1 UHS, Inc. ICD-10-CM/PCS Physician Education Neurology and Neurosurgery

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UHS, Inc.

ICD-10-CM/PCSPhysician Education

Neurology and Neurosurgery

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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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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Signs & Symptoms – document underlying cause / conditions

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Admit with sign / symptom Discharge with a Diagnosis

Altered Mental Status Underlying cause•Encephalopathy (hepatic, metabolic, hypertensive, septic, toxic)•UTI

Subdural / Subarachnoid hemorrhage

• With or without loss of consciousness

• Specify duration (minutes or hours)

• Resulting in death due to brain injury


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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Alzheimer’s Disease

– Onset classification• Early onset• Late onset

– Link manifestations / related conditions• Delirium• Dementia• Senile dementia• Behavioral disturbances• Senile degeneration

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Cerebrovascular Disease – non-traumatic– Type

• Hemorrhage – Subarachnoid– Intracerebral– Intracranial

• Occlusion / Stenosis without cerebral infarction• Cerebral infarction• Sequela of cerebrovascular disease

– Laterality – right, left, bilateral

– Tobacco Exposure • Exposure to environmental tobacco smoke• History of tobacco use• Tobacco use or dependence• Occupational exposure to tobacco smoke

– Alcohol abuse or dependence

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Cerebrovascular Disease – non-traumatic continued

– Location for brain hemorrhage – be as specific as possible

• Subarachnoid– Middle cerebral artery– Basilar artery– Vertebral artery

• Intracerebral– Brain stem– Cerebellum– Intraventricular

• Intracranial– Subdural– Acute, subacute, chronic

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Cerebral Artery Infarction / StrokeSpecify the location or source of the hemorrhage and laterality

–Document cause – thrombosis, embolism, stenosis

–Sites – be as specific as possible• Precerebral – right and left vertebral, basilar, right and left

carotid• Cerebral – right and left middle, right and left anterior, right and

left posterior, right and left cerebellar

–Laterality – right, left, bilateral

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Cerebral Artery Infarction / Stroke

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

hemiparesis and for residual effects

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

–Did the patient receive tPA at a different facility within the 24 hours prior to admission?

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Epilepsy

– Epilepsy Type • Idiopathic or symptomatic• Simple or complex partial seizures• Generalized

– If intractable, include clarification• Poorly controlled• Pharmacoresistant• Treatment resistant• Refractory

– Document with or without status epilepticus

– Seizure - classify as • Febrile, convulsions, new onset, single or hysterical

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Parkinson’s Disease

– Type – primary versus secondary• If secondary, specify underlying cause

– Malignant neuroleptic– Neuroleptic-induced– Postencephalitic– Vascular– Syphilis– Drug-induced, specify drug

– Link manifestations• Dementia• Behavioral disturbance

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Polyneuropathy

– Type • Hereditary• Idiopathic• Inflammatory• Sequelae

– Document underlying cause• Diabetes• Amyloidosis• Radiation-induced• Drug-induced, specify the drug• Alcohol-induced

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Glasgow Coma

– ICD-10-CM coding will need the score from each of the assessment areas

– Eye opening – Verbal response – Motor response

» R40.211 Coma scale, eyes open never» R40.212 Coma scale, eyes open to pain» R40.213 Coma scale, eyes open to sound» R40.214 Coma scale, eyes open spontaneously

– Report the Glasgow coma scale total score» R40.241 Glasgow coma scale score 13 – 15» R40.242 Glasgow coma scale score 9 - 12» R40.243 Glasgow coma scale score 3 – 8

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Glasgow Coma Scale

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Criteria 1 2 3 4 5 6

Eyes open Never To pain To sound Spontaneous n/a n/a

Verbal response

None Incomprehen-sible words

Inappropriate words

Confused conversation

Oriented, converses normally

n/a

Motor response

None Extension to painful stimuli

Abnormal flexion to painful stimuli

Flexion withdrawal from painful stimuli

Localizes painful stimuli

Obeys commands


Drug Under-dosing is a new code in ICD-10-CM.

– It identifies situations in which a patient has taken less of a medication than prescribed by the physician.

• Intentional versus unintentional

– Documentation requirements include:• The medical condition• The patient’s reason for not taking the medication

– example – financial reason– Z91.120 – Patient’s intentional underdosing of

medication due to financial hardship

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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


Example – spinal fusion

•Root Operation–Fusion

•Body Part–Thoracic vertebral joints 2 - 7

•Approach– Open (anterior/posterior) and Column (anterior/posterior)

•Device–Autologous tissue substitute


Most Common Root Operations:

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Bypass – altering the route of passage

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

Reposition – moving to its normal location

Transfer – moving, without taking out, all or a portion of a body part to another location

Dilation – expanding an orifice or the lumen of a tubular body part

Insertion – putting in a non-biological appliance

Resection – cutting out or off without replacement all of a body part

Division – cutting into a body part to transect the body part

Release – freeing a body part from an abnormal physical constraint

Restriction – partially closing an orifice or lumen of a tubular body part

Drainage – taking or letting out fluids &/or gases

Repair – restoring, to the extent possible, a body part

Supplement – putting in a biological/ synthetic material to reinforce / augment


Most Common Device Types:

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Drainage device Infusion device Neurostimulator device

Neurostimulator lead

Autologous tissue substitute

Synthetic substitute

Nonautologous tissue substitute

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 Neurology and Neurosurgery