ICD-10 Data Challenges

1. ICD-10 Data Challenges HIMANYC ANNUAL MEETING May 10, 2013 Ann Zeisset, RHIT, CCS, CCS-P AHIMA-Approved ICD-10-CM/PCS Trainer Ann Zeisset Consulting

2. Learning Objectives Ann Zeisset Consulting

3. Clinical Documentation Improvement Ann Zeisset Consulting

4. CDI Practices • Evaluate current documentation • Quality • Detail • Documentation improvement strategies • Audit records • Report findings Ann Zeisset Consulting

5. Preparation - Provide Training • Characteristics of ICD-10-CM/PCS • Coding guidelines • Data comparability issues • Quality reporting • GEMS and their role Ann Zeisset Consulting

6. Preparation Provide Training • Coding professionals • Anatomy/physiology • Medical Terminology • Pathophysiology • Pharmacology Ann Zeisset Consulting

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8. Differences Impacting Documentation Ann Zeisset Consulting

9. Terminology Differences – ICD-10-CM Ann Zeisset Consulting

10. Terminology Differences – ICD-10-CM Ann Zeisset Consulting

11. Classification Differences Ann Zeisset Consulting

12. Differences in Definitions and Meaning Ann Zeisset Consulting

13. ICD-10-CM Documentation • Diabetes • Mononeuropathy • Polyneuropathy • Autonomic neuropathy • Pregnancy • Unspecified trimester Ann Zeisset Consulting

14. ICD-10-CM Specificity • Type of sepsis • Osteoarthritis • Rheumatoid arthritis • Osteonecrosis • Colitis • Peritonitis • Asthma • Pressure ulcers • Type of cardiomyopathy • Type of heart failure • Respiratory failure • Acute or chronic • With hypoxemia or hypercapnia • Substance and intent combination codes • Adverse effect • Poisoning • Underdosing • Toxic effect Ann Zeisset Consulting

15. ICD-10-CM Specificity Ann Zeisset Consulting

16. Type of Sepsis Ann Zeisset Consulting

17. Type of Sepsis Ann Zeisset Consulting

18. Type of Sepsis Ann Zeisset Consulting

19. Colitis Ann Zeisset Consulting

20. Osteoarthritis • Ankle M19.07- • Generalized M15.9 • Erosive M15.4 • Primary M15.0 • Specified NEC M15.8 • Post-traumatic NEC M19.92 • Ankle M19.17- • Primary M19.91 • Ankle M19.07- • Secondary M19.93 • Ankle M19.27- Ann Zeisset Consulting

21. Rheumatoid Arthritis Ann Zeisset Consulting

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23. Acute Respiratory Failure Ann Zeisset Consulting

24. Injuries • Injuries • Initial • Subsequent • Sequela • More specific sites available for wounds Ann Zeisset Consulting

25. Fractures Ann Zeisset Consulting

26. Gustilo Classification of Open Fractures Ann Zeisset Consulting

27. Fractures For images search on “Types of fractures.” One site is http://orthoinfo.aaos.org/topic.cfm?topic=a00139 Ann Zeisset Consulting

28. CDI ICD-10-CM Documentation Tips: Gustilo Fracture Classification • Chapter 19, “Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T99).” Fracture codes have much greater specificity than in ICD-9-CM and require the level of the encounter be identified. • During the coding process assign the level of encounter using one of the following seventh characters for applicable fracture codes: A = Initial encounter for closed fracture B = Initial encounter for open fracture D = Subsequent encounter for fracture with routine healing G = Subsequent encounter for fracture with delayed healing K = Subsequent encounter for fracture with nonunion P = Subsequent encounter for fracture with malunion S = Sequela Ann Zeisset Consulting

29. CDI ICD-10-CM Documentation Tips: Gustilo Fracture Classification • The seventh (7th) character in some fractures will identify the type of open fracture using the Gustilo Fracture Classification. • Categories S52, S72, and S82 are impacted by the Gustilo Fracture Classification • During the coding process assign the code to capture the type of open fracture using the appropriate seventh character (categories S52, S72, S82): B = Initial encounter for open fracture type I or II C = Initial encounter for open fracture type IIIA, IIIB, or IIIC E = Subsequent encounter for open fracture type I or II with routine healing F = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing H = Subsequent encounter for open fracture type I or II with delayed healing J = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing M = Subsequent encounter for open fracture type I or II with nonunion N = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion Q = Subsequent encounter for open fracture type I or II with malunion R = Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion Ann Zeisset Consulting

30. CDI ICD-10-CM Documentation Tips: Pathologic Fracture • Pathologic (non-traumatic) fracture documentation and coding will need to include: • Exact location of fracture • Site • Laterality • Etiology of fracture • Osteoporosis • Neoplastic disease • Other specified • Encounter type • Initial encounter • Subsequent encounter, routine healing • Subsequent encounter with delayed healing, malunion or nonunion • Sequelae Ann Zeisset Consulting

31. Diabetes ICD-9-CM • 250.x Diabetes mellitus • 5th digit “1” – Type I • 5th digit “0” – Type II or unspecified • 5th digit “2” & “3” – uncontrolled • 249.x Secondary diabetes mellitus • 5th digit “0” & “1” – uncontrolled • 648.8x – Abnormal glucose tolerance complicating pregnancy, childbirth, or puerperium (includes gestational diabetes) ICD-10-CM • Diabetes codes include type of complication • E08 Diabetes mellitus due to underlying condition • E09 Drug or chemical induced diabetes mellitus • E10 Type 1 diabetes mellitus • E11 Type 2 diabetes mellitus • E13 Other specified diabetes mellitus • O24 DM in pregnancy, childbirth, puerperium Ann Zeisset Consulting

32. ICD-10-CM DocumentationDiabetes Neuropathy See category E10.4 • Peripheral • Mononeuropathy – involves one nerve • Polyneuropathy – multiple nerves • Autonomic neuropathy – autonomic nervous system (heart, bladder, lungs, stomach, intestines, sex organs and eyes • Amyotrophy (radiculoplexus neuropathy, femoral neuropathy or proximal neuropathy) Ann Zeisset Consulting

33. CDI ICD-10-CM Documentation Tips: Diabetes • Diabetes documentation and coding will need to include: • Type or cause of diabetes: • Type 1 • Type 2 • Due to drugs or chemicals • Due to underlying condition • Other specified diabetes • Body system complications related to diabetes, such as kidney or neurological complications • Combination codes include diabetes and the manifestation • Specific complications, such as: • Chronic kidney disease • Foot ulcer • Hypoglycemia without coma Ann Zeisset Consulting

34. Ch 15: Pregnancy, Childbirth, and Puerperium Ann Zeisset Consulting

35. Ch 15: Pregnancy, Childbirth, and Puerperium Extensions • 7th character to identify fetus number • 0 – not applicable or unspecified • 1 – fetus 1 4 – fetus 4 • 2 – fetus 2 5 – fetus 5 • 3 – fetus 3 9 – other fetus Ann Zeisset Consulting

36. Ch 15: Pregnancy, Childbirth, and Puerperium - Trimesters Ann Zeisset Consulting

37. CDI ICD-10-CM Documentation Tips: OB/Pregnancy • Documentation of conditions/complications of pregnancy will need to specify the trimester in which that condition occurred. Some codes but not all specify trimester. • ICD-9-CM documentation required “episode of care” (delivered, ante-partum, post-partum) instead of trimester, childbirth, puerperium • If the condition develops prior to admission, the trimester at the time of admission is assigned • If the patient is hospitalized during one trimester and a condition/complication develops during the same hospitalization but in a subsequent trimester, the code for the trimester in which the complication develops is assigned Ann Zeisset Consulting

38. CDI ICD-10-CM Documentation Tips: OB/Pregnancy • The provider’s documentation of “weeks” may be used to assign the appropriate ICD-10 code for trimester • Note: Gestational diabetes needs specification of diet controlled or insulin controlled. If both diet and insulin controlled, the ICD-10-CM code for insulin controlled will be assigned Ann Zeisset Consulting

39. Glasgow Coma Scale • Used in conjunction with traumatic brain injury or sequelae of CVA • Used by trauma registries and researchers • Sequenced after diagnosis • Require three codes • R40.21 – eyes open • R40.22 – best verbal response • R40.23 – best motor response Ann Zeisset Consulting

40. Glasgow (coma scale) score available Typically reported as a total score 0-15 Higher score = higher functioning ICD-10-CM coding will need the score from each of the assessment areas Eye opening Verbal response Motor response CDI ICD-10-CM Documentation Tips: Coma • Category R40 • Somnolence (R40.0) = drowsiness • Stupor (R40.1) = catatonic stupor or semi-coma • Coma (R40.2-) = unconsciousness • Any associated skull fracture or intracranial injury would be coded first • Glasgow (coma scale) score available • 7th character required • Persistent vegetative state (R40.3) • Transient alteration of awareness (R40.4) Ann Zeisset Consulting

41. Ch 10: Diseases of Respiratory System • Terminology used to describe asthma has been updated to reflect current clinical classification of asthma • No longer extrinsic and intrinsic • National Heart, Lung and Blood Institute • http://www.nhlbi.nih.gov/ Ann Zeisset Consulting

42. Ch 10: Diseases of Respiratory System Ann Zeisset Consulting

43. CDI ICD-10-CM Documentation Tips: Asthma • Most adults with asthma will NOT require an inpatient admission • Look for indicators of acute respiratory failure or acute exacerbation with status asthmaticus • Be sure to clarify the relationship between COPD, bronchitis, and asthma • ICD-10 distinguishes between uncomplicated cases and those in exacerbation • Acute exacerbation is a worsening or decompensation of a chronic condition • An acute exacerbation is not equivalent to an infection superimposed on a chronic condition • An additional code should be used regarding exposure to or use of tobacco Ann Zeisset Consulting

44. CDI ICD-10-CM Documentation Tips: Asthma • Incorporate the following scales into documentation templates or queries • The National Heart, Lung, and Blood Institute (NHLBI) asthma severity classification scale accounts for the progressive nature of asthma by measuring it across the dimensions of types of symptoms and lung function • Mild intermittent • Mild persistent • Moderate persistent • Severe persistent Ann Zeisset Consulting

45. Severity of Asthma Classification Ann Zeisset Consulting

46. How Can You Prepare? • Incorporate the following scales into documentation templates or queries: • National Heart, Lung, and Blood Institute (NHLBI) asthma severity classification scale • Intermittent • Mild persistent • Moderate persistent • Severe persistent Ann Zeisset Consulting

47. How Can You Prepare? • Incorporate into query templates: • Glasgow (Coma Scale) • Need a score from each of the three assessment areas, NOT a total score • Eye opening • Verbal response • Motor response • Gustilo Open Fracture Classification • I, II, III, IIIA, IIIB, or IIIC Ann Zeisset Consulting

48. How Can You Prepare? • Respiratory failure • Acute versus chronic • With or without hypoxemia or hypercapnia • Trimester of pregnancy • Default to the trimester when the complication occurred, not the discharge trimester when an admission crosses trimesters • Identification of the substance related to adverse effect, poisoning, underdose or toxic effect Ann Zeisset Consulting

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50. Clinical Documentation ImprovementFormat of ICD-10 PCS There are seven (7) characters in each ICD‑10‑PCS (Procedure Coding System) code. Each character has a slightly different meaning related to that particular section. Ann Zeisset Consulting