Introduction to ICD 10 CM Documentation for Physicians

Introduction to

ICD 10 CM Documentation for

Physicians

Objectives

• Understand the differences and similarities in the code books and code structures of ICD 9 CM and ICD 10 CM • Understand the basic differences in some of the rules and

guidelines

• Understand why there are so many more codes and the documentation this necessitates

ICD 10 CM Coding &

• Code Book Structure is slightly different • Code Structure is slightly different

• Many rules and guidelines same or only slightly change

and coding will carry on just as before

• Many more codes

• Remember that coding facilitates reimbursement as well as enable tracking of services

• So accuracy is important

Book Structure

ICD 9 CM- 17 Chapters

ICD 10 CM vs ICD 9 CM

ICD-10-CM - 21 Chapters

1 Certain infectious & parasitic (A00-B99) 2 Neoplasms (C00-D49)

3 Diseases of blood/blood-forming organs & certain disorders - immune mechanism (D50-D89) 4 Endocrine, nutritional and metabolic diseases (E00-E89)

5 Mental and behavioral disorders (F01-F99) 6 Diseases of the nervous system (G00-G99) 7 Diseases of the eye and adnexa (H00-H59)

8 Diseases of the ear and mastoid process (H60-H95)

9 Diseases of the circulatory system (I00-I99) 10 Diseases of the respiratory system (J00-J99) 11 Diseases of the digestive system (K00-K94) 12 Diseases of the skin and subcutaneous tissue 1. Infectious and Parasitic Diseases

2. Neoplasms

3. Endocrine, Nutritional, & Metabolic Diseases and Immunity Disorders

4. Diseases -Blood/Blood-Forming Organs 5. Mental Disorders

6. Diseases- Nervous System & Sense

Organs

7. Diseases of the Circulatory System 8. Diseases -Respiratory Sys.

9. Diseases - Digestive Sys. 10. Diseases Genitourinary Sys

11. Complications of Pregnancy, Childbirth & Puerpeum

Book Structure

ICD 9 CM- 17 Chapters

ICD 10 CM vs ICD 9 CM

ICD-10-CM - 21 Chapters

13 Diseases of the musculoskeletal system and connective tissue (M00-M99)

14 Diseases of the genitourinary system (N00-N99) 15 Pregnancy, childbirth and the puerperium (O00-O99)

16 Certain conditions originating in the perinatal period (P00-P96)

17 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)

18 Symptoms, signs & abnormal clinical & lab findings, not elsewhere classified (R00-R99) 19 Injury, poisoning and certain other

consequences of external causes (S00-T88) 20 External causes of morbidity (V00-Y99)

21 Factors influencing health status and contact with health services (Z00-Z99)

13. Diseases –Musculoskeletal System & Connective Tissue

14. Congenital Anomalies

15. Certain Conditions Originating in the Perinatal Period

16. Symptoms, Signs, & Ill- Defined Conditions

17. Injury and Poisoning Supplemental Chapters

• Factors influencing health status & contact with healthcare

Book Structure - Conventions

ICD 10 CM vs ICD 9 CM

• Same

• _{‘And’ still means ‘and/or’}

• ‘see’ or ‘see also’ still used as a cross-reference device

• _{Still have ‘other specified’, ‘NEC - not otherwise specified’ and}

‘NOS - not elsewhere classified’

• _{Different - Excludes 1 and Excludes 2}

• Excludes1: “Pure” excludes: the meaning is “not coded here”

• Mutually exclusive codes

Book Structure - Conventions

ICD 10 CM vs ICD 9 CM

• Same

• _{‘And’ still means ‘and/or’}

• ‘see’ or ‘see also’ still used as a cross-reference device

• _{Still have ‘other specified’, ‘NEC - not otherwise specified’ and}

‘NOS - not elsewhere classified’

• _{Different - Excludes 1 and Excludes 2}

• Excludes1: “Pure” excludes: the meaning is “not coded here”

• Mutually exclusive codes

• Two conditions may not be reported together

• Example: M21 Other acquired deformities

of limbs

• Excludes1:

• acquired absence of limb (Z89.-)

Book Structure - Conventions

ICD 10 CM vs ICD 9 CM

• Different - Excludes 1 and Excludes 2

• Excludes2: means “not included here”

• excluded condition not part of the condition it is excluded from, patient may have both conditions at same time

• may be acceptable to use both code & excluded code together

if supported by documentation

Example: L89 Pressure ulcer

• Excludes2: diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622)

• E08 - Diabetes mellitus due to underlying condition

• E09 - Drug or chemical induced diabetes mellitus

•

Difference in Structure & Book

ICD 10 CM vs ICD 9 CM

ICD 9 CM 3-5 characters

 First character is numeric or alpha (E or V)

ICD 10 CM 3-7 characters

 First character is alpha using all letters except U

1st _{character is a capital letter}

– Each letter is associated with a particular chapter

– Chapter 1 (A00-B99) Certain infectious and parasitic diseases

– Chapter 2 (C00-D49) Neoplasms

– Chapter 3 (D50-D89) Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

– Chapter 4 (E00-E89) Endocrine, nutritional and metabolic diseases

– Chapter 5 (F01-F99) Mental, Behavioral & Neurodevelopmental disorders

– Chapter 6 (G00-G99) Diseases of the nervous system – Chapter 7 (H00-H59) Diseases of the eye and adnexa – Chapter 8 (H60-H95) Diseases of the ear and mastoid

process

1st _{character is a capital letter}

– Each letter is associated with a particular chapter

– Chapter 1 (A00-B99) Certain infectious and parasitic diseases

– Chapter 2 (C00-D49) Neoplasms

– Chapter 3 (D50-D89) Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

– Chapter 4 (E00-E89) Endocrine, nutritional and metabolic diseases

– Chapter 5 (F01-F99) Mental, Behavioral & Neurodevelopmental disorders

– Chapter 6 (G00-G99) Diseases of the nervous system – Chapter 7 (H00-H59) Diseases of the eye and adnexa – Chapter 8 (H60-H95) Diseases of the ear and mastoid

process

– Chapter 9 (I00-I99) Diseases of the circulatory system

Code Structure

Example: Cellulites of chest wall

ICD-9-CM ICD-10-CM

682.2 L03.313

• Codes may be 4, 5, 6, or 7 characters in length • Final character may be a letter or a number

• The letters “O” & “I” are used; do not confuse with “0” & “1” • 7th _{Character - Extensions}

– A = initial encounter

– D = subsequent encounter – S = sequela (late effect)

7

characters

• A Initial encounter for closed fracture • B Initial encounter for open fracture

• D Subsequent encounter for fracture with routine healing • G Subsequent encounter for fracture with delayed healing • K Subsequent encounter for fracture with nonunion

• P Subsequent encounter for fracture with malunion • S Sequela

• M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture

• S52.132B, Displaced fracture of neck of left radius, initial encounter for open fracture

7

characters

• A Initial encounter for closed fracture • B Initial encounter for open fracture

• D Subsequent encounter for fracture with routine healing • G Subsequent encounter for fracture with delayed healing • K Subsequent encounter for fracture with nonunion

• P Subsequent encounter for fracture with malunion • S Sequela

• M80.051A, Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture

• S52.132B, Displaced fracture of neck of left radius, initial encounter for open fracture

ICD 10 CM vs ICD 9 CM

O31 – Complications specific to multiple

gestations

0 - not applicable or unspecified

1 - fetus 1

2 - fetus 2

3 - fetus 3

4 - fetus 4

5 - fetus 5

9 - other fetus

Code Structure Example: Fracture of the Patella

A patient is treated for fracture of the patella

ICD 10 CM vs ICD 9 CM

ICD-9-CM

 822.0 - Fracture of patella, closed

ICD-10-CM; to assign an accurate code, sixth and seventh

characters are needed in ICD-10-CM

 S82.021D - Fracture of patella,

displaced longitudinal, right patella -subsequent encounter for closed fracture with routine healing

Code Structure

Dummy placeholder “x” used

• Used in the 5th character position for some 6 or 7

character codes –“Holds”the position for future

expansion without disrupting the 6 digit code

structure

• A “filler”digit with no coding related meaning

associated with it

Dummy placeholder “x” used

• Examples:

• Crushing injury of larynx and trachea. initial

encounter

ICD 10 CM vs ICD 9 CM

•

Why so many codes?

ICD 10 CM vs ICD 9 CM

•

More details and specificity in diagnosis

•

_{Anatomical details}

•

Combination codes with common

comorbidities

•

Laterality

• Extensions for episode of care

14,025

Diagnosis Codes ICD-10-CM

• Why so many codes? more details and

specificity in diagnosis

Signs & Symptoms

R10 Abdominal and pelvic pain – R10.0 Acute abdomen

– R10.1 Pain localized to upper abdomen – R10.2 Pain and perineal pain

– R10.3 Pain localized to other parts of lower abdomen – R10.8 Other abdominal pain

• R10.81 Abdominal tenderness

• Why so many codes? more details and

specificity in diagnosis

Signs & Symptoms

R10 Abdominal and pelvic pain – R10.0 Acute abdomen

– R10.1 Pain localized to upper abdomen – R10.2 Pain and perineal pain

– R10.3 Pain localized to other parts of lower abdomen – R10.8 Other abdominal pain

• R10.81 Abdominal tenderness

• R10.82 Rebound abdominal tenderness

ICD 10 CM Documentation

R10.81 Abdominal tenderness Abdominal tenderness NOS • R10.811 Right upper quadrant abdominal tenderness • R10.812 Left upper quadrant abdominal tenderness • R10.813 Right lower quadrant abdominal tenderness • R10.814 Left lower quadrant abdominal tenderness • R10.815 Periumbilic abdominal tenderness

• R10.816 Epigastric abdominal tenderness • R10.817 Generalized abdominal tenderness • R10.819 Abdominal tenderness, unspecified site

Why so many codes? Details of Anatomy

– S31.623A, Laceration with foreign body of abdominal

wall, right lower quadrant with penetration into

peritoneal cavity, initial encounter

– Q20 Congenital malformations of cardiac chambers and connections

• Q20.0 Common arterial trunk

• Q20.1 Double outlet right ventricle • Q20.2 Double outlet left ventricle

• Q20.3 Discordant ventriculoarterial connection

Why so many codes? Combination Codes with

common comorbidities

ICD 10 CM Documentation

ICD 9 CM

Why so many codes? Combination Codes with

common comorbidities

ICD 10 CM Documentation

ICD 9 CM

UTI-

N30.00 Acute cystitis without hematuria N30.01Acute cystitis with hematuria

N30.10 Interstitial cystitis (chronic) without hematuria

N30.11 Interstitial cystitis (chronic) with hematuria

N30.20 Other chronic cystitis without hematuria

N30.21 Other chronic cystitis with hematuria

ICD 10 CM

N30.40 Irradiation cystitis without hematuria

N30.41 Irradiation cystitis with hematuria

N30.80 Other cystitis without hematuria

N30.81 Other cystitis with hematuria N30.90Cystitis , unspecified without hematuria

Why so many codes? Combination Codes with

common comorbidities

Headaches and Migrane Coding

Why so many codes? Combination Codes with

common comorbidities

ICD 10 CM Documentation

Migraine Documentation

ICD 9 CM – 10 Categories

ICD 10 CM - 14 Categories

Why so many codes? Combination Codes with

common comorbidities

ICD 10 CM Documentation

 G43.0 Migraine without aura  G43.1 Migraine with aura  G43.4 Hemiplegic migraine

 G43.5 Persistent migraine aura without cerebral infarction  G43.6 Persistent migraine aura with cerebral infarction  G43.7 Chronic migraine without aura

 G43.A Cyclical vomiting

 G43.B Ophthalmoplegic migraine

 G43.C Periodic headache syndromes in child or adult

 G43.D Abdominal migraine

Why so many codes? Combination Codes with

common comorbidities - Migrane Coding

• How long has it existed

• When was start of most recent on-set • Is it unilateral or bilateral

• Unilateral location or bilateral

• Quality (throbbing or “pulsating’’) • Worsening pain with normal activity • Intensity (moderate to severe)

• Other signs and symptoms (Nausea and/or vomiting

Why so many codes? Laterality

• Added laterality (indicate right side versus left side. Also codes available for unspecified “sides)

Example:

• C50.212, Malignant neoplasm of upper-inner quadrant of left female breast

• H02.835, Dermatochalasis of left lower eyelid

• I80.01, Phlebitis and thrombophlebitis of superficial vessels of right lower extremity

• Rule for bilateral sites

• No bilateral code provided (condition is bilateral), assign separate codes for both left & right side (unless specific guideline state otherwise)

• Why so many codes?

Extensions for episode of care

• Why so many codes?

Extensions for episode of care

ICD 10 CM vs ICD 9 CM

Example: Greenstick fracture of shaft of humerus, right arm

Why so many codes? Laterality and Episode of Care

• Most codes have site and laterality designations

• Site presents either the •bone •joint •or other muscle involved • Seventh character extensions are:

Why so many codes? Laterality and Episode of Care

• Most codes have site and laterality designations

• Site presents either the •bone •joint •or other muscle involved • Seventh character extensions are:

Why so many codes? Laterality and Episode of Care

• Most codes have site and laterality designations

• Site presents either the •bone •joint •or other muscle involved • Seventh character extensions are:

ICD 10 CM vs ICD 9 CM

Details of Laterality

• Musculoskeletal/Orthopedic

– Laterality, specific bone and specific bone portion

S82.12 Fracture of lateral condyle of tibia

S82.121 Displaced fracture of lateral condyle of right tibia S82.122 Displaced fracture of lateral condyle of left tibia

S82.123 Displaced fracture of lateral condyle of unspecified tibia S82.124 Nondisplaced fracture of lateral condyle of right tibia S82.125 Nondisplaced fracture of lateral condyle of left tibia

S82.126 Nondisplaced fracture of lateral condyle of unspecified tibia

S82.13 Fracture of medial condyle of tibia

S82.131 Displaced fracture of medial condyle of right tibia S82.132 Displaced fracture of medial condyle of left tibia

Many rules-guidelines same or only slightly changed

• Causal Organisms still need to be coded – Can be combination code or additional

• New guideline –use additional code to identify conditions

such as: alcohol abuse/dependence, alcohol dependence in remission, tobacco dependence, history of tobacco use

• Tobacco Coding Required

– Also: use an additional code, where applicable to identify: – Z77.22 exposure to environmental tobacco smoke

– P96.81, exposure to tobacco smoke in the perinatal period – Z87.891, history of tobacco use

– Z57.31 occupational exposure to environmental tobacco smoke – F17.-, tobacco dependence

– Z72.0 tobacco use

Many rules and guidelines same or only slightly

changed

• Pregnancy codes by Trimester NOT episode of care

• based on documentation of trimester (or number of weeks)

for the current admission/encounter.

– Code when complication developed, not the trimester of discharge. – If the condition developed prior to current admission/encounter or

represents a pre-existing condition, the trimester character is “the

time of the admission/encounter”

– “unspecified trimester” code - rarely be used,

– Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being

Many rules and guidelines same or only slightly

changed - Pregnancy

• Assignment based on documentation of trimester (or

number of weeks) for the current admission/encounter.

– Code when complication developed, not the trimester of discharge. – If the condition developed prior to current admission/encounter or

represents a pre-existing condition, the trimester character is “the

time of the admission/encounter”

– “unspecified trimester” code - rarely be used,

– Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned

Many rules and guidelines same or only slightly

changed

• Diabetes - No longer single category (250) with 59 codes as in ICD-9-CM,

• ICD-10-CM More than 200 codes with five categories

expanded to reflect manifestations and/or complication of the disease by using fourth or fifth characters rather than by using an additional code to identify the manifestation

– E08 Diabetes mellitus due to underlying condition – E09 Drug or chemical induced diabetes mellitus – E10 Type 1 diabetes mellitus

– E11 Type 2 diabetes mellitus

Many rules and guidelines same or only slightly

changed

• Diabetes no longer by controlled or uncontrolled

• By Type and manifestations or underlying conditions

– Drug or chemical induced diabetes mellitus – Diabetes mellitus Type 1 or Type 2

– Type 1 Juvenile) – Type 2 (Adult onset)

– Other specified diabetes mellitus

– Post procedural diabetes mellitus due to – genetic defects of beta cell function

– Secondary diabetes mellitus

Many rules and guidelines

same or only slightly

changed

• Must document Relationship

• Must document Severity

• If type not specified will default to type 2

– Assign as many codes from

categories E08 – E13 as needed to identify all of the associated

Many rules and guidelines same or only slightly

changed

Same as ICD 9 CM Chapter 6 Diseases of Nervous System G00 – G99

• Many codes need documentation of dominant or non-dominant

• G89 Pain not elsewhere classified

– Acute? Chronic? Due to trauma? Post Surgical? Due to Neoplasm?

Many rules and guidelines same or only slightly

changed

Poisoning & Adverse Effect - Same as ICD 9 CM – Addition of “Underdosing”

• Failure in dosage during medical and surgical care (Y63.61, Y63.8-Y63.9) • Patient's underdosing of medication regime (Z91.12-, Z91.13-)

Poisoning Overdose of substances

Wrong substance given or taken in error

Adverse effect “Hypersensitivity,” “reaction,” or correct substance properly administered

Underdosing Taking less of medication than is prescribed or instructed

Many rules and guidelines same or only slightly

changed

• Chapter 20 External Causes of Morbidity V00 – Y99

– Same guidelines as ICD 9 CM

• Chapter 21 Factors Influencing health status Z00 – Z99

– Same guidelines as ICD 9 CM

What can you do now?

• Perform Clinical Documentation Assessments.

– This can involve evaluating samples of various types of medical records to determine whether the documentation supports the level of detail found in ICD-10-CM.

• Documentation improvement strategies can be implemented to address areas where documentation is found to be lacking.

• Designate a physician/provider champion to assist in clinical documentation education and promote the positive aspects of moving to ICD-10-CM

• Chat with your coding staff and they will help you understand what is needed to code accurately, timely and complete

Let’s try some documenting

for ICD 10 CM

Example 1 Admitting Diagnosis; Fracture, arm • Patient Name: Som Body

• Medical Record Number: 235-256-235 • Admission Date: 21st _{April, 2015}

• Discharge Date: 22nd _{April, 2015}

• Age: 18 year old male

• Admitting Diagnosis; Fracture, arm

Example 1 Admitting Diagnosis; Fracture, arm • Traumatic or pathologic? (Traumatic)

• What specific bone? (Ulna)

• What specific part of bone? (Styloid)

• Was it displaced or nondisplaced? (Displace) • Laterality? (right)

• Open or Closed? (Open)

• Initial or Subsequent Encounter (Subsequent)

• Fracture Gustillo type and was it routine or delayed healing? (Type IIIA, routine healing)

• Also the patient was Obese, did this have affect?

Example 1 Admitting Diagnosis; Fracture, arm • Traumatic or pathologic? (Traumatic)

• What specific bone? (Ulna)

• What specific part of bone? (Styloid)

• Was it displaced or nondisplaced? (Displace) • Laterality? (right)

• Open or Closed? (Open)

• Initial or Subsequent Encounter (Subsequent)

• Fracture Gustillo type and was it routine or delayed healing? (Type IIIA, routine healing)

ICD 10 CM Documentation

• S52.251F Displaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for open fracture type IIIA, IIIB or IIIC with routine healting

Example 2 Admitting Diagnosis; Cough, History of COPD • Patient Name: Anon Ymous

• Medical Record Number: 235-256-235 • Admission Date: 21st _{April, 2015}

• Discharge Date: 22nd _{April, 2015}

• Age: 42 Obese Female •

• Admitting Diagnosis; Cough, History of COPD

Example 2 Admitting Diagnosis; Cough, History of COPD

•COPD? (not just ‘history’

•Acute on chronic - exacerbation?

•With or without Emphysema? Which lobe?

•Is there Asthma?

–Specificity of asthma (persistent, status asmaticus etc)

•Morbid obesity ? What is the BMI?

•Is there diabetes?

•Chronic respiratory failure? Possible COPD/Emphysema

•Is there Hypertension and/or CKD?

–Hypertensive renal failure/ with CHF/ with CKD stage?

Thank you

Questions?