ICD-10-CM Countdown:

Are You Ready?

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Scope of the Implementation

Prevalence of conditionsNumber of codes to be convertedNumber of new patients per monthNumber of bills sent each month

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ICD-10-CM Official Draft Code Set

• Published effective 10/1 each year

• Facilities must use current, up-to-date manual

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ICD-10-CM Official Draft Coding Guidelines

• Section I of the ICD-10-CM Manual

• Set of rules to accompany and complement the official conventions and instructions provided within ICD-10-CM itself

• Adherence to these Guidelines is mandatory

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AHA Coding Clinic®

• Published quarterly by the AHA and endorsed by CMS, based on a long-standing public and private sector collaboration

• Provides guidance on interpreting and applying the ICD-10-CM and is used in claims review

• Offers coding guidelines and advice based on adherence to the statistical classification scheme of ICD-10-CM

• The purpose: To promote accuracy and consistency in the use of ICD-10-CM

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Coding Sources for the SNF

• History and physical

• Lab reports can confirm or negate a suspected condition

• X-ray results can confirm or negate a suspected condition

• Therapy

• Progress notes may indicate

• Incident reports may contain

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Code Conversion Using GEMs

• Used to promote consistency

• ICD-9 and ICD-10 codes are very different and ICD-10 offers much more specificity

• Software vendors should have them available in their systems

– However, mapping and conversion always needs human intervention!

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Code Conversion Using GEMs

• Some mappings will be an exact match– UTI, site not specified

• ICD-9 = 599.0 • ICD-10 = N39.0

• Some mappings will be an approximate match that needs confirmation

• Some mappings will have a cluster of matches when more specificity is offered

• Some mappings will have no match– Encounter for rehabilitation

• ICD-9 = V57 • ICD-10 = Use procedure codes instead

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Conversion of Existing Codes

• Using the GEMs, try translating some ICD-9-CM codes to ICD-10-CM codes

• Identify where human intervention is needed

• Remember, the purpose of the GEMs is to create a useful, practical, code-to-code translation reference dictionary for both code sets, and to offer acceptable translation alternatives wherever possible

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Using the GEMs for Conversion

• The ICD-9 to ICD-10 (and the reverse) GEMs are in .txt file format with 3 columnsICD-9-CM code ICD-10-CM code Flags

00845 A047 00000

6826 L03119 10000

6826 L03129 10000

• The 1st digit “0” in the Flag column indicates an exact match that needs confirmation

• The 1st digit “1” in the Flag column indicates an approximate match that needs confirmation and frequently additional information

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Convert CHF From ICD-9 to ICD-10 in GEMs

• 4280 I509 10000

• The flag 1 indicates an approximate match

• Check documentation to see if there is additional documentation that could be coded under ICD-10-CM, such as whether the CHF is due to hypertension, which requires coding the hypertension first

• Source system is less specific than many of the alternatives in the target system

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Convert Type 2 Diabetes From ICD-9 to ICD-10 in GEMs• 25000 E119 10000

• The flag 1 indicates an approximate match

• Check documentation to see if there is additional documentation that could be coded under ICD-10-CM, such as whether there are complications specified

• If complications are specified, then this would not be the correct code (E118 or other)

• The target contains many translation alternatives, but the least specific is the one highlighted

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Convert “Aftercare of Healing Traumatic Fracture of Hip (Right)”• V5413 ******** 10000• The flag 1 indicates an approximate match• There are approximately 70+ possible

combinations; all require specificity related to the situation and all need confirmation

• Needs laterality• “Aftercare of a traumatic fracture” is no longer

an acceptable alternative• Source system is less specific along the laterality

axis, and the target system contains the more specific translation alternatives

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New Encounter Coding

• Determine how to improve the diagnostic information flow from physicians to staff.

• Do you have the specificity you need to code?

• When can you obtain clarification so that it does not impede billing and cash flow?

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Updating Existing Codes

• Make sure to build updating into your process

• May need to test with your software vendor

• Every MDS demands updating codes

• Every UB-04 demands updating codes

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Contents of ICD-10-CM Manual

• ICD-10-CM Official Draft Guidelines for Coding and Reporting

• Alphabetic Index of Diseases and Injuries (Volume 2)

• Tabular List of Diseases and Injuries (Volume 1)

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Complete Review of the Guidelines Is Mandatory for Accurate Coding

• Section I of the ICD manual contains the official coding guidelines

– Conventions: New, old, revised

– Lots of new instructions regarding use of codes located in the 21 chapters, including aftercare

– Specific instructions on selecting principal diagnosis and secondary diagnoses

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ICD-10-CM Code Structure

ICD-10 format—can be 3 to 7 charactersCategory Subcategory: Etiology,

anatomical site, severityExtension

X X X X X X X1st Alpha

2ndNumeric

3rd Alpha/numeric

4th Alpha/ numeric

5th Alpha/ numeric

6th Alpha/ numeric

7th Alpha/ numeric

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Examples of ICD-10-CM Codes

Digits Code Description

3 I10 Essential (primary) hypertension

4 N36.0 Urinary tract infection, site not specified

5 I25.10 Arterosclerotic heart disease of native coronary artery without angina pectoris (includes CAD and ASHD, NOS)

6 Z96.641 Presence of right artificial hip joint

7 S72.002S Fracture of unspecified part of neck of left femur, sequela

Reminder: ICD-10-CM uses updated medical terminology. In the beginning, this may present some challenges.

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Brackets [ ]• Identify manifestation codes in the Alpha Index

– Example: Dementia in, Parkinson’s disease G20 [F02.80]

• Identify synonyms or alternative terminology in the Tabular List– Example: B96.2 – Escherichia coli [E. coli] as

the cause of diseases Default code• A code listed next to a main term in the ICD-10-

CM Index

Conventions – What’s the Same?

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• Parentheses ( ) identify “non-essential modifiers” in both the Alpha Index and Tabular List

• NEC identifies “other specified” codes where the information in the medical record provides detail for which a specific code does not exist

• NOS identifies “unspecified” codes where the information in the medical record is insufficient to assign a specific code

Conventions – What’s the Same? IC

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• With or without – When the Alpha Index include options for “with” or “without,” the default will be “without”

• The term “and” when used in a narrative statement may be interpreted as “and/or”

Conventions – What’s the Same?

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Conventions – What’s the Same?

• Etiology and manifestation convention

– ICD-10-CM requires the underlying condition be sequenced first followed by the manifestation—mandatory sequencing

– The “use additional code” instruction will appear at the etiology code and

– The “code first” instruction will appear at the manifestation code

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Conventions – What’s the Same?

Code also

• Identifies that more than one code may be required to fully describe the condition. Sequencing is discretionary (e.g., severity and reason for encounter).

Inclusion terms or example conditions

• Indicates examples of conditions classified to a category; may not be all inclusive.

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• Excludes1= Not coded here! – Indicates that the code excluded should

never be used at the same time as the code above the Excludes1 note

• Excludes2 = Not included here! – Indicates that the condition excluded is

not part of the condition represented by the code but can be assigned in addition

– It is acceptable to use both the code and the excluded code together when appropriate

Conventions – What’s Been Revised? IC

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• ICD-10 can use a “dummy” placeholder for the 4th, 5th, or 6th digits of a code. Examples:

– If a code requires a valid 6th digit, but not a 5th digit, then the “x” is used as the 5th digit

– A code may require 4th and 7th digits but not a 5th or 6th digit; in this case, the “x” is used for the 5th and 6th digits

• Frequently used in the chapters for injuries, external causes, and obstetrics.

New Conventions – Placeholders

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• Some codes within ICD-10-CM have an applicable 7th character

• Most commonly used in chapters:14 Diseases of the Musculoskeletal System

and Connective Tissue15 Pregnancy, Childbirth, and the

Puerperium19 Injury, Poisoning, and Certain Other

Consequences of External Causes20 External Causes of Morbidity

New Conventions – 7th CharactersIC

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• Generally, most categories have a choice of three 7th characters:

– A: Initial encounter

– D: Subsequent encounter

– S: Sequela (late effect)

New Conventions – 7th Characters

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Different categories of fractures may utilize a variety of options for a 7th character, but most identify: • Initial vs. subsequent vs. sequela• Closed vs. open (closed is the default)• Absence or presence of complications during

the healing phase– Routine healing– Delayed healing– Nonunion– Malunion

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A: Initial encounter for closed fractureB: Initial encounter for open fractureD: Subsequent encounter for fracture with

routine healingG: Subsequent encounter for fracture with

delayed healingK: Subsequent encounter for fracture with

nonunionP: Subsequent encounter for fracture with

malunionS: Sequela

7th Characters for Fractures

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• Some codes indicate laterality (e.g., right/left/bilateral)

• If there is no bilateral code, assign separate codes for the left and right side

• If the side is not identified in the medical record, assign the code for unspecified side

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• The dash “-” is used in the Alphabetic Index to indicate whether the code needs additional digits that are found in the Tabular List

• Beware! The dash is NOT used in the Alphabetic Index to identify when 7th characters are required– Example: Stitch, abscess T81.4 is not a valid code.

T81.4xxD is a valid code.

New Conventions – Dash

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General Coding Guidelines

• Signs and symptoms – Codes for symptoms and signs are acceptable when a related definitive diagnosis has not been confirmed

• Multiple coding for a single condition –Requires two codes to fully describe a single condition or a single condition that requires two codes

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General Coding Guidelines

• Acute and chronic conditions – If the same condition is both acute and chronic, and separate subentries exist in the Alphabetic Index at the same level, code both and sequence the acute first

• Remember, some codes have a separate designation for “acute on chronic” or “decompensated”

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• To locate in the Alpha Index, look under the word

• Sequelae– Infarction I69.3 (Sequela of stroke NOS)

• Cerebral I69.30 (Sequela CVA, NOS)– Aphasia I69.320– Ataxia I69.393– Dysphagia I69.391– Dysphasia I69.321– Hemiplegia I69.35-

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Sequelae or “Late Effects” Example

• To confirm in the Tabular List, look under the word

– I69.391 Dysphagia following cerebral infarction

– Use additional code to identify the type of dysphagia, if known (R13.1-)

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Chapter-Specific Coding Guidelines• There is specific coding guidance that applies to

several areas that impact LTC, including:o Sepsis codingo UTI and organism (infections require organism when

available)o HTN codingo MI codingo CVA codingo Diabetes codingo Wounds (need to determine cause)o Fractures (traumatic and pathological)o COPD (special coding rules for asthma), need specificityo CADo Causes of morbidity

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Principal Diagnosis

• Condition chiefly responsible for resident’s admission to the nursing facility

• Diagnosis that provides reason for resident remaining in the nursing facility

• In determining principal diagnosis, coding conventions in ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines

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Principal Diagnosis Sequencing

• When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, and no other coding guideline provides sequencing directions, then any one of the diagnoses may be sequenced first

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Other or Additional Diagnoses

• For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring any of the following:

– Clinical evaluation

– Therapeutic treatment

– Diagnostic procedures

– Extended length of hospital stay

– Increased nursing care and/or monitoring

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Coding Clinic for LTC for ICD-10-CMFourth Quarter 2012

• Dynamic coding for LTC

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Coding Basics

• After you review all the Guidelines, begin to use the Alpha Index and the Tabular List to look up codes

• Locate the condition, diagnosis, or symptom in the Alpha Index– Read all instructions, cross-references before going

to the Tabular List

• Confirm code or codes found in the Tabular List– Read instructions, notes, exclusions, etc.– May be located at the beginning of chapter,

category, or code level

• Assign code – be sure to code to specified digits

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Alpha Index Use

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• Alpha Index of Diseases and Injuries

• Neoplasm Table

• Table of Drugs and Chemicals

• Index of External Causes

• NOTE: The Alpha Index should NOT be used as a source to code in most cases (exception to rule – the Neoplasm Table)

Content of Alpha Index (Volume 2)

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Example of Alpha Index Structure

Main term

Subterm: 1st level

Subterm: 2nd level

Infection, infected, infective (opportunistic) B99.9

withdrug resistant organism – seeresistance (to), druglymphangitis – see Lymphangitisorgan dysfunction (acute) R65.20

abscess (skin) – code by site under AbscessAbsidia – see MucormycosisAcanthamoeba – see AcanthamebiasisAcanthocheilonema (perstans) B74.4accessory sinus (chronic) – see sinusitisacromioclavicular M00.9Actinobacillus A28.8

mallei A24.0muris A25.1

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Let’s Test Your Proficiency – Find These Terms in the Alpha Index

• Chronic obstructive pulmonary disease (COPD)

• Congestive heart failure (CHF)

• Diabetes, Type 2

• Left hip fracture

Let’s see what we learn …

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1. Locate in Alpha under Disease, then site

Disease, diseasedpulmonary (see also Disease, lung)

artery I28.9chronic obstructive J44.9

withacute bronchitis J44.0exacerbation (acute) J44.1lower respiratory infection (acute) J44.9

2. Read notes to ensure you select the code with the correct information

Chronic Obstructive Pulmonary Disease (COPD)

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1. Locate in Alpha under Failure, then site

Failure, failedheart (see also Disease, lung)

congestive (compensated)(decompensated) I50.9

2. If you started with Heart it tells you: see condition

Congestive Heart Failure (CHF)

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1. Locate in Alpha under Diabetes, then type

Diabetes, diabetictype 2 E11.9 (also is the default code if type is not known)

2. A patient may have multiple diabetic codes if he or she has multiple diabetic complications

Diabetes, Type 2IC

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1. Locate in Alpha under Fracture, then site. Noteyou need to know if the fracture is pathological or traumatic.Fracture, traumatic

hip — see Fracture, femur, neck (updated terminology)

femur, femoralupper end

neck S72.00-Fracture, pathological

femur (hip) M84.45-2. Ensure that you obtain the information from the

physician.

Left Hip Fracture

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Tabular List Use

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Tabular List (or Volume 1)Chapter Classification of Diseases Codes

1 Certain Infectious & Parasitic Diseases A00–B99

2 Neoplasms C00–D49

3 Diseases of the Blood & Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

D50–D89

4 Endocrine, Nutritional, and Metabolic Diseases E00–E89

5 Mental, Behavioral, and Neurodevelopmental Disorders

F01–F99

6 Diseases of the Nervous System G00–G99

7 Diseases of the Eye and Adnexa H00–H59

8 Diseases of the Ear and Mastoid Process H60–H95

9 Diseases of the Circulatory System I00–I99

10 Diseases of the Respiratory System J00–J99

11 Diseases of the Digestive System K00–K95

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Tabular List (or Volume 1)Chapter Classification of Diseases Codes

12 Diseases of the Skin & Subcutaneous Tissue L00–L99

13 Diseases of the Musculoskeletal System and Connective Tissue

M00–M99

14 Diseases of the Genitourinary System N00–N99

15 Pregnancy, Childbirth, and the Peurperium O00–O9A

16 Certain Conditions Originating in the Perinatal Period P00–P96

17 Congenital Malformations, Deformations, and Chromosomal Abnormalities

Q00–Q99

18 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

R00–R99

19 Injury, Poisoning, and Certain Other Consequences of External Causes

S00–T88

20 External Causes of Morbidity V00–Y99

21 Factors Influencing Health Status and Contact With Health Services

Z00–Z99

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Example of Tabular ListChapter 10. Diseases of the Respiratory System (J00–J99)

Chronic Lower Respiratory Diseases (J40–J49)

J44 Other chronic obstructive pulmonary disease (4th)

(Read: Includes notes, Code also note, Use additional code notes, Excludes1 notes before proceeding)

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infectionUse additional code to identify the infection

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbationDecompensated COPDDecompensated COPD with (acute) exacerbation

J44.9 Chronic obstructive pulmonary disease, unspecifiedChronic obstructive airway disease NOSChronic obstructive lung disease NOS

Chapter heading

Code block

Category

Subcategory

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Tips for Use of the Tabular List

• Find the chapter that contains the code you are investigating or confirming from the Alpha Index

• Read any instructions at start of chapter

• Locate the section and category

• Read any additional instructions or clarifications

• Follow through with instructions

• Select code

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Confirm Codes From Alpha Index in Tabular List

• Congestive heart failure (CHF)

• Diabetes, Type 2

• Left hip fracture

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Confirm CHF in Tabular ListChapter 9. Diseases of the Circulatory System (I00–I99)

Other Forms of Heart Disease (I30–I52)

I50 Heart failure (4th)

(Read: Code first notes and Excludes1 notes before proceeding)

I50.9 Heart failure, unspecifiedBiventricular (heart) failure NOSCardiac, heart or myocardial failure NOSCongestive heart diseaseRight ventricular failure (secondary to left heart failure)Excludes1 fluid overload (E87.70)AHA: 2012, Q4, 92

Note: Instructions appear at both the category and code level. There was a Coding Clinic released in the 4th quarter of 2012.

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Confirm Diabetes, Type 2 in Tabular List

Chapter 4. Endocrine, Nutritional, and Metabolic Diseases of the Respiratory System (E00–E89)

Diabetes mellitus (E08–E13)

E11 Type 2 diabetes mellitus

(Read: Includes notes,Use additional code to identify any insulin use (Z79.4), and Excludes1 notes before proceeding)

E11.9 Type 2 diabetes mellitus without complications

Note: When reading through the Type 2 diabetes codes, it’s clear that specificity is warranted. This is the default code.

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Confirm Traumatic Left Hip Fracture in Tabular ListChapter 19. Injury, Poisoning, and Certain Other Consequences of External Causes (S00–T88)

Injuries to Hip and Thigh (S70–S79)

S72 Fracture of femur (4th)

(Read: Notes, Excludes1 note, and Excludes2 note before proceeding)

S72.0 Fracture of head and neck of femur (5th)Excludes2 physeal fracture of upper end of femur (S79.0-)

S72.00 Fracture of unspecified part of neck of femur (6th) Fracture of hip NOSFracture of neck of femur NOS

S72.002 Fracture of unspecified part of neck or left femur (7th)

7th character: If therapy is being provided, then the correct 7th character would be “S.” If there is no residual related to the hip fracture, then “D” would be the 7th character to indicate routine healing.

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Wrap-Up

• It’s going to an exciting and challenging year in long-term care

• Now is the time to begin the process

– Remember just how many codes there are to convert

• Questions?