Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM Coding Chapter 6B
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification –Developed in the United States –Used to classify morbidity data from inpatient and outpatient records
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Classification System –Developed in the United States –Used to classify procedures from inpatient records only
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-9-CM Legacy Coding System Effective October 1, 2013, when ICD-10-CM and ICD-10-PCS are implemented, the ICD-9-CM will become a legacy coding system.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Transition to ICD-10-CM/PCS © Cengage Learning 2013
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Transition to ICD-10-CM/PCS (cont.) © Cengage Learning 2013
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Transition to ICD-10-CM/PCS (cont.) © Cengage Learning 2013
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Mandatory Reporting of ICD-10-CM/PCS Codes Effective October 1, 2013, ICD-10-CM will be used for all diagnosis coding and ICD-10-PCS will be used for inpatient hospital procedure coding.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. General Equivalency Mappings These are translation crosswalks used to roughly identify ICD-10-CM codes and their ICD-9-CM equivalent codes.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Purpose of Reporting ICD-10-CM Codes Medical necessity –Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury Reporting a ICD-10-CM justifies the procedure codes reported.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM Index to Diseases and Injuries Alphabetic listing of terms that include –Specific illnesses –Injuries –Eponyms –Abbreviations –Other descriptive diagnostic terms
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM Index The index of ICD-10-CM contains – Index to Diseases and Injuries Table of Neoplasms Table of Drugs and Chemicals –Index to External Causes Main terms, subterms, and qualifiers are used to locate codes in the index.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Index to Diseases Main terms –Printed in boldface type and are followed by the code number Subterms (essential modifiers) –Qualify the main term by listing alternate sites, etiology, or clinical status Qualifiers –Supplementary terms that modify subterms
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM Coding Conventions Format and typeface Eponyms and abbreviations Punctuation Tables Notes, excludes, and inclusion Etiology and manifestation rules “And”, “Due to”, “With” Cross references
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Neoplasm Table Neoplasms –New growths or tumors, where cell reproduction is out of control. –Provider should specify whether the tumor is benign or malignant. –Neoplasms should be coded from the pathology report.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Neoplasm Table Indexed by anatomic site and contains four cellular classifications –Malignant Primary Secondary Carcinoma in situ –Benign –Uncertain behavior –Unspecified
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Neoplasm Table Primary malignancy –Original tumor site –All malignant tumors are considered primary Unless otherwise documented as metastatic or secondary
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Neoplasm Table (cont.) Primary malignancy –Malignancy is coded as the primary site if the diagnostic statement documents Metastatic from a site Spread from a site Primary neoplasm of a site Malignancy for which no specific classification is documented Recurrent (repeating) tumor
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Neoplasm Table (cont.) Secondary malignancy –Tumor has spread to a secondary site. Either adjacent to the primary site or to a distant area of the body
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Secondary Malignancies Metastatic and show that a primary cancer has spread to another area.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Secondary Malignancies (cont.) Cancer described as metastatic from a site is primary of that site. –Assign code to the primary neoplasm. –Assign second code to the secondary neoplasm of the specified site or unspecified site.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Secondary Malignancies (cont.) Cancer described as metastatic to a site is considered secondary of that site. –Assign one code to the secondary site and a second code to the specified primary site or unspecified site.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Secondary Malignancies (cont.) When anatomic sites are recognized as metastatic –Assign secondary neoplasm code(s) to those sites. –Assign unspecified site code to the main malignant neoplasm.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Secondary Malignancies (cont.) If the diagnostic statement does not specify whether the neoplasm site is primary or secondary –Code the site as primary unless the documented site is one of the following: bone, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum, or spinal cord.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Anatomic Site Not Documented If the cancer diagnosis does not contain documentation of the anatomic site but the term metastatic is documented, then assign codes for “unspecified site” for both the primary and secondary sites.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Primary Malignancy Site No Longer Present Do not assign the code for primary unspecified site. Instead, classify the previous primary site by assigning the appropriate code from category Z85, “Personal history of malignant neoplasm.”
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Contiguous or Overlapping Sites Contiguous sites (or overlapping sites) occur when the origin of the tumor (primary site) involves two adjacent sites. Neoplasms with overlapping site boundaries are classified to the fourth-digit subcategory.8, “Other.”
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Re-excision of Tumor A surgeon, when performing a second excision to widen the margins of the original tumor site –Ensures that all tumor cells have been removed. –Uses the diagnostic statement found in the report of the original excision to code the reason for the re-excision.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Coding Tip Read notes that apply to the condition you are coding. Never assign a code directly from the table or Index to Diseases. Be certain codes represent the current status of the neoplasm.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Coding Tip Assign a neoplasm code –If a tumor has been excised and the patient is still undergoing radiation or chemotherapy Assign a Z code –If a tumor is not present –If a patient is not receiving treatment but is returning for follow-ups
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Coding Tip In a pathology report –Classification stated on a pathology report overrides morphology classification in the Index to Diseases.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Table of Drugs and Chemicals Alphabetic index of medicinal, chemical, and biological substances that result in poisonings, adverse effects, and underdosing.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Table of Drugs and Chemicals Six columns in the table –Poisoning: Accidental –Poisoning: Intentional Self-harm –Poisoning: Assault –Poisoning: Undetermined –Adverse effects –Underdosing
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Table of Drugs and Chemicals Codes in categories T36 to T65 are combination codes that include the substance related to the adverse effect, poisoning, toxic effects, and underdosing, as well as the external cause.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Official Guidelines for Coding The occurrence of drug toxicity is classified as Adverse effects Poisoning Underdosing Toxic effects
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Index to External Causes These are arranged in alphabetical order, indicating the main event that caused the injury. These codes are secondary codes.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM Tabular List Chronological list of codes contained in the 21 chapters Based on body system or condition
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Tabular List Major topic headings, also called code block –Printed in bold uppercase letters and followed by codes in parentheses
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Tabular List Categories –Major topics are divided into three-character categories. Subcategories –These contain either four or five characters. Codes may contain three, four, five, six, or seven characters.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Placeholder character ICD-10-CM uses the character “x” as a placeholder. When a placeholder exists, the x must be entered in order for the code to be considered valid.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM External Cause Codes Injury, poisoning, and certain other consequences of external causes of morbidity are incorporated in ICD-10-CM in – Chapter 19 – S and T codes – Chapter 20 – V-Y codes
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM Health Status and Contact with Health Services Codes Factors influencing health status and contact with health services are found in Chapter 21 of the ICD-10-CM (Z codes). These codes are always reported as diagnosis codes.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Morphology of Neoplasm Codes Effective October 1, 2013, provider offices will report morphology codes. Morphology indicates the tissue type of a neoplasm.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Official Guidelines for Coding and Reporting CMS and NCHS prepare the ICD-10-CM Official Guidelines for Coding and Reporting.
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ICD-10-CM Guidelines Sections Section I: Conventions, general coding guidelines, and chapter-specific guidelines Section II: Selection of principal diagnosis Section III: Reporting additional diagnosis Section IV: Diagnostic coding and reporting guidelines for outpatient services Appendix I: Present on admission reporting guidelines
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Guidelines for Outpatient Services Selection of first-listed diagnosis ICD-10-CM Tabular List of Diseases Accurate reporting of ICD-10-CM diagnosis codes Codes that describe signs and symptoms Encounters for circumstances other than a disease or injury (Z codes)
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Guidelines for Outpatient Services (cont.) Level of detail in coding ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit Uncertain diagnosis Chronic diseases Code all documented conditions that coexist Patients receiving diagnostic services only
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Guidelines for Outpatient Services (cont.) Patients receiving therapeutic services only Patients receiving preoperative evaluations only Ambulatory surgery or outpatient surgery Routine outpatient prenatal visits
Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Guidelines for Outpatient Services (cont.) Encounters for general medical examinations with abnormal findings Encounters for routine health screenings