THE BASICS OF ICD-10-CM CODING

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THE BASICS OF ICD-10-CM

CODING

Continuing Education for Long-Term Care Facilities

June 9, 2015

Marla Dumm, CPC, CCS-P

Managing Consultant mdumm@bkd.com

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Objectives

• Distinguish between ICD-9 & ICD-10 code

structure

• Identify necessity to review clinical

documentation & translate information into diagnosis code

• Describe best practices related to accurate &

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Current Status – DEADLINE

• Final Rule CMS-0043-F – https://www.federalregister.gov/articles/2 014/08/04/2014-18347/change-to- thecompliance-date-for-the-international-classification-of-diseases-10th-revision • Issued on July 31, 2014

• Finalized new deadline of

October 1, 2015

• No new code updates until

October 1, 2016

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Resource documents – ICD-9-CM

ICD-9-CM Official Guidelines for Coding &

Reporting

• Effective October 1, 2011

• Last major update

http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2 011.pdf

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Resource Documents – ICD-10-CM

ICD-10-CM Official Guidelines for Coding &

Reporting (2015 Version)

Effective with dates of service October 1, 2015

http://www.cms.gov/Medicare/Coding/ICD10/Downloads /icd10cm-guidelines-2015.pdf

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Official Coding Guidelines

• Minimal changes

• General guidelines for assignment of codes,

order of codes, punctuation, abbreviations, etc., will be very similar

• Some structural differences & modifications to

code classifications or code descriptions due to expanded code detail

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Standard Coding Process

• Be familiar with ICD-10-CM Official Coding

Guidelines & Conventions

–Section I-III

• Review clinical documentation (physician or

non-physician practitioner)

–Nursing facility admission H&P, nursing facility discharge summary, acute hospital discharge, progress notes, consultation reports, diagnostic test reports, etc.

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Standard Coding Process

• Identify main term(s)

• Look up main term(s) in Alphabetic Index

• Look through subterms if applicable

• Review all additional lines & subterms that

may continue to next column

• Refer to all parenthetical terms

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Standard Coding Process

• Grey shaded vertical lines – provide guidance

for indented subterms & additional subterms

• Review all instructional notes & references

–“see,” “see also,” “see category” –“with” or “without”

–“omit code” –“due to”

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Standard Coding Process

Reminder – Do not code from the index

Locate & confirm code(s) in Tabular List

• Read & follow instructions

–“Includes” & “Excludes” notes –“Use additional code”

–“Code first underlying disease” –“Code also”

–Character requirements (4th, 5th, 6th& 7th extensions)

–Age or gender

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Standard Coding Process

• Refer to Official Guidelines to verify rule(s)

• Confirm & assign code(s) to highest level of

specificity (number of characters) supported in documentation

• List on claim form in priority (or sequence) per

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Standard Coding Process

Example

Acute Upper Respiratory Infection

• Infection • Respiratory • Upper • Acute • Code – J06.9 14

Index – Volume 2

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Index – Volume 2

• Alphabetic order

–Can search by condition, disease, sign, symptom, etc

–Anatomical site will refer you to “see condition”

• Index to Diseases & Injury

• Neoplasm Table

• Table of Drugs & Chemicals

• Index to External Causes of Injury

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Index –

What’s not in ICD-10?

Hypertension Table... Malignant... Benign... Unspecified Hypertension, hypertensive (arterial) (arteriolar) (crisis)

(degeneration) (disease) (essential) (fluctuating) (idiopathic) (intermittent) (labile) (low renin) (orthostatic) (paroxysmal) (primary) (systemic)

(uncontrolled) (vascular)... 401.0... 401.1... 401.9 with chronic kidney disease

stage I through stage IV, or unspecified ... 403.00... 403.10... 403.90 stage V or end stage renal disease ... 403.01... 403.11... 403.91 heart involvement (conditions classifiable

to 429.0-429.3, 429.8, 429.9 due to hypertension)

(see also Hypertension, heart)... 402.00... 402.10... 402.90 with kidney involvement see Hypertension,

cardio renal

• This table has been removed. Look for

“Hypertension, hypertensive” in table for code selection

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Main Terms

• Identify disease or condition of site (for

injuries)

Main terms are listed in bold type & start with

an uppercase letter

Examples of main term headings – Complications

– Late Effect(s) or Sequelae (new for ICD-10)

– Fracture – Pneumonia

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Main Terms

• Follow cross references like “see also” & “see”

• Modifiers & Subterms are located under Main

Term

• An indented structure is used

–See shaded lines in index which line up indented terms

• Notes

–Define terms

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Non-Essential Modifiers

• Words that follow main term

• Are always in parenthesis

• Provide additional information for main term

• The presence or absence of these modifiers

has no effect on selection of the code for term

Example

Pneumonia (acute)(double)(migratory)(purulent)(septic) (unresolved)

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Essential Modifiers

• Subterms that modify main term

–Are listed below main term in alphabetical order (exception of “with” & “without”)

• Indented two additional spaces to the right

• Regular type & starts with a lowercase letter

Example

Pneumonia ‒ With

Influenza – see Influenza, with, pneumonia • Lung abscess

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Eponyms & Synonyms

• Eponyms

–Diseases or syndromes named for a person (i.e., who discovered the illness)

–Listed as a main term under both name of person & disease or syndrome

Example

• Guillain-Barre’ Syndrome (look up Guillain or Syndrome)

• Synonyms

–Escherichia coli (E. coli)

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Abbreviations

NEC – Not Elsewhere Classified

• Used when

Coder has specific documented information, but there is no separate or specific code available to represent condition documented in medical record

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Abbreviations

NOS – Not Otherwise Specified

• Used when

Coder lacks or does not have specific documented information

–Equivalent to “unspecified”

• NOS codes should never be used routinely as a

means to avoid having to search for a more specific term

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Cross-Reference Terms

See (Condition, Category) – Mandatory

instruction that the coder must look

elsewhere for an alternative term. Coding cannot be completed without following this instruction

See also – Coder must review another main

term if information documented in record is not reflected under main term

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Cross-Reference Terms

Examples

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Neoplasm Table

• Search by anatomical site where neoplasm is

located

• Columns will detail Primary, Secondary

(metastasis) or Ca in Situ malignancy

• Additional columns will detail benign

neoplasms, those with uncertain behavior & unspecified

Information must be documented in medical

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Table of Drugs & Chemicals

• Used to define code by the toxic effect (i.e.,

poisoning) from a specific drug, medication or solution

• Search by name of drug or medication

–Brand name –Generic name

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Table of Drugs & Chemicals

• Columns

–Poisoning, Accidental (Unintentional) –Poisoning, Intentional Self-Harm –Poisoning, Assault

–Poisoning, Undetermined –Adverse Effect

–Under-Dosing (New Category)

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Restructuring the Index

• Injuries are grouped by anatomical site rather

than by type of injury

• Certain diseases & disorders have been

reclassified

Example: Gout is now in Musculoskeletal instead of Endocrine

• Categories restructured

• Codes have been reorganized to appropriate

chapter

• Familiar codes will appear in different

chapters or sections to reflect current medical knowledge

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Tabular List

• Numerical listing of codes

21 chapters

• Classification of factors influencing health

status & contact with health services – Codes

beginning with V, W, X or Y

• Classification of external causes of injury &

poisoning

– Codes beginning with Z

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New Chapters

• Sensory signs, symptoms &/or conditions

− Chapter 7 - Eyes − Chapter 8 - Ears Example

– H66.001 – Acute suppurative otitis media without spontaneous rupture of ear drum, right ear

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Code Format – What to Expect

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ICD-10-CM structure

• Up to seven digits

• First digit = always alpha, except “U” • Second digit = always numeric

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Structure Comparison

ICD-9-CM 813.06 Closed Fracture of Neck/Radius ICD-10-CM S52.131A Displaced fracture of neck/right radius, initial encounter for treatment of

closed fracture

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Tabular List

Numerical listing of codes divided into 21

chapters

• Code structure

3rdcharacters – main code/category. May be

primary code if no further specificity is required –4thcharacter – After decimal point. Defines site,

etiology & manifestation

5th& 6th characters – further specificity

7thcharacter – Required if instructed in Tabular

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Characters Add Specificity

• Additional characters are added to “main

category” (three character code depending on

code instructions)

Example

– S52 Main category for “Fracture of Forearm” – S52.5 Subcategory code for unspecified

“Fracture of the lower (or distal) end of radius”

– S52.52 Sub classification code for “Torus fracture

of lower (or distal) end of radius

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Characters Add Specificity

Example

–S52.521 Sub classification code for “Torus fracture of lower (or distal) end of right

radius”

–S52.521A Adding the required 7thcharacter “A”

specifies the type of encounter or stage of healing - “Torus fracture of lower end of right radius, initial encounter for closed fracture

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New Features – Placeholders

• Character “x” is used as a placeholder

• Allows for future expansion

• Fills empty characters for codes that require

the full seven characters

–T15.02XD – Foreign body in cornea, left eye, subsequent encounter

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New Features – 7

th

Character

• Will always be listed in the seventh position

• Adds additional information to describe the

encounter

–A = Initial encounter

–D = Subsequent encounter

• Must be used when instructed in Tabular

listing

–S50.02XDContusion of left elbow, subsequent encounter

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New Features – 7

th

Character

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7

th

Character – Type of Encounter

• Initial, subsequent or care of sequela (i.e., late

effect)

• Active treatment

Examples: Surgical treatment, ER encounter, E/M by new physician

• Subsequent encounter

–Routine follow-up care, during healing phase

• Sequela

–Complications of conditions that occur as a direct result of an injury or illness

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New Features – Laterality

• Laterality

–Left, right & bilateral

• The 5thcode character will be defined as

follows –Right side = 1 –Left side = 2 –Bilateral = 3 –Unspecified = 0 or 9 46

Laterality – Examples

–C50.511 – Malignant neoplasm of

lower-outer quadrant of right female breast

–L89.022 – Pressure ulcer of leftelbow, stage

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Punctuation

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Punctuation – Brackets & Parentheses

[ ] - Brackets enclose synonyms, alternative terminology or explanatory phrases - Also to indicate manifestation codes in

index

( ) - Parentheses enclose supplementary words, called nonessential modifiers, which may be present in descriptor of a code without affecting code to which it is assigned

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Punctuation – Brackets & Parentheses

Examples

Amyloid Heart (disease) E85.4 [I43] • Tells coder two codes will be reported

• I43 is listed in [brackets] & will be secondary code reported

–Verify code in Tabular List

Italicized instruction under I43 tells coder to Code First underlying disease, such as

Amyloidosis (E85.-)

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Punctuation – Brackets & Parentheses

• Index listing for electrocardiogram

–Abnormal, Abnormality, abnormalities • Electrocardiogram [ECG] [EKG] R94.31

• Tabular listing for R94.31

–Abnormal electrocardiogram [ECG] [EKG]

• Index listing for acute laryngitis

–Laryngitis (acute)(edematous)(fibrinous)(infective) (infiltrative) (malignant)(membranous)…J04.0

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Punctuation – Colons

: - Colons are used after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category

Example

– C32 Malignant neoplasm of larynx • Use additional code to identify

Alcohol abuse and dependence (F10.-)Exposure to environmental tobacco smoke

(Z77.22)

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Punctuation –

Not in ICD-10-CM

} - Braces are not found in ICD-10. The detail is

now found after the main term or after the code itself &/or found in detail of code instruction in Tabular listing

Example: K56.2 Volvulus

• Strangulation of colon or intestine • Torsion of colon or intestine • Twist of colon or intestine

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Instructional Notes

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Instructional Notes

“Includes”

This note appears immediately under a three-digit code title at beginning of chapter or section. Further defines or clarifies content of category

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Instructional Notes

“Excludes”

• Terms following the word

“excludes” are not classified to code under which it is found • May indicate another code more fully describes a diagnosis 56

Instructional Notes

“Use additional code”

This instruction signals coder that an additional code should be used when documentation states both etiology & manifestation of disease

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Instructional Notes

‒ “Code first”

• The instruction is to code underlying disease (etiology) first (i.e., “code first”)

• Manifestation code is sequenced as secondary diagnosis

• Manifestation codes may never be used alone or sequenced as principal diagnosis

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Official Guidelines

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Principal Diagnosis – Section II

• “The condition established after study to be

chiefly responsible for occasioning the admission of the patient to the hospital for care”

• Definition applies to all non-outpatient

settings, to include LTC

• Principal diagnosis = condition requiring

resident’s admission

Example: Patient with Parkinson’s disease admitted post hospitalization for therapy associated with acute pneumonia

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Primary Diagnosis – Section II

• Primary diagnosis = reason for continued stay

in LTC

–May be same as principal diagnosis (i.e, Parkinson’s disease)

–Is required to support therapy services Example

The pneumonia would be sequenced as second diagnosis as reason for therapy

ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Page 97-100

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MDS versus ICD-10-CM

• MDS lists “Active Diagnoses” under Section I

• Identifies “disease related to the resident’s functional, cognitive, mood or behavior status, medical treatments, nursing monitoring or risk of death”

• Values are assigned to these “groups” of codes

• Resident may have other conditions that also need to be coded

• ICD-10-CM codes may be listed on the MDS if the groups do not identify a condition or diagnostic group that meets criteria in second bullet point

• Consistent, complete & diagnosis codes in MDS & on claim form

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“Additional Diagnoses” – Section III

• “All conditions that coexist at the time of admission, that develop subsequently, or that affect the

treatment received and/or the length of stay” • Applies to LTC setting

• Do not report conditions that are resolved or from previous admissions that have no bearing on the current stay

• Historical diagnoses (Z80-Z87) may be used if there is impact on current care or treatment

ICD-10-CM Official Guidelines for Coding and Reporting, Section III, Pages 100-101

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Signs & Symptoms

• May be coded when they are the reason for

testing

When provider has not made a definitive final

diagnosis

• Signs & symptoms that are a routine part of a

known disease process are not coded separately unless otherwise instructed in Tabular listing

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Abnormal Test Findings

• Do not code unless provider documents clinical

significance in medical record

• If physician or nonphysician practitioner orders

tests based on abnormal findings or findings outside the norm, query physician to verify code assignment

• If an abnormal findings leads to a definitive

diagnosis upon further testing prior to coding the case, definitive diagnosis is always used

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Multiple Coding

• Use of more than one code to fully identify components of a complex diagnostic statement • A complex statement is one that involves connecting

words or phrases such as “associated with,” “due to,” “incidental to,” or “secondary to”

• Is required for certain conditions that are not subject to rules of combination coding

• Identified in Tabular List by instruction to “use additional” or “code first underlying disease”

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Multiple Coding – Example

I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

Use additional code to identify the stage of

chronic kidney disease (N18.5-N18.4, N18.9)

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Combination Codes

• A single code used to classify two diagnoses or

a diagnosis with an associated secondary process (manifestation) or complication

• Only the combination code is assigned when

that code fully identifies the diagnostic conditions involved or when

Tabular/Alphabetical Index so directs

Example

‒ E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy

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Sequela (Late Effects)

• Reflects residual effect or condition produced

by an acute phase of illness or injury

• No time limit applies

• Generally requires two codes

–Condition or nature of the sequela (cause of the sequela) is coded first

– Sequela (late effect) is coded second

Exception: if instructed to code a manifestation or combination code includes sequela

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Late Effects or Sequela of CVA

ICD-9-CM

438.11 – Late effect of cerebrovascular disease, speech & language deficits, aphasia ICD-10-CM I69.020 – Aphasia following nontraumatic subarachnoid hemorrhage I69.120 – Aphasia following nontraumatic intracerebral hemorrhage I69.220 – Aphasia following other nontraumatic intracranial hemorrhage disease

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Aftercare Codes – Fractures or Injuries

• Assign after initial, acute treatment is

completed

• Used in post acute settings

• Patient is admitted to LTC for ongoing care

during healing or recovery phase

• List acute injury code with 7th character “D”

Aftercare Z codes are NOT used for injuries

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Aftercare Coding – Examples

Example A

–Patient status post hip replacement –Admitted to LTC for rehabilitation

S72.111D – Subsequent encounter for closed fracture with routine healing

Example B

–Patient status post fracture of acute pelvic fracture –Admitted to LTC for rehabilitation

S32.9XXD – Fracture/unspecified/lumbosacral spine & pelvis, subsequent encounter for routine

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Ventilator Associated Pneumonia

• J95.851 – Ventilator associated pneumonia

–When provider has documented that it is related to ventilator use

–Assign an additional code for organism –Do not assign if provider does not specify

pneumonia is caused by ventilator

• Refer to Sections J13-J18 for other pneumonia

diagnoses

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Urinary Tract Infection

• ICD-9-CM

–Assigned 599.0 + the organism if identified & documented

• ICD-10-CM

–Assign N39.0

–Assign additional code (B95-B97) for infectious agent if known

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Wound Care

• Z48.0 – code series

–Encounter for attention to dressings, sutures & drains

• Nonsurgical wound dressing • Surgical wound dressing • Removal of sutures

• Change or removal of drains

• Code open wound, ulcer, etc., requiring

treatment

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Wound Care

• Ulcer, Pressure, by site (i.e., decubitus, bed

sores)

–L89. – code series

• Instruction to “code also” associated gangrene

(I96) if documented

• Nursing or provider documentation should

reflect

–Type of wound –Site(s)

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Open Wounds – Code Series

• Head (S00 to S09) • Neck (S10 to S19) • Thorax (S20 to S29)

• Abdomen, lower back, lumbar spine, pelvis, & external genitals (S30 to S39)

• Shoulder & upper arm (S40 to S49) • Elbow & forearm (S50 to S59) • Wrist & hand (S60 to S69) • Hip & thigh (S70 to S79) • Knee & lower leg (S80 to S89) • Ankle & foot (S90 to S99)

• Unspecified multiple injuries (T07)

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Wound Care

• Bacterial/viral infections – B95.0-B96.89

–Used as an additional code if not already in code description for disease, wound or ulcer

• MRSA –MRSA Carrier/colonization Z22.322 –MRSA Susceptible/colonization Z22.321 • Osteomyelitis Acute – M86.00-M86.29 • Osteomyelitis Chronic – M86.30-M86.9 • Asceptic Necrosis – M87.00-M90.59

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Final Thoughts

• Evaluate training needs • Evaluation workflows

• Perform dual coding assessments on a sample of current records & claims

• Provide feedback & education to professional staff on clinical documentation improvement • Send coding personnel to

comprehensive ICD-10 training prior to October 1, 2015

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Resources & References

CMS ICD-9-CM Website http://www.cms.gov/Medicare/Coding/ICD9Provider DiagnosticCodes/index.html CMS ICD-10-CM Website http://www.cms.gov/Medicare/Coding/ICD10/index. html

AHIMA. “ICD-10-CM Coding Guidance for Long-Term Care Facilities.” Journal of AHIMA

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CMS ICD-10-CM Implementation Tools

• ICD-10 Implementation Timelines & Checklists

http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html • CMS Provider Tools http://www.cms.gov/Medicare/Coding/ICD10/Provider Resources.html 82

Coding Industry Resources

• AHIMA http://www.ahima.org/icd10 • AAPC http://www.aapc.com/ http://www.aapc.com/icd-10/index.aspx http://www.aapc.com/ICD-10/resources.aspx

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FOR MORE INFORMATION

THANK YOU!

Marla Dumm, CPC, CCS-P Managing Consultant mdumm@bkd.com

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