ICD-10Getting There…..

Infectious Diseases

What Physicians Need To Know

• Claims for ambulatory and physician services provided on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• CPT Codes will continue to be used for physician inpatient and outpatient services and for hospital outpatient procedures.

• ICD-10-PCS – a NEW procedure coding classification system, must be used to code all inpatient procedures on Facility Claims for discharges on or after 10/1/15.

• ICD-9-CM codes must continue to be used for all dates of services on or before 9/30/2015.

• Further delays are not likely.

ICD-9 vs ICD-10 Diagnosis Codes

ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

3 to 5 digits 7 digits

Alpha “E” & “V” – 1st Character Alpha or numeric for any character

No place holder characters Include place holder characters (“x”)

Terminology Similar

Index and Tabular Structure Similar

Coding Guidelines Somewhat similar

Approximately 14,000 codes Approximately 69,000 codes

Severity parameters limited Extensive severity parameters

Does not include laterality Common definition of laterality

Combination codes limited Combination codes common

Number of Codes by Clinical Area

Clinical Area ICD-9 Codes ICD-10 Codes

Fractures 747 17,099

Poisoning and Toxic Effects 244 4,662

Pregnancy Related Conditions 1,104 2,155

Brain Injury 292 574

Diabetes 69 239

Migraine 40 44

Bleeding Disorders 26 29

Mood Related Disorders 78 71

Hypertensive Disease 33 14

End Stage Renal Disease 11 5

Chronic Respiratory Failure 7 4

Right vs. left

accounts for nearly ½

the increase in the #

of codes.

The Importance of Good Documentation

• The role of the provider is to accurately and specifically document the nature of the patient’s condition and treatment.

• The role of the Clinical Documentation Specialist is to query the provider for clarification, ensuring the documentation accurately reflects the severity of illness and risk of mortality.

• The role of the coder is to ensure that coding is consistent with the documentation.

• Good documentation….• Supports proper payment and reduces denials• Assures accurate measures of quality and efficiency• Captures the level of risk and severity• Supports clinical research• Enhances communication with hospital and other providers• It’s just good care!

Inadequate vs. Adequate Documentation Example 1: Herpes

Inadequate Documentation Required ICD-10 Documentation

DIAGNOSES:

ShinglesConjunctivitisBlepharitis

DIAGNOSES:

Herpes zoster ophthalmicus right eye with conjunctivitis & blepharitis

Needed improvements:

Type, location,

manifestation(s), and

complication(s).

Inadequate vs. Adequate Documentation Example 2: AIDS/HIV

Inadequate Documentation Required ICD-10 Documentation

38-year-old male with pneumonia and Kaposi’s sarcoma.

38-year-old male with P. carinii pneumonia & biopsy proven papular cutaneous Kaposi’s sarcoma both secondary to AIDS. HIV positive for 1 year.

Needed improvements:

HIV status, manifestation(s),

and linkage to secondary

condition(s).

Inadequate Documentation Required ICD-10 Documentation

ASSESSMENT:

1. Influenza2. Speech disturbance3. Sinusitis4. Otitis media with perforated

tympanic membrane

ASSESSMENT:

1. Influenza A2. Laryngitis3. Acute maxillary sinusitis4. Left otitis media with left central

perforated tympanic membrane

Inadequate vs. Adequate Documentation Example 3: Influenza

Needed improvements:

Type, site, acuity, and

manifestation(s) and

laterality.

Inadequate Documentation Required ICD-10 Documentation

Admit for left total knee replacement. Pneumonia. Now septic. Blood cultures positive.

Adult respiratory distress syndrome requiring vent support with increased PEEP.

B/P down to 73/45, Swan placed.

Admit for left total knee replacement. Post op day #6. Staph aureus pneumonia. Now septic with shock. Blood cultures positive for Staph aureus.

Adult respiratory distress syndrome secondary to sepsis requiring vent support with increased PEEP.

B/P down to 73/45, Swan placed.

Inadequate vs. Adequate Documentation Example 4: Sepsis

Needed improvements:

Causal organism, severity,

complication(s), linkage, and

onset.

Key Requirements for Documenting Infectious Diseases

• Indicate the status of the disease as newly diagnosed, acute, or chronic (e.g., HIV or AIDS).

• Describe the site of the infection or infestation (e.g. TB of lung).

• Document any secondary disease process related to the infection (e.g., whooping cough with pneumonia).

• Include the specific cause of the infection or infestation, if known (e.g., Shigellosis due to Shigella boydii).

• Document the infectious agents in other types of diseases (e.g., wound infection caused by Streptococcus).

• Clarify the significance of positive sputum and lab findings (e.g., Pseudomonas in sputum culture, Strep pneumoniae in blood culture).

With ICD-10, the need for specific and accurate documentation is increased significantly.

Using Sign/Symptom and Unspecified Codes

• Sign/symptom and “unspecified” codes have acceptable, even necessary, uses.

• If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs and/or symptoms in lieu of a definitive diagnosis.

• When sufficient clinical information is not known or available about a particular health condition, it is acceptable to report the appropriate “unspecified” code.

• It is inappropriate to select a SPECIFIC code that is not supported by the medical record documentation.

Training for Physicians

Dates Method Content

Nov 2014 – Jan 2015 Department Meetings

Introduction/Overview

Jan 2015 – Mar 2015 Web-based OverviewService Specific DocumentationFuture Order EntryDiagnosis Assistant

Mar 2015 – Jun 2015 Classroom Documenting for ICD10 using the Electronic Health Record

Jun 2015 – Sep 2015 Web-based OverviewDocumenting Operative and Procedure Notes for ICD-10-PCS

Future Orders & Diagnosis Assistant

Demonstration