1/27/2016 ICD-10-CM: NEUROLOGY PART I AGENDA ORGANIZATION & STRUCTURE OF ICD-10-CM

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1 ICD-10-CM: NEUROLOGY PART I AGENDA Goal: Participants will be able to understand the principles of ICD- 10-CM coding related to neurology From ICD-9 to ICD-10: Major Changes Sequencing and Guidelines Practice: Finding the Key Term Chapter 1: Infectious Diseases Chapter 2: Neoplasms 2 ORGANIZATION & STRUCTURE OF ICD-10-CM Alphabetic Index Index to Diseases and Injuries Neoplasm Table Table of Drugs and Chemicals Index to External Causes Morphology codes and Hypertension tables have been eliminated Manifestation Codes Example: Disease, Alzheimer s G30.9 [F02.80] Tabular List Reorganization, addition, and expansion of chapters 3 1

2 BASIC STEPS TO CODING DISEASES 1. Locate main term in Index to Diseases 2. Follow directional terms e.g., see, see also, see category 3. Review diagnostic statement to locate essential modifiers (sub-terms) in Index to Diseases 4. Select and verify code in Tabular List of Diseases 4 BASIC CODING TIPS Start looking up the codes from the top down Looking up codes from the middle of the page will lead you the WRONG way! Use colored tabs to mark the alphabet and the sections 5 ICD-10-CM CODING CONVENTIONS 6 2

3 CODING IN ICD-10-CM Always at least 3 characters but can be up to seven 1 st Character is always a letter. All letters used except U 2 nd Character is always a number. 3 rd through 7 th characters can be numbers or letters. First 3 characters = category. Decimal goes after category (XXX.XXX) Not case-sensitive. First character is often capitalized. 7 CODING AND THE 7 TH CHARACTER EXTENSIONS Alpha (Except U) S Numeric or Alpha Additional Character A Category Etiology, anatomic site, severity Obstetrics, injuries, and external causes ICD-9 TO ICD-10 COMPARISON ICD-9-CM ICD-10-CM M

4 HOW MANY MORE CODES? Code Type ICD-9-CM ICD-10-CM Diagnosis 14,315 codes 69,101 codes 10 MAJOR MODIFICATIONS IN ICD-10 CM 7 th Character Placeholders Episode of Care Abbreviations NEC NOS Punctuation Instructional Notes Excludes Notes Relational Terms V/E Codes? Chapter Layout Default Code 11 SEVENTH CHARACTERS Some categories require a seventh character to provide further specificity about the condition being coded. May be a number or a letter Must always be in the seventh position Examples: S12.000B Displaced fracture, first cervical vertebra, initial encounter for open fracture T23.391D Third degree burn, multiple sites, right hand, subsequent encounter 12 4

5 PLACEHOLDER ICD-10-CM utilizes a Placeholder Character X for codes that requires a 7 th character, but may not have 6 preceding characters. Example: S54.02xA, Injury of ulnar nerve at forearm level, left arm V98.3xxD, Accident involving ski lift, subsequent encounter 13 7 TH CHARACTER INJURY EXTENSIONS Character A B D G K P S 7 th character meaning Initial Encounter/Closed Fracture Initial Encounter/Open Fracture Subsequent Encounter/Fracture Routine Healing Subsequent Encounter/Fracture Delayed Healing Subsequent Encounter/Fracture Nonunion Subsequent Encounter/Fracture Malunion Sequela 14 EPISODE OF CARE DEFINITIONS 7 TH CHARACTER EPISODE OF CARE A patient may see new and/or different providers over the course of treatment for an injury Assignment of the 7 th character is based on whether patient is undergoing active treatment, not whether the provider is seeing the patient for the first time. 15 5

6 EPISODE OF CARE A Initial encounter: Active treatment D Subsequent encounter: Routine followup S Sequela: Complications resulting from a condition EPISODE OF CARE EXAMPLES Case #1: Pt with arm fracture goes to ER. Gets cast put on. Follows up with PCP. Arm is healing normally. Code as SUBSEQUENT: routine care during healing phase Case #2: Pt with displaced fracture goes to ER. They ice it and immobilize, but due to excessive swelling, are unable to cast it. Goes next day to PCP, who puts on cast. Code as INITIAL: PCP is providing the definitive treatment 17 ABBREVIATIONS - NEC NEC = Not Elsewhere Classified For use when the provider documents a specific condition but the ICD-10 does not have a code for it Alphabetic Index uses NEC for a code that will direct the coder to the Tabular List, showing an Other Specified or Not Elsewhere Classified code description Examples: G90.8, Other disorders of autonomic nervous system N14.4, Toxic nephropathy not elsewhere classified 18 6

7 ABBREVIATIONS NOS NOS = Not Otherwise Specified Unspecified Available for use when the documentation of the condition identified by the provider is insufficient to assign a more specific code Example: G95.20 Unspecified cord compression G21.9 Secondary parkinsonism, unspecified 19 PUNCTUATION ( ) Parentheses Nonessential Modifiers Supplementary words that may be present or absent in the disease or procedure which do not affect the code assignment Examples: Alphabetic Index Fracture, jaw (bone) (lower) Dementia (degenerative) (primary) (old age) (persisting), Examples: Tabular List G71.2, Myotubular (centronuclear) myopathy G89.3, Neoplasm related pain (acute) (chronic) 20 PUNCTUATION [ ] Brackets Alphabetic Index: Identify Manifestation Codes Disease, Alzheimer's G30.9 [F02.80] Myelopathy, in pernicious anemia D51.0 [G99.2] Tabular List: Encloses synonyms G71.0, Severe [Duchenne] muscular dystropy M88, Osteitis deformans [Paget s disease of bone] 21 7

8 PUNCTUATION : Colons Used in Tabular List after an incomplete term which needs at least one of the terms following the code to make it assignable G90.2 Myelopathy in diseases classified elsewhere Excludes1 myelopathy in: intervertebral disease spondylosis 22 INSTRUCTIONAL NOTES Code First, Use Additional Code, and Code Also Found only in tabular Code Also does NOT give sequencing directions Examples: E08, Diabetes mellitus due to underlying condition Code first the underlying condition M60.0, Infective myositis Use additional code to identify infectious agent 23 INSTRUCTIONAL NOTES Inclusion Notes Inclusion Notes are used to clarify the conditions included within a particular chapter, section, category, subcategory or code Not Exhaustive Example: M30-M36 Systemic connective tissue disorder Includes: autoimmune disease NOS systemic autoimmune disease collagen (vascular) disease NOS 24 8

9 EXCLUDES NOTES Excludes1: CANNOT BE CODED HERE The code excluded should never be used with the code above the Excludes1 note Used when two codes cannot occur together Example: G82 Paraplegia and quadriplegia Excludes1 congenital cerebral palsy (G80.-) functional quadriplegia (R53.2) hysterical paralysis (F44.4) 25 EXCLUDES 1 UPDATE If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note. Example: Patient with residual effects of a stroke (I69.-) and a current traumatic brain injury (S06.-) Patient with recurrent depression (F33.-) is experiencing vertigo (R42) 26 EXCLUDES NOTES Excludes2: means condition not INCLUDED with this code. Indicates that the Excludes2 condition is not part of the above code, but it is acceptable to use both codes if the patient has both conditions and there is appropriate supporting documentation for both conditions. Example: M62.1 Other rupture of muscle (non-traumatic) Excludes2 rupture of tendon (M66.-) 27 9

10 EXCLUDES NOTES Excludes1 & Excludes2 Tip: Excludes1: There can be only 1 Excludes2: There can be possibly 2 28 RELATIONAL TERMS AND should be interpreted to mean either and or or Example: S83.0-, Subluxation and dislocation of patella Subluxation of patella Dislocation of patella Subluxation and dislocation of patella With, associated with, in, due to are used as synonyms Example: F02, Dementia in other diseases Dementia with other disease Dementia associated with other disease Dementia due to other disease 29 V/E CODES: WHERE ARE THEY NOW? E codes = Chapter 20: External Causes of Morbidity Examples: W21.03XA, Struck by baseball, initial encounter Y92.320, Baseball field as the place of occurrence V codes = Chapter 21: Factors Influencing Health Status and Contact With Health Services Examples: Z02.71, Encounter for disability determination Z82.0, Family history of epilepsy 30 10

11 DEFAULT CODE The default code is the code listed next to the main term in the Alphabetic Index 31 ICD-10 CM CHAPTER LAYOUT Chapter Chapter Title 1 Certain Infectious and Parasitic Diseases (A00-B99) 2 Neoplasms (C00-D48) 3 Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) 4 Endocrine, Nutritional, and Metabolic Diseases (E00-E89) 5 Mental and behavioral disorders (F01 F99) 6 Diseases of Nervous System and Sense Organs (G00-G99) 7 Diseases of Eye and Adnexa (H00-H59) 8 Diseases of Ear and Mastoid Process (H60-H95) 9 Diseases of Circulatory System (I00-I99) 10 Diseases of Respiratory System (J00-J99) 11 Diseases of Digestive System (K00-K94) 32 ICD-10 CM CHAPTER LAYOUT Chapter Chapter Title 12 Diseases of Skin and Subcutaneous Tissue (L00-L99) 13 Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) 14 Diseases of Genitourinary System (N00-N99) 15 Pregnancy, Childbirth, and the Puerperium (O00-O9A) 16 Certain Conditions Originating in the Perinatal Period (P00-P96) 17 Congenital malformations, deformations, and chromosomal abnormalities (Q00- Q99) 18 Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 19 Injury, poisoning, and certain other consequences of external causes (S00-T88) 20 External Causes of Morbidity (V01- Y99) 21 Factors influencing health status and contact with health services (Z00-Z99) 33 11

12 CODING GUIDELINES 34 MAJOR MODIFICATIONS IN ICD-10 CM GUIDELINES Level of Detail Laterality Integral Parts of Disease Acute and Chronic Conditions Combination Code Sequela (Late Effects) Borderline Diagnosis Chapter-Specific Coding Guidelines 35 LEVEL OF DETAIL When reporting a diagnosis code, report the code to the highest number of characters available The 4 th, 5 th, 6 th and 7 th characters provide greater detail A code is not valid if it has not been coded to the full number of characters required for that code, including the 7 th character G89 Pain not elsewhere classified G89.2 Chronic pain not elsewhere classified G89.22 Chronic post-thoracotomy pain 36 12

13 LATERALITY G56.01, Carpal tunnel syndrome, right upper limb M79.642, Pain in left hand H81.03, Ménière s disease, bilateral * If no bilateral code is provided, assign separate codes for the left side and the right side 37 INTEGRAL PARTS OF DISEASE Signs and symptoms that are routinely associated with a disease process should not be assigned as additional codes, unless instructed to do so Signs and symptoms that may not be associated routinely with a disease process should be coded when present Examples: Sciatica, pain, and numbness: Code for sciatica Sciatica, pain, and cough: Code for sciatica and cough 38 CHRONIC AND ACUTE CONDITIONS If the patient has both the acute and chronic forms of the same condition, code both and sequence the acute code first. G89.11 Acute pain due to trauma G89.29 Other chronic pain 39 13

14 COMBINATION CODE A combination code is used for Two diagnoses A diagnosis with an associated manifestation A diagnosis with an associated complication or symptom Examples: G43.A1 Cyclic vomiting with refractory migraine E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy G Narcolepsy with cataplexy 40 SEQUELA (LATE EFFECTS) A sequela is the condition produced, or the late effect, after the acute phase of an illness or injury has terminated. There is no time limit. Two codes required: First code The Sequela Second code Originating Condition of the Sequela Example: Scar after burn First Code: Scar (Sequela) Second Code: Burn (Originating Condition) 41 BORDERLINE DIAGNOSIS Any borderline diagnosis documented at discharge is treated as a confirmed diagnosis If there is a specific code available (borderline diabetes, borderline hypertension), that code should be used Borderline Suspected. In the outpatient setting, we cannot code for anything labeled suspected, probable, rule out, etc

15 CHAPTER- SPECIFIC CODING GUIDELINES 43 LOOKING UP GUIDELINES Beginning of Codebook Section I. Conventions, general coding guidelines and chapter specific guidelines C. Chapter-Specific Coding Guidelines Number after the C tells you which chapter you are in Other characters indicate categories, subcategories, etc. 44 CHAPTER 5: MENTAL AND BEHAVIORAL DISORDERS I.C.5.a: Pain disorders related to psychological factors Assign code F45.41 for pain that is exclusively related to psychological disorders. A code from category G89 should not be assigned with a code F Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain

16 CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM I.C.6.b.1: Pain-Category G89, General Coding Information Codes in category G89, Pain not elsewhere classified, may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain, unless otherwise indicated below. If the pain is not specified as acute or chronic, postthoracotomy, postprocedural, or neoplasm-related, do not assign codes from category G CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM I.C.6.b.1: Pain-Category G89, General Coding Information A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/ management and not management of the underlying condition. When an admission or encounter is for a procedure aimed at treating the underlying condition, a code for the underlying condition should be assigned as the principal diagnosis. No code from category G89 should be assigned. 47 CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM I.C.6.b.3: Postoperative pain The default for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the acute form. Routine or expected postoperative pain immediately after surgery should not be coded

17 CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM I.C.6.b.3: Postoperative pain (a) Postoperative pain not associated with a specific postoperative complication is assigned to the appropriate postoperative pain code in category G89 (b) Postoperative pain associated with a specific postoperative complication is assigned to the appropriate code(s) found in Chapter 19. If appropriate, use additional code(s) from category G89 to identify acute or chronic pain. 49 CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM I.C.6.b.4: Chronic pain Chronic pain is classified to subcategory G89.2. There is no time frame defining when pain becomes chronic pain. The provider s documentation should be used to guide use of these codes. I.C.6.b.6: Chronic pain syndrome Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than the term chronic pain, and therefore codes should only be used when the provider has specifically documented this condition. 50 CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM I.C.6.b.5: Neoplasm related pain Code G89.3 is assigned regardless of whether the pain is acute or chronic. This code may be assigned as the principal or first-listed code when the stated reason for the admission/encounter is documented as pain control/pain management. The underlying neoplasm should be reported as an additional diagnosis. When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89.3 may be assigned as an additional diagnosis. It is not necessary to assign an additional code for the site of the pain

18 Conventions and Guidelines Review The ICD-10-CM code for electrocution is T75.4 and requires the use of a seventh character to identify the encounter. Which of the following is the correct code for an initial encounter to treat the electrocution? A. T75.4A B. T75.4XA C. T75.4XXA D. T What type of punctuation identifies non-essential modifiers? A. Boxes B. Brackets C. Parentheses D. Colons 54 18

19 3. True or false: When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together. A. True B. False The first character of an ICD-10-CM code is: A. Always a number B. Always a letter C. Can be either a number or letter D. None of the above What type of note means not coded here? A. Includes B. Excludes2 C. Excludes1 D. None of the above 57 19

20 6. When are codes titled other specified used? A. When the record itself is not available for review B. When the information in the medical record provides detail for which a specific code does not exist C. When only outpatient diagnostic records are being coded D. When the information in the medical record is insufficient to assign a more specific code True or false: Similar to ICD-9-CM, in ICD-10-CM all categories are three characters. A. True B. False True or false: When the term and is used in a narrative statement it is interpreted to mean only and. A. True B. False 60 20

21 9. True or false: In ICD-10-CM all inclusion notes contain all conditions for which a particular code number is to be used, and are considered to be exhaustive. A. True B. False True or false: In ICD-10-CM a code also note provides sequencing guidance to the coding professional. A. True B. False 62 DETERMINE THE MAIN TERM, THEN LOOK UP THE CODE Secondary Parkinsonism G21.9 Second degree burn of right shoulder, initial encounter T22.251A Low back pain (left) in sciatica M54.42 Family history of epilepsy Z82.0 Intractable migraine with persistent aura G Adjustment of neuropacemaker Z

22 CHAPTER 1 CERTAIN INFECTIOUS AND PARASITIC DISEASES 64 Includes: Diseases generally recognized as communicable or transmissible Chapter 1 Infectious Diseases Excludes1: certain localized infections Excludes2 Carrier or suspected carrier of infectious disease Infections complicating pregnancy Infections in the perinatal period Influenza and other acute respiratory infections Use additional code for any associated drug resistance to antimicrobial drugs (Z16-) 65 Chapter 1 Infectious Diseases Categories B90-B94 are to be used to indicate conditions in categories A00-B89 as the cause of sequela, which are themselves classified elsewhere Code first condition resulting from (sequela) the infectious or parasitic disease Example: R27.0 Ataxia B94.1 Sequela of viral encephalitis 66 22

23 Categories B95-B97 Chapter 1 Infectious Diseases Used as supplementary or additional codes to identify the infectious agent(s) in diseases classified elsewhere Code first underlying disease Infection, bacterial, as cause of disease classified elsewhere 67 GUIDELINES: HIV Code only confirmed cases; provider s statement is considered confirmation Pregnant patient: Code first O98.7- Encounter for HIV-related condition B20, HIV Condition that is the reason for the encounter Any other HIV-related condition(s) Encounter for unrelated condition Code first condition being treated B20, HIV Any other HIV-related condition(s) 68 SCENARIO 1 A 35-year-old female with a previous diagnosis of myasthenia gravis is admitted with a chief complaint of increased muscle weakness, including difficulty walking. Her past medical history documents frequent UTIs. The urinalysis was positive for E. coli. The final diagnosis was acute exacerbation of MG due to a UTI. N39.0 Infection, urinary (tract) B96.20 Infection, Escherichia (E) coli, as causes of disease classified elsewhere G70.01 Myasthenia, gravis, with exacerbation (acute) Z History, personal (of), urinary (recurrent) (tract) infection(s) 69 23

24 SCENARIO 2 Patient has meningitis, which is a late effect from a tuberculosis infection G03.9 Meningitis B90.0 Sequelae, tuberculosis, central nervous system 70 SCENARIO 3 This 34-year-old male is HIV positive. He reports confusion, memory problems, and forgetfulness. The provider diagnoses him with HIV-associated dementia. B20 Human, immunodeficiency virus (HIV) (infection) F02.80 Dementia in (due to), human immunodeficiency virus (HIV) disease 71 CHAPTER 2 NEOPLASMS ICD-10-CM 72 24

25 NEOPLASMS Classifies neoplasm primarily by site (topography), with broad groupings for behavior Malignant Malignant Secondary Ca in situ Benign Uncertain Unspecified Behavior 73 USING THE NEOPLASM TABLE 74 DEFINITIONS Uncertain: the provider cannot determine if the neoplasm is malignant or benign Unspecified: the provider does not state if the neoplasm is malignant or benign

26 If the histological term is not documented, reference the Neoplasm Table, by site Chapter 2 Neoplasms If the histological term is documented, the Alphabetic Index should be referenced first Some types of neoplasms are not in the Table Examples: Small cell carcinoma of the right lower lobe: see Neoplasm Table, by site, malignant. Melanoma: melanoma, skin, by site SEQUENCING Specific guidelines related to sequencing of: Encounter for therapy Treatment directed at secondary site Anemia due to therapy Anemia due to malignancy Management of neoplasm related pain Complications due to therapy Pathological fracture due to neoplasm 77 SEQUENCING: NEOPLASTIC PAIN Manage pain only? Yes G89.3 Neoplasm No Manage pain & neoplasm? Yes Neoplasm G

27 SCENARIO 4 Patient is having difficulty walking and speaking, and right sided weakness. Also reports memory problems, using wrong words (will say stamps when he means phone. ) Lung cancer previously excised, no current treatment. Testing shows metastatic brain tumor. C79.31 Refer to Neoplasm by site, brain NEC, malignant, secondary site Z History, personal, malignant neoplasm, lung NEC SCENARIO 5 Treatment for neoplasm-related pain. Patient is undergoing chemotherapy for colon cancer. G89.3 Pain(s) (see also Painful), chronic, neoplasm related C18.9 Refer to Neoplasm Table, by site, colon, malignant, primary 80 THANK YOU FOR ATTENDING! 81 27