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What Physicians Need To Know
• Claims for ambulatory and physician services provided on or after 10/1/2015 must use ICD-10-CM diagnosis codes.
• Hospital inpatient claims for discharges occurring on or after 10/1/2015 must use ICD-10-CM diagnosis codes.
• CPT Codes will continue to be used for physician inpatient and outpatient services and for hospital outpatient procedures.
• ICD-10-PCS – a NEW procedure coding classification system, must be used to code all inpatient procedures on Facility Claims for discharges on or after 10/1/15.
• ICD-9-CM codes must continue to be used for all dates of services on or before 9/30/2015.
• Further delays are not likely.
ICD-9 vs ICD-10 Diagnosis Codes
ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes
3 to 5 digits 7 digits
Alpha “E” & “V” – 1st Character Alpha or numeric for any character
No place holder characters Include place holder characters (“x”)
Terminology Similar
Index and Tabular Structure Similar
Coding Guidelines Somewhat similar
Approximately 14,000 codes Approximately 69,000 codes
Severity parameters limited Extensive severity parameters
Does not include laterality Common definition of laterality
Combination codes limited Combination codes common
Number of Codes by Clinical Area
Clinical Area ICD-9 Codes ICD-10 Codes
Fractures 747 17,099
Poisoning and Toxic Effects 244 4,662
Pregnancy Related Conditions 1,104 2,155
Brain Injury 292 574
Diabetes 69 239
Migraine 40 44
Bleeding Disorders 26 29
Mood Related Disorders 78 71
Hypertensive Disease 33 14
End Stage Renal Disease 11 5
Chronic Respiratory Failure 7 4
Right vs. left
accounts for nearly ½
the increase in the #
of codes.
The Importance of Good Documentation
• The role of the provider is to accurately and specifically document the nature of the patient’s condition and treatment.
• The role of the Clinical Documentation Specialist is to query the provider for clarification, ensuring the documentation accurately reflects the severity of illness and risk of mortality.
• The role of the coder is to ensure that coding is consistent with the documentation.
• Good documentation….• Supports proper payment and reduces denials• Assures accurate measures of quality and efficiency• Captures the level of risk and severity• Supports clinical research• Enhances communication with hospital and other providers• It’s just good care!
Inadequate vs. Adequate DocumentationExample 1: Dermatitis Related to Ingested Substances
Inadequate Documentation Required ICD-10 Documentation
Here for rash eval. On day 4 of antibiotic course for strep throat.
Woke up with maculopapular rash. Reports taking antibiotics this morning. Rash secondary to drug allergy.
Here for rash eval. On day 4 of Amoxicillin course for strep throat.
Woke up with generalized maculopapular rash. Reports taking antibiotics as prescribed. Rash secondary to PCN allergy.
Needed improvements:
Severity, cause, specific
ingested substance, and
encounter type.
Inadequate vs. Adequate Documentation Example 2: Asthma
Inadequate Documentation Required ICD-10 Documentation
Seven-year-old female with asthma presents to ER in resp distress. Tachycardic and tachypneic, audible in and out wheeze, O2 sat 63% on room air.
Mother reports home inhaler and nebulizers used but didn’t help.
Seven-year-old female with moderate, persistent asthma presents to ER in resp distress d/t status asthmaticus. Tachycardic and tachypneic, audible in and out wheeze, O2 sat 63% on room air.
Mother reports home inhaler and nebulizers used but didn’t help. Dad smokes near child.
Needed improvements:
Type, severity,
exacerbation(s),
complication(s), and
precipitating factor(s).
Inadequate Documentation Required ICD-10 Documentation
11-year-old child resents with sneezing, congestion, itchy, watery eyes, and a rash. Mother states symptoms started approximately one week prior.
Dx: Allergies
11-year-old child resents with sneezing, congestion, itchy, watery eyes, and a rash. Mother states symptoms started approximately one week prior.
Dx: Allergies due to pollen and animal dander with allergic eczema.
Inadequate vs. Adequate Documentation Example 3: Allergies
Needed improvements:
Type and associated
condition(s).
Inadequate Documentation Required ICD-10 Documentation
Three-year-old presents for follow-up visit after testing has confirmed abnormal IgM.
Three-year-old presents for follow-up visit after testing has confirmed X-linked immunodeficiency with hyper IgM.
Inadequate vs. Adequate Documentation Example 4: Immunodeficiencies
Needed improvements:
Type of Immunodeficiency.
Key Requirements for Documentation
• Document the causal agent of the allergy (e.g., pollen, animal dander, medication).
• Disease specificity and granularity (e.g., contact dermatitis due to a detergent)
• For food-induced allergies, include: - The type of current allergic reaction and any allergy history.
- Any dietary counseling or surveillance provided
• Detail asthma as intermittent or persistent and list the severity of persistent asthma as mild, moderate, or severe.
• Describe any exposure to tobacco smoke (e.g., environmental, prenatal, tobacco use).
• List any associated conditions (e.g., asthma, dermatitis)
With ICD-10, the need for specific and accurate documentation is increased significantly.
Using Sign/Symptom and Unspecified Codes
• Sign/symptom and “unspecified” codes have acceptable, even necessary, uses.
• If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs and/or symptoms in lieu of a definitive diagnosis.
• When sufficient clinical information is not known or available about a particular health condition, it is acceptable to report the appropriate “unspecified” code.
• It is inappropriate to select a SPECIFIC code that is not supported by the medical record documentation.
Training for Physicians
Dates Method Content
Nov 2014 – Jan 2015 Department Meetings
Introduction/Overview
Jan 2015 – Mar 2015 Web-based OverviewService Specific DocumentationFuture Order EntryDiagnosis Assistant
Mar 2015 – Jun 2015 Classroom Documenting for ICD10 using the Electronic Health Record
Jun 2015 – Sep 2015 Web-based OverviewDocumenting Operative and Procedure Notes for ICD-10-PCS