1. Anderson Health Information Systems, Inc. ICD-10 Initial Orientation
November 4, 2011
ICD-10
ICD-10 Initial Orientation

2. Anderson Health Information Systems, Inc.
PRESENTED BY
Rhonda L. Anderson, RHIA
President
Anderson Health Information Systems, Inc.
940 W. 17th Street, Suite B
Santa Ana, CA 92706
Tel Fax

3. OBJECTIVES Participants will identify: Dates for New ICD-10
Documentation support
New terms encounter principal diagnosis re-defined
Some general coding guidelines
Will identify the Federal requirements re: ICD-9 changes for this year and coding accuracy.

4. ICD—10 “HAS TWO PARTS” ICD-10 CM = Clinical Modification
ICD-10 PCS = Procedural Code System (used for procedures, operations within the hospital inpatient setting i.e., acute hospital)

5. FINAL REGULATION January 15, 2009 Final Regulation Released
EXCHANGE the ICD-9 for the ICD-10 by October, 1, 2013
ICD-10 for billing purposes as far as ability to accept the code known as “5010” is required by October 2011

6. HIPAA
Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)
HIPAA had three parts HIPAA – 1996, HIPAA-II – HITECH we call it – relates to security and breaches
HIPAA Transactions 5010
ICD-10 Code Set

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, MediCal and private insurances. Current Procedural
Terminology (CPT) is still used for the Physician and some services, but they must have a diagnosis that is ICD-10 Complaint

8. KEY HIGHLIGHTS -2
Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services.
ICD-10 code set, general acute care inpatient reimbursement for Medicare patients will be based on Medicare severity-based diagnosis related groups (MS-DRGs) using ICD-10 – CM – PCS (for those who have procedures).

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 -3
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.
Mapping from ICD-9 to 10 tools are available and will be used by DCTSS.
Called or “GEMS” – general equivalence mappings.

11. ICD-9-CM DIAGNOSIS CODES
3-5 characters in length
Approximately 14,000 codes
First digit may be alpha (E or V) or numeric
Digits 2-5 are numeric
Always at least three digits
Decimal placed after the first three characters
Limited space for new codes

12. ICD-9-CM DIAGNOSIS CODES -2
Lacks detail
Lacks laterality Difficult to analyze dated due to non-specific and do not adequately define diagnoses needed for medical research
Does not support interoperability because it is not used in other countries.

13. ICD-10 STRUCTURE Index and Tabular list similar to ICD-9
ICD-10 index larger, Categories, subcategories and codes are contacted in the tabular list.

14. ICD-10 CM STRUCTURE -2 Requires “use” of proper coding guidelines
Enter website here (for CMS codes for ICD 10)
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

15. ICD-10-CM DIAGNOSIS CODES – FORMAT & STRUCTURE
3-7 characters in length
Approximately 68,000 codes
Digit 1 is alpha, digit 2 and 3 are numeric; digit 4-7 are alpha or numeric
Decimal placed after the first 3 characters
All letters used except “U”
Flexible for adding new codes
Very specific
Has laterality

16. ICD-10 CM STRUCTURE -3
Former V=codes are now Z=codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services (NEW)…

17. 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

18. CONVENTIONS FOR THE ICD-10-CM -2
General rules for use of the classification independent of the guidelines
Format and Structure
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

19. 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

20. ICD-10-CM DIAGNOSIS CODES-2
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.

21. CODE STRUCTURE OF ICD-10
ICD-10 Codes may consist of up to 7 digits, with the 7th digit extensions representing visit encounter or sequel for injuries or external causes.

22. CODE FORMAT ICD-10 Code Format ICD-9-CM Code Format
                                                          
                                                                                   

23. GEM FILES
Before we go further- do not despair…you vendor should prepare as much crosswalk as possible. There are “GEMS” files.
General Equivalence Mappings (GEMS) – translation dictionary for diagnoses
We will talk about those later and how to use them.. Key to early review!!!
Your vendor will most likely provide

24. ICD-10 AND ICD-9 DIFFER Organization Structure, Code composition,
Level of detail
May consist of up to 7 digits with the seventh digit extensions representing visit encounter or sequel as stated above.

25. ICD-10 AND ICD-9 DIFFER
Includes full code titles and no reference back to common 4th and 5th digits)
V and E codes are no longer supplemental

26. ABBREVIATIONS NEC – “Not elsewhere classifiable Punctuation
[ ] Brackets
( ) Parentheses
Use of “and”
“Other” or “other specified”
“Unspecified”
“Includes Notes”
“Inclusion Terms”

27. ABBREVIATIONS -2 “Excludes Notes”
“Code first”, “Use additional code” and “elsewhere notes”
“And”, “and” or “or”
“With”
“See”, “see also”
“Code also note”
“Default codes”
“Syndromes”

28. 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

29. GENERAL CODING GUIDELINES
Multiple coding for a single condition
“Use additional code”
Sequencing rule is the same as the etiology/manifestation pair

30. GENERAL CODING GUIDELINES
Acute and Chronic Conditions
Combination Code
Late Effects (Sequela)
Residual effect (condition produced) after the acute phase of an illness/injury terminated
Condition/nature of the late effect is sequenced; late effect code is second
Acute phase of an illness/injury
Sequelae of complication of pregnancy
See Section 1.C.19. Code extensions

31. GENERAL CODING GUIDELINES
Documentation for BMI and Pressure Ulcer Stages
Assignment may be based on medical record documentation from clinicians who are not the patient’s provider
Physician / qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis
Dietitian often documents the BMI and nurses often documents the pressure ulcer stages

32. GENERAL CODING GUIDELINES
Documentation for BMI and Pressure Ulcer Stages
Associated diagnosis such as overweight, obesity, pressure ulcer must be documented by the patient’s provider
Conflicting medical record documentation queried for clarification
BMI codes should only be reported as secondary diagnoses

33. ICD-10 NEW FEATURES
Combination Codes for Condition s and Common Symptom or Manifestations
I Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris

34. ICD-10 NEW FEATURES -2 Added Laterality
C Malignant neoplasm of upper-inner quadrant of left female breast
H02.835, Dermatochalasis of left lower eyelid
I80>01, Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
L80.213, Pressure Ulcer of right hip, Stage III

35. A FEW CODES YOU WILL LEARN
Pg 479 of the ICD-10 manual
A41.9 Sepsis without cause organism –Sepsis, unspecified
Severe Sepsis – A41.9 Sepsis unspecified for the infection. Additional code for organ must be identified.
UROSEPSIS is not allowed as a dx.

36. A FEW CODES YOU WILL LEARN-2
Anderson Health Information Systems, Inc.
November 4, 2011
A FEW CODES YOU WILL LEARN-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
New guidelines for sequencing Severe Sepsis
Must be clear if it is present on admission

37. ICD-10 NEW FEATURES
Expanded Codes (injury, diabetes alcohol/substance abuse, postoperative complications)
E08.22 Diabetes due to underlying condition with diabetic chronic kidney disease

38. CHAPTER 4 – E00-E89 Endocrine, nutritional and metabolic diseases
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

39. CHAPTER 4 – ENDOCRINE, NUTRITIONAL…(E00-E89)
Endocrine, nutritional and metabolic diseases
Secondary Diabetes Mellitus
Category E08 due to underlying condition
Category E09 for drug/chemical induced
Use code Z79.4 for patients who routinely use insulin; also assigned for long-term (current) use

40. CHAPTERS 5 – 8 Chapter 5 – Mental (F01-F99)
See Section 1.C.6. Pain
Chapter 6 – Diseases of Nervous System (G00-G99)
Chapter 7 – Disease s of Eye and Adnexa (F00-F59)
Chapter 8 – Disease of Ear and Mastoid (H60-H95)

41. CHAPTER 9 – DISEASES OF CIRCULATORY SYS. (I00-I99)
Hypertension with Heart Disease
Heart conditions classified to I50 or I51.4-I51.9 are 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
Heart failure, to identify the type of heart failure

42. CHAPTER 9 – DISEASES OF CIRCULATORY SYS. (I00-I99)
Hypertensive Cerebrovascular Disease
Assign the appropriate code from categories I60-I69, followed by the appropriate hypertension code

43. CHAPTER 10 – DISEASES OF RESPIRATORY SYS. (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 Respiratory Failure
Principle diagnosis when it is the condition established after study to be chiefly responsible

44. CHAPTER 10 – DISEASES OF RESPIRATORY SYS. (J00-J99)
Influenza due to certain identified influenza viruses
Only on confirmed cases (J09.0)
Avian influenza or novel H1N1 or swine flu, code J09.1

45. CHAPTERs 11 & 12 Chapter 11 – Diseases of Digestive System (K00-k94)
Chapter 12 – Diseases Of Skin

46. CHAPTER 13 – DISEASE OF MUSCULOSKELETAL (M00-M99)
Site and laterality
Designations
Represents the bone, joint or the muscle
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

47. ICD-10 NEW FEATURES-4
Laceration with foreign body of the abdominal wall, right lower quadrant w/penetration—an extension used with a laceration code. (all the description is written out) S31.623A

48. CHAPTER 14 – DISEASES OF GENITOURINARY (N00-N99)
Anderson Health Information Systems, Inc.
November 4, 2011
CHAPTER 14 – DISEASES OF GENITOURINARY (N00-N99)

49. Anderson Health Information Systems, Inc.
November 4, 2011
ICD-10 NEW FEATURES -2
Laceration with foreign body of the abdominal wall, right lower quadrant with penetration, an extension used with a laceration code. (All the description is written out – S31.623A.)
Fracture Codes require a seventh character that identified if the fracture is open or closed for an initial encounter or if a subsequent encounter is for routine healing, delayed healing, nonunion, malunion or sequelae.

50. LET’S SEE SOME CODES Hypertensive Cerebrovascular Disease
First assign the code from I followed by hypertension Code
Cerebral atherosclerosis
I69.34 Monoplegia of lower limb following cerebral infarction
I11.9, Hypertensive heart disease without heart failure or W/heart failure I11.0

51. LET’S SEE SOME CODES
Sequencing of codes is determined by the reason for admission/encounter - Hypertensive Retinopathy
H35.03 Hypertensive Retinopathy
031-Right eye, 032, left eye, 033, bilateral,
039 unspecified (and this would be a ?? For billing most likely)!!
I10, Essential Primary Hypertension

52. ICD-10 NEW FEATURES -3
An example S42.321A. Displaced transverse fracture of shaft of humerus, right arm, initial encounter for closed fracture.
This means more specific documentation from the physician (the initial encounter may not have been in your setting).

53. CHAPTER 18
Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)

54. REPEATED FALLS
Code R29.6 Repeated falls for use for encounters when a patient has recently fallen and the reason for the fall is being investigated. Code Z91.81, History of falling, is for use when a patient has fallen in the past is at risk for future falls. Both codes may be assigned

55. CODING OF TRAUMATIC FRACTURES
Fractures of specified sites are coded individually by site..S-codes…need to pay attention to level of detail furnished by medical record content.
Fracture not indicated as open or closed, displaced, initial vs. subsequent encounter for fractures. (use 7th character extension for initial encounter (A.B.C) There are specific instructions related to this area. (#18)

56. FRACTURES
Multiple fractures are sequenced based on the severity of the fracture.

57. AFTERCARE
Visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase or the long term consequences of the disease
Z code should not be used if treatment is directed at a current acute disease

58. AFTERCARE
Exceptions
First listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy

59. PRINCIPAL DIAGNOSIS
Hospital Discharge Data Set (UHDDS) defines as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

60. PRINCIPAL DIAGNOSIS -2
Codes for symptoms, signs, and ill-defined conditions – NOT to be used as a principal diagnosis when definitive diagnosis has been established.

61. PRINCIPAL DIAGNOSIS -3
Two or more interrelated conditions with either one 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

62. PRINCIPAL DIAGNOSIS -4
Two or more interrelated conditions equally meeting the definition
Determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first

63. PRINCIPAL DIAGNOSIS -5
Two or more comparative or contrasting condition
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
Symptom(s) followed by contrasting/comparative diagnoses
Code is sequenced first

64. PRINCIPAL DIAGNOSIS -6 Complications of surgery and other medical care
Is sequenced as the principal diagnosis
Uncertain Diagnosis
“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. CHAPTER 21 –Z CODES
Factors Influencing Health Status and Contact With Health Services
Vaccinations

66. IN FOCUS FOR ACCURACY OF CODING

67. ICD-9 CODE CHANGES AND MORE ON CODING ACCURACY
Contact AHIS for a specialized Webinar on ICD09 Coding Accuracy and Updates

68. REQUIREMENTS
Official coding guidelines require the use of V codes for aftercare and specify that applicable aftercare V-codes are to be used for conditions requiring continued / long term care or healing phase of a condition/disease.

69. REQUIREMENTS -2
The official coding guidelines are developed by CMS (Centers for Medicare and Medicaid Services) & NCHS (National Center for Health Statistics) and updated in October and April of every year.

70. CMS MANUAL SYSTEM TRANSMITTAL 437
Principal Diagnosis Code - SNFs enter the ICD-9-CM code for the principal diagnosis in FL 67. The code must be reported according to Official ICD-9-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-9-CM diagnosis code, including all five digits where applicable.

71. CMS MANUAL SYSTEM TRANSMITTAL 437 -2
Other Diagnosis Codes Required – The SNF enters the full ICD-9-CM codes for up to eight additional conditions in FLs Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-9-CM guidelines.

72. 30 – BILLING SNF PPS SERVICES
(REV. 2011, ISSUED: , EFFECTIVE: , IMPLEMENTATION: )
Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal diagnosis in the appropriate form locator. The code must be reported according to Official ICD-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-CM diagnosis code, including all five digits where applicable.

73. 30 – BILLING SNF PPS SERVICES -2
Other Diagnosis Codes Required – The SNF enters the full ICD-CM codes for up to eight additional conditions in the appropriate form locator. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines.

74. WHAT THIS MEANS TO YOU
The Principal diagnosis can no longer be an acute diagnosis and it may be a V-CODE
800.XX codes for fractures are NO LONGER used

75. DEFINITION OF PRINCIPAL DIAGNOSIS
“FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.”
Medicare – To be covered the extended services must be for the treatment of a condition for which the resident received inpatient hospital services during the 3-day qualifying stay

76. TYPE OF CODES USED IN LTC
Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover.
Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.

77. WHAT TO CODE?
ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT TREATMENT RECEIVED

78. LOCATING THE PRINCIPAL DIAGNOSIS

79. ADMISSIONS/ENCOUNTERS FOR REHABILITATION
When the purpose for the admission/encounter is rehabilitation, sequence the appropriate V code from category V57, Care involving use of rehabilitation procedures, as the principal/first-listed diagnosis. The code for the condition for which the service is being performed should be reported as an additional diagnosis.

80. V57 – CARE INVOLVING REHAB
Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose

81. AFTERCARE
Aftercare are used when the initial treatment has been performed but the patient continues to need care during the healing / recovery phase
Examples:
Aftercare following surgery
Physical and/or occupational therapy
Aftercare for healing traumatic fracture

82. POP QUIZ 5 2 3 4 1 6

83. POP QUIZ ANSWERS Optical Nerve Nares Tibial Distal Left Upper Humerus5 2
Tibial Distal
Left Upper Humerus 3 4 1 6
Phalanges
Sternum

84. CERTIFICATE & EVALUATION
Certificate will be sent upon receipt of evaluation to

85. YOUR ATTENDANCE IS APPRECIATED!!!
Rhonda Anderson, RHIA President, AHIS Mobile: Office: