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UHS, Inc.
ICD-10-CM/PCS
Physician Education
Infectious Disease
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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– Outdated: 30 years old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
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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
Status of disease –
•
•
•
Newly diagnosed
Acute
Chronic
Site of infection or infestation (TB of lung)
Cause of the infection (streptococcus)
Link manifestations and other conditions
Autoimmune and related diseases (Kaposi’s sarcoma)
Infectious agents in other types of disease (wound infection
caused by staph)
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ICD-10 Documentation Tips
AIDS / HIV
– Status of disease
•
•
•
•
•
•
AIDS
HIV positive
HIV-related illness
Newly diagnosed
Asymptomatic
Inconclusive serology
– Clearly indicate the reason for admission
•
For HIV or unrelated condition
– List related conditions and manifestations
•
Document as due to or with
– Is the patient pregnant
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ICD-10 Documentation Tips
Hepatitis
– Specify acuity
•
•
Acute, Chronic, Acute on chronic
With or without hepatic coma
– Identify type
•
A, B, or C
– Hepatitis B patients with hepatitis D (delta agent) must
have documentation to support both viral agents
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ICD-10 Documentation Tips
Influenza
– Organism, document as known or suspected
• Avian influenza
• H1N1 influenza
– Link associated conditions / manifestations
•
•
•
•
•
•
Influenza with secondary gram negative pneumonia
Laryngitis
Pleural effusion
Influenzal encephalopathy
Influenzal myocarditis
Influenzal otitis media
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ICD-10 Documentation Tips
Pneumonia
– Organism, document as known or suspected
• Viral – adenoviral, respiratory syncytial, parainfluenza, human
metapneumovirus, viral unspecified
• Bacterial – streptococcus, hemophilus, E coli, klebsiella, pseudomonas,
staphlococcus, MRSA, MSSA, mycoplasma, bacterial unspecified
– Link associated conditions
•
•
•
•
Influenza with secondary gram negative pneumonia
Sepsis due to pneumonia
Acute respiratory failure due to pneumonia
Whooping cough / pertussis
– Aspiration
• Due to solids or liquids
• Due to anesthesia during L/D or procedure
• Due to anesthesia during puerperium
– Laterality of lung involvement – left, right, both
– Note whether ventilator associated (VAP)
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ICD-10 Documentation Tips
Sepsis
– Acuity – sepsis, severe sepsis, septic shock, SIRS
– Organism due to / suspected
•Streptococcus (A or B)
•Staphylococcus aureus
•MSSA
•MRSA
•Hemophilus influenzae
•Gram-negative organism
•E Coli
•Serratia
•Enterococcus
– Manifestations
•With acute organ dysfunction
•With multiple organ dysfunction
•SIRS due to infectious process with organ dysfunction
•Shock
– Note the term urosepsis is NOT synonymous with sepsis
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ICD-10 Documentation Tips
Sepsis Criteria
–Altered mental status
–Heart rate > 90 beats per minute
–Hypoxemia
–PaCO2 < 32mmHg
–Respiratory rate > 20 breaths per minute
–Temperature > 100.9 F or < 96.8 F
–WBC > 12,000 cells/mm3; < 4,000 cells/mm3; and/or > 10%
immature band
–Blood cultures do not need to be positive to support the diagnosis of
sepsis – the physician may clinically diagnose based on signs and
symptoms
Septic shock – circulatory failure and sepsis that are related,
include severe sepsis in the documentation
When was the onset of sepsis – prior to admission or during
admission
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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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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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