6/1/2015
THE BASICS OF ICD-10-CM
CODING
June 9, 2015
Continuing Education for Long-Term Care Facilities
Marla Dumm, CPC, CCS-P
Managing Consultant
[email protected]
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6/1/2015
TO RECEIVE CPE CREDIT
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webinar
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Objectives
• Distinguish between ICD-9 & ICD-10 code
structure
• Identify necessity to review clinical
documentation & translate information into
diagnosis code
• Describe best practices related to accurate &
specific code assignment
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Current Status – DEADLINE
• Final Rule CMS-0043-F
– https://www.federalregister.gov/articles/2
014/08/04/2014-18347/change-tothecompliance-date-for-the-internationalclassification-of-diseases-10th-revision
• Issued on July 31, 2014
• Finalized new deadline of
October 1, 2015
• No new code updates until
October 1, 2016
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Resource documents – ICD-9-CM
• ICD-9-CM Official Guidelines for Coding &
Reporting
• Effective October 1, 2011
• Last major update
http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2
011.pdf
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Resource Documents – ICD-10-CM
• ICD-10-CM Official Guidelines for Coding &
Reporting (2015 Version)
• Effective with dates of service October 1, 2015
http://www.cms.gov/Medicare/Coding/ICD10/Downloads
/icd10cm-guidelines-2015.pdf
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Will Official Coding Guidelines Differ?
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Official Coding Guidelines
• Minimal changes
• General guidelines for assignment of codes,
order of codes, punctuation, abbreviations,
etc., will be very similar
• Some structural differences & modifications to
code classifications or code descriptions due to
expanded code detail
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Standard Coding Process
• Be familiar with ICD-10-CM Official Coding
Guidelines & Conventions
– Section I-III
• Review clinical documentation (physician or
non-physician practitioner)
– Nursing facility admission H&P, nursing facility
discharge summary, acute hospital discharge,
progress notes, consultation reports, diagnostic
test reports, etc.
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Standard Coding Process
Identify main term(s)
Look up main term(s) in Alphabetic Index
Look through subterms if applicable
Review all additional lines & subterms that
may continue to next column
• Refer to all parenthetical terms
•
•
•
•
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Standard Coding Process
• Grey shaded vertical lines – provide guidance
for indented subterms & additional subterms
• Review all instructional notes & references
– “see,” “see also,” “see category”
– “with” or “without”
– “omit code”
– “due to”
– “code by site” – NEW TO ICD-10-CM
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Standard Coding Process
• Reminder – Do not code from the index
• Locate & confirm code(s) in Tabular List
• Read & follow instructions
– “Includes” & “Excludes” notes
– “Use additional code”
– “Code first underlying disease”
– “Code also”
– Character requirements (4th, 5th, 6th & 7th
extensions)
– Age or gender
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Standard Coding Process
• Refer to Official Guidelines to verify rule(s)
• Confirm & assign code(s) to highest level of
specificity (number of characters) supported in
documentation
• List on claim form in priority (or sequence) per
coding guidelines
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Standard Coding Process
Example
– Acute Upper Respiratory Infection
•
Infection
•
•
•
•
Respiratory
Upper
Acute
Code – J06.9
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Index – Volume 2
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Index – Volume 2
• Alphabetic order
– Can search by condition, disease, sign, symptom,
etc
– Anatomical site will refer you to “see condition”
•
•
•
•
Index to Diseases & Injury
Neoplasm Table
Table of Drugs & Chemicals
Index to External Causes of Injury
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Index – What’s not in ICD-10?
Hypertension Table.................................................................. Malignant..... Benign... Unspecified
Hypertension, hypertensive (arterial) (arteriolar) (crisis)
(degeneration) (disease) (essential) (fluctuating)
(idiopathic) (intermittent) (labile) (low renin)
(orthostatic) (paroxysmal) (primary) (systemic)
(uncontrolled) (vascular).......................................... 401.0......... 401.1......... 401.9
with chronic kidney disease
stage I through stage IV, or unspecified .................. 403.00....... 403.10....... 403.90
stage V or end stage renal disease ......................... 403.01....... 403.11....... 403.91
heart involvement (conditions classifiable
to 429.0-429.3, 429.8, 429.9 due to hypertension)
(see also Hypertension, heart).................................. 402.00....... 402.10....... 402.90
with kidney involvement see Hypertension,
cardio renal
• This table has been removed. Look for
“Hypertension, hypertensive” in table
for code selection
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Main Terms
• Identify disease or condition of site (for
injuries)
• Main terms are listed in bold type & start with
an uppercase letter
Examples of main term headings
–
–
–
–
Complications
Late Effect(s) or Sequelae (new for ICD-10)
Fracture
Pneumonia
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Main Terms
• Follow cross references like “see also” & “see”
• Modifiers & Subterms are located under Main
Term
• An indented structure is used
– See shaded lines in index which line up indented
terms
• Notes
– Define terms
– Provide direction & instruction
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Non-Essential Modifiers
•
•
•
•
Words that follow main term
Are always in parenthesis
Provide additional information for main term
The presence or absence of these modifiers
has no effect on selection of the code for term
Example
– Pneumonia (acute)(double)(migratory)(purulent)(septic)
(unresolved)
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Essential Modifiers
• Subterms that modify main term
– Are listed below main term in alphabetical order
(exception of “with” & “without”)
• Indented two additional spaces to the right
• Regular type & starts with a lowercase letter
Example
• Pneumonia
‒ With
• Influenza – see Influenza, with, pneumonia
• Lung abscess
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Eponyms & Synonyms
• Eponyms
– Diseases or syndromes named for a person (i.e.,
who discovered the illness)
– Listed as a main term under both name of person &
disease or syndrome
Example
• Guillain-Barre’ Syndrome (look up Guillain or Syndrome)
• Synonyms
– Escherichia coli (E. coli)
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Abbreviations
• NEC – Not Elsewhere Classified
• Used when
– Coder has specific documented information, but
there is no separate or specific code available to
represent condition documented in medical
record
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Abbreviations
• NOS – Not Otherwise Specified
• Used when
– Coder lacks or does not have specific documented
information
– Equivalent to “unspecified”
• NOS codes should never be used routinely as a
means to avoid having to search for a more
specific term
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Cross-Reference Terms
• See (Condition, Category) – Mandatory
instruction that the coder must look
elsewhere for an alternative term. Coding
cannot be completed without following this
instruction
• See also – Coder must review another main
term if information documented in record is
not reflected under main term
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Cross-Reference Terms
Examples
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Neoplasm Table
• Search by anatomical site where neoplasm is
located
• Columns will detail Primary, Secondary
(metastasis) or Ca in Situ malignancy
• Additional columns will detail benign
neoplasms, those with uncertain behavior &
unspecified
• Information must be documented in medical
record (i.e., chart note, pathology report)
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Table of Drugs & Chemicals
• Used to define code by the toxic effect (i.e.,
poisoning) from a specific drug, medication or
solution
• Search by name of drug or medication
– Brand name
– Generic name
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Table of Drugs & Chemicals
• Columns
– Poisoning, Accidental (Unintentional)
– Poisoning, Intentional Self-Harm
– Poisoning, Assault
– Poisoning, Undetermined
– Adverse Effect
– Under-Dosing (New Category)
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Argyrol
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Restructuring the Index
• Injuries are grouped by anatomical site rather
than by type of injury
• Certain diseases & disorders have been
reclassified
Example: Gout is now in Musculoskeletal instead of
Endocrine
• Categories restructured
• Codes have been reorganized to appropriate
chapter
• Familiar codes will appear in different
chapters or sections to reflect current medical
knowledge
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Tabular List – Section 1
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Tabular List
• Numerical listing of codes
• 21 chapters
• Classification of factors influencing health
status & contact with health services – Codes
beginning with V, W, X or Y
• Classification of external causes of injury &
poisoning
– Codes beginning with Z
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New Chapters
• Sensory signs, symptoms &/or conditions
− Chapter 7 - Eyes
− Chapter 8 - Ears
Example
– H66.001 – Acute suppurative otitis media without
spontaneous rupture of ear drum, right ear
– H40.11 – Primary open-angle glaucoma
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Code Format – What to Expect
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ICD-10-CM structure
•
•
•
•
Up to seven digits
First digit = always alpha, except “U”
Second digit = always numeric
All other digits = combination (Watch O/0, 5/S, I/1)
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Structure Comparison
ICD-9-CM
ICD-10-CM
813.06
S52.131A
Closed Fracture of
Neck/Radius
Displaced fracture of
neck/right radius, initial
encounter for treatment of
closed fracture
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Tabular List
• Numerical listing of codes divided into 21
chapters
• Code structure
– 3rd characters – main code/category. May be
primary code if no further specificity is required
– 4th character – After decimal point. Defines site,
etiology & manifestation
– 5th & 6th characters – further specificity
– 7th character – Required if instructed in Tabular
section, identifies status of care
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Characters Add Specificity
• Additional characters are added to “main
category” (three character code depending on
code instructions)
Example
– S52
Main category for “Fracture of Forearm”
– S52.5 Subcategory code for unspecified
“Fracture of the lower (or distal) end of
radius”
– S52.52 Sub classification code for “Torus fracture
of lower (or distal) end of radius
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Characters Add Specificity
Example
– S52.521
Sub classification code for “Torus
fracture of lower (or distal) end of right
radius”
– S52.521A Adding the required 7th character “A”
specifies the type of encounter or stage
of healing - “Torus fracture of lower end
of right radius, initial encounter for
closed fracture
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New Features – Placeholders
• Character “x” is used as a placeholder
• Allows for future expansion
• Fills empty characters for codes that require
the full seven characters
– T15.02XD – Foreign body in cornea, left eye,
subsequent encounter
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New Features – 7th Character
• Will always be listed in the seventh position
• Adds additional information to describe the
encounter
– A = Initial encounter
– D = Subsequent encounter
• Must be used when instructed in Tabular
listing
– S50.02XD Contusion of left elbow, subsequent
encounter
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New Features – 7th Character
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7th Character – Type of Encounter
• Initial, subsequent or care of sequela (i.e., late
effect)
• Active treatment
Examples: Surgical treatment, ER encounter, E/M by
new physician
• Subsequent encounter
– Routine follow-up care, during healing phase
• Sequela
– Complications of conditions that occur as a direct
result of an injury or illness
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New Features – Laterality
• Laterality
– Left, right & bilateral
• The 5th code character will be defined as
follows
– Right side = 1
– Left side = 2
– Bilateral = 3
– Unspecified = 0 or 9
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Laterality – Examples
– C50.511 – Malignant neoplasm of lowerouter quadrant of right female breast
– L89.022 – Pressure ulcer of left elbow, stage
II
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Punctuation
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Punctuation – Brackets & Parentheses
[ ] - Brackets enclose synonyms, alternative
terminology or explanatory phrases
- Also to indicate manifestation codes in
index
( ) - Parentheses enclose supplementary words,
called nonessential modifiers, which may
be present in descriptor of a code without
affecting code to which it is assigned
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Punctuation – Brackets & Parentheses
Examples
– Amyloid Heart (disease) E85.4 [I43]
• Tells coder two codes will be reported
• I43 is listed in [brackets] & will be secondary code
reported
– Verify code in Tabular List
• Italicized instruction under I43 tells coder to Code First
underlying disease, such as
– Amyloidosis (E85.-)
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Punctuation – Brackets & Parentheses
• Index listing for electrocardiogram
– Abnormal, Abnormality, abnormalities
• Electrocardiogram [ECG] [EKG] R94.31
• Tabular listing for R94.31
– Abnormal electrocardiogram [ECG] [EKG]
• Index listing for acute laryngitis
– Laryngitis (acute)(edematous)(fibrinous)(infective)
(infiltrative) (malignant)(membranous)…J04.0
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Punctuation – Colons
: - Colons are used after an incomplete term that
needs one or more of the modifiers that follow
to make it assignable to a given category
Example
– C32 Malignant neoplasm of larynx
• Use additional code to identify
– Alcohol abuse and dependence (F10.-)
– Exposure to environmental tobacco smoke
(Z77.22)
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Punctuation – Not in ICD-10-CM
} - Braces are not found in ICD-10. The detail is
now found after the main term or after the code
itself &/or found in detail of code instruction in
Tabular listing
Example: K56.2 Volvulus
•
•
•
Strangulation of colon or intestine
Torsion of colon or intestine
Twist of colon or intestine
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Instructional Notes
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Instructional Notes
• “Includes”
This note appears immediately under a three-digit
code title at beginning of chapter or section.
Further defines or clarifies content of category
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Instructional Notes
“Excludes”
• Terms following
the word
“excludes” are not
classified to code
under which it is
found
• May indicate
another code
more fully
describes a
diagnosis
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Instructional Notes
• “Use additional code”
This instruction signals coder that an additional
code should be used when documentation states
both etiology & manifestation of disease
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Instructional Notes
‒ “Code first”
• The instruction is to code underlying disease
(etiology) first (i.e., “code first”)
• Manifestation code is sequenced as secondary
diagnosis
• Manifestation codes may never be used alone or
sequenced as principal diagnosis
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Instructional Notes – “Code First”
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Official Guidelines
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Principal Diagnosis – Section II
• “The condition established after study to be
chiefly responsible for occasioning the
admission of the patient to the hospital for
care”
• Definition applies to all non-outpatient
settings, to include LTC
• Principal diagnosis = condition requiring
resident’s admission
Example: Patient with Parkinson’s disease admitted
post hospitalization for therapy associated with
acute pneumonia
ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Page 97-100
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Primary Diagnosis – Section II
• Primary diagnosis = reason for continued stay
in LTC
– May be same as principal diagnosis (i.e, Parkinson’s
disease)
– Is required to support therapy services
Example
• The pneumonia would be sequenced as second
diagnosis as reason for therapy
ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Page 97-100
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MDS versus ICD-10-CM
• MDS lists “Active Diagnoses” under Section I
• Identifies “disease related to the resident’s functional,
cognitive, mood or behavior status, medical treatments,
nursing monitoring or risk of death”
• Values are assigned to these “groups” of codes
• Resident may have other conditions that also need to be
coded
• ICD-10-CM codes may be listed on the MDS if the groups
do not identify a condition or diagnostic group that
meets criteria in second bullet point
• Consistent, complete & diagnosis codes in MDS & on
claim form
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“Additional Diagnoses” – Section III
• “All conditions that coexist at the time of admission,
that develop subsequently, or that affect the
treatment received and/or the length of stay”
• Applies to LTC setting
• Do not report conditions that are resolved or from
previous admissions that have no bearing on the
current stay
• Historical diagnoses (Z80-Z87) may be used if there is
impact on current care or treatment
ICD-10-CM Official Guidelines for Coding and Reporting, Section III, Pages 100-101
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Signs & Symptoms
• May be coded when they are the reason for
testing
• When provider has not made a definitive final
diagnosis
• Signs & symptoms that are a routine part of a
known disease process are not coded
separately unless otherwise instructed in
Tabular listing
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Abnormal Test Findings
• Do not code unless provider documents clinical
significance in medical record
• If physician or nonphysician practitioner orders
tests based on abnormal findings or findings
outside the norm, query physician to verify
code assignment
• If an abnormal findings leads to a definitive
diagnosis upon further testing prior to coding
the case, definitive diagnosis is always used
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Multiple Coding
• Use of more than one code to fully identify
components of a complex diagnostic statement
• A complex statement is one that involves connecting
words or phrases such as “associated with,” “due to,”
“incidental to,” or “secondary to”
• Is required for certain conditions that are not subject
to rules of combination coding
• Identified in Tabular List by instruction to “use
additional” or “code first underlying disease”
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Multiple Coding – Example
I12.0 Hypertensive chronic kidney disease with
stage 5 chronic kidney disease or end stage renal
disease
Use additional code to identify the stage of
chronic kidney disease (N18.5-N18.4, N18.9)
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Combination Codes
• A single code used to classify two diagnoses or
a diagnosis with an associated secondary
process (manifestation) or complication
• Only the combination code is assigned when
that code fully identifies the diagnostic
conditions involved or when
Tabular/Alphabetical Index so directs
Example
‒ E10.610 – Type 1 diabetes mellitus with diabetic
neuropathic arthropathy
• Describes type, body system & manifestation
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Sequela (Late Effects)
• Reflects residual effect or condition produced
by an acute phase of illness or injury
• No time limit applies
• Generally requires two codes
– Condition or nature of the sequela (cause of the
sequela) is coded first
– Sequela (late effect) is coded second
Exception: if instructed to code a manifestation or
combination code includes sequela
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Late Effects or Sequela of CVA
ICD-9-CM
438.11 – Late effect
of cerebrovascular
disease, speech &
language deficits,
aphasia
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ICD-10-CM
I69.020 – Aphasia
following nontraumatic
subarachnoid hemorrhage
I69.120 – Aphasia
following nontraumatic
intracerebral hemorrhage
I69.220 – Aphasia
following other
nontraumatic intracranial
hemorrhage disease
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Aftercare Codes – Fractures or Injuries
• Assign after initial, acute treatment is
completed
• Used in post acute settings
• Patient is admitted to LTC for ongoing care
during healing or recovery phase
• List acute injury code with 7th character “D”
• Aftercare Z codes are NOT used for injuries
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Aftercare Coding – Examples
• Example A
– Patient status post hip replacement
– Admitted to LTC for rehabilitation
– S72.111D – Subsequent encounter for closed
fracture with routine healing
• Example B
– Patient status post fracture of acute pelvic fracture
– Admitted to LTC for rehabilitation
– S32.9XXD – Fracture/unspecified/lumbosacral
spine & pelvis, subsequent encounter for routine
healing
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Ventilator Associated Pneumonia
• J95.851 – Ventilator associated pneumonia
– When provider has documented that it is related
to ventilator use
– Assign an additional code for organism
– Do not assign if provider does not specify
pneumonia is caused by ventilator
• Refer to Sections J13-J18 for other pneumonia
diagnoses
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Urinary Tract Infection
• ICD-9-CM
– Assigned 599.0 + the organism if identified &
documented
• ICD-10-CM
– Assign N39.0
– Assign additional code (B95-B97) for infectious
agent if known
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Wound Care
• Z48.0 – code series
– Encounter for attention to dressings, sutures &
drains
•
•
•
•
Nonsurgical wound dressing
Surgical wound dressing
Removal of sutures
Change or removal of drains
• Code open wound, ulcer, etc., requiring
treatment
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Wound Care
• Ulcer, Pressure, by site (i.e., decubitus, bed
sores)
– L89. – code series
• Instruction to “code also” associated gangrene
(I96) if documented
• Nursing or provider documentation should
reflect
– Type of wound
– Site(s)
– Stage(s)
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•
•
•
•
•
•
•
•
•
•
•
Open Wounds – Code Series
Head (S00 to S09)
Neck (S10 to S19)
Thorax (S20 to S29)
Abdomen, lower back, lumbar spine, pelvis, & external genitals
(S30 to S39)
Shoulder & upper arm (S40 to S49)
Elbow & forearm (S50 to S59)
Wrist & hand (S60 to S69)
Hip & thigh (S70 to S79)
Knee & lower leg (S80 to S89)
Ankle & foot (S90 to S99)
Unspecified multiple injuries (T07)
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Wound Care
• Bacterial/viral infections – B95.0-B96.89
– Used as an additional code if not already in code
description for disease, wound or ulcer
• MRSA
– MRSA Carrier/colonization Z22.322
– MRSA Susceptible/colonization Z22.321
•
•
•
•
Osteomyelitis Acute – M86.00-M86.29
Osteomyelitis Chronic – M86.30-M86.9
Asceptic Necrosis – M87.00-M90.59
Cellulitis – L02.02-L02.93, L02.02-L0391
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Final Thoughts
• Evaluate training needs
• Evaluation workflows
• Perform dual coding assessments
on a sample of current records &
claims
• Provide feedback & education to
professional staff on clinical
documentation improvement
• Send coding personnel to
comprehensive ICD-10 training
prior to October 1, 2015
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Resources & References
CMS ICD-9-CM Website
http://www.cms.gov/Medicare/Coding/ICD9Provider
DiagnosticCodes/index.html
CMS ICD-10-CM Website
http://www.cms.gov/Medicare/Coding/ICD10/index.
html
AHIMA. “ICD-10-CM Coding Guidance for
Long-Term Care Facilities.” Journal of AHIMA
86, no. 3, (March 2015): 46-50
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CMS ICD-10-CM Implementation Tools
• ICD-10 Implementation Timelines & Checklists
http://www.cms.gov/Medicare/Coding/ICD10/ICD10ImplementationTimelines.html
• CMS Provider Tools
http://www.cms.gov/Medicare/Coding/ICD10/Provider
Resources.html
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Coding Industry Resources
• AHIMA
http://www.ahima.org/icd10
• AAPC
http://www.aapc.com/
http://www.aapc.com/icd-10/index.aspx
http://www.aapc.com/ICD-10/resources.aspx
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QUESTIONS?
CONTINUING PROFESSIONAL EDUCATION (CPE)
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CPE CREDIT
• CPE credit may be awarded upon verification
of participant attendance
• For questions, concerns or comments
regarding CPE credit, please email the BKD
Learning & Development Department at
[email protected]
86
THANK YOU!
FOR MORE INFORMATION
Marla Dumm, CPC, CCS-P
Managing Consultant
[email protected]
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