Conquering the ICD-10 Documentation Challenge

1. Conquering the ICD-10 Documentation Challenge Barbara Oviatt, CPC, CCS-P

2. Purpose Develop a transition process to prepare clinicians to document in an ICD-10 environment

3. Objectives • Evaluate the documentation impact of ICD-10 • Review significant coding guideline variations between ICD-9 and ICD-10 • Demonstrate effective use of GEMs • Develop an effective chart review strategy

4. Documentation Matters!

5. Documentation Matters! • Provider’s responsibility • Facilitates continuity of care • Supports the claim • Diagnosis codes • CPT codes • Modifiers • Will be impacted by ICD-10 • Begin awareness campaign and chart reviews now

6. Chart Review Process • Establish review team members • Identify goals and objectives • Determine the sample • Conduct the chart review • Educate • Re-review

7. Chart Review Process • Determine the sample • Frequently reported ICD-9 codes • Identify top 20 diagnosis • Generate code lists by specialty • Analyze and adjust the list as needed • Establish sample size • Include all providers who code or whose documentation is the basis for code assignment • Number of codes per provider • Number of charts per code / provider

8. Analyze Your Top 20 • Identify the top 20 codes for each specialty and / or provider • Review the GEMs mapping for each code • Review the additional codes in the category • Note the necessary documentation elements • Note any pertinent coding guidelines • Adjust code selections and revise list as necessary

9. What is GEMs? • General Equivalency Mappings • Developed by CMS • Not a crosswalk! • Attempts to find corresponding diagnosis codes between I-9 and I-10 • Often maps to an unspecified code

10. GEMs Example

11. Avoid the Unspecified Trap • GEMs often leads to unspecified code maps • Unspecified can lead to unpaid • Denied for medical necessity • Denied because you should know if it was the left or right • Look for specific alternatives within the code category

12. Asthma GEMs Map: Unspecified to unspecified; search the category for a better alternative.

13. C A T E G O R Y S E A R C H

14. Asthma ICD-9-CM = 493.90 • Extrinsic vs. intrinsic • Chronic obstructive asthma • With status asthmaticus • With exacerbation • Exercise induced bronchospasm • Cough variant asthma  Additional documentation required ICD-10-CM = J45.909 • Mild intermittent  • Mild persistent  • Moderate persistent  • Severe persistent  • With status asthmaticus • With exacerbation • Exercise induced bronchospasm • Cough variant asthma • Tobacco use or exposure (additional code required)  Notes: • Excludes chronic obstructive asthma

15. Tobacco Use and Exposure NEW! Numerous instructions to useadditional code identifying tobacco use or exposure, if applicable

16. Hypertension GEMs mappings:

17. C A T E G O R Y S E A R C H

18. Hypertension Gems mappings:

19. PARTIAL CATEGORYSEARCH - I1

20. Hypertension ICD-9: 401.X – 404.x • Benign • Malignant • Hypertensive heart disease • Hypertensive CKD • Hypertensive heart and CKD • Secondary hypertension • Renovascular • Indicate as appropriate • With / without heart failure • Type of heart failure • Stage of CKD Additional documentation required ICD-10: I10 – I15.x • Essential (without comorbidities) • Comorbidities Present • Hypertensive heart disease • Hypertensive CKD • Hypertensive heart and CKD • Secondary hypertension • Renovascular, endocrine • Underlying condition • Indicate as appropriate • With / without heart failure • Type of heart failure • Stage of CKD • History of use, current use of, or exposure to tobacco  • Distinguish between hypertension and high blood pressure without diagnosis of HTN (coded with R03.0)

21. Other Common Features • Significant expansion of combinationcodes that will require documented specificity of conditions • E20.21 Type I diabetes mellitus with diabetic nephropathy • I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris • K50.112 Crohn’s disease of large intestine with intestinal obstruction

22. Other Common Features • Placeholder character • T42.4x5A Adverse effect of benzodiazepines, initial encounter • Always the letter “x” • Used to keep other characters in their place 5th digit is a place holder 6th digit indicates external cause 7th digit indicates episode of care

23. Other Common Features • Episode of care is associated with various injuries throughout ICD-10 • M80.08A Age related osteoporosis with current pathological fracture, vertebra(e), initial encounter • S61.421D Laceration with foreign body of right hand, subsequent encounter • T21.31xS Burn of third degree of chest, sequela There are 16 episode of care extensions associated with fractures

24. W56.02XA Struck by a Dolphin, Initial Encounter

25. Other Common Features • Codes reflect laterality when appropriate: • H60.332 Swimmer’s ear, left ear • S63.411A Sprain of carpal joint of right wrist, initial encounter • H65.06 Acute serous otitis media, recurrent, bilateral

26. Conduct the Chart Review • Assess the documentation • Potential ICD-10 code assignment • Note strengths and weaknesses • Identify educational needs • Identify process issues

27. Chart Review Follow Up • Educate • Deliver positive feedback to providers • Be prepared and stay focused • Use effective methodology • Lunch and learn meetings • Contests • Flashcards • Diagnosis of the week campaign • Address needs • Template revisions, etc.

28. Chart Review Follow Up • Monitor on established timeline • Re-review for improvement • Re-educate as necessary • Evaluate effectiveness of strategy • Repeat • Select the next code or re-review • Educate • Address needs • Monitor

29. Chart Review Recap

30. Questions…

31. Thank you! boviatt@cpticdpros.com 855-ICD-10CM/855-423-1026