Transcript Guidelines and more for icd-10-cm

GUIDELINES AND MORE
FOR ICD-10-CM
Presented by: Amy C. Pritchett, BSHA, CPC, CASCC,
CEDC, CCDI, ICDCT, ICDCT-CCC, CMRS, C-AHI
2015 Mobile Chapter President
Guidelines and More for ICD-10-CM
Objectives:
 Members will become aware of changes and the reasons behind the implementation
of ICD-10-CM
 Members will gain an educational perspective for the benefits of ICD-10-CM
implementation
 Members will become confident in the Structure and Format of ICD-10-CM
 Members will become confident in the coding of “Combination Codes”
 Members will learn the difference in the “Two Exclusion Notes” in ICD-10-CM
 Members will define the addition of the 7th character in ICD-10-CM and will apply
correctly
 Members will have knowledge of the “Chapters” in ICD-10-CM and the similarities
between 10 and ICD-9-CM
THE BENEFITS OF ICD-10-CM
Why Coders should be excited about the coming changes
Benefits of ICD-10-CM
 The adoption of ICD-10-CM will have several benefits to the coder as well as the professional (i.e.,
physicians, PA, NPs, etc)
 ICD-10-CM is clinically more relevant than ICD-9-CM
 ICD-10-CM is clinically able to point toward severity of services and complexity of services
whereas ICD-9-CM could not
 ICD-10-CM will give the World Health Organization, CDC, and insurance payers a more accurate
rating of provider performance
 ICD-10-CM will give greater support for medical necessity than has ever in the past
 ICD-10-CM will take the “guess work” out of reporting Evaluation and Management Codes
 ICD-10-CM will make for more accurate payer reimbursement for procedures and office visits
 ICD-10-CM will make it very difficult to misinterpret by auditors, lawyers and 3rd party payers
Benefits of ICD-10-CM Continued….
 ICD-10-CM will also lower administrative costs by providing the following:
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Fewer rejected and incorrectly reimbursed claims
Decreased submission for medical documentation
Increase of automated tools such as to facilitate the coding process
Many less coding errors
Increasing productivity in the coders
Reduced labor costs for the facilities
STRUCTURE OF ICD-10-CM
Quick Comparison of the New ICD-10-CM Structure to the ICD-9-CM we currently use
ICD-10-CM Structure as Compared to ICD-9-CM Side-by-Side
 ICD-9-CM
 3-5 characters
 First character is numeric or
alphanumeric (E or V)
 Characters 2-5 are numeric
 Always at least 3 characters
 Use of decimal after 3
characters
 ICD-10-CM
 3-7 characters
 1st character is alpha (all letters
except U are used)
 2nd character is numeric
 Characters 3-7 are alpha or numeric
 Use of a decimal after 3 characters
 Alpha characters are NOT casesensitive
Common Similarities
 Tabular List
 Chronological list of codes divided into Chapters based on body
system or condition
 Same hierarchy structural of coding
 The Chapters in the Tabular are structured similarly to ICD-9-CM
with a few exceptions
 Some chapters have been restructured
 The sense organs (Eye and Ear) have been removed from the
Nervous System and given their own Chapters for ICD-10-CM
Common Similarities Continued…
 Index
 Alphabetical list of terms and corresponding codes
 Subterms appear under the main terms
 Kept the same structure as we are familiar with in ICD-9-CM
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Alphabetic Index of Diseases and Injuries
Alphabetic Index of External Causes
Table of Neoplasm
Table of Drugs and Chemicals
Common Similarities Continued…..
 Abbreviations, punctuation, symbols, and notes such as “code first”
and “use additional code” are still prelevent in ICD-10-CM
 “Unspecified” or “Not Otherwise Specified” are still used
 Codes will be looked up the same way as ICD-9-CM
 Look up your diagnostic term in the Alphabetic Index
 Verify the code number in the Tabular List
DIFFERENCES IN ICD-10-CM AND
ICD-9-CM
Differences in ICD-10-CM versus ICD-9-CM
 Codes in ICD-10-CM will reflect updated medical terminology and the
use of more “modern medicine”
 The ICD-10-CM has expanded room for more detail and specificity
 The ICD-10-CM has expanded to add “laterality” or the side of the
body that is in question
 Combination Codes are a new expansion to ICD-10-CM
 This will mean that certain conditions and associated symptoms or
manifestations will now be lumped into one code “Combination
Code”
 Poisonings and Associated External Causes are also “Combination
Codes”
Addition of the 7th Character
 The 7th character will be used only in certain chapters of the ICD-10CM manual (Obstetrics, Injury, Musculoskeletal, and External Cause
chapters)
 The 7th character is not used in every chapter
 The 7th character has a different “meaning” depending on which
chapter it is being used
 Coders must always use the 7th character position when this rule
applies, codes that are missing the 7th character are invalid and will
lead to denial of claims
Use of the 7th Character By Chapter…
 In the Obstetrics Chapter, the 7th character is to identify multiple
gestations and identify if the fetus is affected by the condition of the
mother
 In the Injury Chapter, the 7th character is used to identify (Type of
Encounter, Closed vs. Open fractures, Routine vs. Delayed healing
and Malunion or nonunion of fractures)
 In the Musculoskeletal Chapter, the 7th character is used to identify
(Type of Encounter, Routine vs. Delayed Healing, Malunion or
nonunion of fracture, and to give additional clinical information)
Use of the 7th Character by Chapter…
 In the External Cause Chapter, the 7th character is used only to
specify the Type of Encounter
HOW DOES THE 7TH CHARACTER TELL
THE STORY OF AN ENCOUNTER?
The 7th Character Helps to Describe An Encounter!
 In ICD-10-CM we have the choices of Initial Encounter, Subsequent
Encounter or Sequela
 Initial Encounter: Describes an encounter where the patient is
receiving active treatment for a new condition
 Subsequent Encounter: Describes the patient has already received
initial treatment and continues for routine care for the condition
during the recovery or healing phase of the illness
 Sequela: Complications or medical conditions that have arose as a
direct result of a condition (rectal fistula due to adenocarcinoma
removal)
The 7th Character and The Treatment of Fractures
 ICD-10-CM has added the 7th character to fracture codes to show in detail what type
of encounter the patient is being seen and what stage of recovery the patient is in.
 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
Placeholder “X”
 The placeholder “x” is a new concept in ICD-10-CM that was not
originally available in ICD-9-CM
 The “x” is also called a dummy placeholder and is used in certain
situations (codes) to (allow for future expansion of ICD-10-CM, and
also fill empty spaces when a code contains fewer than 6 characters
and a 7th character applies to that code)
 When the placeholder “x” applies it must be used correctly for the
code to become valid
 In ICD-10-CM the placeholder “x” is not case-sensitive
THE ADDITION OF EXCLUDES
NOTES
Excludes Notes:
 There are an addition of (2) Excludes Notes for ICD-10-CM they are:
 Excludes 1 Note:
 Indicates that a code identified in the note and the code where the
note appears cannot be reported together because the 2
conditions cannot occur together
 Example: E10 Type 1 Diabetes mellitus
Excludes1: gestational diabetes (O24.4-)
Excludes Notes:
 Excludes 2 Note:
 This indicates that the condition identified in the note is not part of
the condition represented by the code where the note appears, so
both codes may be reported together if the patient has both
conditions
 Example:
L89 Pressure Ulcer
Excludes2: diabetic ulcers (E08.621, E08.622, etc)
Non pressure chronic ulcer of skin (L97.-)
Skin Infections (L00-L08)
Varicose ulcer (I83.0, I83.2)
ALPHABETIC INDEX OF DISEASES
AND INJURY
Instructional Notations in the Alphabetic Index
Abbreviations
 NEC: Not elsewhere classifiable
Identifies “other specified” when a specific code is not available for a
condition, the Index directs the user to the “other specified” code in the
Tabular list
 Punctuation:
() Parentheses
Used in the Alphabetic Index to enclose supplementary words that
may be present or absent in the statement of a disease/condition
without affecting the code number to which it is assigned. The terms
within the parentheses are referred to as “non-essential” modifiers
Manifestation Codes
 Manifestation codes
 Conditions/diseases that are considered manifestation
codes have a specific entry structure. Both
conditions/diseases are listed together with the etiology
code sequenced First, followed by the manifestation
code second
Morphology Codes
 Some neoplasms contained in the Alphabetic Index include
the morphology code or the histologic type. These codes
are derived from the second edition of the International
Classification of Disease for Oncology (ICD-O)
 The correct morphology code can be found under the main
term and subterm for the type of neoplasm,
adenocarcinoma, sarcoma, etc.
Default Codes
 A code that is listed next to a main term in the Index is referred to as
a “default code”
 The default code represents the condition/disease that is most
commonly associated with the main term, or the unspecified code for
that condition.
 If a condition is documented in the medical record without any
additional information (acute or chronic), the default code should be
assigned
Puncuation
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} Brackets are used in the Tabular List to enclose synonyms,
alternative wording, or explanatory phrases
Colons are used in the Tabular List after an incomplete term,
which needs one or more of the modifiers following the colon to
make it assignable to a given category
Other Abbreviations
 And:
The word “and” should be interpreted to mean either
“and” or “or” when it appears in a title
 With:
The word “with” should be interpreted to mean “associated
with” or “due to” when it appears in a code title, the
Alphabetic Index, or an instructional note in the Tabular
List. The word “with” in the Alphabetic Index is sequenced
immediately following the Main Term, not in alphabetical
order
Other Abbreviations
 See and See Also: The “see” instruction following a main term in
the Alphabetic Index indicates that another
term should be referenced. It is however,
necessary to go to the main term referenced
with the “see” note to locate the correct
code
 See Also:
A “see also” instruction following a main term in
the Alphabetic Index instructs that there is
another main term that may also be referenced
that may provide additional Alphabetic Index
entries that may be useful. It is not necessary to
follow the “see also” note when the original main
term provides the necessary code
Other Abbreviations
 Code Also:
A “code also” note instructs that two codes may be
required to fully describe a condition, but this note
does not provide sequencing directions
 Default Codes:
A code listed next to a main term in the ICD-10-CM
Alphabetic Index is referred to as a default code.
The default code represents that condition that is
most commonly associated with the main term, or is
the unspecified code for the condition. If a
condition is documented in a medical record
without any additional information, such as acute or
chronic, the default code should be assigned
UNSPECIFIED CODES
GENERAL CODING GUIDELINES
Locating a Code, Level of Coding Detail, Code(s) from A00.0-T88.9, Z00-Z99.8, Signs and Symptoms, Conditions that
are an integral part of a disease process, Conditions that are not an integral part of a disease process, Multiple
coding for a single condition, Acute and Chronic Conditions, Combination Codes, Late Effects, Impending or
Threatened Conditions, Reporting Same Diagnosis more than once, Laterality, Documentation of BMI and Pressure
Ulcer Stages, Syndromes, Documentation of Complications of Care
Level of Detail In Coding
 Diagnosis codes are to be used and reported at their highest number
of characters that are available in the coding book
 ICD-10-CM codes are comprised of 3-7 characters
 Codes with 3 characters are included in the ICD-10-CM as the heading
of a “Category Code” that may or may not be further subdivided
 A code is invalid if it has not been coded to the correct amount of
characters required for the code, including the 7th character if
applicable
Code or Codes from A00.0 through T88.9, Z00-Z99.8
 The code from any of these chapters can be used to identify
diagnosis, symptoms, conditions, problems, complaints or other
reason(s) for the patient encounter or visit
Signs and Symptoms
 Codes that eventually describe symptoms and signs, when a diagnosis
is unavailable are acceptable for reporting purposes when a related
diagnosis has not been established or confirmed by the provider
 Chapter 18 of the ICD-10-CM (Symptoms, Signs, and Abnormal Clinical
Laboratory Findings, Not Elsewhere Classified (R00.0-R99) contain
many codes for symptoms but not all that are located in the ICD-10CM
Conditions that are an integral part of a disease process
 For ICD-10-CM signs and symptoms that are associated with a disease
process should NOT be assigned as additional codes, unless instructed by
the classification
 For Conditions that Are Not part of an integral process should be coded
when/if present in the patient
Acute and Chronic Conditions
 In the guidelines for ICD-10-CM as with the guidelines for ICD-9-CM
verify the following information for Acute and Chronic Conditions:
 “If the same condition is described as both acute/subacute and
chronic, and separate subentries exist in the Alphabetic Index at
the same indentation level, code both
 Sequence the Acute condition first
 Sequence the Chronic condition secondary
Combination Codes
 Something new for ICD-10-CM is the use of “Combination Codes”
A Combination Code is a single code that is used to classify the following:
Two diagnoses
A diagnosis with associated secondary *manifestation*
A diagnosis with associated complication
 Combination codes can be identified by referring to the subterm entries in the
Alphabetic Index
 Multiple coding should not be used when the classification for the term provides
a combination code that states and identifies all the “elements” that are
documented in the diagnosis
 When the combination code lacks the necessary specificity that would ultimately
describe the manifestation or complication of a diagnosis, an additional code
should be coded as a secondary code
Late Effects (Sequela)
 Sequela:
A residual effect after the acute phase of an illness or injury has
terminated.
There is no time limit on a sequela code being used
When coding of sequela “generally” requires 2 codes
The condition or “nature” of the sequela is coded first and the
sequela code is coded secondly
**An exception to the rule** is when the sequela is followed by a
manifestation code identified in the Tabular List and title, or the sequela code
has been expanded to the (4-6) character to include the manifestation(s).
Then the code for the appropriate acute phase of illness or injury then led to
the sequela is never used with a code for the late effect.
Impending or Threatened Condition
 Code any condition described at the time of discharge as “impending” or
“threatened” as follows:
If it did occur, code as confirmed diagnosis
If it did not occur, reference the Alphabetic Index to determine if the
condition has a subentry term for “impending” or “threatened” and
also reference the main term entries for “Impending” and for
“Threatened”
If the subterms are listed, assign the given code
If the subterms are not listed, code the existing underlying condition(s)
and not the condition described as impending or threatened
Reporting Same Diagnosis Code More Than Once
 Each ICD-10-Cm code may be reported only Once for an encounter
 This applies also to bilateral codes for conditions when there are no codes
to identify the laterality or two separately identifiable conditions classified to
the same ICD-10-CM diagnosis code
Laterality
 The newest and greatest addition to ICD-10-CM is the use of Laterality
Codes
 For bilateral sites, the final character of the codes in the ICD-10-CM indicate
laterality
 An unspecified side code is also provided but should only be used if the side
is not documented in the medical record
 If there are no bilateral codes to provide and the condition is bilateral,
assign separate codes for both the right and left side
Documentation of BMI and Pressure Ulcers
 For the BMI and pressure ulcer stage codes:
Code assignment may be based on records from clinicians and not
nessicarily from the physician (patient provider)
If the nurse, NP, etc documents overweight, obesity, or pressure ulcer
stages, there must be documentation by the patient’s provider in the
medical record to use these codes
The BMI should only be reported as a secondary diagnosis
The BMI codes should only be assigned when the definition of a
reportable additional diagnosis code has been met
Documenting Complications of Care
 Code assignment for complications of care is based on the provider’s
documentation of the relationship between the condition and the care or
procedure
 The guideline extends to any complications of care, regardless of the
chapter the code is located in
 It is important to know that all conditions that occur during or following
treatment of a patient following surgery are complications
 The physician must clarify a cause-and-effect relationship between the care
provided and the condition the patient currently has
 Query the provider for clarification if the complication is not clearly
documented or the physician does not provide the cause-and-effect
Unspecified Codes
 According to the 2015 ICD-10-CM Guidelines for reporting:
 When sufficient clinical information is not known or available at the
time of a particular health condition is it appropriate to assign an
“unspecified” code in lieu of a more specific code
 It is also inappropriate to select a specific code that is not
supported by medical documentation or conduct medically
unnecessary testing to determine a more appropriate code
EXTERNAL CAUSES OF MORBIDITY
Reporting External Causes of Morbidity
 There is no national requirement for Mandatory ICD-10-CM external
cause code reporting
 Reporting of ICD-10-CM Chapter 20 codes is only required for
providers subject to state-based external cause code reporting
mandate or payer requirement
 Providers are encouraged to voluntarily report external cause codes
Why Report an External Cause of Injury Code?
 External Cause of Injury Codes are used to report the following are are
very helpful in the medical community:
 Provide data for injury research and evaluation of preventions
 Used at the national, state, and local level to identify high-risk
populations
 Used for evaluating the need for emergency medical services and
trauma care centers
CLINICAL DOCUMENTATION
Demand for Quality Documentation from Providers
 The physicians will have to document more accurate detail of the patient’s condition
and the quality of care provided to that patient
 Clinical documentation promotes better patient care and capturing of severity, risk and
acuity
 In 2013, CMS and the OIG came together to form the HAC (Hospital Acquired Condition)
reporting system. The following are all indications under this reporting system:
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Quality performance reporting
Reimbursement
Severity-level profiles
Risk adjustment profiles
Provider profiles
Present on Admission Reporting
HAC conditions Reporting
FORMAT AND STRUCTURE OF ICD10-CM
Let’s learn to code!!!!
Category Code (first 3 characters)
Sub-Categories
7th Character
Comparison of ICD-9-CM and ICD-10-CM Codes
ICD-9-CM Codes/Descriptions
ICD-10-CM Codes/Descriptions
 Gouty Arthropathy Acute
 Gouty Arthropathy Acute
 Gouty Arthropathy Chronic
274.01
274.02
 Gouty Arthropathy Chronic
Idiopathic Right Shoulder
M1A.0110
Idiopathic Left Shoulder
M1A.0120
Idiopathic Unspecified Shoulder
M1A.0190
Idiopathic Right Elbow
M1A.0210
Comparison Side-by-Side ICD-9-CM vs. ICD-10-CM
401.9:
Essential hypertension, unspecified
403.00: Hypertensive chronic kidney disease
(malignant) with chronic kidney
disease stage I through IV, or
unspecified
428.0:
Congestive Heart Failure
428.20: Systolic
428.21: Acute
428.22: Chronic
428.23: Acute on Chronic
 I10:
Essential Hypertension,
unspecified
 I12:
Hypertensive chronic kidney
disease stage I through stage IV chronic
kidney disease, or unspecified chronic
kidney disease
 I50.9:
Heart Failure unspecified
 I50.20:
Unspecified systolic
(congestive) heart failure
 I50.21:
Acute systolic (congestive)
heart failure
 I50.22:
Chronic systolic (congestive)
heart failure
 I50.23:
Acute on Chronic systolic (congestive)
heart failure
Comparison Side-by-Side ICD-9-CM vs ICD-10-CM
 250.00:
Diabetes mellitus without
manifestation or
complication, type II or
unspecified type, not
stated as uncontrolled
 E11.9:
 250.71:
Type I diabetes mellitus
with peripheral circulatory  E10.51:
disorders without
gangrene
 443.81:
with peripheral angiopathy
 I79.8:
Type 2 diabetes mellitus
without complications
Type I diabetes mellitus
with diabetic peripheral
angiopathy without
gangrene
Other disorders of
arteries, arterioles and
capillaries in diseases
classified elsewhere
Comparison Side-by-Side ICD-9-CM vs ICD-10-CM
411.1 AND 414.01
I25.110:
Atherosclerotic heart
disease of native coronary
artery with unstable angina
pectoris
E10.21:
Type I diabetes mellitus
with diabetic retinopathy
N30.01:
Acute cystitis with
hematuria
T39.011A:
Poisoning by aspirin,
accidental (unintentional),
initial encounter
Atherosclerotic heart disease of
native coronary artery with unstable
angina pectoris
250.51 AND 362.01
Type I diabetes mellitus with
diabetic retinopathy
595.0 AND 599.71
Acute cystitis with hematuria
E850.3
Poisoning by aspirin, accidental (no
encounter pointer)
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 Now…………
Questions
References and Quick Links
 www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2015.pdf
 www.cms.gov/icd10cm/readiness
 aihc-assn.org