ICD-10-CM Conventions & General Coding Guidelines January 22, 2014

ICD-10-CM Conventions &

General Coding Guidelines

Disclaimer: It is impossible to review every ICD-10-CM Convention and General Guideline in 60 minutes. Every effort has been made to capture the most significant Conventions and General Guidelines. This presentation is meant to enhance, but does not replace, your personal review of the Conventions and General Guidelines.

CE Certificates

This webinar qualifies for 1 CE credit. Upon

completion of our brief survey at the end of the

p

y

webinar, your CE certificate will be emailed to

you in approximately 1 week.

G2N’s Mission

We work to ensure America’s healthcare

providers have honest & healthy bottom lines in

p

&

y

order to continue to fulfill their mission of

improving community health.

p

g

y

Karri Murphy, RHIA, CCS

Karri is a Senior Client Partner over Quality for G2N, Inc G2N provides coding chargemaster and other Inc. G2N provides coding, chargemaster and other revenue cycle consulting services.

Karri Murphy, RHIA, CCS

• Karri has been a coder for over 20 years, working through all types of coding and coding management ultimately ending up in

th l

the revenue cycle

• B.S. in HIM from ISU; Credentialed as an RHIA and CCS, and an S o SU; C ede t a ed as a a d CCS, a d a AHIMA-Approved ICD-10-CM/PCS Trainer

B k d i l t h it l ith i i ll f t

• Background in large system hospitals, with experience in all facets of the revenue cycle

Agenda

• ICD-10-CM:

C

ti

– Conventions

General Coding Guidelines

– General Coding Guidelines

• Trends

Q

ti

C

ti

Conventions

• Coders must understand conventions

• Found in 2014 Draft of ICD-10-CM book and

training manuals

Conventions

• Alphabetic Index and Tabular List

– ICD-10-CM has:

• Alphabetic Index- alphabetical list of terms and their corresponding code

corresponding code

• Tabular List- structured chronological list of codesTabular List structured chronological list of codes

divided into chapters based on body system or condition

Conventions

• Alphabetic Index consists of the following:

• Index of Diseases and Injury

• Index of External Causes of Injury • Index of External Causes of Injury • Table of NeoplasmsTable of Neoplasms

Conventions

• Format and Structure

– ICD-10-CM Tabular List contains categories,

subcategories, codes

– Characters for categories, subcategories and codes may be a letter or number

Conventions

• Format and Structure

Subcategories are 4 or 5 characters

– Subcategories are 4 or 5 characters

– Codes may be 3 4 5 6 or 7 characters in length

Codes may be 3, 4, 5, 6 or 7 characters in length

– A code that has an applicable 7

pp

character is

considered invalid without the 7

character

Tip: watch for the box with a check mark and “4th_{” “5}th_”

Tip: watch for the box with a check mark and 4 , 5 , “6th_{”, “7}th_{” and “x7th” in it indicating the number of}

Conventions

• Placeholder Character- letter “X” has 2 uses

T56 0X2S Toxic effect of lead and its compounds intentional self harm T56.0X2S Toxic effect of lead and its compounds, intentional self-harm, sequela

• Code has less than 6 characters and 7th character • Code has less than 6 characters and 7 character

required, “X” is assigned for all characters less than 6

Conventions

• Placeholder Character- letter “X”

Tip: Make sure your coders correctly use

this placeholder character

this placeholder character

– Coders incorrectly apply 7

_{character in the 5}

_or

6

character place

Conventions

• Seventh Characters

– Provides further specificity about condition

O64.3XX1 Obstructed labor due to brow presentation, fetus 1

S02.110B Type I occipital condyle fracture, initial encounter for yp p y ,

Conventions

• Abbreviations

– Not Elsewhere Classified (NEC)

• ICD-10-CM contains codes to classify any and all

conditions

• Alphabetic Index uses NEC for a code description that directs the coder to the Tabular List showing an Other directs the coder to the Tabular List showing an Other Specified code description

Conventions

• Abbreviations

– Not Otherwise Specified (NOS)

• Use when the documentation is insufficient to assign a ifi d

Conventions

• Punctuation

( )

– Parentheses ( )

• Used in both Alphabetic Index and Tabular List

• Enclose supplementary words that may be present or • Enclose supplementary words that may be present or

absent in the statement of a disease without affecting the code number to which it is assigned

T ithi th th ti l difi

• Terms within the parentheses are nonessential modifiers Hemophilia (classical) (familial) (hereditary)

Conventions

• Punctuation

– Brackets [ ]

• Used in Tabular List to enclose synonyms, alternative

wordings or explanatory phrases wordings, or explanatory phrases

B06, Rubella [German measles]

• Used in Alphabetic Index to identify manifestation codes Disease, Alzheimer’s G30.9 [F02.80]

Conventions

• Punctuation

C l

– Colon :

• Used in Tabular List after an incomplete term which needs 1 or more modifiers following the colon to make g it assignable to a given category

• Used with “includes” and “excludes” notes

G73.7 Myopathy in diseases classified elsewhere

Excludes1: myopathy in:

l d (M34 82) scleroderma (M34.82)

Polling Question #1

Have you practiced coding in

ICD 10 CM?

ICD-10-CM?

A. Yes, a lot

B. Yes, a little

C. Not yet

D. What is ICD-10-CM?

Conventions

• Other format differences from ICD-9-CM

– Symbols not included in ICD-10-CM:

S ti M k § • Section Mark § • Braces }

Conventions

• Other format differences from ICD-9-CM

– Dashes

• Used in ICD-10-CM Alphabetic Indexes and the Tabular List

Tabular List

• Indexes utilize dash at end of code number to indicate

code is incompletep

• To determine additional character(s), locate code in Tabular List, review the options, assign appropriate code

Conventions

• Other format differences from ICD-9-CM

– Dashes

Fracture, pathologic

ankle M84 47 ankle M84.47-carpus

M84.44-Conventions

• Other format differences from ICD-9-CM

– Dashes

• Tabular List, dash preceded by a decimal point (.-) indicates incomplete code

indicates incomplete code

• To determine additional characters, locate referenced category or subcategory in Tabular List, review g y g y ,

options, assign the appropriate code

J43 Emphysema J43 Emphysema

Conventions

• Instructional Notes

– Variety of notes appear in both the Alphabetic

Index and Tabular List of ICD-10-CM

– The various notes are:

“ l d ” • “excludes” • “code first”

• “use additional code” • use additional code • cross reference

Conventions

• Inclusion Notes

– Used in Tabular List to clarify conditions included

within a particular chapter, section, category,

subcategory code

subcategory, code

– List of inclusions terms not exhaustive, may

include diagnoses not listed in inclusion note

include diagnoses not listed in inclusion note

– Introduced by word “includes” when appearing at

beginning of chapter section category

Conventions

• Inclusion Notes

K25

Gastric Ulcer

Includes: erosion (acute) of stomach

pylorus ulcer (peptic)

t h l ( ti )

Conventions

• Inclusion Notes

At code level the word “includes” does not precede

– At code level, the word includes does not precede

the list of terms included in the code

K31 5 Obstruction of duodenum K31.5 Obstruction of duodenum

Constriction of duodenum Duodenal ileus (chronic) Stenosis of duodenum Stenosis of duodenum Stricture of duodenum Volvulus of duodenum

Conventions

• Exclusion Notes

– ICD-9-CM contains a single type of excludes note

– ICD-9-CM has 2 different meanings leaving it to

coder to determine correct meaning

– In ICD-10-CM, 2 types of excludes notes:

• Excludes2

Either or both may appear under a category subcategory or – Either or both may appear under a category, subcategory, or

Conventions

• Excludes1

– Is a pure “excludes” note

– Means not coded here

– Indicates the code excluded should never be

used at the same time as code above the

E

l d

1

t

Excludes1 note

Conventions

• Excludes1

Q79.5 Other congenital malformations of

abdominal wall

Conventions

• Excludes2

– Means not included here

– Indicates condition excluded is not part of

condition represented by the code, but a patient

may have both conditions at same time

Wh

E

l ld

2

t

d

d

– When an Excluldes2 note appears under a code,

it is acceptable to use both the code and the

excluded code together if patient has both

excluded code together if patient has both

Conventions

• Excludes2

J37.1 Chronic laryngotracheitis

Excludes2: acute laryngotracheitis (J04.2)

t t h iti (J04 1) acute tracheitis (J04.1)

Tip: Make sure your coders understand

Excludes1 and Excludes2 notes

Excludes1 and Excludes2 notes

Conventions

• Code First and Use Additional Code Notes

– Some conditions require an underlying etiology

code and manifestation code

– For these conditions, 10-CM (similar to

ICD-9-CM) requires underlying condition be

Conventions

• Code First and Use Additional Code Notes

– “Use additional code” note appears at etiology

code

Conventions

• Use Additional Code Note

Use additional code to identify: Use additional code to identify:

dementia with behavioral disturbance (F02.81) dementia without behavioral disturbance

dementia without behavioral disturbance (F02.80)

Conventions

• Code First Note

F02 Dementia in other diseases classified elsewhere

Code first the underlying physiological condition such Code first the underlying physiological condition, such

as Alzheimer’s (G30.-)

F02.80 Dementia in other diseases classified

elsewhere, without behavioral disturbance F02.81 Dementia in other diseases classified

elsewhere with behavioral disturbance

Conventions

• Cross Reference Notes

– In ICD-10-CM Alphabetic Index to advise coder

to look elsewhere before assigning a code

– “See”, “See Also” and “See Condition” are same

as those in ICD-9-CM

Conventions

• Cross Reference Notes

mastoid see Mastoiditis acute

-mastoid – see Mastoiditis, acute -sinus (accessory) – see sinusitis -turbinate (bone) J32 9turbinate (bone) J32.9

Conventions

• Relational Terms

/

– “And” means “and/or” when appears in code title

within the ICD-10-CM Tabular List

– “With” means “associated with” or “due to” when

appears in code title, Alphabetic Index, or

appears in code title, Alphabetic Index, or

instructional note in Tabular List

Conventions

• Relational Terms

Salpingitis (catarrhal) (fallopian tube) (nodular)

(pseudofollicular) (purulent) (septic) N70 91 (pseudofollicular) (purulent) (septic) N70.91 with oophoritis N70.93

acute N70 01 acute N70.01

Conventions

• Additional Conventions

– Age edit symbols

Age edit symbols

• Newborn = 0 years

• Pediatric = 0 – 17 years

• Maternity age = 12 55 years • Maternity age = 12 – 55 years • Adult age = 15 – 124 years

– Sex edit symbols

M l • Male • Female

Polling Question #2

Have you heard of the conventions

presented thus far?

presented thus far?

A. Yes, all of them

B Y

f th

B. Yes, some of them

C. No, never heard of them!

D. Where can I find them?

G

l C di

G id li

General Coding Guidelines

1. Locating a Code in ICD-10-CM

– First locate term in Alphabetic Index

– Verify code in Tabular List

Tip: Read instructional notes in Alphabetic

Index and Tabular List, and let them be your

Index and Tabular List, and let them be your

guide to the appropriate code

General Coding Guidelines

2. Level of Detail in Coding

– Diagnosis codes reported at their highest number

of characters available

– Codes may be 3, 4, 5, 6 or 7 characters in

length

General Coding Guidelines

3. Code or Codes from A00.0 through T88.9,

Z00

Z99 8

Z00 – Z99.8

– Identify diagnoses, symptoms, conditions,

problems, complaints, other reason(s) for the

t

/ i it

General Coding Guidelines

4. Signs and Symptoms

– Acceptable for reporting when related definitive

diagnosis has not been established or

diagnosis has not been established or

confirmed by provider

– Chapter 18 (Symptoms, Signs, and Abnormal

Clinical and Laboratory Findings, Not Elsewhere

Cl

ifi d (

d

R00 0

R99)

t i

General Coding Guidelines

5. Conditions that are an Integral Part of a Disease

Process

– Signs and symptoms associated routinely with a disease process should not be assigned as additional codes

process should not be assigned as additional codes

UNLESS otherwise instructed by the classification

Tip: make sure your coders understand what is Tip: make sure your coders understand what is

routinely associated with each disease process to avoid over-coding

General Coding Guidelines

6. Conditions that are not an Integral Part of a

Di

P

Disease Process

– Signs and symptoms that are NOT ROUTINELY

associated with a disease process should be

d d

h

t

General Coding Guidelines

7.

Multiple Coding for a Single Condition

– Etiology/manifestation convention – “Use additional code”

“Code first” – “Code first”

– “Code, if applicable, any causal condition first”

– Multiple codes may be needed for sequela, complication d d b t t i d t f ll d ib diti

General Coding Guidelines

8.

Acute and Chronic Conditions

– If same condition described as both acute (subacute)

and chronic, and separate subentries exist in

Alphabetic Index at same indentation level code

Alphabetic Index at same indentation level, code

both and sequence the acute (subacute) code

first

Polling Question #3

What are you using when practicing coding

in ICD 10 CM?

in ICD-10-CM?

A. Book

B E

d

B. Encoder

C. Book and encoder

General Coding Guidelines

9.

Combination Code

– Used to classify:

• Two diagnoses, orTwo diagnoses, or

– A diagnosis with an associated secondary process (manifestation)

General Coding Guidelines

10. Sequela (Late Effects)

– Residual effect after acute phase of an illness or injury

has terminated

– No time limit on when sequela code can be used

– Residual effect may appear early, may occur months

General Coding Guidelines

10. Sequela (Late Effects)

– Normally 2 codes required- condition or nature of sequela sequenced 1st _{and sequela code is sequenced 2}nd

• Exception- code for sequela is followed by a manifestation code • Exception- code for sequela is followed by a manifestation code

identified in Tabular List and title, or sequela code has been expanded to include the manifestation(s)

Tip: The code for the acute phase of an illness

or injury that led to the sequela is never used

or injury that led to the sequela is never used

General Coding Guidelines

11. Impending or Threatened Condition

– Did occur  code as confirmed diagnosis

– Did not occur  look in Alphabetic Index for “impending” or “threatened”

– Reference main term entries for “Impending” and “Threatened” – Subterms are listed  assign the given code

– Subterms are not listed  code the existing underlying g y g conditions and not the condition described as impending or threatened

General Coding Guidelines

12. Reporting Same Diagnosis Code More than Once

– Each unique ICD-10-CM diagnosis code may be reported only

once for an encounter

– Applies to bilateral conditions when there are no distinct codes identifying laterality or 2 different conditions classified to the same diagnosis code

General Coding Guidelines

13.

Laterality

– If there is a code specifying left, right or bilateral  assign the appropriate code based on documentation

If bil t l d i t d th diti i bil t l  i

– If no bilateral code exists and the condition is bilateral  assign separate codes for both left and right

If the side is not identified in the documentation  assign the – If the side is not identified in the documentation  assign the

General Coding Guidelines

14. Documentation for BMI and Pressure Ulcer

Stages

g

– 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 who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for

p y q p g y

establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g. a dietitian often documents the BMI and nurses often document the pressure ulcer stages).

– The associated diagnosis (such as overweight, obesity, or pressure

General Coding Guidelines

• Documentation for BMI and Pressure Ulcer Stages

– If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification

– The BMI codes should only be reported as secondary diagnoses and

they must meet the definition of a reportable additional diagnosis to be reported

General Coding Guidelines

15. Syndromes

– Follow Alphabetic Index guidance

– In absence of Alphabetic Index guidance, assign codes for if t ti f d

manifestations of syndrome

– Additional manifestation codes that are not integral to the

disease process may be assigned when condition does not disease process may be assigned when condition does not have a unique code

Polling Question #4

Are you excited about ICD-10-CM?

A Y

I

’t

it f

O t b

1 2014!

A. Yes, I can’t wait for October 1, 2014!

B. I’m okay with it, but I wouldn’t call it excited

C. No, I love ICD-9!

General Coding Guidelines

16.

Documentation of Complication of Care

– Not all conditions that occur during or following medical care or

surgery are classified as complications

Must be a cause and effect relationship between care provided – Must be a cause-and-effect relationship between care provided

and the condition

– Must be an indication in documentation that is it a complicationp

General Coding Guidelines

17. Borderline Diagnosis

– Diagnosis is coded as confirmed unless the classification provides a specific entry, (borderline diabetes)

– Not considered uncertain diagnoses

General Coding Guidelines

18. Use of Sign/Symptom/Unspecified Codes

– Instances exist when signs/symptoms or

unspecified codes most accurately reflect

healthcare encounter

– Appropriate to use signs and/or symptoms codes

when definitive diagnosis has not been

General Coding Guidelines

• Use of Sign/Symptom/Unspecified Codes

– Appropriate to report “unspecified” code when

clinical information isn’t known or available to

assign more specific code

– Code each encounter to level of certainty

known

References

• ICD-10-CM The Complete Official Draft Code

S t 2014

Set, 2014 –

D V lt K B t A & E di tt M (2014) ICD 10 CM • DeVault, K., Barta, A., & Endicott, M. (2014). ICD-10-CM

Q

ti

?

Questions?

ICD-10 Classroom Training

ICD-10 Coder Training

AHIMA-Approved CM/PCS AHIMA Approved CM/PCS Classroom Training with 3 instructors

G2N Inc. is offering ICD-10 coder on-site training in your area by AHIMA-Approved ICD-10-CM/PCS

trainers from G2N.

G2N will provide core ICD-10 training on-site at

Golden Valley Memorial Healthcare Clinton, Missouri

The training will include all chapters of the ICD-10-CM code book and all sections of the

ICD-10-PCS code book. AHIMA CEU’s will be available.

Lunch and breaks will be included and all coding and training materials will be provided.

Sessions will include:

CE Certificates

This webinar qualifies for 1 CE credit. Upon

completion of our brief survey at the end of the

p

y

webinar, your CE certificate will be emailed to

you within 1 week.

Questions?

Email me at [email protected]

Email me at [email protected]

314.835.9311