Getting Down to the Nitty Gritty of ICD-10-CM

Getting Down to the Nitty

Gritty of ICD-10-CM

Spring 2016

About the Presenter:

Dana Brown, RHIA, CHC, AHIMA ICD-10 Train the Trainer Ms. Brown founded RMC in 1994, with the desire to assist healthcare facilities in obtaining correct reimbursement and minimizing lost revenue through complete and accurate coding, documentation improvement, and education. Prior to founding RMC, Ms. Brown performed DRG Validation, Admission, and Utilization Reviews for the Oregon PRO/QIO. She has extensive management, education and coding experience spanning her 25+ year career in HIM. Ms. Brown’s expertise in Compliance, Inpatient Coding, DRG’s/MSDRG’s, OIG & RAC Targets, Clinical Documentation Improvement, as well as an interest in HCC and Critical Access Hospitals round out her areas of focus at RMC. Ms. Brown’s vision for RMC is to continue to support our clients with exceptional services, delivered by exceptional staff.

Monique Vanderhoof, CPC, CCA, CRC, AHIMA Approved ICD-10-CM Trainer

Monique joined RMC in September 2011 as Manager of Coding Services…focusing on Risk Adjustment/HCC coding audits and client education. With over 15 years’ experience as a Clinic Manager Monique has a extensive experience working in both outpatient and inpatient physician billing with emphasis in

cardiology. Her skills also include EHR implementation, HIPAA, eRx and Meaningful Use readiness and attestation. Email at:

[email protected]

3

About the Presenter:

RMC’s Disclaimer

Every reasonable effort has been taken to ensure that the educational information provided in this presentation is accurate and useful. Applying

best practice solutions and achieving results will vary in each hospital/facility situation. A thorough individual review of the information is

recommended and to establish individual facility guidelines.

RMC makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any

specific purpose. RMC has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from

the use of this presentation. RMC makes no guarantee that the use of this presentation material will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to

So… How are YOU doing??

ICD 10 Post Implementation

Ref 1

• US Department of Health and Human Services announced

change January 16, 2009 with a compliance date of October 1, 2013

• 2012 delay until October 2014

• March 21, 2013 CMS announces deadline of October 1, 2014

is firm

• March 2014 ICD-10 delayed again until Oct. 1, 2015

• Biggest change to healthcare in the last 20 years!

http://edocket.access.gpo.gov/pdf/E9-743.pdf http://www.cms.hhs.gov/ICD10

History-• ICD-9-CM

– Based on World Health Organization’s (WHO) Ninth

Revision

– Morbidity and mortality reporting

– Made single classification system for hospitals in January

1979

– Physicians required to submit diagnosis codes for Medicare

reimbursement since April 1989

Introduction to ICD-10-CM

• ICD-10-CM

– Developed by National Center for Health Statistics

(NCHS) per WHO’s ICD-10

– Adoption: Final rule January 16, 2009

– Compliance: October 1, 2015

– WHO currently working on ICD-11

Conventions

Nonessential

Modifiers-• Are a term or series of terms

• They appear within parentheses

• They follow the main term or subterm

“See” and “See Also”

• The “see” instruction following a main term in the Alphabetic

Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the “see” note to locate the correct code.

• A “see also” instruction following a main term in the

Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code.

Conventions

“See” and “See Also”

• Examples from Index-“See”

Abduction contracture, hip or other joint —see Contraction, joint

Decubitus (ulcer) —see Ulcer, pressure, by site

“See Also”

Dacryostenosis —see also Stenosis, lacrimal - congenital Q10.5

Febris, febrile —see also Fever

“

Code also note”

• A “code also” note instructs that two codes may be required to

fully describe a condition, but this note does not provide sequencing direction.

Conventions

“Code also note”

Index-Retinopathy (background) H35.00

- arteriosclerotic I70.8 [H35.0-]

Default

Codes-• A code listed next to a main term in the ICD-10-CM

Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly

associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.

Conventions

ICD-10-CM Variances to ICD-9-CM

• Used in certain chapters to provide information about the

characteristic of the encounter

• Must always be used in the 7th_{character data slot}

• If a code has an applicable 7th_{character, for the code to be a}

valid code it must be reported with an appropriate 7th_character

value

• If code does not have 6 characters, a placeholder X must be

used to fill in the empty characters

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

Abbreviations-• NEC: Not Elsewhere Classified

– “other specified”

– When a specific code is not available for a condition

Example:

ICD-10-CM H26.8 Other specified cataract ICD-9-CM 366.8 Other cataract

• NOS: Not Otherwise Specified

– Equivalent of unspecified

Example:

ICD-10-CM H40.9 Unspecified glaucoma

Conventions

 Enclose synonyms, alternative wording or explanatory

phrases

 Used in Index to identify manifestation codes

Example:

M26 Dentofacial anomalies [including malocclusion]

 Enclose supplementary words or explanatory information

 Nonessential modifiers

Example:

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

Conventions

• Used in Tabular List after incomplete term that needs one or

more modifiers following colon to make it assignable

Example:

G73.7 Myopathy in diseases classified elsewhere

Excludes 1: myopathy in:

-rheumatoid arthritis (M05.4-) -sarcoidosis (D86.87) -scleroderma (M34.82)

-sicca syndrome [Sjogren] (M35.03) -systemic lupus erythematosus (M32.19)

-• Used in both Alphabetic Index and Tabular List

• Indicates incomplete code

• Locate code in Tabular List and review options to determine

additional character(s) needed

Example: Fracture, pathologic ankle M84.47-carpus

M84.44-Conventions

– Appears immediately under a three-digit code title to

further define, or give examples of, the content of the category

• Inclusion terms

– Included under some codes

– Conditions for which that code is to be used

• Excludes notes

– Two types in ICD-10-CM

ICD-10-CM: Includes Notes

• This note appears immediately under a three character code title

to further define, or give examples of, the content of the category.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

Conventions

ICD-10-CM: Includes

Notes-•I21 ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction

INCLUDES -cardiac infarction

-coronary (artery) embolism -coronary (artery) occlusion -coronary (artery) rupture -coronary (artery) thrombosis

-infarction of heart, myocardium, or ventricle -myocardial infarction specified as acute or with a -stated duration of 4 weeks (28 days) or less from

onset

ICD-10-CM: Excludes Notes

note-• A type 1 Excludes note is a pure excludes note. It means “NOT

CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

Conventions

ICD-10-CM: Excludes Notes

note-H61.3 Acquired stenosis of external ear canal

Collapse of external ear canal

EXCLUDES1 postprocedural stenosis of external ear canal (H95.81-)

Conventions

Excludes 1

Please see the "Interim advice on excludes 1 note on conditions unrelated" (next slide) posted to the NCHS website with the ICD-10-CM guideline documents. Apparently Excludes1 does not ALWAYS mean the 2 conditions cannot be reported

together...they cannot be reported together when they are RELATED. But if unrelated, per this document, they can still both be reported.

Excludes 1

We have received several questions regarding the interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another. Answer: If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note.

ICD-10-CM: Excludes Notes

• A type 2 Excludes note represents “Not included here”. An

excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

Conventions

ICD-10-CM: Excludes Notes

note-G11 Hereditary ataxia

EXCLUDES 2 cerebral palsy (G80.-)

hereditary and idiopathic neuropathy (G60.-) metabolic disorders (E70-E88)

ICD-10-CM: Placeholder “X”

• Addition of dummy placeholder “X” is used in certain codes

to:

– Fill out empty characters when a code contains fewer than

6 characters and a 7th_{character applies}

– When placeholder character applies, it must be used in

order for the code to be considered valid

– Allow for future expansion

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

Conventions

ICD-10-CM

7

_{Character Injuries and External Causes}

•Application of 7th_{Characters in Chapter 19}

“A” Initial encounter “D” Subsequent encounter “S” Sequela

Note: For aftercare of an injury, assign acute injury code with 7th_{character “D”}

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

ICD-10-CM 7

_Character

Fractures-• 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

Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013

Conventions

Etiology/Manifestation

Conventions-• Underlying condition (etiology), manifestation

• “use additional code”

• “code first”

• “in diseases classified elsewhere”

– Never first listed or principal diagnosis

Example:

F02 Dementia in other diseases classified elsewhere

Code first the underlying physiological condition, such as: Alzheimer’s (G30.0-)

Acute and Chronic

Conditions-• If the same condition is described as both acute (subacute) and

chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

Example:

Acute and Chronic Pancreatitis

Code Acute Pancreatitis unspecified K85.9 and K86.1 Chronic Pancreatitis

Conventions

Combination

Codes-• A combination code is a single code used to classify:

– Two diagnoses, or

– A diagnosis with an associated secondary process

(manifestation)

– A diagnosis with an associated complication

– Identify combination codes by referring to subterm entries

in Alphabetic Index read the inclusion and exclusion notes in the Tabular List

Sequela-• A sequela is the residual effect (condition produced) after the

acute phase of an illness or injury has terminated with no time limit (ICD-9-CM was late effect)

• The residual may be apparent early, such as in cerebral

infarction, or it may occur months or years later, such as that due to a previous injury.

Conventions

Sequela-• An exception to the above guidelines are those instances where

the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s).

• The code for the acute phase of an illness or injury that led to

the sequela is never used with a code for the late effect.

Sequelae (of) —see also condition

- burn and corrosion -- code to injury with seventh character S Burn

-- back —see Burn, dorsum of hand - dorsum of hand T23.069 - - first degree T23.169 - - left T23.062 - - - first degree T23.162 - - - second degree T23.262 - - - third degree T23.362

Conventions

Laterality

– For bilateral sites, the final character of the code indicates

laterality

– If no bilateral code is provided and the condition is

bilateral, assign separate codes for both the left and right side

– Unspecified side is also provided should the side not be

identified in the documentation

Impending or Threatened

Condition-• Code any condition described at the time of discharge as

“impending” or “threatened” as follows:

• If it did occur, code as confirmed diagnosis.

• If it did not occur, reference the Alphabetic Index to

determine if the condition has a subentry term for “impending” or “threatened” and also reference main term entries for “Impending” and for “Threatened.”

Conventions

Impending or Threatened

Condition-• If the subterms are listed, assign the given code.

• If the subterms are not listed, code the existing underlying

condition(s) and not the condition described as impending or threatened.

BMI, Non-Pressure Ulcers and Pressure Ulcer

Stages-• For the Body Mass Index (BMI), depth of non-pressure

chronic ulcers and pressure ulcer stage codes, code assignment may be based on medical record documentation from

clinicians (nursing/dietary etc.) who are not the patient’s provider (i.e., physician or other qualified healthcare

practitioner legally accountable for establishing the patient’s diagnosis).

However!...

Conventions

BMI, Non-Pressure Ulcers and Pressure Ulcer

Stages-• However, the associated diagnosis (such as overweight,

obesity, or pressure ulcer) must be documented by the patient’s provider.

• Conflicting documentation, either from the same clinician or

different clinicians, must be queried and clarified by the patient’s attending provider

Syndromes

• Follow the Alphabetic Index guidance when coding

syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the

syndrome. Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code.

Conventions

Documentation of Complications of Care

• Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure.

• The guideline extends to any complications of care, regardless of the chapter the code is located in

Documentation of Complication of Care

• Notall conditions that occur during or following medical care

or surgery are classified as complications

• Must be a cause-and-effect relationship between the care

provided and the condition and an indication in the documentation that it is a complication

• Query the provider for clarification, if the "complication" is

not clearly documented.

• Coders are caution to not assume a complication

Conventions

Borderline Diagnosis

• If provider documents “borderline” diagnosis, code as

confirmed unless classification provides a specific entry (e.g., borderline diabetes).

• Not considered “uncertain,” so ok to code in outpatient setting

• If a borderline condition has a specific index entry in

ICD-10-CM, it should be coded as such.

• Since borderline conditions are not uncertain diagnoses, no

distinction is made between the care setting (inpatient versus outpatient).

• Query the physician if documentation is unclear regarding a

borderline condition.

AHA Coding Clinic

• Every effort was made to carry over the ICD-9-CM guidelines and concepts into CM, unless there was a specific change in ICD-10-CM that precluded the incorporation of the same concept into ICD-10-ICD-10-CM. However, some of the guidelines in ICD-9-CM included information that may have been clinical in nature and therefore not appropriate for coding guidelines.

• However, there are no plans to translate all previous issues of Coding Clinic for ICD-9-CM into ICD-10-CM/PCS since many of the questions published arose out of the need to provide clarification on the use of ICD-9-CM and would not be readily applicable to ICD-10-CM/PCS

– Care should be exercised as ICD-10-CM has new combination codes as well as instructional notes that may or may not be consistent with ICD-9-CM.

Applying Past Issues of Coding Clinic

for ICD-9-CM to ICD-10-CM

• In general, clinical information and information on documentation best practices published in Coding Clinic were not unique to ICD-9-CM, and remain applicable for ICD-10-CM with some caveats. For example, Coding Clinicmay still be useful to understand clinical clues when applying the guideline regarding not coding separately signs or symptoms that are integral to a condition. Users may continue to use that information, as clues—not clinical criteria.

• As far as previously published advice on documentation is concerned,

documentation issues would generally not be unique to ICD-9-CM, and so long as there is nothing new published in Coding Clinic for ICD-10-CM and ICD-10-PCS

to replace it, the advice would stand.

• Every attempt was made to remain as consistent with the ICD-9-CM guidelines as possible, unless there was a change inherent to the ICD-10-CM classification.

ICD-10.1

There were no new/revised ICD-10-CM diagnosis codes, or changes to ICD-10-CM for FY 2016, because of the partial code set freeze in

preparation of ICD-10 implementation. On October 1, 2016 (one year after implementation of ICD-10), regular updates to CM and ICD-10-PCS will begin. So, get ready…

According to Journal of AHIMA, “A total of 1,943 new ICD-10-CM codes were released by the CDC, and 3,651 new ICD-10-PCS codes were released by the Centers for Medicare and Medicaid Services (CMS). In addition to the new codes, the update also includes revisions and deletions. In the ICD-10-CM proposed update, 422 codes were revised and 305 were deleted. In the proposed ICD-10-PCS update, 351 codes were revised and 313 were deleted. Once finalized following a public review period currently underway, the healthcare industry must start using the updated codes by October 1, 2016.”

CC/MCC Changes

• MDD no longer a CC

• Malignant HTN no longer MCC

• Schatzki’s ring not MCC

– Now defaults to “Acquired” – opposite of I-9

– “Congenital” is still an MCC

• New CCs: Persistent A Fib, Mild malnutrition, nicotine

ICD-10-CM

Chapter 1: Certain Infectious and

Parasitic Diseases (A00-B99)

Coding Notes:

• Term “Septicemia” not used

• Streptococcal sore throat moved to Chapter 10, Diseases of the

Respiratory System

• Combination codes (sepsis)

Chapter 1

Patient with Sepsis & Septic Shock:

Sepsis (generalized) (unspecified organism)A41.9

with

organ dysfunction (acute) (multiple)R65.20

with septic shockR65.21

actinomycoticA42.7

adrenal hemorrhage syndrome (meningococcal)A39.1

Patient with Sepsis & Septic Shock:

R65.2 Severe sepsis

Infection with associated acute organ dysfunction……..

Code first underlying infection, such as:………..

– sepsis NOS A41.9

Use additional code to identify specific acute organ dysfunction, such as:…………

– hepatic failure (K72.0-)

Chapter 1

Infections Resistant to Antibiotics

Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.

Coding Notes:

• Bacterial and viral infectious agents B95-B97

Note:

These categories are provided for use as supplementary or additional codes to identify the infectious agent in diseases

classified elsewhere (Optum, 465)

(Agent is a similar term to “organisms” in ICD-9)

Chapter 1

Chapter 2: Neoplasms (C00-D49)

Coding Notes:

• Category of codes for in situ neoplasms is located before

category for benign neoplasms

• 5th_{character for extranodal and solid organ locations for}

lymphomas and Hodgkin’s

Chapter 2

Example of “sites” of Lymphomas:

C81.7 Other classical Hodgkin lymphoma

Classical Hodgkin lymphoma NOS

C81.70 Other classical Hodgkin lymphoma, unspecified site C81.71 Other classical Hodgkin lymphoma, lymph nodes of head,

face, and neck

C81.72 Other classical Hodgkin lymphoma, intrathoracic lymph nodes

C81.73 Other classical Hodgkin lymphoma, intra-abdominal lymph nodes

ETC…..

General guidelines:

The Neoplasm table in the alphabetic index should be referenced first. However if the histological (type of cancer) term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to

determine which column in the Neoplasm Table is appropriate.

Coding Guideline I.C.2.

Coding Guidelines CH 2

(Code to the histology first if specified)

Adenocarcinoma-in-situ - see also Neoplasm, in situ, by site breast

D05.9-(below is Neoplasm Table)

Malignant Malignant ETC……

Primary Secondary Ca in situ

breast C50.9- C79.81

Primary malignant neoplasm overlapping site

boundaries

A primary malignant neoplasm that overlaps two or more

contiguous (next to each other) sites should be classified to the subcategory/code .8 (‘overlapping lesion’), unless the

combination is specifically indexed elsewhere.

For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Coding Guideline CH 2

Management of dehydration due to malignancy

When the encounter is for management of dehydration due to the malignancy and only the dehydration is being treated

(intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.

Patient admission solely for Administration of

Chemotherapy, Immunotherapy and Radiation

Therapy

If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign

code Z51.0, Encounter for antineoplastic radiation therapy, or

Z51.11, Encounter for antineoplastic chemotherapy, or

Cont’d

Coding Guidelines CH 2

Z51.12 - Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis.

If a patient receives more than one of these therapies during the same admission more than one of these codes maybe assigned, in any sequence.

Then, for proper coding, you would code the Neoplasm and/or Malignancy that is being treated, and any additional diagnoses that are appropriate (present & treated/address)

Chapter 3: Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving

the Immune Mechanism (D50-D89)

Anemia associated with malignancy

When admission/encounter is for management of an

anemia associated with the malignancy and the

treatment is only for anemia, the appropriate code for

the malignancy is sequenced as the principal or first

listed diagnosis followed by code D63.0, Anemia in

neoplastic disease.

ICD-10-CM Official Guidelines for Coding and Reporting 2013, CH 2, c. 1)

Chapter 4: Endocrine, Nutritional and

Metabolic diseases (E00-E89)

Ref. 3

Diabetes

Mellitus-The diabetes mellitus codes are combination codes that include the type of diabetes, body system affected, complications affecting the body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08-E13 as needed to identify all of the

associated conditions that the patient has.

Diabetes

Mellitus-INDEX:

Diabetic - see

E08

-

E13

with .40

……..

mononeuropathy - see

E08

-

E13

with .41

TABULAR:

E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E09.41 Drug or chemical induced diabetes mellitus with neurological complications with

diabetic mononeuropathy

E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E13.41 Other specified diabetes mellitus with diabetic mononeuropathy (no E12)

Coding Guidelines CH 4

Diabetes Mellitus

Notes-• No longer identified as controlled or uncontrolled

• Alphabetical index guides coders to assign diabetes, by type,

with hyperglycemia

• Additional code may be used to signify insulin use (Z79.4)

• Do not use Z79.4 in Diabetes Type 1, where insulin is

required for life

Type 1 Diabetes Mellitus

• Also called insulin dependent diabetes mellitus (IDDM) or

juvenile diabetes

• Can occur at any age but usually develops in childhood or

adolescence before age 25

• Accounts for 10-15% of all cases of DM

• Acute onset and progresses rapidly

• Caused by a complete deficiency of insulin resulting from Beta

cell destruction

Chapter 4

Type 2 Diabetes Mellitus

• Also known as adult onset diabetes, noninsulin dependent

diabetes or maturity onset diabetes

• Accounts for 80-90% of all cases of diabetes

• Usually occurs in adults over 40 years of age

• Onset of symptoms is slow and does not progress rapidly

• Caused mainly by insufficient insulin secretion by Beta cells

due to their destruction

Gestational Diabetes Mellitus

• Is defined as any degree of glucose intolerance, with the onset

of pregnancy

• Is a complication in approximately 4% of the pregnancies in

the US

• Causes increased rate of caesarean section delivery and

chronic hypertension

Chapter 4

Other Specific Types of Diabetes Mellitus

• DM of various known reasons are included in this type.

• Including: diabetes in persons with genetic defects, persons

with endocrinopathies, persons with pancreatic dysfunction.

• Malnutrition may also lead to diabetes and it is common in

young malnourished persons in developing countries.

Secondary Diabetes Mellitus

Codes under category E08, diabetes mellitus due to underlying condition, and E09 Drug or chemical inducted diabetes mellitus, and E13, Other specified diabetes mellitus, identify

complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning.

Coding Guidelines CH 4

Chapter 5: Mental, Behavioral and

Neurodevelopmental Disorders

(F01-F99)

Drug and Alcohol

Use-• Specialized codes not identified as abuse or dependence

• “Continuous” or “episodic” use, no longer indicated

• “In remission” used to code any history of drug or alcohol

dependence

• Combination codes available for drug and alcohol use and

related conditions

• New code for blood alcohol level (Y90)

Chapter 5

Intellectual Disabilities

• In ICD-10-CM any associated physical or developmental

disorder should be coded beforethe intellectually disabled

code

• In ICD-9-CM the associated physical or developmental

disorder was/is coded afterthe intellectually disabled code

In Remission

Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation.

Coding Guidelines CH 5

Coding Notes:

• ICD-10- CM supplies a separate code to identify blood alcohol

level

R78.0 Finding of alcohol in blood

Use additional external cause code (Y90.-), for detail regarding alcohol level.

Chapter 6: Diseases of the Nervous

System (G00-G99)

Ref 5

Terminology for epilepsy has changed

Coders will need to familiarize with new terms

• Myoclonic: Patients have seizure that are brief - the arms, legs, torso, or facial muscles jerk rapidly as though they are being shocked.

• Status epilepticus: A neurological emergency, prolonged seizures can cause permanent neurological injury or death.

• Juvenile epilepsy: Epilepsy that starts in childhood or adolescence.

• Generalized epilepsy: Patients may have myoclonic seizures (sudden and very short duration jerking of the extremities), or absence seizures (staring spells) or generalized tonic-clonic seizures (grand mal seizures).

Neoplasm Related

Pain-Code G89.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy or tumor. This code is assigned regardless of whether the pain is acute or chronic.

This code may be assigned as the principal or first-listed code when the stated reason for the admission/encounter is

documented as pain control/pain management. The underlying

neoplasm should be reported as an additional diagnosis. Cont’d.

Coding Guideline CH 6

Neoplasm Related

Pain-When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89.3 may be assigned as an additional diagnosis. It is not necessary to assign an additional code for the site of the pain.

Chapter 7: Disease of the Eye and

Adnexa (H00-H59)

Ref. 6

Coding Notes:

• Codes can include right, left and bilateral and unspecified eye

• If “bilateral” is not available andthe condition is present in

both eyes, a code for each (right and left) must be used

• Term “age-related” is used in place of “senile” to classify type

of cataract

Chapter 8: Diseases of the Ear and

Mastoid Process (H60-H95)

Ref. 1

Coding Notes:

• Many codes require additional code for “any associated

perforated tympanic membrane”

• Also code first any underlying disease

H66

Suppurative and unspecified otitis media

ADDITIONAL CODE REQUIRED FOR:

• Any exposure to environmental tobacco smoke (Z77.22)

• Any exposure to tobacco smoke in the perinatal period

(P96.81)

• History of tobacco smoke (Z87.891)

• Occupational exposure to environmental tobacco smoke

(Z57.31)

• Tobacco use (Z72.0)

Chapter 8

Chapter 9: Diseases of the

Circulatory System (I00-I99)

Hypertensive Heart and Chronic Kidney Disease

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. If heart failure is present, assign an additional code form category I50 to identify the type of heart failure.

Coding Guidelines CH 9

Myocardial

infarction-REALLY BIG CHANGE!!!

• Time frame for AMI codes:4 weeks or less

(Not8 weeks or less as in ICD-9)

• Also – now codes for AMI’s (I21) and subsequent AMI’s (I22)

ST Elevation Myocardial Infarction (STEMI) and

Non-ST Elevation Myocardial Infraction (NSTEMI)

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as a STEMI.

Coding Guidelines CH 9

AMI documented as nontransmural or

subendocardial but site

provided-If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded to subendocardial AMI.

Bottom line: If documented as subendo – code as subendo…

Subsequent acute myocardial infarction

A code from category I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the

circumstances of the encounter.

Coding Guidelines CH 9

Sequencing of I22 (subsequent) and I21 (acute)

A patient admitted for AMI has subsequent AMI while still in hospital.

Code:

-I21 - Principal diagnosis -I22 – Secondary code

Atherosclerotic Coronary Artery Disease and Angina

ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7 Atherosclerosis of coronary artery bypass graft and coronary artery of transplanted heart with angina pectoris.

Coding Guidelines CH 9

Example of CAD with Angina Pectoris

ICD-10: I25.119 Arteriosclerotic heart disease of native coronary arteries, with angina pectoris

**Disease, artery, coronary – WITH angina pectoris

Category I69, Sequelae of Cerebrovascular Disease

Category I69 is used to indicate conditions classifiable to

categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.

Coding Guidelines CH 9

Example of

Sequelae-ICD-9: 438.11– Late Effect of CVA – Aphasia

ICD-10: “Late Effect – SEE Sequelae”

I69.920Sequelae, CVA - Aphasia

**Sequelae, Disease, Cerebrovascular, Aphasia

Chapter 10: Diseases of the

Respiratory System (J00-J99)

Ref. 3

Updated medical

terminology-J45 - Asthma

Now classified as:

• mild intermittent

• mild persistent

• moderate persistent

• severe persistent

• other and unspecified

Coding Notes:

Excludes 2 note appears under category J45- Asthma

• If an Excludes 2 note is represented under a code, it is

admissible to use both codeand excluded code consecutively

if the patient has both conditions at same time

Chapter 10

Coding Notes:

• Individual codes now available for acute recurrent sinusitis for

each sinus Example:

J01.11Acute recurrent frontal sinusitis

J01.21Acute recurrent ethmoidal sinusitis

Coding Notes:

•

If respiratory condition is described as occurring in

more than one site and is not specifically indexed, it

should be classified to the lower anatomic site.

•

For example: (tracheobronchitis to bronchitis in J40)

Source: ICD10-CM, The Complete Official Draft Code Set, 2013 (p.627)

Chapter 10

Coding Notes:

• Code first the underlying disease

• Code also any associated lung abscess

• Use additional code to describe the infectious agent or virus

• Use additional code for associated pleural effusion

• Use additional code (s) to describe other conditions such as

tobacco use or exposure

ICD-10-CM, The Complete Official Draft Code Set, 2013, Optum

Chapter 11: Diseases of the Digestive

System (K00-K95)

Ref. 4

Important

Note-Term “hemorrhage” is used when indentifying ulcers

Term “bleeding” is documented when classifying gastritis,

duodenitis, diverticulosis, and diverticulitis

• K25.0- Acute gastric ulcer with hemorrhage

• K29.01- Acute gastritis with bleeding

• K57.31- Diverticulosis of large intestine without perforation or

abscess with bleeding

Coding Notes:

Increased specificity is needed to select codes in Chapter 11 Example:

K50._Crohn’s disease

• Must be documented with or without complications including:

-rectal bleeding -intestinal obstruction -fistula

-abscess

Chapter 11

Chapter 12: Diseases of the Skin and

Subcutaneous Tissue (L00-L99)

Coding Notes:

• Increased instructional notes

• Addition of laterality

• Category L89 Pressure ulcer, now classifies by:

-Site -Laterality -Severity

Chapter 12

Pressure Ulcer

Stages-Codes from category L89, Pressure ulcer, are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer.

ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage and unstageable.

Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable.

Chapter 13: Diseases of the

Musculoskeletal System and

Connective Tissue (M00-M99)

Ref. 6

Site and Laterality

Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code available. For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.

7

_Character

extensions-7th_{character extensions are required for classification in}

pathological fracture:

• A-Initial encounter for 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

Chapter 13

Definitions-7th_{Character A- indicates currenttreatment}

Examples:

-Surgical procedure -ER visit

-Evaluation and treatment by a new clinician

Definitions-7th_{Character D- indicates encounters postactive}

Examples:

-Cast change or removal -Extraction of fixation device -Medication alteration

-Other aftercare and follow-up encounters

Chapter 13

Coding Notes:

Three ways to classify pathological

fractures-• As a result of neoplastic disease

• Resulting from osteoporosis

• Caused by other specified disease

Osteoporosis with current pathological fracture

Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathological fracture at the time of the encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

Coding Guidelines CH 13

Chapter 14: Diseases of the

Genitourinary System (N00-N99)

Chronic kidney disease and kidney transplant status

Patients who have undergone kidney transplant may still have some form of chronic kidney disease CKD because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant

complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status.

Coding Guidelines CH 14

Chronic kidney disease and kidney transplant status

If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a

complication of the transplant, query the provider.

Chapter 15: Pregnancy, Childbirth,

and the Puerperium (O00-O9A)

Ref. 1

129

Terminology

ICD-10-CM uses “Sequelae”to indicate something following or

comes later

Example:

• ICD-10 CM, code O94, Sequelaeof complication pregnancy,

childbirth and the puerperium

Time frame changes for ICD-10-CM

• Fetal death now classified as after 20 completed weeks of

gestation

Example:

O36.4xx_- Maternal care for intrauterine death

• Abortion now classified as before completion of 20 weeks

gestation

Example:

Code O02.1-Missed abortion

Chapter 15

131

Time frame changes for ICD-10-CM

• Early vomiting now classified as starting before the end of the

20th_{week gestation}

Example:

O21.0 Mild hyperemesis gravidarum

• Late vomiting now classified as starting after 20 completed

weeks gestation

Example:

O21.2 Late vomiting of pregnancy

Time frame changes for

ICD-10-CM-• Preterm labor classified as before 37 completed weeks of

gestation

Example:

O60.10x0-Preterm labor with preterm delivery, unspecified trimester

Chapter 15

133

Coding Notes:

Axis of classification now trimester in which condition happened NOT episode of care

• Trimesters classified as:

– 1st_{trimester less than 14 weeks gestation}

– 2nd_{trimester 14 weeks to 28 weeks gestation}

– 3rd_{trimester 28 weeks through delivery}

Changes in final character for

trimester-• Final character in code will identify trimester

• No longer used are antepartum, postpartum and if a delivery

occurred

• Clinician documentation should indicate final character

assignment

• Use “in childbirth” when delivery takes place during the

current admission

Chapter 15

135

Obstruction of

labor-• Combination codes- obstructed labor codes now incorporate

the cause of the obstruction into one code

Examples:

ICD-9-CM-660.0and652.4 Obstructed labor due to face

presentation

ICD-10-CM- Subcategory O64.2 Obstructed labor due to face

presentation

Unspecified trimester

• Codes are available for unspecified trimester but should only

be used when not indicated in documentation

Chapter 15

137

Seventh character needed to classify each fetus in 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

Chapter 15

New 7

_{character for fetus identification}

7th_{character required for several categories to identify fetus}

which condition is applicable

• Assign “0”

– Single gestations

– Insufficient documentation to identify fetus affected and

query is not possible

– Clinically impossible to know which fetus is affected

Chapter 15

139

Outcome of delivery

code-Code from categoryZ37, outcome of delivery must be indicated

in maternal record when delivery has happened

Examples:

• ICD-10-CM Z37.0 Single live birth

Weeks of gestation

code-• Codes from category Z3A Weeks of gestation, must be

indicated on mother’s record to identify weeks of gestation in pregnancy.

Chapter 15

141

Abuse in a pregnant

Subcategories-O9A.3_-Physical abuse complication pregnancy, childbirth and the puerperium

O9A.4_-Sexual abuse complication pregnancy, childbirth and the puerperium

O9A.5_-Psychological abuse complicating pregnancy, childbirth and the puerperium

Chapter 16: Certain Conditions

Originating in the Perinatal period

(P00-P96)

Ref. 2

143

Coding Notes:

• Perinatal period classified as before birth through the first

28 days after birth

• Chapter 16 codes are only used on newborn records

NEVERin the mother’s record

Terminology

Term “fetus” not used in ICD-10-CM

• “Newborn” is correct term

Chapter 16

145

Bacterial sepsis of the

newborn-Category P36, bacterial sepsis of the newborn, includes

congenital sepsis. If a perinate is documented as having sepsis without documentation of congenital or community acquired, the default is congenital and a code from category P36 should

be assigned. Cont’d

Bacterial sepsis of the

newborn-If the P36 code includes the causal organism, an additional code from category B95. Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, should not be assigned. If the P36 code does not include the causal organism, assign an additional code from category B96. If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.

Coding Guidelines CH 16

147

Principal diagnosis for Birth

Record-When coding the birth episode in a newborn record, assign a code from category Z38, Liveborn infants according to the place of birth and type of delivery, as the principal diagnosis. A code from Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital. A code from category Z38 is used only on the newborn record,

not on the mother’s record.

Prematurity and Fetal Growth Retardation

Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless it is documented. Assignment of codes in categories P05,

Disorders of the newborn related to slow fetal growth and fetal malnutrition and P07 Disorders of the newborn related to short gestation and low birth weight, not elsewhere classified, should be based on the recorded birth weight and estimated gestational age. Codes from category P05 should not be assigned with codes from category P07.

Coding Guidelines CH 16

149

Prematurity and Fetal Growth

Retardation-When both birth weight and gestational age are available, two codes from category P07 should be assigned, with the code for birth weight sequenced before the code for gestational age.

Coding Notes:

• If both birth weight and gestational age of newborn are

documented, both must be coded

• Birth weight sequenced before gestational age

Chapter 16

151

Stillbirth-• Code P95

• Only for use in facilities that create and maintain separate

records for stillbirth

• CodeP95 must be used alone

• Never used on the maternal record

Chapter 17: Congenital Malformations,

Deformations and Chromosomal

Abnormalities (Q00-Q99)

Ref. 3

153

Updated

Subcategory Q61Cystic kidney disease

• Q61.0_ Congenital renal cyst

• Q61.1_ Polycystic kidney, infantile type

• Q61.2 Polycystic kidney, adult type

Chapter 18: Symptoms, signs and

abnormal clinical and laboratory

findings, NEC (R00-R99)

Ref. 4

155

4. Codes that describe symptoms and signs

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established/confirmed by the provider.

5. Conditions that are an integral part of a disease process

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Coding Guideline 1.B.4/5 – Codes for

symptoms and signs

Coma

Scale-The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code (s).

These codes, one from each subcategory, are needed to complete

the scale. The 7th_{character indicates when the scale was}

recorded. The 7th_{character should match for all three codes.}

Cont’d

Coding Guidelines CH 18

157

Coma

Scale-At a minimum report the initial score documented on presentation your facility. This may be a score from the emergency medicine technician (EMT) or the emergency department. If desired, a facility may choose to capture multiple coma scale scores.

Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score (s).

Coma Scale

-Subcategory examples:

• R40.21_ Coma scale, eyes open

• R40.22_ Coma scale, best verbal response • R40.23_ Coma scale, best motor response

7th_{character required for codes in subcategories}

• R40.211_, Coma scale, eyes open, never

• R40.221 _, Coma scale, best verbal response, none

• R40.231 _, Coma scale, best motor response, none

Chapter 18

159

Chapter 19: Injury, Poisoning and

Certain Other Consequences of

External Causes (S00-T88)

Specificity challenges:

• Inclusion of the term “corrosion”

• Underdosing

• Terminology displaced and nondisplaced

• Increased specificity for fractures

• Fractures require seventh character extension

• Gustilo open fracture classification

• Combination codes

Chapter 19

161

Use of terms displaced or nondisplaced

• Fractures not documented as displaced or nondisplaced must

be coded todisplaced

• Fractures not indicated as open or closed must be classified to

closed

Coding fractures in ICD-10-CM

Documentation needed for correct coding of fractures: - specific type of fracture

-anatomical site

-displaced or nondisplaced -laterality

-delayed or routine healing -nonunions

-malunions

Chapter 19

163

Seventh character extension used in

fractures-• 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

Seventh character extension for open

fractures-Certain fracture categories provide 7th_{character extensions based}

on Gustilo open fracture classification to identify particular type of open fracture

Examples:

• B- used for initial encounter for open fracture type I or II

(initial encounter for open fracture NOS)

• C- initial encounter for open fracture type IIIA, IIIB, IIIC

Chapter 19

165

Application of 7

_{Characters in Chapter 19}

Most categories in Chapter 19 have a seventh character

requirement for each applicable code. Most categories in this

chapter have three 7th_{character values (with the exception of}

fractures)

A-initial encounter D-subsequent encounter S-sequela

Categories for traumatic fractures have additional 7th_character

values.

Initial vs. Subsequent Encounter for Fractures

Traumatic fractures are coded using the appropriate 7th _character

for initial encounter (A,B,C) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. The appropriate seventh character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Coding Guidelines CH 19

167

Initial vs. Subsequent Encounter for Fractures

Care of complications of fractures, such as malunion and

nonunion, should be reported with the appropriate 7th

character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).

Adverse effects, Poisoning, Underdosing and Toxic

Effects

Codes in categories T36-T65 are combination codes that include the substance that was taken as well as the intent. No

additional external cause code is required for poisonings, toxic effects, adverse effects, and underdosing codes.

Coding Guidelines CH 19

169

Adverse Effect

When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50).

The code for the drug should have a 5th_{or 6}th_{character “5”}

(for example T36.0X5-) Examples of the nature of an adverse effect are tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure.

Underdosing

Underdosing refers to taking less of a medication than is

prescribed by a provider or a manufacturer’s instruction. For underdosing, assign codes from categories T36-T50 (fifth or

sixth character 6). Cont’d

.

Coding Guidelines CH 19

171

Underdosing

Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.

Superficial injuries

Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

Coding Guidelines CH 19

173

Chapter 20: External Causes of

Morbidity (V00-Y99

)

External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military).

Coding Guidelines CH 20

175

Place of occurrence

Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify the location of the patient at the time of injury or other condition.

A place of occurrence code Y92 is used only once, at the initial

encounter for treatment. No 7th_{characters are used for Y92.}

Only one code from Y92 should be recorded on a medical record. A place of occurrence code should be used in conjunction with an activity code, Y93.

Activity Code

Assign a code from category Y93, Activity code, to describe the activity of the patient at the time the injury or other health condition occurred.

An activity code Y93 is used only once, at the initial encounter for treatment. Only one code from Y93 should be recorded on a medical record. An activity code should be used in

conjunction with a place of occurrence code, Y92.

Coding Guideline CH 20

177

External Cause Code Used for Length of Treatment

Assign the external cause code with the appropriate seventh character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated.

Chapter 21: Factors Influencing

Health Status and Contact with

Health Services (Z00-Z99)

Ref. 7

179

Coding Notes:

• ICD-10-CM has extended personal and family history coding

• Codes have been added to specify blood type

• No longer used ICD 9-CM Category V57 Care involving use

of rehabilitation procedures

– Instead in ICD-10-CM- code condition that necessitated therapy with appropriate 7th_{character for subsequent} encounter