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Documentation and Coding for ICD- 10 CM Diane Bartlett, CPC Presented March 13,2015

Documentation and coding for icd 10

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Page 1: Documentation and coding for icd 10

Documentation and Coding for ICD-10 CM

Diane Bartlett, CPCPresented March 13,2015

Page 2: Documentation and coding for icd 10

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.

Page 3: Documentation and coding for icd 10

Advantages of ICD-10

• ICD-9-CM is Outdated• •• 30 years old–technology has changed• •• Many categories full• •• Not descriptive enough

Page 4: Documentation and coding for icd 10

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

Page 5: Documentation and coding for icd 10

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

Page 6: Documentation and coding for icd 10

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

Page 7: Documentation and coding for icd 10

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

Page 8: Documentation and coding for icd 10

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

Page 9: Documentation and coding for icd 10

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

Page 10: Documentation and coding for icd 10

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

Page 11: Documentation and coding for icd 10

Placeholder Examples

• Examples• S17.0XXA Crushing injury of larynx and

trachea, initial encounter• S01.02XA Laceration with foreign body of

scalp, initial encounter

Page 12: Documentation and coding for icd 10

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

Page 13: Documentation and coding for icd 10

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.

Page 14: Documentation and coding for icd 10

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

Page 15: Documentation and coding for icd 10

Chapter 4

• 357.2 polyneuropathy in diabetes• In ICD-10-CM• E11.42 Type 2 diabetes with diabetic

polyneuropathy ( and diabetic neuralgia)

Page 16: Documentation and coding for icd 10

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.

Page 17: Documentation and coding for icd 10

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.

Page 18: Documentation and coding for icd 10

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.

Page 19: Documentation and coding for icd 10

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.

Page 20: Documentation and coding for icd 10

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.

Page 21: Documentation and coding for icd 10

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

Page 22: Documentation and coding for icd 10

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)

Page 23: Documentation and coding for icd 10

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

Page 24: Documentation and coding for icd 10

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

Page 25: Documentation and coding for icd 10

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

Page 26: Documentation and coding for icd 10

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

Page 27: Documentation and coding for icd 10

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)

Page 28: Documentation and coding for icd 10

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

Page 29: Documentation and coding for icd 10

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.

Page 30: Documentation and coding for icd 10

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

Page 31: Documentation and coding for icd 10

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.

Page 32: Documentation and coding for icd 10

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

Page 33: Documentation and coding for icd 10

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.

Page 34: Documentation and coding for icd 10

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.

Page 35: Documentation and coding for icd 10

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)

Page 36: Documentation and coding for icd 10

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

Page 37: Documentation and coding for icd 10

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)

Page 38: Documentation and coding for icd 10

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.

Page 39: Documentation and coding for icd 10

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.

Page 40: Documentation and coding for icd 10

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.

Page 41: Documentation and coding for icd 10

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.

Page 42: Documentation and coding for icd 10

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

Page 43: Documentation and coding for icd 10

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

Page 44: Documentation and coding for icd 10

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.

Page 45: Documentation and coding for icd 10

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.

Page 46: Documentation and coding for icd 10

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.

Page 47: Documentation and coding for icd 10

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.

Page 48: Documentation and coding for icd 10

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

Page 49: Documentation and coding for icd 10

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

Page 50: Documentation and coding for icd 10

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

Page 51: Documentation and coding for icd 10

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

Page 52: Documentation and coding for icd 10

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.

Page 53: Documentation and coding for icd 10

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.

Page 54: Documentation and coding for icd 10

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.

Page 55: Documentation and coding for icd 10

Questions ?