Coding Conundrums: ICD-10 Thomas Weida, M.D. Professor, CMO, Associate Dean for Clinical Affairs The University of Alabama College of Community Health Sciences

Disclosures I have nothing to disclose I have no conflicts of interest other than I am conflicted about ICD-10

Objectives  Describe the rationale for ICD-10.  Describe the basics of ICD-10 coding.  Demonstrate knowledge of specific must- have ICD-10 codes. 2015, Thomas J. Weida, M.D.3

How was your transition to ICD-10? A. Very Easy B. Easy C. Neutral D. Difficult E. Very Difficult F. Haven’t Switched Yet

How familiar are you with ICD-10 Coding? A. Very Familiar B. Somewhat Familiar C. Not Familiar D. What’s ICD-10?

Why the Switch to ICD-10?

Why?  Better definition of certain conditions  Increased specificity  Better support of research, population health and value-based payment  Medicare shared savings uses acuity: transition to pay for value, not visits  ICD-9 terms inconsistent with current clinical practice  ICD-9 has run out of space for new codes  Provide more detailed data to better analyze disease patterns and track and respond to public health outbreaks 2015, Thomas J. Weida, M.D.9

The Codes – Two parts  ICD-10 CM  Diagnosis Codes  ICD-10 PCS  Procedure codes which will replace ICD-9 Volume , Thomas J. Weida, M.D.10

Anatomy  3 to 7 Characters  3 Characters before decimal point, up to 4 after  1 st is alpha numeric (except no U)  2 nd is numeric  3-7 alpha numeric or numeric  Not case sensitive 2015, Thomas J. Weida, M.D.11

XXXX Category. Etiology, anatomic site, severity Added code extensions (7 th character) for obstetrics, injuries, and external causes of injury 2015, Thomas J. Weida, M.D.12 Code Anatomy XXX AMS x A Additional Characters Alpha (Except U) Numeric or Alpha 3 – 7 Characters

2014 ICD-10-CM Codes (These links are active) A00-B99A00-B99 Certain infectious and parasitic diseases C00-D49C00-D49 Neoplasms D50-D89D50-D89 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism E00-E89E00-E89 Endocrine, nutritional and metabolic diseases F01-F99F01-F99 Mental, Behavioral and Neurodevelopmental disorders G00-G99G00-G99 Diseases of the nervous system H00-H59H00-H59 Diseases of the eye and adnexa H60-H95H60-H95 Diseases of the ear and mastoid process I00-I99I00-I99 Diseases of the circulatory system J00-J99J00-J99 Diseases of the respiratory system K00-K95K00-K95 Diseases of the digestive system L00-L99L00-L99 Diseases of the skin and subcutaneous tissue M00-M99M00-M99 Diseases of the musculoskeletal system and connective tissue N00-N99N00-N99 Diseases of the genitourinary system O00-O9AO00-O9A Pregnancy, childbirth and the puerperium P00-P96P00-P96 Certain conditions originating in the perinatal period Q00-Q99Q00-Q99 Congenital malformations, deformations and chromosomal abnormalities R00-R99R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified S00-T88S00-T88 Injury, poisoning and certain other consequences of external causes V00-Y99V00-Y99 External causes of morbidity Z00-Z99Z00-Z99 Factors influencing health status and contact with health services

2015, Thomas J. Weida, M.D.14 Major Changes  Laterality  Specific disease pathophysiology  Anterior cerebral artery syndrome,  Middle cerebral artery syndrome  Combination codes  Crohn’s disease large intestine with rectal bleeding  Common clinical guidance scales  Glasgow Coma Scale, Salter-Harris Fracture Scale, Gustilo- Anderson Classification of Open Fractures, Scale for Visual Acuity  7 th character and timing of encounters  Initial or Subsequent encounter or sequela of a previous injury

2015, Thomas J. Weida, M.D.15  ID of trimesters  Increased granularity of disease manifestations  Acute bronchitis due to respiratory syncytial virus, drug induced folate deficiency anemia, Acute peptic ulcer with both hemorrhage and perforation.  X-placeholders  When 7 th place used but 5 th and 6 th are not  Alcohol and drug dependence effects  Effects of use with 4 th digit, aspects of use at 5 th digit and manifestations at the 6th digit  Expansion of injury codes  Post procedure disorders  Post procedure hypothyroidism

Consistent Complete Documentation in Medical Record  Document specific reason for the encounter and conditions treated  In code descriptors “and” can mean “and” or “or.” I.e. A18.0, TB of bones and joints can be both or either  Codes are invalid if they do not include to the full number of characters required of that code.  “Borderline” diagnosis coded as confirmed, i.e borderline hypertension  Signs or symptoms can be coded if Dx unclear: Use all 2015, Thomas J. Weida, M.D.16

Inpatient  Principal diagnosis (reason for admission) coded first  Admission for complication of surgery: Complication Code is principal Dx.  Admission from Obs: Principle Dx is condition leading to hospital admission  Admission after post-op obs: Principle Dx is condition responsible for admission. 2015, Thomas J. Weida, M.D.17

Inpatient  Additional Diagnoses  All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.  Dx relating to earlier episodes which have no bearing on current stay excluded.  History codes (Z80-Z87) used if they impacted care or treatment. 2015, Thomas J. Weida, M.D.18

Outpatient/Observation  Code the chief reason for the visit to highest level of certainty, which may be signs or symptoms  Code all document coexisting conditions that affect treatment or management  Outpt surgery: 1 st Dx reason for surgery  Obs stay: 1 st Dx principle medical condition  Outpt surgery with complication and obs: 1 st Dx reason for surgery, then complication 2015, Thomas J. Weida, M.D.19

Inpatient/Outpatient Differences  Uncertain diagnosis (i.e. probable, likely, etc.)  Inpatient: Code as if established at the time of discharge  Outpatient (includes Observation Care): Code highest degree of certainty (sign, symptom or abnormal test result)  Abnormal test findings  Inpatient: Report if provider indicates clinical significance  Outpatient: Code definitive Dx documented in interpretation 2015, Thomas J. Weida, M.D.20

Example Codes– It’s a ZOO out there Z00.00 Encounter for general adult medical exam without abnormal findings Z00.01 Encounter for general adult medical exam with abnormal findings – then need to code the abnormal finding 2015, Thomas J. Weida, M.D.21

Example , Thomas J. Weida, M.D.22 Well adult visit in a patient previously diagnosed with DM and COPD managed currently, status of disease updated, medications renewed. What’s the correct code? Z00.00 General medical exam without abnormal findings Z00.01 General medical exam with abnormal findings

Example , Thomas J. Weida, M.D.23 Annual preventive visit without any major complaints where physician notices a growth which has grown since the last visit and has irregular borders. Z00.00 Z00.01

Respiratory Problems Streptococcal PharyngitisJ02.2 Acute pharyngitis, unspecifiedJ02.9 Chronic pharyngitisJ31.2 Acute nasopharyngitis (common cold)J , Thomas J. Weida, M.D.24 ASTHMAUncomplicatedAcute Exacerbation Status Asthmaticus Mild intermittentJ45.20J45.21J45.22 Mild persistentJ45.30J45.31J45.32 Moderate persistentJ45.40J45.41J45.42 Severe persistentJ45.50J45.51J45.52 UnspecifiedJ45.909J45.901J45.902

Respiratory Problems SinusitisAcuteRecurrentChronic MaxillaryJ01.00J01.01J32.0 FrontalJ01.10J01.11J32.1 EthmoidalJ01.20J01.21J32.2 SphenoidalJ01.20J01.31J32.3 PansinusitisJ01.40J01.41J32.4 OtherJ01.80J01.81J32.8 UnspecifiedJ01.90J01.91J , Thomas J. Weida, M.D.25 Other: medical record detail for which a specific code does not exist Unspecified: information in the medical record is insufficient to assign a more specific code

Pneumonia Pneumonia, unspecified organismJ18.9 Additional clinical findings, more specific: Bronchopneumonia, unspecified organismJ18.0 Lobar pneumonia, unspecified organismJ18.1 Hypostatic pneumonia, unspecified org.J18.2 Other pneumonia, unspecified organismJ18.8 Positive cultures: lots more codesJ , Thomas J. Weida, M.D.26

GI issues  If you can’t make a diagnosis, need to code signs and symptoms  GI signs and symptoms: R10-R19  No combination codes so must code each symptom separately. 2015, Thomas J. Weida, M.D.27

Abdominal and Pelvic Pain PainTender- ness Rebound tender Swelling mass Rigidity RUQR10.11R10.811R10.821R19.01R10.31 LUQR10.12R10.812R10.822R19.02R19.32 RLQR10.31R10.813R10.823R10.03R19.33 LLQR10.32R10.814R10.824R10.04R19.34 PeriumbilicalR10.33R10.815R10.825R10.05R19.35 EpigastricR10.13R10.816R10.826R10.06R19.36 GeneralizedR10.84R10.817R10.826R10.07R , Thomas J. Weida, M.D.28 If you can’t make a diagnosis, need to code signs and symptoms

Sprains, Strains and Pains  Highly Detailed  E.g. 12 codes for superficial finger abrasion: each finger, unspecified thumb and unspecified finger.  Each finger would be coded separately  Most will use all 7 characters 2015, Thomas J. Weida, M.D.29

Sprains, Strains, and Pains  7 th Character  “A,” initial encounter, patient is receiving active (think change) treatment, initial or new physician (i.e. multiple debridements vs. Fx check up)  “D,” subsequent encounter, routine care during the healing or recovery phase  “S,” sequelae, complications or conditions that arise as a direct result of an injury (e.g. chronic back pain following an accident) 2015, Thomas J. Weida, M.D.30

Documentation Examples: Alzheimer’s disease  Early onset (G30.0)  Late onset (G30.1)  Delirium (F05)  Dementia (F02.80)  Dementia with behavioral disturbances (F02.81)  Senile dementia (F03)  Senile degeneration of the brain NEC (G31.1) 2015, Thomas J. Weida, M.D.31

Essential Hypertension - I10  I10 – Essential (primary) hypertension  No comorbid heart or kidney disease  R03.0 – Elevated blood pressure without a diagnosis of hypertension  However, there are more codes when referring to hypertension with complications, i.e. CHF, chronic renal failure 2015, Thomas J. Weida, M.D.32

Hypertension  9 codes for Primary Hypertension  5 codes for Secondary Hypertension  Reference to benign and malignant hypertension eliminated  Be careful differentiating “I” from 1 in the codes as Hypertension spans from I10 to I15 (no I14). 2015, Thomas J. Weida, M.D.33

Hypertension and Hypertensive Heart Disease - I11  I11.0 – Hypertensive heart disease with heart failure. Must then code type of heart failure  I50.2 Systolic CHF  I50.3 Diastolic CHF  I50.4 Combined systolic and diastolic CHF  I50.9 CHF, Unspecified  I50.1 Left ventricular failure (no EF on chart)  I11.9 – Hypertensive heart disease without heart failure 2015, Thomas J. Weida, M.D.34 For these need 5 th digit specifying acuity 0 – Unspecified 1 – Acute 2 – Chronic 3 – Acute on Chronic

Hypertension and Chronic Kidney Disease – I12  If CKD first, use secondary HTN codes  I12.0 – Hypertensive CKD with stage 5 CKD or end-stage renal disease  I12.9 – Hypertensive CKD with stage 1-4 CKD or unspecified CKD 2015, Thomas J. Weida, M.D.35

The Trifecta: Hypertension, Hypertensive Heart Disease (HHD) and Chronic Kidney Disease – I13  I13.0 – HHD and CKD with CHF with Stage 1-4 CKD, or unspecified CKD  I13.10 – HHD and CKD without CHF with Stage 1-4 CKD or unspecified CKD  I13.11 – HHD and CKD without CHF with Stage 5 CKD or end- stage renal disease  I13.2 – HHD and CKD with CHF and with Stage 5 CKD or end- stage renal disease 2015, Thomas J. Weida, M.D.36

We’re not done yet. Don’t forget Tobacco Use – the F codes  F17 – Nicotine dependence  F17.20 Unspecified  F17.21 Cigarettes  F17.22 Chewing tobacco  F17.29 Other tobacco product 2015, Thomas J. Weida, M.D.37 But if patient is “Not dependent” on tobacco use, then code Z72.0 would apply

Secondary Hypertension - I15  I15.0 – Renovascular hypertension  I15.1 – HTN secondary to other renal disorders  I15.2 – HTN secondary to endocrine disorders  I15.8 – Other secondary HTN  I15.9 – Secondary HTN, unspecified 2015, Thomas J. Weida, M.D.38

Earring Removal  Procedure: Incised pinna to remove retained earring backs.  ICD-10 coded as superficial foreign bodies: S00.451A (right ear) or S00.452A (left ear).  CPT coded as simple incision or 10121, complicated. If no incision, then part of E&M

Immunizations during Well Child Exam  Code Z23 in addition to the code for a well child exam, however the routine childhood exam would be listed first.

Additional Critical Codes to Remember  Dizziness R42  - hysterical F44.89  - psychogenic F45.8  Fatigue R53.83  - chronic R53.82  Mental Cruelty X , Thomas J. Weida, M.D.41

Critical Codes to Remember  Discord (with)  - boss Z56.4  - classmates Z55.4  - counselor Z64.4  - employer Z56.4  - family Z63.8  - fellow employees Z56.4  - in-laws Z63.1  - landlord Z59.2  - lodgers Z59.2  - neighbors Z59.2  - probation officer Z64.4  - social worker Z64.4  - teachers Z55.4  - workmates Z , Thomas J. Weida, M.D. Discord with ICD-10 XXX.XXXX This is the only condition for which there quite possibly is no code

2015, Thomas J. Weida, M.D. Contact with Venomous Caterpillar X58

2015, Thomas J. Weida, M.D. Intelicode.com

Intelicode.com 2015, Thomas J. Weida, M.D.

Intelicode.com

2015, Thomas J. Weida, M.D. Intelicode.com

2015, Thomas J. Weida, M.D. Intelicode.com

Burn due to water-skis on fire, initial encounter 2015, Thomas J. Weida, M.D.

Burn due to water-skis on fire, subsequent encounter: V91.07XD Drowning and submersion due to falling or jumping from burning water-skis, initial encounter: V90.27XA 2015, Thomas J. Weida, M.D.

Intelicode.com

2015, Thomas J. Weida, M.D. CODE BLUE There are more than 155,000 codes in the new ICD-10 set. Lest one doubts the specificity encompassed in that vast trove of categorization, consider this calamitous day at sea. V93.32xA — Fall on bard fishing boat W16.722A — Jumping or diving from boat striking bottom causing other injury W56.01xA — Bitten by dolphin W56.02xA — Struck by dolphin W56.09xA — Other contact with dolphin W56.09xD — Other contact with dolphin, subsequent encounter W56.09xS — Other contact with dolphin, sequela W56.11xA — Bitten by sea lion W56.21xA — Bitten by orca W56.31xA — Bitten by other marine animals

W59.21xA 2015, Thomas J. Weida, M.D. W59.21 xA W59.22 xS

2015, Thomas J. Weida, M.D. Intelicode.com

R46.1: Bizarre Personal Appearance It’s a tie!

W61.01XA: Bitten by parrot, initial encounter Arrrgh!

W53.29XS: Other contact with squirrel, sequela And yes, that must have been some squirrel, bless his heart. If this doesn’t qualify for sequela, nothing will

Hair Causing External Constriction, Initial Visit: W49.01XA

Contact with glass, undetermined intent, initial encounter: Y28.0XXA

Hurt at the opera: Y , Thomas J. Weida, M.D. It’s not over until the Soprano sings.

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