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Why Words Matter Through an Oncology Lens

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Key Objectives for Today’s Session

1. Develop understanding of the role documentation plays in determining patient severity of illness

(SOI), risk of mortality (ROM) and physician quality scores

2. Understand definition and key terminology changes in ICD-10-CM and ICD-10-PCS

3. Understand the concepts of linking conditions and manifestations for more accurate depiction of

patient’s clinical status

©2014 The Advisory Board Company advisory.com

Road Map for Discussion

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Concepts Drive Documentation Requirements

Examples of Diagnoses in ICD-10

Importance of Documentation and Basics of ICD-10-CM/PCS


The Evolution of Clinical Documentation

What was once a tool for communication between providers and clinicians is now the primary data

source to determine quality of patient care. Market forces are leading to Increase in documentation

scrutiny.

Who is the audience for your notes?

Other

Doctors

Care Team

Patients

State

Government

Federal

Government

Insurance

Companies Self


Increased Transparency For Patients

MyCigna.com

HealthGrades- all material and images are sourced from www.healthgrades.com (accessed on 6/18/2012)

Leapfrog- all material and images are sourced from www.leapfroggroup.org (accessed on 6/18/2012)

http://www.healthgrades.com/

http://www.leapfroggroup.org/


Transition from ICD-9-CM to ICD-10-CM/PCS

Per Bill H.R. 4302, “The Secretary of Health and Human Services may not, prior to October 1, 2015,

adopt ICD–10-CM/PCS code sets”.

2011, The Clinical documentation Improvement Specialist's Guide to ICD-10 p.9

Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman,

RN, C-CDI, CCDS.

Benefits and Goals of ICD-10-CM/PCS

• Provides better detail, a more accurate depiction, and improved communication

of patients clinical status

• Allows for more accurate payment for new procedures

• Improves capture of morbidity and mortality data

• Reduces the number of miscoded, rejected and improper claims for

reimbursement


ICD-9-CM vs. ICD-10-CM/PCS: A Comparison

Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory Board

Applications and Technologies Collaborative; CMS (2013). ICD-10 Implementation

guide for small hospitals 1) Code Volume Expansion in ICD-10-CM/PCS

The main difference between ICD-9-CM

and ICD-10-CM/PCS codes, outside of

structural changes, is the SPECIFICITY of

the code.

ICD-10-CM/PCS codes specify several

components not found ICD-9-CM, such as

causal agent, type, laterality, approach,

episode of care, root operation, etc.

Why so many new codes?

14,000

69,000

4,000

72,000

ICD-9 ICD-10

Diagnosis Codes Procedure Codes


Introduction to ICD-10-CM Diagnosis Coding Structure

ICD-10-CM Codes will Contain 3-7 Alphanumeric Characters with the Following Structure

α # α/#

α/# α/# α/#

Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality,

Complication)

Extension

(3-16 options

depending on

category)

α/#

Key ICD-10-CM Documentation Concepts

Specific anatomical location

Degree (mild, moderate, severe, or

unspecified; total/complete vs.

partial/incomplete)

Type (primary, secondary, unspecified) Episode of Care (Initial, Subsequent,

Sequelae)

Acuity (acute, subacute, chronic, acute

on chronic, or unspecified )

Laterality (Right, Left, bilateral, or

unspecified)

Trimester (1,2,3,unspecified) Number of fetus (1-5, other)


Introduction to ICD-10-PCS Coding Structure

In this exercise, we will dissect the structure of an ICD-10-PCS code

Source: AHIMA; The Advisory Board Company research

α/#

α/# α/# α/# α/#

Body

System

Root

Operation

Body

Part

Approach Device Qualifier

α/#

α/#

1. Section –16 options identifying the general type of procedure. Example:

Medical/Surgical Section represents the vast majority of procedures

reported in an inpatient setting

2. Body System - e.g. circulatory system, respiratory system

3. Root Operation - 31 options, based on the objective of the procedure

4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve

5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic

6. Device - 4 basic groups: Grafts/prostheses, implants, simple or mechanical

appliances, and electronic appliance

7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full

thickness burn

Physician documentation

required:

• Type and intent of procedure

(root operation)

• Specific anatomic sites

treated

• Approach

• Specific type of device used

• Validate surgical

complications

• Diagnoses that support

inpatient medical necessity

Section



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Key Concepts To Capture in Your Documentation




Remember: Signs, Symptoms & Test Results Must Be Linked to Related

Diagnoses

While important pieces of the medical record, signs, symptoms and test results are not sufficient for

coders to assign a diagnosis.

The attending physician is responsible for:

• Documenting all conditions in the progress notes and discharge summary

• Resolving conflicts in the documentation

• Linking signs and symptoms to diagnoses may increase

SOI and ROM in the inpatient setting. (The terms

‘probable’, ‘likely’, or ‘suspected’ are all acceptable on the

inpatient record)

• In the ambulatory setting, documentation regarding patient

condition should be to the highest level known, treated or

evaluated

• Abnormal findings (laboratory, x-ray, pathology and other

diagnostic test results) cannot be coded and reported

unless the clinical significance is identified by the treating

provider ICD-10-CM Official Coding Guidelines III.B

Reminder:


Linking Conditions Critical to Capturing Patient Severity

Examples: Linking Diseases

• Hypertension with heart disease

• Endocarditis due to staph aureus

• Right heart failure due to primary pulmonary hypertension

Use terms like “due to” or “with”

Note: Lists, commas, and the word “and” do not link conditions

There is a significant increase in the number of “combination codes” available in the ICD-10-CM/PCS

code set. These codes can help capture the highest level of complexity and acuity in the public eye.

Linking clinically relevant conditions, where appropriate, is the key

takeaway for physicians. Coders cannot assume clinical relationships.


Severity of Illness (SOI) and Risk of Mortality (ROM)

Documentation drives SOI and ROM level assignment. These levels are used to measure patient

acuity, and therefore drive expected patient LOS and mortality rate.

Level Assigned SOI/ROM Category

Minor 1

Moderate 2

Major 3

Extreme 4

Breakdown of SOI/ROM and their Implication on Quality Measures

Four mutually exclusive SOI/ROM categories exist (1-4), and are determined

based on a number of factors including primary and secondary diagnoses,

comorbidities, demographics, patient history, treatment/procedure delivered, etc.



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Key Concepts To Capture in Your Documentation




ICD-10-CM/PCS Oncology Diagnoses Covered Today

Let’s start with these concepts to help explain what documentation will be like in ICD-10-CM/PCS

1 Anemia

2 Sickle Cell Disorders

3 Malnutrition

4 Neoplasms

5 Neoplasm Related Pain


Anemia

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Documentation Concepts

Acuity • Acute

• Chronic

Type • Nutritional Anemia (e.g. iron deficiency, vitamin B12 deficiency,

Folate)

• Hemolytic Anemia

• Enzyme disorders (e.g. glutathione metabolism)

• Thalassemia (e.g. alpha, beta)

• Sickle Cell

• Aplastic Anemia

Etiology • Post hemorrhagic

• Drug induced (autoimmune or non-autoimmune)

• Chemotherapy/Immunotherapy/Radiation

• Malignancy

• Manifestation of an adverse effect or poisoning

Is the anemia secondary to hemorrhage associated with a procedure –

Documentation should specify if Complication or Expected Outcome?


Aplastic Anemia / Pancytopenia

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Specificity impacts Severity of Illness

Condition Documentation Concept Specified Options

Aplastic Anemia Document type and etiology

• Constitutional

• Drug–induced

• Due to other external agents

• Idiopathic

• Other

• Unspecified

Pancytopenia Document etiology

(“due to”)

• Antineoplastic chemotherapy

induced

• Other drug-induced

• Other


Anemia Documentation Takeaways

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When documenting anemia, be sure to document:

1. Acuity of anemia

2. Type of anemia

3. Etiology of anemia

And then specify, specify, specify.


Sickle Cell Disorders

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ICD-10-CM Concepts


Type • Hb-SS

• Thalassemia

• Hb-C

• Other

Clarify if patient is

in Crisis

If yes, document type

• Acute chest syndrome

• Splenic sequestration

• Unspecified

Document any associated fever

Note: If type of Sickle Cell Disorder is not specified – Default is Sickle Cell Disease

without crisis (low SOI)


Sickle Cell Disorders Documentation Takeaways

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When confronting sickle cell disorders,

be sure to document:

1. Type of disorder

2. Acuity of disorder: whether patient is in crisis

3. Any clinical manifestations related to disorder

And then specify, specify, specify.


Malnutrition

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American Academy of Nutrition and Dietetics & American Society for Parental and Enteral Nutrition

(ASPEN) Malnutrition Criteria: Need at least two or more of the following six characteristics help to

identify a malnutrition diagnosis.

Malnutrition Criteria

Insufficient energy intake

Weight Loss

Loss of muscle mass

Loss of subcutaneous fat

Localized or generalized fluid accumulation

that may sometime mask weight loss

Diminished functional status as measure by

hand grip strength

Types of Malnutrition

Major Comorbid Conditions (MCCs)

• Kwashiorkor

• Nutritional marasmus

• Marasmic kwashiorkor

• Unspecified severe protein calorie

malnutrition (United States)

Comorbid Conditions (CCs)

• Mild protein-calorie malnutrition

• Moderate protein-calorie malnutrition

• Unspecified malnutrition

• Cachexia


Malnutrition

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Additional clinical indicators/documentation that support diagnoses of Malnutrition

Multiple Key Components to Weight-Related Diagnoses

BMI<19

• Will impact SOI/ROM

• For protein-calorie malnutrition, indicate mild,

moderate or severe

• Use “starvation” in abuse cases

• Link to other illnesses

BMI>40

• Will impact SOI/ROM

• For severe or morbid obesity:

‒ Link to cause

‒ If drug induced, give the name of the drug

‒ Name bariatric procedures performed

‒ Identify any associated conditions such as obesity

hypoventilation syndrome

Additional

documentation

needs

• History of condition

• Exam

‒Skin care/assessment

• Diagnostic tests

• Diagnoses and linkage

• Treatments in place to treat malnutrition

‒Possible infusion (e.g. TPN)

‒Administration of vitamins/supplements (e.g.

Ensure/Boost)

‒Dietician physical therapy notes

Weight loss, failure to thrive,

cachectic appearing, and

malnourished documentation

does not impact SOI/ROM.

Documentation Tip:


Neoplasms

ICD-10-CM Neoplasm Documentation Concepts

• Specify Site:

• Each specific site

• Primary vs Secondary:

• Are there multiple specific sites and are these sites overlapping?

• Metastases - where is it from and where did it go?

• Laterality – (e.g. right, left bilateral)

• Behavior – (e.g. Benign, In situ, Malignant, Uncertain, or Unspecified)

• Personal history of - is utilized only when the primary neoplasm has been previously excised or

eradicated from its site and is no longer under any type of treatment, and there is no evidence of any

existing primary malignancy

• Documentation that is unclear may result in a query to clarify the status of the neoplasm

• Always link to complications and comorbidities:

• Anemia “due to” neoplastic disease


Neoplasms

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Components to Best Practice Documentation

• Specify Site

• Each specific site

• Primary vs Secondary:

• Metastases - where is it from and where did it go to

• Laterality – Right, left, bilateral

• Behavior – Benign, In situ, Malignant, Uncertain

• Personal history of – Is utilized only when the primary neoplasm has been previously excised or

eradicated from its site and is no longer under any type of treatment, and there is no evidence of any

existing primary malignancy

• Documentation that is unclear may result in a query to clarify the status of the neoplasm

• Always link to complications and comorbidities

• Anemia “due to” neoplastic disease


Best Practice for Neoplasm Documentation

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Components to Best Practice Documentation

• Identify when neoplasms are in different locations in the same site, or they are “overlapping”

(previously known as contiguous)

• Which lung(s), which lobe(s)

• Is it a tumor or a mass

• Is it benign, malignant or uncertain behavior

• Is the neoplasm a primary or secondary site

• “Tumor” and “mass” are coded differently and have different meanings

• Tumor = neoplasm

• Mass = lump

• Lack of clarity in documentation on primary vs secondary sites will generate a query

Specificity is Required


Neoplasm Related Pain

ICD-10-CM Documentation Requirements

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1. Pain related, associated or due to cancer, tumor, or primary or secondary

malignancies is coded consistently regardless of acute or chronic nature.

2. Pain may be the principal diagnosis when the reason for admission is pain

management – the underlying neoplasm is then a secondary diagnosis

3. Link pain type to the condition:

Example:

• Chronic pain due to …

• Phantom limb pain from R BKA

4. Is a spinal neurostimulator or intrathecal infusion pump being used to treat the patient

- If so, document.


Neoplasm Related Pain

Neoplasm related pain (acute) (chronic)

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G 8 9 3

Other disorders of the nervous system Related to cancer,

tumor or malignancy

Synonyms:

• Cancer associated pain

• Pain due to malignancy(primary)

(secondary)

• Tumor associated pain


Summary of Best Practice Documentation Teaching Points

Key Documentation Concepts

• Conflicting, incomplete, or ambiguous documentation will lead to a query

• Carry all documentation from diagnostic test into progress notes to

ensure it will be captured

• Sign, symptoms and test results do not contribute to SOI unless their

significance is documented or they are linked to a named disease

• Identify all primary and secondary sites, and when multiple sites are

separate or overlapping

• Specify when a “history of malignancy” is a current diagnosis or it is

resolved – adds a CC when a secondary diagnosis

• Specify the reason for the inpatient admission – to deliver chemotherapy,

to treat a complication due to malignancy or to provide definitive surgical

treatment

• If neoplasm(s) has been resected, document any evidence of current

disease

• Remember to capture documentation of any procedural complications

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