Obtain ICD-10 Transition Success

Three steps will help you code to the highest level of specificity.

By Julie-Leah J. Harding, CPC, RMC, PCA, CCP, SCP-ED, CDIS

Clinicians must document with clarity the precise conditions they are managing, and how a patient is responding to treatment, to ensure diagnoses and procedures are coded to the level of specificity ICD-10 permits. This sounds like a lot to hope for, but in just three steps, your physician practice or acute care facility can be on its way to clinical documentation improvement (CDI)—and one step closer to a smooth ICD-10 transition.

Assess your current state of documentation. This will reveal whether appropriate and complete treatment has been captured within the medical record. Patient care must be captured accurately, precisely, and in a timely manner.

Analyze claims data. Understand when and why claims are down-coded or rejected due to insufficient documentation for the procedure and/or the diagnosis reported.

Implement clinician education. New practices, policies, and education will hone your clinicians’ skills to limit future deficiencies. (This will be an ongoing process, not a one-time effort.)

CDI Promotes Specificity

Come Oct. 1, 2014, clinicians will have to be much more specific about the procedures they perform and the diagnoses they make. Begin your assent toward CDI by looking at areas of documentation that are commonly deficient.

Laterality

Probably the biggest change clinicians will have to make is stating the side (right or left) on which the injury or neoplasm has occurred. Roughly 5,000 codes have a right and left distinction, including:

  • Joint pain
  • Joint effusion
  • Injury
  • Fractures
  • Sprains
  • Tears, meniscus, cruciate ligament
  • Dislocations
  • Arthritis
  • Cerebral infarction
  • Extremity atherosclerosis
  • Pressure ulcers
  • Cancers, neoplasms (breast, lung, bones, etc.)
  • Arthritis

Example: Clinical indication: Acute pain, right knee

ICD-10: M25.561 Pain in right knee

Stage of Care

Many injuries, particularly fractures, will require documentation to indicate what stage of the patient’s care the physician has rendered, so an appropriate seventh character can be assigned. Stage of care indicators are:

A – Initial encounter (for closed fracture)

B – Initial encounter for open fracture (type I or II or not otherwise specified (NOS))

C – Initial encounter for open fracture type IIIA, IIIB, or IIIC

D – Subsequent encounter (with routine healing)

E – Subsequent encounter for open fracture type I or II with routine healing

F – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

G – Subsequent encounter (closed fracture) with delayed healing

H – Subsequent encounter for open fracture type I or II with delayed healing

J – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

K – Subsequent encounter for fracture with nonunion

M – Subsequent encounter for open fracture type I or II with nonunion

N – Subsequent encounter for open fracture type IIA, IIIB, or IIC with nonunion

P – Subsequent encounter for (closed) fracture with malunion

Q – Subsequent encounter for open fracture type I or II with malunion

R – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

S – Sequela

Example: Final ER Consult Impression: Bucket-handle tear, lateral meniscus, right knee

ICD-10: S83.251A Bucket-handle tear of lateral meniscus, current injury, right knee, initial encounter

Example: ER presentation of right foot pain, previous fracture; final ER impression: Fracture of the base of the second metatarsal

ICD-10: S92.321K Displaced fracture of second metatarsal bone, right foot, subsequent encounter for fracture with nonunion

Although it’s better to query a clinician about missing documention, if the clinician doesn’t indicate whether a fracture is open or closed, the code selection is captured as closed; and if the clinician doesn’t indicate whether a fracture is displaced, the code selection is captured as displaced. Likewise, certain ER visits are generally assumed to be initial encounters, such as:

  • Injury
  • Wound/Laceration
  • Fracture
  • Dislocation
  • Sprain
  • Concussion
  • Contusion
  • Hemorrhage
  • Avulsion
  • Amputation

Example: Final impression for an ER visit: Contusion, right knee

ICD-10: S80.01xA Contusion of right knee, initial encounter.

As this is an injury seen in the ER setting, the seventh character “A,” for initial encounter, stands to reason.

Diabetes

Documentation will need to include the type or cause of diabetes for ICD-10 code selection:

  • Type I
  • Type II
  • Due to drugs and chemicals
  • Due to underlying condition
  • Other specified diabetes
  • Pregnancy

Documentation of conditions/complications of pregnancy will need to specify the trimester in which they occurred. The clinician’s documentation of “weeks” may be used to assign appropriate codes for the trimester:

First trimester = < 14 weeks, 0 days

Second trimester = 14 weeks, 0 days to < 28 weeks, 0 days

Third trimester = > 28 weeks until delivery

Scales

ICD-10 codes will enable you to include documented (or queried) information on measurement scales. For example:

  • Asthma severity classification scale of:
    • intermittent;
    • mild persistent;
    • moderate persistent; and
    • severe persistent.
  • Glasgow Coma Scale will need a score from each of the three assessment areas:
    • eye opening;
    • verbal response; and
    • motor response.
  • Gustilo Open Fracture Classification-I, II, III, IIIB, or IIIC
  • General and Focal Seizures

General seizures require the clinician to identify the specific type of seizure the patient is having, as well as to identify if the seizure is intractable. See ICD-10-CM Tabular List of Diseases and Injuries 2014, chapter 6, Diseases of the nervous system (G00–G99):

G40 Epilepsy and recurrent seizures

Note: the following terms are to be considered equivalent to intractable: pharmacoresistant (pharmacologically resistant), treatment resistant, refractory (medically) and poorly controlled

G40.00 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable

Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset without intractability

G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus

G40.009         Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus

                  Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset NOS

G40.01         Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable

G40.011         Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus

G40.019         Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus

Poisoning

Clinicians must identify and document the substance related to adverse effect, poisoning, or toxic effect encounters (see ICD-10-CM Tabular List of Diseases and Injuries 2014, chapter 19, Injury, poisoning and certain other consequences of external causes). It will be equally important for clinicians to state if the medications were taken as prescribed. Coders, billers, and CDI professionals will benefit from taking a pharmacology course to better understand drug interactions and classifications.

T45.60 Poisoning by, adverse effect of and underdosing of unspecified fibrinolysis-affecting drugs

T45.601 Poisoning by unspecified fibrinolysis-affecting drugs, accidental (unintentional)

Poisoning by fibrinolysis-affecting drug NOS

T45.602 Poisoning by unspecified fibrinolysis-affecting drugs, intentional self-harm

T45.603         Poisoning by unspecified fibrinolysis-affecting drugs, assault

T45.604         Poisoning by unspecified fibrinolysis-affecting drugs, undetermined

T45.605         Adverse effect of unspecified fibrinolysis-affecting drugs

T45.606         Underdosing of unspecified fibrinolysis-affecting drugs

T45.61      Poisoning by, adverse effect of and underdosing of thrombolytic drugs

T45.611         Poisoning by thrombolytic drug, accidental (unintentional)

              Poisoning by thrombolytic drug NOS

T45.612         Poisoning by thrombolytic drug, intentional self-harm

T45.613         Poisoning by thrombolytic drug, assault

T45.614         Poisoning by thrombolytic drug, undetermined

T45.615         Adverse effect of thrombolytic drugs

T45.616         Underdosing of thrombolytic drugs

Be More Specific

Improved code granularity allows for capturing more specific diagnoses. For example, current documentation following barium swallow may state, “dysphagia.” Under ICD-10, this will be insufficient, and the provider will have to provide enough detail to distinguish among the following (see ICD-10-CM Tabular List of Diseases and Injuries 2014, chapter 19, Injury, poisoning and certain other consequences of external causes):

R13.11 Dysphagia, oral phase

R13.12 Dysphagia, oropharyngeal phase

R13.13 Dysphagia, pharyngeal phase

R13.14 Dysphagia, pharyngoesophageal phase

More specificity will also be required for anatomy, as ICD-10 codes point to exact locations. For example, Spondylosis (ICD-10 header M47) allows you to choose among the following locations where the condition may occur:

  • Occipito-atlanto-axial
  • Cervical
  • Cervicothoracic
  • Thoracic
  • Thoracolumbar
  • Lumbar
  • Lumbosacral
  • Sacral and sacrococcygeal

See ICD-10-CM Tabular List of Diseases and Injuries 2014, chapter 13, Diseases of the musculoskeletal system and connective tissue:

M47.0      Anterior spinal and vertebral artery compression syndromes

             M47.01      Anterior spinal artery compression syndromes

M47.011           Anterior spinal artery compression syndromes, occipito-atlanto-axial region

M47.012           Anterior spinal artery compression syndromes, cervical region

M47.013           Anterior spinal artery compression syndromes, cervicothoracic region

M47.014           Anterior spinal artery compression syndromes, thoracic region

M47.015           Anterior spinal artery compression syndromes, thoracolumbar region

M47.016           Anterior spinal artery compression syndromes, lumbar region

M47.019           Anterior spinal artery compression syndromes, site unspecified

             M47.02      Vertebral artery compression syndromes

M47.021           Vertebral artery compression syndromes, occipito-atlanto-axial region

M47.022           Vertebral artery compression syndromes, cervical region

M47.029           Vertebral artery compression syndromes, site unspecified

M47.1      Other spondylosis with myelopathy

             Spondylogenic compression of spinal cord

             Excludes1: Vertebral subluxation (M43.3-M43.59)

M47.10         Other spondylosis with myelopathy, site unspecified

M47.11         Other spondylosis with myelopathy, occipito-atlanto-axial region

M47.12         Other spondylosis with myelopathy, cervical region

M47.13         Other spondylosis with myelopathy, cervicothoracic region

M47.14         Other spondylosis with myelopathy, thoracic region

Grafts must be specified by type:

  • Autologous
  • Nonautologous
  • Nonbiological

Document dominant verses non-dominant side for all paralytic syndrome codes such as hemiplegia, monoplegia, and hemiparesis, as shown here:

G81.0      Flaccid hemiplegia

G81.00        Flaccid hemiplegia affecting unspecified side

G81.01        Flaccid hemiplegia affecting right dominant side

G81.02        Flaccid hemiplegia affecting left dominant side

G81.03        Flaccid hemiplegia affecting right nondominant side

G81.04        Flaccid hemiplegia affecting left nondominant side

G81.1      Spastic hemiplegia

G81.10        Spastic hemiplegia affecting unspecified side

G81.11        Spastic hemiplegia affecting right dominant side

G81.12        Spastic hemiplegia affecting left dominant side

G81.13        Spastic hemiplegia affecting right nondominant side

G81.14        Spastic hemiplegia affecting left nondominant side

Document whether the condition is initial or recurrent, as shown in ICD-10-CM Tabular List of Diseases and Injuries 2014, chapter 7, Diseases of the eye and adnexa (H00-H59) and chapter 10, Diseases of the repiratory system (J00-J99):

H11.06 Recurrent pterygium of eye

H11.061 Recurrent pterygium of right eye

H11.062 Recurrent pterygium of left eye

H11.063 Recurrent pterygium of eye, bilateral

H11.069 Recurrent pterygium of unspecified eye

H65.19      Other acute nonsuppurative otitis media

             Acute and subacute mucoid otitis media

             Acute and subacute nonsuppurative otitis media NOS

             Acute and subacute sanguinous otitis media

             Acute and subacute seromucinous otitis media

H65.191         Other acute nonsuppurative otitis media, right ear

H65.192         Other acute nonsuppurative otitis media, left ear

H65.193         Other acute nonsuppurative otitis media, bilateral

H65.194         Other acute nonsuppurative otitis media, recurrent, right ear

H65.195         Other acute nonsuppurative otitis media, recurrent, left ear

H65.196         Other acute nonsuppurative otitis media, recurrent, bilateral

H65.197         Other acute nonsuppurative otitis media recurrent, unspecified ear

H65.199         Other acute nonsuppurative otitis media, unspecified ear

J01.3      Acute sphenoidal sinusitis

             J01.30      Acute sphenoidal sinusitis, unspecified

             J01.31      Acute recurrent sphenoidal sinusitis

Example Presentation Shows the Way

Consider this common ER presentation:

A middle-aged woman presents to the ER. She was cooking in her kitchen when a cabinet fell off the wall and hit her on the head, causing a concussion and intractable headaches.

Documentation must be as specific as possible to assign the correct ICD-10 codes because of the many variables in this scenario, which include:

  • Type of encounter (initial or subsequent)
  • Applied specificity (did the patient lose consciousness?)
  • Acute versus chronic
  • Relief or non-relief (intractable versus non-intractable)
  • External cause (what caused the accident?)
  • Activity (what was the patient doing when she was injured?)
  • Location (where was the patient when she was injured?)

Time is of the essence—begin your CDI initiative today. Query clinicians on the ICD-9-CM code set to identify whether current documentation practices will support the level of specificity necessary for ICD-10-CM diagnosis and procedure coding. Develop a priority list of diagnoses and procedures requiring greater documentation detail and identify clinicians (including nurses) who would benefit from focused ICD-10 training efforts.

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Julie-Leah J. Harding, CPC, RMC, PCA, CCP, SCP-ED, CDIS, is senior manager of billing compliance at Mass General Hospital with 22 years of experience in coding, compliance, training, practice management, and auditing. She specializes in performing evaluation and management, emergency department, and congenital cardiovascular surgical audits within the acute care and outpatient settings. Harding trains and orients providers on all facets of documentation guidelines, coding, and compliance and is an ICD-10 ambassador and trainer. She implements SNOMED CT® methodology and GEMs, and is a member of the Boston, Mass., local chapter.

Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

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About Has 428 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

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