ICD-10Getting There…..

Orthopaedics

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: Osteoporosis

Inadequate Documentation Required ICD-10 Documentation

67-year-old female with osteoporosis & ovary removal without estrogen replacement, reports sudden pain in arm when opening jar this am. Fractured forearm per films. Cast applied.

Reports previous fracture 6 months ago.

67-year-old female with osteoporosis secondary to ovary removal without estrogen replacement, reports sudden pain in arm when opening jar this am. Path fracture left forearm per films. Cast applied.

Reports collapsed lumbar vertebra 6 months ago secondary to osteoporosis. Now healed..

Needed improvements:

Underlying cause(s), pathological fracture(s)

location, laterality, encounter reason, and

fracture history.

Inadequate vs. Adequate Documentation Example 2: Spondylopathies

Inadequate Documentation Required ICD-10 Documentation

Disc disease and stenosis with spondylolisthesis. Spinal curvature and Schmorl’s node present.

Anterior lumbar interbody fusion scheduled for Tuesday.

Degenerative disc disease and spinal stenosis with lumbar spondylolisthesis. Lumbar scoliotic curve secondary to disc disease. Schmorl’s node @ L3.

Anterior lumbar interbody fusion L2 – L3 and L3 – L4 scheduled for Tuesday.

Needed improvements:

Location, complicating

factor(s), and underlying

disease(s).

Inadequate Documentation Required ICD-10 Documentation

32-year-old female S/P pilon fracture from suicide attempt. S/P fracture repair.

Here for additional surgical intervention.

32-year-old female S/P external fixation right displaced pilon fracture due to jumping from her second story bedroom window in a suicide attempt. Fracture shows nonunion four weeks post op.

Here for additional surgical intervention.

Inadequate vs. Adequate Documentation Example 3: Fractures

Needed improvements:

Location, type, laterality,

complication(s) and

circumstances of injury.

Inadequate Documentation Required ICD-10 Documentation

IMPRESSION:

1. Gout.2. Diabetes.3. Hyperlipidemia.4. Kidney Failure.

IMPRESSION:

1. Chronic gout left elbow secondary to kidney failure.

2. Type II NIDDM.3. Mixed hyperlipidemia.4. End stage kidney failure

requiring peritoneal dialysis secondary to diabetes.

Inadequate vs. Adequate Documentation Example 4: Gout

Needed improvements:

Acuity, insulin use, types,

stage, causal agent, site,

laterality, and dialysis status.

Key Requirements for Documenting Orthopedic Disorders and Diagnoses

• Document the side of body affected (i.e., right, left, or bilateral).

• Specify the site of the disease (e.g. joint versus end of bone).

• Identify the specific bone or joint and laterality for injuries or acquired deformities of fingers, toes, hands, limbs and joints (e.g., hallux varus right foot, unequal length, left tibia).

• Document any underlying disease process (e.g., bone or joint neoplasms, diabetes mellitus).

• Documentation should identify fractures as pathological, stress, or traumatic.

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