1. Neonatal and Pediatrics
UHS, Inc.
ICD-10-CM/PCS
Physician Education
Neonatal and Pediatrics

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Outdated: 30 years old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 Provider Impact Newborn Documentation:
Gestational age / prematurity
Extreme immaturity – less than 28 weeks gestation
Preterm – 28 weeks or more but less than 37 weeks gestation
Post-term – 40 – 42 weeks gestation
Prolonged – more than 42 weeks gestation
Weight
Extremely low birth weight – less than 999 grams
Low birth weight – 1000 – 2499 grams
Heavy – 4000 – 4499 grams
Exceptionally large – 4500 grams or more
Abnormalities in fetal size and health
Differentiate community-acquired versus conditions related to the birthing process
Abnormal results from neonatal screenings

15. ICD-10 Provider Impact Newborn – birth to 28 days of life
Document any condition (even those that may impact future healthcare needs) that requires:
Further clinical evaluation
Therapeutic treatment
Diagnostic procedure
An extended length of hospital stay
Increase in nursing care and / or monitoring
Document maternal conditions that impact the health of the baby

16. 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

17. 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

18. ICD-10 Documentation Tips
Birth Injury
Site and type of trauma
Birth injury to facial nerve
Fractured clavicle due to birth process
Subdural hemorrhage related to birth injury
Erb’s palsy
Contributing factors
Scalp of facial bruising due to forceps
Injury to scalp due to monitoring equipment

19. ICD-10 Documentation Tips
Feeding Problems
Specify related conditions and the feeding problem
Vomiting
bilious or other
Regurgitation
Rumination
Slow feeding
Underfeeding
Overfeeding
Difficulty with breast feeding
Failure to thrive

20. ICD-10 Documentation Tips
Neonatal Jaundice
Specify cause
Associated with preterm delivery
Due to:
Infection
Polycythemia
Swallowed maternal blood
Drugs or toxins
Excessive hemolysis
Breast milk inhibitor
Hepatocellular damage
Document type of hepatitis, if applicable

21. ICD-10 Documentation Tips
Noxious Influences
Specify condition
Withdrawal symptoms
Alcoholic fetor
Allergic reaction
Specify substance
Prescribed or illicit drugs
Alcohol
Smoking
Specify exposure
Via the placenta, maternal use
Administered during labor and delivery
Given directly to newborn

22. ICD-10 Documentation Tips
Respiratory
If disease if unknown, document the signs and symptoms
If known, document the most specific disease
Neonatal aspiration
Meconium, amniotic fluid, mucus, blood
Aspiration of mild or regurgitated food
Respiratory Distress Syndrome
Type I or Type II
Respiratory Failure
Respiratory Arrest
Newborn apnea
Primary obstructive, cyanotic attacks, apnea of prematurity

23. ICD-10 Provider Impact Congenital Malformation Documentation:
Congenital and chromosomal anomalies that impact throughout the patient’s life
Laterality
Right, left, bilateral
Anatomical site and malformation, deformity, abnormality
Associated manifestations
Surgically corrected congenital malformation
Document as history of

24. ICD-10 Provider Impact Chromosomal Abnormality Documentation:
Specific chromosome anomaly
Down syndrome, trisomy 18, Turner’s
Mosaic
Non-mosaicism, mosaicism, translocation
Associated physical conditions and degree of mental retardation
Metabolic disorders
Associated duplications or deletions
Due to unbalanced translocations, inversions and insertions related to complex rearrangements

25. 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

26. 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

27. 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

28. ICD-10 Documentation Tips
Most Common Root Operations:
Destruction – physical eradication of all or a portion of a body part by direct use of energy, force, or destructive agent
Excision – cutting out or off, without replacement, a portion of a body part
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

29. 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