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About Dr. Mario Fucinari, DC, CCSP, MCS-P
Certified Chiropractic Sports Physician (CCSP) Certified Insurance Consultant Certified Medical Compliance Specialist – Physician Post-Graduate Faculty, Logan College Clinical Sciences, Palmer College of Chiropractic, Life West Chiropractic, NYCC ICS Chiropractor of the Year 2012 National Speaker’s Bureau for NCMIC and Foot Levelers Member of ACA and ICS Past President of Illinois Chiropractic Society Chairman of the ICS Medicare Committee Medicare Chiropractic Carrier Advisory Committee Member © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

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Program Goals Differences from ICD-9 Why ICD-10? Impact of ICD-10
Definitions in ICD-10 Structure of the codes Documentation required for the codes Transition Rules Workshop Medicare Updates ICD-10 Understanding ICD-10 Transition ICD-10 Implementation © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10- CM ICD-10 Deadline October 1, 2015
© Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10

ICD-10 Basics The Health insurance Portability and Accountability Act (HIPAA) of 1996 includes provisions for the standardization of health care information ICD-10 Electronic Claim Submissions Provider Identifiers Privacy Code Sets © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

1500 Health Claim Form New 1500 Claim Form has been released. Version 02/12 replaced version 03/08 as of April 1, 2014. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Qualifier 431 Onset of current symptoms or illness

Box 24E allows up to 4 characters (ABCD)
S7001xA W06xxxA Y92013 ABC © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Box 24E allows up to 4 characters (ABCD)
S7001xA W06xxxA Y92013 A-L © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10-CM

ICD-9 Limitations Diagnosis has changed. We know more.
Many sections of the codes are full. Uses obsolete technology leading to inaccurate and limited data Need more description. Sprain/Strain Takes in Global data Medicine advances; codes can’t

Inside ICD-10 ICD–10–CM is entirely alphanumeric (all letters except “U” are used) ICD–10–CM codes may be up to seven characters in length Some diseases have been reclassified in ICD-10-CM New features have been added to ICD-10-CM

ICD-10-CM Pitfalls Confusion between letters and numbers Examples:
S01.80xA 10D00Z1 Number Letter 3 S O 1 I 2 Z

ICD-10-CM 1993 the 10th Edition of the International Classification of Disease (ICD-10) was issued by the World Health Organization (WHO) WHO is responsible for maintaining the ICD-10 Each country is responsible for adapting the ICD-10 to suit its own country’s needs.

Follow Me! No!

ICD-10-CM Exempt Worker’s Compensation, auto and personal injury insurances are exempt from HIPAA and therefore may not be using ICD-10. Your office may have two sets of diagnostic codes

ICD-9 Diagnostic Codes ICD-10 Diagnosis Codes 3-5 Characters in length
Approximately 17,000 codes Approximately 70,000 available codes First digit may be alpha; 2nd through 5th is numeric Character 1 is alpha; character 2 and 3 are numeric; character 4 through 6 can be either. All letters except U are used. Limited space for adding new codes Flexible for adding new codes (“x” added) Lacks detail Very specific Lacks laterality Has laterality Difficult to analyze data due to non-specific codes Specificity improves coding accuracy and quality of data for analysis Codes are non-specific and do not adequately define diagnoses needed for medical research Detail improves the accuracy of data used for medical research including co-morbidities Does not support interoperability because it is not used by other countries Supports interoperability and the exchange of health data between other countries and the U.S. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10-CM Increased Specificity in ICD-10
Increased Detail in Documentation Code to the Highest Level of Specificity

ICD-10-CM Specificity Unspecified codes have acceptable uses in some cases. Unspecified codes should be reported when they most accurately reflect what is known about the patient’s condition at the time of that particular encounter.

ICD-10-CM Specificity It would be inappropriate to select a specific code that is not supported in the documentation. Further testing just to come to a more specific code is not always medically necessary Avoid excessive use of non-specific codes, since it decreases the quality of the data.

ICD-10 Specificity Side of Dominance Trimesters and weeks in pregnancy
Right, Left, or ambidextrous (defaults to the right coding) Trimesters and weeks in pregnancy Stages of healing Laterality All paired organs or structures Ordinality Is this the initial or subsequent visit for the complaint? Are these symptoms the sequela of the initial event? © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Specificity Documentation of diagnoses and procedures
Codes must be supported by the patient’s health documentation ICD-10-CM codes are more specific , therefore the documentation has to be more specific Requires more documentation to support codes Expect a 15% increase in documentation time (per AAPC) Revenue Impacts due to specificity Denials Additional Documentation © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Transition Time is now to have the doctor’s notes audited to see if they meet the specificity needed to transition to ICD-10-CM ICD-10 readiness assessment 65%+ of the time, the notes may not be specific enough © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

The Consultation Symptoms causing patient to seek treatment (Chief Complaint) 99203 should show PHx, Family Hx, Social Hx Family History © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Family History The BIG FIVE
Family History – specific health related events in the patient’s family. Includes information about the health status or cause of death of parents, siblings, and children and the following diseases: Orthopedic (arthritis, scoliosis) neurologic pathology (heart disease, cancer, diabetes) The BIG FIVE © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

The Consultation Past Health history Prior Illness Prior Interventions
Type, date, treatment, current status Prior Interventions Type, date, treatment, outcome Prior Surgery Type, date, reason, results, current status © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

The Consultation Social History Marital status Employment history
Occupational history Use of drugs, alcohol, tobacco Level of education Sexual history and social factors © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

O,P,Q,R,S,T The Consultation

The Consultation Mechanism of Trauma
Onset, duration, intensity, frequency, location and radiation Provoking and Palliative Factors Prior interventions, treatments, medications, secondary complaints © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

The Consultation Quality and character of symptoms/problem
Radiation of symptoms Severity Time © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

S (Subjective) O (Objective) A (Assessment) P (Plan)
A (ADL) © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Subjective – What’s going on?
General Questions Subjective – What’s going on? © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

General Components of the S (Subjective)
Reporting of patient pain, limitations, concerns and problems. Information that cannot be verified or measured during the encounter. You may want to use a quote or summarize what the patient reported. A well-done interview seems like a conversation on the surface. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Subjective – What’s going on? Objective – What did you find?
General Questions Subjective – What’s going on? Objective – What did you find? © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

General Components of the O (Objective)
Reporting of all measurable, quantifiable, and observable data obtained during the encounter. Present a picture by reporting anything that the provider used their senses (vision, hearing, smell, touch) Does not depend on patient reporting. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

P.A.R.T. P.A.R.T. To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under the above physical examination list are required, one of which must be asymmetry/misalignment or range of motion abnormality. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

P.A.R.T. (2 of the 4 Required) 1. Pain/Tenderness - location, quality, intensity Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation, provocation, etc. Furthermore pain intensity may be assessed using one or more of the following: visual analog scales, algometers, pain questionnaires, etc. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

P.A.R.T. 2. Asymmetry/misalignment - sectional or segmental level
Asymmetry/misalignment - Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following: observation (posture and gait analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc. 3. Range of Motion Abnormality Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and Range of motion abnormality - Range of motion abnormalities may be identified through one or more of the following: motion, palpation, observation, stress diagnostic imaging, range of motion measurements, etc. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

P.A.R.T. 4. Tissue, tone changes in skin, fascia, muscle, ligament
Tissue, tone changes using descriptions pertaining to the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament. Tissue/Tone texture may be identified through one or more of the following procedures: observation, palpation, use of instruments, tests for length and strength etc. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Evaluation and Management (E/M) Codes

Determining the Level of Evaluation and Management (E/M) Code
Seven Components of the E/M service Key Components History Examination Medical decision making Contributing Components Counseling Coordination of care Nature of presenting problem; and Time © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

History of Present Illness
HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are: Location (example: left leg); Quality (example: aching, burning, radiating pain); Severity (example: 10 on a scale of 1 to 10); Duration (example: started three days ago); Timing (example: constant or comes and goes); Context (example: lifted large object at work); Modifying factors (example: better when heat is applied); and Associated signs and symptoms (example: numbness in toes). © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Review of Systems ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

IN THE ABSENCE OF ROS, THE E/M CODE AUTOMATICALLY BECOMES A LEVEL ONE (99201) CODE

Cardiovascular: Denies: Shortness of breath, chest pain
Cardiovascular: Denies: Shortness of breath, chest pain. Complains of: hypertension Musculoskeletal: Denies: limb weakness. Complains of: right knee pain, right leg pain into the fifth toe © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Writing the O - Objective
In summary, the physical exam should include: Orthopedic and neurologic tests Palpation findings Pinprick sensitivity tests Reflexes Range of Motion - Give plane and degrees so it can be referenced later to show progress. The more specific the degrees, the better. Note pain. Muscle strength Outcome Questionnaires © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Check the Shoes Pronation?
*Orthopedic Physical Assessment, David J. Magee, Elsevier Sciences. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Impact in Your Office
Coverage and Payment The new coding system will mean new coverage policies, new health care review edits, new reimbursement schedules Changes will be made to accommodate increased specificity May need to discuss changes with patients © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Impact in Your Office
Billing and Eligibility Updated transactions include support for ICD-10 New codes mean more specificity Check with your carriers to find out what their plan is for transition Expect increased rejections, denials, and payment delays as both health plans and providers get used to new codes © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Questions to Ask Your Practice Management Vendor
Will you install products well before the October 1, 2015, deadline, so I can begin testing them in 2014? Will support for my current products be discontinued after the October 1, 2015, ICD-10 deadline? When will you update my current products and applications for ICD-10? Will you provide periodic updates for new products? Will there be a charge for these updates? Will I need new hardware to accommodate ICD-10-related software changes? What are the costs associated with maintaining new products? © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Questions to Ask Your Practice Management Vendor
Will you offer product support? If so, how long will the vendor support the application? How do I report issues and how quickly will you respond? Will you provide training on your software? Will you offer support during and after internal ICD-10 testing? Will you help me test my system with payers and other trading partners? Does your product give me the ability to search for codes by the ICD-10 alphabetic and tabular indexes? By clinical concept? Will your product allow for coding in both ICD-9 and ICD-10 to accommodate transactions with dates of service before October 1, 2015, and transactions with dates of service after October 1, 2015? © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Questions to Ask Your EHR Vendor
Are your EHR products ICD-10 ready? If not, when will they be? Can your products help me with the ICD-10 transition? For example, will the products suggest ICD-10 codes based on the clinical data I enter about specific patients? Do your products map PM to ICD-10 codes to help connect clinical and administrative data? source: © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Impact Planning and Training Yields Success
Plan early. Time to contact your vendors is now! Train in stages. “Little Bites!” Train doctors, coders and staff Measure productivity and retention to determine office procedure and policy changes Retrain when necessary © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Transition Identify your current systems and work processes that use ICD-9 codes. This could include your clinical documentation, encounter forms, superbills, practice management system and electronic health record systems. It is likely that wherever ICD-9 codes now appear, ICD-10 codes will take their place. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Steps to Success Gather your last 40 new patient’s charts
Make a list of the diagnosis © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Steps to Success You have your “Top 40 Playlist” Convert
Mario’s Top 40 ICD-10 © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

I need a break!

ICD-10-CM General Coding Guidelines:
ICD-10-CM codes should be listed at their highest level of specificity and characters. a. Use three digit codes only if there are no four digit codes within the coding category. These are the heading of a category of codes. b. Use the 4, 5, 6, or 7 digit code to the greatest degree of specificity available. These provide further detail

ICD-10-CM Basic Coding Guidelines:
Codes that describe symptoms and signs are only acceptable if that is the highest level of diagnostic certainty documented by the doctor. No other diagnosis has been established (confirmed) by the provider. Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Additional signs and symptoms that are not routinely associated with a disease may be reported.

General Coding Guidelines
“Code signs and symptoms when a related definitive diagnosis has not been established (confirmed) by the provider” (section I.B.6) mostly in ICD-9 R00 to R99 in ICD-10 Example: R45.2 Unhappiness © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

“Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes” (section I.B.7) Example: R68.84 Jaw pain would not be coded with M26.62 temporomandibular joint arthralgia “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.” (section I.B.8) Example: R11.0 Nausea and S13.4xxA Sprain of ligaments of the cervical spine © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Coding for diagnoses that are probable, suspected, likely or questionable are not to be coded, because they indicate uncertainty. Rule out and working diagnosis are not to be coded. Other documentation related coding guidance involves diagnoses documented as “borderline" at the time of discharge. Unless the classification provides a specific entry (e.g., borderline diabetes), borderline diagnoses are coded as confirmed without regard to the care setting (i.e., inpatient versus outpatient). The guidelines clarify that borderline conditions are not considered uncertain diagnoses. As always, coders are encouraged to query the provider for clarification whenever the documentation is unclear regarding the condition.

Code all documented conditions that coexist at the time of the visit that REQUIRE OR AFFECT patient care. Do not code conditions that no longer exist.

Coding for diagnoses that are probable, suspected, rule out, etc are not allowed for outpatient s. The term “first-listed” diagnosis is now to be used instead of the term “principle” diagnosis. The acute condition should always be listed first.

Each unique ICD-10 diagnostic code may be reported only once. If you use a left and right code, you only list the diagnosis with these sides once. If the condition is bilateral and there is no bilateral code, t hen you have to list the left and right code separately. If a condition is borderline, then it is listed as confirmed.

ICD-10-CM An unspecified code should be reported only when it is the code that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the health record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Inside ICD-10

ICD-10 Chapters •Chapter 1 – Certain infections and parasitic diseases (A00-B99) •Chapter 2 – Neoplasms (C00-D49) •Chapter 3 – Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) •Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) •Chapter 5 – Mental and Behavior Disorders (F01-F99) •Chapter 6 - Diseases of the Nervous System (G00-G99) •Chapter 7 – Diseases of the eye and adnexa (H00-H59)

ICD-10 Chapters Chapter 8 – Diseases of the ear and mastoid process (H60-H95) Chapter 9 – Diseases of the Circulatory system (I00-I99) Chapter 10 – Diseases of the Respiratory system (J00-J99) Chapter 11 – Diseases of the Digestive system (K00-K94) Chapter 12 – Diseases of the Skin and Subcutaneous tissue (L00-L99) Chapter 13 – Diseases of the Musculoskeletal system and connective tissue (M00-M99) Chapter 14 - Diseases of the genitourinary system (N00-N99) Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O99)

ICD-10 Chapters Chapter 16 – Certain conditions originating in the perinatal period (P00-P96) •Chapter 17 – Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) •Chapter 18 – Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) •Chapter 19 – Injury, poisoning and certain other consequences of external causes •Chapter 20 – External causes of morbidity (V00-Y99) •Chapter 21 - Factors influencing health status and contact with health services (Z00-Z99)

ICD-10 Cast of Characters
Placeholder “X” character The ICD-10-CM utilizes a placeholder character “X” The “X” is used as a 5th and /or 6th character placeholder at certain 6 and/or 7 character codes to allow for future expansion.

ICD-10 Cast of Characters
7th Characters Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.

ICD-10-CM Basic ICD-10 Coding Guidelines: A – initial encounter for that provider D – Subsequent encounter S – Sequela (late effects)

ICD-10 7th Characters A - The initial encounter character is used as long as the patient is receiving active care for that condition.

ICD-10 –CM 7th Characters D = Subsequent encounter – After the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Chiropractic treatments and physiotherapy are examples of subsequent encounters. Maybe.

ICD-10 -CM 7th Characters S = Sequela – Complications or conditions that arise as a direct result of a condition.

The seventh character (encounter): Which character is correct? Is the patient receiving active treatment? Is the patient in the middle of an active treatment plan? Has the patient’s condition stabilized? Is the patient receiving supportive care? Is the patient in a healing or recovery phase? Is the patient being treated for a complication that is the direct result of some other condition? © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Definitions •“Includes”
This note appears immediately under a three-digit code title to further define, clarify, or give examples of the content of a code category . •“Excludes” Excludes 1 – is used when two conditions cannot occur together or “NOT CODED HERE!” Mutually exclusive codes; two conditions that cannot be reported together. Excludes 2 – indicates “NOT INCLUDED HERE.” Although the excluded condition is not part of the condition, it is excluded from, a patient may have both conditions at the same time. The excluded code and the code above the excludes can be used together if the documentation supports them.

ICD-10 Conventions “Excludes” Excludes1 – consider these codes instead (you can only use 1) (mutually exclusive) Excludes2 – consider these codes in addition (you may use 2 or more) (Not included) © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Definitions “Code First/Use additional code”
Provides instructions on how to “sequence” the codes. Signals that that an additional code should be reported to provide a more complete picture of the diagnosis. •“Code Also” Alerts the coder that more than one code may be required to fully describe the condition. The sequencing of the codes depends on the severity and/or the reason for the encounter.

ICD-9 Hierarchy Hierarchy of the codes: Neurological diagnosis
Structural descriptor diagnosis Functional diagnosis Soft tissue Extremity Complicating factors

Sequencing of Codes Numbers are reported on the insurance claim form because you are communicating to a computer. Be sure to use the correct numbers, to the highest specificity. The diagnosis you provide directly relates to the level of care permitted by the third-party payers. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Sequencing of Codes Hierarchy in ICD-9 = Sequencing in ICD-10

Self-Test #1 The mandatory implementation date for ICD-10 is ___________________ ICD-10 contains how many chapters in the United States? ____________ In ICD-10, the placeholder character used for codes that require a seventh character extender is ______________ The National Center for Health Statistics is responsible for the Clinical Modifications of ICD True or False ICD-10 codes start with a letter, except for the letter _____________ © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Self-Test Key #1 October 1, 2015 21 X True U

The ICD-10 Crosswalk

General Equivalence Mapping (GEMs)
The GEMs will act as a translation dictionary to bridge the “language gap” between the two code sets and can be used to map an ICD-9 code to an ICD-10 code and vice versa. Attempt to include all valid relationships between the codes in the ICD – 9 and ICD – 10 classification © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-9 Cervicalgia 723.1 ICD-10 Cervicalgia M54.2
Coding Examples ICD-9 Cervicalgia ICD-10 Cervicalgia M54.2 © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Coding Examples ICD Sciatica ICD-10 M54.30 Sciatica unspecified side M54.31 Sciatica Right M54.32 Sciatica Left M54.40 Sciatica with lumbago unspecified M54.41 Sciatica with lumbago right M54.42 Sciatica with lumbago left © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Choosing the Diagnosis
Name Abbreviation Code Cervical C1-C7 739.1 Thoracic T1-T12 739.2 Lumbar L1-L5 739.3 Sacrum and Coccyx S or SC 739.4 Ilium/Illi I or SI 739.5 © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

739.1 equivalent ICD-10 code sets
S13.100A‑S13.101S S13.10 Subluxation and dislocation of unspecified cervical vertebrae S13.110A‑S13.111S S13.11 Subluxation and dislocation of C0/C1 cervical vertebrae S13.120A‑S13.121S S13.12 Subluxation and dislocation of C1/C2 cervical vertebrae S13.130A‑S13.131S S13.13 Subluxation and dislocation of C2/C3 cervical vertebrae S13.140A‑S13.141S S13.14 Subluxation and dislocation of C3/C4 cervical vertebrae S13.150A‑S13.151S S13.15 Subluxation and dislocation of C4/C5 cervical vertebrae S13.160A‑S13.161S S13.16 Subluxation and dislocation of C5/C6 cervical vertebrae S13.170A‑S13.171S S13.17 Subluxation and dislocation of C6/C7 cervical vertebrae S13.180A‑S13.181S S13.18 Subluxation and dislocation of C7/T1 cervical vertebrae © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P 114

Subluxation Equivalents
Biomechanical Lesion: Chapter 13 739.1 = M segmental and somatic dysf.- cervical region 739.2 = M segmental and somatic dysf.- thoracic region 739.3 = M segmental and somatic dysf.- lumbar region 739.4 = M segmental and somatic dysf.- sacral region 739.5 = M segmental and somatic dysf.- pelvic region 739.6 = M Segmental and somatic dysf. – lower extremity 739.7 = M Segmental and somatic dysf. – upper extremity 739.8 = M Segmental and somatic dysf. – rib cage © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P 115

ICD-10 Equivalents 847.2 = S39.012D Strain of muscle, fascia and tendon of the lower back, Subsequent Encounter 729.1 = M Myositis, Unspecified = M79.1 – Myalgia = M Fibromyalgia © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P 116

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99)
Rules Are Rules

Chapter 13: Rules for Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99)
M refers to "diseases of the musculoskeletal system and connective tissue." After the letter are two numbers, separated by a decimal, which add more specific information. For example, if you see M21, the 21 refers to "other acquired deformities of limbs“ (pg 181) and the numbers to the right indicate where and what side. Example: M21.172

Site and laterality: For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code. If there is not a multiple sites code, then use multiple codes to indicate the multiple sites involved. Code by site first, then condition.

Site Indicates the bone, joint or muscle involved There may be “multiple site” codes If there is not a multiple site code available, and you have multiple sites involved, then you have to use multiple codes to indicate the different sites involved

Arthritis and osteoarthritis have both site and laterality designations in ICD-10-CM It includes the type of arthritis such as primary, secondary or post-traumatic.

Rheumatoid arthritis (RA) Broken down by
Chapter 13: Rules for Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) Rheumatoid arthritis (RA) Broken down by Site Laterality Complication With or without Rheumatoid Factor Example: M rheumatoid arthritis without rheumatoid factor, left elbow

Site represents Bone Joint Muscle Multiple site codes If there is no multiple site code, multiple codes should be used

ICD-10 Dissected ICD-9 XXX.XX ICD-10 XXX.XXX X A B A B C
A = Category of code B = Etiology, anatomic site, and manifestations C = Extension used for 7th character for obstetrics, injuries, and external causes

ICD-10 Dissected A = Category of code
B = Etiology, anatomic site, and manifestations C = Extension used for 7th character for obstetrics, injuries, and external causes

ICD-10 Dissected 2 Extremity: We are Number One! We are Number Two! 1

ICD-10 Dissected M25.619 Stiffness of unspecified shoulder, not elsewhere classified. Stiffness of right shoulder, not elsewhere classified Stiffness of left shoulder, not elsewhere classified

ICD-10 Dissected M25.619 Stiffness of unspecified shoulder, not elsewhere classified. M25.611 Stiffness of right shoulder, not elsewhere classified Stiffness of left shoulder, not elsewhere classified

ICD-10 Dissected M25.619 Stiffness of unspecified shoulder, not elsewhere classified. M25.611 Stiffness of right shoulder, not elsewhere classified M25.612 Stiffness of left shoulder, not elsewhere classified

Example: M Pain in the Right Knee M Pain in the Left Knee Side is reported in the 6th Character

Spine Specify by level

Spondylolysis Spondylolysis is a defect of a vertebra. More specifically it is defined as a defect in the pars interarticularis of the vertebral arch.

Dorsopathies (M40-M54) The following supplementary sub classification to indicate the site of involvement is provided for optional use with appropriate categories in the block on dorsopathies, except categories M50 and M51; see also note at the beginning of this chapter. 0 Multiple sites in spine 1 Occipito-atlanto-axial region 2 Cervical region 3 Cervicothoracic region 4 Thoracic region 5 Thoracolumbar region 6 Lumbar region 7 Lumbosacral region 8 Sacral and sacrococcygeal region 9 Site unspecified

M43.00 Spondylolysis, Excludes 1 congenital spondylolysis (O76.2), spondylolisthesis, (M43.1). site unspecified Spondylolysis of Cervical region

Dorsopathies (M40-M54) The following supplementary sub classification to indicate the site of involvement is provided for optional use with appropriate categories in the block on dorsopathies, except categories M50 and M51; see also note at the beginning of this chapter. 0 Multiple sites in spine 1 Occipito-atlanto-axial region 2 Cervical region 3 Cervicothoracic region 4 Thoracic region 5 Thoracolumbar region 6 Lumbar region 7 Lumbosacral region 8 Sacral and sacrococcygeal region 9 Site unspecified

M43.00 Spondylolysis, Excludes 1 congenital spondylolysis (O76.2), spondylolisthesis, (M43.1). site unspecified Spondylolysis of Cervical region M43.02

Self-Test #2 What is the term for the crosswalk from ICD-9 to ICD-10 or vice versa? ________________________________ The patient presents with lower back and bilateral leg pain, numbness, and tingling in both legs. Straight leg raise test is positive bilaterally for sciatica. You suspect disc involvement at L5. Your diagnosis is therefore listed as _______________________. Code the diagnosis: _____________________ Rheumatoid arthritis coding requires site, laterality, complications and _________________ If you are diagnosing arthritis in multiple sites and there is no multiple site code, what do you do? ___________________________ What is the ICD-9 code for sciatica? _______________________________ What is the preferred ICD-10 code for a subluxation of the cervical spine? ____________ What is the preferred ICD-10 code for a subluxation at T12? __________________________ © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Self-Test Key #2 General Equivalence Mapping (GEM) M99.01
Bil Sciatica, M54.41, M54.42 With or without RF Factor Use multiple codes 724.3 M99.01 M99.02 © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Obstetrics Chapter 15: Obstetrics Rules Trimesters defined as :
First trimester – less than 14 weeks 0 days Second trimester – 14 weeks 0 days to less than 28 weeks 0 days Third trimester – 28 weeks 0 days until delivery Trimesters are counted from the first day of the last menstrual period © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Obstetrics In 2012, codes were added to indicate the weeks of gestation of the pregnancy. An additional code is used in category Z3A weeks of gestation are added to provide additional information about the pregnancy. Example: 18 weeks of gestation is Z3A.18 © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Obstetrics Codes for unspecified trimester should never be reported unless it is impossible to determine the trimester from the medical record documentation. The “unspecified trimester” code should rarely be used. This is only used when it is not possible to obtain clarification. It is likely that using the “unspecified trimester” code will trigger a denial. Trimesters are counted from the first day of the last menstrual period. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Obstetrics A code from category Z3A, weeks of gestation are for use on the maternal record to indicate the specific week of gestation of the pregnancy. They are to be appended as additional codes to the codes from chapter 15. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Obstetrics ICD-10 CASE FILE: A woman presents to the office at 21 weeks of her pregnancy with back pain caused by her pregnancy. Examination reveals a positive Kemp’s test for right sacroiliac joint pain, tenderness to palpation of the right SI, spasms and edema in the right SI. DIAGNOSIS: O33.0 Maternal care for disproportion due to deformity of maternal pelvic bones Z3A weeks of gestation of pregnancy © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Self-Test #3 1.The patient is seen for her routine visit during her seventh month of pregnancy. She is 28 weeks, 3 days. What is the secondary code for her visit? ___________________ 2 What trimester is 14 weeks, 0 days? ______________ © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Self-Test Key #3 Z3A.28 Second

Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes (S00 – T88)
Most categories in chapter 19 have a 7th character extension requirement for each applicable code. Most categories, except for fractures, will require an A – Initial encounter D – subsequent encounter S – sequela as the 7th character.

7th character A: Initial encounter Used when the patient is receiving active treatment for the condition Surgical treatments Emergency department encounter Evaluation and treatment by a new physician

7th character D: Subsequent encounter After treatment in the active phase of care and the patient is in the healing or recovery phase of care Examples of this care are cast change, medication adjustment, or other aftercare following treatment of the injury or condition (rehabilitation).

7th character S: Sequela For complication or conditions that arise as a direct result of a condition, such as deconditioning of muscle after an injury. When using the Sequela codes, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added to the injury code only, not the sequela code.

7th character S: Sequela The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela is sequenced first on the claim form, followed by the injury code.

Personal Injury

Sports Injuries

ICD-10 examples M Stiffness of left hip, not elsewhere classified

Self-Test #4 What are the three seventh character extension codes? ______________ What extension character is associated with the healing or recovery phase of care? ________ © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

A combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication #4 © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Coding Examples S: A patient enters the office today c/o pain in the lower back and leg. She reports pain for one month duration. Pain is in the posterolateral aspect of the leg with radiation into the foot O: SLR positive at 45 degrees. Patellar DTR +1 bilaterally. Muscle strengths lower extremity +5 bilaterally Diagnosis: M54.30 Sciatica unspecified side M54.31 Sciatica Right M54.32 Sciatica Left M54.40 Sciatica with lumbago unspecified M54.41 Sciatica with lumbago right M54.42 Sciatica with lumbago left © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Coding Examples S: A patient enters the office today c/o pain in the lower back and right leg. She reports pain for one month duration. Pain is in the posterolateral aspect of the leg with radiation into the right foot O: SLR positive on the right at 45 degrees. Patellar DTR +1 bilaterally. Muscle strengths lower extremity +5 bilaterally Diagnosis: M54.30 Sciatica unspecified side M54.31 Sciatica Right M54.32 Sciatica Left M54.40 Sciatica with lumbago unspecified M54.41 Sciatica with lumbago right M54.42 Sciatica with lumbago left © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Coding Examples S: The patient returns today for follow-up pertaining to the ligament injury in the middle thoracic region. He stated that his pain is decreased to 4 out of 10, sharp, constant. O: Hypomobility at T9, Kemp’s test positive on the right, Edema at T8-T11 bilaterally. Diagnosis: S23.3xx S A D © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-10 Chapter 20: External Causes of Morbidity (V00-Y99)

ICD-9 E-Codes Explain External causes
They supplement the primary diagnosis Explain where rather than why the claim should be paid E-Codes are non-pricing, which means they are not used as primary codes, but as secondary to the main ICD-9 codes. Currently not often used © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-9 E-Codes E Motor Vehicle Collision w/ Another Vehicle (Driver) E Motor Vehicle Collision w/ Another Vehicle (Passenger) E Motor Vehicle Traffic Accident Due to Loss of Control, Without Collision on the Highway E813.0, "motor vehicle traffic accident involving collision with other vehicle; driver of motor vehicle other than motorcycle," E Motor Vehicle Collision w/ Stationary Object (Driver) E Motor Vehicle Collision w/ Stationary Object (Passenger) E Accidental Fall on Stairs Home) E Accidental Fall on Stairs Industrial Place) E Accidental Fall on Stairs Place for Recreation) E Accidental Fall on Stairs Public Building) E Accidental Fall on Same Level (Slip, Trip, Stumble) Home) © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

ICD-9 E-Codes E Overexertion from sudden strenuous movement E Overexertion from prolonged static position E Excessive physical exertion from prolonged activity E Cumulative trauma from repetitive motion E Cumulative trauma from repetitive impact © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

E-Codes = External Cause Codes

External Cause Codes No national requirement for mandatory external cause coding May be a state-based or payer-based requirement It is encouraged to voluntarily report external cause codes © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

External Cause Codes External cause codes and place of occurrence codes answer the following questions: What was the patient when the injury happened? Where was the patient? Did the accident happen on the job? © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Coding of Injuries Initial encounters generally require four codes
External cause codes Think of it as a verb Used for length of the treatment of the patient Utilizes 7th character extender Changes with the status of the patient A, D, S Use the full range of external cause codes to fully explain each cause Assign as many codes as necessary, however if only one is used, use the code that most relates to the principal diagnosis An external cause code can never be a principal (first-listed) diagnosis

Place of occurrence (Y92) Used only once, at the initial encounter Use it only if you know where was the location of the injury Never us an unspecified code here

Activity codes (Y93) Used only once, at the initial encounter Use it only if you know what the activity is Never us an unspecified code here Used in conjunction with a place of occurrence code (Y92)

External cause status Used only once at the initial encounter Was the patient working at the time of the injury? Military? Hobby? A work-related activity is any activity for which payment or income is derived. Use Y93.9 if the activity of the patient is not stated or is not applicable

Coding of Injuries Regardless of the number of external cause codes assigned, there should be only one place of occurrence code and one activity code assigned to an encounter.

External Cause of Injury Codes

Burn due to water skis on fire; Initial Encounter V91.07XA

S: The patient presents today after having a new cabinet fall on her last week, suffering a concussion, as well as neck pain. She was cooking dinner at her home, which she shares with her husband. The patient did not seek treatment, prior to our office. She stated that the cabinets were installed incorrectly in her kitchen. Her husband, who was home with her at the time of the injury, told her she was “out cold” for about two minutes. The patient continues to have headaches, primarily in the back of the head, extending up into the head in the occipital and parietal regions bilaterally. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. O: Decreased joint motion at C1 and C7. Tenderness with spasms in the sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical compression is negative. Maximum cervical compression is positive bilaterally at C1 and C7. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

W20.8xxA Struck by falling object (accidently) Initial encounter

Y93.g3 Activity, cooking and baking

Initial encounter (A) S: The patient presents today after having a new cabinet fall on her last week, suffering a concussion, as well as neck pain. She was cooking dinner at her home, which she shares with her husband. The patient did not seek treatment, prior to our office. She stated that the cabinets were installed incorrectly in her kitchen. Her husband, who was home with her at the time of the injury, told her she was “out cold” for about two minutes. The patient continues to have headaches, primarily in the back of the head, extending up into the head in the occipital and parietal regions bilaterally. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. O: Decreased joint motion at C1 and C7. Tenderness with spasms in the sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical compression is negative. Maximum cervical compression is positive bilaterally at C1 and C7. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Y92.010 Place of occurrence, house, single family, kitchen

S06. 0x1A Concussion with loss of conciousness 30 min or less
S06.0x1A Concussion with loss of conciousness 30 min or less Initial encounter S: The patient presents today after having a new cabinet fall on her last week, suffering a concussion, as well as neck pain. She was cooking dinner at her home, which she shares with her husband. The patient did not seek treatment, prior to our office. She stated that the cabinets were installed incorrectly in her kitchen. Her husband, who was home with her at the time of the injury, told her she was “out cold” for about two minutes. The patient continues to have headaches, primarily in the back of the head, extending up into the head in the occipital and parietal regions bilaterally. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. O: Decreased joint motion at C1 and C7. Tenderness with spasms in the sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical compression is negative. Maximum cervical compression is positive bilaterally at C1 and C7. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Intractable S: The patient presents today after having a new cabinet fall on her last week, suffering a concussion, as well as neck pain. She was cooking dinner at her home, which she shares with her husband. The patient did not seek treatment, prior to our office. She stated that the cabinets were installed incorrectly in her kitchen. Her husband, who was home with her at the time of the injury, told her she was “out cold” for about two minutes. The patient continues to have headaches, primarily in the back of the head, extending up into the head in the occipital and parietal regions bilaterally. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. O: Decreased joint motion at C1 and C7. Tenderness with spasms in the sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical compression is negative. Maximum cervical compression is positive bilaterally at C1 and C7. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

S134xxA Cervical Sprain Initial Encounter
S: The patient presents today after having a new cabinet fall on her last week, suffering a concussion, as well as neck pain. She was cooking dinner at her home, which she shares with her husband. The patient did not seek treatment, prior to our office. She stated that the cabinets were installed incorrectly in her kitchen. Her husband, who was home with her at the time of the injury, told her she was “out cold” for about two minutes. The patient continues to have headaches, primarily in the back of the head, extending up into the head in the occipital and parietal regions bilaterally. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. O: Decreased joint motion at C1 and C7. Tenderness with spasms in the sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical compression is negative. Maximum cervical compression is positive bilaterally at C1 and C7. S134xxA Cervical Sprain Initial Encounter G Acute Post traumatic headache Intractable S06.0x1A Concussion with loss of conciousness 30 min or less Initial encounter M Segmental and somatic dysfunction of cervical region W20.8xxA Struck by falling object (accidently) Initial encounter Y93.g Activity, cooking and baking Y Place of occurrence, house, single family, kitchen © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Clinical Example: A patient is a delivery person for a florist
Clinical Example: A patient is a delivery person for a florist. While delivering a bouquet of flowers to a person at a workplace, they slip and fall on untreated ice in the parking lot, at the workplace. In the fall, they fracture their wrist. Is the party at fault the workplace or is it a worker’s compensation claim? While they are deciding, the hospital does not want to wait, so they say to file it with the health insurance. ICD-10 codes are used. Three weeks later, it is decided that the claim will be handled by the worker’s compensation carrier, since the hotel insurance argued that it was an act of God.

Coding of Injuries Broke wrist At hotel In parking lot Walking
Slipped and fell on the ice Working The first line of communication with a carrier is the claim form.

Self-Test #5 Self-Test #5 1. In ICD-9, what are the supplemental codes that describe how or where an injury occurred? ________________________ 2. What kind of policies would you use an e-code? ____________________ 3. Place these in the correct order: Place of occurrence, activity, external cause code, external cause status a. b. c. d. © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Self-Test Key #5 E-Codes Accident Policies a. External cause
b. Place of occurrence c. Activity d. External cause status © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

Resources CMS ICD-10 Training www.cms.gov/icd10
NCHS – Basic ICD-10-CM Information CMS – ICD-10-PCS Information AHIMA - ICD-10 Education AHIMA has a free monthly ICD-10 Newsletter WEDI – ICD-10 Implementation © Copyright 2015, ICD-10 Coding and Documentation 4 Hours, Mario Fucinari DC, MCS-P

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Welcome to... ICD-10 Coding No Recording of ANY TYPE allowed

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