ICD-10-CM/PCS
UPDATE
32nd Annual Primary Care Update
OSU College of Osteopathic Medicine
Sandy Smith, M.Ed., RHIA, CCS
Kelli Horn, RHIT, CCS
HOSPITAL UPDATE
How US HealthCare Fared During
One Month of ICD-10 Implementation
2
ICD-10 Watch, November 4, 2015 Volume 7, Issue 44
WATCH
AND
WAIT
Embrace
“opportunities”
and Correct
3
(4) OBJECTIVES IN THE HOSPITAL
Strengthen coder/Clinical Documentation Improvement
(CDI) Specialist working relationship
 Proactively strive for coder competency
 Evaluate need for and appropriateness of ICD-10
physician queries
 Ensure ongoing ICD-10 education for coders

4
CDI/CODER RELATIONSHIP
Strengthen working relationship

New AVP of CDI and Coding

Coder/CDI pair

Bimonthly CDI/Coder chart discussion
5
CODER COMPETENCY
Proactively strive for coder competency

ICD-10 Question and Answer Spreadsheet

Ongoing Auditing and Feedback

External

Internal

Monthly Coder Education Calls

Bimonthly Inpatient/Outpatient Coding Roundtable
6

***Company Focus on Quality Over Productivity***
Physician Query
Appropriateness
7
BLOOD TRANSFUSION
Blood Component:
 Autologous
 Nonautologous
Site Approach:
 Open
 Percutaneous
Site Administered
 Central Vein
 Central Artery
 Peripheral Vein
 Peripheral Artery
8
CONTRAST
9
Need for
Physician Queries:
Diagnoses
10
GLASGOW COMA SCALE
11
ATRIAL FIBRILLATION
12
CROHN’S DISEASE - SITE
13
CROHN’S DISEASE - COMPLICATION
14
INJURY EPISODE OF CARE
15
MYOCARDIAL INFARCTION
16
ULCERATIVE COLITIS
17
UROSEPSIS CLARIFICATION
18
DIABETES
19
OBESITY
20
OPEN FRACTURE
GUSTILO ANDERSON CLASSIFICATION
21
RESPIRATORY FAILURE
22
SUBSTITUTE
DURING OPERATIVE SESSION
23
Need for
Physician Queries:
Procedures
24
PROCEDURAL APPROACH
This query should be assigned to surgeons only
25
PROCEDURE ANATOMIC SITE
26
GENERAL - INTENT OF PROCEDURE

Umbilical Artery or Vein Catheterization
The code is based on REASON for procedure
 3M Nosology profession advice suggests querying physician

27
ICD-10-PCS CODE STRUCTURE & FORMAT
Alphanumeric Code Structure
 7 Characters – (If insufficient documentation to assign, must
query physician)
 No Decimals
 Characters – Axis of Classification that Represents an
Aspect of the Procedures (ex., Body System, Approach)
 Values – 34 Letters and Numbers (0-9; A-H, J-N, P-Z)
These values have the same meaning within a defined code
range but vary across sections.
The number of unique values differs among characters (ex.,
more body part values than approach values)
The meaning of any single value is a combination of its axis
of classification and any preceding values (ex., body part
values dependent on body system – 0 = Brain in CNS but
0 = Cervical Plexus in the Peripheral Nervous System

28
ICD-10-PCS CODE STRUCTURE & FORMAT
1
2
Section
Body
System
3
Root
Operation
4
Body
Part
5
Approach
6
Device
7
Qualifier
Coding Example
Single Channel Cochlear Prosthesis, Right Inner Ear
29
ICD-10-PCS ALPHA INDEX
ACCESS TO SAMPLE CODE
Insertion of device in
Ear
Left 09HE
Right 09HD
30
ICD-10-PCS SAMPLE GRID
0 Medical and Surgical
9 Ear, Nose Sinus
H Insertion – Putting in a nonbiological appliance that monitors,
assists, performs, or prevents a physiological function but does not
physically take the place of a body part
Body Part
Character 4
Approach
Character 5
Device
Character 6
Qualifier
Character
7
D Inner Ear,
Right
E Inner Ear,
Left
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Hearing Device, Bone Conduction
5 Hearing Device, Single Channel
Cochlear Prosthesis
6 Hearing Device, Multiple Channel
Cochlear Prosthesis
S Hearing Device
Z No
Qualifier
N
Nasopharynx
7 Via Natural or
B Intraluminal Device, Airway
Z No
Qualifier
Artificial Opening
8 Via Natural or
Artificial Opening
Endoscopic
31
ICD-10-PCS EXAMPLE CODE
09HD05Z – Single Channel Cochlear Prosthesis, Right Inner Ear
0
Medical
&
Surgical
9 H D 0
Insertion
Ear
Nose
& Sinus
Z
No
Qualifier
Hearing Device
Single Channel
32
Cochlear Prosthesis
Open
Inner Ear
Right
5
SECTIONS OF ICD-10-PCS
& VALUE CHARACTERS
The section character indicates the general type of procedure performed.
Sections & Values
0
1
2
3
4
5
6
7
8
Medical & Surgical
Obstetrics
Placement
Administration
Measurement & Monitoring
Extracorporeal Assistance &
Performance
Extracorporeal Therapies
Osteopathic
Other Procedures
Sections & Values
9
B
C
D
F
G
H
X
Chiropractic
Imaging
Nuclear Medicine
Radiation Therapy
Physical Rehabilitation &
Diagnostic Audiology
Mental Health
Substance Abuse Treatment
New Technology
No Laboratory Section
33
MEDICAL & SURGICAL SECTION
ICD-10-PCS BODY SYSTEMS – CHARACTER 2
0 Central Nervous
1 Peripheral Nervous
2 Heart & Great Vessels
3 Upper Arteries
4 Lower Arteries
5 Upper Veins
6 Lower Veins
7 Lymphatic & Hemic
8 Eye
9 Ear, Nose & Sinus
B Respiratory
C Mouth & Throat
D Gastrointestinal
F Hepatobiliary & Pancreas
G Endocrine
H Skin & Breast
J Subcutaneous Tissue & Fascia
K Muscles
L Tendons – Includes Synovial
Membrane
M Bursae & Ligaments
N Head and Facial Bones
P Upper Bones
Q Lower Bones
R Upper Joints – Includes Synovial
Membrane
S Lower Joints – Includes Synovial
Membrane
T Urinary
34
MEDICAL & SURGICAL SECTION – CHARACTER 2
U Female Reproductive
V Male Reproductive
W Anatomical Regions –
General

•
•
•
X Anatomical Regions – Upper
Extremities
Y Anatomical Regions – Lower
Extremities
Character Reflects General Physiological System or Anatomical Region
Involved
Some body systems are assigned a single values while others are
broken into subsystems and have multiple values (ex., Respiratory
System = B; Musculoskeletal divided into Muscles = K, Tendons = L,
Bursae and Ligaments = M, Head and Facial Bones = N, Upper Bones
= P, Lower Bones = Q, Upper Joints = R and Lower Joints = S)
W, X, & Y values for anatomical regions should only be used when the
procedure is performed on an anatomical region, rather than a specific
body part or body layers that span more than one body system
35
The diaphragm is the frame of reference for body systems classified
as upper or lower
CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION


•
•
•
Character 3 = Root Operation
The objective of the procedure or what the procedure is trying to
accomplish
Appendix B = Root Operations Definitions
The physician is not expected to use the exact terms in the code
descriptions, rather it is the coder’s responsibility to determine
what the documentation equates to in the ICD-10-PCS definitions
Character 4 = Body Part
The specific part of the body system or anatomical site where the
procedure was performed
Body part values may refer to an entire organ (ex., liver) or to a
specific portion of an organ (ex., liver, right lobe)
Appendix D = Body Part Key – Alternative names for muscles, veins,
nerves or other anatomic sites (ex., Basilar artery = Intracranial
artery)
Appendix E = Body Part Definitions – Body parts or terms included
in the anatomical term
36
CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION

•
•
•
•
•
Character 4 – Body Part – Continued
If a procedure is performed on a portion of a body part that
does not have a separate body part value, code to the
corresponding whole body part value (ex., earlobe codes to
external ear)
Procedures performed on body parts with the prefix “peri”
(meaning around or near) are coded to the body part name (ex.,
perirenal = kidney)
If a specific branch of a body part does not have a separate
value, code to the closest proximal branch that has a value
(ex., mandibular branch of trigeminal nerve = trigeminal nerve)
Bilateral body part values – if applicable, and present use one
code; however, if a bilateral value does not exist two codes are
required one for each side
37
If there is no separate body part value for fingers or toes in the
body system code to the hand and foot
CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION

Procedures on skin, subcutaneous tissue and fascia overlying a
joint are coded to the following body parts:
Shoulder = Upper Arm
Elbow = Lower Arm
Wrist = Lower Arm

•
Hip = Upper Leg
Knee = Lower Leg
Ankle = Foot
Character 5 – Approach – (7 Different Approaches)
Method, technique or approach used to reach the procedure
site
The approach comprises three components: the access
location, method and type of instrumentation.
External – Procedures performed directly on the skin or
mucus membrane and procedures performed indirectly by the
application of external force through the skin or mucous
membrane. Also, includes procedures performed within an
orifice on structures that are visible without the aid of any
instrumentation (Ex., resection tonsils).
38
CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION
•
•
Through the skin or mucous membrane
Open – Cutting through the skin or mucous membrane and any
other body layers necessary to expose the site of the procedure
Includes open approach with percutaneous endoscopic assistance
(Ex. Laparoscopic Assisted Sigmoidectomy)
Percutaneous – Entry, by puncture or minor incision, of
instrumentation through the skin or mucous membrane and/or any
other body layers necessary to reach the site of the procedure
Includes percutaneous procedure via device
Percutaneous Endoscopic – Entry, by puncture or minor incision,
of instrumentation through the skin or mucous membrane and/or
any other body layers necessary to reach and visualize the site of the
procedure
Through an orifice (natural or artificial opening)
Via Natural or Artificial Opening – Entry of instrumentation
through a natural or artificial external opening to reach the site of
39
the procedure
CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION
Via Natural or Artificial Opening Endoscopic – Entry of instrumentation
through a natural or artificial external opening to reach and visualize the site
of the procedure
Via Natural or Artificial Opening with Percutaneous Endoscopic
Assistance – Entry of instrumentation through a natural or artificial external
opening and entry, by puncture or minor incision, of instrumentation
through the skin or mucous membrane and any other body layers necessary
to aid in the performance of the procedure (Currently, sole example,
laparoscopic assisted vaginal hysterectomy)
 Character 6 – Device
Identifies whether or not a device was associated with the procedure
• Only devices that remain in or on the patient’s body after
the procedure is completed are coded
•
Incidental material are not codes (ex., sutures, ligatures, clips, radiological
markers and temporary postoperative wound drains)
40
• Qualifier value “Z” (meaning none or no device)will be assigned for
procedures that do not involve the use of a device
CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION
To be classified as a device the material or appliance should be
central to the procedural objective and located at the procedure
site, without an intention of changing the location of the device
 A device should be capable of being removed
 Substances that are liquid or blood components are not devices
 Equipment that is machinery or other aids that reside primarily
outside the body and are temporarily used during the procedure are
not devices
 Four basic categories:
Grafts and Prostheses – Biological or synthetic material that takes the
place of all or a portion of a body part
Implants – Therapeutic material that is not absorbed, eliminated, or
incorporated into a body part
Simple or Mechanical Appliances – Biological or synthetic material that
assists or prevents a physiological function
41
Electronic Appliances – Assist, take the place of, monitor, or prevent a
physiological function

CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION




Appendix F – Device Key includes both brand and generic
device names and the PCS description for the device or use
for the device. The Device Aggregation Table contains
information to correlate a specific device, listed in the first
column, when used in the root operation and body system,
shown in the second and third column to the general device
term and value listed in the last column.
Appendix G – Device Definitions
Appendix H - Substance Key – Lists the name of some
substances and how the substance should be classified in
ICD-10-PCS
Appendix I – Substance Definitions
42
CHARACTERS 2-7 – CONTINUED
MEDICAL & SURGICAL SECTION

Character 7 – Qualifier
Provides additional information regarding a procedure which
is not reflected by the other code characters
Qualifiers have unique meanings relating to the different
procedures with which they are associated
Examples of information identified by a qualifier are as follows:
Diagnostic Procedure (X – Excision, Extraction &
Drainage)
Stereotatic Procedures
Ending Body Part for a Bypass Procedure
Character value “Z” means none or no qualifier
43
ROOT OPERATIONS TO TAKE OUT SOME OR
ALL OF A BODY PART – COMPARISON TABLE
Root
Operation
Objective of
Procedure
Site of Procedure
Example
Excision
Cutting out/off without
replacement
Portion of a body part
Breast
Lumpectomy
Resection
Cutting out/off without
replacement
All of a body part
Total
Mastectomy
Detachment
Cutting out/off without
replacement
Extremity only, any level
Amputation
above elbow
Destruction
Eradicating by the direct
use of energy, force or
destructive agent,
without replacement
Some or all of a body
part
Fulguration of
endometrium
Extraction
Pulling or stripping out
or off by the use of
force without
replacement
Some or all of a body
part
Suction D&C
44
ROOT OPERATIONS TO TAKE OUT
SOLIDS/FLUIDS/GASES FROM A BODY PART –
COMPARISON TABLE
Root
Operation
Objective of
Procedure
Site of Procedure
Example
Drainage
Taking/letting out
fluids/gases
From within a body
part
Incision &
Drainage
Extirpation
Taking/cutting out solid
matter
From within a body
part
Thrombectomy
Fragmentation
Breaking solid matter into Within a body part
pieces
Lithotripsy
45
ROOT OPERATIONS INVOLVING CUTTING OR
SEPARATION ONLY – COMPARISON TABLE
Root
Operation
Objective of Procedure
Site of Procedure
Example
Division
Cutting into/separating
/transecting a body part
without drawing fluids
and/or gases
Within a body part
Neurotomy
Release
Freeing a body part from
abnormal constraint by
cutting or by the use of
force
Around a body part
Adhesiolysis
46
ROOT OPERATION THAT PUT IN/PUT BACK
OR MOVE SOME/ALL OF A BODY PART
COMPARISON TABLE
Root
Operation
Objective of Procedure
Site of
Procedure
Example
Transplantation
Putting in a living body part
from a person/ animal to
physically take the place
and/or function of a similar
body part
Some/all of a
body part
Kidney Transplant
Reattachment
Putting back a detached body
part to its normal or other
suitable location
Some/all of a
body part
Reattach Finger
Transfer
Moving, without taking out a
body part to another location
to function for a similar body
part
Some/all of a
body part
Skin Transfer Flap
Reposition
Moving a body part to normal
or other suitable location
Some/all of a
body part
Move
Undescended
Testicle
47
ROOT OPERATIONS TO ALTER THE
DIAMETER OR ROUTE OF A TUBULAR
BODY PART – COMPARISON TABLE
Root
Operation
Objective of
Procedure
Site of Procedure
Example
Restriction
Partially closing
orifice/lumen
Tubular body part
Gastroesophageal
fundoplication
Occlusion
Completely closing
orifice/lumen
Tubular body part
Fallopian tube ligation
Dilation
Expanding
orifice/lumen
Tubular body part
Percutaneous
Transluminal Coronary
Angioplasty
Bypass
Altering route of
passage
Tubular body part
Coronary Artery Bypass
Graft
48
ROOT OPERATIONS THAT ALWAYS
INVOLVE A DEVICE – COMPARISON TABLE
Root
Operation
Insertion
Objective of Procedure
Site of
Procedure
Putting in non-biological device to
In/on a body
monitor, assist, perform or prevent a part
physiological function
Example
Central line
insertion
Replacement Putting in device that replaces a body
part
Some/all of a
body part
Total hip
replacement
Supplement
Putting in device that reinforces or
augments a body part
In/on a body
part
Abdominal wall
herniorrhaphy using
mesh
Change
Exchanging device without cutting/
puncturing the skin or mucous
membrane
In/on a body
part
Drainage tube
change
Removal
Taking out/off a device
In/on a body
part
Central line
removal
Revision
Correcting a malfunctioning/displaced
device
In/on a body
part
Revision of
pacemaker
insertion
49
ROOT OPERATIONS THAT INVOLVE
EXAMINATION ONLY – COMPARISON TABLE
Root
Operation
Objective of Procedure
Site of
Procedure
Example
Inspection
Visual/manual exploration
Some/all of a
body part
Diagnostic
cystoscopy
Map
Locating the route of passage
of electrical impulses and/or
locating functional areas
Brain/cardiac
conduction
mechanism
Cardiac
electrophysiological
study
50
ROOT OPERATIONS THAT INCLUDE OTHER
REPAIRS – COMPARISON TABLE
Root
Operation
Objective of Procedure
Site of
Procedure
Example
Control
Stopping/attempting to stop
postprocedural bleeding
Anatomical
Region
Post-prostatectomy
bleeding control
Repair
Restoring, to the extent
possible, a body part to its
normal structure and
function
Some/all of a
body part
Suture laceration
(NEC value for
ICD-10-PCS)
51
ROOT OPERATIONS THAT INCLUDE OTHER
OBJECTIVES – COMPARISON TABLE
Root
Operation
Objective of Procedure
Site of
Procedure
Example
Fusion
Rendering joint immobile
Joint
Spinal fusion
Alteration
Modifying body part for cosmetic
purposes without affecting function
Some/all of a Face lift
body part
Creation
Making new structure for sex change
operation
Perineum
Artificial
vagina/penis
52
ROOT OPERATION GUIDELINES






•
•
•
•
The full definition of the root operation must be applied
Components of a procedure specified in the root operation
definition and explanation are not coded separately
Procedural steps necessary to reach the operative site (such as
incision) are not coded separately
Closure of the operative site (ex., suturing) is not coded separately
Anastomosis of a tubular body part is not coded separately
Multiple Procedure Coding
The same root operation is performed on different body parts as
defined by distinct values of the body part character
The same root operation is repeated at different body sites that
are included in the same body part value
Multiple root operations with distinct objectives are performed on
the same body part value
The intended root operation is attempted using one approach but
has to be converted to a different approach
53
ROOT
OPERATION GUIDELINES
-
CONTINUED
When a planned procedure has been started but cannot be
completed, it is coded to the extent to which is was performed
• If the intended procedure is discontinued, code the procedure
to the root operation performed.
• If the procedure is discontinued before any other root
operation is performed, code the root operation “inspection”
of the body part or anatomical region inspected.
 Failed procedures (did not achieve expected results) are coded
as performed
 Biopsy procedures are coded using the root operations
excision, extraction or drainage and assigned the qualifier “X”
for diagnostic (the “diagnostic" qualifier is only used for
biopsies)
54
 Biopsy (excision, extraction or drainage) followed by a more
definitive procedure, code both

ROOT

OPERATION GUIDELINES
-
CONTINUED
If the root operations Excision, Repair or Inspection are
performed on overlapping layers of the musculoskeletal
system, the body part specifying the deepest layer is
coded.
55
APPLICATION OF 7TH CHARACTER EXTENDERS

7th Character Extender are available in the following chapters:

Chapter 15 – Pregnancy, Childbirth & the Puerperium


In multiple gestational pregnancies the 7th character extender identifies the specific
fetus affected by a complication or condition
The value “0” is used for single gestations and multiple gestations where the fetus is
unspecified
Chapter 19 – Injury, Poisoning & Certain Other Consequences of External
Causes
 Chapter 20 – External Causes of Morbidity



7th character extenders used on the cause/intent codes
Use of 7th Character Extenders in Chapters 19 & 20


Provide specific information regarding the episode of care
 Initial Encounter = “A”
 Subsequent Encounter = “D”
 Sequela = “S”
Used with fracture codes to provided additional detail such as open or closed
fracture, Gustilo classification (if applicable), routine or delayed healing, and nonunion
56
or malunion.
INITIAL ENCOUNTER
 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
 Evaluation and continuing
treatment by the same or
a different physician
57
SUBSEQUENT
ENCOUNTER
7th character “D” Subsequent Encounter is used for encounters
after the patient has received active treatment of the condition
and is now receiving routine care for the condition during the
healing or recovery phase (Subsequent Care).
 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.
 Examples of Subsequent Care are:
 Cast change or removal
 An x-ray to check healing status of fracture
 Removal of external or internal fixation device
 Medication adjustment
58
 Other aftercare and follow-up visits
following treatment of the injury or condition

ENCOUNTER FOR SEQUELAE
7th character “S”, Sequelae, is used for complications or
conditions that arise as a direct result of a condition/injury
(ex. ,scar formation after a burn). The scars are sequelae of
the burn. When using 7th character “S”, it is necessary to
code both the residual condition and the injury code that
precipitated the sequelae.
 The “S” is added only to the injury code,
not the sequelae code.
 The residual condition (sequelae) is coded
first with an additional code to show the
cause/injury.

59
EXTENDERS
FOR
EXTERNAL CAUSE CODES
Assign the cause/intent external cause code with the
appropriate 7th character (initial encounter, subsequent
encounter or sequelae) for each encounter in which the
injury or condition is being treated.
 Assignment of the 7th character for the external cause code
should match the 7th character of the code assigned for the
associated injury or condition for the encounter.

EXTENDER ASSIGNMENT REMINDER
Assignment of the 7th character is based on
whether the patient is undergoing active
treatment and not whether the provider is
seeing the patient for the first time. Doesn’t
matter if the physician is in the same group or
a different physician group.
60
EXTENDERS FOR
COMPLICATION CODES

For complication codes, active treatment refers to
treatment for the condition described by the code, even
though it may be related to an earlier precipitating
problem.
For example, code T84.50XA, Infection and
inflammatory reaction due to unspecified internal
joint prosthesis, initial encounter, is used when active
treatment is provided for the infection, even though
the condition relates to the prosthetic device,
implant or graft that was placed at a previous
encounter.
61
EXAMPLE
ED VISIT – TIBIA FRACTURE – 1ST VISIT
Question:
 A 15-year-old male presents to the ED with a nondisplaced
oblique fracture of the right tibia. The injury occurred when
he tripped over another player while running on the field
playing lacrosse. The ED physician stabilized the fracture and
referred the patient to the orthopedist for follow-up care.
How should the ED encounter be coded?
Answer:
 Assign code S82.234A, Nondisplaced oblique fracture of shaft
of right tibia, initial encounter, for the ED visit. Codes
W03.XXXA, Other fall on same level due to collision with
another person, initial encounter, and
Y93.65, Activity, lacrosse and field
hockey, should be assigned to describe
the external cause of injury and
the activity
62
EXAMPLE - PHYSICIAN’S OFFICE
TIBIA FRACTURE – 2ND VISIT
Question:

The same patient presents to a local orthopedist office for
treatment of his nondisplaced fracture of the shaft of the
right tibia. After x-rays, the physician makes plans for ongoing
care, and instructs the mother to return with the patient for
follow-up in three weeks for a recheck. How should this
encounter with the orthopedist be coded?
Answer:

Assign code S82.234A, Nondisplaced oblique fracture of shaft
of right tibia, initial encounter, as the first-listed code for the
visit to the orthopedist. The 7th character “A” is assigned
because the patient is still receiving active treatment of the
fracture. Codes W03.XXXA, Other fall on same level due to
collision with another person, should also be assigned to
describe the external cause of the injury.
63
EXAMPLE - PHYSICIAN’S OFFICE
TIBIA FRACTURE – 3RD VISIT
Question:
 The above patient returns to the orthopedist office, after three
weeks. The provider notes routine healing, but the cast needs to be
changed. The provider instructs the mother to return in three
weeks. However, the mom informs the provider that they are
moving out of state and won’t be returning to the office. The
provider recommends an orthopedist in the new area. How should
the encounter at the orthopedist office be coded?
Answer:
 Assign code S82.234D, Nondisplaced oblique fracture of shaft of
right tibia, subsequent encounter, as the first-listed code for this visit
to the orthopedist. The 7th character “D” is assigned because the
patient is receiving routine care during the healing phase of the
fracture. Cast change or removal is an example of subsequent
treatment. Code W03.XXXD, Other fall on same level due to
collision with another person, subsequent encounter is also
assigned to describe the external cause of injury
64
EXAMPLE – NEW PHYSICIAN’S OFFICE
TIBIA FRACTURE – 4TH VISIT
Question:

The same patient in the above scenario presents to a new orthopedist three
weeks after moving to a new location. The orthopedist orders x-rays and
determines that the right tibia shaft fracture is almost completely healed. He
instructs the patient to return in one week for cast removal.

Even though active treatment for this fracture had previously been completed, this is
an initial encounter with a new physician. Is the 7th character “A” appropriate?
Answer:

Assign code S82.234D, Nondisplaced oblique fracture
of shaft of right tibia, subsequent encounter, as the
first-listed code for this visit. Whether the subsequent
visit is with the original orthopedist or a new
orthopedist does not affect assignment of the 7th
character “D”. The fact that the injury is receiving
routine care during the healing phase is the
determining factor. Code W03.XXXD, Other fall
on same level due to collision with another person,
subsequent encounter is also assigned to describe
the external cause of injury
65
7TH
CHARACTER EXTENDERS
TRAFFIC ACCIDENT INJURIES
Question:
 The patient is a 74-year-old male who was discharged from the hospital after
being treated for injuries sustained in a traffic accident where he was an
unrestrained passenger in a car. At that time, the patient had only suffered a
head injury, and all other imaging results were completely normal. However,
the patient was readmitted after a syncopal episode and was diagnosed with
delayed splenic rupture, grade 3 splenic laceration, with large perisplenic
hematoma.
 Which 7th character (“A” initial encounter or “D” subsequent encounter)
is assigned, since the ruptured spleen was not diagnosed on the initial
admission?
 Also, should the 7th character be the same for the injury and the external
cause codes?
66
7TH
CHARACTER EXTENDERS
TRAFFIC ACCIDENT INJURIES
Answer:

Assign code S36.031A, Moderate laceration of spleen, initial
encounter, for the grade 3 splenic laceration as the principal
diagnosis. Codes S36.029A, Unspecified contusion of spleen, initial
encounter, and V49.9XXA, Car occupant (driver) (passenger)
injured in unspecified traffic accident, initial encounter, should also
be assigned. The splenic laceration is a new injury and this is an
encounter for active treatment of the laceration of the spleen.
Even though the splenic rupture
was not found on the first
admission, the 7th character “A”,
initial encounter is assigned for
the readmission, since the patient
is receiving active treatment for
the delayed splenic rupture.
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EXAMPLE
SEQUELA
7TH
CHARACTER EXTENDER
Question:
 21-year-old male, status post open fracture of left femur secondary to an
accidental gunshot wound, is admitted with intractable pain in the left hip.
The patient’s injury occurred 18 months ago, and he had previously undergone open reduction and internal fixation of his femoral neck fracture.
Radiologic imaging demonstrated ballistic fragments within the acetabulum
and femoral neck. In his diagnostic statement, the provider listed,
“traumatic arthritis of hip secondary to femur fracture”.

Is the traumatic arthritis considered a late effect of the gunshot injury?
Answer:
 Yes, the traumatic arthritis is a late effect of the gunshot injury and is
identified by the injury code with the 7th character “S” sequelae. Assign
code M12.552, Traumatic arthropathy, left hip, as the principal diagnosis.
Assign codes S72.002S, Fracture of unspecified part of neck of left femur,
sequela, and W34.00XS, Accidental discharge from other and unspecified
firearms or gun, sequela, as additional diagnoses.
 Per the official guidelines, a sequelae is the residual effect (condition
produced) after the acute phase of an illness or injury has terminated.
There is no time limit on when a sequelae code can be used. The residual
may be apparent early, or it may occur months or years later. Coding of
sequelae generally requires two codes sequenced in the following order:
The residual condition (sequelae) is sequenced first. The cause of the
sequelae code is sequenced second. Only the cause/intent external cause
code is assigned, no codes for activity, status, or place of occurrence.
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7TH
CHARACTER EXTENDER
–
REHAB FACILITY
Question:
 The patient who is status post treatment of multiple fractures
currently in the healing phase, is transferred to a rehabilitation
facility. At the rehab facility the patient is covered by a new
physician that has never seen the patient before. Should the 7th
character for the fractures be reported as “A” initial encounter
because it’s a new physician, even though the patient is considered
to be in the healing phase?
Answer:
 The key to selecting the 7th character for “initial encounter” is
whether there is still active treatment. The fact that the patient is
new to the physician does not have an
relevance in determining the 7th character.
Rehabilitation services are not considered
active treatment and the encounter should
be reported with the appropriate 7th
character for “subsequent encounter”.
69
POST


Post-Implementation ICD-10 Challenges – George Breen,
Jackie Selby and Bethany Hills – Managed Healthcare Executives
– 9/21/15
Reimbursement Challenges


Specificity of Clinical Documentation Leading to Reimbursement Issues
12-Month Transition Period





ICD-10-CM/PCS
IMPLEMENTATION ISSUES - PHYSICIAN
Quality Penalties & Contractor Claims Denial
Physician or Other Practitioner Part B Claims Only
Based Solely on the Level of Specificity of the ICD-10 Code so Long as a
Valid Code is Used from the Right Family
Does Not Automatically Translate to Managed Care
 Quality Incentives & Value-Based Payments Often Based on Medicare
Reporting & Standards for Private Health Plans
Compliance Challenges

Internal Auditing





Identify Coding Errors & Trend
Prevent or Correct Overpayments
Documentation Must Support Specificity of Coding
Training for the Compliance Department
Anticipate Aggressive Payer Audits (Private and Public)
70
POST

Increased Specificity Challenges for Integrated
Entities


ICD-10-CM/PCS
IMPLEMENTATION ISSUES - PHYSICIAN
Increased Need for Specificity & Consistency
Coverage & Policy Changes
Current Reimbursement Methodologies may not Retain the
Same Level Payment Following ICD-10 Transition
 Possible Changes to Health Plan Coverage Creating Both an
Operational & Financial Impact
 Changes May Require New Documentation Standards and/or
New Coverage Limitations and Impact the Timing & Format
of Quality Reporting to Insurers

71
METRICS TO MONITOR AFTER
ICD-10 IMPLEMENTATION
Top 10 Metrics to Monitor in the First 30 Days – by Mary
Beth Haugen, RHIA, MS, founder & CEO of Haugen
Consulting Group – Published in the ICD-10 Newsletter,
September 2015 Edition
 1. Coder Productivity

Experts agree productivity could decrease by 50%
 Decrease should be followed by gradual increase, if not:

Additional Education Needed
 Documentation Gaps Causing Productivity Lags
 Additional Factors Slowing Coders Down


Factors to help increase productivity
Coder Familiarity With ICD-10-CM/PCS Classification System
 Elimination of Dual Coding (ICD-9-CM and ICD-10-CM/PCS)
 Computerized Coding Systems
 Improved Documentation

72
METRICS TO MONITOR AFTER
ICD-10 IMPLEMENTATION

2. Number of Concurrent Queries

Queries Expected to Increase




3. Number of Retrospective Queries

Increase in Number




Measure Increase in Number of Queries
Physician Education
Templates to Collect Additional Documentation
Communication Breakdown Between CDI or Coders & Physicians
Query Overload for Physicians Leading to Delayed Response
Consider Implementing a Process to Prioritize Queries
4. Days to Final Bill

Average DNFB (Discharged Not Final Billed) with ICD-10 versus ICD9, if increase consider:




Insufficient Physician Documentation
Lack of Physician Response to Queries
Coder Problems with ICD-10 Code Assignments
Technological Glitches
73
METRICS TO MONITOR AFTER
ICD-10 IMPLEMENTATION

5. Pre-Authorization

Ensure that orders and referrals from physician practices include
specific ICD-10 codes



Additional Support for Staff Member Obtaining Authorizations
Be Proactive – Reach out to physician practices to ensure their plans to
submit correct ICD-10 information
6. Claims Edits & Denials
Track for Increase & Monitor Payer Edits, Payment Variations and
Medical Necessity Denials for Trends
 Incorrect Code Mapping



7. Days to Payment – Track by Payer
8. Coder Questions

Establish methodology for coders to submit questions internally
with designated individual

Designated Individual to Research, Query Coding Clinic, etc. and provide
follow-up
74
METRICS TO MONITOR AFTER
ICD-10 IMPLEMENTATION

9. Coding Quality

Conduct Audits
Pre-submission & Retrospective
 High Risk Cases
 Cases Where There is a MS-DRG Shift Between ICD-9 & ICD-10


10. Revenue Cycle Flow




Follow the Entire Flow for all Record Types (IP/ER/OP/SDS and
Recurring Accounts
Follow by all Payer Types – Medicare and Commercial
Revise Generated Reports As Needed & Monitor
11. CMI – Case Mix Index

CMI should not increase or decrease significantly after ICD-10
implementation, barring other factors (ex., seasonal changes,
clinical personnel changes, or service line changes)
75
ICD-10
EDUCATION FOR COMMUNITY
Ensure ongoing ICD-10 education for coders
HIGHLIGHTS
ICD-10-CM – Diagnoses






Excludes Notes
7th Characters
Laterality
Myocardial Infarction
Final character for trimester
Encounter for rehab
76
ICD-10
EDUCATION FOR COMMUNITY
HIGHLIGHTS
ICD-10-PCS – Procedures

New guidelines

Root Operations

Approaches

Multiple Procedures

New Technology section
77
ICD-10 CODING
EDUCATION
For further ICD-10 education, please contact:

Kelli Horn




[email protected]
(918) 851-2092
www.kellihorn.com
Sandy Smith

[email protected]
78
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