1. 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

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 2

3. Why ICD-10 Current ICD-9 Code Set is: – Outdated: 30 years old – Current code structure limits amount of new codes that can be created – Has obsolete groupings of disease families – Lacks specificity and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

4. Diagnosis Code Structure 4

5. ICD-10-CM Diagnosis Code Format 5

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

7. Procedure Code Structure

8. ICD-10-PCS Code Format 8

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? 9

10. 10 ICD-10-CM/PCS Documentation Tips

11. 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

12. 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

13. 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

14. ICD-10 Documentation Tips Document all acute or chronic conditions that are being: – Clinically evaluated or – Diagnostically tested or – Therapeutically treated or – Cause an increased Length of Stay (LOS) or nursing care 14

15. 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

16. ICD-10 Documentation Tips Site and Laterality – right versus left – bilateral body parts or paired organs Example – cellulitis of right upper arm Stage of disease – acute vs. chronic vs. acute on chronic Example – stage of pressure ulcer: – L89.011 Pressure ulcer of right elbow, stage 1 – L89.021 Pressure ulcer of left elbow, stage 1 Episode of care – initial, subsequent, and sequelae Example - lower leg fracture: – A initial encounter for closed fracture – B initial encounter for open fracture type I or II – C initial encounter for open fracture type IIIA, IIIB, or IIIC – D subsequent encounter for closed fracture with routine healing – H subsequent encounter for open fracture type I or II with delayed healing – K subsequent encounter for closed fracture with nonunion – S sequelae 16

17. ICD-10 Documentation Tips Cause of Injury – Mechanism How it happened – Place of occurrence Where it happened – Activity What was the patient doing – External Cause Work-related, leisure 17

18. ICD-10 Documentation Tips Glasgow Coma - ICD-10-CM coding will need the score from each of the assessment areas – Eye opening – Verbal response – Motor response » R40.211 Coma scale, eyes open never » R40.212 Coma scale, eyes open to pain » R40.213 Coma scale, eyes open to sound » R40.214 Coma scale, eyes open spontaneously – Report the Glasgow coma scale total score » R40.241 Glasgow coma scale score 13 – 15 » R40.242 Glasgow coma scale score 9 - 12 » R40.243 Glasgow coma scale score 3 – 8 18

19. ICD-10 Documentation Tips Crohn's disease -Specify the site Colon Duodenum Ilium Jejunum Small intestine Include any manifestations: – K50.00 Crohn's disease of small intestine without complications – K50.011 Crohn's disease of small intestine with rectal bleeding – K50.012 Crohn's disease of small intestine with intestinal obstruction – K50.013 Crohn's disease of small intestine with fistula – K50.014 Crohn's disease of small intestine with abscess – K50.018 Crohn's disease of small intestine with other complication – K50.019 Crohn's disease of small intestine with unspecified complications 19

20. 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 E08 - Diabetes mellitus due to underlying condition – E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma – E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E11 - Type 2 diabetes mellitus – E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema – E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular edema 20

21. ICD-10 Documentation Tips Fractures – clearly document all aspects – Cause – traumatic, stress, pathological – Location – which bone, which part of the bone, laterality – Type – displaced, non-displaced, open, closed – Encounter – initial, subsequent, sequelae – External cause – how the fractured occurred and the activity Example - Fall while skiing 21

22. ICD-10 Documentation Tips Open fractures - Please specify the severity using the Gustilo-Anderson Open Fracture Classification system for forearm, femur, and lower leg – Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (i.e., inside-out injury). – Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect. This is also a low-energy injury. – Type III: The wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation. – Type III fractures are further divided into III A: Soft tissue coverage of the fractured bone is adequate. III B: Disruption of the soft tissue is extensive, that local or distant flap coverage is necessary. III C: Any open fracture that is associated with an arterial injury that a physician must repair, regardless of the degree of soft tissue injury. 22

23. ICD-10 Documentation Tips Pathologic (non-traumatic) fractures: – Exact location of fracture – Bone, part of the bone, and laterality – Etiology of the fracture – osteoporosis, neoplastic disease, other specified – Encounter type – initial encounter, subsequent encounter with routine healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae 23

24. 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 24

25. 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 25

26. 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 – Z91.120 – Patient’s intentional underdosing of medication due to financial hardship 26

27. 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 27

28. ICD-10 Documentation Tips 28 Intra-operativePost-procedural Accidental puncture / lacerationTiming: Post-procedure Late effect Same or different body systemClassify 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

29. 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

30. ICD-10 Documentation Tips Example – spinal fusion Root Operation – Fusion Body Part – Thoracic vertebral joints 2 - 7 Approach – Open (anterior/posterior) and Column (anterior/posterior) Device – Autologous tissue substitute

31. ICD-10 Documentation Tips Most Common Root Operations for General Surgery: 31 Bypass – altering the route of passage Drainage – taking or letting out fluids &/or gases Release – freeing a body part from an abnormal physical constraint Resection – cutting out or off without replacement all of a body part Detachment – cutting off all of part of the upper or lower extremity Excision – cutting out or off without replacement a portion of a body part Repair – restoring, to the extent possible, a body part Restriction – partially closing an orifice or lumen of a tubular body part Dilation – expanding an orifice or the lumen of a tubular body part Fusion – joining together portions of an articular body, rendering it immobile Replacement – putting in a biological or synthetic material that takes the place &/or function Supplement – putting in a biological/ synthetic material to reinforce / augment Division – cutting into a body part to transect the body part Reattachment – putting back in or on all or a portion of a separate body part Reposition – moving to its normal location Transfer – moving, without taking out, all or a portion of a body part to another location

32. ICD-10 Documentation Tips Most Common Device Types for General Surgery: 32 Artificial sphincterExternal fixation device Intraluminal device, plain drug-eluting or radioactive Spinal stabilization device, facet replacement Cardiac leadExtraluminal deviceIntramedullary internal fixation device Spinal stabilization device, interspinous process device Cardiac rhythm related device Feeding deviceLinerSpinal stabilization device, pedicle-based device Contraceptive deviceHearing device, bone conduction Monitoring deviceStimulator generator Contractility modulation device Hearing device, cochlear prosthesis Pacemaker, single or dual Stimulator lead DefibrillatorInterbody fusion device Radioactive elementTracheostomy device Drainage deviceInternal fixation deviceSpacerVascular access device, reservoir or pump

33. ICD-10 Documentation Tips Most Common Root Operations for Gastroenterology: 33 Bypass – altering the route of passage Drainage – taking or letting out fluids &/or gases Repair – restoring, to the extent possible, a body part Restriction – partially closing an orifice or lumen of a tubular body part Control – stopping, or attempting to stop, post-procedural bleeding Excision – cutting out or off without replacement a portion of a body part Replacement – putting in a biological or synthetic material that takes the place &/or function Supplement – putting in a biological/ synthetic material to reinforce / augment Dilation – expanding an orifice or the lumen of a tubular body part Reattachment – putting back in or on all or a portion of a separate body part Reposition – moving to its normal location Transfer – moving, without taking out, all or a portion of a body part to another location Division – cutting into a body part to transect the body part Release – freeing a body part from an abnormal physical constraint Resection – cutting out or off without replacement all of a body part Transplantation – putting in or on all or a portion of a living body taken from another individual or animal

34. ICD-10 Documentation Tips Most Common Device Types for Gastroenterology: 34 Artificial sphincterExtraluminal device Intraluminal device, plain or radioactive Radioactive element Drainage deviceFeeding deviceMonitoring device

35. ICD-10 Documentation Tips Most Common Root Operations for Nephrology / Urology: 35 Bypass – altering the route of passage Release – freeing a body part from an abnormal physical constraint Resection – cutting out or off without replacement all of a body part Dilation – expanding an orifice or the lumen of a tubular body part Repair – restoring, to the extent possible, a body part Restriction – partially closing an orifice or lumen of a tubular body part Drainage – taking or letting out fluids &/or gases Replacement – putting in a biological or synthetic material that takes the place &/or function Supplement – putting in a biological/ synthetic material to reinforce / augment Excision – cutting out or off without replacement a portion of a body part Reposition – moving to its normal location Transplantation - putting in or on all or a portion of a living body taken from another individual or animal

36. ICD-10 Documentation Tips Most Common Device Types for Nephrology / Urology: 36 Artificial sphincterExtraluminal device Intraluminal device, plain, drug-eluting or radioactive Stimulator lead Drainage deviceInfusion deviceMonitoring device

37. ICD-10 Documentation Tips Most Common Root Operations for Otorhinolaryngology: 37 Control – stopping, or attempting to stop, post-procedural bleeding Drainage – taking or letting out fluids &/or gases Repair – restoring, to the extent possible, a body part Restriction – partially closing an orifice or lumen of a tubular body part Dilation – expanding an orifice or the lumen of a tubular body part Excision – cutting out or off without replacement a portion of a body part Replacement – putting in a biological or synthetic material that takes the place &/or function Supplement – putting in a biological/ synthetic material to reinforce / augment Division – cutting into a body part without draining fluids &/or gases from the body part in order to transect the body part Release – freeing a body part from an abnormal physical constraint Reposition – moving to its normal location Transfer – moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of the body part Resection – cutting out or off without replacement all of a body part

38. ICD-10 Documentation Tips Most Common Device Types for Otorhinolaryngology : 38 Drainage deviceHearing device, bone conduction Intraluminal device Radioactive element Extraluminal device Hearing device, cochlear prosthesis Monitoring device

39. ICD-10 Documentation Tips Most Common Root Operations for Ophthalmology: 39 Control – stopping, or attempting to stop, post-procedural bleeding Extirpation – taking or cutting out solid matter from a body part Removal – taking out or off a device from a body part Resection – cutting out or off without replacement all of a body part Division – cutting into a body part to transect the body part Extraction – pulling or stripping out or off all of a portion of a body part Repair – restoring, to the extent possible, a body part Supplement – putting in a biological/ synthetic material to reinforce / augment Drainage – taking or letting out fluids &/or gases Insertion – putting in a non-biological appliance that does not take the place of the body part Replacement – putting in a biological or synthetic material that takes the place &/or function Transfer – moving, without taking out, all or a portion of a body part to another location Excision – cutting out or off without replacement a portion of a body part Release – freeing a body part from an abnormal physical constraint Reposition – moving to its normal location

40. 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 40