Presentation on theme: "Official Coding Guidelines ICD-10-CM and PCS"— Presentation transcript:
1 Official Coding Guidelines ICD-10-CM and PCS Presented by:MONICA LEISCH, RHIA, CCSAHIMA Approved ICD-10 TrainerDirector of Compliance / HIM ServicesHealthcare Cost Solutions, Inc.May, 2013
2 DisclaimerThis 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 facility’s situation.
3 IntroductionICD-10-CM Official Guidelines for Coding and Reporting 2013 for Diagnoses and ProceduresWill only cover significant guidelines; too lengthy for one hour to cover all
4 Guidelines DefinedThe 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 IndexRequired under the Health Insurance Portability and Accountability Act (HIPAA)CMS and NCHS are part of The US Fed Gov Department of Health and Human Services, or the DHHS.
5 CM vs PCS ICD-10-CM (Clinical Modification) Morbidity classification developed by the USClassifies diagnoses and reason for visitApplicable to all health care settingsBased on ICD-10 classification system published by WHOICD-10-PCS (Procedural Coding System)Procedure classification published by the USClassifies all proceduresApplicable to inpatient care setting onlyNo such system in the ICD-10 published by WHOWHO = World Health OrganizationCan be used for outpatient for internal facility use only
6 Cooperating PartiesThe 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)
7 Hierarchy In order of Precedence: Coding Conventions of the ICD ClassificationOfficial Coding GuidelinesAll other, including Coding Clinic, LCDs, etc.When applying the codes, use this hierarchy
8 CM Organization CM guidelines are organized into sections: Section I includes the structure and conventions of the classification and general guidelinesSection II includes guidelines for selection of principal diagnosis for non-outpatient settingsSection III includes guidelines for reporting additional diagnoses in non-outpatient settings.Section IV is for outpatient coding and reportingStart with CM first; will discuss significant instructions only
9 Excludes Notes ICD-10-CM ICD-10-CM has two types of excludes notes. a. Excludes 1A 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 2A 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.
10 Impending or Threatened Condition ICD-10-CMImpending or Threatened Condition listed at time of Discharge:If confirmed, code as confirmed diagnosis.If it did not occur, check Alphabetic Index forsubentry 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 threatenedCC in I9; The example here is impending MI is coded as unstable angina; what if it is listed as impending/threatened at discharge not confirmed or did not occur
11 Laterality Laterality ICD-10-CMLateralityFor 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.
12 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.10 includes sequela.
13 BMI & UlcersICD-10-CMDocumentation for BMI (Body Mass Index) and Ulcers for coding:Codes may be assigned from clinician, (non physician) documentationThe provider responsible for the patient’s care must provide coordinating diagnosisWhen conflicting documentation is present, query the responsible providerBMI codes should only be secondary diagnosis codesCoding Clinic instruction included here in guidelines
14 Signs, Symptoms Signs and symptoms ICD-10-CMSigns and symptomsCodes 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.
15 Complication of Care Complications of care ICD-10-CM As with all procedural or post-procedural complications, code assignment is based on the provider’s 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.
16 Borderline Diagnosis Borderline Diagnosis documented at Discharge: ICD-10-CMBorderline Diagnosis documented at Discharge:Coded as confirmed unless the classification provides a specific entryBorderline conditions are not uncertain conditions so no distinction between inpatient and outpatient settings.If documentation is unclear, queryExample here is borderline diabetes
17 Human Immunodeficiency Virus Infections ICD-10-CMHIV 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 B20Asymptomatic human immunodeficiency virus Z21 is used for:no documentation of symptomsHIV positive, known HIV, HIV test positive or similarDo 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 illnessPreviously diagnosed HIV – related illness:Once a patient has developed an HIV related illness, assign B20 on every subsequent admission/encounter
18 Sepsis/Severe Sepsis and Septic Shock ICD-10-CMSepsis, Severe Sepsis, and Septic ShockSepsis: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
19 Septic Shock Septic shock: ICD-10-CMSeptic 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.Difference here is that I10 includes septic shock in the code for sepsis
20 Urosepsis Urosepsis Nonspecific term. ICD-10-CMUrosepsisNonspecific 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.
21 Sequencing of SepsisICD-10-CMIf 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.
22 Sepsis/Severe Sepsis with Infections ICD-10-CMIf sepsis is present with a localized infection:Sequence sepsis codes firstList localized infections secondIf due to a post-procedural infection:Sequence the code for the post-procedural infection firstList sepsis codes secondIf septic shock is documented, list second as well
23 Sepsis/Severe Sepsis with Non-infectious Process ICD-10-CMIf sepsis is present with a non-infectious process:If the sepsis is due to the non-infectious process, list the non-infectious process firstList the sepsis codes secondIf the non-infectious process leads to an infection with sepsis, the infection should be listed firstCode for Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin is not neededThis direction is slightly different from I9
24 Death NOSICD-10-CMDeath NOSCode 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 arrivalDoes not represent the discharge disposition of death.
25 Neoplasms General Guidelines ICD-10-CMA 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 eachExample: tumors in different quadrants of same breastI9 does include section on neoplasms just not this info
26 Neoplasms General Guidelines (cont.) ICD-10-CMMalignant neoplasms of ectopic tissue are to be coded to origin of mentioned siteExample: ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9)Check the Alphabetic Index first before going to the Neoplasm Table
27 Neoplasms Coding & Sequencing of Complications (Anemia Associated w/ Malignancy) ICD-10-CMWhen admitted for management of anemia associated with malignancy & treatment:Sequence the code for malignancy as principalFollowed by appropriate code for anemiaI9 anemia first, I10 anemia second
28 Neoplasms Coding & Sequencing of Complications (Anemia assoc Neoplasms Coding & Sequencing of Complications (Anemia assoc. w/ therapies)ICD-10-CMManagement 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 effectManagement 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 . . .
29 Neoplasms Malignancy in 2 or more noncontiguous sites ICD-10-CMIn 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
30 Neoplasms Admission to Determine Extent of Malignancy ICD-10-CMWhen the reason for admission is to determine the extent of the malignancy, list the malignancy first, even if chemotherapy or radiotherapy is administered.same
31 Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CMMalignant 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
32 Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CMEncounter 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 neoplasmException: Anemia (see slide above)
33 Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CMWhen 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)
34 Neoplasms Sequencing of neoplasm codes (cont.) ICD-10-CMPathologic fracture due to neoplasmIf 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 fractureThe determination here is the focus of treatment
35 Neoplasms Current malignancy vs. personal history of malignancy ICD-10-CMWhen primary malignancy has been excised but further treatment is directed to that site, use primary malignancy code until treatment is completedUse 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
36 Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal historyICD-10-CMCategories 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
37 Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal history (cont.)ICD-10-CMIf it is unclear in the documentation as to whether or not the leukemia has achieved remission, query the provider.Remission must be documented in order to use that code
38 Malignant Neoplasm associated with Transplanted Organ ICD-10-CMCoded as tranplant complicationAssign the code for the specific malignancy second
39 Diabetes Diabetes Mellitus ICD-10-CMDiabetes mellitus codes are combination codes to include type of diabetes, body system affected, and complications affecting that body systemAssign as many codes within category as are necessary to describe all complications of diseaseI10 No longer indication of controlled or uncontrolled
40 Diabetes Underdose of insulin due to insulin pump failure ICD-10-CMAssign 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 principalAssign T38.3x6-, Underdosing of insulin and oral hypoglycemic (antidiabetic drugs) as secondaryAssign codes for type of diabetes mellitus and associated complications if appropriateI10 adds code for underdosing; note just like any other complication of a device, list the complication first, followed by the code for the underdosing
41 Diabetes Overdose of insulin due to insulin pump failure ICD-10-CMAssign 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 principalAssign T38.3x1-, Poisoning by insulin and oral hypoglycemic drugs, accidental as secondaryAgain assign the code for the pump failure as pdx followed by the poisoning
42 Diabetes Secondary Diabetes Mellitus ICD-10-CMCodes 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 mellitusSecondary DM is always caused by another conditionI10 has a specific code category for drug or chemical induced DM
43 Diabetes Assigning and sequencing secondary diabetes codes and its causes ICD-10-CMSequencing 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.Same info different language
44 Mental & Behavioral Disorders Pain disorders related to psychological factors ICD-10-CMAssign code F45.41, for pain that is exclusively related to psychological disordersDo not assign a code from category G89, Pain, not elsewhere classified with is codeNo guidance for psych pain in I9 NOTE THIS ONE IS “TO”
45 Mental & Behavioral Disorders Pain disorders related to psychological factors ICD-10-CMCode 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 painI10 if pain is due to related psych factors, then this code is used and the NEC as well NOTE THIS ONE IS “WITH”
46 Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CMIn RemissionAssigned only if so documented.Selection of codes for “in remission” categories F10-F19, Mental and behavioral disorders due to psychoactive substance useLarge I10 section for mental disorders for guidance
47 Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CMPsychoactive 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:Continues on next screen
48 Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CMPsychoactive Substance Use, Abuse and Dependence (cont.)If both use and abuse are documented, assign only the code for abuseIf both abuse and dependence are documented, assign only code for dependenceIf use, abuse and dependence are all documented, assign only the code for dependenceI10 specific definitions for use, abuse and dependence; continued on next screen
49 Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CMPsychoactive Substance Use, Abuse and Dependence (cont.)If both use and dependence are documented, assign only the code for dependence
50 Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CMPsychoactive Substance UseThe 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 providerDon’t assume a relationship without documentation by the provider
51 Nervous System Dominant/nondominant side ICD-10-CMCodes 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 affectedI10 ability to report paralysis is dominant vs nondominant
52 Nervous System Dominant/nondominant side (cont.) ICD-10-CMIf 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 dominantIf left side is affected, default is non-dominantIf right side is affected, default is dominant
53 Pain Reporting General Coding Info ICD-10-CMOnly assign code from category G89 if pain is specified as acute or chronic, post-thoracotomy, post-procedural, or neoplasm-relatedPain codes are only assigned as principal if:Pain control or management is reason for encounterPatient is admitted for insertion of neurostimulator for pain controlNot for neurostimulator insertion for definitive underlying cause.I10 excludes central pain syndrome
54 Circulatory System Hypertensive Heart & Chronic Kidney Disease ICD-10-CMThe 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 diseaseI13 codes are combination codes that include hypertension, heart disease and chronic kidney diseaseBoth have combo codes, but the type of hypertension(malignant, benign) is missing in I10
55 Circulatory System Hypertensive Heart & Chronic Kidney Disease ICD-10-CMThe Includes note at I13 specifies that the conditions included in I11 and I12 are included together in I13If a patient has hypertension, heart disease and CKD then a code from I13 should be used rather than individual codesFor patients w/ both acute renal failure and CKD an add’l code for acute renal failure is requiredIt appears that I10 assumes a cause and effect relationship in hypertension with both heart and kidney disease
56 Circulatory System Hypertensive Retinopathy ICD-10-CMSubcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertensionSequence based on reason for encounterI10 does not have a code for hypertensive retinopathy but instructs to use a background retinopathy code
57 Circulatory System Atherosclerotic Coronary Artery Disease & Angina ICD-10-CMCombination codes for atherosclerotic heart disease with angina pectorisWhen using one of these combo codes it is not necessary to use an additional code for anginaIf a patient with coronary artery disease is admitted due to acute myocardial infarction (AMI), sequence AMI firstI10 has combo code for ASHD and angina
58 Circulatory System Intraoperative and Postprocedural Cerebrovascular Accident ICD-10-CMProper 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 performedCVA intraoperative vs postprocedural
59 Circulatory System Sequelae of Cerebrovascular Disease ICD-10-CMCategory 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.Use the same definition for dominant vs non-dominant as before
60 Circulatory System Acute myocardial infarction (AMI) ICD-10-CMFor 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 reportedFor encounters > 4 weeks old and patient is still receiving care related to MI, appropriate aftercare code should be assignedIf the NSTEMI evolves to a STEMI, assign the STEMI onlyFor old or healed MI not requiring care, code I25.2, Old myocardial infarction
61 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 AMIThe sequencing of the I22 and I21 codes depends on the circumstances of the encounter
62 Circulatory System Documentation of Ventilator Associated Pneumonia ICD-10-CMCode J95.851, Ventilator associated pneumonia, (VAP), should be assigned only when the provider has documented VAPAdd’l code to identify organism should also be assignedDo not assign add’l code from J12-J19 to identify the type of pneumonia, unless the VAP develops after admission, and the patient is admitted with pneumonia.
63 Pressure Ulcer StagesICD-10-CMCodes from category L89 Pressure Ulcer, combo codes that show the ulcer as well as the stageIf documented as healed, no code is assignedIf 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.Note in I9 this info is found in CC
64 Diseases of the Musculoskeletal System and Connective Tissue ICD-10-CMSite and LateralitySite represents bone, joint or muscleFor conditions where more than one, bone, joint or muscle are involved there is a multiple sites codeBone vs. jointThough the portion of bone affected may be the joint, the site designation will be the bone not the joint
65 Coding of Pathologic Fractures ICD-10-CM7th Character A is for active fracture treatmentsurgicalEDEval by new physician7th Character D is used for encounters after the patient has completed active treatmentOther 7th Characters are used for subsequent encounters associated with healing such as malunions, nonunions and sequelae
66 Chronic Kidney Disease ICD-10-CMStages of chronic kidney disease (CKD)Classify severityEnd stage renal disease with CKD is assigned with one code N18.6, which include both conditionsCKD with TransplantThe presence of CKD alone may not constitute a transplant complicationIf unclear query
67 Pregnancy, Childbirth, Puerperium Final character for trimester ICD-10-CMMajority of Ch 15 codes have a final character indicating trimester of pregnancyWhere trimester isn’t part of the code it is because the condition always occurs in a specific trimesterI9 does not include trimester specificity – continues on next screen
68 Pregnancy, Childbirth, Puerperium Final character for trimester ICD-10-CMFinal trimester codes also apply for pre-existing conditions and those that develop during or are caused by the pregnancyIf delivery occurs during the current admission and there is an “in childbirth” option for the obstetric complication, the “in childbirth” code should be assignedsame
69 Pregnancy, Childbirth, Puerperium Final character for trimester ICD-10-CMIf 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 dischargeThe unspecified trimester should not be used; obtain further clarificationTrimester assigned to when the complication developed, not the one at discharge, also continued on next page
70 Pregnancy, Childbirth, Puerperium 7th character Fetus Identification ICD-10-CMIf applicable, a 7th character should be assigned for certain categories to identify the fetus for which the complication code appliesAssign 7th character “0”:For singe gestationsWhen the documentation in the record is insufficient to determine the fetus affectedWhen it is not possible to clinically determine which fetus is affectedI10 differs in not having a separate code for “outcome” of delivery (V27) included in the 7th character
71 Pregnancy, Childbirth, Puerperium Pre-existing conditions vs Pregnancy, Childbirth, Puerperium Pre-existing conditions vs. conditions due to pregnancyICD-10-CMCertain categories in Chapter 15 distinguish between conditions of the mother than existed prior to pregnancy and those that are a direct result of the pregnancyFor categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for eitherSame as I9, but not listed in their guidelines.
72 Pregnancy, Childbirth, Puerperium Gestational (pregnancy induced) diabetes ICD-10-CMGestational (Pregnancy Induced) diabetesCodes under subcategory O24.4 include diet controlled and insulin controlledIf gestational diabetes is treated with both diet and insulin, only code insulin-controlledCode Z79.4, Long-term (current) use of insulin, should not be assigned with codes from subcategory O24.4Abnormal glucose tolerance in pregnancy is assigned a code from subcategory O99.81, Abnormal glucose complicating pregnancy, childbirth, and the puerperiumI9 codes only for gestational DM vs I10 has codes for both diet controlled and insulin controlled
73 Pregnancy, Childbirth, Puerperium Alcohol, tobacco use during pregnancy, childbirth and the puerperiumICD-10-CMSubcategory O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium - assigned when a mother uses alcohol during the pregnancy or postpartumAlso assign a secondary code from category F10, Alcohol related disorders, to identify manifestations of alcohol useI9 has same instruction, just not in the guidelines
74 Pregnancy, Childbirth, Puerperium Alcohol, tobacco use during pregnancy, childbirth and the puerperiumICD-10-CMSubcategory O99.33, Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium - assign when a mother uses any type of tobacco product during the pregnancy or postpartumAlso assign a secondary code from category F17, Nicotine dependence, or code Z72.0, Tobacco use, to identify the type of nicotine dependenceI9 only reports one code for this, as it does not have codes for nicotine dependence.
75 Pregnancy, Childbirth, Puerperium Poisoning, toxic effects, adverse effects and underdosing in a pregnant patientICD-10-CMSubcategory O9A.2, Injury, poisoning and certain other consequences of external causes complicating pregnancy, childbirth, and puerperium, is sequenced firstNext assign the appropriate injury, poisoning, toxic effect, adverse effect or underdosing codeThen assign additional code(s) that specifies the condition causing poisoning, toxic effect, adverse effect or underdosingSame guideline, I10 uses terminology of “underdosing”
76 Pregnancy, Childbirth, Puerperium Pregnancy associated cardiomyopathy ICD-10-CMPregnancy associated cardiomyopathy, code O90.3, is unique in that it may be diagnosed in the 3rd trimester of pregnancy but may continue to progress months after deliveryAs such, it is referred to as peripartum cardiomyopathyCode 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 diseaseI9 does not have this code; requires 2, cardiovascular disease in pregnancy, and cardiomyopathy code.
77 Sequelae of complication of Pregnancy, Childbirth, and the Puerperium ICD-10-CMUse code O94 in cases when an initial complication of pregnancy develops a sequelae requiring care or treatment at a future dateThe sequela code is sequenced following the code for the complication
78 Abuse in a Pregnant Patient ICD-10-CMSuspected 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 puerperiumSee also Section I.C.19, Adult and child abuse, neglect and other maltreatment
79 NewBorns Conditions Originating in the Perinatal Period ICD-10-CMPrincipal Diagnosis for the Birth RecordAssign a code from category Z38, Liveborn infants according to place of birth and type of delivery as principal diagnosis for the birth episodeA code from category Z38 should only be used onceThis code is the same as the ICD-9 V30 series
80 Newborns Use of Codes from other Chapters ICD-10-CMCodes from other chapters may be used w/ codes from chapter 16 if the codes from the other chapters provide more specific detailIf the reason for the encounter is a perinatal condition, the code from chapter 16 should be principalI9 instructs to use code , specified conditions originating in the perinatal period, if no specific code is found in the index; I10 use additional codes with the newborn codes
81 Newborns Low birth weight and immaturity status ICD-10-CMCodes 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 patient’s current healthSame as I9
82 Newborns Bacterial Sepsis of Newborn ICD-10-CMCategory 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 assignedI10 specifies congenital sepsis as the default if the infection is not listed as congenital or community acquired
83 Newborns Bacterial Sepsis of Newborn ICD-10-CMIf the P36 code includes the causal organism, an add’l code from category B95 or B96 should not be assignedIf the P36 code does not include the causal organism, assign an add’l code from category B96I10 specific codes for newborn sepsis with some specifying the organism.
84 Newborns StillbirthICD-10-CMCode P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirthNo other code should be used with P95P95 should not be used on the mother’s recordI9 has no specific code for stillbirth, outcome only
85 Coma ScaleICD-10-CMThe coma scale codes are used in conjunction with traumatic brain injury codes, acute cerebrovascular disease and cerebrovascular disease codes.The 7th character indicates when the scale was recordedAt a minimum report the initial score documented on presentationAssign R40.24, Glasgow coma scale, total score, when only the total score is documentedComa scale is not assigned in I9
86 Injuries Application of 7th Characters ICD-10-CMMost categories in chapter 19 have a 7th character requirement for each applicable codeMost categories have three 7th character values (exception: fracture):A, initial encounterD, subsequent encounterS, sequelaI10 7th character designation
87 Injuries Application of 7th Characters ICD-10-CM7th character “A”, intial encounter is used while the patient is receiving active treatment for the conditionExamples:Surgical treatmentED encounterEvaluation and treatment by a new physician
88 Injuries Application of 7th Characters ICD-10-CM7th 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 phaseExamples:Cast change or removalRemoval of external or internal fixation deviceMedication adjustmentCare during the healing process
89 Injuries Application of 7th Characters ICD-10-CM7th 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 burnWhen using “S,” it is necessary to use both the injury code that precipitated the sequela and the sequela itselfAdd “S” only to the injury code, not the sequela code
90 Injuries Application of 7th Characters ICD-10-CMAftercare Z codes should not be used for aftercare conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent careExample: for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter)Z codes not for injuries and poisoning, use D for those
91 Injuries Coding of Traumatic Fractures ICD-10-CMA fracture not indicated as open or closed should be coded to closedA fracture not indicated whether displaced or not displaced should be coded to not displacedSame as I9 just not in the guidelines
92 Injuries Initial vs. Subsequent Encounter for Fractures ICD-10-CMWhen patient is receiving active treatment for fracture, traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C)continues on next screen
93 Injuries Initial vs. Subsequent Encounter for Fractures ICD-10-CMFor encounters after the patient has completed active treatment and is receiving routine care during the healing/recovery phase, fractures are coded with appropriate 7th character for subsequent careSame, 7th character difference in I10
94 Injuries Coding of Burns and Corrosions ICD-10-CMDistinction between burns and corrosionsBurn codes are for thermal burns, except sunburns, that come from a heat source or burns resulting from electricity and radiationCorrosions are burns due to chemicalsGuidelines are the same for bothNon-healing burns are coded as acute burnsI10 has different codes for thermal burn vs corrosive burns
95 Injuries Encounters for treatment of sequela burns ICD-10-CMEncounters for the treatment of the late effects of burns or corrosions should be coded with a burn or corrosion code with the 7th character “S” for sequelaI10 does not use late effect codes, sequela 7th character instead
96 Injuries Adverse Effects, Poisoning, Underdosing & Toxic Effects ICD-10-CMCodes in categories T36-T65 are combination codes that include substance that was taken as well as the intentDo not code directly from Table of Drugs; refer back to Tabular ListIf the same code would describe the causative agent for more than one adverse reaction, toxic effect or underdosing, assign the code only onceI10 has combo code for substance taken and intent
97 Injuries Adverse Effect ICD-10-CMWhen 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 5th or 6th character of 55th/6th character of 5, (signifying adverse effect)
98 Injuries Poisoning Codes ICD-10-CMAssign code from categories T36-T50 firstPoisoning codes have an associated intent as their 5th or 6th characterUse additional code(s) for all manifestations of poisoningsFollow with abuse or dependence code, if applicableI10 include intent in the 5th/6th character
99 Injuries UnderdosingICD-10-CMUnderdosing refers to taking less of a medication than is prescribed by a providerFor underdosing, assign code from T36-T50 (5th or 6th character “6”)Codes for underdosing should not be listed firstSpecific instructions in I10, found in CC in I9 both poisoning, but I10 uses underdosing – continues on next screen
100 Injuries UnderdosingICD-10-CMIf a patient has a relapse of the medical condition for which drug is prescribed because of underdosing, the medical condition itself should be codedNoncompliance (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
101 Injuries Complications of Care: Complication codes that include the external cause ICD-10-CMAs with some other T codes, some of the complications of care codes have the external cause included in the codeThe code includes the nature of the complication as well as the type of procedure that caused the complicationNo external cause code indicating the type of procedure is necessary for these codesI10 includes combo codes and difference here is that code for type of procedure is not necessary
102 External Causes of Morbidity Introduction ICD-10-CMCodes V01-Y99 are provided for the reporting of external causes of morbidityAlways secondary codesI10 V & Y codes same as I9 E codes
103 Injuries Complications of Care: Complication codes within the body system chapters ICD-10-CMIntraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body systemThese codes should be sequenced first, followed by a code(s) for the specific complicationfound in the body system chapters
104 External Causes of Morbidity General External Cause Coding Guidelines ICD-10-CMAn 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 causeI10 specifies health condition
105 External Causes of Morbidity General External Cause Coding Guidelines ICD-10-CMMostly applicable to injuriesAlso valid for infections or diseases due to an external source, and other health conditions, such as a heart attack that occurs during strenuous physical activityI10 gives the examples found in I9 CC
106 External Causes of Morbidity Length of Treatment ICD-10-CMAssign the external cause code with the appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treatedDifference is the 7th character in I10
107 External Causes of Morbidity Combination external cause codes ICD-10-CMSome 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 objectAssign regardless of seriousness of injuryInjury may be due to either event or bothSame just in the guidelines, but I10 has more combo codes
108 External Causes of Morbidity Place of Occurrence Guideline ICD-10-CMCodes 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/conditionPlace of occurrence used at initial encounter w/ no 7th characterSimilar, note the initial encounter uses no 7th character
109 External Causes of Morbidity Unknown or Undetermined Intent Guideline ICD-10-CMIf 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 determinedI10 must be stated as undetermined in order to use the undetermined cause code
110 Factors Influencing Health Status Aftercare ICD-10-CMAftercare Z codes should not be used for aftercare for injuries.Use Z codes for care following treatmentFor aftercare of an injury, assign the acute injury code with the appropriate 7th character for subsequent encounterDifference I10 uses 7th character to designate aftercare, no separate code is needed as in I9
111 Factors Influencing Health Status “With” or “without” abnormal findings ICD-10-CMSome codes for routine health exams distinguish between “with” and “without” abnormal findingsCode assignment depends on info known at the time encounter is being codedE.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,” add’l code(s) should identify specific abnormal findingsSpecific instruction given when to use abnormal vs normal findings codes – continues on the next screen
112 Outpatient Coding Guidelines Encounters for medical exams w/ abnormal findings ICD-10-CMThe subcategories for encounters for general medications, Z00.0-, provide codes for with and without abnormal findingsShould a general medical exam result in an abnormal finding, the code for general medical examination with abnormal finding should be first-listed diagnosisA secondary code for the abnormal finding should also be codedSpecific instruction given when to use abnormal vs normal findings codes
113 PCS Organization Conventions Medical and Surgical Section Guidelines ICD-10-PCSConventionsMedical and Surgical Section GuidelinesBody SystemRoot OperationBody PartApproachDeviceObstetrics Section Guidelines
114 PCS Conventions ICD-10-PCS Composed of 7 characters Characters = numbers 0 through 9 and alpha except I and OThe valid values for an axis of classification can be added as neededThe meaning of any single value is a combination of its axis of classification and any preceding valuesWith expansion more values will depend on the preceding value
115 PCS Conventions continued ICD-10-PCSAlphabetic index provides for location table necessary to construct codeCode 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 codeWithin a PCS table, valid codes include all combinations of choices for characters 4 through 7The term “And” means “and/or”It is the coder’s responsibility to determine which code to choose from the documentation
116 Device General Guidelines -change -irrigation ICD-10-PCSGeneral GuidelinesCoded only if it remains after procedure is codedSutures, ligature, radiological markers an temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devicesProcedures performed on a device only and not on a body part are specified in the root operations:-change -irrigation-removal -revisionDue to lengthy, only will discuss device from the med/surg section
117 Obstetrics Section ICD-10-PCS Productions of conception Procedures performed on the products of conception are coded to the obstetrics sectionProcedures following delivery or abortionAll 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.
118 Summary and Questions Questions? The ICD-10 Official Guidelines mirror the ICD-9 Official Guidelines in most casesICD-10 Official Guidelines contain ICD-9 Coding Clinic GuidelinesQuestions?
119 References:ICD-10-CM Official Guidelines for Coding and Reporting 2013ICD-10-PCS Official Guidelines for Coding and Reporting 2013