1. Internal Medicine and Family Practice
UHS, Inc.
ICD-10-CM/PCS
Physician Education
Internal Medicine and Family Practice

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Outdated: 30 years old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
Signs & Symptoms – document underlying cause / conditions
Admit with sign / symptom
Discharge with a Diagnosis
Fever
Underlying condition (due to)
Infection type (example: pneumonia)
Chest pain
GERD
Atelectasis
Costochondritis
Pleurisy
Cholecystitis
AMI
Altered Mental Status
Underlying cause
Encephalopathy
UTI

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, Chronic
Intermittent, Recurrent, Transient
Primary, Secondary
Stage I, II, III, IV
Example – stage of pressure ulcer:
L Pressure ulcer of right elbow, stage 1
L Pressure ulcer of left elbow, stage 1

17. ICD-10 Documentation Tips
Asthma
Specificity
Intermittent [less than or equal to two times per week]
Mild persistent [more than two times per week]
Moderate persistent [daily-may restrict physical activity]
Severe persistent [throughout the day-frequent severe attacks that limit the ability to breathe]
Acuity
With acute exacerbation
With status asthmaticus
Type / Form
Childhood
Exercise induced
Extrinsic allergenic
Late onset
Tobacco Exposure
Exposure to environmental tobacco smoke
History of tobacco use
Occupational exposure to tobacco smoke

18. ICD-10 Documentation Tips
COPD
Acuity
With acute exacerbation
With acute lower respiratory infection
Specificity
With asthma
With bronchitis
With emphysema
Tobacco Exposure
Exposure to environmental tobacco smoke
History of tobacco use
Occupational exposure to tobacco smoke

19. 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
E11 - Type 2 diabetes mellitus
E Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema
E Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular edema

20. ICD-10 Documentation Tips
Encephalopathy
Acuity – acute, subacute, chronic
Severity – with or without coma
Type
Alcoholic
Hepatic
Hypertensive
Metabolic
Septic
Toxic
Due to disease classified elsewhere
Due to influenza, syphilis, hydrocephalus, neoplastic disease, etc…
Link altered mental status to encephalopathy with the specific type

21. ICD-10 Documentation Tips
Heart Failure
Specify acuity
Acute
Chronic
Acute on chronic
Identify type
Systolic
Diastolic
Combined systolic and diastolic
List relationship of hypertension to heart failure or heart disease
Identify underlying cause
Example - Exacerbation of stable heart failure due to fluid overload or due to missed dialysis

22. ICD-10 Documentation Tips
Kidney Disease
Specify acuity
Acute, Chronic, Acute on chronic
Identify stage
Stage I – GFR > 90
Stage II – GFR 60 – 89
Stage III – GFR 30 – 59
Stage IV – GFR 15 – 29
Stage V – GFR < 15
List relationship of hypertension &/ or diabetes
Document as due to or with
Example – Type 2 DM with diabetic CKD stage 5
Transplant Status – has the patient had a transplant or is a transplant candidate

23. ICD-10 Documentation Tips
Otitis Media
Type
Serous
Sanguinous
Suppurative
Allergic
Mucoid
Infectious Agent
Strep
Staph
Influenza
Measles, Mumps
Laterality – left, right, both
Note whether tympanic membrane is ruptured

24. ICD-10 Documentation Tips
Malnutrition
Specify acuity – mild, moderate, severe
Specify type
Protein calorie
Protein energy
Marasmus
Nutritional deficiency
At least 2 of the following are required to help identify malnutrition:
Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized / generalized fluid accumulation
Diminished functional status as measure by hand grip strength

25. ICD-10 Documentation Tips
Weight-related diagnoses and BMI
BMI < 19
BMI > 40
For protein-calorie malnutrition, indicate mild, moderate, severe
Document “starvation” in abuse cases
Link other illnesses
Obesity, specify 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)

26. ICD-10 Documentation Tips
Pneumonia
Organism, document as known or suspected
Viral – adenoviral, respiratory syncytial, parainfluenza, human metapneumovirus, viral unspecified
Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas, staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified
Link associated conditions
Influenza with secondary gram negative pneumonia
Sepsis due to pneumonia
Acute respiratory failure due to pneumonia
Aspiration
Due to solids or liquids
Due to anesthesia during L/D or procedure
Due to anesthesia during puerperium
Laterality of lung involvement – left, right, both
Note whether ventilator associated (VAP)

27. ICD-10 Documentation Tips
Pressure Ulcers
Site – specific ulcer location
Ankle, back, buttock, coccyx, elbow, face, head, heel, hip, sacral region, other site
Laterality – left, right, both
Stage
1 – pre-ulcer skin changes limited to persistent focal edema
2 – abrasion, blister, partial thickness skin loss involving epidermis &/or dermis
3 – full thickness skin loss involving damage or necrosis of subcutaneous tissue
4 – necrosis of soft tissue through to underlying muscle, tendon or bone
Unspecified – not documented
Unstageable – full thickness tissue loss, covered with slough or eschar
Note whether the pressure ulcer was present on admission

28. ICD-10 Documentation Tips
Respiratory Failure
Acuity - acute, chronic, acute on chronic
Specificity – with hypoxia or hypercapnia
Tobacco Use
Exposure to environmental tobacco smoke
History of tobacco use
Occupational exposure to tobacco
Does the patient require continuous home oxygen or is dependent on home oxygen
Respiratory distress and respiratory insufficiency are NOT respiratory failure

29. ICD-10 Documentation Tips
Respiratory Failure Criteria
Acute
Chronic
Symptoms – difficulty breathing, shortness of breath, dyspnea, tachypnea, respiratory distress, labored breathing, use of accessory muscles, cyanosis, unable to speak
Symptoms – severe COPD, chronic lung disease such as cystic or pulmonary fibrosis
Ph < 7.35 & pCO2 > 50 or pO2 < 55 & FIO2 > 28 %
pO2 < 55 or pCO2 > 50
Hypoxemia
Hypercapnia
pO2 < 60 mmHg OR
pO2 / FIO2 ratio < OR
10 mmHg decrease in baseline pO2
pCO2 > 50mmHg with pH < 7.35 OR
10 mmHg increase in baseline pCO2

30. ICD-10 Documentation Tips
Sepsis
Acuity – sepsis, severe sepsis, septic shock, SIRS
Organism due to / suspected
Streptococcus (A or B)
Staphylococcus aureus
MSSA
MRSA
Hemophilus influenzae
Gram-negative organism
E Coli
Serratia
Enterococcus
Manifestations
With acute organ dysfunction
With multiple organ dysfunction
SIRS due to infectious process with organ dysfunction
Shock
Note the term urosepsis is NOT synonymous with sepsis

31. ICD-10 Documentation Tips
Sepsis Criteria
Altered mental status
Heart rate > 90 beats per minute
Hypoxemia
PaCO2 < 32mmHg
Respiratory rate > 20 breaths per minute
Temperature > F or < 96.8 F
WBC > 12,000 cells/mm3; < 4,000 cells/mm3; and/or > 10% immature band
Blood cultures do not need to be positive to support the diagnosis of sepsis – the physician may clinically diagnose based on signs and symptoms

32. ICD-10 Documentation Tips
Strokes – dominant vs. non-dominant side
Specify the location or source of the hemorrhage and laterality
Document other causes – thrombosis, embolism, occlusion, stenosis
Sites – precerebral or cerebral arteries
Laterality
Document dominant verses non-dominant side for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesis and for residual effects
Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.

33. ICD-10 Documentation Tips
Drug and Alcohol Use
Expanded code set to classify cause-and-effect indicators
Documentation requirements include:
Specific aspects of the effects
Example – abuse and dependence
Specify the aspects of use
Example – withdrawal state
Identify manifestations
Example – hallucinations, delusions

34. 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

35. 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

36. ICD-10 Documentation Tips
Most Common Root Operations:
Destruction – physical eradication of all of a portion of a body part by direct use of energy, force or destructive agent
Drainage – taking or letting out fluids &/or gases from a body part
Excision – cutting out or off, without replacement, a portion of a body part; diagnostic or therapeutic
Repair – restoring to the extent possible, a body part to its anatomic structure and function

37. 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