hcca official site - p2 neville breuker ppt · 2012-10-02 · 9/25/2012 6 understanding...
TRANSCRIPT
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ICD‐10‐CM Transition: Key Activities for Physician Practices
Deb Neville, RHIA, CCS‐P, Elsevier/MC StrategiesJudy Breuker, CPC, CPMA, CCS‐P, CHCA, PCS, CEMC, CHC, CHAP, AHIMA‐Approved ICD‐10‐CM/PCS Trainer
Clinical Practice Compliance Conference Oct 14, 2012
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Objectives
• Provide background information to help build a transitional plan
• Determine methods for providing education
• Identify important similarities and differences between ICD‐9‐CM and ICD‐10‐CM/PCS
• Pinpoint key focus areas for education
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Setting the Stage
New code sets scheduled for implementation 10/1/14
Coding means changing clinical terminology to coded data
provides a picture of the patient’s condition
demonstrates that evidence‐based care plans were followed
used for quality reporting and payment
identifies patterns that are helpful for planning ‐ for instance, resource use by demographics; resource use by condition
Partial Code Freeze: ICD‐10‐CM remains draft
Applicable to all entities that now use ICD‐9‐CM
ICD‐10‐CM for diagnoses in all settings
ICD‐10‐CM Official Guidelines for Coding and Reporting: Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
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Setting the Stage
Dual Reporting
All services that are provided through 9/30/14 will be reported with ICD‐9‐CM
Will require knowledge of both code sets to process claims past 10/1/14
Some payers will continue to use ICD‐9‐CM
Affects or requires:
All systems that currently hold ICD‐9‐CM data
Changes to physician documentation ‐ consider physician office practice and needs of hospital (for MDs w/privileges) Queries, templates
Coverage policies and/or payer communication (denial mgt)
Charge capture processes
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Getting Started: Considerations for Developing a Plan
Plan for the future, not just up to the implementation date
Evaluate needs two years past implementation
Identify the staff’s current interaction with ICD‐9‐CM
Ascertain staff skill set
Discover baseline skill sets and core deficiencies
Detect similarities and differences among staff
Across job functions
Within job functions
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Getting Started: Considerations for Developing a Plan
Determine where positions will be redefined
Need for cross‐training
Workflow changes
Understand the results of inadequate knowledge or ineffectual preparation
Internal training
Vendor readiness
Payer readiness
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Identify Stakeholders and Their Unique Needs
Non‐clinical staff
Advance Beneficiary Notice (ABN)
Charge capture process
Modify forms or method
How to identify most specific diagnosis
Denial management activities
Coverage policies and payer requirements
Verification of coverage for beneficiaries
Medical necessity for services
Communicating with hospitals (preadmission, scheduling)
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Identify Stakeholders and Their Unique Needs
Supervisors/Managers
Revising systems and data conversion
Reporting – dual reporting (trending & analysis)
Financial impact
Reimbursement (medical necessity)
Productivity & accuracy
A/R days
Payer, vendor and clearinghouse readiness
Clinical Staff/physicians/non‐physician practitioners
Changes in documentation requirements
Charge capture process
Quality reporting protocols
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Preparing for Education – Recognize Learning Styles (structured, social, auditory, visual, interactive)
Engage and Understand! Reduce Anxiety
Adult learners: build on experience, learn by doing, want to know why
Generational differences ‐ Traditionalists (1900‐1945), Baby Boomers
(1946‐1964), Generation X (1965‐1980), Millenials (1981‐2000)
Objective (one way) ‐ Reading an article, lecture, webinar, computer‐
aided learning, symposium
Subjective (two way) ‐ Group discussion, role playing, problem
solving, case studies
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Helpful Tips
Incorporate education into daily processes – provide pinpointed education “The right education at the right time to the right audience”
Be thoughtful about timing
Revise & train on changes to charge capture forms, contracts, policies – consider collaborative arrangements
Assess payer readiness & model revenue impact according to plan
Implement aggressive retention & recruitment efforts or plan for outsourcing
Implement communication plans – engage employees
Understand perceptions
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About ICD‐10‐CM and ICD‐10‐PCS
ICD‐10 used internationally ‐ United Kingdom (1995), France (1997), Australia (1998), Belgium (1999), Germany (2000), and Canada (2001)
ICD‐10‐CM (clinical modification) used for diagnosis coding in any setting
Introduction of 68,000+ new diagnosis codes
ICD‐10‐PCS (procedural coding system) used to report hospital inpatient procedures
CPT will still be used to report outpatient procedures/services
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Comparison of Coding Systems – Outpatient Similarities
Outpatient Similarities– Code what is known at time of encounter
– Signs/symptoms/other circumstances
– Can use radiology interpretation
– Encounter for therapy, report condition as secondary dx
– NEC, NOS, punctuation
– Coding process – alphabetic index and tabular list
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Comparison of Coding Systems ‐ Differences
Differences Alpha numeric, for example, an ICD‐9‐CM code might read
250.50 but an ICD‐10‐CM code would read as E11.52 3‐7 characters versus 3‐5 (many to one ratio) ‐Categories 3
characters, subcategories 4‐5 characters) Laterality, complications, placeholder of X for future expansion
7th character can be alpha or numeric, example: initial, subsequent with complication or sequela.
New Exclude notes Chapters renamed, rearranged, added No abbreviations, e.g. TIA, CVA
Where does the learning process start?
CMS and CDC Provider Resources
Understanding the Basics
Implementation Guides
Large Practices
Small Hospitals
Small/Medium Provider Practices
Official Guidelines for Coding and Reporting and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) http://www.cdc.gov/nchs/icd/icd10cm.htm
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Understanding ICD‐10‐CM Coding
Read the ICD‐10‐CM Draft Official Guidelines for Coding and Reporting
Section I. Conventions, general coding guidelines and chapter specific Guidelines
Section II. Selection of Principles Diagnosis
Uniform Hospital Discharge Data Set (UHDDS) used by hospitals to report inpatient data
Section III. Reporting Additional Diagnoses
Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
Part of the Introduction…
These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD‐10‐CM itself.
Adherence to these guidelines when assigning ICD‐10‐CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.
• continued
Part of the Introduction……
A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
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Notes / Excludes / 7th Characters
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2013/
Notes
Two types of Excludes Notes
Extensions
Examples of Level of Detail
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2013/
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Key Educational Focus Areas – Things to Know
Fundamental education is necessary to understand documented clinical data for greater specificity
Medical Terminology – be able to read and understand an entry in the health record
Anatomy, Physiology, Pathophysiology – identify what is normal versus abnormal and may need clarification
Pharmacology – link medications to conditions being treated
Stage and laterality Kidney disease, ulcers
Laterality for any unilateral or bilateral site (e.g. musculoskeletal) e.g. L89.113 Pressure ulcer of right upper back, stage III
Terminology changes Mental retardation is now intellectual disabilities
Late effect is now sequela
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Key Educational Focus Areas – Things to Know
Similar guidelines between ICD‐9‐CM & ICD‐10‐CM
Refer to Official Coding and Reporting Guidelines
Guidelines for conditions are made more consistent such as sepsis and MRSA
Reclassification – some conditions are now moved to other chapters
hemorrhoids move from circulatory system to digestive system
TIA moves from circulatory to nervous system
Combination codes – more combination codes are available to identify etiology and manifestation, complication, episode of care, outcome of care
I25.110 Atherosclerotic heart disease of native coronary arterywith unstable angina pectoris
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
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Key Educational Focus Areas – Things to Know
Mass and growth are classified as signs/symptoms, or specific type of neoplasm
“Mass” is not assigned to a code from Chapter 2
Example: R22.1 Localized swelling, mass and lump, neck
“Growth” – follow the instructions and subterms in the Index:
Growth
adenoid (vegetative) J35.8
benign – see Neoplasm, benign, by site
malignant – see Neoplasm, malignant, by site
secondary – see Neoplasm, secondary, by site
No hypertension table identify type, due to, with with kidney disease see cardiorenal and identify stage
I13.10 hypertensive heart and chronic kidney disease without heart failure with stage 1‐4 chronic kidney disease (use add’l code for stage)
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Key Educational Focus Areas – Things to Know con’t
Musculoskeletal
Fractures – episode of care, site, type of fx (open, closed); malunion, non‐union, delayed healing, routine healing
Other: laterality, complications, manifestations, associated conditions
M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip
Trimesters for OB 1st trimester – less than 14 weeks 0 days
2nd trimester – 14 weeks 0 days to less than 28 weeks 0 days
3rd trimester – 29 weeks 0 days until delivery
Poisoning and Adverse Effects now include intent and underdosing
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Key Educational Focus Areas – Things to Know con’t
Myocardial Infarctions (MI)
Specific site and vessel involved
ST elevation (STEMI) and non‐ST elevation (NSTEMI) myocardial infarction
Timing (Ref: Guideline Section I.C.9.e. 1.)
Acute MI is within 4 week/28 day period
Greater than 4 weeks still under care, use aftercare
Old or healed without aftercare I21
Subsequent – new MI within 4 weeks of previous MI
Mental, Behavioral and Neurodevelopmental disorders now have coding guidelines
Intraoperative or post operative complications – example: I97.610 Post‐procedural hemorrhage and hematoma of a circulatory system organ or structure following a cardiac catheterization
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Key Educational Focus Areas – Things to Know con’t
Use additional code to identify:
exposure to environmental tobacco smoke (Z77.22)
history of tobacco use (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.‐)
tobacco use (Z72.0)
Applies to all codes in these categories:
• Hypertensive diseases (I10‐I15)
• Ischemic heart disease (I20‐I25)
• Cerebrovascular diseases (I60‐I69)
• Atherosclerosis (I70)
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Example: Breast Cancer
Documentation elements necessary for coding:
• Type of cancer: Malignant primary, malignant secondary, in‐situ, benign, uncertain behavior, unspecified behavior
• Site: specify site to lowest denominator, e.g. areola; inner, lower (quadrant), upper (quadrant), midline, skin, central, axillary tail, nipple, etc.
• Laterality and sex of patient: left, right, male, female
Guidelines: If reason for encounter is chemotherapy, sequence chemotherapy code first. Code also estrogen receptor status.
Example: 39‐year‐old female presents for chemotherapy for treatment of malignant neoplasm of lower inner quadrant right breast
Z51.11 Encounter for antineolpastic chemotherapy
C50.311 Malignant neoplasm of lower‐inner quadrant of right female breast
Z17.0 Estrogen receptor negative status
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Example: Acute Sinusitis
Documentation elements necessary for coding:
• Site: maxillary, frontal, ethmoidal, sphenoidal, pansinusitis, other
• Acuity: acute, chronic Timing: recurrent or unspecified
Guidelines:
• Excludes1 (not coded here‐conditions cannot exist together) ‐ sinusitis NOS goes to chronic sinusitis
• Excludes2 (not included here) Chronic Sinusitis
• Use additional code to identify infectious agent
Example: acute recurrent maxillary sinusitis J01.01
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Example: Pregnancy Complicated by Diabetes
Documentation elements necessary for coding:
• Trimester: 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 0 days until delivery
• Number of pregnancies
• Additional information based on condition: pre‐existing, incidental, number of fetuses
Example: 15‐year‐old gravida 1, para 1, presents for routine prenatal care at 16 weeks gestation.
O09.612 Supervision of young primigravida, second trimester
Z3A.16 16 weeks gestation of pregnancy
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Example: Traumatic Fracture of Radius
Documentation elements necessary for coding:
• Specific site: distal end, head, upper end, lower end, extra‐articular, intra‐articular, physeal, neck, shaft
• Type: displaced, non‐displaced (comminuted, greenstick, oblique, segmental, spiral, transverse), open, closed
• Laterality and type of healing: left, right, routine, delayed, nonunion, malunion
• Episode of care: initial, subsequent, sequela
Example: Patient presented for follow‐up of a healing displaced right radial neck fracture.
S52.131D Displaced fracture of neck of right radius, subsequent encounter for fracture with routine healing
*note: if pathological fracture, note etiology such as neoplasm or osteoarthritis
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Urinary Tract Infection and Urosepsis
Documentation elements necessary for coding:
The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.
(Ref: Section C.1.d.1.a.ii).
N39.0 Urinary tract infection, site not specified
Use additional code (B95‐B97), to identify infectious agent.
Excludes1: candidiasis of urinary tract (B37.4‐)
neonatal urinary tract infection (P39.3)
urinary tract infection of specified site, such as:
cystitis (N30.‐)
urethritis (N34.‐)
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Example: Diabetes
Documentation elements necessary for coding:
Type of diabetes – type 1, type 2, secondary, gestational, etc.
Poorly controlled – hyperglycemia (hypoglycemia)
Manifestations or complications (by system)
Guidelines:
Section I.C.4.a.1‐6 of the ICD‐10‐CM Official Coding & Reporting
Assign as many codes within a particular category as are necessary to describe all of the complications of the disease. Sequencing is based on the reason for a particular encounter.
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, then assign the following:
• E11.‐, Type 2 diabetes mellitus
• Z79.4, Long‐term (current) use of insulin, to indicate the patient uses insulin. However, do not assign code Z79.4 if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter
E11.621 Type 2 diabetes mellitus with foot ulcer (use add’l code to identify site of ulcer (I.97.4‐, L97.5‐)
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Overweight and Obesity (E66)
Documentation elements necessary for coding:
Obesity – drug induced, obesity, morbid (severe), other due to excess calories, alveolar hypoventilation
If drug induced, identify adverse effect, type of drug
Guidelines: Use additional code to identify body mass index (BMI), if known, (Z68.‐)
Note: E66.01 maps to 278.01 Morbid obesity
E66.09, E66.1, E66.8, E66.9 map to 278.00 Obesity unspecified
E66.2 maps to 278.03 Obesity hypoventilation syndrome
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Thank You
Elsevier |MC Strategies :Your Partner in ICD‐10 Implementation
Deb Neville, RHIA, CCS‐[email protected]‐10online.com
_____________________________________________
Judy B Breuker, CPC, CPMA, CCS‐P, CHCA, PCS, CEMC, CHC, CHAP,
AHIMA‐Approved ICD‐10‐CM/PCS [email protected]