1 UHS, Inc. ICD-10-CM/PCS Physician Education Infectious Disease

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Why ICD-10 Current ICD-9 Code Set is: – Outdated: 30 years old – Current code structure limits amount of new codes that can be created – Has obsolete groupings of disease families – Lacks specificity and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 Status of disease – Newly diagnosed Acute Chronic Site of infection or infestation (TB of lung) Cause of the infection (streptococcus) Link manifestations and other conditions Autoimmune and related diseases (Kaposi’s sarcoma) Infectious agents in other types of disease (wound infection caused by staph) 15

ICD-10 Documentation Tips AIDS / HIV – Status of disease AIDS HIV positive HIV-related illness Newly diagnosed Asymptomatic Inconclusive serology – Clearly indicate the reason for admission For HIV or unrelated condition – List related conditions and manifestations Document as due to or with – Is the patient pregnant 16

ICD-10 Documentation Tips Hepatitis – Specify acuity Acute, Chronic, Acute on chronic With or without hepatic coma – Identify type A, B, or C – Hepatitis B patients with hepatitis D (delta agent) must have documentation to support both viral agents 17

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 18

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 Whooping cough / pertussis – 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) 19

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 20

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 > F or < 96.8 F – WBC > 12,000 cells/mm3; 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 Septic shock – circulatory failure and sepsis that are related, include severe sepsis in the documentation When was the onset of sepsis – prior to admission or during admission 21

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 22

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 23