UHS, Inc.

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UHS, Inc. ICD-10-CM/PCS Physician Education
Hematology and Oncology
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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• Outdated 30 years old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

• Signs Symptoms document underlying cause /
  conditions

Admit with sign / symptom Discharge with a Diagnosis
Fever Underlying condition (due to) Infection type (example pneumonia) Neutropenic fever Neutropenic sepsis
Pain Underlying condition (due to) Neoplasm Other cause Treatments pain pumps, intrathecal treatments, etc.
Altered Mental Status Underlying cause Encephalopathy UTI
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ICD-10 Documentation Tips

• Site and Laterality right versus left
• bilateral body parts or paired organs
• Stage of disease
• Acute, Chronic
• Intermittent, Recurrent, Transient
• Primary, Secondary
• Stage I, II, III, IV
• Disease Status
• Current disease, in treatment
• History of disease, treatment complete
• Also include family history

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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

• Breast Neoplasm
• in addition to information on previous
  slides, also include
• Location
• Must include the quadrant of the breast
• Gender
• Specify clearly if patient is a male or female

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ICD-10 Documentation Tips

• Leukemia
• Acuity
• Acute, chronic
• Type
• Acute lymphoblastic
• Chronic lymphocytic
• Hairy cell
• Adult T-cell
• Disease Status
• Remission not achieved
• In remission
• In relapse

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ICD-10 Documentation Tips

• Lymphoma
• Classify based on histiologic type with lymph
  node, extranodal and solid organ involvement
• Hodgkin examples
• Nodular lymphocytic predominat
• Mixed cellularity classical
• Lymphocytic-rich classical
• Follicular examples
• Grade I IIIb
• Cutaneous follicle center
• Diffuse follicle center
• Non-follicular examples
• Small B-cell
• Diffuse large B-cell
• Lymphoblastic
• Mature T/NK-Cell

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ICD-10 Documentation Tips

• Anemia
• Type
• Nutritional iron deficiency, vitamin B12
  deficiency
• Hemolytic enzyme disorder, thalassemia
• Acquired versus hereditary
• Aplastic drug induced, idiopathic
• Cause / Underlying disease
• Post hemorrhagic
• Drug induced
• Malignancy
• Manifestation of adverse effect or poisoning
• Example neoplasm, kidney disease
• Document if part of the disease process, or an
  adverse effect of treatment
• Anemia due to malignancy or chemotherpay

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ICD-10 Documentation Tips

• Sickle Cell Anemia
• Type
• Hb-SS
• Thalassemia
• HB-C
• Trait
• Sickle-cell crisis
• Specify with or without crisis
• If in crisis, document manifestations
• Acute chest syndrome
• Splenic sequestration

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ICD-10 Documentation Tips

• Coagulation
• Type
• Hemorrhagic Disorder
• Coagulation defect
• Cause
• Hereditary
• Acquired
• Document underlying or associated disease
• Specify medications or drug use affiliated with
  manifestations
• Hematuria due to Coumadin

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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

• Most Common Root Operations

Bypass altering the route of passage of the contents of a tubular body part Excision cutting out or off, without replacement a portion of a body part Reposition moving to its normal location all or a portion of a body part
Control stopping or attempting to stop, post-procedural bleeding Release freeing a body part from an abnormal physical constraint Resection cutting out or off, without replacement, all of a body part
Division cutting into a body part without draining fluids /or gases in order to separate or transect the body part Repair restoring, to the extent possible, a body part to its normal anatomic structure function Restriction partially closing an orifice or the lumen of a tubular body part
Drainage taking or letting out fluids /or gases from a body part Replacement putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part Replacement putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
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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