1. © 2018 American Health Information Management Association ICD-10-CM Organization and Format ICD-10-CM code books differ depending on publisher of the book. Many have colored or shaded outer edges to help coders differentiate between sections of the book. –Adding tabs to these sections helps with faster code location Code book is divided into two major sections: –Index –Tabular List 1

2. © 2018 American Health Information Management Association ICD-10-CM Index The ICD-10-CM Index is divided into four sections: –Index to Diseases and Injury (Main Index) –Table of Neoplasms –Table of Drugs and Chemicals –External Causes of Injury Index 2

3. © 2018 American Health Information Management Association Index to Diseases and Injury (Main Index) Index to Diseases and Injury is the main index to the ICD-10-CM book. Look up any healthcare condition by following these steps: 3

4. © 2018 American Health Information Management Association Find the Main Term 1. Find the main term for the condition, disease, or reason for the encounter Main term is the noun that describes the patient’s diagnosis or reason for the encounter. Coder must abstract the diagnosis from documentation, then locate the main term for the diagnosis and locate that main term in the Index. –Example: Patient with abdominal distension presented to the clinic for treatment. –Diagnosis: abdominal distension –Main term: Distention 4

5. © 2018 American Health Information Management Association Check Cross-References 2. Check for cross-references, subterms, and nonessential modifiers Cross-references instructs the coder to look elsewhere for the condition. See instructs the coder that another term should be referenced. It is necessary to go to the main term referenced. See also instructs the coder to look elsewhere for a code if the condition cannot be found in the current entry. It is not necessary to go to the main term referenced (only if needed). 5

6. © 2018 American Health Information Management Association Check Cross-References See condition cross-reference tells the coder to search for the code by looking up the term for the actual healthcare condition –Example: Patient with abdominal distension presented to the clinic for treatment. –Diagnosis: abdominal distension –Index entry for “abdomen” instructs the coder to see condition. Condition is distention, coder should look up distention and then locate the code for abdomen in the subterms below the main term. 6

7. © 2018 American Health Information Management Association Check Subterms Subterms are indented under the main term and identify variations of the main term. Scan through the list of subterms to ensure that you have selected the correct term. If the subterm for your condition does not exist, then refer to the default code listed next to the main term entry in the Index. 7

8. © 2018 American Health Information Management Association Check Essential and Nonessential Modifiers Essential modifiers, such as subterms, impact the code selected. These are not listed in parenthesis. Nonessential modifiers are words or phrases in parentheses located next to the main term or subterm in the Index. These are informational only and do not impact code selection. 8

9. © 2018 American Health Information Management Association Locate the Code 3. Locate the code in the Main Index once all subterms, cross-references, and modifiers have been noted. If there are no applicable subterms or cross-references, locate the default code listed directly after the main entry for the condition. 9

10. © 2018 American Health Information Management Association Verify the Code 4. Verify the code in the Tabular List to: Verify that the code selected is correct, Assign all necessary characters to the code, and Check guidelines and sequencing instructions for the code. 10

11. © 2018 American Health Information Management Association Guided Example Patient presents with vitamin B deficiency with pellagra. 1.Find the main term for the condition: –Deficiency 2.Check cross-references, subterms, and modifiers: –Vitamin (multiple), B (complex) NOS, with, pellagra 11

12. © 2018 American Health Information Management Association Guided Example 3. Locate the code –E52 4. Verify the code in the Tabular –E52 Niacin deficiency [pellagra] 12

13. © 2018 American Health Information Management Association Table of Neoplasms Table of Neoplasms is an Index that allows coders to identify code for neoplastic conditions. Neoplasm = abnormal growth of tissue. Ranges from moles to benign tumors and cancerous tumors and lesions. 13

14. © 2018 American Health Information Management Association Neoplasm Behavior Benign neoplasms are non-cancerous growths of tissue. Malignant neoplasms are commonly referred to as cancer. Three types in the Neoplasm table: –Primary –Secondary –Carcinoma in situ 14

15. © 2018 American Health Information Management Association Malignant Neoplasms Primary neoplasm is the original site of the neoplasm. Secondary neoplasms are areas to which the primary neoplasm has metastasized, or spread. Carcinoma in situ neoplasms are growths of tissue that are potentially cancerous, but are currently non-invasive. 15

16. © 2018 American Health Information Management Association Other Neoplasms Neoplasms of uncertain behavior have not yet been determined to be either benign nor malignant. May be considered suspicious and require further evaluation before behavior can be determined Codes for unspecified behavior neoplasms should only be chosen when the documentation does not specify the behavior as any of the other types. Should be used as a last resort; query the provider for more detail. 16

17. © 2018 American Health Information Management Association Neoplasm Table 17 Source: Casto 2018, 324.

18. © 2018 American Health Information Management Association Looking up a Code for a Neoplasm 1.Look up the morphological type of the neoplasm in the Main Index. –Many times this will refer the coder to the Table of Neoplasms. –If the morphological type is listed and includes codes, follow subterms and cross-references to locate a code –Verify the code in the Tabular List. –If the morphology cross-references you to the Neoplasm Table, follow the additional steps. 18

19. © 2018 American Health Information Management Association Looking up a Code for a Neoplasm 2.Search for the site of the neoplasm in the Neoplasm Table. –Use the site terms on the edge of the page for easier location of the site. –Check cross-references, subterms, and modifiers. 19

20. © 2018 American Health Information Management Association Looking up a Code for a Neoplasm 3.Identify the behavior of the neoplasm and select the code. –Refer to the correct column to identify the behavior and then locate the code by matching the row for the site to the column for the behavior. –If there is a dash (-) in the column for the specified behavior, then no such code exists for the site/behavior combination. 4.Verify the code in the Tabular List. 20

21. © 2018 American Health Information Management Association Guided Example Patient presents with basal cell carcinoma of the upper right eyelid (primary malignancy) 1.Search for the morphological type of neoplasm in the Main Index. –Carcinoma 2.Check cross-references, subterms, and modifiers: –Basal cell (pigmented) (see also Neoplasm, skin, malignant) No further subterms for the site of the neoplasm, so it is necessary to follow the cross-reference to see also Neoplasm, skin, malignant 21

22. © 2018 American Health Information Management Association Guided Example Patient presents with basal cell carcinoma of the upper right eyelid (primary malignancy) 3.Identify the behavior of the neoplasm and select the code. –Malignant, primary –Skin, eyelid, basal cell carcinoma, C44.11- 4.Verify the code in the Tabular List. –C44.112, Basal cell carcinoma of skin of right eyelid, including canthus 22

23. © 2018 American Health Information Management Association Table of Drugs and Chemicals Table of Drugs and Chemicals lists the toxic effects of drugs, chemicals, and other substances. Toxic effect is the result of a toxin such as burn of the skin or loss of consciousness. Codes identify the substance that caused the toxic effect, the intent of the poisoning, and the encounter. 23

24. © 2018 American Health Information Management Association Looking up a Code in the Table of Drugs 1.Identify the substance that caused the toxic effect. –Locate the entry for the substance in the Table of Drugs –Follow cross-references and subterms 2.Identify the intent of the toxic effect. –Accidental intent: Unintentional effect of a substance that was taken accidentally or in excess 24

25. © 2018 American Health Information Management Association Looking up a Code in the Table of Drugs 2.Identify the intent of the toxic effect (cont’d). –Intentional self-harm: Substance taken deliberately as an act of hurting oneself –Assault: Toxic effect of a substance that was purposefully inflicted upon one person by another –Undetermined intent: Intent of the toxic effect cannot be determined; use this intent ONLY if the intent cannot be determined 25

26. © 2018 American Health Information Management Association Looking up a Code in the Table of Drugs 2.Identify the intent of the toxic effect (cont’d). –Adverse effect: Unintended effect caused by a medical substance that was correctly prescribed and administered –Underdosing: A patient takes too little of a prescribed substance and suffers an unintended consequence 26

27. © 2018 American Health Information Management Association Looking up a Code in the Table of Drugs 3.Locate the code. –Locate the row for the toxic substance and match it with the correct intent to identify the code. 4.Verify the code in the Tabular List and add seventh character extension. –Verify the code in the Tabular List. –Add the seventh character extension to complete the code. Note that the seventh characters are only listed in the Tabular List. Seventh character extensions are discussed in detail later. 27

28. © 2018 American Health Information Management Association Looking up a Code in the Table of Drugs 5.Check for additional codes and sequencing. –Additional codes may be needed to identify manifestations (signs, symptoms, or medical condition that occurred as a result of of the poisoning). –Sequencing is placing multiple diagnosis codes in the correct order. Sequencing instructions are listed in the Tabular List. 28

29. © 2018 American Health Information Management Association Guided Example Patient presents with exacerbation of allergic contact dermatitis due to nickel, due to underdosing of antihistamine drug 1.Identify the substance that caused the toxic effect. –Antihistamine 2.Identify the intent of the toxic effect. –Underdosing 3.Locate the code. –T45.0X6- 4.Verify the code in the Tabular List and add seventh character extension. –T45.0X6A, Underdosing of antiallergic and antiemetic drugs, initial encounter 29

30. © 2018 American Health Information Management Association Guided Example Patient presents with exacerbation of allergic contact dermatitis due to nickel, due to underdosing of antihistamine drug 5.Check for additional codes and sequencing. –Use additional code(s) to specify manifestations of the poisoning (notation found at the beginning of section for T36 to T50) –Add the additional code for the manifestation, L23.0, Allergic contact dermatitis due to metals –Sequence with the toxic effect code first, following by the manifestation of the poisoning: 1.T45.0X6A 2.L23.0 30

31. © 2018 American Health Information Management Association External Causes of Injury Index External Causes of Injury Index allows coders to locate codes that identify the extenuating circumstances surrounding an injury or other healthcare condition. –They identify how, where, and why an injury occurred. –May or may not be required depending on state or insurance regulations. 31

32. © 2018 American Health Information Management Association Looking up Codes in the External Causes Index 1.Identify the extenuating circumstances surrounding the injury. There are four possible circumstances that may be identified: –Injury mechanism identifies how the injury occurred, such as a fall from a ladder. –Patient activity identifies what the patient was doing when the injury occurred, such as painting a house. 32

33. © 2018 American Health Information Management Association Looking up Codes in the External Causes Index 1.Identify the extenuating circumstance surrounding the injury (cont’d). –Place of occurrence identifies where the patient was when the injury occurred, such as a single family home. –Patient status identifies the patient work status during the accident, such as leisure status. 33

34. © 2018 American Health Information Management Association Looking up Codes in the External Causes Index 2.Locate the external cause codes using the External Causes Index. –Look up the main term, identify subterms, cross- references, and modifiers, and then locate the code. –One code per extenuating circumstance. 3.Verify the codes in the Tabular List. 4.Add the seventh character for episode of care. –Episode of care is discussed later in this chapter. –Only the injury mechanism requires the seventh character. 34

35. © 2018 American Health Information Management Association Guided Example Patient presents with fracture of the ankle due to a collision with another player while playing soccer for high school practice at a local soccer field. 1.Identify the extenuating circumstances surrounding the injury. –Injury mechanism: collision with another player –Activity: soccer –Place of occurrence: soccer field –Patient status: high school practice (recreation or sport) 35

36. © 2018 American Health Information Management Association Guided Example Patient presents with fracture of the ankle due to a collision with another player while playing soccer for high school practice at a local soccer field. 2.Locate the external cause codes using the External Causes Index. –Injury mechanism: W51 –Activity: Y93.66 –Place of occurrence: Y92.322 –Patient status: Y99.8 36

37. © 2018 American Health Information Management Association Guided Example Patient presents with fracture of the ankle due to a collision with another player while playing soccer for high school practice at a local soccer field. 3.Verify the codes in the Tabular List 4.Add the seventh character for episode of care. –Injury mechanism: W51.XXXA –Activity: Y93.66 –Place of occurrence: Y92.322 –Patient status: Y99.8 37

38. © 2018 American Health Information Management Association Tabular List Structured list of ICD-10-CM codes –Chapters organized alphabetically –Codes within each chapter organized numerically 21 chapters, divided based on a specific body system or condition –Example: Chapter 2 Neoplasms (C00-D49) –Example: Chapter 6 Diseases of the Nervous System (G00-G99) 38

39. © 2018 American Health Information Management Association Format of the Tabular List Sections combine conditions that are similar in nature. –Intestinal Infectious Diseases (A00-A09) Categories are the first three characters of a code. –A00, Cholera (invalid code, requires further characters) –They can be valid codes if they are not further subdivided. A09, Infectious gastroenteritis and colitis, unspecified (valid code) 39

40. © 2018 American Health Information Management Association Format of the Tabular List Subcategories are extensions of the code that may extend the code out to four, five, six, or seven characters. –A00.1, Cholera due to Vibrio cholera 01, bivoar eltor (valid code) –A02.22, Salmonella pneumonia (valid code) Codes have been extended out to the required number of characters and may be used to report medical conditions or other reasons for encounters (valid codes) 40

41. © 2018 American Health Information Management Association Seventh Character Extensions To save space, not all individual codes are listed within the Tabular List. Seventh character extension options are not listed under each code. These are listed in a box within the category. Instructional notations within the Tabular List inform the coder that a seventh character extension is necessary. –“+7th” 41

42. © 2018 American Health Information Management Association Seventh Character Extensions 42 Source: Casto 2018, 950.

43. © 2018 American Health Information Management Association Specificity Specificity is the amount of detail included within a code description. Always code to the highest level of specificity. –Report the code with the most possible characters. 43

44. © 2018 American Health Information Management Association NOS and NEC NOS = Not otherwise specified –Unspecified –Documentation is not specific enough to select a code with more detail –R13.10, Dysphagia, unspecified NEC = Not elsewhere classifiable –Other –No code exists for the condition specified in the documentation –R13.19, Other dysphagia 44

45. © 2018 American Health Information Management Association Tabular Notations Includes notes further define and give examples of the conditions included within each category of codes. –Inclusion terms Excludes notes identify conditions that are similar but are coded independently of each other. –Excludes1: Conditions are mutually exclusive –Excludes2: Condition is “not included here” 45

46. © 2018 American Health Information Management Association Tabular Conventions and = And/or with = Associated with or due to, presumes a causal relationship between two conditions code also = Additional conditions should also be coded (does not give sequencing instructions) 46

47. © 2018 American Health Information Management Association Sequencing Instructions code first = Code the conditions listed before the code identified use additional code = Code the conditions listed after the code identified Notations may be listed at the beginning of a code, subcategory, or category of codes. –Refer to the beginning of the category of the code being reported to locate any sequencing instructions or other important notations or conventions. 47

48. © 2018 American Health Information Management Association Etiology and Manifestation Etiology = Cause of a disease Manifestation = Signs and symptoms of a disease Combination code reports both the etiology and the manifestation in ONE code. –One code combines the etiology and manifestation of a disease. 48

49. © 2018 American Health Information Management Association Etiology and Manifestation When a combination code does NOT exist, report one code for the etiology and one code for the manifestation of a disease, when known. –Follow the notations within the Tabular List for sequencing instructions. 49

50. © 2018 American Health Information Management Association Signs and Symptoms vs. Definitive Diagnosis Signs = Objective evidence of a disease process (for example, fever) Symptoms = Subjective evidence of a disease process (for example, headache) Definitive diagnosis = The condition or disease that has been determined to be the cause of the signs or symptoms When the definitive diagnosis is known, do not report the signs or symptoms of that diagnosis. 50

51. © 2018 American Health Information Management Association Acute and Chronic Conditions An acute condition has a severe and sudden onset (like acute bronchitis) A chronic condition is a syndrome or condition that has been in development for an extended amount of time, and is a constant disease state (for example, chronic obstructive bronchitis) Acute and chronic conditions –Report the combination code if available –If no combination code available, report both codes and sequence the acute code first 51

52. © 2018 American Health Information Management Association Laterality Laterality = The side on which a condition appears Bilateral = Condition presents on both sides Many ICD-10-CM codes identify laterality (right, left, or bilateral). When a condition presents bilaterally and no bilateral code exists, report one code for each side. 52

53. © 2018 American Health Information Management Association First-Listed Diagnosis First-listed diagnosis is the first diagnosis code listed on a claim when more than one code is reported. –Primary diagnosis –The diagnosis chiefly responsible for the healthcare service provided –Coexisting conditions are sequenced after the first-listed diagnosis –Follow sequencing guidelines in the Tabular List if they differ 53

54. © 2018 American Health Information Management Association Uncertain Diagnosis NEVER report an uncertain diagnosis as if it exists in the outpatient setting. –Suspected –Rule out –Probable –Questionable Report the signs and symptoms of the disease until a definitive diagnosis has been confirmed. 54

55. © 2018 American Health Information Management Association Reporting Multiple Conditions Report all conditions that coexist at the time of the encounter that require patient care, management, or treatment. –Family and personal history –Chronic diseases –Coexisting conditions –Additional information regarding patient’s health (BMI, old heart attack, noncompliance with medication regimen, amputation or organ transplant status) 55

56. © 2018 American Health Information Management Association ICD-10-CM Code Structure 56

57. © 2018 American Health Information Management Association ICD-10-CM Code Structure First three characters = Category –Codes that start with the same three characters are all within the same category Category followed by a decimal point and up to four additional characters. Characters four, five, and six give further detail to the code description. –Etiology, anatomic site, severity, laterality, and such. Character seven = seventh character extension –Usually represents the episode of care 57

58. © 2018 American Health Information Management Association ICD-10-CM Code Structure 58 Source: Adapted from DeVault et. al 2014.

59. © 2018 American Health Information Management Association Seventh Character Extensions Seventh character extension –Always placed in the seventh location –Usually identifies the episode of care for an encounter –May be a letter or a number 59

60. © 2018 American Health Information Management Association Episode of Care A- Initial Encounter: Used during the active treatment phase of a condition, patient still receiving treatment; not just the first time the patient bas been treated (fracture treatment) A = Active Care D- Subsequent Encounter: Used during the healing phase of an encounter or for aftercare, patient no longer receiving active care or treatment (removal of cast) S- Sequela: When patient is seen for a consequence of a previous disease or injury or a late effect (arthritis or pain due to old fracture) 60

61. © 2018 American Health Information Management Association Episode of Care Episode of care extensions are all located in the seventh character location of the ICD-10-CM code. Seventh character locations are listed in the shaded box preceding the code and there may be many codes or pages before the code being selected. 61

62. © 2018 American Health Information Management Association Placeholder X When a seventh character extension is required but the code does not extend to six characters, a placeholder must be used to keep the place of the missing characters. Placeholder X is used to extend a code to the required number of characters so that the seventh character may be placed in the seventh character location and to create a valid code. Add as many placeholders as necessary to allow for the placement of the seventh character. –Example: W52.XXXA, Crushed, pushed or stepped on by crowd or human stampede, initial encounter 62