FLORIDA 2014 ANNUAL DISTRICT MEETING
WHAT THE DELAY IN ICD-10 MEANS —AND OTHER CODING TIPS
Friday, August 15, 2014 The Ritz-Carlton Orlando, Grande Lakes Orlando, FL
SYLLABUS
www.obgpathways.com PROGRAM AGENDA
The Coding Course will be held in Tuscany A-D, unless otherwise noted below.
7:00‒8:00 AM REGISTRATION AND BREAKFAST Tuscany Foyer
8:00‒10:00 AM Introduction a. Understanding the Change b. History of ICD-10 c. Key Differences between ICD-9 and ICD-10 d. Structure and Format of ICD-10 e. Impact on Reimbursement and Future Reimbursement Models
General Guidelines a. Key Guidelines and Definitions b. Inpatient Guidelines vs. Outpatient Guidelines
Outpatient Guidelines a. Selecting the First-listed Diagnosis b. Coding for Uncertain Conditions c. Signs and Symptoms vs. Condition Specific Codes d. Coding for Multiple Diagnoses
10:00‒10:15 AM BREAK Tuscany Foyer
10:15 AM‒12:00 PM Chapter Specific Guidelines a. Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC i. Key Changes ii. Examples for Specific Areas b. Chapter 21: Factors Influencing Health Status and Contact with Health Services i. Key Changes ii. Examples for Specific Areas c. Chapter 14: Diseases of the Genitourinary System i. Key Changes ii. Examples for Specific Areas iii. Case Presentations d. Chapter 15: Pregnancy, Childbirth and the Puerperium i. Key Changes ii. Examples for Specific Areas iii. Case Presentations
Coding and Reimbursement Update a. Evaluation and Management Coding and the EHR b. CMS Initiatives c. Third-party Payer Initiatives
12:00‒12:15 PM Q&A Session
12:15 PM Adjourn FACULTY/PLANNING COMMITTEE
CODING COURSE INSTRUCTOR
Emily Hill, PA President Hill & Associates Wilmington, NC
Emily is the President of Hill and Associates, and has a broad professional background in the health care industry. Her clinical, administrative, and consulting experience gives her a unique perspective in advising healthcare providers and their staff in medical practice management. With over 20 years of experience as a health care consultant, she has worked with numerous academic and private practices on coding, reimbursement, compliance, and practice management issues.
Ms. Hill has taught coding seminars for a number of medical specialty societies including ACOG. She is a well-received national speaker and currently serves as a representative on the Health Care Professional’s Advisory Committee Review Board for the Relative Value Update Committee and as an advisor to the Society of Gynecologic Oncology and the American Academy of Pain Medicine on coding and reimbursement issues.
PLANNING COMMITTEE
Karen E. Harris, MD, MPH Gainesville, FL
Robert W. Yelverton, MD Tampa, FL
LEARNING OBJECTIVES /ACCREDITATION
TARGET AUDIENCE This program has been designed for physicians, coders, technicians and administrators with a basic understanding of CPT and ICD-9.
LEARNING OBJECTIVES At the conclusion of this activity, the attendee should be able to:
Discuss ICD-10 code structure; Apply the key ICD-10-CM guidelines applicable to the female genitourinary system and maternity care; Demonstrate the clinical documentation specificity necessary to appropriately assign ICD-10-CM codes for Ob-Gyn services; Describe ICD-10 coding conventions and principles.
ACCME ACCREDITATION The American College of Obstetricians and Gynecologists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
AMA PRA Category 1 Credit(s)™ The American College of Obstetricians and Gynecologists designates this live activity for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
College Cognate Credit(s) The American College of Obstetricians and Gynecologists designates this live activity for a maximum of 4 Category 1 College Cognate Credits. The College has a reciprocity agreement with the AMA that allows AMA PRA Category 1 Credits™ to be equivalent to College Cognate Credits.
CRITERIA FOR SUCCESS To claim credit for attending the meeting, please remember to sign-in at the registration desk each day of the meeting. Credits will be awarded based on the participant’s attendance. Attendees can complete the online meeting evaluation and claim credit at www.obgpathways.com until Friday, September 12, 2014. If you have further questions regarding the evaluation, please contact Allison Fellers at [email protected].
COMMERCIAL SUPPORT No commercial support was received for this program.
FACULTY /PLANNING COMMITTEE DISCLOSURES
Faculty Relationship Company Emily Hill, PA N/A Nothing to disclose Karen E. Harris, MD, MPH N/A Nothing to disclose Robert W. Yelverton, MD N/A Nothing to disclose
Disclosure What the Delay in ICD-10 I have no disclosures to declare Means And Other Coding Tips Presented by: Emily Hill, PA Hill & Associates, Inc. Wilmington, NC August 15, 2014
Learning Objectives Learning Objectives
At the conclusion of the presentation, At the conclusion of the presentation, participants should be able to: participants should be able to: Discuss ICD-10 code structure Demonstrate the clinical documentation Apply the key ICD-10-CM guidelines specificity necessary to appropriately applicable to the female genitourinary assign ICD-10-CM codes for OB/GYN system and maternity care services Describe ICD-10 coding conventions and principles
Disclaimer Understanding ICD-10
ICD-10 codes included in this presentation ICD-10 developed and copyrighted by the are not valid prior to the implementation date World Health Organization (WHO) ICD-10 codes included in this presentation Classification of diseases, signs/symptoms, may be revised prior to implementation abnormal findings and complaints, social ICD-9 codes should continue to be used until circumstances and external causes of disease the transition date and injury Used for morbidity and mortality statistics and in reimbursement systems ICD-10 replaces ICD-9 that was first adopted in 1975
1 Understanding ICD-10 Understanding ICD-10
ICD is comprised of two code sets: ICD-10-CM codes describe the clinical picture ICD-10-CM for diagnostic coding of the patient ICD-10-PCS for procedural coding 3-7 character alphanumeric codes ICD-10-PCS only impacts reporting of Organized by organ system or condition inpatient procedures by hospitals ICD-10-PCS describes procedures Physicians, other professionals, and 7 character alphanumeric codes outpatient facilities continue to use CPT and Detail anatomic site, approach, device and HCPCS Level II codes to report services other qualifying information
The Need for Change The Need for Change
Department of Health and Human Services Updates current terminology and reclassifies (HHS) announced adoption of ICD-10 in 2009 certain conditions to coincide with current ICD-9-CM: Out of date - Out of space! clinical practice ICD-10: International standard for reporting Increases categories for disease and provides and monitoring diseases and mortality higher level of clinical specificity ICD-10: Codes are core elements of HIT Increased flexibility and potential for systems expansion
The Need for Change The Need for Change
Allows international disease surveillance Important part of reimbursement models Facilitates comparison of morbidity and Facilitates payment of claims, monitoring of mortality data in U.S. utilization patterns, and review of costs Facilitates collection of information on quality Communicates justification for clinical of care services through increased specificity Improves public health tracking Facilitates Value Based Purchasing Appropriate code selection critical for evaluation and planning of health care needs
2 History of ICD History of ICD
Francois Bossier de Lacroix (1706-1777) first In 1900 a parallel system for the classification person credited with attempting to of diseases was adopted systematically classify diseases The 6th Revision of the system was adopted William Cullen published a classification in in 1948 and was accepted by the World 1785 Health Organization (WHO) In 1891, Jacques Bertillon was charged by the This marked the beginning of the use of a set International Statistical Institute to prepare a of rules and guidelines and established a plan classification of death for international cooperation
Structure and Format of History of ICD ICD-10-CM
World Health Organization (WHO) adopted First character is always alphabetic letter ICD-10 in 1990 Chapter 14 Diseases of the GU system Australia implemented its version, ICD-10- (N00-N99) AM, in 1998 Chapter 15 Pregnancy, Childbirth and Canada adopted ICD-10-CA in 2001 Puerperium (O00-O9A) Current implementation date for ICD-10-CM in Second character is always a number the U.S. is October 1, 2015 Characters 3-7 alpha or numeric All modifications to ICD-10 must conform to O9A.311: Physical abuse complicating WHO conventions for ICD pregnancy, first trimester
Structure and Format of Structure and Format of ICD-10-CM ICD-10-CM
Code Format: XXX.XXX X Labor and delivery complicated by cord XXX = Category around neck, without compression: O69.81X2 XXX = Etiology, anatomic site, severity O69: Labor and delivery complicated by X = Extension umbilical cord complications Placeholder Character X 81: Cord around neck, without compression Used with certain codes for potential future X: Placeholder expansion 2: Fetus 2 Placeholder x must be used to fill empty characters for codes that require 7th character but are not 6 characters long
3 Key Changes: Key Changes: ICD-9-CM to ICD-10-CM ICD-9-CM to ICD-10-CM
Increased specificity and therefore increased Reclassification of certain diseases to reflect documentation requirements current medical knowledge or more Chapters divided into “blocks” of codes with appropriate placement in system additional subcategories Codes for postoperative complications in V and E (ICD-9-CM) supplemental applicable system chapters classifications are part of main classifications in ICD-10
Key Changes: Key Changes: ICD-9-CM to ICD-10-CM ICD-9-CM to ICD-10-CM
Combination codes for conditions with Over 1/3 of the expansion in coding for ICD- common symptoms/manifestations 10 is related to laterality Combination codes for poisoning and external Manageable change for most practices causes Estimated that 5% of ICD codes make up Added laterality for some codes (right vs. left) 70% of volume New types of “exclusion” notes Three Main Categories of Change: Definition changes Terminology differences Specificity
Key Changes for OB/Gyn
Inclusion of trimesters in obstetric codes Extensions to denote specific fetus Changes in timeframes: General Guidelines Abortion vs. Fetal death ( 20 weeks) Early vs. Late pregnancy (20 weeks) New GU codes and notes including category title changes
4 ICD-10-CM Official Guidelines Section I: Conventions, General Sections Guidelines, Chapter Specific Guidelines
Section I: Conventions, General guidelines, Alphabetic Index is alphabetical listing of Chapter specific guidelines terms and corresponding codes Section II: Selection of Principle Diagnosis Index of Diseases and Injury Section III: Reporting Additional Diagnoses Index of External Causes of Injury Section IV: Coding and Reporting for Table of Neoplasms Outpatient Services Table of Drugs and Chemicals Section V: Present on Admission Guidelines and Exempt Codes
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
Tabular List is a structured chronological list Use both Alphabetic Index and Tabular List of codes divided into chapters based on body Index does not always provide the full code system or condition. A dash (-) after a code in Alphabetic Index Tabular list contains: indicates additional characters are required Categories (all 3 characters) Absence of dash still requires Tabular List for 7th character extensions Subcategories (4 or 5 characters) Selection of the full code including laterality Codes (3-7 characters in length) and applicable 7th character only appear in Tabular List
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
Includes notes: Appear immediately under 3 N92.0 Excessive and frequent menstruation character code title to further define or give with regular cycle examples of the content of the category Heavy periods NOS Inclusion Terms: Terms are the conditions for Menorrhagia NOS which the code is to be used Polymenorrhea NOS May be synonyms List of various conditions assigned to that code Terms found only in the Alphabetic Index may also be assigned to code Not an exhaustive list
5 Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
Exclude Notes: 2 Types Exclude Notes: 2 Types Excludes 1: Means “NOT CODED HERE!” Excludes 2: Means “Not included here” Cannot report excluded code(s) with code Acceptable to use both the code and the above note excluded code together Used when two conditions cannot occur Indicates condition excluded is not part of together the condition represented by the code; patient may have both conditions
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
N97 Female infertility “Other” or “other specified” codes Includes inability to achieve pregnancy NEC Not elsewhere classifiable sterility, female NOS Used when information in the medical record Excludes 1 female infertility associated with: provides detail for which a specific code does hypopituitarism (E23.0) not exist Stein-Leventhal syndrome (E28.2) “Unspecified” codes NOS Not otherwise specified Excludes 2 incompetence of cervix (N88.3) Used when information in the medical record is insufficient to assign a more specific code
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
N75.0 Cyst of Bartholin's gland Etiology/Manifestation Convention N75.1 Abscess of Bartholin's gland Certain conditions may have underlying N75.8 Other diseases of Bartholin’s gland cause and multiple body system signs/symptoms due to the underlying N75.9 Disease of Bartholin’s gland, unspecified condition ICD guidelines require that the underlying If unspecified code is not available for the category, use “other specified” code condition be coded first followed by the manifestation Other codes require multiple coding also
6 Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
N72 Inflammatory disease of the cervix uteri O22.3-Deep phlebothrombosis in pregnancy Use additional code (B95-B97) to identify Deep vein thrombosis, antepartum infectious agent Use additional code to identify the deep R50.81 Fever presenting with conditions classified vein thrombosis (I82.4-,I82.5-, I82.62, elsewhere I82.72) Code first underlying condition such as with: Use additional code, if applicable, for Leukemia (C91-C95) associated long-term use of anticoagulants Neutropenia (D70.-) (Z79.01) Sickle-cell disease (D57.-)
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
Level of Detail Level of Certainty Code to the highest level of specificity Specific diagnosis code should be used available when supported by documentation and Includes placeholder “X” when applicable clinical knowledge Includes 7th character extension when Codes based on clinical knowledge applicable Must be accurate reflection of encounter Failure to report all characters results in invalid code and likely claim denial
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
Level of Certainty Level of Certainty Signs/symptoms may be most appropriate if Limited clinical information may result in definitive condition not established “unspecified” code Signs/symptoms found in disease chapters Example: Ovarian cyst and Chapter 18: Symptoms, Signs and N83.0 Follicular cyst Abnormal Clinical and Laboratory Findings, N83.1 Corpus luteum cyst NEC (R00-R99) N83.20 Unspecified ovarian cyst N83.29 Other specified cyst
7 Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
Acute and Chronic Conditions Laterality If condition described as acute (subacute) Some codes indicate whether condition is and chronic, and there are separate right, left, or bilateral subentries in Alphabetic Index, both are If no bilateral code exists, then report code reported for right and left (two codes) Code acute condition first followed by If site not identified, then report code for chronic unspecified side N73.3 Female acute pelvic peritonitis N73.4 Female chronic pelvic peritonitis
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
N60.0 Solitary cyst of breast Combination Code is a single code used to N60.01 Solitary cyst of right breast classify: N60.02 Solitary cyst of left breast Two diagnoses N60.09 Solitary cyst of unspecified breast Diagnosis with an associated secondary process (manifestation) Note: Laterality is not specified in codes for ovarian cyst (N83-) Diagnosis with associated complication Multiple coding should not be used when there is a combination code that describes all the documented elements
Section I: Conventions, General Section I: Conventions, General Guidelines, Chapter Specific Guidelines Guidelines, Chapter Specific Guidelines
Combination code Complications of Care Additional codes may be reported if needed Coding must be based on documentation of the to describe full clinical picture relationship between the condition and the care/procedure Identified by referring to subterm entries in Must be a cause and effect relationship between Index and reading notes in Tabular List care and condition to assign complication code N83.53 Torsion of ovary, ovarian pedicle and Documentation must be present indicating it is a fallopian tube complication Not all conditions after care are classified as complications
8 Section I: Conventions, General Guidelines, Chapter Specific Guidelines
Complications of Care Post-operative complications found in disease chapter Outpatient Guidelines Other complications found in Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)
Section IV: Diagnostic Coding and Reporting Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services Guidelines for Outpatient Services
First-Listed Diagnosis Uncertain Diagnoses: The condition chiefly responsible for the Do not report condition documented as service “rule out”, “probable”, “suspected”, First-listed may be a symptom if a diagnosis “questionable” or the like has not been established Code only to the highest degree of certainty Preventive services, screening services and Signs/symptoms tests, preoperative evaluations and routine Abnormal test results prenatal visits can all be first-listed Other reasons for the visit diagnoses
Section IV: Diagnostic Coding and Reporting Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services Guidelines for Outpatient Services
Diagnostic Services Only: Diagnostic Services Only: First-listed diagnosis is the one chiefly Routine lab/radiology testing in the absence responsible for the service of signs/symptoms/diagnosis, report Z01.89 Outpatient tests that have been interpreted (Encounter for other specified special by the provider and final report is available: examinations) Code definitive or confirmed diagnoses Chapter 21: Factors Influencing Health documented in the interpretation Status and Contact with Health Services (Z00-Z99) Do not code related signs/symptoms as additional diagnoses
9 Section IV: Diagnostic Coding and Reporting Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services Guidelines for Outpatient Services
Reporting additional diagnoses Reporting additional diagnoses Report other conditions that coexist at the time Do not code conditions that were previously of the encounter and require treatment or treated and no longer exist management Report history codes (Z80-Z87) as Chronic conditions may be reported as many secondary codes if the condition or family times as the patient receives treatment and history has an impact on treatment care for the condition
Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC (R00-R99) Chapter 18: Symptoms, Signs, and 14 “Blocks” R00-R09 Symptoms/signs involving Abnormal Clinical and circulatory and respiratory systems Laboratory Findings, NEC R10-R19 Symptoms/signs involving digestive system and abdomen (R00-R99) R20-R23 Symptoms/signs involving skin and subcutaneous tissue R25-R29 Symptoms/signs involving nervous and musculoskeletal systems
Chapter 18: Symptoms, Signs, and Abnormal Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC (R00-R99) Clinical and Laboratory Findings, NEC (R00-R99)
14 “Blocks” 14 “Blocks” R30-R39 Symptoms/signs involving R70-R79 Abnormal findings on examination genitourinary system of blood, without diagnosis R40-R46 Symptoms/signs involving R80-R82 Abnormal findings on examination cognition, perception, emotional of urine, without diagnosis status and behavior R83-R89 Abnormal findings on examination R47-R49 Symptoms/signs involving speech of other body fluids, substances and voice and tissues, without diagnosis R50-R69 General symptoms/signs
10 Chapter 18: Symptoms, Signs, and Abnormal Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC (R00-R99) Clinical and Laboratory Findings, NEC (R00-R99)
14 “Blocks” Chapter includes conditions for which there is no R90-R94 Abnormal findings on diagnostic classifiable diagnosis imaging and in function studies, Also contains codes for abnormal test findings without diagnosis without definitive diagnosis R97 Abnormal tumor markings Signs and symptoms that point to a specific R99 Ill-defined and unknown causes of diagnosis are assigned to a category in the mortality respective chapter N95.0 Postmenopausal bleeding
Chapter 18: Symptoms, Signs, and Abnormal Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC (R00-R99) Clinical and Laboratory Findings, NEC (R00-R99)
Signs/symptoms routinely associated with a When both reported, the definitive diagnosis is disease process should not be assigned as an sequenced first, followed by the sign/symptom additional diagnosis E28.2 (polycystic ovarian syndrome) and N30.0 (dysuria) would NOT be reported if code R23.4 (changes in skin texture) N39.0 (UTI) reported Sign not routinely associated with PCOS Codes may be reported in addition to a definitive diagnosis when the sign/symptom is not routinely associated with the definitive diagnosis
Let’s Practice! Abby Let’s Practice! Abby
Abby, who had a previous ruptured ovarian Abby is sent to the hospital for an immediate cyst, presents to the office as a work-in sonogram and laboratory work to rule out complaining of lower right-sided abdominal ruptured cyst, ovarian torsion and pain that began the evening prior. appendicitis. On physical exam she has a slightly elevated temperature and rebound tenderness in the RLQ. She has an elevated blood pressure. BP readings in the past have been normal.
11 Answer- Abby Answer- Abby
R10.823 Right lower quadrant rebound Signs/Symptoms are reported because a abdominal tenderness definitive diagnosis was not made R11.2 Nausea with vomiting, unspecified R10 category distinguishes between R50.9 Fever, unspecified abdominal tenderness and tenderness with rebound (only one category in ICD-9) R03.0 Elevated blood pressure reading, without diagnosis of hypertension NOTE: Pelvic pain is reported with code from Chapter 18: R10.2 (Pelvic and peritoneal pain) ICD-9 unspecified code in GU chapter
Let’s Practice! Betsy Answer-Betsy
Betsy, a 60 year-old postmenopausal patient, R87.619 (Other abnormal cytological findings is seen for f/up to discuss the findings of her on specimens from the cervix uteri) recent Pap test. The cervical Pap pathology Only report code R87.619 if documentation report indicates atypical endometrial cells. indicates atypical endometrial cells The Pap test is otherwise normal. If Pap was taken from pre-menopausal An EMB is scheduled for the next week. woman, especially around time of menses, then finding of endometrial cells is not abnormal
Answer-Betsy Abnormal Pap Test Findings
R87.619 Unspecified abnormal cytological findings R87.6 (Abnormal cytological findings in in specimens from cervix uteri specimens from female genital organs) Abnormal cervical cytology NOS R87.61- Cervical smears Abnormal Papanicolaou smear of cervix NOS R87.62- Vaginal smears Abnormal thin preparation smear of cervix NOS Atypical endocervical cells of cervix NOS Atypical endometrial cells of cervix NOS Atypical glandular cells of cervix NOS
12 Abnormal Pap Test Findings Abnormal Pap Test Findings
ICD-9 Abnormal Cervical Pap ICD-10 ICD-9 Abnormal Cervical Pap ICD-10 795.01 ASC-US R87.610 ASC-US 795.4 Other non-specific R87.618 Other abnormal abnormal histological findings findings 795.02 ASC-H R87.611 ASC-H 795.00 Abnormal glandular R87.619 Unspecified 795.03 LGSIL R87.612 LGSIL Papanicolaou smear of abnormal findings (includes 795.04 HGSIL R87.613 HGSIL cervix OR atypical glandular cells, 795.06 Cytologic evidence of R87.614 Cytologic 795.4 Other non-specific atypical endometrial, and malignancy evidence of malignancy abnormal histological findings atypical endocervical cells) 795.08 Unsatisfactory smear of R87.615 Unsatisfactory cervix smear of cervix 795.07 Satisfactory smear but R87.616 Satisfactory lacking transformation zone smear but lacking transformation zone
Abnormal Pap Test Findings Let’s Practice! Cindy
ICD-9 HPV Status ICD-10 Cindy, is a 58 year-old postmenopausal 795.05 Cervical high-risk R87.810 Cervical high-risk patient seen for abnormal bleeding. She is not human papillomavirus (HPV) human papillomavirus (HPV) DNA test positive DNA test positive on HT. A transvaginal ultrasound performed 795.09 Other abnormal R87.820 Cervical low risk in the office is normal except for an Papanicolaou smear of HPV DNA test positive endometrial thickness of 9mm. cervix and cervical HPV The medical record states: Abnormal bleeding Thickened endometrium on ultrasound EMB next week to rule out malignancy
Answer- Cindy Answer- Cindy
N95.0 Postmenopausal bleeding R93.8 Abnormal findings on diagnostic imaging R93.8 Abnormal findings on diagnostic imaging of other specified body structure of other specified body structure Inclusion lists under codes are not exhaustive, Do not code for malignancy since the thus can be reported for circumstances other diagnosis has not been established than those listed Cross-walk from Index points directly to code R93.8 Link R code to ultrasound code May also link to E/M code as additional diagnosis
13 Answer- Cindy Answer- Cindy
R93.8 Abnormal findings on diagnostic N95.0 Postmenopausal bleeding imaging of other specified body May be linked to E/M service structure Does not need to be linked to ultrasound code Abnormal finding by radioisotope since finding is documented localization of placenta Abnormal radiological finding in skin and subcutaneous tissue Mediastinal shift
Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Chapter 21 : Factors Influencing Health 14 “Blocks” Z00-Z13 Persons encountering health Status and Contact with services for examinations Health Services Z14-Z15 Genetic carrier and genetic susceptibility to disease (Z00-Z99) Z16 Resistance to antimicrobial disease Z17 Estrogen receptor status Z18 Retained foreign body fragments
Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
14 “Blocks” 14 “Blocks” Z20-Z28 Persons with potential health hazards Z66 Do not resuscitate status related to communicable diseases Z68 Body Mass Index (BMI) Z30-Z39 Persons encountering health services in circumstances related Z69-Z76 Persons encountering health to reproduction services in other circumstances Z40-Z53 Encounters for other specific health Z77-Z99 Persons with potential health care hazards related to family and Z55-Z65 Persons with potential health hazards personal history and certain related to socioeconomic and conditions influencing health status
psychosocial83 circumstances
14 Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
Z codes can be used in any healthcare setting History of codes: Personal and Family Z codes indicate a reason for an encounter Personal history: They are NOT procedure codes Past medical condition that no longer exists and Must have a corresponding CPT or HCPCS code No treatment is being received and Condition has potential for recurrence and Z codes may be first-listed diagnosis or secondary diagnosis Therefore continued monitoring is required May be reported in addition to follow-up codes If Z code most accurate code, it must be reported Acceptable on any medical record regardless of the reason for the visit
Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
“History of” codes: Personal and Family Follow-Up codes Family history: Used when patient has a Used to explain continuing surveillance family member(s) who has had a particular following completed treatment of a disease, disease which places the patient at higher condition, or injury risk for the disease Implies that condition has been fully treated May be reported in addition to screening and no longer exists codes to explain reason for test/procedure May be used to explain multiple visits Acceptable on any medical record regardless of the reason for the visit
Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
Follow-Up codes Z08 Encounter for follow-up examination May be used in conjunction with history after completed treatment for malignant codes to describe complete picture of neoplasm condition and treatment Z09 Encounter for follow-up examination Follow-up code is sequenced first after completed treatment for conditions other than malignant neoplasm If condition found to recur, then diagnosis code for condition used in place of follow-up Post-operative visits code With Z08: Report additional codes for acquired absence of organs (Z90.-) and personal history of malignant neoplasm (Z85.-)
15 Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
Screening Codes Screening Codes Screening is testing for disease or disease May be first-listed diagnosis if reason for precursors in seemingly well individuals for visit is specifically for screening purposes of early detection and treatment May be additional code if screening done at Diagnostic testing is when person has the time of problem visit sign/symptom to rule out or confirm Screening codes must be accompanied by suspected diagnosis appropriate CPT or HCPCS code Sign/symptom is reason for test
Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
Screening Codes Routine and Administrative Examinations If condition discovered during the screening, Codes for routine exams (general check- then code for condition assigned as additional up) or administrative exams (pre- diagnosis employment physical) Screening code is not necessary if inherent Not used if visit for diagnosis of suspected part of a routine examination condition or treatment of a problem Pap test at time of routine gyn exam If condition found during routine visit, then May report screening such as Chlamydia coded as additional diagnosis (Z11.8) at time of routine gyn exam since not indicated for all age groups
Let’s Practice! Helen Answer-Helen
Helen is a 45 year-old female seen for her Z01.411 Encounter for gynecological exam well-woman exam. She has no complaints but with abnormal findings a mass is noted in her left breast on physical N63 Unspecified lump in breast exam. A diagnostic mammogram is ordered. Some codes distinguish between with and without abnormal findings Code dependent on what is known at time of encounter Additional code is reported to describe abnormal finding
16 Answer-Helen Common Codes In GYN
Z01.411 Encounter for gynecological exam ICD-9 ICD-10 (general) (routine) with abnormal findings V72.31 Routine Z04.011 Encounter for Gynecological Exam gynecological examination Z01.419 Encounter for gynecological exam (general) (routine) with (general) (routine) without abnormal findings abnormal findings Z01.419 Encounter for If no abnormal findings at exam but gynecological examination subsequent test shows abnormality (general) (routine) without abnormal findings Report without abnormal findings Subsequent visits will include code for the condition
Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
Counseling Codes Counseling Codes Used when patient or family member Z30.0- Encounter for general counseling receives assistance in the aftermath of an and advice on contraception illness OR Z31.5 Encounter for genetic counseling Support is required in coping with family or Z31.6- Encounter for general counseling social problems and advice on procreation Not used in conjunction with diagnosis code Z32.2 Encounter for childbirth instruction when counseling is considered integral to standard treatment
Chapter 21 : Factors Influencing Health Status Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) and Contact with Health Services (Z00-Z99)
Encounters for Obstetrical and Reproductive Encounters for Obstetrical and Reproductive Services (Z30-Z39) Services Used when none of the problems or Z30 Contraceptive management complications included in the Obstetrical Z31 Encounter for procreative management chapter exist Z32.2 Encounter for childbirth instruction Includes routine prenatal or postpartum care Z32.3 Encounter for childcare instruction Routine prenatal care for high-risk Z33 Pregnant state pregnancies coded from the Obstetrical Chapter. Z34 Supervision of normal pregnancy
17 Chapter 21 : Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Let’s Practice-Ingrid
Encounters for Obstetrical and Reproductive Ingrid is a 23 year-old G1P0 female who Services presents for her first prenatal visit at 8 weeks. Z36 Encounter for antenatal screening of She had a positive home pregnancy test and mother subsequent confirmatory blood test 1 week ago. Her history and examination were Z3A Weeks gestation negative for medical problems or concerns Z37 Outcome of delivery regarding this pregnancy. Z39 Encounter for maternal postpartum care and examination
Answer- Ingrid Answer- Ingrid
Z34.01 Encounter for supervision of normal Excludes 1 for Z34 first pregnancy, first trimester Any complications of pregnancy (O00-O9A) Z3A.08 8 weeks gestation of pregnancy Encounter for pregnancy test (Z32.0-) Codes in Z34 are first-listed diagnosis Encounter for supervision of high-risk codes pregnancy (O09.-) Never reported with code from Chapter 15: Category Z3A includes codes specifying Pregnancy, Childbirth and the Puerperium weeks of gestation Trimester incorporated into code title Should be reported with Chapter 15 codes Optional for routine prenatal visits/services
Let’s Practice-Julie Answer- Julie
Julie, a G2P1, returns for a routine antepartum Z34.82 Encounter for supervision of other visit at 18 weeks. Findings at all prior normal pregnancy, second trimester antepartum visits were normal. A routine Z3A.18 18 weeks gestation of pregnancy screening ultrasound is performed on the Z36 Encounter for antenatal screening of same day with normal findings. mother
18 Answer- Julie Answer- Julie
Z36 Only code for routine antenatal screening of Excludes 2 mother Genetic counseling and testing (Z31.43-, Excludes 1 Z31.5-) Abnormal findings on antenatal screening of mother (O28.-) Routine prenatal care (Z34) Diagnostic examination-code to sign or symptom Encounter for suspected maternal and fetal conditions ruled out (Z03.7-) Suspected fetal condition affecting management of mother-code to condition in Chapter 15
Chapter 14: Diseases of the Genitourinary System (N00-N99)
Chapter 14: 11 “Blocks” Diseases of the N60-N65 Disorders of breast N70-N77 Inflammatory diseases of female Genitourinary System pelvic organs N80-N98 Non-inflammatory disorders of (N00-N99) female genital tract N99 Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified
Chapter 14: Diseases of the Chapter 14: Diseases of the Genitourinary System (N00-N99) Genitourinary System (N00-N99)
Specific guidelines relate to chronic kidney Increased specificity disease Some conditions will require increased Changes to code titles, terminology, and specificity to avoid unspecified codes inclusion/exclusion notes N76 (Other inflammation of vagina and Some changes require more specific vulva) documentation N76.0 Acute vaginitis Others are 1-to-1 crosswalk from ICD-9-CM N76.1 Subacute and chronic vaginitis N76.2 Acute vulvitis N76.3 Subacute and chronic vulvitis
19 Chapter 14: Diseases of the Chapter 14: Diseases of the Genitourinary System (N00-N99) Genitourinary System (N00-N99)
Increased specificity ICD-10 Salpingitis and oophoritis N76.4 Abscess of vulva N70.01 Acute salpingitis N76.5 Ulceration of vagina N70.02 Acute oophoritis N76.6 Ulceration of vulva N70.03 Acute salpingitis and oophoritis N76.8 Other specified inflammation of N70.11 Chronic salpingitis vagina and vulva N70.12 Chronic oophoritis N76.81 Mucositis (ulcerative) of vagina and vulva N70.13 Chronic salpingitis and oophoritis N76.89 Other specified inflammation of vagina and vulva
Chapter 14: Diseases of the Chapter 14: Diseases of the Genitourinary System (N00-N99) Genitourinary System (N00-N99)
ICD-10 Salpingitis and oophoritis Postoperative Complications N70.91 Salpingitis, unspecified Codes in specific body chapters N70.92 Oophoritis, unspecified Codes for complicating GU procedure vs. N70.93 Salpingitis and oophoritis, other procedure unspecified Documentation will guide code selection Instructions to identify the infectious agent (B95-B97)
Chapter 14: Diseases of the Chapter 14: Diseases of the Genitourinary System (N00-N99) Genitourinary System (N00-N99)
Postoperative Complications N99.6 Intraoperative hemorrhage and N99 Intraoperative and postprocedural hematoma of a genitourinary system organ or complications and disorders of genitourinary structure complicating a procedure system, NEC N99.61… complicating a genitourinary Codes distinguish between intraoperative procedure and postoperative N99.62… complicating other procedure Complicating GU vs. other procedure
20 Chapter 14: Diseases of the Complications of Medical Genitourinary System (N00-N99) And Surgical Care, NEC
N99.3 Prolapse of vaginal vault after Chapter 19: Injury, poisoning and certain hysterectomy other consequences of external causes (S00- N99.83 Residual ovary syndrome T88) In disease chapters in ICD-9 T80-T88 specifically relate to complications of surgical and medical care Most codes require 6th and 7th characters Many will have placeholder X
Complications of Medical Complications of Medical And Surgical Care, NEC And Surgical Care, NEC
Three 7th character extensions identify type of Initial encounter for displacement of IUD: encounter T83.32XA: Displacement of intrauterine A Initial encounter contraceptive device, initial encounter D Subsequent encounter T83.32 Displacement of IUD S Sequela X Placeholder “A” used when it is individual provider’s initial A: Initial encounter encounter with patient Patient seen in ED and then presents to gynecologist who reports “A”
Complications of Medical Let’s Practice! Diedra And Surgical Care, NEC
Surgical treatment for patient previously seen in Diedra is a 28-year-old patient who presents office with exposure of vaginal mesh into vagina to the office with complaints of burning on T83.721D Exposure of implanted mesh and other urination and urinary urgency and frequency. prosthetic materials into surrounding organ or She states she’s had symptoms for the last 4 tissue, subsequent encounter days and yesterday her urine was red tinged. T83.721 = Exposure She has no other complaints. D = Subsequent encounter The office U/A shows increased WBCs and Placeholder X is not required since code has 6 RBCs. The physician diagnoses acute cystitis meaningful characters and gives her a prescription for an antibiotic.
21 Answer - Diedra Answer - Diedra
N30.01 Acute cystitis with hematuria Other classifications: ICD-10 has combination codes for cystitis N30.1- Interstitial cystitis (chronic) that specify with and without hematuria N30.2- Other chronic Entire record can be used to appropriately N30.3- Trigonitis assign a diagnosis N30.4- Irradiation cystitis Recently clarified that hematuria means N30.8- Other cystitis presence of frank blood in urine N30.9- Cystitis, unspecified All specify with or without hematuria
Answer - Diedra Answer - Diedra
If urinary tract infection documented, then Instructions for both cystitis and the unspecified code N39.0 (urinary tract infection, site not UTI code state to use additional code to identify specified) reported infectious agent (B95-B97) if identified Category N39 (Disorders of the urinary B code would be reported on any subsequent system) also includes codes for incontinence visits if culture performed and test results are conditions available Important if medication change N39.3 stress incontinence can be used for male or female (change from ICD-9)
Common Codes In GYN Common Codes In GYN
ICD-9 Urinary ICD-10 ICD-9 Urinary ICD-10 symptoms/conditions symptoms/conditions 595.0 Acute cystitis N30.00 Acute cystitis without 788.1 Dysuria R30.0 Dysuria hematuria R30.9 Painful micturition, unspecified 788.21 Incomplete bladder R39.14 Feeling of incomplete bladder N30.01 Acute cystitis with emptying emptying hematuria 788.30 Urinary incontinence, R32 Unspecified urinary incontinence N30.90 Cystitis, unspecified unspecified without hematuria 788.31 Urge incontinence N39.41 Urge incontinence N30.91 Cystitis unspecified 788.33 Mixed incontinence N39.46 Mixed incontinence with hematuria 788.41 Urinary frequency R35.0 Frequency of micturition 599.0 UTI, site not specified N39.0 UTI, site not specified 788.63 Urgency of urination R39.15 Urgency of urination 788.65 Straining on urination R39.16 Straining to void
22 Let’s Practice! Evelyn Answer - Evelyn
Evelyn is a 19-year-old established patient who N92.0 Excessive and frequent menstruation presents with complaints of heavy periods for the with regular cycle past 6 months. She states the bleeding lasts for Inclusion terms are: 10-12 days and requires up to 10 pads per day. She has had occasional bed soiling at night. Her Heavy periods NOS periods occur every 26-28 days. She denies Menorrhagia NOS pain, breast tenderness or bloating. She is not Polymenorrhea sexually active. The physician prescribes NSAIDS and discusses the use of oral contraceptives.
Answer - Evelyn Answer - Evelyn
N92 Excessive, frequent, and irregular N92.1 Excessive and frequent menstruation menstruation with irregular cycles N92.0 Excessive and frequent menstruation Code reported if Evelyn had shortened with regular cycles intervals between cycles or if physician documented any of the other inclusion terms N92.1 Excessive and frequent menstruation with irregular cycles Inclusion terms: Irregular intermenstrual bleeding N92.2 Excessive menstruation at puberty Menometrorrhagia Metrorrhagia
Answer - Evelyn Answer - Evelyn
Code N92.6 (Irregular menstruation, N91 Absent, scanty and rare menstruation unspecified) has Excludes 1 note: N91.0 Primary amenorrhea Irregular menstruation with: N91.1 Secondary amenorrhea Lengthened intervals or scanty bleeding N91.2 Amenorrhea, unspecified (N91.3-N91.5) N91.3 Primary oligomenorrhea Shortened intervals or excessive bleeding N91.4 Secondary oligomenorrhea (N92.1) N91.5 Oligomenorrhea, unspecified Excludes 1 ovarian dysfunction (E28.-)
23 Answer - Evelyn Common Codes In GYN
ICD-9 Excessive, Frequent, Irregular ICD-10 If documentation does not distinguish Menstruation between primary or secondary, then 626.2 Excessive and frequent N92.0 Excessive and frequent menstruation menstruation with regular cycle unspecified code reported 626.6 Metrorrhagia N92.1 Excessive and frequent menstruation with irregular cycle Secondary amenorrhea and oligomenorrhea 626.3 Puberty bleeding N92.2 Excessive menstruation at puberty are conditions that occur after a period of normal menses 626.5 Ovulation bleeding N92.3 Ovulation bleeding 627.0 Premenopausal menorrhagia N92.4 Excessive bleeding in the May be determined from history but should premenopausal period 626.4 Irregular menstrual cycle N92.5 Other specified irregular verify with physician before assigning code 626.8 Other disorders of menstruation and menstruation other abnormal bleeding 626.9 Unspecified disorders of N92.6 Irregular menstruation, menstruation and other abnormal bleeding unspecified
Common Codes In GYN Let’s Practice! Fran
ICD-9 Absent, scanty and ICD-10 Fran is a 39-year-old established patient who rare menstruation presents with a complaint of painful menses 626.0 Absence of N91.0 Primary amenorrhea menstruation N91.1 Secondary that began 4-5 cycles ago. She was amenorrhea previously diagnosed with endometriosis that N91.2 Amenorrhea, was found incidentally during an elective tubal unspecified ligation three years ago. Her medical history 626.1 Scanty or infrequent N91.3 Primary menstruation oligomenorrhea is otherwise negative. N91.4 Secondary The physician’s impression states: oligomenorrhea N91.5 Oligomenorrhea, dysmenorrhea due to endometriosis. unspecified
Answer - Fran Answer - Fran
N94.5 Secondary dysmenorrhea N94 Pain and other conditions associated N80.9 Endometriosis, unspecified with female genital organs and menstrual cycle ICD-10 distinguishes between primary, secondary, and unspecified dysmenorrhea N94.4 Primary dysmenorrhea Secondary dysmenorrhea is pain caused by N94.5 Secondary dysmenorrhea other disorder N94.6 Dysmenorrhea, unspecified
24 Answer - Fran Answer - Fran
Although not required by ICD-10, an N80.4 Endometriosis of rectovaginal septum additional code is reported for the and vagina endometriosis N80.5 Endometriosis of intestine Since site of endometriosis was not N80.6 Endometriosis in cutaneous scar documented, unspecified code was reported N80.8 Other endometriosis N80.0 Endometriosis of uterus N80.9 Endometriosis, unspecified N80.1 Endometriosis of ovary N80.2 Endometriosis of fallopian tube N80.3 Endometriosis of pelvic peritoneum
Let’s Practice - Greta Answer - Greta
Greta, a 62-year-old postmenopausal patient, N85.02 Endometrial intraepithelial neoplasm is seen in follow-up to discuss findings of her [EIN] recent endometrial biopsy. She presented to ICD-10 has fewer codes for endometrial the office the week prior with complaints of hyperplasia than ICD-9 abnormal bleeding and an EMB was Simple and complex without atypia performed. The biopsy results indicate combined into single code (N85.01) endometrial hyperplasia with atypia. Hyperplasia with atypia included in code for EIN (N85.02)
Chapter 14: Diseases of the Chapter 14: Diseases of the Genitourinary System (N00-N99) Genitourinary System (N00-N99)
N85.00 Endometrial hyperplasia, unspecified N85.02 Endometrial intraepithelial Hyperplasia (adenomatous) (cystic) neoplasm [EIN] (glandular) of endometrium Endometrial hyperplasia with atypia Hyperplasticendometritis N85.01 Benign endometrial hyperplasia Excludes 1 malignant neoplasm of Endometrial hyperplasia (complex) endometrium (w/ endometrial (simple) without atypia intraepithelial neoplasm [EIN]) (C54.1)
25 Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
Chapter 15: 9 “Blocks” Pregnancy, Childbirth, and O00-O08 Pregnancy with abortive outcome the Puerperium O09-O09 Supervision of high-risk pregnancy O10-O16 Edema, proteinuria and (O00-O9A) hypertensive disorders in pregnancy, childbirth and the puerperium O20-O29 Other maternal disorders predominantly related to pregnancy
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
9 “Blocks” Used for conditions related to or aggravated O30-O48 Maternal care related to the fetus by the pregnancy, childbirth, or by the and amniotic cavity and possible puerperium delivery problems Codes from other chapters can be reported O60-O77 Complications of labor and delivery but Chapter 15 codes have sequencing O80-O82 Encounter for delivery priority O85-O92 Complications predominantly related to the puerperium O94-O9A Other obstetric conditions, not elsewhere classified
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Final character indicating trimester present for Trimester counted from first day of LMP and majority of codes best clinical information If no trimester designation, then occurs only in Trimester based on the trimester documented specific trimester or concept not applicable (trimester or number of weeks) for current Some codes have characters for only certain encounter/admission trimesters if condition exists in more than one Applies to pre-existing conditions and those but not all trimesters that develop during or are due to pregnancy Unspecified trimester an option but should be Delivery during current encounter coded using rarely used- not present in record and/or “in childbirth” option if present cannot be obtained
26 Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
1st trimester: less than 14 weeks 0 days Certain codes require 7th character to identify 2nd trimester: 14 weeks 0 days to less than 28 multiple gestation affected by condition weeks 0 days 0: Not applicable 3rd trimester: 28 weeks 0 days until delivery 1-5: Fetus number Additional code from category Z3A (weeks of 9: Other fetus gestation) should be reported to identify specific Must also report code from O30 category week of pregnancy (multiple gestations) which include placenta Z3A.12 = 12 weeks gestation status (Monoamniotic/monochorionic, etc.) Z3A.28 = 28 weeks gestation If condition affects more than one fetus, then code must be assigned for each fetus affected
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
7th character 0 assigned: Categories requiring 7th character Single gestation O31: Complications specific to multiple Documentation insufficient to determine and gestations unable to obtain clarification O32: Maternal care for malpresentation of Not clinically possible to determine which fetus fetus is affected O33.3-O33.7: Maternal care for disproportion O35: Maternal care for known or suspected fetal abnormality and damage
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Categories requiring 7th character Categories requiring 7th character O36: Maternal care for other fetal problems O64: Obstructed labor due to malposition and O40: Polyhydramnios malpresentation of fetus O41: Other disorders of amniotic fluid and O69: Labor and delivery complicated by membranes umbilical cord complication O60.1: Preterm labor with preterm delivery O60.2: Term delivery with preterm labor
27 Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Twin pregnancy with preterm labor in the second Principal or First-Listed Diagnosis trimester and delivery in the third trimester at 34 Prenatal visits for high-risk patients weeks: O09.- Supervision of high-risk pregnancy O60.13X1 Preterm labor second trimester with preterm delivery third trimester, fetus 1 Other Chapter 15 diagnoses can be listed as secondary diagnoses as appropriate O60.13X2 Preterm labor second trimester with preterm delivery third trimester, fetus 2 O30.043 Twin pregnancy, dichorionic/diamniotic, third trimester Z3A.34 34 weeks gestation
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Principal or First-Listed Diagnosis Pre-Existing Conditions vs. Conditions Due to Routine outpatient prenatal visits when no Pregnancy complications are present Certain categories distinguish between conditions that existed prior to pregnancy and Z34.- Encounter for supervision of normal pregnancy those that are direct results of pregnancy Categories that do not distinguish between Z34.- codes are never reported with pre-existing and pregnancy-related conditions Chapter 15 codes can be used for either Important to determine and document information for proper code assignment
Let’s Practice! Kelly Answer - Kelly
Kelly, a 36-year-old G2P1, who is 34 weeks O09.523 Supervision of elderly multigravida, pregnant, is seen for her routine antepartum third trimester visit. She developed mild hypertension early O13.3 Gestational [pregnancy-induced] in the second trimester of pregnancy. hypertension without significant proteinuria, She is having no complications as a result of third trimester the hypertension and has no other Z3A.34 34 weeks gestation complaints.
28 Chapter 15: Pregnancy, Childbirth, and Answer - Kelly the Puerperium (O00-O9A)
Must go to Tabular list for trimester designations O13 Gestational HTN without significant Trimester is selected based on the date of the proteinuria encounter and not when condition first presented O14 Pre-eclampsia Chapter instructions state: O15 Eclampsia Report supervision of pregnancy code first O16 Unspecified maternal HTN (O09.-) Use additional codes from category Z3A.-, Weeks of gestation, to identify the specific week of the pregnancy
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
All subcategories require trimester O12 Gestational edema and proteinuria O14 Pre-eclampsia requires notation of without HTN severity O12.0- Gestational edema Mild to moderate (O14.0-) O12.1- Gestational proteinuria Severe (O14.1-) O12.2- Gestational edema and proteinuria HELLP syndrome (O14.2-) Unspecified (O14.9-) Eclampsia (O15) includes codes for trimesters, labor, and puerperium
Let’s Practice! - Linda Let’s Practice! - Linda
Linda is at 24 weeks’ gestation with low Her obstetrician reviewed her medication use weight gain and pre-existing essential and diet. Linda will be seen every two weeks hypertension complicating the pregnancy. to monitor her weight gain and blood She presents to the office as a work-in stating pressure. her blood pressure has ranged between 160/90 and 170/95 for the last two days. Her exam is normal.
29 Answer - Linda Answer - Linda
O10.012 Pre-existing essential hypertension Routine visit coded first, followed by complicating pregnancy, second trimester complications O26.12 Low weight gain in pregnancy, Sequencing based on condition chiefly second trimester responsible for encounter Z3A.24 24 weeks’ gestation Low weight gain and hypertension are indexed under complications of pregnancy
Chapter 15: Pregnancy, Childbirth, and Answer-Linda the Puerperium (O00-O9A)
Coder directed to hypertension in the index for Pre-existing hypertension the essential hypertension Hypertensive heart (O10.1-) Additional hypertension related codes not Hypertensive chronic kidney disease (O10.2-) required when reporting essential hypertension Hypertensive heart and chronic kidney disease Low weight gain in pregnancy (mother): (O10.3-) Pregnancy→complicated by→ insufficient→ Pre-existing secondary hypertension (O10.4-) weight gain OR Weight→gain→in pregnancy→low Unspecified pre-existing hypertension (O10.9-) Fetus: O26.84 Uterine size-date discrepancy complicating pregnancy
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Each category (except pre-eclampsia) contains O11 Pre-existing hypertension with pre- codes for trimester, childbirth, and puerperium eclampsia Must add additional code to specify type of Additional code from I10 must be reported to heart, kidney, or secondary hypertensive disease identify type O10.111: Pre-existing hypertensive heart O14 Pre-eclampsia has Excludes 1 note for disease complicating pregnancy, first trimester codes in O11 PLUS I11.9: Hypertensive heart disease without heart failure
30 Let’s Practice! - Mavis Answer - Mavis
Mavis, who is at 28 weeks’ gestation, has O09.893 Supervision of other high-risk gestational diabetes that is well-controlled by pregnancy, third trimester diet. She is seen for her routine antepartum O24.410 Gestational diabetes mellitus in visit. pregnancy, diet controlled Z3A.28 28 weeks’ gestation Supervision of pregnancy code reported first since prenatal visit Weeks gestation reported
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Gestational Diabetes is coded in sub-category A 5th character in O24.4 (gestational diabetes) O24.4- sub-category specifies: No other code from category O24 (Diabetes in In pregnancy Pregnancy) should be reported with a code from In childbirth O24.4 subcategory In the puerperium There are no trimester designations in sub- A 6th character specifies category for gestational diabetes Diet controlled vs. insulin controlled O99.81- reported for Abnormal glucose complicating pregnancy, childbirth, and the Patients treated with both are coded only puerperium as insulin controlled
Let’s Practice! Nell Answer - Nell
Nell is seen for her first prenatal visit at 8 O09.891 Supervision of other high-risk weeks. She has Type I diabetes but has no pregnancy, first trimester complications. Her FBS range between 120- O24.011 Pre-existing diabetes mellitus, type 1, 135. She smokes ½ to 1 pack of cigarettes in pregnancy, first trimester per day. E10.9 Type 1 diabetes mellitus without Her obstetrician explains the risks associated complications with diabetes, smoking and pregnancy. She is O99.331 Smoking (tobacco) complicating advised to stop smoking and pay strict pregnancy, first trimester attention to her diet. F17.210 Nicotine dependence, uncomplicated Z3A.08 8 weeks’ gestation
31 Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Pre-existing diabetes reported with code from A 5th character in each subcategory of pre- category O24 existing diabetes specifies: Pre-existing Type 1 (O24.0-) In pregnancy Pre-existing Type 2 (O24.1-) In childbirth Unspecified (O24.3-) In the puerperium Other unspecified (O24.8-) A 6th character specifies trimester
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Code for pre-existing diabetes reported first, O80 Full-term uncomplicated delivery followed by the appropriate diabetes code (E08- Always principal or first-listed diagnosis E13) Full-term, uncomplicated delivery E10.649 Type 1 diabetes mellitus with hypoglycemia without coma Single, healthy infant E11.21 Type 2 diabetes mellitus with diabetic Absence of complications during nephropathy antepartum, delivery, or postpartum during delivery episode Code Z79.4 Long term (current) use of insulin should be assigned as appropriate for Type 2 diabetes only
Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
O80 Full-term uncomplicated delivery O80 Full-term uncomplicated delivery Not used if other Chapter 15 code is reported May be used if there was a complication to describe current complication during pregnancy that is not present at time of Codes from other chapters can be reported if admission for delivery they are not related to pregnancy and in any Hyperemesis early in pregnancy and no way complicating the pregnancy complications at delivery Z37.0 Single live birth is only outcome of delivery code that can be reported with O80
32 Chapter 15: Pregnancy, Childbirth, and Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) the Puerperium (O00-O9A)
Complications during delivery reported with Routine postpartum care Chapter 15 code Z39.2 Encounter for routine postpartum care O66.0- Obstructed labor due to shoulder Admission following delivery outside the hospital dystocia If no complications noted, report code Z39.0 O24.12 Pre-existing diabetes mellitus, type 2, (Encounter for care and examination of mother in childbirth immediately after delivery) Postpartum complications Most codes within O85-O92 O86.81 Puerperal septic thrombophlebitis
Let’s Practice! Olive Answer - Olive
Olive is a G1P0 at 37 weeks with a Antepartum visit: monochorionic/monoamniotic twin gestation. O30.013 Twin pregnancy, She is seen in the office for an antepartum monochorionic/monoamniotic, 3rd trimester visit. Z3A.37 37 weeks’ gestation The following day she presents to the hospital in active labor complicated by prolapse of the cord of fetus 2. She is delivered by cesarean. Both infants were born healthy.
Answer - Olive Answer - Olive
O30 category for multiple gestation Delivery encounter: Placenta/amniotic sac status is incorporated O69.0XX2 Labor and delivery complicated by into the multiple gestation codes prolapse of cord, fetus 2 If placenta status not known, then unspecified O30.013 Twin pregnancy, category reported (O30.00) monochorionic/monoamniotic, 3rd trimester Trimester required (unspecified available) Z3A.37 37 weeks gestation Z37.2 Twins both liveborn
33 Summary Finally - Do This!
Some crosswalks are 1:1 Some are 1:many ICD-10 does not always offer more specificity Terminology and placement in ICD-10 is different than ICD-9 for some conditions Documentation is important to ensure the most accurate code Start getting prepared now !
200
Not This!
More Coding
201
Selecting E/M Services
Based on “physician work” History, Exam, MDM, or time Includes services medically necessary to evaluate/tx the patient Code selection must be supported by “work” and “medical necessity”
34 Documenting Services in 2014 Documenting Services in 2014
Electronic Health Records (EHR) present both Medicare Carrier Manual: opportunities and challenges The volume of documentation should not be Increased efficiency/ improvements in quality the primary influence upon which a specific of care level of service is billed Concern about accuracy and specificity of Medical necessity of a service is the clinical information overarching criterion for payment in addition to the individual requirements of a CPT code
Documenting Services in 2014 Documenting Services in 2014
Medicare has noted increase frequency of OIG Work Plans have focused on E/M codes identical information across services suggested or determined by EHRs and (copy/paste) templated notes Providers must select codes based on content Review of multiple E/M services for the same of service and support selection with provider and same patient to identify improper documentation payments
Documenting Services in 2014 Medically Necessary Services
Other government and non-government AMA’s Model Managed Care Contract payers initiating similar reviews definition: Must consider the integrity of the medical “Health care services or procedures that a record prudent physician would provide to a patient Information that is not customized to the for the purpose of preventing, diagnosing, or individual patient may jeopardize patient care treating an illness, injury, disease or its symptoms in a manner that is:
35 1995 and 1997 Medically Necessary Services Documentation Guidelines
In accordance with generally accepted Documentation Guidelines standards for medical practice; (DG) developed by AMA Clinically appropriate in terms of type, and CMS frequency, extent, site, and duration; and In many instances, the Not primarily for the economic benefit of the DGs “quantify” the extent health plans and purchasers or for the of the key components convenience of the patient, physician, or other Both sets of guidelines still health care provider.” in effect
1995 and 1997 Documentation Guidelines
1995 1997 Exam based on Created single- Selecting Levels of number of organ organ system systems/body exams to reflect E/M Services areas examined work of specialists Criticized for not Criticized for reflecting work of complexity of specialists system
Medicare OB/GYN E/M Distribution Medicare OB/GYN E/M Distribution Outpt. Services - New Outpt. Services - Established
36 Key Components Contributing Components
History Counseling Exam Coordination of Care Medical Decision Nature of presenting problem Making
Reference Category Requirements
Visits requiring 3 of 3 Visits requiring 2 of 3 key components key components Time New Outpatient Established Consultations Outpatient Initial Inpatient Subsequent inpatient Initial Observation care Subsequent observation care ED services
Time Factors Using Time To Determine Levels
Physician may perform PE, obtain history Time may be the key BUT may spend most of the encounter factor for the selection providing counseling, OR of the level of service All of the visit involves counseling with when counseling patient/family and/or coordination of care dominates the encounter (more than 50%)
37 Documentation Measuring Time
Document description Outpatient: Time spent by the of the counseling/ provider face-to-face with the coordination activities patient and/or family Inpatient: Time spent both with Document total time the patient and on the patient’s and time spent unit or floor counseling with the Report using the code with the patient closest actual time Verify Medicare contractor policy as may vary from CPT
Typical Times for Time Factors: Hester Outpatient E/M Services
Outpatient - New Hester is a 55-year-old new patient referred to Codes 99201 99202 99203 99204 99205 Dr. Dimmesdale by her friend to discuss Times 10 min. 20 min. 30 min. 45 min. 60 min. treatment options for menorrhagia. Another Outpatient - Established physician has suggested a vaginal Codes 99211 99212 99213 99214 99215 hysterectomy and Hester would like to Times 5 min. 10 min. 15 min. 25 min. 40 min. discuss other options including alternative Outpatient - Consultations surgical approaches. She refuses a physical Codes 99241 99242 99243 99244 99245 Times 15 min. 30 min. 40 min. 60 min. 80 min. exam today.
Hester Dr. Dimmesdale Hester 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by line) 22. MEDICAID RESUBMISSION 1. N92.6 Irregular menstruation, unspecified CODE ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER Dr. Dimmesdale spends 40 minutes 2. 3. discussing the risks and benefits of various 24. A. B. D. E. F. G. I. J. DATE(S) OF SERVICE PROCEDURES, SERVICES/SUPPLIES DAYS RENDERING From To (Explain Unusual Circumstances) DX $ OR ID. PROVIDER ID. # treatment options with Hester. She will make MM DD YY MM DD YY POS CPT/HCPCS MODIFIER POINTER CHARGES UNITS QUAL
a return appointment once she has 11 99204 1 1 NPI
determined her preferred course of treatment. NPI
Typical times for E/M codes are included in the CPT-4 code descriptors. Code 99203 lists 30 minutes as its “typical time”. Code 99204 lists 45 minutes as its “typical time”.
38 Tess Tess
Progress Note: 02/15/0X She also notes that she has urine loss on CC/HPI: Tess is a 63-year-old established coughing or sneezing. She finds herself patient who was last seen 4 years ago. She is avoiding public places for extended periods of being seen today with complaints of urinary time. She has not discussed the issue with urgency and frequency that has worsened over her primary care physician who she sees the last several months. She states that periodically for hypercholesterolemia and occasionally she can make it to the bathroom in routine exams. time but then it takes her a long time to urinate.
Tess Tess
ROS: She denies burning on urination, EXAM: vaginal bleeding, or discharge. Has not Constitutional: BP 120/85; Pulse 85; Wt 125; experienced loss of bowel control or other GI Ht. 5’4. Pleasant, cooperative, appears stated symptoms. Weight remained stable. All other age systems are negative. Abdomen: No masses, no tenderness and no PMH: She currently takes a statin medication enlargement of liver or spleen for high cholesterol. She is not currently on any other medications. SH: She is sexually active. She does not smoke or use alcohol.
Tess Tess
Pelvic: External genitalia: no lesions. Urethra IMP: and meatus: no lesions. Vagina: normal Pelvic relaxation with second degree uterine appearance. Cervix: normal appearance. prolapse Second degree uterine prolapse. First degree Stress incontinence cystocele/rectocele. Bimanual: Uterus small, Possible UTI anterior, mobile, and non-tender. Adnexa: no masses or tenderness. Rectal: Confirms exam and rectocele
39 Tess Office or Other Outpatient Services New Patient 99201 99202 99203 99204 99205 HISTORY CC Required Required Required Required Required Plan: 1-3 elements 1-3 elements > 4 elements OR > 4 elements OR > 4 elements OR HPI > 3 chronic or > 3 chronic or > 3 chronic or In office urine dipstick, non-automated w/o Inactive conditions Inactive conditions Inactive conditions ROS N/A 1 system 2-9 systems 10-14 systems 10-14 systems microscopy PFSH N/A N/A 1 element 3 elements 3 elements Level PF Expanded PF Detailed Comprehensive Comprehensive Return in 2 months for re-exam PHYSICAL EXAMINATION 1 System 2-4 systems 5-7 systems > 8 systems > 8 systems Pelvic instructions given 1995 1997 1-5 elements 6-11 elements > 12 elements Comprehensive Comprehensive Consider vaginal hysterectomy or TAH and Level PF Expanded PF Detailed Comprehensive Comprehensive MEDICAL DECISION MAKING sacrocolpopexy. Dx Mgmt Options Minimal Minimal Limited Multiple Extensive Minimal or Minimal or Limited Moderate Extensive Data Reviewed Risks/benefits discussed. Literature and None None Risk Minimal Minimal Low Moderate High informed consent form sent home for review. Level SF SF Low Moderate High TIME Face-to-face 10 min. 20 min. 30 min. 45 min. 60 min.
Office or Other Outpatient Services
Established Pt. 99211 99212 99213 99214 99215 HISTORY CC N/A Required Required Required Required N/A 1-3 elements 1-3 elements OR > 4 elements OR > 4 elements OR HPI > 3 chronic or > 3 chronic or > 3 chronic or CMS Proposed Policy Inactive conditions Inactive conditions Inactive conditions ROS N/A N/A 1 system 2-9 systems 10-14 systems PFSH N/A N/A N/A 1 element 2 elements and Payment Changes Level N/A PF Expanded PF Detailed Comprehensive PHYSICAL EXAMINATION 1995 N/A 1 system 2-4 systems 5-7 systems > 8 systems for 2015 1997 N/A 1-5 elements 6-11 elements > 12 elements Comprehensive Level N/A PF Expanded PF Detailed Comprehensive MEDICAL DECISION MAKING Dx Mgmt Options N/A Minimal Limited Multiple Extensive N/A Minimal or Limited Moderate Extensive Data Reviewed None Risk N/A Minimal Low Moderate High Level N/A SF Low Moderate High TIME 5 min. 10 min. 15 min. 25 min. 40 min. Face-to-face supervision
Proposed Rule Proposed Rule
Issued July 3 for changes effective Jan.1, Proposal to change all 10- and 90-day global 2015 codes to 0-day global. Proposal would pay Key Issues: separately for post-op visits Continues to emphasize primary care Enhance transparency of rate setting to management services-payment for chronic include opportunities for public comments care management prior to rate changes-beginning 2016 Continues process of identifying potentially Continues PQRS and Value Based Modifier misvalued services-no ob/gyn specific codes implementation included
40 Other Issues Thank You
OIG: It was a pleasure to Continues review of E/M services be here Place of Service Errors I hope to see you at CMS a future ACOG Coding Workshop Considering alternatives to the 2 Midnight rule for inpatient status Continue plans for Open Payments or Sunshine Act
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