The Road to ICD-10 by Trinity Mother Frances

The Road to ICD-10 See details inside

The Road to ICD-10 The Logic Behind ICD-10-CM/PCS WHY DOCUMENTATION? It is sometimes a challenge for providers to directly relate documentation to quality of care and the reimbursement process. However, they are directly related. The main concern of providers is and should always be patient care and treatment. ICD-10 does not change that. In fact, it seeks the same thing, which is improving patient care data in order to support the full clinical story. The additional specificity in documentation for ICD-10 does not require a provider to do more testing, treatment, or services. It only requires the documentation of the full patient and clinical details that the provider already knows.

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We all know that we have to increase our knowledge of documentation needs for ICD-10-CM/PCS. But what does this mean? It means we need to know the specific documentation requirements in ICD-10 that tell the complete biomedical and pathophysiological story, which supports compliant billing and fair reimbursement. ICD-10-CM/PCS are really more logical and specific; they can report an unambiguous clinical picture to support quality communication and fair compensation for services rendered.

The Road to ICD-10

How is ICD-10 Different? ICD-9-CM was first published in 1979 and since then, healthcare knowledge and technology have greatly advanced. ICD-9 lacks the structure and system to handle these advances and now struggles to allow a provider to capture the complete clinical story of all services rendered. ICD-10 was designed to support ever-changing and advancing healthcare delivery and technology. It offers far greater granularity, specificity, and the ability to expand as healthcare advances. The changes in ICD-10 compared to ICD-9 (see box to right) do not require a change in the way we provide clinical care. They allow us to capture a more complete clinical story.

The Major Changes: • Axis of Classification • Possible 7-digit codes • Laterality • Trimester Specificity for Obstetrical Coding • Expansion of Drug and Alcohol Codes • 7th Digit Extension Codes • Complication Codes • Combination Codes • Increased Specificity

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The Road to ICD-10 ICD-10-CM is a multi-axial system

AXIS OF CLASSIFICATION ICD-10-CM is a multi-axial classification of the site, morphology, behavior, and grading of diseases and conditions. An ICD-10 code tells a complete story of the patient’s condition and services provided. As an example, in ICD-10-CM, Respiratory tuberculosis is subdivided based on sites such as the lungs, lymph nodes, larynx, and bronchi. The documentation of site will allow an accurate representation of services utilized. Another example is hernias. All hernia codes are grouped by site in ICD-10-CM, whereas ICD-9-CM only groups inguinal hernias by site. This means site specificity for other hernias, such as ventral hernias has increased in ICD-10-CM.

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In ICD-10-CM, anatomy is the primary axis of classification and codes are based on the anatomical systems. The systems that are titled Diseases of the Circulatory System and Diseases of the Genitourinary System are based on the anatomy of the system.

Other axes used are: • Etiology or cause of disease (certain infectious and parasitic diseases) • Site of disease (Crohn’s Disease of the larger intestine) • Type of disease (cardiac arrhythmia) • Morphology or structure and form of an organism (leukemia)

The Road to ICD-10 7-Digit Codes Beginning with the fourth character in an ICD10-CM code, subcategories are added. These define the axis of classification by describing site, etiology, or the treatment level for the disease. Each subcategory requires specific documentation regarding the disease process to support the corresponding character. The new documentation adds specificity and accuracy to the ICD-10-CM code. Please note that if present: • The 5th character requires documentation regarding the type of complication present • The 6th character requires documentation of the device (e.g., vascular vs. cardiac device) • The 7th character requires documentation indicating an initial encounter

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The codes in ICD-10-CM can be up to seven characters in length. Three-character codes are also present and work the same way as in ICD-9-CM. In rare instances, these are complete codes. However, more commonly they are CATEGORY codes which require 4th, 5th, 6th, and 7th character codes for greater medical specificity. To show this specificity, here are some of the codes in ICD-10-CM for an acute embolism and thrombosis of deep veins of the lower extremities. I82.411 - Acute embolism and thrombosis of right femoral vein. I82.412 - Acute embolism and thrombosis of left femoral vein. I82.413 - Acute embolism and thrombosis of femoral vein, bilateral. I82.419 - Acute embolism and thrombosis of unspecified femoral.

The Road to ICD-10

Laterality Laterality has been added to ICD-10-CM to increase specificity. However, it is not a requirement for every condition that could encompass a left, right, or bilateral site. For example, a congenital megaureter does not require laterality specification for coding and reporting purposes. Conditions such as fractures, burns, neoplasms, and pressure ulcers require documented evidence of the affected side of the body. Documentation of laterality for bilateral body parts and paired organs will assist in expediting the billing and payment process.

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Laterality is one of the main reasons ICD-10 has such a large increase in the number of codes when compared to ICD-9. Non-specific ICD-9 codes identify the disease or condition but provide no information on the laterality of that condition. As an example, ICD-9 may identify a condition/disease of the ovary in only one code. ICD-10 allows us the ability to capture and identify within four codes: unspecified ovary, right ovary, left ovary, or bilateral condition of the ovaries. In this way, laterality allows the full capture of the condition leading to enhanced capture of severity of illness and specific data to be used in research and studies. In many cases, it only requires the documentation of one or a few additional words.

The Road to ICD-10

Trimester Specificity for Obstetrical Coding In ICD-10, complications that occur during gestation, labor, and delivery have been modified to support severity and services provided to treat any aberrations from a normal delivery. In order to substantiate the severity of any complications that arise during pregnancy, the time period or stage of the pregnancy must be identified by the trimester in which the care is delivered. ICD-10-CM further requires documentation of the effect of the complication on both the mother and the fetus.

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Weeks of Gestation When utilizing the ICD-10-CM codes, providers will need to report pregnancy complication by the standard trimesters. Documentation of “weeks of gestation” can also be used to calculate the correct trimester.

Trimesters are defined in ICD-10-CM as: First trimester: – Fewer than 14 weeks, zero days Second trimester: – 14 weeks, zero days to fewer than 28 weeks, zero days Third trimester: – 28 weeks, zero days until delivery

The Road to ICD-10 ICD-10-CM uses

Expansion of Drug and Alcohol CoDES ICD-10-CM greatly expands the ability to capture the history, abuse, dependence, and impact of drugs and alcohol on the patient. ICD-10-CM has increased specificity in the form of extra digits to further clarify the exact pathophysiological processes for these codes.

increased causeand-effect indicators to classify this controversial set of diagnoses, which enables increased accuracy and specificity in

• 4th digit to qualify the specific aspects of the effects (abuse and dependence)

diagnostic translation.

• 5th digit to identify the aspects of use (withdrawal state)

This is why it is important to

• 6th digit to identify some of the manifestations

document histories,

EXAMPLE: F10.150 Alcohol abuse with alcoholinduced psychotic disorder with delusions.

dependences, and

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manifestations.

The Road to ICD-10 ICD-10-CM uses

7th Digit Extension Codes

7th digit extension characters to convey

The increase in characters with ICD-10 was not done to add complexity or increased workload to the healthcare professional. Instead, they were added to allow expandability as well as the ability to capture more specific information on the condition or injury.

level of care, medical specificity, and severity data. Documentation for

The seventh character is an example of this capture of additional specificity. Examples of what the seventh character represents...

the seventh character

• Multiple gestations

increased specificity,

not only supports but also expedites

• For fractures, it identifies the encounter type (e.g., initial, subsequent, sequelae), the type of fracture (e.g., open or closed), or the type of healing (e.g., routine, delayed, malunion, or nonunion)

• Where applicable, it identifies the Salter-Harris fracture classification This ICD-10 Tip is brought to you by Precyse University. For more information, go to:

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billing and provides a clearer picture of services and

treatment rendered.

The Road to ICD-10 COMPLICATION CODES ICD-10 makes a distinction between complications that occur during a procedure and those that occur post-procedure. There is no time limitation as to when complications can occur; however, providers must document the relationship between the complication and the procedure performed. Documentation of these unforeseen occurrences supports extended care. Practitioners may have varied opinions of what qualifies as a complication after a procedure, but consider the following as potential examples of postoperative complications: • Wound infections • Coronary artery bypass graft thrombosis • Pulmonary emboli within one week of surgery Remember: there is a difference between an expected condition following a procedure and a complication. Only practitioners can determine whether conditions are expected outcomes or complications.

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Examples of expected outcomes following procedures may include: • Low grade temperature of 99.8 for one to two days following surgery • Postoperative ileus immediately following certain abdominal surgeries • Hyperglycemia following total pancreatectomy The key to documenting conditions that arise during or following procedures is to state when the condition occurred, if it is an expected outcome, or a complication of the procedure. This type of documentation assists with appropriate code assignment.

The Road to ICD-10

Increased specificity The following are examples of increased specificity in ICD-10-CM: S72.044G Nondisplaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing. I69.351 Sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Z47.81 Encounter for orthopedic aftercare following surgical amputation. Z48.21 Encounter for aftercare following heart transplant.

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By far, increased specificity is the most impactful change, as it affects our documentation of disease origins, types, and locations. Adopting these documentation practices will reap many benefits, such as accurate reimbursement and improved continuity of care.