family practice icd-10 cm training. icd-10-cm will be valid for dates of service on or after october...
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Family Practice
ICD-10 CM Training
• ICD-10-CM will be valid for dates of service on or after October 1, 2015– Outpatient dates of service of October 1, 2015 and
beyond. – Inpatient hospital service claims, is effective for dates of
discharge after September 30, 2015
ICD-10-CM Compliance Dates
• Covered Entities– Everyone covered by the Health Insurance Portability
Accountability Act (HIPPA)
• Non-Covered Entities– Worker’s Compensation– Auto Insurance– Non covered HIPAA entities are exempt but are
encouraged to adapt the new code set
Covered and Non-Covered Entities
• 21 Chapters• Alpha-numeric codes; not case-sensitive
– Codes begin with Alpha letter, A-Z, excluding U– Common errors
• I verses 1• O verses 0
• “X” Placeholder• 3 to 7 characters
– Decimal following 3rd character
ICD-10 Code Structure
• Placeholder “X”– Used for future expansion of a code– Fills in empty characters when a 6th and/or 7th character
apply– The placeholder may be used in different scenarios but
should never serve as the final character.
Example: W19.XXXA Unspecified fall, Initial Encounter
ICD-10 Code Structure
• 7th Character– Provides specified information regarding the clinical visit– Is required for certain categories and must be reported in
the seventh position– May be alpha or numeric– Has different meanings depending on the coding category
ICD-10 Code Structure
• Laterality– Some ICD-10-CM codes indicate laterality, specifying
whether the condition occurs on the left, right or is bilateral.
– If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.
– If the side is not identified in the medical record, assign the code for the unspecified side.
OGCR section 1.B.13
ICD-10 Code Structure
• “Other” Codes– Codes titled “other” or “other specified” are for use when
the information in the medical record provides detail for which a specific code does not exist.
• “Unspecified” Codes– Codes titled “unspecified” are for use when the
information in the medical record is insufficient to assign a more specific code.
OGCR section 1.A.9.a.b
ICD-10 Code Structure
• Excludes Notes– Excludes1
• A type 1 Excludes note is a pure excludes note• It means “NOT CODED HERE”• The code excluded should never be used at the same time• When two conditions cannot occur together
– Excludes2• Represents “Not included here”• The condition excluded is not part of the condition represented
by the code• It is acceptable to use both the code and the excluded code
together, when appropriateOGCR section 1.A.12.a.b
ICD-10 Structure
• “Code First” and “Use Additional Code”– ICD-10 has a coding convention that requires the
underlying condition be sequenced first followed by the manifestation.
– These instructional notes indicate the proper sequencing order of the codes.
OGCR section 1.A.13
• The “-” indicates there are additional reporting options
ICD-10 Code Structure
Most Common Diagnosis Codes
DiabetesICD-9 Code ICD-10 Code Description Excludes1 Excludes2
250.00 E11.9 Type 2 Diabetes mellitus without complications• Diabetes (mellitus)
due to insulin secretory defect
• Diabetes (NOS)• Insulin resistant
diabetes (mellitus)Use additional code to identify any insulin use (Z79.4)
• Diabetes mellitus due to underlying condition (E08.-)
• Drug or chemical induced diabetes mellitus (E09.1-)
• Gestational diabetes (O24.4-)
• Neonatal diabetes mellitus (P70.2)
• Postpancreatectomy diabetes mellitus (E13.-)
• Postprocedural diabetes mellitus (E13.-)
• Secondary diabetes mellitus NEC (E13.-)
• Type 1 diabetes mellitus (E10.-)
• transitory endocrine and metabolic disorders specific to newborn (P70-P74
N/A
250.02 E11.65 Type 2 diabetes mellitus with hyperglycemia• Diabetes (mellitus)
due to insulin secretory defect
• Diabetes (NOS)• Insulin resistant
diabetes (mellitusUse additional code to identify any insulin use (Z79.4)
• Diabetes mellitus due to underlying condition (E08.-)
• Drug or chemical induced diabetes mellitus (E09.1-)
• Gestational diabetes (O24.4-)
• Neonatal diabetes mellitus (P70.2)
• Postpancreatectomy diabetes mellitus (E13.-)
• Postprocedural diabetes mellitus (E13.-)
• Secondary diabetes mellitus NEC (E13.-)
• Type 1 diabetes mellitus (E10.-)
• transitory endocrine and metabolic disorders specific to newborn (P70-P74
N/A
Diabetes mellitus codes are now combination codes that include the type of diabetes, the body system affected, and the complication affecting that body system. They are no longer classified as controlled or uncontrolled.• Type
– Type 1– Type 2– Due to underlying conditions– Drug or chemical induced– Other specified
Diabetes Documentation Tips
• Complication Status– Without complication– With circulatory complication– With diabetic arthropathy– With hyperglycemia– With hyperosmolarity– With hypoglycemia– With ketoacidosis– With kidney complications– With neurologic complications– With ophthalmic complications– With oral complications– With skin complications– With other specified complications
Diabetes Documentation Tips
• Complication Detail– With diabetic retinopathy– With cataract– With other ophthalmic complication– With chronic kidney disease– With nephropathy– With other kidney complication– With amyotrophy– With autonomic neuropathy– With mononeuropathy– With polyneuropathy– With other neurological complication– With unspecified neuropathy– With or without coma– With peripheral angiopathy with or without gangrene– With other circulatory complications– With neuropathic arthropathy– With other arthropathy– With dermatitis– With foot ulcer– With other skin ulcer– With other skin complication– With periodontal disease– With other oral complications
Diabetes Documentation Tips
Diabetes is a chronic condition that requires multi-specialty management. • The documentation should indicate relevant details regarding the
management of each case as it relates to the services rendered or actions taken to coordinate the patients care.
• The HPI, at a minimal, should include some indication of the historical timeline or duration of the illness, levels as it relates to the date of service, manifestations or impairments associated with the condition and effectiveness of current medication regimen.
• The examination should notate any physical signs related to the diabetic conditions. (Ulcers, nails, edema, discoloration sensitivity to touch)
Diabetes Documentation Tips
HypertensionICD-9 Code ICD-10 Code Description Excludes1 Excludes2
401.1401.9401.0
I10 Essential (Primary) HypertensionIncludes: high blood pressure, Hypertension (arterial) (benign) (essential) (malignant) (systemic)
• Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16)
• Neonatal hypertension (P29.2)
• Primary pulmonary hypertension (I127.0)
• Essential (primary) hypertension involving vessels of brain (I60-I69)
• Essential (primary) hypertension involving vessels of eye (H35.0-)
Hypertensive Diseases Categories (I10-I15)
The use additional codes and Excludes1 codes apply for all categories.
(I10-I15) Use additional code to identify:• Exposure to
environmental tobacco smoke (Z77.22)
• History of tobacco use (Z87.891)
• Occupational exposure to environmental tobacco smoke (Z57.31)
• Tobacco dependence (F17.-)
• Tobacco use (Z72.0)
• Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11. O13-O16)
• Neonatal hypertension (P29.2)
• Primary Pulmonary hypertension (I27.0)
Hypertension cont.
ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
402.01402.11402.91
I11.0 Hypertensive Heart Disease with heart failure• Use additional code to
identify type of heart failure (I50.-)
N/A N/A
402.00402.10402.90
I11.9 Hypertensive Heart Disease without heart failure
N/A N/A
403.01403.11403.91
I12.0 Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or end stage renal disease.• Use additional code to
identify the stage of chronic kidney disease (N185.5, N18.6)
• Hypertension due to Kidney Disease (I15.0, I15.1)
• Renovascular Hypertension (I15.0)
• Secondary Hypertension (I115.-)
Acute Kidney Failure (N17.-)
403.00403.10403.90
I12.9 Hypertensive Chronic Kidney Disease with stage 1-4 Chronic Kidney Disease, or unspecified Chronic Kidney Disease.• Use additional code to
identify the stage of chronic kidney disease (N18.1-N18.9)
• Hypertension due to Kidney Disease (I15.0, I15.1)
• Renovascular Hypertension (I15.0)
• Secondary Hypertension (I115.-)
Acute Kidney Failure (N17.-)
Hypertension cont.ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
404.01404.11404.91
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney disease• Use additional code to identify
type of heart failure (I50.-)• Use additional code to identify
stage of chronic kidney disease (N18.1-NN18.4, N18.9)
N/A N/A
404.00404.10404.90
I13.10 Hypertensive Heart and Chronic Kidney Disease without heart failure, with stage 1-4 chronic kidney disease, or unspecified chronic kidney disease.• Use additional code to identify
the stage of chronic kidney disease (N18.1-N18.4, N18.9)
N/A N/A
404.02404.12404.92
I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease.• Use additional code to identify
the stage of chronic kidney disease (N18.5, N18.6)
N/A N/A
404.03404.13404.93
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease.• Use additional code to identify
type of heart failure (I50.-)• Use additional code to identify
the stage of chronic kidney disease (N18.5. N18.6)
N/A N/A
Hypertension cont.ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
405.01405.11405.91
I15.0 Renovascular Hypertension• Code also underlying
condition
Postprocedural hypertension (I97.3)
• Secondary hypertension involving vessels of brain (I60-I69)
• Secondary hypertension involving vessels of eye (H35.0-)
405.91 I15.1 Hypertension secondary to other renal disorders• Code also underlying
condition
Postprocedural hypertension (I97.3)
• Secondary hypertension involving vessels of brain (I60-I69)
• Secondary hypertension involving vessels of eye (H35.0-)
405.99 I15.2 Hypertension secondary to endocrine disorders• Code also underlying
condition
Postprocedural hypertension (I97.3)
• Secondary hypertension involving vessels of brain (I60-I69)
• Secondary hypertension involving vessels of eye (H35.0-)
405.09405.19405.99
I15.8 Other secondary hypertension• Code also underlying
condition
Postprocedural hypertension (I97.3)
• Secondary hypertension involving vessels of brain (I60-I69)
• Secondary hypertension involving vessels of eye (H35.0-)
405.99 I15.9 Secondary hypertension, unspecified• Code also underlying
condition
Postprocedural hypertension (I97.3)
• Secondary hypertension involving vessels of brain (I60-I69)
• Secondary hypertension involving vessels of eye (H35.0-)
• Hypertension is no longer classified as benign, malignant or unspecified.• ICD-10 Codes have been grouped according to disease progression:
– I10 Essential Hypertension– I11.- Hypertensive Heart Disease– I12.- Hypertensive CKD
» Further subdivided by stage of kidney disease
– I13.- Hypertensive Heart and CKD» Further subdivided by stage of kidney disease
– I15.- Secondary Hypertension
• Transient Hypertension– A code for hypertension is NOT assigned unless the patient has a
documented, established diagnosis of hypertension.• R03.0 Elevated blood pressure reading without diagnosis of hypertension
• Document requirements– Type– Current Status– Associated relationships
Hypertension Documentation Tips
HyperlipidemiaICD-9 Code ICD-10 Code Description Excludes1 Excludes2
272.4 E78.4 Other Hyperlipidemia• Familial
combined hyperlipidemia
• Sphingolipidosis (E75.0-E75.3)
N/A
272.4 E78.5 Hyperlipidemia, unspecified
There are more specific code choice selections available below:
272.0 E78.0 Pure Hypercholesterolemia
272.1 E78.1 Pure Hypercholesterolemia
272.2 E78.2 Mixed Hyperlipidemia
272.3 E78.3 Hyperchylomicronemia
272.5 E78.6 Lipoprotein deficiency
• Type– Mixed– Other– Unspecified
Hyperlipidemia Documentation Tips
DorsalgiaCategory M54 Excludes1 Excludes2
N/A N/A
CervicalgiaICD-9 Code ICD-10 Code Description Excludes1 Excludes2
723.1 M54.2 Cervicalgia • Cervicalgia due to intervertebral cervical disc disorder (M50.-)
• Category M54 Excludes2
SciaticaICD-9 Code ICD-10 Code Description Excludes1 Excludes2
724.3 M54.30 Sciatica, unspecified side • Lesion of sciatic nerve (G57.0)
• Sciatica due to intervertebral disc disorder (M51.1-)
• Sciatica with lumago (M54.4-)
• Category M54 Excludes2
724.3 M54.31 Sciatica, right side • Lesion of sciatic nerve (G57.0)
• Sciatica due to intervertebral disc disorder (M51.1-)
• Sciatica with lumago (M54.4-)
• Category M54 Excludes2
724.3 M54.32 Sciatica, left side • Lesion of sciatic nerve (G57.0)
• Sciatica due to intervertebral disc disorder (M51.1-)
• Sciatica with lumago (M54.4-)
• Category M54 Excludes2
Lumbago with Sciatica724.3ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
724.3 M54.40 Lumbago with sciatica, unspecified side
• Lumbago with sciatica due to intervertebral disc disorder (M51.1-)
• Category M54 Excludes2
724.3 M54.41 Lumbago with sciatica, right side
• Lumbago with sciatica due to intervertebral disc disorder (M51.1-)
• Category M54 Excludes2
724.3 M54.42 Lumbago with sciatica, left side
• Lumbago with sciatica due to intervertebral disc disorder (M51.1-)
• Category M54 Excludes2
Low Back PainICD-9 Code ICD-10 Code Description Excludes1 Excludes2
724.2 M54.5 Low back pain
• Loin pain• Lumbago NOS
• low back strain (S39.012)
• lumbago due to intervertebral disc displacement (M51.2-)
• lumbago with sciatica (M54.4-)
• Category M54 Excludes2
Pain in Thoracic Spine724.1 M54.6 Pain in thoracic spine • Pain in thoracic spine due
to intervertebral disc disorder (M51.-)
• Category M54 Excludes2
DorsalgiaICD-9 Code ICD-10 Code Description Excludes1 Excludes2
724.5 M54.89 Other dorsalgia • current injury - see injury of spine by body region discitis NOS (M46.4-)
• Dorsalgia in thoracic region (M54.6)
• Low back pain (M54.5-)
• Category M54 Excludes2
724.5 M54.9 Dorsalgia, unspecified
N/A • Category M54 Excludes2
• Document site and laterality– Unspecified codes should be used only in rare
circumstances
• Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.
Documentation Tips
Encounter for General Adult Medical ExaminationICD-9 Code ICD-10 Code Description Excludes1 Excludes2
V70.0 Z00.00 Encounter for general adult medical examination without abnormal findings• Encounter for adult
health check-up NOS
• Examinations related to pregnancy and reproduction (Z30-Z36, Z39-)
• Encounter for examination for administrative purposes (Z02.-)
• Encounter for pre-procedural examinations (Z01.81-)
• Special screening examinations (Z11-Z13)
V70.0 Z00.01 Encounter for general adult medical examination with abnormal findings• Use additional code
to identify abnormal findings
Note: Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.
• Examinations related to pregnancy and reproduction (Z30-Z36, Z39-)
• Encounter for examination for administrative purposes (Z02.-)
• Encounter for pre-procedural examinations (Z01.81-)
• Special screening examinations (Z11-Z13)
• Identify routine health check– Adult– Child– Newborn
• Under 8 days old• 8-28 days old
• Identify presence/absence of abnormal findings– With abnormal findings– Without abnormal findings
• Use an additional code for any abnormal findings– Document abnormal findings
Well Examination Documentation Tips
Chronic Obstructive Pulmonary Disease (COPD)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2
496 J44.9 Chronic obstructive pulmonary disease, unspecified
Applicable to:• Chronic obstructive
airway disease NOS• Chronic obstructive
lung disease NOS
• Bronchiectasis (J47.-)• Chronic bronchitis NOS
(J43)• Chronic simple and
mucopurulent bronchitis (J14.-)
• Chronic tracheitis (J42)• Chronic tracheobronchitis
(J42)• Emphyysema without
chronic bronchitis (J43.-)• Lung diseases due to
external agents (J60-J70)
N/A
There are more specific code choice selections below:
491.22493.21
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
491.21493.22
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
• Type– Chronic bronchitis
• Simple• Mucopurulent• Mixed simple and mucopurulent
– Emphysema• Centrilobular• Panlobular• Unilateral
– COPD with acute exacerbation– COPD with acute lower respiratory injection
• Identify the infection (use additional code)
COPD Documentation Tips
• Code also type of asthma, if applicable (J45-)• Use additional code to identify:
– Exposure to environmental tobacco smoke (Z77.22)– History of tobacco use (Z87.891)– Occupational exposure to environmental tobacco
smoke (Z57.31)– Tobacco dependence (F17.-)– Tobacco use (Z72.0)
COPD Documentation Tips
Encounter for other preprocedural examinationICD-9 Code ICD-10 Code Description Excludes1 Excludes2
V72.83 Z01.818 Encounter for other preprocedural examination
Applicable To:• Encounter for
preprocedural examination NOS
• Encounter for examinations prior to antineoplastic chemotherapy
• encounter for examination for administrative purposes (Z02.-)
• encounter for examination for suspected conditions, proven not to exist (Z03.-)
• encounter for laboratory and radiologic examinations as a component of general medical examinations(Z00.0-)
• encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to the sign(s) or symptom(s)
• special screening examinations (Z11-Z13)
There are more specific code choice selections below:
V72.81 Z01.810 Encounter for preprocedural cardiovascular examination
V72.82 Z01.811 Encounter for preprocedural respiratory examination
V72.63 Z01.812 Encounter for preprocedural laboratory examinationBlood and urine tests prior to treatment or procedure
• Includes: routine examination of specific system• Codes from category Z01 represent the reason for
the encounter. • Use when a patient is being cleared for a procedure
or surgery and no treatment is given.
Documentation Tips
Atrial fibrillationICD-9 Code ICD-10 Code Description Excludes1 Excludes2
427.31 I48.91 Unspecified atrial fibrillation
N/A N/A
There are more specific code choice selections available below:
I48.0 Paroxysmal atrial fibrillation
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillationPermanent atrial fibrillation
• Type– Chronic– Paroxysmal– Persistent
Atrial Fibrillation Documentation Tips
Abdominal painICD-9 Code ICD-10 Code Description Excludes1 Excludes2
789.00 R10.9 Unspecified abdominal pain
• renal colic (N23) • dorsalgia (M54.-)• flatulence and
related conditions (R14.-)
There are more specific code choice selections below:
R10.0 Acute abdomen
R10.10 Upper abdominal pain, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain, unspecified
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.81- Other abdominal pain
R10.82- Rebound abdominal tenderness
Abdominal Pain Documentation Tips
• Document specific location:– LLQ, LUQ, RUQ, RLQ – Periumbilical – Epigastric – Generalized (R10.84)– Colic (R10.83)– Acute abdominal pain (R10.0)– Abdominal tenderness (R10.811-R10.819)– Rebound abdominal pain (R10.821-R10.829)
CoughICD-9 Code ICD-10 Code Description Excludes1 Excludes2
786.2 R05 Cough • Cough with hemorrhage (R04.2)
• Smoker’s Cough (J41.0)
N/A
• Symptom Codes – Codes that describe symptoms and signs are acceptable for reporting
purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
• Use of a symptom code with a definitive diagnosis code– Codes for signs and symptoms may be reported in addition to a
related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis code.
• Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
Cough Documentation Tips
Atherosclerotic heart disease of native coronary artery without angina pectorisICD-9 Code ICD-10 Code Description Excludes1 Excludes2
414.00 I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
Applicable To:• Atherosclerotic heart
disease NOS
N/A • atheroembolism (I75.-)• atherosclerosis of coronary artery
bypass graft(s) and transplanted heart (I25.7-)414.01 I25.10
No ICD-10 code exists for unspecified vessel; native or bypass graft must be indicated
Use additional code, if applicable, to identify:• coronary atherosclerosis due to calcified coronary lesion (I25.84)• coronary atherosclerosis due to lipid rich plaque (I25.83)
• chronic total occlusion of coronary artery (I25.82)• exposure to environmental tobacco smoke (Z77.22)• history of tobacco use (Z87.891)• occupational exposure to environmental tobacco smoke (Z57.31)• tobacco dependence (F17.-)• tobacco use (Z72.0)
• Associated Artery/Lesion Type– Native artery– Bypass graft– Bypass graft, autologous artery– Bypass graft, autologous vein– Bypass graft, nonautologous biological– Bypass graft, other– Due to calcified coronary lesion– Due to lipid rich plaque
• Native vs Transplanted Heart• Associated angina
– Without angina– With unstable angina– With angina and spasm
Artherosclerotic Heart DiseaseCoronary Artery Documentation Tips
Chronic pain syndromeICD-9 Code ICD-10 Code Description Excludes1 Excludes2
338.4 G89.4 Chronic pain syndrome
Applicable To:• Chronic pain
associated with significant psychosocial dysfunction
• generalized pain NOS (R52)
• pain disorders exclusively related to psychological factors (F45.41)
• pain NOS (R52)
• atypical face pain (G50.1)• headache syndromes (G44.-)• localized pain, unspecified type - code to pain by
site, such as:• abdomen pain (R10.-)• back pain (M54.9)• breast pain (N64.4)• chest pain (R07.1-R07.9)• ear pain (H92.0-)• eye pain (H57.1)• headache (R51)• joint pain (M25.5-)• limb pain (M79.6-)• lumbar region pain (M54.5)• painful urination (R30.9)• pelvic and perineal pain (R10.2)• shoulder pain (M25.51-)• spine pain (M54.-)• throat pain (R07.0)• tongue pain (K14.6)• tooth pain (K08.8)• renal colic (N23)• migraines (G43.-)• myalgia (M79.1)• pain from prosthetic devices, implants, and
grafts (T82.84, T83.84, T84.84, T85.84)• phantom limb syndrome with pain (G54.6)• vulvar vestibulitis (N94.810)• vulvodynia (N94.81-)
• Type– Chronic pain syndrome (G89.4)– Due to neoplasm (G89.3)– Due to trauma ((G89.21)– Chronic post-thoracotomy pain (G89.22)– Other chronic postprocedural pain (G89.28)
Chronic Pain Syndrome Documentation Tips
Encounter for Immunization Influenza VirusICD-9 Code ICD-10 Code Description Excludes1 Excludes2
V04.81 Z23 Encounter for immunization
N/A N/A
• The procedural code will indicate the type of immunization to the carrier.
Encounter for Immunization Documentation Tips
Urinary Tract InfectionICD-9 Code ICD-10 Code Description Excludes1 Excludes2
599.0 N39.0 Urinary tract infection, site not specified
• candidiasis of urinary tract (B37.4-)
• neonatal urinary tract infection (P39.3)
• urinary tract infection of specified site, such as:
• cystitis (N30.-)• urethritis (N34.-)
• hematuria NOS (R31.-)
• recurrent or persistent hematuria (N02.-)
• recurrent or persistent hematuria with specified morphological lesion (N02.-)
• proteinuria NOS (R80.-)
Use additional code (B95-B97), to identify infectious agent.
• Encounter type– Initial– Subsequent– sequela
• Urinary Tract Infection type– Acute cystitis– Acute pyelonephritis– Urethritis– Catheter-associated UTI
• Hematuria present– With or without
• Identify any retained foreign body, if applicable (Z18.-), code additional• Use Additional code (B95-B97), to identify infectious agent
Urinary Tract Infection Documentation Tips
Anxiety, generalizedICD-9 Code ICD-10 Code Description Excludes1 Excludes2
300.02 F41.1 Generalized anxiety disorder• Anxiety
neurosis• Anxiety state• Anxiety reaction• Overanxious
disorder
N/A • Acute stress reaction (F43.0)
• Transient adjustment reaction (F43.2)
• Neurasthenia (F48.8)
• Psychophysiologic disorders (F45.-)
• Separation anxiety (F93.0)
There are more code choice selections below:
300.01 F41.0 Panic disorder without agoraphobia
300.09 F41.3 Other mixed anxiety disorders
300.00 F41.9 Anxiety disorder, unspecified
• Type– Generalized – Panic Disorder
• With agoraphobia• Without agoraphobia
– Other– Mixed– Unspecified
Anxiety Documentation Tips
On October 01, 2015 we will monitor claims for date of service rules
• Outpatient claims cannot have crossover dates • Outpatient claims will be coded according to date of
service• Inpatient facility claims will be coded per date of discharge
We will monitor claims to resolve any unanticipated problems with the submission process
Monitor Claims
• We will monitor for claim denials• We will monitor editing trends for ICD-10 Coding
guidelines• We will provide feedback to the physicians regarding
supporting documentation requirements • We will monitor WC or Liability carriers for published
rules on use of ICD-9 or ICD-10 code sets
Claim Denial and Management
• Client will need to update – Templates– Order Sets– Superbills– Favorites
• Future Orders– Remove ICD-9 code add ICD-10 code
Client Responsibilities
All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection.
• Site specificity• Document notation of qualifiers
– Exacerbation– Manifestations– Relapse– Status– Stages
• Indicate acute or chronic• Indicate underlying or external cause factors
– Medication– Smoke– Accidents– Mechanical failure
• Laterality– Bilateral– Right – Left
Documentation – Start Now
• Episode of Care for injuries, poisoning, external causes and other conditions– Initial Encounter
• Use while the patient is receiving active treatment of the condition– Active treatment includes surgical treatment, an emergency encounter, and
evaluation and treatment by a new physician
– Subsequent Encounter• Used on encounter after the patient has received active treatment of
the condition and is receiving routine care for the condition during the healing or recovery phase.
– Medication adjustments, aftercare, device adjustments, cast change
– Sequela• Used for complications or conditions that arise as a direct result of a
condition, late effect
Documentation – Start Now
• Combination codes that capture– Etiology and manifestation– Related conditions– Disease, injury or other medical condition and
complications– Disease or other medical conditions and common signs or
symptoms
• Add ICD-10 Codes to patient Problem List
Documentation – Start Now
Centers for Disease Control and Prevention (ICD-10-CM)http://www.cdc.gov/nchs/icd/icd10cm.htm
Questions