4/22/2015
ICD-10 FROM A NURSE
PERSPECTIVE
Learning Objectives
1. New ICD-10-CM diagnostic
system for Dermatology.
2. Impact of new codes on
nursing and clinical support
staff.
3. Education and resources
available.
Adoption of ICD-10 Classification of Diseases
CD-10-CM Diagnostic Codes
Mandated and goes into effect October 1,
2015
Required for all physicians and health care
professionals.
ICD-9 goes away
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Why is ICD-9 going away?
ICD-9-CM codes no longer fit with the needs of the 21st century
healthcare system.
ICD-9-CM is unable to support current health information needs.
ICD-9-CM does not meet current needs to track, identify, and
analyze new clinical services and treatments available to
patients.
ICD-9-CM codes are becoming obsolete and out of date for a
modern healthcare delivery system
ICD-10-CM (diagnoses) will be used by all providers in
every health care setting –
Will replace ICD-9 codes currently in place
are 8 digits in length/alpha numeric sequence, and
they always start with an alpha character, which
references the chapters of the ICD-10 code book.
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
Developed by WHO (World Healthcare
Organization).
Been in use by other countries since the
1960’s.
Will affect diagnosis and inpatient procedure
coding for everyone covered ty the Health
Insurance an Portability and Accountability Act
(HIPAA)
Currently accepted and being used in over 100
industrialized countries
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Expansion of codes selection to reveal;
quality of care, so the data can be used in a more
meaningful way to better understand
complications
better design clinically robust algorithms
to better track the outcomes of care
Will be in align with the rest of the world for
tracking healthcare data
ICD-10
Classification system Number of codes Digits
ICD-9-CM
13,000
•3-5 digits
•Digit 1 is alpha (E or V) or
numeric
•Digits 2-5 are numeric
ICD-10-CM
68,000+
•3-7 digits
•Digit 1 is alpha
•Digit 2 is numeric
•Digits 3-7 are alpha or
numeric
Quality Problem with ICD-9 -CM
• Example – fracture of wrist
• Patient fractures left wrist
• A month later, fractures right wrist
• ICD-9-CM does not identify left versus
right –
• Requires additional documentation
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• -ICD-10-CM describes
• Left versus right
• Initial encounter, subsequent
encounter
• Routine healing, delayed healing,
nonunion, or malunion
Physicians and clinicians are at the
center
The physician is the driver of patient care, but that’s not all;
Involved in running a business
Driving appropriate reimbursement of care provided
Keeping abreast of new technology and the ever changing
health care regulatory environment
Ensures standards of medical necessity, severity of illness,
and quality of care are met
ICD-10-CM affects all these areas and requires further work, so that
better medical outcomes happen.
Coding Data Is Also The Basis For Physician Profiling
Today’s health care trends allow for more transparency
CMS has implemented the Physician Comparison
Website
Information is now made public as of January 1, 2014
With the implementation and trends of ICD-10-CM,
physicians will only be viewed to be as good as the data
that is collected about them
Patients are becoming consumers, and using tools to
evaluate, compare, and ultimately select a provider for
their care
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Why is Documentation Necessary
For payment purposes, each patient’s medical record must
accurately reflect the health care services provided, and the
code(s) billed for those services must be supported by adequate
documentation.
Documentation also describes what you did and why it was
necessary. Supports the billing you submit for your services.
From an auditor’s perspective, if there is no documentation than
the service did not occur.
Documenting more (or less) than what was performed, and/or
billing for more or less than what was performed and
documented is FRAUD.
ICD-10 Codes for Dermatology
• In ICD-9 coding, dermatology comprised of only 13,000
diagnosis codes.
• In ICD-10 coding, dermatology has expanded to more than
68,000 diagnosis codes to select from.
What’s new to Dermatology
• Expansion of codes:
- Non pressure ulcers
- Wound care
- Diabetes
- Neoplasm
- Other psoriasis
- New personal and family history codes
• Documentation in a patient chart must be
more specific
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ICD-10 Codes for Dermatology
Codes are now selected for:
greater specificity
Laterality
clinical detail to provide information for clinical decisionmaking and outcomes research
ICD-10-CM’s also:
allow for the creation of a post-procedural category, and
other factors that can affect health (e.g., lifestyle,
socioeconomic status, and family relationships)
Quality coded data is dependent on accurate and
complete clinical documentation
CLINICAL DOCUMENTATION
IMPROVEMENT
Pressure ulcers
Site (include laterality)
Pressure ulcer stage
Stage 1
Stage 2
Stage 3
Stage 4
Unspecified
Document any associated
diagnosis/conditions
Document if ulcer
(including stage) is present
on admission
CODING CONVENTION/GUIDELINE:
LATERALITY
• “Laterality” (side of the body affected) is a new coding
convention added to relevant ICD-10 codes to increase
specificity.
• Designated codes for conditions such as ulcers, burns,
fractures…will require documentation of the side/region of
the body where the condition occurs.
• In ICD-10, laterality descriptions include right, left, bilateral or
unspecified designations:
• Right side = character 1
• Left side = character 2
• Bilateral = character 3
• Unspecified side/region = character 0 or 9 (depending on
whether it is a 5th or 6th character)
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NEW CODING TERMINOLOGY
• ICD-9-Terminology
• Senile
• Intermediate
coronary syndrome
• Acute myocardial
infarction
• ICD-10 Terminology
• Age-related
• Unstable Angina
• ST elevation (STEMI)
or
• Non-ST elevation
(NSTEMI) myocardial
infarction
CLINICAL DOCUMENTATION
IMPROVEMENT
Non-Pressure Ulcers
Site
Ulcer depth
Cause of lower limb
ulcers
With gangrene
Document any
associated
diagnoses/conditions
CLINICAL DOCUMENTATION
IMPROVEMENT
• Pressure ulcer coding
• Ulcer site
• Unstageable
• Stage 1
• Stage 2
• Stage 3
• Stage 4
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CLINICAL DOCUMENTATION
IMPROVEMENT
Diabetes
Type
Control
Insulin use
Document any
associated
diagnoses/conditions
Manifestation/
complication
ClinicaDocumentation
Improvement
Neoplasms
Behavior
Laterality
Anatomical site
Other conditions
Complication(s)
• History of:
WOUND CARE AND ICD-10
• 2015 ICD-10-CM Diagnosis code Z48.00
• Encounter for change or removal of
nonsurgical wound dressing
• Z48.00 is a billable ICD-10-CM Code that
can be used to indicate a diagnosis for
reimbursement purposes
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Expanded Diagnosis code
examples
ICD-9
696.1 Other Psoriasis
ICD-10
L40.0 Psoriasis vulgaris
L40.1 General pustular psoriasis
L40.2 Acrodermatitis continua
L40.3 Pustulosis palmaris et
plantaris
L40.4 Guttate psoriasis
L40.8 Other psoriasis
L40.9 Psoriasis unspecified
Expanded Diagnosis Code Examples
ICD-9
ICD-10
• 696.1 Other Psoriasis
• L40.0 Psoriasis vulgaris
• L40.1 General pustular
psoriasis
• L40.2 Acrodermatitis
continua
• L40.3 Pustulosis palmaris
et plantaris
• L40.4 Guttate psoriasis
• L40.8 Other psoriasis
• L40.9 Psoriasis
unspecified
Expanded Diagnosis code example
ICD-9
• 173.50 Other malignant
neoplasm of skin of trunk, except
scrotum
ICD-10
•
•
•
•
•
•
•
•
•
•
•
•
C44.500 Unspecified malignant neoplasm of
anal skin
C44.501 Unspecified malignant neoplasm of skin
of breast
C44.509 Unspecified malignant neoplasm of skin
of other part of trunk
C44.510 Basal cell carcinoma of anal skin
C44.511 Basal cell carcinoma of skin of breast
C44.519 Basal cell carcinoma of skin of other part
of trunk
C44.520 Squamous cell carcinoma of anal skin
C44.521 Squamous cell carcinoma of skin of
breast
C44.529 Squamous cell carcinoma of skin of other
part of trunk
C44.590 Other specified malignant neoplasm of
anal skin
C44.591 Other specified malignant neoplasm of
skin of breast
C44.599 Other specified malignant neoplasm of
skin of other part of trunk
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Reimbursement Changes due to ICD-10-CM
• Payers might be ok at first for billing general unspecified ICD10-CM’s
• will later catch up and reduce your payments significantly
• Reduction of payments would be a huge loss to a practice trying
to provide any level of quality of care, if they cannot afford to
staff it
• If documentation is missing, payers might come back and recoup
money paid, and/or audit patient chart notes more frequently,
when unspecified diagnosis ICD-10-CM Codes are billed.
Minimizing Costs For Your Practice for ICD-10
Education
• Use free webinar and education training on internet
• A.A.D. Members have access to tools and resources on the
AAD website
• D.N.A. Website also has tools and resources available
• Hire an outside vendor
• Utilize your current EHR
• Create a more robust IT department
• If staffing allows, hold regular educational sessions internally
with coders and physicians and non-physician providers.
How to minimize costs for training of ICD-10
• Take advantage of all the free online training CMS, Medicare,
and various agencies have to offer, and encourage staff to go
online and educate themselves
• Utilize online member training and tools and tricks that the
A.A.D. (Academy of Dermatology) puts out on their website
• If your practice does hire an outside vendor, make sure when
you select them, that their staff is qualified, and they tailor to
meet the needs of your practice
- Ensure that the vendor focuses on documentation
techniques. Codes are important, but appropriate
documentation is the key to ICD-10
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Other ways to minimize costs for ICD-10
training
• Using EHR (electronic health record):
- Create EHR Templates internally to meet the needs of your
practice.
- Templates can prompt staff to select the best specificity and
laterality for documentation and coding selection
- Revise your current patient health care questionnaire and/or internal
forms, to prompt more specific patient information, that can get to
better coding practices with the new ICD-10 coding system.
- Work with your hospital or staff to create some disease templates
with specificity and granularity check boxes.
Centers for Medicare & Medicaid
Services
• cms.hhs.gov
• Provides consumer information and insurance oversight
of governmental and private health plans; resources and
tools for Medicare and Medicaid/CHIP agencies;
regulatory and guidance info; updated quarterly
• Daily email updates (free)
Other Resources on Web
• www.aad.org
• Provides online tools and resources for both physicians and nonphysicians as it pertains to ICD-10 coding system
• Can subscribe to newsletters and access their Q&A sessions with other
dermatology practices nationwide on ICD-10 education and training.
• www.ahima.org
a.k.a. American Health Information Management Association
Provides free online education and resources to health care practices.
Most experienced and highly cost-effective ICD-10 training provider.
• www.encoderpro.com
Web based software that incorporates the AMA CPT, HCPCS Codes,
ICD9-CM and ICD10-CM code look up (crosswalks ICD-9 to ICD-10)
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Other Resources for ICD-10 Education and Training
• www.noridianmedicare.com
• Medicare agency for 10 states to include OR, WA, AZ, WY, ID, UT, ND,
MT, SD, and AK.
• Provides updates to implementation of ICD-10
• Hosts live Webinars with Q&A sessions and slide presentations for
free
www.dnanurse.org
• Dermatology Nursing association website – provides online tools and
resources for continuing education and updates within the
dermatology community.
• www.precyse.com
• Vendor and leader in Performance Management and Technology
• Provides online learning modules and tests for ICD-10 preparation in
all aspects of health care settings.
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