ICD-10-CM/PCS Structural Code Change Overview ...

1 Section Body System Root Operation Body Part Approach Device Qualifier ICD-10-CM/PCS Structural code Change Overview The coding system used to classify diseases and other conditions will transition to International Classification of Diseases version 10, or ICD-10-CM. Anatomy is the primary axis of classification of ICD-10-CM, or diagnosis. The structure of ICD-10-CM diagnosis codes captures a greater degree of detail than could be captured using the ICD-9-CM classification. ICD-10 CM codes are 3 7 Characters (alphanumeric) with all codes starting with an alphabetic character: documentation Tips general Surgery documentation Overview Your documentation tells a patient s story. H&P = Introduction Progress/Op Notes = Body Discharge summary = Conclusion It is critical to paint a clear picture from start to finish and cover the initial situation, changes through the stay, and a clear summary that brings it all together.

2 documentation Best Practices Always document the diagnosis(es) that contributed to the reason for inpatient admission Indicate what additional diagnoses are present on admission (POA) Indicate acuity/severity of all diagnoses: acute, chronic, acute on chronic, exacerbation Indicate suspected, probable, can t rule out, presumed or likely if you are treating a condition based on medical decision making or risk factors ( probable sepsis due to acute cholecystitis). Coding guidelines require that uncertain diagnoses are reconfirmed at the time of discharge (include in the discharge summary). Identify the significance of radiology/pathology/diagnostic test results including lab with a corresponding diagnosis in your documentation Link each diagnosis to signs/symptoms/ clinical indicators/descriptors ( ; altered mental status secondary to metabolic encephalopathy ) and treatment Link diagnoses to underlying etiology or manifestations whenever possible ( GI bleed due to peptic ulcer hemorrhage or DM2 uncontrolled with PVD and ischemic ulcer of left calf) Clearly identify conditions that have been ruled out and those resolved.

3 Utilize consults to improve specificity of diagnoses, if agree, then confirm, The attending needs to clarify conflicting documentation by various providers within the record. Instead of appreciate hospitalist s consult , can say hospitalist s consult reviewed and agreed. Avoid use of arrows/symbols. Spell out acronyms and abbreviations at least one time ( , hyponatremia instead of Na) 2445 M Street NW, Washington DC 20037 | P | F | 2014 The Advisory Board Company /# Category /# # /# /# /# Etiology Anatomic Site Complication Severity Laterality Subcategories: Extension (7th character) Have more questions about documentation ? Reach out to your clinical documentation Improvement Team ICD-10-PCS - All ICD-10-PCS procedure codes contain 7 alphanumeric characters.

4 /# /# /# /# /# /# /# Key general Surgery Diagnosis documentation Requirements in ICD-10-CM ICD-10-CM codes require additional specificity for code assignment. To reduce coder queries and ensure coded data properly capture conditions treated, provide the following additional specificity. Unspecified diagnoses do not exist for some conditions in ICD-10. Respiratory Failure Acuity Acute* Acute on Chronic* Chronic** Acute postprocedural ( )* Acute on chronic postprocedural ( )* Specificity With Hypoxia* Hypercapnia* Unspecified* Sepsis Sepsis* Identify Organism Document what Sepsis is due to: Streptococcus (Group A or B), Staphylococcus aureus, MSSA, MSRA, Hemophilus influenzae, anaerobes.

5 Gram-negative organism, Escherichia Coli, Serratia, Enterococcus Severe Sepsis* Acuity Severe Identify Organism See above Document with or without organ dysfunction With acute organ dysfunction With multiple organ dysfunction SIRS d/t infectious process with acute organ dysfunction Document with or without Septic Shock* Note: The term Urosepsis is not considered synonymous with It does not default to UTI in ICD-10-CM. Should a provider use this term a query must be submitted for clarification GI Hemorrhage Acuity Acute Chronic Link to underlying condition Note: Active bleeding does not have to be present Gastritis Hemorrhage of anus and rectum Angiodysplasia of stomach with hemorrhage Diverticular disease with hemorrhage Gastritis and duodenitis with hemorrhage Peptic ulcer with hemorrhage SBO repair Example.

6 0DB84ZZ - Excision of Small Intestine, Percutaneous Endoscopic Approach *High Impact Diagnosis **Low Impact Diagnosis Capturing Severity of Illness (SOI) in ICD-10-CM Terms A patient s SOI is conveyed to CMS and quality organizations via ICD-10-CM codes, assigned by a coder reading the medical record. Document known or suspected relationships between concomitant conditions wherever possible to ensure accurate capture of the patient s true risk of mortality and/or readmission. ICD-10-PCS Changes to Procedural documentation Requirements PCS includes significant changes to how procedures must be captured and coded, with more specificity required for code assignment. All 7 characters of the PCS code need to be captured.

7 documentation of procedures should identify sufficient information to capture these items to avoid excessive queries from your CDI or coding staff. Best Practice Procedure Note documentation Date/Time of procedure Procedure Intended Procedure Performed (Document reason for difference) Any additional procedures performed: Device Identified What made the procedure difficult/longer Document any unusual findings Complications Accidental or complication? Due to: Disease/condition Patient characteristics Surgery Drugs (name the drug) Unrelated to the surgery Clarify whether they are: An expected post-procedural or post-surgical condition An unexpected post-procedural or post-surgical condition, unrelated to surgical procedure An unexpected post-procedural or post-surgical condition, related to the patient s underlying medical comorbidities An unexpected post-procedural or post-surgical condition related to surgical care (a complication of care) Remember.

8 All 7 characters of a procedure (PCS code ) need to be captured to submit a claim Section Body system Root operation Body part Approach Devices Qualifier Resection of Large Intestine documentation Required Possible Options Root Operation Resection Approach Open, Percutaneous Endoscopic, Via Natural or Artificial Opening, or Via Natural or Artificial Opening Endoscopic Laterality Right or Left Body Part Large Intestine Type of Device None 0 DTF4ZZ Resection of Right Large Intestine, Percutaneous Endoscopic Approach Mechanical Ventilation documentation Required Possible Options Root Operation Performance Body Part Respiratory Duration <24 consecutive hours 24-96 consecutive hours >96 hours Function Ventilation Qualifier None 5A1935Z - Performance, Respiratory, <24 consecutive hours, Ventilation, No Qualifier Note: Duration of mechanical ventilation needs to be documented.

9 Please capture date/time of intubation and extubation SBO Repair Appendectomy Debridement documentation Required Possible Options Possible Options Possible Options Root Operation Excision Resection Excision Body Part Small Intestine Appendix Subcutaneous tissue and fascia, left lower extremity Approach Open, Percutaneous Endoscopic, Via Natural or Artificial Opening, or Via Natural or Artificial Opening Endoscopic Open, Percutaneous Endoscopic, Via Natural or Artificial Opening, or Via Natural or Artificial Opening Endoscopic Open, Percutaneous Device None None Diagnostic or none Qualifier None None None 0DB84ZZ - Excision of Small Intestine, Percutaneous Endoscopic Approach 0 DTJ4ZZ Resection of Appendix, Percutaneous Endoscopic Approach 0 JBM0ZZ Subcutaneous Tissue & Fascia, Excision, Left Upper Leg, Open, No device, No Qualifier If Please Consider (Higher SOI) Chronic Kidney Disease Identify the Stage: I-V Stages IV & V** BMI 40** or BMI <19** Provider must document the correlating medical diagnoses: Morbid obesity Obesity Cachexia** Altered Mental Status Encephalopathy Type: hepatic, metabolic, hypertensive, septic, toxic, post operative Acuity: acute* or chronic Urinary Tract Infection Delirium with associated condition and acuity Acute confusion** Pressure Ulcers Note.

10 Non pressure ulcers also need depth (tissue level) documented Include : Type (pressure) Laterality Site Stage 1-4 or unstageable (Stages 3 & 4 *) Provider also must document whether it is Present On Admission (POA) Diabetes Mellitus Type Diabetes Type 1 Diabetes Type 2 Specify if due to underlying condition ( drug or chemical induced, cystic fibrosis, malignant neoplasm of pancreas, adverse effect of drug) Identify the cause and effect relationship between the manifestation and the DM before it can be coded to a DM complications ( CKD Stage 4 due to DM Type 2) Note: If the type of DM is not documented or unclear the default is Type 2