4/17/2014 Paragraph Page #1 - Header ICD-10 ICD 10-CM M For the - - PDF document

4/17/2014 1 Paragraph Page #1 - Header

Subhead

Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here. Add text in here.

ICD ICD-10 10-CM M For the Audit ditor

It May Be Delayed But It’s Not Going Away

John F. Burns, CPMA, CPC, CPC-I, CEMC AHIMA Ambassador and ICD-10 Trainer Webinar: April 22, 2014 This on-demand training is pre-approved for AAPC CEU’s

Your Faculty

• John Frederick Burns
• Rome, NY native
• SUNY Cortland (Health Science -1995)
• CPC, CPC-I, CPMA, CEMC
• AHIMA Ambassador and ICD-10 Trainer
• 19 years in Healthcare
• DoctorsManagement, NAMAS (2013-present)
• NAMAS and DoctorsManagement Senior Auditor and Consultant
• Modern Conventions in Compliance, Inc (2004-2012)
• Medical Management Institute (1995-2004)

ICD-10-CM Background

• International Classification of Disease (ICD) has been around

since 1893

• 1948: WHO took over
• 1970s (late): US has used ICD-9-CM
• 1988: Required on claims
• 1990: ICD-10-CM adopted by 43rd World Health Assembly
• Used in many other countries around the world since 1994
• According to WHO, ICD-11 is already in the works and will be

completed in 2015

4/17/2014 2 The “New” ICD-10-CM Timetable

• Final Rule published April 1 , 2011
• October 1, 2014= Compliance date for

implementation of ICD-10-CM and ICD-10- PCS

• H.R. 4302 passed both the House and

Senate with Presidential approval on March 31, 2014

• SGR “patch” and 1 year ICD-10 delay (Effective October 1,

2015)

ICD-10-CM vs. ICD-9-CM

• 68,000+ ICD-10-CM codes compared to 13,000+ in ICD-9-CM
• 21 chapters in ICD-10-CM compared to 17 in ICD-9-CM
• ICD-10-CM codes are 3-7 characters compared to 3-5 digits in

ICD-9-CM

• All alpha characters used (except letter “U”)
• Expanded injury codes
• External causes and places of occurrence
• Much greater specificity
• Laterality, episodes of care, under-dosing (Table of Drugs/Chem)
• V-codes and E-codes are assigned in applicable chapters
• Combination codes (diagnosis/symptom)

Basic Comparison of Code Sets

ICD-9-CM ICD-10-CM Three to five characters Three to seven characters First digit is numeric but can be alpha (E or V) First character always alpha 2–5 are numeric All letters used except U Always at least three digits Character 2 always numeric: 3–7 can be alpha or numeric Decimal placed after the first three characters (or with E codes, placed after the first four characters) Always at least three digits Alpha characters are not case-sensitive Decimal placed after the first three characters Alpha characters are not case-sensitive

4/17/2014 3

• Chapter 1: Infectious and Parasitic Disease (A00-B99)
• Chapter 2: Neoplasms (C00-D49)
• Chapter 3: Diseases of Blood and Blood Forming Organs (D50-D89)
• Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89)
• Diabetes is located in this section (E08-E13)
• Chapter 5: Mental and Behavioral Disorders (F01-F99)
• Chapter 6: Diseases of the Nervous System and Sense Organs (G00-G99)
• Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
• Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)
• Chapter 9: Disease of the Circulatory System (I00-I99)
• Hypertension is located in this section (I10-I15), R03.0 for elevated BP (ICD-9 code 796.2)
• Chapter 10: Diseases of the Respiratory System (J00-J99)
• Chapter 11: Diseases of the Digestive System (K00-K94)
• Chapter 12: Diseases of Skin and Subcutaneous Tissue (L00-L99)
• Chapter 13: Diseases of the Musculoskeletal System and Connective

Tissue (M00-M99)

The Guidelines: Section I:

• C. Chapter Specific Coding Guidelines
• Chapter 14: Diseases of the Genitourinary System (N00-N99)
• Chapter 15: Pregnancy, Childbirth, Pueperium (O00-O9A)
• OB, Delivery and Postpartum Services (Beware of 7th characters)
• Chapter 16: Newborn (Perinatal) Guidelines (P00-P96)
• Chapter 17: Congenital Malformations, Deformations, and Chromosomal

Abnormalities (Q00-Q99)

• Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory

Findings, Not Elsewhere Classified (R00-R99)

• Codes that describe symptoms and signs are acceptable for reporting

purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

• Chapter 19: Injury, Poisoning and Certain Other Consequences of

External Causes (S00-T88)

• Chapter 20: External Causes of Morbidity (V01-Y99)
• Chapter 21: Factors Influencing Health Status and Contact With Health

Services (Z00-Z99)

The Guidelines: Section I:

• C. Chapter Specific Coding Guidelines

General Equivalence Mappings (GEMS)

• Mappings between ICD-9-CM and ICD-10-CM

classification systems have been developed to facilitate the transition from ICD-9 to ICD-10.

• Two GEM files available
• ICD-9-CM to ICD-10-CM (forward mapping)
• ICD-10-CM to ICD-9-CM (backward mapping)
• May be used along with ICD-9-CM utilization data to

assist in cross-walking your “key” diagnosis codes

• Obtain the top 50 ICD-9 codes your practice utilizes and use as basis

to begin training and education for providers and staff

4/17/2014 4 The Index and Tabular List

• Both ICD-9-CM and ICD-10-CM require users to

consult the index and then the Tabular

• Tabular List and Alphabetic Index
• Chapters in Tabular structured similarly to ICD-9-CM , with minor

exceptions such as Eye and Ear separated from the Nervous System chapter in ICD-9-CM

• Index structured the same as ICD-9-CM
• Alphabetic Index of Diseases and Injuries
• Alphabetic Index of External Causes
• Table of Neoplasms
• Table of Drugs and Chemicals

Similarities With ICD-9 and ICD-10

• The Official Reporting Guidelines should be carefully

consulted to understand proper reporting

• Code to the highest levels of specificity and certainty
• “Code first” provides sequencing guidance while “code

also” does not

• All “categories” within both ICD-9 and ICD-10 are 3

characters long

• Code conditions as long as the patient receives active

treatment

Structure of the Tabular List

• NEVER code from the Alphabetic Index
• Categories (3 characters)
• Subcategories
• Codes
• All Categories are 3 characters (decimal point follows)
• A 3-character category without 4th-7th characters is a

reportable code

• J17 (Pneumonia in diseases classified elsewhere)
• A code with an applicable 7th character is invalid without the 7th

character…use an “X” placeholder

• Placeholders are common with fractures, injuries, external causes,

maternal care, labor and delivery, glaucoma, etc.

4/17/2014 5

Auditing Diagnostic Codes When Specific Codes Are Not Available

• Nonspecific codes (“unspecified” or “not otherwise

specified”) are available to use when detailed documentation to support a more specific code is not available…auditors be aware!

• “Other” and “other specified” are not to be interpreted

to mean “unspecified”

• Reserved for when the information in the medical record provides detail for

which a specific code does not exist (ICD-10-CM Coding Guideline I.A.9.a)

• Many conventions have the same meaning
• Abbreviations, punctuation, symbols, notes such as “code first” and

“use additional code”

ICD-10-CM Conventions

• Placeholder Character “X”
• ICD-10 instructs users to place an “X” in the 4th, 5th and/or

6th positions when a 7th character is required but the 4th, 5th and/or 6th characters are not provided.

• ICD-10-CM Coding Guideline I.A.5 states that the seventh

character must always be the seventh character in the data

• field. If a code that requires a seventh character is not six

characters long, a placeholder X must be used to fill in the empty characters. Additionally, Guideline A.4 indicates that ICD-10-CM utilizes a placeholder character X and where a placeholder exists, the X must be used in order for the code to be considered a valid code. Example: T37.0X1A Poisoning by sulfonamides, accident (unintentional), initial encounter

Dashes in the Alphabetic Index

• The indexes utilize the dash at the end of a code

number to indicate the code is incomplete. To determine the additional character(s), locate the code in the Tabular List, review the options, and assign the appropriate code.

• Example:

Fracture, pathologic ankle M84.47- carpus M84.44-

4/17/2014 6 Exclusion Notes

• In ICD-10-CM there are two types of excludes

notes:

• Excludes 1
• “NOT CODED HERE”
• Excludes 2
• NOT INCLUDED HERE”
• Either or both may appear under a category,

subcategory, or code

Human Immunodeficiency Virus (HIV) Infections

1. Is the patient asymptomatic?

• Z21 if asymptomatic

2. Has the patient had an HIV or AIDS related condition in the past?

• Once AIDS/HIV infection is established, it is always reported on

subsequent admissions but sequencing will depend…

3. What is the purpose for the encounter or admission?

• If AIDS/HIV related admission, B20 is to be reported as principle ICD-

10

Neoplasm: Principle Diagnosis for Chemotherapy

• Admissions/Encounters involving chemotherapy
• If a patient admission or encounter is solely for the

administration of chemotherapy, immunotherapy, or radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy; or Z51.11, Encounter for antineoplastic chemotherapy; or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis.

• Admission for Anemia associated with Malignancy

(D63.0). The malignancy is sequenced as “principle diagnosis”

4/17/2014 7 Diabetes Coding/Auditing

• Diabetes categories:
• E08 DM due to underlying condition
• E09 Drug or chemical induced DM
• E10 Type I DM
• E11 Type II DM
• E13 Other specified DM
• Use additional code Z79.4 to identify insulin use
• Not required for Type I diabetics

Diabetes- Clinical Example

A 68 year old woman with poorly controlled DM II presents with an ulcer

• n her left 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.

• 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
• ICD-10
• E11.621 Type 2 diabetes mellitus with foot ulcer
• 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-CM ICD-10-CM

Pain in Joint 5th digit Joint 719.4 X 1 Shoulder 2 Upper arm 3 Forearm 4 Hand 5 Pelvis/hip 6 Lower leg 7 Ankle/foot 8 Other specified 9

Unspecified

Pain in Joint

Laterality Joint

M25.51 X 1, 2, 9 Shoulder M25.52 X 1, 2, 9 Elbow M25.53 X 1, 2, 9 Wrist M25.55 X 1, 2, 9 Hip M25.56 X 1, 2, 9 Knee M25.57 X 1, 2, 9 Ankle and Foot 1=Right 2=Left 9=UNSPEC

4/17/2014 8

Fractures: Auditing the 7th Character

• Stress Fractures (M84.3---) & Pathologic Fractures (M84.4---)
• Indexing: Fracture, pathologic, stress, traumatic (specify location)
• Requires 7th characters:
• A – initial encounter for fracture (ED visit, surgical treatment, new providers)
• D – subsequent encounter for fracture with normal healing
• G - subsequent encounter for fracture with delayed healing
• K - subsequent encounter for fracture with nonunion
• P - subsequent encounter for fracture with malunion
• S – sequela (late effects)
• Traumatic Fractures (S02.0XX- through S92.919):
• Indexing: Fracture, traumatic, specify location (now structured

anatomically)

• Located in Chapter 19, Injury, Poisoning & Consequences of

External Causes rather than chapter 13

• Z00.00

Encounter for general adult medical examination without abnormal findings

• Z00.01

Encounter for general adult medical examination with abnormal findings

• Z00.121

Encounter for routine child health examination with abnormal findings

• Z00.129

Encounter for routine child health examination without abnormal findings

• Z01.411

Encounter for gynecological examination with abnormal findings

• Z01.419

Encounter for gynecological examination without abnormal findings

ICD-10-CM Codes for Preventive Examinations

Helpful ICD-10 Products

• For specialty specific “mappers”, visit our website
• http://namas-auditing.3dcartstores.com/ICD-10-Tools_c_19.html

4/17/2014 9

• History of the development of the ICD, World Health Organization

website, http://www.who.int/classifications/icd/en/

• ICD-10-CM Official Guidelines for Coding and Reporting-Centers for

Disease Control (CDC), National Center for Health Statistics

• http://www.cdc.gov/nchs/icd/icd10cm.htm
• Centers for Medicare & Medicaid Services ICD-10 page:
• http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/

ICD10

• Assorted guidelines and concepts created and/or approved by the
• fficial ICD-10 Cooperating Parties:
• American Hospital Association (AHA),
• American Health Information Management Association (AHIMA),
• Centers for Medicare and Medicaid Services (CMS), and
• National Center of Health Statistics (NCHS)

Main References National Alliance of Medical Auditing Specialists

John Burns: jburns@gmail.com

10401 Kings gston

• n Pike, Knox
• xvi

ville, le, TN 37922 P: 1-877-418-5564 F: 1-865 865-531-0722

Web: www.N .NAMA MAS.c .co Email: namas as@nam amas as-auditing.com .com