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2016 JLU Health Record Systems 1
ICD-10 for Beginners
Four-Part Series
© 2016 JLU Health Records Systems
www.jluhealth.com 1
© 2016 JLU Health Records Systems
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PRESENTER:
Joan L. Usher, BS, RHIA, COS-C ACE
AHIMA Approved ICD-10-CM Trainer
JLU HEALTH RECORD SYSTEMS
TEL: (781) 829-9632 FAX: (781) 829-9636
www.jluhealth.com
Understanding Common
Diagnostic Areas - Where
Coding Mistakes Occur: Part 1
2016 JLU Health Record Systems 2
© 2016 JLU Health Records Systems
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Learning Objectives:
Understand common Home Health & Hospice
coding areas under ICD-10
Including:
Neoplasms
Diabetes
Neuro
Circulatory
Respiratory
Digestive
Neoplasms
C00-D49
Contained in this chapter is codes for most benign and malignant neoplasms
Use Neoplasm Table
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Neoplasms – Official Coding
Guidelines
The neoplasm table in the Alphabetic Index should be
referenced first
Found after “Z” in its own table
However, if the histological term is documented, that
term should be referenced first
For example, if the documentation indicates
“adenoma,” refer to the term in the Alphabetic Index
Read the instructional note to “see also neoplasm, by site,
benign.”
© 2016 JLU Health Records Systems
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© 2016 JLU Health Records Systems
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Neoplasms
Determine if neoplasm is malignant or benign
Reference alphabetical listing
Instructions will state- see also neoplasm by site, malignant
Determine if malignant neoplasm is primary site or secondary site
Code any metastatic sites
Unknown site for primary and secondary exists
Look up code in neoplasm table under the correct column
Use only in situ column, if stated
Use only uncertain behavior or unspecified column, if stated
Mass – see Mass
Tumor – see neoplasm, unspecified behavior, by site
Code any Neoplasm related pain G89.3
If admission is solely for chemotherapy, code Z51.11 as primary
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Neoplasm, Intestine
8
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Unknown Site
Malignant (primary)
neoplasm, unspecified C80.1
Cancer NOS
Cancer unspecified site
(primary)
Carcinoma unspecified site
(primary)
Malignancy unspecified site
(primary)
Excludes1:
secondary malignant
neoplasm of unspecified site
(C79.9)
Secondary malignant
neoplasm of unspecified site
C79.9
Metastatic cancer NOS
Metastatic disease NOS
Excludes1:
carcinomatosis NOS (C80.0)
generalized cancer NOS (C80.0)
malignant (primary) neoplasm of
unspecified site (C80.1)
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Current Malignancy Vs.
Personal History
When a primary malignancy has been excised but further treatment
such as an additional surgery for the malignancy, radiation therapy
or chemotherapy is directed to that site
Primary malignancy code should be used until treatment is
completed
When a primary malignancy has been previously excised or
eradicated from its site, there is no further treatment (of the
malignancy) directed to that site, and there is no evidence of any
existing primary malignancy
Z85, Personal history of malignant neoplasm
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Aftercare Following
Surgery Neoplasm
Z48.3
Use additional code to identify the
neoplasm
Z90.– Acquired absence of organ
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Test Your Knowledge
1. CA of descending colon mets to breast
2. Small cell lung CA of right lung
3. Leukemia
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Answers
1. C18.6 Malignant Neoplasm of
Descending colon, C79.81 Secondary
malignant neoplasm of breast
2. C34.91 Malignant neoplasm of
unspecified part of right bronchus & lung
3. C95.90 Leukemia, unspecified, not
having achieved remission
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Diabetes
E08-E13
Diabetes codes are categorized by type of diabetes & associated manifestation
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Diabetes Official Coding
Guidelines
If type of diabetes mellitus is not
documented in the medical record,
default is E11.-, Type 2 diabetes mellitus
Code Z79.4, Long-term (current) use of
insulin, should also be assigned to indicate
that any type 2 patient that uses insulin
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Diabetes – 5 Categories
1. E08* Due to underlying condition
2. E09* Drug or chemical induced
3. E10 Type 1
4. E11* Type 2
5. E13* Other specified diabetes
*Use additional code to identify any insulin
use Z79.4
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Diabetes Uncontrolled
Inadequately Controlled
Out of Control
Poorly Controlled
Code to diabetes by type, with
hyperglycemia E11.65
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Test Your Knowledge
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1. Diabetes Mellitus, uncontrolled, patient on
insulin
2. Diabetes with Stage II Chronic Kidney Disease
3. Type 1 Diabetic with Right heel ulcer (skin
breakdown only)
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Answer Key: Diabetes
1. E11.65 Type 2 diabetes with hyperglycemia,
Z79.4 Long term (current) use of insulin
2. E11.22 Type 2 diabetes with diabetic chronic
kidney disease, N18.2 CKD stage 2
3. E10.621 Type 1 diabetes with foot ulcer,
L97.411 Non-pressure chronic ulcer of right
heel and midfoot limited to skin breakdown
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Diseases of the
Nervous System
G00-G99
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Test Your Knowledge
1. Bell’s Palsy
2. Huntington’s Disease with Dementia with
aggression
3. Multiple Sclerosis
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Diseases of Nervous System
1. G51.0 Bell’s Palsy
2. G10 Huntington’s disease,
F02.81 Dementia in diseases classified
elsewhere with behavioral disturbances
3. G35 Multiple Sclerosis
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Diseases of the
Circulatory System
I00-I99
Be sure to review the new guidance for Hypertension, Myocardial infarctions, ASHD and angina, sequela of CVAs
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To be Coded in Circulatory &
Respiratory Patients
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Use additional code to identify presence of:
exposure to environmental tobacco smoke (Z77.22)
history of tobacco use (Z87.891)
occupational exposure to environmental tobacco smoke
(Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)
24
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Ischemic Heart Disease
Arteriosclerotic heart disease, ASHD (I25.10)
Arteriosclerotic heart disease, ASHD with angina
pectoris I25.119 (see Arteriosclerosis, coronary
artery)
Coronary artery disease, CAD (I25.10)
Coronary artery disease, CAD with angina pectoris
I25.119 (see Arteriosclerosis, coronary artery)
Hint: I25.1- includes: Atherosclerotic
cardiovascular disease, ASHD, CAD
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Ischemic Heart Disease with
Angina
The 6th character of the code of Ischemic heart disease with angina identifies the type of angina
0 unstable angina
1 angina with documented spasm
8 other forms of angina
9 unspecified angina
I25.110 ASHD with unstable angina
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Myocardial Infarction
For encounters occurring while the myocardial infarction is
equal to, or less than, 4 weeks old, including transfers to
another acute setting or a postacute setting, & patient
requires continued care for the myocardial infarction, codes
from category I21 may continue to be reported.
For encounters after the 4 week time frame & patient is still
receiving care related to the MI, the appropriate aftercare
code should be assigned
When documentation is not sufficient to assign a specific
code the default code is I21.3 MI of unspecified site
(NOS)
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Myocardial Infarction If a patient with coronary artery disease is admitted due
to an acute myocardial infarction (AMI), the AMI should
be sequenced before the coronary artery disease.
A subsequent MI (I22.-) is utilized when the patient has
a second MI within the 4 week period from the initial MI. Hint: Subsequent in this case is not like a 7th character and does
not mean the episode of care.
For old or healed myocardial infarctions not requiring
further care, code I25.2, Old MI, may be assigned.
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Myocardial Infarction
4th character identifies location
I21.- Acute MI
I21.1 IMI
I22 Subsequent acute MI
I23 Certain current complications following acute MI within 4 weeks (28 days)
Subsequent MI (I22) may be used with code from I21 or I23
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CHF - More Detailed
Documentation Needed
CHF NOS I50.9
Will state “Heart Failure Unspecified”
In order to code this to a more specific code, documentation
must reflect the type of heart failure and severity
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CHF Specifics
Type
Systolic (congestive)
heart failure I50.2x
Diastolic (congestive)
heart failure I50.3x
Combined systolic
(congestive) & diastolic
(congestive) heart failure
I50.4x
Severity
Unspecified I50.20
Acute I50.21
Chronic I50.22
Acute on Chronic I50.23
Exacerbation
Decompensated
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Sequelae
Late Effect CVA NOS
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Cerebrovascular diseases (I60-I69)
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Use additional code to identify presence of:
alcohol abuse and dependence (F10.-)
exposure to environmental tobacco smoke (Z77.22)
history of tobacco use (Z87.891)
hypertension (I10-I15)
occupational exposure to environmental tobacco smoke
(Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)
Excludes1:
transient cerebral ischemic attacks and related syndromes
(G45.-)
traumatic intracranial hemorrhage (S06.-)
Dominant Vs.
Non-Dominant Side
Should the affected side be documented, but not
specified as dominant or non-dominant, and the
classification system does not indicate a default, code
selection is as follows:
For ambidextrous patients, the default should be
dominant.
If the left side is affected, the default is non-dominant.
If the right side is affected, the default is dominant.
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Test Your Knowledge
1. Dysphagia following Late Effect CVA
2. Late Effect CVA with hemiparesis right
dominant side, ambidextrous patient
3. Late Effect CVA with left sided neglect
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Answers
1. I69.391 Dysphagia following cerebral
infarction, R13.10 Dysphagia
2. I69.351 Hemiplegia and hemiparesis
following cerebral infarction right
dominant side
3. I69.398 Other sequelae of cerebral
infarction, R41.4 Neurologic neglect
syndrome (left sided neglect)
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Diseases of the
Respiratory
System
J00-J99
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COPD
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
Code also type of asthma, if applicable (J45.-)
Excludes1: bronchiectasis (J47.-)
chronic bronchitis NOS (J42)
chronic simple and mucopurulent bronchitis (J41.-)
chronic tracheitis (J42)
emphysema without chronic bronchitis (J43.-)
lung diseases due to external agents (J60-J70)
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COPD
J44.0
Chronic obstructive pulmonary disease with acute lower
respiratory infection
Use additional code to identify the infection
J44.1
Chronic obstructive pulmonary disease with (acute) exacerbation
Decompensated COPD
Decompensated COPD with (acute) exacerbation
Excludes2: chronic obstructive pulmonary disease [COPD] with
acute bronchitis (J44.0)
J44.9
Chronic obstructive pulmonary disease, unspecified
Chronic obstructive airway disease NOS
Chronic obstructive lung disease NOS
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Test Your Knowledge
1. Chronic bronchitis with emphysema
2. Chronic bronchitis
3. Emphysema
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Answers
1. J44.9
2. J42
3. J43.9
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Diseases of the
Digestive
System
K00-K95
There is no Official Coding Guidelines for this chapter however remember to follow the coding conventions
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Digestive
Ulcers K25-K28
Gastric, duodenal, peptic, gastrojejunal,
Acute, chronic
With hemorrhage, perforation
Ulcerative Colitis K51
Rectal bleeding, intestinal obstruction, abscess,
other
Excludes1 Crohn’s Disease K50-
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Crohn’s Disease
ICD-10-CM
K50.919 Crohn’s Disease, unspecified, with
unspecified complications
K50 Crohn’s Disease
4th character -site (small intestine, large
intestine)
5th character-with or without complications
6th character- with fistula, abscess, rectal
bleeding
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Test Your Knowledge
1. Chronic peptic ulcer
2. Regional Enteritis
3. Crohn’s Disease with fistula
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Answers
1. K27.7 Chronic peptic ulcer, site
unspecified, without hemorrhage or
perforation
2. K50.90 Crohn’s disease unspecified
without complications
3. K50.913 Crohn’s disease unspecified
with fistula
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Chronic
pain due to
coding
class
G89.29
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Questions????
2016 JLU Health Record Systems 25
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Next Session Understanding Common Diagnostic
Areas - Where Coding Mistakes Occur:
Part 2
© 2016 JLU Health Records Systems
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Class Companion:
Rapid Reference Guide
Available for beginners & for quick reference.
Allows for easy look-up of home health codes. Pages are organized how clinicians think and by medical abbreviation. Book includes coding updates for 2016.
Cost is for Webinar participants only is $74 (5% discount) including s/h. Offer valid until September 15, 2016.
To download order blank, go to www.jluhealth.com Use discount code NH.
2016 JLU Health Record Systems 26
Resources
Coding
Coding Guidelines
http://www.cdc.gov/nchs/icd/icd
10cm.htm
CMS Materials
https://www.cms.gov/Medicare/
Coding/ICD10/Downloads/ICD1
0ListservCodingResources.pdf
Rapid Reference Guide © 2016
www.jluhealth.com
OASIS
HHA Final Rule 2016 CMS-1625-F
https://www.cms.gov/Medicare/Medi
care-Fee-for-Service-
Payment/HomeHealthPPS/Home-
Health-Prospective-Payment-
System-Regulations-and-Notices-
Items/CMS-1625-F.html
Home Health Agency Center
https://www.cms.gov/center/provide
r-Type/home-Health-Agency-HHA-
Center.html
OASIS Manual
https://www.cms.gov/Medicare/Qual
ity-Initiatives-Patient-Assessment-
Instruments/OASIS/index.html
© 2016 JLU Health Records Systems
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ABOUT THE SPEAKER:
JOAN L. USHER, BS, RHIA, ACE, President,
JLU Health Record Systems, Pembroke, MA
Degree in Health Information Management
Certified OASIS and Coding Specialist over 9
years
AHIMA Approved ICD-10-CM Trainer
Author, Rapid Reference Coding Guide, 2016
edition www.jluhealth.com © 2016
Author, Online ICD Coding Courses in
partnership with Libman Education 2012-2016
http://www.libmaneducation.com/healthcare-
education-training/home-health-coding/
Author, ICD-10 Essentials for Home Care:
Your Guide to Preparation & Implementation
www.hcmarketplace.com © 2011
Author, ICD-10 for Home Health: A Guide to
Medical Necessity and Payment
http://www.beaconhealth.org © 2014
Author/Editor Online E-Learning Coding
Courses: Home Health Diagnostic Coding;
Home Health Reimbursement Methods, Home
Health Documentation & Health Record
Requirements AHIMA www.ahimastore.org
© 2011
Contributing editor, Schraffenberger/Keuhn, Effective Mgmt of Coding Services, AHIMA, © 2009
Editor & Contributing Author, MaHIMA, Medicio- Legal Guide to Health Record Information, © 2004, Contributing Author © 2016
Massachusetts Health Information Management Association (MaHIMA), BOD 2004-2011
President , 2006, under her leadership, MA received 4 national awards from AHIMA in Continuing Education Programs, Support for Accredited HIM Education Programs, Legislative Advocacy and Electronic Communications
Co-Chair ICD-10 Task Force 2013-2015
Professional Achievement Award Recipient, MaHIMA, 2008
American Health Information Management Association (AHIMA) delegate 2002-2006
Taught ICD coding for over 20 years and has educated over 17,000 people nationwide
Home Care Alliance of MA, Board of Director 2012-2017, member QI Committee, Facilitator ICD-10 Group 2013-2016
Hospice & Palliative Care Federation MA, Board of Director 2008-2017
©2016 JLU Health Record Systems
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