Rehabilitation and Community Providers Association of Pennsylvania Annual Conference

Transcription

1 ICD/DSM CODING AND DOCUMENTATION: WHAT ADMINISTRATORS AND CLINICIANS NEED TO KNOW Rehabilitation and Community Providers Association of Pennsylvania Annual Conference By: Behavioral Health Solutions Lisette Wright, M.A., LP, Executive Director September 27, 2016 (c) 2016 Lisette Wright All Rights Reserved 2 Learning Objectives Describe the challenges of utilizing two disparate diagnostic systems in the behavioral health industry Demonstrate familiarity with and knowledge of correct coding and documentation procedures per CMS guidelines Synthesize knowledge gained to develop a consistent approach to diagnosing, coding and documenting supportive of ICD- 10- CM specificity and requirements Formulate concrete steps to mitigate past, and future, revenue loss 1

2 (c) 2016 Lisette Wright All Rights Reserved 3 Laying the Groundwork ü Industry- use and reliance on the DSM- series ü Many see the DSM- series as code book, unaware of ICD- series ü May 2013: DSM- 5 published ü October 1, 2015: The ICD- system is mandated for all HIPAA- Covered Entities. This includes Coding and Documentation Guidelines and all other ICD- 10 rules ü CMS: ICD- 10- CM First year flexibility Myth: ICD does not apply to behavioral health (c) 2016 Lisette Wright All Rights Reserved 4 The Reality CACREP 2016 Standards: "current diagnostic classification systems" 2 disparate diagnostic manuals Coding and documentation standards Full diagnostic spectrum not being captured in codes (text narrative vs discreet data) Denied Claims Non- compliance with the ICD- series and standards 2

3 (c) 2016 Lisette Wright All Rights Reserved 5 ICD- series is a System Coding Rules & Standards Documentation Guidelines ICD Price: FREE Diagnostic Guidelines Official Code Listings (c) 2016 Lisette Wright All Rights Reserved 6 Differences Between ICD and DSM Actual Diagnoses Categories of Disorders (i.e.: childhood/adolescent disorders) Diagnostic Criteria: symptoms, timeframes/durations Conditions: Abuse versus Dependence 3

4 (c) 2016 Lisette Wright All Rights Reserved 7 Diagnosis Confusion: Asperger's Example DSM- 5: Asperger s is no longer a coded disorder, having been merged into the new Autistic Spectrum Disorder ICD- 10 includes a code for Asperger s Syndrome, F84.5 ICD- 11: MAY replace Asperger's, but MAY NOT no final decision has been made (c) 2016 Lisette Wright All Rights Reserved 8 Pause: A Word on ICD- 11 Approximately 2018 by the WHO Some years after that for the US to adapt to ICD- 11- CM 2016 to?: We are living with the discrepancies 4

5 (c) 2016 Lisette Wright All Rights Reserved 9 Understanding The ICD- DSM Relationship ICD- 9/DSM- IV- TR ICD- 10/DSM- 5 Code values aligned Code values different Diagnosis names aligned Example: = Differences between manuals Utilization of both manuals may be mandated (c) 2016 Lisette Wright All Rights Reserved 10 Expanded Diagnoses Examples In ICD- 10 Substance Use codes contain the most expansion ICD- 9/DSM- IV- TR has ~9 diagnoses involving Cannabis DSM- 5 has ~22 diagnoses involving Cannabis ICD- 10- CM has ~34 diagnoses involving Cannabis Most Expansion: Bipolar Substance Use Anxiety Mania s, Childhood DO s, SU, Medical, Other Codes (i.e.: X, N & R codes) are present in one manual but not the other 5

6 (c) 2016 Lisette Wright All Rights Reserved 11 Substance Use Disorder (SUD): Difference in Number of Diagnostic Codes F10's: Alcohol F11's: Opiods F12's: Cannabis F13's: Sedative, hypnotic, or anxiolytics F14's: Cocaine F15's: Other stimulants F16's: Hallucinogens DSM- 5 ICD- 10 F17's: Nicotine F18's: Inhalants F19's: Other psychoactive substances (c) 2016 Lisette Wright All Rights Reserved 12 DSM- 5 To ICD- 10 Specificity Example DSM- 5 ICD- 10 F51.5 Nightmare Disorder F51.5 Nightmare Disorder F51.8 Other sleep disorders not due to a substance or known physiological condition F51.05 Insomnia due to other mental condition F51.01 Insomnia Disorder F51.01 Primary Insomnia F51.13 Hypersomnia due to other mental condition F51.19 Other hypersomnia not due to a substance or known physiological condition 6

7 (c) 2016 Lisette Wright All Rights Reserved 13 ICD- 9 To ICD- 10 Specificity Example: The One- To- Many Concept Alcohol- Induced Psychotic Disorder with Hallucinations F Alcohol Abuse with Alcohol- Induced Psychotic Disorder with Hallucinations F Alcohol dependence with alcohol- induced psychotic disorder with hallucinations F Alcohol Use, unspecified with alcohol- induced psychotic disorder with hallucinations (c) 2016 Lisette Wright All Rights Reserved 14 Schizophrenia Sample DSM- 5 ICD- 10- CM F20.0 Paranoid Schizophrenia F20.1 Disorganized Schizophrenia F20.2 Catatonic Schizophrenia F20.3 Undifferentiated Schizophrenia F20.5 Residual Schizophrenia F20.8 Other Schizophrenia F20.9 Schizophrenia, Unspecified F20.9 Schizophrenia, Unspecified 7

8 (c) 2016 Lisette Wright All Rights Reserved 15 PTSD: Three Flavors DSM- 5 F43.10: PTSD, Unspecified ICD- 10- CM F43.10: PTSD, Unspecified F43.11: PTSD, acute F43.12: PTSD, chronic (c) 2016 Lisette Wright All Rights Reserved 16 Agoraphobia: Three Variations on a Theme DSM- 5 F40.00: Agoraphobia ICD- 10- CM F40.00: Agoraphobia, Unspecified F40.01: Agoraphobia with panic disorder F40.02: Agoraphobia without panic disorder 8

9 (c) 2016 Lisette Wright All Rights Reserved 17 Another Challenge One- to- Many Concept: You may need 2 DSM codes to fully describe 1 ICD- 10 code that is all- encompassing Example: ICD- 10: F41.0, Panic Disorder with agoraphobia DSM- 5: F41.0, Panic Disorder DSM- 5: F40.00, Agoraphobia Tabular Index: F40.00 = Agoraphobia, unspecified F40.01 = Agoraphobia with panic disorder F40.02 = Agoraphobia without panic disorder (c) 2016 Lisette Wright All Rights Reserved 18 ICD- 10- CM Tabular List: Where Do You Get Correct Codes? Recognized as the "last stop diagnosis and coding: This is what Payers are using Lists only diagnoses and codes Use Tabular Index to verify Codes in EHR The Tabular Index does not list clinical criteria 9

10 (c) 2016 Lisette Wright All Rights Reserved 19 How to Support ICD- 10 Diagnoses ICD- 10 Clinical Descriptions and Diagnostic Guidelines (CDDG) Free PDF or Hardcopy from Amazon AKA: 1992 Blue Book ICD- 11 CDDG release with ICD- 11 (2018 +) 1. Hybrid Approach 2. Blue Book Only 3. DSM Only Policy and Procedure and there is uniformity, you are fine! (c) 2016 Lisette Wright All Rights Reserved Tabular Index 10

11 (c) 2016 Lisette Wright All Rights Reserved 21 (c) 2016 Lisette Wright All Rights Reserved 22 Cannabis Abuse Sample From Tabular Index 11

12 (c) 2016 Lisette Wright All Rights Reserved 23 ICD- 10- CM Flavors of Schizophrenia DSM- 5 DX; APA Digital Version embedded in some EHR s Take note of Unspecified (c) 2016 Lisette Wright All Rights Reserved 24 DSM- 5 compared to ICD- 10- CM 12

13 (c) 2016 Lisette Wright All Rights Reserved 25 DSM- 5 DX ICD- 10 DX (c) 2016 Lisette Wright All Rights Reserved 26 Awesome Diagnosis! 13

14 (c) 2016 Lisette Wright All Rights Reserved 27 T- codes??? Critical for epidemiology, legal/custody issues, etc. (c) 2016 Lisette Wright All Rights Reserved 28 14

15 (c) 2016 Lisette Wright All Rights Reserved 29 (c) 2016 Lisette Wright All Rights Reserved 30 Where Do I Get Code Numbers? Not recommended to use any ICD- 10- CM numbers (without validation and sign- off) from any source, including but not limited to: DSM- 5 Blue Book Internet EHR (see below in italics) Anywhere else! ONLY GET ICD- 10- CM Codes From: The ICD- 10- CM Tabular Index published by the CDC for the current year!! It s your job to verify the EHR is accurate; vendor s job to make sure the right codes are available 15

16 (c) 2016 Lisette Wright All Rights Reserved ICD- 10 CM Official Coding Guidelines Published by: CMS and National Center for Health Statistics (NCHS) Approved by: American Hospital Association, AHIMA, CMS, and NCHS These guidelines are a set of rules that have been developed to accompany and compliment ICD- 10- CM itself.these guidelines are based on the coding and sequencing.adherence to these guidelines when assigning ICD- 10- CM diagnosis codes is required under HIPAA. (c) 2016 Lisette Wright All Rights Reserved 32 CMS Audits: June 2016 "CMS and HHS requires issuers of Medicare Advantage and certain ACA compliant commercial plans to submit detailed documentation pertaining to each Medicare Advantage/Commercial patient in a specific format on an ongoing basis. Specifically, under CMS rules pertaining to the implementation of the Medicare Modernization Act, the specific diagnoses of each plan member must be documented in accordance with ICD- 10 standards and supported by valid documentation with the patient's medical chart. HHS also adheres to the standard requiring valid documentation support via medical chart reviews. 16

17 (c) 2016 Lisette Wright All Rights Reserved 33 Itemization Of Pertinent Rules To BH/SU 1. Highest level of specify (i.e.: as many digits as applicable) 2. Other and Unspecified 3. Etiology and Manifestation, Code First 4. Multiple coding for a single condition 5. Excludes 1 and Excludes 2 6. NEC and NOS 7. External Cause Code (c) 2016 Lisette Wright All Rights Reserved 34 Code To The Highest Level Of Specificity Diagnosis codes are to be used and reported at their highest number of characters available Implications: NOS, NEC, Unspecified, are to be used ONLY if they meet the guidelines Diagnosis codes are composed of codes with 3,4,5,6,or 7 characters A 3- charater code is to be used ONLY if it is not further subdivided. A code is INVALID if it has not been coded to the full number of characters required 17

18 (c) 2016 Lisette Wright All Rights Reserved 35 Level Of Detail In Coding And Charting Diagnosis codes are to be used and reported at their highest number of characters available A three- character code is to be used only if it is not further subdivided Example: If a condition has 6 digits, then use all 6 digits AND document to account for all 6 aspects of the condition Example: Do NOT use just F10. Alcohol? What? (c) 2016 Lisette Wright All Rights Reserved 36 Rules About Other And Unspecified Unspecified Codes: Use these when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the other specified code may represent both other and unspecified. Other Codes: Codes titled other or other specified for use when the information in the medical record provides detail for which a specific code does not exist. 18

19 (c) 2016 Lisette Wright All Rights Reserved 37 Use Of Sign/Symptom/Unspecified Codes Unspecified codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient s health condition, there are instances when unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to code an unspecified in lieu of a definitive diagnosis. 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 next page (c) 2016 Lisette Wright All Rights Reserved 38 Unspecified Codes Should Be Reported When..Unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient s condition at the time of that particular encounter. 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. THEREFORE: What if: you want to down- code? Protect the consumer from discrimination? Just don t want to write all the necessary info in the chart because you have better things to do on a sunny day? 19

20 (c) 2016 Lisette Wright All Rights Reserved 39 The Code First Challenge Longstanding coding rule but BH has used Axes Who used Axis III? DSM- 5: No Axes Certain conditions have an underlying cause (etiology) and a possible underlying manifestation due to the underlying etiology This convention requires that the underlying cause be sequenced (listed/coded/diagnosed) first Problem? Assigning an actual code number to a medical condition (c) 2016 Lisette Wright All Rights Reserved 40 Integrated Care Models and Coding Medical Putting medical conditions in record as text narrative is risky Coding for medical conditions is problematic; there are no established industry guidelines (APA does not apply to the majority of behavioral health clinicians in the US) Suggestions: Written clinical policy and procedure Code medical at a high level (3-4 character codes) Example: (DSM- 5, page ) Bipolar and Related Disorder Due to Another Medical Condition DSM directions: Include the name of medical condition in the diagnosis (i.e..: hyperthyroidism); code the medical condition separately and first: E05.90 Hyperthyroidism; then: F06.33 Mood disorder due to hyperthyroidism, with manic features DSM says Bipolar ; Tabular says Mood 20

21 (c) 2016 Lisette Wright All Rights Reserved Coding Medical Concerns in BH: Standards and Application to Our Industry 41 Item/Condition Coding and Documentation Guideline states: Interpretation/Comments Poisoning When coding a poisoning or reaction to the improper use of a medication This particular item will most (e.g., overdose, wrong substance given or taken in error, wrong route of likely be experienced when administration), first assign the appropriate code from categories T36- T50. working in substance use or acute The poisoning codes have an associated intent as their 5 or 6 character care facilities. Note the references (accidental, intentional self- harm, assault and undetermined. Use additional code(s) for all manifestations of poisonings. to intent and the categories of use, abuse, and dependence. Under dosing If there is also a diagnosis of abuse or dependence of the substance, the abuse or dependence is assigned as an additional code. Under dosing refers to taking less of a medication than is prescribed by a provider or a manufacturer s instruction. For under dosing, assign the code from categories T36- T50 (fifth or sixth character 6 ). Also note the requirement to diagnose additionally abuse and dependence warranted. of the substance, if This is a nice option to track medication non- compliance. Toxic Effects Codes for under dos ing s hould never be ass igned as principal or firs t- listed codes. Noncompliance (Z91.12-, Z ) or complication of care (Y63.6- Y63.9) codes are to be used with an under dosing code to indicate intent, if known. When a harmful substance is ingested or comes in contact with a person, this is classified as a toxic effect. The toxic effect codes are in categories T51- T65. Toxic effect codes have an associated intent: accidental, intentional self- harm, assault and undetermined. This will be helpful to document and code when there are intentional self- harm episodes. (c) 2016 Lisette Wright All Rights Reserved 42 ICD- 10, EHR s and Health Information Technology What are the codes in your EHR? DSM codes? ICD codes? Where do they come from? Are all the codes listed? Search/find/crosswalk versions How easy is it to navigate? 21

22 (c) 2016 Lisette Wright All Rights Reserved 43 Reported Challenges Industry- Wide 1. Finding the right codes in the drop down 2. Unspecified and Other diagnoses first populated versus more specific ( Why does unspecified come up first? ) 3. Search engine troubles 4. Persistent documentation habits despite increased specificity in codes and diagnoses 5. Documentation not supporting the more specific codes (c) 2016 Lisette Wright All Rights Reserved 44 ICD- 10- CM Codes in EHR s Only F Codes, or Select F Codes "Only those we bill" No Z, R, T, X and other codes Unable to track suicide attempts and severity Exclusive use of APA Digital version of DSM How to pick and document the degree of medical specificity? 22

23 (c) 2016 Lisette Wright All Rights Reserved 45 Lost in Translation: Substance Use You assign or pick a DMS- 5 Substance Use code, and notate the specifier as mild, moderate, or severe in the narrative The system automatically crosswalks it Do you know what the actual diagnosis is that goes out the door on the claim? Does this correspond with the client s understanding of their condition? (c) 2016 Lisette Wright All Rights Reserved 46 Substance Use Issues for Consideration Language used with Clients Trans parency and information to clients regarding ICD - 10 labels DSM- ICD Alignment: Best when there is no diagnosis or a severe diagnosis Some "mild use" cases in the DSM- 5 would not meet the threshold for a substance use diagnosis in ICD- 10- CM Diagnostic Criteria between the two manuals produce differing diagnoses 23

24 (c) 2016 Lisette Wright All Rights Reserved 47 Reported ICD- 10- CM Problems Since Go- Live 1. PTSD and Schizophrenia, Unspecified + 38 other codes (LCD s) 2. Eating Disorder clinics using other diagnoses for DSM- 5 diagnoses 3. Nevada Medicaid Provider bulletin: Some Z codes are billable. Those billed in December that were denied the Z (personal history of neglect in childhood) were recently rebilled and paid. Nevada MMIS responded to my question with: DHCFP decided to change the requirement and allow Z codes to be submitted on the claim form as primary. The announcement was only addressing the claim form requirement. This does not mean a change to the NV State Medicaid policy or the policy regarding medical necessity. Question originated on a national list serve, from Ohio (c) 2016 Lisette Wright All Rights Reserved 48 Continued ICD- 10- CM Problems 4. California: Some guidelines for a particular mental health system paid for all pervasive developmental disorders except for autism disorder. The problem? The system insisted on using the DSM- 5, and it s mapped code to ICD- 10- CM s Autistic Disorder there were delays. Sole use of the DSM- 5 would have disqualified a huge portion of the clients. 5. APA issued a Fact Sheet, retracted, reissued 6. Ohio foster care: Medicaid requires code. No diagnosis was V Now what? Answer: Z03.89 here s how I got here: I first turned to the DSM- 5 for their suggestion. Nothing itemized in the DSM- 5. I then turned to AAPC, which is the certified coder industry. They are suggesting the Z I then double- checked with my certified coder medical colleague, and she verified the Z

25 (c) 2016 Lisette Wright All Rights Reserved 49 Revenue Cycle Considerations Revenues are generally going smoothly overall Still in the CMS 1- year "flex" period What's Happening Now? Data analytics, aggregation and prepping audit strategies, some tweaking and increased denials Gearing up: both payers and providers for next phase of ICD- 10 (c) 2016 Lisette Wright All Rights Reserved 50 Mitigation Strategies Concurrent/ pre- bill audits with this perspective: "why should we pay this claim?" Track denials using a systemic process Analyze root causes of denials Track Remit Advice and Claim Adjustments for trends Documentation Reviews: does the documentation support a more specific diagnosis? Improve pre- service Certification and monitor authorization trends Review contracts for appeals timeframes, process, and conditions Using Unspecified: documentation to support diagnosis 25

26 (c) 2016 Lisette Wright All Rights Reserved 51 Next Steps Determine current state: EHR, revenue cycle, manuals used When you pull reports of your top diagnoses, what trends have you noticed compared to pre- ICD- 10- CM implementation? What about secondary and tertiary diagnoses? How are you tracking medical conditions? How have you been managing the Substance Use dilemma, including transparency to clients they are being diagnosed with either Abuse or Dependence? Develop policies and procedures to ensure consistent utilization of diagnostic, coding, and documentation Education and training of staff Institute a CDI Program Consider prospective audits (c) 2016 Lisette Wright All Rights Reserved 52 Final Thoughts Value- based reimbursement that encourages population health will require a solid, yet nimble, IT/EHR infrastructure Discreet data elements, as opposed to narrative text, must capture the comprehensive healthcare picture of an individual, including self- harm and medical ICD- 10 is a unified singular system that will enable us to become true compatriots in the healthcare delivery system 26

27 (c) 2016 Lisette Wright All Rights Reserved 53 Contact Information RCPA Lisette Wright Thank you! 27