ICD-10 The Basics 20150703 - c.ymcdn.com · Includes Excludes 1 and 2 ... Reading inclusion and exclusion notes in the Tabular List Combination Code ... • Certain ICD-10-CM = 7

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ICD-10… THE BASICS

© 2015, PMG, Inc. All Rights Reserved

PMG, Inc. 700 School Street Pawtucket, RI 02860 P: 401-616-2000 F: 401-616-2001 E: [email protected]

Agenda •  Intro •  ICD-9 vs. ICD-10 •  ICD Basics (9 & 10) •  Understanding ICD 10: the book •  Assigning a code •  Interesting nomenclature •  Coding Tips •  Examples •  Summary

© 2015, PMG, Inc. All Rights Reserved. www.GoPMG.com

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Ray Jorgensen is Co-Founder & CEO of PMG, Inc. Responsible for vision creation, C-level relationships, national speaking/consulting engagements, and partner oversight of PMG Consulting, Ray is nationally recognized healthcare expert and sought after speaker having personally trained thousands from all 50 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles. Ray’s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer’s objectives and process unlike other medical business consultants groomed from the provider side. •  BA from The College of the Holy Cross (Worcester, MA) •  MS from Northeastern University (Boston, MA) •  CPC from the American Academy of Professional Coders (Salt Lake City, UT) •  CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)


Speaker: Ray Jorgensen, MS, CPC, CHBME

1.  The coding guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Priority Management Group, Inc. does not accept any liability or responsibility in this regard.

2.  The presentation today includes discussion about a particular commercial product/service and the presenter has significant financial interest/relationship with the organization that provides this product/service.


Disclaimer

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ICD-9 vs. ICD-10… Textbook

ICD-9-CM •  Code Totals: 13,500 •  Chapters: 17 •  Primarily Numeric

Similarities: •  Alphabetical Index & Tabular List •  PCS & CM •  Similar Nomenclature

ICD-10-CM •  Code Totals: 68,000 •  Chapters: 21 •  All Alpha-Numeric


ICD-9 vs. ICD-10…Structure ICD-9-CM •  3 to 5 characters

– Primary Numeric •  Except V & E

Codes –  4 & 5 afford additional

specificity – Example: 917.6

Splinter, foot/toes

ICD-10-CM •  3 to 7 characters

– Character 1 alpha – Character 2 & 3,

numeric – Character 3 to 7,

alpha/numeric – Example: S90.452A

Superficial foreign body, left great toe, initial encounter


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ICD-9 Usage Guidelines •  October 1st Effective Date •  Identify all diagnoses,

symptoms, conditions, problems, complaints, or reason for service or procedure

•  List primary condition first, then current/active issues

•  Utilize max characters •  Probable, suspected, rule out,

or questionable diagnoses should not be coded until the diagnosis is confirmed; code symptoms, signs, conditions, test results, or other reasons for the encounter

•  Chronic diseases: report as many times as the patient receives treatment for the condition

•  Ancillary diagnostic or therapeutic service: –  List diagnosis or problem

initiating service first, “V” code second

•  Surgical Service: –  Code condition for which

service is performed or definitive diagnosis if different

•  DO NOT CODE WHAT NO LONGER EXISTS! © 2015, PMG, Inc. All Rights Reserved.

www.GoPMG.com

ICD to CPT Linkage Example

1 388.702 380.43 389.904 034.0

A 99213-25B 69210C 87880D 92557 Audiometry 3

"Linked" ICD to CPT

Level 3, established patient 1Removal impacted cerumen 2

Rapid strep 4

ICD Codes In Order of Provider's Perceived AcuityOtalgiaCerumen ImpactionHearing LossStrep Throat

Rendered Services:


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Basics of the ICD Book:

•  ICD-10’s two volumes – Alphabetic Index (Vol. 1) – Tabular List (Vol. 2)

– Procedural Code System (Vol. 3)… not needed!!


The Alphabetical Index

•  Consists of ▶  Alphabetical list of terms ▶  Corresponding code

•  Additional sections: ▶  Index of Diseases and Injury ▶  Index of External Causes of Injury ▶  Table of Neoplasms ▶  Table of Drugs and Chemicals


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Alpha Index E.g.


•  Structured list of codes •  Chapters based on body system or condition •  All in alpha-numerical order •  Instructional notes and directions

▶  Includes ▶  Excludes 1 and 2 ▶  Status/stage of care (A,D,S) ▶  NOTES ▶  Placeholders and/or additional digits

The Tabular List


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Tabular List Example


•  Start in the Index •  Follow instructions

▶ Subsets ▶ See ▶ See also ▶ Omit codes

•  DO NOT CODE FROM THE INDEX •  Locate code in the Tabular List •  Read all the instructional materials •  Consult and apply any coding guidelines •  Confirm and assign the code(s)

ICD Code Assignment Steps


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4. Chalazion, right lower eyelid ICD Code Assignment E.g.


•  Main terms: Identify Conditions or Injuries ▶  Acute Appendicitis: Look under Appendicitis ▶  Stress Fracture: Look under Fracture

•  Sub Terms: Under the main terms ▶  Indented to the right ▶  Lower case letter ▶  Not in bold ▶  Find Bronchospasm in your Index

Start with the Index


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Bronchospasm (acute) J98.01 - with - - bronchiolitis, acute J21.9 - - bronchitis, acute (conditions in J20) —see Bronchitis, acute - due to external agent —see condition, respiratory, acute, due to - exercise induced J45.990

First step: Identify Main Term


•  Characters may be a letter or a number •  All categories = 3 characters

▶  If 3-character category with no subdivision… …3-character item IS the full ICD code

•  Subcategories: 4 or 5 characters •  ICD Codes are 3 to 7 characters •  Subcategory = each level of subdivision •  Final level of a subdivision = selected code •  Codes with 7th character invalid without 7th

Categories & Subdivision


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•  Z30: Category Encounter for contraceptive management

•  Z30.4: Subcategory Encounter for surveillance of contraceptives

•  Z30.41 Encounter for surveillance of contraceptive pills Inclusion Term Encounter for repeat prescription for contraceptive pill

Contraception (was V25)


•  Found in Alphabetical index •  Code listed next to a main term •  Default code =

▶  Condition most commonly associated with the main term OR

▶  Unspecified code for the condition •  Documented condition without additional detail, assign

default code ▶  E.g., N80.9 for endometriosis

Default Codes


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Alpha Index Example


Alpha Index Example


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Similar to “unspecified” ICD-9 Unspecified exists in ICD-10 but avoidable

•  Because so many options exist •  Concern some payers may deny “unspecified” •  Too early to know for certain but avoidable

As always, code & DOCUMENT what you know

Concern about Default Codes


Crosswalk Examples


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•  One code may capture two diagnoses (E.g. #1) ▶  E.g., Flu with digestive issues

•  Other conditions may require two codes (E.g., #2) ▶  E.g., Type II diabetic who uses insulin

Multiple Diagnoses


E.g. #1: Influenza with digestive manifestations


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E.g. #2: Type 2 diabetic with diabetic cataract, patient uses insulin regularly


•  Code first causal conditions when known ▶  Assign as principal when causal condition unknown/not

applicable

•  Causal condition known, code the condition as the principal or first-listed diagnosis

•  Multiple codes possible if ▶  Sequela ▶  Complication codes ▶  Obstetric codes, more fully describe condition(s)

•  See specific guidelines for further instruction

Multiple codes, single condition


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E.g.: Chronic Pain in right knee


•  Used to classify: ▶  Two diagnoses, or ▶  Diagnosis with associated secondary process

(manifestation) ▶  Diagnosis with associated complication

•  Identified by

▶  Referring to subterm entries in the Alphabetic Index ▶  Reading inclusion and exclusion notes in the Tabular List

Combination Code (1 of 2)


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•  Assign only combination code when: ▶  Code fully identifies diagnostic conditions involved ▶  Alphabetic Index so directs

•  Multiple codes NOT used when ▶  Code exists which clearly identifies all of the elements

documented in the diagnosis ▶  Code lacks necessary specificity describing manifestation

or complication, •  Additional code as a secondary code

Combination Code (2 of 2)


Answer, Part 1: H72.91

Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (1 of 2)

Combo Code Example (1 of 2)


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Final Answer: H66.3X1, H72.91

Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (2 of 2)

Answer, Part 2: H66.3X1

Combo Code Example (2 of 2)


•  If it did occur: ▶  Code confirmed diagnosis

•  If it did not occur ▶  Reference Alphabetic Index ▶  Determine if condition has subentry term for “impending” or

“threatened” ▶  Reference main term entries for “impending” or “threatened”

Impending/Threatened Condition (1 of 2)


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•  Sub terms listed, assign given code •  Sub terms not listed

▶  Code existing underlying condition(s) ▶  Code not condition described as impending or threatened

Impending/Threatened Condition (2 of 2)


Impending/Threatened Condition Example


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•  Patient condition ▶  Both acute (sub acute) and chronic

•  Separate subentries in Alphabetic Index •  Code both with acute (sub acute) code primary

Acute & Chronic Conditions


Acute & Chronic Example


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•  Some codes indicate Left vs. Right •  No bilateral code, code each L & R code •  Side not documented = unspecified

Laterality


Laterality Example 1


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Laterality Example 2


•  Results available? Code results •  No Results, code symptoms/condition

Code what you know… diagnostic tests


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•  Excludes1… REALLY means do not code with main term

•  Excludes2… SHOULD say “OK to code also” if it exists

Excludes 1 & Excludes 2


Excludes 1 & 2 Example


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•  Placeholder = character “X” •  “X” used to allow for future expansion •  E.g., adverse effect and under dosing (T36-T50)

•  Certain ICD-10-CM = 7 characters –  i.e., 7th character required for all codes within the

category •  Code requires a 7th character < 6 characters,

placeholder X needed

Place Holder (X) Character


Place Holder (X) E.g., #1


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Place Holder (X) E.g., #2


Place Holder (X) E.g. #3


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CODING EXAMPLES


1. RUE internally rotated (2 of 2)


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Answer: M99.07

1. RUE internally rotated (2 of 2)


2. Cervical radicular pain (1 of 2)


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Answer: M54.12

2. Cervical radicular pain (2 of 2)


3. Low back strain/pain (1 of 2)


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3. Low back strain/pain (2 of 2)

Answer: M54.5


Answer: H01.119

4. Contact Dermatitis of the Eye


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Answer: L60.0

5. Ingrown toenail, right great toe


Answer: J45.22

6. Mild intermittent asthma, status asthmaticus


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Answer, Part 1: H72.91

7. Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (1 of 3)




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Answer, Part 2: H66.3X1

Final Answer: H66.3X1, H72.91



8. Type 1 diabetes with diabetic nephrosis (1 of 2)


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Answer: E10.21

8. Type 1 diabetes with diabetic nephrosis (2 of 2)


Answer: Z48.01

9. Visit to change surgical dressing


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Answer: R30.0

10. Dysuria


Answer: Z00.129

11. Well baby exam, without abnormal findings, aged 3 months


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Answer: Z23

12. Immunization for MMR


Answer: S53.032A

13. Nursemaid’s elbow, left elbow, initial encounter


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14. Anaphylactic reaction due to eating peanuts, initial encounter (1 of 2)


Answer: T78.01XA

14. Anaphylactic reaction due to eating peanuts, initial encounter (2 of 2)


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Z79.01

15. Long Term Anticoagulant therapy


Z13.220

16. Screening for cholesterol


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17. Pre-operative clearance in patient with heart disease


18. Chronic Pain in right knee (1 of 2)


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18. Chronic Pain in right knee (2 of 2)


•  ICD 10… Larger universe but similar process •  Expanded documentation requirements •  Capture (in writing & code) what you know •  Uncertain about code…

– Expanding (fine tuned) favorite’s list –  IMO (via EMR) – On-line Options

Summary


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Questions


Documents

ICD-10 The Basics 20150703 - c.ymcdn.com · Includes Excludes 1 and 2 ... Reading inclusion and exclusion notes in the Tabular List Combination Code ... • Certain ICD-10-CM = 7