ICD-10Getting There…..

Neurosurgery

What Physicians Need To Know

• Claims for ambulatory and physician services provided on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• CPT Codes will continue to be used for physician inpatient and outpatient services and for hospital outpatient procedures.

• ICD-10-PCS – a NEW procedure coding classification system, must be used to code all inpatient procedures on Facility Claims for discharges on or after 10/1/15.

• ICD-9-CM codes must continue to be used for all dates of services on or before 9/30/2015.

• Further delays are not likely.

ICD-9 vs ICD-10 Diagnosis Codes

ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

3 to 5 digits 7 digits

Alpha “E” & “V” – 1st Character Alpha or numeric for any character

No place holder characters Include place holder characters (“x”)

Terminology Similar

Index and Tabular Structure Similar

Coding Guidelines Somewhat similar

Approximately 14,000 codes Approximately 69,000 codes

Severity parameters limited Extensive severity parameters

Does not include laterality Common definition of laterality

Combination codes limited Combination codes common

Number of Codes by Clinical Area

Clinical Area ICD-9 Codes ICD-10 Codes

Fractures 747 17,099

Poisoning and Toxic Effects 244 4,662

Pregnancy Related Conditions 1,104 2,155

Brain Injury 292 574

Diabetes 69 239

Migraine 40 44

Bleeding Disorders 26 29

Mood Related Disorders 78 71

Hypertensive Disease 33 14

End Stage Renal Disease 11 5

Chronic Respiratory Failure 7 4

Right vs. left

accounts for nearly ½

the increase in the #

of codes.

The Importance of Good Documentation

• The role of the provider is to accurately and specifically document the nature of the patient’s condition and treatment.

• The role of the Clinical Documentation Specialist is to query the provider for clarification, ensuring the documentation accurately reflects the severity of illness and risk of mortality.

• The role of the coder is to ensure that coding is consistent with the documentation.

• Good documentation….• Supports proper payment and reduces denials• Assures accurate measures of quality and efficiency• Captures the level of risk and severity• Supports clinical research• Enhances communication with hospital and other providers• It’s just good care!

Inadequate vs. Adequate Documentation Example 1: Spina Bifida

Inadequate Documentation Required ICD-10 Documentation

Spina bifida with paralysis.

Previous ventriculoperitoneal shunt placement.

Lumbar spina bifida cystica, bilateral lower limb paralysis and hydrocephalus with previous ventriculoperitoneal shunt placement.

Needed improvements:

Location, type, and presence of complicating

factors.

Inadequate vs. Adequate Documentation Example 2: Spondylopathies

Inadequate Documentation Required ICD-10 Documentation

Disc disease and stenosis with spondylolisthesis. Spinal curvature and Schmorl’s node present.

Anterior lumbar interbody fusion scheduled for Tuesday.

Degenerative disc disease and spinal stenosis with lumbar spondylolisthesis. Lumbar scoliotic curve secondary to disc disease. Schmorl’s node @ L3.

Anterior lumbar interbody fusion L2 – L3 and L3 – L4 scheduled for Tuesday.

Needed improvements:

Location, complicating

factor(s), and underlying

disease(s).

Inadequate Documentation Required ICD-10 Documentation

IMPRESSION:

Epilepsy.

IMPRESSION:Well controlled, cryptogenic left temporal lobe epilepsy with complex partial seizures, no status epilepticus.

Inadequate vs. Adequate Documentation Example 3: Epilepsy

Needed improvements:

Types, control status, and

presence or abscence of status

epilepticus.

Inadequate Documentation Required ICD-10 Documentation

Admitted for psychiatric eval. Back pain. Psychosocial dysfunction. Depressed, agoraphobia, and reports sleeping difficulty.

Admitted for psychiatric eval. Chronic low back pain due to lumbar spinal stenosis. Psychosocial dysfunction secondary to pain. Recurrent major depression with psychotic symptoms such as locking self in bedroom for weeks at a time, agoraphobia with frequent panic attacks, and reports difficulty falling asleep.

Inadequate vs. Adequate Documentation Example 4: Pain

Needed improvements:

Encounter reason, pain

location, acute vs. chronic,

underlying cause, and related

psychological factors.

Inadequate Documentation Required ICD-10 Documentation

42-year-old with chronic kidney disease, HTN, & diabetes.

Hbg & Hct decreased, transfuse 2 units PRBCs.

42-year-old on transplant list with ESRD on dialysis, HTN, IDDM type 2 with nephropathy & neuropathy.

Chronic kidney disease related iron deficiency anemia, transfuse 2 units PRBCs.

Inadequate vs. Adequate Documentation Example 5: Chronic Kidney Disease

Needed improvements: Stage, transplant status, and

related or contributing disease.

E11.21 Type 2 diabetes mellitus with diabetic nephropathyI112.0 Hypertensive End Stage Renal DiseaseN18.6 Chronic Kidney Disease requiring chronic dialysisZ99.2 Dependence on Renal DialysisE11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecifiedD63.1 Anemia in chronic kidney diseaseZ76.82 Awaiting Organ Transplant Status

I12.9 Hypertensive Chronic Kidney Disease, NOSE11.9 Type 2 Diabetes Mellitus Without ComplicationsN18.9 Chronic Kidney Disease, Unspecified (Stage)

Using Sign/Symptom and Unspecified Codes

• Sign/symptom and “unspecified” codes have acceptable, even necessary, uses.

• If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs and/or symptoms in lieu of a definitive diagnosis.

• When sufficient clinical information is not known or available about a particular health condition, it is acceptable to report the appropriate “unspecified” code.

• It is inappropriate to select a SPECIFIC code that is not supported by the medical record documentation.

Training for Physicians

Dates Method Content

Nov 2014 – Feb 2015 Dept. Meetings ICD-10 Introduction/Overview

Feb 2015 – Mar 2015 On-line/Classroom Future Order EntryDiagnosis Assistant

Feb 2015 – Jul 2015 Web-based ICD-10-CM Overview &Service Specific Documentation

Mar 2015 – Jun 2015 Classroom Physician Playbooks/Documenting for ICD10 using the Electronic Health Record

Jul 2015 – Sep 2015 Web-based Documenting Operative and Procedure Notes for ICD-10-PCS

Future Orders & Diagnosis Assistant

Demonstration