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Clinical Documentation Improvement for ICD-10

HiMAH 2013 Annual Meeting

Honolulu, HawaiiMay 3, 2013

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Laura Legg, RHIT, CCS AHIMA approved ICD-10 Trainer

Experienced as a leader, consultant, coding expert, speaker, trainer and auditor for acute care and critical access hospitals and major health

systemsllegg@hrgpros.com

Presenter:

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To gain an awareness of the complexity of ICD-10 and the challenges of

implementationIdentify chapter by chapter challenges in

documentation specificity for ICD-10Identify diagnosis-specific sample

queries for ICD-104. Questions/Answers

Objectives

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ICD-10-CM/PCS-Introduction

• US Department of Health and Human Services announced change January 16, 2009 with a compliance date of October 1, 2013

• 2012 delay til October 2014• Biggest change to healthcare in the

last 20 years!

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• US department of Health and Human Services announced the change:

19881/19/200910/1/201310/1/2014

History of ICD-10

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More than 200 countries have adopted ICD-10•Nordic countries-1997•UK-1995•France-1997•Australia-1998•Germany-2000•Canada-2001

History

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• Ask questions• Learn what testing reveals • Be proactive using what we are

learning• Continue learning up until the time of

implementation• Go-live planning• Plan for after go live

Now is a time to learn everything we can-

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• Earlier misconceptions-DRG variance 2-6%-MDC shifts not expected• Expected results-Coder productivity decrease-If you are not proficient now you won’t

be proficient using ICD-10

ICD-10 Testing Revealed:

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DRG variances much higher than expectedExample:DRG variance in the Nervous SystemExpected 8%Actual 27%DRG variance in the Digestive SystemExpected 8%Actual 20%

Testing Revealed:

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• MDC shifts did occur• Time-to-code IP claims decreased from 3-5

per hour to 1-2 per hour• Coding errors included:

-invalid codes

-decimals in incorrect places

-coding not following coding conventions

This caused increased rejected and pended claims

Testing Revealed:

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• The answer “DOCUMENTATION”• Back to the Basics• Look at Processes and Workflow now• Staff adjustments• Dual coding • Peer review• Physician queries

What should we do?

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“Any testing that doesn’t find things is a waste of time.”

Mark Lott, HIMSS/WEDI ICD-10 National Pilot Program

Testing Revealed:

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Go From ICD-9 to ICD-10

Remember:

• If it was not working that well for ICD-9-CM/PCS it won’t work for ICD 10 CM!

Think about this:

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• Top 10 common clinical diagnoses • If physicians are motivated or

conditioned to include specificity in these top clinical diagnoses then the road to a successful transition to clinical documentation under ICD-10 can be established

Focus your efforts:

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• Run a report of the top 20 MS DRGs for the last fiscal year

• Review diagnoses• Tailor ICD-10 training for the common

clinical diagnoses that your physicians manage

Tailor your CDI program:

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Greater specificityIncrease accuracy in documentationIncrease accuracy in billing and

reimbursementImproved statistical analysis which

means:-improved disease management-better understanding of health care

outcomes

ICD-10 Clinical documentation

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• Revise query forms and focus on some specific areas:

AsthmaComaFractureStrokeCardiac-hypertension, CAD, CHFDiabetesOB

Review Query forms

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•Queries will be mandatory for the diagnosis “urosepsis” in ICD-10-CM•More specific documentation is needed when reporting sepsis. Septicemia is no longer synonymous with sepsis•Specific cell types are required to code malignancy neoplasms of the blood and immune system accurately•Nutritional anemia require more information on the cause of the anemia•More specific information on the type of immune disorder is required

Chapter 1: Infectious and Parasitic diseases

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• When an admission is solely for anemia associated with a malignancy, the appropriate malignancy code is sequenced as the principal diagnosis followed by the code for anemia in neoplastic disease. D63.0

Chapter 2: Neoplasms

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• Anemia appears in code categories D50-D64.

• ICD-10 also identifies anemia according to type, but the categories rely on different language

-nutritional (iron deficiency in ICD-9)

-Hemolytic (e.g., sickle cell)

-Aplastic and other anemia, which include acute blood loss anemia and anemia of chronic disease.

Chapter 3: Blood and blood forming organs

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• In ICD-9-CM diabetes mellitus was classified as to type 1, type 2, or secondary

• The 5th digit indicates the type of diabetes mellitus or unspecified diabetes and also indicates if the diabetes is controlled or uncontrolled

• In ICD-10-CM diabetes mellitus is not classified as controlled or uncontrolled

Chapter 4: Endocrine, Nutritional, and Metabolic

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• ICD-10-CM classifies diabetes mellitus as follows:

E08-Diabetes mellitus due to an underlying condition (code first the underlying condition)

E09-Drug or chemical-induced diabetes mellitus.

E10-Type I diabetes mellitusE11-Type 2 or diabetes NOS

Chapter 4: Endocrine, Nutritional and Metabolic

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E13-Other specified diabetes mellitus (diabetes due to pancreatectomy)

E12-left for expansion of ICD-10Sequencing has changed with “code first”

notesCombination codesEncourage physicians to document mild,

moderate or severe retinopathy for the added specificity in ICD-10 diabetes mellitus codes

Chapter 4: Endocrine, Nutritional and Metabolic

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• More specific information is required to code the type of congenital hypothyroidism

• More specific information is needed to code iodine deficiency thyroid disorders

• More specific information is needed to code disorders of the parathyroid gland

• Cushing’s syndrome is now differentiated by type and cause

• Vitamin, mineral and other nutritional deficiencies require more information as the specific vitamin and mineral

• Disorders related to hyperalimentation require documentation of the specific condition

• Metabolic disorders require greater detail related to the specific amino acid, carbohydrate and lipid enzyme deficiency responsible for the metabolic disorder

Chapter 4: Endocrine, Nutritional and Metabolic

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Drug and alcohol-related disordersAssignment is based on type of substance and whether the person abuses the substance or is dependent on itWhen documentation identifies that the patient has use, abuse, and dependence the most severe state is codedHierarchy is use---abuse----dependence lowest to high severity

Chapter 5: Mental and behavioral disorders

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• Encourage neurologists and other providers to review ICD-10-CM code descriptions for seizures and epilepsy and to document accordingly.

• These codes are more specific than their ICD-9-CM counterparts and require more specific documentation

Chapter 6: Nervous System/Sense Organs

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• Terminology for epilepsy has been updated to include terms such as:Epilepsy, juvenile myoclonicEpilepsy, generalized, idiopathicEpilepsy, generalized, idiopathic,

intractable, without status epilepticus

• Code assignment will depend on specific documentation (documentation opportunity)

Chapter 6: Nervous System/Sense Organs

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• In ICD-10-CM more specificity is possible in the coding of epilepsy such as identifying seizures as

-localized onset-complex partial seizures-intractable and status epilepticus

Chapter 6: Nervous system/Sense Organs

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Other key documentation elements for the Nervous system are:•Dominant vs. nondominant side•Laterality•Episode of care for injuries and other external causes-initial, subsequent, sequela•Loss of consciousness time duration

Chapter 6: Nervous system/Sense Organs

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• Codes have been expanded to increase anatomic specificity and add the concept of laterality

• Many codes include right, left, bilateral, and unspecified eye

• If the option of bilateral is not available and the condition is present in both eyes, assign the code for right and left

• If a code for bilateral exists it should be assigned

Chapter 7: Eye and Adnexa

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• Codes have been expanded to increase anatomic specificity and add the concept of laterality

• New instructional notes have been added• A note at the beginning of the chapter

states to use an external cause code following the code for the ear condition, if applicable, to identify the cause of the ear condition

Chapter 8: Ear and Mastoid

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• Infective otitis externa codes require documentation for more specific causes:

-abscess-cellulitis-diffuse-hemorrhagic

Chapter 8: Ear and Mastoid

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• Noninfective otitis externa codes require documentation as:

-actinic-chemical-contact-eczematoid-reactive

Chapter 8: Ear and Mastoid

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• Meniere’s disease is no longer coded as active or inactive, cochlear or vestibular, but laterality

• Conductive hearing loss is no longer differentiated by the location of the dysfunction

Chapter 8: Ear and Mastoid

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• Acute myocardial infarction must be identified as initial or subsequent

• Embolism, thrombosis, phlebitis and thrombophlebitis of veins require identification of laterality and the specific lower extremity vein

Chapter 9: Circulatory system

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Documentation for coding CVAs in ICD-10-CM•To make the correct code for CVAs the documentation must reflect the location/source and laterality•If bilateral sites are indicated, codes should be assigned for each side as there is no bilateral option in this series

Chapter 9: Circulatory System

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• When assigning codes for patients with COPD with asthma it is necessary to assign two codes.

• A code from category J44 is assigned for the COPD and is accompanied by a second code from J45 to identify the severity and status of the asthma.

Chapter 10: Respiratory System

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• Key Documentation elements:Asthma must be documented as mild,

moderate or severeMild asthma must be documented as

intermittent or persistent

Chapter 10: Respiratory System

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• Some terminology changes have occurred

• Some revisions to the classification of specific digestive conditions have occurred in ICD-10-CM as well

• Example: K50, Crohn’s disease has been expanded to the 4th, 5th and 6th character, in contrast to the ICD-9-CM code 555, Regional enteritis

Chapter 11: Digestive System

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Documentation Note:The term “hemorrhage” is used when referring to ulcers, and the term “bleeding” is used when classifying gastritis, duodenitis, diverticulosis, and diverticulitis•K25.0, Acute gastric ulcer with hemorrhage•K29.01, Acute gastritis with bleeding

Chapter 11: Digestive System

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• Irritable bowel syndrome must be documented as with or without diarrhea

• Anal fissure must be documented as acute or chronic

• Abscess of the anal and rectal region must be specifically documented as to site

• Alcoholic disease of the liver must be documented as with or without ascites

• Hepatitis must be documented as acute, subacute, or chronic and with or without coma

Chapter 11: Digestive System

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• Acute pancreatitis must be documented as

-idiopathic-biliary-alcohol-induced-drug-induced-other-unspecified

Chapter 11: Digestive System

HRG_Tiah 4/15/13Changed "Drug-induced" to "drug-induced"

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Coding Pressure Ulcers:•In ICD-9-CM coders assigned 2 codes for pressure ulcers-one from category707.0x (location) and one from 707.2x (stage of the ulcer)•In ICD-10-CM pressure ulcers appear in code category L89.-•Code L89.001 stage 1 pressure ulcer of the right elbow (note location and stage in one code)

Chapter 12: Skin/Subcu Tissue

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Fracture codes include greater specificity in:•Type of fracture•Specific anatomic site•Displaced or nondisplaced•Laterality•Routine vs. delayed healing•Non union and malnunion•Fracture 7th character value•Gustilo open fracture classification

Chapter 13: Musculoskeletal System

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Pathologic fracture documentation:Exact location of the fracture site with lateralityEtiology of the fracture-osteoporosis, neoplasm, other specifiedEncounter type-initial, subsequent with routine healing, subsequent with delayed healing, malunion and nonunion or sequelae

Chapter 13: Pathological fractures

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How do you prepare?•Work with clinicians and physicians where terminologies and specificity is required•Work with CDI team to assist regarding documentation requirements

Chapter 13: Musculoskeletal System

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Gustilo classification•Type I-clean wound < 1 cm long•Type II-wound > 1 cm without extensive soft tissue damage•Type IIIA-extensive soft tissue lacerations (>10 cm) but maintain adequate soft tissue coverage of bone•Type IIIB-extensive soft tissue loss with periosteal stripping and bony exposure, usually massive contamination•Type IIIC- with arterial injury that requires repair regardless of size of wound

Chapter 13: Musculoskeletal System

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Chronic Kidney disease and Kidney Transplant Status•Patient who have undergone kidney transplant may still have some form of CKD, because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. •Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0 Kidney transplant status.• If a transplant complication such as failure or rejection or other transplant complication is documented see section I.C.19.g for information on coding complications of a kidney transplant.

Chapter 14: Genitourinary System

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• The final character in the code will indicate the trimester

• Antepartum, postpartum and whether a deliver has occurred are not used.

• Final character assignment should be based on provider’s documentation

• Gestational diabetes needs specification of diet controlled or insulin controlled

Chapter 15: Pregnancy/Childbirth

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• When both birth weight and gestational age of the newborn are available both should be coded with birth weight sequenced before gestational age

Chapter 16: Newborn

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• Modifications have been made to specific categories to update terminology

• Example:Q61 Cystic kidney disease

Q61.0 Congenital renal cystQ61.1 Polycystic kidney, infantile typeQ61.2 Polycystic kidney, adult type

• Patau’s syndrome updated to Trisomy 13

Chapter 17: Congenital Malformations

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Glasgow Coma Scale-The Glasgow coma scale codes (R40.2-) can be used

in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. The codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis codes.

At a minimum report the initial score documented on presentation at the facility. This may be a score from the emergency medicine technician or the ER department. If desired a facility may choose to capture several scores.

Chapter 18: Signs and Symptoms

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Underdosing-Underdosing refers to taking less of a

medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing assign the code from categories T36-T50 (fifth or sixth character6) Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

Chapter 19: Injury/poisoning

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• Personal and family history codes have been expanded in ICD-10 CM

• New codes to identify the patient’s blood type

• Category V57 Care involving use of rehabilitation procedures no longer exists-report instead the underlying condition for which the therapy is being provided with the 7th character indicating subsequent encounter

Chapter 21: Factors Influencing Health

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• ICD-10-PCS presents a totally new model

• Drastically different from its ICD-9 counterpart

• Entirely new coding logic and will be new territory for coders

• The changes in the meaning of characters may be confusing

It’s brand new!

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• Improve the accuracy and efficiency of procedure coding

• Replace ICD-9 CM with a more logical system

• Improve communication with physicians by developing a code system that aligns more with the clinical aspects of various procedures

• Allow coders to construct accurate codes with minimal effort

Benefits of ICD-10 CM/PCS

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Procedure code comparison

Characteristic ICD-9-CM volume 3 ICD-10-PCS

Field length 3-4 characters 7 alphanumeric characters

Available codes 3,000 72,081

Available space for new codes

Limited Flexible

Overall detail embedded in codes

Ambiguous Precise definition regarding anatomic site, approach, device used, and qualifying information

Laterality Code does not identify right vs. left

Code identifies right vs. left

Terminology for body parts

Generic description Detailed description

Procedure description Lacks description of procedure approach

Detailed description of approach.

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HRG_Tiah 4/15/13Do you want the slide number to be in the footer with hrgpros.com? Slides 57 and 58 have it but the others don't?

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Procedure code comparison, cont..

Characteristic ICD-9-CM vol. 3 ICD-10-PCS

Character position within code

N/A 16 PCS sections identify procedures in a variety of classifications (e.g. medical surgical, mental health). Among these sections there may be variations in the meaning of various character positions, though the meaning is consistent within each section.

Example code 39.24 Aorta-renal bypass

04104J3 bypass abdominal aorta to right renal artery with synthetic substitute, percutaneous endoscopic approach

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• All codes in PCS are seven characters• Letters O and I not used in PCS

Numbers 0 and 1 used• Each character has a meaning• Meanings change by sections• Section provides first character value• Sections of ICD-10-PCS listed in manual

PCS:

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Third character of the procedure code--Defines the objective of the procedure-New terminology used to define the different types of root operations-Physician does not have to document root operation terms; coders will translate

Root Operations:

HRG_Tiah 4/15/13Capitalized "new" to keep formatting the same

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Examples of Root operations: • Bypass• Drainage• Reattachment• Resection• Inspection

Root Operations:

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• Root Operation• Body Part• Body System

Anticipate Queries for ICD-10-PCS:

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• Physicians• How well do they already document?• Have you already started education?

Current Documentation Issues

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National heart, lung and blood institute asthma severity classification scale of intermittent, mild persistent, moderate and severe persistent

Glasgow Coma ScaleGustilo Open Fracture Classification

Incorporate the following scales into queries:

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• Review the ICD-10-CM/PCS Guidelines• Compare to the ICD-9-CM Guidelines• Review Current Documentation• Have a positive outlook• Expect the unexpected

What about you? Are you ready?

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• Do you have buy in?• Physicians want to document

correctly• Educate physicians by giving specific

facts by specialty• Educate surgeons on the details of

PCS

Physician Education needed now

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• Additional queries-guaranteed• Not just diagnoses but procedure

queries• Think laterality• Muscle/vessel specificity• Think joints and fractures

Anticipate query increase

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• Queries need to be rewritten• CDI staff educated on changes and

anticipate the rework of queries• Physician educated on the new

queries and the new code structure

New queries

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• Anticipate loss of productivity for a short time

• Canada had a 50% reduction in productivity

• Due to physician education, more queries, more time spent reviewing charts

• Lay the groundwork now

Productivity for coders and others

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• Become familiar with ICD-10 CM/PCS codes

• Review the Official Coding Guidelines• Work with the physicians• Re-audit documentation, query forms,

make revisions and improvements• Assess your ICD-10 needs• Increase your clinical knowledge

What to do?

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Get out of your comfort zone!

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More will be learned about ICD-10More clinical documentation issues

will be brought forwardBE preparedThe key to successful ICD-10

implementation is improving your clinical documentation now!

In the coming months

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Leap into ICD-10

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• Laura Legg, RHIT, CCS• HIM Director for Healthcare Resource

Group• llegg@hrgpros.com

Questions?

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• http://www.nlm.nih.gov/medlineplus/ency/article/001214.htm

• ICD-10 CM official coding guidelines @ www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf

• ICD-10-CM Coder Training Manual-AHIMA• Gustilo classification-http://eoriff.com/general/Open

%20Fx%20Class.html• Salter-Harris

classification-http://www.bridgeport.edu/gwl/salter-harrisclassification/htm

• AHA Coding Guidelines-October 1, 2012• ICD-10-CM the complete draft code set

2012http://www.cms.hhs.gove/ICD10

References: