james s. kennedy, md, ccs, cdip - st. joseph health · james s. kennedy, md, ccs, cdip ......

James S. Kennedy, MD, CCS, CDIP Founder and President, CDIMD

• American Health Information Management Association (AHIMA) certified coding specialist since 2001

• Association of Clinical Documentation Improvement Specialists (ACDIS) Advisory Board

• Multiple author on clinical aspects of ICD-10 and DRGs

Contact: (615) 479-7021 jkennedy@CDIMD.com CDIMD

Physician Champions

Goals

• Identify what is new or different in ICD-10 • How it affects risk-adjustment and quality measures

• Implementation date: October 1, 2015

• Review clinical aspects or definitions of selected new, revised, or deleted codes

• Outline CCH’s ICD-10 documentation improvement strategies

ICD-10 Implementation Date October 1, 2015

Diagnoses Procedures ICD-10-CM

(Clinical Modification) Used by all covered entities: (providers & facilities) for diagnoses To be used in all settings: – Hospital inpatients – Hospital outpatients – Physicians offices – Emergency department – Home health – Long-term care – Rehabilitation facilities

ICD-10-PCS (Procedure Coding System)

Used by inpatient facilities ONLY • Includes outpatient facility services

rendered within the prior 72 hours of writing the inpatient order

• Very different than ICD-9-CM or CPT

CPT • Physician and outpatient/observation

facility services still utilize CPT • CPT does not change!!

International Classification of Disease Versions

• First edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893

• WHO took in 1948 when the Sixth Revision, which included causes of morbidity for the first time, was published. • 1977 - ICD-9

• 1993 - ICD-10

• 2017 (tentative) - ICD-11

US Modifications – ICD-10-CM & PCS The Cooperating Parties

• CDC • Responsible for diagnoses

• CMS • Responsible for inpatient

procedures

• American Hospital Assn. • Responsible for interpreting

ICD-9 or ICD-10 (Coding Clinic)

• American HIM Assn. • Provides input from coding

community

What’s Old? ICD-9-CM

What’s New ICD-10-CM

ICD-9-CM and ICD-10-CM/PCS Diagnoses and Procedures

Code Type ICD-9-CM ICD-10-CM ICD-10 PCS

Diagnosis 14,567 codes 69,832 codes

OB Diagnosis 1107 codes 2155 codes

Inpatient Facility

Procedure 3,878 codes 71,920 codes

http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

“Family of Codes”

• “Family of codes” is the same as the ICD-10 three-character category. • Codes within a category are clinically related and provide

differences in capturing specific information on the type of condition.

• For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.

• Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters.

• One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Medi-Cal ICD-10 Medical Necessity - Crosswalk • Medi-Cal implementation of ICD-10

• Medi-Cal will be using a crosswalk solution in the legacy California Medicaid Management Information System (CA-MMIS).

• Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes by starting with the General Equivalence Mappings (GEMs) provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy.

• Claims will be run against the crosswalk to determine the ICD-9 value to process through the system.

• Will an ICD-10 to ICD-9 crosswalk be published? • Medi-Cal will not publish the crosswalk. • However, the provider manuals will be updated with the ICD-

10 codes as appropriate.

Mapping Tool http://tinyurl.com/I9toI10crosswalk

Note how ICD-10-CM combined benign, malignant, and unspecified HTN into one code, I10 - HTN

Applications Bundled Payments

• IHA is Oakland-based

• Bundled payments could be DRG based • APR-DRG for Medi-CAL

• MS-DRGs for others

• Structure of the IHA OB demonstration project

Bundle Components

Potential Risk Adjusters

Potential Risk-Adjusters

Depression

ICD-10-CM – Preterm and PROM w/Labor Onset w/in 24 hr.

Pre-term and PROM w/Labor Onset > 24 hours

Preterm Labor with Term Delivery Meditech 5.67

Medi-CAL APR-DRGs Bundles = RW x Base rate ($6000)

DRG Title

Relative weight Reimbursement

540-1 CESAREAN DELIVERY 0.5237 $ 3,258.99 540-2 CESAREAN DELIVERY 0.6291 $ 3,914.89 540-3 CESAREAN DELIVERY 0.9323 $ 5,801.70 540-4 CESAREAN DELIVERY 2.2502 $ 14,002.99 560-1 VAGINAL DELIVERY 0.3070 $ 1,910.46 560-2 VAGINAL DELIVERY 0.3477 $ 2,163.74 560-3 VAGINAL DELIVERY 0.5057 $ 3,146.97 560-4 VAGINAL DELIVERY 1.3646 $ 8,491.91

SOI Resource Intensity Example

Obese woman undergoing C-section Uses Unprescribed Oxycodone

Anemic post procedure

Acute Blood Loss Anemia or Opoid Dependency

Morbid Obesity with BMI of 40

Major organ dysfunctions Sepsis or Severe Sepsis

$14K $5.8K $3.9K $3.2K

Commonly Missing Diagnoses with California Medicaid • Advanced maternal age

(mom is 35 or older)

• Anemia

• Electrolyte abnormalities

• Insufficient prenatal care

• Lacerations (and repair of)

• Maternal drug dependence

• Obesity/morbid obesity

• Preeclampsia or HTN • Moderate vs. severe

• Preterm labor

• PROM (premature rupture of membranes) vs. PPROM (preterm premature rupture of membranes)

• Rh incompatibility

APR-DRG Complications of Care Risk-Adjusted

Determined by

Patient Characteristics and Care Quality

Observed Complications • Complications = -------------------------------------------------- Expected Complications

Determined by Documentation and coding using ICD-9-CM

or ICD-10-CM

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ICD-10 Codes Defining Complications

ICD-10 Code

Description AHRQ

PSI

MS-DRG

MCC/CC

MS-DRG HAC

APR-DRG SOI

APR-DRG ROM

APR-DRG PPC

O702 Third degree perineal laceration during delivery

18/19 CC 1 1 57 & 58

O703 Fourth degree perineal laceration during delivery

18/19 CC 1 1 57 & 58

O704 Anal sphincter tear complicating delivery, not associated with third degree laceration

CC 1 1 57 & 58

O713 Obstetric laceration of cervix CC 1 1 57 & 58

O721 Other immediate postpartum hemorrhage CC 2 1 55 & 56

O722 Delayed and secondary postpartum hemorrhage

CC 2 1 55 & 56

Lacerations

• First degree lacerations involve injury to the skin and subcutaneous tissue of the perineum and vaginal epithelium only. The perineal muscles remain intact.

• Second degree lacerations extend into the fascia and musculature of the perineal body, which includes the deep and superficial transverse perineal muscles and fibers of the pubococcygeus and bulbocavernosus muscles. The anal sphincter muscles remain intact.

• Third degree lacerations extend through the fascia and musculature of the perineal body and involve some or all of the fibers of the EAS and/or the IAS.

• Fourth degree lacerations involve the perineal structures, EAS, IAS, and the rectal mucosa.

Laceration Repair

• 2nd degree – must describe the repair of the perineal muscles

• 3rd degree – must describe the repair of the EAS and/or IAS and the perineal muscles

• 4th degree – must describe the repair of the EAS and/or IAS AND the repair of the anal and/or rectal mucosa AND the repair of the perineal muscles

Postpartum Hemorrhage • Challenging Definitions

• >500 cc – Vaginal delivery • >1000 cc – C-section • In Gabbe’s OB book, these are “average”

• Challenging measurement • Not always accurate

• What’s the underlying cause? • Uterine atony • Retained placenta

• Especially placenta accreta • Defects in coagulation • Uterine inversion • Subinvolution of placental site • Retained products of conception • Infection • Inherited coagulation defects

1. Use the following as a standard clinical definition of PPH: Estimated blood loss greater than 500 ml or hemodynamic instability as a “trigger” for heightened surveillance and/or more aggressive treatment in the face of ongoing bleeding.

2. Use the following standard definition for safety and quality monitoring: Blood loss of 1000 ml as a “trigger” for monitoring safety related to maternal health care quality.

3. Birthing facilities adopt and maintain protocols addressing: A. Quantification of blood loss at all births B. Management of all women with cumulative blood loss 500

ml 1) Nursing personnel should notify the attending physician and

proceed with administration of Methergine 0.2 mg IM (if no contraindications) and fundal massage.

2) Clinical Triggers: surveillance and intervention: a. Heart Rate >110 b. Blood Pressure < 85/45 (>15% drop) c. Oxygen Saturation <95%

4. Hospitals and other health care organizations internally monitor and report all cases with EBL >500 ml for internal site-specific quality monitoring to ensure adherence to institutional guideline.

5. Hospitals and other health care organizations internally monitor and report rates and associated outcomes for all women with cumulative blood loss >1000 ml.

Note the Underlying Causes • Retained placenta

• Adherent placenta • Placenta accretia • Placenta incretia • Placenta percretia

• Uterine atony

• Retained POCs

• Coagulation defects

• Other causes

Intraoperative or Postoperative Hemorrhage

ICD-10 Code

Description AHRQ

PSI MS-DRG MCC/CC

APR-DRG SOI

APR-DRG ROM

APR-DRG PPC

N9961

Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure

CC 2 1 40

N9962

Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating other procedure

CC 2 1 40

N99820

Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure

9 (90)/27 CC 2 1 40

N99821

Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following other procedure

9 (90)/27 CC 2 1 40

Meditech 5.67

Differentiations

• Describe the source of any hemorrhage or hematoma, whether it is • Associated with (or a direct result) of the procedure • Integral to or routinely expected with the procedure or is a

complication of the procedure, to what extent it is due to another medical condition or medication, and the steps taken to address the bleeding

• If the bleeding is routine for the procedure, it won’t be coded

• In cases of perioperative hemorrhage or hematoma • Accurately describe whether the amount of blood loss or the

size of the hematoma exceeded what you would normally expect for such a procedure.

• Try to distinguish whether the bleeding is a result of the underlying disease process (e.g. GI hemorrhage) or if it is a result of the procedure.

Differentiations

• Remember that it is important to distinguish between: • Ecchymosis (flat bruising of the skin or other tissue)

• Hematoma (mass due to a collection of blood or clot)

• Whether a fluid collection or mass is a hematoma versus a seroma or an abscess that did not develop from a hematoma).

• Always respond, promptly and comprehensively, to requests for clarification of clinical documentation.

Overall Changes

• 34,250 (50%) are related to the musculoskeletal system

• 17,045 (25%) are related to fractures

• 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’

• ~25,000 (36%) of all ICD-10 codes to distinguish ‘right’ vs. ‘left’

Clinical Changes Expansions and Deletions

• Marked expansion of codes • Trauma, overdoses, or complications

treatment phases • Office encounters • Asthma • Diabetes mellitus • Obstetrics (trimesters) • Non-pressure ulcer staging • Myocardial infarction timing and

vessel involvement • Open fractures staging • Cerebral hemorrhage location • Ischemic stroke vessel involvement • Coma (Glasgow Coma Scale) • Atrial flutter and fibrillation • Drug underdosing

• Deletion of MD language, such as: • Urosepsis

• Must say “sepsis due to UTI”

• SIRS due to infection • Must say “sepsis” or

“severe sepsis” • Accelerated or

malignant hypertension

• Must describe the organ dysfunction caused by hypertension to measure severity

MD progress notes and DC summaries must use ICD-10-CM’s language (Index or Table) as to defend the assigned code

Differences from ICD-9-CM to ICD-10-CM

ICD-9-CM

Diagnosis Codes ICD-10-CM

Diagnosis Codes

Laterality No Laterality

Laterality –

Right or Left account for 35-40% of codes

Code Construction

3-5 digits 7 digits

First digit is alpha (E or V) or numeric

Digit 1 is alpha; Digit 2 is numeric

Digits 2-5 are numeric Digits 3–7 are alpha or numeric

Decimal is placed after the third character

Decimal is placed after the third character

Placeholders No placeholder characters “X” placeholders

# of Codes 14,000 codes 69,000 codes

Severity Limited Severity Parameters Extensive Severity Parameters

Combination Limited Combination Codes Extensive Combination Codes

Excludes Notes

1 type of Excludes Notes 2 types of Excludes Notes

ICD-10-CM Codes with Placeholders

ICD9 ICD9 Title ICD10 ICD-10 Title Mapping Theory

65201

Unstable lie, delivered, with or without mention of antepartum condition

O320XX0 Maternal care for unstable lie, not applicable or unspecified

Approximate match

O320XX1 Maternal care for unstable lie, fetus 1

Approximate match

O320XX2 Maternal care for unstable lie, fetus 2

Approximate match

O320XX3 Maternal care for unstable lie, fetus 3

Approximate match

O320XX4 Maternal care for unstable lie, fetus 4

Approximate match

O320XX5 Maternal care for unstable lie, fetus 5

Approximate match

O320XX9 Maternal care for unstable lie, other fetus

Approximate match

ICD-10-CM requires some categories or chapters to have 7 digits, no matter what, and for certain elements to be designated at the 7th digit. As such, placeholder digits (“X”, “XX”, or “XXX”) may occupy the character spaces between the code and the 7th digit

New and Consolidated Coded ICD9 ICD9 Title ICD10 ICD-10 Title

630 Hydatidiform mole O010 Classical hydatidiform mole

630 Hydatidiform mole O011 Incomplete and partial hydatidiform mole

630 Hydatidiform mole O019 Hydatidiform mole, unspecified

6318 Other abnormal products of conception O020 Blighted ovum and nonhydatidiform mole

6318 Other abnormal products of conception O0289 Other abnormal products of conception

6318 Other abnormal products of conception O029 Abnormal product of conception, unspecified

63300 Abdominal pregnancy without intrauterine pregnancy

O000 Abdominal pregnancy

63301 Abdominal pregnancy with intrauterine pregnancy O000 Abdominal pregnancy

63310 Tubal pregnancy without intrauterine pregnancy O001 Tubal pregnancy

63311 Tubal pregnancy with intrauterine pregnancy O001 Tubal pregnancy

63320 Ovarian pregnancy without intrauterine pregnancy O002 Ovarian pregnancy

63321 Ovarian pregnancy with intrauterine pregnancy O002 Ovarian pregnancy

63380 Other ectopic pregnancy without intrauterine pregnancy

O008 Other ectopic pregnancy

63381 Other ectopic pregnancy with intrauterine pregnancy

O008 Other ectopic pregnancy

63390 Unspecified ectopic pregnancy without intrauterine pregnancy

O009 Ectopic pregnancy, unspecified

63391 Unspecified ectopic pregnancy with intrauterine pregnancy

O009 Ectopic pregnancy, unspecified

Meditech 5.67

ICD-9-CM and ICD-10-CM/PCS Diagnoses and Procedures

Code Type ICD-9-CM ICD-10-CM ICD-10 PCS

Diagnosis 14,567 codes 69,832 codes

OB Diagnosis 1107 codes 2155 codes

Inpatient Facility

Procedure 3,878 codes 71,920 codes

Chapter 15: Pregnancy, Childbirth, and the Puerperium O00‐O99 • Codes start with an

“O” (as in Ostrich or Octopus), not the number “0” (zero)

• All ICD-10 codes start with a letter

• Chapter 15 codes have sequencing priority over codes from other chapters.

• Additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions.

• O00–O08, Pregnancy with abortive outcome

• O09, Supervision of high-risk pregnancy

• O10–O16, Edema, proteinuria, and hypertensive disorders in pregnancy, childbirth, and the puerperium

• O20–O29, Other maternal disorders predominantly related to pregnancy

• O30–O48, Maternal care related to the fetus and amniotic cavity and possible delivery problems

• O60–O77, Complications of labor and delivery

• O80, O82, Encounter for delivery

• O85–O92, Complications predominantly related to the puerperium

• O94–O9A, Other obstetric conditions, not elsewhere classified

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New Changes Excludes Notes

Excludes1 - A type 1 Excludes note is a pure excludes. • It means 'NOT CODED HERE!' • An Excludes1 note indicates that the code excluded should

never be used at the same time as the code above the Excludes1 note.

• An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Excludes2 - A type 2 excludes note represents 'Not included here'. • An excludes2 note indicates that the condition excluded is not

part of the condition it is excluded from but a patient may have both conditions at the same time.

• When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.

Excludes1 and Excludes2 Examples

Note that a code for supervision of normal pregnancy (Z34.-) can never be used if a condition related to or aggravated by the pregnancy, childbirth, or the puerperium exists

All Conditions in Pregnancy are related unless stated otherwise • ICD-10-CM’s default is that any condition

encountered in a pregnancy is related to the pregnancy unless explicitly documented otherwise • It is the provider’s responsibility to state that the

condition being treated is not affecting the pregnancy.

• Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in place of any chapter 15 (Obstetrical) codes.

48

Pregnant State, Incidental

Supervision of Normal Pregnancy Used if No Other “O” code used

Meditech 5.67

Elimination of Episodes of Care Current ICD-9-CM Classification

ICD-9-CM

• 6480x Diabetes mellitus of mother, complicating pregnancy, childbirth, or the puerperium,

• 0 - unspecified as to episode of care or not applicable

• 1 - with or without mention of antepartum condition

• 2 - delivered, with mention of postpartum complication

• 3 - antepartum condition or complication

• 4 - postpartum condition or complication

• Gestational diabetes coded to “glucose intolerance

Creation of Trimesters ICD-10 • First Trimester

• Less than 14 weeks, 0 days

• Second Trimester • 14 weeks, 0 days to less than 28

weeks, 0 days

• Third Trimester • 28 weeks, 0 days until delivery

• Trimester not always applicable • 032 Maternal care for

malpresentation of fetus (condition associated with delivery i.e. third trimester)

• Codes are no longer viewed as antepartum, delivered and postpartum. • It is now necessary to

know what trimester the patient is in to select the appropriate code.

53

Trimesters are counted from the first day of the last menstrual period by the number of days/weeks of the pregnancy.

Gestational Week In Addition to Trimester • ICD-10-CM provides the ability to report

the specific gestational week of pregnancy with codes from category Z3A. • Gestational week codes would be reported in

addition to codes for complications of pregnancy.

• Examples: • Z3A.0 Weeks of gestation of pregnancy,

unspecified or less than 10 weeks • Z3A.00 Weeks of gestation of pregnancy not

specified • Z3A.01 Less than 8 weeks gestation of

pregnancy • Z3A.08 8 weeks gestation of pregnancy • Z3A.09 9 weeks gestation of pregnancy

Trimester can be calculated from the documented weeks. Weeks cannot be calculated from the documented trimester

Meditech 5.67

Preeclampsia and Eclampsia Trimester Importance

HELLP – Hemolysis, Elevated Liver enzymes, Low Platelet count Eclampsia – new onset grand-mal seizure in setting of pre-eclampsia

High Risk Pregnancy

High Risk Pregnancy

High Risk Pregnancy

• Grand multiparity – 5 or more births

Early vs. Late Pregnancy Now 20 weeks (versus 22 weeks)

• Hyperemesis gravidarum • O21.0 Mild hyperemesis

gravidarum Hyperemesis gravidarum, mild or unspecified, starting before the end of the 20th week of gestation

• O21.1 Hyperemesis gravidarum with metabolic disturbance

Hyperemesis gravidarum, starting before the end of the 20th week of gestation, with metabolic disturbance such as carbohydrate depletion, dehydration, or electrolyte imbalence

• O21.2 Late vomiting of pregnancy

• Excessive vomiting starting after 20 completed weeks of gestation

• Abortions and fetal deaths • O02.1 Missed abortion

Early fetal death, before completion of 20 weeks of gestation, with retention of dead fetus

• OB hemorrhage • O20 Hemorrhage in early

pregnancy Includes: hemorrhage before completion of 20 weeks gestation

Diabetes Classifications in Pregnancy

• Classifications

• Gestational

• Preexisting Type 1

• Preexisting Type 2

• Other primary diabetes

• Due to underlying diseases • e.g., Cushing’s

syndrome, pancreatitis, cystic fibrosis,

• Due to drug or chemical e.g., steroid-induced

• Necessary documentation

• Diabetes type (e.g. gestational, type 1, type 2, or other etiologies)

• If currently with hyperglycemia or hypoglycemia

• All acute or chronic complications (e.g. DKA, neuropathies)

• Any effect on the fetus

Diabetes

Meditech 5.67

Diabetic Complications

Must come from the chapter corresponding to the type of diabetes For example, Drug/Chemical Induced is E9; Type 1 DM is E10; Type 2 DM is E11

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Gestational Hypertension

• Gestational hypertension is defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg in a previously normotensive pregnant woman who is ≥20 weeks of gestation and has no proteinuria or new signs of end-organ dysfunction. • The blood pressure readings should be documented on

at least two occasions at least four hours apart. • It is considered severe when sustained elevations in

systolic blood pressure ≥160 mmHg and/or diastolic blood pressure ≥110 mmHg are present for at least four hours.

69

Meditech 5.67

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Preeclampsia Diagnostic Criteria

NOTE: If any criteria in red or bold is present, qualifies for severe pre-eclampsia

Blood pressure • Systolic ≥ 140 mm Hg or diastolic ≥ 90 mm Hg on 2 occasions at least 4 hours apart after 20 weeks gestation in a woman with previously normal BP

• Systolic ≥ 160 mm Hg or diastolic ≥ 110 mm Hg confirmed in a short interval (minutes) to facilitate antihypertensive Rx*

AND proteinuria • ≥ 300 mg/24 hr urine collection, or • Protein/creatinine ratio ≥ 0.3 (each measured in mg/dl), or • Dipstick reading of 1+ (used if quantitative methods not available)

OR, in the absence of proteinuria, new onset HTN (as above) w/new onset of any of the following:

Thrombocytopenia Platelet count less than 100,000/microliter (CDI note; thrombocytopenia can be coded if documented separately)

Renal insufficiency Serum creatinine > 1.1 mg/dl or doubling w/o other renal disease (CDI note; qualifies as acute kidney injury, which can be coded if documented)

Impaired liver function Elevated transaminases to twice normal concentration (CDI note; note any protime elevations c/w acute liver failure)

Pulmonary edema (CDI note; specify if non-cardiogenic pulmonary edema)

Cerebral or visual symptoms

(CDI note; specify if consistent with metabolic encephalopathy or if hallucinations are present)

New Codes- HELLP

Meditech 5.67

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Preeclampsia & Eclampsia Trimester Importance

HELLP – Hemolysis, Elevated Liver enzymes, Low Platelet count Eclampsia – new onset grand-mal seizure in setting of pre-eclampsia

Multiple Gestations Fetus Identification

• ICD 10-CM identifies the specific fetus in multiple gestations • A numerical character is assigned to identify the fetus

for which a complication applies: • Example: 064.1xx2 “obstructed labor due to breech

presentation, fetus 2”

• OK to equate “Fetus A” as #1, “Fetus B” as #2, etc.

• If an adverse event occurs with a fetus, the physician must designate which fetus (e.g. fetus 1, fetus 2) was involved

Pre-Term Labor with Pre-Term Delivery

Pre-term Labor Pre-term and Term Delivery

Don’t forget the 7th digit of 0 for single gestation and others for multiple gestations

Meditech 5.67

Meditech 5.67

ICD-10-CM: A Dictionary w/o Definitions Drug Use/Abuse/Addiction

SEPAS - January 2013 85

ICD-10-CM: A Dictionary w/o Definitions Drug Use/Abuse/Addiction

SEPAS - January 2013 86

ICD-10-CM: A Dictionary w/o Definitions Drug Use/Abuse/Addiction

SEPAS - January 2013 87

Definitions – DSM-5 Use vs. Abuse vs. Dependency • Use – legal use of a drug or chemical

• Abuse – Illegal or excessive use of a drug or chemical causing adverse consequences

• Dependency (at least 2 of the following) • Item taken in larger amounts or over a longer period than intended • Persistent desire or unsuccessful efforts to cut down or control use • Great deal of time spent to obtain the chemical • Craving or a strong desire to use • Continued use despite adverse consequences due to drug/chemical • Failure to meet major role obligations at home, work, or school • Recurrent use in situations that are hazardous (2 DWIs) • Continued use despite knowledge of having a physical or mental condition that

is worsened by the chemical use • Tolerance (need for more drug to have the same effect) • Withdrawal symptoms when drug is discontinued

Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

SEPAS - January 2013 88

Meditech 5.67

Definitions – DSM-5 Remission • Intoxication - Reversible substance-specific syndrome due

to recent ingestion of a substance

• Delirium - A disturbance in attention (e.g. reduced ability to direct, focus, or sustain) and awareness (reduced orientation to environment that develops over a short period of time, that is different over baseline, and tends to fluctuate in severity over the course of a day than cannot be better explained by a preexisting neurocognitive disorder

• Remission - After full criteria for dependency were previously met, none of the criteria (except for craving or a strong desire to use) have been met for a least 3 months • Early remission – between 3 to 12 months • Sustained remission – over 12 months

Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

SEPAS - January 2013 90

New or Significant Changes in GYN

• Laterality • left, right, bilateral

• Specificity of acuity • Acute, subacute or

chronic • Mild, moderate, severe,

or unspecified

• Specificity of location • Salpingitis, oophoritis or

both • Ovary, fallopian tube, or

both

• Specificity of conditions, such as for pelvic inflammatory disease • Chlamydial female

pelvic inflammatory disease

• Female pelvic peritonitis

• Female pelvic inflammatory disease unspecified

ICD-10-CM Acuity

SOI = severity of illness ROM = risk of mortality

MSDRG DescriptionMSDRGCC/MCC

SOI ROM

N7001 Acutesalpingitis CC 2 1

N7002 Acuteoophoritis CC 2 1

N7003 Acutesalpingitisandoophoritis CC 2 1

N7011 Chronicsalpingitis

1 1

N7091 Salpingitis,unspecified 1 1

• Acute versus chronic salpingitis or oophoritis

ICD-10-CM - Current malignancy vs. personal history of malignancy • When a primary malignancy has been excised but further

treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed • For liquid cancers, indicate whether the malignancy is active, in

remission, or in relapse • For solid cancers, any patient receiving adjuvant treatment should

be documented as being active, not a “history of malignancy”

• When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

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Source: ICD-10 Official Guidelines for Coding and Reporting

Complications and Trauma Episodes of Care

• Initial encounter: receiving active treatment for an injury.

• Fx care: Emergency physician, orthopedist, radiologist, etc. • Poisonings – initial treatment during the hospital stay • DOES NOT CORRELATE WITH CPT’S DEFINITION OF INITIAL

• Subsequent encounter: care during a period of healing or recovery.

• Cast change, suture removal, etc. • Poisonings – could be during a hospital stay or immediate visit • DOES NOT CORRELATE WITH CPT’S DEFINITION OF SUBSEQUENT

• Sequela: After the healing process is complete. • Fx care: Arthritis remotely after trauma, etc. • Poisonings – If related to a long-standing consequence (e.g. anoxic

encephalopathy from carbon monoxide poisoning

Episodes of Care Injuries and Encounter

• Note that to serve as a “CC”, the treatment must be for the initial encounter

Physician

CCH’s ICD-10 Strategy - CDI

CDI Team

ICD-10 Coder

Questions