Getting Ready for ICD-10 ICD-10-CM Coding Conventions Mary Gregory RHIT,CCS,CPC, CPC-I, CCS MAS Coding Solutions, LTD www.mascodingsolutions.com

Disclaimer MAS (Medical Administrative Solutions) makes no representation or guarantee with respect to the contents here and specifically disclaims any implied guarantee of suitability for any specific purpose. MAS has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of the workshop material, including but not limited to any loss of revenue, interruption of service, loss of business or indirect damage resulting from the use of this information. This information is current as of December 2011

Objectives Review ICD-10 format and structure Review of ICD-10 coding and conventions Review PCS format and structure Review PCS root operations Review of ICD-10-CM Applications

ICD-10-CM History and Future of ICD-10-CM The ICD-10-CM classification system was developed by the National Center for Health Statistics (NCHS) as a clinical modification to the ICD-10 system developed by the World Health Organization (WHO), primarily as unique system for use in the United States for morbidity and mortality reporting.

ICD-10-CM These revisions to ICD-10-CM have included: Information relevant to ambulatory and managed care encounters Expanded injury codes Creation of combination diagnosis/symptom codes to reduce the number of codes needed to fully describe a condition The addition of sixth and seventh character subclassifications Incorporation of common 4th and 5th digit subclassifications Classifications specific to laterality Classification refinement for increased data granularity

Alphabetic Index and Tabular List ICD-10-CM is divided into the Index and the Tabular List Index an Alphabetical list of terms and their corresponding code Divided into two part Index to Diseases and Injury Neoplasm Table Table of Drugs and Chemicals Index to External Causes of Injury Tabular List-a chronological list of codes divided into chapters based on body system or condition

Alphabetic Index

Format and Structure Tabular List Categories Subcategories Codes 3 digit character Characters (maybe a letter or a number) Equivalent to a code when not further subdivided Subcategories Either 4 or 5 character May be a letter or a number Codes May be 4,5,6 or 7 characters The final level of a subdivision is a code

Alphabetic Index Alphabetic Index to Diseases The Alphabetic Index to Diseases is arranged in alphabetic order by disease, by specific illness, injury, eponym, abbreviation, or other descriptive diagnostic term. The index also lists diagnostic terms for other reasons for encounter with health care professionals.

Alphabetic Index Index to External Causes The Alphabetic Index to External Causes of injuries is arranged in alphabetic order by main term indicating the event.

ICD-10-CM Tabular List of Diseases ICD-10-CM codes and descriptors are arranged numerically within the Tabular List of Diseases within 21 separate chapters according to body system or nature of injury and disease Chapters 20 External Causes of Morbidity and 21 Factors Influencing Health Status and Contact with Health Services include chapter-specific guidelines. Classifications which were previously considered supplemental to ICD-9-CM were deleted or moved into the appropriate chapter.

Placeholder Placeholder: The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a 5th character placeholder at certain 6 character codes to allow for future expansion. An example of this is at the Poisoning, Adverse Effect and Under dosing codes, categories T36-T50. Where a placeholder exists, the X must be used in order for the code to be considered a valid code

Example of 5th Character Placeholder

7th Character 7th Character: Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is less than 7th a placeholder X must be used to fill in the empty characters.

etiology anatomic site, severity 7th Character Format ICD-10-CM Code Format M 8 8 X A etiology anatomic site, severity extension category

Abbreviations Index abbreviations: NEC “Not elsewhere classifiable” In the index this abbreviation represents “other specified” when a specific code is not available for a condition the Index directs the coder to the “other specified” code in the Tabular. Tabular abbreviations: In the Tabular this abbreviation represents “other specified”. When a specific code is not available for a condition the Tabular includes and NEC entry under code to identify the code as the “other specified” code.

NEC-Index

NEC-Tabular List

Punctuation [ ] Brackets are used in the tabular list to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Index to identify manifestation codes ( ) Parentheses are used in both the Index and Tabular to enclose supplementary words that maybe present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. These are referred to as nonessential modifiers.

Punctuation : Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

Other Guidelines And Other and unspecified codes When the term “and” is used in a narrative statement it represent and/or Other and unspecified codes “Other” codes These codes are for use when the information in the medical record provides detail for which a specific code does not exist. Index entries with NEC in the line designate “other” codes in the Tabular

Other Guidelines “With” The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetic order. “See” and “See Also” See instruction following a main term in the Index indicates that another term should be referenced. It is necessary to to the main term referenced with the “see” note to locate the correct code.

Other Guidelines “See Also” This instruction following a main term in the index instructs that there is another main term may also be referenced that may provide additional index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code.

Other Guidelines “Code also note” A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. Default codes A code listed next to a main term in the ICD-10-CM Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition.

Other Guidelines “Unspecified” codes Codes (usually a code with a 4th digit 9 or 5th digit 0 for diagnosis codes) titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” may represent both other and unspecified.

Inclusion Notes This note appears immediately under a three-digit code title to further define, or give examples of, the content of the category. A list of terms included under some codes. These terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Index may also be assigned to a code.

Exclusion Notes ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other.

Excludes Note 1 Pure exclude note. It means “NOTE CODED HERE!”. An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the Exclude 1 note. An Exclude 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Excludes 2 A type 2 excludes note represents “Not included here” . An excludes 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Etiology/manifestation convention Code first Use additonal code In disease classified elsewhere

Etiology/manifestation convention Certain conditions have both an underlying etiology and multiple body system manifestations due the underlying etiology. When this occurs ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes “etiology followed by manifestation.

Etiology/manifestation convention In disease classified elsewhere

Etiology/manifestation convention

Signs and symptoms Codes that describes symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM , Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0-R99) contains many, but not all codes for symptoms.

Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Conditions that are not an integral part of a disease process Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. Ld b

Lets Talk What are some of the challenges with combination coding? Loss of potential Major CC or CC Poor documentation of relationship by the providing physician Diabetes with autonomic neuropathy E11.43

Lets Talk What are some of the challenges? Insufficient documentation of the relationship between the neoplasm and the anemia The cause of the anemia is not always identified Insufficient documentation of conditions related to the neoplasm Sepsis versus Urosepsis Sepsis criteria must be continue to be met

Lets Talk What are some of the challenges? Loss of MCC/CC Insufficient documentation of the relationship between the condition and the DM Insufficient documentation of what is the cause of the secondary diabetes Diabetes controlled or uncontrolled is not a factor

Lets Talk What are some of the challenges? Insufficient documentation to determine when the pain is due to neoplasm Poor documentation of postoperative pain No potential loss of CCs Coding affect revenue and/or compliance

Case Scenario The following diagnoses are listed: Diseases of Musculoskeletal System and Connective Tissue The following diagnoses are listed: Traumatic stress fracture of the right lower tibia Traumatic stress fracture right metatarsal. Code(s): __________________________________ M84.361A Stress Fracture, right tibia M84.374A Stress Fracture, right metatarsal

Case Scenario Answer: N18.3 Disease, kidney (functional) (pelvis), Diseases of Genitourinary System Answer: N18.3 Disease, kidney (functional) (pelvis), chronic, stage III. Use additional code to identify kidney transplant status, if applicable. Z94.0 Status (post), transplant – see Transplant, Kidney E89.0 Hypothyroidism (acquired), postsurgical Z85.840 History, personal (of), malignant neoplasm (of), thyroid Rationale: The coding guidelines state that the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney Transplant status.

Lets Talk What are some of the challenges? Insufficient documentation of the relationship between the sign/symptoms and the condition Lack of consistency in knowing what signs/symptoms are part of a disease process

Welcome to ICD-10-PCS

ICD-10-PCS ICD-10 Procedure Coding System (ICD-10-PCS) The development of ICD-10-PCS had as its goal the incorporation of four major attributes: Completeness There should be a unique code for all substantially different procedures. In Volume 3 of ICD-9-CM, procedures on different body parts, with different approaches, or of different types are sometimes assigned to same code. Expandability As new procedures are developed, the structure of ICD-10-PCS should allow them to be easily incorporated as unique codes

ICD-10-PCS Multiaxial ICD-10-PCS codes should consist of independent characters, with each individual axis retaining its meaning across broad ranges of codes to the extent possible. Standard Terminology ICD-10-PCS should include definitions of the terminology used. While the meaning of specific words varies in common usage. If these four objectives are met, then ICD-10-PCS should enhance the ability of health information coders to construct accurate codes with minimal effort.

ICD-10-PCS General Development Principles Diagnostic Information is Not included in Procedure Description When procedures are performed for specific diseases or disorders, the disease or disorder is not contained in the procedure code. There are no codes for procedures exclusive to aneurysms, cleft lip, strictures, neoplasms, hernias, etc. The diagnosis codes, not the procedure codes, specify the disease or disorder.

ICD-10-PCS Not Otherwise Specified (NOS) Options are Restricted ICD-9-CM often provides a “not otherwise specified” code option. Certain NOS options made available in ICD-10-PCS are restricted to the uses laid out in the ICD-10-PCS draft guidelines. A minimal level of specificity is required for each component of the procedure.

ICD-10-PCS General Development Principles Limited Use of Note Elsewhere Classified (NEC) Option All significant components of a procedure are classified in ICD-10-PCS, there is generally no need for an NEC code option. Limited NEC options are incorporated into ICD-10-PCS. Level of Specificity ICD-10-PCS has seven character alphanumeric code structure. The ten digits 0-9 and 24 letters A-H,J-N and P-Z may be used in each character. Letters O and I are not used in order to avoid confusion with the digits 0 and 1.

PCS-Index It is not possible to construct a procedure code from the alphabetic index. The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code.

PCS-Index The ICD-10-PCS Tables and the definitions that accompany them, the Body Part Key, and the draft guidelines contain the complete information for correct coding. While the index contains a hierarchical lookup for finding a table, and supplemental procedure terms that refer the user to the corresponding root operation options, the index does not contain exclusive coding instruction unavailable elsewhere. The user is not required to consult the index first before proceeding to the tables to complete the code. The user may choose a valid code directly from the tables.

PCS-Index the index does not contain exclusive coding instruction unavailable elsewhere. The user is not required to consult the index first before proceeding to the tables to complete the code. The user may choose a valid code directly from the tables. All seven characters must contain valid values to be a valid procedure code. If the documentation is incomplete for coding purposes, the physician should be queried for the necessary information.

General Information PCS The columns in the Tables contain the values for characters four through seven. The rows delineate the valid combinations of values. Any combination of values not contained in a single row of the Tables is invalid. “And,” when used in a code description, means “and/or.” Example: Lower Arm and Wrist Muscle means lower arm and/or wrist muscle.

ICD-10 PCS ICD-10-PCS Format The ICD-10-PCS is made up of three separate parts: Tables Index List of Codes The Index allows codes to be located by an alphabetic lookup. The index entry refers to a specific location in the Tables. The Tables must be used in order to construct a complete and valid code. The list of Codes provides a comprehensive listing of all valid codes with a complete text description accompanying each code.

ICD-10 PCS The root operation is specified in the third character. In the medical and surgical section there are 31 different root operation values. The root operation identifies the objective of the procedure. Each root operation has a precise definition. The body part is specified in the fourth character. The body part indicates the specific part of the body system on which the procedure was performed Tubular body parts are defined in ICD-10-PCS as those hollow body parts that provide a route of passage for solids, liquids, or gases.

ICD-10 PCS Approach: The technique used to reach the site of the procedure is specified in the fifth character. There are seven different approaches Access Location Method Type of instrumentation External Approaches Device Qualifier

ICD-10 PCS General Development Principles Procedures are divided into sections that identify the general type of procedure (e.g., medical and surgical, obstetrics, imaging). The first character of the procedure code always specifies the section. The sections are shown below. Medical and Surgical 1 Obstetrics 2 Placement 3 Administration 4 Measurement and Monitoring 5 Extracorporeal Assistance and Performance 6 Extracorporeal Therapies 7 Osteopathic

ICD-10 PCS General Development Principles 8 Other Procedure 9 Chiropractic B Imaging C Nuclear Medicine D Radiation Oncology F Physical Rehabilitation and Diagnostic Audiology G Mental Health H Substance Abuse Treatment The second through seventh characters mean the same thing within each section, but may mean different things in other sections. In all section, the third character specifies, the general type of procedure performed.

ICD-10 PCS Obstetrics Obstetrics Section The seven characters in the obstetrics section have the same meaning as in the medical and surgical section: Character 1= Section Character 2= Body System Character 3= Root Operation Character 4= Body Part Character 5= Approach Character 6= Device Character 7= Qualifier

ICD-10 PCS The obstertics section includes procedures performed on the products of conception only; procedures on the pregnant female are coded in the medical and surgical section. The fifth character specifies approaches as defined in the medical and surgical section. The sixth character is used for devices such as fetal monitoring electrodes.

Coding Procedures in the Medical and Surgical Section – Section 0 Character 1 Section 2 Body System 3 Root Operation 4 Body Part 5 Approach 6 Device 7 Qualifier Character 1 refers to the broad procedure category where the code is found (0) for Medical and Surgical Character 2 defines the body system or general physiological system or anatomical region. Character 3 defines the root operation, or the objective of the procedure. Character 4 defines the body part or anatomical site where the procedure was performed. Character 5 defines the approach, or the technique used to reach the procedure site. Character 6 defines the device (if any) left in place at the end of the procedure. Character defines qualifier for the code.

What Happen To? Biopsy Right liver lobe needle biopsy Excision, diagnostic Site Approach Right liver lobe needle biopsy Excision lesion right lobe liver 0FB13ZX OFB10ZZ

What Happen To? Colonoscopy, sigmoidoscopy, bronchoscopy etc Colonoscopy with and without biopsy 0DJ08ZZ 0DBE8ZX Bronchoscopy right lower lobe with and without biopsy (right lower lobe) 0BJK8ZZ OBBF8ZX

What Happen to? Excisional Debridement Excisional debridement of a 15x20cm necrotic tissues left thigh including subcutaneous tissues it was removed using a number 2 blade. OHBJXZZ OJBM0ZZ

What Happen To? Percutaneous thrombectomy of left artery and venous access using Angio-jet? (brachial vein and axillary artery 05CA3ZZ 03C36ZZ

What Happen To? Left total hip replacement with metal-on-metal 0SR90J6 Right total hip replacement ORIF-Left distal femur 0QSC04Z

What Happen To? Spontaneous Vaginal Delivery Repeat C-Section left lower uterine Primary C-Section right lower uterine 10E0XZZ 10D00Z1

Wrap-UP Brief review of ICD-10 and PCS Alleviated some of the fear of ICD-10 and PCS “This to shall pass”

References ICD-10-CM 2011 Edition Official Guidelines for Coding and Reporting (Draft 2011) Official Coding Guidelines PCS

Any Questions