Introduction to ICD 10 CM Documentation for Physicians

Transcription

1 Introduction to ICD 10 CM Documentation for Physicians 1

2 ICD 10 CM Coding & Documentation for Physicians Objectives Understand the differences and similarities in the code books and code structures of ICD 9 CM and ICD 10 CM Understand the basic differences in some of the rules and guidelines Understand why there are so many more codes and the documentation this necessitates 2

3 Code Book Structure is slightly different Code Structure is slightly different Many rules and guidelines same or only slightly change and coding will carry on just as before Many more codes Remember that coding facilitates reimbursement as well as enable tracking of services So accuracy is important 3

4 Book Structure ICD 9 CM- 17 Chapters 1. Infectious and Parasitic Diseases 2. Neoplasms 3. Endocrine, Nutritional, & Metabolic Diseases and Immunity Disorders 4. Diseases -Blood/Blood-Forming Organs 5. Mental Disorders 6. Diseases- Nervous System & Sense Organs 7. Diseases of the Circulatory System 8. Diseases -Respiratory Sys. 9. Diseases - Digestive Sys. 10. Diseases Genitourinary Sys 11. Complications of Pregnancy, Childbirth & Puerpeum 12. Diseases of the Skin & Subcutaneous Tissue ICD-10-CM - 21 Chapters 1 Certain infectious & parasitic (A00-B99) 2 Neoplasms (C00-D49) 3 Diseases of blood/blood-forming organs & certain disorders - immune mechanism (D50-D89) 4 Endocrine, nutritional and metabolic diseases (E00-E89) 5 Mental and behavioral disorders (F01-F99) 6 Diseases of the nervous system (G00-G99) 7 Diseases of the eye and adnexa (H00-H59) 8 Diseases of the ear and mastoid process (H60-H95) 9 Diseases of the circulatory system (I00-I99) 10 Diseases of the respiratory system (J00-J99) 11 Diseases of the digestive system (K00-K94) 12 Diseases of the skin and subcutaneous tissue (L00-L99) 4

5 Book Structure ICD 9 CM- 17 Chapters 13. Diseases Musculoskeletal System & Connective Tissue 14. Congenital Anomalies 15. Certain Conditions Originating in the Perinatal Period 16. Symptoms, Signs, & Ill- Defined Conditions 17. Injury and Poisoning Supplemental Chapters Factors influencing health status & contact with healthcare External Cause Codes ICD-10-CM - 21 Chapters 13 Diseases of the musculoskeletal system and connective tissue (M00-M99) 14 Diseases of the genitourinary system (N00-N99) 15 Pregnancy, childbirth and the puerperium (O00- O99) 16 Certain conditions originating in the perinatal period (P00-P96) 17 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 18 Symptoms, signs & abnormal clinical & lab findings, not elsewhere classified (R00-R99) 19 Injury, poisoning and certain other consequences of external causes (S00-T88) 20 External causes of morbidity (V00-Y99) 21 Factors influencing health status and contact with health services (Z00-Z99) 5

6 Book Structure - Conventions Same And still means and/or see or see also still used as a cross-reference device Still have other specified, NEC - not otherwise specified and NOS - not elsewhere classified Different - Excludes 1 and Excludes 2 Excludes1: Pure excludes: the meaning is not coded here Mutually exclusive codes Two conditions may not be reported together 6

7 Book Structure - Conventions Same And still means and/or see or see also still used as a cross-reference device Still have other specified, NEC - not otherwise specified and NOS - not elsewhere classified Example: M21 Other acquired deformities Different - Excludes 1 and Excludes of limbs2 Excludes1: Pure excludes: the Excludes1: meaning is not coded here Mutually exclusive codes acquired absence of limb (Z89.-) Two conditions may not be reported congenital together absence of limbs (Q71-Q73)24 7

8 Book Structure - Conventions Different - Excludes 1 and Excludes 2 Excludes2: means not included here excluded condition not part of the condition it is excluded from, patient may have both conditions at same time may be acceptable to use both code & excluded code together if supported by documentation Example: L89 Pressure ulcer Excludes2: diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622) 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 8

9 Difference in Structure & Book ICD 9 CM 3-5 characters First character is numeric or alpha (E or V) ICD 10 CM 3-7 characters First character is alpha using all letters except U 9

10 ICD 10 CM 1 st character is a capital letter Each letter is associated with a particular chapter Chapter 1 (A00-B99) Certain infectious and parasitic diseases Chapter 2 (C00-D49) Neoplasms Chapter 3 (D50-D89) Diseases of the blood and bloodforming organs and certain disorders involving the immune mechanism Chapter 4 (E00-E89) Endocrine, nutritional and metabolic diseases Chapter 5 (F01-F99) Mental, Behavioral & Neurodevelopmental disorders Chapter 6 (G00-G99) Diseases of the nervous system Chapter 7 (H00-H59) Diseases of the eye and adnexa Chapter 8 (H60-H95) Diseases of the ear and mastoid process Chapter 9 (I00-I99) Diseases of the circulatory system 10

11 ICD 10 CM 1 st character is a capital letter Each letter is associated with a particular chapter Chapter 1 (A00-B99) Certain infectious and parasitic diseases Chapter 2 (C00-D49) Neoplasms Chapter 3 (D50-D89) Diseases of the blood and bloodforming organs and certain disorders involving the immune mechanism Chapter 4 (E00-E89) Endocrine, nutritional and metabolic diseases Chapter 5 (F01-F99) Mental, Behavioral & Neurodevelopmental disorders Chapter 6 (G00-G99) Diseases of the nervous system Chapter 7 (H00-H59) Diseases of the eye and adnexa Chapter 8 (H60-H95) Diseases of the ear and mastoid process Chapter 9 (I00-I99) Diseases of the circulatory system 11

12 Code Structure Example: Cellulites of chest wall ICD-9-CM ICD-10-CM L

13 Codes may be 4, 5, 6, or 7 characters in length Final character may be a letter or a number The letters O & I are used; do not confuse with 0 & 1 7 th Character - Extensions A = initial encounter D = subsequent encounter S = sequela (late effect) 13

14 7 th characters A Initial encounter for closed fracture B Initial encounter for open fracture D Subsequent encounter for fracture with routine healing G Subsequent encounter for fracture with delayed healing K Subsequent encounter for fracture with nonunion P Subsequent encounter for fracture with malunion S Sequela M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture S52.132B, Displaced fracture of neck of left radius, initial encounter for open fracture 14

15 7 th characters O31 Complications specific to multiple A Initial encounter gestations for closed fracture B Initial encounter 0 - not for applicable open fracture or unspecified D Subsequent 1 - fetus encounter 1 for fracture with routine healing G Subsequent 2 - fetus encounter 2 for fracture with delayed healing K Subsequent encounter for fracture with nonunion 3 - fetus 3 P Subsequent encounter for fracture with malunion 4 - fetus 4 S Sequela 5 - fetus 5 right femur, 9 initial - other encounter fetus for fracture M80.051A, Age-related osteoporosis with current pathological fracture, S52.132B, Displaced fracture of neck of left radius, initial encounter for open fracture 15

16 Code Structure Example: Fracture of the Patella A patient is treated for fracture of the patella ICD-9-CM Fracture of patella, closed ICD-10-CM; to assign an accurate code, sixth and seventh characters are needed in ICD-10- CM S82.021D - Fracture of patella, displaced longitudinal, right patella - subsequent encounter for closed fracture with routine healing 16

17 Code Structure Dummy placeholder x used Used in the 5th character position for some 6 or 7 character codes Holds the position for future expansion without disrupting the 6 digit code structure A filler digit with no coding related meaning associated with it 17

18 Dummy placeholder x used Examples: Crushing injury of larynx and trachea. initial encounter S17.0XXA, 18

19 Why so many codes? ICD-9-CM 14,025 Diagnosis Codes ICD-10-CM 68,069 More details and specificity in diagnosis Anatomical details Combination codes with common comorbidities Laterality Extensions for episode of care 19

20 ICD 10 CM Documentation Why so many codes? more details and specificity in diagnosis Signs & Symptoms R10 Abdominal and pelvic pain R10.0 Acute abdomen R10.1 Pain localized to upper abdomen R10.2 Pain and perineal pain R10.3 Pain localized to other parts of lower abdomen R10.8 Other abdominal pain R10.81 Abdominal tenderness R10.82 Rebound abdominal tenderness 20

21 ICD 10 CM Documentation Why so many codes? more details and specificity in diagnosis Signs & Symptoms R10.81 Abdominal tenderness Abdominal tenderness NOS R10 Abdominal and pelvic pain R Right upper quadrant abdominal tenderness R10.0 Acute abdomen R Left upper quadrant abdominal tenderness R10.1 Pain localized to upper abdomen R Right lower quadrant abdominal tenderness R10.2 Pain and perineal pain R Left lower quadrant abdominal tenderness R10.3 Pain localized to other parts of lower abdomen R Periumbilic abdominal tenderness R Epigastric abdominal tenderness R10.8 Other abdominal pain R R10.81 Generalized Abdominal abdominal tenderness tenderness R R10.82 Abdominal Rebound tenderness, abdominal unspecified tenderness site 21

22 Why so many codes? Details of Anatomy S31.623A, Laceration with foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity, initial encounter Q20 Congenital malformations of cardiac chambers and connections Q20.0 Common arterial trunk Q20.1 Double outlet right ventricle Q20.2 Double outlet left ventricle Q20.3 Discordant ventriculoarterial connection Q20.4 Double inlet ventricle 22

23 ICD 10 CM Documentation Why so many codes? Combination Codes with common comorbidities ICD 9 CM UTI Urinary tract infection, site not specified 23

24 ICD 10 CM Documentation Why so many codes? Combination Codes with common comorbidities ICD 10 CM ICD 9 CM N30.00 Acute cystitis without hematuria UTI Urinary tract infection, site hematuria not specified N30.01Acute cystitis with hematuria N30.10 Interstitial cystitis (chronic) without hematuria N30.11 Interstitial cystitis (chronic) with hematuria N30.20 Other chronic cystitis without hematuria N30.21 Other chronic cystitis with hematuria N30.30 Trigonitis without hematuria N30.31Trigonitiswith hematuria ICD 10 CM N30.40 Irradiation cystitis without N30.41 Irradiation cystitis with hematuria N30.80 Other cystitis without hematuria N30.81 Other cystitis with hematuria N30.90Cystitis, unspecified without hematuria N30.91 Cystitis unspec. With hematuria 24

25 ICD 10 CM Documentation Why so many codes? Combination Codes with common comorbidities Headaches and Migrane Coding 25

26 ICD 10 CM Documentation Why so many codes? Combination Codes with common comorbidities Migraine Documentation ICD 9 CM 10 Categories ICD 10 CM - 14 Categories 26

27 ICD 10 CM Documentation Why so many codes? Combination Codes with common comorbidities G43.0 Migraine without aura G43.1 Migraine with aura G43.4 Hemiplegic migraine G43.5 Persistent migraine aura without cerebral infarction G43.6 Persistent migraine aura with cerebral infarction G43.7 Chronic migraine without aura G43.A Cyclical vomiting G43.B Ophthalmoplegic migraine G43.C Periodic headache syndromes in child or adult G43.D Abdominal migraine G43.8 Other migraine (other & Menstrual) G43.9 Migraine, unspecified 27

28 ICD 10 CM Documentation Why so many codes? Combination Codes with common comorbidities - Migrane Coding How long has it existed When was start of most recent on-set Is it unilateral or bilateral Unilateral location or bilateral Quality (throbbing or pulsating ) Worsening pain with normal activity Intensity (moderate to severe) Other signs and symptoms (Nausea and/or vomiting Photophobia and phonophobia) 28

29 Why so many codes? Laterality Added laterality (indicate right side versus left side. Also codes available for unspecified sides) Example: C50.212, Malignant neoplasm of upper-inner quadrant of left female breast H02.835, Dermatochalasis of left lower eyelid I80.01, Phlebitis and thrombophlebitis of superficial vessels of right lower extremity Rule for bilateral sites No bilateral code provided (condition is bilateral), assign separate codes for both left & right side (unless specific guideline state otherwise) 29

30 Why so many codes? Extensions for episode of care 30

31 Why so many codes? Extensions for episode of care Example: Greenstick fracture of shaft of humerus, right arm ICD-10-CM S42.311K ICD-9-CM

32 Why so many codes? Laterality and Episode of Care Most codes have site and laterality designations Site presents either the bone joint or other muscle involved Seventh character extensions are: 32

33 Why so many codes? Laterality and Episode of Care Most codes have site and laterality designations Site presents either the bone joint or other muscle involved Seventh character extensions are: 33

34 Details of Laterality Why so many codes? Laterality and Episode of Care Musculoskeletal/Orthopedic Most codes Laterality, have site specific and laterality bone and designations specific bone portion Site presents S82.12 either Fracture the of bone lateral condyle joint or of other tibia muscle involved S Displaced fracture of lateral condyle of right tibia Seventh character extensions are: S Displaced fracture of lateral condyle of left tibia S Displaced fracture of lateral condyle of unspecified tibia S Nondisplaced fracture of lateral condyle of right tibia S Nondisplaced fracture of lateral condyle of left tibia S Nondisplaced fracture of lateral condyle of unspecified tibia S82.13 Fracture of medial condyle of tibia S Displaced fracture of medial condyle of right tibia S Displaced fracture of medial condyle of left tibia S Displaced fracture of medial condyle of unspecified tibia S Nondisplaced fracture of medial condyle of right tibia S Nondisplaced fracture of medial condyle of left tibia S Nondisplaced fracture of medial condyle of unspecified tibia 34

35 Many rules-guidelines same or only slightly changed Causal Organisms still need to be coded Can be combination code or additional New guideline use additional code to identify conditions such as: alcohol abuse/dependence, alcohol dependence in remission, tobacco dependence, history of tobacco use Tobacco Coding Required Also: use an additional code, where applicable to identify: Z77.22 exposure to environmental tobacco smoke P96.81, exposure to tobacco smoke in the perinatal period Z87.891, history of tobacco use Z57.31 occupational exposure to environmental tobacco smoke F17.-, tobacco dependence Z72.0 tobacco use 35

36 Many rules and guidelines same or only slightly changed Pregnancy codes by Trimester NOT episode of care based on documentation of trimester (or number of weeks) for the current admission/encounter. Code when complication developed, not the trimester of discharge. If the condition developed prior to current admission/encounter or represents a pre-existing condition, the trimester character is the time of the admission/encounter unspecified trimester code - rarely be used, Whenever delivery occurs during the current admission, and there is an in childbirth option for the obstetric complication being coded, the in childbirth code should be assigned 36

37 Many rules and guidelines same or only slightly changed - Pregnancy Assignment based on documentation of trimester (or number of weeks) for the current admission/encounter. Code when complication developed, not the trimester of discharge. If the condition developed prior to current admission/encounter or represents a pre-existing condition, the trimester character is the time of the admission/encounter unspecified trimester code - rarely be used, Whenever delivery occurs during the current admission, and there is an in childbirth option for the obstetric complication being coded, the in childbirth code should be assigned 37

38 Many rules and guidelines same or only slightly changed Diabetes - No longer single category (250) with 59 codes as in ICD-9-CM, ICD-10-CM More than 200 codes with five categories expanded to reflect manifestations and/or complication of the disease by using fourth or fifth characters rather than by using an additional code to identify the manifestation 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 38

39 Many rules and guidelines same or only slightly changed Diabetes no longer by controlled or uncontrolled By Type and manifestations or underlying conditions Drug or chemical induced diabetes mellitus Diabetes mellitus Type 1 or Type 2 Type 1 Juvenile) Type 2 (Adult onset) Other specified diabetes mellitus Post procedural diabetes mellitus due to genetic defects of beta cell function Secondary diabetes mellitus 39

40 ICD 10 CM Documentation Many rules and guidelines same or only slightly changed Must document Relationship Must document Severity If type not specified will default to type 2 Assign as many codes from categories E08 E13 as needed to identify all of the associated conditions 40

41 Many rules and guidelines same or only slightly changed Same as ICD 9 CM Chapter 6 Diseases of Nervous System G00 G99 Many codes need documentation of dominant or nondominant G89 Pain not elsewhere classified Acute? Chronic? Due to trauma? Post Surgical? Due to Neoplasm? 41

42 Many rules and guidelines same or only slightly changed Poisoning & Adverse Effect - Same as ICD 9 CM Addition of Underdosing Failure in dosage during medical and surgical care (Y63.61, Y63.8-Y63.9) Patient's underdosing of medication regime (Z91.12-, Z91.13-) Poisoning Adverse effect Underdosing Overdose of substances Wrong substance given or taken in error Hypersensitivity, reaction, or correct substance properly administered Taking less of medication than is prescribed or instructed by manufacturer either inadvertently or deliberately 42

43 Many rules and guidelines same or only slightly changed Chapter 20 External Causes of Morbidity V00 Y99 Same guidelines as ICD 9 CM Chapter 21 Factors Influencing health status Z00 Z99 Same guidelines as ICD 9 CM 43

44 ICD 10 CM Documentation What can you do now? Perform Clinical Documentation Assessments. This can involve evaluating samples of various types of medical records to determine whether the documentation supports the level of detail found in ICD-10-CM. Documentation improvement strategies can be implemented to address areas where documentation is found to be lacking. Designate a physician/provider champion to assist in clinical documentation education and promote the positive aspects of moving to ICD-10-CM Chat with your coding staff and they will help you understand what is needed to code accurately, timely and complete 44

45 Let s try some documenting for ICD 10 CM 45

46 ICD 10 CM Documentation Example 1 Admitting Diagnosis; Fracture, arm Patient Name: Som Body Medical Record Number: Admission Date: 21 st April, 2015 Discharge Date: 22 nd April, 2015 Age: 18 year old male Admitting Diagnosis; Fracture, arm 46

47 ICD 10 CM Documentation Example 1 Admitting Diagnosis; Fracture, arm Traumatic or pathologic? (Traumatic) What specific bone? (Ulna) What specific part of bone? (Styloid) Was it displaced or nondisplaced? (Displace) Laterality? (right) Open or Closed? (Open) Initial or Subsequent Encounter (Subsequent) Fracture Gustillo type and was it routine or delayed healing? (Type IIIA, routine healing) Also the patient was Obese, did this have affect? 47

48 ICD 10 CM Documentation Example 1 Admitting Diagnosis; Fracture, arm Traumatic or pathologic? (Traumatic) What specific bone? (Ulna) What S52.251F specific Displaced part of bone? comminuted (Styloid) fracture of shaft of Was ulna, it displaced right arm, or subsequent nondisplaced? encounter (Displace) for open fracture Laterality? type IIIA, (right) IIIB or IIIC with routine healting Open or Closed? (Open) Initial or Subsequent Encounter (Subsequent) Fracture Gustillo type and was it routine or delayed healing? (Type IIIA, routine healing) Also the patient was Obese, did this have affect? 48

49 ICD 10 CM Documentation Example 2 Admitting Diagnosis; Cough, History of COPD Patient Name: Anon Ymous Medical Record Number: Admission Date: 21 st April, 2015 Discharge Date: 22 nd April, 2015 Age: 42 Obese Female Admitting Diagnosis; Cough, History of COPD 49

50 ICD 10 CM Documentation Example 2 Admitting Diagnosis; Cough, History of COPD COPD? (not just history Acute on chronic - exacerbation? With or without Emphysema? Which lobe? Is there Asthma? Specificity of asthma (persistent, status asmaticus etc) Morbid obesity? What is the BMI? Is there diabetes? Chronic respiratory failure? Possible COPD/Emphysema Is there Hypertension and/or CKD? Hypertensive renal failure/ with CHF/ with CKD stage? Was there any Acute Kidney Failure? 50

51 Thank you Questions? 51