2 Skin Diagnostic Coding ICD-9-CMChapter 2 NeoplasmsChapter 15 Diseases of Skin and SQ TissueChapter 17 Injury and PoisoningICD-10-CMChapter 2 (C00-D49) – NeoplasmsChapter 12 (L00-L99) – Diseases of Skin & SubQChapter 19 (S00-T88) – Injury, Poisoning, & Other consequences of External CausesSimilarities / Differences
3 Similarity Coding Steps remain the same Identify all main terms in diagnostic statementsApply your knowledge of A& P and pathology, pharmaceuticals, and treatmentsMain terms are USUALLY NounsIdentify modifiers in diagnostic statementModifiers are USUALLY adjectivesLocate main terms in AIIf terms not identical, use your medical terminology knowledge to translate from documentation to code book
4 Coding Steps Locate modifiers in subterms under main terms Check for special instructions or cross-referencesTENTATIVELY select a codeTurn to code category in TLCheck for any instructional notes for code category/chapterApply your knowledge of code book conventionsAssign code when all elements of dx statement accounted for and code verified in TL
5 Similarities ICD-10-CM = Same hierarchical structure 1st three characters are category of codeAll codes within same category have similar traitsAlphabetic Index to Diseases and InjuriesSame format and use as ICD-9-CM AITable of Drugs and ChemicalsNeoplasm TableIndex to External Causes
6 Differences ICD-10-CM Codes Other changes Higher specificity LateralityAdd’l characters for more detailsOther changesMore combination codesEtiology and ManifestationPoisoning and external causeDiagnosis and symptoms
7 DifferencesCode titles & language that reflect accepted clinical practiceCodes able to reveal more about quality of care, so data can be used in more meaningful ways to betterUnderstand complicationsDesign clinically robust algorithmsTrack outcomes of careInformation for clinical decision making and outcome research
8 DifferencesICD-10-CM consists of 21 chapters compared to 17 chapters in ICD-9-CMICD-9-CM’s V and E codes incorporated into main classification in ICD-10-CMReflecting current medical knowledge, certain diseases reclassified (reassigned) to more appropriate chapter in ICD-10-CMInjuries classified by site and THEN type
9 Improved Excludes notes Excludes1 = NOT coded hereExcluded code is NEVER used with codeTwo conditions cannot occur togetherExcludes2 = NOT INCLUDED hereExcluded condition is NOT part of condition represented by codeAcceptable to use both codes together IF patient has both conditions
10 Excludes Notes Examples L 24 Irritant contact dermatitisExcludes2:allergic contact dermatitis L23.-dermatitis due to substances taken internally L27.-dermatitis of eyelid H01.1-diaper dermatitis L22eczema of external ear H60.5-perioral dermatitis L71.0radiation-related disorders of skin and subcutaneous tissue L55-L59Excludes1:allergy NOS T78.40contact dermatitis NOS L25.9dermatitis NOS L30.9
11 Neoplasm Chapters Most chapter-specific guidelines same, except I.C.2.c.1, Anemia associated with malignancyI.C.2.c.2 Anemia associated with chemotherapy, immunotherapy and radiation therapy
12 ICD-10- CM I.C.2.c.1, Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease)Reverse of ICD-9-CM
13 ICD-10-CM I.C.2.c.2Anemia associated with chemotherapy, immunotherapy and radiation therapyWhen admission/encounter is for mgt of an anemia associated with adverse effect of administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by appropriate codes for neoplasm & adverse effect (T45.1X5)Same sequencing as ICD-9-CM
14 ICD-10-CM I.C.2.c.2When admission/encounter is for mgt of anemia associated with adverse effect of radiotherapy, anemia code should be sequenced first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure.
15 ICD-9-CM 2012 173 - Other and unspecified malignant neoplasm of skin All subcategories were expanded to fifth-digit level to classifyBasal cell carcinomaSquamous cell carcinomaOther specified and unspecified malignant neoplasmsNew codes addedPilar cyst (704.41)Trichilemmal cyst (704.42)Outer root sheath of hair
16 Neoplasm Example 1This 25-year-old female is treated for melanoma of the left breast and left arm
17 Example 1 ICD-9-CM Answer Melanoma, breastMalignant melanoma of skin – 172Includes melanoma (skin) NOSTrunk, except scrotum – 172.5Includes breastMelanoma, forearmUpper limb, including shoulder – 172.6172.5172.6
18 Example 1 ICD-10-CM Answer C43.52 Melanoma (malignant), skin, breast (female) (male)C43.62 Melanoma (malignant), skin, arm
19 Example 1 ICD-10-CM Explanation To code Melanoma, code is found directly in Index rather than Neoplasm TableNOT correct to assign primary site of skin (C44.52, C44.62) when melanoma documentedMelanoma in situ = category D03.1
20 Neoplasm Example 250-y-o female diagnosed w/ left breast carcinoma four years ago, when she had left mastectomy performed w/ chemotherapy. She has been well since then w/ no further tx except for yearly checkups. Pt is now being seen w/visual disturbances, dizziness, headaches, and blurred vision.Workup revealed metastasis to brain, accounting for symptoms. Identified as metastatic from breast, not new primary.
21 Example 2 ICD-9-CM Answer Carcinoma, metastatic – See Metastastis, cancerto specified site (M8000/6) See Neoplasm, by site, secondaryNeoplasm, brain NECHistory, malignancy (personal), breastPersonal history of malignant neoplasm, breast – V10.3Absence, acquired, breastV45.71History, Chemotherapy, antineoplastic diseaseV67.41
22 Example 2 ICD-10-CM Answer C79.31 Refer to Neoplasm Table, by site, brain, malignant, secondary siteZ85.3 History, personal (of), malignant neoplasm (of), breastZ90.12 Absence (of) (organ or part) (complete or partial), breast(s) (and nipple(s)) (acquired)Z92.21 History, personal (of), chemotherapy for neoplastic condition
23 Example 2 ICD-10-CM Explanation Encounter for metastatic brain caPreviously excised primary ca w/ no further tx: therefore, coded hx of breast cancerPrevious mastectomy, so code for acquired absence of breast. Laterality can be specified in Z90.1 subcategoryDocumented brain metastasis caused symptoms, so not codedCode available for hx chemotherapy IF facility codes to that level of detail
24 ICD-10-CM Skin ChapterNearly all categories & subcategories expanded to either fourth- or fifth-character levelMore codes with following directivesUse additional code (B95–B97) to id organismCode 1st (T36–T65) to identify drug or substanceCode 1st underlying diseaseCode 1st any associated . . .
25 Coding Guidelines For Skin chapter in both ICD-9 and ICD-10 Only Pressure ulcersSeveral identicalSome different for ICD-10-CMDue to more specific codes availableTherefore, coder will apply general coding guidelines and codebook conventions when coding other skin conditions
26 Non-Pressure UlcersGenerally, underlying condition responsible for non-decubitus ulcer of lower limb (L97)When underlying condition documented, use Combination codeL97 can be PrDx, when underlying condition NOT documented
27 Non-Pressure Ulcers in ICD-10-CM (L97) Non-pressure chronic ulcers of lower limbChronic ulcer of skin (NOS)Non-healing ulcer of skinNon-infected sinus of skinTrophic ulcer NOSTropical ulcer NOSUlcer of skin NOSCan be Pr Dx IF no underlying condition
28 Non-Pressure Ulcers in ICD-10-CM Assume causal condition any condition below with LE ulcerAtherosclerosis of LEChronic venous hypertensionDiabetic ulcersPostphlebitic syndromePostthrombotic syndromeVaricose ulcerAny associated gangrene
29 Non-Pressure Ulcer Example Pt tx in outpatient hospital wound care clinic for severe non-healing ulcer of L midfoot and heel w/ bone necrosis due to diabetes mellitusICD-9-CMICD-10-CMDiabetes with otherspecified manifestations,type I[juvenile type], notstated as uncontrolledE Diabetes mellitus dueto underlying conditionwith foot ulcerUlcer of heel andmidfootL Non-pressurechronic ulcer ofLeft heel and midfootwith necrosisof bone
30 Pressure Ulcers in ICD-9-CM Need two codesOne for ulcerOne for stageGangrene IF present is add’l codeMultiple ulcers of same siteOnly assign code for most severe ulcer
31 Pressure Ulcers in ICD-10-CM (L89) Similarities to ICD-9-CMStage I-IVUn-stageableUnspecifiedNeed to know locationDifferencesONLY one code in ICD-10-CM –ulcer & stage4th character = anatomy detailsRight vs LeftUpper vs Lower5th character = specific site6th character = ulcer depth (Stage)Gangrene IF present is sequenced FIRST
32 Pressure Ulcers ICD-10-CM (L89) Stages I –IVUn-stageableReasons pressure ulcers unstageableCan’t examineUnder dressing/Not debridedCovered by eschar/blisterBest practice - Let healing occur until skin breaks downUlcer is evolvingEventual extent of injury unclear until tissue demarcatesUnspecified
33 Pressure Ulcer Examples Dr called by Nursing Home to treat Pt with bed sores on R buttockDr documentsDecubitus ulcer, R buttock, stage IIICD-9-CMICD-10-CMDecubitus ulcerof the buttockL Pressure ulcer of right buttock stage IIPressure ulcerstage II
34 Pressure Ulcer Examples Pt with gangrenous pressure ulcer of Left ankle, with necrosis of muscle & boneICD-9-CMICD-10-CMPressure ulcer, ankleI96 Gangrene, NECPressure ulcer, stage IVL Pressure ulcerLeft ankle, stage IV785.4 Gangrene
35 Skin Example 1Dermatitis covering entire body due to antibiotics (penicillin) taken correctly as prescribed.
36 Skin Example 1 ICD-9-CM Answer DermatitisDue toDrugs taken internallyUse add’l code to id drug –E (Therapeutic Use)693.0E930.0
37 Example 1 ICD-10-CM ANSWER L27.0 Dermatitis (eczematous), due to, drugs and medicaments (generalized) (internal use)T36.0X5A Table of Drugs and Chemicals, Penicillin (any), Adverse Effect, initial encounter
38 Skin Example 1 Explanation Reason for encounter - extensive dermatitis - adverse effect of penicillinInstructional note in Tabular under code L27.0Use additional code for adverse effect, if applicable, to identify drugFollowing note, T36.0X5A sequenced as 2ndary DXSeventh character of T36.0X5AInitial encounter (A) for this condition
39 Skin Example 2Pt seen for IV antibiotic treatment of cellulitis of R anterior neck. Pt also known morphine drug abuser & exhibited considerable drug-seeking behavior; continuously requested morphine. All narcotics discontinued & pt exhibited no drug withdrawal symptoms.Diagnoses: Cellulitis, right anterior neck; morphine drug abuse
40 Example 2 ICD-9-CM Answer CellulitisNeck – 682.1Use additional code to identify organism (note at 682)Abuse, drugs nondependentmorphine type –Person feigning illness (Malingerer)V65.2
41 Example 2 ICD-10-CM Answer L Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), neck (region)F11.10 Abuse, drug, morphine type (opioids)Z72.89 Behavior, drug seeking
42 Skin Example 3Pt w/ gangrenous pressure ulcer of R hip w/cellulitis & pressure ulcer of sacrum documented by physician.Nursing assessment indicates stage 2 pressure ulcer of the sacrum w/stage 3 decubitus ulcer of R hip.
43 Skin Example 3 ICD-9-CM Answer Ulcer, PressureHipStage III707.23SacrumStage IICellulitisSpecified site NECUlcer codes do NOT include cellulitis
44 Example 3 ICD-10-CM Answer I96 Ulcer, gangrenousL Ulcer, … ulceration, ulcerative, pressure (pressure area) stage 3, (healing) (full thickness skin loss involving damage or necrosis of subcutaneous tissue), hipL Ulcer, … stage 2, … partial thickness skin loss involving epidermis and/or dermis) sacral region (tailbone)L Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), hip
45 Example 3 Explanation Decubitus ulcers classified to pressure ulcers L89 NOTE indicates sequencingAny associated gangrene listed 1stL89.2 classifies pressure ulcers of hipReview Tabular to select correct stage & lateralityId code L = stage 3 of right hipExcludes2 note at beginning of category L89 includes “skin infections L00-L08.”Therefore Hip cellulitis = additional Dx
46 Example 3 ExplanationPressure ulcer of sacral region documented stage 2L assignedSacral region includes tailbone & coccyx - Coding GuidelineCoding Guideline I.B.14Stage of pressure ulcer may be documented by another healthcare clinician & coded as long as pressure ulcer documented by provider
47 Skin Example 4Atherosclerosis of R ankle (native artery), w. non-healing ulcer, w/ breakdown of skin
48 Example 4 ICD-9-CM Answer AtherosclerosisSee AteriosclerosisWith Ulceration –Use add’l code for ulcerUlcer, lower extremity, ankle –440.23707.13
49 Example 4 ICD-10-CM Answer I Atherosclerosis … (diffuse) (obliterans) (of) (senile) (with calcification), extremities (native arteries) leg, right, with ulceration (and intermittent claudication & rest pain), ankleL Ulcer, … ulcerative, lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic) (tropical) ankle, right, with skin breakdown only
50 Example 4 Explanation NB: In Index under arteriosclerosis Bypass graft codes of extremities listed 1stMUST scan until reaching Leg –left/right, etc.I70.23 – Note: Use add’l code to identify severity of ulcer (L97.- w/ 5th charL97 - Note: Code 1st any associated underlying condition
51 Example 4 ExplanationL97 code may be used as PrDx/First listed code IF no underlying condition documentedIF one of underlying conditions listed hereis documented w/ lower extremity ulcerCausal condition should be assumedatherosclerosis of lower extremitieschronic venous hypertensiondiabetic ulcers, postphlebitic syndrome, varicose ulcerCodes must be listed in this order
52 Skin Example 535-y-o male presents w/ edema, redness, & pain of L big toe. He didn’t seek tx because thought it would improve. He doesn’t remember an injury, but pain has been progressively worse for past weekDiagnosis: Gangrenous abscess of entire L big toe.
53 Example 5 ICD-9-CM Answer Abscess, toe681Cellulitis and abscess of finger and toe, ToeCellulitis and abscess, unspecifiedGangrene 785.4Code 1st any associated underlying condition681.10785.4
54 Example 5 ICD-10-CM Answer L Abscess (connective tissue) (embolic) (fistulous) (infective) (metastatic)(multiple) (pernicious) (pyogenic) (septic), toe (any) see also Abscess, foot.I96 Gangrene, gangrenous (connective tissue) (dropsical) (dry) (moist) (skin)(ulcer) (see also necrosis).
55 Example 5 ExplanationIndividual categories for abscess (L02) & cellulitis (L03)In ICD-9-CM, these are combinedNote: In IndexAbscess of toe classifies to abscess of footAbscess of toenail classifies to cellulitis, toeNo Includes/Excludes notesStop use of abscess & gangrene code togetherNo sequencing guideline available
56 Skin Example 6Elderly patient seen for tx of cellulitis in R LE. Cultures grew streptococcus B; documented by physician as etiology of cellulitis. Patient also has stage 1 decubitus ulcer of L buttock & stage 2 decubitus ulcer in R gluteal region
57 Example 6 ICD-9-CM Answer Cellulitis, leg682.6041.02Use add’l code to id organism, such as Staphylococcus (Note at 682)705.05707.21707.22Per Faye Brown - Same site, different stages: Assign one code for site & separate codes for each stage
58 Example 6 ICD-10-CM Answer L Cellulitis, lower limbB95.1 Infection, bacterial NOS, as cause of disease classified elsewhere, Strep group BL Ulcer, pressure, by site. Pressure (pressure area) stage 2, … buttockL Ulcer, pressure, by site. Pressure (pressure area) stage 1, (healing) (pre-ulcer skin changes limited to persistent focal edema), buttock
59 Skin Example 6 Explanation Documentation supports cellulitis as 1st dxICD-10-CM classifies laterality of cellulitis of LE w/ L = RLENote in Tabular at (L00-L08)Use add’l code (B95-B97) to id infectious agentICD-10-CM also classifies decubitus ulcers of buttocks stage AND lateralityGluteus not in classification, but refers to buttockCoder must apply A&P knowledge
60 Skin Example 7Pt seen for tx of fine rash developing on pt’s trunk & UEs over last 3-4 days. Pt dxed w/ HTN 7 days ago & on Ramipril 10 mg daily. Physician determined cause of rash as dermatitis due to Ramipril; discontinued & Pt prescribed new anti-HTNmedication, Captopril.Also, physician prescribedtopical cream forlocalized dermatitis.
61 Example 7 ICD-9-CM Answer RashDrug (internal use) – 693.0Use additional E code to identify drug (693.0 note)E942.6401.9Ramipril = Alcace (ACE inhibitor)In Table - antihypertensive agents NEC
62 Example 7 ICD-10-CM Answer L27.1 Dermatitis, (eczematous) due to drugs and medicaments, (generalized) (internal use) localized skin eruptionT46.4X5A Table of Drugs and Chemicals, Ramipril, Adverse Effect, initial encounterI10 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic)
63 Skin Example 7 Explanation Reason, after study, for encounter is dermatitis; adverse effect of RamiprilInstructional note in Tabular at L27.1Use add’al code for adverse effect, if applicable, to id drug (T36-T50 with 5th/6th character 5)T46.4X5A sequenced as 2ndary dx7th character of A indicates initial encounter for conditionDocumentation = localized dermatitisDocumentation doesn’t = long-term use of drug
64 Skin Example 8Pt seen w/extensive inflammation & irritation of skin of upper eyelids & under eyebrows; spreading to temples & forehead. During H&P, she stated recently used new eye cosmetics. Pt seen during prior visit for cystic acne.
65 Skin Example 8Physician also examined pt’s cystic acne on forehead & jawline. Pt advised to use medication previously prescribed.Dx = irritant contact dermatitis due to cosmetics & cystic acne.Pt was advised to immediately discontinue use of any make-up on face & given topical medication to resolve inflammation.
66 Example 8 ICD-9-CM Answer DermatitisDue to cosmetics692 = contact dermatitisAcne, cystic706.1
67 Example 8 ICD-10-CM Answer L24.3 Dermatitis (eczematous), contact, irritant, due to, cosmeticsH Dermatitis (eczematous), eyelid, contact – left, upperH Dermatitis (eczematous), eyelid, contact – right, upperT49.8X5A Table of Drugs and Chemicals, Cosmetics, adverse effectL70.0 Acne, cystic
68 Skin Example 8 Explanation Reason for encounter was contact dermatitis due to adverse reaction to use of new eye cosmetics7th character A = initial encounter for condition.Several different Index terms for dermatitis.
69 Skin Example 8 Explanation Irritant contact dermatitis, but not allergicIndex = Contact, irritant, due to cosmetics, L24.3.Contact, allergic, due to cosmetics = L23.2Contact dermatitis (not documented as irritant) due to cosmetics is coded L25.0Careful review of record and Index required
70 Skin Example 8 Explanation In addition, reference to specific site (upper eyelids) – has separate classificationL24,Excludes2 note for dermatitis of eyelid (H01.1-)IF both conditions present, both codes may be assignedCystic acne assigned as 2ndary conditionAlso E&M during encounter
71 Dermal Appendages Office Visit Example 54-y-o female presents w/ infected cuticle on left thumbnail. Pt states started about one week ago. She denies any discharge from nail but throbbing pain at night. She is a bartender, hands frequently in water. Denies any trauma to hand. No possibility of fracture. No nausea, vomiting or diarrhea, fever or chills.Pt has cough. She has smoked pack/day for past 20+ years. Cough is typical and sometimes productive of whitish clear sputum.
72 Office Visit ExampleAllergies: Penicillin & iodine both which produce hives.Social Hx: Drinks 2 beers/day. No illicit drug use.ROS: Pt never had chest x-ray. Up to date on Pap smears and mammogram.PE: Blood pressure is 118/66. Pulse 70. Respiration 12. Temp is Lungs are clear to auscultation. No rales, rhonchi, or wheezing. Heart is RRR. Abdomen is soft, nontender, and nondistended. To the lateral aspect of the left thumbnail bed there is increased swelling and erythema with no discharge noted. There is exquisite tenderness on palpation.
73 Office Visit Example Impression: 1. Paronychia left thumbnail - levaquin 750 mg once a day for five days2. Smokers’ cough - chest x-ray ordered, CMP, lipids, TSH and CBC ordered.3. Tobacco abuse
74 ICD-9-CM Answer Paronychia, finger Cough, Smokers’ Tobacco abuse Onychia and paronychia of fingerCough, Smokers’491.0 Simple chronic bronchitisTobacco abuse305.1 Tobacco use disorder
75 ICD-10-CM Answer Paronychia – see also Cellulitis, digit L Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), digit, finger – see Cellulitis, finger (intrathecal) (periosteal) (subcutaneous) (subcuticular)J41.0 Cough (affected) (chronic) (epidemic) (nervous), smokers’Z72.0 Tobacco (nicotine), use
76 ICD-10-CM ExplanationCellulitis of finger (Thumb NOT specified) is L with a sixth digit of 2 for left finger.The Index does NOT provide entry for tobacco or nicotine under Abuse Main Term, but category J41.0 does direct coder to use add’l code to id tobacco use, Z72.0.
77 Pressure ulcer CaseA 73 year old male is followed in your clinic DiagnosesType II Diabetes MellitusHypertensionHyperlipidemiaCVA 18 mos agoObesity54-pack-year smoking history (quit 2 years ago)Diabetic neuropathyDiabetic retinopathyDiabetic gastroparesisMedications70/30 insulin bidLisinoprilSimvastationEnteric coated aspirinMetoclopramide ac and hs
78 PU CaseAfter stroke 18 months ago, dx w/ depression, tx for 6 months with sertraline, with improvement of mood to normal. Drug discontinued.Most recent functional assessment by visiting RN was that pt needed assistance w/bathing, otherwise independent. HH aide provided assistance w/ bathing & light housework, daughter visited almost every day.
79 PU CasePt brought into ED by ambulance, after his daughter found him at home lying on floor, unconscious. ED room physician admits him w/ Dx of pneumonia, fall with long lie, dehydration, and altered mental status.By 2nd hospital day, he developed new pressure ulcer over right lateral malleolus.Examination of ulcer shows a round, 3 cm black eschar that is debrided to an ulcer that extends through dermis.
84 Injury and Poisoning ICD-9-CM – Chapter 17 ICD-10-CM – Chapter 19 Organized by TYPE of Injury, then body partICD-10-CM – Chapter 19Organized by BODY REGION, then specific types of injuriesStarting head & ending with ankle and footAlso blocks forEffects of foreign bodyBurnsFrostbites, Poisoning, Adverse effects and Other consequences of external causes.
85 Injury and Poisoning Chapter ICD-10-CM Chapter 19 – 2 sectionsS =Various types of injuries related to single body regionsT =Injuries to unspecified body regionsPoisonings & certain other consequences of external causes7th Character Extension required for many chapter codes
86 ICD-10-CM Chapter 19 More details Laterality & type of encounter (initial, subsequent, sequela)Significant component of code expansion7th character = type of encounter
87 Initial Encounters (A) Initial encounter 7th character used while patient receiving active treatment for conditionSurgical treatmentEmergency department encounterEvaluation and treatment by new physicianCan be used each time pt actively treated for same condition
88 Subsequent Encounter (D) Subsequent encounter 7th Character used for encounters after patient received active tx for conditionNow receiving routine care for condition during healing or recovery phaseCast change or removalRemoval of external or internal fixation deviceMedication adjustmentOther aftercare & follow-up visits following treatment of injury or condition
89 Sequela Encounter (S)Sequela 7th character used for complications or conditions directly due to condition, such as scar formation after burn (Scar is sequela).MUST use both injury code that caused sequela AND code for sequela itselfS added ONLY to injury code (burn), NOTsequela code (scar)Type of sequela (e.g., scar) sequenced 1st, then injury code
90 Aftercare CodesAftercare Z codes NOT used for aftercare for conditions when 7th seventh characters available to id subsequent episodes of careFor aftercare of injury, assign acute injury code with 7th character for “subsequent encounter.”
91 Adverse Effects and Poisonings (T36-T50) Nature of adverse effect firstFollowed by code for drugPoisoningsPoisoning CodeCode(s) for all manifestationsSame sequencing as ICD-9-CM
92 T36-T50Includes:Adverse effect of correct substance properly administered (hypersensitivity, reaction, etc.)Poisoning byOverdose of substanceWrong substance given or taken in errorUnderdosing by (NOT in ICD-9-CM)(inadvertently) (deliberately) taking less substance than prescribed or instructedUse add’l code for INTENT OF underdosingFailure to dose during medical/surgical carePt’s underdosing
93 Multiple InjuriesCode for most severe injury is sequenced as Principal DiagnosisDetermined by physicianTreatment provided
94 Sequencing Multiple Injuries Injury attending physician ids as most resource-intensive is PDX.General sequencing guidelines from Rules of Certification and Medical Classification of ICD-9 areA. Fx of skull & cervical vertebraeB. Internal injury of chest,abdomen, & pelvisC. Fx of face bones, spine, & trunkD. Other head injuryOpen wounds of neck & chestTraumatic amputation of limbsSpinal cord lesion w/ mention ofvertebrae fxE. Fx of limbsF. Burn G. Other injuries not listed above
95 Burns ICD-9-CM Burns classified by Review documentation for Depth ExtentAgent (E code)Review documentation forLocation/anatomic site of burnExtent/severity of burnPercentage of body surface burntCause of burn
96 Burns ICD-10-CM Guidelines are same for burns & corrosions Current burns (T20–T25) are classified byDepth (1st, 2nd, 3rd)Extent (TBA)Agent (X code). (E code in ICD-9-CM)Burns of eye & internal organs (T26–T28) classified by site, NOT degreeAdd’l Code for infected burnSeparate codes for each burn siteT30, Burn & corrosion, body region unspecified -extremely vague -use rarely
97 Rule of Nines ADULT: I. Head and Neck = 9% II. Posterior Trunk = 18% III. Anterior Trunk = 18% IV. Each Upper Extremity = 9% V. Each Lower Extremity = 9%VI. Perineum = 1%
98 Rule of Nines BABY: I. Head and Neck = 18% II. Posterior Trunk = 18% III. Anterior Trunk = 18% IV. Each Upper Extremity = 9% V. Each Lower Extremity = 14%
100 Multiple Burns Sequencing PDX is burn site of greatest severityThen use following orderA. Deep necrosis of underlying tissues w/loss of body part (deep 3rd/4th degree)B. Deep necrosis of underlying tissues without C. Full-thickness skin loss (3rd degree) D. Blisters, epidermal loss (2nd degree) E. Eythema (1st degree) F. Unspecified
101 ER Burn Example Pt seen in ER today for burn of right ankle. Pt was cooking dinner in kitchen of her single family home & carrying pot of boiling hot liquid that splashed on her ankle.Physician states DX as:2nd degree burn, right ankle.
102 ER Burn Example ICD-9-CM Answer Burn, Ankle, 2nd DegreeE924.0 Accident Due to Hot Liquid/VaporE849.0 Accident Occurring in HomeE015.0 Activities Involving FoodPreparation And Clean UpE Leisure Activity
103 ICD-10-CM AnswerT25.211A Burn (electricity) (flame) (hot gas, liquid or hot object) (radiation) (steam) (thermal), ankle, right, second degreeX12.XXXA Index to External Causes, Burn, burned, burning (accidental) (by) (from) (on), hot liquidY Index to External Causes, Place of occurrence, residence (noninstitutional) (private), house, single family, kitchenY93.G3 Index to External Causes, Activity (involving) (of victim at time of event), cooking and bakingY99.8 Index to External Causes, External cause status, leisure activity
104 ICD-10-CM ExplanationDocumentation states that patient was cooking dinner at home.External cause status for this is leisure.Burn code and external cause code are coded with 7th character AInitial encounter because pt seen in ED today
105 Wounds ICD-9-CM 4th-digit subcategory may id wound is complicated Complicated open wound includes mention ofDelayed healingDelayed treatmentFB retentionInfection
106 Delayed HealingDelayed treatment & healing tends to lead to infections, which = complicated open woundNO strict definition of delayed healing or txEx: If pt delays seeking treatment by one week, & wound does not appear to be healing appropriately, then use complicated codeIf coder NOT sure, query physician
107 Open Wounds Coding directive before category 860 Description ‘with open wound,’ used in 4th-digit subdivisions, includes those w/ mention of infection or foreign body.Do NOT code Superficial injuries (abrasions, contusions, etc.) when associated with more severe injuries of same site.
108 Cellulitis Vs Open Wound Sequencing depends on circumstances of admission/encounterPt suffered laceration of lower leg while hiking 2 days ago; came to hospital on his return.Cellulitis beginning to develop. Wound cleansed, nonexcisional debridement, & antibiotics started for cellulitis.891.1, CellulitisPt suffered minor puncture injury to finger removing staple at office. 5 days later, admitted to hospital because of cellulitis of finger, tx with IV.Wound didn’t require tx, therefore not codedCellulitis
109 Wounds ICD-10-CM Injuries are classified by Body SITE, then type Open wounds consistent across body sitesTypes of open wounds classified in ICD-10-CMLaceration without foreign bodyLaceration with foreign bodyPuncture wound without foreign bodyPuncture wound with foreign bodyOpen biteUnspecified open wound
110 Wounds in ICD-10-CM Note: Code also any associated wound infection NO concept of delayed healing/treatmentSome types may have add’l and/or unique code specificityw/ or w/o penetration into body cavity or organAdd’l specificity of laceration as minor, moderate, or majorAdd’l anatomic specificationleft/right, front/back, flexor/extensor
111 Wound Example 2 cm laceration of left heel with foreign body ICD-9-CM Laceration – see also Wound, open, by site892.1 Open wound of foot except toe(s) alone, Complication
112 Wound Example ICD-10-CM Answer S91.322A Laceration, heel – see Laceration, foot (except toe(s) alone), left, with foreign body. Review Tabular for correct 7th characterExplanation:ICD-10-CM Index ids both laterality & presence of FB with laceration code7th character A indicates initial encounter
113 Poisonings in ICD-10-CMCombination codes for poisonings & associated external cause (accidental, intentional self-harm, assault, undetermined)Rearranged Table of Drugs & ChemicalsAll poisoning columns together, then adverse effect and underdosingWhen intent is NOT documented, code AccidentalUndetermined intent = specific documentation in record; intent of toxic effect can’t be determined
114 Poisoning ExampleWoman admitted for intentional overdose of marijuana & cocaine. She sustained fall, resulting in left cheek & scalp laceration.After she stabilizes medically, she will be transferred to a psychiatric unit.
115 Poisoning Example ICD-9-CM Answer 969.6 Poisoning by Psychodysleptic [Hallucinogen]E950.3 Self-Inflicted Poison w Tranquilizer/Psychotropic970.81Poisoning by CocaineSelf-Inflicted Poison w Drug/Medicine NECWound, open, CheekWound, open, scalpE Fall, unspecified
116 Poisoning Example ICD-10-CM Answer T40.7X2A Table of Drugs and Chemicals, Marijuana, Poisoning, Intentional, Self-harm. Review Tabular for 7th character.T40.5X2A Table of Drugs and Chemicals, Cocaine, Poisoning, Intentional, Self-harm.S01.412A Laceration, cheek (external).S01.01XA Laceration, scalp.W19.XXXA Unspecified fall, initial encounter
117 Poisoning Example ICD-10-CM Explanation If overdose of drug intentionally taken or administered and resulted in drug toxicity, coded as poisoning.7th character is required for all codes in this Example.
119 Skin (Integumentary)Adjacent Tissue Transfer/Rearrangement – defined by anatomic site & defect sizeIncludes excision of defect or lesionDo NOT code separatelyNOT used when traumatic wounds incidentally result in configurations such as Z-plasty, etc.Describe moving normal tissue from donor site to recipient siteDonor site adjacent (next to) recipient site, therefore donor tissue remains attached to its original blood supply.
120 Biopsy ServicesRemoval of small amount of tissue to determine extent of disease or to determine or confirm dxInclude: needle aspiration, incisional bx, partial excision, scraping, curetting, skin punchUse integumentary codes when bx of skin and SQ tissue ONLY Incisional Bx code = tissue SAMPLEDExcision code used when ALL suspect tissue removed
121 Burn Treatment Local (16000-16036) Application of materials is includedReview MR to Id% of body surface (Rule of Nines)Severity of burnPartial- thickness (1st-2nd degree)Full-thickness (3rd degree)
122 Destruction of Lesions Ablation ofB9Premalignant orMalignant tissueBy any combination ofElectrosurgeryCryosurgeryLaserChemical txDestruction includes local anesthesiaNO tissue left for pathology = DestructionIF there is pathology report, was NOT destruction
123 Diagnostic VS Therapeutic Services Dx Services – Determine or establish pt’s dx Help establish nature of pt’s disease or condition for future, definitive careFollow-up care for dx procedures includes ONLY care directly related to dx procedureCare of condition identified by dx procedure is NOT included; may be listed separatelyTx Services – Treat specific, known conditionInclude procedure, various incidental incidents, and normal, related follow-up care
124 Excision of LesionsFull-thickness removal of lesion & INCLUDES simple closureAdd’l code needed for intermediate (layered) or complex closures (see wound repair)Coder must determinetype of lesion (B9/malignant)anatomic sitelesion diameter
125 Types of LesionsB9 –Cicatricial, fibrous, inflammatory, congenital, cystic, noninvasiveMalignantInvasive, potential to metastasize, BCC and melanomas
126 Flaps and Grafts Involve moving normal tissue from one site to another Donor site = where tissue originatesRecipient site = where it is relocatedSurgical preparation of recipient site is reported separately
127 Flaps Flaps of skin and deep tissues Defined by graft type (direct, tube, delayed, intermediate, muscle, myocutaneous, fascio-cutaneous) AND siteSite listed in code descriptionRecipient site when flap attached to final siteIF flap formed for DELAYED transfer, site refers to donor siteAny extensive immobilizationAdd’l procedure coded separatelyRepair of donor site with skin grafts/local flaps reported separately
128 Free skin grafts Defined by size, location of recipient site (defect area), and type of graftReported separately when done in conjunction with other proceduresMastectomy , etc.
129 Laser Surgery Usually included in “destruction by any method.” IF using laser significantly alters procedure performance, use codes that specifically identify laser in their descriptions
130 Wound RepairSurgical closure of wound; may be caused by injury/ trauma OR surgically created defect3 categories of wounds –simple, intermediate, complex,described by anatomic site, then sizeAdhesive strips ONLY = E/M code ONLY
131 Wound Repair Categories Simple – superficial wound (partial/full-thickness damage to skin/SQ). ONE layer suturingIncludes local anesthetic, chemical or electrocauterization of non-closed woundsIntermediate – one or more of deeper skin tissue layers & non-muscle fascia repairedMay be single-layer closure IF wound heavily contaminated & requires extensive cleaningComplex – more than layered closureNeeding revision, debridement, undermining, placement of stents/retention suturesNeeding creation of defect (extending excision), and special preparation of site
132 Wound Repair Rules Measure length of wounds & report in cms Add together lengths of multiple wounds in SAME classification (same category AND same anatomic grouping) and report ONCEWounds in more than one classificationListed separately w/ more complicated procedure listed 1stDecontamination/debridement integral to repair EXCEPT when gross contamination requiresProlonged cleaningRemoval of appreciable amounts of devitalized/ contaminated tissue
133 Wound Repair Rules, cont. Repair of nerves, blood vessels, & tendons reported using appropriate section codesRepair of associated skin wounds is considered INTEGRAL to repair & NOT reported unless COMPLEX skin repairadd -51 to complex skin repair codeSimple exploration of nerves, vessels, & tendons exposed in wound part of repair Wounds requiring exploration, enlargement, extension, dissection, removal of FB, &/or ligation/coagulation of minor blood vessels reported with
134 CPT Wound Example 1Foot and ankle surgeon performs débridement to muscle of 6 sq cm open wound on lateral posterior calf and selective débridement of skin in 3 sq cm wound on medial posterior calf.
135 Use -59 indicates selective débridement of separate wound. 11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); 1st 20 sq cm or less97597—Débridement (eg, high pressure waterjet with/w/out suction, sharp selective débridement w/ scissors, scalpel & forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), incl. topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or lessUse -59 indicates selective débridement of separate wound.
136 CPT Wound Example 2a patient has a contaminated laceration on the foot. When the patient was first seen, the orthopaedic surgeon débrided the laceration. Several days later, the patient was taken to the operating room and the surgeon performed a surface area débridement to prepare the wound for a complex closure. The patient was not in a global period.
137 13121—Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm 13122—Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)—Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1 percent of body area of infants and children
138 Alternative coding format reports units for add-on code, 13122 This format should be used only if payer requiresWhen all units are reported on one line, fees should reflect number of units.Because single line for code reflects 3 units, fees are tripled.*Some payers may require use of - 59 on 2nd-5th add-on code, while others may require add-on code reported in units
139 CPT Wound Example 3Foot & ankle surgeon sees elderly F pt with open ulcerated area on left lower leg and separate lesion on right lower leg. The surgeon documents excision of skin, subcutaneous tissue, & muscle (4.0 cm × 3.0 cm, or 12 sq cm) in right lower leg and excision of skin and subcutaneous tissue in left lower leg (3.0 cm × 8.0 cm, or 24 sq cm).
140 Wound Coding Answer Document needed Anatomic locationDepth of débridementSurface area of wound(s)Report each wound separately because depths of débridement not the sameUse -59 with both distinct second procedure and associated add-on code
141 Reported Codes11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less (Right lower leg)—Débridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (Left lower leg)—Each add’l 20 sq cm, or part thereof (List separately in addition to code for primary procedure) (Left lower leg)
142 CPT Same-Day Surgery Example 55-y-o female pt who had a lesion removal 2 weeks ago, returns now for wide excision of a malignant melanoma on right calf. Excision consists of 3-cm diameter area. Layer closure is required. The Pathology report shows clear margins.
144 Questions from previous Sessions CMS confirmed that code freeze will hold until ICD-10-CM/PCS implemented regardless of delay
145 General Resources Comparison of ICD-9-CM & ICD-10-CM Chapters - 2010 Faye Brown Coding Handbook Rev. Ed.Green, M Code It! 3rd ed Delmar.ICD-9-CM Coordination and Maintenance Committee Meeting December 6, 2002
146 General ResourcesICD-9-CM Official Guidelines for Coding and Reporting, Effective October 1, 2011.Endicott, M. E. et. al. Clinical Coding Workout: Practice Exercises for Skill Development; With Answers AHIMA.Endicott, M. New ICD-9-CM Diagnosis Codes for FY 2012.Resource Library. SelectData. (Home Health and Hospice)
147 Burn Coding ResourcesCoding for Burns. ICD-9-CM Medical Coding Exercises.Understanding Burn Codes Just Made Easy.ICD-9 coding for burns. Quiz. Just coding. HCPro.Understanding Burn Codes. PPT Slides.
148 Skin Coding Resources2012 Major Coding Changes to Skin Replacement and Skin Substitute CPT Codes.Address medical necessity, coding challenges related to wound care. JustCoding News: Inpatient, 6/20/2012Budny, A. M., Budny, J. M. Diabetic Wound Healing Experience in the Rural Health Care Setting (Cases with Pictures). The Journal of Diabetic Foot Complications, Vol 1, Issue 3, No. 1.
149 Skin Coding ResourcesCoding compliance: Open Wound as a primary diagnosis. Video minutes. Home Care Coding.Grider, D. Walk Through Skin and Subcutaneous Tissue Crossovers. AAPC Coding Edge.Howard, A. Coding for Open Wounds. For The Record, Vol. 24 No. 7 P /9/2012
150 Skin Coding ResourcesJones, L. Skin Ulcer Coding in ICD-10-CM. ICD10 Monitor. 2/2012LeGrand, M. Changes in reporting wound débridement—2. July AAOS.Q&A: Coding for dry skin due to cold weather. HIM Connection, May 29, 2012
151 Skin Coding ResourcesSkin biopsies. Coding for physician work associated with skin biopsies (e.g. CPT codes or 11101). AAD.Update on 2012 CPT codes for wound care. Wound Healing Society.Verhovshek, G. J. 3 Rules to Correct Benign and Malignant Skin Lesion Excision Coding. SurgiStrategies. 3/5/2012.Zeisset, A. "Coding Injuries in ICD-10-CM." Journal of AHIMA 82, no.1 (January 2011):
152 CPT Coding Resources CPT Coding Questions - Skin and Integumentary. Janevicius, R. Multiple new CPT codes appear in /19/2012.