ICD-10-CM: Focus on Documentation

Family Practice, Internal Medicine, Primary Care



ReadyTalk Customer Care

Phone: 800.843.9166

Email: [email protected]

Should You Have Technical Difficulties

During The Webinar:



The Payers Collaboration is a group of payers

working together to provide a resource for providers

in their ICD-10 readiness activity



We are working as one voice to provide valuable

information to the provider community about

transitioning to ICD-10 and show that the transition

doesn’t have to be overly costly or burdensome.



Questions regarding today’s webinar can be emailed to:

[email protected]

Contact Us With Questions



Questions will be answered and posted on the

following web sites:



https://www.unitedhealthcareonline.com/b2c/CmaActi

on.do?channelId=6fa2600ae29fb210VgnVCM1000002f

10b10a

http://www.priorityhealth.com/provider/news-and-education/icd-10

Humana.com/providerwebinars

https://www.hap.org/providers/icd10.php

bcbsm.com/icd10

Part 1



Introduction to ICD-10-CM



ICD-10 Timeline & Billing Dates of Service

Part 2



Specialty Specific Documentation Examples

Part 3



Next Steps and Wrap Up



Identify the “What”, “Why” and “When”

of ICD-10 implementation



Recognize the format of ICD-10 codes



Apply documentation tips for the most common

diagnoses in a given specialty



Value the benefits of ICD-10 documentation



Introduction to ICD-10-CM



ICD-10 Timeline & Billing Dates of Service

I

nternational

C

lassification of

D

iseases-

10

_Revision-

_C

_linical

_M

_odification

Listed by the

W

orld

H

ealth

O

rganization

(WHO) and the

N

ational

C

enter for

H

ealth

S

tatistics (NCHS)

The Centers for Medicare and Medicaid Services (CMS)

announced on July 31, 2014 that the new deadline for ICD-10

Implementation will be

October 1, 2015.

ICD-9 codes provide limited data about patients’ medical

conditions and hospital inpatient procedures.

ICD-10 codes allow for greater specificity and exactness in

describing a patient’s diagnosis and in classifying inpatient

procedures.

HOW WILL ICD-10-CM IMPACT

ME ?

The required specificity of ICD-10-CM

documentation will

have a positive provider impact in the areas

Implementation Delays

ICD-10 implementation has been delayed several times but the

current implementation date is

October 1, 2015.

Why so many delays?

The most common reason cited for delaying ICD-10 is the

complexity and cost involved on the health care provider side

Another reason is the possibility of rejected claims due to

noncompliance and the impact on health care providers and

cash flow

Everyone agrees that disruption to the claims processing system is

the greatest danger of ICD-10 implementation



It could lead to cash flow problems and disruptions



It could also increase inquiries and resources straining health

plans resources (i.e., longer hold times, response times, etc.)

We need to work

together

to ensure that all stakeholders are

ready to minimize disruption

“It can cost (a provider office) $80k to transition from

ICD-9 to ICD-10”

We too have heard “facts” like this, but believe that this figure

assumes implementation, planning, and costs that will not be seen

by the majority of health care providers. For most specialties, cost

are much lower.

-United HC findings

http://www.medscape.com/viewarticle/839670

WHAT PROVIDER DOCUMENTATION WILL

BE IMPACTED BY ICD-10-CM?

IMPACTED

NOT IMPACTED

Diagnosis documentation for

inpatients

Diagnosis documentation for

outpatients

Procedure documentation for

BOTH outpatient and inpatient

services

Procedure documentation for

certain professional services,

and medical supplies

WHAT ARE SOME KEY DIFFERENCES BETWEEN

ICD-9-CM AND ICD-10-CM?

ICD-9 Diagnosis codes ICD-10 Diagnosis codes

3-5 characters in length 3-7 characters in length Approximately 14,000 codes Approximately 69,000 codes First digit may be alpha (E or V) or numeric;

Digits 2-5 are numeric Character 1 is alpha; Characters 2 & 3 are numeric; Characters 4-7 are alphanumeric Limited space for expansion Room for expansion

Lacks detail and laterality Very specific and added laterality

Difficult to analyze data due to non specific codes

Specificity improved coding

accuracy/richness for data analysis/medical research

Date of service

Code Set Billed

Prior to October 1, 2015

ICD-9-CM

October 1, 2015 and later ICD-10-CM

Provider outpatient AND inpatient claims are

based on date of service. (DOS)

Note: Overlapping dates require separate

claims.

IS ICD-10 REQUIRED ON CALENDAR DATE

OR DATE OF SERVICE OCT 1, 2015?

WHICH CODE SET FOR WHICH DATE?

Date of service (DOS) Code Set Accepted / NOT Accepted

10/1/2015

or later ICD-10 Accepted

9/30/2015

or prior ICD-9 Accepted

Discharge Date Code Set Accepted / NOT Accepted

10/1/2015

or later ICD-10 Accepted

9/30/2015

or prior ICD-9 Accepted

Outpatient



Specialty Specific Documentation Examples

ICD-9

250.00 Diabetes Mellitus, type 2, without mention of

complication, uncontrolled 250.82 Diabetes Mellitus, type 2, with

other specified manifestations 250.42 Diabetes with renal

manifestations

585.6 End stage renal disease

Diabetes Mellitus: Codes at a Glance

ICD-10

E11.641 Type 2 Diabetes Mellitus with hypoglycemia with coma

E11.642 Type 2 Diabetes Mellitus with hypoglycemia without coma

E11.65 Type 2 Diabetes Mellitus with hyperglycemia

E11.22 Type 2 Diabetes Mellitus with diabetic CKD

Patient is seen in follow up for his diabetes mellitus and chronic kidney disease. He is on dialysis twice a week and he has no complaints. He will

continue on his current regimen. Diagnosis is documented as diabetes mellitus and CKD

E11.22 Type 2 diabetes mellitus with chronic kidney disease

N18.9 Chronic kidney disease, unspecified

Documentation:

Diabetes Mellitus

Patient is seen in follow up for his

diabetes mellitus, type 2 with end stage chronic kidney disease. He is on dialysis twice a week and he has no complaints. He will continue on his current regimen. Diagnosis is documented as diabetes mellitus, type 2 with stage 5 chronic kidney disease

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease N18.6 End stage renal disease

ICD-9

V70.0 Routine general medical examination at a health care facility

V20.2 Routine infant or child health check

General Medical Examination:

Codes at a Glance

ICD-10

Z00.00 Encounter for general adult medical examination without abnormal findings Z00.01 Encounter for general adult

medical examination with abnormal findings

Z00.121 Encounter for routine child health examination with abnormal findings

Z00.129 Encounter for routine child health examination without abnormal findings

A 34-year-old female presents for her annual physical exam. The patient

complains of recent frequency and burning on urination. A urinalysis is positive for bacteria and is nitrate positive.

Diagnosis is documented as annual physical exam

Z00.00 Encounter for general adult medical examination without abnormal finding

Documentation:

General Medical Exam

A 34-year-old female presents for her annual physical exam. The patient complains of recent frequency and burning on urination. A urinalysis is positive for bacteria and is nitrate positive.

Diagnoses are documented as annual physical exam and urinary tract

infection

Z00.01 Encounter for general adult medical examination with abnormal findings

N39.0 Urinary tract infection, site not specified

ICD-9

729.5 Pain in Limb

Limb Pain: Codes at a Glance

ICD-10

M79.602 Pain in left arm

M79.621 Pain in right upper arm M79.622 Pain in left upper arm M79.629 Pain in unspecified

upper arm

M79.651 Pain in right thigh M79.652 Pain in left thigh M79.671 Pain in right foot M79.672 Pain in left foot

Patient presents with complaints of leg pain. The pain is dull in nature and has worsened over the last 2 weeks. Physical exam is unremarkable with normal reflexes and tone. There is no history of trauma.

Diagnosis is documented as leg pain, unknown etiology

M79.606 Pain in leg, unspecified

NOT ICD-10 SPECIFIC

Documentation:

Limb Pain

Patient presents with complaints of left lower leg pain. The pain is dull in nature and has worsened over the last 2 weeks. Physical exam is unremarkable with

normal reflexes and tone. There is no history of trauma.

Diagnosis is documented as left lower leg pain, unknown etiology

M79.662 Pain in left lower leg

ICD-9

780.79 Other malaise and fatigue

Malaise and Fatigue:

Codes at a Glance

ICD-10

R53.82 Chronic fatigue syndrome R53.83 Other fatigue

A 56-year-old male presents with complaints of increasing fatigue over the past 2 months. Patient was

diagnosed with advanced stage lung cancer one year ago and has been receiving hospice care over the last 6 weeks.

Diagnoses are documented as fatigue and end stage lung cancer

R53.83 Other fatigue

C34.90 Malignant neoplasm of unspecified part of

unspecified bronchus or lung

NOT ICD-10 SPECIFIC

Documentation:

Malaise and Fatigue

A 56-year-old male presents with

complaints of increasing fatigue over the past 2 months. Patient was diagnosed with neoplasm of the upper lobe of the right lung one year ago and has been receiving hospice care over the last 6 weeks.

Diagnoses are documented as right upper lobe lung cancer with neoplasm-related fatigue

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

R53.0 Neoplastic (malignant) related fatigue

ICD-9

882.0 Open wound of hand except finger(s) alone without mention of complication 882.1 Open wound of hand except

finger(s) alone with complication

882.2 Open wound of hand except finger(s) alone with tendon involvement

Open Wounds:

Codes at a Glance

ICD-10

S61.411A Laceration without foreign body of right hand, initial encounter

S61.441D Puncture wound without foreign body of right hand, subsequent encounter S61.452S Open bite of left hand,

sequela

A 25-year-old male presents to the emergency department immediately following a dog bite to his finger.

The dog has been vaccinated against rabies. The wound is irrigated and debrided.

Diagnosis is documented as dog bite of finger

S61.259 Open bite of unspecified without damage to nail

NOT ICD-10 SPECIFIC

Documentation:

Open Wound

A 25-year-old male presents to the emergency department immediately

following a dog bite to his right index finger

without damage to the nail. The wound is irrigated and debrided.

Diagnosis is documented as dog bite to the right index finger without damage to the nail

S61.250A Open bite to right index finger without damage to nail, initial encounter

W54.0XXA Bitten by dog, initial encounter

ICD-9

410.11 Acute myocardial infarction of other anterior wall, initial

episode of care

410.22 Acute myocardial infarction of inferolateral wall, subsequent episode

410.90 Acute myocardial infarction of unspecified site, episode of care unspecified

Myocardial Infarction:

Codes at a Glance

ICD-10

I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery

I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I22.0 Subsequent ST elevation

(STEMI) myocardial infarction of anterior wall

I21.4 Non-ST elevation (NSTEMI) myocardial infarction

I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

A 55-year-old male is being seen in the emergency department with complaints of acute substernal chest pain following a hospital admission a few weeks ago for an acute

myocardial infarction. Workup in the ED is conclusive for a new acute MI. Diagnosis is documented as acute myocardial infarction

I21.3 ST elevation (STEMI) myocardial infarction of unspecified site

Documentation:

Myocardial Infarction

A 55-year-old male is being seen in the ED with complaints of acute substernal chest pain following a hospital admission three weeks ago for an acute left anterior

descending artery MI. Workup in the ED is conclusive for a new acute inferior MI. Diagnosis is documented as acute inferior wall MI following an acute anterior wall LAD infarction 3 weeks ago

I22.1 Subsequent ST elevation

(STEMI) inferior wall myocardial infarction

I21.02 ST elevation (STEMI) myocardial infarction involving left LAD

ICD-9

496 Chronic airway obstruction, not elsewhere classified 491.21 Obstructive chronic

bronchitis with acute exacerbation

Chronic Obstructive Pulmonary Disease:

Codes at a Glance

ICD-10

with acute lower respiratory infection

J44.1 Chronic obstructive

pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive

pulmonary disease, unspecified

A 48-year-old male patient presents with a history of COPD. He has been experiencing increasing shortness of breath and a productive cough over the last 10 days. Physical exam reveals a temperature of 99.8 and diminished breath sounds on the right side.

Diagnosis is documented as COPD exacerbation

J44.1 COPD exacerbation

NOT ICD-10 SPECIFIC

Documentation:

COPD

A 48-year-old male patient presents with a history of COPD. He has been experiencing increasing shortness of breath and a

productive cough over the last 10 days. He is a one pack-per-day smoker and works in an auto repair shop. Physical exam reveals a temperature of 99.8 and diminished breath sounds on the right side.

Diagnosis is documented as COPD with acute bronchitis and tobacco dependence

J44.0 COPD with acute bronchitis

J20.9 Acute bronchitis, unspecified

F17.210 Nicotine dependence, cigarettes, uncomplicated

Z57.5 Occupational exposure toxic agents in other industries

ICD-9

707.03 Pressure ulcer, lower back 707.04 Pressure ulcer, hip

707.05 Pressure ulcer, buttock 707.20 Pressure ulcer, unspecified

stage

707.21 Pressure ulcer, stage 1

Decubitus Ulcer:

Codes at a Glance

ICD-10

L89.41 Pressure ulcer of contiguous

site of back, buttock and hip, stage 1

L89.311 Pressure ulcer of right buttock, stage 1

L89.622 Pressure ulcer of left heel, stage 2

L89.310 Pressure ulcer of right buttock, unstageable

A 78-year-old female nursing home resident is seen with a nonblanching red area involving the epidermis and superficial dermis of the buttock. The patient’s caregiver has been instructed on pressure ulcer prevention.

Diagnosis is documented as decubitus ulcer of buttock

L89.309 Pressure ulcer of unspecified buttock, unspecified stage

NOT ICD-10 SPECIFIC

Documentation: Decubitus Ulcer

A 78-year-old female nursing home

resident is seen with a nonblanching red area involving the epidermis and

superficial dermis of the right buttock. The patient’s caregiver has been

instructed on pressure ulcer prevention. Diagnosis is documented as decubitus ulcer, right buttock, stage 1

jjL89.311 Pressure ulcer of right buttock,

stage 1

ICD-9

461.0 Acute maxillary sinusitis 461.1 Acute frontal sinusitis 461.2 Acute ethmoidal sinusitis 461.3 Acute sphenoidal sinusitis 461.8 Other acute sinusitis

461.9 Acute sinusitis, unspecified

Acute Sinusitis:

Codes at a Glance

ICD-10

J01.00 Acute maxillary sinusitis

J01.01 Acute recurrent maxillary sinusitis

J01.10 Acute frontal sinusitis J01.11 Acute recurrent frontal

sinusitis

J01.20 Acute ethmoidal sinusitis J01.21 Acute recurrent ethmoidal

sinusitis

J01.30 Acute sphenoidal sinusitis J01.31 Acute recurrent sphenoidal

A 50-year-old female is evaluated with complaints of fever, nasal congestion, and worsening forehead pain that has lasted for 3 weeks. She has

experienced similar symptoms several times over the past 2 years and was treated with antibiotics each time. The diagnosis is documented as

sinusitis

J32.9 Sinusitis, unspecified

NOT ICD-10 SPECIFIC

Documentation:

Acute Sinusitis

A 50-year-old female is evaluated with complaints of fever, nasal congestion and worsening forehead pain that has lasted for 3 weeks. She has experienced similar symptoms several times over the last 2 years and was treated with

antibiotics each time.

The diagnosis is documented as acute recurrent frontal sinusitis

J01.11 Acute recurrent frontal sinusitis

ICD-9

493.80 Other forms of asthma 493.90 Asthma, unspecified

Asthma:

Codes at a Glance

ICD-10

J45.20 Mild intermittent asthma, uncomplicated

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.30 Mild persistent asthma, uncomplicated

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild persistent asthma with status asthmaticus

A 34-year-old female with a history of asthma is evaluated with increased nighttime cough and wheezing with

physical activity. She uses her inhaler when these symptoms persist. She will be

treated with an inhaled corticosteroid and long-acting bronchodilator.

The diagnosis is documented as asthma exacerbation

J45.909 Unspecified asthma, uncomplicated

NOT ICD-10 SPECIFIC

Documentation:

Asthma

A 34-year-old female with a history of asthma is evaluated with increased

nighttime cough, wheezing with physical activity and tiredness after normal

activities over the last 5 days. She uses her inhaler daily. Her husband smokes in the home. She will be treated with an inhaled corticosteroid and long-acting bronchodilator.

The diagnosis is documented as moderate persistent asthma with acute

exacerbation

J45.41 Moderate persistent asthma with (acute) exacerbation Z77.22 Exposure environmental smoke

ICD-9

311 Depressive disorder, not elsewhere classified

296.21 Major depressive disorder, single episode

296.31 Major depressive disorder, recurrent episode

Depressive Disorder:

Codes at a Glance

ICD-10

F32.0 Major depressive disorder, single episode, mild

F32.1 Major depressive disorder, single episode, moderate

F32.2 Major depressive disorder, single episode, severe

without psychotic features F32.9 Major depressive disorder,

single episode, unspecified

Documentation:

ICD-10 Major Depressive Episodes

In typical depressive episodes of all three varieties described on the slide (mild F32.0), moderate (F32.1), and severe (F32.2 and F32.3), the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common

symptoms are:

a) Reduced concentration and attention; b) Reduced self-esteem and self-confidence;

c) Ideas of guilt and unworthiness (even in a mild type of episode); d) Bleak and pessimistic views of the future;

e) Ideas or acts of self-harm or suicide; f) Disturbed sleep

Documentation:

ICD-10 Major Depressive Disorder

• Mild Depressive Episode – Diagnostic guidelines include a depressed mood, loss of

interest and enjoyment, and increased fatigability are usually regarded as the most typical symptoms of depression, and at least two of these, plus as least two of the other symptoms described on the previous slide should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks. An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

• Moderate Depressive Episode – Diagnostic guidelines include at least two of the three

most typical symptoms noted for mild depressive episode (F32.0) should be present, plus at least three (and preferably four) of the other symptoms. Several symptoms are likely to be present to a marked degree, but this is not essential if a particular wide variety of symptoms is present overall. Minimum duration of the whole episode is about 2 weeks.

The patient is seen today with complaints of feeling quite sad,

unhappy, withdrawn, apathetic and lacking energy or ambition to do much. He is bursting into tears without provocation. He’s not sleeping well. His appetite is not good and he often feels miserable. The diagnosis is documented as

depression

F32.9 Major depressive disorder, single episode, unspecified

NOT ICD-10 SPECIFIC

Documentation:

Depressive Disorder

The patient is seen today with

complaints of feeling quite depressed, sad, unhappy, withdrawn, apathetic and lacking energy or ambition to do much. He is bursting into tears without

provocation. He’s not sleeping well. His appetite is not good and he often feels miserable.

The diagnosis is documented as

moderate major depression, single episode

F32.1 Major depressive disorder, single episode, moderate

Code Structure Reminder

ICD-10 Code Structure

ICD-10 (Diagnosis) CM codes 3 to 7 alphanumeric characters

Digit 1 = alpha (A-Z, not case sensitive) Digit 2 = numeric

Digit 3 = alpha (not case sensitive) or numeric Digits 4-7 = alpha (not case sensitive) or numeric

ICD-10 (Procedure) PCS codes

7 alphanumeric characters (not case sensitive) Numbers 0-9 are used

Letters O and I are not used to avoid confusion with numbers 0 and 1

Inpatient Inpatient &

Code Structure Reminder – Stay in the Lane

Body Part Approach Device Qualifier

0 Liver

1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas

0 Open

4 Percutaneous Endoscopic Z No Device Z No Qualifier

5 Hepatic Duct, Right 6 Hepatic Duct, Left 8 Cystic Duct

9 Common Bile Duct

0 Open

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

Z No Device No Qualifier

Section 0 Medical and Surgical

Body System F Hepatobiliary System and Pancreas

Operation T Resection: Cutting out or off, without replacement, all of a body part

When building PCS codes, choose characters from left to right within the same lane or row

0FT40ZZ is correct, all characters are chosen from the same lane

Part 3



Next Steps and Wrap Up

•

Physician claims for outpatient and inpatient services will

transition to using ICD-10 Clinical Modification (ICD-10-CM) for

reporting diagnoses on October 1, 2015.

•

Also, please note that ICD-10-CM will NOT replace the CPT

procedure codes.

•

Remember, insurers making payment decisions, rating severity

of illness, or trying to predict recovery time, all need physician

documentation that is at the highest level of specificity.



Obtain a list of your most commonly use ICD-9 codes



Use existing tools to develop a list of viable ICD-10 codes

Study those codes to understand the level of detail

needed in the medical record



Make sure that medical record documentation supports

ICD-10 codes



Use existing content-based testing environments and

practice ICD-10 coding of those scenarios

Note: This transition activity is not the end game solution, but it will minimize immediate disruption and get you over the hump for 10/1/15.

Content-based testing links

Humana

BCBSM

Michigan Dept of Community Health

http://www.michigan.gov/mdch/

0,1607,7-132-2945_42542_42543_42546_42552_42696-256928--,00.html#Testing

Additional ICD-10 Coding Resources

Crosswalks for the Top 50 Codes by Specialty

ICD-10 CM/PCS Documentation Tips

100 Tips for ICD-10-PCS Coding

Free Code Conversion Tool

FAQs: ICD-10 Transition Basics

DISCLAIMER

This presentation is intended only for information use accompanying a live teleconference by the Payer

Collaboration (Collaboration). No copy or use of this presentation should occur without expressed permission from the Collaboration. While our best efforts are to provide accurate and useful information, the

Collaboration makes no claim, promise, or guarantee of any kind about the accuracy, completeness, or

adequacy of the content of the presentation and expressly disclaims liability for errors and omissions in such content.

As diagnostic codes changes annually, you should reference the current version of coding guidelines for the most detailed and up-to-date information. The information contained in this presentation is intended for informational purposes only.

The Collaboration has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this seminar, including but not limited to any loss of revenue, interruption of service, loss of business or indirect damages resulting from the use of this program. The Collaboration makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.

The material is designed and provided to communicate information about coding and documentation in an educational format and manner. The presenter(s) are not providing or offering legal advice, but rather,

practical and useful information and tools in the area of clinical documentation, data quality and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful.