common icd-10 documentation deficienciesruralhealth.med.uky.edu/sites/default/files/korh...common...
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CommonICD-10DocumentationDeficiencies
SharonShover,CPC,[email protected]
Agenda
ChapterSpecificCodingGuidelines:• Chapter1:InfectiousandParasiticDiseases(A00-B99)• Chapter2:Neoplasms(C00-D49)• Chapter3:DiseasesofBloodandBloodFormingOrgans(D50-D89)• Chapter4:Endocrine,NutritionalandMetabolicDiseases(E00-E89)
• Diabetes(E08-E13)• Chapter5:MentalandBehavioralDisorders(F01-F99)• Chapter6:DiseasesoftheNervousSystemandSenseOrgans(G00-G99)• Chapter7:DiseasesoftheEyeandAdnexa(H00-H59)• Chapter8:DiseasesoftheEarandMastoidProcess(H60-H95)• Chapter9:DiseasesoftheCirculatorySystemandSenseOrgans(I00-I99)
• Hypertension(I10-I15),RO3.0forelevatedBP(ICD-9code796.2)• Chapter10:DiseasesoftheRespiratorySystem(J00-J99)• Chapter11:DiseasesoftheDigestiveSystem(K00-K94)• Chapter12:DiseasesoftheSkinandSubcutaneousTissue(L00-L99)• Chapter13:DiseasesoftheMusculoskeletalSystemandConnectiveTissue
(M00-M99)
Agenda
• Chapter14:DiseaseoftheGenitourinarySystem(N00-N99)• Chapter15:Pregnancy,Childbirth,Puerperium(O00-O9A)
• OB,deliveryandpostpartumservices• Chapter16:Newborn(Perinatal)Guidelines(P00-P96)
• Newbornservicesandreportingstillborn• Chapter17:CongenitalMalformations,DeformationsandChromosomal
Abnormalities(Q00-Q99)• Chapter18:Systems,SignsandAbnormalClinicalandLaboratoryFindings,Not
ElsewhereClassified(R00-R99)• Codesthatdescribesymptomsandsignsthatareacceptableforreporting
purposesandwhenarelateddefinitivediagnosishasnotbeenestablished(confirmed)bytheprovider.
• Chapter19:Injury,PoisoningandCertainOtherConsequencesofExternalCauses(S00-T88)
• Chapter20:ExternalCausesofMorbidity(V01-Y99)• Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices
(Z00-Z99)
ProceduresThatRemainwithUpdatedICD-10-CM
• Reasonforfirstvisit
• Codetothehighestlevelofknownspecificity
• Donotcodefor“probable,suspectedorquestionable”
• Codechronicdiseasesaslongaspatientisstillreceivingtreatment
HierarchicalConditionCategory(HCC)Coding
• MedicareAdvantagePlans• Onceevery12months• Usuallyperformedatwellnessexam(AWV)
• Causesconfusionwhenperformedduringmedicalvisit
• Medicalnecessitybasedontreatment
ChapterSpecificGuidelines
Chapter1:InfectiousandParasiticDiseases(A00-B99)
Encounters for testing for HIV• If patient is being seen to determine his/her HIV status, use code
Z11.4, Encounter for screening for human immunodeficiencyvirus [HIV]. Use additional codes for any associated high riskbehavior.
• If patient with signs or symptoms is being seen for HIV testing,code the signs and symptoms. An additional counseling codeZ71.7, Human immunodeficiency virus [HIV] counseling, may beused if counseling is provided during the encounter for the test.
• When a patient returns to be informed of his/her HIV test resultsand the test result is negative, use code Z71.7 , Humanimmunodeficiency virus [HIV] counseling.
• If the results are positive, see previous guidelines and assigncodes as appropriate.
Chapter2:Neoplasms(C00-D49)
Currentmalignancyversuspersonalhistoryormalignancy• When a primary malignancy has been excised butfurther treatment, such as additional surgery for themalignancy, radiation therapy or chemotherapy isdirected to that site, the primary malignancy codeshould be used until treatment is completed.
Chapter4:Endocrine,NutritionalandMetabolicDiseases(E00-E89)
Diabetesmellitusandtheuseofinsulinandoralhypoglycemics• If the documentation in a medical record does notindicate the type of diabetes but does indicate thatthe patient uses insulin, code E11, Type 2 diabetesmellitus, should be assigned. Code Z79.4, Long-term(current) use of insulin, or Z79.84, Long-term(current) use of oral hypoglycemic drugs, shouldalso be assigned to indicate that the patient usesinsulin or hypoglycemic drugs.
Chapter4:Endocrine,NutritionalandMetabolicDiseases(E00-E89)
• E66– Overweightorobese• Useadditionalcodetoidentifybodymassindex(BMI),ifknown(Z68.-)• BMI,20-29,adult• BMI,30-39,adult• BMI,40orgreater,adult• BMI,pediatric
– Bypercentile
Chapter5:MentalandBehavioralDisorders(F01-F99)
PsychoactiveSubstanceUse,AbuseAndDependence• When the provider documentation refers to use, abuse and
dependence of the same substance (e.g. alcohol, opioid,cannabis, etc.), only one code should be assigned to identifythe pattern of use based on the following hierarchy:• If both use and abuse are documented, assign only the code for
abuse• If both abuse and dependence are documented, assign only
code for dependence• If use, abuse and dependence are all documented, assign only
the code for dependence• If both use and dependence are documented, assign only code
for dependence
Chapter6:DiseasesoftheNervousSystemandSenseOrgans(G00-G99)
ChronicPain• Chronic pain is classified to subcategory G89.2. Thereis no time frame defining when pain becomeschronic. The provider’s documentation should beused to guide use of these codes.
Chapter7:DiseasesoftheEyeandAdnexa(H00-H59)
AssigningGlaucomaCodes• Assign as many codes from category H40, Glaucoma,as needed to identify the type of glaucoma, theaffected eye, and the glaucoma stage.GlaucomaScale:0-Unspecified1-Midorearlystage2-Moderatestage3-Advanced,late,severeStage4-Indeterminate
Chapter9:DiseasesoftheCirculatorySystemandSenseOrgans(I00-I99)
Hypertension,Transient• Assign code R03.0, Elevated blood pressure readingwithout diagnosis of hypertension, unless patient hasan established diagnosis of hypertension.
• Assign code 013.-, Gestational [pregnancy-induced]hypertension without significant proteinuria, or 014.-,Pre-eclampsia, for transient hypertension ofpregnancy.
Chapter10:DiseasesoftheRespiratorySystem(J00-J99)
TobaccoExposure• Use additional code, where applicable, to identify:• Exposure to environmental tobacco smoke - Z77.22• Exposure to tobacco smoke in the perinatal period –P96.81
• History of tobacco dependence – Z87.891• Occupational exposure to environmental tobaccosmoke – Z57.31
• Tobacco dependence – F17.-• Tobacco use – Z272.0
Chapter12:DiseasesoftheSkinandSubcutaneousTissue(L00-L99)
Pressureulcerstages• Codes from category L89,
Pressure ulcer, identify thesite of the pressure ulcer aswell as the stage of the ulcer.
• The ICD-10-CM classifiespressure ulcer stages basedon the severity, which isdesignated by stages 1-4,unspecified stage andunstageable.
• Assign as many codes fromcategory L89 as needed toidentify all the pressureulcers the patient has, ifapplicable.
Chapter13:DiseasesoftheMusculoskeletalSystemandConnectiveTissue(M00-M99)
Osteoporosis• Osteoporosisisasystemiccondition,meaningthatallbonesofthemusculoskeletalsystemareaffected.Therefore,siteisnotacomponentofthecodesundercategoryM81Osteoporosiswithoutcurrentpathologicalfracture.
• ThesitecodesundercategoryM80,Osteoporosiswithcurrentpathologicalfracture,identifythesiteofthefracturenottheosteoporosis.
Chapter15:Pregnancy,Childbirth,Puerperium(O00-O9A)
Diabetesmellitusinpregnancy• Diabetesmellitusisasignificantcomplicatingfactorinpregnancy.Pregnantwomenwhoarediabeticshouldbeassignedacodefromcategory024,Diabetesmellitusinpregnancy,childbirthandthepuerperium,first,followedbytheappropriatediabetescode(s)(E08-E13)fromChapter4.
Chapter15:Pregnancy,Childbirth,Puerperium(O00-O9A)
Alcoholuseduringpregnancy,childbirthandthepuerperium• Codes under subcategory 099.31, Alcohol usecomplicating pregnancy, childbirth and thepuerperium, should be assigned for any pregnancycase when a mother uses alcohol during thepregnancy or postpartum.
Chapter15:Pregnancy,Childbirth,Puerperium(O00-O9A)
Tobaccouseduringpregnancy,childbirthandthepuerperium• Codes under subcategory 099.33, Smoking (tobacco)complicating pregnancy, childbirth and thepuerperium, should be assigned for any pregnancycase when a mother uses any type of tobaccoproduct during pregnancy or postpartum.
Chapter19:Injury,PoisoningandCertainOtherConsequencesofExternalCauses(S00-T88)
Applicationof7th CharactersinChapter19• 7th Character“A”
Initial encounter is used for each encounterwhere the patient is receiving active treatmentfor the condition.
Chapter19:Injury,PoisoningandCertainOtherConsequencesofExternalCauses(S00-T88)
Applicationof7th CharactersinChapter19th
• 7th Character“D”Subsequent encounter is used for encountersafter the patient has completed active treatmentof the condition and is receiving routine care forthe condition during the healing or recoveryphase• The aftercare Z-codes should not be used for aftercarefor conditions such as injuries or poisonings where 7thcharacters are provided to identify subsequent care.
Chapter19:Injury,PoisoningandCertainOtherConsequencesofExternalCauses(S00-T88)
Applicationof7th CharactersinChapter19th• 7th Character“S”
Sequela, is for use for complications orconditions that arise as a direct result of acondition, such as scar formation after a burn.The scars are a sequela of the burn. When using7th character “S” it is necessary to use both theinjury code that precipitated the sequela and thecode for the sequela itself. The “S” is added onlyto the injury code. The specific type of sequela issequenced first, followed by the injury code.
Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)
Z00.0-Encounter for general adult medical examination (with or withoutabnormal findings)• Not to be used for examinations done regarding a sign or symptomZ00.1-Encounter for health exam of the newborns and routine children(with or without abnormal findings)• If examination is done strictly for administrative purposes not relating
to any specific conditions then pre-existing, chronic and history codesmay be applied
Z00.121-Encounter for routine child health examination WITHabnormal findingsZ00.129-Encounter for routine child health examinationWITHOUT abnormal findings
Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)
Z01.41-AnnualGYNexam(withorwithoutabnormalfindings)
Z01.411-EncounterforGYN(exam)(routine)WITHabnormalfindingsZ01.419-EncounterforGYN(exam)(routine)WITHOUTabnormalfindingsZ01.42-Encounterforcervicalsmeartoconfirmfindingsofrecentnormalsmearfollowinginitialabnormalsmear
• Ifencounteriscodedwhiletestresultsareoutstandingitisacceptabletocodefor“withoutabnormalfindings”
Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)
Z01.20-.21 - Encounters fordental exam and cleaning (withor without abnormal findings)
Z01.8 - Encounters for pre-procedural exams for cardio,respiratory, lab, allergy, bloodtyping, antibody responses
Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)
Z02-Z04-EncountersforadministrativeexamsZ02.5-SportsphysicalZ02.71-DisabilityexamsZ04.71andZ04.72-Examsfollowingallegedadultorchildabuse
Z11-Encounterforscreeningforinfectiousandparasiticdisease
Z11.3-EncounterforscreeningforinfectionwithpredominatelysexualmodeoftransmissionZ11.4-EncounterforHIVZ11.59-Encounterforotherviraldisease
Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)
Z13-Encounter for screening for other disease anddisorder
Z13.6-Encounter for screening for cardiovasculardisorder
Z23-Encounter for Immunization• Code first any routine childhood examinations
Z28-Immunization not carried out and underimmunization status
Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)
Z30-ContraceptivemanagementZ30.42-EncoutnerforsurveillanceofinjectablecontraceptivesZ30.49-Encounterforsurveillanceofothercontraceptives
• Codesusedtoidentifyinitialprescriptionaswellasongoingsurveillance
• Optionsincludepills,injectableorIUD’s
Z32-Encounterforpregnancytest,resultsunknown
Z48-Encountersforpost-proceduralaftercareZ48.00-Change/removalofnonsurgicaldressingZ48.01-Change/removalofsurgicalwounddressingZ48.02-Encounterforremovalofsutures
Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)
Z72-ProblemsrelatedtolifestyleZ72.0-TobaccouseZ72.3-LackofexerciseZ72.4-Inappropriatedietandeatinghabits
Z73-Problems relating to life management difficultyZ79-Long-term (current) drug therapy; Includinganticoagulants, antithrombotic, NSAID, hormonalcontraceptives, insulin, steroids
Z51.81-Codeanytherapeuticdrug-levelmonitoring
Questions?