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THE BASICS OF ICD-10-CM CODING

Continuing Education for Long-Term Care FacilitiesJune 9, 2015

Marla Dumm, CPC, CCS-PManaging Consultantmdumm@bkd.com

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Objectives

• Distinguish between ICD-9 & ICD-10 code structure

• Identify necessity to review clinical documentation & translate information into diagnosis code

• Describe best practices related to accurate & specific code assignment

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Current Status – DEADLINE• Final Rule CMS-0043-F

– https://www.federalregister.gov/articles/2014/08/04/2014-18347/change-to-thecompliance-date-for-the-international-classification-of-diseases-10th-revision

• Issued on July 31, 2014• Finalized new deadline of

October 1, 2015• No new code updates until

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Resource documents – ICD-9-CM• ICD-9-CM Official Guidelines for Coding &

Reporting• Effective October 1, 2011• Last major updatehttp://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf

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Resource Documents – ICD-10-CM

• ICD-10-CM Official Guidelines for Coding & Reporting (2015 Version)

• Effective with dates of service October 1, 2015

http://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cm-guidelines-2015.pdf

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Will Official Coding Guidelines Differ?

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Official Coding Guidelines

• Minimal changes • General guidelines for assignment of codes,

order of codes, punctuation, abbreviations, etc., will be very similar

• Some structural differences & modifications to code classifications or code descriptions due to expanded code detail

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Standard Coding Process• Be familiar with ICD-10-CM Official Coding

Guidelines & Conventions– Section I-III

• Review clinical documentation (physician or non-physician practitioner)– Nursing facility admission H&P, nursing facility

discharge summary, acute hospital discharge, progress notes, consultation reports, diagnostic test reports, etc.

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Standard Coding Process

• Identify main term(s)• Look up main term(s) in Alphabetic Index• Look through subterms if applicable• Review all additional lines & subterms that

may continue to next column • Refer to all parenthetical terms

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Standard Coding Process

• Grey shaded vertical lines – provide guidance for indented subterms & additional subterms

• Review all instructional notes & references– “see,” “see also,” “see category”– “with” or “without”– “omit code”– “due to”– “code by site” – NEW TO ICD-10-CM

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Standard Coding Process• Reminder – Do not code from the index• Locate & confirm code(s) in Tabular List• Read & follow instructions

– “Includes” & “Excludes” notes– “Use additional code”– “Code first underlying disease” – “Code also”– Character requirements (4th, 5th, 6th & 7th

extensions)– Age or gender

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Standard Coding Process

• Refer to Official Guidelines to verify rule(s)• Confirm & assign code(s) to highest level of

specificity (number of characters) supported in documentation

• List on claim form in priority (or sequence) per coding guidelines

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Standard Coding Process

Example– Acute Upper Respiratory Infection

• Infection• Respiratory• Upper• Acute• Code – J06.9

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Index – Volume 2

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Index – Volume 2

• Alphabetic order– Can search by condition, disease, sign, symptom,

etc– Anatomical site will refer you to “see condition”

• Index to Diseases & Injury • Neoplasm Table• Table of Drugs & Chemicals• Index to External Causes of Injury

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Index – What’s not in ICD-10?Hypertension Table.................................................................. Malignant..... Benign... UnspecifiedHypertension, hypertensive (arterial) (arteriolar) (crisis) (degeneration) (disease) (essential) (fluctuating) (idiopathic) (intermittent) (labile) (low renin) (orthostatic) (paroxysmal) (primary) (systemic) (uncontrolled) (vascular).......................................... 401.0......... 401.1......... 401.9with chronic kidney diseasestage I through stage IV, or unspecified .................. 403.00....... 403.10....... 403.90stage V or end stage renal disease ......................... 403.01....... 403.11....... 403.91heart involvement (conditions classifiableto 429.0-429.3, 429.8, 429.9 due to hypertension)(see also Hypertension, heart).................................. 402.00....... 402.10....... 402.90with kidney involvement see Hypertension, cardio renal

• This table has been removed. Look for “Hypertension, hypertensive” in table for code selection

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Main Terms• Identify disease or condition of site (for

injuries)• Main terms are listed in bold type & start with

an uppercase letterExamples of main term headings

– Complications– Late Effect(s) or Sequelae (new for ICD-10)– Fracture– Pneumonia

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Main Terms• Follow cross references like “see also” & “see”• Modifiers & Subterms are located under Main

Term• An indented structure is used

– See shaded lines in index which line up indented terms

• Notes– Define terms– Provide direction & instruction

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Non-Essential Modifiers

• Words that follow main term• Are always in parenthesis• Provide additional information for main term• The presence or absence of these modifiers

has no effect on selection of the code for termExample

– Pneumonia (acute)(double)(migratory)(purulent)(septic) (unresolved)

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Essential Modifiers• Subterms that modify main term

– Are listed below main term in alphabetical order (exception of “with” & “without”)

• Indented two additional spaces to the right• Regular type & starts with a lowercase letterExample

• Pneumonia‒ With

• Influenza – see Influenza, with, pneumonia• Lung abscess

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Eponyms & Synonyms• Eponyms

– Diseases or syndromes named for a person (i.e., who discovered the illness)

– Listed as a main term under both name of person & disease or syndrome

Example• Guillain-Barre’ Syndrome (look up Guillain or Syndrome)

• Synonyms– Escherichia coli (E. coli)

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Abbreviations• NEC – Not Elsewhere Classified• Used when

– Coder has specific documented information, but there is no separate or specific code available to represent condition documented in medical record

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Abbreviations• NOS – Not Otherwise Specified• Used when

– Coder lacks or does not have specific documented information

– Equivalent to “unspecified”

• NOS codes should never be used routinely as a means to avoid having to search for a more specific term

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Cross-Reference Terms• See (Condition, Category) – Mandatory

instruction that the coder must look elsewhere for an alternative term. Coding cannot be completed without following this instruction

• See also – Coder must review another main term if information documented in record is not reflected under main term

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Cross-Reference Terms

Examples

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Neoplasm Table• Search by anatomical site where neoplasm is

located• Columns will detail Primary, Secondary

(metastasis) or Ca in Situ malignancy• Additional columns will detail benign

neoplasms, those with uncertain behavior & unspecified

• Information must be documented in medical record (i.e., chart note, pathology report)

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Table of Drugs & Chemicals• Used to define code by the toxic effect (i.e.,

poisoning) from a specific drug, medication or solution

• Search by name of drug or medication– Brand name– Generic name

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Table of Drugs & Chemicals• Columns

– Poisoning, Accidental (Unintentional)– Poisoning, Intentional Self-Harm– Poisoning, Assault– Poisoning, Undetermined– Adverse Effect– Under-Dosing (New Category)

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Argyrol

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Restructuring the Index• Injuries are grouped by anatomical site rather

than by type of injury• Certain diseases & disorders have been

reclassifiedExample: Gout is now in Musculoskeletal instead of Endocrine

• Categories restructured• Codes have been reorganized to appropriate

chapter• Familiar codes will appear in different

chapters or sections to reflect current medical knowledge

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Tabular List – Section 1

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Tabular List• Numerical listing of codes• 21 chapters • Classification of factors influencing health

status & contact with health services – Codes beginning with V, W, X or Y

• Classification of external causes of injury & poisoning– Codes beginning with Z

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New Chapters• Sensory signs, symptoms &/or conditions

− Chapter 7 - Eyes− Chapter 8 - Ears

Example– H66.001 – Acute suppurative otitis media without

spontaneous rupture of ear drum, right ear– H40.11 – Primary open-angle glaucoma

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Code Format – What to Expect

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ICD-10-CM structure• Up to seven digits• First digit = always alpha, except “U”• Second digit = always numeric • All other digits = combination (Watch O/0, 5/S, I/1)

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Structure Comparison

ICD-9-CM

813.06

Closed Fracture of Neck/Radius

ICD-10-CM

S52.131A

Displaced fracture of neck/right radius, initial

encounter for treatment of closed fracture

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Tabular List • Numerical listing of codes divided into 21

chapters • Code structure

– 3rd characters – main code/category. May be primary code if no further specificity is required

– 4th character – After decimal point. Defines site, etiology & manifestation

– 5th & 6th characters – further specificity– 7th character – Required if instructed in Tabular

section, identifies status of care

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Characters Add Specificity• Additional characters are added to “main

category” (three character code depending on code instructions)

Example– S52 Main category for “Fracture of Forearm”– S52.5 Subcategory code for unspecified

“Fracture of the lower (or distal) end of radius”

– S52.52 Sub classification code for “Torus fracture of lower (or distal) end of radius

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Characters Add SpecificityExample

– S52.521 Sub classification code for “Torus fracture of lower (or distal) end of rightradius”

– S52.521A Adding the required 7th character “A”specifies the type of encounter or stage of healing - “Torus fracture of lower end of right radius, initial encounter for closed fracture

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New Features – Placeholders

• Character “x” is used as a placeholder• Allows for future expansion• Fills empty characters for codes that require

the full seven characters– T15.02XD – Foreign body in cornea, left eye,

subsequent encounter

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New Features – 7th Character• Will always be listed in the seventh position• Adds additional information to describe the

encounter– A = Initial encounter– D = Subsequent encounter

• Must be used when instructed in Tabular listing– S50.02XD Contusion of left elbow, subsequent

encounter

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New Features – 7th Character

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7th Character – Type of Encounter• Initial, subsequent or care of sequela (i.e., late

effect)• Active treatment

Examples: Surgical treatment, ER encounter, E/M by new physician

• Subsequent encounter– Routine follow-up care, during healing phase

• Sequela– Complications of conditions that occur as a direct

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New Features – Laterality• Laterality

– Left, right & bilateral

• The 5th code character will be defined as follows– Right side = 1– Left side = 2– Bilateral = 3– Unspecified = 0 or 9

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Laterality – Examples

– C50.511 – Malignant neoplasm of lower-outer quadrant of right female breast

– L89.022 – Pressure ulcer of left elbow, stage II

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Punctuation

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Punctuation – Brackets & Parentheses[ ] - Brackets enclose synonyms, alternative

terminology or explanatory phrases- Also to indicate manifestation codes in

index

( ) - Parentheses enclose supplementary words, called nonessential modifiers, which may be present in descriptor of a code without affecting code to which it is assigned

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Punctuation – Brackets & ParenthesesExamples

– Amyloid Heart (disease) E85.4 [I43]• Tells coder two codes will be reported• I43 is listed in [brackets] & will be secondary code

reported

– Verify code in Tabular List• Italicized instruction under I43 tells coder to Code First

underlying disease, such as– Amyloidosis (E85.-)

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Punctuation – Brackets & Parentheses• Index listing for electrocardiogram

– Abnormal, Abnormality, abnormalities • Electrocardiogram [ECG] [EKG] R94.31

• Tabular listing for R94.31– Abnormal electrocardiogram [ECG] [EKG]

• Index listing for acute laryngitis– Laryngitis (acute)(edematous)(fibrinous)(infective)

(infiltrative) (malignant)(membranous)…J04.0

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Punctuation – Colons: - Colons are used after an incomplete term that

needs one or more of the modifiers that followto make it assignable to a given category

Example– C32 Malignant neoplasm of larynx

• Use additional code to identify– Alcohol abuse and dependence (F10.-)– Exposure to environmental tobacco smoke

(Z77.22)

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Punctuation – Not in ICD-10-CM} - Braces are not found in ICD-10. The detail is now found after the main term or after the code itself &/or found in detail of code instruction in Tabular listing

Example: K56.2 Volvulus• Strangulation of colon or intestine• Torsion of colon or intestine• Twist of colon or intestine

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Instructional Notes

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Instructional Notes• “Includes”

This note appears immediately under a three-digit code title at beginning of chapter or section. Further defines or clarifies content of category

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Instructional Notes“Excludes”• Terms following

the word “excludes” are not classified to code under which it is found

• May indicate another code more fully describes a diagnosis

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Instructional Notes• “Use additional code”

This instruction signals coder that an additional code should be used when documentation states both etiology & manifestation of disease

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Instructional Notes‒ “Code first”

• The instruction is to code underlying disease (etiology) first (i.e., “code first”)

• Manifestation code is sequenced as secondary diagnosis

• Manifestation codes may never be used alone or sequenced as principal diagnosis

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Instructional Notes – “Code First”

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Official Guidelines

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Principal Diagnosis – Section II• “The condition established after study to be

chiefly responsible for occasioning the admission of the patient to the hospital for care”

• Definition applies to all non-outpatient settings, to include LTC

• Principal diagnosis = condition requiring resident’s admission Example: Patient with Parkinson’s disease admitted post hospitalization for therapy associated with acute pneumonia

ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Page 97-10061

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Primary Diagnosis – Section II• Primary diagnosis = reason for continued stay

in LTC– May be same as principal diagnosis (i.e, Parkinson’s

disease) – Is required to support therapy services Example

• The pneumonia would be sequenced as second diagnosis as reason for therapy

ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Page 97-100

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MDS versus ICD-10-CM• MDS lists “Active Diagnoses” under Section I• Identifies “disease related to the resident’s functional,

cognitive, mood or behavior status, medical treatments,nursing monitoring or risk of death”

• Values are assigned to these “groups” of codes• Resident may have other conditions that also need to be

coded• ICD-10-CM codes may be listed on the MDS if the groups

do not identify a condition or diagnostic group thatmeets criteria in second bullet point

• Consistent, complete & diagnosis codes in MDS & onclaim form

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“Additional Diagnoses” – Section III• “All conditions that coexist at the time of admission,

that develop subsequently, or that affect the treatment received and/or the length of stay”

• Applies to LTC setting• Do not report conditions that are resolved or from

previous admissions that have no bearing on the current stay

• Historical diagnoses (Z80-Z87) may be used if there is impact on current care or treatment

ICD-10-CM Official Guidelines for Coding and Reporting, Section III, Pages 100-101

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Signs & Symptoms• May be coded when they are the reason for

testing• When provider has not made a definitive final

diagnosis• Signs & symptoms that are a routine part of a

known disease process are not coded separately unless otherwise instructed in Tabular listing

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Abnormal Test Findings• Do not code unless provider documents clinical

significance in medical record• If physician or nonphysician practitioner orders

tests based on abnormal findings or findings outside the norm, query physician to verify code assignment

• If an abnormal findings leads to a definitive diagnosis upon further testing prior to coding the case, definitive diagnosis is always used

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Multiple Coding• Use of more than one code to fully identify

components of a complex diagnostic statement • A complex statement is one that involves connecting

words or phrases such as “associated with,” “due to,” “incidental to,” or “secondary to”

• Is required for certain conditions that are not subject to rules of combination coding

• Identified in Tabular List by instruction to “use additional” or “code first underlying disease”

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Multiple Coding – Example

I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

Use additional code to identify the stage of chronic kidney disease (N18.5-N18.4, N18.9)

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Combination Codes• A single code used to classify two diagnoses or

a diagnosis with an associated secondary process (manifestation) or complication

• Only the combination code is assigned when that code fully identifies the diagnostic conditions involved or when Tabular/Alphabetical Index so directs

Example‒ E10.610 – Type 1 diabetes mellitus with diabetic

neuropathic arthropathy• Describes type, body system & manifestation

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Sequela (Late Effects)• Reflects residual effect or condition produced

by an acute phase of illness or injury• No time limit applies • Generally requires two codes

– Condition or nature of the sequela (cause of the sequela) is coded first

– Sequela (late effect) is coded secondException: if instructed to code a manifestation or combination code includes sequela

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Late Effects or Sequela of CVAICD-9-CM

438.11 – Late effect of cerebrovascular disease, speech & language deficits, aphasia

ICD-10-CMI69.020 – Aphasia following nontraumatic subarachnoid hemorrhageI69.120 – Aphasia following nontraumatic intracerebral hemorrhageI69.220 – Aphasia following other nontraumatic intracranial hemorrhage disease

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Aftercare Codes – Fractures or Injuries

• Assign after initial, acute treatment is completed

• Used in post acute settings• Patient is admitted to LTC for ongoing care

during healing or recovery phase• List acute injury code with 7th character “D”• Aftercare Z codes are NOT used for injuries

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Aftercare Coding – Examples• Example A

– Patient status post hip replacement– Admitted to LTC for rehabilitation– S72.111D – Subsequent encounter for closed

fracture with routine healing

• Example B – Patient status post fracture of acute pelvic fracture– Admitted to LTC for rehabilitation– S32.9XXD – Fracture/unspecified/lumbosacral

spine & pelvis, subsequent encounter for routine healing

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Ventilator Associated Pneumonia

• J95.851 – Ventilator associated pneumonia– When provider has documented that it is related

to ventilator use– Assign an additional code for organism– Do not assign if provider does not specify

pneumonia is caused by ventilator

• Refer to Sections J13-J18 for other pneumonia diagnoses

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Urinary Tract Infection• ICD-9-CM

– Assigned 599.0 + the organism if identified & documented

• ICD-10-CM– Assign N39.0– Assign additional code (B95-B97) for infectious

agent if known

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Wound Care• Z48.0 – code series

– Encounter for attention to dressings, sutures & drains

• Nonsurgical wound dressing• Surgical wound dressing• Removal of sutures• Change or removal of drains

• Code open wound, ulcer, etc., requiring treatment

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Wound Care• Ulcer, Pressure, by site (i.e., decubitus, bed

sores)– L89. – code series

• Instruction to “code also” associated gangrene (I96) if documented

• Nursing or provider documentation should reflect– Type of wound– Site(s)– Stage(s)

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Open Wounds – Code Series• Head (S00 to S09)• Neck (S10 to S19)• Thorax (S20 to S29)• Abdomen, lower back, lumbar spine, pelvis, & external genitals

(S30 to S39)• Shoulder & upper arm (S40 to S49)• Elbow & forearm (S50 to S59)• Wrist & hand (S60 to S69)• Hip & thigh (S70 to S79)• Knee & lower leg (S80 to S89)• Ankle & foot (S90 to S99)• Unspecified multiple injuries (T07)

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Wound Care• Bacterial/viral infections – B95.0-B96.89

– Used as an additional code if not already in code description for disease, wound or ulcer

• MRSA– MRSA Carrier/colonization Z22.322– MRSA Susceptible/colonization Z22.321

• Osteomyelitis Acute – M86.00-M86.29• Osteomyelitis Chronic – M86.30-M86.9• Asceptic Necrosis – M87.00-M90.59• Cellulitis – L02.02-L02.93, L02.02-L0391

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Final Thoughts• Evaluate training needs• Evaluation workflows • Perform dual coding assessments

on a sample of current records & claims

• Provide feedback & education to professional staff on clinical documentation improvement

• Send coding personnel to comprehensive ICD-10 training prior to October 1, 2015

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Resources & ReferencesCMS ICD-9-CM Websitehttp://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html

CMS ICD-10-CM Websitehttp://www.cms.gov/Medicare/Coding/ICD10/index.html

AHIMA. “ICD-10-CM Coding Guidance for Long-Term Care Facilities.” Journal of AHIMA 86, no. 3, (March 2015): 46-50

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CMS ICD-10-CM Implementation Tools

• ICD-10 Implementation Timelines & Checklistshttp://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html

• CMS Provider Toolshttp://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

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Coding Industry Resources• AHIMA

http://www.ahima.org/icd10• AAPC

http://www.aapc.com/http://www.aapc.com/icd-10/index.aspxhttp://www.aapc.com/ICD-10/resources.aspx

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THANK YOU!Marla Dumm, CPC, CCS-PManaging Consultantmdumm@bkd.com

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