ICD-10-CM Conventions & General Coding Guidelines March 26, 2014

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1 ICD-10-CM & March 26, 2014 Content Provided by To Receive CPE Credit Individual Attendee Participate in entire webinar Answer polls when they are provided Group Attendees Complete group attendance form with Title & date of live webinar Your company name Your printed name, signature & address All group attendance sheets must be submitted to within 24 hours of live webinar Answer polls when they are provided If all eligibility requirements are met, each participant will be ed a CPE certificate within 15 business days of live webinar 2 CPT Updates

2 Disclaimer: It is impossible to review every ICD-10-CM Convention and General Guideline in 60 minutes. Every effort has been made to capture the most significant and General Guidelines. This presentation is meant to enhance, but does not replace, your personal review of the and General Guidelines. Agenda ICD-10-CM: Trends Trends Questions 4 CPT Updates

3 Coders must understand conventions Found in 2014 Draft of ICD-10-CM book and training manuals 6 CPT Updates

4 Alphabetic Index and Tabular List ICD-10-CM has: Alphabetic Index- alphabetical list of terms and their corresponding code Tabular List- structured chronological list of codes divided into chapters based on body system or condition 7 Alphabetic Index consists of the following: Index of Diseases and Injury Index of External Causes of Injury Table of Neoplasms Table of Drugs and Chemicals 8 CPT Updates

5 Format and Structure ICD-10-CM Tabular List contains categories, subcategories, codes Characters for categories, subcategories and codes may be a letter or number Categories are 3 characters A 3 character category that has no further subdivision is equivalent to a code 9 Format and Structure Subcategories are 4 or 5 characters Codes may be 3, 4, 5, 6 or 7 characters in length A code that has an applicable 7 th character is considered invalid without the 7 th character Tip: watch for the box with a check mark and 4 th, 5 th, 6 th, 7 th and x7th in it indicating the number of characters needed for a complete code 10 CPT Updates

6 Placeholder Character- letter X has 2 uses 5 th character for some 6 character codes T56.0X2S Toxic effect of lead and its compounds, intentional self-harm, sequela Code has less than 6 characters and 7 th character required, X is assigned for all characters less than 6 S17.0XXA Crushing injury of larynx and trachea, initial encounter Tip: decimal does not count as a character 11 Placeholder Character- letter X Tip: Make sure your coders correctly use this placeholder character Coders incorrectly apply 7 th character in the 5 th or 6 th character place 12 CPT Updates

7 Seventh Characters Provides further specificity about condition O64.3XX1 Obstructed labor due to brow presentation, fetus 1 S02.110B Type I occipital condyle fracture, initial encounter for open fracture 13 Abbreviations Not Elsewhere Classified (NEC) ICD-10-CM contains codes to classify any and all conditions Alphabetic Index uses NEC for a code description that directs the coder to the Tabular List showing an Other Specified code description 14 CPT Updates

8 Abbreviations Not Otherwise Specified (NOS) Use when the documentation is insufficient to assign a more specific code 15 Punctuation Parentheses ( ) Used in both Alphabetic Index and Tabular List Enclose supplementary words that may be present or absent in the statement of a disease without affecting the code number to which it is assigned Terms within the parentheses are nonessential modifiers Hemophilia (classical) (familial) (hereditary) I10, Essential (primary) hypertension 16 CPT Updates

9 Punctuation Brackets [ ] Used in Tabular List to enclose synonyms, alternative wordings, or explanatory phrases B06, Rubella [German measles] Used in Alphabetic Index to identify manifestation codes Disease, Alzheimer s G30.9 [F02.80] 17 Punctuation Colon : Used in Tabular List after an incomplete term which needs 1 or more modifiers following the colon to make it assignable to a given category Used with includes and excludes notes G73.7 Myopathy in diseases classified elsewhere Excludes1: myopathy in: scleroderma (M34.82) 18 CPT Updates

10 Other format differences from ICD-9-CM Symbols not included in ICD-10-CM: Lozenge Section Mark Braces } 19 Other format differences from ICD-9-CM Dashes Used in ICD-10-CM Alphabetic Indexes and the Tabular List Indexes utilize dash at end of code number to indicate code is incomplete To determine additional character(s), locate code in Tabular List, review the options, assign appropriate code 20 CPT Updates

11 Other format differences from ICD-9-CM Dashes Fracture, pathologic ankle M carpus M Other format differences from ICD-9-CM Dashes Tabular List, dash preceded by a decimal point (.-) indicates incomplete code To determine additional characters, locate referenced category or subcategory in Tabular List, review options, assign the appropriate code J43 Emphysema Excudes1: emphysematous (obstructive) bronchitis (J44.-) 22 CPT Updates

12 Instructional Notes Variety of notes appear in both the Alphabetic Index and Tabular List of ICD-10-CM The various notes are: includes excludes code first use additional code cross reference 23 Inclusion Notes Used in Tabular List to clarify conditions included within a particular chapter, section, category, subcategory, code List of inclusions terms not exhaustive, may include diagnoses not listed in inclusion note Introduced by word includes when appearing at beginning of chapter, section, category 24 CPT Updates

13 Inclusion Notes K25 Gastric Ulcer Includes: erosion (acute) of stomach pylorus ulcer (peptic) stomach ulcer (peptic) 25 Inclusion Notes At code level, the word includes does not precede the list of terms included in the code K31.5 Obstruction of duodenum Constriction of duodenum Duodenal ileus (chronic) Stenosis of duodenum Stricture of duodenum Volvulus of duodenum 26 CPT Updates

14 Exclusion Notes ICD-9-CM contains a single type of excludes note ICD-9-CM has 2 different meanings leaving it to coder to determine correct meaning In ICD-10-CM, 2 types of excludes notes: Excludes1 Excludes2 Either or both may appear under a category, subcategory, or code 27 Excludes1 Is a pure excludes note Means not coded here Indicates the code excluded should never be used at the same time as code above the Excludes1 note Used when 2 conditions cannot occur together congenital form versus acquired form of the same condition 28 CPT Updates

15 Excludes1 Q79.5 Other congenital malformations of abdominal wall Excludes1: umbilical hernia (K42.-) 29 Excludes2 Means not included here Indicates condition excluded is not part of condition represented by the code, but a patient may have both conditions at same time When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together if patient has both conditions 30 CPT Updates

16 Excludes2 J37.1 Chronic laryngotracheitis Excludes2: acute laryngotracheitis (J04.2) acute tracheitis (J04.1) Tip: Make sure your coders understand Excludes1 and Excludes2 notes 31 Code First and Use Additional Code Notes Some conditions require an underlying etiology code and manifestation code For these conditions, ICD-10-CM (similar to ICD- 9-CM) requires underlying condition be sequenced first followed by manifestation 32 CPT Updates

17 Code First and Use Additional Code Notes Use additional code note appears at etiology code Code first note appears at manifestation code 33 Use Additional Code Note G30 Alzheimer s disease Use additional code to identify: dementia with behavioral disturbance (F02.81) dementia without behavioral disturbance (F02.80) 34 CPT Updates

18 Code First Note F02 Dementia in other diseases classified elsewhere Code first the underlying physiological condition, such as Alzheimer s (G30.-) F02.80 Dementia in other diseases classified elsewhere, without behavioral disturbance F02.81 Dementia in other diseases classified elsewhere, with behavioral disturbance 35 Cross Reference Notes In ICD-10-CM Alphabetic Index to advise coder to look elsewhere before assigning a code See, See Also and See Condition are same as those in ICD-9-CM 36 CPT Updates

19 Cross Reference Notes Pyocele -mastoid see Mastoiditis, acute -sinus (accessory) see sinusitis -turbinate (bone) J32.9 -urethra (see also Urethritis) N Relational Terms And means and/or when appears in code title within the ICD-10-CM Tabular List With means associated with or due to when appears in code title, Alphabetic Index, or instructional note in Tabular List With in the Alphabetic Index is sequenced immediately following the main term, not in alphabetic order 38 CPT Updates

20 Relational Terms Salpingitis (catarrhal) (fallopian tube) (nodular) (pseudofollicular) (purulent) (septic) N70.91 with oophoritis N70.93 acute N70.01 with oophoritis N Additional Age edit symbols Newborn = 0 years Pediatric = 0 17 years Maternity age = years Adult age = years Sex edit symbols Male Female 40 CPT Updates

21 1. Locating a Code in ICD-10-CM First locate term in Alphabetic Index Verify code in Tabular List Tip: Read instructional notes in Alphabetic Index and Tabular List, and let them be your guide to the appropriate code 42 CPT Updates

22 2. Level of Detail in Coding Diagnosis codes reported at their highest number of characters available Codes may be 3, 4, 5, 6 or 7 characters in length Code or Codes from A00.0 through T88.9, Z00 Z99.8 Identify diagnoses, symptoms, conditions, problems, complaints, other reason(s) for the encounter/visit 44 CPT Updates

23 4. Signs and Symptoms Acceptable for reporting when related definitive diagnosis has not been established or confirmed by provider Chapter 18 (Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 R99) contains many, but not all codes for symptoms Conditions that are an Integral Part of a Disease Process Signs and symptoms associated routinely with a disease process should not be assigned as additional codes UNLESS otherwise instructed by the classification Tip: make sure your coders understand what is routinely associated with each disease process to avoid over-coding 46 CPT Updates

24 6. Conditions that are not an Integral Part of a Disease Process Signs and symptoms that are NOT ROUTINELY associated with a disease process should be coded when present Multiple Coding for a Single Condition Etiology/manifestation convention Use additional code Code first Code, if applicable, any causal condition first Multiple codes may be needed for sequela, complication codes and obstetric codes to fully describe condition 48 CPT Updates

25 8. Acute and Chronic Conditions If same condition described as both acute (subacute) and chronic, and separate subentries exist in Alphabetic Index at same indentation level, code both and sequence the acute (subacute) code first Combination Code Used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication 50 CPT Updates

26 10. Sequela (Late Effects) Residual effect after acute phase of an illness or injury has terminated No time limit on when sequela code can be used Residual effect may appear early, may occur months or years later Sequela (Late Effects) Normally 2 codes required- condition or nature of sequela sequenced 1 st and sequela code is sequenced 2 nd Exception- code for sequela is followed by a manifestation code identified in Tabular List and title, or sequela code has been expanded to include the manifestation(s) Tip: The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect 52 CPT Updates

27 11. Impending or Threatened Condition Did occur code as confirmed diagnosis Did not occur look in Alphabetic Index for impending or threatened Reference main term entries for Impending and Threatened Subterms are listed assign the given code Subterms are not listed code the existing underlying conditions and not the condition described as impending or threatened Reporting Same Diagnosis Code More than Once Each unique ICD-10-CM diagnosis code may be reported only once for an encounter Applies to bilateral conditions when there are no distinct codes identifying laterality or 2 different conditions classified to the same diagnosis code 54 CPT Updates

28 13. Laterality If there is a code specifying left, right or bilateral assign the appropriate code based on documentation If no bilateral code exists and the condition is bilateral assign separate codes for both left and right If the side is not identified in the documentation assign the code for the unspecified side Documentation for BMI and Pressure Ulcer Stages Body Mass Index (BMI), depth of non-pressure chronic ulcers and pressure ulcer stage codes- code assignment may be based on medical record documentation from clinicians who are not the patient s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often document the pressure ulcer stages). The associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient s provider 56 CPT Updates

29 Documentation for BMI and Pressure Ulcer Stages If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient s attending provider should be queried for clarification The BMI codes should only be reported as secondary diagnoses and they must meet the definition of a reportable additional diagnosis to be reported Syndromes Follow Alphabetic Index guidance In absence of Alphabetic Index guidance, assign codes for manifestations of syndrome Additional manifestation codes that are not integral to the disease process may be assigned when condition does not have a unique code 58 CPT Updates

30 16. Documentation of Complication of Care Not all conditions that occur during or following medical care or surgery are classified as complications Must be a cause-and-effect relationship between care provided and the condition Must be an indication in documentation that is it a complication Query provider if complication is not clearly documented Borderline Diagnosis Diagnosis is coded as confirmed unless the classification provides a specific entry, (borderline diabetes) Not considered uncertain diagnoses Query for clarification if documentation is unclear 60 CPT Updates

31 18. Use of Sign/Symptom/Unspecified Codes Instances exist when signs/symptoms or unspecified codes most accurately reflect healthcare encounter Appropriate to use signs and/or symptoms codes when definitive diagnosis has not been established 61 Use of Sign/Symptom/Unspecified Codes Appropriate to report unspecified code when clinical information isn t known or available to assign more specific code Code each encounter to level of certainty known 62 CPT Updates

32 References ICD-10-CM The Complete Official Draft Code Set, 2014 Optum Book DeVault, K., Barta, A., & Endicott, M. (2014). ICD-10-CM Coder Training Manual. Chicago, IL: AHIMA 63 Questions? CPT Updates

33 Continuing Professional Education (CPE) Credits BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: The information in BKD webinars is presented by BKD professionals, but applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered in these webinars. 65 CPE Credit 1 CPE credit may be awarded upon verification of polling question responses and attendance of the entire webinar CPE certificates will be ed to eligible attendees within 15 business days of the live event For questions, concerns or comments regarding CPE credit, please the BKD Learning & Development Department at 66 CPT Updates

34 Questions? me at Content Provided by CPT Updates

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