ICD-10 Getting There….. Infectious Diseases

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: Herpes Inadequate DocumentationRequired ICD-10 Documentation DIAGNOSES: Shingles Conjunctivitis Blepharitis DIAGNOSES: Herpes zoster ophthalmicus right eye with conjunctivitis & blepharitis Needed improvements: Type, location, manifestation(s), and complication(s).

Inadequate vs. Adequate Documentation Example 2: AIDS/HIV Inadequate DocumentationRequired ICD-10 Documentation 38-year-old male with pneumonia and Kaposi’s sarcoma. 38-year-old male with P. carinii pneumonia & biopsy proven papular cutaneous Kaposi’s sarcoma both secondary to AIDS. HIV positive for 1 year. Needed improvements: HIV status, manifestation(s), and linkage to secondary condition(s).

Inadequate DocumentationRequired ICD-10 Documentation ASSESSMENT: 1.Influenza 2.Speech disturbance 3.Sinusitis 4.Otitis media with perforated tympanic membrane ASSESSMENT: 1.Influenza A 2.Laryngitis 3.Acute maxillary sinusitis 4.Left otitis media with left central perforated tympanic membrane Inadequate vs. Adequate Documentation Example 3: Influenza Needed improvements: Type, site, acuity, and manifestation(s) and laterality.

Inadequate DocumentationRequired ICD-10 Documentation Admit for left total knee replacement. Pneumonia. Now septic. Blood cultures positive. Adult respiratory distress syndrome requiring vent support with increased PEEP. B/P down to 73/45, Swan placed. Admit for left total knee replacement. Post op day #6. Staph aureus pneumonia. Now septic with shock. Blood cultures positive for Staph aureus. Adult respiratory distress syndrome secondary to sepsis requiring vent support with increased PEEP. B/P down to 73/45, Swan placed. Inadequate vs. Adequate Documentation Example 4: Sepsis Needed improvements: Causal organism, severity, complication(s), linkage, and onset.

Key Requirements for Documenting Infectious Diseases Indicate the status of the disease as newly diagnosed, acute, or chronic (e.g., HIV or AIDS). Describe the site of the infection or infestation (e.g. TB of lung). Document any secondary disease process related to the infection (e.g., whooping cough with pneumonia). Include the specific cause of the infection or infestation, if known (e.g., Shigellosis due to Shigella boydii). Document the infectious agents in other types of diseases (e.g., wound infection caused by Streptococcus). Clarify the significance of positive sputum and lab findings (e.g., Pseudomonas in sputum culture, Strep pneumoniae in blood culture). 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