THE ICD-10 JOURNEY HANDS ON CODING WSHIMA 04.30.2016 1 - PowerPoint PPT Presentation

UW MEDICINE | ICD-10 Program THE ICD-10 JOURNEY HANDS ON CODING WSHIMA 04.30.2016 1

DISCLAIMER This material is designed to provide information about clinical documentation, coding, and compliance in an educational format. It is a snapshot of some aspects of ICD-10. Carefully review all coding rules, guidelines, and codes. This session is not meant to be a substitute for careful review of all coding rules, guidelines, and codes as well as medical documentation when coding in ICD 10. ICD-10 2 Program

GOALS/OBJECTIVES • Background UW Medicine • Post Go-Live Audit of all UW Medicine Coders − Inpatient: I10 CM, PCS, DRG − Outpatient Ambulatory Surgery: I10 CM/PCS − ProFee/Clinic: I10 CM • ICD-10-CM Examples Clinic & ProFee • CM/PCS Examples Outpatient • CM/PCS Examples Inpatient ICD-10 3 Program

UW MEDICINE IN BRIEF Airlift Northwest (serving AK, ID, MT & WA) Harborview Medical Center (413 beds) Northwest Hospital & Medical Center (281 beds) Seattle Cancer Care Alliance (20 beds)* UW Medical Center (450 beds) UW Clinics (10 clinics) UW Physicians (1,800+ physicians) UW School of Medicine (1,000+ students) Valley Medical Center (303 beds) * An alliance of UW Medicine, Fred Hutchinson Cancer Research Center and Seattle Children’s Hospital ICD-10 4 Program

BACKGROUND • April 2014 – Dual coding started for all coders across UW Medicine • May 2014 – Internal DRG analysis /Shifts • Coder/CDI education  Newsletter  Webinar twice a month • Outside audits pre and post go-live  2 Pre go-live audits  Post go-live audit ICD-10 5 Program

POST G0-LIVE OUTSIDE AUDIT • Outside audit of ICD-10 Coding • All coders who assign diagnosis and procedure codes in ICD-10. • November 2015 • 5 cases per coder (150 coders) • Results of the audit late Dec.-Mar. • Education team reviewed • Feedback provided to individual coders ICD-10 6 Program

CODING/CDI GUIDANCE • Excision saphenous vein for graft (CABG)  Greater vs. lesser • Radial artery lines • Devices placed at outside facilities (Impella) • List of contrast by type (low osmolar) • Aflutter ICD-10 7 Program

CASE # 1: EMERGENCY ROOM Diagnosis Descriptor Codes O02.1 Missed abortion (Early fetal death before completion 20 weeks) 14 weeks gestation of pregnancy Z3A.14 ICD-10 8 Program

CASE #2: CLINIC VISIT Diagnosis Descriptor Codes S01.112D Laceration w/o FB left eyelid and periocular area, subsequent encounter W01.118D Fall on same level from slipping, tripping and stumbling with subsequent striking against other sharp object, subsequent encounter ICD-10 9 Program

CASE #2: CODING CLINIC Coding Clinic, First Quarter ICD-10 2015 Question: The physician checks the wounds and removes sutures from both the scalp and cheek. What code should be assigned. Should code Z48.02, Encounter or removal of sutures, be assigned since the encounter is for suture removal? Answer: Assign code S01.02XD, Laceration with foreign body of scalp, subsequent encounter, as the first-listed diagnosis for the office visit for suture. Code also the code for the external cause of mortality. ICD-10 10 Program

CASE # 3: RADIOLOGY Diagnosis Codes Descriptor O36.5920 Maternal care for other known or suspected poor fetal growth, second trimester (6 th character 2 is for second trimester, 7 th character 0 for not applicable or unspecified fetus) Oligohydramnios, second trimester (7 th character O41.02X0 0 for not applicable or unspecified fetus) Z3A22 22 weeks gestation of pregnancy ICD-10 11 Program

CASE # 4: AMBULATORY SURGERY Diagnosis Descriptor Codes S32.810D Multiple fractures of pelvis with disruption of pelvic ring, subsequent encounter for fracture with routine healing W13.2XXD Fall from, out of or through roof, subsequent encounter Procedure Codes 0QP304Z Removal of internal fixation device left pelvic bone, open approach ICD-10 12 Program

CASE # 5: DIAGNOSIS CODES Diagnosis Descriptor Codes Aftercare following explantation of knee joint Z47.33 prosthesis J44.9 COPD, unspecified E11.9 Type II diabetes mellitus without complication K21.9 GERD I10 Hypertension ICD-10 13 Program

CASE #5: CODING CLINIC Coding Clinic, First Quarter ICD-10 2015 Pages:16-17 Question: A patient develops an infection after a primary hip prosthesis and the prosthesis is removed. How do you code the admit when the patient returns for removal of spacer and revision of hip replacement with new hip prosthesis. Answer: Assign code Z47.32 Aftercare following explantation of hip joint prosthesis as the PDx for the second admission. Code Z47.32 is used to report patient encounters for joint prosthesis insertion following a prior explantation of the prosthesis, where it was necessary to stage the procedure ICD-10 14 Program

CASE #6: Diagnosis Codes Descriptor T84.52XA Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter M86.68 Other chronic osteomyelitis, other site Z85.830 Personal history of malignant neoplasm of bone Procedure Codes Descriptor 0SPB0JZ Removal of synthetic substitute from left hip joint, open approach 0SHB08Z Insertion of Spacer into left hip joint, open approach ICD-10 15 Program

CASE # 7: EMERGENCY ROOM Diagnosis Descriptor Codes S066X9A Traumatic subarachnoid hemorrhage with loss of consciousness unspecified duration, initial encounter S065X9A Traumatic subdural hemorrhage with loss of consciousness unspecified duration, initial encounter W10.9XXA Fall (on)(from) unspecified stairs and steps, initial episode of care ICD-10 16 Program

CASE # 8: CLINIC VISIT Diagnosis Descriptor Codes T54.2X1D Toxic effects of corrosive acids & acid-like substances, accidental (unintentional), subsequent encounter T26.91XD Corrosion of right eye and adnexa, subsequent encounter ICD-10 17 Program

CASE # 9: INPATIENT CARDIAC CATH DX Diagnosis Descriptor Codes I21.09 STEMI involving other coronary artery of anterior wall I25.10 Atherosclerotic heart disease of native coronary artery w/o angina I25.84 Coronary atherosclerosis due to calcified coronary lesion N18.6 End stage renal disease (ESRD) E11.21 Type II diabetes mellitus with diabetic nephropathy Z79.4 Long term (current) use of insulin Z76.82 Awaiting organ transplant status Z99.2 Dependence on renal dialysis ICD-10 18 Program

CASE #9: INPATIENT CARDIAC CATH PX Procedure Descriptor Codes 027134Z Dilation coronary artery 2 sites with drug eluting intraluminal device (stent), percutaneous approach 4A023N7 Measurement Cardiac sampling/pressure, left heart, percutaneous approach (Left heart catheterization) 02C03ZZ Extirpation matter from coronary artery, one site , percutaneous B2111ZZ Fluoroscopy of multiple coronary arteries using low osmolar contrast B2151ZZ Fluoroscopy left heart using low osmolar contrast ICD-10 19 Program

CASE # 10: INPATIENT CABG Diagnosis Codes Descriptor I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris E78.5 Hyperlipidemia, unspecified Hyponatremia E87.1 Hypertension I10 Procedure Codes Descriptor 02100Z9 Bypass coronary artery, one site from left internal mammary, open approach Bypass coronary artery, one site from aorta with autologous venous 021009W tissue, open approach Excision of right greater saphenous vein, open approach 06BP0ZZ Performance Cardiac Output, continuous 5A1221Z ICD-10 20 Program

CASE #11: AMBULATORY SURGERY Diagnosis Codes Descriptor N20.0 Calculus of kidney Procedure Descriptor Codes 0TF3XZZ Fragmentation right kidney pelvis, external approach 0TJB8ZZ Inspection of bladder, via natural or artificial opening BT1DZZZ Fluoroscopy of right kidney, ureter and bladder ICD-10 21 Program

CASE #12: AMB. SURG. MENORRHAGIA Diagnosis Codes Descriptor N92.0 Excessive/frequent menstruation with regular cycle (Menorrhagia) Z01.419 Encounter for gynecological examination w/o abnormal findings B37.3 Candidiasis of vulva and vagina (yeast vaginitis) Procedure Descriptor Codes 8E0UXY7 Examination of female reproductive system 0UH97HZ Insertion Contraceptive device into uterus, via natural or artificial opening (mirena) ICD-10 22 Program

CASE #13: WHIPPLE Diagnosis Codes Descriptor C25.0 Malignant neoplasm head of pancreas Procedure Codes Descriptor 0FBG0ZZ Excision pancreas, open approach 0DB90ZZ Excision duodenum, open approach 0FT40ZZ Resection gallbladder 0DBAZ0ZZ Excision jejunum 0FB90ZZ Excision CBD 0DB60ZZ Excision stomach 07BB0ZZ Excision mesenteric lymphatic 06B50ZZ Excision superior mesenteric vein ICD-10 23 Program

CASE #14: COLECTOMY Diagnosis Codes Descriptor C18.6 Malignant neoplasm descending colon K42.09 Umbilical hernia without obstruction or gangrene Procedure Codes Descriptor 0DTM4ZZ Resection descending colon, percutaneous endoscopic approach 0DBN4ZZ Excision sigmoid colon, percutaneous endoscopic approach 0DBL4ZZ Excision transverse colon, percutaneous endoscopic approach 0WQF4ZZ Repair abdominal wall, percutaneous endoscopic approach ICD-10 24 Program