ICD-10-CM Orientation in Post Acute Care

ICD-10-CM Orientation in Post Acute Care
Rhonda Anderson, RHIA, President Anderson Health Information Systems, Inc. ICD-10 Coding Training Post Acute 2 Hrs ( )

Objectives Participants will identify: Dates for New ICD-10-CM
Documentation support New terms encounter principal diagnosis re-defined Some general coding guidelines ICD-10 Coding Training Post Acute 2 Hrs ( )

Final Regulation January 15, 2009 Final Regulation Released
Exchange the ICD-9-CM for the ICD-10-CM on October, 1, 2014

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, Medi-Cal or Private Ins. ICD-10-PCS = Procedural Code System (used for Acute Hospital procedures, operations

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

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.

Various Roles That Are Affected
HIM personnel Nurse managers MDS nurses Nursing unit staff/clerks Case managers Administration Therapy personnel (PT/OT/ST) Billing/admitting personnel Medical Directors/Providers

More Affected Roles... Corporate Office personnel
Compliance Office personnel working with ICD coding Corporate administrative departments

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-CM

What Does This Mean?? The guidelines in the ICD-10-CM manual were developed for the provider AND the coder (person reviewing the documentation and assigning the diagnosis codes) Consistent, complete documentation in the medical record is a major emphasis

Key Highlights ICD-10-CM replaces ICD-9-CM diagnosis codes in all settings Current Procedural Terminology (CPT) is still used for the Physician, and some services, but they must have a diagnosis that is ICD-10-CM compliant Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services

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

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.

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

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

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

ICD-10-CM Diagnosis Codes – Format & Structure -2
Codes that have applicable 7th character are considered invalid without the 7th character. Expanded codes Flexible for adding new codes Addition of placeholder “X” Has laterality (right, left, lower, upper, outer, etc.)

Example Of Placeholder “X”
ICD-10-CM utilizes a placeholder character “X” The “X” is used as a placeholder at certain codes to allow for expansion Categories T36-T50, poisoning and injury codes T36.8X1D Also, pathological vertebral fracture due to age-related osteoporosis, subsequent encounter with delayed healing M80.08XG

Example Of Laterality For bilateral sites, the final character of the codes in ICD-10-CM 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

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

Diabetes Diabetic Mellitus:
With arthropathy E (Type 2 diabetes with other diabetic arthropathy) With cataract E11.36 (Type 2 with diabetic cataract) With gangrene E11.52 (Type 2 with diabetic peripheral angiopathy with gangrene) With foot ulcer E (Type 2 diabetes with foot ulcer) (use additional code to identify site) With hypoglycemia E (Type 2 diabetes with hypoglycemia without coma) With kidney complications E11.29 (Type 2 diabetes with other diabetic kidney complication)

ICD-10-CM Structure Requires “use” of proper coding guidelines
Relies on the use of the guidelines and in our case Skilled/ICF/IRF rules ICD-10-CM Index of disease, injury and external causes of Injury ICD-10-CM Tabular list of diseases and injuries

ICD-10-CM Structure -2 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: G30.0 Alzheimer’s with early onset G30.1 Alzheimer’s with late onset G30.8 Other alzheimer’s disease G30.9 Alzheimer’s disease, unspecified

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-CM with one additional guideline - laterality

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

Code Format ICD-10-CM Code Format: ICD-9-CM Code Format

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 a 7th character is not 6 characters, a placeholder “X” must be used to fill in the empty characters

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 K = subsequent encounter for fracture with nonunion P = subsequent encounter for fracture with mal-union S = sequela

Fracture Fracture Traumatic (abduction, adduction, separation)
Acetabulum – anterior, displaced, iliopubic S32.43__ or non-displaced S32.436_ Acetabulum – dome (displaced) S32.48__ Fracture, lumbar vertebrae - (NOS) S32.009_

Fracture -2 Fracture of 1st lumbar vertebrae – S32.01__
Wedge compression, stable burst, unstable burst, other, or unspecified Look at documentation to identify what type of fracture is it? ICD-10 Coding Training Post Acute 2 Hrs ( )

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.

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

GEM Files -2 There is NOT a one-to-one match between ICD-9-CM and ICD-10-CM codes We will talk about GEMS later and how to use them. Key to early review!

What Does This 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 need for additional specificity at the QA/PI meetings Keep staff informed as we progress

What Does This Mean To Me? -2
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 identified diagnoses Focus on review of Acute Hospital Records more closely – Impact Inquiries Review for Medicare must be more specific/triple-check

ICD-9 & ICD-10 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.

ICD-9 & ICD-10 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

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

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

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 S32. fracture of LS and pelvis Exclusion1 transection of abdomen (S38.3) Exclusion2 fracture of hip (S72.0_) ICD-10 Coding Training Post Acute 2 Hrs ( )

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

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

General Coding Guidelines
Locating a code in the ICD-10-CM Level of detail coding Codes range from A00.0 through Z99.8 Signs and symptoms are acceptable for reporting purposes when a related diagnosis has not been established

General Coding Guidelines -2
Signs and symptoms that are associated routinely with a disease process should NOT be assigned as additional codes

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

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

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

Documentation for BMI and Pressure Ulcer Stages Assignment may be based on medical record documentation from clinicians who are not the patient’s provider

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

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

Complications of Care -2
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, the condition and an indication in the documentation that it is a complication

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

Acute Hospital – Principal Diagnosis
What that means to a SNF Acute hospital diagnosis Late effects of the acute diagnosis Reason for the admission to Acute and the SNF (bundled payments) – one facility gets paid and the other is paid by that facility.

Principal Diagnosis Two or more interrelated conditions with each potentially meeting the definition Diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, or the code book indicate otherwise

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

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

Other Diagnoses -2 When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first All the contrasting/comparative diagnoses should be coded as additional diagnoses These should never be principal diagnoses

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: long term care, acute and other health-care locations

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

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

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)

The importance of consistent, complete documentation in the medical record CANNOT be overemphasized.
Without such documentation the application of all coding guidelines is a difficult, if not impossible task.

Sepsis UROsepsis – The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alpha index. QUERY THE DOCTOR!!! Sepsis with organ dysfunction -follow guidelines for severe sepsis

Severe Sepsis Requires two codes
First code for underlying systemic infection followed by a code from subcategory R65.2, Severe sepsis Casual organism should be documented; if not – assign A41.9 Sepsis, unspecified organism Where do we look for this information?

Chapter 1 – Infectious & Parasitic Diseases A00-B99
B95 Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere B96 Other bacterial agents as the cause of diseases classified elsewhere B97 Viral agents as the cause of diseases classified elsewhere

Chapter 1 – Infectious & Parasitic Diseases A00-B99 -2
Sepsis Unspecified organism, A41.9, if type of infection is not specified Severe sepsis R65.2 should NOT be assigned unless severe sepsis or acute organ dysfunction is documented

Sepsis Example This long-term multiple sclerosis patient was admitted for continuing long-term antibiotic therapy for a urinary tract infection due to E. coli. What do we code?

Sepsis Answers N39.0 Infection, urinary tract
B96.20 Infection, E. coli Z79.2 Long-term use of antibiotics G35 Sclerosis, multiple the long-term use code is assigned for use of the antibiotics. Instructional notes under N39.0 indicate to use an additional code (B95-B97), to identify infectious agent

When a patient is diagnosed with an infection that is due to MRSA, and that infection has a combination code that includes the causal organism, assign the appropriate combo code: A41.02 Sepsis d/t MRSA, or J Pneumonia d/t MRSA B95.62 MRSA as the cause of conditions classified elsewhere Only used when the infection does not have a combo code that includes the causal organism

MRSA/MSSA Colonization: A positive MRSA colonization test may be documented by the MD as “MRSA screen positive” or “MRSA nasal swab positive” Assign Z22.322, carrier or suspected carrier of MRSA Colonization is not indicative of a disease process If patient is documented as having both MRSA colonization and infection, code both

HIV infections Code only confirmed cases of HIV infection, MD’s diagnostic statement is sufficient Admit for HIV-related condition, principal diagnosis should be B20, followed by code for HIV-related condition Z21 is assigned when the patient without any documentation of symptoms is listed as “HIV positive” or “known HIV”

Chapter 2 – Neoplasms C00-D49
The neoplasm table should be referenced first Anemia also with malignancy If encounter is for management of anemia associated with malignancy, and treatment is only for anemia, principal diagnosis = malignancy code, followed by anemia code D63.0

Chapter 2 – Neoplasms C00-D49 -2
Anemia associated with chemotherapy, and other treatment Encounter for management of anemia associated with adverse effect of chemotherapy or treatment, code anemia 1st, followed by neoplasm code and adverse effect

Primary Malignancy Previously Excised
When there is no further treatment directed to a primary site and no evidence of any primary malignancy, the following is coded: Z85 personal history of malignant neoplasm Any mention of metastasis to another site is coded as a secondary malignant neoplasm to that site

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

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89 -2
E08 Diabetes due to 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 only being used temporarily

Type of Diabetes If the type of diabetes is not documented in the record, the default is E11., Type 2 diabetes If the type is not indicated, but the patient uses insulin, code E11. Type 2 diabetes + Z79.4 long-term use of insulin

Diabetes Example Resident admitted to SNF following foot amputation due to diabetic PVD. PT and OT ordered with plan for the resident to return home. Staff to change dressings and report any suture site breakdown to MD. Other diagnoses include gastroparesis due to Type 2 diabetes (receiving insulin), mitral valve regurgitation with aortic stenosis, inguinal hernia, generalized DJD and COPD.

Diabetic Answer Z47.81 Aftercare, following surgery, amp
E11.51 Diabetes, type 2, w/peri angiopath E11.43 Diabetes, type 2, w/gastroparesis I08.0 Regurgitation, mitral, w/aortic valve K40.90 Hernia, inguinal M15.9 Disease, joint, degenerative J44.9 Disease, pulmonary, chronic obstruc Z79.4 Long-term use insulin Z Acquired absence of unspec foot

Rationale Both PVD and gastroparesis are due to type 2 diabetes. Codes assigned for both conditions. Z47.81 has a “use add’l code” note to identify the limb and level of amputation - Z (documentation doesn’t specify which foot was amp, so 6th digit of 9 is assigned) Patient uses insulin, so Z79.4 is assigned.

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

Key to Psychoactive Drug Use
Make sure each psychoactive drug includes diagnosis for use Behavioral disturbance??? Justification for psychotropic meds??? Documentation of aggressive, combative or violent? Use of antipsychotic meds need specific medical diagnosis to justify use: Schizophrenia, Bipolar, Psychosis (delusions or hallucinations)

Chapter 6 – Diseases Of The Nervous System G00-G99
If the affected side is documented, but not specified as dominant or non-dominant: For ambidextrous patients, the default should be dominant Left side affected, the default is non-dominant Right side affected, the default is dominant *Hemiplegia, unspecified, affecting right dominant side G81.91 *excludes hemiplegia due to sequela of CVD

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

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 Chronic pain syndrome G89.4 vs. chronic pain G89.2 Provider must specifically document the condition

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.

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

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, myocarditis, left ventricular failure, etc.

Hypertensive chronic kidney disease/CKD I12 Cause and effect relationship is presumed Need additional code to identify the stage of CKD Hypertensive heart and CKD I13 Causal relationship for hypertension and heart disease must be documented

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 Z92.82 Cerebral infarction – also have to document and code if tPA/rtPA were given in a different facility within 24 hrs. prior to admit

Chapter 9 – Acute Myocardial Infarction (AMI)
I21 For encounters occurring while the AMI is equal to, or less than, 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 Subsequent acute myocardial infarction When a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI, code I22 in conjunction with I21 code

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

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)

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

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

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 of “D” for subsequent encounters after active treatment is completed, if routine healing is occurring

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

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

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.

Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab Findings (R00-R99)
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 ICD-10 Coding Training Post Acute 2 Hrs ( )

Chapter 18 – Signs/Symptoms Codes
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

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 risk for future falls When appropriate, both of the above codes may be assigned together

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

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)

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

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” ICD-10 Coding Training Post Acute 2 Hrs ( )

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)

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

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

Y Codes Y92. Place of occurrence code is used only once, at the initial encounter Y93. Activity code is used to indicate the activity the person was doing when the incident occurred Y99. External cause status codes should be assigned whenever any other external cause code is assigned for an encounter, to indicate the work status of the person at the time of the incident Old E codes What happened (W codes),Where did it happen, who are you? ICD-10 Coding Training Post Acute 2 Hrs ( )

Y Codes -2 Activity codes are NOT applicable to poisonings, adverse effects, misadventures, or late effects Do NOT assign Y93.9 unspecified activity, if the activity is NOT stated Do NOT assign Y99.9, unspecified external cause status, if the status is not stated

Y Code Example Patient fell while walking down the hall of the nursing facility where she lives and dislocated her right wrist. Upon readmission from ER, code: S63.004D Unspec dislocation R wrist W18.30XD Fall on same level Y93.01 Activity, walking Y99.8 Other external cause status

Chapter 21 – 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 (personal and family hx) Now have a code for patients blood type, Z67

Chapter 21 – Factors Influencing Health Status and Contact with Health Services (Z00-Z99) -2
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 Old V codes ICD-10 Coding Training Post Acute 2 Hrs ( )

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

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

Chapter 21 – Z Codes -3 Code Z92.82 when transfer facility has administered 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

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

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

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

ICD-10-CM Readiness Identify corporate/facility steering committees
Identify who needs education/pretest 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 *see AHIS Implementation Plan/pg 1 ICD-10 Coding Training Post Acute 2 Hrs ( )

Different Knowledge Levels Defined As
A general knowledge of the code system and important differences between ICD-9 and ICD-10 Use and/or knowledge level 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 ICD-10 Coding Training Post Acute 2 Hrs ( )

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 to six months before implementation

Steps To Take Now Educational tasks/phase I
Learn about the structure, organization, and unique features of ICD-10 Create an educational plan for all roles which require education at various levels 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

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 Develop a budget Identify current systems that input, store and utilize ICD data Identify who is currently performing coding AHIS Plan – pgs 1-4 ICD-10 Coding Training Post Acute 2 Hrs ( )

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 AHIS Plan – pg 3-5 ICD-10 Coding Training Post Acute 2 Hrs ( )

Educational Implementation Tasks/Phase I
Conduct detailed assessment of staff educational needs Assess knowledge of ICD-9 of current staff so that basic education can be obtained Assess areas of strength/weakness of coding staff in the biomedical sciences Evaluate barriers to preparing coding staff Communicate the ICD-10 prep activities throughout the organization AHIS Plan – pg 2 ICD-10 Coding Training Post Acute 2 Hrs ( )

Educational Resources
Listen to ICD-10 webcasts Have coding staff take medical terminology and Anatomy and Physiology courses (from local college or online)

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 AHIS Plan – pg 3-4 ICD-10 Coding Training Post Acute 2 Hrs ( )

General Implementation Tasks/Phase 2
Talk with vendors and other business associates regarding their ability to be prepared to accept ICD-10 codes Determine the date of installation of facilities ICD-10 database software (must be utilized in a parallel manner with current ICD-9 code library) Do NOT uninstall ICD-9 database AHIS Plan – pg 4-5 ICD-10 Coding Training Post Acute 2 Hrs ( )

General Implementation -2
Continue to address impact of code change such as required system changes and report modifications Address legacy data issues in regards to how ICD-9 coded data is currently used Evaluate barriers or potential barriers to preparing staff for ICD-10 Address timeline to begin coding current residents’ dx

Educational Tasks/Phase 2
Create an educational plan Provide education on the fundamentals of the ICD-10 systems Provide opportunity for coders to refresh knowledge of anatomy and physiology concepts Continue to have educational sessions with clinical staff in the facility to learn more about commonly reported conditions and dx r/t LTC facilities AHIS Plan – pg 5 ICD-10 Coding Training Post Acute 2 Hrs ( )

General Implementation Tasks/Phase 3
Install ICD-10 vendor software into the system to prepare for transition/perform software system testing ICD-9 legacy data must be maintained and available Closely monitor productivity and quality measures for issues r/t implementation of new code sets

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 Provide more intensive educational and consultative support to coders and users of coded data AHIS Plan – pg 5-6 ICD-10 Coding Training Post Acute 2 Hrs ( )

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ICD-10-CM Orientation in Post Acute Care

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ICD-10-CM Orientation in Post Acute Care

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