Obstetrics and Gynecology

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• Outdated 30 years old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

• Site and Laterality right versus left
• bilateral body parts or paired organs
• Example right fallopian tube
• Stage of disease
• Acute, Chronic
• Intermittent, Recurrent, Transient
• Primary, Secondary
• Stage I, II, III, IV
• Example chronic kidney disease, stage II

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ICD-10 Documentation Tips

• Female Reproductive
• Inflammatory Disease
• Examples - Salpingitis, Oophoritis, PID
• Severity acute, subacute, chronic
• Manifestation / cause / underlying condition
• Pelvic adhesions causing the disorder or
  exacerbating
• Current or past antineoplastic therapy or
  radiological procedures
• Non-inflammatory Disease
• Examples Endometriosis, Prolapse, Dysplasia
• Post-surgical state
• Post-surgical complication
• Location
• Acuity mild, moderate, severe
• Origin of infertility
• Tubal, uterine, other

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ICD-10 Documentation Tips

• Female Reproductive continued
• Prolapse
• Classification
• Urethrocele
• Cystocele
• Rectocele
• Vaginal enterocele
• Location lateral or midline
• Severity
• Incomplete / First degree
• Incomplete / Second degree
• Complete / Third degree

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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

• Pregnancy
• ICD-10-CM definitions of trimesters
• First trimester less than 14 weeks, 0 days
• Second trimester 14 weeks, 0 days to less than
  28 weeks, 0 days
• Third trimester 28 weeks until delivery
• Documentation of conditions/complications of
  pregnancy will need to specify the trimester in
  which the condition occurred.
• If the condition develops prior to admission,
  assign the trimester at the time of admission.

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ICD-10 Documentation Tips

• Pregnancy continued
• Past infertility / poor reproductive history
• Abortive outcomes
• Ectopic
• Hydatidiform mole
• Abnormal products of conception (e.g. - blighted
  ovum)
• Spontaneous abortion
• Induced termination of pregnancy
• Specify abortive agent or method used
• Failed attempted termination of pregnancy
• Incomplete abortion
• Pre-term labor
• Pregnancy induced conditions
• Pregnancy induced hypertension
• document acuity of pre-eclampsia (mild, moderate
  or severe)
• Gestational diabetes

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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
• Use of Insulin long term, current
• Example
• 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

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ICD-10 Documentation Tips

• Pregnancy continued
• High risk pregnancy
• History of infertility
• Ectopic or molar pregnancy
• Substance abuse
• Insufficient care
• Specify any pre-existing condition, infection or
  disorder
• HIV
• Smoking
• Anemia
• Hypertension

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ICD-10 Documentation Tips

• Labor and Delivery
• Labor is categorized by weeks of gestation
• Pre-term before 37 weeks gestation
• Post-term over 40 weeks but less than 42 weeks
  gestation
• Prolonged over 42 weeks gestation
• Document specifics of delivery
• Outcome of delivery
• List method of delivery
• Specify instrumentation used
• Severity of any perineal laceration and level of
  repair
• Method of labor induction if applicable
• Malposition, malpresentation
• Include if obstructed or non-obstructed
• If obstructed, what is the condition causing the
  obstruction of labor
• Large fetus, locked twins, etc.

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ICD-10 Documentation Tips

• Labor and Delivery continued
• Reason for C-section, if performed
• List past history of C-section, when applicable
• Complications of anesthesia
• Aspiration pneumonitis
• Pressure collapse of lung
• Cardiac complication
• CNS complication
• Toxic reaction to local anesthesia
• Spinal / epidural headache
• Failed or difficult intubation

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ICD-10 Documentation Tips

• Fetal Anomalies
• Multiples
• Number of fetuses (numeric designation of 1 -9)
• include number of placenta and number of amniotic
  sacs
• Identify fetus with complication with assigned
  number
• Fetal conditions
• Central nervous system malformation
• Chromosomal abnormality
• Hereditary disease
• Damage to fetus due to viral disease, alcohol,
  drugs, radiation, medical procedure
• Isoimmunization Rh, ABO, other

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ICD-10 Documentation Tips

• Puerperium
• Retained placenta
• With or without membranes
• Infection
• Cesarean wound infection
• UTI
• Endometritis
• Other conditions requiring treatment
• Disruption of obstetric wound
• Postpartum mood disturbance
• Post-delivery anemia
• Abscess of the breast
• Mastitis
• Retracted or cracked nipple

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ICD-10 Documentation Tips

• Weight-related diagnoses and BMI

BMI lt 19 BMI gt 40
For malnutrition, specify type (e.g. - protein-calorie malnutrition) and severity (indicate mild, moderate, severe) Document starvation in abuse cases Link other illnesses Overweight versus obesity, specify if severe or morbid Link to the cause Document if drug-induced and provide the specific drug Bariatric procedures performed Associated conditions (example obesity hypoventilation syndrome)
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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

Abortion artificially terminating a pregnancy Excision cutting out or off, without replacement a portion of a body part Resection cutting out or off, without replacement, all of a body part Restriction partially closing an orifice
Delivery assisting the passage of products of conception from the birth canal Extraction pulling or stripping out or off all or a portion of a body part Reposition moving to its normal location/other location all or portion of a body part Reposition moving to its normal location/other location all or portion of a body part
Dilation expanding an orifice Occlusion completely closing an orifice Supplement putting in biological or synthetic material that physically reinforces /or augments the function Supplement putting in biological or synthetic material that physically reinforces /or augments the function
Drainage taking or letting out fluids /or gases from a body part Repair restoring, to the extent possible, a body part to its normal anatomic structure function Transplantation putting in all or a portion of a living body part taken from another individual or animal Transplantation putting in all or a portion of a living body part taken from another individual or animal
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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