1 UHS, Inc. ICD-10-CM/PCS Physician Education Hematology and Oncology

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Why ICD-10 Current ICD-9 Code Set is: – Outdated: 30 years old – Current code structure limits amount of new codes that can be created – Has obsolete groupings of disease families – Lacks specificity and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 FeverUnderlying condition (due to) Infection type (example: pneumonia) Neutropenic fever Neutropenic sepsis PainUnderlying condition (due to) Neoplasm Other cause Treatments – pain pumps, intrathecal treatments, etc. Altered Mental StatusUnderlying cause Encephalopathy UTI

ICD-10 Documentation Tips Site and Laterality – right versus left – bilateral body parts or paired organs Stage of disease – Acute, Chronic – Intermittent, Recurrent, Transient – Primary, Secondary – Stage I, II, III, IV Disease Status – Current disease, in treatment – History of disease, treatment complete – Also include family history 16

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 17

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 18

ICD-10 Documentation Tips Breast Neoplasm – in addition to information on previous slides, also include: – Location Must include the quadrant of the breast – Gender Specify clearly if patient is a male or female 19

ICD-10 Documentation Tips Leukemia – Acuity Acute, chronic – Type Acute lymphoblastic Chronic lymphocytic Hairy cell Adult T-cell – Disease Status Remission not achieved In remission In relapse 20

ICD-10 Documentation Tips Lymphoma – Classify based on histiologic type with lymph node, extranodal and solid organ involvement – Hodgkin examples Nodular lymphocytic predominat Mixed cellularity classical Lymphocytic-rich classical – Follicular examples Grade I – IIIb Cutaneous follicle center Diffuse follicle center – Non-follicular examples Small B-cell Diffuse large B-cell Lymphoblastic – Mature T/NK-Cell Mycosis fungoides Anaplastic large cell, ALK- 21

ICD-10 Documentation Tips Anemia – Type Nutritional – iron deficiency, vitamin B12 deficiency Hemolytic – enzyme disorder, thalassemia – Acquired versus hereditary Aplastic – drug induced, idiopathic – Cause / Underlying disease Post hemorrhagic Drug induced Malignancy Manifestation of adverse effect or poisoning – Example – neoplasm, kidney disease – Document if part of the disease process, or an adverse effect of treatment Anemia due to malignancy or chemotherpay 22

ICD-10 Documentation Tips Sickle Cell Anemia – Type Hb-SS Thalassemia HB-C Trait – Sickle-cell crisis Specify with or without crisis If in crisis, document manifestations – Acute chest syndrome – Splenic sequestration 23

ICD-10 Documentation Tips Coagulation – Type Hemorrhagic Disorder Coagulation defect – Cause Hereditary Acquired – Document underlying or associated disease – Specify medications or drug use affiliated with manifestations Hematuria due to Coumadin 24

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 25

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 26

ICD-10 Documentation Tips 27 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 Most Common Root Operations: 29 Bypass – altering the route of passage of the contents of a tubular body part Excision – cutting out or off, without replacement a portion of a body part Reposition – moving to its normal location all or a portion of a body part Control – stopping or attempting to stop, post- procedural bleeding Release – freeing a body part from an abnormal physical constraint Resection – cutting out or off, without replacement, all of a body part Division – cutting into a body part without draining fluids &/or gases in order to separate or transect the body part Repair – restoring, to the extent possible, a body part to its normal anatomic structure & function Restriction – partially closing an orifice or the lumen of a tubular body part Drainage – taking or letting out fluids &/or gases from a body part Replacement – putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

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 30