6/17/2013 Mastering ICD-10 Chart Reviews€¦ · Mastering ICD-10 Chart Reviews Barbara Oviatt,...
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6/17/2013 1 Mastering ICD-10 Chart Reviews Barbara Oviatt, CPC, CCS-P Purpose Learn how to conduct a practice specific chart analysis and develop an ICD-10 documentation improvement program. Course Objectives • Successfully evaluate the documentation impact of ICD-10 • Develop a chart review strategy • Develop strategies for implementing ICD-10 documentation education
Transcript of 6/17/2013 Mastering ICD-10 Chart Reviews€¦ · Mastering ICD-10 Chart Reviews Barbara Oviatt,...
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Mastering ICD-10 Chart Reviews
Barbara Oviatt, CPC, CCS-P
Purpose
Learn how to conduct a practice specific chart analysis and
develop an ICD-10 documentation improvement
program.
Course Objectives
• Successfully evaluate the documentation impact of ICD-10
• Develop a chart review strategy
• Develop strategies for implementing ICD-10 documentation education
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Oct. 1, 2014
Documentation is the Cornerstone
Documentation • Continuity of Care
• Basis for code assignment
Coding • Based on documentation
• Directly affects cash flow
Reimbur$ement • Paid or delayed?
Coding Challenges
• Insufficient documentation leads to
– Unspecified code selection
– Services viewed as not medically necessary
– Inaccurate reporting
– Incorrect code assignment
– Irritating discussions between providers, coders and billers
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Documentation Awareness
• Documentation awareness among clinical providers should start now
• Documentation is the cornerstone for ICD-10 Transition success
• Accurate documentation is the primary responsibility physicians and other clinical providers have in the move to ICD-10
• Focus on documentation elements and not the overwhelming number of new codes
Chart Reviews
Chart Review Process
• Establish review team members
• Identify goals and objectives
• Determine the sample
• Conduct the chart review
• Educate
• Re-review
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Chart Review Process
• Establish review team members
– Include at least one provider
– Include at least one person with strong coding skills
– Develop at least one ICD-10 expert immediately
Chart Review Process
• Identify goals and objectives
– Define the project scope
• Diagnosis coding
• CPT
• HCPCS
• Quality
Chart Review Process
• Determine the sample • Frequently reported ICD-9 codes
• Identify top 20 diagnosis – Generate code lists by specialty
– Analyze and adjust the list as needed
• Establish sample size – Include all providers who code or whose
documentation is the basis for code assignment
– Number of codes per provider
– Number of charts per code / provider
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Analyze Your Top 20
• Identify the top 20 codes for each specialty and / or provider
• Review the GEMs mapping for each code
– Review the additional codes in the category
– Note the necessary documentation elements
– Note any pertinent coding guidelines
• Adjust code selections as necessary
What is GEMs?
• General Equivalency Mappings
• Attempts to find corresponding diagnosis codes between I-9 and I-10
• I-10 is more specific than I-9, so mapping is often to an unspecified I-10 code
• I-9 to I-10 mapping contains all I-9 codes, but only I-10 codes with plausible translations
• Approximate – indicates entry is/is not considered equivalent
• No Map – indicates that a source code is not linked to any target code
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• Combination – indicates more than one code in target system is required
• Scenario – using all combination codes from target system will satisfy equivalent meaning of source code
• Choice list – one or more target code must be chosen to satisfy equivalent meaning of source code
“Unspecified” may lead to “Unpaid”
“Physicians may be ICD-10 compliant, but if they abuse the “other” or “unspecified” codes, payment will not occur if a more specific alternative exists.” David Winkler - Director of Technical Program Management
BCBS Michigan
Justifying medically necessary procedures and services depends on specificity of
diagnoses coding!
Conduct the Chart Review
• Assess the documentation
– Potential ICD-10 code assignment
– Note strengths and weaknesses
– Identify educational needs
– Identify process issues
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My Practice Top 20 List
1. Asthma, unspecified - 493.90
2. Hypertension, unspecified - 401.9
3. Diabetes - 250.52
4. Ankle sprain – 845.00
5. Attention deficit disorder with hyperactivity – 314.01
6. Acute Myocardial Infarction, unspecified site – 410.90
Asthma
GEMs Map:
C A T E G O R Y S E A R C H
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Asthma
ICD-9-CM = 493.90 • Extrinsic vs. intrinsic • Chronic obstructive asthma • With status asthmaticus • With exacerbation • Exercise induced
bronchospasm • Cough variant asthma
Additional documentation required
ICD-10-CM = J45.909 • Mild intermittent • Mild persistent • Moderate persistent • Severe persistent • With status asthmaticus • With exacerbation • Exercise induced
bronchospasm • Cough variant asthma • Tobacco use or exposure
(additional code required) Notes: • Excludes chronic obstructive
asthma
Exposure to Tobacco Smoke
• Z77.22 Contact with and exposure to environmental tobacco smoke
• Z57.31 Occupational exposure to environmental tobacco smoke
• P96.81 Exposure to tobacco smoke in perinatal period
Other Tobacco Use Codes
• F17.xxx Nicotine Dependence
• O99.33- Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium
• Z72.0 Tobacco Use (non-dependent)
• Z87.891 History of Tobacco Use
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N I C O T I N E
D E P E N D E N C E
Tobacco Use & Nicotine Dependence
Reference ICD-9-CM = 305.1
• Current smoker
Additional documentation required
ICD-10-CM = F17 • Terminology change to
Nicotine dependence
• Type of nicotine (cigarette, chewing tobacco, other)
• Remission
• Withdrawal
• Uncomplicated
• Other nicotine-induced disorder
• Z87.891 for History of nicotine dependence
• Z72.0 Tobacco Use (non-dependent)
Chart Review – Asthma SUBJECTIVE: This is a 42-year-old white female who comes in today for a follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily but continues to work as a bartender and is exposed to cigarette smoke on a daily basis. ASSESSMENT/PLAN: 1. Intrinsic asthma. Seems to be worse than in the past. She is just using her Proventil inhaler but is using it daily. We will add Flovent 44 mcg two puffs p.o. b.i.d. May need to increase the dose. She is to call me if she is not improving. Advised her that her job is likely contributing to her condition and seeking employment without exposure to tobacco smoke is advisable. We will plan on following up for reevaluation in one month.
ICD-9 Code(s) Assigned: 493.10
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Chart Review Asthma
Hypertension
Gems mappings:
C A T E G O R Y S E A R C H
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Hypertension
Gems mappings:
PARTIAL CATEGORY SEARCH - I1
Hypertension
ICD-9: 401.X – 404.x • Benign
• Malignant
• Hypertensive heart disease
• Hypertensive CKD
• Hypertensive heart and CKD
• Secondary hypertension
– Renovascular
• Indicate as appropriate
– With / without heart failure
– Type of heart failure
– Stage of CKD
Additional documentation required
ICD-10: I10 – I15.x • Essential (without comorbidities)
• Comorbidities Present
– Hypertensive heart disease
– Hypertensive CKD
– Hypertensive heart and CKD
– Secondary hypertension
• Renovascular, endocrine
• Underlying condition
– Indicate as appropriate
• With / without heart failure
• Type of heart failure
• Stage of CKD
• History of use, current use of, or exposure to tobacco
• Distinguish between hypertension and high blood pressure without diagnosis of HTN (coded with R03.0)
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Diabetes
• GEMs Mappings
C A T E G O R Y S E A R C H
Diabetes ICD-9-CM = Category 250 • Type 1 or Type 2 • Secondary • Hyperosmolarity • Ketoacidosis • Neurological manifestation • Coma • Ophthalmic manifestation • Peripheral circulatory disorder • Renal manifestations
Additional documentation required
ICD-10-CM = Categories E8 - E11
• Type 1 or Type 2 • Due to underlying condition • Drug or chemical induced • Ketoacidosis
– With/without coma • Kidney complications
– Diabetic nephropathy – Chronic kidney disease
• Neurological complications – Amyotrophy – Autonomic (poly) neuropathy
– Mononeuropathy – Polyneuropathy
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Diabetes, Continued ICD-10-CM = Category E10
• Ophthalmic complications – Diabetic Retinopathy
• Nonproliferative – Mild/Moderate/Severe – W/wo Macular Edema
• Proliferative – W/wo Macular Edema
– Diabetic Cataract
• Peripheral angiopathy – W/WO gangrene
• Neuropathic arthropathy • Skin complication
– Dermatitis – Foot ulcer
• Periodontal disease • Hypoglycemia w/wo coma * Long term insulin use – Z79.4
Chart Review – Diabetes Mellitus HPI: The patient is a 39-year-old woman returns for follow-up management of type 2 diabetes mellitus. She has diabetic retinopathy and is reporting blurred vision. Her last visit was approximately 4 months ago. She is not exercising, is working on a full-time basis, and has little time for physical activity; thus her glucometer readings range from 110 to 250.
A/P:
Diabetes mellitus not in good control. Instructed the patient to increase activity and provided sliding scale so she can adjust her insulin accordingly. She needs to see her ophthalmologist as soon as possible.
ICD-9 Assigned: 250.52 – Diabetes with ophthalmic manifestations
Chart Review Diabetes Mellitus
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Combination Codes
• There are many other new combination codes for conditions, common symptoms or manifestations
– E20.21 Type I diabetes mellitus with diabetic nephropathy
– I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
– K50.112 Crohn’s disease of large intestine with intestinal obstruction
Combination Codes
• Combination codes also report poisonings and external causes – T38.3x1A Poisoning by insulin, accidental
(unintentional), initial encounter
– T42.4x5A Adverse effect of benzodiazepines, initial encounter
5th digit is a place holder 6th digit indicates external cause 7th digit indicates episode of care
Placeholder Character
• Placeholder is always the letter “x”
• Used as the 5th character for certain 6 character codes to provide future expansion
• When a code has <6 characters and a 7th character extension is needed – “x” is assigned for all characters less than 7 to meet the number of characters need to add the 7th character extension
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Poisoning, Adverse Effect, and Underdosing of Insulin
Poisoning, Adverse Effect, Underdosing ICD-9-CM = 960-979 & E-Codes
• Accidental • Therapeutic • Suicide • Assault
Additional documentation required
ICD-10-CM = T Codes
• Cause of poisoning and manifestation(s)
– Accidental
– Intentional Self Harm
– Assault
– Undetermined
• Cause of adverse effect and manifestation(s)
• Underdosing
– Failure in dosing during medical / surgical care
– Patient’s underdosing of medication regime
• Episode of care
Episode of Care
• Episode of care is associated with various injuries throughout ICD-10
– M80.08A Age related osteoporosis with current pathological fracture, vertebra(e), initial encounter
– S61.421D Laceration with foreign body of right hand, subsequent encounter
– T21.31xS Burn of third degree of chest, sequela
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Episode of Care Definitions
• Initial encounter
– First visit to provider
• Subsequent encounter
– Under active treatment
• Sequela
– Not under active treatment for acute condition
– New name for Late Effects, same rules
– No time limit
W56.02XA Struck by a Dolphin, Initial Encounter
W56.02XD Struck by a Dolphin, Subsequent Encounter
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W56.02XS Struck by a Dolphin, Sequela with F32.8 Depressive Episode
Ankle Sprain
GEMs map:
C A T E G O R Y S E A R C H
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Sprain of Ankle
ICD-9-CM = 845.00 – 845.09
• Sprain – Deltoid ligament – Calcaneofibular
ligament – Tibiofibular ligament – Other
Additional documentation required
ICD-10-CM = J45.909 • Ligament sprained
– Deltoid ligament – Calcaneofibular ligament – Tibiofibular ligament – Other ligament
• Laterality • Episode of Care • External cause of injury
Injuries are Reorganized • Injuries classified by site and then by
injury:
Ankle and Foot • Ankle • Foot • Toes
Injury Type • Superficial Injury • Open wound • Fracture • Dislocation/Sprain • Nerve injury • Blood vessel injury • Muscle injury • Traumatic amputation
Laterality
• Codes reflect laterality when appropriate:
– H60.332 Swimmer’s ear, left ear
– S63.411A Sprain of carpal joint of right wrist, initial encounter
– H65.06 Acute serous otitis media, recurrent, bilateral
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Coding Rules for Laterality
• Use a bilateral code if available
• Assign separate unilateral codes for a bilateral condition when no bilateral code is available
Chart Review - Ankle Sprain
This 35 year old white male presents after being tackled from behind while playing football this afternoon. He felt extreme pain in his right ankle when attempting to get up. The right ankle is swollen and tender to the touch. X-ray reveals no fracture.
Diagnosis: Ankle sprain
ICD-10 code assigned: 845.00
Chart Review – Ankle Sprain
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Attention Deficit Disorder • GEMs map:
Category Search
Attention Deficit Disorder ICD-9-CM = Category 314
• With/without
hyperactivity
Additional documentation required
ICD-10-CM = Category F90
• Predominantly
hyperactive • Predominantly
inattentive • Combined type • Use additional code for
developmental delay • Use additional code for
conduct disorder
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Chart Review - ADHD Subjective: This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.
Diagnosis: Attention deficit hyperactivity disorder
ICD-9 Code Assigned: 314.01
Chart Review - ADHD
Acute MI, Site Unspecified
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Category Search
Acute MI ICD-9-CM = 410.xx • Site of MI
– Wall (ST elevation) – Subendocardial (Non-ST)
• Episode of care – Subsequent <8 weeks
• Current complications • Presence of hypertension
Additional documentation required
ICD-10-CM = I21.x • Episode of care
– Initial - all care ≤ 28 days – Subsequent – new,
unrelated MI during the first 28 days of a previous MI
• Type of MI – STEMI
• Specify wall and artery
– Non STEMI • Current complications • History of use, current use
of, or exposure to tobacco • BMI
Chart Review - Acute MI
Patient presents with crescendo angina with rapid progression of his symptoms without stabilization. All efforts to avert the pending MI failed.
Diagnosis: Acute MI, initial episode
ICD-9 Code Assigned: 410.90
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Chart Review – Acute MI
Chart Review Follow Up • Educate
– Deliver positive feedback to providers
• Use effective methodology
– Lunch and learn meetings
– Contests
– Flashcards
– Diagnosis of the week campaign
• Address needs
– Template revisions
Chart Review Follow Up
• Monitor on established timeline
– Re-review for improvement
– Re-educate as necessary
– Evaluate effectiveness of strategy
• Repeat
– Select the next code or re-review
– Educate
– Address needs
– Monitor
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Evaluate the sample
Review the documentation
Analyze the results
Educate providers and
improve documentation
Re-review as necessary
Questions…
