ICD-10 6 Months Later - Kansas Home Care & Hospice … · Participants will understand the icd-10 chapters (first half) Review of each chapter to review the layout, ... Step 1- Look

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ICD-106 Months Later

Presented by

Sharon M. Litwin, RN, BSHS, MHA, HCS-D

Senior Managing Partner

5 Star Consultants, LLC

© 2016, 5 Star Consultants, LLC

Objectives - Day 1

ICD- 10 basics - participant will understand the differences with ICD-10 from ICD-9

Changes since OCTOBER in ICD-10- participants will understand the new rules for the 7 th character A, the excludes notes and other changes to date

Participants will understand the icd-10 chapters (first half) Review of each chapter to review the layout, how to find diagnoses,

Review challenging diagnoses

Review common diagnoses

ICD-10 Scenarios


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Objectives - Day 2

Participants will understand the icd-10 chapters (second half) Review of each chapter to review the layout, how to find diagnoses,

Review challenging diagnoses

Review common diagnoses

Participants will understand the reasons seen for RTPs (billing rejections) and possible denials

ICD-10 Scenarios



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Why on Earth did we change to ICD-10 ?

ICD-9 codes provide limited data about patients’ medical conditions and hospital inpatient procedures

ICD-9 is 30 years old, has outdated and obsolete terms, and is inconsistent with many current medical practices

Many ICD-9 categories are full

ICD-10 Codes have greater specificity and exactness in describing a patient’s diagnosis ICD-10 has many more codes with “one to many” matches to ICD-9 in many instances

Easier to “talk” the same language as other countries on ICD-10


DIFFERENCES

ICD-9- 14,315 diagnosis codes

ICD-10- 69,099 diagnosis codes WOW!

21 chapters including all letters, A to Z (except U)

Much more detailed knowledge of anatomy and physiology will be needed.

Much more specificity is needed in documentation from physician and clinician in order to choose the right diagnoses and follow the new coding rules and guidelines.

Any yet with all these codes, there are some you just cant find!


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DIFFERENCES

Surgical Procedures

ICD-9 – 3,838 ICD-10 – 71,957

Significantly more complex and specific!

BUT SIGH OF RELIEF!!!!!!!!!!!!!Homecare and Hospice do not have to do!!!!!


DIFFERENCES

Added 7th Character for Episodes of Care- much more on this later!

A—Initial encounter – originally said not to be used in HC & HP-rules changed!

D—Subsequent encounter S—Sequela- (Late effects)

Changes in time frames Ex: Acute Myocardial Infarction—time period changed from 8 to 4 weeks

Injuries Grouped by Anatomical Site


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DIFFERENCES

ICD- 9 ICD-10

3-5 characters in length 3-7 characters in length

First character is numeric or alpha (E or V)

First character is alpha (all letters except U)

Characters 2-5 are numeric Character 2 is numeric; Characters 3-7 are alpha or numeric

No placeholders Use of dummy place holder ‘X’

Alpha characters are case sensitive Alpha characters are NOT case sensitive© 2016, 5 Star Consultants, LLC

General Coding Differences

Injuries grouped by anatomical site

Post-Op complications moved to separate chapter

Manifestation codes- some together in one code E11.40 -Type 2 diabetes mellitus with diabetic neuropathy,

unspecified

Unlike in ICD-9 in which you use 2 codes:

250.60- DM with neurological manifestations, followed by 357.2-polyneuropathy in DM


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Combination Codes –AHD of native coronary artery with unstable angina

ICD -10 I25.110In ICD-9 there are 2 codes:

414.00- CAD, and 413.9- angina

Poisonings and External Causes T36.0x1D- Poisoning by penicillin, accidental, subsequent encounter

ICD-9 - various codes -Poisoning -Effect

-E code for Accidental© 2016, 5 Star Consultants, LLC


E Codes have been replaced with T, W, X and Y Codes, all of which appear in the tabular list

Fractures! Will code for homecare! The 7th digit of the acute fracture must show that it's the subsequent encounter.

Laterality- Code specific location, i.e., left and right

Nonspecific codes fewer in number but still available if not enough info to code specifics (will pay less in some cases)

Code descriptions have changed in some cases

ex: Diabetes is no longer classified as controlled/ uncontrolled


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Guidelines Accompany Code Set

ICD-10-CM Official Guidelines for Coding and Reporting set conventions and instructions

To ensure accurate coding, providers must use these guidelines in conjunction with the code set

Adherence to the official coding guidelines in all health care settings is required under HIPAA


Guideline Examples

For assignment of hemiplegia/hemiparesis, if the documentation specifies which side is affected but not whether it is the dominant or non-dominant side, code selection is guided by the following: If the right side is affected, code as dominant

If the left side is affected, code as non-dominant

When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, assign the appropriate code for each eye rather than the code for bilateral glaucoma


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Guidelines - Laterality

Laterality (which side of the body is affected) has been added in

ICD-10-CM to allow better identification of anatomic site

If condition is bilateral but only one side of focus of treatment during current encounter, assign bilateral code

Do Not put Unspecified for Laterality


Guidelines- Use of 7th Character

7th character is not used in all ICD-10-CM chapters

Used in Musculoskeletal, Obstetrics, Injuries, External Causes chapters

Different meaning depending on section where it is being used

Must always be used in the 7th character position use dummy placeholder ‘X’ if code is less digits

When 7thcharacter applies, codes missing 7th character are invalid


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Guidelines – 7th character S (Sequela)

Sequela (Late Effect): Residual effect (condition produced) arising as a direct result of an acute condition

Examples: Traumatic arthritis following previous gunshot wound

Quadriplegia due to spinal cord injury

Skin contractures due to previous burns

Auricular chondritis due to previous burns

Chronic respiratory failure following drug overdose


CMS Coding example- 7th CharacterDisplaced fracture of medial malleolus, right ankle

Step 1- Look up term in Alphabetic Index: Fracture, traumatic - ankle, medial malleolus (displaced) S82.5- Step 2- Verify code in Tabular: S82 Fracture of lower leg, including ankle Note: A fracture not indicated as displaced or nondisplaced should be coded to

displaced Note: A fracture not indicated as open or closed should be coded to closed Assign laterality The appropriate 7th character is to be added to all codes from category S82

Code Assignment: S82.51xD WHAT DOES THE 1 IN THE 5TH DIGIT MEAN? WHAT DOES THE X IN THE 6TH DIGIT MEAN? WHAT DOES THE D IN THE 7TH DIGIT MEAN?


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Changes in guidance for ICD 10 to date“A” Character Usage

Many codes require 7 digits

7th digit is typically A, D, S

A has meant Initial Encounter D is Subsequent Encounter – and has primarily been for homecare & hospice

S is Sequela- Late Effect- used for residual symptoms

Home Health has Not been able to use “A” characters in 7th digit before and therefore have not received case mix rates for the ‘A’ character.

This has been challenged and has been revised!



In the January 1 Final Rule for Homecare there are case mix diagnoses given for codes with 7th digit of “A”!

The Guidance has been changed so that now we will think of “A” character as “Active Treatment”

This “Active Treatment” does NOT mean routine homecare, so MAY be used fairly infrequently

Main example given is: post op infection requiring homecare for wound vac and/or IV antibiotics

Therefore , “D” for subsequent is still the most common 7th character


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Chapter 19 – Injury, poisoning and certain other consequences of external causes –New Guidelines Most of the codes in chapter 19 have 7 characters

While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

Whether or not the patient is still receiving active treatment is key

A = Disregard what we have been taught- Initial encounter It is ACTIVE that matters now!


Chapter 19 – Injury, poisoning and certain other consequences of external causes –New Guidelines

For complication codes, Active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem.

For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter.


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7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician

7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.



Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician

Additional examples of “initial” encounter (examples of active treatment)

Antibiotic therapy for postoperative infection

Wound vac treatment of wound dehiscence


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CMS example- 7th CharacterPatient admitted to home health care where antibiotic treatment for a postoperative wound infection continues to be administered

T81.4xxA, Infection following a procedure, initial encounter

S72.002D, Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing


Z & S

The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th

character “D” (subsequent encounter).

7th character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character “S”, it is necessary to use both the injury code that

precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S”

identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.


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Recerts and ROCs – 7th character

Documentation from previous encounter – May NOT be used to determine 7th character

The SOC or a previous Recert or ROC may have had ACTIVE treatment , such as wound vac and IV antibiotics for infection, but this may not be carried to the subsequent episodes if the ACTIVE treatment is resolved.

So this could mean that now the pt is on oral antibiotics and simple dressing changes for this recert. Therefore, “A” would not be used as 7th character, a “D” for subsequent is now to be used!


CMS - Guidelines- Unspecified codes

Each healthcare encounter should be coded to the level of certainty known for that encounter

•Unspecified codes should be reported when they most accurately reflect what is known about the patient’s condition at the time of that particular encounter

When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code

•Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter


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Unspecified Codes Still Acceptable

It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code

These guidelines are part of the ICD-10-CM Official Guidelines for Coding and Reporting, which all HIPAA-covered entities must comply with


Common Unspecified Codes

Heart Failure (CHF)- ICD-9: 428.0 ICD-10: I50.9 Anemia- ICD-9: 285.9 ICD-10: D64.9Abdominal pain- ICD-9: 789.00 ICD-10: R10.9Stroke, sequela unspecified-ICD-9: 438.9 ICD-10: I69.3

Angina- ICD-9: 413.9 ICD-10: I20.9Chronic obstructive pulmonary diseaseICD-9: 496 ICD-10: J44.9


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“Unspecified” Coding Example

Chest pain

Step 1 Look up term in Alphabetic Index: Pain, chest (central) R07.9

Step 2 Verify code in Tabular: R07.9 Chest pain, unspecified


Guideline Examples

For assignment of hemiplegia/hemiparesis, if the documentation specifies which side is affected but not whether it is the dominant or non-dominant side, code selection is guided by the following:

If the right side is affected, code as dominant

If the left side is affected, code as non-dominant

When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, assign the appropriate code for each eye rather than the code for bilateral glaucoma


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Excludes 1 & 2 Notes- Changes in Guidance

Excludes 1: An excludes 1 note is a pure excludes note. It means “NOT CODED HERE”

Indicates the codes listed should never be used at the same time as the code above the Excludes 1 notes.

Is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition

Excludes 2 : An excludes 2 note represents “NOT INCLUDED HERE”. Indicates the condition excluded is not part of the condition

represented by the code, but a patient may have both conditions at the same time


Changes to Excludes 1 Notes –Non Related Diagnoses

If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note.

For example, the Excludes1 note at code range R40-R46, states that symptoms and signs constituting part of a pattern of mental disorder (F01-F99) cannot be assigned with the R40-R46 codes.

However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and bipolar disorder.


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Changes to Excludes 1 Notes-Non Related Diagnoses

In another example, code range I60-I69 (Cerebrovascular Diseases) has an Excludes1 note for traumatic intracranial hemorrhage (S06.-).

Codes in I60-I69 should not be used for a diagnosis of traumatic intracranial hemorrhage.

However, if the patient has both a current traumatic intracranial hemorrhage and sequela from a previous stroke, it would be appropriate to assign codes from S06- and I69-.


External Causes of Morbidity- ICD-10-CM codes in Chapter 20 V,W,X,Y

No national requirement for mandatory ICD-10-CM external cause code reporting

Reporting of, External Causes of Morbidity

Provide valuable data for injury research and evaluation of injury prevention strategies

•External cause of injury data are used at the national, state, and local levels to identify high-risk populations, set priorities, and plan and evaluate injury prevention programs and policies, and are potentially useful for evaluating Emergency Medical Services (EMS) and trauma care systems

Some coders spend Hours trying to find very specific code out of these thousands. Put this in perspective when you are coding …………………


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Clinician Documentation

What is needed in Documentation & Practice to succeed with ICD-10


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Biggest Challenges

Getting the specific information and diagnoses in referral info- H&P, Consultation reports, FTF, DC summaries from physicians

Intake staff need to work closely with referral sources to get as complete information as possible at referral Request the documents you want that will give you the best physician confirmed information and diagnosesEx: hospice agency that gets 60 pages of SNF daily

clinician notes


Biggest Challenges

Clinicians need to document detailed assessment information If unsure of any diagnosis information then Must query the

physician to get clarificationExamples: wound types, if neuropathy is from the diabetes

Best to do at end of admission assessment- give report and get clarification of diagnoses, as well as meds, etc.


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Physician confirmation of Diagnoses

All diagnoses on the plan of care must be documented in the medical record by the physician

These may be in the FTF and/or H&P, Discharge summaries, Diagnoses List, etc

If Diagnoses are not in these documents, then they are to be documented as having been confirmed with the physician by the HHA.

Diagnoses are not coded based solely on medications, treatments, or patient/caregiver report without contacting the physician to confirm in most cases


CMS says Assessing Clinician is the one responsible for diagnosis selection& sequencing of diagnoses

Assessing clinician: Reads the referral information from physicians, hospitals

etc: H&P, Discharge Summaries, Consultation Reports

Completes the patient’s comprehensive assessment to get the “story of the patient”.

Contacts physician for report, pt adverse s/s, and clarification needs on meds, wounds, diagnoses, etc.


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CMS says Assessing Clinician is the one responsible for diagnosis selection& sequencing of diagnoses

Assessing clinician:

Identifies primary diagnosis and secondary diagnoses and sequencing (order of diagnoses)

This can be listed in the narrative, does Not have to be entered into the M1021/23 spots or have the codes.

Then the clinician information goes to the Coder.

Coder will review and enter the diagnosis with appropriate coding.

Coder will “collaborate” with the assessing clinician on any recommended changes based on the coding rules and guidelines.


Clinician documentation to code without physician verification

There are 3 areas that are coded by what the clinician assesses and identifies and then documents:

Body Mass Index (BMI) Pressure ulcer stages Depth of tissue damage in non-pressure chronic ulcers


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Body Mass Index (BMI)

Hospice patients should have a BMI done by the clinician (on most patients).

BMI will be coded on SOC and recerts Homecare patients with diagnoses and signs/symptoms relating

to weight, and/or to diagnoses should have a BMI performed by the clinician also. Then this will then be coded by the coder.

The physician does not have to confirm the BMI.


Pressure ulcer stages

The clinician will have to be knowledgeable in wound assessment in order to identify the stage of the patient’s pressure ulcers.

The agency should provide WOCN and NPUAP inservices(with pictures) on pressure ulcer stages for the clinicians to be able to accurately stage pressure ulcers.

Often there will be documentation of stages of pressure ulcers in the referral documentation. If the clinician assesses that the stage is different that what is in the referral documentation, then the physician should be notified for clarification.


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Coding Wounds- Non Pressure Wounds Depth

ICD-10 codes – L97 for non-pressure wounds, require the depth of tissue affected by the wound including diabetic, arterial and venous stasis ulcers

The L97 codes combine the site and the depth:

L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed The 6th character 1 indicates right leg, and the 7th digit 2 indicates fat layer

depth

The clinician is responsible for assessing depth and documenting it. Unspecified should be rarely used! Agency needs to provide clinician with inservice (and pictures) to allow

the clinician to be accurately assessing the depth of non pressure wounds.


Codes for depth of non pressure wounds

L97.201 - Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin

L97.202 - Non-pressure chronic ulcer of unspecified calf with fat layer exposed

L97.203 - Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

L97.204 - Non-pressure chronic ulcer of unspecified calf with necrosis of bone

L97.209 - Non-pressure chronic ulcer of unspecified calf with unspecified severity- USE RARELY!


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Wound TypesAlthough the clinician assesses the pt wounds and identifies the types- this should always be confirmed with physician documentation – from referral information, wound clinic, or clarifying with the physician.

Wound Types - Most common area that Coder cannot code because of lack of specific information or inconsistencies!

Commonly due to non specific site, type of wound, stage of pu and / or depth of non pressure ulcer. ICD-10 is much more specific

Non Pressure Ulcers - Diabetic, Arterial, Venous

Pressure Ulcers

Trauma Wounds- open wounds from Laceration, Abrasion, Puncture, etc-

Surgical Wounds – aftercare or complications

Superficial Wounds – Skin tears


Recerts and ROCs – 7th character-clinician documentation

Since documentation from previous SOC/ROC/Recert May NOT be used to determine 7th character, the documentation Must be specific !

Previously patient may have had ACTIVE treatment , such as wound vacand IV antibiotics for infection, but this may be resolved.

IF the pt is Now on oral antibiotics and simple dressing changes for this recert, “A” would not be used as 7th character, a “D” for subsequent is now to be used

The clinician must document this well in OASIS, narrative, 60 day summaries etc so that the coder knows if an “A” or a “D” would be used for this episode.


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Excludes 1 Notes- Changes in Guidance

CHANGE IN GUIDANCE: If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes 1 note.

SO…..the physician and clinician must document if they are Not related so we know to code both diagnoses


CVA - document the residuals

Still cannot code acute CVA in HH coding. Acute is only coded in M1011- code for hospitalization and M1017- code for changes in dx and med tx in past 14 days.

HH codes the sequela (late effects) of the CVA so the Clinician Must document residuals for both Homecare AND Hospice See a lot of documentation from clinician re CVA, but with no residuals noted.

If NO residuals present in pt, then it is a history of CVA code

SO be sure to document specific residuals

Hemiplegia – which side is affected and which side if dominant?

Need to have physician documentation or confirmation that the “residuals” (Cognitive, dysphagia, speech, seizures. –other as muscle weakness) are indeed residuals related to the CVA so can be coded as sequlea of CVA


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Heart Failure

CHF is coded as heart failure, unspecified. This is still acceptable and Is a case mix diagnosis.

BUT Always document and code the most specific type of heart failure when that is documented:

Congestive systolic diastolic Acute on chronic Systolic and diastolic New info on pleural effusion- pleural effusion in heart

failure is coded in i50, heart failure, and not coded as pleural effusion in J91.0


Heart disease / diagnoses

CAD / ASHD is combination code stating if pt has angina pectoris or not: Atherosclerotic heart disease of native coronary artery without angina pectoris or

Atherosclerotic heart disease of native coronary artery with angina pectoris

Clinician needs to document on a CAD pt if pt has angina pectoris or not

Acute Myocardial Infarction— Time period changed from 8 to 4 weeks so need to document the specific date the patient had

the MI.

Also need to know if MI is stemi or non stemi in order to code an MI, so will have to query physician if this is not in the referral documentation.

Must include a code for a patient’s current or past nicotine use when assigning certain respiratory and cardiac codes in ICD-10- so document specific – history, dependence, etc.


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Infections

Sepsis – have to document if the patient continues to have sepsis when comes home

Severe sepsis (with organ dysfunction or organ failure) If the organ dysfunction related to the sepsis, then automatically

severe sepsis. So needs to be documented

Infections—what’s the organism? If you know, document so can be coded

Is the infection a complication of a surgical procedure? Need confirmation from the physician to code this!


Neoplasms

Need specific documentation on:

Sites – be specific instead of Lung Cancer, need which lung, which lobe if possible.

Laterality is needed

If post-op, state if neoplasm is eradicated

Document if pt on further treatment and if so , chemo and/or radiation

Document if remission, relapse etc- leukemia is type that needs this to code

Often see: pt has lung CA. then in narrative from clinician states in comorbidities that pt has had prostate CA. is this primary site and now lung CA is secondary (mets)? Is prostate ca active? Or is it a history code?

Need specifics!© 2016, 5 Star Consultants, LLC

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Conclusion

Clinicians need to understand key points of ICD-10 in order to know what needs to be confirmed with physician, what needs to be assessed and documented in order to code.

Be specific in your documentation! Laterality, wound types and depth, types of specific diagnosis, treatments for diagnoses, etc.

If getting bare info from referrals, talk to management and intake to see what can be done to have more.

Be sure to READ all referral info prior to your SOC patient assessment

If not clear on a diagnosis, Must confirm with the physician!



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ICD-10 Chapters


Tabular Coding Chapters

A,B – Infectious and parasitic diseasesC – NeoplasmsD – Neoplasms & blood and blood forming organsE – Endocrine, nutritional, and metabolicF – Mental and behavioral disordersG – Nervous systemH – Eye and adnexa, ear and mastoid processI – Circulatory systemJ – Respiratory systemK – Digestive system


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L – Skin and subcutaneous tissue

M – Musculoskeletal and connective tissue

N – Genitourinary system

O – Pregnancy, childbirth, and the puerperium

P – Perinatal period

Q – Congenital malformations, deformations and chromosomal abnormalities

R – Symptoms, signs and abnormal clinical and laboratory findings



S,T – Injury, poisoning and certain other consequences of external causes

U – Reserved by WHO for emergency codes

V,W,X,Y – External causes of morbidity

- How were they hurt

- Where they were when they were hurt

- What activity were they doing

- External cause status

Z – Factors influencing health status and contact with health services


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Chapter 1: Certain Infectious & Parasitic Diseases (A00-B99)


Notes at beginning of chapter: diseases generally recognized as communicable or transmissible diseases

Includes: Intestinal infectious diseases, TB, Bacterial diseases, STDs, Viral infections and hemorrhagic fevers, Herpes viruses, Viral Hepatitis, HIV, Sequelae of infectious and parasitic diseases

Use additional code to identify resistance to antimicrobial drugs (Z16._) following the infection code if the infection code does not identify the drug resistance.

Z16.11 Resistance to penicillins - Clarifying Terms: Resistance to amoxicillin Resistance to ampicillin

Z16 - Excludes 1 notes

Methicillin resistant Staphylococcus aureus infection (A49.02)

Methicillin resistant Staphylococcus aureus infection in diseases classified elsewhere (B95.62)

Methicillin resistant Staphylococcus aureus pneumonia (J15.212)

Sepsis due to Methicillin resistant Staphylococcus aureus (A41.02)

Code First (Z16)

the infection


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Coding Sepsis

Urosepsis (referring to urinary tract infections), is the most common sepsis diagnosis seen in home health and is removed from ICD-10.

The reason it is removed is that the ICD Official Guidelines state, “Urosepsis is a nonspecific term.”

Physicians need to clarify if pt has a UTI, bladder infection or bloodstream infection


Septicemia is mainly removed in ICD-10

Code A41.9 (Sepsis, unspecified organism) includes Septicemia NOS as a clarifying term

That is the only place you’ll find “septicemia” listed anywhere in the ICD-10 tabular listing.

The ICD-10 alphabetical index redirects coders looking to code septicemia. A search for that term yields A41.9 but also tells them: “meaning sepsis — see sepsis.”


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Combination codes mean greater specificity in ICD-10

There are primarily combination codes for sepsis in ICD-10.

Example: ICD-9 codes 995.92 (Severe sepsis) and either 785.52 (Septic shock) or 998.02 (Postoperative septic shock) are used to indicate septic shock.

In ICD-10 code, R65.21 (Severe sepsis with septic shock) or T81.12 (Postprocedural septic shock) is used.


Combination codes mean greater specificity in ICD-10

Example: ICD-9 Streptococcal septicemia code 038.0 maps to 5 different codes in ICD-10 category A40 (Streptococcal sepsis) that allow agencies to specify the type of infection:• A40.0, Sepsis due to streptococcus, group A• A40.1, Sepsis due to streptococcus, group B• A40.3, Sepsis due to Streptococcus pneumoniae• A40.8, Other streptococcal sepsis • A40.9, Streptococcal sepsis, unspecified© 2016, 5 Star Consultants, LLC

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Chapter 1: Certain Infectious & Parasitic Diseases (A00-B99)

Scenarios


Chapter 2: Neoplasms(C00-D49)


• Classifies neoplasms primarily by site (topography) with broad groupings for behavior, malignant, in situ, benign, etc

• The table of neoplasms should be used to identify the correct topographical code.

• There are some examples where the morphology types are just included in the alpha index- ex: malignant melanoma

• Z85 codes are for personal history of CA (V10 codes)

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Aftercare following surgery for neoplasm

As in ICD-9, coding aftercare following surgery to remove a neoplasm in ICD-10 requires a code for the aftercare following the surgery, as well as a code for the neoplasm itself

Ex: Diagnosis of malignant neoplasm of the breast: first code is Z48.3 (Aftercare following surgery for neoplasm) followed by the

code for the specific neoplasm IF still exists. Malignant neoplasm of an unspecified site of the right female breast, the ICD-

10 code is C50.911 May not know site within the breast, but Always code laterality (6th digit) 5th digit 1 is female, 2 would be male Code Z17.0 (Estrogen receptor positive status), when known, as ICD-10

requires use of an additional code to indicate the patient’s estrogen receptor status.


Neoplasm Table


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Primary Secondary In Situ Benign Uncertain Behavior

Unspecified

Lung C34.9 C78.0 D02.2 D14.3 D38.1 D49.1

Azyos lobe

Carina

Hilus

Lingual

Lobe NEC

Lower lobe

Main bronchus

Middle lobe

Overlapping lesion

Upper lobe

Other Common Neoplasms seen in Homecare & Hospice

Primary Secondary

Pancreas C25.9 C78.89

Colon C18.9 C78.5

Prostate C61 C79.82

Multiple Myeloma C90.0 Not found in Neoplasm table


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Chapter 2: Neoplasms(C00-D49)

Scenarios


Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)

D50-53 Nutritional anemias

D55-59 Hemolytic anemias

D60-64 Aplastic & other anemias & other bone marrow failure syndromes

D65-69 Coagulation defects, purpura, & other hemorrhagic conditions

D70-77 Other disorders of blood & blood forming organs

D78 Intraoperative & postprocedural complications of the spleen

D80-89 Certain disorders involving the immune mechanism


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Common chapter 3 codes

D51- Vitamin B12 deficiency anemia Includes Six 4 character codes for pernicious anemia (D51.0) as well as vitamin

B-12 malabsorption, dietary B 12 etc.

D63.0- Anemia in neoplastic disease Code first the neoplasm (C00-D49)

D63.1- Anemia in chronic kidney disease Code first the CKD (N18.-)

D64.9- Anemia, unspecified – COMMON as often we don’t get specifics

D69.8- Thrombocytopenia, unspecified


Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)

Scenarios


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Chapter 4: Endocrine, Nutritional and Metabolic diseases (E00-E89) E00-07 – Disorders of thyroid gland E08-13 – Diabetes Mellitus E15-16 – Other disorders of glucose regulation & pancreatic internal secretions E20-35 – Disorders of other endocrine glands E36 – Intraoperative complications of endocrine system E40-46 – Malnutrition E50-64 – Other nutritional deficiencies E65-68 – Overweight, obesity & other hyperalimentation E70-88 – Metabolic disorders E89 – Postprocedural endocrine & metabolic complications & disorders, not

elsewhere classified


Coding Diabetes

Diabetes mellitus coding in ICD-10 can be much more specific than in ICD-9.

Most diabetes codes in ICD-10 are combination codes that include not only the underlying etiology and the type, but the specific manifestation as well.

There are 5 code categories instead of the 2 code categories (249 and 250) in ICD-9.


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Diabetes - Manifestations

Need documentation from the physician or query them to identify if a diagnosis is separate or a manifestation of the Diabetes

They cannot be assumed to be manifestation, including:

Retinopathy, nephropathy, neuropathy

No longer assumptions with gangrene and osteomyelitis

Confirm foot ulcers and skin ulcers are manifestation of Diabetes or separate wound

Document specifically re these diagnoses so that coder knows if these diseases are part of the diabetes or not.


Coding Diabetes

Five code categories signifying primary and secondary diabetes mellitus are:

E08 – Diabetes mellitus due to underlying condition

E09 – Drug or chemical induced diabetes mellitus

E10 – Type 1 diabetes mellitusE11 – Type 2 diabetes mellitusE13 – Other specified diabetes mellitus


42

Coding Diabetes Combination Codes

Type 2 diabetes mellitus with diabetic polyneuropathy

Type 2 diabetes mellitus with diabetic gangreneType 2 diabetes mellitus with foot ulcer

Type 2 diabetes mellitus with other skin ulcer Use additional code for the ulcer

E11.64- HypoglycemiaE11.65- Hypergylcemia (see next slide)D11.69- Other manifestations – use additional code to identify the complication

Ex: Diabetic Osteomyelitis – code with an M86 code following E11.69


Diabetes with Hyperglycemia

Uncontrolled diabetes codes are not in ICD-10 In ICD-10, when a patient’s diabetes is described as “uncontrolled,” it is coded

as “diabetes with hyperglycemia”. Alphabetic index listings for “poorly controlled” diabetes and “out of control”

diabetes all lead to the same place — “diabetes, by type, with hyperglycemia.” Diabetes stated as “poorly controlled” could not be coded as uncontrolled,

whereas Hyperglycemia is a broader term that points to persistently high blood sugar versus a hard definition of uncontrolled.

The physician must specify that the patient’s diabetes is poorly controlled, uncontrolled or out of control, but all can be coded as diabetes with hyperglycemia

Do not code diabetes with hyperglycemia based on a few high blood glucose readings without a physician’s statement that the hyperglycemia is persistent


43

Diabetes- HgA1C

The MAC’s are now are requesting that HH clinical records include HgA1C on all diabetic patients. It is in the LCD (local coverage determination) for Diabetes in Palmetto.

And Palmetto has begun giving denials if it is not documented in the HH record.

So be sure to contact the physician’s office to get the most recent results.

HgA1C test results measures a patient’s blood sugar over time and most physicians do order this lab test regularly on their Diabetic patients.


Coding Diabetes- ex: ICD-9 took3 codes and ICD-10 takes 1!

Diabetes type 2 with macular edema and unspecified retinopathy.

ICD-9 250.50 Diabetes with ophthalmic manifestations,

type II or unspecified type, not stated as uncontrolled

362.07 Diabetic macular edema362.01 Background diabetic retinopathy

ICD-10E11.311 Type 2 diabetes mellitus with

unspecified diabetic retinopathy with macular edema


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Chapter 4: Endocrine, Nutritional and Metabolic diseases (E00-E89)

Scenarios


Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-99) F01-09 – Mental disorders due to known psychological conditions F10-19 – Mental & behavioral disorders due to psychoactive substance use F20-29 – Schizophrenia, schizotypal, delusional & other non- mood psychotic disorders F30-39 – Mood (affective) disorders F40-48 – Anxiety, dissociative, stress-related, somatoform & other nonpsychotic mental

disorders F50-59 – Behavioral syndromes associated with physiological disturbances & physical

factors F60-69 – Disorders of adult personality & behavior F70-79 – Intellectual disabilities F80-89 – Pervasive & specific developmental disorders F90-98 – Behavioral & emotional disorders with onset occurring in childhood &adolescent F99 – Unspecified mental disorder


45

Dementia

F01 – Vascular dementia Vascular Dementia – in Hospice - cannot be primary diagnosis - the underlying physiological

condition or sequelae of cerebrovascular disease should be the primary terminal diagnosis. Vascular dementia must be specified by the physician and may also be reported as "multi-infarct

dementia." In this case it should be coded as a sequelae of cerebrovascular accident (stroke).

This type of dementia also may be related to other cerebral vascular disorders including vascular hypertension and cerebral atherosclerosis.

If the patient has not had a stroke, query the physician regarding conditions as causes of vascular dementia.

Code first the underlying physiological condition or sequelae of CV disease,

ex: I69.31 Cognitive deficits following cerebral infarction

F01.50- without behavioral disturbance

F01.51 – with behavioral disturbance.


Dementia

Use Z91.93 if wandering documented

F02- Dementia in other diseases classified elsewhere- F02.80 or F02.81 Code first the underlying physiological condition, such as Alzheimers

Excludes dementia w/Parkinsonism (G31.82)

F03- Unspecified dementia Includes senile dementia and presenile dementia

Excludes 1 – senility (R41.81 – Symptom Code)

F03.90 without behavioral disturbance [Dementia NOS]

F03.91 with behavioral disturbance


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Common Chapter 5 codes

Major Depressive disorder F32.- Single episode

Has 8 codes differentiating mild, moderate, severe w/o psychotic features, severe with psychotic features, in partial remission, in full remission, other depressive episodes and major depressive disorder

F32.9- Unspecified ( Depression NOS, Depressive disorder NOS, Major Depression NOS)

When physician documentation specifies depression with anxiety, F41.8 should be assigned.

F41.9 – Anxiety NOS F41.1 – General anxiety disorders F31.9- Bipolar disorder, unspecified


Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-99)

Scenarios


47

Chapter 6: Diseases of the Nervous system - (G00-G99)


Common Codes:

G20- Parkinson’s Disease

G30 – Alzheimer’s Disease

G30.0- Alzheimers’ with early onset

G30.1 – Alzheimer’s with late onset

G30.9 – Alzheimer’s disease , unspecified

G35 – Multiple Sclerosis

G40 – Epilepsy &recurrent Seizures

R56.9 = 780.39 - Seizure NOS, unspecified convulsions – S/S chapter

Alzheimer’s – with dementia is most common. Must have physician documentation of Alzheimers

Do not code early or late based on patient’s age- must be specified by Dr.

Includes Alzheimer's dementia senile and presenile forms Excludes 1 (what does that mean? )

senile degeneration of brain NEC (G31.1)

senile dementia NOS (F03)

senility NOS (R41.81)

Use Additional Code to identify: delirium, if applicable (F05)

dementia with behavioral disturbance (F02.81)

dementia without behavioral disturbance (F02.80)© 2016, 5 Star Consultants, LLC

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Parkinsons Disease is Different than Parkinsonism/Lewy body dementia

Excludes 1 note! Can’t code both together

Be sure to get physician confirmation if both are documented

See this frequently in hospice as interchangeable terms when they are not

Parkinsonism, also known as Lewy Body Dementia, (G31.83) has symptoms similar to Parkinson's Disease. Dementia with Parkinsonism

Lewy body dementia

Lewy body disease


Multiple Sclerosis- G35

G35 should be listed primary when patient is being seen for more than one aspect of the disease.

Don’t code symptoms integral to MS Eg: don’t typically code: spasms, muscle weakness, decreased range of motion

in joints, poor functional mobility and an ataxic gait pattern.

But you would code neurogenic bladder, and a history of urinary tract infections.


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G45.9 Transient cerebral ischemic attack, unspecified (TIA)

Category G45.- is reserved for acute settings only. In home health, it may be placed in M1011 and/or M1017, but not M1021, M1023 or M1025.

ICD-10 does not include a code for TIA with residual deficits since the term TIA indicates that the condition was transient.

A history of a TIA should be coded to Z86.73, personal history of TIA and cerebral infarction without residual deficit.


Chapter 6: Diseases of the Nervous system - (G00-G99)

Scenarios


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Chapter 7- Diseases of the eye and adnexa (H00-H59) H40 codes- Glaucoma

H54 codes – Blindness and Low Vision

H35 codes- Macular degeneration

Chapter 8- Diseases of the ear and mastoid process (H60-H95)

H65 & 66- Otitis media H68 & 69- Eustachian disorders H70- Mastoiditis disorders


Chapter 7 & 8 - Diseases of the eye and ear

Scenarios


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Chapter 9: Diseases of the Circulatory system (I00-I99) I00-02 – Acute rheumatic fever I05-09 – Chronic rheumatic heart diseases I10-15 – Hypertensive heart diseases I20-25 – Ischemic heart diseases I26-28 – Pulmonary heart disease & diseases of pulmonary circulation I30-52 – Other forms of heart disease I60-69 – Cerebrovascular diseases I70-79 – Diseases of arteries, arterioles & capillaries I80-89 – Disease of veins, lymphatic vessels & lymph nodes, not elsewhere

classified I90-99 – Other & unspecified disorders of the circulatory system


Hypertensive diseases (I10-15)

Notes at top of this section:

Use additional code to identify:

History of tobacco use (Z87.891)

Tobacco dependence (F17._)

Tobacco Use (Z72.0)

Similar rules as with ICD9:

ICD 10 presumes a cause and effect relationship between CKD (N18) and HTN.


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Atherosclerotic Coronary Artery Disease and Angina Causal relationship can be assumed with both

Combination codes

I25.11- Atherosclerotic Coronary Artery Disease with Angina pectoris

I20-25- Ischemic heart diseases Use additional code for HTN (I10-15)

I20- Angina pectoris

I25- Chronic ischemic heart disease

I25.5- Ischemic cardiomyopathy


Coding Acute MIs

- Code a myocardial infarction (MI), as an acute condition with a code from the I21 series (ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction) only if the event occurred within 4 weeks of the home care admission

- If the MI is older than 4 weeks code with the history code I25.2 (Old myocardial infarction)- Assign code I25.9 (Chronic ischemic heart disease, unspecified) for a patient whose MI is more than four weeks old, but who is still experiencing MI symptoms- Ensure documentation states the specific type of MI suffered either an ST elevation MI or a non-ST elevation MI. The I21 series in ICD-10 requires differentiating between the two.


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Other common circulatory

I48 - Atrial fibrillation I50 – Heart Failure codes I50.9 – Heart failure , unspecified (CHF 428.0) Use more specific code for type of heart failure I60-69 - Cerebrovascular diseases I73.9 – Peripheral vascular disease (443.9) I82.401 - Acute embolism and thrombosis of unspecified deep veins of right

lower extremity (453.40) I87.2 – Venous insufficiency , chronic, peripheral I89.0 - Lymphedema (457.1)


Coding Late Effects (Sequelae)

- In ICD-10 Late Effects are categorized using the term Sequelae.

- Sequelae are the residual deficits that remain after an acute illness or injury.

- Sequela means one deficit, while sequelae are the plural form of the word.

- To find the right code in ICD-10, instead of searching for the “late effect of a particular illness or injury”, search for the term sequelae in the alphabetic index.


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Similar to in ICD-9, there are codes that incorporate the underlying etiology and late effect/sequelae into one code, such as I69.320 (Aphasia following cerebral infarction).

There are other late effects, or sequelae, that require two codes: the code to represent the sequela or residual, and the code to describe what caused it.

Example: ICD-10 code G40.909 describes a seizure disorder, and when paired with S06.5x9S, it’s indicated that it was

caused by a traumatic subdural hematoma. Note that the seventh character “S,” (for “sequela”) on the S06.5x9S code shows that the hematoma is no longer an active diagnosis but one that caused a sequelae condition.© 2016, 5 Star Consultants, LLC


The general rules to coding late effects/sequelae in ICD-10 remain the same as in ICD-9. If the acute illness or injury that caused the late effect/sequela still exists, code the acute form of illness or injury followed by the specific condition, the sequela that remains.

Example: if a patient has a traumatic subdural hematoma that results in a seizure disorder, and the subdural hematoma still

exists at the start of the home health episode, you would code the active form of the subdural hematoma (S06.5x9D) followed

by the seizure disorder (G40.909).

The seventh character “D,” for “subsequent encounter,” on the subdural hematoma code (S06.5x9D) indicates that the

condition is still being actively treated in the home health setting.


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One exception to this sequencing rule is when the code for the specific sequela condition is noted to be a manifestation. Then the sequela would be sequenced first.

Example: Hemiplegia following nontraumatic intracerebral hemorrhage

affecting left non-dominant side- I69.154 (438.22)Aphasia following non-traumatic intracerebral hemorrhage-

I69.120 (438.11)

If the medical record information does not indicate left- or right-hand dominance for the patient, coding guidelines indicate that, when specific information is not available, if the left side of the body is affected, the default code for non-dominant should be used.


Chapter 9: Diseases of the Circulatory system (I00-I99)

SCENARIOS


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Chapter 10: Diseases of the Respiratory system (J00-J99) J14 – 18 – Many Pneumonia codes!

J18.9 - Pneumonia, unspecified organism (486)

J40-47 - Chronic lower respiratory diseases

J40-42 – Bronchitis codes

J43 – Emphysema

J44 – Chronic obstructive pulmonary diseases

J44.9 - Chronic obstructive pulmonary disease, unspecified (496)

J44.1 - Chronic obstructive pulmonary disease with (acute) exacerbation

J45- Asthma codes


J44 - Other chronic obstructive pulmonary disease Includes asthma with chronic obstructive pulmonary disease

chronic asthmatic (obstructive) bronchitis

chronic bronchitis with airways obstruction

chronic bronchitis with emphysema

chronic emphysematous bronchitis

chronic obstructive asthma

chronic obstructive bronchitis

chronic obstructive tracheobronchitis


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J44.1 Chronic obstructive pulmonary disease with (acute) exacerbationClarifying Terms

Decompensated COPD; Decompensated COPD with (acute) exacerbation

The codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

J44.9 Chronic obstructive pulmonary disease, unspecified This code can only be used for chronic obstructive bronchitis without exacerbation.

If COPD is documented with exacerbation, upper respiratory infection, do not code J44.9 and use the most specific code.

Respiratory insufficiency is an integral part of COPD; therefore do not assign additional code R06.89. If there is an exacerbation of COPD, code J44.1 is the appropriate code.


J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection Excludes 1 (J44) bronchiectasis (J47.-)

chronic bronchitis NOS (J42)

chronic simple and mucopurulent bronchitis (J41.-)

chronic tracheitis (J42)

chronic tracheobronchitis (J42)

emphysema without chronic bronchitis (J43.-)

lung diseases due to external agents (J60-J70)

Use Additional Code- to identify the infection


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J43.9 Emphysema, unspecified

Do not assign a code from J43.- when the physician documentation reports emphysema with chronic bronchitis or emphysematous bronchitis.

Emphysema with bronchitis and emphysematous bronchitis should be coded to J44.- and cannot be coded on the same claim as J43.-.

When a diagnosis supports coding a more specific code for emphysema, such as interstitial emphysema (J98.2), compensatory emphysema (J98.3), or subcutaneous emphysema due to trauma (T79.7), then do not assign J43.-, but assign the more specific code.

Codes in the subclassification J43 include respiratory insufficiency, therefore do not assign R06.89 as an additional cod


Chapter 10: Diseases of the Respiratory system (J00-J99)

SCENARIOS


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Chapter 11- Diseases of the digestive system (K00-K95) K00-14 - Diseases of the oral cavity & salivary gland K20-31 – Diseases of esophagus, stomach & duodenum K35-38 – Diseases of appendix K40-46 – Hernia K50-52 – Noninfective enteritis & colitis K55-64 – Other diseases of intestines K65-68 – Diseases of peritoneum & retroperitoneum K70-77 – Diseases of liver K80-87 – Diseases of gallbladder, biliary tract and pancreas K90-95 – Other disease of the digestive system


Digestive system

If GERD is also diagnosed as well as esophagitis, use code K21.0 Gastro-esophageal reflux disease with esophagitis, instead of k20 and K21.9

When cholecystitis or cholelithiasis has been diagnosed and treated by surgery, and is resolved by surgery upon home health admission, assign the appropriate code from K80-K81 in M1011/M1017 and code aftercare in M1021 or M1023. Z48.815 Encounter for surgical aftercare following surgery on the digestive system

Do not assign a code from K50-K52 when enteritis/colitis is specified as infectious. This is coded in infectious disease chapter 1- A09- Infectious colitis, unspecified


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Chapter 11- Diseases of the digestive system (K00-K95)

SCENARIOS


Chapter 12 - Diseases of the skin and subcutaneous tissue (L00-L99)-

Pressure Ulcers

Codes from category L89 are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer.

Pressure ulcers are based on severity, stages 1-4, unspecified and unstageable.(DON’T use unspecified)

Many codes from L89 as needed are coded to identify all of the pressure ulcers.

Ex:L89.122 Pressure ulcer of left upper back, stage 2

L89.203 Pressure ulcer of unspecified hip, stage 3- should not have this, instead:L89.223 Pressure ulcer of left hip, stage 3


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Coding Wounds- Trauma Wounds

Like many ICD-10 codes are more specific than ICD-9

Example:Instead of open wound of forearm in

ICD-9, 881.0 ICD-10 would be coded, S51.811 Laceration

without foreign body of right forearm


Coding Wounds- Non Pressure Wounds

ICD-10 codes to describe non-pressure wounds, including diabetic, arterial and venous stasis ulcers, require the assignment of an additional code from the L97 series to describe the depth of tissue affected by the wound. L97.201 - Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin

L97.202 - Non-pressure chronic ulcer of unspecified calf with fat layer exposed

L97.203 - Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

L97.204 - Non-pressure chronic ulcer of unspecified calf with necrosis of bone

L97.209 - Non-pressure chronic ulcer of unspecified calf with unspecified severity


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See a lot of clinicians in many agencies not documenting the depth measurementsThis then requires coder to send back to nurse,

who may have difficulty if did not assess on visit

This is a big variation for clinicians, which requires added assessment education.

Agency needs protocols for measurement- use WOCN and wound clinics.



Coding an arterial ulcer: ICD- 9- 440.23 - Atherosclerosis of native arteries of

extremities, with ulceration 707.12 – ulcer of calf

ICD-10-I70.232- Atherosclerosis of native arteries of right leg, with ulceration of calf

L97.212- Non-pressure chronic ulcer of right calf with fat layer exposed


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Abscess and Cellulitis

Abscesses, carbuncles and furuncles (boils) are coded separately from cellulitis (L03) in ICD-10 .

Use an additional code to identify the causative organism.

L02.91 Cutaneous abscess, unspecified L02.31 Cutaneous abscess of buttock

Excludes 1 (L02.3)

pilonidal cyst with abscess (L05.01)

Excludes 2 (L02)

abscess of anus and rectal regions (K61.-)


Cellulitis and acute lymphangitis are grouped together, then separated by 5th

character:

L03.0 Cellulitis and acute lymphangitis of finger and toe- states 5 digit required

L03.01 Cellulitis of finger- states 6th character required for laterality L03.011 Cellulitis of right finger

L03.021 Acute lymphangitis of right finger


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Chapter 12 - Diseases of the skin and subcutaneous tissue (L00-L99)

SCENARIOS


Chapter 13- Diseases of the musculoskeletal system and connective tissue (M00-M99) M00-02 – Infectious arthropathies M05-14 – Inflammatory polyarthropathies M15-19- Osteoarthritis M20-25 – Other joint disorders M26-27 – Dentofacial anomalies & other disorders of jaw M30-36 – Systemic connective tissue disorders M40-43 – Deforming dordopathies M45-49 – Spondylopathies M50-54 – Other dorsopathies M60-63 – Disorders of muscles


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Chapter 13- Diseases of the musculoskeletal system and connective tissue (M00-M99)

M65-67 – Disorders of synovium & tendon

M70-79 – Other soft tissue disorders

M80-85- Disorders of bone density & structure

M86-90 – Other osteopathies

M91-94 – Chondropathies

M95 – Other disorders of MS system & connective tissue

M96 – Intraoperative & postprocedural complications & disorders of MS system, not classified elsewhere

M99 – Biomechanical lesions, not elsewhere classified


Common MS System Codes

M05 – Rheumatoid arthritis codes with rheumatoid factor M06 - Rheumatoid arthritis codes without rheumatoid factor M10 – Gout codes M15-19 – Osteoarthritis codes

M15- Polyosteoarthritis has 7 - 4digit codes

M16- OA of hip includes 15 - 4-5digit codes – bilateral, due to dysplasia, post traumatic & other secondary OA of the hip.

M32 – Systemic lupus erythematosus M79.7 – Fibromyalgia M81.0 - Age-related osteoporosis without current pathological fracture Age related osteoporosis includes post-menopausal and senile

osteoporosis, as well as unspecified.


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M80 -Osteoporosis with current pathological fracture

Pathological fractures not coded in S chapter Unlike ICD-9, ICD-10 - an assumption is made when a patient who has

osteoporosis also has a fracture that is not specified as due to another cause. When a patient with osteoporosis is noted to have an active fracture not clearly

attributed to trauma, it should be coded using a combination code from M80.- . Excludes 1 collapsed vertebra NOS (M48.5) pathological fracture NOS (M84.4) - NO osteoporosis wedging of vertebra NOS (M48.5)

personal history of (healed) osteoporosis fracture (Z87.310)


Osteomyelitis – 260 codes!M86.9 Osteomyelitis, unspecified• Osteomyelitis commonly occurs in diabetic patients. However, no manifestation

combination code pairing for diabetic osteomyelitis exists. When osteomyelitis occurs in a diabetic patient and is confirmed as due to diabetes, the appropriate code from E08-E13 should be assigned with 4th & 5th characters -.69 followed by the appropriate code for osteomyelitis.

• Documentation must include acute or chronic to be able to code osteomyelitis to the site

• M86.10 Other acute osteomyelitis, unspecified site• M86.60 Other chronic osteomyelitis, unspecified site

• Code (B95-B97) to identify infectious agent• Code to identify major osseous defect, if applicable (M89.7-)• Codes classified to M86.- do not include osteomyelitis of the orbit- H05 codes,

petrous bone H70, or vertebrae- M46 codes


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Chapter 13- Diseases of the musculoskeletal system and connective tissue (M00-M99)

SCENARIOS


Chapter 14- Diseases of the Genitourinary system (N00-N99)• Acute Kidney Failure & Chronic Kidney Disease (N17-19)

• If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure [category N17] is required.

• Ensure acute kidney failure is still active in home health

• N18- CKD – similar to ICD-9 guidelines (see following slide)

• N39.0 - UTI, site unspecified (use additional code B95-97 to identify infectious agent

• N39.4- other specified urinary incontinence. • There are 10 codes describing specific types of urinary incontinence!

• If you do not know from documentation a type, the R32 code is urinary incontinence NOS and is most related to 788.30


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Relationship between CKD & HTN may be assumed

I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

N18.3 Chronic kidney disease, stage 3 (moderate)

N18 - Code First (N18)

any associated:

diabetic chronic kidney disease (E08.22, E09.22, E10.22, E11.22, E13.22)

hypertensive chronic kidney disease (I12.-, I13.-)


Other common GU codes

BPH- Unlike ICD-9, in ICD-10, both Benign Prostatic Hyperplasia and Benign Prostatic Hypertrophy are classified to the same code. N40.0 Enlarged prostate without lower urinary tract symptoms

If has lower urinary tract symptoms present – such as obstruction, incontinence, hesitancy, frequency, urgency, or other included conditions – code N40.1 Enlarged prostate with lower urinary tract symptoms

N31.9 Neuromuscular dysfunction of bladder, unspecified code to identify any associated urinary incontinence (N39.3-N39.4-)


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Chapter 14- Diseases of the Genitourinary system (N00-N99)

SCENARIOS


Chapter 15: Pregnancy, childbirth and the puerperium

(O00-O9A)

Chapter 16: Certain conditions originating in the perinatal period

(P00-P96)

Chapter 17: Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)


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Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Coding symptoms in ICD-10

Similar to ICD-9, with greater specificity This is a large category that covers many signs and symptoms that are not

specific to a particular body system. Here you will find codes for symptoms such as

fever, headache, pain, malaise and fatigue.



The chapter is divided into the following categories that correspond to specific body systems:R00-R09: Circulatory and Respiratory SystemsR10-R19: Digestive System and AbdomenR20-R23: Skin and Subcutaneous TissueR25-R29: Nervous and Musculoskeletal SystemsR30-R39: Urinary SystemR40-R46: Cognition, Perception, Emotional State,

and BehaviorR47-R49: Speech and VoiceR50-R69: General symptoms and signs. © 2016, 5 Star Consultants, LLC

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As in ICD-9, some ICD-10 symptom codes are found within their specific body system chapters, and some are categorized in Chapter 18.

Some code placement changes have been made in the new system that do not correspond directly to ICD-9. But you have to look at the guidelines and notes because it varies:


Code Placement Changes

Example: Unspecified gangrene (785.4) is categorized as a symptom in chapter 16 (Symptoms, Signs and Ill-Defined Conditions). In ICD-10, it is found in diseases of the circulatory

system (Chapter 9), coded as I96.

Example: Difficulty walking (719.7) is in the ICD-9 chapter for diseases of the musculoskeletal system. In ICD-10, it is a symptom code in Chapter 18, coded R26.2© 2016, 5 Star Consultants, LLC

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When to code symptoms in ICD-10

Do not code signs and symptoms in ICD-10 if a more definitive diagnosis is known.

But coding of signs and symptoms will have to be done.

Code signs and symptoms when: they most accurately reflect the patient’s condition when a patient is experiencing signs and symptoms that

aren’t integral parts of a specific disease process.


When to code symptoms in ICD-10

Ex: A patient with Parkinson’s disease (G20) with dysphagia.

Dysphagia is not considered integral to the Parkinson’s, therefore a symptom code for the dysphagia (R13.1_) should also be assigned.

In cases like this, sequence the disease process (Parkinson’s, G20) before the symptom code (dysphagia, R13.1_).


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When to code symptoms in ICD-10 ICD-10 symptom codes provide significantly greater

specificity, which will require more detailed documentation.

For example, there is one code for abnormality of gait in ICD-9, 781.2.

In ICD-10 there are 6 different options, coded to the R26- (Abnormalities of gait and mobility) category.

Other Symptom Examples: Nausea without vomiting- R11.0 Localized edema – R60.0Anterior chest wall pain NOS- R07.89


Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

SCENARIOS


74

Chapter 19- Injury, poisoning and certain other consequences of external causes (S00-T88) No Aftercare Codes in this chapter!

Largest section of ICD-10

S Section has Injuries to most parts of body:

S00-09 Head; S10-19 Neck; S20-29 Thorax;

S30-39 Abdomen, lower back , lumbar spine, pelvis & genitalia (ext)

S40-49 Shoulder & upper arm; S50-59 Elbow & forearm

S60-69 Wrist, hand & fingers; S70-79 Hip & thigh

S80-89 Knee & lower leg; S90-99 Ankle & foot


Chapter 19 guidelines

Most have a 7th character for codes:

A Initial encounter (ER, New eval/treatment by new physician,surgery) ACTIVE TREATMENT FOR HOMECARE !

ONLY TREATMENTS SUCH AS IV THERAPY AND/OR WOUND VACS

CASE MIX DIAGNOSES

D Subsequent encounter (AFTER active treatment – Home Health!)

S Sequelae (complications or conditions arising as direct result of a condition)


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Fractures

Different than ICD-9: Home Health assigns codes for the fractures rather than aftercare codes

for the fractures.

The aftercare in home health will be specified by a seventh character extension.

According to ICD-10 coding guidelines, Z codes are not to be used for injuries. The acute code for the injury is to be assigned, with the seventh character denoting the reason for the encounter.

Ex: traumatic fracture of the shaft of the left tibia- S82.20 (Unspecified fracture of shaft of tibia). A 2 is coded in 6th digit for left, then the letter saying type of encounter- D for a subsequent encounter for a closed fracture with routine healing- S82.202D


Appropriate 7th character is to be added to all fracture codes from category S82

A Initial encounter for closed fractureB Initial encounter for open fracture type I or IIC Initial encounter for open fracture type IIIA, IIIB, or IIICD Subsequent encounter for closed fracture with routine healing

ESubsequent encounter for open fracture type I or II with routine healing

FSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

G Subsequent encounter for closed fracture with delayed healing

HSubsequent encounter for open fracture type I or II with delayed healing


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Appropriate 7th character is to be added to all fracture codes from category S82

JSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

K Subsequent encounter for closed fracture with nonunionM Subsequent encounter for open fracture type I or II with nonunion

NSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

P Subsequent encounter for closed fracture with malunionQ Subsequent encounter for open fracture type I or II with malunion

RSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

S Sequela


Chapter 19- Examples of S codes

S00.00XD Unspecified superficial injury of scalp, subsequent encounter S06.0X1D Concussion with loss of consciousness of 30 minutes or less,

subsequent encounter- traumatic brain injury Excludes 1- head injury NOS (S09.90)

S60.511D Abrasion of right hand, subsequent encounter S61.421D Laceration with foreign body of right hand, subsequent encounter S72.002D Fracture of unspecified part of neck of left femur, subsequent

encounter for closed fracture with routine healing


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Chapter 19 T section categories

T07 Injuries involving multiple body regions T14 Injuries of unspecified body region - wouldn’t use these codes since would

know the body region, except: T14.91- suicide attempt T15-19 Effects of foreign body entering through natural orifice T20-32 Burns & corrosions T33-34 Frostbite T36-50 Poisoning by adverse effect of & underdosing of drugs, medicaments &

biological substances T51-65 Toxic effects of substances chiefly nonmedicinal as to source T66-78 Other & unspecified effects or external causes T79 Certain early complications of trauma T80-88 Complications of surgical & medical care, not elsewhere classified


T Codes - Burns

T23.362D Burn of third degree of back of left hand, subsequent encounter Y92.000 Kitchen of unspecified non-institutional (private) residence as the

place of occurrence of the external cause Use Additional Code- external cause code to identify the source, place

and intent of the burn (X00-X19, X75-X77, X96-X98, Y92)


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T Codes - Poisoning Guidelines (T36)-Section I.C.19.e.5)(b)

When coding a poisoning or reaction to the improper use of a medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50.

The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self harm, assault and undetermined.

Use additional code(s) for all manifestations of poisonings. If there is also a diagnosis of abuse or dependence of the substance, the abuse or dependence is assigned as an additional code.

Section I.C.19.e.5)(c) For underdosing, assign the code from categories T36-T50 (fifth or sixth character "6").

Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.


Poisoning, adverse event, underdosing

T36.0X1D Poisoning by penicillins, accidental (unintentional), subsequent encounter

T36.0X5D Adverse effect of penicillins, subsequent encounter T45.515A Adverse effect of anticoagulants, initial encounter

Table of Drugs and Chemicals

HCS-D ICD-10 test has a lot of questions on this! Practice!


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Dehiscence & Post Op Infections

T81.31 Disruption of external operation (surgical) wound, not elsewhere classified (common error that is rejected- note 7 characters required)

T81.31XD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter Dehiscence of operation wound NOS

Excludes 1- dehiscence of amputation stump (T87.81)

T81.4XXD Infection following a procedure, subsequent encounter Use Additional Code (T81.4) to identify infection

code (R65.2-) to identify severe sepsis, if applicable


Chapter 19- Injury, poisoning and certain other consequences of external causes (S00-T88)

SCENARIOS


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Chapter 20 - External causes of morbidity (V00-Y99)

V, W, X and Y Codes- 9624 Codes!

Examples: Injury/cause – how the injury or health condition happened

Place of occurrence- location of pt at time of injury

Similar to E Codes


Examples

V93.33XD Fall on board other powered watercraft, subsequent encounter V10.1XXD Pedal cycle passenger injured in collision with pedestrian or

animal in nontraffic accident, subsequent encounter W08.XXXD Fall from other furniture, subsequent encounter V97.21XD Parachutist entangled in object, subsequent encounter W52.XXXD Crushed, pushed or stepped on by crowd or human stampede,

subsequent encounter


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Chapter 21- Factors influencing health status and contact with health services (Z00-Z99)

Similar to V Codes V15.88 = Z91.81 History and risk of falling

Aftercare Codes:

Surgical

Attention to:

Fitting & adjustment

Status

History© 2016, 5 Star Consultants, LLC

Z Codes:

Z43 - encounter for attention to artificial opening (v55)

Z93- Status code for artificial opening (v44)

NON Compliance codes - Many More!

Z91.11 – Pt’s noncompliance with dietary regimen

Z91.12- Pt’s intentional underdosing of medication regimen

Z91.120- Pt’s unintentional underdosing of medication regimen due to financial hardship

Z46.82 - Encounter for fitting and adjustment of non-vascular catheter (v58.81)

Z46.6 – Encounter for fitting & adjustment of urinary device (v53.6)


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Aftercare following joint replacement

Z47.1 Aftercare following joint replacement surgery

The 2nd code is to identify which joint was replaced. Z96.641 (Presence of right artificial hip joint). The 6th character indicates the right or left hip.

Do not use 9 as the 6th digit as this is unspecified laterality.



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Problematic areas causing RTP’s and potential denials


“X” place holders

Diagnosis codes require a certain number of digits that will be notated

Confusing as the code is actually 5 codes, for example, but the code Requires a 7th digit code, A,D or S

Common errors are: putting the A,D or S in a spot prior to the 7th digit or not putting it at all. Both of these will be rejected

When 7th character applies, codes missing 7th character are invalid


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“X” place holders Example:

T81.31 Disruption of external operation (surgical) wound, not elsewhere classified States 7 digits, however, does Not state that there is NO 6th digit , and that an

“X” dummy place holder is to be assigned to the 6th spot!

It just states that the 7th digit is to be and A, D or S

Therefore, errors are made with : T81.31 or T81.31D being submitted

The Correct is T81.83XD- for Subsequent Encounter


Non specific codes & Incorrect codes

Use caution, when coding an unspecified code, particularly in the primary diagnosis spot. Many times these are NOT case mix diagnoses and will cost you

money! If it is not a case mix diagnosis, or even if it is, try to get a more specific diagnosis.

Code appropriate number of digits - L97.20 Non-pressure chronic ulcer of unspecified calf requires 6 digits. The 6th is for Laterality.

Code Laterality! Do not use 9 for unspecified site! (Left, right, lower, upper, etc)

Code the severity (depth) of non pressure ulcers- do not put unspecified unless cannot see it. Clinician can specify depth without physician stating it. So have inservice for clinicians so they are able to do this!


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Non specific codes & Incorrect codes

When coding a sequela (late effect CVA), be careful, as a lot of coders are using the I69.9 codes instead of the I69.3 codes. When entering 438.21 for ex for the ICD-10 match, this is what comes up:

I69.952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side

If you choose that without looking further you have unspecified cerebrovascular disease , not sequela of CVA

I69.352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side


Problematic areas causing RTP’s and potential denials

Lack of documentation to support codes Auditors are looking for supportive documentation to support the ICD-10 codes

that are entered. This should be in the form of Face To Face documentation, Referral information

from physician, such as H&P, Discharge summaries, etc Use caution if you are coding diagnoses without having this information as this

may lead to denials down the road! For therapy , ensure that you have diagnoses that are listed in the LCD’s for the

MAC’s (local coverage determinations that require this) Denials now seen for Diabetics that do not have A1C lab results too! So …………moral of story is to get as Much information and document as

specific as possible to avoid denials down the road!


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Resources

CMS –free resources at cms.gov/ICD10:Code set, Official Coding Guidelines for ICD-10-CM and ICD-10-PCS

General equivalence Mappings Medicare Learning Network® MLN Connects videos are part of the

Medicare Learning Network

AHIMA resources at www.ahima.org/topics/icd10:Training (on-line, face-to-face)Coding training Clinical documentation training for ICD-10 by specialty Webinars ICD-10-CM/PCS Documentation Tips

Practical coding assistance through Code-Check™


Resources –CMS- Coding Clinic

AHA Coding Clinic for ICD-10-CM and ICD-10-PCS

www.codingclinicadvisor.comFree coding webinars, including Best of Coding Clinic

www.ahacentraloffice.org/codes/webinarsICD-10-CM and ICD-10-PCS Coding Handbook© 2016, 5 Star Consultants, LLC

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Sharon M. Litwin5 Star Consultants

[email protected]© 2016, 5 Star Consultants, LLC

Documents

ICD-10 6 Months Later - Kansas Home Care & Hospice … · Participants will understand the icd-10 chapters (first half) Review of each chapter to review the layout, ... Step 1- Look