1. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 9 USING ICD-10-CM

2. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 ICD-10-CM Official Guidelines Official Guidelines for Coding and ReportingOfficial Guidelines for Coding and Reporting Developed by Cooperating PartiesDeveloped by Cooperating Parties –AHA –CMS –NCHS (Cont’d...)

3. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 ICD-10-CM Official Guidelines (Cont’d …) Arranged in sectionsArranged in sections –Section I, structure, conventions, general guidelines –Section II and III, inpatient PDX (principal diagnosis) and additional DX –Section IV, outpatient Outpatient also reference Sections I, II, and IIIOutpatient also reference Sections I, II, and III

4. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Index and Tabular Example of the Use of Both the Alphabetic Index and Tabular ListExample of the Use of Both the Alphabetic Index and Tabular List 1.Diagnosis: Hodgkin’s Disease Index:Hodgkin (main term) disease (subterm) - see Lymphoma, Hodgkin C81.90 Tabular:C81 Hodgkin’s disease [category code] C81.9 Unspecified Hodgkin’s disease [subcategory code] C81.90 Unspecified Hodgkin’s disease, unspecified site (subclassification code) Code:C81.90 Unspecified Hodgkin’s disease, unspecified site

5. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Level of Specificity Report highest character availableReport highest character available Cannot report 5 th character if 6 th character availableCannot report 5 th character if 6 th character available Highest level of specificity 7 charactersHighest level of specificity 7 characters –M48.49xA (A= initial encounter) –No 6 th character for M48.49, but there is a 7 th, x = placeholder

6. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Integral Conditions Diagnosis stated: Do not report signs and symptoms separatelyDiagnosis stated: Do not report signs and symptoms separately –Fever and shortness of breath due to pneumonia –Report only pneumonia –Fever and shortness of breath = symptoms of pneumonia

7. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Not Integral Condition Sign or symptom NOT part of disease condition = report separatelySign or symptom NOT part of disease condition = report separately Pneumonia and dehydrationPneumonia and dehydration –J18.9, Pneumonia –E86.0, Dehydration –Not all patients with pneumonia have dehydration –Dehydration was not stated to be due to

8. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Etiology and Manifestation Diabetic retinopathyDiabetic retinopathy –Diabetes = etiology (cause) –Retinopathy = manifestation (symptom) –Combination code E10.319 Type 1 diabetic retinopathyE10.319 Type 1 diabetic retinopathy Staphylococcal aureus cellulitis of faceStaphylococcal aureus cellulitis of face –Multiple Code L03.211 (Cellulitis) and B95.6 (Staph)L03.211 (Cellulitis) and B95.6 (Staph)

9. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Acute and Chronic Same condition, both acute and chronic, with separate, same level of indention in Index, report acute firstSame condition, both acute and chronic, with separate, same level of indention in Index, report acute first Figure: 9.1 I-10 Index entry Pancreatitis (From Buck CJ: 2010 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2010, Saunders. )

10. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Combination Codes ReportsReports –Two diagnoses –Diagnosis with manifestation –Diagnosis with associated complication K80.00 Acute cholecystitis with cholelithiasisK80.00 Acute cholecystitis with cholelithiasis

11. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Residual and Cause Sequela or ResidualSequela or Residual –Malunion of fracture—Residual –Late effect of fracture—Cause Report residual as first-listed diagnosisReport residual as first-listed diagnosis Followed by late effects codeFollowed by late effects code Some combination codes report 1 code, others require 2 codesSome combination codes report 1 code, others require 2 codes

12. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Laterality Left/Right = extensive in I-10Left/Right = extensive in I-10 Figure: 9.4 Laterality of codes in I-10. (From Buck CJ: 2010 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2010, Saunders. )

13. Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Conclusion CHAPTER 9 USING the ICD-10-CM