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Presented byYvette M. DeVay, MHA, CPC, CIC, CPC-I

Craneware, Inc.

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2017 ICD-10 Additions, Revisions and Deletions

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DisclaimerThis presentation was prepared by Craneware for informational and educational purposes only; it is not legal advice or a legal document, and should not be relied upon. The presentation serves as a general summary of the 2017 ICD-10 Coding; the presentation is not guaranteed to be complete, correct, timely or current, and Craneware Inc., Craneware Insights or Craneware PLC bears no responsibility or liability for the results or consequences of the use or reliance on the information in this presentation. No portion or element of this presentation may be copied, in whole or in part, for profit-making purposes without the express written consent of Craneware Inc. or its associated companies. This presentation is copyrighted by Craneware and should not be redistributed outside your facility.

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Question and Answer • Please submit any questions during the

presentation via the Webex chat and Q&A panels. • Any ICD-10 and coding questions will be compiled

into a Q&A document to help us provide you with the best answers possible. After the webinar, Craneware will email you a PDF of the slides and subsequently the Q&A document.

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Craneware Clients –Continuing Education Units

• Available to Craneware clients only.• To receive the approved AAPC 1.0 CEU, a short

10 question quiz must be completed in the Craneware Performance Center.

• Step-by-step instructions will be provided at conclusion of webinar.

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Speaker:

9/14/2016 5

Yvette M. DeVayMHA, CPC, CIC, CPC-I Outpatient Coding Consultant Craneware, Inc.

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What Will We Cover ?• We will be presenting pertinent changes for ICD-

10-CM and PCS coding systems• We will focus on:

– ICD-10-CM and ICD-10-PCS Guideline Changes, Code Additions, Deletions and Revisions

• In addition we will review ICD-10-PCS Section X

We strongly recommend that your organization review the 2017 ICD-10-CM and PCS guidelines in their entirety

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Background• An October 1, 2015 ICD-10 compliance date was issued

through final rule by the U.S. Department of Health and Human Services

• The ICD-9-CM Coordination and Maintenance Committee implemented a partial freeze of the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior to the implementation of ICD-10

• The last regular, annual update to the ICD-10 code sets were made on October 1, 2011

• Regular ICD-10 Updates will begin October 1, 2016

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Effects of a Five Year Code Freeze – Catch Up!

Approximately 5,551 ICD-10 Codes Added for 2017

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ICD-10-PCSGuidelines and Code Revisions

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ICD-10 PCS Guideline Changes

• The Majority of Revisions to the PCS Guidelines for 2017 are found in the following Three Sections

– Body System Guidelines – B2– Root Operation Guidelines – B3– Body Part Guidelines – B4

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Body System Guideline B2.1a• The procedure codes in the general anatomical regions body systems

can be used when the procedure is performed on an anatomical region rather than a specific body part (e.g., root operations Control and Detachment, Drainage of a body cavity) or on the rare occasion when no information is available to support assignment of a code to a specific body part.

• Examples: Control of postoperative hemorrhage is coded to the root operation Control found in the general anatomical regions body systems.

• Chest tube drainage of the pleural cavity is coded to the root operation Drainage found in the general anatomical regions body systems. Suture repair of the abdominal wall is coded to the root operation Repair in the general anatomical regions body system.

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Root Operation – Multiple Procedures Guideline B3.2b

During the same operative episode, multiple procedures are coded if: a. The same root operation is performed on different body parts as defined by distinct values of the body part character. Example: Diagnostic excision of liver and pancreas are coded separately. Excision of lesion in the ascending colon and excision of lesion in the transverse colon are coded separately b. The same root operation is repeated at different body sites that are included in the same body part value. Example: Excision of the sartorius muscle and excision of the gracilis muscle are both included in the upper leg muscle body part value, and multiple procedures are coded. Extraction of multiple toenails are coded separately. c. Multiple root operations with distinct objectives are performed on the same body part. Example: Destruction of sigmoid lesion and bypass of sigmoid colon are coded separately. d. The intended root operation is attempted using one approach, but is converted to a different approach. Example: Laparoscopic cholecystectomy converted to an open cholecystectomy is coded as percutaneous endoscopic Inspection and open Resection.

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Root Operation- Biopsy Procedures - Guideline B3.4a

Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic.

Examples: Fine needle aspiration biopsy of fluid in the lung is coded to the root operation Drainage with the qualifier Diagnostic. The qualifier Diagnostic is used only for biopsies.

Biopsy of bone marrow is coded to the root operation Extraction with the qualifier Diagnostic.

Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic.

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Root Operation – Coronary Arteries Guideline B3.6b

• Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary arteries bypassed to, and the qualifier specifies the vessel bypassed from.

• Example: Aortocoronary artery bypass of the left anterior descending coronary artery and the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary arteries, and the qualifier specifies the aorta as the body part bypassed from.

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Root Operation – Coronary Arteries -Guideline B3.6c

• If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.

• Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately.

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Root Operation – Control vs. More Definitive Root Operation Guideline B3.7

• The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural bleeding or other acute bleeding.” If an attempt to stop postprocedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

Example: Resection of spleen to stop postprocedural bleeding is coded to Resection instead of Control.

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Root Operation – Control vs. More Definitive Root Operation Guideline B3.7

• ….“or other acute,”…– Increases the applicability of this operation.– Consider Scenarios that can now be included in the root

operation control:• Control of post-prostatectomy hemorrhage,• Control of intracranial subdural hemorrhage, • Control of bleeding duodenal ulcer, • Control of retroperitoneal hemorrhage

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Root Operation – Control vs. More Definitive Root Operation Guideline B3.7

• 2017 ICD-10-PCS Index Entry• “Control postprocedural bleeding in” will change

to “Control bleeding in,” – Removing the term postprocedural.

• Table Change– Example:– Anatomical Regions, General, Control - 0W3

• New Definition

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Root Operation – Excision vs. Resection Guideline B3.9

• If an autograft is obtained from a different body part procedure site in order to complete the objective of the procedure, a separate procedure is coded.

• Example: Coronary bypass with excision of saphenous vein graft, excision of saphenous vein is coded separately.

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Body Part– Branches of Body PartsGuideline B4.2 Revision

• Where a specific branch of a body part does not have its own body part value in PCS, the body part is typically coded to the closest proximal branch that has a specific body part value. In the cardiovascular body systems, if a general body part is available in the correct root operation table, and coding to a proximal branch would require assigning a code in a different body system, the procedure is coded using the general body part value.

Examples: A procedure performed on the mandibular branch of the trigeminal nerve is coded to the trigeminal nerve body part value. Occlusion of the bronchial artery is coded to the body part value Upper Artery in the body system Upper Arteries, and not to the body part value Thoracic Aorta, Descending in the body system Heart and Great Vessels.

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Body Part – Coronary Arteries Guideline B4.4

• The coronary arteries are classified as a single body part that is further specified by number of arteries treated. One procedure code specifying multiple arteries is used when the same procedure is performed, including the same device and qualifier values.

Examples:Angioplasty of two distinct coronary arteries with placement of two stents is coded as Dilation of Coronary Artery, Two Arteries with Two Intraluminal Devices. Angioplasty of two distinct coronary arteries, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Artery with Intraluminal Device, and Dilation of Coronary Artery, One Artery with no device.

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Root Operation - Creation• Changes

– Section 0 – Medical and Surgical– 2016 Definition: Making a new genital structure that

does not take over the function of a body part– 2017 Definition: Putting in or on biological or synthetic

material to form a new body part that to the extent possible replicates the anatomic structure or function of an absent body part

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Root Operation - Creation• Changes

– Section 0 – Medical and Surgical– In 2016, creation was only used for gender

reassignment• Examples: Creation of vagina in a male, creation of penis in a

female

– In 2017, it will be used for gender reassignment surgery and corrective procedures in individuals with congenital anomalies

• Examples: Creation of vagina in a male, creation of right and left atrioventricular valve from common atrioventricular valve

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INPATIENT PROCEDURE CODES2017

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2017 Inpatient Procedure Codes• Majority of New Codes are Cardiovascular

Procedures– 3,549 or 97 percent– Area of Change

• Monitoring Device Insertion and Revision• Combination Codes for Pacemakers

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2017 Cardiovascular Changes• Implantable Cardiac Monitor (Loop Recorder)

– Background• In ICD-9, the procedure (37.79) was classified as an OR

procedure• The ICD-9 procedure code translates to 6 ICD-10-PCS codes

that are classified as OR and Non-OR procedures

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2017 Cardiovascular Changes• Implantable Cardiac Monitor (Loop Recorder)

– 0JH602Z: Insertion of monitoring device into chest subcutaneous tissue and fascia, open approach

– 0JH632Z: Insertion of monitoring device into chest subcutaneous tissue and fascia, percutaneous approach

– 0JWT02Z: Revision of monitoring device in trunk subcutaneous tissue and fascia, open approach

– 0JWT32Z: Revision of monitoring device in trunk subcutaneous tissue and fascia, percutaneous approach

– 0JWT0PZ: Revision of cardiac rhythm related device in trunk subcutaneous tissue and fascia, open approach

– 0JWT3PZ: Revision of cardiac rhythm related device in trunk subcutaneous tissue and fascia, open approach

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2017 Cardiovascular Changes• Implantable Cardiac Monitor (Loop Recorder)

– Designate as OR Procedures– 0JH602Z: Insertion of monitoring device into chest subcutaneous

tissue and fascia, open approach– 0JH632Z: Insertion of monitoring device into chest subcutaneous

tissue and fascia, percutaneous approach– 0JWT02Z: Revision of monitoring device in trunk subcutaneous

tissue and fascia, open approach– 0JWT32Z: Revision of monitoring device in trunk subcutaneous

tissue and fascia, percutaneous approach• Replicate the I-9 MS-DRG assignment for procedure code 37.79 as an

OR procedure (that is, MS-DRGs 040, 041, 042, 260, 261, 262, 579,580, 581, 907, 908, 909, 957, 958, and 959).

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2017 Cardiovascular Changes• Pacemakers

– Combination Codes for Pacemakers• Previously codes for pacemaker procedures were excluded

from the ICD-10-MS-DRG Assignments– DRGs 242, 243, and 244

» Permanent cardiac pacemaker implant with MCC, with CC, and without CC/MCC).

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2017 Cardiovascular Changes• CMS has reduced the complexity of specificity of

procedure code combinations involving pacemakers and leads

• When qualifying procedures involving both pacemakers and pacemaker leads are reported in combination with one another, the case would be assigned to ICD-10 MS-DRGs 242, 243, and 244.

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2017 Inpatient Procedure Codes• Changes in Rehabilitation Codes

– Guidelines for Primary Diagnosis Code Selection• Review Diagnoses is MDC 23

– Factors Influencing Health Status and Other Contacts with Health Services

• Code Rehabilitation Procedures– Not previously coded as they are non-OR procedures

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Rehabilitation IllustrationExample:

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DRG DRG Descriptor CC/MCC

945 REHABILITATION W CC/MCC Yes

946 REHABILITATION W/O CC/MCC No

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MDC 23• Diagnoses

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ICD-10-CMCode

Descriptor

Z44.8 Encounter for fitting and adjustment of other external prosthetic devices

Z44.9 Encounter for fitting and adjustment of unspecified external prosthetic device

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MDC 23• Example of Procedure Codes

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ICD-10-PCSCode

Descriptor

F0100UZ Muscle Performance Assessment of Neurological System - Head and Neck using Prosthesis

F07J2YZ Coordination/Dexterity Treatment of Musculoskeletal System - Head and Neck using

Other Equipment

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Rehabilitation Coding• Two ways to assign cases to DRG 945/946

– Principal diagnosis code Z44.8 or Z44.9– Principal diagnosis and also code one of the

rehabilitation procedure codes listed under MS-DRGs 945 and 946.

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Rehabilitation Coding• For 2017

– Only cases with a principal diagnosis from MDC-23 will be assigned to MS-DRGs 945/946

– Cases with a procedure listed for MS-DRG 945/946 but without an MDC 23 diagnosis will be assigned to the MS-DRG within the MDC of the listed principal diagnosis.

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2017 Inpatient ProceduresSurgical to Non-Surgical Procedures

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Procedure Description

Insertion of an Infusion Device

Dilation of Stomach ( various approaches)

Removal of Drainage or Infusion Device (percutaneous approach)

Inspection of Certain Body Sites ( percutaneous and endoscopic approach)

Endoscopic Removal of Infusion or Monitoring Devices ( thorax, GI, GU)

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NEW TECHNOLOGYICD-10-PCS Section X

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New Technology – Section X

• Codes that uniquely identify procedures requested via the New Technology Application Process,

• Capture new technologies not currently classified in ICD-10-PCS.

• Includes codes for medical and surgical procedures, medical and surgical-related procedures, or ancillary procedures designated as new technology.

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Section X – Character Definitions• First Character: (X)• Second Character: Body System• Third Character : Root Operation• Fourth Character: Body Part• Fifth Character: Approach• Sixth Character: Device /Substance/Technology• Seventh Character: New Technology Group

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Section X – New Technology

• Procedures Grouped to this Section Include:– Infusions of New Technology Drugs– Medical Technology– Surgical Procedures– Ancillary Procedures

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Section X – Seventh Character Qualifier• Seventh Character is used Exclusively to Indicate the New

Technology Group• The 7th Character Number or Letter is Dependent upon the

Year the New Technology is added to the ICD-10-PCS System

• Example:– Section X codes added for the first year have the seventh character

value 1, New Technology Group 1. Next year, the 7th character Qualifier will be New Technology Group 2, with the following year Group 3 and so on.

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Section X – Seventh Character Qualifier

• A Unique Value for the 7th Character for Each Year’s Codes Allows ICD-10-PCS to Recycle the 3rd, 4th, 5th and 6th

Characters• If Necessary, the Unique Value of the 7th character, allows

the Root Operation, Body Part and Device/Substance/Technology Values to Specify a Different Meaning with Every New Technology Group

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Section X – Body System Values• Fixed Set of Values

– X2 – Cardiovascular System– XR- Joints– XW – Anatomical Regions

• The second character, body system values are broader values than found in other sections of ICD-10-PCS

• This allows body part values to be as general or specific as they need to be to efficiently represent the body part applicable to a new technology.

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Section X – Root Operations• Same Values Used in other Sections of ICD-10-

PCS– Examples:

• 0 – Introduction: Putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products

• C – Extirpation (taking or cutting out solid matter from a body part)

• 2 - Monitoring (determining the level of a physiological or physical function repetitively over a period of time)

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2017 Changes• Section X New Root Operations

– Assistance– Fusion– Insertion– Removal– Replacement– Reposition– Revision

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Section X – Body Part Values• Fourth Character

– Uses the Same Values as the Closest Counterpart Sections in ICD-10-PCS

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Section X Device/Substance/Technology

• Sixth Character– Provides a General Description of the Key Feature of

the New Technology

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Section X- Qualifier• Seventh Character

– Used Exclusively to Indicate the New Technology Group– Character Value Specifically Identifies the Year the New

Technology Group was added to ICD-10-PCS– Example:

• Qualifier -1– Procedure was added with the New Technology Group 1

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ADDITIONS, REVISIONS, AND DELETIONS

2017 ICD-10- CM

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2017 ICD-10 Changes

• Due to the Code Freeze which Accompanied the ICD-10 Implementation, October 1, 2016 will begin with a significant number of ICD-10-CM Changes– 1974 New Codes– 425 Code Descriptor Revisions– 311 Deleted Codes

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2017 ICD-10 Changes

– Guidelines– Alphabetic Index – Tabular Listing

• Pay particular attention to the Excludes Notes

– Instructional Notes

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GUIDELINE CHANGES2017 ICD-10-CM

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ICD-10-CM Guidelines Structure and Convention

• Currently Guideline I.A.12a States:

– 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.

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ICD-10-CM Guidelines Structure and Convention

• Guideline I. A.12a – Excludes 1 Revision– 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.

– An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.

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ICD-10-CM Guidelines Structure and Convention

• Guideline I.A.15 • Currently States:

– The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

– The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

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ICD-10-CM GuidelinesStructure and Convention

• Guideline I.A.15 Revision• “With”

– The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.

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ICD-10-CM GuidelinesStructure and Convention

• Alphabetic Index

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ICD-10-CM Guidelines Structure and Convention

• New!– Guideline I.19.A Code assignment and Clinical

Criteria• The assignment of a diagnosis code is based on the provider’s

diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis..

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General Coding Guidelines• I.B.13 – Laterality

– Currently:• Some ICD-10-CM codes indicate laterality, specifying whether

the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

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General Coding Guidelines• I.B.13 – Laterality Revision• Currently:

– Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

– When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.

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General Coding Guidelines

Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale - I.B.14• For the Body Mass Index (BMI), depth of non-pressure chronic ulcers,

pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale).

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General Coding Guidelines

Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale I.B.14

….However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

• The BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses.

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CHAPTER SPECIFIC GUIDELINES2017 ICD-10-CM

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Chapter 1• New!

– Zika Virus I.C.1.f.1• Code only a confirmed diagnosis of Zika virus (A92.5, Zika

virus disease) as documented by the provider. This is an exception to the hospital inpatient guideline Section II, H.

• In this context, “confirmation” does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission.

• If the provider documents "suspected", "possible" or "probable" Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

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Chapter 4

Diabetes mellitus and the use of insulin and oral hypoglycemic – I.C.4.a.3

– If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned. Code Z79.4, Long-term (current) use of insulin, or Z79.84, Long term (current) use of oral hypoglycemic drugs, should also be assigned to indicate that the patient uses insulin or hypoglycemic drugs. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter.

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Chapter 9

Hypertension – I.C.9• The classification presumes a causal relationship between

hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.

• For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with” or “due to” in the classification, provider documentation must link the conditions in order to code them as related.

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Chapter 9

Hypertension – I.C.9

• Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.

• The same heart conditions (I50.-, I51.4-I51.9) with hypertension are coded separately if the provider has specifically documented a different cause. Sequence according to the circumstances of the admission/encounter.

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Chapter Specific Coding Guidelines – Chapter 9

Hypertension – I.C.9• Hypertensive Chronic Kidney Disease • Assign codes from category I12, Hypertensive chronic kidney disease,

when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as hypertensive if the physician has specifically documented a different cause.

• The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease.

• See Section I.C.14. Chronic kidney disease. • If a patient has hypertensive chronic kidney disease and acute renal

failure, an additional code for the acute renal failure is required.

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Chapter Specific Coding Guidelines – Chapter 9

Hypertension – I.C.9• New!

– Hypertensive Crisis• Assign a code from category I16, Hypertensive crisis, for

documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter.

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Chapter 12

Patients admitted with pressure ulcers documented as healing I.C.12.a.5• Pressure ulcers described as healing should be assigned the

appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.

• If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.

• For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.

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Chapter 15

New!Supervision of High Risk Pregnancy I.C.15.b.2• Supervision of High-Risk Pregnancy

– Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery..

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Chapter 15

When a delivery Occurs I.C.15.b.4• When an obstetric patient is admitted and delivers during that

admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission should be selected as the principal diagnosis.

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Chapter 15

Long term use of insulin and oral hypoglycemic -I.C.15.g

• Code Z79.4, Long-term (current) use of insulin, or code Z79.84, Long-term (current) use of oral hypoglycemic drugs, should also be assigned if the diabetes mellitus is being treated with insulin or oral medications. If the patient is treated with both oral medications and insulin, only the code for insulin-controlled should be assigned.

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Chapter 15

Gestational (pregnancy induced) diabetes-I.C.15.i• Gestational (pregnancy induced) diabetes can occur during the second

and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. It also puts the woman at greater risk of developing diabetes after the pregnancy. Codes for gestational diabetes are in subcategory O24.4, Gestational diabetes mellitus. No other code from category O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium, should be used with a code from O24.4.

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Chapter Specific Coding Guidelines – Chapter 15

Gestational (pregnancy induced) diabetes-I.C.15.i• The codes under subcategory O24.4 include diet controlled, insulin

controlled, and controlled by oral hypoglycemic drugs. If a patient with gestational diabetes is treated with both diet and insulin, only the code for insulin-controlled is required. If a patient with gestational diabetes is treated with both diet and oral hypoglycemic medications, only the code for "controlled by oral hypoglycemic drugs" is required. Code Z79.4, Long-term (current) use of insulin or code Z79.84, Long-term (current) use of oral hypoglycemic drugs, should not be assigned with codes from subcategory O24.4.

• An abnormal glucose tolerance in pregnancy is assigned a code from subcategory O99.81, Abnormal glucose complicating pregnancy, childbirth, and the puerperium.

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Chapter 16• New!• Observation and Evaluation of Newborns for

Suspected Conditions not Found I.C.16.b.1– Assign a code from category Z05, Observation and

evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. Do not use a code from category Z05 when the patient has identified signs or symptoms of a suspected problem; in such cases code the sign or symptom.

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Chapter 16• Observation and Evaluation of Newborns for

Suspected Conditions not Found I.C.16.b.1– ….2) A code from category Z05 may also be assigned

as a principal or first-listed code for readmissions or encounters when the code from category Z38 code no longer applies. Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present.

– 3) Z05 on a birth record– A code from category Z05 is to be used as a secondary

code after the code from category Z38, Live born infants according to place of birth and type of delivery.

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Chapter 18• Coma Scale I.C.18.e

– The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition. The coma scale codes should be sequenced after the diagnosis code(s).

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Chapter 18• New!

– NIHSS Stroke Scale I.C.18.i– The NIH stroke scale (NIHSS) codes (R29.7- -) can be used in

conjunction with acute stroke codes (I63) to identify the patient's neurological status and the severity of the stroke. The stroke scale codes should be sequenced after the acute stroke diagnosis code(s).

– At a minimum, report the initial score documented. If desired, a facility may choose to capture multiple stroke scale scores.

– See Section I.B.14. for information concerning the medical record documentation that may be used for assignment of the NIHSS codes.

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Chapter 19• Initial vs. subsequent encounters for fractures - I.C.19.c.1

– ….The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture type I or II should be assigned (B, E, H, M, Q).

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OVERVIEW OF CODE CHANGES2017 ICD-10-CM

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Infectious and Parasitic Diseases

• Zika Virus – A 92.5• The ZIKA virus is a flavivirus causing flu like

symptoms in patients• Spread by infected Aedes mosquitoes• Poses a big risk to pregnant women and their

unborn babies

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Infectious and Parasitic Diseases

• Viral Hepatitis Carrier Status– Now reported with chronic codes in category

B18• B18 – Chronic viral hepatitis

– Previously reported with status codes Z22.5-• Z22.5- subcategory codes have been deleted for

2017

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Neoplasms• Category C49.A- Gastrointestinal stromal tumor (GIST) has

been added• C81 – Hodgkin lymphoma

– Language change , the word “classical” has been deleted from the code definition for consistency with current use

• D49.5-– Neoplasms of unspecified behavior of genitourinary

organs

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Blood and Blood Forming Organs

• D78 - Intraoperative and postprocedural complications of the spleen– New and revised codes to distinguish between

postprocedural hemorrhage and post procedural hematoma

• D89.4 – New codes for mast cell activation syndrome

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• Z79.84– New code for long term use of oral hypoglycemic drugs

• Volume Depletion – E86– New instructional note to use additional code for

electrolyte or acid base disorders• Code Category E89

– New and revised codes which allow for the distinction between postprocedural hemorrhage and postprocedural hematoma.

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Endocrine

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Endocrine

• Familial hypercholesterolemia– Currently – E78.0

• Deleted for 2017

– New codes for 2017• E78.00, Pure hypercholesterolemia, unspecified• E78.01, Familial hypercholesterolemia

– New code for reporting family history of hypercholesterolemia

• Z83.42, Family history of familial hypercholesterolemia

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Endocrine• Proliferative diabetic retinopathy and diabetic

macular edema have been expanded to include severity and laterality

• Addition of a 7th character to a number of codes in categories E08-E13

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Mental and Behavioral Health

• F10 - Alcohol Related Disorders

– Alcohol use disorder (AUD) has been added to the inclusion notes

– Instructional notes have been added • Mild AUD is coded as alcohol abuse• Moderate and severe AUD is coded as alcohol dependence

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Mental and Behavioral Health

• New codes:– Binge eating disorder – F50.81– Hoarding disorder F42.3– Premenstrual dysphoric disorder F34.81

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Nervous System• G56

– Mononeuropathies of upper limb• G57

– Mononeuropathies of lower limb• G97

– New and revised codes to distinction between postprocedural hemorrhage and postprocedural hematoma

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Eye and Adnexa• H34 – Retinal Vascular Occlusion

– Added 7th characters for severity• H35.3

– New codes for laterality– Seventh characters added for severity

• Primary open-angle glaucoma and amblyopia suspect expanded for laterality

• H59 – New and revised codes for postprocedural hemorrhage,

hematoma, or seroma

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Ear and Mastoid• New Hearing Loss Codes with Additional

Information– H90.A – Conductive and sensorineural hearing loss with

restricted hearing on the contralateral side• Expanded for laterality

– Pulsatile Tinnitus – H93.A• Expanded for

– laterality

– H95• New and revised codes for postprocedural hemorrhage,

hematoma, or seroma

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Circulatory System• Hypertensive Urgency, Emergency or Crisis• Expansion of Cerebral Infarction and Sequela of

Stroke Codes• Aneurysm of Precerebral and Vertebral Arteries• Dissection of Unspecified Arteries

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Circulatory System• Hypertensive Crisis: Emergency or Urgency

– A hypertensive crisis refers to a sudden, severe rise in blood pressure that can be dangerous, which requires early intervention and evaluation of blood pressure elevation as well as organ function.

• Presents as an urgency or an emergency

– Hypertensive Emergency • Blood pressure levels exceeding 180 systolic OR 120 diastolic

and organ damage

– Hypertensive Urgency • Blood pressure levels exceeding 180 systolic OR 110 diastolic

with no associated organ damage

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Circulatory System• Hypertensive Crisis:

– Hypertensive Emergency I16.1• Blood pressure levels exceeding 180 systolic OR 120 diastolic

and organ damage

– Hypertensive Urgency I16.0• Blood pressure levels exceeding 180 systolic OR 110 diastolic

with no associated organ damage

– Hypertensive Crisis, Unspecified I16.9

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Respiratory System• J98.5- Diseases of the mediastinum, not

elsewhere classified– Expanded to include Mediastinitis J98.51

• J95 - - Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified– New and revised codes for postprocedural hemorrhage,

hematoma, or seroma

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Respiratory System• New Code - J47.0

– Bronchiectasis with acute lower respiratory infection• Use additional code to identify infection

– The conditions applicable to the infection are not listed with the code, but are found at the beginning of the respiratory chapter

– Instructional notes are also listed at the start of the chapter

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Digestive System• New codes

– Dental conditions– K55.0- Acute vascular disorders of intestine

• Ischemia and Infarction

– K85 – Acute pancreatitis• Necrosis or Infection

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Digestive System

• K53.3 – Acute appendicitis with localized peritonitis– Inclusion term revision to indicate that “with peritonitis”

must be specified• K58.1 – Irritable bowel syndrome with constipation• K58.8 – Irritable bowel syndrome• K59.03 – Drug induced constipation• K59.04 – Chronic idiopathic constipation• K90.41 – Non-celiac gluten sensitivity

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Muculoskeletal System and Connective Tissue

• M26.6- Temporomandibular joints– Revision for laterality

• New Code M62.84 – Sarcopenia

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Genitourinary System• Clinical Language Changes

– N10• Renamed to Acute pyelonephritis, previously named acute

tubule-interstitial nephritis

– N40 • Renamed to benign prostatic hyperplasia, previously referred to

as enlarged prostate

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Pregnancy Childbirth and Puerperium

• Z3A - used to identify the specific week of pregnancy if known

• O42 - Clarification– Premature rupture of membranes changed from after

“37 weeks” to “at or after 37 weeks”• O70.2 – Third degree perineal laceration during delivery

– Expanded to include specific codes for the laceration grade.• O70.20 …unspecified• O70.21 … IIIa• O70.22 …IIIb• O70.23 …IIIc

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Pregnancy Childbirth and Puerperium

• O00 – Category Expansion– Codes will include simultaneous intrauterine and ectopic pregnancy

• O24.4 New codes added – Indicating that the patient’s blood sugar is controlled by oral

hypoglycemic drugs

• O44 Placenta Previa– Revised and expanded to include codes for complete/ partial

placenta previa and low lying placenta

• O34.21- Scar from previous C section– Expanded to indicate type of scar

• O34.211 – low transverse• O34.212 – vertical• O34.219 - unspecified

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Congenital Malformations, Deformations, Chromosomal Abnormalities

• Significant code title updates• Two new codes for newborns

– P05.09 - Light for gestational age greater than 2500 grams– P05.19 - Newborn light for gestational age other.

• New Notes– P05.0 –newborns with weight below but length above

10th percentile for gestational age– P05.1 –newborns with weight and length below 10th

percentile for gestational age

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Symptoms, Signs, and Abnormal Clinical and Laboratory Findings

• New Codes– National Institute of Health Stroke Scale (NIHSS) scores– Expansion of total Glasgow Coma Score– Additional Examples of New Codes

• R31.21 Asymptomatic microhematuria that requires urologic work up

• R39.82 – Chronic bladder pain• R97.20 - Elevated prostate specific antigen (PSA)• R73.03 Prediabetes (abnormal blood sugar but not high enough

to qualify as DM)

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Injuries, Poisoning, and Certain Other Consequences of External Causes

• Numerous concussion codes have been deleted• For 2017 only three concussion codes

– S06.0X0 – Concussion without LOC– S06.0X1 – Concussion with LOC less than 30 minutes– S06.0X9 – Concussion with LOC unspecified duration

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Injuries, Poisoning, and Certain Other Consequences of External Causes

• New Codes– S92.81- Sesamoid fractures – Physeal fractures of the bones of the foot

• S99.0 – Physeal fracture of the calcaneus• S99.1 - Physeal fracture of the metatarsal• S99.2 – Physeal fracture of the phalanx of toe

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Factors Influencing Health Status and Contact with Health Services

• Minimally Invasive Procedures Converted to Open Procedures– New Codes

• Laparoscopic - Z53.31• Thoracoscopic – Z53.32• Arthroscopic - Z53.33• Other procedures - Z53.59

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Factors Influencing Health Status and Contact with Health Services

• Z79.84 – New code for the long term use of oral hypoglycemic

drugs• Used to capture patients who take oral medication for their

diabetes

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Factors Influencing Health Status and Contact with Health Services

• New Category – Z29– Encounter for other prophylactic measures

• New Codes Include:– Z29.1 – prophylactic immunotherapy– Z29.3 – prophylactic fluoride– Z29,8 – other specified prophylactic measures– Z29.9 - prophylactic measures, unspecified

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Factors Influencing Health Status and Contact with Health Services

• New Codes – Subcategories Z30.01- and Z30.4-

• Initial prescription and surveillance of vaginal ring, transdermal patch and implantable subdermal contraceptives

– New Codes established for gestational carrier status• Z31.7 -Encounter for procreative management and counseling

for gestational carrier• Z33.3 - Pregnant state, gestational carrier

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FINAL THOUGHTS2017 ICD-10-CM

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Language Change - Pressure Ulcers• National Pressure Ulcer Advisory Panel is

Changing the Clinical Description of Pressure Ulcers

• Currently Documented as a Staged Pressure Ulcer

• New Terminology – Pressure Injury• The Use of the Word, Injury is going to lead

Coders to Look up Injury rather than Ulcer– Stage 4 pressure ulcers are MCCs, and incorrect coding

could lead to missed reimbursement.

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The End of ICD-10 Flexibilities • CMS grace period is set to end Oct. 1, 2016• There will be no phase-in period• Providers should be coding to the highest level of

specificity

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Specificity • When coding for specificity

– Sometimes an unspecified code is appropriate– Give consideration to the following:

• Site of Service• Specialty of treating physician• When is the encounter taking place- Where are you in the

patient’s diagnostic and treatment plan?

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Success with 2017 ICD-10 Changes• Read the guidelines and make notes on the changes and

revisions• Discuss within your coding and clinical documentation

improvement (CDI) staff • Share information with your medical staff.• Develop educational material

– Include coding practice time of case scenarios• Review the American Health Association (AHA) Coding

Clinic ICD-10-CM/PCS for the fourth quarter• Give consideration to conducting audit and assessment

within the first quarter.

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Thank You• On behalf of Craneware staff we would like to

thank you for your participation today.

Resources• 2017 ICD-10- PCS

– https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html

• 2017 ICD-10-CM– https://www.cms.gov/Medicare/Coding/ICD10/2017-

ICD-10-CM-and-GEMs.html

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Question and Answer • Please submit any questions during the

presentation via the Webex chat and Q&A panels. • Any ICD-10 and coding questions will be compiled

into a Q&A document to help us provide the best answers possible. After the webinar, Craneware will email you a PDF of the slides and subsequently the Q&A document.

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Craneware Clients – earn a CEU

1. Login to Online Reference Toolkit: http://ort.craneware.com

2. Click on the self-led training button3. Click on “Register for Courses”4. Register for “2017 ICD-10 Changes”5. After registering, open the course in

“My Courses.” You can skip the recorded version of this presentation and take the exam immediately by clicking “Open Exam”. No CEU certificate is awarded unless you complete the exam.

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Contact Craneware Support at 1 888 601 4162 or support@craneware.com if you need assistance.