Overview of ER Dx Coding in ICD-10-CM

OrHIMA Fall ConferenceOctober 2014

• Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS• 30+ year HIM professional and Leader• Past-President CHIA

– National Director Coding Quality, Education, Systems and Support• National Revenue Cycle – Program Office (Oakland)

The opinions and comments expressed during this presentation are those of the speaker and not of Kaiser Permanente.

Speakers

• This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner. The author are not providing or offering legal advice, but rather practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding.

• Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation.

• This is presentation is only a snapshot of some aspect of ICD-10-CM and should not be considered complete. All participants are encouraged to carefully review all chapters and guidelines relating to ICD-10.

Disclaimer

• Review some basic OP Dx Coding Guidelines for ICD-10

• Learn the ICD-10 coding of common ER diagnosis

• Understand the specifics of documentation • Practice with case examples • Q&A

Goals/Objectives

Today: Patient Story

• The clinical documentation should tell the patients full story

• Paint the true picture – use the right brush and color

• If something isn’t documented then the story is incomplete

• BUT Caution: to capture and report an incidental finding . . . This goes into the patient medical profile

Today: Data Integrity• A wide spectrum of data is collected in

healthcare and must be collected accurately, completely, and consistently.

• Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers.

• Coded data is an enabler• Documentation is the source

Today’s Data: National• In the United States in 2010, there were 100.7 million

outpatient department visits, 128.7 million ED visits, and 51.4 million procedures according to the Centers for Disease Control and Prevention (CDC) FastStats. That translates to a lot of outpatients and even more medical and procedural documentation.

• The most common reasons for ED visits resulting in discharge:– fever and otitis media (infants and patients aged 1–17 years), – superficial injury (all age groups except infants)– open wounds of the head, neck, and trunk (patients aged 1–17

years and adults aged 85+ years)– nonspecific chest pain (adults aged 45 years and older)– abdominal pain and back pain (all adult age groups except those

aged 85+ years).

Source: HCUP Report June 2014: Overview of Emergency Department Visits in the United States, 2011

Today’s Data: National

• Among patients younger than 18 years, the most common reasons for admission to the hospital after an ED visit were:– acute bronchitis (infants younger than 1 year)– asthma (patients aged 1–17 years)– pneumonia (infants and patients aged 1–17 years).

• For Adults aged 45–84 years– septicemia (infection in the bloodstream) was the

most frequent reason for admission to the hospital after an ED visit.

Today: Medical Record Review of EMT/Paramedic

• Chief Compliant• Review the patients vital signs at the time of arrival

in the ER• Check if O2 sats (see if there is a reading before O2

is given) …. WHY?• Check for a blood glucose reading …. WHY?• Breathing status: labored; able to speak in complete

sentences …. WHY?• Is there a description on the mental status• Level of consciousness

– Alert or confused, lethargic– Responsiveness– Coma scale?

Today: Review the Emergency Room Notes

• Chief Compliant• EMT documentation• Circumstances of the encounter• Past Medical History

– Problem List• Current medical history• Physical exam• Testing (Lab/Radiology/EKG, etc.) and results• Current Medication and those on the administration

record• Treatment• Impression

ICD-10

• “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d-2(c)) and section 162.1002 of title 45, Code of Federal Regulations.”

ICD-10 Delay

ICD-10 Final Rule with 10/2015 Date

CMS Resources

ICD-10 Delay: Immediate Next Steps

• Pause, take stock ICD-10 efforts, and redeploy resources appropriately– Review your timeline

• Continue or not . . . your Code Set Education, Training and Awareness– Refresh in 2015– Practice and more Practice

• Practice with new documentation and new codes– Dual Coding

• Time to Understand MS-DRG shifts: analyze– Conduct an audit/review– Analyze the findings– Recommendation and

documentation targets

• Review physician awareness and training plan– Documentation improvement

• CDI: continue focus on documentation improvement activities– ICD-10 Education– Dx enhancements

• Coding Tip Sheets – prepare & continue

• IT & systems programming with ICD-10 10/2014 start date– Rework

• Contracts with ICD-10 10/2014 date may need to be addressed

Background: ICD-10 Development

• 1990 –Endorsed by World Health Assembly (diagnosis only)• 1994 –Release of full ICD-10 by WHO • 1999 – WHO adopts ICD-10• 2002 (October) –ICD-10 published in 42 languages (including 6

official WHO languages)– Implementation138 countries for mortality– 99 countries for morbidity

• January 1, 1999 –U.S. implemented for mortality (death certificates)• 2000 – 2009 U.S. continued to work on implementation strategies• January 2009 Final Rule with implementation date of 10/2013

– 5 year timeline with 10/1/2013 go-live date• One Year Delay: October 2014 • Now another delay: October 2015

Background: ICD-10-CM Developers

• American Academy of Dermatology

• American Academy of Neurology

• American Academy of Oral and Maxillofacial Surgeons

• American Academy of Orthopedic Surgeons

• American Academy of Pediatrics

• American College of Obstetricians and Gynecologists

• American Burn Association• American Diabetes Association• American Nursing Association• American Psychiatric Association• American Urological Association• ANSI Z16.2 Workgroup

(Worker’s Comp)• National Association of

Children’s Hospitals and Related Institutions

ICD-10 Benefits & Goals

• Higher-quality data, which will result in: – Improved ability to measure

the quality, efficacy, and safety of patient care

– Increased sensitivity when refining grouping and reimbursement methodologies

– Enhanced ability to conduct public health surveillance

– Greater achievement of the anticipated benefits from electronic health record adoption

– Improvements in Setting health policy;

– Operational and strategic planning

• Designing health care delivery systems;

• Monitoring resource utilization;

• Improving clinical, financial, and administrative performance;

• Preventing and detecting health care fraud and abuse; and

• Tracking public health and risks

ICD-10-CM• 21 chapters and expanded

codes – Some chapters reorganized,

some conditions put in to different chapters

• Alphanumeric – first character is always a letter

• Addition of up to 7 characters • 7th character code extensions

in some cases – Injuries

• Initial encounter • Subsequent encounter • Sequela

- Obstetrics - Glaucoma

• Three primary changes to the code set:– Location– Laterality– Severity

ICD-9-CM vs ICD-10-CM

• ICD-9-CM Diagnosis Codes ICD-10-CM • 3-5 digits 3-7 characters

• 1st digit is numeric (except E and V codes) 1st character is always alphabetic, including I and

O but not U

• Digits 2-5 are numeric Characters 2-7 numeric or alphabetic

• Always at least 3 digits Always at least 3 characters

• Use of decimal after the 3rd digit Use of decimal after the 3rd

character

ICD-10-CM Code Format

Key ICD-10 Coding Conventions and Guidelines

• Conventions and guidelines are the foundation.• Documentation is the mortar to the foundation.• The granularity of ICD-10-CM and ICD-10-PCS is

vastly improved over ICD-9-CM and will enable greater specificity in identifying health conditions.

• It also provides better data for measuring and tracking health care utilization and the quality of patient care.

ICD-10-CM Guidelines for Coding and Reporting

• Guidelines have been approved by the four organizations that make up the four Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS (National Center Health Statistics).

• The instructions and conventions of the classification take precedence over guidelines.

• These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction.

ICD-10-CM Guidelines for Coding and Reporting (con’t)

• Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.

• The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

ICD-10-CM Guidelines for Coding and Reporting (con’t)

• The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.

• Only this set of guidelines, approved by the Cooperating Parties, is official.

Conventions• NEW AND DIFFERENT

• Excludes Notes • The ICD-10-CM has two types of excludes notes. Each type of note has a

different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other.

• a. Excludes1 • A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!”

An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

• b. Excludes2 • A type 2 Excludes note represents “Not included here”. An excludes2 note

indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

ICD-10 Guideline Sections• Section I includes the structure and conventions of the

classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification.

• Section II includes guidelines for selection of principal diagnosis for non-outpatient settings.

• Section III includes guidelines for reporting additional diagnoses in non-outpatient settings.

• Section IV is for outpatient coding and reporting. • It is necessary to review all sections of the guidelines to

fully understand all of the rules and instructions needed to code properly.

ICD-10 General Guidelines• Locating a code in the ICD-10-CM • To select a code in the classification that corresponds to a diagnosis or

reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.

• It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.

ICD-10-CM General Guidelines (con’t)

• Signs and Symptoms– Codes that describe signs and symptoms, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider

• Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (Codes R00.0 - R99)– contains many codes for symptoms

ICD-10-CM General Guidelines (con’t)

• Acute and Chronic– Code both and sequence the acute (subacute) code first

• If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level

Documentation needs to reflect the severity

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

• A. Selection of first-listed condition– 1. Outpatient Surgery.– 2. Observation Stay

• B. Codes from A00. 0 through T88.9, Z00-Z99.• C. Accurate reporting of ICD-10-CM diagnosis codes• D. Codes that describe symptoms and signs• E. Encounters for circumstances other than a disease or injury• F. Level of Detail in Coding

– 1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters– 2. Use of full number of characters required for a code

• G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit. • H. Uncertain diagnosis• I. Chronic diseases• J. Code all documented conditions that coexist• K. Patients receiving diagnostic services only .• L. Patients receiving therapeutic services only • M. Patients receiving preoperative evaluations only• N. Ambulatory surgery• O. Routine outpatient prenatal visits• P. Encounters for general medical examinations with abnormal findings• Q. Encounters for routine health screenings

ICD-10-CM• The conventions, general guidelines and

chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. – In addition to general coding guidelines, there are

guidelines for specific diagnoses and/or conditions in the classification.

• Unless otherwise indicated, these guidelines apply to all health care settings.

• The conventions and instructions of the classification take precedence over guidelines.

Documentation• ICD-10-CM• Additional specificity in these key areas to

meet specificity in coding and particularly in ICD-10 (check your queries): – Cause of disease or disorder – Severity – Acute or chronic – With or without crisis – Site – Etiology – Secondary disease process

Documentation Basics (con’t)• Few basics:

– The medical record can be compared to a story book of the patient.

– Does the documentation paint the complete picture of the patient?

– Any documentation – the good, the bad and the ugly does affect ALL: The hospital, the provider, the payer, and specifically, the patient.

– A basic understanding of documentation requirements is critical.

• Up and Down arrows?– Do not code on the basis of up and down arrows– Variable interpretations– Indicating change– Query provider regarding meaning– Applies for both inpatient and outpatient admissions

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Chapter 1• Chapter I: Certain Infectious and Parasitic

Diseases (A00-B99) • Includes diseases generally recognized as

communicable or transmissible. • This chapter uses additional ….codes to identify

resistance to antimicrobial drugs • Use additional code to identify resistance to

antimicrobial drugs (Z16) • There is a new section called ….infections with a

predominantly sexual mode of transmission A50-A64

Diagnosis: Sepsis

• Document whether the sepsis is infectious or non-infectious

• Include information regarding any cause and effective relationship or another condition or problem

• Document if “severe sepsis” is present.

• Document if there is “organ dysfunction” present

• State the specific type of organ that is failing or has failed ie respiratory failure, renal failure, etc.

• Document whether “septic shock” is present

Enterovirus• The following ICD-10-CM Index entries contain back-references

to ICD-10-CM B34.1: – Coxsackie (virus) (infection) B34.1– Disease, diseased - see also Syndrome– coxsackie (virus) B34.1– echovirus NEC B34.1– enteroviral, enterovirus NEC B34.1– nonarthropod-borne NOS (viral) B34.9– enterovirus NEC B34.1

• Infection, infected, infective (opportunistic) B99.9– enterovirus B34.1– unspecified nature or site B34.1

• ICD-10-CM B34.1 is grouped within Diagnostic Related Group(s) (MS-DRG v30.0): • 865 Viral illness with mcc• 866 Viral illness without mcc

EV-D68: The virus is related to the rhinovirus, which is responsible for the common cold, and causes symptoms similar to a cold, including runny nose and coughing. But those symptoms can rapidly escalate into more serious symptoms, such as wheezing, low blood oxygen, and difficulty breathing. The virus can be particularly dangerous for children who have asthma or other respiratory conditions.

Chapter 2• Chapter II: Neoplasms (C00-D49) • Chapter 2 of the ICD-10-CM contains the codes

for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined.

Diagnosis: Neoplasm

• Document the specific site of the neoplasm.

• Document whether the neoplasm is benign, primary, secondary, In situ, uncertain or unknown.– Always include ALL secondary

neoplasms• For neoplasms of the lung,

liver and intestines, document the specific anatomic location, (ie quadrant, lobe, section).– Lower-Outer Quadrant of

Female Breast

• Laterality is needed for paired organs (ie ovary).

• Document the gender (male/female) if needed in the classification ie breast neoplasm

• Complications of the neoplasm should be documented (ie anemia).

• Documentation should identify if the complication is due to any chemo/radiotherapy treatment.

Chapter 3

• Chapter III: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)

• Reserved for future guideline expansion

• Anemia Groups: • Deficiency anemias • Hemolytic anemias • Aplastic anemia and other bone marrow failure

syndromes

ICD-10 Documentation: Anemia• Documentation of anemia

should specify type of anemia: nutritional, hemolytic, aplastic or due to blood loss

• Include documentation if the anemia is due to nutrition or minerals deficits; resulting in a nutritional anemia

• Include documentation of whether the hemolytic anemia is hereditary, acquired, enzyme disorder, autoimmune, or non-autoimmune

• List the name and purpose of any medications causing the anemia

• Link any laboratory findings to a related diagnosis (if appropriate)

• Document whether the anemia is related to chemo or radiotherapy treatments

• Document if the anemia is caused by a neoplasm (primary and/or secondary)

• Document any cause –and-effect relationship between the intervention and the blood or immune disorder

Does your Physician Query Process include this specificity?

Hemolytic Anemia• Due to “Enzyme Disorders”:

– Glucose-6-phosphate dehydrogenase

– Glutathion metabolism– Glycolytic enzymes– Due to nucleotide metabolism

• Thalassemias:– Alpha thalassemia– Beta thalassemia– Delta-beta thalassemia– Thalassemia minor– Hereditary persistence of fetal

hemoglobin– Hemoglobin E-beta thalassemia

• Sickle Cell Disorders is present– Specify if “With or Without

Crisis”• Sickle Cell thalassemia

– Specify if “With or Without Crisis”

• Include documentation of whether the HEMOLYTIC ANEMIA is:

• Hereditary• Acquired• enzyme disorder• Autoimmune• Non-autoimmune• Document the

disorder/condition that is causing the anemia

• Document any associated diagnoses/conditions

Guideline Change: Anemia• Coding and Sequencing of

Complications – Anemia

• Associated with Malignancy- admission for management of anemia associated with malignancy and treatment is only for the anemia

• Code for malignancy sequenced first

• Code for anemia, such as D63.0 – Anemia in Neoplastic Disease

• Sequencing is completely different in ICD-10-CM – Changes the MS-DRG

• Associated with Chemotherapy, Immunotherapy or Radiation Therapy-treatment only for anemia – Anemia code first, neoplasm

code also – Additional codes

• Adverse effect of chemotherapy or immunotherapy- also code

– T45.1X5- adverse effects of antineoplastic and immunosuppressive drugs

• Adverse effect of radiation therapy-also code

– Y84.2 – radiological procedure and therapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure

Chapter 4

• Chapter IV: Endocrine, Nutritional and Metabolic Diseases (E00-E89)

• Diabetes mellitus • The diabetes mellitus codes are combination

codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.

Diagnosis: Diabetes

• Documentation should reflect the “type”

• Documentation should include any manifestations or complications of diabetes

• Documentation should include if “hypoglycemia” or “hyperglycemia”

• If hypoglycemia is present; document whether there is a coma present

• When there are manifestations and/or complications; document additional details:– Arthropathy– Gangrene– Hyperglycemia– Site of ulcer– Severity of retinopathy– Stage of the CKD– Whether with or without

macular edema

Documentation & Coding Diagnosis: Obesity

• ICD-9-CM Key aspects of documentation for coding:

• Overweight, obesity and other hyperalimentation• Overweight and

obesity

• Body Mass Index (BMI)

• ICD-10-CM Key aspects of documentation for coding:

• Overweight and obesity• Obesity due to excess

calories• Drug-induced obesity• Morbid (severe) obesity

with alveolar hypoventilation

• Overweight• Other• Unspecified• Body Mass Index (BMI)

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Documentation: ICD-10 Obesity

• Document whether the patient is overweight or Obese

• Specify if the patient has “morbid obesity” and if due to excess calories

• Document the underlying or causal condition if known (ie adverse effect of drug)

• With obesity, document if hypoventilation syndrome is present

• Also document the Body Mass Index (BMI) if known

Diagnosis: Malnutrition (ICD-9)• Hospital inpatient MS-DRG

MCC Secondary DX, if further supported by the documentation and a plan of care:

• ICD-9-CM code 260—kwashiorkor

• ICD-9-CM code 261—nutritional marasmus

• ICD-9-CM code 262— other, severe protein calorie malnutrition

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• The malnutrition diagnoses that qualify as CC Secondary DXs, if further supported by the documentation or in a plan of care, include these:

• ICD-9-CM code 263.0—malnutrition of a moderate degree

• ICD-9-CM code 263.1—malnutrition of a mild degree

• ICD-9-CM code 263.2—arrested development following protein-calorie malnutrition

• ICD-9-CM code 263.8 –other protein-calorie malnutrition

• ICD-9-CM code 263.9—unspecified protein-calorie malnutrition

Documentation & Coding Diagnosis: Malnutrition

•ICD-9-CM•260 Kwashiorkor •261 Nutritional marasmus •262 Other, Severe protein calorie malnutrition•263.0 Malnutrition of a moderate degree•263.1 Malnutrition of a mild degree•263.2 Arrested development

following protein-calorie malnutrition•263.8 Other protein-calorie malnutrition•263.9 Unspecified protein-calorie malnutrition

•ICD-10-CMType and Degree•E40 Kwashiorkor •E41 Nutritional marasmus •E42 Marasmic kwashiorkor •E43 Unspecified severe protein-calorie malnutrition •E44 Protein-calorie malnutrition of moderate and mild degree • E44.0 Moderate protein-calorie

malnutrition• E44.1 Mild protein-calorie malnutrition•E45 Retarded development following protein-calorie malnutrition •E46 Unspecified protein-calorie malnutrition

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Mild, Moderate or Severe

Diagnosis: Dehydration •ICD-9-CM•Dehydration (cachexia) 276.51•with•hypernatremia 276.0•hyponatremia 276.1•newborn 775.5

•ICD-10-CM•Dehydration E86.0•hypertonic E87.0•hypotonic E87.1•newborn P74.1

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Chapter 5

• Chapter V: Mental, Behavioral and Neurodevelopmental Disorders (F01-F99)

• Increased need for documentation of etiology of disease is critical.

• The relationship between two or more diagnoses (or associated process) cannot be assumed and provider documentation must clearly state causal relationship of conditions.

Documentation: Depression

• “Major Depressive Disorder” should specify or include the following information:– Single episode vs recurrent– Mild, moderate, or severe– With or without psychotic features– In partial or full remission

Documentation: Anxiety

• Document whether is anxiety if “phobic” or “other”

• Document whether the anxiety is generalized, a panic disorder (ie panic attack), mixed anxiety or anxiety unspecified

• There are many codes to describe the patients life situation; ie problems with life cycle transitions

• There are Chapter 18 codes to describe signs and symptoms; nervousness, restlessness and agitation, worries

Alcohol, Tobacco & Substance Use

• Identify the specific type of drug or substance

• Describe the frequency of usage as:

– Use– Abuse– Dependence– In remission

• Describe mode of nicotine use as cigarettes, chewing tobacco, pipe, and/or gum

• Specify intoxication/withdrawal as “Uncomplicated” or “With delirium”

• Document any withdrawal symptoms

• Document any associated diagnoses/conditions

• List the blood alcohol level, if available

• State “no related complications,” when applicable

• Document any related mood disorder

Chapter 6

• Chapter VI: Diseases of the Nervous System (G00-G99)

• Additional codes required for: Alzheimer’s disease with delirium Alzheimer’s with dementia with behavioral disturbance Alzheimer’s with dementia without behavioral disturbance

• Dominant/nondominant side • Codes from category G81, Hemiplegia and hemiparesis, and subcategories, G83.1,

Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:

– For ambidextrous patients, the default should be dominant. – If the left side is affected, the default is non-dominant. – If the right side is affected, the default is dominant.

Diagnosis: Alzheimer’s• Document whether the

Alzheimer’s disease is with early onset or with late onset

• Document if Delirium, is present • Document if there is Dementia

without behavioral disturbance • Document Alzheimer’s disease

with delirium • Document Alzheimer’s with

dementia with behavioral disturbance

• Document Alzheimer’s with dementia without behavioral disturbance

• Document Alzheimer's dementia w delirium

• Specify the following if applicable:– Alzheimer's dementia w

delusions– Alzheimer's dementia w

depressed mood– Alzheimer's dementia with

delirium– Alzheimer's dementia with

delusions– Alzheimer's dementia with

depressed mood

EVERY 67 seconds someone in the United States develops this disease!

Diagnosis: Parkinson Disease• Document when

“Dementia” is associated with Parkinson's Disease

• Document when there are “behavioral disturbance” associated with Parkinson Disease

• Document “Paralysis agitans” if present

• Identify drug induced Secondary Parkinsonism or external agent(s)

Approximately 60,000 Americans are diagnosed with Parkinson's disease each year, and this number does not reflect the thousands of cases that go

undetected.An estimated seven to 10 million people worldwide are living with Parkinson's

disease.

Chapter 8

• Chapter VIII: Diseases of the Ear and Mastoid Process (H60-H95)

• Reserved for future guideline expansion

• Increased specificity for laterality • Increased specificity for Otitis Externa • Type must be identified in ICD-10

Documentation: Otitis Media• Document laterality

– right, left or bilateral• Include documentation of the

severity:– Acute/subacute – Acute recurrent– Chronic

• Document whether tympanic membrane rupture is present

– Without or without Spontaneous rupture

• Document any secondary cause for otitis ie., tobacco smoke

• Document the specific type: – Serous– Sanguineous– Suppurative – Allergic– Mucoid– Tubotympanic – Atticoantral

• Document any associated infectious agent: strep, staph, Scarlett fever, influenza, Measles or Mumps

Chapter 9

• Chapter IX: Diseases of the Circulatory System (I00-I99)

• Hypertension = I10• Heart Failure• AMI• Cardiac Arrest• CVA

Hypertension• No Hypertension Table in ICD-10-CM• Coding is I10 = Hypertension • –No distinction of benign, malignant, unspecified • Same specific documentation required for

Hypertension with Heart Disease • Assumed relationship between Hypertensive and

Chronic Kidney Disease• Combination of Hypertensive Heart and Chronic

Kidney Disease • Elevated Blood Pressure

– ICD-9-CM 796.2 – ICD-10-CM R03.0

Coding Diagnosis: Heart Failure•ICD-9-CM Key aspects of documentation for coding:•Failure, heart (acute) (sudden) 428.9•congestive (compensated) (decompensated) (see also Failure, heart) 428.0• with rheumatic fever (conditions classifiable to 390)• active 391.8• inactive or quiescent (with

chorea) 398.91• fetus or newborn 779.89• hypertensive (see also Hypertension, heart) 402.91• with renal disease (see also Hypertension, cardiorenal) 404.91• with renal failure 404.93• benign 402.11• malignant 402.01• rheumatic (chronic) (inactive) (with chorea) 398.91• active or acute 391.8• with chorea (Sydenham's)

392.0

•ICD-10-CM Key aspects of coding:•Failure, heart •congestive(compensated) (decompensated) I50.9• with rheumatic fever(conditions in I00) • active I01.8• inactive or quiescent(with chorea) I09.81•newborn P29.0•rheumatic(chronic) (inactive) (with chorea) I09.81• active or acute I01.8• with chorea I02.0

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Documentation: Heart Failure• Acuity

– Acute– Chronic– Acute on Chronic

• Type– Diastolic – Systolic– Combined systolic and

diastolic

• Include whether due to or associated with – Cardiac or other surgery – Hypertension– Valvular disease– Rheumatic heart disease

• Endocarditis (valvitis) • Pericarditis• Myocarditis

Shortness of breath and/or respiratory distress are common symptoms.

Chapter 18• Chapter XVIII: Symptoms, signs, and abnormal clinical and

laboratory findings, not elsewhere classified (R00-R99)• Includes: • Symptoms and signs involving the circulatory and respiratory systems• Symptoms and signs involving the digestive system and abdomen• Symptoms and signs involving the skin and subcutaneous tissue• Symptoms and signs involving the nervous and musculoskeletal systems• Symptoms and signs involving the urinary system• Symptoms and signs involving cognition, perception, emotional state and

behavior• Symptoms and signs involving speech and voice• General symptoms and signs• Abnormal findings on examination of blood, without diagnosis• Abnormal findings on examination of urine, without diagnosis• Abnormal findings on examination of other body fluids, substances and

tissues, without diagnosis• Abnormal findings on diagnostic imaging and in function studies, without

diagnosis• Abnormal tumor markers• Ill-defined and unknown cause of mortality

Documentation & Coding: Cough•ICD-9-CM•Cough 786.2•with hemorrhage (see also Hemoptysis) 786.39•affected 786.2•bronchial 786.2•with grippe or influenza (see also Influenza) 487.1•chronic 786.2•epidemic 786.2•functional 306.1•hemorrhagic 786.39•hysterical 300.11•laryngeal, spasmodic 786.2•nervous 786.2•psychogenic 306.1•smokers' 491.0•tea tasters' 112.89

•ICD-10-CM•Cough(affected) (chronic) (epidemic) (nervous) R05•with hemorrhage- see Hemoptysis•bronchial R05•with grippe or influenza- see Influenza, with, respiratory manifestations NEC•functional F45.8•hysterical F45.8•laryngeal, spasmodic R05•psychogenic F45.8•smokers' J41.0•tea taster's B49

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Documentation & Coding: Chest Pain

•ICD-9-CM•Alphabetic Index •chest (central) 786.50•atypical 786.59•midsternal 786.51•musculoskeletal 786.59•noncardiac 786.59•substernal 786.51•wall (anterior) 786.52

•ICD-10-CM•chest(central) R07.9•anterior wall R07.89•atypical R07.89•ischemic I20.9•musculoskeletal R07.89•non-cardiac R07.89•on breathing R07.1•pleurodynia R07.81•precordial R07.2•wall(anterior) R07.89

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Documentation & Coding: Fever•ICD-9-CM (long list – ck your codebook)•Fever 780.60•with chills 780.60•in malarial regions (see also Malaria) 084.6•abortus NEC 023.9•aden 061•African tick-borne 087.1•American•mountain tick 066.1•spotted 082.0•and ague (see also Malaria) 084.6•aphthous 078.4•arbovirus hemorrhagic 065.9•Assam 085.0•Australian A or Q 083.0• . . .

•ICD-10-CM (long list of diagnosis)•Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor) R50.9•abortus A23.1•Aden(dengue) A90•African tick-borne A68.1•American•mountain(tick) A93.2•spotted A77.0•aphthous B08.8•arbovirus, arboviral A94•hemorrhagic A94•specified NEC A93.8•Argentinian hemorrhagic A96.0•Assam B55.0•Australian Q A78•Bangkok hemorrhagic A91

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Injury ICD-10

Details of the injuryWhere were they” Home, SNF, Work,

Restaurant, park, etc.What were they doing? Pedestrian, riding a bike, driving a vehicle (car, bus, heavy equipment) or

a passenger

Case Scenario• A 54 year old female patient was seen in the ER with moderate

weakness and fatigue. She has a history of ovarian carcinoma and had surgery 3 months ago to remove her Tubes and Ovaries.

• She’s been on chemotherapy for the past 6 weeks and has 2 weeks more of treatment and had been doing well until 1 week ago. She has also complained of hip pain off and on over the past 4 weeks.

• During the past week she has been feeling weakness and fatigued. OP Lab (CBC) work revealed the patient to be anemic and needing blood transfusion. A blood transfusion of 2 units of PRBC were transfused on the first hour, followed by an additional 1 unit over a 3 hour period. Her condition improved and she was discharged from the hospital. Impression: “Anemia due to chemotherapy and history of ovarian carcinoma”.

• What is documented and can be coded? (correct sequence): ________________________________

Case Scenario• A 10 year old patient came to the ER with his parents

complaining of ear pain and fever.• Examination found the patient to have a 100.8 fever and

the right eardrum was red and inflamed. The left ear was normal. The family history revealed that a relative had been visiting in the home for the past 3 weeks and they were smoking.

• Final impression in the medical record was “fever due to acute Otitis media right ear with 2nd hand smoke exposure”.

• What is documented and can be coded? (correct sequence): ________________________________

AHA Coding Clinic

• AHA Central Office on ICD-10-CM/PCS is NOT reverting back to accepting or publishing questions on ICD 9 CM • ‐ ‐ Coding Clinic will focus time and attention on

• ICD 10 CM and ICD 10 PCS to better address ‐ ‐ ‐ ‐issues in advance of implementation and ensure a smoother ICD 10 transition.‐

• Your HIM Coding Department is great resource regarding “Coding Clinic”– Subscription (paper or online)

Summary• Know the coding convention• Understand the coding guidelines• Apply the chapter specific guidelines• Review each ICD-10-CM chapter closely• Practice coding; repeat and repeat

– Dual coding• Watch for documentation changes with ICD-10

– New terminology and specificity• Engage, enhance and educate• ADVOCATE!

Questions?

Thank you

References/Resources

• ICD-10-CM Draft Codebook 2014• ICD-10-CM Official Guidelines 2014

– ICD-10-CM Reporting and Coding Guidelines

• 3M Encoder• Bielby, Judy A. "Coding Neoplasms in ICD-10-

CM." Journal of AHIMA 82, no.10 (October 2011): 72-74.

• MedicineNet.com