ICD-10-CM: Focus on Documentation Family Practice, Internal Medicine, Primary Care
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Who We Are & Why We re Here The Payers Collaboration is a group of payers working together to provide a resource for providers in their ICD-10 readiness activity We are working as one voice to provide valuable information to the provider community about transitioning to ICD-10 and show that the transition doesn t have to be overly costly or burdensome.
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Agenda Part 1 Introduction to ICD-10-CM Part 2 Part 3 ICD-10 Timeline & Billing Dates of Service Specialty Specific Documentation Examples Next Steps and Wrap Up
Objectives Identify the What, Why and When of ICD-10 implementation Recognize the format of ICD-10 codes Apply documentation tips for the most common diagnoses in a given specialty Value the benefits of ICD-10 documentation
Part 1 Introduction to ICD-10-CM ICD-10 Timeline & Billing Dates of Service
WHAT IS ICD-10-CM? International Classification of Diseases- 10 th Revision-Clinical Modification Listed by the World Health Organization (WHO) and the National Center for Health Statistics (NCHS)
WHY ARE WE IMPLEMENTING ICD-10? The Centers for Medicare and Medicaid Services (CMS) announced on July 31, 2014 that the new deadline for ICD-10 Implementation will be October 1, 2015. ICD-9 codes provide limited data about patients medical conditions and hospital inpatient procedures. ICD-10 codes allow for greater specificity and exactness in describing a patient s diagnosis and in classifying inpatient procedures.
ICD-10 WORLD ADOPTION
HOW WILL ICD-10-CM IMPACT ME? The required specificity of ICD-10-CM documentation will have a positive provider impact in the areas listed to the right.
Implementation Delays ICD-10 implementation has been delayed several times but the current implementation date is October 1, 2015. Why so many delays? The most common reason cited for delaying ICD-10 is the complexity and cost involved on the health care provider side Another reason is the possibility of rejected claims due to noncompliance and the impact on health care providers and cash flow
Provider & Payer Concerns Everyone agrees that disruption to the claims processing system is the greatest danger of ICD-10 implementation It could lead to cash flow problems and disruptions It could also increase inquiries and resources straining health plans resources (i.e., longer hold times, response times, etc.) We need to work together to ensure that all stakeholders are ready to minimize disruption
Fact or Fiction? It can cost (a provider office) $80k to transition from ICD-9 to ICD-10 We too have heard facts like this, but believe that this figure assumes implementation, planning, and costs that will not be seen by the majority of health care providers. For most specialties, cost are much lower. -United HC findings http://www.medscape.com/viewarticle/839670
WHAT PROVIDER DOCUMENTATION WILL BE IMPACTED BY ICD-10-CM? IMPACTED Diagnosis documentation for inpatients Diagnosis documentation for outpatients NOT IMPACTED Procedure documentation for BOTH outpatient and inpatient services Procedure documentation for certain professional services, and medical supplies
WHAT ARE SOME KEY DIFFERENCES BETWEEN ICD-9-CM AND ICD-10-CM? ICD-9 Diagnosis codes ICD-10 Diagnosis codes 3-5 characters in length 3-7 characters in length Approximately 14,000 codes First digit may be alpha (E or V) or numeric; Digits 2-5 are numeric Limited space for expansion Lacks detail and laterality Difficult to analyze data due to non specific codes Approximately 69,000 codes Character 1 is alpha; Characters 2 & 3 are numeric; Characters 4-7 are alphanumeric Room for expansion Very specific and added laterality Specificity improved coding accuracy/richness for data analysis/medical research
IS ICD-10 REQUIRED ON CALENDAR DATE OR DATE OF SERVICE OCT 1, 2015? Date of service Code Set Billed Prior to October 1, 2015 ICD-9-CM October 1, 2015 and later ICD-10-CM Provider outpatient AND inpatient claims are based on date of service. (DOS) Note: Overlapping dates require separate claims.
WHICH CODE SET FOR WHICH DATE? Outpatient Date of service (DOS) Code Set Accepted / NOT Accepted 10/1/2015 or later ICD-10 Accepted 9/30/2015 or prior ICD-9 Accepted Inpatient Discharge Date Code Set Accepted / NOT Accepted 10/1/2015 or later ICD-10 Accepted 9/30/2015 or prior ICD-9 Accepted
Part 2 Specialty Specific Documentation Examples
Diabetes Mellitus: Codes at a Glance ICD-9 ICD-10 250.00 Diabetes Mellitus, type 2, without mention of complication, uncontrolled 250.82 Diabetes Mellitus, type 2, with other specified manifestations 250.42 Diabetes with renal manifestations 585.6 End stage renal disease E11.641 Type 2 Diabetes Mellitus with hypoglycemia with coma E11.642 Type 2 Diabetes Mellitus with hypoglycemia without coma E11.65 Type 2 Diabetes Mellitus with hyperglycemia E11.22 Type 2 Diabetes Mellitus with diabetic CKD
Documentation: Diabetes Mellitus Patient is seen in follow up for his diabetes mellitus and chronic kidney disease. He is on dialysis twice a week and he has no complaints. He will continue on his current regimen. Diagnosis is documented as diabetes mellitus and CKD E11.22 Type 2 diabetes mellitus with chronic kidney disease N18.9 Chronic kidney disease, unspecified NOT ICD-10 SPECIFIC Patient is seen in follow up for his diabetes mellitus, type 2 with end stage chronic kidney disease. He is on dialysis twice a week and he has no complaints. He will continue on his current regimen. Diagnosis is documented as diabetes mellitus, type 2 with stage 5 chronic kidney disease E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease N18.6 End stage renal disease Z99.2 Dependence on renal dialysis ICD-10 SPECIFIC
General Medical Examination: Codes at a Glance ICD-9 ICD-10 V70.0 Routine general medical examination at a health care facility V20.2 Routine infant or child health check Z00.00 Encounter for general adult medical examination without abnormal findings Z00.01 Encounter for general adult medical examination with abnormal findings Z00.121 Encounter for routine child health examination with abnormal findings Z00.129 Encounter for routine child health examination without abnormal findings
A 34-year-old female presents for her annual physical exam. The patient complains of recent frequency and burning on urination. A urinalysis is positive for bacteria and is nitrate positive. Diagnosis is documented as annual physical exam Z00.00 Encounter for general adult medical examination without abnormal finding NOT ICD-10 SPECIFIC Documentation: General Medical Exam A 34-year-old female presents for her annual physical exam. The patient complains of recent frequency and burning on urination. A urinalysis is positive for bacteria and is nitrate positive. Diagnoses are documented as annual physical exam and urinary tract infection Z00.01 Encounter for general adult medical examination with abnormal findings N39.0 Urinary tract infection, site not specified ICD-10 SPECIFIC
Limb Pain: Codes at a Glance ICD-9 ICD-10 729.5 Pain in Limb M79.602 Pain in left arm M79.621 Pain in right upper arm M79.622 Pain in left upper arm M79.629 Pain in unspecified upper arm M79.651 Pain in right thigh M79.652 Pain in left thigh M79.671 Pain in right foot M79.672 Pain in left foot
Documentation: Limb Pain Patient presents with complaints of leg pain. The pain is dull in nature and has worsened over the last 2 weeks. Physical exam is unremarkable with normal reflexes and tone. There is no history of trauma. Diagnosis is documented as leg pain, unknown etiology Patient presents with complaints of left lower leg pain. The pain is dull in nature and has worsened over the last 2 weeks. Physical exam is unremarkable with normal reflexes and tone. There is no history of trauma. Diagnosis is documented as left lower leg pain, unknown etiology M79.606 Pain in leg, unspecified M79.662 Pain in left lower leg NOT ICD-10 SPECIFIC ICD-10 SPECIFIC
Malaise and Fatigue: Codes at a Glance ICD-9 ICD-10 780.79 Other malaise and fatigue R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.81 Other malaise R53.82 Chronic fatigue syndrome R53.83 Other fatigue
A 56-year-old male presents with complaints of increasing fatigue over the past 2 months. Patient was diagnosed with advanced stage lung cancer one year ago and has been receiving hospice care over the last 6 weeks. Diagnoses are documented as fatigue and end stage lung cancer R53.83 Other fatigue C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung NOT ICD-10 SPECIFIC Documentation: Malaise and Fatigue A 56-year-old male presents with complaints of increasing fatigue over the past 2 months. Patient was diagnosed with neoplasm of the upper lobe of the right lung one year ago and has been receiving hospice care over the last 6 weeks. Diagnoses are documented as right upper lobe lung cancer with neoplasm-related fatigue C34.11 Malignant neoplasm of upper lobe, right bronchus or lung R53.0 Neoplastic (malignant) related fatigue ICD-10 SPECIFIC
ICD-9 Open Wounds: Codes at a Glance ICD-10 882.0 Open wound of hand except finger(s) alone without mention of complication 882.1 Open wound of hand except finger(s) alone with complication 882.2 Open wound of hand except finger(s) alone with tendon involvement S61.411A S61.441D S61.452S Laceration without foreign body of right hand, initial encounter Puncture wound without foreign body of right hand, subsequent encounter Open bite of left hand, sequela
Documentation: Open Wound A 25-year-old male presents to the emergency department immediately following a dog bite to his finger. The dog has been vaccinated against rabies. The wound is irrigated and debrided. Diagnosis is documented as dog bite of finger S61.259 Open bite of unspecified without damage to nail NOT ICD-10 SPECIFIC A 25-year-old male presents to the emergency department immediately following a dog bite to his right index finger without damage to the nail. The wound is irrigated and debrided. Diagnosis is documented as dog bite to the right index finger without damage to the nail S61.250A Open bite to right index finger without damage to nail, initial encounter W54.0XXA Bitten by dog, initial encounter ICD-10 SPECIFIC
Myocardial Infarction: Codes at a Glance ICD-9 ICD-10 410.11 Acute myocardial infarction of other anterior wall, initial episode of care 410.22 Acute myocardial infarction of inferolateral wall, subsequent episode 410.90 Acute myocardial infarction of unspecified site, episode of care unspecified I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I21.4 Non-ST elevation (NSTEMI) myocardial infarction I22.2 Subsequent non-st elevation (NSTEMI) myocardial infarction
A 55-year-old male is being seen in the emergency department with complaints of acute substernal chest pain following a hospital admission a few weeks ago for an acute myocardial infarction. Workup in the ED is conclusive for a new acute MI. Diagnosis is documented as acute myocardial infarction I21.3 ST elevation (STEMI) myocardial infarction of unspecified site NOT ICD-10 SPECIFIC Documentation: Myocardial Infarction A 55-year-old male is being seen in the ED with complaints of acute substernal chest pain following a hospital admission three weeks ago for an acute left anterior descending artery MI. Workup in the ED is conclusive for a new acute inferior MI. Diagnosis is documented as acute inferior wall MI following an acute anterior wall LAD infarction 3 weeks ago I22.1 Subsequent ST elevation (STEMI) inferior wall myocardial infarction I21.02 ST elevation (STEMI) myocardial infarction involving left LAD ICD-10 SPECIFIC
Chronic Obstructive Pulmonary Disease: Codes at a Glance ICD-9 ICD-10 496 Chronic airway obstruction, not elsewhere classified 491.21 Obstructive chronic bronchitis with acute exacerbation J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified
A 48-year-old male patient presents with a history of COPD. He has been experiencing increasing shortness of breath and a productive cough over the last 10 days. Physical exam reveals a temperature of 99.8 and diminished breath sounds on the right side. Diagnosis is documented as COPD exacerbation J44.1 COPD exacerbation NOT ICD-10 SPECIFIC Documentation: COPD A 48-year-old male patient presents with a history of COPD. He has been experiencing increasing shortness of breath and a productive cough over the last 10 days. He is a one pack-per-day smoker and works in an auto repair shop. Physical exam reveals a temperature of 99.8 and diminished breath sounds on the right side. Diagnosis is documented as COPD with acute bronchitis and tobacco dependence J44.0 COPD with acute bronchitis J20.9 Acute bronchitis, unspecified F17.210 Nicotine dependence, cigarettes, uncomplicated Z57.5 Occupational exposure toxic agents in other industries ICD-10 SPECIFIC
ICD-9 Decubitus Ulcer: Codes at a Glance ICD-10 707.03 Pressure ulcer, lower back 707.04 Pressure ulcer, hip 707.05 Pressure ulcer, buttock 707.20 Pressure ulcer, unspecified stage 707.21 Pressure ulcer, stage 1 L89.41 Pressure ulcer of contiguous site of back, buttock and hip, stage 1 L89.311 Pressure ulcer of right buttock, stage 1 L89.622 Pressure ulcer of left heel, stage 2 L89.310 Pressure ulcer of right buttock, unstageable
Documentation: Decubitus Ulcer A 78-year-old female nursing home resident is seen with a nonblanching red area involving the epidermis and superficial dermis of the buttock. The patient s caregiver has been instructed on pressure ulcer prevention. Diagnosis is documented as decubitus ulcer of buttock L89.309 Pressure ulcer of unspecified buttock, unspecified stage NOT ICD-10 SPECIFIC A 78-year-old female nursing home resident is seen with a nonblanching red area involving the epidermis and superficial dermis of the right buttock. The patient s caregiver has been instructed on pressure ulcer prevention. Diagnosis is documented as decubitus ulcer, right buttock, stage 1 jjl89.311 Pressure ulcer of right buttock, stage 1 ICD-10 SPECIFIC
ICD-9 Acute Sinusitis: Codes at a Glance ICD-10 461.0 Acute maxillary sinusitis 461.1 Acute frontal sinusitis 461.2 Acute ethmoidal sinusitis 461.3 Acute sphenoidal sinusitis 461.8 Other acute sinusitis 461.9 Acute sinusitis, unspecified J01.00 Acute maxillary sinusitis J01.01 Acute recurrent maxillary sinusitis J01.10 Acute frontal sinusitis J01.11 Acute recurrent frontal sinusitis J01.20 Acute ethmoidal sinusitis J01.21 Acute recurrent ethmoidal sinusitis J01.30 Acute sphenoidal sinusitis J01.31 Acute recurrent sphenoidal sinusitis
Documentation: Acute Sinusitis A 50-year-old female is evaluated with complaints of fever, nasal congestion, and worsening forehead pain that has lasted for 3 weeks. She has experienced similar symptoms several times over the past 2 years and was treated with antibiotics each time. The diagnosis is documented as sinusitis J32.9 Sinusitis, unspecified NOT ICD-10 SPECIFIC A 50-year-old female is evaluated with complaints of fever, nasal congestion and worsening forehead pain that has lasted for 3 weeks. She has experienced similar symptoms several times over the last 2 years and was treated with antibiotics each time. The diagnosis is documented as acute recurrent frontal sinusitis J01.11 Acute recurrent frontal sinusitis ICD-10 SPECIFIC
ICD-9 Asthma: Codes at a Glance ICD-10 493.00 Extrinsic asthma 493.10 Intrinsic asthma 493.20 Chronic obstructive asthma 493.80 Other forms of asthma 493.90 Asthma, unspecified J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus
A 34-year-old female with a history of asthma is evaluated with increased nighttime cough and wheezing with physical activity. She uses her inhaler when these symptoms persist. She will be treated with an inhaled corticosteroid and long-acting bronchodilator. The diagnosis is documented as asthma exacerbation J45.909 Unspecified asthma, uncomplicated NOT ICD-10 SPECIFIC Documentation: Asthma A 34-year-old female with a history of asthma is evaluated with increased nighttime cough, wheezing with physical activity and tiredness after normal activities over the last 5 days. She uses her inhaler daily. Her husband smokes in the home. She will be treated with an inhaled corticosteroid and long-acting bronchodilator. The diagnosis is documented as moderate persistent asthma with acute exacerbation J45.41 Moderate persistent asthma with (acute) exacerbation Z77.22 Exposure environmental smoke ICD-10 SPECIFIC
Depressive Disorder: Codes at a Glance ICD-9 311 Depressive disorder, not elsewhere classified 296.21 Major depressive disorder, single episode 296.31 Major depressive disorder, recurrent episode ICD-10 F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features F32.9 Major depressive disorder, single episode, unspecified
Documentation: ICD-10 Major Depressive Episodes In typical depressive episodes of all three varieties described on the slide (mild F32.0), moderate (F32.1), and severe (F32.2 and F32.3), the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are: a) Reduced concentration and attention; b) Reduced self-esteem and self-confidence; c) Ideas of guilt and unworthiness (even in a mild type of episode); d) Bleak and pessimistic views of the future; e) Ideas or acts of self-harm or suicide; f) Disturbed sleep g) Diminished appetite
Documentation: ICD-10 Major Depressive Disorder Mild Depressive Episode Diagnostic guidelines include a depressed mood, loss of interest and enjoyment, and increased fatigability are usually regarded as the most typical symptoms of depression, and at least two of these, plus as least two of the other symptoms described on the previous slide should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks. An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely. Moderate Depressive Episode Diagnostic guidelines include at least two of the three most typical symptoms noted for mild depressive episode (F32.0) should be present, plus at least three (and preferably four) of the other symptoms. Several symptoms are likely to be present to a marked degree, but this is not essential if a particular wide variety of symptoms is present overall. Minimum duration of the whole episode is about 2 weeks.
Documentation: Depressive Disorder The patient is seen today with complaints of feeling quite sad, unhappy, withdrawn, apathetic and lacking energy or ambition to do much. He is bursting into tears without provocation. He s not sleeping well. His appetite is not good and he often feels miserable. The diagnosis is documented as depression F32.9 Major depressive disorder, single episode, unspecified NOT ICD-10 SPECIFIC The patient is seen today with complaints of feeling quite depressed, sad, unhappy, withdrawn, apathetic and lacking energy or ambition to do much. He is bursting into tears without provocation. He s not sleeping well. His appetite is not good and he often feels miserable. The diagnosis is documented as moderate major depression, single episode F32.1 Major depressive disorder, single episode, moderate ICD-10 SPECIFIC
Code Structure Reminder ICD-10 Code Structure Inpatient & Outpatient ICD-10 (Diagnosis) CM codes 3 to 7 alphanumeric characters Digit 1 = alpha (A-Z, not case sensitive) Digit 2 = numeric Digit 3 = alpha (not case sensitive) or numeric Digits 4-7 = alpha (not case sensitive) or numeric Inpatient ICD-10 (Procedure) PCS codes 7 alphanumeric characters (not case sensitive) Numbers 0-9 are used Letters O and I are not used to avoid confusion with numbers 0 and 1
Code Structure Reminder Stay in the Lane Section 0 Medical and Surgical Body System F Hepatobiliary System and Pancreas Operation T Resection: Cutting out or off, without replacement, all of a body part Body Part Approach Device Qualifier 0 Liver 1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 0 Open 4 Percutaneous Endoscopic Z No Device Z No Qualifier 5 Hepatic Duct, Right 6 Hepatic Duct, Left 8 Cystic Duct 9 Common Bile Duct 0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic Z No Device No Qualifier When building PCS codes, choose characters from left to right within the same lane or row 0FT40ZZ is correct, all characters are chosen from the same lane 0FT47ZZ is incorrect, the approach (7 Via Natural or Artificial Opening) is not a valid option for body part (4 Gallbladder), it is in a different lane than the body part
Part 3 Part 3 Next Steps and Wrap Up
In Summary Physician claims for outpatient and inpatient services will transition to using ICD-10 Clinical Modification (ICD-10-CM) for reporting diagnoses on October 1, 2015. Also, please note that ICD-10-CM will NOT replace the CPT procedure codes. Remember, insurers making payment decisions, rating severity of illness, or trying to predict recovery time, all need physician documentation that is at the highest level of specificity.
Start with a checklist Obtain a list of your most commonly use ICD-9 codes Use existing tools to develop a list of viable ICD-10 codes Study those codes to understand the level of detail needed in the medical record Make sure that medical record documentation supports ICD-10 codes Use existing content-based testing environments and practice ICD-10 coding of those scenarios Note: This transition activity is not the end game solution, but it will minimize immediate disruption and get you over the hump for 10/1/15.
Content-based testing links Humana http://hureg.providercodingimpact.com/registration.aspx BCBSM http://bcbsmicd10providerregistry.highpointsolutions.com/registration.aspx?test=y Michigan Dept of Community Health http://www.michigan.gov/mdch/ 0,1607,7-132-2945_42542_42543_42546_42552_42696-256928--,00.html#Testing
Additional ICD-10 Coding Resources Crosswalks for the Top 50 Codes by Specialty http://www.aapc.com/icd-10/crosswalks/pdf-documents.aspx ICD-10 CM/PCS Documentation Tips http://bok.ahima.org/pdfview?oid=300621 100 Tips for ICD-10-PCS Coding http://icd10monitor.com/enews/item/615-100-tips-for-icd-10-pcs-coding-tips-1-10 Free Code Conversion Tool http://www.icd10data.com/convert FAQs: ICD-10 Transition Basics http://www.cms.gov/medicare/coding/icd10/downloads/icd10faqs.pdf
Thank you!
DISCLAIMER This presentation is intended only for information use accompanying a live teleconference by the Payer Collaboration (Collaboration). No copy or use of this presentation should occur without expressed permission from the Collaboration. While our best efforts are to provide accurate and useful information, the Collaboration makes no claim, promise, or guarantee of any kind about the accuracy, completeness, or adequacy of the content of the presentation and expressly disclaims liability for errors and omissions in such content. As diagnostic codes changes annually, you should reference the current version of coding guidelines for the most detailed and up-to-date information. The information contained in this presentation is intended for informational purposes only. The Collaboration has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this seminar, including but not limited to any loss of revenue, interruption of service, loss of business or indirect damages resulting from the use of this program. The Collaboration makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. The material is designed and provided to communicate information about coding and documentation in an educational format and manner. The presenter(s) are not providing or offering legal advice, but rather, practical and useful information and tools in the area of clinical documentation, data quality and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful.