ICD-10-CM
Adult Day Health
Care Council
October 8, 2015
Karen L. Fabrizio, MBA RHIA CHTS-CP CPRA
AHIMA Approved ICD-10-CM Trainer
Objectives
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Review code structure;
Review format of ICD-10-CM Volumes 1 and 2
Review coding conventions
Review basic coding guidelines
Review documentation concerns relating to code assignment
Code Structure
• Alphanumeric structure with all codes starting with an alphabetic character.
• Basic code structure consists of three characters.
• A decimal point is used to separate the basic three-character category code from its
subcategory and sub-classifications.
• Most ICD-10-CM codes contain a maximum of six characters, with a few categories
X
having a seventh-character code value
X
X
Category
X
X
X
X
Etiology, anatomic
site, severity
X
Extension
Code Structure, continued
• All categories have three characters. The basic code used to classify a particular
disease or injury consists of three characters and is called a category
• Example: K29, Gastritis and duodenitis
• Valid codes may be three, four, five, six, or seven characters. That is, each level of
subdivision after a category is a subcategory. The final level of subdivision is a code.
• A code that has an applicable seventh character is considered invalid without the
seventh character
• Truncated codes are codes that are “cut off” or incomplete. These codes are invalid
and will be rejected when submitted on a bill
Placeholder Character
• The letter “x” is used as a placeholder
character at certain codes to allow for
future expansion.
• Certain categories have an additional
seventh-character value. The applicable
seventh-character value is required for all
codes within the category, or as the notes
in the Tabular List instruct. The seventh
character must always be the seventh
character in the code.
• If a code is not a full six characters, a
placeholder character “x” must be used
to fill in the empty characters when a
seventh character value is required
• CANNOT SKIP THE X AND MOVE
CHARACTERS OVER
Format of ICD-10-CM book
• The ICD-10-CM is divided into the Tabular List and the Alphabetic Index.
• The Tabular List is a chronological list of codes divided into chapters based on body system
or condition.
• There are three-, four-, five-, six-, and seven-character codes.
• Codes appear in alphanumerical order
• The Index is an alphabetical list of terms and their corresponding code. There is a pattern
to indentations found in this volume
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Main terms are flush to the left-hand margin.
Subterms are indented. The more specific the subterm, the farther the indent.
Carryover lines are two indents from the indent level of the preceding line.
There are also strict alphabetization rules
Tabular List of Disease and Injuries
• The main classification of diseases
and injuries in the Tabular List of
Diseases and Injuries consists of 21
chapters.
• Approximately half of the chapters are
devoted to conditions that affect a
specific body system; the rest classify
conditions according to etiology.
• Codes in the Tabular List appear in
numerical order.
• References from the Alphabetic Index
to the Tabular List are by code number,
not by page number.
• Code numbers and titles appear in
bold type in the Tabular List.
Alphabetic Index
• The Alphabetic Index consists of:
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Index of Diseases and Injuries
Index to External Causes
Neoplasm Table, and
Table of Drugs and Chemicals.
• The Alphabetic Index includes
entries for main terms, subterms,
and more specific subterms.
• An indented format is used for
ease of reference.
• Main terms identify disease
conditions or injuries.
• Subterms indicate site, type, or
etiology for conditions or injuries.
Connecting Words
• Words such as “with,” “in,” “due to,” and
“associated with” are used to express the
relationship between the main term or a
subterm indicating an associated
condition or etiology.
• Subterms preceded by “with” or
“without” are not listed in alphabetical
order but appear immediately below the
main term or appropriate subterm
entries.
• Subterms beginning with other connecting
words appear in alphabetical order.
• Coders who fail to remember this feature
of the alphabetization rules often make
coding errors by overlooking the
appropriate subterm.
Coding Conventions
• General notes appear in the Tabular List of Diseases and Injuries, providing
information on usage in a specific section
• Inclusion and Exclusion notes indicate when certain conditions are or are not
included in a given subdivision. Their location at the beginning of a chapter or a
section—applies to all codes within the chapter or section and is not repeated with
individual categories or specific codes.
• Cross Reference Notes indicate the user should refer to another area within the
alphabetical index; “see also….”
Inclusion Notes
• Used to further define, or give examples of, the content of the chapter,
section, or category.
• Conditions may be synonyms or conditions similar enough to be classified to
the same code.
• In the case of “other specified codes,” the terms may be a list of the various
conditions that are assigned to that code.
• Inclusion notes are not exhaustive; rather, they list certain conditions to
reassure the coder.
Exclusion Notes
• Excludes 1
• Should never be used at the same
time as the code above.
• Two conditions cannot occur together.
• Do not use two codes together.
• Excludes 2
• Condition excluded is not part of the
condition represented by the code.
• Acceptable to use both codes
together if both conditions are
present at the same time.
• Look elsewhere
“Code First”
• Tabular List
• Identifies a code for a condition that is a
manifestation of an underlying disease.
• Underlying condition must be sequenced
before the code for the manifestation.
• The code for the underlying disease will
also have an instructional note in the
Tabular List to “use additional code” for
the manifestation.
• The
manifestation codes usually have the
6/11/2015 7:54 AM - Screen Clipping
phrase “in diseases classified elsewhere”
as part of the code title. Codes with this
phrase are never used as a first-listed or
principal diagnosis code. They must be
used with the underlying condition code
sequenced first.
“Use Additional Code”
• Indicates that another code may
be needed to include a
complete statement of the
condition.
• If the condition mentioned in
the note is documented as
present, the additional code
should always be assigned.
• It is not necessary to report the
code identified in a "use
additional code" note in the
diagnosis field immediately
following the primary code.
Abbreviations - NEC
• “Not Elsewhere Classified”
• Used in Alphabetic Index and Tabular List.
• This abbreviation means there is no unique code for the condition, even though the
diagnostic statement may be very specific.
• Codes are ordinarily classified to a code with a fourth or sixth character “8” (or a fifth
character “9”), and with a title that includes the words “other specified” or “not
elsewhere classified.”
Abbreviations - NOS
• “Not Otherwise Specified,” equivalent of “unspecified”
• Used in the Alphabetic Index and Tabular List
• Used only when neither the diagnostic statement nor the medical record provides
information that permits classification to a more specific code.
• The codes are ordinarily classified to codes with a fourth or sixth character “9” and
fifth character “0.”
• Conditions listed as both “not elsewhere classified” and “unspecified” are
sometimes combined in one code.
Essential Modifiers
• Nonessential modifiers
• Supplementary words or
explanatory information that may
either be present or absent in the
statement of diagnosis or
procedure without affecting the
code to which it is assigned.
• Denoted in parentheses ( )
• Essential modifiers
• Listed as subterms in the
Alphabetic Index, not in
parentheses; they do affect code
assignment
Relational Terms
“and” or “with”
• The word “and” should be interpreted
to mean either “and” or “or” when it
appears in a title.
• The word “with” should be interpreted
to mean “associated with” or “due to”
when it appears in a code title, the
Alphabetic Index, or an instructional
note in the Tabular List.
• The word “with” in the Alphabetic Index
is sequenced immediately following the
main term, not in alphabetical order.
“Due to”
• The words “due to” in either the
Alphabetic Index or the Tabular List
indicate that a causal relationship
between two conditions is present.
• ICD-10-CM occasionally makes such an
assumption when both conditions are
present.
• In other combinations, however, the
diagnostic statement must indicate this
relationship.
Basic Coding Steps
• Locate the main term in the Alphabetic Index.
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Review subterms and nonessential modifiers related to the main term.
Follow any cross-reference instructions.
Refer to any notes in the Alphabetic Index.
A dash (-) at the end of an Index entry indicates additional characters are required.
• Verify the code number in the Tabular List.
• Read the code title.
• Read and follow any instructional notes. Refer to other codes as instructed.
• Determine whether an additional character must be added.
• Assign the verified code(s).
Basic Coding Steps – Important Tips for
Alphabetical Index
• Search for subterms, notes, or cross-references.
• Subterms provide more specific information of many types and must be checked
carefully, following all alphabetization rules.
• Do not assign main term code entry until all subterm possibilities have been exhausted.
• Some conditions are indexed under more than one main term.
• Consider synonym, eponym, or other alternative term.
Basic Coding Steps – Verification of code
• Do not assign codes without verifying the Tabular List.
• Review title for the code entry, chapter, section, and category to ensure accuracy.
• Note: Title in the Tabular List does not always match the Alphabetic Index entry exactly.
• Significant discrepancies between the Index entry and the Tabular List alert the coder
to review Alphabetic Index for more appropriate term.
• Read and follow all instructional terms and notes.
• Pay particular attention to exclusion notes.
• Ordinarily the code listed with the main term entry in the index is for unspecified
condition.
• Review other codes in the related area to determine whether more specific code can
be assigned.
Coding example:
• Abscess abdominal wall due to Staphylococcus
• Main term Abscess
• Subterm abdomen, abdominal L02.211
• Note under L02.- states: “Use additional code” note: assign a code to identify the
responsible organism (B95-B96).
• Look up main term Infection and subterm staphylococcal as cause of disease classified
elsewhere B95.8
• Code title is “Unspecified staphylococcus as the cause of diseases classified elsewhere.”
• Review medical record for mention of the specific type of Staphylococcus. If mentioned,
consider B95.6- or B95.7; if not, assign code B95.8 as an additional code
Important things to remember:
Level of detail in coding
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Diagnosis codes are to be used and reported at their highest number of digits available.
Composed of codes with three to seven digits
A three-digit code is to be used only if it is not further subdivided.
Truncated codes are not considered valid codes and may lead to rejection in claims and
other reporting systems
General Coding Guidelines
Multiple coding for a single condition
• “dual classification” describes the required assignment of two codes to provide
information about both a manifestation and the associated underlying disease or
etiology.
• Mandatory multiple coding is identified in the Alphabetic Index by the use of a second
code in brackets. The first code identifies the underlying condition, and the second
identifies the manifestation. Both codes must be assigned and sequenced in the order
listed.
• Also identified with “Use additional code”, “Code first”, “Code, if applicable, any
causal condition first”
• Example: Dementia in Parkinson’s Disease is coded to G20 + F02.80
General Coding Guidelines
Combination codes
• Identified by referring to subterm entries in the Alphabetic Index and by reading the
inclusion and exclusion notes in the Tabular List
• Assign only the combination code when that code fully identifies the diagnostic conditions
involved or when the Alphabetic Index so directs
• Example: Acute pharyngitis due to streptococcal infection is coded to J02.0
General Coding Guidelines
Sequelae (Late Effects)
• The condition or nature of the sequelae is sequenced first.
• The sequelae code is sequenced second.
• There is NO time limit to when the sequelae can be used; may be apparent early as
in a cerebral infarction, or may appear months or years late, as in an injury
• The fact that a condition is a late effect may be inferred when the diagnostic
statement includes terms such as the following:
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•
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Late
Old
Due to previous injury or illness
Following previous injury or illness
Traumatic, unless there is evidence of current injury
Example: Post-traumatic osteoarthritis of right shoulder due to old
fracture of right humerus is coded as M19.11 + S42.301S
General Coding Guidelines
Sequelae (Late Effects) - Exception to the “two code rule”
• When the late effect code has been expanded at the fourth-, fifth-, or sixth-character
level(s) to include the manifestation condition, only the cause of the late effect code
is assigned.
• Example: I69.01, Cognitive deficits following nontraumatic subarachnoid
hemorrhage, includes the cause of the late effect (nontraumatic subarachnoid
hemorrhage), as well as the manifestation (cognitive deficits).
Signs and Symptoms
CG C.18.a: 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.
CG B.5: Signs and symptoms that are associated routinely with a disease
process should not be assigned as additional codes, unless otherwise
instructed by the classification.
Diagnoses of Possible, Probable . . .
• Diagnoses described as possible, probable, and so on at the time of discharge are
treated differently depending on whether the patient:
• Is an inpatient; the diagnosis is considered to be an established diagnosis.
• Is a outpatient client; the diagnosis is not considered to be an established diagnosis.
• If there is not an established diagnosis, only whatever symptoms or signs that are available at
the highest level of certainty are assigned.
• Need to be careful when “carrying over” diagnoses from another healthcare setting as they may
be required to code a probable condition as confirmed.
Abnormal Findings
• Categories R90 through R97 in chapter 18 are provided for coding
nonspecific abnormal findings.
• If the documentation indicates clinical findings outside the normal range but
no related diagnosis is stated:
• Review record to determine whether additional tests and/or consultations were carried
out related to these findings or whether specific related care was given.
• Ask the physician whether a code should be assigned.
Falls
• ICD-10 allows us to capture frequent falls and history of falls.
• Facilities should develop coding policies to ensure consistent use of these codes
C.18.d: Repeated falls
Code R29.6, Repeated falls, is for use for “encounters” when a patient has
recently fallen and the reason for the fall is being investigated.
Code Z91.81, History of falling, is for use when a patient has fallen in the
past and is at risk for future falls.
When appropriate, both codes R29.6 and Z91.81 may be assigned together.
Infections by Type
• When coding infections, you start by locating the type of infection in the alphabetical
listing.
• Coding a specific organism will require a culture or detailed description from the
referral source.
Example:
Staphylococcal (staph) unspecified site:
A49.01 methicillin susceptible
A49.01 methicillin resistant
Streptococcal (strep) unspecified site: A49.1
MRSA
CG C.1.e (1)(a): When a patient is diagnosed with an infection that is due to methicillin
resistant Staphylococcus aureus (MRSA), and that infection has a combination code that
includes the causal organism (e.g., sepsis, pneumonia) assign the appropriate combination
code for the condition (e.g., code A41.02, Sepsis due to Methicillin resistant
Staphylococcus aureus or code J15.212, Pneumonia due to Methicillin resistant
Staphylococcus aureus). Do not assign a code from subcategory Z16.11, Resistance to
penicillins, as an additional diagnosis.
CG C.1.e (1)(b): When there is documentation of a current infection (e.g., wound infection,
stitch abscess, urinary tract infection) due to MRSA, and that infection does not have a
combination code that includes the causal organism, assign the appropriate code to
identify the condition along with code B95.62, Methicillin resistant Staphylococcus aureus
infection as the cause of diseases classified elsewhere for the MRSA infection. Do not
assign a code from subcategory Z16.11, Resistance to penicillins.
MRSA colonization versus carrier
• Use a code from subcategory Z22.3- to show possible or suspected carrier or
colonization.
• Colonization means that MSSA or MSRA is present on or in the body without
necessarily causing illness. Do not automatically use an active MRSA infection code
• Assign code Z22.322, Carrier or suspected carrier of Methicillin resistant
Staphylococcus aureus, for patients documented as having MRSA colonization.
Assign code Z22.321, Carrier or suspected carrier of Methicillin susceptible
Staphylococcus aureus, for patient documented as having MSSA colonization.
• It is acceptable to combine codes from subcategory Z22.3 and the MRSA codes when
a registrant is suspected of being a carrier AND has an active MRSA infection.
• Reference: Coding Guideline C.1.e (1)(c)
Diabetes
• Distinction between Type I, Type II, and Secondary Diabetes.
• No longer based on insulin dependent versus non-insulin dependent
• Type I often referred to as juvenile diabetes
• If the type is not specified, must assume Type II
• If type is not specified and registrant uses insulin, must assume Type II
• Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that
the patient uses insulin. Code Z79.4 should not be assigned if insulin is given
temporarily to bring a type 2 patient’s blood sugar under control during an encounter.
Reference: Coding Guideline C.4.a.1 – C.4.a.3
Diabetes, continued
Coding guidelines C.4.a states "as many codes within a particular category to describe
ALL complications may be used." When coding multiple manifestations, a diabetic code
is assigned with each manifestation from a different category
Example: Diabetic neuropathy and diabetic angiopathy have two codes.
E11.42 Diabetes with polyneuropathy
E11.51 Diabetes with peripheral angiopathy without gangrene
(or E11.52 with gangrene)
Diabetes
• Uncontrolled diabetes is coded to diabetes, by type, with hyperglycemia
• E10.65, Type I diabetes with hyperglycemia
• E11.65, Type II diabetes with hyperglycemia
• Facility should develop policy regarding use of code Z79.4, Long-term (current) use of
insulin to ensure consistency
• Note under E11 to use additional code to identify insulin use
Dementia
• Many of the dementia codes are also combined with another underlying problem.
• Before coding dementia, read all the notes at the beginning of the category and next
to the main term.
• Read all of the includes and excludes notes in the Tabular list to ensure you
completely code the condition(s)
Dementias
Code first any neurological condition
Presenile dementia NOS
Senile dementia NOS
F03.90
F03.90
Dementia due to another condition
• The code F02.80 Dementia in
other diseases classified elsewhere
without behavioral disturbance or
• F02.81 Dementia in other diseases
classified elsewhere with
behavioral disturbance
• requires the underlying condition to be
coded first and requires the fifth
character to identify whether there are
behavioral disturbances
• Facilities/ADHC programs should
develop internal policy relating to
behavior disturbance to ensure
consistency
Dementia in other diseases classified
elsewhere
F02
Code first underlying physical
condition:
Alzheimer’s disease G30.Picks
G31.01
Parkinson
G20
MS
G35
Epilepsy
G40.Excludes 1: Dementia with
Parkinsonism (G31.83)
Altered mental state
• When a loss of consciousness or change in level of consciousness occurs without
delirium, category R40.- should be considered.
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somnolence (R40.0),
stupor (R40.1),
coma (R40.2-),
persistent vegetative state (R40.3),
transient alteration of awareness (R40.4).
• When the etiology or underlying cause is unknown, R41.82, Altered mental state,
unspecified, is assigned.
• This code should not be used continually as the cause should be investigated
Diseases of Nervous System
Dominant/Nondominant
• 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:
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant
• categories G81, Hemiplegia and hemiparesis,
• Subcategories G83.1, Monoplegia of lower limb,
• Subcategories G83.2, Monoplegia of upper limb, Subcategories G83.3, Monoplegia,
unspecified
• Reference CG: C.6.1
Dominant versus Non-dominant
Hemiplegia on
Left Side
Hemiplegia on
Right side
Registrant "eats" with left hand
Code as
Code as
Registrant "eats" with right hand
Left Dominant
Code as
Right Non-Dominant
Code as
Left Non-Dominant
Code as
Right Dominant
Code as
Left Dominant
Code as
Right Dominant
Code as
Left Non-Dominant
Right Dominant
Registrant is identified as being "ambidexterous"
Documentation not available identifying which hand registrant
previously or currently eats with
Acute Myocardial Infarction (AMI)
Acute Myocardial Infarction
• Acute myocardial infarction (AMI) with a duration of 4 weeks or less is classified to
category I21:
• ST elevation (STEMI); or
• Non-ST elevation (NSTEMI).
• 4th character indicates wall involved (e.g., anterolateral or inferior wall).
• Codes I21.0- through I21.2- provide a 5th character to describe the coronary artery
involved (e.g., left main coronary artery).
• Codes I21.0-I21.3- identify transmural infarctions.
• Code I21.4- describes subendocardial infarction (not involving full-thickness of
myocardium).
• Assign code I21.3, ST elevation (STEMI) myocardial infarction of unspecified site, if site
or ST-elevation or non- ST-elevation is not documented.
Acute Myocardial Infarction, continued
• If a patient suffers a new AMI within 4 weeks of an initial AMI,
assign category I22 with category I21
• Continue to use I21 codes from the onset of the AMI up to 4
weeks duration when the patient requires continued care:
• Including patients who are transferred from the acute care setting to the postacute setting within the 4 week timeframe.
• After the 4 weeks duration, assign an aftercare code to describe
continued care.
• If MI is healed or old, assign history code I25.2 for old MI not requiring
further care.
Cerebrovascular Disorders
• Acute organic (non-traumatic) conditions affecting the cerebral arteries:
• Codes in categories I60-I68 classify cerebral hemorrhage, occlusion, and thrombosis.
• Category I63 describes cerebral infarction due to occlusion or stenosis of cerebral or
precerebral arteries:
• 6th characters identify the specific artery.
• Assign category I65 or I66 for occlusion or stenosis of cerebral or precerebral arteries
without cerebral infarction:
• 5th characters in subcategories I65.0, I65.2, I66.0, I66.1, and I66.2 indicate laterality (i.e.,
right, left or bilateral, or unspecified arteries).
• Z86.73 = history of TIA and cerebral infarction without residual deficits
• Screenshots from tabular list on next page…….
Sequelae of Cerebrovascular Disease
• Codes from category I69, sequelae of cerebrovascular disease, allow for
the specificity in coding residual effects of cerebrovascular disease.
• ICD-10 removes the definitive time frame for a condition to be
considered a late effect of a condition
• Category I69 provides instructional notes to assign additional codes to
identify:
• Type of paralytic syndrome;
• Type of dysphagia; or
• Other sequelae of cerebrovascular disease:
• 4th characters indicate the causal condition.
• 5th characters provide information about neurological deficit.
Hypertension (I10)
• Hypertension described as accelerated, benign, essential, idiopathic,
malignant, or systemic is assigned to code I10, Essential (primary)
hypertension.
• Whether hypertension is controlled or uncontrolled does not affect code assignment.
• Secondary hypertension (category I15) is caused by other primary disease and
requires two codes.
• Report the underlying cause first, followed by hypertension code.
• Transient hypertension is assigned code R03.0:
• Unless the patient has an established diagnosis of hypertension.
• Diagnosis of hypertension is based on a series of readings, rather than a single reading
Hypertensive Heart Disease
• Category I11 classifies
hypertensive heart disease,
including:
• Cardiomegaly;
• Cardiovascular disease;
• Myocarditis; and
• Degeneration of the
myocardium.
• Causal relationship between
hypertension and heart
disease must be documented.
• If no relationship is
documented, assign
separate codes.
Hypertension and Chronic Kidney Disease
• ICD-10-CM assumes a causal relationship between hypertension
and chronic kidney disease.
• Category I12, Hypertensive chronic kidney disease:
• 4th character indicates stage of chronic kidney disease.
• Assign the appropriate code from category I12 with a code from
category N18 to identify the stage of chronic kidney disease.
• Category I12 does not include acute kidney failure.
Hypertensive Heart and Chronic Kidney Disease
• Category I13 classifies hypertensive heart and chronic kidney disease:
• Combination codes include hypertension, heart disease, and kidney disease.
• Inclusion note at category I13 indicates conditions classified to categories I11I12 included in category I13.
• 4th and 5th characters indicate with/without heart failure, and stage of chronic
kidney disease.
• Also assign category I50 to describe type of heart failure.
• Assign category N18- for stage of chronic kidney disease.
• If acute and chronic renal failure present, code both.
Respiratory System
• When a respiratory condition is described as occurring in more than one site, and is
not specifically indexed (listed in the alphabetical index as a subterm), it should be
classified to the lower anatomical site (eg: tracheobronchitis to bronchitis)
• Code also, where applicable:
•
•
•
•
•
•
Exposure to tobacco smoke
Exposure to tobacco smoke in perinatal period
History of tobacco use
Occupational exposure to environmental tobacco smoke
Tobacco dependence
Tobacco use
Asthma Coding Notes
• Wheezing alone is not considered asthma
• Never assume presence of status asthmaticus without a specific
statement from the physician.
• Status asthmaticus means no relieved or managed by treatments
• When there is documentation of both acute exacerbation and
status asthmaticus, only the code with the final character of 2
should be assigned.
• Example: Acute atopic asthma, status asthmaticus
• Reference: C.10.a.1
Influenza
C.10.c: Influenza due to certain identified influenza viruses
•Code only confirmed cases of influenza due to certain identified influenza viruses (category J09),
and due to other identified influenza virus (category J10). This is an exception to the hospital
inpatient guideline Section II, H. (Uncertain Diagnosis).
•In this context, “confirmation” does not require documentation of positive laboratory testing
specific for avian or other novel influenza A or other identified influenza virus. However, coding
should be based on the provider’s diagnostic statement that the patient has avian influenza, or other
novel influenza A, for category J09, or has another particular identified strain of influenza, such as
H1N1 or H3N2, but not identified as novel or variant, for category J10.
•If the provider records “suspected” or “possible” or “probable” avian influenza, or novel influenza,
or other identified influenza, then the appropriate influenza code from category J11, Influenza due to
unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain
identified influenza viruses, should not be assigned nor should a code from category J10, Influenza
due to other identified influenza virus.
Influenza in non-Inpatient setting
• J11.- (influenza due to unidentified influenza virus) should
not be used in an outpatient or long term care setting
• If culture is ordered, do not code suspected or probable
influenza
• Code the presenting symptoms as the reason for the test
Make sure your codes represent the fact you do know your registrants!
Acute Traumatic versus Chronic or Recurrent Musculoskeletal Conditions
CG: I.C.13.b
Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are
recurrent conditions. Bone, joint or muscle conditions that are the result of a healed injury
are usually found in chapter 13. Recurrent bone, joint or muscle conditions are also usually
found in chapter 13.
Any current, acute injury should be coded to the appropriate injury code from chapter 19.
Chronic and recurrent conditions should generally be coded with a code from chapter 13.
If it is difficult to determine from the documentation in the record which code is best to
describe a condition query the provider.
Musculoskeletal conditions
• Placeholders in use!
• Laterality codes in use!
• Several codes contain letters in the category code
• M1a. – Idiopathic gouty arthritis
Osteoporosis
I.C.13.d
Osteoporosis is a systemic condition, meaning all bones of the
musculoskeletal system are affected. Therefore, site is not a
component of the codes under category M81, Osteoporosis
without current pathological fracture.
The site codes under category M80, Osteoporosis with current
pathological fracture, identify the site of the fracture, not the
osteoporosis.
Osteoporosis without pathological fracture
I.C.13.d.(1)
Category M81, Osteoporosis without current pathological
fracture, is for use for patients with osteoporosis who do not
currently have a pathological fracture due to the osteoporosis,
even if they have had a fracture in the past.
For patients with a history of osteoporosis fractures, status code
Z87.310, Personal history of (healed) osteoporosis fracture should
follow the code from M81.
Pathological Fractures
I.C.13.c.
7th character A is for use as long as the patient is receiving active treatment
for the fracture. Examples of active treatment are: surgical treatment,
emergency department encounter, evaluation and treatment by a new
physician.
7th character D is to used for encounters after the patient has completed
active treatment.
The other 7th characters, listed under each subcategory in the Tabular List,
are to be used for subsequent encounters for treatment of problems
associated with the healing such as malunions, nonunions, and sequelae.
Care for complications of surgical treatment for fracture repairs during the
healing or recovery phase should be coded with the appropriate
complication code.
Arthritis (M19.-)
• Need to review all subterms under arthritis to ensure appropriate
coding
• Primary axis
• Site—whether it involves multiple sites (M15.-, Osteoarthritis) or
single joints.
• Verification of the arthritis code in the Tabular Listing is necessary
for correct fifth and sixth character assignment.
Coding Injuries
• Two axes for coding injuries:
• Anatomical site
• Type of injury
• Important to review instructional notes:
• Instructional notes (i.e., inclusion and exclusion notes) are used extensively in chapter
19.
• These notes assist in correct code assignment.
• Many sections also contain Excludes 1 and Excludes 2 notes
• 7th Character value
• If a seventh character is required, and the code is not six characters:
• a placeholder “x” must be used to fill in empty spaces.
• Most categories in this chapter have three 7th character values (with the exception of
fractures): A, initial encounter, D, subsequent encounter and S, sequela
C.19.a Application of 7th Characters in Chapter 19
•7th character “A”, initial encounter is used while the patient is receiving active
treatment for the condition. Examples of active treatment are: surgical treatment,
emergency department encounter, and evaluation and treatment by a new physician.
•7th character “D” subsequent encounter is used for encounters after the patient has
received active treatment of the condition and is receiving routine care for the
condition during the healing or recovery phase. Examples of subsequent care are:
cast change or removal, removal of external or internal fixation device, medication
adjustment, other aftercare and follow up visits following treatment of the injury or
condition.
C.19.a Application of 7th Characters in Chapter 19
•The aftercare Z codes should not be used for aftercare for conditions such as injuries
or poisonings, where 7th characters are provided to identify subsequent care.
•For example, for aftercare of an injury, assign the acute injury code with the 7th
character “D” (subsequent encounter).
•7th character “S”, sequela, is for use for complications or conditions that arise as a
direct result of a condition, such as scar formation after a burn. The scars are
sequelae of the burn. When using 7th character “S”, it is necessary to use both the
injury code that precipitated the sequela and the code for the sequela itself. The “S”
is added only to the injury code, not the sequela code.
•The 7th character “S” identifies the injury responsible for the sequela.
•The specific type of sequela (e.g. scar) is sequenced first, followed by the injury
code.
C.19.c Coding of Traumatic Fractures
•The principles of multiple coding of injuries should be followed in coding fractures. Fractures
of specified sites are coded individually by site in accordance with both the provisions within
categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 ICD-10-CM
Official Guidelines for Coding and Reporting 2015 Page 67 of 115
•A fracture not indicated as open or closed should be coded to closed. A fracture not indicated
whether displaced or not displaced should be coded to displaced.
C.19.c.1 Initial vs. Subsequent Encounter for Fractures , continued
Care of complications of fractures, such as malunion and nonunion, should be
reported with the appropriate 7th character for subsequent care with nonunion
(K, M, N,) or subsequent care with malunion (P, Q, R).
•A code from category M80, not a traumatic fracture code, should be used for
any patient with known osteoporosis who suffers a fracture, even if the patient
had a minor fall or trauma, if that fall or trauma would not usually break a
normal, healthy bone.
•See Section I.C.13. Osteoporosis.
Aftercare for Fractures
• Aftercare for traumatic fractures is coded to the acute
fracture with the appropriate seventh-character value for
subsequent care.
• The aftercare Z codes should not be used for aftercare of
injuries.
• Instead, the acute injury code is assigned with the
appropriate seventh-character value for subsequent
encounter.
Circulatory Status Z Codes
• Circulatory status Z codes indicate
circulatory-related health status as
follows:
•
•
•
•
•
•
•
•
Heart valve transplant (Z94.1)
Presence of cardiac pacemaker (Z95.0)
Aortocoronary bypass status (Z95.1)
Presence of prosthetic heart valve
(Z95.2)
Presence of xenogenic heart valve
(Z95.3)
Presence of other heart-valve
replacement (Z95.4)
Presence of coronary angioplasty implant
and graft (Z95.5)
Presence of other cardiac and vascular
implants and grafts (Z95.8)
• Presence of automatic (implantable)
cardiac defibrillator (Z95.810)
• Presence of other cardiac and vascular
implants and grafts (Z95.811)
• Presence of fully implantable artificial
heart (Z95.812)
• Presence of other cardiac implants and
grafts (Z95.818)
• Peripheral vascular angioplasty status
with implants and grafts (Z95.820)
• Presence of other vascular implants and
grafts (Z95.828)
• Report these codes when status
affects patient care:
• Status Z codes assigned as an additional
code only.
Miscellaneous Z-Codes
• Recommend facility-specific coding policies to indicate when and if the following
codes will be used:
•
•
•
•
•
•
•
•
•
•
Do not resuscitate status (Z66)
Carrier of infectious diseases (Z22.-)
Personal history of neoplasm (Z85.-)
Long-term (current) drug use (Z79.-)
Acquired absence of limb (Z89.-)
Acquired absence of organ (Z90.-)
History of falling (Z79.81)
Artificial opening status (Z93.-)
Transplanted organ and tissue status (Z94.-)
Presence of cardiac and vascular implants (Z95.-)
Who has heard this before?
The computer will do
the coding
“We do not need to
train our coders”
.
“Our software vendor says the
system will do it automatically”
Who has heard this before?
John Smith is being
admitted today
“We do not need to
train our coders”
.
“The hospital has already coded
the record, we can use those
codes”
What do we say then?
• This has been seen before…. Many times…..
• The additional number of codes, fields and characters used by ICD-10 coding schemes
allow for significantly more granularity and a wider variety of codes.
• •ICD-9-CM Total codes = 24,000
• •ICD-10-CM/PCS codes = 155,000
• ICD-10-CM: 68,000 unique codes
• ICD-10-PCS: 87,000 unique codes
GEMS Coding
• Care needs to be used when utilizing ICD-9 to ICD-10 crosswalks.
• GEMS was developed to build correlation between codes; NOT to facilitate coding
• The GEMS attempts to identify a cross-reference by linking one code to many
possible alternative codes
• Need to understand the difference in the codes to be able to reconcile the
differences
Example: Hemiplegia
• In ICD-10, Dominance and side affected are key to code assignment
• ICD-9-CM: 342.91: Hemiplegia, unspecified, affecting dominant side
•
•
•
•
•
G81.90: Hemiplegia, unspecified affecting unspecified side
G81.91: Hemiplegia, unspecified affecting right dominant side
G81.92: Hemiplegia, unspecified affecting left dominant side
G81.93: Hemiplegia, unspecified affecting right nondominant side
G81.94: Hemiplegia, unspecified affecting left nondominant side
???????????
References/Resources:
ICD-10 Coding Guidelines
http://www.cdc.gov/nchs/data/icd/ICD10cmguidelines_2015%209_26_2014.pdf
ICD-10 News & Information
https://www.cms.gov/ICD10
ICD-10 Online Implementation Guide
https://implementsicd10.noblis.org
2015 ICD-10-CM General Equivalency Mappings (GEMs)
http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html
ICD-10 Provider Resources
http://www.roadto10.org
http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
• Disclaimer: This presentation was prepared to give a basic overview of the ICD-10-CM classification System. Due to
the number of possible codes, the presentation is intended to introduce commonly used diagnoses. Participants are
encouraged to read the current guidelines for applicability to their organizations.