ICD-10 Orientation In Post Acute Care (Part IV)Rhonda Anderson, RHIA

Anderson Health Information Systems, Inc.

Location, Date, Time

•Northern CaliforniaFairfield Post Acute Rehab

March 20, 2014

9:00am – 3:00pm

• Southern CaliforniaGarden View Post Acute Rehab

April 9, 2014

9:00am – 3:00pm2

Presenters

• Staci LePage, RHIT

Email: stacilepage@comcast.net

Mobile: 916-202-5797

•Khaleelah Wagner, RHIA

Email: khaleelahwagner@hotmail.com

Mobile: 909-717-71023

Chapter 17 – Congenital Malformations, Deformations & Chromosomal Abnormalities Q00-Q99•Nothing significantly changed• Some reorganization of the section•Organized by system

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Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab Findings (R00-R99)• Expanded abdominal pain by quadrants•Abnormality of gait now has 6 types• Sepsis now in this chapter•Abnormal lab findings now specify “without

diagnosis” rather than “nonspecific abnormal finding”

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Signs/Symptoms Coding

• R65 Symptoms and signs specifically asso with systemic inflammation and infection• R65.1- Systemic inflammatory response

syndrome/SIRS of non-infectious origin • Need to know with/without organ dysfunction

• R65.2- Severe sepsis• Need to know with/without septic shock, also code 1st

underlying infection

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Signs/Symptoms Codes -2

•Use of symptom codes are acceptable for use when a related diagnosis has NOT been established by the provider•A symptom code with a diagnosis code may

be reported when the sign or symptom is NOT routinely associated with that diagnosis• Signs or symptoms that are associated

routinely with a disease process should NOT be assigned as additional codes

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General Signs and Symptoms R50-R69• R50 Fever of unknown origin• R51 Headache• R52 Pain, unspecified• Excludes acute and chronic pain, NEC (G89.-)

• R53 Malaise and fatigue• R55 Syncope and collapse• R56 Convulsions, not elsewhere classified• Excludes seizure disorder G40. 8

Dysphagia

• R13.10 Dysphagia, unspecified• R13.11 Dysphagia, oral phase• R13.12 Dysphagia, oropharyngeal phase• R13.13 Dysphagia, pharyngeal phase• R13.14 Dysphagia, pharyngoesophageal

phase• R13.19 Other dysphagia

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Dysphagia -2

• Code first, if applicable, dysphagia following CVD (I69.-)• Need to know phase of dysphagia (therapist)

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Other Symptoms and Signs Involving Cognitive Functions• Expanded category:• R41.81 Age-related cognitive decline• R41.82 Altered mental status• Excludes altered mental status d/t known condition –

code to condition

• R41.83 Borderline intellectual functioning• R41.84- Other specified cognitive deficit• R41.841 Cognitive communication deficit

• R41.89 Other S/S involving cognitive function• R41.9 Unspecified S/S involving cog function

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Other Symptoms and Signs Involving Cognitive Functions -2

• R29.6 Repeated falls is used when a patient has recently fallen and reason for the fall is being investigated.• Z91.81 Hx falls is used when a pt has fallen

in the past and is at risk for future falls• Need to know which are appropriate, as

both of the above codes may be assigned together, as needed

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Lack of Coordination

• Expanded codes in ICD-10-CM•Now with subcategories:• R27.0 Ataxia, unspecified• R27.8 Other lack of coordination• R27.9 Unspecified lack of coordination

• Need to know type of lack of coordination (therapist determines)

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Signs/Symptoms Involving Speech and Voice R47-R49• R47.0 Dysphasia and aphasia• R47.1 Dysarthria and anarthria• R47.8 Other speech disturbances• R47.9 Unspecified speech disturbances• Excludes these conditions when following

Cerebrovascular disease I69• Therapist needs to know type of speech

disturbance 14

Dyslexia and Other Symbolic Dysfunctions R48• Expanded category:• R48.0 Dyslexia and alexia• R48.1 Agnosia• R48.2 Apraxia• R48.3 Visual agnosia• R48.8 Other symbolic dysfunctions• R48.9 Unspecified symbolic dysfunctions

• Therapist needs to know type of symbolic dysfunction 15

Weakness

• R53.1 Weakness

vs.•M62.81 Generalized muscle weakness• Need to know if just “weakness” or

“muscle weakness”

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Abnormality of Gait

•Difficulty in walking category has changed from unspecified joint disorders to abnormalities of gait and mobility• R26.0 Ataxic gait• R26.1 Paralytic gait• R26.2 Difficulty in walking• R26.8- Other abnormalities of gait/mobility• R26.9 Unspecified abnormalities gait/mobility

• Need to know type of gait abnormality (therapist)

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Quadriplegia

• R53.2 Functional quadriplegia• Complete immobility d/t severe physical

disability or frailty

vs. •G82.5- Quadriplegia

vs. • I69.- Paresis d/t sequelae of CVD

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Malaise and Fatigue R53

• Expanded category:• R53.0 Neoplastic related fatigue• R53.1 Weakness• R53.2 Functional quadriplegia• R53.8- Other malaise and fatigue• R53.81 Other malaise (debility)• R53.82 Chronic fatigue, unspecified• R53.83 Other fatigue (lethargy)

•Only code if malaise/fatigue is NOT d/t another condition

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Chapter 19 – Injury, Poisoning & Certain Other Consequences of External Causes S00-T88

• Fractures in sub-categories by:• Displaced and non-displaced, then• Site on the specific bone or type/name of

fracture (torus, green stick, transverse, oblique spiral, comminuted, segmental), then• Right or left

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Traumatic Fractures

•A fracture not indicated as open or closed should be coded to closed•A fracture not indicated whether displaced

or not should be coded to displaced• Example:• S42.321D Displaced transverse fracture of shaft

of humerus, right arm, subsequent encounter for fracture with routine healing

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Traumatic Fractures -2

• Need to carefully look at the pink text boxes (in the tabular) for assigning the correct 7th digit• Need to know if displaced or not, type of

fracture/bone, laterality

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Types of Fractures

•Displaced fracture - fracture in which the two ends of the broken bone are separated from one another•Non-displaced fracture - the bone cracks

either part or all of the way through, but does move and maintains its proper alignment.• Closed fracture - the bone breaks but there is

no puncture or open wound in the skin 23

Types of Fractures

•Open fracture - the bone breaks through the skin

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Poisoning by, Adverse Effects of and Underdosing of Drugs• Table of drugs shows following categories:• Poisoning, accidental (unintentional)• Poisoning, intentional (self-harm)• Poisoning, assault• Poisoning, undetermined•Adverse effect *•Underdosing *• Categories have changed – be aware *was

therapeutic use

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Underdosing

•Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction •Assign T36-T50 with 6th character of “6”• Codes for underdosing should never be

assigned as principal dx•Noncompliance (Z91.12-) codes are to be

used with an underdosing code, if known 26

Chapter 20 External Causes

•Not used in long term care, not required to use

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Chapter 21 – Factors Influencing Health Status and Contact with Health Services (Z00-Z99)• For use in any healthcare setting•May be used as either a principal diagnosis

or secondary code• Certain Z-codes may only be used as

principal diagnosis *but these codes are not applicable to long term care setting

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Z Codes -2

• Provided for occasions when circumstances other than a dx, injury or external cause are recorded• Several codes have been expanded, i.e.

personal and family hx•Now have a code for patients blood type, i.e.

Z67• Z code should not be used if treatment is

directed at a current acute disease29

Z Codes -3

•No longer have V57 codes • Code the underlying condition, i.e. injury,

etc. with the appropriate 7th character for subsequent encounter• Z68 BMI is divided into adult and pediatric

codes (Adults = age 21 or older)• RD in facility can assist with documenting

the BMI30

Z Codes -4

• Code Z92.82 when tsf facility has admin tPA within 24 hrs prior to admit (usually with new dx of MI or CVD)•Aftercare Z codes should NOT be used for

aftercare of fractures• For aftercare of fractures, assign fracture

code with 7th character D for subsequent encounter

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Z47 Orthopedic Aftercare

• Excludes aftercare for healing fracture – code to fracture with 7th character D• Z47.1 Aftercare following joint replacement

surg• Use add’l code to id the joint (Z96.6-)

• Z47.3 Aftercare following explantation of joint prosthesis• Need to know joint (shoulder, knee, hip)

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Z47 Orthopedic Aftercare -2

• Z47.8 Encounter for other orthopedic aftercare• Z47.81 following surgical amputation• Use add’l code to identify the limb amputated (Z89.-)

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Joint Replacement

• ICD-9-CM:• V54.81 Aftercare following joint replacement • V43.64 Joint replacement, hip

• ICD-10-CM:• Z47.1 Aftercare following joint replacement

surgery• Excludes aftercare for healing fracture

• Z96.641 Presence of right artificial hip joint• Need to know right or left and which joint 34

Therapy Admission

• Resident admitted for physical therapy following CABG• Z48.812 Encounter for surgical aftercare

following surgery on the circulatory system• Z95.1 Presence of aortocoronary bypass graft• Plus, therapy treatment codes (muscle weakness,

gait disturbance, etc), per therapists

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Amputee Status

• Status post L BKA admitted for dressing changes following resolved infection of the amputation stump• Z48.01 Encounter for change or removal of

surgical wound dressing• Z89.522 Acquired absence of leg below left knee• Need to know which knee and above or below

the joint

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ICD-10-CM Readiness

• Identify if education is needed•Knowledge is a key step in successful

implementation• Separate roles into two groups• Group that primarily assigns codes • Group that primarily does NOT assign codes

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Different Knowledge Levels Defined As•A general knowledge of the code system and

important differences between ICD-9 and ICD-10•Use/professional knowledge level which

would be for an individual who uses coded data but is typically not assigning codes daily•Application of the code set would be for

those individuals who are routinely applying codes

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Education Time

•An employee with experience in coding (who was trained on the job) is estimated to need 18 hours of cumulative education for ICD-10• Education varies based upon the needs of

each individuals skill level• Intense coding education should NOT be

initiated until three months before implementation 39

Steps To Take Now

• Educational Tasks/Phase I• Learn about the structure, organization, and

unique features of ICD-10• Network with peers, access resources, and read

literature to identify transition issues and best practices• Provide opportunity for coders to review code

structure and coding conventions for ICD-10

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General Implementation Task / Phase I•Develop an implementation plan • Identify steps to prepare for implementation• Identify who should be involved in preparation• Develop time frames for implementation phases• Identify current systems that input, store and

utilize ICD data • Identify who is currently performing coding; in

addition to other individuals who may be cross-trained for code assignment 41

General Implementation -2

• Review current workflow to identify areas of impact and analyze opportunities for improvement (data in MDS, health record, and claim form)• Common workflow examples are diagnostic

tests (laboratory, radiology, therapy diagnoses and billing)•Document improvement processes

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Improvement Processes

•Analyze current documentation practices, physician, nursing and therapy to identify areas in need of improvement• Identify current processes that may lead to

poor data quality due to inadequate or outdated documentation practices• Conduct detailed assessment of staff

educational needs r/t documentation 43

Improvement Processes -2

• Review current workflow to identify the areas of impact and analyze areas for improvement

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General Implementation Tasks / Phase 2•Determine the date of installation of

facilities ICD-10 database software (must be utilized in a parallel manner with current ICD-9 code library) *by April•Do NOT uninstall ICD-9 database •Address timeline to begin coding current

residents’ dx

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Educational Tasks / Phase 3

• Continue educational plan, including intensive education for roles who primarily assign codes• Practice ICD-10 coding of current records • Implement process for parallel coding of

current residents with ICD-10 to facilitate future data entry

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Educational Tasks / Phase 3

• Provide more intensive educational and consultative support to coders and users of coded data • Continue documentation improvements in

areas identified for Improvement• Install ICD-10 vendor software into the

system to prepare for transition• Perform software system testing

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General Implementation Tasks/Phase 3• ICD-9 legacy data must be maintained and

available• Closely monitor productivity and quality

measures for issues that might be r/t implementation of new code sets

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Thanks for attending!!

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