Preparing for ICD-10: Are

You should be well on your way with plans to implement ICD-10, effective October 1, 2013. If you have not begun your preparation for ICD-10, it is imperative that you start planning now. Below is a suggested action plan to begin your move towards compliance with this federally mandated requirement. • Educate office staff on the ICD-10 compliance requirements. • Review your current systems and work processes – electronic or manual. • Investigate the potential changes to existing practice work flow and business processes. • Contact your current practice management system vendor, clearinghouse or billing service to identify submission upgrade expectations. • Compare options and benefits of full system upgrades vs. minimal compliance to take advantage of new automated features. • Determine installation, testing and implementation timeframes. • Evaluate and plan for staff training needs.


Disclaimer
• This presentation is designed to provide participants with reimbursement and coding related news, updates and guidance.
• The materials and documents presented are not intended to supersede any policies, procedures, or templates that vRad or your facility has approved and implemented, unless specifically noted.
• The information, while accurate, to the best of our knowledge, at the time of production, may not be current at the time of use.
• Information is provided as general guidance only and is not a recommendation for a specific situation.Viewers should consult official sources (CMS, ACR, AMA) or a qualified attorney for specific legal guidance.
• "ICD-10 is a greatly intuitive system.If we know stuff about our patient, there's probably a code for it.Describe the patient's symptoms or diseases as you'd talk about them with a family member or with your office manager.
Identify the cause of a disease and identify the effects of that disease on other body parts.And there are codes for most of these.Not a big deal." Dr. Roberts S. Gold, M.D.

AAPC Tips & Resources
Issue 58, April 10, 2015 Dr. Gold is founder of DCBA, Inc. which is a consulting company in Atlanta that provides physician-to-physician education for documentation improvement programs nationwide.The radiologist does not necessarily have a face-to-face interaction with the patient.The radiologist must rely on the referring physician and the technologist who is performing the exam to provide the patient's story.Therefore, the story must be included in both the orders and final report.

Where is the clinical documentation coming from?
• Referring physicians and in-hospital referrals (ER, hospitalists, nurses)  The implementation deadline for ICD-10 is rapidly approaching.The new code set requires a higher degree of specificity in order to improve clinical outcomes and documentation.[Sender's facility] currently receives a high volume of non-specific indications from referring physicians.As we transition into ICD-10, we will be requesting more clinical detail (as well as ICD-10 codes) on the referral orders you send to us.
When ordering a study, consider including these additional details for the reason for the exam: • Location: Please provide the specific anatomical location of the symptoms or condition (laterality, proximal or distal, quadrant, part of the lung, specific part of the bone, etc.).ICD-10-CM Code vs Clinical Descriptive Information?
• Will the ICD-10-CM code you receive be documented in the legal medical record?
• Code selection varies amongst coders, even some selecting inaccurate codes.That inaccuracy rate will likely increase with ICD-10-CM.
• Do you know who is selecting the ICD-10-CM code?Is it the ordering physician, a nurse, a scheduler, or a coder who has ICD-10-CM proficiency certification?
• Are you willing to trust somebody else providing an accurate code?Keep in mind, the billing provider is responsible for appropriate services for appropriate medical reasons.
• Start NOW • Evaluate order forms.
• Ask more specific, leading questions versus providing a free text area.
• Provide scheduling tools to front desk staff taking orders by telephone.
• Consider basing order forms and tools on the study ordered.
Each of these CT body areas require very different information for indications.
What about laterality?
• Referring physicians: -Revamp order forms -Request patient medical records, e.g.history and physician exam notes -Canned questions for the schedulers to ask (general and specific to topordered procedures) • • Create canned questions to ask when scheduling exams by phone.
• Specific questions by procedures: We create specific prep instructions by exam type, why not scheduling questions to gather pertinent clinical information?

Abdominal Pain:
Ask about specific site of pain (quadrant, generalized, epigastric, periumbilical, etc.) Ask about context of pain (sudden, chronic, stabbing, colicky, after eating, etc.) Ask about severity of pain (pain scale on 1 to 10.Ten being unbearable) Ask about duration of pain Ask if there was any injury or related possible cause of pain Ask if there are any related signs or symptoms (GI/GU symptoms, rigidity, rebound, etc.) Ask if there is any associated disease/condition (GI/GU condition, cancer, etc.) Page 27 | vrad.com| 800.737.0610

The Radiology Technologist
The radiology technologists play a critical role in the process!They are the last link between the patient and the interpreting radiologist.
• They have clinical knowledge and can gather pertinent clinical information.
• Customer service!When you ask about the patient's condition it makes the patient feel that you have their medical well-being at heart.
• Review the patient history form and ask for specific details that are missing.
• Good quality and pertinent medical information leads to better outcomes as the radiologist is better equipped to critically review the images.
• The Radiologist By design, radiologists have to rely on referring physicians and others for clinical information about the patient.However, radiologists must document all pertinent positive findings.
• It will be the radiologist's responsibility to capture required details for positive findings.
• Radiologists cover a wide spectrum of clinical conditions in the scope of the services they provide.
• Education is a must!
• Coding tools will be important to their success.
• Audit now to provide feedback.
Page 29 | vrad.com| 800.737.0610 The Medical Coder Codes selected for billing purposes must be supported by the medical record.
• Radiology coders typically do not have access to the patient's electronic medical record.
• Radiology coders rely on the final dictated report to code and bill radiology services.
• Codes for signs and symptoms should not be reported with a confirmed diagnosis if the symptoms are integral to the diagnosis.
• Training is critical.Certified coders must spend time studying the guidelines.
• Productivity will suffer: Practice, practice, practice.If they do not spend significant time using the new code set claims will be delayed.Duel code over the next few months!
• Order or Scheduling management systems  Please submit questions using Chat.
Answers, with supporting resources, will be posted on the webinar series webpage: http://webinars.vrad.com/reimbursement_seriesvRad team members with specific scenarios or questions are encouraged to contact Sharon Roeder for further support.
Enter question here Thank You Page 5 | vrad.com| 800.737.0610 Information provided is based on Medicare Part B billing guidelines and may or may not pertain to Medicare Part A billing.Viewers should consult their Part A -Medicare Administrative Contractor website for hospital billing guidelines.Page 6 | vrad.com| 800.737.0610Our Agenda It's not too late to take proactive action Be smart and focus your final push on areas where the results will have the largest positive impact Strategies for gathering clinical details from referring physicians and departments Training key staff and radiologists Documentation tool examples Page 7 | vrad.com| 800.737.0610 Page 8 | vrad.com| 800.737.0610Tell the Story Location: • Specific anatomical site • Laterality / Quadrants / proximal or distal Context: • Timing: Onset date / duration /recurring / active treatment, during healing phase, or due to complication • Injury: is the exam to help with diagnostic or treatment decisions OR is exam to evaluate healing process?• Cause(s) of the symptoms or condition • Chronic, acute, transient?• Severity of the symptoms/condition • Stage, status, or type of the disease Associated or Concurrent Condition: • Existing disease/condition that contribute to the symptoms/condition • Pregnant?(Start date of the Last Menstrual Period) • Medical history pertinent to exam (personal /family) Page 9 | vrad.com| 800.737.0610"How can we provide clinical details on our orders and radiology reports if the referring physician does not provide us with detailed indications?This is out of our control!"Page 10 | vrad.com| 800.737.0610There are only 104 days left to prepare!Have you resigned your fate to your referring physicians?How are you going to take control of getting more specific clinical details from your referring resources?It is not too late!Capturing Clinical Details in the Order Intake Process Page 12 | vrad.com| 800.737.0610

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and thigh, not specified LOCATION: Hip or thigh?Muscle or tendon?Laterality?CONTEXT: Type of injury (strain, contusion, puncture wound, foreign body), symptoms, or unconscious.TIMING: Initial, follow-up, sequela CONCURRENT CONDITIONS: Pregnant (LMP for trimester and gestation) These claims were denied due to medical necessity TIP: Focus on top volume codes for: • Communications to referring physicians • Training for internal staff • Redesigning referral or order forms to capture detailed indications Page 17 | vrad.com| 800.737.0610Sample Letter to Your Referring Physicians Dear Dr.Jones, • Context: Please include clinical information that provides context or explains "who, what, when, where, why, and how." • Associated or concurrent conditions: Please state if there are any underlying or related diseases, or medical history, that is pertinent to the reason for exam.If the patient is pregnant, include the first day of their last menstrual period (LMP).• Injuries: Please provide the date of the injury.It is helpful for us to understand if you are seeking a diagnostic interpretation for treatment decisions, status on the healing process, or an evaluation of a residual problem.Providing this additional clinical information will allow us to provide better care and assessment or your patient.Please feel free to contact me with any questions.Page 18 | vrad.com| 800.737.0610Redesigning Order Forms One generic order form will not work effectively for ICD-10.Devote more space for collecting procedure and clinical details.One Size Does Not Fit All Page 19 | vrad.com| 800.737.0610

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Emergency room -How will your radiology department get the information from the ER? -Gather the clinical details after the exam?-Collaborate with ER management staff • Patient and/or caregiver: -Check-in: Symptom and history forms -Empower technologists to interview and document patient's chief complaints!Page 23 | vrad.com| 800.737.0610Patient and Caregivers Create check-in forms to gather details of the patient's chief complaint and history.General form vs. specific forms for high volume procedures?Page 24 | vrad.com| 800.737.0610What missing details could be added to this Mammogram Worksheet?Focus training on high volume procedures and frequently used diagnoses.• Consider Medical Terminology and Anatomy 101 training.(KISS) Training on ICD-10-CM for technologists is critical so that they understand what is needed!Page 28 | vrad.com| 800.737.0610

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Patient medical records • RIS or PACS for clinical history • DICOM header tags • Queries to the radiologists • Queries to the facility performing the technical component • Queries to the ordering physician Training and Documentation Tools Page 32 | vrad.com| 800.737.0610Common Risks in Radiology • Pain -Specific anatomical location -Severity or pain scale -Context (stabbing, with breathing, with activity) -Duration (onset, frequency) -Associated disease or condition -Related possible cause • Injury -Timing:  During diagnostic or active treatment phase  During healing phase, or  Due to complication after end of treatment -What type of injury?(animal bite, contusion, laceration) -What anatomical area is involved?-Are there other associated symptoms?(foreign body, closed or open fracture, unconsciousness) Motor Vehicle Accident (MVA) -What type of injury was sustained?-What part of the body was injured?-What symptoms is the patient experiencing?-Is the patient conscious?-Where and how? -Timing (during active treatment, during healing phase, or complication) • Rule out, probable, suspicious • Pre-operative screening -Does the patient have a medical condition that increases intraoperative risk?-What type of surgery?Is it a cardiovascular or pulmonary procedure?Pulmonary Fibrosis Page 34 | vrad.com| 800.737.0610Capturing Details about Pain Page 35 | vrad.com| 800.737.0610Capturing Details about Pain Limb Pain: Document specific site of pain (RT/LT, upper/lower, site specific on arm/leg, etc.) Document context of pain (sudden, at rest/exercise, radiating, etc.) Document severity of pain (pain scale) Document duration of pain Document any injury or related possible cause of pain Document any related signs or symptoms (numbness, cyanosis, tingling, etc.) Document any associated disease/condition (arthritis, pathologic fractures, cancer, etc.) Headache: Document specific site of pain (frontal, temporal, facial, etc.) Document context of pain (sudden, tension, cluster, migraine, throbbing, chronic, etc.) Document severity of pain (pain scale) Document duration of pain Document any injury or related possible cause of pain Document any related signs or symptoms (vision changes, sinusitis, etc.) Document any associated disease/condition (neurologic condition, sinus, cancer, etc.) Page 36 | vrad.com| 800.737.0610Fractures: Documentation Tips and Classifications DOCUMENTATION FOR FRACTURES Traumatic fracture Pathological fracture Anatomical location: (e.g.shaft, sternal end) Underlying cause (neoplastic or osteoporosis) Laterality: Right, Left, or Bilateral What type of cancer?Displaced or nondisplaced?What type of osteoporosis?(e.g.age-related, idiopathic, drug-indcued) Type of fracture (e.g.Greenstick, oblique, spiral, comminuted) Anatomical Location -which bone Open or closed fracture?Laterality (right, left, bilateral) Episode of care (Initial, subsequent, or sequela) Episode of care (Initial, subsequent, or sequela) Subsequent radiology exams, indicate one of the below: ALL subsequent exams, (open and closed) indicate one of the below: Wound less than 1 cm with minimal soft tissue injury Initial -Encounter for diagnosis or active treatment Type II -Wound greater than 1 cm with moderate soft tissue injury Subsequent -Routine care in the healing or recovery phase Type III -Extensive damage to soft tissue Sequela -Residual or late effect Anderson and D'Alonzo Classification (DENS Fractures) Type I -Oblique avulsion fracture of tip of odontoid.Due to avulsion of alar ligament.Type II -Fracture through waist (high nonunion rate due to interruption of blood supply).Type III -Fracture extends into cancellous body of C2 & involves a variable portion of the C1-C2 joint.Page 37 | vrad.com| 800.737.0610Grading Vertebral Injury: Spondylolisthesis Spondylolisthesis is graded according to the degree that one vertebral body has slipped forward on another.Grade I -Less than 25 percent slip Grade II -Between 25 and 50 percent slip Grade III -Between 50 and 75 percent slip Grade IV -More than 75 percent slip Grade V -Upper vertebral body has slid all the way forward off the front of the lower vertebral body.Very rare.Page 38 | vrad.com| 800.737.0610Asthma: Documentation Guidelines for Severity

can we ensure that the clinical details make it from the referring physician to the radiology report? Are the key people receiving ICD-10 training? Do they have helpful tools?
Select the pertinent finding for the primary diagnosis • In absence of positive findings, select the pertinent reason for the exam for the primary diagnosis • Look for diagnostic details in the body of the report Now is the time to start educating and training all pertinent players!
Capture the Details in Study Orders and Final Reports Page 13 | vrad.com| 800.737.0610From the Order to the Claim • Communicate with these referring physicians now and after October 1

Diagnosis Volume Code Description Additional Clinical Information for ICD-10-CM
LOCATION: Anatomical location of the injury CONTEXT: Type of injury, how & where injured, sx CONCURRENT CONDITION: HIV, pregnant 511.9 42,354 Pleural effusion, not specified LOCATION: known (pleural) CONTEXT: Symptoms, recurrent, onset CONCURRENT CONDITION: Cancer (type), CHF, TB, Lupus, Influenza or pneumonia, ESRD, Cirrhosis or liver disease Page 16 | vrad.com| 800.737.0610Analyze Code Volumes by Procedure

7th Character Extender to Designate Fetus Involved in the Condition
Document the site of the ulcer and laterality when it applies.Document and code first any associated gangrene.Document the site of the ulcer and laterality when it applies.Document and code first any associated gangrene.Trimesters and gestational age are counted from the first day of the last menstrual period.ICD-10-CM Official Guidelines for Coding and Reporting, 2015; Centers for Disease Control and Prevention (CDC) website: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cm-guidelines-2015.pdf• 2015 ICD-10-CM Complete Draft Code Set; Optum Insight, Inc. • CMS ICD-10 resources: http://www.cms.gov/Medicare/Coding/ICD10/index.html• American Academy of Professional Coders Resources (AAPC) website: http://www.aapc.com Page 40 | vrad.com| 800.737.0610Documenting Ulcers NOTE: Gestational age must be documented/calculated to select appropriate codes Gestational Age Calculator -http://www.perinatology.com/calculators/Due-Date.htm Page 42 | vrad.com| 800.737.0610Resources • Page 43 | vrad.com| 800.737.0610