Sherry Thomas, CCP, CCP-AS CEO/Director of Education
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1 Sherry Thomas, CCP, CCP-AS CEO/Director of Education
2 Implementation date October 1, 2013 Oops maybe not
3 On Oct 1, 2012 there will be only limited code updates to both ICD-9 CM and ICD-10 code sets On Oct 1, 2013 there will be only limited updates to ICD-10 code sets These limited updates will capture new technology and new diseases only On Oct 1, 2014 regular updates to ICD-10 will begin, ending the freeze
4 3 5 characters in length Numeric code 3 digit code = Category
5 3 7 characters in length Alpha-numeric code 1 st digit of 3 digit code = Alpha 2 nd and 3 rd digit = Number 4 th, 5 th, 6 th digit = Subcategory May be a Number or Alpha 7 th digit - Alpha
6 Applies to certain categories Required when noted in the tabular Must ALWAYS be the last character If code is NOT a full 6 digit code: Place-holder X must be used Place in the 5 th position within code
7 ICD-10 Affect on Clinical Documentation A large number of ICD-10-CM codes only differ in one parameter. For example: 25 % of the ICD-10-CM codes are the same except for indicating the right and left side of the patient s body. 25 % of the codes differ only in the way they distinguish among encounters: initial encounter, vs subsequent encounter, vs sequelae.
8 Even though there are more than 1,800 available codes for coding fractures of the radius, there are only approximately 50 distinct recurring concepts.
9 CATEGORY Fracture Type DOCUMENTATION REQUIREMENTS Healing Localization Encounter Displacement Classification Laterality Joint Involvement Fracture Pattern Named Fractures
10 ICD-9 to ICD-10 Documentation Comparisons
11 Review Example #1
12 ICD-9-CM Coding Concussion w/loss of consciousness <30 minutes Headache Somatic dysfunction
13 Patient has been remodeling his home and presents today after having a new bedroom door fall on his head 4 days ago. He states that his buddy accidently let go of the door when they were trying to hang it. His friend also told him he was knocked out for about three minutes. He suffered a concussion, as well as some neck pain but did not see anyone at that time. The patient continues to have headaches since it happened. They come on suddenly, last for long periods of time and occur every day but the Advil has not relieved them. He denies vision, taste or smell changes. The patient states he has a lot of pain across his left shoulder and back of his neck. O: WT 188, BP 144/82, PR70, R 18. He has full strength in his upper extremities and DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear. Severe tenderness in the superior trapezius muscle. ROM in neck limited. A: What will need to be documented? How many codes will that involve? P: I will send him for physical therapy, 3 X/week for 4 weeks for cervical soft tissue muscle massage, as well as upper dorsal. Patient has been instructed to return in 1 month, sooner if needed.
14 ICD-10-CM Coding G Headache, intractable, acute post-traumatic S06.0x1A Concussion w/loss of consciousness of <30 minutes, initial encounter M99.01 Segmental and somatic dysfunction of cervical region W20.8xxA Y93.e9 Struck by falling object (accidentally), initial encounter Activity, maintenance household, interior Y Place of occurrence, house, single family, bedroom
15 Review Example #2
16 ICD-9-CM Coding sprain, ankle, unspec. site no code suspect tendon strain and partial tear
17 S: Patient works in the healthcare industry and presents today after falling at home last Thursday night. She stated she hit the stone walk in her back yard wearing high heels and rolled her right ankle. Heard a loud pop before hitting the fence, deck, wheel barrow and then the ground. States she became nauseous afterwards due to the pain level. She has no prior injury or problems with her ankle and feels she was otherwise uninjured. She has a lot of bruising on the side of her right ankle and hindfoot and she has a lot of swelling. Her ankle seems to ache all the time however bearing weight on it causes stabbing pains and burning sensations. When at rest she does experience stabbing pain in the lateral aspect of her right ankle. No medial or calf pain. No chest pain, SOB, numbness, or tingling.
18 O: She is alert and oriented X3, pleasant and cooperative. Has a limp antalgic from the right. She has exquisite pain in the area of the ATFL and the CFL of her right ankle and tenderness along the distal fibula near the peroneal tendons. Active eversion reproduces significant pain especially posterolaterally. I do not detect any subluxation of the peroneals. No tenderness over the deltoid or posteriorly over the Achilles. Severe bruising of the lateral ankle and the lateral hindfoot. No tenderness in the midfoot.
19 X-RAY: 3 view x-ray shows soft tissue swelling but no evidence of fracture. Mortis is properly aligned. A: What will need to be documented? How many codes will that involve? P: recommended boot, crutches and no driving. Return in 3 weeks for re-evaluation. All activity restrictions, recommendations and precautions remain in effect until further notice. Patient understands.
20 ICD-10-CM Coding S93.491A Sprain, anterior talofibular (ATFL) right ankle, initial encounter S93.411A Sprain, calcaneal fibular ligaments (CFL), right ankle, initial encounter W01.198A Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter Y93.01 Activity, walking, marching and hiking on level or elevated terrain Y Place of occurrence, house, single family, yard
21 Reason for visit Associated DX Status of DX Acute vs Chronic Exact body part involved If an injury: Location at time of injury Cause of injury Activity involved at time of injury Only billed on 1 st claim
22 Review Example #3
23 DIAGNOSIS: 1. Hypertension Ischemia of the heart Hyperlipidemia Old CVA w/gait issues V Depression 311
24 1. Hypertension NO UNSPECIFIED CODE (accelerated, benign, essential, idiopathic, malignant, systemic). with, Cardio, Renal, Cardio-Renal, due to 2. Ischemia of the heart (must state duration) chronic, acute, subacute, vessel, atherosclerotic, arteriosclerosis
25 Hyperlipidemia unspecified pure hypercholesterolemia pure hyperglyceridemia mixed hyperlipidemia hyperchylomicronemia familial combined hyperlipidemia lipoprotein deficiency
26 Old CVA Z86.73 w/late effects Sequelae of cerebral infarction involves: Left vs right Dominant vs non-dominant side upper vs lower limb (specific) deficits such as cognitive, speech, language, dysphagia, etc.
27 Depression, major unspecified Single episode vs Recurrent Mild vs moderate vs severe With or without psychotic features Partial remission vs full remission does it involve: Postpartum, schizophrenia, bipolar, manic depressive, etc.
28 Review Example #4
29 1) Sinusitis 2) Chronic fatigue/malaise 3) Possible anxiety 4) Arthralgia/low back pain/chronic headaches 5) Obesity 6) Palpitations 7) Probable allergies
30 Sinusitis unspecified (accessory, chronic, hyperplastic, nasal, nonpurulent, purulent) acute vs chronic site: ethmoidal, frontal, maxillary, pansinusitis, sphenoidal does it involve more than one sinus? recurrent due to high altitude
31 Chronic fatigue/malaise R53.81 Malaise R53.82 Fatigue
32 Arthralgia Site specific: ankle, elbow, finger, foot, hand, hip, knee, shoulder, toe, wrist, TMJ, + caisson disease Low back pain Cervical, low back, low back + sciatica, thoracic Headaches 85codes type specific Allergic, associated with, chronic, lumbar puncture, periodic, tension, vascular, etc., etc., etc. Does NOT include migraines
33 Obesity Due to excess calories, morbid, drug induced, w/alveolar hypoventilation, overweight, other, unspecified + BMI adult or pediatric Palpitations R00.2
34 Diabetes, diabetic (mellitus) (familial) (sugar) with manifestation due to drug or chemical E09.9 with due to underlying condition E08.9 with Gestational diabetes Specified type NEC E13.9 With.. Type 1 E10.9 Type 2 E11.9 with with STATUS: Controlled vs Uncontrolled
35 E Type 2 diabetes mellitus with foot ulcer Use additional code to identify site of ulcer (L97.4- L97.5-) L97.4 Non-pressure chronic ulcer of heel and midfoot Non-pressure chronic ulcer of plantar surface of midfoot L97.5 Non-pressure chronic ulcer of other part of foot Non-pressure chronic ulcer of toe
36 Specified Site right heel and midfoot left heel and midfoot unspecified heel and midfoot other part of foot Specified Degree of Ulcer limited to breakdown of skin fat layer exposed necrosis of muscle necrosis of bone unspecified severity
37 Infections of the skin and subcutaneous tissue (L00-L08) Use additional code (B95-B97) to identify infectious agent Excludes 2: hordeolum (H00.0) infective dermatitis (L30.3) local infections of skin classified in Chapter 1 lupus panniculitis (L93.2) panniculitis NOS (M79.3) panniculitis of neck and back (M54.0) Perle che due to candidiasis (B37.0) Perle che due to riboflavin deficiency (E53.0) pyogenic granuloma (L98.0) relapsing panniculitis [Weber-Christian](M35.6) viral warts (B07-) zoster (B02-)
38 B95 Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere B96 Other bacterial agents as the cause of diseases classified elsewhere B97 Viral agents as the cause of diseases classified elsewhere * Require 4 th and 5 th digits for complete code
39 L00-L08 o o Impetigo Cutaneous abscess, furuncle and carbuncle o o o o o Cellulitis Acute lymphangitis Pilonidal cyst/sinus Pyoderma Erythrasma
40 6 th I25.11 Atherosclerotic heart disease of native coronary artery with angina pectoris I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris EXCLUDES 1 unstable angina without documented spasm without atherosclerotic heart disease (I20.0) I Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm EXCLUDES 1 angina pectoris with documented spasm without atherosclerotic heart disease (I20.1)
41 Site specific: aorta, brain, leg, etc. Vessel specific: coronary, native Right vs Left vs Bilateral Angina pectoris: stable vs unstable documented spasm? QUESTIONS: Bypass graft involved? Autologous vein graft involved? Is gangrene, intermittent claudication, rest pain or ulceration involved? If yes, what is location? ankle, calf, foot site, heel, lower leg, midfoot, thigh
42 Join PHIA for the 2012 Annual National CEU Conference The time to prepare for BIG change..is HERE! Topic Includes: Hands on ICD-10 Coding (Current ICD-10 draft included in your Registration Fee) Overview regarding the structure of ICD-10 codes, guidelines and rules will be presented. To help you prepare for this new coding system examples, games, & puzzles involving all specialtieswill be involved in this hands on workshop October 4, 2012 Louisville, KY 7:30 a.m. -5:00 p.m. The Olmsted Announcing CEU Approvals PHIA approved AAPC 6.5 approved Visit for details Prizes, Prizes, Prizes * PHIA Conference T-shirt * Breakfast & Lunch Exhibitor Booths * PHIA Conference Bag * ICD-10 Coding book
43 Sherry Thomas, CEO/ Director of Education Certified Coding Professional (CCP) Certified Coding Professional Audit Specialist (CCP-AS) 30 years experience in healthcare Clinical, Administrative, Education Services includes: Chart Auditing Healthcare Seminars/Workshops Qualified IRO - Integrity Agreements National Credentialing Organization ONLINE Coding/Billing Courses (Certification/Diploma) Provider/Staff Education
44 For additional information please contact: SHERRY THOMAS, CCP, CCP-AS CEO/Director of Education Medical Staff SOS, Inc./ PHIA
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