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Mooresville AAPC ChapterICD-10 Review Class
Registrant Information
Name: _______________________________________________________________________________________________________
Address:________________________________________________________________________________________________________ _
__________________________________________________________________________________________________________________
Contact Number:_____________________________________________________________________________________________
E-mail: _____________________________________________________________________________
Registrant Information:
ICD-10 Review Class (6CEUs) Saturday, April 11, 2015 9am-4pm $60.00
Payment Information:
Please make checks/money orders payable to Mooresville AAPC Chapter
Send Payments to:Sylvia Hale192 Crystal CircleMooresville, NC 28117E-mail: [email protected]: (704)660-0275
Payments must be postmarked no later than 4/1/15 and will be deposited on that date. Only cash payments will be accepted the day of the class, and registration is first come first serve. Cash payments should be confirmed by e-mail to [email protected] no later than 4/1/15. All payments are non-refundable, your check will serve as your registration confirmation. Receipts and CEU certificates will be given out at the conclusion of the class.
All attendees will be responsible for providing their own ICD-10 books for this class, Materials will be provided for the class
***Sign in starts at 8:30- Please arrive no later than 8:45, as the class will start promptly at 9am***
ICD-10-CM Diagnosis Coding:Let’s Get Ready!
Taught byNancy G. Higgins, CPC,
CPC-I, CIRCC, CPMA, CEMC
© 2015 Nancy G. Higgins
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What we are going to cover:
• Introduction to ICD-10-CM• The benefits of the new system and
how it differs from ICD-9-CM• ICD-10-CM code format• Code selection process• ICD-10-CM book format and how it
differs from ICD-9-CM• General ICD-10-CM diagnosis coding
guidelines• Chapter-specific ICD-10-CM diagnosis
coding guidelines that differ from ICD-9-CM
• How to get your providers ready for ICD-10-CM
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Introduction to ICD-10-CM• ICD-10-CM = International Classification of
Diseases, 10th Revision, Clinical Modification• World Health Organization (WHO) developed
the International Classification of Diseases– Used worldwide
• Clinical Modification was developed by the National Center for Health Statistics– Used only in the United States
Implementation date isOctober 1, 2015
• Beginning with this date, all HIPAA covered entities will be required to use ICD-10-CM codes to report diagnoses– HIPAA covered entities includes physicians,
hospitals, outpatient hospital departments, etc. and most payers
– Exception is Workers’ Compensation
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Benefits of ICD-10-CM
• Significant increase in number of codes allows for greater specificity in code definition
ICD-9-CM has approximately 14,000 codesICD-10-CM has approximately 68,000 codes!!
• New code format allows for addition of future codes in appropriate category and location
• Updated terminology and disease classifications
• More detailed data for analysis of disease patterns
• Possibility of new reimbursement methods that recognize the complexity of treating more severe conditions
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Differences between ICD-10-CM and ICD-9-CM
ICD-9-CM ICD-10-CM
Codes consist of up to 5 numbers (except V and E codes – letter and up to 4 numbers)
Codes consist of up to 7 characters (combination of letters and numbers)
17 chapters plus sections for V codes and E codes 21 chapters
Approximately 14,000 codes
Approximately 68,000 codes
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ICD-10-CM code format…
• Codes have up to 7 characters• 1st is always a LETTER• 2nd and 3rd are usually NUMBERS
– First three characters determine the category of the medical condition
• 4th through 7th can be a LETTER OR A NUMBER– 4th, 5th and 6th characters provide
subclassifications with more specificity– 7th character is reserved for additional info
when needed, e.g., trimester of pregnancy, episode of care, etc.
It’s important to know the first character is always a letter because the letter O is used.
It is the letter O, not the number 0 (zero).
Only letter not used is U.
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How to select a code …
• Determine the main term related to the disease, condition, or symptom you want to code
• Look it up in the Alphabetic Index• Review all possible options listed• Identify a potential code selection
DO NOT STOP HERE!!!• Turn to that code in the Tabular Listing and
read all the instructional notes, alternative listings, etc.
• Determine whether that is the correct code• Determine whether additional codes are
needed
Be sure you have read all of the guidelines before you start using the ICD-10-CM book!
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ICD-10-CM book …
• Introductory material• ICD-10-CM Draft Official Guidelines for
Coding and ReportingYOU MUST READ THESE AND UNDERSTAND
THE INFORMATION CONTAINED IN THIS SECTION!!!
• Volume 2 – Alphabetic Index to Diseases– Main terms are in bold– Subterms (variations of main terms)
are indented and in regular font– Look for condition, disease, symptom
or problem– Do NOT look under body location or
part … not usually there– Notice there’s no hypertension table in
ICD-10-CM
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ICD-10-CM book …
• Volume 2 – Alphabetic Index to Diseases– Neoplasm table – moved to the end of
the Alphabetical Index in ICD-10-CM• Neoplasm = new growth• Malignant = cancer• Benign = NOT cancer• Uncertain behavior = pathology
report specifies that the specimen is not clearly malignant or clearly benign; the specimen is of “uncertain behavior”• Unspecified = the physician’s
documentation in the chart or EMR does not state whether the growth is malignant or benign
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ICD-10-CM book …
• Volume 2 – Table of Drugs and Chemicals– Immediately after the Neoplasm Table– Contains a list of all the drugs and other
chemical substances that can poison a person
– Series of options for each drug or substance• Poisoning, Accidental (Unintentional)• Poisoning, Intentional Self-Harm• Poisoning, Assault• Poisoning, Undetermined• Adverse Effect – allergic reaction• Underdosing – patient did not take
correct dosage (took less than instructed) and became sick or sicker as a result new in ICD-10-CM
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ICD-10-CM book …
• Volume 2 – Alphabetic Index to External Causes of Injury and Poisoning– Immediately after the Table of Drugs and
Chemicals– Contains an alphabetic listing of all the
ways a person could be injured
• Volume 1 – Tabular Listing– Codes are listed in order beginning with
A00 through Z99.8– Organized by chapter– 21 chapters (ICD-9-CM only had 19
chapters)• Some chapters renamed• Some chapters moved• Some chapters reorganized so that sections
have been moved to other chapters• Codes for eye conditions and ear conditions
have been moved out of the Nervous System chapter into separate chapters
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ICD-10-CM book …
Chapter Title1 Certain infectious and parasitic diseases
2 Neoplasms
3Diseases of the blood and blood-forming organs and certain disorders involving the immune system
4 Endocrine, nutritional and metabolic diseases
5 Mental, behavioral, and neurodevelopmental disorders
6 Diseases of the nervous system
7 Diseases of the eye and adnexa
8 Diseases of the ear and mastoid process
9 Diseases of the circulatory system
10 Diseases of the respiratory system
11 Diseases of the digestive system
12 Diseases of the skin and subcutaneous tissue
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ICD-10-CM book …
Chapter Title13 Diseases of the musculoskeletal system and
connective tissue14 Diseases of the genitourinary system
15 Pregnancy, childbirth and the puerperium
16 Certain conditions originating in the perinatal period
17 Congenital malformations, deformations and chromosomal abnormalities
18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
19 Injury, poisoning and certain other consequences of external causes
20 External causes of morbidity
21 Factors influencing health status and contact with health services
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Basic coding conventions …• Codes can be 3 to 7 characters in length• Letter X is used as dummy placeholder to
allow for future expansion of codes new in ICD-10-CM
• Example: S52.91 Unspecified fracture of right forearm requires a 7th character to specify the episode of care so letter “X” is used to hold the 6th place so that the 7th character will be in the correct position
• If the encounter is the initial encounter for a closed fracture, the code would be:
S52.91xA Unspecified fracture of right forearm, initial encounter for closed fracture
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Basic coding conventions …• ICD-10-CM has two types of Excludes notes• Excludes1 identifies two conditions that cannot
be reported togetherExample: Category G43 Migraine has an Excludes1 note for Headache NOS (R51). – These two codes should never be reported together– Headache is a symptom commonly associated with a
migraine
• Excludes2 indicates that the excluded condition is not part of the condition defined by the code you are viewing but the patient may have both conditions at the same time– The excluded condition is simply not part of the
definition for the code you are viewing– These two codes CAN be reported togetherExample: Category G47 Sleep disorders includes insomnia, hypersomnia, Circadian rhythm sleep disorders, sleep apnea, narcolepsy, etc. The category has an Excludes2 note for nightmares, sleep terrors, and sleep walking. The patient CAN have insomnia and nightmares (for example) so both can be coded. The Excludes2 note indicates that nightmares are not part of the insomnia definitions.
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Basic coding conventions …• Default codes – In the Alphabetic Index, the default code is
the code listed next to the main term– Represents condition most commonly
associated with main term– Assign this code when the documentation
does not provide enough information to assign a more specific code
• AND– The term “and” should be interpreted as
“and/or”!!!
IIMPORTANT!!!
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Basic coding conventions …• NEC
– “Not elsewhere classifiable”– Use when a specific code is not available for
a condition• NOS
– “Not otherwise specified”– Equivalent of unspecified
• Etiology/manifestation convention– Certain conditions have an underlying cause
(etiology) and manifestations due to that underlying cause
– Code underlying condition first and manifestation following that unless otherwise instructed by notes in book
– Look for “use additional code” to identify manifestations
– Look for “code first” to identify etiology
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Basic coding conventions …• WITH– Should be interpreted to mean “associated
with” or “due to”• Do not code any condition described in the
physician’s documentation as “probable,” “suspected” or “rule out”
• If a diagnosis has not been confirmed, code the patient’s symptoms
• Once a diagnosis has been confirmed, do NOT code the symptoms routinely associated with that diagnosis
• Sequela = late effects– Residual effect after the acute phase of an
illness or injury has terminated– May be apparent early or may occur
months or years later
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General coding guidelines…• The majority of the general coding guidelines in
ICD-10-CM are similar to those in ICD-9-CM• Concept of laterality is addressed in ICD-10-CM
because it has a huge impact on the code definitions throughout the book– In general, the final character of the codes specifies
the side of the body affected– 1 = right side– 2 = left side– 3 = bilateral (note that this option is not always
available)– 0 or 9 = unspecified depending on whether it is in
the 5th or 6th character position• Documentation associated with complications is
addressed in ICD-10-CM– To be classified as a complication, the
documentation must establish a cause-and-effect relationship between the care provided and the condition
– Not all conditions that occur during or following medical care or surgery are classified as complications
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General coding guidelines…• Example of documentation of complications
– Documentation states: Patient suffers from severe lymphedema resulting from the mastectomy she underwent six months agoI97.2 Postmastectomy lymphedema syndrome The cause and effect relationship is clear
– Documentation states: Patient suffers from severe lymphedema. Past medical history significant for mastectomy six months ago.I89.0 Lymphedema, not elsewhere classified The cause and effect relationship is not documented
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General coding guidelines: same or similar in ICD-9-CM and ICD-10-CM …
• Selection of first-listed diagnosis code– The diagnosis documented first in the assessment
and plan section (or impression and plan section) should indicate the main reason for the encounter and this condition typically should be coded first
– Always follow any instructional notes about sequencing at the code classification
– If two or more confirmed diagnoses meet the criteria for first-listed diagnosis, the order does not matter
• Selection of additional diagnosis codes– Do not code conditions that no longer exist (except
a code for the history of a previous condition if it affects patient care or indicates the need for the patient encounter)
• For a surgical procedure, code the postoperative diagnosis
• Always code to the highest level of specificity
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General coding guidelines: same or similar in ICD-9-CM and ICD-10-CM …• When a definitive diagnosis has not been
established by the provider, code the signs and symptoms experienced by the patient
• Signs and symptoms commonly associated with an established or confirmed diagnosis should not be coded unless the instructions in ICD-10-CM direct you to do so
• Signs and symptoms that are not commonly associated with an established or confirmed diagnosis should be coded when described in the documentation
• Acute and chronic conditions– If the same condition is documented as acute or
subacute and chronic and there are separate codes for these conditions, report both codes and list the acute or subacute code first
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Chapter specific guidelines …
• Some chapters have similar guidelines in ICD-10-CM and ICD-9-CM but some have very different guidelines and should be reviewed carefully prior to coding
• We will now begin our review of the chapter-specific guidelines focusing on what is different in ICD-9-CM and ICD-10-CM
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Chapter 1: Certain infectious and parasitic diseases (A00 – B99) …• This chapter includes diseases typically
recognized as communicable or transmissible• The guidelines in ICD-10-CM are similar to
those in ICD-9-CM with the following exceptions:– Term “septicemia” is no longer used because it has
been used to describe multiple conditions by different providers and has no clear definition
– Term “urosepsis” should not be used because it is nonspecific and is not the same thing as sepsis
– If a patient develops sepsis due to a postprocedural infection, the relationship between the infection and the procedure must be clearly documented
– Because many bacterial infections have become resistant to antibiotics, if the infection code does not specify drug resistance in its definition, use the following code in addition to the infection code:Z16 Infection with drug resistant microorganisms
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Chapter 2: Neoplasms (C00 – D49) …
• This chapter includes malignant neoplasms, carcinoma in situ, benign neoplasms, neoplasms of uncertain behavior, and neoplasms of unspecified behavior
• Some benign neoplasms have been moved to the specific body system chapters in ICD-10-CM
• Note that this chapter has a significant expansion of codes in ICD-10-CM due to the incorporation of laterality, more detail regarding anatomic location, and more detail regarding neoplasm type or histology– ICD-9-CM contains approximately 1000 codes in this
chapter while ICD-10-CM contains over 1500 codes• Some of the malignancy code series now have
an option for primary malignant neoplasm with overlapping sites– The malignancy must overlap two or more
contiguous sites (next to each other) specified by different codes
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Chapter 2: Neoplasms (C00 – D49) …
• The guideline for Anemia associated with malignancy is different in ICD-10-CM!– If the encounter is for evaluation and management
of anemia associated with a malignancy and the treatment is only for the anemia, sequence the codes as follows:
1. Code for the malignancy 2. Code for the anemia (D63.0 Anemia in neoplastic disease)
• The guidelines for anemia associated with chemotherapy, immunotherapy, or radiation therapy are expanded in ICD-10-CM– Code as follows: 1. Code for the anemia 2. Code for the malignancy 3. One of the following codes depending on the treatment that caused the anemia:T45.1x5_ Adverse effect of antineoplastic and immunosuppressive drugs, ORY84.2 Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
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Chapter 2: Neoplasms (C00 – D49) …
• ICD-10-CM contains a new guideline for Malignant neoplasm in a pregnant patient that states the following codes should be assigned:1. Code from O9A.1_ Malignant neoplasm
complicating pregnancy, childbirth and the puerperium
2. Code for the malignancy• ICD-10-CM also contains a new guideline that
states that if a patient encounter is solely for treatment of a complication associated with a neoplasm, the following codes should be reported:1. Code for complication2. Code for malignancy
Remember that the guideline for anemia associated with a malignancy is an exception to this
guideline.
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Chapter 2: Neoplasms (C00 – D49) …
• ICD-10-CM contains guidelines about two new codes and their use:– C80.0 Disseminated malignant neoplasm,
unspecified should be used when the patient has advanced metastatic disease and no primary or secondary sites are documented
– C80.1 Malignant (primary) neoplasm, unspecified is the equivalent of “Cancer, unspecified”
• There are more chapter-specific guidelines for chapter 2 but they are unchanged from those in ICD-9-CM
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Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50 – D89) …
• This chapter has been moved and now includes the immunity disorders– Chapter 3 in ICD-9-CM included Immunity Disorders
with Endocrine, Nutritional and Metabolic Diseases– Chapter 4 in ICD-9-CM contained Diseases of the Blood
and Blood-Forming Organs
• This chapter now has categories of codes while the chapter in ICD-9-CM had no specific categories
• Codes for lymphadenitis were previously included in this chapter but in ICD-10-CM can now be found in Chapter 9 – Diseases of the circulatory system
• This chapter, like the others in ICD-10-CM, contains a significant expansion of codes
• ICD-10-CM contains no chapter-specific guidelines for this chapter
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Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00 – E89) …
• All of the chapter-specific guidelines in ICD-10-CM are for the diabetes codes and are similar to those found in ICD-9-CM
• The diabetes codes are now combination codes that include the following:– Type of diabetes mellitus (Type 1, Type 2, Secondary)– The body system affected, and– Complications affecting that body system
• The guidelines state to use as many codes within a particular category as are necessary to describe all of the complications experienced by the patient
• Codes should be sequenced based on the reason for the encounter
• ICD-10-CM does include guidelines for overdose or underdose of insulin due to insulin pump failure
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Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00 – E89) …
• Example of combination code found in ICD-10-CM:Patient is seen and evaluated for Type 2 diabetes with moderate nonproliferative diabetic retinopathy with macular edema
ICD-10-CM Code Description
E11.331Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
ICD-9-CM Codes Description250.50
362.05
362.07
Diabetes, type II, with opthalmic manifestationsModerate nonproliferative diabetic retinopathyDiabetic macular edema
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Chapter 5: Mental, Behavioral, and Neuro-developmental Disorders (F01 – F99) …
• This chapter is similar to the chapter in ICD-9-CM
• The biggest change is the incorporation of guidelines and codes for mental disorders due to drug use, abuse or dependence
• Guidelines for mental and behavioral disorders due to psychoactive substance use – new in ICD-10-CM– Codes should be used only when the drug use is
associated with a mental or behavioral disorder AND the relationship between the two is documented by the provider
– Hierarchy exists for determining what to code:• If use and abuse are documented assign code for
abuse• If use and/or abuse AND dependence are
documented assign code for dependence
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Chapter 6: Diseases of the Nervous System (G00 – G99) …
• The ICD-10-CM chapter set-up differs significantly from the ICD-9-CM chapter– Diseases of the eye and ear have been moved to their
own chapters (chapters 7 and 8)– New categories of codes have been developed based
on the type of disease or disorder – The codes are slightly rearranged because of the new
categories
• This chapter also has a significant expansion of the number of codes– For example, ICD-9-CM has 10 codes that can be used
to report Migraines while ICD-10-CM has 44 codes in this category.
– Codes are also expanded due to the incorporation of laterality (left versus right)
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Chapter 6: Diseases of the Nervous System (G00 – G99) …
• The guidelines in ICD-10-CM are the same as those in ICD-9-CM except for a new section that addresses dominant versus nondominant side
• Some code categories incorporate code descriptions that describe the affected side as dominant or nondominant
• If the documentation does not indicate whether the affected side is dominant or nondominant, the code should be selected as follows:– If the patient is ambidextrous, default = dominant– If the right side is affected, default = dominant– If the left side is affected, default = nondominant
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Chapter 7: Diseases of the Eye and Adnexa (H00 – H59) …
• Codes for these conditions are included in the Nervous System chapter in ICD-9-CM
• ICD-10-CM has extensive additions to the codes because of the addition of laterality and increased specificity– Most of the codes have four subcategories as follows:
• Right eye• Left eye• Bilateral• Unspecified eye
• All chapter-specific guidelines relate to glaucoma coding – Assign as many codes from category H40 Glaucoma as
needed to identify:• Type of glaucoma• Affected eye• Stage of glaucoma
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Chapter 8: Diseases of the Ear and Mastoid Process (H60 – H95) …
• Codes for these conditions are included in the Nervous System chapter in ICD-9-CM
• ICD-10-CM has extensive additions to the codes because of the addition of laterality and increased specificity– Most of the codes have four subcategories as follows:
• Right ear• Left ear• Bilateral• Unspecified ear
• There are no chapter-specific guidelines for this chapter
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Chapter 9: Diseases of the Circulatory System (I00 – I99) …
• The ICD-10-CM chapter set-up is similar to that in ICD-9-CM
• Codes are expanded significantly in some areas– A new code category exists for Subsequent ST
elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarctions
– Many code series have been expanded to account for laterality
• Many guidelines remain the same as those in ICD-9-CM
• New or modified guidelines in ICD-10-CM relate to:– Atherosclerotic coronary artery disease and angina– Acute myocardial infarctions (AMI)– Subsequent acute myocardial infarctions
• The chapter also contains many additional instructional notes regarding use of additional codes to identify tobacco use and exposure
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Chapter 9: Diseases of the Circulatory System (I00 – I99) …
• Atherosclerotic heart disease and angina– ICD-10-CM contains combination codes for these
conditionsI25.11 Atherosclerotic heart disease of native coronary artery with angina pectorisI25.7 Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris
– A causal relationship is assumed and does not have to be documented
• Acute myocardial infarctions (MIs)– This section contains significant differences from ICD-9-
CM– The acute phase was designed as eight weeks or less in
ICD-9-CM but is defined as four weeks (28 days) or less in ICD-10-CM
– Episode of care concept has been eliminated in ICD-10-CM
– Two categories of codes exist – initial MI and subsequent MI
– Codes for STEMIs have been significantly expanded– Subsequent MI is defined as occurring with in 4-week
acute phase
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Chapter 10: Diseases of the Respiratory System (J00 – J99) …
• The chapter set-up is similar to that found in ICD-9-CM
• ICD-10-CM contains numerous combination codes that describe a condition and the infection that is its underlying causeExample: J20.2 Acute bronchitis due to streptococcus
• Guidelines in ICD-10-CM address the following:– Acute exacerbation of chronic obstructive bronchitis
and asthma – An acute exacerbation is a worsening or a decompensation of a chronic condition, not an infection superimposed on a chronic condition.
– Sequencing of acute respiratory failure codes• List first if it is the reason chiefly responsible for
admission to the hospital
• Asthma codes contain options for– Mild– Moderate– Severe
• This chapter contains significant instructional notes to use additional codes to report tobacco use or exposure
41
Chapter 11: Diseases of the Digestive System (K00 – K95) …
• The chapter set-up is similar to that found in ICD-9-CM although three additional sub-categories have been added allowing for more specificity of category title
• Combination codes also exist in some cases that include the drug, nature of the condition (e.g., adverse effect), and external cause eliminates the need for E-codes
Example: Fran was a healthy 30 year old female diagnosed with a UTI and prescribed a course of Doxycycline. Approximately one week after beginning to take her antibiotics, Fran’s UTI had resolved but she returned to the office with odynophagia, chest pain and dysphagia. After diagnostic testing, Fran was diagnosed with an esophageal ulcer. Her physician determined her ulcer was caused by the antibiotic.K22.10 Ulcer of esophagus without bleedingT36.4x5A Adverse effect of tetracyclines, initial encounter
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Chapter 11: Diseases of the Digestive System (K00 – K95) …
• One major change in this chapter is that the ulcer code definitions no longer mention obstruction– This has eliminated approximately 50% of the ulcer
codes since ICD-9-CM typically had options for “with obstruction” and “without obstruction”
• Codes in ICD-9-CM for dentofacial anomalies have been moved to the chapter for Diseases of the Musculoskeletal System in ICD-10-CM
43
Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00 – L99) …
• ICD-10-CM has many more subcategories than ICD-9-CM but the conditions are generally in the same order as in ICD-9-CM
• There is a significant expansion in the number of codes for– Laterality (left versus right)– Upper limb versus lower limb
• The pressure ulcer codes have been significantly expanded in ICD-10-CM (almost 6 pages while ICD-9-CM had less than one page)
• All chapter-specific guidelines in ICD-10-CM relate to the pressure ulcer codes
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Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00 – L99) …
• Pressure ulcer guidelines state:– Assign as many codes as needed from the L89 Pressure
ulcer series to identify multiple pressure ulcers by anatomic site and stage
– Code first any associated Gangrene (I96)– No code should be assigned for a pressure ulcer
described as “healed”
• Information needed to code a pressure ulcer– Body area or anatomic site (4th digit)– Laterality (5th digit)– Stage of ulcer / depth (6th digit)
• Note that the dermatitis codes have also been expanded significantly reflecting the cause of the dermatitis– Providers may need to add more specific information
to their documentation so that the cause of the dermatitis can be used to determine the appropriate code
45
Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) …
• The chapter in ICD-10-CM again has a significant expansion of codes due to the addition of laterality and other specificity
• The chapter includes all diseases typically associated with the musculoskeletal system and connected tissue as well as the following:– Bone, joint or muscle conditions that are the result of a
healed injury– Recurrent bone, joint or muscle conditions– Pathological fractures– Stress fractures
• Current, acute injuries should be coded using codes form Chapter 19 – Injury, Poisoning and Certain Other Consequences of External Causes
• The majority of the guidelines in ICD-10-CM relate to coding pathological fractures
46
Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) …
• A pathological fracture occurs in a diseased or weakened bone when either no trauma or only minor trauma that would not normally break a healthy bone has occurred
• Pathological fractures are also known as “spontaneous fractures”
• Bones can become weakened as the result of many conditions including– Malignancies– Osteoporosis– Osteomyelitis– Hyperparathyroidism
• Pathologic fractures also include instructions to code the underlying condition
• The 7th character specifies the episode of care and is different from what is seen in ICD-9-CM
47
Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) …
• 7th characters for pathological fractures:
7th Character Description
A Initial encounter for 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
48
Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99) …
• Stress fracture codes are in this chapter• Stress fractures
– Occur in weight-bearing bones– Are caused by repeated minimal stresses to the bone– Should be coded using category M84.3 Stress fracture
• Note that when you code a stress fracture, you must also select an external cause code to identify the cause of the stress fracture
49
Chapter 14: Diseases of the Genitourinary System (N00 – N99) …
• In ICD-10-CM, renal manifestations of systemic diseases classified in other chapters have been moved to those chaptersExample: Nephrotic syndromes, nephritis, and nephropathies associated with diabetes have been moved to chapter 4, Endocrine, Nutritional and Metabolic Diseases
• The codes in many categories again are significantly expanded due to the increased specificity of the definitions
• Some of the terminology used to describe conditions in this chapter has changedExample: Benign prostatic hypertrophy (BPH) is called enlargement of the prostate in ICD-10-CM
• This chapter includes Disorders of the Breast (N60 – N65) – codes are expanded due to the addition of laterality
• The dysplasia codes for the cervix and vagina have been redefined to differentiate the severity of the condition (mild, moderate, or unspecified; severe is in chapter 2)
50
Chapter 15: Pregnancy, Childbirth and the Puerperium (O00 – O9a) …
• In ICD-10-CM, the categories and codes are more detailed
• ICD-10-CM eliminates the concept of antepartum, delivery, etc. in the code definition and instead incorporates the trimester of the pregnancy into many of the codes including those for supervision of the pregnancy
• The trimesters are defined as follows:– First trimester – less than 14 weeks– Second trimester – 14 weeks 0 days to less than 28
weeks– Third trimester – 28 weeks 0 days until delivery
• The guidelines address the importance of knowing whether a condition developed due to the pregnancy or if it was a pre-existing condition this will impact the code selection
51
Chapter 16: Certain Conditions Originating in the Perinatal Period (P00 – P96) …
• In ICD-10-CM, the codes have been structured to bring together related conditions into distinct code blocks while ICD-9-CM grouped the conditions into two subchapters
• Remember these codes are used only on the newborn’s record (birth to 28 days of age)
52
Chapter 17: Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00 – Q96) …
• The chapter title has been updated in ICD-10-CM to reflect the categories in this chapter– In ICD-9-CM, the chapter title was Congenital
Anomalies
• The chapter has also been moved so that it follows Chapter 16: Certain Conditions Originating in the Perinatal Period
• Many of the code definitions from ICD-9-CM have been modified or grouped as alternate listings under another code definition
• In ICD-10-CM, the codes are grouped into categories based on organ system or body area
• The guidelines state that once a congenital condition has been corrected, a personal history code should be used to identify the history of the malformation or deformity
53
Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, NEC (R00 – R99) …
• Although this chapter is similar to Chapter 16 in ICD-9-CM, the categories are significantly different in ICD-10-CM– Categories for symptoms and signs involving various
organ systems or functions– Category for General symptoms and signs– Categories for abnormal findings from test results– Category for Ill-defined and unknown cause of
mortality
• This chapter also contains an expanded number of codes due to the increase in specificity of code definition
• New codes are available in ICD-10-CM for fallsR29.6 Repeated fallsZ91.81 History of falling
54
Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00 – T88) …
• Most of the injury coding guidelines remain the same as those in ICD-9-CM
• ICD-10-CM includes significantly more codes due to the inclusion of greater specificity, laterality, and introduction of a new 7th character extension to indicate the episode of treatment– Initial encounter – used while patient is receiving
active treatment for the condition– Subsequent encounter – used while patient is receiving
routine care for the condition during the healing or recovery phase
– Sequela – used for complications or conditions that arise as a direct result of a condition (late effect)
• Chapter 19 of ICD-10-CM groups injuries by specific site/body part, while in ICD-9-CM injuries are grouped by types of injuries, e.g., fractures, dislocations, open wounds, etc.
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Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00 – T88) …
• Coding of traumatic fractures– Fractures are coded individually by site– If the documentation does not indicate whether the
fracture is open or closed, select the code for closed– If the documentation does not indicate whether the
fracture is displaced or nondisplaced, select the code for DISPLACED opposite of ICD-9-CM
• ICD-10-CM distinguishes between burns and corrosions – guidelines are the same by codes are new and distinct– Burns – thermal burns that come from a heat source,
burns from electricity and radiation– Corrosions – burns due to chemicals– Guidelines for coding burns are the same as those in
ICD-9-CM
• In ICD-10-CM, the poisoning codes are combination codes that include the substance that was taken and how the poisoning occurred
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Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00 – T88) …
• Underdosing – new concept in ICD-10-CM!– Used when a patient has taken less of a medication
than prescribed resulting in illness– Should NEVER be the first-listed code– First-listed code is what is wrong with the patient as a
result of the underdosing
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Chapter 20: External Causes of Morbidity (V00 – Y99) …
• Similar to the E codes in ICD-9-CM• ICD-10-CM does contain some specific
sequencing guidelines• If two or more events cause separate injuries, an
external cause code should be assigned for each cause– Child and adult abuse take priority over all other
causes– Terrorism events take priority over all other causes
except child and adult abuse– Cataclysmic events take priority over all causes except
child and adult abuse and terrorism– Transport accidents take priority over all causes except
child and adult abuse, terrorism, and cataclysmic events
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Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00 – Z99) …
• Similar to the V codes in ICD-9-CM• ICD-10-CM does contain some changes in code
set-up and in guidelines• Code range Z00 – Z13 is used to describe
encounters related to routine examinations (general check-ups, sports physicals, pre-employment physicals)– Categories now have options for
• Exam without abnormal findings• Exam with abnormal findings
– If the exam results show abnormal findings, additional code(s) should be used to identify those findings
• Pre-operative examination codes are used only when a patient is being cleared for surgery and no treatment is rendered
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Educating your providers …
• Dual coding• Tools you can develop – base them on your
utilization reports• Other ideas
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Questions?
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