1. The Revolution in Diagnosis Coding Mindy Burns Smith, RN CPC PCS CHAA
ICD-10-CM Basics
The Revolution in Diagnosis Coding
Mindy Burns Smith, RN CPC PCS CHAA

2. ICD-10-CM is the expanded diagnosis coding system that was due to be implemented 10-1- 2014
It has been pushed back until
Current ICD-9 codes, approx. 15,000
Future ICD-10 codes, approx. 124,000
ICD-10-CM Basics

3. ICD-10-CM Basics

4. ICD-10-CM Basics ICD-9 codes are 3-5 digits in length: 185 234.5
562.78
There is no more room for code expansion in the ICD-9 system
ICD-10-CM Guidelines
ICD-10-CM Basics

5. ICD-10-CM Basics ICD-10 codes are alphanumeric and have 3-7 characters
They have the ability to be expanded
I20
H62.41
E11.321
T21.33xA
ICD-10-CM Basics

6. More combination codes are used in ICD-10 which allows fewer codes to be submitted while still explaining the patient’s clinical condition
ICD-10-CM BASICS

7. ICD-10 codes now include laterality designations
ICD-10 codes now include laterality designations. Right is usually 1, Left is usually 2, and bilateral is usually 3
Physician documentation must be specific when using ICD-10 as to the laterality
ICD-10-CM Basics

8. All categories in ICD-10 are three characters
All categories in ICD-10 are three characters. The first character in a code is always a letter
B99—Other infectious diseases
C15-C26—Neoplasms of digestive organs
E70-E89—Metabolic disorders
P84—Other problems with newborn
S00-S09—Injuries to the head
Etc.
ICD-10-CM Basics

9. The four character categories define the site, etiology, manifestation or state of the disease
C15.5—Malignant neoplasm of lower third, esophagus
C15.9—Malignant neoplasm of esophagus, unspecified
Z71.7—{HIV} Human immunodeficiency virus counseling
ICD-10-CM Basics

10. The fifth or sixth character identifies the most precise or most accurate level of specificity
J10.82—Influenza due to other identified influenza with myocarditis
M88.811—Osteitis deformans of right shoulder
E10.311—Type 1 diabetes with diabetic retinopathy
ICD-10-CM Basics

11. ICD-10-CM Basics

12. Certain I-10 categories have applicable seven characters
Certain I-10 categories have applicable seven characters. The seventh character is required for all codes in that category. It always needs to be in the seventh character position so the dummy placeholder “x” is used in the fifth or sixth position so the seventh character is correctly placed.
T15.12xS—Foreign body conjunctival sac, left eye, sequela
ICD-10-CM Basics

13. The process of looking up codes in ICD-10 remains exactly the same as in ICD-9. The term is located in the index, verify the code in the tabular list. The term will have a “default” code listed next to the term in the index. This code will help you locate it in the tabular list
ICD-10-CM Basics

14. ICD-10-CM Basics Code first/use additional code notes
The underlying condition is coded first, followed by the manifestation. These instructional notes indicate the proper sequence of codes
H42—Glaucoma in diseases classified elsewhere
Code first underlying condition, such as:
Amyloidosis (E85.-)
Lowe’s syndrome (E72.03)
ICD-10-CM Basics

15. A Type 1 Excludes note indicates that the excluded code should never be used at the same time as the code above it. This note is used when two conditions cannot occur together
E11 Type 2 diabetes
Excludes 1---gestational diabetes (O24.2)
ICD-10-CM Basics

16. A Type 2 Excludes note indicates that the condition excluded is not part of the condition represented by the code, but it is acceptable to use both when both conditions exist
J03 Acute tonsillitis
Excludes 2: Chronic tonsillitis (J35.0)
ICD-10-CM Basics

17. When “with/without” are the two options for the final character of a set of codes, the default is always “without”.
For 5 character codes—0=without, 1=with
For 6 character codes—1=with, 9=without
G40.501—Epileptic seizures related to external causes, not intractable, with status epilepticus
G40.509
ICD-10-CM Basics

18. Signs and symptoms that are routinely associated with a disease process should not be assigned as additional codes, unless the code category calls for it
ICD-10-CM Basics

19. ICD-10-CM Basics B20—Human Immunodeficiency Virus {HIV}
Includes AIDS & AIDS-related complex
Use B20 as first-listed diagnosis when pt. is treated for an HIV related condition.
When pt. is treated for an unrelated condition, sequence the condition first, followed by the HIV related condition, either B20 if symptomatic or Z21 for an asymptomatic pt.
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
ICD-10-CM Basics

20. Six months ago, Susan tested positive for HIV, but has remained to date, symptom free. At today’s visit she comes to the doctor and is diagnosed with acute tonsillitis.
The proper sequencing would be:
J03.90—Acute tonsillitis, unspecified
Z21—Asymptomatic HIV infection status
ICD-10-CM Basics

21. The coding of severe sepsis requires a minimum of two codes:
The first code for an underlying systemic infection.
Then a code from subcategory R65.2—Severe sepsis
ICD-10-CM Basics

22. Malignant,Benign, Unspecified
ICD-10 Code
Site
Malignant,Benign, Unspecified
Chapter 2: Neoplasms (C00-D49)
ICD-10-CM Basics

23. ICD-10-CM Basics Malignant, Primary Malignant, secondary
Malignant, Ca in situ
Benign
Uncertainbehavior
Unspecified
Left side, female breast
C50.112
C79.81
D05.92
D24.2
D48.62
D49.3
ICD-10-CM Basics

24. John B. has been diagnosed with a malignancy of the frontal lobe
John B. has been diagnosed with a malignancy of the frontal lobe. He is also suffering from anemia because of the tumor. Proper sequencing would be:
C71.1—Malignant neoplasm of frontal lobe
D63.0—Anemia in neoplastic disease
ICD-10-CM Basics

25. ICD-10-CM Basics Diabetes coding varies markedly from ICD-9 to ICD-10:
The fifth digit in ICD-9 indicates type and controlled vs uncontrolled, ICD-10 does not use that concept
Multiple codes are needed in ICD-9 for the manifestations
ICD-10 uses combination codes to indicate manifestations
Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)
ICD-10-CM Basics

26. Diabetes Mellitus codes in ICD-10 are combination codes that include:
Type of diabetes mellitus
Body System affected
The complications affecting that body system
ICD-10-CM Basics

27. When the type of diabetes is not indicated, the default code is Type II Diabetes Mellitus
E10.36—Type I Diabetes Mellitus with diabetic cataract
E10.321—Type I Diabetes Mellitus with mild nonproliferative diabetic retinopathy with macular edema
ICD-10-CM Basics

28. When provider documents use, abuse, or dependence of same substance:
If use & abuse documented, assign abuse code only
If abuse & dependence documented, assign dependence code only
If use & dependence documented, assign dependence code only
If use, abuse & dependence documented, assign dependence code only
Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders (F01-F99)
ICD-10-CM Basics

29. When coding cerebral palsy, hemiplegia, hemiparesis, paraplegia, quadriplegia, and other paralytic syndromes, ICD-10 codes provide specificity for laterality and whether dominant/non dominant side is involved.
Physician documentation must include those concepts.
Jim suffers from paralysis of his upper right arm. He is left-handed. ICD-10—G83.23
Chapter 6: Diseases of the Nervous System (G00-G99)
ICD-10-CM Basics

30. When a patient has bilateral glaucoma, different types or stages for each eye; assign the appropriate code for each eye:
H —Low-tension glaucoma, left eye, moderate stage
H —Low-tension glaucoma, right eye, mild stage
Chapter 7: Diseases of Eye and Adnexa (H00-H59) Adnexa—parts accessory to an organ or structure (Stedman’s)
ICD-10-CM Basics

31. Use an external cause code following the code for the ear condition, if applicable, to identify the cause of the ear condition
Lily is seen by her pediatrician after having been at the swimming pool two days ago. Her left outer ear is red, swollen, and the patient is pulling on it. The ICD-10 code would be:
Swimmer’s ear—H60.332
Additional ICD-10 codes:
Impacted cerumen of both ears—H61.23
Abscess, external ear, left—H60.02
Chapter 8: Diseases of Ear and Mastoid Process (H60-H95)
ICD-10-CM Basics

32. ICD-10-CM Basics Angina Type of vessel affected Ischemic heart disease
Chapter 9: Diseases of Circulatory System (I00-I99)
ICD-10-CM separates code for the ischemic ht. disease by the type of vessel and if there is angina. Heart failure is coded by type such as systolic, diastolic or both and whether it is acute or chronic
ICD-10-CM Basics

33. There is no hypertension table in ICD-10
There is no hypertension table in ICD-10. The rule of thumb for hypertension codes:
Diseases Present
Coding Process
High BP & heart disease
Code separately
Hypertensive heart disease
Combine codes
High BP & Acute renal failure
High BP & Chronic renal failure
ICD-10-CM Basics

34. Megan visits her cardiologist for her three- month follow-up visit
Megan visits her cardiologist for her three- month follow-up visit. She is being treated for hypertensive heart disease with benign hypertension:
I 11.9—Hypertensive heart disease without heart failure
Tim suffers from hypertension that is uncontrolled—I 10
ICD-10-CM Basics

35. Unlike hypertension with heart disease, ICD-10 presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease. Thus, that relationship does NOT need to be documented.
ICD-10-CM Basics

36. ICD-10-CM Basics

37. Secondary hypertension is due to an underlying condition
Secondary hypertension is due to an underlying condition. Assign a code for the underlying condition and one from category I 15 to identify the hypertension
For transient hypertension or simple elevated high blood pressure—code R03.0—Elevated blood pressure reading without diagnosis of hypertension
ICD-10-CM Basics

38. If a patient with coronary artery disease is admitted due to an acute myocardial infarction {AMI}, the AMI should be sequenced before the coronary artery disease.
In ICD-9, MI’s are coded as acute or chronic, using an 8-week guideline.
In ICD-10, MI’s are coded as initial or subsequent, using a 4-week rule
ICD-10-CM Basics

39. For old or healed myocardial infarctions that don not need further care, code I25.2—Old myocardial infarction
ICD-10-CM Basics

40. Coding for asthma includes intermittent, mild persistent, moderate persistent, and severe persistent
Code only confirmed cases of influenza due to certain influenza viruses—category J09. Coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A
Acute influenza upper respiratory infection due to Avian flu---J09.x2
Chapter 10: Diseases of Respiratory System (J00-J99)
ICD-10-CM Basics

41. ICD-10-CM Basics Crohn’s disease codes are greatly expanded in ICD-10:
K50.814—Crohn’s disease of both small/large intestine with abscess
K50.112—Crohn’s disease of lg. intestine with intestinal obstruction
K50.013—Crohn’s disease of small intestine with fistula
Chapter 11: Diseases of Digestive System (K00-K94)
ICD-10-CM Basics

42. K35—K38 Appendicitis and diseases of the appendix
K35—K38 Appendicitis and diseases of the appendix. Include acute and chronic and with or without peritonitis
K35.2—Acute appendicitis with generalized peritonitis
K36—Chronic appendicitis
K38.3—Fistula of appendix
ICD-10-CM Basics

43. L89, Pressure ulcer codes are combination codes that identify the site of the pressure ulcer and stage of the ulcer
L89.511—Pressure ulcer of right ankle, stage 1
L89.320—Pressure ulcer of left buttock, unstageable
Chapter 12: Diseases of Skin and Subcutaneous Tissue (L00-L99)
ICD-10-CM Basics

44. Arthritis and osteoarthritis have both site and laterality designations
The site represents either the bone, joint or muscle involved. For conditions where more than one bone, joint, or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code available
M17.11 Unilateral primary osteoarthritis, right knee
Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)
ICD-10-CM Basics

45. Coding for Fractures in ICD-10
Coding for Fractures in ICD-10. Seventh digit characters are used to indicate:
A—use when patient is receiving active treatment for the fracture. Surgery, ER, evaluation/treatment by a new doctor
D—use when patient has completed active treatment
G—use when encounter is for delayed healing
S—use for the sequelae of fracture
ICD-10-CM Basics

46. ICD-10 classifies Chronic Kidney Disease {CKD} based on severity:
N18.2—Stage 2 or mild CKD
N18.3—Stage 3 or moderate CKD
N18.4—Stage 4 or severe CKD
N18.6—End stage renal disease {ESRD}
If both a stage of CKD and ESRD are documented, assign code N18.6 only
Chapter 14: Diseases of Genitourinary System (N00-N99)
ICD-10-CM Basics

47. Obstetric cases require codes from the range O00-O99
Obstetric cases require codes from the range O00-O99. These codes have sequencing priority over codes from other chapters. They are used only on the mother’s chart, never on the newborn record
Weeks of gestation codes are used on the maternal record
O22.42—Hemorrhoids in pregnancy, second trimester
Z3A.16—16 weeks gestation of pregnancy
Chapter 15: Pregnancy, Childbirth and the Puerperium (O 00-O 9A)
ICD-10-CM Basics

48. A code from Z37, outcome of delivery, is included on every maternal record when the baby has been delivered
Abby is HIV positive and visits her doctor for a routine visit. She is 26 weeks, 0 days
O98.712—HIV disease complicating pregnancy, second trimester
Z21—HIV positive NOS
Z3A.26—26 weeks gestation of pregnancy
ICD-10-CM Basics

49. Diabetes Mellitus is a significant complicating factor in pregnancy:
Martha, who has gestational diabetes, sees her OB/Gyn during her seventh month. Her diabetes is well controlled with diet and she is at 28 weeks, 3 days
O24.410—Gestational diabetes mellitus in pregnancy, diet-controlled
Z3A.28—28 weeks gestation of pregnancy
ICD-10-CM Basics

50. Code O80 is used when a patient is admitted for a full-term normal delivery and delivers a single, healthy infant. It is always a principal diagnosis
Outcome of delivery code for O80 is Z37.0— single live birth. It is the only outcome of delivery code appropriate for use
ICD-10-CM Basics

51. Birth codes in the newborn record should be coded from category Z38, Liveborn according to place of birth and type of delivery
Z38.0—Single liveborn infant, born in hospital
Z38.01—Single liveborn infant, delivered by cesarean
Chapter 16: Newborn (Perinatal) Guidelines (P00-P96)
ICD-10-CM Basics

52. When both birth weight and gestational age are available, two codes from P07 should be assigned, with the code for birth weight sequenced before the code for gestational age:
A baby born at 32 weeks and weighs grams. The codes would be
P07.17—Other low birth weight newborn grams
P07.35—Preterm newborn, gestational age, 32 completed weeks
ICD-10-CM Basics

53. Codes for cleft lip/cleft palate are broken down by laterality, portion of the palate, and if conditions occur separately or together:
Q36.0 Cleft lip, bilateral
Q37.1 Cleft hard palate with unilateral cleft lip
Q37.4 Cleft hard and soft palate with bilateral cleft lip
Chapter 17: Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99)
ICD-10-CM Basics

54. Codes for symptoms and signs are acceptable to code when a definitive diagnosis has not been established by the provider
Signs/symptoms can be reported with a confirmed diagnosis when the S/S is not routinely associated with that diagnosis. The definitive code is always sequenced first
Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)
ICD-10-CM Basics

55. Code R29.6—Repeated falls- is to be used when the patient has recently fallen and the reason is being investigated
Code Z91.81—History of falling– is for use when patient has fallen in the past and is at risk for repeat falls
The two codes can be used together when appropriate
ICD-10-CM Basics

56. Most categories in chapter 19 have seventh character extensions that are required for each code
While playing tennis, the patient sprained his right wrist and was treated at the local ER
S63.501A—Unspecified sprain of right wrist, initial encounter
Y93.73—Activity, racquet and hand sports
Y92.312—Tennis court as POC as external cause
Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) Big very important chapter!!
ICD-10-CM Basics

57. Seventh character “A” should be used for ALL encounters when pt
Seventh character “A” should be used for ALL encounters when pt. is actively undergoing treatment
Seventh character “D” is used for encounters after the active treatment—i.e.-routine care in healing phase. Cast change, removal, removal fixator, medication adjustment, etc.
ICD-10-CM Basics

58. Seventh character “S,” sequela is used for complications or conditions that arise as a direct result of the injury, such as a burn scar
When using “S” it is necessary to use both the injury code and the code for the sequela itself. The “S” is added to the injury code only, not the sequela
S01.01xA—Laceration without foreign body of scalp, initial encounter
ICD-10-CM Basics

59. Fractures in ICD-10 will be classified into specific types of open fractures—{Gustilo classifications} depending on the mechanism of injury, soft tissue damage, and degree of skeletal involvement
Type I
Type II
Type III
Documentation will need to be precise
ICD-10-CM Basics

60. ICD-10 distinguishes between burns and corrosions
ICD-10 distinguishes between burns and corrosions. Burn codes are for thermal burns, fire, hot appliances, electricity, and radiation. Sunburns are coded separately, as in ICD-9
T21.33xA—Burn of third degree upper back, initial
T22.311A—Burn of third degree right forearm, initial encounter
T31.11 Burns involving % of body surface
X00.0xxA—Exposure to flames in uncontrolled fire in building, initial encounter
ICD-10-CM Basics

61. ICD-10-CM Basics Corrosions are burns due to chemicals
T31 and T32 categories are based on the classic ”rule of nines” in estimating body surface
An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where is occurred
ICD-10-CM Basics

62. When a patient takes a drug properly and has an adverse effect, code first the effect and then the adverse effect of the drug, as in ICD-9
Mary took a dose of penicillin that was prescribed properly and had projectile vomiting:
R11.12—Projectile vomiting
T36.0x5A—Adverse effect of penicillins, initial encounter
ICD-10-CM Basics

63. External cause codes are not required for reporting to some third-party payers. They provide data for injury research and evaluation of injury prevention
The number of available codes in I-10 have vastly increased over ICD-9. In ICD-10, they are the V— W—X—Y codes. More precise documentation will be necessary for code selection
As in I-9, these codes can NEVER be first-listed (primary) codes
Chapter 20: External Causes of Morbidity (V00-Y99) These codes compare to the E codes in ICD-9
ICD-10-CM Basics

64. While alpine skiing in Utah, the patient fell and suffered a stress fracture of the right femur:
M84.351A—Stress fracture, right femur, initial encounter
V00.321A—Snow ski accident
Y92.39—Other specified sports and athletic area as the place of occurrence of external cause
Y93.23—Other individual sport (Activity)
ICD-10-CM Basics

65. 1) Z codes may be used as either a first-listed code or secondary code
1) Z codes may be used as either a first-listed code or secondary code. These codes include: contact/exposure or inoculations/vaccinations
2) Status codes indicate a patient has the residual of a past illness or injury or is a carrier
3) History (of)—either personal or family
4) Screening
5) Observation
6) Aftercare
Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z00) These equal the V codes in ICD-9
ICD-10-CM Basics

66. ICD-10-CM Basics 7) Follow-up 8) Donor 9) Counseling
10) Encounters for OB /Reproductive services
11) Newborns and Infants
12) Routine & Administrative Exams
13) Prophylactic Organ Removal
ICD-10-CM Basics

67. A brief introduction to ICD-10-CM
Resources:
1) ICD-10-CM General Code set Training Manual from AAPC with 2014 draft copy ICD-10 code book
2) Medical Coding—Understanding ICD-10-CM and ICD-10-PCS Leah Grebner, Angela Suarez, 2012
A brief introduction to ICD-10-CM

68. ICD-10-CM Basics