Getting Ready for ICD-10
Part 2: ICD-10 Coding
In the United States, on October 1, 2015 the ICD‐9 code set
used to report medical diagnoses and inpatient procedures will be replaced by International Classification of Disease, Tenth
Edition (ICD‐10).
The purpose of this module is to provide a more in‐depth look at ICD‐10 Coding and to learn to navigate the ICD‐10 Manual.
Introduction
After completion of this module the learner will be able to:
1. Discuss the difference in the organization of the ICD‐10 Coding Manual.
2. Describe what a combination code is and its purpose.
3. Discuss the level of specificity possible with ICD‐10 Codes.
4. Identify common terminology and symbols used in ICD‐10.
Objectives:
Directions:
Review the content of this module and complete the attached post‐
test. Successful completion of the post‐test is worth 0.5 PRMC educational credit and will be documented on your NetLearning transcript.
A Review: What is ICD‐10?
• ICD‐10 is the updated version of medical codes used for coding patients’ medical treatments and care. It will replace the ICD‐9 codes (International Classification of Diseases, 9th edition).
• ICD‐10 contains 2 “classification” code sets:
1. Diagnoses for all providers (ICD‐10‐CM) CM stands for Clinical Modifications
2. Inpatient hospital procedures (ICD‐10‐PCS) PCS stands for Procedure Coding System
• ICD‐10‐CM replaces ICD‐9‐CM for diagnosis coding:
ICD‐10 CM diagnosis codes will be 3 to 7 digits
• ICD‐10‐PCS replaces ICD‐9‐CM for inpatient procedure coding:
ICD‐10‐PCS codes must be 7 alphanumeric digits Each position has a specific meaning.
• ICD‐10 expands details for many conditions.
A Review: ICD‐10 Structure
Please Note:
The change to ICD‐10 does not affect Current Procedure Terminology (CPT) for outpatient procedures.
The new structure of ICD‐10‐CM will be:
category etiology extension anatomic site
severity
X X X X X X X
ICD‐10‐CM replaces ICD‐9‐CM
for Diagnosis Coding:
The new structure of ICD‐10‐PCS will be:
Section Root Approach Qualifier Operation
Body Body Device System Part
1 2 3 4 5 6 7
ICD‐10‐PCS replaces ICD‐9‐CM
(Volume 3, Procedural Codes)for Inpatient Procedure Coding
Comparison of ICD‐9‐CM to ICD‐10
ICD-9 ICD-10
18,000 codes
‐ 14,000 diagnosis codes
‐ 4,000 procedure codes
‐ 1,592 MCCs (major comorbid conditions)
‐ 3,427 CCs (comorbid conditions)
155,000 codes
‐ 68,000 diagnosis codes
‐ 87,000 procedure codes
‐ 3,152 MCCs (major comorbid conditions)
‐ 13,594 CCs (comorbid conditions)
• Little detail
• Difficult to analyze data
• High definition
• Laterality, bilaterally dominance
• Supports data analysis
• Greater specificity
• Full description and consistency within the code set
• Uses modern terminology for descriptions
• Sense organs have been separated from nervous system disorders
• Injuries are grouped by anatomical site rather than injury category
• Postoperative complications have been moved to procedure‐specific body
system chapters
As an example: In ICD‐10, injuries of the head and neck will be grouped together, but in ICD‐9 they are grouped by fractures or open wounds.
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Organization of the ICD‐10 Coding Manual
The organization of the ICD‐10 Coding Manual differs from the ICD‐9 manual in the following ways:
In ICD‐10 ‐
• It makes a difference whether the right or left limb is the subject of the problem.
• Some codes contain descriptions to include right or left designation. The right is usually character 1 and left is
character 2. In the case of a bilateral code the character is usually 3 and if the laterality is not specified, the character 9 is used.
M25.551 Pain in right hip M25.552 Pain in left hip M25.553 Pain in both hips
M25.559 Pain in unspecified hip
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Laterality
In ICD‐10 ‐
There is a selection for “unspecified” found in every category.
It should be used sparingly because it could result in denial of payment.
Example
The following ICD‐10 code: 86.909 translates as:
Unspecified injury of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg.
This code does not provide enough detail regarding the injury to correctly identify the problem, which could lead to inaccurate reimbursement.
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Use “Unspecified” Code Sparingly
Combination codes are used to represent an illness and/or disease with an associated:• sign or symptom
• manifestation
• and/or complication
Individual codes should not be used when there is a combination code provided. Combination codes allow fewer codes to be
submitted.
Examples of combination codes• H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side
• H90.42 Sensorineural hearing loss, unilateral left ear with unrestricted hearing on the contralateral side
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Combination Codes
• I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery
• I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery
• I11.0 Heart failure due to hypertension
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Additional Examples of Combination Codes
In ICD‐10 ‐
All codes in ICD‐10‐PCS, and some in ICD‐10‐CM, require 7 characters, however when coding a procedure or condition ‐ there may not be 7 characters used to identify that condition.
When this occurs, an “X” is used as a dummy placeholder
For example, the code T19.0xxD represents “Foreign body in urethra, subsequent encounter”. The two “x” in the code are place holders because a 7th digit extension is needed for this code.
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Dummy Placeholder
The ICD‐10 code 035.2 – translates as “maternal care
(suspected) hereditary disease in fetus”. This code requires a seventh character to indicate the number of fetuses there are.
The choices are:
0 = Not applicable or unspecified 1 = fetus one
2 = fetus two 3 = fetus three 4 = fetus four 5 = fetus 5
9 = other fetus
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Another Example of Dummy Placeholders
If there is one fetus, the code will be ‐ 035.2xx1.
If there are two fetuses the code will be 035.2xx2.
In order to indicate the number of fetuses there are 2
placeholders (x x ) needed to make the 7th positon.
A big benefit of ICD‐10 coding is that it allows for much more specific information regarding a disease or condition.
For example:
In ICD‐9‐CM, Diabetes Mellitus was identified by one code ‐ 250.
In ICD‐10‐CM, Diabetes Mellitus is broken down and split into specific category codes:
• E08 Diabetes mellitus due to underlying condition
• E09 Drug or chemical induced diabetes mellitus
• E10 Type 1 diabetes mellitus
• E11 Type 2 diabetes mellitus
• E13 Other specified diabetes mellitus
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ICD‐10‐CM Specificity
Staying with the example of diabetes, in ICD10‐CM, diabetes can again be further broken down into codes which represent specific classifications of diabetes and/or manifestations.
• E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
• E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
• E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
• E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
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Examples of ICD‐10‐CM Specificity
In ICD‐9‐CM this is the code for hematuria ‐
• 599.7 Hematuria (blood in urine)
In ICD‐10‐CM these codes are used for hematuria:
• R31.0 Gross hematuria
• R31.1 Benign essential microscopic hematuria
• R31.2 Other microscopic hematuria
• R31.9 Hematuria, unspecified
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Another Example of ICD‐10‐CM Specificity
Examples include:
•
W21.00 Struck by hit or thrown ball, unspecified type•
W21.01 Struck by football•
W21.02 Struck by soccer ball•
W21.03 Struck by baseball•
W21.04 Struck by golf ball•
W21.05 struck by basketball19
A Further Example of ICD‐10‐CM Specificity
Looking at a Sports Injury:
In ICD‐9‐CM‐ the injury of “striking against or struck accidentally in sports without subsequent fall” would be coded ‐ E917.0
In ICD‐10‐CM, sports injuries are now coded with sport and
reasons for injury. There are 24 ICD‐10‐CM detailed sports injury codes!
In ICD‐10‐CM, acute tonsillitis is expanded at the fourth
character (to indicate organism) and fifth character (to indicate acute and recurrent) levels.
J03 Acute Tonsillitis
• J03.0 Streptococcal tonsillitis
• J03.00 Acute streptococcal tonsillitis unspecified
• J03.01 Acute recurrent streptococcal tonsillitis
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One Last Example of ICD‐10‐CM Specificity
Tonsillitis
• It allows for unique coding of procedures (easy to distinguish procedures).
• There is room for code expansion as it is needed.
• It uses standardized terminology.
• There is consistency in coding from chapter‐to‐chapter.
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ICD‐10‐PCS Coding
The benefits of the ICD‐10‐PCS coding procedure includes:
In ICD‐9‐CM, the code for laparoscopic appendectomy is 47.01.
In ICD‐10‐PCS, laparoscopic appendectomy will be coded as 0DTJ4ZZ, in which:
0 = Medical and Surgical Section D = Gastrointestinal system
T = Resection (root operation) J = Appendix (body part)
4 = Percutaneous endoscopic (approach) Z = No device
X = No qualifier
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An Example of ICD‐10‐PCS Coding
In ICD‐9‐CM, there is one code for artery suture.
In ICD‐10‐PCS, there are 195 codes for artery suture, which includes:
4 different approaches
67 possible arteries23
ICD‐10‐PCS Coding Example
To locate a code in ICD‐10‐CM:
• Locate the term in the Index – which is an alphabetical list of terms and their corresponding code. It contains Diseases and Injuries, Neoplasm Table, and Table of Drugs and Chemicals and Index of External Causes of Injuries.
• Verify the code in the Tabular List ‐ a sequential alphanumeric list of codes divided into chapters based on body systems and condition.
Consists of categories, subcategories and valid codes.
• Read and be guided by instructional notations that appear in both the Index and Tabular List.
• The Index does not always provide the full code. Selection of the full code can only be done in the Tabular List.
• A dash (‐) at the end of an Index indicates additional characters are required.
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Locating a Code in ICD‐10‐CM
NEC stands for – “Not Elsewhere Classified”
An alphabetical Index entry that states “NEC” directs the coder to “Other Specified Code” in the Tabular List.
• “Other or Other Specified Code” are used when the
documentation in the Medical Record provides detail for which a code does not exist.
Example NEC: Diabetic, type 2 E11.9 with circulatory complication NEC E11.59
NOS stands for ‐ “Not Otherwise Specified”
This is the equivalent of unspecified
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ICD‐10 Coding Manual ‐ Terminology
NEC and NOS
[ ] Brackets are used in the Tabular List to enclose synonyms,alternative wording, or explanatory wording. They are used in the alphabetical listing to identify manifestation codes.
( ) Parentheses are used in both the Alphabetical Index and Tabular List to enclose supplemental words that do not affect the codenumber.
: A colon is used after an incomplete term that needs one or more of the modifiers following the colon to make it assignable to a givencategory.
} The brace encloses a series of terms of which is modified by the statement appearing at the right of the brace.
, a comma ‐ words following a comma are essential modifiers.
A “Code Also” note indicates that two codes may be required.26
ICD‐10 Coding Manual ‐ Punctuation
You need to know how ICD ‐10 affects you:
• The ICD‐10 code set differs significantly from ICD‐9.
• The ICD‐10 code set conveys significantly more information and detail than ICD‐9.
• The change in code sets has significant impact on healthcare providers, patients and payers.
• It is important for you to understand and be aware of the coding structure of ICD‐10 in order to support Patient
Financial Services functions. Coding experience is not required – you are not expected to be a “coder”.
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In Summary
Resources
www.cms.gov/ICD10.
• Sign up for e‐mail updates
• Follow @CMS.gov on Twitter for the latest news and resources www.wedi.rog
• WEDO‐ICD‐10 Implementation
www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
• NCHS Basic ICD‐10‐CM Information www.ahima.org/icd10/index.asp
• AHIMA‐ICD‐10 Education
www.cms.gov/Medicare/Coding/ICD10/downloads/gems‐
crosswalksbasicfaq.pdf
• General Equivalence Mappings ‐ Frequently Asked Questions
