ICD 10: The Road Forward - Molina HealthcareICD-10 Overview ICD-10 Documentation Examples...

ICD 10: The Road Forward

Puerto Rico

Agenda

ICD-10 Overview ICD-10 Documentation Examples Implementation Putting into Practice Resources

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Overview

Final Rule Issued

On July 31st, 2014, The U.S. Department of Health and Human Services (HHS) issued a rule finalizing Oct. 1, 2015 as the new compliance date.

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Now is the Time to PrepareCompliance Date – Oct. 1, 2015

Training

Jul 2014

Aug Sep Oct Nov Dec Jan2015

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan2016

Feb

ICD-10 Go LiveOctober 1, 2015

Jul 1 – Dec 31, 2014Build and Maintain

Momentum

Jul 1, 2014 – Sep 30, 2015 Acknowledgement Testing

with Stakeholders

Apr 1 – Sep 30, 2015Operational Readiness

Oct 1, 2015 – Feb 29, 2016Post-Implementation

Activities

Jan 2015End-to-End Testing

Apr 2015End-to-End Testing

Jul 2015End-to-End Testing

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ICD10 Quick Facts ICD-10 international version

– Adopted by WHO in 1990– Most countries other than the US currently use ICD-

10– ICD-10 (International version) ~ 12,500 diagnostic

codes– ICD-10 used for mortality reporting in the US - 1999

ICD-10-CM (US version) – ~ 69,000 diagnostic codes– Final rule published – 2009

ICD-10-PCS– ~72,000 codes– Not part of an international standard– Inpatient procedures only

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The “Anatomy” of ICD-10 structure

7th

character1st

character4th

character2nd

character3rd

character5th

character6th

character

Alpha (not U) Numeric

<Can be any combination of alpha or numeric characters>

Category Etiology, Anatomical Site, Severity

• 3 character codes ONLY if not further subdivided• Codes without all required characters are invalid• Alpha characters are NOT case specific (e.g., s93.401A)

Extension

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7th character

The following are examples of the many possible alpha and numeric characters that are used in the 7th

character position:

ICD-10 codes have UP TO 7 characters

A = Initial Encounter D = Subsequent Encounter S = Sequelae 3 = Fetus #3 in multiple

gestation, complication of

Often seen in: Obstetrics, Musculoskeletal conditions such as fractures, injuries, and many others

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ICD9 Comparison to ICD10-CMDiagnosis Codes – Clinical Example

A patient is seen in the emergency room with an acute exacerbation of her severe persistent asthma.

ICD-9 only captures part of the information available for this patient.

ICD9 Code Description49312 Intrinsic asthma with (acute) exacerbation

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ICD9 Comparison to ICD10-CMDiagnosis Codes – Clinical Example

A patient is seen in the emergency room with an acute exacerbation of her severe persistent asthma.

ICD-10 provides a more complete description of this patient’s condition compared to the limited information available in ICD-9

ICD9 Code Description49312 Intrinsic asthma with (acute) exacerbation

ICD10 Code DescriptionJ4551 Severe persistent asthma with (acute) exacerbation

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Each Physician Will Use a Small Subset of ICD-10 Codes

34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system

17,045 (25%) of all ICD-10-CM codes are related to fractures

~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’

Only a very small percentage of the codes will be used by most providers

Source: Health Data Consulting 11

Clinical Area ICD-9 Codes ICD-10 CodesFractures 747 17099Poisoning and toxic effects 244 4662Pregnancy related conditions 1104 2155Brain Injury 292 574Diabetes 69 239Migraine 40 44Bleeding disorders 26 29Mood related disorders 78 71Hypertensive Disease 33 14End stage renal disease 11 5Chronic respiratory failure 7 4

Source: Health Data Consulting

Varying Code VolumeBy Clinical Area

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Current Distribution ofICD-9 Diagnosis Codes

Over 72% of all charges involve only 5% of codes

Almost 85% of all chargeare covered by 10% of codes

Over 95% of all charges are covered by 15% of codes

Similar results are expected with ICD-10 codes

s

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

5%ne

xt 5

% … … … … … … … … … … … … … … … … … …

Total Charges by Code3 years - $10 Bill

Charge %

3 Years of Data – All claims – 1 Million Lives

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If there is sufficient information available to more accurately define the condition

For basic concepts such as:– Laterality (Right, Left, Bilateral, Unilateral)– Anatomical locations– Trimester– Type of diabetes– Known complications or comorbidities – Description of severity, acute or chronic or other known parameters…

Where care is implemented that demands a more specific level of detail

At specialty level that should be able to define the detail required

Source: Health Data Consulting

Coding SpecificityNo Place for “Unspecified” Codes

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Sometimes unspecified makes sense…– The patient may be early in the course of

evaluation

– The claim may be coming from a provider who is not directly related to diagnosing the patient’s condition and unfamiliar with all the details

– The clinician seeing the patient may be more of a generalist and not able to define the condition at a level of detail expected by a specialist

Coding SpecificityA place for “Unspecified” Codes

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Greater detail

Enhanced categorization models

Greater severity and risk definition

Greater precision of definition

Greater forward flexibility

Greater ability to integrate clinical information

Leveraging ICD10Better Information

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ICD-10 Documentation

ICD-10 Clinical Documentation Impacts

Timing of care

Anatomical site specificity

Laterality

Disease acuity

Combination codes with Symptoms

and/or Manifestations

Complications

Status codes, personal and family history

codes

General – BMI, tobacco use/smoking exposure,

health status

Timing of care

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The role of the clinician is to document as accurately as possible the nature of the patient’s conditions and services provide to maintain or improve those conditions

The role of the coding professional is to assure that coding is consistent with the documentation

The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts

Clinical DocumentationKnow Your Role

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Clinical Documentation –The Patient InterfaceWhere It All Begins

History

Physical ExamInternal Record Review

External Record Review

Assessment/Diagnosis

Studies

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Observation of all objective and subjective facts relevant to the patient condition

Documentation of all of the key medical concepts relevant to patient care currently and in the future

Coding that includes all of the key medical concepts supported by the coding standard and guidelines

Good Patient DataIt’s all About Good Patient Care…

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Clinical DocumentationWhat They Taught Us in Medical School

Type of ConditionOnsetEtiology / CauseAnatomical LocationLateralitySeverityEnvironmental FactorsTime Parameters

ComorbiditiesComplicationsManifestationsHealing LevelFindings & SymptomsExternal CausesType of Encounter

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Supports proper payment and reduces denials

Assures accurate measures of quality and efficiency

Addresses the issue of accountability and transparency

Creates a competitive advantage

Provides better business intelligence

Supports clinical research

Supports interoperable sharing of data

It’s just good care!

DocumentationWhy Is It Important?

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Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated

processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support population risk

management More accurate measures of quality and efficiency

How documentation Impacts The PracticeA Changing World of Cost Containment

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Examples

Exercise 1 Asthma

Current History8 year old female here for follow up to ER visit 2 days ago for shortness of breath. The patient was discharged with a diagnosis of asthma and Albuterol inhaler prescription. Patient is stable on inhaler.

History Patient has seasonal allergies with rhinorrhea and a history of wheezing during

physical exertion. Last episode occurred during PE at school and the patient was taken to the ER for assessment and treatment.

Patient has been exposed to second hand cigarette smoke since infancy; father is a pack-a-day smoke

The patient has a history of moderately severe episodes of awakening at night approximately 2 times a week requiring the use of an inhaler.

Assessment Moderate persistent asthma Seasonal allergic rhinitis Second hand smoke exposure

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Answer 1Asthma

CODING ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

493.02 – Asthma, extrinsic, acute exacerbation J45.41– Moderate persistent asthma with (acute) exacerbation

477.0 – Allergic rhinitis, due to pollen J30.1 – Allergic rhinitis, due to pollenZ77.22 – Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)

ANALYSIS• ICD-10 does not include the concept of extrinsic, but does include whether asthma is mild

intermittent or persistent or moderate and severe persistent.• ICD-10 guidelines now require the use of an additional code to indicate if a patient is exposed

to tobacco smoke.• Moderate Persistent Asthma• Symptoms occur daily, and the disease severity warrants regular use of medications for

control.• Patients are constantly aware of their disease, require medications on a daily basis, have

their sleep interrupted at least weekly, and have to accommodate their life style to thedisease.

• Pulmonary function is moderately abnormal, with the FEV1 being 60-8027

Exercise 2 Breast Cancer with Chemotherapy Induced Anemia

Current History:The patient is a 44 year old female with Estrogen positive, Stage II invasive ductal carcinoma in the lower inner quadrant of the left breast.She has been receiving chemotherapy and complains of extreme fatigue, headaches, dizziness and rapid heart rate. Hematology studies indicate aplastic anemia consistent with chemotherapy treatment.

History Patient has completed first round of chemotherapy.

Assessment Malignancy left breast; estrogen positive Drug induced aplastic anemia

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Exercise 2 AnswerBreast Cancer with Chemotherapy Induced

AnemiaCODING

ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes284.89 – Other specified aplastic anemias D61.1 - Drug-induced aplastic anemiaE933.1 Therapeutic use of Antineoplastic agents

T45.1X5D - Adverse effect of antineoplastic and immunosuppressive drugs

174.3 – Malignant neoplasm of female breast, lower-inner quadrant

C50.312 - Malignant neoplasm of lower-inner quadrant of left female breast

V86.0 Estrogen receptor positive Z17.0 - Estrogen receptor positive status [ER+]

ANALYSIS• ICD-10 includes a new guideline that requires the reporting of an adverse effect code

when anemia is associated with chemotherapy.• ICD-10 has codes for Estrogen receptor positive or negative status codes.• Adverse effect codes are found in the Table of Drugs and Chemicals in ICD-10-CM.

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Exercise 3Musculoskeletal

Current HistoryPatient’s neck hurts and I have a tingling pain sensation going down my right arm.

History Patient is a 68 year-old male with history of neck pain that has been worsening

over the last two years. Recently, he has experienced some numbness and a painful tingling sensation in his right arm going down to his thumb. No other symptoms or pertinent medical history.

Assessment Review of systems is negative except for the neck pain and sensations in his

right arm described above. No history of acute injury to neck or arm. Physical exam is normal except for neurological exam of the right upper

extremity, which reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6 nerve root distribution. No evidence of weakness in the muscles of the arm or hand.

MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of disc material. No other abnormalities noted.

Cervical transforaminal injection at C5-6.

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Exercise 3 AnswerMusculoskeletal

CODING ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

722.0 Cervical disc displacement without myelopathy

M50.12 Cervical disc disorder withradiculopathy, mid-cervical region

722.4 Degeneration of cervical intervertebral disc

Analysis• The code category M50.12 Cervical disc disease includes degeneration of the disc as a combination

code.• Subcategory M50.1 describes cervical disc disorders.• The 5th character differentiates various regions of the cervical spine (high cervical C2-3 and C3-4;

mid-cervical C4-5, C5-6, and C6-7; cervicothoracic C7-T1 and the associated radiculopathies at eachlevel).

• This is a combination code that includes the disc degeneration and radiculopathy31

Exercise 4Diabetes

Current HistoryA 55 year old male with type 2 diabetes mellitus complains of numbness and tingling in feet x 2 months. Patient also states that he did not feel pain in his left foot after striking his big toe against the driveway while barefoot about a month ago. Injury resulted in superficial abrasion that is still visibly healing. The blood sugar recorded in the office today was 200 mg/dL with only a light breakfast 3 hours earlier. On further discussion with the patient it is apparent that he is intentionally not taking his insulin dosage on an appropriate basis.

History Patient has been on insulin x 5 years with poor control x 6 months. Patient has hypertension and is taking an ACE inhibitor. x 3 years. Blood

pressure is stable.

Assessment Type 2 diabetes with diabetic polyneuropathy Hyperglycemia Hypertension Ongoing insulin use

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Exercise 4 AnswerDiabetes

CODING ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes

250.62 - Diabetes mellitus with peripheral neurological disorders, type II, uncontrolled

E11.42 - Type 2 diabetes mellitus with diabetic polyneuropathy

357.2 - Polyneuropathy E11.65 - Type 2 diabetes mellitus with hyperglycemia

401.9 – Hypertension ,unspecified I10 - Essential (primary) hypertensionV58.67 - Long term (current) insulin use Z79.4 - Long term (current) insulin useV15.81 - History of noncompliance T38.3X6D - Underdosing of insulin and oral

hypoglycemic [antidiabetic] drugs, subsequent encounterZ91.112 - Patient’s intentional underdosing of medication regimen for other reason

Analysis• Diabetes which is poorly controlled is not a concept that is carried over to ICD-10.• Unlike ICD-9, ICD-10 provides codes to indicate hyper or hypoglycemia.• Manifestations in diabetes are not generally reported separately, but rather as part of the ICD-10

diabetes mellitus code.• Unlike ICD-9, ICD-10 supports the reporting underdosing of medication by the patient. Note found

at the beginning of category T36 – T50 referencing the use of underdosing with codes Z91.12-, orZ91.13-

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Endocrine - Diabetes

DiabetesMellitus

Diabetes found at E08 thru E13

E08 Diabetes mellitus due to underlyingcondition E09 Drug or chemical induced diabetesmellitus E10 Type 1 diabetes mellitusE11 Type 2 diabetes mellitusE13 Other specified diabetes mellitus

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Documenting Diabetes (continued)

If there are complications/manifestations of the diabetes, additional details may be necessary for the following conditions:

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Arthropathy Site of ulcer Severity of retinopathy

With/without macular edema

Stage of CKD Gangrene Hyperglycemia

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Each manifestation documented should be coded separately

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MANIFESTATIONS OF DIABETES

E08.621 Diabetes mellitus due to underlying condition

with foot ulcer

E09.621 Drug or chemical induced diabetes mellitus with

foot ulcer

E10.621 Type 1 diabetes mellitus with foot ulcer

E11.621 Type 2 diabetes mellitus with foot ulcer

E13.621 Other specified diabetes mellitus with foot ulcer

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JOINT PAIN

M25.511 Pain in right shoulderM25.512 Pain in left shoulderM25.519 Pain in unspecified shoulderM25.521 Pain in right elbowM25.522 Pain in left elbowM25.529 Pain in unspecified elbowM25.531 Pain in right wristM25.532 Pain in left wristM25.539 Pain in unspecified wrist

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M25.411 thru M25.48 Effusion of Joint

By joint, left versus right

M25.411 Effusion, right shoulderM25.412 Effusion, left shoulderM25.419 Effusion, unspecified shoulderM25.421 Effusion, right elbowM25.422 Effusion, left elbow

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CREATING TOOLS

M25.5 __ __ Pain, joint______location [ ]right [ ]leftM24.4__ __ Effusion, joint,__location [ ]right [ ]left

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Z CODES REPLACE V CODES

Z CODES

In the absence of disease or injury, it is still necessary to "match" an ICD-10-CM code to a service or procedure code (CPT).

Z codes state the reason for your patient's visit in just such circumstances.

The following is a list of index words that will help you to begin the code search in the Index to Diseases.

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WELL ADULT EXAMINATIONS

Z00.00Encounter for generaladult medical examination without abnormal findings

Encounter for adult healthcheck-up NOS

Z00.01Encounter for general adult medicalexamination with abnormal findings

→Use additional code toidentify abnormalfindings

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Implementation

Getting Started

Establish awareness across members of your organization

Clearly define strategic goals

Identify internal and external dependencies

Identify and prioritize key risks

Clearly define all business requirements and implementation tasks

Create a realistic project plan and support it as a priority

Test early and often

Get started now!!

Source: Health Data Consulting

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Road to 10:Small Physician Practice Portal

Visit: http://www.roadto10.org

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Plan Your Journey

Train Your Team

Update Your Processes

Engage Your Vendors & Payers

Test Your Systems and Processes

1

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5VISIT HTTP:// WWW.ROADTO10.ORG TODAY TO GET STARTED

“Road to 10” Physician Portalhttp://www.roadto10.org

In collaboration with physicians, CMS developed www.roadto10.org, a no cost tool:• Designed from a physician perspective Specialty specific

• Customizable, actionable, bite-sized, short cuts

• Answers the key questions: What is ICD-10 How do I get started What is the path to success What questions to ask What resources and tools are

available

The Road to 10 Action Plan contains a checklist of items to consider when planning the transition to ICD-10, organized into 5 key steps:

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Road to 10: Plan Your JourneyCustomize Your Action Plan

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Road to 10: Action Plan 1

Road to 10: Train Your Team2

Road to 10: Update Your Processes3

Road to 10: Engage Your Vendors and Payers

Ensure that your EHR and practice management systems are ready.

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Road to 10: Test Your Systems and Processes5

Road to 10: Specialty Specific Webcasts

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Your Stories Are Important

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Moving Forward Alongthe Road to 10

In the coming months, there is opportunity to work on several critical activities that will help you maximize your ICD-10 preparedness.

I encourage you to visit http://www.roadto10.org for tools and resources to help you prepare for the ICD-10 transition.

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Putting ICD-10 into Practice

The role of the clinician is to document as accurately as possible the nature of the patient’s conditions and services provide to maintain or improve those conditions

The role of the coding professional is to assure that coding is consistent with the documentation

The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts

Clinical DocumentationKnow Your Role

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•Connect the pieces of the medical record together for problems, assessments, procedures, and treatments

Clinical Documentation Drives Code Selection

•Support and supplement provider documentation

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Ten for Ten for Overview ICD-10-CM

1. Concept of laterality: Right, Left, Bilateral and Unspecified in many categories.

2. Injuries grouped by body part rather than category of injury

3. Acute MI codes changed from 8 weeks duration to 4 weeks duration or less

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Ten for Ten

4. New terminology for asthma from worldallergy.org

5. Infectious Diseases now spans 2 alpha characters of A and B in Chapter 1.

6. New combination of codes for complications commonly associated with intestinal disorders such as Crohn’s disease, diverticulitis, etc.

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Ten for Ten

7. Pressure and Non-pressure ulcers are classified by site, laterality, and severity.

8. Three different categories for pathologic fractures – due to neoplastic disease, due to osteoporosis, and due to other specified disease

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Ten for Ten

9. Use additional code to identify resistance to antimicrobial drugs (Z16-) whenever infection is documented and the resistance is documented.

10. Systemic Hypertension no longer subcategorized by “benign” or “malignant”.

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Diagnostic Coding and Reporting Guidelines for Outpatient Services

A. Selection of first-listed condition

In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.

→ Chiefly responsible for today’s encounter

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Diagnostic Coding and Reporting Guidelines for Outpatient Services

C. Accurate reporting of ICD-10-CM diagnosis codes

For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to describe all of these.

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Diagnostic Coding and Reporting Guidelines for Outpatient Services

H. Uncertain diagnosis

Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty.

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Table of Neoplasms

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Drugs and Chemicals

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Timing of care

SCENARIO

Patient returns for a follow up visit for a sprained right ankle of the tibiofibular ligament. Still attending PT for strengthening exercises.

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Timing of care

ANSWER

KEY WORD: SPRAIN, TIBIOFIBULAR LIGAMENT S93.43-

S93.431DD= subsequent episode

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Anatomical Site Specificity/ LATERALITY

ScenarioDx: Patient has osteoarthritis of the left hip.

→M16.0 Bilateral primary osteoarthritis of hip

M16.1 Unilateral primary osteoarthritis of hipPrimary osteoarthritis of hip NOS

M16.10 Unilateral primary osteoarthritis, unspecified hip Avoid unspecified whenever possibleM16.11 Unilateral primary osteoarthritis, right hip→M16.12 Unilateral primary osteoarthritis, left hip

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Combination codes with Symptoms and/or Manifestations

K57.2 Diverticulitis of large intestine with perforation and abscess

Diverticulitis of colon with peritonitis→Excludes1: diverticulitis of both small and large intestine with perforation and abscess (K57.4-)

K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding

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Status codes, personal and family history codes

ICD-10-CMZ91.81 History of fallingAt risk for falling

ICD-9-CMV15.88 History of fall

At risk for fallingThis code can be first listed or secondary depending on “chiefly responsible” for today’s encounter

This code can be first listed or secondary depending on “chiefly responsible” for today’s encounter

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General – BMI, tobacco use/smoking exposure, health status

Use additional code, if applicable, to identify: →exposure to environmental tobacco smoke (Z77.22) →history of tobacco use (Z87.891)→occupational exposure to environmental tobacco smoke (Z57.31)→tobacco dependence (F17.-)→tobacco use (Z72.0)

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T38.3X6A - Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter

T38.3X6D - Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, subsequent encounter

T38.3X6S - Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, sequelae

Z91.120 - Patient’s intentional underdosing of medication regimen due to financial hardshipZ91.128 - Patient’s intentional underdosing of medication regimen for other reasonZ91.130 - Patient’s unintentional underdosing of medication regimen due to age-related debilityZ91.138 - Patient’s unintentional underdosing of medication regimen for other reason

New Concepts: Underdosing

The concept of underdosing has been added to the poisoning and adverse effect classification

– Includes the ability to report why the underdosing is occurring

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Free ICD -10 Resources and Tools

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ICD-10 Resources

ICD-10 Website

• http://www.cms.gov/Medicare/Coding/ICD10/index.html

• http://www.cms.gov/Medicare/Medicare-fee-for-service-Payment/HomeHealthPPS/index.html

CMS Home Health Resources

• GEMs Crosswalk documents• http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-

CM-and-GEMs.html

Mapping (GEMs)

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ICD-10 Resources (cont’d)

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1501.pdf

Medicare Learning Network Articles

• http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html

ICD-10 National Provider Calls

• http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

Provider Resources

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ICD-10 Resources (cont’d)

• http://www.ahima.org/education/onlineed/Programs/ICD10

American Health Information Management Association (AHIMA)

• http://www.aapc.com/medical-coding/

American Academy of Professional Coders (AAPC)

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Questions and Discussion

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