UHS, Inc. ICD-10-CM/PCS Physician Education Orthopaedics

1. UHS, Inc. ICD-10-CM/PCS Physician Education Orthopaedics

2. ICD-10 Implementation • October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) • Ambulatory and physician services provided on or after 10/1/15 • Inpatient discharges occurring on or after 10/1/15 • ICD-10-CM (diagnoses) will be used by all providers in every health care setting • ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures • ICD-10-PCS will not be used on physician claims, even those for inpatient visits

3. Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and detail to support: • Accurate anatomical positions • Differentiation of risk & severity • Key parameters to differentiate disease manifestations

4. Diagnosis Code Structure

5. ICD-10-CM Diagnosis Code Format

6. Comparison: ICD-9 to ICD-10-CM

7. Procedure Code Structure

8. ICD-10-PCS Code Format

9. ICD-10 Changes Everything! • ICD-10 is a Business Function Change, not just another code set change. • ICD-10 Implementation will impact everyone: • Registration, Nurses, Managers, Lab, Clinical Areas, Billing, Physicians, and Coding • How is ICD-10 going to change what you do?

10. ICD-10-CM/PCS Documentation Tips

11. ICD-10 Provider Impact • Clinical documentation is the foundation of successful ICD-10 Implementation • Golden Rule of Documentation • If it isn’t documented by the physician, it didn’t happen • If it didn’t happen, it can’t be billed • The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient • what services were rendered and what is the severity of illness • The key word is SPECIFICITY • Granularity • Laterality • Complete and concise documentation allows for accurate coding and reimbursement

12. Gold Standard Documentation Practices • Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms • Document diagnoses, rather that descriptors • Indicate acuity/severity of all diagnoses • Link all diseases/diagnoses to their underlying cause • Indicate “suspected”, “possible”, or “likely” when treating a condition empirically • Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers • Clarify diagnoses that are present on admission • Clearly indicate what has been ruled out • Avoid the use of arrows and symbols • Clarify the significance of diagnostic tests

13. ICD-10 Provider Impact The 7 Key Documentation Elements: • Acuity – acute versus chronic • Site – be as specific as possible • Laterality – right, left, bilateral for paired organs and anatomic sites • Etiology – causative disease or contributory drug, chemical, or non-medicinal substance • Manifestations – any other associated conditions • External Cause of Injury – circumstances of the injury or accident and the place of occurrence • Signs & Symptoms – clarify if related to a specific condition or disease process

14. ICD-10 Documentation Tips Do not use symbols to indicate a disease. For example “↑lipids” means that a laboratory result indicates the lipids are elevated • or “↑BP” means that a blood pressure reading is high These are not the same as hyperlipidemia or hypertension

15. ICD-10 Documentation Tips Site and Laterality – right versus left • bilateral body parts or paired organs Example – cellulitis of right upper arm Stage of disease – acute vs. chronic vs. acute on chronic Example – stage of pressure ulcer: • L89.011 Pressure ulcer of right elbow, stage 1 • L89.021 Pressure ulcer of left elbow, stage 1 Episode of care – initial, subsequent, and sequelae Example - lower leg fracture: • A initial encounter for closed fracture • B initial encounter for open fracture type I or II • C initial encounter for open fracture type IIIA, IIIB, or IIIC • D subsequent encounter for closed fracture with routine healing • H subsequent encounter for open fracture type I or II with delayed healing • K subsequent encounter for closed fracture with nonunion • S sequelae

16. ICD-10 Documentation Tips Fractures – clearly document all aspects • Cause– traumatic, stress, pathological • Location – which bone, where on the bone, laterality • Type– compound, delayed, union, depressed, elevated, greenstick, impacted, oblique, etc. • If open – use Gustilo classification • Displacement – displaced or non-displaced • Encounter– initial, subsequent, sequelae • Healing process – routine aftercare, delayed, nonunion, malunion • External cause – how the fractured occurred and the activity • Example - Fall while skiing

17. ICD-10 Documentation Tips Open fractures - Please specify the severity using the Gustilo-Anderson Open Fracture Classification system for forearm, femur, and lower leg • Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (i.e., inside-out injury). • Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect. This is also a low-energy injury. • Type III: The wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation. • Type III fractures are further divided into • III A: Soft tissue coverage of the fractured bone is adequate. • III B: Disruption of the soft tissue is extensive, that local or distant flap coverage is necessary. • III C: Any open fracture that is associated with an arterial injury that a physician must repair, regardless of the degree of soft tissue injury.

18. ICD-10 Documentation Tips Pathologic (non-traumatic) fractures: • Exact location of fracture – • Bone, part of the bone, and laterality • Etiology of the fracture – • osteoporosis, neoplastic disease,drug induced • Encounter type – • initial encounter, subsequent encounter with routine healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae • Healing status – • Routine, delayed, nonunion, malunion • Any past history of healed pathological fractures

19. ICD-10 Documentation Tips Arthropathies • Type • Traumatic • Infectious – document specific organism • Site – include laterality (right, left, bilateral) • Link underlying or associated conditions • Bone changes related to DM • Examples: • Traumatic arthropathy, left shoulder • Arthropathy following intestinal bypass, left shoulder

20. ICD-10 Documentation Tips Bursa Disorders • Type • Bursitis • Bursopathy • Abscess of bursa • Infective bursitis • Synovial cyst • Bursal cyst • Calcium deposit • Site – bursa affected and laterality (right, left, bilateral) • Link underlying or associated conditions • Activity causing the disorder • Related to use, overuse, pressure, post-procedural complication • Rupture of synovial or bursa cyst

21. ICD-10 Documentation Tips Osteomyelitis • Site – include laterality (right, left, bilateral) • Severity / Type • Acute, chronic, subacute • Hematogenous • Link underlying or associated conditions • Multifocal osteomyelitis • With or without draining sinus • Chronic hematogenous • Major osseous defect • Document if any associated injury is current or old

22. ICD-10 Documentation Tips Osteoarthritis • Site – joint affected • include laterality (right, left, bilateral) • Severity / Type • Acute, chronic, subacute • Hematogenous • Link underlying or associated conditions • Presence or absence of hip dysplasia • Polyosteoarthritis • Document if any associated injury is current or old • Primary, secondary, or post-traumatic

23. ICD-10 Documentation Tips Rheumatoid Arthritis • Site • Laterality • Link manifestations • With or without Rheumatoid Factor • Felt’s syndrome • Rheumatoid lung disease • Rheumatoid vasculitis • Rheumatoid heart disease • Rheumatoid polyneuropathy • With involvement of other organs or systems

24. ICD-10 Documentation Tips Drug Under-dosing is a new code in ICD-10-CM. • It identifies situations in which a patient has taken less of a medication than prescribed by the physician. • Intentional versus unintentional • Documentation requirements include: • The medical condition • The patient’s reason for not taking the medication • example – financial reason • Z91.120 – Patient’s intentional underdosing of medication due to financial hardship

25. ICD-10 Documentation Tips Cause of Injury • Mechanism • How it happened • Place of occurrence • Where it happened • Activity • What was the patient doing • External Cause • Work-related, leisure

26. ICD-10 Documentation Tips Glasgow Coma -ICD-10-CM coding will need the score from each of the assessment areas • Eye opening • Verbal response • Motor response • R40.211 Coma scale, eyes open never • R40.212 Coma scale, eyes open to pain • R40.213 Coma scale, eyes open to sound • R40.214 Coma scale, eyes open spontaneously • Report the Glasgow coma scale total score • R40.241 Glasgow coma scale score 13 – 15 • R40.242 Glasgow coma scale score 9 - 12 • R40.243 Glasgow coma scale score 3 – 8

27. ICD-10 Documentation Tips Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post-procedural disorders • The provider must clearly document the relationship between the condition and the procedure • Example: • D78.01 –Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen • D78.21 –Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen

28. ICD-10 Documentation Tips

29. ICD-10 Documentation Tips ICD-10-PCS does not allow for unspecified procedures, clearly document: • Body System • general physiological system / anatomic region • Root Operation • objective of the procedure • Body Part • specific anatomical site • Approach • technique used to reach the site of the procedure • Device • Devices left at the operative site

30. ICD-10 Documentation Tips Most Common Root Operations:

31. ICD-10 Documentation Tips Approaches:

32. Summary The 7 Key Documentation Elements: • Acuity – acute versus chronic • Site – be as specific as possible • Laterality – right, left, bilateral for paired organs and anatomic sites • Etiology – causative disease or contributory drug, chemical, or non-medicinal substance • Manifestations – any other associated conditions • External Cause of Injury – circumstances of the injury or accident and the place of occurrence • Signs & Symptoms – clarify if related to a specific condition or disease process