ICD 10 CM IMPLEMENTATION DATE OCT 1, 2015

Transcription

1 Presented by: Teri Romano, RN, MBA, CPC, CMDP ICD 10 CM IMPLEMENTATION DATE OCT 1, 2015 Source: house committee to hold hearing on icd 10 implementation/ Web_Non Traumatic Spine ICD10 (TR) v2 1

2 ICD 9 CM 3 5 characters in length 1st character may be alpha, but is usually numeric; 2nd 5th characters are numeric Approximately 14,000 codes Limited space for adding new codes Lacks detail vs. ICD 10 CM 3 7 characters in length Character 1 is alpha, character 2 is always numeric, characters 3 7 can be either alpha or numeric Approximately 69,000 codes Flexibility for adding new codes Very specific 3 Example: S12 Fracture of cervical vertebra and other parts of neck Note: A fracture not indicated as displaced or nondisplaced should be coded to displaced A fracture not indicated as open or closed should be coded to closed Includes: Fracture of cervical neural arch Fracture of cervical spine Fracture of cervical spinous process Fracture of cervical transverse process Fracture of cervical vertebral arch Fracture of neck Web_Non Traumatic Spine ICD10 (TR) v2 2

3 Excludes Notes The ICD 10 CM has two types of excludes notes (recall that ICD 9 CM had only one type of excludes notes). Excludes1 Excludes2 5 Excludes1 This is a pure excludes. It means 'NOT CODED HERE!' and the code excluded should never be used at the same time as the code above the Excludes1 note. M48.5 Collapsed vertebra, not elsewhere classified Excludes 1 Current injury see injury of spine pathological fracture of vertebra due to neoplasm (M84.58) Web_Non Traumatic Spine ICD10 (TR) v2 3

4 Excludes2 Means NOT INCLUDED HERE. An Excludes2 note indicates that the condition is not part of the condition represented by the code, but a patient could possibly have both conditions at the same time. In this case, it could be acceptable to use both the code and the excluded code together; such as: M51 Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders Excludes2 Cervical and cervicothoracic disc disorder (M50. ) 7 Other or Other Specified ( Not Elsewhere Classified NEC) Use when information in the medical record provide detail for which a specific code does not exist. Specific disease is documented but there is no diagnosis code. Unspecified ( Not Otherwise Specified NOS) Use when the information in the medical record is insufficient to assign a more specific code Web_Non Traumatic Spine ICD10 (TR) v2 4

5 CHAPTER 13: DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE (M00 M99) Chapter Organization M00 M99 M Image sources: Web_Non Traumatic Spine ICD10 (TR) v2 5

6 This chapter BLOCK is broken down into the following categories: M00 M02 Infectious arthropathies M05 M14 Inflammatory polyarthropathies M15 M19 Osteoarthritis M20 M25 Other joint disorders M26 M27 Dentofacial anomalies and other jaw disorders M30 M36 Systemic connective tissue disorders M40 M43 Deforming dorsopathies (e.g., kyphosis, scoliosis, spondylolysis, spondylolisthesis) M45 M49 Spondylopathies (e.g., osteomyelitis of vertebra, infection of intervertebral disc, discitis, spondylosis, spinal stenosis) M50 M54 Other dorsopathies (e.g., disc disorders, spinal instabilities, radiculopathy, sciatica, lumbago, low back pain) M60 M63 Disorders of muscles (e.g., myositis) M65 M67 Disorders of synovium and tendon (e.g., trigger finger) M70 M79 Other soft tissue disorders (e.g., spinal synovial cyst) M80 M85 Disorders of bone density and structure (e.g., osteoporosis with current pathological fracture, pathological fracture in neoplastic disease) M86 M90 Other osteopathies (e.g., osteomyelitis, osteonecrosis) M91 M94 Chondropathies M95 Other disorders of the musculoskeletal system and connective tissue M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified (e.g., fracture following insertion of implant, puncture, laceration, hemorrhage) M99 Biomechanical lesions, not elsewhere classified 11 SPINE DISORDER WHERE YOU LL FIND IT Stenosis, disc, spondylolisthesis, spondylosis, degenerative scoliosis/kyphosis M40 M99.9 Musculoskeletal Chapter Chapter 13 Spine fractures, spinal cord injury, traumatic disc, subluxation, etc S12 S34.9 Injuries, Poisonings and Other Consequences of External Causes Chapter 19 Spinal and vertebral tumors C and D Neoplasms Chapter 2 Spinal abscesses, cysts, chronic pain, dural G00 G99.8 Nervous System Chapter 6 tear Complications of devices ( spine hardware, neurostimulator, etc) Post op wound infection, spine T81 T88.9 Injuries, Poisonings and Other Consequences of External Causes Chapter Web_Non Traumatic Spine ICD10 (TR) v2 6

7 SPINE DISORDER Stenosis, disc, spondylolisthesis, spondylosis, degenerative scoliosis/kyphoses Spine fractures, spinal cord injury, traumatic disc, subluxation, etc WHERE YOU LL FIND IT M40 M99.9 Musculoskeletal Chapter Chapter 13 S12 S34.9 Injuries, Poisonings and Other Consequences of External Causes Chapter 19 Spinal and vertebral tumors C and D Neoplasms Chapter 2 Spinal abscesses, cysts, chronic pain, dural tear G00 G99.8 Nervous System Chapter 6 Complications of devices ( spine hardware, neurostimulator, etc) Post op wound infection, spine T81 T88.9 Injuries, Poisonings and Other Consequences of External Causes Chapter Major Differences for Non Traumatic Spine? Site specific, (occipito atlanto axial, high cervical) Combination codes (with myelopathy and radiculopathy) Character X and the 7 Th character for healing status Clinical concepts added (radiculopathy) Codes expanded (increased sites and increased categories of codes) Complications expanded Web_Non Traumatic Spine ICD10 (TR) v2 7

8 M40: Kyphosis and lordosis M40. Postural M40.1 Other secondary kyphosis M40.2 Other and unspecified kyphosis M40.3 Flatback syndrome M40.4 Postural lordosis, acquired lordosis Additional character(s) required for specific spinal region for the M40 M43 code block. M40.5 Lordosis, unspecified Tip: Use M96. for post procedural kyphosis, scoliosis, etc. 15 M41: Scoliosis M41.0 Infantile idiopathic scoliosis M41.1 Juvenile and adolescent idiopathic scoliosis M41.2 Other idiopathic scoliosis M41.3 Thoracogenic scoliosis M41.4 Neuromuscular scoliosis (e.g., scoliosis secondary to cerebral palsy) M41.5 Other secondary scoliosis M41.8 Other forms of scoliosis M41.9 Scoliosis, unspecified Additional character(s) required for specific spinal region for the M40 M43 code block Web_Non Traumatic Spine ICD10 (TR) v2 8

9 M43.0 Spondylolysis M43.1 Spondylolisthesis (excludes traumatic and congenital) 0 site unspecified 1 occipito atlanto axial (C1 C2) 2 cervical 3 Cervicothoracic 4 thoracic 5 thoracolumbar 6 Lumbar 7 lumbosacral 8 sacral and sacrococcygeal 9 multiple sites 17 M47.1 Spondylosis M47.1 Other spondylosis with Myelopathy 5 th Character 0 Site unspecified 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal M47.82 Other Spondylosis with Radiculopathy 6 th Character 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal 9 Site unspecified Web_Non Traumatic Spine ICD10 (TR) v2 9

10 M47. Spondylosis M47.81 Spondylosis without myelopathy or radiculopathy 6 th Character 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal 9 Site unspecified M47.89 Other spondylosis, by site M47.9 Spondylosis, unspecified 19 M48.0 Spinal stenosis 5 th Character 0 Site unspecified 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal Web_Non Traumatic Spine ICD10 (TR) v2 10

11 M54.01 Radiculopathy 5 th Character 0 Site unspecified 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal New in ICD M46.2 Osteomyelitis of vertebra M46.4 Discitis 5 th Character 0 Site unspecified 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal Web_Non Traumatic Spine ICD10 (TR) v2 11

12 M50. Cervical: requires 5th character for all subcategories listed below 5 th Character 0 Unspecified region 1 High cervical region (C2 C3, C3 C4) 2 Mid cervical region (C4 C5, C5 C6, C6 C7) 3 Cervicothoracic region (C7 T1) Code to the most superior level! M50.0 With myelopathy M50.1 With radiculopathy M50.2 Other disc displacement M50.3 Other disc degeneration M50.8 Other disc disorders M50.9 Unspecified 23 M51. Thoracic, thoracolumbar and lumbosacral: requires 5th character for all subcategories listed below 5 th Character 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) M51.0 With myelopathy M51.1 With radiculopathy M51.2 Other disc displacement M51.3 Other disc degeneration M51.4 Schmorl s nodes M51.8 Other disc disorders M51.9 Unspecified Web_Non Traumatic Spine ICD10 (TR) v2 12

13 M54.2 Cervicalgia M54.3 Sciatica New!! Unspecified side, right, left M54.4 Lumbago with sciatica New!! Unspecified side, right, left M54.5 Low back pain M54.6 Pain in thoracic spine M54.9 Dorsalgia, unspecified. Code symptoms only when a more definite diagnosis is not known. 25 M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified. Examples: M96.0 Pseudarthrosis after fusion or arthrodesis M96.1 Postlaminectomy syndrome, not elsewhere classified M96.81 Intraoperative hemorrhage and hematoma M96.83 Postprocedural hemorrhage and hematoma Web_Non Traumatic Spine ICD10 (TR) v2 13

14 Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. For example: Code the primary reason for the visit (lumbar stenosis) but code underlying conditions if they affect your treatment/surgical plan. For example, are you sending the patient to their cardiologist for a pre op evaluation for co existing cardiac conditions? Code those conditions. Important for risk based contracting and potential future payment models such as bundled payments and ACOs. 27 X placeholder is used to provide room for future expansion X placeholder is used to keep applicable 7 th character in the 7 th position when the code is less than 6 characters long Web_Non Traumatic Spine ICD10 (TR) v2 14

15 M53.2 Spinal instabilities M53.2X1 Spinal instabilities, occipito atlanto axial region M53.2X2 Spinal instabilities, cervical region M53.2X3 Spinal instabilities, cervicothoracic region M53.2X4 Spinal instabilities, thoracic region Etc. 29 X placeholder is used to provide room for future expansion. X placeholder is used to keep the 7 th character in the 7 th position when a code is less than 6 characters long Web_Non Traumatic Spine ICD10 (TR) v2 15

16 For Fractures 6 options The appropriate 7 th character is to be added to each code from category S02 A initial encounter for closed fracture B initial encounter for open fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion S sequela For Non Fractures 3 options The appropriate 7 th character is to be added to each code from category S14 A initial encounter D subsequent encounter S sequela 31 Initial Encounter (A, B) = In Active Treatment Examples include: surgical treatment, emergency department encounter and evaluation and continuing treatment by a new or the same physician. (2015 Guideline update!) Web_Non Traumatic Spine ICD10 (TR) v2 16

17 Subsequent Encounter (D, G, K, P) = In Healing or Recovery Phase Examples include: cast change or removal, an x ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition 33 Sequela (S) = Late effect, residual effect of a prior condition not a complication Examples include: scar formation resulting from a burn, deviated septum due to nasal fracture, infertility due to tubal occlusion from prior disease Web_Non Traumatic Spine ICD10 (TR) v2 17

18 7th Character Diagnosis (ICD 10 CM) Coding Procedure (CPT) Coding Term Encounter Visit Type Initial: the patient is in the active phase or treatment for an injury or fracture New patient: the patient has not been seen by the physician or other qualified health care provider in the same specialty, same group in Subsequent: after the active treatment phase is over the past 3 years Established patient: the patient has been seen by a physician or other qualified health care provider in the same specialty, same group practice within the past 3 years Web_Non Traumatic Spine ICD10 (TR) v2 18

19 Web_Non Traumatic Spine ICD10 (TR) v2 19

20 Chapter Highlights Pathologic Fracture/ Osteoporosis Related M80 M80.08 x 7 th Osteoporosis with current pathological fracture, vertebra(e) M80.88 x 7 th Other osteoporosis with current pathological fracture, vertebra(e) Image source: 39 Chapter Highlights Pathologic Fracture in Neoplastic Disease M84 M84.58 x 7 th Pathological fracture in neoplastic disease, other specified site (vertebrae) Code also underlying neoplasm Image source: Web_Non Traumatic Spine ICD10 (TR) v2 20

21 Coding of Pathologic Fractures For pathological fractures The appropriate 7 th character A initial encounter for fracture D subsequent encounter for fracture w/ routine healing G subsequent encounter for fracture w/ delayed healing K subsequent encounter for fracture w/ nonunion P subsequent encounter for fracture w/ malunion S sequela Image source: 41 Fatigue fractures (M48.40 M48.48) (A type of stress fracture due to abnormal stress on normal bone) Collapsed vertebra (M48.50 M48.58 Codes) Each of these categories of codes will need an X placeholder for a valid code Web_Non Traumatic Spine ICD10 (TR) v2 21

22 For fatigue fractures and collapsed vertebra 4 options The appropriate 7 th character is to be added to each code A initial encounter for closed fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing S sequela 43 All will require a 7 th character: T81.4 Infection following a procedure T84.84 Pain due to orthopedic internal prosthetic device, implants and grafts. (painful hardware) T85.1 Mechanical complication of implanted electronic stimulator of nervous system ( codes for breakdown, displacement, other) T84.2 Breakdown, displacement, other of internal fixation device of vertebrae Web_Non Traumatic Spine ICD10 (TR) v2 22

23 3 options The appropriate 7 th character is to be added to each code A initial encounter D subsequent encounter S sequela 45 EXERCISES 1. C3 C7 spondylosis with myelopathy M47.12 Spondylosis with myelopathy Web_Non Traumatic Spine ICD10 (TR) v2 23

24 EXERCISES 2. L4 L5 spinal stenosis, herniated disc and spondylolisthesis M48.06 Stenosis lumbar region M51.26 Herniated lumbar disc M43.16 Spondylolisthesis 47 EXERCISES 3. L4 L5 spinal stenosis M48.06 Stenosis lumbar region Web_Non Traumatic Spine ICD10 (TR) v2 24

25 EXERCISES 4. L4 S1 spinal stenosis M48.06 Stenosis lumbar region M48.07 Stenosis lumbosacral region Teaching point: 2 diagnoses may be needed who knows? 49 EXERCISES 5. C5 C6 herniated disc. Radiculopathy M50.12 Herniated disc with radiculopathy, mid cervical region Teaching point: ICD 10 CM includes specific spinal regions of high, mid and junctional for some codes Web_Non Traumatic Spine ICD10 (TR) v2 25

26 EXERCISES 6. L5 S1 herniated disc M51.27 Other lumbosacral disc displacement 51 EXERCISES 7. L4 radiculopathy M54.16 Radiculopathy, lumbar Teaching point: Code did not exist in ICD 9 CM Web_Non Traumatic Spine ICD10 (TR) v2 26

27 EXERCISES 8. Low back pain M54.5 Lumbago 53 EXERCISES 9. Synovial cyst at L4 L5. Stenosis at L3 L5 M71.38 Other bursal cyst, other site M48.06 Stenosis, lumbar Web_Non Traumatic Spine ICD10 (TR) v2 27

28 EXERCISES 10. Operative note shows the following Postoperative diagnosis: T4 pathologic fracture secondary to osteodiscitis M84.58XA Pathological fracture in other disease, other site M46.44 Discitis, unspecified, thoracic region 55 EXERCISES 11. T12 pathologic fracture due to metastatic lung cancer at time of vertebral augmentation procedure M84.58XA Pathologic fracture due to neoplastic disease C79.51 Vertebral mets Teaching point: Code also underlying neoplasm Web_Non Traumatic Spine ICD10 (TR) v2 28

29 EXERCISES 12. L4 L5 osteomyelitis M46.26 Osteomyelitis of vertebra, lumbar region 57 EXERCISES 13. Pseudoarthrosis L4 L5 M96.0 Pseudoarthrosis after fusion or arthrodesis Web_Non Traumatic Spine ICD10 (TR) v2 29

30 EXERCISES 14. Lumbar instability, lumbar stenosis 1) M53.2X6 Spinal instabilities, lumbar region 2) M48.06 Stenosis, lumbar region 59 EXERCISES 15. Post op diagnosis; Spondylolisthesis, grade 1, L4 L5, degenerative disc disease lumbar spine, spinal stenosis, neural foraminal stenosis, lumbago, sciatica M43.16 Spondylolisthesis, lumbar region M51.36 Other intervertebral disc degeneration, lumbar region M48.06 Stenosis, lumbar region Web_Non Traumatic Spine ICD10 (TR) v2 30

31 Teri Romano RN, MBA, CPC, karenzupkoandassociates 2015 Web_Non Traumatic Spine ICD10 (TR) v2 31