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ICD-10-CM: Delayed But Not Dead
Teaching the Provider ICD-10
Faculty:
John F. Burns, CPMA, CPC, CPC-I, CEMC
AHIMA ICD-10 Ambassador and Trainer
© 2014 2
Agenda & Housekeeping
• ICD background and history
• Official Reporting Guidelines
o These 32 pages provide guidance to ICD-10-CM code use
• Auditing and Communicating Information Toward Clinical
Documentation Improvements
• Some exercises
You will notice throughout the slide deck that AHIMA slides
are the primary source. AHIMA Ambassadors are permitted
to use the training materials but are not permitted to make
any changes to the slides in appearance or content.
© 2014
ICD-10 For the Provider
• Run ICD-9-CM utilization and “map”
out ICD-10-CM equivalents
• Perform some internal audits of
common claims to determine the
extent of education that will be
necessary
• Provide education for providers that
specifically address their discipline(s)
o No sense taking OB with an Orthopedist
o There are 21 chapters in ICD-10, not all
will apply to everyone
2
© 2014
ICD-10 From The Auditor’s
Perspective • Consider the following:
o Laterality
• Some codes can be bilateral
(e.g., injectons/x-rays)
o External causes of injury
• For fractures, the specific type
(e.g. traumatic) must be documented
o Activity codes
o Place of occurrence codes
o Severity
o If it’s not documented as treated,
it should not be coded either, right?
© 2014 5
ICD-10-CM Background
• International Classification of Disease (ICD) has been
around since 1893
o 1948: WHO took over
o 1970s (late): US has used ICD-9-CM
1988: Required on claims
• Used in many other countries around the world since 1994
• HHS announced October 1, 2015 compliance deadline
o H.R. 4302, Protecting Access to Medicare Act of 2014
• In the US, ICD-10 codes have been used for reporting
mortality on death certificates since 1999
• According to WHO, ICD-11 is already in the works and will
be completed in 2015…hmmmm
© 2014 6
ICD-10-CM vs. ICD-9-CM
• 68,000+ ICD-10-CM codes compared to 13,000+ in ICD-9-CM
• 21 chapters in ICD-10-CM compared to 17 in ICD-9-CM
• ICD-10-CM codes are 3-7 characters compared to 3-5 digits
in ICD-9-CM
o All alpha characters used (except letter “U”)
• Expanded injury codes
o External causes and places of occurrence
• Greater specificity
o Laterality and granularity
• V-codes and E-codes are assigned in applicable chapters
• Combination codes (diagnosis/symptom)
• Documentation will be critical for accurate code assignment
3
© 2014 7
The Tabular List
• Categories (3 characters)
o Subcategories
Codes
• All Categories are 3 characters (decimal follows)
o A 3-character category without 4th/5th is a reportable code
J17 (Pneumonia in diseases classified elsewhere)
Be aware of “Code first underlying disease”
• A code with an applicable 7th character is invalid without the 7th
character…use an “X” placeholder
o Placeholders are common with fractures, injuries, external causes,
maternal care, labor and delivery, glaucoma, etc.
© 2014
X X X X
Category
. Etiology, anatomic
site, severity
Added 7th character for obstetrics, injuries, and external causes of injury
X X X A M S 0 2 6 . 5 x A
Additional
Characters
Alpha
(Except
U)
2 Numeric
3-7 Numeric or Alpha
3–7 Characters
© 2014
Coding in ICD-10-CM ICD-9-CM ICD-10-CM
Three to five characters Three to seven characters
First digit is numeric but can be alpha
(E or V)
First character always alpha
2–5 are numeric All letters used except U
Always at least three digits Character 2 always numeric: 3–7 can
be alpha or numeric
Decimal placed after the first three
characters (or with E codes, placed after
the first four characters)
Always at least three digits
Alpha characters are not case-sensitive Decimal placed after the first three
characters
Alpha characters are not case-sensitive
4
© 2014
The first character of an ICD-10-CM code is:
Answer: Always a letter
Rationale: This is an ICD-10-CM convention with all codes beginning
with a letter of the alphabet except the letter U.
© 2014
If an encounter is solely for chemotherapy, immunotherapy, or
radiation therapy for a neoplastic condition, the first reported
diagnosis is:
Answer:The appropriate Z51 code
Rationale: If a patient admission or encounter is solely for the
administration of chemotherapy, immunotherapy, or radiation
therapy assign code Z51.0, Encounter for antineoplastic radiation
therapy; or Z51.11, Encounter for antineoplastic chemotherapy; or
Z51.12, Encounter for antineoplastic immunotherapy as the first-
listed or principal diagnosis. If a patient receives more than one of
these therapies during the same admission more than one of these
codes may be assigned, in any sequence (ICD-10-CM Coding
Guideline I.C.2.e.2). An encounter for chemotherapy and
immunotherapy for a nonneoplastic condition should be coded to the
condition.
© 2014
True or false? When assigning the principal diagnosis for a patient
with AIDS, the AIDS code would always be sequenced before any
other conditions.
Answer: False
Rationale: When a patient is admitted with an HIV-related
condition, the principal diagnosis should be B20, Human
immunodeficiency virus [HIV] disease, followed by additional
diagnosis codes for all reported HIV-related conditions (ICD-10-CM
Coding Guideline I.C.1.a.2.a). When a patient with HIV disease is
admitted for an unrelated condition, for example, trauma, the code
for the unrelated condition should be the principal diagnosis with
B20 listed as an additional code (ICD-10-CM Coding Guideline
I.C.1.a.2.b).
5
© 2014
A patient has liver metastasis due to adenocarcinoma of the rectum
which was resected two years ago. The patient has been receiving
radiotherapy to the liver with some relief of pain. The patient is
being admitted at this time for management of severe anemia due
to the malignancy. The principal diagnosis listed on this admission
is:
© 2014
Answer: Liver metastasis
Rationale: When an admission or encounter is for the
management of an anemia associated with the malignancy, and the
treatment is only for anemia, the appropriate code for the
malignancy is sequenced as the principal or first listed diagnosis
followed by the appropriate code for the anemia (such as D63.0,
Anemia in neoplastic disease)
(ICD-10-CM Coding Guideline I.C.2.c.1). In addition, in the Tabular,
the note under D63.0 states to code first neoplasm (C00-D49).
© 2014
True or false? A fracture not described as“displaced” or “not
displaced” by default should be coded as “not displaced.”
Answer: False
Rationale: A fracture not indicated whether displaced or not
displaced should be coded to displaced (ICD-10-CM Coding
Guideline I.C.19.c). This information is also available in notes in the
Tabular (see category S52). A fracture not described as open or
closed is coded to the default of closed.
6
© 2014
True or false? A place of occurrence code should be used only at
the initial encounter for treatment.
Answer: True
Rationale: Codes from category Y92, Place of occurrence
of the external cause, are secondary codes for use after other
external cause codes to identify the location of the patient at the
time of injury. A place of occurrence code is used only once, at the
initial encounter for treatment and only one code from Y92 should
be recorded. A place of occurrence code should be used in
conjunction with an activity code, Y93. Only one code from Y93
should be recorded on a medical record (ICD-10-CM Coding
Guidelines I.C.20.b and c).
© 2014
In ICD-10-CM, diabetes mellitus codes include:
a. Type of diabetes
b. Body system affected
c. Complications affecting that body system
d. All of the above
Answer: d. All of the above
Rationale: The diabetes mellitus codes are combination codes
that include the type of diabetes mellitus, the body system affected
and the complications affecting that body system (ICD-10-CM
Coding Guideline I.C.4.a).
© 2014
True or False? Patients with a prior diagnosis of an HIV-related
illness should be assigned the code for AIDS (B20) on every
subsequent admission.
Answer: True
Rationale: Patients with any known prior diagnosis of an HIV-related
illness should be coded to B20. Once a patient has developed an
HIV-related illness, the patient should always be assigned code B20
on every subsequent admission or encounter. Patients previously
diagnosed with any HIV illness (B20) should never be assigned to
R75 or Z21, Asymptomatic human immunodeficiency virus [HIV]
infection status (ICD-10-CM Coding Guideline I.C.1.a.2.f).
7
© 2014
When an OB patient enters the hospital for complications of
pregnancy during one trimester and remains in the hospital into a
subsequent trimester, the final character selected for the
antepartum conditions should be:
a. For the trimester in which the complication first occurred
b. The trimester in which the patient was discharged
© 2014
Answer: a. For the trimester in which the complication first
occurred
Rationale: ICD-10-CM Coding Guideline I.C.15.a.4. states
in the instances when a patient is admitted to a hospital for
complications of pregnancy during one trimester and remains in the
hospital into a subsequent trimester, the trimester character for the
antepartum complication code should be assigned on the basis of
the trimester when the complication developed, not the trimester of
the discharge. If the condition developed prior to the current
admission
or encounter or represents a pre-existing condition, the trimester
character for the trimester at the time of the admission or encounter
should be assigned.
© 2014
When a patient seeks medical attention for an injury that occurred
several days prior to the medical encounter, what is the appropriate
seventh character to use?
Answer: A, initial encounter
Rationale: Seventh character A, initial encounter, is used while the
patient is receiving active treatment for the condition. Seventh
character D, subsequent encounter, is used for encounters after the
patient has received active treatment for the condition and is
receiving routine care for the condition during the healing or
recovery phase. Seventh character S, sequela, is used for
complications or conditions that arise as a direct result of a
condition (ICD-10-CM Coding Guideline I.C.19.a).
8
© 2014
• A primary malignant neoplasm overlapping two or more
contiguous (next to each other) sites should be classified to the
subcategory/code .8 (overlapping lesion), unless the
combination is specifically indexed elsewhere.
• For multiple neoplasms of the same site that are not contiguous,
such as tumors in different quadrants of the same breast, codes
for each site should be assigned.
© 2014 23
Neoplasms (C00-D49)
The diagnosis for this 61 year old female patient is small cell carcinoma of
the right lower lobe of the lung with metastasis to the intrathoracic lymph
node, brain, and right rib.
What are the diagnosis codes assigned?
© 2014
C34.31 Carcinoma, see also Neoplasm, by site,malignant.Refer to
Neoplasm Table, by site(lung), malignant, primary site, lower lobe
C77.1 Refer to Neoplasm Table, by site, lymph gland, malignant,
intrathoracic, secondary site
C79.31 Refer to Neoplasm Table, by site, brain, malignant,
secondary site
C79.51 Refer to Neoplasm Table, by site, bone, malignant, rib,
secondary site
9
© 2014
Diabetes mellitus
• Combination codes
• No longer classified as controlled
or uncontrolled
• Inadequately, out of control or
poorly controlled coded by type
with hyperglycemia
© 2014 26
Diabetes Coding
(E00-E89)
This 62 year old male is being seen for mild nonproliferative
diabetic retinopathy with macular edema. He has type II DM and
takes insulin on a daily basis. He also has diabetic cataract in his
right eye.
What diagnosis codes are assigned?
© 2014
E11.321Diabetes, diabetic (mellitus) (sugar), type 2, with,
retinopathy, nonproliferative, mild, with macular edema
E11.36Diabetes, diabetic (mellitus) (sugar), type 2, with, cataract
Z79.4Long-term (current) (prophylactic) drug therapy(use of),
insulin
10
© 2014 28
Diseases of the ear
(H60-H95)
A five year old female is seen for acute ear pain. Examination reveals
left acute serous otitis media. Further examination revealed a total
perforated tympanic membrane of the right ear due to chronic otitis
media.
What diagnosis codes are assigned?
© 2014
H65.02Otitis (acute), media (hemorrhagic)(staphylococcal)
(streptococcal) acute, subacuteserous – see Otitis, media,
nonsuppurative, acute, serous.Otitis media, nonsuppurative, acute
or subacute, serous
H66.91Otitis (acute), media (hemorrhagic) (staphylococcal)
(streptococcal), chronic
H72.821Perforation, perforated (nontraumatic) (of), tympanum,
tympanic (membrane) (persistent post-traumatic)
(postinflammatory), total
© 2014
• Type of hypertension not used
as an axis
• Acute MI codes changed from
8 weeks to 4 weeks or less
11
© 2014 31
Hypertension Example
A patient is seen today in follow-up for his benign hypertension.
What is the correct diagnosis code?
© 2014
I10Hypertension, hypertensive, (accelerated)(benign) (essential)
(idiopathic) (malignant) (systemic)
Rationale: ICD-10-CM does not differentiate between benign and
malignant hypertension.
© 2014 33
Hypertension with complications
Stage 3 chronic kidney disease with congestive heart failure (CHF) due to
hypertension.
What diagnosis codes are assigned?
12
© 2014
I13.0 Hypertension, hypertensive, (accelerated)(benign)
(essential) (idiopathic) (malignant)(systemic), cardiorenal
(disease), with heart failure, with stage 1 through stage 4 chronic
kidney disease
I50.9 Failure, failed, heart (acute) (senile) (sudden), congestive
(compensated) (decompensated)
N18.3 Disease, diseased, kidney (functional) (pelvis), chronic,
stage 3 (moderate)
© 2014 35
COPD
A patient has increasing shortness of breath, weakness, and
ineffective cough. Treatment included oxygen therapy and advice
for smoking cessation. Diagnosis listed as acute respiratory
insufficiency due to acute exacerbation of COPD and tobacco
dependence.
What diagnosis codes are assigned?
© 2014
J44.1 Disease, diseased, pulmonary, chronic obstructive, with
exacerbation (acute)
F17.200 Dependence (on) (syndrome), tobacco – see
dependence, drug, nicotine
Z71.6 Counseling (for), substance abuse, tobacco
Rationale: The acute respiratory insufficiency is a symptom that
is an integral part of the COPD and is not coded.
13
© 2014
Asthma Severity Frequency of Daytime Symptoms
Intermittent Less than or equal to 2 times per week
Mild Persistent More than 2 times per week
Moderate Persistent Daily.May restrict physical activity
Severe Persistent Throughout the day.Frequent severe attacks
limiting ability to breathe.
Source: Worldallergy.org
© 2014 38
Asthma
A 10 year old female child is being seen because of
severe persistent asthma with acute exacerbation.
What diagnosis codes are assigned?
© 2014
J45.51 Asthma, asthmatic (bronchial) (catarrh) (spasmodic), persistent,
severe, with exacerbation(acute)
Rationale: There are categories of the three degrees of persistent
asthma, with the ability to identify with or without exacerbation and status
asthmaticus.
14
© 2014 40
Thank You John F. Burns, CPC, CPMA, CPC-I, CEMC
Senior Consultant/Approved NAMAS Instructor
AHIMA Approved ICD-10-CM/PCS Trainer & ICD-10 Ambassador
(Phone) 518-796-7227 (Fax) 928-833-2267
jburns@namas.co
CEU Index #: 38878RDP
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