Pulmonology ICD-10 CM Training. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1, 2015

Pulmonology

ICD-10 CM Training

• ICD-10-CM will be valid for dates of service on or after October 1, 2015– Outpatient dates of service of October 1, 2015 and

beyond. – Inpatient hospital service claims, is effective for dates of

discharge after September 30, 2015

ICD-10-CM Compliance Dates

• Covered Entities– Everyone covered by the Health Insurance Portability

Accountability Act (HIPPA)

• Non-Covered Entities– Worker’s Compensation– Auto Insurance– Non covered HIPAA entities are exempt but are

encouraged to adapt the new code set

Covered and Non-Covered Entities

• 21 Chapters• Alpha-numeric codes; not case-sensitive

– Codes begin with Alpha letter, A-Z, excluding U– Common errors

• I verses 1• O verses 0

• “X” Placeholder• 3 to 7 characters

– Decimal following 3rd character

ICD-10 Code Structure

• Placeholder “X”– Used for future expansion of a code– Fills in empty characters when a 6th and/or 7th character

apply– The placeholder may be used in different scenarios but

should never serve as the final character.

Example: W19.XXXA Unspecified fall, Initial Encounter


• 7th Character– Provides specified information regarding the clinical visit– Is required for certain categories and must be reported in

the seventh position– May be alpha or numeric– Has different meanings depending on the coding category


• Laterality– Some ICD-10-CM codes indicate laterality, specifying

whether the condition occurs on the left, right or is bilateral.

– 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.

OGCR section 1.B.13


• “Other” Codes– Codes titled “other” or “other specified” are for use when

the information in the medical record provides detail for which a specific code does not exist.

• “Unspecified” Codes– Codes titled “unspecified” are for use when the

information in the medical record is insufficient to assign a more specific code.

OGCR section 1.A.9.a.b


• Excludes Notes– Excludes1

• A type 1 Excludes note is a pure excludes note• It means “NOT CODED HERE”• The code excluded should never be used at the same time• When two conditions cannot occur together

– Excludes2• Represents “Not included here”• The condition excluded is not part of the condition represented

by the code• It is acceptable to use both the code and the excluded code

together, when appropriateOGCR section 1.A.12.a.b

ICD-10 Structure

• “Code First” and “Use Additional Code”– ICD-10 has a coding convention that requires the

underlying condition be sequenced first followed by the manifestation.

– These instructional notes indicate the proper sequencing order of the codes.

OGCR section 1.A.13

• The “-” indicates there are additional reporting options


Most Common Diagnosis Codes

Chronic Obstructive Pulmonary Disease (COPD)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2

496 J44.9 Chronic obstructive pulmonary disease, unspecified

Applicable to:• Chronic obstructive

airway disease NOS• Chronic obstructive

lung disease NOS

• Bronchiectasis (J47.-)• Chronic bronchitis NOS

(J43)• Chronic simple and

mucopurulent bronchitis (J14.-)

• Chronic tracheitis (J42)• Chronic tracheobronchitis

(J42)• Emphyysema without

chronic bronchitis (J43.-)• Lung diseases due to

external agents (J60-J70)

N/A

There are more specific code choice selections below:

491.22493.21

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

491.21493.22

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

• Code also type of asthma, if applicable (J45)• Use additional code to identify:

– Exposure to environmental tobacco smoke (Z77.22)– History of tobacco use (Z87.891)– Occupational exposure to environmental tobacco

smoke (Z57.31)– Tobacco dependence (F17.-)– Tobacco use (Z72.0)

COPD Documentation Tips

Shortness of breathICD-9 Code ICD-10 Code Description Excludes1 Excludes2

786.05 R06.02 Shortness of breath

• abnormalities originating in the perinatal period (P29.1-)

• specified arrhythmias (I47-I49)

• acute respiratory distress syndrome (J80)

• respiratory arrest (R09.2)• respiratory arrest of

newborn (P28.81)• respiratory distress

syndrome of newborn (P22.-)

• respiratory failure (J96.-)• respiratory failure of

newborn (P28.5)• tachypnea NOS (R06.82)• transient tachypnea of

newborn (P22.1)

• abnormal findings on antenatal screening of mother (O28.-)

• certain conditions originating in the perinatal period (P04-P96)

• signs and symptoms classified in the body system chapters

• Page 935• signs and symptoms of

breast (N63, N64.5)


786.09 R06.00 Dyspnea, unspecified

786.02 R06.01 Orthopnea

786.09 R06.09 Other forms of dyspnea

• Dyspnea Type– Shortness of breath– Orthopnea– Other forms

Documentation Tips

• Use of symptom codes– Codes that describe symptoms and signs are acceptable for reporting purposes when a

related definitive diagnosis has not been established (confirmed) by the provider.

• Use of a symptom code with a definitive diagnosis code– Codes for signs and symptoms may be reported in addition to a related definitive

diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.

– Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

• Combination codes that include symptoms– ICD-10-CM contains a number of combination codes that identify both the definitive

diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.

Documentation Tips

Sleep apnea (adult) (pediatric)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2

327.20780.51

G47.30 Sleep apnea, unspecified

Applicable to:• Sleep apnea NOS

• Apnea NOS (R06.81)

• Cheyne-Stokes breathing (R06.3)

• Pickwickian syndrome (E66.2)

• Sleep apnea of newborn (P28.3)

• nightmares (F51.5)• nonorganic sleep disorders

(F51.-)• sleep terrors (F51.4)• sleepwalking (F51.3)

There are more specific code choice selections below: SEE NEXT SLIDE

Sleep apneaICD-9 Code ICD-10 Code Description Excludes1 Excludes2

327.21 G47.31 Primary central sleep apnea • Apnea NOS (R06.81)

• Cheyne-Stokes breathing (R06.3)

• Pickwickian syndrome (E66.2)

• Sleep apnea of newborn (P28.3)

• nightmares (F51.5)

• nonorganic sleep disorders (F51.-)

• sleep terrors (F51.4)

• sleepwalking (F51.3)

327.22 G47.32 High altitude periodic breathing

327.23 G47.33 Obstructive sleep apnea (adult) (pediatric)

327.24 G47.34 Idiopathic sleep related nonobstructive alveolar hypoventilation

Applicable To:• Sleep related hypoxia

327.25 G47.35 Congenital central alveolar hypoventilation syndrome

327.26 G47.36 Sleep related hypoventilation in conditions classified elsewhere

327.27 G47.37 Central sleep apnea in conditions classified elsewhere

327.29 G47.39 Other sleep apnea

Code also any associated underlying condition

Other nonspecific abnormal finding of lung fieldICD-9 Code ICD-10 Code Description Excludes1 Excludes2

793.19 R91.8 Other nonspecific abnormal finding of lung field

Applicable To:• Lung mass NOS found

on diagnostic imaging of lung

• Pulmonary infiltrate NOS

• Shadow, lung


• diagnostic abnormal findings classified elsewhere - see Alphabetical Index

N/A


793.11 R91.1 Solitary pulmonary nodule

Applicable to:• Coin lesion lung• Solitary pulmonary nodule, subsegmental branch of the

bronchial tree

Includes:• nonspecific abnormal findings on diagnostic imaging by computerized axial tomography [CAT

scan]• nonspecific abnormal findings on diagnostic imaging by magnetic resonance imaging [MRI]

[NMR]• nonspecific abnormal findings on diagnostic imaging by positron emission tomography [PET

scan]• nonspecific abnormal findings on diagnostic imaging by thermography• nonspecific abnormal findings on diagnostic imaging by ultrasound [echogram]• nonspecific abnormal findings on diagnostic imaging by X-ray examination

Documentation Tips

AsthmaICD-9 Code ICD-10 Code Description Excludes1 Excludes2

493.00, 493.10 J45.20 Mild intermittent asthma, uncomplicated or NOS

• bronchitis due to chemicals, gases, fumes and vapors (J68.0)

• cystic fibrosis (E84.-)

493.01, 493.11 J45.22 Mild intermittent asthma with status asthmaticus

N/A N/A

493.02, 493.12 J45.21 Mild intermittent asthma with (acute) exacerbation

N/A N/A

493.82 J45.991 Cough variant asthma N/A N/A

493.90 J45.909J45.998

Unspecified asthma, uncomplicatedOther asthma

N/A N/A

493.91 J45.902 Unspecified asthma with status asthmaticus


• cystic fibrosis (E84.-)

493.92 J45.901 Unspecified asthma with (acute) exacerbation


cystic fibrosis (E84.-)

Asthma Severity ChartINTERMITTENT MILD

PERSISTENTMODERATE PERSISTENT

SEVERE PERSISTENT

SYMPTOMS 2 or less daysper week

More than 2days perweek

Daily Throughoutthe day

NIGHTIME AWAKENINGS

2 x’s permonth or less

3 – 4 x’s permonth

More thanonce perweek but notnightly

Nightly

RESCUE INHALER USE

2 or less daysper week

More than 2days perweek, but notdaily

Daily Several timesper day

INTERFERENCE WITH NORMAL ACTIVITY

None Minorlimitation

Somelimitation

Extremelylimited

LUNG FUNCTION FEVI>80% predicted and normal between exacerbations

FEV1>80%predicted

FEV1 60 –80%predicted

FEV1 lessthan 60%predicted

• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).

• Use additional code, where applicable, 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)

Documentation Tips

CoughICD-9 Code ICD-10 Code Description Excludes1 Excludes2

786.2 R05 Cough • Cough with hemorrhage (R04.2)

• Smoker’s Cough (J41.0)

N/A

• Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting

purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

• Use of a symptom code with a definitive diagnosis code– Codes for signs and symptoms may be reported in addition to a

related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code.

• Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Cough Documentation Tips

Cystic fibrosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2

277.00 E84.9 Cystic fibrosis, unspecified

Includes:mucoviscidosis

• androgen insensitivity syndrome (E34.5-)

• congenital adrenal hyperplasia (E25.0)

• Ehlers-Danlos syndrome (Q79.6)

• hemolytic anemias attributable to enzyme disorders (D55.-)

• Marfan's syndrome (Q87.4)• 5-alpha-reductase

deficiency (E29.1)

N/A


277.02 E84.0 Cystic fibrosis with pulmonary manifestationsUse additional code to identify any infectious organism present, such as: Pseudomonas (B96.5)

277.01 E84.11 Meconium ileus in cystic fibrosisExcludes1: meconium ileus not due to cystic fibrosis (P76.0)

277.03 E84.19 Cystic fibrosis with other intestinal manifestationsDistal intestinal obstruction syndrome

277.09 E84.8 Cystic fibrosis with other manifestations

Identify:• Anatomical site• Manifestations (e.g. bronchopneumonia)

Documentation Tips

Pulmonary fibrosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2

515 J84.10 Pulmonary fibrosis, unspecified

Applicable to:• Capillary fibrosis of lung• Cirrhosis of lung

(chronic) NOS• Fibrosis of lung

(atrophic) (chronic) (confluent) (massive) (perialveolar) (peribronchial) NOS

• Induration of lung (chronic) NOS

• Postinflammatory pulmonary fibrosis

• drug-induced interstitial lung disorders (J70.2-J70.4)

• interstitial emphysema (J98.2)• lung diseases due to external

agents (J60-J70)• pulmonary fibrosis (chronic)

due to inhalation of chemicals, gases, fumes or vapors (J68.4)

• pulmonary fibrosis (chronic) following radiation (J70.1)

N/A


J84.89 Other specified interstitial pulmonary diseases

• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).

• Use additional code, where applicable, 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)

Documentation Tips

SarcoidosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2

135 D86.9 Sarcoidosis, unspecified • autoimmune disease (systemic) NOS (M35.9)

• functional disorders of polymorphonuclear neutrophils (D71)

• human immunodeficiency virus [HIV] disease (B20)

N/A


135 D86.0 Sarcoidosis of lung

Idiopathic interstitial pneumoniaICD-9 Code ICD-10 Code Description Excludes1 Excludes2

516.30 J84.111 Idiopathic interstitial pneumonia, not otherwise specified

• lymphoid interstitial pneumonia (J84.2)

• pneumocystis pneumonia (B59)

N/A


516.31 J84.112 Idiopathic pulmonary fibrosis

516.32 J84.113 Idiopathic non-specific interstitial pneumonitis

516.33 J84.114 Acute interstitial pneumonitis

516.34 J84.115 Respiratory bronchiolitis interstitial lung disease

516.36 J84.116 Cryptogenic organizing pneumonia

516.37 J84.117 Desquamative interstitial pneumonia

• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it shouldbe classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).

• Use additional code, where applicable, 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)

Documentation Tips

BronchiectasisICD-9 Code ICD-10 Code Description Excludes1 Excludes2

494.0 J47.9 Bronchiectasis, uncomplicated

Applicable to:• Bronchiectasis NOS

• congenital bronchiectasis (Q33.4)

• tuberculous bronchiectasis (current disease) (A15.0))

N/A


494.1 J47.0 Bronchiectasis with acute lower respiratory infectionApplicable to: Bronchiectasis with acute bronchitis

494.1 J47.1 Bronchiectasis with (acute) exacerbation



Documentation Tips

Multiple sclerosisICD-9 Code ICD-10 Code Description Excludes1 Excludes2

340 G35 Multiple sclerosis

Applicable To:• Disseminated multiple

sclerosis• Generalized multiple

sclerosis• Multiple sclerosis NOS• Multiple sclerosis of

brain stem• Multiple sclerosis of

cord

N/A

Chronic Obstructive Pulmonary Disease (COPD)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2

496491.20

J44.9 Chronic obstructive pulmonary disease, unspecified

Applicable to:• Chronic obstructive

airway disease NOS• Chronic obstructive

lung disease NOS

• Bronchiectasis (J47.-)• Chronic bronchitis NOS

(J43)• Chronic simple and

mucopurulent bronchitis (J14.-)

• Chronic tracheitis (J42)• Chronic tracheobronchitis

(J42)• Emphyysema without

chronic bronchitis (J43.-)• Lung diseases due to

external agents (J60-J70)

N/A


491.22493.21

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

491.21493.22

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

• Code also type of asthma, if applicable (J45)• Use additional code to identify:

– Exposure to environmental tobacco smoke (Z77.22)– History of tobacco use (Z87.891)– Occupational exposure to environmental tobacco

smoke (Z57.31)– Tobacco dependence (F17.-)– Tobacco use (Z72.0)

COPD Documentation Tips

Other respiratory disordersICD-9 Code ICD-10 Code Description Excludes1 Excludes2

519.8 J98.8 Other specified respiratory disorders

• newborn apnea (P28.4)

• newborn sleep apnea (P28.3)

• apnea NOS (R06.81)• sleep apnea (G47.3-)


J98.01 Acute bronchospasm

J98.09 Other diseases of bronchus, not elsewhere classified

J98.11 Atelectasis

J98.19 Other pulmonary collapse

J98.2 Interstitial emphysema

J98.3 Compensatory emphysema

J98.4 Other disorders of lung

J98.5 Diseases of mediastinum, not elsewhere classified

J98.6 Disorders of diaphragm

J98.9 Respiratory disorder, unspecified



Documentation Tips

Localized swelling, mass and lump, trunkICD-9 Code ICD-10 Code Description Excludes1 Excludes2

786.6 R22.2 Localized swelling, mass and lump, trunk

• abnormal findings on diagnostic imaging (R90-R93)

• edema (R60.-)• enlarged lymph

nodes (R59.-)• localized adiposity

(E65)• swelling of joint

(M25.4-)• intra-abdominal or

pelvic mass and lump (R19.0-)

• intra-abdominal or pelvic swelling (R19.0-)


• certain conditions originating in the perinatal period (P04-P96)

• signs and symptoms classified in the body system chapters

• signs and symptoms of breast (N63, N64.5)

• breast mass and lump (N63)

• Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting

purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

• Use of a symptom code with a definitive diagnosis code– Codes for signs and symptoms may be reported in addition to a

related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code.

• Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Documentation Tips

On October 01, 2015 we will monitor claims for date of service rules

• Outpatient claims cannot have crossover dates • Outpatient claims will be coded according to date of

service• Inpatient facility claims will be coded per date of discharge

We will monitor claims to resolve any unanticipated problems with the submission process

Monitor Claims

• We will monitor for claim denials• We will monitor editing trends for ICD-10 Coding

guidelines• We will provide feedback to the physicians regarding

supporting documentation requirements • We will monitor WC or Liability carriers for published

rules on use of ICD-9 or ICD-10 code sets

Claim Denial and Management

• Client will need to update – Templates– Order Sets– Superbills– Favorites

• Future Orders– Remove ICD-9 code add ICD-10 code

Client Responsibilities

All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection.

• Site specificity• Document notation of qualifiers

– Exacerbation– Manifestations– Relapse– Status– Stages

• Indicate acute or chronic• Indicate underlying or external cause factors

– Medication– Smoke– Accidents– Mechanical failure

• Laterality– Bilateral– Right – Left

Documentation – Start Now

• Episode of Care for injuries, poisoning, external causes and other conditions– Initial Encounter

• Use while the patient is receiving active treatment of the condition– Active treatment includes surgical treatment, an emergency encounter, and

evaluation and treatment by a new physician

– Subsequent Encounter• Used on encounter after the patient has received active treatment of

the condition and is receiving routine care for the condition during the healing or recovery phase.

– Medication adjustments, aftercare, device adjustments, cast change

– Sequela• Used for complications or conditions that arise as a direct result of a

condition, late effect


• Combination codes that capture– Etiology and manifestation– Related conditions– Disease, injury or other medical condition and

complications– Disease or other medical conditions and common signs or

symptoms

• Add ICD-10 Codes to patient Problem List


UnderdosingUnderdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”).

Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.

OGCR Section 1.C.19.e.5.c

Official Guidelines for Coding and Reporting

[email protected]

Centers for Disease Control and Prevention (ICD-10-CM)http://www.cdc.gov/nchs/icd/icd10cm.htm

Questions

mailto:[email protected]

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

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

Documents

Pulmonology ICD-10 CM Training. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1, 2015