ICD-10-CM Training for Medical Office Staff. Presented by: Angie Audler, MBA, RHIT, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer

Transcription

1 ICD-10-CM Training for Medical Office Staff Presented by: Angie Audler, MBA, RHIT, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer

2 Disclaimer This PowerPoint presentation is an education tool to provide basic information for coding. The information is the sole view of the author and was put together based on experience, research and expertise in the coding profession. It is not intended to be an exhaustive review and should not be considered a substitution for Coding Guidelines. The presenter does not accept any responsibility or liability with regard to errors, omissions misinterpretations or misuse by the audience. Copyright c 2015

3 Are you Ready? If Not, It s... We re only days away! Implementation Date October 1, 2015

4 Today s Topics Readiness Checklist Where You Can Find the Code Sets What ICD-10 Related Changes are of Particular Importance to Your Practice What Will Be the Impact of the Transition How To Look Up A Code Applying Coding Concepts Recommendations

5 ICD-10 Readiness Checklist Source: Have both your Practice Management and EHR been updated to be ICD-10 compliant? Have you tested submitting ICD-10 codes to your Practice Management system? Have you considered updating your existing Encounter Forms to include ICD-10 codes with more specificity and using laterally to meet the ICD-10 requirements? Have you contacted all your vendors to ensure they are ICD-10 compliant, such as payers, clearinghouses, and any lab or radiology vendors? If necessary, have you loaded the ICD-10 dictionaries in both your Practice Management and EHR applications? Have you tested submitting codes from your Practice Management system to your payers and clearinghouses? Have you tested submitting orders (labs/diagnostics/imaging studies) from your EHR to appropriate vendors with ICD-10 codes? Have you identified the top diagnoses for each specialty (based on volume and/or high revenue) and trained appropriate staff on ICD-10 criteria for coding, billing, and clinical documentation? Have you optimized all preferences and enhancements within your systems to assist in the ICD-10 transition such as Billable Indicators and Clinical Qualifiers? Have you reviewed current clinical documentation and identified gaps for ICD-10 requirements? What else do you need to know and consider?

6 ICD-10-CM Impacts. Coverage of services Payment for services Documentation requirements Ordering diagnostic tests, obtaining authorizations, ordering prescriptions Collection of accurate data Submission of accurate data through claims Reporting of quality indicators Outcomes Measurement Copyright 2015 MEDKODER LLC 6

7 Ordering Diagnostic Tests A physician order must include the following elements in order to be considered valid: Reason for ordering the test or service (diagnosis description, ICD-10 code, sign(s), symptoms) Test or service requested Provider s name Provider s signature Patient complete name Patient date of birth

8 Obtaining Authorizations Authorizations must contain a valid diagnosis code for date-of-service not date authorization was obtained

9 Ordering Prescriptions CMS FAQ 7579 Refills Payer/pharmacy requiring a diagnosis code for a prescription (e.g. Medicaid): When conducting a standard transaction, medical data code sets (ICD-9 and ICD-10) that are valid at the time that the service is provided (prescription fill date) must be used (45 CFR ).

10 ICD-10-CM Changes There are three main categories of changes in ICD-10-CM - Definition Changes - Differences in Terminology - Increased Documentation Specificity ICD-10 doesn t affect coding only; it involves physician reporting, billing, information technology, and revenue management Copyright 2015

11 ICD-10-CM Although there are approximately 70,000 codes in ICD-10, specialists will use only a small subset of those codes Over 1/3 of the expansion codes are due to laterality (physicians are already documenting right, left, bilateral) If bilateral and there is no specific code for bilateral, you code both right and left sides 11

12 ICD-10 Major Modifications Expanded categories for postoperative complications Addition of sixth and seventh characters or accidents and injuries, adverse effects Addition of laterality Combination codes for common diagnosis and symptoms Copyright 2015 MEDKODER LLC 12

13 Where Can You Find the Code Sets? The code sets are available on the CMS website ICD-10-CM Coding Manual Practice Management Systems

14 What ICD-10 Related Changes Are of Particular Importance to Your Practice? Training is especially important to familiarize staff with the concepts of ICD-10 Physician specificity in documentation Workflow disruptions

15 What Will Be the Impact of the Transition? Even the best prepared office may run into problems directly following the transition Be prepared to see a decrease in productivity and accuracy Expect delays in claim processing Potential increase in the number of rejected or denied claims

16 How Do I Look Up a Code? How you look up a code is dependent upon the method used for code selection Coding Manual Electronic code search System Internet

17 Organization of the ICD-10-CM Coding Manual The ICD-10-CM coding manual contains an Alphabetic Index and Tabular List The Alphabetic Index for ICD-10-CM has a similar format as ICD-9-CM. It contains an Alphabetic Index of Diseases and Injuries, Alphabetic Index of External Causes, Table of Neoplasms, and Table of Drugs and Chemicals. However, ICD-10-CM does not contain a Hypertension Table Morphology codes are not listed next to the descriptor in the Alphabetic Index and no longer have a separate Appendix Copyright 2015 MEDKODER LLC 17

18 Organization of the Coding Manual Some codes in ICD-10-CM have a single inclusive code for manifestations, while others require two codes to report a manifestation. Example: In ICD-9-CM diabetes with a manifestation often required the use of two codes. The diabetic code was coded first, followed by the manifestation code Diabetes with peripheral autonomic neuropathy , In ICD-10-CM, a single code describes Diabetes with peripheral autonomic neuropathy G99.0 Copyright 2015 MEDKODER LLC 18

19 Alphabetic Index of Diseases and Injuries Main terms are listed in alphabetical order in bold print with subterms indented under the main term. Non-essential modifiers are listed in parenthesis ( ) behind the main term. Nonessential modifiers do not change code assignment Many non-essential modifiers that appeared behind main terms in ICD-9-CM may appear as subterms in ICD-10-CM with their own code Copyright 2015 MEDKODER LLC 19

20 Alphabetic Index of External Causes External Cause codes describe environmental events and circumstances as the cause of an injury and other adverse effects They are always secondary codes and provide additional information Copyright 2015 MEDKODER LLC 20

21 Hypertension Table The Hypertension Table in ICD-10-CM has been eliminated. The same code is used regardless of whether the hypertension is described as benign, malignant or whether or no qualifier is used Copyright 2015 MEDKODER LLC 21

22 Malignant Neoplasm Malignant Secondary CA in-situ Benign Uncertain Unspecified Behavior Table of Neoplasms The Neoplasm Table is formatted similarly to the table in ICD-9-CM and contains the same Headings Neoplasm, neoplastic Copyright 2015 MEDKODER LLC 22

23 Poisoning, Accidental (unintentional) Poisoning, Intentional Self-harm Poisoning, Assault Poisoning, Undetermined Adverse Effect Underdosing Table of Drugs and Chemicals The Table of Drugs and Chemicals Headings better describe the circumstance of the encounter It also contains new columns for Adverse Effect and Underdosing Substance Copyright 2015 MEDKODER LLC 23

24 Tabular List The Tabular List contains a chronological list of codes divided by body system or condition. It contains 21 Chapters The restructuring and reorganization of codes has resulted in additional chapters Each Chapter in the Tabular List contains a summary of the categories within the Chapter Copyright 2015 MEDKODER LLC 24

25 Conventions Abbreviations Like ICD-9-CM, the abbreviations NEC and NOS are used: NEC Not Elsewhere Classified (referring to other specified conditions) NOS Not Otherwise Specified (referring to unspecified conditions) Copyright 2015 MEDKODER LLC 25

26 Conventions Cross-reference, punctuation marks Cross-reference and punctuation marks are used the same as they were in ICD-9-CM Copyright 2015 MEDKODER LLC 26

27 Conventions Excludes Notes There are two types of Excludes Notes in ICD-10- CM. Exclude 1 means the two conditions cannot be coded together (e.g. congenital and acquired form of the same condition) Exclude 2 means not included and can be coded if the patient has both conditions Copyright 2015 MEDKODER LLC 27

28 Conventions And Interpreted to mean and/or With Interpreted as associated with or due to Copyright 2015 MEDKODER LLC 28

29 Conventions Default Code The term default code refers to a code listed next to the main term in the Alphabetic Index It represents that the term is most commonly associated with the main term or is unspecified Copyright 2015 MEDKODER LLC 29

30 Full Code Titles ICD-9-CM 143 Malignant neoplasm of gum Upper gum Lower gum ICD-10-CM C03 Malignant neoplasm of gum C03.0 Malignant neoplasm of upper gum C03.1 Malignant neoplasm of lower gum Copyright 2015 MEDKODER LLC 30

31 Conventions Instructional Notes Instructional notes are the same as they were in ICD-9-CM: Code first Use additional code Code also Copyright 2015 MEDKODER LLC 31

32 ICD-10 Convention Code First Notes Used when certain conditions have both an underlying etiology and multiple body system manifestations Requires the underlying condition be sequenced first followed by the manifestation Proper sequencing order of the codes: etiology followed by manifestation (same coding convention as ICD-9-CM) Copyright 2015 MEDKODER LLC 32

33 ICD10 Conventions Use Additional Codes are secondary codes that identify manifestations

34 ICD-10 Conventions Code Also Notes A code also note instructs that 2 codes may be required to fully describe a condition but the sequencing of the two codes depends on the circumstances of the encounter Copyright 2015 MEDKODER LLC 34

35 Understanding Basic Phrases Phrases due to and manifested by It is not sufficient to say the patient has an ulcer and history of radiation therapy It needs to be stated whether or not the ulcer is due to radiation Copyright 2015 MEDKODER LLC 35

36 Outpatient Services The terms encounter and visit are synonymous when describing outpatient services Copyright 2015 MEDKODER LLC 36

37 ICD-10-CM Structure 37

38 ICD-10-CM Structure Alpha characters are not case sensitive First character is Alpha. The letter U is reserved by the WHO for future use of new diseases of uncertain etiology (U00-U49) and bacterial agents resistant to antibiotics (U80-89) Second character is always numeric Characters three, four, five, six and seven can be alpha or numeric The decimal (.) is placed after the third character Copyright 2015 MEDKODER LLC 38

39 ICD-10-CM Structure The seventh character represents a visit encounter or sequelae (condition resulting from a previous disease; also known as Late Effects) for injuries and external causes. The seventh character extender must always be the seventh character of a code. A hyphen - at the end of an ICD-10 code in the Alphabetic Index indicates that additional characters are required. Placeholder: An x is used as a fifth character in certain six character codes to allow for future expansion. An x is also used as a placeholder when a code has less than six characters and the code requires a seventh character. For Example: Adverse effect of calcium-channel blockers, initial encounter T46.1x5A Exposure to electric transmission lines, initial encounter W85.xxxA Post-procedural cardiogenic shock, initial encounter T81.11xA Copyright 2015 MEDKODER LLC 39

40 Characteristics 21 Chapters and Expanded Codes Some chapters are reorganized Some conditions are put in different Chapters Alphanumeric first character is always a letter Addition of up to 7 characters 7 th character code extensions in some cases Injuries Initial encounter Subsequent encounter Sequela Copyright 2015 MEDKODER LLC 40

41 Code Structure and Format ICD-10-CM Diagnosis Code Some Other Differences of ICD-10-CM Laterality Right and left Dummy placeholders x Done to allow for future expansion without disrupting the sixth or seventh character structure for codes where the sixth or seventh character has a specific use Intent T37.5x1 Poisoning by antiviral drugs, accidental (unintentional) Encounter Information relevant to ambulatory and managed care encounters T16.1xxA Foreign body in right ear (initial encounter) Other Factors that can affect health Lifestyle, socioeconomic, family relationships Copyright 2015 MEDKODER LLC 41

42 Abstracting Perfecting the practice of abstracting allows (the coder) and others to have more confidence in the data, be able to defend audits, justify medical necessity, and ensure correct coding Copyright 2015 MEDKODER LLC 42

43 ICD-10-CM It is important for clinical providers, staff and coders to understand how diseases are classified differently in ICD-10, as the change affects the specific documentation that will be needed for coders to abstract the information for appropriate code assignment and noncoders to understand the concepts to address rejections and denials Copyright 2015 MEDKODER LLC 43

44 Reporting Differences, Trending and Analytic Modifications Converting from ICD9 to ICD10 more than triples the number of available codes Looking at historical data becomes problematic unless you can identify and capture needed information from the two coding systems Simple forward mapping will not be sufficient for most providers to make a successful transition Copyright 2015 MEDKODER LLC 44

45 Steps in Coding with ICD-10-CM Coding Steps remain the same Identify all main terms in diagnostic statements Apply your knowledge of A& P and pathology, pharmaceuticals, and treatments Main terms are USUALLY Nouns Identify subterms terms in diagnostic statement Subterms terms are USUALLY adjectives Locate main terms in the Alphabetic Listing If terms not identical, use your medical terminology knowledge to translate from documentation to code book Copyright 2015 MEDKODER LLC 45

46 Steps in Coding with ICD-10-CM Locate subterms under main terms Check for special instructions or cross-references TENTATIVELY select a code Turn to code category in the Tabular Listing Check for any instructional notes for code category/chapter Apply your knowledge of code book conventions Assign code when all elements of the diagnostic statement accounted for and code verified in Tabular Listing Copyright 2015 MEDKODER LLC 46

47 Risk Mitigation Denials can run high for not medically necessary reasons In the beginning there is risk of payers not fully mapping procedures with new allowed diagnosis reasons Healthcare providers need to be prepared for short term reduced revenues 47

48 General Equivalency Maps (GEMS) CMS GEMS (General Equivalency Maps) demonstrate the complexity involved in moving between the two coding systems NCHS/CDC released General Equivalence Mappings (GEMS) to help facilitate the transition between ICD-9-CM and ICD-10-CM. It was intended for use by professionals working in health information, medical research and informatics who may use the mappings in their work to assist in the migration of historical data Two files were created for bi-directional mapping: ICD-9-CM to ICD-10-CM ICD10-CM to ICD-9-CM Copyright 2015 MEDKODER LLC 48

49 GEMS The correlation between the two coding systems is not one-to-one in most instances Since ICD-10 codes contain more extensive descriptors, body part specificity, and other components, most codes are one-to-many Copyright 2015 MEDKODER LLC 49

50 ICD9/ICD10 Relationships 1:1, Cluster, Combination, Complex Individual ICD-9 codes that map to several ICD-10 code alternatives; Individual ICD-9 codes that map to a set of two of more ICD- 10 codes; Two or more ICD-9 codes that map to individual ICD-10 codes; ICD-9 codes with no representation in ICD-10; ICD-9 codes with an exact match in ICD-10; and Individual ICD-9 codes that map to codes with similar but not identical meanings in ICD-10 Copyright 2015 MEDKODER LLC 50

51 CMS General Equivalent Mappings Source: Copyright 2015 MEDKODER LLC 51

52 ICD-10 Requires Providers to Provide greater specificity in documentation to meet the needs of ICD-10-CM code requirements Copyright 2015 MEDKODER LLC 52

53 Laterality Left vs. Right C50.2 Malignant neoplasm, of upper-inner quadrant of breast C50.21 Malignant neoplasm of upper-inner quadrant of breast, female C Malignant neoplasm of upper-inner quadrant of right female breast C Malignant neoplasm of upper-inner quadrant of left female breast C Malignant neoplasm of upper-inner quadrant of unspecified female breast 53

54 Tabular List The Tabular List is a chronological list of codes divided into Chapters based on body system or condition Copyright 2015 MEDKODER LLC 54

55 Injuries A seventh character extension identifies the encounter type A for the initial encounter D for the subsequent encounter S - Sequela Size and depth of injury is also coded Initial vs. subsequent vs. sequela/late effects Copyright 2015 MEDKODER LLC 55

56 Applying ICD-10-CM Concepts Orthopedic cases will need additional documentation clarity from physicians Site: joint vs. bone/limb Laterality Type and Classification of Fracture Salter-Harris Gustilo Classification for Open Fractures e.g., Type I Low energy, wound less than 1cm Type II Wound greater than 1cm with moderate soft tissue damage A fracture not clearly identified as open or closed is coded to closed Copyright 2015 MEDKODER LLC 56

57 Fractures Laterality Mechanism of injury Etiology of Fracture -Traumatic, pathologic, osteoporosis, neoplastic disease Site -Name of the bone -Medial, lateral, midshaft, epiphysis, etc. Displaced vs. Non-displaced Closed or open (use Gustilo- Anderson classification for open fractures) Type of Fracture -Comminuted, greenstick, oblique, segmental, spiral, transverse, compression, burst, etc. Note Injury to Surrounding Tissue Encounter Type -Initial encounter for fracture (type) -Subsequent encounter for fracture with routine healing -Subsequent encounter for fracture with delayed healing -Subsequent encounter for fracture with nonunion -Subsequent encounter for fracture with malunion -Sequela Copyright 2015 MEDKODER LLC 57

58 Fracture Codes ICD-9 Fractures, closed Comminuted Depressed Elevated Fissured Greenstick Linear Spiral Fractures, open Compound Infected Missile Copyright 2015 MEDKODER LLC 58

59 ICD-10 Expanded Fracture Codes Instead of just open vs. closed, ICD-10 has expanded the fracture codes to identify the specific type of fracture S Greenstick fracture of shaft of humerus S Transverse fracture of shaft of humerus S Oblique fracture of shaft of humerus S Comminuted supracondylar fracture without intercondylar fracture of humerus Copyright 2015 MEDKODER LLC 59

60 Documentation Example Instead of documenting fractured right arm, documentation will now need to include: Fell while running, traumatic, acute, closed, transverse right distal radial fracture with surrounding soft tissue hematoma and swelling Copyright 2015 MEDKODER LLC 60

61 7 th Character Open Fractures The open fracture designations are based on the Gustilo open fracture classification The appropriate 7th character is to be added to each code from category S52 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunion Q - subsequent encounter for open fracture type I or II with malunion R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - sequela Copyright 2015 MEDKODER LLC 61

62 Place of Occurrence Y92.0x Home Y92.1x Residential institution Y92.2x School, other institution and public administrative area Y92.3x Sports and athletic area Y92.4 Street and highway Y92.5x Trade and service areas Y92.6 Industrial and construction area Y92.7 Farm Y92.8x Other specified place Copyright 2015 MEDKODER LLC 62

63 Activity Y93.0x - Injured while engaged in sports activity Y Injured while engaged in leisure activity Y93.3x - Injured while engaged in other types of work Y Injured while resting, sleeping, eating or engaging in other vital activities Y Injured while engaged in personal hygiene Y Injured during unspecified activity Copyright 2015 MEDKODER LLC 63

64 Factors Influencing Health Status and Contact with Health Service New Features Z72 Problems related to lifestyle Z72.3 Lack of physical exercise Z72.4 Inappropriate diet and eating habits Z73 Problems related to life-management difficulty Z73.1 Type A behavior pattern Z73.2 Lack of relaxation and leisure Copyright 2015 MEDKODER LLC 64

65 Unspecified Codes Surveys indicate that as much as 50% of physician documentation cannot be coded to appropriate level of specificity with ICD-10 Copyright 2015 MEDKODER LLC 65

66 Unspecified Codes Sometimes the use of unspecified codes makes sense Early in the course of evaluation Secondary diagnoses not directly being treated by that provider but impacts that encounter Generalist vs specialist Payers are discouraging the use of unspecified codes When providers review their severity and risk scores it may impact their reimbursement because it won t have the specificity in their codes that are needed to justify higher levels and better reimbursement 66

67 Ordering Diagnostic/Therapeutic Services Governmental and third party payers require the performing provider (hospital ancillary departments, outpatient freestanding centers, independent labs, etc.) to provide ICD9/10 codes for outpatient diagnostic and/or therapeutic testing/services that they perform and submit for payment on behalf of your patients These providers rely on the ordering physician to submit the appropriate diagnosis code at the time of ordering to establish medical necessity for the test ordered Copyright 2015

68 Communication Hospital ancillary departments depend on the referring physician to give the order for and the reason behind services They are also dependent on the physician for pertinent information related to an ordered exam With ICD10 codes, it is not the amount of information required from the referring physician but the specificity of the information that will determine payment Copyright 2015 MEDKODER LLC 68

69 Key Updates to Infectious and Parasitic Diseases (A00-B99) Terminology change - the term Sepsis has replaced the term Septicemia Urosepsis is a nonspecific term and is not coded in ICD-10- CM. Coding guidelines direct the coder to query the provider for clarification if this term is used Infections resistant to antibiotics require the use of an additional code for any associated drug resistance only if the infection code does not identify drug resistance (Z16 category, resistance to antimicrobial drugs if the infection code does not identify drug resistance) The codes have been expanded to reflect manifestations of the disease 69

70 ICD-9-CM West Nile Virus (manifestation example) West Nile fever, unspecified West Nile fever with encephalitis West Nile fever with other neurologic manifestation ICD-10-CM Copyright c 2015 A92.30 West Nile fever infection, unspecified A92.31 West Nile fever infection with encephalitis A92.32 West Nile infection with other neurologic manifestation *Use additional code to specify the neurologic manifestation: A92.39 West Nile virus with other complications **Use additional code to specify the other conditions: A93.8 Other specified arthropod-borne viral fevers A94 Unspecified arthropod-borne viral fever

71 Key Updates for Neoplasms (C00-D49) This section contains code expansions Many codes in this section instruct us to Use An Additional code Significant expansions or revisions are related to: laterality for some of the neoplasm sites Malignant neoplasm of the male breast The use of an additional code to identify estrogen receptor status (Z17.0, Z17.1) 71

72 Neoplasm Documentation Neoplasm Documentation Awareness Documentation should include: Behavior - Malignant (primary, secondary, in-situ) - Document any secondary sites - Benign - Unspecified behavior - Of certain histological behavior Laterality (right/left) Anatomical site (topography) Other condition(s) associated with malignancy (dehydration, anemia, etc.) Complication(s) associated with neoplasm Include estrogen receptor status (if applicable) History of: - Has the malignancy been excised or eradicated? - Is there still treatment being provided for the primary and/or secondary site? - Is there evidence of remaining malignancy at the primary site? Document any associated diagnoses/conditions Copyright 2015 MEDKODER LLC 72

73 Neoplasms Overlapping sites Laterality Left vs. Right C50.2 Malignant neoplasm, of upper-inner quadrant of breast) C50.21 Malignant neoplasm of upper-inner quadrant of breast, female C Malignant neoplasm of upper-inner quadrant of right female breast C Malignant neoplasm of upper-inner quadrant of left female breast C Malignant neoplasm of upper-inner quadrant of unspecified female breast Copyright 2015 MEDKODER LLC 73

74 CA of Breast ICD-9-CM Malignant neoplasm of breast (female, unspecified) ICD-10-CM C Malignant neoplasm of unspecified site of unspecified female breast * Use additional code to identify estrogen receptor status (Z17.0, Z17.1) Copyright 2015 MEDKODER LLC 74

75 Key Updates for Diseases of Blood & Blood Forming Organs (D50-D89) Anemia is the most common condition included in this section. The use of specific terminology is important in applying codes for this condition Procedural complications affecting the spleen are included in this section 75

76 Anemia Anemia Documentation Awareness Documentation of Anemia should include the type of anemia: -- Nutritional -- Hemolytic -- Aplastic -- Due to blood loss -- Other (please specify) Include in documentation if Anemia is due to nutrition or mineral deficits, resulting in a nutritional anemia Document if the Anemia is due to a neoplasm (primary and/or secondary) Document whether the ANEMIA is related to or due to chemo or radiotherapy treatments Document any cause and-effect relationship between the intervention and the blood or immune disorder Document the specific drug if anemia is drug-induced Link any laboratory findings to a related diagnosis (if appropriate) Document any associated diagnoses/conditions Copyright 2015 MEDKODER LLC 76

77 Anemia ICD-9-CM ICD-10-CM Anemia, unspecified D64.9 *Anemia, unspecified *There are more specific code choice selections available in ICD-10-CM. These include: D64.81 Anemia due to antineoplastic chemotherapy D63.0 Anemia in neoplastic disease D61.1 Aplastic anemia due to antineoplastic chemotherapy Copyright 2015 MEDKODER LLC 77

78 Key Updates for Endocrine, Nutritional & Metabolic Disorders (E00-E89) Many codes in this section instruct us to Use An Additional Code ICD-10-CM Diabetes Mellitus codes are now combination codes that include the type of diabetes (1 or 2), the body system affected and complications affecting the body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. Diabetes Mellitus (E08-E13) is no longer classified as controlled or uncontrolled in ICD-10- CM. ICD-10-CM there are 5 category codes for Diabetes Mellitus: E08 Diabetes Mellitus due to underlying conditions E09 - Drug or chemical induced Diabetes Mellitus E10 Type 1 Diabetes Mellitus E11 - Type 2 Diabetes Mellitus E13 - Other specified Diabetes Mellitus 78

79 Key Updates for Endocrine, Nutritional & Metabolic Disorders (E00-E89) Overweight and obesity codes: The classification for overweight and obesity has been expanded in ICD-10-CM to include: Obesity due to excess calories Morbid (severe) obesity due to excess calories Drug induced obesity Morbid (severe) obesity due to alveolar hypoventilation Overweight An additional code (Z68 category) is used to identify the body mass index (BMI), if known 79

80 Diabetes Mellitus ICD-9-CM Type Type I Type 2 Secondary diabetes mellitus Control Controlled Uncontrolled Manifestation/Complication Hyperosmolarity Ketoacidosis Neurological manifestations Other coma Peripheral circulatory disorder Renal Manifestations Other specified manifestations Without Complications Insulin Use ICD-10-CM Type Type 1 Type 2 Drug/chemical induced Due to underlying condition Specified Type Control Inadequately controlled Out of control Poorly controlled Hypoglycemia Hyperglycemia Manifestation/Complication Arthropathy Circulatory complications Hyperosmolarity Hypoglycemia Ketoacidosis Kidney complications Neurological complications Ophthalmic complications Oral complications Skin complications Without complications Insulin Use No longer required for Type 1 For Type 2 any long-term or current use is reported 80

81 Diabetes Mellitus ICD-9-CM Code Diabetes mellitus without mention of complications type II or unspecified type, not states as controlled ICD-10-CM Code(s) E11.9 Type 2 diabetes mellitus without complications Diabetes Mellitus Documentation Awareness Capturing the correct code for Diabetes Mellitus requires clear and precise documentation of the underlying cause. Diabetes mellitus codes in ICD-10 reflect combination codes. The components of the combination codes are: Type of Diabetes Body System Affected Specified complications/manifestations affecting the body system 81

82 Diabetes Mellitus Documentation Awareness Type of Diabetes Drug or Chemical Induced (E09) (anticonvulsants; antihypertensive drugs including diuretics and beta blockers; antipsychotic drugs including lithium and antidepressants; antiretroviral drugs; chemotherapy drugs; hormone supplements including anabolic steroids, contraceptives, estrogen, growth hormones and hormones for prostate cancer) Due to an underlying condition (E08) Type I diabetes (E10) controlled/not specified; uncontrolled Type 2 diabetes (E11) controlled/not specified; uncontrolled Other specified diabetes (E13) secondary diabetes mellitus controlled/not specified; uncontrolled For Type 2 diabetes mellitus and secondary diabetes mellitus, any long-term or current use of insulin is reported as an additional code. You may report more than one diabetes code for patients with multiple complications or when multiple body systems are affected as a result of the diabetes. Secondary diabetes is defined as a diabetic condition with an underlying cause other than genetics or environmental conditions (includes due to drugs, chemicals, medical conditions, surgical procedures or trauma) 82

83 Diabetes Diabetes Mellitus Documentation Awareness Body System Affected Circulatory complications Hyperosmolarity Kidney complications Ketoacidosis Other coma Neurological complications Ophthalmic complications Other specified complications/manifestations Unspecified complications/manifestations Without complications/manifestations 83

84 Diabetes Mellitus Documentation Awareness Specified complications/manifestations affecting the body system Circulatory complications peripheral Hyperosmolarity Hypoglycemia (with or without coma) Kidney complications diabetic nephropathy; chronic kidney disease; other Ketoacidosis with or without coma Neurological complications amyotrophy; autonomic polyneuropathy; mononeuropathy, polyneuropathy; other; unspecified Ophthalmic complications diabetic retinopathy (mild, moderate or severe nonproliferative with or without macular edema); diabetic cataract; other Other specified complications/manifestations skin complications (dermatitis, foot ulcer; other skin ulcer; other skin complications; oral complications (periodontal disease; other) Unspecified complications/manifestations Without complications/manifestations 84

85 Key Updates for Mental, Behavioral, Neurodevelopment Disorders (F01-F99) Classification improvements (different categories) Code expansions: Most notably, Other Isolated or Specific Phobias Updates to medical terminology: Bipolar I disorder, single manic episode will change to manic episode Undersocialized conduct disorders, aggressive will become Conduct disorder childhood-onset type Nicotine dependence updated to identify specific tobacco products (cigarettes, chewing tobacco, and other tobacco) ICD-10-CM does not provide separate history codes for alcohol and drug abuse. These conditions are identified as in remission. 85

86 Attention Deficit Hyperactivity Disorder (ADHD) ICD-9-CM ADD w/o mention of hyperactivity ADD w/ mention of hyperactivity ICD-10-CM F90.0 ADHD, predominantly inattentive type F90.1 ADHD, predominantly hyperactive type F90.2 ADHD, combined type F90.8 ADHD, other type F90.9 ADHD, unspecified type Note: codes within this category may be used regardless of the age of a patient. These disorders generally have onset within the childhood or adolescent years, but may continue throughout life or not be diagnosed until adulthood. ADD & ADHD is now classified at just ADHD

87 Key Updates for Diseases of the Nervous System (G00-G99) Classification improvements (significant changes to sleep disorders) Code expansions (e.g. Alzheimer s, headaches) Updates to medical terminology (epilepsy, seizures) Codes for TIA are now included in the nervous system chapter, rather than circulatory Codes for migraine have been expanded to fifth and sixth characters to indicate if the migraine is intractable and to provide additional specificity within the code description 87

88 Headache Documentation Tips Headache Document type: - Cluster - Vascular - Tension-type - Post-traumatic - Drug-induced (specify drug) - Other Document: - Intractable - Not intractable Document timing: - Episodic - Chronic - Episodic paroxysmal hemicrania - Chronic paroxysmal hemicrania - Short lasting unilateral Headache Copyright c 2015

89 Headache ICD-9-CM ICD-10-CM Headache R51 Headache G44.10 Vascular headache, NEC, not intractable G4411 Vascular headache, NEC, intractable Copyright c 2015

90 Migraine Document type: - Migraine w/ aura - Migraine w/o aura - Hemiplegic migraine - Persistent migraine aura w/o cerebral infarction - Persistent migraine aura w/ cerebral infarction - Chronic migraine Identify when migraine is due to drugs and specify the drug Document: - With status migrainosus - Without status migrainosus - Intractable - Not intractable Identify when migraine is associated with seizures or cerebral infarction Copyright c 2015

91 Migraine ICD-9-CM Hemiplegic migraine, with intractable migraine, so stated, without mention of status migrainosus Hemiplegic migraine, without mention of intractable migraine with status migrainosus Hemiplegic migraine, with intractable migraine, so stated, with status migrainosus Menstrual migraine, without mention of intractable migraine without mention of status migrainosus ICD-10-CM G Hemiplegic migraine, intractable, without status migrainosus G Hemiplegic migraine, not intractable, with status migrainosus G Hemiplegic migraine, intractable, with status migrainosus G Menstrual migraine, not intractable, without status migrainosus Copyright c 2015

92 Migraine (cont d) ICD-9-CM Menstrual migraine, with intractable migraine, so stated, without mention of status migrainosus Menstrual migraine, without mention of intractable migraine with status migrainosus Menstrual migraine, with intractable migraine, so stated, with status migrainosus Persistent migraine aura without cerebral infarction, without mention of intractable migraine without mention of status migrainosus ID-10-CM G Menstrual migraine, intractable, without status migrainosus G Menstrual migraine, not intractable, with status migrainosus G Menstrual migraine, intractable, with status migrainosus G Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus Copyright c 2015

93 Migraine (cont d) ICD-9-CM Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus ICD-10-CM G Persistent migraine aura without cerebral infarction, intractable, without status migrainosus *There are additional codes to further describe migraine. Copyright c 2015

94 Key Updates for Eye and Adnexa (H00-H59) Terminology improvements (bringing terms up to date) Many codes in this section instruct us to Use An Additional code Revisions to identify laterality: Many of the codes have laterality designation and, in some instances bilateral designation for diseases of the eye A code for unspecified site is also provided 94

95 Key Updates for the Ear & Mastoid Process (H60-H95) There is greater specificity and detail in the codes Many of the codes have laterality designation Many conditions in this section (e.g. otitis media) tell us to Use An Additional Code to identify: Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke in the perinatal period (P96.81) History of tobacco use (Z87.891) Occupational tobacco exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0) 95

96 Chronic Suppurative Otitis Media ICD-9-CM Unspecified chronic suppurative otitis media ICD-10-CM H66.3x1 Other chronic suppurative otitis media, right ear H66.3x2 Other chronic suppurative otitis media, left ear H66.3x3 Other chronic suppurative otitis media, bilateral H66.3x9 Other chronic suppurative otitis media, unspecified ear *Use additional code for any associated perforated tympanic membrane (H72-) Copyright c 2015

97 Chronic Suppurative Otitis Media ICD-9-CM ICD-10-CM Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke in the perinatal period (P96.81) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17-) Tobacco use (Z72.0) Copyright c 2015

98 Perforation of Tympanic Membrane ICD-9-CM Perforation of tympanic membrane, unspecified ICD-10-CM H72.90 Unspecified perforation of tympanic membrane, unspecified ear ** Code first any associated otitis media (H65-, H66.1-, H66.2-, H66.3-, H66.4-, H66.9-, H67-) H72.91 Unspecified perforation of tympanic membrane, right ear H72.92 Unspecified perforation of tympanic membrane, left ear H72.93 Unspecified perforation of tympanic membrane, bilateral Copyright c 2015

99 Perforation of Tympanic Membrane ICD-9-CM ICD-10-CM ** There are more specific code choice selections available in ICD-10-CM. These include: H72.00 Central perforation of tympanic membrane, unspecified ear H72.01 Central perforation of tympanic membrane, right ear H72.02 Central perforation of tympanic membrane, left ear H72.03 Central perforation of tympanic membrane, bilateral H72.10 Attic perforation of tympanic membrane, unspecified ear H72.11 Attic perforation of tympanic membrane, right ear Copyright c 2015

100 Perforation of Tympanic Membrane ICD-9-CM ICD-10-CM H72.12 Attic perforation of tympanic membrane, left ear H72.13 Attic perforation of tympanic membrane, bilateral H72.2x1 Other marginal perforations of tympanic membrane, right ear H72.2x2 Other marginal perforations of tympanic membrane, left ear H72.2x3 Other marginal perforations of tympanic membrane, bilateral H72.2x9 Other marginal perforations of tympanic membrane, unspecified ear Copyright c 2015

101 Perforation of Tympanic Membrane ICD-9-CM ICD-10-CM H Multiple perforations of tympanic membrane, right ear H Multiple perforations of tympanic membrane, left ear H Multiple perforations of tympanic membrane, bilateral H Multiple perforations of tympanic membrane, unspecified ear H Total perforations of tympanic membrane, right ear H Total perforations of tympanic membrane, left ear H Total perforations of tympanic membrane, bilateral H Total perforations of tympanic membrane, unspecified ear

102 Key Updates to Diseases of the Circulatory System (I00-I99) The time frame for assigning the acute MI code is four (4) weeks in ICD-10-CM A new category has been added for coding a subsequent acute MI, which is an MI that occurs within 28 days (4 weeks) of a previous acute MI Terminology used to describe several cardiovascular conditions has been revised to reflect more current medical practice Many codes in this section instruct us to Use An Additional Code A major change is the classification of hypertension, which in ICD-9- CM was classified by type: Benign, Malignant or Unspecified That classification is not required in ICD-10-CM There is only one code for hypertension I10 - Essential (Primary) Hypertension 102

103 Coronary Artery Disease (CAD) ICD-9-CM Coronary artery disease, native vessel Unstable angina ICD-10-CM I Atherosclerotic heart disease of native coronary artery with unstable angina I Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm I Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris I Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris 103

104 Key Updates for Diseases of the Respiratory System (J00-J99) Modifications have been made to specific categories that bring the terminology up-todate with current medical practice Emphysema now contains codes with panlobular and centrilobular in their description Asthma is now classified as mild intermittent, mild persistent, moderate persistent and severe persistent Many codes in this section instruct us to Use An Additional Code 104

105 Asthma Severity Asthma Severity Frequency of Daytime Symptoms Intermittent Less than or equal to 2 times per week. Mild Persistent Moderate Persistent More than 2 times per week. Daily. May restrict physical activity. Severe Persistent Throughout the day. Frequent severe attacks limiting ability to breathe. 105

106 Key Updates for Diseases of the Respiratory System (J00-J99) continued Specificity increased for diseases like influenza, acute bronchitis Coding notes updated to require the coder to include information about tobacco use/dependence, where applicable Procedural complications that affect the respiratory system are now included 106

107 Acuity: Cause: Severity (for persistent asthma patients) Temporal factors Documentation Awareness Tips Asthma Documentation Awareness e.g. acute, chronic e.g. exercise induced, cough variant, related to smoking, chemical or particulate cause, occupational e.g. mild, moderate or severe persistent e.g. intermittent, persistent, status asthmaticus, acute exacerbation

108 Asthma ICD-9-CM ICD-10-CM Extrinsic asthma with status asthmaticus J45.21 Mild intermittent asthma with acute exacerbation Extrinsic asthma with acute exacerbation J45.22 Mild intermittent asthma with status asthmaticus Intrinsic asthma with status asthmaticus J45.31 Mild persistent asthma with acute exacerbation Intrinsic asthma with acute exacerbation J45.32 Mild persistent asthma with status asthmaticus Chronic obstructive asthma with status asthmaticus Chronic obstructive asthma with acute exacerbation J45.41 Moderate persistent asthma with acute exacerbation J45.42 Moderate persistent asthma with status asthmaticus Exercise induced bronchospasm J45.51 Severe persistent asthma with acute exacerbation Cough variant asthma J45.52 Severe persistent asthma with status asthmaticus

109 ICD-9-CM Asthma, unspecified with status asthmaticus Asthma, unspecified with acute exacerbation ICD-10-CM Asthma J Unspecified asthma with acute exacerbation* J Unspecified with status asthmaticus* J Unspecified asthma, uncomplicated* J44.0 COPD with acute lower respiratory infection ** 5 th digit of each code represents unspecified J44.1 COPD with acute exacerbation J Exercise induced bronchospasm J Cough variant asthma ** 5 th digit of 0 is uncomplicated except for unspecified J *Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke in perinatal period (P96.81) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17-) Tobacco use (Z72.0-)

110 Tobacco Dependence and Abuse ICD-9-CM Tobacco abuse/dependence ICD-10-CM F Nicotine dependence, cigarettes, in remission F Nicotine dependence, cigarettes, with withdrawal F Nicotine dependence, cigarettes, with other nicotine-induced disorders F Nicotine dependence, chewing tobacco, in remission F Nicotine dependence, chewing tobacco, with withdrawal F Nicotine dependence, chewing tobacco, with other nicotine-induced disorders Z72.0 Tobacco use 110

111 Key Updates for Diseases of the Digestive System (K00-K95) A number of new subcategories have been added to this chapter Hernia with both gangrene and obstruction is classified to Hernia with gangrene Codes for Crohn s disease have been expanded to specify site, if a complication is present, and what that complication is Many codes in this section instruct us to Use An Additional Code Some terminology changes and revisions to the classification of specific digestive conditions have occurred in ICD-10-CM as well. The term hemorrhage is used when referring to ulcers. The term bleeding is used when classifying gastritis, duodenitis, diverticulosis and diverticulitis 111

112 Clinical Documentation Awareness Tips Enteritis / Crohn s Documentation Awareness Site: e.g. small, large, both With complication: e.g. abscess, fistula, intestinal obstruction, rectal bleeding

113 Enteritis / Crohn s Disease ICD-9-CM Regional enteritis of unspecified site ICD-10-CM K50.90 Crohn s disease, unspecified, without complications ** Use additional code to identify manifestations, such as: pyoderma gangrenosum (L88) * There are more specific code choice selections available in ICD-10-CM. These include: K50.00 Crohn s disease of small intestine without complications Copyright c 2015

114 Crohn s Disease ICD-9-CM ICD-10-CM K Crohn s disease of small intestine with rectal bleeding K Crohn s disease of small intestine with intestinal obstruction K Crohn s disease of small intestine with fistula K Crohn s disease of small intestine with abscess K Crohn s disease of small intestine with other complication K Crohn s disease of small intestine with unspecified complications Copyright c 2015

115 Crohn s Disease ICD-9-CM ICD-10-CM K50.10 Crohn s disease of large intestine without complications K Crohn s disease of large intestine with rectal bleeding K Crohn s disease of large intestine with intestinal obstruction K Crohn s disease of large intestine with fistula K Crohn s disease of large intestine with abscess K Crohn s disease of large intestine with other complication Copyright c 2015

116 Crohn s Disease ICD-9-CM ICD-10-CM K Crohn s disease of large intestine with unspecified complications K50.80 Crohn s disease of both small and large intestine without complications K Crohn s disease of both small and large intestine with rectal bleeding K Crohn s disease of both small and large intestine with intestinal obstruction K Crohn s disease of both small and large intestine with fistula K Crohn s disease of both small and large intestine with abscess Copyright c 2015

117 Crohn s Disease ICD-9-CM ICD-10-CM K Crohn s disease of both small and large intestine with other complication K Crohn s disease of both small and large intestine with unspecified complications K Crohn s disease, unspecified, with rectal bleeding K Crohn s disease, unspecified, with intestinal obstruction K Crohn s disease, unspecified, with fistula K Crohn s disease, unspecified, with abscess K Crohn s disease, unspecified, with other complication K Crohn s disease, unspecified, with unspecified complications

118 Key Updates for Diseases of the Skin and Subcutaneous System (L00-L99) This section has been restructured to include groups of diseases that are related to one another Assume causal condition with any condition listed below with Lower Extremity ulcer Atherosclerosis of Lower Extremity Chronic venous hypertension Diabetic ulcers Postphlebitic syndrome Postthrombotic syndrome Varicose ulcer Any associated gangrene Unlike ICD-9 codes, pressure ulcer codes are now combination codes that identify the site and stage of the ulcer. Procedural complications of the skin and subcutaneous tissue have been enhanced 118

119 Non-pressure Chronic Ulcer Left Heel and Midfoot Open into Dermis ICD-9-CM ICD-10-CM Ulcer of heel and midfoot L Non-pressure chronic ulcer of the left heel and midfoot limited to breakdown of skin

120 Key Updates for Diseases of the Musculoskeletal System and Connective System (M00-M99) Site and laterality designations Three different causes for pathological fractures: Neoplastic disease, Osteoporosis, and other specified disease The 7th character describes type of encounter, or the state of a fractures healing and any sequelae. Some codes in this chapter will have the 7th character applied 120