Presented by: Lizeth Flores, RHIT, RAC-CT Anderson Health Information Systems, Inc.
Participants will : Correctly assign ICD-9-CM codes to diagnoses Correctly identify primary / Secondary diagnoses Identify correct sequence of diagnoses for coding assignment Identify difference between ICD-9-CM and ICD-10 Learn ICD-10 transition timeline
Gather statistical data Reporting diagnoses and provides a method for sequencing diagnosis to support billing transactions / reimbursement Ensure compliance with Federal Reporting Standards for diagnoses Provide insight into the types of residents and conditions Health Research
HIPAA Latest revision October 1, 2011
Skilled Nursing Facility (SNF) Inpatient Rehab Facility (IRF) Home Health Agency (HHA) Long Term Acute Care Hospital (LTACH)
Disease and Procedures (Books 1-3) Alphabetical/Tabular (numeric) Index
Both the Alphabetic Index and the Tabular List must be used when locating and assigning a code. Do not rely on just one since this can lead to errors in code assignment and a less specific code selection
Locate each main term and sub term in the alphabetical index, i.e., Chronic Kidney Disease 1. Disease 2. Kidney 3. Chronic Verify the code selected in the Tabular list Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List
Assign 3 digit codes only if there are no four digit codes within the category. There are only 100 codes with only 3 digits Assign 4 digit codes only if there is no fifth digit. Assign 5 digit codes when indicated. Samples – 486, 401.x, 250.xx
Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover. Categories V51-V58 Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.
Chronic Conditions – Conditions that are stable but still require management or treatment. Acute Conditions –acute care codes should only be reported until the condition is resolved. Therapy – Physical, occupational, speech and respiratory therapy.
History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter. A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state. There are two types of history V-codes, personal and family.
Status post upper arm fracture V54.11 History of frequent falls V15.88 Admission for physical therapy following hip fracture V57.1, V54.13
Hemiplegia due to recent CVA Total Hip Replacement Acute UTI treated with Cipro. Dementia Late Effect After Care Acute Condition Chronic Condition
ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT TREATMENT RECEIVED
DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY WHEN CONDITION NO LONGER EXISTS DO NOT ASSIGN PROCEDURE CODES Examples: Fractured forearm 6 years ago, pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics )
“FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admission to the facility and the diagnosis that supports the reimbursement and should be sequenced first.”
Transfer Records History & Physical Progress Notes Admission Orders
Discharge summary Transfer documentation, Surgical reports Consultations Physician Progress notes Lab reports and radiological studies
When two or more inter-related conditions potentially meet the definition of principal diagnosis Either may be sequenced first unless therapy is being provided, the Tabular list or Alphabetic Index indicate otherwise. Inter-related conditions – two or more diagnosis that equally meet the definition of principal diagnosis.
Resident admitted with Pneumonia and UTI – either can be used as the principal diagnosis if the resident is still receiving antibiotic therapy
Fall 3 months ago Chronic kidney disease Above the knee amputation Rt. Leg (10 days ago) with infection still on antibiotics Anemia
NEC – Not Elsewhere Classified NOS – Not Otherwise Specified Codes are used only when neither the diagnostic statement nor a thorough review of the clinical record provides adequate information to permit assignment of a more specific code
The coder must review the titles and inclusions under the three or four digit category to determine if the diagnosis is included in the category; however, the specific diagnosis may not always be listed Example: Spinal Cord Inflammation 323.9
Single codes used to classify two diagnosis or a diagnosis with a manifestation Example: Candidiasis with meningitis
Etiology codes – USE ADDITIONAL CODE Manifestation codes – CODE 1 st Underlying Dx. Codes in parentheses identify conditions that require multiple coding. Also, codes in parentheses CAN NOT be sequenced as PRINCIPAL Dx.
Instructions for conditions that require multiple coding can appear in the Tabular List. “Code also underlying disease”, “Use additional code, if desired, to identify manifestation, as …” “Code also” instructs the coder to: ▪ Code the underlying disease, or etiology first as the primary diagnosis, followed by the code (s) for manifestation (s). ▪ It is mandatory to follow the “code also” instructions to assign both codes.
Anosmia following CVA 438.6, “with”, “with mention of”, or “associated with” – this code can only be used if both conditions are present Kidney Infection … with Calculus 592.0
Indicate proper sequencing for the two codes listed. The code number before the bracket is coded first. The code number inside the brackets is coded second. Codes in brackets in the alphabetic index can NEVER be sequenced as the principal diagnosis.
1.Arthritis, arthritic --- due to or associated with hypothyroidism [713.0]
Examples: Aftercare following kidney transplant V58.44 (aftercare involving organ transplant), V42.0 (Organ/tissue replacement by transplant, kidney) Aftercare following arteriocoronary bypass V58.73 (aftercare following surgery of the circulatory system), V45.81(aortocoronary bypass status) use aftercare codes to provide better detail
“Using Additional Codes” When the instructions say “Use additional code….” the additional code is sequences second. Example UTI due to E.coli [041.4]
Let’s have a look: See 429 section Under Cardiovascular Disease, Unspecified ▪ Excludes: That due to hypertension
The order in which codes are listed is called sequencing. The coder should make every effort to record the codes in a logical sequence that is descriptive of the resident’s condition.
Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNF Examples: MRSA Pneumonia UTI
May have multiple secondary codes List and code conditions related to therapy and services provided Review and update as condition changes – sequence may change over time Billing staff should work with Nursing and Health Information Department to know which diagnoses are current, which is principal, etc.
Order by complexity. Assign the condition with the higher complexity first. (those that require the most resources i.e. wound care vs. hypertension) All conditions present at the time of admission, and that affect the treatment provided and length of stay should be coded.
Residual condition After initial / acute phase of illness
Official coding guidelines state that Category 438 is used for admission and encounter for post acute care following treatment of the CVA in the acute hospital Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying hospital stay and should not be used in SNF
WWhich of the following is a late effect? a. End stage renal disease b. Anosmia following recent CVA c. Diabetic retinopathy d. Paraplegia due to polio
Left hemiplegia secondary to CVA (patient is right handed) Late Effects Cerebrovascular disease With hemiplegia – nondominant side
Codes from categories 041 or 079 can be used as principal diagnosis as long as the nature or site of the infection is not specified or when the Alphabetical index instructs you to do so.
Gastroenteritis due to E.coli MRSA infection of Lt. toe Herpetic septicimia 054.5
Go to alphabetic index Look up Ex: fibroma, upper jaw Find “fibroma” Cross reference “see neoplasm, by site, benign” Turn to neoplasm locate sub term “Jaw / upper” Follow across to Benign Locate code Go to Tabular list for any coding instructions or notes*
Only used when stated as such in Alpha Index Unspecified Behavior – Only used when Neoplasm is not fully described Or not specified as to behavior Or listed in Alphabetic index Ex: Neoplastic Cyst of Tongue Cross reference Alpha Index Under Cyst, neoplastic see neoplasm, by site, unspecified nature
Two codes One for primary (original site) One for each secondary site Code primary before secondary Except when using “V” code for primary site that has been surgically removed
Determine the primary site Turn to Neoplasms Table Ex: Carcinoma of Rectum (154.1) Find Neoplasm, rectum, malignant, primary
Ex: Secondary malignant neoplasm of prostate (198.82) Find Neoplasm, prostate, malignant, secondary Determine the site(s) of metastasis Turn to Neoplasm table Find correct sub term(s) for site Cross over to Malignant and column secondary
Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0) Code primary site first To code the unknown secondary site Refer to Neoplasm table Multiple sites NEC Cross over to column for code (199.0)
Refer to neoplasm table Unknown or Unspecified site Cross over to primary column Sequence after secondary site(s) Ex: abdominal metastasis from unknown origin (198.89, 199.1) Unknown primary would not be used as principle diagnosis in SNF The metastatic site is coded first
Primary site must still be identified if removed, eradicated no longer under treatment Use a personal history V-code, History, site, malignant neoplasm Identify primary site responsible for metastasis but no longer present Secondary site code is sequenced first and then the V-code
Do not use codes from category V10 for secondary metastatic sites removed or not ICD-9-CM does not provide code numbers for “history of secondary neoplasm site
Official coding guidelines for neoplasm apply when using the aftercare following surgery for neoplasm V58.42 Aftercare code V58.42 may be used with either the current neoplasm code or a code from category V10, whichever is applicable
History of breast cancer with metastasis to the lung 197.0, V10.3 Carcinoma of prostate with metastasis to spine 185, Basal cell carcinoma of chest 173.5
Examples: Hypothyroidism Diabetes Metabolic disorders Obesity
Hypothyroidism due to history of thyroid cancer (thyroid removed) 244.0, V10.87 Uncontrolled, Type II Diabetes
There are written instructions in ICD-9-CM coding books for sequencing codes. The underlying Dx (cause/s) coded first, followed by codes for manifestations.
Some Diabetic Conditions Require 2 Codes “Diabetic” or “Due to” ▪ One Code for Cause ▪ One Code for Complication Always sequence cause before complication
Example: Diabetic foot ulcer ▪ Diabetes with other manifestation ▪ 250.8x ▪ Ulcer of lower limb, except decubitus ▪ 707.1x
Diabetic Neuropathy Diabetes with neurological manifestations must be coded first (250.60) The tabular list will guide you to “Use additional code to identify manifestation, as:” Polyneuropathy in diabetes (357.2) The tabular section will tell you that this code is not allowed as a principal Dx and will guide you to code underlying disease, as (Diabetes with complication…)
1. ALZHEIMER’S DEMENTIA 331.0, 2. DIABETIC GLAUCOMA , 365.9
Chronic illnesses that are managed with medication or treatments, such as hypertension, hypothyroidism, diabetes mellitus, atrial fibrillation, assign the appropriate ICD 9 code The chronic condition exists, but is under control by medication
A code from category 410.XX must be assigned if the admission is strictly for rehabilitation within eight weeks of the acute MI. The fifth digit 2 would be used in LTC to designate observation, treatment or evaluation of MI within eight weeks of onset, following the acute phase or in the healing state.
The fifth digit “1” should be used if the acute myocardial infarction occurred at the nursing facility and was the reason for transfer to the hospital or the cause of death. If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction
Unless the diagnosis statement specifies as “benign” or “Malignant” “unspecified” code (401.9) must be assigned
When there is a causal relationship stated as “hypertensive” or “due to hypertension” heart conditions are assigned by Category 402 Hypertensive Heart Disease Arteriosclerotic disease due to hypertension
Let’s Code 1. Chronic hypertensive kidney disease , Deep vein thrombosis patient on Coumadin , V58.61
Let’s Code Aspiration Pneumonia Chronic bronchitis with emphysema
Clarification of clinical terms related to skin ulcers trans/r4som.pdfwww.cms.hhs.gov/manuals/pm trans/r4som.pdf Pressure Ulcer is a synonym for decubitus ulcer – due to prolonged pressure Subcategory 707.0x has fifth digits to identify site New- additional code must be used to identify stage
Non pressure ulcers of lower leg Fifth digits to identify site Multiple coding, code first the underlying dx, such as arteriosclerosis, diabetes, venous hypertension i.e. diabetic ulcer of left fifth toe ,
The most common type of vascular ulcers In Alphabetical index under “ulcer”, the index lists “venous” as a non-essential modifier under the sub term “stasis” that refers to code Under section in the Tabular List you will be instructed to code any associated ulceration from category
Category Codes for wounds are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds
Per ICD-9-CM Official Guidelines for Coding and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission) Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequela For others (V codes) the condition is inherent in code title
Published rules for the use of V codes Addressed the use of V codes in LTC settings Coding clinic Fourth Quarter 2003 Clarified the use of aftercare V codes for all subsequent encounters after the initial treatment for a fracture “for statistical purposes, a facture should only be reported once”
V-codes are assigned to problems that affect the patient’s health but are not in themselves a current illness or injury V-codes can be used to represent status or history. Examples: Status Cardiac Pacemaker V45.01 Status heart valve prosthesis V43.3 History of falls V15.88 History of alcoholism V11.3 ▪ Remember not to use acute care codes when coding aftercare
A resident is admitted for physical therapy following a hip replacement for an inter- trochanteric right hip fracture due to a fall.
Physical therapy: ▪ V57.1 Physical Therapy Intertrochantic right hip fracture due to a fall: ▪ V54.13 Aftercare following traumatic hip fracture Hip replacement: ▪ V54.81 Aftercare following joint replacement ▪ V43.64 Joint replacement, hip
A resident is admitted for P.T. & O.T. following a hip fracture after a fall. The physician indicated that the fracture was due to osteoporosis. The Discharge Summary stated that old compression fractures of the vertebrae due to osteoporosis were present on x-ray.
Physical Therapy and Occupational Therapy ▪ V57.89 Multiple therapies Hip Fracture (due to osteoporosis) ▪ V54.23 Aftercare for continuing treatment of healing pathologic fracture of hip Osteoporosis ▪ Osteoporosis Compression fractures of vertebrae ▪ Pathologic fractures of vertebrae
Admitted for physical therapy, status post total knee replacement due to arthritis 1) Admission – rehabilitation – physical 2 ) Aftercare – following surgery for – joint replacement 3) Replacement – joint – Knee V57.1, V54.81, V43.65
Post hysterectomy for uterine cancer three years ago (no further treatment) History – personal – malignant neoplasm – uterus V10.42
Select the correct Code Fracture of upper arm due to fall, resident wearing a sling, admitted for ADL assistance. V (NO)
For residents admitted to a SNF for care following treatment in the acute hospital for a traumatic fx use the aftercare codes from Subcategory V54.1 Do not code the (acute) fracture Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx.
For statistical purposes, a fracture should only be coded once. If the same fx is coded for all encounters, it makes collection of fracture statistics difficult The V54.1 identifies the site of the fracture and that it is in the healing phases Aftercare for Fractures; Pathologic and Traumatic
The fifth digits identify the specific site of the healing fracture The fifth digit 9 is used for other specified sites If there are several bones that would be classified to the other specified site, only one code is used
DO NOT code V58.43 Aftercare following surgery for injury and trauma (conditions classifiable to ) Exclusion note states “Excludes: aftercare for healing traumatic fracture” Remember to always refer to the tabular list and carefully read the instructions and exclusions.
Pathological fracture is a fracture in a bone due to weakening of the bone structure by disease process such as osteoporosis. For admissions in LTC following a hospital stay for treatment of a pathological fracture assign a code from Subcategory V54.2 Aftercare for healing pathologic fracture A compression fracture of the vertebrae is considered pathologic if it is not caused by trauma
V13.51 personal hx of healed pathologic fx V13.52 personal hx of healed stress fx V15.51 personal hx of healed traumatic fx Note added to subcategory use add’l code to identify personal hx of pathologic (healed) fx (V13.51)
Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65 Do not code the disease condition that was treated with the surgery 2008 will have a change in the tabular list for V58.78 that will exclude it when there is orthopedic aftercare; codes from section V54.01-V54.9 will be used.
Use multiple coding to fully describe the resident’s condition FX hip (traumatic) with joint replacement V54.13, V54.81, V43.64 Do not use V58.43 Aftercare following surgery for injury and trauma-(not for fx) (conditions classifiable to ) see excludes note: (V54.10-V54.19)
Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose Use only one code from Category V57 for an admission If the resident is admitted for multiple therapies, use V57.89
Code also the condition requiring the rehab, such as: Residuals Late effects Aftercare symptoms
The acute dx for which the surgery was preformed is not reported for aftercare encounters or admissions Use other aftercare or symptom codes to provide better detail Note the instructions with each code that identifies the range of conditions that are included in the aftercare code number i.e. aftercare post cataract extraction with lens implant: V58.71, V45.61, V43.1
Implementation date of new, revised and invalid codes October 1, 201
Chart # 1
Chart # 2
Provide a roadmap back to the qualifying stay Paint a clear picture of your patient Pay attention to details Go beyond the code and communicate through documentation
ICD 10 Presented by: Lizeth Flores, RHIT, RAC-CT Anderson Health Information Systems, Inc.
OBJECTIVES Participants will identify: ◦ Dates for New ICD-10 ◦ Documentation support ◦ New terms encounter principal diagnosis re- defined ◦ Some general coding guidelines ◦. 113
FINAL REGULATION January 15, 2009 Final Regulation Released EXCHANGE the ICD-9 for the ICD-10 by October, 1, 2013 – 2014? ICD-10 for billing purposes as far as ability to accept the code known as “5010” is required by October
HIPAA Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA) HIPAA has evolved from HIPAA – 1996, to (HIPAA-II) HITECH which relates to security and breaches And most recently HIPAA Transactions 5010 ICD-10 Code Set 115
WHO IS AFFECTED?? All inpatient and outpatient facility visits as well as freestanding providers and ancillary services “that means all of us really” who provide services and bill for them under Medicare, MediCal and private insurances. Current Procedural Terminology (CPT) is still used for the Physician and some services, but they must have a diagnosis that is ICD-10 Complaint 116
Benefits More specific coding system Reflects medical advancements Standardization, UK implemented in 1995 used worldwide
What do you think? The U.S. is the only industrialized nation that has not yet implemented ICD-10? True What is the date for implementation of ICD-10 10/1/2013 OR 2014? ICD-10-CM has more chapters than ICD-9-CM True ICD10 has 21 chapters while ICD-9-CM only had 17
ICD-9 vs ICD 10 What are the differences? ICD-9 …… 3-5 characters in length Approximately 14,000 codes First digit may be alpha (E or V) or numeric Digits 2-5 are numeric Always at least three digits Decimal placed after the first three characters Limited space for new codes 119
ICD-9-CM DIAGNOSIS CODES -2 Lacks detail Lacks laterality, difficult to analyze, dated, non-specific and does not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries. 120
ICD-10-CM DIAGNOSIS CODES – FORMAT & STRUCTURE 3-7 characters in length Over 69,000 codes Digit 1 is always alpha, digit 2 is always numeric, 3-7 are alpha or numeric Decimal placed after the first 3 characters All letters used except “U” Flexible for adding new codes Very specific Has laterality 121
ICD-10 STRUCTURE Index and Tabular list similar to ICD-9 ICD-10 index larger, Categories, subcategories and codes are contacted in the tabular list. More combined codes i.e. diabetic retinopathy More specificity i.e. Alzheimer’s disease with specific details of early or late onset 122
CONVENTIONS FOR THE ICD- 10-CM General rules for use of the classification independent of the guidelines ◦ Alphabetic Index and Tabular List Alphabetic Index – List of terms and their corresponding code Tabular List – chronological list of codes divided into chapters based on body system/condition 123
CONVENTIONS FOR THE ICD- 10-CM -2 General rules for use of the classification independent of the guidelines ◦ Format and Structure Three character category that has no further subdivision is equivalent to a code Subcategories are either 4 or 5 characters Codes may be 3, 4, 5, 6 or 7 characters 124
CODE FORMAT ICD-10 Code Format 125 ICD-9-CM Code FormatICD-10-CM Code Format
NO MORE V CODES Former V=codes are nowZ=codes 126
Some of the differences 274 –Gout ICD-10-CM = M – Diabetes ICD-10-CM= E10 Type 1 E12 Type 2 E13 Other
Aftercare Aftercare Z code is not to be used with injuries. The acute injury code with the appropriate seventh character (for subsequent encounter)
Let’s take a look Aftercare for fracture of right upper arm V54.11 Aftercare fracture – code to fracture with extension D Fracture arm (upper) see also fracture, humerus, shaft) S42.30 S42.301(right arm) S42.301D (subsequent encounter for fracture with routine healing)
Right Hip replacement: Now: V54.81 Aftercare following joint replacement V43.64 Joint replacement, hip Then: Z47.1 Aftercare following joint replacement surgery Z96.6 Presence of right artificial hip joint
DIABETIC RETINOPATHY Now: , Then: E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
Deep vein thrombosis patient on Coumadin Now = , V58.61 Then= I Could be more specific with laterality Long Term use of Coumadin = Z79.01
Therapy ICD-10-CM does not provide a separate code for physical, occupational and speech therapy
You will no longer code admission for rehab services V57 With ICD-10-CM you will only code the pertinent diagnoses
What now????? Resident admitted for physical therapy following CABG. ICD-10-CM codes Z Aftercare following surgery (for) (on), circulatory system Z95.1 Status (post) aortocoronary bypass
Status post Lt BKA. Admitted for dressing changes following resolved infection of the amputation stump Z48.01 Aftercare, following surgery, attention to dressings, surgical Z89.52 Absence (of) (organ or part) (complete partial), extremity(acquired), lower, below knee
Stage 3 decubitus ulcer to Rt. Ankle with gangrene I96 Gangrene lower extremity L Decubitus ulcer of Rt. Ankle Stage 3
Late effects of CVA I69 = Sequelae of Cerebrovascular Disease Admission for OT and PT due to left hemiplegia of non-dominant side secondary to a recent CVA I Hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side
Examples Acute Hepatitis with Hepatic Coma ICD-9-CM = ICD-10-CM =B17.11 Alzheimer’s Disease with Behavioral Disturbance ICD-9-CM = 331.0, ICD-10-CM = F02.81
Examples Stage 4 pressure ulcer of the sacrum ICD-9-CM = ICD-10-CM = L89.154
ICD 10 “HAS TWO PARTS” ICD-10 CM = Clinical Modification ICD-10 PCS = Procedural Code System (used for procedures, operations within the hospital inpatient setting i.e., acute hospital) 141
ICD-10 has 21 Chapters Chapter 1- Certain Infectious & Parasitic Diseases (A00-B99) Chapter 2-Neoplasms (C00-D49) Chapter 3- Diseases Blood & Blood Forming Organs & disorders Immune System (D50-D89) Chapter 4- Endocrine, Nutritional and Metabolic Diseases (E00-E89)
CHAPTERS 5 – 8 Chapter 5 – Mental (F00-F99) Chapter 6 – Diseases of Nervous System (G00-G99) Chapter 7 – Disease s of Eye and Adnexa (H00-H59) Chapter 8 – Disease of Ear and Mastoid (H60-H95) 143
Chapters 9-12 Chapter 9- Diseases of the Circulatory System (I00-I99) Chapter 10- Diseases of the Respiratory System (J00-J99) Chapter 11- Diseases of the Digestive System (K00-K94) Chapter 12-Diseases of the skin and Subcutaneous Tissue (L00-L99)
Chapters Chapter 13- Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) Chapter 14- Diseases of the Genitourinary System (N00-N99) Chapter 15- Conditions Related to Pregnancy and Childbirth (O00-O99) Chapter 16- Conditions Originating in the Perinatal Period (P00-P96)
Chapters Chapter 17- Congenital Malformations, Deformations, & Chromosomal Abnormalities (Q00-Q99) Chapter 18- Symptoms, Signs & Abnormal Clinical & Laboratory Findings (R00-R99) Chapter 19- Injury, Poisoning & Certain Other Consequences of External Causes (S00-T88) Chapter 20- External Causes of Morbidity (V00-Y99)
Chapter 21 Chapter 21- Factors Influencing Health Status & Contact with Health Services (Z00-Z99)
CONVENTIONS FOR THE ICD- 10-CM -3 General rules for use of the classification independent of the guidelines – 7 th Characters Certain ICD-10-Cm categories have applicable 7 th characters Required for all codes within the category or as instructed by the notes in the Tabular List Must always be the 7 th character in the data field If a code that requires a7th character is not 6 characters, a placeholder X must be used to fill in the empty characters 148
Example 7 th characters for a fracture - A = initial encounter for fracture - D = Subsequent encounter for fracture with routine healing - G = Subsequent encounter for fracture with delayed healing - K = Subsequent encounter for fracture with non-union - P = Subsequent encounter for fracture with malunion - S= Sequela
It’s in the details….. Coma scale - Eyes open - Best verbal response - Best motor response
CODE STRUCTURE OF ICD-10 ICD-10 Codes may consist of up to 7 digits, with the 7 th digit extensions representing visit encounter or sequel for injuries or external causes. In some cases the place holder “X” will be used to expand the code and accommodate the 7 th character Example: Pathological vertebral fracture due to age related osteoporosis (Subsequent encounter with delayed healing M80.80XG 151
ICD-10-CM DIAGNOSIS CODES-2 Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data between other countries and the U.S. 152
ICD-10 NEW FEATURES -2 Added Laterality ◦ C Malignant neoplasm of upper-inner quadrant of left female breast ◦ L80.213, Pressure Ulcer of right hip, Stage III 153
LET’S SEE SOME CODES Hypertensive Retinopathy ◦ H35.03 Hypertensive Retinopathy ◦ 031-Right eye, 032, left eye, 033, bilateral, ◦ 039 unspecified (and this would be a ?? For billing most likely)!! ◦ I10, Essential Primary Hypertension 154
ABBREVIATIONS NEC – “Not elsewhere classifiable Punctuation – [ ] Brackets – ( ) Parentheses Use of “and” “Other” or “other specified” “Unspecified” “Includes Notes” “Inclusion Terms” 155
ABBREVIATIONS -2 “Excludes Notes” “Code first”, “Use additional code” and “elsewhere notes” “And”, “and” or “or” “With” “See”, “see also” “Code also note” “Default codes” “Syndromes” 156
PRINCIPAL DIAGNOSIS -6 Complications of surgery and other medical care ◦ Is sequenced as the principal diagnosis Uncertain Diagnosis ◦ “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed/established ◦ Applicable only to inpatient admissions to short-term, acute, long-term care & psychiatric hospitals 157
Focus DOCUMENTATIO N
TIMELINE 10/01/2011 – Last major update to ICD- 9-CM and ICD10-CM/PCS 10/01/2012 – Limited changes to ICD-9- CM and ICD-10CM/PCS 10/01/2013 ICD-10-CM/PCS Implemented
References
Questions and Answers
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