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UHS, Inc.

ICD-10-CM/PCSPhysician Education

Infectious Disease

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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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

Status of disease – • Newly diagnosed• Acute• Chronic

Site of infection or infestation (TB of lung)

Cause of the infection (streptococcus)

Link manifestations and other conditions

Autoimmune and related diseases (Kaposi’s sarcoma)

Infectious agents in other types of disease (wound infection caused by staph)

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ICD-10 Documentation TipsICD-10 Documentation Tips

AIDS / HIV

– Status of disease• AIDS• HIV positive• HIV-related illness• Newly diagnosed• Asymptomatic• Inconclusive serology

– Clearly indicate the reason for admission• For HIV or unrelated condition

– List related conditions and manifestations• Document as due to or with

– Is the patient pregnant

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ICD-10 Documentation TipsICD-10 Documentation Tips

Hepatitis

– Specify acuity• Acute, Chronic, Acute on chronic• With or without hepatic coma

– Identify type• A, B, or C

– Hepatitis B patients with hepatitis D (delta agent) must have documentation to support both viral agents

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ICD-10 Documentation TipsICD-10 Documentation Tips

Influenza– Organism, document as known or suspected

• Avian influenza• H1N1 influenza

– Link associated conditions / manifestations• Influenza with secondary gram negative pneumonia• Laryngitis• Pleural effusion• Influenzal encephalopathy• Influenzal myocarditis• Influenzal otitis media

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ICD-10 Documentation TipsICD-10 Documentation Tips

Pneumonia– Organism, document as known or suspected

• Viral – adenoviral, respiratory syncytial, parainfluenza, human metapneumovirus, viral unspecified

• Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas, staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified

– Link associated conditions• Influenza with secondary gram negative pneumonia• Sepsis due to pneumonia• Acute respiratory failure due to pneumonia• Whooping cough / pertussis

– Aspiration• Due to solids or liquids• Due to anesthesia during L/D or procedure• Due to anesthesia during puerperium

– Laterality of lung involvement – left, right, both

– Note whether ventilator associated (VAP)19

ICD-10 Documentation TipsICD-10 Documentation Tips

Sepsis– Acuity – sepsis, severe sepsis, septic shock, SIRS

– Organism due to / suspected•Streptococcus (A or B)•Staphylococcus aureus•MSSA•MRSA•Hemophilus influenzae•Gram-negative organism•E Coli•Serratia•Enterococcus

– Manifestations•With acute organ dysfunction•With multiple organ dysfunction•SIRS due to infectious process with organ dysfunction•Shock

– Note the term urosepsis is NOT synonymous with sepsis

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ICD-10 Documentation TipsICD-10 Documentation Tips

Sepsis Criteria–Altered mental status–Heart rate > 90 beats per minute–Hypoxemia–PaCO2 < 32mmHg–Respiratory rate > 20 breaths per minute–Temperature > 100.9 F or < 96.8 F–WBC > 12,000 cells/mm3; < 4,000 cells/mm3; and/or > 10% immature band

–Blood cultures do not need to be positive to support the diagnosis of sepsis – the physician may clinically diagnose based on signs and symptoms

Septic shock – circulatory failure and sepsis that are related, include severe sepsis in the documentation

When was the onset of sepsis – prior to admission or during admission

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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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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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