2Objectives. What is CDI and why is it associated with ICD-10. 2 Objectives. !. What is CDI and why is it associated with ICD-10? 2. How to share information with physicians. 3.Longer time frame now. Delayed 10/1/ Will it be ICD-10 or ICD-11
3Diabetes Mellitus –Diabetes Mellitus Coding in ICD-10CM The codes for diabetes mellitus have expanded in ICD-10-CM into five categories of codes. The codes were made into combination codes that bundle in the type, the body system affected, and any complications of the body system. The five categories are as follows:E08 Diabetes mellitus due to an underlying condition E09 Drug or chemically induced diabetes mellitus E10 Type 1 diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus
4Notice that there is no unspecified diabetes mellitus code category Notice that there is no unspecified diabetes mellitus code category. According to the guidelines (I.C.4.a.2), if the type of diabetes mellitus is not documented in the medical record the default is E11, Type 2 diabetes mellitus.
5The differences from ICD-9-CM include the fact that the codes do not include the fact that the codes do not include "uncontrolled" and "not stated as uncontrolled" in the descriptors any longer. Instead, the codes are listed as with and without complications. The second difference is the combination of the complication into the code
6Definitions for the types of diabetes mellitus are located in the "Includes notes" under each DM category. Physicians and other providers should be instructed to document the type of diabetes as type 1 or type 2, when appropriate, and not insulin and non-insulin dependent as these terms are no longer used in the coding world.Our first CDI:
7Code This one.Paulette, a type 1 diabetic, comes in today for a recheck of her diabetic right heel ulcer. Upon examination, it is healing well, with the breakdown limited to the skin.
8E10. 621 Type 1 diabetes mellitus with foot ulcer L97 E10.621 Type 1 diabetes mellitus with foot ulcer L97.411 Non-pressure chronic ulcer of right heal and midfoot limited to breakdown of skinDid you get it right???Notice that although combination codes exist, more than one code is still necessary to indicate the site, laterality, and severity of the ulcer.
9All Conditions of DMIf the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, a code from category E11 should be assigned. Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.
10DMMary is a type 2 diabetic that presents to the clinic. She is doing well with her diet and exercise routine. She uses Lantus at bedtime and has her diabetes under good control. She will remain on same medication regimen and come for follow-up in three months.
11How did you do????ICD-10-CM Codes: E11.9 Type 2 diabetes mellitus without complications Z79.4 Long=term (current) use of insulinRationale: Although the patient is using insulin, it cannot be assumed that she is a type 1 diabetic. This example brings in two guidelines. Guideline I.C.4.a.2 states if the type of diabetes mellitus is not documented in the medical record the default is E11, Type 2 diabetes mellitus. The second is regarding the use of insulin. Guideline I.C.4.a.3 states if the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.
12Atrial FibrillationAtrial fibrillation and flutter, separate codes for flutter.I48.91 Unspecified atrial fibrillationDocumentation needed for AF.: CDI1. Type: Paroxysmal I48.0Persistent I48.1Chronic I48.2
13Hyperlipidemia 272.4E78.4Other hyperlipidemia, Familial combined hyperlipidemia.E78.5Hyperlipidemia, unspecified Try to Avoid!!!
14LIPIDSMore specific documentation is needed when coding disorders of lipoprotein metabolism and other lipidemiaCDIE78.0 Pure HypercholesterolemiaE78.1 Pure hyperglyceridemiaE78.2 Mixed hyperlipidemiaE78.3 Hyperchylomicronemia
15Routine General Physicals. V70.0/ V20.2 Documentation needed for the ICD-10 codes:There are three general medical exams.1. General Medical Adult exam.A. Z without abnormal findings.B Z with abnormal findings.Abnormal findings are identify as those found on the exam for that day.
16V20.2 2. Encounter for newborn, infant, & child exam. A.Z Newborn, under 8 days.B. Z Newborn 8 to 28 days.3. Encounter for Routine Child Health Exam.A. Z with abnormal findings.B. Z without abnormal findings
17Also when coding immunizations you will code Z23 as the diagnosis code.
18Sports/DOT/ETC V70.3 In ICD-10, these codes are: Z02.0 Encounter for Administrative purposes.Z02.1 Pre-employmentZ02.2 Residential institutionZ02.3 Recruitment to armed forcesZ02.4 Driving LicenseZ02.5 SportsZ02.6 Insurance purpose
19Unspecified Sinusitis. 473.9 X reference to: J32.9 Unspec. Chronic sinusitisCDI:Providers /Staff must Specify:Acute/ChronicSite of SinusitisExample, Maxillary, frontal, ethmoidal, etc.Recurrent
20Acute sinusitis 461.9 J01.90 Acute sinusitis, unspec. CDI Site of SinusitisSite of the sinusitis, Example: Maxillary, frontal, ethmoidal, etc.Recurrent
21Pharyngitis and Tonsillitis 462 and 463 J03.00 – Acute Streptococcal tonsillitisJ Acute recurrent streptococcal tonsillitisJ03.80 – Acute tonsillitis due to other specify organisms (additional code must be used to identify infectious agent)J03.81 – – Acute recurrent tonsillitis due to other specified organism(additional code must be used to identify infectious agent)J Acute tonsillitis, unspecJ03.91-Acute recurrent tonsillitis, unspec Avoid
22Pharyngitis and Tonsillitis 462 and 463 J02.0 –Acute Streptococcal pharyngitisJ02.8 – Acute pharyngitis due to other specified organism(additional code must be used to identify infectious agent)J02.9 Acute pharyngitis, unspec. (Avoid)
23CDI1. Specify acute vs. Chronic (Chronic will code a different path i.e. tonsillitis, adenoid involvement, etc.)2. What Organism. Streptococcal, mono, coxsacki, herpes simplex, unknown, etc.Admin staff: When scheduling appointment for sore throat ask how long they have had symptomsNursing staff: 1-Make sure surgical history accurately reflects if patient has had tonsils or adenoids removed
24Otitis Media, AcuteH Acute suppurative OM w/o spontaneous rupture of ear drum .CDISpecify where infection: internal vs. external ear (i.e. “media)Acute vs. Chronic or whether it is both (i.e. patient has had multiple episodes visits for Otitis Media and now has a current infection)Which EAR – Right, Left, Bilateral (both)Is the ear draining? Suppurative vs serousIs the drum ruptured? Specify with or without ruptureOther manifestation – ESPECIALLY exposure to tobacco smoke