ICD-10 CM & Audits Dr. Karen Walters Graduated: New York Chiropractic College in 1982 Chiropractic & Physical Therapy clinic for over 25 years

Transcription

1 ICD-10 CM & Audits Dr. Karen Walters Graduated: New York Chiropractic College in 1982 Chiropractic & Physical Therapy clinic for over 25 years Advised practice management consultants on setup & maintenance of combined physical therapy and chiropractic clinics. Primary designer for content & layout of ECLIPSE documentation component since Merged ICD-9 and ICD-10 for ECLIPSE users with a custom database that included 2800 ICD-10 codes along with a crosswalk to help doctors transition to the new coding standard. Inducted as a Fellow of The American College of Chiropractors in Taught Anatomy & Physiology, Microbiology, and General Biology within the NJ College & University system. Teaching: Biology, Chemistry and Forensics, Ridgewood H.S. Adjunct Professor at Syracuse University. 1

2 ICD - 10 includes everything! 2

3 drowning from jumping off of burning water skis... roughed up by Killer whale injured in a spacecraft. V Drowning and submersion due to falling or jumping from burning water-skis V Spacecraft crash injuring occupant W Struck by an Orca ICD-10 covers many more conditions and injuries 3

4 Introduction Transition date: October 1, 2015 Why? ICD-9 (since 1979) can t accommodate all the new diagnoses. scientific knowledge = number of diagnosed diseases Change from ~14,000 to ~68,000 codes. accuracy/specificity of codes in ICD-10 Increase in codes for: Focuses on assessing quality of care tracking diagnoses, signs & symptoms, diseases & external causes of injury. ICD-10 started in the 1990s U.S. one of the last nations to change over. Today s Objective: Show how ICD-10 works and how to use it in your practice. By the end of the hour, you should have most of the tools needed to decipher and understand the ICD-10 codes. Disclaimer: Check with your local carrier and Medicare for ICD-10CM guidelines and updates. 4

5 Bad news and Good news Bad news: ALL codes have been changed. Must make sure your software will handle the new codes. Good news: If you have: ECLIPSE Practice Management Software Either: All ICD-10 or Subset specific for chiropractic & physical therapy. More specificity = better documentation. Example: If a person injures right hip, then later the left hip two separate codes - obvious that it is a new condition. There are websites/apps and books - choose wisely! 5

6 ICD-10 at a glance More codes Longer codes up to 7 alpha/numeric Injury codes are grouped by anatomical site (rather than the category of injury). More divisions (21 chapters). Higher specificity; distinguishes between: Right and left Initial encounter, subsequent encounter, sequela coding specificity for statistical analysis & research. 6

7 Is there an easy equivalence map between 9 and 10? NO one-to-one match. But there is a crosswalk BEWARE: In coding individual claims, it will be more efficient and accurate to work from the medical record documentation and then select the appropriate code(s) from the coding book or encoder system. The GEMs are not a substitute for learning how to use the ICD-10-CM. 7

8 Where do I find the codes? Sources for Codes: 1. Free download PDF of codes & PDF of guidelines 2. General Equivalence Mapping: Internet, Apps for Android, ipads -choose wisely! 3. Book from : ChiroCode Institute: ICD-10 Coding for Chiropractic 8

9 The basics 9

10 Chapters to ICD-10CM 1. Infectious 2. Neoplasms 3. Endocrine, Nutritional 4. Blood and blood-forming 5. Mental disorders 6. Diseases of Nervous system 7. Diseases of the eye 8. Diseases of the ear 9. Diseases of Circulatory 10. Diseases of Respiratory 11. Diseases of Digestive 12. Diseases of Skin 13. Disease of Musculoskeletal & Connective Tissue 14. Disease of the genitourinary 15. Pregnancy 16. Perinatal 17. Congenital 18. Symptoms, Signs and abnormal clinical & lab findings 19. Injury and Poisoning 20. External causes of morbidity 21. Factors influencing health status. 10

11 Chiropractic 1. Infectious 2. Neoplasms 3. Endocrine, Nutritional 4. Blood and blood-forming 5. Mental disorders 6. Diseases of Nervous system 7. Diseases of the eye 8. Diseases of the ear 9. Diseases of Circulatory 10. Diseases of Respiratory 11. Diseases of Digestive 12. Diseases of Skin 13. Disease of Musculoskeletal & Connective Tissue 14. Disease of the genitourinary 15. Pregnancy 16. Perinatal 17. Congenital 18. Symptoms, Signs and abnormal clinical & lab findings 19. Injury and Poisoning 20. External causes of morbidity 21. Factors influencing health status. 11

12 General Layout & Definitions

13 ICD-10 Layout and Definitions Includes and Excludes - Includes: gives definitions and examples 13

14 ICD-10 Layout and Definitions - Excludes 1: not coded here (when two conditions cannot occur together). - 14

15 ICD-10 Layout and Definitions - Excludes 2: condition not included here (need additional code if documentations supports it). Code also: two codes may be required to fully describe a condition. 15

16 Non-essential modifiers [ ] Brackets enclose alternative wording or explanatory phrases. ( ) extra words present/absent that does not affect the code number. 16

17 Non-essential modifiers AND : Either and or or Example: A18.0 Tuberculosis of bones and joints. With: associated with or due to 17

18 X = place holder ICD-10 Layout and Definitions When the 7 th character is needed, but there is no 6 th character, an X is used as a placeholder. M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region 18

19 Signs and Symptoms Codes that describe signs and symptoms are acceptable for reporting IF a definitive diagnosis has not been established (confirmed). 1. Infectious 2. Neoplasms 3. Endocrine, Nutritional 4. Blood and blood-forming 5. Mental disorders 6. Diseases of Nervous system 7. Diseases of the eye 8. Diseases of the ear 9. Diseases of Circulatory 10. Diseases of Respiratory 11. Diseases of Digestive 12. Diseases of Skin 13. Disease of Musculoskeletal & Connective Tissue 14. Disease of the genitourinary 15. Pregnancy 16. Perinatal 17. Congenital 18. Symptoms, Signs and abnormal clinical & lab findings 19. Injury and Poisoning 20. External causes of morbidity 21. Factors influencing health status. 19

20 Don t use S & S Signs and Symptoms (S & S) if they are routinely associated with a disease. Do use S&S if: not routinely with a disease process. Example: Person comes in with a tremor 20

21 G20 Parkinson s

22 Uncertain Diagnosis Code to the highest degree of certainty for that encounter/visit. Do NOT use a diagnosis without certainty/documentation. Do not code: probable suspected questionable rule out working diagnosis 22

23 Etiology (cause)/ Manifestation Underlying condition sequenced first Manifestation second Example: Parkinson s disease (G20) with dementia F02.80 or F

24 Acute and Chronic Acute conditions get listed before chronic if both are present. 24

25 Code all documented conditions that coexist Code all documented conditions that require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. History codes (categories Z80-Z87) may be used as 2 o if it impacts current care or influences treatment. Examples: Z89.61 Acquired absence of leg above knee Z82.62 Family history of osteoporosis Z82.69 Family history of other diseases of the musculoskeletal system and connective tissue 25

26 Chapter 13 M codes 26

27 M codes M prefix diseases of musculoskeletal or connective. Diseases related to: Bone Joint Muscle 27

28 ICD-10-CM Tabular List of Diseases and Injuries M prefix diseases of musculoskeletal or connective 28

29 Example patient with low back pain with sciatica 29

30 How to find the code 1. Use a GEM (General Equivalence Mapping): Sciatica Low back pain (lumbago): Disclaimer: This tool is based on the General Equivalency Mapping (GEM) files published by CMS, and is not intended to be used as an ICD- 10 conversion, ICD-10 mapping, or ICD-9 to ICD-10 crosswalk tool. Always review mapping results before applying them. 30

31 ICD-10-CM Tabular List of Diseases and Injuries Use code that is as specific as your documentation 31

32 ICD-10-CM Tabular List of Diseases and Injuries Use code that is as specific as your documentation 32

33 Laterality Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate characters for both the left and right side. 0 unspecified 1 right 2 left If the side is not identified in the medical record, assign the code for the unspecified side. 33

34 Try another M code Cervical Radiculitis 34

35 How to find the code 1. Use a GEM: General Equivalence Mapping Cervical Radiculitis 35

36 ICD-10-CM Tabular List of Diseases and Injuries ICD 9: Cervical Radiculitis 36

37 ICD-10-CM Tabular List of Diseases and Injuries ICD 9: Cervical Radiculitis 37

38 MUST have documentation USE the most specific code that is SUPPORTED by your documentation. More changes to the diagnosis 15% more time documenting diagnosis. Who submits electronically?? LEGALLY responsible for EVERYTHING on the bill- on paper or electronically. 38

39 Chapter 19: Injury S codes ICD 9: Acromioclavicular Sprain/Strain 39

40 Injury - S codes (Chapter 19) 1. ICD 9 : Acromioclavicular sprain Look at GEM s (General Equivalence Mapping) 40

41 Injury codes require additional digits ICD 9 : Acromioclavicular sprain Types of treatment S codes require a 7 character 41

42 Choosing the 7 th character: A, D, S While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

43 7 th Character: A, D, S Initial (seventh character = A) used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician. ***This is direct from the guidelines 1/2015. *** How with this code be interpreted by insurance companies and Medicare? Unknown; follow the information on the cdc.gov site & chiropractic association websites.

44 7 th Character: A, D, S Subsequent encounter (7 th character = D): 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: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition. How will this code be interpreted by insurance companies and Medicare? Unknown; follow the information on the cdc.gov site & chiropractic association websites.

45 7 th Character: A, D, S Sequela (7 th character = S): sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code. The 7th character S identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. Ex: scar formation after a burn. The scars are sequela of the burn. There is no time limit on when a sequela code can be used.

46 S codes 46

47 S codes Require 7 th character S43.51xA right S43.51xD S43.51xS placeholder Initial care 47

48 More S Codes 48

49 Injury - S codes (Chapter 19) ICD 9 : Cervical sprain 49

50 S13.4xxA S13.4xxD S13.4xxS 50

51 What codes Do I Use? MUST be supported by documentation. USE the most specific code that is SUPPORTED by your documentation. 51

52 Subluxation two possibilities 52

53 ICD 9 and Subluxation 739 Non-allopathic lesions, not elsewhere classified (739.1 non-allopathic lesion cervical area) Biomechanical lesions, not elsewhere classified This category should not be used if the condition can be classified elsewhere. 53

54 Coding Subluxations ICD9 839 Other, multiple, and ill-defined dislocations Cervical vertebra, closed

55 S13 Look further down the page 55

56 5 th position: subluxation level S13.120_ Subluxation C1/C2 0 in the sixth position = Subluxation 1 = dislocation S13.120A S13.120D S13.120S Encounter type 56

57 So far

58 Don t mix codes! Bill out ICD 9 prior to October 1 st. All services rendered PRIOR to October 1 st require ICD9 codes even if bill is sent in AFTER October 1 st. All services on or after October 1 st will use ICD-10. What codes will be used (9 or 10) by Worker s Compensation and Auto insurance? So far, there is no definitive answer. Follow the information, as it becomes available, on the appropriate websites.

59 So far

60 Search by: - ICD 9 to ICD-10 comparable - Categories - Description - Codes - Unlimited conditions easily move back and forth.

61 ECLIPSE Practice Management Search by: Search by: - ICD 9 to ICD-10 comparable - Categories - Description - Codes - Reference the Government list to determine exclusions/inclusions. - Make sure the documentation supports the diagnosis. 61

62 Steps to take: 1. Stop by ECLIPSE Booth- for business card containing the reference list. Free download Book from : ChiroCode Institute: ICD-10 Coding for Chiropractic General Equivalence Mapping: Internet, Apps for Android, ipads -choose wisely! 62

63 Steps to Take 1. Stop by ECLIPSE - for business card containing the reference list and for any questions. 2. Make sure your software has the ICD-10 codes. 3. BILL out ICD9 BEFORE ICD-10 Do not mix bills with ICD 9 and ICD-10. Prior to October 1 st : Use ICD 9 codes. 4. Download PDF of ICD-10 from government site and guidelines. 5. PRACTICE! Update any cheat sheets 6. EXPECT to take more time keeping diagnoses updated for all patients throughout care. 7. Keep current on information as it gets closer to October 1, Delay in payment. KEEP a reserve! Perhaps, line of credit.

64 Thank you Karen Walters, DC