P70.2) Postpancreatectomy diabetes mellitus (E13.-) Postprocedural diabetes mellitus (E13.-) Secondary diabetes mellitus NEC (E13.-) Type 1 diabetes mellitus (E10.-) transitory endocrine and metabolic disorders specific to newborn (P70-P74 Diabetes mellitus due to underlying condition (E08.-) Drug or chemical induced diabetes mellitus (E09.1-) Gestational diabetes (O24.4-) Neonatal diabetes mellitus (P70.2) Postpancreatectomy diabetes mellitus (E13.-) Postprocedural diabetes mellitus (E13.-) Secondary diabetes mellitus NEC (E13.-) Type 1 diabetes mellitus (E10.-) transitory endocrine and metabolic disorders specific to newborn (P70-P74 N/A N/A

18 Diabetes Documentation Tips Diabetes mellitus codes are now combination codes that include the type of diabetes, the body system affected, and the complication affecting that body system. They are no longer classified as controlled or uncontrolled. Type Type 1 Type 2 Due to underlying conditions Drug or chemical induced Other specified

19 Diabetes Documentation Tips Complication Status Without complication With circulatory complication With diabetic arthropathy With hyperglycemia With hyperosmolarity With hypoglycemia With ketoacidosis With kidney complications With neurologic complications With ophthalmic complications With oral complications With skin complications With other specified complications

20 Diabetes Documentation Tips Complication Detail With diabetic retinopathy With cataract With other ophthalmic complication With chronic kidney disease With nephropathy With other kidney complication With amyotrophy With autonomic neuropathy With mononeuropathy With polyneuropathy With other neurological complication With unspecified neuropathy With or without coma With peripheral angiopathy with or without gangrene With other circulatory complications With neuropathic arthropathy With other arthropathy With dermatitis With foot ulcer With other skin ulcer With other skin complication With periodontal disease With other oral complications

21 Diabetes Documentation Tips Diabetes is a chronic condition that requires multi-specialty management. The documentation should indicate relevant details regarding the management of each case as it relates to the services rendered or actions taken to coordinate the patients care. The HPI, at a minimal, should include some indication of the historical timeline or duration of the illness, levels as it relates to the date of service, manifestations or impairments associated with the condition and effectiveness of current medication regimen. The examination should notate any physical signs related to the diabetic conditions. (Ulcers, nails, edema, discoloration sensitivity to touch)

22 Hyperlipidemia ICD-9 Code ICD-10 Code Description Excludes1 Excludes E78.4 Other Hyperlipidemia Familial combined hyperlipidemia E78.5 Hyperlipidemia, unspecified There are more specific code choice selections available below: Sphingolipidosis (E75.0-E75.3) N/A E78.0 Pure Hypercholesterolemia E78.1 Pure Hypercholesterolemia E78.2 Mixed Hyperlipidemia E78.3 Hyperchylomicronemia E78.6 Lipoprotein deficiency

23 Hyperlipidemia Documentation Tips Type Mixed Other Unspecified

24 Encounter for General Adult Medical Examination ICD-9 Code ICD-10 Code Description Excludes1 Excludes2 V70.0 Z00.00 Encounter for general adult medical examination without abnormal findings Encounter for adult health check-up NOS Examinations related to pregnancy and reproduction (Z30-Z36, Z39-) Encounter for examination for administrative purposes (Z02.-) Encounter for preprocedural examinations (Z01.81-) Special screening examinations (Z11- Z13) V70.0 Z00.01 Encounter for general adult medical examination with abnormal findings Use additional code to identify abnormal findings Note: Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94. Examinations related to pregnancy and reproduction (Z30-Z36, Z39-) Encounter for examination for administrative purposes (Z02.-) Encounter for preprocedural examinations (Z01.81-) Special screening examinations (Z11- Z13)

25 Well Examination Documentation Tips Identify routine health check Adult Child Newborn Under 8 days old 8-28 days old Identify presence/absence of abnormal findings With abnormal findings Without abnormal findings Use an additional code for any abnormal findings Document abnormal findings

26 Atherosclerotic heart disease of native coronary artery without angina pectoris ICD-9 Code ICD-10 Code Description Excludes1 Excludes I25.10 Atherosclerotic heart disease of native I25.10 coronary artery without angina pectoris N/A atheroembolism (I75.-) atherosclerosis of coronary artery bypass graft(s) and transplanted heart (I25.7-) Applicable To: Atherosclerotic heart disease NOS No ICD-10 code exists for unspecified vessel; native or bypass graft must be indicated Use additional code, if applicable, to identify: coronary atherosclerosis due to calcified coronary lesion (I25.84) coronary atherosclerosis due to lipid rich plaque (I25.83) chronic total occlusion of coronary artery (I25.82) exposure to environmental tobacco smoke (Z77.22) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0)

27 Artherosclerotic Heart Disease Coronary Artery Documentation Tips Associated Artery/Lesion Type Native artery Bypass graft Bypass graft, autologous artery Bypass graft, autologous vein Bypass graft, nonautologous biological Bypass graft, other Due to calcified coronary lesion Due to lipid rich plaque Native vs Transplanted Heart Associated angina Without angina With unstable angina With angina and spasm

28 Encounter for other preprocedural examination ICD-9 Code ICD-10 Code Description Excludes1 Excludes2 V72.83 Z Encounter for other preprocedural examination Applicable To: Encounter for preprocedural examination NOS Encounter for examinations prior to antineoplastic chemotherapy There are more specific code choice selections below: encounter for examination for administrative purposes (Z02.-) encounter for examination for suspected conditions, proven not to exist (Z03.-) encounter for laboratory and radiologic examinations as a component of general medical examinations(z00.0-) encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to the sign(s) or symptom(s) special screening examinations (Z11-Z13) V72.81 Z Encounter for preprocedural cardiovascular examination V72.82 Z Encounter for preprocedural respiratory examination V72.63 Z Encounter for preprocedural laboratory examination Blood and urine tests prior to treatment or procedure

29 Documentation Tips Includes: routine examination of specific system Codes from category Z01 represent the reason for the encounter. Use when a patient is being cleared for a procedure or surgery and no treatment is given.

30 Other Malaise and Fatigue ICD-9 Code ICD-10 Code Description Excludes1 Excludes R53.1 Weakness Asthenia NOS R53.81 Other malaise Chronic debility Debility NOS General physical deterioration Malaise NOS Nervous debility R53.82 Chronic fatigue, unspecified R53.83 Other fatigue Fatigue NOS Lack of energy Lethargy Tiredness age-related weakness (R54) muscle weakness (M62.8-) senile asthenia (R54) age-related physical debility (R54) Postviral fatigue syndrome NOS N/A N/A N/A N/A N/A

31 Other Malaise and Fatigue Documentation Tips Identify type of malaise and fatigue Neoplastic related fatigue Weakness Functional quadriplegia Other malaise Chronic fatigue, unspecified Other fatigue

32 Chronic Obstructive Pulmonary Disease (COPD) ICD-9 Code ICD-10 Code Description Excludes1 Excludes2 496 J44.9 Chronic obstructive pulmonary disease, unspecified There are more specific code choice selections below: Applicable to: Chronic obstructive airway disease NOS Chronic obstructive lung disease NOS Bronchiectasis (J47.-) Chronic bronchitis NOS (J43) Chronic simple and mucopurulent bronchitis (J14.-) Chronic tracheitis (J42) Chronic tracheobronchitis (J42) Emphyysema without chronic bronchitis (J43.-) Lung diseases due to external agents (J60-J70) N/A J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

33 COPD Documentation Tips Type Chronic bronchitis Simple Mucopurulent Mixed simple and mucopurulent Emphysema Centrilobular Panlobular Unilateral COPD with acute exacerbation COPD with acute lower respiratory injection Identify the infection (use additional code)

34 COPD Documentation Tips Code also type of asthma, if applicable (J45-) Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0)

35 Atrial fibrillation ICD-9 Code ICD-10 Code Description Excludes1 Excludes I48.91 Unspecified atrial fibrillation N/A There are more specific code choice selections available below: N/A I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation Permanent atrial fibrillation

36 Atrial Fibrillation Documentation Tips Type Chronic Paroxysmal Persistent

37 Encounter for Immunization Influenza Virus ICD-9 Code ICD-10 Code Description Excludes1 Excludes2 V04.81 Z23 Encounter for immunization N/A N/A

38 Encounter for Immunization Documentation Tips The procedural code will indicate the type of immunization to the carrier.

39 Cough ICD-9 Code ICD-10 Code Description Excludes1 Excludes R05 Cough Cough with hemorrhage (R04.2) Smoker s Cough (J41.0) N/A

40 Cough Documentation Tips Symptom Codes Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Use of a symptom code with a definitive diagnosis code Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

41 Major depressive disorder, single episode ICD-9 Code ICD-10 Code Description Excludes1 Excludes2 311 F32.9 Major depressive disorder, single episode, unspecified Applicable To: Depression NOS Depressive disorder NOS Major depression NOS Bipolar disorder (F31.-) Manic episode (F30.-) Recurrent depressive disorder (F33.-) Adjustment disorder (F43.2) F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features F32.3 Major depressive disorder, single episode, severe with psychotic features F32.4 Major depressive disorder, single episode, in partial remission F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes

42 Documentation Tips In Remission Selection of codes for in remission for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider s clinical judgment. The appropriate codes for in remission are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting).

43 Documentation Tips Psychoactive Substance Use, Abuse And Dependence When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy: If both use and abuse are documented, assign only the code for abuse If both abuse and dependence are documented, assign only the code for dependence If use, abuse and dependence are all documented, assign only the code for dependence If both use and dependence are documented, assign only the code for dependence.

44 Documentation Tips Psychoactive Substance Use As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider.

45 Pain in limb ICD-9 Code ICD-10 Code Description Excludes1 Excludes M Pain in limb, unspecified psychogenic rheumatism (F45.8) soft tissue pain, psychogenic (F45.41) There are more specific code choice selections below: Pain in joint (M25.5-) M Pain in upper arm M Pain in forearm M Pain in hand and fingers M Pain in thigh M Pain in leg M Pain in foot and toes

46 Documentation Tips Site Laterality Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition

47 Heart failure, unspecified ICD-9 Code ICD-10 Code Description Excludes1 Excludes I50.9 Heart failure, unspecified Applicable To: Biventricular (heart) failure NOS Cardiac, heart or myocardial failure NOS Congestive heart disease Congestive heart failure NOS Right ventricular failure (secondary to left heart failure) Cardia arrest (I46.-) Neonatal cardiac failure (P29.0) fluid overload (E87.70) Code first: Heart failure complicating abortion or ectopic or molar pregnancy (O00-O07, O08.8) Heart failure following surgery (I97.13-) Heart failure due to hypertension (I11.0) Heart failure due to hypertension with chronic kidney disease (I13.-) Obstetrics surgery and procedures (O75.4) Rheumatic heart failure (I09.81) N/A

48 Heart failure, unspecified Documentation Tips Type Systolic Diastolic Combined Chronicity Acute Chronic Acute on chronic

49 Heart failure, unspecified Documentation Tips 1) Hypertension with Heart Disease Heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease, when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.

50 Heart failure, unspecified Documentation Tips 2) Hypertensive Chronic Kidney Disease Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease. The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease. See Section I.C.14. Chronic kidney disease. If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.

51 Monitor Claims On October 01, 2015 we will monitor claims for date of service rules Outpatient claims cannot have crossover dates Outpatient claims will be coded according to date of service Inpatient facility claims will be coded per date of discharge We will monitor claims to resolve any unanticipated problems with the submission process

52 Claim Denial and Management We will monitor for claim denials We will monitor editing trends for ICD-10 Coding guidelines We will provide feedback to the physicians regarding supporting documentation requirements We will monitor WC or Liability carriers for published rules on use of ICD-9 or ICD-10 code sets

53 Client Responsibilities Client will need to update Templates Order Sets Superbills Favorites Future Orders Remove ICD-9 code add ICD-10 code

54 Documentation Start Now All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection. Site specificity Document notation of qualifiers Exacerbation Manifestations Relapse Status Stages Indicate acute or chronic Indicate underlying or external cause factors Medication Smoke Accidents Mechanical failure Laterality Bilateral Right Left

55 Documentation Start Now Episode of Care for injuries, poisoning, external causes and other conditions Initial Encounter Use while the patient is receiving active treatment of the condition Active treatment includes surgical treatment, an emergency encounter, and evaluation and treatment by a new physician Subsequent Encounter Used on encounter after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Medication adjustments, aftercare, device adjustments, cast change Sequela Used for complications or conditions that arise as a direct result of a condition, late effect

56 Documentation Start Now Combination codes that capture Etiology and manifestation Related conditions Disease, injury or other medical condition and complications Disease or other medical conditions and common signs or symptoms Add ICD-10 Codes to patient Problem List

57 Questions Centers for Disease Control and Prevention (ICD-10-CM)