2012 CliftonLarsonAllen LLP. NE PA HFMA Meeting. ICD-10-CM Structure Overview/ Evaluation and Management Documentation

Transcription

1 NE PA HFMA Meeting ICD-10-CM Structure Overview/ Evaluation and Management Documentation 1 1

2 We have a code for that! W22.02XA- Injury occurred walking into a lamppost V97.33XA- Sucked into a jet engine, initial encounter W34.111A- Accidental malfunction of paintball gun, initial encounter W58.13XD- Crushed by crocodile, subsequent encounter W17.82XA- Fall from (out of) grocery cart, initial encounter 2

3 Latest On ICD codes are posted on the CMS website AMA submits letter to CMS requesting additional delay of 1 year on top of the 10/01/2014 date. Continued concerns over the cost to implement and the number of new codes. The Centers for Medicare and Medicaid Services (CMS) has sent its proposed rule for delaying the ICD-10 implementation date until Oct. 1, 2014, to the Office of Management and Budget (OMB). This is the last step before the rule is published as a final rule. CMS releases memo announcing final implementation date of 10/1/2014 to be published in Federal Register on 9/5/

4 ICD-10 Refresher Introduced by the World Health Organization (WHO) in 1998 Has been adopted by most other countries Mandated by HIPAA Codes are centered around gathering data Clinical modification has been done by the U.S. Adoption for ICD-10 effective 10/01/2013 Proposed new implementation date of 10/01/2014 (still waiting for this to be finalized by CMS) 4

5 ICD-10-CM Codes New coding system allows for approximately 70,000 coding combinations Room for expansion ICD-10-CM codes should tell a story of what the injury/illness is and how it happened Codes indicate laterality(left/right) and initial vs. subsequent encounter These distinctions are straight forward and unambiguous to code 5

6 Benefits of ICD-10-CM More accurate decisions/conclusions based on better, more precise data Reduced coding errors based on more accurate and updated terminology More precision coding with ICD-10 due to the ability of the structure to accommodate requested modifications Specific codes mean less manual intervention for claims processing and more automation leading to better accuracy and timely processing 6

7 Benefits of ICD-10-CM Expansion of ICD-10-CM injury and external cause code sections will create new opportunities for injury research and evaluation of trauma services for providers Ability to collect more detailed health information from post-acute settings than what is currently available in ICD-9-CM Ability to differentiate between multiple occurrences for an injury vs. a new injury 7

8 Chapter 1 Certain Infectious and Parasitic Diseases 8 8

9 Chapter 1 Includes categories for HIV, infections with a predominately sexual mode of transmission, intestinal infections, Tuberculosis and others Expansion to include manifestations of the disease and use of 4 th or 5 th digits allowing the infectious disease and manifestation to be captured in 1 code instead of 2 codes Example: A01.02, Typhoid fever with heart involvement 9

10 Chapter 2 Neoplasms 10 10

11 Chapter 2 Minor organizational changes 5 th character for extranodal and solid organ sites for lymphomas and Hodgkin's are examples of classification improvements in chapter 2 11

12 Chapter 3 Diseases of the Blood and Blood- Forming Organs and Certain Disorders Involving the Immune Mechanism 12 12

13 Chapter 3 Improvement in organizational structure Disorders and diseases are grouped in to subchapters for easier identification of conditions Terminology has also been updated Greater specificity than ICD-9 Chapter guidelines are currently reserved for future expansion 13

14 Chapter 3 Example 1: ICD-9-CM Folate deficiency anemia ICD-10-CM D52 Folate deficiency anemia D52.0 Dietary folate deficiency anemia D52.1 Drug-induced folate deficiency anemia (code first to identify drug T36-T50) D52.8 Other folate deficiency anemia's D52.9 Folate deficiency anemia, unspecified 14

15 Chapter 3 Example 2: ICD-9-CM Thalassemias ICD-10-CM D56 Thalassemia D56.0 Alpha thalassemia D56.1 Beta thalassemia D56.2 Delta-beta thalassemia D56.3 Thalassemia minor D56.4 Hereditary persistence of fetal hemoglobin D56.8 Other thalassemia D56.9 Thalassemia, unspecified 15

16 Chapter 4 Endocrine, Nutritional and Metabolic Diseases 16 16

17 Chapter 4 New subchapters have been added for endocrine, nutritional and metabolic diseases. Expanded codes for all 3 disorders but the most significant change is to diabetes section Diabetes and malnutrition have own subcategories in ICD-10-CM Current ICD-9-CM diagnosis code category for diabetes is limited Diabetes diagnosis codes have been expanded in ICD-10-CM 17

18 Chapter 4 Codes are combinations that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system ICD-10-CM includes 5 categories for Diabetes Mellitus: E08- Diabetes mellitus due to underlying condition E09- Drug or chemical induced diabetes mellitus E10- Type 1 diabetes mellitus E11- Type 2 diabetes mellitus E13- Other specified diabetes mellitus 18

19 Chapter 5 Mental and Behavioral Disorders 19 19

20 Chapter 5 This chapter contains more subchapters, categories, subcategories and codes than ICD-9-CM ICD-10-CM contains a separate category for nicotine dependence with subcategories identifying the type of tobacco product and nicotine-induced disorder In most cases, codes in this chapter parallel codes in DSM-IV TR (current Diagnostic and Statistical Manual of Mental Disorders) Major classification changes were made to the codes for drug and alcohol abuse and dependence 20

21 Chapter 6 Diseases of the Nervous System 21 21

22 Chapter 6 Organization of chapter 6 in ICD-10-CM is similar to current chapter in ICD-9-CM Only diseases of the nervous system are contained in this chapter in ICD-10-CM. ICD-9-CM combines diseases of the nervous system with diseases of the sense and sense organs Some codes for diseases of the nervous system have been expanded in ICD-10-CM Organic sleep disorders (i.e. sleep apnea) have significantly changed 22

23 Chapter 7 Diseases of Eyes and Adnexa 23 23

24 Chapter 7 New chapter in ICD-10-CM Conditions in this chapter are currently located in Chapter 6 of ICD-9-CM: Diseases of the Nervous System and Sensor Organs The organizational structure of this chapter is by site Chapter 7 also contains changes to reflect terminology used today This chapter has also expanded to include laterality (left/right/bilateral) 24

25 Chapter 8 Diseases of the ear and mastoid process 25 25

26 Chapter 8 New chapter in ICD-10-CM Conditions are located in Chapter 6: Diseases of the Nervous System and Sense Organs, in ICD-9-CM Codes are arranged to easily identify types of conditions that might occur in the following: External ear Middle ear and mastoid Inner ear Additional categories are present for other disorders of the ear and intra-operative & post-procedural complications 26

27 Chapter 9 Diseases of the Circulatory System 27 27

28 Chapter 9 Organizational structure for this chapter is comparable to chapter 7 in ICD-9-CM Terminology describing some cardiovascular conditions has been revised to reflect current medical practice. Example: ICD-9-CM 410- Acute myocardial infarction ICD-10-CM I21- ST elevation (STEMI) and non-st elevation (NSTEMI) myocardial infarction 28

29 Chapter 10 Diseases of the respiratory system 29 29

30 Chapter 10 Certain codes have been updated in this chapter to include notes indicating additional diagnosis codes must be assigned. Examples: Identifying infectious agents Identifying viruses Associated lung abscess Underlying diseases Identifying tobacco use or exposure Terms have been added to describe asthma 30

31 Chapter 10 ICD-10-CM has individual codes to describe acute recurrent sinusitis for each sinus, currently ICD-9-CM does not have this level of detail The subcategory for influenza has been expanded to identify additional manifestations. Example: J Influenza due to other identified influenza virus with encephalopathy J Influenza due to other identified influenza virus with myocarditis J Influenza due to other identified influenza virus with otitis media 31

32 Chapter 10 The category for acute bronchitis has been expanded to reflect manifestations of the acute bronchitis. Example: J20.0- Acute bronchitis due to Mycoplasma pneumoniae J20.1- Acute bronchitis due to Hemophilus Influenzae J20.2- Acute bronchitis due to streptococcus J20.5- Acute bronchitis due to respiratory syncytial virus 32

33 Chapter 11 Diseases of the Digestive System 33 33

34 Chapter 11 Restructured to bring related groups together Two new sections added: Diseases of liver and Disorders of gallbladder, biliary tract, and pancreas Crohn s disease has been updated with expanded 4 th, 5 th, and 6 th digits: 4 th digit specifies the site of the Crohn s disease 5 th digit indicates whether a complication was present 6 th digit further classifies the specific complication K Crohn s disease of large intestine with rectal bleeding 34

35 Chapter 12 Disease of Skin and Subcutaneous Tissue 35 35

36 Chapter 12 Restructured to bring groups of related diseases together This expanded from 3 subsections in ICD-9-CM to nine subsections in ICD-10-CM Instructional notes for coding have been expanded to include sequencing instructions Non-pressure chronic ulcers of lower limbs specify site, laterality and severity 36

37 Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue 37 37

38 Chapter 13 This chapter is organized by musculoskeletal system and connective tissue Almost every code in this chapter has been expanded with specific sites and laterality Pathological or stress fractures require a 7 th character: A- Initial encounter for fracture D- Subsequent encounter for fracture w/routine healing G- Subsequent encounter for fracture w/delayed healing 38

39 Chapter 13 Pathological or stress fracture 7 th character, Con t: K- Subsequent encounter for fracture w/nonunion P- Subsequent encounter for fracture w/malunion S- Sequela (late affect) Coding from this chapter should include bone, joint or muscle conditions that are the result of a healed injury and recurrent bone, joint or muscle conditions 39

40 Chapter 14 Diseases of the genitourinary system 40 40

41 Chapter 14 Not many significant changes to this chapter Terminology was updated. Example: ICD-10-CM includes a category for male erectile dysfunction with subcategories identifying different causes of the dysfunction Chapter 14 includes notes to help clarify types of disorders. Example: N00- Acute nephritis syndrome Includes: Acute glomerular disease Acute glomerulonephritis Acute nephritis 41

42 Chapter 15 Pregnancy, Childbirth and the Puerperium 42 42

43 Chapter 15 Codes from this chapter are used for conditions related to or aggravated by the pregnancy, childbirth, or by the puerperium Episode of care (antepartum, delivery, postpartum) is no longer the base of classification ICD-10-CM will use trimesters for coding conditions Some conditions do not include a trimester classification because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy does not apply 43

44 Chapter 15 New 7 th character codes required to identify the fetus in a multiple gestation 0- not applicable or unspecified 1- fetus 1 2- fetus 2 3- fetus 3 4- fetus 4 5- fetus 5 9- unspecified Note: Zero (0) is for a single gestation and multiple gestations where the affected fetus is unspecified 44

45 Chapter 15 New coding combinations for obstructed labor to include the reason for obstruction. Only 1 diagnosis code is needed in ICD-10-CM as opposed to 2 in ICD- 9-CM. Example: O64.2XX0- Obstructed labor due to face presentation, not applicable or unspecified This chapter is to be used for maternal records only ICD-10-CM requires a secondary Z code indicating weeks of gestation for the current encounter 45

46 Chapter 15 Gestation code examples: Z3A.20 (20 weeks gestation) Z3A.21 (21 weeks gestation) Z3A.34 (34 weeks gestation) Z3A.38 (38 weeks gestation) New codes indicating outcome of delivery. Example: Z37.00 (Single live birth) Z37.4 (Twins, both stillborn) Z37.61 (Triplets, some liveborn) 46

47 Chapter 16 Certain Conditions Originating in the Perinatal Period 47 47

48 Chapter 16 Codes from this chapter are coded for newborns only Codes should be used for conditions originating in the perinatal period Terminology updates: fetus or newborn are not used in ICD-10-CM code titles 48

49 Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities 49 49

50 Chapter 17 Expansion to congenital conditions and chromosomal abnormality codes Codes from this chapter can be used throughout the life of the patient Examples: Q05.0- Cervical spina bifida with hydrocephalus Q10.3- Other congenital malformations of eyelid 50

51 Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 51 51

52 Chapter 18 For signs and symptoms that do not definitely point to a particular Dx This chapter includes less well defined conditions and symptoms Conditions, signs and symptoms in this chapter consist of: 1. Cases for which a specific diagnosis can be made after all the facts of the case have been investigated 2. Signs or symptoms existing at the time of initial encounter proved to be short-term 52

53 Chapter 18 Conditions, signs and symptoms con t.: 3. Interim diagnosis for a patient who did not return for additional investigation or care 4. Referral cases for investigation or treatment before the diagnosis was made 5. Cases where a more precise diagnosis was not available for any other reason 6. Certain symptoms, for which supplementary information is not provided, that represent important problems in medical care 53

54 Glasgow Coma Scale Chapter 18 Scoring system used to describe the level of consciousness in a patient following traumatic brain injury Measures eye opening, verbal response and motor response Glasgow coma scale is primarily used by trauma registries and research use May also be used in any setting where information is collected 54

55 Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes 55 55

56 Chapter 19 Similarities between ICD-9-CM and ICD-10-CM: Separate codes should be assigned for multiple injuries Most serious injury is sequenced first Superficial injuries (abrasions or contusions) are not coded when associated with more severe injuries of the same site Primary injuries resulting in damage to nerves/blood vessels: injury is coded first; primary injury to blood vessels/nerves, this injury is coded first 56

57 Changes in ICD-10-CM: Chapter 19 Injuries are grouped by body part rather than category of injury S section covers injuries related to single body system The T section covers injuries to unspecified body regions as well as poisonings and other consequences of external causes 57

58 Changes in ICD-10-CM: Chapter 19 Most categories in this chapter have a 7 th character requirement 3 different choices for 7 th character value: A- Initial Encounter D- Subsequent Encounter S- Sequela 58

59 Chapter 19 Coding Example: A 9 month old girl is seen for increased fussiness and vomiting. After exam, the patient is diagnosed with shaken baby syndrome. T74.4xxA (Syndrome, shaken infant) The diagnosis code must be 7 digits, therefore the X placeholder is needed. The A at the end of the code is indicating this is an initial encounter. 59

60 Chapter 19 Fracture codes contain much greater specificity Fractures are coded by site If a fracture is not indicated as open or closed, it should be coded as closed If a fracture is not indicated as displaced or not displaced, it should be coded as not displaced 7 th character expansion indicates the encounter and type of fracture 60

61 Chapter 19 7 th Character Extensions for Fracture Care A- Initial encounter for closed fracture B- initial encounter for open fracture D- Subsequent encounter for fracture w/routine healing G- Subsequent encounter for fracture w/delayed healing K- Subsequent encounter for fracture w/nonunion P- Subsequent encounter for fracture w/malunion S- Sequela 61

62 Chapter 19 ICD-10-CM includes combination codes for poisonings and associated external causes Table of drugs and chemicals contains the following columns: Substance Poisoning, Accidental (unintentional) Poisoning, Intentional Self-Harm Poisoning, Assault Poisoning, Undetermined Adverse Affect Under-dosing 62

63 Chapter 20 External Causes of Morbidity 63 63

64 Chapter 20 Used to classify environmental events and circumstances as the cause of injury and other adverse effects Codes in this chapter are used to provide additional information on the cause of the condition Important for physician to be specific when documenting May be used with any code in range A00.0-T88.9 and Z00-Z99 Is a massive expansion from ICD-9-CM 64

65 Chapter 20 Transport accidents are divided into 12 groups Codes related to land transportation accidents reflect the victim s mode of transportation and are further subdivided to identify other victim s or type of event Place of occurrence codes: these codes identify the place where an injury occurred and is to be used with an activity code Activity codes: used to indicate the activity the patient had been performing when the injury occurred 65

66 Chapter 20 Coding example: A 20 year old female driver of a car that collided with a pickup truck on the interstate highway. The driver stated she was using her cell phone to send a text message to her boyfriend. V43.52XA- Car driver injured in collision with other type car in traffic accident, initial encounter Y Interstate highway as the place of occurrence of the external cause Y93.C2- Activity, hand held interactive electronic device 66

67 Chapter 21 Factors Influencing Health Status and Contact with Health Services 67 67

68 Chapter 21 Personal and family history codes have been expanded in this section Codes have been added that don t exist in ICD-9-CM such as: Z66 (Do not resuscitate) and category Z67 which identifies patient blood type. Z codes represent reasons for encounters and must be accompanied by a corresponding procedure code, if a procedure is performed Z codes are to be used when a patient is seen for reasons other than disease, illness or injury, which are classified under categories A00-Y89 68

69 Coding example: Chapter 21 Single female newborn was born vaginally in the hospital. The baby is being treated for Rh incompatibility. The baby has type A+ blood and the mother is type A-. Z Single liveborn infant, born vaginally P55.0- Rh isoimmunization of newborn Z Type A blood, Rh positive 69

70 Steps To Take Now Appoint a project manager or point person for ICD- 10 transition Determine initial tasks Schedule regular meetings Conduct an impact assessment Plan a budget Identify internal and external stakeholders Develop and stick with a specific implementation timeline Test your documentation process 70

71 Steps To Take Now Have coding staff determine what diagnosis codes are most commonly used and crosswalk those to new ICD-10 codes Create an inventory of documents that contain ICD-9 codes (i.e. Superbills, patient documents, notices) Encourage staff to start looking at ICD-10 structure and guidelines to get comfortable with the changes Contact an outside ICD-10 educator to present basic ICD-10 information to your practice 71

72 Implementation Tips Consider tailoring training for your coding staff rather than generic training Conduct a coder assessment Review current cases and volume to determine your focus for transitioning from ICD-9-CM to ICD-10-CM Determine if you have educational needs for only the coding staff vs. others in your practice Allow coders time to digest ICD-10-CM while consideration is given to current work load Become familiar with underlying ICD-10-CM structure 72

73 ICD-11 In May, WHO (World Health Organization) released a Beta version of ICD-11 This version will be tested and final approval is slated for 2015 As part of this testing process, the WHO will be working to ensure that the transition from ICD-10 to ICD-11 is seamless Technically ICD-10 could be skipped for ICD-11, but the WHO feels for a smooth transition ICD-10 should be implemented first 73

74 Implementation Tips Remember: ICD-10-CM transition is a marathon, not a sprint! 74

75 Chart Documentation 75 75

76 Chart Documentation Proper chart documentation is critical for appropriate billing and verifying services provided In particular, documentation and billing of Evaluation and Management codes (E/M) comes under scrutinization Past chart reviews show a wide variety of documentation styles Documentation habits need to change for ICD-10 Remember, if it s not documented it s not done! 76

77 Chart Documentation In addition to improving documentation for ICD-10, services billed need to be appropriately documented to justify billing Common issues: Non-specific Chief Complaint Review of systems stating See HPI Hand written documentation that cannot be read Diagnosis codes that don t match documented notes Ancillary services with no order on file 77

78 Challenges with EHR: Chart Documentation Copy and paste function Lack of medical necessity documentation Notes that are fragmented Fields that automatically populate Lack of customization on templates Issues with documentation and E/M codes Chart documentation for ICD-10 needs to be descriptive OIG scrutinizing E/M codes 78

79 Chart Documentation Office of Inspector General 2011 Work plan Payments for Evaluation and Management Services We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS s Medicare Claims Processing Manual, Pub. No , ch. 12, instructs providers to select the code for the service based upon the content of the service and says that documentation should support the level of service reported. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. (OEI; ; ; expected issue date: FY 2012; work in progress) 79

80 Chart Documentation Office of Inspector General 2012 Work plan Evaluation and Management Services: Trends in Coding of Claims We will review evaluation and management (E/M) claims to identify trends in the coding of E/M services from We will also identify providers that exhibited questionable billing for E/M services in Medicare paid $32 billion for E/M services in 2009, representing 19 percent of all Medicare Part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. (CMS s Medicare Claims Processing Manual, Pub. No , ch. 12, ) E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. 80

81 Chart Documentation Office of Inspector General 2012 Work plan Evaluation and Management Services: Potentially Inappropriate Payments We will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. 81

82 Things to Remember Correct clinical documentation is critical to the patient, physician and healthcare organization Documentation should be timely, accurate, complete and legible Health records should be documented at the time of service Documentation must support services billed With ICD-10 on the horizon now is a great time for physicians to work on documentation practices 82

83 Questions? 83

84 Contact Us Thank you so much! Please contact me with any questions. Karla VonEschen, CPC AHIMA Certified ICD-10-CM/PCS Trainer Follow our blog for current discussions on health care larsonallen 84