icd-10 training for otolaryngologistsmissoto.org/uploads/mckusick_-_thursday_2014...injury,...
TRANSCRIPT
ICD-10 Training for Otolaryngologists
Sponsored by: Alabama Society of Otolaryngology
June 12, 2014 Destin, Florida
Presented by: Joy McKusick, RHIA
www.karenzupko.com
Sign up for our free KZAlerts!
“Like” us on Facebook to get great tips and exclusive deals!
2
Attention
©KarenZupko & Associates, Inc. 2014 All Rights Reserved No part of this presentation (including slides and handout materials) may be copied, modified, re-used, distributed, or otherwise reproduced in part or in entirety without the express written consent of KarenZupko & Associates, Inc.
3
Agenda
Format and Structure
Other Coding Conventions and Guidelines
Diseases of the Ear and Mastoid Process (H60 – H95)
Diseases of the Digestive System (K00 – K95)
Diseases of the Respiratory System (J00 – J99)
Neoplasms (C00 – D49)
Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00 – Q99)
Diseases of the Skin and Subcutaneous Tissue (L00 – L99)
Symptoms, Signs and Abnormal Clinical and Laboratory Findings (R00 – R99)
Injury, Poisoning and Certain other Consequences of External Causes (S00 – T88)
Getting Ready
4
Learning Objectives
At the conclusion of this activity, participants will be able to:
Understand ICD-10 code structure and concepts.
Use relevant ICD-10 chapters and codes as they relate to ENT.
Identify and address documentation deficiencies.
Map current ICD-9 codes to ICD-10 codes.
5
Resources
ICD10data.com commerce.ama-assn.org
ICD-10 Delay…AGAIN October 2013 October
2014 October
2015
7
Implementation
Take a breath!
9
Implementation
Now is not the time to put off preparation! Be proactive! Make changes now to lessen problems later!
10
Format and Structure 11
Format and Structure
What’s the same and what’s different?
12
Format and Structure 13
Contains:-Index to Diseases and InjuriesAlso includes:
-Neoplasm Table-Table of Drugs and Chemicals-Index to External Cause of Injuries
Alphabetic Index List of
alphanumeric codes divided into chapters based on condition and/or body system
Contains categories, subcategories and valid codes
Tabular List
Finding the Code
Look up the main term
Index instructions
Locate code in
Tabular List
14
Finding the Code
Read all instructional
material Review
guidelines Confirm
and assign code
15
Finding the Code
A
Fracture, mandible
16
Finding the Code
B
Complication, postmastoidectomy,
granulation *Granulation tissue-see Complications,
postmastoidectomy, granulation
17
Finding the Code
C
Wound, open, nose
18
Finding the Code
D
Pain, ear Index directs user to see
subcategory H92.0-
19
Finding the Code
E
Foreign body, pharynx
20
Differences?
Chapters
Titles
Injury codes
Postoperative Complications
21
Comparison of ICD-9 and ICD-10
Diagnosis codes 3-5 characters in length
First character may be alpha or numeric; characters 2-5 are numeric
Limited space for new codes
Lacks detail
Lacks laterality
Diagnosis codes are 3-7 characters in length
Character 1 is alpha; 2 is numeric; characters 3-7 are alpha or numeric
Utilizes every letter except “U”
Flexible for adding new codes
Very specific
Has laterality
ICD-9 ICD-10
22
What makes up the code?
ICD-9-CM ICD-10-CM
23
Category S00
Superficial Injury
of the head
Subcategory S00.53-
Contusion of lip and oral cavity
Code S00.531A
Contusion of lip, initial encounter
7th Character Extension and “X” Placeholder
Applies only to certain categories of codes.
7th character must always be in the 7th data field.
“X” placeholder is used to fill in empty characters when the code is not 6 characters.
25
7th Character Extension 26
7th Character Extension and “X” Placeholder
27
7th Character Extension and “X” Placeholder
Foreign body in right ear T16.1-
Incorrect code assignment:
T16.1A Correct code assignment:
T16.1XXA
28
7th Character Definitions
Initial encounter = A This extension is used when the patient is receiving
active treatment for the condition. Examples include: surgical treatment, emergency department
encounter and evaluation and treatment by a new physician.
29
7th Character Definitions
Subsequent encounter = D This extension is used for encounters after the patient
has received active treatment and is now in the healing phase receiving routine care for the condition.
Examples include: cast change or removal, removal of
external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition
30
7th Character Definitions
Sequela = S ICD-10-CM no longer has late effect codes. To indicate a
condition is the result of a previous injury, the 7th character extension “S” is used on the active injury code.
When using this extension it is necessary to use both the injury code that is the cause of the sequela and the code for the sequela itself. Example: L91.0 Hypertrophic scar
S01.411S Laceration without foreign body of right
temporomandibular area, sequela
31
Practice Questions
Practice Questions
Practice 1.1
Answer: A initial encounter
Practice 1.2
Answer: True
33
Practice Questions
Practice 1.3
Answer: Chapter 7 eye/adnexa and Chapter 8 Ear and Mastoid process
Practice 1.4
Answer: False
34
Practice Questions
Practice 1.5
Answer: A, D, S
Practice 1.6
Answer: A, B, D, G, K, S
35
Practice Questions
Practice 1.7
Answer: False
Practice 1.8
S02.3XXD
36
Practice Questions
Practice 1.9
Answer: T17.1XXA
Practice 1.10
“U”
37
Other Coding Conventions and Guidelines
38
Other Coding Conventions and Guidelines
Abbreviations and Punctuation
39
Other Coding Conventions and Guidelines
Instructional Notes, sequencing and new concepts
“NEC” and “NOS”
“Other”
“Unspecified” Info
40
Other Coding Conventions and Guidelines
Punctuation
Brackets [ ] Parentheses ( ) Colons : Dash –
41
Other Coding Conventions and Guidelines
Excludes 1 Code should not be
used at the same time as the code above the Excludes 1 note.
Excludes 2 Acceptable to use both
the excluded code and the code above the Excludes 2 note.
Excludes 1 Excludes 2
42
Other Coding Conventions and Guidelines
Etiology and manifestation Underlying condition is sequenced first, followed by
the manifestation “code first”
Noted at manifestation
“use additional code” Noted at etiology code
43
Other Coding Conventions and Guidelines
“And”
“With”
“See” and “See Also”
“Code also”
44
Other Coding Conventions and Guidelines
Acute and Chronic conditions If separate entries exist, code both sequencing the acute
condition first.
Laterality Codes available for right, left and bilateral conditions. If a condition is bilateral, but a bilateral code is not
available, assign a code for both the right and left side.
45
Complications of Care
Some complications have been moved to specific body system chapters.
Cause-and-effect relationship. Documentation must support that there is a
relationship between the care provided and the condition.
46
Practice Questions
Practice Questions
Practice 2.1
Answer: False
Practice 2.2
Answer: not coded here/code can’t be used at the same time as code above the excludes 1 note
48
Practice Questions
Practice 2.3
Answer: right, left, bilateral, unspecified
Practice 2.4
Answer: True
49
Practice Questions
Practice 2.5
Answer: Not otherwise specified, unspecified codes
Practice 2.6
Answer: A code for both the right and left side should be assigned
50
Chapter Specifics 51
(H60 – H95)
Chapter 8 Diseases of the Ear and Mastoid Process
52
Chapter 8 Diseases of the Ear and Mastoid Process
Highlights Laterality
Conventions Code first underlying
disease
Use additional code
Instructional Notes Excludes 1 and 2
53
Chapter 8 Diseases of the Ear and Mastoid Process
Infective Otitis
Externa 380.10
Abscess Cellulitis
Diffuse
NOS
Hemorrhagica
Infective NOS Circumscribed
54
Other acute otitis
externa 380.22
Specified type, NEC
Reactive Eczematoid
Contact
Actinic Chemical
Chapter 8 Diseases of the Ear and Mastoid Process
55
Chapter 8 Disease of the Ear and Mastoid Process
Cerumen removal Laterality
Acquired stenosis of external ear canal Changed some of the code titles
56
Chapter 8 Diseases of the Ear and Mastoid Process
Nonsuppurative otitis media Inflammation without the production of pus.
Instructional notes Tympanic membrane perforation. Smoking use/dependence/exposure
57
Otitis Media
Acute otitis media (AOM) The rapid onset of signs and symptoms of inflammation of
the middle ear. Recurrent AOM
Three or more well-documented and separate AOM episodes in the past 6 months or at least 4 well-documented and separate AOM episodes in the past 12 months with at lease 1 in the past 6 months.
Chronic otitis media with effusion (OME) OME persisting for 3 months or longer from the date of
onset or from the date of diagnosis.
58
Otitis Media
Suppurative Purulent (pus) fluid in the middle ear
Excludes 1 for tympanic membrane perforation for subcategory H66.01-
Use additional code for smoking use/dependence or
exposure.
59
Hearing Loss Unilateral
Right or left
Types of loss Conductive
Sensorineural Mixed
Chapter 8 Diseases of the Ear and Mastoid Process
60
Complications
Documentation Examples 62
What code(s) are assigned for the clinic encounter? H65.91 Unspecified nonsuppurative otitis media,
right ear H72.01 Central perforation of tympanic
membrane, right ear
Documentation Examples 63
Potential documentation gaps: 1. Laterality is noted for specific code selection. 2. Mucoid fluid is noted in exam, but impression and plan
only state otitis media. Be as specific as possible when describing the diagnosis using ICD-10 code language when possible.
3. Acute/chronic is not documented. Forced to use an unspecified OM code. Inclusion terms under the unspecified category list mucoid OM, NOS.
Other issues for code selection:
Documentation Examples 64
What code(s) are assigned for the clinic encounter? H91.90 Unspecified hearing loss, unspecified ear H93.19 Tinnitus, unspecified ear R42 Dizziness Potential documentation gaps: Laterality-Specify which ear or if bilateral ears have hearing loss and/or tinnitus Specific type of hearing loss if known.
Other issues for code selection: Unilateral/bilateral issue for hearing loss code selection.
(K00 – K95)
Chapter 11 Diseases of the Digestive System
65
Chapter 11 Diseases of the Digestive System
Highlights Conditions reclassified
Instructional notes Alcohol use/dependence Smoking
66
Chapter 11 Diseases of the Digestive System
Salivary glands → 1-1 mapping → Sialoadenitis acute recurrent chronic
Image Source: http://upload.wikimedia.org/wikipedia/commons/d/df/Blausen_0780_SalivaryGlands.png
67
Chapter 11 Diseases of the Digestive System
Mouth
Lips
Tongue
Image Source: http://upload.wikimedia.org/wikipedia/commons/6/6a/Illu03_mouth.jpg
68
Chapter 11 Diseases of the Digestive System
Gastro-Esophageal Reflux Disease
HEARTBURN
69
Practice Questions
Practice Questions
Practice 3.11.1 Answer: Biting Answer: K13.1
Practice 3.11.2 Answer: K21.9
Practice 3.11.3
Answer: T45.1X5 A, D, S Answer: Y84.2
71
Practice Questions
Practice 3.11.4 Answer: K11.21
Practice 3.11.5
Answer: K11.22
72
Practice Questions
Practice 3.11.6 Answer: K14.5
Practice 3.11.7
Answer: K22.711
73
(J00 – J99)
Chapter 10 Diseases of the Respiratory System
74
Chapter 10 Diseases of the Respiratory System
Highlights
Instructional notes
Excludes 1 and 2
75
Chapter 10 Diseases of the Respiratory System
Infectious agent code assignment. Use code for “in diseases classified elsewhere” A49.02 Methicillin resistant staphylococcus aureus
Excludes 1 note indicating not to use with bacterial agent as cause of disease classified elsewhere.
B95.62 MRSA as cause of disease classified elsewhere
Watch for correct code assignment!
76
Sinusitis
Acute Lasts up to four weeks
Recurrent Several attacks in a year Three or more episodes in a year with each
lasting two weeks.
77
Sinusitis
Chronic Last more than 12 weeks Three months or more Longer than 8 weeks
Pansinusitis All four sinuses are infected
78
Chapter 10 Diseases of the Respiratory System
Tonsillitis Acute Acute recurrent Chronic Streptococcal Other
Tonsillitis and Adenoiditis Chronic Hypertrophy
Image Source: http://upload.wikimedia.org/wikipedia/commons/thumb/8/89/Blausen_0861_Tonsils%26Throat_Anatomy2.png/600px-Blausen_0861_Tonsils%26Throat_Anatomy2.png
79
Chapter 10 Tonsillitis
Acute Fever, sore throat, foul breath, tender cervical lymph nodes. Airway obstruction due to swollen tonsils Symptoms usually resolve in three to four days, may last up
to two weeks.
Recurrent Multiple episodes of acute tonsillitis in a year.
Chronic Individuals have chronic sore throat, halitosis, tonsillitis and
persistently tender cervical nodes.
80
Rhinitis
Vasomotor Rhinitis not caused by hay fever or allergies Non-allergic rhinitis
Allergic Similar code titles 1-1 mapping
81
1-1 mapping!!!!! 82
Chapter 10 Diseases of the Respiratory System
Asthma
Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
83
Chapter 10 Diseases of the Respiratory System
Asthma
Intermittent
Wheezing/coughing no more than 2 days/week
Nighttime flare-ups occur twice a month at most
Mild persistent
Symptoms occur more than twice a week, but less than one per day
Nighttime flare-ups occur more than twice/month, but less than once/week
84
Chapter 10 Diseases of the Respiratory System
Asthma Moderate persistent
Symptoms occur daily
Flare-ups occur and usually last several days
Severe persistent
Symptoms occur daily and often
Curtails activities and disrupts sleep
Lung function less than 60% without treatment
www.healthychildren.org
85
Chapter 10 Diseases of the Respiratory System
Intraoperative and Postprocedural Complications Documentation requirements
86
Documentation Examples 87
What code(s) are assigned for the clinic encounter? J03.01 Acute recurrent streptococcal tonsillitis Potential documentation gaps:
1. Acute vs. recurrent-Documentation states patient has had 6 plus infections in the last year. Documentation in plan states acute strep, but would advise physician to use term recurrent to code more specifically to show severity of rate of infections.
2. Would also code for enlarged lymph nodes. R59.0 Localized enlarged lymph nodes.
Other issues for code selection:
Documentation Examples 88
What code(s) are assigned for the clinic encounter? J32.4 Pansinusitis NOS J33.0 Polyp of nasal cavity J34.2 Deviated septum Potential documentation gaps: Chronic vs. NOS. If acute or chronic isn’t documented, sinusitis codes default to chronic. Asthma is noted in HPI, but isn’t addressed in plan and impression. Asthma should be addressed in the plan and impression if it influences the care of the patient. Also, added as an additional diagnosis.
Documentation Examples 89
Other issues for code selection: Acute sinusitis codes now have options for recurrent acute infections. ICD-10- has specific codes available for pansinusitis. New guideline for coding more than one sinus infected, but less than 4. Use other specified sinusitis codes per the guideline.
(C00 – D49)
Chapter 2 Neoplasms
90
Chapter 2 Neoplasms
Neoplasm Table
Reference first unless a histologic term is documented
Malignant
Benign
In situ
Uncertain histologic behavior
Unspecified behavior
91
Chapter 2 Neoplasms
Overlapping sites Separate code within the category.
History of vs. active neoplasm Primary malignancy is excised/eradicated and no
further treatment is directed to the site, use code from category Z85.
92
Chapter 2 Neoplasms (C00 – C49)
Use additional code
Includes and Excludes
NOS
Laterality
93
Chapter 2 Neoplasms (C00 – C49)
Malignant neoplasms
1 – 1 mapping
141.0 = C01 Malignant neoplasm of base of tongue
1 – many mapping
146.8 Malignant neoplasm other specified sites of oropharynx
C10.4 Malignant neoplasm of branchial cleft
C10.8 malignant neoplasm of overlapping sites of oropharynx
Expanded for greater specificity of location.
94
Chapter 2 Neoplasms (C00 – C49)
Melanoma and other skin cancers
Malignant melanoma and melanoma in situ
Separate codes to indicate malignant melanoma or in situ.
Image source: http://en.wikipedia.org/wiki/File:HumanSkinDiagram.jpg
95
Skin Cancer
Categorized by type of skin cancer, like ICD-9-CM. Basal cell Squamous cell Merkel cell Other specified
malignant neoplasm Unspecified malignant
neoplasm
Source: http://upload.wikimedia.org/wikipedia/commons/thumb/c/c1/ Layers_of_the_skin.jpg/495px-Layers_of_the_skin.jpg
96
Chapter 2 Neoplasms (C00 – C49)
Benign neoplasms Similar to malignant neoplasm with many 1-1 mapping.
Benign skin neoplasms Melanocytic nevi Other benign neoplasm
97
Documentation Examples 98
What code(s) are assigned for the clinic encounter? R22.1 Neck mass R09.81 Nasal congestion Z72.0 Tobacco use Potential documentation gaps: For current diagnoses, documentation supports most specific code available. Other issues for code selection: Codes for head and neck mass now have different codes depending on location.
Documentation Examples 99
What code(s) are assigned for the clinic encounter? C07 Malignant neoplasm of parotid gland C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of
head, face and neck Z72.0 Tobacco use Potential documentation gaps: Code fully for primary and secondary sites. Document specific location of cancer. Other issues for code selection: Instructional note to add tobacco use/dependence/exposure as well as any alcohol abuse and dependence.
(Q00 – Q99)
Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities
100
Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities
Highlights
Eye, Ear, Face and Neck
Respiratory System Nose Larynx Trachea and Bronchus
Cleft lip and palate
Down Syndrome
101
Practice Questions
Practice Questions
Practice 3.17.1
Answer: Q37.5
Practice 3.17.2
Answer: False
103
Practice Questions
Practice 3.17.3
Answer: Q17.5
Practice 3.17.4
Answer: Q32.0
104
Practice Questions
Practice 3.17.5
Answer: Q30.0
Practice 3.17.6
Answer: True
105
Practice Questions
Practice 3.17.7
Answer: Q31.0
106
(L00 – L99)
Chapter 12 Diseases of the Skin and Subcutaneous Tissue
107
Chapter 12 Diseases of the Skin and Subcutaneous Tissue
Highlights
Instructional notes
Image Source: http://upload.wikimedia.org/wikipedia/commons/5/5d/Anatomy_The_Skin_-_NCI_Visuals_Online.jpg
108
Chapter 12 Diseases of the Skin and Subcutaneous Tissue
Infections of the skin and subcutaneous tissue Radiation-related disorders Disorders of skin appendages Complications Other skin disorders
109
Practice Questions
Practice Questions
Practice 3.12.1
Answer: True
Practice 3.12.2
Answer: Cyst
111
Practice Questions
Practice 3.12.3
Answer: Use additional code to identify infectious agent
Practice 3.12.4
Answer: Additional code to indicate type of retained foreign body
112
Practice Questions
Practice 3.12.5
Answer: Code for the condition being treated first with the active injury code second.
Answer: S – sequela
113
(R00 – R99)
Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings
114
Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings
Highlights
Use of symptom codes
Instructional notes
115
Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings
1-1 mapping Same code titles for many conditions.
Epistaxis 784.7 = R04.0 Hemorrhage from throat 784.8 = R04.1 Postnasal drip 784.91 = R09.82 Jaw pain 784.92 = R68.84
Others have been expanded R06.5 mouth breathing R06.7 sneezing
116
Sleep Conditions
Most codes were reclassified to the Nervous System chapter.
Some sleep codes fall into the Mental, Behavioral
and Neurodevelopmental disorders chapter. Obstructive sleep apnea (adult) (pediatric)
ICD-10-CM = G47.33
117
(S00 – T88)
Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes
118
Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes
Highlights
S-section and T-section
7th character extension definitions
119
Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes
“X” Placeholder
Future code expansion
T36.8X1A
Fill in empty character positions to assign 7th character to 7th data field.
S02.2XXA
120
Practice Questions
Practice
A: A initial encounter for closed fracture
B: D subsequent encounter
C: S sequela
D: A initial encounter
E: A initial encounter
121
Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes
Coding guidelines for injuries and fractures
KNOW THE RULES!
122
Injuries to the Head and Neck
Superficial
Open wound
Fracture
Dislocation and sprain
Image Source: http://upload.wikimedia.org/wikipedia/commons/thumb/1/1a/Human_skull_front_simplified_%28bones%29.svg/399px-Human_skull_front_simplified_%28bones%29.svg.png
Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes
123
Foreign body
Superficial
Entering through natural orifice
Respiratory Tract
Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes
124
Complications of Surgical and Medical Care, NEC
Wound infections
Mechanical complications
Disruption of surgical wounds
Infections due to prosthetic devices, implants, grafts
Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes
125
Documentation Examples 126
What code(s) are assigned for the clinic encounter?
T16.1XXA Foreign body of right ear, initial encounter T16.2XXA Foreign body of left ear, initial encounter
What code(s) are assigned for the surgical encounter? T16.1XXA Foreign body of right ear, initial encounter T16.2XXA Foreign body of left ear, initial encounter
What codes(s) are assigned for the post-operative visit? T16.1XXD Foreign body of right ear, initial encounter T16.2XXD Foreign body of left ear, initial encounter
Documentation Examples 127
Potential documentation gaps: Laterality is clearly documented
7th character extension-initial or subsequent
Other issues for code selection:
X placeholder Assign two codes because there isn’t a bilateral option
Documentation Examples 128
What code(s) are assigned for the clinic encounter?
S09.22XA Traumatic rupture of left ear drum, initial encounter
H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side.
What code(s) would be assigned if patient required a paper patch at the next visit and why? S09.22XA Traumatic rupture of left ear drum, initial encounter Surgical care is considered initial encounter. Patient is being actively treated for the condition. Hearing loss code if still present.
Documentation Examples 129
What code(s) would be assigned at the next visit if the patient did not require further treatment and why? S09.22XD Traumatic rupture of left ear drum, subsequent encounter Patient has entered the healing/recovery phase. Hearing loss code if still present. Potential documentation gaps: Laterality-Documentation addresses which ear has the condition. 7th character extension-initial or subsequent
Documentation Examples 130
Other issues for code selection: X placeholder
Codes are assigned to the injury chapter rather than ear and mastoid process chapter. Traumatic ear drum ruptures are not specific to type of perforation (e.g., marginal, central) like the codes from the H72 category in the Ear and Mastoid Chapter.
Getting Ready 131
Steps to Implementation 132
Steps to Implementation
1. Form a Team
2. Inventory the Practice
3. Frequency Reports
4. Mapping
5. Gap Analysis
133
