1 UHS, Inc. ICD-10-CM/PCS Physician Education Pulmonology and Respiratory

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Why ICD-10 Current ICD-9 Code Set is: – Outdated: 30 years old – Current code structure limits amount of new codes that can be created – Has obsolete groupings of disease families – Lacks specificity and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 – frontal sinusitis 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 15

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] – Type / Form Childhood Exercise induced Extrinsic allergenic Late onset Allergic Allergic bronchitis Allergic rhinitis w/ asthma Atopic asthma Extrinsic allergic asthma Intrinsic non-allergic asthma Idiosyncratic asthma 16

ICD-10 Documentation Tips Asthma continued – Acuity With acute exacerbation With status asthmaticus – Tobacco Exposure Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to tobacco smoke – Cause and Effect – environmental Detergent Coal workers Miners Wood 17

ICD-10 Documentation Tips COPD – Type Chronic obstructive bronchitis Chronic bronchitis with airway obstruction Chronic bronchitis with emphysema Chronic obstructive tracheobronchitis – 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 18

ICD-10 Documentation Tips Influenza – Organism, document as known or suspected Avian influenza H1N1 influenza – Link associated conditions / manifestations Influenza with secondary gram negative pneumonia Laryngitis Pleural effusion Influenzal encephalopathy Influenzal myocarditis Influenzal otitis media 19

ICD-10 Documentation Tips Lung Cancer – Location Detailed location of lesion site 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 20

ICD-10 Documentation Tips Lung Cancer 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 21

ICD-10 Documentation Tips Pneumonia – Type – bacterial, viral, fungal, aspiration, drug-induced – 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 / underlying 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) 22

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 – Differentiate pulmonary collapse from therapeutic collapse – Respiratory distress and respiratory insufficiency are NOT respiratory failure 23

ICD-10 Documentation Tips Respiratory Failure Criteria 24 AcuteChronic 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 50 or pO2 28 % pO2 50 HypoxemiaHypercapnia 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 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 Control – stopping or attempting to stop Excision – cutting out or off without replacement a portion of a body part Repair – restoring, to the extent possible, a body part Restriction – partially closing an orifice or lumen of a tubular body part Dilation – expanding an orifice or the lumen of a tubular body part Extirpation – taking or cutting out solid matter Replacement – putting in a biological /synthetic material that takes the place or function Supplement – putting in a biological/ synthetic material to reinforce / augment Division – cutting into a body part to transect the body part Insertion – putting in a non-biological appliance Reposition – moving to its normal location Transfer – moving, without taking out, all or a portion of a body part to another location Drainage – taking or letting out fluids &/or gases Release – freeing a body part from an abnormal physical constraint Resection – cutting out or off without replacement all of a body part Transplantation – putting in all or a portion of a living part from another individual or animal

ICD-10 Documentation Tips Most Common Device Types: 30 Diaphragmatic pacemaker lead Endobronchial valveIntraluminal device: plain, drug-eluting, or radioactive Drainage deviceEndotracheal airwayMonitoring deviceTracheostomy device Extraluminal deviceInfusion deviceRadioactive element

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 31