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Documentation for
ICD-10
Moving From Here to There
Presented by
Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT
President & Chief Medical Officer
Executive Physician Educator
DocuComp LLC
© aihcd.org 2011
Dr. Betty B. Bibbins, MD, BSN, CHC, CCDI, CPEHR, CPHIT
President, Chief Medical Officer, and
Executive Physician Educator, DocuComp
LLC
Dr. Bibbins, a physician with a background
in Nursing, is certified in Healthcare
Compliance, Clinical Documentation
Improvement, Electronic Health Records
and Health Information Technology.
Dr. Bibbins has over 35 years of healthcare experience as an educator, clinician and
administrator. She is President, Chief Medical Officer and Executive Physician Educator
for DocuComp LLC. She has presented at numerous conferences and written many
articles on physician documentation improvement.
Dr. Bibbins focus is on the needs of Physicians, Nurses and HIM’s in the provision of
healthcare and the Hospitals that depend on clinical documentation to capture
appropriate levels of service, severity of illness, third party reimbursements, maintain
Compliance, prepare for increasing standards for the utilization-of-healthcare services,
Medical Cost Recovery and prepare for
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aihcd.org
2011
“Quality-of-Care standards.
Why ICD-10?
• ICD-9 classification system out of date (30
years old)
• Many Categories in ICD-9 are full
• Need improved description of diagnoses
and procedures
• Many categories of classification
outdated, do not correspond to current
clinical perspectives of medicine
• The rest of the world using ICD-10
© aihcd.org 2011
ICD-9-CM to ICD-10: Basic Overview
ICD-9 CM
• 14,000 Diagnoses Codes
• Numeric Codes:
– Max of 5 digits
• 4,000 Procedure Codes
• Numeric Codes:
– Max of 4 digits
ICD-10
Approximately 68,000
Diagnoses Codes
Alphanumeric Codes:
 Always Start with a Letter (Exc.
U) Max of 7 Char.
 87,000 Procedure Codes
(ICD-10-PCS)
Alpha/Numeric Codes:
 Start with a Number or Letter
(Exc. O or I to avoid confusion
with 0/1)
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7th Character Extension
Code Extensions
 Chapter 19-Injury, Poisoning, and Certain Other
Consequences of External Causes (S00-T88)
 Most categories have 7th character extensions
required for each applicable code
Include A, D, S, Z
 A- Initial encounter
 D-Subsequent encounter
 S- Sequela
 Z - Aftercare
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Common Character Extensions
Extension A
 Extension “A”, initial encounter is used while the
patient is receiving active treatment for the injury.
Examples of active treatment are: surgical treatment,
emergency department encounter, and evaluation
and treatment by a new physician
Extension D
 Extension “D” subsequent encounter is used for
encounters after the patient has received active
treatment of the injury and is receiving routine care
for the injury during the healing or recovery phase.
Examples of subsequent care are: cast change or
removal, removal of external or internal fixation
device, medication adjustment, other follow up visits
following injury treatment.
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Common Character Extensions
• Extension “S”, sequela, is for use for
complications or conditions that arise as a
direct result of an injury, such as scar
formation after a burn. The scars are sequela
of the burn. When using extension “S”, it is
necessary to document both the injury that
precipitated the sequela and document the
sequela itself. The “S” extension identifies
the injury responsible for the sequela. The
specific type of sequela (e.g. scar) is
sequenced first, followed by the injury code.
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ICD-10 Common Theme
Expansion of Code Sets
 Specificity in clinical documentation
 Specificity in clinical classification
Change in clinical documentation thought process
 “Clinical medicine” versus “CC/MCC Capture”
Completeness and accuracy of clinical documentation
 Severity of illness
 Risk of Morbidity and Mortality
Pay For Performance
 Risk of Admission
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Common Clinical Examples
ICD-9
ICD-10
• Respiratory Failure
– 518.81- Acute
– 518.83-Chronic
– 518.84- Acute-onChronic
J96.00- Acute
respiratory failure,
unspecified with hypoxia
or hypercapnia
J96.01- Acute
respiratory failure with
hypoxia
J96.02- Acute
respiratory failure with
hypercapnia
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© aihcd.org 2011
Common Clinical Examples
ICD-10
ICD-10
J96.10- Chronic
respiratory failure,
unspecified with
hypercapnia or hypoxia
J96.11- Chronic
respiratory failure with
hypoxia
J96.12- Chronic
respiratory failure with
hypercapnia
• J96.20- Acute & Chronic
respiratory failure,
unspecified
• J96.21- Acute and
chronic respiratory
failure with hypoxia
• J96.22- Acute and
chronic with
hypercapnia
© aihcd.org 2011
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Common Clinical Examples
ICD-10
• J96.90- Respiratory failure,
unspecified, unspecified with
hypoxia or hypercapnia
• J96.91-Respiratory failure,
unspecified, with hypoxia
• J96.92-Respiratory failure,
unspecified, with hypercapnia
© aihcd.org 2011
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Common Clinical Examples
ICD-9
• 599.7- Hematuria
ICD-10
• R31.9- Hematuria,
unspecified
• N30.01- Acute cystitis
with hematuria
• N02.0- Recurrent and
persistent hematuria
with minor glomerular
abnormality
© aihcd.org 2011
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Common Clinical Examples
ICD-10
ICD-10
• N02.1-Recurrent and
persistent hematuria
with focal and
segmental glomerular
lesions
• N02.2- Recurrent and
persistent hematuria
with diffuse
membranous
glomerulonephritis
N02.3 - Recurrent and
persistent hematuria
with diffuse mesangial
proliferative
glomerulonephritis
N02.4- Recurrent and
persistent hematuria
with diffuse
endocapillary
proliferative
glomerulonephritis
© aihcd.org 2011
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Common Clinical Examples
ICD-10
ICD-10
• N02.5- Recurrent and
persistent hematuria with
diffuse mesangiocapillary
glomerulonephritis
• N02.6- Recurrent and
persistent hematuria with
dense deposit disease
N02.7- Recurrent and
persistent hematuria with
diffuse crescentic
glomerulonephritis
N02.8- Recurrent and
persistent hematuria with
other morphologic changes
N02.9- Recurrent and
persistent hematuria with
unspecified morphologic
changes
© aihcd.org 2011
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Heart failure
I50.1
I50.2
I50.20
I50.21
I50.22
I50.23
I50.30
I50.30
I50.31
I50.32
I50.33
I50.40
I50.40
failure
I50.41
I50.42
failure
I50.43
Left ventricular failure
Systolic (congestive) heart failure
Unspecified systolic (congestive) heart failure
Acute systolic (congestive) heart failure
Chronic systolic (congestive) heart failure
Acute on chronic systolic (congestive) heart failure
Diastolic (congestive) heart failure
Unspecified diastolic (congestive) heart failure
Acute diastolic (congestive) heart failure
Chronic diastolic (congestive) heart failure
Acute on chronic diastolic (congestive) heart failure
Combined systolic (congestive) and diastolic (congestive) heart failure
Unspecified combined systolic (congestive) and diastolic (congestive) heart
Acute combined systolic (congestive) and diastolic (congestive) heart failure
Chronic combined systolic (congestive) and diastolic (congestive) heart
Acute on chronic combined systolic (congestive) and diastolic (congestive)
heart failure
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I50.9 Heart failure, unspecified
© aihcd.org 2011
Example:Combination Diagnosis
Decubitus Ulcers - appropriate documentation of the exact
location and stage must be present.
Stages of Pressure (Decubitus) Ulcers:
Pressure ulcer, Stage I - Intact skin with non-blanchable redness of a localized area
usually over a bony prominence)
Pressure ulcer, Stage II - Partial thickness loss of dermis presenting as a shallow
open ulcer with a red pink wound bed, without slough. May also present as an intact
or open/ruptured serum-filled blister.
Pressure ulcer, Stage III - Full thickness tissue loss. Subcutaneous fat may be visible
but bone, tendon or muscle are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining and tunneling.
Pressure ulcer, Stage IV - Full thickness tissue loss with exposed bone, tendon or
muscle. Slough or eschar may be present on some parts of the wound bed. Often
include undermining and tunneling.
Pressure ulcer, Unstageable - Full thickness tissue loss in which the base of the ulcer
is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or
black) in the wound bed.
National Pressure Ulcer Advisory Panel
© aihcd.org 2011
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Sad but true……
Documentation of Urosepsis
Has no code within ICD 10……..
UTI with Sepsis, Bladder Infection,
or other Dx must be explicitly
documented.
© aihcd.org 2011
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Strategies for ICD-10 Preparation
• “Build and expand” upon present Clinical
Documentation Initiatives
– Focus on communicating severity-of-illness and
medical necessity
– Familiarity with ICD-10 documentation specificity
requirements
• Clinical specificity
– Time capsule:
• Tomorrow is Today!
• Proceed with Explicitness!
© aihcd.org 2011
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It is so important to remember……
Physicians know how to practice
medicine.
What is needed now is to better
understand how to
DOCUMENT the practice of
medicine!
© aihcd.org 2011
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© aihcd.org 2011
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Questions?
© aihcd.org 2011
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Thank You
Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT
President & Chief Medical Officer
DocuComp LLC
Email: [email protected]
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References
•
www.CMS.gov/icd10
•
Bibbins, Betty. “Inpatient (IPPS)
Documentation Tips for Physicians.”
2011 Edition. DocuComp LLC Press.
•
Krauss, Glenn and Hoffman, Sylvia. 2011. “The
Clinical Documentation Improvement Specialist’s
Guide to ICD-10. HCPro.
www.icd10data.com/ICD10CM/Codes/
•
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