ICD10 PEARLS AND PITFALLS -Eckenrodt · 2014. 10. 14. · ICD –ICD –––9999----CMCCMMCM ICD ICDICD – ––– 10 110010- ---CMCCMMCM Approx.14,000 codes Over 68,000 codes

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Presented by:Connie Eckenrodt, RHIT, CHCA, CHC

Every reasonable effort has been taken to ensure that the educational information provided in this presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation. A thorough individual

review of the information is recommended and to establish individual facility guidelines.

Presenter makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied

guarantee of suitability for any specific purpose. Presenter has no liability or responsibility to any person or entity with respect to any

loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this presentation. Presenter makes no guarantee that the

use of this presentation material will prevent differences of opinion or disputes with Medicare or other third party payers as to

the amount that will be paid to providers of service.

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With 20 years in health information management, Ms. Eckenrodt’s focus has been on outpatient coding in the hospital and ambulatory settings, with particular emphasis on professional fee coding and documentation improvement. Consulting has been provided in myriad settings, from small practices to large multi-specialty medical and surgical groups. Areas of expertise include: � New provider coding orientations

� Individual and group coding education for providers and professional fee coders

� Pre-bill and retrospective coding audits

� Risk assessment and focus review audits for internal compliance initiatives and compliance initiatives pursuant to federal investigations

Ms. Eckenrodt received her A.A.S. in Health Information Management from Portland Community College. Dedicated to excellence in coding compliance, quality education and health care auditing, Ms. Eckenrodt is a certified professional with the American Health Information Management Association (AHIMA), the Health Care Compliance Association (HCCA) and the Association of Health Care Auditors and Educators (AHCAE). Ms. Eckenrodt is also a member of the American Academy of Professional Coders (AAPC).

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� Discuss history of ICD code set

� Review fundamental differences between ICD-9-CM and ICD-10-CM

� Review what PAs need to do now to prepare

� Understand actions practices need to take to implement on time

HistoryHistoryHistoryHistory

ICDICDICDICD----9999----CMCMCMCM• Based on World Health Organization’s (WHO) Ninth

Revision

• Main purpose morbidity and mortality reporting

• Made single classification system for hospitals in January 1979

• Physicians required to submit diagnosis codes for Medicare reimbursement since April 1989

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• January 2009 –• Final Rule requiring replacement of ICD-9 with ICD-10• Compliance date set for October 1, 2013

• 2012 –• Department of Health and Human Services (DHHS)

announced a 1-yr delay• Implementation pushed back to October 1, 2014• April 1, 2014 –• Language inserted into Protecting Access to Medicare Act

delayed implementation to no sooner than October 1, 2015

• August 4, 2014 –• DHHS sets new compliance date of October 1, 2015

� ICDICDICDICD----10101010----CM CM CM CM will be used by all healthcare providers in all settings to assign and/or interpret diagnoses

� HIPAA Transaction Code Set

-Principal or First-Listed diagnosis

-Secondary diagnoses

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ICDICDICDICD----9999----CMCMCMCM

� Outdated – terminology does not reflect current medical practice

� Lack of adequate space to add new codes

� Lack of detail

� Inability to capture new and emerging technologies

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� Provide anatomically specific clinical dataProvide anatomically specific clinical dataProvide anatomically specific clinical dataProvide anatomically specific clinical data

� More detailed information More detailed information More detailed information More detailed information on ◦ Condition

◦ Severity

◦ Comorbidities

◦ Complications

◦ Location

ICDICDICDICD ––––9999----CMCMCMCM ICDICDICDICD –––– 10101010----CMCMCMCM

Approx.14,000 codes Over 68,000 codes

17 chapters 21 chapters

Codes have 3 to 5 characters Codes have 3 to 7 characters

1st character is numeric or alpha (E

or V)

1st character is alpha (all letters

except U)

Second character

is always numeric

Second character

is always numeric

Third, fourth, and fifth

characters are always numeric

Third, fourth, fifth, sixth, and

seventh characters can be alpha or numeric

Shorter code descriptions because

of lack of specificity; abbreviated code titles

Longer code descriptions because

of greater clinical detail and specificity;

full code titles

Introduction to ICD-10-CM

Comparison Comparison Comparison Comparison ---- Format and StructureFormat and StructureFormat and StructureFormat and Structure

� 34,250 (50%) are related to the musculoskeletal system

� 17,045 (25%) are related to fractures

� ~25,000 (36%) distinguish ‘right’ vs. ‘left’

� Small percentage of codes will be used by most providers

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� ICD-10-CM code book retains same format

� Index:

� Alphabetical list of terms and corresponding codes

� Indented sub-terms under main terms

� Same structure

� Alpha Index of Diseases and Injuries

� Alpha Index of External Causes

� Table of Neoplasms

� Table of Drugs & Chemicals

� Tabular:

� Sequential list of codes divided into chapters based on body system or condition

� Same hierarchical structure

Codes are looked up the same way!

Alphabetic Index Example:Alphabetic Index Example:Alphabetic Index Example:Alphabetic Index Example:

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Tabular List Example:Tabular List Example:Tabular List Example:Tabular List Example:

EXCLUDES 1 note • Pure excludes note, means “NOT CODED HERE!”

• Indicates that the code excluded should never be used at the

same time as the code above the Excludes 1 note.

• Used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same

condition.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

EXCLUDES 1 note EXCLUDES 1 note EXCLUDES 1 note EXCLUDES 1 note

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EXCLUDES 2 note

• Represents “Not included here”

• Indicates that the condition excluded is not part of

the condition represented by the code, and a patient

may have both conditions at the same time.

� When an Excludes 2 note appears under a code, it is

acceptable to use both the code and the excluded code

together, when appropriate.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

EXCLUDES 2 noteEXCLUDES 2 noteEXCLUDES 2 noteEXCLUDES 2 note

Placeholder “X”Placeholder “X”Placeholder “X”Placeholder “X”

� Provides for future expansion

� Two uses:

◦ As 5th character for certain 6-character codes.

Example: Example: Example: Example:

T36.0T36.0T36.0T36.0xxxx5A Penicillin adverse effect, initial 5A Penicillin adverse effect, initial 5A Penicillin adverse effect, initial 5A Penicillin adverse effect, initial encounter encounter encounter encounter

◦ When code has less than 6 characters and 7th

character extension is required.


S01.02xA Laceration with foreign body of S01.02xA Laceration with foreign body of S01.02xA Laceration with foreign body of S01.02xA Laceration with foreign body of scalp, scalp, scalp, scalp, initial encounterinitial encounterinitial encounterinitial encounter

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7777 thththth CharacterCharacterCharacterCharacter

� Certain codes have 7 characters

◦ Obstetrics, injuries, external causes of injuries

� Can be number or letter

� Must always be the 7th character

� If the code is not 6 characters a placeholder X must be used


O65.0xx1 Obstructed labor due to deformed O65.0xx1 Obstructed labor due to deformed O65.0xx1 Obstructed labor due to deformed O65.0xx1 Obstructed labor due to deformed pelvis, pelvis, pelvis, pelvis, fetus 1fetus 1fetus 1fetus 1

7777 thththth Character FracturesCharacter FracturesCharacter FracturesCharacter 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

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 2013 2013 2013

Combination CodesCombination CodesCombination CodesCombination Codes

Single code used to classify:Single code used to classify:Single code used to classify:Single code used to classify:

� Two diagnoses

� A diagnosis with an associated secondary process or manifestation

� A diagnosis with an associated complication Example: Example: Example: Example: Pressure ulcer, site, stagePressure ulcer, site, stagePressure ulcer, site, stagePressure ulcer, site, stageL89.312 Pressure ulcer of right buttock, stage L89.312 Pressure ulcer of right buttock, stage L89.312 Pressure ulcer of right buttock, stage L89.312 Pressure ulcer of right buttock, stage

2222

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Laterality Laterality Laterality Laterality ◦ For bilateral sites, the final character of the code

indicates laterality

◦ If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side

◦ Unspecified side is also provided should the side not be identified in the documentation

ICDICDICDICD----9999----CMCMCMCM CodesCodesCodesCodes ICDICDICDICD----10101010----CMCMCMCM Codes Codes Codes Codes

Pressure ulcer codes

9 codes 707.00 – 707.09

Pressure ulcer codes

125 codesL89.0-L89.94

Codes:707.0 Pressure ulcer

707.00 - unspecified site707.01 - elbow 707.02 - upper back 707.03 - lower back

707.04 - hip707.05 - buttock707.06 - ankle 707.07 - heel

707.09 - other site

Code Examples:L89.131 – Pressure ulcer of right lower back, stage I

L89.132 – Pressure ulcer of right lower back, stage IIL89.133 – Pressure ulcer of right lower back, stage IIIL89.134 – Pressure ulcer of right lower back, stage IVL89.139 – Pressure ulcer of right lower back,

unspecified stageL89.141 – Pressure ulcer of left lower back, stage IL89.142 – Pressure ulcer of left lower back, stage IIL89.143 – Pressure ulcer of left lower back, stage III

L89.144 – Pressure ulcer of left lower back, stage IVL89.149 – Pressure ulcer of left lower back, unspecified stageL89.151 – Pressure ulcer of sacral region, stage I

L89.152 – Pressure ulcer of sacral region, stage II…L89.90 – Pressure ulcer of unspecified site,

unspecified stage

Borderline DiagnosisBorderline DiagnosisBorderline DiagnosisBorderline Diagnosis◦ If provider documents “borderline” diagnosis,

code as confirmed unless classification provides a specific entry (e.g., borderline diabetes).

◦ Not considered “uncertain,” so ok to code in outpatient setting

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� Evaluation, treatment and monitoring of patient health

� Communication and continuity of care

� Accurate and timely claims review and payment

� Utilization review and quality of care

� Collection of data for research and education

~1995/1997 CMS Documentation Guidelines

� Poor quality documentation impacts…◦ Billing accuracy

◦Quality measures

◦ Risk management

◦Healthcare analytics

◦ Patient carePatient carePatient carePatient care

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� Detailed diagnosis codes require clinical documentation that supports the code selection

� Risk for refunding payments if negative audit findings

� “Unspecified” codes still available, however benefits of new code set not fully realized if used

� Inclusion of clinical concepts that do not exist in ICD-9-CM

No need to learn over 68,000 No need to learn over 68,000 No need to learn over 68,000 No need to learn over 68,000 codes!codes!codes!codes!

Focus on the clinical concepts and the codes

will fall into place…

� Type Type Type Type ◦ Description of the condition, “type of”

� Type II diabetes or pathological fracture

� Temporal FactorsTemporal FactorsTemporal FactorsTemporal Factors◦ Time parameter associated with the condition

� Acute, chronic, paroxysmal, recurrent

� Caused by/Contributing FactorsCaused by/Contributing FactorsCaused by/Contributing FactorsCaused by/Contributing Factors◦ Relates the cause of a condition to another

condition, “due to”

� Drugs, alcohol, physical or mental disease

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� Symptoms/Findings/ManifestationsSymptoms/Findings/ManifestationsSymptoms/Findings/ManifestationsSymptoms/Findings/Manifestations

� Localization/LateralityLocalization/LateralityLocalization/LateralityLocalization/Laterality� Proximal or distal, right side or left side

� Anatomical locationAnatomical locationAnatomical locationAnatomical location

� Associated withAssociated withAssociated withAssociated with

� SeveritySeveritySeveritySeverity◦ Acuity of the condition

� Mild, moderate, severe

� EpisodeEpisodeEpisodeEpisode� Single, recurrent; initial encounter, subsequent

encounter

� Remission statusRemission statusRemission statusRemission status� Partial, full

� History ofHistory ofHistory ofHistory of

� MorphologyMorphologyMorphologyMorphology

� Complicated byComplicated byComplicated byComplicated by

� External CauseExternal CauseExternal CauseExternal Cause

� ActivityActivityActivityActivity

� Place of OccurrencePlace of OccurrencePlace of OccurrencePlace of Occurrence

� Level of ConsciousnessLevel of ConsciousnessLevel of ConsciousnessLevel of Consciousness

� SubstanceSubstanceSubstanceSubstance

� Number of GestationsNumber of GestationsNumber of GestationsNumber of Gestations

� Outcome of DeliveryOutcome of DeliveryOutcome of DeliveryOutcome of Delivery

� BMIBMIBMIBMI

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� Primarily used in inpatient setting

� Clinical indicators used to identify missed diagnoses or under-documented conditions that may impact reimbursement

� Coders may query the physician regarding the condition to determine if the condition should be reported or whether the condition might be better reported with a more specific code

Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 23 month-old male brought to

ED after pt witnessed to have a seizure. Parents indicate pt has had cough and congestion x 2 days.

O: T: 105.4, BP: 76/52, HR 116. Breath sounds decreased in the left base and scattered rales and wheezes present throughout. Blood drawn for CBC and blood cultures. Chest x-ray shows infiltr ates.

A: Acute pneumonia.

P: Admit to PICU for antibiotic therapy.

J18.9J18.9J18.9J18.9 Pneumonia, unspecified organism

Adequate DocumentationS: 23 month-old male brought to ED after suffering a

seizure at home. Parents indicate pt has had cough and

congestion x 2 days. This morning pt was witnessed to

have a generalized motor seizure.

O: T: 105.4, BP: 76/52, HR 116. Breath sounds

decreased in the left base and scattered rales and

wheezes present throughout. Blood drawn for CBC

and blood cultures. Chest x-ray shows left lower lobe

inf iltrates. Blood test positive for Pseudomonas.

A: Acute pneumonia due to H. influenza, f ebrile

seizure.

P: Admit to PICU for antibiotic therapy.

J15.1 Pneumonia due to Pseudomonas

R56.00 Simple febrile convulsions

� Discharge diagnosis = Pneumonia� Sputum cultures, medications administered

indicate bacterial infection as cause

� Codes cannot be assigned based on coder’s interpretation of lab results – query!query!query!query!

� Codes assigned solely on physician documentation

� Discharge diagnosis = Pneumonia due to Pneumonia due to Pneumonia due to Pneumonia due to PseudomonasPseudomonasPseudomonasPseudomonas

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ICDICDICDICD----10 CLINICAL CONCEPTS 10 CLINICAL CONCEPTS 10 CLINICAL CONCEPTS 10 CLINICAL CONCEPTS ExamplesExamplesExamplesExamples

Identify:Identify:Identify:Identify:

Associated withAssociated withAssociated withAssociated with

� Acute lower respiratory infection

� Acute exacerbation

Environmental factorEnvironmental factorEnvironmental factorEnvironmental factor

� Exposure to tobacco smoke

� History of tobacco use

� Occupational exposure to environmental tobacco smoke

� Tobacco dependence

� Tobacco use

Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 40 year-old woman here for

follow-up of her COPD. She is exper iencing more SOB

O: Vital signs stable today. CV: RRR, No murmurs. Lungs: distinct breath sounds with no wheezes.

A: COPD

P: Change to Combivent inhaler 2 puffs QID. RTC 2 weeks.

J44.9J44.9J44.9J44.9 Chronic obstructive pulmonary disease, unspecified

Adequate DocumentationS: 40 year-old woman here for follow-up of her

COPD. She is experiencing more SOB with

exertion since her last visit. She is c/o a new feeling

of “ compression” in her chest. She has been eating

larger meals later at night and this seems to coincide

with her symptoms.

O: Vital signs stable today. CV: RRR, No murmurs.

Lungs: distinct breath sounds with no wheezes.

A: Chest pain and COPD with acute exacerbation.

P: Refrain from eating 2-3 hours prior to sleeping and

eat smaller meals. If chest pain symptoms continue

RTC immediately. COPD exacerbated recently.

Change to Combivent inhaler 2 puffs QID. RTC 2

weeks.

J44.1 Chronic obstructive pulmonary disease with

(acute) exacerbation

R07.9 Chest pain, unspecified

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Severity/type, if knownSeverity/type, if knownSeverity/type, if knownSeverity/type, if known

� Mild intermittent

� Mild persistent

� Moderate persistent

� Severe persistent

� Other specified type◦ Exercise induced bronchospasm

◦ Cough variant

ComplicationsComplicationsComplicationsComplications

� Uncomplicated

� With acute exacerbationWith acute exacerbationWith acute exacerbationWith acute exacerbation

� With status With status With status With status asthmaticusasthmaticusasthmaticusasthmaticus

Environmental factorsEnvironmental factorsEnvironmental factorsEnvironmental factors


� History of tobacco use

� Occupational exposure to environmental tobacco smoke

� Tobacco dependence

� Tobacco use

Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 55 year-old black female

presents with acuteacuteacuteacute asthma episode.

O: She is SOB and very anxious. Wheezing can be heard without stethoscope. O2 sat was 92% on RA but increased to 95% after initiation of O2 4L/m via NC. Nebulizer tr eatment given.

A: Asthma

P: Admit for overnight breathing tr eatments and IV steroids.

J45.901 J45.901 J45.901 J45.901 Unspecified asthma with (acute) exacerbation

Adequate DocumentationS: 55 year-old black female presents with acute asthma

episode. Pt has had dx of asthma since childhood.

Allergic triggers include cold weather, pollen and mold.

She uses oral and inhaled steroids extensively.

O: She is SOB and very anxious. Wheezing can be heard

without stethoscope. O2 sat was 92% on RA but

increased to 95% after initiation of O2 4L/m via NC.

Nebulizer treatment given. Chest x-ray r/o pneumonia.

A: Moderate persistent asthma with acute

exacerbation most likely due to weather change.

P : Admit for overnight breathing treatments and IV

steroids.

J45.41 Moderate persistent asthma with (acute)

exacerbation

Z79.51 Long term (current) use of inhaled steroids

Z79.52 Long term (current) use of systemic steroids

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Type Type Type Type (no longer benign, malignant, or unspecified)(no longer benign, malignant, or unspecified)(no longer benign, malignant, or unspecified)(no longer benign, malignant, or unspecified)

� Essential hypertension

� Hypertensive heart disease

Also document:

With heart failureWith heart failureWith heart failureWith heart failure

Without heart failureWithout heart failureWithout heart failureWithout heart failure

� Hypertensive chronic kidney disease

� Hypertensive heart and chronic kidney disease

Also document:

With heart failureWith heart failureWith heart failureWith heart failure

Without heart failureWithout heart failureWithout heart failureWithout heart failure

With chronic kidney disease, includeWith chronic kidney disease, includeWith chronic kidney disease, includeWith chronic kidney disease, include

� Stage 1-4 or unspecified

� Stage 5 or end stage CKD

EEEEnvironmental factornvironmental factornvironmental factornvironmental factor


� Tobacco dependence� Tobacco use

ICDICDICDICD----9999----CM Code/DocumentationCM Code/DocumentationCM Code/DocumentationCM Code/Documentation ICDICDICDICD----10101010----CMCMCMCM Code/DocumentationCode/DocumentationCode/DocumentationCode/Documentation

401.0 Essential hypertension,

malignant

I10 Essential hypertension


benign


unspecified

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Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 30 year-old patient seen in

follow-up for high blood pressure. Pt home BP r eadings are consistently above 140/90. Pt is not taking any medications at this time.

O: BP today 156/98, HR 82.

A: High blood pressure

P: Star t Cozaar 25mg qd. RTC 1 month with BP r eadings.

R03.0 R03.0 R03.0 R03.0 Elevated blood-pressure r eading, without diagnosis of hyper tension

Adequate DocumentationS: 30 year-old patient seen in follow-up for

hypertension. P t home BP readings are consistently

above 140/90. P t is not taking any medications at this

time. P t is a long time cigarette smoker.

O: BP today 156/98, HR 82. P t is counseled on long

term effects of hypertension and risks of not treating.

P t also counseled on quitting smoking. P t is unwilling

to try now.

A: Hypertension. Nicotine dependence.

P: Start Cozaar 25mg qd. RTC 1 month with BP

readings.

I10 Essential hypertension

F17.200 Nicotine dependence, unspecified,

uncomplicated

IdentifyIdentifyIdentifyIdentify::::

TypeTypeTypeType

� Type 1

� Type 2

� Secondary diabetes

- Drug or chemical induced

- Due to underlying condition

- Other specified

Body system Body system Body system Body system affected/manifestationsaffected/manifestationsaffected/manifestationsaffected/manifestations

� Circulatory complications

� Hyperglycemia

� Hypoglycemia

� Ketoacidosis

� Kidney complications

� Neurological complications� Ophthalmic complications

- Diabetic retinopathy

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With Diabetic retinopathy, identify severityWith Diabetic retinopathy, identify severityWith Diabetic retinopathy, identify severityWith Diabetic retinopathy, identify severity

� Mild

� Moderate

� Severe

� Proliferative

� Unspecified

With Diabetic retinopathy, includeWith Diabetic retinopathy, includeWith Diabetic retinopathy, includeWith Diabetic retinopathy, include

� With macular edema

� Without macular edema

Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 56 year-old female here for

follow-up of diabetes. She checks her BS faithfully and all are between 90-130. She has had no episodes of hypoglycemia.

O: Wt. 151 lb, Ht. 66 in, BMI 26kg/m2. Sensory function and pulses of lower extremities diminished. Last HbA1C = 6.2 (3 weeks ago).

A: Diabetes mellitus. Neuropathy.

P: Continue cur rent meds. Add Gabapentin for neuropathy. RTC in 1 month. Fasting labs 1 week pr ior to appointment.

E11.9 E11.9 E11.9 E11.9 Type 2 diabetes mellitus without complications

Adequate DocumentationS: 56 year-old female here for follow-up of diabetes

type 2. She checks her BS faithfully and all are

between 90-130. She has had no episodes of

hypoglycemia. She does complain on neuropathy in

both feet. The pain is worse at night.

O: Wt. 151 lb, Ht. 66 in. Sensory function and pulses

of lower extremities diminished. Last HbA1C = 6.2 (3

weeks ago).

A: Type II diabetes mellitus with diabetic

peripheral neuropathy.

P: Continue current meds. Add Gabapentin for

neuropathy. RTC in 1 month. Fasting labs 1 week

prior to appointment.

E11.40 Type 2 diabetes mellitus with diabetic

neuropathy, unspecified


ConditionConditionConditionCondition

� With current pathological fracture

� Without current pathological fracture

TypeTypeTypeType

� Age-related

� Localized

� Other

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SiteSiteSiteSite

� Shoulder

� Humerus

� Forearm

� Hand

� Femur

� Lower leg

� Ankle/foot

� Vertebrae

Episode of careEpisode of careEpisode of careEpisode of care

� Initial encounter

� Subsequent encounter

- With routine healing

- With delayed healing

- With nonunion

- With malunion

� Sequela

Encounter Type:Encounter Type:Encounter Type:Encounter Type:◦ Initial Encounter – patient is receiving active

treatment for injury (surgical, emergency department, evaluation and treatment by new physician)

◦ Subsequent Encounter – patient is no longer receiving active treatment of injury, and receiving routine care during healing or recovery phase

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Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 80 year-old female with senile

osteoporosis here complaining of severe back pain. No history of trauma or falls.

O: Vital signs stable. Lumbar vertebra palpitation causes severe pain reaction from patient. Pt reports pain is 8 on a scale of 1-10.

A: Senile osteoporosis.

P: PT for strengthening exercises. Bone density testing is overdue.

M81.0M81.0M81.0M81.0 Age related osteoporosis without current pathological fracture

Adequate DocumentationS: 80 year-old female with senile osteoporosis

here complaining of severe back pain. No history

of trauma or falls.

O: Vital signs stable. Lumbar vertebra palpitation

causes severe pain reaction from patient. Pt reports pain is 8 on a scale of 1-10. X-rays reveal

pathological compression fracture of several

lumbar vertebrae.

A: Pathological fracture of vertebrae due to

osteoporosis.

P: PT for strengthening exercises. Bone density testing is overdue.

M80.08XA Age related osteoporosis with current pathological fracture, vertebrae, initial encounter

for fracture

Pathological Fractures Pathological Fractures Pathological Fractures Pathological Fractures –––– documentation will require:◦ Exact locationlocationlocationlocation of fracture with lateralitylateralitylateralitylaterality

◦ EtiologyEtiologyEtiologyEtiology of the fracture: Due to osteoporosis or neoplastic disease or other specified disease

◦ Encounter typeEncounter typeEncounter typeEncounter type

◦ Physician MUST make connection between a fall and a fracture due to osteoporosis

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TypeTypeTypeType

� Acute

� Generalized

� Localized

Localization/LateralityLocalization/LateralityLocalization/LateralityLocalization/Laterality

� Right upper quadrant, left lower quadrant, etc.

� Epigastric

� Periumbilic

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ICDICDICDICD----9999----CM Code/DocumentationCM Code/DocumentationCM Code/DocumentationCM Code/Documentation ICDICDICDICD----10101010----CM Code/DocumentationCM Code/DocumentationCM Code/DocumentationCM Code/Documentation

789.00 Abdominal pain,

unspecified site

R10.0 Acute abdomen

R10.10 Upper abdominal pain,

unspecified

R10.11 Right upper quadrant, pain

R10.12 Left upper quadrant pain

R10.13 Epigastric pain

R10.2 Pelvic and perineal pain

R10.30 lower abdominal pain,

unspecified

R10.31 Right lower quadrant pain

R10.32 Left lower quadrant pain

R10.33 Periumbilical pain

Inadequate Inadequate Inadequate Inadequate DocumentationDocumentationDocumentationDocumentationS: 70 year-old female c/o abdominal

pain and indigestion. The pain is descr ibed as a dull constant pain.Nausea accompanies the pain and is worsened by eating. On a 10 point pain scale the patient r ates the pain a 7.

O: T: 99.2, BP 125/80, HR 70. Normal bowel sounds. Abdominal discomfor t was felt on palpitation. Liver and spleen not enlarged. . . .

A: Abdominal pain suggestive of gall stone disease.

P: Obtain abdominal ultrasound, lab tests and EKG.

R10.9R10.9R10.9R10.9 Unspecified abdominal pain

Adequate DocumentationS: 70 year-old female c/o abdominal pain and

indigestion. The pain is described as a dull constant

pain in the RUQ. Nausea accompanies the pain and is

worsened by eating. On a 10 point pain scale the

patient rates the pain a 7.

O: T: 99.2, BP 125/80, HR 70. Normal bowel sounds.

Abdominal discomfort was felt on palpitation in the

RUQ. Liver and spleen not enlarged. Family history

positive for gallbladder disease and MI.

A: RUQ abdominal pain suggestive of gall stone

disease.

P : Obtain abdominal ultrasound, lab tests and EKG.

R10.11 Right upper quadrant abdominal pain

Z83.79 Family history of other diseases of the

digestive system

Z82.49 Family history of cardiovascular disease

� The requirements for good documentation haven’t changed

� ICD-10-CM is BUILT BETTER for coding clinical concepts that more fully describe the patient’s condition

� Documentation of the clinical concepts is integral to good patient care and better reporting of healthcare data

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QUESTIONS?QUESTIONS?QUESTIONS?QUESTIONS?

Connie Eckenrodt, RHIT, CHCA, CHCDirector, Physician Coding & Compliance

[email protected]

On the Web: www.rmcinc.org

� 2013 ICD-10-CM◦ Official Coding Guidelines

◦ ICD-10-CM PDF Format

◦ Addenda

◦ List of Codes and Descriptions

◦ General Equivalence Mapping (GEM) files

httphttphttphttp://://://://www.cdc.gov/nchs/icd/icd10cm.htm#10uwww.cdc.gov/nchs/icd/icd10cm.htm#10uwww.cdc.gov/nchs/icd/icd10cm.htm#10uwww.cdc.gov/nchs/icd/icd10cm.htm#10updatepdatepdatepdate

� ICD-10-CM Official Coding Guidelines

� ICD-10-CM Coder Training Manual-AHIMA

• ICD-10-CM Official Guidelines for Coding and Reporting 2013

• ICD-10-CM Documentation: A How-To Guide for Coders, Physicians, and Healthcare Facilities 2014, Contexo Media

• Final Rule: http://www.gpo.gov/fdsys/pkg/FR-2009-01-16/pdf/E9-743.pdf

� http://www.cms.hhs.gov/ICD10

� http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005426.hcsp?dDocName=bok3_005426

• http://www.ama-assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_full.pdf

• http://www.cms.gov/Medicare/Coding/ICD10/Downloads/PCS2011guidelines.pdf

• http://www.cdc.gov/nchs/icd/icd10.htm

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ICD10 PEARLS AND PITFALLS -Eckenrodt · 2014. 10. 14. · ICD –ICD –––9999----CMCCMMCM ICD ICDICD – ––– 10 110010- ---CMCCMMCM Approx.14,000 codes Over 68,000 codes