Presentation on theme: "Official Coding Guidelines ICD-10-CM and PCS Presented by: MONICA LEISCH, RHIA, CCS AHIMA Approved ICD-10 Trainer Director of Compliance / HIM Services."— Presentation transcript:
Official Coding Guidelines ICD-10-CM and PCS Presented by: MONICA LEISCH, RHIA, CCS AHIMA Approved ICD-10 Trainer Director of Compliance / HIM Services Healthcare Cost Solutions, Inc. May, 2013
Disclaimer This material is designed and provided to communicate information about clinical documentation, coding and compliance in an educational format and manner. The author is not providing or offering legal advice but rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality and coding. Every reasonable effort has been taken to ensure that the educational information is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital or facilitys situation.
Introduction ICD-10-CM Official Guidelines for Coding and Reporting 2013 for Diagnoses and Procedures
Guidelines Defined The guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD itself. Developed by The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) Based on the coding and sequencing instructions in the Tabular List and Alphabetic Index Required under the Health Insurance Portability and Accountability Act (HIPAA)
CM vs PCS ICD-10-CM (Clinical Modification) – Morbidity classification developed by the US – Classifies diagnoses and reason for visit – Applicable to all health care settings – Based on ICD-10 classification system published by WHO ICD-10-PCS (Procedural Coding System) – Procedure classification published by the US – Classifies all procedures – Applicable to inpatient care setting only – No such system in the ICD-10 published by WHO
Cooperating Parties The guidelines have been approved by the four organizations that make up the Cooperating Parties: American Hospital Association (AHA) American Health Information Management Association (AHIMA) The Federal Government represented by Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)
Hierarchy In order of Precedence: 1.Coding Conventions of the ICD Classification 2.Official Coding Guidelines 3.All other, including Coding Clinic, LCDs, etc.
CM Organization CM guidelines are organized into sections: Section I includes the structure and conventions of the classification and general guidelines Section II includes guidelines for selection of principal diagnosis for non-outpatient settings Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting
Excludes Notes ICD-10-CM ICD-10-CM has two types of excludes notes. a. Excludes 1 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. b. Excludes 2 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.
Impending or Threatened Condition ICD-10-CM Impending or Threatened Condition listed at time of Discharge: If confirmed, code as confirmed diagnosis. If it did not occur, check Alphabetic Index for – subentry for the term impending or threatened and use that code if listed. – If no subentry, code the existing underlying condition(s) and not the condition described as impending or threatened
Laterality ICD-10-CM Laterality For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality. An unspecified side code is also provided should the side not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.
Late Effects/Sequela ICD-10-CM Late Effects (Sequela) A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. 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. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect 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 late effect is never used with a code for the late effect.
BMI & Ulcers ICD-10-CM Documentation for BMI (Body Mass Index) and Ulcers for coding: Codes may be assigned from clinician, (non physician) documentation The provider responsible for the patients care must provide coordinating diagnosis When conflicting documentation is present, query the responsible provider BMI codes should only be secondary diagnosis codes
Signs, Symptoms ICD-10-CM Signs and symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R R99) contains many, but not all codes for symptoms.
Complication of Care ICD-10-CM Complications of care As with all procedural or post-procedural complications, code assignment is based on the providers documentation of the relationship between the condition and the procedure. Includes pain, and transplant complications, and information that complication codes that include the external cause, and complication of care codes within the body system chapters.
Borderline Diagnosis ICD-10-CM Borderline Diagnosis documented at Discharge: Coded as confirmed unless the classification provides a specific entry Borderline conditions are not uncertain conditions so no distinction between inpatient and outpatient settings. If documentation is unclear, query
Human Immunodeficiency Virus Infections ICD-10-CM HIV Related Condition: Principal diagnosis is B20, HIV disease followed by addition diagnosis codes for the HIV related condition(s) HIV Unrelated Condition: Code the unrelated condition first following by B20 Asymptomatic human immunodeficiency virus Z21 is used for: no documentation of symptoms HIV positive, known HIV, HIV test positive or similar Do not use if AIDS is documented, treated for HIV-related illness or described as having any condition(s) resulting from his/her HIV positive status (use B20 instead) Patients with inconclusive HIV serology: Assign R75, Inconclusive laboratory evidence of HIV for patients with inconclusive HIV serology, for patient without definitive diagnosis or manifestations of the illness Previously diagnosed HIV – related illness: Once a patient has developed an HIV related illness, assign B20 on every subsequent admission/encounter
ICD-10-CM Sepsis, Severe Sepsis, and Septic Shock Sepsis: assign the appropriate code for the underlying systemic infection. Type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified. Do not assign a code from subcategory R65.2, Severe sepsis, unless severe sepsis or an associated acute organ dysfunction is documented. Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition, however, query the provider Sepsis/Severe Sepsis and Septic Shock
ICD-10-CM Septic shock: Code first the systemic infection, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Post-procedural septic shock. Add codes for other acute organ dysfunctions. The code for septic shock cannot be assigned as a principal diagnosis. Septic Shock
ICD-10-CM Urosepsis Nonspecific term. not to be considered synonymous with sepsis. Has no default code in the Alphabetic Index. If used, the provider must be queried for clarification. Urosepsis
ICD-10-CM If it is present on admission and meets principal diagnosis definition: not to be considered synonymous with sepsis. Has no default code in the Alphabetic Index. If used, the provider must be queried for clarification. Sequencing of Sepsis
ICD-10-CM If sepsis is present with a localized infection: Sequence sepsis codes first List localized infections second If due to a post-procedural infection: Sequence the code for the post-procedural infection first List sepsis codes second If septic shock is documented, list second as well Sepsis/Severe Sepsis with Infections
ICD-10-CM If sepsis is present with a non-infectious process: If the sepsis is due to the non-infectious process, list the non-infectious process first List the sepsis codes second If the non-infectious process leads to an infection with sepsis, the infection should be listed first Code for Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin is not needed Sepsis/Severe Sepsis with Non-infectious Process
ICD-10-CM Death NOS Code R99, Ill-defined and unknown cause of mortality, Use only, when an expired patient is brought to the ED other healthcare entity and is pronounced dead upon arrival Does not represent the discharge disposition of death. Death NOS
Neoplasms General Guidelines ICD-10-CM A primary malignant neoplasm that overlaps two or more contiguous sites should be classified to subcategory/code.8 (overlapping lesion), unless the combo is specifically indexed elsewhere. For multiple neoplasms of same site, not contiguous, assign codes for each – Example: tumors in different quadrants of same breast
Neoplasms General Guidelines (cont.) ICD-10-CM Malignant neoplasms of ectopic tissue are to be coded to origin of mentioned site Example: ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9) Check the Alphabetic Index first before going to the Neoplasm Table
Neoplasms Coding & Sequencing of Complications (Anemia Associated w/ Malignancy) ICD-10-CM When admitted for management of anemia associated with malignancy & treatment: – Sequence the code for malignancy as principal – Followed by appropriate code for anemia
Neoplasms Coding & Sequencing of Complications (Anemia assoc. w/ therapies) ICD-10-CM Management of anemia associated with adverse effect of administration of chemotherapy or immunotherapy and treatment is only for anemia, sequence the anemia code first, followed by appropriate codes for neoplasm and adverse effect Management of anemia associated with adverse effect of radiotherapy, sequence the anemia code first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient...
Neoplasms Malignancy in 2 or more noncontiguous sites ICD-10-CM In case where patient has more than one malignant tumor in the same organ, different tumors may constitute different primaries or metastatic disease, depending on site. If documentation unclear, query provider as to status so that coding is correct
Neoplasms Admission to Determine Extent of Malignancy ICD-10-CM When the reason for admission is to determine the extent of the malignancy, list the malignancy first, even if chemotherapy or radiotherapy is administered.
Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CM Malignant neoplasm in pregnant patient: use code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, sequenced first, followed by appropriate code from Chapter 2 to indicate type of neoplasm
Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CM Encounter for complication associated with neoplasm: – When encounter is for mgmt of complication associated w/ neoplasm and treatment is only for complication, code complication first, followed by appropriate code for neoplasm – Exception: Anemia (see slide above)
Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CM When encounter is for treatment of complication resulting from surgical procedure performed for treatment of neoplasm, designate complication as principal diagnosis. (See guideline regarding the coding of current malignancy vs personal history to determine if code for neoplasm should also be assigned)
Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CM Pathologic fracture due to neoplasm -If focus of treatment is the fracture, code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by neoplasm code - If focus of treatment is neoplasm with an associated pathological fracture, code neoplasm first, followed by code from M84.5 for the pathological fracture
Neoplasms Current malignancy vs. personal history of malignancy ICD-10-CM When primary malignancy has been excised but further treatment is directed to that site, use primary malignancy code until treatment is completed Use code Z85, Personal history of malignant neoplasm, to indicate former site of malignancy once it has been excised/eradicated, there is no further treatment directed to that site, and there is no evidence of existing malignancy
Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal history ICD-10-CM Categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. There are also codes for personal history of leukemia or malignant neoplasms of hymphoid, hematopoietic and related tissues
Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal history (cont.) ICD-10-CM If it is unclear in the documentation as to whether or not the leukemia has achieved remission, query the provider.
M alignant Neoplasm associated with Transplanted Organ ICD-10-CM Coded as tranplant complication Assign the code for the specific malignancy second
Diabetes Diabetes Mellitus ICD-10-CM Diabetes mellitus codes are combination codes to include type of diabetes, body system affected, and complications affecting that body system Assign as many codes within category as are necessary to describe all complications of disease
Diabetes Underdose of insulin due to insulin pump failure ICD-10-CM Assign code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal Assign T38.3x6-, Underdosing of insulin and oral hypoglycemic (antidiabetic drugs) as secondary Assign codes for type of diabetes mellitus and associated complications if appropriate
Diabetes Overdose of insulin due to insulin pump failure ICD-10-CM Assign code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal Assign T38.3x1-, Poisoning by insulin and oral hypoglycemic drugs, accidental as secondary
Diabetes Secondary Diabetes Mellitus ICD-10-CM Codes under categories E08, Diabetes mellitus (DM) due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, show complications and manifestations associated with secondary diabetes mellitus Secondary DM is always caused by another condition
Diabetes Assigning and sequencing secondary diabetes codes and its causes ICD-10-CM Sequencing of secondary diabetes codes in relationship to codes for the cause of the diabetes is based on the Tabular List instructions for categories E08 and E09.
Mental & Behavioral Disorders Pain disorders related to psychological factors ICD-10-CM Assign code F45.41, for pain that is exclusively related to psychological disorders Do not assign a code from category G89, Pain, not elsewhere classified with is code
Mental & Behavioral Disorders Pain disorders related to psychological factors ICD-10-CM Code 45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified if documentation shows a psychological component for a patient with acute or chronic pain
Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM 1.In Remission Assigned only if so documented. Selection of codes for in remission categories F10-F19, Mental and behavioral disorders due to psychoactive substance use
Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM 2.Psychoactive Substance Use, Abuse and Dependence - When provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use based on the following:
Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM 2.Psychoactive Substance Use, Abuse and Dependence (cont.) -If both use and abuse are documented, assign only the code for abuse -If both abuse and dependence are documented, assign only code for dependence -If use, abuse and dependence are all documented, assign only the code for dependence
Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM 2.Psychoactive Substance Use, Abuse and Dependence (cont.) -If both use and dependence are documented, assign only the code for dependence
Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM 3.Psychoactive Substance Use -The codes for psychoactive substance use should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis - Codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and this relationship is documented by provider
Nervous System Dominant/nondominant side ICD-10-CM Codes from G81, Hemiplegia and hemiparesis, and subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether dominant or nondominant side is affected
Nervous System Dominant/nondominant side (cont.) ICD-10-CM If the affected side is documented, but it is not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows: – For ambidextrous pt, default should be dominant – If left side is affected, default is non-dominant – If right side is affected, default is dominant
Pain Reporting General Coding Info ICD-10-CM Only assign code from category G89 if pain is specified as acute or chronic, post-thoracotomy, post-procedural, or neoplasm-related Pain codes are only assigned as principal if: – Pain control or management is reason for encounter – Patient is admitted for insertion of neurostimulator for pain control – Not for neurostimulator insertion for definitive underlying cause.
Circulatory System Hypertensive Heart & Chronic Kidney Disease ICD-10-CM The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease I13 codes are combination codes that include hypertension, heart disease and chronic kidney disease
Circulatory System Hypertensive Heart & Chronic Kidney Disease ICD-10-CM The Includes note at I13 specifies that the conditions included in I11 and I12 are included together in I13 If a patient has hypertension, heart disease and CKD then a code from I13 should be used rather than individual codes For patients w/ both acute renal failure and CKD an addl code for acute renal failure is required
Circulatory System Hypertensive Retinopathy ICD-10-CM Subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertension Sequence based on reason for encounter
Circulatory System Atherosclerotic Coronary Artery Disease & Angina ICD-10-CM Combination codes for atherosclerotic heart disease with angina pectoris When using one of these combo codes it is not necessary to use an additional code for angina If a patient with coronary artery disease is admitted due to acute myocardial infarction (AMI), sequence AMI first
Circulatory System Intraoperative and Postprocedural Cerebrovascular Accident ICD-10-CM Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on type of procedure performed
Circulatory System Sequelae of Cerebrovascular Disease ICD-10-CM Category I69 indicates conditions classifiable to categories I60-I67, as causes of sequela (neurologic deficits). These late effects include neurologic deficits that persist after initial onset of the conditions in categories I60-I67. I69 codes specify hemiplegia, hemiparesis and monoplegia; whether dominant or nondominant side affected. No default code is available. Codes from category I69 should not be assigned if the patient does not have neurologic deficits.
Circulatory System Acute myocardial infarction (AMI) ICD-10-CM For encounters 4 weeks old, including transfers to another acute setting or a postacute setting, and the patient requires continued care for MI, codes from category I21 may continue to be reported For encounters > 4 weeks old and patient is still receiving care related to MI, appropriate aftercare code should be assigned If the NSTEMI evolves to a STEMI, assign the STEMI only For old or healed MI not requiring care, code I25.2, Old myocardial infarction
Circulatory System Subsequent acute myocardial infarction ICD-10-CM 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 The sequencing of the I22 and I21 codes depends on the circumstances of the encounter
Circulatory System Documentation of Ventilator Associated Pneumonia A ICD-10-CM Code J95.851, Ventilator associated pneumonia, (VAP), should be assigned only when the provider has documented VAP Addl code to identify organism should also be assigned Do not assign addl code from J12-J19 to identify the type of pneumonia, unless the VAP develops after admission, and the patient is admitted with pneumonia.
Pressure Ulcer Stages ICD-10-CM Codes from category L89 Pressure Ulcer, combo codes that show the ulcer as well as the stage If documented as healed, no code is assigned If documented as healing, the appropriate code for type and stage should be assigned. If the stage evolves into a higher stage, assign only the highest stage.
Diseases of the Musculoskeletal System and Connective Tissue ICD-10-CM Site and Laterality – Site represents bone, joint or muscle – For conditions where more than one, bone, joint or muscle are involved there is a multiple sites code Bone vs. joint – Though the portion of bone affected may be the joint, the site designation will be the bone not the joint
Coding of Pathologic Fractures ICD-10-CM 7 th Character A is for active fracture treatment surgical ED Eval by new physician 7 th Character D is used for encounters after the patient has completed active treatment Other 7 th Characters are used for subsequent encounters associated with healing such as malunions, nonunions and sequelae
Chronic Kidney Disease ICD-10-CM Stages of chronic kidney disease (CKD) – Classify severity – End stage renal disease with CKD is assigned with one code N18.6, which include both conditions CKD with Transplant – The presence of CKD alone may not constitute a transplant complication – If unclear query
Pregnancy, Childbirth, Puerperium Final character for trimester ICD-10-CM Majority of Ch 15 codes have a final character indicating trimester of pregnancy Where trimester isnt part of the code it is because the condition always occurs in a specific trimester
Pregnancy, Childbirth, Puerperium Final character for trimester ICD-10-CM Final trimester codes also apply for pre-existing conditions and those that develop during or are caused by the pregnancy If delivery occurs during the current admission and there is an in childbirth option for the obstetric complication, the in childbirth code should be assigned
Pregnancy, Childbirth, Puerperium Final character for trimester ICD-10-CM If a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into the next trimester, the trimester character for the antepartum complication code should be assigned based on the trimester when the complication developed rather than trimester of discharge The unspecified trimester should not be used; obtain further clarification
Pregnancy, Childbirth, Puerperium 7th character Fetus Identification ICD-10-CM If applicable, a 7 th character should be assigned for certain categories to identify the fetus for which the complication code applies Assign 7 th character 0: – For singe gestations – When the documentation in the record is insufficient to determine the fetus affected – When it is not possible to clinically determine which fetus is affected
Pregnancy, Childbirth, Puerperium Pre-existing conditions vs. conditions due to pregnancy ICD-10-CM Certain categories in Chapter 15 distinguish between conditions of the mother than existed prior to pregnancy and those that are a direct result of the pregnancy For categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either
Pregnancy, Childbirth, Puerperium Gestational (pregnancy induced) diabetes ICD-10-CM Gestational (Pregnancy Induced) diabetes Codes under subcategory O24.4 include diet controlled and insulin controlled If gestational diabetes is treated with both diet and insulin, only code insulin-controlled Code Z79.4, Long-term (current) use of insulin, should not be assigned with codes from subcategory O24.4 Abnormal glucose tolerance in pregnancy is assigned a code from subcategory O99.81, Abnormal glucose complicating pregnancy, childbirth, and the puerperium
Pregnancy, Childbirth, Puerperium Alcohol, tobacco use during pregnancy, childbirth and the puerperium ICD-10-CM Subcategory O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium - assigned when a mother uses alcohol during the pregnancy or postpartum Also assign a secondary code from category F10, Alcohol related disorders, to identify manifestations of alcohol use
Pregnancy, Childbirth, Puerperium Alcohol, tobacco use during pregnancy, childbirth and the puerperium ICD-10-CM Subcategory O99.33, Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium - assign when a mother uses any type of tobacco product during the pregnancy or postpartum Also assign a secondary code from category F17, Nicotine dependence, or code Z72.0, Tobacco use, to identify the type of nicotine dependence
Pregnancy, Childbirth, Puerperium Poisoning, toxic effects, adverse effects and underdosing in a pregnant patient ICD-10-CM Subcategory O9A.2, Injury, poisoning and certain other consequences of external causes complicating pregnancy, childbirth, and puerperium, is sequenced first Next assign the appropriate injury, poisoning, toxic effect, adverse effect or underdosing code Then assign additional code(s) that specifies the condition causing poisoning, toxic effect, adverse effect or underdosing
Pregnancy, Childbirth, Puerperium Pregnancy associated cardiomyopathy ICD-10-CM Pregnancy associated cardiomyopathy, code O90.3, is unique in that it may be diagnosed in the 3 rd trimester of pregnancy but may continue to progress months after delivery As such, it is referred to as peripartum cardiomyopathy Code O90.3 is only for use when the cardiomyopathy develops as a result of pregnancy in a woman who did not have pre-existing heart disease
Sequelae of complication of Pregnancy, Childbirth, and the Puerperium ICD-10-CM Use code O94 in cases when an initial complication of pregnancy develops a sequelae requiring care or treatment at a future date The sequela code is sequenced following the code for the complication
Abuse in a Pregnant Patient ICD-10-CM Suspected or confirmed cases of abuse in a pregnant patient are coded from subcategories O9A.3, Sexual abuse complicating pregnancy, childbirth and the puerperium, and O9a.5, Psychological abuse complicating pregnancy, childbirth, and the puerperium See also Section I.C.19, Adult and child abuse, neglect and other maltreatment
NewBorns Conditions Originating in the Perinatal Period ICD-10-CM Principal Diagnosis for the Birth Record Assign a code from category Z38, Liveborn infants according to place of birth and type of delivery as principal diagnosis for the birth episode A code from category Z38 should only be used once
Newborns Use of Codes from other Chapters ICD-10-CM Codes from other chapters may be used w/ codes from chapter 16 if the codes from the other chapters provide more specific detail If the reason for the encounter is a perinatal condition, the code from chapter 16 should be principal
Newborns Low birth weight and immaturity status ICD-10-CM Codes from category P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, are for use for a child or adult who was premature or had low birth weight as a newborn newborn and this is affecting the patients current health
Newborns Bacterial Sepsis of Newborn ICD-10-CM Category P36, Bacterial sepsis of newborn, includes congenital sepsis. If a perinate is documented as having sepsis w/o documentation of congenital or community acquired, the default is congenital & a code from category P36 should be assigned
Newborns Bacterial Sepsis of Newborn ICD-10-CM If the P36 code includes the causal organism, an addl code from category B95 or B96 should not be assigned If the P36 code does not include the causal organism, assign an addl code from category B96
Newborns Stillbirth ICD-10-CM Code P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirth No other code should be used with P95 P95 should not be used on the mothers record
Coma Scale ICD-10-CM The coma scale codes are used in conjunction with traumatic brain injury codes, acute cerebrovascular disease and cerebrovascular disease codes. The 7 th character indicates when the scale was recorded At a minimum report the initial score documented on presentation Assign R40.24, Glasgow coma scale, total score, when only the total score is documented
Injuries Application of 7 th Characters ICD-10-CM Most categories in chapter 19 have a 7 th character requirement for each applicable code Most categories have three 7 th character values (exception: fracture): – A, initial encounter – D, subsequent encounter – S, sequela
Injuries Application of 7 th Characters ICD-10-CM 7 th character A, intial encounter is used while the patient is receiving active treatment for the condition Examples: – Surgical treatment – ED encounter – Evaluation and treatment by a new physician
Injuries Application of 7 th Characters ICD-10-CM 7 th 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 healing/recovery phase Examples: – Cast change or removal – Removal of external or internal fixation device – Medication adjustment
Injuries Application of 7 th Characters ICD-10-CM 7 th character S, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as a scar formation after a burn When using S, it is necessary to use both the injury code that precipitated the sequela and the sequela itself Add S only to the injury code, not the sequela code
Injuries Application of 7 th Characters ICD-10-CM Aftercare Z codes should not be used for aftercare conditions such as injuries or poisonings, where 7 th characters are provided to identify subsequent care Example: for aftercare of an injury, assign the acute injury code with the 7 th character D (subsequent encounter)
Injuries Coding of Traumatic Fractures ICD-10-CM A fracture not indicated as open or closed should be coded to closed A fracture not indicated whether displaced or not displaced should be coded to not displaced
Injuries Initial vs. Subsequent Encounter for Fractures ICD-10-CM When patient is receiving active treatment for fracture, traumatic fractures are coded using the appropriate 7 th character for initial encounter (A, B, C)
Injuries Initial vs. Subsequent Encounter for Fractures ICD-10-CM For encounters after the patient has completed active treatment and is receiving routine care during the healing/recovery phase, fractures are coded with appropriate 7 th character for subsequent care
Injuries Coding of Burns and Corrosions ICD-10-CM Distinction between burns and corrosions Burn codes are for thermal burns, except sunburns, that come from a heat source or burns resulting from electricity and radiation Corrosions are burns due to chemicals Guidelines are the same for both Non-healing burns are coded as acute burns
Injuries Encounters for treatment of sequela burns ICD-10-CM Encounters for the treatment of the late effects of burns or corrosions should be coded with a burn or corrosion code with the 7 th character S for sequela
Injuries Adverse Effects, Poisoning, Underdosing & Toxic Effects ICD-10-CM Codes in categories T36-T65 are combination codes that include substance that was taken as well as the intent Do not code directly from Table of Drugs; refer back to Tabular List If the same code would describe the causative agent for more than one adverse reaction, toxic effect or underdosing, assign the code only once
Injuries Adverse Effect ICD-10-CM When drug was correctly prescribed and properly administered, assign appropriate code for nature of adverse effect followed by code for the adverse effect of the drug (T36-T50) Code for the drug should have 5 th or 6 th character of 5
Injuries Poisoning Codes ICD-10-CM Assign code from categories T36-T50 first Poisoning codes have an associated intent as their 5 th or 6 th character Use additional code(s) for all manifestations of poisonings Follow with abuse or dependence code, if applicable
Injuries Underdosing ICD-10-CM Underdosing refers to taking less of a medication than is prescribed by a provider For underdosing, assign code from T36-T50 (5 th or 6 th character 6) Codes for underdosing should not be listed first
Injuries Underdosing ICD-10-CM If a patient has a relapse of the medical condition for which drug is prescribed because of underdosing, the medical condition itself should be coded Noncompliance (Z91.12-Z91.13-) or complication of care (Y63.8-Y63.9) codes are to be used with an underdosing code to indicate intent, if known
Injuries Complications of Care: Complication codes that include the external cause ICD-10-CM As with some other T codes, some of the complications of care codes have the external cause included in the code The code includes the nature of the complication as well as the type of procedure that caused the complication No external cause code indicating the type of procedure is necessary for these codes
External Causes of Morbidity Introduction ICD-10-CM Codes V01-Y99 are provided for the reporting of external causes of morbidity Always secondary codes
Injuries Complications of Care: Complication codes within the body system chapters ICD-10-CM Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system These codes should be sequenced first, followed by a code(s) for the specific complication
External Causes of Morbidity General External Cause Coding Guidelines ICD-10-CM An external cause code may be used with any code in the range A00.0-T88.9, Z00-Z99, classification that is a health condition due to an external cause
External Causes of Morbidity General External Cause Coding Guidelines ICD-10-CM Mostly applicable to injuries Also valid for infections or diseases due to an external source, and other health conditions, such as a heart attack that occurs during strenuous physical activity
External Causes of Morbidity Length of Treatment ICD-10-CM Assign the external cause code with the appropriate 7 th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated
External Causes of Morbidity Combination external cause codes ICD-10-CM Some external cause codes are combination codes that identify sequential events that result in an injury, such as a fall which results in striking against an object Assign regardless of seriousness of injury Injury may be due to either event or both
External Causes of Morbidity Place of Occurrence Guideline ICD-10-CM Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify location of patient at time of injury/condition Place of occurrence used at initial encounter w/ no 7 th character
External Causes of Morbidity Unknown or Undetermined Intent Guideline ICD-10-CM If the intent of the cause of injury/other condition is unknown or unspecified, code intent as accidental. External cause codes for events of undetermined intent are only for use if the documentation in the record specifies that the intent cannot be determined
Factors Influencing Health Status Aftercare ICD-10-CM Aftercare Z codes should not be used for aftercare for injuries. Use Z codes for care following treatment For aftercare of an injury, assign the acute injury code with the appropriate 7 th character for subsequent encounter
Factors Influencing Health Status With or without abnormal findings ICD-10-CM Some codes for routine health exams distinguish between with and without abnormal findings Code assignment depends on info known at the time encounter is being coded E.g. if no abnormal findings were found during exam, but test results are not in at time of coding, assign code for without abnormal findings When assigning a code for with abnormal findings, addl code(s) should identify specific abnormal findings
Outpatient Coding Guidelines Encounters for medical exams w/ abnormal findings ICD-10-CM The subcategories for encounters for general medications, Z00.0-, provide codes for with and without abnormal findings Should a general medical exam result in an abnormal finding, the code for general medical examination with abnormal finding should be first-listed diagnosis A secondary code for the abnormal finding should also be coded
PCS Organization ICD-10-PCS Conventions Medical and Surgical Section Guidelines – Body System – Root Operation – Body Part – Approach – Device Obstetrics Section Guidelines
PCS Conventions ICD-10-PCS Composed of 7 characters Characters = numbers 0 through 9 and alpha except I and O The valid values for an axis of classification can be added as needed The meaning of any single value is a combination of its axis of classification and any preceding values With expansion more values will depend on the preceding value
PCS Conventions continued ICD-10-PCS Alphabetic index provides for location table necessary to construct code Code may be chosen from the table, (the alpha index does not need to be consulted first) All seven characters must be specified to be a valid code Within a PCS table, valid codes include all combinations of choices for characters 4 through 7 The term And means and/or It is the coders responsibility to determine which code to choose from the documentation
Device ICD-10-PCS General Guidelines Coded only if it remains after procedure is coded Sutures, ligature, radiological markers an temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices Procedures performed on a device only and not on a body part are specified in the root operations: - change-irrigation -removal-revision
Obstetrics Section ICD-10-PCS Productions of conception – Procedures performed on the products of conception are coded to the obstetrics section Procedures following delivery or abortion – All coded to the root operation Extraction and the body part Products of Conception, Retained. – Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are coded in the Medical and Surgical section.
Summary and Questions The ICD-10 Official Guidelines mirror the ICD-9 Official Guidelines in most cases ICD-10 Official Guidelines contain ICD-9 Coding Clinic Guidelines Questions?
References: ICD-10-CM Official Guidelines for Coding and Reporting 2013 ICD-10-PCS Official Guidelines for Coding and Reporting 2013