ICD-10 CM Training. Family Practice

(1)

Family Practice

(2)

• ICD-10-CM will be valid for dates of service on or

after

October 1, 2015

– Outpatient dates of service of October 1, 2015 and

beyond.

– Inpatient hospital service claims, is effective for dates of

discharge after September 30, 2015

(3)

• Covered Entities

– Everyone covered by the Health Insurance Portability

Accountability Act (HIPPA)

• Non-Covered Entities

– Worker’s Compensation

– Auto Insurance

– Non covered HIPAA entities are exempt but are

encouraged to adapt the new code set

(4)

• 21 Chapters

• Alpha-numeric codes; not case-sensitive

– Codes begin with Alpha letter, A-Z, excluding U

– Common errors

• I verses 1

• O verses 0

• “X” Placeholder

• 3 to 7 characters

– Decimal following 3

rd

_character

(5)

• Placeholder “X”

– Used for future expansion of a code

– Fills in empty characters when a 6

th

_{and/or 7}

th

_character

apply

– The placeholder may be used in different scenarios but

should never serve as the final character.

Example: W19.XXXA Unspecified fall, Initial Encounter

(6)

• 7

th

_Character

– Provides specified information regarding the clinical visit

– Is required for certain categories and must be reported in

the seventh position

– May be alpha or numeric

– Has different meanings depending on the coding category

(7)

• Laterality

– Some ICD-10-CM codes indicate laterality, specifying

whether the condition occurs on the

left, right or is

bilateral

.

– 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, assign the

code for the unspecified side

.

OGCR section 1.B.13

(8)

• “Other” Codes

– Codes titled “other” or “other specified” are for use when

the information in the medical record provides detail for

which a specific code does not exist.

• “Unspecified” Codes

– Codes titled “unspecified” are for use when the

information in the medical record is insufficient to assign a

more specific code

.

OGCR section 1.A.9.a.b

(9)

• Excludes Notes

– Excludes1

• A type 1 Excludes note is a pure excludes note

• It means “NOT CODED HERE”

• The code excluded should never be used at the same time

• When two conditions cannot occur togethe

r

– Excludes2

• Represents “Not included here”

• The condition excluded is not part of the condition represented by

the code

• It is acceptable to use both the code and the excluded code

together, when appropriate

OGCR section 1.A.12.a.b

(10)

• “Code First” and “Use Additional Code”

– ICD-10 has a coding convention that requires the

underlying condition be sequenced first followed

by the manifestation.

– These instructional notes indicate the proper

sequencing order of the codes.

OGCR section 1.A.13

• The “-” indicates there are additional reporting

options

(11)

(12)

Diabetes

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

250.00 E11.9 Type 2 Diabetes mellitus without complications • Diabetes (mellitus) due to insulin secretory defect • Diabetes (NOS) • Insulin resistant diabetes (mellitus) Use additional code to identify any insulin use (Z79.4)

• Diabetes mellitus due to underlying condition (E08.-) • Drug or chemical induced

diabetes mellitus (E09.1-) • Gestational diabetes

(O24.4-)

• Neonatal diabetes mellitus (P70.2)

• Postpancreatectomy diabetes mellitus (E13.-) • Postprocedural diabetes

mellitus (E13.-)

• Secondary diabetes mellitus NEC (E13.-)

• Type 1 diabetes mellitus (E10.-)

• transitory endocrine and metabolic disorders specific to newborn (P70-P74

N/A

250.02 E11.65 Type 2 diabetes mellitus with hyperglycemia • Diabetes (mellitus) due to insulin secretory defect • Diabetes (NOS) • Insulin resistant diabetes (mellitus Use additional code to identify any insulin use (Z79.4)

• Diabetes mellitus due to underlying condition (E08.-) • Drug or chemical induced

diabetes mellitus (E09.1-) • Gestational diabetes

(O24.4-)

• Neonatal diabetes mellitus (P70.2)

• Postpancreatectomy diabetes mellitus (E13.-) • Postprocedural diabetes

mellitus (E13.-)

• Secondary diabetes mellitus NEC (E13.-)

• Type 1 diabetes mellitus (E10.-)

• transitory endocrine and metabolic disorders specific to newborn (P70-P74

(13)

Diabetes mellitus codes are now combination codes

that include the type of diabetes, the body system

affected, and the complication affecting that body

system. They are no longer classified as controlled or

uncontrolled.

• Type

– Type 1

– Type 2

– Due to underlying conditions

– Drug or chemical induced

– Other specified

(14)

• Complication Status

–

Without complication

–

With circulatory complication

–

With diabetic arthropathy

–

With hyperglycemia

–

With hyperosmolarity

–

With hypoglycemia

–

With ketoacidosis

–

With kidney complications

–

With neurologic complications

–

With ophthalmic complications

–

With oral complications

–

With skin complications

–

With other specified complications

(15)

• Complication Detail

–

With diabetic retinopathy

–

With cataract

–

With other ophthalmic complication

–

With chronic kidney disease

–

With nephropathy

–

With other kidney complication

–

With amyotrophy

–

With autonomic neuropathy

–

With mononeuropathy

–

With polyneuropathy

–

With other neurological complication

–

With unspecified neuropathy

–

With or without coma

–

With peripheral angiopathy with or without gangrene

–

With other circulatory complications

–

With neuropathic arthropathy

–

With other arthropathy

–

With dermatitis

–

With foot ulcer

–

With other skin ulcer

–

With other skin complication

–

With periodontal disease

–

With other oral complications

(16)

Diabetes is a chronic condition that requires multi-specialty

management.

• The documentation should indicate relevant details regarding the

management of each case as it relates to the services rendered or

actions taken to coordinate the patients care.

• The HPI, at a minimal, should include some indication of the

historical timeline or duration of the illness, levels as it relates to

the date of service, manifestations or impairments associated with

the condition and effectiveness of current medication regimen.

• The examination should notate any physical signs related to the

diabetic conditions. (Ulcers, nails, edema, discoloration sensitivity

to touch)

(17)

Hypertension

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

401.1 401.9 401.0

I10 Essential (Primary) Hypertension Includes: high blood pressure, Hypertension (arterial) (benign) (essential) (malignant) (systemic) • Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16) • Neonatal hypertension (P29.2) • Primary pulmonary hypertension (I127.0) • Essential (primary) hypertension involving vessels of brain (I60-I69) • Essential (primary)

hypertension involving vessels of eye (H35.0-)

Hypertensive Diseases Categories (I10-I15) The use additional codes and Excludes1 codes apply for all categories.

(I10-I15) Use additional code to identify:

• Exposure to

environmental tobacco smoke (Z77.22) • History of tobacco use

(18)

Hypertension cont.

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

402.01 402.11 402.91

I11.0 Hypertensive Heart Disease with heart failure

• Use additional code to identify type of heart failure (I50.-)

N/A N/A

402.00 402.10 402.90

I11.9 Hypertensive Heart Disease without heart failure

N/A N/A

403.01 403.11 403.91

I12.0 Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or end stage renal disease. • Use additional code to

identify the stage of chronic kidney disease (N185.5, N18.6)

• Hypertension due to Kidney Disease (I15.0, I15.1)

• Renovascular Hypertension (I15.0) • Secondary Hypertension

(I115.-)

Acute Kidney Failure (N17.-)

403.00 403.10 403.90

I12.9 Hypertensive Chronic Kidney Disease with stage 1-4 Chronic Kidney Disease, or unspecified Chronic Kidney Disease.

• Use additional code to identify the stage of chronic kidney disease (N18.1-N18.9)

• Hypertension due to Kidney Disease (I15.0, I15.1)

• Renovascular Hypertension (I15.0) • Secondary Hypertension

(I115.-)

(19)

Hypertension cont.

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

404.01 404.11 404.91

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney disease

• Use additional code to identify type of heart failure (I50.-) • Use additional code to identify

stage of chronic kidney disease (N18.1-NN18.4, N18.9)

N/A N/A

404.00 404.10 404.90

I13.10 Hypertensive Heart and Chronic Kidney Disease without heart failure, with stage 1-4 chronic kidney disease, or unspecified chronic kidney disease.

• Use additional code to identify the stage of chronic kidney disease (N18.1-N18.4, N18.9)

N/A N/A

404.02 404.12 404.92

I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease.

• Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6)

N/A N/A

404.03 404.13 404.93

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease.

• Use additional code to identify type of heart failure (I50.-) • Use additional code to identify

the stage of chronic kidney disease (N18.5. N18.6)

(20)

Hypertension cont.

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

405.01 405.11 405.91

I15.0 Renovascular Hypertension • Code also underlying

condition

Postprocedural hypertension (I97.3)

• Secondary hypertension involving vessels of brain (I60-I69)

• Secondary hypertension involving vessels of eye (H35.0-)

405.91 I15.1 Hypertension secondary to other renal disorders • Code also underlying

condition

405.99 I15.2 Hypertension secondary to endocrine disorders • Code also underlying

condition

405.09 405.19 405.99

I15.8 Other secondary hypertension

• Code also underlying condition

405.99 I15.9 Secondary hypertension, unspecified

• Code also underlying condition

(21)

• Hypertension is no longer classified as benign, malignant or unspecified.

• ICD-10 Codes have been grouped according to disease progression:

– I10

Essential Hypertension

– I11.-

Hypertensive Heart Disease

– I12.-

Hypertensive CKD

»

Further subdivided by stage of kidney disease

– I13.-

Hypertensive Heart and CKD

»

Further subdivided by stage of kidney disease

– I15.-

Secondary Hypertension

• Transient Hypertension

– A code for hypertension is NOT assigned unless the patient has a

documented, established diagnosis of hypertension.

• R03.0 Elevated blood pressure reading without diagnosis of hypertension

• Document requirements

– Type

– Current Status

– Associated relationships

(22)

Hyperlipidemia

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

272.4 E78.4

Other

Hyperlipidemia

• Familial

combined

hyperlipidemia

• Sphingolipidosis

(E75.0-E75.3)

N/A

272.4 E78.5

Hyperlipidemia,

unspecified

There are more specific code choice selections available below:

(23)

• Type

– Mixed

– Other

– Unspecified

(24)

Dorsalgia

Category M54

Excludes1

Excludes2

(25)

Cervicalgia

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

723.1 M54.2

Cervicalgia

• Cervicalgia due to

intervertebral

cervical disc

disorder (M50.-)

• Category M54

Excludes2

Sciatica

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

724.3 M54.30

Sciatica, unspecified side

• Lesion of sciatic

nerve (G57.0)

• Sciatica due to

intervertebral disc

disorder (M51.1-)

• Sciatica with

lumago (M54.4-)

• Category M54

Excludes2

724.3 M54.31

Sciatica, right side

• Lesion of sciatic

nerve (G57.0)

• Sciatica due to

intervertebral disc

disorder (M51.1-)

• Sciatica with

lumago (M54.4-)

• Category M54

Excludes2

(26)

Lumbago with Sciatica724.3

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

724.3 M54.40

Lumbago with sciatica,

unspecified side

• Lumbago with sciatica due

to intervertebral disc

disorder (M51.1-)

• Category M54

Excludes2

724.3 M54.41

Lumbago with sciatica,

right side

• Lumbago with sciatica due

to intervertebral disc

disorder (M51.1-)

• Category M54

Excludes2

724.3 M54.42

Lumbago with sciatica, left

side

• Lumbago with sciatica due

to intervertebral disc

disorder (M51.1-)

• Category M54

Excludes2

Low Back Pain

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

724.2 M54.5

Low back pain

• Loin pain

• Lumbago NOS

• low back strain

(S39.012)

• lumbago due to

intervertebral disc

displacement (M51.2-)

• lumbago with sciatica

(M54.4-)

• Category M54

Excludes2

Pain in Thoracic Spine

724.1 M54.6

Pain in thoracic spine

• Pain in thoracic spine due

to intervertebral disc

disorder (M51.-)

(27)

Dorsalgia

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

724.5 M54.89

Other dorsalgia

• current injury - see injury

of spine by body region

discitis NOS (M46.4-)

• Dorsalgia in thoracic

region (M54.6)

• Low back pain (M54.5-)

(28)

• Document site and laterality

– Unspecified codes should be used only in rare

circumstances

• Use an external cause code following the code for

the musculoskeletal condition, if applicable, to

identify the cause of the musculoskeletal condition.

(29)

Encounter for General Adult Medical Examination

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

V70.0

Z00.00

Encounter for general

adult medical

examination without

abnormal findings

• Encounter for adult

health check-up

NOS

• Examinations

related to pregnancy

and reproduction

(Z30-Z36, Z39-)

• Encounter for

examination for

administrative

purposes (Z02.-)

• Encounter for

pre-procedural

examinations

(Z01.81-)

• Special screening

examinations

(Z11-Z13)

V70.0

Z00.01

Encounter for general

adult medical

examination with

abnormal findings

• Use additional code

to identify abnormal

findings

Note: Nonspecific

abnormal findings

disclosed at the time of

these examinations are

classified to categories

R70-R94.

• Examinations

related to pregnancy

and reproduction

(Z30-Z36, Z39-)

• Encounter for

examination for

administrative

purposes (Z02.-)

(30)

• Identify routine health check

– Adult

– Child

– Newborn

• Under 8 days old

• 8-28 days old

• Identify presence/absence of abnormal findings

– With abnormal findings

– Without abnormal findings

• Use an additional code for any abnormal findings

– Document abnormal findings

(31)

Chronic Obstructive Pulmonary Disease (COPD)

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

496 J44.9

Chronic obstructive

pulmonary disease,

unspecified

Applicable to:

• Chronic obstructive

airway disease NOS

• Chronic obstructive

lung disease NOS

• Bronchiectasis (J47.-)

• Chronic bronchitis NOS

(J43)

• Chronic simple and

mucopurulent bronchitis

(J14.-)

• Chronic tracheitis (J42)

• Chronic tracheobronchitis

(J42)

• Emphyysema without

chronic bronchitis (J43.-)

• Lung diseases due to

external agents (J60-J70)

N/A

There are more specific code choice selections below:

491.22

493.21 J44.0

Chronic obstructive pulmonary disease with acute lower respiratory

infection

491.21

493.22

(32)

• Type

– Chronic bronchitis

• Simple

• Mucopurulent

• Mixed simple and mucopurulent

– Emphysema

• Centrilobular

• Panlobular

• Unilateral

– COPD with acute exacerbation

– COPD with acute lower respiratory injection

• Identify the infection (use additional code)

(33)

• Code also type of asthma, if applicable (J45-)

• Use additional code to identify:

– Exposure to environmental tobacco smoke (Z77.22)

– History of tobacco use (Z87.891)

– Occupational exposure to environmental tobacco

smoke (Z57.31)

– Tobacco dependence (F17.-)

– Tobacco use (Z72.0)

(34)

Encounter for other preprocedural examination

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

V72.83

Z01.818

Encounter for other

preprocedural examination

Applicable To:

• Encounter for

preprocedural

examination NOS

• Encounter for

examinations prior to

antineoplastic

chemotherapy

• encounter for

examination for

administrative purposes

(Z02.-)

• encounter for

examination for

suspected conditions,

proven not to exist (Z03.-)

• encounter for laboratory

and radiologic

examinations as a

component of general

medical

examinations(Z00.0-)

• encounter for laboratory,

radiologic and imaging

examinations for sign(s)

and symptom(s) - code to

the sign(s) or symptom(s)

• special

screening

examinations

(Z11-Z13)

There are more specific code choice selections below:

V72.81

Z01.810

Encounter for preprocedural cardiovascular examination

V72.82

Z01.811

Encounter for preprocedural respiratory examination

V72.63

Z01.812

Encounter for preprocedural laboratory examination

(35)

• Includes: routine examination of specific system

• Codes from category Z01 represent the reason for

the encounter.

• Use when a patient is being cleared for a procedure

or surgery and no treatment is given.

(36)

Atrial fibrillation

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

427.31 I48.91

Unspecified atrial

fibrillation

N/A

There are more specific code choice selections available below:

I48.0

Paroxysmal atrial fibrillation

I48.1

Persistent atrial fibrillation

I48.2

Chronic atrial fibrillation

(37)

• Type

– Chronic

– Paroxysmal

– Persistent

(38)

Abdominal pain

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

789.00 R10.9

Unspecified

abdominal pain

• renal colic (N23)

• dorsalgia (M54.-)

• flatulence and

related conditions

(R14.-)

There are more specific code choice selections below:

R10.0

Acute abdomen

R10.10

Upper abdominal pain, unspecified

R10.11

Right upper quadrant pain

R10.12

Left upper quadrant pain

R10.13

Epigastric pain

R10.2

Pelvic and perineal pain

R10.30

Lower abdominal pain, unspecified

R10.31

Right lower quadrant pain

R10.32

Left lower quadrant pain

R10.33

Periumbilical pain

R10.81-

Other abdominal pain

(39)

Abdominal Pain Documentation Tips

• Document specific location:

– LLQ, LUQ, RUQ, RLQ

– Periumbilical

– Epigastric

– Generalized (R10.84)

– Colic (R10.83)

– Acute abdominal pain (R10.0)

(40)

Cough

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

786.2 R05

Cough

• Cough with

hemorrhage

(R04.2)

• Smoker’s Cough

(J41.0)

(41)

• Symptom Codes

– Codes that describe symptoms and signs are acceptable for reporting

purposes when a related definitive diagnosis has not been established

(confirmed) by the provider.

• Use of a symptom code with a definitive diagnosis code

– Codes for signs and symptoms may be reported in addition to a

related definitive diagnosis when the sign or symptom is not routinely

associated with that diagnosis code.

• Signs or symptoms that are associated routinely with a

disease process should not be assigned as additional codes,

unless otherwise instructed by the classification.

(42)

Atherosclerotic heart disease of native coronary artery without angina pectoris

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

414.00 I25.10

Atherosclerotic heart

disease of native

coronary artery without

angina pectoris

Applicable To:

• Atherosclerotic heart

disease NOS

N/A

• atheroembolism (I75.-)

• atherosclerosis of coronary artery

bypass graft(s) and transplanted heart

(I25.7-)

414.01 I25.10

No ICD-10 code exists for unspecified vessel; native or bypass graft must be indicated

Use additional code, if applicable, to identify:

• coronary atherosclerosis due to calcified coronary lesion (I25.84)

• coronary atherosclerosis due to lipid rich plaque (I25.83)

• chronic total occlusion of coronary artery (I25.82)

• exposure to environmental tobacco smoke (Z77.22)

• history of tobacco use (Z87.891)

• occupational exposure to environmental tobacco smoke (Z57.31)

• tobacco dependence (F17.-)

(43)

• Associated Artery/Lesion Type

– Native artery

– Bypass graft

– Bypass graft, autologous artery

– Bypass graft, autologous vein

– Bypass graft, nonautologous biological

– Bypass graft, other

– Due to calcified coronary lesion

– Due to lipid rich plaque

• Native vs Transplanted Heart

• Associated angina

–

Without angina

–

With unstable angina

–

With angina and spasm

Artherosclerotic Heart Disease

(44)

Chronic pain syndrome

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

338.4 G89.4

Chronic pain

syndrome

Applicable To:

• Chronic pain

associated with

significant

psychosocial

dysfunction

• generalized

pain NOS

(R52)

• pain

disorders

exclusively

related to

psychological

factors

(F45.41)

• pain NOS

(R52)

• atypical face pain (G50.1)

• headache syndromes (G44.-)

• localized pain, unspecified type - code to pain by

site, such as:

• abdomen pain (R10.-)

• back pain (M54.9)

• breast pain (N64.4)

• chest pain (R07.1-R07.9)

• ear pain (H92.0-)

• eye pain (H57.1)

• headache (R51)

• joint pain (M25.5-)

• limb pain (M79.6-)

• lumbar region pain (M54.5)

• painful urination (R30.9)

• pelvic and perineal pain (R10.2)

• shoulder pain (M25.51-)

• spine pain (M54.-)

• throat pain (R07.0)

• tongue pain (K14.6)

• tooth pain (K08.8)

• renal colic (N23)

• migraines (G43.-)

• myalgia (M79.1)

• pain from prosthetic devices, implants, and

grafts (T82.84, T83.84, T84.84, T85.84)

• phantom limb syndrome with pain (G54.6)

• vulvar vestibulitis (N94.810)

(45)

• Type

– Chronic pain syndrome (G89.4)

– Due to neoplasm (G89.3)

– Due to trauma ((G89.21)

– Chronic post-thoracotomy pain (G89.22)

– Other chronic postprocedural pain (G89.28)

(46)

Encounter for Immunization Influenza Virus

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

V04.81

Z23

Encounter for

immunization

(47)

• The procedural code will indicate the type of

immunization to the carrier.

(48)

Urinary Tract Infection

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

599.0 N39.0

Urinary tract infection,

site not specified

• candidiasis of urinary

tract (B37.4-)

• neonatal urinary tract

infection (P39.3)

• urinary tract infection

(49)

• Encounter type

– Initial

– Subsequent

– sequela

• Urinary Tract Infection type

– Acute cystitis

– Acute pyelonephritis

– Urethritis

– Catheter-associated UTI

• Hematuria present

– With or without

• Identify any retained foreign body, if applicable

(Z18.-), code

additional

• Use Additional code (B95-B97), to identify infectious agent

(50)

Anxiety, generalized

ICD-9 Code

ICD-10 Code

Description

Excludes1

Excludes2

300.02 F41.1

Generalized anxiety

disorder

• Anxiety

neurosis

• Anxiety state

• Anxiety

reaction

• Overanxious

disorder

N/A

• Acute stress

reaction (F43.0)

• Transient

adjustment

reaction (F43.2)

• Neurasthenia

(F48.8)

• Psychophysiolo

gic disorders

(F45.-)

• Separation

anxiety (F93.0)

There are more code choice selections below:

300.01 F41.0

Panic disorder without agoraphobia

300.09 F41.3

Other mixed anxiety disorders

(51)

• Type

– Generalized

– Panic Disorder

• With agoraphobia

• Without agoraphobia

– Other

– Mixed

– Unspecified

(52)

On October 01, 2015 we will monitor claims for date of

service rules

• Outpatient claims cannot have crossover dates

• Outpatient claims will be coded according to date of

service

• Inpatient facility claims will be coded per date of discharge

We will monitor claims to resolve any unanticipated

problems with the submission process

(53)

• We will monitor for claim denials

• We will monitor editing trends for ICD-10 Coding

guidelines

• We will provide feedback to the physicians regarding

supporting documentation requirements

• We will monitor WC or Liability carriers for published

rules on use of ICD-9 or ICD-10 code sets

(54)

• Client will need to update

– Templates

– Order Sets

– Superbills

– Favorites

• Future Orders

– Remove ICD-9 code add ICD-10 code

(55)

All Conditions treated or assessed must be documented in the medical

record. In addition to the documentation tips reviewed, below are more

areas to document that will ensure proper ICD-10-CM code selection.

• Site specificity

• Document notation of qualifiers

–

Exacerbation

–

Manifestations

–

Relapse

–

Status

–

Stages

• Indicate acute or chronic

• Indicate underlying or external cause factors

–

Medication

–

Smoke

–

Accidents

–

Mechanical failure

• Laterality

– Bilateral

– Right

– Left

(56)

• Episode of Care for injuries, poisoning, external

causes and other conditions

– Initial Encounter

• Use while the patient is receiving active treatment of the condition

– Active treatment includes surgical treatment, an emergency

encounter, and evaluation and treatment by a new physician

– Subsequent Encounter

• Used on encounter after the patient has received active treatment

of the condition and is receiving routine care for the condition

during the healing or recovery phase.

– Medication adjustments, aftercare, device adjustments, cast change

– Sequela

• Used for complications or conditions that arise as a direct result of

a condition, late effect

(57)

• Combination codes that capture

– Etiology and manifestation

– Related conditions

– Disease, injury or other medical condition and

complications

– Disease or other medical conditions and common signs or

symptoms

• Add ICD-10 Codes to patient Problem List

(58)

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Centers for Disease Control and Prevention (ICD-10-CM)

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