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ICD-10-CM/PCS
Physician Education
Mental Health and Substance Abuse
1
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 visits
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Why 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– Outdated: 30 years old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
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Diagnosis Code Structure
4
ICD-10-CM Diagnosis Code Format
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Comparison: ICD-9 to ICD-10-CM
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Procedure Code Structure
ICD-10-PCS Code Format
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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?
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ICD-10-CM/PCS
Documentation Tips
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ICD-10 Provider Impact
• Clinical documentation is the foundation of successful ICD10 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
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Gold 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 tests
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ICD-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
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ICD-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
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ICD-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
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ICD-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
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ICD-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?
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ICD-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
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ICD-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
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ICD-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
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ICD-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
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ICD-10 Documentation Tips
Intellectual Disability
₋ Specify the Type
₋ Acuity
₋
₋
₋
₋
Mild
Moderate
Severe
Profound
₋ Document associated physical or developmental
disorders
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ICD-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
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ICD-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
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ICD-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
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ICD-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
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ICD-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
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ICD-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
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ICD-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
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ICD-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 Tips
Most Common Root Operations:
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
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Summary
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
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