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ICD – 10 CMCoding

Hosted by Lori Blaney, RN, BSN, APN, COS –C HCS-D, AHIMA Approved ICD-10 CM

Trainer

Getting Ready

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TOPICS

� ICD-10 PURPOSE

� CODING BASICS

� GENERAL CODING GUIDELINES AND CONVENTIONS

� NAVIGATING THE ICD-10 CM CODES

� OVERVIEW OF ORGANIZATIONAL AND STRUCTURAL CHANGES BETWEEN ICD-9 AND ICD-10

� SELECTING AND SEQUENCING PRIMARY & SECONDARY DIAGNOSIS – Dissecting the diagnostic statement

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TOPICS ….cont

� Introduction of New ICD-10 Concepts, Chapter by Chapter

� Equivalent Mapping – Converting ICD-9 to ICD-10

� Impact of CMS' PPS and OASIS-C1 on Home Health Coding

� Exploration of the Relationship Between Z Codes, Case Mix Diagnoses and M1025

� Timeline & Recommended Resources for the Transition to ICD-10-CM

� The Implementation of Oasis C-1

� Exercises and Scenarios are throughout presentation

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International Classification of Diseases (ICD)

� The International Classification of Diseases (ICD) is the standard diagnostic tool for:

– epidemiology

– health management

– clinical purposes.

� This includes the analysis of the general health situation of population groups.

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� It is also used to:– monitor the incidence of diseases

– prevalence of diseases

– classify diseases recorded on many types of health and vital records � death certificates

� health records.

� In addition to enabling the storage and retrieval of diagnostic information for:

– clinical

– epidemiological and

– quality purposes

These records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States. It is used for reimbursement and resource allocation decision-making by countries.

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What else does this ‘data’ do ??

� better measure quality, safety and efficacy of care

� design payment systems

� process claims for reimbursement

� conduct research

� clinical trials

� set health policy

� strategically plan and design healthcare delivery systems

� prevent and detect healthcare fraud and abuse

� track public health risks

� Identify high risk populations

� Provider profiling

� Evaluating EMS and trauma care systems

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For Home Health Purposes

Coding contributes to :

� The patient’s Plan of Care

� Patient outcome reports

� Accurate and optimal reimbursement

� Establishes medical necessity for our claims

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IMPORTANCE OF CODING

� The Medicare Catastrophic Act of 1988 requires diagnosis coding using ICD-CM codes for each procedure, service, and supply billed.

� Coding “paints a picture” for the regional intermediary or surveyor relative to your patient’s needs and services.

� Coding is a vital link between providing services and the first step toward receiving payment for them.

� Coding is the key to compliance and reimbursement!

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ICD-10 and the US

� The US has only used ICD-10 for mortality reporting –the coding used on death certificates

� ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States as from 1994. The 11th revision of the classification has already started and will continue until 2017.

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ICD-10 Implementation

• CPT and HCPCS codes will not be affected

• ICD-10-CM (diagnoses) will be used by all providers in all health care settings if that provider currently uses ICD-9 codes

• ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital Procedures

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Purpose of changing to ICD-10

� ICD-9 system is 30 years old

� Many categories are full

� Not descriptive enough

� Outdated medical terms

� New technologies are not included

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Why Switch Now ??

In a 2004 cost/benefit analysis for the Department of Health andHuman Services, the RAND Corporation quantified some of the benefits of improved data derived from ICD-10-CM and ICD-10-PCS. RAND concluded that the benefits far outweigh the costs of implementation, estimating the dollar value of the benefits in the following categories:

� More accurate payment for new procedures

� Fewer rejected claims

� Fewer fraudulent claims

� Better understanding of new procedures

� Improved disease management

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When is the implementation date for ICD-10?

� It’s official: October 1, 2015.

� A new OASIS data set, designated OASIS C -1, with the revisions centered on the switch to ICD -10 coding, is set to be implemented at the same time

� The Oasis C-1, ICD-9 hybrid was implemented on January 1, 2015

– It contains all elements of the new Oasis C-1 but with the ICD-9 codes still in place

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Yikes !! How does this affect billing, SOE, EOE, RAPs etc????

� 5010 (the electronic transmission) will accept ICD-10 codes but you cant send them anywhere yet.

� You have to consider coding prior to Oct 1 because episodes that end Oct 1 or later will have to be coded on around August due to SOE – RAP

� You will have to pay close attention

to dates and double code RAP in ICD-9 and EOE in ICD-10

� Pay attention to use of Oasis C-1 also which is also Oct 1 and will only take ICD -10 codes (so you cant use it sooner )

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SIMILARITIES

� All codes will have at least three characters with a decimal point

� Brackets, parentheses, colons, and commas are still used

� Terms such as “Not Elsewhere Classified”(NEC), “Not Otherwise Specified” (NOS), “code first,” “Use additional code,” and “code also” are still used

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SIMILARITIES

� Entries that have notes and instructions will apply as they do in ICD-9

– those at the beginning of the chapter apply to the whole chapterand those at the beginning of a category will apply to all in that category

� The tabular list is set up the same – in order by code number

� Cross references are included to provide instructions to reference other or additional terms

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Major differences

� All codes start with an alpha character

� Separate codes for laterality

� Placeholders

� Excludes 1 and Excludes 2 notes

� Additional characters for expanded detail

� Codes can be up to 7 characters

� Combining diagnosis and symptoms into a single code

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Other DIFFERENCES

� More combination codes: for example, most diabetes manifestations will be a single combination code in ICD-10 instead of the multiple codes currently used.

� Combining poisoning and external cause status

� The codes for postoperative complications include a distinction between intraoperative complications and postprocedural disorders

� Code titles and language that complement accepted clinical practice

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Differences ….cont

� Injuries grouped by anatomical site in ICD-10 (head, leg, arm etc..) instead of type of injury as in ICD-9 (burn, wound, fracture)

� AMI reduced from 8 to 4 weeks

� 7th digit Extensions Specify Encounter

� Full Descriptions Reduce Cross-Referencing

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CODING BASICS

To master the basics of ICD-10-CM coding, you mustunderstand the foundation of coding in the home health environment.

ICD-10 coding involves understanding:

• Guidelines and Conventions• Sequencing issues and Z codes, sequelae and complications and OASIS

item rules• V,W,X,Y code use• Manifestation coding when necessary

In order to be an accurate and proficient coder, you must begin with the fundamental basics. They are the building blocks for a strong coding foundation.

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HOW TO SUCCEED

� Excellent assessment skills, with new and improved focus on anatomy/physiology

� Interdisciplinary communication

� Supporting documentation

� Adherence to official sources

� OASIS and coding accuracy

� A basic understand of Medicare PPS

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WHEN DO WE CODE

We Code:� UP FRONT – Intake / Admission� Per CMS, Complete the patient’s comprehensive assessment BEFORE

assigning the home health diagnoses Each patient’s overall medical condition and care needs must be comprehensively assessed before the HHA selects and assigns the OASIS diagnoses.

Coding in Home Care:

� Diagnosis codes should provide an updated, accurate picture of the patient’s health status that requires referral to home care or recertification.

� Focus of care is episodic.� Coding should reflect accurate prioritization of care.� Coding must be in compliance with the official coding guidelines

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Characteristics of ICD-10-CM

The official ICD-10-CM code book is published by the U.S. Department of Health and Human Services, its comprised of two volumes:

Volume 1: Tabular List of Diseases and Injuries Volume 2: Alphabetic Index to Diseases

Its available only on CD-ROM from the U.S. Government PrintingOffice in Washington, DC. A copyright of ICD-10-CM does not exist, so many versions of the

codebook appear on the market. Although each book may offer special features, the ICD-10-CM codes themselves remain the same.

Because ICD-10-CM is reviewed annually, it is important to remember that all ICD-10-CM codebooks must be kept current to reflect the revisions, deletions, and additions of codes that are generally implemented in the United States on October 1 of each year.

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New for ICD -10

� NO hypertension table

� Neoplasm Table is located after the alphabetized list and no more Morphology appendix

� ICD -10 will not use aftercare codes for fractures– Example : with ICD-9 we have “orthopedic aftercare” as a V-

code and in ICD-10 it will be included in the code as a 7th

character

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ALSO :

• The PLACEHOLDER

� Addition of dummy placeholder ‘X’ is used incertain codes to:

– Allow for future expansion– Fill out empty characters when a code

contains fewer than 6 characters and a 7thcharacter applies

� A new convention of using dashes ( - ) instead of an X in the alphabetical index will be instituted to help avoid confusion due to the addition of the “x” as a placeholder (watch for them in this presentation - don’t get confused !)

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Laterality

� The last character of the code denotes right or left

� In the case of a bilateral condition and no bilateral code available then 2 codes should be assigned for right and left.

� An unspecified code can be used if needed

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Unspecific Codes

� With the increased specificity of ICD-10 the use of unspecified codes is questioned

� You will still be able to use “unspecified”, “NOS” or “NEC” codes if needed

� You do want to avoid excessive use of unspecified –especially if the information is obtainable

Plan to make a lot more calls to MD

office for clarification ……..

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Manual Structure of ICD-10 CM

� Alpha index (Volume 2) structured the same– Index to Diseases and Injury – Index to External Causes of Injury.

� Tabular (Volume 1) similar but with exceptions– Codes listed in alphabetical order based on body system or

condition– All letters of the alphabet used except ‘U’ (some chapters

include 2 letters)

� Full code titles used in ICD-10 except where 7th digit extension required

� Some chapters have been restructured

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Chapter Changes

� ICD-9 has one chapter for Diseases of the Nervous System and Sense Organs ICD-10 has three separate chapters.

� ICD-10 does not separate External Causes of Injury and Poisonings (ICD-9 E codes) and the Factors Influencing Health Status and Contact with Health Services (ICD-9 V codes)

� The order of some of the chapters differs

� Category restructuring and code reorganization makes the classification of certain diseases and disorders different from ICD-9

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SO………

WHAT DO WE DO FIRST ????

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Hierarchy of Rules

� CONVENTIONS and instructions take precedence over the guidelines

� GUIDELINES are next in line

� CHAPTER specific guidelines are last to follow

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Conventions

� These are the general rules for the use of the classification system

� These are independent of the guidelines

� They are incorporated within the Index and Tabular list as instructional notes

� They are applicable regardless of the healthcare setting

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Conventions include :

� Punctuation

� Abbreviations– NEC

– NOS

� Includes notes

� Inclusion Terms

� Excludes Notes– Excludes 1

– Excludes 2

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More Conventions

� Typeface– Italicized

– Boldface

� Default Codes

� Syndromes

� And

� With / Without

� Use Additional Code

� Code First / Also

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Guidelines

� The set of rules that have been developed to accompany and complement the official conventions and instructions provided within ICD-10 itself

� They are based on the coding and sequencing instructions in the Tabular List and Alphabetical list

� Adherence to these guidelines is required under HIPPA

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Lets cover the

conventions first

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Punctuation

: The COLON is used with both includes and excludes notes

in which the words that precede the colon are not considered complete terms and therefore must be appended by one of the modifiers indented under the statement before the condition can

be assigned the correct code.

( ) PARENTHESES

Include non-essential modifiers – all words may mean the same code, the correct diagnosis doesn't have to be listed.

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Brackets indicate

<~~~~manifestation

BRACKETS BRACKETS [ ][ ]In Alphabetical In Alphabetical

list list ––

means a means a

manifestation manifestation

codecode

In the Tabular List -indicates synonyms, alternative wording, or explanatory phrases

You must code the etiology D89.1, first

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ABBREVIATIONS

� NEC - not elsewhere classified – means the diagnosis does not have a specific code

� NOS – means Not Otherwise Specified – you don’t have any more information on the condition/diagnosis

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INCLUDES NOTES

� INCLUDES means it can be in there but doesn’t have to be

� They define, clarify or give examples of the content of a code category

� Gives clues to the correct code

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Inclusion Terms

� Found under certain codes

� Indicate some of the conditions that the code may be used for

� Usually synonyms

� Not an exhaustive list

� Give clues to correct code

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Excludes notes

� The use of Excludes 1 and Excludes 2 is new for ICD-10

� The differences are :– Excludes 1

� This is a true excludes note like in ICD-9

� The patient cannot have both conditions

� Code only one condition

– Excludes 2 � Patient can have both conditions

� Code both if they have both

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EXCLUDES 1 and EXCLUDES 2

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TYPEFACE

� Italics – in brackets and in diagnoses in Alphabetical and Tabular list – mean manifestations, (that should NOT be coded primary or EXCLUDES notes

� BOLDFACE – indicates Main Entry Terms in Alphabetic Index, all codes, and description in Tabular list

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Default Codes

� The default code is listed next to the main term

in the alphabetic index

� Represents the condition most commonly associated with the main term

� This code may be assigned when there's no documentation for a more specific code

� May be an unspecified code

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Syndromes

� Follow the alphabetic index guidance when coding syndromes – look up by name of syndrome and then code symptoms or manifestations if instructed

� In the absence of index guidance, assign codes for the documented manifestations of the syndrome

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WITH/WITHOUT

� WITH – interpreted to mean “associated with”or “due to” when it appears in a code title, the alpha index or in an instructional note in the tabular list

– "with" is sequenced immediately following the main term in the alphabetic index

� WITHOUT – usually the default

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AND

� AND – interpreted to mean “and/or” when it appears in a code title within the tabular list

<~~~

<~~~

With/without

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Additional Code

� means just that

� You use and “additional code” to be more specific

� Optional and you only have to add it if you have the information

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Code First

� “Code first “ – means just that - unlike the option of an additional code, you MUST code another code first (usually an underlying condition)

� The Code first underlying disease instructional note found under certain codes is a sequencing rule. Most often this sequencing rule applies to the etiology/manifestation convention and is found under at the manifestation code

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ADDITIONAL CONVENTIONS

PAY ATTENTION TO :

� Icons for coding instructions

– Additional character required – indicate the characters needed for a code to be valid

– Manifestation codes – in italics

NOTE

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NOW FOR THE GUIDELINES

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Included are :

� Punctuation� Notes� Terms� Abbreviations� Sequela� Etiology/manifestation� Laterality ……etc….

These guidelines are found at the beginning of the code book and go through chapter specific guidelines

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Found at the beginning of some chapters

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COLOR CODING

� different books may have different color coding combinations for different things such as :

– Laterality

– Additional codes needed

– “code first” notes

– Clinical dimension

– Primary (also known as ‘Principle’ or ‘first-listed') or secondary only diagnoses or unspecified codes

– Manifestation codes

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Manifestation code

~~~>Note – italics and in blue

Note : ‘Excludes Notes’Also in italics

~~~~~~~~~>

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Red box ~~~~~>for additional character needed

Color coded yellow ~~~~~>For “unspecified code”

Color coded red

~~~~~~~>For ‘use additional code’

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Laterality

� If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

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ICD-9

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ICD-10

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Complications

� It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications.

� There must be a cause-and-effect relationship between the care provided and the condition along with an indication in the documentation that it is a complication.

� Query the provider for clarification, if the complication is not clearly documented

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Complications

� Chapter T contains the codes for “Complications of procedures, not elsewhere classified”

� If the procedure is found elsewhere, then the complication will be coded from that chapter– Example : Gastrostomy infection

� Found under Chapter K – Digestive System

� Coded as K94.22 Gastrostomy Infection

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Manifestation/Etiology

� The manifestation code may never be used alone or as a primary diagnosis (i.e., sequenced first). The instructional note, the code, and its descriptor appear in italics in the Tabular List

� The etiology MUST precede the manifestation otherwise its invalid

� Known as ‘dual coding’ and is mandatory

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PRIMARY ONLY

Look for symbols that tell whether itLook for symbols that tell whether it’’s a Primary only (Zs a Primary only (Z--codes)codes) or or

Secondary only (manifestations) diagnosis. Secondary only (manifestations) diagnosis.

Not to many Not to many ““Primary OnlyPrimary Only”” in home health anymore in home health anymore

PT only codes are gone but sequencing things like PT only codes are gone but sequencing things like ‘‘long term long term

use use ofof’’ or dressing changes as primary is not done in Home Healthor dressing changes as primary is not done in Home Health

HIV can now be primary also (In Texas)HIV can now be primary also (In Texas)

Follow footnotes, cross references and color coded promptsFollow footnotes, cross references and color coded prompts

Dual Coding (Mandatory)Dual Coding (Mandatory)A slanted bracket is in the Tabular list to indicate mandatory cA slanted bracket is in the Tabular list to indicate mandatory coding of both oding of both

etiology and manifestation.etiology and manifestation.

The Alphabetic Index also indentifies mandatory dual coding by uThe Alphabetic Index also indentifies mandatory dual coding by using the slanted sing the slanted

bracket [ ] with the code in italics.bracket [ ] with the code in italics.

SEQUENCING RULES

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A Change in Combination Codes

� Currently with ICD-9 you must follow the Etiology/Manifestation sequencing coding rule with diabetic codes, code the diabetes code and the manifestation code right after. With ICD-10 many become a combination code.

� Only one code is needed !!!

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NAVIGATING THE CODES

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STEP 1

� DO A GREAT AND COMPLETE ASSESSMENT !!

� Gather all MD information

– Face to Face

– Admit order

– H & P

– Discharge paperwork ect..

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Assessment Strategies

� Interview patient/caregiver to obtain past health history

� additional information may be obtained from the physician.

� Review current medications and other treatment approaches.

� Determine if additional diagnoses are suggested by current treatment regimen, and verify this information with the patient/caregiver and physician

� What medications is this patient taking for acute/chronic conditions?

� What therapies is this patient receiving (i.e., IV therapy, oxygen, renal dialysis),and for what reason?

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#1 . Lets dissect the “diagnostic statement”………

� The term is very vague but we need to clarify what to use and what not to use.

� The diagnostic statement comes from an MD. Usually in the form of a referral or a verbal order from a referral.

� It must be specific and state what the agency is to do for the patient.

� An order is NOT a referral from a social worker or a family member.

� You may see the patient for an initial assessment but the comprehensive assessment cannot be done till the order is in place.

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Must have specific orders if D/C only from hospital or rehab

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This patient is ready to start care immediately !!

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Thanks Doc !!

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Sometimes you have to pull out the diagnoses from the narrative

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Sometimes the diagnoses are all ready but we still have to prioritize and remove any resolved conditions – REMEMBER TO ALWAYS CHECK CODES !!

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This is why we must always check codes !!

(Its 618.82)

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And this is why…………

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They could also be wrong code numbers……..

Needs 5 digits !!

This one has to many digits !

(295.9)

(298.80)

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CODING CONSIDERATIONS

� The assessing clinician determines the primary and secondary diagnoses and records the symptom control ratings.

� The clinician should write in the diagnoses and a coding specialistmay enter the actual codes once the assessment is completed.

� It is prudent to allow for a policy and procedure that includescorrection or completion of a clinical record in the absence of the original clinician due to vacation, sick time, or termination or for correction or clarification of records to meet professional standards.

� This applies to M1010, M1016, and 1020/M1022/M1024. (which will have some changes when Oasis C-1 comes out)

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STEP 2

SEQUENCE DIAGNOSES -Choose primary and secondary

in order of priority

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CHOOSING AND SEQUENCING

When determining the primary diagnosis, ask yourself :

Why are we seeing this patient?

What other diagnoses affect/impact this patient’s care?

What co-morbid conditions should be monitored, evaluated, or treated as part of this patient’s POC?

The Plan of Care diagnoses MUST match the OASIS !!!

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What do we code ?

• Code only those diagnoses that are unresolved. If a patient has a resolved condition, which has no impact on the patient’s current plan of care, then the condition does not meet the criteria for a home health diagnosis, and should not be coded.

• Things like depression, Hx of CVA, joint replacement etc….will always affect patient care and should be coded

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What if no sequencing rules apply ?

Sequencing is part art, so even the best coders/clinicians can disagree on certain sequencing issues.

Sequencing is based on many clinical factors. The assessing clinicians judgment and development of the POC are key components.

There is no formula for sequencing.

Diagnoses should not be sequenced based on symptom control ratings, per OASIS-C guidance for M1020 and M1022.

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IF THE DIAGNOSIS UNDER CONSIDERATION IS NOT SUPPORTED BY

THE PATIENTS MEDICAL CONDITION AND CLINICAL CARE NEEDS,

THEN THE DIAGNOSIS MUST NOT BE REPORTED ON THE OASIS.

Do not code from med profile alone !!

Do not make up diagnosis, or change diagnosis because it “may pay better” or “its not billable” that is upcoding and NOT ALLOWED

HHAs are expected to report any indication of fraudulent coding directly

to the administrator of the HHA. If appropriate action is not taken, then

the clinician is expected to report this activity to the appropriate RHHI

hotline and/or to the State Surveyor hotline.

REMEMBER …….

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CHOOSING THE PRIMARY DIAGNOSIS

M1020a : (will be M1021a in October)The patient’s primary diagnosis is defined as the diagnosis most related to the current home health plan of care.

The primary diagnosis may or may not relate to the patient’s most recent hospitalstay, but must relate to the services rendered by the HHA.

They should not include any “busy” work, such as dressing changes, injections or any thing that is pertinent to care but is technically “unskilled”

What is ……..THE FOCUS OF CARE ?!

If more than one diagnosis is treated concurrently, the diagnosis that represents the most acute condition and requires the most intensiveservices should be assigned to M1020 of the OASIS.

It can be a Z code.

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Guidelines

� There are specific guidelines for selecting the primary diagnosis

� These can apply to all codes or chapter specific

� Those include : – Follow conventions first when sequencing diagnoses that

equally can be primary

– Don’t use symptom codes as primary if there is a more appropriate primary

– Don’t use symptom codes when coding a condition with those symptoms

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Guidelines cont….

– If diagnoses are documented as “either/or” then are coded as if both are confirmed and either can be primary

– Complications should be coded first

– If documented conditions are listed as “borderline”Code as if established diagnoses (clarify if needed)

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CHOOSING THE SECONDARY DIAGNOSIS

Can be V, W, X, Y or Z codes

They should also include any health factors that will affect a patients responsiveness to treatment and rehabilitative process

The order should also follow all sequencing rules and conventions.

Their order should best reflect the seriousness of the patients condition.

They include all pertinent diagnoses relevant to the care being rendered.

Secondary DOESN’T MEAN SECOND

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Guidelines

� “Other diagnoses” are defined as “all conditions that co-exist at the time of admission, that develop subsequently, or that affect the treatment and/or length of stay”

� In home health treatment would be considered the POC

� Earlier diagnoses that have no bearing on the current admission would not be considered.

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Guidelines – what not to include

� Resolved conditions – History codes that would impact POC can be included

� Abnormal Findings – X-rays, lab results etc.. Unless they are found to have a clinical significance (eg. R73.09 – abnormal glucose)

� Uncertain Diagnoses – only if documented “borderline” can it be coded in Home Health

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Coding symptoms

� Remember to not code symptoms as primary if you have a more specific diagnosis

� Do not code symptoms if you are coding a diagnosis that includesthose symptoms

� Code symptoms if there is no definitive diagnosis to list� Or if the symptom is not connected to a diagnosis� Home Health should use symptoms codes if any of the following

words appear in the documentation of diagnoses – “Probable”– “Suspected”– “Rule out”– “Working diagnosis”– “questionable”

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STEP 3

�Take first diagnosis and go to the alphabetical list……

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Index to Diseases and InjuriesVolume 2

� The Index to Diseases and Injuries includes the terminology for all the codes appearing in Volume 1.

� The Alphabetic Index employs levels of indentations:

- Main terms- Sub terms

Main Terms

� Printed in boldface type, main terms are set flush with the left margin of each column for easy reference. They may represent the following:

– • Diseases: influenza, bronchitis– • Conditions: fatigue, fracture, injury– • Nouns: disease, disturbance, syndrome– • Adjectives: double, large, kink

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SUB TERMS

� Some main terms are followed by a list of indented subterms(modifiers) that affect the selection of an appropriate code for a given diagnosis.

� Subterms are indented one standard indentation to the right under the main term. They describe essential differences in site, cause, or clinical type.

� More specific subterms are indented farther to the right, as needed; indented one standard indentation after the preceding subterm; and listed in alphabetical order.

A point to remember: Many conditions are found in more than one place in the Alphabetic Index

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0

Prior to selecting a code, all subentries following the main term should be reviewed to determine the appropriate code. Note that the terms with and without are listed at the beginning of all the subterms, rather than in alphabetical order.

Example :

Incontinence R32 ← Main Term

anal sphincter R15.9 ← Site

stress (female) N39.3 ← Cause

(male)

continuous N39.45 ← Clinical Type

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Terms

TERMS YOU MAY SEE IN ALPHABETICAL INDEX ARE :

� SEE – means you have to go there to find the right code

� SEE ALSO – for cross reference, look there also to see if that code is more specific

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Finding terms

� Myocardial Infarction� Vitamin B deficiency� Coronary Artery Disease� Acute renal failure� Staph infection� Congestive Heart Failure� Peptic ulcer� Closed fracture of femur� Stage III, pressure ulcer on heel

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Step 4

�Find the code in the Tabular list

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Volume 1: Tabular List of Diseases and Injuries

It includes:

� Classification of Diseases and Injuries from A to Z – with the exception of “U” which is reserved for WHO (the World Health Organization) for emergency codes

Classification of Diseases and Injuries

Volume 1

Classification of Diseases and Injuries, contains 21 chapters (by letters of the Alphabet, with some letters combined into a single chapter) that classify conditions according to etiology (cause of disease) or by specific anatomical (body) system.

EXAMPLE: Chapter 1 letters A & BCertain Infectious and Parasitic Diseases, represents

classification by etiology or cause of disease.Chapter 9 letter I

Diseases of the Circulatory System, representsclassification by anatomical system.

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The Tabular List contains the following 25 chapters:

A, B Infectious and Parasitic Diseases

C Neoplasm

D Neoplasms, Diseases of the Blood and Blood-Forming Organs

E Endocrine, Nutritional and Metabolic Diseases,and Immunity Disorders

F Mental Disorders

G Diseases of the Nervous System and Sense Organs

H Eye and Adnexa, Ear and Mastoid Process

I Diseases of the Circulatory System

J Diseases of the Respiratory System

K Diseases of the Digestive System

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L Diseases of the Skin and Subcutaneous Tissue

M Diseases of the Musculoskeletal System and Connective Tissue

N Diseases of the Genitourinary System

O Complications of Pregnancy, Childbirth, and the Puerperium

P Certain Conditions Originating in the Perinatal Period

Q Congenital Malformations, deformations and chromosomal abnormalities

R Symptoms, Signs, and abnormal clinical and laboratory findings

S, T Injury, Poisoning and certain other consequences of external causes

U Reserved for WHO emergency codes

V,W,X,Y External Causes of Morbidity

Z Factors influencing health status and contact with health services

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STEP 5

�Check Section Title

�Check Category

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Format

� Each chapter of Volume 1 is structured into the following subdivisions: Sections, Categories, and Subcategories.

Sections

� A section consists of a group of three-digit categories that represent a single disease entity, or a group of similar or closely related conditions.

– Example: DISEASES OF THE RESPIRATORY SYSTEM

(Chapter 10, Letter J)

Categories

� A three-digit category represents a single disease entity, or a group of similar or closely related conditions.

– Example: J01 ACUTE SINUSITIS

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Subcategories

� The fourth-digit subcategory provides more specificity or information regarding the etiology (cause of a disease or illness), site (location), or manifestation (display of characteristic signs, symptoms, or secondary processes of a disease or illness).

� A three-digit code cannot be assigned if a category has been subdivided and fourth digits are available.

– Example: J01 ACUTE SINUSITISJ01.0 ACUTE MAXILLARY SINUSITIS

11

0

11

1

Sub classifications

� In some cases, fourth-digit subcategories have been expanded to the fifth-digit level, and fifth digit subcategories expanded to the sixth digit level to provide even greater specificity..

11

2

FIFTH CHARACTER

11

3

STEP 6

READ

EVERYTHING !!!

11

4

STEP 6 …….again

� Chapter notes

� Includes Notes

� Excludes 1 Notes

� Excludes 2 Notes

� Code First Notes

� Additional Code Notes

EVERYTHING MEANS SOMETHING !!

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5

Additional Codes, Code First …….

11

6

The beginning of the chapter will give you

instructions such as “Excludes” notes and identify Blocks –as seen here –which break the chapter down

11

7

Some also include a to help code properlyNOTE

11

8

Analyze code structure

Current ICD – 9 structure

3 digits 1 digit 1 digit

11

9

ICD -10 CM STRUCTURE

12

0

STEP 7

� CHECK VALID CODE DIGITS

– Usually to the left of the code there is an indicator

– Keep moving down until there are no indicators

12

1

Fifth and sixth characters

12

2

Fifth and Sixth Characters

(subcategories and subclassifications)

� The fifth-character assignments and instructions that used to appear at the beginning of a chapter, a section or a three-character category, now are 6th and 7th character codes – combination codes

� These can be Alpha codes for site, such as proximal or distal, identify trimester (for OB cases), or time of assessment (such as coma/neuro ie. R40.21) –more specific then ICD-9

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3

STEP 8

ASSIGN YOUR CODE !!

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4

Example

Lets look at our commonly used Osteoarthritis

(OA) coding scenario

Diagnosis – OA, right hip. Left hip replaced

And compare the differences between ICD-9 and ICD-10 with additional characters

12

5

First we look up Osteoarthritis and it brings us to our 715 codes

Then we have to then decidePrimary, Secondary, Localized or Generalized

Then decide what partOf the body is affected, If it was given

FOR ICD-9

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6

Then we have to refer back to the beginning of the chapter to confirm the body part we want is the correct number

That will then give us the full correct code

715.15

12

7

For ICD-10

It is all separated into :•Sites•right/left•Bilateral•unilateral

M16.11

12

8

•Primary

12

9

and•Secondary(post traumatic)

13

0

ALERT……

“SEQUELA”is a new term for ICD – 10

It replaces

“LATE EFFECT”for ICD – 9

For the purposes of the 7th character it means “Late Effect” also

13

1

The 7th Character

Addition of 7th Character

� Used in certain chapters to provide information about the characteristic of the encounter

– Musculoskeletal

– Obstetrics

– Injuries

– External Causes

� Must always be used in the 7th character position

� Is a number in the Obstetrics chapter and Coma codes and a letter all others

� If a code has an applicable 7th character, the code must be reported with an appropriate 7th character value in order to be valid

� There is a different meaning depending on when it is used

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2

Acute Fracture Codes

ICD-10 does not have aftercare codes for trauma, allows home health to use the acute fracture code with a seventh digit to show it is asubsequent encounter for care:

The usual ones :

– Extension A, initial encounter: used while patient receiving active treatment (doesn’t always have to be “the first” encounter for that injury)

– Extension D, subsequent encounter: used for encounters after patient has had active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase(current definition of aftercare code)

– Extension S, sequela: used for complications or conditions that arise as a direct result of an injury (current definition of late effect code)

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3

Example 7th Character

Injury and External Cause� A = Initial encounter� D = Subsequent encounter� S = Sequela

Fractures� A = Initial encounter for closed fracture� B = Initial encounter for open fracture� D = Subsequent encounter for fracture with routine healing� G = Subsequent encounter for fracture with delayed healing� K = Subsequent encounter for fracture with nonunion� P = Subsequent encounter for fracture with malunion� S = Sequela

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4

Here is how it will look in the book

Lets break it down………

13

5

Be sure to read the notes included

13

6

Options for the 7th

character will be given in the category that requires it

13

7

Find what code you need. Use placeholder if its less then 6 characters then add appropriate 7th

character

13

8

Using 7th Characters correctly� A – initial encounter

– Should not be used – this is for

active treatment

(usually done in the hospital)

� D – subsequent encounter– After active treatment and receiving routine care

� “AFTERCARE”

� S – sequela– Complications

� LATE EFFECT

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9

Be careful to watch between injury/trauma fractures and pathological/stress fractures

Note : these will need the placeholder (x) in the 6th place due to only having 5 characters

~~~~~>

14

0

SEQUELA

� Sequela is the residual effect of a condition after the acute phase has ended

� There is no time limit on when the sequela code can be used

� 2 codes – one for the condition produced and the sequela code - are usually needed to code sequelacorrectly, unless :

– The sequela code has been expanded to include the manifestation

– Or the condition is a manifestation and cannot go first

14

1

Assessing Degree of Symptom Control

� Assessing the degree of symptom control includes review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care providers.

� Inquire about the degree to which each condition limits daily activities. Assess the patient to determine if symptoms are controlled by current treatments. Clarify which diagnoses/symptoms have been poorly controlled in the recent past.

� Utilize definitions given in OASIS

14

2

SYMPTOM CONTROL RATING

14

3

NEVER ENDING CODES …….

� Certain things that will always impact the patient will always be coded such as :

� Hx of any malignancy (and ONLY if its been erradicated)

� Depression

� Tobacco use

� Stage III or Stage IV pressure ulcers (even if closed)

� Hx CVA

� Hx of MI

� Allergic reactions

– Use clinical judgment for others

14

4

OASIS CONSIDERATIONS

� We must consider codes not only in M1020 - which will be (M1021) and M1022- which will be (M1023) but in other areas of OASIS.

� Coding in the other M values have slightly different rules (only certain codes are accepted)

� These areas are necessary for OASIS compliance

14

5

14

6

Was M1016 now M1017

14

7

Was M1010 now M1011

14

8

OLD ICD-9 structure

250 6 0

Diabetes Mellitus with neurological manifestations

14

9

Etiology/Manifestation

� In ICD-9 you would need an additional code for addressing any neurological conditions

– Example :

� DM II with diabetic polyneuropathy

– Coded currently as

� 250.60 Diabetes with neurological manifestations

AND

� 357.2 Polyneuropathy in Diabetes

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0

OLD ICD-9 structure

357 2

Diabetic polyneuropathy

No subclass

15

1

NEW ICD -10 STRUCTURE

E 1 0 4 2Not

needed

Not needed

Type 1 Diabetes Mellitus with diabetic polyneuropathy

15

2

LETS TRY CODING !

Referral for patient comes in and states :

Orders : Admit to home health

Diagnosis :

HTN, DM II, GERD, polyneuropathy, arthritis

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3

Narrative:

Pt is a 75 year old Caucasian male, with history of DM II, polyneuropathy, HTN, arthritis and GERD(controlled with meds). Pt reports having right knee surgery over 15 years ago, cataracts removed 4 or 5 years ago, caregiver states he was hospitalized for “depression” 2 years ago. Patient takes daily insulin for about 6 years and says he lost about 10 pounds a “couple months ago”, states he gets SOB when “going to next room”, and takes Tums when he has “heartburn”

Assessment notes :

BM yesterday, edema – 1 + bilat, feet, ankles to lower calf , breath sounds clear and unlabored bilat, pain level at 3 on 0-10 scale in knees/feet

Medications : Tramadol, Sertraline (Zoloft), Lasix, Reg Insulin 4 Units prior to meals, Losartan, Miralax, Simvastatin, Tums OTC, Potassium

15

4

15

5

Chapter

by

Chapter

15

6

� Always make sure to read guidelines in the beginning of book and the beginning of each chapter

� Follow notes that may appear at the beginning of each category– Excludes 1

– Excludes 2

� Follow notes that are at the beginning of each sub category– “use additional code”

– “code first”

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7

Chapter 1

INFECTIOUS AND PARASITIC DISEASES

Letters A and B

15

8

Notes :

� This will be the chapter used for infectious agents. – HINT : A = we have the ‘bug’ but no specific site

B = we know the site and ‘bug’

� Some of these will still fall under “additional codes”when prompted by other diagnoses

� Sequencing can depend on different codes instructions

15

9

Sepsis

� Sepsis replaced Septicemia in Chapter 1

– Assign code for underlying systemic infection

� “Urosepsis” is a non specific term and has no code ask MD for clarification !

� Post-procedural sepsis

– Must be documented by MD

– T –code first

– Use A 40 (streptococcal sepis) to A 41 (other sepsis) code

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0

Severe sepsis

� Bacteremia is coded to R78.81 and septicemia to A41.9. A code from subcategory R65.2 should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.

� Septic Shock cannot be primary– Infection should be sequenced first

� Severe sepsis is in Chapter R (symptoms, signs, abnormal findings) (R65.21)

� Severe sepsis will usually need 3 codes (min. of 2)– Infection– R code (R65.2 category)– Associated organ problems

16

1

MRSA

� Should not use A49 , site is needed

� Use instead B95.62 (MRSA in diseases classified elsewhere) if there is no appropriate combo code

� Do not use Z16.11, that would be the equivalent V-code for resistant bacteria but check Excludes notes (watch the A49.02 code is listed but remember try NOT to use it !)

� Always code ANY drug resistance (when applicable) ~ from Z16 category

16

2

HIV

� Code B20, Human immunodeficiency virus disease, is used to report a diagnosis of symptomatic HIV disease.

� If a patient is admitted for an HIV related condition then the HIV (B20) is coded first

� Code Z21, Asymptomatic human immunodeficiency virus infection is used to report a patient who has tested HIV positive but has not yet developed symptoms from the HIV disease

16

3

Example

� Patient seen with symptoms of UTI. UA was positive and culture showed E.coli. A 10 day course of antibiotics were prescribed.

� Assign the codes.

16

4

Answer

� N39.0 = Urinary tract infection

� B96.20 = E coli – in diseases classified elsewhere

16

5

Chapter 2

NEOPLASMS

Chapter C and D

16

6

� First look up the terms given in the alphabetical index first

� Then refer to the neoplasm table– Located AFTER the index in the ICD-10 book

� Then go to the tabular list to confirm� Do not report “history of” neoplasm unless you are sure it

has been eradicated. (Z85-)

Remember : MD must state remission status. Do not rely on patient account

16

7

Primary vs. Secondary

� If the primary site is the reason for care then the primary goes first followed by any metastatic sites

� If the metastatic site is the reason for care then it can go primary followed by the primary site

� Only use HX code if primary site was eradicated

� Default to coding the site as a current neoplasm if your not sure

16

8

MORPHOLOGY CODE CHANGES

ICD - 10

ICD - 9

16

9

Found at the beginning of Chapter 2

17

0

Site Specific codes

� For overlapping sites (called contiguous sites in ICD-9) : – For tumors that extend to other sites :

� Example : – C16.8 = Malignant neoplasm of overlapping sites of stomach OR

– C 41.0 = Malignant neoplasm of skull and face

– For 2 different neoplasms same site, code each site separately � Example :

– C34.11 = Malignant neoplasm of upper lobe, right bronchus or lungAND

– C34.31 = Malignant neoplasm of lower lobe, right bronchus or lung

17

1

5th Character

� A change in classification - The addition of a separate fifth character for extranodal and solid organ sites

� In ICD-9 theres a fifth digit for unspecified site in codes for Hodgkin’s disease, non-Hodgkin’s lymphoma, peripheral, and cutaneous T-cell lymphomas.

17

2

Unspecified / NOS

� Use C80.0 = Generalized Malignancy – only if metastatic neoplasms and there is no known primary site

� Use C80.1 = Cancer NOS – used only if the primary site is unknown

� Its always better to code multiple sites if known then to used a general non specific code

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3

Other Neoplasm Codes

� G89.3 = Neoplasm related pain, chronic or acute, malignant or benign

� M84.5- or M84.5--- = pathological fracture due to neoplasm

– Sequence first if the fracture is the reason for homecare

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4

Chapter 3

DISEASES OF THE BLOOD AND

BLOOD FORMING ORGANS AND

CERTAIN DISORDERS INVOLVING

THE IMMUNE MECHANISM

Chapter D

17

5

What's new

� The Immune Disorders are now classified here instead of the Endocrine Chapter as in ICD-9

� Diseases and disorders have been classified better to make finding them easier

� Categories have been modified to bring the terminology up to date with current medical practice

� More classifications mean greater specificity

17

6

� For “anemia associated with an adverse effect of the administration of chemotherapy or immunotherapy”

– and treatment is for the anemia, the anemia code is sequenced first followed by the appropriate codes for the neoplasm and the adverse effect

� For “anemia associated with an adverse effect of radiotherapy”– the anemia code should be sequenced first

– followed by the appropriate neoplasm code and code Y84.2, “Radiological procedure and radiotherapy as the cause of abnormalreaction of the patient, or of later complication, without mention of misadventure at the time of the procedure”

Anemia

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7

Sequencing Notes

� For ‘anemia associated with the malignancy’ and the treatment is only for anemia, the appropriate code for the malignancy is sequenced followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease). This is a change from ICD-9

� Sequence the complication first even if it’s a symptom, if that is the reason for the homecare

– Example : dehydration, pain, weakness

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8

Example

� A 67 year old male admitted to home health with colon cancer and pain related to tumors. He is anemic due to the cancer and needs monitoring of pain meds, diet and HTN.

Hint : for anemia - do not look under “due to”

17

9

Answer

� C18.9 = colon cancer

� G89.3 = neoplasm pain

� D63.0 = anemia from neoplasm

� I10 = HTN

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0

Chapter 4

ENDOCRINE, NUTRITIONAL AND METABOLIC

DISORDERS

Chapter E

18

1

What's new

� Expansion of the instructions for coding "late effects" or sequelae– Example: Excludes1 notes have been added to some categories in

E50–E63 to indicate that the sequelae of the nutritional deficiency are assigned a code from category E64

� New instructional notes that clarify code usage also are found under specific codes

– Example: E34.0, Carcinoid syndrome, includes a note that states this code may be used as an additional code to identify functional activity associated with a carcinoid tumor.

*(No such note appears under the ICD-9-CM code 259.2 for this same condition.)

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2

� Diabetes mellitus and malnutrition have their own subchapter

� The common diabetic codes will now be combo codes ! Yay !

– Which means less codes to look up and take up space

� MD must still clarify if neuropathy is diabetic related or specify “poly” neuropathy

� If MD doesn’t specify or only writes “DM” the default code is E11, Type 2 DM

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3

DM II coding

� E11.9 – Type 2 DM without complications – now found at end of category instead of beginning

� “Additional code” still needed for glaucoma, insulin use,

gastroparesis, osteomylitis and any ulcers

� You can still use as many DM codes as needed for multiple manifestations

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4

NEW CODE !!

� *New Code* DM with high blood sugars. A good substitute for the “controlled” and “uncontrolled” code issue

E11.65 DM II with hyperglycemia

E11.64- DM II with hypoglycemia

18

5

Diabetes 4th Characters

E11. -� 2 = Renal

� 3 = Ophthalmic

� 4 = Neurological

� 5 = Circulatory

� 6 = Other

� 7 ……doesn’t exist

� 8 = unspecified – (DO NOT USE)

� 9 = Without complications

– This is our equivalent to 250.00

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6

Manifestation Notes

� E11.22 ~ Type 2 Diabetes with diabetic chronic kidney disease (DM II, Renal)

– Still needs additional note for stage

� E11.3- Has retinopathy and macular edema here

� E11.4- includes the neuropathies

– Will still need additional code for gastroparesis

� E11.5- gangrene, includes the peripheral angiopathy

� E11.610 ~ includes Charcots

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7

More Manifestation notes

� E11.6 –

– Need additional code for site of ulcer

� E11.64- Hypoglycemia

� E11.65 ~ Hyperglycemia

� E11.69 Any other manifestations

– Needs additional code

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8

Example

� The patient was referred for disease management of diabetes, HTN & CKD. He has ESRD and is supposed to go to dialysis 3x’s a week but he only goes when he is in severe distress. He is also on insulin, but has knowledge deficit regarding disease process, insulin, blood sugar and foot care. The patient also has mild emphysema.

18

9

19

0

Diabetes is the primary focus of care. Since the patient’s kidney disease is linked to both the Diabetes and the HTN, it is correct to code the E11.22

(Diabetes type II with kidney complications) as primary followed by the I12.0 (Hypertensive chronic kidney disease) since coding guidelines instructs us to assume the relationship between the HTN and the kidney disease (CKD). Emphysema(J43.9) is a comorbidity that should always be coded.

N18.6 (ESRD) and Z79.4 (long-term use of insulin) are added because the above categories say to “use additional code”.

This patient is on dialysis but since he is often non-compliant, it is appropriate to code Z91.15 (non-compliance with

dialysis).

Rationale

19

1

Other nutritional and Endocrine

� Hyperlipidemia is classified here

� Obesity\Overweight must be documented by MD

� BMI can be coded based on height and weight

19

2

Chapter 5

MENTAL, BEHAVIORAL,

NEURODEVELOPMENTAL

DISORDERS

Chapter F

19

3

Includes :

� Depression

� Anxiety / bipolar disorders

� Pain associated with psychological causes

� Behavioral disturbances

� Dementias

19

4

What's new

� Organization, terminology, some different instructional notes– Example: F54, “Psychological and behavioral factors associated with

disorders or diseases classified elsewhere” the note states to "code first the associated physical disorder."

• The ICD-9 equvalent—316—has a note to "use additional code to identify the associated physical condition”

� Due to the overwhelming evidence of all of the problems nicotineuse causes ~ there is a new separate category F17 for nicotine dependence with subcategories to identify the specific tobacco product and nicotine-induced disorder

19

5

� This is the chapter that will give you the substance use/abuse/and dependence codes. Remember to code correctly based on what the MD diagnosis states.

– If “use/abuse” both documented then code for “abuse

– If “ abuse/dependence” both documented then code for dependence”

– If “use/abuse/dependence” all documented then code only for dependence

– If ‘use/dependence” documented then code for dependence

19

6

Remember

� Depression – Do NOT code unless documented by MD

� Not all meds are used for depression

� Pain associated with psychological causes– F45.41 for pain exclusive to psychological disorder– Pain with related psychological factors should be coded from category

G89 (and code related factors)

� Behavioral disturbances– Be sure to check if it’s a manifestation code (it would be in italics)

because you need to make sure you code the etiology first

� Dementias– Be sure if its F02 category it needs an etiology code– Unspecified is F03 category

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7

Chapter 6

DISEASES OF THE NERVOUS

SYSTEM

Chapter G

19

8

Includes :

� Pain, Pain syndromes

� Sequela (Late Effects)

� Parkinsons

� Alzheimers

� Menengitis

� Seizures

� Neuropathies

19

9

What's new ?

� A few categories have rephrased titles and include a combination of conditions.

� The classification of sleep disorders has changed – These disorders are now included in here rather than the signs

and symptoms chapter as in ICD-9

– Sleep apnea has its own subcategory (G47.3) with fifth characterspecificity to identify type

� A number of codes for diseases of the nervous system have been expanded

– Example :Alzheimer’s disease (G30) has been expanded to reflect onset (early vs. late)

20

0

Pain

� Don’t code pain if it is not addressed on the POC– Should be specified Acute, Chronic, post op, neoplasm related

etc….

� The Pain codes in G89 (Pain, NEC) should not be assigned if the cause of the pain is from a more specific cause (see excludes 2 notes)

� You can add additional codes if the pain code from G89 doesn't describe it fully

� Post op pain should be documented by MD– Because post op pain should be expected unless its not ordinary

20

1

More Pain

� No time limit from ‘acute’ to ‘chronic’

� “Chronic pain” should be documented by MD

� “Chronic Pain Syndrome” is different then chronic painand MUST be documented by MD

� If ‘pain management’ is the focus then the pain code goes first

� Neoplasm related Pain– G89.3

– Can be primary or secondary

– Includes acute and chronic

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2

Dominance RuleDiseases of the Nervous System

For any :– Hemiplegia (paralysis one side)

– Hemiparesis (weakness one side)

– Monoplegia (paralysis one limb/muscle group)

– Monoparesis (weakness one limb/muscle group)

� When dominant side is not known or specified– Default to dominant for ambidextrous

– Left side defaults to non-dominant

– Right side defaults to dominant

20

3

SEIZURES

� G40.309 (generalized idiopathic epilepsy and eplileptic syndromes, not intractable, without status epilepticus) Is the general code for seizures. It is eqivalent to 345.80 which is used for “recurrent seizures”

� The symptom code R56.9 (unspecified convulsions) which is equivalent to 780.39 “seizure NOS” or “recurrent convulsions”should only be used if the patient has one seizure and maybe a diagnosis is pending

20

4

Chapter 7, 8

EYE AND ADNEXA

EAR AND MASTOID PROCESS

Chapter H

20

5

Includes :

� Glaucoma

� Retinopathy

� Cataracts

� Blindness

� Vertigo

This chapter used to be part of the Nervous System chapter

20

6

What's new

� Chapter 7 is an entirely new chapter

� Many codes have been expanded for laterality

� Some title changes reflect new terminology– Example : "senile cataract" now changed to "age-

related cataract"

20

7

Retinopathy

– DM with retinopathy is now a combo code, with can include macular edema

– MD must specify relationship between DM and retinopathy, otherwise its just a retinopathy code

20

8

Glaucoma

– If each eye has different types and/or stages you will need a code for each eye

– Assign as many codes as needed for each eye

– For ‘indeterminate” stage the 7th character should be “4”� Not “0” which is to be used when the stage is NOT documented

– You can use the bilateral code with the 7th digit if they are the same� If they are the same type but different stage then utilize 7th character

for stage

– Code for highest stage documented

– If not known � H40.9 (unspecified glaucoma)

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9

Chapter 8

� Be sure to use an External Cause code when known for coding Ear Conditions

� And for “nonsuppurative otitis media” (H65) and “suppurative and unspecified otitis media” (H66)

Also identify :– Exposure to environmental tobacco smoke (Z77.22); – Exposure to tobacco smoke in the perinatal period (P96.81); – History of tobacco use (Z87.891); – Occupational exposure to environmental tobacco smoke (Z57.31); – Tobacco dependence (F17.-); and – Tobacco use (Z72.0).

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0

Chapter 9

DISEASES OF THE

CIRCULATORY SYSTEM

Chapter I

21

1

What’s New

� Some terminology has been revised

Examples:– ICD-9 = 411.1 Intermediate coronary syndrome

– ICD-10 = I20.0 Unstable angina

– ICD-9 = 410 Acute myocardial infarction

– ICD-10 = I21 ST elevation (STEMI) and non-ST (NSTEMI) myocardial infarction

– ICD-9 = 411.81 Acute coronary occlusion without myocardial infarction

– ICD-10 = I24.0 Acute coronary thrombosis not resulting in myocardial infarction

21

2

MI’s

� There is a change from ICD-9 to ICD-10 when it comes to coding MI’s

– MI’s can only be coded as “acute” for 4 weeks post occurrence - ICD-9 was up to 8 weeks

– There is no longer a fifth digit to represent what episode of care the encounter is

21

3

Hypertension

� Hypertensive Heart Disease

– Can be a stated or implied (heart disease unspecified I51.9)

– MD must state a relationship

� Hypertensive Chronic Kidney Disease

– Can assume a relationship between HTN and CKD and code to I12-

� If it is essential HTN with no stated/assumed cause then its I10 (401.9 in ICD-9, there is no more 401.0 or 401.1 malignant/benign)

21

4

Example of “implied” relationship

� If a patient has both acute systolic heart failure and hypertension, no causal condition relationship needs to be documented to use the combination code, I11.0. (hypertensive

heart disease with heart failure)

� Or the word “hypertensive” is used

21

5

Hypertensive Heart Disease

� When using a code from category I11, “Hypertensive heart disease”, when a relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category I50, heart failure, to identify the type of heart failure.

� If a patient has the same heart conditions with

hypertension, but without a stated causal relationship they are coded separately.

21

6

Remember :

� there is no hypertension table in ICD-10

� no more classifying the type of HTN– ie. Essential, malignant, benign

� Category I10 (essential (primary) hypertension) to I15 (secondary hypertension) includes “controlled”and “uncontrolled”

– Controlled = meds are working

– Uncontrolled = untreated or meds not working

21

7

Other considerations

� Heart failure should only be coded if diagnosed by MD

� CVA effects should be documented by MD

� Documentation must support HTN coding of I11(hypertensive heart disease) or I13 (hypertensive

heart and chronic kidney disease)

21

8

Angina

� I120 Angina codes are used when no CAD is present ~ there is a separate code for CAD w/angina

� Post infarction angina would also be a separate code I23-

21

9

Guidelines

� Guidelines are very important for these three categories (I21, I22, I23) to indicate correct usage.

– Category I22, “Subsequent acute myocardial infarction”must be used in conjunction with a code from I21, ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI).

– Category I23, Certain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction must be used in conjunction with a code from category I21 or I22.

22

0

Coding MI’sThere are essentially three codes to choose from There are essentially three codes to choose from when coding an MI in home health: when coding an MI in home health:

I21.0I21.0-- (acute myocardial infarction, last digits will (acute myocardial infarction, last digits will

depend on what part of the heart was depend on what part of the heart was affected) affected)

I25.2 (old myocardial infarction)I25.2 (old myocardial infarction)I25.89 (other forms of ischemic heart disease)I25.89 (other forms of ischemic heart disease)

An MI occurring in the past four weeks is considered An MI occurring in the past four weeks is considered acute and is coded to the I21 category. The codes in acute and is coded to the I21 category. The codes in

categories I21 require four or five digits. But categories I21 require four or five digits. But remember, no need to indicate what episode of care it remember, no need to indicate what episode of care it

is. is.

““Acute MIAcute MI”” will be coded before CADwill be coded before CAD

22

1

CODING MI’s (cont)

If the MI occurred more than four weeks prior to the home health episode, you must choose between two codes: I25.2 or I25.89

•Assign code I25.2 when the MI is specified as old or if it has healed and is no longer presenting with symptoms.

• If the patient is still presenting with symptoms more than four weeks after the date of the infarction, assign code I25.89

This code can also be used when documentation indicates that the MI is chronic.

22

2

Heart Failure

� Our go to 428.0 for CHF is no longer available in ICD-10� Its counterpart 428.9 Heart Failure, Unspecified, is what

the equivalent would be– I50.9 Heart Failure, Unspecified includes Congestive Heart

Failure NOS

� This is the reason we have to get more info from MD and know more anatomy to get the right code. It is not known if I50.9 will get points like 428.0 did. Grouper logic will change so we wont know until then

� Remember, MD must specify if diastolic or systolic so we must know before we code one !

22

3

Example

� Patient has just been discharged to home following an anterior wall STEMI. Home health will be monitoring her HTN, and teaching on diet and CAD. She had already had an inferior wall MI 3 and a half weeks prior.

� Lets code this

22

4

Answer

� I22.0 = Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

� I21.19 = ST elevation (STEMI) myocardial infarction involving right coronary artery

� I10 = Essential (primary) hypertension

� I25.10 = Atherosclerotic heart disease of native coronary artery without angina pectoris

22

5

CVA

� Remember the term “Late Effects” is now obsolete ~ the new term is “Sequelae” (in the alphabetical index)

� Knowing what type of CVA is expected because the sequelae is divided up into types of strokes – clots / bleeds

� There is a NOS code for sequelae of documented “stroke” ~ I69.3 - - (most require 6 digits)

� Do not use I69.9- Excludes notes indicate ‘stroke’sequelae is found elsewhere

22

6

SEQUELAI 69

� Sequela is the residual effect of a condition after the acute phase has ended

� There is no time limit on when the sequela code can be used

� 2 codes – one for the condition produced and the sequela code - are usually needed to code sequelacorrectly, unless :

– The sequela code has been expanded to include the manifestation

– Or the condition is a manifestation and cannot go first

22

7

Dominance Rule (for CVA sequela)

For any :– Hemiplegia (paralysis one side)

– Hemiparesis (weakness one side)

– Monoplegia (paralysis one limb/muscle group)

– Monoparesis (weakness one limb/muscle group)

� When dominant side is not known or specified

– Default to dominant for ambidextrous

– Left side defaults to non-dominant

– Right side defaults to dominant

22

8

Example

� Patient has a history of stroke and now has right sided hemiparesis and cannot perform most ADL’s or take medications appropriately. He Will get PT and has HTN with elevations.

22

9

Answer

� I69.351 = hemiplegia and hemiparesis

following cerebral infarction affecting right

dominant side

� I10 – Essential (primary) hypertension

23

0

Chapter 10

DISEASES OF THE RESPIRATORY SYSTEM

Chapter J

23

1

What’s New

� Some diseases have been rearranged.

� Greater specificity than found in ICD-9

– Examples: � ICD-10 - J10.8, Influenza due to other identified virus with

other manifestations, has been expanded to reflect the manifestations of the influenza

� ICD-10 - J20, Acute bronchitis, has been expanded to reflect the manifestations of the acute bronchitis

23

2

Instructional notes

� Use an additional code, where applicable through out entire chapter to identify:

– Exposure to environmental tobacco smoke (Z77.22) – Exposure to tobacco smoke in the perinatal period (P96.81) – History of tobacco use (Z87.891) – Occupational exposure to environmental tobacco smoke (Z57.31) – Tobacco dependence (F17.-) – Tobacco use (Z72.0)

� When a respiratory condition is described as occurring in more than one site, it should be classified to the lower anatomic site."

– Example: Tracheobronchitis is classified to bronchitis in J40, Bronchitis, not specified as acute or chronic.

23

3

Others

� Terminology brought up-to-date

– Examples:

� ICD-10 - J43, Emphysema, contains codes with panlobular emphysema and centrilobar emphysema in their titles

� ICD-10 - J45, Asthma, classifies asthma as mild intermittent, mild persistent, moderate persistent and severe persistent

23

4

Conditions

� Acute Respiratory Failure ~ can be primary if it is the chief reason the person was hospitalized

� Influenza ~ code only confirmed cases of influenza due to certain viruses– Can be MD confirmation

– Assign “influenza due to unidentified influenza virus” if MD states :� “suspected” , “possible” or “probable”

23

5

Example

� Pt has COPD and was hospitalized due to an acute exacerbation. He is admitted to home health to be monitored. He is receiving supplemental 02 at night, and the discharge papers state he also has emphysema along with his HTN

� Lets code this

23

6

Answer

� J44.1 = chronic obstructive pulmonary

disease with (acute) exacerbation

� J43.9 = emphysema, unspecified

� I10 = essential (primary) hypertension

� Z99.81 = dependence on supplemental

oxygen

23

7

Chapter 11

DISEASES OF THE DIGESTIVE SYSTEM

Chapter K

23

8

What’s New

� New subchapters have been added

– diseases of the liver

� Some terminology changes and revisions to the classification of specific digestive conditions

23

9

Examples

� “Regional enteritis” (Crohns disease)– The expansion at the fourth character level specifies the site of

the Crohn’s disease, the fifth character indicates whether a complication was present, and the sixth character further classifies the specific complication.

� K50.00 Crohn’s disease, has been expanded to the fourth, fifth, and sixth character

� Ulcers

– The presence or absence of obstruction is used as a basis for classifying ulcers.

24

0

Example

� There were some instructional note modifications made to specific codes

– Examples:� ICD-9 556 Ulcerative colitis

– no instructions for code usage

� ICD-10 K51 Ulcerative colitis– Use an additional code to identify manifestations

� ICD-9 550 - 553 Hernia– no instructions for code usage

� ICD-10 K40 – K46 Hernia– Hernia with both gangrene and obstruction is classified to hernia

with gangrene

24

1

Chapter 12

DISEASES OF THE SKIN AND

SUBCUTANEOUS TISSUES

Chapter L

24

2

What’s New

� Restructuring: – It brings together related groups of diseases

– Greater specificity has been added to many of the codes at the fourth-, fifth- and even the sixth-character levels

� The addition of a subchapter (or block) for “radiation-related disorders of the skin and subcutaneous tissue”

– The conditions found in this block are not located together in ICD-9

24

3

What else

� Classification improvement ~ the addition of characters to represent the site and severity of the decubitus ulcer

� New terminology

– Example : "androgenic alopecia"

24

4

Chapter Guidelines

� A note has been added to categories L20–L30 that reads: "in this block the terms dermatitis and eczema are used synonymously and interchangeably."

� Excludes notes have been expanded

24

5

Pressure Ulcers

� In ICD-9 two codes were required to code this specificity. ICD-10-CM provides the site (including laterality) and the stage all in one code.

� Don’t confuse “unstageable” with “unspecified stage”– Unstageable means you cant see the depth to stage it – Unspecified means MD did not stage the ulcer

� Check clinical terms in alphabetical index

24

6

NON – PRESSURE ULCER – with terms

24

7

PRESSURE ULCER – with terms

24

8

Superficial injuries

•Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

• Skin Tears = Partial Thickness Wounds = Injuries, superficial

• Payne-Martin Classification1) Is care skilled? Skin tears don’t ordinarily require

the skills of a nurse.2) If an underlying condition will complicate thehealing…

24

9

Lets try an example

MD orders state :CHF, COPD, Diabetic foot ulcer, DM II,diabetic retinopathy, do wound care

Narrative: 68 year old Hispanic female with Hx of CHF, COPD, DM II. Diabetic ulcer present on left

outside ankle that needs wound care. Patient reports cataract surgery X 8 years ago, knee surgery X 10 years ago, hysterectomy “many years ago” and pacemaker inserted 4 years ago. Pt c/o cough with occasional clear sputum, “cant always catch her breath”. Pain is 5 of 0-10 scale on left knee and both ankles, “especially where sore is at”

Meds :Metformin, lasix, coumadin, albuterol, ducolax, Vitamin B

Assessment :

Mild wheezes bilat, BM 2 days ago, 3 cm X 5 cm ulcer on left outside ankle with fatty tissue showing, patient has a lot of trouble reading medication bottles when asked

25

0

25

1

Chapter 13

DISEASES OF THE

MUSCULOSKELETAL SYSTEM

AND CONNECTIVE TISSUE

Chapter M

25

2

What's New

� Almost every code has been expanded

� Many codes were moved from various chapters

– Examples:

� Category 274, Gout, moved from the Endocrine chapter in ICD-9 to here

� Code 268.2, Osteomalacia, unspecified, also moved from the Endocrine chapter to here

� Code 524.4, Malocclusion, unspecified, moved from the Digestive chapter to here

25

3

What else

� Category M80 classifies the type of osteoporosis with the site of a current pathological fracture into one combination code.

� Some categories and subcategories in require the use of seventh characters.

� The seventh characters found in Chapter 13 are: – A initial encounter for fracture

– B subsequent encounter for fracture with routine healing

– G subsequent encounter for fracture with delayed healing

– K subsequent encounter for fracture with nonunion

– P subsequent encounter for fracture with malunion

– S sequelae

25

4

Chapter Guidelines

� For the correct usage of categories M00–M02, (infectious arthropathies) new guidelines provide definitions for direct and indirect infection.

– Direct infection of joint, where organisms invade synovial tissue and microbial antigen is present in the joint.

– Indirect infection, which may be of two types: a reactive arthropathy, where microbial infection of the body is established but neitherorganisms nor antigens can be identified in the joint, and a postinfectivearthropathy, where microbial antigen is present but recovery of an organism is inconstant and evidence of local multiplication is lacking.

25

5

More guidelines

� Instructional notes have been added to different categories or subcategories to explain how codes should be assigned.

– Examples:� M21.7 Unequal limb length (acquired)

Note: The site used should correspond to the shorter limb

� M50 Cervical disc disordersNote: Code to the most superior level of disorder

� Instructional notes have also been added to define terms. – Examples:

� M66 Spontaneous rupture of synovium and tendonNote: A spontaneous rupture is one that occurs when a normal force is applied to tissues that are inferred to have less than normal strength

25

6

Highlights

� Abnormality of gait has its own sub category

– GO TO : ~~~~~ > R26.9

– Includes all gaits and “difficulty in walking” also

� Repeated falls is a new code in symptoms and signs –different from hx of falling

� Gout is now found here instead of in Endocrine as in ICD-9

� If a bone is affected at the joint the site will be the bone and not the joint

25

7

Site and laterality

� Site represents the bone joint or muscle involved

� For some conditions there may be a ‘multiple site’ code

� If no ‘multiple site’ code available then a code for each site is used

25

8

Included in this chapter

� Recurrent conditions

� Result of previous trauma, and

� Chronic conditions

� Stress fractures and pathological fractures :

Of Bone, Joint or Muscle is in this chapter

~ Acute or current injuries are found in Chapter S

25

9

The 7th character

� For fractures the 7 th character is used

� Letter “A” is used for active, or initial treatment

– Initial treatment doesn’t have to mean the very first encounter

– It can be any first encounter – ie. a specialist, an x-ray etc –evaluation at treatment by a new MD

� Letter “D” is an encounter after active treatment has been received

26

0

Choosing the 7th character

� The 7th character for different codes will be found at the beginning of the categories

� Check the list for other specific qualifiers ie. delayed healing, malunion, sequela etc..

� Complications will be coded in the 7th

character

26

1

26

2

26

3

Other

� Complications would still use complication codes (in the injury/consequences chapter S-T)

� Aftercare of fracture is coded together with fracture

– Example : Aftercare of right hip fracture is

� M84.451D

– Which translates to : “pathological fracture, right

femur, subsequent encounter for fracture with routine

healing”

26

4

Guidelines

� If a fracture is not indicated as open or closed it should be coded as closed

� Complications of surgical treatment for fractures would be coded with appropriate complications code

26

5

Osteoporosis

� Osteoporosis now has 2 categories

– Osteoporosis without current fracture

– Osteoporosis with current fracture

� Must have fracture at the time of encounter

� Don’t use if patient had fracture from Osteoporosis in the past and is healed

– Use History code Z87.310 (history of healed pathological fracture due to Osteoporosis)

26

6

Osteoporosis Fractures

� Always use a code from category M80 and identify the site even if the patient fell and got the fracture (which would usually be considered a traumatic fracture) IF the fall would not have normally cause a bone to break

26

7

Chapter 14

DISEASES OF THE

GENITOURINARY SYSTEM

Chapter N

26

8

What’s New

� Some changes were made because of outdated terminology. – Example: Given what has been discovered about

male erectile dysfunction, ICD-10 includes category N52 for this condition with subcategories to identify the different causes of dysfunction.

* (ICD-9-CM has a single code, 607.84, for impotence of organic origin)

26

9

Chapter Guidelines

New Includes Notes

� Examples:

– N00Acute nephritic syndrome

� Includes: acute glomerular diseaseacute glomerulonephritisacute nephritis

27

0

CKD

� Stage 2 = mild CKD

� Stage 3 = moderate CKD

� Stage 4 = severe CKD

27

1

Chapter 15

PREGNANCY, CHILDBIRTH

AND THE PUERPERIUM

Chapter O

27

2

What's New

� CODES FROM THIS CHAPTER ARE FOR USE ONLY ON MATERNAL RECORDS, NEVER ON

NEWBORN RECORDS

� Guideline changes to a number of codes

– Examples:

� ICD-9 Category 643

– early and late vomiting differentiated by 22 completed weeks

� ICD-10 Category O21

– early and late vomiting differentiated by 20 completed weeks

27

3

References

� Trimesters are counted from the first day of the last menstrual period

– 1st trimester—less than 14 weeks 0 days – 2nd trimester—14 weeks 0 days to less than 28 weeks 0

days – 3rd trimester—28 weeks 0 days until delivery

� Postpartum– Begins immediately after delivery and continues for 6 weeks

� Peripartum– Last month of pregnancy until 5 months postpartum

27

4

Chapter Guidelines

� Chapter 15 codes have sequencing priority over other chapters

� Additional codes from other chapters can be used in addition to clarify

� It is the providers responsibility to state that the condition is not affected by the pregnancy

� The final character indicates trimester in most codes– In some codes it designates the fetus

27

5

Chapter 16

CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD

Chapter P

27

6

What's New

� New notes that help to clarify how codes are to be used.

� Codes are only for use on the newborn or infant record, never on the maternal record

� Codes are also only applicable for liveborn infants

� When a condition originates in the perinatal period and continues throughout the life of the child, the perinatalcode should continue to be used regardless of the age of the patient

27

7

Chapter Guidelines

� Perinatal period – Before birth and through the 28th day following

birth

� Codes from other chapter may be used to specify condition

� A condition is defaulted to the birth process if MD doesn’t specify between community or birth related

27

8

Chapter 17

CONGENITAL MALFORMATIONS,

DEFORMATIONS AND

CHROMOSOMAL ABNORMALITIES

Chapter Q

27

9

What's New/Guidelines

� Modifications made to specific codes

� Congenital anomalies or syndromes may occur as a set of symptoms or multiple malformations. If there is no specific code, a code should be assigned from any chapter in the classification for each manifestation of the syndrome.

28

0

Chapter Guidelines

� May be principle or secondary

� Can be used for the life of the patient

� For syndromes with specific codes, additional codes may be assigned to identify manifestations not included in the specific code.

28

1

Chapter 18

SYMPTOMS, SIGNS AND

ABNORMAL CLINICAL AND

LABORATRORY FINDINGS

Chapter R

28

2

What’s New

� Some codes have been moved from one chapter to another.

– Examples:

� ICD-9 Chapter 7 427.89

– Other specified cardiac dysrythmias

� ICD-10 Chapter 18 R00.1

– Bradycardia, unspecified

� ICD-9 Chapter 8 511.0

– Pleurisy without mention of effusion or current tuberculosis

� ICD-10 Chapter 18 R09.1

– Pleurisy

28

3

What else

� Hematuria is coded in Chapter 18 unless included with the underlying condition such as acute cystitis with hematuria. Then the code is found in Chapter 14, Diseases of the genitourinary system

� Many of the categories have extensive Excludes1 notes

28

4

Chapter Guidelines

� General guidelines and specific instructions have been published in the ICD-10 Guidelines for Coding and Reporting for the following:

– SIRS due to a non-infectious process

– Repeated falls

– Glasgow coma scale

– Death not otherwise specified

28

5

When to use

� When no definitive diagnosis has been established

� When a symptom not normally associated with the condition is present

� Code definitive diagnosis first

� Use a combo code if/when available

28

6

Example

� Repeated Falls (R29.6)

– Used when fall happened and reason is being investigated

� History of Falling (Z91.81)

– Used when patient has fallen in the past and is at risk for future falls

� You may assign these codes together

28

7

Chapter 19

INJURY, POISONING AND

CERTAIN OTHER

CONSEQUENCES OF

EXTERNAL CAUSES

Chapter S,T

28

8

What's New

� Injury types are grouped together under by site and not by injury

� Some categories have undergone title changes to reflect new terminology

– Example: the terms "displaced" and "nondisplaced" in the code descriptors; these terms are not used in ICD-9

28

9

What else

� The term “corrosion” is an added term

� The burn codes identify thermal burns, except for sunburns, that come from a heat source.

� The burn codes are also for burns resulting from electricity and radiation.

� Corrosions are burns due to chemicals.

29

0

More Changes

� ‘Poisonings’ and ‘adverse effect’. Are under a single category for the specific drug

� Codes for poisonings, adverse effects, and underdosingof drugs, medicaments, and biological substances are all found in the same table

� Underdosing is a new term and is defined as :– taking less of a medication than is prescribed by a physician or

the manufacturer’s instructions with a resulting negative health consequence.

29

1

Poisonings, adverse effects and underdosing are combination codes.

� Example:

T37.5 Poisoning by, adverse effect of and underdosing of antiviral drugs

– T37.5X1 Poisoning by antiviral drugs, accidental (unintentional)

– T37.5X2 Poisoning by antiviral drugs, intentional self-harm

– T37.5X3 Poisoning by antiviral drugs, assault

– T37.5X4 Poisoning by antiviral drugs, undetermined

– T37.5X5 Adverse effect of antiviral drugs

– T37.5X6 Underdosing of antiviral drugs

29

2

Adverse effects, poisoning etc..

� Do not code directly from Table of Drugs

– Always refer to the tabular list as usual

� Use as many codes as needed

� Code only one code for agent if it contributed to 2 different coded conditions

� Code both agents if they both contributed to condition

29

3

Adverse Effect

� Drug has been correctly prescribed and properly administered

– Code the adverse effect followed by the “adverse effect” code

29

4

Poisoning

� Assign appropriate code from Category T36 – T50

� Check that 7th character is appropriate

� Use additional code for manifestations

� Use additional code for abuse or dependence if applicable

29

5

Underdosing

� Taking less of a medication then was prescribed by provider or by directions

� Underdosing is NOT a primary diagnosis

� Non Compliance (Z91.12- or Z91.13-) or Complication of Care (Y63.61, Y63.8 or Y63.9) are to be used if reason is known

29

6

Toxic Effects

� A harmful substance has come in contact with a person or has been injested

� Include :

– Accidental

– Self harm

– Assault

– Undetermined

29

7

Chapter Guidelines

� Use secondary code(s) from External Causes of Morbidity, to

indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code.

� Instructions for coding open wounds have changed – In the fourth-digit subdivisions under ICD-9, a note defined complicated

to mean open wounds with infection.

– ICD-10 contains a note under the different categories for open wounds (e.g., S01, S11) that states to code also any associated wound infection.

29

8

More Chapter Guidelines

� A change in the instructions for complications of surgical and medical care, not elsewhere classified (T80–T88).

– ICD-10 includes a note stating to use additional code (Y62–Y82) to identify devices involved and details of circumstances.

29

9

Listings of Conditions

Generally, the listings of conditions that follow the site are as follows: � Superficial injury � Open wound � Fracture � Dislocation and sprain � Injury of nerves � Injury of blood vessels � Injury of muscle and tendon � Crushing injury � Traumatic amputation � Other and unspecified injuries

30

0

The Difference

� ICD – 9

– Fractures (800-829)

– Dislocations (830–839)

– Strains and Sprains (840-848)

� ICD – 10

– Injuries to the Head (S00-S09)

– Injuries to the Neck (S10-S19)

– Injuries to the Thorax (S20-S29)� And so on…

30

1

Comparison

30

2

7th Characters

� Most categories in Chapter 19 have seventh characters that identify the encounter.

� Review the fracture seventh characters carefully before assigning a seventh character extension

� Appropriate 7 th characters are found at the beginning of the category

� Most are :– A initial encounter– D subsequent encounter (includes aftercare)– S sequela

� Make sure to sequence the sequela first then the injury that caused it

30

3

30

4

UP CLOSE……. OPTIONS for 7th character

30

5

Note complications included some options

30

6

Injuries

� Assign separate codes for each injury unless a combination code is provided

� Code the most serious injury first

� Don’t code a superficial injury when there is a more serious one at the same site

� Make sure you don’t code surgical

wounds here !!!

30

7

Example - Trauma Wound

� Patient was mowing lawn at his house and ran over wire hanger which penetrated his right calf above the Achilles tendon. He pulled it out and kept mowing. Three days later he has an infected necrosed wound. He undergoes surgery to clean it up and close the laceration

30

8

S81.811DM1020 Laceration right lower leg

M1020If CleanT81.4xxDM1020

open

wound calf,

complicated

M1020If complicated

Add, dressing changes if applicable and the infection if known

30

9

For ICD-10

� There is no Aftercare codes for trauma.

� Code the injury and the 7th character will identify the aftercare.

� In this case the “D” designates the subsequent encounter which the home health agency is.

31

0

891.0M1022 open

wound calf, no

mention of

complication

V58.43M1020 AC inj

or trauma

M1024M1020If Clean

891.1M1020

open

wound calf,

complicated

M1020If complicated

DIFFERS FROM ICD-9

31

1

Fractures

� This is for traumatic fractures only

� Use appropriate 7th character

� Do not use “Z” aftercare codes for traumatic fractures

� Stress or Osteoporosis related fractures would come from M80 category

31

2

Burns

� Burn codes are for:– “thermal” burns (from heat source)

– Burns from electricity or radiation

� Corrosions are – From burns from chemical sources

� Guidelines are the same for both

31

3

Burn Guidelines

� Current Burns are classified by

– Depth

– Agent

– Extent

� First degree ~ erythemal

� Second degree ~ blistering

� Third degree ~ full thickness

� Burns of the eye and internal organs are classified by site

31

4

Burn Guidelines cont..

� Code worst burn first

� Non-healing burns are coded as ‘acute’

� Use additional code for infected burn

� Assign separate codes for each burn site

� External Cause Code should be used with burns/corrosions to identify source

� Use category T31 and T32 when using the “rule of nines”

31

5

Reference

� Head and Neck = 9 %

� Each arm = 9 %

� Each leg = 18 %

� Anterior trunk = 18 %

� Posterior trunk = 18 %

� Genitalia = 1 %

Providers may change these numbers based on individual (ex. Child, obese etc..)

31

6

Current V and E codes

V,W,X,Y – External causes of morbidity (“E – codes”)

- How were they hurt *

-Where they were when they were hurt

-What activity were they doing

- External cause status

• Note: * only required external cause code in HH

Z – Factors influencing health status and contact with health services (“V - codes”)

31

7

Chapter 20

EXTERNAL CAUSES OF

MORBIDITY

Chapter V,W,X,Y

31

8

What’s New

� 7th character added� The codes for external causes are no longer found in a

separate section they are in :

– Chapter 19 ~ Injury, Poisoning and Certain Other Consequences of External Causes

or to

– Chapter 20 ~ External Causes of Morbidity.

31

9

What Else

� Changes made in terminology

� Category changes allow for expansion of codes at the fourth-, fifth-, or sixth-character level.

– Example:� ICD-9 E884.0 Fall from playground equipment

– ICD-10 W09 Fall on and from playground equipment– W09.0 Fall on or from playground slide

– W09.1 Fall from playground swing

– W09.2 Fall on or from jungle gym

– W09.8 Fall on or from other playground equipment

32

0

Chapter Guidelines

� These are secondary codes

� Intended to provide data for injury research and injury prevention strategies

� These codes capture :– How the injury/death happened

� The cause

– Intent� Accidental

� Intentional– Suicide

– Assault

– Place

– Activity at the time

– Persons status� Civilian

� military

32

1

More Guidelines

� These codes are not mandatory but strongly encouraged

� Use as many codes as needed to describe event

� Use Alphabetical list and Inclusion/Exclusion notes to help with selection

� NEVER a primary diagnosis !

� ‘Place of Occurence’ codes are after ‘cause’ code

� ‘Activity’ codes are not applicable to poisonings, adverse effects, misadventures or sequela

32

2

Using External Cause Codes

� Code all External Cause codes when known– Cause– Place– Activity– Status

� Do not use a STATUS (Y99) code if no other External Codes are applicable

� Place of Occurrence codes AND

� Activity codesAre only used at the INITIAL encounter visit

32

3

Example - Trauma Wound

� Patient was mowing lawn at his house and ran over wire hanger which penetrated his right calf above the Achilles tendon. He pulled it out and kept mowing. Three days later he has an infected necrosed wound. He undergoes surgery to clean it up and close the laceration

� Finish coding External codes

32

4

E- codes - Answer

� Y92.017 = yard

� W45.8xD = foreign object entering skin

� Y93.H2 = Activity involving exterior property maintenance

� Y99.8 = leisure activity

32

5

W31.81xA

Contact with Flying Horse……

32

6

Chapter 21

FACTORS INFLUENCING

HEALTH STATUS AND

CONTACT WITH HEALTH

SERVICES

Chapter Z

32

7

What’s New

� Some rephrased titles

� Some conditions no longer have the specificity that they did in ICD-9

– Example: Code Z23, Encounter for immunization is not further classified. (ICD-9 category codes V03, V04, V05 and V06 are used to identify the types of immunizations)

32

8

Tobacco/Drug Use

� If a patient smokes it is appropriate to use the “use”� If a patient has been a smoker in the past then code – Z87.891

(personal history of nicotine dependence)� If MD writes diagnosis of “use” then code it as - Z72.0 (tobacco

use)� If diagnosis of “dependence” (or both dependence/abuse) then

code as – F17.2xx (dependence on nicotine – xx = clarification needed (ie. cigarettes, chewing, withdrawal etc…) for x values)

� If MD diagnoses “abuse” (or both use/abuse) code for ‘dependence’ for nicotine and ‘abuse’ code for any other drugs

For drugs – same guidelines apply – except for drugs they have an “use, dependence and abuse code”

32

9

Z codes(previously V codes)

� History of

� Acquired absence of

� Aftercare

� Joint replacement

� Long term use of

� Adjustments and Fittings

� Status of

� Attn to

� BMI codes

33

0

Using Z codes

� Z codes represent reasons for encounters

� Same basic guidelines as using V-codes

– When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.

� Attn to – present but SN is providing care

33

1

Status

Indications :

� Patient has sequela, past disease, or carrier

� Presence of prosthetic or mechanical device

� Is informative ~ status may affect care

� Use when present but someone else provides care (such as trach or colostomy)

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History of

� Personal and Family

� Explains :– Patient no longer has condition

– Not receiving treatment

– Potential for recurrence

� Family Hx codes are used when patient is at high risk for disease due to family history (usually used for “screening” visit purposes)

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Aftercare

� Has to be routine healing (no complications, fracture/injury)

� Aftercare is coded in those codes with 7th

character

� Generally primary diagnosis

� Should be used with other codes to clarify

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AFTERCARE Example:

The patient had a ruptured appendix and underwent surgery. The wound is healing by secondary intention without complications. The patient also has HTN and persistent redness without blanching on her left elbow.

Answer :

• Z48.815 Encounter for surgical aftercare on the digestive system

• I10 Essential (primary) hypertension

•L89.021 Pressure ulcer of left elbow, stage 1

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Changes

� Non-compliance codes have expanded – good for data collection and explanation of care

Examples :

– Non compliance with dietary regimen (Z91.11)

– Unintentional underdosing due to financial hardship (Z91.120)

� NO more PHYSICAL THERAPY only codes

– Code the problem instead

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PT Example

� Mrs. January is receiving physical therapy thru the agency for recurrent falls due to progressing Parkinson's disease

– Primary Parkinson’s G20

– Recurrent Falls R29.6

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Z code cheat sheet

� Aftercare for joint replacement – Z47.1

� Use additional code to identify joint

� Tobacco Use – Z72.0 (not dependence/history)

� Long term insulin use – Z79.4

� Foley catheter change – Z46.6

� Anticoagulant use – Z79.01

� Attn. to colostomy - Z43.3

� Colostomy status – Z93.3

� History of Falls - Z91.81

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Z code cheat sheet

� Dependance on supplemental oxygen - Z99.81

� Routine IV care – Z45.2

� Pacemaker status – Z95.0

� Cardiac defibrillator – Z95.810

� Amputation status – Z89.---– --- = site amputated, most sites have

laterality included � Example – Z89.411 – acquired absence of right great toe

� Bed bound - Z74.01

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Full code descriptions

� ICD – 10

– http://www.cdc.gov/nchs/icd/icd10cm.htm

� ICD – 9

– http://www.cdc.gov/nchs/icd/icd9cm.htm

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Equivalent Mapping

� http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html.

� Go to : 2014 General Equivalence Mappings – Diagnosis Codes and Guide

– Then open : Dxgem_guide_2014.pdf

� The GEMS contain an entry for every ICD-9 code but not every ICD-10 code

� You can “forward map” from ICD-9 to ICD-10 or “backward map” from ICD-10 to ICD-9 (a ‘source code’and a ‘target code’)

� Be sure to download the “How to” guide along with it for ease of mapping

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Sample of Mapping

� T422X1A 9662 10111 � T422X1A E8558 10112 � T422X1A 9660 10121 � T422X1A E8558 10122 � T422X1D V5889 10000 � T422X1S 9090 10111 � T422X1S E9292 10112 � T422X2A 9662 10111 � T422X2A E9504 10112 � T422X2A 9660 10121 � T422X2A E9504 10122 � T422X2D V5889 10000 � T422X2S 9090 10111 � T422X2S E959 10112

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T422X1A 9662 10111

� The first set of numbers is ICD-10 (T42.2x1A)

� The second set of numbers is ICD-9 “EQUIVALENT”(966.2)

� The third set of numbers is possible “flags” to coder– 1 - Approximate code (may or may not be the same)

– 0 - No Map (no equivalent code)

– 1 - Combination (may have other equivalent codes)

– 1 - Scenario (you need to combine codes to get equivalent)

– 1 - Choice (you need to choose from a combination of codes to get the equivalent)

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Sample entry

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Translation

� In this instance the I-9 code specifies that the traumatic amputation is bilateral but does not specify whether it is partial or complete. Since both types of information—left or right foot, and whether the amputation is partial or complete—are specified in separate codes in I-10, the entry in the I-9 to I-10 GEM is a combination entry. There are two choice lists in this entry, because two codes in I-10 are required to satisfy the equivalent meaning in the I-9 combination code. And because the injury can be partial on one side and complete on the other,both sides partial, or both sides complete, there are two choices in each choice list.

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� After collating the combination entries into their respective choice lists (there is only one scenario), the four valid clusters are:

� 896.2 Traumatic amputation of foot (complete) (partial), bilateral, without mention of complication � To � S98.011A � Complete traumatic amputation of right foot at ankle level � AND

� S98.012A

� Complete traumatic amputation of left foot at ankle level16 � OR

� S98.011A � Complete traumatic amputation of right foot at ankle level � AND

� S98.022A � Partial traumatic amputation of left foot at ankle level � OR

� S98.021A � Partial traumatic amputation of right foot at ankle level � AND

� S98.012A � Complete traumatic amputation of left foot at ankle level � OR

� S98.021A � Partial traumatic amputation of right foot at ankle level � AND

� S98.022A � Partial traumatic amputation of left foot at ankle level

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IMPACT OF THE PPS ON ICD-9 CODING

•On October 1, 2000, Medicare began reimbursing home health agencies a

specific amount (referred to as a “unit of payment” or fixed amount) for

all services provided during a 60-day episode of care.

•The law requires the 60-day episode to include all covered home health

services and routine/non-routine medical supplies.

•Certain drugs and durable medical equipment are reimbursed separately.

Redefined OASIS items and ICD-10 codes that determine

payment based on a case mix adjustment model

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Case Mix Points

� Case Mix Diagnosis Points

� Case mix points are earned for primary and other (secondary) diagnoses

� Three diagnosis groups yield varying case mix points depending on primary or secondary status:

– Diabetes

– Neuro 1 (Brain and paralysis)

– Skin 1 (Traumatic wounds, burns, and postoperative wound complications)

� Points are counted only once for the same diagnosis group by theGrouper.

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� How do we get case mix points?

� Case mix points are determined by:

� Certain OASIS data items in three dimensions- Clinical Severity: C1 – C3

- Functional Status: F1 – F3

- Service Utilization: S1 – S5

� Primary versus secondary diagnosis

� Diagnosis interactions

� Diagnosis and OASIS interactions

� Early versus later episode

� Number of therapy visits

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PPS and Case Mix

Payment for all Medicare providers paid on a prospective payment system is based on a case mix.

Home Health AgenciesHospitalsNursing Homes

CMS analyzed home care claims data and developed a list of diagnoses that require more intensive resources and contribute to the case mix.

These are the case mix diagnoses:

•Blindness•Blood disorders•Cancer & select benign neoplasms•Diabetes•Dysphagia•Gait AbnormalityGastrointestinaldisorders•Heart Disease•Hypertension•Neuro 1 (Brain)•Neuro 2 (Peripheral)

•Neuro 3 (CVA)•Neuro 4 (MS)•Ortho 1•Ortho 2•Psych 1 (Affective)•Psych 2 (Degenerative)•Pulmonary disorders•Skin 1 (Trauma, burns,

post-operative complications)•Skin 2 (Ulcers, abscesses)•Tracheostomy Care•Urostomy/Cystostomy Care

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Case Mix and Case Mix DiagnosesRecognizes that patients use different amounts of resourcesPredicts patient resource use based on characteristics determined by data collected using the OASIS data set

Data elements describe three dimensions – Clinical Severity, Functional Status, and Service UtilizationClassifies patients into case mix groups or home health resource groups (HHRGs)

153 case mix weightsEach combination = a different weight and a different payment

Case mix diagnoses = Potential pointsThe 22 case mix diagnosis groups can earn case mix points when coded in:

M1021a, Primary diagnosisM1023b-f, Other (Secondary) diagnoses

Case mix diagnosis points contribute to the clinical severity dimension when calculating the HHRG.

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Skin 1—Case Mix Diagnoses

22Primary or Other Diagnosis = Skin 1 –

Traumatic wounds, burns, and postoperative

complications OR Skin 2- Ulcers and other skin

conditions

AND M1030 =1 (IV/Infusion) or 2 (Parenteral)

4466Other Diagnosis = Skin 1 – Traumatic

wounds, burns, and post-operative

complications

2082010Primary Diagnosis = Skin 1 – Traumatic

wounds, burns, and post-operative

complications

4321Equation

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Example: Mrs. Warren was admitted to Home health, only due to worsening of her emphysema. She has dyspnea with moderate exertion when performing ADLs and walking less than 20 feet using her walker. She said she’s “feeling down” about being hospitalized again, but denies being depressed. She’s on an antidepressant and the MD documented a history of depression and A fib in the H&P. She also said she’s incontinent at night because she can’t get to the bathroom in time.

Functional score = F2No therapy = S11st Medicare episode of care

$1, 901.47Reimbursement

C1F2S1HHRG

4Clinical points (ICD-10-CM and

OASIS)

1Emphysema + Ambulation = 1 or >M1860

2Dyspnea = 2 (walking < 20 feet)M1400

0Atrial fib M1022

1Emphysema M1020

Case Mix

Points

Diagnoses and OASIS ItemsData Items

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Reviewed by coder/QA

$2,288.89Reimbursement

C3F2S1HHRG

7Clinical points (ICD-9-CM and OASIS)

1Emphysema + Ambulation = 1 or >M1860

2Dyspnea = 2 (walking < 20 feet)M1400

3Depression NOS M1022

0Atrial fib M1022

1Emphysema M1020

Case Mix PointsDiagnoses and OASIS ItemsData Items

Financial ImpactC3F2S1 = $2,288.89C2F2S1 = $1,901.47

could amount to a $387.42 loss !!

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!

Non-Routine Supplies (NRS)

Placement of diagnoses as primary or secondary may affect NRS points.Diagnoses must support OASIS data items related to NRS – for example if a pressure ulcer is identified in M1308 or M1322, it should be coded in M1020, M1022, or as an “other” diagnosis.NRS points are cumulative and payment is in addition to the HHRG payment, which could add hundreds of dollars to the episode payment!

Clinicians must…Determine correct diagnoses and sequencingUnderstand the underlying etiology of ulcersCorrectly stage pressure ulcersAccurately describe the healing status of pressure ulcers, stasis ulcers, and surgical woundsHave supporting and consistent documentation!Additional Resource: www.wocn.org

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Non-Routine Supplies (NRS)

DiagnosesSkin conditions such as abscesses, cellulitis, gangrene, chronic ulcers, trauma wounds, burns, post-op complications, and care of tracheostomy,

cystostomy, and urostomy.

OASIS data elementsPressure ulcers, stasis ulcers, surgical wounds, ostomy for bowel elimination, therapy at home (IV, parenteral, or enteral), urinary catheter, and bowel incontinence.

Supplies Provided Supplies Not Provided

Severity Level 1 S 1 $14.12Severity Level 2 T 2 $51.00Severity Level 3 U 3 $139.84Severity Level 4 V 4 $207.76Severity Level 5 W 5 $320.37Severity Level 6 X 6 $500.00

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TRANSITIONING

What do home health agencies need to do to prepare for ICD -10-CM?

� Watch for the updated version of the OASIS data set, OASIS C -1, with revisions to accommodate ICD-10 diagnosis codes in M1010, 1016, 1020, and M1022.

� Develop an implementation strategy that includes an assessment of the impact on your organization, a detailed timeline, and a realistic budget. Identify personnel that will require training and start preparing them. TYNET INSTITUTE estimates 16 hours of coding training andan additional 10 hours of practice coding to become proficient in ICD-10 coding.

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TRANSITIONING

� Begin updating your clinicians’ knowledge of anatomy, pathophysiology, medical terminology, and pharmacology. Express the importance of doing a thorough assessment ICD-10 CM is much more detailed and complex than ICD-9

� Get familiar with ICD-10 codes: learn the ICD-10 counterparts for the most commonly used ICD-9 codes, gradually orient to the ICD-10 system

� Begin training on the ICD -10 code set, purchase an ICD-10 manual, schedule training for your coding staff, arrange coding coverage(outsource if you have to – THINK TYNET !!) while coders are in training, allow for the “learning curve” when ICD-10 finally goes live.

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What are we all going to look like on 10/2 ???

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QUESTIONS

� Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?

� No. This change does not affect CPT coding for outpatient procedures. ICD-10 procedure codes are for hospital inpatient procedures only.

� Who is affected by the transition to ICD-10? If I don’t deal with Medicare claims, will I have to transition?

� Everyone covered by the HIPAA must transition to ICD-10 on October 1, 2015, including providers and payers who do not deal with Medicare claims.

� Do state Medicaid programs need to transition to ICD-10? � Yes. Like all other HIPAA covered entities, state Medicaid programs must

comply with ICD-10 by October 1, 2015. CMS is continuing to work with Medicaid programs to help ensure they meet the deadline.

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� What happens if I don’t switch to ICD-10? � Claims for all services and hospital inpatient procedures provided

on or after October 1, 2015, must use ICD-10 diagnosis and

inpatient procedure codes. (This does not apply to CPT coding for outpatient procedures.) Claims that do not use ICD-10 diagnosis and inpatient procedure codes cannot be processed. It is important to note, however, that claims for services and inpatient procedures provided before October 1, 2015, must use ICD-9 codes even if they are submitted after the compliance date.

� If I transition early to ICD-10, will CMS be able to process my claims?

– No. CMS and other payers will not be able to process claims using ICD-10 until the October 1, 2015, compliance date. However, keep in mind the dates for episodes that end after October 1 – you will most likely have to dual code for RAP/EOE.

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Summary of Changes for the OASIS C-1

The Centers for Medicare & Medicaid Services (CMS) has issued a draft version of the Outcome and Assessment Information Set (OASIS) C-1.

The proposed version - OASIS - C1 - reflects changes to accommodate coding of diagnoses using the ICD-10-CM coding set that will most likely take effect with ICD-10 implementation. Additionally, revisions reflect issues raised by stakeholders - such as updating clinical concepts and modifying item wording and response categories to improve item clarity.

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OASIS C-1…. cont.

� Further, CMS has removed items not currently used for payment, quality, or risk adjustment to reduce the burden associated with the OASIS data collection.Below is a summary of the key changes to the OASIS C-1 assessment instrument.

ICD-10 related changes - Items in the OASIS-C that report patient diagnoses (M1010, M1016, M1020, M1022, and M1024) have been revised to accommodate ICD-10-CM coding.

� These items now have space to enter 7-digit codes, and references to prior ICD-9 “E” and “V” codes were removed.

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Was M1010 now M1011

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Was M1016 now M1017

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OASIS C-1 …..cont.

� Modifying and clarifying item wording – Wording changes designed to clarify questions, responses or directions were made to 44 items in OASIS-C1. These include clarification of data collection time periods and spelling out abbreviations such as “e.g.” and “i.e.” with clearer language such as “for example” and “specifically”.

Increased Harmonization – Column 2 on M1308 was eliminated at all time points and replaced with M1309 at Discharge to collect information on worsening pressure ulcer status using wording harmonized with other post-acute data collection instruments.

Updated clinical concepts – M1032, Risk for Hospitalization, was revised to collect data on factors that have been identified in the literature as predictive of hospitalization, and to order responses based on length of the appropriate look-back period.

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OASIS C-1… cont.

� Deleted at Discharge

� Collection of the following items will no longer occur at discharge since they are used only for risk adjustment of quality measures. They will continue to be collected at SOC and ROC.

� Item M1350 reports whether the patient has a skin lesion or openwound that is receiving intervention from the home health agency, other than a surgical wound, pressure or stasis ulcer.

� Item M1410 reports the types of respiratory treatments (oxygen, ventilator etc) the patient is receiving at home.

� Item M2110 reports how frequently the patient receives assistance with activities of daily living from caregivers other than the home health agency.

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OASIS C-1 …cont.

Deleted Items

� Item M1012, Inpatient Procedures.

� Items M1310, M1312, and M1314, which report the length, width and depth of the pressure ulcer with the largest surface dimension.

� Item M2440- Reason patient was admitted to a nursing facility. Collected at the time of transfer from home health to a skilled nursing facility.

�

Note: When changes to an item substantively change the question or response options, a new item number has been assigned to the item

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Summary of items used

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OASIS C-1 ….cont.

Impact of Item Deletion

The impact of these changes on the number of items in the OASIS dataset is shown in Table

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Resources

� Selman-Holman & Associates, LLC

� http://www.who.int/classifications/icd/en/

� https://www.youtube.com/watch?v=kCV6aFlA-Sc&feature=youtu.be

� Sue Bowman is the author of the March 2008 AHIMA Journal article "Why ICD-10 is Worth the Trouble”

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Official Sources

� Coding Guidelines and Conventions

� Coding Clinic (by CMS)

� Medicare Benefit and Claims Processing Manual

� OASIS – C Guidance Manual

– Appendix – D (diagnoses)

– Chapter 3 (data items)

� From CMS

� PPS Final Rules

� CMS Q & A’s

� OASIS ANSWERS.com

� ICD-9-C M Official Guidelines forCoding and Reporting,

http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf

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Available AHIMA Resources

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THANK YOU!

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