ICDICD--1010--CM: CM:

Let’s Code, Part ILet’s Code, Part I

Kathryn DeVault, RHIA, CCS, CCS-PDirector, HIM Solutions, AHIMA

Agenda

• ICD-10-CM Overview

• Review of ICD-10-CM Draft Official Guidelines for Coding and ReportingGuidelines for Coding and Reporting

• Coding questions answered

2012 ICD-10-CM is available at

http://www.cdc.gov/nchs/icd/icd10cm.htm or

http://www.cms.hhs.gov/ICD10

• 2012 ICD-10-CM Index to Diseases and Injuries

• 2012 ICD-10-CM Tabular List of Diseases and Injuries

– Instructional Notations– Instructional Notations

• 2012 Official Guidelines for Coding and Reporting

• 2012 Table of Drugs and Chemicals

• 2012 Neoplasm Table

• 2012 Index to External Causes

• 2012 Mapping “ICD-9-CM to ICD-10-CM” and “ICD-10-CM

to ICD-9-CM”3

XX XX XX XX.

Coding and 7Coding and 7thth Character Character

XX XX XXAAMMSS 00 22 66. 55 XX AA

Additional

CharactersAlpha

(Except U)

2 Numeric

3 - 7 Numeric or Alpha

XX XX XX XX

Category

.Etiology, anatomic

site, severity

Added seventh characters for obstetrics, injuries, and external causes of injury

XX XX XX

4

AAMMSS 00 22 66. 55 XX AA

3 – 7 Characters

Coding in ICD-10-CMICD-9-CM ICD-10-CM

Three to five characters Three to seven characters

First digit is numeric but can be alpha

(E or V)

First character always alpha

2-5 are numeric All letters used except U

5

2-5 are numeric All letters used except U

Always at least three digits Character 2 always numeric: 3-7 can

be alpha or numeric

Decimal placed after the first three

characters (or with E codes, placed

after the first four characters)

Always at least three digits

Alpha characters are not case-sensitive Decimal placed after the first three

characters

Alpha characters are not case-sensitive

Code Set Freeze

• Last regular annual updates -ICD-9-CM and ICD-1010/1/11

• Limited code updates - ICD-9-CM and ICD-1010/1/12 ICD-10

• New technologies and diseases10/1/12

• Limited code updates - ICD-10

• New technologies and diseases10/1/13

• Regular updates to ICD-1010/1/146

ICDICD--1010--CM/PCS Final RegulationCM/PCS Final Regulation

Physician Behavioral

Health

Hospitalinpatient

All Other

7

Long Term

Healthcare

Laboratoryoutpatient

Chapter Highlights Chapter Highlights

DiabetesICD-9-CM• 250.x Diabetes mellitus

5th digit “1” – Type I 5th digit “0” – Type II or

unspecified5th digit “2” & “3” –

uncontrolled

ICD-10-CM• Diabetes codes include type

of complication

• E08 Diabetes mellitus due to underlying condition

• E09 Drug or chemical induced diabetes mellitusuncontrolled

• 249.x Secondary diabetes mellitus

5th digit “0” & “1” –uncontrolled

• 648.8x – Abnormal glucose tolerance complicating pregnancy, childbirth, or puerperium (includes gestational diabetes)

induced diabetes mellitus

• E10 Type 1 diabetes mellitus

• E11 Type 2 diabetes mellitus

• E13 Other specified diabetes mellitus

• O24 DM in pregnancy, childbirth, puerperium

9

Diabetes, continued • E10.4 Type I diabetes mellitus with neurological

complications

– E10.40 Type I diabetes mellitus with diabetic neuropathy, unspecified

– E10.41 Type I diabetes mellitus with diabetic mononeuropathy

– E10.42 Type I diabetes mellitus with diabetic – E10.42 Type I diabetes mellitus with diabetic polyneuropathy

– E10.43 Type I diabetes mellitus with diabetic autonomic (poly) neuropathy

– E10.44 Type I diabetes mellitus with diabetic amyotrophy

– E10.49 Type I diabetes mellitus with other diabetic neurological complication

Mental and Behavioral Disorders

• Use . . . Abuse . . . . Dependence

• No longer identify continuous or episodic use

• History of drug or alcohol dependence coded as ‘in remission’ as ‘in remission’

• Combination codes including conditions such as withdrawal, sleep disorders, or psychosis

• Y90.- Blood alcohol level (external cause index)

ICD-10-CM Circulatory System Changes• Age definition for acute myocardial infarction has

changed

• New category for subsequent acute myocardial infarctioninfarction

• New category for complications within 28 days of acute myocardial infarction

• Transient ischemic attacks re-classified to nervous

system chapter

• Late effects of stroke differentiated by type of stroke

• Combination codes for common etiologies/ manifestations12

Pressure UlcersICD-9-CM• 707.0x Pressure ulcer by

site

• 707.2x Pressure ulcer stages

• Code first site of pressure

ICD-10-CM• L89 Pressure ulcer by site

and stage

• Site and stage captured by single code

• Specific codes for • Code first site of pressure ulcer

• Specific codes for pressure ulcer of contiguous site of back, buttock, and hip

• Code first any associated gangrene

13

ICD-10-CM – Pressure Ulcers

• L89.013 - Pressure ulcer of right elbow, stage

III

• L89.134 - Pressure ulcer of right lower back,

stage IV

• L89.312 - Pressure ulcer of right buttock, stage

II

• L89.219 - Pressure ulcer of right hip,

unspecified stage

• L89.42 - Pressure ulcer of contiguous site of

back, buttock and hip, stage II14

ICD-10-CM - Obstetrics

• Addition of trimester and deletion of episode of care– O15.03 Eclampsia in pregnancy, third trimester

– O23.12 Infections of bladder in pregnancy, second trimestertrimester

– O22.21 Superficial thrombophlebitis in pregnancy, first trimester

• Encounter for supervision of high-risk pregnancy has been moved to OB chapter

• Category Z3A, Weeks of gestation15

ICD-10-CM - Obstetrics

• Seventh character to identify specific fetus

affected by obstetric condition

– O64.1xx2 Obstructed labor due to breech presentation, fetus 2

– O30.113 Triplet pregnancy, third trimester– O30.113 Triplet pregnancy, third trimester

• Elective, legal, or therapeutic abortions are not classified to the abortion codes (code Z33.2, Encounter for elective termination of pregnancy)

• Obstructed labor codes incorporate reason for obstruction

16

Injury, Poisoning and Certain Other

Consequences of External Causes • Chapter 19 encompasses two alpha

characters

– S-codes includes injuries related to single body

regionsregions

– T-codes cover injuries to unspecified body

regions, poisonings, and certain other

consequences of external causes

• Greater specificity found in this chapter

– Type of fracture, specific anatomical site,

laterality, routine vs. delayed healing, nonunions,

malunions

Injuries grouped

by body part

rather than

category of

•(S00-S09)Head

•(S10-S19)category of

injury•(S10-S19)Neck

•(S20-S29)Thorax

18

Coding and Use of 7th

Character

•Obstetrics

•Injury

•External cause

•Either alpha or

Injury and External Cause -Identifies Injury

Subsequent –receiving

Sequela –•Either alpha or

numeric

•Placeholder “x”

•Meanings vary

19

Initial –receiving

active treatment

receiving routine care

during healing or recovery (after active treatment)

Sequela –complications or conditions

arising as result of a condition

Coding and Use of 7th

Character

Aftercare Z codes are not used for aftercare for conditions such as injuries or poisonings

20

Combination codes for poisonings and external cause (accidental, intentional self-harm, assault, undetermined)

Chapter 15 – represents fetus in multiple gestation affected by condition being coded

Expansion of Seventh Character – Fractures

• A – Initial encounter for closed fracture

• B – Initial encounter for open fracture

• D – Subsequent encounter for fracture with routine

healing healing

• G – Subsequent encounter for fracture with delayed

healing

• K – Subsequent encounter for fracture with nonunion

• P – Subsequent encounter for fracture with malunion

• S – Sequela

Gustilo Open Fracture Classification

I• Low energy, Wound less than 1 cm• Low energy, Wound less than 1 cm

II• Greater than 1 cm with moderate soft tissue damage• Greater than 1 cm with moderate soft tissue damage

III• High energy wound greater than 1 cm with extensive soft tissue damage• High energy wound greater than 1 cm with extensive soft tissue damage

III• High energy wound greater than 1 cm with extensive soft tissue damage• High energy wound greater than 1 cm with extensive soft tissue damage

IIIA• Adequate soft tissue cover• Adequate soft tissue cover

IIIB• Inadequate soft tissue cover• Inadequate soft tissue cover

IIIC• Associated with arterial injury• Associated with arterial injury

22

ICDICD--1010--CM CM DraftDraft Official Official Guidelines for Coding and Guidelines for Coding and

Reporting Reporting Reporting Reporting

ICD-10-CM Guidelines• Used as a companion document to the

official version of ICD-10-CM

• Approved by the Cooperating Parties

– CMS, NCHS, AHIMA, AHA

• Developed to accompany and complement the official conventions and instructions provided within ICD-10-CM itself

• Instructions and conventions of the classification take precedence over guidelines

ICD-10-CM Guidelines

• No changes to many areas of the guidelines

• I.A.4 – Placeholder character

– Placeholder “x”– Placeholder “x”

• I.A.5 – 7th Characters

– Applicable 7th characters

• I.A.12.a – Excludes1 – NOT coded here

• I.A.12.b – Excludes2 – Not included here

ICD-10-CM Guidelines• I.B.16 – Documentation of Complications

of Care

– Must be a cause-and-effect relationship

• I.C.1.d.2.a – Septic Shock (additional wording)wording)

– . . . the code for septic shock cannot be

assigned as a principal diagnosis

• I.C.1.d.5 – Sepsis due to a postprocedural infection

– Documentation of a causal relationship

ICD-10-CM Guidelines

• I.C.2.c.1 - Anemia associated with malignancy

– Malignancy sequenced as principal/first-listed

• I.C.2.c.2 – Anemia associated with • I.C.2.c.2 – Anemia associated with chemotherapy, Immunotherapy and radiation therapy

– Anemia sequenced first

– Followed by codes for neoplasm and the

adverse effect

ICD-10-CM Guidelines• I.C.7.a – Glaucoma

– New guidelines associated with the new

Glaucoma codes

• I.C.9.e.4 – Subsequent acute myocardial infarctioninfarction

– I22, Subsequent ST elevation (STEMI) and

non ST elevation (NSTEMI) myocardial

infarction, is to be used when a patient who

has suffered an AMI has a new AMI within the

4 week time frame of the initial AMI

– Sequencing depends of circumstances of

admission

ICD-10-CM Guidelines• I.C.15.a.3 – Final character for trimester

– Final character indicating the trimester of

pregnancy

• I.C.15.a.6 – 7th character for fetus identificationidentification

– 7th character to be assigned for certain

categories to identify the fetus for which the

complication code applies

– O31, O32, O33.3-O33.6, O35, O36, O40, O41,

O60.1, O60.2, O64, and O69

ICD-10-CM Guidelines

• I.C.18.e – Coma scale

– Assign code R40.24, Glasgow coma scale,

total score, when only the total score is

documented in the medical record and not the documented in the medical record and not the

individual score(s).

• I.C.19.e.5.a – Adverse effect

– Nature of the adverse effect followed by the

appropriate code for the adverse effect of the

drug

ICD-10-CM GuidelinesA patient has liver metastasis due to

adenocarcinoma of the rectum which was

resected two years ago. The patient has been

receiving radiotherapy to the liver with some

relief of pain. The patient is being admitted at

this time for management of severe anemia due this time for management of severe anemia due

to the malignancy. The principal diagnosis listed

on this admission is:

a. Liver metastasis

b. Adenocarcinoma of the rectum

c. Anemia

d. Admission for radiotherapy

ICD-10-CM GuidelinesAnswer: A liver metastasis

Rationale: When an admission or encounter is

for the management of an anemia associated

with the malignancy, and the treatment is only

for anemia, the appropriate code for the for anemia, the appropriate code for the

malignancy is sequenced as the principal or first

listed diagnosis followed by the appropriate code

for the anemia, (such as D63.0, Anemia in

neoplastic disease) (ICD-10-CM coding

guideline I.C.2.c.1). In addition, in the Tabular,

the note under D63.0 states to code first

neoplasm (C00-D49).

ICD-10-CM GuidelinesTrue or False? A fracture not described as

“displaced” or “not displaced” by default

should be coded as “not displaced.”

Answer: B False

Rationale: A fracture not indicated whether Rationale: A fracture not indicated whether

displaced or not displaced should be coded

to displaced (ICD-10-CM coding guideline

I.C.19.c). This information is also available in

notes in the Tabular (see category S52). A

fracture not described as open or closed is

coded to the default of closed.

ICD-10-CM Guidelines

In ICD-10-CM diabetes mellitus codes include:

a. The type of diabetes mellitus

b. The body system affectedb. The body system affected

c. The complication affecting that body system

d. All of the above

ICD-10-CM Guidelines

Answer: D all of the above

Rationale: The diabetes mellitus codes are combination codes that include the are combination codes that include the type of diabetes mellitus, the body system affected and the complications affecting that body system (ICD-10-CM coding guideline I.C.4.a).

ICD-10-CM GuidelinesTrue or False? A noncompliance code or

complication of care code is to be used with an

underdosing code to indicate intent.

Answer: A True

Rationale: Underdosing refers to taking less of a Rationale: Underdosing refers to taking less of a

medication than is prescribed by a provider or a

manufacturer’s instruction. Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.8-Y63.9) codes are to be used with an underdosing code to indicate intent, if known (ICD-10-CM coding guideline I.C.19.e.5.c). Codes for underdosing should never be assigned as principal or first-listed codes.

ICD-10-CM GuidelinesTrue or False? When coding severe sepsis a

minimum of three codes is required.

Answer: B False

Rationale: The coding of severe sepsis requires a

minimum of two codes: first a code for the underlying minimum of two codes: first a code for the underlying

systemic infection, followed by a code from subcategory

R65.2, Severe sepsis. If the causal organism is not

documented, assign code A41.9, Sepsis, unspecified

organism, for the infection (ICD-10-CM coding guideline

I.C.1.d.1.b). Additional codes for the other acute organ

dysfunctions should also be assigned. This condition

usually will result in a total of three codes, except in the

case of combination codes, such as severe sepsis with

septic shock.

ICDICD--1010--CM Coding CM Coding Questions Questions Questions Questions

Coding Questions . . .

• Seizure, rule out sinus thrombosis

– Should the seizure be assigned as a

secondary diagnosis?

• Review of literature does not indicate that • Review of literature does not indicate that seizure is always an integral part of sinus thrombosis

• Recommend adding seizure as a secondary diagnosis

Coding Questions . . .

• ICD-10-CM Codes:

– G08 Intracranial and intraspinal phlebitis and thrombophlebitis

– R56.9 Unspecified convulsions – R56.9 Unspecified convulsions

Coding Questions . . . • Pulmonary TB and Bronchiolitis with

severe Dyspnea

– Should R06.00 be assigned for severe

dyspnea?

• Dyspnea is a symptom of the patient’s • Dyspnea is a symptom of the patient’s Bronchiolitis and should not be assigned as a secondary diagnosis.

• Guideline I.C.18.b – Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes

Coding Questions . . .

• ICD-10-CM Coding:

– A15.0 Tuberculosis of lung

– J21.9 Acute bronchiolitis, unspecified

Coding Questions . . .

• Acute gangrenous appendicitis with local peritonitis. Post-op ileus. Laparoscopic appendectomy with insertion of drain

– Should Y93.8 be assigned to identify the ileus – Should Y93.8 be assigned to identify the ileus

complication?

• The use of this range of codes (Y83-Y84) is optional and generally specific to each organization

Coding Questions . . .

• ICD-10-CM & ICD-10-PCS Coding:

– K35.3 Acute appendicitis with localized

peritonitis

– K91.3 Postprocedural intestinal obstruction

– Y83.6 Removal of other organ (partial)

(total) as the cause of abnormal reaction of

the patient, or of later complication, without

mention of misadventure at the time of the

procedure . . . Optional coding

– ODTJ4ZZ Laparoscopic Appendectomy

Coding Questions . . .

• Lower lip through-and-through laceration. Contusions/abrasions bilateral knees. Broken tooth. Traffic accident; person hurt in car collisionin car collision

• Debridement and repair of lower lip

– Should a code for abrasion be assigned for a

patient with contusion and abrasion?

Coding Questions . . . • Guideline I.C.19.b.1 Superficial Injuries

– Superficial injuries such as abrasions or

contusions are not coded when associated

with more severe injuries of the same site

– No specific guidance for cases of only– No specific guidance for cases of only

contusion and abrasion at the same site

– As indexed, would code only the contusions

• S80 Superficial injury of knee and lower leg

– S80.0Contusion of knee

• S80.2 Other superficial injuries of knee

– S80.21 Abrasion of knee

Coding Questions . . .

• ICD-10-CM and ICD-10-PCS Coding:

– S01.511A Laceration without foreign body

of lip, initial encounter

– S80.01xA Contusion of right knee, initial – S80.01xA Contusion of right knee, initial

encounter

– S80.02xA Contusion of left knee, initial

encounter

– S02.5xxA Fracture of tooth (traumatic),

initial encounter for closed

fracture

Coding Questions . . .

• ICD-10-CM and ICD-10-PCS coding, continued

– V89.2xxA Person injured in unspecified

motor-vehicle accident, traffic, motor-vehicle accident, traffic,

initial encounter

– 0CQ1XZZ Repair lower lip, external

approach

– 0CB1XZZ Excision lower lip, external

approach

Coding Questions . . . To be continued