2 By attending this workshop, participants will Identify theReasons for implementing ICD-10-CM in the United StatesSettings that will require ICD-10-CMKnowledge that coders will need to apply ICD-10-CMSimilarities between ICD-9-CM and ICD-10-CMDifferences between ICD-9-CM and ICD-10-CMReceiveICD-10-CM Coding Examples and CasesICD-10-CM Resources Listing for future use
3 Why Change to ICD-10-CM?ICD-9-CM out of space to accommodate new codesAdvances in medical knowledgeNew technologyNewly identified diseasesLimited space = Lack sufficient clinical detailSeverity or complexity of diagnoses
4 Why Change to ICD-10-CM?Updated classification system allows ability toMeasure quality of careInitiate pay-for-performanceEvaluate resource utilizationTrack public health threats, such as avian fluIdentify medical errors and patient safety issuesExchange meaningful health data with other organizations and government agencies
5 Reasons for ICD-10-CM Implementation Represents significant improvementDesigned to overcome issues & limitations ofICD-9-CMUpdates healthcare coding with unambiguous codes for conditionsMore flexibility in adding new codesHas greater specificity and clinical detailMajor improvements in quality & usefulness of coded data
6 Reasons for ICD-10-CM Implementation Updated Medical terminology & classification of diseases to reflect current clinical practiceImproved structure & capacity for capturing technological advancesMore flexibleAccommodates revisions necessitated by medical advances
7 Why Change to ICD-10-CM?ICD-10 first published by WHO1999 – Australia1999 – US for death certificate coding2000 – Canada2005 – FranceThailand2008 – Korea25 countries use ICD-10 for healthcare reimbursement & resource allocationICD-11 – development from now thru 2015
8 ICD-10-CM Implementation Compliance date =Date of discharge for inpatient claimsDate of service for outpatient claims
9 ICD-10-CM Control Cooperating Parties for ICD-10-CM AHA AHIMA CMS NCHS
10 Settings requiring ICD-10-CM ALL healthcare settings, because ICD-10-CM required for ALL diagnosis coding when implementedWill affect every part of HCOs, not just coders
11 Knowledge Base for ICD-10-CM CMS Final rule - Recommends 50 hours of training for Inpt Coders (16 for Outpt Coders)PRESUMES coding professionals already possess required knowledge in biomedical sciences needed to correctly apply codes using ICD-10-CMAnatomyPhysiologyPathophysiologyPharmacologyMedical terminology
12 Knowledge Base for ICD-10-CM Inpatient coders MUSTHave sufficient foundational knowledge of biomedical sciencesLearn how to apply ICD-10-CM codes correctly on inpatient encountersUnderstand how to apply maps and crosswalks between ICD-9-CM and ICD10 systems
13 Knowledge Base for ICD-10-CM Outpatient coders MUSTHave sufficient foundational knowledge of biomedical sciencesLearn how to apply ICD-10-CM codes correctly on outpatient encountersUnderstand how to apply maps and crosswalks between ICD-9-CM and ICD-10-CM
15 Basic ICD-10-CM Coding Steps ID all main terms in dx statementID all modifiers (subterms) in dx statementLocate mainterm(s) in AILocate subterm(s) (site, etiology, clinical type)Follow any cross-references IF not under 1st codeVerify tentative code in TLFollow any instructionsAssign codes to highest level of specificity
16 Code Structure Categories Subcategories Codes Three-character category without any subdivision = CodeCodes w/o correct # of characters = INVALIDCodes assigned MUST have highest # of characters available/highest level of specificity
17 Structure and Conventions Much of hierarchical structure similarMany conventions similarTabular ListChaptersSubchapters (Blocks in ICD-10-CM)Alphabetic IndexTwo partsIndex to Diseases and InjuriesNeoplasm TableTable of Drugs & ChemicalsIndex to External Causes
18 Similar AI Conventions Boldface MaintermsIndented subterms/essential modifiersNon-essential modifiers in ( )SeeSee AlsoSee Condition
19 Similar Conventions Abbreviations Instructional Notes NEC (Other Specified)AI and TLNOS (Unspecified)TL onlyInstructional NotesIncludesExamplesLocationCode firstUse add’l codeCode AlsoNo Sequencing
25 ICD-10-CM Codes Sub-catergories = 4 or 5 characters Codes are 3 – 7 characters1st character is LETTERO IS used; U is NOT usedCode format
26 Which of the following is a valid ICD-10-CM code? 428.9L03.313T37.0XX1AM12X.58
27 Tabular List TL = 21 chapters Axes of Classification List of blocks at beginning of each chapterAxes of ClassificationBody/organ systemEtiology/Disease processE & V codes NOT supplementalOrder of Chapters – some reorderingSome chapters reorderedInjuries = 1st by specific site, then type of injuryPostop complications moved to procedure-specific body system (mostly)
28 Dashes in AI and TL AI – Dash at end of code = incomplete code MUST review TLEx: Fracture, pathologicAnkle M84.47-Carpus M84.44-TL - Dash preceded by decimal point (.-) = incomplete codeMUST review referenced code in TLEx: J43 EmphysemaExcludes1: emphysematous (obstructive) bronchitis (J44.-)
29 Exclusion Notes Two types Excludes1 – Pure, NOT CODED HERE! Located at category, subcategory, or code levelExcludes1 – Pure, NOT CODED HERE!NEVER used with code above noteTwo conditions can’t occur togetherCongenital and AquiredExcludes2 – Not coded hereCondition excluded is NOT INCLUDED HEREPatient may have both at same timeCan code both if both present
31 Morphology CodesNo longer listed in AI with descriptors and standard ICD-10-CM codesNo longer separate appendix in ICD-10-CM
32 NEC and NOS SeparatedOther Specified and Unspecified each have their own codeExample:
33 Placeholder Character (X) Two usesFuture expansion WITHOUT disturbing overall code structure (5th character for some 6-character codes)Code with less than 6 characters that requires a 7th character extensionObstetrics, Injuries, and External causes of injuries
34 Placeholder ExamplesT37.0X1A, Poisoning by sulfonamides, accidental (unintentional), initial encounterT56.0X2S, Toxic effect of lead and its compounds, intentional self-harm, sequelaW42.0XXA, Exposure to supersonic waves, initial encounter
35 Placeholder Example -TL Category Code X12 with 7th Character Extension
36 Pregnancy Trimester Coding Inclusion of trimesters in obstetrics codesEpisode of Care 5th Digits EliminatedExamples:O10.012, Pre-existing essential hypertension complicating pregnancy, second trimesterO99.013, Anemia complicating pregnancy, third trimester
38 Seventh CharacterSOME ICD-10-CM categories require 7th character to further specify conditionMay be number or letterMUST always be 7th characterExamples:O65.0XX1, Obstructed labor due to deformed pelvis, fetus 1S02.110B, Type I occipital condyle fracture, initial encounter for open fractureT17.220D, Food in pharynx causing asphyxiation, subsequent encounter
39 Specificity Laterality Other expanded detail Combining in single code Etiology and manifestationsPoisoning and external causeDiagnosis and symptomsCode titles and language complement accepted clinical practice
46 ICD-10-CM Coding Guidelines Section IStructure and conventions of classificationGeneral guidelines that apply to entire classificationChapter-specific guidelines that correspond to chapters as arranged in classificationSection IISelection of principal diagnosis for non-outpatient settings.Section IIIReporting additional diagnoses in non-outpatient settingsSection IVOutpatient coding and reporting
47 ICD-10-CM Coding Guidelines Similar to ICD-9-CM, EXCEPTLaterality (New)Documentation of Complications of Care
48 Laterality GuidelineFor bilateral sites, final character of codes indicates lateralityUnspecified site code also provided if side not identified in medical recordIf no bilateral code provided and condition bilateral, assign separate codes for both left and right side
49 Documentation of Complications of Care Code assignment based on provider’s documentation of relationship bet. condition and care or procedureGuideline extends to any complications of care, regardless of chapter where code locatedImportant to note NOT all conditions occurring during/following medical care/surgery are classified as complicationsThere must be cause-and-effect relationship between care provided & condition, and indication in documentation that it is complicationQuery provider for clarification, if complication not clearly documented
51 ICD-10-CM Coding Case 1Pt seen w/ amenorrhea, characteristics of masculinization, and high levels of serum testosterone. Pelvic ultrasound revealed a left discrete ovarian mass.GYN performed laparoscopic unilateral salpingo-oophorectomy as outpatient.Pathologic diagnosis returned as ovarian Sertoli-Leydig cell tumor.
52 Case 1 Coding Process - AI Tumor —see also Neoplasm, unspecified behavior, by siteSertoli-Leydig cell —see Neoplasm, benign, by siteMain Term = TumorSub Term = Sertoli- Leydig CellNeoplasm Site = Ovary
53 Case 1 Coding Process – Neoplasm Table D What does Dash tell coder???
54 Case 1 Coding Process - TL D 27 Benign neoplasm of ovaryUse additional code to identify any functional activity - ????Excludes2:corpus albicans cyst (N83.2)corpus luteum cyst (N83.1)endometrial cyst (N80.1)follicular (atretic) cyst (N83.0)graafian follicle cyst (N83.0)ovarian cyst NEC (N83.2)ovarian retention cyst (N83.2)
55 Case 1 Coding Process -TL D27.0 Benign neoplasm of right ovaryD27.1 Benign neoplasm of left ovaryD27.2 Benign neoplasm of unspecified ovaryDo we need a code for masculinization as a functional activity of the tumor?Per Use Add’l Code note at D27
56 Case 1 ANSWER D27.1 Benign neoplasm of left ovary Do we need a code for masculinization as a functional activity of the tumor?Per Use Add’l Code note at D27NO – Mainterm Masculinzation or Virilization goes to D27.-
57 Coding Case 2Doctor 16-y-o pt w/ myasthenia gravis & adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion cancelled after pt had positive TB skin test during preop workup, suggesting latent TB.Today’s visit – pt started on Isoniazid 300 mg daily & instructed on possible side effects. Will reschedule surgery after two months of INH treatment.
58 Case 2 Coding Process - AI Findings, abnormal, inconclusive, without diagnosis —see also Abnormaltuberculin skin test (without active tuberculosis) R76.11Myasthenia G70.9gravis G70.00
59 Case 2 Coding Process - AI Scoliosis (acquired) (postural) M41.9adolescent (idiopathic) —see Scoliosis, idiopathic, juvenileidiopathic M41.20- - adolescent M41.129- - - cervical region M41.122- - - lumbar region M41.126- - - thoracic region M41.124- - juvenile M41.119
60 Case 2 Coding Process - TL M41 ScoliosisIncludes: KyphoscoliosisExcludes1: congenital scoliosis NOS (Q67.5)congenital scoliosis due to bony malformation (Q76.3)postural congenital scoliosis (Q67.5)kyphoscoliotic heart disease (I27.1)postprocedural scoliosis (M96.-)
61 FYI Juvenile vs Adolescent Juvenile idiopathic scoliosis usu. occurs from about age 4 to puberty-about age 10 or 11 for girls, age 12 for boys. Usu. R thoracic curves.Adolescent idiopathic scoliosis usu. occurs in early puberty, w/ most rapid worsening during early growth spurt. Females more than males – 5:1. Also, usu. R thoracic curves.
62 sequenced in this order? Case 2 ANSWERR76.11 Findings, abnormal, inconclusive, without diagnosis, tuberculin skin test (without active tuberculosis)G70.00 Myasthenia gravisM Adolescent idiopathic scoliosis, thoracic regionWhy are codes for this casesequenced in this order?
63 Coding Case 362-y-o female visits her family practice physician for annual physical and follow-up on her chronic gout with tophi. She has her annual Pap smear and flu shot for the season.
64 Case 3 Coding Process - AI Examination (for) (following) (general) (of) (routine) Z00.00-annual (adult) (periodic) (physical) Z00.00- - with abnormal findings Z00.01- - gynecological Z01.419- - - with abnormal findings Z01.411Can both Z00.- and Z01.- be coded?
65 Case 3 Coding Process - AI Z01 Encounter for other special examination w/o complaint, suspected or reported diagnosisIncludes: routine examination of specific systemNote: Codes from category Z01 represent reason for encounter. A separate procedure code is required to id any exam or procedures performedExcludes1:encounter for examination for administrative purposes (Z02.-)encounter for examination for suspected conditions, proven not to exist (Z03.-)encounter for laboratory and radiologic examinations as a component of general medical examinations (Z00.0-)encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to sign(s) or symptom(s)screening examinations (Z11-Z13)
66 Case 3 Coding Process - AI Z01.4 Encounter for gynecological examinationExcludes2: pregnancy examination or test (Z32.0-)routine exam for contraceptive maintenance (Z30.4-)Z01.41 Encounter for routine gynecological examinationEncounter for general gynecological examination w/wo cervical smearEncounter for gynecological examination (general) (routine) NOSEncounter for pelvic examination (annual) (periodic)Use additional code:for screening for human papillomavirus, if applicable, (Z11.51)for screening vaginal pap smear, if applicable (Z12.72)to identify acquired absence of uterus, if applicable (Z90.71-)Excludes1:gynecologic examination status-post hysterectomy for malignant condition (Z08)screening cervical pap smear not a part of a routine gynecological exam Z12.4)
67 Case 3 Coding Process - AI Gout, gouty (acute) (attack) (flare) (see also Gout, chronic) M10.9-- tophi —see Gout by typeGout, chronic (see also Gout, gouty) M1A.9
68 Case 3 Coding Process – AI & TL Flu ShotImmunization —see also Vaccinationencounter for Z23Z 23 Encounter for immunizationCode First: any routine childhood examinationNote: procedure codes are required to identify the types of immunizations given
69 Case 3 Coding Process - TL Persons encountering health services for examinations (Z00-Z13)Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.Excludes1: examinations related to pregnancy and reproduction (Z30-Z36, Z39.-)
70 Case 3 Coding Process - TL Z00 Encounter for general examination without complaint, suspected or reported diagnosisExcludes1: encounter for examination for administrative purposes (Z02.-)Excludes2: encounter for pre-procedural examinations (Z01.81-)special screening examinations (Z11-Z13)
71 Case 3 Coding Process - TL Z00.0 Encounter for general adult medical examinationEncounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologicexaminationsExcludes1: encounter for examination of sign or symptom- code to sign or symptomgeneral health check-up of infant or child (Z )Z00.00 Encounter for general adult medical examination without abnormal findingsEncounter for adult health check-up NOSZ00.01Encounter for general adult medical examination with abnormal findingsUse additional code to identify abnormal findings
72 Case 3 Coding Process –Documentation Issue Gout, chronicdrug-induced M1A.20idiopathic M1A.00in (due to)renal impairment M1A.30lead-induced M1A.10primary —see Gout, chronic, idiopathicsaturnine —see Gout, chronic, lead-inducedsecondary NEC M1A.40syphilitic (see also subcategory M14.8-) A52.77tophi —see Gout by typeThese sub-terms require body part and laterality
73 Case 3 Coding Process - TL M1A Chronic goutThe appropriate 7th character is to be added to each code from category M1A0 - without tophus (tophi)1 - with tophus (tophi)M1A.9 Chronic gout, unspecified
74 Case 3 ANSWERZ Examination (for) (following) (general) (of) (routine), annual (adult) (periodic) (physical), gynecologicalM1A.9XX1 Gout, chronic, with tophiZ23 Vaccination (prophylactic), encounter for
75 Coding Case 4 Office Visit; 36-y-o male pt, primary care physician. Hx: Pt here for follow-up of lab work from earlier in week. Bitten by tick last month & has had body aches, some swelling to R upper arm, pain & stiffness in R elbow, as well as feeling fatigued. Had + Lyme test; pt to have repeat blood test (Western Blot), as 2ndary follow-up.PE: Alert & in no acute distress. Temp Pulse 108. Resp 20. BP 118/70.
76 Coding Case 4PE: Weight 296 on a 5’ 9” frame. Up 3 pounds from last week & 22 pounds up since beginning of year. Arm continues to display circular erythematous lesion with 2+ pitting edema. Lesion hasn’t grown outside perimeter markings from first visit.Impression:1. Localized arthritis, right elbow in Lyme disease due to tick bite2. Morbid obesity, BMI of 43.7
77 Coding Case 4Pt has blood drawn & was put on Doxycycline 100 mg b.i.d. × 4 weeks.Additional educational material on Lyme disease given. Should follow-up immediately if affected area grows larger than current, marked area or if any new symptoms develop.We discussed again need for exercise program, when able, & portion control due to over-nourishment status.
78 Case 4 Coding Process - AI Localized arthritis, right elbow in Lyme disease due to tick biteArthritis, arthritic (acute) (chronic) (nonpyogenic) (subacute) M19.90- due to or associated with- - Lyme disease A69.23
79 Case 4Coding Process - AI Bite (s) (animal) (human)- arm (upper) S41.15-- - lower —see Bite, forearm- - superficial NEC S40.87-- - - insect S40.86-
80 Case 4 Coding Process – AI for External Causes Bite, bitten byinsect (nonvenomous) W57TL = Exposure to animate mechanical forces (W50-W64)Excludes1: Toxic effect of contact with venomous animals and plants (T63.-)
81 Case 4 Coding Process -TL W57 Bitten or stung by nonvenomous insect and other nonvenomous arthropodsExcludes1: contact with venomous insects and arthropods (T63.2-, T63.3-, T63.4-)The appropriate 7th character is to be added to code W57A - initial encounterD - subsequent encounterS - sequela
82 Case 4 Coding Process - AI Morbid obesity, BMI of 43.7Obesity E66.9- morbid E66.01- - with alveolar hypoventilation E66.2- - due to excess calories E66.01
84 Case 4 Coding Process – AI BMI, 43.7 – Use Add’l Note at E66 = Z68.-Body, bodies- mass index (BMI)- - adultor less Z68.1Z68.20Z68.21Z68.22Z68.23Z68.24Z68.25Z68.26Z Z Z Z Z Z Z Z Z Z and over Z68.45
85 Coding Case 4 ANSWERA69.23 Arthritis, arthritic, (acute) (chronic) (nonpyogenic) (subacute) due to or associated with Lyme diseaseS40.861S Bite(s), (animal) (human), arm (upper), superficial NEC, insect..E66.01 Obesity, morbidZ68.41 Body, bodies, mass index (BMI), adult, 40–44.9W57.XXXS Index to External Causes, Bite, bitten by, insect, (nonvenomous)
86 Coding Case 549-y-o female with CC of painful mouth ulcers over last month. Treated with acyclovir for 10 days and penicillin on two occasions, including tapering doses of steroids on second occasion. Pt states she feels somewhat better but continues to have these ulcers with pain.Denies fever, chills, dysphagia, or lymphadenopathy. No high risk behavior.
87 Coding Case 5PE: Reveals whitish patches measuring 1 mm × 1 mm on buccal musoca and hard palate; erythematous and inflamed.Assessment: Aphthous ulcers and herpanginaPlan: Will start patient on clindamycin orally for buccal cellulitis and Amlexanox 5% as oral paste along with the Xylocaine mouth wash. Patient should follow up with me in 2 weeks.
88 Case 5 Coding Process - AI Aphthous ulcersHerpanginaIs there another diagnosis that needs to be coded?
93 General ResourcesFrazier, M. S. & Drzymkowski, J. W. Essentials of Human Diseases and Conditions, 4th ed., Saunders, 2009Gray, H. Anatomy of the Human Body Scott, A. S. & Fong, E. Body Structures and Functions, 11th ed., Delmar, 2009Whonamedit? A dictionary of medical eponyms
94 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
95 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.
96 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.
97 ICD-9-CM Codes 486 Pneumonia 401.9 HTN 707.06, Pressure Ulcer R lateral malleolusDehydration780.97Altered mental statusDM type 2NeuropathyRetinopathyGastroparesis260.60, 357.2, 563.3250.50,401.9 HTN272.4 HyperlipidemiaObesityV12.54 Hx CVAV15.82 Hx SmokingE888.9 FallE849.0 At Home
98 ICD-10-CM Codes J18.9 Pneumonia L Pressure Ulcer R lateral malleolusE86.0 DehydrationR41.82 Altered mental statusAltered mental status due to known condition - code to conditionDM type 2E11.40 NeuropathyE Retinopathy -- MUST know w/wo Macular EdemaE11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathyIncludes: Type 2 diabetes mellitus with diabetic gastroparesis
99 ICD-10-CM Codes I10 HTN - LESS Specific E78.5 Hyperlipidemia E66.9 ObesityZ86.73 Hx CVAZ Hx SmokingW19.XXXA FallY At Home
100 General ResourcesFrazier, M. S. & Drzymkowski, J. W. Essentials of Human Diseases and Conditions, 4th ed., Saunders, 2009Gray, H. Anatomy of the Human Body Scott, A. S. & Fong, E. Body Structures and Functions, 11th ed., Delmar, 2009Whonamedit? A dictionary of medical eponyms
101 ICD-10-CM Resources AAPC. ICD-10 Connect (e-Newsletter) https://www.aapc.com/icd-10/icd-10-connect.aspxAAPC. ICD-10 ImplementationAHIMA. ICD-10-CM/PCS Implementation ToolkitCDC. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)CDC. ICD-10-CM Official Guidelines for Coding and Reporting 2012
102 ICD-10-CM ResourcesClinical Documentation Challenges with ICD-10-CM, 11/2011. ICD-10 Taskforce Bulletin. NCHICA.CMS-AAPC ICD-10 Code-a-thon Video. YouTube. One hour and 16 minutes.Endicott, M. ICD-10-CM/PCS codes for musculoskeletal system include greater level of specificity. 8/30/2011Giannangelo, K. and Hyde, L. ICD-10’s impact on quality measures. Just Coding.
103 ICD-10-CM ResourcesGrant, C & Wierz, C. An Essential Guide to ICD-10 Implementation. Courtyard Group.Gray, L. ICD-10-CM Coding of Physeal Fractures Using the Salter-Harris Classification SystemICD-10 Articles. Just Coding News. HCPro.ICD10Data.com. Free 2012 ICD-10 reference, including all codes, a search engine, ICD-9-CM conversion, all indexes and 10.6 million instant coding notes.
104 ICD-10-CM ResourcesKostick, K. M. Coding Diabetes Mellitus in ICD-10-CMLeon-Chisen, N. ICD-10 Overview and How Does ICD-10 Impact Departments? AHA. 11/03/2011Let's Get The Terms Straight. National Scoliosis Foundation.Role-based Model for ICD-10 Implementation: Inpatient Coders. AHIMA.
105 ICD-10-CM ResourcesRole-based Model for ICD-10 Implementation: Outpatient Coders. AHIMA.Schraffenberger, L. Basic ICD-10-CM/PCS and ICD-9-CM Coding, 2012 ed. Chicago: AHIMASchreck, B. Late Effects (Sequela) in ICD-10-CM August 10, 2011Simmons, C. R. The Musculoskeletal System and ICD-10-CM. ICD TEN, April 2011.AHIMA.https://newsletters.ahima.org/newsletters/ICDTen/2011/April/April_ICD.html
106 ICD-10-CM ResourcesWHO. International Classification of Diseases (ICD)Zeisset, A. Coding Injuries in ICD-10-CM.Zeisset, A. ICD-10-CM Enhancements: A Look at the Features That Will Improve Coding Accuracy