1 UHS, Inc. ICD-10-CM/PCS Physician Education Neonatal and Pediatrics

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UHS, Inc.

ICD-10-CM/PCSPhysician Education

Neonatal and Pediatrics

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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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


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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Newborn Documentation:

1.Gestational age / prematurity• Extreme immaturity – less than 28 weeks gestation• Preterm – 28 weeks or more but less than 37 weeks gestation• Post-term – 40 – 42 weeks gestation• Prolonged – more than 42 weeks gestation

2.Weight• Extremely low birth weight – less than 999 grams• Low birth weight – 1000 – 2499 grams• Heavy – 4000 – 4499 grams• Exceptionally large – 4500 grams or more

3.Abnormalities in fetal size and health

4.Differentiate community-acquired versus conditions related to the birthing process

5.Abnormal results from neonatal screenings14


Newborn – birth to 28 days of life

Document any condition (even those that may impact future healthcare needs) that requires:

1. Further clinical evaluation

2. Therapeutic treatment

3. Diagnostic procedure

4. An extended length of hospital stay

5. Increase in nursing care and / or monitoring

Document maternal conditions that impact the health of the baby

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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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Birth Injury

–Site and type of trauma– Birth injury to facial nerve– Fractured clavicle due to birth process– Subdural hemorrhage related to birth injury– Erb’s palsy

–Contributing factors– Scalp of facial bruising due to forceps– Injury to scalp due to monitoring equipment

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Feeding Problems

–Specify related conditions and the feeding problem– Vomiting

» bilious or other– Regurgitation– Rumination– Slow feeding– Underfeeding– Overfeeding– Difficulty with breast feeding– Failure to thrive

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Neonatal Jaundice

–Specify cause– Associated with preterm delivery– Due to:

» Infection» Polycythemia» Swallowed maternal blood» Drugs or toxins» Excessive hemolysis» Breast milk inhibitor» Hepatocellular damage

–Document type of hepatitis, if applicable

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Noxious Influences

–Specify condition• Withdrawal symptoms• Alcoholic fetor• Allergic reaction

–Specify substance– Prescribed or illicit drugs– Alcohol– Smoking

–Specify exposure– Via the placenta, maternal use– Administered during labor and delivery– Given directly to newborn

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Respiratory

–If disease if unknown, document the signs and symptoms

–If known, document the most specific disease– Neonatal aspiration

» Meconium, amniotic fluid, mucus, blood» Aspiration of mild or regurgitated food

– Respiratory Distress Syndrome» Type I or Type II

– Respiratory Failure– Respiratory Arrest– Newborn apnea

» Primary obstructive, cyanotic attacks, apnea of prematurity

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Congenital Malformation Documentation:

1.Congenital and chromosomal anomalies that impact

throughout the patient’s life

2.Laterality•Right, left, bilateral

3.Anatomical site and malformation, deformity, abnormality

4.Associated manifestations

5.Surgically corrected congenital malformation•Document as history of

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Chromosomal Abnormality Documentation:

1.Specific chromosome anomaly• Down syndrome, trisomy 18, Turner’s

2.Mosaic• Non-mosaicism, mosaicism, translocation

3.Associated physical conditions and degree of mental retardation

4.Metabolic disorders

5.Associated duplications or deletions• Due to unbalanced translocations, inversions and insertions related

to complex rearrangements

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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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Destruction – physical eradication of all or a portion of a body part by direct use of energy, force, or destructive agent

Excision – cutting out or off, without replacement, a portion of a body part

Drainage – taking or letting out fluids &/or gases from a body part

Repair – restoring, to the extent possible, a body part to its normal anatomic structure & function

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 Neonatal and Pediatrics