PPS Coding in the Rehabilitation Setting. Copyright (c) 2015 by American Hospital Association. All rights reserved.

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1 PPS Coding in the Rehabilitation Setting 1

2 Gretchen Young-Charles, RHIA Senior Coding Consultant 2

3 Disclaimer This presentation is designed to provide accurate and authoritative information in regard to the subject matter covered. It is provided with the understanding that neither the presenter (s) nor the event sponsor is engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought. The views expressed in this publication are strictly those of the presenter (s) and do not necessarily represent official positions of the American Hospital Association. 3

4 Objectives Review ICD-10 Structure and Principles Identify workflow and process issues that may require revising to be ready for ICD-10 Learn about the top areas requiring documentation changes for ICD-10-CM/PCS to address potential gaps Show examples of specific coding scenarios for rehabilitation 4

5 INTRODUCTION 5

6 Clinical Coding Diagnosis vs. Procedure ICD-9-CM Volumes 1 and 2, HIPAA standard diagnosis coding for all clinical care settings (e.g. hospitals, physicians, home health, skilled nursing, insurance, etc.) Upgrade to ICD-10-CM ICD-9-CM Volume 3, HIPAA standard coding for hospitals to report inpatient services Upgrade to ICD-10-PCS CPT/HCPCS HIPAA standard for reporting outpatient services by hospitals and both inpatient and outpatient services by nonhospital providers (physicians, therapists, clinics, insurance, etc.) No change 6

7 Number of ICD-9 and ICD-10 Codes for Diagnoses and Procedures So Where is the Additional Detail? 80,000 69,823 71,924 40,000 ICD-9 ICD-10 13,000 0 Diagnosis codes 3,000 Procedure codes 7

8 Changes Classifications ICD-9-CM Structured Format Numeric or Alpha (E or V) Numeric V X E 58 X 0 X 5. X 0 X 0 Category 3 5 Characters Etiology, anatomic site, manifestation 8

9 Alpha (Except U) Changes Classifications ICD-10-CM Structured Format 2-7 Numeric or Alpha Additional Characters S X X A Category Etiology, anatomic site, severity Added code extensions (7 th character) for obstetrics, injuries, and external causes of injury 3 7 Characters 9

10 Greater Specificity Laterality Example Pressure ulcer ICD-9-CM Pressure ulcer buttock Pressure ulcer stage II Pressure ulcer stage IV ICD-10-CM L Pressure ulcer of right buttock, stage II L Pressure ulcer of left buttock, stage IV OR L Pressure ulcer of left buttock, stage II L Pressure ulcer of right buttock, stage IV 10

11 Greater Specificity Precision Example Patient noncompliance: Information may be useful to identify reasons for readmissions and prevent readmissions ICD-9-CM V15.81 Noncompliance with medical treatment ICD-10-CM Z91.11 Patient's noncompliance with dietary regimen Z Patient's intentional underdosing of medication regimen due to financial hardship Z Patient's intentional underdosing of medication regimen for other reason Z Patient's unintentional underdosing of medication regimen due to age-related debility Z Patient's unintentional underdosing of medication regimen for other reason Z91.14 Patient's other noncompliance with medication regimen Z91.15 Patient's noncompliance with renal dialysis Z91.19 Patient's noncompliance with other medical treatment and regimen 11

12 ICD-9-CM vs. ICD-10-CM Sample Codes ICD-9-CM Late effect of cerebrovascular disease, speech and language deficits, aphasia NOTE: Category 438 is to be used to indicate conditions in (subarachnoid hemorrhage, intracerebral hemorrhage, infarction cerebral arteries, infarction precerebral arteries), as the cause of late effects ICD-10-CM I Aphasia following nontraumatic subarachnoid hemorrhage I Aphasia following nontraumatic intracerebral hemorrhage I Aphasia following other nontraumatic intracranial hemorrhage I Aphasia following cerebral infarction I Aphasia following unspecified cerebrovascular disease 12

13 ICD-9-CM vs. ICD-10-CM Sample Codes ICD-9-CM Fractures are coded using the aftercare codes (subcategories V54.0, V54.1, V54.8, or V54.9) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. ICD-10-CM The aftercare Z codes should not be used for aftercare of injuries. For aftercare of an injury, assign the acute care injury code with the appropriate 7 th character for subsequent encounter (e.g. S72.002G Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with delayed healing) Etiologic diagnosis: S72.002A, Fracture of unspecified part of neck of left femur, initial encounter 13

14 THINGS THAT REMAIN THE SAME 14

15 What is NOT Changing with ICD-10 Transition? Official coding guidelines and AHA s Coding Clinic will continue to provide coding guidance Adherence to the official coding guidelines in all healthcare settings is still required under the Health Insurance Portability and Accountability Act (HIPAA) Uniform Hospital Discharge Data Set definitions are the same. 15

16 Unchanged Documentation Principles Associated Conditions and Documentation of a Linkage It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g., hypertension with chronic kidney involvement). When the provider establishes a linkage or relationship between the two conditions, they should be coded as such. 16

17 Unchanged Documentation Principles (cont.) Associated Conditions and Documentation of a Linkage (cont.) However, the entire record should be reviewed to determine whether a relationship between the two conditions exists. The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related. A different cause may be documented by the provider. If it is not clear whether or not two conditions are related, query the provider. Coding Clinic, Third Quarter 2012 Page: 3 Republished Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter

18 Unchanged Documentation Principles (cont.) Physician documentation Which Physicians? Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. Coding Clinic, First Quarter 2004 Page: 18 to 19 Republished Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter

19 Unchanged Documentation Principles (cont.) Resident s documentation Resident The issue of whether a resident s documentation needs to be confirmed by the attending physician is best addressed by the hospital s internal policies, medical staff bylaws, and/or any other applicable local/state/federal regulations. Coding Clinic, Third Quarter 2008 Page: 3 Republished Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter

20 Unchanged Documentation Principles (cont.) Physician documentation Resolving Conflicts A physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis. This information is consistent with the American Health Information Management Association's (AHIMA) documentation guidelines. Coding Clinic, First Quarter 2004 Page: 18 to 19 Republished Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter

21 Unchanged Documentation Principles (cont.) Physician documentation Which documents? Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding. Coding Clinic, Second Quarter 2000 Page: 17 to 18 Republished Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter

22 Unchanged Documentation Principles (cont.) Mid-Level Provider Documentation It would be appropriate to use the health record documentation of other providers, such as nurse practitioners and physician assistants as the basis for code assignment to report new diagnoses, if they are considered legally accountable for establishing a diagnosis within the regulations governing the provider and the facility. The Official Guidelines for Coding and Reporting define a provider as the individual legally accountable for establishing a diagnosis. Coding Clinic, Fourth Quarter 2004 Page:

23 Unchanged Documentation Principles (cont.) Do not code on the basis of up and down arrows Can have variable interpretations and do not necessarily mean "abnormal." Could simply be indicating change (including improvement) over past results. Query provider regarding meaning and request that the appropriate documentation of a condition or diagnosis be provided. Applies for both inpatient and outpatient admissions. Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter

24 Unchanged Documentation Principles (cont.) If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report. 24

25 Unchanged Documentation Principles (cont.) Inpatient coding guidelines concerning abnormal findings Abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the finding are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added. 25

26 Unchanged Documentation Principles Facility-Specific Coding Guidelines Should not replace physician documentation Can guide when to query physicians for clarification, but not interpret abnormal findings or replace physician documentation or query Must be applied consistently to all records coded. Must not conflict with Official Guidelines Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter

27 Assigning Codes Using Prior Encounters Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter. Conditions documented on previous encounters may not be clinically relevant on the current encounter. The physician is responsible for diagnosing and documenting all relevant conditions. A patient s historical problem list is not necessarily the same for every encounter/visit. It is the physician s responsibility to determine the diagnoses applicable to the current encounter and document in the patient s record. 27

28 Assigning Codes Using Prior Encounters (cont.) When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition should be documented in the medical record with each encounter/admission. However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation. Coding Clinic, Third Quarter 2013 Pages:

29 Use of Unspecified Codes When sufficient clinical information isn t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. 29

30 Documentation Focus Areas for ICD- 10-CM Disease type Disease acuity Disease stage Site specificity Laterality Most likely documented for injuries, but what about other conditions involving laterality? Missing combination code detail Changes in timeframes associated with familiar codes 30

31 Seventh Character Determination Initial vs. subsequent encounter vs. sequela Injuries Poisoning, adverse effects, and underdosing Most external cause codes (except for place of occurrence, activity or status) 31

32 Seventh Character Determination, cont. Seventh characters: A Initial Based on whether patient is receiving active treatment for the condition Not based on provider D Subsequent Used for encounters after patient has received active treatment Patient is now receiving routine care during healing or recovery phase S Sequela Used for complications or conditions that arise as a direct result of a condition (i.e., scar formation after burn) 32

33 Fractures Open vs. closed Gustilo classification of open fractures (I, II, IIIA, IIIB, IIIC) S52 Forearm S72 Femur S82 Lower leg, including ankle Displaced vs. nondisplaced 33

34 Fractures (cont.) Instructional notes indicate: Fracture not indicated as displaced or nondisplaced should be coded to displaced Fracture not indicated as open or closed should be coded to closed Subsequent encounters Routine vs. delayed healing Nonunion Malunion Traumatic vs. Pathological 34

35 Pathological Fractures Documentation will need to include: Exact location of fracture Site Laterality Etiology of fracture Osteoporosis Neoplastic disease Other specified Unspecified Encounter type Current fracture and/or personal history 35

36 Myocardial Infarction Does the patient require continued care for acute myocardial infarction (AMI)? Is it within 4 weeks time frame? New concept: Has the patient suffered a NEW AMI within the 4 week time frame of the initial AMI? The sequencing depends on the circumstances of the encounter Is the myocardial infarction old or healed not requiring further care? 36

37 Adverse Effects, Poisoning, Underdosing and Toxic Effects Combination codes that include the substances related to adverse effects, poisonings, toxic effects and underdosing, as well as the external cause. Will require knowing intent: accidental, intentional self-harm, assault, undetermined New information for states where external cause coding is not mandated. 37

38 Underdosing Taking less of a medication than is prescribed Provider or manufacturer Never assigned as principal or first-listed If relapse, medical condition itself is coded Noncompliance or complication of care codes are used with underdosing code to indicate intent, if known. 38

39 Non-physician Documentation External Cause Codes Based on physician documentation If not documented, coders may use documentation available from non-physicians. If there is conflict, the physician s documentation takes precedence. Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter 2014, page 19 39

40 Hyperglycemia in Diabetes ICD-10-CM no longer classifies diabetes as controlled or uncontrolled Instructional notes in the Index under Diabetes, diabetic, inadequately controlled, out of control and/or poorly controlled direct: Code to Diabetes, by type, with hyperglycemia 40

41 Diabetes and Osteomyelitis ICD-9-CM assumes a relationship between diabetes and osteomyelitis when both conditions are present Unless the physician documentation indicates the osteomyelitis is unrelated to the diabetes ICD-10-CM does NOT presume a linkage between diabetes and osteomyelitis Physician will need to document a linkage/relationship in order to code as such Coding Clinic, Fourth Quarter 2013, page

42 Diabetes Gastroparesis Diabetic gastroparesis is caused by damage to the vagus nerve In ICD-10-CM diabetes mellitus with diabetic gastroparesis" are inclusion terms under the diabetes codes (E08.43, E09.43, E10.43, E11.43, and E13.43) Code titles are not specific for diabetic gastroparesis Assign an additional code to identify the manifestation as gastroparesis: E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy K31.84, Gastroparesis Coding Clinic, Fourth Quarter 2013, pages

43 Sepsis and Bacteremia Sepsis: assign the appropriate code for the underlying systemic infection. If type of infection or causal organism not further specified, assign code A41.9. Severe sepsis must be specifically documented or have documentation of an associated organ dysfunction. Sepsis and bacteremia go to different codes. Bacteremia with sepsis see Sepsis 43

44 Urosepsis Alphabetical Index code to condition Generalized sepsis? Urine contaminated by bacteria, bacterial byproducts, or other toxic material but without other findings? ICD-10-CM no longer defaults to urinary tract infection. 44

45 Nonhealing Surgical Wound Occurs when a surgical incision (wound) does not heal normally ICD-10-CM does not provide a specific code for nonhealing surgical wound Assign code T81.89X-, Other complications of procedures, not elsewhere classified If a postsurgical wound does not heal due to infection, assign code T81.4XX-, Infection following a procedure Assign code T81.3-, Disruption of wound, not elsewhere classified, if the wound was closed at one time and is no longer closed. Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter 2014, page 23 45

46 Workflow Issues/Internal Processes 46

47 Query Forms Will need to redesign physician queries. Coders and documentation specialists most likely already know where the gaps in documentation are Engage them to watch for gaps and work on closing those gaps now! Review query form inventory 47

48 Dictation/Transcription Much more difficult (if not impossible in some instances) to code without an operative report Do you want your coders to wait for the dictation and/or transcription of the report? Filing (if working with paper) Address any workflow deficiencies upfront 48

49 Additional Coder Education With limited time and money, where should you concentrate additional education, besides coding rules? Anatomy and physiology? Terminology? Surgical procedures? Coders need to understand components of a surgical procedure No embedded code also notes in ICD-10- PCS (e.g. pacemaker and leads) 49

50 Don t Forget the Medical Staff Collaboration is key Training Documentation changes ICD-10 requires more detailed documentation to specify aspects of diagnoses and procedures required for more detailed codes Partnering Help them understand the impact Include their office staff in training Assist them to convert their super bills 50

51 Documentation Improvement Program Work with your medical staff Share information on ICD-10 Request their help in advance for most common procedures Most importantly, be patient with coders as they learn ICD-10! Audit- what is the quality of your documentation today? Are diagnoses and procedures documented in in sufficient detail for coding? Are all significant secondary diagnoses properly documented? Refine any existing CDI programs to include ICD-10-CM/PCS requirements Can you incorporate into existing processes already in place today? For example, documentation for RACs? Will need support from administration 51

52 CODING FOR REHAB PPS VS. IRF-PAI 52

53 IRF PPS VS. IRF-PAI Information regarding how to complete the IRF PPS. Different from IRF-PAI For IRF-PAI coding, refer to IRF-PAI manual 53

54 PRINCIPAL DIAGNOSIS UHDDS definition of principal diagnosis: that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Definition has been expanded to include all nonoutpatient settings. Acute care Home health agencies Rehab facilities Nursing homes 54

55 ICD-9-CM vs. ICD-10-CM ICD-9-CM Category V57, Care involving use of rehabilitation procedures ICD-10-CM Guideline for Admissions/encounters for rehabilitation has been removed from ICD-10-CM Code condition instead. 55

56 Rehabilitation Guideline Section II. Selection of Principal Diagnosis: Admission/encounter is for rehabilitation: Sequence first the code for condition for services performed. Ex.: Rehab for right-sided dominant hemiplegia following CVA, report code I69.351, Hemiplegia and hemiparesis, following cerebral infarction affecting right dominant side.» Etiologic diagnosis: I63.9, Cerebral infarction, unspecified If condition no longer present, report first the appropriate aftercare code. Ex.: Severe degenerative osteoarthritis of hip, had hip replacement and now encounter for rehab. Report code Z47.1, Aftercare following joint replacement surgery.» Etiologic diagnosis: M16.10, Osteoarthritis 56

57 Coding Scenario #1 Direction on coding admission/encounter when purpose is rehabilitation. There is no counterpart to category V57 in ICD- 10-CM. For example, patient transferred from acute into inpatient rehab for rehab following an acute stroke. How is this admission coded? Assign appropriate code from subcategory I69.3, Sequelae of cerebral infarction, as the principal or first listed diagnosis (condition for which rehab is being performed; hemiparesis, aphasia, etc.). These patients are being transferred to deal with the sequelae resulting from the stroke, not to treat the acute CVA. IRF-PAI etiologic diagnosis: I63.9, Cerebral infarction, unspecified. 57

58 Coding Scenario #2 Patient suffered an acute cerebral infarction with residual aphasia and right hemiplegia (dominant side). Admitted to rehab to receive occupational therapy, physical therapy and speech therapy. Patient also has CAD, chronic atrial fib, HTN, and type II DM. What codes are assigned? Either I69.320, Aphasia following cerebral infraction, or code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the principal diagnosis. Codes for the CAD, atrial fib, and DM should be assigned as additional diagnoses. IRF-PAI etiologic diagnosis: I63.9, Cerebral infarction, unspecified. Additional diagnoses: Assign codes for other conditions that are present on admission. 58

59 Coding Scenario #3 Patient admitted in inpatient rehab following acute care for surgical treatment of a displaced fracture of femur. Admitted for physical and occupational therapy as well as fracture aftercare. What are the codes? Assign code S72.141D, Displaced intertrochanteric fracture of right femur, subsequent encounter, as the principal diagnosis. IRF-PAI etiologic diagnosis: S72.141A, Displaced intertrochanteric fracture of right femur, initial encounter. 59

60 Coding Scenario #4 Patient status post treatment of multiple fractures in the healing phase, is transferred to rehab. At the rehab facility, the patient is covered by a new physician that has never seen the patient before. Is the 7 th character A, Initial encounter since the patient is seeing a new physician? The key to selecting the 7 th character for initial encounter is whether there is still active treatment (i.e., surgical treatment, emergency department encounter, or evaluation and continuing (ongoing) treatment.). The fact that the patient is seeing a new physician does not have any relevance in determining the 7 th character. IRF-PAI etiologic diagnosis 7 th character would be A 60

61 Addressing Questions to the Central Office Please be sure to read the FAQ section to find out what types of questions we can and cannot answer. Changes to AHA Coding Clinic The paper version of the AHA Coding Clinic for ICD-10-CM/ICD-10-PCS and HCPCS will be phased out at the end of Look for more information in the coming months as we announce new ways to access these great resources. 61

62 Questions? 62