Transcript Overview of ICD-10-CM

Overview of ICD-10-CM
Webinar Sponsored by WVHIMSS
Garnet Career Center
Maggie McCabe, PAHM, CPC, CPC-H, CPC-P, CPC-I, CMOM, CMC
January 30, 2015
Disclaimer
The information contained in this document should not be
construed as legal representation. It is current as of October 1,
2014. All information is from the extensive training and
interpretation of the presenter. Garnet Career Center and
Maggie McCabe retain ownership of the information contained
herein. No part of this presentation may be reproduced or
transmitted in any form or by any means without the express
permission of Maggie McCabe.
Why this Change?
 Very simply, ICD-9-CM is running out of codes
 Increased specificity
 Provide the medical necessity for services that are currently
being rendered
 For the betterment of healthcare
 Because the government says so (tongue in cheek)
 No delays
 No grace period for using ICD-9-CM
The ICD Manual
 ICD-9-CM
 Volume 1--Tabular
 Volume 2--Index
 ICD-9-PCS
 Volume 3
 ICD-10-CM
 Alphabetic Index
 Tabular
What is the Effective Date Now?
October 1, 2015
 ICD-9-CM ends September 30, 2015
 Will there be another delay?
Federal Rule August 4, 2014
This final rule establishes October 1, 2015 as the compliance
date for ICD–10.
It also requires the continued use of ICD–9–CM through
September 30, 2015.
Who Does This Change Effect?
 Those covered by HIPAA
 Small, medium and large practices
 Clinics
 Hospitals, SNFs, FQHC
 Payers
 Clearing Houses
 All staff
 Patients
Training?
 Who
 When
 Why
Similarities
 Several Conventions
 NEC/NOS
 Punctuation
 Includes Notes
Borderline Diagnosis
 If the provider documents a "borderline" diagnosis at the time of
discharge, the diagnosis is coded as confirmed, unless the
classification provides a specific entry (e.g., borderline diabetes).
 If a borderline condition has a specific index entry in ICD-10-CM, it
should be coded as such.
 Since borderline conditions are not uncertain diagnoses, no
distinction is made between the care setting (inpatient versus
outpatient).
 Whenever the documentation is unclear regarding a borderline
condition, coders are encouraged to query for clarification.
Chapters and Such
 ICD-9-CM had 17 Chapters along with V-codes and E-codes
 ICD-10-CM has 21 chapters including the equivalent of the V and E Codes
 Titles may change slightly
 Order of chapters may vary
 Some diagnoses have been moved to other chapters to be more consistent
 Streptococcal Sore Throat
 ICD-9-CM was listed with Infectious Diseases
 ICD-10-CM has been moved to Respiratory System
 2 New Chapters
 Eye and Adnexa
 Ear and Mastoid Process
Chapter &
I-10 Range
ICD-9CM
ICD-10-CM
1 (A00-B99)
Infectious & Parasitic Disease
Certain Infections & Parasitic Diseases
2 (C00-D49)
Neoplasms
Neoplasms
3 (D50-D89)
Endocrine, Nutritional & Metabolic
Diseases, & Immunity Disorders
Diseases of the Blood & Blood forming
Organs & Certain Disorders Involving the
Immune Mechanism
4 (E00-E90)
Diseases of the Blood and Blood
Forming Organs
Endocrine, Nutritional & Metabolic
Diseases
5 (F01-F99)
Mental Disorders
Mental, Behavioral & Neurodevelopmental
Disorders
6 (G00-G99)
Diseases of the Nervous System and
Sense Organs
Diseases of the Nervous System
7 (H00-H59)
Diseases of the Circulatory System
Diseases of the Eye and Adnexa
8 (H60-H95)
Diseases of the Respiratory System
Diseases of the Ear & Mastoid Process
9 (I00-I99)
Diseases of the Digestive System
Diseases of the Circulatory System
10 (J00-J99)
Diseases of the Genitourinary System
Diseases of the Respiratory System
Chapter &
I-10 Range
ICD-9CM
ICD-10-CM
11 (K00-K95)
Complications of Pregnancy,
Childbirth & the Peurperium
Diseases of the Digestive System
12 (L00-L99)
Diseases of the Skin & Subcutaneous
Tissue
Diseases of the Skin & Subcutaneous Tissue
13 (M00M99)
Diseases of the musculoskeletal System
& Connective Tissue
Diseases of the musculoskeletal System &
Connective Tissue
14 (N00-N99) Congenital Anomalies
Diseases of the Genitourinary System
15 (O00O9A)
Certain Conditions Originating in the
Perinatal Period
Pregnancy, Childbirth & the Puerperium
16 (P00-P96)
Symptom, Signs & Ill-Defined
Conditions
Certain Conditions Originating in the
Perinatal Period
17 (Q00-Q99) Injury and Poisoning
Congenital Malformations, Deformations &
Chromosal Abnormalities
18 (R00-R99)
Symptoms, Signs & Abnormal Clinical &
Laboratory Findings, Not Elsewhere
Classified
N/A
Chapter & I10 Range
ICD-9CM
ICD-10-CM
19 (S00-T88)
N/A
Injury, Poisoning & Certain Other
Consequences of External Causes
20 (V00-Y99)
N/A
External Causes of Morbidity
21 (Z00-Z99)
N/A
Factors Influencing Health Status & Contact
with Health Services
Supplementary
Classification
V-Codes
Classification of Factors Influencing
Health Status & Contact with Health
Services
N/A
Supplementary
Classification
E-Codes
Classification of External Cause of
Injury & Poisoning
Alphanumeric
 Every code begins with an Alpha character
 United States does not use “U”
 Alpha characters may appear in other positions
 Be Careful:
 “O” versus “0”
 OB/GYN codes
 “I” versus “1”
 Circulatory
ICD-9-CM Digits
 Highest Level of Specificity
 Format
 3rd digit = Category
 4th digit = Sub-Category
 5th digit = Sub-Classification
ICD-10-CM Characters
 Highest Level of Specificity
 Format
 3rd character = Category
 4th character = Sub-Category
 5th character = Sub-Category
 6th character = Sub-Category
 7th character = Sub-Category
Four Character Categories
 Define
 Site
 Etiology
 Manifestation
Five - Six Character Sub-Classification
 Either of these characters represent the most accurate level
of specificity
 Related to patient’s condition or diagnosis
Seventh Character Extension
 Must always be in the 7th character position
Therefore
 Dummy placeholder of “X” may be needed in the 5th and/or
6th character
Placeholder
 7 character format
 Sometimes not all characters used
 Value of X is used in the 5th or 6th position
 Blanks or dashes are not acceptable
Excludes Notes
 Excludes 1
AND
 Excludes 2
Locating a Code
 NEVER Code from the Index of ANY Code Manual
 ICD-9-CM
 Index –Volume 2
 Tabular –Volume 1
 ICD-10-CM
 Index
 Tabular
Sequela
 Residual Effect
 Acute Encounter
Laterality
 Right
 Left
 Bilateral
 Consistency with CPT
Diabetes
 ICD-10-CM Combination Codes
 Type of diabetes mellitus
 Body system affected
 Complications affecting that body system
 Five Categories of Diabetes in ICD-10-CM
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E08 Diabetes mellitus due to an underlying condition
E09 Drug or chemical induce diabetes mellitus
E10 Type 1 diabetes mellitus
E11 Type 2 diabetes mellitus
E13 Other specified diabetes mellitus
Eye
 Patient presents to the physician with acute serous
conjunctivitis, non-viral, bilaterally
ICD-CM-10 Code =
 Edema right orbit
ICD-CM-10 Code =
OB/GYN
 High risk pregnancy in ICD-9-CM was a V-code; now it is located in
Chapter 15 with the other codes
 Guideline in ICD-CM-10:
 Pre-existing condition vs. condition related to the pregnancy
 Pre-existing hypertension in pregnancy
 Sepsis and Septic Shock
 Alcohol and tobacco use
 Poisoning, toxic effects, adverse effects and underdosing in a pregnant patient
 Pregnancy associated with cardiomyopathy
 7th character for fetus identification
 Selection of trimester and weeks gestation
Sprain, Lower Extremity
 Grade I – mild sprain, ligaments stretched but not torn
 Grade II – moderate sprain, ligaments are partially torn and
there may be some loss of function
 Grade III – severe sprain, ligament is completely
torn/ruptured
 Episode of care
 A Initial encounter
 D Subsequent encounter
 S Sequela
Pathologic Fracture
 7th character A is for use as long as the patient is receiving
active treatment for the fracture. Examples of active
treatment are: surgical treatment, emergency department
encounter, evaluation and treatment by a new physician.
 7th character, D is to be used for encounters after the patient
has completed active treatment.
 The other 7th characters, listed under each subcategory in
the Tabular List, are to be used for subsequent encounters for
treatment of problems associated with the healing, such as
malunions, nonunions, and sequelae.
Fractures
 7th Character Extension Example
A = initial encounter for closed fracture
B = initial encounter for open fracture
D = subsequent encounter for fracture with routine healing
G = subsequent encounter for fracture with delayed healing
K = subsequent encounter for fracture with nonunion
P = subsequent encounter for fracture with malunion
S = sequela
Traumatic Fractures

Grade I
The wound is less than 1cm long. It is usually a moderately clean puncture, through which a spike of
bone has pierced the skin. There is little soft-tissue damage and no sign of crushing injury. The
fracture is usually simple, transverse, or short oblique, with little commination.
Grade II
The laceration is more than 1 cm long, and there is no extensive soft-tissue damage, flap, or
avulsion. There is slight or moderate crushing injury, moderate commination of the fracture, and
moderate contamination.
Grade III
These are characterized by extensive damage to soft-tissues, including muscles, skin, and
neurovascular structures, and a high degree of contamination. The fracture is often caused by high
velocity trauma, resulting in a great deal of commination and instability.
 III A – Soft tissue coverage of the fractured bone is adequate
 III B – Extensive injury to, or loss of soft tissue, with periosteal stripping and exposure of bone,
massive contamination, and severe commination of the fracture. After debridement and irrigation a
local or free flap is needed for coverage.
 III C – Any open fracture that is associated with an arterial injury that must be repaired, regardless of
the degree of soft tissue injury.
The definitive grade should be assigned in theatre after thorough debridement.
The risk of infection in an open fracture depends on the amount of contamination, severity of soft
tissue injury, and operative treatment of the fracture
Fracture of the Femur
 The appropriate 7th character is to be added to all codes from category S72
A = initial encounter for closed fracture
B = initial encounter for open fracture type I or II
C = initial encounter for open fracture type IIIA, IIIB, or IIIC
D = subsequent encounter for closed fracture with routine healing
E = subsequent encounter for open fracture type I or II with routine healing
F = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
G = subsequent encounter for closed fracture with delayed healing
H = subsequent encounter for open fracture type I or II with delayed healing
J = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
K = subsequent encounter for closed fracture with nonunion
M = subsequent encounter for open fracture type I or II with nonunion
N = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
P = subsequent encounter for closed fracture with malunion
Q = subsequent encounter for open fracture type I or II with malunion
R = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
S = sequela
Behavior Health Depressive Disorder
 No Chapter Specific Guidelines ICD-9-CM
 Pain disorders related to psychological factors
 Remission
 Psychoactive Substance Use, Abuse and Dependence
 If both use and abuse are documented, assign only the code for abuse
 If both abuse and dependence are documented, assign only the code for
dependence
 If use, abuse and dependence are all documented, assign only the code for
dependence
 If both use and dependence are documented, assign only the code for
dependence
 Psychoactive Substance Abuse
Circulatory Documentation
 AMI must be identified as initial or subsequent (occurring w/in 4
weeks (28 day) acute phase of the initial MI
 Atherosclerosis of the extremities now sub-divided into legs & other
extremities
 Laterality required with embolism, thrombosis, varicose veins, etc
Endocrine, Nutritional & Metabolic
 More specific information is required to code the type of congenital
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hypothyroidism; iodine deficiency thyroid disorders; parathyroid
gland
Secondary diabetes requires documentation related to whether the
condition is due to an underlying condition or whether it is drug or
chemical induced
Cushing’s syndrome is not differentiated by type and cause
Disorders related to hyperalimentation require documentation of the
specific condition
Metabolic disorders require greater detail related to the specific
amino-acid, carbohydrate or lipid enzyme deficiency responsible for
the disorder
Documentation Suggestions
 “Not Documented, Didn’t Happen”
 Therefore
 Can’t Code It
 Can’t Bill It
 No Reimbursement
 True today, even truer tomorrow!!!!!
Documentation
 Address the reason for the encounter or the problem
 Show an examination
 Tie it all together
 Assessment
 Plan
Documentation
 Reduce Coder/Auditor Queries
 Be specific
 If it is a thought, document it
Documentation
 Seven elements current documentation lacks
 Disease type is not indicated
 Exact details pertaining to disease are not mentioned
 Documentation missing in entirely
 Specific location (if relevant) is not identified
 Stages of diseases are missing documentation
 Right/left sides are not properly identified
 Documentation for combination codes is improperly
documented to code accurately
Neoplasm
 Require more specific documentation of the site of the
malignancy
 Require laterality for the extremities
 Require stages for melanoma
 Stage I – localized
 Stage IA – less than 1.0 mm thick, no ulceration
 Stage IB – less than 1.0 mm thick, ulceration
 Continues through stage IV
Follicular Lymphoma
 Several different types; some with a grading system
 Grade I – 0-5 centroblasts per hpf with a predominance of small
centrocytes
 Grade II – 6-15 centroblasts per hpf with centrocytes present
 Grade III -- >15 centroblasts per hpf with decreased or no
centroctyes still present
 Grade IIIA -- >15 ecntroblasts per hpf with centrocytes still present
 Grade IIIB -- >15 centroblasts per hpf presenting as solid sheets with no
centrocytes present
How Will Superbills Change?
 Current, CPT one side
 ICD-9 Flip side
 Future, CPT one side
 Many examples on Internet, especially with ….
WEDI Survey Information
 Vendor product development – 40% of vendors indicate complete.
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Improvement over 2013 survey
Vendor product availability – More than 25% responded their
products would not be ready until2015
Health plan impact assessment – Nearly 75% completed their impact
assessment
Health plan testing – More 50% already begun external testing
compared to 25% in prior survey
Provider Impact Assessment – About 50% completed assessment
Provider testing – About 35% have completed; in 2013 60% expected
to begin in 2014
External testing approach – 60% providers expect to test with a
sample or providers; 20% indicated they will test with a majority of
providers
In Summary
 When do we start – should have started 2-3 years ago
 What has to be done – internal/external audits; training;
testing
 How do we do it – talk to your providers immediately;
contact your vendor and health plans; test as much as possible
 It is very important to take the time now!
References
 AAPC Professional Medical Coding Curriculum
 AAPC Licensed Instructor Curriculum
 AAPC ICD-10-CM Expert
 AAPC Coder References
 ICD-10-CM Coding Guidelines
 CMS Website Information
Questions???
 Thank you