Clinical Documentation for ICD-10-CM

ADOPTERS OR LAGGARDS – WHICH ARE YOU?

Pamela Marasco MEd, CPC

Adjunct Faculty, IUPUI School of Informatics and ComputingDepartment of BioInformatics, Human-Centered Computing, Library and Information ScienceHealth Information Management Program

American Academy of Professional Coders (AAPC) Approved ICD-10-CM Trainer

How Do You Rate Yourself as an Adopter of Change?Assess your willingness to implement new clinical documentation for ICD-10-CMImprove your practices for clinical documentation to ensure proper selection of ICD-10-CM Coding Guidelines Because EVERYTHING IS CHANGING!

From Everett Rogers "Diffusion of Innovations"

Innovator

Early Adopter

Early Majority

Late Majority

Laggards

Everything is Different

ICD-10-CM changes the way healthcare providers deliver healthcare.

• Increased number of index chapters and codes• Length of codes• Level of specificity• Increased number of ICD-10-CM External Cause

Codes • Enhanced statistical gathering of health

information • Refined levels of documentation

10-01-2015ICD-10-CM

Don’t Be Like This Version

Don’t be a provider version of a documentation laggard for ICD-10-CM implementation on Oct 1st

2015.

Be an active adopter of ICD-10-CM Documentation Guidelines in your practice for effective and quality patient care, as well as for billing, reimbursement, research and healthcare policy improvement. Assess your clinical documentation NOW!

Looking For Good DataHeath care policy makers are looking for ICD-10-CM to provide good data to Evaluate disease management Evaluate population needs Eliminate waste Capture financial metrics Assist in forecasting budgets Provide care management More precisely identify and track

specific conditions Guide other business decisions that

affect the bottom line

Documentation - Capturing DataCurrent ICD-10-CM revisions and coding guidelines are intended to capture a snapshot of population health to aid in the decision making

and management of health systems worldwide

as well as establish medical necessity of procedures and services provided to patients during an encounter

It’s About the Clinical Picture of the Patient

Documenting the medical decision making process . . . rather than just the medical decision determines and supports medical necessity

IDC-10-CM Documentation is All About the Process

For Example“Mrs. Rose is a 68 year old female with multiple comorbidities. She has a moderate size aneurysm. This does not currently require treatment but will in the future. Bilateral lower extremity claudication is a major problem which will require surgery. Endovascular intervention is not a good idea because of the aneurysm and total occlusion on the left. Open surgery would treat both of these problems…”

Rather Than

“Bilateral claudication; surgery to be scheduled for next week”.

Good Documentation is Needed

To justify medical necessity To ensure accurate documentation

for equitable reimbursement and future payment trends

Minimize reduced or denied payments

Avoid audit takebacks Ensure quality health care

Documentation Mistakes MatterDon’t take documentation for granted.Providers need to review and update practice policies for ICD-10-CM Clinical Documentation Guidelines to provide good and proper data.

Avoid EHR Documentation Shortcuts Don’t rely on “cut and paste”

platforms to support medical necessity.

Progress notes must be dedicated to each patient encounter or payers may question whether services are medically necessary.

Avoid carrying forward documentation.

Avoid cloned documentation.

Cloned DocumentationCMS has stated that “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries”. “Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment”

But Don’t Blame Your EHRDon’t Misuse Your EHRJust because some poor documentation practices are possible in an EHR doesn’t mean that EHRs in general lead to poor or faulty documentation.

Review your practice EHR programs and the way that you use them.

Don’t Rely on GEMs?

GEM translations on computer based systems are a helpful way to start looking for a code when you move from ICD-9-CM to ICD-10-CM.

GEMs will get you to the area of search but do not rely on them to assign a specific code.

GEMs are not a one-to-one match for ICD-10-CM codes because of the increased specificity in ICD-10-CM.

Documentation must support crosswalk coding and GEM mapping.

General Equivalence Mapping

Documentation Integrity and ICD-10-CMThe documentation of each patient encounter should include relevant information on the reason for the encounter relevant patient history physical examination findings prior diagnostic test results assessment clinical impression diagnosis plan for care dated legible identity of the observer

Documentation integrity is based on a flow of information that is • Credible• Reliable • Patient Specific • Avoid non-specific or irrelevant

documentation.

“”

If it isn’t written down it didn’t happen”

DOCUMENTATION - MATERIAL THAT PROVIDES OFFICIAL INFORMATION OR EVIDENCE OR THAT SERVES AS A RECORD TO ESTABLISH MEDICAL NECESSITY.

Who hasn’t heard this old adage at some point or another. The principle underlying this old rule of thumb is more true now than ever before.

• ICD-10-CM code structure reflects the need for proper documentation.

• In ICD-10-CM up to 7 alphanumeric characters and placeholders are used to define provider documentation with greater specificity.

ICD-10-CM Code S82.221A

ICD-10-CM Restructures the Reporting of Diagnoses

Coding’s New Zip Code

Place MattersDefaultsThere are specific ICD-10-CM Guidelines for circumstances in the medical record when the provider does not mention a modifying condition. In this case the coder would accept a preselected agreed upon option choice. Examples include

Diabetes mellitus - If the type of diabetes is not mentioned in the medical record it defaults to Type II

Fractures - If the provider does not indicate whether the fracture was open or closed the code defaults to closed. If the physician does not indicate whether the fracture is displaced or nondisplaced, the code defaults to displaced

PositionWhere X character is located matters

► X at the beginning of a code indicates a code from ICD-10-CM Chapter 20: External Causes of Morbidity

X78.0 X located in the 5th and/or 6th character X

is a dummy placeholder S03.0XXD

X Marks the SpotWhich answer choice is best?1. The X serves as a placeholder for future expansion2. The X serves as a placeholder to allow a code to

meet the specific requirement of coding to the highest level of specificity when the code has fewer than 6 characters and requires a 7th character extension

3. Both 1 and 2 are correct4. The “X” is a signal that the code is incomplete

Number 3

ICD-10-CM Documentation Granularity

There are nearly 5 times as many diagnostic codes in ICD-10-CM than in ICD-9-CM.ICD-10-CM has 70,000 codes vs14,000 codes in ICD-9-CM.There are nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM volume 3.

Granularity - greater specificity in identifying health conditions.

The greater level of detail in the new ICD-10-CM code sets includes

• Laterality• Severity• Complexity of Disease

Conditions

.

ICD-10-CM Documentation Granularity Means Greater SpecificityMore Specific Codes Are Used in ICD-10-CM To Report

Expanded “cause” codes (V-W-X-Y) to replace E codes

Laterality Episode of care – initial, subsequent, sequela

injuries, poisonings, complications of pregnancy Trimester of Pregnancy Clinical details such as acute vs.

chronic Place of occurrence (used only once at

initial encounter)

CollegeDaycare centerElementary schoolHigh schoolKindergartenMiddle schoolUniversityVocational school

Macaws vs Parrots

ICD-10-CM Coding Specificity How to code “bitten by a bird”Patient bitten by a macaw initial encounterThere is a specific code for that type of bird. (injuries –external causes – contact with birds – parrot –macaw etc.W61.11XAMacaws are a type of tropical parrot whereas parrots are found all over the world except Antarctica. Very specific, indeed!

ICD-10-CM

Requires More

Specificity

The Specifics of Coding a Fall While Snow Skiing in Aspen

While skiing in Colorado, the patient fell and was diagnosed with a fracture of the right ankle1. identified fx as traumatic vs pathological

2. query provider as to specific location (lateral malleolus)

4 codes needed:S82.61XA Displaced fx, rt ankle, lateral malleolus, initial encounterV00.321A Snow – ski accidentY92.39 Other specified sports and athletic area as the place of occurrenceY93.23 Other individual sport

Need more documentation

If the provider does not indicate whether the fracture was open or closed the code defaults to closed. If the physician does not indicate whether the fracture is displaced or nondisplaced, the code defaults to displaced

ICD-10-CM Documentation Laterality

Code descriptors include a right and left designation that enables documentation reflecting the importance of which side of the body or limb is subject to evaluationICD-10-CM Code S72.351C (1 )indicates right side(C) Indicates initial encounter for open fracture type IIIA, IIIB, or IIIC

ICD-10-CM DocumentationEncounters – Episode of Care

(A) Initial - active treatment (D) Subsequent - healing or recovery phase (S) Sequela = aftercare - residual

complications or conditions that arise as a direct result of the injury

Initial Encounter –

Seen by multiple physicians (ED, radiologist, neurologist) or over an extensive period of time (entire acute care hospital stay).

Subsequent Encounter – Received active tx and physician is providing routine care during the healing or recovery phase.

Do not confuse initial encounter with first visit andsubsequent encounter doesn’t mean that ‘it happened again’.

ICD-10-CM Documentation for SequelaSequela (ICD-9-CM Late Effect) The residual effect (condition

produced) after the acute phase of a illness or injury has terminated

You can report a sequela code at any time after the acute phase ends

There is no time limit on when a late effect can occur; the residual condition may come directly after the disease or condition, or years later

Coding Guidelines When coding for sequela(e), there are typically two

codes that are required. The condition or nature of the sequela(e)/late effect is sequenced first and the sequela(e) (late effect) sequenced second

Example: M81.8 Other osteoporosis without current

pathological fracture E64.8 Sequelae of other nutritional deficiencies

(calcium deficiency) Exceptions to this rule are if the code for the late

effect is followed by a manifestation code, identified in the Tabular List and title or if the late effect code has been included in the fourth, fifth, or sixth character levels to include the manifestation(s).

Example: I69.191 Dysphagia following nontraumatic intracerebral hemorrhage

Worms in the Head

Coding Sequela (Late Effects) Patient presents with a personal

history of parasitic worm invasion of the brain. The worm is dead but the patient is suffering from the after effects (severe headaches).

Heaches (R51) the condition or nature of the sequela) are listed first followed by the

Sequela(as an after effect) (B94.9) – of other unspecified parasitic and infectious disease

R51 – B94.9

ICD-10-CM Documentation Complications of Care

Certain intraoperative and post-procedural complications are reclassified to specific body system chapters; yet others remain in chapter 19 (chapter 17, ICD-9-CM).

Not all conditions that occur during or following medical care or surgery are classified as complications.

Must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.

Guidelines require the presence of a cause-and-effect relationship

If it is anticipated, expected, and routine for certain types of procedures, it is not a complication

Complications Sequence the complication code

first followed by additional codes to specify the nature of the complication, when necessary:

Examples Chapter 19: T86.43 Liver transplant infection B25.1 Cytomegaloviral hepatitis

Extend Yourself Coding injuries, poisonings, and certain

other conditions in ICD-10-CM will require additional documentation in order to capture episode of care

As are certain complications of pregnancy with multiple gestation to identify which fetus(es) is(are)affected by the condition described by the code

Code extenders often infer morphology and treatment parameters

Make sure to look at Extendor Boxes and Chapter Guidelines for instructions

Example from category S52 .

A initial encounter for closed fractureB initial encounter for open fracture type I or IIinitial encounter for open fracture NOSC initial encounter for open fracture type IIIA, IIIB, or IIICD subsequent encounter for closed fracture with routine healingE subsequent encounter for open fracture type I or II with routine healingF subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healingG subsequent encounter for closed fracture with delayed healingH subsequent encounter for open fracture type I or II with delayed healingJ subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healingK subsequent encounter for closed fracture with nonunionM subsequent encounter for open fracture type I or II with nonunionN subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunionP subsequent encounter for closed fracture with malunionQ subsequent encounter for open fracture type I or II with malunionR subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunionS sequela

An ICD-10 –CM Code with a 7th Character Extension

S92.412A initial visit for a displaced fracture of the proximal phalanx of the left great toe

A - Initial Encounter for closed FXB - Initial Encounter for open FXD - Subsequent Encounter for FX with routine healingG – Subsequent Encounter for FX with delayed healingK – Subsequent Encounter for FX with nonunionP – Subsequent Encounter for FX with malunionS – Sequela – late effect - residual complications or conditions that arise as a direct result of the injury

The aftercare Z codes should not be used for aftercare of injuries. For aftercare of an injury, the coder will assign the acute injury code with the appropriate seventh character for subsequent encounter.

ICD-10-CM DocumentationTerminology

Terminology and disease classification are now consistent with new technology and current clinical practice.

In certain cases the following terms with associated clinical criterion are needed to assign the proper ICD-10-CM code Frequency Severity Type Complications Contributing factors

ICD-10-CM Terminology Changes First Listed Replaces use of the term Primary Diagnosis

Encounter SequelaReplaces Late Effect. Also known as lasting effects .For example after a CVA patient may suffer additional health problems lasting after the event has passedUnderdosing

Taking less of a medication that is prescribed by the physician or manufacturer’s instructions resulting in a negative health consequence

Initial – receiving active tx even if seen by multiple physicians (ED, radiologist, neurologist) or over an extensive period of time (entire acute care hospital stay)

Subsequent – has received active tx and physician is providing routine care during the healing or recovery phase

Do not confuse initial encounter with first visit

RubricA grouping of similar conditions.In ICD-10-CM, rubric denotes either a three-character category or a four-character subcategory.

ICD-10-CM Terminology DocumentationControlled vs Uncontrolled

In ICD-10-CM, the diabetes mellitus codes are no longer classified as controlled or uncontrolled.

If the type of diabetes is unclear or not mentioned in the medical record it defaults to Type II

If provider documentation includes words such as uncontrolled, out of control, or poorly controlled, the classification directs the coder to code the type of diabetes with hyperglycemia.

ICD-10-CM Terminology DocumentationControlled vs Uncontrolled

ICD-10-CM does not use controlled and uncontrolled to describe hypertension as did ICD-9-CM

Coders should look in documentation for terms such as “transient hypertension” when a provider records an episode of elevated blood pressure w/o a formal diagnosis of hypertension

Report Code R03.0 (elevated BP reading w/o diagnosis of hypertension)

ICD-10-CM Terminology DocumentationCombination Coding

A Combination code combines documented information in a single code. Such as A diagnosis with an associated secondary

process (manifestation) A diagnosis with an associated complication A diagnosis that includes condition and

symptoms or manifestations A diagnosis that includes location and stage As many combination codes as necessary can

be used to fully describe all complications or conditions met. They should be sequenced based on the reason for a particular encounter.

ICD-10-CM Combination Code E11.351Type 2 diabetes with proliferative diabetic neuropathy with macular edemaICD-10-CM Combination Code N41.01Acute prostatitis with hematuriaICD-10-CM Combination Code K50.841Crohn’s disease of both small and large intestine with abscess

Working Together Combination codes must fully

identify the diagnostic conditions involved.

If a combination code exists, and the documentation does not include all of the pertinent information to assign the combination code, the coder will need to query the provider to assign the most appropriate code.

ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis

Expanded combination coding allow for a greater level of specificity and clinical detail

ICD-10-CM Terminology Documentation Guidelines and Conventions

Excludes 1 NoteAn Excludes1 note is a pure excludes note. An Excludes1 note indicates that a coder should never use the excluded code with the code above the Excludes1 note. The two conditions cannot occur together

Excludes 2 Note Supporting Documentation

An Excludes 2 note means a condition is not included in the code. An Excludes 2 note indicates that the excluded condition is not part of the condition the code represents, but a patient may have both conditions simultaneously. When an Excludes 2 note appears under a code may report both the code and the excluded code together when appropriate.

ICD-10-CM Common Coding Conventions Punctuation/Symbols Instructional notes as in “code first” and “use additional code” Abbreviations such as NEC “Not Elsewhere Classifiable”. Used when the physician provides the detail,

but no code exists to report it. An Alphabetic Index entry that directs the coder to an “other specified” code in the Tabular List.

NOS – “Not Otherwise Specified”. The equivalent of unspecified. NOS codes are used when the physician does not document enough information for coders to select a more specific code. Documentation of the condition identified by the provider is insufficient to assign a more specific code. Even though ICD-10-CM codes include more detail than ICD-9-CM codes, coders will still have the option to use an unspecified code. What remains unclear is how payers will reimburse for the unspecified codes.

Sequencing as in etiology and manifestation

“”

CONVENTION - A WAY IN WHICH SOMETHING IS USUALLY DONE, AN AGREEMENT COVERING PARTICULAR MATTERS

A Word About ICD-10-CM Conventions

Do Not Ignore. Conventions provide important information that lead you to the proper code and require supporting documentation

A Word About Guidelines

Understanding and adhering to the guidelines will ensure that you achieve accurate and complete documentation and reporting of diagnoses and code assignmentsGuidelines are found at the beginning of the ICD-10-CM book and at the beginning of each Chapter section.

Example of Coding Guideilnes from Coding of Injuries When coding injuries, assign separate codes for each injury unless a

combination code is provided, in which case the combination code is assigned. Code T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.

Guidelines are a set of rules developed to complement and accompany the official conventions provided in ICD-10-CM

ICD-10-CM Terminology Documentation Manifest Destiny

• A manifestation is a display of the signs or symptoms or the disease

• A manifestation is an extension of the primary illness

• A manifestation is due to the primary illness and would not exist if not for the primary illness

• Manifestation codes will have “in diseases classified elsewhere” in the code title and used in conjunction with an underlying condition code

• Manifestation codes must be listed following the underlying condition etiology code

Meaning and Use of Manifestation in ICD-10-CM

Example: Neuropathy is a manifestation of diabetes

CODE FIRST Diabetes

Who’s on First? What’s on Second?

ICD-10-CM Code Conventions for Etiology and ManifestationGuidelines for certain conditions that have both an underlying etiology and multiple body system manifestations due to the underlying etiology • Sequence the etiology (underlying condition) FIRST

followed by the manifestation • Look for “use additional code” note at the etiology code• Look for “code first” at the manifestation code• [ ] brackets are used in the Alphabetic Index to identify

manifestation codes

Note - [ ] brackets are used in the Tabular List to include synonyms, alternate or explanatory wording

Code First

Sequencing and Pregnancy

Codes for pregnancy, childbirth and the puerperium (Chapter 15) are always sequenced first

024.012 Pre-existing diabetes mellitus, Type I (in pregnancy -2nd trimester)Z3A.18 18 weeks gestation of pregnancy

ICD-10-CM Terminology DocumentationUp in SmokeTobacco Terms

You will notice as a constant recurrent theme in ICD-10, if there's any exposure to tobacco

Whether it's in the cardiovascular system, respiratory system, or during pregnancy you're going find notes on these terms with required documentation

The statement “patient smokes” or “patient smokes occasionally” or “patient is a social smoker” is tobacco use

Patient “smokes 2 packs a day” or “patient has 40 pack per year habit” is nicotine dependence.

Tobacco Codes Exposure to environmental tobacco

smoke Z77.22 History of tobacco use Z87.891 Occupational exposure to

environmental tobacco smoke Z57.31

Tobacco dependence F17. - Tobacco use Z72. 0

Need for ChangeThe updated code sets will allow, and in fact will require, significant changes in the way providers document and support medical necessity resulting in the way health plans reimburse services, and in the way coverage of services is determined.

• ICD-10-CM has been designed to enable significant improvements in data reporting for care management, research, and quality measurement

• ICD-10-CM will allow better exchange of information with other countries who have already adopted ICD-10 and encourage international compatibility.

Coding’s Y-2-K

The Final Rule Requiring Replacement of ICD-9-CM with ICD-10-CM Sets the

Compliance Date for October 1, 2015.

• Purpose • Scope • Evidence • Value

with consistent, complete, specific and accuratedocumentation to justify procedures and level of service provided.

Clinical Documentation For ICD-10-CM Requires

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