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ICD‐10 01/02/2012

© 2012 Selman‐Holman & Associates. LLC 1

ICD-10-CM:Report toReport to

Training CampMAHC Annual Conference, May 2013

Teresa Northcutt, BSN, RN, COS‐C, HCS‐D

Selman‐Holman & Associates LLC, Senior Associate

Selman‐Holman & Associates, LLC

Lisa Selman‐Holman, JD, BSN, RN, HCS‐D, COS‐C, HCS‐O

AHIMA Approved ICD‐10‐CM/PCS TrainerAHIMA ICD‐10‐CM Ambassador

Home Health Insight—Consulting, Education and ProductsCoDR—Coding Done RightCoDR Coding Done Right

606 N. Bell Ave.Denton, Texas 76209

940.383.2130 phone; 972.692.5908 [email protected]

Teresa@selmanholman.comwww.selmanholmanblog.comwww.selmanholman.com

Implementation Date: Oct. 1, 2014

ICD‐10 01/02/2012


ICD‐10 Final Rule

• Published September 5, 2012

• Applies to all HIPAA covered entities

• Single implementation date for all usersg p

• Date of service for all except inpatient settings (including home care)

• Date of discharge for inpatient settings

• NO GRACE PERIOD

Code Freeze

• No new codes for ICD‐9‐CM

• No new codes for ICD‐10‐CM

• But that doesn’t mean no changesICD 10 CM changes to the tabular and indices– ICD‐10‐CM changes to the tabular and indices have been issued

– ICD‐10‐CM guideline changes expected

– There will be a few new changes in the tabular and index for October 1, 2014

• First REAL update to ICD‐10 will be October 1, 2015

What about ICD‐11?• AHIMA House of Delegates adopted a policy to evaluate ICD‐

11 as a potential “alternative” to replace ICD‐9• It took the US eight years to adapt the WHO version of ICD‐10

and create ICD‐10‐CM for use in this country• “Regardless of the benefits of ICD‐11, the US would need a

national version to allow for the annual updating required by Congress and US stakeholders. Assuming that the d l i li f i l i li i ldevelopment timeline for a national version or clinical modification of ICD‐11 could be cut in half down to four years, it would then take an additional two years to get through the HIPAA rulemaking process. As with ICD‐10‐CM/PCS, the industry would want at least a three year period for converting systems to ICD‐11.”

• Assuming that ICD‐11 becomes available on schedule from WHO in 2016, then the earliest the U.S. could move to ICD‐11 would be 2025, or 13 years from now.

http://journal.ahima.org.

ICD‐10 01/02/2012


OPERATIONAL PREPARATION

ICD‐10 is NOT just about CODING!

• Impact ALL healthcare entities across the care continuum including: hospitals, physicians, ambulatory care and all payer sources (Medicare, Medicaid, insurance)

• Impact entire agency

• Do not assume current processes are adequate and effective

• Know where your agency currently stands operationally

• ICD‐10‐CM is NOT just a clinical operational issue

Don’t underestimate the impact of this transition

Failure to be fully prepared for ICD‐10 can result in the following:• Increased claims rejections and denials• Increased delays in processing authorization and reimbursement claimsreimbursement claims

• Improper claims payment• Cash flow issues• Coding backlogs• Compliance issues• Decisions based on inaccurate data

ICD‐10 01/02/2012


Cost of the transition to ICD‐10• CMS expects the home health industry as a whole to have an overall transition cost at $16.58 million dollars

• You will need to determine the impact on your agency’s budget in the following areas:

C t f t i i / d ti– Cost of training/education– Updating forms/printing– Consulting costs– Staff time/loss of productivity– Temp or contract staffing– Data conversion– Additional operational tools

Establish Realistic Timelines for the Transition

• Utilize time between now and January 1, 2014 to conduct a thorough agency assessment, identify operational challenges, d l d i l t ti l l tidevelop and implement operational solutions and provide high‐level ICD‐10‐CM education

• You will not only be well prepared for ICD‐10, but your agency will operate much more smoothly and effectively in the meantime!

Recommended Timeline Overview

2012 3rd Quarter Preparation and Planning Phase• Establish Transition Team• Establish Timelines

2012 4th Quarter ‐2013 1st Quarter

Assessment Phase• Current Operations Assessment• ICD‐10 Impact Assessment and Analysisp y• Identify Areas for Improvement/Modification

2013 2nd Quarter –2013 4th Quarter

Development Phase• Develop Operational Solutions and Strategies• Initial Training

2014 1st Quarter –2014 3rd Quarter

Implementation Phase• Execute Operational Strategies and Solutions• Testing• Intense Training for Staff

October 1, 2014 ICD‐10‐CM Implementation Date!

ICD‐10 01/02/2012


Preparation and Planning

• Establish a Transition Implementation Team

• Establish Timelines

• This should be in place NOW!

Transition Team Purpose

• Gather information and provide input through a multi‐disciplinary team approach

• Oversee and drive all phases of the• Oversee and drive all phases of the project

• Meet regularly with a specific “to‐do” list

• Meetings should be purposeful and effective

Establish your ICD‐10‐CM Transition Team

• Depends on the size of your agency

• Choose people that others naturally follow (leaders) and have a positive attitude towards changechange

• All departments should be represented

• Consider outside vendors/consultants

• Identify a Program Chairman

ICD‐10 01/02/2012


Assessment PhaseQ4 2012 ‐ Q1 2013

• Current Operations Assessment

• ICD‐10‐CM Impact Assessment & Analysis

• Identify Areas for Improvement and/or Modification

• This should be happening now!

Be prepared!

• The importance of having strong, effective systems in place PRIOR to the implementation of ICD‐10‐CM cannot be overemphasized

• Any operational or clinical weaknesses or• Any operational or clinical weaknesses or inefficiencies that currently exist within your agency will only be magnified during the transition and implementation of a change with the magnitude and scope of ICD‐10‐CM

What to do first….

• A thorough assessment of both internal and external processes, policies, people and technologies

• Establish your agency’s current level of y g yefficiency and compliance

• Some processes will need little or no adjustments

• Some processes will need to undergo major modifications

ICD‐10 01/02/2012


Everyone will be affected:

• Intake Process

• Billing/accounting

• Quality Assurance

• Clinical processes

• Data entry/administrative support

• Leadership/management

• Coders

Systems that will be affected:

• IT systems

• Agency management software

• Other outside vendors (billing services, d l i h )coders, clearinghouses)

• Payers (Medicare, Medicaid, private insurance)

Referral Intake Process

Who is affected?

• Nurses and admin staff that process referrals received from outside

What is the potential impact?

• Inaccurate coding and information from

sources (hospitals, SNF’s, rehab facilities, physicians)

referral source

• Preliminary coding

• Data entry of referral information

ICD‐10 01/02/2012


Intake Process‐Operational Analysis

• Does your agency have an effective Intake Process?• Is it documented as part of a Process Manual?• Is it updated as the process, systems or people change?• How are referrals received? Fax, email?• What criteria are used to evaluate appropriateness of a pp p

referral for evaluation?• How is payer information verified and documented?• Once the referral is accepted, what process exists to staff

the evaluation?• How is communication with clinician, referral source and

patient handled?• Who is responsible?

Billing and Accounting

Who is affected? Staff responsible for:

• Pre billing audits

Potential Impact?

• Temporary increase in coding errors resulting in rejected claims CMS• Claims reviews

• Collections

• Appeals and denials

• Insurance verification and authorizations

rejected claims. CMS estimates 10% increase

• Need to be prepared to handle increased rejections, denials, incorrectly submitted claims, MAC issues and cash flow issues

Billing/Accounting Process Operational Analysis

• Does your agency have a documented, effective claims/billing/collections process?

• Do you conduct a pre‐billing audit? What does that audit consist of? Who is responsible?

• How are audit findings communicated to billers? Who• How are audit findings communicated to billers? Who is responsible for handling identified problems and resolving them?

• How are claims rejections handled and by whom?

• What is your process for “working” A/R and ensuring payments are accurate and current?

• What is your average days to RAP? To Final Claim?

ICD‐10 01/02/2012


Clinical Case Management Process

Who is affected?

• Nurses and Therapists who provide direct patient care and/or case

Potential impact?

• Accurate completion of OASIS‐C and narrative assessment

management • Diagnosis based 485/Plan of Care development

Clinical Case Management Operational Analysis

• What clinical processes does your agency currently have in place?

• Are they up to date?• What method of training and orientation exists for new clinicians?for new clinicians?

• Does your agency utilize standardized care pathways and patient teaching materials?

• How is your clinical department structured? What care model do you utilize? (office based Case Management, Field Case Managers, etc.)

• OASIS‐C and coding training a key component of training and education for clinicians?

Quality Assurance Process Operational Analysis

• Does your agency have a documented, effective QA process?

• What is it comprised of? • Who is responsible?I h U ili i /R i (UR) i ?• Is there a Utilization/Review (UR) piece?

• What process exists to ensure appropriate and accurate completion of documentation, including OASIS‐C and coding?

• Who is responsible for ensuring compliance with rules and regulations, keeping up with changes?

• What types of outcomes reports are run routinely? Who is responsible? How used?

ICD‐10 01/02/2012


Agency Leadership/Management

• Clinical managers may be affected by changes in documentation requirements, forms, processes, 485/POC development, OASIS‐C changes as well as the actual ICD‐10 coding changes

• CFO will need to budget and monitor ICD‐10 conversion costs from software upgrades and trainingconversion costs from software upgrades and training to form revisions, as well as model for cash flow disruptions. May need to consider securing lines of credit

• Administrators need to consider staffing needs, productivity impacts, and contingency plans like outsourcing partnerships. Strong project management will be key given all the moving parts necessary to make this transition successful

Leadership/Management Operational Analysis

• Do the managers in your agency have authority to identify problems AND make changes within their departments?

• Does your agency have a working organization chart clearly defining who is responsible for what?D li i l h b i• Do your non‐clinical managers have a basic understanding of the home health industry?

• What kind of training and education process exists for Managers? Are they provided with the tools needed to be successful in their management role?

Let’s talk about your Coders!

• Is accurate and appropriate ICD coding considered a high priority at your agency?

– If not, then why not?

• Who is responsible for coding in your agency• Who is responsible for coding in your agency and are they qualified?

– Do you employ or contract with certified and/or experienced coding specialists?

• Is coding just one more task added on to very busy field RNs/Case Managers?

ICD‐10 01/02/2012


More on coding….

• How confident are you that the coding in your agency is accurate and appropriate?

• What QA and review processes take place prior to OASIS‐C and claims submission?

• What is the quality and quantity of the training• What is the quality and quantity of the training your agency provides to staff responsible for this critical function?

• Is there a coding piece in orientation process?• How does your average HHRG compare to those agencies that utilize certified coders?

• Are you leaving revenue on the table through inaccurate coding practices?

Benefits of certified coders and coding specialists

• Purpose of home health agencies is to provide appropriate, quality patient care to those we serve. There is an expectation that agency field staff will provide the highest level of quality care

• Is it realistic to also expect those same cliniciansIs it realistic to also expect those same clinicians to have abilities as a coding specialist?

• Utilizing certified coding specialists will improve your coding accuracy and compliance and likely your reimbursement as well

• It will also afford your clinicians more time and resources to care for their patients

Impact Assessment & Analysis

• Documentation changes

• Reimbursement Structures

• Systems and vendor contracts• Systems and vendor contracts

• Business practices

• Testing

ICD‐10 01/02/2012


Documentation Changes

• Increased specificity of ICD‐10 codes, compared to ICD‐9 codes, will require more detailed and comprehensive descriptions of patient clinicaldescriptions of patient clinical conditions

• Are your clinicians able to provide this more specific assessment documentation??

Reimbursement Structures

• Coordinate with payers on contract negotiations and new policies that reflect the expanded ICD‐10 code set

• Consider physician work flow and patientConsider physician work flow and patient volume changes

• Revise forms, documents, encounter forms to reflect ICD‐10 codes

• Evaluate process for ordering/reporting lab/diagnostic services to health plans

Systems and Vendor Contracts

• Can vendors meet ICD‐10 needs

• Check how and when your vendors plan to update your existing systems

• Review current and new vendor contracts for ICD‐10 capabilities

• Work with vendors to draft schedule for needed tasks

ICD‐10 01/02/2012


Business Practices

• How will ICD‐10 codes affect processes for referrals, patient intake, authorizations, pre‐certifications, h i i dphysician orders, F2F encounter

documentation, patient visits, data entry, billing, tracking accounts receivable, development of ADR’s

Testing

• Work with vendors to determine the amount of time needed for testing of ICD‐10 implementation processes p pand schedule accordingly

Don’t put it off…

• This is just the beginning of the dialog for the upcoming ICD‐10‐CM transition. It is important that you stay abreast of what is happening as this change will have ahappening, as this change will have a tremendous impact on your agency.

• Delaying putting this transition on your radar will only contribute to the challenges that will eventually need to be faced.

ICD‐10 01/02/2012


Just do it!

~ "The best way to get

something done is to begin." ~something done is to begin.

THE CLINICAL ASPECTS

XX XX XX XX

Coding and 7th Character

XX XX XXAAMMSS ØØ 22 66 55 xx AA

Additional Characters

Alpha (Except U)

3 – 7 Characters

XX XX XX XX

Category

.Etiology, anatomic

site, severity

Added code extensions (7th

character) for obstetrics, injuries, and external causes of injury

XX XX XXAAMMSS ØØ 22 66. 55 xx AA

ICD‐10 01/02/2012


Tabular Chapters

• A,B – Infectious and parasitic diseases• C – Neoplasms• D – Neoplasms & blood and blood forming organs E E d i i i l d b li• E – Endocrine, nutritional, and metabolic

• F – Mental and behavioral disorders• G – Nervous system• H – Eye and adnexa, ear and mastoid process• I – Circulatory system • J – Respiratory system• K – Digestive system

Tabular Chapters

• L – Skin and subcutaneous tissue

• M – Musculoskeletal and connective tissue

• N – Genitourinary system

• O Pregnancy childbirth and the• O – Pregnancy, childbirth, and the puerperium

• P – Perinatal period

• Q – Congenital malformations, deformations and chromosomal abnormalities

• R – Symptoms, signs and abnormal clinical and laboratory findings

Tabular Chapters• S,T – Injury, poisoning and certain other consequences of

external causes

• U – Reserved by WHO for emergency codes

• V,W,X,Y – External causes of morbidity

‐ How were they hurt *

‐Where they were when they were hurt

‐What activity were they doing

‐ External cause status

• Z – Factors influencing health status and contact with health services

• Note: * only required external cause code in HH

ICD‐10 01/02/2012


OverviewOfficial Conventions

Placeholder ‘X’

• Addition of dummy placeholder ‘X’ is used in certain codes to:

• Allow for future expansion p

• Fill out empty characters when a code contains fewer than 6 characters and a 7th character applies

ExampleAddition of 7th Character

• Used in certain chapters to provide information about the characteristic of the encounter

• Must always be used in the 7th character• Must always be used in the 7th character position

• If a code has an applicable 7th character, the code must be reported with an appropriate 7th character value in order to be valid

ICD‐10 01/02/2012


Excludes Notes

•Excludes 1: • An excludes 1 note is a pure excludes note. It means “NOT CODED

HERE” • Indicates the code excluded should never be used at the same

time as the code above the Excludes 1 notes. • Is used when two conditions cannot occur together, such as a g ,

congenital form versus an acquired form of the same condition

•Excludes 2• An excludes 2 note represents “not included here”. • Indicates the condition excluded is not part of the condition

represented by the code, but a patient may have both conditions at the same time

Excludes Note Example

• J18.Ø Bronchopneumonia, unspecified organism

• Excludes1:

hypostatic bronchopneumonia (J18 2)hypostatic bronchopneumonia (J18.2)

lipid pneumonia (J69.1)

• Excludes2:

acute bronchiolitis (J21.‐)

chronic bronchiolitis (J44.9)

Sequencing

ICD‐10‐CM coding guideline I.A.17 states a “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencingthis note does not provide sequencing direction.

In contrast, the Code First/Use Additional Code notes provide sequencing order of the codes.

ICD‐10 01/02/2012


Laterality

• For bilateral sites, the final character of the code indicates laterality

• If no bilateral code is provided and the condition is bilateral assign separate codescondition is bilateral, assign separate codes for both the left and right side

• An unspecified code is also provided should the side not be identified in the medical

record

Laterality Example

Osteoarthritis • M16.Ø Bilateral primary osteoarthritis of

hip

• M16.11 Unilateral primary osteoarthritis, right hip

• M16.12 Unilateral primary osteoarthritis, left hip

Clinical Documentation Improvement

• Dependent to some degree on improvement in physician/inpatient documentation

• Increased specificity of ICD‐10 codes will require detailed clinical descriptions in the q pcomprehensive assessment:

– If injury, need to know how that injury happened

– If late effect of injury, need to know how that injury happened

– Laterality, dominant/non‐dominant

ICD‐10 01/02/2012


COMMON HOME HEALTH DIAGNOSIS SPECIFIC EXAMPLES

Common Home Health Specific

Coding Examples in ICD‐10

Diabetes Mellitus Type 1 E10

E1Ø: Type 1 DM

Includes:

• ‐ brittle diabetes (mellitus)

• ‐ diabetes (mellitus) due to autoimmune processdiabetes (mellitus) due to autoimmune process

• ‐ diabetes (mellitus) due to immune mediated pancreatic islet beta‐cell destruction

• ‐ idiopathic diabetes (mellitus)

• ‐ juvenile onset diabetes (mellitus)

• ‐ ketosis‐prone diabetes (mellitus)

• Note: no code first or use additional insulin code


E1Ø: Type I DM

Excludes 1 ‐ diabetes mellitus due to underlying condition (EØ8.‐)‐ drug or chemical induced diabetes mellitus (EØ9.‐)‐ gestational diabetes (O24.4‐)‐ hyperglycemia NOS (R73.9)‐ neonatal diabetes mellitus (P7Ø.2)‐ postpancreatectomy diabetes mellitus (E13.‐)‐ postprocedural diabetes mellitus (E13.‐)‐ secondary diabetes mellitus NEC (E13.‐)‐ type 2 diabetes mellitus (E11.‐)

ICD‐10 01/02/2012


Diabetes MellitusE1Ø Example

• Type I insulin dependent diabetic admitted for management of new meds related to exacerbation of macular d d ild lif iedema and mild non‐proliferative retinopathy related to the diabetes

Diabetes MellitusE1Ø Answer

• M1Ø2Ø: E1Ø.321

• Type 1 diabetes mellitus with mild nonproliferative diabetic pretinopathy with macular edema

• Note: Combination code includes all aspects of disease


E11: Type II Diabetes Mellitus

Includes:

‐ diabetes (mellitus) due to insulin secretory d fdefect

‐ diabetes NOS

‐ insulin resistant diabetes (mellitus)

Use an additional code for insulin use (Z79.4)

ICD‐10 01/02/2012



E11: Type II Diabetes Mellitus

Excludes1:‐ diabetes mellitus due to underlying condition (EØ8‐)‐ drug or chemical induced diabetes mellitus (EØ9.‐)‐ gestational diabetes (O24 4‐)gestational diabetes (O24.4 )‐ neonatal diabetes mellitus (P7Ø.2)‐ postpancreatectomy diabetes mellitus (E13.‐)‐ postprocedural diabetes mellitus (E13.‐)‐ secondary diabetes mellitus NEC (E13.‐)‐ type 1 diabetes mellitus (E1Ø.‐)

Diabetes Mellitus E11 Example

• Patient was admitted to home care for uncontrolled diabetes type II with neuropathy. Patient takes insulin.

• Note: neuropathy is unspecified

Diabetes Mellitus E11 Answer

• M1Ø2Ø: E11.4Ø Type II diabetes mellitus with diabetic neuropathy, unspecified

• M1Ø22: E11.65 Type II diabetes mellitus Ø ypwith hyperglycemia

• M1Ø22: Z79.4 Long term current use insulin

• Note: alpha instruction: out of control ‐ code to Diabetes, by type, with hyperglycemia

• Neuropathy is coded unspecified. Polyneuropathy is a specific code E11.42

ICD‐10 01/02/2012



• Patient was admitted for diabetes type II with gangrene. Patient takes insulin.


• M1Ø2Ø: E11.52 Type II diabetes mellitus with diabetic peripheral angiopathy with gangrene



• Patient was admitted for diabetes type II with Charcot’s foot. Patient takes insulin for his uncontrolled diabetes.

ICD‐10 01/02/2012



• M1Ø2Ø: E11.610 Type II diabetes mellitus with diabetic neuropathic arthropathy

• M1Ø22: E11.65 Type II diabetes with hyperglycemia


Pressure UlcerExample

• Patient admitted with a stage III pressure ulcer to left heel. A stage II pressure ulcer to right heel. The stage III

d iwound is gangrenous.

Pressure UlcerAnswer

• M1Ø2Ø: I96 Gangrenous cellulitis

• M1Ø22: L89.623 Pressure ulcer of left heel, stage 3

Ø l f i h• M1Ø22: L89.612 Pressure ulcer of right heel, stage 2

• Note: Code first any associated gangrene (I96)

ICD‐10 01/02/2012


Pressure Ulcers

• The patient has a Stage 3 on the right buttock and a Stage 4 on right shoulder blade. There is a suspected DTI on the i h h l l h di bright heel. He also has Type 2 diabetes and failure to thrive. Dressing changes on Stage 3 and Stage 4. Pressure relief for DTI with no dressings.

Answer

ICD‐10‐CM Code

Description

L89.114 Pressure ulcer R upper back Stage 4

L89.313 Pressure ulcer R buttock Stage 3

E11 9 T 2 di b i h li iE11.9 Type 2 diabetes without complications

R62.7 Failure to thrive, adult

L89.610 Pressure ulcer R heel, unstageable

Z48.00 Non surgical dressing change

Arterial UlcerExample

• Patient admitted with arterial skin ulcer of left calf due to atherosclerosis

ICD‐10 01/02/2012


Arterial Ulcer Answer

• M1Ø2Ø: I7Ø.242 Atherosclerosis of native arteries of left leg with ulceration of calf

• M1Ø22: L97.221 Non pressure ulcer of left calf limited to skincalf limited to skin

• Note: Reason for ulcer, if known, should be sequenced first

• Note: Codes available for severity of ulcer

Ulcer Severity

L97.22‐ Non‐pressure chronic ulcer of left calf

‐1Non‐pressure chronic ulcer of left calf limited to breakdown of skin‐2Non‐pressure chronic ulcer of left calf with fat layer‐2Non‐pressure chronic ulcer of left calf with fat layer exposed‐3Non‐pressure chronic ulcer of left calf with necrosis of muscle‐4Non‐pressure chronic ulcer of left calf with necrosis of bone‐9Non‐pressure chronic ulcer of left calf with unspecified severity

Injuries

• No aftercare code for injuries

• A = Initial encounter

• D = Subsequent encounter

• S = Sequela

• Required to add the external cause code for how the injury happened for home care

ICD‐10 01/02/2012


Open Wound Example

• Patient admitted for wound care to lacerated right forearm due to falling from moving motorized mobility scooter.

Open Wound Answer

• M1Ø2Ø: S51.811D Laceration without foreign body of right forearm, subsequent encounter

• M1Ø22: VØØ.831D Fall from moving motorized mobility scootermotorized mobility scooter

• Note: Fall from non‐moving motorized mobility scooter WØ5.2xxD

Acute Burn Example

• Patient admitted for wound care due to second degree burn of left foot due to hot bath water

ICD‐10 01/02/2012


Acute Burn Answer

• M1Ø2Ø: T25.222D Burn of second degree of left foot

• M1Ø22: X11.ØxxD Contact with hot bath waterwater

Note: 5th and 6th character ‘x’ required

Note: 7th character required

Sequela (Late Effect) Burn Example

• Patient admitted for PT and OT due to joint contracture after the healing of a third degree burn to the right foot when the hot oil from a fry kettle poured on his foot at the restaurantfry kettle poured on his foot at the restaurant at which he worked.

• Sequela are coded with a “S” 7th character.

Sequela (Late Effect) Burn Answer

• M1Ø2Ø: M24.574 Joint contracture right foot• M1Ø22: T25.321S Burn of third degree of right

foot, sequela• M1Ø22: X1Ø.2xxS Contact with hot oil, sequela

• The condition or nature of the sequela is sequenced first. The sequela code is sequenced second.

Note: 5th and 6th character ‘x’ required Note: 7th character required

ICD‐10 01/02/2012


Traumatic Hip FractureExample

• Patient admitted for aftercare of traumatic right hip fracture after falling out of wheelchair

Traumatic Hip FractureAnswer

• M1Ø2Ø: S72.ØØ1D Subsequent encounter for closed fracture of unspecified part of neck of right femur with routine healingwith routine healing

• M1Ø22: WØ5.ØxxD Fall from wheelchair

• Note: A fracture not indicated as open or closed should be coded to closed

Example 7th Characterfor Fractures

• 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 = Sequela

ICD‐10 01/02/2012


Osteoporosis With FractureExample

• Patient admitted for aftercare of pathological fractured vertebra due to age related osteoporosis. Documentation indicates patient had previous healed pathologicalpatient had previous healed pathological fracture of humerus due to osteoporosis

Osteoporosis With FractureAnswer

• M1Ø2Ø: M8Ø.Ø8xD Age related osteoporosis with current pathological fracture of vertebra, subsequent encounter

• M1Ø22: Z87.31Ø Personal history of healed osteoporosis fracture

• Note: Age related osteoporosis is separate category from other osteoporosis

• Note: Pathological fracture is separate category from osteoporosis fracture

Osteoporosis FractureDefinition

• “Fragility fracture” is defined as a fracture sustained with trauma no more than a fall from a standing height or less that occurs under circumstances that would not cause aunder circumstances that would not cause a fracture in a normal healthy bone

ICD‐10 01/02/2012


CVA Example

• Patient admitted for CVA with right sided hemiparesis

CVA Example

• M1Ø2Ø: I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side

• Note: Should the affected side be documented, but not specified as dominant or non‐dominant and the p fclassification system does not indicate a default, code selection as follows:

For ambidextrous patients, the default should be dominant

If the left side is affected, the default is non dominant

If the right side is affected, the default is dominant

CVA Example

• The patient is admitted to home care with dysphagia, dysphasia, and ataxia following cerebral infarction.

ICD‐10 01/02/2012


CVA Answer

• The patient is admitted to home care with dysphagia, dysphasia, and ataxia following cerebral infarction.

ICD‐10‐CM Code

Description

I69.393 Ataxia following CVA

I69.391 Dysphagia following CVA

R13.10 Dysphagia, unspecified

I69.321 Dysphasia following CVA

Myocardial InfarctionExample

• Patient admitted to home health with new diagnosis of CAD after acute MI 5 weeks ago. Patient is no longer having symptoms

Myocardial Infarction Answer

• M1Ø2Ø: I25.1Ø Atherosclerotic heart disease of native coronary artery without angina

• M1Ø22: I25.2 Old healed MI

• Note: ICD‐1Ø definition acute MI = 4 weeks

ICD‐9 definition acute MI = 8 weeks

ICD‐10 01/02/2012


Myocardial Infarction Example

• Patient was treated for an inferior wall MI in last 3 weeks and then was readmitted to hospital for anterior wall

i b i d i d hMI. He is being admitted to home care for Observation and Assessment of unstable angina and his CAD and teaching on his multiple new cardiac meds.

Myocardial Infarction Answers

• M1Ø2Ø: I25.11Ø AHD with unstable angina

• M1Ø22: I21.19 MI other coronary artery inferior wall

Ø22 22 Ø f i ll• M1Ø22: I22.Ø MI of anterior wall

• M1Ø22: Z79.899 Other long term (current) drug therapy

Notes

• Angina is considered integral to CAD unless otherwise noted by physician.

• MI is coded as I21.‐ in first 4 weeks.

• If the patient has a second MI in the first 4 weeks, it is coded with I22.‐

• The sequencing of the I21 and I22 codes depends on the circumstances of the encounter.

ICD‐10 01/02/2012


Hypertension

• I10 Essential hypertension

• I11 Hypertensive Heart Disease– Use additional code for heart failure (I50.‐)

• I12 Hypertensive Chronic Kidney Disease– Use additional code for CKD (N18.‐)

• I13 Hypertensive Heart and Chronic Kidney Disease– Use additional code for heart failure

– Use additional code for CKD

• No malignant or benign

Hypertension Examples

• Hypertensive chronic diastolic heart failure– I11.0 Hypertensive heart disease with heart failure

– I50.32 Chronic diastolic (congestive) heart failure

• Hypertension– I10 Hypertension

• Hypertension and ESRD on dialysis– I12.0 Hypertensive CKD with Stage 5 or ESRD

– N18.6 ESRD

– Z99.2 dialysis status

Neuro Examples• Parkinson’s: G20• Multiple sclerosis: G35• Spastic hemiplegia of the left side after CHI and subdural hemorrhage in 1988 after he fell off a ladder– G81.14– S06.5x9S– W11.xxxS

• Quadriplegia after a spinal cord injury at C6 one year ago when the auto he was driving ran into a tree. H&P mentions complete lesion of spinal cord.– G82.53 Quadriplegia – S14.116S Complete lesion C6– V47.52xS Driver of other car collision with fixed or stationary object

ICD‐10 01/02/2012


Anemia Due To NeoplasmExample

• Patient admitted for management of anemia related to colon cancer. The focus of care is the anemia.

Anemia Due To NeoplasmAnswer

• M1Ø2Ø: C18.9 Colon cancer unspecified

• M1Ø22: D63.Ø Anemia in neoplastic disease

• Note: Different sequencing in ICD‐9

Antineoplastic Chemotherapy AnemiaExample

• Patient admitted for management of anemia related to chemotherapy due to colon cancer. The focus of care is the anemia.

ICD‐10 01/02/2012


Antineoplastic Chemotherapy AnemiaAnswer

• M1Ø2Ø: D64.81 Anemia due to antineoplastic chemotherapy

• M1Ø22: T45.1x5D Adverse effect of antineoplastic and immunosuppressive drugsantineoplastic and immunosuppressive drugs subsequent

• M1Ø22: C18.9 Colon cancer unspecified

Neoplasm Example

• Patient with history of prostate cancer and mets to the right femur has pathological fxwith routine healing to the right femur. He is admitted for therapy and nursing for O & Aadmitted for therapy and nursing for O & A, strengthening, transfers and pain management. He is taking Morphine for pain.

Neoplasm Answers

•M1Ø2Ø: M84.551D Pathological fracture in neoplastic disease, right femur, routine healing

•M1Ø22: C79.51 Secondary malignant neoplasm, bone

•M1Ø22: G89.3 Neoplasm related pain

•M1Ø22: Z85.46 History of prostate CA

•M1Ø22: Z79.891 Long term (current) use of opiate analgesic

ICD‐10 01/02/2012


Remember…

• No aftercare codes for trauma or fractures

• CMS intends to delete M1024

• We do not have information regarding case i dmix codes yet.

Example

• Patient had left BKA for diabetic gangrene. Providing aftercare, observation and assessment and dressing changes.

Answers

ICD‐10‐CM Description

Z47.81 Aftercare amputation

E11.51 DM w/peripheral angiopathy wogangrene

Z89.512 Acquired absence of left leg below knee

Z48.01 Encounter for surgical dressing changes

ICD‐10 01/02/2012


Same patient, but….

• The amputation site is infected (MRSA) and necrosed. Orders: provide care to the surgical wound and dressing changes.


T87.54 Necrosis of amp stump, LLE

T87.44 Infection of amp stump, LLE

B95.62 MRSA (cause of diseases classified elsewhere)

Aftercare

• The patient had a cholecystectomy due to acute cholecystitis. She also has a history of breast cancer and is taking Tamoxifenprophylactically She’s had some problemsprophylactically. She s had some problems with urinary retention after surgery. You are to DC the indwelling catheter and attempt to instruct patient on intermittent cath.

Answers


Z48.815 Aftercare following digestive system surgery

R33.9 Urinary retention, unspecified

Z46.6 Fitting and adjustment of urinary catheter

Z79.810 Long term use of Tamoxifen

Z85.3 History of breast cancer

ICD‐10 01/02/2012


Same patient but one of the surgical wounds is dehisced


T81.31xD Disruption of external surg wound

R33 9 Urinary retention unspecifiedR33.9 Urinary retention, unspecified

Z46.6 Fitting and adjustment of urinary catheter

Z79.810 Long term use of Tamoxifen

Z85.3 History of breast cancer

ICD‐10 TIMELINE

Q2 2013 ‐ Starting Now!

• Begin reviewing ICD‐10 resources

• Coordinate with vendors and payers

• Inform staff of upcoming changes

A di d d• Assess agency readiness and needs

• Identify needed process modifications

• Design ICD‐10 implementation plan – Set up agency time line

– Assign responsibilities

ICD‐10 01/02/2012


Q2‐Q3 2013

• Assess readiness and trainability of coding staff for ICD‐10 transition

• Assess clinical assessment skills of field staff and training needsstaff and training needs

• Assess clinical staff A&P knowledge and education needs

• Assess documentation deficits and training needs

Q2‐Q4 2013

• Clinical documentation training–Comprehensive assessment

–Detailed documentation

–How to select primary and secondary diagnoses

• Implement clinical process improvements

Q4 2013

• Introductory ICD‐10‐CM training for coding staff

• CMS recommends agencies begin submitting test claims for ICD‐10 by October 2013 to January 2014

– Identify problem areas for coding, claim submission, process modifications, and other agency training needs

ICD‐10 01/02/2012


Q1‐Q2 2014

• Review implementation plan for effectiveness and needed changes

• Detailed ICD‐10‐CM training for coding staff

• Monitor field staff documentation to sustain improvements

• Assure vendor readiness

Q1‐Q2 2014

• Anatomy & Physiology training series

– Infectious diseases, neoplasms, blood, endocrine, metabolic

–Mental, neurological, sensory

–Circulatory, respiratory

–Digestive, genitourinary, congenital

–Skin, musculoskeletal, connective

Q2‐Q3 2014

• Complete ICD‐10‐CM coding training

• Additional modules as information comes available from CMS

• Revision of OASIS‐C items

–Clinical staff education

• Grouper changes for HHRG’s

ICD‐10 01/02/2012


OASIS‐C Revisions

• OASIS‐C draft changes at OMB now

• Watch for publication in Federal Register and comment period

• Modifications:Modifications:– To accommodate ICD‐10

– Deletion of some items in Transfer, DC

– Changes to some items to “decrease confusion”

• OASIS‐C revisions implemented Oct. 1, 2014 with ICD‐10

October 1, 2014

• Clinical staff with assessment skills, A&P knowledge, documentation skills and familiar with OASIS‐C changes

• Clinical managers with necessary intake information, scheduling support, case management skills

• Coding staff competent in ICD‐10

October 1, 2014

• Smooth, timely work flow processes

• Data entry, billing and accounting familiar and competent with process

• Vendors and payers integrated into agency systems

• All agency services initiated on/after Oct. 1 coded correctly using ICD‐10

ICD‐10 01/02/2012


ICD‐10 Resources

• AHIMA: http://ahima.org/icd10– ICD‐10 Implementation Toolkits

– Clinical Documentation Improvement Toolkit

– ICD‐10 Readiness Assessment and Prioritization– ICD‐10 Readiness Assessment and Prioritization Tool

– ICD‐10 Vendor questionnaire

– ICD‐10 Transition Planning and Preparation Check Lists (Phases 1‐4)

– Training and Education

ICD‐10 Resources

• CMS: www.cms.gov/ICD10

• Consultant Services

• State and National Associations• State and National Associations

Look to MAHC

for comprehensive ICD‐10 education!

Questions?? [email protected]

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