ICD-10 Coding Questions & Answers2015

Teresa L, Martin, C.P.C.

Revenue Cycle ManagementCoding Supervisor

ICD-10-CM Basics ICD-10-CM is very similar to

ICD-9-CM as far as look up and basic guideline information

Total number of codes expands from about 13,000 ICD-9-CM codes to well over 68,000 in ICD-10-CM

ICD-10 Uses full code titles, ICD-9 does not

Plenty of room for expansion in ICD-10

ICD-9-CM Diagnosis Codes

Are 3–5 digits;•The first digit is alpha (E or V) or numeric

(alpha characters are not case sensitive); •Digits 2–5 are numeric; and

A decimal is used after the third character. Examples:• 496 – Chronic airway obstruction, not elsewhere

classified (NEC); • 511.9 – Unspecified pleural effusion; and • V02.61 – Hepatitis B carrier

ICD-10-CM Diagnosis Codes

Are 3–7 digits; •Digit 1 is alpha; •Digit 2 is numeric; •Digits 3–7 are alpha or numeric

(alpha characters are not case sensitive); and a decimal is used after the third character. Examples:

• A78 – Q fever;

• A69.21 – Meningitis due to Lyme disease; and

• S52.131A – Displaced fracture of neck of right* radius, initial encounter for closed fracture.

*the 6th digit is the laterality, in certain codes, and will be 1 for right or 2 for left

ICD-10-CM Code Structure

Categoryfirst threecharacters

Etiology, anatomic site, severity, laterality for fourth,

fifth, sixth characters (if applicable)

Extensionseventh

character(if applicable)

M84 Disorders of continuity of bone

M84 .311 Stress Fracture, right shoulder

M84.311A Stress fracture, right shoulder; initial encounter

New Features in ICD-10-CM

• Laterality (Left, Right, Bilateral)681.00 Cellulitis and abscess,

unspecified

• Combination codes for certain conditions and common associated symptoms and manifestations

M1A.3120 Chronic gout due to renal

impairment, left shoulder without tophus

• Obstetric codes identify trimester instead of episode of care:1st Trimester - less than 14 weeks 0 days2nd Trimester – 14 weeks 0 days to less than 28 weeks 0 days3rd Trimester – 28 weeks 0 days until delivery

024.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester

024.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester

TIP: THE 6TH DIGIT FOLLOWS THE TRIMESTER

• Combination codes for poisonings and their associated external cause:

T43.612A Poisoning by caffeine, intentional self harm, initial encounter

New Features in ICD-10-CMPlaceholder “X” CharacterPlaceholder character

The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a placeholder at certain codes to allow for future expansion. An example of this is at the poisoning, adverse effect and under dosing codes, categories T36-T50. Where a placeholder exists, the X must be used in order for the code to be considered a valid code.

Example: H40.11 Primary open-angle glaucomaH40.11X0 …… stage unspecifiedH40.11X1 …… mild stageH40.11X2 …… moderate stageH40.11X3 …… severe stageH40.11X4 …… indeterminate stage

H40.11X1 Primary open-angle glaucoma mild stage

. 7th Characters Certain ICD-10-CM categories have 7th characters. The 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character does not have a 6th character for defining the code, a placeholder X must be used to fill in the empty characters.

Example 1:

T79.0XXA Initial encounter for a traumatic air embolism Some codes have even more!

Example 2:

W06.XXXD Subsequent encounter for a fall from a bed

New Features in ICD-10-CM cont.

The 7th character in ICD-10-CM is used in several chapters (for example, the Obstetrics, Injury, Musculoskeletal, and External Cause chapters). It has a different meaning depending on the section where it is being used (for example, in the Injury and External Cause sections, the 7th character often classifies an initial encounter, subsequent encounter, or sequelae (late effect) but may include others.

Primarily, changes in ICD-10-CM are in its organization and structure, code composition and level of detail.

Two Types of Excludes NotesExcludes 1 – Indicates that the code excluded should never be used with the code where the note is located (do not report both codes).

Example:Q03 – Congenital hydrocephalus.

Excludes 1: Acquired hydrocephalus (G91.-).

Excludes 2 – Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together (both codes can be reported to capture both conditions).

Example:L27.2 – Dermatitis due to ingested food.

Excludes 2: Dermatitis due to food in contact with skin (L23.6, L24.6, L25.4).

7) Inclusion of Clinical Concepts That Do Not Exist in ICD-9-CM (For Example, Underdosing, Blood Type, Blood Alcohol Level)

Examples:T45.526D – Underdosing of antithrombotic drugs, subsequent encounter;Z67.40 – Type O blood, Rh positive; andY90.6 – Blood alcohol level of 120 – 199 mg/100 ml.

8) A Number of Codes Are Significantly Expanded (For Example, Injuries, Diabetes, Substance Abuse, Postoperative Complications)Examples:E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy;F10.182 – Alcohol abuse with alcohol-induced sleep disorder; andT82.02xA – Displacement of heart valve prosthesis, initial encounter.

9) Codes for Postoperative Complications Are Expanded and a Distinction is Made Between Intraoperative Complications and Postprocedural DisordersExamples:D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen; andD78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen.

Examples of the Numbers by Specialty

Specialty # ICD-9 Codes # ICD-10 Codes

Gastroenterologists 596 706

Pulmonologists 255 336

Urologists 389 591

Endocrinologists 335 675

Neurologists 459 591

Pediatricians 702 591

Infectious Disease 1,270 1,056

2014 ICD-10-CM Guideline Change

Where are most of the new codes?

• The majority are in musculoskeletal and injury/poisoning:- Increased specificity of type of fracture, laterality, specific

bone and encounter information.*- Increased doesn’t mean increased complexity, if you take

away the 7th character for encounter, the number of codes drop significantly.

*Tip – documenting these additional elements will simplify the ICD-10 transition.

Routine infant/child exam with abnormal findings

Z00.121 – Routine infant/child exam with abnormal findings

Does this include a separate and identifiable

problem like an ear infection or is this limited

to a problem within normal growth and

development such as failing a

hearing screening Z00.121

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

P. Encounters for general medical examinations with abnormal findings The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first-listed diagnosis. A secondary code for the abnormal finding should also be coded.

Viral Syndrome

We frequently use 079.99 – Viral syndromeand have identified a couple of options for coding with ICD-10:

•B34.9 Viral infection, unspecified, or

•B97.89 Other viral agents as the cause of disease classified elsewhere (Use of this code indicates we have diagnosed a disease.)

– When we see these children, the disease is a basket of symptoms that point to a viral illness. Which one should we use?

– Let’s look at GEMS………………These can be found on the CMS website or the CDC website

GEMS (General Equivalency Mapping System)

ICD-9-CM ICD-10-CM Flag Meaning

07999 B9789 10000 Approximate Match

080 A750 00000 Exact Match

CAUTION!You cannot rely simply on the GEMS system to cross-match everything. If the flag is other than “00000” there are other potential possibilities. It’s best to start in the alphabetic index a then complete the look up process in the tabular.

Viral Syndrome

Let’s look up Viral syndrome in ICD-10-CM1.Alphabetic Index:

Syndrome

- virus B34.9

2.Tabular Index:

B34.9 Viral Infection Infection,

unspecified

-

10 things You Should Know 1. Increase in number of Codes and Specificity Addition of more than 50,000 new diagnosis codes Will demand a high level of coder expertise in the areas of anatomy, physiology,

pathophysiology and medical terminology

2. ICD-10 has tens of thousands of more terms than ICD-9-CM. To use ICD-10 effectively coders must know: Greek and Latin prefixes, suffixes, roots and combining forms used as the basis of

most medical terms Commonly accepted and approved medical abbreviations (AKA Above the Knee

Amputation) Eponyms (who it is named after “Achilles tendon”) and names of syndromes (a

group of signs or symptoms that create a condition, “Sick Sinus Syndrome”) Alternative names and descriptions for diseases (GERD-Gastroesophageal Reflux

Disease) Adjectives used to describe and define diseases and disorders (purulent, necrotic,

etc.) Technology driven and manufacturer given names for tests, devices and procedures

10 Things continued3. Changes will impact all departments Need multi-disciplinary approach Planning needs to include representatives across all departments that are

impacted

4. Enormous healthcare-wide impact All Providers All health plans and payers Technology solutions that require coding input

5. First FULL replacement in 30 years

6. Complicated Mapping No one-to-one mapping from ICD-9 to ICD-10 There may be multiple one-to-one possibilities There may be multiple cluster possibilities ICD-10 may be a combination of

codes to fully describe the patients issues

10 Things continued

7. Anticipated short-term consequences of implementation Coding productivity estimated to decline by 10% – 15% Declining reimbursements and increased days in A/R (quantify?) Increased claims denials

8. Anticipated Long-Term Benefits Improved analytics based on increased specificity More accurate reimbursements

10 Things continued

9. Extensive foundational Knowledge will be required Medical record fundamentals (foundation of) Coding fundamentals Documentation guidelines Anatomy (study of the structure of organisms and their parts) Physiology (nature or origin of) Pathophysiology (changes associated with a disease or injury) Pharmacology (study of drug action) Medical and Surgical Procedures Medical Terminology

10 Things continued10. Training is Critical

Preparing Outpatient Coders It is estimated that approximately 16 hours of coding training are

needed for each outpatient coder to learn ICD-10-CM. This estimate presumes that coders already possess the necessary knowledge in the biomedical sciences. More is always better in this case.

Similar to inpatient coders, outpatient coders should focus on obtaining the foundational knowledge of the biomedical sciences and understanding how ICD-10-CM is different from ICD-9-CM (including familiarity with the maps between them). It is critical that they apply knowledge of anatomy, physiology, and clinical disease processes to support correct coding assignment for diagnoses in ICD-10-CM.

“Understand how to apply maps and crosswalks between ICD-9-CM and the ICD10 systems “ and most of all how to use your books

Let’s Code-S.O.A.P.S: (Subjective) Mrs. Finley presents today after having a new cabinet fall on her last week, suffering a concussion, as well as some cervicalgia. She was cooking dinner at the home she shares with her husband. She did not seek treatment at that time. She states that the people that put in the cabinet in her kitchen missed the stud by about two inches. Her husband, who was home with her at the time told her she was “out cold” for about two minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius.

O: (Objective) Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear.

A: (Assessment)1. Status post concussion with acute persistent headaches2. Cervicalgia3. Cervical somatic dysfunction

P: (Plan)The plan at this time is to send her for physical therapy, three times a week for four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month, sooner if needed.

ICD-10-CM Coding:S06.0X1A Concussion with loss of consciousness of 30 minutes or less,

initial encounter

G44.311 Acute post traumatic headache, intractable

M54.2 Cervicalgia

M99.01 Segmental and somatic dysfunction of cervical region

W20.8xxA Struck by falling object (accidentally), initial encounter Remember the alpha characters are not case sensitive

Y93.g3 Activity, cooking and baking

Y92.010 Place of occurrence, house, single family, kitchen

Communication with 3rd Parties

• PM/EHR Vendors System capabilities: updates/upgrades/interfaces – Table redesign/user interface formats – Dual Coding Capabilities (system) – Template modifications – Billing edits

• Clearinghouses/Billing Companies– Billing edits/other services – Clearinghouse to Payer transmissions

•Payers End to end testing opportunities – Changes in coverage determinations or authorization processes

Management

• Cash Flow– Possible A/R Days – Cash reserves – Credit Lines

• Dual Coding Capabilities (Staff) – New code orientation – Increased time in PM/EHR – Volume

• Patient Communications

Identify Most Used Codes

• Identify the top 100 primary care diagnosis codes. • Identify other specialty codes, if required. • Map those codes from ICD-9 to ICD-10.

• Identify the specificity which may be required in the ICD-10 documentation for those codes. • Analyze current work flow processes. • Identify “gaps” in assigning the codes and in other workflow

processes. This may vary depending on how automated your processes are now.

• Identify any changes needed to internal forms, templates, or processes.

• Identify educational needs.

Educate and Train

• Identify the educational needs of your staff based on role and responsibilities.

• Develop or seek educational resources which target specific needs. • Do not over-train beyond scope of practice or duty. Train appropriately.

Train methodically. • Use applicable case scenarios or actual past encounters as training

materials. • Incorporate the coding guidelines in your training. • Practice dual coding in both ICD-9 and ICD-10. • Ensure that education is relevant to the provider’s specialty. • Select or design training materials carefully.

Watch your $’s

• Have established internal benchmarks prior to “go live”. • Identify weaknesses you have in ICD-9 claims now. • Monitor Claims Submission and Remittance Advises to

quickly identify any problems with claims adjudication. • Monitor % of posted adjustments to identify problems with

reimbursement or coverage. • Know who to contact with each payer or 3rd party. • Know resubmission and appeal processes in advance. • Do follow-up auditing to identify areas for re-education and

training.

Useful Website Resources to Assist!

AHIMA: https://www.ahima.org/icd10/

AMA: https://www.ama-assn.org/go/icd-10

CMS: https://www.cms.gov/icd10/

CDC: http://www.cdc.gov/nchs/icd/icd10cm.htm

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