official coding guidelines icd-10-cm and pcs presented by: monica leisch, rhia, ccs ahima approved...

Official Coding Guidelines ICD-10-CM and PCS

Presented by:

MONICA LEISCH, RHIA, CCSAHIMA Approved ICD-10 Trainer

Director of Compliance / HIM ServicesHealthcare Cost Solutions, Inc.

[email protected]

May, 2013

Disclaimer• This material is designed and provided to communicate

information about clinical documentation, coding and compliance in an educational format and manner.

• The author is not providing or offering legal advice but rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality and coding.

• Every reasonable effort has been taken to ensure that the educational information is accurate and useful.

• Applying best practice solutions and achieving results will vary in each hospital or facility’s situation.

Introduction

ICD-10-CM Official Guidelines for Coding and Reporting 2013 for Diagnoses and Procedures

Guidelines DefinedThe guidelines are a set of rules that have been

developed to accompany and complement the official conventions and instructions provided within the ICD itself.

• Developed by The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

• Based on the coding and sequencing instructions in the Tabular List and Alphabetic Index

• Required under the Health Insurance Portability and Accountability Act (HIPAA)

CM vs PCS• ICD-10-CM (Clinical Modification)– Morbidity classification developed by the US– Classifies diagnoses and reason for visit– Applicable to all health care settings– Based on ICD-10 classification system published by

WHO• ICD-10-PCS (Procedural Coding System)– Procedure classification published by the US– Classifies all procedures– Applicable to inpatient care setting only– No such system in the ICD-10 published by WHO

Cooperating PartiesThe guidelines have been approved by the four

organizations that make up the Cooperating Parties:

• American Hospital Association (AHA)• American Health Information Management

Association (AHIMA) • The Federal Government represented by Centers

for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

Hierarchy

In order of Precedence:1. Coding Conventions of the ICD Classification2. Official Coding Guidelines3. All other, including Coding Clinic, LCDs, etc.

CM OrganizationCM guidelines are organized into sections:

• Section I includes the structure and conventions of the classification and general guidelines

• Section II includes guidelines for selection of principal diagnosis for non-outpatient settings

• Section III includes guidelines for reporting additional

diagnoses in non-outpatient settings.

• Section IV is for outpatient coding and reporting

Excludes NotesICD-10-CM

ICD-10-CM has two types of excludes notes. a. Excludes 1 • A type 1 Excludes note is a pure excludes note. It means “NOT CODED

HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

b. Excludes 2 • A type 2 excludes note represents “Not included here”. An excludes2

note 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. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Impending or Threatened Condition

ICD-10-CM

Impending or Threatened Condition listed at time of Discharge:

• If confirmed, code as confirmed diagnosis.• If it did not occur, check Alphabetic Index for – subentry for the term impending or threatened and use

that code if listed. – If no subentry, code the existing underlying condition(s)

and not the condition described as impending or threatened

Laterality

ICD-10-CM

Laterality • For bilateral sites, the final character of the

codes in the ICD-10-CM indicates laterality.• An unspecified side code is also provided should

the side not be identified in the medical record. • If no bilateral code is provided and the

condition is bilateral, assign separate codes for both the left and right side.

Late Effects/SequelaICD-10-CM

Late Effects (Sequela) • A late effect is the residual effect (condition produced) after the acute

phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second.

• An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.

BMI & UlcersICD-10-CM

Documentation for BMI (Body Mass Index) and Ulcers for coding:

• Codes may be assigned from clinician, (non physician) documentation

• The provider responsible for the patient’s care must provide coordinating diagnosis

• When conflicting documentation is present, query the responsible provider

• BMI codes should only be secondary diagnosis codes

Signs, SymptomsICD-10-CM

Signs and symptoms • Codes that describe symptoms and signs, as

opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

• Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all codes for symptoms.

Complication of Care

Complications of care • As with all procedural or post-procedural

complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure.

• Includes pain, and transplant complications, and information that complication codes that include the external cause, and complication of care codes within the body system chapters.

Borderline Diagnosis

ICD-10-CM

Borderline Diagnosis documented at Discharge:

• Coded as confirmed unless the classification provides a specific entry

• Borderline conditions are not uncertain conditions so no distinction between inpatient and outpatient settings.

• If documentation is unclear, query

Human Immunodeficiency Virus Infections

ICD-10-CMHIV Related Condition:• Principal diagnosis is B20, HIV disease followed by addition diagnosis codes for the HIV

related condition(s)

HIV Unrelated Condition:• Code the unrelated condition first following by B20

Asymptomatic human immunodeficiency virus Z21 is used for:• no documentation of symptoms • HIV positive, known HIV, HIV test positive or similar • Do not use if AIDS is documented, treated for HIV-related illness or described as having

any condition(s) resulting from his/her HIV positive status (use B20 instead)

Patients with inconclusive HIV serology:• Assign R75, Inconclusive laboratory evidence of HIV for patients with inconclusive HIV

serology, for patient without definitive diagnosis or manifestations of the illness

Previously diagnosed HIV – related illness:• Once a patient has developed an HIV related illness, assign B20 on every subsequent

admission/encounter

ICD-10-CMSepsis, Severe Sepsis, and Septic Shock Sepsis:• assign the appropriate code for the underlying systemic infection.

• Type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified.

• Do not assign a code from subcategory R65.2, Severe sepsis, unless severe sepsis or an associated acute organ dysfunction is documented.

• Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition, however, query the provider

Sepsis/Severe Sepsis and Septic Shock

ICD-10-CMSeptic shock:• Code first the systemic infection, followed by

code R65.21, Severe sepsis with septic shock or code T81.12, Post-procedural septic shock.

• Add codes for other acute organ dysfunctions. • The code for septic shock cannot be assigned as

a principal diagnosis.

Septic Shock

ICD-10-CM

Urosepsis • Nonspecific term. • not to be considered synonymous with sepsis. • Has no default code in the Alphabetic Index. • If used, the provider must be queried for

clarification.

Urosepsis

ICD-10-CMIf it is present on admission and meets principal diagnosis definition: • not to be considered synonymous with sepsis. • Has no default code in the Alphabetic Index. • If used, the provider must be queried for

clarification.

Sequencing of Sepsis

ICD-10-CMIf sepsis is present with a localized infection: • Sequence sepsis codes first • List localized infections second

If due to a post-procedural infection:• Sequence the code for the post-procedural infection

first• List sepsis codes second• If septic shock is documented, list second as well

Sepsis/Severe Sepsis with Infections

ICD-10-CMIf sepsis is present with a non-infectious process: • If the sepsis is due to the non-infectious process,

list the non-infectious process first• List the sepsis codes second• If the non-infectious process leads to an infection

with sepsis, the infection should be listed first• Code for Systemic Inflammatory Response

Syndrome (SIRS) of non-infectious origin is not needed

Sepsis/Severe Sepsis with Non-infectious Process

ICD-10-CM

Death NOSCode R99, Ill-defined and unknown cause of mortality,• Use only, when an expired patient is brought to

the ED other healthcare entity and is pronounced dead upon arrival

• Does not represent the discharge disposition of death.

Death NOS

NeoplasmsGeneral Guidelines

ICD-10-CM• A primary malignant neoplasm that overlaps

two or more contiguous sites should be classified to subcategory/code .8 (‘overlapping lesion’), unless the combo is specifically indexed elsewhere.

• For multiple neoplasms of same site, not contiguous, assign codes for each– Example: tumors in different quadrants of same

breast

NeoplasmsGeneral Guidelines (cont.)

ICD-10-CM• Malignant neoplasms of ectopic tissue are to

be coded to origin of mentioned site

• Example: ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9)

• Check the Alphabetic Index first before going to the Neoplasm Table

NeoplasmsCoding & Sequencing of Complications

(Anemia Associated w/ Malignancy)

ICD-10-CM• When admitted for management of anemia

associated with malignancy & treatment:– Sequence the code for malignancy as principal

– Followed by appropriate code for anemia

Neoplasms Coding & Sequencing of Complications

(Anemia assoc. w/ therapies)

ICD-10-CM• Management of anemia associated with adverse effect

of administration of chemotherapy or immunotherapy and treatment is only for anemia, sequence the anemia code first, followed by appropriate codes for neoplasm and adverse effect

• Management of anemia associated with adverse effect of radiotherapy, sequence the anemia code first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient . . .

Neoplasms Malignancy in 2 or more noncontiguous sites

ICD-10-CM

• In case where patient has more than one malignant tumor in the same organ, different tumors may constitute different primaries or metastatic disease, depending on site.

• If documentation unclear, query provider as to status so that coding is correct

Neoplasms Admission to Determine Extent of Malignancy

ICD-10-CM

• When the reason for admission is to determine the extent of the malignancy, list the malignancy first, even if chemotherapy or radiotherapy is administered.

Neoplasms Sequencing of neoplasm codes (cont.)

ICD-10-CM

• Malignant neoplasm in pregnant patient: use code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, sequenced first, followed by appropriate code from Chapter 2 to indicate type of neoplasm


ICD-10-CM

• Encounter for complication associated with neoplasm: – When encounter is for mgmt of complication

associated w/ neoplasm and treatment is only for complication, code complication first, followed by appropriate code for neoplasm

– Exception: Anemia (see slide above)


ICD-10-CM

• When encounter is for treatment of complication resulting from surgical procedure performed for treatment of neoplasm, designate complication as principal diagnosis. (See guideline regarding the coding of current malignancy vs personal history to determine if code for neoplasm should also be assigned)


ICD-10-CM• Pathologic fracture due to neoplasm

- If focus of treatment is the fracture, code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by neoplasm code

- If focus of treatment is neoplasm with an associated pathological fracture, code neoplasm first, followed by code from M84.5 for the pathological fracture

Neoplasms Current malignancy vs.

personal history of malignancy

ICD-10-CM• When primary malignancy has been excised but further treatment is directed to that site, use primary malignancy code until treatment is completed

• Use code Z85, Personal history of malignant neoplasm, to indicate former site of malignancy once it has been excised/eradicated, there is no further treatment directed to that site, and there is no evidence of existing malignancy

Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell

Neoplams in remission vs personal history

ICD-10-CM• Categories for leukemia, and category C90,

Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission.

• There are also codes for personal history of leukemia or malignant neoplasms of hymphoid, hematopoietic and related tissues

Neoplasms Leukemia, Multiple Myeloma, and Malignant Plasma Cell

Neoplams in remission vs personal history (cont.)

ICD-10-CM• If it is unclear in the documentation as to

whether or not the leukemia has achieved remission, query the provider.

Malignant Neoplasm associated with Transplanted Organ

ICD-10-CM• Coded as tranplant complication• Assign the code for the specific malignancy

second

Diabetes Diabetes Mellitus

ICD-10-CM• Diabetes mellitus codes are combination codes

to include type of diabetes, body system affected, and complications affecting that body system

• Assign as many codes within category as are necessary to describe all complications of disease

Diabetes Underdose of insulin due to

insulin pump failure

ICD-10-CM• Assign code from subcategory T85.6, Mechanical

complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal

• Assign T38.3x6-, Underdosing of insulin and oral hypoglycemic (antidiabetic drugs) as secondary

• Assign codes for type of diabetes mellitus and associated complications if appropriate

Diabetes Overdose of insulin due to

insulin pump failure

ICD-10-CM• Assign code from subcategory T85.6, Mechanical

complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal

• Assign T38.3x1-, Poisoning by insulin and oral hypoglycemic drugs, accidental as secondary

Diabetes Secondary Diabetes Mellitus

ICD-10-CM• Codes under categories E08, Diabetes mellitus

(DM) due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, show complications and manifestations associated with secondary diabetes mellitus

• Secondary DM is always caused by another condition

Diabetes Assigning and sequencing secondary

diabetes codes and its causes

ICD-10-CM• Sequencing of secondary diabetes codes in

relationship to codes for the cause of the diabetes is based on the Tabular List instructions for categories E08 and E09.

Mental & Behavioral Disorders Pain disorders related to psychological factors

ICD-10-CM• Assign code F45.41, for pain that is exclusively

related to psychological disorders• Do not assign a code from category G89, Pain, not

elsewhere classified with is code

Mental & Behavioral Disorders Pain disorders related to psychological factors

ICD-10-CM• Code 45.42, Pain disorders with related

psychological factors, should be used with a code from category G89, Pain, not elsewhere classified if documentation shows a psychological component for a patient with acute or chronic pain

Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance

use

ICD-10-CM1. In Remission• Assigned only if so documented.• Selection of codes for “in remission” categories

F10-F19, Mental and behavioral disorders due to psychoactive substance use


use

ICD-10-CM

2. Psychoactive Substance Use, Abuse and Dependence

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


use

ICD-10-CM2. Psychoactive Substance Use, Abuse and

Dependence (cont.)- If both use and abuse are documented, assign

only the code for abuse- If both abuse and dependence are documented,

assign only code for dependence - If use, abuse and dependence are all

documented, assign only the code for dependence


use

ICD-10-CM2. Psychoactive Substance Use, Abuse and

Dependence (cont.)- If both use and dependence are documented,

assign only the code for dependence


use

ICD-10-CM3. Psychoactive Substance Use- The codes for psychoactive substance use should

only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis

- Codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and this relationship is documented by provider

Nervous System Dominant/nondominant side

ICD-10-CM• Codes from G81, Hemiplegia and hemiparesis,

and subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether dominant or nondominant side is affected

Nervous System Dominant/nondominant side (cont.)

ICD-10-CM• If the affected side is documented, but it is not

specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:– For ambidextrous pt, default should be dominant– If left side is affected, default is non-dominant– If right side is affected, default is dominant

Pain ReportingGeneral Coding Info

ICD-10-CM• Only assign code from category G89 if pain is

specified as acute or chronic, post-thoracotomy, post-procedural, or neoplasm-related

• Pain codes are only assigned as principal if:– Pain control or management is reason for encounter– Patient is admitted for insertion of neurostimulator for

pain control– Not for neurostimulator insertion for definitive

underlying cause.

Circulatory SystemHypertensive Heart & Chronic Kidney Disease

ICD-10-CM• The appropriate code from category N18,

Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease

• I13 codes are combination codes that include hypertension, heart disease and chronic kidney disease

Circulatory SystemHypertensive Heart & Chronic Kidney Disease

ICD-10-CM• The Includes note at I13 specifies that the

conditions included in I11 and I12 are included together in I13

• If a patient has hypertension, heart disease and CKD then a code from I13 should be used rather than individual codes

• For patients w/ both acute renal failure and CKD an add’l code for acute renal failure is required

Circulatory SystemHypertensive Retinopathy

ICD-10-CM• Subcategory H35.0, Background retinopathy and

retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertension

• Sequence based on reason for encounter

Circulatory SystemAtherosclerotic Coronary

Artery Disease & Angina

ICD-10-CM• Combination codes for atherosclerotic heart

disease with angina pectoris• When using one of these combo codes it is not

necessary to use an additional code for angina• If a patient with coronary artery disease is

admitted due to acute myocardial infarction (AMI), sequence AMI first

Circulatory SystemIntraoperative and Postprocedural Cerebrovascular Accident

ICD-10-CM• Proper code assignment depends on whether it

was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively.

• If it was a cerebral hemorrhage, code assignment depends on type of procedure performed

Circulatory SystemSequelae of Cerebrovascular Disease

ICD-10-CM• Category I69 indicates conditions classifiable to

categories I60-I67, as causes of sequela (neurologic deficits). These late effects include neurologic deficits that persist after initial onset of the conditions in categories I60-I67.

• I69 codes specify hemiplegia, hemiparesis and monoplegia; whether dominant or nondominant side affected. No default code is available.

• Codes from category I69 should not be assigned if the patient does not have neurologic deficits.

Circulatory SystemAcute myocardial infarction (AMI)

ICD-10-CM• For encounters ≤ 4 weeks old, including transfers to

another acute setting or a postacute setting, and the patient requires continued care for MI, codes from category I21 may continue to be reported

• For encounters > 4 weeks old and patient is still receiving care related to MI, appropriate aftercare code should be assigned

• If the NSTEMI evolves to a STEMI, assign the STEMI only

• For old or healed MI not requiring care, code I25.2, Old myocardial infarction

Circulatory SystemSubsequent acute myocardial infarction

ICD-10-CM• Code from category I22, Subsequent ST elevation

(STEMI) and non ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI

• The sequencing of the I22 and I21 codes depends on the circumstances of the encounter

Circulatory SystemDocumentation of Ventilator

Associated PneumoniaA

ICD-10-CM• Code J95.851, Ventilator associated pneumonia,

(VAP), should be assigned only when the provider has documented VAP

• Add’l code to identify organism should also be assigned

• Do not assign add’l code from J12-J19 to identify the type of pneumonia, unless the VAP develops after admission, and the patient is admitted with pneumonia.

Pressure Ulcer Stages

ICD-10-CM• Codes from category L89 Pressure Ulcer, combo

codes that show the ulcer as well as the stage• If documented as healed, no code is assigned• If documented as healing, the appropriate code

for type and stage should be assigned.• If the stage evolves into a higher stage, assign only

the highest stage.

Diseases of the Musculoskeletal System and Connective Tissue

ICD-10-CM

• Site and Laterality– Site represents bone, joint or muscle– For conditions where more than one, bone, joint or

muscle are involved there is a multiple sites code

• Bone vs. joint– Though the portion of bone affected may be the joint,

the site designation will be the bone not the joint

Coding of Pathologic FracturesICD-10-CM

7th Character A is for active fracture treatmentsurgicalEDEval by new physician

7th Character D is used for encounters after the patient has completed active treatment

Other 7th Characters are used for subsequent encounters associated with healing such as malunions, nonunions and sequelae

Chronic Kidney DiseaseICD-10-CM

• Stages of chronic kidney disease (CKD)– Classify severity– End stage renal disease with CKD is assigned with

one code N18.6, which include both conditions• CKD with Transplant – The presence of CKD alone may not constitute a

transplant complication– If unclear query

Pregnancy, Childbirth, PuerperiumFinal character for trimester

ICD-10-CM• Majority of Ch 15 codes have a final character

indicating trimester of pregnancy• Where trimester isn’t part of the code it is

because the condition always occurs in a specific trimester


ICD-10-CM• Final trimester codes also apply for pre-existing

conditions and those that develop during or are caused by the pregnancy

• If delivery occurs during the current admission and there is an “in childbirth” option for the obstetric complication, the “in childbirth” code should be assigned


ICD-10-CM• If a patient is admitted to a hospital for

complications of pregnancy during one trimester and remains in the hospital into the next trimester, the trimester character for the antepartum complication code should be assigned based on the trimester when the complication developed rather than trimester of discharge

• The unspecified trimester should not be used; obtain further clarification

Pregnancy, Childbirth, Puerperium7th character Fetus Identification

ICD-10-CM• If applicable, a 7th character should be assigned for

certain categories to identify the fetus for which the complication code applies

• Assign 7th character “0”:– For singe gestations– When the documentation in the record is

insufficient to determine the fetus affected– When it is not possible to clinically determine

which fetus is affected

Pregnancy, Childbirth, PuerperiumPre-existing conditions vs.

conditions due to pregnancy

ICD-10-CM• Certain categories in Chapter 15 distinguish

between conditions of the mother than existed prior to pregnancy and those that are a direct result of the pregnancy

• For categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either

Pregnancy, Childbirth, PuerperiumGestational (pregnancy induced)

diabetes

ICD-10-CMGestational (Pregnancy Induced) diabetes • Codes under subcategory O24.4 include diet

controlled and insulin controlled• If gestational diabetes is treated with both diet and

insulin, only code insulin-controlled • Code Z79.4, Long-term (current) use of insulin, should

not be assigned with codes from subcategory O24.4• Abnormal glucose tolerance in pregnancy is assigned a

code from subcategory O99.81, Abnormal glucose complicating pregnancy, childbirth, and the puerperium

Pregnancy, Childbirth, PuerperiumAlcohol, tobacco use during pregnancy, childbirth and the

puerperium

ICD-10-CM• Subcategory O99.31, Alcohol use complicating

pregnancy, childbirth, and the puerperium - assigned when a mother uses alcohol during the pregnancy or postpartum

• Also assign a secondary code from category F10, Alcohol related disorders, to identify manifestations of alcohol use

Pregnancy, Childbirth, PuerperiumAlcohol, tobacco use during pregnancy, childbirth and the

puerperium

ICD-10-CM• Subcategory O99.33, Smoking (tobacco)

complicating pregnancy, childbirth, and the puerperium - assign when a mother uses any type of tobacco product during the pregnancy or postpartum

• Also assign a secondary code from category F17, Nicotine dependence, or code Z72.0, Tobacco use, to identify the type of nicotine dependence

Pregnancy, Childbirth, PuerperiumPoisoning, toxic effects, adverse

effects and underdosing in a pregnant patient

ICD-10-CM• Subcategory O9A.2, Injury, poisoning and certain

other consequences of external causes complicating pregnancy, childbirth, and puerperium, is sequenced first

• Next assign the appropriate injury, poisoning, toxic effect, adverse effect or underdosing code

• Then assign additional code(s) that specifies the condition causing poisoning, toxic effect, adverse effect or underdosing

Pregnancy, Childbirth, PuerperiumPregnancy associated cardiomyopathy

ICD-10-CM• Pregnancy associated cardiomyopathy, code

O90.3, is unique in that it may be diagnosed in the 3rd trimester of pregnancy but may continue to progress months after delivery

• As such, it is referred to as peripartum cardiomyopathy

• Code O90.3 is only for use when the cardiomyopathy develops as a result of pregnancy in a woman who did not have pre-existing heart disease

Sequelae of complication of Pregnancy, Childbirth, and the Puerperium

ICD-10-CM

• Use code O94 in cases when an initial complication of pregnancy develops a sequelae requiring care or treatment at a future date

• The sequela code is sequenced following the code for the complication

Abuse in a Pregnant PatientICD-10-CM

• Suspected or confirmed cases of abuse in a pregnant patient are coded from subcategories O9A.3, Sexual abuse complicating pregnancy, childbirth and the puerperium, and O9a.5, Psychological abuse complicating pregnancy, childbirth, and the puerperium

• See also Section I.C.19, Adult and child abuse, neglect and other maltreatment

NewBornsConditions Originating in the Perinatal Period

ICD-10-CMPrincipal Diagnosis for the Birth Record• Assign a code from category Z38, Liveborn infants

according to place of birth and type of delivery as principal diagnosis for the birth episode

• A code from category Z38 should only be used once

NewbornsUse of Codes from other Chapters

ICD-10-CM• Codes from other chapters may be used w/

codes from chapter 16 if the codes from the other chapters provide more specific detail

• If the reason for the encounter is a perinatal condition, the code from chapter 16 should be principal

NewbornsLow birth weight and immaturity status

ICD-10-CM• Codes from category P07, Disorders of newborn

related to short gestation and low birth weight, not elsewhere classified, are for use for a child or adult who was premature or had low birth weight as a newborn newborn and this is affecting the patient’s current health

NewbornsBacterial Sepsis of Newborn

ICD-10-CM• Category P36, Bacterial sepsis of newborn,

includes congenital sepsis. If a perinate is documented as having sepsis w/o documentation of congenital or community acquired, the default is congenital & a code from category P36 should be assigned

NewbornsBacterial Sepsis of Newborn

ICD-10-CM• If the P36 code includes the causal organism, an

add’l code from category B95 or B96 should not be assigned

• If the P36 code does not include the causal organism, assign an add’l code from category B96

NewbornsStillbirth

ICD-10-CM• Code P95, Stillbirth, is only for use in institutions

that maintain separate records for stillbirth• No other code should be used with P95• P95 should not be used on the mother’s record

Coma Scale

ICD-10-CM• The coma scale codes are used in conjunction with

traumatic brain injury codes, acute cerebrovascular disease and cerebrovascular disease codes.

• The 7th character indicates when the scale was recorded

• At a minimum report the initial score documented on presentation

• Assign R40.24, Glasgow coma scale, total score, when only the total score is documented

InjuriesApplication of 7th Characters

ICD-10-CM• Most categories in chapter 19 have a 7th character

requirement for each applicable code• Most categories have three 7th character values

(exception: fracture):– A, initial encounter– D, subsequent encounter– S, sequela


ICD-10-CM• 7th character “A”, intial encounter is used while

the patient is receiving active treatment for the condition

• Examples:– Surgical treatment– ED encounter– Evaluation and treatment by a new physician


ICD-10-CM• 7th character “D”, subsequent encounter is used

for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during healing/recovery phase

• Examples:– Cast change or removal– Removal of external or internal fixation device– Medication adjustment


ICD-10-CM• 7th character “S,” sequela, is for use for

complications or conditions that arise as a direct result of a condition, such as a scar formation after a burn

• When using “S,” it is necessary to use both the injury code that precipitated the sequela and the sequela itself

• Add “S” only to the injury code, not the sequela code


ICD-10-CM• Aftercare Z codes should not be used for aftercare

conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care

• Example: for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter)

InjuriesCoding of Traumatic Fractures

ICD-10-CM

• A fracture not indicated as open or closed should be coded to closed

• A fracture not indicated whether displaced or not displaced should be coded to not displaced

InjuriesInitial vs. Subsequent Encounter

for Fractures

ICD-10-CM

• When patient is receiving active treatment for fracture, traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C)

InjuriesInitial vs. Subsequent Encounter

for Fractures

ICD-10-CM• For encounters after the patient has completed active

treatment and is receiving routine care during the healing/recovery phase, fractures are coded with appropriate 7th character for subsequent care

InjuriesCoding of Burns and Corrosions

ICD-10-CM• Distinction between burns and corrosions• Burn codes are for thermal burns, except

sunburns, that come from a heat source or burns resulting from electricity and radiation

• Corrosions are burns due to chemicals• Guidelines are the same for both• Non-healing burns are coded as acute burns

InjuriesEncounters for treatment of sequela burns

ICD-10-CM• Encounters for the treatment of the late effects of

burns or corrosions should be coded with a burn or corrosion code with the 7th character “S” for sequela

InjuriesAdverse Effects, Poisoning, Underdosing & Toxic Effects

ICD-10-CM• Codes in categories T36-T65 are combination

codes that include substance that was taken as well as the intent

• Do not code directly from Table of Drugs; refer back to Tabular List

• If the same code would describe the causative agent for more than one adverse reaction, toxic effect or underdosing, assign the code only once

InjuriesAdverse Effect

ICD-10-CM• When drug was correctly prescribed and properly

administered, assign appropriate code for nature of adverse effect followed by code for the adverse effect of the drug (T36-T50)

• Code for the drug should have 5th or 6th character of 5

InjuriesPoisoning Codes

ICD-10-CM• Assign code from categories T36-T50 first• Poisoning codes have an associated intent as their

5th or 6th character• Use additional code(s) for all manifestations of

poisonings• Follow with abuse or dependence code, if

applicable

InjuriesUnderdosing

ICD-10-CM• Underdosing refers to taking less of a medication

than is prescribed by a provider• For underdosing, assign code from T36-T50 (5th or

6th character “6”)• Codes for underdosing should not be listed first

InjuriesUnderdosing

ICD-10-CM• If a patient has a relapse of the medical condition

for which drug is prescribed because of underdosing, the medical condition itself should be coded

• Noncompliance (Z91.12-Z91.13-) or complication of care (Y63.8-Y63.9) codes are to be used with an underdosing code to indicate intent, if known

InjuriesComplications of Care: Complication codes that include the external cause

ICD-10-CM• As with some other T codes, some of the

complications of care codes have the external cause included in the code

• The code includes the nature of the complication as well as the type of procedure that caused the complication

• No external cause code indicating the type of procedure is necessary for these codes

External Causes of MorbidityIntroduction

ICD-10-CM• Codes V01-Y99 are provided for the reporting of

external causes of morbidity • Always secondary codes

InjuriesComplications of Care: Complication

codes within the body system chapters

ICD-10-CM• Intraoperative and postprocedural complication

codes are found within the body system chapters with codes specific to the organs and structures of that body system

• These codes should be sequenced first, followed by a code(s) for the specific complication

External Causes of MorbidityGeneral External Cause Coding Guidelines

ICD-10-CM• An external cause code may be used with any

code in the range A00.0-T88.9, Z00-Z99, classification that is a health condition due to an external cause

External Causes of MorbidityGeneral External Cause Coding Guidelines

ICD-10-CM• Mostly applicable to injuries• Also valid for infections or diseases due to an

external source, and other health conditions, such as a heart attack that occurs during strenuous physical activity

External Causes of MorbidityLength of Treatment

ICD-10-CM• Assign the external cause code with the

appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated

External Causes of MorbidityCombination external cause codes

ICD-10-CM• Some external cause codes are combination

codes that identify sequential events that result in an injury, such as a fall which results in striking against an object

• Assign regardless of seriousness of injury• Injury may be due to either event or both

External Causes of MorbidityPlace of Occurrence Guideline

ICD-10-CM• Codes from category Y92, Place of occurrence of

the external cause, are secondary codes for use after other external cause codes to identify location of patient at time of injury/condition

• Place of occurrence used at initial encounter w/ no 7th character

External Causes of MorbidityUnknown or Undetermined Intent Guideline

ICD-10-CM• If the intent of the cause of injury/other

condition is unknown or unspecified, code intent as accidental.

• External cause codes for events of undetermined intent are only for use if the documentation in the record specifies that the intent cannot be determined

Factors Influencing Health StatusAftercare

ICD-10-CM• Aftercare Z codes should not be used for

aftercare for injuries. • Use Z codes for care following treatment • For aftercare of an injury, assign the acute injury

code with the appropriate 7th character for subsequent encounter

Factors Influencing Health Status“With” or “without” abnormal findings

ICD-10-CM• Some codes for routine health exams distinguish

between “with” and “without” abnormal findings• Code assignment depends on info known at the

time encounter is being coded• E.g. if no abnormal findings were found during

exam, but test results are not in at time of coding, assign code for “without abnormal findings”

• When assigning a code for “with abnormal findings,” add’l code(s) should identify specific abnormal findings

Outpatient Coding GuidelinesEncounters for medical exams

w/ abnormal findings

ICD-10-CM• The subcategories for encounters for general

medications, Z00.0-, provide codes for with and without abnormal findings

• Should a general medical exam result in an abnormal finding, the code for general medical examination with abnormal finding should be first-listed diagnosis

• A secondary code for the abnormal finding should also be coded

PCS OrganizationICD-10-PCS

• Conventions• Medical and Surgical Section Guidelines

– Body System– Root Operation– Body Part– Approach– Device

• Obstetrics Section Guidelines

PCS ConventionsICD-10-PCS

• Composed of 7 characters• Characters = numbers 0 through 9 and alpha except I

and O• The valid values for an axis of classification can be

added as needed• The meaning of any single value is a combination of its

axis of classification and any preceding values• With expansion more values will depend on the

preceding value

PCS Conventions continuedICD-10-PCS

• Alphabetic index provides for location table necessary to construct code

• Code may be chosen from the table, (the alpha index does not need to be consulted first)

• All seven characters must be specified to be a valid code• Within a PCS table, valid codes include all combinations

of choices for characters 4 through 7• The term “And” means “and/or”• It is the coder’s responsibility to determine which code

to choose from the documentation

DeviceICD-10-PCS

General Guidelines• Coded only if it remains after procedure is coded• Sutures, ligature, radiological markers an

temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices

• Procedures performed on a device only and not on a body part are specified in the root operations:

-change -irrigation-removal -revision

Obstetrics SectionICD-10-PCS

• Productions of conception– Procedures performed on the products of conception are

coded to the obstetrics section

• Procedures following delivery or abortion– All coded to the root operation Extraction and the body part

Products of Conception, Retained.– Diagnostic or therapeutic dilation and curettage performed

during times other than the postpartum or post-abortion period are coded in the Medical and Surgical section.

Summary and Questions

• The ICD-10 Official Guidelines mirror the ICD-9 Official Guidelines in most cases

• ICD-10 Official Guidelines contain ICD-9 Coding Clinic Guidelines

Questions?

References:

• ICD-10-CM Official Guidelines for Coding and Reporting 2013• ICD-10-PCS Official Guidelines for Coding and Reporting 2013

official coding guidelines icd-10-cm and pcs presented by: monica leisch, rhia, ccs ahima approved...

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