Slide 1
Three ways to find the right ICD-10 code
Presented by Wyn L Staheli
Director of Research & Editing
1
ICD-10 can be overwhelming, but,
with some strategizing and planning it
can be managed. In this presentation
we will look at a few ICD-10
fundamentals, then familiarize
ourselves with three methods for
finding the right ICD-10 code. Each
one is a different path, but all lead to
the same destination: the right code.
Slide 2
2
You may remember that there were
some who thought the world would
end on December 21, 2012 (because
that was the end of the Mayan
calendar). When that date passed,
some thought that maybe it would be
the next year, or the one after that.
Many physicians feel that ICD-10 could
be the end too. But that date keeps
passing us by with no end in sight. It
looks like 2015 will finally be the year.
Don’t worry though, with the right
plan and the right tools, you will make
it through the ICD-10-ocolypse.
Slide 3 Wyn L Staheli
• Education• Bachelor’s of Science, Management Information Systems (MIS)
• Experience• Office Manager for an Infectious Disease specialist and behavioral health
group
• Computer Programmer for a large insurance carrier as well as a California hospital system
• Writer and editor of medical resource books
• Founder of InstaCode Institute (which has been serving the medical community since 1996)
• Cofounder of FindACode.com
3
Just in case you are wondering
about who I am, here’s my
background.
I’ve played on both sides of the
insurance game.
Slide 4
ICD-914,567 codes
ICD-1069,832codes
4
Why can’t we keep using ICD-9?
A common question, especially from
providers, is: “Why can’t we just keep
using ICD-9? It works fine.”
The truth is that if you drop ICD-9 and
ICD-10 into a ring together, ICD-10 will
win every time. Not only is it much
bigger, it is better. The codes are more
detailed, more logical, and better
organized.
Sure, ICD-10 is a bigger code set, but
as CMS recently stated in an alert
about ICD-10:
“You don’t have to use 68,000
codes. Your practice does not
use all 13,000 diagnosis codes
available in ICD-9. Nor will it be
required to use the 68,000
codes that ICD-10 offers. As
you do now, your practice will
use a very small subset of the
codes.”
Because ICD-10 is more logical,
detailed and better organized, sticking
with ICD-9 is like sticking with a type
writer when you could be using
Microsoft Word.
Slide 5
5
ICD-10 examples
In ICD-9: E844.8
Sucked into jet without accident to aircraft; ground crew
To illustrate to you just how detailed
ICD-10 can be, we will take this ICD-9
code and translate it so that you can
see how much information can be
conveyed in the new codes. This really
is an actual ICD-9 code.
Slide 6
6
ICD-10 examples
In ICD-10: V97.3
Person on ground injured in air transport accident;
Here we see the first four characters
of the ICD-10 equivalent. Not much
new yet.
Slide 7
7
ICD-10 examples
In ICD-10: V97.33
Person on ground injured in air transport accident; sucked into jet engine
As we add the fifth character we see
some detail, but the code does not
really offer anything that the ICD-9
equivalent did not.
Slide 8
8
ICD-10 examples
In ICD-10: V97.33&
Person on ground injured in air transport accident; sucked into jet engine, male;
Now it gets interesting. The
ampersand symbol offers the gender
of the patient.
Slide 9
9
ICD-10 examples
In ICD-10: V97.33&µ
Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height;
The greek letter, “mew”, describes the
patient’s vertical stature.
Slide 10
10
ICD-10 examples
In ICD-10: V97.33&µ#
Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height; slightly bald;
The hashtag identifies the patient’s
hair status
Slide 11
11
ICD-10 examples
In ICD-10: V97.33&µ#$
Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height; slightly bald; wearing a jump suit;
The dollar sign describes his or her
fashion choice.
Slide 12
12
ICD-10 examples
In ICD-10: V97.33&µ#$€
Person on ground injured in air transport accident; sucked into jet engine, male; under 5’5” in height; slightly bald; wearing a jump suit; during a full moon
And the euro symbol identifies the
phase of the moon at the time of the
incident.
So, if you have not already guessed,
most of this is made up. Symbols are
not used in ICD-10, just letters and
numbers. And the codes can be up to
seven characters long, not ten, like
this silly code.
However, the characters and
description you see in blue, V97.33 are
all part of a real code.
Some ICD-10 naysayers suggest that
the codes are useless because they
provide detail that is not necessary.
However, as you will see, much of the
detail in real codes can actually be
quite helpful in communicating the
medical necessity of a claim to a third
party payer.
Slide 13
ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus.
Note: there are 11 gout codes in ICD-9 and 365 in ICD-10
13
ICD-10 examples
Here is a real code that clearly
demonstrates the additional detail
available in ICD-10. The first three
characters (M1A) represent the
category, which is a group of related
conditions. This one is chronic gout.
The other gout category is M10 and it
contains acute gout.
The fourth character identifies the
cause or etiology for this case of gout.
There are actually six different digits
that could go here, but we have
selected the “3” for “renal
impairment” for this example.
The fifth character identifies the
location. Even though gout usually
occurs in the big toe, there are ten
choices for this character, each one a
different joint where gout could occur.
The sixth character is a “1” for right,
“2” for left, or “9” for unspecified.
This is one of the new features of ICD-
10 that ICD-9 lacked: laterality.
This category is one that offers a
seventh character extension. It is a
“0” or a “1” for without and with
tophus, which is an accumulation of
uric acid crystals in the joint.
You can see that this seven character
code tells quite the story. A third
party is less likely to ask for
documentation when all this detail
appears on the claim form.
It is interesting to note that there are
11 codes for gout in ICD-9, but 365 in
ICD-10, just because of all of the extra
detail available.
Slide 14 Tabular list layout
Chapter
21 of them
from A to Z
Block
Ranges of categories
Categories
3 charactersSubcategories
4th or 5th
characters
Codes
6th or 7th
characters
14Note: Codes may be complete with fewer than 6 characters. Some codes only have 3.
Before we learn how to select the
right codes, you need to know how
the tabular list is organized.
If you open up the tabular list of a
code book, the first major subdivision
you will find is chapters. There are 21
in ICD-10, which is up from 17 (plus 2)
in ICD-9. They run from A to Z.
The next subdivision of a chapter is a
block. These cover ranges of
categories, such as I70-I79 Diseases of
arteries, arterioles, and capillaries.
Blocks can be broken down to the
three digit categories, such as I70
Atherosclerosis.
Next, you add fourth and fifth
characters, which are considered
subcategories.
Once you get down to sixth and
seventh characters, those are just
called “codes”. But note that codes
may be complete with fewer than six
characters. Some only have three
characters, such as R42 Dizziness and
giddiness. In the book I am using as
an example, complete codes will
always be in bold, so it is easy to know
if you have enough characters.
Slide 15 Tabular
List
15
Chapter: 13, Diseases of the Musculoskeletal System and Connective Tissue (M00 – M99)(always white font in a black box)
Let’s see how this looks in a coding
manual. This is the beginning of
chapter 13, which covers diseases of
the musculoskeletal system.
Every code in this chapter begins with
the letter “M”. It spans the range of
M00 to M99.
Notice all of the rules listed under the
chapter heading. Just like ICD-9, these
guidelines apply to every code in this
chapter, so it is important to come
back to them from time to time to
make sure your code is the right one.
Slide 16 Tabular
List
16
Block: Deforming Dorsopathies(M40 – M43)(Always bold CAPS, lined above and below)
A chapter is divided into blocks, or a
range of three digit categories.
This one is deforming dorsopathies. If
there were guidelines that pertained
to the whole block, they would appear
under this heading. The formatting
here makes it easy to see when a new
block begins.
Slide 17 Tabular
List
17
Category: M43- Other Deforming Dorsopathies(Always all CAPS, with a line above)
Blocks are divided into three digit
categories. This one, M43-, is for
“other deforming dorsopathies”. The
use of the word “other” is diagnosis
coding just means that the diagnosis
can’t be found in one of the other
nearby categories.
Notice that the formatting here makes
it easy to spot when you are at the
beginning of a new category because
of the line above the three character
heading. Also notice that M43- is
followed by a hyphen, which indicates
that this is not a complete code.
All of the complete codes on this page
lack a hyphen and they are in bold.
Some have four, and some have five
characters.
Slide 18 Tabular
List
18
Subcategory: M43.1- Spondylolisthesis
Once you add a fourth or fifth
character you have entered a
subcategory. This one is
spondylolisthesis (spän-də-lō-lis-ˈthē-
səs), which is a condition where the
front part of a vertebra separates from
the back part and slips forward.
Notice that the subcategory is not a
complete code because it is not in
bold and it has a hyphen, which tips
off the reader that he or she needs to
keep adding characters. However,
there are some instructions below this
subcategory heading, and they apply
to all codes which contain these four
characters.
The fifth character adds detail about
the specific anatomic level in the
spine. We will come back and visit
this code category in a minute.
Slide 19 Finding the
ICD-10 code
Now that we have covered some basic
tabular list orientation, we are ready
to actually learn how to find the right
code. Translating from ICD-9 to ICD-10
is a lot like translating from English to
French. You can’t just take a sentence
and translate each word one at a time.
You have to consider the rules of
grammar, such as proper sentence
structure and grammar rules. The
same is true in ICD-10.
• Some codes translate as an exact
match. These are convenient, but
few and far between.
• Some ICD-9 codes translate into
multiple ICD-10 codes. These are
called scenarios.
• Since there are five times as many
ICD-10 codes as there are ICD-9
codes, some can only be mapped
backwards from ICD-10. Likewise
there may be words in French that
do not really have an English
equivalent. You need to learn more
than just a simple forwards
translation to figure out how to use
these new words (or codes)
• In some cases multiple ICD-9 codes
can be combined into a single ICD-
10 code.
• But frequently, we find that the
match is only approximate.
Slide 20
Three methods using the InstaCode ICD-10 book:1. Commonly used code list (but don’t stop there!)2. GEMs code map (don’t stop here either!)3. Alphabetic index (still not safe!)
Always confirm the code using the Tabular List 20
Finding the
ICD-10 code
Finally, we are where the rubber
meets the road. Here are the three
strategies for finding the right ICD-10
code. They are [see above]. But the
truth is that these methods are just
step one of a slightly bigger process.
Let’s say that you walk into the
supermarket, looking for grape juice.
You might ask a clerk where to find it
and he could point you to aisle 3.
Once you get there you might find
exactly what you are looking for on
the end cap. Or, you might have to
wander up and down the aisle until
you spot it. Then you might want to
compare brands, or nutritional
content, or look for the best price. In
fact, you might realize that you really
need apple-grape juice, or, after
searching for a while, you decide you
really wanted chocolate milk all along.
These three strategies all get you to
aisle 3. But often you have to do some
investigating before you can be certain
that you have chosen the right
product (or code). You do this by
digging through the Tabular List.
Slide 21
1. Common Codes
21
This is an example of a common codes
list. This one is for spinal conditions in
the lumbar region. It can be helpful
because the provider won’t need to
search through all 70,000 ICD-10
codes. He or she can just browse this
much shorter list, specific to the
anatomical region of interest, and the
provider’s specialty.
Unfortunately, using common code
lists are a little misleading because
ICD-10 has not yet been used in the
US, so no one really knows which
codes are truly “common”. These lists
are being produced by specialty
associations and coding book
publishers, but at this point in time,
they are really just best guesses.
Hence, they cannot be relied upon
completely.
Whatever path they lead us down (like
the aisle in the grocery store), we
must confirm with the tabular list.
Slide 22
22
2. GEMs
General Equivalence Mappings (GEMs)
o Created by the National Center for Health Statistics, part of the CDC
o Forward maps from ICD-9 to ICD-10
o Backward maps from ICD-10 to ICD-9
o Approximations only
Many providers will say, “Here is my
old code. Just translate to the new
one.” That is what GEMs does.
GEMs is a government database that
allows us to crosswalk from ICD-9 to
ICD-10, or from ICD-10 to ICD-9. It
seems like it could eliminate all the
concern about finding the right code,
but, unfortunately, it does not work
like that. We have been warned by
CMS that GEMs are only
approximations and they should not
be used to code. Codes should only
be selected based on the key terms
found in the provider documentation.
Nonetheless, GEMs can be helpful in
identifying good prospects. Since
GEMs was created by the government,
it is in the public domain. You can
obtain it for free, such as with the
FindACode smart phone app.
Slide 23
2. GEMs
23
Here is an example of a printed
crosswalk based on GEMs forward
mapping from ICD-9 to ICD-10. The
ICD-9 codes are listed in numeric order
in the left hand column and the ICD-10
equivalents are on the right.
Many times there is only one ICD-10
code listed, but sometimes multiple
options are offered. Unfortunately, as
we’ll see in a moment, GEMs
frequently crosses to unspecified codes
because the original ICD-9 code was
not very specific. Unspecified codes
are expected to be denied, or lead to
delayed payment if more detail could
have been reported.
In this customized crosswalk, you’ll
notice that unspecified codes do not
appear. Rather, code categories and
subcategories are provided. They are
not in bold and end with a hyphen to
encourage the reader to go to the
Tabular List to research the detail
needed to complete the code. If a
complete code is available, it is
bolded.
Slide 24
3. Alphabetic
index
24
The third, and best, strategy for
finding the right ICD-10 code is the
alphabetic index. This is the method
that CMS recommends. For this
approach, you do not need to know
what the ICD-9 code was. You just
need to read the provider
documentation, pick out the key
terms, and look them up in the index.
Sometimes the index will take you
right to a complete code, which will be
in bold (in this book anyway), but
often it only provides the first three or
four characters of a code. This is
indicated by a hyphen (and no bold),
which means that the reader needs to
seek out the rest of the code in the
Tabular List.
However, it is very important to then
review the Tabular List before making
the final code selection. There are
often specific guidelines that should
be considered before making the final
code decision.
Slide 25 Example
A 32 year old female presents with low back pain at L4/L5. The pain worsens with extension and with exercise. The patient complains of tight hamstrings and pain in the low back. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2015, the diagnosis is 738.4 Acquired Spondylolisthesis. On October 1, 2015, it is:
25
Here is an example of a case. We will
use all three methods to seek out the
appropriate ICD-10 code, then confirm
using the tabular list. [read the
example]
Note that, at this time, we have been
instructed to report ICD-9 codes for
dates of service that occur prior to
October 1. There is no testing or dual
reporting period. But there has been
some movement among some
healthcare provider’s organizations to
create a sort of transitionary period
where both codes could be accepted.
Slide 26 1. Common Codes
26
This common codes list contains
musculoskeletal diagnoses for the
lumbar spine. It is simply listed in
alphanumeric order, so the only way
to try to find our new code is to
browse the list until we see something
we like.
Highlighted in the bottom left corner,
you can see two possible codes under
the heading for “spondylolisthesis”.
One is for the lumbar region, M43.16,
and the other is lumbosacral. Since
the note said L4, we can stick with
M43.16.
This could be the right code, and we
might be done with our search.
However, we should use the other
two strategies, then confirm with the
Tabular List, just to be sure.
Slide 27
27
2. GEMs
This is a GEMs based crosswalk or
code map. As we scan the ICD-9
column, we come to 738.4, which is
the code we are starting with. This is
a one-to-two map. Upon examination,
we’ll see that that only one of the ICD-
10 codes matches the wording from
the provider documentation, M43.1-
Spondylolisthesis.
However, we were only given the
subcategory, not the complete code.
We’ll have to go to the Tabular List to
see how many more characters we
need to code to the highest level of
specificity. The official GEMs
crosswalk points to an unspecified
code, but this list omits those codes
and replaces them with an unbold,
hyphenated subcategory, forcing the
user to dig deeper, rather than default
to the undesirable unspecified code.
Before we go to the Tabular List, let’s
use the third strategy.
Slide 28
28
3. Alphabetic
index
As we look up the key term,
“spondylolisthesis” in the alphabetic
index, we are led to a few options.
The first code suggested is M43.10,
and it might just be the one we are
looking for. But, a little closer
inspection will lead us to M43.16
which is specific to the lumbar region.
Sometimes the alpha index does not
offer a complete code, but we know it
does in this case because the code is
in bold.
Now we need to go take a look at the
Tabular list and see if M43.10 or
M43.16 is a better choice.
Slide 29
29
The three strategies have all led us
here, to the Tabular List.
The first option we found, using a
commonly codes list, was M43.16.
This was also suggested by the
Alphabetic Index. It looks pretty good.
We now see that M43.10 was the
unspecified code, so it should be
avoided if we have information to
choose a better code.
M43.1- is just the subcategory. It is
not bold, so it is incomplete, but it
does help us to identify some
guidelines that apply to the code(s) we
are interested in.
Excludes1 means that these other
codes are mutually exclusive and
cannot be coded along with any
M43.1- codes. For example, a patient
can either have congenital
spondylolisthesis, or acquired
spondylolisthesis, but not both.
Within the Tabular List, we should
always trace back to the beginning of
the category to see if there are any
other important guidelines. On the
left of this page, we see that M43- has
list of Excludes1 notes. We should
look over that list to see if any of those
diagnoses provide a better option.
Notice that there are some rules on
the bottom left, under M43.0- as well.
Those rules do not apply to the
M43.1- subcategory, so we can ignore
them.
Slide 30 Example
A 32 year old female presents with low back pain at L4/L5. The pain worsens with extension and with exercise. The patient complains of tight hamstrings and pain in the low back. An x-ray reveals a grade II spondylolisthesis at L4. On September 30, 2015, the diagnosis is 738.4 Acquired Spondylolisthesis. On October 1, 2015, it is:
M43.16 Spondylolisthesis, lumbar region
Note:
Common codes lists are just an expert guess
GEMs is often unspecified
Alphabetic Index often gives incomplete or multiple options30
If we go back to our example, we can
choose our code. We went down to
aisle 3, we compared all the grape
juice and we found the one that meets
our needs. M43.16. It really is not
that different from the ICD-9 code that
we started with, except that it offers
the specific anatomical region.
Note that the common codes list gave
two options, each with a different
anatomical region. We had to know
our anatomy in order to select the
right code.
The code map did not give us a
complete code, and the alpha index
gave a few options too.
However, it was only in the Tabular
List where we found the detail we
needed to confidently choose the
correct code.
Slide 31 Example 2
68 year old Hispanic female with Type 2 DM, controlled with insulin, with mild nonproliferative diabetic retinopathy without macular edema. On September 30, 2015, the diagnosis is 250.50 DM Type 2, insulin dependent with ophthalmic manifestations, controlled. On October 1, 2015, it is:
31
Example 2 is an example of a common
coding situation – diabetes.
Slide 32 1. Common Codes
32
This sample of commonly used codes
from a professional organization
shows Type 2 diabetes codes. It is
simply listed in alphanumeric order, so
the only way to try to find our new
code is to browse the list until we see
something we like.
One possible code is highlighted. This
could be the right code, and we might
be done with our search. However,
we should use the other two
strategies, then confirm with the
Tabular List, just to be sure.
Slide 33
33
2. GEMs
Using a GEMs based crosswalk or code
map we can scan the ICD-9 column,
we come to 250.50, which is the code
we are familiar with. This is a one-to-
many map. Upon examination, we’ll
see that that only one of the ICD-10
codes matches the wording from the
provider documentation, E11.3-Type 2
Diabetes Mellitus with ophthalmic
manifestations.
However, we were only given the
subcategory, not the complete code.
There is on information in the ICD-10-
CM column about “not stated as
uncontrolled”. We’ll have to go to the
Tabular List to see how many more
characters we need to code to the
highest level of specificity. The official
GEMs crosswalk points to an
unspecified code, but this list omits
those codes and replaces them with
an unbold, hyphenated subcategory,
forcing the user to dig deeper, rather
than default to the undesirable
unspecified code.
Before we go to the Tabular List, let’s
use the third strategy.
Slide 34
34
3. Alphabetic
index
As we look up the key terms,
“diabetes, type 2 with retinopathy” in
the alphabetic index, we are led to a
few options. The first code shown is
E11.319, however, it does not include
all the required elements of our
coding example.
By continuing the same as we have
become accustomed to with ICD-9
indexes, we find E11.329 which
includes all the elements of our coding
example.
Sometimes the alpha index does not
offer a complete code, but we know it
does in this case because the code is
in bold.
Now we need to go take a look at the
Tabular list to make sure that there are
no exclusions or guidelines which
might reveal a better code choice.
Slide 35
35
All three strategies have all led us
here, to the Tabular List.
There are no guidelines associated
with this code, however, just like ICD-
9, we should always trace back to the
beginning of the category to see if
there are any other relevant
guidelines. On the left of this page,
we see that E11- has list of Excludes1
notes. It is important to look over that
list to see if any of those diagnoses
provide a better option. In our
example, none are applicable.
However, there is an important “use
additional code” guideline that
applies. With ICD-10, insulin use is
documented with it’s own code, in this
case Z79.4.
Remember, an Excludes1 guideline
means that these other codes are
mutually exclusive and cannot be
coded along with any E11- codes. For
example, if the patient’s diabetes is
due to an underlying condition, you
cannot use an E11- code.
Finally, take a look at the highlighted
“See Guidelines” notation. That is a
unique InstaCode Institute helpful tool
which lets you know that there are
official guidelines regarding the coding
of Type 2 Diabetes Mellitus. It also
tells the user WHERE to look in the
guidelines to find those instructions.
Very handy!
Slide 36 The next step for converting to ICD-10
36
1. Go to the Tabular Listo Look at the following:
1. Notes
2. Includes and alternative wording
3. Excludes1
4. Excludes2
5. Code Also, Code First, Use Additional
6. Seventh character extensions
2. Repeat at the level of the code, then the subcategory, category, block, and chapter
3. Reverse map for confirmation if necessary
We don’t have time to go through all
of the ICD-10 conventions and
guidelines, but be sure to get
educated on these rules so that you
can become “fluent” in ICD-10. Just
like you need to study French in order
to become fluent, you need to get
familiar with the “rules of grammar”
in ICD-10 coding so that you can speak
with the natives, or rather avoid
interruptions to your reimbursement.
Slide 37
37
In many cases, ICD-10 requires that
provider documentation meet new
standards in order to properly select
codes. But with all the changes, this
might seem a little daunting.
To assist healthcare providers with this
issue, InstaCode Institute created
“Provider Documentation Guides”
which are part of our ICD-10 books.
There are 3-5 Examples of these
documentation guides in each book.
These guides are great to use for 10
minute training sessions to prepare
providers for the new ICD-10
requirements.
This slide shows a PDG for Type 2
Diabetes Mellitus using the example
we just used.
The “What to Document” section
becomes the healthcare provider’s
documentation ‘cheat sheet’. It lets
them know what information a coder
needs to know and helps prompt them
to include additional information
where required.
Slide 38
38
Here is a continuation of the “Provider
Documentation Guide” (PDG) showing
the remaining character options.
This standard can be used for other
commonly used codes for your
specialty. Look at your codes and
review your provider documentation
and see where you need to ‘beef up’
your documentation. Create your own
PDGs to begin proper documentation
right now.
Slide 39
The examples shown today were from
InstaCode Institute’s ICD-10 specialty
books. There are 24 different
specialties, each with their own
customized ICD-10 code listings,
training and Provider Documentation
Guides. Come to our booth to see
some examples and get a flyer. We
have special pricing available for those
who wish to order one today.