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UHS, Inc.
ICD-10-CM/PCSPhysician Education
Obstetrics and Gynecology
ICD-10 Implementation
• October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) – Ambulatory and physician services provided on or after
10/1/15– Inpatient discharges occurring on or after 10/1/15
• ICD-10-CM (diagnoses) will be used by all providers in every health care setting
• ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures – ICD-10-PCS will not be used on physician claims, even
those for inpatient visits2
Why ICD-10Why ICD-10
Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of
new codes that can be created– Has obsolete groupings of disease families– Lacks specificity and detail to support:
• Accurate anatomical positions• Differentiation of risk & severity• Key parameters to differentiate disease manifestations
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Diagnosis Code StructureDiagnosis Code Structure
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ICD-10-CM Diagnosis Code FormatICD-10-CM Diagnosis Code Format
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Comparison: ICD-9 to ICD-10-CMComparison: ICD-9 to ICD-10-CM
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Procedure Code Structure Procedure Code Structure
ICD-10-PCS Code FormatICD-10-PCS Code Format
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ICD-10 Changes Everything!ICD-10 Changes Everything!
• ICD-10 is a Business Function Change, not just another code set change.
• ICD-10 Implementation will impact everyone:– Registration, Nurses, Managers, Lab, Clinical Areas,
Billing, Physicians, and Coding
• How is ICD-10 going to change what you do?
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ICD-10-CM/PCSDocumentation Tips
ICD-10 Provider ImpactICD-10 Provider Impact
• Clinical documentation is the foundation of successful ICD-10 Implementation
• Golden Rule of Documentation– If it isn’t documented by the physician, it didn’t happen– If it didn’t happen, it can’t be billed
• The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient
– what services were rendered and what is the severity of illness
• The key word is SPECIFICITY– Granularity– Laterality
• Complete and concise documentation allows for accurate coding and reimbursement
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Gold Standard Documentation PracticesGold Standard Documentation Practices
1. Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms
2. Document diagnoses, rather that descriptors
3. Indicate acuity/severity of all diagnoses
4. Link all diseases/diagnoses to their underlying cause
5. Indicate “suspected”, “possible”, or “likely” when treating a condition empirically
6. Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers
7. Clarify diagnoses that are present on admission
8. Clearly indicate what has been ruled out
9. Avoid the use of arrows and symbols
10. Clarify the significance of diagnostic tests12
ICD-10 Provider ImpactICD-10 Provider Impact
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and anatomic sites
4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition or disease process
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ICD-10 Documentation TipsICD-10 Documentation Tips
Do not use symbols to indicate a disease.
For example “↑lipids” means that a laboratory result indicates the lipids are elevated
– or “↑BP” means that a blood pressure reading is high
These are not the same as hyperlipidemia or hypertension
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ICD-10 Documentation TipsICD-10 Documentation Tips
Site and Laterality – right versus left–bilateral body parts or paired organs
Example – right fallopian tube
Stage of disease –Acute, Chronic–Intermittent, Recurrent, Transient–Primary, Secondary–Stage I, II, III, IV
Example – chronic kidney disease, stage II
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ICD-10 Documentation TipsICD-10 Documentation Tips
Female Reproductive
– Inflammatory Disease• Examples - Salpingitis, Oophoritis, PID• Severity – acute, subacute, chronic• Manifestation / cause / underlying condition• Pelvic adhesions causing the disorder or exacerbating• Current or past antineoplastic therapy or radiological procedures
– Non-inflammatory Disease• Examples – Endometriosis, Prolapse, Dysplasia• Post-surgical state• Post-surgical complication• Location • Acuity – mild, moderate, severe
– Origin of infertility• Tubal, uterine, other
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ICD-10 Documentation TipsICD-10 Documentation Tips
Female Reproductive continued
– Prolapse• Classification
– Urethrocele– Cystocele– Rectocele– Vaginal enterocele
• Location – lateral or midline• Severity
– Incomplete / First degree– Incomplete / Second degree– Complete / Third degree
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ICD-10 Documentation TipsICD-10 Documentation Tips
Neoplasm
– Location• Detailed location• Left, Right, Bilateral
– Morphology• Malignant, Benign• Primary , Secondary• In situ• Uncertain behavior, Unspecified behavior
– Histology• Identified by cytology, histology or pathology findings
– Stage / Metastatic • Different, distinct locations
– Different primaries– Metastatic sites
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ICD-10 Documentation TipsICD-10 Documentation Tips
Neoplasm continued
– Is patient being admitted for treatment of the neoplasm or an adverse reaction / complication?
• Treatment - surgery, chemotherapy, immunotherapy, radiation• Adverse reaction of treatment – neutropenic fever secondary to chemo• Complication of the disease – anemia due to malignancy
– Document if a complication is part of the disease process or an adverse effect of treatment
• Anemia due to malignancy or due to chemotherapy
– History of• Malignancies previously removed and no longer receiving active
treatment• Clearly document for follow-up and medical surveillance
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ICD-10 Documentation TipsICD-10 Documentation Tips
Pregnancy
ICD-10-CM definitions of trimesters:• First trimester = less than 14 weeks, 0 days• Second trimester = 14 weeks, 0 days to less than 28
weeks, 0 days• Third trimester = 28 weeks until delivery
–Documentation of conditions/complications of pregnancy will need to specify the trimester in which the condition occurred.
• If the condition develops prior to admission, assign the trimester at the time of admission.
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ICD-10 Documentation TipsICD-10 Documentation Tips
Pregnancy continued
– Past infertility / poor reproductive history• Abortive outcomes
– Ectopic– Hydatidiform mole– Abnormal products of conception (e.g. - blighted ovum)– Spontaneous abortion– Induced termination of pregnancy
» Specify abortive agent or method used– Failed attempted termination of pregnancy– Incomplete abortion
• Pre-term labor
– Pregnancy induced conditions• Pregnancy induced hypertension
– document acuity of pre-eclampsia (mild, moderate or severe)• Gestational diabetes
– needs specification of diet controlled or insulin controlled
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ICD-10 Documentation TipsICD-10 Documentation Tips
Diabetes - include the type or cause of diabetes– Type I– Type II– Due to drugs and chemicals– Due to underlying condition– Other specified diabetes– Link any manifestations to the diabetes
• Circulatory, renal, neurological, ophthalmic, skin, other
Use of Insulin – long term, current
Example:•E08 - Diabetes mellitus due to underlying condition
– E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma– E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
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ICD-10 Documentation TipsICD-10 Documentation Tips
Pregnancy continued
– High risk pregnancy• History of infertility• Ectopic or molar pregnancy• Substance abuse• Insufficient care
– Specify any pre-existing condition, infection or disorder
• HIV• Smoking• Anemia• Hypertension
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ICD-10 Documentation TipsICD-10 Documentation Tips
Labor and Delivery
– Labor is categorized by weeks of gestation• Pre-term = before 37 weeks gestation• Post-term = over 40 weeks but less than 42 weeks gestation• Prolonged = over 42 weeks gestation
– Document specifics of delivery• Outcome of delivery• List method of delivery
– Specify instrumentation used– Severity of any perineal laceration and level of repair
• Method of labor induction if applicable• Malposition, malpresentation
– Include if obstructed or non-obstructed– If obstructed, what is the condition causing the obstruction of
labor» Large fetus, locked twins, etc.
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ICD-10 Documentation TipsICD-10 Documentation Tips
Labor and Delivery continued
– Reason for C-section, if performed• List past history of C-section, when applicable
– Complications of anesthesia• Aspiration pneumonitis • Pressure collapse of lung• Cardiac complication• CNS complication• Toxic reaction to local anesthesia• Spinal / epidural headache• Failed or difficult intubation
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ICD-10 Documentation TipsICD-10 Documentation Tips
Fetal Anomalies
– Multiples• Number of fetuses (numeric designation of 1 -9)
– include number of placenta and number of amniotic sacs• Identify fetus with complication with assigned number
– Fetal conditions• Central nervous system malformation• Chromosomal abnormality• Hereditary disease• Damage to fetus due to viral disease, alcohol, drugs, radiation,
medical procedure• Isoimmunization – Rh, ABO, other
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ICD-10 Documentation TipsICD-10 Documentation Tips
Puerperium
– Retained placenta• With or without membranes
– Infection• Cesarean wound infection• UTI• Endometritis
– Other conditions requiring treatment• Disruption of obstetric wound• Postpartum mood disturbance• Post-delivery anemia• Abscess of the breast• Mastitis• Retracted or cracked nipple
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ICD-10 Documentation TipsICD-10 Documentation Tips
Weight-related diagnoses and BMI
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BMI < 19 BMI > 40
• For malnutrition, specify type (e.g. - protein-calorie malnutrition) and severity (indicate mild, moderate, severe)
• Document “starvation” in abuse cases
• Link other illnesses
• Overweight versus obesity, specify if severe or morbid
• Link to the cause
• Document if drug-induced and provide the specific drug
• Bariatric procedures performed
• Associated conditions (example – obesity hypoventilation syndrome)
ICD-10 Documentation TipsICD-10 Documentation Tips
Drug Under-dosing is a new code in ICD-10-CM.
– It identifies situations in which a patient has taken less of a medication than prescribed by the physician.
• Intentional versus unintentional
– Documentation requirements include:• The medical condition• The patient’s reason for not taking the medication
– example – financial reason– Z91.120 – Patient’s intentional underdosing of
medication due to financial hardship
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ICD-10 Documentation TipsICD-10 Documentation Tips
Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post-procedural disorders
•The provider must clearly document the relationship between the condition and the procedure
– Example: • D78.01 –Intraoperative hemorrhage and hematoma of spleen
complicating a procedure on the spleen • D78.21 –Post-procedural hemorrhage and hematoma of spleen following
a procedure on the spleen
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ICD-10 Documentation TipsICD-10 Documentation Tips
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Intra-operative Post-procedural
Accidental puncture / laceration Timing:•Post-procedure•Late effect
Same or different body system Classify as:•An expected post-procedural condition•An unexpected post-procedural condition, related to the patient’s underlying medical comorbidities•An unexpected post-procedural condition, unrelated to the procedure•An unexpected post-procedural condition related to surgical care (a complication of care)
Blood product
Central venous catheter
Drug:•What adverse effect•Drug name•Correctly prescribed•Properly administered
Encounter:•Initial•Subsequent•Sequelae
ICD-10 Documentation TipsICD-10 Documentation Tips
ICD-10-PCS does not allow for unspecified procedures, clearly document:
•Body System– general physiological system / anatomic region
•Root Operation– objective of the procedure
•Body Part– specific anatomical site
•Approach– technique used to reach the site of the procedure
•Device– Devices left at the operative site
ICD-10 Documentation TipsICD-10 Documentation Tips
Most Common Root Operations:
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Abortion – artificially terminating a pregnancy
Excision – cutting out or off, without replacement a portion of a body part
Resection – cutting out or off, without replacement, all of a body part
Restriction – partially closing an orifice
Delivery – assisting the passage of products of conception from the birth canal
Extraction – pulling or stripping out or off all or a portion of a body part
Reposition – moving to its normal location/other location all or portion of a body part
Dilation – expanding an orifice
Occlusion – completely closing an orifice
Supplement – putting in biological or synthetic material that physically reinforces &/or augments the function
Drainage – taking or letting out fluids &/or gases from a body part
Repair – restoring, to the extent possible, a body part to its normal anatomic structure & function
Transplantation – putting in all or a portion of a living body part taken from another individual or animal
SummarySummary
The 7 Key Documentation Elements:
1.Acuity – acute versus chronic
2.Site – be as specific as possible
3.Laterality – right, left, bilateral for paired organs and anatomic sites
4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance
5.Manifestations – any other associated conditions
6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence
7.Signs & Symptoms – clarify if related to a specific condition or disease process
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