ICD-10 Getting There….. Plastic Surgery

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

Inadequate vs. Adequate Documentation Example 1: Cleft Lip and Palate Inadequate Documentation Required ICD-10 Documentation Cleft palate repair in a 22-year-old male. Cleft soft palate repair in a 22-year-old male with an accompanying nasal deformity and unilateral cleft lip. Needed improvements: Specific anatomical site, laterality, and associated nasal malformation. Inadequate vs. Adequate Documentation Example 1: Cleft Lip and Palate

Inadequate vs. Adequate Documentation Example 2: Facial Deformity Inadequate Documentation Required ICD-10 Documentation 50-year-old woman with a history of squamous cell carcinoma and previous Mohs procedure on her eyelid presents for surgical consult. She desires plastic correction of scarring from Mohs procedure. 50-year-old woman with a history of squamous cell carcinoma of left lower eyelid and previous Mohs procedure on left lower eyelid presents for surgical consult. She desires plastic correction of scarring from Mohs procedure. This is her initial visit to our practice. Needed improvements: Anatomical site, laterality and encounter type. Inadequate vs. Adequate Documentation Example 2: Facial Deformity

Inadequate vs. Adequate Documentation Example 3: Burns Inadequate Documentation Required ICD-10 Documentation 26-year-old female scheduled for revision of a scar on her arm resulting from a burn she sustained during an accident. 26-year-old female scheduled for revision of a contracture scar on her left forearm resulting from a third degree thermal burn she sustained after pulling a pan of hot oil off a stove. Total body surface area burned was 1.5%. Needed improvements: Type of burn, anatomical site, laterality, degree of burn, percentage of total body surface area burned, and circumstances surrounding the injury. Inadequate vs. Adequate Documentation Example 3: Burns

Anatomical site, type of deformity, and any functional abnormalities. Inadequate Documentation Required ICD-10 Documentation Maxillary deformity due to Down’s syndrome. Scheduled for reconstructive surgery. Maxillary hypoplasia due to Down’s syndrome. Patient has been diagnosed with severe obstructive sleep apnea. Scheduled for reconstructive surgery. Needed improvements: Anatomical site, type of deformity, and any functional abnormalities. Inadequate vs. Adequate Documentation Example 4: Dentofacial Anomalies

Key Requirements for Documentation Document the specific anatomical site (i.e., maxillary or mandibular, soft or hard palate). Detail laterality as right, left, bilateral, median or unilateral. Identify the patient’s encounter statues (i.e., initial, subsequent, sequela) Detail how the injury occurred (e.g., punch to the face during a bar fight) Document any underlying disease (e.g., rheumatoid arthritis, ). Include the type of open wound (e.g. puncture, laceration, bite) and the presence or absence of foreign bodies. Document any associated conditions, such as scars or joint contractures. 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