Adelaide M. La Rosa, RN, BSN, CCDS Director of Clinical Documentation Improvement Program St. Francis Hospital-the Heart Center, Roslyn, NY On Your Marks,

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Presentation transcript:

Adelaide M. La Rosa, RN, BSN, CCDS Director of Clinical Documentation Improvement Program St. Francis Hospital-the Heart Center, Roslyn, NY On Your Marks, Get Set, Go: Prepare Physicians and Mid-Level Practitioners for ICD-10

ICD.9.CM 30 years old not allowing for new technology Outdated / obsolete terms and classification of several conditions Does not support today’s health Information needs Can not meet the need for accurate and complete health care data in US Lacks detail and laterality

ICD.10.CM US is the only industrialized country which has not implemented ICD.10.CM for morbidity reporting Detailed and has laterality New codes can be added Permits exchange of health data between US and other countries – Record both mortality and morbidity data by many countries

How To Get Started: Stratify your population of patients being treated within your hospital – Top 25 ICD.9.CM Principal Diagnosis Codes – Top 25 ICD.9.CM Secondary Procedure Codes – Top 25 ICD.9.CM Principal Procedure Codes

Diagnosis Codes ICD.9.CM 14,025 ICD.10.CM 68,069

How To Get Started: Identify principal and secondary diagnoses and principal procedures which will require more specific documentation ICD.10 = Higher Level of Specificity

Preparing for ICD.10: Documentation Education and Training IT Systems Billing / Financial Processes

Physician Engagement Engagement Starts with Awareness Annual Clinical Documentation Improvement Program Celebration Week. – 3rd Week of September which aligns with Fiscal Year (October 1st) Coding / DRG updates. – Theme: Bridging the Gap…, Staying in Shape with Clinical Documentation, CDIP Has You Covered with ICD-10

BRIDGING THE GAP … CLINICAL DOCUMENTATION IMPROVEMENT PROGRAM Bridging the Gap…

Staying in Shape with Clinical Documentation

CDIP Has You Covered with ICD-10 Oct 1 st, 2013 Sep 14 th, 2010

ICD – 10 Timeline Kickoff Meeting ICD-10 Transition Task Force Meeting Monthly Meetings Hospital Level 6 / 0912 / 09 1 / 102 / 10 ________________________________________ Transition to ICD-10 Implementation Workgroup ________________________________________ System Level Kickoff Meeting ICD-10 Steering Committee Meeting Current Monthly Meetings

ICD – 10 Timeline ___________________________________ 7-8 / 106 / 109 / / 10 ICD-10 Exam Prepared Physician Educational Session Identified High Volume Principal & Secondary diagnosis Prepared budget to include ICD-10 cost for education & training Educated CDS Staff regarding specific ICD-10 documentation opportunities 10 / 10 Physician Education Session Clinical Documentation Improvement Celebration Week ICD-9 Coding/DRG Changes Effective Updated ICD-10 Coding Rules & Regulations Physician Practice Manager Educational Session Schedule 2011 Physician Specialty Meetings Developed Physician Practice Manager Newsletter Administration Staff Presentation on ICD-10 Monthly: Medical Staff Newsletter (May 2008 CDIP given an official column) System ICD-10 Transition Task Force Meeting Hospital ICD-10 Steering Committee Meeting Clinical Documentation Improvement Steering Committee AHIMA ICD-10-CM/PC Expert Trainers in Diagnosis and Procedure Coding Director CDIP Assistant Director CDIP Physician Advisor CDIP

2011 Clinical Documentation Specialist: 1. Assessing and Determining / Educational Needs Refresh or Expand knowledge in: – Anatomy and Physiology – Pharmacology – Pathophysiology – Medical Terminology – Official Coding Guideline – Documentation Opportunities 2. Internally and Externally providing Education and Training utilizing a monthly 2 hour meeting 3. Physician Specialty Education Session 4. Mid Level Provider Education Sessions 5. Budgeting for continued cost for Education and Training

Cerebrovascular disease CVA Stroke Cerebral Infarction Cerebral artery Occlusion unspecified with cerebral infarction DocumentationICD.9.CM

CVA Severity Of Illness Intracerebral hemorrhage431 Cerebral thrombosis with cerebral infarction Cerebral embolism with cerebral infarction Aborted cerebrovascular acute (TPA given) Documentation ICD.9.CM

Comparison of ICD.9.CM to ICD.10.CM Nontraumatic Intracerebral Hemorrhage I61.0 In hemisphere, subcortical I61.1 In hemisphere, cortical I61.2 In hemisphere, unspecified I61.3 In brain stem I61.4 In cerebellum I61.5 In intraventricular I61.6 In multiple localized I61.8 In specified NEC I61.9 unspecified 431 Intracerebral 431 is the only code available to capture any location of bleeding in the brain ICD.9.CMICD.10.CM

Comparison of ICD.9.CM to ICD.10.CM Cerebral thrombosis with cerebral infarct Code represents thrombosis of cerebral arteries with infarction I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery I63.39 Of other cerebral artery I Of right middle cerebral artery I Of left middle cerebral artery I Of unspecified middle cerebral artery I Of right anterior cerebral artery I Of left anterior cerebral artery I Of unspecified anterior cerebral artery I Of left posterior cerebral artery I Of right posterior cerebral artery I Of unspecified posterior cerebral artery I Of right cerebellar artery I Of left cerebellar artery I Of unspecified cerebellar artery ICD.9.CM ICD.10.CM

Comparison of ICD.9.CM to ICD.10.CM Cerebral embolism with infarction Code represents embolism of cerebral arteries with infarction I63.40Cerebral infarction due to embolism of unspecified cerebral artery I63.49Of other cerebral artery I63.411Of right middle cerebral artery I63.412Of left middle cerebral artery I63.419Of unspecified middle cerebral artery I63.421Of right anterior cerebral artery I63.422Of left anterior cerebral artery I63.429Of unspecified anterior cerebral artery I Of left posterior cerebral artery I Of right posterior cerebral artery I Of unspecified posterior cerebral artery I Of right cerebellar artery I Of left cerebellar artery I Of unspecified cerebellar artery ICD.9.CMICD.10.CM

Comparison of ICD.9.CM to ICD.10.CM Cerebral artery occlusion with infarct I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I63.59Of other cerebral artery I63.511Of right middle cerebral artery I63.512Of left middle cerebral artery I63.519Of unspecified middle cerebral artery I63.521Of right anterior cerebral artery I63.522Of left anterior cerebral artery I63.529Of unspecified anterior cerebral artery I Of left posterior cerebral artery I Of right posterior cerebral artery I Of unspecified posterior cerebral artery I Of left cerebellar artery I Of right cerebellar artery I Of unspecified cerebellar artery ICD.10.CMICD.9.CM

ST Elevation (STEMI) Myocardial Infarction of Anterior Wall ICD.9.CM Anterolateral wall Anterior wall ICD.10.CM I21.01 Involving left main coronary artery I Involving left anterior descending coronary artery  Diagonal coronary artery I21.09 Involving other coronary artery of anterior of anterior wall

ST Elevation (STEMI) Myocardial Infarction of Inferior Wall ICD-9-CM Inferolateral wall Inferoposterior wall Inferior wall ICD-10-CM I21.11 Involving right coronary artery I21.19 Involving other coronary artery of inferior wall

ST Elevation (STEMI) Myocardial Infarction of other site ICD-9-CM Lateral wall Posterior wall ICD-10-CM I21.21 Involving left circumflex coronary artery Oblique marginal coronary artery I21.29 Involving other sites Lateral Posterior Septal

ST Elevation (STEMI) Myocardial Infarction of Unspecified site ICD-9-CM ICD-10-CM I21.3

Non-ST Elevation Myocardial Infarction ICD-9-CM ICD-10-CM I21.4

ASHD of Native Coronary Artery I25.10without angina pectoris I25.110with unstable angina pectoris I25.111with angina pectoris with documented spasm I25.118with other form of angina pectoris I25.119with unspecified angina pectoris ICD.9.CMICD.10.CM

ASHD of Coronary Artery Bypass Graft(s) (unspecified type of bypass graft) I25.700unspecified, with unstable angina pectoris I25.701unspecified, with angina pectoris with documented spasm I25.708unspecified, with other forms of angina pectoris I25.709unspecified, with unspecified angina pectoris ICD.9.CMICD.10.CM

ASHD of Autologous Artery Coronary Artery Bypass Graft(s) I25.720with unstable angina pectoris I25.721with angina pectoris with documented spasm I25.728with other forms of angina pectoris I25.729with unspecified angina pectoris ICD.10.CM ICD.9.CM

ASHD of Autologous Vein Coronary Artery Bypass Graft(s) I25.710with unstable angina pectoris I25.711with angina pectoris with documented spasm I25.718with other forms of angina pectoris I25.719with unspecified angina pectoris ICD.10.CM ICD.9.CM

Asthma Mild intermittent Mild persistent Moderate persistent Severe persistent

Diabetic Mellitus DM due to underlying condition – Drug or Chemical Induced DM – Type I DM – Type II DM – Other specified DM Documentation that Impacts Severity of Illness – Manifestations – Complications

Laterality (Right / Left) Cancers Cerebral Infarction Pressure Ulcers Extremity Atherosclerosis Arthritis Fractures Sprains Injury Joint Pain Joint Effusion Tears, Meniscus, Cruciate Ligament Dislocations

Bone, Joint and Muscle Site - upper, lower Laterality – left, right

Fractures Type (Gustilo open fracture classification) Specific anatomical site Displaced or not Laterality Type of encounter

Traumatic Fractures Initial Encounter Subsequent Encounter

Gout: Acute or Chronic Drug induced Idiopathic Due to renal impairment Lead induced Primary secondary ankle elbow foot joint hand joint hip knee multiple site shoulder specific joint NEC wrist Left right Code to highest level of specificity Due to Site Specific =

Infection Identify all infections Document as antibiotics resistant

Ulcers Cause Site Laterality Severity (Stage 1 – Stage 4)

2012 & 2013 Clinical Documentation Specialist: Assessing Effectiveness of Education and Training – Chart Audit Review – Queries Review – Continue Education and Training

Questions