Slide 1

Three ways to find the right ICD-10 code

Presented by Wyn L Staheli

Director of Research & Editing

1

ICD-10 can be overwhelming, but,

with some strategizing and planning it

can be managed. In this presentation

we will look at a few ICD-10

fundamentals, then familiarize

ourselves with three methods for

finding the right ICD-10 code. Each

one is a different path, but all lead to

the same destination: the right code.

Slide 2

2

You may remember that there were

some who thought the world would

end on December 21, 2012 (because

that was the end of the Mayan

calendar). When that date passed,

some thought that maybe it would be

the next year, or the one after that.

Many physicians feel that ICD-10 could

be the end too. But that date keeps

passing us by with no end in sight. It

looks like 2015 will finally be the year.

Don’t worry though, with the right

plan and the right tools, you will make

it through the ICD-10-ocolypse.

Slide 3 Wyn L Staheli

• Education• Bachelor’s of Science, Management Information Systems (MIS)

• Experience• Office Manager for an Infectious Disease specialist and behavioral health

group

• Computer Programmer for a large insurance carrier as well as a California hospital system

• Writer and editor of medical resource books

• Founder of InstaCode Institute (which has been serving the medical community since 1996)

• Cofounder of FindACode.com

3

Just in case you are wondering

about who I am, here’s my

background.

I’ve played on both sides of the

insurance game.

Slide 4

ICD-914,567 codes

ICD-1069,832codes

4

Why can’t we keep using ICD-9?

A common question, especially from

providers, is: “Why can’t we just keep

using ICD-9? It works fine.”

The truth is that if you drop ICD-9 and

ICD-10 into a ring together, ICD-10 will

win every time. Not only is it much

bigger, it is better. The codes are more

detailed, more logical, and better

organized.

Sure, ICD-10 is a bigger code set, but

as CMS recently stated in an alert

about ICD-10:

“You don’t have to use 68,000

codes. Your practice does not

use all 13,000 diagnosis codes

available in ICD-9. Nor will it be

required to use the 68,000

codes that ICD-10 offers. As

you do now, your practice will

use a very small subset of the

codes.”

Because ICD-10 is more logical,

detailed and better organized, sticking

with ICD-9 is like sticking with a type

writer when you could be using

Microsoft Word.

Slide 5

5

ICD-10 examples

In ICD-9: E844.8

Sucked into jet without accident to aircraft; ground crew

To illustrate to you just how detailed

ICD-10 can be, we will take this ICD-9

code and translate it so that you can

see how much information can be

conveyed in the new codes. This really

is an actual ICD-9 code.

Slide 6

6

ICD-10 examples

In ICD-10: V97.3

Person on ground injured in air transport accident;

Here we see the first four characters

of the ICD-10 equivalent. Not much

new yet.

Slide 7

7

ICD-10 examples

In ICD-10: V97.33

Person on ground injured in air transport accident; sucked into jet engine

As we add the fifth character we see

some detail, but the code does not

really offer anything that the ICD-9

equivalent did not.

Slide 8

8

ICD-10 examples

In ICD-10: V97.33&

Person on ground injured in air transport accident; sucked into jet engine, male;

Now it gets interesting. The

ampersand symbol offers the gender

of the patient.

Slide 9

9

ICD-10 examples

In ICD-10: V97.33&µ

Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height;

The greek letter, “mew”, describes the

patient’s vertical stature.

Slide 10

10

ICD-10 examples

In ICD-10: V97.33&µ#

Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height; slightly bald;

The hashtag identifies the patient’s

hair status

Slide 11

11

ICD-10 examples

In ICD-10: V97.33&µ#$

Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height; slightly bald; wearing a jump suit;

The dollar sign describes his or her

fashion choice.

Slide 12

12

ICD-10 examples

In ICD-10: V97.33&µ#$€

Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height; slightly bald; wearing a jump suit; during a full moon

And the euro symbol identifies the

phase of the moon at the time of the

incident.

So, if you have not already guessed,

most of this is made up. Symbols are

not used in ICD-10, just letters and

numbers. And the codes can be up to

seven characters long, not ten, like

this silly code.

However, the characters and

description you see in blue, V97.33 are

all part of a real code.

Some ICD-10 naysayers suggest that

the codes are useless because they

provide detail that is not necessary.

However, as you will see, much of the

detail in real codes can actually be

quite helpful in communicating the

medical necessity of a claim to a third

party payer.

Slide 13

ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus.

Note: there are 11 gout codes in ICD-9 and 365 in ICD-10

13

ICD-10 examples

Here is a real code that clearly

demonstrates the additional detail

available in ICD-10. The first three

characters (M1A) represent the

category, which is a group of related

conditions. This one is chronic gout.

The other gout category is M10 and it

contains acute gout.

The fourth character identifies the

cause or etiology for this case of gout.

There are actually six different digits

that could go here, but we have

selected the “3” for “renal

impairment” for this example.

The fifth character identifies the

location. Even though gout usually

occurs in the big toe, there are ten

choices for this character, each one a

different joint where gout could occur.

The sixth character is a “1” for right,

“2” for left, or “9” for unspecified.

This is one of the new features of ICD-

10 that ICD-9 lacked: laterality.

This category is one that offers a

seventh character extension. It is a

“0” or a “1” for without and with

tophus, which is an accumulation of

uric acid crystals in the joint.

You can see that this seven character

code tells quite the story. A third

party is less likely to ask for

documentation when all this detail

appears on the claim form.

It is interesting to note that there are

11 codes for gout in ICD-9, but 365 in

ICD-10, just because of all of the extra

detail available.

Slide 14 Tabular list layout

Chapter

21 of them

from A to Z

Block

Ranges of categories

Categories

3 charactersSubcategories

4th or 5th

characters

Codes

6th or 7th

characters

14Note: Codes may be complete with fewer than 6 characters. Some codes only have 3.

Before we learn how to select the

right codes, you need to know how

the tabular list is organized.

If you open up the tabular list of a

code book, the first major subdivision

you will find is chapters. There are 21

in ICD-10, which is up from 17 (plus 2)

in ICD-9. They run from A to Z.

The next subdivision of a chapter is a

block. These cover ranges of

categories, such as I70-I79 Diseases of

arteries, arterioles, and capillaries.

Blocks can be broken down to the

three digit categories, such as I70

Atherosclerosis.

Next, you add fourth and fifth

characters, which are considered

subcategories.

Once you get down to sixth and

seventh characters, those are just

called “codes”. But note that codes

may be complete with fewer than six

characters. Some only have three

characters, such as R42 Dizziness and

giddiness. In the book I am using as

an example, complete codes will

always be in bold, so it is easy to know

if you have enough characters.

Slide 15 Tabular

List

15

Chapter: 13, Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99)(always white font in a black box)

Let’s see how this looks in a coding

manual. This is the beginning of

chapter 13, which covers diseases of

the musculoskeletal system.

Every code in this chapter begins with

the letter “M”. It spans the range of

M00 to M99.

Notice all of the rules listed under the

chapter heading. Just like ICD-9, these

guidelines apply to every code in this

chapter, so it is important to come

back to them from time to time to

make sure your code is the right one.

Slide 16 Tabular

List

16

Block: Deforming Dorsopathies(M40 – M43)(Always bold CAPS, lined above and below)

A chapter is divided into blocks, or a

range of three digit categories.

This one is deforming dorsopathies. If

there were guidelines that pertained

to the whole block, they would appear

under this heading. The formatting

here makes it easy to see when a new

block begins.

Slide 17 Tabular

List

17

Category: M43- Other Deforming Dorsopathies(Always all CAPS, with a line above)

Blocks are divided into three digit

categories. This one, M43-, is for

“other deforming dorsopathies”. The

use of the word “other” is diagnosis

coding just means that the diagnosis

can’t be found in one of the other

nearby categories.

Notice that the formatting here makes

it easy to spot when you are at the

beginning of a new category because

of the line above the three character

heading. Also notice that M43- is

followed by a hyphen, which indicates

that this is not a complete code.

All of the complete codes on this page

lack a hyphen and they are in bold.

Some have four, and some have five

characters.

Slide 18 Tabular

List

18

Subcategory: M43.1- Spondylolisthesis

Once you add a fourth or fifth

character you have entered a

subcategory. This one is

spondylolisthesis (spän-də-lō-lis-ˈthē-

səs), which is a condition where the

front part of a vertebra separates from

the back part and slips forward.

Notice that the subcategory is not a

complete code because it is not in

bold and it has a hyphen, which tips

off the reader that he or she needs to

keep adding characters. However,

there are some instructions below this

subcategory heading, and they apply

to all codes which contain these four

characters.

The fifth character adds detail about

the specific anatomic level in the

spine. We will come back and visit

this code category in a minute.

Slide 19 Finding the

ICD-10 code

Now that we have covered some basic

tabular list orientation, we are ready

to actually learn how to find the right

code. Translating from ICD-9 to ICD-10

is a lot like translating from English to

French. You can’t just take a sentence

and translate each word one at a time.

You have to consider the rules of

grammar, such as proper sentence

structure and grammar rules. The

same is true in ICD-10.

• Some codes translate as an exact

match. These are convenient, but

few and far between.

• Some ICD-9 codes translate into

multiple ICD-10 codes. These are

called scenarios.

• Since there are five times as many

ICD-10 codes as there are ICD-9

codes, some can only be mapped

backwards from ICD-10. Likewise

there may be words in French that

do not really have an English

equivalent. You need to learn more

than just a simple forwards

translation to figure out how to use

these new words (or codes)

• In some cases multiple ICD-9 codes

can be combined into a single ICD-

10 code.

• But frequently, we find that the

match is only approximate.

Slide 20

Three methods using the InstaCode ICD-10 book:1. Commonly used code list (but don’t stop there!)2. GEMs code map (don’t stop here either!)3. Alphabetic index (still not safe!)

Always confirm the code using the Tabular List 20

Finding the

ICD-10 code

Finally, we are where the rubber

meets the road. Here are the three

strategies for finding the right ICD-10

code. They are [see above]. But the

truth is that these methods are just

step one of a slightly bigger process.

Let’s say that you walk into the

supermarket, looking for grape juice.

You might ask a clerk where to find it

and he could point you to aisle 3.

Once you get there you might find

exactly what you are looking for on

the end cap. Or, you might have to

wander up and down the aisle until

you spot it. Then you might want to

compare brands, or nutritional

content, or look for the best price. In

fact, you might realize that you really

need apple-grape juice, or, after

searching for a while, you decide you

really wanted chocolate milk all along.

These three strategies all get you to

aisle 3. But often you have to do some

investigating before you can be certain

that you have chosen the right

product (or code). You do this by

digging through the Tabular List.

Slide 21

1. Common Codes

21

This is an example of a common codes

list. This one is for spinal conditions in

the lumbar region. It can be helpful

because the provider won’t need to

search through all 70,000 ICD-10

codes. He or she can just browse this

much shorter list, specific to the

anatomical region of interest, and the

provider’s specialty.

Unfortunately, using common code

lists are a little misleading because

ICD-10 has not yet been used in the

US, so no one really knows which

codes are truly “common”. These lists

are being produced by specialty

associations and coding book

publishers, but at this point in time,

they are really just best guesses.

Hence, they cannot be relied upon

completely.

Whatever path they lead us down (like

the aisle in the grocery store), we

must confirm with the tabular list.

Slide 22

22

2. GEMs

General Equivalence Mappings (GEMs)

o Created by the National Center for Health Statistics, part of the CDC

o Forward maps from ICD-9 to ICD-10

o Backward maps from ICD-10 to ICD-9

o Approximations only

Many providers will say, “Here is my

old code. Just translate to the new

one.” That is what GEMs does.

GEMs is a government database that

allows us to crosswalk from ICD-9 to

ICD-10, or from ICD-10 to ICD-9. It

seems like it could eliminate all the

concern about finding the right code,

but, unfortunately, it does not work

like that. We have been warned by

CMS that GEMs are only

approximations and they should not

be used to code. Codes should only

be selected based on the key terms

found in the provider documentation.

Nonetheless, GEMs can be helpful in

identifying good prospects. Since

GEMs was created by the government,

it is in the public domain. You can

obtain it for free, such as with the

FindACode smart phone app.

Slide 23

2. GEMs

23

Here is an example of a printed

crosswalk based on GEMs forward

mapping from ICD-9 to ICD-10. The

ICD-9 codes are listed in numeric order

in the left hand column and the ICD-10

equivalents are on the right.

Many times there is only one ICD-10

code listed, but sometimes multiple

options are offered. Unfortunately, as

we’ll see in a moment, GEMs

frequently crosses to unspecified codes

because the original ICD-9 code was

not very specific. Unspecified codes

are expected to be denied, or lead to

delayed payment if more detail could

have been reported.

In this customized crosswalk, you’ll

notice that unspecified codes do not

appear. Rather, code categories and

subcategories are provided. They are

not in bold and end with a hyphen to

encourage the reader to go to the

Tabular List to research the detail

needed to complete the code. If a

complete code is available, it is

bolded.

Slide 24

3. Alphabetic

index

24

The third, and best, strategy for

finding the right ICD-10 code is the

alphabetic index. This is the method

that CMS recommends. For this

approach, you do not need to know

what the ICD-9 code was. You just

need to read the provider

documentation, pick out the key

terms, and look them up in the index.

Sometimes the index will take you

right to a complete code, which will be

in bold (in this book anyway), but

often it only provides the first three or

four characters of a code. This is

indicated by a hyphen (and no bold),

which means that the reader needs to

seek out the rest of the code in the

Tabular List.

However, it is very important to then

review the Tabular List before making

the final code selection. There are

often specific guidelines that should

be considered before making the final

code decision.

Slide 25 Example

A 32 year old female presents with low back pain at L4/L5. The pain worsens with extension and with exercise. The patient complains of tight hamstrings and pain in the low back. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2015, the diagnosis is 738.4 Acquired Spondylolisthesis. On October 1, 2015, it is:

25

Here is an example of a case. We will

use all three methods to seek out the

appropriate ICD-10 code, then confirm

using the tabular list. [read the

example]

Note that, at this time, we have been

instructed to report ICD-9 codes for

dates of service that occur prior to

October 1. There is no testing or dual

reporting period. But there has been

some movement among some

healthcare provider’s organizations to

create a sort of transitionary period

where both codes could be accepted.

Slide 26 1. Common Codes

26

This common codes list contains

musculoskeletal diagnoses for the

lumbar spine. It is simply listed in

alphanumeric order, so the only way

to try to find our new code is to

browse the list until we see something

we like.

Highlighted in the bottom left corner,

you can see two possible codes under

the heading for “spondylolisthesis”.

One is for the lumbar region, M43.16,

and the other is lumbosacral. Since

the note said L4, we can stick with

M43.16.

This could be the right code, and we

might be done with our search.

However, we should use the other

two strategies, then confirm with the

Tabular List, just to be sure.

Slide 27

27

2. GEMs

This is a GEMs based crosswalk or

code map. As we scan the ICD-9

column, we come to 738.4, which is

the code we are starting with. This is

a one-to-two map. Upon examination,

we’ll see that that only one of the ICD-

10 codes matches the wording from

the provider documentation, M43.1-

Spondylolisthesis.

However, we were only given the

subcategory, not the complete code.

We’ll have to go to the Tabular List to

see how many more characters we

need to code to the highest level of

specificity. The official GEMs

crosswalk points to an unspecified

code, but this list omits those codes

and replaces them with an unbold,

hyphenated subcategory, forcing the

user to dig deeper, rather than default

to the undesirable unspecified code.

Before we go to the Tabular List, let’s

use the third strategy.

Slide 28

28

3. Alphabetic

index

As we look up the key term,

“spondylolisthesis” in the alphabetic

index, we are led to a few options.

The first code suggested is M43.10,

and it might just be the one we are

looking for. But, a little closer

inspection will lead us to M43.16

which is specific to the lumbar region.

Sometimes the alpha index does not

offer a complete code, but we know it

does in this case because the code is

in bold.

Now we need to go take a look at the

Tabular list and see if M43.10 or

M43.16 is a better choice.

Slide 29

29

The three strategies have all led us

here, to the Tabular List.

The first option we found, using a

commonly codes list, was M43.16.

This was also suggested by the

Alphabetic Index. It looks pretty good.

We now see that M43.10 was the

unspecified code, so it should be

avoided if we have information to

choose a better code.

M43.1- is just the subcategory. It is

not bold, so it is incomplete, but it

does help us to identify some

guidelines that apply to the code(s) we

are interested in.

Excludes1 means that these other

codes are mutually exclusive and

cannot be coded along with any

M43.1- codes. For example, a patient

can either have congenital

spondylolisthesis, or acquired

spondylolisthesis, but not both.

Within the Tabular List, we should

always trace back to the beginning of

the category to see if there are any

other important guidelines. On the

left of this page, we see that M43- has

list of Excludes1 notes. We should

look over that list to see if any of those

diagnoses provide a better option.

Notice that there are some rules on

the bottom left, under M43.0- as well.

Those rules do not apply to the

M43.1- subcategory, so we can ignore

them.

Slide 30 Example

A 32 year old female presents with low back pain at L4/L5. The pain worsens with extension and with exercise. The patient complains of tight hamstrings and pain in the low back. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2015, the diagnosis is 738.4 Acquired Spondylolisthesis. On October 1, 2015, it is:

M43.16 Spondylolisthesis, lumbar region

Note:

Common codes lists are just an expert guess

GEMs is often unspecified

Alphabetic Index often gives incomplete or multiple options30

If we go back to our example, we can

choose our code. We went down to

aisle 3, we compared all the grape

juice and we found the one that meets

our needs. M43.16. It really is not

that different from the ICD-9 code that

we started with, except that it offers

the specific anatomical region.

Note that the common codes list gave

two options, each with a different

anatomical region. We had to know

our anatomy in order to select the

right code.

The code map did not give us a

complete code, and the alpha index

gave a few options too.

However, it was only in the Tabular

List where we found the detail we

needed to confidently choose the

correct code.

Slide 31 Example 2

68 year old Hispanic female with Type 2 DM, controlled with insulin, with mild nonproliferative diabetic retinopathy without macular edema. On September 30, 2015, the diagnosis is 250.50 DM Type 2, insulin dependent with ophthalmic manifestations, controlled. On October 1, 2015, it is:

31

Example 2 is an example of a common

coding situation – diabetes.

Slide 32 1. Common Codes

32

This sample of commonly used codes

from a professional organization

shows Type 2 diabetes codes. It is

simply listed in alphanumeric order, so

the only way to try to find our new

code is to browse the list until we see

something we like.

One possible code is highlighted. This

could be the right code, and we might

be done with our search. However,

we should use the other two

strategies, then confirm with the

Tabular List, just to be sure.

Slide 33

33

2. GEMs

Using a GEMs based crosswalk or code

map we can scan the ICD-9 column,

we come to 250.50, which is the code

we are familiar with. This is a one-to-

many map. Upon examination, we’ll

see that that only one of the ICD-10

codes matches the wording from the

provider documentation, E11.3-Type 2

Diabetes Mellitus with ophthalmic

manifestations.

However, we were only given the

subcategory, not the complete code.

There is on information in the ICD-10-

CM column about “not stated as

uncontrolled”. We’ll have to go to the

Tabular List to see how many more

characters we need to code to the

highest level of specificity. The official

GEMs crosswalk points to an

unspecified code, but this list omits

those codes and replaces them with

an unbold, hyphenated subcategory,

forcing the user to dig deeper, rather

than default to the undesirable

unspecified code.

Before we go to the Tabular List, let’s

use the third strategy.

Slide 34

34

3. Alphabetic

index

As we look up the key terms,

“diabetes, type 2 with retinopathy” in

the alphabetic index, we are led to a

few options. The first code shown is

E11.319, however, it does not include

all the required elements of our

coding example.

By continuing the same as we have

become accustomed to with ICD-9

indexes, we find E11.329 which

includes all the elements of our coding

example.

Sometimes the alpha index does not

offer a complete code, but we know it

does in this case because the code is

in bold.

Now we need to go take a look at the

Tabular list to make sure that there are

no exclusions or guidelines which

might reveal a better code choice.

Slide 35

35

All three strategies have all led us

here, to the Tabular List.

There are no guidelines associated

with this code, however, just like ICD-

9, we should always trace back to the

beginning of the category to see if

there are any other relevant

guidelines. On the left of this page,

we see that E11- has list of Excludes1

notes. It is important to look over that

list to see if any of those diagnoses

provide a better option. In our

example, none are applicable.

However, there is an important “use

additional code” guideline that

applies. With ICD-10, insulin use is

documented with it’s own code, in this

case Z79.4.

Remember, an Excludes1 guideline

means that these other codes are

mutually exclusive and cannot be

coded along with any E11- codes. For

example, if the patient’s diabetes is

due to an underlying condition, you

cannot use an E11- code.

Finally, take a look at the highlighted

“See Guidelines” notation. That is a

unique InstaCode Institute helpful tool

which lets you know that there are

official guidelines regarding the coding

of Type 2 Diabetes Mellitus. It also

tells the user WHERE to look in the

guidelines to find those instructions.

Very handy!

Slide 36 The next step for converting to ICD-10

36

1. Go to the Tabular Listo Look at the following:

1. Notes

2. Includes and alternative wording

3. Excludes1

4. Excludes2

5. Code Also, Code First, Use Additional

6. Seventh character extensions

2. Repeat at the level of the code, then the subcategory, category, block, and chapter

3. Reverse map for confirmation if necessary

We don’t have time to go through all

of the ICD-10 conventions and

guidelines, but be sure to get

educated on these rules so that you

can become “fluent” in ICD-10. Just

like you need to study French in order

to become fluent, you need to get

familiar with the “rules of grammar”

in ICD-10 coding so that you can speak

with the natives, or rather avoid

interruptions to your reimbursement.

Slide 37

37

In many cases, ICD-10 requires that

provider documentation meet new

standards in order to properly select

codes. But with all the changes, this

might seem a little daunting.

To assist healthcare providers with this

issue, InstaCode Institute created

“Provider Documentation Guides”

which are part of our ICD-10 books.

There are 3-5 Examples of these

documentation guides in each book.

These guides are great to use for 10

minute training sessions to prepare

providers for the new ICD-10

requirements.

This slide shows a PDG for Type 2

Diabetes Mellitus using the example

we just used.

The “What to Document” section

becomes the healthcare provider’s

documentation ‘cheat sheet’. It lets

them know what information a coder

needs to know and helps prompt them

to include additional information

where required.

Slide 38

38

Here is a continuation of the “Provider

Documentation Guide” (PDG) showing

the remaining character options.

This standard can be used for other

commonly used codes for your

specialty. Look at your codes and

review your provider documentation

and see where you need to ‘beef up’

your documentation. Create your own

PDGs to begin proper documentation

right now.

Slide 39

The examples shown today were from

InstaCode Institute’s ICD-10 specialty

books. There are 24 different

specialties, each with their own

customized ICD-10 code listings,

training and Provider Documentation

Guides. Come to our booth to see

some examples and get a flyer. We

have special pricing available for those

who wish to order one today.