icd-10 data challenges

HIMANYC ANNUAL MEETING

May 10, 2013Ann Zeisset, RHIT, CCS, CCS-PAHIMA-Approved ICD-10-CM/PCS Trainer

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ICD-10 Data Challenges

Learning Objectives

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Clinical Documentation Improvement

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CDI Practices

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Evaluate current documentationQualityDetail

Documentation improvement strategies

Audit recordsReport findings

Preparation - Provide Training

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Characteristics of ICD-10-CM/PCS

Coding guidelinesData comparability

issuesQuality reportingGEMS and their

role

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

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

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-

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

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

CDI ICD-10-CM Documentation Tips: Gustilo Fracture Classification

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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

CDI ICD-10-CM Documentation Tips: Gustilo Fracture Classification

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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

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

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

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

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

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

Ch 15: Pregnancy, Childbirth, and Puerperium - Trimesters

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CDI ICD-10-CM Documentation Tips: OB/Pregnancy

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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

CDI ICD-10-CM Documentation Tips: OB/Pregnancy

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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

Glasgow Coma Scale

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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

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

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/

Ch 10: Diseases of Respiratory System

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CDI ICD-10-CM Documentation Tips: Asthma

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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

CDI ICD-10-CM Documentation Tips: Asthma

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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

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

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

How Can You Prepare?

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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

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.

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

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

ICD-10-PCS Documentation

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Root operationIntentExcision/resectionOcclusion/restrictionBypass

ICD-10-PCS Documentation

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Body partPart of intestineSite of biopsy or

procedureSubdivision of organs into

body partsOmentumLungLiverParathyroidEsophagus

ICD-10-PCS Documentation

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ArteriesVeinsLymph nodes

SiteChains

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National Cancer Institute

ICD-10-PCS Documentation

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Qualifier in hip replacement

ICD-10-PCS Documentation

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Hours on ventilator

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

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

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

References

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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

Questions

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Ann Zeissetazconsulting@sbcglobal.net