AnesthesiaICD 10 Documentation Tips

Effective Date

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Definition of ICD-10

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ICD-9 vs. ICD-10

• CM ( Clinical Modification)– ICD-9: 14,000 codes vs ICD-10 68,000!

• PCS ( Procedure Coding System)– ICD-9 3,800 Procedure codes vs ICD-10 87,000!

– Outpatient will still use CPT codes (Current Procedural Terminology)

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ICD-10 and Monitoring

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Claims Review and ICD-10

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Work Burden

The Hard Way

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ICD-10 – CM

• Diagnosis classification system developed by the Centers for Disease Control and Prevention for use inall U.S. health care treatment settings

• ICD 10 CM codes can have 3, 4, 5, 6 or 7 characters (alphanumeric)

A joint effort between the healthcare provider and the coder is essential to achieve complete andaccurate documentation, code assignment, and reporting of diagnoses and procedures

Character 1 Character 2 Character 3

• Category of disease

Character 4 Character 5 Character 6 Character 7

• Place-holder forextensionof code

• Body part affected

• Etiology of disease

• Severity of illness

S20.221A S20- Superficial injury tothorax

2 – Contusion 2 – Back wall ofthorax

1- Right A- Initial encounter

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ICD-10 Made Simple For Those That

Have Coders- DOCUMENT!

• Acuity- acute, chronic, intermittent

• Severity- mild, moderate, severe

• Etiology- trauma, diabetes, renal failure, exercise or infectioninduced

• Location- where is it- be specific about which joint, chest, femur,posterior thorax

• Laterality- which side is it? Left, right, both?

• Detail: Present on admission status, associated symptoms(hypoxia, loss of consciousness), additional medical diagnoses,

initial versus subsequent encounter

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If you like mnemonics

Any: Acuity

Small: Severity

Error: Etiology

Loses: Location

Large: Laterality

Dollars: Detail- Present on admission status, associated symptoms,additional medical diagnoses, initial versus subsequent encounter

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SOI / ROM

Documentation should reflect the acuity of the patient…

If a patient dies because he or she was severely ill, but thedocumentation translates into codes that do not reflect theseverity, the adjusted SOI and ROM poorly reflect the careprovided.

• MI- specific type, location, vessel

• PE- location

• CHF- systolic, diastolic, both?

• Arrhythmias: type ex: A fib: acute, chronic ( permanent);paroxysmal, persistent

Key Items

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Fractures for Anesthesiologist

Common Coder Queries: BloodLoss

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• “Blood loss anemia” or “post-operative anemia”

• **Queries: acute vs chronic. Per CodingGuidelines, postoperative anemia withoutspecification of acute blood loss is coded to Anemia,unspecified

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Case Presentation: Sepsis

67 year old male presents with altered mental status, fever to 104F, and a blood

pressure of 70/30 mm Hg, HR of 110 bpm and RR of 20 breaths/ minute. His

oxygen saturation is 90% on RA but increases to 95% with 2 liters of oxygen. His

WBC is 20,000 and his abdomen is rigid. His BP does not improve with normal

saline and therefore he is started on pressors. The surgeon would like to take him

to the OR immediately.

PMH: History of MI

Social history: Smokes 2 packs of cigarettes per day

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Sepsis: Example

ACUITY acute

SEVERITY severe

ETIOLOGY Intra-abdominal infection

LOCATION N/A

LATERALITY N/A

DETAILInitial encounter. Associated findings: Hypoxia, encephalopathy, presenton admission

ASSOCIATED

FINDINGShypoxia, cigarette (tobacco) dependence

ALL PUT TOGETHER

1. Acute, severe septic shock due to intra-abdominal infection– presenton admission

2. Acute hypoxia3. Acute encephalopathy4. History of Myocardial infarction5. Cigarette dependence

Case Example: Respiratory Failure

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Example COPD Exacerbation

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Key Documentation Elements

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Asthma

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Documentation Example

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Difference between use, abuse, and

dependence in ICD-10Abuse – Problematic use of drugs or alcohol but without dependence

Dependence – Increased tolerance to drug or alcohol with a compulsion to continue taking the substance despite the cost, withdrawal symptoms oftenoccur upon cessation

Documentation should be clear as to the abuse or dependence of alcohol/drugs and the associated complications/conditions

F12.1 - Cannabis abuseF12.10 - Cannabis abuse, uncomplicated

F12.12 - Cannabis abuse with intoxicationF12.120 - Cannabis abuse with intoxication, uncomplicatedF12.121 - Cannabis abuse with intoxication deliriumF12.122 - Cannabis abuse with intoxication with perceptual

disturbanceF12.129 - Cannabis abuse with intoxication, unspecified

F12.15 - Cannabis abuse with psychotic disorderF12.150 - Cannabis abuse with psychotic disorder with delusionsF12.151 - Cannabis abuse with psychotic disorder with

hallucinationsF12.159 - Cannabis abuse with psychotic disorder, unspecified

F12.18 - Cannabis abuse with other cannabis-induced disorderF12.180 - Cannabis abuse with cannabis-induced anxiety disorderF12.188 - Cannabis abuse with other cannabis-induced disorder

F12.19 - Cannabis abuse with unspecified cannabis-induced disorder

F12.2 - Cannabis dependenceF12.20 - Cannabis dependence, uncomplicated

F12.21 - Cannabis dependence, in remission

F12.22 - Cannabis dependence with intoxicationF12.220 - Cannabis dependence with intoxication, uncomplicatedF12.221 - Cannabis dependence with intoxication deliriumF12.222 - Cannabis dependence with intoxication with perceptual disturbanceF12.229 - Cannabis dependence with intoxication, unspecified

F12.25 - Cannabis dependence with psychotic disorderF12.250 - Cannabis dependence with psychotic disorder with delusionsF12.251 - Cannabis dependence with psychotic disorder with hallucinationsF12.259 - Cannabis dependence with psychotic disorder, unspecified

F12.28 - Cannabis dependence with other cannabis-induced disorderF12.280 - Cannabis dependence with cannabis-induced anxiety disorderF12.288 - Cannabis dependence with other cannabis-induced disorder

F12.29 - Cannabis dependence with unspecified cannabis-induced disorder

F12.9 – Cannabis use – (similar classification for cannabis use)

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Procedure code structure

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Important Documentation for

Procedures

PROCEDURE DOCUMENTATION

Type of Procedure(Root Operation):

specifies the primary objective of the procedureEx: drainage, excision, resection

Body Part: the specific organ or site on which the procedure isperformed

Approach: the technique/method used to access the operative siteEx: Open, percutaneous, external, endoscopic

Devices: any device or material that remains at the site uponcompletion of the procedure

Qualifier: unique character for specific proceduresEx: diagnostic, therapeutic

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ICD-10 Made Simple For Those That

Have Coders- DOCUMENT!

• Acuity- acute, chronic, intermittent

• Severity- mild, moderate, severe

• Etiology- trauma, diabetes, renal failure, exercise or infectioninduced

• Location- where is it- be specific about which joint, chest, femur,posterior thorax

• Laterality- which side is it? Left, right, both?

• Detail: Present on admission status, associated symptoms(hypoxia, loss of consciousness), additional medical diagnoses,

initial versus subsequent encounter

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Thank you

Sharieff.Ghazala@scrippshealth.org