THE BASICS OF ICD-10-CM CODING

THE BASICS OF ICD-10-CM CODING June 9, 2015 Continuing Education for Long-Term Care Facilities Marla Dumm, CPC, CCS-P Managing Consultant mdumm@bkd.com 1

TO RECEIVE CPE CREDIT Participate in entire webinar Answer polls when they are provided If you are viewing this webinar in a group Complete group attendance form with Title & date of live webinar Your company name Your printed name, signature & email address All group attendance sheets must be submitted to training@bkd.com within 24 hours of live webinar Answer polls when they are provided If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar 2 Objectives Distinguish between ICD-9 & ICD-10 code structure Identify necessity to review clinical documentation & translate information into diagnosis code Describe best practices related to accurate & specific code assignment 3 2

Current Status DEADLINE Final Rule CMS-0043-F https://www.federalregister.gov/articles/2 014/08/04/2014-18347/change-tothecompliance-date-for-the-internationalclassification-of-diseases-10th-revision Issued on July 31, 2014 Finalized new deadline of October 1, 2015 No new code updates until October 1, 2016 5 4 Resource documents ICD-9-CM ICD-9-CM Official Guidelines for Coding & Reporting Effective October 1, 2011 Last major update http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2 011.pdf 5 3

Resource Documents ICD-10-CM ICD-10-CM Official Guidelines for Coding & Reporting (2015 Version) Effective with dates of service October 1, 2015 http://www.cms.gov/medicare/coding/icd10/downloads /icd10cm-guidelines-2015.pdf 6 Will Official Coding Guidelines Differ? 7 4

Official Coding Guidelines Minimal changes General guidelines for assignment of codes, order of codes, punctuation, abbreviations, etc., will be very similar Some structural differences & modifications to code classifications or code descriptions due to expanded code detail 8 Standard Coding Process Be familiar with ICD-10-CM Official Coding Guidelines & Conventions Section I-III Review clinical documentation (physician or non-physician practitioner) Nursing facility admission H&P, nursing facility discharge summary, acute hospital discharge, progress notes, consultation reports, diagnostic test reports, etc. 9 5

Standard Coding Process Identify main term(s) Look up main term(s) in Alphabetic Index Look through subterms if applicable Review all additional lines & subterms that may continue to next column Refer to all parenthetical terms 10 Standard Coding Process Grey shaded vertical lines provide guidance for indented subterms & additional subterms Review all instructional notes & references see, see also, see category with or without omit code due to code by site NEW TO ICD-10-CM 11 6

Standard Coding Process Reminder Do not code from the index Locate & confirm code(s) in Tabular List Read & follow instructions Includes & Excludes notes Use additional code Code first underlying disease Code also Character requirements (4 th, 5 th, 6 th & 7 th extensions) Age or gender 12 Standard Coding Process Refer to Official Guidelines to verify rule(s) Confirm & assign code(s) to highest level of specificity (number of characters) supported in documentation List on claim form in priority (or sequence) per coding guidelines 13 7

Example Standard Coding Process Acute Upper Respiratory Infection Infection Respiratory Upper Acute Code J06.9 14 Index Volume 2 15 8

Alphabetic order Index Volume 2 Can search by condition, disease, sign, symptom, etc Anatomical site will refer you to see condition Index to Diseases & Injury Neoplasm Table Table of Drugs & Chemicals Index to External Causes of Injury 16 Index What s not in ICD-10? Hypertension Table... Malignant... Benign... Unspecified Hypertension, hypertensive (arterial) (arteriolar) (crisis) (degeneration) (disease) (essential) (fluctuating) (idiopathic) (intermittent) (labile) (low renin) (orthostatic) (paroxysmal) (primary) (systemic) (uncontrolled) (vascular)... 401.0... 401.1... 401.9 with chronic kidney disease stage I through stage IV, or unspecified... 403.00... 403.10... 403.90 stage V or end stage renal disease... 403.01... 403.11... 403.91 heart involvement (conditions classifiable to 429.0-429.3, 429.8, 429.9 due to hypertension) (see also Hypertension, heart)... 402.00... 402.10... 402.90 with kidney involvement see Hypertension, cardio renal This table has been removed. Look for Hypertension, hypertensive in table for code selection 17 9

Main Terms Identify disease or condition of site (for injuries) Main terms are listed in bold type & start with an uppercase letter Examples of main term headings Complications Late Effect(s) or Sequelae (new for ICD-10) Fracture Pneumonia 18 Main Terms Follow cross references like see also & see Modifiers & Subterms are located under Main Term An indented structure is used See shaded lines in index which line up indented terms Notes Define terms Provide direction & instruction 19 10

Non-Essential Modifiers Words that follow main term Are always in parenthesis Provide additional information for main term The presence or absence of these modifiers has no effect on selection of the code for term Example Pneumonia (acute)(double)(migratory)(purulent)(septic) (unresolved) 20 Essential Modifiers Subterms that modify main term Are listed below main term in alphabetical order (exception of with & without ) Indented two additional spaces to the right Regular type & starts with a lowercase letter Example Pneumonia With Influenza see Influenza, with, pneumonia Lung abscess 21 11

Eponyms & Synonyms Eponyms Diseases or syndromes named for a person (i.e., who discovered the illness) Listed as a main term under both name of person & disease or syndrome Example Guillain-Barre Syndrome (look up Guillain or Syndrome) Synonyms Escherichia coli (E. coli) 22 Abbreviations NEC Not Elsewhere Classified Used when Coder has specific documented information, but there is no separate or specific code available to represent condition documented in medical record 23 12

Abbreviations NOS Not Otherwise Specified Used when Coder lacks or does not have specific documented information Equivalent to unspecified NOS codes should never be used routinely as a means to avoid having to search for a more specific term 24 Cross-Reference Terms See (Condition, Category) Mandatory instruction that the coder must look elsewhere for an alternative term. Coding cannot be completed without following this instruction See also Coder must review another main term if information documented in record is not reflected under main term 25 13

Cross-Reference Terms Examples 26 Neoplasm Table Search by anatomical site where neoplasm is located Columns will detail Primary, Secondary (metastasis) or Ca in Situ malignancy Additional columns will detail benign neoplasms, those with uncertain behavior & unspecified Information must be documented in medical record (i.e., chart note, pathology report) 27 14

28 Table of Drugs & Chemicals Used to define code by the toxic effect (i.e., poisoning) from a specific drug, medication or solution Search by name of drug or medication Brand name Generic name 29 15

Table of Drugs & Chemicals Columns Poisoning, Accidental (Unintentional) Poisoning, Intentional Self-Harm Poisoning, Assault Poisoning, Undetermined Adverse Effect Under-Dosing (New Category) 30 Argyrol 31 16

Restructuring the Index Injuries are grouped by anatomical site rather than by type of injury Certain diseases & disorders have been reclassified Example: Gout is now in Musculoskeletal instead of Endocrine Categories restructured Codes have been reorganized to appropriate chapter Familiar codes will appear in different chapters or sections to reflect current medical knowledge 32 Tabular List Section 1 33 17

Tabular List Numerical listing of codes 21 chapters Classification of factors influencing health status & contact with health services Codes beginning with V, W, X or Y Classification of external causes of injury & poisoning Codes beginning with Z 34 New Chapters Sensory signs, symptoms &/or conditions Chapter 7 - Eyes Chapter 8 - Ears Example H66.001 Acute suppurative otitis media without spontaneous rupture of ear drum, right ear H40.11 Primary open-angle glaucoma 35 18

Code Format What to Expect 36 ICD-10-CM structure Up to seven digits First digit = always alpha, except U Second digit = always numeric All other digits = combination (Watch O/0, 5/S, I/1) 37 19

Structure Comparison ICD-9-CM ICD-10-CM 813.06 S52.131A Closed Fracture of Neck/Radius Displaced fracture of neck/right radius, initial encounter for treatment of closed fracture 38 Tabular List Numerical listing of codes divided into 21 chapters Code structure 3 rd characters main code/category. May be primary code if no further specificity is required 4 th character After decimal point. Defines site, etiology & manifestation 5 th &6 th characters further specificity 7 th character Required if instructed in Tabular section, identifies status of care 39 20

Characters Add Specificity Additional characters are added to main category (three character code depending on code instructions) Example S52 Main category for Fracture of Forearm S52.5 Subcategory code for unspecified Fracture of the lower (or distal) end of radius S52.52 Sub classification code for Torus fracture of lower (or distal) end of radius 40 Example Characters Add Specificity S52.521 Sub classification code for Torus fracture of lower (or distal) end of right radius S52.521A Adding the required 7 th character A specifies the type of encounter or stage of healing - Torus fracture of lower end of right radius, initial encounter for closed fracture 41 21

New Features Placeholders Character x is used as a placeholder Allows for future expansion Fills empty characters for codes that require the full seven characters T15.02XD Foreign body in cornea, left eye, subsequent encounter 42 New Features 7 th Character Will always be listed in the seventh position Adds additional information to describe the encounter A = Initial encounter D = Subsequent encounter Must be used when instructed in Tabular listing S50.02XD Contusion of left elbow, subsequent encounter 43 22

New Features 7 th Character 44 7 th Character Type of Encounter Initial, subsequent or care of sequela (i.e., late effect) Active treatment Examples: Surgical treatment, ER encounter, E/M by new physician Subsequent encounter Routine follow-up care, during healing phase Sequela Complications of conditions that occur as a direct result of an injury or illness 45 23

Laterality New Features Laterality Left, right & bilateral The 5 th code character will be defined as follows Right side = 1 Left side = 2 Bilateral = 3 Unspecified = 0 or 9 46 Laterality Examples C50.511 Malignant neoplasm of lowerouter quadrant of right female breast L89.022 Pressure ulcer of left elbow, stage II 47 24

Punctuation 48 Punctuation Brackets & Parentheses [ ] - Brackets enclose synonyms, alternative terminology or explanatory phrases - Also to indicate manifestation codes in index ( ) - Parentheses enclose supplementary words, called nonessential modifiers, which may be present in descriptor of a code without affecting code to which it is assigned 49 25

Punctuation Brackets & Parentheses Examples Amyloid Heart (disease) E85.4 [I43] Tells coder two codes will be reported I43 is listed in [brackets] & will be secondary code reported Verify code in Tabular List Italicized instruction under I43 tells coder to Code First underlying disease, such as Amyloidosis (E85.-) 50 Punctuation Brackets & Parentheses Index listing for electrocardiogram Abnormal, Abnormality, abnormalities Electrocardiogram [ECG] [EKG] R94.31 Tabular listing for R94.31 Abnormal electrocardiogram [ECG] [EKG] Index listing for acute laryngitis Laryngitis (acute)(edematous)(fibrinous)(infective) (infiltrative) (malignant)(membranous) J04.0 51 26

Punctuation Colons : - Colons are used after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category Example C32 Malignant neoplasm of larynx Use additional code to identify Alcohol abuse and dependence (F10.-) Exposure to environmental tobacco smoke (Z77.22) 52 Punctuation Not in ICD-10-CM } - Braces are not found in ICD-10. The detail is now found after the main term or after the code itself &/or found in detail of code instruction in Tabular listing Example: K56.2 Volvulus Strangulation of colon or intestine Torsion of colon or intestine Twist of colon or intestine 53 27

Instructional Notes 54 Includes Instructional Notes This note appears immediately under a three-digit code title at beginning of chapter or section. Further defines or clarifies content of category 55 28

Excludes Terms following the word excludes are not classified to code under which it is found May indicate another code more fully describes a diagnosis Instructional Notes 56 Instructional Notes Use additional code This instruction signals coder that an additional code should be used when documentation states both etiology & manifestation of disease 57 29

Code first Instructional Notes The instruction is to code underlying disease (etiology) first (i.e., code first ) Manifestation code is sequenced as secondary diagnosis Manifestation codes may never be used alone or sequenced as principal diagnosis 58 Instructional Notes Code First 59 30

Official Guidelines 60 Principal Diagnosis Section II The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care Definition applies to all non-outpatient settings, to include LTC Principal diagnosis = condition requiring resident s admission Example: Patient with Parkinson s disease admitted post hospitalization for therapy associated with acute pneumonia ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Page 97-100 61 31

Primary Diagnosis Section II Primary diagnosis = reason for continued stay in LTC May be same as principal diagnosis (i.e, Parkinson s disease) Is required to support therapy services Example The pneumonia would be sequenced as second diagnosis as reason for therapy ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Page 97-100 62 MDS versus ICD-10-CM MDS lists Active Diagnoses under Section I Identifies disease related to the resident s functional, cognitive, mood or behavior status, medical treatments, nursing monitoring or risk of death Values are assigned to these groups of codes Resident may have other conditions that also need to be coded ICD-10-CM codes may be listed on the MDS if the groups do not identify a condition or diagnostic group that meets criteria in second bullet point Consistent, complete & diagnosis codes in MDS & on claim form 63 32

Additional Diagnoses Section III All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay Applies to LTC setting Do not report conditions that are resolved or from previous admissions that have no bearing on the current stay Historical diagnoses (Z80-Z87) may be used if there is impact on current care or treatment ICD-10-CM Official Guidelines for Coding and Reporting, Section III, Pages 100-101 64 Signs & Symptoms May be coded when they are the reason for testing When provider has not made a definitive final diagnosis Signs & symptoms that are a routine part of a known disease process are not coded separately unless otherwise instructed in Tabular listing 65 33

Abnormal Test Findings Do not code unless provider documents clinical significance in medical record If physician or nonphysician practitioner orders tests based on abnormal findings or findings outside the norm, query physician to verify code assignment If an abnormal findings leads to a definitive diagnosis upon further testing prior to coding the case, definitive diagnosis is always used 66 Multiple Coding Use of more than one code to fully identify components of a complex diagnostic statement A complex statement is one that involves connecting words or phrases such as associated with, due to, incidental to, or secondary to Is required for certain conditions that are not subject to rules of combination coding Identified in Tabular List by instruction to use additional or code first underlying disease 67 34

Multiple Coding Example I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease Use additional code to identify the stage of chronic kidney disease (N18.5-N18.4, N18.9) 68 Combination Codes A single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation) or complication Only the combination code is assigned when that code fully identifies the diagnostic conditions involved or when Tabular/Alphabetical Index so directs Example E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy Describes type, body system & manifestation 69 35

Sequela (Late Effects) Reflects residual effect or condition produced by an acute phase of illness or injury No time limit applies Generally requires two codes Condition or nature of the sequela (cause of the sequela) is coded first Sequela (late effect) is coded second Exception: if instructed to code a manifestation or combination code includes sequela 70 Late Effects or Sequela of CVA ICD-9-CM 438.11 Late effect of cerebrovascular disease, speech & language deficits, aphasia 72 ICD-10-CM I69.020 Aphasia following nontraumatic subarachnoid hemorrhage I69.120 Aphasia following nontraumatic intracerebral hemorrhage I69.220 Aphasia following other nontraumatic intracranial hemorrhage disease 71 36

Aftercare Codes Fractures or Injuries Assign after initial, acute treatment is completed Used in post acute settings Patient is admitted to LTC for ongoing care during healing or recovery phase List acute injury code with 7 th character D Aftercare Z codes are NOT used for injuries 72 Aftercare Coding Examples Example A Patient status post hip replacement Admitted to LTC for rehabilitation S72.111D Subsequent encounter for closed fracture with routine healing Example B Patient status post fracture of acute pelvic fracture Admitted to LTC for rehabilitation S32.9XXD Fracture/unspecified/lumbosacral spine & pelvis, subsequent encounter for routine healing 73 37

Ventilator Associated Pneumonia J95.851 Ventilator associated pneumonia When provider has documented that it is related to ventilator use Assign an additional code for organism Do not assign if provider does not specify pneumonia is caused by ventilator Refer to Sections J13-J18 for other pneumonia diagnoses 74 ICD-9-CM Urinary Tract Infection Assigned 599.0 + the organism if identified & documented ICD-10-CM Assign N39.0 Assign additional code (B95-B97) for infectious agent if known 75 38

Z48.0 code series Wound Care Encounter for attention to dressings, sutures & drains Nonsurgical wound dressing Surgical wound dressing Removal of sutures Change or removal of drains Code open wound, ulcer, etc., requiring treatment 76 Wound Care Ulcer, Pressure, by site (i.e., decubitus, bed sores) L89. code series Instruction to code also associated gangrene (I96) if documented Nursing or provider documentation should reflect Type of wound Site(s) Stage(s) 77 39

Open Wounds Code Series Head (S00 to S09) Neck (S10 to S19) Thorax (S20 to S29) Abdomen, lower back, lumbar spine, pelvis, & external genitals (S30 to S39) Shoulder & upper arm (S40 to S49) Elbow & forearm (S50 to S59) Wrist & hand (S60 to S69) Hip & thigh (S70 to S79) Knee & lower leg (S80 to S89) Ankle & foot (S90 to S99) Unspecified multiple injuries (T07) 78 Wound Care Bacterial/viral infections B95.0-B96.89 Used as an additional code if not already in code description for disease, wound or ulcer MRSA MRSA Carrier/colonization Z22.322 MRSA Susceptible/colonization Z22.321 Osteomyelitis Acute M86.00-M86.29 Osteomyelitis Chronic M86.30-M86.9 Asceptic Necrosis M87.00-M90.59 Cellulitis L02.02-L02.93, L02.02-L0391 79 40

Final Thoughts Evaluate training needs Evaluation workflows Perform dual coding assessments on a sample of current records & claims Provide feedback & education to professional staff on clinical documentation improvement Send coding personnel to comprehensive ICD-10 training prior to October 1, 2015 80 Resources & References CMS ICD-9-CM Website http://www.cms.gov/medicare/coding/icd9provider DiagnosticCodes/index.html CMS ICD-10-CM Website http://www.cms.gov/medicare/coding/icd10/index. html AHIMA. ICD-10-CM Coding Guidance for Long-Term Care Facilities. Journal of AHIMA 86, no. 3, (March 2015): 46-50 81 41

CMS ICD-10-CM Implementation Tools ICD-10 Implementation Timelines & Checklists http://www.cms.gov/medicare/coding/icd10/icd- 10ImplementationTimelines.html CMS Provider Tools http://www.cms.gov/medicare/coding/icd10/provider Resources.html 82 Coding Industry Resources AHIMA http://www.ahima.org/icd10 AAPC http://www.aapc.com/ http://www.aapc.com/icd-10/index.aspx http://www.aapc.com/icd-10/resources.aspx 83 42

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CPE CREDIT CPE credit may be awarded upon verification of participant attendance For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at training@bkd.com 86 THANK YOU! FOR MORE INFORMATION Marla Dumm, CPC, CCS-P Managing Consultant mdumm@bkd.com 44

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