Medtronic Cardiac Rhythm and Heart Failure ICD-10 Coding for Physicians

Transcription

1 Medtronic Cardiac Rhythm and Heart Failure ICD-10 Coding for Physicians May 19, 2015

2 Disclaimer This presentation is intended for educational use. Any duplication is prohibited without written consent of Medtronic s Economics and Health Policy department. This information does not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for their interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. 2

3 Topics Implementation Background Diagnosis Codes Diagnosis Code Crosswalks ICD-10-PCS Procedure Codes Implementation Issues Appendix : Key Resources Questions Attachment : Diagnosis Code Crosswalks 3

4 Implementation Background 4

5 Effective Date ICD-10 goes into effect October 1, Use of ICD-10 in the United States was formally proposed in August 2008 and finalized in January Implementation of ICD-10 was initially scheduled for October 2013 and has been postponed twice since then. ICD-10 is effective by date of discharge, not by date of admission. for diagnosis codes and ICD-10-PCS for procedure codes go into effect together on the same date. 5

6 Who Uses What Physicians, hospitals and all other providers must use ICD-10 diagnosis codes. Hospitals must also use ICD-10-PCS procedure codes for inpatient cases. Implementation of ICD-10 does not affect use of CPT. Provider Setting Diagnoses Procedures Physicians Facility/Office CPT Hospitals Outpatient CPT ASCs Outpatient CPT Hospitals Inpatient ICD-10-PCS 6

7 Diagnosis Codes 7

8 Need an Codebook? diagnosis codes are administered by the Centers for Disease Control. Physician offices can download a copy of the entire codebook from the CDC website: This version is official, complete, current, and free. Offices will need at least the Tabular and the Index. The Tabular is the running list of diagnosis codes with their descriptions and instructions for use. The codes are updated once a year on October 1. 8

9 Diagnosis Code Structure Codes are organized by chapter, mostly by body system. The chapters are virtually identical to those in. Codes are alpha-numeric and can be 3 to 7 digits long. Category Decimal Details Extension T 8 2 alpha number R A alpha or number T82.120A Displacement of cardiac electrode, initial encounter R55 Syncope I I50.23 Acute on chronic systolic heart failure 9

10 Volume of Diagnosis Codes has far more diagnosis codes than and provides a greater level of specificity. Most physicians will use a small subset of the total codes. Physicians do not use external cause codes. Many of the additional codes are due to laterality. 14,567 codes 69,823 codes Specialty societies have been very active in requesting new diagnosis codes with additional clinical detail. There are still unspecified codes. Much of the additional specificity captured by diagnosis codes is already documented by physicians. 10

11 Greater Specificity Or Less Some conditions that use the same code in are differentiated in and have separate codes. Example: Non-ischemic cardiomyopathy Other primary cardiomyopathies I42.0 Dilated cardiomyopathy (congestive) I42.5 Other restrictive cardiomyopathy (constrictive cardiomyopathy) I42.8 Other cardiomyopathies I42.9 Cardiomyopathy, unspecified For some conditions though, it s the opposite. Example: Bifascicular blocks Right bundle branch block and left posterior fascicular block Right bundle branch block and left anterior fascicular block Bilateral bundle branch block, other I45.2 Bifascicular block 11

12 ICD-10 Guidelines Guidelines for use of are offered by multiple sources, but two sources are mandatory: Instructions within the ICD-10 codebook itself The ICD-10 Official Guidelines for Coding and Reporting Use of these guidelines is mandated under HIPAA. Physicians only need to use the diagnosis guidelines (there s a separate set of official guidelines for procedures) The guidelines can be found at: Physicians will be most interested in Section IV: Diagnostic Coding 12

13 13 Diagnosis Code Crosswalks

14 14 General Equivalence Mappings CDC posts General Equivalence Mappings (GEMs) on its website. These are a useful tool for going back-and-forth between codes and ICD-10 codes. The first GEM goes forward from ICD-9 to ICD-10. The second GEM goes backward from ICD-10 to ICD-9. Both GEMs are updated once a year. The GEMs can be found at: Although GEMs are useful, CDC and CMS strongly recommend using the codebook directly, as studies have consistently indicated that this is most accurate.

15 Crosswalk: Heart Failure Hypertensive Heart Disease with Heart Failure Hypertensive heart disease, malignant, with heart failure Hypertensive heart disease, benign, with heart failure Hypertensive heart disease, unspecified, with heart failure Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage V or end stage renal disease Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease I11.0 I13.0 I13.2 Hypertensive heart disease with heart failure Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease 15 There s no distinction between malignant and benign hypertension. The specific type of heart failure is coded separately.

16 Crosswalk: Heart Failure Congestive heart failure, unspecified I50.9 Heart failure, unspecified Left heart failure I50.1 Left ventricular failure Systolic heart failure, unspecified I50.20 Unspecified systolic (congestive) heart failure Acute systolic heart failure I50.21 Acute systolic (congestive) heart failure Chronic systolic heart failure I50.22 Chronic systolic (congestive) heart failure Acute on chronic systolic heart failure I50.23 Acute on chronic systolic (congestive) heart failure Unspecified diastolic heart failure I50.30 Unspecified diastolic (congestive) heart failure Acute diastolic heart failure I50.31 Acute diastolic (congestive) heart failure Chronic diastolic heart failure I50.32 Chronic diastolic (congestive) heart failure Acute on chronic diastolic heart failure I50.33 Acute on chronic diastolic (congestive) heart failure Unspecified combined systolic and diastolic Unspecified combined systolic (congestive) and diastolic I50.40 heart failure (congestive) heart failure Acute combined systolic and diastolic heart Acute combined systolic (congestive) and diastolic I50.41 failure (congestive) heart failure Chronic combined systolic and diastolic heart Chronic combined systolic (congestive) and diastolic I50.42 failure (congestive) heart failure Acute on chronic combined systolic and I50.43 Acute on chronic combined systolic (congestive) and diastolic heart failure diastolic (congestive) heart failure Unspecified heart failure I50.9 Heart failure, unspecified Documentation must still specify if the heart failure is acute or chronic, systolic or diastolic. Congestive heart failure does not have its own code. 16

17 Crosswalk: Conduction Disorders Atrioventricular Block AV block, complete I44.2 Atrioventricular block, complete AV block, unspecified I44.30 Unspecified atrioventricular block AV block, first degree I44.0 Atrioventricular block, first degree AV block, Mobitz II AV block, other second degree I44.1 Atrioventricular block, second degree Bundle Branch Blocks I44.4 Left anterior fascicular block Left bundle branch hemiblock I44.5 Left posterior fascicular block I44.60 Unspecified fascicular block Other left bundle branch block I44.69 Other fascicular block I44.7 Left bundle branch block, unspecified I45.0 Right fascicular block Right bundle branch block I45.10 Unspecified right bundle branch block I45.19 Other right bundle branch block Bundle branch block, unspecified I45.4 Nonspecific intraventricular block (BBB NOS) RBBB and left posterior fascicular block RBBB and left anterior fascicular block Bilateral bundle branch block, other Trifascicular block I45.2 I45.3 Bifascicular block Trifascicular block 17

18 Crosswalk: Conduction Disorders Other Blocks Other heart block I45.5 Other specified heart block Other Conduction Disorders Anomalous atrioventricular excitation (WPW) Lown-Ganong-Levine syndrome (LGL) I45.6 Pre-excitation syndrome (WPW) (LGL) Long QT syndrome I45.81 Long QT syndrome Other specified conduction disorders I45.89 Other specified conduction disorders Conduction disorder, unspecified I45.9 Conduction disorder, unspecified 18

19 Crosswalk: Arrhythmias Tachycardia Paroxysmal supraventricular tachycardia I47.1 Supraventricular tachycardia (includes AVNRT) I49.2 Junctional premature depolarization Paroxysmal ventricular tachycardia I47.0 Re-entry ventricular arrhythmia I47.2 Ventricular tachycardia Paroxysmal tachycardia, unspecified I47.9 Paroxysmal tachycardia, unspecified Tachycardia, unspecified R00.0 Tachycardia, unspecified Paroxysmal does not need to be documented SVT and VT. Tachycardia that s unspecified is assigned to symptom code R00.0. Atrial Fibrillation and Flutter Atrial fibrillation Atrial flutter I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation I48.3 Typical atrial flutter (type I) I48.4 Atypical atrial flutter (type II) I48.92 Unspecified atrial flutter Documentation should specify the type of atrial fibrillation, and the abbreviation PAF should be avoided.

20 Crosswalk: Arrhythmias Ventricular Fibrillation and Flutter Ventricular fibrillation I49.01 Ventricular fibrillation Ventricular flutter I49.02 Ventricular flutter Bradycardia Sinoatrial node dysfunction (SSS) I49.5 Sick sinus syndrome (tachy-brady syndrome) R00.1 Bradycardia, unspecified Particularly for surgical patients, documentation should specify bradycardia as sick sinus syndrome or tachycardia-bradycardia syndrome. Bradycardia that is unspecified or documented only as sinoatrial bradycardia or sinus bradycardia is assigned to symptom code R

21 Crosswalk: Arrhythmias Other Arrhythmias Premature beats, unspecified I49.40 Unspecified premature depolarization Supraventricular premature beats I49.1 Atrial premature depolarization Other premature beats I49.3 Ventricular premature depolarization I49.49 Other premature depolarization Other specified cardiac dysrhythmias I49.8 Other specified cardiac arrhythmias Cardiac dysrhythmia, unspecified I49.9 Cardiac arrhythmia, unspecified Abnormal electrocardiogram R94.31 Abnormal electrocardiogram Cardiac Arrest (Sudden Cardiac Death) Cardiac arrest I46.2 Cardiac arrest due to underlying cardiac condition I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified If the underlying cause is known, it should be documented and coded separately. The cause code is sequenced before code I46.-. V12.53 V17.41 Personal history of sudden cardiac arrest (SCD) (successfully resuscitated) Family history of sudden cardiac death (SCD) Z86.74 Personal history of sudden cardiac arrest (SCD) (successfully resuscitated) Z82.41 Family history of sudden cardiac death 21

22 Crosswalk: Acute Myocardial Infarction handles acute myocardial infarction differently from. AMI: 410.0x Acute myocardial infarction, of anterolateral wall 410.1x Acute myocardial infarction, of other anterior wall 410.2x Acute myocardial infarction, of inferolateral wall 410.3x Acute myocardial infarction, of inferoposterior wall 410.4x Acute myocardial infarction, of other inferior wall 410.5x Acute myocardial infarction, of other lateral wall 410.6x Acute myocardial infarction, true posterior wall 410.7x Acute myocardial infarction, subendocardial (NSTEMI) 410.8x Acute myocardial infarction, of other specified sites 410.9x Acute myocardial infarction, unspecified site 5 th digit 0 unspecified episode of care 1 initial episode of care 2 subsequent episode of care AMI: Episode of care is not identified per se. AMI is differentiated between initial AMI (I21) and subsequent AMI (I22) The AMI site identifies the specific coronary artery involved. 22

23 Crosswalk: Acute Myocardial Infarction Initial AMI (I21) I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I21.4 Non-ST elevation (NSTEMI) myocardial infarction Documentation should specify the coronary artery or wall involved. Initial AMI codes continue to be assigned to encounters for continued care, including transfer to another hospital or post-acute setting, while the AMI is within 28 days of onset. 23

24 Crosswalk: Acute Myocardial Infarction Subsequent AMI (I22) I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I22.2 Subsequent non-st elevation (NSTEMI) myocardial infarction I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site Old AMI A subsequent AMI is a new AMI that occurs within 28 days of a previous AMI, regardless of site. Codes from I22 cannot be assigned alone. They must always be assigned with a code from I21. Sequencing of the codes depends on the circumstances. 412 Old myocardial infarction I25.2 Old myocardial infarction 24

25 Crosswalk: Other Heart Disorders Cardiomyopathy Other specified forms of chronic ischemic heart disease (used for ischemic cardiomyopathy) I25.5 Ischemic cardiomyopathy Hypertrophic obstructive cardiomyopathy I42.1 Obstructive hypertrophic cardiomyopathy I42.0 Dilated cardiomyopathy (congestive) Other restrictive cardiomyopathy (constrictive I Other primary cardiomyopathies cardiomyopathy) I42.8 Other cardiomyopathies I42.9 Cardiomyopathy, unspecified Shock Shock, unspecified R57.9 Shock, unspecified Cardiogenic shock R57.0 Cardiogenic shock Shock, other R57.1 Hypovolemic shock R57.8 Other shock 25

26 Crosswalk: Symptoms Syncope Syncope R55 Syncope Chest Pain Chest pain, unspecified R07.9 Chest pain, unspecified Precordial pain R07.2 Precordial pain Chest pain, other R07.89 Other chest pain Other Symptoms Dizziness R42 Dizziness Palpitations R00.2 Palpitations 26

27 Crosswalk: Cerebrovascular Disorders Cryptogenic Stroke Cerebral artery occlusion, unspecified (used for cryptogenic ischemic stroke) I63.9 Cerebral infarction, unspecified Transient Cerebral Ischemia Unspecified transient cerebral ischemia G45.9 Transient cerebral ischemic attack, unspecified 27

28 Crosswalk: Device Complications Mechanical Complication of Pacemaker and Defibrillator Mechanical complication due to cardiac pacemaker Mechanical complication due to implantable defibrillator T82.110A T82.111A T82.118A T82.120A T82.121A T82.128A T82.190A T82.191A T82.198A Breakdown (mechanical) of cardiac electrode, initial encounter Breakdown (mechanical) of cardiac pulse generator, initial encounter Breakdown (mechanical) of other cardiac electronic device, initial encounter Displacement of cardiac electrode, initial encounter Displacement of cardiac pulse generator, initial encounter Displacement of other cardiac electronic device, initial encounter Other mechanical complication of cardiac electrode, initial encounter Other mechanical complication of cardiac pulse generator, initial encounter Other mechanical complication of other cardiac electronic device, initial encounter Mechanical complication is defined the same way in as it is in. Breakage of device Malposition of device Leakage of device Mechanical obstruction of device Perforation of device Protrusion of device 28

29 Crosswalk: Device Complications Infection of implanted cardiac device Infection due to cardiac device, implant and graft T82.7xxA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter x is a placeholder. This code is only four digits but extension A must always be in the 7 th position. So x holds the empty 5 th and 6 th positions. Other complications T82.817A Embolism of cardiac prosthetic devices, implants and grafts, initial encounter T82.827A Fibrosis of cardiac prosthetic devices, implants and grafts, initial encounter Other complication due to other cardiac device, implant and graft T82.837A T82.847A T82.857A T82.867A Hemorrhage of cardiac prosthetic devices, implants, grafts, initial encounter Pain from cardiac prosthetic devices, implants and grafts, initial encounter Stenosis of cardiac prosthetic devices, implants and grafts, initial encounter Thrombosis of cardiac prosthetic devices, implants, grafts, initial encounter T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter 29 A diagnosis of failed device must be further specified.

30 Crosswalk: Encounters and Status Encounters V53.31 Fitting and adjustment of cardiac pacemaker V53.32 Fitting and adjustment of automatic implantable cardiac defibrillator Z Z Z45.02 V53.39 Fitting and adjustment of other cardiac device Z45.09 Encounter for checking and testing of cardiac pacemaker pulse generator [battery] Encounter for adjustment and management of other part of cardiac pacemaker Encounter for adjustment and management of automatic implantable cardiac defibrillator Encounter for adjustment and management of other cardiac device Use Z45.- for encounters for device replacement due to expected end-oflife and expected device removal (eg, end of surveillance). These types of encounters are not coded as complications. Device Status V45.01 Cardiac pacemaker in situ Z95.0 Presence of cardiac pacemaker V45.02 Automatic implantable cardiac defibrillator in situ Z Presence of automatic (implantable) cardiac defibrillator V45.09 Other specified cardiac device in situ Z Presence of other cardiac implants and grafts 30

31 ICD-10-PCS Procedure Codes 31

32 ICD-10-PCS Format ICD-10-PCS procedure codes are administered by CMS. Codes are alpha-numeric and are always 7 digits long. There are virtually no unspecified or default codes. ICD-10-PCS uses standardized definitions throughout. Each position in an ICD-10-PCS procedure code represents a distinct element section root operation approach qualifier body system body part device 32

33 Structure of ICD-10-PCS Codes In ICD-10-PCS, codes are not assigned per se. They are constructed, character by character. Rather than a Tabular list of codes, ICD-10-PCS displays tables from which values for each position are selected. Defibrillator generator: Evera 0JH608Z Insertion of defibrillator generator, into chest subcutaneous tissue and fascia, open approach CRT-D generator: Viva 0JH609Z Insertion of cardiac resynchronization defibrillator pulse generator into chest subcutaneous tissue and fascia, open approach 33

34 ICD-10-PCS Terminology Pulmonary vein isolation (ie. for atrial fibrillation) 02583ZZ Destruction of conduction mechanism, percutaneous approach It is the coder s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions No need to document Destruction, keep documenting PVI or ablation No need to document Percutaneous Endoscopic, thoracoscopic is fine 34

35 Volume of Procedure Codes ICD-10-PCS has far more procedure codes than and provides much greater specificity. Full system CRT-D ICD-10-PCS 1 code 4 codes 3,882 codes ICD-10-PCS 71,962 codes CRT-D generator with transvenous RA, RV, LV leads 0JH609Z Insertion of CRT-D generator into chest subcutaneous tissue, open approach 02H63KZ Insertion of defibrillator lead into right atrium, percutaneous approach 02HK3KZ Insertion of defibrillator lead into right ventricle, percutaneous approach 02H43KZ Insertion of defibrillator lead into coronary vein, percutaneous approach 35

36 36 Implementation Issues

37 37 Documentation Practices ICD-10 raises the bar on specificity in documentation for diagnoses. Documentation for Diagnosis Specificity Culprit lesion or site of acute myocardial infarction Type of cardiomyopathy: ischemic/non-ischemic, congestive, constrictive Acuity and type of heart failure: acute/chronic, systolic/diastolic Type of atrial fibrillation: paroxysmal, persistent, chronic Type of atrial flutter: type I, type II Nature of bradycardia: SSS, tachycardia-bradycardia syndrome Nature of tachycardia: SVT, VT, AVNRT Device complication: true complication or expected end-of-life? Nature of device complication: stenosis, breakdown, premature depletion PAF CHF device failure tachycardia bradycardia STEMI (unspecified) decompensated HF

38 Documentation Practices ICD-10 also raises the bar on specificity in documentation for procedures. Documentation for Procedure Specificity Conventional or resynchronization pacemaker or defibrillator Exact anatomic location of subcutaneous devices: chest, back, abdominal wall Specific name and model of devices used Other documentation considerations Take note of coder queries requesting additional information and include those details in similar cases going forward. CMS has a useful primer for cardiology documentation: 38

39 Coverage Issues CMS has converted its NCDs and codes are already being displayed on LCDs and on private payers medical policies. Identify the practice s largest payers and check the codes on their on-line medical polices for familiarity as well as omissions. Check practice superbills against payer policies for differences. Alert the payer to possible discrepancies. Be aware that the specificity of may allow payers to now enforce existing coverage rules more stringently. 39

40 Practice Implementation Checklist 1. Lay out a plan Identify which ICD-9 codes you use heavily Identify the staff that need to be trained in coding and/or documentation Contact vendors to learn their plans, ICD-10 related costs to the practice, and resources available to the practice Contact the specialty society for any resources available to the practice Visit the CMS website for useful tools and materials 2. Get trained Buy or download an ICD-10 diagnosis codebook Arrange and implement ICD-10 coding training for staff Arrange and obtain documentation training for physicians and other clinicians Crosswalk common diagnosis codes to ICD-10 and identify new requirements or differences in essential documentation Sign up for key CMS webinars to increase understanding of the ICD-10 environment 3. Update internal practice tools Convert superbills to ICD-10 Convert other materials to ICD-10, such as authorizations, orders and referrals Identify common code-related causes for current claim denials and identify areas where ICD-10's specificity in documentation and code assignment can address this Obtain payer medical polices with ICD-10 codes for comparison 40

41 Practice Implementation Checklist Work with vendors and payers Arrange and implement ICD-10 software upgrades Train staff on use of new software, either directly or via the vendor Identify EHR documentation templates and assess how they support ICD-10 specificity for claims submission and medical necessity Engage payers on any discrepancies and omissions in ICD-10 coding for medical policies Identify if payers anticipate any changes in processing and payment due to ICD-10 Identify availability of testing with major payers 5. Test the process Perform testing on systems within the practice Perform end-to-end testing with vendors and/or payers Identify and correct issues raised during testing Educate staff on the impact of ICD-10 to payer edits, adjudication, and other claims elements to processes within the practice Repeat!

42 42 Appendix

43 Key Websites CDC and CMS have a wealth of resources and educational materials available on-line for physician practices. CDC Tabular and Index Official guidelines Diagnosis code GEMS CMS Webcasts FAQs on ICD-10 Templates for assessing vendors, billing services, payers Specialty references (common codes, documentation primers) Customizable practice action plans 43

44 Medtronic Contacts Medtronic is available to assist with your ICD-10 questions and issues. Hotline: us: Visit the CRHF reimbursement website at: We re here to help make this transition smoother for you 44

45 Questions