1 UHS, Inc. ICD-10-CM/PCS Physician Education Neurology and Neurosurgery

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Why ICD-10 Current ICD-9 Code Set is: – Outdated: 30 years old – Current code structure limits amount of new codes that can be created – Has obsolete groupings of disease families – Lacks specificity and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 Signs & Symptoms – document underlying cause / conditions 15 Admit with sign / symptomDischarge with a Diagnosis Altered Mental StatusUnderlying cause Encephalopathy (hepatic, metabolic, hypertensive, septic, toxic) UTI Subdural / Subarachnoid hemorrhage With or without loss of consciousness Specify duration (minutes or hours) Resulting in death due to brain injury

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 – Primary, Secondary – Stage I, II, III, IV Example – stage of pressure ulcer: – L Pressure ulcer of right elbow, stage 1 – L Pressure ulcer of left elbow, stage 1 16

ICD-10 Documentation Tips Alzheimer’s Disease – Onset classification Early onset Late onset – Link manifestations / related conditions Delirium Dementia Senile dementia Behavioral disturbances Senile degeneration 17

ICD-10 Documentation Tips Cerebrovascular Disease – non-traumatic – Type Hemorrhage – Subarachnoid – Intracerebral – Intracranial Occlusion / Stenosis without cerebral infarction Cerebral infarction Sequela of cerebrovascular disease – Laterality – right, left, bilateral – Tobacco Exposure Exposure to environmental tobacco smoke History of tobacco use Tobacco use or dependence Occupational exposure to tobacco smoke – Alcohol abuse or dependence 18

ICD-10 Documentation Tips Cerebrovascular Disease – non-traumatic continued – Location for brain hemorrhage – be as specific as possible Subarachnoid – Middle cerebral artery – Basilar artery – Vertebral artery Intracerebral – Brain stem – Cerebellum – Intraventricular Intracranial – Subdural – Acute, subacute, chronic 19

ICD-10 Documentation Tips Cerebral Artery Infarction / Stroke Specify the location or source of the hemorrhage and laterality – Document cause – thrombosis, embolism, stenosis – Sites – be as specific as possible Precerebral – right and left vertebral, basilar, right and left carotid Cerebral – right and left middle, right and left anterior, right and left posterior, right and left cerebellar – Laterality – right, left, bilateral 20

ICD-10 Documentation Tips Cerebral Artery Infarction / Stroke – Document dominant verses non-dominant side for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesis and for residual effects Example: previous cerebral infarction 6 months ago with residual left-sided hemiparesis on his nondominant side. – Did the patient receive tPA at a different facility within the 24 hours prior to admission? 21

ICD-10 Documentation Tips Epilepsy – Epilepsy Type Idiopathic or symptomatic Simple or complex partial seizures Generalized – If intractable, include clarification Poorly controlled Pharmacoresistant Treatment resistant Refractory – Document with or without status epilepticus – Seizure - classify as Febrile, convulsions, new onset, single or hysterical 22

ICD-10 Documentation Tips Parkinson’s Disease – Type – primary versus secondary If secondary, specify underlying cause – Malignant neuroleptic – Neuroleptic-induced – Postencephalitic – Vascular – Syphilis – Drug-induced, specify drug – Link manifestations Dementia Behavioral disturbance 23

ICD-10 Documentation Tips Polyneuropathy – Type Hereditary Idiopathic Inflammatory Sequelae – Document underlying cause Diabetes Amyloidosis Radiation-induced Drug-induced, specify the drug Alcohol-induced 24

ICD-10 Documentation Tips Glasgow Coma – ICD-10-CM coding will need the score from each of the assessment areas – Eye opening – Verbal response – Motor response » R Coma scale, eyes open never » R Coma scale, eyes open to pain » R Coma scale, eyes open to sound » R Coma scale, eyes open spontaneously – Report the Glasgow coma scale total score » R Glasgow coma scale score 13 – 15 » R Glasgow coma scale score » R Glasgow coma scale score 3 – 8 25

ICD-10 Documentation Tips Glasgow Coma Scale 26 Criteria Eyes openNeverTo painTo soundSpontaneousn/a Verbal response NoneIncomprehen -sible words Inappropriate words Confused conversation Oriented, converses normally n/a Motor response NoneExtension to painful stimuli Abnormal flexion to painful stimuli Flexion withdrawal from painful stimuli Localizes painful stimuli Obeys commands

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 27

ICD-10 Documentation Tips Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post- procedural disorders The provider must clearly document the relationship between the condition and the procedure – Example: D78.01 –Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen D78.21 –Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen 28

ICD-10 Documentation Tips 29 Intra-operativePost-procedural Accidental puncture / lacerationTiming: Post-procedure Late effect Same or different body systemClassify as: An expected post-procedural condition An unexpected post-procedural condition, related to the patient’s underlying medical comorbidities An unexpected post-procedural condition, unrelated to the procedure An unexpected post-procedural condition related to surgical care (a complication of care) Blood product Central venous catheter Drug: What adverse effect Drug name Correctly prescribed Properly administered Encounter: Initial Subsequent Sequelae

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 Example – spinal fusion Root Operation – Fusion Body Part – Thoracic vertebral joints Approach – Open (anterior/posterior) and Column (anterior/posterior) Device – Autologous tissue substitute

ICD-10 Documentation Tips Most Common Root Operations: 32 Bypass – altering the route of passage Excision – cutting out or off without replacement a portion of a body part Reposition – moving to its normal location Transfer – moving, without taking out, all or a portion of a body part to another location Dilation – expanding an orifice or the lumen of a tubular body part Insertion – putting in a non-biological appliance Resection – cutting out or off without replacement all of a body part Division – cutting into a body part to transect the body part Release – freeing a body part from an abnormal physical constraint Restriction – partially closing an orifice or lumen of a tubular body part Drainage – taking or letting out fluids &/or gases Repair – restoring, to the extent possible, a body part Supplement – putting in a biological/ synthetic material to reinforce / augment

ICD-10 Documentation Tips Most Common Device Types: 33 Drainage deviceInfusion deviceNeurostimulator device Neurostimulator lead Autologous tissue substitute Synthetic substitute Nonautologous tissue substitute

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 34