ICD-10Getting There…..

Ophthalmology

What Physicians Need To Know

• Claims for ambulatory and physician services provided on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use ICD-10-CM diagnosis codes.

• CPT Codes will continue to be used for physician inpatient and outpatient services and for hospital outpatient procedures.

• ICD-10-PCS – a NEW procedure coding classification system, must be used to code all inpatient procedures on Facility Claims for discharges on or after 10/1/15.

• ICD-9-CM codes must continue to be used for all dates of services on or before 9/30/2015.

• Further delays are not likely.

ICD-9 vs ICD-10 Diagnosis Codes

ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

3 to 5 digits 7 digits

Alpha “E” & “V” – 1st Character Alpha or numeric for any character

No place holder characters Include place holder characters (“x”)

Terminology Similar

Index and Tabular Structure Similar

Coding Guidelines Somewhat similar

Approximately 14,000 codes Approximately 69,000 codes

Severity parameters limited Extensive severity parameters

Does not include laterality Common definition of laterality

Combination codes limited Combination codes common

Number of Codes by Clinical Area

Clinical Area ICD-9 Codes ICD-10 Codes

Fractures 747 17,099

Poisoning and Toxic Effects 244 4,662

Pregnancy Related Conditions 1,104 2,155

Brain Injury 292 574

Diabetes 69 239

Migraine 40 44

Bleeding Disorders 26 29

Mood Related Disorders 78 71

Hypertensive Disease 33 14

End Stage Renal Disease 11 5

Chronic Respiratory Failure 7 4

Right vs. left

accounts for nearly ½

the increase in the #

of codes.

The Importance of Good Documentation

• The role of the provider is to accurately and specifically document the nature of the patient’s condition and treatment.

• The role of the Clinical Documentation Specialist is to query the provider for clarification, ensuring the documentation accurately reflects the severity of illness and risk of mortality.

• The role of the coder is to ensure that coding is consistent with the documentation.

• Good documentation….• Supports proper payment and reduces denials• Assures accurate measures of quality and efficiency• Captures the level of risk and severity• Supports clinical research• Enhances communication with hospital and other providers• It’s just good care!

Inadequate vs. Adequate Documentation Example 1: Blindness

Inadequate Documentation Required ICD-10 Documentation

Impression:

1. Blindness and low vision.

2. Stroke.

Impression:

1. Sudden left monocular blindness due to right middle cerebral artery thrombosis.

2. Low vision right eye.

Needed improvements:

laterality, visual differences,

and underlying cause.

Inadequate vs. Adequate Documentation Example 2: Cataracts

Inadequate Documentation Required ICD-10 Documentation

Cataract removal with placement of an acrylic lens.

Removal of a left cortisone induced cataract in a patient with Cushing’s disease. Placement of an acrylic lens.

Needed improvements:

Laterality, cause, and

underlying disease.

Inadequate Documentation Required ICD-10 Documentation

Conjunctivitis. Glaucoma. Acute atopic conjunctivitis on the right due to seasonal allergies. Bilateral chronic closed-angle glaucoma.

Inadequate vs. Adequate Documentation Example 3: Conjunctivitis

Needed improvements:

types, laterality, underlying

cause, and acuity.

Inadequate Documentation Required ICD-10 Documentation

Diabetic with retinopathy. Bleeding and edema visualized on exam.

Type 1 diabetic with moderate nonproliferative retinopathy and macular edema. Right vitreous hemorrhage visualized on exam.

Inadequate vs. Adequate Documentation Example 4: Diabetic Retinopathy

Needed improvements: type,

complicating factor(s), and

underlying disease(s).

Inadequate Documentation Required ICD-10 Documentation

85-year-old female with macular degeneration presents for regular follow up exam. Exam stable. Monitor @ 3 month intervals.

85-year-old female with bilateral dry age-related macular degeneration presents for regular follow up exam. Exam shows several high risk drusen bilaterally. Stable in comparison with last exam. Monitor @ 3 month intervals.

Inadequate vs. Adequate Documentation Example 5: Macular Degeneration

Needed improvements:

Laterality, type, and

additional exam findings.

Using Sign/Symptom and Unspecified Codes

• Sign/symptom and “unspecified” codes have acceptable, even necessary, uses.

• If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs and/or symptoms in lieu of a definitive diagnosis.

• When sufficient clinical information is not known or available about a particular health condition, it is acceptable to report the appropriate “unspecified” code.

• It is inappropriate to select a SPECIFIC code that is not supported by the medical record documentation.

Training for Physicians

Dates Method Content

Nov 2014 – Jan 2015 Department Meetings

Introduction/Overview

Jan 2015 – Mar 2015 Web-based OverviewService Specific DocumentationFuture Order EntryDiagnosis Assistant

Mar 2015 – Jun 2015 Classroom Documenting for ICD10 using the Electronic Health Record

Jun 2015 – Sep 2015 Web-based OverviewDocumenting Operative and Procedure Notes for ICD-10-PCS

Future Orders & Diagnosis Assistant

Demonstration