ICD9 CM Why it is important and how it affects you as a physician Jeni Smith CPC The Major Issues Quality Report Suffers It will not paint an accurate picture of the severity of the illnesses ID: 697894
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Slide1
Coding to Highest SpecificityICD-9 CM
Why it is important and how it affects you as a physician.
Jeni
Smith, CPCSlide2
The Major Issues
Quality Report Suffers
It will not paint an accurate picture of the severity of the illnesses
Severity of illness is a measure of the patient's overall health status reflected by the resources necessary for care and the risk of morbidity and mortality
“severity of illness is understated 8%-15% of the time. Mortality is understated 15%-25% of the time.” (
For the Record
, page 11)
Reporting
comorbidities
and illness severity will help better define quality of care and medical necessity for that care. Slide3
The Major Issues Continued
RAC Audits
85
% of Medicare RAC audit identified
overpayments
have been directly related
to
coding,
determination of
medical
necessity
and/or
a need to
enhance
detailed documentation
gathered
in
support
of submitted
claims
.
RAC took back over $900 Million from hospitals (Took 3 Mil. from AGH)
More MCC, can lead to increased level of visit
Increases in morbidity, mortality, and length of stay will not correlate with the documented severity of illness which could lead to red flags
Slide4
Major Issues Continued
Transfer to ICD-10 System Inevitable
ICD-10
offers more detailed information and the ability to expand specificity
Greater
specificity and clinical information, which results in:
Improved
ability to measure health care
services
Increased
sensitivity when refining grouping and reimbursement
methodologiesSlide5
How to Code for Specificity
A
code is invalid if it has not been coded to
the full
number of digits required for that code
.
Provider
reports the full ICD-9-CM
ICD-9 codes may have three to five digits depending on their category.
Each digit provides important information about the patient's condition.
http://www.aafp.org/fpm/990700fm/27.htmlSlide6
ExamplesChronic Kidney Disease (CKD)
ICD- D
9-CM Diagnosis Code
Descripition
(Can be found on lab
sheet)
585.1
Stage 1
585.2
Stage 2
(mild
)
585.3
Stage 3 (moderate)
585.4
Stage 4 (severe)
585.5
Stage 5
585.6
End Stage Renal Disease
585.9
Chronic
Kidney Disease, (unspecified)Slide7
Examples ContinuedDiabetes
250.13, uncontrolled type 1 diabetes with
ketoacidosis
.
Choosing the most specific code means coding only what you know to be a fact.
The
three-digit code
(in this case, 250) represents the
diagnostic
category.
The
fourth digit
identifies
complications associated
with diabetes
The
fifth digit
describes the
type of diabetes and its level of control
.
To correctly code an encounter with a patient who has uncontrolled type 1 diabetes complicated by
ketoacidosis
, you should use
all five digits.Slide8
Examples ContinuedHypertension
Patient, follow-up of benign essential hypertension = 401.1 (
The fourth digit identifies the disease as benign and thus is the most specific description of your patient's condition
)
However, patient also has benign hypertensive heart disease, include a fifth digit = 402.10 or 402.11 (
depending on the absence or presence, respectively, of congestive heart failure)
http://www.aafp.org/fpm/990700fm/27.html
Slide9
Conclusion
Y
ou must always code to the highest number of digits that best describe your patient's condition
Physicians are legally responsible for the codes selected and submitted
to payers.
Coding to the highest specificity allows for more accurate report of quality of care and will prepare you for possible RAC audits and the implementation of ICD-10-CM.Slide10
Additional Diagnosis to watch
Heart Failure – Systolic or Diastolic
COPD – Need to state acute exacerbation
Sepsis – If code as 599.0, translates to UTI
-Need to state Sepsis due to UTI
CVA – State with Residual or presenting symptoms
Anemia – Chronic, Acute blood loss, iron deficiency
Pneumonia – Which Bacteria
DM – Need type and whether controlled/uncontrolled
Morbid Obesity – Must state BMI, can increase reimbursement by thousands (Already calculated on MAR)