1. Excellence in Optometric Education John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute Introducing ICD-10-CM

2. JAM John A. McGreal Jr., O.D. n Missouri Eye Associates n 11710 Old Ballas Rd. n St. Louis, MO. 63141 n 314.569.2020 n 314.569.1596 FAX n mcgrealjohn@gmail.com

3. JAM Understanding the Basics & Getting Ready n Differences between ICD-9 & ICD-10 n How the ICD-10CM is laid out n How to Use the Alphabetic Index n How to Use the Tabular List n How to Use the Index of injuries n How to Use the Table of Drugs & Chemicals n How to Understand new Abbreviations n How to Use Placeholders n How to Use Code Extensions n Understand laterality

4. JAM The Lilliputians Take Control of the Healthcare Giant n ICD-9 has 13,000 codes n ICD-10 has 140,000 n Effective date – October 1, 2014 n Transition will be difficult as there is little in common with our current coding paradigms n Requires doctors, not staff to do the specific coding n Every artery and nerve has been issued a number n Number of physicians = 800,000/ 35% own their own practice (Source Accenture with data from Medical Group management Assoc and AMA)

5. JAM Introduction to ICD-10-CM n Clinical modification of WHO’s ICD-10 – Clinical emphasizes the intent to serve as a tool in classification of morbidity data for indexing, medical records care review, medical & ambulatory care programs, health statistics n Better understand complications n Better design robust algorithms n Track outcomes – To describe the “clinical” picture the codes must be more precise – Far exceeds ICD-9 in number of concepts and codes – Disease classification expanded to include health related conditions and provides greater specificity

6. JAM Improvements Over ICD-9 Improvements Over ICD-9 n Index MUCH longer – Ex 28 pterygium, 69 conjunctivitis, 12 astigmatism codes n Adds information relevant to ambulatory & MC encounters n Expanded injury codes n Combination diagnosis/symptom codes n Addition of 6 th & 7 th characters n Incorporates common 4 th & 5 th digit subclassification n Laterality n Allows further expansion

7. JAM Organization of ICD-10-CM n Alphabetical Index – Alphabetical list of terms and corresponding codes – Index of Diseases & Injury – Table of Neoplasm – Table of Drugs & Chemicals – Index of External causes of injury n Tabular List – Chronological list of codes – Divided into chapters – Based on body systems

8. JAM Tabular List Detail n Chapter 1Infectious and parasitic diseases n Chapter 2 Neoplasms n Chapter 3 Diseases of Blood and blood forms n Chapter 4Endocrine, nutritional, metabolic n Chapter 5 Mental & behavioral n Chapter 6 Nervous system n Chapter 7 Eye & adnexa n Chapter 8Ear and mastoid n Chapter 9Circulatory system n Chapter 10Respiratory system n Chapter 11Digestive system

9. JAM Tabular List Detail n Chapter 12Skin & subcutaneous n Chapter 13Musculoskeletal n Chapter 14Gastrointestinal n Chapter 15Pregnancy & childbirth n Chapter 16 Conditions of perinatal period n Chapter 17 Congenital / Malformations n Chapter 18Signs/Symptoms/abnormal clinical laboratory findings n Chapter 19Injury, Poisoning, consequences of external causes n Chapter 20External causes of morbidity n Chapter 21Factors influencing health status & contact with health services

10. JAM Chapter 7: Diseases of Eye/Adnexa Detail n H00-H05Eyelid, lacrimal, orbit n H10-11Conjunctiva n H15-H22Sclera, cornea, iris, ciliary body n H25-H28Lens n H30-H36Choroid/retina n H40-H42Glaucoma n H43-H44Vitreous & globe n H46-H47Optic nerve & pathways n H49-H52Ocular muscles, accomodation, refraction n H53-H54Visual disturbances and blindness n H55-H57Other disorders eye & adnexa n H59Intra-operative & post-procedural complications

11. JAM Format & Structure Format & Structure n Tabular list contains categories, subcategories & codes n Characters may be letter or numbers n Categories are 3 characters – Character 1 is alpha n All letter used except U – Character 2 is numeric – Character 3-7 are alpha or numeric – Use decimal after 3 characters n Subcategories are 4 or 5 characters n Codes may be 3, 4, 5, 6 or 7 characters n Laterality specific

12. JAM Placeholder Characters Placeholder Characters n Character “X” used as a placeholder – Allows for future expansion – Where it exists it must be used to be valid – Ex S05.8x1A

13. JAM Placeholder Characters Placeholder Characters n Code extensions (seventh character) have been added for injuries and consequences of external causes (S00-T88), to identify the encounter – “A” Initial encounter – receiving active treatment – “D” Subsequent encounter-use after Pt received active treamt – “S” Sequelae-used for complications/conditions arise as result of injury n S only added to injury code, not sequela code n Sequela code first, followed by injury code – Ex: S30 superficial injury of abdomen n S30.810, code requires extension to indicate episode of care n S30.810A

14. JAM 7 th Character 7 th Character n Certain ICD-10-CM categories have 7 th digit characters n Applicable 7 th character is required within the category n If code requires 7 th character and is not 6 characters, a placeholder “X” must be used to fill empty character n Ex: S05 Injury of eye and orbit, subsequent visit – S05.00 n Looking it up you find “x7th” meaning no 6 th character exists but there is a 7 th character mandatory – S05.00xD

15. JAM Laterality Laterality n For bilateral sites, final character of code indicates laterality n Unspecified side codes if side not identified in medical record n If no bilateral code provided and condition is bilateral – Assign separate codes for both left and right n Ex: – H43.811 Vitreous degeneration, right side – H43.812 Vitreous degeneration, left side – H43.813 Vitreous degeneration, bilateral – H43.819 Vitreous degeneration, unspecified

16. JAM Abbreviations Abbreviations n NEC “not elsewhere classifiable” n NOS “not otherwise specified” n “and” represents and / or n “code also” instructs two codes may be required n [ ] Brackets identify manifestation codes n ( ) parenthesis terms are non essential modifiers n : Colon incomplete term needing more modifiers

17. JAM Excludes Codes Excludes Codes n Excludes 1 – pure excludes notes – Means “NOT CODED HERE” – Indicated code exclude should never be used same time as code above it n Ex congenital vs acquired condition n Exclude 2 – “Not included here” – Condition excluded is not part of the condition represented by the code

18. JAM Etiology / Manifestation Convention n Some conditions have underlying etiology and multiple body system manifestations due to the etiology n Coding convention requires underlying condition be sequenced first, followed by manifestation – “use additional code” note exists at etiology codes – “code first” note at the manifestation code n Ex; Dementia in Parkinson’s disease – Code G20 represents etiology – [F02.80 or F02.81] represents manifestation of dementia n With behavioral or without behavioral disturbances

19. JAM General Coding Guidelines n Locating a code in ICD-10-CM – Locate term in Alphabetic Index – Then verify code in the Tabular List – Read and be guided by instructional notations appearing in both – Essential to use BOTH n Alphabetic index doesn’t always provide FULL code n Need Tabular List to assign laterality and 7 th character

20. JAM Sign & Symptoms Sign & Symptoms n Codes that describe symptoms and signs, as opposed to diagnosis n Are accepted when a definitive diagnosis has not been established n Chapter 18

21. JAM Acute & Chronic Conditions n Acute & Chronic – Code acute or chronic – If condition is both, code both with acute first n Late Effects (Sequela) – Residual effect after acute phase of illness or injury has terminated – No time limit – Coding requires 2 codes sequenced in order n Condition first n Late effect code second

22. JAM External Cause Codes n Chapter 20 n Use full range of external cause codes to completely describe: – the cause, – the intent, – the place of occurrence, – and if applicable the activity of the patient at the time of the event and – the patient’s status for all injuries and other health conditions due to an external cause

23. JAM Z Codes n Z codes are analogous to the ICD-9CM “V” codes n Most rules of V codes transfer over to the use of Z codes n Used to describe routine examinations of many varieties n Each with different codes n Ex Z00Encounter for general examination without complaint, suspected or reported diagnosis n Ex Z01 Encounter for other special examination without complaint, suspected or reported diagnosis

24. JAM Steroid Responder Visit Scenario – Old Way n 57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS n CPT 99214 n ICD: 365.04

25. JAM Steroid Responder Visit Scenario – New Way n 57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS n CPT 99204 n ICD: T38.0x5 – T38.0x1 = accident – T38.0x2 = self harm – T38.0x3 = assault – T38.0x4 = undetermined – T38.0x5 = adverse effect – T38.0x6 = under-dosing n ICD: H40.62 Glaucoma secondary to drugs, left eye – Note states “code first” T36-T50 to identify drug

26. JAM Notable & Quotable n “…Jonathan Swift, where are you today? The Lilliputians are tying down the healthcare giant with 140,000 threads and calling it a “fundamental advance” MD Tucson AZ n “…this has everything to do with the government forcing more expense, inefficiency and reimbursement delays on already dispirited practitioners…many of my burned out colleagues will gladly follow me into early retirement if this continues” MD Meadville, PA n ‘…if this is a small taste of the increasing role of government involvement in healthcare, it is a wonder that any young person has any interest in a career in medicine” SDC, Pittsburgh, PA

27. JAM Notable & Quotable n “…this is government medicine causing the addition of more ancillary office personnel, more intrusion into the patient’s privacy, more paperwork hours for doctors and one more nail in the coffin of private practice” MD Newport OR n “..every contact will require one of 140,000 codes in order to submit a bill. How much time will medical providers spend choosing the right one, how much will that raise overall medical costs and why is it all worth it? MD Portland OR n “..doctors closing their practices in droves; is there a code for that? MD Niceville FL

28. JAM Notable & Quotable n “…is there an app for that??” OD Los Angeles, CA n “..the Mayan Calendar says the world comes to an end the October before this becomes effective, so don’t worry about any of this..” OD Belize City, Belize

29. Thank you Excellence in Optometric Education Missouri Eye Associates McGreal Educational Institute Missouri Eye Associates McGreal Educational Institute