ICD-9 to ICD-10 Prep Presented by: Lizeth Flores, RHIT Khaleelah Wagner, RHIA Staci LePage, RHIT ICD-9 to ICD-10 Prep 07-01-14

Objectives Participants will: Correctly assign diagnoses to ICD-9-CM codes Correctly identify primary/secondary diagnoses Identify correct sequence of diagnoses for coding assignment Identify documentation needed for ICD-10-CM coding

ICD-9 and ICD-10 History The 9th revision was published in 1977. The U.S. National Center for Health Statistics (NCHS) and CMS are responsible for maintaining ICD-9-CM. The World Health Organization (WHO) adopted ICD-10 (International Classification of Diseases, Tenth Revision) in 1990 and it came into use in 1994 by other countries. The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) was developed under the oversight of National Center for Health Statistics in 1997 and has undergone several modifications since then. Page 2 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

2014 ICD-9-CM and ICD-10-CM Availability http://www.cdc.gov/nchs/icd/icd9cm.htm http://www.cdc.gov/nchs/icd/icd10cm.htm or http://www.cms.hhs.gov/ICD10 2014 ICD-10-CM Index to Diseases and Injuries 2014 ICD-10-CM Tabular List of Diseases and Injuries Instructional Notations 2014 Official Guidelines for Coding and Reporting 2014 Table of Drugs and Chemicals 2014 Neoplasm Table 2014 Mapping ICD-9-CM to ICD-10-CM and ICD-10-CM to ICD-9-CM” ICD-9 to ICD-10 Prep 07-01-14

ICD-9-CM and ICD-10-CM Coding Guidelines The guidelines are approved by four organizations: American Hospital Association (AHA) American Health Information Management Association (AHIMA) Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) Page 24 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding to Support Need for Medicare The principal diagnosis and secondary top 8 diagnoses are entered onto the UB-04. Accurate reporting of ICD-9 CM codes effect: Medicare billing Quality measures Data collected Overall accuracy of MDS/RUG categories The main benefit of correct coding is validation of service delivered and reduced compliance risk. The industry is using more checks and balances to reject claims and review for fraud and abuse. Inaccurate codes will lead to rejection of claims and services.

Coding Conventions and Guidelines ICD-9-cm ICD-9 to ICD-10 Prep 07-01-14

Coding from ICD-9-CM to ICD-10-CM Three to five characters Three to seven characters First digit is numeric but can be alpha (E or V) First character always alpha 2–5 are numeric All letters used except U Always at least three digits Character 2 always numeric: 3–7 can be alpha or numeric Decimal placed after the first three characters (or with E codes, placed after the first four characters) Alpha characters are not case-sensitive Decimal placed after the first three characters

Alphabetic Index -2 Main terms in boldface font are listed in alphabetic order. Then, indented beneath the main term, any applicable subterm or essential modifier will be shown in alphabetical order. The indented subterm is always read in combination with the main term. Pneumonia 486 (J18.9) aspiration 507.0 (J69.0) due to food 507.0(J69.0) Page 9 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Alphabetic Index -3 Nonessential modifiers appear in parentheses ( ) and do not affect the code number assigned. The “-” at end of an index entry indicates that additional characters are required (ICD-10) Amblyopia (congenital) (ex anopsia) (partial) (suppression) 368.00 (H53.00-) deprivation 368.02 (H53.01-) Page 9 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Alphabetic Index -4 Manifestation codes are included in the alphabetic index by including a second code, shown in brackets [ ] directly after the underlying or etiology code which should always be reported first. Chorioretinitis – see also inflammation chorioretinal Tuberculosis 017.3 [363.13] Egyptian B76.9 [D63.8] Page 9 - 10 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Tabular List Most but not all categories are subdivided into four or five character subcategories, e.g. (496 COPD or I10 – Hypertension) The fourth character when placed after the decimal point of: 8 - (.8) is used to indicate “other specified”, and 9 - (.9) is usually reserved for “unspecified” Page 12 of the Instructor & Student Training Guide 365.89 Other specified glaucoma 365.9 Unspecified glaucoma K52.89 Other specified noninfective gastroenteritis and colitis K52.9 Noninfective gastroenteritis and colitis, unspecified ICD-9 to ICD-10 Prep 07-01-14

Tabular List -4 (NEC) – “not elsewhere classified” (NOS) – “not otherwise specified” Both NEC and NOS have their own codes Five and six character codes provider greater specificity or more information about the condition Codes must be assigned to the highest number of characters available or to the highest level of specificity, or bills will be rejected Page 12 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Convention Abbreviations Not Elsewhere Classified “NEC” – A residual category, subdivision, or subclassification that provides a location for “other” types of specified conditions that have not been classified anywhere else in the code set. These residual codes may also contain the term “NEC” as part of their descriptor. 276.9 Electrolyte and fluid disorders, not elsewhere classified E87.8 Other Disorder of electrolyte and fluid balance, not elsewhere classified Page 19 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Beginning of the chapter – 780-799 or R00-R99 Tabular List Notes Pertinent coding information is located at the beginning of chapters or any subdivisions that follow and apply to all the categories within it. Beginning of the chapter – 780-799 or R00-R99 Beginning of a subchapter – 235-238 or D37-D48 Page 13 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Convention Abbreviations -2 Not Otherwise Specified “NOS” - for use when the documentation of the condition identified by the provider is insufficient to assign a more specific code. 294.20 Unspecified dementia without behavioral disturbance or Dementia, NOS F03.90 Unspecified dementia without behavioral disturbance – Dementia, NOS Page 19 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Conventions Punctuation ( ) Parentheses – supplemental words that may or may not be present. [ ] - Brackets – synonyms, alternative workings or explanatory phrases. 401.9 Hypertension (essential) (primary) I10 – Essential (primary) hypertension Page 19 & 20 of the Instructor & Student Training Guide 814.02 Fracture of lunate [semilunar] S62.12 Fracture of lunate [semilunar] ICD-9 to ICD-10 Prep 07-01-14

Coding Conventions Punctuation -2 Colon ( : ) – used after an incomplete term which needs one or more of the modifiers following the colon. Used in both “includes” and “excludes” notes in which the words that precede the colon are not considered complete terms and therefore must be appended by one of the modifiers indented under the statement. 359.6 Symptomatic inflammatory myopathy in diseases classified elsewhere Code first underlying disease, as: malignant neoplasm (140.0-208.9) rheumatoid arthritis (714.0) Page 20 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Conventions Punctuation -3 Dashes ( - ) in the Alphabetic Index, dashes at the end of a code indicates an incomplete code *ICD-10 only In the Tabular List, a dash preceded by a decimal point (.-) indicates an incomplete code *ICD-10 only Fracture, pathological ankle M84.47- carpus M84.44- J43 Emphysema Excludes 1: emphysematous (obstructive) bronchitis (J44.-) Page 20 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Convention Instructional Notes Includes notes – used to clarify the condition included within a particular chapter, section, category, subcategory or code. They are not exhaustive and may include diagnoses not listed in the inclusion note. The word “includes” is not preceded by the list of terms at the code level. 531 Gastric ulcer Includes: ulcer, stomach K25 Gastric ulcer Includes: stomach ulcer (peptic) Page 21 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Convention Instructional Notes -2 Excludes 1 – not coded here. Used when two codes cannot occur together *ICD-10 Excludes – terms excluded from the code are to be coded elsewhere *ICD-9 355.9 Mononeuritis of unspecified site Excludes: Causalgia, upper/lower limb (355.71/354.4) G59 Mononeuropathy in disease classified elsewhere Excludes 1: Diabetic mononeuropathy (E09 – E14 with .41) Page 21 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Convention Instructional Notes -3 Excludes 2 – not included here. Used when the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time *ICD-10 only J01 Acute Sinusitis Excludes 1 – Sinusitis NOS (J32.9) Excludes 2 – Chronic Sinusitis (J32.0 – J32.8) Page 21 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Conventions Code First & Use Additional Code Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. The underlying condition is sequenced first followed by the manifestation. The “use additional code” note appears at the etiology and a “code first” note at the manifestation code. Page 22 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Convention Instructional Notes -3 331.0 Alzheimer’s disease Use additional code to identify… 294 Persistent mental disorders due to conditions classified elsewhere Code first underlying condition G30 Alzheimer’s disease Use additional code to identify: dementia with behavioral disturbance (F02.81) dementia without behavioral disturbance (F02.80) F02 Dementia in other diseases classified elsewhere Code first the underlying physiological condition, such as: Alzheimer’s (G30.-) Page 21 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Conventions Cross Reference Notes Cross reference notes are used in the Alphabetic Index to advise the coding professional to look elsewhere before assigning a code. There are three terms used: see, see also, see condition Hemorrhage, cranial – see Hemorrhage, intracranial Labyrinthitis (circumscribed) (destructive) (diffuse) (inner ear) (latent) (purulent) (suppurative) – see also subcategory H83.0 Hematoma (traumatic) (skin surface intact) (see also Contusion) Page 22 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Conventions Relational Terms And – should be interpreted to mean “and/or” when it appears in the code title within the Tabular List. 451 Phlebitis and thrombophlebitis I80 Phlebitis and thrombophlebitis 453 Other venous embolism and thrombosis I82 Other venous embolism and thrombosis Page 23 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Coding Conventions Relational Terms -2 With – should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetical Index, or an instructional note in the Tabular List. The term “with” in the Alphabetical Index is sequenced immediately following the main term, not in alphabetical order. Asthma, asthmatic with chronic obstructive pulmonary disease 493.2/J44.9 493.2 Chronic obstructive asthma J44 Other chronic obstructive pulmonary disease Includes asthma with COPD Page 23 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Signs and Symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider Chapter 16 of ICD-9-CM contains many, but not all codes for symptoms Chapter R00 – R99, for ICD-10-CM, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified contains many, but not all codes for symptoms Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Integral Part of a Disease Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Examples: Altered Mental Status due to UTI -599.0/N39.0 COPD with Shortness of Breath -496/J44.9 Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Not an Integral Part of Disease -2 Signs and symptoms that may not be associated routinely with a disease process should be coded when present. Resident has a culture that returned difficile. The resident has diarrhea with additional symptoms of malaise, low-grade fever and frequent diarrhea. The resident was started on Flagyl. The resident is weak, dehydrated, and needs IV fluids. Infection, Clostridium, difficile, food borne (disease) 008.45/A04.7 Dehydration 276.51/E86.0 Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Multiple Coding In addition to the etiology/manifestation convention that requires two codes, there are other single conditions that also require more than one code. See “Use additional code” notes in the Tabular List at the code level. These are sequenced secondary to the condition code. Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Multiple Coding -2 “Code first” notes are under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a “code first” note and an underlying condition is present, the underlying condition is sequenced first. “Code if applicable, any causal condition” notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If the causal condition is known, then the code for that condition should be sequenced as the principal diagnosis or first-listed diagnosis. Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Multiple Coding Example Multiple codes may be needed for sequela conditions. See Guideline #10. E. coli urinary tract infection Infection, Urinary (tract) 599.0/N39.0 Use additional code to identify infectious organism/agent Infection, bacterial, Escherichia coli [E. coli] (see also Escherichia coli) 041.04/B96.20 Not in the instructor manual “Use additional code” is part of the tabular, not alpha index ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Acute and Chronic Conditions If the same condition is described as both acute (subacute) and chronic and separate subentries exist in the Alphabetic Index at the same indention level, code both and sequence the acute (subacute) code first Acute and chronic bronchitis Bronchitis, acute or subacute (with bronchospasm or obstruction) 466.0/J20.9 Bronchitis, chronic 491.9/J42 Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Combination Code A combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary manifestation, or Type 2 diabetes with other specified complication 250.80/E11.69 Use additional code to identify complication A diagnosis with an associated complication Acute Bronchitis with COPD 491.22/J44.0

General Coding Guidelines Combination Code -2 Assign only the combination code that fully identifies the diagnostic conditions involved or when directed by the Alphabetical Index Multiple coding should not be used when the classification provides a combination code that clearly identifies all the elements documented in the diagnosis When a combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Late Effects/Sequela “A residual effect (condition produced) after the acute phase of an illness or injury has terminated.” There is no time limit for the late effect or sequela code The residual may be apparent early or years later Generally requires two codes: The condition or nature of the late effect/sequela – first 438.5/I69.16 Other paralytic syndrome following intracerebral hemorrhage The late effect/sequela code – second 344.00/G82.5- Quadriplegia Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Sequela Exceptions to above guideline. In instances where the code for the late effect/sequela is followed by a manifestation code identified in the Tabular List and title, or the late effect/sequela code has been to include the manifestation. Example: 438/I69 Late Effects/Sequela of Cerebrovascular Disease The code for the acute phase of an illness or injury that led to the late effect/sequela is never used with a code for the late effect. Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Reporting Same Dx More than Once Each unique ICD-10-CM code may be reported only once for an encounter This applies to bilateral conditions when there are no distinct codes for laterality or two different conditions classified to the same ICD-9-CM or ICD-10-CM diagnosis code Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Laterality *ICD-10 only Laterality Guidelines For bilateral sites, the final character of the codes indicates laterality. An unspecified site code is also provided should the side not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side Page 24 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Documentation of BMI and Pressure Ulcer Stages Body Mass Index (BMI) and pressure ulcer stage codes may be based on the medical record documentation from clinicians who are not the patient’s provider, such as a dietician for BMI or licensed nurse for pressure ulcer staging. Associated conditions (overweight, obesity, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification. Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

General Coding Guidelines Syndromes Follow the Alphabetical Index for guidance when coding syndromes If there is no guidance in the Alphabetical Index assign codes for the documented manifestations of the syndrome Look for the syndrome by its name in the alphabetical index first and then if not there, under syndrome Not in the instructor manual ICD-9 to ICD-10 Prep 07-01-14

Coding Guidelines Complications “Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure.” The guideline extends to any complications of care, regardless of the chapter the code is located in. Note: not all conditions that occur during or following medical care or surgery are classified as complications. Page 24 of the Instructor & Student Training Guide Will not always be able to look under “complications” in alpha index ICD-9 to ICD-10 Prep 07-01-14

Coding Guidelines Complications -2 There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. If the complication is not clearly documented, query the provider for clarification. Page 24 of the Instructor & Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

Infectious and Parasitic Diseases ICD-9 to ICD-10 Prep 07-01-14

HIV Infections Code Only Confirmed Cases Code only confirmed cases of HIV “Confirmation” does not require documentation of positive serology, the provider’s diagnostic statement that the patient is HIV positive is sufficient Asymptomatic HIV is to be applied when the patient without documentation of symptoms is listed as being “HIV Positive”. Do not use this code if the terms AIDS is used or if the patient is treated for any HIV-related illness.

Infectious Agents Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code An additional code from Chapter 1 should be used to identify the organism: 041/B95 Streptococcus, Staphylococcus, and Enterococcus 041.8/B96, Other bacterial agents 079/B97 Viral agents

Infectious Agents -2 An instructional note will be found at the infection code advising that an additional organism code is required Use an additional code to identify infectious agent

Examples UTI with hematuria due to E.coli 599.0, 599.70 UTI, hematuria, or N30.91, Cystitis unspecified with hematuria 041.4 Escherichia coli, or B96.2, Escherichia coli [E. coli] as the cause of diseases classified elsewhere Pneumonia due to streptococcus group B with sepsis 482.32, or J15.3, Pneumonia due to streptococcus, group B 995.91, or A41.9 Sepsis, unspecified organism Septicemia NOS ICD-9 to ICD-10 Prep 07-01-14

Infections Resistant to Antibiotics Identify all infections documented as antibiotic resistant Assign code V09.9-/Z16 Infection with drug-resistant microorganisms following the infection code

Septicemia, SIRS, Sepsis, Severe Sepsis, and Septic Shock Septicemia and sepsis are often used interchangeably, but they are NOT considered synonymous terms. Septicemia refers to a systemic disease associated with the presence of toxins in the blood Systemic inflammatory response syndrome/SIRS refers to the systemic response to infection with symptoms of fever, tachycardia, tachypnea and leukocytosis Sepsis refers to SIRS d/t infection Severe sepsis refers to sepsis with associated acute organ dysfunction Septic shock refers to circulatory failure associated w/severe sepsis

Coding of SIRS, Sepsis and Severe Sepsis Requires a minimum of 2 codes: A code for the underlying cause (such as infection; if unspecified septicemia, code 038.9) *sequence first And a code from subcategory 995.9- *sequence second Severe sepsis requires an additional code for the associated acute organ dysfunction Either the term sepsis or SIRS must be documented to assign a code from subcategory 995.9-

meaning urinary tract infection 599.0 Urosepsis – code to condition Urosepsis Guidelines Urosepsis cannot be coded in ICD-10-CM Guideline states: “The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.” ICD-9-CM Alpha Index Urosepsis 599.0 meaning sepsis 995.91 meaning urinary tract infection 599.0 ICD-10-CM Alpha Index Urosepsis – code to condition

Sepsis documentation to look for… Or query MD for… Streptococcal sepsis Sepsis d/t Staphylococcus aureus Sepsis d/t other Gram-negative organisms Severe sepsis Sepsis d/t MRSA Sepsis d/t MSSA d/t joint prosthesis (complication) d/t catheter (complication) Other organism??

Severe Sepsis Coding Example ICD-9-CM Severe sepsis due to hemophilus influenza with septic shock and acute renal failure 038.41 (Hemophilus influenza septicemia) 995.92 (Severe sepsis) 785.52 (Septic shock) 584.9 (Acute renal failure) ICD-10-CM A41.3 (Hemophilus influenza sepsis) R65.21 (Severe sepsis with septic shock) N17.9 (Acute renal failure)

Coding Note: In ICD-10-CM, when coding an infection due to an indwelling urinary catheter, the coding professional is instructed to use an additional code to identify the infection (besides coding the complication 996.31). Additionally, if the infectious agent is also known, this should be assigned as an additional diagnosis. ICD-9 to ICD-10 Prep 07-01-14

Methicillin Resistant Staphylococcus Aureus (MRSA) Conditions Selection and sequencing of MRSA codes (a) Combination codes for MRSA infection – when an infection due to MRSA has a combination code that includes the causal organism assign the appropriate combination code Do not code B95.62 MRSA infection as the cause of diseases elsewhere or Z16.11 Resistance to penicillin as additional codes (b) Other codes for MRSA infection – when there is a current infection and that infection does not have a combination code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62 Do not use Z16.11 Resistance to penicillin

Methicillin Resistant Staphylococcus Aureus (MRSA) Conditions -2 Selection and sequencing of MRSA codes c) Methicillin susceptible Staphylococcus aureus (MSSA) and MRSA colonization- means that MSSA or MSRA is present on or in the body without necessarily causing illness Assign code Z22.322 Carrier or suspected carrier of MRSA, or Z22.321 Carrier or suspected carrier of MSSA

Neoplasms ICD-9 to ICD-10 Prep 07-01-14

General Neoplasm Guidelines The Neoplasm Table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.

Neoplasm Table

Neoplasm Table -2 Malignant – Primary Original site of cancer 2 primary sites may be coded, if indicated Alphabetic Instructions will indicate if malignant Primary site unknown or unspecified Use 199.1/C80.1, Malignant (primary) neoplasm, unspecified

Neoplasm Table -3 Malignant – Secondary The site where the cancer spreads to (metastasizes) Primary cancer that spreads to a secondary site may be stated as: Primary site with metastasis to secondary site Secondary site with metastasis from primary site Secondary site due to metastatic primary site If secondary site unknown - use 199.1/C79.9, secondary malignant neoplasm of unspecified site

Neoplasm Table -4 Ca in situ Benign Atypical malignancy; encapsulated – has not spread Physician must indicate “in situ” or index will instruct you to code this type Benign Not malignant Does not metastasize

Neoplasm Table -5 Uncertain Unspecified Behavior Alphabetic index will instruct to use this type if appropriate – See neoplasm, by site, uncertain behavior Not used if it is the coder that is uncertain of the behavior Unspecified Behavior Not specified as malignant or benign Index instructions will direct here as appropriate – See neoplasm, by site, unspecified behavior

Current vs. History of Neoplasm is coded as a current condition if being actively treated Diagnosed but no treatment administered Has been removed surgically but treatment is still being administered (for example, chemotherapy/radiation) Neoplasm is coded as a “history of” if Site has ben surgically removed and/or treatment has been completed AND There is no mention of recurrence Use V10/Z85 category to indicate a personal history of neoplasm ICD-9 to ICD-10 Prep 07-01-14

Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism ICD-9 to ICD-10 Prep 07-01-14

Anemia Defined A condition in which your blood has a reduced number of circulating red blood cells usually defined as an abnormally low hemoglobin or hematocrit level. Caused by: Disease (malignancy, kidney failure, immunity) Blood loss Decreased blood formation or destruction of cells Nutritional Deficiency Drug induced

Anemia, Due to D50.0 – Iron deficiency secondary to blood loss (chronic blood loss) D50.9 – Iron deficiency Anemia D51.0 – Vitamin B12 deficiency anemia D53.0 – Protein deficiency anemia D62 – Acute blood loss D63.1 – Anemia in chronic kidney disease D63.8 – Anemia in neoplastic disease D64.81 – Anemia due to antineoplastic chemotherapy

Anemia Associated with Malignancy Coding Guideline 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 D63.0, Anemia in neoplastic disease). Page 114 of the Instructor and Student Training Guide ICD-9 to ICD-10 Prep 07-01-14

ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES

Diabetes Combination Codes Documentation needs to include type of diabetes Type I Type II Secondary Other specified Is there a body system affected: Kidney Ophthalmic Neurological Circulatory Other specified (diabetic ulcer, etc.) Note two new categories of diabetes. Discuss how to look up…diabetes, type, complication ICD-9 to ICD-10 Prep 07-01-14

Diabetes Combination Codes -2 What is the specific complication affecting the system(s)? Note two new categories of diabetes. Discuss how to look up…diabetes, type, complication ICD-9 to ICD-10 Prep 07-01-14

DIABETES TYPE I DIABETES TYPE II What’s the difference?

Diabetes Types Age Not Sole Factor Determining Type Diabetes, Type I Cause: Absent or insufficient insulin production 10% of diabetics Usually juvenile onset Does not respond to oral anti-glycemic agents Always requires insulin Diabetes, Type II Cause: Improper utilization of insulin 90% adult onset (age 40>, but being seen more in younger population) Responds to oral anti-glycemic agents May require insulin

Secondary Diabetes Due to another underlying condition Cystic Fibrosis Malignant Neoplasm of Pancreas Pancreatectomy Drug or chemical induced Adverse effect of drug Poisoning *Follow coding directions at the beginning of each category! Discuss how to look up…diabetes, type, complication ICD-9 to ICD-10 Prep 07-01-14

Diabetes Type Not Documented? Default = Type II Diabetes DEFAULT Or physician query… ICD-9 to ICD-10 Prep 07-01-14

Q: Do I always use an additional code for long term use of insulin when ordered? A: No

Diabetes and Use of Insulin Type I: Do NOT code long term use of insulin Type II: Code long term use of insulin Secondary to underlying condition: Code use of insulin Drug/Chemical induced: Code use of insulin ICD-9 to ICD-10 Prep 07-01-14

CDAT Example for Diabetes 250.00

Obesity Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat, and/or body water. Both terms mean that a person's weight is greater than what's considered healthy for his or her height. Type of obesity Morbid/severe Due to excess calories Drug-induced obesity Vs. Overweight (code for this too) ICD-9 to ICD-10 Prep 07-01-14

Gout Gout is a kind of arthritis. It can cause an attack of sudden burning pain, stiffness, and swelling in a joint, usually a big toe. Types: acute, chronic or secondary Idiopathic Gouty bursitis Drug-induced gout Due to renal impairment Other secondary gout Specify joint site/laterality

Dehydration The excessive loss of body water with an accompanying disruption of metabolic processes Note: make sure this is a current condition that is being actively treated upon admission to your facility, otherwise do NOT code

Hypothyroidism Often called underactive thyroid, it is a common endocrine disorder in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as tiredness, poor ability to tolerate cold, and weight gain Acquired or congenital? Due to: Iodine deficiency Post-irradiation therapy Post-surgery Other

Hypercholesterolemia Hypercholesterolemia is the presence of high levels of cholesterol in the blood. It is a form of “hyperlipidemia" (elevated levels of lipids in the blood) and "hyperlipoproteinemia" (elevated levels of lipoproteins in the blood). Does documentation show: With hyperglyceridemia (an elevated concentration of glycerides in the blood), or With dietary counseling (use additional code)

Hyperlipidemia Abnormally elevated levels of any or all lipids and/or lipoproteins in the blood. It is the most common form of dyslipidemia (which includes any abnormal lipid levels). Specified type: Combined (also known as "Multiple-type hyperlipoproteinemia” ) Familial combined hyperlipidemia Group A, B, C or D Mixed Other specified type Lipoprotein deficiency

Anemia ICD-9/Diseases of the blood – Anemia, NOS 285.9 ICD-10/Endocrine, Nut’l, Metabolic diseases D58-D64 Chapter change Anemia has three main causes: blood loss, lack of red blood cell production, or high rates of red blood cell destruction.

Anemia -2 Specified type General = unspecified Acquired hemolytic *caused by high rates of red blood cell destruction Chronic blood loss *such as chronic posthemorrhagic anemia Iron *fewer red blood cells made or red blood cells that are too small Nutritional *such as simple chronic anemia In chronic diseases *such as neoplastic disease, CKD, hypothyroidism

Mental and Behavioral Disorders ICD-9 to ICD-10 Prep 07-01-14

Dementia Specific type Vascular/multi-infarct *a result of infarction of the brain due to vascular disease, including hypertensive cerebrovascular disease. Code 1st underlying condition (CVD, etc.) In diseases classified elsewhere code 1st underlying condition (Alzheimer’s, Parkinson’s, etc.) Senile *separate code in ICD-9, but dementia unspecified in ICD-10 Delirium superimposed on dementia *ICD-10 only, code 1st underlying condition Unspecified

Dementia -2 With or without behavioral disturbance Aggressive, combative, violent behavior Old code 294.8 *should NOT be using anymore, invalid Additional code for wandering Z91.83 *ICD-10 only If psychotherapeutic drugs given, check guidelines

Episodic Mood Disorders/Bipolar Disorder Episodic Mood Disorders/Bipolar Disorder *also known as Manic-depressive Illness Bipolar and Major depression have separate categories in ICD-10 Bipolar disorder, severe *with or without psychotic features

ICD-9 Single or Recurrent w/ Episodic Mood Disorders/Bipolar Disorder *also known as Manic-Depressive Illness -2 Specify type If psychotherapeutic drugs given, check guidelines ICD-9 Single or Recurrent w/ Subchronic Chronic Subchronic w/acute exacerbation Chronic w/acute exacerbation In remission ICD-10 Hypomanic Manic Depressed Mixed Other

Major Depression Has its own category in ICD-10 In ICD-10, Depression, NEC is coded to Major depressive disorder, single episode, unspecified Specify type Major depressive disorder, single episode Major depressive disorder, recurrent Major depressive disorder, recurrent, in remission Specify intensity: mild, moderate or severe If severe: with or without psychotic features If psychotherapeutic drugs given, check guidelines

Schizophrenia Specify type Paranoid Disorganized Catatonic Undifferentiated *atypical Residual Schizophreniform disorder Schizotypal disorder *borderline, latent, etc. Schizoaffective disorder *bipolar, depressive, other – ICD-10 Other In ICD-10, 5th digit of chronic, in remission, etc. is gone If psychotherapeutic drugs given, check guidelines

Psychosis If d/t a known mental disorder, code to that condition Delusional disorder *includes paranoia, paranoid state Mood disorder w/psychotic symptoms *includes Manic episode, Bipolar disorder, Major depressive disorder Brief psychotic disorder *includes paranoid reaction Shared psychotic disorder *includes induced paranoid disorder Unspecified mental disorder d/t known physiological condition *includes OBS, NOS; mental disorder NOS , *code 1st underlying physiological condition Unspecified psychosis NOT d/t known physiological condition *includes Psychosis, NOS

Psychosis -2 If d/t a known mental disorder, code to that condition (cont.) Other psychotic disorder NOT d/t known physiological condition *includes chronic hallucinatory psychosis Mental disorder, NOS *includes mental illness, NOS If psychotherapeutic drugs given, check guidelines

Anxiety Specify type Panic disorder *includes panic attack, panic state Generalized anxiety disorder *includes anxiety reaction, anxiety state Other mixed anxiety disorders *suffer from both anxiety and depressive symptoms Other specified anxiety disorders *includes anxiety depression If psychotherapeutic drugs given, check guidelines

Diseases of the Nervous System ICD-9 to ICD-10 Prep 07-01-14

Hemiplegia These codes are only to be used when the paralytic syndrome is specified w/o further specification, or is stated to be old but unspecified cause This category is also for use in multiple coding to identify the specific type of hemiplegia resulting from any cause *flaccid or spastic *ICD-10 only

Hemiplegia -2 Should the affected side be documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code selection is as follows: For ambidextrous (using both sides equally) patient, the default should be dominant If the left side is affected, the default is non dominant If the right side is affected, the default is dominant

Dementia with Parkinson’s Disease vs. Parkinsonism Parkinson's disease (PD) belongs to a group of conditions called motor system disorders, which are the result of the loss of dopamine-producing brain cells *code 332.0/G20, with dementia add 294.1-/F02.- Parkinsonism shares symptoms found in Parkinson’s disease, from which it is named; but Parkinsonism is a symptom complex, and differs from Parkinson’s disease which is a progressive neurodegenerative illness *code 331.82/G31.83 *same as Lewy body dementia *ICD-10 only Parkinsonism is not synonymous with Parkinson’s disease. Parkinsonism dementia (G31.83) and dementia due to Parkinson’s disease (G20) describe different conditions. Refer to Excludes 1 note under F02 for dementia with Parkinsonism (G31.83). ICD-9 to ICD-10 Prep 07-01-14

Alzheimer’s Disease Identify type Use additional code to identify Alzheimer’s disease with early onset Alzheimer’s disease with late onset Other Alzheimer’s disease Alzheimer’s disease, unspecified Use additional code to identify Dementia w/behavioral disturbance Dementia w/o behavioral disturbance Delirium , if applicable *ICD-10 requires the use of both the Alzheimer and dementia codes

Seizure Disorder vs. Convulsions Epilepsy/seizure disorder is a spectrum of brain disorders ranging from severe, life-threatening and disabling, to ones that are much more benign Convulsion is a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body If seizures repeatedly continue after the underlying problem is treated, the condition is called epilepsy (resident is usually on a routine med for seizures)

Epilepsy, Recurrent Seizures and Migraines The following terms are equivalent to intractable: pharmacoresistent (pharmacologically resistant), treatment resistant, refractory (medically), and poorly controlled.

Coding of Epilepsy Identify if epilepsy or seizure disorder, or just convulsion, NOS Specify type Intractable Not intractable With status epilepticus Without status epilepticus

Peripheral Neuropathy Specify type Polyneuropathy in diseases classified elsewhere ICD-9 Diabetes 250.6- + 357.2 Malignant dx CA code + 357.3 ICD-10 Diabetes, type 2 E11.42 Neoplasm Code CA + G63

Diseases of the Eye and adnexa ICD-9 to ICD-10 Prep 07-01-14

Coding Note Use additional external cause code, if applicable, to identify the cause of the eye condition Glaucoma types: Borderline glaucoma Open-angle glaucoma Primary angle-closure glaucoma Corticosteroid-induced glaucoma Glaucoma asso w/congenital anomalies, dystrophies, and systemic syndromes *includes glaucoma d/t diabetes 250.50, 365.44 Glaucoma associated with disorders of the lens Glaucoma associated with other ocular disorders Other specified forms of glaucoma *Where do you get this information from?

Combination Codes & Laterality ICD-9-CM Diabetic Retinopathy with Macular Degeneration needs three codes: 250.50, 362.01, 362.50 Cystic Macular Degeneration 362.54 ICD-10-CM Combination Code: Diabetic Retinopathy with Macular Degeneration uses a combination code: E08.351 Laterality: Macular cyst, hole, right eye H35.341

ICD-10 Glaucoma Coding Changes Identify the type of glaucoma, the affected eye, and the glaucoma stage. A 7th character is to be assigned to designate the stage of glaucoma: mild, moderate, severe, indeterminate, or unspecified

ICD-10 Cataract Terms ICD-10 CM uses the terms “age-related” cataract and “senile cataract” interchangeably. There are also terms for “age-related”, “infantile & juvenile cataract”, “traumatic cataract”, “complicated cataract”, “drug-induced cataract”, and “secondary cataract”. Within the age-related/senile category there are cortical, subcapsular, incipient, nuclear, and morgagnian cataracts. *Similar terminology to ICD-9

Blindness and Low Vision Definitions Visual impairment refers to a functional limitation of the eye Visual disability indicates a limitation of the abilities of the individual For international reporting, WHO, defines blindness as profound impairment The definition of legal blindness as a severe impairment is used in the USA

ICD-10 Terms for Blindness In the case of blindness, the code H54 has a note: Code first any associated underlying cause of blindness. Blindness codes include laterality. Example: H54.52, which is low vision left eye, normal vision right eye.

Diseases of the Circulatory System ICD-9 to ICD-10 Prep 07-01-14

Cardiac dysrhythmias 427.0 Paroxysmal supraventricular tachycardia 427.1 Paroxysmal ventricular tachycardia 427.2 Paroxysmal tachycardia, unspecified 427.3- Atrial fibrillation and flutter *ICD-10 Includes a code for chronic a-fib 427.4- Ventricular fibrillation and flutter 427.5 Cardiac arrest 427.6- Premature beats 427.8- Other specified cardiac dysrhythmias Sick sinus syndrome

Heart Failure 428.0 Congestive heart failure, unspecified 428.1 Left heart failure 428.2- Systolic heart failure ** 428.3- Diastolic heart failure ** 428.4- Combined systolic and diastolic heart failure ** Code, if applicable, heart failure d/t HTN 1st *if supporting MD documentation **these codes also need to know if acute, chronic or acute on chronic (ICD-10 will need for CHF too)

Acute Myocardial Infarction (AMI) Myocardial infarction or acute myocardial infarction (AMI) is the medical term for an event commonly known as a heart attack. It happens when blood stops flowing properly to part of the heart and the heart muscles are injured due to not receiving enough oxygen.

Acute Myocardial Infarction (AMI) -2 Usually this is because one of the coronary arteries that supplies blood to the heart develops a blockage due to a buildup of white blood cells, cholesterol and fat. The event is called "acute" if it is sudden and serious

Acute MI ICD-10 Code changes: STEMI or NSTEMI? Occurred 8 weeks or less? 5th digit needed 2 = Subsequent episode of care *appropriate code for SNF, if treated 1st at hospital ICD-10 Code changes: I21 – Initial AMIs I22 – Subsequent AMIs *New for ICD-10

Atherosclerotic Coronary Artery Disease and Angina Atherosclerosis (hardening of the arteries) can slowly narrow and harden the arteries throughout the body when atherosclerosis affects the arteries of the heart, it’s referred to as coronary artery disease Coronary artery disease is the No. 1 killer of Americans. Most of these deaths are from heart attacks, caused by sudden blood clots in the heart’s arteries.

Atherosclerotic Coronary Artery Disease and Angina Atherosclerosis is a blood clot causing an acute coronary syndrome. Two things can happen: Unstable angina - the clot doesn't totally block the blood vessel and then dissolves without causing a heart attack Myocardial infarction (heart attack) - the coronary artery is blocked by the clot the heart muscle, starved for nutrients and oxygen, dies

Coding Coronary Artery Disease/CAD Should be coding to 414.01, unless a CABG has been done or MD specifies otherwise Differentiate between coding of coronary arteries 414 and of the extremities 440…

ICD-10 Coding of Arteriosclerosis 4th digit Vessel: Native, bypass graft, autologous vein bypass graft, non- autologous biological bypass graft, non-biological bypass graft 5th digit Symptom: claudication, rest pain, ulcer and with gangrene. 6th digit Extremities: right, left, bilateral, other, unspecified Site of leg: thigh, calf, ankle, heel, mid-foot, foot, other. *ICD-10 will also have a combination code for CAD with angina

Cerebrovascular System

CVA Versus TIA CVA Brain infarction or hemorrhage usually associated with permanent or temporary neurologic deficits; includes transient focal neurological deficits lasting longer than 24 hours Persistent neurological deficit >24 hours Positive image study (MRI/CT) TIA A brief period of focal neurologic deficit lasting less than 24 hours (usually less than one hour) due to temporarily blocked blood flow to a specific area of the brain Symptoms resolve in 24 hours (usually < 1 hour) No infarction or hemorrhage Negative MRI/CT

Coding Post CVA Once cerebrovascular disease/CVD has been treated at the hospital, just the late effects/sequelae are being treated, if any. Category 438 is used to indicate conditions/residuals that have occurred any time after the onset of CVD. Use a separate code for each residual effect. Should NOT be coding 436. If no residual effects should code V12.54

Hypertension Hypertension, also referred to as high blood pressure, it is a condition in which the arteries have persistently elevated blood pressure. Every time the human heart beats, it pumps blood to the whole body through the arteries.

ICD-10 Hypertension Coding Changes Type of hypertension (benign, malignant, unspecified) is not used as an axis for the ICD-10-CM hypertension codes, there is only one code for essential hypertension (I10)

Types of Hypertension 401 Essential hypertension 402 Hypertensive heart disease *MD must document causal relationship 403 Hypertensive chronic kidney disease *implied relationship if both diagnoses documented, also need to code CKD to indicate the stage 585.- 404 Hypertensive heart and chronic kidney disease *if resident has all three diagnoses/AKA cardiorenal – MD must still indicate heart dx and hypertension have causal relationship 405 Secondary hypertension *is high blood pressure that's caused by another medical condition

CDAT Example for Hypertension 401.9

Peripheral Vascular Disease 443.81 Peripheral angiopathy in diseases classified elsewhere *code 1st underlying disease *ICD-10 will have a combo code for DM w/PVD 443.9 Peripheral/arterial/vascular disease *Excludes atherosclerosis of the extremities

Venous Embolism and Thrombosis 453.40 DVT, NOS is coded to acute venous embolism and thrombosis of deep vessels of the lower extremity 453.41 DVT of proximal lower extremity 453.42 DVT of distal lower extremity 453.5- Chronic DVT *also code V58.61 for long term use of anticoagulants *if vein specified, make sure have correct code *make sure treatment is currently being given and is NOT for prophylactic measures (Coumadin tx) *if no current treatment given, code V12.51 for hx of DVT

Diseases of the Respiratory System (J00-J99) National Cancer Institute ICD-9 to ICD-10 Prep 07-01-14

Asthma Terminology for ICD-10 Terminology used to describe asthma has been updated to reflect the current clinical classification of asthma The following terms have been added to describe asthma: Mild intermittent, and Three degrees of persistent mild, moderate, severe

Symptoms Stage 1: mild Stage 2: moderate Stage 3: Severe Possible chronic cough and sputum production Stage 2: moderate Shortness of breath on exertion Stage 3: Severe Shortness of breath Fatigue Multiple exacerbations Reduced exercise tolerance GOLD = Global Initiative for Obstructive Lung dx Worldallergy.org ICD-9 to ICD-10 Prep 07-01-14

Symptoms -2 Stage IV: Very severe Respiratory failure Elevation of jugular venous pressure Pitting ankle edema.

Current Asthma Coding 493.0- Extrinsic asthma 493.1- Intrinsic asthma 493.2- Chronic obstructive asthma *includes asthma w/COPD and chronic asthmatic bronchitis 5th digit for: Status asthmaticus, and Acute exacerbation

Pneumonia Remember, if you know the organism code it! Default code = 486 Pneumonia, unspecified organism 480- Viral pneumonia 481 Pneumococcal pneumonia (includes lobar) 482- Other bacterial pneumonia 483- Pneumonia d/t other specified organism 484- Pneumonia in infectious disease classified elsewhere 485 Bronchopneumonia, organism unspecified 507.0 Aspiration pneumonia d/t inhalation food/vomitus

COPD - 496 This code is not to be used with any code from categories 491.- 493. (bronchitis, emphysema, asthma) COPD w/emphysema 492.8 COPD w/bronchitis: Acute 491.22 Chronic 491.20 COPD w/exacerbation 491.21

Other Diseases of the Lung – 518.8- Acute respiratory failure - can develop quickly and may require emergency treatment and is usually treated in an intensive care unit Acute respiratory insufficiency - condition in which the lungs cannot take in sufficient oxygen or expel sufficient carbon dioxide to meet the needs of the cells of the body. Chronic respiratory failure - develops more slowly and lasts longer. Chronic respiratory failure can be treated at home or at a long-term care center Acute on chronic respiratory failure – pt exhibits severe pulmonary impairment as a baseline characteristic which may require hospitalization and mechanical ventilation

Diseases of the Digestive System National Cancer Institute ICD-9 to ICD-10 Prep 07-01-14

Esophageal Reflux Disease 530.81 Esophageal reflux/GERD Includes acid reflux Excludes reflux esophagitis 530.11 Excludes hemorrhage d/t esophageal varices 456 Esophageal w/esophagitis 530.11

Constipation 564.0- Constipation 564.1 Irritable bowel syndrome Slow transit - there is a prolonged delay in the transit of stool through the colon. Outlet dysfunction - difficulty or inability to expel the stool Other – atonic, neurogenic, spastic 564.1 Irritable bowel syndrome sometimes alternating bouts of constipation and diarrhea

Gastrointestinal Hemorrhage 578.0 Hematemesis – vomiting of blood 578.1 Blood in stool – melena 578.9 Hemorrhage of GI tract, unspecified Excludes: that with mention of: diverticulitis of lg and sm intestine, diverticulosis of lg and sm intestine, gastritis and duodenitis, and stomach ulcers

Diseases of the Skin and Subcutaneous Tissue National Cancer Institute ICD-9 to ICD-10 Prep 07-01-14

Cellulitis and Abscess 682.0 Face 682.1 Neck 682.2 Trunk 682.3 Upper arm/forearm 682.4 Hand, except fingers and thumb (681.0-) 682.5 Buttock 682.6 Leg, except foot 682.7 Foot, except toes (681.1-) 682.8 Other specified sites 682.9 Unspecified site Use additional code to identify organism ICD-10 with MORE specific sites AND laterality ICD-9 to ICD-10 Prep 07-01-14

Chronic Ulcer of Skin 707.0- Pressure ulcer (elbow, upper back, lower back, hip, buttock, ankle, heel, other) 707.1- Ulcer of lower limb, except pressure ulcer (lower limb, thigh, calf, ankle, hell and midfoot, other part of ft) *code any causal condition first 707.2- Pressure ulcer stages (I-IV, unstageable) *must use this code after coding 707.0- *should NOT be using an “unspecified site” code 707.9 Causal conditions include: atherosclerosis of extremities, chronic venous HTN, DM ICD-9 to ICD-10 Prep 07-01-14

VISUAL GUIDE TO SOME FREQUENTLY SEEN SKIN PROBLEMS NCHS Coding Guidelines page 48 - 49 ICD-9 to ICD-10 Prep 07-01-14

A pressure ulcer results when there is localized damage ro the skin and underlying tissue as a result of compression between a bony prominence and an external surface. Damage is caused by the force of pressure, shear, and friction acting individually or in combination with each other. Stage I: Skin is intact with an area of nonblanching erythema. This is usually over a bony prominence. Pressure Ulcer Stage I ICD-9 to ICD-10 Prep 07-01-14

Pressure Ulcer Stage II Stage II: Partial thickness skin loss with loss of epidermis and some of the dermis. It appears as a shallow ulcer with a red-pink color. No slough or necrotic tissue is present in the base. It may also appear as an enclosed or open serum-filled blister. Pressure Ulcer Stage II ICD-9 to ICD-10 Prep 07-01-14

Pressure Ulcer Stage III Stage III: Full-thickness loss of skin with the epidermis and dermis gone and damage to or necrosis of subcutaneous tissues. Damage extends down to but not through the underlying fascia. Subcutaneous fat may be visible, but muscle, tendon, or bone is not seen. Tunneling or undermining may be present. Pressure Ulcer Stage III ICD-9 to ICD-10 Prep 07-01-14

Pressure Ulcer Stage IV Stage IV: Full-thickness loss of skin with extensive destruction, tissue necrosis. And damage to bone, muscle or other supporting structures that are exposed. Pressure Ulcer Stage IV ICD-9 to ICD-10 Prep 07-01-14

Suspected Deep Tissue Injury Suspected Deep Tissue Injury: Area of localized, discolored intact skin that is purple or maroon-red in color. It may also appear as a blood filled blister resulting from damage to underlying soft tissue. Preceding skin changes may include skin that is painful, firm, boggy or that has a different temperature compared to the surrounding skin. Suspected Deep Tissue Injury ICD-9 to ICD-10 Prep 07-01-14

Unstageable Pressure Ulcer Unstageable Pressure Ulcer: Full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed. Unstageable Pressure Ulcer ICD-9 to ICD-10 Prep 07-01-14

Diabetic foot ulcers occur as a result of various factors, such as mechanical changes in conformation of the bony architecture of the foot, peripheral neuropathy, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the diabetic population. Nonenzymatic glycosylation predisposes ligaments to stiffness. Neuropathy causes loss of protective sensation and loss of coordination of muscle groups in the foot and leg, both of which increase mechanical stresses during ambulation. Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States, with approximately 5% of diabetics developing foot ulcers each year and 1% requiring amputations. Physical examination of the extremity having a diabetic ulcer can be divided into examination of the ulcer and the general condition of the extremity, assessment of the possibility of vascular insufficiency, and assessment for the possibility of peripheral neuropathy. A vascular surgeon and/or podiatric surgeon should evaluate all patients with diabetic foot ulcers so as to determine the need for debridement, revisional surgery on bony architecture, vascular reconstruction, or soft tissue coverage. Diabetic Ulcer ICD-9 to ICD-10 Prep 07-01-14

Vascular Ulcers Vascular Ulcers: A skin ulcer is a type of wound that develops on the skin. A venous skin ulcer is a shallow wound that occurs when the leg veins don't return blood back toward the heart the way they should. This is called venous insufficiency. See a picture of abnormal blood flow caused by venous insufficiency. These ulcers usually form on the sides of the lower leg, above the ankle and below the calf. Venous skin ulcers are slow to heal and often come back if you don't take steps to prevent them. ICD-9 to ICD-10 Prep 07-01-14

Cellulitis is a common bacterial skin infection Cellulitis is a common bacterial skin infection. Cellulitis may first appear as a red, swollen area that feels hot and tender to the touch. The redness and swelling often spread rapidly. Cellulitis is usually painful. In most cases, the skin on the lower legs is affected, although the infection can occur anywhere on the body or face. Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds, intravenous drug injection sites or sites of intravenous catheter insertion. Cellulitis ICD-9 to ICD-10 Prep 07-01-14

Diseases of the Musculoskeletal System and Connective Tissue ICD-9 to ICD-10 Prep 07-01-14

Arthropathy vs. Arthritis vs. Osteoarthritis Arthropathy = disease of the joints Arthritis = inflammation of the joints Osteoarthritis = degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth *Arthritis is a form of Arthropathy

Osteoarthritis/OA Arthropathy/DJD 715.0- Osteoarthrosis, generalized 715.1- Osteoarthrosis, localized, primary 715.2- Osteoarthrosis, localized, secondary 715.3- Osteoarthrosis, localized, not specified whetehr primary or secondary 715.8- Osteoarthrosis involving, or with mention of more than one site/polyarthritis 715.9- Osteoarthrosis, unspecified whether generalized or localized

5th digits for Osteoarthrosis 0 – site unspecified 1 – shoulder region 2 – upper arm *use for elbow 3 – forearm *use for wrist 4 – hand 5 – pelvic region and thigh *use for hip 6 – lower leg *use for knee 7 – ankle and foot 8 – other specified sites 9 – multiple sites

Other Derangement of Joint 718.1- Loose body in joint *Loose bodies are fragments of bone and/or cartilage that freely float in the joint space 718.3- Recurrent dislocation of joint 718.4- Contracture of joint *a permanent shortening of a joint 718.5- Ankylosis of joint *stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease 718.8- Other joint derangement, NEC *instability of joint

Osteoporosis 733.00 Osteoporosis, unspecified 733.01 Senile osteoporosis *a geriatric syndrome with a particular pathophysiology 733.03 Disuse osteoporosis *bone loss that results from not enough stress or pressure on the bones. Bones become brittle and weak, causing them to fracture easily. Use additional code to identify personal hx of pathologic fracture V13.51

Definition of Terms Spontaneous rupture Fragility fracture Occurs when normal force is applied to tissues that are inferred to have less than normal strength Fragility fracture Sustained with trauma no more than a fall from a standing height or less occurring under circumstances that would not cause a fracture in a normal healthy bone ICD-9 to ICD-10 Prep 07-01-14

Pathologic Fracture 733.11 Pathologic fracture of humerus 733.12 Pathologic fracture of distal radius/ulna 733.13 Pathologic fracture of vertebrae 733.14 Pathologic fracture of neck of femur Includes chronic fracture, spontaneous fracture Excludes stress fracture, traumatic fracture

Other and Unspecified Disorders of Joint/Gait disorders 719.7 Difficulty in walking 781.2 Abnormality of gait/ataxic/gait disturbance/paralytic/spastic/staggering gait

Other Disorders of the Back 724.1 Pain in thoracic spine 724.2 Lumbago/low back pain/lumbalgia 724.3 Sciatica *neuralgia or neuritis of sciatic nerve 724.5 Backache

Muscle Weakness/ Muscle Wasting and Disuse Atrophy 728.87 Muscle weakness (generalized) *different than generalized weakness/malaise and fatigue 780.79 728.2 Muscular wasting and disuse atrophy 728.3 Other specific muscle disorders

Diseases of the Genitourinary System National Cancer Institute Alan Hoofring ICD-9 to ICD-10 Prep 07-01-14

Acute and Chronic Kidney Failure 584.- Acute kidney failure - develops rapidly over a few hours or a few days, can be fatal and requires intensive treatment. Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care. 585.- Chronic kidney disease/CKD 4th digit for stage ESRD is 585.6 *includes stage V requiring dialysis *code first any associated condition: diabetic chronic kidney disease 250.4- hypertensive chronic kidney disease 403.-, 404.- 586 Renal failure, unspecified Acute kidney failure is the rapid  loss of your kidneys' ability to remove waste and help balance fluids and electrolytes in your body. In this case, rapid means less than 2 days. There are many possible causes of kidney damage. They include: Acute tubular necrosis (ATN) Autoimmune kidney disease Blood clot from cholesterol (cholesterol emboli) Decreased blood flow due to very low blood pressure, which can result from: Burns Dehydration Hemorrhage Injury Septic shock Serious illness Surgery Disorders that cause clotting within the kidney's blood vessels Infections that directly injure the kidney, such as: Acute pyelonephritis Septicemia Urinary tract blockage *usually, you have to stay overnight in the hospital for treatment. ICD-9 to ICD-10 Prep 07-01-14

Stages of Chronic Kidney Disease/CKD CKD, Stage 1 585.1/N18.1 CKD, Stage 2 (mild) 585.2/N18.2 CKD, Stage 3 (moderate) 585.3/N18.3 CKD, Stage 4 (severe) 585.4/N18.4 CKD, Stage 5 585.5/N18.5 End Stage Renal Disease (CKD requiring chronic dialysis) 585.6/N18.6 ICD 10 classifies CKD based on severity. The severity of CKD is designated by stages 1 – 5, and ESRD. N18.6 or ESRD is coded when the provider has documented end-stage renal disease (ESRD) If both the stage of the CKD and ESRD are documented assign code N18.6. If the patient is on renal dialysis the appropriate code is N18.6 ICD-9 to ICD-10 Prep 07-01-14

CKD and Kidney Transplant Status Following kidney transplant, a patient may continue to have some form of CKD, because the kidney transplant may not fully restore kidney function. The presence of CKD alone does not constitute a transplant complication. Assign the appropriate code for the stage of CKD & code kidney transplant status. ICD-9 to ICD-10 Prep 07-01-14

Urinary Tract Infection 599.0 is the code for site not specified, if site is known this would be an incorrect code: -bladder – see cystitis -kidney – see infection, kidney -urethra – see urethritis Use additional code to identify organism, if known B95-B97 = bacterial or viral infectious agent ICD-9 to ICD-10 Prep 07-01-14

Hyperplasia/Enlarged Prostate Includes BPH 600.0- Subcategories for enlarged and nodular: 600.00 Enlarged prostate without lower urinary tract symptoms/LUTS (incomplete bladder emptying, nocturia, straining on urination, urinary freq, urinary hesitancy, urinary incont, urinary obstruction, urinary retention, urinary urgency weak urinary stream) 600.01 Enlarged prostate with LUTS 600.10 Nodular prostate without LUTS * 600.11 Nodular prostate with LUTS * *a nodular = a "bump" that can be felt in the prostate BPH, NOS = N40.0 LUTS = lower urinary tract symptoms *if symptoms, note to use additional code for associated symptoms, if specified -incomplete bladder emptying, nocturia, straining on urination, urinary freq, urinary hesitancy, urinary incont, urinary obstruction, urinary retention, urinary urgency weak urinary stream ICD-9 to ICD-10 Prep 07-01-14

Symptoms, Signs and Abnormal Clinical and Laboratory Findings ICD-9 to ICD-10 Prep 07-01-14

Codes Used For a No more specific diagnosis can be made even after all facts have been investigated b Signs or symptoms existing at time of initial encounter - transient and causes not determined c Provisional diagnosis in patient failing to return d Referred elsewhere before diagnosis made e More precise diagnosis not available f Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right

Signs and symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the code book. Examples: SOB in COPD Edema in CHF Fever in strep throat Urinary urgency in UTI In LTC, often symptoms are used as therapy treatment diagnoses. Code as long as therapy is treating.

Superficial injuries, such as abrasions or contusions are not coded when associated with more severe injuries of the same site. ICD-9 to ICD-10 Prep 07-01-14

Coding from Lab/X-Ray Reports Attending physician must document the significance of any abnormal finding Can use lab/x-ray reports to further define documented diagnoses, but not to code a new diagnosis when the provider has not documented

Common Signs and Symptoms 780.2 Syncope and collapse/fainting 780.79 Other malaise and fatigue/gen. weakness 799.3 Debility *weak and feeble 780.96 Generalized pain *site? 780.97 Altered mental status *on ER report 780.99 Other general symptoms *?? 783.7 Adult failure to thrive *a descriptive, non-specific term that encompasses "not doing well" 782.3 Edema *is the s/s code approx. or should we be coding the dx that caused it? Is s/s code giving more specific pertinent info about the pt? ICD-9 to ICD-10 Prep 07-01-14

Common Signs and Symptoms -2 786.05 Shortness of breath 786.2 Cough 787.01 Nausea with vomiting *is the s/s code approx. or should we be coding the dx that caused it? Is s/s code giving more specific pertinent info about the pt? ICD-9 to ICD-10 Prep 07-01-14

Insomnia 780.50 Sleep disturbance, unspecified 780.51 Insomnia with sleep apnea, unspecified 780.52 Insomnia, unspecified 780.57 Unspecified sleep apnea 327.01 Insomnia d/t medical condition classified elsewhere *code first underlying condition

Common Therapy Treatment Diagnoses 781.2 Abnormality of gait *excludes ataxic gait, difficulty walking 781.3 Lack of coordination/muscular incoordination 781.92 Abnormal posture 784.3 Aphasia *if following CVA, code 438.11 784.60 Symbolic dysfunction may experience a lack of ability to initiate and/or terminate a conversation, as well as difficulty with other forms of communication 787.2- Dysphagia *identify phase of dysphagia after eval *if d/t CVA, code first 438.82 799.52 Cognitive communication deficit *and characteristic that acts as a barrier to the cognition process

Factors Influencing Health Status & Contact with Health Services ICD-9 to ICD-10 Prep 07-01-14

Amputations Traumatic = due to an incident An amputation not identified as partial or complete should be coded to complete Use the appropriate 7th character: “D” subsequent encounter “S” sequela If acquired amputation, go to Absence, by site, acquired (Z89) Need emergency room doc to determine amputation status, if traumatic ICD-9 to ICD-10 Prep 07-01-14

Acute Fractures vs. Aftercare Traumatic fractures are coded using the acute fracture codes (800-829) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. Fractures are coded using the aftercare codes (V54) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.

V Codes Represent reasons for encounters When person who may or may not be sick encounters health services for some specific purpose, i.e. to receive limited care or service for current condition, donate an organ or tissue, receive prophylactic vaccination, discuss problem When some circumstance or problem is present which influences person’s health status but is not a current illness or injury

V Codes Represent Reasons for Encounters Identify significant past health histories Identify services provided following an acute care episode Identify services related to the provision of aftercare Identify delivery of specific healthcare services: screening, tests & vaccinations Identify presence of problem influencing health status but which is not a current illness (history of)

Use of V Codes in any Healthcare Setting V codes are for use in any healthcare setting V codes may be used as either first-listed or secondary diagnosis, depending on the circumstances of the encounter Certain V codes may only be used as first-listed or principal diagnosis *See the Official Coding Guidelines for a list of these codes I.C.21.c.16. Z codes are NOT procedure codes, but indicate when aftercare is being given for a procedure recently done ICD-9 to ICD-10 Prep 07-01-14

Categories of V Codes There are numerous categories for V Codes We will define the categories most frequently seen in post-acute care We will explore examples of the common codes from frequently used categories in LTC. We will practice coding conditions found in this chapter.

V01 Contact / Exposure These codes are for patients who do not show any signs or symptoms of a disease but are suspected to have been exposed to it by close personal contact or are in an area where a disease is epidemic. This category also indicates contact with and suspected exposures hazardous to health *may be used as a first-listed or secondary code

V03 – V06 Inoculations and Vaccinations Codes are for encounters for inoculations and vaccinations It indicates that a patient is being seen to receive a prophylactic inoculation against a disease There is only one code for inoculations, and if coded, need an additional procedure code to identify the vaccine We don’t usually code these, but you could ICD-9 to ICD-10 Prep 07-01-14

Status Codes Status codes indicate that a patient is either a carrier of a disease or has the residual of a past disease or condition Includes presence of prosthetic or mechanical devices resulting from past treatment A status code is informative, because the status may affect the course of treatment or its outcome A status code is distinct from a history code (history code indicates that patient no longer has the condition)

Resistance to Antimicrobial Drugs V09 NOTE: The codes in this category are provided for use as additional codes to identify the resistance and non responsiveness of a condition to antimicrobial drugs. Exclude 1: Code first the infection: MRSA infections (038.12) MSSA infections (038.11) MRSA pneumonia (482.42)

Carrier of Infectious Disease/V02 V02 Carrier of Infectious Disease Colonization status Suspected carrier Example: V02.54 Carrier or (suspected) carrier of Methicillin resistant Staphylococcus aureus MRSA colonization Carrier = person that harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection Carrier = person that harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection ICD-9 to ICD-10 Prep 07-01-14

Long Term (current) Drug Therapy V58.6- Codes from this category indicate a patient’s continued use of a prescribed drug for the long term treatment of a condition or for prophylactic use. Not used for patients with addictions to drugs Used for patients receiving a medication for an extended period of time There is no definition of “Extended period of time” However, codes in this category are not used for short term conditions. Example: LT current use of antibiotics would not be used to treat the normal course of an infection ICD-9 to ICD-10 Prep 07-01-14

Long Term (current) Drug Therapy Includes: Long term (current) drug use for prophylactic purposes Exclude 1: Code also any therapeutic drug level monitoring (V58.83) V58.61 Long term (current) use of anticoagulants V58.66 Long term (current) use of aspirin V58.62 Long term (current) use of antibiotics V58.67 Long term (current) use of insulin Check the new drugs included and those that have been moved to this section from other sections of the ICD-9 code book. NSAIDS = non-steroidal anti-inflammatories (for pain and inflammation) Note that long term steroid use has a separate code for inhaled steroids, (those commonly used for COPD) and systemic steroids (Prednisone) LT use of insulin is NOT coded if type I DM Bisphosphonates are used to tx Osteoporosis 198 ICD-9 to ICD-10 Prep 07-01-14

V49.- Acquired Absence of Limb V45.7 Acquired Absence of Organ Examples: V49.75 Amputation status below knee V49.76 Amputation status above knee V45.71 Acquired absence breast and nipple V45.73 Acquired absence of kidney Code after tx is completed and no residual effects/sequela ICD-9 to ICD-10 Prep 07-01-14

V44 Artificial Opening Status V42 Transplanted Organ Status Examples: V44.1 Gastrostomy status V44.3 Colostomy status V44.0 Tracheostomy status V42.0 Kidney transplant status V42.5 Corneal transplant status Note that there are added cystostomy status codes at Z93.5 given medical – surgical advances. Z93 codes, only use if NO tx for these sites is being given, otherwise Z43 codes should be used to capture mgmt of these sites (cleansing, etc) ICD-9 to ICD-10 Prep 07-01-14

Organ Or Tissue Replaced By Other Means Examples: V43.1 Presence of intraocular lens (s/p cataract removal surgery) V43.64 Presence of artificial hip joint (s/p joint replacement) V43.21 Presence of heart assist device (cardiac shunt, etc.) ICD-9 to ICD-10 Prep 07-01-14

V45.- Other Postprocedural Status Examples: V45.61 Cataract extraction status V45.87 Transplant organ removal status V45.11 Dependence on renal dialysis V45.12 Noncompliance with renal dialysis V45.01 Cardiac pacemaker status ICD-9 to ICD-10 Prep 07-01-14

History (of) Two types, family and personal A history codes indicate that a patient no longer has the condition, and is no longer receiving any treatment, but has the potential for recurrence, and therefore may require continued monitoring History codes are acceptable on any medical record, as the history of an illness is important information that may alter the type of treatment ordered There is limited value to code family history in SNFs due to the age of the patients Don’t get family hx instead of personal hx – look at the tabular to confirm code! Family hx Z80-Z84 Personal hx Z85-Z87 ICD-9 to ICD-10 Prep 07-01-14

History (of), Personal V10.3 Personal history breast cancer V12.04 Personal history MRSA infection V12.51 Personal hx of venous thrombosis/embolism V13.51 Personal hx pathological fx V15.51 Personal hx traumatic fracture (healed) V15.88 Personal history of falling *at risk for falling Hx UTI Z87.440 Hx corrected cleft hlip/palate Z87.730 Hx traumatic brain injury Z87.820 - no residuals ICD-9 to ICD-10 Prep 07-01-14

History Allergy to Drugs and Other Substances Examples: V14.0 Allergy status to penicillin V14.5 Allergy status to narcotic drugs V15.01 Peanut allergy status V15.06 Insect allergy status V15.07 Latex allergy status V15.08 Radiographic dye allergy status

Personal History of Medical Treatment V87.41 Personal history of antineoplastic chemotherapy V87.43 Personal history of estrogen therapy V87.44 Personal history of inhaled steroid therapy V87.45 Personal history of systemic steroid therapy V15.3 Personal history of irradiation Women were encouraged to do estrogen therapy for menopausal symptoms; However, now women are being discouraged from taking estrogen therapy as it has become controversial. ICD-9 to ICD-10 Prep 07-01-14

Aftercare Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare V code should not be used if treatment is directed at a current, acute disease or injury. Aftercare codes are generally first listed to explain the specific reason for the encounter. This Z code category will be the most used in post acute care ICD-9 to ICD-10 Prep 07-01-14

Aftercare + Status Codes Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare or to indicate the surgery for which the aftercare is being performed Example: V58.73 Encounter for surgical aftercare following surgery on the circulatory system V45.81 Aortocoronary bypass status – “CABG” status

Aftercare Categories V55 Attention to artificial openings V54 Orthopedic aftercare V57 Care involving the use of rehabilitation procedures *code that may only be principal/first-listed dx *only use one code in this category (if > one therapy, code multiple therapy V57.89) V58 Aftercare following surgery

V55 Attention to Artificial Openings V58 Encounter for Other Aftercare V55.0 Attention to tracheostomy V55.3 Attention to colostomy *includes toileting/cleansing V58.31 Attention to surgical dressings V58.32 Attention to sutures Good code to use to show that facility is taking care of an artificial opening site Z45.018 terminology changed from ICD-9 – now includes mgmt of device – facility is managing device ICD-9 to ICD-10 Prep 07-01-14

V54 Orthopedic Aftercare V54.13 Aftercare for healing traumatic fracture of hip V54.81 Aftercare following joint replacement *Use additional code to identify the joint (V43.-) V54.82 Aftercare following explanation of joint prosthesis V54.09 Other aftercare involving internal fixation device V54.89 Other orthopedic aftercare There are separate codes to identify the aftercare for this procedure on the shoulder, hip and knee joints Note the Excludes 1 for acquired absence of joint following prior explanation of the particular joint prosthesis and joint prosthesis explanation status. Z47.81 is a new code ICD-9 to ICD-10 Prep 07-01-14

Aftercare Following Surgery for Neoplasm V58.42 Aftercare following surgery for Neoplasm *Use additional code to identify the neoplasm *If an organ was removed, in total or partial, use a code for acquired absence of the organ This code overrides the codes in category Z48.81- Encounter for surgical aftercare following surgery on a specific body system, when a tumor is removed ICD-9 to ICD-10 Prep 07-01-14

Aftercare following Surgery on Specified Body Systems V58.7- NOTE: These codes identify the body system requiring aftercare. They are for use in conjunction with other aftercare codes to fully explain the aftercare encounter. The condition treated should also be coded if still present. Excludes Aftercare following organ transplant V58.44 Excludes Aftercare following surgery for neoplasm V58.42 Note that a few of the systems have been divided in two from codes in ICD-9. The digestive system was all inclusive in ICD-9. In ICD-10 we have separate codes for surgery on the teeth and oral cavity and one for the remaining parts of the digestive system. ICD-9 to ICD-10 Prep 07-01-14

Aftercare Following Surgery to Specified Body Systems V58.71 Sense organs *conditions classifiable to 360-379, 380-389 V58.73 Circulatory system *conditions classifiable to 390-459 V58.75 Teeth, oral cavity and digestive system *conditions classifiable to 520-579 V58.78 Musculoskeletal system *conditions classifiable to 710-739 *Should not need to use V58.49 Other specified aftercare following surgery **get those operative reports!

Encounter for Care Involving Renal Dialysis and Miscellaneous V56.1 Encounter for fitting/adjustment of dialysis catheter *includes cleansing of renal dialysis catheter *Use additional code to identify the associated condition *Use additional code for current dialysis status V45.11 V66.7 Encounter for palliative care V66.2 Convalescence following chemotherapy

Procedure for Updating Codes At Quarterly Care Conference, look at facesheet and physician orders Resolve any diagnoses that are NOT current Make sure that you have MD documentation to support ALL current diagnoses in the record. Start querying MD’s for any additional documentation needed for ICD-10 (laterality, etc.) ICD-10 Confidentiality Test ICD-9 to ICD-10 Prep 07-01-14

Tips for Correct Coding Use code book! Always count the number of digits and compare with the number of digits required *use tabular listing in code book Avoid unspecified codes *Remember: payers may reject payment based on missing digits

Questions? Thanks for coming!!