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9/13/2013ICD-10 IN PRIMARY CAREAn Approach to ClinicalDocumentation ImprovementLYNN M. MYERS MD, CPC, CHCAgenda The Challenge of ICD-10The Assessment of our ProvidersActions TakenThe ResultThe ChallengeTrain providers on ICD-1Ø– Coding guidelines– Documentation– EMR upgrades– Paper vs. electronic– Hospital and ambulatory1


9/13/2013ICD-9-10 Diagnosis Orthopedics Obstetrics Internal MedFamilyPracticeCardiology9/13/20138ICD9 vs. ICD10 0%Provider 19/13/2013Provider 2Provider 3Provider 4Provider 593

9/13/2013Summary ogy9/13/201310ICD9 vs. ICD10 Family ider 1Provider 2Provider 3Provider 4Provider 59/13/201311Summary Family Practice80%70%60%50%ICD1040%ICD930%20%10%0%Family Practice9/13/2013124

9/13/2013ICD9 vs. ICD10 Internal Medicine(not including hospitalists or r 1Provider 2Provider 3Provider 4Provider 59/13/201313Internal Medicine nternal Med9/13/201314ICD9 vs. ICD10 der 19/13/2013Provider 2Provider 3Provider 4Provider 5155

9/13/2013Summary ICD9 vs. ICD10 Orthopedics120%100%80%ICD1060%ICD940%20%0%Provider 1Provider 2Provider 3Provider 4Provider 59/13/201317Summary 76%Orthopedics9/13/2013186

9/13/2013Diabetes EØØ-E89 In ICD-9– 4th digit (if other than 0 or 9, requires add’l code)– 5th digit (describes control and type) In ICD-10-Combination codes– Type of DM– Body system affected– Complications affecting that body systemDiabetes EØ8-E13 5 categories– EØ8-DM due to underlying condition (secondary) Cushing’s, CF, pancreatitis, etc.– EØ9-DM induced by drug or chemical (secondary) Steroids– E1Ø-Type 1 DM (insulin deficiency)– E11-Type 2 DM (insulin resistance)– E13-Other specified DM (secondary) Genetic defects, post-surgicalDiabetes Codes expanded to reflect manifestations andcomplications by use of 4th or 5th charactersinstead of additional ‘companion codes’ Inadequately controlled, out of control, poorlycontrolled are coded to diabetes, by type, withhyperglycemia7

9/13/2013Diabetes-Key Terms DocumentDocumentDocumentDocumentinsulin use! Z79.4the causal condition, drug or chemicalthe underlying associated conditioninsulin pump complications– Initial, subsequent or sequela– Overdose or under-dosing of insulin related to pumpmalfunction Document complications – Hyperglycemia,hypoglycemia, renal, ophthalmic, etc.Diabetes in Pregnancy O24 Document if– diabetes pre-dates pregnancy– gestational Document trimester Document treatment– Diet controlled– Insulin controlled– Unspecified controlHyperlipidemia ICD-9 Ability to define hypercholesterolemia,hypertriglyceridemia, and mixed ICD-10 Similar format8

9/13/2013Hyperlipidemia-Key TermsEncourage specificity by documenting significantlaboratory test data. Coders cannot code from labreport.– Pure hypercholesterolemia– Pure glyceridemia (hypertriglyceridemia)– Mixed (elevated cholesterol and triglycerides)– Lipoprotein holesterolemia272.0E78.0Familial, inherited,elevated LDLPureHyperglyceridemia272.1E78.1Elevated Very LowDensity evated cholesteroland triglyceridesOther and ow HDL withnormal cholesterolObesity-E66 ICD-9 defined as– Overweight, morbid and unspecified ICD-10 Documented by type and severity andBMI Pediatrics should be documented in BMIpercentile (0-20yrs)– Overweight (85th to less than 95th percentile)– Obese (equal to or greater than the 95th percentile)9

9/13/2013Obesity-Key Terms– Obesity due to excess calories E66.0 Morbid (severely) obese due to excess calories (Adult BMI40 ) E66.01 Other obesity due to excess calories (Adult BMI 30 ) E66.02– Drug-induced obesity E66.1 (use additional code foradverse effect of drug)– Morbid severe obesity with alveolar hypoventilationsyndrome E66.2 (Pickwickian syndrome)– Overweight (Adult BMI 25-29.9) E66.3– Adult BMI codes are assigned for patient age 21 Chapter IX i00-i99Diseases of the Circulatory System Heart disease Cerebrovascular diseases Vascular diseasesHypertension i1Ø-i15 In ICD-9– Requires documentation of benign, etc.– Combination codes/dual code requirement Hypertensive heart disease code Hypertensive renal renal disease code Hypertensive heart and renal both and renal codes In ICD-10– Combination codes– Dual code requirement remains– Hypertension in pregnancy is not included in ChapterIX10

9/13/2013Hypertensive Heart Disease i11Documentation Causal relationship “due to”– Echocardiogram– ECG findings– Exam findings of JVD and edema Type of heart failure- i50.-Hypertensive Kidney Disease i12Documentation Causal relationship may be assumed Stage of CKD included with the code Still requires additional code for CKD (N18.-)Hypertensive Heart and Kidney Disease i13Documentation Causal relationship Additional codes for heart failure (i50.-) andCKD-(N18-) Stage of CKD included in the code11

9/13/2013Heart Failure i50 Be sure that associated hypertensive heartand/or hypertensive heart & renal disease aredocumented Documentation must identify the cause-andeffect relationship between HTN and CHF.Heart Failure i50.Key Terms Cardiac asthmaEdema of lung with heart diseaseEdema of lung with heart failureLeft heart failurePulmonary edema with heart diseasePulmonary edema with heart failureBiventricular (heart) failureCardiac or myocardial failureCongestive heart disease or failureRight ventricular failure (secondary to left heart failure)Heart Failure-Definitions Systolic HF i5Ø.2 A dilated ventricle thatdoes not empty properly. ‘Exacerbation’indicates an acute flare. If the patient haschronic HF, use the ‘acute on chronic’ CHFcodes Diastolic HF i5Ø.3- 40-60% of CHF;Impaired myocardial relaxation results inincreased diastolic pressure12

9/13/2013Cerebrovascular Disease i60-i67Key Terms Type Use Additional Code for– Cerebral infarction– Occlusion– Hemorrhage Site– Cerebral– Subarachnoid– Carotid–––––Alcohol abuse/dependenceExposure to tobacco smokeHistory of tobacco useTobacco dependenceTobacco use Cause– Embolism– Occlusion– ThrombosisCVA or StrokeDocumentation Acute diagnosis within the first 24 hours, sonot usually an ambulatory diagnosis Need specific information– Acute process Cause, site, type– Late residual deficits (Sequela) if not acute-(i69)Sequela of Cerebrovascular DiseaseKey Terms Type of sequela– Apraxia– Dysphagia– Ataxia– Paralysis– Hemiplegia– Monoplegia Dominant or non-dominant side of the brain13

9/13/2013Peripheral Vascular Disease Diabetic PVD coded in combination codesindicating type and nature of DM and PVD– Type 1 or 2 DM– Gangrene, peripheral angiopathy without gangrene Raynaud’s syndrome -With or withoutgangrene i73.0 Buerger’s diseasePeripheral Vascular DiseaseKey Terms Type– Aneurysm– Atherosclerosis Site Laterality Complications– Ulceration– Gangrene Type of vessel– Native– Autologous vein bypass– Non-autologous biologicalIschemic Heart Disease i20-i25Documentation Combination codes for atheroscleroticCoronary Artery Disease & Angina i20– Native coronaries– Bypass grafts– Transplant With AMI i2114

9/13/2013Mental, Behavioral &Neurodevelopmental Disorders ICD-9 is grouped by psychotic, nonpsychoticor mental retardation ICD-10 is grouped in blocksF01-F09 Due to known physiologic issuesF10-F19 Due to psychoactive substance useF20-F29 Schizophrenia, etc.F30-F39 Mood [affective] disorders-depressionF40-F48 Anxiety, dissociative, etc.FDementia FØ1-FØ3 Progressive decline in mental ability– Usually 60 y/o– Due to trauma, disease, toxins Often diagnosed by symptoms and behavior– Confirmation of diagnosis sometimes at autopsy Document the type of dementia AND anybehavioral component– None– Aggressive, combative, violent, wandering offDementia-Key Terms Vascular-with or without behavioral disturbance Other causes-with or without behavioraldisturbance Identify underlying disease as causative–––––Alzheimer’s with dementiaCreutzfeldt-JakobLewy body diseaseFronto-temporalDue to hypercalcemia, MS, syphilis, etc.15

9/13/2013Depression F30-39Key Terms Very much like ICD-9!Single, recurrent, persistentMild, moderate, severeRemission– Full– Partial Psychosis– With– WithoutAlzheimer’s Disease G3Ø. Currently coded to 331.0 Key terms– Early onset- before age 65 - New!– Late onset-New!– Other type causing diffuse atrophy of cerebrum– UnspecifiedInjury and Poisoning SØØ-T88 InjuriesTraumatic fracturesBurns and corrosionsAdverse effects– Poisoning, under-dosing and toxic effects Child and Adult abuse and neglect Complications of care16

9/13/2013Injuries Specific types of injuries are arranged by body regionbeginning with the head and concluding with the ankleand foot External cause codes capture the cause of the injury orcondition, the intent, the place where the event occurredand the activity of the patient at the time of the eventand the person’s status (military, etc.) Most diagnoses will have 7th character– A-initial encounter– D-subsequent encounter– S-sequelaInjuries Documentation of most serious injury iscritical– Primary injury with minor damage to peripheralnerves or vessel– Primary injury to nerves, spinal cord or vesselsTraumatic fractures– A-patient receiving active treatment Surgical ED encounter Evaluation by new physician– D-routine care during recovery Cast change or removalRemoval of external or internal fixation deviceMedication adjustmentOther aftercare and follow up following treatment– S-complications or conditions that arise as a directresult of a condition scar17

9/13/2013Traumatic FracturesDocumentation Site Laterality-(if bilateral, and no bilateral code isprovided, both sides are coded) Open or closed Displaced Initial or Subsequent encounter Complications– Malunion or nonunion? Presence of Osteoporosis (M80)Late Effects (Sequela) The residual effect after the acute phase of anillness or injury has terminated No time limit Document the nature of the sequela as well asthe cause of the sequelaBurns and Corrosions Burn codes are for burns that come from a heatsource such as fire, a hot appliance, electricity& radiations– Depth 1st- erythema 2nd – blistering 3rd – full thickness Corrosions are burns due to chemicals18

9/13/2013 Burns-DocumentationSiteSource of burn and place of occurrenceDegreeFocus of treatment (most severe)Non-healing or necrosisInfectionLate effect (scar or contracture)-Head & neckRule of 9s 9%9% -Each arm18%-Each leg18%-Anterior trunk18%-Posterior trunk1% -GenitaliaAdverse Effects T36-T6DocumentationCombination codes that include the substance aswell as the intentAdverse Effect: effect of a drug properlyprescribed and administeredExamples of Effect: tachycardia, delirium,gastro-intestinal hemorrhaging, vomiting,hepatitis, renal failure, respiratory failurePoisoning-Documentation A reaction to the improper use of a medication––––OverdoseWrong substance given in errorWrong substance taken in errorWrong route of administration Intent––––AccidentalIntentional self-harmAssaultUndetermined19

9/13/2013Poisoning-Examples Error in drug prescription or administration ofthe drug by the provider, nurse, patient or otherperson Overdose of a drug intentionally taken Non-prescribed drug taken with correctlyprescribed and properly administered drug Interaction of drug and alcoholUnder DosingDocumentation New code available to describe taking less of amedication than is prescribed by a provider or amanufacturer’s instruction– Financial reasons– Side effects Relapse or exacerbation of the medical conditionfor which the drug is prescribed should bedocumented Noncompliance should be documented, if knownToxic Effects-Documentation When a harmful substance is ingested orcomes in contact with a person Document intent– Accidental– Intentional self-harm– Assault– Undetermined20

9/13/2013GERD ICD-9 Gastroesophageal Reflux vs. RefluxEsophagitis ICD-10 Gastroesophageal Reflux Disease isnow a combination codeGERD Key TermsWith esophagitis K20.9Without esophagitis K21.9Sinusitis ICD-9 Acute vs. chronic and location ICD-10 Similar structure– Document acute vs. acute recurrent by site (useadditional code to identify infectious agent – e.g.,Staphylococcus)– Chronic (include tobacco exposure)21

9/13/2013SinusitisDocumentation for acute sinusitis may support specific codesbased upon which sinuses are involved, and the causativeorganism. In primary care, the causative organism is oftenunknown, as indicated by the word ‘unspecified’ in the codesbelow. If the organism is known, a code from the B95-B97series is also coded. J01.00 Acute maxillary sinusitis, unspecified J01.10 Acute frontal sinusitis, unspecified J01.20 Acute ethmoidal sinusitis, unspecified J01.30 Acute sphenoidal sinusitis, unspecified J01.40 Acute pansinusitis, unspecified J01.80 Other acute sinusitis-use for more than one sinus, butnot pansinusitisKey Terms-Sinusitis FrontalMaxillaryEthmoidalSphenoidalPansinusitis (inflammation of all paranasalsinuses on one or both sides) Tobacco detailsArthritisChapter 13 MØØ-M99 ICD-9 Type and site involved no designation forlaterality ICD-10 Cause, Site & Laterality– For certain conditions the upper or lower end may beinvolved, the designation is still the bone and not thejoint– Bone vs. joint– Document whether acute traumatic, chronic orrecurrent– Some types include ability to code for multiple sites22

9/13/2013Arthritis-Key Terms Pyogenic (infectious)(document organism) Primary– Rheumatoid, by site– Other symptoms With/without RF With/without rheumatoid nodule Involvement of other organs or systems– Juvenile– Psoriatic Secondary arthritis– Post-traumatic– Osteoarthritis (polyosteoarthritis-multiple sites)Tobacco ExposureMany different categories suggest coding tobacco exposure– Neoplasms, Heart Disease, Pulmonary, ObstetricsDocument specific types of exposure: Exposure to environmental tobacco smoke– Second hand exposure (acute)(chronic)– Passive smoking (acute)(chronic) History of tobacco use (personal) Occupational exposure to environmental tobacco smoke (servers) Document type of Nicotine dependence– Cigarettes, chewing tobacco, other types Document uncomplicated, withdrawal, remission, other nicotineinduced disordersTobacco Environmental exposure to tobacco smokeHistory of tobacco useTobacco dependenceTobacco use-use when criteria for dependenceis not met.23

9/13/2013Defining Tobacco DependenceAt least 3 of the following in 12 months: Tolerance Withdrawal Nicotine is used in larger amounts or over a longer period than intended. The user has a persistent desire or makes unsuccessful attempts to cut downon tobacco. A great deal of time is spent in obtaining or using the substance (e.g., chainsmoking). Reduction in activities because of tobacco use Recurrent use of the substance continues despite recurrent physical orpsychological problemsCOPD J44.Ø-J44.9 ICD-9 Chronic bronchitis, obstructive chronicbronchitis, emphysema ICD-10 Chronic obstructive pulmonary diseaseCOPD-Key Terms Chronic bronchitisChronic obstructive asthmaEmphysemaExacerbationDecompensationChronic lung diseaseTobacco details24

9/13/2013Asthma ICD-9 defined as intrinsic, extrinsic, exerciseinduced, other specified types ICD10 Document type includes allergic andnon-allergic asthma.Asthma Key Terms Mild intermittentMild persistentModerate persistentSevere persistentTobacco Exposure25

9/13/2013Asthma Documentation .IntermittentMild ms2 or less days perweekMore than 2 daysper weekDailyThroughout the dayNighttimeAwakenings2 X’s per month orless3-4 X’s per monthMore than once perweek but notnightlyNightlyRescue Inhaler2 or less days perweekMore than 2 daysper week but notdailyDailySeveral times perdayInterference withNormal activityNoneMinor limitationsSome limitationsExtremely limitedLung FunctionFEVI 80%predicted andnormal betweenexacerbationsFEVI 80%predictedFEVI 60-80%predictedFEVI less that 60%predictedHeadache-Key terms Type–––––––Migraine G43.Cluster G44.0Vascular G44.1Tension G44.2Post-traumatic G44.3Drug induced G44.4Menstrual G44.8- Aura (with or without) Intractable (or not)Rhinitis J30-31Key TermsVasomotor & Allergic J3Ø. Allergic rhinitisVasomotor rhinitisAllergic rhinitis due to pollenOther seasonal allergic rhinitisAllergic rhinitis, unspecifiedChronic rhinitis J31.ØAcute nasopharyngitis (common cold) JØØ26

9/13/2013UTIKey Terms Site– Cystitis N30.– Urethritis N34.– Not specified N39.Ø Infectious Agent B95-B97Training Make the most of ‘Teachable Moments’ Regular newsletter publications– “ICD-10 Coding Corner” Audit RecommendationsFormal Training Leverage system resources Capitalize on existing educational offerings– Medicare Advantage– ACO– Meaningful Use27

9/13/2013Training Schedule Web-based training– Awareness– Non-coders that use ICD codes in daily work Providers Staff Instructor-led training– Coders– Providers Ambulatory : Five 2-hour sessions in each of 3 zones Hospital – Two 2-day one hour sessions in each of 14hospitals, followed by on site coder accessThe Result To Be Determined! Chart Audits for ICD-10 to begin in the 4thquarter28

9/13/2013THANK YOU!LynnMyers@TexasHealth.org29

code description count % total 401.9 hypertension nos 72652 13.85% 244.9 hypothyroidism nos 68916 11.61% 268.9 vitamin d deficiency nos 47850 10.59% 477.9 allergic rhinitis nos 30912 7.65% 285.9 anemia nos 29669 7.95% 461.9 acute sinusitis nos 22670 6.60% 465.9 acute uri nos 20344 6.34% 724.

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