ICD-10Getting There…..

Plastic Surgery

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: Cleft Lip and Palate

Inadequate Documentation Required ICD-10 Documentation

Cleft palate repair in a 22-year-old male.

Cleft soft palate repair in a 22-year-old male with an accompanying nasal deformity and unilateral cleft lip.

Needed improvements:

Specific anatomical site, laterality,

and associated nasal malformation.

Inadequate vs. Adequate Documentation Example 2: Facial Deformity

Inadequate Documentation Required ICD-10 Documentation

50-year-old woman with a history of squamous cell carcinoma and previous Mohs procedure on her eyelid presents for surgical consult. She desires plastic correction of scarring from Mohs procedure.

50-year-old woman with a history of squamous cell carcinoma of left lower eyelid and previous Mohs procedure on left lower eyelid presents for surgical consult. She desires plastic correction of scarring from Mohs procedure.

This is her initial visit to our practice.

Needed improvements:

Anatomical site, laterality

and encounter type.

Inadequate Documentation Required ICD-10 Documentation

26-year-old female scheduled for revision of a scar on her arm resulting from a burn she sustained during an accident.

26-year-old female scheduled for revision of a contracture scar on her left forearm resulting from a third degree thermal burn she sustained after pulling a pan of hot oil off a stove. Total body surface area burned was 1.5%.

Inadequate vs. Adequate Documentation Example 3: Burns

Needed improvements:

Type of burn, anatomical site,

laterality, degree of burn,

percentage of total body surface

area burned, and circumstances

surrounding the injury.

Inadequate Documentation Required ICD-10 Documentation

Maxillary deformity due to Down’s syndrome. Scheduled for reconstructive surgery.

Maxillary hypoplasia due to Down’s syndrome. Patient has been diagnosed with severe obstructive sleep apnea. Scheduled for reconstructive surgery.

Inadequate vs. Adequate Documentation Example 4: Dentofacial Anomalies

Needed improvements:

Anatomical site, type of

deformity, and any functional

abnormalities.

Key Requirements for Documentation

• Document the specific anatomical site (i.e., maxillary or mandibular, soft or hard palate).

• Detail laterality as right, left, bilateral, median or unilateral.

• Identify the patient’s encounter statues (i.e., initial, subsequent, sequela)

• Detail how the injury occurred (e.g., punch to the face during a bar fight)

• Document any underlying disease (e.g., rheumatoid arthritis, ).

• Include the type of open wound (e.g. puncture, laceration, bite) and the presence or absence of foreign bodies.

• Document any associated conditions, such as scars or joint contractures.

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