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Documentation and Coding for ICD-10 CM
Diane Bartlett, CPCPresented March 13,2015
History of ICD-9
• History of ICD-9-CM• •• World Health Organization (WHO) developed ICD-9
for use worldwide• •• U.S. developed clinical modification (ICD-9-CM)
• It was Implemented in 1979 in U.S. and annual updates are done on October 1st.
Advantages of ICD-10
• ICD-9-CM is Outdated• •• 30 years old–technology has changed• •• Many categories full• •• Not descriptive enough
Advantages of ICD-10
• What Characteristics Are• Needed in a Coding System?• •• Flexible enough to quickly incorporate emerging
diagnoses and procedures• •• Exact enough to identify diagnoses and procedures
precisely
• ICD-9-CM is neither of these
Advantages of ICD-10
• Reimbursement and Quality Problems With ICD-9• Example–fracture of wrist–Patient fractures left wrist• A month later, fractures right wrist• ICD-9-CM does not identify left versus right–requires
additional documentation–ICD-10-CM describes Left versus right,
• Initial encounter, subsequent encounter• Routine healing, delayed healing, nonunion, or mal-
union
Some ICD-10 Major Modifications
• Added trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used)
• •• Revised diabetes mellitus codes (5th digits from ICD-9-CM
will not be used for controlled or uncontrolled)• •• Expanded codes (e.g., injury, diabetes)• •• Added code extensions for injuries and• external causes of injuries
Laterality is added
• Laterality –Left Versus Right• C50.1Malignant neoplasm, of central portion• of breast• C50.111Malignant neoplasm of central
portion of right female breast• C50.112 Malignant neoplasm of central
portion of left female breast
Structural Differences
• Structural Differences–ICD-9-CM• Diagnoses•ICD-9-CM has 3–5 digits• Chapters 1–17: all characters are numeric• Supplemental chapters: first digit is alpha (E or V),
remainder are numeric• •• Examples:• 496 Chronic airway obstruction (NEC)• 511.9 Unspecified pleural effusion• V02.61 Hepatitis B carrier
Structural Differences
• Structural Differences ICD-10-CM Diagnoses• ICD-10-CM has 3–7 digits• Digit 1 is alpha (A–Z, not case sensitive)• Digit 2 is numeric• Digit 3 is alpha (not case sensitive) or numeric• Digits 4–7 are alpha (not case sensitive) or numeric• –A66 Yaws• –A69.20 Lyme disease, unspecified• –O9A.311 Physical abuse complicating pregnancy, first• trimester• –S42.001A Fracture of unspecified part of right clavicle,• initial encounter for closed fracture
The Placeholder Character
• In ICD-10 the placeholder is character X• It is used in certain codes to allow for future
expansion• Certain codes have a 7th character. If a code
that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters
Placeholder Examples
• Examples• S17.0XXA Crushing injury of larynx and
trachea, initial encounter• S01.02XA Laceration with foreign body of
scalp, initial encounter
Chapter Specific Changes
• Chapter 4: Endocrine, nutritional and metabolic diseases
• ICD-10-CMs five categories for diabetes mellitus• E08 Diabetes mellitus due to underlying
conditions (examples, cystic fibrosis, malignant neoplasm, cushings)
• E09 Drug, or chemical induced diabetes• E10 Type 1 diabetes mellitus
Chapter 4
• E11 Type 2 diabetes mellitus• E13 Other specified diabetes mellitus
(examples post-pancreatectomy diabetes mellitus)
• ICD-10-CM classifies inadequately controlled, out of control, and poorly controlled DM to DM, by type, with hyperglycemia
• The terms controlled and uncontrolled are eliminated.
Chapter 4
• Diabetes Mellitus codes have been expanded to reflect manifestations and complications of the disease by using 4th or 5th characters rather than by using an additional code.Examples:
In ICD-9-CM Diabetes type II with diabetic peripheral
neuropathy (not uncontrolled)250.60 DM with neurological complications
Chapter 4
• 357.2 polyneuropathy in diabetes• In ICD-10-CM• E11.42 Type 2 diabetes with diabetic
polyneuropathy ( and diabetic neuralgia)
Chapter 6Diseases of the Nervous System
• Dominant/Nondominant Side• Codes from category G81, Hemiplegia and
hemiparesis, and Monplegia of upper and lower limb indentify whether the dominant or nondominant side is affected, as do codes from category I69, Sequelae of Cerebrovascular Disease, that specify hemiplegia or hemiparesis.
Chapter 9Diseases of the Circulatory System
• Hypertension• In ICD-9 hypertension codes classify the type of
hypertension (benign, malignant, unspecified).• In ICD-10 hypertension codes no longer specify
the type.• Cerebral infarctions are now coded by artery
affected by the thrombosis or embolism and by laterality. Cerebral occlusion without infarction are classified by artery and laterality as well.
Chapter 9Diseases of the Circulatory System
• Acute myocardial infarction in ICD-10• These codes specify ST elevation MI and non
ST elevation MI and identify the site, such as anterolateral wall or true posterior wall as well as the artery involved.
• A new category, I22, has been added for subsequent STEMI and non STEMI occurring within four weeks of a previous acute MI.
MI Continued
• Examples:• I21.01 ST elevation (STEMI) myocardial
infarction of anterior wall involving left main coronary artery.
• I21.02 ST elevation myocardial infarction of anterior wall involving left anterior descending coronary artery.
• Non-STEMI infarctions do not specify the site.
Chapter 13Diseases of the Musculoskeletal System
• Recurrent bone, joint or muscle conditions that are the result of a healed injury are found in this chapter.
• Any current, acute injury should be coded with an injury code from chapter 19.
Chapter 13
• Osteoporosis• Osteoporosis is classified as either• Age related (M80.0-) or• Other osteoporosis (each having its own code)• Drug-induced• Idiopathic• Osteoporosis of disuse• Post-oophorectomy osteoporosis• Post –surgical osteoporosis• Post –traumatic osteoporosis
Osteoporosis
• In addition, osteoporosis is coded either:• With current pathological fracture• Or• Without current pathological fracture• In ICD-10 the default code for a fracture
following a minor injury in a patient with known osteoporosis is M80.- (Osteoporosis with current pathological fracture)
Chapter 19Injury and Poisoning
• In ICD-10 injuries are first classified by site of injury, then by type of injury.
• In ICD-9 injuries are first classified by type of injury
Chapter 19
• Use of 7th characters in Chapter 19• Most codes in this chapter have a 7th character
requirement • A: Initial encounter• D: Subsequent encounter• S: Sequela
7th Characters in Chapter 19
• A: Initial encounter• This is used while the patient is receiving
active treatment for the condition.• Examples of active treatment are:• Surgical treatment• ED encounter• Evaluation and Management by a new
physician
7th Characters in Chapter 19
• D: Subsequent encounter• This is used for encounters after the patient
has received active treatment and is receiving routine care during the healing or recovery phase.
• Examples • Follow-up visits including med adjustments• Cast change or removal
7th Characters in Chapter 19
• S: Sequela• This is used for complications or conditions
that arise as a direct result of a condition, such as scar formation after a burn.
• We use two codes to describe a sequela• The code for the sequela itself• The code that precipitated the sequela (with
7th character S)
7th Characters for FracturesEpisode of care
• A: Initial encounter for closed fracture• B: Initial encounter for open fracture• D: Subsequent encounter for fx with routine
healing• G: Subsequent encounter for fx with delayed
healing• K: Subsequent enc for fx with nonunion• S: Sequela
Burns and CorrosionsChapter 19
• The ICD-10 CM makes a distinction between burns and corrosions.
• The burn codes are for thermal burns, (except sunburn) as well as burns from electricity or radiation.
• Burns are classified by depth, extent, and by agent.
Adverse effect, Poisoning and Underdosing
• An adverse effect code is used when a drug has been correctly prescribed and properly administered.
• A code to describe the nature of the adverse effect is coded, followed by a code for the adverse effect of the drug.
• Example: Tachycardia R00.0, T48.6X5A
Adverse Effect, Poisoning and Underdosing
• Poisoning is coded when a medication is improperly used
• Examples are overdose, wrong substance given or taken in error, wrong route of administration.
• When a reaction results from the interaction of drugs or alcohol, this would be classified as a poisoning.
Adverse Effect, Poisoning and Underdosing
• Underdosing is a new category and refers to taking less of a medication prescribed by a provider or manufacturer’s instructions.
• There are additional codes for noncompliance to indicate intent, if known. (Z91-)
• Examples:• Patient’s intentional underdosing due to cost
of medicine. Z91.128
Inoculations and VaccinationsChapter 21
• Code Z23 is for encounters for inoculations and vaccinations, or as a secondary code if the vaccination is given as a routine part of preventive health care.
• The procedure code (the vaccine product) indentifies the type(s) of immunizations given.
Chapter 10 Diseases of the Respiratory System
• Sinusitis• ICD-10 classifies sinusitis as acute or chronic
similar to ICD-9, but ICD-10 also classifies acute, recurrent sinusitis.
• Recurrent sinusitis in ICD-10 is 3 or more episodes in a year, each lasting less than 2 weeks.
Chapter 10Diseases of the Respiratory System
• Asthma J45.-• In ICD-10, there are 6 categories of asthma• Mild intermittent asthma• Mild persistent asthma• Moderate persistent asthma• Severe persistent asthma• Unspecified asthma• Other asthma (including exercise induced and
cough variant asthma)
Preventive Care Codes
• The categories for routine preventive (well) exams now include codes for exams with and without abnormal findings.
• Z00.00 Encounter for general adult medical exam without abnormal findings
• Z00.01 Encounter for general adult medical exam with abnormal findings
Preventive Care Codes
• In this context, abnormal findings mean abnormal results are known at the time the visit is being coded.
• If the encounter is being coded before test results are back, it is acceptable to assign the code for with normal findings.
Routine exams for children (Z00.021 and Z00.029 are also classified with and without abnormal findings, as are Encounters for routine gynecological exam (Z01.411 and Z01.419)
So How Does This Affect Documentation
• The Diabetes complication must be stated in the encounter note or the correct code cannot be assigned.
• For patients who have hemi-paresis from a stroke, dominant or dominant side affected should be stated in the encounter note.
• An acute MI should be stated as STEMI or Non STEMI and by the wall affected.
Documentation Challenges
• Osteoporosis should be stated as age-related or due to other causes to be correctly coded.
• It should also be stated if there is a current pathological fracture
• Asthma should be stated as mild, moderate or severe and also intermittent or persistent.
Documentation Challenges
• Injuries • It should be stated in the encounter note or
easily inferred, if this is the initial encounter or a subsequent encounter for an injury.
• Fractures• It should be stated in the note if the patient is
being seen for initial or subsequent encounter, and if routine healing is taking place or a complication.
Sample Notes
• X is a 9 Years & 7 Months Old male accompanied by a his mother. His medical records were obtained from the patient and his mother. This 9 years & 7 months old male was seen today for injury to his right little toe. The injury to his right little toe occurred on 02/26/2015 when he was walking and stubbed his right little toe on a wooden bench.
• There was immediate pain right little toe. He did try to walk on it. There was swelling when the injury occurred: right little toe. There was bruising when the injury occurred: . His skin is intact.
• He had X-rays on 02/27/2015 at X hospital. • The patient is full weight bearing on right.
Continued Note
• Assessment of Studies • X-RAY: X Hospital 2/27/15 left toes: this study
was reviewed. There is a Salter II fracture of the proximal phalanx left little toe, in good position.
• Assessment• fracture proximal phalanx left little toe
Coding this condition
• ICD-9 code 826.0 Fracture of one or more phalanges of the foot
• ICD-10 S92.515A• S92.51 is Fracture of proximal phalanx of lesser
toe(s)• 6th character 5 indicates non-displaced and left
toe• 7th character indicates initial visit for closed
fracture
Rationale
• The ED physician would code initial encounter for non-displaced fracture and this orthopedic physician would also code initial encounter.
• The character A indicates this is the initial encounter while the patient is receiving active care for the fracture (new doctor).
• ICD-10 specifies the laterality, displaced vs non-displaced and the specific part of the bone fractured.
Salter-Harris Classification
• In ICD-10 physeal fractures of the long bones (Humerus, femur, tibia, radius and ulna) can also be specifically coded as Salter-Harris fractures types I-IV.
Sample Note
• Reason For Visit: Follow up right navicular foot fracture
• HPI: Patient presents today for follow up of his right navicular foot fracture which occurred on 12/16/14. He was casted on 1/5/15. He denies any discomfort at this time. He feels that his cast is loose and it is bothering him. His short leg cast has been removed and his skin is clean, dry and intact. His exogen unit remains intact. He has been using it daily as instructed.
Note Continued
• Assessment• fracture right navicular• Assessed FRACTURE, FOOT as unchanged Dr X MD• Plan:• Patient instructed to call with any questions or concerns.He
had a CT scan 2/18/15 which showed the osteopenia and further healing of the navicular. His original xrays did not show the fracture, so no follow up xray was done today. He will weight bear to tolerance out of the cast. He will work on motion and strength. He will use the exogen unit for a total of 3 months. The trainer was contacted as well.
Coding this note
• ICD-9 825.22 Fracture of navicular, foot, closed• ICD-10 S92.254D• The 6th character indicates non-displaced and
right foot.• The 7th character indicates a subsequent
encounter for fracture with routine healing.• M85.871 Other specified disorders (osteopenia)
of bone density and structure, right ankle and foot
Sample Note
• CC: f/u htn and dm.• History of Present Illness:• Patient is here for f/u htn and dm. Diabetes is
not well controlled and complicated by diabetic neuropathy. Followed by dr. X. Patient is on Insulin pump. Asthma is well controlled.
• Problem # 1: DIABETES MELLITUS, TYPE II, ON INSULIN
• Assessment: Unchanged
Note Continued
• Problem # 2: ASTHMA, PERSISTENT, MILD (ICD-493.90) (ICD10-J45.30)
• Assessment: Improved
• ICD-9 Coding• 250.62 DM Type II uncontrolled, with neurological
complications• 357.2 Diabetic peripheral neuropathy• 493.90 Asthma, unspecified• V58.67 Long term use (current) of insulin
Note Continued
• ICD-10 Coding• E11.42 Type 2 DM with diabetic neuralgia• E11.65 Type 2 DM with hyperglycemia • Z79.4 Long term (current) use of insulin• J45.30 Mild persistent asthma, uncomplicated
Rationale
• In ICD-9 Diabetes is classified as controlled or uncontrolled. In ICD-10 diabetes stated as poorly controlled, out of control or inadequate control is coded as Diabetes (by type) with hyperglycemia.
• Two codes are required to code DM type 2 with diabetic neuralgia in ICD-9. In ICD-10 one code encompasses both conditions.
Rationale
• In both ICD-9 and ICD-10, routine use of insulin is coded, except that in ICD-10 long term (current) use of insulin is not coded for Type 1 diabetes.
• In ICD-9, there is no code to specify the severity or frequency of asthma symptoms. In ICD-10 there is a specific code to identify mild, persistent asthma.
Final Thoughts
• Many physicians are worried about the increased specificity requirements they hear about ICD-10.
• While there are many more codes to select from, many of the increases in codes are due to laterality.
• Most of ICD-10 follows the same coding guidelines as ICD-9.
Questions ?
