Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA Vice President of HIM Consulting Services United Audit Systems, Inc. Cincinnati, OH Focusing CDI for Success With ICD- 10

Points to Cover Brief overview of differences between ICD-9-CM and ICD-10-CM/PCS Examples of differences in required documentation to support code assignment Discussion of identified trends, common documentation gaps Exploration of impact on CDI programs and how should you prepare

3–5 characters First is numeric or alpha (E, V) 2–5 are numeric Always at least 3 characters Use of decimal after first 3 characters 3–7 characters First is always alpha 2–7 are alpha or numeric Always at least 3 characters Use of decimal after first 3 characters ICD-9-CM ICD-10-CM Diagnosis Code Structure

X. XXXX5E1201. V Category Etiology, anatomic site, manifestation 8 Numeric or alpha (E or V) Numeric 3–5 characters ICD-9-CM Format

XXXX Category. Etiology, anatomic site, severity Added code extensions (7th character) for obstetrics, injuries, and external causes of injury XXX AMS A Alpha (except U) 2–7 numeric or alpha 3–7 characters Additional characters ICD-10-CM Format

New With ICD-10-CM Combination codes for conditions and common symptoms or manifestations, poisonings and external causes Added laterality Expanded codes (injury, diabetes, alcohol/substance abuse, postoperative complications) Updated clinical terminology (e.g., diabetes mellitus, malignant/benign hypertension) Changes in time frames specified in certain codes

3–4 characters All characters are numeric All codes have at least 3 characters 7 characters All either alpha or numeric Uses 0–9, A–H, J–N, P–Z Alpha not case sensitive All codes must have 7 characters ICD-9-CM Vol. III ICD-10-PCS Procedure Code Structure

ICD-9-CM Vol. III ICD-10-PCS XXXXXXX3E04F8010HZ0730DBX58Z Procedure Code Structure

PCS Characters for Med-Surg Body system Section Rootoperation Body part Approach Device Qualifier

17 Sections in ICD-10-PCS Medical/Surgical Obstetrics Placement Administration Measurement/Monitoring Imaging Nuclear Medicine Radiation Oncology Osteopathic Rehabilitation and Diagnostic Audiology Extracorporeal Assistance and Performance Extracorporeal Therapies Laboratory Mental Health Chiropractic Miscellaneous Substance Abuse Treatment

Specificity for ICD-10-PCS: Med/Surg Section Section (1) – type of procedure Body system (2) – general body system Root operation (3) – objective of procedure Body part (4) – specific part of body system on which procedure is being performed Approach (5) – technique used to reach the site of the procedure Device (6) – specifies devices that remain after procedure is completed Qualifier (7) – additional information about the procedure

Specificity for ICD-10-PCS: Other Sections Substance (6) – substance given in administration section Function (6) – physiological function tested, assisted or performed Duration (5) – single, multiple occurrence, etc. Method (6) – method of osteopathic treatment Contrast (5) – defines contrast if used Radionuclide (5) – source of the radiation used Isotope (6) – administered in oncology treatment Equipment (6) – category of equipment used

Documentation for ICD-10- CM/PCS Unspecified diagnosis codes available, but undesirable Unspecified not available for most procedures More specific anatomical sites Terminology differences Diagnosis includes episode of care Diagnosis code specifies laterality Obstetrical codes specify trimester …

Fracture Left Radius ICD-9: Other fractures of distal end of radius (alone) Site of radius fracture Whether the ulna is involved Open or closed ICD-10: S52.502a Unspecified fracture of the lower end of left radius, initial encounter for closed fracture Site of radius fracture Open or closed Displaced or non- displaced Right or left Episode of care

ORIF Fracture L Radius ICD-9: Open reduction of fracture with internal fixation of radius/ulna Site of reduction Open vs. closed With or without internal fixation PCS: 0PSJ04Z – 0 Med/surg (procedure) – P Upper bones (body sys) – S Reposition (root op) – J Radius, left (body part) – 0 Open (approach) – 4 Internal fixation device – Z No qualifier Site of reduction Laterality Approach Specific type of internal fixation device

Derangement R Knee ICD-9: Derangement of posterior horn of medical meniscus Site of derangement of meniscus of knee— lateral or medial meniscus, anterior horn or posterior horn ICD-10: M Derangement of posterior horn of medial meniscus due to old tear or injury, right knee Type of derangement: cystic, degenerate, due to old tear or injury, other Site of derangement Right or left knee

R Total Knee Replacement ICD-9: Total knee replacement PCS: 0SRC0JZ – 0 Med/surg (procedure) – S Lower joints (body sys) – R Replacement (root op) – C Knee joint, right (body part) – 0 Open (approach) – J Synthetic substitute (device) – Z No qualifier Total knee replacement Right or left side Type of device: synthetic, autologous tissue, or non-autologous tissue

Respiratory Failure ICD-9: Acute and chronic respiratory failure Acute, chronic, or both acute and chronic ICD-10: J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia Acute, chronic, or both acute and chronic If associated with hypoxia or hypercapnia

Mechanical Ventilation, 20 hrs ICD-9: Continuous invasive mechanical ventilation for less than 96 consecutive hours Duration as 96 consecutive hours PCS: 5A1935Z – 5 Extracorporeal assistance and performance – A Physiological systems – 1 Performance – 9 Respiratory – 3 Less than 24 consecutive hours – 5 Ventilation – Z No qualifier Duration 96 consecutive hrs

Cerebral Infarction Due to Embolism ICD-9: Cerebral embolism, with cerebral infarction Thrombosis or embolism With or without infarction ICD-10: I63.9 Cerebral infarction, unspecified Same, plus specific site: Cerebral or pre- cerebral artery Middle, anterior, posterior Right or left

Biopsy R Breast ICD-9: Closed (percutaneous/needle) biopsy of breast Organ or body part biopsied Biopsy approach PCS: 0HBT3ZX – 0 Med/surg (procedure) – H Skin/breast (body sys) – B Excision (root op) – T Breast, rt. (body part) – 3 Percutaneous (approach) – Z No device – X Diagnostic Organ or body part biopsied Right, left, or both breasts Biopsy approach Diagnostic or therapeutic

STEMI, Anterior Wall Initial Episode of Care ICD-9: Acute myocardial infarction of other anterior wall, initial episode of care Site of MI Episode of care How long ago the infarct occurred (acute if < 8 weeks) ICD-10: I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall STEMI or NSTEMI Site of MI How long ago the infarct occurred (acute if < 4 weeks)

Example of MS-DRG Impact ICD-9-CMICD-10-CM/PCS 486 Pneumonia Subendocardial infarction, subsequent episode of care J18.9 Pneumonia I21.4 Non-ST elevation (NSTEMI) myocardial infarction (MCC) MS-DRG 195 Simple pneumonia without CC/MCC RW MS-DRG 193 Simple pneumonia with MCC RW Case example: Pneumonia patient with NSTEMI MI two wks ago

Laparoscopic Appendectomy ICD-9: Laparoscopic appendectomy Laparoscopic Intentional, not incidental PCS: 0DTJ4ZZ – 0 Med/surg (procedure) – D Gastrointestinal (body sys) – T Resection (root op) – J Appendix (body part) – 4 Percutaneous endoscopic (approach) – Z No device – Z No qualifier Root op is resection if entire appendix removed, but excision if only a portion removed Approach

Examples of Documentation Gaps Missing information for primary Sx procedure – Amputation qualifier (complete, high, mid, low) Missing information for secondary procedures – Route of administration and substance transfused Clarification needed for sequencing principal Dx – Anemia in neoplastic disease Missing information for secondary diagnoses – Acuity of respiratory failure and with or without hypoxia/hypercapnia

Standard Query Language Sepsis Respiratory failure ICD-9-CMICD-10-CM/PCS Sepsis, SIRS, severe sepsis, septicemia, septic shock Same, plus if due to Foley catheter or vascular catheter ICD-9-CMICD-10-CM/PCS Acute, chronic, or acute on chronic Same, plus if associated with hypercapnia or hypoxia

Standard Query Language Diabetes Skin ulcer ICD-9-CMICD-10-CM/PCS Type: pressure, stasis, diabetic, neuropathic; site; stage Same, plus type non- pressure chronic; more specific sites; presence of gangrene ICD-9-CMICD-10-CM/PCS Type I or II; controlled or uncontrolled Type I or II; underlying etiology; eliminate controlled or uncontrolled

Pressure Ulcer With Gangrene ICD-9-CMICD-10-CM/PCS Pressure ulcer, buttock Pressure ulcer, stage III (MCC) Gangrene (CC) I96 Gangrene, NEC L Pressure ulcer of unspecified buttock, stage III (MCC) MS-DRG 592 Skin ulcers w/ MCC RW MS-DRG 299 Peripheral vascular disorders w/ MCC RW

Standard Query Language Pneumonia Heart failure ICD-9-CMICD-10-CM/PCS Causative organismSame ICD-9-CMICD-10-CM/PCS Systolic, diastolic, or combined; acute, chronic, or acute on chronic Same

Capturing ICD-10-CM/PCS Details Identify documentation gaps in your health records Identify best solution: – Charge description master – Forms design – Physician education—build awareness over time Prioritize and focus on low-hanging fruit

CDI Programs Important for smooth transition Early preparation is critical Assess documentation gaps: diagnoses AND surgical procedures Look for simple solutions (forms redesign, CDM) Tweak CDI program focus to include ICD-10- CM/PCS documentation Review/revise standard query language

References CMS ICD-10 website ICD-10-CM/PCS MS-DRGv28 definitions manual s/P0031.html AHIMA WEDI (Workgroup for Electronic Data Interchange) HIMSS (Health Information and Management Systems Society) ICD-10 PlayBook

T HANK YOU ! M ARY H. S TANFILL, MBI, RHIA, CCS, CCS-P, FAHIMA VP, HIM C ONSULTING S ERVICES U NITED A UDIT S YSTEMS, I NC. P H. 800/ UASISOLUTIONS. COM

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