ICD-10-CM/PCS Physician Education Infectious Disease

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UHS, Inc. ICD-10-CM/PCS Physician Education
Infectious Disease
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ICD-10 Implementation

• October 1, 2015 Compliance date for
  implementation of ICD-10-CM (diagnoses) and
  ICD-10-PCS (procedures)
• Ambulatory and physician services provided on or
  after 10/1/15
• Inpatient discharges occurring on or after
  10/1/15
• ICD-10-CM (diagnoses) will be used by all
  providers in every health care setting
• ICD-10-PCS (procedures) will be used only for
  hospital claims for inpatient hospital procedures
  
• ICD-10-PCS will not be used on physician claims,
  even those for inpatient visits

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Why ICD-10

• Current ICD-9 Code Set is
• Outdated 30 years old
• Current code structure limits amount of new codes
  that can be created
• Has obsolete groupings of disease families
• Lacks specificity and detail to support
• Accurate anatomical positions
• Differentiation of risk severity
• Key parameters to differentiate disease
  manifestations

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Diagnosis Code Structure
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ICD-10-CM Diagnosis Code Format
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Comparison ICD-9 to ICD-10-CM
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Procedure Code Structure
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ICD-10-PCS Code Format
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ICD-10 Changes Everything!

• ICD-10 is a Business Function Change, not just
  another code set change.
• ICD-10 Implementation will impact everyone
• Registration, Nurses, Managers, Lab, Clinical
  Areas, Billing, Physicians, and Coding
• How is ICD-10 going to change what you do?

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ICD-10-CM/PCS Documentation Tips
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ICD-10 Provider Impact

• Clinical documentation is the foundation of
  successful ICD-10 Implementation
• Golden Rule of Documentation
• If it isnt documented by the physician, it
  didnt happen
• If it didnt happen, it cant be billed
• The purpose in documentation is to tell the story
  of what was performed and what is diagnosed
  accurately and thoroughly reflecting the
  condition of the patient
• what services were rendered and what is the
  severity of illness
• The key word is SPECIFICITY
• Granularity
• Laterality
• Complete and concise documentation allows for
  accurate coding and reimbursement

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Gold Standard Documentation Practices

1. Always document diagnoses that contributed to the
   reason for admission, not just the presenting
   symptoms
2. Document diagnoses, rather that descriptors
3. Indicate acuity/severity of all diagnoses
4. Link all diseases/diagnoses to their underlying
   cause
5. Indicate suspected, possible, or likely
   when treating a condition empirically
6. Use supporting documentation from the dietician /
   wound care to accurately document nutritional
   disorders and pressure ulcers
7. Clarify diagnoses that are present on admission
8. Clearly indicate what has been ruled out
9. Avoid the use of arrows and symbols
10. Clarify the significance of diagnostic tests

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ICD-10 Provider Impact

• The 7 Key Documentation Elements
• Acuity acute versus chronic
• Site be as specific as possible
• Laterality right, left, bilateral for paired
  organs and anatomic sites
• Etiology causative disease or contributory
  drug, chemical, or non-medicinal substance
• Manifestations any other associated conditions
• External Cause of Injury circumstances of the
  injury or accident and the place of occurrence
• Signs Symptoms clarify if related to a
  specific condition or disease process

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ICD-10 Documentation Tips

• Do not use symbols to indicate a disease.
• For example ?lipids means that a laboratory
  result indicates the lipids are elevated
• or ?BP means that a blood pressure reading is
  high
• These are not the same as hyperlipidemia or
  hypertension

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ICD-10 Documentation Tips

• Status of disease
• Newly diagnosed
• Acute
• Chronic
• Site of infection or infestation (TB of lung)
• Cause of the infection (streptococcus)
• Link manifestations and other conditions
• Autoimmune and related diseases (Kaposis
  sarcoma)
• Infectious agents in other types of disease
  (wound infection caused by staph)

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ICD-10 Documentation Tips

• AIDS / HIV
• Status of disease
• AIDS
• HIV positive
• HIV-related illness
• Newly diagnosed
• Asymptomatic
• Inconclusive serology
• Clearly indicate the reason for admission
• For HIV or unrelated condition
• List related conditions and manifestations
• Document as due to or with
• Is the patient pregnant

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ICD-10 Documentation Tips

• Hepatitis
• Specify acuity
• Acute, Chronic, Acute on chronic
• With or without hepatic coma
• Identify type
• A, B, or C
• Hepatitis B patients with hepatitis D (delta
  agent) must have documentation to support both
  viral agents

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ICD-10 Documentation Tips

• Influenza
• Organism, document as known or suspected
• Avian influenza
• H1N1 influenza
• Link associated conditions / manifestations
• Influenza with secondary gram negative pneumonia
• Laryngitis
• Pleural effusion
• Influenzal encephalopathy
• Influenzal myocarditis
• Influenzal otitis media

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ICD-10 Documentation Tips

• Pneumonia
• Organism, document as known or suspected
• Viral adenoviral, respiratory syncytial,
  parainfluenza, human metapneumovirus, viral
  unspecified
• Bacterial streptococcus, hemophilus, E coli,
  klebsiella, pseudomonas, staphlococcus, MRSA,
  MSSA, mycoplasma, bacterial unspecified
• Link associated conditions
• Influenza with secondary gram negative pneumonia
• Sepsis due to pneumonia
• Acute respiratory failure due to pneumonia
• Whooping cough / pertussis
• Aspiration
• Due to solids or liquids
• Due to anesthesia during L/D or procedure
• Due to anesthesia during puerperium
• Laterality of lung involvement left, right,
  both

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ICD-10 Documentation Tips

• Sepsis
• Acuity sepsis, severe sepsis, septic shock,
  SIRS
• Organism due to / suspected
• Streptococcus (A or B)
• Staphylococcus aureus
• MSSA
• MRSA
• Hemophilus influenzae
• Gram-negative organism
• E Coli
• Serratia
• Enterococcus
• Manifestations
• With acute organ dysfunction
• With multiple organ dysfunction
• SIRS due to infectious process with organ
  dysfunction
• Shock

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ICD-10 Documentation Tips

• Sepsis Criteria
• Altered mental status
• Heart rate gt 90 beats per minute
• Hypoxemia
• PaCO2 lt 32mmHg
• Respiratory rate gt 20 breaths per minute
• Temperature gt 100.9 F or lt 96.8 F
• WBC gt 12,000 cells/mm3 lt 4,000 cells/mm3 and/or
  gt 10 immature band
• Blood cultures do not need to be positive to
  support the diagnosis of sepsis the physician
  may clinically diagnose based on signs and
  symptoms
• Septic shock circulatory failure and sepsis
  that are related, include severe sepsis in the
  documentation
• When was the onset of sepsis prior to admission
  or during admission

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ICD-10 Documentation Tips

• Drug Under-dosing is a new code in ICD-10-CM.
• It identifies situations in which a patient has
  taken less of a medication than prescribed by the
  physician.
• Intentional versus unintentional
• Documentation requirements include
• The medical condition
• The patients reason for not taking the
  medication
• example financial reason
• Z91.120 Patients intentional underdosing of
  medication due to financial hardship

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Summary

• The 7 Key Documentation Elements
• Acuity acute versus chronic
• Site be as specific as possible
• Laterality right, left, bilateral for paired
  organs and anatomic sites
• Etiology causative disease or contributory
  drug, chemical, or non-medicinal substance
• Manifestations any other associated conditions
• External Cause of Injury circumstances of the
  injury or accident and the place of occurrence
• Signs Symptoms clarify if related to a
  specific condition or disease process