1. ICD-10 – Orientation in SNFs International Classification of Diseases – CM
RHONDA L. ANDERSON, RHIA
President, AHIS, Inc.
DRAFT 9/20/11

2. ICD-10 Orientation in snfs
Staci LePage, RHIT,
Anderson Health Information Systems, Inc.

3. Objectives Participants will identify: Dates for New ICD-10
Documentation support
New terms encounter principal diagnosis re-defined
Some general coding guidelines

4. Final Regulation January 15, 2009 Final Regulation Released
EXCHANGE the ICD-9 for the ICD-10 on October, 1, 2014

5. ICD-10 “Has Two Parts”
ICD-10 CM = Clinical Modification, ICD-10 CM – applies to SNF, Intermediate Care, Physician’s Offices, Clinics, Dialysis, Home Health, other health care settings who bill Medicare, MediCal or Private Ins.
ICD-10 PCS = Procedural Code System (used for Acute Hospital procedures, operations

6. HIPAA
Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)
HIPAA has evolved from 1996 to HITECH which relates to security and breaches
HIPAA Transactions 5010 went into effect October 2011
HITECH – HIPAA Privacy and Security final rule was released January 2013

7. Who Is Affected??
All inpatient and outpatient facility visits as well as freestanding providers and ancillary services “that means all of us really” who provide services and bill for them under Medicare, Medi-Cal and private insurances.

8. Benefits More specific coding system Reflects medical advancements
Standardization, UK implemented in 1995, used worldwide
The United States is the only industrialized nation that has not yet implemented ICD-10

9. What Does This Mean??
The guidelines in the ICD-10 manual developed for the provider and the coder….(person who may review the documentation and determine if code is accurate.
Consistent, complete documentation in the medical record is a major emphasis.

10. Key Highlights
ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings
ICD-10 PCS (Procedural Code System)
– replaces ICD-9 CM in the inpatient
hospital setting
Current Procedural Terminology (CPT) is still used for the Physician, and some services, but they must have a diagnosis that is ICD-10 compliant

11. Key Highlights -2
Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services.
ICD-10 CM/PCS – Increased level of detail required for medicine advancements in technology, $$, improved data quality for clinical and financial decision making, to support value based purchasing and facilitate quality reporting.

12. ICD-9-CM Diagnosis Codes
3-5 characters in length
Approximately 14,000 codes
First digit may be alpha or numeric
Digits 2-5 are numeric
Always at least three digits
Decimal placed after the first three characters
Limited space for new codes

13. ICD-9-CM Diagnosis Codes -2
Lacks detail
Lacks laterality, difficult to analyze, dated, non-specific and does not adequately define diagnoses needed for medical research
Does not support interoperability because it is not used in other countries.

14. ICD-10 CM Structure
Index and Tabular list have the same hierarchical structure as ICD-9
ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list.

15. ICD-10 CM Structure -2
ICD-9 V and E code supplemental classifications are incorporated into the main classification in ICD-10
ICD-9 V codes are now Z codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services
Postoperative complications have been moved to procedure-specific body system chapters

16. ICD-10-CM Diagnosis Codes – Format & Structure
3-7 characters in length and alphanumeric
21 chapters (compared to 17 in ICD-9)
Approximately 68,000 codes
Digit 1 is always alpha, digit 2 is numeric; digits 3-7 can be alpha or numeric
Decimal placed after the first 3 characters

17. ICD-10-CM Diagnosis Codes – Format & Structure
Codes that have applicable 7th character is considered invalid without the 7th character.
Expanded codes
Flexible for adding new codes
Addition of placeholder “X”
Has laterality (rt. Left, lower, upper, outer, etc.)

18. Example Of Placeholder “X”
ICD-10 utilizes a placeholder character “x”
The “x” is used as a placeholder at certain codes to allow for expansion
See categories T36-T50, poisoning codes T36.8X1
Also, Pathological vertebral fracture due to age-related osteoporosis, subsequent encounter with delayed healing M80.08XG

19. Example Of Laterality
For bilateral sites, the final character of the codes in ICD-10 indicates laterality.
C Malignant Neoplasm of upper-inner quadrant of left female breast
H Dermatochalasis of left lower eyelid
I80.01 Phlebitis and Thrombophlebitis of superficial vessels of right lower extremity
L Pressure Ulcer of right hip, Stage 3
An unspecified site code is also provided should the site not be identified.

20. Example Of Expanded Codes
Expanded Codes (injury, diabetes, alcohol/substance abuse, postoperative complications)
E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease

21. Diabetes Diabetic Mellitus –
w/arthropathy NEC# (Type 2 diabetes with other diabetic arthropathy)
w/cataract E11.36 (Type 2 with diabetic cataract)
w/gangrene E11.52 (Type 2 with diabetic peripheral angiopathy w/gangrene)

22. Diabetes #2 w/foot ulcer E11.621 (type 2 diabetes with foot ulcer
(use additional code to identify site)

23. Diabetic #3
w/hypoglycemia E11.65
w/kidney complications E11.29

24. ICD-10 CM Structure - Requires “use” of proper coding guidelines
Relies on the use of the guidelines and in our case Skilled/ICF rules (more on this subject later during full training)
ICD-10 CM Index – disease and injury and external causes of Injury

25. ICD-10 CM Structure
More combined codes, i.e. Diabetic retinopathy is one code
More specificity, i.e. Alzheimer’s disease with specific details of early or late onset
G-30.9 et’l’
G30.0 Alzheimer’s with early onset
G “ with late onset
G30.9 Other Alzheimer’s

26. ICD-10 CM Structure
Alzheimers…you may need to use with behavioral disturbance and without behavioral disturbance.
>>key to psychoactive Drugs!!
???behavioral disturbance ???justification for psychotrophics ????

27. Conventions For The ICD-10-CM
General rules for use of the classification independent of the guidelines
Alphabetic Index and Tabular List
Alphabetic Index – List of terms and their corresponding code
Tabular List – chronological list of codes divided into chapters based on body system/condition
General coding guidelines are similar to ICD-9 with one additional guideline - laterality

28. Conventions For The ICD-10-CM -2
General rules for use of the classification independent of the guidelines
Format and Structure
First character is always alpha
Three character category that has no further subdivision is equivalent to a code
Subcategories are either 4 or 5 characters
Codes may be 3, 4, 5, 6 or 7 characters

29. Conventions For The ICD-10-CM -3
General rules for use of the classification independent of the guidelines
7th Characters
Certain ICD-10-CM categories have applicable 7th characters
Required for all codes within the category or as instructed by the notes in the Tabular List
Must always be the 7th character in the data field
If a code that requires a7th character is not 6 characters, a placeholder X must be used to fill in the empty characters

30. Examples Of 7th Character
Seventh character for a fracture
A = initial encounter for fracture
D = subsequent encounter for fracture with routine healing
G = subsequent encounter for fracture with delayed healing

31. Examples of 7th Character
K = subsequent encounter for fracture with nonunion
P = subsequent encounter for fracture with mal-union
S = sequela

32. FRACTURE Fracture Traumatic (abduction, adduction, separation)
Acetabulum – anterior, displaced, illopubic S32.43 or non-displaced S32.436
Acetablum – dome (displaced) S32.48
Fracture, lumbar vertebrae - (NOS .

33. FRACTURE
Fracture of lst lumbar vertebrae – S32.01, wedge compression, stable burse, unestablish, other, unspecified

34. ICD-10-CM Diagnosis Codes -4
Specificity improves coding accuracy and depth of data for analysis
Detail improves the accuracy of data used in medical research
Supports interoperability and the exchange of health care data between other countries and the U.S.

35. Code Format ICD-10 Code Format ICD-9-CM Code Format
                                                          
                                                                                   

36. GEM Files
Before we go further- do not despair…your vendor should prepare as much crosswalk as possible. There are “GEM” files.
General Equivalence Mappings (GEM)
translation dictionary for diagnoses !!

37. GEM FILES
There is NOT a one-to-one match between ICD-9 and ICD-10 codes
We will talk about GEMS later and how to use them. Key to early review!

38. \WHAT DOES THAT MEAN TO ME?
Identify your most common diagnoses.
Determine in advance some of the documentation issues that you will have with the nurses and the physicians
Discuss the specificity at the QA/PI meetings
Keep staff informed as we progress

39. WHAT DOES THIS MEAN TO ME?
The organization will need to know for all facilities or your facility what the most common diagnoses that are admitted and focus on those first
Focus on the documentation to support those
Focus on review of Acute Hospital Records more closely – Impact Inquiries

40. WHAT DOES THIS MEAN TO ME?
Review for Medicare must be more specific

41. ICD-10 & ICD-9 Differences
Organization
Structure
Code composition
Level of detail
May consist of 3 to 7 digits, with the seventh digit extensions representing visit encounter or sequel, as stated above.

42. ICD-10 & ICD-9 Differences -2
Includes full code titles for all codes (no reference back to common 4th and 5th digits)
V and E codes are no longer supplemental classifications, as stated previously

43. Abbreviations & Punctuation
NEC – Not Elsewhere Classified for conditions not classified elsewhere
NOS – Not Otherwise Specified if condition is insufficient to assign more specific code

44. Abbreviations & Punctuation #2
[ ] Brackets (synonyms, alt wordings, explanatory phrases)
( ) Parentheses (nonessential modifiers/ supplementary words)
: Colon (used with includes and excludes notes)

45. Instructional Notes
Inclusion notes further define, or give examples of the content of the category
Exclusion notes – Excludes1 vs. Excludes2
Excludes1 means “not coded here”
Excludes2 means “not included here” may need to use both the code and the excluded code together if patient has both conditions
Code first and Use additional code notes are similar to ICD-9

46. Instructional Notes -2
Cross Reference Notes advise coder to look elsewhere before assigning code (see, see also, see condition)
And = and/or
With = associated with or due to
Code also note instructs that two codes may be required – does NOT pertain to sequencing

47. Instructional Notes -3
Etiology/manifestation - “Code first”, “use additional code” and “in diseases classified elsewhere” notes
Requires that the underlying condition be sequenced 1st, followed by the manifestation
Provides assistance with proper sequencing order of the codes
Level of detail in coding
-must use and report the highest number of characters available

48. General Coding Guidelines
Locating a code in the ICD-10-CM
Level of detail coding
Code/codes from A00.0 through T88.9, Z00-Z99.8
Signs and symptoms are acceptable for reporting purposes when a related diagnosis has not been established

49. CODING GENERAL GUIDELINES #2
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes

50. General Coding Guidelines -2
Acute and Chronic Conditions
If the same condition is described as both acute and chronic, and separate subentries exist, code both and sequence the acute code 1st
Combination Code
Is a single code used to classify two diagnoses, or
A diagnosis with an associated complication or manifestation

51. General Coding Guidelines -3
Late Effects (Sequela)
Residual effect (condition produced) after the acute phase of an illness/injury has terminated
There is no time limit on when a sequela code can be used
Coding generally requires two codes
Condition/nature of the late effect is sequenced 1st; the sequela code is sequenced 2nd

52. General Coding Guidelines -4
Late Effects (Sequela)
Exception is when the sequela code is part of the 4th, 5th or 6th character of a code
The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect

53. General Coding Guidelines -5
Documentation for BMI and Pressure Ulcer Stages
Assignment may be based on medical record documentation from clinicians who are not the patient’s provider

54. GENERAL CODING GUIDELINES
Dietitian often documents the BMI and nurse often documents the pressure ulcer stages
The associated diagnosis must be documented by the patient’s provider
BMI codes should only be reported as secondary diagnoses

55. Complications Of Care
Code assignment is based on the provider’s documentation
Not all conditions that occur during or following surgery are classified as complications

56. COMPLICATIONS OF CARE
When admission is for treatment of a complication, the complication code is sequenced as the principal diagnosis
Must be a cause-and-effect relationship between the care provided and the condition and an indication in the documentation that it is a complication

57. OSHPD / Principal Diagnosis Definition
Uniform Hospital Discharge Data Set (UHDDS)/Principal diagnosis is defined as that condition established, after study, to be the chief cause of the admission of the patient to the facility for care
Condition must be identified in the H&P or documented in the current inpatient medical record

58. ACUTE HOSPITAL – PRINCIPAL DX
What that means to a SNF
Acute hospital diagnosis
Late effects
Reason for the admission to Acute and the SNF (bundled payments) – one facility gets paid and the other is paid by that facility.

59. Principal Diagnosis
Two or more interrelated conditions with each potentially meeting the definition
Such as diseases in the same ICD-10-CM or manifestations characteristically associated with a certain disease potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise

60. Principal Diagnosis -2
Two or more interrelated conditions that equally meet the definition
When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the code book does NOT provide sequencing direction, any one of the diagnoses may be sequenced first

61. Other Diagnoses Two or more comparative or contrasting conditions
When two or more diagnoses are documented as “either/or”, they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission.
Either diagnosis may be sequenced first.

62. OTHER DIAGNOSES
When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first.
These should never be principal diagnoses

63. Signs, Symptoms, Ill-defined Conditions
Codes for symptoms, signs, and ill-defined conditions – are NOT to be used as a principal diagnosis when a definitive diagnosis has been established.
THIS APPLIES TO SNF, ACUTE and other health locations

64. Uncertain Diagnoses Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed/established
Applicable only to inpatient admissions to short-term, acute, long-term care & psychiatric hospitals

65. Sequencing Of Codes
Determined by the reason for admission/encounter, with the highest acuity diagnoses sequenced 1st

66. Specificity Of Coding
With added laterality, need greater documentation from your MD’s
Hypertensive Retinopathy H35.03
H right eye
H left eye
H bilateral
H unspecified (this would be a ?? for billing most likely!!)
Code also any associated hypertension (I10)

67. Chapter 1 – Infectious & Parasitic Diseases A00-B99
Sepsis
Unspecified organism, A41.9, if type of infection is not specified
Sepsis d/t MRSA A41.02
B95.62 MRSA as the cause of conditions classified elsewhere
When the infection does not have a combo code that includes the causal organism

68. Chapter 1 – Infectious & Parasitic Diseases A00-B99 -2
HIV infections
Admit for HIV-related condition, principal diagnosis should be B20, followed by code for HIV-related condition

69. SEPSIS
UROsepsis – The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. Iy has no default code in the Alpha index.
QUERY THE DOCTOR!!!
Sepsis with organ dysfunctioin
- follow Severe sepsis guidance

70. SEPSIS - SEVERE Requires two codes
First code for underlying systemic infection followed by a code from subcategory R65.2
Casual organism should be documented; if not – assign A41.9 unspecified for the infection. (where would you look)

71. Chapter 2 – Neoplasms C00-d49
The neoplasm table should be referenced first
Anemia also w /malignancy
If encounter is for mgmt of anemia asso w /malignancy, and tx is only for anemia, principal dx = malignancy code, followed by anemia code D63.0

72. Chapter 2 – Neoplasms C00-d49 -2
Anemia asso w/chemotherapy
Encounter for mgmt of anemia asso w/adverse effect of chemo or tx, code anemia 1st, followed by neoplasm code and adverse effect

73. Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89
Diabetes Mellitus
Combination codes
Includes the body system affected and complications affecting the body system
Many codes particular category as are necessary to describe all of the complications of the disease may be used
Sequenced base on the reason for a particular encounter

74. Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89) -2
E08 Diabetes d/t underlying condition
E09 Drug or chemical induced diabetes
Secondary diabetes is always caused by another condition or event
E10 Type I Diabetes
E11 Type II Diabetes
Z79.4 long-term use of insulin
Not used when insulin is being used temporarily

75. Chapters 5 – Mental & Behavior Disorders F01-F99
Vascular Dementia
Dementia in other diseases classified elsewhere
Unspecified Dementia
All of above are coded:
With behavioral disturbance, or
Without behavioral disturbance

76. Chapter 6 – Diseases Of The Nervous System G00-G99
Chronic pain syndrome G89.4 vs. chronic pain G89.2
Provider must specifically document which condition
Hemiplegia - Dominant/non-dominant side G81
For ambidextrous patients, the default should be dominant
Left side affected, the default is non-dominant
Right side affected, the default is dominant

77. Chapter 6 – Diseases Of The Nervous System G00-G99 -2
Pain – category G89
Used in conjunction with codes from other categories to provide more detail about acute or chronic pain, neoplasm pain, or post-procedural pain
Can be listed as principal diagnosis
When pain control or pain mgmt is reason for admit, the underlying cause and site of pain should be reported as additional dx, if known.

78. Chapter 6 – Diseases Of The Nervous System G00-G99 -3
If encounter is for any other reason, and dx has not been established, assign the code for the site of pain 1st, followed by code from G89

79. Chapter 7 – Diseases Of Eye And Adnexa H00-H59
Assigning glaucoma codes:
Assign as many codes from category H40, as needed, to identify the type of glaucoma, the affected eye, and the glaucoma stage.

80. Chapter 9 – Diseases Of The Circulatory System I00-I99
Combination Codes for Conditions and Common Symptoms or Manifestations
I Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris

81. Chapter 9 – Diseases Of The Circulatory System I00-I99 -2
Hypertension with Heart Disease I11
Heart conditions classified to I50 or I51.4-I51.9 are also assigned to, a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive)
Use an additional code from category I50
Outlines the different conditions, i.e., Cardiomegaly, Mycarditis, Left Ventricular failure, etc.

82. Chapter 9 – Diseases Of The Circulatory System I00-I99 -3
Hypertensive chronic kidney disease/CKD I12
Cause and effect relationship is presumed
Need add’l code to identify the stage of CKD
Hypertensive heart and CKD I13
Causal relationship for HTN and heart dx must be doc’d

83. Chapter 9 – Diseases Of The Circulatory System I00-I99 -4
Sequelae of cerebrovascular disease I69
Used to indicate conditions in I60-I67 as the cause of sequelae. The “sequelae” include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition
I.E., CEREBRAL INFARC – also have to document and code if tPA or rtPA in different facility in 24 hrs. (Z92.82—review)

84. Chapter 9 – Diseases Of The Circulatory System I00-I99 -5
CEREBROVASCULAR DISEASE
Use added codes – identify presence of
Alcohol abuse/dependence – (H&P/Social Eval)
Exposure to tobacco smoke
Hx. Of tobacco use
Hypertension
Occupational exposure to tobacco smoke

85. Chapter 9 – Diseases Of The Circulatory System I00-I99 -6
Tobacco dependence
Tobacco Use
(see where the History from the Physician and the Social Hx. Is Important).

86. Chapter 9 – Acute Myocardial Infarction (AMI)
I21 For encounters occurring while the AMI is equal to, or less tan, four weeks old, including transfers to another acute setting or another acute setting or a post-acute setting and pt requires continued care for the AMI

87. Chapter 9 – Acute Myocardial Infarction (AMI) #2
Subsequent acute MI
When a pt who has suffered an AMI has a new AMI within the 4 wk time frame of the initial AMI, code I22 in conjunction with I21 code

88. Chapter 10 – Diseases Of Respiratory System (J00-J99)
Chronic Obstructive Pulmonary Disease (COPD) and Asthma
Acute exacerbation of chronic obstructive bronchitis and asthma
J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation
Acute exacerbation is a worsening or a decompensation of a chronic condition

89. Chapter 10 – Diseases Of Respiratory System (J00-J99) -2
Acute and Chronic Respiratory Failure
Principle diagnosis when it is the condition established after study to be chiefly responsible for admission to the hospital
Influenza due to certain identified influenza viruses (J09)
Only on confirmed cases
Avian influenza or novel H1N1 or swine flu, code J09.X_ (depending on associated manifestations)

90. Chapter 12 – Diseases Of Skin & Subcutaneous Tissue L00-l99
L89 codes for Pressure Ulcer are combination codes that identify the site as well as the stage of the ulcer
Assignment of the pressure ulcer stage should be guided by clinical documentation of the stage
Assign code for the highest stage reported for that site

91. Chapter 13 – Disease Of Musculoskeletal (M00-M99)
Site and laterality
Designations
Represents the bone, joint or muscle involved
Where more than one bone, joint or muscle is involved, such as osteoarthritis, use the assigned “multiple sites” code; if not available, use multiple codes to indicate the sites
Bone vs. Joint – Certain conditions where the bone may be affected at the upper & lower end; site designation will be the bone, not the joint

92. Chapter 13 – Disease Of Musculoskeletal (M00-M99) -2
Bone, joint or muscle conditions that are the result of a healed injury are coded to this chapter
Chronic or recurrent conditions are also coded to this chapter
Pathologic fractures are coded with 7th character D for encounters after active treatment is completed, if routine healing is occurring

93. Chapter 13 – Osteoporosis
M80 category is used for any patient with known osteoporosis who suffers fracture, even if pt had minor fall or trauma, if that fall would not usually break a normal bone
Osteoporosis without pathological fracture M81 is used for patients who do not currently have a pathologic fracture d/t osteoporosis, even if they have had a fracture in the past

94. Chapter 13 – Osteoporosis #2
Osteoporosis with pathological fracture, M80, is used for pts who have a current pathologic fracture at the time of the encounter

95. Chapter 14 – Diseases Of Genitourinary (N00-N99)
Stages of chronic kidney disease (CKD)
If both a stage of CKD and ESRD are documented, then assign code N18.6 only
Patients who have had kidney transplant may still have some form of CKD, because the transplant may not fully restore kidney function. Therefore, presence of CKD alone does NOT constitute a transplant complication.

96. Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab Findings (R00-R99)
A41.9 Sepsis, unspecified organism –Septicemia, unspecified (Chapter 1 Infectious & Parasitic Diseases)
Severe Sepsis – R65.20 – code first underlying infection, and use additional code to identify specific organ
Urosepsis – cannot code, code to condition

97. Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab Findings (R00-R99) -2
Septic Shock
Circulatory failure associated with severe sepsis; represents a type of acute organ dysfunction. Underlying infection sequenced first, followed by code R Severe sepsis with septic shock. Add additional codes for other acute organ dysfunction
DRAFT 9/20/11

98. Chapter 18 – Signs/Symptoms Codes
Use of symptom codes are acceptable for use when a related diagnosis has NOT been established by the provider
Use 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

99. Chapter 18 – Signs/Symptoms Codes -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 right for future falls
When appropriate, both of the above codes may be assigned together

100. Chapter 18 – Functional Quadriplegia
R53.2 is the lack of ability to use one’s limbs or to ambulate d/t extreme debility.
It is NOT associated with neurologic deficit or injury, code R53.2 should NOT be used for cases of neurologic quadriplegia.
It should only be assigned if functional quadriplegia is specifically documented in the medical record

101. Chapter 19 – Injury, Poisoning & Certain Other Consequences of External Causes S00-T88
An example S42.321D. Displaced transverse fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing
This means more specific documentation from the physician (the initial encounter of treatment is usually in the Emergency room).

102. Chapter 19 – Injury, Poisoning & Certain Other Consequences of External Causes S00-T88 -2
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

103. Chapter 19 – Drug Toxicity
When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the code for the adverse effect of the drug (T36-T50)
The code for the drug should have a 5th or 6th character “S”
DRAFT 9/20/11

104. Chapter 19 – Poisoning
When coding a poisoning or reaction to the improper use of a medication, i.e. overdose, wrong substance given or taken in error, assign the appropriate code from categories T36-T50
The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined)

105. Chapter 19
Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction
Assign T36-T50 with 5th or 6th character of “6”
Codes for underdosing should never be assigned as principal dx
Noncompliance (Z91.___) or complication of care (Y63.___) codes are to be used with an underdosing code, if known

106. Chapter 20 – External Causes of Morbidity (V00-Y99)
These codes are secondary codes for use in any health care setting
These codes capture how the injury happened (cause) or the intent
Assign the external cause code with the appropriate 7th character for each encounter for which the injury or condition is being treated (initial, subsequent or sequela)
What happened? V03 pedestrian injured in collision with car, pick-up truck or van

107. 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

108. Chapter 21 – Z Codes
Z code should not be used if treatment is directed at a current acute disease
Exceptions
First listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy Z51.0
Code also condition requiring care

109. CHAPTER 21 – Z Codes
Factors Influencing Health Status and Contact With Health Services Z00-Z99
Former V codes are now Z codes
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

110. Chapter 21 – Z Codes -2 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

111. Chapter 21 – Z Codes -3
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

112. Right Hip Replacement Now: Then:
V54.81 Aftercare following joint replacement
V43.64 Joint replacement, hip
Then:
Z47.1 Aftercare following joint replacement surgery
*only use above code for OA, not injury
Z Presence of right artificial hip joint

113. Z Code Examples 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

114. More Z Code Examples
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 left knee

115. Questions and Answers
Rhonda L. Anderson, RHIA President, AHIS, Inc

116. Thanks for attending!!