sherry thomas, ccp, ccp-as ceo/director of education

Sherry Thomas, CCP, CCP-AS CEO/Director of Education

ICD-10-CM:

What You Need To Know

Guidelines

Coding Structure

Documentation Issues

Auditing

Provide a more accurate description of patients illness/disease process

Codes go beyond “statistical and trend” analysis

©2010 PHIA/Medical Staff SOS,. Inc

Joint effort between the healthcare provider and the coder

Consistent AND complete documentation in the medical record is IMPERATIVE!

FOR CODING ACCURACY: ◦ ICD-10-CM suggests the “entire record” be reviewed to

determine the specific “reason for the visit” AND the “condition(s) treated”.


Based on the process for adoption of standard under the HealthInsurance Portability and Accountability Act of 1996 (HIPAA).

FINAL RULE for adoption of:◦ ICD-10-CM (physician/out-pt) ◦ ICD-10-PCS (hospital)

January 16, 2009 Federal Registry: 45 CFR part 162 [CMS-0013-F]


Effective Date of the regulation: March 17, 2009 Level I Compliance by: December 31, 2010 Level II Compliance by: December 31, 2011

All covered entities have to be fully compliant on: January 1, 2012

Level I compliance means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing.“

Level II compliance means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards."


Addition of information relevant to ambulatory and managed care encounters

Expanded injury codes

Creation of combination diagnosis/symptom codes ◦ Reducing the number of codes needed to fully describe a

condition

Addition of 6th and 7th characters◦ Providing greater specificity in code assignment


2 Main Parts:

◦Index = Alphabetical list of terms Index to Diseases and Injuries Index to External Causes of Injury Neoplasm Table Table of Drugs and Chemicals

◦Tabular = Based on body system and condition Categories, subcategories, and valid codes


Section1: General guidelines, structure and conventions

Section 2: Guidelines for selection of principal diagnosis for “non-outpatient” settings

Section 3: Guidelines for reporting additional diagnoses in “non-outpatient” settings

Section 4: Outpatient coding and reporting


Encounter = used for ALL settings including hospital admissions.

Provider = physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.


Codes R00 – R99 Use ONLY when NO definitive diagnosis is

available.

Code “in addition to” definitive diagnosis ONLY if “the sign/symptom is NOT routinely associated with that definitive diagnosis”.◦ Code the definitive diagnosis first◦ Then code the sign/symptom


If a “combination” definitive/sign & symptom code is billed do NOT bill a separate code for the sign/symptom.

Repeat Falls:

◦ R29.6 = Repeated Falls use for encounters when patient has “recently fallen” and the reason

for the fall is being investigated.

◦ Z91.81 = H/O falling use for encounters when patient has “fallen in the past” and is at risk

for future falls.

* R29.6 and Z91.81 can be coded together. Documentation must support both codes.


Codes S00 – T88 (previously E codes) Most categories in this chapter have 3 extensions

◦ A = initial encounter

◦ D = subsequent encounter

◦ S = sequela


3 – 7 characters in length

Alpha-numeric code

◦1st digit of 3 digit code = Alpha◦2nd and 3rd digit = Number◦4th, 5th, 6th digit = Subcategory May be a Number or Alpha

◦7th digit - Alpha

Q10.0

N99.520

L20

M22.42 T46.995A


Applies to certain categories

Required when noted in the tabular

Must ALWAYS be the last character

If code is NOT a full 6 digit code:◦ Place-holder “X” must be used◦ Place in the 5th position within code

S91.001D


S91 Open Wound of ankle, foot and toes Code also any associated wound infection Excludes 1: open fracture of ankle, foot and toes (S92.- with 7 th

character B) traumatic amputation of ankle and foot (S98. -) The appropriate 7th character is to be added to each code from

category S91A initial encounterD subsequent encounterS sequela

S91.0 Open wound of ankleS91.00 Unspecified open wound of ankleS91.001 Unspecified open wound, right ankleS91.002 Unspecified open wound, left ankleS91.009 Unspecified open wound, unspecified

ankle

A initial encounter

D subsequent encounter

S sequela

Use “while” patient is receiving “active”treatment for the injury

Examples: Surgical treatment Emergency department encounter Evaluation and treatment by a new physician


Use “after” the patient has received activetreatment of the injury and receiving “routinecare” for the injury during the healing orrecovery phase Examples:

Cast change or removal Removal of external or internal fixation device Medication adjustment Other aftercare* and follow up visits following

injury treatment


Use for complications or conditions that arise as a direct result of an injury Example: scar formation after a burn

Use both the injury code (that precipitated the sequela) AND the code for the sequela

“S” is ONLY added to the sequela code, NOT the injury code

List the sequela code first AND the injury code second


G subsequent encounter for fracture with delayed healing

K subsequent encounter for fracture with nonunion

P subsequent encounter for fracture with malunion

M80.0 Age-related osteoporosis with current pathological fracture M81 Osteoporosis without current pathological fracture M83 Adult osteomalacia M84 Disorder of continuity of bone M85 Other disorders of bone density and structure M86 Osteomyelitis M87 Osteonecrosis M88 Osteitits deformans (Paget’s disease of bone) M89 Other disorders of bone

and the list goes on and on ……….

“Filler” or “place holder” character

Use as 5th digit for certain 6 character codes Allows for expansion of code in future

T47.0x1©2010 PHIA/Medical Staff SOS,. Inc

T47 Poisoning by, adverse effect of an underdosing of agents primarily affecting the gastrointestinal system

The appropriate 7th character is to be added to each code from category T47

A initial encounterD subsequent encounterS sequela

T47.0 Poisoning by, adverse effect of and underdosing of histamine H2-receptor blockers

T47.0x Poisoning by, adverse effect of and underdosing of histamine H2-receptor blockers

T47.0x1 Poisoning by histamine H2-receptor blockers, accidental (unintentional)

T47.0x2 Poisoning by histamine H2-receptor blockers, accidental (intentional-self harm)

T47.0x3 Poisoning by histamine H2-receptor blockers, accidental (assault)

X00 Exposure to uncontrolled fire in building or structure Includes: Conflagration in building or structure Code first any associated cataclysm Excludes 2: Exposure to ignition or melting of nightwear (X05)

Exposure to ignition or melting of other clothing and apparel (X06-) Exposure to other specified smoke, fire and flames (X08.-)

The appropriate 7th character is to be added to each code from category X00A initial encounterD subsequent encounterS sequela

X00.0 Exposure to flames in uncontrolled fire in building or structure X00.1 Exposure to smoke in uncontrolled fire in building or structure X00.2 Injury due to collapse of burning building or structure in uncontrolled

fireX00.3 Fall from burning building or structure in uncontrolled fireX00.4 Hit by object from burning building or structure in uncontrolled fireX00.5 Jump from burning building or structure in uncontrolled fireX00.8 Other exposure to uncontrolled fire in building or structure

3 digit code = Heading of a Category

Indicates this condition is the “most commonly associated” code with the main term or it’s “unspecified”

Take back to provider for more specific documentation

Diagnosis codes are suppose to be used and reported at their “highest number of digits” available!


Will be listed at end of code

Indicates additional characters are REQUIRED

Even if code does not indicate ( - ) at the end of the code be sure to check the Tabular listing as it may be indicated there.

M13.12-


Final character of code indicates side

Unspecified side codes available◦ Take back to provider for additional information

If there is NO bilateral code available◦ Assign separate codes for both the left and right


Index indicates: Monoarthritis, elbow M13.12 -

M13 Other arthritis Excludes 1: arthrosis (M15 – M19)

osteoarthritis (M15 – M19)

M13.0 Polyarthritis, unspecified M13.1 Monoarthritis, not elsewhere classified

M13.10 Monoarthritis, not elsewhere classified, unspecified siteM13.11 Monoarthritis, not elsewhere classified, shoulder

M13.111 Monoarthritis, not elsewhere classified, right shoulder M13.112 Monoarthritis, not elsewhere classified, left shoulder M13.119 Monoarthritis, not elsewhere classified, unspec.

shoulderM13.12 Monoarthritis, not elsewhere classified, elbow

M13.121 Monoarthritis, not elsewhere classified, right elbow M13.122 Monoarthritis, not elsewhere classified, left elbow M13.129 Monoarthritis, not elsewhere classified, unspec.

elbow

[ ] Brackets ◦ In the Tabular = Used to enclose synonyms, alternative wording or

explanatory phrases. ◦ In the Index = used to identify “manifestation” codes.

( ) Parentheses ◦ In Tabular and Index

Used to enclose supplementary words without affecting the code assignment.

: Colon ◦ In Tabular

Used for incomplete term


NEC = “Not Elsewhere Classifiable”

◦ Indicates “other specified” in ICD-10-CM◦ Index entry = directs you to “other specified” in Tabular◦ Codes listed as “Other” or “Other Specified” in Tabular are

used when a “more specific code” does not exist◦ Will find in codes with a:

4th or 6th character of “8 or Z” AND 5th digit character of “9”


NOS = “Not Otherwise Specified”

◦ Indicates “unspecified” in the Tabular

◦ Codes listed as “Unspecified” in Tabular are used when documentation lacks specific information needed to obtain better code. Take back to provider.

◦ Will find in codes with a: 4th or 6th character of “9” AND 5th digit character of “0”


Appears directly under the category name

Further defines, clarifies, or gives examples

Inclusion terms listed: ◦ Indicates “some” of the condition that may be associated

with that code◦ NOT an “all inclusive” list


EXCLUDES 1:◦ Considered a “pure” exclude

◦ NOT CODED HERE!

◦ Mutually exclusive codes: two codes that can NOT be coded together


EXCLUDES 2:◦ NOT included here

◦ Indicates “although the excluded condition is NOT part of the condition it is excluded from, a patient may have both conditions at the same time”

◦ May be acceptable to use both the code AND the “excluded code together (if documentation can support both).


CHAPTER 10 – Diseases of the respiratory system (J00 – J99)

Note: When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).

Use additional code, where applicable, to identify:exposure to enviromental tobacco smoke (Z58.7)exposure to tobacco smoke in the perinatal period (P96.81)history of tobacco use (Z87.82)occupational exposure to environmental tobacco smoke (Z57.31)tobacco dependence (F17.-)tobacco use (Z72.0)

Excludes 2: certain conditions originating in the perinatal period (P04 – P96) certain infectious and parasitic diseases (A00 – B99) complications of pregnancy, childbirth and the puerperium (O00 – O00) congenital malformations, deformations and chromosomal abnormalities (Q00 – Q99) endocrine, nutritional and metabolic diseases (E00 – E90) injury, poisoning and certain other consequences of external causes (E00 – T98) neoplasms (C00 – D48) smoke inhalation (T59.81-) symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00 – R94)

ACUTE UPPER RESPIRATORY INFECTIONS (J00 – J06)J00 Acute nasopharyngitis [common cold]

Includes: acute rhinitis coryza (acute) infective nasopharyngitis NOS infective rhinitis nasal catarrh, acute nasopharyngitis NOS

Excludes 1: acute pharyngitis (J02.-) acute sore throat NOS (J02.9) pharyngitis NOS (J02.9) rhinitis NOS (J31.0) sore throat NOS (J02.9)

Excludes 2: allergic rhinitis (J30.1-J30.9) chronic pharyngitis (J31.2)

chronic rhinitis (J31.0) chronic sore throat (J31.2) nasopharyngitis, chronic (J31.1) vasomotor rhinitis (J30.0)

J02 Acute pharyngitis Includes: acute sore throat Excludes 1: acute laryngopharyngitis (J06.0) peritonsillar abscess (J36) pharyngeal abscess (J39.1) pharyngitis due to coxsackie virus (B08.5) pharyngitis due to gonococcus (A54.5) retropharyngeal abscess (J39.0) Excludes 2: chronic pharyngitis (J31.2)

J02.0 Streptococcal pharyngitis Septic pharyngitis

Streptococcal sore throat Excludes 1: scarlet fever (A38.-)

J02.8 Acute pharyngitis due to other specified organisms Use additional code (B95 – B97) to identify infectious agent Excludes 1: acute pharyngitis due to herpes [simplex] virus (B00.2) acute pharyngitis due to infectious monomucleosis (B27.-) acute pharyngitis due to influenza virus (J10.1) enteroviral vesicular pharyngitis (B08.5)

CODE ALSO◦ 2 codes may be required to fully describe condition◦ Sequencing depends on “reason for visit” and “severity of

condition(s)”

AND◦ Implied as “and/or”


WITH/WITHOUT◦ When both are options for the final character, the default is

ALWAYS “without”

◦ 5 character codes 0 in the 5th position = without 1 in the 5th position = with

◦ 6 character codes 9 in the 6th position = without 1 in the 6th position = with


Z codes = Factors influencing health status

Should NOT be used for aftercare relating to “injuries”

For aftercare of an injury◦ Assign the acute injury code with the 7th character “D”

(subsequent encounter)


Sherry Thomas, CCP, CCP-AS CEO/Director of Education

Previously reported diagnoses that no longer exist, should not be reported

for the current date of service.

©2010 PHIA/Medical Staff SOS, Inc.

Example 1Mr. Johnson is being seen for fever, headache and nasal congestion.

Acute sinusitis and acute tonsillitis documented in assessment.

Fee ticket lists otitis media and otitis externa (from previous diagnoses).


SinusitisICD-9……………currently 23 codes

ICD-10…………..going to 34 codes

New term with acute sinusitis: “recurrent” Must have location of sinusitis documented

ethmoidal, frontal, maxillary, pansinusitis, sphenoidal, also one for “involving more than one sinus”

Tonsilitis

ICD-9……………currently 10 codes

ICD-10…………..going to 15 codes

New term with tonsilitis: “recurrent” Must list organism when documented

Ms. Baker is seen today for knee pain resulting from a fall. She was last seen in January with chest congestion, which has since resolved. After completing the remainder of the SOAP note, the physician documents knee pain in the assessment.

ICD - 9 = 719.46


Knee pain = M25.56 –Knee pain = M25.56 –* * Excludes 2: pain in hand (M79.65-)

pain in fingers (M79.64-) pain in foot (M79.67-) pain in limb (M79.6-) pain in toes (M79.67-)

M25.56 Pain in kneeM25.56 Pain in knee M25.561 Pain in right knee M25.562 Pain in left knee

M25.563 Pain in unspecified knee


Unspecified fall - W19Unspecified fall - W19Includes: accidental fall NOSIncludes: accidental fall NOS

Requires a 7th character of A, D, or S

Code W19W19XXXAA


Diagnoses should be billed as they appear in the assessment.


The assessment is documented as:

1. COPD2. Benign HTN, controlled3. DM II, controlled4. H/O bladder cancer

The physician writes on the fee ticket:

Bladder cancer, DM II, and circles COPD and HTN.


Mr. Simpson presents for hip and knee pain and this is documented as the chief complaint. During the visit the physician also documents the patient to have a skin lesion on his right arm.

The diagnosis is listed in the assessment as skin lesion rt arm, knee and hip osteoarthritis.


knee and hip osteoarthritis ICD-9 = approx. 12 codes

site specific generalized

localized (idiopathic, primary, secondary) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

ICD-10 = approx. 63 codes site specific

generalized (erosive, primary, specified) post traumatic (primary, secondary)

Ongoing, chronic conditions that

are NOT documented for this date of service should NOT be reported.


Ms. Johnson presents today for a follow-up of her high blood pressure. She has been closely followed for benign hypertension and diabetes mellitus, which are both under control at this time. Her history includes stable emphysema and a history of colon cancer 12 years ago.

After completing the exam, the physician documents HTN, DM II, emphysema, CHF, gout, and H/O colon CA.


History of……….History of……….◦ Personal or FamilyPersonal or Family◦ Personal = condition no longer exists and not receiving any

treatment◦ Family = patient may be at risk for said condition/disease

Used in conjunction with screening codes Z Z codes Used to indicate medical necessity for

ordering/performing test(s) and/or procedure(s)


The provider documented on 1/1/10 new onset diabetes mellitus.

On 2/5/10 the patient is seen again in the office. For this encounter the physician documents chest pain, abnormal EKG, and hyperlipidemia in the assessment.


ICD-10 Manifestation codes include the phrase: ◦ “in diseases classified elsewhere”◦ Indicates this is a “manifestation” code

NEVER billed as “primary” diagnosis

Use “in conjunction with” the underlying condition


Diabetes, diabetic (mellitus) (familial) (sugar) E11.9 (Type 2 diabetes mellitus without complications)

with …………………………………

due to drug or chemical E09.9with …………………………………

due to underlying condition E08.9with …………………………………

Gestational diabetesSpecified type NEC E13.9With ………………………………..

Type 1 E10.9with …………………………………

Type 2 E11.9with …………………………………

Combination codes Sequence based on the “reason” for a particular encounter Assign as many codes as needed from E08 – E13 to identify all associated

conditions If type of diabetes is not documented then E11.-, Type 2 is the DEFAULT

code

The provider documents foot ulcer in the assessment portion of the SOAP note.

On the encounter form the provider writes diabetic foot ulcer.

The ICD-9 codes are incorrectly reported as 250.80 and 707.15.

The correct code to report is: 707.15


The provider documents foot ulcer in the assessment portion of the SOAP note.

On the encounter form the provider writes diabetic foot ulcer.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The correct ICD-10 code(s) to report: E11.621 or E10.621?


E11 Type 2 diabetes mellitus E11 Type 2 diabetes mellitus Includes: diabetes (mellitus) due to insulin secretory defect

diabetes NOS insulin resistant diabetes (mellitus) Use additional code to identify any insulin use

(Z79.4)

Excludes 1: diabetes mellitus due to underlying condition (E08.-) drug or chemical induced diabetes mellitus (E09.-) gestational diabetes (O24.4-) Type 1 diabetes mellitus (E10.-)


E11.621E11.621 Type 2 diabetes mellitus with foot ulcerType 2 diabetes mellitus with foot ulcer

Use additional code to identify site of ulcer (L97.4- – L97.5-)

L97.4 Non-pressure chronic ulcer of L97.4 Non-pressure chronic ulcer of heel and midfootheel and midfoot Non-pressure chronic ulcer of plantar surface of midfoot

L97.5 Non-pressure chronic ulcer of L97.5 Non-pressure chronic ulcer of other part of footother part of foot Non-pressure chronic ulcer of toe


Specified Site Specified Site right heel and midfoot

left heel and midfoot unspecified heel and midfoot other part of foot (toes)

Specified Degree of UlcerSpecified Degree of Ulcer limited to breakdown of skin fat layer exposed necrosis of muscle necrosis of bone unspecified severity


CPT and ICD-9 codes MUST

be properly linked on the claim form to

prove medical necessity.


The provider marks the encounter form as: 99213, 71010 (AP chest x-ray)

The diagnosis codes listed for this encounter are: 1) 786.50 2) 786.05 3) 784.0 4) 250.00


250.00786.05

784.0

99213

71010

1,2,3,4

1, 2


786.50

The diagnosis or sign/symptom that is documented in the assessment

should be reported.

NOT what is written on the encounter form/fee ticket.


The physician documents strep throat, pneumonia, and high blood pressure in the assessment

On the encounter form the physician writes pneumonia and HTN.

The codes are incorrectly reported as 486 and 401.9

The correct codes to report are: 034.0, 486, and 796.2


The provider documents chronic interstitial cystitis and urethritis in the assessment.

The provider circles UTI on the fee ticket. Code 599.0 is incorrectly reported.

The correct ICD-9 codes to report are: 595.1 and 597.80


The provider documents chronic interstitial cystitis and urethritis in the assessment.

The provider circles UTI on the fee ticket. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The correct ICD-10 codes to report are:

N30.10 and N34.2


Always reference the LCD! Determine the diagnosis

you are reporting is an approved diagnosis

by Medicare. This also substantiates

medical necessity.


Always report current diagnoses only.

Choose the correct order to report the diagnoses.

Do not bill a chronic condition if it is not documented for this date of service.

Properly link CPT and ICD-9 codes to clearly show medical necessity.

Report what is documented in the assessment, not what is written on the fee ticket.

Use the LCD!


ICD-10 final rule is available at http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf

5010 - D.0 http://www.cms.hhs.gov/electronicbillingeditrans/18_5010d0.asp


www.ncvhs.hhs.gov/070730p4.pdf www.cms.hhs.gov/Versions5010andD0/ www.cms.hhs.gov/ICD10/ www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm http://journal.ahima.org/category/coding/icd-10-coding/ http://www.cms.hhs.gov/TransactionCodeSetsStands/

02_TransactionsandCodeSetsRegulations.asp


Sherry Thomas, CEO/ Director of Education

Certified Coding Professional (CCP) Certified Coding Professional – Audit Specialist (CCP-AS) 30 years experience in healthcare

◦ Clinical, Administrative, Education

Services includes:

• Chart Auditing • Healthcare Seminars/Workshops• Qualified IRO - Integrity Agreements

• National Credentialing Organization• ONLINE Coding/Billing Courses (Certification/Diploma)• Provider/Staff Education


For additional information please contact:

SHERRY THOMAS, CCP, CCP-ASSHERRY THOMAS, CCP, CCP-ASCEO/Director of Education

Medical Staff SOS, Inc./ PHIA502.473.8806866.473.3036

[email protected] [email protected]

www.PHIA.com ©2010 PHIA/Medical Staff SOS,. Inc

sherry thomas, ccp, ccp-as ceo/director of education

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