ICD-10 Getting There….. Pulmonary Medicine

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: Pneumothorax Inadequate Documentation Required ICD-10 Documentation Patient received via ambulance, multi stab wounds torso & hands. Stabbed repeatedly by husband at school. Hemopneumothorax & subcutaneous emphysema. Chest tube placement. Stabilized to OR. Patient received via ambulance, multi stab wounds bilateral anterior & posterior torso & both hands. Stabbed repeatedly with hunting knife by husband at school where she worked. Bilateral hemopneumothorax & subcutaneous emphysema. Bilateral chest tube placement. Stabilized, to OR. Needed improvements: Location, laterality, injury and encounter specifics. Inadequate vs. Adequate Documentation Example 1: Pneumothorax

Inadequate vs. Adequate Documentation Example 2: Pulmonary Embolism Inadequate Documentation Required ICD-10 Documentation 38-year-old female presented with fever, dyspnea, toothache & chest pain. Oral exam reveals significant periodontal disease. Elevated C-reactive protein & WBC. CT demonstrates large PE. Dx: Pulmonary Embolism Dx: Acute septic pulmonary embolism secondary to cytomegalovirus. No cor pulmonale. Needed improvements: Acuity, type, presence or absence of cor pulmonale, and underlying infection. Inadequate vs. Adequate Documentation Example 2: Pulmonary Embolism

Inadequate vs. Adequate Documentation Example 3: Respiratory Failure Inadequate Documentation Required ICD-10 Documentation 78-year-old male admitted with respiratory failure. ABGs showed respiratory acidosis. Long-standing history of COPD & asthma with exacerbation. Hx tobacco abuse. O2 use. Found to be in atrial flutter. 78-year-old male admitted with acute on chronic respiratory failure. ABGs showed hypoxia & hypercapnia. Long-standing history of COPD & moderate persistent asthma with exacerbation of both. Nicotine dependent, smokes 3 PPD despite O2 use. Found to be in atypical atrial flutter. Needed improvements: Acuity, presence of hypoxia or hypercapnia, underlying condition(s), type, complication(s) and tobacco status. Inadequate vs. Adequate Documentation Example 3: Respiratory Failure

Causal organism, severity, complication(s), linkage, and onset. Inadequate Documentation Required 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. Needed improvements: Causal organism, severity, complication(s), linkage, and onset. Inadequate vs. Adequate Documentation Example 4: Sepsis

Stage, transplant status, and related or contributing disease. Inadequate Documentation Required ICD-10 Documentation 42-year-old with chronic kidney disease, HTN, & diabetes. Hbg & Hct decreased, transfuse 2 units PRBCs. 42-year-old on transplant list with ESRD on dialysis, HTN, IDDM type 2 with nephropathy & neuropathy. Chronic kidney disease related iron deficiency anemia, transfuse 2 units PRBCs. I12.9 Hypertensive Chronic Kidney Disease, NOS E11.9 Type 2 Diabetes Mellitus Without Complications N18.9 Chronic Kidney Disease, Unspecified (Stage) Needed improvements: Stage, transplant status, and related or contributing disease. E11.21 Type 2 diabetes mellitus with diabetic nephropathy I112.0 Hypertensive End Stage Renal Disease N18.6 Chronic Kidney Disease requiring chronic dialysis Z99.2 Dependence on Renal Dialysis E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified D63.1 Anemia in chronic kidney disease Z76.82 Awaiting Organ Transplant Status Inadequate vs. Adequate Documentation Example 5: Chronic Kidney Disease

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 – Feb 2015 Dept. Meetings ICD-10 Introduction/Overview Feb 2015 – Mar 2015 On-line/Classroom Future Order Entry Diagnosis Assistant Feb 2015 – Jul 2015 Web-based ICD-10-CM Overview & Service Specific Documentation Mar 2015 – Jun 2015 Classroom Physician Playbooks/ Documenting for ICD10 using the Electronic Health Record Jul 2015 – Sep 2015 Documenting Operative and Procedure Notes for ICD-10-PCS Training for Physicians

Future Orders & Diagnosis Assistant Demonstration Future Orders & Diagnosis Assistant