Mastering ICD-10 Coding

Mastering ICD-10 Coding For Experienced Coding Professionals Presented by: Barbara Oviatt CPC, CCS P

Course Objectives Review the structure and organization of the ICD 10 CM book Examine organizational changes to ICD 10 Identify the areas of similarities and differences between ICD 9 CM and ICD 10 CM Successfully apply ICD 10 CM coding conventions and principles by assigning accurate codes to diagnostic documentation 2

Introduction ICD 10 CM CM OVERVIEW 3

Official Guidelines Developed by the Cooperating Parties: American Hospital Association (AHA) American Health hinformation management Association (AHIMA) Centers for Medicare and Medicaid Services (CMS) National Center for Health Statistics (NCHS) 4

2014 Update 0 9 28 Additions Deletions Revisions 5

Overall Coding Process is the Same! 1. Capture the required encounter documentation 2. Choose the correct code Alphabetic Index Tabular List Read instructional notations 6

ICD 10 Changes Organizational Changes Structural Changes New Features Changes to Guidelines Terminology Updates 7

Official Guidelines I II III IV Conventions, General and Chapter specific Guidelines Selection of Principal Diagnosis Reporting Additional Diagnoses Guidelines for Outpatient Services 8

Section 1 CONVENTIONS 9

Alphabetic Index Divided into two parts: Diseases and Injuries Neoplasm Table Table of Drugs and Chemicals External Causes Formatted like ICD 9 CM Main terms in boldface Subterms and essential modifiers are indented under main terms 10

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Alphabetic Index, Cont. Subterms always read in combination with the main term Nonessential modifiers appear in parentheses and do not affect the code number assigned The dash at tthe end of an index entry indicates that additional characters are required 11

Alphabetic Index, Cont. 12

Alphabetic Index, Cont. 13

Alphabetic Index, Cont. Morphology codes no longer listed in ICD 10 Manifestation codes are suggested in the same manner as ICD 9 CM CM, by including the code as a second code in brackets 14

Tabular List Organizational Changes ICD 9 CM 17 Chapters V codes Ecodes ICD 10 CM 21 Chapters Z codes V, W, X and Y codes 15

Code Structure Chapters are further subdivided into subchapters (blocks) that contain three character categories and form the foundation of the code 16

ICD 10 CM vs. ICD 9 Code Structure ICD 10 CM Code Format ICD 9 CM Code Format Ex: Unspecified asthma with acute exacerbation ICD 10 J45.901 ICD 9 493.92 17

Code Structure Most, but not all, categories are further subdivided into 4 or 5 character subcategories If a category is not further subdivided it is considered to be a valid code Fourth character 8 is used to indicate other specified Fourth character 9 is used to indicate unspecified 18

Compare Codes L03.313 Cellulitis of 682.2 Cellulitis and chest wall abscess of trunk S42.311K Greenstick fracture of shaft of 733.82 Nonunion of Fracture humerus, right arm, Subsequent encounter for fx with nonunion T45.2X5A Adverse effect of vitamins, Initial encounter E933.5 Vitamins, not elsewhere classified, causing adverse effects in therapeutic use 19

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Seventh Character Used in Obstetrics and Injury Sections Meanings vary Either alpha or numeric Placeholder X 20

Use of Seventh Character Episode of care for injuries and external cause Chapter 15 (OB) Represents fetus in multiple gestation affected by coded condition Coma Scale 21

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Placeholder ld Character Provides for future expansion as 5 th character for certain 6 character codes without disturbing the 6 th character structure Assign for all characters less than 6 in order to meet requirement of coding when 7 th character is required 22

Placeholder Character Exercise: What is the use of the X placeholder in subcategory O45.8? What is the use of the X placeholder in category X78? 23

Abbreviations and Punctuation No changes from ICD 9 CM guidelines NEC NOS Brackets [ ] Parentheses ( ) Colons Other Unspecified Includes Notes Inclusion Terms 24

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Excludes Notes Two types of exclusion notes: Excludes 1 indicates not coded here The code excluded is never used with the code selected Excludes 2 indicates not included here The excluded condition is not part of the condition represented by the code and it is acceptable to use both codes together if the patient has both conditions 25

Etiology and Manifestations No changes from ICD 9 CM guidelines Code First Use In diseases Additional classified Code elsewhere And With See and See Also 26

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Code Also Note Not a new concept, but new in the guidelines Instructs that two codes may be required to fully describe a condition, but does not provide sequencing direction 27

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Default Codes Not a new concept, but new in the guidelines A code listed next to a main term in the Index Represents the condition most commonly associated with that t term, or is the unspecified code for the condition 28

Default Codes ICD 10 Index 29

Section 1 GENERAL CODING GUIDELINES 30

General Coding Guidelines Locating a code Most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors. 31

General Coding Guidelines No change in guidelines from ICD 9 Code to highest level of specificity Code signs and symptoms in the absence of a definitive diagnosis Do not code signs and symptoms that are an integral part of a disease process Code signs and symptoms that are not an integral part of a disease process 32

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Combination codes for conditions and common symptoms or manifestations E20.21 Type I diabetes mellitus with diabetic nephropathy I25.110 Ah Atherosclerotic heart disease of native coronary artery with unstable angina pectoris K50.112 Crohn s disease of flarge intestine ti with intestinal obstruction 33

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Combination codes for poisonings and external causes T36.0x1A Poisoning by penicillin, accidental (unintentional), initial encounter T42.4x5A4x5A Adverse effect of benzodiazepines, initial encounter 5 th digit it is a place holder 6 th digit indicates external cause 7 th digit indicates episode of care 34

Sequela (Late Effects) Residual effect after the acute phase of an illness or injury No time limit May occur months or years later Requires two codes 1 st Condition i or nature of sequela 2 nd Sequela code 35

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Sequela (Late Effects) Exception Sequela is followed by a manifestation code identified in the Tabular List Sequela code has been expanded to included manifestation Special chapter specific guidelines for sequela in Cerebrovascular, Complications of Pregnancy, and Injury sections 36

Sequela (Late Effects) Example: Atrophy of muscle of lower leg as a late effect of polio M62.561 Muscle wasting and atrophy, not elsewhere classified, right lower leg B91 Sequelae of poliomyelitis Excludes1: postpolio syndrome (G14) 37

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Laterality Right Left Bilateral If no bilateral code is provided, code both right and left If the side is not indicated in the documentation, code unspecified 38

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Laterality H60.332 Swimmer s ear, left ear S63.411A Sprain of carpal joint of right wrist, initial encounter H65.06 Acute serous otitis media, recurrent, bilateral 39

Section 2 CHAPTER SPECIFIC GUIDELINES 40

Certain Infections and Parasitic Diseases (A00 B99) CHAPTER 1 41

No rule changes HIV B20 Human immunodeficiency virus [HIV] disease Z21 Asymptomatic human immunodeficiency virus [HIV] infection status Z11.4 Encounter for screening for human immunodeficiency virus [HIV] 42

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Infections Resistant to Antibiotics Identify all infections documented as antibiotic resistant Assign code from category Z16 43

Sepsis Assign appropriate code for the underlying systemic infection Assign a code for the organism; if type or causal organism is not further specified, assign code A41.9 Negative or inconclusive blood cultures do not preclude a dx of sepsis 44

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Urosepsis Urosepsis has no default code Provider must be queried Not synonymous with Sepsis 45

Severe Sepsis Requires acute organ dysfunction associated with sepsis Requires a minimum of 3 codes Underlying systemic infection Code from subcategory R65.2 (severe sepsis) If organism is not documented assign A41.9 Associated acute organ dysfunction 46

Severe Sepsis 47

MRSA B95.62 Guidelines remain the same Be aware of new combination codes that include MRSA J15.212 Pneumonia due to MRSA Do not code B95.62 with J15.212 Assign Z22.322 for a person who is a carrier Do not assign code Z16.11 Z1611 48

Coding Scenario 78 year old gentleman is seen for continued follow up for C. diff colitis. Cultures of the organism have found this infection to be resistant to Flagyl. A new drug regimen will be started at this time. What is the correct diagnosis code(s)? 49

A04.7 Colitis (acute) (catarrhal) (chronic)(noninfective) (hemorrhagic), Clostridium difficile Z16.39 Resistance, resistant (to), organism(s), to drug, antimicrobial (single), specified NEC Rationale: ICD 10 CM provides a code to identify resistance to antimicrobial drugs (Z16. ). The use additional code note is found at the beginning of Chapter 1. 50

Neoplasms (C00 D49) CHAPTER 2 51

Organization i and Classification i In situ neoplasms now appear before the block for benign neoplasms Contiguous sites is now referred to as overlapping sites 52

Chapter 2 Guidelines Guidelines in Chapter 2 are consistent with ICD 9 CM; sequencing anemia associated with malignancy is changed form ICD 10 2013 When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the malignancy is sequenced as the principal diagnosis followed by the anemia. 53

Chapter 2 Guidelines, Cont. When the admission is for management of an anemia associated with an adverse effect of the administration of chemotherapy and the only treatment is for the anemia, the anemia is sequenced first, followed by the neoplasm, and the adverse effect code T45.1X5 When the admission is for management of an anemia associated with an adverse effect of radiotherapy, the anemia code should be sequenced first, followed by the neoplasm, and code Y84.2 for abnormal reaction to a radiological procedure 54

Coding Scenario Assign the code(s) for the following diagnosis: i Subacute monocytic leukemia in remission 55

C93.91 Leukemia, leukemic, monocytic (subacute) Rationale: Leukemia is not coded from the Neoplasm Table, but rather indexed under the term Leukemia. Subacute monocytic is classified to subcategory C93.9-. 56

Disease of the Blood and Blood forming Organs and Certain Disorders involving the Immune Mechanism (D50 D89) CHAPTER 3 57

Organization and Classification Immunodeficiency disorders have been reclassified from ICD 9 CM Chapter 4 (Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders) to ICD 10 CM Chapter 3 Diseases and disorders have been grouped into subchapters Terminology changes and greater specificity 58

Chapter 3 Guidelines No chapter specific guidelines for Chapter 3 Important instructional notes throughout the chapter 59

Coding Scenario A 48 year old female is seen for sickle cell crisis ii with acute chest syndrome. Assign the correct diagnosis code(s). 60

D57.01 Anemia, sickle-cell See Disease, sickle-cell, cell with crisis (vasoocclusive pain), with acute chest syndrome Rationale: In some cases, combination codes are used for sickle-cell crisis with manifestation. Note guideline under category D57 to use additional code for any associated fever (R50.81) 61

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Endocrine, Nutritional, and Metabolic Diseases (E00 E89) CHAPTER 4 63

Organization and Classification Diabetes and malnutrition have their own subchapters and code titles revised Diabetes now has five categories (E08 E13) Controlled/uncontrolled is not a factor in code selection 64

Diabetes Mellitus Type of DM Combination codes include Body system affected Complications affecting that body system 65

Diabetes Mellitus Use as many codes as necessary to identify all of the associated conditions Type 2 DM is default if type is not documented Z79.4 Long term (current) use of insulin Use only with Type 2 DM as appropriate Do not use if insulin is given temporarily 66

Chapter 4 Category Guidelines Secondary Diabetes Mellitus Refer to the instructional notes in the Tabular List for categories E08, E09, and E13 for sequencing guidelines 67

Coding Scenario 62 year old male is seen for mild nonproliferative diabetic retinopathy with macular edema. He has type 2 DM and takes insulin on a daily basis. He also has diabetic cataract in his right eye. What diagnosis codes are assigned? 68

E11.321 Diabetes, diabetic (mellitus)(sugar), type 2, with, retinopathy, nonproliferative, mild, with macular edema E11.36 Diabetes, diabetic (mellitus) (sugar), type 2, with, cataract Z79.4 Long-term (current) (prophylactic) drug therapy (use of), insulin Rationale: There is a combination code for the type 2 diabetes with nonproliferative diabetic retinopathy with macular edema. The diabetic cataract was documented and should be coded, but it requires a separate code. Since the patient has type 2 DM, and is on insulin, code Z79.4 should be assigned as indicated by the note at category E11 Use additional code to identify any insulin use (Z79.4) 69

Mental, Behavioral and Neurodevelopmental Disorders (F01 F99) CHAPTER 5 70

Organization and Classification Unique codes for alcohol and drug use, abuse, and dependence Continuous or episodic no longer classified Combination codes Blood alcohol l level l (Y90. ) 71

Pain Disorders F45.41 Pain exclusively related to psychological l disordersd F45.42 Pain disorders with related psychological factors + code from category G89 72

Remission Selection of codes for in remission for categories F10 F19 F19 requires the provider s clinical judgment. The appropriate codes for in remission i are assigned on the basis of provider documentation 73

The ICD-10-CM CM classification system does not provide separate "history" codes for alcohol and drug abuse. These conditions are identified as in remission in ICD-10-CM. 74

Use, Abuse, Dependence When the provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use based on the following: Dependence Abuse Use 75

Coding Note: ICD-10-CM provides a code to indicate blood alcohol level. Under the category F10, there is a "use additional code" note for blood alcohol level. Blood alcohol l level l can be indexed d in the Index to External Causes. 76

Nicotine i Dependence ICD 9 CM CM = 305.1 Tobacco Use Disorder Current smoker Additional documentation required ICD 10 CM CM = F17 Terminology change to Nicotine dependence Type of nicotine (cigarette, chewing tobacco, cigar, pipe, etc.) Remission/Withdrawal/ Uncomplicated Use Z87.891 for History of nicotine dependence Use Z72.0 Tobacco Use (non dependent) 77

Other Tobacco Use Codes Z87.891 History of Tobacco Use Z72.0 Tobacco Use (non dependent) O99.33 Smoking (tobacco) complicating i pregnancy, childbirth, h and the puerperium 78

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Eposreto Exposure Tobacco Smoke Z77.22 Contact with and exposure to environmental tobacco smoke P96.81 Exposure to tobacco smoke in perinatal period Z57.31 Occupational exposure to environmental tobacco smoke 79

Coding Scenario Joe, a 43 year old male, is currently receiving treatment for alcohol dependence. As a result of Joe s drinking, he is also on medication for chronic gastritis. He also has a history of cocaine dependence. What codes are assigned? 80

F10.20 Dependence, (on) (syndrome), alcohol (ethyl) (methyl) (without remission) K29.20 Gastritis (simple), alcoholic F14.21 History, personal (of), drug dependence see Dependence, drug, by type, in remission. Dependence,,(on) (syndrome), drug, cocaine, in remission Rationale: The cocaine dependence is coded as in remission because there is not a history code for drug dependence. d 81

Diseases of the Nervous System (G00 G99) CHAPTER 6 82

Organization and Classification Sleep disorders have been moved from signs and symptoms (ICD 9) to nervous system Sleep apnea has its own subcategory with greater specificity to identify type Diseases of the sense organs are no longer contained in the same chapter as the nervous system 83

Eyes and Ears Have Moved Eyes Chapter 7 H00 H59 Ears Chapter 8 H60 H95 84

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Dominant v. Non Dominant Document Dominant/Non dominant i t in addition to Left or Right If dominant side is not documented use the following default guidelines: For ambidextrous patients, the default should be dominant. If the left side is affected, the default is nondominant. If the right side is affected, the default is dominant. 85

Pain Category G89 May be used in conjunction with other codes to provide more detail Acute or Chronic Neoplasm related Post procedural, Post thoracotomy or Posttraumatic Do not use category G89 if pain is not specified as one of the above 86

Sequencing Pain Category G89 Primary Pain control/pain management is the reason for encounter Neurostimulator is inserted for pain Secondary Encounter is for any other reason except pain control/management 87

Terminology Update Epilepsy terminology updated Localization related idiopathic Generalized idiopathic Special epileptic syndromes Provides specificity for Seizures of localized onset Complex partial seizures Intractable Status epilepticus 88

Category G40 (Epilepsy (p pyand Recurrent Seizures) and G43 (Migraine) 89

Hemiplegia and Hemiparesis Category G81 Hemiplegia, G82 Paraplegia and quadriplegia, G83 Other paralytic syndromes Use only when listed conditions are reported without further specification or are stated to be old or longstanding, with unspecified cause Paralytic sequelae of infarct/stroke are in Chapter 9 90

Coding Scenario Assign the code(s) for left sided hemiplegia 91

G81.94 Hemiplegia. Review Tabular for complete code assignment. Rationale: Under the term Hemiplegia i in the index, the only code option for this diagnosis is G81.9-. Review the Tabular under G81.9-, which offers five code choices. Coding Guideline I.C.6.a states Should the affected side be documented, but not specified as dominant or nondominant and the classification system does not indicate a default, code selection is as follows: If the left side is affected the default is nondominant. 92

Diseases of the Eye and Adnexa (H00 H59) CHAPTER 7 93

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Organization and Classification Entirely new chapter Different organization than ICD 9 Structure still by site but order differs Title changes to some categories to reflect current terminology Expansion of characters to provide for anatomic specificity and laterality 94

Glaucoma Eye Type Stage Glaucoma 95

Glaucoma Guidelines Only use bilateral code when type and stage are the same in both eyes indeterminate should be used based on clinical documentation when the state cannot be clinically determined (do not use for unspecified) 96

Coding Scenario Patient is seen by the physician for moderate primary open angle glaucoma of the left eye. What is the correct diagnosis code for this case? 97

H40.11X2 Glaucoma, open angle, primary. See Tabular for complete code assignment. Rationale: Review of the tabular at code H40.11 indicates the need for a seventh character to designate the stage of the glaucoma. Primary open-angle glaucoma is characterized by visual field abnormalities and intraocular pressure that is too high for the continued health of the eye. In this case, ICD-10-CM does not have separate codes to identify specific eyes. 98

Disease of the Ear and Mastoid Process CHAPTER 8 99

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Organization and Classification New chapter in ICD 10 CM Diseases have been arranged into blocks for easier identification: External ear Middle ear and mastoid Inner ear Other disorders of the ear Intraoperative and postprocedural complications 100

Official Guidelines There are no official i guidelines at this time except for those contained in the Chapter and subchapter headings 101

Otitis Media Use additional code for any associated perforated tympanic membrane (H72. ) Use additional code to identify Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke in the perinatal period (P96.81) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17. ) Tobacco use (Z72.0) 102

Coding Scenario A five year old female is seen for acute ear pain. Examination reveals left acute serous otitis media. Further examination revealed a total perforated tympanic membrane of the right ear due to chronic otitis media. What diagnoses codes are assigned? 103

H65.02 Otitis (acute), media (hemorrhagic) (staphylococcal) (streptococcal) acute, subacute serous see Otitis, media, nonsuppurative, acute, serous. Otitis media, nonsuppurative, acute or subacute, serous H66.91 Otitis (acute), media (hemorrhagic) (staphylococcal) (streptococcal), chronic H72.821 Perforation, perforated (nontraumatic) (of), tympanum, tympanic (membrane) (persistent post-traumatic) (postinflammatory), total 104

Rationale: Otitis media has an expansion of codes in ICD-10-CM to classify these conditions. Laterality is also part of the classification in ICD-10-CM. In category H65, distinction is made between recurrent infections. A note is present stating that an additional code for any associated perforated tympanic membrane should be coded separately. It is then possible to show which tympanic membrane is perforated by assigning the correct code for right side associated with the chronic otitis media. Otitis media refers to inflammation of the middle ear (area between ear drum and inner ear including the eustachian tube.) Serous otitis involves a collection of fluid that occurs in the middle ear space caused by altered eustachian tube function. This is also referred to as secretory or with effusion. 105

Diseases of the Circulatory System CHAPTER 9 106

Organization and Classification Terminology was revised to reflect more current medical practice Hypertension is no longer classified as benign, malignant or unspecified 107

Hypertension More than just I10 HTN with Heart Disease requires documentation causal relationship Heart disease due to hypertension Hypertensive heart disease HTN with CKD Presumes cause and effect Read guidelines carefully 108

Atherosclerotic CAD & Angina Use combination code from I25.11 Not necessary to use an additional code for angina Causal relationship can be assumed in a patient with both Atherosclerotic CAD and Angina 109

Sequelae of Cerebrovascular Disease (CVD) (Category I69) Sequelae of conditions classifiable to I60 I67 May be present at onset or anytime after the onset Use same guidelines for dominant vs. non dominant as Chapter 6 Use I69 if patient has current CVD with deficits from old CVD 110

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Acute Myocardial linfarction Acute MI codes changed dfrom 8 weeks to 4 weeks (28 days) or less I21 Initial AMI code used the entire 28 day period I22 Subsequent AMI code used when a subsequent AMI occurs during the 28 day period of the Initial AMI I23 Complications following AMI must be used in conjunction with a code from I21 or I22 Do not use AMI codes for encounters >28 days 111

Category I22 Category I22 is never used alone A code from category I22 must be used in conjunction with a code from category I21 The sequencing of the I22 and I21 codes depends on the circumstances of the encounter 112

Coding Note: The I23 code should be sequenced first, if it is the reason for encounter, or, it should be sequenced after the I21 or I22 code if the complication of the MI occurs during the encounter for the MI. 113

Coding Scenario This 54 year old female had an acute non ST anterior wall myocardial infarction on August 1 st. On August 15 th she suffered an acute inferior wall myocardial infarction. She is still being monitored for her NSTEMI two weeks earlier. She also has atrial fibrillation. 114

I22.1 Infarct, Infarction, myocardium, myocardial (acute) (with stated duration of 4 weeks or less), subsequent (recurrent) (reinfarction), inferior (diaphragmatic) (inferolateral) (inferoposterior) (wall) I21.4 Infarct, Infarction, myocardium, myocardial (acute) (with stated duration of 4 weeks or less), non-st elevation (NSTEMI) I48.91 Fibrillation, atrial or auricular (established) 115

Rationale: The Official Coding Guidelines specifically address the sequencing of I22 and I21 and this is stated as: The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. 116

Diseases of the Respiratory system (J00 J99) CHAPTER 10 117

Organization and Classification Organized similarly to ICD 9 CM; however, diseases have been rearranged. Terminology changes Example: Asthma classified as mild persistent, moderate persistent, and severe persistent Classification changes that provide greater specificity Manifestations are reflected in the code 118

Chapter 10 Guidelines When assigning any code from this chapter, use an additional code to identify any tobacco dependence, use, or exposure J10 Influenza contains a note to use an additional code to identify the virus J44 and J45 distinguish between uncomplicated cases vs. acute exacerbation 119

Stages of Asthma: Intermittent, mild persistent, moderate persistent, and severe persistent asthma. The following table provides one comparison in children. Asthma Severity Intermittent Frequency of Daytime Symptoms Less than or equal to 2 times per week Mild Persistent Moderate Persistent Severe Persistent More than 2 times per week Daily. May restrict physical activity Throughout the day. Frequent severe attacks limiting ability to breathe. Source: Worldallergy.org 120

Coding Note: In the Tabular there is an Excludes2 note under category J45 for asthma with chronic obstructive pulmonary disease. By definition, when an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together th if the patient t has both conditions at the same time. 121

Coding Scenario The patient has increasing shortness of breath, weakness, and ineffective cough. Treatment included oxygen therapy and advice for smoking cessation. Diagnoses listed as acute respiratory insufficiency due to acute exacerbation of COPD and tobacco dependence. What diagnosis codes are assigned? 122

J44.1 Disease, diseased, pulmonary, chronic obstructive, with exacerbation (acute) F17.200 Dependence (on) (syndrome), tobacco see dependence, drug, nicotine Z71.6 Counseling (for), substance abuse, tobacco Rationale: The acute respiratory insufficiency is a symptom that is an integral part of the COPD and is not coded. 123

Diseases of the Digestive System (K00 K95) CHAPTER 11 124

Organization i and Classification i New subchapters have been added Example: Diseases of the liver Terminology changes Hemorrhage is used for ulcers Bleeding is used for gastritis, duodenitis, diverticulosis, and diverticulitis Identification of obstruction is no longer a part of the ulcer code structure 125

Organization i and Classification i K50 Crohn s Disease has been expanded to 6 characters: 4 th character specifies site 5 th character indicates if a complication is present 6 th character further classifies the specific complication 126

Chapter 11 Guidelines There are no chapter specific guidelines at this time Some code specific guidelines were added 127

Coding Scenario This patient is seen for treatment of a recurrent right inguinal hernia with gangrene and obstruction. What is the correct code assignment for this case? 128

K40.41 Hernia, hernial, (acquired) (recurrent), inguinal (direct) (external) (funicular) (indirect) (internal) (oblique) (scrotal) (sliding), unilateral, with, gangrene (and obstruction), recurrent Rationale: When coding hernias, ICD-10-CM provides specificity by type, laterality, with or without obstruction and recurrence. 129

Diseases of the Skin and Subcutaneous Tissue (L00 L99) CHAPTER 12 130

Organization i and Classification i Complete restructuring Brings together groups of diseases that are related Greater specificity has been added Title changes to reflect current terminology Note: Dermatitis and eczema are used synonymously and interchangeably 131

Pressure Ulcers Pressure ulcer codes are combination codes that identify site, laterality and stage of the ulcer Assignment of pressure ulcer stage is guided by clinical documentation of terms found in the Alphabetic Index Terms not found in the index or no documentation, the provider should be queried 132

Pressure Ulcers, cont. Unstageable is NOT unspecified Based on the clinical documentation No code is assigned if the ulcer is healed Healing ulcers are coded based on the stage documented in the medical record 133

Coding Scenario This 35 year old male patient presents with edema, redness, and pain of the left big toe. He does not remember any injury, but the pain has gotten progressively worse for the past week. Diagnosis: Gangrenous abscess of the entire left big toe. What diagnosis codes are assigned? 134

L02.612 Abscess (connective tissue) (embolic) (fistulous) (infective) (metastatic) )(multiple) (pernicious) (pyogenic) (septic), toe (any) see also Abscess, foot. Abscess, foot I96 Gangrene, gangrenous (connective tissue) (dropsical) (dry) (moist) (skin) (ulcer) (see also necrosis). Necrosis, skin or subcutaneous tissue NEC 135

Rationale: In ICD-10-CM, there are individual categories for abscess (L02) and cellulitis (L03). In ICD-9-CM, these were combined. Note in the Index that abscess of the toe classifies to abscess of the foot, while abscess of the toe nail, classifies to cellulitis, liti toe. There are no includes or excludes notes that preclude the use of the abscess and gangrene code together, nor is there any sequencing guideline available. 136

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Diseases of the Musculoskeletal System and Connective Tissue (M00 M99) CHAPTER 13 138

Organization i and Classification i Almost every code in Chapter 13 of ICD 10 CM has been expanded Greater specificity of sites Laterality Many codes moved from various chapter in ICD 9 CM to Chapter 13 in ICD 10 CM Gout moved from Endocrine Osteomalacia moved from Endocrine 139

Organization and Classification Recurrent and conditions related to a healed injury are usually found in Chapter 13 Current, acute, newinjuries are found in Chapter 19 Osteoporosis with the site of a current pathological fracture is now one code 140

Coding Note: ICD-10-CM CM has three different categories for pathologic fractures due to neoplastic disease, due to osteoporosis, and due to other specified disease. 141

Sub Categories Organized by Site and Laterality Bone Joint Muscle Multiple If no multiple code exists, assign a code for each site Right Left Bilateral If no bilateral code exists, assign a code for each side 142

A D G K P S Pathological or Stress Fracture Seventh Characters Initial encounter Subsequent routine healing Subsequent delayed healing Subsequent nonunion Subsequent malunion Sequela 143

Definitions Spontaneous rupture Occurs when normal force is applied to tissues that are inferred to have less than normal strength Fragility fracture Sustained with trauma no more than a fall from a standing height or less occurring under circumstances that would not cause a fracture in a normal healthy bone 144

Coding Tip: The interpretation of Coding Guideline I.C.13.d.2 must be made by the physician. It is not appropriate for the coder to interpret if the patient had a minor fall or trauma that would not usually break a normal, healthy bone. The physician provides a connection between the fall and fracture due to osteoporosis. 145

Dfiii Definitions Direct Infection of joint, where organisms invade synovial tissue and microbial antigen is present in the joint Indirect Infection,, which may be a reactive arthropathy where microbial infection is established but cannot be identified in the joint, and a postinfective arthropathy 146

Instructional Notes Instructional notes added to explain how codes should be assigned or to define terms 147

Coding Scenario Julia is an 80 year old female seen for the first time by Dr. Welby with senile osteoporosis. She complains of severe back pain with no history of trauma. X rays revealed pathological compression fractures of several lumbar vertebrae. 148

M80.08XA08XA Fracture, pathological (pathologic), due to osteoporosis, specified cause NEC see Osteoporosis, specified type NEC, with pathological l fracture. Osteoporosis (female) (male), senile see Osteoporosis, age-related, with current pathologic fracture, vertebra(e) Rationale: In ICD-10-CM CM, a combination code is utilized to report osteoporosis with an associated pathological fracture. When identifying senile osteoporosis, the code book directs the coder to agerelated osteoporosis. 149

Diseases of the Genitourinary System (N00 N99) CHAPTER 14 150

Organization and Classification Changes made due to outdated terminology Male erectile dysfunction requires identification of cause N52 vs. 607.84 Post traumatic urethral stricture now requires gender identification 151

Chapter 14 Guidelines No changes in CKD guidelines from ICD 9 to ICD 10 Instructions added to menopausal and other perimenopausal p disorders to clarify due to naturally occurring (age related) menopause and perimenopause p are classified to category N95 152

Additional Codes Required N17 Code also underlying condition N18 Code first etiology N30 N31 N33 N40.1 Additional code infectious agent Additional code urinary incontinence Code first underlying disease Additional code for associated symptoms 153

Coding Scenario A 78 year old female is seen with fever, malaise, and left flank pain. A urinalysis shows bacteria of more than 100,000/ml present in the urine and subsequent urine culture shows Proteus growth as the cause of the UTI. The patient also has a history of repeated UTIs over the past several years. 154

N39.0 Infection, infected, infective, (opportunistic), urinary (tract) B96.4 Infection, infected, infective (opportunistic), bacterial NOS, as cause of disease classified elsewhere, proteus (mirabilis) (morganii) Z87.440 History, personal (of), infection, urinary (recurrent) (tract) Rationale: As in ICD-9-CM, the bacteria causing the urinary tract infection is coded as a secondary diagnosis. The following note at code N39.0 states Use additional code (B95-B97) to identify infectious agent. The history of UTI does have a separate history code that t should be added d as an additional diagnosis. i 155

Pregnancy, Childbirth, and the Puerperium (O00 O9A) CHAPTER 15 156

Organization i and Classification i Code titles have been revised to better describe what the code represents Obstructed labor incorporates the reason for the obstruction into the code Some codes require the number of weeks completed (trimester) for code selection Elective abortion (w/o complications) has been moved to Chapter 21 (Z33.2) 157

Chapter 15 Guidelines For use only on maternal records, never on newborn records For use for conditions related to or aggravated by the pregnancy, childbirth, or by the puerperium (maternal causes or obstetric causes) Category Z3A Weeks of Gestation, added to identify specific week of pregnancy 158

Chapter 15 Sequencing Chapter 15 codes (O00 O9A) have priority over codes from other chapters Codes from other chapters may be used as additional (secondary) codes Pregnancy incidental to the encounter code Z33.1 provider must state the condition treated is not affecting the pregnancy 159

Organization i and Classification i Episode of care is no longer a secondary axis of classification Trimesters 1 st Less than 14 weeks 0 days 2 nd 14 weeks 0 days to less than 28 weeks 0 days 3 rd 28 weeks 0 days until delivery Counted from first day of last menstrual period 160

New Features in ICD 10 CM CM O10.012 Pre existing essential hypertension complicating pregnancy, second trimester O99.013 Anemia complicating i pregnancy, third trimester Remember the first digit is the letter O not the number zero 161

Organization and Classification 7 th Character Extensions 162

h 7 th Character Extension OB One of the 7th characters is to be assigned to each code under category O31, O32, O33.3 O33.6, O35, O36, O40, O41, O60.1, O60.2, O64, and O69 The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O31 163

Chapter 15 Sequencing Routine prenatal visit it with no complications Z34 List first Do not use with Chapter 15 codes High risk prenatal visit Category O09 List first Use additional Chapter 15 codes as appropriate 164

Chapter 15 Sequencing No delivery occurs Code principal complication which necessitated t the encounter Code all that apply When delivery occurs Main circumstances or complication Outcome of delivery Category Z37 Secondary code on all maternal records when a delivery occurs 165

Pre Existing vs. Due to Pregnancy Certain categories are distinguished between pre existing and a direct result of pregnancy Assess documentation to determine if condition was pre existing Category O10 Note additional code required on subcategories for pre existing heart disease and CKD 166

HIV in Pregnancy Patient treated for an HIV related illness during pregnancy subcategory O98.7 followed by the code(s) for the HIVrelated illness Use O98.7 and Z21 for asymptomatic HIV status 167

Diabetes in Pregnancy Assign code from category O24 followed by code from diabetes category code(s) E08 E13 as appropriate Code Z79.4 for use of long term insulin Gestational diabetes assign code from sub category O24.4 Do not use Z79.4 for long term insulin with O24.4 Use O99.81 for abnormal glucose 168

Alcohol and Tobacco Use Alcohol Subcategory O99.31 assigned as primary Category F10 assigned as secondary Tobacco Subcategory O99.33 Category F17 assigned as secondary 169

Normal ldelivery Code O80 for normal delivery Always primary Do not use with other Chapter 15 codes Do not code complication if resolved at the time of the delivery Also code Z37.0 for outcome of delivery 170

Peripartum Last month of pregnancy to 5 months post partum Postpartum Immediately after delivery to 6 weeks following delivery Abortion vs. fetal death 20 weeks (ICD 10) instead of 22 (ICD 9) Early vs. late vomiting 20 weeks (ICD 10) instead of 22 (ICD 9) 171

Coding Scenario A 36 year old G2 P1 woman is 26 weeks pregnant and dbeing seen for gestational hypertension. At this time, she is not having any other problems. 172

O13.2 Pregnancy (single) (uterine), complicated by (care of) (management affected by), hypertension, -see Hypertension, complicating, pregnancy, gestational (pregnancy induced) (transient) (without proteinuria). Review the Tabular for complete code assignment. O09.522 Pregnancy (single) (uterine), complicated by (care of) (management affected by), elderly, multigravida. Review the Tabular for complete code assignment. Z3A.26 Pregnancy (single) (uterine), weeks of gestation, 26 weeks 173

Rationale: For both of these codes, the range of codes is further subdivided by the trimester for the current encounter. The note at the beginning of Chapter 15 defines the second trimester as 14 weeks 0 days to less than 28 weeks 0 days. The Index does not provide complete codes; therefore, it is necessary to review the Tabular for complete code assignment. The Z code identifying the weeks of gestation should also be assigned per the use additional code note at the beginning of Chapter 15. 174

Certain Conditions Originating in the Perinatal Period (P00 P96) CHAPTER 16 175

Organization and Classification Suspected to be is included in some code titles as a nonessential modifier New subchapters added 176

Guidelines Only used on newborn records For conditions that originate in the fetal or perinatal period May be used throughout the patient s life 177

Category Z38 Classifies Classifies liveborn Place of birth Type of delivery Principal Principal code Initial record Initial record Newborn Not used Mother record 178

Perinatal period: Before birth through first 28 days after birth B lock P00 P 04 For use for newborns who are suspected of having an abnormal condition resulting from exposure from the mother or the birth process, but without signs or symptoms, and which after examination and observation, is found not to exist May be used even if treatment is begun for a suspected condition that is ruled out 179

Short gestation/ low birth weight and long gestation/ high birth weight Catego ories P07 an nd P0 08 When both birth weight and gestational age of the newborn are available, both should be coded with birth weight sequenced before gestational age. 180

Coding Scenario This full term newborn was delivered four days ago and she was discharged with no problems. After going home she was noticed to be somewhat jaundiced, and her mother brought her to the pediatrician s office. She was diagnosed with hyperbilirubinemia and will have phototherapy provided at home. 181

P59.9 Newborn (infant) (liveborn) (singleton), hyperbilirubinemia Rationale: The birth did not occur at this encounter, so the Z38 category is not assigned. Hyperbilirubinemia without mention of prematurity or specified cause is coded to P59.9. If prematurity was documented, there is a specific code to identify that condition (P59.0). 182

Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00 Q99) CHAPTER 17 183

Organization i and Classification i Arrangement of categories have been grouped into subchapters making it easier to identify types of conditions Terminology changes Greater specificity 184

Codes may be used throughout life of patient. Chapter 17 co odes For birth admission, the appropriate code from category Z38, Live born infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, Q00 Q89. 185

Codes may be used throughout life of patient. Chapter 17 co odes If congenital malformation has been corrected, a personal history code is used Although present at birth, abnormality may not be identified until later in life, and if diagnosed by physician, assign a code from codes Q00 Q99 186

Code may be principal or first listed diagnosis or secondary diagnosis Malform mation n/abno ormali ity When no unique code is available, assign additional code(s) for any manifestations When the code assignment specifically identifies the malformation, deformation, or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately Additional codes should be assigned for manifestations that are not an inherent component 187

Coding Scenario Assign the code(s) for: Cleft palate involving i both the soft and hard palate, with bilateral cleft lip. 188

Q37.4 Cleft, (congenital) lip (unilateral), bilateral, with cleft palate, hard with soft Rationale: Careful review of the documentation is indicated to select the one code that combines these conditions. Cleft lip and palate are congenital defects caused when the bones and tissues don t fuse together in utero. The palate is the roof of the mouth, and consists of the soft (back part near the throat) and the hard (front part behind the teeth) palates. Frequently cleft lip and palate are both present. A cleft lip can be either unilateral or bilateral. The unilateral cleft lip has a gap on one side of the lip under either the left or right nostril, but in a bilateral cleft lip, the gap is on both side of the lip. 189

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Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC (R00 R99) CHAPTER 18 191

Organization and Classification General signs and symptoms follow those related specifically to a body system or other relevant grouping Some codes have been moved to a chapter more specific to the symptom Hematuria now includes various types 192

Codes Used for: 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 Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right 193

Chapter 18 Guidelines Extensive Excludes 1 notes 194

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Repeated dfll Falls R29.6 Use for encounter regarding a current fall Z91.81 History of falling 195

Primarily for use by trauma registries and research use, but may be used in any setting Sequenced after the diagnosis Used with code(s) traumatic One from each subcategory brain injury (R40.21, R40.22, R40.23) needed or sequelae Seventh character indicates when recorded should match of cerebrovascular disease codes Coma Scale 0 Unspecified time 1 In field (EMT or ambulance) 2 At arrival to ER 3 At hospital admission 4 24 hours after admission 196

SIRS Category R65 Codes identify SIRS of noninfectious 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 Sepsis not classified to R65 coded to infection. e.g., A41.9 assigned for sepsis, unspecified 197