ICD-10 Getting There….. Allergy

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. What Physicians Need To Know

ICD-9 vs ICD-10 Diagnosis Codes ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes 3 to 5 digits 7 digits Alpha “E” & “V” – 1st Character Alpha or numeric for any character No place holder characters Include place holder characters (“x”) Terminology Similar Index and Tabular Structure Coding Guidelines Somewhat similar Approximately 14,000 codes Approximately 69,000 codes Severity parameters limited Extensive severity parameters Does not include laterality Common definition of laterality Combination codes limited Combination codes common ICD-9 vs ICD-10 Diagnosis Codes

Number of Codes by Clinical Area ICD-9 Codes ICD-10 Codes Fractures 747 17,099 Poisoning and Toxic Effects 244 4,662 Pregnancy Related Conditions 1,104 2,155 Brain Injury 292 574 Diabetes 69 239 Migraine 40 44 Bleeding Disorders 26 29 Mood Related Disorders 78 71 Hypertensive Disease 33 14 End Stage Renal Disease 11 5 Chronic Respiratory Failure 7 4 Right vs. left accounts for nearly ½ the increase in the # of codes. Number of Codes by Clinical Area

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! The Importance of Good Documentation

Severity, cause, specific ingested substance, and encounter type. Inadequate Documentation Required ICD-10 Documentation Here for rash eval. On day 4 of antibiotic course for strep throat. Woke up with maculopapular rash. Reports taking antibiotics this morning. Rash secondary to drug allergy. Here for rash eval. On day 4 of Amoxicillin course for strep throat. Woke up with generalized maculopapular rash. Reports taking antibiotics as prescribed. Rash secondary to PCN allergy. Needed improvements: Severity, cause, specific ingested substance, and encounter type. Inadequate vs. Adequate Documentation Example 1: Dermatitis Related to Ingested Substances

Inadequate vs. Adequate Documentation Example 2: Asthma Inadequate Documentation Required ICD-10 Documentation Seven-year-old female with asthma presents to ER in resp distress. Tachycardic and tachypneic, audible in and out wheeze, O2 sat 63% on room air. Mother reports home inhaler and nebulizers used but didn’t help. Seven-year-old female with moderate, persistent asthma presents to ER in resp distress d/t status asthmaticus. Tachycardic and tachypneic, audible in and out wheeze, O2 sat 63% on room air. Mother reports home inhaler and nebulizers used but didn’t help. Dad smokes near child. Needed improvements: Type, severity, exacerbation(s), complication(s), and precipitating factor(s). Inadequate vs. Adequate Documentation Example 2: Asthma

Type and associated condition(s). Inadequate Documentation Required ICD-10 Documentation 11-year-old child resents with sneezing, congestion, itchy, watery eyes, and a rash. Mother states symptoms started approximately one week prior. Dx: Allergies Dx: Allergies due to pollen and animal dander with allergic eczema. Needed improvements: Type and associated condition(s). Inadequate vs. Adequate Documentation Example 3: Allergies

Type of Immunodeficiency. Inadequate Documentation Required ICD-10 Documentation Three-year-old presents for follow-up visit after testing has confirmed abnormal IgM. Three-year-old presents for follow-up visit after testing has confirmed X-linked immunodeficiency with hyper IgM. Needed improvements: Type of Immunodeficiency. Inadequate vs. Adequate Documentation Example 4: Immunodeficiencies

Key Requirements for Documentation Document the causal agent of the allergy (e.g., pollen, animal dander, medication). Disease specificity and granularity (e.g., contact dermatitis due to a detergent) For food-induced allergies, include: - The type of current allergic reaction and any allergy history. - Any dietary counseling or surveillance provided Detail asthma as intermittent or persistent and list the severity of persistent asthma as mild, moderate, or severe. Describe any exposure to tobacco smoke (e.g., environmental, prenatal, tobacco use). List any associated conditions (e.g., asthma, dermatitis) 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. Using Sign/Symptom and Unspecified Codes

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

Future Orders & Diagnosis Assistant Demonstration Future Orders & Diagnosis Assistant