1. Overview of ER Dx Coding in ICD-10-CM
OrHIMA Fall Conference
October 2014

2. Speakers Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS
30+ year HIM professional and Leader
Past-President CHIA
National Director Coding Quality, Education, Systems and Support
National Revenue Cycle – Program Office (Oakland)
The opinions and comments expressed during this presentation are those of the speaker and not of Kaiser Permanente.
Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS
30+ year HIM professional and Leader
Past-President CHIA
National Director Coding Quality, Education, Systems and Support
National Revenue Cycle – Program Office (Oakland)
The opinions and comments expressed during this presentation are those of the speaker and not of Kaiser Permanente.

3. Disclaimer
This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner. The author are 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 provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation.
This is presentation is only a snapshot of some aspect of ICD-10-CM and should not be considered complete. All participants are encouraged to carefully review all chapters and guidelines relating to ICD-10.
This is presentation is only a snapshot of some aspect of FY 2015 IPPS Rule and should not be considered complete. All participants are encouraged to carefully review the full Final Rule.

4. Goals/Objectives Review some basic OP Dx Coding Guidelines for ICD-10
Learn the ICD-10 coding of common ER diagnosis
Understand the specifics of documentation
Practice with case examples
Q&A
Enhance knowledge regarding MS-DRG Wt & LOS Changes
Changes and Updates to the Hospital Value-based Purchasing (VBP) Program
Changes and Updates to Hospital-Acquired Condition (HAC) Reduction Program
Review Direct graduate medical education (GME) and indirect medical education (IME) payment changes
Understand Next Steps and Action to Take

5. Today: Patient Story
The clinical documentation should tell the patients full story
Paint the true picture
use the right brush and color
If something isn’t documented then the story is incomplete
BUT Caution: to capture and report an incidental finding This goes into the patient medical profile
Gloryanne:
Remember who’s it ALL ABOUT? The patient and his or her story, situation.
Documentation comes is all shapes and sizes. With painting the patient story we need to use all the tools and all the appropriate colors.
The clinical documentation should tell the patients full story
Paint the true picture…..different tools for painting that picture.
If something isn’t documented then the story is incomplete
BUT Caution: to capture and report an incidental finding This goes into the patient medical profile

6. Today: Data Integrity
A wide spectrum of data is collected in healthcare and must be collected accurately, completely, and consistently.
Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers.
Coded data is an enabler
Documentation is the source
Gloryanne
Inaccuracy in clinical coding creates distorted or misinterpreted information about patient care which can also result in faulty investment decisions to improve health delivery. A wide spectrum of data is collected in healthcare and must be collected accurately, completely, and consistently.
Documentation integrity involves the accuracy of the complete health record. It encompasses information governance, patient identification, authorship validation, amendments and record corrections as well as auditing the record for documentation validity when submitting reimbursement claims.

7. Today’s Data: National
In the United States in 2010, there were million outpatient department visits, million ED visits, and 51.4 million procedures according to the Centers for Disease Control and Prevention (CDC) FastStats. That translates to a lot of outpatients and even more medical and procedural documentation.
The most common reasons for ED visits resulting in discharge:
fever and otitis media (infants and patients aged 1–17 years),
superficial injury (all age groups except infants)
open wounds of the head, neck, and trunk (patients aged 1–17 years and adults aged 85+ years)
nonspecific chest pain (adults aged 45 years and older)
abdominal pain and back pain (all adult age groups except those aged 85+ years).
Gloryanne
In the United States in 2010, there were million outpatient department visits, million ED visits, and 51.4 million procedures according to the Centers for Disease Control and Prevention (CDC) FastStats. Those visits translate to a lot of outpatients and even more medical and procedural documentation
Source: HCUP Report June 2014: Overview of Emergency Department Visits in the United States, 2011

8. Today’s Data: National
Among patients younger than 18 years, the most common reasons for admission to the hospital after an ED visit were:
acute bronchitis (infants younger than 1 year)
asthma (patients aged 1–17 years)
pneumonia (infants and patients aged 1–17 years).
For Adults aged 45–84 years
septicemia (infection in the bloodstream) was the most frequent reason for admission to the hospital after an ED visit.
Gloryanne
Among patients younger than 18 years, the most common reasons for admission to the hospital after an ED visit were:
acute bronchitis (infants younger than 1 year)
asthma (patients aged 1–17 years)
pneumonia (infants and patients aged 1–17 years).
For Adults aged 45–84 years
septicemia (infection in the bloodstream) was the most frequent reason for admission to the hospital after an ED visit.

9. Today: Medical Record Review of EMT/Paramedic
Chief Compliant
Review the patients vital signs at the time of arrival in the ER
Check if O2 sats (see if there is a reading before O2 is given) …. WHY?
Check for a blood glucose reading …. WHY?
Breathing status: labored; able to speak in complete sentences …. WHY?
Is there a description on the mental status
Level of consciousness
Alert or confused, lethargic
Responsiveness
Coma scale?
Gloryanne:
Review the documentation regarding the call to the paramedics, was there a chief complaint?
Review the description on how the patient was when the EMT came; was the patient lying on floor, bathroom? Stairs?
What is the patients appearance; clean, disheveled

10. Today: Review the Emergency Room Notes
Chief Compliant
EMT documentation
Circumstances of the encounter
Past Medical History
Problem List
Current medical history
Physical exam
Testing (Lab/Radiology/EKG, etc.) and results
Current Medication and those on the administration record
Treatment
Impression
Gloryanne:
Re viewing the Emergency Room Notes …
Documentation that paints the picture comes from…….
Chief Compliant
EMT documentation
Circumstances of the encounter
Past Medical History
Problem List
Current medical history
Physical exam
Testing (Lab/Radiology/EKG, etc.) and results
Current Medication and those on the administration record
Treatment
Impression

11. ICD-10 Gloryanne All right now let’s move into the ICD-10 world.
Transition from ICD-9 to ICD-10 is because the ICD-9 codes are outdated and over 30 years old. Because we are continuously advancing in technology, it is important that these codes are useable for today’s treatments, reporting procedures, and payment processes.   Although this transition may cause a lot of extra work for physicians, the good news is that this change is additional proof that we are progressing, especially in the medical industry.

12. ICD-10 Delay
“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d-2(c)) and section of title 45, Code of Federal Regulations.”
Gloryanne
Let’s take a look at the last 6 months or so.
ICD-10 is one of many legislative provisions recently that impacts physician payment and operations.
•You all know the announced of the Delay that occurred back in April.
“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d-2(c)) and section of title 45, Code of Federal Regulations.”

13. ICD-10 Final Rule with 10/2015 Date
Gloryanne: Gloryanne: in the May 1st announced from HHS/CMS, they said that the New Date of 10/1/2015 would be official and that they would release a FINAL RULE soon.
THEN On July 31, 2014, CMS released ICD-10 Final Rule with 10/2015 Date
The U.S. Department of Health and Human Services (HHS) issued a rule July 31st, 2014, finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases. This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015.
The ICD-10 codes on a claim are used to classify diagnoses and procedures on claims submitted to Medicare and private insurance payers

14. CMS Resources Gloryanne
CMS Has released MANY resources to help the healthcare industry especially physician practices and they are all free.

15. ICD-10 Delay: Immediate Next Steps
Pause, take stock ICD-10 efforts, and redeploy resources appropriately
Review your timeline
Continue or not your Code Set Education, Training and Awareness
Refresh in 2015
Practice and more Practice
Practice with new documentation and new codes
Dual Coding
Time to Understand MS-DRG shifts: analyze
Conduct an audit/review
Analyze the findings
Recommendation and documentation targets
Review physician awareness and training plan
Documentation improvement
CDI: continue focus on documentation improvement activities
ICD-10 Education
Dx enhancements
Coding Tip Sheets – prepare & continue
IT & systems programming with ICD-10 10/2014 start date
Rework
Contracts with ICD-10 10/2014 date may need to be addressed
Gloryanne: Certainly take a short Pause, take stock ICD-10 efforts, and redeploy resources appropriately
Review your timeline
Continue or not your Code Set Education, Training and Awareness
Refresh in 2015
Practice and more Practice
Practice with new documentation and new codes
Dual Coding
Time to Understand MS-DRG shifts: analyze
Conduct an audit/review
Analyze the findings
Recommendation and documentation targets
Review physician awareness and training plan
Documentation improvement
CDI: continue focus on documentation improvement activities
ICD-10 Education
Dx enhancements
Coding Tip Sheets – prepare & continue
IT & systems programming with ICD-10 10/2014 start date
Rework
Contracts with ICD-10 10/2014 date may need to be addressed

16. Background: ICD-10 Development
1990 –Endorsed by World Health Assembly (diagnosis only)
1994 –Release of full ICD-10 by WHO
1999 – WHO adopts ICD-10
2002 (October) –ICD-10 published in 42 languages (including 6 official WHO languages)
Implementation138 countries for mortality
99 countries for morbidity
January 1, 1999 –U.S. implemented for mortality (death certificates)
2000 – 2009 U.S. continued to work on implementation strategies
January 2009 Final Rule with implementation date of 10/2013
5 year timeline with 10/1/2013 go-live date
One Year Delay: October 2014
Now another delay: October 2015
Gloryanne: Looking specifically at ICD-10 the historical background crosses many years……this is a high level overview of that timeline and work effort. January 2009 Final Rule with implementation date of 10/2013
5 year timeline with 10/1/2013 go-live date
New date pending October 2014 (proposed one year delay)

17. Background: ICD-10-CM Developers
American Academy of Dermatology
American Academy of Neurology
American Academy of Oral and Maxillofacial Surgeons
American Academy of Orthopedic Surgeons
American Academy of Pediatrics
American College of Obstetricians and Gynecologists
American Burn Association
American Diabetes Association
American Nursing Association
American Psychiatric Association
American Urological Association
ANSI Z16.2 Workgroup (Worker’s Comp)
National Association of Children’s Hospitals and Related Institutions
Gloryanne: Often we hear about the lack of clinicians involvement in the development of Icd-10 and this just is not true. I recommend you use this slide to help clarify with physicians and other clinician groups about ICD-10.

18. ICD-10 Benefits & Goals Higher-quality data, which will result in:
Improved ability to measure the quality, efficacy, and safety of patient care
Increased sensitivity when refining grouping and reimbursement methodologies
Enhanced ability to conduct public health surveillance
Greater achievement of the anticipated benefits from electronic health record adoption
Improvements in Setting health policy;
Operational and strategic planning
Designing health care delivery systems;
Monitoring resource utilization;
Improving clinical, financial, and administrative performance;
Preventing and detecting health care fraud and abuse; and
Tracking public health and risks
Gloryanne: Transition to ICD‐10 is a long, complicated migration that many are just beginning.
A successful conversion from ICD-9 to ICD-10 depends upon good planning and preparation.

19. ICD-10-CM Three primary changes to the code set: Location Laterality
21 chapters and expanded codes
Some chapters reorganized, some conditions put in to different chapters
Alphanumeric – first character is always a letter
Addition of up to 7 characters
7th character code extensions in some cases
Injuries
Initial encounter
Subsequent encounter
Sequela
- Obstetrics
- Glaucoma
Three primary changes to the code set:
Location
Laterality
Severity
Gloryanne: Currently we have 20 chapter for ICD-9, and with ICD-10 we will now have 21 chapters.
Gloryanne
CMS has published educational material and stated that there are three primary changes to the code set

20. ICD-9-CM vs ICD-10-CM ICD-9-CM Diagnosis Codes ICD-10-CM
3-5 digits characters
1st digit is numeric (except E and V codes) 1st character is always alphabetic, including I and O but not U
Digits 2-5 are numeric Characters 2-7 numeric or alphabetic
Always at least 3 digits Always at least 3 characters
Use of decimal after the 3rd digit Use of decimal after the 3rd character
Gloryanne
Here we have a side by side overview of the structural changes within ICD-10 compared to ICD-9, I’m sure the majority of you are by now aware of these changes.
Notice the term “digits” is used with ICD-9-CM but with ICD-10-CM it’s “CHARACTERS”

21. ICD-10-CM Code Format Gloryanne
You’ve most likely see the ICD-10-CM format
Greater emphasis on an understanding of A&P or the health sciences

22. Key ICD-10 Coding Conventions and Guidelines
Conventions and guidelines are the foundation.
Documentation is the mortar to the foundation.
The granularity of ICD-10-CM and ICD-10-PCS is vastly improved over ICD-9-CM and will enable greater specificity in identifying health conditions.
It also provides better data for measuring and tracking health care utilization and the quality of patient care.
Gloryanne
The granularity of ICD-10-CM and ICD-10-PCS is vastly improved over ICD-9-CM and will enable greater specificity in identifying health conditions. It also provides better data for measuring and tracking health care utilization and the quality of patient care.

23. Gloryanne
Official guidelines as KEY to successful coding accuracy and compliance. In learning ICD-10-CM one needs to read through all 117 pages of the guidelines. We will not cover ALL the guidelines components today.

24. ICD-10-CM Guidelines for Coding and Reporting
Guidelines have been approved by the four organizations that make up the four Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS (National Center Health Statistics).
The instructions and conventions of the classification take precedence over guidelines.
These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction.
Gloryanne: Let’s begin to review the wording in the guidelines to gain a deep understanding of the direction and content. Familiarizing yourself with the structure and key concepts
today will make learning the system less difficult
• You can become a key leader in the implementation
process
– Assist in explaining differences to other members of the
healthcare team
– Determine areas where additional training is needed
– Analyze available documentation and determine areas
where greater specificity may be required
– Identify potential impact to reimbursement (e.g. contract
negotiations)
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.

25. ICD-10-CM Guidelines for Coding and Reporting (con’t)
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.
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Gloryanne: the guidelines tell us….. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

26. ICD-10-CM Guidelines for Coding and Reporting (con’t)
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.
Only this set of guidelines, approved by the Cooperating Parties, is official.
Gloryanne: this guideline and definition is important to understand and know….. The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.

27. Conventions NEW AND DIFFERENT Excludes Notes
The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other.
a. Excludes1
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. Excludes2
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.
Victoria:
There are some new and different CONVENTIONS in ICD-10 to be aware of even for CDI professionals.

28. ICD-10 Guideline Sections
Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification.
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.
It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly.
Victoria:
the guidelines have many section…..it is necessary to review all sections of the guidelines to fully understand all the rules and instructions needed to ode properly. We will not have time to get into the guidelines too deeply today but this information should help start the process of learning ICD-10 guidelines as we move along the continuum of educational knowledge enhancement. :

29. ICD-10 General Guidelines
Locating a code in the ICD-10-CM
To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.
It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.
Victoria (read slide):
Locating a code in the ICD-10-CM
To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.

30. ICD-10-CM General Guidelines (con’t)
Signs and Symptoms
– Codes that describe signs and symptoms, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider
• Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (Codes R R99)
contains many codes for symptoms
Victoria:
Chapter 18 is where we find Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R99)
– Includes:
• Symptoms
• Signs
• Abnormal results of clinical or other investigative
procedures
• Ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.
– Signs and symptoms that point to a specific diagnosis have been assigned to a category in other chapters of the classification

31. ICD-10-CM General Guidelines (con’t)
Acute and Chronic
– Code both and sequence the acute (subacute) code first
• If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level
Victoria:
Documentation needs to reflect the severity
Documentation needs to reflect the severity

32. Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
A. Selection of first-listed condition
1. Outpatient Surgery.
2. Observation Stay
B. Codes from A00. 0 through T88.9, Z00-Z99.
C. Accurate reporting of ICD-10-CM diagnosis codes
D. Codes that describe symptoms and signs
E. Encounters for circumstances other than a disease or injury
F. Level of Detail in Coding
1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters
2. Use of full number of characters required for a code
G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit.
H. Uncertain diagnosis
I. Chronic diseases
J. Code all documented conditions that coexist
K. Patients receiving diagnostic services only .
L. Patients receiving therapeutic services only
M. Patients receiving preoperative evaluations only
N. Ambulatory surgery
O. Routine outpatient prenatal visits
P. Encounters for general medical examinations with abnormal findings
Q. Encounters for routine health screenings
These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting hospital-based outpatient services and provider-based office visits.
Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles), can be found in Section IA of these guidelines, under “Conventions Used in the Tabular List.” Section I.B. contains general guidelines that apply to the entire classification. Section I.C. contains chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Information about the correct sequence to use in finding a code is also described in Section I.

33. ICD-10-CM
The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated.
In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification.
Unless otherwise indicated, these guidelines apply to all health care settings.
The conventions and instructions of the classification take precedence over guidelines.
The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated.
The conventions and instructions of the classification take precedence over guidelines.

34. Documentation ICD-10-CM
Additional specificity in these key areas to meet specificity in coding and particularly in ICD-10 (check your queries):
Cause of disease or disorder
Severity
Acute or chronic
With or without crisis
Site
Etiology
Secondary disease process
Victoria:
Additional specificity in these key areas to meet specificity in ICD-10:
Cause of disease or disorder
Severity
Acute or chronic
With or without crisis
Site
Etiology
Secondary disease process

35. Documentation Basics (con’t)
Few basics:
The medical record can be compared to a story book of the patient.
Does the documentation paint the complete picture of the patient?
Any documentation – the good, the bad and the ugly does affect ALL: The hospital, the provider, the payer, and specifically, the patient.
A basic understanding of documentation requirements is critical.
Up and Down arrows?
Do not code on the basis of up and down arrows
Variable interpretations
Indicating change
Query provider regarding meaning
Applies for both inpatient and outpatient admissions
Victoria:
Just a few basics:
The medical record can be compared to a story book of the patient.
Does the documentation paint the complete picture of the patient?
Any documentation – the good, the bad and the ugly does affect ALL: The hospital, the provider, the payer, and specifically, the patient.
A basic understanding of documentation requirements is critical.
Per AHA Coding Clinic: Do not code on the basis of up and down arrows
Variable interpretations
Indicating change
Query provider regarding meaning
Applies for both inpatient and outpatient admission

36. Chapter 1
Chapter I: Certain Infectious and Parasitic Diseases (A00-B99)
Includes diseases generally recognized as communicable or transmissible.
This chapter uses additional ….codes to identify resistance to antimicrobial drugs
Use additional code to identify resistance to antimicrobial drugs (Z16)
There is a new section called ….infections with a predominantly sexual mode of transmission A50-A64

37. Diagnosis: Sepsis Document if there is “organ dysfunction” present
Document whether the sepsis is infectious or non-infectious
Include information regarding any cause and effective relationship or another condition or problem
Document if “severe sepsis” is present.
Document if there is “organ dysfunction” present
State the specific type of organ that is failing or has failed ie respiratory failure, renal failure, etc.
Document whether “septic shock” is present

38. Enterovirus
The following ICD-10-CM Index entries contain back-references to ICD-10-CM B34.1:
Coxsackie (virus) (infection) B34.1
Disease, diseased - see also Syndrome
coxsackie (virus) B34.1
echovirus NEC B34.1
enteroviral, enterovirus NEC B34.1
nonarthropod-borne NOS (viral) B34.9
enterovirus NEC B34.1
Infection, infected, infective (opportunistic) B99.9
enterovirus B34.1
unspecified nature or site B34.1
ICD-10-CM B34.1 is grouped within Diagnostic Related Group(s) (MS-DRG v30.0):
865 Viral illness with mcc
866 Viral illness without mcc
Clinical Information A heterogeneous group of infections produced by coxsackieviruses, including herpangina, aseptic meningitis (meningitis, aseptic), a common-cold-like syndrome, a non-paralytic poliomyelitis-like syndrome, epidemic pleurodynia (pleurodynia, epidemic) and a serious myocarditis.
Infectious disease processes, including meningitis, diarrhea, and respiratory disorders, caused by echoviruses.
ICD-10-CM B34.1 is grouped within Diagnostic Related Group(s) (MS-DRG v30.0):
865 Viral illness with mcc
866 Viral illness without mcc
EV-D68
The virus is related to the rhinovirus, which is responsible for the common cold, and causes symptoms similar to a cold, including runny nose and coughing. But those symptoms can rapidly escalate into more serious symptoms, such as wheezing, low blood oxygen, and difficulty breathing. The virus can be particularly dangerous for children who have asthma or other respiratory conditions.
The virus spreads like the common cold—through sneezing, coughing, or touching things that have been infected by another carrier, officials say. There is no specific treatment for the virus
EV-D68: The virus is related to the rhinovirus, which is responsible for the common cold, and causes symptoms similar to a cold, including runny nose and coughing. But those symptoms can rapidly escalate into more serious symptoms, such as wheezing, low blood oxygen, and difficulty breathing. The virus can be particularly dangerous for children who have asthma or other respiratory conditions.

39. Chapter 2 Chapter II: Neoplasms (C00-D49)
Chapter 2 of the ICD-10-CM contains the codes for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined.

40. Diagnosis: Neoplasm Document the specific site of the neoplasm.
Document whether the neoplasm is benign, primary, secondary, In situ, uncertain or unknown.
Always include ALL secondary neoplasms
For neoplasms of the lung, liver and intestines, document the specific anatomic location, (ie quadrant, lobe, section).
Lower-Outer Quadrant of Female Breast
Laterality is needed for paired organs (ie ovary).
Document the gender (male/female) if needed in the classification ie breast neoplasm
Complications of the neoplasm should be documented (ie anemia).
Documentation should identify if the complication is due to any chemo/radiotherapy treatment.
ICD-10-CM shares a number of similarities with ICD-9-CM in terms of neoplasm coding. ICD-10-CM includes a tabular list and an alphabetic index like ICD-9-CM. ICD-10-CM also includes a neoplasm table organized much like the neoplasm table in ICD-9-CM.

41. Chapter 3
Chapter III: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)
Reserved for future guideline expansion
Anemia Groups:
Deficiency anemias
Hemolytic anemias
Aplastic anemia and other bone marrow failure syndromes

42. ICD-10 Documentation: Anemia
Documentation of anemia should specify type of anemia: nutritional, hemolytic, aplastic or due to blood loss
Include documentation if the anemia is due to nutrition or minerals deficits; resulting in a nutritional anemia
Include documentation of whether the hemolytic anemia is hereditary, acquired, enzyme disorder, autoimmune, or non-autoimmune
List the name and purpose of any medications causing the anemia
Link any laboratory findings to a related diagnosis (if appropriate)
Document whether the anemia is related to chemo or radiotherapy treatments
Document if the anemia is caused by a neoplasm (primary and/or secondary)
Document any cause –and-effect relationship between the intervention and the blood or immune disorder
Gloryanne: Some documentation tips for this chapter include:
Identifying the specific type of anemia: nutritional, hemolytic, aplastic or due to blood loss
Documenting if the anemia is due to nutrition or minerals deficits; resulting in a nutritional anemia
Including in clinical documentation whether the hemolytic anemia is hereditary, acquired, enzyme disorder, autoimmune, or non-autoimmune
Does your Physician Query Process include this specificity?

43. Hemolytic Anemia Due to “Enzyme Disorders”:
Glucose-6-phosphate dehydrogenase
Glutathion metabolism
Glycolytic enzymes
Due to nucleotide metabolism
Thalassemias:
Alpha thalassemia
Beta thalassemia
Delta-beta thalassemia
Thalassemia minor
Hereditary persistence of fetal hemoglobin
Hemoglobin E-beta thalassemia
Sickle Cell Disorders is present
Specify if “With or Without Crisis”
Sickle Cell thalassemia
Include documentation of whether the HEMOLYTIC ANEMIA is:
Hereditary
Acquired
enzyme disorder
Autoimmune
Non-autoimmune
Document the disorder/condition that is causing the anemia
Document any associated diagnoses/conditions

44. Guideline Change: Anemia
Coding and Sequencing of Complications
Anemia
Associated with Malignancy- admission for management of anemia associated with malignancy and treatment is only for the anemia
Code for malignancy sequenced first
Code for anemia, such as D63.0 – Anemia in Neoplastic Disease
Sequencing is completely different in ICD-10-CM
Changes the MS-DRG
Associated with Chemotherapy, Immunotherapy or Radiation Therapy-treatment only for anemia
Anemia code first, neoplasm code also
Additional codes
Adverse effect of chemotherapy or immunotherapy- also code
T45.1X5- adverse effects of antineoplastic and immunosuppressive drugs
Adverse effect of radiation therapy-also code
Y84.2 – radiological procedure and therapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
Victoria:
Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:
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 ICD-10-CM Official Guidelines for Coding and Reporting as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease

45. Chapter 4
Chapter IV: Endocrine, Nutritional and Metabolic Diseases (E00-E89)
Diabetes mellitus
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.

46. Diagnosis: Diabetes
When there are manifestations and/or complications; document additional details:
Arthropathy
Gangrene
Hyperglycemia
Site of ulcer
Severity of retinopathy
Stage of the CKD
Whether with or without macular edema
Documentation should reflect the “type”
Documentation should include any manifestations or complications of diabetes
Documentation should include if “hypoglycemia” or “hyperglycemia”
If hypoglycemia is present; document whether there is a coma present

47. Documentation & Coding Diagnosis: Obesity
ICD-9-CM Key aspects of documentation for coding:
Overweight, obesity and other hyperalimentation
Overweight and obesity
Body Mass Index (BMI)
ICD-10-CM Key aspects of documentation for coding:
Overweight and obesity
Obesity due to excess calories
Drug-induced obesity
Morbid (severe) obesity with alveolar hypoventilation
Overweight
Other
Unspecified
Body Mass Index (BMI)
Gloryanne: Compared today with ICD-9 and in the ICD-10-CM world, the Key aspects of documentation for coding:
Overweight and obesity
Obesity due to excess calories
Drug-induced obesity
Morbid (severe) obesity with alveolar hypoventilation
Overweight
Other
Unspecified
Body Mass Index (BMI)

48. Documentation: ICD-10 Obesity
Document whether the patient is overweight or Obese
Specify if the patient has “morbid obesity” and if due to excess calories
Document the underlying or causal condition if known (ie adverse effect of drug)
With obesity, document if hypoventilation syndrome is present
Also document the Body Mass Index (BMI) if known
Gloryanne: In ICD-10-CM, overweight and obesity codes are listed in category E66. Overweight is reported with code E66.3. Obesity may be due to excess calories (E66.0-), drug-induced (E66.1), with alveolar hypoventilation (E66.2), due to other specified causes (E66.8) or unspecified (E66.9). Obesity due to excess calories is further differentiated as severe/morbid (E66.01) or other (E66.09). For drug-induced obesity, the drug is coded first from categories T36-T50. If the body mass index (BMI) is known, it is reported with an additional code from category Z68.

49. Diagnosis: Malnutrition (ICD-9)
Hospital inpatient MS-DRG MCC Secondary DX, if further supported by the documentation and a plan of care:
ICD-9-CM code 260—kwashiorkor
ICD-9-CM code 261—nutritional marasmus
ICD-9-CM code 262— other, severe protein calorie malnutrition
The malnutrition diagnoses that qualify as CC Secondary DXs, if further supported by the documentation or in a plan of care, include these:
ICD-9-CM code 263.0—malnutrition of a moderate degree
ICD-9-CM code 263.1—malnutrition of a mild degree
ICD-9-CM code 263.2—arrested development following protein-calorie malnutrition
ICD-9-CM code –other protein-calorie malnutrition
ICD-9-CM code 263.9—unspecified protein-calorie malnutrition
Gloryanne: The negative impact of malnutrition on wound healing, the immune system, maintenance of muscle mass,
survival rate, length of stay, and hospitalization costs has been well established.
To effectively integrate clinical coding, billing, and reimbursement the early identification, documentation, and treatment of patients diagnosed with malnutrition is needed.

50. Documentation & Coding Diagnosis: Malnutrition
ICD-10-CM Type and Degree
E40 Kwashiorkor
E41 Nutritional marasmus
E42 Marasmic kwashiorkor
E43 Unspecified severe protein-calorie malnutrition
E44 Protein-calorie malnutrition of moderate and mild degree
E44.0 Moderate protein-calorie malnutrition
E44.1 Mild protein-calorie malnutrition
E45 Retarded development following protein-calorie malnutrition
E46 Unspecified protein-calorie malnutrition
ICD-9-CM
260 Kwashiorkor
261 Nutritional marasmus
262 Other, Severe protein calorie malnutrition
263.0 Malnutrition of a moderate degree
263.1 Malnutrition of a mild degree
263.2 Arrested development following protein-calorie malnutrition
263.8 Other protein-calorie malnutrition
263.9 Unspecified protein-calorie malnutrition
Gloryanne: Let’s now take a look at ICD-9 compared to ICD-10 side by side.
Start on the left side of the slide. We know these very well.
Gloryanne: On the right side are the ICD-10-CM diagnosis
Note the type and Degree is key.
Mild, Moderate or Severe

51. Diagnosis: Dehydration
ICD-9-CM
Dehydration (cachexia)
with
hypernatremia 276.0
hyponatremia 276.1
newborn 775.5
ICD-10-CM
Dehydration E86.0
hypertonic E87.0
hypotonic E87.1
newborn P74.1
Gloryanne: When comparing dehydration between ICD-9 and ICD-10 you see some changes to the wording or terms.

52. Chapter 5
Chapter V: Mental, Behavioral and Neurodevelopmental Disorders (F01-F99)
Increased need for documentation of etiology of disease is critical.
The relationship between two or more diagnoses (or associated process) cannot be assumed and provider documentation must clearly state causal relationship of conditions.

53. Documentation: Depression
“Major Depressive Disorder” should specify or include the following information:
Single episode vs recurrent
Mild, moderate, or severe
With or without psychotic features
In partial or full remission
Gloryanne:
“Major Depressive Disorder” should specify or include the following information:
Single episode vs recurrent
Mild, moderate, or severe
With or without psychotic features
In partial or full remission

54. Documentation: Anxiety
Document whether is anxiety if “phobic” or “other”
Document whether the anxiety is generalized, a panic disorder (ie panic attack), mixed anxiety or anxiety unspecified
There are many codes to describe the patients life situation; ie problems with life cycle transitions
There are Chapter 18 codes to describe signs and symptoms; nervousness, restlessness and agitation, worries
Gloryanne:
Document whether is anxiety if “phobic” or “other”
Document whether the anxiety is generalized, a panic disorder (ie panic attack), mixed anxiety or anxiety unspecified

55. Alcohol, Tobacco & Substance Use
Identify the specific type of drug or substance
Describe the frequency of usage as:
Use
Abuse
Dependence
In remission
Describe mode of nicotine use as cigarettes, chewing tobacco, pipe, and/or gum
Specify intoxication/withdrawal as “Uncomplicated” or “With delirium”
Document any withdrawal symptoms
Document any associated diagnoses/conditions
List the blood alcohol level, if available
State “no related complications,” when applicable
Document any related mood disorder

56. Chapter 6 Chapter VI: Diseases of the Nervous System (G00-G99)
Additional codes required for:
Alzheimer’s disease with delirium
Alzheimer’s with dementia with behavioral disturbance
Alzheimer’s with dementia without behavioral disturbance
Dominant/nondominant side
Codes from category 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 the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:
For ambidextrous patients, 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.

57. Diagnosis: Alzheimer’s
Document whether the Alzheimer’s disease is with early onset or with late onset
Document if Delirium, is present
Document if there is Dementia without behavioral disturbance
Document Alzheimer’s disease with delirium
Document Alzheimer’s with dementia with behavioral disturbance
Document Alzheimer’s with dementia without behavioral disturbance
Document Alzheimer's dementia w delirium
Specify the following if applicable:
Alzheimer's dementia w delusions
Alzheimer's dementia w depressed mood
Alzheimer's dementia with delirium
Alzheimer's dementia with delusions
Alzheimer's dementia with depressed mood
Clinical Information A brain disorder that usually starts in late middle age or old age and gets worse over time. Symptoms include loss of memory, confusion, difficulty thinking, and changes in language, behavior, and personality.
A degenerative disease of the brain characterized by the insidious onset of dementia. Impairment of memory, judgment, attention span, and problem solving skills are followed by severe apraxias and a global loss of cognitive abilities. The condition primarily occurs after age 60, and is marked pathologically by severe cortical atrophy and the triad of senile plaques; neurofibrillary tangles; and neuropil threads. (from Adams et al., Principles of Neurology, 6th ed, pp )
A disabling degenerative disease of the nervous system occurring in middle-aged or older persons and characterized by dementia and failure of memory for recent events, followed by total incapacitation and death.
According to the
EVERY 67 seconds someone in the United States develops this disease!

59. Diagnosis: Parkinson Disease
Document when “Dementia” is associated with Parkinson's Disease
Document when there are “behavioral disturbance” associated with Parkinson Disease
Document “Paralysis agitans” if present
Identify drug induced Secondary Parkinsonism or external agent(s)
Parkinson’s A disease characterized as a progressive motor disability manifested by tremors, shaking, muscular rigidity, and lack of postural reflexes.
A progressive degenerative disorder of the central nervous system characterized by loss of dopamine producing neurons in the substantia nigra and the presence of lewy bodies in the substantia nigra and locus coeruleus. Signs and symptoms include tremor which is most pronounced during rest, muscle rigidity, slowing of the voluntary movements, a tendency to fall back, and a mask-like facial expression.
Between there were 157,984 deaths in the United States where ICD-10 G20 was indicated as the underlying cause of death
Approximately 60,000 Americans are diagnosed with Parkinson's disease each year, and this number does not reflect the thousands of cases that go undetected.
An estimated seven to 10 million people worldwide are living with Parkinson's disease.

60. Chapter 8
Chapter VIII: Diseases of the Ear and Mastoid Process (H60-H95)
Reserved for future guideline expansion
Increased specificity for laterality
Increased specificity for Otitis Externa
Type must be identified in ICD-10

61. Documentation: Otitis Media
Document laterality
right, left or bilateral
Include documentation of the severity:
Acute/subacute
Acute recurrent
Chronic
Document whether tympanic membrane rupture is present
Without or without Spontaneous rupture
Document any secondary cause for otitis ie., tobacco smoke
Document the specific type:
Serous
Sanguineous
Suppurative
Allergic
Mucoid
Tubotympanic
Atticoantral
Document any associated infectious agent: strep, staph, Scarlett fever, influenza, Measles or Mumps
Gloryanne: Otitis Media……is Latin for "inflammation of the middle ear“ and is the medical term for middle-ear inflammation. There are 2 major types of otitis media: acute otitis media and otitis media with effusion. The former is usually symptomatic, especially ear pain (otalgia), whereas the latter is most commonly without acute symptoms.
Document laterality
right, left or bilateral
Include documentation of the severity:
Acute/subacute
Acute recurrent
Chronic

62. Chapter 9 Chapter IX: Diseases of the Circulatory System (I00-I99)
Hypertension = I10
Heart Failure
AMI
Cardiac Arrest
CVA

63. Hypertension No Hypertension Table in ICD-10-CM
Coding is I10 = Hypertension
–No distinction of benign, malignant, unspecified
Same specific documentation required for Hypertension with Heart Disease
Assumed relationship between Hypertensive and Chronic Kidney Disease
Combination of Hypertensive Heart and Chronic Kidney Disease
Elevated Blood Pressure
ICD-9-CM 796.2
ICD-10-CM R03.0
Gloryanne:
No Hypertension Table
–I10 = Hypertension
–No distinction of benign, malignant, unspecified
•Hypertension with Heart Disease
•Hypertensive Chronic Kidney Disease
•Hypertensive Heart and Chronic Kidney Disease
•Elevated Blood Pressure
–ICD-9-CM 796.2
–ICD-10-CM R03.0

64. Coding Diagnosis: Heart Failure
ICD-10-CM Key aspects of coding:
Failure, heart
congestive(compensated) (decompensated) I50.9
with rheumatic fever(conditions in I00)
active I01.8
inactive or quiescent(with chorea) I09.81
newborn P29.0
rheumatic(chronic) (inactive) (with chorea) I09.81
active or acute I01.8
with chorea I02.0
ICD-9-CM Key aspects of documentation for coding:
Failure, heart (acute) (sudden) 428.9
congestive (compensated) (decompensated) (see also Failure, heart) 428.0
with rheumatic fever (conditions classifiable to 390)
active 391.8
inactive or quiescent (with chorea)
fetus or newborn
hypertensive (see also Hypertension, heart)
with renal disease (see also Hypertension, cardiorenal)
with renal failure
benign
malignant
rheumatic (chronic) (inactive) (with chorea)
active or acute 391.8
with chorea (Sydenham's)
Gloryanne: “decompensated”
indicates that there has been a flare‐up (acute
phase) of a chronic condition.
Coding Clinic, Second Quarter 2013, page 33
ICD-10-CM Key aspects of coding:
Failure, heart
congestive(compensated) (decompensated) I50.9
with rheumatic fever(conditions in I00)
active I01.8
inactive or quiescent(with chorea) I09.81
newborn P29.0
rheumatic(chronic) (inactive) (with chorea) I09.81
active or acute I01.8
with chorea I02.0

65. Documentation: Heart Failure
Acuity
Acute
Chronic
Acute on Chronic
Type
Diastolic
Systolic
Combined systolic and diastolic
Include whether due to or associated with
Cardiac or other surgery
Hypertension
Valvular disease
Rheumatic heart disease
Endocarditis (valvitis)
Pericarditis
Myocarditis
Gloryanne:
HEART FAILURE means the heart is not pumping enough blood to keep the organs alive. Since its unable to pump the blood fast enough, the blood ON THE WAY TO THE HEART gets backed up in the veins. Reduced blood flow to the kidneys results in water retention. You end up with fluid in the lungs and edema on the body. This is a very serious condition.
Using CPAP to keep alveoli open and O2 going in can help AND….. Reducing the workload on the heart by using drugs like Nitroclycerin, and getting the fluid off by using drugs like Furosemide (Lasix.)
Shortness of breath and/or respiratory distress are common symptoms.

66. Chapter 18
Chapter XVIII: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
Includes:
Symptoms and signs involving the circulatory and respiratory systems
Symptoms and signs involving the digestive system and abdomen
Symptoms and signs involving the skin and subcutaneous tissue
Symptoms and signs involving the nervous and musculoskeletal systems
Symptoms and signs involving the urinary system
Symptoms and signs involving cognition, perception, emotional state and behavior
Symptoms and signs involving speech and voice
General symptoms and signs
Abnormal findings on examination of blood, without diagnosis
Abnormal findings on examination of urine, without diagnosis
Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
Abnormal findings on diagnostic imaging and in function studies, without diagnosis
Abnormal tumor markers
Ill-defined and unknown cause of mortality
Some of the codes that previously were found in body system chapters are now in this particular ICD-10-CM chapter, and the reverse is true for some ICD-9 codes that once were located in the symptoms/signs chapter and now will be located in specific ICD-10 body system chapters. For example, in ICD-9-CM “hematuria, unspecified” currently is coded to in Chapter 10, “Diseases of the Genitourinary System”
This chapter for Signs and Symptoms contains the following blocks:
Symptoms and signs involving the circulatory and respiratory systems
R10-R19 Symptoms and signs involving the digestive system and abdomen
R20-R23 Symptoms and signs involving the skin and subcutaneous tissue
R25-R29 Symptoms and signs involving the nervous and musculoskeletal systems
R30-R39 Symptoms and signs involving the urinary system
R40-R46 Symptoms and signs involving cognition, perception, emotional state and behavior
R47-R49 Symptoms and signs involving speech and voice
R50-R69 General symptoms and signs
R70-R79 Abnormal findings on examination of blood, without diagnosis
R80-R82 Abnormal findings on examination of urine, without diagnosis
R83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
R90-R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosis
R97 Abnormal tumor markers
R99 Ill-defined and unknown cause of mortality

67. Documentation & Coding: Cough
ICD-9-CM
Cough 786.2
with hemorrhage (see also Hemoptysis)
affected 786.2
bronchial 786.2
with grippe or influenza (see also Influenza) 487.1
chronic 786.2
epidemic 786.2
functional 306.1
hemorrhagic
hysterical
laryngeal, spasmodic 786.2
nervous 786.2
psychogenic 306.1
smokers' 491.0
tea tasters'
ICD-10-CM
Cough(affected) (chronic) (epidemic) (nervous) R05
with hemorrhage- see Hemoptysis
bronchial R05
with grippe or influenza- see Influenza, with, respiratory manifestations NEC
functional F45.8
hysterical F45.8
laryngeal, spasmodic R05
psychogenic F45.8
smokers' J41.0
tea taster's B49
Now turn to the word/term “COUGH” in ICD-9-CM

68. Documentation & Coding: Chest Pain
ICD-9-CM
Alphabetic Index
chest (central)
atypical
midsternal
musculoskeletal
noncardiac
substernal
wall (anterior)
ICD-10-CM
chest(central) R07.9
anterior wall R07.89
atypical R07.89
ischemic I20.9
musculoskeletal R07.89
non-cardiac R07.89
on breathing R07.1
pleurodynia R07.81
precordial R07.2
wall(anterior) R07.89
Specificity to describe the type of chest pain is important.

69. Documentation & Coding: Fever
ICD-9-CM (long list – ck your codebook)
Fever
with chills
in malarial regions (see also Malaria) 084.6
abortus NEC 023.9
aden 061
African tick-borne 087.1
American
mountain tick 066.1
spotted 082.0
and ague (see also Malaria) 084.6
aphthous 078.4
arbovirus hemorrhagic 065.9
Assam 085.0
Australian A or Q 083.0
. . .
ICD-10-CM (long list of diagnosis)
Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor) R50.9
abortus A23.1
Aden(dengue) A90
African tick-borne A68.1
American
mountain(tick) A93.2
spotted A77.0
aphthous B08.8
arbovirus, arboviral A94
hemorrhagic A94
specified NEC A93.8
Argentinian hemorrhagic A96.0
Assam B55.0
Australian Q A78
Bangkok hemorrhagic A91
Another common symptoms that is reported is FEVER.

70. Where were they” Home, SNF, Work, Restaurant, park, etc.
Injury ICD-10
Details of the injury
Where were they” Home, SNF, Work, Restaurant, park, etc.
What were they doing? Pedestrian, riding a bike, driving a vehicle (car, bus, heavy equipment) or a passenger

71. Case Scenario
A 54 year old female patient was seen in the ER with moderate weakness and fatigue. She has a history of ovarian carcinoma and had surgery 3 months ago to remove her Tubes and Ovaries.
She’s been on chemotherapy for the past 6 weeks and has 2 weeks more of treatment and had been doing well until 1 week ago. She has also complained of hip pain off and on over the past 4 weeks.
During the past week she has been feeling weakness and fatigued. OP Lab (CBC) work revealed the patient to be anemic and needing blood transfusion. A blood transfusion of 2 units of PRBC were transfused on the first hour, followed by an additional 1 unit over a 3 hour period. Her condition improved and she was discharged from the hospital. Impression: “Anemia due to chemotherapy and history of ovarian carcinoma”.
What is documented and can be coded? (correct sequence): ________________________________
Gloryanne:
Case #4: We would follow the guideline for neoplasm coding with anemia:
Ovarian neoplasm (not a history code due to the current treated directed at the malignancy)=
Anemia due to chemotherapy =
History of Chemo?

72. Case Scenario
A 10 year old patient came to the ER with his parents complaining of ear pain and fever.
Examination found the patient to have a fever and the right eardrum was red and inflamed. The left ear was normal. The family history revealed that a relative had been visiting in the home for the past 3 weeks and they were smoking.
Final impression in the medical record was “fever due to acute Otitis media right ear with 2nd hand smoke exposure”.
What is documented and can be coded? (correct sequence): ________________________________

73. AHA Coding Clinic
AHA Central Office on ICD-10-CM/PCS is NOT reverting back to accepting or publishing questions on ICD‐9‐CM • Coding Clinic will focus time and attention on
ICD‐10‐CM and ICD‐10‐PCS to better address issues in advance of implementation and ensure a smoother ICD‐10 transition.
Your HIM Coding Department is great resource regarding “Coding Clinic”
Subscription (paper or online)
Gloryanne: AHA Central Office is NOT reverting back to
accepting or publishing questions on ICD‐9‐CM
• Coding Clinic will focus time and attention on
ICD‐10‐CM and ICD‐10‐PCS to better address
issues in advance of implementation and ensure a smoother ICD‐10 transition.

74. Summary Know the coding convention Understand the coding guidelines
Apply the chapter specific guidelines
Review each ICD-10-CM chapter closely
Practice coding; repeat and repeat
Dual coding
Watch for documentation changes with ICD-10
New terminology and specificity
Engage, enhance and educate
ADVOCATE!

75. Questions?

76. Thank you

77. References/Resources
ICD-10-CM Draft Codebook 2014
ICD-10-CM Official Guidelines 2014
ICD-10-CM Reporting and Coding Guidelines
3M Encoder
Bielby, Judy A. "Coding Neoplasms in ICD-10-CM." Journal of AHIMA 82, no.10 (October 2011):
MedicineNet.com