nancy troutt, rhia, cpc, cpc-i – provider coding consultant – blue cross and blue shield of...
TRANSCRIPT
Consulting With The Coder- ICD-10
Nancy Troutt, RHIA, CPC, CPC-I – Provider Coding Consultant –
Blue Cross and Blue Shield of Alabama
Purpose
• To have a better understanding of documentation and coding guidelines.
• To have a better understanding of International Classification of Diseases, Tenth Edition (ICD-10).
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What We Will Learn Today
• Importance of:-Good Documentation-Accurate Coding
• Blue Cross and Blue Shield of Alabama’s Role forSmooth Transition
• ICD-10: Differences and 7th Characters
• ICD-10: 21 Classifications
• ICD-10: New Chapter-Specific Features
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Accurate and Complete Documentation is Important
ICD-9* and ICD-10
Use codes describing symptoms, conditions,problems, complaints, or other reasons for visits
*International Classification of Diseases, Ninth Edition (ICD-9)
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Accurate and Complete Documentation is Important
• Accurate documentation and coding
• Difference in Clinical and Coding guidelines
• The coder/biller cannot assume
• Information on claim and documentation should match
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Accurate and Complete Documentation is Important!
Payors Compare Documentation with Claims!
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Documentation Errors Found
• Diagnosis on claim and documentation do not match
• Codes not “linked” in documentation or claims
• Manifestations not coded
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Documentation Tips
Documentation should show:• Reason for visit
• Updated problem lists
• Detailed chief complaint, should “stand alone”
• Signature/Credentials
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EMR Reminders
Providers should:
• Include relevant documentation
• HPI, MDM, exam documented by provider
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Accurate ICD-9 Coding Will Not Change with ICD-10
• Reason
• Highest level specificity
• Chronic conditions
• Coexisting conditions
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Accurate Coding Will Not Change With ICD-10
Reasons for correct coding/documentation:
• Required
• Future payments based on severity
• Medical necessity
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Accurate Coding Will Not Change With ICD-10
Codes are invalid if:
• Not coded to full number of digits
This applies to both ICD-9 and ICD-10
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NEC and NOS
Same Meaning in ICD-9 and ICD-10
• NEC – “not elsewhere classifiable”
• NOS – “not otherwise specified”
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Accurate Coding Will Not Change With ICD-10
• List first the chief complaint (reason for visit)
• Diagnoses may be a symptom until diagnosis is confirmed by the physician
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Accurate Coding Will Not Change with ICD-10
• Do not – code “rule outs”, probable, suspect
• Code highest degree of certainty
• Code signs and symptoms if diagnosis is not yet established
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Accurate ICD-9 Coding Will Not Change With ICD-10
• Additional signs and symptoms should be coded that may not be associated with a disease process
• Chronic diseases should be coded as many times as patient receives treatment.
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Accurate ICD-9 Coding Will Not Change With ICD-10
• Code all documented co-existing conditions
• Do not code conditions that no longer exist
• Exception is “history of” codes
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Blue Cross Claims
• All HIPAA-covered entities will adopt ICD-10 by October 1, 2015
• Blue Cross will not process claims with ICD-10 codes before that date
• ICD-9 will no longer be accepted for dos after Sept. 30, 2015
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ICD-9 to ICD-10 Mapping
GEMS (General Equivalency Mappings)
• Blue Cross will use GEMS
• GEMS not to be used exclusively
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ICD-10 Diagnosis Mapping Tool
To access the mapping tool on Blue Cross website,Alabamablue.com/providers.
• Log into ProviderAccess.• Select “Provider Functions.”• Look for “ICD-10 Diagnosis Code Mapping Tool” under Claim Information.
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Blue Cross “Front-End Testing”
Submission of claims to verify diagnosis code information:
Contact Your EDI Services Representative205-220-6899
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ICD-10
October 1, 2015
ICD-9 vs. ICD-10
ICD-9• Has 3-5 characters, always at least 3• First is numeric, except E and V codes
ICD-10• Has 3-7 characters, always at least 3• First character always alpha, all letters used except U
In both, the decimal is after 3rd character, and alpha characters are not case sensitive
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X X X X
Category
.Etiology, anatomic
site, severity
Added 7th character for obstetrics, injuries, and external causes of injury
Coding and Seventh Characters
X X X
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AMS 0 2 6. 5 x A
Additional Characters
Alpha (Except U)
2 Numeric3-7 Numeric or Alpha
3–7 Characters
Coding and Seventh Characters
Seventh Characters:• Injury, external cause and obstetrics
• Alpha or numeric, at end in the 7th position
• Has different meanings
• Codes requiring 7th digit, leaving off makes invalid
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Added seventh-characters for episode of care
Examples:
• M80.051A• S06.0X1A• S52.132B
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Coding and Seventh Characters
Coding and Use of Seventh CharactersIn Injury and External Cause, the 7th character identifies:
• Initial- for patient receiving active treatment
• Subsequent - for after the patient has received active treatment
• Sequela - for complications arise as a result of a condition
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New features in ICD-10-CM
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Chapters of the ICD-10-CM Classification System
A – GA00 – B99 Certain Infectious and Parasitic Diseases
C00 – D49 Neoplasms
D50 – D89 Diseases of Blood and Blood forming organs and certain disorders involving the immune mechanism
E00 – E89 Endocrine, nutritional and metabolic disorders
F01 – F99 Mental, Behavioral and Neurodevelopment Disorders
G00 – G99 Disease of Nervous System
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Chapters of the ICD-10-CM Classification System
H – L H00 – H59 Diseases of the Eye and Adnexa
H60 – H95 Diseases of the Ear and Mastoid Process
I00 – I99 Diseases of the Circulatory System
J00 – J99 Diseases of the Respiratory System
K00 – K95 Diseases of the Digestive System
L00 – L99 Diseases of the Skin and Subcutaneous Tissue
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Chapters of the ICD-10-CM Classification System
M – R M00 – M99 Diseases of the Musculoskeletal System and
Connective Tissue
N00 – N99 Diseases of the Genitourinary System
O00 – O9A Pregnancy, Childbirth and the Puerperium Period
P00 – P96 Certain Conditions Originating in the Perinatal Period
Q00 – Q99 Congenital Malformations, Deformations and Chromosomal Abnormalities
R00 – R99 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, NEC
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Chapters of the ICD-10-CM Classification System
S – Z
S00 – T88 Injury, Poisoning and Certain other consequences of External Causes
V00 – Y99 External Causes of Morbidity
Z00 – Z99 Factors Influencing Health Status and Contact with Health Services
New Features in ICD-10-CM
Greater level of specificity and clinical detail:
Combination Codes of Common Symptoms• Diabetes with manifestations will only require
one code instead of two.
• Atherosclerotic heart disease with unstable angina only one code instead of two.
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New Features in ICD-10-CM
Combination codes for poisoning and external causes:
• Accidental poisoning
• Adverse effects
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New Features in ICD-10-CM
LateralityCoding guidelines are basically the same in ICD-10 as in ICD-9, except with one additional guideline: laterality
• Right• Left• Bilateral
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New Features in ICD-10-CM
Expanded codesExamples:
E11.341 DM type II with retinopathy and macular edema
F14.221 Cocaine dependence with intoxication delirium
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New Features in ICD-10-CM
Changes in time frames specific to certain codes
Acute MI – “acute” time period change from 8 weeks to 4 weeks in iCD-10
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Chapter 4 – Endocrine, Nutritional and Metabolic Disease
Diabetes Mellitus
• Combination codes in ICD-10
• No longer “controlled or uncontrolled”
• Poorly controlled coded by type with hyperglycemia
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Chapter 4 – Endocrine, Nutritional and Metabolic Disease
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Diabetes Mellitus: 5 Categories
E08 Diabetes due to underlying condition
E09 Drug or chemical-induced Diabetes
E10 Type I Diabetes
E11 Type II Diabetes
E13 Other specified Diabetes
Chapter 4 – Endocrine, Nutritional and Metabolic Disease
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Long-term (Current) Use of Insulin
ICD-9 V58.67
ICD-10 Z79.4
Chapter 4 – Endocrine, Nutritional and Metabolic Disease
Patient presents with type II diabetes with diabetic chronic kidney disease, stage IV. She is on insulin and her glucose is documented as uncontrolled.
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ICD-9 ICD-10• 250.42: Diabetes mellitus with
renal manifestations, type II, uncontrolled
• 585.4: CKD, Stage IV
• E10.65: Diabetes type II with hyperglycemia
• E10.22: Diabetes type II with chronic kidney disease
• N18.4: Chronic kidney disease, stage IV
Chapter 9 – Circulatory System
• Acute MI has changed from 8 to 4 weeks acute status
• Hypertensive heart and Kidney disease; same guidelines:– Link hypertension and heart disease in documentation– Hypertension and chronic kidney disease: can assume
linkage
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Hypertension
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ICD-9401.1 – benign essential hypertension
ICD-10I10 – essential hypertension
Stage 3 CKD with CHF Due to HTN
ICD-9 ICD-10404.91 I13.0428.0 I50.9585.3 N18.3
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Coding Stroke (CVA)
Acute Stroke (CVA)ICD-9: 493.91 acute cerebral artery occlusion
with cerebral infarctionICD-10: I63.9 Cerebral infarction, unspecified
“History of”Stroke (CVA)ICD-9: V12.54ICD-10: Z86.73
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Chapter 20 – External Causes
External causes are:
• Health condition due to external cause
• Mostly used for injuries
• V, W, X and Y codes
• Used in 7th character
• Not required or mandated
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Chapter 21 Factors Influencing Health Status
General (adult) medical examination code
ICD-9 V70.0
ICD-10 Z00.00 w/out abnormal findingsZ00.01 with abnormal findings
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Chapter 21 Factors Influencing Health Status
Patient is in for his Annual Wellness Visit (AWV) and he also has hypertension and diabetes.
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ICD-9 ICD-10V70.0 Routine physical exam Z00.01 General medical examination
with abnormal findings
401.9 Diabetes hypertension I10 Hypertension
250.00Diabetes type II, without complications, not stated
as uncontrolledE11.9 Type II diabetes,
without complications
New Non-compliance Codes for ICD-10
Z91.19 Medical Noncompliance
Z91.11 Dietary regimen
Z91.15 Renal Dialysis
Z91.14 Medication regiment, NEC
Z91.14 Underdosing (see also Table of Drugs and chemicals T36-50 with fifth or sixth character 6)
Z91.128 Intentional NEC
Z91.120 Due to financial hardship
Z91.138 Unintentional NEC
Z91.130 Due to patient’s age-related disability
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QUESTIONS?