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

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

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

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

Outpatient Coder Training Approximately 16 hours 2011-2012 Review code Structure & Coding Conventions. Learn the fundamentals Analyze & practice applying the ICD-10-CM guidelines Review and refresh knowledge of A & P concepts

Outpatient Coding Training 2012-2013 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

Inpatient Coder Training Approximately 50 hours 2011-12 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

Inpatient Coder Training 2012-13 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

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, 2011 thru December 31, 2013 2009 or 2010 ICD-10 –CM Academy

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

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

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

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

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

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

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

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

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

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 I25.110- Arteriosclerotic Heart Disease of native coronary artery with unstable angina pectoris K571.51- Toxic Liver disease with chronic active hepatitis with ascites E10.610- Type 1 diabetes mellitus with diabetic neuropathic arthropathy

ICD-10-CM Combination codes for poisonings and their external cause T42.3x2S- Poisoning by barbituates, intentional self-harm, sequela Laterality C50.212- Malignant neoplasm of upper-inner quadrant of left female breast L89.213- Pressure ulcer of right hip, stage III Example of Superbill 20

ICD-10-CM Codes for clinical concepts that do not exist in ICD-9-CM T45.526D-Underdosing of antithrombotic drugs, subsequent encounter Z67.40- Type O Blood, RH positive Codes for postoperative complications, intraoperative, and post- procedural disorders D78.01- Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen D78.21- Post-procedural hemorrhage and hematoma of spleen following a procedure on the spleen Obstetric codes identify trimester instead of episode of care 026.02- Excessive weight gain in pregnancy, second trimester

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

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

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: I25.110 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

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 L89.213 Ulcer, ulcerated, ulcerating, ulceration, ulcerative, pressure (pressure area) stage III, (healing) (full thickness skin loss involving damage or necrosis of subcutaneous tissue) L89.152 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

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.  

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 Z91.130 Noncompliance, medication regimen, underdosing, unintentional, due to patient’s age-related debility

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) Y92.411 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

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

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

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

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

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

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.

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.

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

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.

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

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.

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

ICD-10-CM/PCS Resources http://www.cms.gov/ICD10/ Download the Index & Tabular Compliance Dates Quick Reference Guide www.ahima.org ICD-10-CM/PCS Resource Page

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