Mastering ICD-10 Coding

(1)

Mastering ICD-10 Coding

For Experienced Coding

Presented by:

Professionals

Presented by:

(2)

C

Obj ti

Course

Objectives

• Review the structure and organization of the ICD‐10 CM book • Examine organizational changes to ICD‐10 • Identify the areas of similarities and differences between ICD‐9‐CM and ICD‐10‐CM • Successfully apply ICD‐10‐CM coding d l b conventions and principles by assigning accurate codes to diagnostic documentation

(3)

ICD

‐

10 ‐

CM OVERVIEW

Introduction

(4)

Official

Guidelines

Developed by the Cooperating Parties: • American Hospital Association (AHA) A i H l h I f i • American Health Information management Association (AHIMA) • Centers for Medicare and Medicaid Services (CMS) (CMS) • National Center for Health Statistics (NCHS)

(5)

2014 U d

2014

Update

0 Additions

9 Deletions

28 Revisions

(6)

ll

di

i h

!

Overall

Coding

Process

is

the

Same!

1. Capture the required encounter documentation documentation 2. Choose the correct code   Alphabetic Index  Tabular List  Read instructional notations

(7)

ICD

‐

10 Changes

Organizational Changes Structural Changes Structural Changes New Features Changes to Guidelines Terminology Updates

(8)

Official

Guidelines

I

• Conventions, General and Chapter

specific Guidelines

II

• Selection of Principal Diagnosis

III

• Reporting Additional Diagnoses

IV

• Guidelines for Outpatient Services

(9)

CONVENTIONS

Section 1

(10)

Al h b i I d

Alphabetic

Index

• Divided into two parts: – Diseases and Injuries • Neoplasm Table • Table of Drugs and Chemicals – External Causes • Formatted like ICD‐9‐CM – Main terms in boldface – Subterms and essential modifiers are

(11)

Alphabetic

Index,

Cont.

• Subterms always read in combination with the main term • Nonessential modifiers appear in parentheses and do not affect the code p number assigned Th d h t th d f i d t

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

• The dash

–

at the end of an index entry indicates that additional characters are

(12)

(13)

(14)

Al h b i I d

C

Alphabetic

Index,

Cont.

• Morphology codes no longer listed in

ICD‐10

• Manifestation codes are suggested in the same manner as ICD‐9‐CM by including same manner as ICD 9 CM, by including the code as a second code in brackets

(15)

Tabular List

Tabular

List

Organizational

Changes

ICD – 9 – CM • 17 Chapters ICD – 10 – CM • 21 Chapters • 17 Chapters • V codes • E codes • 21 Chapters • Z codes • V, W, X and Y codes E codes V, W, X and Y codes

(16)

Code Structure

Code

Structure

Chapters are further subdivided into p subchapters (blocks) that contain three character categories and form the g foundation of the code

(17)

ICD

‐

10 ‐

CM

vs.

ICD

‐

9 Code

Structure

ICD‐10‐CM Code Format ICD‐9‐CM Code Format

Ex: Unspecified asthma with acute exacerbation Ex: Unspecified asthma with acute exacerbation

(18)

C d S

Code

Structure

• Most, but not all, categories are further subdivided into 4 or 5 character subcategories • If a category is not further subdivided it is g y considered to be a valid code

• Fourth character 8 is used to indicateFourth character 8 is used to indicate “other specified”

• Fourth character 9 is used to indicate

(19)

Compare Codes

Compare

Codes

• L03.313 Cellulitis of • 682.2 Cellulitis and chest wall • S42.311K Greenstick f t f h ft f abscess of trunk • 733.82 Nonunion of F t fracture of shaft of humerus, right arm, Subsequent encounter Fracture for fx with nonunion

T45 2X5A Ad • E933.5 Vitamins, not

• T45.2X5A Adverse

effect of vitamins, Initial

,

elsewhere classified, causing adverse effects

(20)

Seventh

Character

• Used in Obstetrics and Injury

Sections

• Meanings vary

g

y

• Either alpha or numeric

• Placeholder X

(21)

Use of Seventh Character

Use

of

Seventh

Character

• Episode of care for injuries and external cause • Chapter 15 (OB) – Represents fetus in multiple gestation affected by coded p g y condition • Coma Scale

(22)

Pl

h ld

Ch

Placeholder

Character

• Provides for future expansion as 5th character for certain 6 character codes without disturbing the 6th _character structure • Assign for all characters less than 6 in

order to meet requirement of coding order to meet requirement of coding when 7th _{character is required}

(23)

Placeholder

Character

Exercise:

• What is the use of the “X” placeholder in

• What is the use of the X placeholder in subcategory O45.8?

• What is the use of the “X” placeholder in

(24)

Abbreviations

and

Punctuation

• No changes from ICD‐9‐CM guidelines

k [ ] NEC NOS Brackets [ ]

Parentheses

( ) Colons Other

(25)

Excludes

Notes

• Two types of exclusion notes:

– ExcludesExcludes 11 – indicatesindicates not coded herenot coded here TheThe code excluded is never used with the code selected

– Excludes 2 – indicates not included here – The excluded condition is not part of the condition represented by the code and it is acceptable to use both codes together if the

(26)

Etiology

and

Manifestations

• No changes from ICD‐9‐CM guidelines

U I di

Code First Additional Use

Code

…In diseases classified elsewhere

A d With See and See

(27)

Code

Also

Note

• Not a new concept, but new in the guidelines • Instructs that two codes may be required to fully describe a condition, q y , but does not provide sequencing direction

(28)

Default

Codes

• Not a new concept, but new in the guidelines guidelines • A code listed next to a main term in the Index Index • Represents the condition most l i t d ith th t t commonly associated with that term, or is the unspecified code for the condition

(29)

Default Codes

Default

Codes

• ICD‐10 Index

(30)

GENERAL CODING GUIDELINES

Section 1

(31)

General

Coding

Guidelines

• Locating a code

Most critical rule involves beginning

the search for the correct code

assignment through the Alphabetic

Index. Never begin searching

initially in the Tabular List as this

(32)

General

Coding

Guidelines

• No change in guidelines from ICD9 – Code to highest level of specificityg p y – Code signs and symptoms in the absence of a definitive diagnosis – Do not code signs and symptoms that are an integral part of a disease process

– Code signs and symptoms that are not an integral part of a disease process

(33)

Combination codes for conditions and

Combination

codes

for

conditions

and

common

symptoms

or

manifestations

E20.21 Type I diabetes mellitus with diabetic nephropathy

I25 110 A h l i h di f i

I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

K50 112 C h ’ di f l i t ti ith

K50.112 Crohn’s disease of large intestine with

(34)

Combination codes for poisonings

Combination

codes

for

poisonings

and

external

causes

T36 0x1A Poisoning by penicillin accidental

T36.0x1A Poisoning by penicillin, accidental (unintentional), initial encounter

T42 4x5A Adverse effect of benzodiazepines

T42.4x5A Adverse effect of benzodiazepines, initial encounter

5th _{di it i} _l _{h ld}

5th _{digit is a place holder}

6th _{digit indicates external cause}

(35)

Sequela

(Late

Effects)

• Residual effect after the acute phase of an illness or injury

• No time limit

• May occur months or years laterMay occur months or years later • Requires two codes

1st _{C di i} _f _l

– 1st _{‐ Condition or nature of sequela}

(36)

Sequela

(Late

Effects)

• Exception – – Sequela is followed by a manifestation code q y identified in the Tabular List – Sequela code has been expanded to included manifestation

– Special chapter specific guidelines for

sequela in Cerebrovascular,

Complications of Pregnancy, and Injury

sections sections

(37)

Sequela

(Late

Effects)

Example: Atrophy of muscle of lower leg as a late effect of poliog p

• M62.561 Muscle wasting and atrophy, not elsewhere classified right lower leg not elsewhere classified, right lower leg

• B91 Sequelae of poliomyelitis

E l d 1 li d (G14)

(38)

Laterality

Right

Left

Bilateral

Right

Left

Bilateral

 If no bilateral code is provided, code both

right and left

 If the side is not indicated in the documentation, code unspecified

(39)

Laterality

H60.332 Swimmer’s ear, left ear

S63 411A S i f l j i f i h

S63.411A Sprain of carpal joint of right

wrist, initial encounter

(40)

CHAPTER SPECIFIC GUIDELINES

Section 2

(41)

CHAPTER 1

Certain Infections and Parasitic Diseases (A00‐B99)

(42)

HIV

• No rule changes • No rule changes – B20 Human immunodeficiency virus [HIV] disease disease – Z21 Asymptomatic human

immunodeficiency virus [HIV] infection immunodeficiency virus [HIV] infection status

– Z11.4Z11.4 Encounter for screening for humanEncounter for screening for human immunodeficiency virus [HIV]

(43)

Infections

Resistant

to

Antibiotics

• Identify all infections documented as

antibiotic resistant

(44)

Sepsis

• Assign appropriate code for the underlying systemic infection • Assign a code for the organism; if type or causal organism is not further specified, g p , assign code A41.9

• Negative or inconclusive blood culturesNegative or inconclusive blood cultures do not preclude a dx of sepsis

(45)

Urosepsis

• Urosepsis has no default code – Provider must be queried

(46)

Severe

Sepsis

• Requires acute organ dysfunction associated with sepsis

• Requires a minimum of 3 codes

– Underlying systemic infectionUnderlying systemic infection

– Code from subcategory R65.2 (severe sepsis)p )

• If organism is not documented assign A41.9

(47)

(48)

MRSA

– B95.62

• Guidelines remain the same

• Be aware of new combination codes that include MRSA

– J15.212 – Pneumonia due to MRSAJ15.212 Pneumonia due to MRSA

– Do not code B95.62 with J15.212

• Assign Z22 322 for a person who is a

• Assign Z22.322 for a person who is a carrier

(49)

C di

S

i

Coding

Scenario

78‐year‐old gentleman is seen for continued follow‐up for C. diff colitis. Cultures of the organism have found this infection to be resistant to Flagyl. A new drug regimen will be started at this time. What is the correct diagnosis code(s)?

(50)

A04 7 Colitis (acute) (catarrhal)

A04.7 Colitis (acute) (catarrhal)

(chronic)(noninfective)

(hemorrhagic), Clostridium difficile

( g ),

Z16.39 Resistance, resistant (to),

organism(s),g ( ) to drug,g antimicrobial

(single), specified NEC

Rationale: ICD‐10‐CM provides a code to identify resistance to antimicrobial drugs (Z16.‐). The

“ dditi l d ” t i f d t th “use additional code” note is found at the beginning of Chapter 1.

(51)

CHAPTER 2

Neoplasms (C00‐D49)

(52)

O

i

d Cl

ifi

i

Organization

and

Classification

• In situ neoplasms now appear before the

block for benign neoplasms block for benign neoplasms

• “Contiguous sites” is now referred to as “ l i it ”

(53)

Chapter

2 Guidelines

• Guidelines in Chapter 2 are consistent with ICD‐9‐CM; sequencing anemia

associated with malignancy is changed form ICD‐10 2013

When admission/encounter is for management of an anemia associated with the malignancy, and the

treatment is only for anemia, the malignancy is

sequenced as the principal diagnosis followed by the sequenced as the principal diagnosis followed by the anemia.

(54)

Ch

2 G id li

C

Chapter

2 – Guidelines,

Cont.

When the admission is for management of an anemia associated with an adverse effect of the administration of chemotherapy and the only treatment is for the

of chemotherapy and the only treatment is for the

anemia, the anemia is sequenced first, followed by the neoplasm, and the adverse effect code T45.1X5

When the admission is for management of an anemia associated with an adverse effect of radiotherapy, the

i d h ld b d fi f ll d b

anemia code should be sequenced first, followed by the neoplasm, and code Y84.2 for abnormal reaction to a radiological procedureg p

(55)

Coding

Scenario

Assign the code(s) for the following

di i S b t ti l k i

diagnosis: Subacute monocytic leukemia in remission

(56)

C93.91 Leukemia, leukemic, monocytic (subacute)

Rationale: Leukemia is not coded from the Neoplasm

Table but rather indexed under the term Leukemia Table, but rather indexed under the term Leukemia.

(57)

Disease of the Blood and Blood forming Organs and Certain Disorders

CHAPTER 3

Disease of the Blood and Blood‐forming Organs and Certain Disorders involving the Immune Mechanism (D50‐D89)

(58)

Organization

and

Classification

• Immunodeficiency disorders have been reclassified from ICD‐9‐CM Chapter 4 (Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders) to ICD‐ 10‐CM Chapter 3 • Diseases and disorders have been grouped into subchapters • Terminology changes and greater specificity

(59)

Chapter

3 ‐

Guidelines

• No chapter‐specific guidelines for Chapter 3p • Important instructional notes throughout the chapter the chapter

(60)

Coding

Scenario

A 48‐year‐old female is seen for sickle‐cell

i i ith t h t d A i

crisis with acute chest syndrome. Assign the correct diagnosis code(s).

(61)

D57.01 Anemia, sickle-cell – See Disease, sickle cell with crisis (vasoocclusive sickle-cell, with crisis (vasoocclusive pain), with acute chest syndrome

Rationale: In some cases, combination codes are used

for sickle-cell crisis with manifestation. Note guideline under category D57 to use additional code for any g y y

(62)

(63)

CHAPTER 4

Endocrine, Nutritional, and Metabolic Diseases (E00‐E89)

(64)

Organization

and

Classification

• Diabetes and malnutrition have their own

subchapters and code titles revised subchapters and code titles revised • Diabetes now has five categories (E08 E13) – (E08 – E13) • Controlled/uncontrolled is not a factor in d l i code selection

(65)

Diabetes

Mellitus

Type of DM

Combination Body system

Combination

codes include Bodyaffected system

Complications

(66)

Diabetes

Mellitus

• Use as many codes as necessary to identify all of the associated conditions • Type 2 DM is default if type is not documented • Z79.4 Long term (current) use of insulin Use only with Type 2 DM as appropriate

– Use only with Type 2 DM as appropriate

(67)

Chapter

4 Guidelines

• Secondary Diabetes Mellitus

– Refer to the instructional notes in the

Tabular List for categories E08, E09, and E13 for sequencing guidelines

(68)

Coding Scenario

Coding

Scenario

62‐year‐old male is seen for mild nonproliferative diabetic retinopathy with p p y macular edema. He has type 2 DM and takes insulin on a daily basis. He also has y diabetic cataract in his right eye. What diagnosis codes are assigned?g g

(69)

E11 321 Diabetes diabetic (mellitus)(sugar) type 2

E11.321 Diabetes, diabetic (mellitus)(sugar), type 2, with, retinopathy, nonproliferative, mild, with macular edema

E11 36 Di b t di b ti ( llit ) ( ) t 2

E11.36 Diabetes, diabetic (mellitus) (sugar), type 2, with, cataract

Z79.4 Long-term (current) (prophylactic) drug therapy (use of), insulin

Rationale: There is a combination code for the type 2 Rationale: There is a combination code for the type 2

diabetes with nonproliferative diabetic retinopathy with macular edema. The diabetic cataract was documented and should be coded but it requires a separate code

and should be coded, but it requires a separate code. Since the patient has type 2 DM, and is on insulin, code

(70)

CHAPTER 5

Mental, Behavioral and Neurodevelopmental Disorders (F01‐F99)

(71)

Organization

and

Classification

• Unique codes for alcohol and drug use, abuse, and dependence, p • Continuous or episodic no longer classified classified • Combination codes Bl d l h l l l (Y90 ) • Blood alcohol level (Y90.‐)

(72)

Pain

Disorders

• F45.41 – Pain exclusively related to h l i l di d psychological disorders • F45.42 – Pain disorders with related psychological factors + code from category G89

(73)

Remission

• Selection of codes for “in remission” for t i F10 F19 i th categories F10‐F19 requires the provider’s clinical judgment. Th i d f “i i i ” – The appropriate codes for “in remission” are assigned on the basis of provider documentation documentation

(74)

The ICD-10-CM classification The ICD 10 CM classification system does not provide

separate "history" codes for separate history codes for

alcohol and drug abuse. These conditions are identified as

conditions are identified as “in remission” in ICD-10-CM.

(75)

Use Abuse Dependence

Use,

Abuse,

Dependence

When the provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use based

D d should be assigned to identify the pattern of use based on the following: Dependence Abuse Abuse Use

(76)

Coding Note: ICD-10-CM

provides a code to indicate provides a code to indicate

blood alcohol level. Under the category F10, there is a "use g y additional code" note for

blood alcohol level. Blood l h l l l b i d d alcohol level can be indexed in the Index to External

Causes Causes.

(77)

Ni

i

D

d

Nicotine

Dependence

ICD 9 CM 305 1 ICD 10 CM F17 ICD9CM = 305.1 • Tobacco Use Disorder ‐ Current smoker ICD10CM = F17

• Terminology change to Nicotine dependence • Type of nicotine (cigarette, chewing tobacco, cigar, pipe, etc.) Additional documentation • Remission/Withdrawal/ Uncomplicated • Use Z87.891 for History of Additional documentation required y nicotine dependence • Use Z72.0 Tobacco Use

(78)

Other Tobacco Use Codes

Other

Tobacco

Use

Codes

• Z87.891 History of Tobacco Use

• Z72 0 Tobacco Use (non dependent)

• Z72.0 Tobacco Use (non‐dependent)

• O99.33‐ Smoking (tobacco)

li i hildbi h d

complicating pregnancy, childbirth, and the puerperium

(79)

E pos re to Tobacco Smoke

Exposure

to

Tobacco

Smoke

• Z77.22 Contact with and exposure to p environmental tobacco smoke

• P96.81P96.81 Exposure to tobacco smoke inExposure to tobacco smoke in perinatal period

• Z57 31 Occupational exposure to

• Z57.31 Occupational exposure to environmental tobacco smoke

(80)

Coding

Scenario

Joe, a 43‐year‐old male, is currently receiving treatment for alcohol dependence. As a result of Joe’s drinking, he is also on medication for chronic gastritis. He also has a history of cocaine dependence. What codes are assigned?

(81)

F10.20 Dependence, (on) (syndrome), alcohol (ethyl) (methyl) (without remission)

K29.20 Gastritis (simple), alcoholic

F14.21 History, personal (of), drug dependence – see Dependence, drug, by type, in

remission. Dependence, (on) p , ( ) (syndrome), drug, cocaine, in remission

(82)

CHAPTER 6

Diseases of the Nervous System (G00 – G99)

(83)

Organization

and

Classification

• Sleep disorders have been moved from signs and symptoms (ICD‐9) to nervous system – Sleep apnea has its own subcategory with greater specificity to identify type • Diseases of the sense organs are no longer contained in the same chapter as

(84)

Eyes

and

Ears

Have

Moved

• Eyes – Chapter 7  H00 – H59 • Ears – Chapter 8  H60 – H95

(85)

Dominant

v.

Non

‐

Dominant

D t D i t/N d i t • Document ‐ Dominant/Non‐dominant in addition to Left or Right • If dominant side is not documented use the following default guidelines:g g – For ambidextrous patients, the default should be dominant. – If the left side is affected, the default is non‐ dominant.

(86)

Pain

– Category

G89

• May be used in conjunction with other codes to provide more detail – Acute or Chronic – Neoplasm‐related – Post procedural , Post‐thoracotomy or Post‐ traumatic • Do not use category G89 if pain is not specified as one of the abovep

(87)

Sequencing

Pain

– Category

G89

• Primary – Pain control/pain management is the /p g reason for encounter – Neurostimulator is inserted for pain • Secondary

– Encounter is for any other reason exceptEncounter is for any other reason except pain control/management

(88)

Terminology

Update

• Epilepsy terminology updated – Localization‐related idiopathic – Generalized idiopathic – Special epileptic syndromes • Provides specificity for

– Seizures of localized onsetSeizures of localized onset

– Complex partial seizures

(89)

Categoryg y G40 (Epilepsy( p p y and Recurrent

(90)

Hemiplegia

and

Hemiparesis

• Category G81 Hemiplegia, G82

Paraplegia and quadriplegia, G83 Other p g q p g , paralytic syndromes

– Use only when listed conditions areUse only when listed conditions are

reported without further specification or are stated to be old or longstanding, with

unspecified cause

(91)

C di

S

i

Coding

Scenario

Assign the code(s) for left‐sided hemiplegia Assign the code(s) for left sided hemiplegia

(92)

G81 94 Hemiplegia Review Tabular for

G81.94 Hemiplegia. Review Tabular for complete code assignment.

R ti l U d th t H i l i i th i d th Rationale: Under the term Hemiplegia in the index, the

only code option for this diagnosis is G81.9-. Review the Tabular under G81.9-, which offers five code

choices. Coding Guideline I.C.6.a states “Should the affected side be documented, but not specified as

dominant or nondominant and the classification system dominant or nondominant and the classification system does not indicate a default, code selection is as follows: If the left side is affected the default is nondominant.”

(93)

CHAPTER 7

Diseases of the Eye and Adnexa (H00 – H59)

(94)

Organization

and

Classification

• Entirely new chapter

• Different organization than ICD‐9g

– Structure still by “site” but order differs

• Title changes to some categories toTitle changes to some categories to reflect current terminology

• Expansion of characters to provide for

• Expansion of characters to provide for anatomic specificity and laterality

(95)

Glaucoma

Eye

T

Eye

St

Type

Stage

(96)

Glaucoma

Guidelines

• Only use bilateral code when type and stage are the same in both eyes

stage are the same in both eyes

• “indeterminate” should be used based on clinical documentation when the state clinical documentation when the state

cannot be clinically determined (do not use for unspecified)

(97)

Coding

Scenario

Patient is seen by the physician for d l l f moderate primary open‐angle glaucoma of the left eye. What is the correct diagnosis d f h ? code for this case?

(98)

H40 11X2 Glaucoma open angle primary

H40.11X2 Glaucoma, open angle, primary. See Tabular for complete code assignment.

Rationale: Review of the tabular at code H40.11

indicates the need for a seventh character to designate g the stage of the glaucoma. Primary open-angle

glaucoma is characterized by visual field abnormalities and intraocular pressure that is too high for the

and intraocular pressure that is too high for the

continued health of the eye. In this case, ICD-10-CM does not have separate codes to identify specific eyes.

(99)

CHAPTER 8

Disease of the Ear and Mastoid Process

(100)

Organization

and

Classification

• New chapter in ICD‐10‐CM • Diseases have been arranged into blocks g for easier identification: – External ear – Middle ear and mastoid – Inner ear – Other disorders of the ear

(101)

Official

Guidelines

Th ffi i l id li • There are no official guidelines at this time except for those i d i h Ch d b contained in the Chapter and sub‐ chapter headings

(102)

Otitis

Media

dd l d f d f d

• Use additional code for any associated perforated tympanic membrane (H72.‐)

• Use additional code to identifyUse additional code to identify

– Exposure to environmental tobacco smoke (Z77.22)

– Exposure to tobacco smoke in the perinatal period (P96.81)

– History of tobacco use (Z87.891)

– Occupational exposure to environmental tobacco smokeOccupational exposure to environmental tobacco smoke (Z57.31)

(103)

Coding

Scenario

A five‐year‐old female is seen for acute ear pain. Examination reveals left acute serous otitis media. Further examination revealed a total perforated tympanic membrane of the right ear due to chronic otitis media. What diagnoses codes are assigned?

(104)

H65 02 Otitis (acute) media (hemorrhagic)

H65.02 Otitis (acute), media (hemorrhagic)

(staphylococcal) (streptococcal) acute, subacute serous – see Otitis, media, nonsuppurative, acute, serous. Otitis media, nonsuppurative, acute or

subacute, serous ,

H66.91 Otitis (acute), media (hemorrhagic) (staphylococcal) (streptococcal), chronic

chronic

H72.821 Perforation, perforated (nontraumatic) (of), tympanum, tympanic (membrane) (persistent post-traumatic)

(105)

Rationale: Otitis media has an expansion of codes in Rationale: Otitis media has an expansion of codes in

ICD-10-CM to classify these conditions. Laterality is

also part of the classification in ICD-10-CM. In category

H65 di ti ti i d b t t i f ti A

H65, distinction is made between recurrent infections. A note is present stating that an additional code for any associated perforated tympanic membrane should be coded separately. It is then possible to show which tympanic membrane is perforated by assigning the correct code for right side associated with the chronic correct code for right side associated with the chronic otitis media. Otitis media refers to inflammation of the middle ear (area between ear drum and inner ear

including the eustachian tube ) Serous otitis involves a including the eustachian tube.) Serous otitis involves a collection of fluid that occurs in the middle ear space

(106)

CHAPTER 9

Diseases of the Circulatory System

(107)

Organization

and

Classification

• Terminology was revised to reflect more current medical practice H t i i l l ifi d • Hypertension is no longer classified as benign, malignant or unspecified

(108)

Hypertension

• More than just I10

• HTN “with” Heart Disease requires q documentation causal relationship

– Heart disease due to hypertensionyp

– Hypertensive heart disease

• HTN with CKDHTN with CKD

– Presumes cause‐and‐effect

• Read guidelines carefully

(109)

Atherosclerotic

CAD

&

Angina

• Use combination code from I25.11‐

• Not necessary to use an additional code y for angina

• Causal relationship can be assumed inCausal relationship can be assumed in

a patient with both Atherosclerotic CAD and Angina

(110)

Sequelae of Cerebrovascular

Sequelae

of

Cerebrovascular

Disease

(CVD)

(Category

I69)

• Sequelae of conditions classifiable to I60 – I67 • May be present at onset or anytime after the onset • Use same guidelines for dominant vs. non‐dominant as Chapter 6 non dominant as Chapter 6 • Use I69 if patient has current CVD with deficits from old CVD

(111)

A

M

di l I f

i

Acute

Myocardial

Infarction

A t MI d h d f 8 k t 4

• Acute MI codes changed from 8 weeks to 4 weeks (28 days) or less

I21 I iti l AMI d d th ti 28 d

– I21‐ Initial AMI – code used the entire 28 day period

– I22‐ Subsequent AMI – code used when aI22 Subsequent AMI code used when a

subsequent AMI occurs during the 28 day period of the Initial AMI

– I23‐ Complications following AMI must be used in conjunction with a code from I21‐ or I22‐

(112)

C

I22

• Category I22 is never used alone

– A code from category I22 must be used inA code from category I22 must be used in conjunction with a code from category I21

• The sequencing of the I22 and I21 codesThe sequencing of the I22 and I21 codes depends on the circumstances of the

encounter encounter

(113)

Coding Note: The I23 code

should be sequenced first, if it is the reason for encounter, or, it

h ld b d ft th I21 should be sequenced after the I21 or I22 code if the complication of the MI occurs during the encounter the MI occurs during the encounter for the MI.

(114)

Coding

Scenario

This 54‐year‐old female had an acute non‐ ST anterior wall myocardial infarction on August 1st_{. On August 15}th _{she suffered an}

acute inferior wall myocardial infarction. She is still being monitored for her

NSTEMI two weeks earlier. She also has atrial fibrillation.

(115)

I22 1 Infarct Infarction myocardium

I22.1 Infarct, Infarction, myocardium, myocardial (acute) (with stated duration of 4 weeks or less),

subsequent (recurrent) (reinfarction), inferior (diaphragmatic) (inferolateral) (inferoposterior) (wall)

(inferoposterior) (wall)

I21.4 Infarct, Infarction, myocardium, myocardial (acute) (with stated

duration of 4 weeks or less) non ST duration of 4 weeks or less), non-ST elevation (NSTEMI)

I48.91 Fibrillation, atrial or auricular (established)

(116)

Rationale: The Official Coding Guidelines specifically g p y

address the sequencing of I22 and I21 and this is stated as: “The sequencing of the I22 and I21 codes depends on the circumstances of the encounter ”

(117)

CHAPTER 10

Diseases of the Respiratory system (J00‐J99)

(118)

Organization

and

Classification

• Organized similarly to ICD‐9‐CM; however, diseases have been rearranged. • Terminology changes – Example: Asthma classified as mild persistent, moderate persistent, and severe persistent • Classification changes that provide greater specificity – Manifestations are reflected in the code

(119)

Chapter

10 ‐

Guidelines

• When assigning any code from this chapter, use an additional code to identify any tobacco dependence, use, or exposure • J10 Influenza contains a note to use an additional code to identify the virus • J44 and J45 distinguish between

(120)

St f A th

Stages of Asthma: Intermittent,

mild persistent, moderate persistent, and

severe persistent asthma. The following table

provides one comparison in children.

Asthma Frequency of Daytime Symptoms Severity

q y y y p

Intermittent Less than or equal to 2 times per week

Mild Persistent More than 2 times per week Moderate

Persistent

Daily. May restrict physical activity Persistent

Severe Persistent

Throughout the day. Frequent severe attacks limiting ability to breathe.

(121)

Coding Note: In the Tabular there is

an Excludes2 note under category J45

for asthma with chronic obstructive pulmonary disease. By definition, when an Excludes2 note appears

when an Excludes2 note appears

under a code, it is acceptable to use both the code and the excluded code t th if th ti t h b th

together if the patient has both conditions at the same time.

(122)

Coding

Scenario

The patient has increasing shortness of breath, weakness, and ineffective cough. Treatment included oxygen therapy and advice for smoking cessation. Diagnoses listed as acute respiratory insufficiency due to acute exacerbation of COPD and tobacco dependence. What diagnosis codes are assigned?

(123)

J44.1 Disease, diseased, pulmonary, chronic obstructive, with exacerbation (acute)

F17.200 Dependence (on) (syndrome), tobacco

F17.200 Dependence (on) (syndrome), tobacco – see dependence, drug, nicotine

Z71.6 Counseling (for), substance abuse, tobacco

tobacco

Rationale: The acute respiratory insufficiency is a

symptom that is an integral part of the COPD and is not coded.

(124)

CHAPTER 11

Diseases of the Digestive System (K00‐K95)

(125)

O

i

d Cl

ifi

i

Organization

and

Classification

• New subchapters have been added

– Example: Diseases of the liverExample: Diseases of the liver

• Terminology changes

Hemorrhage is used for ulcers

– Hemorrhage is used for ulcers

– Bleeding is used for gastritis, duodenitis, diverticulosis and diverticulitis

diverticulosis, and diverticulitis

(126)

O

i

d Cl

ifi

i

Organization

and

Classification

• K50 Crohn’s Disease has been expanded

to 6 characters:

– 4th _{character specifies site}

– 5_{5 character indicates if a complication is}th _{character indicates if a complication is}

present

– 6th _{character further classifies the specific}_p

(127)

Ch

11 G id li

Chapter

11 ‐

Guidelines

• There are no chapter‐specific guidelines at

this time

(128)

C di

S

i

Coding

Scenario

This patient is seen for treatment of a h l h h recurrent right inguinal hernia with gangrene and obstruction. What is the d f h ? correct code assignment for this case?

(129)

K40.41 Hernia, hernial, (acquired) (recurrent), inguinal (direct) (external) (funicular) (i di t) (i t l) ( bli ) ( t l) (indirect) (internal) (oblique) (scrotal) (sliding), unilateral, with, gangrene (and obstruction), recurrent

Rationale: When coding hernias, ICD-10-CM provides

specificity by type laterality with or without obstruction specificity by type, laterality, with or without obstruction and recurrence.

(130)

CHAPTER 12

Diseases of the Skin and Subcutaneous Tissue (L00‐L99)

(131)

O

i

d Cl

ifi

i

Organization

and

Classification

• Complete restructuring

– Brings together groups of diseases that are g g g p related

– Greater specificity has been added

– Title changes to reflect current terminology

Note: Dermatitis and eczema are used

(132)

P

Ul

Pressure

Ulcers

• Pressure ulcer codes are combination codes that identify site, laterality and stage of the ulcer ulcer • Assignment of pressure ulcer stage is guided by clinical documentation of terms found in the

clinical documentation of terms found in the Alphabetic Index

– Terms not found in the index or no documentation, , the provider should be queried

(133)

Pressure

Ulcers,

cont.

• “Unstageable” is NOT “unspecified”

– Based on the clinical documentationBased on the clinical documentation

• No code is assigned if the ulcer is healed

• Healing ulcers are coded based on the

• Healing ulcers are coded based on the stage documented in the medical record

(134)

C di

S

i

Coding

Scenario

This 35‐year‐old male patient presents with edema, redness, and pain of the left big toe. He does not remember any injury, but the pain has gotten progressively worse for the past week. Diagnosis: Gangrenous abscess of the entire left big toe. What diagnosis codes are assigned?

(135)

L02 612 Abscess (connective tissue) L02.612 Abscess (connective tissue)

(embolic) (fistulous) (infective) (metastatic) (multiple)

( ) ( p )

(pernicious) (pyogenic) (septic), toe (any) see also Abscess, foot. Abscess, foot

I96 Gangrene, gangrenous

(connective tissue) (dropsical) (connective tissue) (dropsical) (dry) (moist) (skin) (ulcer) (see

also necrosis). Necrosis, skin or also necrosis). Necrosis, skin or

(136)

Rationale: In ICD-10-CM, there are individual

categories for abscess (L02) and cellulitis (L03) In categories for abscess (L02) and cellulitis (L03). In

ICD-9-CM, these were combined. Note in the Index that abscess of the toe classifies to abscess of the foot,

hil b f th t il l ifi t ll liti t

while abscess of the toe nail, classifies to cellulitis, toe. There are no “includes” or “excludes” notes that

preclude the use of the abscess and gangrene code together, nor is there any sequencing guideline

(137)

(138)

Diseases of the Musculoskeletal System and Connective Tissue

CHAPTER 13

Diseases of the Musculoskeletal System and Connective Tissue (M00‐M99)

(139)

O

i

d Cl

ifi

i

Organization

and

Classification

• Almost every code in Chapter 13 of ICD‐10‐CM has been expandedp – Greater specificity of sites – Laterality • Many codes moved from various chapter in ICD‐9‐CM to Chapter 13 in ICD‐10‐CM – Gout moved from Endocrine – Osteomalacia moved from Endocrine

(140)

Organization

and

Classification

• Recurrent and conditions related to a

healed injuryj y are usually found in y Chapter 13

• Current acute new injuriesCurrent, acute, new injuries are found inare found in Chapter 19

• Osteoporosis with the site of a current

• Osteoporosis with the site of a current pathological fracture is now one code

(141)

Coding Note:

ICD 10 CM has three different ICD-10-CM has three different categories for pathologic

fractures due to neoplastic fractures – due to neoplastic disease, due to osteoporosis, and due to other specified

and due to other specified disease.

(142)

Sub

‐

Categories Organized by

Sub

‐

Organized

by

Site

and

Laterality

• Bone • Joint • Right • Left • Muscle • Multiple • Bilateral • If no “bilateral” code • If no “multiple” code exists, assign a code exists, assign a code for each side for each site

(143)

Pathological or Stress Fracture Seventh Characters • Initial encounter • Initial encounter

A

Characters • Subsequent – routine healing • Subsequent – routine healing

D

• Subsequent – delayed healing • Subsequent – delayed healing

G

• Subsequent – delayed healing• Subsequent – delayed healing

G

• Subsequent – nonunion • Subsequent – nonunion

K

• Subsequent – malunion • Subsequent – malunion

P

(144)

Definitions

• Spontaneous rupture – Occurs when normal force is applied to tissues that are inferred to have less than normal strength • Fragility fracture – Sustained with trauma no more than a fall from a standing height or less occurring under circumstances that would not cause a fracture in a normal healthy bone

(145)

Coding Tip: The

interpretation of Coding Guideline

I.C.13.d.2 must be made by the

physician. It is not appropriate for

the coder to interpret if the patient

had a minor fall or trauma that

would not usuallyy break a normal,,

healthy bone. The physician

provides a connection between the

fall and fracture due to

(146)

D fi i i

Definitions

• Direct Infection of joint, where

organisms invade synovial tissue and microbial antigen is present in the joint

• Indirect Infection, which may be a , y

reactive arthropathy where microbial infection is established but cannot be

identified in the joint, and a postinfective arthropathyp y

(147)

Instructional

Notes

• Instructional notes added to explain how codes should be assigned or to define terms

(148)

C di

S

i

Coding

Scenario

Julia is an 80‐year‐old female seen for the first time by Dr. Welby with senile osteoporosis. She complains of severe back pain with no history of trauma. X‐rays revealed pathological compression fractures of several lumbar vertebrae.

(149)

M80 08XA Fracture pathological (pathologic)

M80.08XA Fracture, pathological (pathologic), due to osteoporosis, specified cause NEC – see Osteoporosis, specified t NEC ith th l i l f t

type NEC, with pathological fracture. Osteoporosis (female) (male), senile – see Osteoporosis, age-related, with current pathologic fracture, vertebra(e) Rationale: In ICD-10-CM a combination code is

Rationale: In ICD 10 CM, a combination code is

utilized to report osteoporosis with an associated pathological fracture. When identifying senile

osteoporosis the code book directs the coder to age osteoporosis, the code book directs the coder to age-related osteoporosis.

(150)

CHAPTER 14

Diseases of the Genitourinary System (N00‐N99)

(151)

Organization

and

Classification

• Changes made due to outdated terminology – Male erectile dysfunction requires identification of cause N52‐ vs. 607.84 • Post‐traumatic urethral stricture now requires gender identificationq g

(152)

Chapter

14 ‐

Guidelines

• No changes in CKD guidelines from ICD‐9 to ICD‐10 • Instructions added to menopausal and other perimenopausal disorders to clarify p p y “due to naturally occurring (age‐related) menopause and perimenopause” are p p p classified to category N95

(153)

Additional Codes Required • Code also underlying condition

N17

18

• Code first etiology

N18

• Additional code infectious agent

N30

g

N30

• Additional code urinary incontinence

N31

• Code first underlying disease

N33

(154)

C di

S

i

Coding

Scenario

A 78‐year‐old female is seen with fever, malaise, and left flank pain. A urinalysis shows bacteria of more than 100,000/ml present in the urine and subsequent urine culture shows Proteus growth as the cause of the UTI. The patient also has a history of repeated UTIs over the past several years.