Official Coding Guidelines ICD-10-CM and PCS

Official Coding Guidelines ICD-10-CM and PCS
Presented by: MONICA LEISCH, RHIA, CCS AHIMA Approved ICD-10 Trainer Director of Compliance / HIM Services Healthcare Cost Solutions, Inc. May, 2013

Disclaimer This material is designed and provided to communicate information about clinical documentation, coding and compliance in an educational format and manner. The author is not providing or offering legal advice but rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality and coding. Every reasonable effort has been taken to ensure that the educational information is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital or facility’s situation.

Introduction ICD-10-CM Official Guidelines for Coding and Reporting 2013 for Diagnoses and Procedures Will only cover significant guidelines; too lengthy for one hour to cover all

Guidelines Defined The guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD itself. Developed by The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) Based on the coding and sequencing instructions in the Tabular List and Alphabetic Index Required under the Health Insurance Portability and Accountability Act (HIPAA) CMS and NCHS are part of The US Fed Gov Department of Health and Human Services, or the DHHS.

CM vs PCS ICD-10-CM (Clinical Modification)
Morbidity classification developed by the US Classifies diagnoses and reason for visit Applicable to all health care settings Based on ICD-10 classification system published by WHO ICD-10-PCS (Procedural Coding System) Procedure classification published by the US Classifies all procedures Applicable to inpatient care setting only No such system in the ICD-10 published by WHO WHO = World Health Organization Can be used for outpatient for internal facility use only

Cooperating Parties The guidelines have been approved by the four organizations that make up the Cooperating Parties: American Hospital Association (AHA) American Health Information Management Association (AHIMA) The Federal Government represented by Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

Hierarchy In order of Precedence:
Coding Conventions of the ICD Classification Official Coding Guidelines All other, including Coding Clinic, LCDs, etc. When applying the codes, use this hierarchy

CM Organization CM guidelines are organized into sections:
Section I includes the structure and conventions of the classification and general guidelines Section II includes guidelines for selection of principal diagnosis for non-outpatient settings Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting Start with CM first; will discuss significant instructions only

Excludes Notes ICD-10-CM ICD-10-CM has two types of excludes notes.
a. Excludes 1 A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. b. Excludes 2 A type 2 excludes note represents “Not included here”. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Impending or Threatened Condition
ICD-10-CM Impending or Threatened Condition listed at time of Discharge: If confirmed, code as confirmed diagnosis. If it did not occur, check Alphabetic Index for subentry for the term impending or threatened and use that code if listed. If no subentry, code the existing underlying condition(s) and not the condition described as impending or threatened CC in I9; The example here is impending MI is coded as unstable angina; what if it is listed as impending/threatened at discharge not confirmed or did not occur

Laterality Laterality
ICD-10-CM Laterality For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality. An unspecified side 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.

Late Effects/Sequela ICD-10-CM Late Effects (Sequela)
A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect. 10 includes sequela.

BMI & Ulcers ICD-10-CM Documentation for BMI (Body Mass Index) and Ulcers for coding: Codes may be assigned from clinician, (non physician) documentation The provider responsible for the patient’s care must provide coordinating diagnosis When conflicting documentation is present, query the responsible provider BMI codes should only be secondary diagnosis codes Coding Clinic instruction included here in guidelines

Signs, Symptoms Signs and symptoms
ICD-10-CM 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 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R R99) contains many, but not all codes for symptoms.

Complication of Care Complications of care ICD-10-CM
As with all procedural or post-procedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure. Includes pain, and transplant complications, and information that complication codes that include the external cause, and complication of care codes within the body system chapters.

Borderline Diagnosis Borderline Diagnosis documented at Discharge:
ICD-10-CM Borderline Diagnosis documented at Discharge: Coded as confirmed unless the classification provides a specific entry Borderline conditions are not uncertain conditions so no distinction between inpatient and outpatient settings. If documentation is unclear, query Example here is borderline diabetes

Human Immunodeficiency Virus Infections
ICD-10-CM HIV Related Condition: Principal diagnosis is B20, HIV disease followed by addition diagnosis codes for the HIV related condition(s) HIV Unrelated Condition: Code the unrelated condition first following by B20 Asymptomatic human immunodeficiency virus Z21 is used for: no documentation of symptoms HIV positive, known HIV, HIV test positive or similar Do not use if AIDS is documented, treated for HIV-related illness or described as having any condition(s) resulting from his/her HIV positive status (use B20 instead) Patients with inconclusive HIV serology: Assign R75, Inconclusive laboratory evidence of HIV for patients with inconclusive HIV serology, for patient without definitive diagnosis or manifestations of the illness Previously diagnosed HIV – related illness: Once a patient has developed an HIV related illness, assign B20 on every subsequent admission/encounter

Sepsis/Severe Sepsis and Septic Shock
ICD-10-CM Sepsis, Severe Sepsis, and Septic Shock Sepsis: assign the appropriate code for the underlying systemic infection. Type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified. Do not assign a code from subcategory R65.2, Severe sepsis, unless severe sepsis or an associated acute organ dysfunction is documented. Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition, however, query the provider

Septic Shock Septic shock:
ICD-10-CM Septic shock: Code first the systemic infection, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Post-procedural septic shock. Add codes for other acute organ dysfunctions. The code for septic shock cannot be assigned as a principal diagnosis. Difference here is that I10 includes septic shock in the code for sepsis

Urosepsis Urosepsis Nonspecific term.
ICD-10-CM Urosepsis Nonspecific term. not to be considered synonymous with sepsis. Has no default code in the Alphabetic Index. If used, the provider must be queried for clarification.

Sequencing of Sepsis ICD-10-CM If it is present on admission and meets principal diagnosis definition: not to be considered synonymous with sepsis. Has no default code in the Alphabetic Index. If used, the provider must be queried for clarification.

Sepsis/Severe Sepsis with Infections
ICD-10-CM If sepsis is present with a localized infection: Sequence sepsis codes first List localized infections second If due to a post-procedural infection: Sequence the code for the post-procedural infection first List sepsis codes second If septic shock is documented, list second as well

Sepsis/Severe Sepsis with Non-infectious Process
ICD-10-CM If sepsis is present with a non-infectious process: If the sepsis is due to the non-infectious process, list the non-infectious process first List the sepsis codes second If the non-infectious process leads to an infection with sepsis, the infection should be listed first Code for Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin is not needed This direction is slightly different from I9

Death NOS ICD-10-CM Death NOS Code R99, Ill-defined and unknown cause of mortality, Use only, when an expired patient is brought to the ED other healthcare entity and is pronounced dead upon arrival Does not represent the discharge disposition of death.

Neoplasms General Guidelines
ICD-10-CM A primary malignant neoplasm that overlaps two or more contiguous sites should be classified to subcategory/code .8 (‘overlapping lesion’), unless the combo is specifically indexed elsewhere. For multiple neoplasms of same site, not contiguous, assign codes for each Example: tumors in different quadrants of same breast I9 does include section on neoplasms just not this info

Neoplasms General Guidelines (cont.)
ICD-10-CM Malignant neoplasms of ectopic tissue are to be coded to origin of mentioned site Example: ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9) Check the Alphabetic Index first before going to the Neoplasm Table

Neoplasms Coding & Sequencing of Complications (Anemia Associated w/ Malignancy)
ICD-10-CM When admitted for management of anemia associated with malignancy & treatment: Sequence the code for malignancy as principal Followed by appropriate code for anemia I9 anemia first, I10 anemia second

Neoplasms Coding & Sequencing of Complications (Anemia assoc
Neoplasms Coding & Sequencing of Complications (Anemia assoc. w/ therapies) ICD-10-CM Management of anemia associated with adverse effect of administration of chemotherapy or immunotherapy and treatment is only for anemia, sequence the anemia code first, followed by appropriate codes for neoplasm and adverse effect Management of anemia associated with adverse effect of radiotherapy, sequence the anemia code first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient . . .

Neoplasms Malignancy in 2 or more noncontiguous sites
ICD-10-CM In case where patient has more than one malignant tumor in the same organ, different tumors may constitute different primaries or metastatic disease, depending on site. If documentation unclear, query provider as to status so that coding is correct

Neoplasms Admission to Determine Extent of Malignancy
ICD-10-CM When the reason for admission is to determine the extent of the malignancy, list the malignancy first, even if chemotherapy or radiotherapy is administered. same

Neoplasms Sequencing of neoplasm codes (cont.)
ICD-10-CM Malignant neoplasm in pregnant patient: use code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, sequenced first, followed by appropriate code from Chapter 2 to indicate type of neoplasm

ICD-10-CM Encounter for complication associated with neoplasm: When encounter is for mgmt of complication associated w/ neoplasm and treatment is only for complication, code complication first, followed by appropriate code for neoplasm Exception: Anemia (see slide above)

ICD-10-CM When encounter is for treatment of complication resulting from surgical procedure performed for treatment of neoplasm, designate complication as principal diagnosis. (See guideline regarding the coding of current malignancy vs personal history to determine if code for neoplasm should also be assigned)

ICD-10-CM Pathologic fracture due to neoplasm If focus of treatment is the fracture, code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by neoplasm code - If focus of treatment is neoplasm with an associated pathological fracture, code neoplasm first, followed by code from M84.5 for the pathological fracture The determination here is the focus of treatment

Neoplasms Current malignancy vs. personal history of malignancy
ICD-10-CM When primary malignancy has been excised but further treatment is directed to that site, use primary malignancy code until treatment is completed Use code Z85, Personal history of malignant neoplasm, to indicate former site of malignancy once it has been excised/eradicated, there is no further treatment directed to that site, and there is no evidence of existing malignancy

Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal history ICD-10-CM Categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. There are also codes for personal history of leukemia or malignant neoplasms of hymphoid, hematopoietic and related tissues

Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal history (cont.) ICD-10-CM If it is unclear in the documentation as to whether or not the leukemia has achieved remission, query the provider. Remission must be documented in order to use that code

Malignant Neoplasm associated with Transplanted Organ
ICD-10-CM Coded as tranplant complication Assign the code for the specific malignancy second

Diabetes Diabetes Mellitus
ICD-10-CM Diabetes mellitus codes are combination codes to include type of diabetes, body system affected, and complications affecting that body system Assign as many codes within category as are necessary to describe all complications of disease I10 No longer indication of controlled or uncontrolled

Diabetes Underdose of insulin due to insulin pump failure
ICD-10-CM Assign code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal Assign T38.3x6-, Underdosing of insulin and oral hypoglycemic (antidiabetic drugs) as secondary Assign codes for type of diabetes mellitus and associated complications if appropriate I10 adds code for underdosing; note just like any other complication of a device, list the complication first, followed by the code for the underdosing

Diabetes Overdose of insulin due to insulin pump failure
ICD-10-CM Assign code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal Assign T38.3x1-, Poisoning by insulin and oral hypoglycemic drugs, accidental as secondary Again assign the code for the pump failure as pdx followed by the poisoning

Diabetes Secondary Diabetes Mellitus
ICD-10-CM Codes under categories E08, Diabetes mellitus (DM) due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, show complications and manifestations associated with secondary diabetes mellitus Secondary DM is always caused by another condition I10 has a specific code category for drug or chemical induced DM

Diabetes Assigning and sequencing secondary diabetes codes and its causes
ICD-10-CM Sequencing of 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. Same info different language

Mental & Behavioral Disorders Pain disorders related to psychological factors
ICD-10-CM Assign code F45.41, for pain that is exclusively related to psychological disorders Do not assign a code from category G89, Pain, not elsewhere classified with is code No guidance for psych pain in I9 NOTE THIS ONE IS “TO”

Mental & Behavioral Disorders Pain disorders related to psychological factors
ICD-10-CM Code 45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified if documentation shows a psychological component for a patient with acute or chronic pain I10 if pain is due to related psych factors, then this code is used and the NEC as well NOTE THIS ONE IS “WITH”

Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use
ICD-10-CM In Remission Assigned only if so documented. Selection of codes for “in remission” categories F10-F19, Mental and behavioral disorders due to psychoactive substance use Large I10 section for mental disorders for guidance

ICD-10-CM Psychoactive Substance Use, Abuse and Dependence - When provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use based on the following: Continues on next screen

ICD-10-CM Psychoactive Substance Use, Abuse and Dependence (cont.) If both use and abuse are documented, assign only the code for abuse If both abuse and dependence are documented, assign only code for dependence If use, abuse and dependence are all documented, assign only the code for dependence I10 specific definitions for use, abuse and dependence; continued on next screen

ICD-10-CM Psychoactive Substance Use, Abuse and Dependence (cont.) If both use and dependence are documented, assign only the code for dependence

ICD-10-CM Psychoactive Substance Use The codes for psychoactive substance use should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis - Codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and this relationship is documented by provider Don’t assume a relationship without documentation by the provider

Nervous System Dominant/nondominant side
ICD-10-CM Codes from G81, Hemiplegia and hemiparesis, and subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether dominant or nondominant side is affected I10 ability to report paralysis is dominant vs nondominant

Nervous System Dominant/nondominant side (cont.)
ICD-10-CM If the affected side is documented, but it is not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows: For ambidextrous pt, default should be dominant If left side is affected, default is non-dominant If right side is affected, default is dominant

Pain Reporting General Coding Info
ICD-10-CM Only assign code from category G89 if pain is specified as acute or chronic, post-thoracotomy, post-procedural, or neoplasm-related Pain codes are only assigned as principal if: Pain control or management is reason for encounter Patient is admitted for insertion of neurostimulator for pain control Not for neurostimulator insertion for definitive underlying cause. I10 excludes central pain syndrome

Circulatory System Hypertensive Heart & Chronic Kidney Disease
ICD-10-CM The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease I13 codes are combination codes that include hypertension, heart disease and chronic kidney disease Both have combo codes, but the type of hypertension(malignant, benign) is missing in I10

Circulatory System Hypertensive Heart & Chronic Kidney Disease
ICD-10-CM The Includes note at I13 specifies that the conditions included in I11 and I12 are included together in I13 If a patient has hypertension, heart disease and CKD then a code from I13 should be used rather than individual codes For patients w/ both acute renal failure and CKD an add’l code for acute renal failure is required It appears that I10 assumes a cause and effect relationship in hypertension with both heart and kidney disease

Circulatory System Hypertensive Retinopathy
ICD-10-CM Subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertension Sequence based on reason for encounter I10 does not have a code for hypertensive retinopathy but instructs to use a background retinopathy code

Circulatory System Atherosclerotic Coronary Artery Disease & Angina
ICD-10-CM Combination codes for atherosclerotic heart disease with angina pectoris When using one of these combo codes it is not necessary to use an additional code for angina If a patient with coronary artery disease is admitted due to acute myocardial infarction (AMI), sequence AMI first I10 has combo code for ASHD and angina

Circulatory System Intraoperative and Postprocedural Cerebrovascular Accident
ICD-10-CM Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on type of procedure performed CVA intraoperative vs postprocedural

Circulatory System Sequelae of Cerebrovascular Disease
ICD-10-CM Category I69 indicates conditions classifiable to categories I60-I67, as causes of sequela (neurologic deficits). These late effects include neurologic deficits that persist after initial onset of the conditions in categories I60-I67. I69 codes specify hemiplegia, hemiparesis and monoplegia; whether dominant or nondominant side affected. No default code is available. Codes from category I69 should not be assigned if the patient does not have neurologic deficits. Use the same definition for dominant vs non-dominant as before

Circulatory System Acute myocardial infarction (AMI)
ICD-10-CM For encounters ≤ 4 weeks old, including transfers to another acute setting or a postacute setting, and the patient requires continued care for MI, codes from category I21 may continue to be reported For encounters > 4 weeks old and patient is still receiving care related to MI, appropriate aftercare code should be assigned If the NSTEMI evolves to a STEMI, assign the STEMI only For old or healed MI not requiring care, code I25.2, Old myocardial infarction

Circulatory System Subsequent acute myocardial infarction
ICD-10-CM • Code from category I22, Subsequent ST elevation (STEMI) and non ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI The sequencing of the I22 and I21 codes depends on the circumstances of the encounter

Circulatory System Documentation of Ventilator Associated Pneumonia
ICD-10-CM Code J95.851, Ventilator associated pneumonia, (VAP), should be assigned only when the provider has documented VAP Add’l code to identify organism should also be assigned Do not assign add’l code from J12-J19 to identify the type of pneumonia, unless the VAP develops after admission, and the patient is admitted with pneumonia.

Pressure Ulcer Stages ICD-10-CM Codes from category L89 Pressure Ulcer, combo codes that show the ulcer as well as the stage If documented as healed, no code is assigned If documented as healing, the appropriate code for type and stage should be assigned. If the stage evolves into a higher stage, assign only the highest stage. Note in I9 this info is found in CC

Diseases of the Musculoskeletal System and Connective Tissue
ICD-10-CM Site and Laterality Site represents bone, joint or muscle For conditions where more than one, bone, joint or muscle are involved there is a multiple sites code Bone vs. joint Though the portion of bone affected may be the joint, the site designation will be the bone not the joint

Coding of Pathologic Fractures
ICD-10-CM 7th Character A is for active fracture treatment surgical ED Eval by new physician 7th Character D is used for encounters after the patient has completed active treatment Other 7th Characters are used for subsequent encounters associated with healing such as malunions, nonunions and sequelae

Chronic Kidney Disease
ICD-10-CM Stages of chronic kidney disease (CKD) Classify severity End stage renal disease with CKD is assigned with one code N18.6, which include both conditions CKD with Transplant The presence of CKD alone may not constitute a transplant complication If unclear query

Pregnancy, Childbirth, Puerperium Final character for trimester
ICD-10-CM Majority of Ch 15 codes have a final character indicating trimester of pregnancy Where trimester isn’t part of the code it is because the condition always occurs in a specific trimester I9 does not include trimester specificity – continues on next screen

ICD-10-CM Final trimester codes also apply for pre-existing conditions and those that develop during or are caused by the pregnancy If delivery occurs during the current admission and there is an “in childbirth” option for the obstetric complication, the “in childbirth” code should be assigned same

ICD-10-CM If a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into the next trimester, the trimester character for the antepartum complication code should be assigned based on the trimester when the complication developed rather than trimester of discharge The unspecified trimester should not be used; obtain further clarification Trimester assigned to when the complication developed, not the one at discharge, also continued on next page

Pregnancy, Childbirth, Puerperium 7th character Fetus Identification
ICD-10-CM If applicable, a 7th character should be assigned for certain categories to identify the fetus for which the complication code applies Assign 7th character “0”: For singe gestations When the documentation in the record is insufficient to determine the fetus affected When it is not possible to clinically determine which fetus is affected I10 differs in not having a separate code for “outcome” of delivery (V27) included in the 7th character

Pregnancy, Childbirth, Puerperium Pre-existing conditions vs
Pregnancy, Childbirth, Puerperium Pre-existing conditions vs. conditions due to pregnancy ICD-10-CM Certain categories in Chapter 15 distinguish between conditions of the mother than existed prior to pregnancy and those that are a direct result of the pregnancy For categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either Same as I9, but not listed in their guidelines.

Pregnancy, Childbirth, Puerperium Gestational (pregnancy induced) diabetes
ICD-10-CM Gestational (Pregnancy Induced) diabetes Codes under subcategory O24.4 include diet controlled and insulin controlled If gestational diabetes is treated with both diet and insulin, only code insulin-controlled Code Z79.4, Long-term (current) use of insulin, should not be assigned with codes from subcategory O24.4 Abnormal glucose tolerance in pregnancy is assigned a code from subcategory O99.81, Abnormal glucose complicating pregnancy, childbirth, and the puerperium I9 codes only for gestational DM vs I10 has codes for both diet controlled and insulin controlled

Pregnancy, Childbirth, Puerperium Alcohol, tobacco use during pregnancy, childbirth and the puerperium ICD-10-CM Subcategory O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium - assigned when a mother uses alcohol during the pregnancy or postpartum Also assign a secondary code from category F10, Alcohol related disorders, to identify manifestations of alcohol use I9 has same instruction, just not in the guidelines

Pregnancy, Childbirth, Puerperium Alcohol, tobacco use during pregnancy, childbirth and the puerperium ICD-10-CM Subcategory O99.33, Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium - assign when a mother uses any type of tobacco product during the pregnancy or postpartum Also assign a secondary code from category F17, Nicotine dependence, or code Z72.0, Tobacco use, to identify the type of nicotine dependence I9 only reports one code for this, as it does not have codes for nicotine dependence.

Pregnancy, Childbirth, Puerperium Poisoning, toxic effects, adverse effects and underdosing in a pregnant patient ICD-10-CM Subcategory O9A.2, Injury, poisoning and certain other consequences of external causes complicating pregnancy, childbirth, and puerperium, is sequenced first Next assign the appropriate injury, poisoning, toxic effect, adverse effect or underdosing code Then assign additional code(s) that specifies the condition causing poisoning, toxic effect, adverse effect or underdosing Same guideline, I10 uses terminology of “underdosing”

Pregnancy, Childbirth, Puerperium Pregnancy associated cardiomyopathy
ICD-10-CM Pregnancy associated cardiomyopathy, code O90.3, is unique in that it may be diagnosed in the 3rd trimester of pregnancy but may continue to progress months after delivery As such, it is referred to as peripartum cardiomyopathy Code O90.3 is only for use when the cardiomyopathy develops as a result of pregnancy in a woman who did not have pre-existing heart disease I9 does not have this code; requires 2, cardiovascular disease in pregnancy, and cardiomyopathy code.

Sequelae of complication of Pregnancy, Childbirth, and the Puerperium
ICD-10-CM Use code O94 in cases when an initial complication of pregnancy develops a sequelae requiring care or treatment at a future date The sequela code is sequenced following the code for the complication

Abuse in a Pregnant Patient
ICD-10-CM Suspected or confirmed cases of abuse in a pregnant patient are coded from subcategories O9A.3, Sexual abuse complicating pregnancy, childbirth and the puerperium, and O9a.5, Psychological abuse complicating pregnancy, childbirth, and the puerperium See also Section I.C.19, Adult and child abuse, neglect and other maltreatment

NewBorns Conditions Originating in the Perinatal Period
ICD-10-CM Principal Diagnosis for the Birth Record Assign a code from category Z38, Liveborn infants according to place of birth and type of delivery as principal diagnosis for the birth episode A code from category Z38 should only be used once This code is the same as the ICD-9 V30 series

Newborns Use of Codes from other Chapters
ICD-10-CM Codes from other chapters may be used w/ codes from chapter 16 if the codes from the other chapters provide more specific detail If the reason for the encounter is a perinatal condition, the code from chapter 16 should be principal I9 instructs to use code , specified conditions originating in the perinatal period, if no specific code is found in the index; I10 use additional codes with the newborn codes

Newborns Low birth weight and immaturity status
ICD-10-CM Codes from category P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, are for use for a child or adult who was premature or had low birth weight as a newborn newborn and this is affecting the patient’s current health Same as I9

Newborns Bacterial Sepsis of Newborn
ICD-10-CM Category P36, Bacterial sepsis of newborn, includes congenital sepsis. If a perinate is documented as having sepsis w/o documentation of congenital or community acquired, the default is congenital & a code from category P36 should be assigned I10 specifies congenital sepsis as the default if the infection is not listed as congenital or community acquired

Newborns Bacterial Sepsis of Newborn
ICD-10-CM If the P36 code includes the causal organism, an add’l code from category B95 or B96 should not be assigned If the P36 code does not include the causal organism, assign an add’l code from category B96 I10 specific codes for newborn sepsis with some specifying the organism.

Newborns Stillbirth ICD-10-CM Code P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirth No other code should be used with P95 P95 should not be used on the mother’s record I9 has no specific code for stillbirth, outcome only

Coma Scale ICD-10-CM The coma scale codes are used in conjunction with traumatic brain injury codes, acute cerebrovascular disease and cerebrovascular disease codes. The 7th character indicates when the scale was recorded At a minimum report the initial score documented on presentation Assign R40.24, Glasgow coma scale, total score, when only the total score is documented Coma scale is not assigned in I9

Injuries Application of 7th Characters
ICD-10-CM Most categories in chapter 19 have a 7th character requirement for each applicable code Most categories have three 7th character values (exception: fracture): A, initial encounter D, subsequent encounter S, sequela I10 7th character designation

ICD-10-CM 7th character “A”, intial encounter is used while the patient is receiving active treatment for the condition Examples: Surgical treatment ED encounter Evaluation and treatment by a new physician

ICD-10-CM 7th character “D”, subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during healing/recovery phase Examples: Cast change or removal Removal of external or internal fixation device Medication adjustment Care during the healing process

ICD-10-CM 7th character “S,” sequela, is for use for complications or conditions that arise as a direct result of a condition, such as a scar formation after a burn When using “S,” it is necessary to use both the injury code that precipitated the sequela and the sequela itself Add “S” only to the injury code, not the sequela code

ICD-10-CM Aftercare Z codes should not be used for aftercare conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care Example: for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter) Z codes not for injuries and poisoning, use D for those

Injuries Coding of Traumatic Fractures
ICD-10-CM A fracture not indicated as open or closed should be coded to closed A fracture not indicated whether displaced or not displaced should be coded to not displaced Same as I9 just not in the guidelines

Injuries Initial vs. Subsequent Encounter for Fractures
ICD-10-CM When patient is receiving active treatment for fracture, traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) continues on next screen

Injuries Initial vs. Subsequent Encounter for Fractures
ICD-10-CM For encounters after the patient has completed active treatment and is receiving routine care during the healing/recovery phase, fractures are coded with appropriate 7th character for subsequent care Same, 7th character difference in I10

Injuries Coding of Burns and Corrosions
ICD-10-CM Distinction between burns and corrosions Burn codes are for thermal burns, except sunburns, that come from a heat source or burns resulting from electricity and radiation Corrosions are burns due to chemicals Guidelines are the same for both Non-healing burns are coded as acute burns I10 has different codes for thermal burn vs corrosive burns

Injuries Encounters for treatment of sequela burns
ICD-10-CM Encounters for the treatment of the late effects of burns or corrosions should be coded with a burn or corrosion code with the 7th character “S” for sequela I10 does not use late effect codes, sequela 7th character instead

Injuries Adverse Effects, Poisoning, Underdosing & Toxic Effects
ICD-10-CM Codes in categories T36-T65 are combination codes that include substance that was taken as well as the intent Do not code directly from Table of Drugs; refer back to Tabular List If the same code would describe the causative agent for more than one adverse reaction, toxic effect or underdosing, assign the code only once I10 has combo code for substance taken and intent

Injuries Adverse Effect
ICD-10-CM When drug was correctly prescribed and properly administered, assign appropriate code for nature of adverse effect followed by code for the adverse effect of the drug (T36-T50) Code for the drug should have 5th or 6th character of 5 5th/6th character of 5, (signifying adverse effect)

Injuries Poisoning Codes
ICD-10-CM Assign code from categories T36-T50 first Poisoning codes have an associated intent as their 5th or 6th character Use additional code(s) for all manifestations of poisonings Follow with abuse or dependence code, if applicable I10 include intent in the 5th/6th character

Injuries Underdosing ICD-10-CM Underdosing refers to taking less of a medication than is prescribed by a provider For underdosing, assign code from T36-T50 (5th or 6th character “6”) Codes for underdosing should not be listed first Specific instructions in I10, found in CC in I9 both poisoning, but I10 uses underdosing – continues on next screen

Injuries Underdosing ICD-10-CM If a patient has a relapse of the medical condition for which drug is prescribed because of underdosing, the medical condition itself should be coded Noncompliance (Z91.12-Z91.13-) or complication of care (Y63.8-Y63.9) codes are to be used with an underdosing code to indicate intent, if known

Injuries Complications of Care: Complication codes that include the external cause
ICD-10-CM As with some other T codes, some of the complications of care codes have the external cause included in the code The code includes the nature of the complication as well as the type of procedure that caused the complication No external cause code indicating the type of procedure is necessary for these codes I10 includes combo codes and difference here is that code for type of procedure is not necessary

External Causes of Morbidity Introduction
ICD-10-CM Codes V01-Y99 are provided for the reporting of external causes of morbidity Always secondary codes I10 V & Y codes same as I9 E codes

Injuries Complications of Care: Complication codes within the body system chapters
ICD-10-CM Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system These codes should be sequenced first, followed by a code(s) for the specific complication found in the body system chapters

External Causes of Morbidity General External Cause Coding Guidelines
ICD-10-CM An external cause code may be used with any code in the range A00.0-T88.9, Z00-Z99, classification that is a health condition due to an external cause I10 specifies health condition

External Causes of Morbidity General External Cause Coding Guidelines
ICD-10-CM Mostly applicable to injuries Also valid for infections or diseases due to an external source, and other health conditions, such as a heart attack that occurs during strenuous physical activity I10 gives the examples found in I9 CC

External Causes of Morbidity Length of Treatment
ICD-10-CM Assign the external cause code with the appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated Difference is the 7th character in I10

External Causes of Morbidity Combination external cause codes
ICD-10-CM Some external cause codes are combination codes that identify sequential events that result in an injury, such as a fall which results in striking against an object Assign regardless of seriousness of injury Injury may be due to either event or both Same just in the guidelines, but I10 has more combo codes

External Causes of Morbidity Place of Occurrence Guideline
ICD-10-CM Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify location of patient at time of injury/condition Place of occurrence used at initial encounter w/ no 7th character Similar, note the initial encounter uses no 7th character

External Causes of Morbidity Unknown or Undetermined Intent Guideline
ICD-10-CM If the intent of the cause of injury/other condition is unknown or unspecified, code intent as accidental. External cause codes for events of undetermined intent are only for use if the documentation in the record specifies that the intent cannot be determined I10 must be stated as undetermined in order to use the undetermined cause code

Factors Influencing Health Status Aftercare
ICD-10-CM Aftercare Z codes should not be used for aftercare for injuries. Use Z codes for care following treatment For aftercare of an injury, assign the acute injury code with the appropriate 7th character for subsequent encounter Difference I10 uses 7th character to designate aftercare, no separate code is needed as in I9

Factors Influencing Health Status “With” or “without” abnormal findings
ICD-10-CM Some codes for routine health exams distinguish between “with” and “without” abnormal findings Code assignment depends on info known at the time encounter is being coded E.g. if no abnormal findings were found during exam, but test results are not in at time of coding, assign code for “without abnormal findings” When assigning a code for “with abnormal findings,” add’l code(s) should identify specific abnormal findings Specific instruction given when to use abnormal vs normal findings codes – continues on the next screen

Outpatient Coding Guidelines Encounters for medical exams w/ abnormal findings
ICD-10-CM The subcategories for encounters for general medications, Z00.0-, provide codes for with and without abnormal findings Should a general medical exam result in an abnormal finding, the code for general medical examination with abnormal finding should be first-listed diagnosis A secondary code for the abnormal finding should also be coded Specific instruction given when to use abnormal vs normal findings codes

PCS Organization Conventions Medical and Surgical Section Guidelines
ICD-10-PCS Conventions Medical and Surgical Section Guidelines Body System Root Operation Body Part Approach Device Obstetrics Section Guidelines

PCS Conventions ICD-10-PCS Composed of 7 characters
Characters = numbers 0 through 9 and alpha except I and O The valid values for an axis of classification can be added as needed The meaning of any single value is a combination of its axis of classification and any preceding values With expansion more values will depend on the preceding value

PCS Conventions continued
ICD-10-PCS Alphabetic index provides for location table necessary to construct code Code may be chosen from the table, (the alpha index does not need to be consulted first) All seven characters must be specified to be a valid code Within a PCS table, valid codes include all combinations of choices for characters 4 through 7 The term “And” means “and/or” It is the coder’s responsibility to determine which code to choose from the documentation

Device General Guidelines -change -irrigation
ICD-10-PCS General Guidelines Coded only if it remains after procedure is coded Sutures, ligature, radiological markers an temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices Procedures performed on a device only and not on a body part are specified in the root operations: -change -irrigation -removal -revision Due to lengthy, only will discuss device from the med/surg section

Obstetrics Section ICD-10-PCS Productions of conception
Procedures performed on the products of conception are coded to the obstetrics section Procedures following delivery or abortion All coded 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 coded in the Medical and Surgical section.

Summary and Questions Questions?
The ICD-10 Official Guidelines mirror the ICD-9 Official Guidelines in most cases ICD-10 Official Guidelines contain ICD-9 Coding Clinic Guidelines Questions?

References: ICD-10-CM Official Guidelines for Coding and Reporting 2013 ICD-10-PCS Official Guidelines for Coding and Reporting 2013

Official Coding Guidelines ICD-10-CM and PCS

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Official Coding Guidelines ICD-10-CM and PCS

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