Real World Experiences with ICD-10:Trips, Traps, and Shifts

Jzanus Consulting Inc. 1

Eva M. Gregorek, RHIT, CCSSenior Consultant

AHIMA Approved ICD-10-CM/PCS TrainerJzanus Consulting, Inc

• Overview of ICD-10 Shift• Examples• Tools

ICD-10 Shift Project

DRG Shift Project

• A DRG change due to ICD-10-CM/PCS implementation

• Findings are used to evaluate– Financial/case mix impact– Coding education need– Physician documentation gaps

• Coders will experience this when doing dual coding

My Reaction to the First ICD-10 Shift Project

Day Two

Day Three

Eventually

DRG Shifts

• Identify why the shift happened– Procedure mapping– Diagnosis mapping– PCS change– Coding Guideline Change– Incorrect ICD-9 DRG • Not really a shift

DRG ShiftExamples

ICD-9 Decompressive Laminectomy

• Spinal Fusion

ICD-10 Decompressive Laminectomy

ICD-10 Spinal Decompression Guidance• Spinal Decompression

• Coding Clinic, Fourth Quarter 2013 Page: 116• New codes contained in this issue effective with discharges October1, 2013. Other coding advice or

code assignments contained in this issue effective with discharges October 21, 2013.

• Question:

• What is the appropriate code assignment for a spinal decompression?

• Answer:

• Spinal decompression is the removal of pressure from the spinal cord. Assign a code for the surgery that is performed to relieve the pressure. For example, if a laminectomy is performed to remove pressure from the spinal cord, assign a code from table 0QB or 0PB based on the Index to Procedures:

• Laminectomy• see Excision, Lower Bones 0QB-• see Excision, Upper Bones 0PB-

ICD-9 Embolization

ICD-10 Embolization

ICD-9 Embolization

ICD-10 Embolization

Spinal Tap ICD-9

Spinal Tap – ICD-10

Placement of Central Venous Catheter– ICD-9

Isolation –ICD-9

Isolation –ICD-10

Opioid Dependence –ICD-9

Drainage of Retroperitoneal abscess–ICD-9

Planning a Positive ICD-10 Experience

• You might need a bigger boat

Education/Development• ICD-10-CM/PCS training program

– Include payment methodology

• Dual Coding/Review– Peer review– Independent review

• Coding Roundtable– Group discussion about specific cases– Document decisions– Recognize that initial decisions may change– Send questions to Coding Clinic

Education/Development

• Identify opportunities from shift analysis• Invite physicians to any/all of your educational

activities.– The usual suspects in physician documentation• Laterality• Site• Depth of debridement• Specificity in general

Cerebral Infarction

• ICD-9-CM

• Etiology: – Embolism – Thrombosis – Unspecified

occlusion/stenosis

• ICD-10-CM

• Etiology: Same as ICD-9-CM – Embolism – Thrombosis – Unspecified occlusion/stenosis

• Site: – Cerebral artery – Anterior – Middle – Posterior – Cerebellar – Other specified cerebral artery – Unspecified cerebral artery

• Laterality– Right – Left – Bilateral

AsthmaICD-9-CM

Forms – Chronic obstructive – Cough variant – Exercise induced bronchospasm – Extrinsic – Intrinsic – Unspecified

Complications – Acute exacerbation – Status asthmaticus – Unspecified

ICD-10-CM

Forms – Cough variant – Exercise induced bronchospasm – Extrinsic allergic – Idiosyncratic – Intrinsic nonallergic – Other – Unspecified

Severity – Mild intermittent – Mild persistent – Moderate persistent – Severe persistent – Complications – Acute exacerbation – Status asthmaticus – Uncomplicated

Best Effort

Dual Coding Review Non Punitive Feedback/Education/Roundtable

Research/Document Decisions/Follow-up

Research

• It is important to dig in with research. • Attend meetings• Network• Use resources– Coding Clinic– Regulatory– Professional Associations

Example

• Removal of polydactyl• Multiple opinions– Detachment– Repair– Resection– Excision

• Posted question on professional websites including AHIMA Engage Online Community

• Sent to Coding Clinic

Follow-up• DRG shift was identified for a total hip revision that involved ICD-10-PCS codes

0SR9049

• Grouped to MS-DRG 464 - wound debridement and skin graft exc hand, for musculoskeletal connective tissue disease with CC.

• MS-DRG 467 - revision of hip or knee replacement with CC as did the other PCS codes for hip replacement seemed more appropriate

• Checked with various encoders and it to be appeared to be global in nature. Contacted Center for Medicaid and Medicare Services (CMS) ICD-10 Coordination Committee. Informed that it would be included on the next ICD-10 Coordination Committee agenda.

• It wasn’t

Coder responsibilities

• Identify how many hats coders are wearing.– Deficiency Analysis– Filing– Registry– Birth certificates– Charges/billing– Phone duty

• Validate and take action.– Delegate to other staff

or department– Eliminate the issue

Identification without validation or action

Just because!

A well balanced 2 hat coder

Other helpful hints

• Ancillary procedure coding– What needs to be coded– Why is it being coded– Who is using the data

• Work setting

Other helpful hints

• Queries–Develop or convert templates– http://journal.ahima.org/2013/02/01/physician-

query-examples/

• Tools– Encoder– Publications

So you need a bigger boat

• Temporary vs permanent staff

• Consultants

• Mentor new professionals

• Be creative

Resources

• www.ahima.org• www.munsonhealthcare.org/icd10/tips• www.cms.gov

Thank you

• Contact information– Phone 518-649-2151– Email – egregorek@jzanus.com

Real World Experiences with ICD-10:Trips, Traps, and Shifts

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