UHS, Inc. ICD-10-CM/PCS Physician Education Neonatal and Pediatrics

1. UHS, Inc. ICD-10-CM/PCS Physician Education Neonatal and Pediatrics

2. ICD-10 Implementation • October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) • Ambulatory and physician services provided on or after 10/1/15 • Inpatient discharges occurring on or after 10/1/15 • ICD-10-CM (diagnoses) will be used by all providers in every health care setting • ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures • ICD-10-PCS will not be used on physician claims, even those for inpatient visits

3. Why ICD-10 Current ICD-9 Code Set is: • Outdated: 30 years old • Current code structure limits amount of new codes that can be created • Has obsolete groupings of disease families • Lacks specificity and detail to support: • Accurate anatomical positions • Differentiation of risk & severity • Key parameters to differentiate disease manifestations

4. Diagnosis Code Structure

5. ICD-10-CM Diagnosis Code Format

6. Comparison: ICD-9 to ICD-10-CM

7. Procedure Code Structure

8. ICD-10-PCS Code Format

9. ICD-10 Changes Everything! • ICD-10 is a Business Function Change, not just another code set change. • ICD-10 Implementation will impact everyone: • Registration, Nurses, Managers, Lab, Clinical Areas, Billing, Physicians, and Coding • How is ICD-10 going to change what you do?

10. ICD-10-CM/PCS Documentation Tips

11. ICD-10 Provider Impact • Clinical documentation is the foundation of successful ICD-10 Implementation • Golden Rule of Documentation • If it isn’t documented by the physician, it didn’t happen • If it didn’t happen, it can’t be billed • The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient • what services were rendered and what is the severity of illness • The key word is SPECIFICITY • Granularity • Laterality • Complete and concise documentation allows for accurate coding and reimbursement

12. Gold Standard Documentation Practices • Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms • Document diagnoses, rather that descriptors • Indicate acuity/severity of all diagnoses • Link all diseases/diagnoses to their underlying cause • Indicate “suspected”, “possible”, or “likely” when treating a condition empirically • Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers • Clarify diagnoses that are present on admission • Clearly indicate what has been ruled out • Avoid the use of arrows and symbols • Clarify the significance of diagnostic tests

13. ICD-10 Provider Impact The 7 Key Documentation Elements: • Acuity – acute versus chronic • Site – be as specific as possible • Laterality – right, left, bilateral for paired organs and anatomic sites • Etiology – causative disease or contributory drug, chemical, or non-medicinal substance • Manifestations – any other associated conditions • External Cause of Injury – circumstances of the injury or accident and the place of occurrence • Signs & Symptoms – clarify if related to a specific condition or disease process

14. ICD-10 Provider Impact Newborn Documentation: • Gestational age / prematurity • Extreme immaturity – less than 28 weeks gestation • Preterm – 28 weeks or more but less than 37 weeks gestation • Post-term – 40 – 42 weeks gestation • Prolonged – more than 42 weeks gestation • Weight • Extremely low birth weight – less than 999 grams • Low birth weight – 1000 – 2499 grams • Heavy – 4000 – 4499 grams • Exceptionally large – 4500 grams or more • Abnormalities in fetal size and health • Differentiate community-acquired versus conditions related to the birthing process • Abnormal results from neonatal screenings

15. ICD-10 Provider Impact Newborn – birth to 28 days of life Document any condition (even those that may impact future healthcare needs) that requires: • Further clinical evaluation • Therapeutic treatment • Diagnostic procedure • An extended length of hospital stay • Increase in nursing care and / or monitoring Document maternal conditions that impact the health of the baby

16. ICD-10 Documentation Tips Do not use symbols to indicate a disease. For example “↑lipids” means that a laboratory result indicates the lipids are elevated • or “↑BP” means that a blood pressure reading is high These are not the same as hyperlipidemia or hypertension

17. ICD-10 Documentation Tips Site and Laterality – right versus left • bilateral body parts or paired organs Example – cellulitis of right upper arm Stage of disease • Acute, Chronic • Intermittent, Recurrent, Transient • Primary, Secondary • Stage I, II, III, IV Example – stage of pressure ulcer: • L89.011 Pressure ulcer of right elbow, stage 1 • L89.021 Pressure ulcer of left elbow, stage 1

18. ICD-10 Documentation Tips Birth Injury • Site and type of trauma • Birth injury to facial nerve • Fractured clavicle due to birth process • Subdural hemorrhage related to birth injury • Erb’s palsy • Contributing factors • Scalp of facial bruising due to forceps • Injury to scalp due to monitoring equipment

19. ICD-10 Documentation Tips Feeding Problems • Specify related conditions and the feeding problem • Vomiting • bilious or other • Regurgitation • Rumination • Slow feeding • Underfeeding • Overfeeding • Difficulty with breast feeding • Failure to thrive

20. ICD-10 Documentation Tips Neonatal Jaundice • Specify cause • Associated with preterm delivery • Due to: • Infection • Polycythemia • Swallowed maternal blood • Drugs or toxins • Excessive hemolysis • Breast milk inhibitor • Hepatocellular damage • Document type of hepatitis, if applicable

21. ICD-10 Documentation Tips Noxious Influences • Specify condition • Withdrawal symptoms • Alcoholic fetor • Allergic reaction • Specify substance • Prescribed or illicit drugs • Alcohol • Smoking • Specify exposure • Via the placenta, maternal use • Administered during labor and delivery • Given directly to newborn

22. ICD-10 Documentation Tips Respiratory • If disease if unknown, document the signs and symptoms • If known, document the most specific disease • Neonatal aspiration • Meconium, amniotic fluid, mucus, blood • Aspiration of mild or regurgitated food • Respiratory Distress Syndrome • Type I or Type II • Respiratory Failure • Respiratory Arrest • Newborn apnea • Primary obstructive, cyanotic attacks, apnea of prematurity

23. ICD-10 Provider Impact Congenital Malformation Documentation: • Congenital and chromosomal anomalies that impact throughout the patient’s life • Laterality • Right, left, bilateral • Anatomical site and malformation, deformity, abnormality • Associated manifestations • Surgically corrected congenital malformation • Document as history of

24. ICD-10 Provider Impact Chromosomal Abnormality Documentation: • Specific chromosome anomaly • Down syndrome, trisomy 18, Turner’s • Mosaic • Non-mosaicism, mosaicism, translocation • Associated physical conditions and degree of mental retardation • Metabolic disorders • Associated duplications or deletions • Due to unbalanced translocations, inversions and insertions related to complex rearrangements

25. ICD-10 Documentation Tips Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post-procedural disorders • The provider must clearly document the relationship between the condition and the procedure • Example: • D78.01 –Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen • D78.21 –Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen

26. ICD-10 Documentation Tips

27. ICD-10 Documentation Tips ICD-10-PCS does not allow for unspecified procedures, clearly document: • Body System • general physiological system / anatomic region • Root Operation • objective of the procedure • Body Part • specific anatomical site • Approach • technique used to reach the site of the procedure • Device • Devices left at the operative site

28. ICD-10 Documentation Tips Most Common Root Operations:

29. Summary The 7 Key Documentation Elements: • Acuity – acute versus chronic • Site – be as specific as possible • Laterality – right, left, bilateral for paired organs and anatomic sites • Etiology – causative disease or contributory drug, chemical, or non-medicinal substance • Manifestations – any other associated conditions • External Cause of Injury – circumstances of the injury or accident and the place of occurrence • Signs & Symptoms – clarify if related to a specific condition or disease process