Preparing for ICD-10-CM: Reporting Pain Practical Tips for Radiologists and Radiology Departments

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1 Preparing for ICD-10-CM: Reporting Pain Practical Tips for Radiologists and Radiology Departments Webinar starts 11:00 a.m. central time This presentation will begin at 11:00 a.m. central time (no sound until then) Trouble connecting to audio? Click the audio button on the right side of your screen. Question? Please use chat. Enter question here Today s presentation is informational only - no credit is available. Page 1 vrad.com Preparing for ICD-10-CM: Reporting Pain Practical Tips for Radiologists and Radiology Departments Sharon Roeder, CPC Manager of Payer Coding Compliance, vrad November 19,

2 Disclaimer This presentation is designed to provide participants with reimbursement and coding related news, updates and guidance. The materials and documents presented are not intended to supersede any policies, procedures, or templates that vrad or your facility has approved and implemented, unless specifically noted. The information, while accurate, to the best of our knowledge, at the time of production, may not be current at the time of use. Information is provided as general guidance only and is not a recommendation for a specific situation. Viewers should consult official sources (CMS, ACR, AMA) or a qualified attorney for specific legal guidance. Information provided is based on Medicare Part B billing guidelines and may or may not pertain to Medicare Part A billing. Viewers should consult their Part A Medicare Administrative Contractor website for hospital billing guidelines. Page 3 vrad.com Our Agenda Introduction Reporting Pain Pain Codes in Chapter 6: Central Nervous System Pain Codes in Chapter 18: Signs and Symptoms Pain Codes in Chapter 13: Musculoskeletal & Connective Tissues Page 4 vrad.com

3 ICD-10 represents a significant change that impacts the entire health care community. It will provide greater data analytics, which will lead to better patient care. The degree of success a practice will have transitioning to the new ICD-10 code set will largely be determined by how well they prepare themselves Dixon Davis, MBA/MHSA Page 5 vrad.com Experts report 47% of physician documentation does not contain adequate specificity to transition to ICD-10. The remaining presentations in the ICD-10 webinar series from vrad will provide concrete examples of the degree of specificity to which we will be required to document after October 1, 2015, when ICD-10-CM is implemented. Page 6 vrad.com

4 Gap Analysis on Documentation Weaknesses A vrad audit of 400 radiology reports revealed ICD-10-CM documentation gaps in 46% of the orders and reports. Documentation tips to bridge the gaps: Anatomical details Laterality Severity, quality, type, or status/stage of disease Complications or manifestations Nature of an injury Site Type of injury Etiology Place of occurrence Page 7 vrad.com Gap Analysis on Documentation Weaknesses A vrad audit of 400 radiology reports revealed ICD-10-CM documentation gaps in 46% of the orders and reports. Documentation tips to bridge the gaps: Encounter not documented on injuries/fractures Initial Subsequent Sequela Routine healing or delayed healing Disease relationships Page 8 vrad.com

5 ICD-10-CM Official Guidelines for Coding and Reporting 2014 Many of the same structures and conventions of classification found in ICD-9-CM remain the same in the ICD-10-CM Guidelines. Coding Tip Centers for Disease Control and Prevention However, there are also new concepts found in the ICD-10-CM guidelines. One new concept is the Excludes 2 notes. Exclude notes are important in making the appropriate selection of diagnostic codes. These guidelines are approved by four organizations: Excludes 1 notes that the code excluded should never be used at the same time as the code above the Excludes 1 note. Excludes 2 notes indicate that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When appropriate, it is acceptable to use both codes together. American Hospital Association (AHA) American Health Information Management Association (AHIMA) Centers for Medicare & Medicaid Services (CMS) National Center for Health Statistics (NCHS) Page 9 vrad.com ICD-10-CM Chapter List Coding Tip Chapter Code Range Title I A00-B99 Certain infectious and parasitic diseases II C00-D48 Neoplasms III D50-D89 Disesees of blood and blood-forming organs & certain disorders involving the immune mechanism IV E00-E90 Endocrine, nutritional and metabolic diseases V F00-F99 Mental and behavioural disorders VI G00-G99 Diseases of the nervous system VII H00-H59 Diseases of the eye and adnexa VIII H60-H95 Diseases of the ear and mastoid process IX I00-I99 Diseases of the circulatory system X J00-J99 Diseases of the respiratory system XI K00-K93 Diseases of the digestive system XII L00-L99 Diseases of the skin and subcutaneous tissue XIII M00-M99 Diseases of the musculoskeletal system and connective tissue XIV N00-N99 Diseases of the genitourinary system XV O00-O99 Pregnancy, childbirth and the puerperium XVI P00-P96 Certain conditions originating in the perinatal period XVII Q00-Q99 Congenital malformations, deformations and chromosomal abnormalities XVIII R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified XIX S00-T98 Injury, poisoning and certain other consequences of external causes XX V01-Y98 External causes of morbidity and mortality XXI Z00-Z99 Factors influencing health status and contact with health services XXII U00-U99 Codes for special purposes Page 10 vrad.com World Health Organization 5

6 Reporting Pain Types of Pain in ICD-10-CM Coding Tip Many imaging studies are ordered because the patient is experiencing pain. Three places to find pain codes in the ICD-10-CM manual: 1. Pain that points to disorders of specific body systems are classified in the body system chapters, for example: Low back pain is in the Musculoskeletal chapter (M54.5) Limb pain (M79.6 ) Testicular pain is in the Genitourinary chapter (N5Ø.8) 2. Pain that does not point to a specific body system is in the Symptoms and Signs chapter, e.g. abdominal pain (R1Ø._ ) 3. Acute or chronic pain are in the Nervous System chapter (G89._ ) Page 12 vrad.com

7 Pain Codes in Chapter 6: Diseases of the Central Nervous System (GØØ-G99) Pain Codes in the Central Nervous System Category Coding Tip Category G89, Chapter 6: Acute and Chronic pain Neoplasm-related pain Pain syndromes Excludes generalized pain (R52) and pain related to psychological factors (F45.41) Pain, not elsewhere specified Pain management or pain control Use as the primary diagnosis when this is the reason for an encounter Underlying cause of the pain should be documented/coded if known Use codes in category G89 in conjunction with site-specific pain codes Page 14 vrad.com

8 Acute, Chronic, Neoplasm Related, and Pain Syndromes If the purpose of the encounter is to manage the pain rather than the underlying condition, use a pain code as the primary of first listed code. If the cause of the pain is known, assign the underlying diagnosis. Examples: A patient is referred to an interventional radiologist for a facet joint injection. The patient has chronic low back pain due to degenerative disc disease (DDD) of the thoracic spine with radiculopathy. G89.29 Other chronic pain (encounter is for pain control) M51.14 Intervertebral disc disorders with radiculopathy, thoracic region An interventional radiologists performs kyphoplasty on a patient who has chronic back pain due to an osteoporotic compression fracture of the thoracic spine. M8Ø.Ø8 Age-related osteoporosis with current pathological fracture, vertebra (encounter is to treat the vertebral compression fracture) Page 15 vrad.com Acute and Chronic Pain Category G89: Acute pain Due to trauma Post-thoracotomy pain Postoperative or postprocedural pain (beyond routine pain associated with procedure) Chronic Pain Due to trauma Post-thoracotomy pain Postoperative or postprocedural pain Other chronic pain Coding Tips: Default to acute when documentation does not indicate if pain is acute or chronic. There is no time frame rule guiding when pain becomes chronic. Do not use a G89 code for specific postoperative complications such as painful wire sutures, postoperative infection, complications of implants. Do not use G89 codes for expected postoperative pain immediately after surgery Page 16 vrad.com

9 Neoplasm-Related Pain and Two Pain Syndromes Category G89: Neoplasm related pain Cancer associated pain Pain due to malignancy, either the primary or metastatic site Tumor associated pain Central pain syndrome A neurological condition caused by damage to or dysfunction of the central nervous system (CNS). Result of a stroke Multiple Sclerosis Parkinson s disease CNS trauma Chronic pain syndrome (CPS) Associated with significant psychosocial dysfunction CPS has an unclear etiology and poor response to therapy Page 17 vrad.com Acute and Chronic Pain Documentation and Coding Patient presents with neck pain. He states he has been suffering stiffness for a few days. M54.2 Cervicalgia Do not use a code from G89 category: not related to pain management, a neoplasm or postprocedural pain After a procedure, a patient complains of severe post-thoracotomy pain. The pain does not abate with medication. The patient presents for radiological exam. G89.12 Acute pain post-thoracotomy pain Patient presents for evaluation of his chronic bilateral knee pain. The pain has been becoming more severe lately. Further radiological examination is ordered. M Pain in the right knee M Pain in the left knee G89.29 Other Chronic pain Coding Tip: When no bilateral code is provided, assign separate codes for both the right & left side Page 18 vrad.com

10 Neoplasm-Related Pain Documentation and Coding A female patient is referred for a PET/CT scan who is currently being treated for breast cancer, central portion of the right breast with bone metastasis. She is experiencing increased cancer pain. (the purpose is to evaluate her cancer, not manage the pain). C Malignant neoplasm of the central portion of Rt. female breast C79.51 Secondary malignant neoplasm (metastasis) of the bone G89.3 Neoplasm related pain Coding Tip for Neoplasms: When the reason for the encounter is management of the neoplasm and cancer pain is also documented, code G89.3 may be assigned as an additional diagnosis. It is not necessary to assign an additional code for the site of the pain. When a patient admission or encounter is because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis, even though the primary malignancy is still present. Page 19 vrad.com Pain Codes in Chapter 6: Headaches 10

11 Types of Migraine Headaches Chapter 6: Diseases of the Nervous System Category G43 Migraine Hemiplegic migraines are very serious and rare. Symptoms range from concerning to debilitating. Patient may experience paralysis. Symptoms usually last from 5 to 60 minutes. Chronic migraines are classified by the International Headache Society as a migraine that occurs more than 15 days per month for at least three (3) months. Characteristics of Migraines: Migraine with aura ( classic migraine) Bright flashing lights Blind spots Distorted vision Temporary vision loss Wavy lines Ringing in ears Funny feeling Migraine without aura ( common migraine) Persistent migraines last more than three (3) months and occur daily from within three (3) days of onset. Page 21 vrad.com Migraine Medical Terms Opthalmoplegic (ocular) migraines cause pain around the eyes. They may also cause dilated pupils and eye movement is associated with pain. These migraines are rare and most commonly occur in children. Menstrual migraines are primarily caused by estrogen. When the levels of estrogen change, a female patient is more likely to suffer from these type of headaches. They most commonly occur before, during, or immediately after ovulation or menstruation. Abdominal migraines usually affect children between the ages of 5-9. They are hard to diagnose because the patient may only complain of pain in the abdomen without an associated headache. Characteristics of Migraines: Status migrainosus is a rare and severe type of migraine that can last 72 hours or longer. The pain and nausea are so severe that it may lead to hospitalization. Intractable headaches (refractory) do not respond to standard medication or therapy. Page 22 vrad.com

12 Coding and Documenting Migraines Migraine Migraine without aura G43.Ø Migraine with aura G43.1 Hemiplegic migraine G43.4 Persistent migraine G43.5 Chronic Migraine Without Aura G43.7 Opthalmoplegic Migraine G43.B Abdominal migraine G43.D Menstrual Migraine G43.82 Not Intractable or Intractable With or Without Status Migrainosus Not Intractable or Intractable With or Without Status Migrainosus Not Intractable or Intractable With or Without Status Migrainosus With or Without Cerebral Infarction Not Intractable or Intractable With or Without Status Migrainosus Not Intractable or Intractable With or Without Status Migrainosus Not Intractable or Intractable Not Intractable or Intractable Other and Unspecified Migraines: Requires knowing if the migraine is Intractable or not intractable, as well as with or without status migrainosus. When status unknown, default to G Migraine, unspecified, not intractable, without status migrainosus. Not Intractable or Intractable With or Without Status Migrainosus Page 23 vrad.com Migraine Headache Clinical Example Documentation of the clinical history: The patient has been suffering from ongoing migraines for several years and they are tension type migraines. What information is lacking? Because chronic migraines are classified by the International Headache Society as occurring more than 15 days per month for at least three months, the documentation of several years does not provide the information required to code this as chronic migraine. The documentation does not indicate if the headaches are intractable or not intractable or if they are with or without status migrainosus. How it would be coded based on the documentation: In this example, without further information from a query to the radiologist or the ordering provider, the report would be coded as a tension type headache: G Chronic tension head, non-specified NOTE: tension headaches also require documentation of intractable or not intractable Page 24 vrad.com

13 Other Headache Syndromes G44 Other headache syndromes Excludes 1: headache NOS (R51) Excludes 2: atypical facial pain (G5Ø.1) Headache due to lumbar puncture (G97.1) Migraines (G43._) Trigeminal neuralgia (G5Ø.Ø) Other Types of headaches: Allergic headaches Cluster headaches Tension headaches Vascular headaches Post-traumatic Drug-induced Page 25 vrad.com Other Headache Syndromes Other headache syndromes G44 Cluster headaches G44.Ø Unspecified G44.ØØ_ Episodic G44.Ø1_ Chronic G44.Ø2_ Episodic paroxysmal hemicrania G44.Ø3_ Chronic paroxysmal hemicrania G44.Ø4_ SUNCT 1. G44.Ø5_ TAC 2. G44.Ø9_ Sixth Digit: 1 = Intractable 9 = not intractable (NOS) Vascular headache G44.1 Tension headaches G44.2 Unspecified G44.2Ø_ Episodic G44.21_ Chronic G44.22 Sixth Digit: 1 = Intractable 9 = not intractable (NOS) Posttraumatic headaches G44.3 Unspecified G44.3Ø_ Acute G44.31_ Chronic G44.32_ Sixth Digit: 1 = Intractable 9 = not intractable (NOS) Druginduced headaches G44.4_ Intractable G44.41 Not Intractable G44.4Ø Complicated headache syndromes G44.5_ Hemicrania continua G44.51 NDPH 3. G44.52 Primary thunderclap G44.53 Other complicated headache syndromes G SUNCT Short-lasting unilateral neualgiform headache with conjunctival injection and tearing 2. TAC - Trigeminal autonomic cephalgias 3. NDPH New daily persistent headache Other specified headache syndromes G44.8_ Hypnic G44.81 Associated with sexual activity G44.82 Primary cough G44.83 Primary exertional G44.84 Primary stabbing G44.85 Page 26 vrad.com

14 Headache NOS (not otherwise specified) R51 Headache The go-to code for "headache when information is lacking or if chronic daily headache nasal septum headache Read notes and look for other indications that direct to more appropriate and specific codes Page 27 vrad.com Pain Codes in Chapter 18: Signs, Symptoms, and Abnormal Clinical Findings (RØØ-R99) 14

15 Signs, Symptoms, and Abnormal Clinical Findings Signs, symptoms, and abnormal test/clinical findings are used when a definitive diagnosis has not been established by the provider. Use codes from Chapter 18 (RØØ-R99) when the radiological exam is investigational: Rule-out a condition Consistent with condition Suggesting a condition Codes from this chapter can be used in addition to a related definitive diagnosis when the signs and symptoms are not normally associated with that diagnosis Page 29 vrad.com Order Scenario Definitive diagnosis: A chest x-ray has been ordered on a patient who has spiked a fever and their cough has worsened. The patient is being treated for bacterial pneumonia caused by Klebsiella pneumoniae. J15.0 Pneumonia due to Klebsiella pneumoniae In this example the symptoms are related to the condition and would not require coding these symptoms. No definitive diagnosis established: A chest x-ray has been ordered on a patient who has a high fever and cough. The ordering physician wants to rule out pneumonia. R05 Cough R5Ø.9 Fever of unknown origin In this example, the condition is not confirmed so the rule-out pneumonia cannot be coded. If the CXR is normal, the signs and symptoms must be coded. Page 30 vrad.com

16 Chest Pain Types of Chest Pain: Ischemic chest pain (mycardial ischemia) Unpleasant, often excruciating pain associated with decreased blood flow. Caused by mechanical obstruction, constricting orthopedic casts, insufficient blood flow that results from injury /surgical trauma, or possible myocardial infarction. Chest pain on breathing can be a sign of pulmonary embolism. Precordial pain is located in the precordium (the lower chest and epigastric area). Pleurodynia Spasms of pain in the intercostal muscles between the ribs or in the chest wall area. Inflammation of the pleural membranes. Patient may also have a fever. Intercostal pain Pain originating in the intercostal nerves. Intercostal nerves run between pairs of adjacent ribs. Page 31 vrad.com Coding and Documenting Chest Pain Chest Pain Chest Pain on Breathing RØ7.1 Precordial Pain RØ7.2 Other Chest Pain R07.8 Unspecified Chest Pain RØ7.9 Pleurodynia RØ7.81 Excludes epidemic pleurodynia Intercostal pain RØ7.82 Other chest pain RØ7.82 Anterior chest-wall pain NOS Page 32 vrad.com

17 Abdominal and Pelvic Pain ICD-10-CM codes contains over 30 different codes for abdominal and pelvic pain. Documentation tips: Abdominal area or quadrant of the abdomen Pelvic or perineal area Code is for both male and female patients Perineal pain is between: a man s anus and scrotum a woman s anus and vulva Acute abdominal pain: Sudden, severe pain Likely to have a condition that requires surgery Page 33 vrad.com Coding and Documenting Abdominal/Pelvic Pain Abdominal and Pelvic Pain Pelvic & Perineal Pain R1Ø.2 Acute Abdominal Pain Abdominal Tenderness Upper R1Ø.1Ø Lower R1Ø.3Ø RUQ R1Ø.11 LUQ R1Ø.12 RLQ R1Ø.31 LLQ R1Ø.32 Periumbilic R1Ø.33 Epigastric R1Ø.13 Generalized R1Ø.84 Unspecified R1Ø.9 Rebound Tenderness RUQ R1Ø.821 LUQ R1Ø.822 RLQ R1Ø.823 LLQ R1Ø.824 Periumbilic R1Ø.825 Epigastric R1Ø.826 Generalized R1Ø.827 Unspecified R1Ø.829 Other Abdominal Tenderness RLQ R1Ø.811 LUQ R1Ø.812 RLQ R1Ø.813 LLQ R1Ø.814 Periumbilic R1Ø.815 Epigastric R1Ø.816 Generalized R1Ø.817 Unspecified R1Ø.819 Page 34 vrad.com

18 Pain Codes in Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (MØØ-M99) Extremity Pain (M79. _) Coding Tip ICD-10-CM codes contain over 30 different codes for extremity pain. Documentation tips: Unspecified codes are included but will likely be denied as laterality should be easily identified Laterality Code for bilateral is not included Code both the right and left code to indicate bilateral pain Arm and leg codes should be used when pain is not localized to specific areas of the upper or lower extremities Joint pain is coded with the M25 code series Page 36 vrad.com

19 Extremity Pain Pain in Unspecified Limb M79.6Ø9 Arm Pain Right M79.6Ø1 Left M79.6Ø2 Leg Pain Right M79.6Ø4 Left M79.6Ø5 Upper Arm Pain Right M Left M Thigh Pain Right M Left M Forearm Pain Right M Left M Lower Leg Pain Right M Left M Hand Pain Right M Left M Foot Pain Right M Left M Finger(s) Pain Right M Left M Toe(s) Pain Right M Left M Page 37 vrad.com Joint Pain Pain in Unspecified Joint M25.5Ø Shoulder Pain Right M Left M Hip Pain Right M Left M Elbow Pain Right M Left M Knee Pain Right M Left M Wrist Pain Right M Left M Ankle and Foot Joint Pain Right M Left M Page 38 vrad.com

20 Documentation Example for Joint Pain Example: A patient is referred for ankle x-rays for chronic right ankle pain. The exam is negative and does not reveal any findings regarding the pain. M Pain in the right ankle G89.29 Other chronic pain Page 39 vrad.com Resources ICD-10-CM Official Guidelines for Coding and Reporting, 2014; Centers for Disease Control and Prevention (CDC) website: ICD-10-CM Complete Draft Code Set; Optum Insight, Inc. CMS ICD-10 resources: American Academy of Professional Coders Resources (AAPC) website: Page 40 vrad.com

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