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“Improving the Financial Health of the Practices we Serve.” Documentation Challenges of ICD-10-CM Orthopedic Documentation

Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

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Page 1: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

“Improving the Financial Health of the Practices we Serve.”

Documentation Challenges of ICD-10-CM

Orthopedic Documentation

Page 2: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Documentation

• Implementation date 10/01/2015

• ICD-10 tremendous impact in health care

• Biggest challenge?

DOCUMENTATION!

Page 3: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Documentation Parameters

Its important to remember that ICD-10 may not change the way you care for patients, it should change how you document that care.

The new documentation requirements for ICD-10 are examined and are all important in identifying the nature of the patients condition.

Page 4: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Documentation Concepts

These key medical concepts are information that should be documented and will be mandated when selecting a ICD-10 code.

Page 5: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Documentation Concepts

• Type • Location

• Severity • Laterality

• Episode • Anatomy

• Temporal Factors • Time Parameters

• Findings • Infectious Agent

• Manifestation • Remission Status

• Cause (External Causes) • Associated Conditions

• Associated with • Contributing Factors

• Agent • History Of

• Pregnancy Related

Page 6: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

So How Extensive Are the Concepts?

Example of Laterality:

Describes on what site of the body is involved.

If the injury happens on the right side, left side, bilaterally, or unilaterally then documentation should include that detail.

Page 7: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Parameters of Laterality

Postthrombotic syndrome without complications of the RIGHT lower extremity.

Page 8: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Parameters of Laterality

Postthrombotic syndrome without complications of the LEFT lower extremity.

Page 9: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Parameters of Laterality

Postthrombotic syndrome without complications of the BILATERAL lower extremity.

Page 10: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Parameters of Laterality

Postthrombotic syndrome without complications of the UNSPECIFIED lower extremity.

Note: Unspecified should never be used

Page 11: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Type

Torus Fracture

• Torus

• Colles’

• Smith’s

• Other extraarticular

• Barton’s

• Other intraarticular

• Other

Page 12: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Type + Laterality

Torus fracture, lower end of right radius,

• Right

• Left

• Unspecified

Page 13: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Episode

Initial vs. Subsequent vs. Sequela

This 7th character is based on the phase of the treatment. It has nothing to do with the new, established or consultation CPT code being used for that encounter. It also does not depend on the problem being a new one to the provider.

Page 14: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Episode

Initial vs. Subsequent vs. Sequela

ICD-10 Description Orthopedic Reality 7th Character

Initial Encounter Active treatment A

Subsequent Encounter Routine healing/Follow-up care D

Sequela Cause of current Injury/illness S

Page 15: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Laterality + Type + Episode

Initial visit and Tx of torus fracture, lower end of right radius fracture. (healing mechanism)

• Initial = Active Tx for the condition.

• Subsequent

• Sequela

Page 16: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Laterality + Type + Episode

Follow-up (established patient) visit and closed reduction of torus fracture, lower end of right

radius fracture. (healing mechanism?)

• Initial Encounter = Active Tx for the condition.

• Subsequent

• Sequela

Page 17: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Laterality + Type + Episode

Follow-up visit for torus fracture, lower end of right radius fracture, with proper alignment.

• Initial

• Subsequent Encounter = Routine healing of condition.

• Sequela

Page 18: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Laterality + Type + Episode

New patient consult for a torus fracture, lower end of right radius fracture, with proper alignment, pursuant to the ER reduction.

• Initial

• Subsequent Encounter = Routine healing of condition.

• Sequela

Page 19: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Laterality + Type + Episode

Initial visit for a healed torus fracture, lower end of right radius fracture with abnormal bone

growth.

• Initial

• Subsequent

• Sequela = Cause of current illness or injury.

Page 20: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Episode

Initial vs. Subsequent vs. Sequela

This 7th character is based on the phase of the treatment. It has nothing to do with the new, established or consultation CPT code being used. It also does not depend on the problem being a new one to the provider.

Page 21: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Episode, Cont.

Torus fracture, lower end of right radius, subsequent encounter for fracture, with nonunion

Subsequent

• Routine healing

• Delayed healing

• Nonunion

• Malunion

Page 22: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Laterality vs. Localization

The concepts of laterality and localization should not be confused with each other. In documentation terms these two concepts are separate and distinct from one another.

Laterality Localization

• Right • Medial

• Left • Lateral

• Bilateral • Proximal

• Unilateral • Distal

• Unspecified • Central

• Peripheral

Page 23: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Quick Breakdown

Open fracture of shaft of femur:

ICD-9-CM = 821.11

ICD-10-CM = Not enough information to assign a code.

Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC:

ICD-10-CM = S72.351C

Page 24: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

How Extensive is ICD-10-CM?

Femur Fracture:

ICD-9-CM = 16 total codes

ICD-10-CM = 1530+ total code combinations

Page 25: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Overview of Musculoskeletal Guidelines

Most of the ICD-10-CM codes within chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, designate site and laterality through the code range of M00 – M99.

Page 26: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Chapter Specific Guidelines of Musculoskeletal

Site and Laterality

The site represents the bone, joint, or muscle involved.

• For some conditions where more than one bone, joint, or muscle usually involved, such as osteoarthritis, there is a “multiple sites” code available.

• For categories where no multiple site code is provided and more than one bone, joint, or muscle is involved, multiple codes should be used to indicate the different sites involved.

Page 27: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Chapter Specific Guidelines of Musculoskeletal

Bone vs. Joint

The code is assigned to the bone, not the joint even though the documentation is indicating that the bone is affected and the upper or lower end.

Page 28: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Chapter Specific Guidelines of Musculoskeletal

Acute traumatic vs. chronic or recurrent musculoskeletal conditions Many musculoskeletal conditions are a result of a previous injury or trauma to a site, or are the result of a healed injury are usually found in chapter 13. • Recurrent bone, joint, or muscle conditions are also

usually found in chapter 13. Chronic or recurrent conditions should generally be coded with a code found in chapter 13.

• Any current, acute injury should be coded to the appropriate injury code from chapter 19.

Page 29: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Chapter Specific Guidelines of Musculoskeletal

Acute traumatic vs. chronic or recurrent musculoskeletal conditions cont.

Note: As the documenting physician, ensure that you provide adequate detail to decrease queries from coding staff later

Page 30: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

External Causes

Page 31: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

External Causes

Page 32: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

External Causes

Page 33: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

External Causes (Reality)

• Can be fun to review and think about the individuals who created them.

• Similar to the “E” type codes of ICD-9. • There is not a national or federal requirement

for mandatory reporting. • The only foreseeable reason for mandatory use

is a state program requirement or payer requirement.

• Voluntary usage to help provide for injury research and prevention.

Page 34: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Let’s Review In Detail..

Page 35: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Concepts to Consider for Proper Documentation

Overview of the following Orthopedic Conditions:

• Colles’ Fracture

• Joint Pain – Knee

• Pain in the Limbs

• Femur Fracture

• Hallux Valgus

• Tibia Fracture

Page 36: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Fracture Concept

Clinical Concepts to Consider:Type• Displaced• NondisplacedLocalization/Laterality • Right• Left• Unspecified

Episode• Initial = Active Tx Phase

– Closed– Open type I or II– Open type IIIA, IIIB, IIIC

• Subsequent = Routine Healing phase – Closed– Open type I or II– Open type IIIA, IIIIB, IIIC– Closed with routine healing– Open type I or II with routine healing– Open type IIIA, IIIB, IIIC with routine healing– Closed with delayed healing– Open type I or II with delayed healing– Open type IIIA, IIIB, IIIC with nonunion– Closed with malunion– Open type I or II with malunion– Open type IIIA, IIIB, IIC with malunion

• Sequela = Healed, but causing current condition

Page 37: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Colles’ Fracture

Case Example : Type, Localization/Laterality, Episode

Subjective: The patient is a 57-year-old right-hand-dominant female who fell 4 to 5 days ago and is continuing to have left wrist pain

Objective: X-rays show an impacted distal radius fracture with possible intraarticularcomponent and an associated ulnar styloid fracture

Assessment: Displaced impacted Colles fracture, left distal radius, and ulna

Page 38: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Colles’ Fracture

Answer: S52.532A Colles’ fracture of left radius, initial encounter for

closed fracture.

Page 39: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Joint Pain - Knee

Clinical Concepts to Consider:

Localization/Laterality

• Right

• Left

• Unspecified

Page 40: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Joint Pain - Knee

Case Example:

Subjective: The patient is a 55-year-old male who presents for left knee joint pain. Present for 5 months. Reports burning pain. Rated as 6/10 in severity right now.

Objective: EXAM: Wt Prior: 140 as of 11/16/06 Const: Appears healthy and well developed. Speech is appropriate. Head/Face: Normal on inspection. Facial strength normal. CV: Normal Extremities: No Cyanosis, edema or mottling. Musculo: Head/Neck: Insp/Palp: Head is erect. Symmetric. No hypertrophy. Spine: Insp/Palp: Spinal contour is normal. Incrased pelvic tilt. Stability: No obvious instability. Knees: Insp/Palp: left knee normal to inspection and palpitation. Right knee normal to inspection and palpation. Stability : No instability in the left. No instabilityty in the right. Normal muscle tone of the left knee. Normal muscle tone of the right knee. ROM: Left knee: full ROM. Right knee: full ROM. Skin: No rashes, lesions or ecchymosis.

Page 41: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Joint Pain - Knee

Answer: M25.562 pain in the left knee

Page 42: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Pain in the Limbs

Clinical Concepts to Consider:

Caused by/ Contributing Factors

• Trauma

• Neoplasm

• Post-operative

• Psychogenic

Localization/Laterality

• Left

• Right

Anatomy

• Lower– Foot

– Lower Leg

– Thigh

– Toe

• Upper– Axilla

– Finger

– Forearm

– Hand

– Upper Arm

Page 43: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Pain in LimbsCase Example:

Subjective: A 77-year-old female presents to the emergency department with mild discomfort in her right hand and left knee. Patient states that she struck her hand against something one week ago, near her right pinky knuckle (MCP). Since that time, her right index finger has become slightly red and swollen. She states that she also " banged" her left knee and has had some swelling and discomfort in the knee for the past 24 hours. She denies redness, heat of the left knee. She denies headache, fever, neck pain, chest pain, difficulty breathing, abdominal pain, nausea, vomiting, or diarrhea. She denies numbness, tingling, or weakness.

Page 44: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Pain in Limbs

Answer: M79.644 Pain in right finger(s)

M79.662 Pain in left lower leg

Page 45: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Femur Fracture

Clinical Concepts to Consider:Type• Displaced• Nondisplaced

Localization/Laterality• Trochaneteric

– Apophyseal– Greater– Intertrochanteric– Lesser

• Right• Left• Unspecified

Episode• Initial Encounter

– Closed– Open type I or II– Open type IIIA, IIIB, IIIC

• Subsequent– Closed– Open type I or II– Closed with routine healing– Open type I or II with routine healing– Open type IIIA, IIIB, IIIC with routine healing– Closed with delayed healing– Open type I or II with delayed healing– Open type IIIA, IIIB, IIIC with delayed healing– Closed with nonunion– Open type IIIA, IIIB, IIIC with nonunion– Closed with malunion– Open type IIIA, IIIB, IIC with malunion

• Sequela

Page 46: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Femur Fracture

Case Example:

Subjective: The patient is an 84-year-old man who fell onto his right hip.

Objective: An x-ray confirmed the patient sustained a closed basicervical intertrochanteric femur fracture of his right hip

Assessment: Closed basicervical/intertrochanteric femur fracture, right hip

Page 47: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Femur Fracture

Answer: S72.141A Displaced intertrochanteric fracture of right femur, initial encounter for closed

fracture

Page 48: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Tibia Fracture

Clinical Concepts to Consider: Type• Unspecified• Salter-Harris I• Salter-Harris II• Salter-Harris III• Salter-Harris IV• OtherLocalization/Laterality• Right• Left• Unspecified

Episode• Initial

– Closed– Open

• Subsequent– Routine healing– Delayed healing– Nonunion– Malunion

• Sequela

Page 49: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Tibia Fracture

Case Example:

Subjective: The patient is a 12-year-old male who has been injured while running down a hill today. He is having pain in his left ankle.

Objective: He is intact to sensation. Capillary refill of toes remains stable. No skin breakdown. AP and mortise view radiographs of left ankle were obtained and show a Salter-Harris II fracture of the distal tibia

Assessment: Left tibia fracture

Page 50: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Tibia Fracture

Answer: S89.122A Salter – Harris Type II physeal fracture of lower end of tibia, initial encounter for

closed fracture

Page 51: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Hallux Valgus

Clinical Concepts to Consider:

Localization/Laterality

• Unspecified

• Right

• Left

Page 52: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Hallux Valgus

Case Example:

Subjective: A 35 year old female patient comes in today for a bump on the side of her right foot. She also experiences aching pain and burning in her foot, especially when wearing high heels, which she wears 5 days a week.

Objective: On Examination, the patient has a bump on the side of the right foot near the big toe. The skin appears slightly red and a little swollen. X-ray was ordered and performed showing a deformity of the foot.

Assessment: Hallux Valgus

Page 53: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Hallux Valgus

Answer: M20.11 Hallux valgus (acquired), right foot.

Page 54: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Unspecified Codes

So what about using those unspecified codes?

Page 55: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Unspecified Code Warning

• Unspecified codes should only be used if specific information is unavailable about the diseases process.

• Goal: ensure medical record documentation is as comprehensive as possible

• More specificity = reduction in payment denials and claim delays for documentation requests.

Request clarification of documentation, update documentation vs. submission with unspecified codes.

Page 56: Documentation Challenges of ICD-10-CM Part 2 - COA · Documentation Parameters Its important to remember that ICD-10 may not change the way you care for patients, it should change

Resources

www.aapc.com

Orthopedic learning

www.cms.gov

Documentation to the new code set

There is very little good orthopedic specific content to be referenced.

http://www.aapc.com/
http://www.cms.gov/

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