1. Cardiology ICD-10 CM Training

2. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1, 2015 and beyond. – Inpatient hospital service claims, is effective for dates of discharge after September 30, 2015 ICD-10-CM Compliance Dates

3. Covered Entities – Everyone covered by the Health Insurance Portability Accountability Act (HIPPA) Non-Covered Entities – Worker’s Compensation – Auto Insurance – Non covered HIPAA entities are exempt but are encouraged to adapt the new code set Covered and Non-Covered Entities

4. 21 Chapters Alpha-numeric codes; not case-sensitive – Codes begin with Alpha letter, A-Z, excluding U – Common errors I verses 1 O verses 0 “X” Placeholder 3 to 7 characters – Decimal following 3 rd character ICD-10 Code Structure

5. Placeholder “X” – Used for future expansion of a code – Fills in empty characters when a 6 th and/or 7 th character apply – The placeholder may be used in different scenarios but should never serve as the final character. Example: W19.XXXA Unspecified fall, Initial Encounter ICD-10 Code Structure

6. 7 th Character – Provides specified information regarding the clinical visit – Is required for certain categories and must be reported in the seventh position – May be alpha or numeric – Has different meanings depending on the coding category ICD-10 Code Structure

7. Laterality – Some I CD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. – If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. – If the side is not identified in the medical record, assign the code for the unspecified side. OGCR section 1.B.13 ICD-10 Code Structure

8. “Other” Codes – Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. “Unspecified” Codes – Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. OGCR section 1.A.9.a.b ICD-10 Code Structure

9. Excludes Notes – Excludes1 A type 1 Excludes note is a pure excludes note It means “NOT CODED HERE” The code excluded should never be used at the same time When two conditions cannot occur togethe r – Excludes2 Represents “Not included here” The condition excluded is not part of the condition represented by the code It is acceptable to use both the code and the excluded code together, when appropriate OGCR section 1.A.12.a.b ICD-10 Structure

10. “Code First” and “Use Additional Code” – ICD-10 has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. – These instructional notes indicate the proper sequencing order of the codes. OGCR section 1.A.13 The “-” indicates there are additional reporting options ICD-10 Code Structure

11. Most Common Diagnosis Codes

12. Chest pain ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 786.50R07.9Chest pain, unspecified epidemic myalgia (B33.0) jaw pain R68.84 pain in breast (N64.4) There are more specific code choice selections: 786.51R07.2Precordial pain 786.52R07.1Chest pain on breathing 786.52R07.81Pleurodynia 786.59R07.82Intercostal pain 786.59R07.89Other chest pain

13. Type – Chest pain due to myocardial ischemia – Chest pain on breathing – Intercostal pain – Pleurodynia – Precordial chest pain Use of a symptom code with a definitive diagnosis code Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. OGCR Section I.C.18.b Documentation Tips

14. Atherosclerotic heart disease of native coronary artery without angina pectoris ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 414.00I25.10Atherosclerotic heart disease of native coronary artery without angina pectoris Applicable To: Atherosclerotic heart disease NOS N/A atheroembolism (I75.-) atherosclerosis of coronary artery bypass graft(s) and transplanted heart (I25.7-) 414.01I25.10 No ICD-10 code exists for unspecified vessel; native or bypass graft must be indicated Use additional code, if applicable, to identify: coronary atherosclerosis due to calcified coronary lesion (I25.84) coronary atherosclerosis due to lipid rich plaque (I25.83) chronic total occlusion of coronary artery (I25.82) exposure to environmental tobacco smoke (Z77.22) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0)

15. Associated Artery/Lesion Type – Native artery – Bypass graft – Bypass graft, autologous artery – Bypass graft, autologous vein – Bypass graft, nonautologous biological – Bypass graft, other – Due to calcified coronary lesion – Due to lipid rich plaque Native vs Transplanted Heart Associated angina – Without angina – With unstable angina – With angina and spasm Artherosclerotic Heart Disease Coronary Artery Documentation Tips

16. Atrial fibrillation ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 427.31I48.91Unspecified atrial fibrillation N/A There are more specific code choice selections available below: I48.0Paroxysmal atrial fibrillation I48.1Persistent atrial fibrillation I48.2Chronic atrial fibrillation Permanent atrial fibrillation

17. Type – Chronic (I48.2) – Paroxysmal (I48.0) – Persistent (I48.1) Atrial Fibrillation Documentation Tips

18. Cardiac Arrhythmias ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 427.89I49.8Other specified cardiac arrhythmias Applicable To: Coronary sinus rhythm disorder Ectopic rhythm disorder Nodal rhythm disorder bradycardia NOS (R00.1) neonatal dysrhythmia (P29.1-) sinoatrial bradycardia (R00.1) sinus bradycardia (R00.1) vagal bradycardia (R00.1) N/A 427.89R00.1Bradycardia, unspecified Applicable To: Sinoatrial bradycardia Sinus bradycardia Slow heart beat Vagal bradycardia abnormalities originating in the perinatal period (P29.1-) specified arrhythmias (I47- I49) neonatal bradycardia (P29.12) N/A There are more code choice selections below: 427.9I49.9Cardiac arrhythmia, unspecified

19. Type – Atrial fibrillation – Atrial flutter – Premature depolarization – Re-entry ventricular arrhythmia – Sick sinus syndrome – Supraventricular tachycardia – Ventricular fibrillation – Ventricular flutter – Ventricular tachycardia – Paroxysmal tachycardia – Cardiac arrhythmia Cardiac Arrhythmias Documentation Tips

20. Fibrillation Type – Chronic – Paroxysmal – Persistent Flutter Type – Typical – Atypical Premature Depolarization Type – Atrial – Junctional – Ventricular Cardiac Arrhythmias Documentation Tips

21. R00.1 - Use Additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5) I49 - Code first cardiac arrhythmia complicating: – Abortion or ectopic or molar pregnancy (O00-O07, O08.8) – Obstetric surgery and procedures (O75.4) Cardiac Arrhythmias Documentation Tips

22. Abnormal electrocardiogram [ECG] [EKG] ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 794.31R94.31Abnormal electrocardiogram [ECG] [EKG] long QT syndrome (I45.81) abnormal findings on antenatal screening of mother (O28. -) certain conditions originating in the perinatal period (P04- P96) signs and symptoms classified in the body system chapters signs and symptoms of breast (N63, N64.5)

23. Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Use of a symptom code with a definitive diagnosis code – Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Documentation Tips Documentation Tips

24. Aortic Valve Disorders Nonrheumatic ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 424.1I35.0Nonrheumatic aortic (valve) stenosis Aortic valve disorder of unspecified cause but with diseases of mitral and/or tricuspid valve(s) (I08.-) Aortic valve disorder specified as congential (Q23.0, Q23.1) Aortic valve disorder specified as rheumatic (I06.-) Hypertrophic subaortic stenosis (I42.1) N/A There are more specific code choice selections below: 424.1I35.1Nonrheumatic aortic (valve) insufficiency 424.1I35.2Nonrheumatic aortic (valve) stenosis with insufficiency 424.1I35.8Other nonrheumatic aortic valve disorders 424.1I35.9Nonrheumatic aortic valve disorder, unspecified

25. Type – Stenosis – Insufficiency – Stenosis with insufficiency – List other Documentation Tips

26. Shortness of breath ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 786.05R06.02Shortness of breath abnormalities originating in the perinatal period (P29.1-) specified arrhythmias (I47-I49) acute respiratory distress syndrome (J80) respiratory arrest (R09.2) respiratory arrest of newborn (P28.81) respiratory distress syndrome of newborn (P22.-) respiratory failure (J96.-) respiratory failure of newborn (P28.5) tachypnea NOS (R06.82) transient tachypnea of newborn (P22.1) N/A There are more specific code choice selections below: 786.09R06.00Dyspnea, unspecified 786.02R06.01Orthopnea 786.09R06.09Other forms of dyspnea

27. Dyspnea Type – Shortness of breath – Orthopnea – Other forms Documentation Tips

28. Ventricular premature depolarization ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 427.69I49.3Ventricular premature depolarization bradycardia NOS (R00.1) neonatal dyrhythmia (P29.1-) sinoatrial bradycaria (R00.1) sinus bradycaria (R00.1) vagal bradycaria (R00.1) N/A There are more specific code choice selections below: 427.69I49.49 Other premature depolarization Code first cardiac arrhythmia complicating: Abortion or ectopic or molar pregnancy (O00.-O07, O08.8) Obstetric surgery and procedures (O75.4)

29. Type – Atrial premature depolarization (I49.1) – Junctional premature depolarization (I49.2) – Ventricular premature depolarization (I49.3) – Other specified cardiac arrhythmias (I49.8) Documentation Tips

30. Ventricular tachycardia ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 427.1I47.2Ventricular tachycardia tachycardia NOS (R00.0) Sinoatrial tachycaria (R00.0) sinus tachycardia (R00.0) Code first cardiac arrhythmia complicating: Abortion or ectopic or molar pregnancy (O00.-O07, O08.8) Obstetric surgery and procedures (O75.4)

31. Other cardiomyopathies ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 425.4I42.8Primary cardiomyopathies, NEC Ischemic cardiomyopathy (I25.5) Peripartum cardiomyopathy (O90.3) Ventricular hypertrophy (I51.7) There are more specific code choice selections below: 425.4I42.2Other hypertrophic cardiomyopathy 425.4I42.5Other restrictive cardiomyopathy 425.4I42.9Cardiomyopathy, unspecified (familial)(idiopathic) Code first pre-existing cardiomyopathy complicating pregnancy and puerperium (O99.4)

32. Syncope and collapse ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 780.2R55Syncope and collapse Applicable To: Blackout Fainting Vasovagal attack cardiogenic shock (R57.0) carotid sinus syncope (G90.01) heat syncope (T67.1) neurocirculatory asthenia (F45.8) neurogenic orthostatic hypotension (G90.3) orthostatic hypotension (I95.1) postprocedural shock (T81.1-) psychogenic syncope (F48.8) shock NOS (R57.9) shock complicating or following abortion or ectopic or molar pregnancy (O00-O07, O08.3) shock complicating or following labor and delivery (O75.1) Stokes-Adams attack (I45.9) unconsciousness NOS (R40.2-) abnormal findings on antenatal screening of mother (O28.-) certain conditions originating in the perinatal period (P04- P96) signs and symptoms classified in the body system chapters signs and symptoms of breast (N63, N64.5)

33. Type – Carotid sinus syncope (G90.01) – Heat syncope Initial encounter (T67.1XXA) Subsequent encounter (T67.1XXD) Sequela (T67.1XXS) – Psychogenic syncope (F48.8) – Stokes-Adams syncope (I45.9) – Vasovagal syncope (R55) Documentation Tips

34. Cardiomegaly ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 429.3I51.7Cardiomegaly Applicable To: Cardiac dilatation Cardiac hypertrophy Ventricular dilatation N/A certain conditions originating in the perinatal period (P04-P96) certain infectious and parasitic diseases (A00-B99) complications of pregnancy, childbirth and the puerperium (O00-O9A) congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99) endocrine, nutritional and metabolic diseases (E00-E88) injury, poisoning and certain other consequences of external causes (S00-T88) neoplasms (C00-D49) symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94) systemic connective tissue disorders (M30-M36) transient cerebral ischemic attacks and related syndromes (G45.-)

35. Hypertension ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 401.1 401.9 401.0 I10Essential (Primary) Hypertension Includes: high blood pressure, Hypertension (arterial) (benign) (essential) (malignant) (systemic) Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16) Neonatal hypertension (P29.2) Primary pulmonary hypertension (I127.0) Essential (primary) hypertension involving vessels of brain (I60-I69) Essential (primary) hypertension involving vessels of eye (H35.0-) Hypertensive Diseases Categories (I10-I15) The use additional codes and Excludes1 codes apply for all categories. (I10-I15)Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0) Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11. O13-O16) Neonatal hypertension (P29.2) Primary Pulmonary hypertension (I27.0)

36. Hypertension cont. ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 402.01 402.11 402.91 I11.0Hypertensive Heart Disease with heart failure Use additional code to identify type of heart failure (I50.-) N/A 402.00 402.10 402.90 I11.9Hypertensive Heart Disease without heart failure N/A 403.01 403.11 403.91 I12.0Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or end stage renal disease. Use additional code to identify the stage of chronic kidney disease (N185.5, N18.6) Hypertension due to Kidney Disease (I15.0, I15.1) Renovascular Hypertension (I15.0) Secondary Hypertension (I115.-) Acute Kidney Failure (N17.-) 403.00 403.10 403.90 I12.9Hypertensive Chronic Kidney Disease with stage 1-4 Chronic Kidney Disease, or unspecified Chronic Kidney Disease. Use additional code to identify the stage of chronic kidney disease (N18.1-N18.9) Hypertension due to Kidney Disease (I15.0, I15.1) Renovascular Hypertension (I15.0) Secondary Hypertension (I115.-) Acute Kidney Failure (N17.-)

37. Hypertension cont. ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 404.01 404.11 404.91 I13.0Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney disease Use additional code to identify type of heart failure (I50.-) Use additional code to identify stage of chronic kidney disease (N18.1-NN18.4, N18.9) N/A 404.00 404.10 404.90 I13.10Hypertensive Heart and Chronic Kidney Disease without heart failure, with stage 1-4 chronic kidney disease, or unspecified chronic kidney disease. Use additional code to identify the stage of chronic kidney disease (N18.1-N18.4, N18.9) N/A 404.02 404.12 404.92 I13.11Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease. Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6) N/A 404.03 404.13 404.93 I13.2Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Use additional code to identify type of heart failure (I50.-) Use additional code to identify the stage of chronic kidney disease (N18.5. N18.6) N/A

38. Hypertension cont. ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 405.01 405.11 405.91 I15.0Renovascular Hypertension Code also underlying condition Postprocedural hypertension (I97.3) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) 405.91I15.1Hypertension secondary to other renal disorders Code also underlying condition Postprocedural hypertension (I97.3) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) 405.99I15.2Hypertension secondary to endocrine disorders Code also underlying condition Postprocedural hypertension (I97.3) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) 405.09 405.19 405.99 I15.8Other secondary hypertension Code also underlying condition Postprocedural hypertension (I97.3) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-) 405.99I15.9Secondary hypertension, unspecified Code also underlying condition Postprocedural hypertension (I97.3) Secondary hypertension involving vessels of brain (I60-I69) Secondary hypertension involving vessels of eye (H35.0-)

39. Hypertension is no longer classified as benign, malignant or unspecified. ICD-10 Codes have been grouped according to disease progression: – I10Essential Hypertension – I11.-Hypertensive Heart Disease – I12.-Hypertensive CKD » Further subdivided by stage of kidney disease – I13.-Hypertensive Heart and CKD » Further subdivided by stage of kidney disease – I15.-Secondary Hypertension Transient Hypertension – A code for hypertension is NOT assigned unless the patient has a documented, established diagnosis of hypertension. R03.0 Elevated blood pressure reading without diagnosis of hypertension Document requirements – Type – Current Status – Associated relationships Hypertension Documentation Tips

40. Hyperlipidemia ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 272.4E78.4Other Hyperlipidemia Familial combined hyperlipidemia Sphingolipidosis (E75.0-E75.3) N/A 272.4E78.5Hyperlipidemia, unspecified There are more specific code choice selections available below: 272.0E78.0Pure Hypercholesterolemia 272.1E78.1Pure Hypercholesterolemia 272.2E78.2Mixed Hyperlipidemia 272.3E78.3Hyperchylomicronemia 272.5E78.6Lipoprotein deficiency

41. Type – Mixed – Other – Unspecified Hyperlipidemia Documentation Tips

42. Heart failure, unspecified ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 428.0I50.9Heart failure, unspecified Applicable To: Biventricular (heart) failure NOS Cardiac, heart or myocardial failure NOS Congestive heart disease Congestive heart failure NOS Right ventricular failure (secondary to left heart failure) Cardia arrest (I46.-) Neonatal cardiac failure (P29.0) fluid overload (E87.70) N/A Code first: Heart failure complicating abortion or ectopic or molar pregnancy (O00-O07, O08.8) Heart failure following surgery (I97.13-) Heart failure due to hypertension (I11.0) Heart failure due to hypertension with chronic kidney disease (I13.-) Obstetrics surgery and procedures (O75.4) Rheumatic heart failure (I09.81)

43. Type – Systolic – Diastolic – Combined Chronicity – Acute – Chronic – Acute on chronic Heart failure, unspecified Documentation Tips

44. 1) Hypertension with Heart Disease Heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease, 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 in those patients with heart failure. Heart failure, unspecified Documentation Tips

45. 2) Hypertensive Chronic Kidney Disease Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease. The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease. See Section I.C.14. Chronic kidney disease. If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required. Heart failure, unspecified Documentation Tips

46. On October 01, 2015 we will monitor claims for date of service rules Outpatient claims cannot have crossover dates Outpatient claims will be coded according to date of service Inpatient facility claims will be coded per date of discharge We will monitor claims to resolve any unanticipated problems with the submission process Monitor Claims

47. We will monitor for claim denials We will monitor editing trends for ICD-10 Coding guidelines We will provide feedback to the physicians regarding supporting documentation requirements We will monitor WC or Liability carriers for published rules on use of ICD-9 or ICD-10 code sets Claim Denial and Management

48. Client will need to update – Templates – Order Sets – Superbills – Favorites Future Orders – Remove ICD-9 code add ICD-10 code Client Responsibilities

49. All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection. Site specificity Document notation of qualifiers – Exacerbation – Manifestations – Relapse – Status – Stages Indicate acute or chronic Indicate underlying or external cause factors – Medication – Smoke – Accidents – Mechanical failure Laterality – Bilateral – Right – Left Documentation – Start Now

50. Episode of Care for injuries, poisoning, external causes and other conditions – Initial Encounter Use while the patient is receiving active treatment of the condition – Active treatment includes surgical treatment, an emergency encounter, and evaluation and treatment by a new physician – Subsequent Encounter Used on encounter after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. – Medication adjustments, aftercare, device adjustments, cast change – Sequela Used for complications or conditions that arise as a direct result of a condition, late effect Documentation – Start Now

51. Combination codes that capture – Etiology and manifestation – Related conditions – Disease, injury or other medical condition and complications – Disease or other medical conditions and common signs or symptoms Add ICD-10 Codes to patient Problem List Documentation – Start Now

52. codingresource@g1hs.com Centers for Disease Control and Prevention (ICD-10-CM) http://www.cdc.gov/nchs/icd/icd10cm.htmQuestions