1. ICD-10 Getting There….. Orthopaedics

2. What Physicians Need To Know Claims for ambulatory and physician services provided on or after 10/1/2015 must use ICD-10-CM diagnosis codes. Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use ICD-10-CM diagnosis codes. CPT Codes will continue to be used for physician inpatient and outpatient services and for hospital outpatient procedures. ICD-10-PCS – a NEW procedure coding classification system, must be used to code all inpatient procedures on Facility Claims for discharges on or after 10/1/15. ICD-9-CM codes must continue to be used for all dates of services on or before 9/30/2015. Further delays are not likely.

3. ICD-9 vs ICD-10 Diagnosis Codes ICD-9-CM Diagnosis CodesICD-10-CM Diagnosis Codes 3 to 5 digits7 digits Alpha “E” & “V” – 1 st CharacterAlpha or numeric for any character No place holder charactersInclude place holder characters (“x”) TerminologySimilar Index and Tabular StructureSimilar Coding GuidelinesSomewhat similar Approximately 14,000 codesApproximately 69,000 codes Severity parameters limitedExtensive severity parameters Does not include lateralityCommon definition of laterality Combination codes limitedCombination codes common

4. Number of Codes by Clinical Area Clinical AreaICD-9 CodesICD-10 Codes Fractures74717,099 Poisoning and Toxic Effects2444,662 Pregnancy Related Conditions1,1042,155 Brain Injury292574 Diabetes69239 Migraine4044 Bleeding Disorders2629 Mood Related Disorders7871 Hypertensive Disease3314 End Stage Renal Disease115 Chronic Respiratory Failure74 Right vs. left accounts for nearly ½ the increase in the # of codes.

5. The Importance of Good Documentation The role of the provider is to accurately and specifically document the nature of the patient’s condition and treatment. The role of the Clinical Documentation Specialist is to query the provider for clarification, ensuring the documentation accurately reflects the severity of illness and risk of mortality. The role of the coder is to ensure that coding is consistent with the documentation. Good documentation…. Supports proper payment and reduces denials Assures accurate measures of quality and efficiency Captures the level of risk and severity Supports clinical research Enhances communication with hospital and other providers It’s just good care!

6. Inadequate vs. Adequate Documentation Example 1: Osteoporosis Inadequate DocumentationRequired ICD-10 Documentation 67-year-old female with osteoporosis & ovary removal without estrogen replacement, reports sudden pain in arm when opening jar this am. Fractured forearm per films. Cast applied. Reports previous fracture 6 months ago. 67-year-old female with osteoporosis secondary to ovary removal without estrogen replacement, reports sudden pain in arm when opening jar this am. Path fracture left forearm per films. Cast applied. Reports collapsed lumbar vertebra 6 months ago secondary to osteoporosis. Now healed.. Needed improvements: Underlying cause(s), pathological fracture(s) location, laterality, encounter reason, and fracture history.

7. Inadequate vs. Adequate Documentation Example 2: Spondylopathies Inadequate DocumentationRequired ICD-10 Documentation Disc disease and stenosis with spondylolisthesis. Spinal curvature and Schmorl’s node present. Anterior lumbar interbody fusion scheduled for Tuesday. Degenerative disc disease and spinal stenosis with lumbar spondylolisthesis. Lumbar scoliotic curve secondary to disc disease. Schmorl’s node @ L3. Anterior lumbar interbody fusion L2 – L3 and L3 – L4 scheduled for Tuesday. Needed improvements: Location, complicating factor(s), and underlying disease(s).

8. Inadequate DocumentationRequired ICD-10 Documentation 32-year-old female S/P pilon fracture from suicide attempt. S/P fracture repair. Here for additional surgical intervention. 32-year-old female S/P external fixation right displaced pilon fracture due to jumping from her second story bedroom window in a suicide attempt. Fracture shows nonunion four weeks post op. Here for additional surgical intervention. Inadequate vs. Adequate Documentation Example 3: Fractures Needed improvements: Location, type, laterality, complication(s) and circumstances of injury.

9. Inadequate DocumentationRequired ICD-10 Documentation IMPRESSION: 1.Gout. 2.Diabetes. 3.Hyperlipidemia. 4.Kidney Failure. IMPRESSION: 1.Chronic gout left elbow secondary to kidney failure. 2.Type II NIDDM. 3.Mixed hyperlipidemia. 4.End stage kidney failure requiring peritoneal dialysis secondary to diabetes. Inadequate vs. Adequate Documentation Example 4: Gout Needed improvements: Acuity, insulin use, types, stage, causal agent, site, laterality, and dialysis status.

10. Key Requirements for Documenting Orthopedic Disorders and Diagnoses Document the side of body affected (i.e., right, left, or bilateral). Specify the site of the disease (e.g. joint versus end of bone). Identify the specific bone or joint and laterality for injuries or acquired deformities of fingers, toes, hands, limbs and joints (e.g., hallux varus right foot, unequal length, left tibia). Document any underlying disease process (e.g., bone or joint neoplasms, diabetes mellitus). Documentation should identify fractures as pathological, stress, or traumatic. With ICD-10, the need for specific and accurate documentation is increased significantly.

11. Using Sign/Symptom and Unspecified Codes Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs and/or symptoms in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition, it is acceptable to report the appropriate “unspecified” code. It is inappropriate to select a SPECIFIC code that is not supported by the medical record documentation.

12. Training for Physicians DatesMethodContent Nov 2014 – Jan 2015Department Meetings Introduction/Overview Jan 2015 – Mar 2015Web-basedOverview Service Specific Documentation Future Order Entry Diagnosis Assistant Mar 2015 – Jun 2015ClassroomDocumenting for ICD10 using the Electronic Health Record Jun 2015 – Sep 2015Web-basedOverview Documenting Operative and Procedure Notes for ICD-10-PCS

13. Future Orders & Diagnosis Assistant Demonstration