ICD-10 for Family Practice

LAFP 68th Annual Assembly and Exhibition New Orleans, LA August 6-9, 2015

Presenter: Patty Harper

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These presentations may includes selected content that is the intellectual property of AHIMA. Those portions of the presentation will bear the AHIMA logo and have been extracted from the ICD-10 Academy materials. These slides are used with permission as granted to AHIMA Ambassadors and Trainers. These slides have not been revised or modified by the secondary user other than to renumber the slides for this unique presentation. Slides not bearing the AHIMA logo are the intellectual property of InQuiseek LLC. These slides may or may not bear the InQuiseek LLC logo. These slides may not represent content in the same format or method as the ICD-10 Academy materials although no effort has been made to misrepresent or contradict information otherwise presented. This presentation may be reproduced and redistributed by Winn Community Health Center for the purpose of internal training only. Selected graphics are provided under a licensing agreement with . ICD-10 cartoon provided under a licensing agreement through www.hipaacartoons.com. Other cartoons are identified with were published as public educational tools.

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What is ICD-10? Why? When?

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Canada 2000

Australia 1998

Thailand 2002

China 2002 France 1997 Korea 2008

Sweden 1997

Germany 2000 UK 1995 Netherlands 1994

US 2015

South Africa 1996

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• The World Health Organization (WHO) publishes the International Classification of Disease (ICD) code set, which defines diseases, illnesses, sign & symptoms, complaints, abnormal findings as well as external causes of injury or illness and social factors.

• ICD-10 is the tenth edition. ICD-11 is due to be released in 2015.

• NCHS is the federal agency responsible for adapting the WHO version to a clinical modification (CM) for use in the United States.

• ICD-10-CM is mandatory for all entities covered under HIPAA. It is not mandatory for worker’s comp or MVA liability claims.

• Version 5010, electronic health care transaction standards, was a precursor to ICD-10.

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How did we adopt ICD-10 in the US?

WHO • World Health Organization Releases New Version of

International Classification of Diseases (ICD-XX) • http://www.who.int/classifications/icd/en/

NCHS • National Center for Health Care Statistics develops a Clinical

Modification for use in the United States (1999) • http://www.cdc.gov/nchs/icd/icd10cm.htm

ACA • Affordable Care Act (HIPAA Administrative Simplification)

mandated an implementation date for ICD-10 in the US. • http://www.gpo.gov/fdsys/pkg/FR-2009-01-16/pdf/E9-743.pdf

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Used under license agreement with RJ Romero via www.hipaacartoons.com

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Why ICD-10-CM ?

• We are running out of codes. ICD-9 is not expandable in the current format.

• ICD-9 codes are not specific enough and do not reflect current terminology or practice. ICD-9-CM has been in use for almost 30 years.

• To provide health care statistics that are more easily comparable worldwide.

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ICD-10: Two Code Sets

ICD-10- CM for Diagnosis Coding: This is the US Clinical Modification (CM) of the World Health Organization classification system or ICD-10-CM. ICD-10-CM will be used in ALL settings. It will replace the ICD-9-CM codes in Vol. 1 and Vol. 2 that have been used in the United States since 1988.

ICD-10-PCS for Procedure Coding: In 1993, Centers for Medicare and Medicaid Services (CMS) commissioned 3M Health Information Systems to develop the new system. This is ICD-10-PCS. It will be used for Inpatient Procedures only. Will replace ICD-9-CM Volume 3 Codes. Notes: 1. All ICD-10 codes set are in draft version until implementation. 2. CPT Codes will remain in use for all Physician Services and Outpatient/Ambulatory

Services. 9

Date of Service or Discharge Date

Prior to October 1, 2015 On or After October 1, 2015

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Type of Code Before 10/1/2015 After 10/1/2015

INPATIENT

Diagnoses ICD-9-CM ICD-10-CM

Procedures ICD-9, Volume 3 ICD-10-PCS

OUTPATIENT/AMBULATORY

Diagnoses ICD-9-CM ICD-10-CM

Procedures CPT® Codes CPT® Codes

Effective Dates for Code Sets

There will be a need for dual coding for at least two years for complete claims adjudication and audit.

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CPT® Coding Will Not Change • CPT® is a registered trademark of the American Medical

Association. CPT = Current Procedural Terminology

• Codes are updated at least annually with some quarterly revisions or clarifications.

• Will still be used after 10/1/2015 for outpatient services.

Examples of CPT® Codes Used for Ambulatory Care

• Evaluation & Management Services (99201-99215)

• Office Procedures, for example: 10060- Simple I & D

• Lab Services, for example: 81003- Automated UA w/o micro

• X-ray, for example: 71020- CXR 2 View 12

“With less than three months remaining until the nation switches from ICD-9 to ICD-10 coding for medical diagnoses and inpatient hospital procedures, The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) are announcing efforts to continue to help physicians get ready ahead of the October 1 deadline. In response to requests from the provider community, CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set.” --CMS “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs.”--AMA President Steven J. Stack, MD http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-06.html

CMS Announcement of ICD-10 Coding Errors 7/6/2015

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So, when did I become a

coder? I thought I was

a doctor?

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Physician ≠ Coder Coder ≠ Biller

Assigning a code after having completed an assessment and plan seems redundant and counter-intuitive. The work flow is not logical.

Coding is the process of abstracting the medical record to assign a classification. Billing is the process of administratively reporting the services to a third-party for reimbursement.

The advent and implementation of electronic medical records, especially in physician offices and other outpatient settings have put the burden of code selection on the providers. This is a burdensome task for which most physicians have received minimal training. Certified coders have been trained and educated in medical terminology, anatomy and physiology, medical science, disease processes and epidemiology. They have also been trained to read a medical record and abstract diagnoses. There are several recognized coding credentials which recognize varying levels of training. A medical biller understands the claims reporting processes and third-party billing requirements. A biller may or may not have formal coding training. In physician offices, the coder-biller function is more commonly combined than in hospital settings.

But, then came EHRs.

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If we aren’t assigning codes correctly in ICD-9, then we will not be doing it correctly in ICD-10. There are specific guidelines for assigning and sequencing codes correctly. With more specificity in the ICD-10 codes, there are a more opportunities for coding errors.

2015 ICD-10-CM Alphabetic Index and Tabular Code Descriptions

The ICD-10-CM Index and Tabular volumes as well as

the ICD-10-CM Official Guidelines are available for download from the CDC.

http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2015

The formats are not as user friendly as code manuals published by other sources. The GEM files which are

also available for download are in text file which requires additional formatting.

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Sequencing Codes for Outpatient Services

• The “first-listed” diagnosis is the condition which occasioned the visit (chief complaint). Use a definitive diagnosis if one is available.

• Rule Out or Differential Diagnoses are not used in Outpatient coding. • Refer to the notes in the Tabular for “code first” and “use additional

code” notes. • All coexisting conditions which are present at the time of the visit and

affect care or treatment can also be listed. • If two conditions co-exist and are both responsible for the service, either

may be coded as primary. • Acute conditions are listed above chronic, stable conditions. • Signs and symptoms which are integral to the diagnosis should not be

listed. (cough, fever, pneumonia). • Signs and symptoms are listed if there is no definitive diagnosis during the

encounter. • Conditions which have been resolved or do not affect current treatment

are not coded. • Refer to specific Chapter guidelines for notes on specific conditions.

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ICD-10-CM: The organization and structure of the

diagnoses codes

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ICD-10: More Codes

ICD-9-CM has ± 14,025 diagnosis codes ICD-10-CM has ± 69,823 diagnosis codes

One of the biggest challenge for providers and payers is that there is not a one-to-one

correlation of the codes. 22

ICD-10: Code Format & Structure • Diagnosis Codes are longer in character

length. • ICD-9: 3-5 Characters in length • ICD-10: 3-7 Characters in length • Addition of 7th character Extension character • Use of placeholder in codes not requiring a

4th, 5th or 6th character.

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Diagnosis Code Structure Comparison

ICD-9-CM ICD-10-CM

Codes can be 3-5 characters/positions in length. Decimal after the 3rd character.

Codes can be 3-7 characters/positions in length. Decimal is after the 3rd character. Placeholders “x” are used if an extension is required.

Category Sub-Classification: Etiology, Anatomical Site or Manifestation

Category or Code Block

Extension Sub-Classification: Etiology, Anatomical Site or Manifestation

X X X . X X X

X

X

.

X

X

X

X

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ICD-10: Code Format & Structure Digit or

Character ICD-9 ICD-10

1 Numeric with exception of V & E codes

Letter

2 Numeric Numeric

3 Numeric Numeric

4 Numeric Numeric or Alpha or Placeholder

5 Numeric Numeric or Alpha or Placeholder

6 None Numeric or Alpha or Placeholder

7 None Extension

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ICD-10: More Chapters • The codes are organized into 21 chapters in

ICD-10-CM compared to 17 chapters in ICD-9-CM.

• Chapters are classified differently due to the changes in code formats.

• Reorganized to give subdivide some body systems.

• Injuries are now organized by site and then type of injury. 26

Diagnosis Code Comparison Diagnosis ICD-9 ICD-10

Hypertension, unspecified 401.9

I10

Sprain, left ankle Fall from stairs Initial Treatment

845.00 E880.9

S93.402A W10.9xxA

Diabetes mellitus Type II, Not uncontrolled.

250.00

E11.9

Diabetes mellitus, Unspecified, uncontrolled

250.02

E11.65

Full-term uncomplicated delivery, single live birth

650 V27.0

O80 Z37.0

Placeholders

7th Characters

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ICD-9 474.02 Chronic Tonsillitis and Adenoiditis ICD-10 J35.Ø3 Chronic Tonsillitis and Adenoiditis

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More Specificity in Code Assignment

• Correlation of contributing factors and complications through use of combination codes and additional code add-ons. Official reporting guidelines require PFSH elements or more detail about the episode of care.

• More specificity in code assignment. (Examples: Laterality, severity,

episode of care, injury details) • Codes are not a one-to-one correlation from ICD-9 to ICD-10. May be

one to many or many to one (combinations codes). • Code formats are completely different in format and appearance.

• New codes may change medical necessity and local coverage

determinations for procedures and tests. 29

Increased Specificity • Laterality (left, right, unilateral, bilateral)

There have been modifiers for CPT® codes to report laterality, but never captured in the diagnosis before.

• Etiology (cause, organism)

• Specific Anatomical Site

• Characteristics/Manifestations of the Disease

• Presence of Complications

• Use of Combination Codes

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ICD-10-CM Code Description

J01.21 Acute recurrent ethmoidal sinusitis

K02.52 Dental caries on pit and fissure surface penetrating into dentin

M17.2 Bilateral post-traumatic osteoarthritis of the knee

M16.11 Unilateral primary osteoarthritis, right hip

I80.221 Phlebitis of right popliteal vein

Codes Examples: Specificity

ICD-10-CM Code Description

E11.641 Type 2 DM with hypoglycemia with coma

H66.016 Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral

F10.232 Alcohol dependence with withdrawal with perpetual disturbance

Codes Examples: Complications or Severity or Severity of Illness

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Crosswalks and Mapping Tools • There is not a crosswalk that maps ICD-9-CM codes to

ICD-10-CM codes on a code-to-code basis. • There is not a 1:1 correlation of code sets. • There are General Equivalency Mappings or GEMs. • There are tools which use the GEMs to get you in the

ballpark. Some EHRs have mapping tools. • There is not going to be a “cheat sheet” for every code

you to use. • CMS GEM files can be found: http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and- GEMs.html

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Mapping Bronchitis from ICD-9 to ICD-10 Superbill Example

ICD-9 ICD-10

Source: http://www.aafp.org/online/en/home/publications/journals/fpm/fpmtoolbox.html

There is one acute bronchitis code in ICD-9. There are 10 codes in ICD-10 when comparing superbills.

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External Causes of Morbidity Codes

• Found in Chapter 20 • Accidents VØØ – X58 • Intentional Self Harm X71 – X83 • Assault X92 –YØ8 • Event of Undetermined Intent Y21 –Y33 • Legal Intervention, Operations of War, Terrorism Y35 –Y38 • Complications of Medical & Surgical Care Y62 – Y84 • Supplemental Factors Related to causes of morbidity Y90 – Y99 • Not to be confused with ICD-9 codes which begin with the letter V. • Not used as a Primary Diagnosis Code • Report using your specific payer’s billing instructions. • These are the codes in which we can often find humor.

W56.22xA: Struck by Orca, Initial Encounter

ICD-10-PCS: Inpatient Procedure Codes

ICD-9-CM, Vol. 3

Procedure Codes ICD-10-PCS

Codes

Increase in Codes

3,824 69,823 19 x as many codes

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ICD-10-PCS

• New procedure codes for inpatient procedures only. ICD-9 had procedure codes (ICD-9-CM, Volume 3, but this is a new taxonomy.)

• Unique to the United States. • Facilities and systems may choose to code outpatient

procedures using both PCS and CPT so that they can compare procedure statistics and utilization internally.

• ICD-10-PCS will not be used for billing for outpatient or ambulatory care.

• Physicians and Providers who provide inpatient services may need to enhance clinical documentation to facilitate inpatient coding in ICD-10-PCS.

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Understanding ICD-10-PCS Code Structure

Overview of Conventions

Seven Characters (all 7 must be included to make a valid code). Each Character is an axis of classification. 34 possible values for each character (Ø -9; A-Z, excluding letters O & I); room

for expansion The meaning of any single values is a combination of its axis of classification and

is dependent on the preceding characters for context. The code set includes an index and tables. The index is used only to find the

appropriate table. Valid codes are selected only from the tables. Tables are organized by Characters 1-3 with additional rows for Characters 4-7. A valid code must contain values for characters 4-7 from within the same row in the table. 38

Procedural Code Comparison

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Crash Course in ICD-10 Implementation

Considerations When Interacting with Others about ICD-10

• ICD-10 is NEW to everyone. • ICD-10 is CHANGE—MORE CHANGE! • ICD-10 may required upgrades to systems. • ICD-10 will slow down the process, ANY process. • ICD-10 will result in errors. • ICD-10 will increase the need for record review/audit. • ICD-10 will require process re-engineering. • ICD-10 may result in delays in pre-authorizations and

reimbursement. • ICD-10 will confuse the public. • ICD-10 will get blamed for unrelated problems. • ICD-10 will require patience. • ICD-10 will require good communication. • ICD-10 will require training and re-training.

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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 (may be too late) • Changes in coverage determinations or

authorization processes. 42

Managerial Considerations • Cash Flow

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

• Dual Coding Capabilities (Staff)

• Productivity Impact • New code orientation • Increased time in PM/EHR • Volume

• Patient Communications 43

Top Diagnosis Code Analysis • Identify the top 50 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. 44

Education and Training • 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.

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Claims Adjudication • 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.

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Date of Service or Discharge Date

Prior to October 1, 2015 On or After October 1, 2015

Other Possible Resources CMS http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html AMA https://download.ama-assn.org/resources/doc/bookstore/x-pub/no-index/icd-10-action-plan-12-step-transition.pdf AAFP http://www.aafp.org/practice-management/payment/coding.html AHIMA http://www.ahima.org/topics/icd10/physicians RURAL ICD-10 http://www.ruralicd10.com/ Note: These links should provide free information and resources. The presenters or sponsors of this program do not endorse, recommend or promote any specific products or services which may be offered for purchase or under agreement by any of these entities. 48

ICD-10-CM Code Assignment and Guidelines

2015 ICD-10-CM Alphabetic Index and Tabular Code Descriptions

The Index and Tabular volumes are available for download. http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2015

The Guidelines are also available for download. http://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cm-guidelines-2015.pdf

The GEM Mapping Files are available for download.

http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html The formats are not as user friendly as code manuals published by other sources. The GEM files are in text format and require additional formatting.

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How Do I find a Code in the Manual?

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Chapter Description Code Range

1 Certain Infectious and Parasitic Diseases AØØ – B99 2 Neoplasms CØØ – D49

3 Diseases of Blood and Blood-Forming Organs D5Ø – D89

4 Endocrine, Nutritional and Metabolic Diseases EØØ – E89

5 Mental, Behavioral, and Neurodevelopmental FØ1 – F99

6 Diseases of the Nervous System GØØ – G99

7 Diseases of the Eye and Adnexa HØØ – H59

8 Diseases of the Ear and Mastoid Process H6Ø – H95

9 Diseases of the Circulatory Process IØØ – I99

10 Diseases of the Respiratory System JØØ – J99

11 Diseases of the Digestive System KØØ – K95

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Chapter Description Code Range 12 Diseases of the Skin and Subcutaneous Tissue LØØ – L99

13 Diseases of the Musculoskeletal System and Connective Tissue

MØØ –M99

14 Diseases of the Genitourinary System NØØ – N99

15 Pregnancy, Childbirth, and the Puerperium OØØ –O9A

16 Certain Conditions Originating in the Perinatal Period

PØØ – P96

17 Congenital Malformations, Deformations, and Chromosomal Abnormalities

QØØ –Q99

18 Symptoms, Signs, and Abnormal Clinical & Laboratory Findings

RØØ – R99

19 Injury, Poisoning and Certain Other Consequences of External Causes

SØØ– T88

20 External Causes of Morbidity VØØ – V99

21 Factors Influencing Health Status and Contact with Health Services

ZØØ – Z99

Codes are generally organized from head to toe. This applies to the chapter sequencing and the sequencing within the chapters, categories and subcategories.

Step 1: Locate the Main Term in the Alphabetic Index located in the front of the coding manual.

Condition Alphabetic Index; Main Term, Indentions. RLQ Pain Pain; then Abdominal, then Lower; then Right

Quadrant. ADHD Disorder, Attention-deficit hyperactivity, then type. Routine Child Exam (EPSDT)

Examination, Child (over 28 days), then with or without findings.

Image from AMA 2015 ICD-10-CM Official Draft Codebook

Step 2: Locate the Code Section or Block in the Tabular List. The Tabular List is organized by Chapters. There are 21 Chapters in ICD-10. You must go to the Tabular list to see coding instructions and notes. Looking up a condition or disease in the Index will not guarantee the correct code selection.

Image from AMA 2015 ICD-10-CM Official Draft Codebook

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Code Descriptions: In ICD-10-CM, there are full code descriptions for each code. This removes the confusion of indented lines under main descriptions in ICD-9-CM. Notes, Include Notes and Terms : Further define conditions which may be included in the code category or give examples of diagnoses included within or give instruction. Excludes Notes: There are two types of Excludes Notes in ICD-10-CM. An Exclude 1 note means that the codes should never be used in conjunction with another code. It is a pure exclusion. Example: D51—Vitamin B12 deficiency anemia Excludes 1: Vitamin B12 deficiency E53.8 An Exclude 2 note indicates that although a specific condition is not reported using this code the two conditions can be coded at the same time. Example: JØØ –Acute nasopharyngitis Excludes 2: Allergic Rhinitis JØ.1

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Image from AMA 2015 ICD-10-CM Official Draft Codebook

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Code Also, Code First: Notes which give instructional guidance on sequencing.

NOS and NEC

Not Otherwise Specified (NOS): No additional information is available in the clinical documentation to allow a more specific code assignment.

Not Elsewhere Classified (NEC): The condition described in the clinical documentation cannot be found classified more specifically within the code set. Reminder: The correct code is the one that reflects the highest degree of specificity in the clinical documentation.

How to Assign an ICD-10 Code YES, you probably need a code book or two!

1. Start with the Index. Look up the main term for the

condition, disease or symptom. Codes should NOT be assigned from the Index without verifying the code selection in the Tabular volume.

2. Next, find the chapter & code set block for the condition. 3. Locate the condition in the Tabular section. 4. Consider the “includes”, “excludes”, “code first” and “use

additional code” notes. 5. Is a 7th character needed? If so, look at the key at the

beginning of the code chapter or block. 6. Select the most detailed code which is supported in the

clinical documentation. Code to the highest specificity and the highest number of characters.

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Code Sequencing Chapter Guidelines

Code Assignment Use Most Specific Code Available

ICD-10-CM Tabular Index Includes & Exclude Notes Code First and Use Additional Codes

ICD-10-CM Alphabetic Index Main term Gets you in the neighborhood

Clinical Documentation/Medical Record Notes and Reports ICD-10 Official Coding Guidelines

Steps to Assigning Codes

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ICD-10 Guidelines for Common Diagnoses and

Examples

ICD-9 ICD-10 Code Description Code Description V20.2 Routine Infant or Child

Check (Developmental testing, health check, immunizations, routine vision and hearing for child over 28 days old)

ZØØ.121 Encounter for routine child health examination with abnormal findings

ZØØ.129 Encounter for routine child health examination without abnormal findings

Routine Child Health Exam

• Not reported when a known problem or symptom exists. • Follow payer guidelines on reporting additional findings or multiple

diagnoses per encounter.

Routine Gynecological Exam

ICD-9 ICD-10 Code Description Code Description V72.31 Routine gynecological

examination (General gynecological examination with or without Papanicolaou cervical smear Pelvic examination (annual) (periodic)

ZØ1.411 Encounter for routine gynecological (general exam) with abnormal findings

ZØ1.419 Encounter for routine gynecological (general exam) examination without abnormal findings

• Used as the first-listed diagnosis only. • Follow payer guidelines on reporting multiple diagnosis codes for

same encounter. • Not used for status-post exams

Encounter Description ICD-10-CM

Encounter for pregnancy test, result unknown

Z32.ØØ

Encounter for pregnancy test, positive result Z32. Ø1

Encounter for pregnancy test, negative result Z32. Ø2

67

Encounter for Pregnancy Test

Used to report a visit in which no other services were performed.

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• Acute or Chronic • Specific Anatomical Site • Infectious Agent • Manifestations • Recurrent Infection or Not • Tobacco Use or Exposure to 2nd Hand Smoke

Examples of URI Codes in ICD-10-CM

ICD-10 Code Description

JØ3.Ø1 Acute recurrent streptococcal tonsillitis

J32.2 Chronic ethmoidal sinusitis JØ6.Ø Acute Laryngopharyngitis

Upper Respiratory Infections

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ICD-9 ICD-10

Code Description Code Description 461.0 Acute Sinusitis, Maxillary JØ1.ØØ Acute maxillary sinusitis, unspecified

JØ1.Ø1 Acute recurrent maxillary sinusitis 461.1 Acute Sinusitis, Frontal JØ1.1Ø Acute frontal sinusitis, unspecified

JØ1.11 Acute recurrent frontal sinusitis 461.2 Acute Sinusitis, Ethmoidal JØ1.2Ø Acute ethmoidal sinusitis,

unspecified JØ1.21 Acute recurrent ethmoidal sinusitis

461.3 Acute Sinusitis, Sphenoidal

JØ1.3Ø Acute sphenoidal sinusitis, unspecified

JØ1.31 Acute recurrent sphenoidal sinusitis 461.8 Acute Sinusitis, Other

(including pansinusitis) JØ1.4Ø Acute pansinusitis, unspecified JØ1.41 Acute recurrent pansinusitis JØ1.8Ø Other Acute sinusitis, unspecified

(more than one sinus, but not pansinusitis)

JØ1.81 Other Acute recurrent sinusitis 461.9 Acute sinusitis,

unspecified JØ1.3Ø Acute sinusitis, unspecified JØ1.3Ø Acute recurrent sinusitis

Mapping Sinusitis from ICD-9 to ICD-10

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For example, if our clinical documentation indicated that the patient presented with acute onset of nasal congestion, pain over both cheeks and tenderness with pressure; we confirmed bilateral maxillary sinusitis; and the provider noted that it was the 3rd similar infection in two months; the correct code assignment in ICD-9 would be 461.Ø, Acute Sinusitis, Maxillary. In ICD-10 it would be JØ1.Ø1, Acute Recurrent Maxillary Sinusitis.

It would be incorrect to assign either 461.9, Acute sinusitis, unspecified in ICD-9 or JØ1.3Ø, Acute Sinusitis, unspecified in ICD-10 because the clinical documentation is more specific about the nature and site of the infection.

In contrast, if the clinical documentation were less robust and indicated that the patient presented with acute onset of general symptoms indicative of sinusitis but no details were noted about the site or status of the infection, it would be appropriate to assign 461.9, Acute sinusitis, unspecified in ICD-9 or JØ1.3Ø, Acute Sinusitis, unspecified in ICD-10.

It all depends on the clinical documentation.

What about Sinusitis, Unspecified?

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• Acute or Chronic • Exposure to Smoking and Tobacco Use • Severity of Illness • Status or Complications of Illness • “Acute on Chronic” May or May Not Result in

Exacerbation • Acute and Chronic may be reported concurrently

if the clinical documentation supports both. • See Includes and Excludes Notes in Each Category

and Subcategory.

Bronchitis, Asthma and COPD

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Asthma • No Extrinsic or Intrinsic Asthma in ICD-10 • Classified by Severity of Asthma in ICD-10

• Mild Intermittent • Mild Persistent • Moderate Persistent • Severe Persistent • Unspecified • Other (Exercise-induced, cough variant, other)

• Sub-classified by: • Uncomplicated • With (acute) exacerbation • With status asthimaticus

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Chronic Lower Respiratory Diseases Category or Block

Main Description Notes (Examples) * refer to code set

J40 Bronchitis, not specified as acute or chronic

Excludes Asthmatic bronchitis; Bronchitis NOS

J41 Simple & Micopurulent Chronic Bronchitis

Excludes Chronic Obstructive Bronchitis

J42 Unspecified Chronic Bronchitis Excludes Conditions in J41 and J44

J 43 Emphysema Excludes Emphysema with Chronic Obstructive Bronchitis.

J44 Other Chronic Obstructive Pulmonary Disease

Includes Asthma with COPD, Chronic Obstructive Bronchitis, Chromic Asthmatic Bronchitis.

J45 Asthma Excludes Wheezing NOS

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• No separate codes for benign or malignant hypertension

• New combination codes for hypertensive heart disease

• New combinations codes for hypertensive kidney disease

• New combination codes for hypertensive heart and kidney disease.

• Fewer codes in ICD-10 than ICD-9 for hypertension.

Hypertension

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DX ICD-9 ICD-10 Code Description Code Description

HYP

ERTE

NSI

ON

401.0 Essential hypertension, Malignant

I1Ø Essential (primary) Hypertension

401.1 Essential hypertension, Benign

401.9 Essential hypertension, unspecified

ABN

ORM

AL B

LOO

D

PRES

SURE

REA

DIN

G 796.2 Elevated blood pressure

reading without diagnosis of hypertension

RØ3.Ø Elevated blood-pressure reading, without a diagnosis of hypertension. (incidental finding)

796.3 Nonspecific low blood pressure reading

RØ3.1 Nonspecific low blood-pressure reading (incidental finding)

Hypertension & Blood Pressure

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ICD-10-CM Coding Guidelines Hypertension with Heart Disease

– A causal relationship must be stated. – Additional code for heart failure by type. – Heart conditions not stated as due to hypertension are coded

separately. I11.0 Hypertensive Heart Disease I50.43 Acute on Chronic Combined systolic (congestive) and diastolic (congestive) heart failure

Hypertensive Chronic Kidney Disease – ICD-10 presumes a cause and effect relationship even if not stated. – Additional code for stage. – Additional code for acute renal failure. I12.9 Hypertensive Chronic Kidney Disease (Stage 1-4) N18.4 Chronic Kidney Disease (Stage 4) N17.9 Acute Kidney Failure, Unspecified

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Hypertension, Heart Disease & Kidney Disease

Hypertensive Heart and CKD – New combination codes – Hypertensive heart and hypertensive kidney disease must be stated in

diagnosis. I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease or unspecified stage chronic kidney disease.

ICD-10-CM Coding Guidelines:

A few examples • No longer necessary to code in or out of control using a 5th digit. • Out of control will be coded by type with hyperglycemia. So, type

2, stated as uncontrolled: • Type II is the default code if not specified. • Combination codes for complications/manifestations. Example:

E11.52 = Type 2 DM with diabetic peripheral angiopathy with gangrene. --Would have been 3 codes in ICD-9 250.7x; 443.81; and 785.4

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ICD-9 ICD-10 250.02

E11.65

Diabetes mellitus, Type 2, stated as uncontrolled.

Type 2 diabetes mellitus with

hyperglycemia

Diabetes Mellitus

DM diagnosis codes are reorganized in ICD-10

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ICD-10

E08 Diabetes Mellitus due to an underlying condition

E09 Drug or chemical induced diabetes mellitus E10 Type I diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus E14 Unspecified diabetes mellitus

ICD-9

250.0 Diabetes Mellitus w/o Complication 250.1 Diabetes with ketoacidosis 250.2 Diabetes with hyperosmolarity 250.3 Diabetes with other coma 250.4 Diabetes with renal manifestations 250.5 Diabetes with ophthalmic manifestations 250.6 Diabetes with Neurological manifestations 250.7 Diabetes with Peripheral Circulatory Disorders 250.8 Diabetes with other specified manifestations 250.9 Diabetes with unspecified manifestations

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Coding Case: Diabetes Mellitus

A 68 year old woman with poorly controlled DM II presents with an ulcer on her right foot. There is a significant breakdown of the skin. The patient is insulin dependent and has a history of non-compliance. Patient acknowledges that she is still not following her diet. Random blood glucose taken this office visit is 300 mg/dL. A1c = 11.0%.

ICD-10 E11.621 Type 2 diabetes mellitus with foot ulcer E11.65 Type 2 diabetes mellitus with hyperglycemia L97.522 Non-pressure chronic ulcer of other part of left foot Z79.4 Long term (current) use of Insulin Z91.11 Patient’s noncompliance with dietary regimen

ICD-9 250.82 Diabetes with other specified manifestations 707.15 Ulcer of lower limbs, except pressure ulcer, ulcer of other part of the foot V58.67 Long term use of insulin V15.81 Non-compliance with medical treatment

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• Specific anatomical Site • Type of Injury • Severity • Episode of Cared (7th Character) • How injury occurred • Where injury occurred • External Cause

Examples S91.211A Laceration without FB of right great toe with damage to nail, initial encounter. T20.29xD Burn of second degree of multiple sites of head, face and neck, subsequent encounter

Injuries

May be payer or facility specific

7th Character Extensions Charter Injuries Fractures

A Initial Encounter Initial encounter for closed fracture

B - Initial encounter for open fracture

D Subsequent Encounter

Subsequent encounter for fx with routine healing

G Subsequent encounter for fx with delayed healing

K Subsequent encounter for fx with nonunion

P Subsequent encounter for fx with malunion

S Sequela Sequela

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More examples of Injury Codes Injury codes are organized by site and then by type of injury. Secondary codes used to provider more information about external cause of morbidity.

Case #1: A 10 year old child is sting on the lip by a wasp while playing in a tree house. T63.461 Toxic effect of venom of wasp, unintentional

Case #2: His sister receives a tick bite her right thigh while playing in the same tree house. S70.361A Insect bite (nonvenomous), right thigh, initial encounter for care W57.xxxA Bitten or stung by nonvenomous insect

Case #3: A 36 year old man is treated for a second degree burn on the back of his left hand during a welding accident. This is the second visit for this injury. T23.262D Burn of second degree of back of left hand X18.xxxD Contact with other hot metals

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For most Diseases of the Digestive System: • Also code alcohol use or abuse

• Also code Tobacco use or exposure • Chronic or Acute

• Complication or Manifestation Present?

Digestive System/ GI

ICD-9 Code Description ICD-10 Code

Description

530.11 Reflux esophagitis K21.Ø Gastro-esophageal reflux disease with esophagitis

531.70 Chronic gastric ulcer w/o mention of hemorrhage perforation w/o obstruction

K25.7 Chronic gastric ulcer without hemorrhage or perforation

531.71 As above, with obstruction

Recap

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• October 1, 2015 is the scheduled implementation date!

• Dates of service or discharge dates after 10/1/2015will be

reported with ICD-10; dates prior to 10/1/2015 will be reported with ICD-9. Recurring services will be split billed by date.

• ICD-10 is more specific, has about 5 times more diagnosis codes than ICD-9

• ICD-9 and ICD-10 codes do not map or crosswalk exactly. There is not a one-to-one correlation between codes.

• ICD-10 will required improvements in the quality of clinical documentation and may require more record reviews.

• ICD-10 has new Coding Guidelines. 86

• Successful implementation will require time, planning, CHANGE, education, and teamwork.

• ICD-10 will required upgrades or revisions to practice management, HIS and EHR systems for providers.

• ICD-10 may result in delays in work processes.

• ICD-10 will require improved communication and empathy.

• ICD-10 is mandatory for all HIPAA entities

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Questions or Comments?

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Patty Harper is CEO of InQuiseek, LLC, a business and healthcare consulting company based in Louisiana. She has over 16 years of healthcare experience in the areas of healthcare finance & reimbursement, health information management, compliance, and physician practice management. Patty holds a B.S. in Health Information Administration (cum laude) from Louisiana Tech University. She is credentialed through AHIMA as a Registered Health Information Administrator (RHIA) and is also recognized as an AHIMA-Approved ICD-10-CM/PCS Trainer & AHIMA Ambassador. Patty has holds AHIMA Certified Healthcare Technology Specialist (CHTS) credentials as a CHTS-IM (EHR Implementation Specialist) and CHTS-PW (Practice Workflow and Information Management Redesign Specialist). She is also a frequent speaker and contributor for national, state and regional and rural healthcare associations on these and other related-reimbursement topics. She holds active memberships in a number of regional, state and national organizations including NARHC, NRHA, AHIMA, MGMA and HFMA. Patty Harper 318-243-2687 pharper@inquiseek.com

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