Clinical Documentation
Improvement for ICD-10
HiMAH 2013 Annual Meeting
Honolulu, Hawaii
May 3, 2013
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Presenter:
Laura Legg, RHIT, CCS AHIMA approved
ICD-10 Trainer
Experienced as a leader, consultant, coding
expert, speaker, trainer and auditor for
acute care and critical access hospitals and
major health systems
llegg@hrgpros.com
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Objectives
To gain an awareness of the complexity of
ICD-10 and the challenges of
implementation
Identify chapter by chapter challenges in
documentation specificity for ICD-10
Identify diagnosis-specific sample queries for
ICD-10
4. Questions/Answers
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ICD-10-CM/PCSIntroduction
• US Department of Health and Human
Services announced change January 16,
2009 with a compliance date of October 1,
2013
• 2012 delay til October 2014
• Biggest change to healthcare in the last 20
years!
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History of ICD-10
• US department of Health and Human
Services announced the change:
1988
1/19/2009
10/1/2013
10/1/2014
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History
More than 200 countries have adopted
ICD-10
•Nordic countries-1997
•UK-1995
•France-1997
•Australia-1998
•Germany-2000
•Canada-2001
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Now is a time to learn everything we
can-
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Ask questions
Learn what testing reveals
Be proactive using what we are learning
Continue learning up until the time of
implementation
• Go-live planning
• Plan for after go live
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ICD-10 Testing Revealed:
• Earlier misconceptions
-DRG variance 2-6%
-MDC shifts not expected
• Expected results
-Coder productivity decrease
-If you are not proficient now you won’t be
proficient using ICD-10
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Testing Revealed:
DRG variances much higher than
expected
Example:
DRG variance in the Nervous System
Expected 8%
Actual 27%
DRG variance in the Digestive System
Expected 8%
Actual 20%
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Testing Revealed:
• MDC shifts did occur
• Time-to-code IP claims decreased from 3-5 per
hour to 1-2 per hour
• Coding errors included:
-invalid codes
-decimals in incorrect places
-coding not following coding conventions
This caused increased rejected and pended
claims
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What should we do?
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The answer “DOCUMENTATION”
Back to the Basics
Look at Processes and Workflow now
Staff adjustments
Dual coding
Peer review
Physician queries
Testing Revealed:
“Any testing that doesn’t find things
is a waste of time.”
Mark Lott, HIMSS/WEDI ICD-10 National Pilot Program
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Go From ICD-9 to ICD-10
Think about this:
Remember:
• If it was not working that
well for ICD-9-CM/PCS it
won’t work for ICD 10 CM!
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Focus your efforts:
• Top 10 common clinical diagnoses
• If physicians are motivated or conditioned
to include specificity in these top clinical
diagnoses then the road to a successful
transition to clinical documentation under
ICD-10 can be established
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Tailor your CDI program:
• Run a report of the top 20 MS DRGs for the
last fiscal year
• Review diagnoses
• Tailor ICD-10 training for the common
clinical diagnoses that your physicians
manage
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ICD-10 Clinical documentation
 Greater specificity
Increase accuracy in documentation
Increase accuracy in billing and
reimbursement
Improved statistical analysis which means:
-improved disease management
-better understanding of health care
outcomes
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Review Query forms
• Revise query forms and focus on some specific
areas:
Asthma
Coma
Fracture
Stroke
Cardiac-hypertension, CAD, CHF
Diabetes
OB
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Chapter 1: Infectious and Parasitic diseases
•Queries will be mandatory for the diagnosis “urosepsis” in
ICD-10-CM
•More specific documentation is needed when reporting
sepsis. Septicemia is no longer synonymous with sepsis
•Specific cell types are required to code malignancy
neoplasms of the blood and immune system accurately
•Nutritional anemia require more information on the cause of
the anemia
•More specific information on the type of immune disorder is
required
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Chapter 2: Neoplasms
• When an admission is solely for anemia
associated with a malignancy, the
appropriate malignancy code is sequenced
as the principal diagnosis followed by the
code for anemia in neoplastic disease.
D63.0
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Chapter 3: Blood and blood forming organs
• Anemia appears in code categories D50-D64.
• ICD-10 also identifies anemia according to type,
but the categories rely on different language
-nutritional (iron deficiency in ICD-9)
-Hemolytic (e.g., sickle cell)
-Aplastic and other anemia, which include acute
blood loss anemia and anemia of chronic
disease.
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Chapter 4: Endocrine, Nutritional, and Metabolic
• In ICD-9-CM diabetes mellitus was
classified as to type 1, type 2, or secondary
• The 5th digit indicates the type of diabetes
mellitus or unspecified diabetes and also
indicates if the diabetes is controlled or
uncontrolled
• In ICD-10-CM diabetes mellitus is not
classified as controlled or uncontrolled
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Chapter 4: Endocrine, Nutritional and Metabolic
• ICD-10-CM classifies diabetes mellitus as
follows:
E08-Diabetes mellitus due to an underlying
condition (code first the underlying
condition)
E09-Drug or chemical-induced diabetes
mellitus.
E10-Type I diabetes mellitus
E11-Type 2 or diabetes NOS
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Chapter 4: Endocrine, Nutritional and Metabolic
E13-Other specified diabetes mellitus (diabetes
due to pancreatectomy)
E12-left for expansion of ICD-10
Sequencing has changed with “code first” notes
Combination codes
Encourage physicians to document mild,
moderate or severe retinopathy for the added
specificity in ICD-10 diabetes mellitus codes
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Chapter 4: Endocrine, Nutritional and Metabolic
• More specific information is required to code the type of
congenital hypothyroidism
• More specific information is needed to code iodine deficiency
thyroid disorders
• More specific information is needed to code disorders of the
parathyroid gland
• Cushing’s syndrome is now differentiated by type and cause
• Vitamin, mineral and other nutritional deficiencies require more
information as the specific vitamin and mineral
• Disorders related to hyperalimentation require documentation
of the specific condition
• Metabolic disorders require greater detail related to the specific
amino acid, carbohydrate and lipid enzyme deficiency
responsible for the metabolic disorder
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Chapter 5: Mental and behavioral disorders
Drug and alcohol-related disorders
Assignment is based on type of substance
and whether the person abuses the
substance or is dependent on it
When documentation identifies that the
patient has use, abuse, and dependence the
most severe state is coded
Hierarchy is use---abuse----dependence
lowest to high severity
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Chapter 6: Nervous System/Sense
Organs
• Encourage neurologists and other
providers to review ICD-10-CM code
descriptions for seizures and epilepsy and
to document accordingly.
• These codes are more specific than their
ICD-9-CM counterparts and require more
specific documentation
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Chapter 6: Nervous System/Sense
Organs
• Terminology for epilepsy has been updated
to include terms such as:
Epilepsy, juvenile myoclonic
Epilepsy, generalized, idiopathic
Epilepsy, generalized, idiopathic, intractable,
without status epilepticus
• Code assignment will depend on specific
documentation (documentation opportunity)
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Chapter 6: Nervous system/Sense
Organs
• In ICD-10-CM more specificity is possible
in the coding of epilepsy such as identifying
seizures as
-localized onset
-complex partial seizures
-intractable and status epilepticus
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Chapter 6: Nervous system/Sense
Organs
Other key documentation elements for the
Nervous system are:
•Dominant vs. nondominant side
•Laterality
•Episode of care for injuries and other
external causes-initial, subsequent, sequela
•Loss of consciousness time duration
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Chapter 7: Eye and Adnexa
• Codes have been expanded to increase
anatomic specificity and add the concept of
laterality
• Many codes include right, left, bilateral, and
unspecified eye
• If the option of bilateral is not available and the
condition is present in both eyes, assign the
code for right and left
• If a code for bilateral exists it should be
assigned
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Chapter 8: Ear and Mastoid
• Codes have been expanded to increase
anatomic specificity and add the concept of
laterality
• New instructional notes have been added
• A note at the beginning of the chapter
states to use an external cause code
following the code for the ear condition, if
applicable, to identify the cause of the ear
condition
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Chapter 8: Ear and Mastoid
• Infective otitis externa codes require
documentation for more specific causes:
-abscess
-cellulitis
-diffuse
-hemorrhagic
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Chapter 8: Ear and Mastoid
• Noninfective otitis externa codes require
documentation as:
-actinic
-chemical
-contact
-eczematoid
-reactive
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Chapter 8: Ear and Mastoid
• Meniere’s disease is no longer coded as
active or inactive, cochlear or vestibular,
but laterality
• Conductive hearing loss is no longer
differentiated by the location of the
dysfunction
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Chapter 9: Circulatory system
• Acute myocardial infarction must be
identified as initial or subsequent
• Embolism, thrombosis, phlebitis and
thrombophlebitis of veins require
identification of laterality and the specific
lower extremity vein
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Chapter 9: Circulatory System
Documentation for coding CVAs in ICD-10CM
•To make the correct code for CVAs the
documentation must reflect the
location/source and laterality
•If bilateral sites are indicated, codes should
be assigned for each side as there is no
bilateral option in this series
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Chapter 10: Respiratory System
• When assigning codes for patients with
COPD with asthma it is necessary to
assign two codes.
• A code from category J44 is assigned for
the COPD and is accompanied by a
second code from J45 to identify the
severity and status of the asthma.
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Chapter 10: Respiratory System
• Key Documentation elements:
Asthma must be documented as mild,
moderate or severe
Mild asthma must be documented as
intermittent or persistent
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Chapter 11: Digestive System
• Some terminology changes have occurred
• Some revisions to the classification of
specific digestive conditions have occurred
in ICD-10-CM as well
• Example: K50, Crohn’s disease has been
expanded to the 4th, 5th and 6th character, in
contrast to the ICD-9-CM code 555,
Regional enteritis
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Chapter 11: Digestive System
Documentation Note:
The term “hemorrhage” is used when
referring to ulcers, and the term “bleeding” is
used when classifying gastritis, duodenitis,
diverticulosis, and diverticulitis
•K25.0, Acute gastric ulcer with hemorrhage
•K29.01, Acute gastritis with bleeding
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Chapter 11: Digestive System
• Irritable bowel syndrome must be documented
as with or without diarrhea
• Anal fissure must be documented as acute or
chronic
• Abscess of the anal and rectal region must be
specifically documented as to site
• Alcoholic disease of the liver must be
documented as with or without ascites
• Hepatitis must be documented as acute,
subacute, or chronic and with or without coma
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Chapter 11: Digestive System
• Acute pancreatitis must be documented as
-idiopathic
-biliary
-alcohol-induced
-drug-induced
-other
-unspecified
HRG_Tiah 4/15/13
Changed "Drug-induced" to "druginduced"
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Chapter 12: Skin/Subcu Tissue
Coding Pressure Ulcers:
•In ICD-9-CM coders assigned 2 codes for
pressure ulcers-one from category707.0x
(location) and one from 707.2x (stage of the
ulcer)
•In ICD-10-CM pressure ulcers appear in code
category L89.•Code L89.001 stage 1 pressure ulcer of the right
elbow (note location and stage in one code)
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Chapter 13: Musculoskeletal System
Fracture codes include greater specificity in:
•Type of fracture
•Specific anatomic site
•Displaced or nondisplaced
•Laterality
•Routine vs. delayed healing
•Non union and malnunion
•Fracture 7th character value
•Gustilo open fracture classification
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Chapter 13: Pathological fractures
Pathologic fracture documentation:
Exact location of the fracture site with
laterality
Etiology of the fracture-osteoporosis,
neoplasm, other specified
Encounter type-initial, subsequent with
routine healing, subsequent with delayed
healing, malunion and nonunion or sequelae
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Chapter 13: Musculoskeletal
System
How do you prepare?
•Work with clinicians and physicians where
terminologies and specificity is required
•Work with CDI team to assist regarding
documentation requirements
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Chapter 13: Musculoskeletal System
Gustilo classification
•Type I-clean wound < 1 cm long
•Type II-wound > 1 cm without extensive soft tissue
damage
•Type IIIA-extensive soft tissue lacerations (>10 cm)
but maintain adequate soft tissue coverage of bone
•Type IIIB-extensive soft tissue loss with periosteal
stripping and bony exposure, usually massive
contamination
•Type IIIC- with arterial injury that requires repair
regardless of size of wound
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Chapter 14: Genitourinary System
Chronic Kidney disease and Kidney Transplant Status
•Patient who have undergone kidney transplant may still
have some form of CKD, because the kidney transplant may
not fully restore kidney function. Therefore, the presence of
CKD alone does not constitute a transplant complication.
•Assign the appropriate N18 code for the patient’s stage of
CKD and code Z94.0 Kidney transplant status.
• If a transplant complication such as failure or rejection or
other transplant complication is documented see section
I.C.19.g for information on coding complications of a kidney
transplant.
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Chapter 15: Pregnancy/Childbirth
• The final character in the code will indicate
the trimester
• Antepartum, postpartum and whether a
deliver has occurred are not used.
• Final character assignment should be
based on provider’s documentation
• Gestational diabetes needs specification of
diet controlled or insulin controlled
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Chapter 16: Newborn
• When both birth weight and gestational age
of the newborn are available both should
be coded with birth weight sequenced
before gestational age
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Chapter 17: Congenital Malformations
• Modifications have been made to specific
categories to update terminology
• Example:
Q61 Cystic kidney disease
Q61.0 Congenital renal cyst
Q61.1 Polycystic kidney, infantile type
Q61.2 Polycystic kidney, adult type
• Patau’s syndrome updated to Trisomy 13
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Chapter 18: Signs and Symptoms
Glasgow Coma ScaleThe Glasgow coma scale codes (R40.2-) can be used in
conjunction with traumatic brain injury codes, acute
cerebrovascular disease or sequelae of cerebrovascular
disease codes. The codes are primarily for use by trauma
registries, but they may be used in any setting where this
information is collected. The coma scale codes should be
sequenced after the diagnosis codes.
At a minimum report the initial score documented on
presentation at the facility. This may be a score from the
emergency medicine technician or the ER department. If
desired a facility may choose to capture several scores.
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Chapter 19: Injury/poisoning
UnderdosingUnderdosing refers to taking less of a medication
than is prescribed by a provider or a
manufacturer’s instruction. For underdosing
assign the code from categories T36-T50 (fifth
or sixth character6) Codes for underdosing
should never be assigned as principal or firstlisted codes. If a patient has a relapse or
exacerbation of the medical condition for which
the drug is prescribed because of the reduction
in dose, then the medical condition itself should
be coded.
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Chapter 21: Factors Influencing Health
• Personal and family history codes have
been expanded in ICD-10 CM
• New codes to identify the patient’s blood
type
• Category V57 Care involving use of
rehabilitation procedures no longer existsreport instead the underlying condition for
which the therapy is being provided with
the 7th character indicating subsequent
encounter
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It’s brand new!
• ICD-10-PCS presents a totally new model
• Drastically different from its ICD-9
counterpart
• Entirely new coding logic and will be new
territory for coders
• The changes in the meaning of characters
may be confusing
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Benefits of ICD-10 CM/PCS
• Improve the accuracy and efficiency of
procedure coding
• Replace ICD-9 CM with a more logical
system
• Improve communication with physicians by
developing a code system that aligns more
with the clinical aspects of various
procedures
• Allow coders to construct accurate codes
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HRG_Tiah 4/15/13
Do you want the slide number to be in
the footer with hrgpros.com? Slides 57
and 58 have it but the others don't?
Procedure code comparison
Characteristic
ICD-9-CM volume 3
ICD-10-PCS
Field length
3-4 characters
7 alphanumeric
characters
Available codes
3,000
72,081
Available space for new
codes
Limited
Flexible
Overall detail embedded
in codes
Ambiguous
Precise definition
regarding anatomic site,
approach, device used,
and qualifying information
Laterality
Code does not identify
right vs. left
Code identifies right vs.
left
Terminology for body
parts
Generic description
Detailed description
Procedure description
Lacks description of
procedure approach
Detailed description of
approach.
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Procedure code comparison, cont..
Characteristic
ICD-9-CM vol. 3
ICD-10-PCS
Character position within
code
N/A
16 PCS sections identify
procedures in a variety of
classifications (e.g.
medical surgical, mental
health). Among these
sections there may be
variations in the meaning
of various character
positions, though the
meaning is consistent
within each section.
Example code
39.24 Aorta-renal bypass 04104J3 bypass
abdominal aorta to right
renal artery with synthetic
substitute, percutaneous
endoscopic approach
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PCS:
• All codes in PCS are seven characters
• Letters O and I not used in PCS
Numbers 0 and 1 used
• Each character has a meaning
• Meanings change by sections
• Section provides first character value
• Sections of ICD-10-PCS listed in manual
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Root Operations:
Third character of the procedure code
--Defines the objective of the procedure
-New terminology used to define the different
types of root operations
-Physician does not have to document root
operation terms; coders will translate
HRG_Tiah 4/15/13
Capitalized "new" to keep formatting
the same
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Root Operations:
Examples of Root operations:
• Bypass
• Drainage
• Reattachment
• Resection
• Inspection
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Anticipate Queries for ICD-10-PCS:
• Root Operation
• Body Part
• Body System
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Current Documentation Issues
• Physicians
• How well do they already document?
• Have you already started education?
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Incorporate the following scales into
queries:
National heart, lung and blood institute
asthma severity classification scale of
intermittent, mild persistent, moderate and
severe persistent
Glasgow Coma Scale
Gustilo Open Fracture Classification
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What about you? Are you ready?
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Review the ICD-10-CM/PCS Guidelines
Compare to the ICD-9-CM Guidelines
Review Current Documentation
Have a positive outlook
Expect the unexpected
Physician Education needed now
• Do you have buy in?
• Physicians want to document correctly
• Educate physicians by giving specific facts
by specialty
• Educate surgeons on the details of PCS
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Anticipate query increase
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Additional queries-guaranteed
Not just diagnoses but procedure queries
Think laterality
Muscle/vessel specificity
Think joints and fractures
New queries
• Queries need to be rewritten
• CDI staff educated on changes and
anticipate the rework of queries
• Physician educated on the new queries and
the new code structure
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Productivity for coders and others
• Anticipate loss of productivity for a short
time
• Canada had a 50% reduction in productivity
• Due to physician education, more queries,
more time spent reviewing charts
• Lay the groundwork now
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What to do?
• Become familiar with ICD-10 CM/PCS
codes
• Review the Official Coding Guidelines
• Work with the physicians
• Re-audit documentation, query forms,
make revisions and improvements
• Assess your ICD-10 needs
• Increase your clinical knowledge
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Get out of your comfort zone!
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In the coming months
More will be learned about ICD-10
More clinical documentation issues will be
brought forward
BE prepared
The key to successful ICD-10
implementation is improving your clinical
documentation now!
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Leap into ICD-10
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Questions?
• Laura Legg, RHIT, CCS
• HIM Director for Healthcare Resource
Group
• llegg@hrgpros.com
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References:
• http://www.nlm.nih.gov/medlineplus/ency/article/001214.htm
• ICD-10 CM official coding guidelines @
www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf
• ICD-10-CM Coder Training Manual-AHIMA
• Gustilo classificationhttp://eoriff.com/general/Open%20Fx%20Class.html
• Salter-Harris classificationhttp://www.bridgeport.edu/gwl/salter-harrisclassification/htm
• AHA Coding Guidelines-October 1, 2012
• ICD-10-CM the complete draft code set
2012http://www.cms.hhs.gove/ICD10
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