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Casey Bastemeyer RHIT,CCA, CHPS, RAC-CTLead HIPAA / ICD Coding Compliance PartnerApproved AHIMA ICD-10-CM Trainer

Tammy Combs RN, MSN, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

AANAC and AHIMA present:Top ICD-10 Coding Challenges and

Best Practices

Presented by:

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Faculty Disclosure

• The speakers have no financial relationships to disclose

• The speakers have no conflicts of interests to disclose

• The speakers will not promote any commercial products or services

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Requirements for Successful Completion

• 1.0 contact hour will be awarded for this continuing nursing education activity

• Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded.

• Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services.

American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the

American Nurses Credentialing Center’s Commission on accreditation.

*AAPACN d/b/a American Association of Nurse Assessment Coordination

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Learning Objectives, Section 1

• Review ICD-10 Guidelines

– Review the addition of the 7th Character and the X placeholder

– How to sequence ICD-10-CM Diagnoses Codes

– Aftercare Codes / Fracture Codes

– Unspecified Codes

• Coding as a team

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Reviewing ICD-10 Guidelines

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Placeholder Character X

• ICD-10-CM utilizes a placeholder which is always the letter “X” and it has two uses:– As the fifth character for certain six character

codes. The X provides for future expansion without disturbing the sixth character structure.

– Examples:• T37.0X1A Poisoning by sulfonamides, accidental

(unintentional), initial encounter

• T56.0X2S Toxic effect of lead and its compounds, intentional self-harm, sequela

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Placeholder Character cont’d

• When a code has less than six characters and a seventh is required, the X is assign for all characters less than six in order to meet the requirement of coding to the highest level of specificity.

• Examples:– W85.XXXA Exposure to electric transmission lines,

initial encounter– S17.0XXA Crushing injury of larynx and trachea, initial

encounter– S01.02XA Laceration with foreign body of scalp,

initial encounter

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Addition of 7th Character

• Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.

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7th Character Continued

• Required for chapter 19: injuries, poisoning, and other consequences of external causes (S00-T88)

• Examples:– S02.110B Type 1 occipital condyle fracture, initial

encounter for open fracture

– T17.220D Food in pharynx causing asphyxiation, subsequent encounter

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Sequencing

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Where to Find Diagnoses

• Review clinical record, including but not limited to:

– Discharge Summary

– MD, NP, PA or OD progress notes

– Consultations

– History and Physical H&P

– Orders

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Principal Diagnosis Definition and Guidance

• Below are the definitions of the different terms for principal diagnosis:

• First-listed diagnosis: The diagnosis that is sequenced first. Terms "principal" and "primary" are often used interchangeably to define the diagnosis that is sequenced first.

• Principal diagnosis: Condition established after study to be chiefly responsible for the patient's admission to the hospital. It is always the first-listed diagnosis on the health record and the UB-04 claim form. This direction applies to nursing homes as stated in the guidelines.

• Primary diagnosis: This term is often used to indicate the reason for the continued stay in the LTC facility. It is also used interchangeably with principal diagnosis.

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How to Sequence Diagnoses

• Secondary diagnoses :

– Any and all conditions that co-exist when resident is admitted to the facility, or

– Develop subsequently during a resident’s stay, or

– Affect treatment the resident receives or the resident’s length of stay

– Diagnoses that relate to an earlier episode which have no bearing on the current stay are to be excluded.

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How to Sequence Diagnoses

• When you look at all your codes rank them on a scale from 1-5: – (1) Symptoms are poorly controlled and the resident

has a history of re-hospitalization for this diagnosis– (2) Symptoms are poorly controlled – (3) Symptoms are controlled with difficulty, and are

affecting daily functioning– (4) Symptoms are well controlled– (5) Asymptomatic

• Note: Different Chapters will have more specific sequencing rules.

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Finalizing Codes

• Review diagnosis list with clinical staff as applicable:

– Nursing representative (MDS or other)

– Therapy

– Inclusion of therapy treatment and medical diagnoses

– May want to label treatment diagnoses/ codes from therapy

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Aftercare Codes / Fracture Codes

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Pathological or Stress Fractures

• Quick review of 7th characters:

• The following seventh characters are required for codes that represent pathological or stress fractures in category M84.3 – M84.6 :– A – initial encounter for fracture

– 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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Traumatic Fracture

• Quick review of 7th characters:

• The following seventh characters are required for codes that represent traumatic fractures:

• The seventh character are expanded to include:– A-initial encounter for closed fracture (acute code)

– B-initial encounter for open fracture (acute code)

– 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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Seventh Characters for Fracture

• The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisoning where the seventh characters are provided to identify subsequent cases.

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Aftercare Codes

• When you look at a patient/resident recovering from a recent surgery we need to first ask ourselves why they need our services. Most of time it is going to be to heal from the surgery so in that case we need to look at aftercare codes.

• I know when ICD-10 first came out we said no aftercare codes; this only applies to our fracture codes. There are times when it is appropriate to code an aftercare code.

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Unspecified Codes

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Unspecified Codes

• In both ICD-9 and ICD-10, it has been appropriate, and even necessary at times, to use signs/symptoms and unspecified codes.

• However we do need to report specific diagnosis codes when they are supported by the medical record documentation. Part of the enhancements of ICD-10 is we have very specific codes for diagnosis.

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Coding as a Team

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Team Work

• Because ICD-10 codes are needed for

– The MDS

– UB04

– Therapy Treatment Plan

It is so important to work together as a team. Not every facility has a certified coder in the building. So it is more important then ever to make sure we are sharing our knowledge.

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References

• Centers for Medical and Medical Service's (2014). ICD-10-CM Official Guidelines for Coding and Reporting. – [ONLINE] Available at:

http://www.cms.gov/Medicare/Coding/ICD10/Downloads/pcs-2014-guidelines.pdf

• Devault, RHIA, CCS, CCS-P, K., Barta, MSA, RHIA, CDIP, A., & Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, M. (2014). ICD-10-CM Coder Training Manual. Retrieved from www.ahima.org

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Learning Objectives, Section 2Clinical Documentation Improvement

(CDI) Best Practices

• Discuss the 7 criteria of High-Quality Documentation

• Evaluate a consistent theme within clinical documentation

• Critique documentation within a case study

• Assess the impact of High-Quality Documentation

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7 Criteria of High-Quality Documentation

Criteria Example/Description

Legibility Required under all government and regulatory agencies

Reliability Treatment provided without documentation of condition being treated

Precision No specific diagnosis documented, more specific diagnosis appears to be supported

Completeness Abnormal test results without documentation for clinical significance (Joint Commission requirement)

Consistency Disagreement between two or more treating physicians without obvious resolution of the conflicting documentation upon discharge

Clarity Vague or ambiguous documentation, especially in the case of symptom principal diagnosis

Timeliness Documentation that is not complete within the guidelines set by the facility, CMS, state, Joint Commission, and other regulatory agencies

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Consistent Theme in Documentation

Diagnosis Specificity

Procedural Specificity

AssessmentsClinical

Evidence

Treatment

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Case Study-Inpatient

85 year old male is admitted to the hospital as an inpatient for a fractured right hip after he fell from the front steps of his home. He was leaving to go to the doctor because he has been SOB for the last 3 days which has progressively gotten worse.PMH: Hypertension, COPD, and Chronic Kidney Disease (CKD). Lab work results include: WBC 14.2, RBC 3.5 million cells/mcL, Hemoglobin 10.0 gm/dl, Hematocrit 35%, GFR 32 , CXR show pneumoniaVital Signs: Temp 100.6, Heart Rate 95, Respiratory Rate 28, Pulse Ox 87% on Room AirDiagnosis: Fractured Right Hip, Anemia, COPD, Hypertension, CKDPlan: ORIF of Right Hip

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Gaps in the documentation85 year old male is admitted to the hospital as an inpatient for a fractured right hip after he fell from the front steps of his home. He was leaving to go to the doctor because he has been SOB for the last 3 days which has progressively gotten worse.PMH: Hypertension, COPD, Chronic Kidney Disease (CKD). Lab work results include: WBC 14.2, RBC 3.5 million cells/mcL, Hemoglobin 10.0 gm/dl, Hematocrit 35%, GFR 32 , CXR show pneumoniaVital Signs: Temp 100.6, Heart Rate 95, Respiratory Rate 28, Pulse Ox 87% on Room AirDiagnosis: Fractured Right Hip, Anemia, COPD, Hypertension, CKDPlan: ORIF of Right Hip

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Diagnosis-Related Group (DRG) & Length of Stay (LOS)

CurrentFractured Right Hip (default is neck of the femur)AnemiaCOPDHypertensive CKD

DRG- 517 other musculoskeletal system and connective tissue with OR procedure without CC/MCCGLOS-2.6 days

PossibleFractured Right Ischium with disruption of the pelvic ringAnemia secondary to CKDCOPD exacerbationPneumoniaHypertensive CKD stage 3

DRG- 515 other musculoskeletal system and connective tissue with OR procedure with a MCCGLOS-7 days

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Case Study- Skilled Nursing Facility (SNF)

The same 85 year old male is admitted to a SNF for physical therapy and IV antibiotics.

Diagnoses: Fractured Right Hip, Anemia secondary to CKD, COPD, Hypertension, CKD stage 3Nurses Assessment: 85 year old male requiring minimal assistancePhysical Therapy Assessment: 85 year old male requiring extensive assistance requiring 720 minutes of therapy

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Gaps in Documentation

The same 85 year old male is admitted to a SNF for physical therapy and IV antibiotics.

Diagnoses: Fractured Right Hip, Anemia secondary to CKD, COPD, Hypertension, CKD stage 3Nurses Assessment: 85 year old male requiring minimal assistancePhysical Therapy Assessment: 85 y/o male requiring extensive assistance requiring 720 minutes of therapy

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Impact of High Quality Clinical Documentation

Appropriate Reimbursement

Accurate Quality Scores

Reduction in Denials

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References

• Hess, Pamela. Clinical Documentation Improvement: Principles and Practice. AHIMA Press: 2015. https://www.ahimastore.org/ProductDetailBooks.aspx?ProductID=18202

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Questions?