hts icd-10 training -...

HTS ICD-10 Training 5/19/2015

Proactive Medical Review & Consultants, LLC. 1

HTS ICD-10-CM

Training

Objectives • Will learn the history and development of ICD-10

• Will understand the ICD-10 terminology and coding

guidelines

• Distinguish the similarities and differences between ICD-9 and ICD-10

• Demonstrate the ability to assign correct ICD-10

codes within Rehab Optima

ICD History • ICD – International Classification of Diseases

We have been using this system since the 1990’s

to assign diagnosis codes for reimbursement, morbidity & mortality statistics, and automated

decision support in health care

• Owned and published by World Health

Organization (WHO)

• ICD-9-CM: the ninth revision, clinical modification has been used since 1979

• ICD-10: was developed in the 90’s and has been

used in other countries



ICD-10 Compliance Dates • The Federal Government has mandated the

change from ICD-9 to ICD-10 effective October 1,

2015

• SNF claims will be based on DOS

September, 2015 claims will use ICD-9

October, 2015 claims will use ICD-10

Why Change? • Greater specificity and detail

• Combination codes

• Code titles and languages complement accepted

clinical practice

• Potential to reveal more about quality of care

Organizational Changes ICD-9-CM ICD-10-CM

17,000 codes 70,000 codes

Uses of V and E codes Incorporated into the main classifications

Classifies injuries by type Groups injuries first by specific site and then type

3-5 numeric characters (except V and E)

3-7 alpha and numeric codes, all letters except “U” is used

No Laterality Laterality

No place holders May use place holders (i.e. X)



Example of Structure

• S52 - Fracture of forearm

• S52.5 – Fracture of lower end of radius

• S52.52 – Torus fracture of lower end of radius

• S52.521 – Torus fracture of lower end of Right radius

• S52.521D – Torus fracture of lower end of R radius,

subsequent care

Episode of Care 7th Character used for Injuries and certain other

consequences of external causes

• “A” - Initial encounter: used in the hospital (surgery, emergency room visit/observation)

• “D” – Subsequent encounter: used after the patient

has received active treatment of the condition and

is receiving routine care during the healing or recovery phase

• “S” – Sequela: used to indicate conditions after the

acute phase of illness has ended



CVA • Sequela of cerebrovascular disease (I69) – residual

effects after the acute phase of illness has ended

• Types of CVA’s:

Nontraumatic subarachnoid hemorrhage

Nontraumatic intracerebral hemorrhage

Nontraumatic intracranial hemorrhage

Cerebral infarction

Other cerebrovascular disease

Unspecified cerebrovascular disease

Dominant vs. Non-dominant

• Hemiplegia – “Should the affected side be

documented, but not specified as dominant or nondominant then left side is always nondominant.”

Myocardial Infarction • Acute myocardial infarction – 4 weeks or less (I21)

even if transferred to a post-acute setting, as

long as receiving continued care for the MI

• If receiving care r/t MI after 4 week time frame, use most appropriate aftercare code

• For MI > 4 weeks old not requiring further care use

125.2- Old MI



Fractures Should not use aftercare codes and instead code the fracture and then use the appropriate 7th character describing the episode of care (usually subsequent care)

Example: Patient admitted for rehab following a nondisplaced greenstick fracture of the shaft of the left humerus due to a fall at home one month ago when she tripped over her cat. She has pain in the shoulder and now has muscle weakness and shoulder joint stiffness.

• S42.312D - D in 7th character indicates subsequent care for routine healing of traumatic fracture

• Would also code the joint stiffness M25.612, shoulder pain M25.512, and muscle weakness/atrophy M62.512

Fracture Specificity Type of fracture

Anatomical Site

Displaced vs. nondisplaced

Laterality

Routine vs delayed healing

Nonunion vs malunion

Type of encounter

Fracture Specificity Rules • A fracture not indicated as displaced or

nondisplaced should be coded to displaced

• A fracture not designated as open or closed should be coded to closed

• Pathological fracture must describe the underlying

disease

• Traumatic fracture s/p ORIF surgery, code the

fracture first and then the presence of the artificial joint

• No fracture, just ORIF surgery, code just the

presence of the artificial joint



Pathological Example • Patient is an 82 year old female with a known history of

osteoporosis who is referred to outpatient therapy for a

pathological fracture of the shaft of her left humerus that occurred 1 month ago. She has pain in the shoulder

and now has muscle weakness/atrophy and shoulder

joint stiffness. She is still being seen by the physician for routine healing of the fracture during the recovery phase

• Since patient has a known history of OP that caused the

fracture and she is still under the care of a physician for routine healing, you would code: M80.022D

• Would also code the joint stiffness M25.612, shoulder

pain M25.512, and muscle weakness/atrophy M62.512

Traumatic Fx s/p ORIF Example

• Patient is an 83 year old female who fell out of her

bed and fractured her right hip. Patient had a right

total hip arthroplasty performed 2 weeks ago and is now entering a SNF for rehab. She is WBAT using a

walker for ambulation and her right hip pain is 4/10.

• Would code Z96.641 for the presence of right artificial hip joint, S72.111D for displaced fracture of

greater trochanter of right femur, R26.2 for difficulty in walking, M25.551 for the right hip pain

Non-traumatic/No Fx, S/P ORIF

Example • Patient is a 74 year old male who underwent a left

total knee replacement one week ago. Patient is

WBAT using a walker, complains of 6/10 pain in the left knee, presents with left knee effusion and

impaired ROM in knee extension and flexion.

• Would code left knee pain M25.562, difficulty walking R26.2, left knee effusion M25.462, left knee

stiffness M25.662, and presence of left artificial knee joint Z96.652



Laterality • Right

• Left

• Bilateral

• Unspecified

• If bilateral is not available, assign code for right and

left

Other specified vs. Unspecified

• Other specified - your know what specific type it is,

but it is not listed for you to choose

• Unspecified – you do not know the specific type, so you are using a “general” code

Admission/Encounters for Rehab

• No equivalent code for V57 therapy codes o V57.89 Multiple therapies

o V57.1 Care involving PT

o V57.21 Care involving OT

o V57.3 Care involving ST

• When reason for admission is for rehabilitation,

sequence first code for condition for which the

service is being performed

Example: Admitted for therapy for right sided dominant hemiplegia following a CVA.

o Code I69.351-Hemiplegia & hemiparesis following cerebral

infarction affecting right dominant side



Encounter for Rehab Example:

• 74-year-old patient fell at home and sustained a

subtrochanteric fracture of the left femur and was

discharged from the hospital to a SNF. Physician ordered PT for difficulty in walking.

ICD-10 codes on the UB-04

Medicare Part A Rehab to Home Medicare Part A LTC Resident

• Principal diagnosis - the medical reason for hospitalization

Example:

Hospitalized for COPD exacerbation admitted to SNF for short-term rehab

Code principal diagnosis as COPD exacerbation (J44.1)

Therapy would also code COPD as medical diagnosis

• Principal diagnosis - the medical reason for why they require LTC

Example:

Hospitalized for COPD exacerbation admitted to SNF for rehab and will remain in LTC

Code principal diagnosis as Alzheimer’s disease (G30.9)

Therapy would use COPD as medical diagnosis

Secondary Codes Currently no guidelines on sequencing secondary

codes:

These additional codes should include other comorbidities that have an effect on resident’s

complexity, clinical conditions that arose in the

SNF, and diagnosis that may affect the resident’s treatment or length of stay



Therapy Medical Diagnosis

• On the therapy evaluation/POC, therapists always

use the medical reason for why therapy is medically necessary regardless of rehab to home or LTC

placement. This may or may not be the same as

the facilities principal diagnosis

Therapy Medical Diagnosis Example:

• Resident with Parkinson’s Disease returns after a MCR qualifying hospitalization for pneumonia to start a new Medicare Part A stay.

Pneumonia is listed as the medical diagnosis on the therapy eval/POC to support the skilled therapy services along with the appropriate therapy treatment diagnoses. However, Parkinson’s is the reason for the continued facility stay (principal diagnosis) and continues to be sequenced first on the diagnosis list and UB-04, with pneumonia being sequenced second.

Diagnosis Management

o Only the provider can determine a diagnosis

o Only code what is documented in the medical

record by the provider

o Always code to the highest level of specificity

o Inconsistent, missing, or conflicting documentation must be resolved by the provider



Facility Process for Assigning ICD-10 Codes

• Who determines what codes to use?

• Within 24 hours?

• Where will they be recorded? o On Face Sheets?

o A diagnosis list?

o In the computer

• Do all staff have access to the diagnosis?

• How are they updated?

• Are they recorded in section “I” of the MDS?

Resources

• CMS website: www.cms.gov.ICD10 • ICD-10-CM Tabular List of Diseases and Injuries – lists the 21 chapters of the

Code Book by National Center for Health Statistics (NCHS)

• ICD-10-CM Index to Diseases and Injuries – alphabetical index

• NCHS ICD-10 Guidelines:

http://www.cdc.gov/nchs/icd10cm.htm

• Proactive SNF Diagnosis Documentation Guidance

• Proactive Table of Commonly used Primary/Medical

and Therapy Treatment diagnosis in SNF

Local Coverage Determinations

WPS Indiana CGS Kentucky

• LCD Dysphagia

(L34438)

• LCD Wound Care (L34587)

www.wpsmedicare.com

• LCD Speech-language

pathology (L34046)

• LCD Outpatient PT and OT services (L34049)

www.cgsmedicare.com

http://www.cms.gov.icd10/

http://www.cdc.gov/nchs/icd10cm.htm

http://www.wpsmedicare.com/

http://www.cgsmedicare.com/



CGS LCD Outpatient PT and OT Services (L34049)

• No ICD-10 codes are listed to support medical

necessity

ICD-10-CM Tabular List of Diseases & Injuries

• 1. Certain Infectious and Parasitic Diseases (A00-B99)

• 2. Neoplasms (C00-D49)

• 3. Diseases if the Blood and Blood-forming organs (D50-D89)

• 4. Endocrine, Nutritional, and Metabolic diseases (E00-E89)

• 5. Mental, Behavioral, and Neurodevelopmental disorders (F01-99)

• 6. Diseases of the Nervous System (G00-G99)

• 7. Diseases of the Eye and Adnexa (H00-H59)

• 8. Diseases of the Ear and Mastoid Process (H60-H95)

• 9. Diseases of the Circulatory System (I00-I99)

• 10. Diseases of the Respiratory System (J00-J99)

ICD-10-CM Tabular List of Diseases & Injuries

• 11. Diseases of the Digestive System (K00-K95)

• 12. Diseases of the Skin and Subcutaneous Tissue (L00-L99)

• 13. Diseases of the Musculoskeletal System & Connective Tissue (M00-M99)

• 14. Diseases of the Genitourinary System (N00-N99)

• 15. Pregnancy & Childbirth (O00-O9A)

• 16. Certain conditions originating in the Perinatal Period (P00-P96)

• 17. Congenital Malformations, Deformities, and Chromosomal Abnormalities (Q00-Q99)

• 18. Symptoms, Signs and Abnormal Clinical and Laboratory Findings (R00-R99)

• 19. Injury, Poisoning, and certain other consequences of external causes (S00-T88)

• 20. External Causes of Morbidity (V00-Y99)

• 21. Factors influencing health status and contact with health services (Z00-Z99)



Rehab Optima Searching for ICD-10 Codes

• Keywords o If keywords results in over 1,000 results, there will be a prompt to enter in

additional words

• Code o Enter full ICD.10 code or ICD.10 codes up to the last two places

• Mapping from ICD-9 o General Equivalence Mappings (GEM) from ICD.9 codes

Rehab Optima • HTS will begin using ICD.10 codes as early as July 4th

o 9 0 day certifications will require both ICD.9 & ICD.10 codes

• All certification periods including dates of service on or before September 30th and on or after October

1st will require both ICD.9 and ICD.10 codes

Case Study #1 Resident admitted following hospital stay for an acute

cerebral infarction. He will receive PT, OT, and ST for

the resulting left hemiplegia of the non-dominant side, dysphasia, and facial droop. Other admitting

diagnosis include: GERD, rheumatoid arthritis, and early onset Alzheimer’s

with dementia and aggressive

behavior.

What diagnosis codes are assigned?



Case Study #1 Answers

• I69.354 Hemiplegia, following, cerebrovascular disease, cerebral infarction, or Sequelae (of), infarction, cerebral, hemiplegia

• I69.321 Dysphasia, following, cerebrovascular disease, cerebral infarction or Sequelae (of), infarction, cerebral, dysphasia

• I69.392 Sequelae (of), infarction, cerebral, facial droop

• K21.9 Disease, diseased, gastroesophageal reflux (GERD)

• M06.9 Arthritis, arthritic (acute),(chronic),(nonpyogenic) (subacute), rheumatoid

• G30.0 Disease, diseased, Alzheimer’s, early onset, with behavioral disturbance

• F02.81 Dementia with behavioral disturbance

Case Study #1 Rationale

• The hemiplegia, dysphasia, and facial droop are

considered residual conditions of the acute

cerebral infarction and are the reason that the patient is admitted to the nursing home. Coding

guidelines state that the residual condition is sequenced first, followed by the cause of the

sequela. In this case of cerebrovascular disease, the

sequela code has been expanded to include the manifestation and is an exception to the coding

guideline.

Case Study #2 81-year-old long term resident due to CHF and atrial

fibrillation was transferred to hospital following a fall

from the bed. She was re-admitted to nursing facility to resume care and add PT following open reduction

and pinning of left comminuted subcapital femoral neck fracture.

What diagnosis codes

are assigned?



Case Study #2 Answers

I50.9 Failure, failed, heart (acute) (senile) (sudden)

congestive (compensated) (decompensated)

I48.91 Fibrillation, atrial or auricular (established)

S72.012D Fracture, traumatic (abduction) (adduction) (separation), femur, femoral neck, see

Fracture, femur upper end, subcapital

(displaced)

Case Study #2 Rationale

• The sixth character 2 for the left hip is obtained from

the Tabular. The seventh character D is used for the

subsequent encounter with routine healing. The external cause code is assigned, but no place of

occurrence or activity codes because this is subsequent care. The reason for the readmission is

the CHF and atrial fibrillation.

Questions? • Thank you

Emily King, OTR/L, RAC-CT

Clinical Consultant

Proactive Medical Review & Consulting, LLC Cell: (317) 874-8667 Fax: (866) 448-3983

[email protected]

Stacy Baker, OTR/L, RAC-CT

Clinical Consultant

Proactive Medical Review & Consulting, LLC Cell: (270) 860-3010 Fax: (317) 534-3582

[email protected]

mailto:[email protected]

mailto:[email protected]

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