1. ICD-10
Getting There…..
Plastic Surgery

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.
What Physicians Need To Know

3. ICD-9 vs ICD-10 Diagnosis Codes
ICD-9-CM Diagnosis Codes
ICD-10-CM Diagnosis Codes
3 to 5 digits
7 digits
Alpha “E” & “V” – 1st Character
Alpha or numeric for any character
No place holder characters
Include place holder characters (“x”)
Terminology
Similar
Index and Tabular Structure
Coding Guidelines
Somewhat similar
Approximately 14,000 codes
Approximately 69,000 codes
Severity parameters limited
Extensive severity parameters
Does not include laterality
Common definition of laterality
Combination codes limited
Combination codes common
ICD-9 vs ICD-10 Diagnosis Codes

4. Number of Codes by Clinical Area
ICD-9 Codes
ICD-10 Codes
Fractures
747
17,099
Poisoning and Toxic Effects
244
4,662
Pregnancy Related Conditions
1,104
2,155
Brain Injury
292
574
Diabetes 69
239
Migraine 40 44
Bleeding Disorders 26 29
Mood Related Disorders 78 71
Hypertensive Disease 33 14
End Stage Renal Disease 11 5
Chronic Respiratory Failure 7 4
Right vs. left accounts for nearly ½ the increase in the # of codes.
Number of Codes by Clinical Area

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!
The Importance of Good Documentation

6. Inadequate vs. Adequate Documentation Example 1: Cleft Lip and Palate
Inadequate Documentation
Required ICD-10 Documentation
Cleft palate repair in a 22-year-old male.
Cleft soft palate repair in a 22-year-old male with an accompanying nasal deformity and unilateral cleft lip.
Needed improvements:
Specific anatomical site, laterality, and associated nasal malformation.
Inadequate vs. Adequate Documentation Example 1: Cleft Lip and Palate

7. Inadequate vs. Adequate Documentation Example 2: Facial Deformity
Inadequate Documentation
Required ICD-10 Documentation
50-year-old woman with a history of squamous cell carcinoma and previous Mohs procedure on her eyelid presents for surgical consult. She desires plastic correction of scarring from Mohs procedure.
50-year-old woman with a history of squamous cell carcinoma of left lower eyelid and previous Mohs procedure on left lower eyelid presents for surgical consult. She desires plastic correction of scarring from Mohs procedure.
This is her initial visit to our practice.
Needed improvements:
Anatomical site, laterality and encounter type.
Inadequate vs. Adequate Documentation Example 2: Facial Deformity

8. Inadequate vs. Adequate Documentation Example 3: Burns
Inadequate Documentation
Required ICD-10 Documentation
26-year-old female scheduled for revision of a scar on her arm resulting from a burn she sustained during an accident.
26-year-old female scheduled for revision of a contracture scar on her left forearm resulting from a third degree thermal burn she sustained after pulling a pan of hot oil off a stove. Total body surface area burned was 1.5%.
Needed improvements:
Type of burn, anatomical site, laterality, degree of burn, percentage of total body surface area burned, and circumstances surrounding the injury.
Inadequate vs. Adequate Documentation Example 3: Burns

9. Anatomical site, type of deformity, and any functional abnormalities.
Inadequate Documentation
Required ICD-10 Documentation
Maxillary deformity due to Down’s syndrome. Scheduled for reconstructive surgery.
Maxillary hypoplasia due to Down’s syndrome. Patient has been diagnosed with severe obstructive sleep apnea. Scheduled for reconstructive surgery.
Needed improvements:
Anatomical site, type of deformity, and any functional abnormalities.
Inadequate vs. Adequate Documentation Example 4: Dentofacial Anomalies

10. Key Requirements for Documentation
Document the specific anatomical site (i.e., maxillary or mandibular, soft or hard palate).
Detail laterality as right, left, bilateral, median or unilateral.
Identify the patient’s encounter statues (i.e., initial, subsequent, sequela)
Detail how the injury occurred (e.g., punch to the face during a bar fight)
Document any underlying disease (e.g., rheumatoid arthritis, ).
Include the type of open wound (e.g. puncture, laceration, bite) and the presence or absence of foreign bodies.
Document any associated conditions, such as scars or joint contractures.
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.
Using Sign/Symptom and Unspecified Codes

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

13. Future Orders & Diagnosis Assistant
Demonstration
Future Orders & Diagnosis Assistant