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EFFECTIVENESS IN CLINICAL
DOCUMENTATION
ICD-10 Around the Corner,
Practical Steps for Physician
Preparation
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OBJECTIVES
• Understand and appreciate the underpinnings of
the ICD-10 system
• Compare and contrast structural differences
between ICD-9 and ICD-10
• Learn how to best effectively prepare for ICD-10 in
your office and hospital practice from a clinical
documentation perspective
• Take away best practice clinical documentation
strategies that can be immediately employed in
your practice of medicine.
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ICD-10 VS. ICD-9 CM
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Outpatient vs. Inpatient
Still only need to be concerned with diagnoses
Documentation is key
Clinical specificity
• 2014 ICD-9-CM: 14,567 codes
• 2015 ICD-10-CM: 69,832 codes
• ICD-10 more clinically relevant than ICD-9
• There is Constancy!
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PRACTICE OF MEDICINE
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BENEFITS OF ICD-10
• ICD-10-CM incorporates much greater clinical detail and
specificity than ICD-9-CM. Terminology and disease
classification are updated to be consistent with current clinical
practice. The modern classification system will provide much
better data needed for:
• Measuring the quality, safety, and efficacy of care;
• Reducing the need for attachments to explain the patient’s
condition;
• Designing payment systems and processing claims for
reimbursement;
• Conducting research, epidemiological studies, and clinical
trials;
• Setting health policy;
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BENEFITS OF ICD-10
Operational and strategic planning;
Designing health care delivery systems;
Monitoring resource use;
Improving clinical, financial, and administrative
performance;
• Preventing and detecting health care fraud and
abuse; and
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• Tracking public health and risks.
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PRACTICE OF MEDICINE
• Practice of medicine involves diagnosis, treatment, or
correction of human conditions, ailments, diseases, injuries, or
infirmities whether physical or mental, by any means, methods,
devices, or instruments. The practice of medicine includes, but
is not limited to:
• Undertaking to perform any surgical operation upon any
person; and
• Performing any act or procedure that uses a biologic or
synthetic material, or chemical application of any kind if it
alters or damages or is capable of altering or damaging
living tissue; and
• Performing any act or procedure using a mechanical
device, or displaced energy form of any kind if it damages
or is capable of damaging living tissue.
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PRACTICE OF MEDICINE
Sign and
Symptom
Assessment &
Plan
Patient
Patient
Evaluation
Physical
Exam
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PRACTICE OF MEDICINE
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Clinical analytical skills
Problem solving ability
Clinical judgment
Medical decision making
Diagnoses
• Definitive
• Diagnostic considerations
• Presenting problem(s)
• Differential Diagnoses
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MEDICAL DECISION MAKING
• Medical Decision Making
• Refers to the complexity of establishing a diagnosis and/or
selecting a management option. It is the E/M component in
which providers assess, advise and assist their patients in
managing their health. The end result is an individual plan of
care.
• MDM- Three components
• Number of diagnoses and management options
• Amount and complexity of data
• Risk of significant complications, morbidity and/or
mortality
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KEY TO MEDICAL DECISION MAKING
• Documentation is Key
• Complete, clear, succinct and legible medical
records, supporting the medical necessity for the
service performed.
• Medical observational information logically presented
• All problems directly addressed in the encounter
should be used to determine the level of decision
making
• Documented initiation of, or changes in, treatment
• MDM level billed depends on the status of the patient
and/or the services performed by the provider
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GENERAL PRINCIPLES OF MDM
• Medical decision making is generally easier for an
already diagnosed problem than for an
undiagnosed one.
• In addition, problems which are improving or
resolving are less complex than those which are
worsening or failing to change.
• Keep in mind that MDM should reflect the nature of
the presenting problem
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MAJOR POINT
• Beyond its clinical value, good documentation is a good
business practice, and ICD-10 allows better documentation of
patient complexity and level of care.
• Patient complexity, physician cognitive and physical work
performed and standards of care
• Integral and fundamental to the business of the practice of
medicine
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COMMON THEME
• “Sign & Symptoms” Vs. “Diagnoses”
• Clinical Specificity vs Generic
• Culmination of Work Performed
• Clinical specificity and demonstrated relevance of
diagnoses to medical decision making and presenting
problem
• Generic terms misrepresent amount of work performed and
complexity of the patient management
• Clinical Specificity Requirement
• Not optional
• Necessity today and October 1, 2015
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SPEAKING OF SPECIFICITY
• ICD-10
• Enhanced specificity in diagnoses selection
• Opportunity to report cause and effect relationship in
diagnoses
• Laterality of disease processes
• 5 Character ICD-9 code vs. Up to 7 alphanumeric characters
under ICD-10
• Recording and Reporting of your clinical judgment, medical decision
making and problem solving ability through effective documentation
of encompassing, disease specific diagnoses that describe the true
acuity and complexity of the patient assessment and plan of care is
• Good Medicine reflective of the quality of
care provided
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CLINICAL SPECIFICITY (TODAY AND
TOMORROW)
• Laterality (Left, Right, Bilateral)
• Examples:
• C50.511 – Malignant neoplasm of lower-outer quadrant of
right female breast;
• H16.013 – Central corneal ulcer, bilateral; and
• L89.012 – Pressure ulcer of right elbow, stage II
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CLINICAL SPECIFICITY (TODAY AND
TOMORROW)
• Combination Codes For Certain Conditions and Common
Associated Symptoms and Manifestations
• Examples:
• K57.21 – Diverticulitis of large intestine with perforation and
abscess with bleeding;
• E11.341 – Type 2 diabetes mellitus with severe
nonproliferative diabetic retinopathy with macular edema;
and
• I25.110 – Atherosclerotic heart disease of native coronary
artery with unstable angina pectoris.
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CLINICAL SPECIFICITY (TODAY AND
TOMORROW)
• Combination Codes for Poisonings and Their Associated External
Cause
• Example:
• T42.3x2S – Poisoning by barbiturates, intentional self-harm, sequela.
• Obstetric Codes Identify Trimester Instead of Episode of Care
• Example:
• O26.02 – Excessive weight gain in pregnancy, second trimester.
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CLINICAL SPECIFICITY (TODAY AND
TOMORROW)
• Inclusion of Clinical Concepts That Do Not Exist in ICD-9-CM
(For Example, Underdosing, Blood Type, Blood Alcohol Level)
• Examples:
• T45.526D – Underdosing of antithrombotic drugs,
subsequent encounter;
• Z67.40 – Type O blood, Rh positive; and
• Y90.6 – Blood alcohol level of 120 – 199 mg/100 ml.
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CLINICAL SPECIFICITY (TODAY AND
TOMORROW)
• A Number of Codes Are Significantly Expanded (For Example,
Injuries, Diabetes, Substance Abuse, Postoperative
Complications)
• Examples:
• E10.610 – Type 1 diabetes mellitus with diabetic neuropathic
arthropathy;
• F10.182 – Alcohol abuse with alcohol-induced sleep disorder; and
• T82.02xA – Displacement of heart valve prosthesis, initial
encounter.
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CLINICAL SPECIFICITY (TODAY AND
TOMORROW)
• Codes for Postoperative Complications Are Expanded and a
Distinction is Made Between Intraoperative Complications and
Postprocedural Disorders
• Examples:
• D78.01 – Intraoperative hemorrhage and hematoma of spleen
complicating a procedure on the spleen; and
• D78.21 – Postprocedural hemorrhage and hematoma of spleen
following a procedure on the spleen.
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OTHER CHANGES
• Laterality is a component of relevant codes
• Expanded use of combination codes
• Injuries are grouped by anatomical site rather than by the
type of injury
• Specificity is greatly expanded
• More clinical concepts
• Timelines and episode of care is defined for relevant codes
• Modern medicine and today’s terms are utilized
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OTHER CHANGES
• Borderline clinical conditions
• Diabetes- R73.09
• Hypertension-R03.0
• Osteopenia- M85.8
• Pelvis, with obstruction during labor- O65.1
• Personality-F60.3
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OTHER CHANGES
• DM – New language regarding uncontrolled
• CD-10 diabetes codes are no longer classified as controlled
or uncontrolled Index now tells us that inadequately
controlled, out of control, and poorly controlled are coded
to Diabetes, by Type, with hyperglycemia
• Diabetes with Hypoglycemia will be part of each DM type
• E.08 -Diabetes mellitus due to underlying condition
• Code first the underlying condition such as:
• Congenital rubella (P35.0)
Malnutrition (E40-E46)
• Cushing’s syndrome (E24.-)
Pancreatitis and other
• Cystic fibrosis (E84.-)
diseases of the pancreas (K85Malignant neoplasm (C00-C96)
K86)
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INCREASED USE OF COMBINATION
CODES
ICD-9
ICD-10
• Steroid induced DM with
diabetic peripheral angiopathy
with gangrene of right calf, DM
uncontrolled
• 249.71 Secondary DM
uncontrolled
• 443.81 Peripheral angiopathy
• 785.4 Gangrene
• E932.0 Adverse effect of steroid
• Steroid induced DM with
diabetic peripheral angiopathy
with gangrene of right calf, DM
uncontrolled
• T38.0x5D – Adverse effect of
steroid subsequent encounter
• E09.52 - Secondary DM with
peripheral angiopathy with
gangrene
REST EASY
• Complete, clinically accurate, relevant information
in the chart best strategy to meet challenges and
take advantage of ICD1-10 opportunities
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DON’T PANIC
• F41.0- Panic Attack
• F43.0- Panic reaction to exceptional stress
• I10- Essential (primary) hypertension
• (arterial, benign, essential, accelerated, malignant, primary,
systemic)
• Use additional code to identify:
• Exposure to environmental tobacco smoke (Z77.22)
• History of tobacco use (Z87.891)
• Occupational exposure to environmental tobacco smoke (
Z57.31)
• Tobacco dependence (F17.-)
• Tobacco use (Z72.0)
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NONCOMPLIANCE
• Noncompliance Z91.19
• With
• dietary regimen Z91.11
• Dialysis Z91.15
• Medical treatment Z91.19
• Medication regimen Z91.14
• Underdosing Z91.14
• Intentional NEC Z91.128
• Due to financial hardship of patient Z91.120
• Unintentional NEC Z91.138
• Due to patient’s age related debility Z91.130
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AMI CHANGES
• AMI changes
• AMI equal to or less than four weeks (28 days) including
transfers to other acute settings is coded to I21
• I22 (subsequent MI) is coded when a patient had a previous
MI and has a new MI within the 4 week time frame from the
initial MI
• –I22 will never be reported without I21
• –Sequencing will depend on the circumstance of the
encounter
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AMI DETAIL
• Specific artery can be captured
• Left Main
• Left Anterior Descending
• Other Anterior wall artery
• Right coronary artery
• Other Inferior wall artery
• Left circumflex
• Other and unspecified site
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ASTHMA SPECIFICITY
• Asthma now classified by WAO frequency
indicators
• Greater Detail within our respiratory distress options
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ASTHMA DOCUMENTATION
EXPECTATIONS
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FRACTURES HAVE FURTHER 7TH
CHARACTER EXTENSIONS
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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
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INJURY DESIGNATION
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Initial
Injury is actively treated
Surgical treatment
ED encounter
Evaluation by new physician
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Subsequent
Used after active treatment
Now receiving only routine care for the injury
Usually in healing or recovery phase
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INJURY DESIGNATION
• Initial - A
• Any new Fx
• Fx now requiring surgery
• Fx now requiring manipulation
• Fx now requiring consult by ortho MD
• Delayed treatment for fx or non-union
• Subsequent - D
• Cast change or removal
• Removal of IF/EF device
• Follow-up (ancillary) x-rays
• Rehab (PT/OT)
• Swing Bed encounters for healing fx/injury
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RESPIRATORY FAILURE
ICD-9
• 518.81- Acute
respiratory failure
• 518.83- Chronic
respiratory failure
• 518.84- Acute-onChronic respiratory
failure
ICD-10
• J96.00- Acute
respiratory failure
• J96.02- ARF with
hypercapnia
• J96.01- ARF with
hypoxia
RESPIRATORY FAILURE
• J96.20- Acute-on-Chronic Respiratory Failure
• With Hypercapnia- J96.22
• With Hypoxia- J96.21
• J96.10- Chronic Respiratory Failure
• With Hypercapnia- J96.12
• With Hypoxia- J96.11
OVERALL STRATEGIES TO MEET ICD10 GOALS
• Focus upon accurate and effective capture of clinical
thoughts, judgments, medical decision making and thought
processes
• Capitalize and seize upon the opportunity to support your
medical decision making with clinically specific diagnoses
• Avoid non-specific diagnostic terms
• Don’t fret over the coding rules and coding conventions
• Focus upon accurate reporting of patient acuity and clinical
severity reflective of severity of illness, risk of morbidity/mortality
supportive of physician work performed
• Good Luck!
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FINAL THOUGHTS
• ICD-10 and clinical specificity
• Billing accuracy
• Quality measures
• Population management
• Risk Management
• Health care analytics
• PQRS
• Patient Care
• Inadequate clinical documentation→ Inaccurate coding→
Increased denials
• Identify common clinical diagnosis codes in your practice
• Focus upon and correct deficiencies relative to ICD-10
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FINAL THOUGHTS…..
• Sound business principles and practices
• Effective and complete clinical documentation reflective of
good patient data
• Observation of all facts relevant to patient condition
• Translate into documentation of medical concepts relevant to
current and future patient care
• Medical concepts related to ICD-10 not new to clinical practice
• Beyond its clinical value, good documentation is a good
business practice, and ICD-10 allows better documentation
of patient complexity and level of care.
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CONTACT INFORMATION
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Glenn Krauss
[email protected]
(603) 303-3337
Thanks for attending
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APPENDIX A-
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FIVE STEP ICD-10 IMPLEMENTATION
PROCESS
• Make a Transition Plan
• Determine where diagnosis codes are used in your practice
• Identify who on your staff will help with the ICD-10 transition
• Prepare a budget
• Train Your Staff
• Training needs will vary among practices and individuals
• Some practices may want to obtain an ICD-10 code book or
software for staff to try before deciding whether more training is
necessary
• Update Your Processes
• Confirm that good clinical documentation processes are in place
• Revise paper forms/templates
• Modify policies and procedures
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FIVE STEP ICD-10 IMPLEMENTATION
PROCESS
• Talk to Your Vendors and Payers
• Contact your clearinghouses, EHR and practice
management system vendors, billing services, and other
vendors
• Test Your Systems and Processes
• Perform internal testing of systems and work flow processes
using ICD-10 diagnosis codes
• Conduct external testing with vendors and payers using
data that contain ICD-10 diagnosis codes
• Practice coding in ICD-10 and validate supporting clinical
documentation
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