1. Preparing for ICD-10-CM/PCS: What does a coder need to do now?
Presented by:
Jennifer McManis, RHIT

2. ICD-10-CM/PCS Compliance Timeline Training Timeline
Continuing Education Requirements
Myth Busters
Code Structure
Coding Fundamentals
Case Studies
Resources

3. Implementation Date ICD-10-CM/PCS Compliance Deadline October 1, 2013
Claims for services provided on or after this date must use ICD-10 codes
CPT codes will continue to be used for outpatient services

4. Compliance Timeline January 1, 2010
Internal testing of Version 5010 for electronic claims
December 31, 2010
Internal testing must be complete
January 1, 2011
External Testing of Version 5010 claims
CMS begins accepting Version 5010
Version 4010 continue to be accepted
January 1, 2012
All claims must use Version 5010
Version 4010 no longer accepted 4

5. Outpatient Coder Training
Approximately 16 hours
Review code Structure & Coding Conventions.
Learn the fundamentals
Analyze & practice applying the ICD-10-CM guidelines
Review and refresh knowledge of A & P concepts

6. Outpatient Coding Training
Become an expert in applying ICD-10-CM codes to outpatient cases in the six to nine months preceding October 1, 2013.
Practice using ICD-10-CM codes each week leading into “go live” on October 1, 2013.
Network with peers to seek answers to cases and confirm application of ICD-10-CM codes.
Take advantage of component MHIMA training opportunities

7. Inpatient Coder Training
Approximately 50 hours
Review code structure and coding conventions for ICD-10-CM and ICD-10-PCS.
Learn the fundamentals of the ICD-10-CM and ICD-10-PCS systems.
Analyze and practice applying the ICD-10-CM and ICD-10-PCS Coding Guidelines.
Continue to study ICD-10-PCS definitions (memorize the definitions of approaches and root operations).
Continue to review and refresh knowledge of anatomy and physiology concepts

8. Inpatient Coder Training
Become an expert in applying ICD-10-CM and ICD-10-PCS codes to inpatient cases in the 6 to 9 months preceding October 1, 2013
Practice using ICD-10-CM and ICD-10-PCS codes each week leading into “go live” on October 1, 2013
Network with peers to seek answers to cases and confirm application of ICD-10-CM/PCS codes
Take advantage of MHIMA training opportunities

9. Continuing Education Unit (CEU) Requirements
Required to participate in a predetermined number of mandatory baseline educational experiences specific to ICD-10-CM/PCS.
*Can Begin Earning CEU’s January 1, thru December 31, 2013
2009 or 2010 ICD-10 –CM Academy

10. CEU Requirements
Total number of ICD-10-cm/PCS CEU required, by AHIMA Credential
CHPS- 1 CEU
CHDA; RHIT;RHIA- 6 CEUs
CCS-P- 12 CEUs
CCS; CCA- 18 CEUs
If you hold more than one credential, only report the highest number of CEUs

11. CEU Requirements
CEU requirements will be included within the total number of CEUs required for a given CEU Cycle. For example, if you hold an RHIA credential, you will obtain 6 CEUs that are in relation to ICD-10-CM/PCS along with the additional 24 CEUs to complete your recertification cycle.
Reporting of the CEUs will be made available by Fall of 2011

12. Myths October 1, 2013 is considered a flexible date
Implementation planning should be undertaken with an assumption that DPHHS will grant an extension
Worker’s comp & auto insurance companies may choose not to implement ICD-10-CM/PCS
State Medicaid Programs will not be required to update their systems in order to utilize ICD-10-CM/PCS
The increased number of codes will make the new coding system impossible to use
Developed without any clinical input
There will no hard copy of ICD-10-CM/PCS
All coding will be done electronically

13. Myths Developed a number of years ago, so it is out of date
Unnecessarily detailed medical record documentation will be required
Implementation can wait until after electronic health records and other health care initiatives have been established
ICD-10-CM based super bills will be too long or too complex
The GEMs are intended to facilitate the process of coding medical records
Each payer will be required to develop their own mappings, GEM have been developed for CMS use only
Medically unnecessary diagnostic tests will need to be performed in order to assign an ICD-10-CM code
CPT will be replaced by ICD-10-CM/PCS

14. ICD 10-CM Code Structure ICD 10-CM Contains more than 68,000 codes
Compare this to ICD-9-CM which contains 13,000 codes
Consists of 3-7 characters
First digit is alpha
All Letters are used except U
4th,5th,6th & 7th Digits can be numeric
Decimal placed after the 1st three characters

15. ICD-10-CM Code Structure
XXX.XXX X
1st 3 Characters- Category
4th 5th 6th Characters-Etiology, Anatomic Site, Severity
7th Character-Extension (Visit Encounter, Sequelae, External Causes)
ICD-9-CM Code Structure
XXX.XX
1st 3 Characters-Category
4th 5th Characters- Etiology, Anatomic Site, Manifestation

16. ICD-10-CM Structure Index & Tabular List Two Parts of the Index
Disease & Injury
Table of Drugs & Chemicals
Neoplasm Table
External Causes
Coding Guidelines
Some changes from ICD-9
Fractures- Default Displaced
2 Categories for Acute MI
Acute MI is 4 weeks instead of 8 weeks
Osteoporosis with current pathological fracture
V codes are now Z Codes

17. ICD-10-CM
New Features
Combination codes for conditions & common symptoms
Combination codes for poisonings & external causes
Added laterality
Added extensions for episode of care
Expanded codes
Inclusion of trimester in obstetric codes and elimination of fifth digits for episode of care
External cause codes no longer a supplementary classification

18. ICD-10-CM Diabetes Mellitus Codes Injuries
No Longer Classified as uncontrolled/controlled
Includes diabetes & the complication
Injuries
Grouped by Anatomical site rather than type of injury
Code Extension to identify (7th Character)
A- Initial encounter
D-Subsequent encounter
S-Sequelae

19. ICD-10-CM Code Examples I10- Hypertension Hypertension Table Removed
Combination codes Certain Conditions and Associated Symptoms
K57.21-Diverticulitis of large intestine with perforation and abscess with bleeding
I Arteriosclerotic Heart Disease of native coronary artery with unstable angina pectoris
K Toxic Liver disease with chronic active hepatitis with ascites
E Type 1 diabetes mellitus with diabetic neuropathic arthropathy

20. ICD-10-CM Combination codes for poisonings and their external cause
T42.3x2S- Poisoning by barbituates, intentional self-harm, sequela
Laterality
C Malignant neoplasm of upper-inner quadrant of left female breast
L Pressure ulcer of right hip, stage III
Example of Superbill 20

21. ICD-10-CM Codes for clinical concepts that do not exist in ICD-9-CM
T45.526D-Underdosing of antithrombotic drugs, subsequent encounter
Z Type O Blood, RH positive
Codes for postoperative complications, intraoperative, and post- procedural disorders
D Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen
D Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen
Obstetric codes identify trimester instead of episode of care
Excessive weight gain in pregnancy, second trimester

22. ICD-10-CM Coding Guidelines
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
d. Sepsis, Severe Sepsis, and Septic Shock
Case Study:
Patient was taken to the emergency department and admitted to the hospital after being found semi-conscious with markedly abnormal vital signs, a fever of over 39 degrees C, a heart rate of 110, and a respiratory rate of 22/min. Final diagnoses included sepsis and septic shock with acute respiratory failure
Answer:
A41.9 Sepsis (generalized)
R65.21 Shock, septic (due to severe sepsis)
J96.0 Failure, respiration, respiratory, acute
(b) Severe sepsis
The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified, for the infection. Additional code(s) for the associated acute organ dysfunction are also required.
Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.
2) Septic shock
Septic shock is circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. For all cases of septic shock, the code for the underlying systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned.
Septic shock indicates the presence of severe sepsis. Code R65.21, Severe sepsis with septic shock, must be assigned if septic shock is documented in the medical record, even if the term severe sepsis is not documented. 22

23. ICD-10-CM Coding Guidelines
Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) a. Diabetes mellitus
6) Secondary Diabetes Mellitus
Case Study
This 34-year-old patient is being seen for ongoing management of steroid- induced diabetes mellitus which was due to the prolonged use of corticosteroids, which have been discontinued. The patient’s diabetes is managed with insulin which he has been taking for the last two years
Answer:
T38.0x5S Refer to Drug and Chemical Table, Corticosteroid, adverse effect
E09.9 Diabetes, diabetic, (mellitus) (sugar), due to drug or chemical
Z79.4 Long-term (current) drug therapy (use of), insulin
6) Secondary Diabetes Mellitus
Codes under categories E08, Diabetes mellitus due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning).
(b) Assigning and sequencing secondary diabetes codes and its causes
The sequencing of the 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. For example, for category E08, Diabetes mellitus due to underlying condition, code first the underlying condition; for category E09, Drug or chemical induced diabetes mellitus, code first the drug or chemical (T36-T65). 23

24. ICD-10-CM Coding Guidelines
Chapter 9 Diseases of Circulatory System (I00-I99)
Case Study
Patient is seen for treatment of unstable angina. The patient has a history of atherosclerotic heart disease and underwent a 3-vessel coronary bypass approximately 2 years ago. The patient recently underwent a cardiac catheterization of all three coronary bypass grafts which showed them patent
Answer:
I Angina (attack) (cardiac) (chest) (heart) (pectoris) (syndrome) (vasomotor), with atherosclerotic heart disease – see Arteriosclerosis, coronary (artery), native vessel with angina pectoris, unstable
Z95.1 Status (post), aortocoronary bypass
b. Atherosclerotic Coronary Artery Disease and Angina
ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7, Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.
When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.
If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease. 24

25. ICD-10-CM Coding Guidelines
Chapter 12: Diseases of Skin and Subcutaneous Tissue (L00-L99)
a. Pressure ulcer stage codes
Case Study
This patient has a gangrenous pressure ulcer of the right hip and a pressure ulcer of the sacrum documented by the physician. The nursing assessment indicates a stage II pressure ulcer of the sacrum with a stage III decubitus ulcer of the right hip.
Answer:
I96 Ulcer, gangrenous – see Gangrene. Gangrene, gangrenous (connective tissue) (dropsical) (dry) (moist) (skin) (ulcer) (see also necrosis), Necrosis, skin or subcutaneous tissue NEC
L Ulcer, ulcerated, ulcerating, ulceration, ulcerative, pressure (pressure area) stage III, (healing) (full thickness skin loss involving damage or necrosis of subcutaneous tissue)
L Ulcer, ulcerated, ulcerating, ulceration, ulcerative, pressure (pressure area) stage II, (healing) (abrasion, blister, partial thickness skin loss involving epidermis and/or dermis) sacral region (tailbone
What is different- only one code required for ulcers combination code 25

26. ICD-10-CM Coding Guidelines
Chapter 9: Diseases of Circulatory System (I00-I99)
a. Hypertension
1) Hypertension with Heart Disease
3) Hypertensive Heart and Chronic Kidney Disease
Case Study
This patient is hospitalized with a diagnosis of congestive heart failure due to hypertensive heart disease. Patient also has Stage 5 chronic kidney failure. The patient has been prescribed Lasix previously but admits he forgets to take his medication every day. This is due to his advanced age.

27. ICD-10-CM Coding Guidelines
Answer:
I13.2 Disease, diseased, heart (organic), hypertensive – see Hypertension, heart. Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic), heart (disease) with kidney disease (chronic) – see Hypertension, cardiorenal (disease), with heart failure, with stage 5 or end stage renal disease
I50.9 Failure, heart (acute) (sudden), congestive (compensated) (decompensated). The “use additional code” statement under code I13.2 indicates the use of this code to identify the type of heart failure
N18.5 Disease, diseased, kidney (functional) (pelvis), chronic, stage 5. The “use additional code” statement under code I13.2 indicates the use of this code to identify the stage of the chronic kidney disease
T50.1x6A Refer to Table of Drugs and Chemicals, Lasix, underdosing
Z Noncompliance, medication regimen, underdosing, unintentional, due to patient’s age-related debility

28. ICD-10-CM Coding Guidelines
Chapter 20: Chapter 20: External Causes of Morbidity (V01- Y99)
Case Study
An 18 year-old driver of a car that collided with a pickup truck on the interstate highway. The driver confessed to using his cell phone to send a text message to his girlfriend.
Assign the external cause codes only
Answer:
V43.53xA Index to External Causes. Accident, car – see Accident, transport, car occupant, Accident, transport, car occupant, driver, collision (with) pickup truck (traffic)
Y Index to External Causes, Place of occurrence, highway (interstate)
Y93.c2 Index to External Causes, Activity (involving) (of victim at time of event), cellular, telephone
External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military).
External Cause may be used for subsequent visits, Place of Occurrence, Activity only used once 28

29. ICD-9-CM Coding Guidelines
Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
Case Study
This patient had a lateral wall STEMI and was brought by ambulance to the emergency room. He received tPA and was transferred to a tertiary care center for continued care. The patient was received with tPA infusion continuing, and immediately taken to the cardiac cath lab.
 Answer:
I21.29 Infarct, infarction, myocardium, myocardial (acute) (with stated duration of 4 weeks or less), ST elevation (STEMI), lateral (apical-lateral) (basal-lateral) (high)
Z92.82 Status(post) – see also Presence (of), administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility
Old V codes- DNR status, Tpa status, restraints- page 80 29

30. ICD-10-PCS ICD-10-PCS Inpatient Procedures Contains
Over 72,000 codes
7 Character-alphanumeric code structure
Each character contains up to 34 possible values
The letter O is not used
No Decimals

31. ICD-10-PCS Structure Index Root Operations Approach
Codes found based on type of procedure- No diagnostic information in the description
One you know the tables; you can go directly to the tables the index does not need to be used first
First Three values in the index direct you to the table
Tables
Each page in the section is composed of rows that specify valid combinations of code values
Root Operations
Approach

32. ICD-10-PCS ICD-10 Structure XXXXXXX
1st- Section (Medical & Surgical; OB; Imaging)
2nd- Body System
3rd- Root Operation ( Resection, Transfusion)
4th- Body Part
5th- Approach
6th- Device
7th- Qualifier

33. ICD-10-PCS Code Examples 0HTT0ZZ- Right Total Mastectomy
0X6C0ZZ- Amputation at left elbow level
0FT44ZZ- Lap Chole
0HBT0ZX- Right Breast Biopsy
0- Medical Surgical
H- Skin & Breast
B-Excision
T- body Part
0- Approach
Z-Device
X-Qualifier
Mastectomy- resection
Chole- resection
Amputation- Detachment
Biopsy 33

34. ICD-10-PCS Root Operations 30 Root Operations
Identifies the objective of the procedure
In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied.
Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site are also not coded separately.
Example: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately.

35. ICD-10-PCS: Root Operations
Excision vs. Resection
PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part.
Example: Left upper lung lobectomy is coded to Resection of Upper Lung Lobe, Left rather than Excision of Lung, Left.

36. ICD-10-PCS: Root Operations
Biopsy followed by more definitive treatment
If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded.
Example: Biopsy of breast followed by partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy procedure are coded.
Control vs. more definitive root operations
The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural bleeding.” If an attempt to stop postprocedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.
Example: Resection of spleen to stop postprocedural bleeding is coded to Resection instead of Control

37. ICD-10-PCS: Root Operations
Release procedures
In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part.
Example: Lysis of intestinal adhesions is coded to the specific intestine body part value.
Release vs. Division
If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division.
Examples: Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division.

38. ICD-10-PCS Approach Technique used to reach the site of the procedure
7 Different Approaches
Open
Percutaneous
Percutaneous Endoscopic
Via Natural or Artificial Opening
Open with Percutaneous endoscopic assistance
External

39. ICD-10-PCS
Device
A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded.

40. ICD-10-PCS Obstetrics Products of conception
Procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section.
Example: Amniocentesis is coded to the products of conception body part in the Obstetrics section. Repair of obstetric urethral laceration is coded to the urethra body part in the Medical and Surgical section.
Procedures following delivery or abortion
Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the Obstetrics section, 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 all coded in the Medical and Surgical section, to the root operation Extraction and the body part Endometrium

41. ICD-10-CM/PCS Resources
Download the Index & Tabular
Compliance Dates
Quick Reference Guide
ICD-10-CM/PCS Resource Page

42. ICD-10-CM/PCS Resources
Subscribe and read the monthly ICD- TEN free newsletter from AHIMA
Complete exercises in the CodeWrite free e-newsletter from AHIMA
Network with peers in the ICD-10 Implementation CoP (available only to AHIMA members)