ICD-10-CM

OVERVIEW OF UPCOMING DOCUMENTATION COMPONENTS OF ICD-10-CM

Presenter

Sue Haley, RHIT, CCS, CCDS

AHIMA certified ICD-10 instructor

Over 20 years coding experience– Both inpatient and outpatient

OCTOBER 2013

ICD-9-CM 3-5 characters Only V & E codes start

with letter Limited space for

adding new codes Cannot identify laterality

ICD-10-CM 3-7 characters ALL codes start with

letter Flexible for adding new

codes Can identify laterality

EXCLUDES NOTES

ICD-10-CM

– Exclude notes are better defined in ICD-10 – EXCLUDES 1 means don’t code together

– EXCLUDES 2 means “not included here”. Therefore, if both conditions exist, two codes are necessary

Official Guidelines for Coding & Reporting Conventions for ICD-10

www.cdc.gov/nchs/icd/icd10cm.htm

Many new and revised coding guidelines for ICD-10-CM but also newly published guidelines for ICD-10-PCS

AHA Coding Clinic for ICD-9-CM will not be converting their guidelines for ICD-10-CM use

Documentation Considerations by Chapters in ICD-10-CM

Infectious & Parasitic Disease– New terminology to review– Includes the drug resistant classifications

Blood & Blood Forming Organ– New terminology to review– Greater specificity

Endocrine, Nutritional, Metabolic– Greater specificity for diabetes & malnutrition

Documentation Considerations by Chapters in ICD-10-CM

Mental & Behavioral Disorders– Many changes to terminology– Tobacco use vs dependence

Nervous System– Significant changes in the specificity of sleep disorders

Eye & Adnexa (new chapter)– Terminology changes– Laterality classified

Ears & Mastoid (new chapter)– Laterality classified

Documentation Considerations by Chapters in ICD-10-CM

Circulatory– Includes gangrene– Hypertension no longer classified malignant, benign, or unspecified. – Definition on coding AMI now 4 weeks

Respiratory– Asthma now classified as mild intermittent & three degree’s of persistent-

mild, moderate, and severe Digestive

– Ulcers no longer specified as obstructive– Bleeding assigned to gastritis, duodenitis, diverticulosis– Crohn’s has specific sites & now identifies that with complications

Skin & Subcutaneous– More specificity in sites & severity of decubitus ulcers

Documentation Considerations by Chapters in ICD-10-CM

Musculoskeletal & Connective Tissue

– Fractures further define encounters as: A initial encounter for fracture B Initial encounter for fracture routine healing G subsequent encounter for fracture delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture for malunion S sequela

Documentation Considerations by Chapters in ICD-10-CM

Musculoskeletal & Connective Tissue– Uses the GUSTILO open fracture classification

Mechanism of injury Soft tissue damage Degree of skeletal involvement

– Physician teaching opportunity during your implementation of ICD-10

Documentation Considerations by Chapters in ICD-10-CM

GUSTILO open fracture classification– B initial encounter open fx type I or II– C initial encounter open fx type IIIA, IIIB, or routine healing– E subseq. encounter open fx type I or II with routine healing– F subsuq. encounter open fx type IIIA, IIIB, or IIIC with routine

healing– H subseq. Encounter open fx type I or II with delayed healing– J subseq. Encounter for open fx type IIIA,IIIB, or IIIC with

delayed healing– M subseq. Encounter for open fx type I or II with nonunion– N subseq. Encounter for open fracture type IIIA, IIIB, or IIIC

with nonunion– Q subseq. Encounter for open fx type I or II with malunion– R subseq. Encounter for open fx

Documentation Considerations by Chapters in ICD-10-CM

– Musculoskeletal & Connective Tissue Laterality

New definitions associated with classification of joint involvement (direct, indirect, post-infective)

– Direct organism invades synovial tissue and microbial agent

is present in joint

– Indirect no joint involvement

– Post-infective antigen present

Documentation Considerations by Chapters in ICD-10-CM

Musculoskeletal & Connective Tissue

– Pathological fractures have 3 categories: Due to neoplastic disease, Due to osteoporosis, Due to other specified disease

Documentation Considerations by Chapters in ICD-10-CM

Diseases of genitourinary system

– New terminology

– Post-traumatic urethral strictures will need to identify patients gender

Documentation Considerations by Chapters in ICD-10-CM

Pregnancy, childbirth, & periperium– Episode of care is no longer classified

– Trimester is now used to classify the condition 1st trimester- less than 14 wks and 0 days 2nd trimester- 14 wks 0 days to less than 28 wks 0 days 3rd trimester- 28 weeks 0 days until delivery

Documentation Considerations by Chapters in ICD-10-CM

Pregnancy, childbirth, & periperium– Physician’s must calculate the weeks, the coder

can not– Coder can use the weeks to determine the

trimester if the physician documents– The time frames for differentiating the abortion

from fetal death have changed from 22 to 20 weeks.

Documentation Considerations by Chapters in ICD-10-CM

Signs, Symptoms, and abnormal clinical and laboratory findings, NEC

– Fairly substantial classification changes to hematuria

– GLASCOW coma scale (TBI/sequelae CVA)

– Primarily used by trauma registries & research

– Organizational decision the frequency of capturing a Glasgow coma scale scores

Documentation Considerations by Chapters in ICD-10-CM

GLASCOW COMA SCALE

7th digit character will indicate: 0 unspecified time 1 in the field (EMT or ambulance) 2 at arrival to ER 3 at hospital admission 4 24 hours or more after admission

Documentation Considerations by Chapters in ICD-10-CM

Injuries, poisoning, & certain other consequences of external causes

– New category for underdosing Taking less of a medication than is prescribed

– Classify burns and corrosions (new term ICD-10)

Documentation Considerations by Chapters in ICD-10-CM

– Injuries, poisoning, & certain other consequences of external causes

– New extensions for identification of:A initial encounterD subsequent encounterS sequela

–

Documentation Considerations by Chapters in ICD-10-CM

Injuries, poisoning, & certain other consequences of external causes

Fractures further define encounters as: A initial encounter for closed fracture B Initial encounter for open fracture D subsequent encounter fracture routing healing G subsequent encounter for fracture delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture for malunion S sequela

Closing Remarks

Encourage review of ICD-10 coding guidelines now to become familiar with similarities and differences

Pay close attention to new guidelines for PCS and the new guidance being provided

Develop educational plans that incorporate the new documentation requirements

Don’t wait until 2013 start now!