ICD-10 UPDATE
DEBBY B. HOUSTON,
CMA(AAMA), CPC
BILLING OUTREACH
EDUCATOR, UVA
PHYSICIANS GROUP
ICD- 10
• Will it be here on October 1, 2013
• Or
NOT
DOCUMENTATION AND THE
ELECTRONIC MEDICAL RECORD
Objectives
• ICD-10-CM Regulatory Environment
• ICD-9-CM vs. ICD-10-CM
• ICD-10-CM Draft Guidelines for Coding and
Reporting 2011
• Documentation Challenges
• Electronic Medical Record (EMR)
• Failure to Implement
• Opportunities
• How To Prepare
ICD-9 TO ICD-10
NOW
THEN
•
CH 1 Infectious and Parasitic Diseases 001-139
•
CH 2 Neoplasms 140-239
Neoplasms C00-D499
•
•
•
CH 3 Endocrine, Nutritional and Metabolic Diseases
and Immunity Disorders 240-279
CH 4 Diseases of the Blood and Blood-forming
Organs 280-289
CH 5 Mental Disorders 290-319
Diseases of the Blood and Blood-forming Organs D50D89
•
•
•
•
CH 6 Diseases of Nervous System and Sense Organs
320-389
CH 7 Diseases of the Circulatory System 390-459
CH 8 Diseases of the Respiratory System 460-519
•
Certain infectious and parasitic diseases A00-B99
Endocrine, Nutritional and Metabolic Diseases E00-E89
Mental and Behavioral Disorders F01-F99
Diseases of the Nervous System G00-G99
Diseases of the Eye and Adnexa (new) H00-H59
Diseases of the Ear and Mastoid Process (new) H60-H95
ICD-9 TO ICD-10
NOW
THEN
•
CH 9 Diseases of the Digestive System 520-579
•
Diseases of the Circulatory System I00-I99
•
CH 10 Diseases of the Genitourinary System 580-629
•
Diseases of the Respiratory System J00-J99
•
CH 11 Complications of Pregnancy, Childbirth and
the Puerperium 630-679
•
Diseases of the Digestive K00-K94
CH 12 Diseases of the Skin and Subcutaneous Tissue
680-709
CH 13 Diseases of Musculoskeletal and Connective
Tissue 710-739
•
•
Diseases of the Skin and Subcutaneous Tissue L00L99
•
Diseases of the Musculoskeletal System and
Connective Tissue M00-M99
•
•
•
CH 14 Congenital Anomalies 740-759
CH 15 Newborn (Perinatal) Guidelines 760-779
•
•
Diseases of the Genitourinary System N00-N99
Pregnancy, Childbirth and the Puerperium O00-O9a
•
CH 16 Signs, Symptoms and ILL-Defined Conditions
780-799
•
Certain Conditions Originating in the Perinatal
Period P05-P96
ICD-9 TO ICD-10
NOW
THEN
•
CH 17 Injury and Poisoning 800-999
•
•
CH 18 N/A –
•
•
CH 19 N/A –
•
•
•
CH 20 N/A –
CH 21 N/A –
•
•
•
Index
•
•
•
•
Neoplasm Table
Table of Drugs and Chemicals –
Index to External Causes Classification of Factors influencing Health Status
and Contact with Health Service V01-V89
•
Supplemental Classification of External Causes of
Injury and Poisoning E800-E999
•
•
•
•
Congenital Malformations, Deformations and
Chromosonal Abnormalities Q00-Q99
Symptoms, Signs and Abnormal Clinical and
Laboratory Findings R00-R99
Injury, Poisoning and Certain Other Consequences
of External Causes S00-T88
External Causes of Morbidity (new) V00-Y99
Factors Influencing Health Status and Contact with
Health Services (new) Z00-Z99
Index
Neoplasm Table
- Table of Drugs and Chemicals
Index to External Causes
ICD-9-CM VS ICD-10-CM
ICD-9-CM
ICD-10-CM
17 Chapters
21 Chapters
E and V code Supplemental
Classification
All codes are alphanumeric
Sense organ conditions in Nervous
System
Separate Chapters
Outdated language
Current terminology
Injuries by type
Injuries group by site , then type
Complications of Medical care in 1
Chapter
Complications have been
categorized to procedure-specific
body system chapters
Maximum of 5 characters
Maximum of 7 characters
Partial code titles
Full code titles
Code extensors for specificity and
laterality
ICD-10-CM STRUCTURAL CHANGES
ICD-9-CM
3-5 characters
ICD-10-CM
3- 7 characters
First character is numeric or alpha (E First character is alpha
or V)
Characters 2-5 are numeric
All letters except U
Always at least 3 characters
Characters 2-7 are alpha or numeric
Use of decimal after 3 characters
Use of decimal after 3 characters
13,000 codes
72,000 codes (approximately)
ICD-10-CM FORMAT
SI 2 5
Category
Chronic heart disease
. 7 0 1
Atherosclerosis of coronary artery bypass
graft(s), complication, manifestation
Atherosclerosis of coronary bypass graft(s), unspecified, with angina pectoris with
documented spasm
GENERAL CODING GUIDELINES FOR
2011
For reporting purposes only codes are permissible not categories, subcategories.
The 7th character is applicable when required.
Place holder “x” is used as a placeholder on certain codes to allow for future
expansion of the code. Example: poisoning, adverse effect, and underdosing
codes (T36-T50) may need a placeholder to be considered a valid code.
7th Character – The 7th character must always be the 7th character in the data
field. If a code that requires a 7th character is not 6 characters, then a place
holder must be used to fill in the empty characters.
• “NEC”- still represents not elsewhere classifiable in the Alphabetical Index.
• NOS – still represents not other wise specified and is the equivalent of
unspecified in the
Alphabetic Index.
• “NEC” still represents not elsewhere classifiable in the Tabular list.
• NOS still represents not otherwise specified and is the equivalent of
unspecified in the
Tabular List
GENERAL CODING GUIDELINES
Locating a code- Locate a code in the Alphabetical Index and verify the code in the Tabular list.
Apply instructional notes that appear in both the Alphabetical Index and the Tabular List. (same)
Level of detail in Coding- Codes must be reported to the highest level of detail. Codes from A00 – T88.9,
Z00-Z99 - must be used to identify diagnosis, symptoms conditions, problems, complaints, or other
reason(s) for a
encounter/visit. (same)
Signs and symptoms – signs and symptoms must be reported when a related definitive diagnosis has not
be established by the provider. (same)
Conditions that are integral part of a disease process – signs and symptoms that are routinely associated
with a disease process should not be coded, unless otherwise instructed by the classification. (same)
Laterality – for bilateral sites the sites the final character of the code in ICD-10-CM indicates laterality. If
no bilateral code is provided, and the condition is bilateral then assign separate codes for both the left
and the right side (new).
Combination code - is a single code used to classify:
- Two diagnoses, or a diagnosis with an associated secondary process (manifestation
- A diagnosis with an associated complication (new)
DIAGNOSTIC CODING AND REPORTING GUIDELINES FOR
OUTPATIENT SERVICES
Selection of first listed diagnosis – Coding conventions of ICD-10-CM as well as general
disease
specific guidelines take precedence over the outpatient guidelines.
Codes from A00 – T88.9, Z00-Z99 - must be used to identify diagnosis, symptoms conditions,
problems, complaints, or other reason(s) for a encounter/visit.
Accurate reporting of ICD-10-CM diagnosis codes – Documentation should describe the
patient’s condition using terminology which includes specific diagnoses as well as
symptoms,
problems, or reason for the encounter.
Factors influencing health status – Z00- Z99 are provided to deal with occasions when
circumstances other than a disease or injury are recorded as diagnosis or problems.
Level of detail in Coding – ICD-10-CM codes are 3,4,5,6 or 7 characters. Codes with three
characters are head of a category codes. Subdivided by the use of fourth, fifth, sixth, or
seventh
characters to provide greater specificity. A code is not valid if it has not been coded to the
full number of
characters required for that code, including the 7th character extension, if applicable.
ICD-9-CM VS ICD-10-CM
ICD-9-CM
305.0 Nondependent alcohol
abuse
305.00 Nondependent alcohol
abuse, unspecified drunkenness
305.1 Nondependent alcohol
abuse, continuous drunkenness
305.2 Nondependent alcohol
abuse, episodic drunkenness
305.03 Nondependent alcohol
abuse, in remission
ICD-10-CM
F 10.12 Alcohol abuse with
intoxication
F10.120 Alcohol abuse with
intoxication, uncomplicated
F10.121 Alcohol abuse with
intoxication delirium
F10.129 Alcohol abuse with
intoxication, unspecified
ICD-10-CM
Y90.Evidence of alcohol
involvement determined by
blood alcohol. Code first
any associated alcohol
related disorders.
• Y 90.0
Blood alcohol level less than
20mg/100ml
• Y90.1
Blood alcohol level of 20-39
mg/100ml
• Y90.2
Blood alcohol level of 40-59 mg/100
ml
• Y90.3
Blood alcohol level of 60-79
mg/100ml
• Y90.4
Blood alcohol level of 80-99 mg/100
ml
• Y 90.5
Blood alcohol level of 100- 119
mg/100ml
• Y90.6
Blood alcohol level of 120-199
mg/100ml
• Y90.7
Blood alcohol of 200-239 mg/100ml
• Y90.8
Blood alcohol level of 240 mg/100ml
• Y90.9
Presence of alcohol in blood, level
not
specified
DOCUMENTATION
CHALLENGE
Reason for visit : Follow-up- Nephrology
Progress Note: __________is a 87 y.o. male who presents for follow-up of chronic kidney disease stage 3. It appears that
he developed sudden onset of shortness of breath after seeing me and was hospitalized for a few days with CHF
exacerbation and pneumonia. Since then he has been doing better.
ROS (Review of Systems)
• Review of Systems
• Constitutional: Positive for malaise/fatigue. Negative for fever, chills and weight loss.
• Mostly on a wheel chair
• Eyes: Negative for blurred vision.
• Cardiovascular: Positive for leg swelling. Negative for chest pain and palpitations.
• Continues to have dyspnea on exertion
• Gastrointestinal: Negative for nausea, vomiting and diarrhea.
• Genitourinary: Negative for dysuria and hematuria.
• Skin: Negative for rash.
• Neurological: Negative for weakness and headaches.
• Psychiatric/Behavioral: The patient does not have insomnia.
• All other systems reviewed and are negative
Physical Exam
• Nursing note and vitals reviewed.
• Constitutional: He is oriented to person, place, and time and well-developed, well-nourished, and in no distress.
No distress.
On a wheel chair and in no distress. Normal speech, on oxygen
• HENT:
• Mouth/Throat: Oropharynx is clear and moist.
• Eyes: Conjunctivae and EOM are normal.
• Neck:
DOCUMENTATION
CHALLENGE
Not able to assess JVD as he was sitting up in his wheel chair during the exam
Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop
and no friction rub.
• No murmur heard.
• Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes.
Few crackles left lung base
• Abdominal: Soft. Bowel sounds are normal. He exhibits no mass. No tenderness. He has no rebound and
no guarding.
Musculoskeletal: Normal range of motion. He exhibits edema. He exhibits no tenderness.
1+ bilateral lower extremity edema
Lymphadenopathy:
He has no cervical adenopathy.
Neurological: He is alert and oriented to person, place, and time. Gait normal.
• Skin: No rash noted. No erythema
Assessment & Plan
•
•
•
•
•
•
•
•
•
•
Chronic Kidney Disease stage 3 with episodes of AKI secondary to ischemic nephropathy and possibly
hypertension . According to him his renal function was checked a month ago at his PCP's office and he
was told it was better. I will check renal function again.
No proteinuria or even microalbuminuria .
Secondary hyperparathyroidism of renal origin. Patient is being treated with vitamin D. I will check PTH,
phosphorus and calcium today.
Anemia of chronic kidney disease. Hemoglobin has been was below the goal of 10 - 12 g/dL for CKD. I
will check a CBC today. He may benefit from treatment with ESA.
Blood pressure. Patients blood pressure ( 131/60 ) is within the desired goal of <130/80 for CKD.
Volume status. The patient appears to be hypervolemic but better than his last visit. His lungs sounded
better and edema is less. He is now on Bumetanide. I did not change the dose.
Discussed health maintenance, including regular aerobic exercise, low fat/low salt diet, and periodic
exams.
Return to Clinic in 6 months and as needed. Patient has issues with transportation and stated that it costs
him a lot of money to come and see me. I left the decision regarding future appointments.
DOCUMENTATION
CHALLENGE
Addendum: Hyperkalemia has resolved. No microalbuminuria, normal vitamin D
level. PTH remains unchanged and not too high for degree of renal function. He
remains anemic, but no indication for treatment with ESA. I suggest checking his
iron stores.
Visit Diagnoses and Associated Orders:
•
•
•
•
Chronic kidney disease, stage III (moderate) [585.3]
Secondary hyperparathyroidism (of renal origin) [588.81]
Hypertensive kidney disease with chronic kidney disease stage III [403.90BK]
Congestive heart failure, unspecified [428.0]
DOCUMENTATION
CHALLENGE
Documentation must validate the codes
assigned
Assessment & Plan
Visit Diagnoses
Chronic Kidney Disease , stage Chronic kidney disease, stage III
III
(N18.3)
Secondary
hyperparathyroidism
Anemia of chronic disease
Secondary hyperparathyroidism (
N25.81)
Hypertensive kidney disease with
chronic kidney disease stage III (
I12.9)
Congestive heart failure, (150.9)
DOCUMENTATION
CHALLENGE
Actions:
Issues:
• The CHF was mentioned in the HPI,
but was not documented and
addressed in the Assessment and
Plan.
• The CHF was not specified
• Anemia of chronic kidney disease
is not listed in the visit diagnoses
section in the EMR.
• Are the codes sequenced
appropriately?
• Coding guidelines state that
chronic conditions that are
addressed during the encounter
should be coded. Coding
Professional (CP) should contact
provider about clinical
significance of CHF.
• Anemia of chronic kidney disease
needs to be added to the list of visit
diagnoses.
• Codes should be sequenced in
accordance with coding
guidelines.
DOCUMENTATION
CHALLENGE
Documentation issues are resolved:
CP contacts the provider and CHF is added to the assessment and plan. The provider
documents that the patient has chronic systolic heart failure. Anemia of chronic kidney
disease is added to the visit diagnoses list
Visit diagnoses for this encounter have been revised:
1. I12.9 – Hypertensive chronic kidney disease, with stage 1-4 chronic kidney
disease, or unspec CKD
2. N18.3 – Chronic kidney disease, stage III (moderate)
3. I50.22 - Chronic systolic congestive heart failure
4. N25.1 - Hyperparathyroidism
5. D63.1 – Anemia in chronic kidney disease
FAILURE TO IMPLEMENT
Failure to successfully implement ICD-10-CM:
Potential to create distorted or misinterpreted information about
patient care
Impacts decisions to improve healthcare delivery
Creates coding and billing backlog
Increases in claims rejections/denials
Causes cash flow delays
Places payer contracts and/or market share arrangements at risk
due to poor quality rating or higher costs
OPPORTUNITIES
• IT coupled with the adoption of ICD-10-CM can effect the
quality, effectiveness, and delivery of health care
services
• The classification requires front-end documentation
improvement of medical information
• Significant shift in delivery and finance
• Development of EHR components
HOW TO PREPARE
Assess ICD-10-CM readiness
Evaluate documentation requirements
Improve documentation
HOW TO PREPARE
Centers for Disease Control and Prevention
http://www.cdc.gov/nchs/icd/icd10cm.htm#10up
date
Centers for Medicare and Medicaid
http://www.cms.gov/ICD10/12_2010_ICD_10_CM.a
sp
QUESTIONS???
THANK YOU!!!!!