ICD-10-CM Training for the Most Common Diagnosis

Transcription

1 ICD-10-CM Training fr the Mst Cmmn Diagnsis Presented by Inland Empire Health Plan Debra Bales, LVN, CPC Jnay Rischer, BSHA, CPC Vilma Smith, LVN, CPC, CCS, AHIMA Apprved ICD-10-CM/PCS Trainer 1 Revised July, 2015

2 Medical Cding Currently, HIPAA requires cvered entities t reprt healthcare data using ne r mre f the fllwing three cdes sets: ICD-9-CM diagnsis cdes Used by all healthcare prviders in all settings ICD-9-CM prcedure cdes Limited t inpatient medical interventins/prcedures Current Prcedural Terminlgy (CPT) cdes Used t identify medical services and prcedures furnished in the utpatient setting 2

3 Medical Cding Octber 1, 2015 ICD-10-CM/PCS All settings will use ICD-10-CM HCPCS/CPT are used in the utpatient setting which is billed t Medicare Part B ICD-10-PCS will be used in the inpatient setting, which is billed t Medicare Part A Prviders will cntinue t dcument and bill HCPCS/CPT cdes as there will cntinue t be annual updates t these cdes sets 3

4 HIPAA: Transactin and Cde Set Rule Adherence t ICD-10-CM/PCS cding guidelines is required under the Health Insurance Prtability and Accuntability Act (HIPAA) Cding guidelines require a cde be reprted t the highest specificity, but specificity will nt always translate int higher reimbursement 4

5 ICD-10 Clinical Mdificatin A Clinical Mdified versin f the Internatinal Classificatin f Disease (ICD) in its 10 th revisin, as develped by the Wrld Health Organizatin (WHO), will be implemented Octber 1, 2015 fr general use by the United States healthcare industry fr the purpse f reimbursement and reprting f healthcare data as mandated under HIPAA ICD-10-CM is nly a disease classificatin system and des nt include classificatin f inpatient prcedures ICD-10-PCS (Prcedure Cding System) replaces vlume III f ICD-9-CM It is unique t the United States. Additinally, ther cuntries have created a prcedural cding system t accmpany the ICD-10 diagnsis cde set ICD-10-PCS has its wn fficial cding guidelines 5

6 ICD-10 Implementatin ICD-10-CM The new diagnsis cding system Develped as a replacement fr ICD-9-CM, vlumes 1 & 2 (Diagnsis cdes) 2015 cde set includes 69,000+ diagnses cdes (increase frm 15,000+ in 2014) Implementatin date: Octber 1, 2015 Accrding t CMS, the transitin t ICD-10 is required fr everyne cvered by the Health Insurance Prtability Accuntability Act (HIPAA). In additin, CMS indicated that the change t ICD-10 will nt affect CPT cding fr utpatient prcedures and physician services. Please refer t CMS fr further ICD-10 updates 6

7 ICD-10 Implementatin ICD-10-CM ICD-9-CM cdes will nt be accepted fr services prvided n r after Octber 1, 2015 ICD-9-CM claims fr services rendered prir t the implementatin date will cntinue t prcess fr an undetermined perid f time There will be NO grace perid se/press-releases/2015-press-releases-items/ html#} 7

8 Benefits f Transitining t ICD-10-CM Benefits f Transitining t ICD-10-CM Prvides greater specificity and expansin f the cding system Prvides cde titles and language that cmplement accepted clinical practice Includes emerging diseases and mst recent medical knwledge alng with new cncepts Prvides mre detailed infrmatin t prviders, payers and plicy makers Imprves the delivery and quality f healthcare services Mnitrs resurce utilizatin Prevents and detects healthcare Fraud, Waste and Abuse (FWA) Tracks public health and risks 8

9 ICD-10-CM FORMAT & STRUCTURE ICD-10-CM FORMAT & STRUCTURE Cmparing Cmparing ICD-9-CM ICD-9-CM and and ICD-10-CM ICD-10-CM ICD-9-CM Cnsists f 3-5 digits First digit is numeric r alpha (E r V) Secnd, third, furth, & fifth digits are numeric Always at least three (3) digits Use f decimal after 3 digits ICD-10-CM Cnsists f 3-7 characters First (1 st ) character is always an alpha (all letters used except U ) Secnd (2 nd ) character always numeric Characters 3 thru 7 can be an alpha r numeric Decimal placed after the first 3 characters Use f dummy placehlder X, t allw fr future expansin Alpha characters are nt case-sensitive 9

10 ICD-10-CM Frmat & Structure ICD-10-CM: Alpha-numeric (A-Z) except fr the letter U Reserved by the Wrld Health Organizatin (WHO) fr the prvisinal assignment f: New diseases f uncertain etilgy (U00-U49) Fr bacterial agents resistant t antibitics (U80-U89) Minimum: 3 characters Maximum: 7 characters Decimal Pint: Yes 10

11 ICD-10-CM Structure-Frmat ICD-10-CM Frmat & Structure Cnsists f 3-7 Characters Examples: I10 Hypertensin (accelerated, malignant, benign) S32.010A (Wedge cmpressin fracture f first Lumbar vertebrae, initial encunter fr clsed fracture) O9A.211 (Injury, pisning and certain ther cnsequences f external causes cmplicating pregnancy, First Trimester 11

12 ICD-10-CM FORMAT & STRUCTURE Cmparing ICD-9-CM and ICD-10-CM ICD-9-CM Cnsists f 17 Chapters Disease and cnditins f the sense rgans (eyes and ears) included in the nervus system disease Classifies injuries by type rather than by anatmical site ICD-10-CM Cnsists f 21 Chapters Disease and cnditins f the sense rgans (eyes and ears) have their wn chapters Injuries are gruped by anatmical site (e.g., head, arm, leg) and then by type f injury (e.g., fracture, pen wund) Pstperative cmplicatins have been mved t prcedure-specific bdy system Certain diseases have been reassigned t a mre apprpriate chapter (e.g., Gut = reclassified frm the endcrine chapter t the musculskeletal chapter) Cdes reflect current medical knwledge and mdern medicine 14

13 Cde Structure f ICD-10-CM versus ICD-9-CM ICD-9 ICD-10 ICD-9-CM Cde Frmat ICD-10-CM Cde Frmat categry etilgy, anatmic site, manifestatin categry etilgy, anatmic site, manifestatin extensin 13

14 ICD-10-CM Frmat & Structure Review Questins: 1. The final rule t adpt ICD-10-CM & ICD-10-PCS states the cmpliance date fr ICD-10 is: A. August 1, 2015 B. Octber 1, 2015 C. January 1, 2016 D. Octber 1, 2016 Answer: B. Octber 1, 2015 Ratinale: The new cmpliance date fr implementatin is Octber 1, 2015 Please check ut CMS website fr ICD True r False? V and E cdes are supplemental classificatins in ICD-10-CM. Answer: False Ratinale: There are n supplemental classificatins in ICD-10-CM. The V and E cdes fund in ICD-9-CM have separate chapters in ICD-10-CM, chapter 20 & 21, respectively 3. What is the maximum number in f characters in ICD-10-CM? Answer: 7 Ratinale: Seven (7) is the maximum number in ICD-10-CM. ICD-10-CM cdes range in length frm three t seven characters 14

15 ICD-10-CM Frmat & Structure Review Questins: 4. Hw many chapters des ICD-10-CM cntain? Answer: 21 Ratinale: ICD-10-CM cntains 21 chapters as ppsed t the 17 chapter in ICD-9-CM 5. Gut is classified t the chapter in ICD-10-CM A. Certain infectius and parasitic disease B. Endcrine, nutritinal and metablic disease C. Musculskeletal system and cnnective tissue D. Symptms, signs and abnrmal clinical labratry findings, NEC Answer: C. Musculskeletal system and cnnective tissue Ratinale: Gut is classified t the Musculskeletal system and cnnective tissue chapter in ICD-10-CM. In ICD-9-CM, gut is classified t the Endcrine, Nutritinal and Metablic Diseases chapter 15

16 ICD-10-CM Frmat & Structure Review Questins: 6. True r False? In ICD-10-CM, injuries are gruped by anatmical site rather than injury categry. Answer: True Ratinale: This is ppsite t what is currently fund in ICD-9-CM 7. All f the fllwing are structural differences between ICD-9-CM and ICD-10-CM except: A. Additin f 6 th character in sme chapters B. Additin f placehlder C. Disease and cnditins f the eyes and ears are classified in the same chapters as diseases f the nervus system D. Pstperative cmplicatins have been mved t prcedure-specific bdy system chapters Answer: C. Diseases and cnditins f the eyes and ears are classified in the same chapters as disease f the nervus system Ratinale: In ICD-10-CM, the eyes and ears are split ut int their wn chapters and are n lnger classified in the same chapter with the nervus system 16

17 ICD-10-CM Frmat & Structure Review Questins: 8. True r False? The United States is the nly industrialized natin that has nt yet implemented ICD-10-CM? Answer: True Ratinale: The United States is the nly industrialized natin that has nt yet implemented ICD-10 r a clinical mdificatin f ICD-10. Fr example, Australia implemented ICD-10 in 1998 and Canada in Which f the fllwing is a true statement regarding ICD-10-CM cdes? A. N decimals are used B. The first character is always an alpha C. Cnsist f three t five characters D. The secnd and third characters are always numeric Answer: B. The first character is always an alpha Ratinale: The first character f an ICD-10-CM cde is always an alphabetic letter. All ther statements are false because ICD-10-CM cdes d have a decimal placed after the first three characters 17

18 New Features in ICD-10-CM Features in ICD-10-CM allw fr a greater level f specificity and clinical detail Cmbinatin Cdes fr cnditins and cmmn symptms r manifestatins Examples: Case Example: What is the crrect diagnsis cding fr a patient with crnary artery disease (CAD) with angina? The patient has n previus histry f CABG. Answer: I Athersclertic heart disease f native crnary artery with unspecified angina pectris Ratinale: A causal relatinship can be assumed in a patient with bth athersclersis and angina, unless the dcumentatin indicates the angina is due t smething ther than the CAD ICD-10-CM Cde I I K71.51 Descriptin Athersclertic heart disease f native crnary artery with angina pectris with dcumented spasm Athersclertic heart disease f native crnary artery with unstable angina pectris Txic liver disease with chrnic active hepatitis with ascites K Crhn s disease f small intestine with intestinal bstructin 18

19 New Features in ICD-10-CM Cmbinatin cdes fr pisnings and external causes: Case Example: A tddler is seen emergently fr nausea and vmiting after an accidental verdse f acetaminphen. He inadvertently ate several f these when he fund an pen bttle at hme. What is the crrect diagnsis cde(s)? D nt assign external cause cdes Answer: T39.1X1A Pisning by 4-Aminphenl derivatives, accidental (unintentinal), initial encunter R11.2 Nausea with vmiting, unspecified Cmbinatin Cdes fr pisnings and external causes Examples: ICD-10-CM Cde T36.0x1D R11.2 T39.1x4A Descriptin Pisning by Penicillin, accidental (unintentinal), subsequent encunter Nausea with vmiting, unspecified Pisning by 4-Aminphenl derivatives, accidental (undetermined), initial encunter Ratinale: The 7 th character is used with pisning cdes in ICD-10-CM. Manifestatins f pisnings shuld be assigned as an additinal cde R11.2 Nausea with vmiting, unspecified 19

20 New Features in ICD-10-CM Added laterality Added laterality Examples: Case Example: What is the crrect ICD-10-CM cde fr acute nnsuppurative titis media, right ear? Answer: H Acute nnsuppurative titis media f the right ear ICD-10-CM Cde H H Descriptin Chrnic allergic titis media, right ear Chrnic allergic titis media, left ear Ratinale: H is the crrect cde fr acute nnsuppurative titis media f the right ear. The sixth character f the cde indicates the right ear H Other acute nnsuppurative titis media, recurrent, right ear 20

21 New Features in ICD-10-CM Added seventh-characters fr episde f care Added seventh-characters fr episde f care Examples: Case Example: An 85 year ld patient is being treated fr a pathlgical fracture f the right humerus due t severe senile steprsis. This fracture was previusly diagnsed during an acute-care hspital stay. Assign the crrect cde(s) Answer: M80.021D Age-related steprsis with current pathlgical fracture, right humerus, subsequent encunter fr fracture with rutine healing Ratinale: The seventh character D is used in this case because this is a subsequent encunter Fr the pathlgical fracture with rutine healing. There is n dcumentatin f delayed healing, nnunin, r malunin ICD-10-CM Cde M80.051A M80.031D S52.132B Descriptin Age-related steprsis with current pathlgical fracture, right femur, initial encunter fr fracture Age-related steprsis with current pathlgical fracture, right frearm, subsequent encunter fr fracture with rutine healing Displaced fracture f neck f left radius, initial encunter fr pen fracture type I r II, initial encunter fr pen fracture NOS 21

22 New Features in ICD-10-CM New Features in ICD-10-CM Expanded cdes (injuries, diabetes, alchl and substance abuse, pstperative cmplicatins) Case Example: Expanded cdes fr injuries, diabetes, alchl and substance abuse, pstperative cmplicatins ICD-10-CM Cde Examples: Descriptin A 38 year ld female is seen in phthalmlgy fr nging diabetes related eye prblems. Patient experienced nset f Type I diabetes mellitus at age seven. Final diagnsis: Advance t mderate nnprliferative retinpathy with macular edema, right eye. Answer: E (Type I diabetes mellitus with mderate nnprliferative diabetic retinpathy with macular edema) Ratinale: A cmbinatin cde captures the Type1 diabetes mellitus, the bdy system affected (eye) and the specific cmplicatin ( macular edema) E F K Type 2 diabetes with mderate nnprliferative diabetic retinpathy with macular edema Sedative, hypntic r anxilytic dependence with withdrawal delirium Pst prcedural hemrrhage and hematma f a digestive system rgan r structure fllwing a digestive system prcedure 22

23 New Features in ICD-10-CM New Features in ICD-10-CM Inclusin f trimesters in bstetrics cdes and eliminatin f 5 th digits fr episde f care Case Example: A 30 year ld female, wh is G4, P3, 28 weeks, is seen tday in the clinic fr cntinued fllw-up f her gestatinal diabetes. Her diabetes has been well cntrlled n ral medicatins. What is the crrect diagnsis cde? Answer: O Gestatinal diabetes mellitus in pregnancy, unspecified cntrl Nte add: Z3A weeks gestatin f pregnancy Ratinale: The 6 th character indicates the type f cntrl (namely, diet r insulin) fr the gestatinal diabetes. ICD-10-CM des nt prvide a specific 6 th character fr cntrl with ral medicatin; therefre, the unspecified cntrl cde is used. Inclusin f trimesters in bstetrics cdes and eliminatin f episde f care Examples: ICD-10-CM Cde O O O O Descriptin Pre-existing essential hypertensin cmplicating pregnancy, first trimester Gestatinal diabetes mellitus in pregnancy, unspecified cntrl Anemia cmplicating pregnancy, secnd trimester Other infectins with a predminantly sexual mde f transmissin cmplicating pregnancy, secnd trimester 23

24 New Features in ICD-10-CM Changes in time frames specified in certain cdes Case Examples: Time frame changed frm 22 weeks t 20 weeks Fetal Death vs. Abrtin 27 year ld female cmes t ER with severe lwer abdminal pain and bleeding. She says she is 19 weeks pregnant and saw her OB 2 days ag, she has nt felt mvement in a 24hur perid. Answer: Z3A weeks gestatin f pregnancy O20.1 Cmplete Abrtin 19 year ld female presents in her OB ffice fr ultrasund fr dates. Ultrasund shws patient is 19 weeks + 4 days. Patient has decided she wants an abrtin. Patient is scheduled fr surgery in 2 days. Answer: Z33.2 Elective terminatin f pregnancy 24

25 New Features in ICD-10-CM Changes in time frames specified in certain cdes Changes in time frames specified in certain cdes Example: Case Example: A 54 year ld female is being treated fr an acute nn- ST anterir wall mycardial infarctin which she suffered 5 days ag. She als has atrial fibrillatin. What is the crrect diagnsis cde(s)? Answer: I21.4 Nn-ST elevatin (NSTEMI) mycardial infarctin I48.91 Unspecified atrial fibrillatin Ratinale: Per the Official Cding Guidelines, If an AMI is dcumented as nntransmural r subendcardial, but the site is prvided, it is still cded as subendcardial AMI. Cding Guideline I.C.9.e.3 Diagnsis Acute mycardial infarctin Changes in time frames Time perid changed frm 8 weeks t 4 weeks 25

26 New Features in ICD-10-CM Changes in time frames specified in certain cdes Changes in time frames specified in certain cdes Example: Case Example: The same patient presented t the ER 2 weeks later and was diagnsed with an acute inferir wall MI. She is still being mnitred fllwing her initial heart attack 2 weeks earlier and cntinues t have atrial fibrillatin. She will be transferred t a larger facility fr cardiac catheterizatin and pssible further interventin. What diagnsis cde(s) are assigned? Answer: I22.1 = Subsequent ST elevatin (STEMI) mycardial infarctin f inferir wall I21.4 = Nn-ST elevatin (NSTEMI) mycardial infarctin I48.91 = Unspecified Atrial Fibrillatin Diagnsis Acute mycardial infarctin Changes in time frames Time perid changed frm 8 weeks t 4 weeks Ratinale: The Official Cding Guidelines, A Subsequent ST elevatin (STEMI) and nn-st elevatin (NSTEMI) MI is t be used when a patient wh has suffered an AMI has a new AMI within the 4 week time frame f the initial AMI. Cding Guideline I.C.9.e.4 26

27 New Features in ICD-10-CM Added standard definitins fr tw (2) types f excludes ntes Type f excludes Excludes1 Excludes2 Definitin NOT CODED HERE The cde being excluded is never used with the cde. The 2 cnditins cannt ccur tgether. NOT INCLUDED HERE The excluded cnditin is nt part f the cnditin represented by the cde. It is acceptable t use bth cdes tgether if the patient has bth cnditins Example ICD-10-CM DESCRIPTION COMMENT B06 B18.2 Rubella (German Measles) Chrnic viral hepatitis C J04.0 Acute laryngitis Rubella r German measles cannt ccur tgether with cngenital rubella syndrme (P35.0) Chrnic viral hepatitis C cannt ccur tgether with Sequela f viral hepatitis (B94.2) If the prvider dcumented Acute & chrnic laryngitis. It is acceptable t use bth cdes fr acute laryngitis (J04.0) and chrnic laryngitis (J37.0) 27

28 New Features in ICD-10-CM Review Questins: 1. Hw are bstetric cases classified in ICD-10-CM? Answer: By trimester Ratinale: Episde f Care is n lnger classified in ICD-10-CM 2. True r false? When an Excludes2 nte appears under a cde, it is acceptable t use bth the cde and the excluded cde tgether. Answer: True Ratinale: An excludes2 nte indicates that the cnditin excluded is nt part f the cnditin represented, but a patient may have bth cnditins at the same time. 3. A nte means NOT CODED HERE A. Includes B. Excludes2 C. Excludes1 D. Nne f the abve Answer: C. Excludes1 Ratinale: An Excludes1 nte indicates that the cde excluded shuld never be used at the same time as the cde abve the Excludes1 nte. 28

29 ICD-10-CM Dcumentatin Medicare specifically requires that all services be supprted by cmplete dcumentatin t validate cdes submitted The Office f Inspectr General (OIG) fund in ne year that 43.7% f errrs were due t dcumentatin insufficiencies, psing a significant cmpliance risk OIG target is EMR Clning and Security 29

30 ICD-10-CM Dcumentatin Examples f General Dcumentatin Requirements Increased site specificity Laterality (right, left, bilateral) Cmbinatin cdes that capture: Etilgy and Manifestatins Fr the purpse f HCC the prvider must dcument etilgy and manifestatins n the same prgress nte in rder t capture the cmbinatin cdes. Related cnditins; (i.e. HTN and CKD) Disease, injury r ther medical cnditin r cmplicatins Diseases r ther medical cnditins and cmmn signs and symptms Identificatin f the fetus affected by certain cmplicatins f pregnancy, childbirth and puerperium in multiple gestatin pregnancies Identificatin f the trimester fr cmplicatins ccurring during pregnancy Increased specificity related t histlgical behavir f certain neplasms Episdes f care (initial, subsequent, sequela) fr injuries, pisning, external causes, and ther cnditins Use f fracture classificatin systems (Gustil, Salter-Harris, Neer) Intraperative and pst prcedural cmplicatins Reclassificatin f cdes int new categries r chapters Revised terminlgy 30

31 ICD-10-CM Dcumentatin Examples f General Dcumentatin Requirements 7 th character describing episdes f care (initial, subsequent, sequelae) fr injuries, pisning, external causes, and ther cnditins Initial encunter: As lng as the patient is receiving active treatment fr a cnditin (i.e. ER dept. encunter, treatment by a new physician) Subsequent encunter: After patient has received active treatment and is nw receiving rutine care during the healing r recvery phase (i.e. change f cast, medicatin adjustment) Sequelae: Cmplicatins r cnditins that arise as a direct result f the initial cnditin (i.e. scar frmatin after a burn, hemiplegia fllwing an acute CVA) Increased specificity related t the type f injury 31

32 ICD-10-CM Dcumentatin Sequelae A sequelae r late effect is the residual effect r cnditin prduced, after the acute phase f an illness r injury has terminated. There is n time limit n when a sequelae cde can be used Sequelae f Tuberculsis Dcument : Site f the Sequelae Central Nervus System Geniturinary Bnes and jints Other rgans Respiratry Sequelae f plimyelitis Sequelae f leprsy Sequelae f ther & unspecified infectius & parasitic diseases Dcument as: Trachma Viral encephalitis Viral hepatitis 32

33 ICD-10-CM Dcumentatin Human Immundeficiency Virus (HIV) Encunter fr screening withut signs/symptms Z11.4 Dcument assciated high risk behavir Specify (hetersexual, hmsexual, bisexual ) Z72.5- Encunter fr HIV infectin status with signs/symptms Use the cdes fr the signs/symptms If HIV cunseling is prvided during the test, an additinal cunseling cde is reprted Z71.7 Encunter fr HIV test results: If results are negative use Z71.7, HIV Cunseling Dcument and cde psitive test results based n symptmatlgy: Fr Asymptmatic HIV psitive status cde Z21 Once the patient exhibits signs f HIV related illnesses yu wuld dcument thse symptms and cde B20 AIDS. Never cde Z21 again. Prvider must state HIV status r HIV related illness Cde nly cnfirmed cases f HIV infectin r illness 33

34 ICD-10-CM Dcumentatin Case Example: A 42 year ld HIV psitive male presented in the clinic with cmplaints f fever and shrtness f breath. The diagnstic wrkup, including chest x-ray and sputum culture, resulted in a diagnsis f pneumnia. The patient was immediately transferred t the emergency rm fr further wrk-up. The ER dctr s final diagnsis was dcumented as pneumcystis pneumnia due t AIDS. Assessment & Plan: Admit What diagnses cdes are assigned? Answer: B20 Human Immundeficiency virus (HIV) disease B59 Pneumcystsis Ratinale: Cding Guideline 1.C.1.a.2.a A 40-year-ld wman with knwn chrnic viral hepatitis, resulting frm hepatitis B, is seen fr initiatin f antiviral therapy. What diagnsis cdes are assigned? Answer: B18.1 Chrnic viral hepatitis B withut delta-agent 34

35 ICD-10-CM Dcumentatin Infectius and Parasitic Diseases Dcumentatin must be specific t the type f bacterial, prtzal r virus related t infectius and parasitic diseases Fd Pisnings (Bacterial) Dcumentatin must identify bacterial cause f gastrenteritis/fd pisning such as: Clstridium (btulinum, perfringens, welchii) Salmnella Staphylcccus Vibri (parahaemlyticus, vulnificus) Herpes Simplex Dcumentatin must identify site/manifestatin/cmplicatin such as: Dermatitis (facialis, simplex labialis), Gingivstmatitis and pharyngtnsillitis Disseminated, Ocular, Nervus system (meningitis, encephalitis) Angenital rgans r Visceral 35

36 ICD-10-CM Dcumentatin Infectius and Parasitic Diseases ICD-10-CM has created a range f cdes t identify infectins with a predminantly sexual mde f transmissin Sexually transmitted diseases due t Chlamydia infectin Dcumentatin must identify the site f the Chlamydia infectin such as: Chlamydial infectin f the lwer geniturinary tract Cystitis and urethritis Vulvvaginitis Cervicitis Chlamydial infectin f the pelviperitneum and ther geniturinary rgans Female pelvic inflammatry disease Other geniturinary infectin Chlamydial infectin f anus and rectum Chlamydial infectin f pharynx 36

37 ICD-10-CM Dcumentatin Case Examples: 19 year ld female became suddenly ill after her and her 2 friends went ut fr Pizza and salad. Within an hur f eating, she became ill with stmach pain, cramping, and nausea and vmiting. While at hme resting her symptms wrsened and she began vmiting. She presented in the Urgent Care where she was diagnsed with fd pisning due t staph. Prvider s plan: clear liquids fr hurs, rest What diagnses cdes are assigned? Answer: A05.0 Fd brne staphylcccal intxicatin The patient is seen fr right lwer leg muscle atrphy as a result f a previus but f pli. What diagnses cdes are assigned? Answer: M Muscle wasting and atrphy, NEC, right lwer leg B91 Sequela f Pli Ratinale: In ICD-10-CM, late effect cnditins are classified t sequelae. Cding guideline I.B.10 Sequelae (late effects) 37

38 ICD-10-CM Dcumentatin Neplasms The first step in understanding the dcumentatin challenges fr neplasms requires a cmparisn f the sectins in ICD-9-CM with the cde blcks in ICD-10-CM Neplasm Medical Recrd Dcumentatin: In ICD-10-CM, dcumentatin must include: Lcatin f the Neplasm; new in ICD-10-CM is the cnslidatin f female and male breast malignancy int ne categry Dcumentatin will require: Laterality (Right, Left, Bilateral) Stage Type Sex f the patient (Male r Female) Mrphlgy as Malignant, Benign, In situ, r Uncertain behavir Sme neplasms f uncertain behavir Have mre specific cdes Sme cnditins have been reclassified under neplasm 38

39 ICD-10-CM Dcumentatin Neplasm Medical Recrd Dcumentatin Stage f the Neplasm Accrding t Cding Clinic, 2 nd Quarter 2010, pg 7-8 (republished by Cding Clinic fr ICD-10-CM/PCS, 1 st Quarter 2014), n Cancer Staging, It is apprpriate t use the cmpleted cancer staging frm fr cding purpses when it is authenticated by the attending physician. Cell type identified by cytlgy, histlgy, r pathlgy findings When mre than ne tumr is present in the same rgan, it must be clarified as different primaries r metastatic disease within the same rgan Primary neplasm must be dcumented fllwed by any metastasis by specificity f site and type 39

40 ICD-10-CM Neplasm Dcumentatin Neplasm Medical Recrd Dcumentatin Prvider dcumentatin must include (when apprpriate): Cmplicatins f the neplasm and/r the treatment side effects T reprt the highest level f specificity fr the cnditin T validate the diagnsis cde submitted Assciated cnditins f the neplasm (i.e. anemia, pain, etc) Dcumentatin f a linkage r a cause and effect relatinship in the prgress ntes (i.e. due t, secndary t, caused by ) Dcumentatin must be clear as t whether a cancer patient has: Active Cancer Assess and evaluate if patient: Is currently n cntinuus cancer treatment On adjunct therapy Watchful waiting patient r family refusing surgery r any ther cancer treatment Persnal Histry f Cancer Dcument persnal histry f if a patient has been disease free r in remissin fr a prlnged perid and is cnsidered cured, r the prvider dcuments n evidence f the disease 40

41 ICD-10-CM Neplasm Dcumentatin ICD-9-CM Dcumentatin ICD-10-CM Dcumentatin Malignant neplasm liver, primary C22.0 Liver cell carcinma (includes hepatcellular carcinma and hepatma) C22.2 Hepatblastma C22.3 Angisarcma f liver (includes kupffer cell sarcma) C22.4 Other sarcmas f liver C22.8 Malignant neplasm f liver, primary, unspecified as t type Malignant neplasm intrahepatic bile ducts C22.1 Intrahepatic bile duct carcinma (includes chlangicarcinma) Malignant neplasm liver, nt specified as primary r secndary C22.9 Malignant neplasm f liver, nt specified as primary r secndary 41

42 ICD-10-CM Neplasm Dcumentatin Tips fr Dcumentatin Instead f: Neutrpenia, thrmbcytpenia and anemia Please cnsider: Panyctpenia (due t diseases, chem, medicatin) CA f the breast r CA f Prstate, Anemia Anemia in malignancy r neplastic disease Altered Mental Status Encephalpathy (Alchlic, Hepatic, Hypertensive, Txic, Metablic, Septic) 42

43 ICD-10-CM Dcumentatin Case Examples: Neplasm The diagnsis fr a 61 year ld female patient is small cell carcinma f the right lwer lbe f the lung with metastasis t the intrathracic lymph ndes, brain, and right rib. What diagnses cdes are assigned? Answer: C34.31 Malignant neplasm f lwer lbe, right brnchus r lung C77.1 Secndary and unspecified malignant neplasm f intrathracic lymph ndes C79.31 Secndary malignant neplasm f brain C79.51 Secndary neplasm f bne Ratinale: The primary site is the small cell carcinma f the right lwer lbe f the lung. The intrathracic lymph ndes, brain, and rib are secndary sites. It is crrect t list each metastatic site Assign the cde (s) fr the fllwing diagnsis: Benign carcinid f the cecum Answer: D3A.021 Benign carcinid tumr f the cecum Ratinale: When indexing carcinid, the nte directs t tumr. It is nt necessary t use the Neplasm Table t find the cde fr tumr. Under carcinid, there is a differentiatin between benign r malignant, with specific sites listed. Benign carcinid tumrs fall int categry D3A, Benign neurendcrine tumrs 43

44 ICD-10-CM Dcumentatin Asthma/COPD Dcumentatin Asthma Dcumentatin must state whether r nt the cnditin is an acute exacerbatin r uncmplicated disease An acute exacerbatin is nt the same as an infectin superimpsed n a chrnic cnditin Verbiage such as wrsening r decmpensatin f a chrnic cnditin shuld always be dcumented t shw status The type f asthma and the severity must be dcumented clearly in the prgress nte (i.e. Intermittent, persistent, mild, mderate etc. fr extrinsic and intrinsic asthmas) COPD with Brnchitis Dcumentatin shuld als include the infectin cde (if knwn) fr highest specificity Classificatins fr chrnic brnchitis nw include a cde specific fr COPD with acute lwer respiratry infectin 44

45 ICD-10-CM Dcumentatin Types f Asthma: Asthma/COPD Dcumentatin Exercise-induced asthma Cugh-variant asthma Allergic asthma Other types: Occupatinal asthma Ncturnal asthma 45

46 ICD-10-CM Dcumentatin ICD-9-CM (Asthma) ICD-9-CM Classificatin (493) Classified as either intrinsic, extrinsic, ther r unspecified asthma Finally asthma is classified as uncmplicated, with acute exacerbatin r with status asthmaticus ICD-10-CM (Asthma) ICD-10-CM Classificatin (J45) Bth intrinsic and extrinsic asthma included in this categry Asthma classified as mild, mderate, severe, r unspecified Mild asthma is further classified as intermittent r persistent Finally, asthma is classified as uncmplicated, with acute exacerbatin r with status asthmaticus Ttal f 10 valid cdes Ttal f 18 valid cdes 46

47 ICD-10-CM Dcumentatin ASTHMA: Other ICD-10-CM dcumentatin cnsideratins: New instructinal ntes t use additinal cdes t identify (if specified: it is NOT mandatry): Expsure t envirnmental tbacc smke Expsure t tbacc smke in the perinatal perid Histry f tbacc use Occupatinal expsure t envirnmental tbacc smke Tbacc dependence Tbacc use 47

48 ICD-10-CM Dcumentatin Case Examples: Asthma/COPD A 10-year-ld female child is being seen because f severe persistent asthma with acute exacerbatin. What diagnsis cdes are assigned? Answer: J45.51 Severe persistent asthma with (acute) exacerbatin Ratinale: There are categries f the three degrees f persistent asthma, with the ability t identify with r withut exacerbatin and status asthmaticus The physician has dcumented the fllwing diagnses fr an elderly patient: COPD with emphysema, CHF, HTN, and atrial fibrillatin. What diagnsis cdes are assigned? Answer: J43.9 Emphysema, unspecified I50.9 Heart Failure, unspecified I10 Essential (primary) hypertensin I48.91 Unspecified atrial fibrillatin Ratinale: Emphysema included with COPD as indicated by the instructinal ntes f ICD-10-CM CHF and HTN are cded separately since there is n stated causal relatinship 48

49 ICD-10-CM Dcumentatin Diabetes Mellitus (DM) Diabetes Mellitus cdes in ICD-10-CM are cmbinatin cdes that include: Type f Diabetes Mellitus Bdy system affected Cmplicatins affecting that bdy system There are five (5) Diabetes Mellitus categries in ICD-10-CM Diabetes Mellitus due t underlying cnditin (E08.-) Drug r chemical induced diabetes mellitus (E09.-) Type 1 diabetes mellitus (E10.-) Type 2 diabetes mellitus (E11.-) Other specified diabetes mellitus (E13.-) DM Type nt dcumented defaults t Type 2 (E11.-) Fr lng term (current) use f insulin, assign cde Z79.4 Fr the purpse f Risk Adjustment (HCC) cde capture, the cause and effect f the manifestatin/cmplicatin must be dcumented specifically in rder t capture all the apprpriate HCC cdes 49

50 ICD-10-CM Dcumentatin Diabetes Mellitus Diabetes Mellitus dcumentatin requirements: Type 1 Diabetes Mellitus Brittle diabetes (mellitus), diabetes (mellitus) due t autimmune prcess, idipathic diabetes (mellitus), juvenile nset diabetes (mellitus) and ketsis-prne diabetes (mellitus) Type 2 Diabetes Mellitus r Adult nset Diabetes Mellitus Diabetes (mellitus) due t insulin secretry defect, Diabetes NOS, Insulin resistant diabetes (mellitus) Secndary Diabetes Mellitus Due t an underlying cnditin Cushing s syndrme Cystic fibrsis Malignant neplasm Malnutritin Pancreatitis r ther diseases f the pancreas Drug induced r chemically induced (dcument drug/chemical) Due t ther specified cnditin Genetic defects f beta-cell functin Genetic defects in insulin actin Pstpancreatectmy diabetes mellitus Pst prcedural diabetes mellitus Secndary diabetes mellitus NEC 50

51 ICD-10-CM Dcumentatin ICD-9-CM (Diabetes Mellitus) ICD-9-CM (DM Dcumentatin) 250/249 Identify the type f diabetes mellitus: Type I Cntrlled/nt specified Uncntrlled Type II Cntrlled/nt specified Uncntrlled Secndary diabetes mellitus Cntrlled/nt specified Uncntrlled ICD-10-CM (Diabetes Mellitus) ICD-10-CM (DM Dcumentatin) E08-E13 Identify the type f diabetes mellitus: Drug r chemical induced Due t underlying cnditin Type 1 Type 2 Other specified diabetes mellitus, which includes: Due t genetic defects f beta-cell functin Due t genetic defects f insulin actin Pstpancreatectmy Pstprcedural Secndary diabetes nt elsewhere classified Identify bdy system affected by diabetes: Hypersmlarity Ketacidsis Neurlgical manifestatin Other cma Ophthalmic manifestatin Peripheral circulatry disrders Renal manifestatins Other r unspecified manifestatins Withut cmplicatins/manifestatins Identify the bdy system affected and any manifestatins/cmplicatins: N cmplicatins Ketacidsis with cma withut cma Kidney cmplicatins Diabetic nephrpathy Chrnic kidney disease Other diabetic kidney cmplicatin Additinal dcumentatin is needed t identify the specific cmplicatin r manifestatin f the disease 51

52 ICD-10-CM Dcumentatin Diabetes Mellitus: Other ICD-10-CM dcumentatin cnsideratins: Cause and effect linking wrds are: due t, caused by, secndary t Example: CKD 3 due t DM Type2 E11.22 N18.3 Inadequately cntrlled, prly cntrlled r ut f cntrl cdes t Diabetes, by type, with hyperglycemia Fr lng term (current) use f insulin, assign cde Z79.4 D nt assign lng term use f insulin, if the insulin was given temprarily t bring Type 2 patient s bld sugar under cntrl during the encunter 52

53 ICD-10-CM Dcumentatin Review Questins: Diabetes Mellitus True r False? In ICD-10-CM, all diabetes cdes require dcumentatin f whether the cnditin is under cntrl r nt. Answer: False Ratinale: ICD-10-CM classifies diabetes mellitus ut f cntrl t diabetes mellitus, by type, with hyperglycemia In ICD-10-CM diabetes mellitus cdes include: A. The type f diabetes mellitus B. The bdy system affected C. The cmplicatin affecting that bdy system D. All f the abve Answer: D. All f the abve Ratinale: The diabetes mellitus cdes are cmbinatin cdes that include the type f diabetes mellitus, the bdy system affected and the cmplicatins affecting that bdy system (Cding Guideline I.C.4.a) 53

54 ICD-10-CM Dcumentatin Pregnancy Cdes frm chapter 15 will always be cded as primary t any ther chapter cdes Dcumentatin must als state which fetus fr multiple fetal pregnancies has a fund cnditin ie: Fetus 1, 2, etc. Dcumentatin shuld als state pre-existing cnditins s as nt t cnfuse pregnancy related cnditins Examples: Pre-existing hypertensin, diabetes in pregnancy and pregnancy related hypertensin and gestatinal diabetes 54

55 ICD-10-CM Dcumentatin Diabetes Mellitus in a Pregnant Patient Expansin f diagnses cde in ICD-10-CM fr Diabetes Mellitus in pregnancy, childbirth & puerperium Dcument: Pre-existing Diabetes Mellitus in pregnancy, childbirth and puerperium Type 1 Diabetes Mellitus Trimesters (first, secnd and third) Type 2 Diabetes Mellitus in pregnancy, childbirth and puerperium Trimesters (first, secnd and third) Gestatinal Diabetes Mellitus in pregnancy, childbirth and puerperium Diet cntrlled Insulin cntrlled 55

56 ICD-10-CM Dcumentatin Case Example: Diabetes Mellitus in a Pregnant Patient A 24 year ld patient with a past medical histry f Type 1 Diabetes Mellitus, presented t the PCP clinic fr a rutine fllw up visit. The prvider dcumented in his prgress nte, a female patient, nw in her 2 nd trimester at 19 weeks withut any cmplaints. VS stable. Bld sugar well cntrlled. The patient als indicated that she was ding well with her diet and exercise regimen. The prvider s assessment & plan: cntinue t mnitr bld sugar, cntinue diet and exercise, see OB/GYN as scheduled. PCP scheduled the patient fr fllw-up in ne mnth ICD-10-CM cdes: O Pre-existing Diabetes Mellitus, type 1 in pregnancy, secnd trimester Z3A weeks gestatin f pregnancy 56

57 ICD-10-CM Dcumentatin Pregnancy Dcumentatin fr pregnancy and pregnancy related cnditins requires calculatin f weeks f gestatin fr each visit First trimester LMP t 14 weeks 0 days Secnd trimester 14 weeks 0 days t less than 28 weeks, 0 days Third trimester 28 weeks 0 days t delivery Case Example: Patient presents t her PCP ffice fr irregular menses, she states she had a very light menses 2 mnths ag n March 15 and nthing fr the past 2 mnths. Prvider has rdered a urine pregnancy test which was psitive, s the patient was sent fr an Ultrasund t cnfirm dates. Ultrasund results n June 28 shwed pregnancy t be at 14 weeks 6 days. This wuld put the patient in her secnd trimester Belw is a table t shw the trimester dates fr the abve Case Example: First Trimester March 15 t June 24 LMP was March 15 accrding t the patient Secnd Trimester June 25 t September 30 June 28th ultrasund results put her at 14 weeks 6 days Third Trimester Octber 1 t Delivery 57

58 ICD-10-CM Dcumentatin Overweight and Obesity Identify cnditins: Obesity Drug-induced E66.1 Due t excess calries E66.0 Mrbid Other Mrbid/Severe with alvelar hypventilatin E66.2 (Pickwickian Syndrme) Other E66.8 Overweight E66.3 BMI Dcument weight and BMI in medical recrd fr each face t face encunter: Overweight BMI Obese BMI Mrbid Obesity BMI 40.0 and abve (Adult) BMI cde als Z68.1-Z

59 ICD-10-CM Dcumentatin Endcrine, Nutritinal and Metablic Diseases Case Example: Mrbid Obesity 43 year ld male presents with SOB all day wrsening at night T: 98.2 P: 88 R: 16 B/P: 160/84 H: 62 W: 282 BMI: 51.6 Patient states he has been heavy all his life, states having increased difficulty catching his breath at night. O2 saturatin n RA is 92% Prviders assessment and plan: Fr mrbid besity see nutritinist fr weight lss guidance, Issue referral fr sleep study t rule ut sleep apnea ICD-10-CM Cdes: E66.01 Mrbid (severe) Obesity due t excess calries Z68.43 BMI

60 ICD-10-CM Dcumentatin Mental, Behaviral, and Neurdevelpment Disrders This chapter has revised terminlgy t use disrder rather than disease r illness as in ICD-9-CM Disrder clarifies and describes a clinically recgnized set f behavirs r symptms which are assciated with interference f persnal functin and distress A depressin diagnsis will default t Majr Depressive Disrder in ICD-10-CM Substance Abuse versus Substance Dependence have been classified as separate cnditins. In ICD-10-CM, abuse and dependence terms cannt be used interchangeably in dcumentatin There are detailed guidelines fr certain cnditins in chapter 5 such as: Pain disrders with related psychlgical factrs Mental and Behavir disrders due t psychactive substances Psychactive substance abuse cdes are nly used if the dcumentatin links the assciated mental and behaviral disrders 60

61 ICD-10-CM Dcumentatin Case Example: Chrnic pain Patient has chrnic pain due t a back injury years ag, patient admits t being depressed ff and n since he is in cnstant pain. Patient sees a psychiatrist wh prescribes antidepressants t him, patient has been ging t pain management with fair results. Prviders assessment and plan: Cntinue t mnitr patient ICD-10-CM Cdes: F45.42 Pain disrder with related psychlgical factrs G89 Chrnic pain syndrme 61

62 ICD-10-CM Dcumentatin There are detailed guidelines fr Attentin Deficit Disrder (ADD) Clinical dcumentatin must clearly differentiate attentin deficit disrder frm hyperkinesia, hyperkinetic syndrme r cnduct disrders. Specific dcumentatin shuld clarify: Predminantly hyperactive Predminantly inattentive Cmbined type Other type must specify 62

63 ICD-10-CM Dcumentatin Guidelines fr Use, Abuse r Dependence Hierarchy If bth use and abuse are dcumented - cde nly the abuse cde If bth use and dependence are dcumented - cde nly the dependence cde If use, abuse and dependence all are dcumented - cde nly the dependence cde If abuse and dependence are dcumented - cde nly the dependence cde Sme mental disrders have an rganic rigin, sme may be a result f develpmental r intellectual disabilities and must be linked in detail fr each diagnsis dcumented Organic mental and behaviral disrders are caused by a physilgical cnditin and dcumentatin f the underlying disrder is required Dcumenting the severity f mental illness is KEY! The Fllwing slides are cde-specific dcumentatin requirements fr use, abuse, r dependence 63

64 ICD-10-CM Dcumentatin Alchl Induced/Drug Induced Mental Disrders Identify substance: Identify type f disrder: Alchl Cannabis Ccaine Hallucingen Inhalant Nictine Opiid Sedative/hypntic/anxilytic Stimulant related (ther than ccaine) Other psychactive substance Abuse Dependence Use, unspecified Criteria fr ETOH use/abuse: 64

65 ICD-10-CM Dcumentatin Fr Abuse, identify mental/behaviral cmplicatins Uncmplicated With intxicatin Uncmplicated With intxicatin delirium Unspecified With substance-induced md disrder With substance-induced psychtic disrder With delusins With hallucinatins Unspecified With ther substance-induced disrders Anxiety disrder Sexual dysfunctin Sleep disrder Other disrder Unspecified cmplicatins Fr Dependence, identify mental/behaviral cmplicatins Uncmplicated In remissin (VERY imprtant t dcument) With intxicatin Uncmplicated With intxicatin delirium Unspecified With persisting amnesiac disrder With persisting dementia With substance-induced md disrder With substance-induced psychtic disrder With delusins With hallucinatins Unspecified With ther substance-induced disrders Anxiety disrder Sexual dysfunctin Sleep disrder Other disrder Unspecified cmplicatins 65

66 ICD-10-CM Dcumentatin Fr Use, identify mental/ behaviral cmplicatins Uncmplicated With intxicatin Uncmplicated With intxicatin delirium Unspecified With persisting amnesiac disrder With persisting dementia With substance-induced md disrder With substance-induced psychtic disrder With delusins With hallucinatins Unspecified With ther substance-induced disrders Anxiety disrder Sexual dysfunctin Sleep disrder Other disrder Unspecified cmplicatins Fr Nictine Dependence Identify nictine prduct Cigarettes Chewing tbacc Other specified prduct Unspecified prduct Identify dependence status/cmplicatins Uncmplicated In remissin With withdrawal With ther nictine-induced disrder NOTE: Use f nictine nt dcumented as dependence is cded Z

67 ICD-10-CM Dcumentatin Review Questins: Drug Dependence/Alchl Abuse with intxicatin A yung man is seen fr cntinued fllw-up fr treatment f his dependence n amphetamines. Hw shuld this diagnsis be cded? Answer: F15.20 Other stimulant dependence uncmplicated Ratinale: ICD-10-CM classifies each drug by its type. If intxicatin with the dependence is dcumented, an additinal digit wuld be added Cde the fllwing diagnsis: Alchl abuse with intxicatin Answer: F Alchl abuse (nn-dependent) with intxicatin Ratinale: ICD-10-CM des nt specify the severity f alchl use as previusly seen in ICD-9-CM. If alchl dependence was dcumented, the cding wuld be fund in the F10.2 sub-categry 67

68 ICD-10-CM Dcumentatin Circulatry System Disrders Increased site specificity (i.e. Nntraumatic subdural hemrrhage in brain stem r cerebellum, intraventricular r multiple lcalized) Required prvider dcumentatin fr type and acuity f a cnditin (i.e. acute, subacute, chrnic) Cmbinatin cdes that capture: Etilgy and Manifestatins Prvider needs t dcument a cause and effect relatinship (when applicable) Example : CHF due t Hypertensin Hypertensive heart with Chrnic Kidney Disease Fr the purpse f HCC the prvider must dcument etilgy and manifestatins n the same prgress nte in rder t capture the cmbinatin cdes. Related cnditins (i.e. HTN and CKD; CAD and Angina) Mst cmmn instructinal terms: Factrs influencing health status: Expsure t envirnmental tbacc smke Histry f tbacc use Occupatinal expsure t envirnmental tbacc smke Tbacc dependence Tbacc use 68

69 ICD-10-CM Dcumentatin Hypertensin N lnger classified as malignant, accelerated r benign N hypertensin table Guidelines are unchanged fr hypertensive causal relatinships Same ICD-10-CM fficial guidelines fr hypertensin with heart disease (I11.-) Dcument the type f heart failure Same guidelines fr hypertensin and chrnic kidney disease (I12.-) Dcument the stage f the Chrnic Kidney Disease Acute CVA Same guidelines fr hypertensive heart and chrnic kidney disease (I13.-) Dcument type f heart failure Dcument stage f Chrnic Kidney Disease Prvider dcumentatin requirements (I60.- t I66.-) Circulatry System Disrders (cnt.) Site specific Nn Traumatic Traumatic (which may cde t injury T cdes) Hemrrhagic Emblic Thrmbtic 69

70 ICD-10-CM Dcumentatin Hypertensin Identify the presence/absence f Hypertensive heart and/r kidney disease Hypertensive heart disease With heart failure Withut heart failure *Dcument als the heart failure (type & acuity) Hypertensive chrnic kidney disease cde als stage f CKD With stage 1-4 CKD With stage 5 CKD r ESRD Als identify and dcument: Expsure t envirnmental tbacc smke Histry f tbacc use Tbacc dependence Tbacc use Cmbinatin cdes fr Circulatry system Crnary athersclersis and angina have an assumed cause and effect when they ccur tgether Identify the site f crnary athersclersis Native crnary artery Graft Autlgus Artery bypass graft Vein bypass graft Nn autlgus bilgical bypass graft Transplanted heart Als identify and dcument: Chrnic ttal cclusin f crnary artery Crnary athersclersis due t: Calcified crnary lesin Lipid rich plaque 70

71 ICD-10-CM Dcumentatin Determine the underlying diagnsis Sequelae f CVA (terminlgy change frm late effect) Cervical spinal crd diseases Peripheral nervus system diseases Precise detailed dcumentatin is key t crrect cde assignment Laterality Dminant versus nn-dminant (Unless dcumented in nte) Hemiplegia and Hemiparesis Left side default is nn-dminant Right side default is dminant Ambidextrus defaults t dminant HINT: Verbiage f left r right sided weakness is nt accepted by CMS fr sequelae f CVA (this maps t anther diagnsis unrelated t CVA) 71

72 ICD-10-CM Dcumentatin Case Examples: Hemiplegia A 78 year ld right-handed female, with lngstanding flaccid hemiplegia f unspecified cause affecting her left side, was transferred t a nursing hme frm the clinic. Final diagnsis: Left-sided flaccid hemiplegia What diagnsis cdes shuld be assigned? Answer: G81.04 Flaccid hemiplegia affecting left nndminant side Ratinale: This case is cded as flaccid hemiplegia f the nndminant side because the dcumentatin describes the patient as right handed, s the right side is the dminant side In cases, where the affected side is dcumented, but nt specified as dminant r nndminant, hw shuld a right side mnplegia be classified? Answer: Dminant Ratinale: If the right side is affected, the default is dminant (Guideline 1.C.6.a) 72

73 ICD-10-CM Dcumentatin Late effects r Sequelae f Cerebrvascular Disease and ICD-10-CM Dcumentatin: Residual Cerebrvascular Disease Sequelae Cgnitive deficits Aphasia Dysphasia Dysarthria Fluency disrder Mnplegia f upper r lwer limb Hemiplegia and hemiparesis Other Paralytic Syndrme Type f cerebrvascular disease (hemrrhage, infarctin) Dminance with hemiparesis (i.e. right r left dminant, right r left nn-dminant) 73

74 ICD-10-CM Dcumentatin Cerebrvascular Disease Sequelae Case Example: Sequelae f CVA There is a 65 year ld female wh has a histry f cerebral emblism with infarctin frm 6 mnths ag. She presents tday in the clinic due t residuals f altered sense f taste and left dminant hemiplegia. What diagnsis cdes are assigned? Answer: I Hemiplegia fllwing cerebral infarctin affecting left dminant side I Other sequelae f cerebral infarctin R43.9 Unspecified disturbances f smell and taste Ratinale: Left dminant hemiplegia and altered sense f taste are the reasns fr the patient t see the PCP. The nte at cde I states t use an additinal cde t identify the sequelae 74

75 ICD-10-CM Dcumentatin Diseases f the Nervus System Increased specificity in ICD-10 CM will need mre precise clinical dcumentatin Many nervus system cnditins are manifestatins f ther diseases and dual cding is ften required t reprt the underlying cnditin and the manifestatin alng with linking them with due t verbiage In this chapter the diseases and cnditins have additinal elements which are captured in the cde. Laterality is extremely imprtant in ICD-10 CM dcumentatin in rder t chse the crrect cdes Dcumentatin in the medical recrd shuld clearly specify the cause-and-effect relatinship between a symptm, manifestatin r cmplicatin and a disease r medical interventin In additin t general dcumentatin requirements, there are specific diseases and disrders that require greater detail t ensure accurate cde assignment The fllwing slides are cde-specific dcumentatin requirements fr sme f the diseases f the nervus system 75

76 ICD-10-CM Dcumentatin Alzheimer s Disease Identify type/nset: Early nset (G30.0) Late nset (G30.1) Other Alzheimer s disease (G30.8) Use additinal cde when Alzheimer s is assciated with: Delirium (F05) Dementia with behaviral disturbance (F02.81) Dementia withut behaviral disturbance (F02.80) Secndary Parkinsnism Identify the cause f secndary parkinsnism: Drug-induced Malignant neurleptic syndrme (G21.0) Neurleptic induced parkinsnism (G21.11) Due t ther external agents (G21.2) Pstencephalitic (G21.3) Other specific cause (G21.8) Unspecified cause (G