Embed Size (px)
Citation preview
ICD-10: Physicians meeting documentation expectations
Christopher Betts MD
Objectives
By the end of this discussion, the viewer should be able to:• Define what is ICD and its function.• Describe difference between ICD-10 and ICD-9• Explain why ICD-9 is changing to ICD-10• Explain how ICD-10 will affect documentation
in patient encounters
Objectives
By the end of this discussion, the viewer should be able to:• Understand the process to transition toward ICD-
10 coding• Understand who/what are of priority in
transitioning toward ICD-10• Give examples of major ways to prepare for ICD-
10.• Understand the goals of preparing for ICD-10
ICD Coding Background
International Classification of Diseases (ICD) is a taxonomy system of mortality data from death
certificates and morbidity data from health-service records, used as the global standard in
reporting, defining, and categorizing all types of health conditions.
ICD Coding Background
• Main purpose of disease coding– To assist in record retrieval– To produce statistics– Utilized for morbidity & Mortality coding
• Morbidity – codes are assigned from sources of information that relate to contacts for health services (e.g., medical records)
• Mortality – codes are assigned from registrations of deaths
• The global standard to report and categorize diseases, health-related conditions, and external causes of disease & injury.
ICD 10
• Modification of the coding system used for classifying diagnoses and reasons for visits in health care settings.
• Endorsed by WHO in 1990• Used by at least 11 countries to determine
reimbursement in some way in morbidity data. • January 1, 1999 – US implemented it for mortality
(death certificates)– The only industrialized country not using ICD-10 for
morbidity reporting.
Why is ICD-10 coming?
• ICD-9 is 30 years old and no longer compatible with most other countries.
• Relevant concepts in each medical condition are better captured in ICD-10 with the use of more specific coding.
• ICD-10 provides improved ability to understand risk, severity, and complexity.
Why is ICD-10 coming?
• ICD-10 is supposed to be an enhanced version of ICD-9 that more accurately reflects medical practice.
• It will allow reimbursement to better reflect the intensity of patient needs.
Why is ICD-10 coming?
• The increased specificity and clinical detail captured by ICD-10 will: – Improve healthcare quality, safety and efficiency
measurements– Reduce the need for supporting documentation to
accompany claims in order to validate the level of service
– Enhance Public Health Surveillance – Provide more reliable comparative data regarding the
causes of human morbidity and mortality.
Why is ICD-10 coming?
• Improvements in all of the following areas: – Payment– Public health– Education– Research– Quality Improvement
What improvements and changes can be expected in ICD-10?
• The addition of information relevant to ambulatory and managed care encounters
• A more logical format• Expanded injury codes• The creation of combination diagnosis/symptom codes to
reduce the number of codes needed to fully describe a condition
• The addition of sixth and seventh characters• Incorporation of common 4th and 5th digit sub classifications• Laterality (right side, left side, bilateral)• Greater specificity in code assignment.
ICD-9-CM• 3-5 digits• Approx. 13,000 codes • Numeric +V and E codes • Limited space for adding new
codes• Lacks detail• Lacks laterality• Difficult to analyze data due to
non-specific codes• Non-specific codes that do not
adequately define diagnosis needed for medical research
• Does not support interoperability because it is not used by other countries.
ICD-10-CM• 3-7 digits• Approx. 68,000 codes• Alphanumeric• Flexible for adding new codes • Very specific• Has laterality • Specificity improves coding
accuracy & richness of data for analysis
• Detail improves the accuracy of data used for medical research
• Supports interoperability & the exchange of health data between other countries and the US.
Who are our priorities in preparing for ICD-10?
• Internal processes– Physicians the focus of this presentation– Billers and code assigners– Staff (managers, nurses, secretaries, etc.)
• Electronic Health Records– Contacting vendors and discussing the changes are
they making to ensure ICD-10 is compatible with the current EMR software and finding if additional training be required by staff .
Who are our priorities in preparing for ICD-10?
• External processes– Associated hospitals– Associated specialty centers (Cardiology, Endocrinology, Neurology, etc.)– Associated therapeutic centers (PT/OT, chiropractors, rehab facilities,
etc.)– Radiologic and laboratory facilities used by the office.– DME providers– Any axillary services utilized by our physicians in the office for their
patients– Third-party billing services– Payers– Clearinghouses
The essential role of the physician in meeting ICD-10 codes…
…improving documentation of our patient notes
How ICD-10 will affect documentation
• The more specific the code, the more specific the documentation must be to support it.
• This means that physicians will have to add details to their patient notes that may seem obvious to them but would not be obvious to those abstracting the record for coding purposes.
• Even though your coder may understand what you meant, that will not satisfy an outside auditor or claims payer.
How ICD-10 will affect documentation
• Therefore, the primary focus for all physicians now is to identify what needs to be included in their documentation per diagnosis.
• As long as key medical concepts are captured somewhere in the medical record, either by the provider directly or during initial intake by office or nursing staff, the coder will be able to select an appropriate ICD-10 code.
Three questions a physician should ask
• In this patient encounter, what diagnoses am I documenting today?
• What in my past documentation is missing if I applied an ICD-10 code to these diagnoses?
• How can I ensure that I document accurately for good patient care?
Three questions a physician should ask
• In this patient encounter, what diagnoses am I documenting today?
• What in my past documentation is missing if I applied an ICD-10 code to these diagnoses?
GAP ANALYSIS• How can I ensure that I document accurately
for good patient care?
ICD-10-CM code anatomy
Each group of characters in a code provides specific information regarding the disease process.
ICD-10-CM code anatomy
The first character represents the main Section/Category (e.g. CNS, Endocrine, Circulatory, MSK, Behavioral etc.)The second and third represent a general condition/symptom within that section or category (e.g. Multiple sclerosis, essential hypertension, etc.)
ICD-10-CM code anatomy
The fourth through sixth characters reference etiology, anatomic site, and severity. They can represent subcategories and subclassifications of a given physical condition (e.g. Atherosclerotic Heart disease with angina or without angina.
ICD-10-CM code anatomy
The seventh character represents an extension that is used to provide additional information related to the condition being reported. This may be qualifying information for certain codes related to Obstetrics, Injuries, and External Causes of Injuries (e.g. Episode of care, Reason for encounter, or fetus affected by condition).
ICD-10-CM code anatomy
Examples of codes
Three characters: G35 (Multiple Sclerosis); I10 (Essential HTN), I11 (Hypertensive Heart Disease)Four characters: K86.0 (Alcohol-induced Chronic Pancreatitis), I11.9 (Hypertensive Heart disease w/ HF)Five characters: C7B.03 (Secondary Carcinoid Tumor of Bone)Six characters: M79.621 (Pain in Right Upper Arm)Seven characters: T23.351 A (Burn of 3rd degree of Right palm Initial Encounter)
Example 1: patient w/ intervertebral disc complaint
• HPI: thirty-three year old CF is referred to neurology clinic for right arm pain and weakness. She is a NICU RN working 3-5 twelve hour shifts/week primarily with premature infants. She can recall no injury to her neck or arm but simply awoke two weeks ago with a sharp pain that radiated through her shoulder, down her right arm to the tip of her thumb.
Example 1: patient w/ intervertebral disc complaint
• HPI cont’d: She is left handed. The pain is resolving but she continues to have weakness, numbness, and tingling in the arm. She treated her symptoms with rest, heat, and ibuprofen during 2 regularly scheduled days off and was able to return to work for her next scheduled shift. She was concerned about the residual weakness in her arm and called her PMD who ordered cervical spine films and an MRI which showed disc displacement/protrusion at C5-C6. PMD prescribed oral steroids and Tramadol for pain, Lunesta for sleep and referred her to Neurology.
Example 1: patient w/ intervertebral disc complaint
• Exam: – Moderately obese female who appears her stated age– HEENT: PERRL, stiffness and decreased ROM in her neck, CN
grossly intact– Lung: CTAB– Heart: RRR, no m/r/g– MSK/Neuro: L upper extremity is unremarkable with intact
pulses, reflexes, ROM and strength; R arm is significant for moderate weakness in R bicep muscle and wrist extensor muscles; Sensation to both dull and sharp stimuli is decreased along the anterior R arm beginning at shoulder to mid forearm level. Pincher grasp is weak on right.
Example 1: patient w/ intervertebral disc complaint
• Studies:– MRI is reviewed with patient and she does indeed have a small
herniation of the disc at C5-C6 space which is most likely the cause of her current myelopathy.
• A/P:1. Cervical disc disorder with myelopathy at C5-C6
a) Patient advised to stop taking Lunesta and Tramadol.b) Will prescribe Celebrex and acetaminophen for pain.c) Will refer to physical therapist who has agreed to see her this
afternoon for initial evaluation, possible soft cervical collar. d) Patient is cleared to work as long as she does not lift more than 10 lbs. e) Return to clinic in 2 weeks for recheck.
Example 1: patient w/ intervertebral disc complaint
• ICD-10-CM Diagnosis Code: M50.02– Cervical disc disorder with myelopathy, mid-
cervical region.• This code is identified as the correct cod for
Disorder, disc, with myelopathy, mid-cervical region. Even though the physician has not specified the site as the mid-cervical region, the level is identified as C5-C6 which is located in the mid-cervical region.
Example 2: Asthma case• HPI: 52 yo AAF presents to the ED with an acute asthma
episode. She is dyspnea, anxious, using accessory muscles in neck and chest to try and move air. She has used oral and inhaled steroids extensively in the past.
• PMHx: asthma/allergies (since 2 yr old). Triggers include animal dander, pollen, mold, cold weather, and URI. Documented osteoporosis on bone density 2 yrs ago.
• Medications:– Qvar– Singulair daily– Xopenex (last used 1 hr ago)
Example 2: Asthma case
• Exam: – VS: T 98.8 HR 120, RR 22, BP 150/90, Sat 95% 4L – Gen: moderate distress; less anxious and able to
speak sentences following neb and O2 treatment– HEENT: PERRL, mmm, no LAD, OP clear, no JVD– Lung: expiratory wheezes heard bilaterally– Heart: tachycardic, sinus rhythm, no m/r/g– GI: S, NT, BS hypoactive– Ext: no swelling or rashes; +2 pulses
Example 2: Asthma case
• Immediate actions– IV started in L hand– 125mg Solumedrol administered
• A/P:1. Moderate persistent asthma with acute
exacerbationa) Most likely due to weather change/temperature
drop.b) Admit overnight for breathing treatments and IV
steroids.
Example 2: Asthma case• ICD-10-CM Diagnosis Codes:
– J45.41 Moderate persistent asthma with (acute) exacerbation– Z79.51 Long term (current) use of inhaled steroids– Z79.52 Long term (current) use of systemic steroids
• In ICD-10-CM, both extrinsic and intrinsic asthma are reported with codes from category J45. The code is selected based on the severity of the asthma, which in this case is documented as moderate. Long term use of steroids in ICD-10-CM is differentiated as systemic use or inhaled uses. Since the patient has used both types, codes for both are assigned.
Example 3: Headache• HPI: 37 yo AAM is comes for follow up for treatment of his
headaches. His PMH is significant for being struck in the L temple/eye area by a baseball ten month ago during a recreational game with friends. He had no loss of consciousness or visual changes, but significant pain and swelling of the face and eye. He was evaluated in the ED, where ophthalmology exam, XR, and CT scan showed no eye damage, facial/skull frx, or intracranial bleeding. The first HA occurred 2 months after this injury and wok him from sleep with intense stabbing pain in the L eye, accompanied by tearing and eye redness. The pain subsided in about 15 min only to reoccur twice in the next few hours.
Example 3: Headache• HPI: He was seen emergently by his ophthalmologist and the exam
was entirely benign. The HA continued, usually awaking him from sleep with a stabbing sensation in his L eye that lasted 30-60 minutes. When the acute pain abated he often had residual aching in the periorbital area and stabbing pain again within a few hours. His PCP advised taking ibuprofen which was no helpful, prescribed Toradol which was also not helpful and finally Percodan which the patient states caused nausea and hallucinations. The patient has researched alternative treatment options and has tried acupuncture, melatonin, and removing foods containing tyramine and MSG form his diet. He estimates HA began again one week ago and the patient requested a referral to the pain clinic.
Example 3: Headache• Exam:
– Wt 150lbs, T96.8, P 58, R 14, BP 138/88,– HEENT: PERRLA, L eye has incr’d lacrimation, conjunctival injection
and mild ptosis of upper lid. Both nares patent and L naris has thin, clear mucus drainage; mmm, OP clear, neck supple w/o masses, CN’s II-XII intact
– Ext: upper and lower extremities have brisk reflexes and good tone; muscles are w/o atrophy, weakness, rigidity, or tenderness.
– Heart: RRR, no m/r/g– Lungs: CTAB– GI: S, NT, BS present; no hernias– Neuro: gait normal; no focalities
Example 3: Headache
• A/P:1. Episodic cluster headache, poorly controlled with
current medications.a) Consider a trial of verapamil for headache prophylaxis
and Sumatriptan nasal spray for acute headache. b) Treatment options d/w patient and patient agrees to
try verapamil 40mg PO bid x 2 weeks and RTC for re-evaluation.
c) Patient declines Sumatriptan nasal spray at this time. He is however interested in oxygen therapy and we will discuss that at his next session.
Example 3: Headache
• ICD-10-CM Diagnosis Code: G44.011– Episodic cluster headache, intractable
• ICD-10-CM requires identification of the headache syndrome as intractable or not intractable. These terms describe the response to treatment. Intractable indicates that the episodic cluster headache is not responding to current treatment. This is documented using the term “poorly controlled” which, according to coding notes is a term that is considered the equivalent to intractable.
HTN and ICD-10
Hypertension
• ICD-9: malignant (401.0), benign (401.1), and unspecified (401.9)
• ICD-10: – Essential (primary) hypertension (I10.0)
= Individuals w/ HTN and no comorbid heart or kidney disease.
Essential (primary) hypertension (I10.0)
• Documentation criteria: SBP>140 and/or DBP>90 w/ at least two readings on separate office visits. – I10.0 code does not include “high blood pressure
without the diagnosis of hypertension”, e.g. single mildly elevated blood pressure. R03.0
– If a patient progresses from prehypertension to a formal diagnosis of hypertension, a good documentation practice would be to include the reason for progressing the formal diagnosis.
Hypertension
• ICD-10: – Essential (primary) hypertension (I10)
= Individuals w/ HTN and no comorbid heart or kidney disease.
– Hypertensive heart disease (I11)= Individuals w/ HTN and a comorbid heart disease• Hypertensive heart disease WITH heart failure = I11.0• Hypertensive heart disease WITHOUT heart failure =
I11.9
Hypertensive heart disease (I11)
• The ICD-10 manual does not list the required documentation for hypertensive heart disease. It is recommended, however, that the provider document the basis for the diagnosis (via exam, ECG, echo, etc.) at least the first time this diagnosis is made for the patient.
Hypertensive heart disease (I11)
= Individuals w/ HTN and a comorbid heart disease– Hypertensive heart disease WITH heart failure = I11.0
• A separate, compound diagnosis code: TYPE of heart failure• I50.1 = Left ventricular failure• I50.2 = Systolic (congestive) HF• I50.3 = Diastolic (congestive) HF• I50.4 = Combined systolic and diastolic HF• I50.9 = Heart failure, unspecified
– Hypertensive heart disease WITHOUT heart failure = I11.9
Hypertensive heart disease (I11)• Hypertensive heart disease WITH heart failure = I11.0
– I50.1 = Left ventricular failure– I50.2 = Systolic (congestive) HF– I50.3 = Diastolic (congestive) HF– I50.4 = Combined systolic and diastolic HF– I50.9 = Heart failure, unspecified
• The three codes systolic, diastolic, and combined failure also require a fifth digit specifying the acuity of the diagnosis: – Unspecified (0)– Acute (1)– Chronic (2)– Acute on chronic (3).
Example:• You have been following a 60-year-old male with
hypertension and mild heart failure. You have coded I11.0 and I50.9. He recently had an acute exacerbation of his heart failure, was briefly hospitalized, and had an echocardiogram performed documenting combined systolic and diastolic failure.
• At discharge, you update his diagnosis codes to I11.0 and I50.43. When you see him in the office two weeks post-discharge and he is asymptomatic, his diagnosis codes could be I11.0 and I50.42 reflecting the chronic nature of his condition.
Hypertension and chronic kidney disease (I12)
• ICD 9 & 10 both require specifying the stage of the CKD to properly code the condition, this involves documenting their specific level GFR.
• Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease = I12.0
• Hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease or unspecified chronic kidney disease = I12.9
Hypertension and chronic kidney disease (I12)
• ICD 9 & 10 both require specifying the stage of the CKD to properly code the condition, this involves documenting their specific level GFR.
• Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease = I12.0
• Hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease or unspecified chronic kidney disease = I12.9
Hypertension and chronic kidney disease (I12)
• Hypertensive chronic kidney disease with stage 5 CKD or ESRD = I12.0
• Hypertensive chronic kidney disease with stage 1-4 CKD or unspecified CKD = I12.9
• Either code requires a separate compound code known as N18 which identifies the stage of the kidney disease.– N18.1 to N18.5 = CKD I to CKD V– N18.6 = ESRD– N18.9 = CKD, unspecified
HTN and CKD in ICD-10’s eyes
• Unlike Hypertensive heart disease, ICD-10 assumes a causal relationship between HTN and CKD, if granted that the patient is assumed to have HTN prior to acquiring renal insufficiency, and requires no additional supporting documentation.
• Supporting evidence needs to be shown when putting a diagnosis code of I11 for Hypertensive heart disease.
Hypertension, hypertensive heart disease, and chronic kidney disease (I13)
• Hypertensive heart disease + HF + CKD 1-4 or unspecified = I13.0
• Hypertensive heart disease + no HF + CKD 1-4 or unspecified = I13.10
• Hypertensive heart disease + no HF + CKD 5 or ESRD = I13.11
• Hypertensive heart disease + HF + CKD 5 or ESRD = I13.2– Yes…AND adding the corresponding compound codes for type
of heart failure and acuity (150.__) AND the stage of CKD (N18._).
Coding for secondary hypertension
• Each of these require that you also code the underlying condition, including its supporting documentation.
• Renovascular HTN = I15.0• HTN secondary to other renal disorders = I15.1• HTN secondary to endocrine disorders = I15.2• Other secondary HTN = I15.8• Secondary HTN, unspecified = I15.9
In terms of clinician documentation in the patient record, what is most important from the perspective
of the provider?
• Answer: Capture of key medical concepts• As long as key medical concepts are captured somewhere in
the medical record, either by the provider directly or during initial intake by office or nursing staff, the coder will be able to select an appropriate ICD-10 code. Coders may choose to enroll in formal training and office staff may be involved in ongoing discussions with external partners, but providers will simply need to understand which concepts (e.g., initial encounter vs subsequent encounter, first trimester vs third trimester, etc.) should be entered into the patient record that will then enable the coder to identify the appropriate ICD-10 code.
Always remember…
The essential role of the physician: improving documentation of all patient encounters.
• Always asking in your given patient encounter:– What diagnoses am I documenting today?– What in the past have been missing? – How can I ensure that I document accurately?• Capture the key medical concepts per encounter.
Resources• AMA –2014 ICD-10-CM Documentation: A How-To Guide for Coders, Physicians, and
Healthcare Facilities. Contexo Media, a DecisionHealth Company (2013). ISBN: 978-1-60359-912-2
• Beckman, Kenneth D. MD, MBA, CPE, CPC. How to Document and Code for Hypertensive Diseases in ICD-10. Family Practice Management, March/April 2014
• AAFP: Links on ICD-10 in Family Practice Management • Family Practice Management - What You Need To Know About ICD-10 Now • Centers for Medicare - ICD 10 • Medscape - ICD 10: A Roadmap for Small Clinical Practices • Medscape - Transition to ICD-10: Getting Started • American Health Information Management Association (AHIMA) • Medscape - ICD-10: Small Practice Guide to a Smooth Transition • Medscape - ICD-10: Getting Ready When You'd Rather Ignore It • Medscape: What Your Favorite ICD-9 Codes Become in ICD-10 • Contact: [email protected]
