1 UHS, Inc. ICD-10-CM/PCS Physician Education Mental Health and Substance Abuse

ICD-10 Implementation October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) – Ambulatory and physician services provided on or after 10/1/15 – Inpatient discharges occurring on or after 10/1/15 ICD-10-CM (diagnoses) will be used by all providers in every health care setting ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures – ICD-10-PCS will not be used on physician claims, even those for inpatient visits 2

Why ICD-10 Current ICD-9 Code Set is: – Outdated: 30 years old – Current code structure limits amount of new codes that can be created – Has obsolete groupings of disease families – Lacks specificity and detail to support: Accurate anatomical positions Differentiation of risk & severity Key parameters to differentiate disease manifestations 3

Diagnosis Code Structure 4

ICD-10-CM Diagnosis Code Format 5

Comparison: ICD-9 to ICD-10-CM 6

Procedure Code Structure

ICD-10-PCS Code Format 8

ICD-10 Changes Everything! ICD-10 is a Business Function Change, not just another code set change. ICD-10 Implementation will impact everyone: – Registration, Nurses, Managers, Lab, Clinical Areas, Billing, Physicians, and Coding How is ICD-10 going to change what you do? 9

10 ICD-10-CM/PCS Documentation Tips

ICD-10 Provider Impact Clinical documentation is the foundation of successful ICD- 10 Implementation Golden Rule of Documentation – If it isn’t documented by the physician, it didn’t happen – If it didn’t happen, it can’t be billed The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient – what services were rendered and what is the severity of illness The key word is SPECIFICITY – Granularity – Laterality Complete and concise documentation allows for accurate coding and reimbursement 11

Gold Standard Documentation Practices 1.Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms 2.Document diagnoses, rather that descriptors 3.Indicate acuity/severity of all diagnoses 4.Link all diseases/diagnoses to their underlying cause 5.Indicate “suspected”, “possible”, or “likely” when treating a condition empirically 6.Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers 7.Clarify diagnoses that are present on admission 8.Clearly indicate what has been ruled out 9.Avoid the use of arrows and symbols 10.Clarify the significance of diagnostic tests 12

ICD-10 Provider Impact The 7 Key Documentation Elements: 1.Acuity – acute versus chronic 2.Site – be as specific as possible 3.Laterality – right, left, bilateral for paired organs and anatomic sites 4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance 5.Manifestations – any other associated conditions 6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence 7.Signs & Symptoms – clarify if related to a specific condition or disease process 13

ICD-10 Documentation Tips Do not use symbols to indicate a disease. For example “↑lipids” means that a laboratory result indicates the lipids are elevated – or “↑BP” means that a blood pressure reading is high These are not the same as hyperlipidemia or hypertension 14

ICD-10 Documentation Tips Site and Laterality – right versus left – bilateral body parts or paired organs Example – cellulitis of right upper arm Stage of disease – Acute, Chronic – Intermittent, Recurrent, Transient, Persistent – Primary, Secondary – Stage I, II, III, IV 15

ICD-10 Documentation Tips Status of disease – Mild – Moderate – Severe – Major – In remission, Not in remission – Single episode, Recurrent major Link manifestations with a mental or behavioral disorder – Speech impediment with autism Identify disease related to behavioral disorder – Alzheimer’s with aggressive behavior 16

ICD-10 Documentation Tips Mental disorders due to physiologic condition ₋Document associated conditions ₋Personality and behavior disorders due to physiological condition ₋Specify the physiological condition ₋List underlying physiological condition ₋Specify if dementia is with / in underlying condition ₋Clearly identify any associated alcohol or psychoactive substance use / disorders ₋Any behavior disturbances? 17

ICD-10 Documentation Tips Mood Disorders ₋Most recent episode ₋Depressed ₋Manic ₋Mixed ₋Acuity ₋Mild ₋Moderate ₋Severe ₋Status ₋Partial remission ₋Full remission ₋Episode of care ₋Single or recurrent 18

ICD-10 Documentation Tips Non-Psychotic Mental Disorders ₋Type ₋Anxiety ₋Dissociative ₋Stress-related ₋Somatoform ₋Acuity ₋Mild, Moderate, Severe ₋Status ₋With or without panic attacks ₋Conversion disorders ₋List symptoms – seizures, motor deficit 19

ICD-10 Documentation Tips Non-Psychotic Mental Disorders continued ₋Somatoform ₋Specify disorder – hypochondriacal disorders, pain disorders ₋Specify type of phobia ₋PTSD – acute or chronic ₋OCD specificity ₋Obsessive-compulsive personality depression ₋Obsessive compulsive disorder ₋Schizophrenia ₋Link and manifestations or related conditions ₋Depressed mood ₋Conduct disturbance ₋Mixed emotion disturbance 20

ICD-10 Documentation Tips Physical Factors ₋Type ₋Eating disorder ₋Sleep disorder ₋Sexual dysfunction ₋Postpartum depression ₋Specify type – be as specific as possible ₋Eating Disorder ₋Specify type and binge eating / purging ₋Document any associated mental or adjustment disorder 21

ICD-10 Documentation Tips Intellectual Disability ₋Specify the Type ₋Acuity ₋Mild ₋Moderate ₋Severe ₋Profound ₋Document associated physical or developmental disorders 22

ICD-10 Documentation Tips Schizophrenia ₋Type ₋Schizophrenia ₋Schizoaffective disorder ₋Schizophrenic reaction ₋Schizotypal disorder ₋Document associated conditions ₋Asperger’s ₋Epilepsy ₋Brain disease ₋Alcoholism ₋Identify any: ₋Acute schizophrenic-like psychotic disorders ₋Post –schizophrenic depression 23

ICD-10 Documentation Tips Childhood / Adolescent ₋Type of conduct disorder ₋Childhood-onset ₋Adolescent-onset ₋Confined to family context ₋Oppositional defiant disorder ₋Type of social functioning disorder ₋Selective mutism ₋Reactive attachment disorder ₋Disinherited attachment disorder ₋Type of ADHD ₋Inactive ₋Hyperactive ₋Combined 24

ICD-10 Documentation Tips Childhood / Adolescent continued ₋Manifestations / related conditions ₋ADHD ₋Mood disorders ₋Emotional disorders ₋Pervasive developmental disorders ₋Schizophrenia ₋Separation anxiety ₋Failure to thrive ₋Growth retardation ₋Asperger’s syndrome ₋Tic disorders with specific type 25

ICD-10 Documentation Tips Adult Personality Disorders ₋Type ₋Paranoid ₋Schizoid ₋Antisocial ₋Borderline ₋Histrionic ₋Obsessive-compulsive ₋Avoidant ₋Dependent ₋Narcissistic ₋Manifestations / related conditions ₋Other mental disorders ₋Alcohol or substance use ₋Impulse disorders 26

ICD-10 Documentation Tips Drug and Alcohol Use – Expanded code set to classify cause-and-effect indicators Specify drug used Document intoxication and blood alcohol levels – Documentation requirements include: Specific aspects of the effects – Example – use, abuse, or dependence Specify the aspects of use – Example – withdrawal state, in remission Identify manifestations / alcohol or drug-induced disorders – See next slide for examples 27

ICD-10 Documentation Tips Drug and Alcohol Use – Conditions associated with Withdrawal Syndromes Delirium Tremors Mood or psychotic disorder Perceptual disturbance Amnesic disorder or dementia Anxiety Sleep disorder – Conditions associated with Alcohol & Drug-induced psychotic disorder Delusions Hallucinations Anxiety Sexual dysfunction Sleep disorder 28

ICD-10 Documentation Tips Drug Under-dosing is a new code in ICD-10-CM. – It identifies situations in which a patient has taken less of a medication than prescribed by the physician. Intentional versus unintentional – Documentation requirements include: The medical condition The patient’s reason for not taking the medication – example – financial reason – Z – Patient’s intentional underdosing of medication due to financial hardship 29

ICD-10 Documentation Tips ICD-10-PCS does not allow for unspecified procedures, clearly document: Body System – general physiological system / anatomic region Root Operation – objective of the procedure Body Part – specific anatomical site Approach – technique used to reach the site of the procedure Device – Devices left at the operative site

ICD-10 Documentation Tips Most Common Root Operations: 31 Detoxification - from alcohol &/or drugs Electroconvulsive Therapy – application of controlled electrical voltages to treat a mental health disorder Light Therapy – application of specialized light treatments to improve unction or well-being Narcosynthesis – administration of IV barbiturates in order to release suppressed or repressed thoughts Psychological Tests – administration and interpretation of standardized tests and measurement instruments for the assessment of psychological function

Summary The 7 Key Documentation Elements: 1.Acuity – acute versus chronic 2.Site – be as specific as possible 3.Laterality – right, left, bilateral for paired organs and anatomic sites 4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance 5.Manifestations – any other associated conditions 6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence 7.Signs & Symptoms – clarify if related to a specific condition or disease process 32