Financial Disclosure
Preparing for ICD-10-CM
Mary Pat Johnson is a Senior Consultant at Corcoran
Consulting Group and acknowledges a financial
interest in the subject matter of this presentation.
Mary Pat Johnson, COMT, CPC, COE, CPMA
Senior Consultant
Corcoran Consulting Group
Key Points in Code Selection
ICD-10-CM Changes Everything
• ICD-10 is more specific than ICD-9
• Attention to detail
• Consider primary diagnosis, cause and/or related
conditions
Who is Impacted?
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Physicians
Administrators
Coders / Billers
Technicians
Receptionists
IT Staff
Billing companies
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How does ICD-10 Impact?
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Payer policies
Pre-authorizations
PQRS
Tracking of services
Marketing
Forms
Practice management system
History of ICD-10-CM
Why Replace ICD-9 ! ?
• International Classification of Diseases, 10th
Revision, Clinical Modification
• ICD-9 is >30 years old, outdated, obsolete
terminology
• Developed by U.S. National Center for Health
Statistics (NCHS) in 1993
• Outdated codes producing inaccurate and limited
data
• ICD-10 copywritten by the World Health
Organization (WHO)
• Inconsistent with current medical practice
• Does not provide enough detail
• ICD-10-CM replaces ICD-9-CM, volumes 1 and 2
• United States is one of last countries to adopt ICD10
ICD-10-CM
• Much greater specificity and clinical information
ICD-10-CM
• Use of most specific code(s) is not optional
• Codes that allow comparison of mortality and
morbidity data
• Provides better data to:
• Increased number of concepts and codes provided
• Measure care
• Process claims
• Disease classifications include health related
conditions
• Track public health
• Identify fraud and abuse
• Conduct research
Benefits of ICD-10
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More accurate payment for new procedures
Fewer rejected claims
Fewer improper claims
Better understanding of new procedures
Improved disease management
Source: Federal Register, Vol. 74, No. 11 1/16/09
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Deadline
• Final rule for adoption of ICD-10-CM
• Published in January 16, 2009 Federal Register (45
CFR part 162)
• Compliance date is October 1, 2013
• Initial delay to October 1, 2014
ICD-10 Delayed Again…
• March 31, 2014 - HR 4302 signed by President
Obama
Compare and Contrast
ICD-9
ICD-10
• 17 Chapters
• 21 Chapters
• SGR formula – temporary fix
• 14,000 codes
• ~ 69,000 codes
• ICD-10 delayed … “The Secretary of Health and
Human Services may not, prior to October 1,
2015, adopt ICD-10 code sets as the standard
code sets under section 1173(c) of the SSA and
section 162.1001 of 45CFR”
• 3-5 digits
• 3-7 digits
• First digit is numeric or
alpha (E or V)
• Digit 1 is alpha
• Digits 2-5 are numeric
• Digits 3-7 are alpha or
numeric (alpha digits are
not case sensitive)
Compare and Contrast
ICD-9
ICD-10
Example:
Example:
• Central corneal ulcer –
370.03
• Central corneal ulcer right
– H16.011
• Central corneal ulcer left
– H16.012
• Central corneal ulcer
bilateral – H16.013
• Central corneal ulcer
unspecified – H16.019
“GEM” Files
• Two sets of files
• ICD-9 to ICD-10
• ICD-10 to ICD-9
• Each file contains “code pairs” – one from each set
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• Digit 2 is numeric
“GEM”
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General Equivalence Mappings
No “simple” crosswalk contained in this file
GEM file is NOT a crosswalk, it is a mapping
Expect annual update of files
Eye codes translation is fairly straightforward
“GEM” Files
• No decimal point in the codes
• Three columns
• Third column describes additional attributes
• Flags (approximate, no map, combination)
• Combination entry
• 1 indicates “on” (Approximate)
• 0 indicates “off” (Direct hit, but verify)
GEM File Layout
Senile Cataract Example
I-9 
36610
36611
36612
36613
36614
36615
36616
36617
36618
36619
36619
I-10
+ Flags
H259
H2589
H25099
H25039
H25049
H25019
H2510
H2589
H2520
H25819
H2589
00000
10000
10000
10000
10000
10000
10000
10000
10000
10000
10000
“GEM” Files
• Use GEMS
• Translating lists of codes
• Converting a system or application
• To study differences in meaning between two
systems
• Use Code Books
• Translating short list of codes
• Access to medical record
“1” in the first position in flag column = approximate
Organization of ICD-10-CM
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Introduction
Conventions and Guidelines
Alphabetic Index to Diseases
Neoplasm Table
Table of Drugs and Chemicals
Index to External Causes
Tabular List of Diseases
Alphabetic Index Notes
• Define terms
• Provide direction
• Wound, superficial (see also specified injury
type)
• Provide coding instructions
• Trichiasis (eyelid) – H02.059
• with entropion – see Entropion
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Conventions for the ICD-10-CM
Format
1. Alphabetic Index
• Index of Diseases and Injury
• Index of External Causes of Injury
• Table of Neoplasms
• Table of Drugs and Chemicals
2. Tabular List
• Categories
• Subcategories
• Codes
Tabular List
• Categories
• 3 characters – Chapter 7 – Disorder of the Eye
and Adnexa (H00-H59)
• Subcategories
• 4th character further defines site, etiology,
manifestation or state of disease or condition
• 5th & 6th character increases specificity
7th Character Extension
Tabular List
• 7th Character Extension
• Some categories have applicable
7th
characters
• Last character
• A
• D
• S
initial encounter
subsequent encounter
sequela
• If code is not six digits, use “x” as placeholder
• “x” as placeholder
• For when characters are needed for expansion
Example
Example
Corneal Abrasion
Corneal Abrasion
• Category – Chapter 19 – Injury, Poisoning . . .
S05 – Injury of eye and orbit
• Subcategory –  5th S05.0 – Injury of conjunctiva and
corneal abrasion without foreign body
• Specificity –  x 7th S05.01 – Injury of conjunctiva
and corneal abrasion without foreign body right eye
• Valid code – S05.01xA -- Injury of conjunctiva and
corneal abrasion without foreign body right eye;
initial encounter
7th Character Extension
For glaucoma staging, 7th denotes severity of disease
• 1 = mild
0 = unspecified
• 2 = moderate
4 = indeterminate
• 3 = severe
Example: Glaucoma Staging
7th character “is to be assigned to each code in
subcategory H40.12 to designate the stage of glaucoma”
• Low-tension Glaucoma
• H40.12
• Low-tension Glaucoma, bilateral
(cannot stop here!)
• H40.123
• Low-tension Glaucoma, right eye, moderate stage
• H40.1212
• Low-tension Glaucoma, left eye, severe stage
• H40.1223
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Laterality
Terminology
“Laterality”
• Right and left designation • Example
1 = right
2 = left
3 = bilateral
0 or 9 = unspecified
H25.11 Age-related nuclear
cataract, right eye
H25.12 Age-related nuclear
cataract, left eye
H25.13 Age-related nuclear
cataract, bilateral
H25.10 Age-related nuclear
cataract, unspecified eye
Terminology
Terminology
“Laterality”
“Combination Code”
Exception example (diseases of eyelids)
• H02.011 Cicatricial entropion of right upper eyelid
• H02.012 Cicatricial entropion of right lower eyelid
• H02.013 Cicatricial entropion of right eye,
unspecified eyelid
• H02.014 Cicatricial entropion of left upper eyelid
• H02.015 Cicatricial entropion of left lower eyelid
• H02.016 Cicatricial entropion of left eye,
unspecified eyelid
• H02.019 Cicatricial entropion of unspecified eye,
unspecified eyelid
Other “Conventions”
• Single code used to
classify two diagnoses
1. Diagnosis with an
associated
manifestation
2. Diagnosis with an
associated
complication
Terminology
“Code Also”
• Instructs that two codes
may be required to fully
describe a condition;
sequencing depends on
severity of conditions and
reason for the encounter.
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• Examples
E11.321 – Type 2 diabetes
mellitus with mild
nonproliferative diabetic
retinopathy with macular
edema
H59.032 – Cystoid macular
edema following cataract
surgery, left eye
• Example
H18.03 – Corneal deposits
in metabolic disorders
Code also associated
metabolic disorder
Terminology
Terminology
“See” and “See Also”
“Code First / Use Additional Code”
• “See” follows a main term • Examples
in the index indicating
Lesion
that it is necessary to go
eyelid – see Disorder,
eyelid
to that term to locate the
correct code.
• “See Also” follows a main
term in the index
indicating that another
term may also be useful.
Retinochoroiditis (see also
Inflammation, chorioretinal)
• Example
H42 – Glaucoma in diseases
classified elsewhere
Code first underlying condition,
such as: aniridia (Q13.1)
• Etiology / manifestation
rule; the underlying
condition is listed first
with the manifestation
listed second.
Q13.1 – Absence of iris
Aniridia
Use additional code for
associated glaucoma (H42)
• “Code first” will be listed
at the etiology code; “Use
additional code” will be
listed at the manifestation
code.
Terminology
Terminology
“Excludes”
“and”
• Examples
• “Excludes 1” – excluded
code should never be used
H01.0 – Blepharitis
at the same time as the
Excludes 1
code above excludes 1 note.
blepharoconjunctivitis (H10.5-)
• “Excludes 2” – represents
“Not included here”;
H00.1 – Chalazion
Condition excluded not part
Meibomian (gland) cyst
of condition represented by
Excludes 2 infected meibomian
the code; patient may have
gland (H00.02-)
both conditions at the same
• When the term “and” is
used in a narrative
statement, it represents
and / or.
• Example
T26.11 – Burn of cornea
and conjunctival sac, right
eye
time; may use both codes
when appropriate.
Abbreviations
• NEC
• “Not elsewhere classifiable”
• Represents “other specified”
• Detail for which a specific code does not exist
• NOS
• “Not otherwise specified”
• Represents “unspecified”
• For when a more specific code cannot be
assigned
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How to find a code
General Guidelines
General Guidelines
• Diagnosis codes are to be used and reported to the
highest number of characters available.
• Multiple codes may be required for a single condition
that affects multiple body systems.
• Signs and symptoms are acceptable when a
definitive diagnosis has not been established by the
provider.
• Principal diagnosis should be based on the condition
that prompted the visit and was the primary focus of
treatment.
• Do not code diagnoses documented as “probable”,
“suspected”, “questionable”, “rule out”, or “working
diagnosis” or other similar terms indicating
uncertainty.
• Code all documented conditions that coexist at the
time of the visit, and require or affect patient care
treatment or management.
How to Use the ICD-10-CM
1. Look up the main term in the Alphabetical Index,
scan subterm entries if needed. Review continued
lines / additional subterms.
2. Note parenthetical terms that help with code
selection but do not affect code assignment
• Do not code conditions that were previously treated
and no longer exist.
How to Use the ICD-10-CM (continued)
3. Pay attention to the following index instructions in the
Alphabetical Index
• “see”, “see also”, and “see category” crossreferences
•
“with” and “without” notes
•
“omit code” notes
•
•
“due to” subterms
other instructions found in note boxes, such as
“code by site”
4. Do not code from the Alphabetical Index without
verifying the accuracy of the code from the Tabular
List
How to Use the ICD-10-CM (continued)
5. Read all instructional material in Tabular Index,
including
Cataract Example
CC: cataracts, OU, slow decrease VA during
past 6 mos, trouble reading, glare worsening
Dx: Nuclear sclerotic cataracts OD>OS
Tx: Schedule phaco IOL OD
•
“includes” and “excludes” notes
•
“use additional code” and “code first underlying
disease”
•
“code also”
ICD-9: 366.16 Nuclear Sclerotic Cataract
•
fourth-, fifth-, sixth-, and seventh- digit
requirements
What is the appropriate ICD-10 code?
6. Consult the ICD-10-CM guidelines for use of specific
codes
7. Confirm and assign the correct code
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Cataract
Step 1: Alpha Index: Search “cataract”
• Cataract (cortical) (immature) (incipient) H26.9
Step 2: Under “cataract” search “nuclear sclerotic”
• - nuclear
• - - sclerosis —see Cataract, senile, nuclear
Cataract
• Step 4: Go to H25.1- in Tabular List
• H25.1 Age-related nuclear cataract
•
•
•
•
•
•
Cataracta brunescens
Nuclear sclerosis cataract
H25.10 Age-related nuclear cataract, unspecified eye
H25.11 Age-related nuclear cataract, right eye
H25.12 Age-related nuclear cataract, left eye
H25.13 Age-related nuclear cataract, bilateral
Cataract
• Step 3: See Cataract Senile Nuclear
• - senile H25.9
• - - brunescens —see Cataract, senile, nuclear
• - - combined forms H25.81• - - coronary —see Cataract, senile, incipient
• - - cortical H25.01• - - hypermature —see Cataract, senile, morgagnian type
• - - incipient (mature) (total) H25.09• - - - cortical —see Cataract, senile, cortical
• - - - subcapsular —see Cataract, senile,
subcapsular
• - - morgagnian type (hypermature) H25.2• - - nuclear (sclerosis) H25.1-
Cataract
CC: Cataracts, OD, slow decrease VA during
past 6 mos, trouble reading, glare worsening
Dx: Nuclear sclerotic cataracts OD>OS
Tx: Phaco IOL OD
H25.13 NS, Cataract, OU
• Step 5: No additional instructions in tabular list
• Step 6: No additional guidelines
• Step 7: Assign code
Chapters
Chapters
1. Certain Infectious and Parasitic Diseases (A00B99)
8. Diseases of Ear and Mastoid Process (H60-H95)
2. Neoplasms (C00-D49)
10.Diseases of Respiratory System (J00-J99)
3. Diseases of the Blood and Blood-forming Organs
(D50-D89)
11.Diseases of Digestive System (K00-K94)
4. Endocrine, Nutritional and Metabolic Diseases
(E00-E90)
9. Diseases of Circulatory System (I00-I99)
12.Diseases of Skin and Subcutaneous Tissue (L00L99)
5. Mental and Behavioral Disorders (F01-F99)
13.Diseases of the Musculoskeletal System and
connective Tissue (M00-M99)
6. Diseases of Nervous System (G00-G99)
14.Diseases of Genitourinary System (N00-N99)
7. Diseases of Eye and Adnexa (H00-H59)
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Chapters
Chapters
15.Pregnancy, Childbirth, and the Puerperium (O00O99)
19.Injury, Poisoning, and Certain Other
Consequences of External Causes (S00-T88)
16.Newborn (Perinatal) Guidelines (P00-P96)
20.External Causes of Morbidity (V01-Y99)
17.Congenital Malformations, Deformations, and
chromosomal Abnormalities (Q00-Q99)
21.Factors Influencing Health Status and Contact with
Health Services (Z00-Z99)
18.Symptoms, Signs, and Abnormal Clinical and Lab
Findings, NEC (R00-R99)
Ch. 4: Endocrine, Nutritional,
and Metabolic Diseases (E00-E89)
•
Diabetes mellitus
• Combination codes that include
• Type of diabetes mellitus
• Body system affected
• Complications affecting body system
• Sequenced based on reason for encounter
Diabetes Mellitus
• Five diabetes mellitus categories
• E08 Diabetes mellitus due to an underlying
condition
• E09 Drug or chemical induced diabetes mellitus
• E10 Type 1 diabetes mellitus
• E11 Type 2 diabetes mellitus
• E13 Other specified diabetes mellitus
*Use E11 if record does not indicate type of DM, but
does indicate insulin use.
Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines
Diabetes Mellitus
Diabetes Mellitus
Insulin use
Examples
• All categories except E10 (Type 1 DM) require use
of additional code to indentify any insulin use
• Z79.4 – Long term (current) use of insulin
• E11.9
Type 2 DM without complications
• E10.339 Type 1 DM with moderate NPDR without
macular edema
• E11.321 Type 2 DM with mild NPDR with
macular edema
&
• Z79.4
Long-term current use of insulin (if
documented)
Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines
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Case Study
Chapters
19.Injury, Poisoning, and Certain Other
Consequences of External Causes (S00-T88)
While sitting at the 10th tee
box, your patient is struck in
the left eye with a golf ball
causing a traumatic
hyphema. Code this
encounter with ICD-10
codes.
20.External Causes of Morbidity (V01-Y99)
21.Factors Influencing Health Status and Contact with
Health Services (Z00-Z99)
Case Study
Documentation Considerations
ICD-10 Codes
S05.12xA Contusion of eyeball and orbital tissues,
left
eye, initial encounter
V86.59xA Driver of golf cart injured in nontraffic
accident
W21.04xA Struck by golf ball
Y92.39
Golf course as place of occurrence
Y93.53
Activity, golf
• Laterality
• Is your assessment specific to which eye or
eyelid?
• Etiology / Manifestation
• Does your chart note list both the disease and
the associated manifestation?
• Specificity
• Is the impression as specific as possible for a
particular condition?
Documentation Considerations
Documentation Considerations
History – ROS
History – HPI & PFSH
Old
New
• Diabetic
• Type II diabetes on insulin
• Cataract OD from injury
• Cataract OD caused by
driver side airbag
• Hypertension
• Shingles
• HIV positive
• Hypertension; history of
tobacco use
• Shingles w/ear infection
• Asymptomatic HIV
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Old
New
• Eyelid laceration
• Laceration right eyelid
from contact with a chisel
(workbench tool)
• FB sensation OD, poor
“blink” 3 days
• FB sensation OD, poor
“blink” 3 days; recent dx of
Bell’s palsy
• Elevated IOP; seen at
health fair
• Family history of glaucoma
Documentation Considerations
Documentation Considerations
Impression
Impression
• BDR OU
• Iritis OU
• Hyphema OD
• No maculopathy
• Chalazion LLL
• Type II diabetes with mild
NPDR w/out macula
edema; taking insulin
• Chronic iritis OU
• Traumatic hyphema OD
• RA taking plaquenil; no
ocular disease
Common Patient Syndromes
• R46.0 – Low level of
personal hygiene
Old
New
Old
• Chalazion OS
• R19.6 – Halitosis (bad
breath)
New
• Myopia
• Myopia OU; regular
astigmatism OD
• CME
• CME OD after cataract sx
• Ptosis
• Mechanical ptosis OU
• Complex cataract
• NS cataract OD, floppy iris
syndrome, adverse effect
of Tamsulosin
Key Points in Preparation
• History and Timeline
• Gather resources
• Assess and Improve Documentation
• Practice, Practice, Practice
• One Step at a Time
Begin Using ICD-10 Codes
• Practice early, practice often!
Begin Using ICD-10 Codes
• Divide tasks in to workable segments
• You are asking people to change habits or
patterns
• refractive error and cataract codes
• This takes time and practice
• cornea and external eye codes (plastics)
• glaucoma
• Continue reporting ICD-9 for claims submission
• retina and diabetes code
• “Double code” a few of claims with ICD-10 codes
• Injuries and infections
• Compare your answers with each other
• Use for training and glossary most common codes
• Use this time to assess tools available to you
• Apps, websites etc
• Use this time to educate staff
• History taking, documentation, anatomy
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Resources
Resource Links
•
•
•
•
•
Useful Aids
• “Apps”
• Apple – iPhone
• Android
• World Health Organization
• AAPC Code Translator
• http://www.aapc.com/ICD-10/codes/index.aspx
• Others
• http://www.icd10data.com/
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www.cms.gov/ICD10/
www.aapcps.com
www.ahima.org
www.cdc.gov/nchs/icd.htm
www.who.int/en/
More help…
For additional assistance or confidential consultation,
please contact us at:
(800) 399-6565
or
www.CorcoranCCG.com
[email protected]
APPENDIX
How To SEARCH For A Code Within ICD‐10‐CM General guidelines: 1.
ALPHABETIC index a place to START 2.
TABULAR List is most specific – code from here! 3.
Report HIGHEST number of characters possible Specific guidelines: 1.
Identify reason for visit/encounter a. Diagnoses b. Problems c. Complaints d. Signs and symptoms i. Used for reporting when no related definitive diagnosis is established e. Conditions i. Report those that are an integral part of a disease process 1. Do not use additional codes ii. Conditions that are not an integral part of a disease process 1. Code when present (see below if “multiple conditions”) 2.
Multiple coding for a single condition a. Required for i. Any condition with a “use additional code” note b. May be needed for i. Fully describing a condition, such as ii. Late effects iii. Complication codes iv. Obstetric codes 3.
Acute and chronic conditions a. If both are present i. Code both ii. Sequence acute code first _______________________________________________________________________________________
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4.
5.
6.
7.
8.
9.
Combination code a. Single code to classify either i. Two diagnoses ii. Diagnosis with associated secondary process iii. Diagnosis with associated complication b. Do not use multiple codes if combination code identifies all elements Late effects (sequelae) a. Residual effect after acute phase of injury/illness b. No time limit c. Condition code sequenced first, late effect code sequenced second d. Do not use with acute injury code Impending or threatened condition a. If condition did occur, code as diagnosis b. If condition did not occur, reference “impending”, “threatened” i. If subentry terms for “impending” or “threatened” are listed: 1. Assign the appropriate code ii. Are not listed: 1. Code existing underlying conditions c. Do not code the impending/threatening condition Reporting same diagnosis code more than once a. Each code may be used once per encounter Laterality a. For codes that can have bilateral sites b. Final character of code indicates laterality (0 or 9, 1, 2, 3) c. If no bilateral code is provided, assign separate codes for right and left sides RARE for Ophthalmology: Documentation for BMI and pressure ulcer stages a. May be based on documentation from clinicians who are not the patient’s provider b. Associated diagnosis must be documented by patient’s provider c. BMI codes are always secondary diagnoses __________________________________________________________________________________________
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