INTROTOTHEICD‐10‐CMSYSTEM—TIMEWAITS FORSYSTEM TIMEWAITSFOR
NOONE2013
Brandi Whitemyer, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10 Trainer & Ambassador
© 2013, S-H&A
Selman‐Holman&Associates,LLC
Brandi Whitemyer, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD 10 Trainer & Ambassador
2
ICD-10 Trainer & AmbassadorHome Health Insight—Consulting, Education and Products for Home
Care and HospiceCoDR—Coding Done RightCoDR Coding Done Right
AHIMA ICD-10-CM/PCS Approved TrainerAHIMA ICD-10-CM Ambassador
606 N Bell Ave606 N. Bell Ave.Denton, Texas 76209
214.550.1477972 692 5908 fax972.692.5908 fax
www selmanholman comwww.selmanholman.com
ICD‐9‐CMHistoryHistory
3
HistoryICD‐9y
• World Health Organization (WHO)4
• World Health Organization (WHO) developed ICD-9 for worldwide useU S developed clinical modification• U.S. developed clinical modification (ICD-9-CM)
• Implemented in U.S. in 1979- Expanded number of diagnosis codesp g- Developed procedure coding system
HistoryICD‐9y
ICD-9-CM is used to:5
ICD-9-CM is used to:Calculate paymentAdjudicate coverageCompile statisticsAssess quality Risk adjustment jOutcomes
HistoryICD‐9y
System is more than 3Ø years old6
• System is more than 3Ø years old• Many categories are full• Not descriptive enough • Outdated medical terms• Outdated medical terms• New technologies are not included
ICD‐10
1998 by WHO7
1998 by WHOUSA is the only industrialized nation
that has not implemented ICD-10 or a clinical modification of ICD-10
USA has been using ICD-10 for coding mortality since 1999coding mortality since 1999.
Clinical modification process began in 19941994.
ICD‐1ØFinalRuleCMS ØØ13 FCMS‐ØØ13‐F
• Published January 16, 2ØØ9 8
y , ØØ• October 1, 2Ø14 - Compliance date for
implementation of ICD-1Ø Clinical ØModification (CM) and ICD-1Ø-
Procedure Coding System (PCS)Si l i l t ti d t f ll• Single implementation date for all users
• Date of service for all except inpatient settingssettings
• Date of discharge for inpatient settings NO GRACE PERIOD• NO GRACE PERIOD
Bill Type(s)
Facility Type/Services
Claims Processing Requirement Use FROM or THROUGH Date
Type(s) Type/Services Date
32X Home Health (Inpatient
Allow HHAs to use the payment group code derived from ICD-9 codes on claims which span
THROUGH
3X2 Home Health – Request for (Inpatient Part B)
codes on claims which span 10/1/2014, but require those claims to be submitted using ICD-10 codes.
3x2 Home Health –Request
* NOTE - RAPs can report either an ICD-9 code or an ICD-10 code based on the one (1)
*See Note
Request for Anticipated Payment
10 code based on the one (1) date reported. Since these dates will be equal to each other, there is no requirement y
(RAPs)* q
needed. The corresponding final claim, however, will need to use an ICD-10 code if the HH
9
episode spans beyond 10/1/2014.
Bill Type(s)
Facility Type/Services
Claims Processing Requirement Use FROM or THROUGH DateType(s) Type/Services Date
81X
.
Hospice-Hospital
Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of
FROM
Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later10/1/2014 and later.
82X Hospice –Non hospital
Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of
FROM
hospital remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 d l t10/1/2014 and later.
83X Hospice—Hospital Based
NA NA
10
Based
MLN Matters® Number: MM7492
ImplementationDate:Oct. 1, 2014Oct.1,2014
11
ICD‐10‐CM
What are we waiting on?12
What are we waiting on?5010 already implementedOASIS C 1 changesOASIS C-1 changesCase mix diagnoses—Any time now?Grouper logic changes April 2014Grouper logic changes—April 2014For hospice—will there be a case mix
system?system?Testing and dual codingS h d l t i iSchedule training
ProposedOASIS‐C1p ProposedOASIS‐C1p
ProposedOASIS‐C1p
(M1021/1023/1025) Diagnoses, Symptom Control, and ( ) g , y p ,Optional Diagnoses: List each diagnosis for which the patient is receiving home care in Column 1, and enter its ICD 10 C M code at the level of highest specificity inICD-10-C M code at the level of highest specificity in Column2 (diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best
f freflects the seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control for each condition in Column 2. ICD-10-C y pM sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that is noreported in Column 2 in place of a diagnosis that is no longer active (a resolved condition), then optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be
l t d i t ti i A di D f th OASIS
ProposedOASIS‐C1p
Code each row according to the following directions for each col mn Re ie Appendi D of the OASIS C1 G idance Man alcolumn. Review Appendix D of the OASIS-C1 Guidance Manual for complete directions on correct completion of M1021, M1023 and M1025.Column 1: Enter the description of the diagnosis. Sequencing ofColumn 1: Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided.Column 2: Enter the ICD-10-C M code for the condition described i C l 1 i l d d ll d C d tin Column 1 - no surgical or procedure codes allowed. Codes must be entered at the level of highest specificity and ICD-10-C M coding rules and sequencing requirements must be followed. Note that external cause codes (ICD-10-C M codes beginning with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023 (Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the underlying condition can often be entered in Column 2, as long as it is an , gactive on-going condition impacting home health care.
ProposedOASIS‐C1p
Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosisd i M1025 (C l 3 d 4) Di t d i M1025 ill t i tcode in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact
payment but may be used to risk adjust quality measures. Agencies may chooseto report an underlying condition in M1025 (Columns 3 and 4) when:
a Z-code is reported in Column 2 ANDthe underlying condition for the Z-code in Column 2 is a resolvedcondition. An example of a resolved condition is uterine cancerthat is no longer being treated following a hysterectomy.
Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and( ) p ( )the agency chooses to report a resolved underlying condition that requires multiplediagnosis codes under ICD-10-C M coding guidelines, enter the diagnosisdescriptions and the ICD-10-C M codes in the same row in Columns 3 and 4. For example if the resolved condition is a manifestation code record the diagnosisexample, if the resolved condition is a manifestation code, record the diagnosisdescription and ICD-10-C M code for the underlying condition in Column 3 of thatrow and the diagnosis description and ICD-10-C M code for the manifestation inColumn 4 of that row. Otherwise, leave Column 4 blank in that row.
CodeFreeze
No new codes for ICD-9-CM19
No new codes for ICD 9 CM No new codes for ICD-10-CM But does that mean no changes? But does that mean no changes?
ICD-10-CM changes to the tabular and indices have been issuedindices have been issued
ICD-10-CM guideline changes There will be a few new changes in theThere will be a few new changes in the
tabular and index for October 1, 2014 First REAL update will be October 1, First REAL update will be October 1,
2015
ComparisonpICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes20
Limited space for adding new codes Flexible for adding new codes
Lacks detail Very specific
Lacks laterality Has laterality
Diffi lt t l d t d t S ifi it i diDifficult to analyze data due to non-specific codes
Specificity improves coding accuracy and richness of data for analysis
Codes do not adequately define Detail improves the accuracy of dataCodes do not adequately define diagnoses needed for medical
research
Detail improves the accuracy of data used for medical research
Doesn’t support interoperability with other countries
Supports interoperability with other countries
ComparisonpICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes21
3-5 characters in length 3-7 characters in length
First character is numeric or alpha (E or V) First character is alpha (all letters except U)
Characters 2-5 are numeric Character 2 is numeric Characters 3-7 are alpha or numeric
Use of decimal required after 3 characters Use of decimal required after 3 characters
No placeholders Use of dummy place holder ‘X’
Alpha characters are case sensitive Alpha characters are NOT case sensitive
Incomplete code titles Complete code titlesp p
14,315 diagnosis codes (Volumes 1,2) 69,Ø99 diagnosis codes (Volumes 1,2)
3 838 procedure codes (Volume 3) 71 957 procedure codes (Volume 3)3,838 procedure codes (Volume 3) 71,957 procedure codes (Volume 3)
Codingand7th CharacterExtensionsExtensions
22
AdditionalAdditional Characters
Alpha (Except U)
2 - 7 Numeric or Alpha
XX XX XX XX. XX XX XXAAMMSS ØØ 22 66. 55 xx AA
C t
.Eti l t i
Added 7th character) for
.Category Etiology, anatomic
site, severity
)obstetrics, injuries, and external causes of injury
3 – 7 Characters
N FNewFeatures23
Features
21 chapters including V W X Y and Z24
21 chapters including V,W,X,Y and Z codes
Injuries Grouped by Anatomical Site Injuries Grouped by Anatomical SiteExcludes 1 and excludes 2 notesPostoperative complications moved
to the specific chapterFull code titlesManifestation codesManifestation codes Etiology [manifestation]
CombinationCodes
E10 21 Type 1 diabetes mellitus with25
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
I25.110 AHD of native coronary artery with unstable anginag
K50.112 Crohn’s disease of lgintestine with intestinal obstructionintestine with intestinal obstruction
CombinationCodesforPoisoningsand External CausesandExternalCauses
T36 0x1D Poisoning by penicillins26
T36.0x1D Poisoning by penicillins, accidental, subsequent encounter
ICD-9 -Poisoning
-Effect -E code for Accidental
T42.4x5A Adverse effect of benzodiazepines initial encounterbenzodiazepines, initial encounter
LateralityExampleExample
Osteoarthritis 27
• M16.Ø Bilateral primary osteoarthritis of hip
• M16.11 Unilateral primary osteoarthritis, yright hip
• M16.12 Unilateral primary osteoarthritis, left hip
OtherFeatures
Added 7th Character for Episodes of28
Added 7 Character for Episodes of CareA—Initial encounterD—Subsequent encounterSubseque t e cou teS—SequelaCh i ti fChanges in time framesAcute myocardial infarction—time y
period changed from 8 to 4 weeks
QuizQ
V and E codes are supplemental29
V and E codes are supplemental classifications in ICD-10-CM. T or F
What is the maximum number of characters in ICD-10-CM?
How many chapters does ICD-10 contain?contain?
IdentifytheDifferencesy
L03 313 682 2 Cellulitis30
L03.313 682.2 Cellulitis and abscess of tr nk
S42 311K
trunk733.82--nonunion
S42.311K
E933 1
T45.1X5D
E933.1 Antineoplastics
T45.1X5D
AlphabeticalIndexp
Index to Diseases and Injuries31
Index to Diseases and Injuries No hypertension table
Neoplasm table is separateTable of Drugs and ChemicalsTable of Drugs and Chemicals Index to External Causes
Volume2—AlphabeticalIndexp
Diagnoses in alphabetical order32
Diagnoses in alphabetical order Term (non-essential modifier)
WithEssential modifiers With
TermTerm
These subtermsunder the
change the code
assignmentSubtermSubterm
under the main terms are called ‘essential
assignment
SubtermSubterm
essential modifiers.’
SubtermSubterm
EssentialModifiers
The indented terms are always read in conjunction with th i t
33
the main term. Diverticulosis K57.90
With bleeding K57.91g Large intestine K57.30With
Bleeding K57 31Bleeding K57.31Small intestine K57.50
With bleeding K57.51 Small intestine K57 10 Small intestine K57.10With
Bleeding K57.11L i t ti K57 50 Large intestine K57.50 With bleeding K57.51
Lookingupatermg p
What’s the34
What s the noun?
Not the body part
AlphabeticalIndexPracticep
Aftercare35
Aftercareinvolving
A iAnemiadeficiency
Failure, failedheart
Long term
TabularChaptersp
A,B – Infectious and parasitic diseases36
p C – Neoplasms D – Neoplasms & blood and blood forming
organsorgans E – Endocrine, nutritional, and metabolic F – Mental and behavioral disorders F Mental and behavioral disorders G – Nervous system H – Eye and adnexa, ear and mastoid processy p I – Circulatory system J – Respiratory system
K Di ti t K – Digestive system
TabularChaptersp
L – Skin and subcutaneous tissue37
M – Musculoskeletal and connective tissue N – Genitourinary system y y O – Pregnancy, childbirth, and the
puerperiumP P i t l i d P – Perinatal period
Q – Congenital malformations, deformations and chromosomaldeformations and chromosomal abnormalities
R – Symptoms, signs and abnormal clinical y p , gand laboratory findings
TabularChaptersp
S,T – Injury, poisoning and certain other consequences
38
, j y, p g qof external causes
U – Reserved by WHO for emergency codes V,W,X,Y – External causes of morbidity
- How were they hurt *Wh th h th h t- Where they were when they were hurt
- What activity were they doingExternal cause status- External cause status
Z – Factors influencing health status and contact with health services
Note: * only encouraged external cause code in HH
TabularList
Within a number of ICD-10-CM chapters39
Within a number of ICD-10-CM chapters, category restructuring and code reorganization have occurred resulting inreorganization have occurred resulting in the classification of certain diseases and disorders different than what is currentlydisorders different than what is currently seen in ICD-9-CM.E l G t Example: Gout
Example: Eyes and ears separated from the Nervous system chapter
Characters
4th character 8: other specified40
4 character 8: other specified 4th character 9: unspecifiedHave their own codes, unlike ICD-9-CM
Used to the highest level of specificityUsed to the highest level of specificityMay require placeholders so any 7th
character will be placed in the 7thcharacter will be placed in the 7th
space, e.g., Fall down steps, stairs W10.8xxD
Activities—Find&Comparep
C40 21 [M90 661] and 170 7 [731 1]41
C40.21 [M90.661] and 170.7 [731.1]Note at the beginning of chapter 18 in
ICD-10 and note at the beginning of chapter 16 in ICD-9
Note for subchapter D37-D48 (ICD-10) and the note at 235-238 (ICD-9)10) and the note at 235-238 (ICD-9)
QuizTime!Q
1. Gout is classified to the chapter.42
____ p2. All of the following are structural
differences except:Additi f th h t ia. Addition of a seventh character in some chapters
b Addition of placeholderb. Addition of placeholderc. Diseases and conditions of the eyes and
ears are classified in the same chapter as pdiseases of the nervous system.
d. Postop complications have been moved to procedure specific body system chaptersprocedure-specific body system chapters.
QuizTime!Q
3. Which of the following statements is true?43
ga. All codes include full code titles.b. All chapters require the addition of code
extensionsextensions.c. All codes are 7 characters in length.d. All codes use the placeholder x.codes use e p ace o de4. Which of the following statements is true?a. No decimals are used.
Th fi h i l l hb. The first character is always an alphac. Consist of 3-5 charactersd The second and third characters are alwaysd. The second and third characters are always
numeric.
QuizTime!Q
5. The alpha for the genitourinary chapter is:44
p g y pa. Pb. Gc. Nd. E6. Which of the following is a valid ICD-10-CM code?a. 428.9b. L03.313
T37 0 1Ac. T37.0xx1Ad. M12x.58
OverviewConventions & Official GuidelinesConventions&OfficialGuidelines
45
ExamplePlaceholder ‘X’Placeholder X
• Addition of dummy placeholder ‘X’ is46
• Addition of dummy placeholder X is used in certain codes to: Allow for future expansion• Allow for future expansion
• T42.0x1D Poisoning by hydantoind i ti id t l b tderivatives, accidental, subsequent
• Fill out empty characters when a code contains fewer than 6 characters and a 7th character applies
• W11.xxxD Fall from ladder, subsequent
ExampleAddition of 7th CharacterAdditionof7th Character
• Used in certain chapters to provide 47
p pinformation about the characteristic of the encounterM t l b d i th 7th h t• Must always be used in the 7th character position
• Can be a letter or a number• Can be a letter or a number• S02.110B• O65.0xx1
• If a code has an applicable 7th character, the code must be reported with an appropriate 7th character value in order toappropriate 7th character value in order to be valid
7th Character—Injuriesj
A, initial encounter, is used while the patient is 48
, , preceiving active treatment for the injury.
D, subsequent encounter, is used for f h i h i d iencounters after the patient has received active
treatment of the injury and is receiving routine care for the injury during the healing or recoverycare for the injury during the healing or recovery phase.
S, sequel, is used for complications or conditions that arise as a direct result of an injury (ICD-10-CM coding guideline I.C.19.a).
Example7th CharacterFracturesFractures
A = Initial encounter for closed fracture49
A Initial encounter for closed fracture B = Initial encounter for open fracture D = Subsequent encounter for fracture with D = Subsequent encounter for fracture with
routine healing G = Subsequent encounter for fracture with G Subsequent encounter for fracture with
delayed healing K = Subsequent encounter for fracture with K Subsequent encounter for fracture with
nonunion P = Subsequent encounter for fracture with q
malunion S = Sequela
Conventions‐‐Parentheses
Parentheses are used in ICD-10-CM in 50
both the Alphabetic Index and Tabular to enclose supplementary words that may be present or absent in the statement of apresent or absent in the statement of a disease without affecting the code number to which it is assigned. The terms within gthe parentheses are referred to as nonessential modifiers.
A iAnemiaDiabetesH44 611H44.611
Conventions—Brackets
Square brackets in ICD-10-CM in the51
Square brackets in ICD-10-CM in the Tabular List are used to enclose synonyms alternative wordingssynonyms, alternative wordings, abbreviations, and explanatory phrases.J00 Acute nasopharyngitis [common cold]J00 Acute nasopharyngitis [common cold]
Brackets are used in the Index to identify if i dmanifestation codes.
Disease, Alzheimer’sAlzheimer’s G30.9 [F02.80]
Conventions
Colons are used in the Tabular List after52
Colons are used in the Tabular List after an incomplete term that needs one or more of the modifiers following the colon gto make it assignable to a given category.G73.7 Myopathy in diseases classified
elsewhereExcludes 1: myopathy in:
rheumatoid arthritis (M05.32)sarcoidosis (D86 87)sarcoidosis (D86.87)scleroderma (M34.82)
Conventions—Dashes
ICD-9-CM 250 xx53
ICD 9 CM 250.xx ICD-10-CM alpha index utilizes a
dash at the end of the code numberdash at the end of the code number to indicate the code is incomplete
F t th l iFracture, pathologicankle M84.47-A d h d d b d i l i t A dash preceded by a decimal point
(.-) indicates an incomplete code in the t b l li t J44tabular list. J44.-
InclusionNotes
Inclusion notes contain terms that are the 54
condition for which that code number is to be used. The terms may be synonyms of the code title or in the case of “other specified” codes thetitle, or in the case of other specified codes, the terms are a list of various conditions assigned to that code. The inclusion terms are not necessarily
h i (ICD 10 CM di id li I A 11)exhaustive (ICD-10-CM coding guideline I.A.11).‘Includes’ appears at the category level and applies
to the entire categoryto the entire category.Inclusion notes also appear at subcategory and
code levels but ‘includes’ is not thereK31.5
ExcludesNotes
Excludes 1: 55
• An excludes 1 note is a pure excludes note. It means “NOT CODED HERE”
• Indicates the code excluded should never be used atIndicates the code excluded should never be used at the same time as the code above the Excludes 1 notes.
• Is used when two conditions cannot occur together• Is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition
Excludes 2Excludes 2• An excludes 2 note represents “not included here”. • Indicates the condition excluded is not part of the
diti t d b th d b t ti tcondition represented by the code, but a patient may have both conditions at the same time
ExcludesNoteExampleExample
• J18 Ø Bronchopneumonia unspecified56
J18.Ø Bronchopneumonia, unspecified organism
Excludes1: Excludes1:hypostatic bronchopneumonia (J18.2)lipid pneumonia (J69 1)lipid pneumonia (J69.1)
Excludes2:t b hi liti (J21 )acute bronchiolitis (J21.-)
chronic bronchiolitis (J44.9)
Other,OtherSpecified,UnspecifiedUnspecified
Codes titled “other” or “other specified” are for57
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 (ICD-10-CM coding guideline I.A.9.a).
NEC—Not elsewhere classified I25.894th digit 8
Other,OtherSpecified,UnspecifiedUnspecified
This can be contrasted with “unspecified”58
This can be contrasted with unspecified codes when the information in the medical record is insufficient to assign amedical record is insufficient to assign a more specific code (ICD-10-CM coding guideline I A 9 b)guideline I.A.9.b).
NOS—Not Otherwise Specified J12 9J12.94th digit 9
Conventions—RelationalTerms
And—interpreted to mean ‘and/or’59
And—interpreted to mean and/or when it appears in a code title within th t b l li tthe tabular list
With—interpreted to mean ‘associated with’ or ‘due to’ when it appears in a code title, the alpha, orappears in a code title, the alpha, or an instructional note in the tabular.
Lateralityy
• For bilateral sites the final character of60
• For bilateral sites, the final character of the code indicates laterality. If no bilateral code is provided and the• If no bilateral code is provided and the condition is bilateral, assign separate
d f b th th l ft d i ht idcodes for both the left and right side • An unspecified code is also provided
should the side not be identified in the medical record
TheUsualBasics
Must use the alpha and the tabular61
Must use the alpha and the tabular.Read everything; it all means
somethingsomething.Code to the level of the highest
ifi itspecificity.Each unique ICD-10-CM diagnosis
code may be reported only once for an encounter.
Sequelaq
A sequela is the residual effect (condition produced) after th t h f ill i j h t i t d
62
the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction or it may occur months or years latercerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of sequelagenerally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced fi t Th l d i d dfirst. The sequela code is sequenced second.
An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title ormanifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to code o t e acute p ase o a ess o ju y t at ed tothe sequela is never used with a code for the late effect.
Sequelaq
1. General Rule: Code what you see first 63
yand the sequela comes later.G81.11 Spastic hemiplegia affecting right
dominant sidedominant sideS06.5x9S Traumatic subdural hemorrhage with
loss of consciousness of unspecified duration, sequelasequela
2. Code the sequela first when what you see cannot go first (manifestationsee cannot go first (manifestation code).
3. Sequela of cerebrovascular accidentsq
Other
For the Body Mass Index (BMI), depth 64
y ( ), pof non-pressure chronic ulcers and pressure ulcer stage codes, code
i t b b d di lassignment may be based on medical record documentation from clinicians who are not the patient’s provider (i ewho are not the patient s provider (i.e., physician or other qualified healthcare practitioner legally accountable for
t bli hi th ti t’ di i )establishing the patient’s diagnosis), since this information is typically documented by other clinicians involveddocumented by other clinicians involved in the care of the patient.
BorderlineDiagnosesg
If the provider documents a "borderline" diagnosis65
If the provider documents a borderline diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD 10 CM it should be coded as such SinceICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting g(inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline
diti d d t fcondition, coders are encouraged to query for clarification.
S iSequencing66
Sequencingq g
ICD-10-CM coding guideline I.A.17 states67
ICD 10 CM coding guideline I.A.17 states a “code also” note instructs that two codes may be required to fully describe a y q ycondition, but this note does not provide sequencing direction. In contrast, the Code First/Use Additional Code notes provide sequencing order of th d ( d l i diti f ll dthe codes (underlying condition followed by the manifestation).
Etiology/Manifestationgy/
An example of the etiology/manifestation 68
p gyconvention is dementia in Parkinson’s disease. In the Alphabetic Index, code G20 i li t d fi t f ll d b dG20 is listed first, followed by code F02.80 or F02.81 in brackets. Code G20 represents the underlying etiologyrepresents the underlying etiology, Parkinson’s disease, and must be sequenced first, whereas codes F02.80
d F02 81 t th if t tiand F02.81 represent the manifestation of dementia in diseases classified elsewhere with or without behavioralelsewhere, with or without behavioral disturbance.
69
Multiplecodingforasingleconditioncondition
In addition to the etiology/manifestation70
In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. “Use additional code” notes are found in the Tabularadditional code notes are found in the Tabular List at codes that are not part of an etiology/manifestation pair where a secondary gy p ycode is useful to fully describe a condition. The sequencing rule is the same as the ti l / if t ti i “ dditi l d ”etiology/manifestation pair, “use additional code”
indicates that a secondary code should be added.
Multiplecodingforasingleconditioncondition
An “use additional code” note will71
An use additional code note will normally be found at the infectious di d i di ti d fdisease code, indicating a need for the organism code to be added as a secondary code.
Find acute cystitis caused by E. coliFind acute cystitis caused by E. coli
Sequencingq g
“Code first” notes are also under certain codes that are
72
not specifically manifestation codes but may be due to an underlying cause. When there is a “code first” note and an underlying condition is present the underlyingand an underlying condition is present, the underlying condition should be sequenced first. L89
“Code, if applicable, any causal condition first”, notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or notdiagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis. L97
73
Sequencingq g
Multiple codes may be needed for74
Multiple codes may be needed for sequela, complication codes and
b t t i d t f ll d ibobstetric codes to more fully describe a condition. See the specific guidelines for these
conditions for further instruction.
ReviewQuestionsQ
1. ICD-10-CM uses inclusion terms in the 75
same way that ICD-9-CM does.T or F
What includes synonyms, alternative wording, or explanatory phrases in the Tabular List?Tabular List?a. Parenthesesb Bracketsb. Bracketsc. Dash d. ColonThe seventh character is always a letter. T or F?
Guidelines76
2013Guidelines
Approved by the Cooperating Parties:77
pp y p gAHA (publishers of the Coding Clinic)AHIMA
CMSCMSNCHS
Section 1 Section 1ConventionsGeneral GuidelinesChapter specific guidelines
Section 2—selection of primary diagnosis Section 3—selection of additional
diagnoses
Complicationsp
Code assignment is based on the 78
gprovider’s documentation of the relationship between the condition and the care and procedureprocedure.
Important to note that not all conditions that occur during or following medical care or occu du g o o o g ed ca ca e osurgery are classified as complications.
There must be a cause and effect l ti hi b t th id d drelationship between the care provided and
the condition and in andication in the documentation that it is a complication. Ifdocumentation that it is a complication. If not clearly documented, query the provider for clarification.
TableofDrugsandChemicalsg
Poisoning accidental79
Poisoning, accidental Poisoning intentional self-harm Poisoning assault Poisoning assault Poisoning undetermined Adverse effect (therapeutic use in ICD-9)( p ) Underdosing
A - Initial encounter D - Subsequent encounter S - Sequela
TableofDrugsandChemicalsg
Includes:80
• Poisoning is defined as:• overdose of substances• wrong substance given or taken in error
• Adverse effect is defined as:'h persensiti it ' 'reaction' etc of correct• 'hypersensitivity', 'reaction', etc. of correct substance properly administered
• Underdosing is defined as:g• taking less of a medication than is prescribed
or instructed by the manufacturer, whether inadvertently or deliberatelyinadvertently or deliberately
TableofDrugsandChemicalsg
Codes from categories T36-T65 are combo codes that 81
C g 36 65include the substance that was taken as well as the intent. • Guideline: When coding a poisoning or improper useGuideline: When coding a poisoning or improper use
of a medication first assign the appropriate code from categories T36-T5Ø. Use additional code(s) for manifestations of poisonings.p g
• Guideline: When coding an adverse effect of a drug that has been correctly prescribed and properlythat has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drugappropriate code for the adverse effect of the drug (T36-T5Ø with a 5th or 6th character of 5).
TableofDrugsandChemicalsg
• Guideline: Codes for underdosing should never82
Guideline: 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, th th di l diti it lf h ld bthen the medical condition itself should be coded. Codes for underdosing should never be• Codes for underdosing should never be assigned as principal or first-listed codes (T36-T5Ø with fifth or sixth character 5)T5Ø with fifth or sixth character 5).
UnderdosingExampleExample
Patient with diagnosis of83
• Patient with diagnosis of Hypertension continued to
i l t d bl dexperience elevated blood pressure while taking blood pressure meds. Upon patient interview, it was found the patient was taking medication p gonce daily instead of twice daily because of the cost of the drugbecause of the cost of the drug.
UnderdosingAnswerAnswer
• M1Ø21: I1Ø Essential (primary)84
• M1Ø21: I1Ø Essential (primary) hypertensionM1Ø23: T46 5x6D Underdosing of• M1Ø23: T46.5x6D Underdosing of other antihypertensive drugs,
b t tsubsequent encounter • M1Ø23: Z91.12Ø Patient's intentional
underdosing of medication regimen due to financial hardship
Underdosing
85
PoisoningExampleExample
Patient has taken his Lasix 4Ømg86
• Patient has taken his Lasix 4Ømg every morning and night. The
i ti b ttl d 4Ø d ilprescription bottle reads 4Ømg daily. Patient is dehydrated and hypokalemic.
PoisoningAnswerAnswer
M1Ø21: T5Ø 1x1D poisoning by87
• M1Ø21: T5Ø.1x1D poisoning by diuretics
Ø Ø• M1Ø23: E86.Ø dehydration• M1Ø23: E87.6 hypokalemiaØ 3 8 6 ypo a e a
AdverseEffectExampleExample
Patient has been taking the88
• Patient has been taking the prescribed amount of Lanoxin, h hi l t i 42however his pulse rate is now 42 and he is toxic according to lab values. SN for observation and assessment, teaching and , gvenipuncture for monitoring levels.
AdverseEffectAnswerAnswer
M1Ø21: R00 1 Bradycardia89
• M1Ø21: R00.1 Bradycardia• M1Ø23: T46.Øx5D cardiotonic
glycosides• M1Ø23: Z51.81 Encounter for Ø 3 5 8 cou te o
monitoringM1Ø23: Z79 899 Long term (current)
Monitoring
• M1Ø23: Z79.899 Long term (current) use of other high risk medication
Long term
ChapterSpecificGuidelinesGuidelines
90
Infectiousagentsasthecauseofdiseases classified to other chaptersdiseasesclassifiedtootherchapters
Certain infections are classified in chapters other than Ch 1 d i i id ifi d f h
91
Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism A code from category B95 Streptococcusorganism. A code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified to other chapters, B96, Other bacterial agents as the cause of diseases classified tobacterial agents as the cause of diseases classified to other chapters, or B97, Viral agents as the cause of diseases classified to other chapters, is to be used as an additional code.an additional code.
Look up Infection, Staphylococcus aureus and compare the A codes to the B codes. A41 0 and B95 6 A41.0 and B95.6-
Infectionsresistanttoantibiotics
Many bacterial infections are resistant to 92
ycurrent antibiotics. It is necessary to identify all infections documented as
tibi ti i t t A i d fantibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs following theantimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.
Except for MRSA Look up resistance, vancomycin
N lNeoplasms93
Neoplasmsp
The neoplasm table in the Alphabetic 94
p pIndex should be referenced first. However, if the histological term is d t d th t t h ld bdocumented, that term should be referenced first, rather than going immediately to the Neoplasm Table inimmediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. Example: Adenoma
If the treatment is directed at the li d i t th limalignancy, designate the malignancy as
the principal diagnosis.
SequencingNeoplasmswithMorethan One SitethanOneSite
When a patient is admitted because95
When a patient is admitted because of a primary neoplasm with
t t i d t t t i di t dmetastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though p p g gthe primary malignancy is still presentpresent.
Primarymalignancypreviouslyexcisedexcised
When a primary malignancy has been 96
p y g ypreviously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing y gprimary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of thebe used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site Thesecondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.
Anemiaassociatedwithmalignancymalignancy
When admission/encounter is for97
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is g y,only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia ( h d D63 0 A i i(such as code D63.0, Anemia in neoplastic disease).
AnemiaDueToNeoplasmExampleExample
Patient admitted for management of98
• Patient admitted for management of anemia related to colon cancer. The f f i th ifocus of care is the anemia.
AnemiaDueToNeoplasmAnswerAnswer
• M1Ø21: C18 9 Colon cancer99
• M1Ø21: C18.9 Colon cancer unspecifiedM1Ø23: D63 Ø Anemia in neoplastic• M1Ø23: D63.Ø Anemia in neoplastic disease
Note: Different sequencing in ICD-9Note: Different sequencing in ICD 9
Anemiaassociatedwithchemotherapy,immunotherapy and radiation therapyimmunotherapyandradiationtherapy
100
When the admission/encounter is for management of an anemia associated with
d ff t f th d i i t ti fan adverse effect of the administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the o y ea e s o e a e a, eanemia code is sequenced first followed by the appropriate codes for the neoplasm and the adverse effect (T45 1X5 Adverse effectthe adverse effect (T45.1X5, Adverse effect of antineoplastic and immunosuppressive drugs). g )
AntineoplasticChemotherapyAnemiaExampleExample
Patient admitted for management of101
• Patient admitted for management of anemia related to chemotherapy due t l Th f f ito colon cancer. The focus of care is the anemia.
AntineoplasticChemotherapyAnemiaAnswerAnswer
• M1Ø21: D64 81 Anemia due to102
• M1Ø21: D64.81 Anemia due to antineoplastic chemotherapyM1Ø23: T45 1x5D Adverse effect of• M1Ø23: T45.1x5D Adverse effect of antineoplastic and immunosuppressive drugsimmunosuppressive drugs subsequentM1Ø23 C18 9 C l• M1Ø23: C18.9 Colon cancer unspecified
OtherGuidelinesforNeoplasmsp
Dehydration103
Dehydration Complication of surgery
C d C80 1 M li ( i ) Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.
Codethese…
Right female breast cancer with mets to 104
gR lung
Right female breast cancer with mets to R lung, treatment directed at lung
History of lung ca and pneumonectomyf l ft l ith ti d kiof left lung with continued smoking
M t t R kid k i Mets to R kidney, unknown primary
Codethese…
Right female breast cancer with mets to R lung105
C50.911 C78.01
Right female breast cancer with mets to R lung, treatment directed at lung C78.01 C50.911
History of lung ca and pneumonectomy of left lung with continued smoking Z85.118 Z90.2 Z72.0
Mets to R kidney, unknown primary C79.01 C80.1
Symptoms,Signs,andIll Defined ConditionsIll‐DefinedConditions
106
Symptoms, signs, and ill-defined conditions listed in Chapter 18 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replacemalignancy cannot be used to replace the malignancy as principal or first-listed diagnosis, regardless of the number of g , gadmissions or encounters for treatment and care of the neoplasm.
Pathologicfractureduetoaneoplasmneoplasm
When an encounter is for a pathological 107
p gfracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84 5 Pathological fracture insubcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm.
If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequencedthe neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture. p g
NeoplasmExamplep p
Patient with history of prostate cancer108
Patient with history of prostate cancer and mets to the right femur has
th l i l f ith ti h li tpathological fx with routine healing to the right femur. He is admitted for therapy and nursing for O & A, strengthening, transfers and pain g g, pmanagement. He is taking Morphine for painfor pain.
NeoplasmAnswersp
M1Ø21: M84 551D Pathological fracture109
M1Ø21: M84.551D Pathological fracture in neoplastic disease, right femur, routine healingM1Ø23: C79.51 Secondary malignant neoplasm, bone
Ø GM1Ø23: G89.3 Neoplasm related painM1Ø23: Z85.46 History of prostate ca
Ø ( )
Pain
M1Ø23: Z79.891 Long term (current) use of opiate analgesic
Di bDiabetes110
DiabetesCategoriesg
E08 DM due to underlying condition111
y gCode first underlying conditionUse additional code to identify insulin useE09 D h i l i d d DM E09 Drug or chemical induced DMNotice difference between adverse effect and
poisoningpoisoning.Use additional code to identify insulin use
E10 Type 1 DMyp E11 Type 2 DM
Use additional code to identify insulin use13 O f E13 Other specified DM
Use additional code to identify insulin use
Guidelines
The diabetes mellitus codes are 112
combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that bodyand the complications affecting that body system. As many codes within a particular category as are necessary to describe all of
fthe complications of the disease may be used. They should be sequenced based on the reason for a particular encounterthe reason for a particular encounter. Assign as many codes from categories E08 –E13 as needed to identify all of the
i t d diti th t th ti t hassociated conditions that the patient has.
Guidelines
If the type of diabetes mellitus is not documented 113
ypin the medical record the default is E11.-, Type 2 diabetes mellitus.If the documentation in a medical record does notIf the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus should be assigneddiabetes mellitus, should be assigned.Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during yp p g gan encounter.
DiabetesMellitusE11E11
E11: Type II Diabetes Mellitus114
E11: Type II Diabetes Mellitus Includes:
diabetes (mellitus) due to insulin- diabetes (mellitus) due to insulin secretory defect
diabetes NOS- diabetes NOS- insulin resistant diabetes (mellitus)
U dditi l d f i li Use an additional code for insulin use (Z79.4)
DiabetesMellitusE11E11
E11: Type II Diabetes Mellitus 115
yp Excludes1:
- diabetes mellitus due to underlying condition (EØ8-)drug or chemical induced diabetes mellitus (EØ9 )- drug or chemical induced diabetes mellitus (EØ9.-)
- gestational diabetes (O24.4-)- neonatal diabetes mellitus (P7Ø.2)( )- postpancreatectomy diabetes mellitus (E13.-)- postprocedural diabetes mellitus (E13.-)
secondary diabetes mellitus NEC (E13 )- secondary diabetes mellitus NEC (E13.-)- type 1 diabetes mellitus (E1Ø.-)
DiabetesMellitusE11 ExampleE11Example
• Type 2 diabetes mellitus with mild 116
ypnonproliferative diabetic retinopathy with macular edema
• M1Ø2Ø: E11.321 Type 2 diabetes mellitus with mild nonproliferative diabeticwith mild nonproliferative diabetic retinopathy with macular edema
• Note: Combination code includes all faspects of disease
DiabetesMellitusE11 ExampleE11Example
Patient was admitted for diabetes117
• Patient was admitted for diabetes type II with gangrene. Patient takes i liinsulin
DiabetesMellitusE11 AnswerE11Answer
M1Ø21: E11 52 Type II diabetes118
• M1Ø21: E11.52 Type II diabetes mellitus with diabetic peripheral
i th ithangiopathy with gangrene• M1Ø23: Z79.4 Long term current g
use insulin
DiabetesMellitusE11 ExampleE11Example
Diabetic neuropathy takes insulin but119
Diabetic neuropathy, takes insulin but BS have been average 250. Focus of care is to get BS under controlcare is to get BS under control.
E11.65 Type 2 DM with hyperglycemiahyperglycemia
E11.40 Type 2 DM with diabetic th ifi dneuropathy, unspecified
Z79.4 Long term use, insulin
Mental Behavioral/MentalBehavioral/NervousSystem
120
PsychoactiveSubstanceUse,Abuse And DependenceAbuseAndDependence
When the provider documentation refers to use, b d d d f h b (
121
abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:following hierarchy:
If both use and abuse are documented, assign only the code for abuse
If both abuse and dependence are documented, assign only the code for dependence
If use, abuse and dependence are all documented, , p ,assign only the code for dependence
If both use and dependence are documented, assign only the code for dependence.only the code for dependence.
Alzheimer'sExampleExample
Patient admitted for worsening122
• Patient admitted for worsening dementia related to early onset Al h i ' i l di d iAlzheimer's, including wandering episodes
Alzheimer'sAnswerAnswer
• M1Ø21: G3Ø.Ø Alzheimer's disease early 123
Ø Ø Ø yonset
• M1Ø23: FØ2.81 Dementia in diseases l ifi d l h i h b h i lclassified elsewhere with behavioral
disturbances M1Ø23: Z91 83 Wandering in diseases• M1Ø23: Z91.83 Wandering in diseases classified elsewhere
N t Al h i ' i id tifi d l l t Note: Alzheimer's is identified as early or late onset
Codethese!
Severe Depression124
Severe Depression
Bi l di d ( i )Bipolar disorder (manic)
Borderline Schizophrenia
Mild Memory Disturbance (Organic brain disease)brain disease)
Codethese!
Severe Depression125
p F32.2 Major depressive disorder, single episode
without psychotic features Bipolar disorder (manic) Bipolar disorder (manic)
F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified
B d li S hi h i Borderline Schizophrenia F21 Schizotypal Disorder
Mild Memory Disturbance (Organic brain Mild Memory Disturbance (Organic brain disease) G93.9
F06 8 F06.8
Dominant/Non‐dominantside/
Codes from category G81, Hemiplegia and 126
g y p ghemiparesis, and subcategories, G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, pp , , p g ,unspecified, identify whether the dominant or nondominant side is affected. Should the affected side be documented but not specifiedaffected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:code selection is as follows: For ambidextrous patients, the default should be
dominant. If the left side is affected the default is non dominant If the left side is affected, the default is non-dominant. If the right side is affected, the default is dominant.
Ci lCirculatory127
HypertensionwithHeartDiseaseyp
Heart conditions classified to I50.- or I51.4-128
I51.9, are assigned to, a code from category I11, Hypertensive heart disease, when a causal relationship is stated (due to hypertension) or p ( yp )implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with hearttype of heart failure in those patients with heart failure.
The same heart conditions (I50.-, I51.4-I51.9) with hypertension but without a stated causalwith hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the
d i i / tadmission/encounter.
HypertensiveChronicKidneyDiseaseDisease
Assign codes from category I12, Hypertensive chronic kid di h b h h i d
129
kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. Unlike hypertension with heart disease ICD 10 CM presumes a cause andheart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney diseasekidney disease.
The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney diseaseI12 to identify the stage of chronic kidney disease.
If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is requiredacute renal failure is required.
HypertensiveHeartandChronic Kidney DiseaseChronicKidneyDisease
Assign codes from combination category 130
g g yI13, Hypertensive heart and chronic kidney disease, when both hypertensive kid di d h t i h tkidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between theAssume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is
d i t d If h t f il i tso designated. If heart failure is present, assign an additional code from category I50 to identify the type of heart failureI50 to identify the type of heart failure.
Hypertensionyp
I10 Essential hypertension131
I10 Essential hypertension I11 Hypertensive Heart Disease
Use additional code for heart failure (I50.-)Use additional code for heart failure (I50. ) I12 Hypertensive Chronic Kidney Disease
Use additional code for CKD (N18.-)Use add t o a code o C ( 8 ) I13 Hypertensive Heart and Chronic Kidney
DiseaseUse additional code for heart failureUse additional code for CKD
No malignant or benign
Examplestocodep
Hypertensive chronic diastolic heart132
Hypertensive chronic diastolic heart failure
Malignant Hypertensiona g a t ype te s o
H t i d ESRD di l iHypertension and ESRD on dialysis
Examplestocodep
Hypertensive chronic diastolic heart failure133
yp I11.0 Hypertensive heart disease with heart
failure I50 32 Chronic diastolic (congestive) heart I50.32 Chronic diastolic (congestive) heart
failure Malignant Hypertensiong yp
I10 Hypertension Hypertension and ESRD on dialysis
I12.0 Hypertensive CKD with Stage 5 or ESRDN18.6 ESRDZ99 2 dialysis statusZ99.2 dialysis status
CategoryI69,Sequelae ofCerebrovascular diseaseCerebrovasculardisease
Category I69 is used to indicate conditions 134
g yclassifiable to categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67 The neurologic deficits caused byI60 I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categoriesonset of the condition classifiable to categories I60-I67.
Personal history of transient ischemic attack (TIA) and cerebral infarction (Z86.73)
CVAExampleExample
Patient admitted for CVA with right135
• Patient admitted for CVA with right sided hemiparesis and dysphagia d t CVAdue to CVA
CVAExampleExample
• M1Ø21: I69.351 Hemiplegia and hemiparesis following
136
p g p gcerebral infarction affecting right dominant side
• M1023: I69.391 Dysphagia following cerebral infarction• M1023: R13.10 Dysphagia, unspecified Note: Should the affected side be documented, but not
specified as dominant or non dominant and thespecified as dominant or non-dominant and the classification system does not indicate a default, code selection as follows:
For ambidextrous patients, the default should be dominantIf th l ft id i ff t d th d f lt i d i t If the left side is affected, the default is non dominant
If the right side is affected, the default is dominant
Notes
Angina is considered integral to CAD137
Angina is considered integral to CAD unless otherwise noted by the physician.
A MI is coded as I21 - in the first 4 A MI is coded as I21. in the first 4 weeks.
If the patient has a second MI in the first If the patient has a second MI in the first 4 weeks, it is coded with I22.-
The sequencing of the I21 and I22 codes The sequencing of the I21 and I22 codes depends on the circumstances of the encounter.encounter.
MyocardialInfarctionExampleExample
Patient admitted to home health with138
• Patient admitted to home health with new diagnosis of CAD after acute MI 5 k P ti t i l5 weeks ago. Patient is no longer having symptoms
MyocardialInfarctionAnswerAnswer
• M1Ø21: I25.1Ø Atherosclerotic heart 139
Ø Ødisease of native coronary artery without angina
Ø• M1Ø23: I25.2 Old healed MI Arteriosclerosis, coronary
I f ti
Note: ICD-1Ø definition acute MI = 4 k
Infarction, myocardium
weeks ICD-9 definition acute MI = 8 weeks
MyocardialInfarctionExampley p
Patient was treated for an inferior wall140
Patient was treated for an inferior wall MI in last 3 weeks and then was
d itt d t h it l f t i llreadmitted to hospital for anterior wall MI. He is being admitted to home care for O and A of unstable angina and his CAD and teaching on his gmultiple new cardiac meds.
MyocardialInfarctionAnswersy
M1Ø21: I25 11Ø AHD with unstable141
M1Ø21: I25.11Ø AHD with unstable angina
ØM1Ø23: I21.19 MI other coronary artery inferior wally
M1Ø23: I22.Ø MI of anterior wallM1Ø23: Z79 899 Other long termM1Ø23: Z79.899 Other long term (current) drug therapy
R iRespiratory142
Acuteexacerbationofchronicobstructive bronchitis and asthmaobstructivebronchitisandasthma
An acute exacerbation is a worsening143
An acute exacerbation is a worsening or a decompensation of a chronic condition An acute exacerbation iscondition. An acute exacerbation is not equivalent to an infection superimposed on a chronic conditionsuperimposed on a chronic condition, though an exacerbation may be triggered by an infectiontriggered by an infection.
See difference between J44 and J45.
Ski d S bSkinandSubcutaneous144
PressureUlcers
Assign as many codes from category L89 as needed id if ll h l h i h if
145
to identify all the pressure ulcers the patient has, if applicable.
Assignment of the code for unstageable pressure g g pulcer (L89.--0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined ( th l i d b h h b(e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma This code shouldnot documented as due to trauma. This code should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer assign the appropriatethe stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.--9).
PressureUlcers146
No code is assigned if the documentation states that the pressure ulcer is completely healed.yStage 1s and 2s healStage 3s and 4s do not healStage 3s and 4s do not heal.
PressureUlcerExampleExample
Patient admitted with a stage III147
• Patient admitted with a stage III pressure ulcer to left heel. A stage II
l t i ht h l Thpressure ulcer to right heel. The stage III wound is gangrenous.
PressureUlcerAnswerAnswer
• M1Ø21: I96 Gangrenous cellulitis148
• M1Ø21: I96 Gangrenous cellulitis • M1Ø23: L89.623 Pressure ulcer of
left heel stage 3left heel, stage 3• M1Ø23: L89.612 Pressure ulcer of
i ht h l t 2right heel, stage 2
Note: Code first any associated gangrene (I96)g g ( )
ArterialUlcerExampleExample
Patient admitted with arterial skin149
• Patient admitted with arterial skin ulcer of left calf due to
th l iatherosclerosis
ArterialUlcerAnswerAnswer
• M1Ø21: I7Ø.242 Atherosclerosis of 150
Ø Ønative arteries of left leg with ulceration of calf, skin
ØArteriosclerosis,
extremities
• M1Ø23: L97.221 Non pressure ulcer of left calf limited to skin
Note: Reason for ulcer, if known, should be sequenced firstbe sequenced first
Note: Codes available for severity of ulcerulcer
UlcerSeverityy
L97 22 Non pressure chronic ulcer of left calf
151
L97.22- Non-pressure chronic ulcer of left calf
-1Non-pressure chronic ulcer of left calf limited to1Non pressure chronic ulcer of left calf limited to breakdown of skin-2Non-pressure chronic ulcer of left calf with fat layer exposedlayer exposed-3Non-pressure chronic ulcer of left calf with necrosis of muscle-4Non-pressure chronic ulcer of left calf with necrosis of bone9Non pressure chronic ulcer of left calf with-9Non-pressure chronic ulcer of left calf with
unspecified severity
M l k l lMusculoskeletal152
Musculoskeletal
Result of previous injury or trauma to a153
Result of previous injury or trauma to a site, or are recurrent conditions.
Bone joint or muscle conditions that are Bone, joint or muscle conditions that are the result of a healed injury
Recurrent bone joint or muscle Recurrent bone, joint or muscle conditions
Chronic or recurrent conditions Chronic or recurrent conditions Any current, acute injury should be
coded to the appropriate injury code fromcoded to the appropriate injury code from chapter 19.
7th CharactersforPathologicalFracturesFractures
7th character A is for use as long as the patient 154
g pis receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, , g y p ,evaluation and treatment by a new physician.
7th character, D is to be used for encounters after the patient has completed active treatmentafter the patient has completed active treatment.
The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae. , , q
OsteoporosisWithFractureExampleExample
Patient admitted for aftercare of155
• Patient admitted for aftercare of pathological fractured vertebra due t l t d t ito age related osteoporosis. Documentation indicates patient had previous healed pathological fracture of humerus due to osteoporosis p
OsteoporosisWithFractureAnswerAnswer
• M1Ø21: M8Ø.Ø8xD Age related osteoporosis 156
g pwith current pathological fracture, vertebra subsequent encounter
• M1Ø23: Z87 31Ø Personal history of healedOsteoporosis
• M1Ø23: Z87.31Ø Personal history of healed osteoporosis fracture
Note: Age related osteoporosis is separate category from other osteoporosis
Note: Pathological fracture is separate category from osteoporosis fracture
Osteoporosiswithcurrentpathological fracturepathologicalfracture
Category M80, Osteoporosis with current 157
g y , ppathological fracture, is for patients who have a current pathologic fracture at the time of an encounter The codes under M80time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture
fcode, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall oreven if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.
Osteoporosiswithoutpathological fracturepathologicalfracture
158
Category M81, Osteoporosis without current pathological fracture, is for use for
ti t ith t i h d tpatients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a e os eopo os s, e e ey a e ad afracture in the past. For patients with a history of osteoporosis fractures, status code Z87 310 Personal history of (healed)code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.
Symptoms, signs, and abnormalSymptoms,signs,andabnormalclinicalandlaboratoryfindings,
t l h l ifi d
159
notelsewhereclassified
Useofsymptomcodesy p
Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established
160
purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
Codes for signs and symptoms may be reported in addition to a 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 thedefinitive 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.
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 andiagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.
Falls161
Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated. C d Z91 81 Hi t f f lli i f Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls Whenis at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.
I j iInjuries162
Applicationof7thCharactersinChapter 19Chapter19
Most categories in chapter 19 have a 7th 163
g pcharacter requirement for each applicable code. • No aftercare code for injuries A = Initial encounter D = Subsequent encounter S = Sequela
• Encouraged to add the external cause d f h th i j h d fcode for how the injury happened for
home care
TraumaticHipFractureExampleExample
Patient admitted for aftercare of164
• Patient admitted for aftercare of traumatic right hip (neck of femur) f t ft f lli t f h l h ifracture after falling out of wheelchair
TraumaticHipFractureAnswerAnswer
• M1Ø21: S72 ØØ1D Subsequent165
M1Ø21: S72.ØØ1D Subsequent encounter for closed fracture of unspecified part of neck of right femur p p gwith routine healing
• M1Ø23: WØ5.ØxxD Fall from wheelchair (optional)
Note: A fracture not indicated as opened or closed should be coded to closedor closed should be coded to closed
OpenWoundExampleExample
Patient admitted for wound care to166
• Patient admitted for wound care to lacerated right forearm due to falling f i t i d bilitfrom moving motorized mobility scooter.
OpenWoundAnswerAnswer
M1Ø21: S51 811D Laceration167
• M1Ø21: S51.811D Laceration without foreign body of right forearm
Ø ØØ• M1Ø23: VØØ.831D Fall from moving motorized mobility scooter (optional) y ( )
Note: Fall from non moving motorizedNote: Fall from non moving motorized mobility scooter WØ5.2xxD Accident,
transporttransport, pedestrian
AcuteBurnExampleExample
Patient admitted for wound care due168
• Patient admitted for wound care due to second degree burn of left foot d t h t b th tdue to hot bath water
AcuteBurnAnswerAnswer
M1Ø21: T25 222D Burn of second169
• M1Ø21: T25.222D Burn of second degree of left foot
Ø Ø• M1Ø23: X11.ØxxD Contact with hot bath water (optional)( )
Note: 5th and 6th character ‘x’ requiredNote: 5th and 6th character x required Note: 7th character required
Sequelaq170
7th character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition such as scar formationresult of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character “S”, it is necessary to use both the injury code that precipitated theuse both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code The 7th character “S” identifiessequela code. The 7th character S identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced fi t f ll d b th i j dfirst, followed by the injury code.
Sequela (LateEffect)BurnExampleExample
• Patient admitted for PT and OT due to joint 171
jcontracture after the healing of a third degree burn to the right foot when the hot oil from a fry kettle poured on his foot atoil from a fry kettle poured on his foot at the restaurant at which he worked.
• Sequela are coded with a S 7th character.• What do you see? Code it firsty• Next code the injury with an S• Next code how the original injury occurred
S ( )with an S (optional).
Sequela (LateEffect)BurnAnswerAnswer
• M1Ø21: M24.574 Joint contracture right foot172
g• M1Ø23: T25.321S Sequela of burn of third
degree of right footM1Ø23: X1Ø 2xxS Contact with hot oil• M1Ø23: X1Ø.2xxS Contact with hot oil, sequela (optional)
The condition or nature of the sequela is sequenced first. The sequela code is sequenced secondsecond.
Note: 5th and 6th character ‘x’ required Note: 7th character required q
Codethese…
Spastic hemiplegia of the left side after CHI and 173
p p gsubdural hemorrhage in 1988 after he fell off a ladder G81 14 G81.14 S06.5x9S W11.xxxS (optional)Q d i l i ft i l d i j t C6 Quadriplegia after a spinal cord injury at C6 one year ago when the auto he was driving ran into a tree. H&P mentions complete lesion.p G82.53 Quadriplegia S14.116S Complete lesion C6 V47 52xS Driver of other car collision with fixed or V47.52xS Driver of other car collision with fixed or
stationary object (optional)
Aftercare & Post‐surgicalAftercare&Post surgicalComplications
174
Examplep
Patient had left BKA for diabetic175
Patient had left BKA for diabetic gangrene. Providing aftercare,
b ti d t dobservation and assessment and dressing changes.
ICD-10-CM Description
Answers176
ICD-10-CM Description
Z47.81 Aftercare amputationE11 51 DM w/peripheral angiopathy woE11.51 DM w/peripheral angiopathy wo
gangreneZ89.512 Acquired absence of left leg below kneeq g
Z48.01 Encounter for surgical dressing changes
Samepatient,but….p ,
The amputation site is infected (MRSA)177
The amputation site is infected (MRSA) and necrosed. Orders are to continue to provide care to the surgical wound andprovide care to the surgical wound and dressing changes.
ICD-10-CM Description
Samepatient,but….p ,
The amputation site is infected (MRSA)178
The amputation site is infected (MRSA) and necrosed. Orders are to continue to provide care to the surgical wound andprovide care to the surgical wound and dressing changes.
ICD-10-CM DescriptionICD 10 CM Description
T87.54 Necrosis of amp stump, LLE
T87 44 Infection of amp st mp LLET87.44 Infection of amp stump, LLE
B95.62 MRSA (cause of diseases classified elsewhere)elsewhere)
E11.51 DM with periph angiopathy wo gangrene
Moresurgicalpatients…g p
Patient is receiving aftercare for an179
Patient is receiving aftercare for an appendectomy.
Patient status post CABGat e t status post C G
P ti t ith i f t d i l dPatient with infected surgical wound
Moresurgicalpatients…g p
Patient is receiving aftercare for an180
Patient is receiving aftercare for an appendectomy.Z48 815Z48.815
Patient status post CABGZ48 812Z48.812
Z95.1Patient with infected surgical woundT81.4xxD
TakeAwayPointsy
• CMS expects the Home Health industry to 181
p yhave an overall transition cost from ICD-9 to ICD-1Ø of 16.58 million dollars P ti i th k• Preparation is the key
• Communication is vitalEstablish a team to implement the• Establish a team to implement the conversion
• Coding Clinic guidance will be retired soCoding Clinic guidance will be retired so ‘unlearning’ rules will be as important as learning the new code setC• Clinicians must document in detail
TakeAwayPointsy
• Improved documentation is being driven by initiatives h li l b d h i
182
such as quality measures, value based purchasing, and patient safety
• Coders must have increased knowledge not just in g jthe new coding system itself, but medical terminology, anatomy and physiology in general
• Payment in part, will be linked to precise codingy p , p g• Accurate coding depends on thorough
documentation• Both are critical to your agency’s success in an ICD-• Both are critical to your agency s success in an ICD-
1Ø environment • There will be a productivity drop and there will be a
slowdown in claims processing what is your plan?slowdown in claims processing—what is your plan?
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