1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery.
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Transcript of 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery.
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UHS, Inc.
ICD-10-CM/PCSPhysician Education
General Surgery
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 visits2
Why ICD-10Why 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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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
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Diagnosis Code StructureDiagnosis Code Structure
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ICD-10-CM Diagnosis Code FormatICD-10-CM Diagnosis Code Format
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Comparison: ICD-9 to ICD-10-CMComparison: ICD-9 to ICD-10-CM
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Procedure Code Structure Procedure Code Structure
ICD-10-PCS Code FormatICD-10-PCS Code Format
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ICD-10 Changes Everything!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?
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ICD-10-CM/PCSDocumentation Tips
ICD-10 Provider ImpactICD-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
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Gold Standard Documentation PracticesGold 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 tests12
ICD-10 Provider ImpactICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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 chronicExample – 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 sequelaeExample - 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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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.
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-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
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ICD-10 Documentation TipsICD-10 Documentation Tips
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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
ICD-10 Documentation TipsICD-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
ICD-10 Documentation TipsICD-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
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Root Operations for General Surgery:
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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
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Device Types for General Surgery:
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Artificial sphincter External fixation device
Intraluminal device, plain drug-eluting or radioactive
Spinal stabilization device, facet replacement
Cardiac lead Extraluminal device Intramedullary internal fixation device
Spinal stabilization device, interspinous process device
Cardiac rhythm related device
Feeding device Liner Spinal stabilization device, pedicle-based device
Contraceptive device Hearing device, bone conduction
Monitoring device Stimulator generator
Contractility modulation device
Hearing device, cochlear prosthesis
Pacemaker, single or dual
Stimulator lead
Defibrillator Interbody fusion device
Radioactive element Tracheostomy device
Drainage device Internal fixation device
Spacer Vascular access device, reservoir or pump
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Root Operations for Gastroenterology:
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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
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Device Types for Gastroenterology:
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Artificial sphincter Extraluminal device
Intraluminal device, plain or radioactive
Radioactive element
Drainage device Feeding device Monitoring device
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Root Operations for Nephrology / Urology:
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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
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Device Types for Nephrology / Urology:
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Artificial sphincter Extraluminal device
Intraluminal device, plain, drug-eluting or radioactive
Stimulator lead
Drainage device Infusion device Monitoring device
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Root Operations for Otorhinolaryngology:
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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
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Device Types for Otorhinolaryngology :
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Drainage device Hearing device, bone conduction
Intraluminal device
Radioactive element
Extraluminal device
Hearing device, cochlear prosthesis
Monitoring device
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Root Operations for Ophthalmology:
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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
SummarySummary
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
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