1. Implementation of ICD-10 Joining the Rest of the World in Coding
Jill Young - CPC, CEDC, CIMC
Young Medical Consulting, LLC
East Lansing, Michigan

2. Disclaimer
This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion

3. ICD
International
Classification of
Diseases

4. Purpose of ICD
Transforming documentation into numeric or alphanumeric designations
Diseases
Injuries
Procedures
Designations are grouped into manageable categories

5. Purpose of ICD A variety of healthcare reporting functions
Not just for reimbursement purposes
Intended as a tool to study outcomes and improve patient care
CDC uses data ** Need accuracy**
National Hospital Discharge Survey
National Ambulatory Medical Care Survey
External Causes of Injury statistics (international)
Diagnosis coding can and does affect your patient’s lives

6. ICD in Statistical Reporting
The CDC uses clinical information for many of their studies:
Leading cause of deaths for males is heart disease – 28.7% (2001)
In 2003 health care expenditures for heart disease and stroke was projected to be $209 billion
Information for consumers and physicians
Most prevalent diseases
Average length of stay
Widely used treatments

7. ICD-9 is obsolete
Developed in early 1970s and has been in use since 1979
Many of the clinical and procedure concepts no longer meet today’s healthcare needs
The U.S. is the only developed country that has yet to adopt ICD-10 for morbidity/mortality classification
No longer supported by the WHO and therefore cannot be significantly modified
ICD9 was developed nearly 30 years ago and cannot accurately describe the diagnoses and inpatient procedures of car delivered in the 21st century

8. More bad news for ICD-9 The system does not comply with:
HIPAA code set standardization
BIPA (Benefits Improvement and Protection Act of 2000) that outlines new services and technology that must be acknowledged in CMS payment systems

9. Details of Implementation
October 1, October 1, 2014
Exacting date for physician and ambulatory services
Date of discharge for inpatient setting
ICD-9-CM codes not accepted for new claims for dates of service * on or after October 1, October 1, 2014
Except discharge as above
ICD-9-CM will still exist to allow claims completion
Unknown how long ICD-9 allowed

10. Comparison ICD‐9‐CM ICD‐10‐CM 3‐5 digits 3‐7 digits
Digits 2-5 are numeric
Alpha V and E codes
Lacks laterality
ICD‐10‐CM
3‐7 digits
Digit 1 is Alpha
Digit 2 and 3 are numeric
Digit 5‐7 are alpha or numeric

11. The Need for ICD-10
Billing and reimbursement specificity more manageable
No room for new codes
Shortage of rubrics
Diagnostic and statistical Manual of Mental Disorders
DSM IV
Chapter 2 (Neoplasms) and morphology codes correspond to ICD-O-2
Cancer registry programs have used since 1995
Misclassifications

12. Misclassifications - Urosepsis
Dorland’s - a term used imprecisely to denote infection ranging from urinary tract infection to generalized sepsis which may result from such infection
Providers – UTI with sepsis
ICD-9 code- without clarification codes to UTI
ICD-10 – “code to condition”

13. ICD-10-CM Guidelines 2013
Adherence to these guidelines when assigning ICD- 10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).
The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.

14. ICD-10-CM Guidelines 2013
A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported.

15. 1995 & E&M Guidelines
If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
Appropriate health risk factors should be identified.
The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

16. 1995 E&M
For a presenting problem with an established diagnosis the record should reflect whether the problem is:
a) improved, well controlled, resolving or resolved; or,
b) inadequately controlled, worsening, or failing to change as expected.
Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.

17. ICD-10-CM Guidelines 2013
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.

18. Poor Preparation Consequences
Increased delays in processing authorizations and reimbursement claims
Improper claims payment
Coding backlogs
Compliance issues
Decisions based on inaccurate data
Problems can be mitigated with proper advance preparation

19. Other Concerns Claims processing Laboratory & other testing
Will there be a significant increase in rejections, pended or appealed claims
Laboratory & other testing
What specificity is needed on order
General symptoms vs specific symptoms
Patient concerns
Change in covered benefits due to policy changes
Perceived change in coverage
Is cause the coding system’s specificity?

20. The Rand Report Implementation costs include: Future benefits include:
Training
Lost productivity during this period
System upgrades and changes
Future benefits include:
More accurate payment for new procedures
Fewer miscoded, rejected, and improperly reimbursed claims
Better understanding of the value of new procedures and outcomes
Improved disease management

22. AHIMA STUDY COMMENTS
Physicians need 5 hours of training to become proficient in ICD-10
AGREE  DISAGREE

23. ICD-10-CM Myths or Misnomers
Physicians will need to learn new system of documentation which may change the way they practice
Coding and billing staff need to start code set training
in 2014
Now
ICD-10 only works with an Electronic Medical Record system
Practices will need additional staff to handle the workload during and after the transition

24. ICD-10: Breaking it Down Disease classifications expanded 21 chapters
Health-related conditions
Greater specificity to 6 digits with 7th digit extension
21 chapters
Additional special group chapters
2 new chapters not in ICD-9
Diseases of the eye and adnexa
Disorders of the ear

25. ICD-10: Breaking it down Alphabetical Index
Organized in the same manner as ICD-9
Codes listed by “main term”
Cross-references and notes appear
Define terms
Provide direction
Provide coding instructions
3 sections
Section I- Index to diseases and nature of injury
Section II- External causes
Section III- Table of drugs and chemicals

26. ICD-10: Breaking it Down
Chapters are further divided into subchapters or “blocks”
Contain rubrics identifying closely related conditions
Each chapter contains a summary subchapter that gives an overview of each block

27. New Concepts
Excludes1
Not coded here
Excludes2
Not included here

28. Fourth Digit Classification
The 4th digit defines site, etiology, manifestation, or state of the disease or condition
Right, left, bilateral
Viral vs. bacterial
Controlled vs. uncontrolled
Primary vs. secondary
Malignant vs. benign
Congenital vs. acquired

29. Fifth & Sixth Digit Classifications
Adverse effect, Poisoning or Reaction to improper use of medication, Toxic effect
Accidental
Intentional self harm
Assault
Undetermined

30. Example
A 32 y.o. hiker was bit by a venomous spider while hiking through the woods. He began experiencing muscle weakness and syncope and was rushed to the ED by a fellow hiker, where he was diagnosed with spider venom toxicity.

31. Example T63.39 Toxic effect of venom of other spider
T Toxic effect of venom of other spider, accidental (unintentional)
T Toxic effect of venom of other spider, intentional self-harm
T Toxic effect of venom of other spider, assault
T Toxic effect of venom of other spider, undetermined

32. New Concepts Placeholder character Seventh character alpha “X”
Used as 5th and 6th character to allow for future expansion
Seventh character alpha
Burns
Initial vs subsequent vs sequela
Fractures
Initial vs subsequent
Healing vs malunion or non union

33. A Seventh character? A seventh character indicates:
A- the initial encounter
First encounter for treatment of the injury
D- subsequent encounter
May be used for as long as the patient is receiving treatment for an injury
S- sequelae
Complication or condition arising as a result of the injury

34. 7th Character Example
A 25 y.o. male presented to the emergency room after accidentally slashing his right arm with a sharp knife while cleaning a fish he caught during a Key West deep sea fishing trip. The Dx reported by the ED is laceration of the ulnar artery at the forearm, right arm
How to code the dx?

35. Laceration of Ulnar Artery at Forearm Level
Laceration - see also Wound open by site
No other specific listing
Wound
Artery – see injury, blood vessel, by site
Ulnar (artery) (vein) 903.3
903. Injury to blood vessels of upper extremity
903.3 Ulnar blood vessels

36. 7th Character Example S55 Injury of blood vessels at forearm level
Code also any associated open wound (S51.-)
Excludes2: injury of blood vessels at wrist and hand level (S65.-)
injury of brachial vessels (S45.1-S45.2)
The appropriate 7th character is to be added to each code from category S55
A - initial encounter
D - subsequent encounter
S - sequela injury of ulnar artery at forearm level, unspecified arm

37. Example S55.0 Injury of ulnar artery at forearm level
S55.00 Unspecified injury of ulnar artery at forearm level
S Unspecified injury of ulnar artery at forearm level, right arm
S Unspecified injury of ulnar artery at forearm level, left arm
S Unspecified injury of ulnar artery at forearm level, unspecified arm
S55.01 Laceration of ulnar artery at forearm level
S Laceration of ulnar artery at forearm level, right arm
S Laceration of ulnar artery at forearm level, left arm
S Laceration of ulnar artery at forearm level, unspecified arm
S55.09 Other specified injury of ulnar artery at forearm level
S Other specified injury of ulnar artery at forearm level, right arm
S Other specified injury of ulnar artery at forearm level, left arm
S Other specified injury of ulnar artery at forearm level, unspecified arm

38. ICD-10-CM Table of Neoplasms
Codes listed with a dash - following the code have a required 5th character for laterality or other location specificity.
The tabular list must be reviewed for the complete code.

39. Notes In Chapter Listing
The chapter uses the S-section for coding different types of injuries related to single body regions
T-section to covers injuries to multiple or unspecified body regions as well as poisoning and certain other consequences of external causes

40. Insect Bite – ICD-9 Insect Bite
Non-venomous
See injury, superficial, by site
919.4 Insect bite non-venomous, without mention of infection
919.5 Insect bite, non-venonomous, infected

41. Insect Bite – ICD-10
S00.06A Insect bite of scalp; Initial encounter S00.06D Insect bite of scalp; Subsequent encounter S00.269A Insect bite of unspecified eyelid and periocular area; Initial encounter S00.269D Insect bite of unspecified eyelid and periocular area; Subsequent encounter S00.36A Insect bite of nose; Initial encounter S00.36D Insect bite of nose; Subsequent encounter S00.469A Insect bite of unspecified ear; Initial encounter S00.469D Insect bite of unspecified ear; Subsequent encounter S00.561A Insect bite of lip; Initial encounter S00.561D Insect bite of lip; Subsequent encounter S00.562A Insect bite of oral cavity; Initial encounter S00.562D Insect bite of oral cavity; Subsequent encounter S10.16A Insect bite of throat; Initial encounter S10.16D Insect bite of throat; Subsequent encounter

42. Insect Bite – ICD-10
S10.86A Insect bite of other part of neck; Initial encounter S10.86S Insect bite of other part of necks; subsequent encounter S10.96A Insect bite of unspecified part of neck; Initial encounter S10.96D Insect bite of unspecified part of neck; Subsequent encounter S20.161A Insect bite of breast, right breast; Initial encounter S20.161D Insect bite of breast, right breast; Subsequent encounter S20.162A Insect bite of breast, left breast; Initial encounter S20.162D Insect bite of breast, left breast; Subsequent encounter S20.169A Insect bite of breast, unspecified breast; Initial encounter S20.169D Insect bite of breast, unspecified breast; Subsequent encounter S20.361A Insect bite of right front wall of thorax; Initial encounter S20.361D Insect bite of right front wall of thorax; Subsequent encounter S20.361S Insect bite of right front wall of thorax; Subsequent encounter S20.362A Insect bite of left front wall of thorax; Initial encounter S20.362D Insect bite of left front wall of thorax; Subsequent encounter S20.369A Insect bite of unspecified front wall of thorax; Initial encounter S20.369D Insect bite of unspecified front wall of thorax; Subsequent encounter

43. Insect Bite – ICD-10
S20.461A Insect bite of right back wall of thorax; Initial encounter S20.461D Insect bite of right back wall of thorax; Subsequent encounter S20.462A Insect bite of left back wall of thorax; Initial encounter S20.462D Insect bite of left back wall of thorax; Subsequent encounter S20.469A Insect bite of unspecified back wall of thorax; Initial encounter S20.469D Insect bite of unspecified back wall of thorax; Subsequent encounter S20.96A Insect bite of unspecified parts of thorax; Initial encounter S20.96D Insect bite of unspecified parts of thorax; Subsequent encounter S30.860A Insect bite of lower back and pelvis; Initial encounter S30.860D Insect bite of lower back and pelvis; Subsequent encounter S30.861A Insect bite of abdominal wall; Initial encounter S30.861D Insect bite of abdominal wall; Subsequent encounter S30.862A Insect bite of penis; Initial encounter S30.862D Insect bite of penis; Subsequent encounter S30.863A Insect bite of scrotum and testes; Initial encounter S30.863D Insect bite of scrotum and testes; Subsequent encounter S30.864A Insect bite of vagina and vulva; Initial encounter S30.864D Insect bite of vagina and vulva; Subsequent encounter S30.865A Insect bite of unspecified external genital organs, male; Initial encounter S30.865D Insect bite of unspecified external genital organs, male; Subsequent encounter S30.866A Insect bite of unspecified external genital organs, female; Initial encounter S30.866D Insect bite of unspecified external genital organs, female; Subsequent encounter

44. Insect Bite – ICD-10
S30.867A Insect bite of anus; Initial encounter S30.867D Insect bite of anus; Subsequent encounter S40.269A Insect bite of unspecified shoulder; Initial encounter S40.269D Insect bite of unspecified shoulder; Subsequent encounter S40.869A Insect bite of unspecified upper arm; Initial encounter S40.869D Insect bite of unspecified upper arm; Subsequent encounter S50.369A Insect bite of unspecified elbow; Initial encounter S50.369D Insect bite of unspecified elbow; Subsequent encounter S50.869A Insect bite of unspecified forearm; Initial encounter S50.869D Insect bite of unspecified forearm; Subsequent encounter S60.369A Insect bite of unspecified thumb; Initial encounter S60.369D Insect bite of unspecified thumb; Subsequent encounter S60.468A Insect bite of other finger; Initial encounter S60.468D Insect bite of other finger; Subsequent encounter S60.469A Insect bite of unspecified finger; Initial encounter S60.469D Insect bite of unspecified finger; Subsequent encounter S60.569A Insect bite of unspecified hand; Initial encounter S60.569D Insect bite of unspecified hand; Subsequent encounter

45. Insect Bite – ICD-10
S60.869A Insect bite of unspecified wrist; Initial encounter S60.869D Insect bite of unspecified wrist; Subsequent encounter S70.269A Insect bite, unspecified hip; Initial encounter S70.269D Insect bite, unspecified hip; Subsequent encounter S70.369A Insect bite, unspecified thigh; Initial encounter S70.369D Insect bite, unspecified thigh; Subsequent encounter S80.269A Insect bite, unspecified knee; Initial encounter S80.269D Insect bite, unspecified knee; Subsequent encounter S90.463A Insect bite, unspecified great toe; Initial encounter S90.463D Insect bite, unspecified great toe; Subsequent encounter S90.466A Insect bite, unspecified lesser toe(s); Initial encounter S90.466D Insect bite, unspecified lesser toe(s); Subsequent encounter S90.569A Insect bite, unspecified ankle; Initial encounter S90.569D Insect bite, unspecified ankle; Subsequent encounter S90.869A Insect bite, unspecified foot; Initial encounter S90.869D Insect bite, unspecified foot; Subsequent encounter

46. Insect Bite – ICD-10

47. Diabetes E08 – Diabetes due to underlying condition
E09 – Drug or chemical induced diabetes mellitus
E10 – Insulin dependent diabetes mellitus
E11 – Non-insulin dependent diabetes mellitus
E12 – Malnutrition related diabetes
E13 – Other specified diabetes mellitus

48. Diabetes Guidelines
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.
As many codes within a particular category as are necessary to describe all of the complications of the disease may be used.
They should be sequenced based on the reason for a particular encounter.

49. Diabetes Guidelines
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned.
Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.
Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.

50. Diabetes Specificity .0 With coma .1 With ketoacidosis
.2 With renal complications
.3 With ophthalmic complications
.4 With neurological complications
.5 With peripheral circulatory complications
.6 With other specified complications
.7 With multiple complications
.8 With unspecified complications
.9 Without complications

51. 4/15/2017
Example
A 30 year old Type I patient has presented with a right foot ulcer due to diabetic atherosclerosis
Diabetes with other specified manifestations, Type I, not stated as uncontrolled
“use additional code to identify manifestation”
Artherosclerosis of the extremities with ulceration
Ulcer, except decubitus, of the heel and mid- foot

52. Type I diabetic with right foot ulcer due to diabetic atherosclerosis
E Type I diabetes mellitus with foot ulcer
Use additional code to identify site of ulcer
I Arteriosclerosis of native arteries of right leg with ulceration of heel and mid foot (other locations)
Use additional code to identify severity of ulcer
Use additional code to identify
Exposure to smoke Tobacco dependence
Tobacco use  History of tobacco use
Occupational exposure to environmental tobacco smoke

53. Example A 30 year old Type I diabetic patient who also has
4/15/2017
Example
A 30 year old Type I diabetic patient who also has
atherosclerosis of the right leg extremity, presents
with a foot ulcer (causal relationship not stated)
Ulcer heel and mid- foot
Diabetes
Atherosclerosis
– Diabetes without mention of complication; Type I, [juvenile type], not stated as uncontrolled
– Atherosclerosis of extremities, unspecified
ALTERNATIVE CODES
– Atherosclerosis of extremities with ulceration
Use additional code for any associated ulceration
Diabetes with other specified manifestations, Type I, not stated as uncontrolled “use additional code to identify manifestation”
WHAT ABOUT SEQUENCING??

54. Complications of Care - Guidelines
Not all conditions that occur during or following medical care or surgery are classified as complications.
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.
Query the provider for clarification, if the complication is not clearly documented.
Guideline extends to any complications of care, regardless of the chapter the code is located in

55. Cause & Effect Relationship
Sepsis
Based on provider’s documentation of the relationship between the infection and the procedure.

56. Cause & Effect Relationship
Presume relationship
Chronic kidney disease with hypertension
as hypertensive chronic kidney disease.
Atherosclerosis and angina pectoris
Unless the documentation indicates the angina is due to something else

57. Acute Exacerbation of Chronic Obstructive Bronchitis & Asthma
ICD-10
ICD-9
The codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation.
An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.
The codes for chronic obstructive bronchitis and asthma distinguish between uncomplicated cases and those in acute exacerbation.
An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

59. Asthma
√ 5th - J45.2 Mild Intermittent asthma J45.20 Mild intermittent asthma, uncomplicated Mild intermittent asthma NOS J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild Intermittent asthma with status asthmaticus √ 5th - J45.3 Mild persistent asthma J45.30 Mild persistent asthma, uncomplicated Mild persistent asthma NOS J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus

60. Asthma
√ 5th - J45.4 Moderate persistent asthma J45.40 Moderate persistent asthma, uncomplicated Moderate persistent asthma NOS J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus √ 5th - J45.5 Severe persistent asthma J45.50 Severe persistent asthma, uncomplicated Severe persistent asthma NOS J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J45.9 Other and unspecified asthma

61. Crohn’s Disease ICD-9 ICD-10 559.x – Regional enteritis
Large, small, combined, unspecified intestine
ICD-10
Rubric contains 28 separate codes
Site
Complications of fistula
Obstruction
Bleeding
Abscess
Other
None

63. Converting from ICD-9 to 10
A MUST DO
Getting everyone “on board”
Physicians, nurses, billing/coding and administration
Education and training is key

64. AHIMA Preparation Create implementation committee Budget planning
Timeline for Implementation
Identify training needs
Information Management System upgrades and review

65. Challenges per AHIMA Coders & Billers Physicians Learn “new” system
Forget “old” system”
Must understand Coding Guidelines
Getting adequate information
Physicians
Need to understand coding world
Need to understand specificity needed
Need to write legibly
Need to give “better” documentation

66. What is your office’s GAP?
Conduct gap analysis of coding professionals’ knowledge and skills
Assess coding professionals’ knowledge in sciences (anatomy and physiology, pathophysiology), medical terminology, and pharmacology
Refresh coding staff knowledge as needed on basis of assessment results

67. Assess Quality of Medical Record Documentation
Evaluate samples of various types of medical records to determine whether documentation supports level of detail found in ICD-10-CM/PCS
Sampling techniques could include random samples, most frequent diagnoses or procedures, or diagnostic or procedural categories known to represent documentation problems with ICD-9-CM
Implement documentation improvement strategies where needed

68. Determine a Training Plan
Who will need education?
What type and level of education will they need?
How will the education be delivered?
When will training be needed?

69. Determine Business Associate Readiness
When will upgrades or replacement systems be available for testing and implementation?
What customer support and training will they provide?
How will their products/services accommodate both ICD-9 and ICD-10?
How long will their products accommodate both code sets?

70. QUESTIONS???
Thank you !