ICD-10- CMTHE TRANSITION FROM ICD9

June 2014| Nina Campus

WHY THE CHANGE?

• ICD9-CM is 30 years old• Many of the categories are full• Codes are not descriptive enough• Technology has changed

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WHEN WILL IT HAPPEN?• ICD9-CM codes will not be accepted for

services provided on or after 10/1/2015.• Claims that do not use ICD10 diagnosis

after 10/1/2015 cannot be processed. • Use ICD9

– Worker’s Compensation & Auto Insurance not required.

• This applies to resubmission or appealed claims.

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NEW STRUCTURE ICD-10- CMICD9 ICD10

3-5 digitsExample: 496

3-7 digitsExample: A66

Chapters 1-17: codes are all numericExample: 511.9

Digit 1 is alphaExample: A69.20

Supplemental chapters: first digit alpha and remainder are numericExample: V02.61

Digit 2 is numericExample: 09A.311

Digit 3 is alpha or numericDigits 4-7 are alpha or numeric

Example: S42.001A

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ICD-10- PCS is used for the hospitals for inpatient services only

NEW STRUCTURE

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ICD-10 CHAPTERS• ICD-9-CM has 17 chapters and ICD-10 CM

has 21 chapters– Chapter 18 which are V codes (Classification of Factors

Influencing Health Status and Contact with Health Service)

• Chapter 20 in ICD-10-CM

– Chapter 19 which are E codes (Supplemental Classification of External Causes of Injury and Poisoning

• Chapter 21 in ICD-10-CM

– Eye and ear have their own chapter in ICD-10• Chapter 7 & 8

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ICD-10-CM CHAPTERS

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ICD-10-CM CHAPTER CATEGORIES

• Chapters are divided in three alphanumeric character categories.– also called Rubric

• There are no alphanumeric character category that start with letter U.– Use of letter I– Use of letter O

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CHAPTER CATEGORIES

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ALPHABETIC INDEXVolume II

• Arranged in alphabetic order by diseases• Divided into sections and organized by main

terms– Index of Diseases and Injury– Index of External Causes of Injury– Table of Neoplasm– Table of Drugs and Chemicals

• Elimination of Hypertension Table– No more benign or malignant

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ALPHABETIC INDEX• Main terms describe the disease and/or

condition– Cross reference “see” “see also”

• Sub-terms are under the main term following an indented format.

• Supplemental (nonessential) descriptions are found in parentheses after the main term.

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Supplementary description

Main term

Sub-term descriptor

Default Code

Secondary sub-term

COMBINATION CODE• A single diagnosis code that is used to

classify two diagnosis codes– A diagnosis with associated sign or symptoms – A diagnosis with associated complication

Example

I25.110

Atherosclerotic heart disease of native coronary artery with unstable angina pectoris.

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GRANULARITY• Granularity is referred to the increased

information to the description of the diagnosis. – Billing up to the highest level of specificity (5th, 6th,

7th digit)

L02.21 Cutaneous abscess of trunk

L02.211 Cutaneous abscess of abdominal wall

L02.212 Cutaneous abscess of back [any party, except buttock]

L02.213 Cutaneous abscess of chest wall

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6th

LATERALITY• Indicates right & left description designation.

H02.84 Edema of eyelid

H02.841 Edema of right upper eyelid

H02.842 Edema of right lower eyelid

H02.843 Edema of right eye, unspecified eyelid

H02.844 Edema of left upper eyelid

H02.845 Edema of left lower eyelid

H02.846 Edema of left eye, unspecified eyelid

H02.849 Edema of unspecified eye, unspecified eyelid15

6th

LATERALITY• Right side is usually character 1

– H04.1111 Dacryops of right lacrimal gland

• Left side is usually character 2– H04.1112 Dacryops of left lacrimal gland

• Bilateral is usually character 3– H04.113 Dacryops of bilateral lacrimal glands

• Unspecified side is usually character 0 or 9– H04.129 Dry eye syndrome of unspecified

lacrimal gland

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TABULAR INDEXVolume I

• CATEGORY– Three-digit character code that represents a single

condition or disease

Example

Chapter 1 A00-B99 Certain Infectious and Parasitic Diseases

A00-A09 Intestinal infectious disease

A15-A19 Tuberculosis

A20-A28 Certain zoonotic bacterial disease

A30-A49 Other bacterial diseases

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TABULAR INDEX• SUBCATEGORY

– Four-digit character code that provides a higher level of specificity compared category. It defines site, etiology and manifestation of the disease or condition.

Example

C15 Malignant neoplasm of the esophagus

C15.3 Malignant neoplasm of upper third of esophagus

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TABULAR INDEX• SUBCLASSIFICATION

– A five-digit or sixth character code that adds precise specificity.

Example

J10.82 Influenza due to other identified influenza virus with myocarditis

M88.861 Other juvenile arthritis, right knee

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TABULAR INDEX• The seventh-digit character code extension is

required if applicable as defined by the tabular index.– Mostly used in injuries and fractures

Example

T65.211A Toxic effect of chewing tobacco, accidental (unintentional), initial encounter

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TABULAR INDEX• Dummy Placeholder

– Used as a placeholder to allow for future expansion or if you code created for that character.

– When a fifth character code is not created but required to code to the sixth and seventh digit.

Example

T37.5X1 Poisoning by antiviral drugs, accidental

(unintentional)

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CONVENTIONS• Code first/use additional code notes

– Etiology/manifestation paired codes have a specific index structure.

– Signals that additional codes should be reported to provide a more complete picture of the patient’s diagnosis.

– Etiology code is first followed by the manifestation codes.

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CODE FIRST/USE ADDITIONAL CODE NOTES

• Manifestation codes will have “in disease classified elsewhere” in the title.

• Possible that more than two codes may be required to

fully describe a condition. ‘Use additional code’ note will be indicated.H42 Glaucoma in disease classified elsewhere

Code first underlying condition, such as:

amyloidsis (E85. - )

aniridia (Q13.1)

Lowe’s syndrome (E72.03)

Reiger’s anomaly (Q13.81)

specified metabolic disorder (E70- E90)

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Code 1st

Code 2nd

CODE FIRST• ‘Code first’ note and an underlying condition is

present, the underlying condition should be sequenced first.

• ‘Code, if applicable, any causal condition first,’ notes indicates that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable.

• If the causal condition is know, then the code for the condition should be sequenced as principal or first-listed diagnosis.

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CONVENTION – ‘NEC’ ‘NOS’

• NEC directed to an ‘other specified’ code in the Tabular List. Reference the inclusion term under the subheading.– No codes defined for the documentation

• NOS is the equivalent of unspecified.– More codes defined that was is documented.

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PUNCTUATION[ ]- used in tabular list to enclose synonyms, alternative wording or explanatory wording. Brackets are used to identify manifestation codes.

( )- used in the alphabetic index and tabular list and referred to as supplementary descriptions (nonessential modifiers)

:- Used after an incomplete term that needs one or more supplementary descriptions.

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PUNCTUATION• } – series of terms which is modified by the

statement appearing at the right of the brace.• , - words that are essential descriptors. The

terms in the inclusion note must be present in the diagnostic statement to assign for this code.

Example

C50.31 Malignant neoplasm of lower-inner quadrant of breast, female27

‘CODE ALSO’, ‘SEE’, ‘SEE ALSO’• Code Also – instructs that two codes may be

required to fully describe a condition.– Sequencing of the two codes depends on the severity

of the condition and the reason for the encounter.

• See- instructions following a main term indicates another term should be referenced.

• See Also – instructions following a main term that another main term may also be referenced.Amentia – see also Disability, intellectual

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DEFAULT CODES• A code next to the main term• Most commonly associated with the main

term• Unspecified code for the condition• If condition documented in medical record

does not provide the additional information, the default code should be assigned.

K37 Appendicitis - not indicated as chronic

or acute29

EXCLUDES NOTES• Two types of EXCLUDES NOTES

– Type I Excludes notes indicates the codes should never be used at the same time as the above the Excludes1 note.

• Two conditions cannot occur together and are mutually exclusive.

• A Type I Excludes note means NOT CODED HERE!Example

E11 Type 2 diabetes

Excludes1: gestational diabetes (Q24.4 -)

Type 1 diabetes (E10. - )

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EXCLUDES NOTES• Type II Excludes note represents ‘Not included

here’. The condition excluded is not part of the condition represented by the code.– It is acceptable to use both the code and the excluded

code together. Example

I10 Essential (primary) Hypertension Includes:

high blood pressure hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)

Excludes2: essential (primary) hypertension involving vessels of brain (I60-I69)

essential (primary) hypertension involving vessels of eye (H35.0)

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INCLUSION TERM• List of codes included under some codes.

Additional terms found only in the index may also be assigned to a code.

ExampleChapter 1 Certain Infectious and Parasitic DiseasesUse additional code to identify resistance to antimicrobial drugs (Z16.-)

Excludes2: carrier or suspected carrier of infectious disease (Z22.-)

B95-B97 Bacterial and viral infectious agents

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USE OF ‘AND’, WITH/WITHOUT• When the term ‘and’ is used in a narrative

statement, it represents and/or. • When ‘with’ and ‘without’ are the two options

for the final character of a set of codes, the default is always ‘without’.– For five character codes, the 0 (zero) represents

‘without’ and 1 represents ‘with’. – For six character codes, the 1 represents ‘with’

and 9 represents ‘without’

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GENERAL CODING GUIDELINES• There are general coding guidelines outlined

in each chapter of the ICD-10-CM.• To find a code, first locate the term in the

alphabetic index and then verify code in the tabular list.

• Diagnosis codes are to be used and reported at their highest number of characters available.

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GENERAL CODING GUIDELINES• Three character code is only used if it is not

further subdivided. • The appropriate codes from A00.0 – T88.9,

Z00-Z99.8 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reasons for the encounter/visit.

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GENERAL CODING GUIDELINES• Codes that describe symptoms and signs, as

opposed to diagnoses, are acceptable for reporting purposes when the relating definitive diagnosis has not be established by the provider. (Reference Chapter 18 of the ICD-10 CM book.)

Abnormal Liver Function Test would be coded R94.5

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GENERAL CODING GUIDELINES– Signs or symptoms should not be reported with a

confirmed diagnosis if the symptom is integral to the diagnosis.

Patient is experiencing ear pain and the diagnosis is otitis media. the ear pan would be integral to the otitis media and

would not be reported.

– Symptom code is used with a confirmed diagnosis only when the symptom is not associated with the confirmed diagnosis.

A patient is diagnosed with epigastric pan and referred the patient to a gastroenterologist to rule out ulcer.

ICD9-CM 789.06 Abdominal pan, epigastric

ICD10- CM R10.13 Epigastric pain37

GENERAL CODING GUIDELINES• Signs and symptoms that are associated

routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classifications.

• Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

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GENERAL CODING GUIDELINES• A physician diagnosed a patient with rheumatoid arthritis

of the right ankle and foot who also has rheumatoid polyneuropathy. The condition is coded in ICD-10-CM using the combination code.

ICD-9-CM 714.0 Rheumatoid arthritis

357.1 Polyneuropathy in collagen vascular disease

In ICD9, we do not have a combination code to fully describe the condition and must use two codes when reporting this diagnosis.

ICD-10-CM a combination code is available:

M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot39

GENERAL CODING GUIDELINESAcute and Chronic Conditions• If the same condition is described as both

acute (sub-acute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (sub-acute) code first.

Patient was diagnosed with acute maxillary sinusitis that is chronic report ICD-10 CM codes J01 (Acute sinusitis) and J32.0 (Chronic maxillary sinusitis)

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GENERAL CODING GUIDELINES• Late Effects (Sequela)• Sequela is a condition produced after the

acute phase of an illness or injury has terminated.

• Not time limit on when sequela can be used.• Coding sequela generally requires two codes

sequenced as follows:– Condition or nature of the sequela is first– Sequela is sequenced second

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Principal Diagnosis Code• Reported in medical record as the primary

reason or the determination at the end of the encounter.

• Providers should only be reporting the diagnosis codes for the conditions they treated in the encounter.

• Not all diagnosis codes can be listed as the primary diagnosis code for an encounter.– Reference ICD-10-CM Draft Official Guidelines for Coding and

Reporting 2014

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Guidelines for Principal DX• Sign or symptom is not used when a definitive

diagnosis for the sign/symptom has been established.

• If anticipated treatment is not carried out due to unforeseen circumstances, the principal code remains the diagnosis that the provider planned to treat.

• When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis/first-listed code.

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Secondary Diagnosis Code• Although a patient has an encounter for the principal

diagnosis, the additional conditions or reasons for the encounter also need to be coded.

• Other diagnosis codes are additional codes that affects patient care in terms of requiring clinical evaluation or therapeutic treatment or diagnostic procedure or extended length of hospital stay or increase nursing care and/or monitoring.

• Diagnoses that relate to an earlier episode that have no bearing on the current hospital stay are to be excluded.

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Abnormal Test Findings• Laboratory, x-ray, pathologic and other

diagnostic results are not coded or reported unless the physician indicates their clinical significance.

• If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribe treatment, it is appropriate to ask the physician whether the abnormal finding should be added.

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Abnormal Test Findings• If the abnormal finding corresponds to a

confirmed diagnosis, it should be coded in addition to the confirmed diagnosis.

• If the diagnosis is confirmed (eg, an X-ray, pathology or laboratory report confirms DX), prior to coding the encounter, the confirmed DX code should be used.

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RESOURCES• CMS ICD10 Website

– www.cms.gov/Medicare/Coding/ICD10

• ICD-10-CM Draft Official Guidelines for Coding and Reporting 2014– http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf

• Center for Disease Control (CDC)– http://www.cdc.gov/nchs/icd/icd10cm.htm

• World Health Organization (WHO)– http://www.who.int/classifications/icd/en/

• AAPC Website– http://www.aapc.com/icd-10

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