Introduction to ICD-10-CM 2015

Teresa L. Martin, C.P.C.

Revenue Cycle Management

Coding Supervisor

Guidelines a Good Read

• ICD-10-CM Official Guidelines for Coding and Reporting accompany and complement ICD-10-CM conventions and instructions

• Adherence to the official coding guidelines in all healthcare settings is required under the Health Insurance Portability and Accountability Act

ICD-10 Final RuleCMS-9998-FC

Published December 7, 2011

•October 1, 2015 –Compliance date for implementation of ICD-10-Clinical

Modification (CM) and ICD-10-Procedure Coding System (PCS)

•http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html

ICD-10 Implementation•Single implementation date for all users (Oct. 1, 2015)

–Date of service for ambulatory and physician reporting

–Date of discharge for inpatient settings

•ICD-9-CM Codes will not be accepted for services provided on or after

October 1, 2015*

•ICD-9-CM Claims for services prior to implementation date will continue to flow through systems for a period of time

•No grace period

*Non-covered entities, which are not covered by HIPAA such as Workers’ Compensation and auto insurance companies, that use ICD-9-CM may choose not to implement ICD-10- CM/PCS.

Because ICD-9-CM will no longer be maintained after ICD-10-CM/PCS is implemented, it is in non-covered entities’ best interest to use the new coding system. The increased detail in ICD-10-CM/PCS is of significant value to non-covered entities. The Centers for Medicare & Medicaid Services (CMS) will work with non-covered entities to encourage them to use ICD-10-CM/PCS.

Effective Dates for Code Sets

Type of Code Before 10/1/2015 After 10/1/2015

INPATIENT Diagnoses ICD-9-CM ICD-10-CM

Procedures ICD-9, Volume 3 ICD-10-PCS

OUTPATIENT/AMBULATORY Diagnoses ICD-9-CM ICD-10-CM

Procedures CPT® Codes CPT® Codes

There will be a need for dual coding for at least two years.

WHY ICD-10-CM?

• We are running out of codes. ICD-9 is not expandable in the current format.

• ICD-9 codes are not specific enough and do not reflect current terminology or practice. ICD-9-CM has been in use for almost 30 years.

• To provide health care statistics that are more easily comparable worldwide.

ICD-10: MORE CODES• ICD-9-CM has roughly 13,000± diagnosis codes

• ICD-10-CM has around 78,000 diagnosis codes and growing

• One of the biggest challenge for providers and payers is that there is not a one-to-one correlation of the codes. No direct mapping for many commonly used codes.

ICD-10: MORE CHAPTERS

• The codes are organized into 21 chapters in ICD-10-CM compared to 17 chapters in ICD-9-CM.

• Chapters are classified differently due to the changes in code formats.

• Reorganized to give subdivision to body systems.

• Injuries are now organized by site and then type of injury.

ICD-9 vs ICD-10

ICD-9-CM • First character is numeric or alpha (E-External Causes of Injury and Poisoning or V-Factors Influencing Health Status and contact with Health Services) • 3 -5 characters• Characters 2-5 are numeric• Always at least 3 characters• Use of decimal after 3 characters

ICD-10-CM • 3 -7 characters• Character 1 is alpha (all letters except U are used)• Character 2 is numeric• Characters 3 -7 are alpha or numeric• Use of decimal after 3 characters• Use of dummy placeholder “X”• Alpha characters are not case-sensitive

ICD-10-CM: Similarities to ICD-9-CM

• Tabular List is a chronological list of codes divided into chapters based on body system or condition

• Tabular List is presented in code number order• Same hierarchical structure• Codes are invalid if they are missing an applicable character (use of

place holder X required)• Codes are looked up the same way

–Look up diagnostic terms in Alphabetic Index

–Then verify code number in Tabular List

Never code from the alphabetic index. This does not always include the full extension of digits required to complete the diagnosis code.

ICD-10-CM Injury Changes

• ICD-9-CM

–Fractures (800-829)

–Dislocations (830-839)

–Sprains and strains(840-848)• ICD-10-CM

–Injuries to the head (S00-S09)

–Injuries to the neck (S10-S19)

–Injuries to the thorax (S20-S29)

10 Specific Body Areas in this category

ICD-10-CM: Differences from ICD-9-CM

• All codes are alphanumeric• –1st character is always alpha and alpha characters may appear elsewhere in

the code as well • C50.9 Malignant neoplasm of breast of unspecified site

– C50.91 Malignant neoplasm of breast of unspecified site, female– C50.911 Malignant neoplasm of unspecified site of right female breast– C50.912 Malignant neoplasm of unspecified site of left female breast– C50.919 Malignant neoplasm of unspecified site of unspecified female breast

• Codes can be up to 7 characters in length• O32.1 Maternal care for breech presentation

– O32.1XX0 …… not applicable or unspecified– O32.1XX1 …… fetus 1– O32.1XX2 …… fetus 2

• Codes are more specific (as indicated above)

• Code titles are more complete (no need to refer back to a category, subcategory, or sub-classification level to determine complete meaning of code)

ICD-10-CM: Differences from ICD-9-CM

• Laterality (side of the body affected) has been added to relevant codes– S62.501A …… initial encounter for closed fracture phalanx rt thumb– S62.502A …… initial encounter for closed fracture phalanx lt thumb

• Expanded use of combination codes

• Certain conditions and associated common symptoms or manifestations (Diabetes with Neurological manifestation)

– E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified– E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy– E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

• Injuries grouped by anatomical site rather than type of injury– S00-S09 Injuries to the head– S10-S19 Injuries to the neck– S20-S29 Injuries to the thorax

• Codes reflect modern medicine and updated medical terminology

ICD-10-CM Laterality Examples

• C50.511 Malignant neoplasm of lower-outer quadrant of right female breast

• C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

• C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast

In the examples the 6th digit identifies the laterality, remember 1 is always right and 2 is always left.

ICD-9-CM Structure –Format

496-Chronic Airway Obstruction

414.00-Coronary Atherosclerosis Unsp Native/Graft

V55.3-Attention to Colostomy

• Codes longer than 3 characters always have decimal point after first 3 characters

• Codes are 3 to 5 in character length

• 1st character: alpha or numeric

• 2nd through 5th characters: numeric

ICD-10-CM Structure – Format

P09-Abnormal Findings on Neonatal Screening

S32.010A-Wedge Compression Fracture of First Lumbar Vertebra, Initial Encounter for Closed Fracture

• Codes longer than 3 characters always have decimal point after first 3

characters

• Codes are longer in character length

• 1st character: alpha

• 2nd through 7th characters: alpha or numeric

• 7th character used in certain chapters (obstetrics, musculoskeletal, injuries, and external causes of injury)

ICD-10-CM Code Structure

Categoryfirst threecharacters

Etiology, anatomic site, severity, laterality for fourth,

fifth, sixth characters (if applicable)

Extensionseventh

character(if applicable)

M84 Disorders of continuity of bone

M84 .311 Stress Fracture, right shoulder

M84.311A Stress fracture, right shoulder; initial encounter

ICD-10-CM: Differences from ICD-9-CM

Addition of 7th character•Used in certain chapters to provide information about the characteristic of the encounter

– S62.501A …… initial encounter for closed fracture phalanx rt thumb– S62.502A …… initial encounter for closed fracture phalanx lt thumb

•Must always be used in the 7th character positionO32.1 Maternal care for breech presentation

– O32.1XX1 …… fetus 1

•If a code has an applicable 7th character, the code must be reported with an appropriate 7th character value in order to be valid. If no descriptive characters for placement of 5th and 6th then you must use the placeholder X

7th Character’s A-D-S• A-Initial encounter: As long as patient is receiving active treatment

for the condition.

Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. • D-Subsequent encounter: After patient has received active treatment

of the condition and is receiving routine care for the condition during the healing or recovery phase.

Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition. • S-Sequela: Complications or conditions that arise as a direct result of

a condition (e.g., scar formation after a burn).

Example of sequela care: A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury.

ICD-10-CM 7th Character – Fractures

A Initial encounter for closed fracture

B Initial encounter for open fracture

D Subsequent encounter for fracture with routine

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

DIAGNOSIS CODE COMPARISON

ICD-10-CM: Placeholder “X”

• Addition of dummy placeholder “X” is used with certain codes:

–Allows for future expansion

–Fill out empty characters when a code contains fewer than 6 characters and a 7th character is required

• When a placeholder character is required, it must be used in order for the code to be considered validS90.01 Contusion of right ankle (not a valid diagnosis code)– S90.01xA ……initial encounter (valid diagnosis code)

• “X” is not case-sensitive

INCREASED SPECIFICITY

• Laterality (left, right, unilateral, bilateral) There have been modifiers for CPT® codes to report laterality, but never captured in the diagnosis before.

• Etiology (cause, organism)

• Specific Anatomical Site

• Characteristics/Manifestations of the Disease

• Presence of Complications

• Use of Combination Codes

ICD-10-CM Specificity Examples

• S72.044G Non-displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing

• I69.351 Sequela of cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (in this example sequela is used differently as the actual effect of the condition not an affect of the condition)

• Z47.81 Encounter for orthopedic aftercare following surgical amputation

• Z48.21 Encounter for aftercare following heart transplant

SPECIFICITY REDEFINED

Combination Codes – Examples

• I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris– ICD-9 414.01 and 411.1

• E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema – ICD-9 250.50, 362.01 and 362.07

• K71.51 Toxic liver disease with chronic active hepatitis with ascites– ICD-9 571.9, 571.49 and 789.59

• K50.012 Crohn’s disease of small intestine with intestinal obstruction– ICD-9 555.0 and 560.9

SPECIFICITY: COMPLICATIONS OR SEVERITY OF ILLNESS

ICD-10-CM: BE AWARE OF “NOTES”

• Many conventions have same meaning

–Abbreviations, punctuation, symbols, notes such as “code first” and “use additional code”

• Nonspecific codes (“unspecified” or “not otherwise specified”) are available to use when detailed documentation* to support a more specific code is not available

*Documentation should be reviewed to determine if more details could or should be included to code to a higher level of specificity.

ICD-10-CM: Excludes Notes

Excludes1 note

–Indicates that code identified in the note and code where the note appears cannot be reported together because the 2 conditions cannot occur together

Example: E10 Type 1 Diabetes mellitus

Excludes1: diabetes mellitus due to underlying condition (E08.-)

drug or chemical induced diabetes mellitus (E09.-)

gestational diabetes (O24.4-)

hyperglycemia NOS (R73.9)

neonatal diabetes mellitus (P70.2)

type 2 diabetes mellitus (E11.-)

If the patient has diabetes and is pregnant you would not code gestational diabetes

ICD-10-CM: Excludes Notes

• Excludes2 note

–Indicates that condition identified in the note is not part of the condition represented by the code where the note appears, so both codes may be reported together if the patient has both conditions

Example:

L89 Pressure ulcerExcludes2: diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622)

non-pressure chronic ulcer of skin (L97.-)

skin infections (L00-L08)

varicose ulcer (I83.0, I83.2)

Coding example: Pressure ulcer rt buttock stage 1 L89.311

Type II Diabetes w/other skin ulcer E11.622

Tabular Format Chapters in Tabular are structured similarly to ICD-9-CM, with minor exceptions

RESTRUCTURE–A few chapters have been restructured:As an example Chapter 2 Neoplasms has key updates

• Classification improvements • Code expansions • Significant expansions or revisions related to:

Identifying laterality for some of the neoplasm sites; and • Malignant neoplasm of male breast codes

NEW–Sense organs (eye and ear) separated from Nervous System and moved to their own

chapters:

Eye and Adnexa (H00-H59) Ear and mastoid Process(H60-H95) External Causes of Morbidity (V00-Y99) Factors Influencing Health Status (Z00-Z99)

Tabular Example

Index StructureTHERE ARE TWO INDEXES WITH TWO TABLES:

–Alphabetic Index of Diseases and InjuriesFrom A to Z; Hypertension table is not included in ICD-10. Main terms in alphabetic order with sub terms indented under main terms

–External Causes of InjuriesFrom A to Z; last section of the index for ICD-10

–Table of NeoplasmsContains Neoplasm and Neoplastic diseases by anatomical location. Many codes will not be complete as used in the table as they require coding for laterality; Neoplasm of Breast central portion (in table C50.1 is not a complete code)

–Table of Drugs and ChemicalsMore definition to the drug and chemical tables

Alphabetic Index Example

How to Assign an ICD-10 Code YES, you will need a code manual even if you use EHR!

1. Start with the Index. Look up the main term for the condition, disease or symptom. Codes should NOT be assigned from the Index without verifying the code selection in the Tabular volume.

2. Next, find the chapter & code set block for the condition.

3. Locate the condition in the Tabular section.

4. Consider the “includes”, “excludes”, “code first” and “use additional code” notes.

5. Is a 7th character needed? If so, look at the key at the beginning of the code chapter or block.

6. Select the most detailed code which is supported in the clinical documentation. Code to the highest specificity and the highest number of characters.

ICD-10-CM Coding Example:

Type 2 diabetes mellitus with diabetic neuropathy

Step 1

Look up term in Alphabetic Index:

Diabetes, diabetic (mellitus) (sugar) E11.9

type 2 E11.9

with nephropathy E11.21

Step 2

Verify code in Tabular:

E11.21 Type 2 diabetes mellitus with diabetic nephropathy

Type 2 diabetes mellitus with intercapillaryglomerulosclerosis Type 2 diabetes mellitus with intracapillaryglomerulonephrosis Type 2 diabetes mellitus with Kimmelstiel-Wilsondisease

ICD-9-CM Coding Example

Malignant Neoplasm of Female Breast: 174.0 – 174.9 (no laterality)

Malignant Neoplasm of Male Breast: 175.0 or 175.9 (no laterality)

1. 174.0-174.9 (Female)

Look up term in Alphabetic Index: Neoplasms Table

Breast, female 174.9 (pg 1444)

2. 175.0-175.9 (Male)

Look up term in Alphabetic Index: Neoplasms Table

Breast, male 175.9 (pg 1445)

ICD-10-CM Coding ExamplesMalignant neoplasm of nipple and areola, right female breast Breast Cancer

Step 1

Look up term in Alphabetic Index: Neoplasm Table

Breast, female, areola – C50.01

Step 2Verify code in Tabular:C50.0 – Malignant neoplasm of nipple and areola C50.01 – Malignant neoplasm nipple and areola, female

breastC50.011 – Malignant neoplasm of nipple and areola,

right female breastC50.021 – Malignant neoplasm of nipple and areola,

right male breast

Code range C50.011 Malignant neoplasm of nipple and areola, female breast to C50.929 – Malignant neoplasm of breast of unspecified site of unspecified male breast

Why is ICD-10 Better

• ICD-10 has many more diagnosis codes—about 68,000+ to ICD-9’s 13,000—and in this case, more is definitely better.

• Why? Because with more codes, medical providers, including rehab therapists, can more accurately document clinical information, including patient diagnoses. – Evaluate patient care– Support research initiatives– Construct payment systems– Process claims– Make clinical decisions– Observe public health trends– Uncover fraud

CMS Resources

• ICD-10

https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

• Medicare Learning NetworkICD-10 Myths and Facts

https://www.cms.gov/medicare/coding/icd10/downloads/icd- 10mythsandfacts.Pdf

• MS-DRG Conversion Report

https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html

• ICD-10 General Information

http://www.cms.hhs.gov/ICD10

Additional Resources

• The following organizations offer providers and others ICD-10 resources and information

– ICD-10 Tenth Revision Volume 2 Second Edition

Tabular list-Instruction manual-Alphabetical Index• http://www.who.int/classifications/icd/ICD-10_2nd_ed_volume2.pdf

– AHIMA (American Health Information Management Association)

• http://www.ahima.org/icd10/default.aspx

– HIMSS (Health Information and Management Systems Society)• http://www.himss.org/icd10

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