ICD-10
Getting There…..
Plastic Surgery
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Claims for ambulatory and physician services provided on or after 10/1/2015 must
use ICD-10-CM diagnosis codes.
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Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use
ICD-10-CM diagnosis codes.
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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.
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ICD-9-CM codes must continue to be used for all dates of services on or before
9/30/2015.
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Further delays are not likely.
What Physicians Need To Know
ICD-9-CM Diagnosis Codes
3 to 5 digits
Alpha “E” & “V” – 1st Character
No place holder characters
ICD-10-CM Diagnosis Codes
7 digits
Alpha or numeric for any character
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
ICD-9 vs ICD-10 Diagnosis Codes
Clinical Area
ICD-9 Codes
ICD-10 Codes
Fractures
747
17,099
Poisoning and Toxic Effects
244
4,662
1,104
2,155
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
7
4
Pregnancy Related Conditions
Brain Injury
Chronic Respiratory Failure
Number of Codes by Clinical Area
• 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….
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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!
The Importance of Good Documentation
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.
Inadequate vs. Adequate Documentation
Example 1: Cleft Lip and Palate
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.
Inadequate vs. Adequate Documentation
Example 2: Facial Deformity
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
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
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.
• 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.
Using Sign/Symptom and Unspecified Codes
Dates
Method
Content
Nov 2014 – Jan 2015
Department
Meetings
Introduction/Overview
Jan 2015 – Mar 2015
Web-based
Overview
Service Specific Documentation
Future Order Entry
Diagnosis Assistant
Mar 2015 – Jun 2015
Classroom
Documenting for ICD10 using
the Electronic Health Record
Jun 2015 – Sep 2015
Web-based
Overview
Documenting Operative and
Procedure Notes for ICD-10-PCS
Training for Physicians
Demonstration
Future Orders & Diagnosis Assistant