CLINICAL DOCUMENTATION ICD-9 and ICD-10

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CLINICAL DOCUMENTATION

ICD-9 and ICD-10

Payers and Providers Partnering for Success

Shannon Chase, CPC, AHIMA Approved ICD-10-CM/PCS Trainer June 2014

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AGENDA

• Importance of Documentation • Criteria for Documentation • EMR Documentation • ICD-10

• Why the change? • Benefits of ICD-10 • Planning

• Productivity

• ICD-10 Code Structure

• Mental and Behavioral Health • Contact Information

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CLINICAL DOCUMENTATION – ICD-9 & ICD-10

IMPORTANCE OF IMPROVING CLINICAL DOCUMENTATION

• Clinical documentation is at the core of every patient encounter.

• In order to be meaningful it must be accurate, timely and reflect the scope of services provided.

• An accurate representation of a patient’s clinical status translates to coded data.

• Coded data is then translated into quality reports, physician report cards, reimbursement, public health, and disease tracking and trends.

• Improving the accuracy of clinical documentation can:

– Reduce compliance risks

– Minimize vulnerability during external audits – Provide insight into legal quality of care issues.

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TIME IS NOW FOR DOCUMENTATION IMPROVEMENT

• Physicians will be judged on documentation more critically in ICD-10. • More detailed description of activities conducted during the encounters. • With ICD-10 there will be an increase in clarification queries from coders.

– Services must be coded to the highest level of specificity

• Well documented medical records facilitate communication, coordination , continuity of care & promotes efficiency & effectiveness of treatments.

• Chronic conditions are important to show not only for resource utilization, but also the severity of illness for statistical purposes.

• Showing medical necessity means you are justifying your treatment choice and help support E/M levels.

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DOCUMENTATION CRITERIA – PHYSICIAN AND STAFF

• Documentation should not include arrows up or down in place of “hyper” or “hypo” as they could be interpreted as elevated.

• Do not use ICD-9/ICD-10 diagnosis codes in place of the actual written/spelled out diagnosis/condition.

• Each progress note must be able to “stand alone”.

• Do not refer to diagnoses from a prior progress note, etc…

• When diagnosing a patients condition make sure you evaluate each condition and not just list it, for example:

• DM w/Neuropathy-meds adjusted • COPD-test ordered

• Hyperlipidemia-stable on meds

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DOCUMENTATION CRITERIA – PHYSICIAN AND STAFF

• All progress notes must be signed by the provider rendering the services and included with signature should be the providers credentials (stamped signatures are no longer acceptable since 1/2009).

• EMR notes must have the following wording as part of the signature and note must be closed to all changes:

• Electronically signed • Authenticated by • Signed by • Validated by • Approved by • Sealed by

• Any changes that are to be made to a closed encounter can be added as a separate addendum to the DOS, but must be done in a timely manner.

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DOCUMENTATION CRITERA – PHYSICIAN AND STAFF

•Charts are well organized

•All chart entries are dated and signed or initialed

•All handwriting is legible

•No unexplained cross outs, write over, or squeezed in notes

•Reason for visit/chief complaint is noted

•Allergies or “NKDA” noted

•Current medication, RX, OTC or recreational are noted

•Medication orders include and renewals are:

–Evidence of dispensed written patient education materials are noted

–Significant phone calls are documented (advice, content and decision made)

–No unsubstantiated, subjective remarks are seen

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THE 10 COMMANDMENTS OF E/M DOCUMENTATION

1. The Documentation Must be Legible

If a record cannot be read or interpreted, it is of little value. However, with a little help, the coder or auditor should be able to handily decipher the provider’s documentation. Dictated or computer generated records can be a great benefit in this area.

2. Every Record Must Contain Basic Data

These include patient name, patient birth date, the encounter date and time, vital signs, allergies, and the location of the service. Upon completion, every record must be signed by the provider, whose printed name should also be a part of the record.

3. The Record Must Be Organized

Encounters should follow the format of: chief complaint, history, exam, and diagnosis/plan. The history (HPI) must be broken down into the review of systems (ROS) and the past, family, and social history (PFSH).

4. Documentation Must Match the Billed Services

Every billed service and its corresponding diagnosis code must be clearly documented in the medical record. For example, if the provider is relying upon the evaluation of two stable medical problems to support a level 4 encounter, the pertinent history and exam for each of the problems must be found in the record.

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THE 10 COMMANDMENTS OF E/M DOCUMENTATION

5. Medical Decision Making (MDM) Must Match Service Level

MDM is the overriding determinant of the level of service, and a billed service level should never exceed the MDM reflected in the documentation.

6. Addendums or Alterations Must Be Properly Identified

Ideally, an encounter should be fully and completely documented within eight hours, and certainly no more than 24 hours after the service. Additions to a completed record should be clearly labeled as such, and include the date, time and reason for the addendum. When making a late addendum, it is preferable to place it on a separate page from the original document to avoid the impression that the author was attempting to alter the original record. 7. Do Not Clone Medical Records

Cloning medical records refers to the abusive use of boilerplate data, or carrying forward large portions of a patient’s prior record to the current encounter.

8. Do Not Abuse Modifier 25

Modifier 25 is proper only when a separately identifiable E/M service is performed, in addition to another procedure or service.

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THE 10 COMMANDMENTS OF E/M DOCUMENTATION

9. The Necessity of Ancillary Testing Must Be Clear

When testing or procedures are part of the encounter, the reason and necessity for these items must be clearly documented or intuitively obvious to medical personnel. Although “rule out” diagnoses are not valid to submit for billing purposes, they can be used in the text of the record to explain the need for testing.

10. Note Face-to-Face Time for Time-Based Encounters

When time-based billing is used, a simple statement that over 50 percent of time was spent in consultation with the patient is required, as well as the total number of minutes spent “face-to-face” with the patient. The subject matter of the counseling should also be recorded in adequate detail to support the amount of counseling time

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EMR DOCUMENTATION - PITFALLS

•Templates and billing driving care and •Failure to review available information charting

•Inaccurate charting •Point-and-click mentality vs. accurate and

ethical documentation _{•Addendums for increased reimbursement}

vs. for patient care •Copy and paste forward

•Relative value unit (RVU) driven care •Charting for services that were not

performed; use of default entries _{•Signing of notes without reading them} •Documentation cloning _{•EHR revealing bad practice patterns} •Negatives listed vs. positives- hard to

discern what is wrong with the patient

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EMR DOCUMENTATION - SOLUTIONS

•Limit the copy and paste functions – In an

audit, copy and paste functions can be perceived as cloning

•Copy and paste also risks introducing documentation errors

•Document in your own words

•Review before closing notes for accuracy •Check the meds, test results and all

interventions with the patient

•Ensure that you are in agreement with the story you have depicted of the patient’s encounter

•Once you close the note, your only option for a correction is an addendum

•Addenda only pertinent clinical information not just revenue based

information – Do not get into the habit of adding documentation to support a higher service level unless the documentation is reflective of medical necessity

•Adding information on radiology

interpretations or documenting medication or other interventions that can boost a visit level should be done at the time of service to reflect the presenting problem’s severity, not as an afterthought.

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SUMMARY OF THE CHAPTERS IN THE TABULAR LIST

Chapter Code Range Estimated # of Codes Descriptions

1 A00-B99 1,056 Certain infectious and parasitic diseases 2 C00-D49 1,620 Neoplasms

3 D50-D89 238 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

4 E00-E89 675 Endocrine, nutritional and metabolic disease

5 F001-F99 724 Mental, Behavioral and Neurodevelopmental disorders 6 G00-G99 591 Diseases of the Nervous system

7 H00-H59 2,452 Diseases of the Eye and Adnexa

8 H60-H95 642 Diseases of the Ear and Mastoid process 9 I00- I99 1,254 Diseases of the Circulatory Process 10 J00-J99 336 Diseases of the Respiratory system

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ICD-10 THE BASICS

SUMMARY OF THE CHAPTERS IN THE TABULAR LIST

Chapter Code Range Estimated # of Codes Descriptions

11 K00-K95 706 Diseases of the Digestive system

12 L00-L99 769 Diseases of Skin and Subcutaneous Tissues 13 M00-M99 6,339 Diseases of the Musculoskeletal/Connective 14 N00-N99 591 Diseases of Genitourinary system

15 O00-O9A 2,155 Pregnancy, Childbirth and Puerperium

16 P00-P96 417 Certain conditions originating in the perinatal period

17 Q00-Q99 790 Congential malformations, deformations and chromosomal abnormalities.

18 R00-R99 639 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

19 S00-T88 39,869 Injury, Poisoning and Certain other consequences of external causes

20 V00-Y99 6,812 External causes of Morbidity

21 Z00-Z99 1,178 Factors influencing heatlh status and contact with health services

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WHY THE CHANGE TO ICD-10?

• The transition to ICD-10 is occurring because ICD-9 reports non-specific data about patients medical conditions and hospital inpatient procedures.

• ICD-9 is 30-years-old, has outdated terms and is inconsistent with current medical practices. • The structure of ICD-9 limits the number of new codes that can be created and many ICD-9

categories are full.

• Because ICD-10 codes are more specific than ICD-9, they will allow for better analysis with disease and public health patterns, in addition to providing for expansion.

• Expanded data capture: • Quality measurement • Reduce coding errors

• Better analysis of disease patterns

• Track and respond to public health outbreaks • Make claim submission more efficient

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ICD-10 THE BASICS

BENEFITS OF ICD-10 CODING SYSTEM

• It will provide much better data needed to:

• Measure the quality, safety and efficacy of care

• Reduce the need for attachments to explain the patient’s condition • Design payment systems and process claims for reimbursement • Conduct research, epidemiological studies and clinical trials • Set health policy

• Support operational and strategic planning • Design health care delivery systems

• Monitor resource utilization

• Improve clinical, financial and administrative performance • Prevent and detect health care fraud and abuse

• Track public health and risks

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OTHER IMPORTANT CHANGES TO NOTE FOR ICD-10

• Importance of Anatomy:

– Injuries are grouped by anatomical site, rather by type of injury.

• Incorporation of E and V codes:

– The V and E codes are incorporated into the main classification rather than separated into supplementary classifications we there were in ICD-9-CM.

• New Definitions

– In Some instances, new code definitions are provided reflecting modern medical practice (definition of acute myocardial infarction is now 4 weeks rather than 8 weeks).

• Restructure and Reorganization

– Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9.

• Reclassification

– Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge>

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ICD-10 CHALLENGES

PLANNING

• Need for physicians and payers to keep open the lines of communication with respect to the implementations of timelines.

• Average age of today’s coding professional is 54 – the health care industry could experience a shortage of qualified coders.

• Providers and payers need to invest resources to recruit and train new coding professionals. • The level of accuracy required for complete documentation will require physicians to be

more detailed in their reporting of patient interactions

• Failure to efficiently and accurately document patient encounters will result in:

– Possible backlogs

– Delays the processing of claims – Impacts the flow of revenue – Time and money lost

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PRODUCTIVITY

• Decreased ability to assign codes from memory

• Increased anatomy and physiology and medical terminology requirements

• Physicians’ encounters with patients will require more detailed description of the activities conducted during the encounters.

• Some estimates have stated that coder productivity could decrease by as much as 50% for an initial 6 – 9 months with an ongoing loss of approximately 15%.

• Learning from Canada’s version of ICD-10:

– After implementation, the average coding time per record doubled from 12-15 minutes to 33 minutes. – Turnaround time increased from 69 days to 139 days.

– Coding backlog also doubled.

• Clarification queries to physicians may also increase so that services can be coded to the highest level of specificity.

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ICD-10 EFFECT ON CLINICAL DOCUMENTATION

• ICD-10 coding introduces accurate representation of health care services through complete and precise reporting of diagnoses and procedures.

• ICD-10 will yield more thorough data for clinical decision making performance reporting, managed care contracting, and financial analysis.

• ICD-10 includes a more robust definition of severity, co-morbidities, complications, sequelae, manifestations, causes and a variety of other important parameters that characterize the patient’s conditions.

• A large number of ICD-10-CM codes only differ in one parameter. For example nearly 25% of the ICD-10-CM codes are the same except for indicating the right or left side of the body • Another 25% of the codes differ only in the way they distinguish among “initial encounter”,

versus “subsequent encounter”, versus “sequelae”.

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ICD-10-CM CODE STRUCTURE

• ICD-10 diagnosis codes have between 3 and 7 characters

• Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of any or all of the 4th_{, 5}th _{and 6}th

characters.

• Digits 4-6 provide greater detail of etiology, anatomical site and severity.

• A code using only the first three digits is to be used only if it is not further subdivided.

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ICD-10 THE BASICS

ICD-10-CM CODE STRUCTURE

• A code is invalid if it has not been coded to the full number of characters required. • This does not mean that all ICD-10 codes must have 7 characters.

• The 7th _{character is only used in certain chapters to provide data about the characteristic of}

the encounter.

• Examples of where the 7th _{character can be used;include injuries and fractures:}

Injuries and External Causes Fracture Value

Description Value Description

A Initial encounter A Initial encounter for closed fracture D Subsequent encounter B Initial encounter for open fracture S Sequela D Subsequent encounter for fracture with

routine healing

G Subsequent encounter for fracture with delayed healing

K Subsequent encounter for fracture with nonunion

P Subsequent encounter for fracture with malunion

S Sequela

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ICD-10-CM CODE STRUCTURE

• A dummy placeholder of “X’ is used with certain codes to allow for future expansion and/or to fill out empty characters when a code contains fewer than 6 characters and a 7th

character applies.

• When a placeholder applies, it must be used in order for the code to be considered valid. • Below are specific examples of ICD-10 diagnosis codes. The use of combination codes,

increased specificity, and the “X” placeholder is illustrated: Code Description

Combination Codes

I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

Increased Specificity

S72.044G Non-displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing

Laterality

C50.511 Malignant neoplasm of lower-outer quadrant of right female breast C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

“X” Placeholder

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ICD-10 THE BASICS

THE DIFFERENCES MAKE THE DIFFERENCE

ICD-9-CM Diagnosis Codes

•No Laterality

•3-5 digits

–First digit is alpha (E or V) or numeric

–Digits 2-5 are numeric

–Decimal is placed after the third character

•No placeholder characters

•14,000 codes

•Limited Severity Parameters

•Limited Combination Codes

•1 type of Excludes Notes

ICD-10-CM Diagnosis Codes

•Laterality –Right or Left account for >40% of codes

•7 digits

–Digit 1 is alpha; Digit 2 is numeric

–Digits 3–7 are alpha or numeric –Decimal is placed after the third character

•“X” placeholders

•69,000 codes to better capture specificity

•Extensive Severity Parameters

•Extensive Combination Codes to better capture complexity

•2 types of Excludes Notes

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MENTAL & BEHAVIORAL HEALTH CHAPTER NOTES

• The codes in this chapter include disorders of psychological development , but exclude symptoms, signs, and abnormal clinical laboratory finding (R00-R99).

• A number of changes to category and subcategory titles have been made; for example, ICD-9-CM subcategory 296.0 is Bipolar I disorder, single manic episode, but ICD-10-CM counterpart, category F30, is Manic episode.

• There is a change in sequencing involving the intellectual disability codes (F70-F79). • In ICD-9-CM, an additional code for any associated psychiatric or physical condition(s)

should be sequenced after the intellectual disability code but in ICD-10-CM any associated physical pr developmental disorder should be coded first.

• Unique codes for alcohol and drug use, abuse, and dependence (not specified as abuse or dependence).

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ICD-10 Mental & Behavioral Health

CHAPTER NOTES (cont.)

• History of drug or alcohol dependence coded as “in remission.”

• Combination codes for drug and alcohol use and associated conditions, such as withdrawal, sleep disorders, or psychosis.

• Blood Alcohol level codes.

• Under category F10, there is a “use additional code” note for blood alcohol level. • Blood alcohol level can be indexed in the index to External Causes.

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PAIN DISORDERS RELATED TO PSYCHOLOGICAL FACTORS

• Assign code F45.41, for pain that is exclusively related to psychological disorders

• As indicated by the Excludes 1 note under category G89, a code from category G89 should

not be assigned with code F45.41.

• Code F45.42, Pain disorders with related psychological factors, should be used with a code

from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain.

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MENTAL AND BEHAVIORAL DISORDERS DUE TO

PSYCHOACTIVE SUBSTANCE USE

In Remission

• Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the providers clinical judgment.

• The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting).

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MENTAL AND BEHAVIORAL DISORDERS DUE TO

PSYCHOACTIVE SUBSTANCE USE (cont.)

Psychoactive Substance Use, Abuse and Dependence

• When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.) only one code should be assigned to identify the pattern of use based on the following hierarchy.

 If both use and abuse are documented, assign only the code for abuse  If both abuse and dependence are documented, assign only the code for

dependence

 If use, abuse and dependence are all documented, assign only the code for dependence

 If both use and dependence are documented, assign only the code for dependence

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MENTAL AND BEHAVIORAL DISORDERS DUE TO

PSYCHOACTIVE SUBSTANCE USE (cont.)

Psychoactive Substance Use

• As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses).

• The codes are to be used only when the psychoactive substance use is associated with a mental or behavior disorder, and such a relationship is documented by the provider.

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CONTACTS

If you have any questions or concerns about the information presented here, please contact Shannon Chase or Mary Ellen Reardon and we will be glad to assist you.

Schenectady - East Shannon Chase

SChase@mvphealthcare.com

518-386-7502

Rochester – Western and Central NY Mary Ellen Reardon

MReardon@mvphealthcare.com

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MVP Health Care

CLINICAL DOCUMENTATION ICD-9 and ICD-10