CHAPTER © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 4 Diagnostic Coding: ICD-10-CM

Learning Outcomes When you finish this chapter, you will be able to: 4.1 Discuss the purpose of ICD-10-CM. 4.2 Describe the organization of ICD-10-CM. 4.3 Summarize the structure, content, and key conventions of the Alphabetic Index. 4.4 Summarize the structure, content, and key conventions of the Tabular List. 4-2

Learning Outcomes (continued) When you finish this chapter, you will be able to: 4.5Apply the rules for outpatient coding that are provided in the ICD-10-CM Official Guidelines for Coding and Reporting. 4.6 Briefly describe the content of Chapters 1 through 21 of the Tabular List. 4.7 Assign correct ICD-10-CM diagnosis codes. 4.8 Differentiate between ICD-9-CM and ICD-10-CM. 4-3

Key Terms acute Alphabetic Index category chief complaint (cc) chronic code coexisting condition combination code convention default code diagnostic statement 4-4 eponym etiology excludes 1 excludes 2 exclusion notes external cause code first-listed code GEMs ICD-9-CM ICD-10-CM

Key Terms (continued) ICD-10-CM Official Guidelines for Coding and Reporting inclusion notes Index to External Causes laterality main term manifestation NEC (not elsewhere classified) Neoplasm Table nonessential modifier 4-5 NOS (not otherwise specified) placeholder character (x) primary diagnosis principal diagnosis sequelae seventh-character extension subcategory subterm Table of Drugs and Chemicals Tabular List Z code

4.1 ICD-10-CM 4-6 Used to code and classify morbidity data Clinical modification (CM) codes describe conditions and illnesses more precisely than ICD-10 Mandated for diagnoses under HIPAA Electronic Health Care Transactions and Code Sets standard beginning October 1, 2014

4.1 ICD-10-CM (continued) 4-7 Code Makeup – 3-7 character alphanumeric Category has three characters Subcategories have four or five character codes Updates called addenda available on government website

4.2 Organization of ICD-10-CM 4-8 Alphabetic Index – lists diseases and injuries alphabetically with appropriate diagnosis codes Tabular List – lists diagnosis codes in chapters alphanumerically Neoplasm Table – table of code numbers for neoplasms by anatomical site, divided by description Table of Drugs and Chemicals – index of drugs and chemicals from Tabular List Index to External Causes – index of external causes from Tabular List

4.2 Organization of ICD-10-CM (continued) 4-9 Diagnostic statement – physician’s description of the main reason for the patient encounter; begins the process of assigning ICD-10-CM code Conventions – technique providing visual guidance for understanding coding information

4.3 The Alphabetic Index 4-10 Main Terms, Subterms and Nonessential Modifiers –Main term – identifies disease or condition –Default code – listed next to main term –Subterm – word or phrase describing a main term –Etiology – cause or origin of disease or condition –Nonessential modifier – supplementary word or phrase helping to define a code

4.3 The Alphabetic Index (continued) 4-11 Common terms – similar names for conditions Eponyms – name or phrase formed from or based on a person’s name Indention: Turnover lines – indented farther to the right than subterms Cross-references see and see also indicate further information is available Not elsewhere classifiable (NEC) – if disease or condition cannot be placed in any category Not otherwise specified (NOS) – if disease or condition is not completely described in medical record

4.3 The Alphabetic Index (continued) 4-12 Multiple Codes, Connecting Words, and Combination Codes –manifestation – disease’s typical signs, symptoms or secondary process – needs second code indicated by brackets after the term –first-listed code – diagnosis that is the main condition –combination code – single code describing etiology and manifestation(s) of a particular condition

4.4 The Tabular List 4-13 placeholder character (x) - character “x” inserted in a code to fill a blank space seventh-character extension – necessary assignment of a seventh character to a code; often for the sequence of an encounter category – three-character code for classifying disease or condition subcategories - four- or five- character code number

4.4 The Tabular List (continued) 4-14 inclusion notes – entries addressing applicability of certain codes to specified conditions exclusion notes – entries limiting applicability of particular codes to specified conditions –excludes 1 – used when two conditions could not exist together, such as an acquired and a congenital condition; means “not coded here” –excludes 2 – means a particular condition is not included here, but a patient could have both conditions at the same time

4.4 The Tabular List (continued) 4-15 Punctuation –colon (:) – indicates an incomplete term –parentheses ( ) – used around descriptions that do not affect the code –brackets [ ] – used around synonyms, alternative wordings, or explanations –NEC and NOS used with same meanings as in Alphabetic Index etiology/manifestation coding – may include instructions on required use of additional code or to code first the underlying disease Laterality – documents side of the body being classified with the fourth, fifth or sixth characters of a code

4.5 ICD-10-CM Official Guidelines for Coding and Reporting 4-16 ICD-10-CM Official Guidelines for Coding and Reporting – General rules, inpatient (hospital) coding guidance, and outpatient (physician office/clinic) coding guidance from the four cooperating parties (CMS, AHA, AHIMA, NCHS) primary diagnosis – listed and coded first coexisting condition – additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter

4.5 ICD-10-CM Official Guidelines for Coding and Reporting (continued) 4-17 acute – illness or condition with severe symptoms and a short duration chronic – illness or condition with a long duration sequelae – conditions that remain after an acute illness or injury has been treated and resolved

4.5 ICD-10-CM Official Guidelines for Coding and Reporting (continued) 4-18 Code to the highest level of certainty –principal diagnosis – in inpatient coding, the condition established after study to be chiefly responsible for the admission of the patient –If different, postoperative diagnosis would have a higher level of certainty than primary diagnosis Code to the highest level of specificity – coder must be able to distinguish between not mentioned in the documentation or not specified in the code listing

4.6 Overview of ICD-10-CM Chapters 4-19 A00-B99 – Certain Infectious and Parasitic Diseases C00-D49 – Neoplasms M codes – used by pathologists D50-D89 – Diseases of the Blood and Blood- forming Organs and Certain Disorders involving the Immune Mechanism E00-E89 – Endocrine, Nutritional, and Metabolic Diseases

4.6 Overview of ICD-10-CM Chapters (continued) 4-20 F01-F99 – Mental and Behavioral Disorders G00-G99 – Diseases of the Nervous System H00-H59 – Diseases of the Eye and Adnexa I00-I99 – Diseases of the Circulatory System J00-J99 – Diseases of the Respiratory System K00-K94 – Diseases of the Digestive System L00-L99 – Diseases of the Skin and Subcutaneous Tissue M00-M99 – Diseases of the Musculoskeletal System and Connective Tissues

4.6 Overview of ICD-10-CM Chapters (continued) 4-21 N00-N99 – Diseases of the Genitourinary System (O00-O9A) – Pregnancy, Childbirth, and the Puerperium P00-P96 – Certain Conditions Originating in the Perinatal Period Q00-Q99 – Congenital Malformations, Deformations, and Chromosomal Abnormalities R00-R99 – Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

4.6 Overview of ICD-10-CM Chapters (continued) 4-22 S00-T88 – Injury, Poisoning, and Certain Other Consequences of External Causes V00-Y99 – External Causes of Morbidity –external cause code reports cause of injuries from events such as transportation accidents, falls, and fires and are not used alone or as first-listed codes Z00-Z99 – Factors Influencing Health Status and Contact with Health Services –Z code is abbreviation for codes identifying encounters not due to illness or injury

4.7 Coding Steps 4-23 Step 1: Review complete medical documentation –chief complaint – patient’s reason for seeking care Step 2: Abstract the medical conditions from the visit documentation Step 3: Identify the main term for each condition Step 4: Locate the main term in the Alphabetic Index Step 5: Verify the code in the Tabular List Step 6: Check compliance with any applicable Official Guidelines and list codes in appropriate order

4.8 ICD-10-CM and ICD-9-CM 4-24 ICD-9-CM – previous HIPAA-mandated diagnosis code set ICD-10-CM provides many more categories for disease and other health-related conditions with higher level of specificity possible Codes in ICD-10-CM combine etiology and manifestations, poisoning and external cause, or diagnosis and symptoms

4.8 ICD-10-CM and ICD-9-CM (continued) 4-25 ICD-9-CM had 17 chapters and two supplemental classifications, V codes, and E codes ICD-10-CM has 21 chapters and the order of chapters has changed ICD-9-CM codes were 3-5 characters and ICD- 10-CM codes are 5-7 characters to reach a higher level of specificity GEMs – general equivalence mappings to assist in the transition from ICD-9-CM to ICD-10-CM

Summary