ICD-10-CM: The Sage Continues UHIMA Kathy DeVault, MSL, RHIA, CCS, - PowerPoint PPT Presentation

ICD-10-CM: The Sage Continues UHIMA Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA UASI Kathy.devault@uasisolutions.com

Objectives • Review quality documentation • Discuss use of unspecified codes • Discuss opportunities in ICD-10-CM • Review relevant Coding Clinic advice for ICD-10-CM

Quality . . . If you pursue reimbursement, you will miss The High Quality Medical Record …but… If you pursue a High Quality Medical Record, The proper reimbursement will follow

Quality . . . Complete, accurate coded data essential for: • Improved quality of patient care • Decision-making on healthcare policies • Optimizing resource utilization • Identifying and reducing medical errors • Clinical research, epidemiological studies Physician documentation . . . Cornerstone of accurate coding

Implementation Concerns Realized? • Documentation • Productivity • Quality • Data • Claims Processing • Denials

Current State of ICD-10 • Too soon to “follow the money” • Workflow has been primary focus • Next steps: • Improve quality • Increase specificity • Some Medicare contractors are still working on issues with local coverage policies and coding

Documentation Deficiencies • Identify documentation deficiencies • Accurate reflection of: • Severity of illness • Risk of mortality • Quality • Core measures • PQRS

Unspecified Codes • Use of some unspecified codes is expected • Unspecified diagnosis codes are indicative of incomplete clinical documentation • Should only be used when no specific code is available or exact diagnosis not known yet • Unspecified code rate: • Recommended rate around 20% • Reflects organizations opportunity to improve documentation and better leverage ICD-10 specificity

ICD-10-CM Coding Opportunities

Respiratory Failure • Acuity • Acute • Chronic • Acute on Chronic • Specificity • Hypercapnic • Hypoxemic • UNSPECIFIED is an option

Anemia • Type of Anemia • Nutritional • Hemolytic • Aplastic • Due to blood loss • Acute • Chronic • Other . . . Specify • Link to laboratory findings

Anemia – Coding Clinic 1 st Quarter, 2014, pages 15-16 • Q: We are considering developing internal guidelines and obtaining medical staff approval to code acute blood loss anemia. The guidelines would specify lab values pre and post-surgery, as well as some clinical signs to allow coders to code acute blood loss anemia without the need to have physician documentation. Would this be acceptable?

Anemia – Coding Clinic • A: No, it is not acceptable. The Official Coding Guidelines, section III.B, states: “Abnormal findings are not coded and reported unless the physician indicates their clinical significance. . . .” • Internal guidelines should not replace physician documentation • Facility guidelines must not conflict with the “Official ICD - 10- CM Guidelines for Coding and Reporting” developed by the Cooperating Parties and, additionally they should not be developed to replace the physician documentation needed to support code assignment

Diabetes Mellitus By type. . . with  Amytrophy  Hyperglycemia  Arthropathy  Hypoglycemia  Autonomic (poly)neuropathy  Kidney complications NEC  Cataract  Nephropathy  Charcot’s joints  Neuralgia  Chronic kidney disease  Neuropathy  Circulatory complication  Ophthalmic complication  Complication  Neuropathy  Dermatitis  Polyneuropathy  Foot ulcer  Retinopathy  Gangrene  Gastroparesis  Skin ulcer  . . . .

Diabetes – Coding Clinic 1 st Q, 2016, pages 11-12 • Q: The ICD-10-CM Alphabetic Index entry for “Diabetes with” includes listing for conditions associated with diabetes, which was not the case in ICD-9-CM. Does the provider need to document a relationship between the two conditions or should the coder assume a causal relationship?

Diabetes – Coding Clinic • A: . . . The term ‘with’ means ‘associated with’ or ‘due to,’ when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List and that is how it’s meant to be interpreted when assigning codes for diabetes with associated manifestations and/or conditions. The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system.

Diabetes – Coding Clinic  A (continued): However, if the physician documentation specifies diabetes mellitus is not the underlying cause of the other condition, the condition should not be coded as a diabetic complication.

Diabetes – Coding Clinic 3 rd Q 2012, page 3 – also applies to ICD-10-CM: • It is note required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g. hypertension with chronic kidney involvement). When the provider establishes a linkage or relationship between the two conditions, they should be coded as such.

Acute Renal Failure • Underlying contributing condition • Due to: • Trauma • Acute tubular necrosis (ATN) • Acute cortical necrosis • Acute medullary necrosis • Acute renal insufficiency and Acute kidney disease not reported as acute renal failure

Chronic Kidney Disease (CKD) • Stage: • Stages 1-5 • ESRD • Underlying cause – diabetes, htn, etc. • Associated diagnoses/conditions • Dependence on dialysis • UNSPECIFIED is an option

ESRD – Coding Clinic 4 th Quarter, 2013, page 124 • Q: There does not appear to be a counterpart ICD-10-CM code to the ICD-9- CM code V56.0, Encounter for extracorporeal dialysis. How should a patient encounter for hemodialysis be coded? Should it be coded to End Stage Renal Disease (ESRD)?

ESRD – Coding Clinc • A: Yes, your are correct. There is no ICD-10- CM counterpart to the ICD-9-CM code V56.0. For an encounter for dialysis, assign the appropriate code for the underlying disease/reason for dialysis. Do not assume that the patient has ESRD. Hemodialysis may be used to treat acute renal failure as well as chronic kidney disease.

Heart Failure – Category I50 • I50.1 Left ventricular failure • I50.2 Systolic (congestive) heart failure • I50.3 Diastolic (congestive) heart failure • I50.4 Combines systolic and diastolic heart failure • I50.9 Heart failure, unspecified • Includes: Acute, chronic and acute on chronic

Heart Failure – Coding Clinic 1 st Q 2016, pages 10-11 • Q: Please reconsider the advice previously published in Coding Clinic, stating that the coder cannot assume either diastolic or systolic failure or a combination of both, based on documentation of heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Would it be appropriate to code diastolic or systolic heart failure when the provider documents HFpEF or HFrEF?

Heart Failure – Coding Clinic • A: Based on additional information received, the EAB for Coding Clinic has reconsidered previously published advice about coding heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). . . .These terms HFpEF and HFrEF are more contemporary terms that are being more frequently used, and can be further described as acute or chronic. • Therefore, when the provider has documented HFpEF, HFrEF, or other similar terms noted above, the coder may interpret these as ‘diastolic heart failure’ or ‘systolic heart failure,’ respectively.

Cardiac Arrest  Due to underlying cardiac condition  Due to other underlying condition  Post-procedural:  During or following cardiac surgery  During or following other surgery  Any associated diagnoses/conditions  UNSPECIFIED is an option

Hepatic Encephalopathy • Due to alcohol • Due to drugs • Post-procedural • Acuity . . . Acute, Subacute, Chronic • Severity . . . With or without coma • Associated diagnoses/conditions

OB – Selection of principal diagnosis 1 st Q 2016, page 3 • When an obstetric patient is admitted, the condition that prompted the admission should be sequenced as the principal diagnosis. A code for any complication of the delivery should be assigned as an addition diagnosis. For example, if a patient is admitted for treatment of preeclampsia, and fetal decelerations complicate spontaneous vaginal delivery, the preeclampsia should be sequenced as the principal diagnosis, rather than fetal decelerations. If there is not pregnancy complication prompting the admission, then a delivery complication code should be assigned as the principal diagnosis.

OB – Selection of principal diagnosis • Q: A patient is admitted for delivery following premature rupture of membranes. During the delivery the patient suffers a perineal laceration. What is the principal diagnosis? • A: Assign a code for pregnancy complicated by premature rupture of membranes as the principal diagnosis. A code for the laceration should be assigned as an additional diagnosis.