UHS, Inc.
ICD-10-CM/PCS
Physician Education
Pulmonology and Respiratory
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ICD-10 Implementation
• October 1, 2015 – Compliance date for
implementation of ICD-10-CM (diagnoses) and
ICD-10-PCS (procedures)
– Ambulatory and physician services provided on or after
10/1/15
– Inpatient discharges occurring on or after 10/1/15
• ICD-10-CM (diagnoses) will be used by all
providers in every health care setting
• ICD-10-PCS (procedures) will be used only for
hospital claims for inpatient hospital procedures
– ICD-10-PCS will not be used on physician claims, even
those for inpatient visits
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Why ICD-10
Current ICD-9 Code Set is:
– Outdated: 30 years old
– Current code structure limits amount of
new codes that can be created
– Has obsolete groupings of disease
families
– Lacks specificity and detail to support:
• Accurate anatomical positions
• Differentiation of risk & severity
• Key parameters to differentiate disease
manifestations
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Diagnosis Code Structure
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ICD-10-CM Diagnosis Code Format
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Comparison: ICD-9 to ICD-10-CM
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Procedure Code Structure
ICD-10-PCS Code Format
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ICD-10 Changes Everything!
• ICD-10 is a Business Function Change, not just
another code set change.
• ICD-10 Implementation will impact everyone:
– Registration, Nurses, Managers, Lab, Clinical Areas,
Billing, Physicians, and Coding
• How is ICD-10 going to change what you do?
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ICD-10-CM/PCS
Documentation Tips
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ICD-10 Provider Impact
• Clinical documentation is the foundation of successful ICD10 Implementation
• Golden Rule of Documentation
– If it isn’t documented by the physician, it didn’t happen
– If it didn’t happen, it can’t be billed
• The purpose in documentation is to tell the story of what
was performed and what is diagnosed accurately and
thoroughly reflecting the condition of the patient
– what services were rendered and what is the severity of illness
• The key word is SPECIFICITY
– Granularity
– Laterality
• Complete and concise documentation allows for accurate
coding and reimbursement
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Gold Standard Documentation Practices
1.
Always document diagnoses that contributed to the reason for
admission, not just the presenting symptoms
2.
Document diagnoses, rather that descriptors
3.
Indicate acuity/severity of all diagnoses
4.
Link all diseases/diagnoses to their underlying cause
5.
Indicate “suspected”, “possible”, or “likely” when treating a
condition empirically
6.
Use supporting documentation from the dietician / wound care to
accurately document nutritional disorders and pressure ulcers
7.
Clarify diagnoses that are present on admission
8.
Clearly indicate what has been ruled out
9.
Avoid the use of arrows and symbols
10. Clarify the significance of diagnostic tests
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ICD-10 Provider Impact
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and
anatomic sites
4.Etiology – causative disease or contributory drug, chemical,
or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or
accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition
or disease process
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ICD-10 Documentation Tips
Do not use symbols to indicate a disease.
For example “↑lipids” means that a laboratory result
indicates the lipids are elevated
– or “↑BP” means that a blood pressure reading is high
These are not the same as hyperlipidemia or hypertension
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ICD-10 Documentation Tips
Site and Laterality – right versus left
–bilateral body parts or paired organs
Example – frontal sinusitis
Stage of disease
–Acute, Chronic
–Intermittent, Recurrent, Transient
–Primary, Secondary
–Stage I, II, III, IV
Example – stage of pressure ulcer:
– L89.011 Pressure ulcer of right elbow, stage 1
– L89.021 Pressure ulcer of left elbow, stage 1
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ICD-10 Documentation Tips
Asthma
–
Specificity
•
•
•
•
Intermittent [less than or equal to two times per week]
Mild persistent [more than two times per week]
Moderate persistent [daily-may restrict physical activity]
Severe persistent [throughout the day-frequent severe attacks that limit
the ability to breathe]
– Type / Form
•
•
•
•
•
•
•
•
•
•
•
Childhood
Exercise induced
Extrinsic allergenic
Late onset
Allergic
Allergic bronchitis
Allergic rhinitis w/ asthma
Atopic asthma
Extrinsic allergic asthma
Intrinsic non-allergic asthma
Idiosyncratic asthma
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ICD-10 Documentation Tips
Asthma
continued
– Acuity
•With acute exacerbation
•With status asthmaticus
– Tobacco Exposure
•Exposure to environmental tobacco smoke
•History of tobacco use
•Occupational exposure to tobacco smoke
– Cause and Effect – environmental
•Detergent
•Coal workers
•Miners
•Wood
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ICD-10 Documentation Tips
COPD
– Type
•
•
•
•
Chronic obstructive bronchitis
Chronic bronchitis with airway obstruction
Chronic bronchitis with emphysema
Chronic obstructive tracheobronchitis
– Acuity
• With acute exacerbation
• With acute lower respiratory infection
– Specificity
• With asthma
• With bronchitis
• With emphysema
– Tobacco Exposure
• Exposure to environmental tobacco smoke
• History of tobacco use
• Occupational exposure to tobacco smoke
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ICD-10 Documentation Tips
Influenza
– Organism, document as known or suspected
• Avian influenza
• H1N1 influenza
– Link associated conditions / manifestations
•
•
•
•
•
•
Influenza with secondary gram negative pneumonia
Laryngitis
Pleural effusion
Influenzal encephalopathy
Influenzal myocarditis
Influenzal otitis media
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ICD-10 Documentation Tips
Lung Cancer
– Location
• Detailed location of lesion site
• Left, Right, Bilateral
– Morphology
•
•
•
•
Malignant, Benign
Primary , Secondary
In situ
Uncertain behavior, Unspecified behavior
– Histology
• Identified by cytology, histology or pathology findings
– Stage / Metastatic
• Different, distinct locations
– Different primaries
– Metastatic sites
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ICD-10 Documentation Tips
Lung Cancer continued
– Is patient being admitted for treatment of the
neoplasm or an adverse reaction / complication?
• Treatment - surgery, chemotherapy, immunotherapy, radiation
• Adverse reaction of treatment – neutropenic fever secondary to
chemo
• Complication of the disease – anemia due to malignancy
– Document if a complication is part of the disease
process or an adverse effect of treatment
• Anemia due to malignancy or due to chemotherapy
– History of
• Malignancies previously removed and no longer receiving active
treatment
• Clearly document for follow-up and medical surveillance
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ICD-10 Documentation Tips
Pneumonia
– Type – bacterial, viral, fungal, aspiration, drug-induced
– Organism, document as known or suspected
• Viral – adenoviral, respiratory syncytial, parainfluenza, human
metapneumovirus, viral unspecified
• Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas,
staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified
– Link associated conditions / underlying conditions
• Influenza with secondary gram negative pneumonia
• Sepsis due to pneumonia
• Acute respiratory failure due to pneumonia
– Aspiration
• Due to solids or liquids
• Due to anesthesia during L/D or procedure
• Due to anesthesia during puerperium
– Laterality of lung involvement – left, right, both
– Note whether ventilator associated (VAP)
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ICD-10 Documentation Tips
Respiratory Failure
– Acuity - acute, chronic, acute on chronic
– Specificity – with hypoxia or hypercapnia
– Tobacco Use
• Exposure to environmental tobacco smoke
• History of tobacco use
• Occupational exposure to tobacco
– Does the patient require continuous home oxygen or is
dependent on home oxygen
– Differentiate pulmonary collapse from therapeutic
collapse
– Respiratory distress and respiratory insufficiency are NOT
respiratory failure
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ICD-10 Documentation Tips
Respiratory Failure Criteria
Acute
Chronic
Symptoms – difficulty breathing, shortness of
breath, dyspnea, tachypnea, respiratory
distress, labored breathing, use of accessory
muscles, cyanosis, unable to speak
Symptoms – severe COPD, chronic lung
disease such as cystic or pulmonary
fibrosis
Ph < 7.35 & pCO2 > 50 or pO2 < 55 & FIO2 >
28 %
pO2 < 55 or pCO2 > 50
Hypoxemia
Hypercapnia
pO2 < 60 mmHg
OR
pO2 / FIO2 ratio < 300 OR
10 mmHg decrease in baseline pO2
pCO2 > 50mmHg with pH < 7.35
OR
10 mmHg increase in baseline pCO2
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ICD-10 Documentation Tips
Drug Under-dosing
is a new code in ICD-10-CM.
– It identifies situations in which a patient has taken less of a
medication than prescribed by the physician.
• Intentional versus unintentional
– Documentation requirements include:
• The medical condition
• The patient’s reason for not taking the medication
– example – financial reason
– Z91.120 – Patient’s intentional underdosing of
medication due to financial hardship
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ICD-10 Documentation Tips
Codes for postoperative complications have been expanded and a
distinction made between intraoperative complications and postprocedural disorders
•The provider must clearly document the relationship between the
condition and the procedure
–
Example:
• D78.01 –Intraoperative hemorrhage and hematoma of spleen
complicating a procedure on the spleen
• D78.21 –Post-procedural hemorrhage and hematoma of spleen following
a procedure on the spleen
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ICD-10 Documentation Tips
Intra-operative
Post-procedural
Accidental puncture / laceration
Timing:
•Post-procedure
•Late effect
Same or different body system
Classify as:
•An expected post-procedural
condition
•An unexpected post-procedural
condition, related to the
patient’s underlying medical
comorbidities
•An unexpected post-procedural
condition, unrelated to the
procedure
•An unexpected post-procedural
condition related to surgical care
(a complication of care)
Blood product
Central venous catheter
Drug:
•What adverse effect
•Drug name
•Correctly prescribed
•Properly administered
Encounter:
•Initial
•Subsequent
•Sequelae
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ICD-10 Documentation Tips
ICD-10-PCS does not allow for unspecified
procedures, clearly document:
• Body System
– general physiological system / anatomic region
• Root Operation
– objective of the procedure
• Body Part
– specific anatomical site
• Approach
–
technique used to reach the site of the procedure
• Device
– Devices left at the operative site
ICD-10 Documentation Tips
Most Common Root Operations:
Control – stopping or
attempting to stop
Excision – cutting out
or off without
replacement a portion
of a body part
Repair – restoring, to
the extent possible, a
body part
Restriction – partially
closing an orifice or
lumen of a tubular
body part
Dilation – expanding
Extirpation – taking or
an orifice or the lumen cutting out solid
of a tubular body part matter
Replacement – putting
in a biological
/synthetic material
that takes the place or
function
Supplement – putting
in a biological/
synthetic material to
reinforce / augment
Division – cutting into
a body part to
transect the body part
Insertion – putting in a
non-biological
appliance
Reposition – moving to Transfer – moving,
its normal location
without taking out, all
or a portion of a body
part to another
location
Drainage – taking or
letting out fluids &/or
gases
Release – freeing a
body part from an
abnormal physical
constraint
Resection – cutting out
or off without
replacement all of a
body part
Transplantation –
putting in all or a
portion of a living part
from another
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individual or animal
ICD-10 Documentation Tips
Most Common Device Types:
Diaphragmatic
pacemaker lead
Endobronchial valve Intraluminal device: plain, drug-eluting, or
radioactive
Drainage device
Endotracheal airway Monitoring device
Extraluminal device
Infusion device
Tracheostomy
device
Radioactive
element
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Summary
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and
anatomic sites
4.Etiology – causative disease or contributory drug, chemical,
or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or
accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition
or disease process
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