Chapter 4 - class notes for quiz. Study guide for quiz and test. All questions are multiple PDF

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Chapter 4 Lecture Notes UNDERSTANDING ICD-10-CM CODING On October 1, 2015, the ICD-10-CM officially replaced the ICD-9-CM coding system. ICD-9-CM had been around for a while, and many found it a limiting system that didn’t really reflect expanded diagnoses and updated technologies. In the ICD-10-CM system, the codes have been greatly expanded to provide more detail. ICD-9-CM contained 13,000 codes, but the ICD-10-CM system has more than 68,000 diagnostic codes! Additionally, ICD-9-CM codes were numeric, but the expanded ICD-10-CM codes are alphanumeric and have been designed to allow for new codes to be added to them, which was one of the major problems with the ICD-9-CM system. You may be feeling overwhelmed by the sheer number of codes, but don’t worry! There are coding books as well as coding software that will help you understand codes and how to use and assign them. You’ll never be expected to memorize 68,000 individual codes. However, if you work with codes regularly, you’ll start to naturally memorize the codes you work with the most. It just happens. The ICD-10 system also introduced changes for procedure codes. In addition to the ICD-10-CM diagnosis changes, ICD-10 also replaced the use of procedure codes in ICD-9-CM with ICD-10-PCS, where the PCS stands for Procedure Coding System Replacement. The ICD-10-PCS system is used for hospital inpatient procedures only. BEFORE ICD-10: AN INTRODUCTION TO CODING The International Classification of Diseases, or ICD, is the standard diagnostic tool for epidemiology, health management, and clinical purposes. It was created to         

Monitor the incidence and prevalence of diseases Keep track of health problems Analyze the health of like groups Report and provide statistics Classify diseases Provide for the storage and retrieval of diagnostic information Record national mortality and morbidity statistics Provide a system for reimbursement Help providers understand resource allocation

ICD-9-CM stands for the International Classification of Diseases, Ninth Revision, Clinical Modification, and until its replacement with ICD-10-CM/PCS in 2015, it was the official system in the United States for assigning codes to diagnoses and procedures for hospital stays. It was based on the World Health Organization’s (WHO) initial Ninth Revision, International Classification of Diseases (ICD-9). However, the National Center

for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS) are the U.S. government agencies responsible for overseeing changes and modifications to the ICD-9 and ICD-10. Though ICD-9-CM has already been replaced by ICD-10-CM/PCS, it’s important that you learn the basics of ICD-9-CM coding, as many healthcare facilities are still transitioning to the new system. ICD-9-CM consisted of three volumes:   

Volume 1: A numerical list of the disease code numbers in tabular form Volume 2: An alphabetical index to the disease entries Volume 3: An alphabetic index and tabular list of surgical, diagnostic, and therapeutic procedures

ICD-10 is very similar to ICD-9 and consists of   

Volume 1: Tabular lists containing cause-of-death titles and codes and inclusion and exclusion terms for cause-of-death titles Volume 2: Descriptions, guidelines, and coding rules Volume 3: An alphabetical index to diseases and nature of injury, external causes of injury, and table of drugs and chemicals

The ICD-9-CM coding system was originally published in the three volumes just discussed. Later editions separated the hospital and outpatient sections. The process of correctly coding diagnoses is challenging. In addition to the procedure of actually selecting the correct code from the code book, there’s a more significant element that we must discuss. The main point to remember (and this isn’t covered in your text) is that the quality of the information you receive from the physician is what determines the ultimate quality of the code. You must develop an effective communication system with your physician to obtain a correct and complete diagnosis, including all secondary and concurrent conditions. Effective communication between you and your physician can be accomplished by means of the patient’s chart, the encounter form, or other special forms used within the office. Whatever the method of communication, you must receive timely and accurate information from the physician. Try to remember that you and the physician are a team with the same goal of reimbursement. The importance of accurate diagnostic coding can’t be stressed enough. Incorrect coding can have serious consequences, including lawsuits. It’s imperative that you have a system in place to obtain all the correct information from the physician before you code diagnoses. Once you have an accurate, written, and complete diagnosis from your physician, you can begin to find the codes. This assignment begins by discussing the different types of diagnoses, including primary versus principal diagnoses. In some instances, a comorbidity diagnosis might be appropriate for certain patients. Note that the term principal procedure applies only to a procedure performed for definitive treatment, rather than diagnostic purposes. Secondary procedures are

additional procedures performed during the same encounter as the principal procedure. Be sure you understand the difference between these two terms. In the ICD-9 and ICD-10 coding systems, various coding conventions (i.e., rules and methods), must be followed. Each volume of ICD-9 and ICD-10 has its own conventions. In the Tabular List (Volume 1), there are important features, such as bold type, braces, colons, and the terms NEC (not elsewhere classifiable) and NOS (not otherwise specified). Each of these conventions has a specific purpose. Learn what each convention means and how to interpret its use. The Disease Index (Volume 2) has boxed notes, cross references, eponyms (specific diseases, disorders, or symptoms that carry the name of a person), and bracketed codes. Coding for special disorders such as HIV/AIDS, fractures, and late effects might be a bit more complicated. The term late effect means an adverse residual effect or sequela of a previous illness, injury, or surgery. The acute condition is gone, but the patient is still suffering some after-effects or even long-term chronic effects. Both ICD-9-CM and ICD-10-CM also contain a Table of Drugs and Chemicals. This table uses generic drug names rather than brand names or manufacturers’ names. It’s used to identify the poisoning status and external causes of adverse effects directly caused by drugs and other chemical substances. To properly use this table, you must know the meaning of the terms poisoning (which involves either the use of the wrong drug/substance or the administration of an incorrect dosage) and adverse effects (pathological reactions following the ingestion of, or exposure to, drugs or other chemical substances). It’s important to understand that although you’ll have a working knowledge of ICD-10 coding, the only way to become proficient is to practice and become comfortable with the terminology and using the manual. You’ll use the ICD-10 manual as part of your course. It’s also important to remember never to code directly from the index. Too many times coders become lazy or are pressed for time and select a code(s) from the index. Coders who do this may not be coding to the highest level of specificity. A coding tip for proper reimbursement is to code only those conditions that the physician is managing or that contribute to the condition. For example, consider the following scenario: A patient has a lower-leg ulcer that won’t heal and is also diabetic. The physician in this case should report the code for the lower-leg ulcer as the primary diagnosis and then supply the code denoting diabetes as the concurrent condition. However, suppose a patient with hypertension is admitted to the hospital by his internist for abdominal pain. The patient is then seen by a surgeon who determines that the patient has cholecystitis and then admits the patient for two days. The surgeon in this case would report cholecystitis, not hypertension, because it isn’t contributing to the cholecystitis and the surgeon isn’t managing that condition. Likewise, the internist would report the abdominal pain and possibly the hypertension if the internist was managing that condition for the patient. If the internist reports the cholecystitis on the claim as the diagnosis for any hospital visits, the claim might get denied for concurrent care because insurance payers usually don’t pay two physicians to manage the same problem.

You can see how important it is to become very familiar with the ICD-10-CM/PCS volumes and to have good communication with the physician. Coders who know where to find tables and special sections can work more quickly and accurately than those who take excessive time searching all over the book to find the correct sections. Spend your time wisely selecting the correct code, not fumbling through the book searching for a place to start. BEGINNING TO CODE As we’ve discussed, there are several separate systems for coding. The main coding systems are the ICD and the CPT systems. As you’ve just read, the ICD-10-CM/PCS volumes are now used to code diagnoses that describe the clinical picture of the patient and to report acute care procedures. The Current Procedural Terminology (CPT) system is used by all healthcare providers (e.g., physicians, hospitals, and therapists) to report procedures and services performed. CPT codes are only one part of an entire coding structure known as HCPCS (Health Care Financing Administration Common Procedure Coding System, pronounced “HIC-pics”). We’ll discuss ICD-10, CPT and HCPCS in greater detail later in this lesson. Diagnoses are diseases, disorders, symptoms, injuries, and conditions that bring the patient into the healthcare facility. The patient diagnosis is the reason the patient is being seen. There may be just one diagnosis, or issue, that brings the patient to the provider, or there may be multiple diagnoses that are being treated at one time. In this case, it’s the healthcare provider’s job to determine the condition that’s the number-one diagnosis that has brought the patient in. This is the principal diagnosis. Any additional conditions are then listed as secondary diagnoses. It’s important for you to understand principal and secondary diagnoses because they affect how a claim is paid and may even cause claims to be denied. Something that seems simple, such as the order in which you list the diagnoses on a claim, can have major effects on reimbursement. You may be wondering how the insurance company knows exactly how much to reimburse the hospital or doctor’s office for costs to treat the patient. Some of these costs are calculated by the diagnosis and procedure codes assigned by a trained coding professional. Coding is the process of reviewing medical documentation for the diagnoses and procedures related to a patient’s care, assigning the correct codes to the corresponding diagnoses or procedures, and then reporting them on the patient’s account. RECOGNIZING ICD-9-CM CODES ICD codes have a specific structure. The structure of ICD-9 codes is very different from the updated ICD-10 codes we use today. ICD-9-CM diagnosis codes are usually three digits. There can also be three digits, a decimal, and then one or two more digits. The digits after the decimal provide a higher level of specificity. Thus, ICD-9 diagnosis codes may have the following formats (where “X” is a digit): XXX XXX.X

XXX.XX For example, if a physician documents congestive heart failure (with no further specification), the ICD-9-CM code is 428.0. However, if the physician documents congestive heart failure with acute systolic heart failure, the code is 428.21. ICD-9-CM procedure codes are generally two digits, a decimal, and then one or two additional digits. Thus, procedure codes may have the following formats (where “X” is a digit): XX.X XX.XX For example, 47.01 is the ICD-9-CM procedure code for laparoscopic appendectomy. MOVING THROUGH THE CODING PROCESS The codes that we’ve been discussing correspond to the written diagnoses or procedures reported by the healthcare provider in the patient’s health record. These codes are then reported on an insurance claim form for reimbursement. They’re grouped together so that they translate into a specific number and are mapped to a specific reimbursement amount. The insurance company then reimburses the provider that amount for the healthcare services provided to the patient. Many people think that ICD coding is for diagnoses and CPT coding is for procedures. In fact, the ICD-9-CM and ICD-10-CM/PCS are for diagnoses and procedures, whereas CPT covers only procedures. Appropriate reimbursement depends on the accuracy of coding. If a coder assigns incorrect codes, then the hospital or physician’s office won’t be fully reimbursed and will lose money. If you’re not familiar with the coding and reimbursement process, then it may seem confusing to you initially. However, the more you work with the process, the easier it will become. Here’s an example of how coding is performed and reimbursement is assigned for a patient who has been discharged from the hospital: 1. A patient is discharged from the hospital. 2. The coder reviews the patient’s health record and reviews documents for relevant diagnoses and procedures for this patient’s stay in the hospital. 3. The coder enters the names of the diagnoses and procedures into a specialized coding computer program, using coding books as a backup when questions arise. 4. The computer program translates the names of the diagnoses and procedures into the corresponding numerical codes (ICD and/or CPT). 5. The computer program then groups all the codes into one numerical classification system and reports it on a claim form. 6. The claim form is sent to the insurance company for reimbursement. The insurance company then equates the numerical codes to a specific reimbursement payment amount.

7. The reimbursement is then sent from the insurance company to the hospital. In some cases, the insurance company may deny the claim and not pay the hospital, or it may ask for additional documentation to back up the codes reported. UNDERSTANDING THE TYPES OF DIAGNOSES AND PROCEDURES As we discussed earlier, the way that diagnoses and procedures are listed on a patient’s claim form can affect the way the provider is reimbursed. Let’s take a closer look at the different types of diagnoses and procedures: 

 

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Admitting diagnosis: The admitting diagnosis is the disease, illness, or trauma that brought the patient to the hospital. The admitting diagnosis isn’t necessarily the same as the principal diagnosis. For example, a patient may come to the hospital with chest pain, but the physician may find that the patient has pneumonia. The pneumonia is then listed as the principal diagnosis. Principal diagnosis: The principal diagnosis is the diagnosis, after study, that the physician determines to be the cause of the patient’s admission to the hospital. Principal procedure: The principal procedure is the procedure that’s performed to address the patient’s principal diagnosis. In some cases, the principal procedure may not be related to the principal diagnosis. For example, say that the patient came into the hospital for pneumonia. While in the hospital she fell and broke her hip and had to have surgery because of it. The principal diagnosis is still pneumonia, but the principal procedure is the hip surgery. Comorbidities: These are additional conditions and illnesses that are present at the time of the patient’s admission to the hospital. They often complicate the treatment or prolong the patient’s stay in the hospital. Comorbidities are coded as additional diagnoses and are reported on the claim form. Some comorbidities increase the reimbursement from the insurance company because they’re more resource intensive (i.e., it costs more to treat a patient who has them). Complications: Conditions or illnesses that develop after a patient has been admitted to the hospital and may prolong the patient’s stay in the hospital are referred to as complications. Complications are coded as additional diagnoses and are reported on the claim form. Some complications increase the amount of reimbursement from the insurance company.

NOTE: Comorbidities and complications are referred to as secondary diagnoses. HISTORY OF ICD-10-CM Many people have questioned the migration from the ICD-9-CM coding system to the ICD-10-CM coding system—especially those who have spent a great deal of time understanding, learning, and using ICD-9-CM. Much has changed in the healthcare world since ICD-9-CM was introduced over 30 years ago, especially technology. A system was needed that reflected the changes that have occurred. Many have found that ICD-9-CM codes weren’t descriptive enough to reflect the changes in treatments and technology. It became clear that a new system

was needed to provide accurate reimbursement for services provided and to deal with the tracking of quality processes and outcomes. ICD-10-CM was created to address all of these issues. ICD-10 was actually endorsed by the WHO in 1990 and implemented on January 1, 1999, for use on U.S. death certificates for designation of the cause of mortality. However, many other countries have been using ICD-10 for reimbursement purposes since 1995. When it became clear that the ICD-9-CM system was limited and outdated, work began on an ICD-10-CM system (where “CM” is the clinical modification of the ICD-10 system, just like it is in the ICD-9 system). ICD-9-CM VERSUS ICD-10-CM ICD-10-CM vastly expanded the number of codes over what was used in ICD- 9-CM. As was mentioned previously, the ICD-10-CM has more than 68,000 diagnostic codes, compared to 13,000 in ICD-9-CM. Additionally, ICD-10-CM includes twice as many categories and also introduces alphanumeric category classifications for the first time. All of this will help coders be more specific when reporting codes on the patient’s account. Visit the CMS website at https://www.cms.gov/ICD10 to learn more about ICD10-CM. To convert codes between the ICD-9-CM and ICD-10-CM systems, use the code translator tool at https://www.aapc.com/icd-10/codes/ . Let’s take a closer look at the structural differences between the two coding systems. Table 1 provides a summary of the differences between the two systems. TABLE 1—ICD-9-CM Versus ICD-10-CM Code Element Number of digits Numeric or alphanumeric

ICD-9-CM 3–5 All numbers

ICD-10-CM 3–7 Alphanumeric: Digit 1 is a letter. Digit 2 is a number. Digit 3 is a letter or a number. Digits 4–7 are letters or numbe

Decimal point

Decimal after third character

Supplemental codes

First digits are letters (V and E codes) Combination codes include the external/supplemental causes

Example: Fracture of unspecified part of 810.00 right clavicle, initial encounter for closed fracture

Decimal after third character

S42.001A

NEW FOR ICD-10-CM As we’ve discussed, the need for a higher level of specificity and better information was one of the driving forces behind ICD-10. With ICD-10-CM, you’ll see more information included in one code, whereas with ICD-9-CM it may have taken several codes to reflect the same information. Other changes for ICD-10- CM include       

Support of directional terms such as laterally-right, left, and bilateral Use of combination codes for conditions and associated symptoms, as well as for poisonings and external causes Inclusion of trimester in obstetric codes Use of the character “X” as a placeholder to allow expansion of future codes Inclusion of clinical concepts (e.g., blood alcohol level, blood type, etc.) Expansion of categories of codes to allow for great specificity Designation of injury by anatomical site rather than just injury type

ICD-10-PCS In addition to the ICD-10-CM diagnosis changes, ICD-10 a...