ICD-10 Getting There….. Digestive Health

What Physicians Need To Know Claims for ambulatory and physician services provided on or after 10/1/2015 must use ICD-10-CM diagnosis codes. Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use ICD-10-CM diagnosis codes. CPT Codes will continue to be used for physician inpatient and outpatient services and for hospital outpatient procedures. ICD-10-PCS – a NEW procedure coding classification system, must be used to code all inpatient procedures on Facility Claims for discharges on or after 10/1/15. ICD-9-CM codes must continue to be used for all dates of services on or before 9/30/2015. Further delays are not likely.

ICD-9 vs ICD-10 Diagnosis Codes ICD-9-CM Diagnosis CodesICD-10-CM Diagnosis Codes 3 to 5 digits7 digits Alpha “E” & “V” – 1 st CharacterAlpha or numeric for any character No place holder charactersInclude place holder characters (“x”) TerminologySimilar Index and Tabular StructureSimilar Coding GuidelinesSomewhat similar Approximately 14,000 codesApproximately 69,000 codes Severity parameters limitedExtensive severity parameters Does not include lateralityCommon definition of laterality Combination codes limitedCombination codes common

Number of Codes by Clinical Area Clinical AreaICD-9 CodesICD-10 Codes Fractures74717,099 Poisoning and Toxic Effects2444,662 Pregnancy Related Conditions1,1042,155 Brain Injury Diabetes69239 Migraine4044 Bleeding Disorders2629 Mood Related Disorders7871 Hypertensive Disease3314 End Stage Renal Disease115 Chronic Respiratory Failure74 Right vs. left accounts for nearly ½ the increase in the # of codes.

The Importance of Good Documentation The role of the provider is to accurately and specifically document the nature of the patient’s condition and treatment. The role of the Clinical Documentation Specialist is to query the provider for clarification, ensuring the documentation accurately reflects the severity of illness and risk of mortality. The role of the coder is to ensure that coding is consistent with the documentation. Good documentation…. Supports proper payment and reduces denials Assures accurate measures of quality and efficiency Captures the level of risk and severity Supports clinical research Enhances communication with hospital and other providers It’s just good care!

Inadequate vs. Adequate Documentation Example 1: Esophagitis Inadequate DocumentationRequired ICD-10 Documentation Patient presents with c/o dysphagia. Hx stomach problems, ETOH +. EGD shows esophagitis. Treatment with include PPI. Patient with oropharyngeal dysphagia. GERD and ETOH abuse. ETOH level on admit 50 mg/dL. EGD shows acute esophagitis secondary to GERD. No ulcers or bleeding in esophagus. Treatment with include proton-pump inhibitor. Needed improvements: Cause, presence or absence of ulcer(s) and bleeding, contributing drug(s) or chemical(s), and alcohol use.

Inadequate vs. Adequate Documentation Example 2: Ulcers Inadequate DocumentationRequired ICD-10 Documentation Burning lower quad abd pain. Vomiting blood on and off x 3 months. Has used tobacco on a daily basis in the past. Ulcer per EGD. Burning left lower quad abd pain. Vomiting blood on and off x 3 months. Remission from chewing tobacco dependence. EGD with chronic gastric ulcer actively bleeding. No perforation, H. pylori positive. Needed improvements: Site, nature, presence or absence of hemorrhage and perforation, related and/or contributing disease(s) and drug(s).

Inadequate DocumentationRequired ICD-10 Documentation Hernia repair with mesh. Minimal blood loss. Tolerated procedure well. Open repair left recurrent, strangulated inguinal hernia with mesh. No gangrene. Tolerated procedure well. Inadequate vs. Adequate Documentation Example 3: Hernias Needed improvements: Location, laterality, presence or absence of obstruction, and/or gangrene.

Inadequate DocumentationRequired ICD-10 Documentation CT abdomen shows exacerbation regional enteritis. CT abdomen shows exacerbation large intestine Crohn’s disease with rectal bleeding. Inadequate vs. Adequate Documentation Example 4: Crohn’s Disease Needed improvements: location, complication(s), and manifestation(s).

Key Requirements for Documenting Diseases of the Digestive System The acuity of the disease (e.g., acute, chronic) Identify significance or related diagnosis to lab findings (e.g., guaiac positive stools) Documentation of the underlying cause or statement of “unknown cause” (e.g., alcoholic cirrhosis) Documentation of the site of any bleeding, visualized or suspected Identify any associated medication or drug use, if applicable (e.g., NSAIDs) Statement of alcohol abuse or dependance With ICD-10, the need for specific and accurate documentation is increased significantly.

Using Sign/Symptom and Unspecified Codes Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs and/or symptoms in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition, it is acceptable to report the appropriate “unspecified” code. It is inappropriate to select a SPECIFIC code that is not supported by the medical record documentation.

Training for Physicians DatesMethodContent Nov 2014 – Jan 2015Department Meetings Introduction/Overview Jan 2015 – Mar 2015Web-basedOverview Service Specific Documentation Future Order Entry Diagnosis Assistant Mar 2015 – Jun 2015ClassroomDocumenting for ICD10 using the Electronic Health Record Jun 2015 – Sep 2015Web-basedOverview Documenting Operative and Procedure Notes for ICD-10-PCS

Future Orders & Diagnosis Assistant Demonstration