Obstetrics and Gynecology UHS, Inc. ICD-10-CM/PCS Physician Education Obstetrics and Gynecology

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

Current ICD-9 Code Set is: Why ICD-10 Current ICD-9 Code Set is: Outdated: 30 years old Current code structure limits amount of new codes that can be created Has obsolete groupings of disease families Lacks specificity and detail to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

Diagnosis Code Structure

ICD-10-CM Diagnosis Code Format

Comparison: ICD-9 to ICD-10-CM

Procedure Code Structure

ICD-10-PCS Code Format

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?

ICD-10-CM/PCS Documentation Tips

ICD-10 Provider Impact Golden Rule of Documentation 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

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

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

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

ICD-10 Documentation Tips Site and Laterality – right versus left bilateral body parts or paired organs Example – right fallopian tube Stage of disease Acute, Chronic Intermittent, Recurrent, Transient Primary, Secondary Stage I, II, III, IV Example – chronic kidney disease, stage II

ICD-10 Documentation Tips Female Reproductive Inflammatory Disease Examples - Salpingitis, Oophoritis, PID Severity – acute, subacute, chronic Manifestation / cause / underlying condition Pelvic adhesions causing the disorder or exacerbating Current or past antineoplastic therapy or radiological procedures Non-inflammatory Disease Examples – Endometriosis, Prolapse, Dysplasia Post-surgical state Post-surgical complication Location Acuity – mild, moderate, severe Origin of infertility Tubal, uterine, other

ICD-10 Documentation Tips Female Reproductive continued Prolapse Classification Urethrocele Cystocele Rectocele Vaginal enterocele Location – lateral or midline Severity Incomplete / First degree Incomplete / Second degree Complete / Third degree

ICD-10 Documentation Tips Neoplasm Location Detailed location Left, Right, Bilateral Morphology Malignant, Benign Primary , Secondary In situ Uncertain behavior, Unspecified behavior Histology Identified by cytology, histology or pathology findings Stage / Metastatic Different, distinct locations Different primaries Metastatic sites

ICD-10 Documentation Tips Neoplasm continued Is patient being admitted for treatment of the neoplasm or an adverse reaction / complication? Treatment - surgery, chemotherapy, immunotherapy, radiation Adverse reaction of treatment – neutropenic fever secondary to chemo Complication of the disease – anemia due to malignancy Document if a complication is part of the disease process or an adverse effect of treatment Anemia due to malignancy or due to chemotherapy History of Malignancies previously removed and no longer receiving active treatment Clearly document for follow-up and medical surveillance

ICD-10 Documentation Tips Pregnancy ICD-10-CM definitions of trimesters: First trimester = less than 14 weeks, 0 days Second trimester = 14 weeks, 0 days to less than 28 weeks, 0 days Third trimester = 28 weeks until delivery Documentation of conditions/complications of pregnancy will need to specify the trimester in which the condition occurred. If the condition develops prior to admission, assign the trimester at the time of admission.

ICD-10 Documentation Tips Pregnancy continued Past infertility / poor reproductive history Abortive outcomes Ectopic Hydatidiform mole Abnormal products of conception (e.g. - blighted ovum) Spontaneous abortion Induced termination of pregnancy Specify abortive agent or method used Failed attempted termination of pregnancy Incomplete abortion Pre-term labor Pregnancy induced conditions Pregnancy induced hypertension document acuity of pre-eclampsia (mild, moderate or severe) Gestational diabetes needs specification of diet controlled or insulin controlled

ICD-10 Documentation Tips Diabetes - include the type or cause of diabetes Type I Type II Due to drugs and chemicals Due to underlying condition Other specified diabetes Link any manifestations to the diabetes Circulatory, renal, neurological, ophthalmic, skin, other Use of Insulin – long term, current Example: E08 - Diabetes mellitus due to underlying condition E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma

ICD-10 Documentation Tips Pregnancy continued High risk pregnancy History of infertility Ectopic or molar pregnancy Substance abuse Insufficient care Specify any pre-existing condition, infection or disorder HIV Smoking Anemia Hypertension

ICD-10 Documentation Tips Labor and Delivery Labor is categorized by weeks of gestation Pre-term = before 37 weeks gestation Post-term = over 40 weeks but less than 42 weeks gestation Prolonged = over 42 weeks gestation Document specifics of delivery Outcome of delivery List method of delivery Specify instrumentation used Severity of any perineal laceration and level of repair Method of labor induction if applicable Malposition, malpresentation Include if obstructed or non-obstructed If obstructed, what is the condition causing the obstruction of labor Large fetus, locked twins, etc.

ICD-10 Documentation Tips Labor and Delivery continued Reason for C-section, if performed List past history of C-section, when applicable Complications of anesthesia Aspiration pneumonitis Pressure collapse of lung Cardiac complication CNS complication Toxic reaction to local anesthesia Spinal / epidural headache Failed or difficult intubation

ICD-10 Documentation Tips Fetal Anomalies Multiples Number of fetuses (numeric designation of 1 -9) include number of placenta and number of amniotic sacs Identify fetus with complication with assigned number Fetal conditions Central nervous system malformation Chromosomal abnormality Hereditary disease Damage to fetus due to viral disease, alcohol, drugs, radiation, medical procedure Isoimmunization – Rh, ABO, other

ICD-10 Documentation Tips Puerperium Retained placenta With or without membranes Infection Cesarean wound infection UTI Endometritis Other conditions requiring treatment Disruption of obstetric wound Postpartum mood disturbance Post-delivery anemia Abscess of the breast Mastitis Retracted or cracked nipple

ICD-10 Documentation Tips Weight-related diagnoses and BMI BMI < 19 BMI > 40 For malnutrition, specify type (e.g. - protein-calorie malnutrition) and severity (indicate mild, moderate, severe) Document “starvation” in abuse cases Link other illnesses Overweight versus obesity, specify if severe or morbid Link to the cause Document if drug-induced and provide the specific drug Bariatric procedures performed Associated conditions (example – obesity hypoventilation syndrome)

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 Z91.120 – Patient’s intentional underdosing of medication due to financial hardship

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

ICD-10 Documentation Tips Intra-operative Post-procedural Accidental puncture / laceration Timing: Post-procedure Late effect Same or different body system Classify 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 Most Common Root Operations: Abortion – artificially terminating a pregnancy Excision – cutting out or off, without replacement a portion of a body part Resection – cutting out or off, without replacement, all of a body part Restriction – partially closing an orifice Delivery – assisting the passage of products of conception from the birth canal Extraction – pulling or stripping out or off all or a portion of a body part Reposition – moving to its normal location/other location all or portion of a body part Dilation – expanding an orifice Occlusion – completely closing an orifice Supplement – putting in biological or synthetic material that physically reinforces &/or augments the function Drainage – taking or letting out fluids &/or gases from a body part Repair – restoring, to the extent possible, a body part to its normal anatomic structure & function Transplantation – putting in all or a portion of a living body part taken from another individual or animal Reposition – moving to its normal location/other location all or portion of a body part

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