1. Pulmonology ICD-10 CM Training

2. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1, 2015 and beyond. – Inpatient hospital service claims, is effective for dates of discharge after September 30, 2015 ICD-10-CM Compliance Dates

3. Covered Entities – Everyone covered by the Health Insurance Portability Accountability Act (HIPPA) Non-Covered Entities – Worker’s Compensation – Auto Insurance – Non covered HIPAA entities are exempt but are encouraged to adapt the new code set Covered and Non-Covered Entities

4. 21 Chapters Alpha-numeric codes; not case-sensitive – Codes begin with Alpha letter, A-Z, excluding U – Common errors I verses 1 O verses 0 “X” Placeholder 3 to 7 characters – Decimal following 3 rd character ICD-10 Code Structure

5. Placeholder “X” – Used for future expansion of a code – Fills in empty characters when a 6 th and/or 7 th character apply – The placeholder may be used in different scenarios but should never serve as the final character. Example: W19.XXXA Unspecified fall, Initial Encounter ICD-10 Code Structure

6. 7 th Character – Provides specified information regarding the clinical visit – Is required for certain categories and must be reported in the seventh position – May be alpha or numeric – Has different meanings depending on the coding category ICD-10 Code Structure

7. Laterality – Some I CD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. – If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. – If the side is not identified in the medical record, assign the code for the unspecified side. OGCR section 1.B.13 ICD-10 Code Structure

8. “Other” Codes – Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. “Unspecified” Codes – Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. OGCR section 1.A.9.a.b ICD-10 Code Structure

9. Excludes Notes – Excludes1 A type 1 Excludes note is a pure excludes note It means “NOT CODED HERE” The code excluded should never be used at the same time When two conditions cannot occur togethe r – Excludes2 Represents “Not included here” The condition excluded is not part of the condition represented by the code It is acceptable to use both the code and the excluded code together, when appropriate OGCR section 1.A.12.a.b ICD-10 Structure

10. “Code First” and “Use Additional Code” – ICD-10 has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. – These instructional notes indicate the proper sequencing order of the codes. OGCR section 1.A.13 The “-” indicates there are additional reporting options ICD-10 Code Structure

11. Most Common Diagnosis Codes

12. Chronic Obstructive Pulmonary Disease (COPD) ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 496J44.9Chronic obstructive pulmonary disease, unspecified Applicable to: Chronic obstructive airway disease NOS Chronic obstructive lung disease NOS Bronchiectasis (J47.-) Chronic bronchitis NOS (J43) Chronic simple and mucopurulent bronchitis (J14.-) Chronic tracheitis (J42) Chronic tracheobronchitis (J42) Emphyysema without chronic bronchitis (J43.-) Lung diseases due to external agents (J60-J70) N/A There are more specific code choice selections below: 491.22 493.21 J44.0Chronic obstructive pulmonary disease with acute lower respiratory infection 491.21 493.22 J44.1Chronic obstructive pulmonary disease with (acute) exacerbation

13. Code also type of asthma, if applicable (J45) Use additional code to identify: – Exposure to environmental tobacco smoke (Z77.22) – History of tobacco use (Z87.891) – Occupational exposure to environmental tobacco smoke (Z57.31) – Tobacco dependence (F17.-) – Tobacco use (Z72.0) COPD Documentation Tips

14. Shortness of breath ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 786.05R06.02Shortness of breath abnormalities originating in the perinatal period (P29.1-) specified arrhythmias (I47-I49) acute respiratory distress syndrome (J80) respiratory arrest (R09.2) respiratory arrest of newborn (P28.81) respiratory distress syndrome of newborn (P22.-) respiratory failure (J96.-) respiratory failure of newborn (P28.5) tachypnea NOS (R06.82) transient tachypnea of newborn (P22.1) abnormal findings on antenatal screening of mother (O28.-) certain conditions originating in the perinatal period (P04- P96) signs and symptoms classified in the body system chapters Page 935 signs and symptoms of breast (N63, N64.5) There are more specific code choice selections below: 786.09R06.00Dyspnea, unspecified 786.02R06.01Orthopnea 786.09R06.09Other forms of dyspnea

15. Dyspnea Type – Shortness of breath – Orthopnea – Other forms Documentation Tips

16. Use of symptom codes – Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Use of a symptom code with a definitive diagnosis code – Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. – Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Combination codes that include symptoms – ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom. Documentation Tips

17. Sleep apnea (adult) (pediatric) ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 327.20 780.51 G47.30Sleep apnea, unspecified Applicable to: Sleep apnea NOS Apnea NOS (R06.81) Cheyne-Stokes breathing (R06.3) Pickwickian syndrome (E66.2) Sleep apnea of newborn (P28.3) nightmares (F51.5) nonorganic sleep disorders (F51.-) sleep terrors (F51.4) sleepwalking (F51.3) There are more specific code choice selections below: SEE NEXT SLIDE

18. Sleep apnea ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 327.21G47.31Primary central sleep apnea Apnea NOS (R06.81) Cheyne-Stokes breathing (R06.3) Pickwickian syndrome (E66.2) Sleep apnea of newborn (P28.3) nightmares (F51.5) nonorganic sleep disorders (F51.-) sleep terrors (F51.4) sleepwalking (F51.3) 327.22G47.32High altitude periodic breathing 327.23G47.33Obstructive sleep apnea (adult) (pediatric) 327.24G47.34Idiopathic sleep related nonobstructive alveolar hypoventilation Applicable To: Sleep related hypoxia 327.25G47.35Congenital central alveolar hypoventilation syndrome 327.26G47.36Sleep related hypoventilation in conditions classified elsewhere 327.27G47.37Central sleep apnea in conditions classified elsewhere 327.29G47.39Other sleep apnea Code also any associated underlying condition

19. Other nonspecific abnormal finding of lung field ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 793.19R91.8Other nonspecific abnormal finding of lung field Applicable To: Lung mass NOS found on diagnostic imaging of lung Pulmonary infiltrate NOS Shadow, lung abnormal findings on antenatal screening of mother (O28.-) diagnostic abnormal findings classified elsewhere - see Alphabetical Index N/A There are more specific code choice selections below: 793.11R91.1Solitary pulmonary nodule Applicable to: Coin lesion lung Solitary pulmonary nodule, subsegmental branch of the bronchial tree

20. Includes: nonspecific abnormal findings on diagnostic imaging by computerized axial tomography [CAT scan] nonspecific abnormal findings on diagnostic imaging by magnetic resonance imaging [MRI][NMR] nonspecific abnormal findings on diagnostic imaging by positron emission tomography [PET scan] nonspecific abnormal findings on diagnostic imaging by thermography nonspecific abnormal findings on diagnostic imaging by ultrasound [echogram] nonspecific abnormal findings on diagnostic imaging by X-ray examination Documentation Tips

21. Asthma ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 493.00, 493.10J45.20Mild intermittent asthma, uncomplicated or NOS bronchitis due to chemicals, gases, fumes and vapors (J68.0) cystic fibrosis (E84.-) 493.01, 493.11J45.22Mild intermittent asthma with status asthmaticus N/A 493.02, 493.12J45.21Mild intermittent asthma with (acute) exacerbation N/A 493.82J45.991Cough variant asthmaN/A 493.90J45.909 J45.998 Unspecified asthma, uncomplicated Other asthma N/A 493.91J45.902Unspecified asthma with status asthmaticus bronchitis due to chemicals, gases, fumes and vapors (J68.0) cystic fibrosis (E84.-) 493.92J45.901Unspecified asthma with (acute) exacerbation bronchitis due to chemicals, gases, fumes and vapors (J68.0) cystic fibrosis (E84.-)

22. Asthma Severity Chart INTERMITTENTMILD PERSISTENT MODERATE PERSISTENT SEVERE PERSISTENT SYMPTOMS2 or less days per week More than 2 days per week DailyThroughout the day NIGHTIME AWAKENINGS 2 x’s per month or less 3 – 4 x’s per month More than once per week but not nightly Nightly RESCUE INHALER USE 2 or less days per week More than 2 days per week, but not daily DailySeveral times per day INTERFERENCE WITH NORMAL ACTIVITY NoneMinor limitation Some limitation Extremely limited LUNG FUNCTIONFEVI>80% predicted and normal between exacerbations FEV1>80% predicted FEV1 60 – 80% predicted FEV1 less than 60% predicted

23. When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40). Use additional code, where applicable, to identify: – exposure to environmental tobacco smoke (Z77.22) – exposure to tobacco smoke in the perinatal period (P96.81) – history of tobacco use (Z87.891) – occupational exposure to environmental tobacco smoke (Z57.31) – tobacco dependence (F17.-) – tobacco use (Z72.0) Documentation Tips

24. Cough ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 786.2R05Cough Cough with hemorrhage (R04.2) Smoker’s Cough (J41.0) N/A

25. Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Use of a symptom code with a definitive diagnosis code – Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Cough Documentation Tips

26. Cystic fibrosis ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 277.00E84.9Cystic fibrosis, unspecified Includes: mucoviscidosis androgen insensitivity syndrome (E34.5-) congenital adrenal hyperplasia (E25.0) Ehlers-Danlos syndrome (Q79.6) hemolytic anemias attributable to enzyme disorders (D55.-) Marfan's syndrome (Q87.4) 5-alpha-reductase deficiency (E29.1) N/A There are more specific code choice selections below: 277.02E84.0Cystic fibrosis with pulmonary manifestations Use additional code to identify any infectious organism present, such as: Pseudomonas (B96.5) 277.01E84.11Meconium ileus in cystic fibrosis Excludes1: meconium ileus not due to cystic fibrosis (P76.0) 277.03E84.19Cystic fibrosis with other intestinal manifestations Distal intestinal obstruction syndrome 277.09E84.8Cystic fibrosis with other manifestations

27. Identify: Anatomical site Manifestations (e.g. bronchopneumonia) Documentation Tips

28. Pulmonary fibrosis ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 515J84.10Pulmonary fibrosis, unspecified Applicable to: Capillary fibrosis of lung Cirrhosis of lung (chronic) NOS Fibrosis of lung (atrophic) (chronic) (confluent) (massive) (perialveolar) (peribronchial) NOS Induration of lung (chronic) NOS Postinflammatory pulmonary fibrosis drug-induced interstitial lung disorders (J70.2-J70.4) interstitial emphysema (J98.2) lung diseases due to external agents (J60-J70) pulmonary fibrosis (chronic) due to inhalation of chemicals, gases, fumes or vapors (J68.4) pulmonary fibrosis (chronic) following radiation (J70.1) N/A There are more specific code choice selections below: J84.89Other specified interstitial pulmonary diseases

29. When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40). Use additional code, where applicable, to identify: – exposure to environmental tobacco smoke (Z77.22) – exposure to tobacco smoke in the perinatal period (P96.81) – history of tobacco use (Z87.891) – occupational exposure to environmental tobacco smoke (Z57.31) – tobacco dependence (F17.-) – tobacco use (Z72.0) Documentation Tips

30. Sarcoidosis ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 135D86.9Sarcoidosis, unspecified autoimmune disease (systemic) NOS (M35.9) functional disorders of polymorphonuclear neutrophils (D71) human immunodeficiency virus [HIV] disease (B20) N/A There are more specific code choice selections below: 135D86.0Sarcoidosis of lung

31. Idiopathic interstitial pneumonia ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 516.30J84.111Idiopathic interstitial pneumonia, not otherwise specified lymphoid interstitial pneumonia (J84.2) pneumocystis pneumonia (B59) N/A There are more specific code choice selections below: 516.31J84.112Idiopathic pulmonary fibrosis 516.32J84.113Idiopathic non-specific interstitial pneumonitis 516.33J84.114Acute interstitial pneumonitis 516.34J84.115Respiratory bronchiolitis interstitial lung disease 516.36J84.116Cryptogenic organizing pneumonia 516.37J84.117Desquamative interstitial pneumonia

32. When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it shouldbe classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40). Use additional code, where applicable, to identify: – exposure to environmental tobacco smoke (Z77.22) – exposure to tobacco smoke in the perinatal period (P96.81) – history of tobacco use (Z87.891) – occupational exposure to environmental tobacco smoke (Z57.31) – tobacco dependence (F17.-) – Tobacco use (Z72.0) Documentation Tips

33. Bronchiectasis ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 494.0J47.9Bronchiectasis, uncomplicated Applicable to: Bronchiectasis NOS congenital bronchiectasis (Q33.4) tuberculous bronchiectasis (current disease) (A15.0)) N/A There are more specific code choice selections below: 494.1J47.0Bronchiectasis with acute lower respiratory infection Applicable to: Bronchiectasis with acute bronchitis 494.1J47.1Bronchiectasis with (acute) exacerbation

34. When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it shouldbe classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40). Use additional code, where applicable, to identify: – exposure to environmental tobacco smoke (Z77.22) – exposure to tobacco smoke in the perinatal period (P96.81) – history of tobacco use (Z87.891) – occupational exposure to environmental tobacco smoke (Z57.31) – tobacco dependence (F17.-) – Tobacco use (Z72.0) Documentation Tips

35. Multiple sclerosis ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 340G35Multiple sclerosis Applicable To: Disseminated multiple sclerosis Generalized multiple sclerosis Multiple sclerosis NOS Multiple sclerosis of brain stem Multiple sclerosis of cord N/A

36. Chronic Obstructive Pulmonary Disease (COPD) ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 496 491.20 J44.9Chronic obstructive pulmonary disease, unspecified Applicable to: Chronic obstructive airway disease NOS Chronic obstructive lung disease NOS Bronchiectasis (J47.-) Chronic bronchitis NOS (J43) Chronic simple and mucopurulent bronchitis (J14.-) Chronic tracheitis (J42) Chronic tracheobronchitis (J42) Emphyysema without chronic bronchitis (J43.-) Lung diseases due to external agents (J60-J70) N/A There are more specific code choice selections below: 491.22 493.21 J44.0Chronic obstructive pulmonary disease with acute lower respiratory infection 491.21 493.22 J44.1Chronic obstructive pulmonary disease with (acute) exacerbation

37. Code also type of asthma, if applicable (J45) Use additional code to identify: – Exposure to environmental tobacco smoke (Z77.22) – History of tobacco use (Z87.891) – Occupational exposure to environmental tobacco smoke (Z57.31) – Tobacco dependence (F17.-) – Tobacco use (Z72.0) COPD Documentation Tips

38. Other respiratory disorders ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 519.8J98.8Other specified respiratory disorders newborn apnea (P28.4) newborn sleep apnea (P28.3) apnea NOS (R06.81) sleep apnea (G47.3-) There are more specific code choice selections below: J98.01Acute bronchospasm J98.09Other diseases of bronchus, not elsewhere classified J98.11Atelectasis J98.19Other pulmonary collapse J98.2Interstitial emphysema J98.3Compensatory emphysema J98.4Other disorders of lung J98.5Diseases of mediastinum, not elsewhere classified J98.6Disorders of diaphragm J98.9Respiratory disorder, unspecified

39. When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it shouldbe classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40). Use additional code, where applicable, to identify: – exposure to environmental tobacco smoke (Z77.22) – exposure to tobacco smoke in the perinatal period (P96.81) – history of tobacco use (Z87.891) – occupational exposure to environmental tobacco smoke (Z57.31) – tobacco dependence (F17.-) – Tobacco use (Z72.0) Documentation Tips

40. Localized swelling, mass and lump, trunk ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 786.6R22.2Localized swelling, mass and lump, trunk abnormal findings on diagnostic imaging (R90-R93) edema (R60.-) enlarged lymph nodes (R59.-) localized adiposity (E65) swelling of joint (M25.4-) intra-abdominal or pelvic mass and lump (R19.0-) intra-abdominal or pelvic swelling (R19.0-) abnormal findings on antenatal screening of mother (O28.-) certain conditions originating in the perinatal period (P04- P96) signs and symptoms classified in the body system chapters signs and symptoms of breast (N63, N64.5) breast mass and lump (N63)

41. Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Use of a symptom code with a definitive diagnosis code – Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Documentation Tips

42. On October 01, 2015 we will monitor claims for date of service rules Outpatient claims cannot have crossover dates Outpatient claims will be coded according to date of service Inpatient facility claims will be coded per date of discharge We will monitor claims to resolve any unanticipated problems with the submission process Monitor Claims

43. We will monitor for claim denials We will monitor editing trends for ICD-10 Coding guidelines We will provide feedback to the physicians regarding supporting documentation requirements We will monitor WC or Liability carriers for published rules on use of ICD-9 or ICD-10 code sets Claim Denial and Management

44. Client will need to update – Templates – Order Sets – Superbills – Favorites Future Orders – Remove ICD-9 code add ICD-10 code Client Responsibilities

45. All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection. Site specificity Document notation of qualifiers – Exacerbation – Manifestations – Relapse – Status – Stages Indicate acute or chronic Indicate underlying or external cause factors – Medication – Smoke – Accidents – Mechanical failure Laterality – Bilateral – Right – Left Documentation – Start Now

46. Episode of Care for injuries, poisoning, external causes and other conditions – Initial Encounter Use while the patient is receiving active treatment of the condition – Active treatment includes surgical treatment, an emergency encounter, and evaluation and treatment by a new physician – Subsequent Encounter Used on encounter after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. – Medication adjustments, aftercare, device adjustments, cast change – Sequela Used for complications or conditions that arise as a direct result of a condition, late effect Documentation – Start Now

47. Combination codes that capture – Etiology and manifestation – Related conditions – Disease, injury or other medical condition and complications – Disease or other medical conditions and common signs or symptoms Add ICD-10 Codes to patient Problem List Documentation – Start Now

48. Underdosing Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”). Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded. Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known. OGCR Section 1.C.19.e.5.c Official Guidelines for Coding and Reporting

49. codingresource@g1hs.com Centers for Disease Control and Prevention (ICD-10-CM) http://www.cdc.gov/nchs/icd/icd10cm.htmQuestions