1 UHS, Inc. ICD-10-CM/PCS Physician Education Pulmonology and Respiratory

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UHS, Inc.

ICD-10-CM/PCSPhysician Education

Pulmonology and Respiratory

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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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

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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Asthma

– Specificity• Intermittent [less than or equal to two times per week]• Mild persistent [more than two times per week]• Moderate persistent [daily-may restrict physical activity]• Severe persistent [throughout the day-frequent severe attacks that limit

the ability to breathe]

– Type / Form• Childhood• Exercise induced• Extrinsic allergenic• Late onset• Allergic• Allergic bronchitis• Allergic rhinitis w/ asthma• Atopic asthma• Extrinsic allergic asthma• Intrinsic non-allergic asthma• Idiosyncratic asthma

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Asthma continued

– Acuity •With acute exacerbation•With status asthmaticus

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

– Cause and Effect – environmental•Detergent•Coal workers•Miners•Wood

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COPD – Type

• Chronic obstructive bronchitis• Chronic bronchitis with airway obstruction• Chronic bronchitis with emphysema• Chronic obstructive tracheobronchitis

– Acuity• With acute exacerbation• With acute lower respiratory infection

– Specificity• With asthma• With bronchitis• With emphysema

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

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Influenza– Organism, document as known or suspected

• Avian influenza• H1N1 influenza

– Link associated conditions / manifestations• Influenza with secondary gram negative pneumonia• Laryngitis• Pleural effusion• Influenzal encephalopathy• Influenzal myocarditis• Influenzal otitis media

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Lung Cancer

– Location• Detailed location of lesion site• Left, Right, Bilateral

– Morphology• Malignant, Benign• Primary , Secondary• In situ• Uncertain behavior, Unspecified behavior

– Histology• Identified by cytology, histology or pathology findings

– Stage / Metastatic • Different, distinct locations

– Different primaries– Metastatic sites

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Lung Cancer continued

– Is patient being admitted for treatment of the neoplasm or an adverse reaction / complication?

• Treatment - surgery, chemotherapy, immunotherapy, radiation• Adverse reaction of treatment – neutropenic fever secondary to chemo• Complication of the disease – anemia due to malignancy

– Document if a complication is part of the disease process or an adverse effect of treatment

• Anemia due to malignancy or due to chemotherapy

– History of• Malignancies previously removed and no longer receiving active

treatment• Clearly document for follow-up and medical surveillance

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Pneumonia– Type – bacterial, viral, fungal, aspiration, drug-induced

– Organism, document as known or suspected• Viral – adenoviral, respiratory syncytial, parainfluenza, human

metapneumovirus, viral unspecified• Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas,

staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified

– Link associated conditions / underlying conditions• Influenza with secondary gram negative pneumonia• Sepsis due to pneumonia• Acute respiratory failure due to pneumonia

– Aspiration• Due to solids or liquids• Due to anesthesia during L/D or procedure• Due to anesthesia during puerperium

– Laterality of lung involvement – left, right, both

– Note whether ventilator associated (VAP)

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Respiratory Failure

– Acuity - acute, chronic, acute on chronic

– Specificity – with hypoxia or hypercapnia

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

– Does the patient require continuous home oxygen or is dependent on home oxygen

– Differentiate pulmonary collapse from therapeutic collapse

– Respiratory distress and respiratory insufficiency are NOT respiratory failure

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Respiratory Failure Criteria

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Acute Chronic

Symptoms – difficulty breathing, shortness of breath, dyspnea, tachypnea, respiratory distress, labored breathing, use of accessory muscles, cyanosis, unable to speak

Symptoms – severe COPD, chronic lung disease such as cystic or pulmonary fibrosis

Ph < 7.35 & pCO2 > 50 or pO2 < 55 & FIO2 > 28 %

pO2 < 55 or pCO2 > 50

Hypoxemia Hypercapnia

pO2 < 60 mmHg ORpO2 / FIO2 ratio < 300 OR10 mmHg decrease in baseline pO2

pCO2 > 50mmHg with pH < 7.35 OR10 mmHg increase in baseline pCO2


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


Most Common Root Operations:

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Control – stopping or attempting to stop

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

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

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

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

Extirpation – taking or cutting out solid matter

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

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

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

Insertion – putting in a non-biological appliance

Reposition – moving to its normal location

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

Drainage – taking or letting out fluids &/or gases

Release – freeing a body part from an abnormal physical constraint

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

Transplantation – putting in all or a portion of a living part from another individual or animal


Most Common Device Types:

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Diaphragmatic pacemaker lead

Endobronchial valve Intraluminal device: plain, drug-eluting, or radioactive

Drainage device Endotracheal airway

Monitoring device Tracheostomy device

Extraluminal device Infusion device Radioactive element

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 Pulmonology and Respiratory