ICD-10-CM Coding Overview AHCA Spring Convention & Trade Show April 21-23, 2015

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ICD-10-CM Coding Overview

AHCA

Spring Convention & Trade Show

April 21-23, 2015

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Why the Conversion to ICD-10-CM?

ICD-10-CM provides more specific data than ICD-9-CM ―Better reflection of current medical practice

– Structure accommodates addition of new codes – The current coding system is running out of capacity

and cannot accommodate future state of health care – Reduce coding errors

– Better analysis of disease patterns

– Track and respond to public health outbreaks – Make claim submission more efficient

– Identify fraud and abuse 2

Structural Differences Between

ICD-9-CM and ICD-10-CM

ICD-9-CM • 3 - 5 characters • First character is numeric or alpha • Characters 2 - 5 are numeric • Always at least 3 characters

• Use of decimal after 3 characters

• 3 - 7 characters • Character 1 is alpha • Character 2 is numeric • Characters 3 - 7 are alpha or

numeric

• Use of decimal after 3 characters

• Use of dummy placeholder “x” • Alphabetical characters are not

case-sensitive

ICD-10-CM

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Other Differences Between

ICD-9-CM and ICD-10-CM

ICD-9-CM

• 14,025 codes • Only uses 2 letters

E, V • 17 Chapters • Hospital codes not

used in LTC • V-Code – Multiple

therapies as primary

ICD-10-CM

• 68,069 codes

• Uses all letters except U • 21 Chapters

• Acute codes with appropriate 7th_{character to indicate}

subsequent care or sequela • No Z code for “Multiple

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CPT and HCPCS

• No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS).

• CPT and HCPCS will continue to be used for Part B claims just as they are currently.

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Systems/Applications Potentially

Affected by Transition

(not all-inclusive list)

• MDS software

– New MDS form effective Oct. 1, 2015 – MDS Section Diagnosis updates – Quality Measure risk factors/exclusions – PPS RUGs – diagnoses

• Billing software

• Electronic health record systems

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ICD-10-CM Format

• ICD-10-CM code set is divided into two main parts:

– The Index which is an alphabetical list of terms and their corresponding code. – Tabular List which is a sequential,

alphanumeric list of codes divided into chapters based on body system or condition.

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The Index

• The Alphabetic Index includes: – The Index of Diseases and Injury – The Index of External Causes of Injury – Neoplasm Table

– Table of Drugs and Chemicals

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Tabular List

• Tabular List contains categories, subcategories, and codes which may be a letter or a number. • All categories are three characters and if there is

no further subdivision that is a code.

• Subcategories are either four or five characters. • Codes can be three to seven characters in length. • A code that has an applicable 7th_{character is}

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ICD-10-CM Websites

• CDC

http://www.cdc.gov/nchs/icd/icd10cm.htm

• CMS

http://cms.gov/Medicare/Coding/ICD10/201 4-ICD-10-CM-and-GEMs.html

• ICD-9-CM to ICD-10-CM Crosswalk

http://www.icd10data.com/Convert

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NEW Coding Conventions and

Terms

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New Placeholder Character

• The ICD-10-CM utilizes a placeholder character “X”.

• The “X” is used as a placeholder for future expansion.

• Where a placeholder exists, the “X” must be used in order for the code to be valid.

• Couldn’t find a common LTC example so will

rarely be used.

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7

th

_{Character Example}

18 Certain ICD-10-CM categories have 7th_character.

Applicable 7th_{character is required for all codes within the category or as}

instructed by the notes in the Tabular List.

S72.00D for example would be Fracture of Unspecified part of neck of femur, and 7th_{character D means subsequent encounter for closed fracture with}

routine healing.

Expanded Combination Codes

• ICD-9-CM had combination codes but

much more prevalent in ICD-10-CM due to greater specificity.

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

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Diabetes Combination Code

Examples

E08.3 Diabetes mellitus due to underlying condition with ophthalmic complications E08.31 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy

E08.311 Diabetes mellitus due to underlying condition with

unspecified diabetic retinopathy with macular edema

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New Laterality – BIG CHANGE

• ICD-10-CM allows us to specify left, right, or bilateral for certain codes. This was not

available with ICD-9-CM.

– If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

• If the side is not identified in the medical record, code unspecified side.

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Expanded - Excludes Notes

• Excludes notes tell you that the code you are looking up excludes a certain diagnosis. • Had Excludes Notes with ICD-9-CM but

they are expanded to include types of excludes notes.

– Now Type 1 and Type 2

• Each type has different definition for use but similar in that codes excluded from each other

are independent of each other. ₂₃

Excludes1 Example

Telling you that aftercare for healing fx is not included in Z47 Orthopedic Aftercare

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Excludes2 Example

Telling you that fitting and adjustment is excluded but may use both codes

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New “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 directions.

• So if you are looking up a code and see a “Code also note”, you would also code any of these diagnoses listed in the note that the resident may have.

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Code Also Example

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New Default Codes

• The default code is listed next to a main term

in the ICD-10-CM Alphabetic Index.

• 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.

• So if you just have a generic diagnosis with no detail use code listed next to main term.

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Default Code Example

29 So if you didn’t have any more

information than a generic dx of Hypertension, you would use the code next to main term hypertension which is I10

ICD-10-CM Coding Examples

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ICD-10-CM Coding Example #1

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ICD-10-CM Coding Example #2

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ICD-10-CM Coding Example #2

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ICD-10-CM Coding Example #3

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ICD-10-CM Coding Example #3

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ICD-10-CM Coding Example #3

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ICD-10-CM Coding Example #4

Unspecified Code

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ICD-10-CM Coding Example #4

Unspecified Code

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ICD-10-CM Coding Example #5

Unspecified Code

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ICD-10-CM Coding Example #5

Unspecified Code

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Chapter Specific Guidelines

Will address additional coding guidelines not already covered in General Guidelines

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Chapter-Specific Coding Guidelines

• In addition to general coding guidelines, there are guidelines for specific diagnoses and/or

conditions in the classification.

• Unless otherwise indicated, these guidelines apply to all health care settings.

• There are 21 chapters in the Official Coding Guidelines for ICD-10-CM.

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Ch. 21: Factors Influencing Health Status and

Contact with Health Services (Z00-Z99)

• NEW letter for V Codes of ICD-9-CM. • Z codes are for use in any healthcare setting.

– Z codes are not procedure codes so are used in LTC • Z codes may be used as either a first-listed

(principal diagnosis code in the inpatient setting) or secondary code, depending on the

circumstances of the encounter.

• Certain Z codes may only be used as first-listed/principal diagnosis.

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Categories of Z Codes

Status

– Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. – A status code is informative, because the

status may affect the course of treatment and its outcome.

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Status Z Code Categories

• Z16, Resistance to antimicrobial drugs

– This code indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first.

• Z22, Carrier of infectious disease

– Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection.

• Z66, Do not resuscitate • Z74.01, Bed confinement status

• Z78.1, Physical restraint status 48

Status Z Code Categories

• Z79 Long-term (current) drug therapy

– Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer).

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Categories of Z Codes

Aftercare

–Aftercare visit codes cover situations

when the initial treatment of a disease

has been performed and the patient

requires continued care during the

healing or recovery phase, or for the

long-term consequences of the disease.

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New - Aftercare Z Codes

• The aftercare Z code should not be used if treatment is directed at a current, acute disease. Use dx code instead.

• The aftercare Z codes should not be used for

injuries.

– For aftercare of an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter).

– The aftercare codes are generally first-listed (principal) diagnosis to explain the specific reason for the encounter.

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Aftercare Z Codes

• Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequela (late effects). For others, the condition is included in the code title.

• Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings.

• Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare.

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Z47 Orthopedic Aftercare Example

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Orthopedic Aftercare Examples

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Chapter 9 Diseases of the Circulatory

System (I00-I99)

• New laterality codes • Dominant/non-dominant

default codes

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Sequela (Late Effects)

• 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 effects.

• We use the Sequela or Late Effects code in

LTC which are the I69 codes in ICD-10-CM just like we used the 438 (Late Effects) codes rather than 436 (Acute) codes in ICD-9-CM.

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Sequelae of Cerebrovascular Disease

Examples

• I69.021 Dysphagia following nontraumatic subarachnoid hemorrhage

• I69.951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side

• I69.30 Unspecified sequelae of cerebral

infarction

**The I69 sequelae codes will be very common for

LTC. ₅₇

New - Application of 7

th

_Characters

in Chapter 19 including Fractures

• Most categories in this chapter have three 7th character values (with the exception of fractures):

– A, initial encounter (not used in LTC) – D, subsequent encounter

– S, sequela

• Categories for traumatic fractures have additional 7th character values.

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New - Application of 7

th

_Characters

in Chapter 19 including Fractures

• 7th character A is for use as long as the patient is receiving active treatment for the fracture in the hospital setting. You will see this on diagnosis coming from the hospital.

– Examples of active treatment which would use 7th

Character A are: » surgical treatment

» emergency department encounter » evaluation and treatment by the same or a

different physician (but still during active

treatment) 59

New - Application of 7

th

_Characters

in Chapter 19 including Fractures

• We would NOT use the 7th_{character A in LTC}

but need to recognize this code coming from the hospital and know that we would need to change 7th_{character to appropriate subsequent}

character such as D or S for (sequela). ****This applies to certain chapters like Chapter

13 (musculoskeletal) and Chapter 19 (Fractures).

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New - Application of 7

th

_Characters

in Chapter 19 including Fractures

• 7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. • Examples of subsequent care are:

– SNF care

– removal of external or internal fixation device – medication adjustment

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Coding of Traumatic

Fractures/Injuries

• The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

• A fracture not indicated as open or closed should be coded as Closed.

• A fracture not indicated whether displaced or not displaced should be coded to Displaced.

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New - Fracture Complications

• 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).

• 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.

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Process for Coding

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Locating a Code

PROCESS IS NOT NEW

• First locate term in the Alphabetic Index. • Then verify in the Tabular List.

• Read and be guided by instructional notations that appear in both.

• Essential to use both Alphabetic Index and Tabular List.

• Alphabetic Index does not always provide the full code.

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Level of Detail

• A three-character code is to be used only if it is not further subdivided.

• A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.

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Assigning ICD-10-CM Codes

• When searching in Alphabetic Index: 1. Review the diagnostic statement

2. Identify the main terms which are diseases or conditions – nouns

3. Do not start with anatomical site

4. Review diagnostic statement from right to left 5. Capture all components of diagnoses when possible

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How to Assign a Code

• Example: COPD

Chronic Obstructive Pulmonary Disease 1. Start with Disease

2. Then, Pulmonary 3. Next, Obstructive 4. Last, Chronic 69

ICD-9-CM to ICD-10-CM

Case Studies

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Coding Example

#1

Resident is admitted to Shiny Skies Nursing and Rehabilitation Center following a CVA resulting in Left-Sided Hemiparesis and Dysphagia that required placement of a G-tube. Resident is left handed. Resident also has Type II Diabetes. Resident will be receiving PT for gait training, OT for muscle weakness, and ST for dysphagia.

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ICD-9-CM Answers for

Coding Example #1:

– V57.89 Care involving use of rehab services; Other (Multiple training or therapy) – 438.82 Late effects of Cerebrovascular Disease,

Dysphagia

– 438.21 Late effects of Cerebrovascular Disease, Hemiplegia affecting dominant side – V55.1 Attention to artificial opening; gastrostomy – 250.00 DM type II without mention of

complication 72

ICD-9-CM Answers for

Coding Example #1, continued:

− 781.2 Abnormality of gait

− 728.87 Generalized muscle weakness − 787.20 Dysphagia, unspecified (Difficulty in

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ICD-10-CM Answers for

Coding Example #1:

– I69.321 Dysphagia following cerebral infarction

– I69.352 Hemiplegia and hemiparesis

following cerebral infarction affecting left dominant side

– Z43.1 Attention to gastrostomy

– E11.9 Type II Diabetes with other circulatory complications

– R26.9 Unspecified abnormalities of gait/mobility – M62.81 Muscle weakness, generalized

– R13.10 Dysphagia, unspecified ₇₄

Coding Example

#2

Resident is admitted to your facility status post traumatic greater trochanter displaced right femur fracture from a fall that occurred at home. Resident presented with a Stage 2 pressure ulcer on both heels and coccyx. Resident will be receiving both PT and OT services. Resident also has a diagnosis of Essential Hypertension. PT will be treating resident for Difficulty Walking and OT for

muscle weakness. 75

ICD-9-CM Answers for

Coding Example #2:

– V57.89 Care involving use of rehab services; Other (Multiple training or therapy) – V54.15 Aftercare from traumatic upper leg

fracture

– 719.7 Difficulty Walking

– 728.87 Muscle Weakness (Generalized) – 707.03 Pressure Ulcer, coccyx – 707.07 Pressure Ulcer, heel – 707.22 Pressure Ulcer, stage 2

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ICD-10-CM Answers for

Coding Example #2:

− S72.111D Displaced fracture of greater trochanter of right femur, subsequent

encounter for closed fracture with routine healing (7th_{character “D”)}

− R26.2 Difficulty in walking, not elsewhere classified − M62.81 Muscle weakness, generalized

− L89.612 Pressure ulcer of right heel, stage 2 − L89.622 Pressure ulcer of left heel, stage 2 − L89.152 Pressure ulcer of sacral region, stage 2 − I10 Essential (primary) Hypertension

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Coding Example

#3

Resident is admitted to Home Sweet Home following abdominal surgery for bowel obstruction. Resident has post operative superficial wound that requires BID dressing changes due to abdominal dehiscence. Resident also has newly diagnosed UTI with E. Coli isolated in the culture. Resident is symptomatic with frequency, urgency and burning upon urination. Oral antibiotics are ordered x10 days. Resident will not receive therapy upon admission.

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ICD-9-CM Answers for

Coding Example #3:

– 998.32 Disruption of external operation (surgical) wound (Abdominal dehiscence)

– V58.75 Aftercare following surgery of teeth, oral cavity and digestive system, NEC

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ICD-10-CM Answers for

Coding Example #3:

− T81.32xD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter

− Z48.815 Encounter for surgical aftercare following surgery on the digestive system

− Z48.01 Encounter for change or removal of surgical wound dressing

− N39.0 Urinary tract infection, site not specified − B96.20 Unspecified E. coli, as the cause of diseases

classified elsewhere 80

Coding Example

#4

Resident is admitted to Shady Grove after repair of a Fractured Left Hip sustained due to a fall. Resident has Left Hip Osteoarthritis from dysplasia with chronic NSAID use. Additional diagnoses include Essential Hypertension, Sinus Bradycardia and Hyperlipidemia NOS. Admission orders include lab work to monitor effect of Simivastatin and Omacor. Resident will be receiving PT for treatment of difficulty walking and OT therapy services for muscle weakness.

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ICD-9-CM Answers for

Coding Example #4:

− V57.89 Care involving use of rehabilitation services; Other (Multiple training or therapy) − V54.13 Aftercare healing traumatic fracture of hip − 715.95 Osteoarthrosis, unspecified whether

generalized or localized, pelvic region and thigh

− 719.7 Difficulty Walking

− 728.87 Muscle Weakness (Generalized)

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ICD-9-CM Answers for

Coding Example #4, continued:

− 401.9 Essential Hypertension, unspecified − 427.89 Sinus Bradycardia NOS

− 272.4 Other and unspecified hyperlipidemia − V58.83 Encounter for therapeutic drug

monitoring

− V58.69 Long-term (current) use of other medications

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ICD-10-CM Answers for

Coding Example #4:

− S72.002D Fracture of unspecified part of neck of left femur (Fracture of hip NOS) (7th

character D- subsequent encounter for closed fracture with routine healing)

− M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip

− Z79.1 Long-term (current) use of NSAIDS

− Z79.899 Other long term (current) drug therapy

− Z51.81 Therapeutic drug level monitoring

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ICD-10-CM Answers for

Coding Example #4:

Continued

− R26.2 Difficulty in walking, not elsewhere classified

− M62.81 Muscle weakness, generalized

−Z51.89

Encounter of other specified Aftercare

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Coding Example

#5

Resident was admitted to Daisy May SNF following a right total hip replacement at the hospital due to primary unilateral Osteoarthritis of right hip. Resident will be receiving PT for gait training due to difficulty walking. Resident will be receiving OT for muscle weakness.

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ICD-9-CM Answers for

Coding Example #5:

− V57.89 Multiple Therapies

− V54.81 Aftercare following joint replacement (note to use additional code to identify joint

replacement site (V43.60-V43.69) − V43.64 Organ or tissue replaced by other means,

joint, hip

− 715.15 Osteoarthrosis, localized, primary, pelvic region and thigh

− 719.7 Difficulty walking

− 728.87 Muscle Weakness (generalized) 87

ICD-10-CM Answers for

Coding Example #5:

− Z47.1 Aftercare following joint replacement surgery (Note to use additional code to identify the joint (Z96.6-)

− Z96.641 Presence of right artificial hip joint − M16.11 Unilateral primary osteoarthritis, right

hip

− Z51.89 Encounter of other specified Aftercare − R26.2 Difficulty in walking, not elsewhere

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Coding Example #6

(Continued Stay)

A current SNF resident resides in the nursing home due to residual effects from a

cerebrovascular accident several years ago. Resident has hemiplegia and hemiparesis affecting right dominant side. Now while in the SNF, the resident developed symptoms of Pneumonia and had to be transferred to the hospital for treatment. Upon return to the SNF, what would be the proper sequencing of

diagnosis codes? 89

Answers for Coding Exercise #6:

(Continued Stay)

ICD-9-CM:

• 438.21, Hemiplegia affecting dominant side • 486, Pneumonia (unspecified)

ICD-10-CM:

• I69.851 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side

• J18.9, Pneumonia, unspecified

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Summary of ICD-10-CM Changes

• Use combination code where available

– Use multiple codes if necessary to fully describe a condition

• Laterality – specify side(s) if code available • Use Placeholder “X” as appropriate

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Summary of ICD-10-CM Changes

• No more Z code (formerly V code) as

primary for therapy. Instead use diagnosis that

warrants the therapy as principal diagnosis. – Continue to use Therapy Treatment codes • No more aftercare for fractures. Use acute

fracture code with appropriate subsequent 7th

character such as “D” for aftercare or “S” for sequela.

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Transitioning to ICD-10-CM

• Identify your current systems and work processes that use ICD-9-CM codes.

• Communicate implementation plans between providers, payers, and vendors.

• Identify potential changes to workflow and business processes.

• Budget for time and money related to the implementation.

• Allow enough time to test transactions.

• Assess staff training needs. 93

Transitioning to ICD-10-CM

• Begin assigning ICD-10-CM codes to long term care residents as part of quarterly review.

– MDS with ARD Oct. 1 or later; use ICD-10-CM codes on MDS

• Begin assigning ICD-10-CM codes to Medicare admission around August.

– MDS with ARD Oct. 1 or later; use ICD-10-CM codes

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Billing Part A through the Transition

• All institutional claims are required to be billed monthly.

• For Part A, use ICD-9-CM codes for September claims and then convert these codes into ICD-10-CM codes for your October claim. You may also need to update/change diagnoses like you normally would on a month to month basis for Part A based on resident status changes.

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Billing Part B through the Transition

• For Part B, with the same therapy regime

or plan of care, you simply need to convert

September ICD-9-CM codes into

ICD-10-CM codes for October.

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Training for ICD-10-CM

Suggested training curriculum

• Basic Understanding of the ICD-10-CM Code Set • ICD-10-CM Coding Diagnoses

• Clinical Definitions and Terms in ICD-10-CM • Using Systems updated for ICD-10-CM