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Transcript of Family Practice ICD-10 CM Training. ICD-10-CM will be valid for dates of service on or after October...

ICD-10 CM Training

Family Practice

ICD-10 CM TrainingICD-10-CM will be valid for dates of service on or after October 1, 2015Outpatient dates of service of October 1, 2015 and beyond. Inpatient hospital service claims, is effective for dates of discharge after September 30, 2015ICD-10-CM Compliance Dates

Covered EntitiesEveryone covered by the Health Insurance Portability Accountability Act (HIPPA)Non-Covered EntitiesWorkers CompensationAuto InsuranceNon covered HIPAA entities are exempt but are encouraged to adapt the new code setCovered and Non-Covered Entities

21 ChaptersAlpha-numeric codes; not case-sensitiveCodes begin with Alpha letter, A-Z, excluding UCommon errorsI verses 1O verses 0X Placeholder3 to 7 characters Decimal following 3rd characterICD-10 Code Structure

Placeholder XUsed for future expansion of a codeFills in empty characters when a 6th and/or 7th character applyThe placeholder may be used in different scenarios but should never serve as the final character.

Example: W19.XXXA Unspecified fall, Initial Encounter

ICD-10 Code Structure

7th CharacterProvides specified information regarding the clinical visitIs required for certain categories and must be reported in the seventh positionMay be alpha or numericHas different meanings depending on the coding category

ICD-10 Code Structure

LateralitySome 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. OGCR section 1.B.13

ICD-10 Code Structure

Other CodesCodes titled other or other specified are for use when the information in the medical record provides detail for which a specific code does not exist.Unspecified CodesCodes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code.OGCR section 1.A.9.a.b

ICD-10 Code Structure

Excludes NotesExcludes1A type 1 Excludes note is a pure excludes noteIt means NOT CODED HEREThe code excluded should never be used at the same timeWhen two conditions cannot occur togetherExcludes2Represents Not included hereThe condition excluded is not part of the condition represented by the codeIt is acceptable to use both the code and the excluded code together, when appropriateOGCR section 1.A.12.a.b

ICD-10 Structure

Code First and Use Additional CodeICD-10 has a coding convention that requires the underlying condition be sequenced first followed by the manifestation.These instructional notes indicate the proper sequencing order of the codes.OGCR section 1.A.13

The - indicates there are additional reporting options

ICD-10 Code Structure

Most Common Diagnosis Codes

DiabetesICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2250.00E11.9Type 2 Diabetes mellitus without complicationsDiabetes (mellitus) due to insulin secretory defectDiabetes (NOS)Insulin resistant diabetes (mellitus)Use additional code to identify any insulin use (Z79.4)Diabetes mellitus due to underlying condition (E08.-)Drug or chemical induced diabetes mellitus (E09.1-)Gestational diabetes (O24.4-)Neonatal diabetes mellitus (P70.2)Postpancreatectomy diabetes mellitus (E13.-)Postprocedural diabetes mellitus (E13.-)Secondary diabetes mellitus NEC (E13.-)Type 1 diabetes mellitus (E10.-)transitory endocrine and metabolic disorders specific to newborn (P70-P74N/A250.02E11.65Type 2 diabetes mellitus with hyperglycemiaDiabetes (mellitus) due to insulin secretory defectDiabetes (NOS)Insulin resistant diabetes (mellitusUse additional code to identify any insulin use (Z79.4)

Diabetes mellitus due to underlying condition (E08.-)Drug or chemical induced diabetes mellitus (E09.1-)Gestational diabetes (O24.4-)Neonatal diabetes mellitus (P70.2)Postpancreatectomy diabetes mellitus (E13.-)Postprocedural diabetes mellitus (E13.-)Secondary diabetes mellitus NEC (E13.-)Type 1 diabetes mellitus (E10.-)transitory endocrine and metabolic disorders specific to newborn (P70-P74

N/A

12Diabetes mellitus codes are now combination codes that include the type of diabetes, the body system affected, and the complication affecting that body system. They are no longer classified as controlled or uncontrolled.TypeType 1Type 2Due to underlying conditionsDrug or chemical inducedOther specified

Diabetes Documentation Tips

13Complication StatusWithout complicationWith circulatory complicationWith diabetic arthropathyWith hyperglycemiaWith hyperosmolarityWith hypoglycemiaWith ketoacidosisWith kidney complicationsWith neurologic complicationsWith ophthalmic complicationsWith oral complicationsWith skin complicationsWith other specified complications

Diabetes Documentation Tips

14Complication DetailWith diabetic retinopathyWith cataractWith other ophthalmic complicationWith chronic kidney diseaseWith nephropathyWith other kidney complicationWith amyotrophyWith autonomic neuropathyWith mononeuropathyWith polyneuropathyWith other neurological complicationWith unspecified neuropathyWith or without comaWith peripheral angiopathy with or without gangreneWith other circulatory complicationsWith neuropathic arthropathyWith other arthropathyWith dermatitisWith foot ulcerWith other skin ulcerWith other skin complicationWith periodontal diseaseWith other oral complications

Diabetes Documentation Tips

15Diabetes is a chronic condition that requires multi-specialty management. The documentation should indicate relevant details regarding the management of each case as it relates to the services rendered or actions taken to coordinate the patients care. The HPI, at a minimal, should include some indication of the historical timeline or duration of the illness, levels as it relates to the date of service, manifestations or impairments associated with the condition and effectiveness of current medication regimen. The examination should notate any physical signs related to the diabetic conditions. (Ulcers, nails, edema, discoloration sensitivity to touch)

Diabetes Documentation Tips

16HypertensionICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2401.1401.9401.0I10Essential (Primary) HypertensionIncludes: high blood pressure, Hypertension (arterial) (benign) (essential) (malignant) (systemic)Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16)Neonatal hypertension (P29.2)Primary pulmonary hypertension (I127.0)Essential (primary) hypertension involving vessels of brain (I60-I69)Essential (primary) hypertension involving vessels of eye (H35.0-)Hypertensive Diseases Categories (I10-I15)

The use additional codes and Excludes1 codes apply for all categories.(I10-I15)Use additional code to identify:Exposure to environmental tobacco smoke (Z77.22)History of tobacco use (Z87.891)Occupational exposure to environmental tobacco smoke (Z57.31)Tobacco dependence (F17.-)Tobacco use (Z72.0)

Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11. O13-O16)Neonatal hypertension (P29.2)Primary Pulmonary hypertension (I27.0)

Hypertension cont.ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2402.01402.11402.91I11.0Hypertensive Heart Disease with heart failureUse additional code to identify type of heart failure (I50.-)N/AN/A402.00402.10402.90I11.9Hypertensive Heart Disease without heart failureN/AN/A403.01403.11403.91I12.0Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or end stage renal disease.Use additional code to identify the stage of chronic kidney disease (N185.5, N18.6)Hypertension due to Kidney Disease (I15.0, I15.1)Renovascular Hypertension (I15.0)Secondary Hypertension (I115.-)Acute Kidney Failure (N17.-)403.00403.10403.90I12.9Hypertensive Chronic Kidney Disease with stage 1-4 Chronic Kidney Disease, or unspecified Chronic Kidney Disease.Use additional code to identify the stage of chronic kidney disease (N18.1-N18.9)Hypertension due to Kidney Disease (I15.0, I15.1)Renovascular Hypertension (I15.0)Secondary Hypertension (I115.-)Acute Kidney Failure (N17.-)

Hypertension cont.ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2404.01404.11404.91I13.0Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney diseaseUse additional code to identify type of heart failure (I50.-)Use additional code to identify stage of chronic kidney disease (N18.1-NN18.4, N18.9)N/AN/A404.00404.10404.90I13.10Hypertensive Heart and Chronic Kidney Disease without heart failure, with stage 1-4 chronic kidney disease, or unspecified chronic kidney disease.Use additional code to identify the stage of chronic kidney disease (N18.1-N18.4, N18.9)N/AN/A404.02404.12404.92I13.11Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease.Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6)N/AN/A404.03404.13404.93I13.2Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease.Use additional code to identify type of heart failure (I50.-)Use additional code to identify the stage of chronic kidney disease (N18.5. N18.6)

N/AN/A

Hypertension cont.ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2405.01405.11405.91I15.0Renovascular HypertensionCode also underlying conditionPostprocedural hypertension (I97.3)Secondary hypertension involving vessels of brain (I60-I69)Secondary hypertension involving vessels of eye (H35.0-)405.91I15.1Hypertension secondary to other renal disordersCode also underlying con