Nancy Troutt, RHIA, CPC, CPC-I – Provider Coding Consultant – Blue Cross and Blue Shield of Alabama

To have a better understanding of documentation and coding guidelines. To have a better understanding of International Classification of Diseases, Tenth Edition (ICD-10). 2

Importance of: -Good Documentation -Accurate Coding Blue Cross and Blue Shield of Alabama’s Role for Smooth Transition ICD-10: Differences and 7 th Characters ICD-10: 21 Classifications ICD-10: New Chapter-Specific Features 3

ICD-9* and ICD-10 Use codes describing symptoms, conditions, problems, complaints, or other reasons for visits *International Classification of Diseases, Ninth Edition (ICD-9) 4

Accurate documentation and coding Difference in Clinical and Coding guidelines The coder/biller cannot assume Information on claim and documentation should match 5

Payors Compare Documentation with Claims! 6

Diagnosis on claim and documentation do not match Codes not “linked” in documentation or claims Manifestations not coded 7

Documentation should show: Reason for visit Updated problem lists Detailed chief complaint, should “stand alone” Signature/Credentials 8

Providers should: Include relevant documentation HPI, MDM, exam documented by provider 9

Reason Highest level specificity Chronic conditions Coexisting conditions 10

Reasons for correct coding/documentation: Required Future payments based on severity Medical necessity 11

Codes are invalid if: Not coded to full number of digits This applies to both ICD-9 and ICD-10 12

Same Meaning in ICD-9 and ICD-10 NEC – “not elsewhere classifiable” NOS – “not otherwise specified” 13

List first the chief complaint (reason for visit) Diagnoses may be a symptom until diagnosis is confirmed by the physician 14

Do not – code “rule outs”, probable, suspect Code highest degree of certainty Code signs and symptoms if diagnosis is not yet established 15

Additional signs and symptoms should be coded that may not be associated with a disease process Chronic diseases should be coded as many times as patient receives treatment. 16

Code all documented co-existing conditions Do not code conditions that no longer exist Exception is “history of” codes 17

All HIPAA-covered entities will adopt ICD-10 by October 1, 2015 Blue Cross will not process claims with ICD-10 codes before that date ICD-9 will no longer be accepted for dos after Sept. 30,

GEMS (General Equivalency Mappings) Blue Cross will use GEMS GEMS not to be used exclusively 19

To access the mapping tool on Blue Cross website, Alabamablue.com/providers. Log into ProviderAccess. Select “Provider Functions.” Look for “ICD-10 Diagnosis Code Mapping Tool” under Claim Information. 20

Submission of claims to verify diagnosis code information: Contact Your EDI Services Representative

October 1, 2015

ICD-9 Has 3-5 characters, always at least 3 First is numeric, except E and V codes ICD-10 Has 3-7 characters, always at least 3 First character always alpha, all letters used except U In both, the decimal is after 3 rd character, and alpha characters are not case sensitive 23

XXXX Category. Etiology, anatomic site, severity Etiology, anatomic site, severity Added 7 th character for obstetrics, injuries, and external causes of injury XXX 24 AM SS xxAA Additional Characters Alpha (Except U) Alpha 2 Numeric 3-7 Numeric or Alpha 2 Numeric 3-7 Numeric or Alpha 3–7 Characters

Seventh Characters: Injury, external cause and obstetrics Alpha or numeric, at end in the 7 th position Has different meanings Codes requiring 7 th digit, leaving off makes invalid 25

Added seventh-characters for episode of care Examples: M80.051A S06.0X1A S52.132B 26

Coding and Use of Seventh Characters In Injury and External Cause, the 7 th character identifies: Initial-for patient receiving active treatment Subsequent -for after the patient has received active treatment Sequela - for complications arise as a result of a condition 27

28 A – G A00 – B99Certain Infectious and Parasitic Diseases C00 – D49Neoplasms D50 – D89 Diseases of Blood and Blood forming organs and certain disorders involving the immune mechanism E00 – E89Endocrine, nutritional and metabolic disorders F01 – F99Mental, Behavioral and Neurodevelopment Disorders G00 – G99Disease of Nervous System

29 H – L H00 – H59Diseases of the Eye and Adnexa H60 – H95Diseases of the Ear and Mastoid Process I00 – I99Diseases of the Circulatory System J00 – J99Diseases of the Respiratory System K00 – K95Diseases of the Digestive System L00 – L99Diseases of the Skin and Subcutaneous Tissue

30 M – R M00 – M99 Diseases of the Musculoskeletal System and Connective Tissue N00 – N99Diseases of the Genitourinary System O00 – O9APregnancy, Childbirth and the Puerperium Period P00 – P96Certain Conditions Originating in the Perinatal Period Q00 – Q99 Congenital Malformations, Deformations and Chromosomal Abnormalities R00 – R99 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, NEC

31 S – Z S00 – T88 Injury, Poisoning and Certain other consequences of External Causes V00 – Y99External Causes of Morbidity Z00 – Z99 Factors Influencing Health Status and Contact with Health Services

Greater level of specificity and clinical detail: Combination Codes of Common Symptoms Diabetes with manifestations will only require one code instead of two. Atherosclerotic heart disease with unstable angina only one code instead of two. 32

Combination codes for poisoning and external causes: Accidental poisoning Adverse effects 33

Laterality Coding guidelines are basically the same in ICD-10 as in ICD-9, except with one additional guideline: laterality Right Left Bilateral 34

Expanded codes Examples: E11.341DM type II with retinopathy and macular edema F14.221Cocaine dependence with intoxication delirium 35

Changes in time frames specific to certain codes Acute MI – “acute” time period change from 8 weeks to 4 weeks in iCD-10 36

Diabetes Mellitus Combination codes in ICD-10 No longer “controlled or uncontrolled” Poorly controlled coded by type with hyperglycemia 37

38 Diabetes Mellitus: 5 Categories E08Diabetes due to underlying condition E09Drug or chemical-induced Diabetes E10Type I Diabetes E11Type II Diabetes E13Other specified Diabetes

39 Long-term (Current) Use of Insulin ICD-9V58.67 ICD-10Z79.4

Patient presents with type II diabetes with diabetic chronic kidney disease, stage IV. She is on insulin and her glucose is documented as uncontrolled. 40ICD-9ICD : Diabetes mellitus with renal manifestations, type II, uncontrolled 585.4: CKD, Stage IV E10.65: Diabetes type II with hyperglycemia E10.22: Diabetes type II with chronic kidney disease N18.4: Chronic kidney disease, stage IV

Acute MI has changed from 8 to 4 weeks acute status Hypertensive heart and Kidney disease; same guidelines: – Link hypertension and heart disease in documentation – Hypertension and chronic kidney disease: can assume linkage 41

42 ICD – benign essential hypertension ICD-10 I10 – essential hypertension

ICD-9ICD I I N

Acute Stroke (CVA) ICD-9: acute cerebral artery occlusion with cerebral infarction ICD-10: I63.9 Cerebral infarction, unspecified “History of”Stroke (CVA) ICD-9: V12.54 ICD-10:Z

External causes are: Health condition due to external cause Mostly used for injuries V, W, X and Y codes Used in 7 th character Not required or mandated 45

General (adult) medical examination code ICD-9V70.0 ICD-10Z00.00w/out abnormal findings Z00.01with abnormal findings 46

Patient is in for his Annual Wellness Visit (AWV) and he also has hypertension and diabetes. 47ICD-9ICD-10 V70.0Routine physical examZ00.01 General medical examination with abnormal findings 401.9Diabetes hypertensionI10Hypertension Diabetes type II, without complications, not stated as uncontrolled E11.9 Type II diabetes, without complications

Z91.19Medical Noncompliance Z91.11Dietary regimen Z91.15Renal Dialysis Z91.14Medication regiment, NEC Z91.14 Underdosing (see also Table of Drugs and chemicals T36-50 with fifth or sixth character 6) Z91.128Intentional NEC Z91.120Due to financial hardship Z91.138Unintentional NEC Z91.130Due to patient’s age-related disability 48

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