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Why Words Matter

Through a Radiology Lens

©2014 The Advisory Board Company • advisory.com 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 2 advisory.com Road Map for Discussion

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

2 Concepts Drive Documentation Requirements

3 Examples of Radiology Diagnoses in ICD-10-CM

©2014 The Advisory Board Company 3 advisory.com 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?

Insurance Companies Self State Government Care Team

Other Patients Federal Doctors Government

©2014 The Advisory Board Company 4 advisory.com 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)

©2014 The Advisory Board Company 5 advisory.com 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”.

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

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.

©2014 The Advisory Board Company 6 advisory.com ICD-9-CM vs. ICD-10-CM/PCS: A Comparison

72,000 69,000

Why so many new codes? The main difference between ICD-9-CM and ICD-10-CM/PCS codes, outside of structural changes, is the SPECIFICITY of the code.

14,000 ICD-10-CM/PCS codes specify several components not found ICD-9-CM, such 4,000 as causal agent, type, laterality, approach, episode of care, root ICD-9 ICD-10 operation, etc. Diagnosis Codes Procedure Codes

Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory Board Applications and Technologies Collaborative; CMS (2013). ICD-10 1) Code Volume Expansion in ICD-10-CM/PCS Implementation guide for small hospitals

©2014 The Advisory Board Company 7 advisory.com 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/# α/#

Category Sub-categories Extension (Etiology, Anatomic Site, Severity, Laterality, (3-16 options Complication) depending on category)

Key ICD-10-CM Documentation Concepts

Degree (mild, moderate, severe, or Specific anatomical location unspecified; total/complete vs. partial/incomplete) Episode of Care (Initial, Subsequent, Type (primary, secondary, unspecified) Sequelae) Acuity (acute, subacute, chronic, acute on Laterality (Right, Left, bilateral, or chronic, or unspecified ) unspecified)

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

©2014 The Advisory Board Company 8 advisory.com Introduction to ICD-10-PCS Coding Structure In this exercise, we will dissect the structure of an ICD-10-PCS code α/# α/# α/# α/# α/# α/# α/#

Section Body Root Body Approach Device Qualifier System Operation Part

1. Section –16 options identifying the general type of procedure. Example: Physician documentation Medical/Surgical Section represents the vast majority of procedures required: reported in an inpatient setting

• Type and intent of procedure 2. Body System - e.g. circulatory system, respiratory system (root operation) 3. Root Operation - 31 options, based on the objective of the procedure • Specific anatomic sites treated 4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve • Approach • Specific type of device used 5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic • Validate surgical 6. Device - 4 basic groups: Grafts/prostheses, implants, simple or complications mechanical appliances, and electronic appliance • Diagnoses that support inpatient medical necessity 7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full thickness burn

Source: AHIMA; The Advisory Board Company research ©2014 The Advisory Board Company 9 advisory.com Road Map for Discussion

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

2 Key Concepts To Capture in Your Documentation

3 Examples of Radiology Diagnoses in ICD-10

©2014 The Advisory Board Company 10 advisory.com 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. • 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: The attending physician is responsible for:

• Documenting all conditions in the progress notes and discharge summary • Resolving conflicts in the documentation

©2014 The Advisory Board Company 11 advisory.com

Linking Conditions Critical to Capturing Patient Severity 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.

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

©2014 The Advisory Board Company 12 advisory.com 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.

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.

Level Assigned SOI/ROM Category

Minor 1

Moderate 2

Major 3

Extreme 4

©2014 The Advisory Board Company 13 advisory.com Road Map for Discussion

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

2 Key Concepts To Capture in Your Documentation

3 Examples of Radiology Diagnoses in ICD-10

©2014 The Advisory Board Company 14 advisory.com ICD-10-PCS Radiology Procedures & Diagnoses Covered Today Let’s start with these concepts to help explain what documentation will be like in ICD-10- PCS.

1 Imaging

2 Nuclear Medicine

3 Radiation Therapy

4 Intervention Radiology

©2014 The Advisory Board Company 15 advisory.com Procedures in the Ancillary Sections - Imaging Key Diagnosis Documentation Concepts for Injuries and Fractures.

Documentation Concept Example Specifications

• Open fracture Documentation Tip 1. Fracture Type • Closed fracture Coders must assign all encounters to one of 2. Specific anatomical site • Humerus, etc. the following definitions: • A – Initial encounter for closed fracture • Left • B – Initial encounter for open fracture 3. Laterality • Right • D – Subsequent encounter for fracture • Bilateral with routine healing • G – Subsequent encounter for • Routine fracture with delayed healing

• Delayed • J – Subsequent encounter for fracture 4. Healing Status • Nonunion with non-union • Malnunion • Q – Sequelae

• Initial encounter If they do not have encounter type, 5. Encounter Type • Subsequent encounter fracture type, and healing status • Sequelae documented in the record, a query will

• Greenstick be issued 6. Additional fracture • Spiral descriptors as relevant • Oblique

©2014 The Advisory Board Company 16 advisory.com Procedures in the Ancillary Sections - Imaging MRI of thyroid gland without contrast, followed by other contrast material

B G 3 4 Y 0 Z

Body Root Body Section Contrast Qualifier Qualifier System Type Part

Endocrine Thyroid Gland Other Unenhanced Imaging MRI None System Contrast enhanced

Options: Contrast Material: Options: Options: • Plain Radiography • High Osmolar • Unenhanced & • Intraoperative • Fluoroscopy • Low Osmolar enhanced • Intravascular • Computerized (contrast) • Transesophageal Tomography • Laser • Magnetic • Intravascular resonance imaging Optical • Ultrasonography Coherence

©2014 The Advisory Board Company 17 advisory.com Nuclear Medicine Procedure codes capture great specificity; ensure your documentation can support full code assignment

When documenting nuclear medicine procedures, be sure your documentation includes:

1. Function performed (“root operation” type) 2. Specific Body part imaged 3. Source of radiation used

©2014 The Advisory Board Company 18 advisory.com Procedures in the Ancillary Sections – Nuclear Medicine PET scan of myocardium using Fluorine 18

C 2 3 G K Z Z

Section Body Root Body Radionuclide Qualifier Qualifier System Type Part

Nuclear Myocardium None Heart PET Imaging Fluorine 18 None Medicine

Options: Source of the radiation: • Nonimaging Uptake • Fluorine 18 • Nonimaging Probe • Oxygen 15 • Nonimaging Assay • Rubidium 82 • Planar Imaging • Nitrogen 13 • Positron Emission • Other Radionuclide – Tomography (PET) (used to capture new • Systemic Therapy FDA • Tomographic radiopharmaceuticals) (Tomo) Imaging

¹In coding, a “valid” OR procedure is a procedure that will shift a Medical DRG to s Surgical DRG assignment.

©2014 The Advisory Board Company 19 advisory.com Radiation Therapy Procedure codes capture great specificity; ensure your documentation can support full code assignment

When documenting radiation therapy services, be sure your documentation includes:

1. Basic radiation modality used (“root operation” type) 2. Specific target site or treatment site for radiation performed 3. Treatment modality used 4. Radioactive isotope used

©2014 The Advisory Board Company 20 advisory.com Procedures in the Ancillary Sections – Radiation Therapy Brachytherapy of prostate, HDR using Cesium 137

D V 1 0 9 7 Z

Body Root Modality/ Section Treatment Isotope Qualifier System Type site Qualifier Male Radiation Reproductive Brachytherapy Prostate HDR Cesium 137 None Therapy System

Options: Options: Options: • Beam radiation • High Dose Rate • Cesium137 • Brachytherapy (HDR) • Iridium 192 • Stereotactic • Low dose Rate • Iodine 125 radiosurgery (LDR) • Palladium 103 • Other • Californium 252 • Other Isotope

¹In coding, a “valid” OR procedure is a procedure that will shift a Medical DRG to s Surgical DRG assignment.

©2014 The Advisory Board Company 21 advisory.com Interventional Radiology Documentation Concepts Example: Aorto-Bifemoral Bypass Graft

• Bypass procedures for non-coronary vessels require clarification of the body part bypassed from (character 4) and body part bypassed to (character 7)

• The diaphragm is the dividing line for upper and lower vessels

Body part bypassed FROM includes: Body part bypassed TO includes:

• Abdominal aorta Iliac arteries • Abdominal aorta (include laterality-right or left) • Celiac artery • Common • Mesenteric artery These procedures also require • Internal • Renal artery clarification of the type of device • External • Iliac arteries used as the bypass

• Popliteal • Common Options include: • Splenic artery • Internal • Autologous venous tissue • Femoral • External • Autologous arterial tissue • Femoral artery • Synthetic substitute • Renal artery • Nonautologous tissue substitute • No device (this is when the graft • Popliteal artery vessel from the patient is not • Peroneal artery completely relocated, i.e. • Posterior tibia artery remains attached at one end) • Foot artery • Lower extremity artery

* Of note, Iliac, popliteal and femoral * Of note, for the majority of these arteries require documentation of arteries, the options to clarify laterality laterality (right or left) also include bilateral

©2014 The Advisory Board Company 22 advisory.com Summary of Best Practice Documentation Teaching Points

Key Documentation Concepts

• Conflicting, incomplete, or ambiguous documentation will lead to a query • Abnormal findings (laboratory, x-ray, pathological and other diagnostic test results) cannot be coded and reported unless the clinical significance is explicitly linked by the treating provider • Sign, symptoms and test results do not contribute to SOI unless their significance is documented or they are linked to a named disease • Remember to use the terms “with” or “due to” when applicable and appropriate • Fracture documentation will need to include type, specific anatomical site, laterality, healing status , displaced or nondisplaced (default will be to displaced if not documented) and encounter type • Document type of contrast used • Clarify approach or place of care (intraoperative, densitometry, intravascular, transesophageal or guidance) • Clarify the source of the radiation for nuclear medicine studies • Clarify approach or place of care (intraoperative, densitometry, intravascular, transesophageal or guidance) • For radiation therapy clarify: Basic modality, target site or treatment site of the radiation, specify treatment modality, specify radioactive isotope

©2014 The Advisory Board Company 23 advisory.com