1. Family Practice 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. Diabetes ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 250.00E11.9Type 2 Diabetes mellitus without complications Diabetes (mellitus) due to insulin secretory defect Diabetes (NOS) Insulin resistant diabetes (mellitus) Use additional code to identify any insulin use (Z79.4) Diabetes mellitus due to underlying condition (E08.-) Drug or chemical induced diabetes mellitus (E09.1-) Gestational diabetes (O24.4-) Neonatal diabetes mellitus (P70.2) Postpancreatectomy diabetes mellitus (E13.-) Postprocedural diabetes mellitus (E13.-) Secondary diabetes mellitus NEC (E13.-) Type 1 diabetes mellitus (E10.-) transitory endocrine and metabolic disorders specific to newborn (P70-P74 N/A 250.02E11.65Type 2 diabetes mellitus with hyperglycemia Diabetes (mellitus) due to insulin secretory defect Diabetes (NOS) Insulin resistant diabetes (mellitus Use additional code to identify any insulin use (Z79.4) Diabetes mellitus due to underlying condition (E08.-) Drug or chemical induced diabetes mellitus (E09.1-) Gestational diabetes (O24.4-) Neonatal diabetes mellitus (P70.2) Postpancreatectomy diabetes mellitus (E13.-) Postprocedural diabetes mellitus (E13.-) Secondary diabetes mellitus NEC (E13.-) Type 1 diabetes mellitus (E10.-) transitory endocrine and metabolic disorders specific to newborn (P70-P74 N/A

13. Diabetes mellitus codes are now combination codes that include the type of diabetes, the body system affected, and the complication affecting that body system. They are no longer classified as controlled or uncontrolled. Type – Type 1 – Type 2 – Due to underlying conditions – Drug or chemical induced – Other specified Diabetes Documentation Tips

14. Complication Status – Without complication – With circulatory complication – With diabetic arthropathy – With hyperglycemia – With hyperosmolarity – With hypoglycemia – With ketoacidosis – With kidney complications – With neurologic complications – With ophthalmic complications – With oral complications – With skin complications – With other specified complications Diabetes Documentation Tips

15. Complication Detail – With diabetic retinopathy – With cataract – With other ophthalmic complication – With chronic kidney disease – With nephropathy – With other kidney complication – With amyotrophy – With autonomic neuropathy – With mononeuropathy – With polyneuropathy – With other neurological complication – With unspecified neuropathy – With or without coma – With peripheral angiopathy with or without gangrene – With other circulatory complications – With neuropathic arthropathy – With other arthropathy – With dermatitis – With foot ulcer – With other skin ulcer – With other skin complication – With periodontal disease – With other oral complications Diabetes Documentation Tips

16. Diabetes is a chronic condition that requires multi-specialty management. The documentation should indicate relevant details regarding the management of each case as it relates to the services rendered or actions taken to coordinate the patients care. The HPI, at a minimal, should include some indication of the historical timeline or duration of the illness, levels as it relates to the date of service, manifestations or impairments associated with the condition and effectiveness of current medication regimen. The examination should notate any physical signs related to the diabetic conditions. (Ulcers, nails, edema, discoloration sensitivity to touch) Diabetes Documentation Tips

17. 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)

18. 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.-)

19. 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

20. 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-)

21. 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

22. 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

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

24. Dorsalgia Category M54 Excludes1Excludes2 N/A

25. Cervicalgia ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 723.1M54.2Cervicalgia Cervicalgia due to intervertebral cervical disc disorder (M50.-) Category M54 Excludes2 Sciatica ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 724.3M54.30Sciatica, unspecified side Lesion of sciatic nerve (G57.0) Sciatica due to intervertebral disc disorder (M51.1-) Sciatica with lumago (M54.4-) Category M54 Excludes2 724.3M54.31Sciatica, right side Lesion of sciatic nerve (G57.0) Sciatica due to intervertebral disc disorder (M51.1-) Sciatica with lumago (M54.4-) Category M54 Excludes2 724.3M54.32Sciatica, left side Lesion of sciatic nerve (G57.0) Sciatica due to intervertebral disc disorder (M51.1-) Sciatica with lumago (M54.4-) Category M54 Excludes2

26. Lumbago with Sciatica724.3 ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 724.3M54.40Lumbago with sciatica, unspecified side Lumbago with sciatica due to intervertebral disc disorder (M51.1-) Category M54 Excludes2 724.3M54.41Lumbago with sciatica, right side Lumbago with sciatica due to intervertebral disc disorder (M51.1-) Category M54 Excludes2 724.3M54.42Lumbago with sciatica, left side Lumbago with sciatica due to intervertebral disc disorder (M51.1-) Category M54 Excludes2 Low Back Pain ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 724.2M54.5Low back pain Loin pain Lumbago NOS low back strain (S39.012) lumbago due to intervertebral disc displacement (M51.2-) lumbago with sciatica (M54.4-) Category M54 Excludes2 Pain in Thoracic Spine 724.1M54.6Pain in thoracic spine Pain in thoracic spine due to intervertebral disc disorder (M51.-) Category M54 Excludes2

27. Dorsalgia ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 724.5M54.89Other dorsalgia current injury - see injury of spine by body region discitis NOS (M46.4-) Dorsalgia in thoracic region (M54.6) Low back pain (M54.5-) Category M54 Excludes2 724.5M54.9Dorsalgia, unspecified N/A Category M54 Excludes2

28. Document site and laterality – Unspecified codes should be used only in rare circumstances Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition. Documentation Tips

29. Encounter for General Adult Medical Examination ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 V70.0Z00.00Encounter for general adult medical examination without abnormal findings Encounter for adult health check-up NOS Examinations related to pregnancy and reproduction (Z30-Z36, Z39-) Encounter for examination for administrative purposes (Z02.-) Encounter for pre- procedural examinations (Z01.81-) Special screening examinations (Z11- Z13) V70.0Z00.01Encounter for general adult medical examination with abnormal findings Use additional code to identify abnormal findings Note: Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94. Examinations related to pregnancy and reproduction (Z30-Z36, Z39-) Encounter for examination for administrative purposes (Z02.-) Encounter for pre- procedural examinations (Z01.81-) Special screening examinations (Z11- Z13)

30. Identify routine health check – Adult – Child – Newborn Under 8 days old 8-28 days old Identify presence/absence of abnormal findings – With abnormal findings – Without abnormal findings Use an additional code for any abnormal findings – Document abnormal findings Well Examination Documentation Tips

31. Chronic Obstructive Pulmonary Disease (COPD) ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 496J44.9Chronic obstructive pulmonary disease, unspecified Applicable to: Chronic obstructive airway disease NOS Chronic obstructive lung disease NOS Bronchiectasis (J47.-) Chronic bronchitis NOS (J43) Chronic simple and mucopurulent bronchitis (J14.-) Chronic tracheitis (J42) Chronic tracheobronchitis (J42) Emphyysema without chronic bronchitis (J43.-) Lung diseases due to external agents (J60-J70) N/A There are more specific code choice selections below: 491.22 493.21 J44.0Chronic obstructive pulmonary disease with acute lower respiratory infection 491.21 493.22 J44.1Chronic obstructive pulmonary disease with (acute) exacerbation

32. Type – Chronic bronchitis Simple Mucopurulent Mixed simple and mucopurulent – Emphysema Centrilobular Panlobular Unilateral – COPD with acute exacerbation – COPD with acute lower respiratory injection Identify the infection (use additional code) COPD Documentation Tips

33. Code also type of asthma, if applicable (J45-) 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) COPD Documentation Tips

34. Encounter for other preprocedural examination ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 V72.83Z01.818Encounter for other preprocedural examination Applicable To: Encounter for preprocedural examination NOS Encounter for examinations prior to antineoplastic chemotherapy encounter for examination for administrative purposes (Z02.-) encounter for examination for suspected conditions, proven not to exist (Z03.-) encounter for laboratory and radiologic examinations as a component of general medical examinations(Z00.0-) encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to the sign(s) or symptom(s) special screening examinations (Z11-Z13) There are more specific code choice selections below: V72.81Z01.810Encounter for preprocedural cardiovascular examination V72.82Z01.811Encounter for preprocedural respiratory examination V72.63Z01.812Encounter for preprocedural laboratory examination Blood and urine tests prior to treatment or procedure

35. Includes: routine examination of specific system Codes from category Z01 represent the reason for the encounter. Use when a patient is being cleared for a procedure or surgery and no treatment is given. Documentation Tips

36. 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

37. Type – Chronic – Paroxysmal – Persistent Atrial Fibrillation Documentation Tips

38. Abdominal pain ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 789.00R10.9Unspecified abdominal pain renal colic (N23) dorsalgia (M54.-) flatulence and related conditions (R14.-) There are more specific code choice selections below: R10.0Acute abdomen R10.10Upper abdominal pain, unspecified R10.11Right upper quadrant pain R10.12Left upper quadrant pain R10.13Epigastric pain R10.2Pelvic and perineal pain R10.30Lower abdominal pain, unspecified R10.31Right lower quadrant pain R10.32Left lower quadrant pain R10.33Periumbilical pain R10.81-Other abdominal pain R10.82-Rebound abdominal tenderness

39. Abdominal Pain Documentation Tips Document specific location: – LLQ, LUQ, RUQ, RLQ – Periumbilical – Epigastric – Generalized (R10.84) – Colic (R10.83) – Acute abdominal pain (R10.0) – Abdominal tenderness (R10.811-R10.819) – Rebound abdominal pain (R10.821-R10.829)

40. Cough ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 786.2R05Cough Cough with hemorrhage (R04.2) Smoker’s Cough (J41.0) N/A

41. 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. Cough Documentation Tips

42. 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)

43. 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

44. Chronic pain syndrome ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 338.4G89.4Chronic pain syndrome Applicable To: Chronic pain associated with significant psychosocial dysfunction generalized pain NOS (R52) pain disorders exclusively related to psychological factors (F45.41) pain NOS (R52) atypical face pain (G50.1) headache syndromes (G44.-) localized pain, unspecified type - code to pain by site, such as: abdomen pain (R10.-) back pain (M54.9) breast pain (N64.4) chest pain (R07.1-R07.9) ear pain (H92.0-) eye pain (H57.1) headache (R51) joint pain (M25.5-) limb pain (M79.6-) lumbar region pain (M54.5) painful urination (R30.9) pelvic and perineal pain (R10.2) shoulder pain (M25.51-) spine pain (M54.-) throat pain (R07.0) tongue pain (K14.6) tooth pain (K08.8) renal colic (N23) migraines (G43.-) myalgia (M79.1) pain from prosthetic devices, implants, and grafts (T82.84, T83.84, T84.84, T85.84) phantom limb syndrome with pain (G54.6) vulvar vestibulitis (N94.810) vulvodynia (N94.81-)

45. Type – Chronic pain syndrome (G89.4) – Due to neoplasm (G89.3) – Due to trauma ((G89.21) – Chronic post-thoracotomy pain (G89.22) – Other chronic postprocedural pain (G89.28) Chronic Pain Syndrome Documentation Tips

46. Encounter for Immunization Influenza Virus ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 V04.81Z23Encounter for immunization N/A

47. The procedural code will indicate the type of immunization to the carrier. Encounter for Immunization Documentation Tips

48. Urinary Tract Infection ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 599.0N39.0Urinary tract infection, site not specified candidiasis of urinary tract (B37.4-) neonatal urinary tract infection (P39.3) urinary tract infection of specified site, such as: cystitis (N30.-) urethritis (N34.-) hematuria NOS (R31.-) recurrent or persistent hematuria (N02.-) recurrent or persistent hematuria with specified morphological lesion (N02.-) proteinuria NOS (R80.-) Use additional code (B95-B97), to identify infectious agent.

49. Encounter type – Initial – Subsequent – sequela Urinary Tract Infection type – Acute cystitis – Acute pyelonephritis – Urethritis – Catheter-associated UTI Hematuria present – With or without Identify any retained foreign body, if applicable (Z18.-), code additional Use Additional code (B95-B97), to identify infectious agent Urinary Tract Infection Documentation Tips

50. Anxiety, generalized ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 300.02F41.1Generalized anxiety disorder Anxiety neurosis Anxiety state Anxiety reaction Overanxious disorder N/A Acute stress reaction (F43.0) Transient adjustment reaction (F43.2) Neurasthenia (F48.8) Psychophysiolo gic disorders (F45.-) Separation anxiety (F93.0) There are more code choice selections below: 300.01F41.0Panic disorder without agoraphobia 300.09F41.3Other mixed anxiety disorders 300.00F41.9Anxiety disorder, unspecified

51. Type – Generalized – Panic Disorder With agoraphobia Without agoraphobia – Other – Mixed – Unspecified Anxiety Documentation Tips

52. 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

53. 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

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

55. 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

56. 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

57. 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

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