1 UHS, Inc. ICD-10-CM/PCS Physician Education Orthopaedics

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UHS, Inc.

ICD-10-CM/PCSPhysician Education

Orthopaedics

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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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 vs. chronic vs. acute on chronicExample – stage of pressure ulcer:– L89.011 Pressure ulcer of right elbow, stage 1– L89.021 Pressure ulcer of left elbow, stage 1

Episode of care – initial, subsequent, and sequelaeExample - lower leg fracture:

– A initial encounter for closed fracture– B initial encounter for open fracture type I or II– C initial encounter for open fracture type IIIA, IIIB, or IIIC– D subsequent encounter for closed fracture with routine healing– H subsequent encounter for open fracture type I or II with delayed

healing– K subsequent encounter for closed fracture with nonunion– S sequelae

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Fractures – clearly document all aspects

– Cause – traumatic, stress, pathological

– Location – which bone, where on the bone, laterality

– Type – compound, delayed, union, depressed, elevated,

greenstick, impacted, oblique, etc.

• If open – use Gustilo classification

– Displacement – displaced or non-displaced

– Encounter – initial, subsequent, sequelae

• Healing process – routine aftercare, delayed, nonunion, malunion

– External cause – how the fractured occurred and the activity

• Example - Fall while skiing

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Open fractures - Please specify the severity using the Gustilo-Anderson Open Fracture Classification system for forearm, femur, and lower leg

–Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (i.e., inside-out injury).

–Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect. This is also a low-energy injury.

–Type III: The wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.

–Type III fractures are further divided into

• III A: Soft tissue coverage of the fractured bone is adequate.

• III B: Disruption of the soft tissue is extensive, that local or distant flap coverage is necessary.

• III C: Any open fracture that is associated with an arterial injury that a physician must repair, regardless of the degree of soft tissue injury.

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Pathologic (non-traumatic) fractures:

– Exact location of fracture – • Bone, part of the bone, and laterality

– Etiology of the fracture – • osteoporosis, neoplastic disease, drug induced

– Encounter type –• initial encounter, subsequent encounter with routine

healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae

– Healing status – • Routine, delayed, nonunion, malunion• Any past history of healed pathological fractures

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Arthropathies

•Type–Traumatic–Infectious – document specific organism

•Site – include laterality (right, left, bilateral)

•Link underlying or associated conditions–Bone changes related to DM

•Examples:–Traumatic arthropathy, left shoulder–Arthropathy following intestinal bypass, left shoulder

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Bursa Disorders

•Type–Bursitis–Bursopathy

• Abscess of bursa• Infective bursitis• Synovial cyst• Bursal cyst• Calcium deposit

•Site – bursa affected and laterality (right, left, bilateral)

•Link underlying or associated conditions–Activity causing the disorder–Related to use, overuse, pressure, post-procedural complication–Rupture of synovial or bursa cyst

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Osteomyelitis

•Site – include laterality (right, left, bilateral)

•Severity / Type–Acute, chronic, subacute–Hematogenous

•Link underlying or associated conditions–Multifocal osteomyelitis–With or without draining sinus–Chronic hematogenous–Major osseous defect

•Document if any associated injury is current or old

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Osteoarthritis

•Site – joint affected– include laterality (right, left, bilateral)

•Severity / Type–Acute, chronic, subacute–Hematogenous

•Link underlying or associated conditions–Presence or absence of hip dysplasia–Polyosteoarthritis

•Document if any associated injury is current or old–Primary, secondary, or post-traumatic

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Rheumatoid Arthritis

•Site

•Laterality

•Link manifestations–With or without Rheumatoid Factor–Felt’s syndrome–Rheumatoid lung disease–Rheumatoid vasculitis–Rheumatoid heart disease–Rheumatoid polyneuropathy–With involvement of other organs or systems

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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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Cause of Injury– Mechanism

• How it happened

– Place of occurrence• Where it happened

– Activity• What was the patient doing

– External Cause• Work-related, leisure

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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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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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Detachment – cutting off all or part of the upper or lower extremity

Fusion – joining together portions of an articular body part, rendering the body part immobile

Replacement – putting in or on a biological or synthetic material that takes the place &/or function

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

Division – cutting into a body part without draining fluids &/or gases in order to separate / transect the body part

Reattachment – putting back in or on all or a portion of a separated body part

Reposition – moving to its normal location or other suitable location a body part

Drainage – taking or letting out fluids &/or gases

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

Supplement – putting in or on biological or synthetic material that physically reinforces &/or augments function


Approaches:

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External Via Natural or Artificial Opening

Open Via Natural or Artificial Opening Endoscopic

Percutaneous Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance

Percutaneous Endoscopic

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 Orthopaedics