Preparing for ICD-10

Report
Presented by:
Karen Kvarfordt, RHIA, CCS-P, CCDS
President, DiagnosisPlus, Inc.
2014
It’s on our doorstep! The biggest
change to happen in Health Information
Management and the Revenue Cycle
in more than 30 years!
Preparation is the key.
Will you be ready?
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WHO (World Health Organization) owns &
publishes ‘ICD’ (International Classification of
Diseases).
WHO endorsed ICD-10 in 1990; members began
using ICD-10 or modifications in 1994.
United States is the only industrialized country not
using ICD-10 for our coding & reporting of diseases,
illnesses, and injuries. Why?
What makes us so different?
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United Kingdom (1995)
Denmark, Finland, Iceland, Norway, Sweden
(1994 – 1997)
France (1997)
Australia (1998)
Belgium (1999)
Germany (2000)
Canada (2001)
U.S. (2015) (Reimbursement + Case Mix)
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If it’s not broken, why fix it?
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Bottom line…We have run out of space and
cannot capture any new diseases and/or
procedures.
 Does not capture ‘specificity’ as ICD-10 does.
 In 1979, the year ICD-9 was implemented,
the Nobel Prize was awarded for the CT
scanner.
Just think about how far we have come in
healthcare since then, while our codes have
remained in ICD-9!
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We all know that ICD-10 will
impact the coder, but who else?
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Scheduling – Pre-certs, eligibility
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◦ Don’t forget Medicaid!
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Medical Necessity CPT Codes –
software, manual processes,
cheat sheets
Recurring Accounts – Will need
new pre-certs & re-coded after
October 1, 2015
Payer Acceptance of new ICD-10
codes PLUS ICD-9 codes – 2
batches
Payer Contract Language – Dx
codes
Payer Remark Codes/Denial
Codes
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CDM – Hardcoded RT/LT needs
to match with the soft coded
RT/LT ICD-10 diagnosis code
Trauma Registry – Translation of
codes
All IT Systems Within The
Organization
Decision Support & Utilization
Patterns – Will need to be
translated
Revise Forms To Include New
ICD-10 Codes
◦ Lab Requisitions
◦ Physician encounter forms
◦ EMR
◦ CPOE
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UB submissions with ICD-9 and ICD-10 - conversion
dates
Denials with new reasons – as ICD-10 is far more
specific
Contract language that addresses ICD-10
inclusions/exclusions
Claim scrubbers/payer scrubbers – ABN issues
(LCD/NDC dx codes), ‘if’ rules, edits
Pre-authorization process/coverage
WC and Liability are not subject to HIPAA standard
transactions. Will they convert? What does this really
mean?
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Physician dictates ► hospital coders code ► UB is
created.
New! Why not share the codes with the providers who
are attached to the account? Why repeat the same
coding process in the physician office?
New! Brown bag coding luncheons with the provider
offices. Office brings samples to code, hospital coders
code while teaching ICD-10 concepts.
New! Hospital becomes the outsourcing company to
assist small practices with coding.
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So…what is ICD-10?
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Department of Health and Human Services (HHS)
mandated that HIPAA covered entities must update medical
coding sets, effective October 1, 2015 (1 year delay).
Diagnosis code set changes from ICD-9-CM to ICD-10-CM.
Hospital inpatient procedure code set changes from
ICD-9-CM (Volume 3) to ICD-10-PCS.
No impact on CPT and/or HCPCS codes. Yeah!
We will still report CPT codes for all outpatient
procedures/services & physician hospital visits to
Observation and Inpatients (E&Ms).
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 ICD-10-CM
(Diagnoses)
◦ Will be used by all hospitals, providers, clinics,
lab, radiology, psych, rehab, nursing homes, etc.
 ICD-10-PCS
(Procedures)
◦ Will be used only for hospital claims for inpatient
hospital procedures
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CPT/HCPCS – No change!
◦ Procedures for Hospital Outpatients, Physician
Visits, Lab and Radiology Outpatients, etc.
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October 1, 2015 – Compliance date for
implementation of ICD-10-CM (diagnoses)
and ICD-10-PCS (inpatient procedures).
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CMS initially stated that there would be no
grace period. Then why the 1 year delay?
And now another year?
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CMS clarified policy for processing split claims for
hospital encounters that span the ICD-10
implementation date.
◦ MLN (Medical Learning Network) Matters Number: SE1325
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Split Claims
◦ Require providers split the claim so all ICD-9 codes remain
on one claim with Date of Service (DOS) through September
30, 2015, and all ICD-10 codes placed on the other claim
with DOS beginning October 1, 2015 and later.
◦
Same guidance for Inpatient and Outpatient encounters!
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Diagnosis Coding
(ICD-10-CM)
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ICD-9-CM
◦ 3 - 5 digits or characters
◦ 1st character is numeric or
alpha (E or V codes)
◦ 2nd – 5th characters are
numeric
◦ Decimal placed after the first
3 characters
◦ 17 Chapters and “V” & “E”
codes are ‘supplemental’
◦ 14,000 diagnosis codes
ICD-10-CM
◦ 3 - 7 digits or characters
◦ 1st character is alpha (all
letters used except “U”)
◦ 2nd – 7th characters can be
alpha and/or numeric
◦ Decimal placed after the first
3 characters (the same!)
◦ 21 Chapters and “V” & “E”
codes are ‘not’ supplemental
◦ 69,000+ diagnosis codes
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X X X
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X X X
X
Category
Etiology, anatomic
site, severity
Extension
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Provides many, many more categories for
diseases and other health-related
conditions
Higher level of “specificity”
Combined etiology and manifestations,
poisoning and external causes, or
diagnosis and symptoms into a single
code
Did you know that ICD-11 is already
in draft format?
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Greater “specificity and detail” in all diagnosis codes!
◦ But…is there supporting physician documentation in the
medical record?
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34,250 (50%) of all ICD-10-CM codes are related to
the musculoskeletal system
17,045 (25%) of all ICD-10-CM codes are related to
fractures
◦ 10,582 fracture codes will distinguish ‘right’ vs. ‘left’
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25,000 (36%) of all ICD-10-CM diagnosis codes will
now distinguish right vs. left
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ICD-9-CM (Irregular Astigmatism) (367.22)
◦ Only 1 code in ICD-9-CM
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ICD-10-CM (Irregular Astigmatism)
◦ Will have 4 code choices:
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H52.211 (Irregular astigmatism, right eye)
H52.212 (Irregular astigmatism, left eye)
H52.213 (Irregular astigmatism, bilateral)
H52.219 (Irregular astigmatism, unspecified eye)
Physicians are likely documenting “laterality” now,
but coders aren’t looking for it.
◦ One easy place to look for documentation improvement!
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Combination codes for conditions and common
symptoms or manifestations
 E10.21 Type 1 diabetes mellitus with diabetic nephropathy
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Added laterality (left vs. right)
 M94.211 Chrondromalacia, right shoulder
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Added 7th character extensions for episode of care
 S06.01xA Concussion with loss of consciousness of 30 minutes
or less, initial encounter
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Expanded codes (injuries, diabetes, alcohol &
substance abuse, postoperative complications)
 F14.221 Cocaine dependence with intoxication delirium
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Injuries are grouped by anatomical site rather than by the
type of injury
Diseases of the sense organs (eyes & ears) have their own
chapters, no longer part of the Nervous System chapter
Inclusion of trimesters in obstetric codes and elimination of
5th digits for episode of care
 O99.013 Anemia complicating pregnancy, third trimester
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Change in timeframes specified in certain codes
 Acute myocardial infarction – time period changed from 8 weeks to 4
weeks
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Full code titles for all codes (no reference back to common
fourth and fifth digits)
Post-op complications have been moved to procedurespecific body system chapters
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We tend to focus on the ways ICD-10-CM
is different, such as:
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Number of codes (69,000+)
Length of the codes
The “look” of the codes
Level of specificity
Increased documentation requirements
But wait! The indexes will be structured
very much the same as in ICD-9-CM.
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Two main parts: Alphabetic Index &
Tabular List
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Alphabetic Index
◦ Alphabetical list of terms and their
corresponding codes
◦ Index to Diseases and Injury
 Neoplasm Table
 Table of Drugs and Chemicals
◦ Index to External Causes of Injury
Coding Tip: The “-” at the end of an index entry indicates that
additional characters are required – need to look further!
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Chronological list of codes divided into chapters (21)
based on body system and/or condition. Further divided
into categories and subcategories which may be either
letters or numbers.
For some chapters, the body or organ system is the axis
of the classification.
Diseases/conditions of the sense organs (eyes and ears)
have been separated from the Nervous System
diseases/conditions and have their own chapters in ICD10-CM.
Certain diseases have been reclassified (or reassigned)
to a more appropriate chapter in ICD-10-CM.
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The final character in a code may be either a letter
or a number.
Utilizes dummy place holders, always letter “x”.
◦ Is not case-sensitive (upper/lower case)
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A dummy “x” is used as a 5th character place
holder for certain 6 character codes to allow for
future expansion.
Certain categories have 7th character extensions
(fractures/injuries/obstetrics). The extension is
required for all codes within the category, or as the
notes in the tabular instruct.
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Found predominately in 2 chapters:
◦ Chapter 19 (Injury, Poisoning and Certain Other
Consequences of External Causes)
◦ Chapter 15 (Pregnancy, Childbirth and the Puerperium)
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Injuries/Poisonings:
◦ Episode of Care: Designates the episode of care as initial,
subsequent or sequela
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Pregnancy/Childbirth/Puerperium:
◦ Provides additional information about the fetus:
 Used to identify certain complications of pregnancy with multiple
gestation to identify which fetus(es) is(are) affected by the
condition indicated by the code.
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ALL diagnoses within this category will
require a 7th character (episode of care).
 Tabular list will identify which diagnosis
codes will need this final character in the
code.
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 Provides a shaded box to let you know the
applicable 7th characters for the code.
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Have to “build” the characters to get to the
final spot in the code (7th character).
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A Initial encounter
D Subsequent encounter
S Sequela (disease progression/late effect)
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Coders will need to look for the episode of care. Is
this the patient’s 1st visit for treatment or is it for
routine follow-up? Is it clearly documented in the
medical record?
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Period when a patient is receiving ‘active’ treatment
for an injury, poisoning or other consequences of
an external cause.
“A” may be assigned on more than 1 claim.
 Patient is seen in the ER for a head injury that first
is evaluated by the ER physician. If the ER
physician requests a CT scan that is subsequently
read by a radiologist and/or neurologist, the 7th
character “A” for initial is used by all 3 physicians
and also reported on the ER claim by the hospital.
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Occurs after the active phase of treatment,
when patient is receiving routine care during
a period of healing or recovery.
 Examples of “subsequent” care:
 Cast change or removal
 External or internal fixation removal
 Medication adjustment
 Follow-up visits following fracture
treatment
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Today we code the ‘after care’ code as the
principal diagnosis, i.e., V57.1 (physical
therapy), etc.
 In ICD-10-CM we will have to report the acute
injury code with the correct 7th character, i.e.,
“D”, etc. to identify that it is a ‘subsequent’
encounter.
 What is on your order today? Injury diagnosis
or just order for PT?
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Assigned for complications or conditions that arise as
a direct result of an injury.
◦ Example: Scar resulting from a burn
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When using extension “S”, you will code both the
injury that precipitated the sequela and the sequela
itself.
There is no time limit on when a sequela code can be
used.
◦ Coding Tip! Sequence the specific type of sequela, i.e., scar
first, followed by the injury code, i.e., burn as the secondary
diagnosis.
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Fracture Coding
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Coders will need the following to code a
fracture in ICD-10-CM:
◦ Displaced or non-displaced
◦ Open or closed
◦ Laterality (left vs. right vs. bilateral)
◦ Specific bone and location of the bone
 Distal, proximal, mid-shaft, etc.
◦ Encounter
 Initial, subsequent, sequela
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Identifies if the fracture is open or closed for an
initial encounter, or if a subsequent encounter is
for routine healing, delayed healing, nonunion,
malunion, and/or sequela.
◦ Fracture extensions:
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A
B
D
G
K
P
S
(Initial encounter for closed fracture)
(Initial encounter for open fracture)
(Subsequent encounter for fx with routine healing)
(Subsequent encounter for fx with delayed healing)
(Subsequent encounter for fx with nonunion)
(Subsequent encounter for fx with malunion)
(Sequela)
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Initial encounter for closed and open fractures
◦ Use while the patient is receiving “active” treatment for
the fracture
7th Character Extensions:
 A ► Closed fracture
 B ► Open fracture type I (one) or II (two) or
unspecified
 C ► Open fracture type III (three)
Examples of “active” treatment:
 Surgical treatment
 Emergency Department encounter
 Evaluation & treatment by a new physician
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Subsequent encounter for open and closed
fractures:
◦ Used for encounters after active fracture treatment
has been completed and the patient is receiving
routine care during the healing or recovery period.
 Closed Fracture 7th Character Extensions:
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D ► Routine healing or aftercare
G ► Delayed healing
K ► Nonunion
P ► Malunion
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Gustilo-Anderson classification identifies the energy,
soft-tissue damage, and the degree of contamination
in “open” fractures – may be new to coders and
orthopedic physicians.
◦ Type I: Wound is smaller than 1 cm, clean, and generally
caused by a fracture fragment that pierces the skin (low
energy injury)
◦ Type II: Wound is longer than 1 cm, not contaminated, and
w/o major soft tissue damage or defect (low energy injury)
◦ Type III: Wound is longer than 1 cm, with significant soft
tissue disruption. The mechanism often involves highenergy trauma, resulting in a severely unstable fracture with
varying degrees of fragmentation.
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Purpose of the fracture classification system in the
clinical setting is to allow communication that infers
fracture morphology and treatment parameters.
Important to educate providers on the use of this
scale for the specific documentation necessary in
ICD-10-CM.
Make sure to look at each 7th character box in the
fracture section, as not all categories utilize the
Gustilo classification because it is not for all bones
or all types of fractures.
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 There
are no combination codes for
fractures involving both the radius and
ulna in ICD-10-CM.
 Each fracture will be coded separately.
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24 choices for fracture of clavicle (only 1 in ICD-9-CM)
Documentation must include:
◦ Laterality
◦ Displaced (anterior or posterior displacements)
◦ Nondisplaced
◦ Location: sternal end, shaft, lateral end, unspecified
◦ 7th character extension
◦ Example: S42.011B (Anterior displaced fracture of
sternal end of right clavicle initial encounter open
fracture)
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I10
Essential (primary) hypertension
S01.02xA Laceration with foreign body of scalp, initial
encounter
S01.02xD Laceration with foreign body of scalp,
subsequent encounter
S02.2xxA Fracture of nasal bones, initial encounter for
closed fracture
H65.01
Acute serous otitis media, right ear
H65.02
Acute serous otitis media, left ear
H65.03
Acute serous otitis media, bilateral
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On any given day, anything can happen!
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W17.82xA Fall from (out of) grocery cart, initial
encounter
V94.4xxA Injury to barefoot water-skier, initial
encounter
W61.43xA Pecked by turkey, initial encounter
Y93.C2
Activity, handheld interactive electronic
device, i.e., cellular phone
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CMS has created GEMs (General Equivalence
Mappings) to assist hospitals with cross walking
ICD-9-CM ►ICD-10-CM/PCS “forward mapping” &
ICD-10-CM/PCS ◄ ICD-9-CM “backward
mapping”. The correlation between the 2 code
sets for some codes is fairly close, but not a
straight correlation for others, i.e. OB, etc.
Not always 1 to 1 crosswalk from ICD-9-CM to
ICD-10-CM (www.cms.gov/ICD10/11b15_2013_ICD10PCS.asp)
Available on CMS’s website
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ICD-9-CM Code
Diagnosis
ICD-10-CM Code
V20.2
Routine infant or child examination
Z00.129 (Encounter for routine child exam without
abnormal findings). Z00.121 (Encounter for routine
child exam with abnormal findings). “Use additional
code(s) to identify abnormal findings”.
250.00
DM w/o complications, type II or unspecified
E11.9 (Type II DM without complications)
V04.81
Need for prophylactic vaccination and inoculation
Z23 (Encounter for immunization). “At this time in
ICD-10-CM there is only one code for
immunizations”.
401.1
Hypertension, benign
I10 (Essential [primary] hypertension). “ICD-10-CM
does not differentiate between hypertension that is
controlled or uncontrolled, benign or malignant and
there is only one code”.
427.31
Atrial fibrillation
I48.0 (Atrial fibrillation)
I48.1 (Atrial flutter)
786.50
Chest pain, unspecified
R07.0 (Chest pain, unspecified). “ICD-10-CM
expands upon chest pain symptoms and
unspecified code may no longer be necessary”.
465.9
URI
J06.9 (Acute upper respiratory infection,
unspecified)
724.2
Lumbago
M54.5 (Low back pain)
466.0
Bronchitis, acute
J20.0 (Acute bronchitis, unspecified). “ICD-10-CM
includes 10 choices for acute bronchitis”.
729.5
Limb pain
M79.604 (Pain in right leg)
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ICD-10-CM Code Structure
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1st character is always an alphabetic letter. All the
letters of the alphabet are used except for the
letter “U” which has been reserved for the
provisional assignment of new diseases &
uncertain etiology (U00-U49) & for bacterial
agents resistant to antibiotics (U80-U89).
ICD-10-CM codes may consist of up to seven
characters, with the 7th character extensions
representing ‘visit’ encounter or sequela for
injuries and external causes.
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X X X
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X X X
X
Category
Etiology, anatomic
site, severity
Extension
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Laterality: left vs. right vs. bilateral
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For bilateral sites, the final character of the codes in
ICD-10-CM indicate laterality.
Right side is always character 1 (RT)
Left side is always character 2 (LT)
Bilateral code is always character 3 (RT & LT)
But wait! Not all codes will have a ‘bilateral’
distinction, i.e., carpal tunnel, etc.
“Unspecified” side code is also provided should the
side not be documented in the medical record.
Did we just lose our specificity?
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Providers will need to document which side, left or
right, that the injury or diagnosis has occurred for
over 25,000 + codes.
◦ H60.332 – Swimmer’s ear, left ear
◦ M94.211 – Chrondromalacia, right shoulder
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Coders should always assign the detailed codes,
not the ‘unspecified’ codes that are also in
ICD-10-CM, but to do that, the physician has to
document it in the medical record.
What do they document today?
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Joint pain
Joint effusion
Injury
Fractures
Start working with your physicians
Dislocations
now to get them in the habit of
Arthritis
documenting laterality!
Cerebral infarction
Extremity atherosclerosis
Pressure ulcers
Cancers, neoplasms (breast, lung, bones, etc.)
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Rather than reporting codes according to the
episode of care, coders will report pregnancy
codes by trimester in ICD-10-CM.
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ICD-9-CM: Pregnancy codes are defined by
the ‘episode of care’
 Unspecified
 Delivered
 Antepartum
54
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Under ICD-10-CM diagnosis codes will be based
on the “stage” of pregnancy:
 1st trimester
 2nd trimester
 3rd trimester
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Trimesters are counted from the first day of the
last menstrual period, and defined as:
 First trimester:
Fewer than 14 weeks
 Second trimester: Fourteen weeks
 Third trimester:
Twenty-eight weeks
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Time frame for differentiating the abortion and fetal
death codes has changed from 22 ►20 weeks
Time frame for differentiating early and late vomiting
in pregnancy will now change from 22 ►20 weeks
Pre-term labor is defined as before 37 weeks of
gestation (more defined definition)
And…7th character extension to identify the fetus in
multiple gestation:
0 – Not applicable or unspecified
1 – Fetus 1
2 – Fetus 2
3 – Fetus 3
4 – Fetus 4
5 – Fetus 5
9 – Other fetus
56
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Terms “fetus” and “newborn” used in many of the
ICD-9-CM code titles have been removed in many
of the ICD-10-CM code descriptors.
◦ Single liveborn infant (Z38.00)

Additionally, newborns affected by maternal
factors and by complications of pregnancy, labor &
delivery, the phrase “suspected to be” is included
in the code title.
◦ P00.4 Newborn (suspected to be) affected by maternal
nutritional disorders
◦ P00.5 Newborn (suspected to be) affected by maternal
injury
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Need to specify when intermittent attacks vs. persistent
manifestations
Document the Severity (3 levels):
1. Mild (more than two times per week)
2. Moderate (daily and may restrict physical activity)
3. Severe (throughout the day with frequent severe attacks
limiting the ability to breathe)
Clarification as to whether intrinsic or extrinsic
Exercise-induced or other forms
Specify when chronic state asthmatic bronchitis exists and
when “acute exacerbation” occurs
Differentiate from bronchiolitis (RSV?) and aspiration
Document tobacco exposure or history of
58
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Diabetes mellitus codes are expanded to include
the classification of the diabetes and the
manifestation by using 4th or 5th characters.
◦ Moving from 1 category of “250” ► 5 categories in ICD-10!
◦ ICD-9-CM = 59 diagnosis codes
◦ ICD-10-CM = 200+ diagnosis codes!

Whether or not diabetes is stated as ‘controlled’ or
‘uncontrolled’ is not a factor in ICD-10.
 E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
 E11.41 Type 2 diabetes with diabetic mononeuropathy
 E09.52 Drug or chemical induced diabetes mellitus with
diabetic peripheral angiopathy with gangrene
59
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Documentation needs to distinguish when due to
intake of excessive calories vs. other causes
Identify when morbid obesity exists
Identify when obesity hypoventilation syndrome
exists
Identify when patient is overweight if it impacts
patient care
Diagnosis of obesity or overweight MUST be
documented by the physician
Coding of the patient’s BMI, however, can be taken
from nurses or dietician’s notes
60

Assign the code(s) for the following diagnosis:
Morbid obesity with a BMI of 42 in an adult
E66.01
Z68.41
Morbid (severe) obesity due to excess calories
Body mass index (BMI) 40.0 – 44.9. adult
◦ Tip! In the Tabular, the subcategory is Obesity due to excess
calories. This is the correct code even though it is not
documented that excess calories caused the obesity. This is
the “default” code.
◦ Note at category E66 indicates that an additional code
should be assigned for the BMI when known.
61
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ICD-10-CM provides 50 different codes for
“complications of foreign body accidently left in
body following a procedure”, compared to only
one code in ICD-9-CM.
◦ T81.535 – Perforation due to foreign body accidently left
in body following heart catheterization
◦ T81.524 – Obstruction due to foreign body accidently left
in body following endoscopic examination
◦ T81.516 – Adhesions due to foreign body accidently left
in body following aspiration, puncture or other
catheterization
62
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ICD-10-CM in the Tabular List states:
◦ I10 Essential (primary) hypertension
◦ Includes: High blood pressure
◦ Hypertension (arterial) (benign) (essential) (malignant)
(primary) (systemic)
◦ Excludes1: Hypertensive disease complicating pregnancy,
childbirth and the puerperium
◦ Excludes2: Essential (primary) hypertension involving
vessels of brain, essential (primary)
hypertension involving vessels of eye
No longer matters whether hypertension is malignant
or benign in ICD-10-CM!
63
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ICD-10-CM contains a separate category (F17) for
nicotine dependence with further subcategories to
identify the specific tobacco product and nicotine
induced disorder. Some examples:
 Cigarettes
 Chewing tobacco
 Cigar, etc.

ICD-9 has only one diagnosis code 305.1!
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
In Chapter 11 (Diseases of the Digestive System K00-K94) some terminology changes have occurred.

The term “hemorrhage” is used when referring to
ulcers, and the term “bleeding” is used when
classifying gastritis, duodenitis, diverticulosis and
diverticulitis.
 K25.0 Acute gastric ulcer with hemorrhage
 K29.01 Acute gastritis with bleeding
 K57.31 Diverticulosis of large intestine without perforation or
abscess with bleeding
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

While ICD-9-CM did add a subcategory for
pressure ulcer stages in 2008, two codes are
required to code this specificity today but…
ICD-10-CM provides the site (including laterality)
and the stage all in one code (combination code)!
◦ Let’s code one! Find the diagnosis code for a pressure
ulcer, Stage 2, left ankle
L89.5-
What diagnosis code did you come up with?
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

Code category T20-T32 classifies burns and
corrosions in ICD-10-CM.
Burn codes identify:
◦ Thermal burns, except for sunburns, that come from a
heat source.
◦ Also burns resulting from electricity and/or radiation.

Addition of the term “corrosion” is new in
ICD-10-CM.
◦ Corrosions are burns due to chemicals.
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
“Underdosing” will be a new term to us in
ICD-10-CM and is defined as taking less of a
medication that is prescribed by a physician
and/or manufacturer’s instructions with a
resulting negative health consequence.
 Financial Reasons (#1)
 Patient Non-Compliance
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ICD-10-CM Conventions
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

Many, but not all, of the ICD-10-CM conventions are
similar to the ICD-9-CM conventions.
Similar to ICD-9-CM, abbreviations, punctuation, symbols
and notes are used as conventions and have special
meanings that affect the code assignment.
◦ NEC (Not Elsewhere Classified) – “other” types of
conditions
 H26.8 Other specified cataract
◦ NOS (Not Otherwise Specified) – used when the
documentation of the condition by the provider is
insufficient to assign a more specific code
 J12.9 Viral pneumonia, unspecified
Notice anything familiar?
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
ICD-9-CM uses “Includes” and “Excludes”
notes
◦ Includes: Good indication your in the right
place
◦ Excludes: Better keep looking because you’re
in the wrong place

ICD-10-CM will use:
 Excludes1
 Excludes2
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
Excludes1 note (pure Exclude) indicates ‘not
coded here’. The code being excluded is never
used with the first listed code. The two conditions
cannot occur together.
◦ Example: B06 Rubella [German Measles] has an
Excludes1 of congenital rubella, P35.0

Exlcudes2 note indicates ‘not included here’. The
excluded condition is not in this section of codes,
so you will have to look elsewhere in the book to
code that specific condition.
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Includes
 Excludes Notes

 Excludes1
 Excludes2
Code First/Use Additional Code
 Code Also
 7th characters (extensions) *new*
 Placeholder “x” *new*

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



Dummy placeholder which is always the letter “x”
and is not ‘case sensitive’
When “x” is in the 5th or 6th character, the “x” is
called a placeholder
When “X” (upper case) is at the beginning of a
code, it represents a specific “chapter”
Coders will need to add a placeholder so the 7th
character ends up in the correct position,
otherwise, the code will be invalid
 S01.02xA Laceration with foreign body of scalp, initial
encounter
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ICD-10-CM
Coding Guidelines
75




General coding guidelines for ICD-10-CM are
similar to ICD-9-CM counterparts with one
additional “new” guideline – laterality
The laterality guideline states “For bilateral sites,
the final character of the codes in ICD-10 indicates
laterality”
An “unspecified” side code is also provided should
the side not be identified in the record
If no bilateral code is provided and the condition is
bilateral, assign separate codes for both the left &
right side
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
Chapter 6: Diseases of Nervous System and
Sense Organs (G00-G99)
◦ Dominant vs. Non-Dominant side
 Medical record documentation must identify whether
the dominant or non-dominant side is affected.
 Should the affected side be documented, but not
specified as dominant or non-dominant, code selection
should be:
 If the left side is affected, the “default” is
non-dominant.
 If the right side is affected, the “default” is dominant.
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

Chapter 16: Certain Conditions Originating in the
Perinatal Period (P00-P96)
“New” notes that help clarify how codes are to be
used.
◦ Following note appears under P07:
 When both birth weight and gestational age of the newborn are
available, both should be coded with birth weight sequenced
before gestational age.

Additional note: Codes from this chapter are only
for use on the newborn or infant record, never on
the mother’s record.
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


Currently in ICD-9-CM, if a patient is admitted for
complications due to the malignancy, the complication,
i.e., anemia, is the principal diagnosis.
In ICD-10-CM, if the patient is admitted for anemia
associated with malignancy and the treatment is only for
the anemia, the appropriate code for the malignancy is
sequenced as the principal diagnosis followed by code
D63.0 (anemia in neoplastic disease) as a secondary
diagnosis.
Note! Docs will need to document whether the anemia
is associated with the neoplasm or an adverse effect of
the treatment associated with the malignancy.
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Let’s Take a Sneak Peek At
Procedure Coding In ICD-10!
(ICD-10-PCS)
80
 Only
reported on “inpatient” hospital
procedures.
 Every procedure will be 7 characters
(alphanumeric) with no decimal point.
 Letters “I” and “O” are never used in
the actual procedure code.
 3,000 ►71,920 procedure codes!
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1
2
3
4
Root
Operation
Section
5
6
Approach
Body
Body
System
Part
7
Qualifier
Device
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Endoscopic Esophageal Excision
via Natural or Artificial Opening
ICD-9: 45.16 Esophagogastroduodenoscopy (EGD) with Closed Biopsy
0
D
B
5
8
Z
X
Section
(Medical/Surgical)
Body System
(Gastro-intestinal)
Root
Operation
(Excision)
Body Part
(Esophagus)
Approach
(Via natural or
artificial opening
endoscopic)
Device
(No Device)
Qualifier
(Diagnostic)
83
Physician Documentation
84
ICD-10 impacts physician documentation in
both the office and hospital settings.
 Many physicians consider additional
documentation requirements to be an
unnecessary burden imposed by the
mandated federal requirement of
transitioning to ICD-10.

 But what will they really need to further
document?
85



Documentation requirements will vary greatly by
specialty.
For example, ICD-10-CM codes related to
ophthalmology have changed little in scope whereas
diagnosis codes related to the musculoskeletal system
have increased dramatically.
Only focus on those diagnosis codes that your hospital
and/or physician practice utilizes.
 Note: The sheer # of codes in ICD-10-CM results in the code
book that is over 1,100 pages with very small print!
86
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Laterality (left vs. right) 25,000+ codes!
Stage/Episode of Care (initial, subsequent & sequela)
Stage of Disease (acute vs. chronic, severity of pressure
ulcer)
Specific Anatomy (specific bone in the hand)
Associated and/or Related Conditions (diabetes with
manifestation)
Cause of Injury (hit by baseball, fall)
Additional Symptoms or Conditions
Dominant vs. Non-Dominant Side
Tobacco Exposure or Use
Gustilo-Anderson Scale
87



“CC” = Complication and/or comorbidity
“MCC” = Major complication and/or comorbidity
CC List:
◦ 3,427 codes in the ICD-9-CM based version
◦ Replaced by 13,594 codes in the ICD-10-CM based version

MCC List:
◦ 1,592 codes in the ICD-9-CM based version
◦ Replaced by 3,152 codes in the ICD-10-CM based version

But does our medical record documentation support
the coding of these diagnoses?
88
ICD-10-CM diagnosis codes will impact every
physician office. Large or small!
 Look at all areas that will impact your practice
and identify each one that will be affected:

 Practice Management System
 Electronic Medical Record (EMR)
 Paper record
 Lab requisitions
 Superbill/encounter form – Does it have
diagnosis codes on it?
89

The use of the superbill as a way to capture or
collect data for coding purposes probably will not
be practical under ICD-10-CM.
 Example: Although there are 33 codes for fractures of the
radius in ICD-9-CM, most orthopedic practices superbill
generally include only 6 codes or less. Coding often ‘defaults’
to one of these codes, even though another of the other 33
codes might have been more accurate.
 Under ICD-10-CM there are 392 codes for fractures of the
radius and there is simply not enough room to include these
codes, + the thousands of other diagnosis codes on the
superbill.
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



Although the coding book is “huge”, many physician
practices use only a small set of diagnosis codes.
Work with physicians to develop crosswalks between
ICD-9-CM and ICD-10-CM codes they frequently use.
Begin discussions now with office staff and physicians to
reduce anxiety (hospital & physician offices = TEAM)
 In-depth training should occur at least 6 months prior
to the ‘go-live’ date.
Training should have both a general focus and then a
practice-specific focus:
● Cardiology
● Oncology
● Orthopedic
● Internal Medicine
● General Surgery
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AHIMA estimates approximately 16 hours of
coding training is needed for outpatient
coders and 50 hours for inpatient coders.
 Additional time may be needed to refresh
anatomy & physiology fundamentals.
 Need to allow time for practice, practice,
practice!

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Type
ICD 9/minutes
ICD 10/minutes
Inpt acute care
8.99
15.99
Outpt acute care
4.18
9.03
Physician practice
3.04
6.70
Free standing ASC
2.27
4.82
Nursing/SNF
6.71
12.98
Rehab facility
4.97
10.94
2 minutes additional for
each encounter
30% estimated loss in
productivity
Additional time projected
by CMS
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
AAPC (American Academy of Professional Coders)
 Certified coders will have opportunity to take the ICD-10 proficiency
exam beginning October 1, 2012 and must successfully complete the
exam by September 30, 2015.
 ** Currently being re-evaluated due to the 1 year delay**
 Must take and pass proficiency exam to maintain AAPC certification
► Online, timed, 75 questions, open book
► May use any resource available to complete
► $60 exam fee – includes ability to take the exam twice

AHIMA (American Health Information Management Association)
 Continuing education hours with ICD-10-CM/PCS content will be
required based on the specific AHIMA credential(s).




RHIA/RHIT - Required to have @ least 6 CEUs
CCS-P credential – 12 CEUs
CCS credential – 18 CEUs
And many others…
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That’s ICD-10-CM!
95
Day Egusquiza, President
[email protected]
www.arsystemsdayegusquiza.com
Karen Kvarfordt, RHIA, CCS-P, CCDS
AHIMA Certified ICD-10 Trainer
President, DiagnosisPlus, Inc.
[email protected]
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