Introduction to ICD Andrea Devlin, CPMA, CPC Alta Partners, LLC 2015
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1 Introduction to ICD - 10 Andrea Devlin, CPMA, CPC Alta Partners, LLC 2015
2 Agenda Introduction Benefits of ICD-10 Features of ICD-10 ICD-9 vs. ICD-10 ICD-10 Structure Question & Answer
3 Introducing ICD-10 October 1, 2015 is official transition date for ICD-10 coding system Replaces ICD-9, which has been in use for 30+ years Introduced by World Health Organization in 1998 ICD-10 offers more detail, and is broken down into two parts: ICD-10-CM: clinical modification, 68,000+ diagnosis codes ICD-10-PCS: procedure coding system, 87,000+ procedure codes
4 Introducing ICD-10: Why Change? Current system is 30 years old Many classification categories are full ICD-9 codes lack specificity Consists of outdated terminology US will now be globally aligned when describing diseases, morbidity, and mortality
5 Benefits of ICD-10 Improved ability to measure health care services Enhanced ability to conduct public health surveillance Decreased need to include supporting documentation with claims Includes updated medical terminology and classification of diseases Codes allow for comparison of mortality and morbidity data Provides better data to design payment systems Allows for easier identification of fraud and abuse
6 Features of ICD-10 Combination Codes Laterality Excludes Notes Placeholder X allows for future expansion Injuries grouped by anatomical site Full code titles 21 chapters including V, W, X, Y and Z codes Postoperative complications moved to the specific chapter
7 ICD-9-CM vs. ICD-10-CM ICD-9-CM ICD-10-CM 14,000 codes 68,000+ codes No Laterality Laterality 3-5 digits 7 digits No placeholder Limited Severity Parameters Limited Combination Codes X placeholders Extensive Severity Parameters Extensive Combination Codes to better capture complexity 1 type of Excludes Notes 2 types of Excludes Notes
8 Sequela: complication or condition that arises as a direct result of an injury Example: scar as a result of a burn ICD-10-CM Structure S D Category S: injuries, poisoning and certain consequences of external causes related to single body regions S86: Injury of muscle, fascia and tendon at lower leg Etiology Anatomic Site Severity Other Vital Details S86.0: Injury of Achilles tendon S86.01: Strain of Achilles tendon S86.011: Strain of right Achilles tendon Extension Primarily used to document episode of care for injuries and other conditions with external causes A: initial encounter D: Subsequent Encounter S: Sequela
9 ICD-10-CM Documentation Tips ICD-10 requires increased specificity in documentation to support the most appropriate diagnosis code When documenting, remember to include: Laterality Specific type, class, or organism of infection Example: Anthrax sepsis (A22.7) Cause and effect relationship between procedure and postprocedural sepsis Example: Bloodstream infection due to central venous catheter (T80.211) Infection status Example: Human immunodeficiency virus (HIV) disease (B20) Inconclusive laboratory evidence of HIV (R75) Asymptomatic HIV infection status (Z21) Specific anatomic site Example: Cutaneous abscess of right axilla (L02.411) A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7 th character, if applicable. Source: Optum ICD-10-CM Clinical Documentation Improvement Desk Reference,
10 Code Extensions (7 th digit) Example: Fracture ICD-9-CM Closed fracture of unspecified carpal bone S62.101A S62.101D S62.101G S62.101K S62.101P S62.101S ICD-10-CM Fracture of unspecified carpal bone, right wrist, initial encounter for closed fracture Fracture of unspecified carpal bone, right wrist, subsequent encounter for fracture with routine healing Fracture of unspecified carpal bone, right wrist, subsequent encounter for fracture with delayed healing Fracture of unspecified carpal bone, right wrist, subsequent encounter for fracture with nonunion Fracture of unspecified carpal bone, right wrist, subsequent encounter for fracture with mal-union Fracture of unspecified carpal bone, right wrist, sequela
11 Increased Specificity Example: Obstetrics Trimester Indicator O25.1 Malnutrition in pregnancy O25.10 Malnutrition in pregnancy, unspecified trimester O25.11 Malnutrition in pregnancy, first trimester O25.12 Malnutrition in pregnancy, second trimester O25.13 Malnutrition in pregnancy, third trimester Multiple Gestation Indicator O30.0 Twin Pregnancy O30.1 Triplet Pregnancy O30.2 Quadruplet Pregnancy O30.8 Other multiple gestation O30.9 Multiple gestation, unspecified Can be further classified to show: Monoamniotic/ monochorionic Conjoined twins Other twin pregnancy Unspecified twin pregnancy
12 Increased Specificity Example: Diabetes Mellitus Type II diabetic patient with resulting ulcers on foot ICD-9-CM: 10 Diabetes Subcategories Diabetes mellitus without mention of complication Diabetes with ketoacidosis Diabetes with hyperosmolarity Diabetes with other coma Diabetes with renal manifestations Diabetes with ophthalmic manifestations Diabetes with neurological manifestations Diabetes with peripheral circulatory manifestations Diabetes with other specified manifestations Diabetes with unspecified complications
13 Increased Specificity Example: Diabetes Mellitus Type II diabetic patient with resulting ulcers on foot ICD-10-CM: 5 Diabetes Categories that are Further Subdivided E08 Diabetes mellitus due to underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type I diabetes mellitus E11 Type II diabetes mellitus E13 Other specified diabetes mellitus E14 Unspecified diabetes mellitus Manifestations/ Complications E 1 1. X X X Category Specific Types of Manifestations
14 Increased Specificity Example: Diabetes Mellitus Type II diabetic patient with resulting ulcers on foot ICD-10-CM: Type II Diabetes Mellitus E11.6 Type 2 diabetes mellitus with other specified complications E11.62 Type 2 diabetes mellitus with skin complications E Type 2 diabetes mellitus with diabetic dermatitis E Type 2 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with other skin ulcer E Type 2 diabetes mellitus with other skin complications
15 Laterality Example: Osteoarthritis of Right Hip? ICD-9-CM Osteoarthritis unspecified whether generalized or localized involving unspecified site Osteoarthritis unspecified whether generalized or localized involving pelvic region and thigh Osteoarthritis unspecified whether generalized or localized involving other specified site ICD-10-CM M16.0 Bilateral primary osteoarthritis of hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip
16 Combination Code Single code used to classify: 1. Two diagnoses 2. A diagnosis with an associated sign or symptom 3. A diagnosis with an associated complication Two Diagnosis Codes I Arteriosclerotic heat disease of native coronary artery with unstable angina pectoris A Diagnosis with an Associated Secondary Process K Crohn s disease of large intestine with intestinal obstruction A Diagnosis with an Associated Complication K71.51 Toxic liver disease with chronic active hepatitis with ascites
17 Combination Code Example: Arthritis as a result of mumps Single code used to classify: 1. Infectious organism and manifestation, or two diagnoses 2. A diagnosis with an associated complication 3. A diagnosis with associated signs or symptoms Mumps with other specified complication Unspecified infective arthritis site unspecified B26.89 Mumps arthritis 14
18 Excludes Notes Excludes 1: Not Coded Here Code should never be used at the same time as the code above the Excludes 1 note Excludes 2: Not Included Here Excluded condition is not part of the condition represented by the code, but conditions can co-exist for the patient
19 Example: Excludes Notes J18.0 Bronchopneumonia, unspecified organism Excludes 1 Hypostatic bronchopneumonia (J18.2) Lipid pneumonia (J69.1) Excludes 2 Acute bronchitis (J21.-) Chronic bronchitis (J44.9) J18.2 and J69.1 should never be used at the same time as J18.0 J21.- and J44.9 are not part of J18.0 but conditions can co-exist for the patient
20 Discussion Questions and Answers Session Andrea Devlin, CPMA, CPC Alta Partners, LLC Westpoint Parkway Suite 320 Westlake, OH
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