ICD-10-CM Chapters 18-21 January 16, 2014 Patricia Gowan, RHIA, CPC, AHIMA Approved ICD-10-CM/PCS Trainer
CHAPTER OVERVIEW Chapter 18 Symptoms, Signs and Abnormal Clinical & Laboratory Findings, NEC (R00-R99) Chapter 19 - Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) Chapter 20 External Causes of Morbidity (V00- Y99) Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99) 2
Resources 2014 ICD-10-CM https://www.cms.gov/medicare/coding/icd10/2014- ICD-10-CM-and-GEMs.html 2014 ICD-10-CM Guidelines http://www.cdc.gov/nchs/icd/icd10cm.htm The Complete Official Draft Code Set 2013, Optum (formerly Ingenix) Detailed Instruction for Appropriate ICD-10-CM Coding, 2013 Optum 3
CHAPTER 18 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings 4
Coding Guidelines Signs and symptoms, Section I.B. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. 5
Signs and Symptoms No more specific diagnosis can be made even after all facts have been investigated Signs or symptoms existing at time of initial encounter - transient and causes not determined Provisional diagnosis in patient failing to return Referred elsewhere before diagnosis made More precise diagnosis not available 6
Coma Scale (R40.2-) Can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequela of CVD codes. Primarily for use by trauma registries, but may be used in any setting. Codes should be sequenced after the diagnosis code(s). One from each subcategory (R40.21, R40.22, R40.23) are needed to complete the scale. 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). 7
Coma scale 7th character The 7th character indicates when the scale was recorded. The 7th character should match for all three codes (R40.21- R40.22-, R40.23-) 0 Unspecified Time 1 In the field (EMT or ambulance) 2 At arrival to emergency department 3 At hospital admission 4 24 hours or more after hospital admission 8
Systemic Inflammatory Response Syndrome (SIRS) Category R65 Codes identify SIRS of non-infectious origin with and without acute organ dysfunction and severe sepsis with and without septic shock Instructional note indicates underlying condition or infection should be coded first such as Injury and trauma (S00- T88) Sepsis not classified to R65 - coded to infection, e.g., A41.9 assigned for sepsis, unspecified. 9
Coding Case Chest pain and vertigo 10
Answer: R07.9 R42 Chest pain, unspecified Dizziness & giddiness includes vertigo NOS Diagnosis not confirmed, therefore the symptoms are coded. 11
CHAPTER 19 Injury, Poisoning, and Certain Other Consequences of External Causes 12
CHAPTER 19 (S00-S99) Arranged by body region (site) Head S00-S09 Neck S10-S19 Thorax S20-S29 Ankle & Foot S90-S99 13
Chapter 19 Two alpha characters: S - Injuries related to single body regions T - Injuries to unspecified body regions, poisonings, external causes Use secondary code(s) from Ch. 20, External Causes of Morbidity to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code. 14
7th Characters Most categories in this chapter have three 7th character values (except fractures): A Initial D Subsequent S Sequela Categories for traumatic fractures have additional 7th character values. 15
Initial Encounter A Patient is receiving active treatment surgical treatment emergency department encounter evaluation and treatment by a new physician 16
Subsequent D After patient received active treatment and is receiving care during the healing or recovery phase. Cast change or removal Removal of external or internal fixation device Medication adjustment Other aftercare and follow up visits following treatment of the injury 17
Sequel S Complications or conditions that arise as a result of a condition, e.g., scar formation after a burn Use both the injury code that precipitated the sequela and the code for the sequela S added only to the injury code, not sequela code. S identifies the injury responsible for the sequela Specific type of sequela, e.g, scar is sequenced first, followed by the injury code. 18
Fractures Greater specificity Type of fracture Specific anatomical site Displaced or nondisplaced Laterality Routine vs. delayed healing Nonunion Malunion Type of encounter 19
Traumatic fractures 7th Characters 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 20
Coding of Traumatic Fractures A fracture not indicated whether displaced or not displaced should be coded to displaced. A fracture not indicated as open or closed should be coded to closed. Some fracture categories (S52, FX of forearm, S72, Fx of femur, S82- Fx of lower leg (including ankle), have additional 7th characters based on the Gustilo open fracture classification. 21
Gustilo Open Fracture Classification B initial encounter for open fracture type I or II (open Fx NOS) C initial encounter for open fracture type IIIA, IIIB, or IIIC E subsequent encounter for open fracture type I or II with routine healing F subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing H subsequent encounter for open fracture type I or II with delayed healing J subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing M subsequent encounter for open fracture type I or II with nonunion N subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion Q subsequent encounter for open fracture type I or II with malunion R subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion 22
Gustilo Open Fracture classification Type Type 1 Type 2 Type 3 Description skin lesion less than (<) 1 cm clean simple bone fracture with minimal comminution skin lesion greater than (>) 1 cm no extensive soft tissue damage minimal crushing moderate comminution and contamination Extensive skin damage with muscle and neurovascular involvement AND/OR High-speed crush injury Segmental of highly comminuted fracture Segmental diaphyseal loss Wound from high velocity weapon Extensive contamination of the wound bed Any size open injury with farm contamination 23
Gustilo Open Fracture classification Type A B C Description Extensive laceration of soft tissues with bone fragments covered usually high-speed traumas with severe comminution or segmental fractures Extensive lesion of soft tissues with periosteal stripping and contamination severe comminution due to high-speed traumas usually requires replacement of exposed bone with a local or free flap as a cover Exposed fracture with arterial damage that requires repair http://www.orthobullets.com/trauma/1003/gustilo-classification 24
CHAPTER 19 Z codes The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings. The 7th character, e.g., D identifies subsequent care of an injury. 25
Clinical Documentation Improvement Fractures Site Laterality Type Location Source: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore MD 21244 26
Adverse Effects, Poisoning, Underdosing and Toxic Effects Codes T36-T65 are combination codes that include the substance that was taken and the intent. External cause code is not required for poisonings, toxic effects, adverse effects and underdosing codes. Do not code directly from the Table of Drugs. 27
Adverse Effects, Poisoning, Underdosing and Toxic Effects Adverse Effect Poisoning Toxic Effect Correctly prescribed and properly administered. Code the nature of the adverse effect, e.g., tachycardia, delirium, vomiting followed by the code for drug (T36-T50). Poisoning or reaction to the improper use of a medication, e.g., overdose, wrong substance given or taken in error, wrong route of administration. Use additional code(s) for manifestations of poisonings. A harmful substance is ingested or comes in contact with a person. Toxic effect codes (T51-T65) have an associated intent: accidental, intentional self-harm, assault and undetermined. 28
Underdosing (New!) T36-T50 Taking less of a medication than is prescribed or instructed (inadvertently or deliberately) Never assign as principal or first-listed codes. Use additional code for intent of underdosing: Failure in dosage during medical and surgical care (Y63.8-Y63.9) Patient s underdosing of medication regime (Z91.12-, Z91.13-) 29
Burns & Corrosions Codes T20-T32 classify burns and corrosions. Thermal burns, except for sunburns, that come from a heat source. Burns resulting from electricity and radiation. Corrosions are burns due to chemicals. Guidelines are the same for burns and corrosions. 30
Coding Case Right forearm fracture, nondisplaced, compound comminuted fracture of the radial shaft. Type II open fracture. 31
Answer S52.354B Nondisplaced comminuted fracture of shaft of radius, right arm. Index: Fracture, traumatic, radius, shaft, comminuted, nondisplaced S52.35 See Tabular List for complete code assignment, including the seventh character. A compound fracture is an open fracture and this is documented as a Type II open fracture. The seventh character B indicates the initial treatment for a Type II open fracture. 32
Chapter 20 External Causes of Morbidity 33
External Causes ICD-9 External Causes of Injury and Poisoning (E800-E999) E810 - Motor vehicle traffic accident involving collision with train. ICD-10 External causes of morbidity (V00-Y99) V45 - Car occupant injured in collision with railway train or railway vehicle. 34
Duplicate ICD-10-CM Codes List of Duplicate ICD-10 codes posted at: https://www.cms.gov/medicare/coding/icd10/2014- ICD-10-CM-and-GEMs.html Example: ICD-9-CM E8341 Other fall from one level to another in water transport injuring occupant of small boat, powered ICD-10-CM E8341 Hypermagnesemia 35
External Cause Codes Alpha characters V, W, X and Y Use with any code in the range A00.0-T88.9, Z00- Z99 health condition due to an external cause Valid for use with infections or diseases due to an external source, and other health conditions such as a heart attack during strenuous physical activity, e.g., shoveling snow Assign the external cause code with the appropriate 7th character (initial, subsequent or sequela) An external cause code can never be a principal (firstlisted) diagnosis. 36
Transport Accidents (V00-V99) A transport accident is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident. Definitions of transport vehicles should be reviewed (pedestrian, motorcycle, car (automobile), aircraft, etc. 37
CHAPTER 20 Transport Accident Use additional code to identify: Airbag injury (W22.1) Type of street or road (Y92.4-) Use of cellular telephone and other electronic equipment at the time of the transport accident (Y93.C-) 38
Category Y92 Place of Occurrence Identifies the location of the patient at the time of injury or other condition. Use with activity code Y93 Use only at the initial encounter Do not use code Y92.9 if the place is not stated or is not applicable. 39
Category Y93 Activity Activity of the patient at the time the injury or other health condition occurred, such as a heart attack while shoveling snow. Use only once, at the initial encounter Use in conjunction with Y92, place of occurrence Not applicable to poisonings, adverse effects, misadventures or sequela. Do not assign Y93.9, unspecified, if the activity is not stated. 40
Category Y99 External Cause Status Indicates work status of the person at the time the event occurred. Military activity Non-military person was at work Student or volunteer was involved in a non-work activity at the time of the event. 41
Category Y99 External Cause Status Assign with other external cause codes, such as transport accidents & falls. Not applicable to poisonings, adverse effects, misadventures, or late effects. Use only once, at the initial encounter Do not assign Y99.9, unspecified, if the status is not stated. 42
Clinical Documentation Improvement Injuries External cause Provide the cause of the injury; ask and document how the injury happened. Place of occurrence Document where the patient was when the injury occurred; for example, at home, at work, in the car, etc. Activity code Describe what the patient was doing at the time of the injury; for example, was patient playing a sport or using a tool? External cause status Indicate if the injury was related to military, work, or other. Source: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore MD 21244 43
Coding Case 1. Cat bite 44
Answer W55.01XA W55.01 Bite, bitten by cat The code is confirmed in the Tabular list. Code W55.01 requires a seventh character and placeholder X. The 7th character A indicates initial encounter for treatment. If a code is not a full six characters, a placeholder X must be used to fill in the empty characters when the seventh character is required. 45
CHAPTER 21 Factors Influencing Health Status and Contact with Health Services 46
Chapter 21 Elective, legal, or therapeutic abortions have been moved from ICD-9 Chapter 11 to ICD-10-CM Chapter 21. Personal and family history codes have been expanded. Code Z66 - Do Not Resuscitate (DNR) status Category Z67 - Blood type Z67.40 Type O blood, Rh positive 47
Use of Z Codes Use in any healthcare setting May be used as either a first-listed (principal dx code in inpatient) or secondary code. Certain Z codes may only be used as first-listed or principal diagnosis. 48
Z Codes Reasons for Encounter A person who may or may not be sick encounters the health services for some purpose: limited care or service for a current condition donate an organ or tissue receive prophylactic vaccination (immunization) discuss a problem which is not a disease or injury When some circumstance or problem is present which influences the person s health status but is not a current illness or injury. If procedure is performed, the procedure code must accompany the Z code. 49
Coding of Immunizations ICD-9 Types of Immunizations: V03 prophylactic vac, bacterial diseases V04 prophylactic vac, certain diseases V05 prophylactic vac, single disease V06 prophylactic vac, combinations of dx ICD-10 Z23 Encounter for immunization Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. If an immunization is given as a routine part of health care, such as a well-baby visit (Z00.129), Z23 may be used a secondary code. 50
Categories of Z Codes 1. Contact/exposure 2. Inoculations and vaccinations 3. Status 4. History (of) personal and family 5. Screening 6. Observation 7. Aftercare 8. Follow-up 9. Donor 10. Counseling 11. Encounters for obstetrical and reproductive services 12. Newborns and infants 13. Routine and administrative examinations 14. Miscellaneous Z codes 15. Nonspecific Z codes 16. Z codes that may only be principal/first-listed diagnosis, e.g., Z04 Encounter for examination and observation for other reasons. 51
Coding Case Pregnancy Test NEG 52
Answer Z32.02 Encounter, pregnancy, test, result negative Code Z32.02 is confirmed in the Tabular list. 53
Questions Please post in Chat box 54