PREPARING FOR ICD-10 CM BASIC CONCEPTS

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Objectives

• Understand the scope of the ICD-10 transition

• Identify the benefits of changing to ICD-10 and the association with ICF

• Recognize the similarities and differences between ICD-9 and ICD-10 coding

• Understand the purpose of the 7th character in ICD-10

• Understand unique coding rules for fractures

• Gain understanding of web based resources

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Jenelle Lauchman, PT, DPT, OCS

• 16 years as a PT –majority in OP Orthopedics

• Select Medical/Select PT locally

• Largest Provider of OP Services in the Nation

• Center Manager

• President of the NvAPTA

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Susan Priestman, PT, DPT, OCS

• 30 years as a PT -all in OP Orthopedics

• Select Medical/Select PT locally

• Largest Provider of OP Services in the Nation

• Industry leader /outcomes measurement

• Regional Clinical Coordinator in 7 States AK>OH

• Quality and Compliance -State and Federal Law

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What is ICD-10?

• 10th revision of the International Classification of Diseases and Related Health Problems (ICD)

• Used to code for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases

• Developed by the World Health Organization (WHO) in 1994

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Implementation of ICD-10

• In 2009, the Center for Medicare and Medicaid (CMS) mandated the adoption of ICD-10 code sets

• Implementation of ICD-10 for all providers is October 1, 2015

BASED ON ICF

International Classification of Functioning Disability

and Health (ICF)

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International Classification of Functioning Disability and Health

• Barriers • Facilitators

Body Functions &

Structures

Activities &

Participation

Environmental Factors

• Functions • Structures

• Capacity • Performance

http://apps.who.int/classifications/icfbrowser/

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What is ICF?

• A classification system – not a measurement tool or disease/condition label

• Classifies functioning and disability associated with health conditions – Not a way to describe a consequence of disease, but

rather components of health & functioning with the disease

– Shifts “cause” to impact on the patient or individual

COMPARING ICD-9 TO ICD-10

What’s the Difference?

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ICD-9- why the change? • ICD-9…

–produces limited information about patients’ medical conditions

– Is 30 years old

–has outdated terms

– is inconsistent with current medical practice.

– structure limits the number of new codes that can be created, and many ICD-9 categories are currently full.

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Important Features in ICD-10

• Reflect updated medical terminology

• Expanded detail and specificity: – Injury, fractures and postoperative complications

– Traumatic or non-traumatic injury

– Initial encounter, subsequent encounter, and sequela

• Grouped by anatomical site, then by type of injury

• Laterality: the affected side of the body – Dominant side or non-dominant side

– Single condition or bilateral condition

• ICD-10-CM Outpatient services and ICD-10-PCS inpatient services (not discussed here)

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Comparing ICD-9 to ICD-10

ICD – 9-CM ICD – 10-CM

13,600 codes 69,000 codes

Code book contains 17 chapters Code book contains 21 chapters

Consists of 3 to 5 characters Consists of 3 to 7 characters

1st character is alpha or numeric 1st character is alpha

Only utilizes letters E and V Utilizes all letters (except U)

2nd, 3rd, 4th, and 5th characters are always numeric

2nd character is always numeric

3rd, 4th, 5th, 6th, and 7th characters can be alpha or numeric

Shorter code descriptions because of lack of specificity and abbreviated code titles

Longer code descriptions because of greater clinical detail and specificity and full code titles

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Comparison of ICD-9-CM & ICD-10-CM

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Structure of ICD-10

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Comparison of ICD 9 to ICD-10

ICD-9

A - Category of code

B - Etiology, anatomical

site, and manifestation

ICD-10

A - Category of code

B - Etiology, anatomical site, and/or severity

C - Extension – 7th character for obstetrics,

injuries, and external causes of injury A B

A B C

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ICD-10 Sequence

S83.411.D

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Summary of ICD-10 CM

• The first character is always a letter

• The second character is always a number

• The third character may be a number or letter

• The final characters

– alphabetic extension or

– reserve sub classification (X)

–Placeholder X

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ICD-10 and Laterality

• 5th or 6th character position

• 0 = Unspecified

• 1 = Right

• 2 = Left

• 3 = Bilateral

• If no bilateral code exists, select codes to indicate the right and left side

A B C

S83.411 Sprain Medial Collateral Ligament –Right

Knee

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ICD-10 Specificity Example

ICD-10-CM: UNDERSTANDING ENCOUNTER & THE 7TH CHARACTER

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7th Character Extension for Injuries • Most categories in the injury chapter (#19) of

ICD-10 have a 7th character extension (lesser extent Chapters 13 &15)

• The majority of the categories have 3 extension options, with the exception of fractures which have more.

• A Initial Encounter

• D Subsequent Encounter

• S Sequela

A B C

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7th Character Extension for Injuries

• Patient is receiving initial, active treatment for a condition

• Evaluation or treatment by a new physician

• Direct access therapy – Initial assessment for traumatic injury, illness, sprain/strain or fracture

A = Initial Encounter

Example: Initial assessment of a bucket-handle tear of

medial meniscus, left knee

S83.212A

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7th Character Extension for Injuries

• Patient has previously received initial, active treatment and is now receiving routine care during the healing or recovery phase

• Acute condition treated

• Follow-up visits for the treatment of an injury

D = Subsequent Encounter

Example: Sprain of unspecified ligament of right ankle

S93.401D

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7th Character Extension for Injuries

• Complications or conditions that are a direct result of an acute condition that is no longer being treated

S = Sequalae Encounter

Example: Unilateral post-traumatic osteoarthritis, right

knee following old bucket-handle tear of medial

meniscus, right knee

M17.31, S83.211S

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Example • Displaced, closed fracture of the greater

trochanter of the right femur (S72.111)

• Treated in ED, admitted, and surgery performed

• The correct ICD-10 code is S72.111A

– Initial encounter for closed fracture

– The A indicates the Initial Encounter

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Example

Referred for outpatient physical therapy

• Primary Diagnosis code for PT:

– S72.111D - for subsequent encounter

• Additional Diagnosis codes:

– M25.551 Pain in right hip

– R26.2 Difficulty in walking, not elsewhere classified

– R60.0 Localized edema

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Summary Was the Cause a Trauma

or Fracture?

Use S code with 7th Character S code and 7th Character not

required

Yes

No

Look in Musculoskeletal

Chapter for M code

A = Initial Encounter

D = Subsequent Encounter

S = Sequela Encounter

Identify the injury code that precipitated the

sequela and the code for the sequela itself

ICD-10-CM CODING FOR FRACTURES

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Coding for Fractures

• Indicate the fracture type

• Specific anatomical site

• If the fracture is displaced or not

• Routine versus delayed healing

• Non-union versus mal-union

• The side associated with the fracture

• Type of encounter – initial, subsequent, sequela

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Fracture Extensions

• A- initial for Closed

• B- initial for Open Fx

• D- subseq. with routine healing

• G- subseq. with delayed healing

• K- subseq. with non union

• P- subseq. with mal union

• S- sequella to fracture

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Coding for Open Fractures

• Gustilo open fracture classification • 7th character designations for open fractures

• classifies open fractures into three categories depending on:

– Mechanism of the injury

– Soft tissue damage

– Degree of skeletal involvement

• Applies to categories • S52 Fracture of forearm

• S72 Fracture of femur

• S82 Fracture of lower leg

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Coding for Open Fractures

• The Gustilo classification groups are: ‒ Type I – Wound less than 1 cm, minimal soft tissue

damage

‒ Type II – Wound greater than 1 cm with moderate soft tissue damage

‒ Type III – Wound greater than 1 cm with extensive soft tissue damage o Type IIIA – Adequate soft tissue cover

o Type IIIB – Inadequate soft tissue cover

o Type IIIC – Associated with arterial injury

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Coding for Open Fractures B Initial encounter for open fracture type I or II C Initial encounter for open fracture type IIIA, IIIB, or IIIC E Subsequent encounter for open fracture type I or II with routine healing F Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing H Subsequent encounter for open fracture type I or II with delayed healing J Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing M Subsequent encounter for open fracture type I or II with nonunion N Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion Q Subsequent encounter for open fracture type I or II with malunion R Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

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Mobile Friendly Website • www.ICD10data.com

• Can search by name

• Can search by ICD-9 code

• Here is another free website http://www.findacode.com

Examples:

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Coding for an ACL Sprain Using the Tabular List S83.511 A • Patient is a 16-year-old male.

During a high school soccer game last week, he suffered a right ACL sprain when his knee contacted an opposing player’s leg. He came straight to PT without seeing a physician first.

– Patient’s condition: Presents with pain, edema, and instability in his right knee

– Uses crutches for ambulation

– Has pain with walking

• How to code for this example:

• Primary Codes: S83.511A for the sprain

• W51.XXXA for the external cause

• Y92.322 for place of occurrence

• Y93.66 for the activity

• Additional Codes:R26.2 for difficulty in walking or R26.89 for other abnormalities of gait and mobility

• M25.561 for right knee pain

• M25.361 for the right knee instability

• M25.461 for right knee effusion

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ACL Sprain—Tabular S83 Dislocation and sprain of joints and ligaments of knee

• Includes: avulsion of joint or ligament of knee

• laceration of cartilage, joint or ligament of knee

• sprain of cartilage, joint or ligament of knee

• traumatic hemarthrosis of joint or ligament of knee

• traumatic rupture of joint or ligament of knee

• traumatic subluxation of joint or ligament of knee

• traumatic tear of joint or ligament of knee

• Code also any associated open wound

• The appropriate 7th character is to be added to each code from category S83

• A -initial encounter

• D -subsequent encounter

• S –sequela

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Gait

• Difficulty Walking

– ICD-10 code R26.2 Difficulty in walking, not elsewhere classified

– Description synonyms: Difficulty walking

– Walking disability

• Other Abnormalities of Gait and Mobility

• ICD-10 code R26.89

– Description synonyms:

– Cautious gait

– Gait disorder due to weakness

– Gait disorder, painful gait

– Gait disorder, weakness

– Gait disorder, postural instability

– Gait disorder, multifactorial

– Toe walking and toe-walking gait

– Limping/limping child

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Y93 Activity codes • Provided for use to indicate the activity of the person seeking

healthcare for an injury or health condition such as found in chapter 19 or chapter 13.

• This section contains the following broad activity categories: • Y93.0 Activities involving walking and running

• Y93.1 Activities involving water and water craft

• Y93.2 Activities involving ice and snow

• Y93.3 Activities involving climbing, rappelling, and jumping off

• Y93.4 Activities involving dancing and other rhythmic movement

• Y93.5 Activities involving other sports and athletics played individually

• Y93.6 Activities involving other sports and athletics played as a team or group

• Y93.7 Activities involving other specified sports and athletics

• Y93.A Activities involving other cardiorespiratory exercise

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Coding for a Left Knee Joint Replacement • Patient is a 74-year-old male

who underwent a left total knee replacement one week ago.

• Patient’s condition: complains of 6/10 pain in the left knee

• presents with left knee effusion and impaired range of motion in left knee extension and flexion

• has pain with walking

• is WBAT (weight bearing as tolerated) using a walker

• Primary Codes:

• R26.2 for difficulty in walking or R26.89 for other abnormalities of gait and mobility

• M25.562 for left knee pain

• M25.462 for left knee effusion

• M25.662 for left knee stiffness

• M62.552 for muscle atrophy left quads and hamstrings

• Additional Codes:

• Z96.652 for presence of left artificial knee joint

• Z47.1 for aftercare following joint replacement surgery

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Coding for Down Syndrome

• Patient is a 7-year-old male with Down syndrome (meiotic).

– Patient’s condition:

– generalized muscle weakness

– abnormal posture

– difficulty walking

– Q90.0 for the Down syndrome

– R26.2 for the difficulty walking or R26.89 for other abnormalities of gait and mobility

– M62.81 for generalized muscle weakness

– R29.3 for abnormal posture

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Coding for Benign Paroxysmal Vertigo

Patient is a 33-year-old female who presents to physical therapy with a diagnosis of benign paroxysmal vertigo, right ear.

– Patient’s condition:

– Complains of dizziness and nausea

– H81.11 for Benign Paroxysmal Vertigo, right ear

– R11.0 for nausea without vomiting

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Coding for Jack-O-Lantern Injury

Patient is a 34‐year-old female. While carving a pumpkin, she accidentally lacerated the digital nerves at her palm as well as her flexor tendon superficialis and profundus tendons on fingers two through four.

• Patient’s condition:

• Had surgery last week

• Presents with complaints of pain, swelling, and weakness of the right wrist, hand, and fingers

• Has sensation of “pins and needles” in her hand and fingers

• M79.641 pain in right hand

• M79.644 pain in right fingers

• M25.531 pain in right wrist

• M25.431 for effusion of right wrist

• M25.441 for effusion of right hand

• R20.2 paresthesia of skin

• Additional codes:

• M25.631 stiffness of right wrist

• M25.641 stiffness of right hand

• M62.531 and M62.541 for muscle weakness right forearm and hand

• S66.120D, S66.122D, S66.124D for the lacerations

• W26.0XXD for contact with knife

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