UHS, Inc.

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UHS, Inc. ICD-10-CM/PCS Physician Education
General Surgery
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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• Outdated 30 years old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

• Document all acute or chronic conditions that are
  being
• Clinically evaluated or
• Diagnostically tested or
• Therapeutically treated or
• Cause an increased Length of Stay (LOS) or
  nursing care

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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

• Site and Laterality right versus left
• bilateral body parts or paired organs
• Example cellulitis of right upper arm
• Stage of disease acute vs. chronic vs. acute on
  chronic
• Example stage of pressure ulcer
• L89.011 Pressure ulcer of right elbow, stage 1
• L89.021 Pressure ulcer of left elbow, stage 1
• Episode of care initial, subsequent, and
  sequelae
• Example - lower leg fracture
• A initial encounter for closed fracture
• B initial encounter for open fracture type I or
  II
• C initial encounter for open fracture type IIIA,
  IIIB, or IIIC
• D subsequent encounter for closed fracture with
  routine healing
• H subsequent encounter for open fracture type I
  or II with delayed healing
• K subsequent encounter for closed fracture with
  nonunion
• S sequelae

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ICD-10 Documentation Tips

• Cause of Injury
• Mechanism
• How it happened
• Place of occurrence
• Where it happened
• Activity
• What was the patient doing
• External Cause
• Work-related, leisure

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ICD-10 Documentation Tips

• Glasgow Coma
• - ICD-10-CM coding will need the score from each
  of the assessment areas
• Eye opening
• Verbal response
• Motor response
• R40.211 Coma scale, eyes open never
• R40.212 Coma scale, eyes open to pain
• R40.213 Coma scale, eyes open to sound
• R40.214 Coma scale, eyes open spontaneously
• Report the Glasgow coma scale total score
• R40.241 Glasgow coma scale score 13 15
• R40.242 Glasgow coma scale score 9 - 12
• R40.243 Glasgow coma scale score 3 8

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ICD-10 Documentation Tips

• Crohn's disease
• Specify the site
• Colon
• Duodenum
• Ilium
• Jejunum
• Small intestine
• Include any manifestations
• K50.00 Crohn's disease of small intestine
  without complications
• K50.011 Crohn's disease of small intestine with
  rectal bleeding
• K50.012 Crohn's disease of small intestine with
  intestinal obstruction
• K50.013 Crohn's disease of small intestine with
  fistula
• K50.014 Crohn's disease of small intestine with
  abscess
• K50.018 Crohn's disease of small intestine with
  other complication
• K50.019 Crohn's disease of small intestine with
  unspecified complications

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ICD-10 Documentation Tips

• Diabetes - include the type or cause of diabetes
• Type I
• Type II
• Due to drugs and chemicals
• Due to underlying condition
• Other specified diabetes
• Link any manifestations to the diabetes
• Circulatory, renal, neurological, ophthalmic,
  skin, other
• E08 - Diabetes mellitus due to underlying
  condition
• E08.10 Diabetes mellitus due to underlying
  condition with ketoacidosis without coma
• E08.11 Diabetes mellitus due to underlying
  condition with ketoacidosis with coma
• E11 - Type 2 diabetes mellitus
• E11.311 Type 2 diabetes mellitus w/ unspecified
  diabetic retinopathy with macular edema
• E11.319 Type 2 diabetes mellitus w/ unspecified
  diabetic retinopathy without macular edema

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ICD-10 Documentation Tips

• Fractures clearly document all aspects
• Cause traumatic, stress, pathological
• Location which bone, which part of the bone,
  laterality
• Type displaced, non-displaced, open, closed
• Encounter initial, subsequent, sequelae
• External cause how the fractured occurred and
  the activity
• Example - Fall while skiing

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ICD-10 Documentation Tips

• Open fractures - Please specify the severity
  using the Gustilo-Anderson Open Fracture
  Classification system for forearm, femur, and
  lower leg
• Type I The wound is smaller than 1 cm, clean,
  and generally caused by a fracture fragment that
  pierces the skin (i.e., inside-out injury).
• Type II The wound is longer than 1 cm, not
  contaminated, and without major soft tissue
  damage or defect. This is also a low-energy
  injury.
• Type III The wound is longer than 1 cm, with
  significant soft tissue disruption. The mechanism
  often involves high-energy trauma, resulting in a
  severely unstable fracture with varying degrees
  of fragmentation.
• Type III fractures are further divided into
• III A Soft tissue coverage of the fractured
  bone is adequate.
• III B Disruption of the soft tissue is
  extensive, that local or distant flap coverage is
  necessary.
• III C Any open fracture that is associated with
  an arterial injury that a physician must repair,
  regardless of the degree of soft tissue injury.

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ICD-10 Documentation Tips

• Pathologic (non-traumatic) fractures
• Exact location of fracture
• Bone, part of the bone, and laterality
• Etiology of the fracture
• osteoporosis, neoplastic disease, other specified
• Encounter type
• initial encounter, subsequent encounter with
  routine healing, subsequent encounter with
  delayed healing, malunion, nonunion, or sequelae

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ICD-10 Documentation Tips

• Neoplasm
• Location
• Detailed location
• Left, Right, Bilateral
• Morphology
• Malignant, Benign
• Primary , Secondary
• In situ
• Uncertain behavior, Unspecified behavior
• Histology
• Identified by cytology, histology or pathology
  findings
• Stage / Metastatic
• Different, distinct locations
• Different primaries
• Metastatic sites

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ICD-10 Documentation Tips

• Neoplasm continued
• Is patient being admitted for treatment of the
  neoplasm or an adverse reaction / complication?
• Treatment - surgery, chemotherapy, immunotherapy,
  radiation
• Adverse reaction of treatment neutropenic fever
  secondary to chemo
• Complication of the disease anemia due to
  malignancy
• Document if a complication is part of the disease
  process or an adverse effect of treatment
• Anemia due to malignancy or due to chemotherapy
• History of
• Malignancies previously removed and no longer
  receiving active treatment
• Clearly document for follow-up and medical
  surveillance

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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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ICD-10 Documentation Tips

• Codes for postoperative complications have been
  expanded and a distinction made between
  intraoperative complications and post-procedural
  disorders
• The provider must clearly document the
  relationship between the condition and the
  procedure
• Example
• D78.01 Intraoperative hemorrhage and hematoma of
  spleen complicating a procedure on the spleen
• D78.21 Post-procedural hemorrhage and hematoma
  of spleen following a procedure on the spleen

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ICD-10 Documentation Tips
Intra-operative Post-procedural
Accidental puncture / laceration Timing Post-procedure Late effect
Same or different body system Classify as An expected post-procedural condition An unexpected post-procedural condition, related to the patients underlying medical comorbidities An unexpected post-procedural condition, unrelated to the procedure An unexpected post-procedural condition related to surgical care (a complication of care)
Blood product Classify as An expected post-procedural condition An unexpected post-procedural condition, related to the patients underlying medical comorbidities An unexpected post-procedural condition, unrelated to the procedure An unexpected post-procedural condition related to surgical care (a complication of care)
Central venous catheter Classify as An expected post-procedural condition An unexpected post-procedural condition, related to the patients underlying medical comorbidities An unexpected post-procedural condition, unrelated to the procedure An unexpected post-procedural condition related to surgical care (a complication of care)
Drug What adverse effect Drug name Correctly prescribed Properly administered Classify as An expected post-procedural condition An unexpected post-procedural condition, related to the patients underlying medical comorbidities An unexpected post-procedural condition, unrelated to the procedure An unexpected post-procedural condition related to surgical care (a complication of care)
Encounter Initial Subsequent Sequelae Classify as An expected post-procedural condition An unexpected post-procedural condition, related to the patients underlying medical comorbidities An unexpected post-procedural condition, unrelated to the procedure An unexpected post-procedural condition related to surgical care (a complication of care)
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ICD-10 Documentation Tips

• ICD-10-PCS does not allow for unspecified
  procedures, clearly document
• Body System
• general physiological system / anatomic region
• Root Operation
• objective of the procedure
• Body Part
• specific anatomical site
• Approach
• technique used to reach the site of the
  procedure
• Device
• Devices left at the operative site

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ICD-10 Documentation Tips

• Example spinal fusion
• Root Operation
• Fusion
• Body Part
• Thoracic vertebral joints 2 - 7
• Approach
• Open (anterior/posterior) and Column
  (anterior/posterior)
• Device
• Autologous tissue substitute

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ICD-10 Documentation Tips

• Most Common Root Operations for General Surgery

Bypass altering the route of passage Drainage taking or letting out fluids /or gases Release freeing a body part from an abnormal physical constraint Resection cutting out or off without replacement all of a body part
Detachment cutting off all of part of the upper or lower extremity Excision cutting out or off without replacement a portion of a body part Repair restoring, to the extent possible, a body part Restriction partially closing an orifice or lumen of a tubular body part
Dilation expanding an orifice or the lumen of a tubular body part Fusion joining together portions of an articular body, rendering it immobile Replacement putting in a biological or synthetic material that takes the place /or function Supplement putting in a biological/ synthetic material to reinforce / augment
Division cutting into a body part to transect the body part Reattachment putting back in or on all or a portion of a separate body part Reposition moving to its normal location Transfer moving, without taking out, all or a portion of a body part to another location
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ICD-10 Documentation Tips

• Most Common Device Types for General Surgery

Artificial sphincter External fixation device Intraluminal device, plain drug-eluting or radioactive Spinal stabilization device, facet replacement
Cardiac lead Extraluminal device Intramedullary internal fixation device Spinal stabilization device, interspinous process device
Cardiac rhythm related device Feeding device Liner Spinal stabilization device, pedicle-based device
Contraceptive device Hearing device, bone conduction Monitoring device Stimulator generator
Contractility modulation device Hearing device, cochlear prosthesis Pacemaker, single or dual Stimulator lead
Defibrillator Interbody fusion device Radioactive element Tracheostomy device
Drainage device Internal fixation device Spacer Vascular access device, reservoir or pump
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ICD-10 Documentation Tips

• Most Common Root Operations for Gastroenterology

Bypass altering the route of passage Drainage taking or letting out fluids /or gases Repair restoring, to the extent possible, a body part Restriction partially closing an orifice or lumen of a tubular body part
Control stopping, or attempting to stop, post-procedural bleeding Excision cutting out or off without replacement a portion of a body part Replacement putting in a biological or synthetic material that takes the place /or function Supplement putting in a biological/ synthetic material to reinforce / augment
Dilation expanding an orifice or the lumen of a tubular body part Reattachment putting back in or on all or a portion of a separate body part Reposition moving to its normal location Transfer moving, without taking out, all or a portion of a body part to another location
Division cutting into a body part to transect the body part Release freeing a body part from an abnormal physical constraint Resection cutting out or off without replacement all of a body part Transplantation putting in or on all or a portion of a living body taken from another individual or animal
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ICD-10 Documentation Tips

• Most Common Device Types for Gastroenterology

Artificial sphincter Extraluminal device Intraluminal device, plain or radioactive Radioactive element
Drainage device Feeding device Monitoring device
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ICD-10 Documentation Tips

• Most Common Root Operations for Nephrology /
  Urology

Bypass altering the route of passage Release freeing a body part from an abnormal physical constraint Resection cutting out or off without replacement all of a body part
Dilation expanding an orifice or the lumen of a tubular body part Repair restoring, to the extent possible, a body part Restriction partially closing an orifice or lumen of a tubular body part
Drainage taking or letting out fluids /or gases Replacement putting in a biological or synthetic material that takes the place /or function Supplement putting in a biological/ synthetic material to reinforce / augment
Excision cutting out or off without replacement a portion of a body part Reposition moving to its normal location Transplantation - putting in or on all or a portion of a living body taken from another individual or animal
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ICD-10 Documentation Tips

• Most Common Device Types for Nephrology /
  Urology

Artificial sphincter Extraluminal device Intraluminal device, plain, drug-eluting or radioactive Stimulator lead
Drainage device Infusion device Monitoring device
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ICD-10 Documentation Tips

• Most Common Root Operations for
  Otorhinolaryngology

Control stopping, or attempting to stop, post-procedural bleeding Drainage taking or letting out fluids /or gases Repair restoring, to the extent possible, a body part Restriction partially closing an orifice or lumen of a tubular body part
Dilation expanding an orifice or the lumen of a tubular body part Excision cutting out or off without replacement a portion of a body part Replacement putting in a biological or synthetic material that takes the place /or function Supplement putting in a biological/ synthetic material to reinforce / augment
Division cutting into a body part without draining fluids /or gases from the body part in order to transect the body part Release freeing a body part from an abnormal physical constraint Reposition moving to its normal location Transfer moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of the body part
Division cutting into a body part without draining fluids /or gases from the body part in order to transect the body part Release freeing a body part from an abnormal physical constraint Resection cutting out or off without replacement all of a body part Transfer moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of the body part
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ICD-10 Documentation Tips

• Most Common Device Types for Otorhinolaryngology
  

Drainage device Hearing device, bone conduction Intraluminal device Radioactive element
Extraluminal device Hearing device, cochlear prosthesis Monitoring device
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ICD-10 Documentation Tips

• Most Common Root Operations for Ophthalmology

Control stopping, or attempting to stop, post-procedural bleeding Extirpation taking or cutting out solid matter from a body part Removal taking out or off a device from a body part Resection cutting out or off without replacement all of a body part
Division cutting into a body part to transect the body part Extraction pulling or stripping out or off all of a portion of a body part Repair restoring, to the extent possible, a body part Supplement putting in a biological/ synthetic material to reinforce / augment
Drainage taking or letting out fluids /or gases Insertion putting in a non-biological appliance that does not take the place of the body part Replacement putting in a biological or synthetic material that takes the place /or function Transfer moving, without taking out, all or a portion of a body part to another location
Excision cutting out or off without replacement a portion of a body part Release freeing a body part from an abnormal physical constraint Reposition moving to its normal location
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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