ICD-10 – What Radiologists Need to Know Stephanie Hatton, RCC California Medical Business Services Arcadia, California

Objectives Introduction to ICD-10 Overview of documentation needs specific to radiology Ideas for how you can prepare yourself and your staff for the transition

International Classification of Diseases Translates words into numeric/alpha-numeric codes ICD-9 Introduced in 1978 – Many unspecified code and limited detail ICD-10 Introduced in 1994 – Expanded detail of patient’s conditions – More accurately describes today’s practice of medicine – Designed to handle advances in healthcare for years to come – United States is the only developed country that has not yet adopted ICD-10

Countries using ICD-10 United Kingdom (1995) France (1997) Australia (1998) Canada (2000) South Africa (2005) Korea (2008) Dubai (2012) United States (2015)

Structural Difference ICD Characters First character is numeric or alpha (E or V) Characters 2-5 are numeric Always at least 3 characters Decimal after 3 rd character ICD characters – 3 before decimal/up to 4 after decimal First character is alpha (all letters except U are used) Second character is numeric Characters 3-7 are alpha or numeric

Expanded Detail and specificity Laterality has been added to all relevant codes Stage of healing/type of encounter – Initial – Subsequent – Sequela Codes reflect modern medicine and updated medical terminology

Examples of Specificity in ICD – Osteoarthritis whether generalized or localized involving lower leg M16.0 – Bilateral primary osteoarthritis of hip M16.11 – Unilateral primary osteoarthritis of right hip M Unilateral primary osteoarthritis of left hip M16.6 – Other bilateral secondary osteoarthritis of hip M16.7 – Other unilateral secondary osteoarthritis of hip M Osteoarthritis of hip, unspecified M Bilateral primary osteoarthritis of knee M17.11 – Unilateral primary osteoarthritis of right knee M17.12 – Unilateral primary osteoarthritis of left knee M Other bilateral secondary osteoarthritis of knee M17.9 – Osteoarthritis of knee, unspecified

Fractures TypeLateralityEpisode TorusRightInitial Colles’LeftSubsequent Smith’sUnspecified- Routine healing Barton’s- Delayed healing -Nonunion - Malunion Ex. Fracture of the radius

Neoplasms Some 1-1 translations – 185 Malignant neoplasm prostate is now C61 Some add only laterality – Carcinoma in situ of breast D05.10 – Intraductal carcinoma in situ of unspecified breast D05.11 – Intraductal carcinoma in situ of right breast D05.12 – Intraductal carcinoma in situ of left breast Some require much more specificity

Neoplasms Documentation must state if: – Benign – In-situ – Malignant – Uncertain behavior – Laterality – Location – Morphology

Injuries Most have 3 possible extensions (7 th character) – A – Initial Encounter – D – Subsequent Encounter – S – Sequela Must have specific type of trauma – Patient hit their head on ground – Patient hit by baseball bat in right shoulder

Key Details to Include in Documentation What is the suspected condition? – Rule out… What signs or symptoms is patient having? Specific site, laterality, quadrant, vessel Acute or chronic, traumatic or non traumatic, exacerbation History of other disease or underlying conditions

Some of it is Just Plain Funny W56.22xA – Struck by an orca, initial encounter W2202xD – Walked into a lamppost, subsequent encounter V91.07xA – Burn due to water-skis on fire, initial encounter R46.1 – Bizarre personal appearance

Level of Documentation tied to compensation? We don’t know yet Evolving payment models suggest payors aren’t just looking at what was done, but why it was done. If clinical documentation is vague how can we substantiate medical necessity.

What can you do Coder training Physician and staff training – Billing companies/MSO Have coders actively code “live” reports. Partner with your hospital to provide referring physician education. Reach out to your big IPA’s to see if you can have a few minutes at their next provider meeting. Have your marketers provide “lunch and learn” sessions to referring physician’s office staff

Resources World Health Organization (WHO) Centers for Medicare and Medicaid Services (CMS) html The American Academy of Professional Coders (AAPC) American Health Information Management Association (AHIMA) American Medical Association (AMA) assn.org/store/catalog/subCategoryDetail.jsp?category_id=cat &navAction=push