ICD-10 Data Challenges
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HIMANYC ANNUAL MEETING
May 10, 2013Ann Zeisset, RHIT, CCS, CCS-PAHIMA-Approved ICD-10-CM/PCS Trainer
Ann Zeisset Consulting1
ICD-10 Data Challenges
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Learning Objectives
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Clinical Documentation Improvement
Ann Zeisset Consulting3
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CDI Practices
Ann Zeisset Consulting4
Evaluate current documentationQualityDetail
Documentation improvement strategies
Audit recordsReport findings
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Preparation - Provide Training
Ann Zeisset Consulting5
Characteristics of ICD-10-CM/PCS
Coding guidelinesData comparability
issuesQuality reportingGEMS and their
role
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Preparation Provide Training
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Coding professionals Anatomy/physiologyMedical TerminologyPathophysiologyPharmacology
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Differences Impacting Documentation
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Terminology Differences – ICD-10-CM
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Terminology Differences – ICD-10-CM
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Classification Differences
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Differences in Definitions and Meaning
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ICD-10-CM Documentation
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DiabetesMononeuropathyPolyneuropathyAutonomic
neuropathyPregnancy
Unspecified trimester
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ICD-10-CM Specificity
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Type of sepsisOsteoarthritisRheumatoid arthritisOsteonecrosisColitisPeritonitisAsthmaPressure ulcersType of
cardiomyopathy
Type of heart failureRespiratory failure
Acute or chronicWith hypoxemia or
hypercapniaSubstance and
intent combination codesAdverse effectPoisoningUnderdosingToxic effect
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ICD-10-CM Specificity
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Type of Sepsis
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Type of Sepsis
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Type of Sepsis
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Colitis
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Osteoarthritis
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Ankle M19.07-Generalized M15.9
Erosive M15.4Primary M15.0Specified NEC M15.8
Post-traumatic NEC M19.92Ankle M19.17-
Primary M19.91Ankle M19.07-
Secondary M19.93Ankle M19.27-
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Rheumatoid Arthritis
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Acute Respiratory Failure
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Injuries
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InjuriesInitialSubsequentSequela
More specific sites available for wounds
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Fractures
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Gustilo Classification of Open Fractures
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Fractures
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For images search on “Types of fractures.” One site is http://orthoinfo.aaos.org/topic.cfm?topic=a00139
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CDI ICD-10-CM Documentation Tips: Gustilo Fracture Classification
Ann Zeisset Consulting28
Chapter 19, “Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T99).” Fracture codes have much greater specificity than in ICD-9-CM and require the level of the encounter be identified.
During the coding process assign the level of encounter using one of the following seventh characters for applicable fracture codes:A = Initial encounter for closed fracture
B = Initial encounter for open fracture D = Subsequent encounter for fracture with routine healing
G = Subsequent encounter for fracture with delayed healingK = Subsequent encounter for fracture with nonunionP = Subsequent encounter for fracture with malunionS = Sequela
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CDI ICD-10-CM Documentation Tips: Gustilo Fracture Classification
Ann Zeisset Consulting29
The seventh (7th) character in some fractures will identify the type of open fracture using the Gustilo Fracture Classification.
Categories S52, S72, and S82 are impacted by the Gustilo Fracture Classification
During the coding process assign the code to capture the type of open fracture using the appropriate seventh character (categories S52, S72, S82):B = Initial encounter for open fracture type I or IIC = Initial encounter for open fracture type IIIA, IIIB, or IIIC E = Subsequent encounter for open fracture type I or II with routine healing F = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine
healing H = Subsequent encounter for open fracture type I or II with delayed healing J = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed
healing M = Subsequent encounter for open fracture type I or II with nonunionN = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunionQ = Subsequent encounter for open fracture type I or II with malunionR = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
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CDI ICD-10-CM Documentation Tips: Pathologic Fracture
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Pathologic (non-traumatic) fracture documentation and coding will need to include:Exact location of fractureSiteLaterality
Etiology of fractureOsteoporosisNeoplastic diseaseOther specified
Encounter typeInitial encounterSubsequent encounter, routine healingSubsequent encounter with delayed
healing, malunion or nonunionSequelae
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Diabetes
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ICD-9-CM
250.x Diabetes mellitus• 5th digit “1” – Type I • 5th digit “0” – Type II
or unspecified• 5th digit “2” & “3” –
uncontrolled 249.x Secondary
diabetes mellitus• 5th digit “0” & “1” –
uncontrolled 648.8x – Abnormal
glucose tolerance complicating pregnancy, childbirth, or puerperium (includes gestational diabetes)
ICD-10-CM
Diabetes codes include type of complication
E08 Diabetes mellitus due to underlying condition
E09 Drug or chemical induced diabetes mellitus
E10 Type 1 diabetes mellitus
E11 Type 2 diabetes mellitus
E13 Other specified diabetes mellitus
O24 DM in pregnancy, childbirth, puerperium
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See category
E10.4
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Peripheral Mononeuropathy – involves one
nervePolyneuropathy – multiple nerves
Autonomic neuropathy – autonomic nervous system (heart, bladder, lungs, stomach, intestines, sex organs and eyes
Amyotrophy (radiculoplexus neuropathy, femoral neuropathy or proximal neuropathy)
ICD-10-CM Documentati
onDiabetes
Neuropathy
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CDI ICD-10-CM Documentation Tips: Diabetes
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Diabetes documentation and coding will need to include: Type or cause of diabetes:• Type 1• Type 2• Due to drugs or chemicals• Due to underlying condition• Other specified diabetes
Body system complications related to diabetes, such as kidney or neurological complications
Combination codes include diabetes and the manifestation
Specific complications, such as:• Chronic kidney disease• Foot ulcer• Hypoglycemia without coma
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Ch 15: Pregnancy, Childbirth, and Puerperium
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Ch 15: Pregnancy, Childbirth, and Puerperium Extensions
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7th character to identify fetus number
0 – not applicable or unspecified1 – fetus 1 4 – fetus 42 – fetus 2 5 – fetus 53 – fetus 3 9 – other fetus
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Ch 15: Pregnancy, Childbirth, and Puerperium - Trimesters
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CDI ICD-10-CM Documentation Tips: OB/Pregnancy
Ann Zeisset Consulting37
Documentation of conditions/complications of pregnancy will need to specify the trimester in which that condition occurred. Some codes but not all specify trimester. ICD-9-CM documentation required “episode of care”
(delivered, ante-partum, post-partum) instead of trimester, childbirth, puerperium
If the condition develops prior to admission, the trimester at the time of admission is assigned
If the patient is hospitalized during one trimester and a condition/complication develops during the same hospitalization but in a subsequent trimester, the code for the trimester in which the complication develops is assigned
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CDI ICD-10-CM Documentation Tips: OB/Pregnancy
Ann Zeisset Consulting38
The provider’s documentation of “weeks” may be used to assign the appropriate ICD-10 code for trimester
Note: Gestational diabetes needs specification of diet controlled or insulin controlled. If both diet and insulin controlled, the ICD-10-CM code for insulin controlled will be assigned
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Glasgow Coma Scale
Ann Zeisset Consulting39
Used in conjunction with traumatic brain injury or sequelae of CVA
Used by trauma registries and researchers
Sequenced after diagnosisRequire three codes
R40.21 – eyes openR40.22 – best verbal responseR40.23 – best motor response
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CDI ICD-10-CM Documentation Tips: Coma
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Category R40Somnolence (R40.0) =
drowsinessStupor (R40.1) = catatonic
stupor or semi-comaComa (R40.2-) =
unconsciousnessAny associated skull
fracture or intracranial injury would be coded first
Glasgow (coma scale) score available 7th character required
Persistent vegetative state (R40.3)
Transient alteration of awareness (R40.4)
Glasgow (coma scale) score availableTypically reported as a
total score 0-15Higher score = higher
functioningICD-10-CM coding will
need the score from each of the assessment areasEye opening Verbal response Motor response
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Ch 10: Diseases of Respiratory System
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Terminology used to describe asthma has been updated to reflect current clinical classification of asthmaNo longer extrinsic and intrinsic
National Heart, Lung and Blood Institute
http://www.nhlbi.nih.gov/
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Ch 10: Diseases of Respiratory System
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CDI ICD-10-CM Documentation Tips: Asthma
Ann Zeisset Consulting43
Most adults with asthma will NOT require an inpatient admissionLook for indicators of acute respiratory failure or
acute exacerbation with status asthmaticusBe sure to clarify the relationship between
COPD, bronchitis, and asthmaICD-10 distinguishes between uncomplicated cases
and those in exacerbationAcute exacerbation is a worsening or decompensation of a chronic
conditionAn acute exacerbation is not equivalent to an infection
superimposed on a chronic condition
An additional code should be used regarding exposure to or use of tobacco
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CDI ICD-10-CM Documentation Tips: Asthma
Ann Zeisset Consulting44
Incorporate the following scales into documentation templates or queriesThe National Heart, Lung, and Blood Institute
(NHLBI) asthma severity classification scale accounts for the progressive nature of asthma by measuring it across the dimensions of types of symptoms and lung functionMild intermittent Mild persistent Moderate persistent Severe persistent
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Severity of Asthma Classification
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Presentation of Asthma before (without) Treatment
Type of Asthma
SymptomsNighttime Symptoms
Lung Function
Severe persistent
•Continual symptoms•Limited physical activity•Frequent exacerbations
Frequent• FEV1 or PEF ≤ 60% predicted•PEF variability > 30%
Moderate persistent
•Daily symptoms•Daily use of inhaled short-acting beta2-agnonist•Exacerbation of affect activity•Exacerbation ≥ 2 times/week ≥ 1 day(s)
> 1time/week• FEV1 or PEF 60-80% predicted•PEF variability > 30%
Mild persistent
•Symptoms > 2 times/week but < 1 time/day•Exacerbation may affect activity
> 2 times/month• FEV1 or PEF ≥ 80% predicted•PEF variability 20-30%
Mild intermittent
•Symptoms ≤ 2 times/week•Asymptomatic and normal PEF between exacerbations•Exacerbations of varying intensity are brief (a few hours to a few days)
≤ 2 times/month• FEV1 or PEF ≥ 80% predicted•PEF variability < 20%
FEV1 = The maximal amount of air a person can forcefully exhale over one second accounting for the variables of height, weight, and race used to denote the degree of obstruction with asthmaPEF= Peak Expiratory Flow is the maximum flow of expelled air during expiration following full inspiration (big breath in and then big breath out)Source: National Heart, Lung, and Blood Institute - http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
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How Can You Prepare?
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Incorporate the following scales into documentation templates or queries:National Heart, Lung, and Blood
Institute (NHLBI) asthma severity classification scaleIntermittentMild persistentModerate persistentSevere persistent
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How Can You Prepare?
Ann Zeisset Consulting47
Incorporate into query templates:Glasgow (Coma Scale)
Need a score from each of the three assessment areas, NOT a total score Eye openingVerbal responseMotor response
Gustilo Open Fracture Classification I, II, III, IIIA, IIIB, or IIIC
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How Can You Prepare?
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Respiratory failureAcute versus chronicWith or without hypoxemia or
hypercapniaTrimester of pregnancy
Default to the trimester when the complication occurred, not the discharge trimester when an admission crosses trimesters
Identification of the substance related to adverse effect, poisoning, underdose or toxic effect
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Clinical Documentation ImprovementFormat of ICD-10 PCS
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There are seven (7) characters in each ICD‑10‑PCS (Procedure Coding System)
code. Each character has a slightly different meaning related to that
particular section.
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Terminology Differences – ICD-10-PCSSame Terms May Have Different Meaning
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ICD-9-CM ICD-10-PCSReplacement Insertion + Removal, Replacement,
Revision
Excision Excision, Destruction, Resection
Resection Excision, Resection, Resection + Bypass
Incision Drainage, Extirpation, Insertion, Inspection, Removal, Revision
Repair Dilation, Fragmentation, Reattachment, Release, Repair, Replacement, Reposition, Restriction, Revision, Supplement
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ICD-10-PCS Documentation Tips: Medical-Surgical Section
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ICD-10-PCS Documentation Tips:
Medical-Surgical Section
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Root Operation Examples
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Root Operation Examples
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ICD-10-PCS Documentation Tips:
Medical-Surgical Section
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ICD-10-PCS Documentation Tips:
Medical-Surgical Section
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ICD-10-PCS Documentation Tips:
Medical-Surgical Section
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ICD-10-PCS Documentation Tips: Medical-Surgical Section
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Qualifier Seventh character in procedure codeIn cases where a qualifier is not applicable,
value Z, “No qualifier,” is used
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ICD-10-PCS Documentation
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Root operationIntentExcision/resectionOcclusion/restrictionBypass
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ICD-10-PCS Documentation
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Body partPart of intestineSite of biopsy or
procedureSubdivision of organs into
body partsOmentumLungLiverParathyroidEsophagus
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ICD-10-PCS Documentation
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ArteriesVeinsLymph nodes
SiteChains
63
National Cancer Institute
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ICD-10-PCS Documentation
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Qualifier in hip replacement
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ICD-10-PCS Documentation
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Hours on ventilator
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ICD-10-PCS Documentation
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Blood transfusionPeripheral or central, vein or
artery
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Data Conversion and Analysis Challenges
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GEMs and applied mappings Tools to facilitate transition
Linked codes don’t necessarily have equivalent meaningExample: ICD-10-PCS coronary artery body part values for “number of sites” are linked to ICD-9-CM codes specifying “number of vessels treated”
Terminology differences exist between ICD-9-CM and ICD-10-CM/PCS
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Data Trending Challenges
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ICD-9-CM and ICD-10-CM/PCS not one-to-one matchNew concepts in ICD-10-CM/PCSFor a small number of codes - no corresponding
GEMMore than one ICD-9-CM code may be possible
translationMore than one ICD-9-CM code may be required to
convey complete meaning One ICD-9-CM code may map to multiple ICD-10-
CM or ICD-10-PCS codes
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Data Trending Challenges
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Differences in code sets go beyond changes in code titles or level of specificity Terminology, definitions, meaning of code, or
instructions for code assignment may have changed
When linking coded data, differences need to be reconciledMethod used to reconcile differences may vary
Flawed decisions may be made Caution should be exercised when
interpreting data across transition
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References
Ann Zeisset Consulting71
National Center for Health Statistics – CDC ICD-10-CMwww.cdc.gov/nchs/icd/icd10cm.htm
Centers for Medicare & Medicaid Services ICD-10-PCSwww.cms.hhs.gov/ICD10
ICD-10-CM GEMs and ICD-10-PCS GEMswww.cms.hhs.gov/ICD10