1 UHS, Inc. ICD-10-CM/PCS Physician Education Internal Medicine and Family Practice.

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UHS, Inc.

ICD-10-CM/PCSPhysician Education

Internal Medicine and Family Practice

ICD-10 Implementation

• October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) – Ambulatory and physician services provided on or after

10/1/15– Inpatient discharges occurring on or after 10/1/15

• ICD-10-CM (diagnoses) will be used by all providers in every health care setting

• ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures – ICD-10-PCS will not be used on physician claims, even

those for inpatient visits2

Why ICD-10Why ICD-10

Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of

new codes that can be created– Has obsolete groupings of disease families– Lacks specificity and detail to support:

• Accurate anatomical positions• Differentiation of risk & severity• Key parameters to differentiate disease manifestations

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Diagnosis Code StructureDiagnosis Code Structure

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ICD-10-CM Diagnosis Code FormatICD-10-CM Diagnosis Code Format

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Comparison: ICD-9 to ICD-10-CMComparison: ICD-9 to ICD-10-CM

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Procedure Code Structure Procedure Code Structure

ICD-10-PCS Code FormatICD-10-PCS Code Format

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ICD-10 Changes Everything!ICD-10 Changes Everything!

• ICD-10 is a Business Function Change, not just another code set change.

• ICD-10 Implementation will impact everyone:– Registration, Nurses, Managers, Lab, Clinical Areas,

Billing, Physicians, and Coding

• How is ICD-10 going to change what you do?

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ICD-10-CM/PCSDocumentation Tips

ICD-10 Provider ImpactICD-10 Provider Impact

• Clinical documentation is the foundation of successful ICD-10 Implementation

• Golden Rule of Documentation– If it isn’t documented by the physician, it didn’t happen– If it didn’t happen, it can’t be billed

• The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient

– what services were rendered and what is the severity of illness

• The key word is SPECIFICITY– Granularity– Laterality

• Complete and concise documentation allows for accurate coding and reimbursement

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Gold Standard Documentation PracticesGold Standard Documentation Practices

1. Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms

2. Document diagnoses, rather that descriptors

3. Indicate acuity/severity of all diagnoses

4. Link all diseases/diagnoses to their underlying cause

5. Indicate “suspected”, “possible”, or “likely” when treating a condition empirically

6. Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers

7. Clarify diagnoses that are present on admission

8. Clearly indicate what has been ruled out

9. Avoid the use of arrows and symbols

10. Clarify the significance of diagnostic tests12

ICD-10 Provider ImpactICD-10 Provider Impact

The 7 Key Documentation Elements:

1.Acuity – acute versus chronic

2.Site – be as specific as possible

3.Laterality – right, left, bilateral for paired organs and anatomic sites

4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance

5.Manifestations – any other associated conditions

6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence

7.Signs & Symptoms – clarify if related to a specific condition or disease process

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ICD-10 Documentation TipsICD-10 Documentation Tips

Do not use symbols to indicate a disease.

For example “↑lipids” means that a laboratory result indicates the lipids are elevated

– or “↑BP” means that a blood pressure reading is high

These are not the same as hyperlipidemia or hypertension

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Signs & Symptoms – document underlying cause / conditions

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Admit with sign / symptom Discharge with a Diagnosis

Fever Underlying condition (due to)Infection type (example: pneumonia)

Chest pain Underlying condition (due to)•GERD•Atelectasis•Costochondritis•Pleurisy•Cholecystitis•AMI

Altered Mental Status Underlying cause•Encephalopathy•UTI


Site and Laterality – right versus left–bilateral body parts or paired organs

Example – cellulitis of right upper arm

Stage of disease –Acute, Chronic–Intermittent, Recurrent, Transient–Primary, Secondary–Stage I, II, III, IV

Example – stage of pressure ulcer:– L89.011 Pressure ulcer of right elbow, stage 1– L89.021 Pressure ulcer of left elbow, stage 1

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Asthma – Specificity

• Intermittent [less than or equal to two times per week]• Mild persistent [more than two times per week]• Moderate persistent [daily-may restrict physical activity]• Severe persistent [throughout the day-frequent severe attacks that limit

the ability to breathe]

– Acuity • With acute exacerbation• With status asthmaticus

– Type / Form• Childhood• Exercise induced• Extrinsic allergenic• Late onset

– Tobacco Exposure • Exposure to environmental tobacco smoke• History of tobacco use• Occupational exposure to tobacco smoke

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COPD – Acuity

• With acute exacerbation• With acute lower respiratory infection

– Specificity• With asthma• With bronchitis• With emphysema

– Tobacco Exposure • Exposure to environmental tobacco smoke• History of tobacco use• Occupational exposure to tobacco smoke

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Diabetes - include the type or cause of diabetes– Type I– Type II– Due to drugs and chemicals– Due to underlying condition– Other specified diabetes– Link any manifestations to the diabetes

• Circulatory, renal, neurological, ophthalmic, skin, other

Use of Insulin – long term, current

Example:•E08 - Diabetes mellitus due to underlying condition

– E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma– E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma

•E11 - Type 2 diabetes mellitus– E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with macular edema– E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without macular

edema

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Encephalopathy

– Acuity – acute, subacute, chronic

– Severity – with or without coma

– Type• Alcoholic• Hepatic• Hypertensive• Metabolic• Septic• Toxic• Due to disease classified elsewhere

– Due to influenza, syphilis, hydrocephalus, neoplastic disease, etc…

– Link altered mental status to encephalopathy with the specific type

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Heart Failure

– Specify acuity• Acute• Chronic• Acute on chronic

– Identify type• Systolic• Diastolic• Combined systolic and diastolic

– List relationship of hypertension to heart failure or heart disease

– Identify underlying cause» Example - Exacerbation of stable heart failure due to fluid overload or due to

missed dialysis

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Kidney Disease

– Specify acuity• Acute, Chronic, Acute on chronic

– Identify stage• Stage I – GFR > 90• Stage II – GFR 60 – 89• Stage III – GFR 30 – 59• Stage IV – GFR 15 – 29• Stage V – GFR < 15

– List relationship of hypertension &/ or diabetes » Document as due to or with» Example – Type 2 DM with diabetic CKD stage 5

– Transplant Status – has the patient had a transplant or is a transplant candidate

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Otitis Media

– Type• Serous• Sanguinous• Suppurative• Allergic• Mucoid

– Infectious Agent• Strep• Staph• Influenza• Measles, Mumps

– Laterality – left, right, both

– Note whether tympanic membrane is ruptured

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Malnutrition

– Specify acuity – mild, moderate, severe

– Specify type• Protein calorie• Protein energy• Marasmus• Nutritional deficiency

– At least 2 of the following are required to help identify malnutrition:

• Insufficient energy intake• Weight loss• Loss of muscle mass• Loss of subcutaneous fat• Localized / generalized fluid accumulation• Diminished functional status as measure by hand grip strength

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Weight-related diagnoses and BMI

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BMI < 19 BMI > 40

• For protein-calorie malnutrition, indicate mild, moderate, severe

• Document “starvation” in abuse cases

• Link other illnesses

• Obesity, specify severe or morbid

• Link to the cause

• Document if drug-induced and provide the specific drug

• Bariatric procedures performed

• Associated conditions (example – obesity hypoventilation syndrome)


Pneumonia– Organism, document as known or suspected

• Viral – adenoviral, respiratory syncytial, parainfluenza, human metapneumovirus, viral unspecified

• Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas, staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified

– Link associated conditions• Influenza with secondary gram negative pneumonia• Sepsis due to pneumonia• Acute respiratory failure due to pneumonia

– Aspiration• Due to solids or liquids• Due to anesthesia during L/D or procedure• Due to anesthesia during puerperium

– Laterality of lung involvement – left, right, both

– Note whether ventilator associated (VAP)26


Pressure Ulcers– Site – specific ulcer location

• Ankle, back, buttock, coccyx, elbow, face, head, heel, hip, sacral region, other site

– Laterality – left, right, both

– Stage• 1 – pre-ulcer skin changes limited to persistent focal edema• 2 – abrasion, blister, partial thickness skin loss involving epidermis

&/or dermis• 3 – full thickness skin loss involving damage or necrosis of

subcutaneous tissue• 4 – necrosis of soft tissue through to underlying muscle, tendon or

bone• Unspecified – not documented• Unstageable – full thickness tissue loss, covered with slough or eschar

– Note whether the pressure ulcer was present on admission

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Respiratory Failure

– Acuity - acute, chronic, acute on chronic

– Specificity – with hypoxia or hypercapnia

– Tobacco Use• Exposure to environmental tobacco smoke• History of tobacco use• Occupational exposure to tobacco

– Does the patient require continuous home oxygen or is dependent on home oxygen

– Respiratory distress and respiratory insufficiency are NOT respiratory failure

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Respiratory Failure Criteria

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Acute Chronic

Symptoms – difficulty breathing, shortness of breath, dyspnea, tachypnea, respiratory distress, labored breathing, use of accessory muscles, cyanosis, unable to speak

Symptoms – severe COPD, chronic lung disease such as cystic or pulmonary fibrosis

Ph < 7.35 & pCO2 > 50 or pO2 < 55 & FIO2 > 28 %

pO2 < 55 or pCO2 > 50

Hypoxemia Hypercapnia

pO2 < 60 mmHg ORpO2 / FIO2 ratio < 300 OR10 mmHg decrease in baseline pO2

pCO2 > 50mmHg with pH < 7.35 OR10 mmHg increase in baseline pCO2


Sepsis– Acuity – sepsis, severe sepsis, septic shock, SIRS

– Organism due to / suspected•Streptococcus (A or B)•Staphylococcus aureus•MSSA•MRSA•Hemophilus influenzae•Gram-negative organism•E Coli•Serratia•Enterococcus

– Manifestations•With acute organ dysfunction•With multiple organ dysfunction•SIRS due to infectious process with organ dysfunction•Shock

– Note the term urosepsis is NOT synonymous with sepsis

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Sepsis Criteria

–Altered mental status–Heart rate > 90 beats per minute–Hypoxemia–PaCO2 < 32mmHg–Respiratory rate > 20 breaths per minute–Temperature > 100.9 F or < 96.8 F–WBC > 12,000 cells/mm3; < 4,000 cells/mm3; and/or > 10% immature band

–Blood cultures do not need to be positive to support the diagnosis of sepsis – the physician may clinically diagnose based on signs and symptoms

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Strokes – dominant vs. non-dominant side– Specify the location or source of the hemorrhage and laterality

– Document other causes – thrombosis, embolism, occlusion, stenosis

• Sites – precerebral or cerebral arteries• Laterality

– Document dominant verses non-dominant side for all paralytic syndromes such as hemiplegia, monoplegia and hemiparesis and for residual effects

Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.

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Drug and Alcohol Use

– Expanded code set to classify cause-and-effect indicators

– Documentation requirements include:

• Specific aspects of the effects– Example – abuse and dependence

• Specify the aspects of use– Example – withdrawal state

• Identify manifestations– Example – hallucinations, delusions

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Drug Under-dosing is a new code in ICD-10-CM.

– It identifies situations in which a patient has taken less of a medication than prescribed by the physician.

• Intentional versus unintentional

– Documentation requirements include:• The medical condition• The patient’s reason for not taking the medication

– example – financial reason– Z91.120 – Patient’s intentional underdosing of

medication due to financial hardship

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ICD-10-PCS does not allow for unspecified procedures, clearly document:

•Body System– general physiological system / anatomic region

•Root Operation– objective of the procedure

•Body Part– specific anatomical site

•Approach– technique used to reach the site of the procedure

•Device– Devices left at the operative site


Most Common Root Operations:

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

Drainage – taking or letting out fluids &/or gases from a body part

Excision – cutting out or off, without replacement, a portion of a body part; diagnostic or therapeutic

Repair – restoring to the extent possible, a body part to its anatomic structure and function

SummarySummary

The 7 Key Documentation Elements:

1.Acuity – acute versus chronic

2.Site – be as specific as possible

3.Laterality – right, left, bilateral for paired organs and anatomic sites

4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance

5.Manifestations – any other associated conditions

6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence

7.Signs & Symptoms – clarify if related to a specific condition or disease process

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1 UHS, Inc. ICD-10-CM/PCS Physician Education Internal Medicine and Family Practice.

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