PREPARING FOR ICD-10-CM
PHASE 2
INTRODUCTION TO ICD-10-CM
© RMACI, 2015
TABLE OF CONTENTS
Introduction to ICD-10-CM ........................................................... 1
ICD-10-CM—Is It Ever Going To Happen? .................................... 3
Why Are We Making This Change ................................................. 4
Myths About ICD-10 ..................................................................... 4
Comparing ICD-9-CM to ICD-10-CM ............................................. 7
What Does ICD-10-CM Look Like? .............................................. 12
Tips to Finding ICD-10-CM Codes ............................................... 15
ICD-10-CM Guidelines ................................................................ 18
ICD-10-CM Code Organization .................................................... 22
What’s Next? ............................................................................... 41
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INTRODUCTION TO ICD-10-CM Many who are participating in this ICD-10 training program may have vastly different views about medical billing and coding. Some may not be very familiar with coding and how it works, while others may deal with coding on a daily basis. There are those who may enjoy the coding process, while others may view it as necessary evil that has to be tolerated in order to facilitate the flow of revenue into the practice. Regardless of one’s view today, we are about to undergo a major change in coding in the United States. The usage of ICD-10, beginning on October 1, 2015, completely revises one of the two code sets used to report the health care provided to patients and to submit claims to third party payers, such as health insurers. The transition from ICD-9 to ICD-10 is providing a unique opportunity to upgrade and standardize everyone’s knowledge concerning coding and its influence on billing and revenue. Fundamentally, coding is telling the story of the encounter with the patient in the most accurate manner possible. Words are not used—rather, codes are the communication medium. When we discuss correct coding, it means that we are selecting codes based on:
The most accurate possible description of “what” was done and “why” it was done
What can be supported by the documentation in the medical record Consistency with and adherence coding rules and guidelines
“What” is described by the procedure code, which is reported by either a Current Procedural Terminology (CPT) code or a Healthcare Common Procedure Coding System (HCPCS) Level II code, which describes certain procedures and/or medical supplies. “Why” is described by the diagnosis code, which is reported using the International Classification of Disease (ICD). At present, we are using Revision 9 (ICD-9), but will make the transition to Revision 10 (ICD-10) on October 1, 2015. While the relationship between code selection and documentation will receive greater attention in Phase 3 of this training, it is important to note that documentation requirements are going to change after this transition occurs because ICD-10 codes are more specific than ICD-9 codes. Therefore, it will be necessary to engage in more targeted documentation so that enough information exists within the record to select the appropriate ICD-10 code.
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ICD-10-CM—IS IT EVER GOING TO HAPPEN? The transition to ICD-10 has been bumpy, to say the least. ICD-6 was first adopted for worldwide usage in 1948. For approximately 25 years, regular updates were made, but it was not until 1979 that ICD-9 was formally adopted for usage for the purpose of reporting claims to the Medicare/Medicaid programs, and to commercial insurers shortly thereafter. ICD-10 was formally issued by the World Health Organization (WHO) in 1993 and, over the years, has been adopted for usage by every member nation within the WHO, except for the United States. The United States did not rush into the use of ICD-10 because, even though it had already been in use for more than 15 years, it was not until January 2009 that the Department of Health and Human Services (DHHS) announced an implementation date, which was to be October 1, 2013. Successful “behind-the-scenes” work took place in 2012, when the format for communication of electronic claims was transitioned from the 4010 format to the 5010 format. This transition was necessary in order to make the usage of ICD-10 possible. However, in 2012, HHS recognized that preparations for ICD-10 were lagging and that key players were not going to be ready in time. Therefore, they delayed the implementation by one year, setting a new effective date of October 1, 2014. Everyone was making active progress toward the 10/1/2014 effective date when, during the debate about the Sustainable Growth Rate (SGR) and the impending Medicare reimbursement reductions, Congress became involved in the ICD-10 implementation. Language was inserted in the legislation that prevented the implementation of ICD-10 until at least October 1, 2015. The current effective date for ICD-10 is October 1, 2015. There is no indication that there will be any change to this effective date. The Centers for Medicare and Medicaid Services (CMS), which have always been in favor of a timely implementation, is fully moving forward with preparations. Since Congress is now in the hands of a single party, there is not expected to be any political conflict over the issue. In addition, those in Congress who blocked the implementation in 2014 are now publicly stating that they are in favor of implementation in 2015. Therefore, we must aggressively move forward with plans and preparations for an October 1 “go live” for ICD-10. In order to properly prepare for the transition, the following actions should take place between now and October 1, 2015:
• Continue the introduction and education about ICD-10 • Coach offices in planning for operational changes • Demonstrate the benefits of transitioning to ICD-10
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• Continued enhanced audits to upgrade documentation for ICD-10 • Opportunities to test ICD-10 submissions from billing software to payers
WHY ARE WE MAKING THIS CHANGE? There are three fundamental reasons why we are making the transition from ICD-9 to ICD-10. They are:
1. ICD-9 is outdated and obsolete. It needs to be updated to reflect changes in health care and our understanding of disease processes.
2. There needs to be a greater degree of data collection, both for quality of care and public health needs. ICD-10 allows that to happen and gives the United States the opportunity to participate with the rest of the world in public health monitoring and tracking.
3. The current reimbursement models in place for the healthcare system in the United States are seriously broken, because they incentivize the wrong behaviors and reimburse at levels that have nothing to do with the quality of care delivered. ICD-10 will give the opportunity to modify payment models so that utilization patterns and outcomes are more easily measured and, ultimately, providers are recognized when they treat sicker patients or produce consistently better outcomes.
MYTHS ABOUT ICD-10
One of the factors that has promoted the delays in the implementation of ICD-10 and resistance to the change is a number of myths about the code set that have been spread throughout the health care community. Let’s take a few moments to recognize and address these myths. 1. There is a dramatically larger number of codes that will be
unmanageable. As is the case with most myths, there is a certain element of truth to the statement, followed by something that is not accurate. In this case, it is true that there is a dramatically large number of codes in the ICD-10 code set (approximately 140,000 codes), compared to the ICD-9 code set (approximately 17,000 codes). However, it is not true that the increase in codes is unmanageable. There are two different elements that need to be understood in order to appropriately respond to this myth:
a. The largest increase in the number of codes is in the ICD-10 Procedural Coding System (PCS) data set. ICD-10-PCS is used only by hospitals to report inpatient services and is directly comparable to the ICD-9 Volume 3 codes, which are not used at all by physicians or physician clinics. There are approximately 3,000
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ICD-9 Volume 3 codes, while there are approximately 72,000 ICD-10-PCS codes (an increase of ~2400%). There are approximately 13,000 ICD-9 Clinical Modification (CM) diagnosis codes, compared to approximately 68,000 ICD-10-CM diagnosis codes (an increase of ~500%). Therefore, the increase in diagnosis codes is not nearly as dramatic as the raw numbers would seem to indicate.
b. Most of the increase in the number of diagnosis codes is associated with increased specificity. The information needed to select the correct ICD-10 code is usually already in the medical record. For example,
For obstetrics, what trimester is the patient in? For primary care, what side (right or left) is the injury found? For gastroenterology/general surgery, is the condition acute or chronic?
Is it primary or secondary? For dermatology, what type of ulcer is it and where (specifically) is it
found?
2. I have to report laterality and encounter type for every service.
In ICD-10-CM, there are two significant changes that will be obvious to anyone who has used ICD-9-CM:
The reporting of laterality The reporting of encounter type
There was no functionality in ICD-9-CM to indicate what side of the body was being addressed during the encounter. In many cases, but not all, in ICD-10-CM there is the requirement to indicate whether the condition being treated is:
On the left side On the right side Bilateral Unspecified
Some specialties (e.g. ophthalmology and orthopedics) will be affected by the reporting of laterality in virtually every case. Others will be affected to a much lesser degree. The key point to understand is that this information should be in the medical record already. Second, when laterality is an option, “unspecified” should be avoided if at all possible because it seems to indicate a lack of attention to detail. Many payers may deny claims if an “unspecified” side is used when a reasonable person could/should know what side of the body is being treated. An extreme example of an inappropriate laterality code is as follows:
S49.90X- Unspecified injury of shoulder and upper arm, unspecified arm
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For many codes, certain conditions such as burns, injuries, sprains, strains, and breaks require a 7th character to indicate the type of encounter. The basic encounter types are:
A—Initial encounter D—Subsequent encounter S—Sequelae
For certain conditions (particularly fractures and breaks), there are approximately one dozen other options to report whether it is open or closed fracture, whether it is healing properly or not, etc. Again, this is information that should be present in the record and it does not apply in every circumstance and does not apply to every specialty. 3. ICD-10-CM is exceptionally complicated.
Just because something is specific or new does not mean that it is particularly complicated. Some research conducted in professional training schools are finding that those who are learning ICD-10 without any exposure to ICD-9 are demonstrating proficiency more quickly than those who are learning ICD-9. The reason is that ICD-10-CM is organized more logically and flows more naturally than ICD-9-CM. Another major benefit of the change to ICD-10-CM is that everyone will be receiving training on the new code set and will have the same baseline knowledge. After we are done with the ICD-10-CM training, everyone’s knowledge about diagnosis codes will be greater than it was before, while we were using ICD-9-CM. 4. ICD-10-CM will be a significant burden.
To be sure, the transition to ICD-10-CM will be a burden. For example, the fact that you are taking the time to experience this training is an investment of effort that you would not be doing if it were not for the change to ICD-10-CM. It will also be a burden in the sense that many of us may have key ICD-9-CM codes memorized—in some cases, nearly all the frequently used codes. It will take more time to look up the new codes that represent the diagnoses that we want to report. Also, there may be delayed payment from third party payers as they work their way through the adjustment to the new code set. However, in the long run, the benefits will outweigh the short-term burden that we will experience. The need for specificity will cause us to document in more detail, which will produce better medical records and help facilitate better patient care. In addition, ICD-10-CM may result in faster claim payment because payers will not need to request medical records to clarify the usage of “other specified” and “unspecified” diagnosis codes that were used with ICD-9-CM.
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COMPARING ICD-9-CM TO ICD-10-CM
The Table of Contents ICD-9-CM ICD-10-CM
INTRODUCTION
Official Guidelines for Coding and Reporting
YES YES
ALPHABETIC INDEX
Index to Diseases and Injuries YES YES
Table of Neoplasms NO (included in disease index)
YES
Table of Drugs and Chemicals YES YES
Index to External Causes of Injury
YES YES
TABULAR LIST OF DISEASES
Primary List (# of chapters) 17 21
Supplementary List (# of chapters)
2 0 (included in primary list)
Most discussions of the transition to ICD-10-CM focus on the differences between ICD-9 and ICD-10. However, there are a great number of similarities. This is evident simply by looking at the Table of Contents of each book. Both versions begin with an Introduction, which includes the Official Guidelines for Coding and Reporting. The items included in the Alphabetic Index are unchanged. The only modification is the separation of the Table of Neoplasms into a separate component. In ICD-9-CM, the Table of Neoplasms is a part of the Index to Diseases and Injuries (listed under “Neoplasm.” The Tabular List is not terribly different in its organization, other than the fact that the Supplementary List in ICD-9 (the “V” and “E” codes) have been incorporated into the primary list.
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When considering the differences between the two code sets, they can be characterized as follows:
ICD-10-CM codes are more specific. In order to properly select a code, the medical record must contain documentation with sufficient specificity to support the code.
Each chapter is separated into “blocks” of codes, divided into logical and reasonable subcategories. This will be addressed in much greater detail later in this training.
There are two additional chapters in ICD-10-CM—one for each of the sensory organs (eyes and ears). In ICD-9, the codes for these organs were included as part of the neurologic system.
As mentioned previously, ICD-10 is actually comprised of two code sets. They are:
ICD-10-CM-diagnostic coding ICD-10-PCS—procedural coding
ICD-10-CM codes describe the clinical picture of the patient with 3-7 character alphanumeric codes. These codes are generally organized by organ system, although a few chapters are organized by the patient’s condition/situation (e.g. viral/infectious disease, pregnancy, or congenital conditions). On the other hand, ICD-10-PCS describes procedures reported by hospitals. Every ICD-10-PCS code is a 7 character alphanumeric code, which details anatomic site, surgical approach, device used, and other code-specific information. The usage of Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS) Level II will remain completely unchanged by the transition with ICD.
Some other key changes that will be recognized in the transition are: The codes have been reclassified in some areas to reflect current medical
knowledge and to organize them more logically. Medical care and our understanding of disease processes are different today than they were in 1975 when ICD-9 was introduced. In addition, many of the codes in ICD-9 are organized in a way that doesn’t necessarily make sense, simply because there is no room to place them in the appropriate location.
Separate codes for intraoperative and postoperative complications have been created in some of the individual disease chapters. For example, postoperative complications of digestive system procedures are located in the digestive system chapter, while complications of a genitourinary system procedure are located in that chapter.
In the ICD-10-CM chapter used to report injuries, all of the codes are organized first by the site of the injury, then by the type of injury. In ICD-9-CM, there is a lack of consistency in the way that these codes are organized.
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In ICD-10-CM, there are more combination codes that allow reporting of conditions with their symptoms and/or manifestations. In ICD-9-CM, it would require multiple codes to accomplish the same reporting. There are also additional combination codes for poisonings and the external causes of the poisoning.
There is a new type of “exclusion” notes in ICD-10-CM, which will be discussed at length later in this training.
The following chart more clearly illustrates the differences between ICD-9-CM and ICD-10-CM: ICD-9 ICD-10
Number of characters 3–5 digits in length 3–7 characters in length
Number of codes Approximately 13,000 codes
Approximately 68,000 available codes
Types of characters First digit can be alpha (E or V) or numeric; digits 2–5 are numeric; most codes are all numeric
Character 1 is alpha; character 2 is numeric; characters 3–7 are alpha or numeric
Code capacity Limited space for adding new codes
Flexible for adding new codes
Specificity Lacks detail Very specific
Laterality designations (right vs. left)
Lacks laterality Has laterality
A “convention” is defined as “the way in which something is usually done, especially within a particular area or activity.” There are certainly “conventions” in diagnosis coding. You will be interested to know that the conventions in ICD-9-CM coding are remarkably similar to the conventions in ICD-10-CM coding. The following chart illustrates those similarities: Convention ICD-9-CM ICD-10-CM
Notes Further define terms, clarify information, or list choices for additional digits.
Further define terms, clarify information, or list choices for additional digits. With/without notes are the options for the final character of a set of codes.
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Convention ICD-9-CM ICD-10-CM
Includes Notes that further define or provide examples and can apply to a chapter, section, or category.
Same as ICD-9-CM.
Not otherwise specified
Used when the information at hand does not permit a more specific code assignment.
Same as ICD-9-CM.
Excludes Notes that indicate terms that are to be coded elsewhere.
Same as ICD-9-CM.
Code first underlying disease
Used in categories not intended as the primary diagnosis.
Same as ICD-9-CM
Use additional code
Appears in categories in which further information must be added by using an additional code, to provide a more complete picture.
Same as ICD-9-CM.
Colon
Used after an incomplete term that needs one or more of the modifiers that follows to make it assignable to a category.
Same as ICD-9-CM.
Brackets
Enclose synonyms, alternate wording, or explanatory phrases. Vulvar intraepithelial neoplasia [VIN], grade 1
Same as ICD-9-CM.
Parentheses
Enclose supplementary words that may be present or absent, without affecting the code number to which it is assigned. N39.3 Stress incontinence (male) (female)
Same as ICD-9-CM.
Braces Enclose a series of terms, each of which is modified by the statement appearing at the right.
Not used in ICD-10-CM.
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Convention ICD-9-CM ICD-10-CM
Excludes1 Not used in ICD-9-CM.
Indicates that the code excluded can never be used at the same time as the code to which the excludes list applies. For example, a congenital and acquired condition cannot coexist.
Excludes2 Not used in ICD-9-CM.
Indicates that the condition is not included as part of the code. If the patient has both conditions, a separate code must be used to report it.
As you can see, there are very few changes in the key conventions. The most significant is ensuring that we understand the distinction between the inclusion and exclusion notes. “Includes” is always listed under the 3 character category code that helps define the types of conditions that are included in that category. It may include synonyms or conditions that are associated with that category. In other cases, this may a term that exists in the alphabetic index, but does not appear in the actual code definition. For example, if you look up “ulcer, gastrointestinal” in the alphabetic index, it says, “see ulcer, gastrojejunal.” When you follow that instruction, it points to K28—Gastrojejunal ulcer. In the “includes” notes under K28, it lists “gastrointestinal ulcer.” This cross-reference helps identify codes more easily. “Excludes” notes in ICD-9-CM mean that the code(s) in the exclusion list absolutely cannot be used in conjunction with the codes found in the corresponding section. The Excludes1 convention in ICD-10-CM is exactly the same. If you use a code from the Excludes1 list on the same claim as a code from that category, the claim will be denied by the payer. However, Excludes2 (the new convention), means that the codes listed therein are not included as part of the category in which the list is found. A great example of all three conventions (Includes, Excludes1 and Excludes2) can be found in connection with the code for essential hypertension—I10.
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I10 Essential (primary) hypertension Includes high blood pressure
hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)
Excludes 1 hypertensive disease complicating pregnancy, childbirth, and the puerperium (O10-O11, O13- O16)
Excludes 2 essential (primary) hypertension involving vessels of the brain (I60-I69)
essential (primary) hypertension involving vessels of eye (H35.0-)
To summarize, the code I10 is used to report any kind of high blood pressure that is characterized by the terms in the “includes” list. If the patient has hypertensive disease complicating pregnancy (the Excludes1 list), I10 can’t be used in any circumstance (because it is already included in the pregnancy hypertension codes). If the patient has essential hypertension involving vessels of the brain or eye (the Excludes2 list), simply reporting I10 is not adequate. In this case, you would report only the more specific codes, or you could report both codes, especially if the patient’s underlying hypertension is being treated during the present encounter.
WHAT DOES ICD-10-CM LOOK LIKE?
Thinking about 68,000 codes can be somewhat overwhelming. However, if we break it down into the individual organ system chapters, we will see that the number of codes is not nearly as daunting. ICD-10
Chap.
Description
Code
Range
Number of
Codes
Equivalent ICD-9
Codes
1 Certain Infectious and
Parasitic Diseases
A00-B99 1056 001-139
2 Neoplasms C00-D49 1620 140-239
3 Disease of the Blood and
Blood Forming Organs and
Certain Disorders Involve
the Immune Mechanism
D50-D89 238 280-289
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ICD-10
Chap.
Description
Code
Range
Number of
Codes
Equivalent ICD-9
Codes
4 Endocrine, Nutritional,
and Metabolic
Diseases
E00-E89 675 240-279
5 Mental and Behavior
Disorders
F01-F99 724 290-319
6 Disease of the
Nervous Systems
G00-G99 591 320-389
7 Disease of the Eye and Adnexa
H00-H59 2452 320-389
8 Diseases of Ear and Mastoid Process
H60-H95 642 320-389
9 Disease of the Circulatory System
I00-I99 1254 390-459
10 Diseases of the Respiratory System
J00-J99 336 460-519
11 Diseases of the Digestive System
K00-K95 706 520-579
12 Disease of the Skin and Subcutaneous Tissue
L00-L99 769 680-709
13 Diseases of the Musculoskeletal System and Connective Tissue
M00-M99 6339 710-739
14 Diseases of the Genitourinary System
N00-N99 591 580-629
15 Pregnancy, Childbirth, and the Puerperium
O00-O9A 2155 630-679
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ICD-10 Chap.
Description
Code Range
Number of Codes
Equivalent ICD-9 Codes
16 Certain Conditions Originating in the Perinatal Period
P00-P96 417 760-779
17 Congenital Malformations, Deformations, and Chromosomal Abnormalities
Q00-Q99 790 740-759
18 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
R00-R99 639 780-799
19 Injury, Poisoning, and Certain Other Consequences of External Causes
S00-T88 39869 800-999
20 External Causes of Morbidity
V01-Y99 6812 E800-E999
21 Factors Influencing Health Status and Contact with Health Services
Z00-Z99 1178 V01-V91
After examining this list, you will notice some of the following facts:
More than half of all ICD-10-CM codes are found in Chapter 19. The reason for the large number of codes is the fact that almost all codes in this section require both laterality and encounter type, which dramatically increases the total number of codes.
Another 6800 codes are found in Chapter 20, which are the equivalent of “E” codes in ICD-9-CM. If you don’t frequently use “E” codes in ICD-9-CM, you probably won’t use them frequently in ICD-10-CM.
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Approximately 6300 codes are in the musculoskeletal system (Chapter 13). The large number there is the result of frequently laterality and reporting of encounter types.
The relatively large number of codes in Chapter 7 and Chapter 15 are attributable to the issue of laterality for the eyes (left, right, bilateral, unspecified) and for trimester of pregnancy, respectively.
The bottom line is that the number of codes that are unique to your specialty or that you would use with any frequency are not that significant and are certainly manageable. The raw number of codes you will be using will certainly increase, but it will not be too difficult for you to use.
TIPS TO FINDING ICD-10-CM CODES One problem with the ICD-9-CM code set is that it is primarily numeric, which makes it difficult to easily remember the location of certain codes, unless you memorize them. The fact that ICD-10-CM is alphanumeric gives us the opportunity to use mnemonic (aid in memory) devices associated with the first letter of each code. This means that if you know the general nature of the diagnosis, you will know exactly what chapter to check. The chart on the next page illustrates some mnemonic devices that will help you to know where to begin your search for codes. Here’s the thinking behind each of the mnemonic tools: Chapter 1 If someone has an infectious or parasitic disease, I think we would all
agree that it is “A Bad Thing.” All of the codes for infectious and parasitic diseases begin with either “A” or “B”.
Chapter 2 The codes in the chapter for neoplasms begin with the letters “C” or “D”. While not all neoplasms are Cancerous, it is a good tool to remember the codes. Ironically, all of the codes for malignant neoplasms (traditionally defined as “cancer”) do begin with the letter “C”. In-situ cancers and non-malignant neoplasms all begin with the letter “D”.
Chapter 3 Because this chapter involves diseases of the blood and blood forming organs, the terms “Dripping” or “Dracula” can be used to remind us that these codes all begin with the letter “D”.
Chapter 4 The codes in the chapter for endocrine, nutritional and metabolic diseases all begin with the letter “E” (E for Endocrine).
Chapter 5 Mental and behavioral health providers frequently discuss the patient’s Feelings. Since all of the codes related to mental and behavioral disorders begin with the letter “F”, this is a good tool to guide us to this chapter.
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ICD-10
Chap.
Description
Code Range
Mnemonic
Device
Equivalent
ICD-9
Codes
1 Certain Infectious and Parasitic Diseases A00-B99 A Bad Thing 001-139
2 Neoplasms C00-D49 Cancer 140-239
3 Disease of the Blood and Blood Forming
Organs and Certain Disorders Involve the
Immune Mechanism
D50-D89 Dripping or
Dracula
280-289
4 Endocrine, Nutritional, and Metabolic
Diseases
E00-E89 Endocrine 240-279
5 Mental and Behavior Disorders F01-F99 Feelings 290-319
6 Disease of the Nervous Systems G00-G99 Groggy or Gehrig 320-389
7 Disease of the Eye and Adnexa H00-H59 Head 320-389
8 Diseases of Ear and Mastoid Process H60-H95 Head 320-389
9 Disease of the Circulatory System I00-I99 Ischemic or
Infarction
390-459
10 Diseases of the Respiratory System J00-J99 Junk in the Lungs 460-519
11 Diseases of the Digestive System K00-K95 Kick in the Gut 520-579
12 Disease of the Skin and Subcutaneous
Tissue
L00-L99 Layers 680-709
13 Diseases of the Musculoskeletal System
and Connective Tissue
M00-M99 Musculoskeletal 710-739
14 Diseases of the Genitourinary System N00-N99 Nephrology or
Not Pregnant
580-629
15 Pregnancy, Childbirth, and the Puerperium O00-O9A Obstetrics 630-679
16 Certain Conditions Originating in the
Perinatal Period
P00-P96 Perinatal 760-779
17 Congenital Malformations, Deformations,
and Chromosomal Abnormalities
Q00-Q99 Questions 740-759
18 Symptoms, Signs, and Abnormal Clinical
and Laboratory Findings, Not Elsewhere
Classified
R00-R99 Rule Out 780-799
19 Injury, Poisoning, and Certain Other
Consequences of External Causes
S00-T88 Sprains, Strains,
and Trauma
800-999
20 External Causes of Morbidity V01-Y99 Why, Why E800-E999
21 Factors Influencing Health Status and
Contact with Health Services
Z00-Z99 Zebras V01-V91
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Chapter 6 If someone is “Groggy” or if they have been diagnosed with Lou Gehrig’s Disease, they may have a disease of the nervous system. All codes in this chapter begin with the letter “G”. In ICD-9-CM, these codes are found in the series 320-389, along with the codes for the sensory organs (chapters 7 & 8 in ICD-10-CM).
Chapter 7 Diseases of the eye and adnexa are found in this chapter and all codes begin with the letter “H”. The mnemonic device in this case is “H” for “Head,” where the eyes are found.
Chapter 8 “Head” is also the mnemonic device for the chapter for the diseases of the ear and mastoid process, since they are found in the head. The eye and adnexa are found in the first half of this chapter, while the ear and mastoid processes are found in the last half. An easy way to remember this is that the “eyes” are located in front of the “ears” in the head.
Chapter 9 The diseases of the circulatory system are found in this chapter, which all begin with the letter “I”. A tool to remember this is to use the terms “Ischemic” (shortage of blood flow) or “Infarction” (loss of blood flow resulting in death of tissue).
Chapter 10 The diseases of the respiratory system are found in this chapter, in which all of the codes begin with “J”. If a patient presents with a complaint of “Junk in their lungs,” they likely have a disease of the respiratory system.
Chapter 11 Many digestive diseases cause the patient to feel that they have been “Kicked in the gut.” Codes related to diseases of the digestive system all begin with the letter “K”.
Chapter 12 The codes for diseases of the skin and subcutaneous tissues all begin with the letter “L”. This is good for mnemonic device since the skin is constructed in Layers.
Chapter 13 Diseases of the musculoskeletal system have codes that all begin with the letter “M”, which corresponds with the memory tool, “Musculoskeletal.”
Chapter 14 This chapter has codes for diseases of genitourinary system, which encompasses both the urinary system and the male and female genital systems. Since all of these codes begin with the letter “N”, this can be remember by the terms “Nephrology” (diseases of the kidney) or “Not pregnant” (if the patient being seen has genital system complaints and they are not pregnant).
Chapter 15 Patients who are pregnant are considered to be “Obstetric” patients. For any condition related to pregnancy, childbirth, and the puerperium (postpartum period), the codes begin with “O”.
Chapter 16 Conditions originating in the Perinatal period all begin with the letter “P”. Chapter 17 When the patient has a congenital malformation, deformation, and/or a
chromosomal abnormality, a code beginning with the letter “Q” is used to report it. Often, when someone is born with one of these conditions, the parents have many Questions, such as “Why did it occur?” or “What could have been done to prevent it?”
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Chapter 18 In diagnostic coding, services are not to be coded as “rule out….” When the provider doesn’t yet have a definitive diagnosis, they should use codes for signs and symptoms related to the condition, which all begin with “R” and are found in the chapter for symptoms, signs, and abnormal clinical findings. In other words, these codes are used while you are Ruling out other conditions.
Chapter 19 The chapter for injury, poisoning and certain other consequences of external causes have codes that begin with the letters “S” and “T”. When a patient presents with a Sprain, Strain, or Trauma, the code for their condition will likely be found in this chapter.
Chapter 20 External causes of morbidity are reported with codes that begin with “W”, “V”, “X”, and “Y.” In most cases, these codes explain “how” and “Why” an illness or injury occurred.
Chapter 21 Factors influencing health status and contact with health services are reported with codes beginning with the letter “Z”. The term Zebras is used to remember this chapter because there are so few words that begin with “Z”.
ICD-10-CM GUIDELINES The official guidelines for ICD-10-CM have been created by the “Cooperating Parties for ICD-10-CM.” The organizations involved in this process are the:
American Hospital Association (AHA) American Health Information Management Association (AHIMA) Centers for Medicare and Medicaid Services (CMS) National Center for Health Statistics (NCHS)
These guidelines complement the fundamental conventions and instructions in ICD-10-CM and, under the HIPAA regulations, adherence to them is required. Every ICD-10-CM book has these guidelines printed prior to the alphabetic index. There are five sections to the official guidelines, but only Section I and Section IV are relevant to physician practices. The other sections apply only to diagnosis code selection for inpatient facilities. For the purpose of this training, we will only be discussing Section I: Conventions, General Guidelines, and Chapter Specific Guidelines. The Alphabetic Index is a tool to assist the user find codes, by listing terms and their corresponding codes in alphabetic order. The Tabular List is not a numeric list, but a “chronological” list of the codes sorted by:
Chapter Code Blocks Categories (3 character sections)
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Subcategories (4-5 characters, when necessary) Codes (the actual codes reported, ranging from 3-7 characters in length
The guidelines specifically state that it is necessary to use both the alphabetic index and tabular list in order to select the correct code. This is necessary because the index does not always provide the full code. In some cases, a dash “-“ exists after codes listed in the alphabetic index, which indicates that additional character(s) are required. However, there are other cases in which additional characters are required, even when a dash is not present with the code in the alphabetic index. The alphabetic index never lists codes that are specific to laterality or type of encounter. Therefore, if you select codes only from the alphabetic index, you may select an incomplete code or an altogether incorrect code. The first character of all ICD-10-CM codes is always an alphabetic number and the second character is always a number. The third character is typically a number, although it can be a letter. The fourth through the seventh characters can be either letters or numbers, although distinct patterns can be found in the way that the codes are organized. The codes are organized as follows:
Code Format: XXX.XXX X XXX= Category XXX= Etiology, anatomic site, severity X= Extension
Many codes require that there be a seventh character that indicates the type of encounter, the fetus number, or some other extension. However, not every code has six characters to which to add a seventh character. When that occurs, a placeholder character (X) is added in order to create a valid code. For example:
Initial encounter to treat a burn of the second degree of the lower back: T21.24XA
T21: Burn and corrosion of trunk 24: Burn of second degree of lower back X: Placeholder A: Initial encounter
In ICD-10-CM, as well as ICD-9-CM, there are codes for “other” or “other specified” conditions, as well as codes for “unspecified” conditions. “Other” or “other specified” codes should be used when the provider has a definitive diagnosis, but there simply is not a code available to describe that condition. The “unspecified” code should be used
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only when the provider cannot assign a more precise diagnosis. An example of this pattern can be found in the codes for the Cardiovascular System:
I20.0 Unstable angina I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I20.9 Angina pectoris, unspecified
There are occasions in which it is necessary to use more than one code to accurately report a condition. In these cases, the guidelines will instruct the user to “use additional code” or “report underlying condition first. It may not always necessarily be required in order to receive payment, but it is a best practice to be as complete as possible in reporting services. Examples of these instructions include:
N72 Inflammatory disease of the cervix uteri Use additional code (B95-B97) to identify infectious agent
R50.81 Fever presenting with conditions classified elsewhere Code first underlying condition such as with:
Leukemia (C91-C95) Neutropenia (D70.-) Sickle-cell disease (D57.-)
Degree of Certainty In the coding guidelines, users are encouraged to code to the highest degree of certainty possible. If a definitive diagnosis can’t be assigned, it is perfectly legitimate to report signs or symptoms as the reason for the encounter. Codes can be assigned based on the provider’s clinical knowledge (e.g. a laboratory report is not necessary to indicate a urinary tract infection if the provider clinically believes that one exists). However, it would be quite acceptable to report the signs or symptoms that lead the provider to believe that a urinary tract infection is present. Acute/Chronic Another element of ICD-10-CM that is used more than it was in ICD-9-CM is the classification of conditions as “acute” or “chronic.” It will be important for documentation to clearly indicate how the patient’s condition is classified. The classification is made by the clinical judgment of the provider. The difference between the two categories is primarily related to the time involved in the condition. An “acute” condition is one that usually has a rapid onset and can be rapidly progressive, is of short duration, and usually needs urgent care. On the other hand, a “chronic” condition is one that has an indefinite duration or is relatively stable.
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The precise definition of “acute” can vary by the condition. For example, an acute myocardial infarction (heart attack) may last one week, while an acute sore throat may last only 1-2 days. If a patient has a chronic condition that becomes acute, codes for both conditions are reported, with the acute condition being reported first. For example:
J03.90 Acute tonsillitis, unspecified J35.01 Chronic tonsillitis
Laterality As mentioned previously, some codes indicate whether the condition involves the right side, the left side, is bilateral, or is unspecified. The only time when an unspecified code related to laterality should be used is if the site is not identified in the medical record. This is completely suboptimal and, if the record does not indicate, the provider should be queried as to the location of the condition. The most common chapter in which bilateral conditions can exist are diseases of the eye or adnexa. For example:
H10.42 Simple chronic conjunctivitis H10.421 Simple chronic conjunctivitis, right eye H10.422 Simple chronic conjunctivitis, left eye H10.423 Simple chronic conjunctivitis, bilateral H10.424 Simple chronic conjunctivitis, unspecified eye
When “bilateral” is not an option, but the condition is present bilaterally, codes for both sides are used.
N60.0 Solitary cyst of breast N60.01 Solitary cyst of right breast N60.02 Solitary cyst of left breast N60.09 Solitary cyst of unspecified breast
Combination Codes Combination codes are used when there is/are:
• Two diagnoses • Diagnosis with an associated secondary process (manifestation) • Diagnosis with associated complication
An example of a combination code is E10.321—Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema. This single code encompasses the primary condition (diabetes) and two associated processes or
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complications. It would not be proper to use additional diagnoses related to this condition because this code accurately and adequately reports the condition. Complications of Care Because ICD-10-CM has specific sections related to complications of care, it is essential that the medical record is clear when a condition is the result of a complication vs. when a condition happens to be subsequent to another condition. Just because “B” happens after “A,” it does not automatically mean that “B” is a complication of “A.” Intraoperative, postprocedural, and postoperative complications are typically found in the disease chapter specific to the condition. Other more general complications are found in Chapter 19—Injury, Poisoning and Certain Other Consequences of External Causes.
ICD-10-CM CODE ORGANIZATION It is not the purpose of this phase of the training to discuss specific codes or to begin to practice appropriate code selection. However, we will take some time at this stage to dig a little bit into the organization of the specific chapters and where certain codes are found. At some point, all providers will use codes from nearly every section. Clearly, different specialties will use codes in certain chapters with greater frequency than others and, in some cases, the majority will be from a single chapter (e.g. Ophthalmology and Chapter 7). However, in order to use the codes appropriately, everyone needs to be aware of the fundamental structure of ICD-10-CM. Chapter 1—Infectious and Parasitic Diseases (A00-B99) Code Block
Description
Code Block
Description
A00-A09 Intestinal infectious diseases B10 Other human herpes viruses
A15-A19 Tuberculosis B15-B19 Viral hepatitis
A20-A28 Certain zoonotic bacterial diseases
B20 Human immunodeficiency virus [HIV] disease
A30-A49 Other bacterial diseases B25-B34 Other viral diseases
A50-A64 Infections with a predominantly sexual mode of transmission
B35-B49 Mycoses
A65-A69 Other spirochetal diseases B50-B64 Protozoal diseases
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Code Block
Description
Code Block
Description
A70-A74 Other diseases caused by chlamydiae
B65-B83 Helminthiases
A75-A79 Rickettsioses B85-B89 Pediculosis, acariasis and other infestations
A80-A89 Viral infections of the central nervous system
B90-B94 Sequelae of infectious and parasitic diseases
A90-A99 Arthropod-borne viral fevers and viral hemorrhagic fevers
B95-B97 Bacterial, viral and other infectious agents
B00-B09 Viral infections characterized by skin and mucous membrane lesions
B99 Other infectious diseases
Chapter 1 has more blocks of codes than any other single chapter, because it influences every organ system and every specialty. While Infectious Disease specialists will spend the majority of their time in this chapter, the following blocks will be used by providers across a range of specialties: A00-A09 Intestinal infectious diseases, such as bacterial infections (A04), food
poisoning (A05), and gastroenteritis (A08). A50-A64 Infections with a predominantly sexual mode of transmission, such as
gonococcal infections (A54), chlamydia (A55-A56), trichomonas (A59), herpes (A60), and genital warts (A63).
B00-B09 Viral infections influencing the skin and mucous membranes, such as herpes (B00, B02), chicken pox (varicella) (B01), measles (B05), rubella (B06) and viral warts (B07).
B15-B19 Viral hepatitis (both acute and chronic) B20 HIV (active, confirmed cases) B95-B97 Various types of bacterial and viral infections, including streptococcus,
staphylococcus, E. coli, influenza, H. pylori, retrovirus, etc.
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Chapter 2—Neoplasms (C00-D49) Code Block
Description
Code Block
Description
C00-C14 Malignant neoplasms of lip, oral cavity and pharynx
C73-C75 Malignant neoplasms of thyroid and other endocrine glands
C15-C26 Malignant neoplasms of digestive organs
C7A Malignant neuroendocrine tumors
C30-C39 Malignant neoplasms of respiratory and intrathoracic organs
C7B Secondary neuroendocrine tumors
C40-C41 Malignant neoplasms of bone and articular cartilage
C76-C80 Malignant neoplasms of ill-defined, other secondary and unspecified sites
C43-C44 Malignant neoplasms of skin C81-C96 Malignant neoplasms of lymphoid, hematopoietic and related tissue
C45-C49 Malignant neoplasms of mesothelial and soft tissue
D00-D09 In situ neoplasms
C50 Malignant neoplasms of breast
D10-D36 Benign neoplasms, except benign neuroendocrine tumors
C51-C58 Malignant neoplasms of female genital organs
D3A Benign neuroendocrine tumors
C60-C63 Malignant neoplasms of male genital organs
D37-D48 Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes
C64-C68 Malignant neoplasms of urinary tract
D49 Neoplasms of unspecified behavior
C69-C72 Malignant neoplasms of eye, brain and other parts of central nervous system
Every specialty will use this chapter, with a focus on the organ system(s) that they treat. The codes for all malignant neoplasms begin with “C”. In situ neoplasms, which are malignant, but non-invasive, are found in the D00-D09 block, sorted by organ system. Non-malignant neoplasms are in the block for D10-D36, including uterine fibroids (D25).
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Chapter 3—Disorders of Blood/Blood Forming Organs (D50-D89) Code Block
Description
Code Block
Description
D50-D53 Nutritional anemias D70-D77 Other disorders of blood and blood-forming organs
D55-D59 Hemolytic anemias D78 Intraoperative and postprocedural complications of spleen
D60-D64 Aplastic and other anemias and other bone marrow failure syndromes
D80-D89 Certain disorders involving the immune mechanism
D65-D69 Coagulation defects, purpura and other hemorrhagic conditions
Chapter 3 will primarily be the domain of hematologists, but nutritional anemias, such as iron deficiencies due to blood loss, Vitamin B12 deficiencies, etc. are found in the block for D50-D53. Chapter 4—Endocrine, Nutritional, and Metabolic Diseases (E00-E89) Code Block
Description
Code Block
Description
E00-E07 Disorders of thyroid gland E40-E46 Malnutrition
E08-E13 Diabetes mellitus E50-E64 Other nutritional deficiencies
E15-E16 Other disorders of glucose regulation and pancreatic internal secretion
E65-E68 Overweight, obesity and other hyperalimentation
E20-E35 Disorders of other endocrine glands
E70-E88 Metabolic disorders
E36 Intraoperative complications of endocrine system
E89 Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified
Endocrinologists will clearly spending a great deal of time working in this chapter, but a broad variety of other providers will use codes from this chapter. Some of the more commonly used blocks of codes will be:
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E00-E07 Thyroid disorders, including hypothyroidism, hyperthyroidism, thyroiditis, and goiters.
E08-E13 Diabetes—The distinction is made between diabetes caused by other conditions (E08), drug or chemical induced diabetes (E09), Type 1 diabetes (E10), Type 2 diabetes (E11), and “other specified” diabetes (E13). There is no distinction between “controlled” or “uncontrolled” in ICD-10-CM, as there is in ICD-9-CM. If the patient’s condition is “uncontrolled,” that is considered a complication and it is reported with the appropriate code
E20-E35 The endocrine gland disorders include pituitary gland disorders (E22-E23), ovarian dysfunction (E28), testicular dysfunction (E29), and other glandular disorders.
E65-E68 All types of obesity (from overweight to morbid obesity) are reporting using a code from the E66 series.
Chapter 5—Mental and Behavioral Disorders (F01-F99) Code Block
Description
Code Block
Description
F01-F09 Mental disorders due to known physiological conditions
F60-F69 Disorders of adult personality and behavior
F10-F19 Mental and behavioral disorders due to psychoactive substance use
F70-F79 Mental retardation
F20-F29 Schizophrenia, schizotypal and delusional, and other non-mood psychotic disorders
F80-F89 Pervasive and specific developmental disorders
F30-F39 Mood [affective] disorders F90-F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders
F99 Unspecified mental disorder
F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors
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Mental health professionals will obviously use this code set with great frequency, but there are other occasions in which other providers will use these codes. F10-F19 These codes are used to report any sort of substance use or abuse,
including alcohol (F10), tobacco (F17), and other illicit (legal and illegal) drugs and substances.
F30-F39 Many conditions in this block are serious (e.g. manic episodes, bipolar disorders), but it also includes the full range of depressive disorders (F32-F33), from mild to severe.
F40-F48 This block contains codes for all sorts of anxiety disorders, ranging from phobias, to panic disorders, generalized disorders, and severe dissociative disorders.
F90-F98 Conditions such as ADHD (F90), conduct disorders (F91), as well as other conditions typically associated with or initiated in childhood are found in this block of codes. The instructions for this block are clear that these codes can be used regardless of the age of the patient.
Chapter 6—Diseases of the Nervous System (G00-G99) Code Block
Description
Code Block
Description
G00-G09 Inflammatory diseases of the central nervous system
G50-G59 Nerve, nerve root and plexus disorders
G10-G14 Systemic atrophies primarily affecting the central nervous system
G60-G64 Polyneuropathies and other disorders of the peripheral nervous system
G20-G26 Extrapyramidal and movement disorders
G70-G73 Diseases of myoneural junction and muscle
G30-G32 Other degenerative diseases of the nervous system
G80-G83 Cerebral palsy and other paralytic syndromes
G35-G37 Demyelinating diseases of the central nervous system
G89-G99 Other disorders of the nervous system
G40-G47 Episodic and paroxysmal disorders
Chapter 6 will primarily be the domain of neurologists and gerontologists, as the condition are generally related to the brain and central nervous system. Some of these conditions, which might be seen in the context of other specialties include:
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Meningitis (G00-G03) Huntington’s disease (G10) Lou Gehrig’s disease (G12) Parkinson’s disease (G20) Alzheimer’s disease (G30)
Multiple sclerosis (G35) Epilepsy (G40) Migraines (G43) Sleep disorders (G47)
Chapter 7—Diseases of the Eye and Adnexa (H00-H59) Code Block
Description
Code Block
Description
H00-H05 Disorders of eyelid, lacrimal system and orbit
H43-H44 Disorders of vitreous body and globe
H10-H11 Disorders of conjunctiva H46-H47 Disorders of optic nerve and visual pathways
H15-H22 Disorders of sclera, cornea, iris and ciliary body
H49-H52 Disorders of ocular muscles, binocular movement, accommodation and refraction
H25-H28 Disorders of lens H53-H54 Visual disturbances and blindness
H30-H36 Disorders of choroid and retina
H55-H57 Other disorders of eye and adnexa
H40-H42 Glaucoma H59 Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified
This chapter will almost be the exclusive home of optometrists and ophthalmologists. Common eye infections treated by other specialists will be found in the H10-H11 block. Chapter 8—Diseases of the Ear and Mastoid Process (H60-H95) Code Block
Description
Code Block
Description
H60-H62 Disease of external ear H90-H94 Other disorders of ear
H65-H75 Diseases of middle ear and mastoid
H95 Intraoperative and postprocedural complications and disorders of ear and mastoid process, not elsewhere classified
H80-H83 Diseases of inner ear
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While otolaryngologists (ENT) will use this chapter frequently, it will also be used by others to report various ear infections. The most common type is otitis media, which is found in the block for H65-H75. Chapter 9—Diseases of the Circulatory System (I00-I99) Code Block
Description Code Block
Description
I00-I02 Acute rheumatic fever I30-I52 Other forms of heart disease
I05-I09 Chronic rheumatic heart diseases
I60-I69 Cerebrovascular diseases
I10-I15 Hypertensive diseases I70-I79 Diseases of arteries, arterioles and capillaries
I20-I25 Ischemic heart diseases I80-I89 Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified
I26-I28 Pulmonary heart disease and diseases of pulmonary circulation
I95-I99 Other and unspecified disorders of the circulatory system
Cardiologists and cardiovascular surgeons will use this chapter extensively. Other providers will be using the blocks for hypertensive diseases (I10-I15), arteriosclerosis/atherosclerosis (I70-I79), and phlebitis and deep vein thrombosis (I80-I89). Chapter 10—Diseases of the Respiratory System (J00-J99) Code Block
Description
Code Block
Description
J00-J06 Acute upper respiratory infections
J80-J84 Other respiratory diseases principally affecting the interstitium
J09-J18 Influenza and pneumonia J85-J86 Suppurative and necrotic conditions of the lower respiratory tract
J20-J22 Other acute lower respiratory infections
J90-J94 Other diseases of the pleura
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Code Block
Description
Code Block
Description
J30-J39 Other diseases of upper respiratory tract
J95 Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified
J40-J47 Chronic lower respiratory diseases
J96-J99 Other diseases of the respiratory system
J60-J70 Lung diseases due to external agents
This chapter will largely be the domain of otolaryngologists and pulmonologists, but will be used frequently by primary care physicians when reporting upper respiratory infections (J00-J06) and flu/pneumonia (J09-J18). Chapter 11—Diseases of the Digestive System (K00-K95) Code Block
Description
Code Block
Description
K00-K14 Diseases of oral cavity and salivary glands
K55-K63 Other diseases of intestines
K20-K31 Diseases of esophagus, stomach and duodenum
K65-K68 Diseases of peritoneum and retroperitoneum
K35-K38 Diseases of appendix K70-K77 Diseases of liver
K40-K46 Hernia K80-K87 Disorders of gallbladder, biliary tract and pancreas
K50-K52 Noninfective enteritis and colitis
K90-K95 Other diseases of the digestive system
Chapter 11 will be used extensively by general surgeons, gastroenterologists, and colo-rectal surgeons. The codes are grouped logically, beginning at the mouth (the start of the digestive tract) and continuing throughout the tract, with special blocks for key ancillary organs, such as the appendix, liver, gallbladder, pancreas, etc.
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Chapter 12—Diseases of the Skin and Subcutaneous Tissue (L00-L99) Code Block
Description
Code Block
Description
L00-L08 Infections of the skin and subcutaneous tissue
L55-L59 Radiation-related disorders of the skin and subcutaneous tissue
L10-L14 Bullous disorders L60-L75 Disorders of skin appendages
L20-L30 Dermatitis and eczema L76 Intraoperative and postprocedural complications of skin and subcutaneous tissue
L40-L45 Papulosquamous disorders L80-L99 Other disorders of the skin and subcutaneous tissue
L49-L54 Urticaria and erythema
Dermatologists will spend much of their time working in this chapter, although other specialists will use this chapter as well. Common skin disorders, such as dermatitis and eczema are found in block L20-L30. The block containing codes L60-L75 is used to report conditions such as nail disorders, alopecia, acne, and sweat gland disorders. Chapter 13—Diseases of the Musculoskeltal System and Connective Tissue (M00-M99) Code Block
Description
Code Block
Description
M00-M02 Infectious arthropathies M60-M63 Disorders of muscles
M05-M14 Inflammatory polyarthropathies
M65-M67 Disorders of synovium and tendon
M15-M19 Osteoarthritis M70-M79 Other soft tissue disorders
M20-M25 Other joint disorders M80-M85 Disorders of bone density and structure
M26-M27 Dentofacial anomalies [including malocclusion] and other disorders of jaw
M86-M90 Other osteopathies
M30-M36 Systemic connective tissue disorders
M91-M94 Chondropathies
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Code Block
Description
Code Block
Description
M40-M43 Deforming dorsopathies M95 Other disorders of the musculoskeletal system and connective tissue
M45-M49 Spondylopathies M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified
M50-M54 Other dorsopathies M99 Biomechanical lesions, not elsewhere classified
Diseases of the musculoskeletal system and connective tissue (typically considered the domain of orthopedic surgeons, physical therapists, etc.) will be used widely within other specialties—particularly internal medicine and gerontology. The most commonly used blocks will be M15-M19—Osteoarthritis and M80-M85—Disorders of bone density and structure. This section has a significant number of codes because nearly every code requires laterality (right or left) and the codes related to fractures (M80-M85) require a seventh character to indicate the encounter type (initial, subsequent, progress of fracture healing, etc.) It is important to note that the only fractures that appear in this chapter are pathological in nature—occurring absent a trauma. The reporting of traumatic breaks and fractures use codes from Chapter 19. Chapter 14—Diseases of the Genitourinary System (N00-N99) Code Block
Description
Code Block
Description
N00-N08 Glomerular diseases N40-N51 Diseases of male genital organs
N10-N16 Renal tubulo-interstitial diseases
N60-N65 Disorders of breast
N17-N19 Acute kidney failure and chronic kidney disease
N70-N77 Inflammatory diseases of female pelvic organs
N20-N23 Urolithiasis N80-N98 Noninflammatory disorders of female genital tract
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Code Block
Description
Code Block
Description
N25-N29 Other disorders of kidney and ureter
N99 Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified
N30-N39 Other diseases of the urinary system
This chapter will be used with regularity by nephrologists, urologists, gynecologists, and general surgeons (for breast issues). The most commonly used blocks are as follows: N17-N19 Acute kidney failure and chronic kidney disease, with separate codes for
each of the stages of chronic kidney disease. N30-N39 Conditions of the urinary system that are not related to the kidney or
ureters, such as cystitis (N30), urethritis and urethral stricture (N34-N35), urinary tract infection (N39.0), and stress and urge incontinence (N39.3 and N39.4-).
N40-N51 Male genital conditions, such as prostate issues (N40-N42), testicular issues (N43-N45), and male infertility (N46).
N60-N65 Disorders of the breast, including cysts and fibrocystic breast disease (N60), as well as other non-obstetric disorders related to the breast, such as lumps (N63), nipple discharge (N64.52), and problems with reconstructed breasts (N65).
N70-N77 This block incorporates any infection/inflammation of the female pelvis, including oophoritis, salpingitis, PID, Bartholin’s gland issues, vaginitis, and vulvitis. One major change is a greater emphasis on the distinction between acute and chronic conditions.
N80-N98 This blocks is used to report any female pelvic disorder that is not inflammatory in nature, such as endometriosis, pelvic weakening, ovarian cysts and torsions, dysplasias, female infertility, recurrent pregnancy loss, menopausal issues, and abnormal bleeding and dysmenorrhea.
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Chapter 15—Pregnancy, Childbirth, and the Puerperium (O00-O99) Code Block
Description
Code Block
Description
O00-O08 Pregnancy with abortive outcome
O60-O77 Complications of labor and delivery
O09 Supervision of high risk pregnancy
O80-O82 Encounter for delivery
O10-O16 Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium
O85-O92 Complications predominantly related to the puerperium
O20-O29 Other maternal disorders predominantly related to pregnancy
O94-O9A Other obstetric conditions, not elsewhere classified
O30-O48 Maternal care related to the fetus and amniotic cavity and possible delivery problems
The codes for obstetric services are organized in a highly logical fashion, based on the stage of pregnancy or the type of complication. These codes are only used on the maternal record—never on the newborn’s record. When a patient is being supervised for routine antepartum visits, but they are high risk, the primary diagnosis code will always be a code from the O09 block. There is no “episode of care” reporting in ICD-10-CM. The number of codes in this section is significantly higher than in the corresponding section of ICD-9-CM, because additional codes are required to designate the trimester in which the service is taking place. Chapter 16—Certain Conditions Originating in the Perinatal Period (P00-P96) Code Block
Description
Code Block
Description
P00-P04 Newborn affected by maternal factors and by complications of pregnancy, labor, and delivery
P50-P61 Hemorrhagic and hematological disorders of newborn
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Code Block
Description
Code Block
Description
P05-P08 Disorders related to length of gestation and fetal growth
P70-P74 Transitory endocrine and metabolic disorders specific to newborn
P09 Abnormal findings on neonatal screening
P76-P78 Digestive system disorders of newborn
P10-P15 Birth trauma P80-P83 Conditions involving the integument and temperature regulation of newborn
P19-P29 Respiratory and cardiovascular disorders specific to the perinatal period
P84 Other problems with newborn
P35-P39 Infections specific to the perinatal period
P90-P96 Other disorders originating in the perinatal period
The codes in this chapter will never be used on the maternal record, but will be assigned to the newborn’s record. These codes can be used throughout the life of the newborn, regardless of their age, if the condition is still affecting them later in life. Typically, these codes will be used by pediatricians and neonatologists. If the newborn was delivered prematurely and/or had a low birth weight, codes from the P05-P08 block would be used. If there is a birth trauma, it is reported with codes from the block P10-P15. Chapter 17—Congential Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99) Code Block
Description
Code Block
Description
Q00-Q07 Congenital malformations of the nervous system
Q50-Q56 Congenital malformations of genital organs
Q10-Q18 Congenital malformations of eye, ear, face and neck
Q60-Q64 Congenital malformations of the urinary system
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Code Block
Description
Code Block
Description
Q20-Q28 Congenital malformations of the circulatory system
Q65-Q79 Congenital malformations and deformations of the musculoskeletal system
Q30-Q34 Congenital malformations of the respiratory system
Q80-Q89 Other congenital malformations
Q35-Q37 Cleft lip and cleft palate Q90-Q99 Chromosomal abnormalities, not elsewhere classified
Q38-Q45 Other congenital malformations of the digestive system
Codes from this chapter are not reported on the maternal or fetal record, even if the abnormality is identified before birth. They should be reported on the newborn record if the condition has been identified, and used as long as the condition exists or influences the patient’s medical care. Chapter 18—Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) Code Block
Description
Code Block
Description
R00-R09 Symptoms and signs involving the circulatory and respiratory systems
R50-R69 General symptoms and signs
R10-R19 Symptoms and signs involving the digestive system and abdomen
R70-R79 Abnormal findings on examination of blood, without diagnosis
R20-R23 Symptoms and signs involving the skin and subcutaneous tissue
R80-R82 Abnormal findings on examination of urine, without diagnosis
R25-R29 Symptoms and signs involving the nervous and musculoskeletal systems
R83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
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Code Block
Description
Code Block
Description
R30-R39 Symptoms and signs involving the urinary system
R90-R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosis
R40-R46 Symptoms and signs involving cognition, perception, emotional state and behavior
R97 Abnormal tumor markers
R47-R49 Symptoms and signs involving speech and voice
R99 Ill-defined and unknown cause of mortality
The signs, symptoms, and abnormal findings reported using the codes in this chapter are designed to report circumstances in which a definitive diagnosis has not yet been determined. The codes are largely organized by organ system or the type of abnormal finding that is recorded. Some blocks that require special attention include: R10-R19 For the first time, there is a code that is explicitly for the purpose of
reporting pelvic/perineal pain (R10.2). In ICD-9-CM, a more generalized “unspecified” code was used. In addition, this code block allows the differentiation between abdominal pain and abdominal tenderness.
R83-R89 These codes are used to report abnormal findings on specimens that are not blood or urine. The most common use for this block of codes will be the reporting of abnormal pap smears (R86-R87).
R90-R94 This code block is used to report abnormalities on diagnostic imaging (e.g. x-rays, ultrasounds, mammograms, etc.) and function studies (e.g. EEG, EKG, kidney function, liver function, etc.) prior to a time of a formal diagnosis. These codes simply indicate that an abnormality is noted that prompted further investigation.
Chapter 19—Injury, Poisoning and Certain Other Consequences of External Causes (S00-T98) Code Block
Description
Code Block
Description
S00-S09 Injuries to the head T07 Unspecified multiple injuries
S10-S19 Injuries to the neck T14 Injury of unspecified body region
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Code Block
Description
Code Block
Description
S20-S29 Injuries to the thorax T15-T19 Effects of foreign body entering through natural orifice
S30-S39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals
T20-T32 Burns and corrosions
S40-S49 Injuries to the shoulder and upper arm
T33-T34 Frostbite
S50-S59 Injuries to the elbow and forearm
T36-T50 Poisoning by, adverse effect of and underdosing of drugs, medicaments and biological substances
S60-S69 Injuries to the wrist and hand T51-T65 Toxic effects of substances chiefly nonmedicinal as to source
S70-S79 Injuries to the hip and thigh T66-T78 Other and unspecified effects of external causes
S80-S89 Injuries to the knee and lower leg
T79 Certain early complications of trauma
S90-S99 Injuries to the ankle and foot T80-T88 Complications of surgical and medical care, not elsewhere classified
The usage of this chapter will depend in large part on the frequency with which a given specialist treats injuries and other traumas. This will definitely be used heavily by providers in Emergency Departments and trauma surgeons. This chapter is, by far, the largest in the book because it requires laterality and type of encounter for virtually every code. The specific block that will be used by nearly every specialty at some point will be T80-T88—Complications of surgical and medical care, not elsewhere classified. As mentioned previously, nearly every chapter has its own set of intraoperative and postoperative complication codes. The codes from T80-T88 are used when the codes in those sections are not adequate to describe the situation. Some examples of codes found in this block include:
Complications with transfusions/infusions Foreign bodies left following surgeries
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Mechanical complications of devices, such as heart valve prostheses, or graft leakage
Medical device displacement, such as catheters, IUDs, prostheses, pelvic mesh, artificial joints
Transplant complications Other complications of medical care
Chapter 20—External Causes of Morbidity (V01-Y99) Code Block
Description
Code Block
Description
V00-X58 Accidents Y62-Y69 Misadventures to patients during surgical and medical care
X71-X83 Intentional self-harm Y70-Y82 Medical devices associated with adverse incidents in diagnostic and therapeutic use
X92-Y08 Assault Y83-Y84 Surgical and other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
Y21-Y33 Event of undetermined intent Y90-Y99 Supplementary factors related to causes of morbidity classified elsewhere
Y35-Y38 Legal intervention, operations of war, military operations, and terrorism
This chapter has many additional blocks that are subcategories of the first block—all of them related to an accident of some type. This chapter will typically only be used by those specialties that treat accidents, trauma, or conditions that have external causes. These codes, in effect, explain how the injury or trauma reported from Chapter 19 actually occurred.
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Chapter 21—Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Code Block
Description
Code Block
Description
Z00-Z13 Persons encountering health services for examination and investigation
Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances
Z14-Z15 Genetic carrier and genetic susceptibility to disease
Z66 Do not resuscitate [DNR] status
Z16 Infection with drug resistant microorganisms
Z67 Blood type
Z17 Estrogen receptor status Z68 Body mass index (BMI)
Z20-Z28 Persons with potential health hazards related to communicable diseases
Z69-Z76 Persons encountering health services in other circumstances
Z30-Z39 Persons encountering health services in circumstances related to reproduction
Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status
Z40-Z53 Persons encountering health services for specific procedures and health care
The codes from Chapter 21 are used to report the reason for an encounter when the patient doesn’t have a particular illness or injury present at that moment. Every specialty will use some of these codes at some point. The key blocks are as follows: Z00-Z13 The codes in this block are used to report general examinations, pediatric
examinations, gynecological examinations, administrative exams, postoperative follow-up exams (Z08-Z09), and encounters for all types of screening (Z11-Z13).
Z30-Z39 The codes in this section are used to report management of contraception and procreative management (including infertility diagnosis and treatment) (Z30-Z31), pregnancy tests (Z32), supervision of normal pregnancy (Z34), antenatal screening (Z36), outcome of delivery (Z37), postpartum care (Z39), and the number of weeks gestation (Z3A).
Z68 Body mass index (BMI) codes are to be used in conjunction with the overweight and obesity codes from Chapter 4, to indicate the patient’s precise BMI.
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Z77-Z99 The block of codes for personal history and family history of certain conditions is significantly larger in ICD-10-CM than they were in ICD-9-CM. The purpose of these codes is to indicate that the patient no longer has the condition, but there is a possibility that the condition may return. This, in itself, may justify more careful surveillance than the typical patient.
WHAT’S NEXT? The next phase of the training will be specialty-specific and code-specific, with real-world practice cases involved as part of the education. In the meantime, here are the recommended steps to take that will help you become familiar with the codes that will be used regularly in your practice…. 1. Obtain access to the code set
a. A hard copy of the book b. An electronic version (available within this training)
2. Create a crosswalk between ICD-9-CM and ICD-10-CM for the codes commonly used in your practice
3. Identify online resources to help you increase familiarity 4. Identify the current uses of ICD-9-CM in your office
a. What needs to be adjusted? b. What changes need to be made in your documentation?
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