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Revised October 2017
ICD-10 Provider Training
1
Y0114_16_29875_I_11/21/2016
ICD-10-CM Provider TrainingThe ICD-10 Provider Training is a presentation containing six sections reviewing ICD-10 coding anddocumentation tips. As you review the material, you will see that the first section is an introduction to ICD-10 coding and the remaining five sections focus on ICD-10 coding guidelines related to specific conditions.This training is based on coding guidance from the Official ICD-10-CM Coding Guidelines, American HospitalAssociation’s (AHA) Coding Clinic, and/or Centers for Medicare and Medicaid Services (CMS) guidance andguidelines. Documentation recommendations are based on the official requirements for correct codeassignment per the aforementioned guidelines.
The ICD-10-CM* code set is updated annually. Coding requirements and standards are subject to change,potentially impacting the accuracy of the content contained within this presentation. The practitionersupplying the medical documentation and the individual assigning codes are reminded to verify theaccuracy, specificity, currency, and acceptability of such codes, coding methods, and supportingdocumentation by referencing official sources with up-to-date information.
The contents included in this presentation are for informational purposes only. Anthem, Inc. does not guarantee that the information supplied is without defect. Every attempt has been made to ensure its accuracy, completeness, and relevance. Do not copy (in any form) without written consent from Anthem, Inc.
Note: ICD-10-CM codes must be used to report diagnoses for dates of service on or after October 1, 2015.
In New Mexico, Amerigroup Community Care of New Mexico, Inc. In Texas, Amerigroup members in the Medicaid Rural Service Area are served by
Amerigroup Insurance Company; all other Amerigroup members are served by Amerigroup Texas, Inc. In Washington, Amerigroup Washington, Inc.
Amerivantage is a DSNP plan with a Medicare contract and a contract with the State Medicaid program. In New Mexico: Amerivantage is an HMO with a Medicare contract. Enrollment in Amerivantage depends on contract renewal.
Sections:
•1. Introduction to ICD-10-CM
•2. Chronic Obstructive
Pulmonary Disease
•3. Diabetes Mellitus
•4. Rheumatoid Arthritis
•5. Congestive Heart Failure
•6. Major Depressive Disorder
ICD-10-CM Provider Training
ICD-10-CM Provider Training
Section 1:
Introduction to ICD-10-CM
Section 1: Intro
Topics Covered In This Series:– What is ICD-10-CM?
– ICD-9 Versus ICD-10
– ICD-10-CM Code Structure
– Improvements to Code Set
– 7th Character
– Excludes 1 & 2 Notes
– Combination Code
– Etiology /Manifestation
– Sequela (Late Effects)
– Laterality
– Benefits of ICD-10
Section 1: Intro• What is ICD-10-CM?–ICD-10-CM is the International Classification of Diseases (ICD), 10th
Revision, Clinical Modification.–Implementation Date: October 1, 2015–Updated annually on October 1st –ICD is a coding system of:
• Diseases,• Signs and symptoms,• Abnormal findings,• Complaints,• Social circumstances, and • External causes of injury or diseases
October 1, 2015
Section 1: Intro
ICD-9-CM ICD-10-CM
17 Chapters 21 Chapters
Approximately 14,000 codes Approximately 71,704 codes as of 10/1/17
3-5 characters in length 3-7 characters in length
1st character may be alpha (E or V) or numeric; characters 2-5 are numeric; decimal is used after the third character
1st character is alpha (except “U”); 2nd
character is numeric; characters 3-7 are alpha or numeric; decimal is used after the third character
Limited space for adding new codes Flexibility of adding new codes
Lacks detail More detail and specificity
Lacks laterality Includes laterality (left vs. right)
ICD-9 Versus ICD-10
Section 1: IntroICD-10-CM Structure
–Characters 1-3 are code categories. The 1st character is alpha.
–Characters 4-6 are subcategories indicating the etiology, anatomic site, severity, or other clinical detail.
–Character 7 is an extender.
• In codes that require a 7th character extender, there may be
instances where a placeholder “x” is used to fill a previous empty character.
Category Clinical Detail Extender
Section 1: Intro
Improvements to ICD-10-CM Code Set
– Improvements to the ICD-10-CM code set include:
• The addition of 6th and 7th characters with seventh digit extensions representing visit encounter or sequela for injuries and external causes.
• The division of excludes notes: Excludes 1 and Excludes 2.
• The creation of combination diagnosis/symptom or manifestation codes to reduce the number of codes needed to fully describe a condition.
• The addition of laterality to distinguish left, right, or bilateral.
Section 1: Intro7th Character
–The 7th character must be listed in the 7th character data field.
– If the code indicates a 7th character requirement and there are less than six (6) characters in a code, a placeholder of “x” should be assigned for all missing characters.
• The “x” is used as a placeholder in certain codes to allow for further expansion.
• This keeps the 7th character of a code in position 7.
• If a placeholder exists, the “x” must be used for the code to be valid.
• The placeholder is not case sensitive.
• The icon noted in front of a code indicates the code has a 7th character, such as an encounter, sequela, tophus, fetus, etc.
Section 1: Intro
Injuries & External Cause 7th Characters
A: Initial encounter
D: Subsequent encounter
S: Sequela
Note: For aftercare of an injury, assign acute injury code with 7th character “D”
Fracture 7th Characters
A: Initial encounter for closed fracture
B: Initial encounter for open 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 malunion
S: Sequela
ICD-10-CM Provider Training, Section 1: Intro
•Excludes 1 Note
– Excludes 1 note means “Not coded here.”
– Both codes should not be used together under any circumstance.
– Excludes 1 note is used when two conditions cannot occur together.
• Such as a congenital form versus an acquired form of the same condition.
– Exception is when two conditions are unrelated
• Excludes 2 Note– Excludes 2 note means “Not
included here.”
– Condition excluded is not inherently a part of the condition represented by the code, it may be coded as an additional diagnosis.
– Excludes 2 note is used when two conditions can occur together at the same time.
Section 1: IntroCombination Code
– A combination code is a single code used to classify:
• Two diagnoses, or
• A diagnosis with an associated manifestation (secondary process)
• A diagnosis with an associated companion
– Example: Type 2 DM with mild nonproliferative diabetic retinopathy with macular edema
ICD-9 required 3 separate codes: ICD-10 one combination code:
250.50- Diabetes with ophthalmic manifestations, type II E11.321-Type 2 diabetes mellitus with
mild nonproliferative diabetic retinopathy with macular edema
362.04- Mild nonproliferative diabetic retinopathy
362.07- Diabetic macular edema
Section 1: IntroEtiology/Manifestation
– Certain conditions have both an underlying etiology and multiple body system manifestations caused by the underlying etiology.
– When such a combination exists, there is a:
• “Use additional code” note at the etiology code, and a
• “Code first” note at the manifestation code.
– In the alphabetic index, both conditions are listed together with etiology code first followed by the manifestation code(s) in brackets. The code in brackets is always sequenced second.
Example:
– Dementia with Parkinson’s disease (G20) [F02.80]
Section 1: Intro
Sequela (Late Effects)
– A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has concluded.
– There is no time limit on when a sequela code can be used.
– Coding of sequela generally requires 2 codes sequenced as:
• Condition or nature of the sequela sequenced first, and
• Sequela code sequenced second.
– An exception is when the sequela code is:
• Followed by a manifestation code in the Tabular List and title, or
• The late effect code has been expanded (at the fourth, fifth, or sixth character levels) to include the manifestation(s).
Section 1: IntroLaterality– Some ICD-10 codes indicate laterality that specifies whether the
condition occurs on the left, right, or is bilateral.
– If a bilateral condition is documented and a code does not exist, assign separate codes for both left and right side.
– If laterality is not documented, assign a code for unspecified side.
Left Right
Section 1: Intro
• Benefits of ICD-10
– ICD-10 provides more details regarding the patient’s disease, condition, injury and history which:
• Provides better documentation opportunities.
• Conveys a better understanding of patient’s health.
• Provides better tracking of disease and health outcomes for researchers and public health officials.
ICD-10-CM Provider Training
Section 2:
Chronic Obstructive Pulmonary Disease (COPD)
Section 2: COPD
• Topics Covered In This Series:–COPD Definition
– ICD-9 Versus ICD-10
– Listing of Conditions
– ICD-10 COPD Code Breakdown
–Documentation for COPD
–Coding Instructional Notes
Section 2: COPD
Chronic Obstructive Pulmonary Disease (COPD)
–COPD is a nonspecific term that encompasses many different respiratory conditions that cause progressive damage to the lungs, such as:
• Asthma
• Bronchitis
• Emphysema Asthma
EmphysemaBronchitis
COPD
Section 2: COPD
• ICD-9 Vs. ICD-10 – In ICD-9, there is an excludes
note instructing that code 496 (COPD) is not to be used with any code from categories 491-493 (asthma, chronic bronchitis, emphysema).
– In ICD-10, most of these conditions are included in the same J44 category (other COPD).
496• COPD
491.20-491.22
• Obstructive Chronic Bronchitis
493.20-493.22
• Chronic Obstructive Asthma
Other COPD
J44.0-J44.9
Section 2: COPD
• Asthma with chronic obstructive pulmonary disease
• Chronic asthmatic (obstructive) bronchitis
• Chronic bronchitis with airways obstruction
• Chronic bronchitis with emphysema
• Chronic emphysematous bronchitis
• Chronic obstructive asthma
• Chronic obstructive bronchitis
• Chronic obstructive tracheobronchitis
Listing of Conditions Included
in Category J44 (Other COPD)
ICD-10 COPD Code Breakdown:
Category J44, COPD Type:.0 With acute lower respiratory infection.1 With acute exacerbation.9 Unspecified
Section 2: COPD
Section 2: COPD
Type
Asthma
Bronchitis
Emphysema
Complication
Respiratory infection
• Identify infectious organism
Acute exacerbation
Tobacco
Exposure
Use and/or Dependence
Treatment
Oxygen Use and/or
Dependence
Prescription drugs
Documentation for COPD
• In order to code to the highest degree of specificity, COPD should include documentation of:
Section 2: COPD• Tobacco Related Codes
– In ICD-10, there are instructional notes to additionally identify the following tobacco related codes with category J44. Documentation should provide this additional detail when applicable.
*Those bolded with an asterisk are new tobacco specific codes in ICD-10
Exposure to environmental tobacco smoke
(Z77.22)*
Occupational exposure to
environmental tobacco smoke
(Z57.31)*
History of tobacco use (Z87.891)
Tobacco dependence (F17.200-F17.299)
Tobacco use (Z72.0)*
Section 2: COPD
• Asthma Severity– In ICD-10, there are also instructional notes to identify the type of
asthma (when appropriate) with category J44. Documentation for asthma should include the following:
Severity
• Mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent
• Unspecified or Other
Complication
• Uncomplicated
• With (acute) exacerbation
• With status asthmaticus
ICD-10-CM Provider Training
Section 3:
Diabetes Mellitus (DM)
Section 3: DM
• Topics Covered In This Series:– Diabetes Definition
– ICD-9 Versus ICD-10
– ICD-10 Diabetes Code Breakdown
– Documentation for Diabetes
– Diabetic Complications
– Linking Verbiage
– Specifying Diabetic Complications
– Assumed Relationship in ICD-10
Section 3: DM
Diabetes Mellitus (DM)
– Per AHA Coding Clinic, diabetes mellitus is a disorder of glucose metabolism due to either an absolute decrease in the amount of insulin secreted by the pancreas or to a reduction in the biologic effectiveness of the insulin secreted. It is classified into two major categories:
1. Type I or insulin-dependent diabetes mellitus (IDDM), also known as "Juvenile-onset diabetes mellitus," and
2. Type II or noninsulin-dependent diabetes mellitus (NIDDM), also known as "adult-onset diabetes mellitus."
– There are a variety of other conditions such as pancreatitis, carcinoma of the pancreas, hemochromatosis, pheochromocytoma, and drug usage (e.g., steroids) which can cause secondary diabetes mellitus.
Section 3: DM• ICD-9 Versus ICD-10
– In ICD-9, the status of controlled versus uncontrolled impacted fifth digit code assignment, such as:
• 0- Type II or unspecified type, not stated as uncontrolled
• 1- Type I, not stated as uncontrolled
• 2- Type II, or unspecified type, uncontrolled
• 3- Type I, uncontrolled
– In ICD-10, this concept doesn’t exist. Instead, the following are classified as diabetes (by type) with hyperglycemia:
• Out of control
• Poorly controlled
• Inadequately controlled
Section 3: DM
• ICD-9 Versus ICD-10
– ICD-9 contains paired codes that follow the etiology/manifestation convention of the classification.
– ICD-10 contains combination codes including the type of DM, the body system affected, and the complication(s) affecting that body system.
• Example: Diabetic proliferative retinopathy with macular edema
ICD-9 required 3 separate codes: ICD-10 one combination code:
250.50- DM with ophthalmic manifestations E11.351- Type 2 DM with proliferative
diabetic retinopathy with macular edema362.02- Proliferative diabetic retinopathy
362.07- Diabetic macular edema
ICD-10 Diabetes Code Breakdown:
Diabetes Category E08-E13
Body System Affected
Section 3: DM
Complication Affecting Body System
Section 3: DM
Type
Type 1
Type 2 (default)
Secondary DM
Due to Underlying Condition or Drug
Complication
Ketoacidosis
Kidney
Ophthalmic
Neurologic
Circulatory
Other
Treatment
Insulin Use
Other Prescription Management
Documentation for DM
• In order to code to the highest degree of specificity, diabetes should include documentation of:
Section 3: DM
• Diabetic Complications–Diabetic complications should be documented with linking verbiage to
show the relationship between the two conditions, such as:
DiabeticDue to
DMSecondary
to DM
Associated with DM
Of Diabetes
In Diabetes
Section 3: DM
• Diabetic Complications– Documentation for diabetic complications should include “Diabetes
with…”
Hyperosmolarity
• Without nonketotic hyperglycemic-hypersmolar coma (NKHHC)
• With coma
Kidney Complications
• Nephropathy
• Chronic Kidney Disease
• Including stage
• Other diabetic kidney disease
Ophthalmic Complications
• Retinopathy
• Nonproliferative retinopathy
• Mild, moderate, or severe
• With or w/o macular edema
• Proliferative retinopathy
Neurological Complications
• Neuropathy
• Mononeuropathy
• Polyneuropathy
• Autonomic neuropathy
• Amyotrophy
• Other diabetic neurological complication
Other Specified Complications
• Arthropathy
• Skin complication
• For ulcer, specify location
• Oral complication
• Hypoglycemia with or w/o coma
• Hyperglycemia
Section 3: DM
• Assumed Relationship in ICD-10-CM–The ICD-10-CM classification assumes a cause-and-effect relationship
between diabetes and certain diseases of the kidneys, nerves, and circulatory system.
–Since the relationship is assumed with certain conditions, they will be coded as a diabetic manifestation unless documentation clearly states that diabetes is not the underlying cause.
–For conditions not specifically linked in the ICD-10-CM classification, provider documentation must link the conditions in order to code them as related. (See ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.15. for more detail)
ICD-10-CM Provider Training
Section 4:
Rheumatoid Arthritis (RA)
Section 4: RA
• Topics Covered In This Series:– Rheumatoid Arthritis Definition
– ICD-9 Versus ICD-10
– ICD-10 RA Code Breakdown
– Documentation for RA
– RA Complications
– Linking Verbiage
– Location & Laterality
– RA of the Spine
Section 4: RA
Rheumatoid Arthritis (RA)
– Per 2012 Coder’s Desk Reference:
• Rheumatoid arthritis is a chronic, systemic inflammatory disease of unknown etiology, characterized by a variable but prolonged course with exacerbations and remissions of joint pains and swelling. In early stages, the disease attacks the joints of the hands and feet. As the disease progresses, more joints become involved.
• Joint disease is the major manifestation; systemic involvement (spleen, liver, eye, etc.) is rare.
Section 4: RA• ICD-9 Versus ICD-10
– ICD-9 lacks specificity.
– ICD-10 has more specific site designations and laterality.
• Includes joint site such as shoulder, elbow, wrist, hand, hip, knee, ankle, and foot.
• Includes laterality for extremities such as right, left, or unspecified.
– Coding Tip: Since a bilateral code is not provided, a separate code should be assigned for both left and right side when documented.
LeftRight
Section 4: RA
• ICD-9 Versus ICD-10
– ICD-9 contains paired codes that follow the etiology/manifestation convention of the classification.
– ICD-10 contains combination codes that include the type of RA and manifestation.
• Example: Rheumatoid Arthritis with polyneuropathy of right hand
ICD-9 requires 2 separate codes: ICD-10 one combination code:
714.0- Rheumatoid ArthritisM05.541- Rheumatoid polyneuropathy with rheumatoid arthritis of right hand357.1- Polyneuropathy in collagen
vascular disease
ICD-10 Rheumatoid Arthritis Code Breakdown:
Rheumatoid Arthritis Categories M05-M06
Organ/System Involvement
Section 4: RA
Specific Site & Laterality
Section 4: RA
M05 (RA with Rheumatoid Factor)
• Felty’s Syndrome (association of RA with splenomegaly and leukopenia)
• Rheumatoid Lung Disease
• Rheumatoid Vasculitis
• Rheumatoid Heart Disease
• Rheumatoid Myopathy
• Rheumatoid Polyneuropathy
• RA with or w/o involvement of other organs and systems
M06 (Other RA Types)
• Without Rheumatoid Factor
• Adult-Onset Still’s disease
• Rheumatoid Bursitis
• Rheumatoid Nodule
• Inflammatory Polyarthropathy
• Other Specified RA
Categories M05 & M06
• ICD-10 contains the following RA selections under M05 & M06 Categories
Section 4: RA• Documentation for RA
– In order to code to the highest degree of specificity, rheumatoid arthritis should include documentation of:
Type
Juvenile vs Adult-Onset
External Causes
Complication
With or w/o rheumatoid factor
With or w/o involvement of other organs, systems, etc.
Site
Location
Laterality
Treatment
Long term (current) use of
prescription drugs
Section 4: RA• Rheumatoid Arthritis Complications
– Rheumatoid arthritis complications must be documented with linking verbiage to show the relationship between the two conditions, such as:
Rheumatoid Rheumatic Due to RA
Secondary to RA
Associated with RA
Section 4: RALocation & Laterality
• Ensure that documentation contains the specific site(s) affected by RA.
• Additionally, note laterality as:
– Right,
– Left, or
– Both
• Coding Tip: RA of the spine falls under a different code category, M45.
Shoulder
Elbow
Wrist
HandHip
Ankle
Knee
Foot
Vertebrae
Section 4: RA• RA of Spine (M45.-)–RA of the spine falls under category M45. In order to code to the highest
degree of specificity, the region needs to be documented.
Regions Listed under M45 Category
Occipito-atlanto-axial
Cervical
Cervicothoracic
Thoracic
Thoracolumbar
Lumbar
Lumbosacral
Sacral and sacrococcygeal
Multiple sites in spine
ICD-10-CM Provider Training
Section 5:
Congestive Heart Failure (CHF)
Section 5: CHF
• Topics Covered In This Series:–CHF Definition
– ICD-9 Versus ICD-10
– ICD-10 CHF Code Breakdown
–Documentation for CHF
– ICD-10 Coding Instructional Notes
–Hypertensive Heart Disease with Heart Failure
–AHA Coding Clinic Reference
Section 5: CHF
Congestive Heart Failure (CHF)
– Per 2012 Coder’s Desk Reference:
• Congestive Heart Failure (CHF) is a mechanical inability of the heart to pump blood efficiently, thus compromising circulation and causing systemic complications due to congestion and edema of fluids in the tissues.
Section 5: CHF• ICD-9 Versus ICD-10
– ICD-9 contains paired codes that follow the etiology/manifestation convention of the classification.
– ICD-10 contains combination codes that include the type of CHF.
• Example: Chronic Systolic Congestive Heart Failure
ICD-9 requires 2 separate codes: ICD-10 one combination code:
428.0- Congestive Heart Failure I50.22- Chronic systolic (congestive) heart failure428.22- Chronic Systolic Heart Failure
ICD-10 CHF Code Breakdown:
Heart Failure Category I50
Type
Section 5: CHF
Acuity
Section 5: CHF
Type
• Diastolic
• Systolic
• Combined Systolic and Diastolic
Acuity
• Acute
• Chronic
• Acute on Chronic
• Compensated
• Decompensated
• Exacerbation
Due To or Associated With
• Cardiac or other surgery
• Hypertension
• Valvular disease
• Rheumatic heart disease
• Endocarditis (Valvitis)
• Pericarditis
• Myocarditis
• Other (specify)
Documentation for CHF
• In order to code to the highest degree of specificity, congestive heart failure should include documentation of:
Section 5: CHF• ICD-10 Coding Instructional Notes
– There are instructional notes for category I50 to code first the following conditions. Documentation needs to provide this additional detail for appropriate code assignment.
• heart failure complicating abortion or ectopic or molar pregnancy (O00-O07, O08.8)
• heart failure due to hypertension (I11.0)
• heart failure due to hypertension with chronic kidney disease (I13.-)
• heart failure following surgery (I97.13-)
• obstetric surgery and procedures (O75.4)
• rheumatic heart failure (I09.81)
Code First Note for I50 Category:
Section 5: CHF• Hypertensive Heart Disease with Heart Failure–As of 10/01/2016, the ICD-10-CM classification assumes a cause-and-effect
relationship between hypertension and CHF.
–To be coded as related, unless provider documentation states otherwise.
Code: I11.0
Hypertensive Heart Disease with Heart Failure
Use additional code to identify type of heart failure (I50.-)
Codes: I13.0 & I13.2
Hypertensive Heart Disease with Heart Failure and CKD
Use additional code to identify type of heart failure (I50.-)
Use additional code to identify stage of CKD (N18.-)
Section 5: CHF• AHA Coding Clinic Reference
– Per AHA Coding Clinic, Quarter 2, 2013, Decompensated Systolic Heart Failure:
• “Assign code I50.23, Acute on chronic systolic heart failure, for decompensated systolic heart failure… ‘decompensated’ indicates that there has been a flare-up (acute phase) of a chronic condition.”
ICD-10-CM Provider Training
Section 6:
Major Depressive Disorder (MDD)
Session 6: MDD
• Topics Covered In This Series:– MDD Definition
– ICD-9 Versus ICD-10
– ICD-10 MDD Code Breakdown
– Documentation for MDD
– Linking Verbiage, Depression and Anxiety
– Dysthymia
Session 6: MDDMajor Depressive Disorder (MDD)
–Per Encoder Pro:
• Mood disorder that produces depression; may exhibit as sadness, low self-esteem, or guilt feelings; other manifestations may be withdrawal from friends and family; interrupted sleep.
Session 6: MDD• ICD-9 Versus ICD-10
– In ICD-9, depression unspecified leads to code 311 (depressive disorder, not otherwise specified) listed under Other Nonpsychotic Mental Disorders.
– ICD-10, depression unspecified leads to code F32.9 (major depressive disorder, single episode, unspecified) listed under Mood [Affective] Disorders.
ICD-9 ICD-10
311- Depression NOSF32.9- Major depressive disorder, single episode, unspecified (Depression NOS)296.20- Major depressive disorder, single
episode, unspecified
ICD-10 MDD Code Breakdown:
Major Depressive DisorderCategories F32-F33
Severity
Session 6: MDD
F33.40-F33.42Remission status
Session 6: MDD
Type
• Major
• Chronic
• Anxiety
• Atypical
• Manic-depressive
• “Masked”
• Neurotic
• Situational
• Other types of depression
Episode
• Single
• Recurrent
• Other depressive episode
Severity
• Mild
• Moderate
• Severe with or without psychotic features
Remission Status
• Partial remission
• Full remission
Documentation for Depression
• In order to code to the highest degree of specificity, depression should include documentation of:
Session 6: MDD• Linking Verbiage, Depression and Anxiety
– Depression and anxiety are coded separately unless a documented linkage between the two conditions has been established.
– Examples of linking verbiage:
– Documentation for depression with anxiety should also include severity such as mild (F41.8, anxiety depression) or persistent (F34.1, dysthymic disorder) in order to code to the highest level of specificity.
Depression anxiety
Anxiety depression
Depression with anxiety
Depression associated
with anxiety
Session 6: MDD• Dysthymia
– Dysthymia is a mild but long-term (chronic) form of depression (Mayo Clinic).
– In ICD-10:
• Dysthymia leads to code F34.1 (dysthymic disorder)
• There isn’t a code selection for “chronic” depression. The default is depression NOS (F32.9, Major depressive disorder, single episode, unspecified)
– To assign a more precise ICD-10 code, ensure the diagnosis is documented to the highest degree of specificity in the medical record.
ICD-10-CM Provider Training
• References & Resources:– Hart, A. C., Stegman, M. S., & Ford, B. (2011). ICD-9-CM for physicians, volumes 1 & 2:
2012 professional: International Classification of Diseases, 9th revision, Clinical Modification. Eden Prairie, MN: OptumInsight.
– Anita Schmidt, A.K., K.K., &, P.W. (2017). ICD-10- CM Professional for Physicians: The Complete Official Code Set. Optum360, LLC.
– Centers for Disease Control and Prevention website, ICD-10-CM Official Guidelines for Coding and Reporting (FY 2016): http://www.cdc.gov/nchs/data/icd/10cmguidelines_2016_final.pdf
– Optum’s website (accessed March 2015 and October 2016): EncoderPro.com
– Centers for Medicare and Medicaid Services website (accessed March 2015 and October 2016): http://cms.gov/Medicare/Coding/ICD10/index.html
– American Hospital Association (AHA) Coding Clinic
– Ingenix (2012 Edition) Coders’ Desk Reference for Diagnoses
