Fall Institute October 24, 2012

ICD-10-CM Introduction

Heather Greene, MBA, RHIA, CPC, CPMA

Coding and Compliance Consultant AHIMA Approved ICD-10 CM/PCS Trainer

Why Change?

• ICD-9 had several problems – We have outgrown it – Vague codes – Inability to describe lateral issues such as fractures – We are the last industrialized country to Change – Two decades behind

Why Change?

• Incorporates much greater specificity and clinical information, which results in: – Improved ability to measure health care services – Increased sensitivity when refining grouping and

reimbursement methodologies; – Enhanced ability to conduct public health surveillance; and – Decreased need to include supporting documentation with

claims

Why Change?

• Includes updated medical terminology and classification of diseases;

• Provides codes to allow comparison of mortality and morbidity data; and

Why Change?

• Measuring care furnished to patients; – Designing payment systems; – Processing claims; – Making clinical decisions; – Tracking public health; – Identifying fraud and abuse; and – Conducting research

ICD-9 and ICD-10 Differences ICD-9-CM ICD-10-CM

up to 5 characters up to 7 characters, with required 7th place character extension

no place holders place holder ‘x’ used to fill empty 4th, 5th, or 6th character positions

first character is alpha (V, E) or numeric

first character is alpha, using all but the letter “U”

ICD-9 and ICD-10 Differences ICD-9-CM ICD-10-CM

15,000 Diagnosis Codes Approximately 72,000 diagnosis codes

Lacks Detail Very Specific

Lacks Laterality Has Laterality

ICD-9 and ICD-10 Differences

• ICD-9 Diagnosis Code – 414.01 Coronary atherosclerosis; of native

coronary artery – 540.9 Acute appendicitis – 780.01 Coma

ICD-9 and ICD-10 Differences

• ICD-10 Diagnosis Code – I25.10 Atherosclerotic heart disease of native

coronary artery without angina pectoris – K35.80 Unspecified acute appendicitis – R40.20 Unspecified coma

Getting Ready

• Anatomy and Physiology • Query Forms • Clinical Documentation

– Clinical providers - get it documented – Coders – understanding what must be

documented to code correctly

Getting Ready

• Start reviewing charts using ICD-10-CM codes. • If you code it once, you will code it a thousand

times – Know your ICD-9-CM codes – Learn your ICD-10-CM codes – Break it up - one code at a time

What About Updates?

• Partial code Freeze • The last regular, annual updates to both ICD-9-CM and

ICD-10 code sets were made on October 1, 2011. • On October 1, 2012 and October 1, 2013 limited code

updates to both the ICD-9-CM and ICD-10 • On October 1, 2014, limited code updates to ICD-10

code • On October 1, 2015, regular updates to ICD-10 will

begin.

The ICD-10 Coding book

• Similar to ICD-9-CM • 21 chapters – • The axis is the body or organ system • Etiology or nature

– IE: Disease of the Nervous System and Sense Organs is one chapter in ICD-9-CM

– In ICD-10 this is placed into three different Chapters

ICD-10 -CM Structure

• Characters 1-3 – Category • Characters 4-6 – Etiology, anatomic site,

severity, or other clinical detail • Character 7 – Extension

ICD-10 –CM Structure

• Example – S52 Fracture of forearm – S52.5 Fracture of lower end of radius – S52.52 Torus fracture of lower end of radius – S52.521 Torus fracture of lower end of right radius – S52.521A Torus fracture of lower end of right

radius, initial encounter for closed fracture

ICD-10-CM Structure

• Chapter

–Block ( grouped Categories) • Category ( 3 characters)

–Subcategories (4-5 characters) –Subcategories (4-7 characters)

The ICD-10 Coding book

• Chapter 12 • Diseases of the skin and subcutaneous tissue (L00-L99) • Excludes2: certain conditions originating in the perinatal period (P04-P96)

certain infectious and parasitic diseases (A00-B99) complications of pregnancy, childbirth and the puerperium (O00-O9A) congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99) endocrine, nutritional and metabolic diseases (E00-E88) lipomelanotic reticulosis (I89.8) neoplasms (C00-D49) symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94) systemic connective tissue disorders (M30-M36) viral warts (B07.-) (pg 682)

The ICD-10 Coding book • This chapter contains the following blocks: • L00-L08 Infections of the skin and subcutaneous tissue • L10-L14 Bullous disorders • L20-L30 Dermatitis and eczema • L40-L45 Papulosquamous disorders • L49-L54 Urticaria and erythema • L55-L59 Radiation-related disorders of the skin and

subcutaneous tissue • L60-L75 Disorders of skin appendages • L76 Intraoperative and postprocedural complications of

skin and subcutaneous tissue • L80-L99 Other disorders of the skin and subcutaneous tissue

The ICD-10 Coding book (2)

• Blocks are then divided into categories – Usually 3 characters

• Categories to subcategories – Usually 4-5 characters – If not broken further it is considered a valid code:

• L71.9 Rosacea, unspecified

• Subcategories are divided into subcategories

The ICD-10 Coding book (2&3)

• Categories, subcategories are all eligible to be a code – Code, by definition: the final subdivision

• 3 to 7 character • Broken down to the lowest subcategory

• Reporting purposes – Only codes can be used

Coding Conventions (4&5)

• “x” marks the spot! • Some categories require a seventh digit

– X is used as a placeholder in order to meet this rule • Chapter 19 • Block s03. • Dislocation of Jaw is s03.0 • A seventh digit is required to clarify the encounter

– A – initial encounter – B – Subsequent encounter – C – Sequela

Coding Conventions (4&5)

• So if it is the first encounter, we would code: • S03.0xxA • Second or third encounter • S03.0xxD • Sequela • S03.0xxS

Coding Conventions (6)

• Alphabetic Index Abbreviations • NEC

– “Not elsewhere classifiable” – This abbreviation in the Alphabetic Index

represents “other specified”. When a specific code is not available for a condition, the Alphabetic Index directs the coder to the “other specified” code in the Tabular List.

Coding Convention (6)

• NEC in the Alphabetic Index – Rheumatoid —see also condition – - arthritis —see also Arthritis, rheumatoid – - - with involvement of organs NEC M05.60

• Tabular – – M05.60 – Rheumatoid arthritis of unspecified site with

involvement of other organs and systems

Coding Conventions (6)

• Alphabetic Index Abbreviations • NOS

– “Not otherwise specified” – This abbreviation is the equivalent of unspecified – Used when documentation is not sufficient to

provide a specific code. – Ex. Pulmonary Immaturity

Coding Conventions (6)

• Immaturity--- • fetus or infant light-for-dates —see Light-for-

dates • - lung, newborn P28.0 • - organ or site NEC —see Hypoplasia • - pulmonary, newborn P28.0 • - reaction F60.89

Coding Conventions (6)

• P28 Other respiratory conditions originating in the perinatal period

• Excludes1: congenital malformations of the respiratory system (Q30-Q34)

• P28.0 Primary atelectasis of newborn – Primary failure to expand terminal respiratory units – Pulmonary hypoplasia associated with short gestation – Pulmonary immaturity NOS

Coding Conventions (7) • Punctuation

– Just like ICD-9-CM – [] Brackets are used in the Tabular List to enclose synonyms,

alternative wording or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes.

– ()Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers.

– : Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

Coding Conventions (9)

• Make sure you understand!

• “Other” codes – These Alphabetic Index entries represent specific

disease entities for which no specific code exists so the term is included within an “other” code.

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

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

Coding Conventions (9)

• Fourth Character • “Other specified and “unspecified” each have their

own code - – “8” indicates some “other” specified category –

when placed after a decimal point. – “9” after a decimal point is usually reserved for

“unspecified”

Coding Convention (10 & 11)

• Includes Notes and Inclusion terms – Added for more clarification – Help navigate – Not exhaustive

Coding Conventions (12)

• Excluded Notes – Serious Business • Excludes1 – Don’t Even THINK about it!!!

– A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note.

Coding Conventions (12)

• Excludes2 – A type 2 excludes note represents “Not included

here”. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

• If both Diagnosis are present go for it! • “If there are two – you can use Excludes 2”

Coding Conventions (13)

• Etiology/manifestation convention – Etiology code – you will see “use additional code” – Manifestation code – you will see “code first”

Coding Convention (13)

• “in diseases elsewhere” • Manifestation codes

– Found in the code title of most manifestation codes

– NEVER permitted to be used at the first-listed or principal diagnosis codes

– MUST be used in conjunction with an underlying condition code

– MUST be listed following the underlying condition

Coding Conventions (13)

• Manifestation codes that do not have “in diseases classified elsewhere” in the title – You will find a “use additional code” will still be

present and sequencing rules apply • Alphabetic Index

– Both conditions listed together – Etiology first – Manifestation in brackets (sequencing rules)

Coding Convention (13)

• Example – Alphabetic Index • Parkinsonism (idiopathic) (primary) G20

– with neurogenic orthostatic hypotension (symptomatic) G90.3

– arteriosclerotic G21.4 – dementia G31.83 [F02.80] – - with behavioral disturbance G31.83 [F02.81]

Coding Conventions (13) • Tabular Index - • G31 Other degenerative diseases of nervous system, not

elsewhere classified – Use additional code to identify: – dementia with behavioral disturbance (F02.81) – dementia without behavioral disturbance (F02.80)

• G31.83 Dementia with Lewy bodies – Dementia with Parkinsonism – Lewy body dementia – Lewy body disease

Coding Conventions (14 & 15)

• “And” – Interprets as either “and” or “or” – when it

appears in the title – Represents “and/or” in narratives (8)

• “With” – Interprets as “associated with” or “due to” when it

appears in a code title, the Alphabetic Index, or an instructional note.

Coding Conventions (16)

• “See” – Go to the term reference with “see” – This is a rule – not a suggestion

• “See also” – You may go to the term referenced with “see also” – Not necessary if the original main term provides

the code.

Coding Conventions (17)

• “Code also note” – Two codes may be required to fully describe the

condition – No sequencing direction

Coding Conventions (18)

• Default codes – Alphabetic Index – Represents the condition that is most commonly

associated with the main term – Unspecified code – If documented – without further information

• (acute or chronic)

– Use the default code

Questions?

Heather Greene, MBA, RHIA, CPC, CPMA Coding and Compliance Consultant

AHIMA Approved ICD-10 CM/PCS Trainer heather@krafthealthcare.com

615-782-4297

References

• All information was obtained: • www.cms.gov/ICD10 • The ICD-10-CM 2012 Draft editions