Getting Down to the Nitty Gritty of ICD-10-CM

Transcription

1 Getting Down to the Nitty Gritty of ICD-10-CM Spring 2016 About the Presenter: Dana Brown, RHIA, CHC, AHIMA ICD-10 Train the Trainer Ms. Brown founded RMC in 1994, with the desire to assist healthcare facilities in obtaining correct reimbursement and minimizing lost revenue through complete and accurate coding, documentation improvement, and education. Prior to founding RMC, Ms. Brown performed DRG Validation, Admission, and Utilization Reviews for the Oregon PRO/QIO. She has extensive management, education and coding experience spanning her 25+ year career in HIM. Ms. Brown s expertise in Compliance, Inpatient Coding, DRG s/msdrg s, OIG & RAC Targets, Clinical Documentation Improvement, as well as an interest in HCC and Critical Access Hospitals round out her areas of focus at RMC. Ms. Brown s vision for RMC is to continue to support our clients with exceptional services, delivered by exceptional staff. 2 1

2 About the Presenter: Monique Vanderhoof, CPC, CCA, CRC, AHIMA Approved ICD-10-CM Trainer Monique joined RMC in September 2011 as Manager of Coding Services focusing on Risk Adjustment/HCC coding audits and client education. With over 15 years experience as a Clinic Manager Monique has a extensive experience working in both outpatient and inpatient physician billing with emphasis in cardiology. Her skills also include EHR implementation, HIPAA, erx and Meaningful Use readiness and attestation. at: [email protected] 3 RMC s Disclaimer Every reasonable effort has been taken to ensure that the educational information provided in this presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation. A thorough individual review of the information is recommended and to establish individual facility guidelines. RMC makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. RMC has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this presentation. RMC makes no guarantee that the use of this presentation material will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. 2

3 So How are YOU doing?? Photo Credit: Connie Calvert Ref 5 3

4 ICD 10 Post Implementation Ref 1 Introduction to ICD-10-CM US Department of Health and Human Services announced change January 16, 2009 with a compliance date of October 1, delay until October 2014 March 21, 2013 CMS announces deadline of October 1, 2014 is firm March 2014 ICD-10 delayed again until Oct. 1, 2015 Biggest change to healthcare in the last 20 years!

5 Introduction to ICD-10-CM History- ICD-9-CM Based on World Health Organization s (WHO) Ninth Revision Morbidity and mortality reporting Made single classification system for hospitals in January 1979 Physicians required to submit diagnosis codes for Medicare reimbursement since April 1989 Introduction to ICD-10-CM ICD-10-CM Developed by National Center for Health Statistics (NCHS) per WHO s ICD-10 Adoption: Final rule January 16, 2009 Compliance: October 1, 2015 WHO currently working on ICD-11 5

6 Conventions Conventions Nonessential Modifiers- Are a term or series of terms They appear within parentheses They follow the main term or subterm 6

7 Conventions See and See Also The see instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the see note to locate the correct code. A see also instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the see also note when the original main term provides the necessary code. Conventions See and See Also Examples from Index- See Abduction contracture, hip or other joint see Contraction, joint Decubitus (ulcer) see Ulcer, pressure, by site See Also Dacryostenosis see also Stenosis, lacrimal - congenital Q10.5 Febris, febrile see also Fever 7

8 Conventions Code also note A code also note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. Conventions Code also note Examples from Index- Retinopathy (background) H arteriosclerotic I70.8 [H35.0-] 8

9 Conventions Default Codes- A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned. Conventions ICD-10-CM Variances to ICD-9-CM Addition of 7 th character Used in certain chapters to provide information about the characteristic of the encounter Must always be used in the 7 th character data slot If a code has an applicable 7 th character, for the code to be a valid code it must be reported with an appropriate 7 th character value If code does not have 6 characters, a placeholder X must be used to fill in the empty characters Reference: ICD-10-CM Official Guidelines for Coding and Reporting

10 Conventions NEC: Not Elsewhere Classified other specified When a specific code is not available for a condition Example: ICD-10-CM H26.8 Other specified cataract ICD-9-CM Other cataract NOS: Not Otherwise Specified Equivalent of unspecified Example: ICD-10-CM H40.9 Unspecified glaucoma Conventions Abbreviations- Punctuation- Brackets [ ] Enclose synonyms, alternative wording or explanatory phrases Used in Index to identify manifestation codes Example: M26 Dentofacial anomalies [including malocclusion] 10

11 Conventions Parentheses ( ) Enclose supplementary words or explanatory information Nonessential modifiers Example: Pneumonia (acute) (double) (migratory) (purulent)(septic) (unresolved) Conventions Punctuation- Punctuation- Colon : Used in Tabular List after incomplete term that needs one or more modifiers following colon to make it assignable Example: G73.7 Myopathy in diseases classified elsewhere Excludes 1: myopathy in: -rheumatoid arthritis (M05.4-) -sarcoidosis (D86.87) -scleroderma (M34.82) -sicca syndrome [Sjogren] (M35.03) -systemic lupus erythematosus (M32.19) 11

12 Conventions Punctuation- Conventions Dash - Used in both Alphabetic Index and Tabular List Indicates incomplete code Locate code in Tabular List and review options to determine additional character(s) needed Example: Fracture, pathologic ankle M carpus M Notes- Includes Notes Appears immediately under a three-digit code title to further define, or give examples of, the content of the category Inclusion terms Included under some codes Conditions for which that code is to be used Excludes notes Two types in ICD-10-CM 12

13 Conventions ICD-10-CM: Includes Notes This note appears immediately under a three character code title to further define, or give examples of, the content of the category. Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 Conventions ICD-10-CM: Includes Notes- I21 ST elevation (STEMI) and non-st elevation (NSTEMI) myocardial infarction INCLUDES -cardiac infarction -coronary (artery) embolism -coronary (artery) occlusion -coronary (artery) rupture -coronary (artery) thrombosis -infarction of heart, myocardium, or ventricle -myocardial infarction specified as acute or with a -stated duration of 4 weeks (28 days) or less from onset 13

14 Conventions ICD-10-CM: Excludes Notes Excludes 1 note- A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 Conventions ICD-10-CM: Excludes Notes Excludes 1 note- H61.3 Acquired stenosis of external ear canal Collapse of external ear canal EXCLUDES1 postprocedural stenosis of external ear canal (H95.81-) 14

15 Excludes 1 Please see the "Interim advice on excludes 1 note on conditions unrelated" (next slide) posted to the NCHS website with the ICD- 10-CM guideline documents. Apparently Excludes1 does not ALWAYS mean the 2 conditions cannot be reported together...they cannot be reported together when they are RELATED. But if unrelated, per this document, they can still both be reported. Excludes 1 We have received several questions regarding the interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another. Answer: If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note. Ref: Coding Clinic, Fourth Quarter 2015: Page 40 15

16 Conventions ICD-10-CM: Excludes Notes Excludes 2 note A type 2 Excludes note represents Not included here. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 Conventions ICD-10-CM: Excludes Notes Excludes 2 note- G11 Hereditary ataxia EXCLUDES 2 cerebral palsy (G80.-) hereditary and idiopathic neuropathy (G60.-) metabolic disorders (E70-E88) 16

17 Conventions ICD-10-CM: Placeholder X Addition of dummy placeholder X is used in certain codes to: Fill out empty characters when a code contains fewer than 6 characters and a 7 th character applies When placeholder character applies, it must be used in order for the code to be considered valid Allow for future expansion Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 Conventions ICD-10-CM 7 th Character Injuries and External Causes Application of 7 th Characters in Chapter 19 A Initial encounter D Subsequent encounter S Sequela Note: For aftercare of an injury, assign acute injury code with 7 th character D Reference: ICD-10-CM Official Guidelines for Coding and Reporting

18 Conventions ICD-10-CM 7 th Character Fractures- 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 P Subsequent encounter for fracture with malunion S Sequela Reference: ICD-10-CM Official Guidelines for Coding and Reporting 2013 Conventions Etiology/Manifestation Conventions- Underlying condition (etiology), manifestation use additional code code first in diseases classified elsewhere Never first listed or principal diagnosis Example: F02 Dementia in other diseases classified elsewhere Code first the underlying physiological condition, such as: Alzheimer s (G30.0-) 18

19 Conventions Acute and Chronic Conditions- If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first. Example: Acute and Chronic Pancreatitis Code Acute Pancreatitis unspecified K85.9 and K86.1 Chronic Pancreatitis Conventions Combination Codes- A combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication Identify combination codes by referring to subterm entries in Alphabetic Index read the inclusion and exclusion notes in the Tabular List 19

20 Conventions A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated with no time limit (ICD-9-CM was late effect) The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Conventions Sequela- Sequela- An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. 20

21 Conventions Sequelae (of) see also condition - burn and corrosion -- code to injury with seventh character S Burn -- back see Burn, dorsum of hand - dorsum of hand T first degree T left T first degree T second degree T third degree T Conventions Laterality For bilateral sites, the final character of the code indicates laterality If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side Unspecified side is also provided should the side not be identified in the documentation 21

22 Conventions Impending or Threatened Condition- Code any condition described at the time of discharge as impending or threatened as follows: If it did occur, code as confirmed diagnosis. If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for impending or threatened and also reference main term entries for Impending and for Threatened. Conventions Impending or Threatened Condition- If the subterms are listed, assign the given code. If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened. 22

23 Conventions BMI, Non-Pressure Ulcers and Pressure Ulcer Stages- For the Body Mass Index (BMI), depth of non-pressure chronic ulcers and pressure ulcer stage codes, code assignment may be based on medical record documentation from clinicians (nursing/dietary etc.) who are not the patient s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient s diagnosis). However!... Conventions BMI, Non-Pressure Ulcers and Pressure Ulcer Stages- However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient s provider. Conflicting documentation, either from the same clinician or different clinicians, must be queried and clarified by the patient s attending provider 23

24 Conventions Syndromes Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code. Conventions Documentation of Complications of Care Code assignment is based on the provider s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in 24

25 Conventions Documentation of Complication of Care Not all conditions that occur during or following medical care or surgery are classified as complications Must be a cause-and-effect relationship between the care provided and the condition and an indication in the documentation that it is a complication Query the provider for clarification, if the "complication" is not clearly documented. Coders are caution to not assume a complication Conventions Borderline Diagnosis If provider documents borderline diagnosis, code as confirmed unless classification provides a specific entry (e.g., borderline diabetes). Not considered uncertain, so ok to code in outpatient setting If a borderline condition has a specific index entry in ICD-10- CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Query the physician if documentation is unclear regarding a borderline condition. 25

26 AHA Coding Clinic Every effort was made to carry over the ICD-9-CM guidelines and concepts into ICD-10-CM, unless there was a specific change in ICD-10- CM that precluded the incorporation of the same concept into ICD-10-CM. However, some of the guidelines in ICD-9-CM included information that may have been clinical in nature and therefore not appropriate for coding guidelines. However, there are no plans to translate all previous issues of Coding Clinic for ICD-9-CM into ICD-10-CM/PCS since many of the questions published arose out of the need to provide clarification on the use of ICD- 9-CM and would not be readily applicable to ICD-10-CM/PCS Care should be exercised as ICD-10-CM has new combination codes as well as instructional notes that may or may not be consistent with ICD-9-CM. Applying Past Issues of Coding Clinic for ICD-9-CM to ICD-10-CM In general, clinical information and information on documentation best practices published in Coding Clinic were not unique to ICD-9-CM, and remain applicable for ICD-10-CM with some caveats. For example, Coding Clinic may still be useful to understand clinical clues when applying the guideline regarding not coding separately signs or symptoms that are integral to a condition. Users may continue to use that information, as clues not clinical criteria. As far as previously published advice on documentation is concerned, documentation issues would generally not be unique to ICD-9-CM, and so long as there is nothing new published in Coding Clinic for ICD-10-CM and ICD-10-PCS to replace it, the advice would stand. Every attempt was made to remain as consistent with the ICD-9-CM guidelines as possible, unless there was a change inherent to the ICD-10-CM classification. For more information Ref: Coding Clinic, Fourth Quarter 2015: Page 20 26

27 ICD-10.1 There were no new/revised ICD-10-CM diagnosis codes, or changes to ICD-10-CM for FY 2016, because of the partial code set freeze in preparation of ICD-10 implementation. On October 1, 2016 (one year after implementation of ICD-10), regular updates to ICD-10-CM and ICD-10- PCS will begin. So, get ready According to Journal of AHIMA, A total of 1,943 new ICD-10-CM codes were released by the CDC, and 3,651 new ICD-10-PCS codes were released by the Centers for Medicare and Medicaid Services (CMS). In addition to the new codes, the update also includes revisions and deletions. In the ICD-10-CM proposed update, 422 codes were revised and 305 were deleted. In the proposed ICD-10-PCS update, 351 codes were revised and 313 were deleted. Once finalized following a public review period currently underway, the healthcare industry must start using the updated codes by October 1, CC/MCC Changes MDD no longer a CC Malignant HTN no longer MCC Schatzki s ring not MCC Now defaults to Acquired opposite of I-9 Congenital is still an MCC New CCs: Persistent A Fib, Mild malnutrition, nicotine withdrawal 27

28 ICD-10-CM Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) Ref. 1 28

29 Coding Notes: Chapter 1 Term Septicemia not used Streptococcal sore throat moved to Chapter 10, Diseases of the Respiratory System Combination codes (sepsis) Chapter 1 Patient with Sepsis & Septic Shock: Sepsis (generalized) (unspecified organism) A41.9 with organ dysfunction (acute) (multiple) R65.20 with septic shock R65.21 actinomycotic A42.7 adrenal hemorrhage syndrome (meningococcal) A

30 Chapter 1 Patient with Sepsis & Septic Shock: R65.2 Severe sepsis Infection with associated acute organ dysfunction.. Code first underlying infection, such as:.. sepsis NOS A41.9 Use additional code to identify specific acute organ dysfunction, such as: hepatic failure (K72.0-) Coding Guidelines CH 1 Infections Resistant to Antibiotics Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance. 30

31 Chapter 1 Coding Notes: Bacterial and viral infectious agents B95-B97 Note: These categories are provided for use as supplementary or additional codes to identify the infectious agent in diseases classified elsewhere (Optum, 465) (Agent is a similar term to organisms in ICD-9) Chapter 2: Neoplasms (C00-D49) Ref 2 31

32 Chapter 2 Coding Notes: Category of codes for in situ neoplasms is located before category for benign neoplasms 5 th character for extranodal and solid organ locations for lymphomas and Hodgkin s Chapter 2 Example of sites of Lymphomas: C81.7 Other classical Hodgkin lymphoma Classical Hodgkin lymphoma NOS C81.70 Other classical Hodgkin lymphoma, unspecified site C81.71 Other classical Hodgkin lymphoma, lymph nodes of head, face, and neck C81.72 Other classical Hodgkin lymphoma, intrathoracic lymph nodes C81.73 Other classical Hodgkin lymphoma, intra-abdominal lymph nodes ETC.. 32

33 Coding Guidelines CH 2 General guidelines: The Neoplasm table in the alphabetic index should be referenced first. However if the histological (type of cancer) term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. Coding Guideline I.C.2. Coding Guidelines CH 2 (Code to the histology first if specified) Adenocarcinoma-in-situ - see also Neoplasm, in situ, by site breast D05.9- (below is Neoplasm Table) Malignant Malignant ETC Primary Secondary Ca in situ breast C50.9- C79.81 D

34 Coding Guideline CH 2 Primary malignant neoplasm overlapping site boundaries A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code.8 ( overlapping lesion ), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned. Coding Guideline CH 2 Management of dehydration due to malignancy When the encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy. 34

35 Coding Guidelines CH 2 Patient admission solely for Administration of Chemotherapy, Immunotherapy and Radiation Therapy If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Cont d Coding Guidelines CH 2 (cont d) Z Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes maybe assigned, in any sequence. Then, for proper coding, you would code the Neoplasm and/or Malignancy that is being treated, and any additional diagnoses that are appropriate (present & treated/address) 35

36 Chapter 3: Diseases of the Blood and Bloodforming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) Coding Guidelines CH 2 Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first listed diagnosis followed by code D63.0, Anemia in neoplastic disease. ICD-10-CM Official Guidelines for Coding and Reporting 2013, CH 2, c. 1) 36

37 Chapter 4: Endocrine, Nutritional and Metabolic diseases (E00-E89) Ref. 3 Coding Guidelines CH 4 Diabetes Mellitus- The diabetes mellitus codes are combination codes that include the type of diabetes, body system affected, 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. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08-E13 as needed to identify all of the associated conditions that the patient has. 37

38 Coding Guidelines CH 4 Diabetes Mellitus- INDEX: Diabetic - see E08- E13 with.40.. mononeuropathy - see E08- E13 with.41 TABULAR: E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E13.41 Other specified diabetes mellitus with diabetic mononeuropathy (no E12) Chapter 4 Diabetes Mellitus Notes- No longer identified as controlled or uncontrolled Alphabetical index guides coders to assign diabetes, by type, with hyperglycemia Additional code may be used to signify insulin use (Z79.4) Do not use Z79.4 in Diabetes Type 1, where insulin is required for life 38

39 Chapter 4 Type 1 Diabetes Mellitus Also called insulin dependent diabetes mellitus (IDDM) or juvenile diabetes Can occur at any age but usually develops in childhood or adolescence before age 25 Accounts for 10-15% of all cases of DM Acute onset and progresses rapidly Caused by a complete deficiency of insulin resulting from Beta cell destruction Chapter 4 Type 2 Diabetes Mellitus Also known as adult onset diabetes, noninsulin dependent diabetes or maturity onset diabetes Accounts for 80-90% of all cases of diabetes Usually occurs in adults over 40 years of age Onset of symptoms is slow and does not progress rapidly Caused mainly by insufficient insulin secretion by Beta cells due to their destruction 39

40 Chapter 4 Gestational Diabetes Mellitus Is defined as any degree of glucose intolerance, with the onset of pregnancy Is a complication in approximately 4% of the pregnancies in the US Causes increased rate of caesarean section delivery and chronic hypertension Chapter 4 Other Specific Types of Diabetes Mellitus DM of various known reasons are included in this type. Including: diabetes in persons with genetic defects, persons with endocrinopathies, persons with pancreatic dysfunction. Malnutrition may also lead to diabetes and it is common in young malnourished persons in developing countries. 40

41 Coding Guidelines CH 4 Secondary Diabetes Mellitus Codes under category E08, diabetes mellitus due to underlying condition, and E09 Drug or chemical inducted diabetes mellitus, and E13, Other specified diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning. Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders (F01-F99) Ref. 4 41

42 Chapter 5 Drug and Alcohol Use- Specialized codes not identified as abuse or dependence Continuous or episodic use, no longer indicated In remission used to code any history of drug or alcohol dependence Combination codes available for drug and alcohol use and related conditions New code for blood alcohol level (Y90) Chapter 5 Intellectual Disabilities Coding- Sequencing change: In ICD-10-CM any associated physical or developmental disorder should be coded before the intellectually disabled code In ICD-9-CM the associated physical or developmental disorder was/is coded after the intellectually disabled code 42

43 Coding Guidelines CH 5 In Remission Selection of codes for in remission for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider s clinical judgment. The appropriate codes for in remission are assigned only on the basis of provider documentation. Chapter 5 Coding Notes: ICD-10- CM supplies a separate code to identify blood alcohol level R78.0 Finding of alcohol in blood Use additional external cause code (Y90.-), for detail regarding alcohol level. 43

44 Chapter 6: Diseases of the Nervous System (G00-G99) Ref 5 Chapter 6 Terminology for epilepsy has changed Coders will need to familiarize with new terms Myoclonic: Patients have seizure that are brief - the arms, legs, torso, or facial muscles jerk rapidly as though they are being shocked. Status epilepticus: A neurological emergency, prolonged seizures can cause permanent neurological injury or death. Juvenile epilepsy: Epilepsy that starts in childhood or adolescence. Generalized epilepsy: Patients may have myoclonic seizures (sudden and very short duration jerking of the extremities), or absence seizures (staring spells) or generalized tonic-clonic seizures (grand mal seizures). 44

45 Coding Guideline CH 6 Neoplasm Related Pain- Code G89.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy or tumor. This code 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. Cont d. Coding Guidelines CH 6 Neoplasm Related Pain- 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. 45

46 Chapter 7: Disease of the Eye and Adnexa (H00-H59) Ref. 6 Chapter 7 Coding Notes: Codes can include right, left and bilateral and unspecified eye If bilateral is not available and the condition is present in both eyes, a code for each (right and left) must be used Term age-related is used in place of senile to classify type of cataract 46

47 Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) Ref. 1 Chapter 8 Coding Notes: Many codes require additional code for any associated perforated tympanic membrane Also code first any underlying disease 47

48 Chapter 8 H66 Suppurative and unspecified otitis media ADDITIONAL CODE REQUIRED FOR: Any exposure to environmental tobacco smoke (Z77.22) Any exposure to tobacco smoke in the perinatal period (P96.81) History of tobacco smoke (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco use (Z72.0) Chapter 9: Diseases of the Circulatory System (I00-I99) Ref. 2 48

49 Coding Guidelines CH 9 Hypertensive Heart and Chronic Kidney Disease Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. If heart failure is present, assign an additional code form category I50 to identify the type of heart failure. Chapter 9 Myocardial infarction- REALLY BIG CHANGE!!! Time frame for AMI codes: 4 weeks or less (Not 8 weeks or less as in ICD-9) Also now codes for AMI s (I21) and subsequent AMI s (I22) 49

50 Coding Guidelines CH 9 ST Elevation Myocardial Infarction (STEMI) and Non-ST Elevation Myocardial Infraction (NSTEMI) If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as a STEMI. Coding Guidelines CH 9 AMI documented as nontransmural or subendocardial but site provided- If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded to subendocardial AMI. Bottom line: If documented as subendo code as subendo 50

51 Coding Guidelines CH 9 Subsequent acute myocardial infarction A code from category I22, Subsequent ST elevation (STEMI) and non-st elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. Chapter 9 Sequencing of I22 (subsequent) and I21 (acute) Example: A patient admitted for AMI has subsequent AMI while still in hospital. Code: -I21 - Principal diagnosis -I22 Secondary code 51

52 Coding Guidelines CH 9 Atherosclerotic Coronary Artery Disease and Angina ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7 Atherosclerosis of coronary artery bypass graft and coronary artery of transplanted heart with angina pectoris. Chapter 9 Example of CAD with Angina Pectoris ICD-9: CAD/413.9 Angina Pectoris ICD-10: I Arteriosclerotic heart disease of native coronary arteries, with angina pectoris **Disease, artery, coronary WITH angina pectoris 52

53 Coding Guidelines CH 9 Category I69, Sequelae of Cerebrovascular Disease Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. These late effects include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67. Chapter 9 Example of Sequelae- ICD-9: Late Effect of CVA Aphasia ICD-10: Late Effect SEE Sequelae I Sequelae, CVA - Aphasia **Sequelae, Disease, Cerebrovascular, Aphasia 53

54 Chapter 10: Diseases of the Respiratory System (J00-J99) Ref. 3 Chapter 10 Updated medical terminology- J45 - Asthma Now classified as: mild intermittent mild persistent moderate persistent severe persistent other and unspecified 54

55 Chapter 10 Coding Notes: Excludes 2 note appears under category J45- Asthma If an Excludes 2 note is represented under a code, it is admissible to use both code and excluded code consecutively if the patient has both conditions at same time Chapter 10 Coding Notes: Individual codes now available for acute recurrent sinusitis for each sinus Example: J01.11 Acute recurrent frontal sinusitis J01.21 Acute recurrent ethmoidal sinusitis 55

56 Chapter 10 Coding Notes: If respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site. For example: (tracheobronchitis to bronchitis in J40) Source: ICD10-CM, The Complete Official Draft Code Set, 2013 (p.627) Chapter 10 Coding Notes: Code first the underlying disease Code also any associated lung abscess Use additional code to describe the infectious agent or virus Use additional code for associated pleural effusion Use additional code (s) to describe other conditions such as tobacco use or exposure ICD-10-CM, The Complete Official Draft Code Set, 2013, Optum 56

57 Chapter 11: Diseases of the Digestive System (K00-K95) Ref. 4 Chapter 11 Important Note- Term hemorrhage is used when indentifying ulcers Term bleeding is documented when classifying gastritis, duodenitis, diverticulosis, and diverticulitis K25.0- Acute gastric ulcer with hemorrhage K Acute gastritis with bleeding K Diverticulosis of large intestine without perforation or abscess with bleeding 57

58 Chapter 11 Coding Notes: Increased specificity is needed to select codes in Chapter 11 Example: K50._ Crohn s disease Must be documented with or without complications including: -rectal bleeding -intestinal obstruction -fistula -abscess Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) Ref

59 Chapter 12 Coding Notes: Increased instructional notes Addition of laterality Category L89 Pressure ulcer, now classifies by: -Site -Laterality -Severity Coding Guidelines CH 12 Pressure Ulcer Stages- Codes from category L89, Pressure ulcer, are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer. ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage and unstageable. Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable. 59

60 Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) Ref. 6 Coding Guidelines CH 13 Site and Laterality Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a multiple sites code available. For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved. 60

61 Chapter 13 7 th character extensions are required for classification in pathological fracture: A-Initial encounter for fracture D-Subsequent encounter for fracture with routine healing G-Subsequent encounter for fracture with delayed healing K-Subsequent encounter for fracture with nonunion P-Subsequent encounter for fracture with malunion S-Sequela Chapter 13 7 th Character extensions- Definitions- 7 th Character A- indicates current treatment Examples: -Surgical procedure -ER visit -Evaluation and treatment by a new clinician 61

62 Chapter 13 Definitions- 7 th Character D- indicates encounters post active Examples: -Cast change or removal -Extraction of fixation device -Medication alteration -Other aftercare and follow-up encounters Chapter 13 Coding Notes: Three ways to classify pathological fractures- As a result of neoplastic disease Resulting from osteoporosis Caused by other specified disease 62

63 Coding Guidelines CH 13 Osteoporosis with current pathological fracture Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathological fracture at the time of the encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. Chapter 14: Diseases of the Genitourinary System (N00-N99) Ref. 7 63

64 Coding Guidelines CH 14 Chronic kidney disease and kidney transplant status Patients who have undergone kidney transplant may still have some form of chronic kidney disease CKD because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient s stage of CKD and code Z94.0, Kidney transplant status. Coding Guidelines CH 14 Chronic kidney disease and kidney transplant status If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider. 64

65 Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) Ref Chapter 15 Terminology ICD-10-CM uses Sequelae to indicate something following or comes later Example: ICD-10 CM, code O94, Sequelae of complication pregnancy, childbirth and the puerperium

66 Chapter 15 Time frame changes for ICD-10-CM Fetal death now classified as after 20 completed weeks of gestation Example: O36.4xx_- Maternal care for intrauterine death Abortion now classified as before completion of 20 weeks gestation Example: Code O02.1- Missed abortion 131 Chapter 15 Time frame changes for ICD-10-CM Early vomiting now classified as starting before the end of the 20 th week gestation Example: O21.0 Mild hyperemesis gravidarum Late vomiting now classified as starting after 20 completed weeks gestation Example: O21.2 Late vomiting of pregnancy

67 Chapter 15 Time frame changes for ICD-10-CM- Preterm labor classified as before 37 completed weeks of gestation Example: O60.10x0- Preterm labor with preterm delivery, unspecified trimester 133 Chapter 15 Coding Notes: Axis of classification now trimester in which condition happened NOT episode of care Trimesters classified as: 1 st trimester less than 14 weeks gestation 2 nd trimester 14 weeks to 28 weeks gestation 3 rd trimester 28 weeks through delivery

68 Chapter 15 Changes in final character for trimester- Final character in code will identify trimester No longer used are antepartum, postpartum and if a delivery occurred Clinician documentation should indicate final character assignment Use in childbirth when delivery takes place during the current admission 135 Chapter 15 Obstruction of labor- Combination codes- obstructed labor codes now incorporate the cause of the obstruction into one code Examples: ICD-9-CM and Obstructed labor due to face presentation ICD-10-CM- Subcategory O64.2 Obstructed labor due to face presentation

69 Chapter 15 Unspecified trimester Codes are available for unspecified trimester but should only be used when not indicated in documentation 137 Chapter 15 Seventh character needed to classify each fetus in multiple gestations 0 not applicable or unspecified 1 fetus 1 2 fetus 2 3 fetus 3 4 fetus 4 5 fetus 5 9 other fetus

70 Chapter 15 New 7 th character for fetus identification 7 th character required for several categories to identify fetus which condition is applicable Assign 0 Single gestations Insufficient documentation to identify fetus affected and query is not possible Clinically impossible to know which fetus is affected 139 Chapter 15 Outcome of delivery code- Code from category Z37, outcome of delivery must be indicated in maternal record when delivery has happened Examples: ICD-10-CM Z37.0 Single live birth

71 Weeks of gestation code- Chapter 15 Codes from category Z3A Weeks of gestation, must be indicated on mother s record to identify weeks of gestation in pregnancy. 141 Chapter 15 Abuse in a pregnant patient- Subcategories- O9A.3_ -Physical abuse complication pregnancy, childbirth and the puerperium O9A.4_ -Sexual abuse complication pregnancy, childbirth and the puerperium O9A.5_-Psychological abuse complicating pregnancy, childbirth and the puerperium

72 Chapter 16: Certain Conditions Originating in the Perinatal period (P00-P96) Ref Chapter 16 Coding Notes: Perinatal period classified as before birth through the first 28 days after birth Chapter 16 codes are only used on newborn records NEVER in the mother s record

73 Terminology Chapter 16 Term fetus not used in ICD-10-CM Newborn is correct term 145 Coding Guidelines CH 16 Bacterial sepsis of the newborn- Category P36, bacterial sepsis of the newborn, includes congenital sepsis. If a perinate is documented as having sepsis without documentation of congenital or community acquired, the default is congenital and a code from category P36 should be assigned. Cont d

74 Coding Guidelines CH 16 Bacterial sepsis of the newborn- If the P36 code includes the causal organism, an additional code from category B95. Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, should not be assigned. If the P36 code does not include the causal organism, assign an additional code from category B96. If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction. 147 Coding Guidelines CH 16 Principal diagnosis for Birth Record- When coding the birth episode in a newborn record, assign a code from category Z38, Liveborn infants according to the place of birth and type of delivery, as the principal diagnosis. A code from Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital. A code from category Z38 is used only on the newborn record, not on the mother s record

75 Coding Guidelines CH 16 Prematurity and Fetal Growth Retardation Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless it is documented. Assignment of codes in categories P05, Disorders of the newborn related to slow fetal growth and fetal malnutrition and P07 Disorders of the newborn related to short gestation and low birth weight, not elsewhere classified, should be based on the recorded birth weight and estimated gestational age. Codes from category P05 should not be assigned with codes from category P Coding Guidelines CH 16 Prematurity and Fetal Growth Retardation- When both birth weight and gestational age are available, two codes from category P07 should be assigned, with the code for birth weight sequenced before the code for gestational age

76 Coding Notes: Chapter 16 If both birth weight and gestational age of newborn are documented, both must be coded Birth weight sequenced before gestational age 151 Stillbirth- Chapter 16 Code P95 Only for use in facilities that create and maintain separate records for stillbirth Code P95 must be used alone Never used on the maternal record

77 Chapter 17: Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99) Ref Chapter 17 Updated terminology- Example: Subcategory Q61 Cystic kidney disease Q61.0_ Congenital renal cyst Q61.1_ Polycystic kidney, infantile type Q61.2 Polycystic kidney, adult type

78 Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, NEC (R00-R99) Ref Coding Guideline 1.B.4/5 Codes for symptoms and signs 4. Codes that describe symptoms and signs Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established/confirmed by the provider. 5. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification

79 Coding Guidelines CH 18 Coma Scale- The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code (s). These codes, one from each subcategory, are needed to complete the scale. The 7 th character indicates when the scale was recorded. The 7 th character should match for all three codes. Cont d 157 Coding Guidelines CH 18 Coma Scale- At a minimum report the initial score documented on presentation your facility. This may be a score from the emergency medicine technician (EMT) or the emergency department. If desired, a facility may choose to capture multiple coma scale scores. Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score (s)

80 Coma Scale- Chapter 18 Subcategory examples: R40.21_ Coma scale, eyes open R40.22_ Coma scale, best verbal response R40.23_ Coma scale, best motor response 7 th character required for codes in subcategories R40.211_, Coma scale, eyes open, never R _, Coma scale, best verbal response, none R _, Coma scale, best motor response, none 159 Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) Ref

81 Specificity challenges: Chapter 19 Inclusion of the term corrosion Underdosing Terminology displaced and nondisplaced Increased specificity for fractures Fractures require seventh character extension Gustilo open fracture classification Combination codes 161 Chapter 19 Use of terms displaced or nondisplaced Fractures not documented as displaced or nondisplaced must be coded to displaced Fractures not indicated as open or closed must be classified to closed

82 Chapter 19 Coding fractures in ICD-10-CM Documentation needed for correct coding of fractures: - specific type of fracture -anatomical site -displaced or nondisplaced -laterality -delayed or routine healing -nonunions -malunions 163 Chapter 19 Seventh character extension used in fractures- 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 P-subsequent encounter for fracture with malunion S-sequela

83 Chapter 19 Seventh character extension for open fractures- Certain fracture categories provide 7 th character extensions based on Gustilo open fracture classification to identify particular type of open fracture Examples: B- used for initial encounter for open fracture type I or II (initial encounter for open fracture NOS) C- initial encounter for open fracture type IIIA, IIIB, IIIC 165 Coding Guidelines CH 19 Application of 7 th Characters in Chapter 19 Most categories in Chapter 19 have a seventh character requirement for each applicable code. Most categories in this chapter have three 7 th character values (with the exception of fractures) A-initial encounter D-subsequent encounter S-sequela Categories for traumatic fractures have additional 7 th character values

84 Coding Guidelines CH 19 Initial vs. Subsequent Encounter for Fractures Traumatic fractures are coded using the appropriate 7 th character for initial encounter (A,B,C) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. The appropriate seventh character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. 167 Coding Guidelines CH 19 Initial vs. Subsequent Encounter for Fractures Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7 th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R)

85 Coding Guidelines CH 19 Adverse effects, Poisoning, Underdosing and Toxic Effects Codes in categories T36-T65 are combination codes that include the substance that was taken as well as the intent. No additional external cause code is required for poisonings, toxic effects, adverse effects, and underdosing codes. 169 Coding Guidelines CH 19 Adverse Effect When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). The code for the drug should have a 5 th or 6 th character 5 (for example T36.0X5-) Examples of the nature of an adverse effect are tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure

86 Coding Guidelines CH 19 Underdosing Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer s instruction. For underdosing, assign codes from categories T36-T50 (fifth or sixth character 6). Cont d. 171 Coding Guidelines CH 19 Underdosing Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded. Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known

87 Coding Guidelines CH 19 Superficial injuries Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site. 173 Chapter 20: External Causes of Morbidity (V00-Y99) Ref

88 Coding Guidelines CH 20 External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred the activity of the patient at the time of the event, and the person s status (e.g., civilian, military). 175 Coding Guidelines CH 20 Place of occurrence Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify the location of the patient at the time of injury or other condition. A place of occurrence code Y92 is used only once, at the initial encounter for treatment. No 7 th characters are used for Y92. Only one code from Y92 should be recorded on a medical record. A place of occurrence code should be used in conjunction with an activity code, Y

89 Coding Guideline CH 20 Activity Code Assign a code from category Y93, Activity code, to describe the activity of the patient at the time the injury or other health condition occurred. An activity code Y93 is used only once, at the initial encounter for treatment. Only one code from Y93 should be recorded on a medical record. An activity code should be used in conjunction with a place of occurrence code, Y Coding Guidelines CH 20 External Cause Code Used for Length of Treatment Assign the external cause code with the appropriate seventh character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated

90 Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) Ref Chapter 21 Coding Notes: ICD-10-CM has extended personal and family history coding Codes have been added to specify blood type No longer used ICD 9-CM Category V57 Care involving use of rehabilitation procedures Instead in ICD-10-CM- code condition that necessitated therapy with appropriate 7 th character for subsequent encounter

91 Coding Guidelines CH 21 Status Post Administration of tpa in a Different Facility Within the Last 24 Hours Prior to Admission to a Current Facility Assign code Z92.82, Status post administration of tpa in a different facility within the last 24 hours prior to admission to the current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator with the last 24 hours prior to admission to the current facility. Cont d 181 Coding Guidelines CH 21 Status Post Administration of tpa (rtpa) in a different facility within the last 24 hours prior to admission to a current facility This guideline applies even if the patient is still receiving tpa at the time they are received into the current facility. The appropriate code for the condition for which the tpa was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first. Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record

92 Chapter 21 Coding Notes: ICD-10-CM Z codes for aftercare must not be used for fracture When coding aftercare of a fracture, assign the acute fracture code with the seventh character extension of D, subsequent encounter 183 References AHA Coding Clinic ICD 10 CM and PCS Coding Handbook 2016 ICD-10-PCS: An Applied Approach, 2015, Kuehn, Lynn 2015 Official ICD-10-PCS Coding Guidelines and Code Tables. AHIMA ICD-10-CM/PCS Documentation Tips. Ref 1: Ref 2: Ref 3: D00014.png Ref 4: Ref 6: Ref 7: 10+images&rlz=1C1EODB_enUS584US586&espv=2&biw=1366&bih=667&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahU KEwjl_v_gzdnLAhUT2GMKHXMgBngQ_AUIBigB#tbm=isch&q=icd-10+questions+images&imgrc=8i2o71Xrf8px4M%3A 92

93 References ICD-10 CM official coding International Classification of Disease, tenth revision, Clinical Modification (ICD-10CM) ICD-10-CM Training Manual AHIMA ICD-10-CM The Complete Official Draft Code Set, Optum, 2013 ICD-10-CM Official Guidelines for Coding and Reporting 2013 Reference 1: Reference 2: Reference 3: Reference 4: Reference 5: Reference 6: Reference 7: References ICD-10 CM official coding ICD-10-CM Training Manual AHIMA ICD-10-CM Official Guidelines for Coding and Reporting 2013 ICD-10-CM The Complete Official Draft Code Set 2013, Optum Reference 1: Reference 2: Reference 3: Reference 4: Reference 5: Reference 6: Reference 7: Reference 8: 93

94 References ICD-10 CM official coding ICD-10-CM Coder Training Manual-AHIMA ICD-10-CM The Complete Official Draft Code Set, Optum, 2013 Reference 1: Reference 2; Reference 3: Reference 4: Reference 5: Reference 6: Reference 7: Reference 8: Thank you! [email protected] and [email protected] Ref 6 94