1. ICD-10 Orientation In Post Acute Care (Part IV)
Rhonda Anderson, RHIA
Anderson Health Information Systems, Inc.
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

2. Location, Date, Time Northern California Southern California
Fairfield Post Acute Rehab
March 20, 2014
9:00am – 3:00pm
Southern California
Garden View Post Acute Rehab
April 9, 2014

3. Presenters Staci LePage, RHIT
Mobile:
Khaleelah Wagner, RHIA
Mobile:
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

4. Chapter 17 – Congenital Malformations, Deformations & Chromosomal Abnormalities Q00-Q99
Nothing significantly changed
Some reorganization of the section
Organized by system

5. Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab Findings (R00-R99)
Expanded abdominal pain by quadrants
Abnormality of gait now has 6 types
Sepsis now in this chapter
Abnormal lab findings now specify “without diagnosis” rather than “nonspecific abnormal finding”

6. Signs/Symptoms Coding
R65 Symptoms and signs specifically asso with systemic inflammation and infection
R65.1- Systemic inflammatory response syndrome/SIRS of non-infectious origin
Need to know with/without organ dysfunction
R65.2- Severe sepsis
Need to know with/without septic shock, also code 1st underlying infection
Non-fectious SIRS could be caused by heat stroke or injury and trauma – code this first
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

7. Signs/Symptoms Codes -2
Use of symptom codes are acceptable for use when a related diagnosis has NOT been established by the provider
A symptom code with a diagnosis code may be reported when the sign or symptom is NOT routinely associated with that diagnosis
Signs or symptoms that are associated routinely with a disease process should NOT be assigned as additional codes

8. General Signs and Symptoms R50-R69
R50 Fever of unknown origin
R51 Headache
R52 Pain, unspecified
Excludes acute and chronic pain, NEC (G89.-)
R53 Malaise and fatigue
R55 Syncope and collapse
R56 Convulsions, not elsewhere classified
Excludes seizure disorder G40.
Be aware when coding in this section – should ONLY be using these codes if no further information as to condition causing these symptoms.
A single seizure (usually someone who is NOT on med to control seizures) is coded to R56, but someone with seizure disorder (is usually on med) is coded to Epilepsy G40.-
Epilepsy is a brain disorder in which a person has repeated seizures (convulsions) over time
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

9. Dysphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
R13.13 Dysphagia, pharyngeal phase
R13.14 Dysphagia, pharyngoesophageal phase
R13.19 Other dysphagia
ST knows phase of dysphagia after they do ST eval. Obtain info from them.
Should not have to use unspecified code very often.
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

10. Dysphagia -2
Code first, if applicable, dysphagia following CVD (I69.-)
Need to know phase of dysphagia (therapist)
ST knows phase of dysphagia after they do ST eval. Obtain info from them.
Should not have to use unspecified code very often.
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

11. Other Symptoms and Signs Involving Cognitive Functions
Expanded category:
R41.81 Age-related cognitive decline
R41.82 Altered mental status
Excludes altered mental status d/t known condition – code to condition
R41.83 Borderline intellectual functioning
R Other specified cognitive deficit
R Cognitive communication deficit
R41.89 Other S/S involving cognitive function
R41.9 Unspecified S/S involving cog function
SNF’s should not typically be coding altered mental status, as the condition causing the altered mental status should have been diagnosed already.
R some other codes too -
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

12. Other Symptoms and Signs Involving Cognitive Functions -2
R29.6 Repeated falls is used when a patient has recently fallen and reason for the fall is being investigated.
Z91.81 Hx falls is used when a pt has fallen in the past and is at risk for future falls
Need to know which are appropriate, as both of the above codes may be assigned together, as needed

13. Lack of Coordination Expanded codes in ICD-10-CM
Now with subcategories:
R27.0 Ataxia, unspecified
R27.8 Other lack of coordination
R27.9 Unspecified lack of coordination
Need to know type of lack of coordination (therapist determines)

14. Signs/Symptoms Involving Speech and Voice R47-R49
R47.0 Dysphasia and aphasia
R47.1 Dysarthria and anarthria
R47.8 Other speech disturbances
R47.9 Unspecified speech disturbances
Excludes these conditions when following Cerebrovascular disease I69
Therapist needs to know type of speech disturbance

15. Dyslexia and Other Symbolic Dysfunctions R48
Expanded category:
R48.0 Dyslexia and alexia
R48.1 Agnosia
R48.2 Apraxia
R48.3 Visual agnosia
R48.8 Other symbolic dysfunctions
R48.9 Unspecified symbolic dysfunctions
Therapist needs to know type of symbolic dysfunction
R48.8 includes acalculia and agraphia
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

16. Weakness R53.1 Weakness vs. M62.81 Generalized muscle weakness
Need to know if just “weakness” or “muscle weakness”
R53.1 codes to just signs/symptoms code vs M62.81 codes to musculoskeletal system *preferred code
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

17. Abnormality of Gait
Difficulty in walking category has changed from unspecified joint disorders to abnormalities of gait and mobility
R26.0 Ataxic gait
R26.1 Paralytic gait
R26.2 Difficulty in walking
R26.8- Other abnormalities of gait/mobility
R26.9 Unspecified abnormalities gait/mobility
Need to know type of gait abnormality (therapist)
Code was in ICD-9
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

18. Quadriplegia R53.2 Functional quadriplegia vs. G82.5- Quadriplegia
Complete immobility d/t severe physical disability or frailty
vs.
G82.5- Quadriplegia
I69.- Paresis d/t sequelae of CVD
It should only be assigned if functional quadriplegia is specifically documented in the medical record by MD.
Functional quadriplegia is the lack of ability to use one’s limbs or to ambulate d/t extreme debility
Since it is NOT associated with neurologic deficit or injury, code R53.2 should NOT be used for cases of neurologic quadriplegia (G82.5-)
Quadriplegia, NOS (G82.50)
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

19. Malaise and Fatigue R53 Expanded category:
R53.0 Neoplastic related fatigue
R53.1 Weakness
R53.2 Functional quadriplegia
R53.8- Other malaise and fatigue
R53.81 Other malaise (debility)
R53.82 Chronic fatigue, unspecified
R53.83 Other fatigue (lethargy)
Only code if malaise/fatigue is NOT d/t another condition

20. Chapter 19 – Injury, Poisoning & Certain Other Consequences of External Causes S00-T88
Fractures in sub-categories by:
Displaced and non-displaced, then
Site on the specific bone or type/name of fracture (torus, green stick, transverse, oblique spiral, comminuted, segmental), then
Right or left
Hip fracture has 69 possible codes
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

21. Traumatic Fractures
A fracture not indicated as open or closed should be coded to closed
A fracture not indicated whether displaced or not should be coded to displaced
Example:
S42.321D Displaced transverse fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing

22. Traumatic Fractures -2
Need to carefully look at the pink text boxes (in the tabular) for assigning the correct 7th digit
Need to know if displaced or not, type of fracture/bone, laterality
Pink text box to assign this 7th character is located at the beginning of the category for S42., not on the same pg as the code.
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

23. Types of Fractures
Displaced fracture - fracture in which the two ends of the broken bone are separated from one another
Non-displaced fracture - the bone cracks either part or all of the way through, but does move and maintains its proper alignment.
Closed fracture - the bone breaks but there is no puncture or open wound in the skin

24. Types of Fractures
Open fracture - the bone breaks through the skin

25. Poisoning by, Adverse Effects of and Underdosing of Drugs
Table of drugs shows following categories:
Poisoning, accidental (unintentional)
Poisoning, intentional (self-harm)
Poisoning, assault
Poisoning, undetermined
Adverse effect *
Underdosing *
Categories have changed – be aware *was therapeutic use
ICD-9 drug table with categories of: poisoning, accident, therapeutic use, suicide attempt, assault, undetermined
In ICD-10, the 6th character will be: 1- for accidental, 2 – for intentional, 3 – for assault, 4 – for undetermined, 5 – for adverse effect, 6- for underdosing
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

26. Underdosing
Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction
Assign T36-T50 with 6th character of “6”
Codes for underdosing should never be assigned as principal dx
Noncompliance (Z91.12-) codes are to be used with an underdosing code, if known
Z pt intentional underdosing of med regimen d/t financial hardship
Z pt intentional underdosing of med regimen for other reason
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

27. Chapter 20 External Causes
Not used in long term care, not required to use

28. Chapter 21 – Factors Influencing Health Status and Contact with Health Services (Z00-Z99)
For use in any healthcare setting
May be used as either a principal diagnosis or secondary code
Certain Z-codes may only be used as principal diagnosis *but these codes are not applicable to long term care setting
These are the equivalent to ICD-9 V codes with mult changes
See coding guidelines for lists of allowable first listed Z codes, etc
In long term care, none of the Z codes that may only be principal/first listed are applicable to us.
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

29. Z Codes -2
Provided for occasions when circumstances other than a dx, injury or external cause are recorded
Several codes have been expanded, i.e. personal and family hx
Now have a code for patients blood type, i.e. Z67
Z code should not be used if treatment is directed at a current acute disease
Chapter 20 – former E codes are now V00-Y99 codes *long term care still does not code these
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

30. Z Codes -3 No longer have V57 codes
Code the underlying condition, i.e. injury, etc. with the appropriate 7th character for subsequent encounter
Z68 BMI is divided into adult and pediatric codes (Adults = age 21 or older)
RD in facility can assist with documenting the BMI

31. Z Codes -4
Code Z92.82 when tsf facility has admin tPA within 24 hrs prior to admit (usually with new dx of MI or CVD)
Aftercare Z codes should NOT be used for aftercare of fractures
For aftercare of fractures, assign fracture code with 7th character D for subsequent encounter

32. Z47 Orthopedic Aftercare
Excludes aftercare for healing fracture – code to fracture with 7th character D
Z47.1 Aftercare following joint replacement surg
Use add’l code to id the joint (Z96.6-)
Z47.3 Aftercare following explantation of joint prosthesis
Need to know joint (shoulder, knee, hip)
Z47 excludes aftercare for fx – only for OA, etc. not injury
-Z47.2 Encounter for removal of internal fixation device *would NOT use this code in LTC setting
-explantation = to remove
-Z47.81 encounter for orthopedic aftercare following surgical amputation *new code
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

33. Z47 Orthopedic Aftercare -2
Z47.8 Encounter for other orthopedic aftercare
Z47.81 following surgical amputation
Use add’l code to identify the limb amputated (Z89.-)
Z47 excludes aftercare for fx – only for OA, etc. not injury
-Z47.2 Encounter for removal of internal fixation device *would NOT use this code in LTC setting
-explantation = to remove
-Z47.81 encounter for orthopedic aftercare following surgical amputation *new code
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

34. Joint Replacement ICD-9-CM: ICD-10-CM:
V54.81 Aftercare following joint replacement
V43.64 Joint replacement, hip
ICD-10-CM:
Z47.1 Aftercare following joint replacement surgery
Excludes aftercare for healing fracture
Z Presence of right artificial hip joint
Need to know right or left and which joint
Z47 is only used for musculoskeletal conditions, ie OA, etc.
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

35. Therapy Admission
Resident admitted for physical therapy following CABG
Z Encounter for surgical aftercare following surgery on the circulatory system
Z95.1 Presence of aortocoronary bypass graft
Plus, therapy treatment codes (muscle weakness, gait disturbance, etc), per therapists

36. Amputee Status
Status post L BKA admitted for dressing changes following resolved infection of the amputation stump
Z48.01 Encounter for change or removal of surgical wound dressing
Z Acquired absence of leg below left knee
Need to know which knee and above or below the joint
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

37. ICD-10-CM Readiness Identify if education is needed
Knowledge is a key step in successful implementation
Separate roles into two groups
Group that primarily assigns codes
Group that primarily does NOT assign codes

38. Different Knowledge Levels Defined As
A general knowledge of the code system and important differences between ICD-9 and ICD-10
Use/professional knowledge level which would be for an individual who uses coded data but is typically not assigning codes daily
Application of the code set would be for those individuals who are routinely applying codes

39. Education Time
An employee with experience in coding (who was trained on the job) is estimated to need 18 hours of cumulative education for ICD-10
Education varies based upon the needs of each individuals skill level
Intense coding education should NOT be initiated until three months before implementation

40. Steps To Take Now Educational Tasks/Phase I
Learn about the structure, organization, and unique features of ICD-10
Network with peers, access resources, and read literature to identify transition issues and best practices
Provide opportunity for coders to review code structure and coding conventions for ICD-10

41. General Implementation Task / Phase I
Develop an implementation plan
Identify steps to prepare for implementation
Identify who should be involved in preparation
Develop time frames for implementation phases
Identify current systems that input, store and utilize ICD data
Identify who is currently performing coding; in addition to other individuals who may be cross-trained for code assignment

42. General Implementation -2
Review current workflow to identify areas of impact and analyze opportunities for improvement (data in MDS, health record, and claim form)
Common workflow examples are diagnostic tests (laboratory, radiology, therapy diagnoses and billing)
Document improvement processes

43. Improvement Processes
Analyze current documentation practices, physician, nursing and therapy to identify areas in need of improvement
Identify current processes that may lead to poor data quality due to inadequate or outdated documentation practices
Conduct detailed assessment of staff educational needs r/t documentation

44. Improvement Processes -2
Review current workflow to identify the areas of impact and analyze areas for improvement

45. General Implementation Tasks / Phase 2
Determine the date of installation of facilities ICD-10 database software (must be utilized in a parallel manner with current ICD-9 code library) *by April
Do NOT uninstall ICD-9 database
Address timeline to begin coding current residents’ dx

46. Educational Tasks / Phase 3
Continue educational plan, including intensive education for roles who primarily assign codes
Practice ICD-10 coding of current records
Implement process for parallel coding of current residents with ICD-10 to facilitate future data entry

47. Educational Tasks / Phase 3
Provide more intensive educational and consultative support to coders and users of coded data
Continue documentation improvements in areas identified for Improvement
Install ICD-10 vendor software into the system to prepare for transition
Perform software system testing

48. General Implementation Tasks/Phase 3
ICD-9 legacy data must be maintained and available
Closely monitor productivity and quality measures for issues that might be r/t implementation of new code sets
ICD-10 Orientation in Post Acute Care 4Hrs PART IV

49. Thanks for attending!!