Common Anesthesia Diagnoses: ICD-9 to ICD-10 Mapping1 Introduction ICD-10 CM coding for anesthesia needs increased levels of specificity that should be included in physician documentation

ICD-9-CMADOPTED FORHOSPITAL USE

ICD-9-CMADOPTED FOR

PHYSICIAN USE

WORLD HEALTHORGANIZATIONADOPTS ICD-10

HIPAA LEGISLATIONINTERRUPTS US ICD-10 ADOPTION

CMS PROPOSED RULE TO ADOPT ICD-10 OCT 2011

CMS FINAL RULETO ADOPT ICD-10

OCT 2013

CMS DELAYSIMPLEMENTATION

ONE YEAR

CONGRESS DELAYSIMPLEMENTATION

ONE YEAR

IMPLEMENTATIONOCTOBER 1

1979

1988

1994

1996

2008

2009

2013 2015

2014

ICD-10 HISTORY

CODE STRUCTURE

ICD-9-CM CODE FORMAT

X X X X X

CATEGORY ETIOLOGY,ANATOMIC SITE,MANIFESTATION

3 TO 5 CHARACTERSFIRST DIGIT IS NUMERIC OR E OR VALL OTHER DIGITS ARE NUMERIC

ICD-10-CM CODE FORMAT

X X X

CATEGORY

X X X

ETIOLOGY,ANATOMIC SITE,MANIFESTATION

X

EXTENSION

1 TO 7 CHARACTERSFIRST DIGIT IS ALPHAALL DIGITS EXCEPT SECOND ALPHA OR NUMERIC

NUMBER OF CODES

ICD-9DIAGNOSIS CODES

ICD-10DIAGNOSIS CODES

69,00014,000

PERFORMANCE THAT MATTERS

Common Anesthesia Diagnoses: ICD-9 to ICD-10 Mapping

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Anesthesia Diagnoses: ICD-9 to ICD-10 Mapping

Introduction ................................................................................................. 1

Most Common ICD-9 Anesthesia Codes and ICD-10 Documentation Issues............ 3

Ulcers ......................................................................................................... 4

Glaucoma ................................................................................................... 6

Tears and Ruptures .................................................................................... 7

Neoplasm of Breast .................................................................................... 8

Fractures .................................................................................................... 9

1

Introduction

ICD-10 CM coding for anesthesia needs increased levels of specificity that should be included in

physician documentation. This document provides an overview of the top diagnosis codes for

anesthesia and the critical changes in ICD-10 that may impact coding and claim submission.

The table on the next page shows 3 categories of changes that impact documentation:

1) Diagnoses that require specificity that must be included before claims can be submitted

for payment. If a coder receives documentation without the specificity, it must be

returned to the provider for additional information. This category is highlighted in

red.

2) Diagnoses that request specificity, but “unspecified” or “other” codes are available as a

default. Because the intention of ICD-10 is to capture additional detail, it is unclear

whether payers will accept “unspecified” codes or if they will be denied or delayed.

Therefore, we encourage providers to include the detail in their documentation; the claim

will only be returned to the provider in the event of a denial from the payer. This category

is highlighted in yellow.

3) Conditions which generally provide a straightforward 1-to-1 transition from ICD-9 to

ICD-10. No change to the documentation is required. This category is highlighted in

green.

Following the table is an overview of top anesthesia codes and the documentation issues present

with ICD-10.

Subsequent pages highlight the top diagnoses and the specific documentation requirements and

issues for converting from ICD-9 to ICD-10.

2

ICD10 Change Condition Documentation Requirements

Critical: Must be Included in

Documentation

Encounter/Episode of Care

Episode of care must be included for injuries, poisonings and other conditions. Designations include initial, subsequent, sequela. There is no "not otherwise specified" or "unspecified" option; the code must include the episode of care to be complete.

Fracture Type

Additional details related to fracture type must be included, such as whether the fracture is open or closed, as well as details about the healing phase whether healing is routine or with complications such as delayed healing, nonunion or malunion. Open fractures should include the Gustillo open fracture classification. There is no "not otherwise specified" option.

Important: Codes provide "Unspecified"

option but lack of specificity may

result in delayed or denied

payments by payor.

Site Specificity

Greater level of specificity required, including: * Specific area of limb (calf, ankle, etc) * Specific quadrant of breast or area of chest wall Unspecified codes are available.

Laterality Identify right/left/bilateral/unilateral limb, body location when available. Unspecified codes are available.

Primary/Post Traumatic/ Secondary

Conditions such as osteoarthritis, urethritis, and other UTI diagnoses should include whether it is primary, secondary, or post-traumatic.

Type of Tear Type of tear needed. Examples for cartilage/meniscus (bucket-handle, peripheral, complex) or rotator cuff (incomplete/complete). "Unspecified" and "Other" codes are available.

Patient History Neoplasm screening should include applicable patient history resulting in need for service

Artery and Chest wall specificity

With acute myocardial infarction, chest wall (anterior, inferior) and artery (circumflex coronary, descending coronary artery) should be included. The codes allow for "other sites" and "unspecified site."

Ulcer Stage Pressure ulcers should be categorized based on stages from National Pressure Ulcer Advisory Panel (NPUAP) stages 1-4.

Identification of pregnancy term

Issues related to pregnancy should identify the trimester.

Disease Type Type and origin of the disease should be included for diagnoses such as hypertension, COPD, and hyperlipedemia.

Acute V Chronic Conditions such as respiratory or digestive orders should be designated as "acute" or "chronic"

1-to-1 conversion from ICD9 to ICD10;

no additional documentation

required

Normal or C-section birth/delivery

1-to-1 conversion; no additional documentation required

Calculus of gallbladder or kidney

1-to-1 conversion; no additional documentation required

3

Most Common ICD-9 Anesthesia Codes and ICD-10 Documentation Issues

ICD-9

Code ICD-9 Description

ICD-10 Documentation Issues

Laterality

Episode of Care

Acute/ Chronic

Anatomical Site

Specificity Patient History Other

366.10 – 366.9

Cataract/Nuclear Sclerosis/ Eye conditions (multiple) x

Identify left, right or bilateral eye

365.11 Primary open-angle glaucoma

Specify stage (mild, moderate, severe,

indeterminate, unspecified).

V76.51 Special screening for malignant neoplasm x Direct correlation to ICD10 – Z12.11

Confirm screening not personal history.

174.9 Malignant neoplasm of breast, unspecified x x Specify male/female, specific breast and

quadrant when available

574.20 Calculus of gallbladder w/o mention of cholecystitis, w/o mention of obstruction

Direct correlation to ICD10-K80.20

659.71 Abnormality in Fetal Heart Rate or rhythm delivered w/wo antepartum condition

Direct correlation with ICD10 – O76

836.0 Tear of medial cartilage or meniscus of knee, current x x x x Need type of tear (bucket-handle,

peripheral, complex, other, unspecified)

840.4 Rotator cuff sprain x x

354.0 Carpal tunnel x

654.21 Previous C/S delivery w/wo mention antepartum condition

Direct correlation with ICD10 – O34.21

727.03 Trigger Finger (acquired) x x Specify finger, right/left

820.8 Closed fracture of unspecified part of neck or femur x x

X Specificity of fracture

site needed Need peritrochanteric / subtrochanteric

fracture type

726.10 Rotator cuff syndrome NOS x x

Bursitis vs tendinitis

Need unspecified /incomplete/complete tear or rupture

550.90 Inguinal hernia w/o obstruction or gangrene, unilateral or unspecified x X Identify unilateral or bilateral for inguinal

hernia

722.10 Displacement of lumbar intervertebral disc without myelopathy

x

lumbar vs lumbosacral

715.96 Osteoarthrosis, unspecified whether generalized or local, lower leg x

x

Identify primary/post-traumatic/secondary, bilateral/unilateral

540.9 Acute appendicitis NOS

X Mention peritonitis, abscess, etc . If applicable

4

Ulcers

Documentation for treating ulcers of the limb requires two different types of specificity in ICD-

10:

Site Specificity. Documentation should include the specific area of the body impacted.

For example, in ICD-9, Ulcer of the limb was acceptable. In ICD-10, documentation

should provide the detail required to identify the specific area of the limb (i.e, thigh, calf,

ankle).

Laterality. In addition to site specificity, documentation should include the specific side

of the body impacted (right ankle, left calf).

When reporting ulcers using ICD-10-CM, the severity of the ulcer should be documented. For

non-pressure ulcers, the following levels should be included in the documentation:

Limited to breakdown of skin

Fat layer exposed

With Necrosis of muscle

With Necrosis of bone

With unspecified severity

For pressure ulcers, severity should use the National Pressure Ulcer Advisory Panel (NPUAP)

stages 1-4 and unstageable, listed below:

Stage 1: Pressure pre-ulcer skin changes limited to persistent focal edema

Stage 2: Pressure ulcer with abrasion, blister, partial thickness skin loss involving

epidermis and/or dermis

Stage 3: Pressure ulcer with full thickness skin loss involving damage or necrosis if

subcutaneous tissue

Stage 4 : Pressure ulcer with necrosis of soft tissues through to underlying muscle,

tendon, or bone

Unstageable: Based on clinical documentation pressure ulcers are those “whose stage

cannot be clinically determined (e.g., the ulcer is covered by eschar or has been

treated with a skin or muscle graft) and pressure ulcers that are documented as deep

tissue injury but not documented as due to trauma.”

Unspecified: The ICD-10-CM unspecified coding option is not considered a part of

the NPUAP staging but is provided for reporting when the documentation is

insufficient to assign a more specific code.

The Draft Guidelines note that if the documentation does not provide enough information to

stage the pressure ulcer, the provider should be queried. Pressure ulcers are not reported if they

are documented as healed.

5

Here is an example of the transition from ICD-9 to ICD-10 adding site specificity, laterality and

pressure ulcer stage:

DIAGNOSIS ICD-9 ICD-10 ICD-10 Description (if different)

Pressure Ulcer of ankle 707.06 L89.5 Category: Pressure ulcer of ankle

L89.500 Pressure ulcer of unspecified ankle, unstageable

L89.501 Pressure ulcer of unspecified ankle, stage 1




L89.509 Pressure ulcer of unspecified ankle, unspecified stage

L89.510 Pressure ulcer of right ankle, unstageable

L89.511 Pressure ulcer of right ankle, stage 1




L89.519 Pressure ulcer of right ankle, unspecified stage

L89.520 Pressure ulcer of left ankle, unstageable

L89.521 Pressure ulcer of left ankle, stage 1




L89.529 Pressure ulcer of left ankle, unspecified stage

6

Glaucoma ICD-10 Documentation for glaucoma includes two components:

Severity: Documentation should include severity of the disease:

o Mild

o Moderate

o Severe

o Indeterminate

Laterality: While not all ICD-10 codes require it, identify right, left, bilateral when

possible.


Primary open angle glaucoma 365.11 H40.11 Primary Open-angle glaucoma

H40.11X0 Stage unspecified

H40.11X1 Mild stage

H40.11X2 Moderate stage

H40.11X3 Severe stage

H40.11X4 Indeterminate stage

Acute angle-closure glaucoma 365.22 H40.21 Acute angle-closure glaucoma

H40.211 Right eye

H40.212 Left eye

H40.213 Bilateral

H40.219 Unspecified eye

7

Tears and Ruptures Documenting tears and ruptures for ICD-10 presents significant differences and increased levels

of specificity. Notable changes are:

Encounter/Episode of Care: Documentation must include whether the visit is defined

as initial, subsequent, or sequela.

Type of Tear: Documentation should include the type of tear, such as bucket-handle,

peripheral, or complex, as well as specific location, such as medial or lateral meniscus.

Laterality: Documentation should include whether the fracture is on the right or left side

of the body.

Acute/Chronic: As with ICD-9, documentation for ICD-10 should include

acute/chronic.

Below is an excerpt and partial list of the additional level of specificity needed for a tear of

medial cartilage or meniscus of knee:


Tear of medial cartilage or meniscus of knee, current

836 S83.2 Category: Tear of meniscus, current injury

S83.20 Tear of unspecified meniscus, current injury

836.2 S83.200 Bucket-handle tear of unspecified meniscus,

current injury, right knee

S83.200A -Initial encounter

S83.200D -Subsequent encounter

S83.200S -Sequela

S83.201 Bucket-handle tear of unspecified meniscus, current injury, left knee



S83.201S -Sequela

S83.202 Bucket-handle tear of unspecified meniscus, current injury, unspecified knee



S83.202S -Sequela

836.0 S83.21 Bucket-handle tear of medial meniscus, current

injury

S83.211 Bucket-handle tear of medial meniscus, current injury, right knee



S83.211S -Sequela

8

Neoplasm of Breast ICD-10 offers specific codes to identify laterality (right, left), site specificity (quadrant, specific

area), as well as gender (male, female). While the latter is typically provided in documentation

presently, it is important to note that ICD-10 does not provide an “unspecified” gender code for

malignant neoplasm conditions. Documentation which does not identify the gender for

Neoplasm of Breast cannot be processed without this identification.

Below is an example of the ICD-9 to ICD-10 transition based on gender identification, site

specificity, and laterality. Please note that unspecified codes for laterality and site specificity are

available.


Malignant Neoplasm of Breast C50 Category: Malignant Neoplasm of Breast

C50.0 Malignant neoplasm of nipple and areola

C50.011 Malignant neoplasm of nipple and areola, right female breast

C50.012 Malignant neoplasm of nipple and areola, left female breast

C50.019 Malignant neoplasm of nipple and areola, unspecified female breast

C50.021 Malignant neoplasm of nipple and areola, right male breast

C50.022 Malignant neoplasm of nipple and areola, left male breast

C50.029 Malignant neoplasm of nipple and areola, unspecified male breast

C50.2 Malignant neoplasm of upper-inner quadrant of breast

C50.211 Malignant neoplasm of upper-inner quadrant of right female breast

C50.212 Malignant neoplasm of upper-inner quadrant of left female breast

C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast

C50.221 Malignant neoplasm of upper-inner quadrant of right male breast

C50.222 Malignant neoplasm of upper-inner quadrant of left male breast

C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast

9

Fractures

ICD-10 coding for fractures represents some of the most significant changes in the transition

from ICD-9 to ICD-10. ICD-10 differentiates traumatic fractures from pathological fractures,

and requires increased specificity in the documentation including:

Encounter/Episode of Care: Documentation must include whether the visit is defined

as initial, subsequent, or sequela.

Open/Closed Fracture: Documentation must include a statement describing the fracture

as open or closed.

Classification: Depending on the fracture type, documentation may require the inclusion

of the Gustillo classification of the fracture (such as for an open traumatic fracture of the

long bone).

Fracture Pattern: Documentation should include fracture details such as transverse,

oblique, spiral, segmental, etc.

Alignment: Documentation must note the alignment of the bones, specifically whether

the fracture is displaced or Nondisplaced.

Site Specificity: Documentation should include additional specificity regarding the name

of bone and specific location of the fracture on the bone.

Laterality: Documentation should include whether the fracture is on the right or left side

of the body.

Healing: Documentation is required to identify whether healing is routine, delayed,

malunion or nonunion for each encounter.

10

Here is an example of the increased level of specificity needed in the documentation for ICD-10:

Documents

Common Anesthesia Diagnoses: ICD-9 to ICD-10 Mapping1 Introduction ICD-10 CM coding for anesthesia needs increased levels of specificity that should be included in physician documentation