ICD-10Getting There…..

Pathology

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: Hepatitis

Inadequate Documentation Required ICD-10 Documentation

Ordering physician diagnosis: Hepatitis

Surgery: Liver biopsy

Summary: Hepatitis of severe activity with diffuse process (Batts and Ludwig Grade 4 of 4, Stage 4 of 4) with clinical and histologic features consistent with viral hepatitis.

Ordering physician diagnosis: Hepatitis with hepatic coma

Surgery: Liver biopsy

Summary: Chronic hepatitis of severe activity with diffuse process (Batts and Ludwig Grade 4 of 4, Stage 4 of 4) with clinical and histologic features consistent with viral hepatitis.

Needed improvements:

acuity, presence or absence

of hepatic coma, and type.

Inadequate vs. Adequate Documentation Example 2: Screening Examination

Inadequate Documentation Required ICD-10 Documentation

Provider Diagnosis: Pap smear

Findings:1. Cervical dysplasia2. Human papillomavirus (HPV)

Provider Diagnosis: Routine screeningPap smear

Findings:1. CIN II Cervical dysplasia2. Human papillomavirus (HPV)

Needed improvements:

screening vs. diagnostic test,

cell type, and type of exam.

Inadequate Documentation Required ICD-10 Documentation

Specimen:Lymph node biopsy

Findings:Non-Hodgkin lymphoma

Specimen:Axillary lymph node biopsy

Findings:Anaplastic kinase positive large B-cell lymphoma

Inadequate vs. Adequate Documentation Example 3: Lymphomas

Needed improvements:

anatomical site and type.

Inadequate Documentation Required ICD-10 Documentation

Wedge biopsy of the lung showing: adenocarcinoma, grade 2 with free resection margin.

Wedge biopsy of the right lung, lower lobe showing: adenocarcinoma, grade 2 and metastatic invasion of the overlying pleura with free resection margin.

Inadequate vs. Adequate Documentation Example 4: Lung Cancer with Metastasis

Needed improvements:

anatomical site and local

invasion site(s).

Inadequate Documentation Required ICD-10 Documentation

Specimen type: Uterus and cervix

Procedure: Hysterectomy

Summary of findings: Uterus, 719 grams 13.0 x 12.0 x 9 cm that contains a well-circumscribed leiomyoma of the posterior uterine wall. Endometrial thickening noted.

Specimen type: Uterus and cervix

Procedure: Hysterectomy

Summary of findings: Uterus, 719 grams 13.0 x 12.0 x 9 cm that contains a well-circumscribed submucosal leiomyoma of the posterior uterine wall. Benign endometrial hyperplasia noted.

Inadequate vs. Adequate Documentation Example 5: Uterine Fibroids

Needed improvements:

anatomical site and type

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