ICD-10-CM Coding Overview AHCA Spring Convention & Trade Show April 21-23, 2015

Transcription

1 ICD-10-CM Coding Overview AHCA Spring Convention & Trade Show April 21-23,

2 Why the Conversion to ICD-10-CM? ICD-10-CM provides more specific data than ICD-9-CM Better reflection of current medical practice Structure accommodates addition of new codes The current coding system is running out of capacity and cannot accommodate future state of health care Reduce coding errors Better analysis of disease patterns Track and respond to public health outbreaks Make claim submission more efficient Identify fraud and abuse 2 Structural Differences Between ICD-9-CM and ICD-10-CM ICD-9-CM 3-5 characters First character is numeric or alpha Characters 2-5 are numeric Always at least 3 characters Use of decimal after 3 characters ICD-10-CM 3-7 characters Character 1 is alpha Character 2 is numeric Characters 3-7 are alpha or numeric Use of decimal after 3 characters Use of dummy placeholder x Alphabetical characters are not case-sensitive 3 Other Differences Between ICD-9-CM and ICD-10-CM ICD-9-CM 14,025 codes Only uses 2 letters E, V 17 Chapters Hospital codes not used in LTC V-Code Multiple therapies as primary ICD-10-CM 68,069 codes Uses all letters except U 21 Chapters Acute codes with appropriate 7 th character to indicate subsequent care or sequela No Z code for Multiple Therapies as primary 4 Provided by Polaris Group AHCA Spring Conference Page 1 of 32

3 CPT and HCPCS No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS). CPT and HCPCS will continue to be used for Part B claims just as they are currently. 5 Systems/Applications Potentially Affected by Transition (not all-inclusive list) MDS software New MDS form effective Oct. 1, 2015 MDS Section Diagnosis updates Quality Measure risk factors/exclusions PPS RUGs diagnoses Billing software Electronic health record systems 6 ICD-10-CM Format ICD-10-CM code set is divided into two main parts: The Index which is an alphabetical list of terms and their corresponding code. Tabular List which is a sequential, alphanumeric list of codes divided into chapters based on body system or condition. 7 Provided by Polaris Group AHCA Spring Conference Page 2 of 32

4 The Index The Alphabetic Index includes: The Index of Diseases and Injury The Index of External Causes of Injury Neoplasm Table Table of Drugs and Chemicals 8 9 Tabular List Tabular List contains categories, subcategories, and codes which may be a letter or a number. All categories are three characters and if there is no further subdivision that is a code. Subcategories are either four or five characters. Codes can be three to seven characters in length. A code that has an applicable 7 th character is considered invalid without the 7 th character. 10 Provided by Polaris Group AHCA Spring Conference Page 3 of 32

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6 14 ICD-10-CM Websites CDC CMS 4-ICD-10-CM-and-GEMs.html ICD-9-CM to ICD-10-CM Crosswalk 15 NEW Coding Conventions and Terms in ICD-10-CM 16 Provided by Polaris Group AHCA Spring Conference Page 5 of 32

7 New Placeholder Character The ICD-10-CM utilizes a placeholder character X. The X is used as a placeholder for future expansion. Where a placeholder exists, the X must be used in order for the code to be valid. Couldn t find a common LTC example so will rarely be used th Character Example Certain ICD-10-CM categories have 7 th character. Applicable 7 th character is required for all codes within the category or as instructed by the notes in the Tabular List. S72.00D for example would be Fracture of Unspecified part of neck of femur, and 7 th character D means subsequent encounter for closed fracture with routine healing. 18 Expanded Combination Codes ICD-9-CM had combination codes but much more prevalent in ICD-10-CM due to greater specificity. A combination code is a single code used to classify: Two diagnoses, or A diagnosis with a secondary process (manifestation) A diagnosis with a complication 19 Provided by Polaris Group AHCA Spring Conference Page 6 of 32

8 Diabetes Combination Code Examples E08.3 Diabetes mellitus due to underlying condition with ophthalmic complications E08.31 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy E Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema 20 New Laterality BIG CHANGE ICD-10-CM allows us to specify left, right, or bilateral for certain codes. This was not available with ICD-9-CM. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, code unspecified side. 21 More Laterality Examples 22 Provided by Polaris Group AHCA Spring Conference Page 7 of 32

9 Expanded - Excludes Notes Excludes notes tell you that the code you are looking up excludes a certain diagnosis. Had Excludes Notes with ICD-9-CM but they are expanded to include types of excludes notes. Now Type 1 and Type 2 Each type has different definition for use but similar in that codes excluded from each other are independent of each other. 23 Excludes1 Example Telling you that aftercare for healing fx is not included in Z47 Orthopedic Aftercare 24 Excludes2 Example Telling you that fitting and adjustment is excluded but may use both codes 25 Provided by Polaris Group AHCA Spring Conference Page 8 of 32

10 New Code also note A code also note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing directions. So if you are looking up a code and see a Code also note, you would also code any of these diagnoses listed in the note that the resident may have. 26 Code Also Example 27 New Default Codes The default code is listed next to a main term in the ICD-10-CM Alphabetic Index. Represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned. So if you just have a generic diagnosis with no detail use code listed next to main term. 28 Provided by Polaris Group AHCA Spring Conference Page 9 of 32

11 Default Code Example So if you didn t have any more information than a generic dx of Hypertension, you would use the code next to main term hypertension which is I10 29 ICD-10-CM Coding Examples 30 ICD-10-CM Coding Example #1 31 Provided by Polaris Group AHCA Spring Conference Page 10 of 32

12 ICD-10-CM Coding Example #1 32 ICD-10-CM Coding Example #2 33 ICD-10-CM Coding Example #2 34 Provided by Polaris Group AHCA Spring Conference Page 11 of 32

13 ICD-10-CM Coding Example #2 35 ICD-10-CM Coding Example #3 36 ICD-10-CM Coding Example #3 37 Provided by Polaris Group AHCA Spring Conference Page 12 of 32

14 ICD-10-CM Coding Example #3 38 ICD-10-CM Coding Example #3 39 ICD-10-CM Coding Example #4 Unspecified Code 40 Provided by Polaris Group AHCA Spring Conference Page 13 of 32

15 ICD-10-CM Coding Example #4 Unspecified Code 41 ICD-10-CM Coding Example #5 Unspecified Code 42 ICD-10-CM Coding Example #5 Unspecified Code 43 Provided by Polaris Group AHCA Spring Conference Page 14 of 32

16 Chapter Specific Guidelines Will address additional coding guidelines not already covered in General Guidelines 44 Chapter-Specific Coding Guidelines In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. There are 21 chapters in the Official Coding Guidelines for ICD-10-CM. 45 Ch. 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) NEW letter for V Codes of ICD-9-CM. Z codes are for use in any healthcare setting. Z codes are not procedure codes so are used in LTC Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as firstlisted/principal diagnosis. 46 Provided by Polaris Group AHCA Spring Conference Page 15 of 32

17 Categories of Z Codes Status Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. A status code is informative, because the status may affect the course of treatment and its outcome. 47 Status Z Code Categories Z16, Resistance to antimicrobial drugs This code indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first. Z22, Carrier of infectious disease Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection. Z66, Do not resuscitate Z74.01, Bed confinement status Z78.1, Physical restraint status 48 Status Z Code Categories Z79 Long-term (current) drug therapy Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis). 49 Provided by Polaris Group AHCA Spring Conference Page 16 of 32

18 Categories of Z Codes Aftercare Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. 50 New - Aftercare Z Codes The aftercare Z code should not be used if treatment is directed at a current, acute disease. Use dx code instead. The aftercare Z codes should not be used for injuries. For aftercare of an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter). The aftercare codes are generally first-listed (principal) diagnosis to explain the specific reason for the encounter. 51 Aftercare Z Codes Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequela (late effects). For others, the condition is included in the code title. Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings. Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. 52 Provided by Polaris Group AHCA Spring Conference Page 17 of 32

19 Z47 Orthopedic Aftercare Example 53 Orthopedic Aftercare Examples 54 Chapter 9 Diseases of the Circulatory System (I00-I99) New laterality codes Dominant/non-dominant default codes Sequela 55 Provided by Polaris Group AHCA Spring Conference Page 18 of 32

20 Sequela (Late Effects) The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effects. We use the Sequela or Late Effects code in LTC which are the I69 codes in ICD-10-CM just like we used the 438 (Late Effects) codes rather than 436 (Acute) codes in ICD- 9-CM. 56 Sequelae of Cerebrovascular Disease Examples I Dysphagia following nontraumatic subarachnoid hemorrhage I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side I69.30 Unspecified sequelae of cerebral infarction **The I69 sequelae codes will be very common for LTC. 57 New - Application of 7 th Characters in Chapter 19 including Fractures Most categories in this chapter have three 7th character values (with the exception of fractures): A, initial encounter (not used in LTC) D, subsequent encounter S, sequela Categories for traumatic fractures have additional 7th character values. 58 Provided by Polaris Group AHCA Spring Conference Page 19 of 32

21 New - Application of 7 th Characters in Chapter 19 including Fractures 7th character A is for use as long as the patient is receiving active treatment for the fracture in the hospital setting. You will see this on diagnosis coming from the hospital. Examples of active treatment which would use 7 th Character A are:» surgical treatment» emergency department encounter» evaluation and treatment by the same or a different physician (but still during active treatment) 59 New - Application of 7 th Characters in Chapter 19 including Fractures We would NOT use the 7 th character A in LTC but need to recognize this code coming from the hospital and know that we would need to change 7 th character to appropriate subsequent character such as D or S for (sequela). ****This applies to certain chapters like Chapter 13 (musculoskeletal) and Chapter 19 (Fractures). 60 New - Application of 7 th Characters in Chapter 19 including Fractures 7th character D subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: SNF care removal of external or internal fixation device medication adjustment X-ray to check healing status of a fracture other aftercare and follow-up visits following treatment of the injury or condition 61 Provided by Polaris Group AHCA Spring Conference Page 20 of 32

22 Coding of Traumatic Fractures/Injuries The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first. A fracture not indicated as open or closed should be coded as Closed. A fracture not indicated whether displaced or not displaced should be coded to Displaced. 62 New - Fracture Complications Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R). A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. 63 ICD-10-CM Coding Example #3 64 Provided by Polaris Group AHCA Spring Conference Page 21 of 32

23 Process for Coding 65 Locating a Code PROCESS IS NOT NEW First locate term in the Alphabetic Index. Then verify in the Tabular List. Read and be guided by instructional notations that appear in both. Essential to use both Alphabetic Index and Tabular List. Alphabetic Index does not always provide the full code. 66 Level of Detail A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable. 67 Provided by Polaris Group AHCA Spring Conference Page 22 of 32

24 Assigning ICD-10-CM Codes When searching in Alphabetic Index: 1. Review the diagnostic statement 2. Identify the main terms which are diseases or conditions nouns 3. Do not start with anatomical site 4. Review diagnostic statement from right to left 5. Capture all components of diagnoses when possible 68 How to Assign a Code Example: COPD Chronic Obstructive Pulmonary Disease 1. Start with Disease 2. Then, Pulmonary 3. Next, Obstructive 4. Last, Chronic 69 ICD-9-CM to ICD-10-CM Case Studies 70 Provided by Polaris Group AHCA Spring Conference Page 23 of 32

25 Coding Example #1 Resident is admitted to Shiny Skies Nursing and Rehabilitation Center following a CVA resulting in Left-Sided Hemiparesis and Dysphagia that required placement of a G-tube. Resident is left handed. Resident also has Type II Diabetes. Resident will be receiving PT for gait training, OT for muscle weakness, and ST for dysphagia. 71 ICD-9-CM Answers for Coding Example #1: V57.89 Care involving use of rehab services; Other (Multiple training or therapy) Late effects of Cerebrovascular Disease, Dysphagia Late effects of Cerebrovascular Disease, Hemiplegia affecting dominant side V55.1 Attention to artificial opening; gastrostomy DM type II without mention of complication 72 ICD-9-CM Answers for Coding Example #1, continued: Abnormality of gait Generalized muscle weakness Dysphagia, unspecified (Difficulty in swallowing NOS) 73 Provided by Polaris Group AHCA Spring Conference Page 24 of 32

26 ICD-10-CM Answers for Coding Example #1: I Dysphagia following cerebral infarction I Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side Z43.1 Attention to gastrostomy E11.9 Type II Diabetes with other circulatory complications R26.9 Unspecified abnormalities of gait/mobility M62.81 Muscle weakness, generalized R13.10 Dysphagia, unspecified 74 Coding Example #2 Resident is admitted to your facility status post traumatic greater trochanter displaced right femur fracture from a fall that occurred at home. Resident presented with a Stage 2 pressure ulcer on both heels and coccyx. Resident will be receiving both PT and OT services. Resident also has a diagnosis of Essential Hypertension. PT will be treating resident for Difficulty Walking and OT for muscle weakness. 75 ICD-9-CM Answers for Coding Example #2: V57.89 Care involving use of rehab services; Other (Multiple training or therapy) V54.15 Aftercare from traumatic upper leg fracture Difficulty Walking Muscle Weakness (Generalized) Pressure Ulcer, coccyx Pressure Ulcer, heel Pressure Ulcer, stage Essential Hypertension, unspecified 76 Provided by Polaris Group AHCA Spring Conference Page 25 of 32

27 ICD-10-CM Answers for Coding Example #2: S72.111D Displaced fracture of greater trochanter of right femur, subsequent encounter for closed fracture with routine healing (7 th character D ) R26.2 Difficulty in walking, not elsewhere classified M62.81 Muscle weakness, generalized L Pressure ulcer of right heel, stage 2 L Pressure ulcer of left heel, stage 2 L Pressure ulcer of sacral region, stage 2 I10 Essential (primary) Hypertension 77 Coding Example #3 Resident is admitted to Home Sweet Home following abdominal surgery for bowel obstruction. Resident has post operative superficial wound that requires BID dressing changes due to abdominal dehiscence. Resident also has newly diagnosed UTI with E. Coli isolated in the culture. Resident is symptomatic with frequency, urgency and burning upon urination. Oral antibiotics are ordered x10 days. Resident will not receive therapy upon admission. 78 ICD-9-CM Answers for Coding Example #3: Disruption of external operation (surgical) wound (Abdominal dehiscence) V58.75 Aftercare following surgery of teeth, oral cavity and digestive system, NEC V58.31 Attention to surgical dressings and sutures UTI, site not specified E. Coli 79 Provided by Polaris Group AHCA Spring Conference Page 26 of 32

28 ICD-10-CM Answers for Coding Example #3: T81.32xD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter Z Encounter for surgical aftercare following surgery on the digestive system Z48.01 Encounter for change or removal of surgical wound dressing N39.0 Urinary tract infection, site not specified B96.20 Unspecified E. coli, as the cause of diseases classified elsewhere 80 Coding Example #4 Resident is admitted to Shady Grove after repair of a Fractured Left Hip sustained due to a fall. Resident has Left Hip Osteoarthritis from dysplasia with chronic NSAID use. Additional diagnoses include Essential Hypertension, Sinus Bradycardia and Hyperlipidemia NOS. Admission orders include lab work to monitor effect of Simivastatin and Omacor. Resident will be receiving PT for treatment of difficulty walking and OT therapy services for muscle weakness. 81 ICD-9-CM Answers for Coding Example #4: V57.89 Care involving use of rehabilitation services; Other (Multiple training or therapy) V54.13 Aftercare healing traumatic fracture of hip Osteoarthrosis, unspecified whether generalized or localized, pelvic region and thigh Difficulty Walking Muscle Weakness (Generalized) V58.64 Long-term (current) use of non-steroidal antiinflammatories (NSAID) 82 Provided by Polaris Group AHCA Spring Conference Page 27 of 32

29 ICD-9-CM Answers for Coding Example #4, continued: Essential Hypertension, unspecified Sinus Bradycardia NOS Other and unspecified hyperlipidemia V58.83 Encounter for therapeutic drug monitoring V58.69 Long-term (current) use of other medications 83 ICD-10-CM Answers for Coding Example #4: S72.002D Fracture of unspecified part of neck of left femur (Fracture of hip NOS) (7 th character D- subsequent encounter for closed fracture with routine healing) M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip Z79.1 Long-term (current) use of NSAIDS Z Other long term (current) drug therapy Z51.81 Therapeutic drug level monitoring 84 ICD-10-CM Answers for Coding Example #4: Continued R26.2 Difficulty in walking, not elsewhere classified M62.81 Muscle weakness, generalized Z51.89 Encounter of other specified Aftercare R00.1 Sinus Bradycardia I10 Hypertension (essential) E78.5 Hyperlipidemia (unspecified) 85 Provided by Polaris Group AHCA Spring Conference Page 28 of 32

30 Coding Example #5 Resident was admitted to Daisy May SNF following a right total hip replacement at the hospital due to primary unilateral Osteoarthritis of right hip. Resident will be receiving PT for gait training due to difficulty walking. Resident will be receiving OT for muscle weakness. 86 ICD-9-CM Answers for Coding Example #5: V57.89 Multiple Therapies V54.81 Aftercare following joint replacement (note to use additional code to identify joint replacement site (V43.60-V43.69) V43.64 Organ or tissue replaced by other means, joint, hip Osteoarthrosis, localized, primary, pelvic region and thigh Difficulty walking Muscle Weakness (generalized) 87 ICD-10-CM Answers for Coding Example #5: Z47.1 Aftercare following joint replacement surgery (Note to use additional code to identify the joint (Z96.6-) Z Presence of right artificial hip joint M16.11 Unilateral primary osteoarthritis, right hip Z51.89 Encounter of other specified Aftercare R26.2 Difficulty in walking, not elsewhere classified M62.81 Muscle weakness, generalized 88 Provided by Polaris Group AHCA Spring Conference Page 29 of 32

31 Coding Example #6 (Continued Stay) A current SNF resident resides in the nursing home due to residual effects from a cerebrovascular accident several years ago. Resident has hemiplegia and hemiparesis affecting right dominant side. Now while in the SNF, the resident developed symptoms of Pneumonia and had to be transferred to the hospital for treatment. Upon return to the SNF, what would be the proper sequencing of diagnosis codes? 89 Answers for Coding Exercise #6: (Continued Stay) ICD-9-CM: , Hemiplegia affecting dominant side 486, Pneumonia (unspecified) ICD-10-CM: I Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side J18.9, Pneumonia, unspecified 90 Summary of ICD-10-CM Changes Use combination code where available Use multiple codes if necessary to fully describe a condition Laterality specify side(s) if code available Use Placeholder X as appropriate Use 7 th character if indicated to indicate subsequent care (aftercare) or sequela (late effects). 91 Provided by Polaris Group AHCA Spring Conference Page 30 of 32

32 Summary of ICD-10-CM Changes No more Z code (formerly V code) as primary for therapy. Instead use diagnosis that warrants the therapy as principal diagnosis. Continue to use Therapy Treatment codes No more aftercare for fractures. Use acute fracture code with appropriate subsequent 7 th character such as D for aftercare or S for sequela. 92 Transitioning to ICD-10-CM Identify your current systems and work processes that use ICD-9-CM codes. Communicate implementation plans between providers, payers, and vendors. Identify potential changes to workflow and business processes. Budget for time and money related to the implementation. Allow enough time to test transactions. Assess staff training needs. 93 Transitioning to ICD-10-CM Begin assigning ICD-10-CM codes to long term care residents as part of quarterly review. MDS with ARD Oct. 1 or later; use ICD-10-CM codes on MDS Begin assigning ICD-10-CM codes to Medicare admission around August. MDS with ARD Oct. 1 or later; use ICD-10-CM codes Claims for dates Oct. 1 or later; use ICD-10-CM codes 94 Provided by Polaris Group AHCA Spring Conference Page 31 of 32

33 Billing Part A through the Transition All institutional claims are required to be billed monthly. For Part A, use ICD-9-CM codes for September claims and then convert these codes into ICD- 10-CM codes for your October claim. You may also need to update/change diagnoses like you normally would on a month to month basis for Part A based on resident status changes. 95 Billing Part B through the Transition For Part B, with the same therapy regime or plan of care, you simply need to convert September ICD-9-CM codes into ICD-10- CM codes for October. 96 Training for ICD-10-CM Suggested training curriculum Basic Understanding of the ICD-10-CM Code Set ICD-10-CM Coding Diagnoses Clinical Definitions and Terms in ICD-10-CM Using Systems updated for ICD-10-CM 97 Provided by Polaris Group AHCA Spring Conference Page 32 of 32