12 ky-tn mosier session 5 powerpoint

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3M Health Information Systems

The ICD-10 Coding System & Impact on CM/SW/UM

ACMA KY/TN Chapter Education

© 3M 2012. All rights reserved. Confidential and Proprietary.

Joyce Mosier, MBA, RN, CPHQ, ACMSeptember 6, 2012

Objectives

Explain the premise of ICD-10-CM/PCS

ICD-10 impact for Case Management, Social Work and Utilization Management

Assess ways Case Management Utilization Management and Social

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Assess ways Case Management, Utilization Management and Social Work can benefit from this system

3M Health Information Systems3M Health Information Systems

Global use of ICD-10: US Catching up with the Industrialized World

PolandPoland

United StatesUnited States

IcelandIceland

DenmarkDenmark

AustriaAustria

NorwayNorwayFinlandFinland

CanadaCanada

SwedenSweden

GermanyGermany

SwitzerlandSwitzerland

UKUKIrelandIrelandCzech RepublicCzech RepublicThe NetherlandsThe Netherlands

FranceFrance

ThailandThailand

BrazilBrazil

New New ZealandZealand

ArgentinaArgentinaAustraliaAustralia

SingaporeSingapore

ChinaChina JapanJapan

VenezuelaVenezuela

ColombiaColombia

Costa Costa RicaRica

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Overview

The United States has been using ICD-9-CM since 1979 and is the last industrialized nation to move to ICD-10.

On January 16, 2009, CMS published final rule CMS-0013-F mandating the adoption of the ICD-10-CM and ICD-10-PCS code sets to replace ICD-9-CM under HIPAA.

The original compliance date for implementation was October 1, 2013, however CMS has announced a delay for some entities--the date of implementation is pending.

The delay allows more time for hospitals and physicians to prepare for the ICD-10 transition.

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The Need for ICD-10

The ICD-9-CM code set is 30+ years old.

ICD-9 is no longer supported or maintained by the World Health Organization (ICD-10 was adopted by WHO in 1990).

Difficulty in assigning new codes Many chapters of ICD-9-CM are full

V l bl d t i l t d d t i ffi i t Valuable new codes are not implemented due to insufficient space.

ICD-9 is not able to provide sufficient codes for healthcare encounters for reasons other than disease (e.g. preventive care). Terminology often insufficient, obsolete and inconsistent with current medical practice and the medical technology being developed and in use today.

ICD-9-CM does not meet all HIPAA requirements for adopted standards.

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Federal Register January 16, 2009

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The Need for ICD-10

ICD-10 is needed to obtain full benefit for: Updated medical terminology more consistent with the 21st century Tracking of diseases/procedures/preventative care Better measuring of quality outcomes - Improved data allows for more

accurate severity of illness and risk of mortality data for profiling Data exchange Full use of HIT tools and technology (e g computer assisted coding Full use of HIT tools and technology (e.g. computer assisted coding ,

computer assisted coding for clinical documentation improvement, computer assisted coding for physician documentation)

Better specificity of medical necessity criteria Improved data allows for more accurate reimbursement for services

provided Procedure coding system allows for expansion and addition of new

technology

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Requirements for ICD-10-CM and ICD-10 PCS

Use of ICD-10-CM and ICD-10-PCS applies to all covered entities (health care providers, health plans, and healthcare clearing houses) that transmit electronic data based on the Health Insurance Portability and Accountability Act (HIPAA) transaction standards.

ICD-10-PCS codes are only required to be used by hospitals to report y q y p pinpatient procedures.

CPT codes will continue to be used for outpatient and physician billing.

However, some entities (hospitals, ambulatory surgery centers, etc) are choosing to assign ICD-10- PCS codes in their ambulatory settings even though it is not mandated..

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New Code Set

DiagnosisICD-9 CM ICD-10 CM

In & Outpatient In & Outpatient

# of Codes ~13,000 ~70,000

# of Characters 3-5 Alphanumeric 3-7 Alphanumeric

Effective ?

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ProceduresICD-9 CM ICD-10 PCSInpatient Only Inpatient Only

# of Codes ~4,000 ~72,000

# of Characters 3-4 Numeric 7 Alphanumeric

NOTE: CPT codes will continue to be used for hospital outpatient procedure coding

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ICD-10-CM – Diagnosis Coding

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Examples of ICD-9 and ICD-10 Diagnosis Codes

Acute Anterior

MI410.11410.11 I21.09I21.09

CHF 428 0428 0 I50 9I50 9CHF 428.0428.0 I50.9I50.9

CAD w/ Angina

414.00, 413.9

414.00, 413.9 I25.119I25.119

MVP 424.0424.0 I34.1I34.1

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Myocardial infarction Documentation will need to include:

• Type of infarction• STEMI • NSTEMI

• Age of infarction

Documentation for Cardiology/Cardiothoracic Diagnoses

• If within 4 weeks coded as initial• If older than 4 weeks coded as “old”

• Specific site of myocardium involved• anterior wall• inferior wall

• Coronary artery involved• Information regarding treatment - initial or subsequent MI

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Unique ICD-10-CM Guidelines

Circulatory System

Acute Myocardial Infarctions (AMI) are identified by the site of the infarction along with the coronary artery involved.

The acute phase of the AMI is within 4 weeks of onset.

If a patient suffers a subsequent AMI within 4 weeks, a code for both conditions is used, and sequencing depends on the reason for admission

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admission.

Note the change in the age of the MI. In ICD-9-CM it was 8 weeks. In ICD-10-CM it is 4 weeks. • Think about past data comparing subsequent MI prevalence to current

episodes of subsequent MI occurrence. What impact might that have on data assessment of related outcomes?

A combination (single) code identifies both ASHD or CAD and angina.

Documentation Changes

Combination codes - In some cases a single code has been established to classify: 2 diagnoses A diagnosis with a manifestation or secondary process A diagnosis with a complication

Examples:

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Pathological compression fracture of the vertebrae due to osteoporosis, initial visit -M80.08xA

Type 2 DM with gastroparesis – E11.43 Stage III Pressure Ulcer R. Heel – L89.613 CAD with unstable angina – I25.110 Diverticulitis, large intestine with perforation, abscess and bleeding – K57.21

Documentation for Cardiology/Cardiothoracic Diagnoses

Hypertension HTN and chronic kidney disease are assumed to be a causal relationship;

however, it is important to document the stage of the CKD HTN and heart disease are not assumed to be linked and must be documented

when related. It is also important to state if heart failure is present. Examples include: Heart disease due to hypertension Hypertensive heart disease

H t i h t di d CKD ith h t f il d St 4 CKD Hypertensive heart disease and CKD with heart failure and Stage 4 CKD

CHF Specify acuity - acute , chronic or acute on chronic Specify type - systolic and/or diastolic heart failure Specify if CHF is a manifestation of another etiology (cardiomyopathy, HTN

heart disease, renal failure) The above documentation rules are the same in ICD-9- CM today; however this

remains an area of poor compliance

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Renal Diseases

Chronic Kidney Failure is assigned by Stage in both ICD-9 and ICD-10.

Stage I

Stage II

Stage III

Stage IV

Stage V

ESRD

Acute Kidney Failure is reported based on cause in both ICD-9 and ICD-10 (eg. Acute Kidney Failure due to tubular necrosis)

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Dementia

Dementia is classified by type, or relationship to other disease processes:

Alzheimer’s Dementia Early or late onset

Dementia with or without behavioral disturbances

Aggressive behavior

Combative behavior

Violent behavior

Wandering off

Vascular or Multi-Infarct Dementia

Alcohol or drug induced Dementia

Dementia with Lewy Bodies or Parkinson’s

Pick’s Disease with Dementia

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Examples of Documentation Requirements

In ICD-10, respiratory failure no longer defaults to acute. Physician must specify if acute, chronic or acute on chronic

Respiratory Failure

Specify acuity - acute, chronic or acute on chronic

Document if respiratory failure is due to a specify etiology

Respiratory failure is assigned as a combination code that not only details the severity of respiratory failure, but also association with hypoxia or hypercapnia.

Hypoxia – insufficient oxygen reaching the tissue

Hypercapnia – excess carbon dioxide in the blood

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Examples of Documentation Requirements continued

Asthma

Specify severity type as mild intermittent

mild persistent

moderate persistent or

severe persistent

Specify status of asthma - uncomplicated, with acute exacerbation, or with p y p , ,status asthmaticus

Core measure – “Use of appropriate medications for asthma

Percentage of patient 5-50 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement year. Report three age stratifications (5-11 years, 12-50 years, and total).”

Source: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/CQM_EPs_2012_02_02.pdf

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Examples of Documentation Requirements continued

Specify if the patient has any other diseases associated with asthma (COPD, bronchitis, etc.)

COPD

Specify if acute component such as exacerbation, bronchitis or lower i t i f tirespiratory infection

Specify if oxygen dependent

Specify if in chronic respiratory failure

If Asthma and COPD are reported together, they are coded separately in ICD-10.

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Pneumonia – Core Measure Diagnosis Pneumonia is classified by type and linked to the organism in both ICD-9 and ICD-10.

Types of pneumonia: Lobar pneumonia Aspiration pneumonia Pneumonia with influenza Pneumonia due to bacteria Viral pneumonia Organizing pneumonia Hypostatic pneumoniaHypostatic pneumonia Bronchopneumonia

In ICD-10-CM is there no specific code for ‘isolation’ or for flu shots. If running data related to number of patients over certain age or with specific diagnoses to see if they had a flu shot, proactively assigning an indicator may be needed.

Core measure – Pneumonia vaccination status for older adults – Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

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Anemia

Anemia in both ICD-9 and ICD-10 can be classified by specific type or cause

Anemia due to malignancy – anemia is principal diagnosis in ICD-9-CM. In ICD-10-CM it is secondary and the malignancy is principal.

Take this into consideration if running data for quality or readmission reports.

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Clinical examples of DRG changes in ICD-10

Change in coding

• In ICD-10, malignancy must be sequenced as PDX over the anemia

• Lung Cancer

• Anemia

MS-DRG

182 Respiratory Neoplasms

without CC/MCC

R.W.

ICD-10

$3,643.8096

• Anemia• Lung

Cancer

MS-DRG 812 Red Blood

Cell Disorders without MCC

R.W.

.7957

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ICD-9

ICD-10 MS-DRG is better

Assumes blended rate of $4,500

$3,419


Dominant/Nondominant Hemiplegia and monoplegia codes have a digit to identify dominant versus

nondominant side. If unspecified, the default code is dominant.

Glasgow coma scale In a Traumatic Brain Injury or sequela of a CVA, the Glasgow coma scale

can be coded along with the condition to more accurately reflect the can be coded along with the condition to more accurately reflect the patient’s condition

Musculoskeletal Conditions in the musculoskeletal system involving bone, joint or muscle

are reported by type and cause and have specific designations for site and laterality

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Injuries, Poisoning, Adverse Effects, Underdosing and Toxic Effects Injuries and poisonings, adverse effects, underdosing and toxic effects – For many of

the codes related to these diagnoses there is a character within the code to denote the episode of care for which the condition is being treated – the encounters with their associated characters are: A = initial encounter D = subsequent encounter S = sequela

In ICD-9 levels of the spinal cord were grouped while in ICD-10 there is specificity for levels.

Example: Each cervical level is identified. Thoracic levels have T1 separate and others grouped: T2 – T6, T7 – T10, T11 –

T12.

Fractures have a unique 7th character extension which indicates open or closed fracture, initial or subsequent encounter with delayed healing, malunion or nonunion.

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Injuries, Poisoning, Adverse Effects, Underdosing and Toxic Effects continued

Underdosing is new in ICD-10-CM

Codes for taking less of a drug, medicament or biological substance have been added to the Table of Drugs and Chemicals Specificity exists for intentional or unintentional.

No funds? No access to medications? Taking less than prescribed?

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Clinical examples of DRG changes in ICD-10

• In ICD-10-CM, two rib fractures code to multiple rib fractures and by laterality (S2241xA)

• SDX of Acute Respiratory Failure

MS-DRG 183 Major

Chest Trauma

with MCC

R. W.

1.4942

Change in coding specificity

Rib fractures in ICD-9 CM are classified differently in ICD-10 causing a DRG change based on the increased specificity

ICD-10

$6,7241.4942

• Right Rib FXs are coded in ICD-9-CM by ribs fractured (807.02)

• SDX Acute Respiratory Failure

MS-DRG 205 Other

Respiratory System DX with MCC

R. W.

1.2972

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ICD-9

ICD-10 MS-DRG is better

Assumes Blended Rate of $4500

$5,837

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Fracture of femur

S72021E Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with routine healing

S72021F Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

S72021G Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for closed fracture with delayed healing

72021H Displaced fracture of epiphysis (separation) (upper) of right femur subsequent72021H Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with delayed healing

S72021J Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

S72021K Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for closed fracture with nonunion

72021M Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with nonunion


Diabetes (E08 – E13) A combination code identifies the type of diabetes, the associated

complication or manifestation and the body system involved.

Inadequately controlled, out of control and poorly controlled are coded to Diabetes, by type, with hyperglycemia.

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If the type of diabetes is indicated as secondary to another disease process or a drug, then that diabetic code is listed as secondary to the underlying cause

Most frequent MCC/CC changes within ICD-10

Diagnoses that are no longer MCC/CCs in ICD-10 MS-DRGs Esophageal Hemorrhage (no longer a MCC)

Type II Diabetic Ketoacidosis (no longer a MCC)

Malignant HTN (no longer a CC)

Non-healing surgical wound (no longer a CC)

Schizoaffective Disorders, Specified types (no longer a CC)

Major Depression, NOS (no longer a CC)

Code 403.00, Mal HTN w/ CKD (no longer a CC)

Hemorrhage into bladder wall (596.7) is a CC in I-9 (no longer a CC)

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Most frequent MCC/CC changes within ICD-10

Diagnoses that are CCs in ICD-10 MS-DRGs but are not in ICD-9:• Bi-fasicular Block(s)—Example: 426.52 (RBB/LAFB) is not a CC in

ICD-9, but I452 is a CC in ICD-10.

• Concussion, Unspecified and Unspecified Duration of LOC is a CC in ICD-10in ICD-10.

• 344.61 Cauda Equina is not a CC in ICD-9 but G834 is a CC in ICD-10.

• Code 136.1 Behcet Syndrome (type of vasculitis) is not a CC in ICD-9 but is a CC in ICD-10 (M352).

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ICD-10-PCS - Procedure Coding System

ICD-10-PCS Code Structure

The ICD-10-PCS code structure consists of a seven character, alphanumeric code structure

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

There are no decimal points associated with the structure

00 BB 5 5 88 88 Z Z ZZ There are no decimal points associated with the structure

Each character represents an aspect of the procedure

The same value means the same thing within a section but placed in a different character position has a different meaning

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System Structure: Section Characters -There are 16 sections

0 Medical and Surgical1 Obstetrics2 Placement3 Administration4 Measurement &

Monitoring

8 Other Procedures9 ChiropracticB ImagingC Nuclear MedicineD Radiation Oncology

Monitoring5 Extracorporeal Assistance

& Performance6 Extracorporeal Therapies7 Osteopathic

F Physical Rehabilitation and Diagnostic Audiology

G Mental HealthH Substance Abuse

Treatment

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00 22 11 11 00 9 9 WW

Each Code Tells a Story:

SectionBody

SystemRoot

OperationBodyPart Approach Device Qualifier

ICD-10-PCS

A character is a stable, standardized code componentHolds a fixed place in the codeRetains its meaning across a range of codes

A value is an individual unit defined for each character

Med/Surg

Heart and Great Vessels

Bypass

Coronary Artery, Two

Sites

Open

AutologousVein Tissue

Aorta

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Body-System Values-Medical Surgical0 Central Nervous System1 Peripheral Nervous System2 Heart and Great Vessels3 Upper Arteries4 Lower Arteries5 Upper Veins6 Lower Veins7 Lymphatic and Hemic System

K MusclesL TendonsM Bursae and LigamentsN Head and Facial BonesP Upper Bones Q Lower BonesR Upper JointsS L J i t7 Lymphatic and Hemic System

8 Eye9 Ear, Nose, SinusB Respiratory SystemC Mouth and ThroatD Gastrointestinal SystemF Hepatobiliary System and PancreasG Endocrine SystemH Skin and BreastJ Subcutaneous Tissue and Fascia

S Lower JointsT Urinary SystemU Female Reproductive

SystemV Male Reproductive

SystemAnatomical RegionsW General X Upper ExtremitiesY Lower Extremities

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Body-System and Body-Part Values

Body System (2nd character)Body systems are composed of organs that work together to perform specific functionsDefines the general physiological system/anatomical region on which the procedure is performed

Body Part (4th character)Body parts are those organs that combine to performspecific functionsDefines the specific anatomical site where the procedure is performed

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Uniqueness of ICD-10 PCS

Procedures: Anatomically Driven

ICD-10 –PCS is more anatomically specific than ICD-9 CM procedures codes

Device characteristics (examples) Autologous vein or artery tissue Synthetic substitute Nonautologous tissue substitute Drug eluting intraluminal device Intraluminal device Zooplastic Tissue Implantable heart assist system External heart assist system

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Uniqueness of ICD-10 PCS

Procedures require:

Laterality of site

Specificity of approach

Open

Percutaneous

Percutaneous endoscopic

Via natural or artificial opening

Via natural or artificial opening endoscopic

Open with percutaneous endoscopic assistance

External

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Root operations

Coders are required to know the root operation definitions and apply them accurately.

Physicians are not required to know the root operation definitions and should not be queried.

Example root operations in Medical / Surgical section:

C t l St i tt ti t t t d l bl di Control – Stopping, or attempting to stop, postprocedural bleeding.

Destruction – Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent.

Detachment – Cutting off all or part of the upper or lower extremities

Drainage – Taking or letting out fluids and/or gases from a body part.

The qualifier ‘diagnostic’ is used to identify drainage procedures that are diagnostic.

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Root Operation Examples continued

Extirpation – Taking or cutting out solid matter from a body part. Example: Thrombectomy.

Excision – Cutting out or off, without replacement, a portion of a body part. The qualifier ‘diagnostic’ is used to identify excision procedures that are

diagnostic. Resection – Cutting out or off, without replacement, all of a body part. Repair – Restoring to the extent possible a body part to its normal anatomic Repair – Restoring, to the extent possible, a body part to its normal anatomic

structure and function. Reposition – Moving to its normal location or other suitable location all or a

portion of a body part. Example: fracture reduction. Removal – Taking out or off a device from a body part. Replacement – Putting in or on a biological or synthetic material that

physically takes the place and/or function of all or a portion of a body part. Example: Total hip replacement.

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PCS Section for Bypass

Bypass – Altering the route of passage of the contents a tubular body part.

Cardiology bypass – body part is the number of distinct sites bypassed “to” rather than the name of the vessel. The qualifier captures the origin “from” of the bypass

Example: Two vessel CABG using the right internal mammary artery.

Other bypasses – body part is the origin “from” of the bypass. The qualifier captures the body part bypassed “to”.

Examples: Transverse colon to cutaneous (colostomy to skin) Right femoral artery to right popliteal artery Tracheostomy is trachea to cutaneous Stomach to jejunum

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Example PCS Section for Assigning a Bypass PCS CodeFirst Three Characters are

Obtained Here

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Coronary Bypass Coding Guideline

B3.6b Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from. Example: Aortocoronary artery bypass of one site on the left anterior descending

coronary artery and one site on the obtuse marginal coronary artery is classified y y g y yin the body part axis of classification as two coronary artery sites and the qualifier specifies the aorta as the body part bypassed from.

B3.6c If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier. Example: Aortocoronary artery bypass and internal mammary coronary artery

bypass are coded separately.

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Comparison of ICD-9-CM and ICD-10-PCS Surgery Codes

ICD-9-CM Procedures 3-4 digits

All numeric

Limited expandability

ICD-10-PCS 7 characters

Alpha numeric

Expandable

Patient ICD-9-CM Code ICD-10-PCS Codes

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Patient ICD 9 CM Code ICD 10 PCS Codes

A patient lacerates the digital artery on his/her right index finger while washing dishes requiring suture of the digital artery

3931

Suture of Artery

03QD0ZZ

Repair right hand artery, open approach

A patient is stabbed in the chest lacerating his/her aorta requiring an open chest procedure to suture the aorta

3931

Suture of Artery

02QW0ZZ

Repair Thoracic Aorta, open approach

ICD-10-PCS Example

Cholecystectomy – Is this an excision or resection? Open cholecystectomy – OFT40ZZ

Lap cholecystectomy – OFT44ZZ

ICD-10-PCS Code Structure

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Node biopsy If an ultrasound guided fine needle biopsy of a lymph node is done, the root

operation is drainage – taking or letting out fluids and/or gases from a body part. The qualifier diagnostic is used to identify drainage procedures that are biopsies.

If one or more lymph nodes are removed but less than the entire chain, the root operation is excision – cutting out or off, without replacement, a portion of a body part. The qualifier diagnostic is used to identify drainage procedures that are biopsies. biopsies.

Example: 07B53ZX Excision right axillary lymphatic percutaneous approach diagnostic

If the entire chain is removed the root operation is resection – cutting out or off, without replacement, all of a body part. No qualifier for diagnostic is used.

Example: 07T60ZZ – Resection left axillary lymphatic via open approach

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Documentation detail on forms

Administration of blood products

Specificity is required for Site – peripheral vein, central vein, peripheral artery or central artery

Donor type – as autologous or non-autologous

Ventilator assistance - are forms clear with start time and end time, when i i i ? weaning is in progress?

ICD-10-CM/PCS delineates time as <24 consecutive hours, 24-96 consecutive hours and > 96 consecutive hours. The chart must be clear with the start and end times.

Where are the gaps today?

Largest gaps identified from readiness assessment roadmaps:• Budgetary needs• IT remediation• Lack of physician documentation

I di /CDI d i i• Impact to coding/CDI productivityPlans to dual code prior to October 2014

• Training and education of coding/CDI staff and physicians• Need for assistance in translating ICD-9 codes into

ICD-10 codes

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Common Question- What is the Impact to Reimbursement??

Here is what we know today:

The ICD-10 version of MS-DRGs posted on the CMS website replicates the ICD-9 version of the MS-DRGs (subject to change between now and implementation date) The posted version of ICD-10 version MS-DRGs is unlikely to cause a

significant redistribution of payments across hospitals O ffi i t d t d i ICD 10 CM/PCS b il bl CMS ill Once sufficient data code in ICD-10-CM/PCS becomes available, CMS will

likely use the increased specificity of ICD-10-CM/PCS to enhance the MS-DRGs

If hospitals are losing money in current MS-DRG’s with ICD-9-CM coding and the lack of higher specificity/documentation they will continue to lose money under ICD-10-CM/PCS

Payers have not stated they will remain budget neutral Payer market is very active and ahead of provider market in preparing for ICD-

10-CM/PCS

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Impact on Hospitals

Hospitals and Physicians will be required to undertake significant planning efforts for ICD-10 implementation, budgeting for capital and anticipated operational expenses, a complete systems inventory and development of educational activities to prepare staff.

The implementation of ICD-10 will impact every: Paper and software system Information system Functional department

Scheduling – preauthorization & medical necessity Admission Admission Physician/Clinical Care Case Management Lab, Radiology and other Ancillary areas Transcription Performance management HIM Department & HIM system Billing and Accounting Contract management Payer relationships Data warehouse

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Impact on Clinical Providers

Clinical provider documentation is the foundation of ICD-10 specificity; incomplete documentation will impede ability to code accurately.

Physicians and other Clinicians will need to undergo training to learn about the detailed documentation that ICD-10 requires of them. Training will need to be general awareness as well as specialty-based.g g p y

Clinical providers will need to collaborate closely with the HIM Coding and the Clinical Documentation Improvement teams.

Changes may need to be made to existing systems and processes such as clinical documentation, practice management systems, electronic billing systems, and encounter forms/superbills.

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Impact to Clinical Documentation Improvement Team

If your hospital has a Clinical Documentation Improvement Team, the CDI specialists (CDIS) will need to be trained on the detailed documentation requirements for ICD-10.

A CDI team can be instrumental in working with clinicians/physicians to ensure the specificity and level of detail needed to support ICD 10 is captured in the the specificity and level of detail needed to support ICD-10 is captured in the clinicians’ medical record documentation.

Existing CDI program may only touch Medicare; ICD-10 is across all payers.

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Impact on Coding Staff

Coding Staff will need to be extensively trained to become fully proficient in ICD-10 coding. Educational requirements will differ based on the coder’s responsibility.

Coding Staff will need to have a deeper knowledge of the biomedical sciences than was required under ICD-9-CM. Specifically in the areas of: anatomy and physiology pathophysiology pharmacology pharmacology medical terminology

In addition, staff need better comprehension of operative and procedure reports.

Contrast for radiology or cardiology services Some ICD-10-PCS code descriptions for imaging procedures include the type of

contrast utilized. Example: Arteriogram of left vertebral artery

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Summary

Physician offices and ambulatory care will continue to use CPT for procedural codes.

Hospitals will team with physicians to query when more documentation is needed.

Physician engagement and responsiveness to queries will assist in Physician engagement and responsiveness to queries will assist in capturing the most accurate coding of the patient’s acuity and outcomes.

ICD-10 will require further documentation of specificity of diseases by all entities (inpatient, extended care facilities, physician offices or clinics).

Physician offices will be impacted most in the area of medical necessity and need to provide specified diagnoses, diagnostics, and care.

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Summary continued

Case Management, Social Services and Utilization Management will be impacted in the area of medical necessity and the process to authorize/precertservices, (OR case boarded with use of CPT code or ICD10-PCS?) obtaining readmission data, tracking avoidable day data, facilitating transfer to post discharge care providers, evaluating patients for transfer to another facility with awareness of reimbursement impacted by transfer, and tracking quality p y , g q yindicators.

CM/SW/UM can benefit from more specific data to establish screening priority for discharge planning, assess outlier trends, quality issues, readmission drivers, medical necessity roadblocks.

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Questions?

Queries?

Confabulation?

Wishful thinking?

Hopeful outcomes?

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12 ky-tn mosier session 5 powerpoint

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