Revenue Cycle Solutions Consulting & Management Services Why Words Matter Through an Obstetric/GYN Lens 2014 The Advisory Board Company advisory.

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1 Revenue Cycle Solutions Consulting & Management Services Why Words Matter Through an Obstetric/GYN Lens

2 Key Objectives for Today s Session 1. Develop understanding of the role documentation plays in determining patient severity of illness (SOI), risk of mortality (ROM) and physician quality scores 2. Understand definition and key terminology changes in ICD-10-CM and ICD- 10-PCS 3. Understand the concepts of linking conditions and manifestations for more accurate depiction of patient s clinical status 2

3 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Concepts Drive Documentation Requirements 3 Examples of Obstetric/GYN Diagnoses in ICD-10-CM 3

4 The Evolution of Clinical Documentation What was once a tool for communication between providers and clinicians is now the primary data source to determine quality of patient care. Market forces are leading to Increase in documentation scrutiny. Who is the audience for your notes? Self Care Team State Government Insurance Companies Other Doctors Patients Federal Government 4

5 Increased Transparency For Patients MyCigna.com HealthGrades- all material and images are sourced from (accessed on 6/18/2012) Leapfrog- all material and images are sourced from (accessed on 6/18/2012) 5

6 Transition from ICD-9-CM to ICD-10-CM/PCS Per Bill H.R. 4302, The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD 10-CM/PCS code sets. Benefits and Goals of ICD-10-CM/PCS Provides better detail, a more accurate depiction, and improved communication of patients clinical status Allows for more accurate payment for new procedures Improves capture of morbidity and mortality data Reduces the number of miscoded, rejected and improper claims for reimbursement 2011, The Clinical documentation Improvement Specialist's Guide to ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS. 6

7 ICD-9-CM vs. ICD-10-CM/PCS: A Comparison 69,000 72,000 14,000 4,000 Why so many new codes? The main difference between ICD-9-CM and ICD-10-CM/PCS codes, outside of structural changes, is the SPECIFICITY of the code. ICD-10-CM/PCS codes specify several components not found ICD-9-CM, such as causal agent, type, laterality, approach, episode of care, root operation, etc. ICD-9 Diagnosis Codes ICD-10 Procedure Codes 1) Code Volume Expansion in ICD-10-CM/PCS Source: Nichols, J.C. (2011). ICD-10 Physician impacts. Advisory Board Applications and Technologies Collaborative; CMS (2013). ICD-10 Implementation guide for small hospitals 7

8 Introduction to ICD-10-CM Diagnosis Coding Structure ICD-10-CM Codes will Contain 3-7 Alphanumeric Characters with the Following Structure α # α/# α/# α/# α/# α/# Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality, Complication) Extension (3-16 options depending on category) Key ICD-10-CM Documentation Concepts Specific anatomical location Type (primary, secondary, unspecified) Acuity (acute, subacute, chronic, acute on chronic, or unspecified ) Trimester (1,2,3,unspecified) Degree (mild, moderate, severe, or unspecified; total/complete vs. partial/incomplete) Episode of Care (Initial, Subsequent, Sequelae) Laterality (Right, Left, bilateral, or unspecified) Number of fetus (1-5, other) 8

9 Introduction to ICD-10-PCS Coding Structure In this exercise, we will dissect the structure of an ICD-10-PCS code α/# α/# α/# α/# α/# α/# α/# Section Body System Root Operation Body Part Approach Device Qualifier 1. Section 16 options identifying the general type of procedure. Example: Medical/Surgical Section represents the vast majority of procedures reported in an inpatient setting 2. Body System - e.g. circulatory system, respiratory system 3. Root Operation - 31 options, based on the objective of the procedure 4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve 5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic 6. Device - 4 basic groups: Grafts/prostheses, implants, simple or mechanical appliances, and electronic appliance 7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full thickness burn Physician documentation required: Type and intent of procedure (root operation) Specific anatomic sites treated Approach Specific type of device used Validate surgical complications Diagnoses that support inpatient medical necessity Source: AHIMA; The Advisory Board Company research 9

10 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Key Concepts To Capture in Your Documentation 3 Examples of Obstetric/GYN Diagnoses in ICD-10 10

11 Remember: Signs, Symptoms & Test Results Must Be Linked to Related Diagnoses While important pieces of the medical record, signs, symptoms and test results are not sufficient for coders to assign a diagnosis. Linking signs and symptoms to diagnoses may increase SOI and ROM in the inpatient setting. (The terms probable, likely, or suspected are all acceptable on the inpatient record) In the ambulatory setting, documentation regarding patient condition should be to the highest level known, treated or evaluated Abnormal findings (laboratory, x-ray, pathology and other diagnostic test results) cannot be coded and reported unless the clinical significance is identified by the treating provider ICD-10-CM Official Coding Guidelines III.B Reminder: The attending physician is responsible for: Documenting all conditions in the progress notes and discharge summary Resolving conflicts in the documentation 11

12 Linking Conditions Critical to Capturing Patient Severity There is a significant increase in the number of combination codes available in the ICD-10-CM/PCS code set. These codes can help capture the highest level of complexity and acuity in the public eye. Linking clinically relevant conditions, where appropriate, is the key takeaway for physicians. Coders cannot assume clinical relationships. Examples: Linking Diseases Hypertension with heart disease Endocarditis due to staph aureus Right heart failure due to primary pulmonary hypertension Use terms like due to or with Note: Lists, commas, and the word and do not link conditions 12

13 Severity of Illness (SOI) and Risk of Mortality (ROM) Documentation drives SOI and ROM level assignment. These levels are used to measure patient acuity, and therefore drive expected patient LOS and mortality rate. Breakdown of SOI/ROM and their Implication on Quality Measures Four mutually exclusive SOI/ROM categories exist (1-4), and are determined based on a number of factors including primary and secondary diagnoses, comorbidities, demographics, patient history, treatment/procedure delivered, etc. Level Assigned SOI/ROM Category Minor 1 Moderate 2 Major 3 Extreme 4 13

14 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Key Concepts To Capture in Your Documentation 3 Examples of Obstetric/GYN Diagnoses in ICD-10 14

15 ICD-10-CM Obstetric/GYN Diagnoses Covered Today 1 Trimester Documentation 7 Fetal Abnormalities/Complications 2 Fetus Identification 8 Labor Timing 3 Pre-Existing Conditions 9 Obstructed Labor 4 Maternal Infection/HIV/Sepsis 10 Complications 5 Tobacco Exposure 11 Delivery Documentation 6 High Risk Pregnancy 15

16 Key Changes in OB Definitions in ICD-10-CM/PCS Key Changes in OB Definitions in ICD-10-CM/PCS Abortion vs. fetal death Early vs. late vomiting Post-term pregnancy Prolonged pregnancy Trimester counted from 1 st day of last menstrual period Young primigravida Elderly patients Incomplete abortion Abortion: up to 20 weeks of gestation Fetal death: after 20 weeks of gestation Timeframe changes from 20 to 22 weeks Pregnancy over 40 to 42 weeks of gestation Pregnancy that has advanced beyond 42 weeks of gestation 1st : <14 weeks zero days 2nd: 14 weeks zero days to < 28 weeks zero days 3rd : 28 weeks zero days until delivery Note: The coder cannot use the LMP to determine trimester, but can utilize weeks to determine trimester Younger than 16 years old at expected date of delivery 35 years or older at the expected date of delivery Abortion with retained products of conception 16

17 Key Definitions for OB Key Changes in OB Definitions in ICD-10-CM/PCS Preterm Time period before 37 completed weeks of gestation Postpartum Time period from delivery to 6 weeks after delivery Peripartum Premature rupture of membranes Preterm labor Coagulation defects include Maternal care Last month of pregnancy to 5 months postpartum Onset of labor more than 24 hours after the rupture of membranes Spontaneous onset of labor before 37 completed weeks of gestation Afibrinogenemia Disseminated intravascular coagulation Hyperfibrinolysis Hypofibrinogenemia The reason for observation, hospitalization, other obstetric care, or Cesarean section delivery before onset of care 17

18 Documenting Trimester in ICD-10-CM ICD-10-CM Guidelines for Documenting Trimester In ICD-10-CM, the provider s documentation of the number of weeks is used to assign the appropriate code to identify the trimester If the provider does not document the number of weeks/trimester, a query will likely be issued Coders may not calculate the number of weeks or trimester from the date of Last Menstrual Period Admissions For a pre-existing condition, document the trimester at the time of the encounter of the admission If the condition is concurrent and spans more than one trimester, use the trimester at admission, not discharge trimester Trimester documentation is not needed when The condition always occurs in a specific trimester If delivery occurs during any encounter, the time frame and documentation is in childbirth 18

19 Fetus Identification Documentation Documentation for the Maternal Record (not the Newborn) Multiple gestations Which fetus Number of Placentas Fetuses Amniotic sacs Identify complications for each fetus by number Papyraceous fetus Continuing pregnancy after Spontaneous abortion Intrauterine death Elective fetal reduction Documentation Tip ICD-10-CM coding uses numbers to identify fetuses not letters! Document Trimester 19

20 Pre-existing Conditions 3 Key Concepts to Documenting Pre-Existing Conditions 1. Clarify maternal medical conditions as: Pre-existing or A direct result of pregnancy 2. If preexisting hypertension during pregnancy, document whether there is also: Hypertensive heart disease Heart failure (include type: acute, chronic, acute on chronic, systolic, diastolic) Hypertensive chronic kidney disease (CKD) Stage Transplant and dialysis status 3. Clear documentation is needed on the inpatient H&P for the following conditions: Any condition that is a direct result of the pregnancy Current conditions requiring ongoing care Conditions that have been resolved prior to the inpatient care 20

21 Hypertension ICD-10-CM documentation concepts Pre-existing Hypertension Documentation Hypertension Hypertension with proteinuria Hypertensive Heart disease CKD + stage Heart disease and CKD Secondary hypertension If possible, document the underlying cause Hypertension with pre-eclampsia Gestational Hypertension Documentation Findings without hypertension Edema Edema with proteinuria Proteinuria Hypertension With significant proteinuria Without significant proteinuria Pre-eclampsia Mild to moderate Severe HELLP syndrome Eclampsia 21

22 Diabetes Specificity in diabetes documentation may increase severity of patient captured in the record Document Potential Specifications Type of Diabetes DM Type 1 DM Type 2 DM due to underlying condition (e.g. Cushing s syndrome) Drug/chemical induced DM (Document the drug/chemical) Gestational DM Use of Insulin Long term Current Any manifestations or complications related to DM Example: Hyperglycemia, Hyperosmolarity ICD-10-CM Key Terminology Change If left unspecified, diabetes will default to the DM Type 2 It is no longer required to specify controlled or uncontrolled diabetes Physician Documentation Example ICD-10-CM allows the capture of related conditions with one code instead of multiple codes Type 1 diabetes with nonproliferative diabetic retinopathy Type 1 diabetes with ketoacidosis without coma 22

23 Diabetic Manifestations & Complications DM manifestations and complications increase SOI when linked to DM Two Ways to Capture Documentation: The term with : Diabetes with : Hypoglycemia Hyperglycemia Hyperosmolarity Ketoacidosis Coma/nonketotic hyperglycemic-hyperosmolar coma The term Diabetic : Diabetic nephropathy Diabetic chronic kidney disease stage 4 Diabetic gastroparesis Diabetic neuropathy (mono/poly/autonomic) Example: Type 2DM with hypoglycemia without coma with diabetic gastroparesis Key Terminology Changes: The term uncontrolled or controlled does not exist in ICD-10-CM. When diabetes is documented as inadequately controlled, poorly controlled, or out of control it will be coded to diabetes by type with the complication of hyperglycemia. Common Insufficient Documentation Diagnosis Lists Impression: DM Type 2 Debridement Foot ulcer LINK-LINK-LINK Best Practice Documentation Excisional debridement of Type 2 DM L mid foot ulcer with necrosis of muscle 23

24 Maternal Infection ICD-10-CM documentation Key Documentation Concepts Documentation needed if: Drug resistance Location Carrier state Organism It is complicating the pregnancy It is aggravated by the pregnancy It is the reason for obstetric care It is known or suspected that it can affect the fetus Specify drug name Specify location Examples: bladder, cervix, endometritis, kidney, oophoritis, parametritis, pelvis peritonitis, salpingooophoritis, urethra Specify state of carrier Strephtococcus B carrier state Specify the organism Examples: e. coli, herpes gestationis, obstetrical tetanus, TB, syphilis, gonorrhea, viral hepatitis 24

25 HIV Documentation ICD-10-CM documentation Key Documentation Concepts Document or distinguish If AIDS, document If patient is admitted due to an HIVrelated illness rather than pregnancy Asymptomatic HIV infection AIDS Symptoms Link symptoms to the HIV ( due to / with ) Name the HIV-related condition and link it to HIV The obstetric code (HIV disease complicating pregnancy) always takes sequencing priority whether the OB patient has symptomatic HIV (AIDS) or is simply HIV positive Patients with any known prior diagnosis of an HIV-related illness should be coded as HIV infection on every subsequent admission or encounter. They should never be assigned to asymptomatic HIV infection status. 25

26 Sepsis Documentation ICD-10-CM documentation During labor Sepsis Pyrexia Puerperal infections Puerperal sepsis Fever of unknown origin Genital tract infection (cervix, endometrium, vagina) Urinary tract infection (kidney, bladder, urethra) Infected surgical wound (cesarean, perineal repair) Obstetric pyemic or septic embolism Puerperal septic thrombophlebitis Following abortion Spontaneous, attempted, or elective Complete, incomplete or failed Example: Severe sepsis following failed spontaneous abortion with acute renal failure due to group B strep Documentation Tips Always document: Trimester Childbirth Puerperium Abortion Organism Severe sepsis Organ dysfunction Septic shock Drug resistance 26

27 Documenting Tobacco Exposure ICD-10-CM requires documentation of tobacco exposure, specifically for: Pulmonary & Digestive diseases Diseases of the head, neck, mouth and esophagus During pregnancy, birth and puerperium Document Level of Usage Type of Usage/Exposure No Use Exposure During pregnancy, birth and puerperium Environmental tobacco smoke (2 nd hand smoke) Use Tobacco use (current) Tobacco use (past) Dependence Nicotine dependence and source (e.g. cigarettes, chewing tobacco, other) Nicotine dependence in remission With or without other nicotine-induced disorders 27

28 High-Risk Pregnancy ICD-10-CM Documentation Concepts High Risk Pregnancy Documentation Concepts Document history of Infertility Ectopic or molar pregnancy Poor reproductive or obstetric history Recurrent pregnancy loss Preterm labor In utero procedure during previous pregnancy Specify Insufficient antenatal care Grand multiparity Young primigravida or multigravida Social problems Assisted reproductive technology In utero procedure during current pregnancy 28

29 Fetal Abnormality Documentation Key Documentation Concepts Suspected or proven fetal abnormality In utero surgery Central nervous system abnormality (e.g. anencephaly, hydrocephalus, spina bifida) Chromosomal abnormality Hereditary disease in fetus Considered an obstetric encounter Identify the fetal condition Details of the procedure performed Documentation Tips Always document Fetus Trimester If care of fetal problem modifies maternal care be sure to document the required diagnostic studies, any additional observations, special care, and termination of pregnancy. 29

30 Fetal Complications Document damage to the fetus from disease of the mother Cytomegalovirus infection Listeriosis Rubella Toxoplasmoisis Alcohol or drugs Radiation Other medical procedures (e.g. amniocentesis, biopsies, intrauterine contraceptive device, intrauterine surgery) 30

31 Fetal Complications No New Changes for ICD-10-CM, Except Documentation of Fetus (7th Character) Documentation Concepts Rhesus isoimmunization ABO isoimmunization Anti-D [Rh] antibodies Anti-A sensitization isoimmunization Hydrops fetalis Intrauterine death after completion of 20 weeks of gestation Known or suspected poor fetal growth Known or suspected placental insufficiency Excessive fetal growth Viable fetus in abdominal pregnancy Inconclusive fetal viability Decreased fetal movements Fetal anemia and thrombocytopenia 31

32 Labor Timing Documentation Labor Timing Documentation False Labor Before 37 weeks of gestation At or after 37 weeks of gestation Preterm labor Late Pregnancy Identify the trimester Without delivery With delivery With preterm delivery Document the fetus and trimester With term delivery Post-term 32

33 Obstructed Labor Maternal Avoid nonspecific terms (Low SOI - Cephalopelvic or Fetopelvic disproportion) Is it the mother Is it the baby Both Maternal pelvic abnormality Deformity of maternal pelvic bones Generally contracted pelvis Inlet contraction of pelvis Outlet contraction Fetopelvic disproportion Abnormality of maternal pelvic organs Document exact reason that the mother is the contributing factor for the obstructed labor Fetal causes Fetal Unusually large fetus Hydrocephalus Fetal deformity (e.g. ascites, hydrops, meningomeylocele, sacral teratoma, tumor) Malposition and malpresentation of the fetus Incomplete rotation of fetus Breech presentation Face presentation Brow presentation Shoulder presentation Be sure to document this by individual fetus 33

34 Obstructed Labor Other reasons for obstructed Labor Shoulder dystocia Locked twins Abnormal pelvic organs Failed attempted vaginal birth after previous C-section Attempted application of vacuum or forceps Subsequent delivery by forceps Subsequent delivery by cesarean delivery Multiple fetuses Avoid nonspecific terms Documentation Tips (e.g. dystocia, fetal dystocia, and maternal dystocia) 34

35 Umbilical Cord Complications and Documentation Prolapse of cord Cord around the neck (with or without compression) Cord entanglement (with or without compression) Short cord Vasa previa Vascular lesion of cord Other cord complications ICD-10 Update The term nuchal cord is not used in ICD-10-CM 35

36 Antepartum Complication Documentation Documentation Needed Premature rupture of the membranes Preterm Full-term Number of hours between ROM and onset of labor Onset of labor < 24 hours Onset of labor > 24 hours Antepartum hemorrhage With or without coagulation defect 36

37 Labor and Delivery Complications: Maternal and Fetal Capture Mother, Infant, or Postpartum Hemorrhage for SOI to be Accurate Maternal and Fetal Hemorrhage Hemorrhage Intrapartum (excessive) associated with a coagulation defect Postpartum Third-stage hemorrhage, type of adherent placenta Other immediate postpartum hemorrhage Coagulation defects Delayed and secondary postpartum hemorrhage Retained portions of placenta/membranes, without hemorrhage Delayed delivery after artificial rupture of membranes Onset of labor after 37 but before 39 completed weeks gestation, with delivery by cesarean section, reason for planned cesarean section Maternal Maternal distress, infection, sepsis, identify infection agent, maternal exhaustion, pyrexia, shock, cardiac arrest, failure, cerebral anoxia, pulmonary edema Fetal Abnormality of fetal acid-base balance, meconium in amniotic fluid, fetal stress due to drug administration, abnormality in fetal heart rate or rhythm, other evidence of fetal stress (electrocardiographic, ultrasonic) 37

38 Antepartum Complication Documentation Documentation of Complications of Care ICD-10-CM coding terminology will change to more accurately identify when complications occur Two Key Components To Remember: 1. ICD-10-CM has replaced the term post-operative with post-procedural or post-surgical An expected post-procedural or postsurgical condition 2. Conditions occurring in the post-operative period should be clarified as: An unexpected post-procedural or postsurgical condition, related to the patient s underlying medical comorbidities An unexpected post-procedural or postsurgical condition, unrelated to surgical procedure An unexpected post-procedural or postsurgical condition related to surgical care (a complication of care) 38

39 Documentation of Procedural Complications Procedure notes should reflect any of the following regarding complications Documentation Concepts Timing Procedure Associated with Intraoperative Post-procedure Late effect Aspiration, puncture, other Endoscopic exam Infusion, transfusion, injection Removal of a catheter or packing Medical procedure Name It Accidental puncture/laceration Same or different system Blood products Central venous catheters Drugs: What adverse effect Drug name Correctly prescribed Properly administered Reminders: Often times the terms postsurgical, post-procedural or postoperative are a time stamp and not a complication of care. When documentation within the record is unclear, it is advised that the physician be queried. Encounter Initial Subsequent Sequelae 39

40 Delivery Documentation Delivery Documentation Outcome of Delivery On maternal record when delivery occurs Not on newborn or subsequent record Number of fetuses All live-born Some stillborn All stillborn Place of Birth In a hospital, birthing center, or other healthcare facility Outside of the hospital Type of Delivery Vaginal Cesarean and give reason for admission Circumstances/complication unrelated to cesarean Condition that resulted in cesarean 40

41 Outpatient Procedures & ICD-10-PCS Key Considerations When Documenting Procedures in the Outpatient or Ambulatory Setting 1. ICD-10-PCS is only used on inpatient procedures 2. If you do an outpatient procedure on a patient who is admitted within 3 days, then that procedure is rolled into the inpatient admission if the admission is for a related diagnosis 3. Physician should document outpatient procedures to satisfy ICD-10-PCS, HCPCS and CPT in case the patient is admitted as an inpatient ICD-10-PCS and CPT Billing If this information is not accurate and not coded correctly, the provider may not receive payment due to new Part A/Part B cross claim audits (pre-payment audits). As a result, your surgical fees can be denied because the new ICD-10-PCS codes are not in sync. 41

42 Summary of Best Practice Documentation Teaching Points Key Documentation Concepts Conflicting, incomplete, or ambiguous documentation will lead to a query Carry all documentation from diagnostic test into progress notes to ensure it will be captured Documentation of tobacco exposure is crucial Sign, symptoms and test results do not contribute to SOI unless their significance is documented or they are linked to a named disease Many key definitions changes for OB Trimester is determined from weeks documented Identify complications for each NUMBERED fetus Document preexisting or gestational hypertension and link to underlying conditions Identify the type, associated conditions and manifestations related to DM Clarify if maternal infections were complicating the pregnancy, aggravated by the pregnancy, or the reason for obstetric care Link associated conditions to the pregnancy, or make it clear if a secondary condition is not related to the pregnancy Multiple gestations: document number of placentas, fetuses and amniotic sacs Capture any diseases of the mother including cytomegalovirus infection, listeriosis, rubella and toxoplasmoisis Identify the number of hours between the onset of labor and ROM Documentation should capture reason for obstructed labor Remember to capture documentation of any pregnancy, fetal, maternal, or antepartum complications 42