1

UHS, Inc.

ICD-10-CM/PCSPhysician Education

Mental Health and Substance Abuse

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Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of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

3

Diagnosis Code StructureDiagnosis Code Structure

4

ICD-10-CM Diagnosis Code FormatICD-10-CM Diagnosis Code Format

5

Comparison: ICD-9 to ICD-10-CMComparison: ICD-9 to ICD-10-CM

6

Procedure Code Structure Procedure Code Structure

ICD-10-PCS Code FormatICD-10-PCS Code Format

8

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?

9

10

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

11

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

13

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

14

ICD-10 Documentation TipsICD-10 Documentation Tips

Site and Laterality – right versus left–bilateral body parts or paired organs

Example – cellulitis of right upper arm

Stage of disease –Acute, Chronic–Intermittent, Recurrent, Transient, Persistent–Primary, Secondary–Stage I, II, III, IV

15

ICD-10 Documentation TipsICD-10 Documentation Tips

Status of disease– Mild– Moderate– Severe– Major– In remission, Not in remission– Single episode, Recurrent major

Link manifestations with a mental or behavioral disorder– Speech impediment with autism

Identify disease related to behavioral disorder– Alzheimer’s with aggressive behavior

16

ICD-10 Documentation TipsICD-10 Documentation Tips

Mental disorders due to physiologic condition

₋ Document associated conditions ₋ Personality and behavior disorders due to physiological

condition₋ Specify the physiological condition

₋ List underlying physiological condition

₋ Specify if dementia is with / in underlying condition

₋ Clearly identify any associated alcohol or psychoactive substance use / disorders

₋ Any behavior disturbances?

17

ICD-10 Documentation TipsICD-10 Documentation Tips

Mood Disorders

₋ Most recent episode₋ Depressed₋ Manic₋ Mixed

₋ Acuity₋ Mild₋ Moderate₋ Severe

₋ Status₋ Partial remission₋ Full remission

₋ Episode of care₋ Single or recurrent

18

ICD-10 Documentation TipsICD-10 Documentation Tips

Non-Psychotic Mental Disorders

₋ Type₋ Anxiety₋ Dissociative₋ Stress-related₋ Somatoform

₋ Acuity₋ Mild, Moderate, Severe

₋ Status₋ With or without panic attacks

₋ Conversion disorders₋ List symptoms – seizures, motor deficit

19

ICD-10 Documentation TipsICD-10 Documentation Tips

Non-Psychotic Mental Disorders continued

₋ Somatoform₋ Specify disorder – hypochondriacal disorders, pain disorders

₋ Specify type of phobia

₋ PTSD – acute or chronic

₋ OCD specificity₋ Obsessive-compulsive personality depression₋ Obsessive compulsive disorder₋ Schizophrenia

₋ Link and manifestations or related conditions₋ Depressed mood₋ Conduct disturbance₋ Mixed emotion disturbance

20

ICD-10 Documentation TipsICD-10 Documentation Tips

Physical Factors

₋ Type₋ Eating disorder₋ Sleep disorder₋ Sexual dysfunction₋ Postpartum depression

₋ Specify type – be as specific as possible

₋ Eating Disorder₋ Specify type and binge eating / purging

₋ Document any associated mental or adjustment disorder

21

ICD-10 Documentation TipsICD-10 Documentation Tips

Intellectual Disability

₋ Specify the Type

₋ Acuity₋Mild₋Moderate₋Severe₋Profound

₋ Document associated physical or developmental disorders

22

ICD-10 Documentation TipsICD-10 Documentation Tips

Schizophrenia

₋ Type₋ Schizophrenia₋ Schizoaffective disorder₋ Schizophrenic reaction₋ Schizotypal disorder

₋ Document associated conditions ₋ Asperger’s₋ Epilepsy₋ Brain disease₋ Alcoholism

₋ Identify any:₋ Acute schizophrenic-like psychotic disorders₋ Post –schizophrenic depression

23

ICD-10 Documentation TipsICD-10 Documentation Tips

Childhood / Adolescent

₋ Type of conduct disorder₋ Childhood-onset₋ Adolescent-onset₋ Confined to family context₋ Oppositional defiant disorder

₋ Type of social functioning disorder₋ Selective mutism₋ Reactive attachment disorder₋ Disinherited attachment disorder

₋ Type of ADHD₋ Inactive₋ Hyperactive₋ Combined

24

ICD-10 Documentation TipsICD-10 Documentation Tips

Childhood / Adolescent continued

₋ Manifestations / related conditions₋ADHD₋Mood disorders₋Emotional disorders₋Pervasive developmental disorders₋Schizophrenia₋Separation anxiety₋Failure to thrive₋Growth retardation₋Asperger’s syndrome₋Tic disorders with specific type

25

ICD-10 Documentation TipsICD-10 Documentation Tips

Adult Personality Disorders

₋ Type₋ Paranoid₋ Schizoid₋ Antisocial₋ Borderline₋ Histrionic₋ Obsessive-compulsive₋ Avoidant₋ Dependent₋ Narcissistic

₋ Manifestations / related conditions₋ Other mental disorders₋ Alcohol or substance use₋ Impulse disorders

26

ICD-10 Documentation TipsICD-10 Documentation Tips

Drug and Alcohol Use

– Expanded code set to classify cause-and-effect indicators• Specify drug used• Document intoxication and blood alcohol levels

– Documentation requirements include:

• Specific aspects of the effects– Example – use, abuse, or dependence

• Specify the aspects of use– Example – withdrawal state, in remission

• Identify manifestations / alcohol or drug-induced disorders

– See next slide for examples

27

ICD-10 Documentation TipsICD-10 Documentation Tips

Drug and Alcohol Use

– Conditions associated with Withdrawal Syndromes• Delirium• Tremors• Mood or psychotic disorder• Perceptual disturbance• Amnesic disorder or dementia• Anxiety• Sleep disorder

– Conditions associated with Alcohol & Drug-induced psychotic disorder

• Delusions• Hallucinations• Anxiety• Sexual dysfunction• Sleep disorder

28

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

29

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:

31

Detoxification - from alcohol &/or drugs

Electroconvulsive Therapy – application of controlled electrical voltages to treat a mental health disorder

Light Therapy – application of specialized light treatments to improve unction or well-being

Narcosynthesis – administration of IV barbiturates in order to release suppressed or repressed thoughts

Psychological Tests – administration and interpretation of standardized tests and measurement instruments for the assessment of psychological function

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

32