Transition to ICD-10-CM
HMSA
Long Term Services and
Supports
August 12, 2015
PRESENTED BY:
ESSIE WHITE, CPC, COC, CGSC, CPC-I, CPMA
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1
Disclaimer
• The information presented herein contains the views
of the presenter and does not imply a formal
endorsement or consultation engagement on the part
of Healthcare Coding Consultants of Hawaii. Attendees
are cautioned that information contained in this
presentation is not a substitute for informed medical
coding judgment.
• Healthcare Coding Consultants of Hawaii and the
presenter disclaim all responsibility for any use made
of such information.
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Course Objectives
• Examine and familiarize yourself with the
ICD-10-CM book
• Examine organizational changes to ICD-10
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ICD-10 Transition: Five Phases
1.
2.
3.
4.
5.
Engage and Educate Staff
Assess Current Readiness and Impact
Create a Timeline and Transition Plan
Implement your Transition Plan
Conduct Post Transition Analysis and
Reporting
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4
Documentation & Transition
• Documentation is the cornerstone for ICD-10
transition success
• Accurate documentation is the primary
responsibility physicians and other clinical
providers have in the move to ICD-10
• Providers should focus on documentation
elements and not the overwhelming number
of new codes
• It’s important to engage your referral sources in
providing accurate clinical information to
support medical necessity
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Introduction
ICD-10-CM OVERVIEW
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ICD-10 Background Information
• Published by WHO in 1990
• U.S. last industrialized nation to
implement ICD-10
• Two parts: ICD-10-CM and ICD-10-PCS
– ICD-10-CM - Diagnosis
• 3–7 alpha/numeric characters
– ICD-10-PCS – Inpatient Procedure (only)
• 7 alpha/numeric characters for -PCS
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Official Guidelines
Developed by the Cooperating
Parties:
• American Hospital Association (AHA)
• American Health Information
management Association (AHIMA)
• Centers for Medicare and Medicaid
Services (CMS)
• National Center for Health Statistics
(NCHS)
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Overall Coding Process is the Same!
1. Capture the required encounter
documentation
2. Choose the correct code
 Alphabetic Index
 Tabular List
 Read instructional notations
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ICD-9-CM and ICD-10-CM Differences
ICD-9-CM diagnosis codes
ICD-10-CM diagnosis codes
 3-5 numeric digits in length
 3-7 Alpha-Numeric
characters in length
 First digit may be alpha (E or  Character one is alpha
V) or numeric;
 Character two is numeric
 Digits 2-5 are numeric
 Characters 3-7 are alpha or
numeric
 Lacks detail
 Very specific
 Lacks laterality
 Has laterality
 Approximately 14,000 codes  Approximately 69,000
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available codes
ICD-10 Format
ICD-10 codes are alpha numeric
All letters of the alphabet except U
“V” codes are now in the Z section
“E” codes are now V,W,X,Y codes
Second through seventh characters are
a combination of letters and numbers
• “O is not an 0…...”
• “I is not a 1……”
•
•
•
•
•
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ICD-10-CM vs. ICD-9 Code Structure
ICD-10-CM Code Format
ICD-9-CM Code Format
Ex: Unspecified Hearing loss, right ear
ICD-10
H91.91
ICD-9
389.9
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Code Structure
• Most, but not all, categories are further
subdivided into 4 or 5 character
subcategories
• If a category is not further subdivided
it is considered to be a valid code
• Fourth character 8 is used to indicate
“other specified”
• Fourth character 9 is used to
indicate “unspecified”
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Compare Codes
• H54.41 Blindness right eye,
normal vision left eye
• S42.311K Greenstick
fracture of shaft of humerus,
right arm, Subsequent
encounter for fx with
nonunion
• T45.2X5A Adverse
effect of vitamins, Initial
encounter
• 369.60 Blindness one
eye
• 733.82 Nonunion of
Fracture
• E933.5 Vitamins, not
elsewhere classified,
causing adverse effects
in therapeutic use
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NEW
Placeholder Character
• Provides for future expansion as 5th
character for certain 6 character codes
without disturbing the 6th character
structure
• Assign for all characters less than 6 in
order to meet requirement of coding
when 7th character is required
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Placeholder Character
• What is the use of the “X” placeholder in
subcategory M84.40?
• M84.40XA - Placeholder in 6th
• What is the use of the “X” placeholder(s)
in category X78?
• X78.9XXA – Placeholder in 5th and 6th
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General Coding Guidelines
• No change in guidelines from ICD-9
– Code to highest level of specificity
– Code signs and symptoms in the absence
of a definitive diagnosis
– Do not code signs and symptoms that are
an integral part of a disease process
– Code signs and symptoms that are not an
integral part of a disease process
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Laterality
NEW
Right
Left
Bilateral
 If no bilateral code is provided, code
both right and left
 If the side is not indicated in the
documentation, code unspecified
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NEW
Laterality
H60.332 Swimmer’s ear, left ear
S63.511A Sprain of carpal joint of right
wrist, initial encounter
H65.06 Acute serous otitis media,
recurrent, bilateral
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NEW
Laterality
Right
Left
 Neoplasm codes now include laterality as
well as specific site
 If the side is not indicated in the
documentation, code unspecified
 Examples: breast, ovary, cornea, lung, limb
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Organization and Classification
• Diabetes and malnutrition have their own
subchapters and code titles revised
• Diabetes now has five categories
– (E08 – E13) – NO E12
• Controlled/uncontrolled is not a factor in
code selection
• See index - Diabetes
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Diabetes Mellitus
Type of DM
Combination
codes include
Body system
affected
Complications
affecting that
body system
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Diabetes Mellitus
• Use as many codes as necessary to
identify all of the associated conditions
• Type 2 DM is default if type is not
documented
• Z79.4 Long term (current) use of insulin
– Use only with Type 2 DM as appropriate
– Do not use if insulin is given temporarily
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Mental, Behavioral, and
Neurodevelopmental
Disorders (F01- F99)
CHAPTER 5
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Organization and Classification
• Unique codes for alcohol and drug use,
abuse, and dependence
• Continuous or episodic no longer
classified
• Combination codes
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Pain Disorders
• F45.41 – Pain exclusively related to
psychological disorders
• F45.42 – Pain disorders with related
psychological factors + code from
category G89
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Remission
• Selection of codes for “in remission” for
categories F10-F19 requires the
provider’s clinical judgment.
– The appropriate codes for “in remission”
are assigned on the basis of provider
documentation
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Dementia
• Do not use category F02 – Dementia in
other diseases classified elsewhere as
primary diagnosis
• Use category F01 if dementia is a result
of cerebral infarction
• Use category F03 for unspecified
Dementia
• Use category G30 for Alzheimer’s
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Dementia
• Symptoms common among people living
with advanced dementia:
– Pain
– Agitation
– Nutritional concerns
– Infections
– Delirium
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Mental Health Examples
•
•
•
•
•
•
•
•
F70 Mild intellectual disabilities
F71 Moderate intellectual disabilities
F72 Severe intellectual disabilities
F73 Profound intellectual disabilities
F78 Other intellectual disabilities
F79 Unspecified intellectual disabilities
F80.1 Expressive language disorder
F80.4 Speech and language development delay
DUE to hearing loss
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Diseases of the Nervous
System (G00 – G99)
CHAPTER 6
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Organization and Classification
• Sleep disorders have been moved from
signs and symptoms (ICD-9) to nervous
system
– Sleep apnea has its own subcategory with
greater specificity to identify type
• Diseases of the sense organs are no
longer contained in the same chapter as
the nervous system
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NEW
Dominant v. Non-Dominant
• Document - Dominant/Non-dominant
in addition to Left or Right
• If dominant side is not documented use
the following default guidelines:
– For ambidextrous patients, the default should
be dominant.
– If the left side is affected, the default is nondominant.
– If the right side is affected, the default is
dominant.
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Pain – Category G89
• May be used in conjunction with other
codes to provide more detail
– Acute or Chronic
– Neoplasm-related
– Post procedural , Post-thoracotomy or Posttraumatic
• Do not use category G89 if pain is not
specified as one of the above
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Sequencing Pain – Category G89
• Primary
– Pain control/pain management is the
reason for encounter
– Neurostimulator is inserted for pain
• Secondary
– Encounter is for any other reason except
pain control/management
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Category G40 (Epilepsy and Recurrent
Seizures) and G43 (Migraine)
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Hemiplegia and Hemiparesis
• Category G81 Hemiplegia, G82
Paraplegia and quadriplegia, G83 Other
paralytic syndromes
– Use only when listed conditions are
reported without further specification or are
stated to be old or longstanding, with
unspecified cause
• Paralytic sequelae of infarct/stroke are in
Chapter 9
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Cerebral Palsy
• G80.0 Spastic quadriplegic cerebral palsy
•
•
•
•
•
•
G80.1
G80.2
G80.3
G80.4
G80.8
G80.9
Spastic diplegic cerebral palsy
Spastic hemiplegic cerebral palsy
Athetoid cerebral palsy
Ataxic cerebral palsy
Other cerebral palsy
Cerebral palsy, unspecified
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Left-sided hemiplegia
G81.94
Hemiplegia. Review Tabular for
complete code assignment.
Rationale: Under the term Hemiplegia in the index, the
only code option for this diagnosis is G81.9-. Review
the Tabular under G81.9-, which offers five code
choices. Coding Guideline I.C.6.a states “Should the
affected side be documented, but not specified as
dominant or nondominant and the classification system
does not indicate a default, code selection is as follows:
If the left side is affected the default is nondominant.”
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Diseases of the Eye and
Adnexa (H00 – H59)
CHAPTER 7
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NEW
Organization and Classification
• Entirely new chapter
• Different organization than ICD-9
– Structure still by “site” but order differs
• Title changes to some categories to
reflect current terminology
• Expansion of characters to provide for
anatomic specificity and laterality
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Disease of the Ear and
Mastoid Process (H60-H95)
CHAPTER 8
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NEW
Organization and Classification
• New chapter in ICD-10-CM
• Diseases have been arranged into blocks
for easier identification:
– External ear
– Middle ear and mastoid
– Inner ear
– Other disorders of the ear
– Intraoperative and postprocedural
complications
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Official Guidelines
• There are no official guidelines at
this time except for those
contained in the Chapter and subchapter headings
– i.e. Use add’t code for perforated
tympanic membrane, H72.– i.e. Use add’t code to identify tobacco
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Eyes/Ears Examples
• H54.0 Blindness, both eyes
• H54.12 Blindness left eye normal rt
• H54.8 Legal blindness, as defined in
USA
• H90.0 Conductive hearing loss,bilateral
• H91.03 Ototoxic hearing loss, bilateral
• H91.3 Deaf nonspeaking, not
elsewhere classified
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Diseases of the Circulatory System
(I00-I99)
CHAPTER 9
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Organization and Classification
• Terminology was revised to reflect more
current medical practice
• Hypertension is no longer classified as
benign, malignant or unspecified
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Hypertension
• More than just I10
• HTN “with” Heart Disease requires
documentation causal relationship
– Heart disease due to hypertension
– Hypertensive heart disease
• HTN with CKD
– Presumes cause-and-effect
• Read guidelines carefully
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Sequelae of Cerebrovascular
Disease (CVD) (Category I69)
• Sequelae of conditions classifiable to
I60 – I67
• May be present at onset or anytime
after the onset
• Use same guidelines for dominant vs.
non-dominant as Chapter 6
• Use I69 if patient has current CVD with
deficits from old CVD
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Diseases of the Respiratory
System (J00-J99)
CHAPTER 10
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Organization and Classification
• Organized similarly to ICD-9-CM; however,
diseases have been rearranged.
• Terminology changes
– Example: Asthma classified as mild persistent,
moderate persistent, and severe persistent
• Classification changes that provide greater
specificity
– Manifestations are reflected in the code
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Chapter 10 - Guidelines
• When assigning any code from this
chapter, use an additional code to identify
any tobacco dependence, use, or
exposure
• J10 Influenza contains a note to use an
additional code to identify the virus
• J44 and J45 distinguish between
uncomplicated cases vs. acute
exacerbation
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NEW
Stages of Asthma
Asthma Severity
Intermittent
•
Mild Persistent
•
Moderate Persistent
•
Severe Persistent
•
Frequency of Daytime
Symptoms
Less than or equal to 2
times per week
More than 2 times per
week
Daily. May restrict
physical activity
Throughout the day.
Frequent severe attacks
limiting ability to breathe.
Source: Worldallergy.org
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Coding Scenario
The patient has increasing shortness of
breath, weakness, and ineffective cough.
Treatment included oxygen therapy.
Diagnoses listed as acute respiratory
insufficiency due to acute exacerbation of
COPD and tobacco dependence. What
diagnosis codes are assigned?
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J44.1
F17.200
Z99.81
Disease, diseased, pulmonary,
chronic obstructive, with
exacerbation (acute)
Dependence (on) (syndrome),
tobacco – see dependence, drug,
nicotine
Dependence, oxygen (long-term)
(supplemental)
Rationale: The acute respiratory insufficiency is a
symptom that is an integral part of the COPD and is not
coded.
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Diseases of the Digestive
System (K00-K95)
CHAPTER 11
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Organization and Classification
• New subchapters have been added
– Example: Diseases of the liver
• Terminology changes
– Hemorrhage is used for ulcers
– Bleeding is used for gastritis, duodenitis,
diverticulosis, and diverticulitis
– Identification of obstruction is no longer a
part of the ulcer code structure
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Diseases of the Skin and
Subcutaneous Tissue (L00-L99)
CHAPTER 12
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Organization and Classification
• Complete restructuring
– Brings together groups of diseases that are
related
– Greater specificity has been added
– Title changes to reflect current terminology
Note: Dermatitis and eczema are used
synonymously and interchangeably
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Pressure Ulcers
• Pressure ulcer codes are combination codes
that identify site, laterality and stage of the
ulcer
• Assignment of pressure ulcer stage is guided by
clinical documentation of terms found in the
Alphabetic Index
– Terms not found in the index or no documentation,
the provider should be queried
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Pressure Ulcers, cont.
• “Unstageable” is NOT “unspecified”
– Based on the clinical documentation
– May be documented by nurse
• No code is assigned if the ulcer is healed
• Healing ulcers are coded based on the
stage documented in the medical record
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Non-Pressure Ulcers
• Category L89 require:
– Site
– Laterality
– Severity
• Code first any associated underlying
condition (gangrene, atherosclerosis,
diabetic ulcer, etc.)
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Diseases of the Musculoskeletal
System and Connective Tissue
(M00-M99)
CHAPTER 13
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Organization and Classification
• Almost every code in Chapter 13 of ICD-10-CM
has been expanded
– Greater specificity of sites
– Laterality
• Many codes moved from various chapter in
ICD-9-CM to Chapter 13 in ICD-10-CM
– Gout moved from Endocrine
– Osteomalacia moved from Endocrine
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Organization and Classification
• Recurrent and conditions related to a
healed injury are usually found in
Chapter 13
• Current, acute, new injuries are found in
Chapter 19
• Osteoporosis with the site of a current
pathological fracture is now one code
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Sub-Categories Organized by
Site and Laterality
•
•
•
•
•
Bone
Joint
Muscle
Multiple
If no “multiple” code
exists, assign a code
for each site
•
•
•
•
Right
Left
Bilateral
If no “bilateral”
code exists, assign a
code for each side
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Coding Scenario
Julia is an 80-year-old female with senile
osteoporosis. She complains of severe
back pain with no history of trauma.
X-rays revealed pathological compression
fractures of several lumbar vertebrae.
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M80.08XD Fracture, pathological (pathologic),
due to osteoporosis, specified cause
NEC – see Osteoporosis, specified
type NEC, with pathological fracture.
Osteoporosis (female) (male), senile –
see Osteoporosis, age-related, with
current pathologic fracture, vertebra(e)
Rationale: In ICD-10-CM, a combination code is
utilized to report osteoporosis with an associated
pathological fracture. When identifying senile
osteoporosis, the code book directs the coder to agerelated osteoporosis.
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Diseases of the Genitourinary
System (N00-N99)
CHAPTER 14
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Chapter 14 - Guidelines
• No changes in Chronic Kidney Disease
guidelines from ICD-9 to ICD-10
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Additional Codes Required
• N17.• N18.• N30.• N31.-
• N33
• Code also underlying
condition
• Code first etiology
• Additional code
infectious agent
• Additional code
urinary incontinence
• Code first underlying
disease
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Symptoms, Signs, and Abnormal
Clinical and Laboratory
Findings, NEC (R00-R99)
CHAPTER 18
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Organization and Classification
• General signs and symptoms follow those
related specifically to a body system or
other relevant grouping
• Some codes have been moved to a
chapter more specific to the symptom
• Hematuria now includes various types
– Hematuria, idiopathic N02.9
• Hematuria, unspecified R31.9
– Dyspepsia, functional K30
• Epigastric pain (Dyspepsia) R10.13
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Category R00 – R99
• No more specific diagnosis can be made
even after all facts have been investigated
• Signs or symptoms existing at time of
initial encounter – transient and causes
not determined
• Provisional diagnosis in patient failing to
return
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Category R00 – R99 cont.
• Referred elsewhere before diagnosis is
made
• More precise diagnosis not available
• Certain symptoms, for which supplementary
information is provided, that represent
important problems in medical care in their
own right
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Chapter 18 - Guidelines
• Extensive Excludes 1 notes
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76
NEW
Repeated Falls
• R29.6 - Use for encounter regarding a
current fall
• Z91.81 – History of falling
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Injury, Poisoning, and Certain
Other Consequences of
External Causes (S00-T88)
CHAPTER 19
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Organization and Classification
• Encompasses 2 alpha characters:
• S = Injuries related to body region
• T = Injuries to unspecified region,
Poisonings, external causes
• Note that codes within “T” section that include the
external cause do not require an additional
external cause code.
• Use secondary codes(s) from Chapter 20 to indicate
cause of injury
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Wounds and Superficial Injuries
• Instructions for open wounds have changed
– Complicated wound in ICD-9 meant “with
infection”
– ICD-10 instructs user to “code also any
associated wound infection”
• Superficial injuries such as abrasions or
contusions are not coded when associated
with more severe injuries of the same site
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80
Poisoning, Adverse Effect,
Underdose
• Poisoning
• Overdose of substances
• Wrong substance given
• Taken in error
• Adverse effect - “Hypersensitivity,” “Reaction,” of
correct substance properly administered
• Underdosing - Taking less of medication than is
prescribed or instructed by manufacturer either
inadvertently or deliberately
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Poisoning, Adverse Effect, Underdosing
ICD-9-CM = 960-979 & E-Codes
•
•
•
•
Accidental
Therapeutic
Suicide
Assault
ICD-10-CM = T Codes
•
Cause of poisoning and
manifestation(s)
– Accidental
– Intentional Self Harm
– Assault
– Undetermined
•
Cause of adverse effect and
manifestation(s)
•
Underdosing 
 Additional documentation
required
– Failure in dosing during medical /
surgical care
– Patient’s underdosing of
medication regime
•
Episode of care 
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82
Poisoning, Adverse Effect,
Underdose
• Combination codes for poisonings/ external cause
(accidental, intentional self-harm, assault,
undetermined)
• Table of Drugs and Chemicals groups all poisoning
columns together
– Followed by adverse effect and underdosing
• When no intent of poisoning is indicated, code to
accidental
– Undetermined intent is only for use when there is specific
documentation in record that intent cannot be determined
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Alcohol and Nicotine
• Alcohol and tobacco use or exposure is
required to be coded with many other
conditions, including but not limited to:
– Malignant neoplasms
– Cardiovascular conditions
– Respiratory conditions
Note: History of anything (nicotine
dependence, neoplasm, alcoholism, etc.)
should always mean in the past
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Abuse, Neglect, Maltreatment
• Sequence first code from categories T74
if confirmed or T76 if suspected
• If ruled out during encounter code
Z04.71 or Z04.72; use Z04.41 or Z04.42
for sexual abuse
• Add external cause code (X92-Y08) to
confirmed cases
• Use Y07 when perpetrator is known
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85
Complications of Care
• Use additional from category G89 to
identify acute or chronic pain due to
presence of device, implant or graft
• Combination codes that include external
cause do not require additional code
• Complications of care codes within the
body system chapters should be
sequenced first
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86
External Causes of
Morbidity (V00-Y99)
CHAPTER 20
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87
Organization and Classification
• No longer a supplemental classification
• No one-to-one relationship exists for ICD9-CM E-Codes to ICD-10-CM
– “E-codes” have been disseminated to
Chapters 19 (combination codes) – 20
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88
Organization and Classification
• Most applicable to injuries, also valid
for other use – i.e., infections or heart
attack occurring during strenuous
physical activity
• External cause code may be used
with any code in range A00.0-T88.9,
Z00-Z99, that is health condition due to
external cause
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89
Organization and Classification
• Encompasses alpha characters V, W, X, and Y
• Assign external cause code, with appropriate
seventh character for each encounter for
which injury or condition is being treated
– Initial encounter
– Subsequent encounter
– Sequela
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90
External Cause Guidelines
• Use for the length of treatment
– Cause
– Intent
• Use only on initial encounter
– Place of occurrence
– Activity (if applicable)
– Patient status
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91
External Cause Guidelines
• Assign as many codes as necessary
• Never a principal (first listed) diagnosis
• Assign combination external cause
codes to identify sequential events
corresponding to the sequence of events
• No external cause code needed for
combination codes from another
chapter that include cause and intent
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92
Category Y92 – Place of Occurrence
•
•
•
•
Use with activity code
Only on initial encounter
Only one Y92 code on record
Do not use Y92.9 if place not stated
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93
Category Y93 – Activity
•
•
•
•
•
Use with Y92 and Y99
Only on initial encounter
Only one Y93 code on record
Do not use Y93.9 if activity not stated
Not applicable to poisonings, adverse
effects, misadventures, or late effects
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Category Y99• Assign Y99, External cause status, to
indicate work status
– Civilian activity done for income or pay
– Military activity
– An individual including a student or
volunteer was involved in a non-work
activity
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Transport Note
• Use additional code to identify
– Airbag injury (W22.1)
– Type of street, road, Hwy (Y92.4-)
– Use of cellular telephone at time of
transport accident (Y93.C2)
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Factors Influencing Health
Status and Contact with
Health Services (Z00-Z99)
CHAPTER 21
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Organization and Classification
• Some categories have rephrased titles
• Some conditions no longer have the
specificity they did in ICD-9-CM
Example: In ICD-10, Code Z23,
Encounter for immunization is not
further classified. In ICD-9, category
codes V03 through V06 are used to
identify the types of immunizations.
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Z Codes- Reason for Visit
• When person who may or may not be sick encounters
health services for some specific purpose i.e. to receive
limited care or service for current condition, donate an
organ or tissue, receive prophylactic vaccination,
discuss problem
• Corresponding procedure code must accompany
Z code if procedure is performed
• When some circumstance or problem is present which
influences person’s health status but is not a current
illness or injury
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Use of Z Codes
• Can be used in any healthcare setting
• May be used as either primary or
secondary code, depending on the
circumstances
• Certain Z codes may only be used as
primary
• Corresponding procedure code must
accompany the Z code
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Z Code Examples
• Z64.- Problems related to certain psychosocial
circumstances
• Z65.- Problems related to other psychosocial
circumstances
• Z73.6 Limitation of activities due to disability
• Z74- Problems related to care provider
dependency
• Z74.01 Reduced mobility – Bed confinement
status
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Aftercare
• When the initial treatment has been
performed and patient requires care
during the healing or recovery phase, or
for the long-term consequences of the
disease
• Generally, first-listed (primary) code
• Certain aftercare Z code categories need
a secondary code
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Examples
• Z51.89 Encounter for other specified aftercare
(Physical therapy)
• Z48.81- Encounter for surgical aftercare
following surgery on specified body systems
• Z93.0 Status tracheostomy
• Z43.- Encounter for attention to artificial
openings i.e. Trach/colostomy
• Z99.11 Dependence Ventilator status
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Tools for Success
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Tools for Success: GEMs Translation
GEMs=General Equivalence Mapping:
• A mapping tool that attempts to include all valid
relationships between the codes in ICD-9-CM and
ICD-10-CM
• An excellent training tool to be used to familiarize
differences between ICD 9 and ICD-10 and may also
be used to select the correct ICD-10 code.
• The mapping identifies one-to-one and one-to-many
code relationships
• Only 5% of ICD-9 to ICD-10 are a direct match
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Selecting an ICD-10 GEMs
Transition Software
• Should allow search by code and description
• Should be bi-directional: ICD-9 to ICD-10 and
vice versa
• Look for the ability to perform code searches
and store frequently used codes (“Cheat Sheet”)
• Have a print function to enable creation of
training tools
• May be a stand alone or integrated product
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ICD 10: Next (or first) Steps
Evaluate internal processes:
• Conduct a practice impact assessment (internal
as well as business partners)
• Update ICD 10 coding resources (manual,
encoder or online lookups)
• Perform a chart review to identify areas for CDI
• Provide documentation feedback for
physicians (immediate and ongoing)
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49 Days
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Thank You!
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Questions, Comments or Feedback?
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