Internal Medicine and Family Practice UHS, Inc. ICD-10-CM/PCS Physician Education Internal Medicine and Family Practice

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Current ICD-9 Code Set is: Why ICD-10 Current ICD-9 Code Set is: Outdated: 30 years old Current code structure limits amount of new codes that can be created Has obsolete groupings of disease families Lacks specificity and detail to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 Signs & Symptoms – document underlying cause / conditions Admit with sign / symptom Discharge with a Diagnosis Fever Underlying condition (due to) Infection type (example: pneumonia) Chest pain GERD Atelectasis Costochondritis Pleurisy Cholecystitis AMI Altered Mental Status Underlying cause Encephalopathy UTI

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: L89.011 Pressure ulcer of right elbow, stage 1 L89.021 Pressure ulcer of left elbow, stage 1

ICD-10 Documentation Tips Asthma Specificity Intermittent [less than or equal to two times per week] Mild persistent [more than two times per week] Moderate persistent [daily-may restrict physical activity] Severe persistent [throughout the day-frequent severe attacks that limit the ability to breathe] Acuity With acute exacerbation With status asthmaticus Type / Form Childhood Exercise induced Extrinsic allergenic Late onset Tobacco Exposure Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to tobacco smoke

ICD-10 Documentation Tips COPD Acuity With acute exacerbation With acute lower respiratory infection Specificity With asthma With bronchitis With emphysema Tobacco Exposure Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to tobacco smoke

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 E11 - Type 2 diabetes mellitus E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular edema

ICD-10 Documentation Tips Encephalopathy Acuity – acute, subacute, chronic Severity – with or without coma Type Alcoholic Hepatic Hypertensive Metabolic Septic Toxic Due to disease classified elsewhere Due to influenza, syphilis, hydrocephalus, neoplastic disease, etc… Link altered mental status to encephalopathy with the specific type

ICD-10 Documentation Tips Heart Failure Specify acuity Acute Chronic Acute on chronic Identify type Systolic Diastolic Combined systolic and diastolic List relationship of hypertension to heart failure or heart disease Identify underlying cause Example - Exacerbation of stable heart failure due to fluid overload or due to missed dialysis

ICD-10 Documentation Tips Kidney Disease Specify acuity Acute, Chronic, Acute on chronic Identify stage Stage I – GFR > 90 Stage II – GFR 60 – 89 Stage III – GFR 30 – 59 Stage IV – GFR 15 – 29 Stage V – GFR < 15 List relationship of hypertension &/ or diabetes Document as due to or with Example – Type 2 DM with diabetic CKD stage 5 Transplant Status – has the patient had a transplant or is a transplant candidate

ICD-10 Documentation Tips Otitis Media Type Serous Sanguinous Suppurative Allergic Mucoid Infectious Agent Strep Staph Influenza Measles, Mumps Laterality – left, right, both Note whether tympanic membrane is ruptured

ICD-10 Documentation Tips Malnutrition Specify acuity – mild, moderate, severe Specify type Protein calorie Protein energy Marasmus Nutritional deficiency At least 2 of the following are required to help identify malnutrition: Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized / generalized fluid accumulation Diminished functional status as measure by hand grip strength

ICD-10 Documentation Tips Weight-related diagnoses and BMI BMI < 19 BMI > 40 For protein-calorie malnutrition, indicate mild, moderate, severe Document “starvation” in abuse cases Link other illnesses Obesity, specify 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 Pneumonia Organism, document as known or suspected Viral – adenoviral, respiratory syncytial, parainfluenza, human metapneumovirus, viral unspecified Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas, staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified Link associated conditions Influenza with secondary gram negative pneumonia Sepsis due to pneumonia Acute respiratory failure due to pneumonia Aspiration Due to solids or liquids Due to anesthesia during L/D or procedure Due to anesthesia during puerperium Laterality of lung involvement – left, right, both Note whether ventilator associated (VAP)

ICD-10 Documentation Tips Pressure Ulcers Site – specific ulcer location Ankle, back, buttock, coccyx, elbow, face, head, heel, hip, sacral region, other site Laterality – left, right, both Stage 1 – pre-ulcer skin changes limited to persistent focal edema 2 – abrasion, blister, partial thickness skin loss involving epidermis &/or dermis 3 – full thickness skin loss involving damage or necrosis of subcutaneous tissue 4 – necrosis of soft tissue through to underlying muscle, tendon or bone Unspecified – not documented Unstageable – full thickness tissue loss, covered with slough or eschar Note whether the pressure ulcer was present on admission

ICD-10 Documentation Tips Respiratory Failure Acuity - acute, chronic, acute on chronic Specificity – with hypoxia or hypercapnia Tobacco Use Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to tobacco Does the patient require continuous home oxygen or is dependent on home oxygen Respiratory distress and respiratory insufficiency are NOT respiratory failure

ICD-10 Documentation Tips Respiratory Failure Criteria Acute Chronic Symptoms – difficulty breathing, shortness of breath, dyspnea, tachypnea, respiratory distress, labored breathing, use of accessory muscles, cyanosis, unable to speak Symptoms – severe COPD, chronic lung disease such as cystic or pulmonary fibrosis Ph < 7.35 & pCO2 > 50 or pO2 < 55 & FIO2 > 28 % pO2 < 55 or pCO2 > 50 Hypoxemia Hypercapnia pO2 < 60 mmHg OR pO2 / FIO2 ratio < 300 OR 10 mmHg decrease in baseline pO2 pCO2 > 50mmHg with pH < 7.35 OR 10 mmHg increase in baseline pCO2

ICD-10 Documentation Tips Sepsis Acuity – sepsis, severe sepsis, septic shock, SIRS Organism due to / suspected Streptococcus (A or B) Staphylococcus aureus MSSA MRSA Hemophilus influenzae Gram-negative organism E Coli Serratia Enterococcus Manifestations With acute organ dysfunction With multiple organ dysfunction SIRS due to infectious process with organ dysfunction Shock Note the term urosepsis is NOT synonymous with sepsis

ICD-10 Documentation Tips Sepsis Criteria Altered mental status Heart rate > 90 beats per minute Hypoxemia PaCO2 < 32mmHg Respiratory rate > 20 breaths per minute Temperature > 100.9 F or < 96.8 F WBC > 12,000 cells/mm3; < 4,000 cells/mm3; and/or > 10% immature band Blood cultures do not need to be positive to support the diagnosis of sepsis – the physician may clinically diagnose based on signs and symptoms

ICD-10 Documentation Tips Strokes – dominant vs. non-dominant side Specify the location or source of the hemorrhage and laterality Document other causes – thrombosis, embolism, occlusion, stenosis Sites – precerebral or cerebral arteries Laterality Document dominant verses non-dominant side for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesis and for residual effects Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.

ICD-10 Documentation Tips Drug and Alcohol Use Expanded code set to classify cause-and-effect indicators Documentation requirements include: Specific aspects of the effects Example – abuse and dependence Specify the aspects of use Example – withdrawal state Identify manifestations Example – hallucinations, delusions

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 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: Destruction – physical eradication of all of a portion of a body part by direct use of energy, force or destructive agent Drainage – taking or letting out fluids &/or gases from a body part Excision – cutting out or off, without replacement, a portion of a body part; diagnostic or therapeutic Repair – restoring to the extent possible, a body part to its anatomic structure and function

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