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2. Documentation for ICD-10 Moving From Here to There Presented by Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT President & Chief Medical Officer Executive Physician Educator DocuComp LLC © aihcd.org 2011

3. 3 Dr. Bibbins, a physician with a background in Nursing, is certified in Healthcare Compliance, Clinical Documentation Improvement, Electronic Health Records and Health Information Technology. Dr. Betty B. Bibbins, MD, BSN, CHC, C- CDI, CPEHR, CPHIT President, Chief Medical Officer, and Executive Physician Educator, DocuComp LLC Dr. Bibbins has over 35 years of healthcare experience as an educator, clinician and administrator. She is President, Chief Medical Officer and Executive Physician Educator for DocuComp LLC. She has presented at numerous conferences and written many articles on physician documentation improvement. Dr. Bibbins focus is on the needs of Physicians, Nurses and HIM’s in the provision of healthcare and the Hospitals that depend on clinical documentation to capture appropriate levels of service, severity of illness, third party reimbursements, maintain Compliance, prepare for increasing standards for the utilization-of-healthcare services, Medical Cost Recovery and prepare for “Quality-of-Care standards.

4. Why ICD-10? ICD-9 classification system out of date (30 years old) Many Categories in ICD-9 are full Need improved description of diagnoses and procedures Many categories of classification outdated, do not correspond to current clinical perspectives of medicine The rest of the world using ICD-10 4 © aihcd.org 2011

5. ICD-9-CM to ICD-10: Basic Overview 14,000 Diagnoses Codes Numeric Codes: Numeric Codes: – Max of 5 digits 4,000 Procedure Codes Numeric Codes: Numeric Codes: – Max of 4 digits Approximately 68,000 Diagnoses Codes Alphanumeric Codes: Always Start with a Letter (Exc. U) Max of 7 Char. 87,000 Procedure Codes (ICD-10-PCS) Alpha/Numeric Codes: Start with a Number or Letter (Exc. O or I to avoid confusion with 0/1) ICD-9 CM ICD-10 5 © aihcd.org 2011

6. 7 th Character Extension Code Extensions Chapter 19-Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) Most categories have 7 th character extensions required for each applicable code Include A, D, S, Z A- Initial encounter D-Subsequent encounter S- Sequela Z - Aftercare 6 © aihcd.org 2011

7. Common Character Extensions Extension A Extension “A”, initial encounter is used while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician Extension D Extension “D” subsequent encounter is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other follow up visits following injury treatment. 7 © aihcd.org 2011

8. Common Character Extensions Extension “S”, sequela, is for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequela of the burn. When using extension “S”, it is necessary to document both the injury that precipitated the sequela and document the sequela itself. The “S” extension identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. 8 © aihcd.org 2011

9. ICD-10 Common Theme Expansion of Code Sets Specificity in clinical documentation Specificity in clinical classification Change in clinical documentation thought process “Clinical medicine” versus “CC/MCC Capture” Completeness and accuracy of clinical documentation Severity of illness Risk of Morbidity and Mortality Pay For Performance Risk of Admission 9 © aihcd.org 2011

10. Common Clinical Examples Respiratory Failure Respiratory Failure – 518.81- Acute – 518.83-Chronic – 518.84- Acute-on- Chronic J96.00- Acute respiratory failure, unspecified with hypoxia or hypercapnia J96.01- Acute respiratory failure with hypoxia J96.02- Acute respiratory failure with hypercapnia ICD-9ICD-10 10 © aihcd.org 2011

11. Common Clinical Examples J96.10- Chronic respiratory failure, unspecified with hypercapnia or hypoxia J96.11- Chronic respiratory failure with hypoxia J96.12- Chronic respiratory failure with hypercapnia J96.20- Acute & Chronic respiratory failure, unspecified J96.21- Acute and chronic respiratory failure with hypoxia J96.22- Acute and chronic with hypercapnia ICD-10 11 © aihcd.org 2011

12. Common Clinical Examples 12 ICD-10 J96.90- Respiratory failure, unspecified, unspecified with hypoxia or hypercapnia J96.91-Respiratory failure, unspecified, with hypoxia J96.92-Respiratory failure, unspecified, with hypercapnia © aihcd.org 2011

13. Common Clinical Examples 599.7- Hematuria R31.9- Hematuria, unspecified N30.01- Acute cystitis with hematuria N02.0- Recurrent and persistent hematuria with minor glomerular abnormality ICD-9ICD-10 13 © aihcd.org 2011

14. Common Clinical Examples N02.1-Recurrent and persistent hematuria with focal and segmental glomerular lesions N02.2- Recurrent and persistent hematuria with diffuse membranous glomerulonephritis N02.3 - Recurrent and persistent hematuria with diffuse mesangial proliferative glomerulonephritis N02.4- Recurrent and persistent hematuria with diffuse endocapillary proliferative glomerulonephritis ICD-10 14 © aihcd.org 2011

15. Common Clinical Examples N02.5- Recurrent and persistent hematuria with diffuse mesangiocapillary glomerulonephritis N02.6- Recurrent and persistent hematuria with dense deposit disease N02.7- Recurrent and persistent hematuria with diffuse crescentic glomerulonephritis N02.8- Recurrent and persistent hematuria with other morphologic changes N02.9- Recurrent and persistent hematuria with unspecified morphologic changes ICD-10 15 © aihcd.org 2011

16. 16 I50.1 Left ventricular failure I50.2 Systolic (congestive) heart failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Diastolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Combined systolic (congestive) and diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified Heart failure © aihcd.org 2011

17. 17 © aihcd.org 2011 Example:Combination Diagnosis Decubitus Ulcers - appropriate documentation of the exact location and stage must be present. Stages of Pressure (Decubitus) Ulcers: Pressure ulcer, Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence) Pressure ulcer, Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Pressure ulcer, Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Pressure ulcer, Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Pressure ulcer, Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. National Pressure Ulcer Advisory Panel

18. 18 © aihcd.org 2011 Sad but true…… Documentation of Urosepsis Has no code within ICD 10…….. UTI with Sepsis, Bladder Infection, or other Dx must be explicitly documented.

19. Strategies for ICD-10 Preparation “Build and expand” upon present Clinical Documentation Initiatives – Focus on communicating severity-of-illness and medical necessity – Familiarity with ICD-10 documentation specificity requirements Clinical specificity – Time capsule: Tomorrow is Today! Proceed with Explicitness! 19 © aihcd.org 2011

20. 20 © aihcd.org 2011 Physicians know how to practice medicine. What is needed now is to better understand how to DOCUMENT the practice of medicine! It is so important to remember……

21. © aihcd.org 2011 21

22. Questions? 22 © aihcd.org 2011

23. Thank You Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT President & Chief Medical Officer DocuComp LLC Email: BibbinsMD@DocuCompLLC.com 23

24. References 24 www.CMS.gov/icd10 Bibbins, Betty. “Inpatient (IPPS) Documentation Tips for Physicians.” 2011 Edition. DocuComp LLC Press. Krauss, Glenn and Hoffman, Sylvia. 2011. “The Clinical Documentation Improvement Specialist’s Guide to ICD-10. HCPro. www.icd10data.com/ICD10CM/Codes/