ICD-10 Documentation Concepts - NP Convention 2015.ppt .
7/13/2015Objectives Review the History of ICD‐10 Discuss the Myths and Facts of ICD‐10 DiscussDiGeneralGl DocumentationDt ti ConceptsCtTonya Mitchell, RHITJuly 17, 2015 Review ICD‐10 Documentation Concepts Analyze Documentation for Top Diagnosis in ICD‐10WHY CHANGE FROM ICD‐9 TO ICD‐10? ICD‐9 was developed in the 1970s and cannot support currenthealth information needs There is no room for expansion in ICD‐9 which is used for morepurposes thanth originallyi i ll intendedi t d dPutting your fears at ease ICD‐9 lacks sufficient specificity The United States is the almost the last industrialized nation toadopt ICD‐10 making an integrated world‐wide medical recordssystem impossible1
7/13/2015MYTHS AND FACTSMYTHS AND FACTS MYTH – There was no clinical input into ICD‐10. MYTH – There are only specific codes in ICD‐10. FACT (CMS)– Although this often seems to be the FACT (CMS) ‐ Nonspecific codes are still available incase, a number of medical societies provided input.Shh!!ShhICD‐10. FACT (WSR) – Don’tD ’ tellll your doctorsdthishi littleli l tidbit.idbi MYTH – No hard‐copy code books will be available. FACT (CMS) – ICD‐10 books are already available. MYTH – ICD‐10‐PCS will replace current CPT codes. FACT (WSR)– Medical professionals and staff love FACT (CMS) – Only inpatient procedures will usedead trees despite the push to computerize everything.ICD‐10‐PCS. CPT codes will still be used for office‐based procedures.ICD‐10MYTHS AND FACTS (cont.)GENERAL DOCUMENTATION TIPS Acceptable to use unable to rule out, probable, MYTH ‐ Unnecessary medical testing will be needed to assignICD‐10 codespossible, or suspected on inpatientdocumentation FACTS ‐ ICD‐10ICD 10 contains many more codes for signs and symptoms OnceOa conditiondi i hash beenbruledl d out iti can no longerlbe codedthan ICD‐9 It is better designed for use in ambulatory settings whendefinitive diagnoses may not be known. Proper documentation is the key Avoid using abbreviations: HypoK CANNOT be assumed to mean hypokalemia The same rule applies to disorders of sodium, calcium,etc.72
7/13/2015GENERAL DOCUMENTATION TIPS(cont.) Coders cannot assume linkage Examples: Acceptable: CVA due to right carotid stenosis Unacceptable:Ut bl CVA,CVA carotidtid diseasedi The same rule applies to infection, anemia, renal failure,encephalopathy, diabetic complications, etc.OVERVIEW OF ICD‐10 Implementation date:***********************OCTOBER 1, 2015*********************** ICD‐10 PCS for coding procedures does NOT replace CPT coding forE/M services ICD‐10 codes provide: Greater specificity When in doubtwrite it out! More clinical information Information relevant to ambulatory and managed care encounters Information used for data tracking (example: substance disordersincluding tobacco)TOP INPATIENT DIAGNOSES CHF COPD Pneumonia DM with complicationsCONGESTIVE HEART FAILURE Document acuity: Acute Chronic Acute on chronic Compensated vs.vs exacerbation CKD Document type: Systolic Diastolic Combined systolic and diastolic Anemia Always document EF if known UTI with altered mental status3
7/13/2015CONGESTIVE HEART FAILURE Document if due to or associated with: Hypertension(cont.)PNEUMONIA SPECIFICITYDocument type/organism:Document mechanism: Aspiration – food, Valvular disease Bacterial (gram negative,gram positive, anaerobic) CardiacC di or otherth surgery Viral Post‐obstructivePbi Rheumatic heart disease Fungal Ventilator‐associatedEndocarditis Pericarditis Myocarditis Other (specify) Interstitial Radiation‐induced PNEUMONIA Other (specify) Community acquired orhealthcare associatedpneumonia cannot be coded Other (specify)COPD(cont.) Document any associated illness:liquid, chemicals Specify with or without exacerbation Respiratory failure Sepsis Underlyingd llungldiseased Malignancy Other (specify) Document if associated with: Asthma Bronchiectasis Bronchitis (acute or chronic) Document tobacco use: Present or past4
7/13/2015DIABETES MELLITUS Document type: Type I or type II Drug/chemical‐induced Due to underlying condition Other specified type Specify if patient is on insulin(cont.) Always link complications and manifestations toDM Examples: (cont.) Document manifestations/complications: Circulatory complications Hyperosmolarity With or without coma Renal complications Neurological complications Ophthalmic complications Oral complications Skin complications Arthropathy Other (specify) Document control: Inadequate control Out of control/poorly controlled Hypoglycemia HyperglycemiaDIABETES MELLITUSDIABETES MELLITUSAcceptable: The patient has uncontrolled type II diabeteswith diabetic nephropathy, retinopathy, and neuropathy aswell as a stage 2 diabetic ulcer on the right foot.Unacceptable: Insulin‐dependent diabetes, neuropathy,foot wound Insulin‐ and non‐insulin‐dependent cannot beANEMIA SPECIFICITY Clarify the type/cause Blood loss – acute, chronic, expected post‐operative Chronic disease – renal disease, malignancy, etc. Deficiency – B12, iron Medication‐related And many more coded5
7/13/2015URINARY TRACT INFECTION Specify and link to organismCKD SPECIFICITYStageGFR Specify site: Pyelonephritis I 90 Cystitis II 60‐89 III 30‐59 IV 15‐29 V 15 (and pt is not on Specify if sepsis is present Acceptable: Sepsis secondary to E. coli UTI Unacceptable: Urosepsis Urosepsiscodes to basic UTIALTERED MENTAL STATUS AMS is a non‐specific term along with: Confusion Delirium Mentall status changesh Unresponsiveness Encephalopathy is the preferred term Document type/cause Document any associated diagnosis/conditionsdialysis)ENCEPHALOPATHY Specify type/cause: Alcoholic Anoxic/hypoxic CVA – late effect Hepaticp Hypertensive Hypoglycemic Metabolic/septic Post‐ictal Toxic/drug induced (specify drug) Traumatic Other (specify) If reason is unclear then toxic/metabolic is your default6
7/13/2015KEY ICD‐10 DOCUMENTATION CONCEPTSDOCUMENTATION EXAMPLESUNABLE TO CODE ACCURATELYABLE TO CODE ACCURATELYMSOF, multi-system organ failureLiver failure, acute respiratory failureUrosepsisSepsis secondary to UTISevere respiratory distressRespiratory failure – acute, chronic, combinedHemodynamically unstableHypotension, CHF, cardiogenic shockWill rehydrateDehydration, hypovolemiaRhythm stable todayVentricular tachycardia, atrial flutterUnable to voidUrinary retention due to (name the cause)K 2.0, will give KCLHypokalemiaLLL infiltrates, will give IV antibioticsLLL pneumonia (viral, bacterial, fungal,aspiration, etc.)Hgb 5.2, will transfuseAcute or chronic blood loss anemia due to.Emaciated, total protein/albumin lowSevere protein calorie malnutritionnutrition supplements startedCONCEPTCausal agent/conditionEXAMPLE (CONDITION)Biliary stone, meds(specify), alcohol, hightriglycerides(Acute/chronicpancreatitis)Age, smoking, steroids,other meds (specify)(Osteoporosis)LateralityLeft(CHF, stroke, DJD, kidney stone, tis(Cellulitis)AcuityS. pneumonia, rhinovirus, tumor,medications (specify)(Fever)Excess calories, Cushing’s disease,medications (specify)(Obesity – specify BMI and if morbidly obese)Right(CHF, stroke, DJD, kidney stone, cancer)Bilateral(Injury, pneumonia, hydronephrosis, DJD)Nephropathy, foot ulcer, neuropathy(Diabetes mellitus type I or type II)Abscess, perforation, hemorrhage(Acute diverticulitis)Acute(Otitis media, renal failure, systolic CHF, cystitis, hypoxicrespiratory failure, stroke, diverticulitis)Chronich(Atrial fib, diastolic CHF, sinusitis,bronchitis, respiratory failure)Acute on chronich(Systolic/diastolic CHF, sinusitis, hypercapnicrespiratory failure, , claudication)Persistent(Asthma, atrial fib, angina)EncounterFirst(Initial visit for a condition)Subsequent(F/U visit for the same condition)EpisodeInitial(First occurrence of a condition)Recurrent(Condition recurs despite treatment)**Recurrent conditions are not the same aschronic conditions**Substance disorderSubstance(Tobacco, heroin, marijuana,meth, cocaine, alcohol)State(Active, in remission)Type(Dependence, use, abuse)Delivery method(Cigarettes, chewing tobacco, cigars, inhalation,injection)InjuryBite(Open wound)Laceration(Open wound)Soft tissue involvementFascia(Right plantar, left quadriceps)Hemiparesis, dysarthria,dysphagia(Acute stroke)Puncture(Open wound)Tendon(Left Achilles)Fracture(Bone, joint)Ligament(Right ACL)Strain(Bone, joint)Muscle(Left hamstring, right bicep, bilateral quadriceps)R46.1Bizarre personal appearanceLaughter is always the best medicine(or therethisi a coded forf thatth t)Art by Chelsea Wittenbaugh.Struck by Orca. 20137
7/13/2015V61.6xxDPassenger in heavy transport vehicle injured in collision withpedal cycle in traffic accident, subsequent encounterArt by Sarah Sandock.Struck by Orca. 2013W56.22xAStruck by orca, initial encounterArt by Ellery Addington-White.Struck by Orca. 2013W61.62Struck by duck, sequelaWhat you need to know to surviveArt by Alex Connelly.Struck by Orca. 2013.8
7/13/2015TAKE IT DAY BY DAYZ73.4Inadequate socialskills, notelsewhereclassifiedDON’T STRESS YOURSELF OUTZ73.1Type A behaviorpatternRemember thatICD‐9 was oncenew, and we alladapted to it.Physicians don’tlike change soyour lives willbe miserable forawhile.Art by Erica Samlowski.Struck by Orca. 2013YOU DON’T HAVE TO GO IT ALONEZ89.419Acquired absenceof unspecifiedgreat toeArt by Erica Samlowski.Struck by Orca. 2013Y93.D1Activity,knitting andcrochetingEnjoy yourupcomingweekend butbe careful!Please let usknow if there isanything wecan do to assistyou.Art by Alex Connelly.Struck by Orca. 2013.9
7/13/2015TEST YOUR KNOWLEDGE Is “urosepsis” an acceptable term? No – “sepsis due to urinary tract infection” Is “diabetic foot wound” acceptable documentation? No – “footfoot ulcer secondary to uncontrolled type II DMand diabetic nephropathy” Wound injury due to being stabbed Is “mass” interchangeable with “neoplasm”? No – “pancreatic neoplasm with peritonealcarcinomatosis”REFERENCES & ADDITIONALRESOURCESReferences http://go.cms.gov/MLNProducts, ICD‐10‐CM/PCS/Mythsyand Facts,,April 2013 Advisory Board Company,handouts and presentations,2012‐2015Additional Resources http://go.cms.gov www.ahima.org www.icd10watch.com Is “insulin‐dependent diabetes” acceptable? No – “type I DM” or “type II DM”38Questions and DiscussionCONTACT INFORMATIONTonya Mitchell, RHITTeam Leader, Clinical Documentation Improvement Programtmitchell@mbhs.orgOffice: 601‐292‐4691Whitney Raju, MDPhysician Advisor, Clinical Documentation Improvement Programwraju@mbhs.orgOffice: 601‐968‐467310
7/13/2015 1 Tonya Mitchell, RHIT July 17, 2015 Objectives Review the History of ICD‐10 Discuss the Myths and Facts of ICD‐10 Discuss GlGeneral DttiDocumentation CtConcepts Review ICD‐10 Documentation Concepts Analyze Documentation for Top Diagnosis in ICD‐10 WHY CHANGE FROM ICD‐9 TO ICD‐10? ICD‐9 was developed in the 1970s and cannot support current
ICD-9 724.02 ICD-10 M48.06 Spinal stenosis, lumbar region ICD-9 720.2 ICD-10 M46.1 Sacroiliitis, not elsewhere classified ICD-9 724.8 ICD-10 R29.898 Other symptoms and signs involving the ** musculoskeletal system ICD-9 721.42 ICD-10 M47.16 Other spondylosis with myelopathy, lumbar region ICD-9 723.1 ICD-10 M54.2 Cervicalgia ICD
More on ICD-10. ICD-10-PCS replaces ICD-9-CM inpatient procedure coding: ICD-9-CM procedure codes 3 to 4 numeric digits ICD-10-CM codes 7 alphanumeric digits ICD-10-PCS code format substantially different from ICD -9 Unlike ICD-9, ICD-10
ICD-10 Tips from PHCS The Road to ICD-10 Flyer AMA ICD-10 Project Plan Template Educational Tools Folder Precyse University ICD-10 Physician Office Solution Brochure Precyse Catalog of ICD-10 Courses ICD-10 Precyse Apps for Physicians Resources Folder Free Resources ICD-9 to ICD-10 Crosswalk of Most Common ICD-9 .
Dec 14, 2010 · ICD-9. ICD-10. ICD-9. ICD-10. Inactive. Active. Combined Code Set. Core Technologies. ICD-9 and ICD-10 code values are unique. Generally, the industry is taking one of two approaches as it relates to the ICD-10 transition: Remediation: Modify/expand all systems and processes to accommodate ICD-
ICD-10 to ICD-10-CM Based on FY2017 ICD-10-CM codes Category and subcategory codes are shaded in grey and marked with an Cells shaded in pink and marked with an *indicate the preferred code when a single code maps to multiple codes (see Introduction) Reportable Neoplasms . Type of Code ICD-10 Category Chapter II (Neoplasms) ICD-10 Term . ICD .
by multiple ICD-10 codes or a cluster of ICD-10 codes may be required to describe a single ICD-9 code Some concepts will be lost when translating between ICD-9 and ICD-10 Substance Dependence concept has been removed from ICD-10 Substance Use is now defined by specific substance Overall, by using ICD
of the previous ICD-9 coding system. The volume of ICD-10 codes as compared to ICD-9 codes is significant because in ICD-10, the code size has been expanded, code values and interpretations have been redefined and specificity has been further improved. Global ICD-10 adoption The current version of ICD is ICD-10, which was adopted by the World .
others are just rough paths. Details are given in a document called the Hazard Directory. 1.3 Signals Most running lines have signals to control the trains. Generally, signals are operated from a signal box and have an identifying number displayed on them. Signals are usually attached to posts alongside the track but can also be found on overhead gantries or on the ground. Modern signals tend .
