MASTER THE CODE AN INTRODUCTION TO ICD-10 CODING FOR THE EARLY INTERVENTION POPULATION OCTOBER 23, 2015 KELLY WALSH-HILL, PT GENERAL EQUIVALENCE MAPPINGS (GEMS) ü Convert ICD-9 to ICD-10 codes (Backward map ICD-10 to ICD-9) ü GEMS are limited and not reliable as a Coding Tool Warning: The GEMS tool is not a substitute for learning and Coding from documentation 1
OBJECTIVES Understand the difference between ICD-9 and ICD-10 Understand Coding Families, Characters, and Symbols Understand Coding Terminology and Rules OBJECTIVES Understand the Fundamentals of Diagnosis Selection Understand Diagnosis Coding as it relates to EI Assessment Learn Coding strategies relevant to the Birth to Three Population 2
WHAT HAS CHANGED? ICD-9 14,000 codes Codes are 3-5 Characters 1 st character is Numeric or Alpha Characters 2-5 are numeric Decimal occurs after 3 rd character No laterality No place holder ICD-10 Over 69,000 codes Codes are 3-7 Characters 1 st Character is always Alpha Second Character is always Numeric Characters 3-7 may be Alpha or Numeric Decimal occurs after 3 rd character Laterality of side affected must be coded Place holder may be used ICD-10 CODING WHAT IS THE BENEFIT TO SWITCHING? Provides more Specific Coding Measuring the quality, efficacy, and safety of care for Public Health Monitoring Better sensitivity for Reimbursement Methodology Allows for Detailing a Clinical Case for Therapy Reimbursement 3
WHAT IS OUR GUIDE? ICD-10 CM Stands for Clinical Modification Covers Out-Patient services What will we use in EI ICD-10 PCS Stands for Procedure Coding System Covers In-patient Claims only CONVERTING ICD-9 TO ICD-10 CMS For 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family is submitted, Medicare/Medicaid will process & not audit valid ICD-10 code. Commercial Payors - have to determine whether they will offer similar audit flexibilities ICD-10 Information from the Department of Medical Assistance Services (DMAS) Services should be billed using the most appropriate diagnosis code(s) for the reason of the service being provided. 4
WHAT IS A CODING FAMILY? ü A SET OF CODES THAT REPRESENT A SPECIFIC MEDICAL SYSTEM OR CATEGORY ü SHARE THE SAME FIRST CHARACTER ü LOCATED BY CHAPTERS IN THE TABULAR INDEX MOST RELEVANT TO THE BIRTH-3 POPULATION v Ch. 5 (F01-F99) Mental, Behavioral, and Neurodevelopmental Disorders v Ch. 6 (G00-G99.) Diseases of the Nervous System v Ch. 13 (M00-M99) Diseases of the Musculoskeletal System and Connective Tissue v Ch. 16 (P00-P96) Certain Conditions Originating in the Perinatal Period v Ch. 17 (Q00-Q99)Congenital Malformations, Deformities, and Chromosomal Abnormalities v Ch. 18 (R00-R99) Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified 5
YOU MAY ALSO NEED TO LOOK HERE! Ch. 7 (H00-H59) Diseases of Eye and Adnexa Ch. 8 (H60-H95) Diseases of Ear and Mastoid Process Ch. 19 (S00-T88) Injury, Poisonings, and Certain Other Consequences of External Causes Ch. 20 (V01-Y99) External Causes of Morbidity CODING CHARACTERS 1 2 3-7. X Alpha Numeric Alpha or Numeric Decimal always after 3 rd character Used as placeholder in order to achieve specificity 6
7 TH CHARACTER Allows for coding to the highest level of specificity Used in Chapter 19 which covers injuries and other consequences of external cause such as burns, fractures, and traumatic brain injury 7 TH CODING CHARACTERS A Initial encounter (not likely in EI) D Subsequent encounter (visit after physician during healing phase) S Sequelae (complications that arise as a direct result of a condition). Code Sequelae condition followed by Injury Code. The injury code contains the S in the 7 th character place. Ex. R26.1 Spastic Gait 5G81.11 Spastic hemiparesis affecting right dominant side 7T74.4XXS Shaken Infant Syndrome 7
EXTERNAL CAUSES OF MORBIDITY Chapter 20 lists Codes that describe the CAUSE of the injury and require 7 characters: Ø Pedestrian hit by collision with car, pick up, or van (Child hit by a car) Ø Fall into Swimming Pool (accidental drownings) Ø Contact with Hot tap water (accidental burns) Ø Child abuse, neglect or other maltreatment 8
CODING SYMBOLS WHEN YOU SEE A DASH FOLLOW A CODE IN THE ALPHABETICAL LISTING, IT MEANS THAT MORE SPECIFICITY IS REQUIRED. Ex. Pervasive Developmental Disorder F84.0- GO TO THE TABULAR SECTION: 4 F84. Pervasive Developmental Disorders Note: Use additional codes to identify associated medical conditions and intellectual disabilities. F84.0 Autistic Disorder F84.2 Rett s Syndrome F84.3 Other Childhood Disintegrative Disorder F84.5 Asperger s Syndrome F84.8 Other Pervasive Developmental Disorders Overactive Disorder associated with intellectual disabilities and stereotyped movements CODING TERMINOLOGY EXCLUDES 1: Means the Code excluded should never be used with the code above. The two conditions cannot occur together. Ex. F81.9 Specific Developmental Disorder of Motor Function Excludes 1: Abnormality of gait and mobility(r26.-) Lack of Coordination (R27.-) 9
CODING TERMINOLOGY EXCLUDES 2 Indicates that the condition excluded (listed) is not part of the condition coded above and the patient may have both conditions at the same time. The two codes may be used together. Ex. F80.1 Mixed Receptive-Expressive Language Disorder Excludes 2: Pervasive Developmental Disorders (F84.-) CODING RULES (N Use Specificity First if you have documentation When sufficient clinical information isn t known or available about a condition, it is acceptable to use the Unspecified or Other code. Not Elsewhere Classified Not Otherwise Specified 10
NOT ELSEWHERE CLASSIFIED NEC AKA as Other or Other Specified Use this when the medical information provides detail for which a specific code does not exist. Ex. R26.89 Other abnormality of gait and mobility Q99.8 Other specified chromosome abnormalities NOT OTHERWISE SPECIFIED NOS AKA Unspecified Used when the information in the medical record is insufficient to assign a more specific code. Acceptable: S06.2X9 Diffuse TBI w/ loss of consciousness of unspecified duration. Avoid using (NOS) Unspecified codes unless required to achieve specificity Not Acceptable: Q35.9 Cleft palate, unspecified When in doubt? Select (NEC) Other 11
WHERE DO YOU START? CODING GUIDELINES Ø Codes that describe symptoms and signs are acceptable for reporting purposes when a diagnosis has not been established/confirmed Ø Only Licensed Medical Professionals may diagnose and assign codes within their realm of expertise, training, and in accordance with their Practice Act: OT, PT, SLP, Licensed Clinical Psychologist, Licensed Clinical Social Worker, Licensed Clinical RN, and Nurse Practitioners 12
CODING GUIDELINES Ø For patients receiving therapeutic services, sequence first the condition, problem, or other reason chiefly responsible for the service provided Ø Tell the Story - Use all codes, as applicable, to show the complexity of the patient and what you are addressing Ø Avoid using only one code 3 WAYS TO GET DIAGNOSIS 1. Medical Referral Source (Hospital, Clinic, Pediatrician) 2. Parent Report Listen to their concern (not sitting, walking, talking) 3. OT, PT, Speech Evaluation 13
NO SPECIFIC DIAGNOSIS? Let Your Assessment Guide You SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS Symptoms and signs involving the nervous and musculoskeletal system R26.0 Ataxic gait R26.1 Spastic gait R26.2 Difficulty walking, NEC (walking disability) R 26.89 Other abnormality of gait and mobility (cautious gait, toe-walking gait, gait disorder due to weakness, postural instability, pain, or multi-factoral) R27.8 Other lack of Coordination R29.3 Abnormal Posture 14
SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS Symptoms and signs involving cognitive function and awareness R41.840 Attention and Concentration Deficit Excludes 1: ADHD R41.89 Unspecified symptoms and signs involving cognitive function and awareness Symptoms and Signs involving speech and voice 5R47 Speech disturbance, NEC Excludes 1: Autism R47.01 Aphasia R47.81 Slurred Speech R47.02 Dysphagia R47.89 Other Speech R48.2 Apraxia Disturbance SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS General Symptoms and signs R62.0 Delayed Milestone in Childhood* R 62.50 Unspecified lack of expected normal physiological development in childhood* R62.51 Failure to Thrive (infant/child > 28 dys. of age) R63.3 Feeding Difficulties (infant/child > 28 dys. of age) *Do not use as single code Ask yourself What are you addressing? 15
SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS Sensory Processing Difficulties? R 27.8 Other lack of coordination R 41.840 Attention and concentration deficit R41.841Cognitive communication deficit R41.89 Other symptoms and signs involving cognitive function and awareness R45.1 Restlessness and agitation R45.87 Impulsiveness R46.3 Overactivity R46.4 Slowness and poor responsiveness R43.8 Other disturbance of smell and taste Accurate Reporting = Use Key words in your Assessment to link it to the diagnosis code 16
HANG IN THERE! THE PERINATAL PERIOD Newborn = the first 28 days of life NEWBORN CODES MAY BE USED THROUGHOUT THE LIFE OF THE PATIENT IF THE CONDITION WAS NOTED AS PRESENT DURING THE FIRST 28 DAYS AND IF THE CONDITION REMAINS PRESENT >28 DAYS. List Birthweight before Gestational Age Gestational Age Each WEEK has Separate Code P07.21- P07.26 (less than 23 weeks to 27 completed weeks) P07.31- P07.39 (28 to 36 completed weeks) Low birthweight is different than SGA SGA (P05.10 - P05.18) Low Birthweight (P07.01-P07.03) (P07.10-P07.18) 17
THE PERINATAL PERIOD Code Together: P04.49 Newborn suspected to be affected by maternal use of other drugs of addiction Excludes 2 P96.1 Withdrawal symptoms from maternal use of drugs of addiction Code Separate: P14.0 Erb s Palsy P14.3 Other Brachial Plexus birth injuries P94.1 Congenital Hypertonia Ex. SGA/IUGR, NAS P94.2 Congenital Hypotonia Ex. Premie, Cardiac, RDS THE PERINATAL PERIOD P78.83 Newborn Esophageal Reflux 4 P92. Feeding Problems of the Newborn P92.0 Vomiting P92.2 Regurgitation P92.3 Slow feeding P92.4 Overfeeding P92.5 Neonatal difficulty feeding at the breast P92.6 Failure to Thrive in newborn P92.8 Other feeding problems of newborn Add: What are you addressing weakness, tone, coordination? 18
MUSCULOSKELETAL SYSTEM Replace ICD-9 728.9 and 781.3 with: M62.81 Muscle Weakness, generalized R29.3 Abnormal Posture R26.89 Other abnormality of gait and mobility (add if working on delayed walking) R27.8 Other lack of coordination (add if there are sensorimotor concerns) Fracture defaults - Closed and Displaced Laterality defaults Right side affected = Dominant Left side affected = Non-dominant Ambidextrous = Dominant CONGENITAL MALFORMATIONS, DEFORMITIES, AND CHROMOSOMAL ABNORMALITIES Q90.0 Trisomy 21, meiotic (93-99% of cases) Q04.0 Congenital Malformations of brain Ex. Agenesis of the Corpus Callosum Congenital not Cardiac: Q21.3 Tetralogy of Fallot Q23.4 Hypoplastic left heart Syndrome Each lists specific kinds: 4Q35 Cleft Palate 4Q36 Cleft Lip 4Q37 Cleft Palate and Lip 19
CONGENITAL MALFORMATIONS, DEFORMITIES, AND CHROMOSOMAL ABNORMALITIES Congenital not Musculoskeletal Q78.2 Osteogenesis Imperfecta Increased Specificity Q93.4 Deletion of short arm of Chromosome 5 Ex. Cri-Du-Chat Syndrome Q93.5 Other Deletions of part of a Chromosome Ex. Angelman s Syndrome Q93.7 Deletions with other Complex Rearrangements Q99.8 Other Specified Chromosome Abnormalities Congenital not PDD Q99.2 Fragile X Syndrome MENTAL, BEHAVIORAL, AND NEURODEVELOPMENTAL DISORDERS 4F80. Specific developmental disorders of Speech and Language F80.0 Phonological Disorders (lalling, lisping, speech articulation Dev. Disorder) Excludes 1 Aphasia, Apraxia Excludes 2 impairment due to hearing loss F80.1 Expressive Language Disorder (Dev. Dysphagia or aphasia) Excludes 1 Mixed Receptive-Expressive language disorder Excludes 2 Intellectual Disabilities F80.2 Mixed Receptive-Expressive Language Disorder Excludes 1 Central Auditory Processing Disorder Excludes 2 Intellectual Disabilities F80.4 Speech and Language Dev. Delay due to Hearing Loss (Code type of hearing loss) F80.8 Other Developmental Disorders of Speech and Language F80.81 Childhood Onset Fluency Disorder (Cluttering, Stuttering) F80.89 Other Developmental Disorders of Speech and Language 20
MENTAL, BEHAVIORAL, AND NEURODEVELOPMENTAL DISORDERS 4 F84.Pervasive Developmental Disorders (Autism, Other PDD, Rett s, Asperger s, Other Child Disintegrative Disorder) Use Speech and Language F80 Codes only Speech delay with another primary dx such as CP or Down Syndrome Can use F80 or R47 Codes, not both Speech delay with No other known diagnosis Can use F80 or R47 codes, not both R47 and R 48 Codes (Aphasia, Apraxia) Exclude the F80 Codes MENTAL, BEHAVIORAL, AND NEURODEVELOPMENTAL DISORDERS Behavioral and Emotional Disorders 4F91. Conduct Disorders 4F93. Emotional Disorders 4F94. Disorders of Social Functioning with onset specific to Childhood 4F95. Tic Disorders 4F98. Other behavioral and emotional disorders Must be confirmed by a Physician, Psychiatrist, or Clinical Psychologist 21
MENTAL, BEHAVIORAL, AND NEURODEVELOPMENTAL DISORDERS Confirmed Disorder or Sign, Symptom, Abnormal Clinical Finding? Think about it 5F98.2 Feeding Disorder of Infancy/Childhood Excludes 1 R63.3 Feeding Difficulty of infant/child F82. Specific Developmental Disorder of Motor Function (Clumsy Child Syndrome, Developmental Coordination Disorder, Developmental dyspraxia) Excludes 1 Abnormality of gait and mobility (R26.-) Ask yourself, could it resolve with Intervention? CODING GUIDELINES Ø Code the condition to the highest degree of certainty Ø Code all documented conditions that coexist at the time of your encounter if they are relevant ü Do not code conditions that were previously treated and no longer exist Ø Do not code diagnoses listed as probable or suspected 22
ICD-10 RESOURCES Use the ICD-10 Coding Book for your Coding: ICD-10 CM 2016 the Complete official Draft Set, AMA, 2015 www.optumcoding.com CMS ICD-10 Website http://www.cms.gov/medicare/coding/icd10/ index.html (sign up for newsletter for updates) KELLYH63@COMCAST.NET PH. 540-272-6306 23
CHEERS! YOU ARE ON YOUR WAY TO MASTERING THE CODE! 24