1. Obstetrics and Gynecology
UHS, Inc.
ICD-10-CM/PCS
Physician Education
Obstetrics and Gynecology

2. 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

3. Current ICD-9 Code Set is:
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Outdated: 30 years old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

4. Diagnosis Code Structure

5. ICD-10-CM Diagnosis Code Format

6. Comparison: ICD-9 to ICD-10-CM

7. Procedure Code Structure

8. ICD-10-PCS Code Format

9. 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?

10. ICD-10-CM/PCS
Documentation Tips

11. ICD-10 Provider Impact Golden Rule of Documentation
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

12. Gold Standard Documentation Practices
Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms
Document diagnoses, rather that descriptors
Indicate acuity/severity of all diagnoses
Link all diseases/diagnoses to their underlying cause
Indicate “suspected”, “possible”, or “likely” when treating a condition empirically
Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers
Clarify diagnoses that are present on admission
Clearly indicate what has been ruled out
Avoid the use of arrows and symbols
Clarify the significance of diagnostic tests

13. ICD-10 Provider Impact The 7 Key Documentation Elements:
Acuity – acute versus chronic
Site – be as specific as possible
Laterality – right, left, bilateral for paired organs and anatomic sites
Etiology – causative disease or contributory drug, chemical, or non-medicinal substance
Manifestations – any other associated conditions
External Cause of Injury – circumstances of the injury or accident and the place of occurrence
Signs & Symptoms – clarify if related to a specific condition or disease process

14. 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

15. ICD-10 Documentation Tips
Site and Laterality – right versus left
bilateral body parts or paired organs
Example – right fallopian tube
Stage of disease
Acute, Chronic
Intermittent, Recurrent, Transient
Primary, Secondary
Stage I, II, III, IV
Example – chronic kidney disease, stage II

16. ICD-10 Documentation Tips
Female Reproductive
Inflammatory Disease
Examples - Salpingitis, Oophoritis, PID
Severity – acute, subacute, chronic
Manifestation / cause / underlying condition
Pelvic adhesions causing the disorder or exacerbating
Current or past antineoplastic therapy or radiological procedures
Non-inflammatory Disease
Examples – Endometriosis, Prolapse, Dysplasia
Post-surgical state
Post-surgical complication
Location
Acuity – mild, moderate, severe
Origin of infertility
Tubal, uterine, other

17. ICD-10 Documentation Tips
Female Reproductive continued
Prolapse
Classification
Urethrocele
Cystocele
Rectocele
Vaginal enterocele
Location – lateral or midline
Severity
Incomplete / First degree
Incomplete / Second degree
Complete / Third degree

18. ICD-10 Documentation Tips
Neoplasm
Location
Detailed location
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

19. ICD-10 Documentation Tips
Neoplasm 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

20. ICD-10 Documentation Tips
Pregnancy
ICD-10-CM definitions of trimesters:
First trimester = less than 14 weeks, 0 days
Second trimester = 14 weeks, 0 days to less than 28 weeks, 0 days
Third trimester = 28 weeks until delivery
Documentation of conditions/complications of pregnancy will need to specify the trimester in which the condition occurred.
If the condition develops prior to admission, assign the trimester at the time of admission.

21. ICD-10 Documentation Tips
Pregnancy continued
Past infertility / poor reproductive history
Abortive outcomes
Ectopic
Hydatidiform mole
Abnormal products of conception (e.g. - blighted ovum)
Spontaneous abortion
Induced termination of pregnancy
Specify abortive agent or method used
Failed attempted termination of pregnancy
Incomplete abortion
Pre-term labor
Pregnancy induced conditions
Pregnancy induced hypertension
document acuity of pre-eclampsia (mild, moderate or severe)
Gestational diabetes
needs specification of diet controlled or insulin controlled

22. ICD-10 Documentation Tips
Diabetes - include the type or cause of diabetes
Type I
Type II
Due to drugs and chemicals
Due to underlying condition
Other specified diabetes
Link any manifestations to the diabetes
Circulatory, renal, neurological, ophthalmic, skin, other
Use of Insulin – long term, current
Example:
E08 - Diabetes mellitus due to underlying condition
E Diabetes mellitus due to underlying condition with ketoacidosis without coma
E Diabetes mellitus due to underlying condition with ketoacidosis with coma

23. ICD-10 Documentation Tips
Pregnancy continued
High risk pregnancy
History of infertility
Ectopic or molar pregnancy
Substance abuse
Insufficient care
Specify any pre-existing condition, infection or disorder
HIV
Smoking
Anemia
Hypertension

24. ICD-10 Documentation Tips
Labor and Delivery
Labor is categorized by weeks of gestation
Pre-term = before 37 weeks gestation
Post-term = over 40 weeks but less than 42 weeks gestation
Prolonged = over 42 weeks gestation
Document specifics of delivery
Outcome of delivery
List method of delivery
Specify instrumentation used
Severity of any perineal laceration and level of repair
Method of labor induction if applicable
Malposition, malpresentation
Include if obstructed or non-obstructed
If obstructed, what is the condition causing the obstruction of labor
Large fetus, locked twins, etc.

25. ICD-10 Documentation Tips
Labor and Delivery continued
Reason for C-section, if performed
List past history of C-section, when applicable
Complications of anesthesia
Aspiration pneumonitis
Pressure collapse of lung
Cardiac complication
CNS complication
Toxic reaction to local anesthesia
Spinal / epidural headache
Failed or difficult intubation

26. ICD-10 Documentation Tips
Fetal Anomalies
Multiples
Number of fetuses (numeric designation of 1 -9)
include number of placenta and number of amniotic sacs
Identify fetus with complication with assigned number
Fetal conditions
Central nervous system malformation
Chromosomal abnormality
Hereditary disease
Damage to fetus due to viral disease, alcohol, drugs, radiation, medical procedure
Isoimmunization – Rh, ABO, other

27. ICD-10 Documentation Tips
Puerperium
Retained placenta
With or without membranes
Infection
Cesarean wound infection
UTI
Endometritis
Other conditions requiring treatment
Disruption of obstetric wound
Postpartum mood disturbance
Post-delivery anemia
Abscess of the breast
Mastitis
Retracted or cracked nipple

28. ICD-10 Documentation Tips
Weight-related diagnoses and BMI
BMI < 19
BMI > 40
For malnutrition, specify type (e.g. - protein-calorie malnutrition) and severity (indicate mild, moderate, severe)
Document “starvation” in abuse cases
Link other illnesses
Overweight versus obesity, specify if severe or morbid
Link to the cause
Document if drug-induced and provide the specific drug
Bariatric procedures performed
Associated conditions (example – obesity hypoventilation syndrome)

29. 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

30. 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

31. ICD-10 Documentation Tips
Intra-operative
Post-procedural
Accidental puncture / laceration
Timing:
Post-procedure
Late effect
Same or different body system
Classify 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

32. 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

33. ICD-10 Documentation Tips
Most Common Root Operations:
Abortion – artificially terminating a pregnancy
Excision – cutting out or off, without replacement a portion of a body part
Resection – cutting out or off, without replacement, all of a body part
Restriction – partially closing an orifice
Delivery – assisting the passage of products of conception from the birth canal
Extraction – pulling or stripping out or off all or a portion of a body part
Reposition – moving to its normal location/other location all or portion of a body part
Dilation – expanding an orifice
Occlusion – completely closing an orifice
Supplement – putting in biological or synthetic material that physically reinforces &/or augments the function
Drainage – taking or letting out fluids &/or gases from a body part
Repair – restoring, to the extent possible, a body part to its normal anatomic structure & function
Transplantation – putting in all or a portion of a living body part taken from another individual or animal
Reposition – moving to its normal location/other location all or portion of a body part

34. Summary The 7 Key Documentation Elements:
Acuity – acute versus chronic
Site – be as specific as possible
Laterality – right, left, bilateral for paired organs and anatomic sites
Etiology – causative disease or contributory drug, chemical, or non-medicinal substance
Manifestations – any other associated conditions
External Cause of Injury – circumstances of the injury or accident and the place of occurrence
Signs & Symptoms – clarify if related to a specific condition or disease process