Click here to load reader


  • View

  • Download

Embed Size (px)


Microsoft Word - Phase 2 Study GuideWhy Are We Making This Change ................................................. 4
Myths About ICD-10 ..................................................................... 4
What Does ICD-10-CM Look Like? .............................................. 12
Tips to Finding ICD-10-CM Codes ............................................... 15
ICD-10-CM Guidelines ................................................................ 18
INTRODUCTION TO ICD-10-CM Many who are participating in this ICD-10 training program may have vastly different views about medical billing and coding. Some may not be very familiar with coding and how it works, while others may deal with coding on a daily basis. There are those who may enjoy the coding process, while others may view it as necessary evil that has to be tolerated in order to facilitate the flow of revenue into the practice. Regardless of one’s view today, we are about to undergo a major change in coding in the United States. The usage of ICD-10, beginning on October 1, 2015, completely revises one of the two code sets used to report the health care provided to patients and to submit claims to third party payers, such as health insurers. The transition from ICD-9 to ICD-10 is providing a unique opportunity to upgrade and standardize everyone’s knowledge concerning coding and its influence on billing and revenue. Fundamentally, coding is telling the story of the encounter with the patient in the most accurate manner possible. Words are not used—rather, codes are the communication medium. When we discuss correct coding, it means that we are selecting codes based on:
The most accurate possible description of “what” was done and “why” it was done
ICD-10-CM—IS IT EVER GOING TO HAPPEN? The transition to ICD-10 has been bumpy, to say the least. ICD-6 was first adopted for worldwide usage in 1948. For approximately 25 years, regular updates were made, but it was not until 1979 that ICD-9 was formally adopted for usage for the purpose of reporting claims to the Medicare/Medicaid programs, and to commercial insurers shortly thereafter. ICD-10 was formally issued by the World Health Organization (WHO) in 1993 and, over the years, has been adopted for usage by every member nation within the WHO, except for the United States. The United States did not rush into the use of ICD-10 because, even though it had already been in use for more than 15 years, it was not until January 2009 that the Department of Health and Human Services (DHHS) announced an implementation date, which was to be October 1, 2013. Successful “behind-the-scenes” work took place in 2012, when the format for communication of electronic claims was transitioned from the 4010 format to the 5010 format. This transition was necessary in order to make the usage of ICD-10 possible. However, in 2012, HHS recognized that preparations for ICD-10 were lagging and that key players were not going to be ready in time. Therefore, they delayed the implementation by one year, setting a new effective date of October 1, 2014. Everyone was making active progress toward the 10/1/2014 effective date when, during the debate about the Sustainable Growth Rate (SGR) and the impending Medicare reimbursement reductions, Congress became involved in the ICD-10 implementation. Language was inserted in the legislation that prevented the implementation of ICD-10 until at least October 1, 2015. The current effective date for ICD-10 is October 1, 2015. There is no indication that there will be any change to this effective date. The Centers for Medicare and Medicaid Services (CMS), which have always been in favor of a timely implementation, is fully moving forward with preparations. Since Congress is now in the hands of a single party, there is not expected to be any political conflict over the issue. In addition, those in Congress who blocked the implementation in 2014 are now publicly stating that they are in favor of implementation in 2015. Therefore, we must aggressively move forward with plans and preparations for an October 1 “go live” for ICD-10. In order to properly prepare for the transition, the following actions should take place between now and October 1, 2015:
• Continued enhanced audits to upgrade documentation for ICD-10 • Opportunities to test ICD-10 submissions from billing software to payers
WHY ARE WE MAKING THIS CHANGE? There are three fundamental reasons why we are making the transition from ICD-9 to ICD-10. They are:
1. ICD-9 is outdated and obsolete. It needs to be updated to reflect changes in health care and our understanding of disease processes.
2. There needs to be a greater degree of data collection, both for quality of care and public health needs. ICD-10 allows that to happen and gives the United States the opportunity to participate with the rest of the world in public health monitoring and tracking.
3. The current reimbursement models in place for the healthcare system in the United States are seriously broken, because they incentivize the wrong behaviors and reimburse at levels that have nothing to do with the quality of care delivered. ICD-10 will give the opportunity to modify payment models so that utilization patterns and outcomes are more easily measured and, ultimately, providers are recognized when they treat sicker patients or produce consistently better outcomes.
One of the factors that has promoted the delays in the implementation of ICD-10 and resistance to the change is a number of myths about the code set that have been spread throughout the health care community. Let’s take a few moments to recognize and address these myths. 1. There is a dramatically larger number of codes that will be
unmanageable. As is the case with most myths, there is a certain element of truth to the statement, followed by something that is not accurate. In this case, it is true that there is a dramatically large number of codes in the ICD-10 code set (approximately 140,000 codes), compared to the ICD-9 code set (approximately 17,000 codes). However, it is not true that the increase in codes is unmanageable. There are two different elements that need to be understood in order to appropriately respond to this myth:
ICD-9 Volume 3 codes, while there are approximately 72,000 ICD-10-PCS codes (an increase of ~2400%). There are approximately 13,000 ICD-9 Clinical Modification (CM) diagnosis codes, compared to approximately 68,000 ICD-10- CM diagnosis codes (an increase of ~500%). Therefore, the increase in diagnosis codes is not nearly as dramatic as the raw numbers would seem to indicate.
b. Most of the increase in the number of diagnosis codes is associated with increased specificity. The information needed to select the correct ICD-10 code is usually already in the medical record. For example,
For obstetrics, what trimester is the patient in? For primary care, what side (right or left) is the injury found? For gastroenterology/general surgery, is the condition acute or chronic?
Is it primary or secondary? For dermatology, what type of ulcer is it and where (specifically) is it
2. I have to report laterality and encounter type for every service.
In ICD-10-CM, there are two significant changes that will be obvious to anyone who has used ICD-9-CM:
The reporting of laterality The reporting of encounter type
There was no functionality in ICD-9-CM to indicate what side of the body was being addressed during the encounter. In many cases, but not all, in ICD-10-CM there is the requirement to indicate whether the condition being treated is:
On the left side On the right side Bilateral Unspecified
Some specialties (e.g. ophthalmology and orthopedics) will be affected by the reporting of laterality in virtually every case. Others will be affected to a much lesser degree. The key point to understand is that this information should be in the medical record already. Second, when laterality is an option, “unspecified” should be avoided if at all possible because it seems to indicate a lack of attention to detail. Many payers may deny claims if an “unspecified” side is used when a reasonable person could/should know what side of the body is being treated. An extreme example of an inappropriate laterality code is as follows:
For many codes, certain conditions such as burns, injuries, sprains, strains, and breaks require a 7th character to indicate the type of encounter. The basic encounter types are:
A—Initial encounter D—Subsequent encounter S—Sequelae
For certain conditions (particularly fractures and breaks), there are approximately one dozen other options to report whether it is open or closed fracture, whether it is healing properly or not, etc. Again, this is information that should be present in the record and it does not apply in every circumstance and does not apply to every specialty. 3. ICD-10-CM is exceptionally complicated.
Just because something is specific or new does not mean that it is particularly complicated. Some research conducted in professional training schools are finding that those who are learning ICD-10 without any exposure to ICD-9 are demonstrating proficiency more quickly than those who are learning ICD-9. The reason is that ICD-10- CM is organized more logically and flows more naturally than ICD-9-CM. Another major benefit of the change to ICD-10-CM is that everyone will be receiving training on the new code set and will have the same baseline knowledge. After we are done with the ICD-10-CM training, everyone’s knowledge about diagnosis codes will be greater than it was before, while we were using ICD-9-CM. 4. ICD-10-CM will be a significant burden.
Table of Neoplasms NO (included in disease index)
Index to External Causes of Injury
Supplementary List (# of chapters)
2 0 (included in primary list)
When considering the differences between the two code sets, they can be characterized as follows:
ICD-10-CM codes are more specific. In order to properly select a code, the medical record must contain documentation with sufficient specificity to support the code.
Each chapter is separated into “blocks” of codes, divided into logical and reasonable subcategories. This will be addressed in much greater detail later in this training.
There are two additional chapters in ICD-10-CM—one for each of the sensory organs (eyes and ears). In ICD-9, the codes for these organs were included as part of the neurologic system.
As mentioned previously, ICD-10 is actually comprised of two code sets. They are:
ICD-10-CM-diagnostic coding ICD-10-PCS—procedural coding
ICD-10-CM codes describe the clinical picture of the patient with 3-7 character alphanumeric codes. These codes are generally organized by organ system, although a few chapters are organized by the patient’s condition/situation (e.g. viral/infectious disease, pregnancy, or congenital conditions). On the other hand, ICD-10-PCS describes procedures reported by hospitals. Every ICD-10-PCS code is a 7 character alphanumeric code, which details anatomic site, surgical approach, device used, and other code-specific information. The usage of Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS) Level II will remain completely unchanged by the transition with ICD.
Some other key changes that will be recognized in the transition are: The codes have been reclassified in some areas to reflect current medical
knowledge and to organize them more logically. Medical care and our understanding of disease processes are different today than they were in 1975 when ICD-9 was introduced. In addition, many of the codes in ICD-9 are organized in a way that doesn’t necessarily make sense, simply because there is no room to place them in the appropriate location.
Separate codes for intraoperative and postoperative complications have been created in some of the individual disease chapters. For example, postoperative complications of digestive system procedures are located in the digestive system chapter, while complications of a genitourinary system procedure are located in that chapter.
In ICD-10-CM, there are more combination codes that allow reporting of conditions with their symptoms and/or manifestations. In ICD-9-CM, it would require multiple codes to accomplish the same reporting. There are also additional combination codes for poisonings and the external causes of the poisoning.
There is a new type of “exclusion” notes in ICD-10-CM, which will be discussed at length later in this training.
The following chart more clearly illustrates the differences between ICD-9-CM and ICD- 10-CM: ICD-9 ICD-10
Number of characters 3–5 digits in length 3–7 characters in length
Number of codes Approximately 13,000 codes
Approximately 68,000 available codes
Types of characters First digit can be alpha (E or V) or numeric; digits 2–5 are numeric; most codes are all numeric
Character 1 is alpha; character 2 is numeric; characters 3–7 are alpha or numeric
Code capacity Limited space for adding new codes
Flexible for adding new codes
Specificity Lacks detail Very specific
Laterality designations (right vs. left)
Lacks laterality Has laterality
A “convention” is defined as “the way in which something is usually done, especially within a particular area or activity.” There are certainly “conventions” in diagnosis coding. You will be interested to know that the conventions in ICD-9-CM coding are remarkably similar to the conventions in ICD-10-CM coding. The following chart illustrates those similarities: Convention ICD-9-CM ICD-10-CM
Notes Further define terms, clarify information, or list choices for additional digits.
Convention  ICD-9-CM  ICD-10-CM 
Includes Notes that further define or provide examples and can apply to a chapter, section, or category.
Same as ICD-9-CM.
Not otherwise specified
Used when the information at hand does not permit a more specific code assignment.
Same as ICD-9-CM.
Excludes Notes that indicate terms that are to be coded elsewhere.
Same as ICD-9-CM.
Same as ICD-9-CM
Use additional code
Appears in categories in which further information must be added by using an additional code, to provide a more complete picture.
Same as ICD-9-CM.
Used after an incomplete term that needs one or more of the modifiers that follows to make it assignable to a category.
Same as ICD-9-CM.
Same as ICD-9-CM.
Enclose supplementary words that may be present or absent, without affecting the code number to which it is assigned. N39.3 Stress incontinence (male) (female)
Same as ICD-9-CM.
Braces Enclose a series of terms, each of which is modified by the statement appearing at the right.
Not used in ICD-10-CM.
Excludes1 Not used in ICD-9-CM.
Indicates that the code excluded can never be used at the same time as the code to which the excludes list applies. For example, a congenital and acquired condition cannot coexist.
Excludes2 Not used in ICD-9-CM.
Indicates that the condition is not included as part of the code. If the patient has both conditions, a separate code must be used to report it.
hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)
Excludes 1 hypertensive disease complicating pregnancy, childbirth, and the puerperium (O10-O11, O13- O16)
Excludes 2 essential (primary) hypertension involving vessels of the brain (I60-I69)
essential (primary) hypertension involving vessels of eye (H35.0-)
To summarize, the code I10 is used to report any kind of high blood pressure that is characterized by the terms in the “includes” list. If the patient has hypertensive disease complicating pregnancy (the Excludes1 list), I10 can’t be used in any circumstance (because it is already included in the pregnancy hypertension codes). If the patient has essential hypertension involving vessels of the brain or eye (the Excludes2 list), simply reporting I10 is not adequate. In this case, you would report only the more specific codes, or you could report both codes, especially if the patient’s underlying hypertension is being treated during the present encounter.
Thinking about 68,000 codes can be somewhat overwhelming. However, if we break it down into the individual organ system chapters, we will see that the number of codes is not nearly as daunting. ICD-10 
3 Disease of the Blood and 
Blood Forming Organs and 
H00-H59 2452 320-389
H60-H95 642 320-389
I00-I99 1254 390-459
J00-J99 336 460-519
K00-K95 706 520-579
L00-L99 769 680-709
M00-M99 6339 710-739
N00-N99 591 580-629
O00-O9A 2155 630-679
P00-P96 417 760-779
Q00-Q99 790 740-759
18  Symptoms, Signs, and  Abnormal Clinical and  Laboratory Findings,  Not Elsewhere  Classified 
R00-R99 639 780-799
19  Injury, Poisoning, and  Certain Other  Consequences of  External Causes 
S00-T88 39869 800-999
V01-Y99 6812 E800-E999
21  Factors Influencing  Health Status and  Contact with Health  Services 
Z00-Z99 1178 V01-V91
After examining this list, you will notice some of the following facts:
More than half of all ICD-10-CM codes are found in Chapter 19. The reason for the large number of codes is the fact that almost all codes in this section require both laterality and encounter type, which dramatically increases the total number of codes.
Approximately 6300 codes are in the musculoskeletal system (Chapter 13). The large number there is the result of frequently laterality and reporting of encounter types.
The relatively large number of codes in Chapter 7 and Chapter 15 are attributable to the issue of laterality for the eyes (left, right, bilateral, unspecified) and for trimester of pregnancy, respectively.
The bottom line is that the number of codes that are unique to your specialty or that you would use with any frequency are not that significant and are certainly manageable. The raw number of codes you will be using will certainly increase, but it will not be too difficult for you to use.
TIPS TO FINDING ICD-10-CM CODES One problem with the ICD-9-CM code set is that it is primarily numeric, which makes it difficult to easily remember the location of certain codes, unless you memorize them. The fact that ICD-10-CM is alphanumeric gives us the opportunity to use mnemonic (aid in memory) devices associated with the first letter of each code. This means that if you know the general nature of the diagnosis, you will know exactly what chapter to check. The chart on the next page illustrates some mnemonic devices that will help you to know where to begin your search for codes. Here’s the thinking behind each of the mnemonic tools: Chapter 1 If someone has an infectious or parasitic disease, I think we would all
agree that it is “A Bad Thing.” All of the codes for infectious and parasitic diseases begin with either “A” or “B”.
Chapter 2 The codes in the chapter for neoplasms begin with the letters “C” or “D”. While not all neoplasms are Cancerous, it is a good tool to remember the codes. Ironically, all of the codes for malignant neoplasms (traditionally defined as “cancer”) do begin with the letter “C”. In-situ cancers and non-malignant neoplasms all begin with the letter “D”.
Chapter 3 Because this chapter involves diseases of the blood and blood forming organs, the terms “Dripping” or “Dracula” can be used to remind us that these codes all begin with the letter “D”.
1 Certain Infectious and Parasitic Diseases A00-B99 A Bad Thing 001-139
2 Neoplasms C00-D49 Cancer 140-239
3 Disease of the Blood and Blood Forming 
Organs and Certain Disorders Involve the 
Immune Mechanism
5 Mental and Behavior Disorders F01-F99 Feelings 290-319
6 Disease of the Nervous Systems G00-G99 Groggy or Gehrig 320-389
7  Disease of the Eye and Adnexa  H00-H59  Head  320-389 
8  Diseases of Ear and Mastoid Process  H60-H95  Head  320-389 
9  Disease of the Circulatory System  I00-I99  Ischemic or 
10  Diseases of the Respiratory System  J00-J99  Junk in the Lungs  460-519 
11  Diseases of the Digestive System  K00-K95  Kick in the Gut  520-579 
12  Disease of the Skin and Subcutaneous 
and Connective Tissue 
M00-M99  Musculoskeletal  710-739 
Not Pregnant 
16  Certain Conditions Originating in the 
Perinatal Period 
and Laboratory Findings, Not Elsewhere 
Consequences of External Causes 
21  Factors Influencing Health Status and 
Contact with Health Services 
Chapter 6 If someone is “Groggy” or if they have been diagnosed with Lou Gehrig’s Disease, they may have a disease of the nervous system. All codes in this chapter begin with the letter “G”. In ICD-9-CM, these codes are found in the series 320-389, along with the codes for the sensory organs (chapters 7 & 8 in ICD-10-CM).
Chapter 7 Diseases of the eye and adnexa are found in this chapter and all codes begin with the letter “H”. The mnemonic device in this case is “H” for “Head,” where the eyes are found.
Chapter 8 “Head” is also the mnemonic device for the chapter for the diseases of the ear and mastoid process, since they are found in the head. The eye and adnexa are found in the first half of this chapter, while the ear and mastoid…