1 UHS, Inc. ICD-10-CM/PCS Physician Education Cardiology and Cardiovascular

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UHS, Inc.

ICD-10-CM/PCSPhysician Education

Cardiology and Cardiovascular

ICD-10 Implementation

• October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) – Ambulatory and physician services provided on or after

10/1/15– Inpatient discharges occurring on or after 10/1/15

• ICD-10-CM (diagnoses) will be used by all providers in every health care setting

• ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures – ICD-10-PCS will not be used on physician claims, even

those for inpatient visits2

Why ICD-10Why ICD-10

Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of

new codes that can be created– Has obsolete groupings of disease families– Lacks specificity and detail to support:

• Accurate anatomical positions• Differentiation of risk & severity• Key parameters to differentiate disease manifestations

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Diagnosis Code StructureDiagnosis Code Structure

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ICD-10-CM Diagnosis Code FormatICD-10-CM Diagnosis Code Format

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Comparison: ICD-9 to ICD-10-CMComparison: ICD-9 to ICD-10-CM

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Procedure Code Structure Procedure Code Structure

ICD-10-PCS Code FormatICD-10-PCS Code Format

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ICD-10 Changes Everything!ICD-10 Changes Everything!

• ICD-10 is a Business Function Change, not just another code set change.

• ICD-10 Implementation will impact everyone:– Registration, Nurses, Managers, Lab, Clinical Areas,

Billing, Physicians, and Coding

• How is ICD-10 going to change what you do?

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ICD-10-CM/PCSDocumentation Tips

ICD-10 Provider ImpactICD-10 Provider Impact

• Clinical documentation is the foundation of successful ICD-10 Implementation

• Golden Rule of Documentation– If it isn’t documented by the physician, it didn’t happen– If it didn’t happen, it can’t be billed

• The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient

– what services were rendered and what is the severity of illness

• The key word is SPECIFICITY– Granularity– Laterality

• Complete and concise documentation allows for accurate coding and reimbursement

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Gold Standard Documentation PracticesGold Standard Documentation Practices

1. Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms

2. Document diagnoses, rather that descriptors

3. Indicate acuity/severity of all diagnoses

4. Link all diseases/diagnoses to their underlying cause

5. Indicate “suspected”, “possible”, or “likely” when treating a condition empirically

6. Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers

7. Clarify diagnoses that are present on admission

8. Clearly indicate what has been ruled out

9. Avoid the use of arrows and symbols

10. Clarify the significance of diagnostic tests12

ICD-10 Provider ImpactICD-10 Provider Impact

The 7 Key Documentation Elements:

1.Acuity – acute versus chronic

2.Site – be as specific as possible

3.Laterality – right, left, bilateral for paired organs and anatomic sites

4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance

5.Manifestations – any other associated conditions

6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence

7.Signs & Symptoms – clarify if related to a specific condition or disease process

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ICD-10 Documentation TipsICD-10 Documentation Tips

Do not use symbols to indicate a disease.

For example “↑lipids” means that a laboratory result indicates the lipids are elevated

– or “↑BP” means that a blood pressure reading is high

These are not the same as hyperlipidemia or hypertension

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Site and Laterality – right versus left–bilateral body parts or paired organs

Example – cellulitis of right upper arm

Stage of disease –Acute, Chronic–Intermittent, Recurrent, Transient–Primary, Secondary–Stage I, II, III, IV

Example – stage of pressure ulcer:– L89.011 Pressure ulcer of right elbow, stage 1– L89.021 Pressure ulcer of left elbow, stage 1

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Documentation should always include:

– Patient’s BMI

– Current of past history of tobacco use or dependence

– Exposure to environmental or occupational tobacco

smoke

– History of previous MI

– Administration of tPA at a different facility within 24

hours prior to admission to current facility

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Atherosclerosis

– Specify type of vessel:• Native artery• CABG or Transplanted heart artery

– Specify CABG graft type:• Autologous vein• Autologous artery• Non-autologous biological• Native coronary artery or transplanted heart

– Specify CABG and transplanted heart to include:• With and without angina pectoris• Unstable angina• Documented spasm• Other forms of angina pectoris

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Heart Failure

– Specify acuity• Acute• Chronic• Acute on chronic

– Identify type• Systolic• Diastolic• Combined systolic and diastolic

– List relationship of hypertension to heart failure or heart disease

– Identify underlying cause» Example - Exacerbation of stable heart failure due to fluid overload or due to

missed dialysis

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Disorders of the Heart Valves

– Specify Site• Mitral• Aortic• Tricuspid• Pulmonary

– Specify Type• Rheumatic• Nonrheumatic• Congenital

– Specify Severity – acute versus chronic• If rheumatic, classify with or without heart involvement

– Subclassifications• Insufficiency• Incompetence• Regurgitation• Prolapse• Stenosis 19


Ischemic Heart Disease

– Specify occlusion as:• Total, partial

– Specify the presence of:• Angina pectoris, unstable angina, any spasm of a coronary vessel

– Identify the type and underlying cause of angina» if not related to heart disease

– Identify ischemic heart disease as:• Atherosclerosis• Arteriosclerotic coronary artery disease• Arteriosclerotic heart disease• Coronary artery disease• Coronary arteriosclerosis • Coronary heart disease• Coronary ischemia

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Type of MI along with Myocardium involved – Specify the type – ST elevation, non ST elevation

– Specify the location/site affected• anterior wall, anterolateral wall, interior wall• left anterior descending coronary artery• left main coronary artery, right coronary artery

– Timeframe• Clearly indicate date of recent acute MIs within 28 days prior to current

admission• History of MI (older than 28 days)

– tPA• Was tPA administered within the last 24 hours of admission at a

different facility?

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Diabetes - include the type or cause of diabetes

– Type I– Type II– Due to drugs and chemicals– Due to underlying condition– Link any manifestations / complications to the

diabetes• Circulatory, renal, neurological, ophthalmic, skin,

other

Examples:•E08 - Diabetes mellitus due to underlying condition

– E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma– E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma

•E11 - Type 2 diabetes mellitus– E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema– E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular

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Strokes – dominant vs. non-dominant side– Specify the location or source of the hemorrhage and laterality

– Document other causes – thrombosis, embolism, occlusion, stenosis

• Sites – precerebral or cerebral arteries• Laterality

– Document dominant verses non-dominant side for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesis and for residual effects

Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.

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Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post-procedural disorders

•The provider must clearly document the relationship between the condition and the procedure

– Example: • D78.01 –Intraoperative hemorrhage and hematoma of spleen

complicating a procedure on the spleen • D78.21 –Post-procedural hemorrhage and hematoma of spleen following

a procedure on the spleen

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Intra-operative Post-procedural

Accidental puncture / laceration Timing:•Post-procedure•Late effect

Same or different body system Classify as:•An expected post-procedural condition•An unexpected post-procedural condition, related to the patient’s underlying medical comorbidities•An unexpected post-procedural condition, unrelated to the procedure•An unexpected post-procedural condition related to surgical care (a complication of care)

Blood product

Central venous catheter

Drug:•What adverse effect•Drug name•Correctly prescribed•Properly administered

Encounter:•Initial•Subsequent•Sequelae


ICD-10-PCS does not allow for unspecified procedures, clearly document:

•Body System– general physiological system / anatomic region

•Root Operation– objective of the procedure

•Body Part– specific anatomical site

•Approach– technique used to reach the site of the procedure

•Device– Devices left at the operative site


Most Common Root Operations:

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Bypass – altering the route of passage

Drainage – taking or letting out fluids &/or gases

Insertion – putting in a non-biological appliance

Restriction – partially closing

Control – stopping or attempting to stop bleeding

Excision – cutting out or off

Replacement – putting in a biological / synthetic material to replace or function as a body part

Supplement – putting in a biological / synthetic to reinforce and / or augment function

Dilation - expanding Extirpation – taking or cutting out solid matter

Repair – restoring to its anatomic structure and function

Transfer – moving a body part to another location

Division – cutting into a body part to separate or transect

Extraction – pulling or stripping out of off

Resection – cutting out or off

Transplantation – putting in a living body part from another individual or animal


Most Common Device Types:

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Cardiac Lead Drainage Device Monitoring Device

Stimulator Lead

Cardiac Rhythm Related Device

Extraluminal Device

Pacemaker, single or dual

Tracheostomy Device

Contractility Modulation Device

Feeding Device Radioactive Element

Vascular Access Device, Reservoir or pump

Defibrillator Intraluminal Device: Plain, Drug-Eluting or Radioactive

Stimulator Generator

SummarySummary

The 7 Key Documentation Elements:

1.Acuity – acute versus chronic

2.Site – be as specific as possible

3.Laterality – right, left, bilateral for paired organs and anatomic sites

4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance

5.Manifestations – any other associated conditions

6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence

7.Signs & Symptoms – clarify if related to a specific condition or disease process

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Documents

1 UHS, Inc. ICD-10-CM/PCS Physician Education Cardiology and Cardiovascular