Barbara J. Flynn, RHIA, CCS

1

ICD 10 Documentation Issues for Coders And
Documentation Improvement Specialists

• Barbara J. Flynn, RHIA, CCS
• Vice President, Health Information and Denial
  Management Services
• Florida Hospital Association Management
  Corporation

July 14, 2011
2
Objectives

• Identify the key differences between ICD-9 and
  ICD-10
• Identify key documentation improvement
  opportunities for ICD-10
• Discuss the need for the medical staff and their
  office staff to prepare for ICD-10 to decrease
  the need for physician queries and assure
  accurate reimbursement
• Prepare ancillary outpatient departments for
  ICD-10
• Prevent or decrease RAC denials in under the
  ICD-10 classification system

3
Resources

• 2010 ICD-10-CM is available at http//www.cdc.gov/
  nchs/icd/icd10cm.htm or http//www.cms.hhs.gov/ICD
  10
•  2010 ICD-10-CM Index to Diseases and Injuries
• 2010 ICD-10-CM Tabular List of Diseases and
  Injuries
• Instructional Notations
• 2010 Official Guidelines for Coding and Reporting
  
• 2010 Table of Drugs and Chemicals
• 2010 Neoplasm Table
• 2010 Index to External Causes
• 2010 Mapping ICD-9-CM to ICD-10-CM and
  ICD-10-CM to ICD-9-CM 

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What Does ICD-10 Have to Offer?

• Provides many more categories for diseases and
  other health-related conditions
• Higher level of specificity
• Combine etiology and manifestations,
• poisoning and external cause, or
• diagnosis and symptoms into a single code
• Provides code titles and language that complement
  accepted clinical practice
• Potential to reveal more about quality of care
  and understand complications
• Provide information for clinical decision making
  and outcome research

5
Who Will Use ICD-10?

• All reporting/billing health care providers
• ICD-10-CM
• Hospitals, physicians, clinics, laboratory,
  radiology, psychiatric, rehab, nursing homes etc.
  All diagnosis codes
• ICD-10-PCS
• Procedures for Hospital Inpatients
• CPT/HCPCS
• Procedures for Hospital Outpatients,
• Physician, Laboratory and Radiology
• Outpatients

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Differences Between ICD9 and ICD10
ICD9 ICD10
17 Chapters 21 Chapters
E and V-code Supplemental Classifications All codes are alphanumeric
Sense organ conditions in Nervous System Separate Chapters
Antiquated terminology Current terminology
Injuries by type Injuries Grouped by site, then type
Complications of Medical Care in 1 Chapter Complications have been moved to procedure-specific body system chapters
Maximum of 5 characters Maximum of 7 characters
Partial code titles Full code titles
Code Extensions for specificity and laterality
Dummy placeholder (x)
7
Format

• Two main parts Index and Tabular List
• The Index
• Index to Diseases and Injury
• Neoplasm Table
• Table of Drugs and Chemicals.
• Index to External Causes of Injury

8
Format

• Tabular List contains categories, subcategories
  and codes
• Each character for all categories, subcategories
  and codes may be either a letter or a number
• All categories are 3 characters
• The first character of a category is a letter
• The second and third characters are numbers
• 3-character category that has no further
  subdivision is equivalent to a code
• Subcategories are either 4 or 5 characters

G56.01
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Format

• Subcategory characters may be either letters or
  numbers
• Final character may be either a letter or a
  number
• Dummy place holders, always the letter x
• A dummy x is used as a 5thcharacter place
  holder at certain 6 character codes to allow for
  future expansion
• T36.4x5 Adverse effect of tetracyclines
• Certain categories - 7th character extensions.
• T36.4x5A Adverse effect of
  tetracyclines, initial encounter

AInitial encounter DSubsequent encounter
SSequela
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Notable Differences

• Combination code is a single code used to
  classify
• Two or more diagnoses, or
• Diagnosis with an associated sign or symptom, or
• I25.110, Arteriosclerotic heart disease of native
  coronary artery with unstable angina pectoris
• K71.51, Toxic liver disease with chronic active
  hepatitis with ascites
• Diagnosis with an associated complication
• K50.013, Crohns disease of small intestine with
  fistula
• E08.22, Diabetes mellitus due to an underlying
  condition with diabetic chronic kidney disease

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Notable Differences

• Laterality
• Bilateral sites, the final character of the codes
  in the ICD-10-CM indicate laterality
• Right side is always character 1
• Left side character 2
• Bilateral code is always 3 (when a bilateral code
  is provided)
• An unspecified side code is also provided should
  the side not be identified in the medical record.
  The unspecified side is either a character 0 or 9
  depending on whether it is a 5th or 6th character

I80.01, Phlebitis and thrombophlebitis of
superficial vessels of right lower extremity
C50.212, Malignant neoplasm of upper-inner
quadrant of left female breast
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Includes Notes and Inclusion Terms

• Includes notes
• Give examples of the content of the category
• Inclusion terms
• Terms are some of the conditions for which that
  code number is to be used.
• May be synonyms of the code title, or, in the
  case of other specified codes, the terms are a
  list of some of the various conditions assigned
  to that code
• Are not necessarily exhaustive. Additional terms
  found only in the Index may also be assigned to a
  code

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Excludes Notes

• Excludes1
• Type 1 Excludes note is a pure excludes. It means
  NOT CODED HERE! An Excludes1 note indicates
  that the code excluded should never be used at
  the same time as the code above the Excludes1
  note
• An Excludes1 is for used for when two conditions
  cannot occur together, such as a congenital form
  versus an acquired form of the same condition
• Excludes2
• Type 2 excludes note represents NOT INCLUDED
  HERE
• An excludes2 note indicates that the condition
  excluded is not part of the condition represented
  by the code, from but a patient may have both
  conditions at the same time
• When an Excludes2 note appears under a code, it
  is acceptable to use both the code and the
  excluded code together

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With and Without

• When with and without are the two options for
  the final character of a set of codes, the
  default is always without
• Five-character codes Without 0 in the
  fifth-position for five-character codes, and
• With 1 in the fifth-position
• Six-character codes, 1" represents with and
  9" represents without

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General Principles

• Diagnostic Information is not included in the
  procedure description
• Not Otherwise Specified (NOS) options are
  restricted
• Limited use of Not Elsewhere Classified (NEC)
  option
• Level of specificity

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ICD-10

• All general coding guidelines are the same
• Coding Clinic will still be the authority for
  interpretation
• There are non-specific codes and a code can be
  assigned for non-specific terminology
• Most non-specific codes are NOT considered
  CC/MCCs and many cannot be used as Principal
  Diagnoses

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Locating a code in the ICD-10-CM

• Alphabetic Index Reason or Condition
• Instructional notes (mostly in the Tabular)
• Tabular List
• Assign the code to greatest specificity

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ICD-10-PCS

• The development of ICD-10-PCS had as its goal the
  incorporation of four major attributes
• Completeness
• Expandability
• Multiaxial each character with its own meaning
• Standardized Terminology

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Unique Procedural Coding System

• All currently performed procedures can be
  assigned an ICD-10-PCS code
• Frequency of the procedure was not a
  consideration
• Unique codes describe variations in the procedure
• Does not look like any other procedural coding
  system

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ICD-10-PCS Characteristics

• 7 character alphanumeric codes
• Each character contains up to 34 values
• Letters O and I are not used
• Procedures are divided into sections by general
  type of procedure
• First character is always the section
• Example Medical/Surgical 0
• Obstetrics 1

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Index

• No complete procedure codes exist in the Index
• 0BB Medical/Surgical
• Resp. System
• Excision
• Index is used to identify the proper Table
• Tables are used to construct a complete and valid
  code
• Only characters appearing on the table may be used

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Index

• Locate procedure code table on an alphabetic
  lookup
• Codes may be found in the index based on the
  general type of the procedure
• Resection
• Transfusion
• Fluoroscopy

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M/S Root Operations

• Alteration
• Bypass
• Change
• Control
• Creation
• Destruction
• Detachment
• Division
• Drainage
• Excision

• Extirpation
• Extraction
• Fragmentation
• Fusion
• Insertion
• Inspection
• Map
• Occlusion
• Reattachment
• Release

• Removal
• Repair
• Replacement
• Reposition
• Resection
• Restriction
• Supplement
• Transfer
• Transplantation

CDI Specialists will assist in determining the
root of procedures performed
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Index

• Codes may also be located by common procedure
  names i.e. appendectomy
• The index specifies the first three or four
  values of the code, followed by three or four
  periods (e.g., 027....), or directs the user to
  see another term
• The coder will need to know what the objective of
  the procedure is to find the appropriate code

CDI Specialists will assist in determining the
objective of procedures performed
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Index

• Each table also identifies the first three values
  of the code (e.g., 027)
• Based on the first three values of the code
  obtained from the index, locate the corresponding
  table
• The table is then used to obtain the complete
  code by specifying the last four values

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Tables

• 0 Medical and Surgical
• 2 Heart and Great Vessels
• 7 Dilation Expanding an orifice or the lumen of
  a tubular body part Body Part

Body Part Approach Device Qualifier
0 Coronary Artery, One Site 1 Coronary Arteries, Two Sites 2 Coronary Arteries, Three Sites 3 Coronary Arteries, Four or More Sites 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 4 Drug-eluting Intraluminal Device D Intraluminal Device T Radioactive Intraluminal Device Z No Device 6 Bifurcation Z No Qualifier
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Example

• Dilation of one coronary artery using an
  intraluminal device via percutaneous approach
• ICD 10 Code 02703DZ

ICD 9 Codes 00.66 00.40 00.45 36.07
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New TermExtirpation

• Taking or cutting out solid matter, such as a
  foreign body, embolus or calculus is taken out of
  a body part without taking out any of the body
  part
• Example Percutaneous Endoscopic removal of a
  calculus from right hepatic duct

0FC54ZZ
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New DefinitionsExcision vs. Resection

• Cutting out/off without replacement, some of a
  body part
• Example Breast Lumpectomy
• 0HBU0ZZ
• Cutting out/off without replacement, all of a
  body part
• Example Total Mastectomy
• 0HTT0ZZ

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Totals by Section
Section Number
Medical and Surgical 62,123
Obstetrics 338
Placement 864
Administration 1,435
Measurement and Monitoring 326
Extracorporeal Assistance and Performance 43
Extracorporeal Therapies 42
Osteopathic 100
Other Procedures 60
Chiropractic 90
Imaging 2,673
Nuclear Medicine 463
Radiation Oncology 1,929
Rehabilitation and Diagnostic Audiology 1,382
Mental Health 30
Substance Abuse Treatment 59
Total 71,957
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Clinical Documentation Improvement
CDI FHA
32
Documentation Improvement

• Facilitate accurate, complete, and consistent
  clinical documentation within the health record
  to support coding and reporting of high-quality
  healthcare data
• A query is used to clarify and improve
  documentation of the patients clinical
  condition, procedures, and outcomes without
  consideration to reimbursement
• CDI/Coders should not query the physician only
  when there is a possibility of increased
  reimbursement
• Clarify when conditions are present on admission,
  develop after admission or are a complication

Note We are seeing denials from all Medicare
HMOs and many commercial insurers for both coding
and medical necessity issues
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Why CDI?
CDI FHA
Nontraumatic Brain Hemorrhages
ICD 9 versus ICD 10
430 (subarachnoid hemorrhage) to 21 ICD 10
codes 431 (intracerebral hemorrhage) to 9 ICD 10
codes 432.0 (nontraumatic extradural hemorrhage)
to 1 ICD 10 code 432.1 (subdural hemorrhage) to
4 ICD 10 codes 432.9 (unspecified intracranial
hemorrhage) to 1 ICD 10 code
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ICD 9
CDI FHA
431 Intracerebral hemorrhage
ICD 10
I61.0 Nontraumatic intracerebral hemorrhage in
hemisphere, subcortical I61.1 Nontraumatic
intracerebral hemorrhage in hemisphere, cortical
I61.2 Nontraumatic intracerebral hemorrhage in
hemisphere, unspecified I61.3 Nontraumatic
intracerebral hemorrhage in brain stem I61.4
Nontraumatic intracerebral hemorrhage in
cerebellum I61.5 Nontraumatic intracerebral
hemorrhage, intraventricular I61.6 Nontraumatic
intracerebral hemorrhage, multiple localized
I61.8 Other nontraumatic intracerebral
hemorrhage I61.9 Nontraumatic intracerebral
hemorrhage, unspecified
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Don't Have a Stroke When Coding Stroke!!!!
ICD 9
Code 434.91 Cerebral artery occlusion unspecified
with cerebral infarction
CDI FHA
by etiology
ICD 10
Stroke - occlusion by thrombosis or embolism, by
artery I63.0 Cerebral infarction due to
thrombosis of precerebral arteries I63.4
Cerebral infarction due to embolism of cerebral
arteries
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by artery
I63.4Cerebral infarction due to embolism of
cerebral arteries
I63.40Cerebral infarction due to embolism of
unspecified cerebral artery I63.41Cerebral
infarction due to embolism of middle cerebral
artery I63.411Cerebral infarction due to embolism
of right middle cerebral artery I63.412Cerebral
infarction due to embolism of left middle
cerebral artery I63.419Cerebral infarction due to
embolism of unspecified middle cerebral
artery I63.42Cerebral infarction due to embolism
of anterior cerebral artery I63.421Cerebral
infarction due to embolism of right anterior
cerebral artery I63.422Cerebral infarction due to
embolism of left anterior cerebral
artery I63.429Cerebral infarction due to embolism
of unspecified anterior cerebral
artery I63.43Cerebral infarction due to embolism
of posterior cerebral artery I63.431Cerebral
infarction due to embolism of right posterior
cerebral artery I63.432Cerebral infarction due to
embolism of left posterior cerebral
artery I63.439Cerebral infarction due to embolism
of unspecified posterior cerebral
artery I63.44Cerebral infarction due to embolism
of cerebellar artery I63.441Cerebral infarction
due to embolism of right cerebellar
artery I63.442Cerebral infarction due to embolism
of left cerebellar artery I63.449Cerebral
infarction due to embolism of unspecified
cerebellar artery I63.49Cerebral infarction due
to embolism of other cerebral artery
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Why CDI
CDI FHA
38
Why CDI
CDI FHA

• More detailed documentation from physicians
• Location/origin of the hemorrhage
• Severity (acute, subacute, chronic)
• Strengthen the coders clinical knowledge
• Increased the coders knowledge of anatomy and
  physiology
• Coders cannot take from radiology reports
  (findings)
• More queries for documentation

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Heart Failure
ICD9 ICD10
Separate codes for Congestive HF Systolic and/or Diastolic Heart Failure 428.21 Acute 428.0 Congestive Heart Failure, unspecified Combination codes I50.21 Acute systolic (congestive) heart failure
Note To assign the correct code in ICD10,
Coders and CDI specialists will need to clarify
the specific type of heart failure i.e. systolic,
diastolic, acute and/or chronic.
CDI FHA
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Why CDI and FRACTURES?
The patient is in the office for the first visit
because of closed greenstick fracture of the
right radial shaft
ICD-9 813.21 Fracture of radius and ulna shaft,
closed radius (alone)
ICD-10 S52.311A Greenstick fracture of shaft of
radius, right arm, initial encounter for closed
fracture
Query the statement Non-healing Fracture
A - Initial encounter for closed fracture B -
Initial encounter for open fracture D -
Subsequent encounter for fracture with routine
healing G - Subsequent encounter for fracture
with delayed healing K - Subsequent encounter
for fracture with nonunion P - Subsequent
encounter for fracture with malunion S -
Sequelae
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Why CDI and FRACTURES?
Example S52 Fracture of forearm S52.5
Fracture of lower end of radius S52.52 Torus
fracture of lower end of radius S52.521
Torus fracture of lower end of right radius
S52.521A Torus fracture of lower end of right
radius, initial encounter for closed
fracture .53 - Colles fracture .54 - Smiths
fracture .56 - Bartons fracture
CDI FHA
42
Why CDI and FRACTURES?
CDI FHA

• FOR the Open Fractures of
• S52 (Fracture of forearm)
• S72 (Fracture of femur)
• S82 (Fracture of lower leg)

The extensions available for these open fractures
are B - Initial encounter for open fracture type
I or II C - Initial encounter for open fracture
type IIIA, IIIB, or IIIC E - Subsequent encounter
for open fracture type I or II with routine
healing F - Subsequent encounter for open
fracture type IIIA, IIIB, or IIIC with routine
healing H - Subsequent encounter for open
fracture type I or II with delayed healing J -
Subsequent encounter for open fracture type IIIA,
IIIB, or IIIC with delayed healing M - Subsequent
encounter for open fracture type I or II with
nonunion N - Subsequent encounter for open
fracture type IIIA, IIIB, or IIIC with nonunion Q
- Subsequent encounter for open fracture type I
or II with malunion R - Subsequent encounter for
open fracture type IIIA, IIIB, or IIIC with
malunion
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Recovery Audit Contractor (RAC) Program

• Medicare RAC program
• Medicaid RAC program(approved!)
• Florida

CDI FHA
44
High Numbers of RAC Denials

• Incorrect Principal Diagnosis Code
• Coagulopathy (286.X)
• Symptoms
• Respiratory Failure
• Sepsis/Urosepsis
• Unrelated OR Proc.
• Acute Renal Failure
• Encephalopathy
• Removal of CC/MCC
• Acute Blood Loss Anemia
• Acute Forms of HF
• Body Mass Index
• Change in procedure Code
• Excisional Debridement
• Transbronchial Biopsy
• Lack of legible/valid admission order
• Lack of medical necessity for inpatient status

CDI FHA
45
Coagulopathy

• ICD-9
• 286.9 - Coagulopathy, unspecified
• 790.92 Abnormal Coagulation Profile
• ICD-10
• D68.8, Other specified coagulation defects
• D68.9, Coagulation defects, unspecified
• R79.1 - Abnormal Coagulation Profile

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Coding Clinic Advice

• Patients on Coumadin are expected to have
  elevated clotting time
• 790.92 is used when coagulopathy is due to
  circulating anticoagulants such as Coumadin
• If improper dosage poisoning
• Proper dosage adverse effect

CDI FHA
47
Sepsis, Severe Sepsis, and Septic Shock

• Sepsis
• Assign appropriate code for underlying systemic
  infection (bacterial, fungal, Candida etc.)
• If the type of infection or causal organism is
  not further specified, assign Sepsis, unspecified
  (038.9/A41.9)
• A code for SIRS is added in ICD-9, but is not
  added in ICD-10 unless severe sepsis or an
  associated acute organ dysfunction is documented

48
Systemic Inflammatory Response Syndrome (SIRS)

• Systemic Inflammatory Response Syndrome (SIRS) is
  diagnosed when
• there is a SYSTEMIC RESPONSE to infection, trauma
  or burn. The clinical signs and
• symptoms a physician may consider to diagnosis
  SIRS include but are not
• limited to
• Fever (core temperature above 38 C
• Tachycardia (e.g., heart rate gt 90 bpm)
• Tachypnea (e.g., respiratory rate gt 20 bpm or
  arterial blood gas with PaCO2 lt32mm Hg, acidosis)
• Leukocytosis (e.g., white blood count lt4,000 or
  gt12,000 cells/mm or gt10 percent immature
  neutrophils)
• SIRS does not refer to the infection directly,
  but to the bodys response to an insult.
  Management includes fluids, mostly intravenously
  (IV)

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Sepsis

• SEPSIS refers to the presence of both infection
  and a systemic inflammatory
• Response. Sepsis is diagnosed when SIRS is due
  to a presumed or confirmed
• infection. The diagnostic criteria that a
  physician may consider to diagnose
• Sepsis may include but are not limited to the
  previously diagnosed SIRS signs and symptoms
  with the addition of
• Altered Mental Status
• Significant Edema or positive fluid balance (20
  mL/kg over 24 hours)
• Hyperglycemia (plasma glucose 120 mg/dL or 7.7
  ml/L) in the absence of diabetes
• Plasma CRP (gt2 SD above the normal value)
• Plasma procalcitonin (gt 2 SD above the normal
  value)
• Severe Sepsis is diagnosed when sepsis is
  associated with organ dysfunction,
• hypotension, and hypoperfusion

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Septicemia

• Septicemia is diagnosed when there is systemic
  disease associated with the presence of
  pathological microorganisms or toxins in the
  blood (e.g. bacteria, viruses, fungi, or other
  organisms).
• Patients are frequently suspected of having
  septicemia and are treated for the condition
  even though the blood cultures may not be
  supportive.
• Negative or inconclusive blood cultures do not
  preclude a diagnosis of septicemia in patients
  with clinical evidence of the condition.

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CDI FHA
CDI EVIDENCE-BASED PHYSICIAN EDUCATION
If any of the conditions exist, please document in the Progress Notes, History Physical and/or Discharge Summary. If any of the conditions exist, please document in the Progress Notes, History Physical and/or Discharge Summary. If any of the conditions exist, please document in the Progress Notes, History Physical and/or Discharge Summary. If any of the conditions exist, please document in the Progress Notes, History Physical and/or Discharge Summary. If any of the conditions exist, please document in the Progress Notes, History Physical and/or Discharge Summary.
INFECTION One or more of the following SIRS (Systemic Inflammatory Response Syndrome) Multiple of the following SIRS (Systemic Inflammatory Response Syndrome) Multiple of the following ACUTE ORGAN DYSFUNCTION Use the word failure where appropriate One or more of the following ACUTE ORGAN DYSFUNCTION Use the word failure where appropriate One or more of the following
Documented positive cultures Blood_________________ Sputum_______________ Urine_________________ Other_________________ Temperature__________ HR___________________ RR___________________ gt38 C gt100.4F lt36 C 96.8F Chills gt90bpm gt20 breaths/min Need for supplemental O2 Respiratory Acute Respiratory Failure pCO2 gt 50 (w/ resp. acidosis) PF ratio lt250, PEEP gt7.5 Art. Hypoxemia PaO2/FiO2 ratiolt300 /- Mechanical ventilation /- BiPAP/C-PAP
Anti-infective therapy Antibiotics received______ Antifungal received______ Other________________ WBC Count____________ Bands________________ gt12,000/mm3 / lt4000/mm3 or gt10 immature forms bands(bandemia), myelocytes, metamyelocytes Cardiovascular Hypotension SBP lt90mmHg OR Mean Arterial Pressure 70 mm Hg for 1 hour despite fluid bolus Vasopressor support for hypotension
Infection Pneumonia___________ Urinary Tract Infection___ Cellulites/Abscess______ Septic Arthritis_________ Perforated Organ______ Other _______________ Hyperglycemia_________ C-reactive Protein Plasma Procalcitonin Hypotension___________ Acidosis, Anion Gap_____ Alter mental status______ Muscle weakness_______ Lactate (2-4) gt120mg/dl absence of DM gt2 SD above NL gt2 SD above NL Treated w/ fluid bolus pHlt7.30 Encephalopathy(possible) Rhabdomyolysis gt2mmol/L Hematologic Renal Metabolic Thrombocytopenia - Plt100,000/mm3 Elevated PT/PTT (INRgt1.5 or PTTgt60 secs Acute Renal Failure, Creatinine gt 0.5 from baseline Acute Renal Injury Creatinine gt 0.3mg/dL Oliguria, Anuria Urine Output lt 0.5 mL/kg/h for gt than 2 hours OR Requires Dialysis Acidosis pHlt 7.30, Hyperlactemia gt4
WBCs in Urine_________________ Cerebral spinal fluid______ Other_________________ Immune Compromise May not have some of the above SS Steroids, Chemotherapy, DM, ESRD, Advanced COPD, AIDS, Cirrhosis / ESLD, Cancer/Metastatic Cancer,etc Hepatic /GI CNS Liver enzymes gt 2x NL, Jaundice Bilirub. gt4 mg/dL Liver Failure Ileus Encephalopathy (septic, toxic, metabolic) AMS or Reduced Glasgow Coma score
INFECTION SIRS SEPSIS SEPSIS Acute Organ
Dysfunction / Failure SEVERE SEPSIS SEPSIS
Refractory Hypotension Tissue Hypoperfusion
SEPTIC SHOCK
52
Sepsis
CDI FHA
ICD-9 ICD-10
038.9 Unspecified Septicemia A41.9 Sepsis, Unspecified
038.42 Septicemia due to E. Coli A41.51 Sepsis due to E. Coli
995.91 Sepsis A41.9 Barb!!!
995.92 Severe Sepsis R65.20 Severe Sepsis without Septic Shock
785.52 Septic Shock R65.21 Severe Sepsis with Septic Shock
584.9 Acute Kidney Failure, Unspecified N17.9 Acute Kidney Failure, Unspecified
Case Physician documents sepsis due to E. coli
UTI. BUN 60 and Creatinine 1.6 on admission,
rising to 3.2 two days after admission. MD
documents renal insufficiency on admission and
ARI, 2 days after admission.
53
Urosepsis and Sepsis

• Urosepsis still means Urinary Tract Infection
• Defaults to code 599.0 in ICD-9
• No code in index in ICD-10 (must query)
• Check for systemic infection

CDI Query only if Sepsis criteria met
54
Bacteremia

• Not synonymous with Septicemia
• Codes to 790.7 in ICD9 (abnormal lab finding)
• Codes to R78.81 in ICD10
• Both are symptom codes and should not be
  sequenced as Principal Diagnosis if the site of
  the infection is known
• Abnormal Findings on Examination of blood,
  without diagnosis (R70-R79)

CDI FHA
55
SIRS

• SIRS due to Non-Infectious Process
• Trauma
• Malignant Neoplasm
• Pancreatitis
• SIRS remains a secondary code (R65.10)

56
Malnutrition and Severe Malnutrition
ICD 9 261, 262
ICD 10 E43

• Unplanned weight loss 20 could be a marker
• Symptoms weakness, decreased muscular mass,
  edema, cachexia, waste syndrome
• Slow wound healing, decreased immune response
• Mental status change (confusion, irritability),
  encephalopathy
• Albumin (least specific) lt2.8g/l
• Prealbumin lt15mg/dl
• Total lymphocyte lt800/ml
• BMI lt18.5 (see Nutritionist Notes)
• Serum Transferrin lt200
• Risk factors terminal illness, ESRD, AIDS, end
  stage COPD, end stage liver disease, Dementia,
  Alzheimer, elderly, Stroke, difficulty swallowing
  or chewing, extreme weight loss, chronic
  diarrhea, other debilitating diseases, trauma,
  burns, prolong NPO, post-operative, post stroke
• Receive nutritional support (parenteral/TPN)

CDI Clarify the Severity
57
Principal Diagnosis -Reason for Admission

• That condition established after study to be
  chiefly responsible for occasioning the admission
  of the patient to the hospital for care.
• Codes for symptoms, signs, and ill-defined
  conditions are not to be used as principal
  diagnosis when a related definitive diagnosis has
  been established
• When there are two or more interrelated
  conditions (such as diseases in the same chapter
  or manifestations characteristically associated
  with a certain disease) potentially meeting the
  definition of principal diagnosis, either
  condition may be sequenced first, unless the
  circumstances of the admission, the therapy
  provided, the Tabular List, or the Alphabetic
  Index indicate otherwise

CDI
58
Principal Diagnosis -Reason for Admission

• In the unusual instance when two or more
  diagnoses equally meet the criteria for principal
  diagnosis as determined by the circumstances of
  admission, diagnostic workup and/or therapy
  provided, and the Alphabetic Index, Tabular List,
  or another coding guidelines does not provide
  sequencing direction, any one of the diagnoses
  may be sequenced first.

Documentation Improvement Opportunity Clarify
early in the admission the focus of treatment,
diagnostic workup. Clarify whether conditions
were present at the time of admission.
CDI Early in the admission
59
Secondary Diagnoses

• Section III. Reporting Additional Diagnoses
• GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
• For reporting purposes the definition for other
  diagnoses is interpreted as additional
  conditions that affect patient care in terms of
  requiring
• clinical evaluation or
• therapeutic treatment or
• diagnostic procedures or
• extended length of hospital stay or
• increased nursing care and/or monitoring.

CDI FHA
60
Acute Renal Failure
ICD9 ICD10
584.9 Acute Kidney Failure, Unspecified (CC) N17.9 Acute Kidney Failure, Unspecified
584.8 Acute Kidney Failure with Other Specified Pathologic Lesion in Kidney (MCC) N17.8 Other Acute Kidney Failure
Acute Kidney Failure code is a CC (for
now) Watch for the proposed new codes some of
them might not be CCs
CDI
61
Abnormal Findings

• Abnormal findings (laboratory, x-ray, pathologic,
  and other diagnostic results) are not coded and
  reported unless the provider indicates their
  clinical significance
• If the findings are outside the normal range and
  the attending provider has ordered other tests to
  evaluate the condition or prescribed treatment,
  it is appropriate to ask the provider whether the
  abnormal finding should be added

Documentation Improvement Opportunity Seek
clarification of significance of documented
abnormal findings
CDI
62
Excisional Debridement
ICD9 ICD10
Excisional Excision
Non-Excisional Extraction
Problem remains the same Need to determine
whether excision took place or simple
extraction
CDI Perpetual subject of querying!!!
63
Excision Down to

• Down to does not mean including
• Code to the deepest layer included in the
  debridement
• Assure the description of the procedure
  specifically identifies intent, instruments,
  technique and depth
• Intent debride or drain?
• Coding Clinic references include 3Q2010, page
  11 3Q2008, 2Q2008.

64
Excision in ICD-10

• Important
• Site
• Type of Wound
• Stage i.e. initial or subsequent
• Depth
• Intent

65
Questions?
Barbara Flynn, RHIA, CCS VP, Health Information
and Denial Management Services Florida Hospital
Association Management Corporation,
Inc. Specializing in ICD-10 Education, Clinical
Documentation Improvement and Denial Management
Services Contact e-mail barbaraf_at_fha.org Phone
407-841-6230
CDI FHA