Presentation on theme: "Overview of ER Dx Coding in ICD-10-CM"— Presentation transcript:
1 Overview of ER Dx Coding in ICD-10-CM OrHIMA Fall ConferenceOctober 2014
2 Speakers Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS 30+ year HIM professional and LeaderPast-President CHIANational Director Coding Quality, Education, Systems and SupportNational 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, CCDS30+ year HIM professional and LeaderPast-President CHIANational Director Coding Quality, Education, Systems and SupportNational Revenue Cycle – Program Office (Oakland)The opinions and comments expressed during this presentation are those of the speaker and not of Kaiser Permanente.
3 DisclaimerThis 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 diagnosisUnderstand the specifics of documentationPractice with case examplesQ&AEnhance knowledge regarding MS-DRG Wt & LOS ChangesChanges and Updates to the Hospital Value-based Purchasing (VBP) ProgramChanges and Updates to Hospital-Acquired Condition (HAC) Reduction ProgramReview Direct graduate medical education (GME) and indirect medical education (IME) payment changesUnderstand Next Steps and Action to Take
5 Today: Patient StoryThe clinical documentation should tell the patients full storyPaint the true pictureuse the right brush and colorIf something isn’t documented then the story is incompleteBUT Caution: to capture and report an incidental finding This goes into the patient medical profileGloryanne: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 storyPaint the true picture…..different tools for painting that picture.If something isn’t documented then the story is incompleteBUT Caution: to capture and report an incidental finding This goes into the patient medical profile
6 Today: Data IntegrityA 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 enablerDocumentation is the sourceGloryanneInaccuracy 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).GloryanneIn 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 documentationSource: 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 yearssepticemia (infection in the bloodstream) was the most frequent reason for admission to the hospital after an ED visit.GloryanneAmong 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 yearssepticemia (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 CompliantReview the patients vital signs at the time of arrival in the ERCheck 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 statusLevel of consciousnessAlert or confused, lethargicResponsivenessComa 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 CompliantEMT documentationCircumstances of the encounterPast Medical HistoryProblem ListCurrent medical historyPhysical examTesting (Lab/Radiology/EKG, etc.) and resultsCurrent Medication and those on the administration recordTreatmentImpressionGloryanne:Re viewing the Emergency Room Notes …Documentation that paints the picture comes from…….Chief CompliantEMT documentationCircumstances of the encounterPast Medical HistoryProblem ListCurrent medical historyPhysical examTesting (Lab/Radiology/EKG, etc.) and resultsCurrent Medication and those on the administration recordTreatmentImpression
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.”GloryanneLet’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 DateThe 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 appropriatelyReview your timelineContinue or not your Code Set Education, Training and AwarenessRefresh in 2015Practice and more PracticePractice with new documentation and new codesDual CodingTime to Understand MS-DRG shifts: analyzeConduct an audit/reviewAnalyze the findingsRecommendation and documentation targetsReview physician awareness and training planDocumentation improvementCDI: continue focus on documentation improvement activitiesICD-10 EducationDx enhancementsCoding Tip Sheets – prepare & continueIT & systems programming with ICD-10 10/2014 start dateReworkContracts with ICD-10 10/2014 date may need to be addressedGloryanne: Certainly take a short Pause, take stock ICD-10 efforts, and redeploy resources appropriatelyReview your timelineContinue or not your Code Set Education, Training and AwarenessRefresh in 2015Practice and more PracticePractice with new documentation and new codesDual CodingTime to Understand MS-DRG shifts: analyzeConduct an audit/reviewAnalyze the findingsRecommendation and documentation targetsReview physician awareness and training planDocumentation improvementCDI: continue focus on documentation improvement activitiesICD-10 EducationDx enhancementsCoding Tip Sheets – prepare & continueIT & systems programming with ICD-10 10/2014 start dateReworkContracts 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 WHO1999 – WHO adopts ICD-102002 (October) –ICD-10 published in 42 languages (including 6 official WHO languages)Implementation138 countries for mortality99 countries for morbidityJanuary 1, 1999 –U.S. implemented for mortality (death certificates)2000 – 2009 U.S. continued to work on implementation strategiesJanuary 2009 Final Rule with implementation date of 10/20135 year timeline with 10/1/2013 go-live dateOne Year Delay: October 2014Now another delay: October 2015Gloryanne: 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 10/20135 year timeline with 10/1/2013 go-live dateNew date pending October 2014 (proposed one year delay)
17 Background: ICD-10-CM Developers American Academy of DermatologyAmerican Academy of NeurologyAmerican Academy of Oral and Maxillofacial SurgeonsAmerican Academy of Orthopedic SurgeonsAmerican Academy of PediatricsAmerican College of Obstetricians and GynecologistsAmerican Burn AssociationAmerican Diabetes AssociationAmerican Nursing AssociationAmerican Psychiatric AssociationAmerican Urological AssociationANSI Z16.2 Workgroup (Worker’s Comp)National Association of Children’s Hospitals and Related InstitutionsGloryanne: 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 careIncreased sensitivity when refining grouping and reimbursement methodologiesEnhanced ability to conduct public health surveillanceGreater achievement of the anticipated benefits from electronic health record adoptionImprovements in Setting health policy;Operational and strategic planningDesigning health care delivery systems;Monitoring resource utilization;Improving clinical, financial, and administrative performance;Preventing and detecting health care fraud and abuse; andTracking public health and risksGloryanne: 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 codesSome chapters reorganized, some conditions put in to different chaptersAlphanumeric – first character is always a letterAddition of up to 7 characters7th character code extensions in some casesInjuriesInitial encounterSubsequent encounterSequela- Obstetrics- GlaucomaThree primary changes to the code set:LocationLateralitySeverityGloryanne: Currently we have 20 chapter for ICD-9, and with ICD-10 we will now have 21 chapters.GloryanneCMS 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 characters1st digit is numeric (except E and V codes) 1st character is always alphabetic, including I and O but not UDigits 2-5 are numeric Characters 2-7 numeric or alphabeticAlways at least 3 digits Always at least 3 charactersUse of decimal after the 3rd digit Use of decimal after the 3rd characterGloryanneHere 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 formatGreater 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.GloryanneThe 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 GloryanneOfficial 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 conceptstoday will make learning the system less difficult• You can become a key leader in the implementationprocess– Assist in explaining differences to other members of thehealthcare team– Determine areas where additional training is needed– Analyze available documentation and determine areaswhere greater specificity may be required– Identify potential impact to reimbursement (e.g. contractnegotiations)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. Excludes1A 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. Excludes2A 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-CMTo 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-CMTo 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 symptomsVictoria:Chapter 18 is where we find Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhereclassified (R00-R99)– Includes:• Symptoms• Signs• Abnormal results of clinical or other investigativeprocedures• 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 levelVictoria:Documentation needs to reflect the severityDocumentation needs to reflect the severity
32 Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services A. Selection of first-listed condition1. Outpatient Surgery.2. Observation StayB. Codes from A00. 0 through T88.9, Z00-Z99.C. Accurate reporting of ICD-10-CM diagnosis codesD. Codes that describe symptoms and signsE. Encounters for circumstances other than a disease or injuryF. Level of Detail in Coding1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters2. Use of full number of characters required for a codeG. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit.H. Uncertain diagnosisI. Chronic diseasesJ. Code all documented conditions that coexistK. Patients receiving diagnostic services only .L. Patients receiving therapeutic services onlyM. Patients receiving preoperative evaluations onlyN. Ambulatory surgeryO. Routine outpatient prenatal visitsP. Encounters for general medical examinations with abnormal findingsQ. Encounters for routine health screeningsThese 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-CMThe 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 disorderSeverityAcute or chronicWith or without crisisSiteEtiologySecondary disease processVictoria:Additional specificity in these key areas to meet specificity in ICD-10:Cause of disease or disorderSeverityAcute or chronicWith or without crisisSiteEtiologySecondary 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 arrowsVariable interpretationsIndicating changeQuery provider regarding meaningApplies for both inpatient and outpatient admissionsVictoria: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 arrowsVariable interpretationsIndicating changeQuery provider regarding meaningApplies for both inpatient and outpatient admission
36 Chapter 1Chapter 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 drugsUse 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-infectiousInclude information regarding any cause and effective relationship or another condition or problemDocument if “severe sepsis” is present.Document if there is “organ dysfunction” presentState the specific type of organ that is failing or has failed ie respiratory failure, renal failure, etc.Document whether “septic shock” is present
38 EnterovirusThe following ICD-10-CM Index entries contain back-references to ICD-10-CM B34.1:Coxsackie (virus) (infection) B34.1Disease, diseased - see also Syndromecoxsackie (virus) B34.1echovirus NEC B34.1enteroviral, enterovirus NEC B34.1nonarthropod-borne NOS (viral) B34.9enterovirus NEC B34.1Infection, infected, infective (opportunistic) B99.9enterovirus B34.1unspecified nature or site B34.1ICD-10-CM B34.1 is grouped within Diagnostic Related Group(s) (MS-DRG v30.0):865 Viral illness with mcc866 Viral illness without mccClinical 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 mcc866 Viral illness without mccEV-D68The 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 virusEV-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 neoplasmsFor neoplasms of the lung, liver and intestines, document the specific anatomic location, (ie quadrant, lobe, section).Lower-Outer Quadrant of Female BreastLaterality is needed for paired organs (ie ovary).Document the gender (male/female) if needed in the classification ie breast neoplasmComplications 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 3Chapter III: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)Reserved for future guideline expansionAnemia Groups:Deficiency anemiasHemolytic anemiasAplastic 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 lossInclude documentation if the anemia is due to nutrition or minerals deficits; resulting in a nutritional anemiaInclude documentation of whether the hemolytic anemia is hereditary, acquired, enzyme disorder, autoimmune, or non-autoimmuneList the name and purpose of any medications causing the anemiaLink any laboratory findings to a related diagnosis (if appropriate)Document whether the anemia is related to chemo or radiotherapy treatmentsDocument 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 disorderGloryanne: Some documentation tips for this chapter include:Identifying the specific type of anemia: nutritional, hemolytic, aplastic or due to blood lossDocumenting if the anemia is due to nutrition or minerals deficits; resulting in a nutritional anemiaIncluding in clinical documentation whether the hemolytic anemia is hereditary, acquired, enzyme disorder, autoimmune, or non-autoimmuneDoes your Physician Query Process include this specificity?
43 Hemolytic Anemia Due to “Enzyme Disorders”: Glucose-6-phosphate dehydrogenaseGlutathion metabolismGlycolytic enzymesDue to nucleotide metabolismThalassemias:Alpha thalassemiaBeta thalassemiaDelta-beta thalassemiaThalassemia minorHereditary persistence of fetal hemoglobinHemoglobin E-beta thalassemiaSickle Cell Disorders is presentSpecify if “With or Without Crisis”Sickle Cell thalassemiaInclude documentation of whether the HEMOLYTIC ANEMIA is:HereditaryAcquiredenzyme disorderAutoimmuneNon-autoimmuneDocument the disorder/condition that is causing the anemiaDocument any associated diagnoses/conditions
44 Guideline Change: Anemia Coding and Sequencing of ComplicationsAnemiaAssociated with Malignancy- admission for management of anemia associated with malignancy and treatment is only for the anemiaCode for malignancy sequenced firstCode for anemia, such as D63.0 – Anemia in Neoplastic DiseaseSequencing is completely different in ICD-10-CMChanges the MS-DRGAssociated with Chemotherapy, Immunotherapy or Radiation Therapy-treatment only for anemiaAnemia code first, neoplasm code alsoAdditional codesAdverse effect of chemotherapy or immunotherapy- also codeT45.1X5- adverse effects of antineoplastic and immunosuppressive drugsAdverse effect of radiation therapy-also codeY84.2 – 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 procedureVictoria:Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:1) Anemia associated with malignancyWhen 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 4Chapter IV: Endocrine, Nutritional and Metabolic Diseases (E00-E89)Diabetes mellitusThe 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: DiabetesWhen there are manifestations and/or complications; document additional details:ArthropathyGangreneHyperglycemiaSite of ulcerSeverity of retinopathyStage of the CKDWhether with or without macular edemaDocumentation should reflect the “type”Documentation should include any manifestations or complications of diabetesDocumentation 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 hyperalimentationOverweight and obesityBody Mass Index (BMI)ICD-10-CM Key aspects of documentation for coding:Overweight and obesityObesity due to excess caloriesDrug-induced obesityMorbid (severe) obesity with alveolar hypoventilationOverweightOtherUnspecifiedBody 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 obesityObesity due to excess caloriesDrug-induced obesityMorbid (severe) obesity with alveolar hypoventilationOverweightOtherUnspecifiedBody Mass Index (BMI)
48 Documentation: ICD-10 Obesity Document whether the patient is overweight or ObeseSpecify if the patient has “morbid obesity” and if due to excess caloriesDocument the underlying or causal condition if known (ie adverse effect of drug)With obesity, document if hypoventilation syndrome is presentAlso document the Body Mass Index (BMI) if knownGloryanne: 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—kwashiorkorICD-9-CM code 261—nutritional marasmusICD-9-CM code 262— other, severe protein calorie malnutritionThe 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 degreeICD-9-CM code 263.1—malnutrition of a mild degreeICD-9-CM code 263.2—arrested development following protein-calorie malnutritionICD-9-CM code –other protein-calorie malnutritionICD-9-CM code 263.9—unspecified protein-calorie malnutritionGloryanne: 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 DegreeE40 KwashiorkorE41 Nutritional marasmusE42 Marasmic kwashiorkorE43 Unspecified severe protein-calorie malnutritionE44 Protein-calorie malnutrition of moderate and mild degreeE44.0 Moderate protein-calorie malnutritionE44.1 Mild protein-calorie malnutritionE45 Retarded development following protein-calorie malnutritionE46 Unspecified protein-calorie malnutritionICD-9-CM260 Kwashiorkor261 Nutritional marasmus262 Other, Severe protein calorie malnutrition263.0 Malnutrition of a moderate degree263.1 Malnutrition of a mild degree263.2 Arrested development following protein-calorie malnutrition263.8 Other protein-calorie malnutrition263.9 Unspecified protein-calorie malnutritionGloryanne: 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 diagnosisNote the type and Degree is key.Mild, Moderate or Severe
51 Diagnosis: Dehydration ICD-9-CMDehydration (cachexia)withhypernatremia 276.0hyponatremia 276.1newborn 775.5ICD-10-CMDehydration E86.0hypertonic E87.0hypotonic E87.1newborn P74.1Gloryanne: When comparing dehydration between ICD-9 and ICD-10 you see some changes to the wording or terms.
52 Chapter 5Chapter 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 recurrentMild, moderate, or severeWith or without psychotic featuresIn partial or full remissionGloryanne:“Major Depressive Disorder” should specify or include the following information:Single episode vs recurrentMild, moderate, or severeWith or without psychotic featuresIn 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 unspecifiedThere are many codes to describe the patients life situation; ie problems with life cycle transitionsThere are Chapter 18 codes to describe signs and symptoms; nervousness, restlessness and agitation, worriesGloryanne: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 substanceDescribe the frequency of usage as:UseAbuseDependenceIn remissionDescribe mode of nicotine use as cigarettes, chewing tobacco, pipe, and/or gumSpecify intoxication/withdrawal as “Uncomplicated” or “With delirium”Document any withdrawal symptomsDocument any associated diagnoses/conditionsList the blood alcohol level, if availableState “no related complications,” when applicableDocument any related mood disorder
56 Chapter 6 Chapter VI: Diseases of the Nervous System (G00-G99) Additional codes required for:Alzheimer’s disease with deliriumAlzheimer’s with dementia with behavioral disturbanceAlzheimer’s with dementia without behavioral disturbanceDominant/nondominant sideCodes 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 onsetDocument if Delirium, is presentDocument if there is Dementia without behavioral disturbanceDocument Alzheimer’s disease with deliriumDocument Alzheimer’s with dementia with behavioral disturbanceDocument Alzheimer’s with dementia without behavioral disturbanceDocument Alzheimer's dementia w deliriumSpecify the following if applicable:Alzheimer's dementia w delusionsAlzheimer's dementia w depressed moodAlzheimer's dementia with deliriumAlzheimer's dementia with delusionsAlzheimer's dementia with depressed moodClinical 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 theEVERY 67 seconds someone in the United States develops this disease!
59 Diagnosis: Parkinson Disease Document when “Dementia” is associated with Parkinson's DiseaseDocument when there are “behavioral disturbance” associated with Parkinson DiseaseDocument “Paralysis agitans” if presentIdentify 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 deathApproximately 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 8Chapter VIII: Diseases of the Ear and Mastoid Process (H60-H95)Reserved for future guideline expansionIncreased specificity for lateralityIncreased specificity for Otitis ExternaType must be identified in ICD-10
61 Documentation: Otitis Media Document lateralityright, left or bilateralInclude documentation of the severity:Acute/subacuteAcute recurrentChronicDocument whether tympanic membrane rupture is presentWithout or without Spontaneous ruptureDocument any secondary cause for otitis ie., tobacco smokeDocument the specific type:SerousSanguineousSuppurativeAllergicMucoidTubotympanicAtticoantralDocument any associated infectious agent: strep, staph, Scarlett fever, influenza, Measles or MumpsGloryanne: 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 lateralityright, left or bilateralInclude documentation of the severity:Acute/subacuteAcute recurrentChronic
62 Chapter 9 Chapter IX: Diseases of the Circulatory System (I00-I99) Hypertension = I10Heart FailureAMICardiac ArrestCVA
63 Hypertension No Hypertension Table in ICD-10-CM Coding is I10 = Hypertension–No distinction of benign, malignant, unspecifiedSame specific documentation required for Hypertension with Heart DiseaseAssumed relationship between Hypertensive and Chronic Kidney DiseaseCombination of Hypertensive Heart and Chronic Kidney DiseaseElevated Blood PressureICD-9-CM 796.2ICD-10-CM R03.0Gloryanne: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, heartcongestive(compensated) (decompensated) I50.9with rheumatic fever(conditions in I00)active I01.8inactive or quiescent(with chorea) I09.81newborn P29.0rheumatic(chronic) (inactive) (with chorea) I09.81active or acute I01.8with chorea I02.0ICD-9-CM Key aspects of documentation for coding:Failure, heart (acute) (sudden) 428.9congestive (compensated) (decompensated) (see also Failure, heart) 428.0with rheumatic fever (conditions classifiable to 390)active 391.8inactive or quiescent (with chorea)fetus or newbornhypertensive (see also Hypertension, heart)with renal disease (see also Hypertension, cardiorenal)with renal failurebenignmalignantrheumatic (chronic) (inactive) (with chorea)active or acute 391.8with chorea (Sydenham's)Gloryanne: “decompensated”indicates that there has been a flare‐up (acutephase) of a chronic condition.Coding Clinic, Second Quarter 2013, page 33ICD-10-CM Key aspects of coding:Failure, heartcongestive(compensated) (decompensated) I50.9with rheumatic fever(conditions in I00)active I01.8inactive or quiescent(with chorea) I09.81newborn P29.0rheumatic(chronic) (inactive) (with chorea) I09.81active or acute I01.8with chorea I02.0
65 Documentation: Heart Failure AcuityAcuteChronicAcute on ChronicTypeDiastolicSystolicCombined systolic and diastolicInclude whether due to or associated withCardiac or other surgeryHypertensionValvular diseaseRheumatic heart diseaseEndocarditis (valvitis)PericarditisMyocarditisGloryanne: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 18Chapter XVIII: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)Includes:Symptoms and signs involving the circulatory and respiratory systemsSymptoms and signs involving the digestive system and abdomenSymptoms and signs involving the skin and subcutaneous tissueSymptoms and signs involving the nervous and musculoskeletal systemsSymptoms and signs involving the urinary systemSymptoms and signs involving cognition, perception, emotional state and behaviorSymptoms and signs involving speech and voiceGeneral symptoms and signsAbnormal findings on examination of blood, without diagnosisAbnormal findings on examination of urine, without diagnosisAbnormal findings on examination of other body fluids, substances and tissues, without diagnosisAbnormal findings on diagnostic imaging and in function studies, without diagnosisAbnormal tumor markersIll-defined and unknown cause of mortalitySome 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 systemsR10-R19 Symptoms and signs involving the digestive system and abdomenR20-R23 Symptoms and signs involving the skin and subcutaneous tissueR25-R29 Symptoms and signs involving the nervous and musculoskeletal systemsR30-R39 Symptoms and signs involving the urinary systemR40-R46 Symptoms and signs involving cognition, perception, emotional state and behaviorR47-R49 Symptoms and signs involving speech and voiceR50-R69 General symptoms and signsR70-R79 Abnormal findings on examination of blood, without diagnosisR80-R82 Abnormal findings on examination of urine, without diagnosisR83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosisR90-R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosisR97 Abnormal tumor markersR99 Ill-defined and unknown cause of mortality
67 Documentation & Coding: Cough ICD-9-CMCough 786.2with hemorrhage (see also Hemoptysis)affected 786.2bronchial 786.2with grippe or influenza (see also Influenza) 487.1chronic 786.2epidemic 786.2functional 306.1hemorrhagichystericallaryngeal, spasmodic 786.2nervous 786.2psychogenic 306.1smokers' 491.0tea tasters'ICD-10-CMCough(affected) (chronic) (epidemic) (nervous) R05with hemorrhage- see Hemoptysisbronchial R05with grippe or influenza- see Influenza, with, respiratory manifestations NECfunctional F45.8hysterical F45.8laryngeal, spasmodic R05psychogenic F45.8smokers' J41.0tea taster's B49Now turn to the word/term “COUGH” in ICD-9-CM
68 Documentation & Coding: Chest Pain ICD-9-CMAlphabetic Indexchest (central)atypicalmidsternalmusculoskeletalnoncardiacsubsternalwall (anterior)ICD-10-CMchest(central) R07.9anterior wall R07.89atypical R07.89ischemic I20.9musculoskeletal R07.89non-cardiac R07.89on breathing R07.1pleurodynia R07.81precordial R07.2wall(anterior) R07.89Specificity to describe the type of chest pain is important.
69 Documentation & Coding: Fever ICD-9-CM (long list – ck your codebook)Feverwith chillsin malarial regions (see also Malaria) 084.6abortus NEC 023.9aden 061African tick-borne 087.1Americanmountain tick 066.1spotted 082.0and ague (see also Malaria) 084.6aphthous 078.4arbovirus hemorrhagic 065.9Assam 085.0Australian A or Q 083.0. . .ICD-10-CM (long list of diagnosis)Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor) R50.9abortus A23.1Aden(dengue) A90African tick-borne A68.1Americanmountain(tick) A93.2spotted A77.0aphthous B08.8arbovirus, arboviral A94hemorrhagic A94specified NEC A93.8Argentinian hemorrhagic A96.0Assam B55.0Australian Q A78Bangkok hemorrhagic A91Another common symptoms that is reported is FEVER.
70 Where were they” Home, SNF, Work, Restaurant, park, etc. Injury ICD-10Details of the injuryWhere 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 ScenarioA 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 ScenarioA 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 ClinicAHA 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 onICD‐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 toaccepting or publishing questions on ICD‐9‐CM• Coding Clinic will focus time and attention onICD‐10‐CM and ICD‐10‐PCS to better addressissues 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 guidelinesReview each ICD-10-CM chapter closelyPractice coding; repeat and repeatDual codingWatch for documentation changes with ICD-10New terminology and specificityEngage, enhance and educateADVOCATE!