icd 10 basics€¦ · icd‐10 basics learning the rules ... relationship with chronic kidney...

ICD‐10 BASICSLEARNING THE RULES FIRST

Presenter:Jennie W. Brown, RHIT, CPC

AHIMA Approved ICD‐10 Trainer

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DisclaimerThe information contained in this presentation is for review only and is based on the latest published information from the Centers of Medicare and Medicaid and AHIMA. Every effort has been made to assure accurate information. Responsibility for correct application of the rules listed in this presentation lies with the participant. Reprint of information should be approved by the presenter.

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Presenters

Jennie Brown, RHIT, CPC is an AHIMA Approved ICD‐10 Trainer. Serves as the Imaging Coding Compliance Coordinator for Grady Health System. She is a Registered Health Information Technician and a Certified Professional Coder with over twenty years experience in the healthcare environment. She has served as a Coder, Coding Consultant, Coding Supervisor, Compliance Auditor and HIMS Department Manager. She has presented seminars on fraud and abuse, revenue cycle management and billing compliance.

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AGENDA

• Introduction• Objective• ICD‐10 Pre‐Assessment• What is ICD‐10?• ICD‐10‐CM Coding Convention Rules• ICD‐10‐CM Chapter Specific Rules• Applying the Rules• ICD‐10 Post Assessment• ICD‐10‐CM Vs ICD‐9‐CM Tips

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Introduction

• This presentation is designed to serve as an educational guide to assist the participant in learning the basic rules of ICD‐10‐CM

• Knowing the rules to use and understanding how to apply them are keys to getting the correct code assignment

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Objective

• Explain the background of ICD‐10• Understand some basic ICD‐10‐CM Convention Rules

• Explain some of the Chapter Specific Rules• Explain the ICD‐10‐CM vs ICD‐9‐CM Tips

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What is ICD‐10?• International Classification of Diseases, 10thRevision– The CM is for the clinical modification used in the United States

• Full release in 1994 by World Health Organization (WHO)

• In 1999 the U.S. decided to use for mortality (death certificates)

• Used in other countries for mortality and morbidity

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What is ICD 10?(cont’d)• Implementation date for ICD‐10‐CM October 1, 2013 in the U.S.(date currently delayed)– CM is for the clinical modification of ICD‐10 by the U.S.

– Addresses reimbursement and quality issues• Characteristics of ICD‐10‐CM

– Has 3‐7 digits• A 3 digit code may be assigned

– Digit 1 is alpha– Digit 2 is numeric

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What is ICD‐10?

(cont’d)• Characteristics of ICD‐10‐CM

– Digit 3 is alpha– Digits 4‐7 are alpha or numeric

• Unique Features– There are full code titles– Laterality (identifies which side of body)– Encounters

• Injuries and external causes9

ICD‐10‐CM Rules

• General Conventions– Alphabetic Index– Tabular List– Neoplasm Table– Table of Drugs and Chemicals– No Table for Hypertension

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ICD‐10‐CM Rules

• General Conventions– 7th Characters

• Applicable for specified chapters– Obstetrics– Musculoskeletal– Injuries– External cause of injury

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ICD‐10‐CM Rules(cont’d)– Encounters

• Initial• Subsequent• Sequela

– Placeholder character (aka dummy placeholder)• “X” used at certain codes for future expansion• Completes empty characters when a code has less than 6 and a 7th character is applicable

– T50.1x5A

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ICD‐10‐CM Rules

• Punctuation– Parentheses used in both the Alphabetic Index and Tabular List

– Abbreviations• NEC represents other specified in the Alphabetic Index

– In the Tabular List represents other specified

• NOS equivalent of unspecified– In the Tabular List equivalent of unspecified

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ICD‐10‐CM Rules

• Includes Notes appear under a 3 digit code title

• Inclusion Terms are conditions for which that code is to be used – Some codes have a list of terms that may be synonyms or other various conditions assigned to that code

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ICD‐10‐CM Rules

– Brackets used in Tabular to enclose synonyms• In the Alphabetic Index , identifies manifestation codes

• Excludes Notes– Two types:

• Excludes 1 means not coded here• Excludes 2 indicates both the code and the excluded code can be used together

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ICD‐10‐CM Rules

• “See”– Used in the Alphabetic Index to indicate that another term should be referenced

• “See Also”– Used in the Alphabetic Index indicates that another term may be reference

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ICD‐10‐CM Rules

• “And” should be interpreted as either and/or in when it appears in a title

• “With” should be interpreted as “associated with” or “due to”

• Acute and Chronic Conditions– If both acute and chronic with separate subentries and same indentation level in Alphabetic Index, assign both codes and sequence acute condition first

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ICD‐10‐CM Rules

• Default Code– Code listed in the Alphabetic Index that is commonly associated with the condition without additional information (example urosepsis)

• Late Effects– Residual of illness/injury– No time limit– Requires two codes– Late effect code is sequenced second– Exceptions to the rule

• Follow guidelines if late effect code expanded• Do not included acute phase of illness/injury

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ICD‐10‐CM Rules

• ICD‐10 CM code can only be reported once for an encounter

• Laterality– Final character indicates laterality

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ICD‐10‐CM Rules

• BMI and Pressure Ulcer Stages– Coding may be based on medical record documentation from non‐physicians

– However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient’s physician

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Chapter Specific Rules

• Complications of Care– Not all conditions that occur during or following medical care or surgery are classified as complications

– A cause‐and‐effect relationship must clearly exist

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• Infectious Diseases– HIV code only confirmed cases– HIV related admission or visit

• First listed or pdx is Human immunodeficiency virus disease (B20)

• Follow with diagnosis codes for reported HIV related condition

• If encounter is not for related HIV disease, list the unrelated condition first/pdx followed by B20

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• Severe Sepsis– Requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis

– Query the physician if documentation is not clear– If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the code from subcategory R65.2

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Chapter Specific Rules• Neoplasm

– Encounters involving management of an anemia associated malignancy with treatment directed only toward the anemia, should have the malignant neoplasm as the first listed code/pdx followed by the applicable anemia code

– Encounters involving management of an anemia associated with an adverse effect of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by the applicable codes for the neoplasm and the adverse effect

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• Neoplasm (cont’d)– Encounters for pain that is related to a malignant neoplasm may be assigned as pdx or first listed code, when the documentation states that the encounter is for pain control or pain management

– When a primary malignancy has been excised but further treatment is continued for that site, the primary malignancy code should still be used until treatment is completed

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Chapter Specific Rules• Neoplasm (cont’d)

– HX of personal malignancy should be used when the primary site has been excised or eradicated with no further treatment

– A pregnant woman with a malignant neoplasm, should have the first listed/pdx code for malignant neoplasm complicating pregnancy, childbirth, and the puerperium, followed by the appropriate code for the malignant neoplasm

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Chapter Specific Rules• Diabetes

– Combination codes are used to identify the conditions (ICD‐10 does not include control or not controlled)

– Two types (Type I and Type 2)– Classified by the type of diabetes and any associated complications (code as many codes necessary to identify the condition)

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Chapter Specific Rules• Diabetes (cont’d)

– If type of diabetes is not documented, the default is type II

– Type II is always coded to type II regardless of the patient’s use of insulin

– If medical record documentation states patient uses insulin, assign long term current use of insulin (do not assign long term use for insulin usage on a temporary basis)

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Chapter Specific Rules• Circulatory System

– Myocardial Infarction acute phase duration is 4 weeks or less (not 8 weeks)

– If another myocardial infarction occurs within the acute phase duration, a subsequent AMI code must be assigned

– Identification of risk factors codes may be assigned

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Chapter Specific Rules– Unstable angina with coronary arteriosclerosis is a combination code (therefore, requires one 1 instead of 2)

– Coronary atherosclerosis due to lipid rich plaque still utilizes 2 codes (the first listed code required is still atherosclerosis)

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• Hypertension– ICD‐10‐CM presumes a cause‐and‐effect relationship with chronic kidney disease and hypertension (this is not the case with hypertension and heart disease)

– No classification of benign or malignant

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• Pregnancy– Coding based on trimesters (first, second and third)

– No association with episode of care involving antepartum or delivery

– Admissions with complications that involve stays with more than one trimester, should have the pdx sequenced according to the basis of the trimester when the complication developed, not the trimester at the time of discharge

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Chapter Specific Rules– Seventh Character is applicable for certain pregnancy categories to classify the fetus for which a complication has occurred

• Single gestations• Insufficient documentation to determine fetus affected• Cannot clinically determine which fetus is affected

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– Abortion time frame for ICD‐10 is 20 weeks gestation (ICD‐9 the time frame for abortion was less than an estimated 22 weeks gestation)

– Early and late vomiting in pregnancy has changed from 22 weeks to 20 weeks)

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Chapter Specific Rules• Ulcers

– Chronic ulcers of skin are typically classified into categories of a pressure ulcer or non‐pressure ulcer of lower extremity

– Combination coding is used for assignment of code to identify the site, laterality and severity in ICD‐10

• The 5th character will specify the site

– If there is associated gangrene, the gangrene should be sequenced first

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Chapter Specific Rules– If underlying condition is known, it should be sequenced first

• Assume a causal relationship with – Atherosclerosis of the lower extremity– Chronic venous hypertension– Diabetic ulcers– Postphlebitic syndrome– Varicose ulcer

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Chapter Specific Rules– Pressure ulcers stated as healed should not have a code assigned

– Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record

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Chapter Specific Rules• Osteoporosis

– Site is not a component of the code– A patient who suffers a fracture and has known osteoporosis should have a code assigned stating (not a traumatic fracture) even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone

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– Pathological fractures• You should not assign a code for both a traumatic fracture and a pathological fracture of the same bone

• Classified categories (New to ICD‐10)–Osteoporosis with current pathological fracture– Pathological fracture not else where classified– Pathological fracture in neoplastic disease– Pathological fracture in other disease

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Chapter Specific Rules– Pathological fractures (cont’d)

• Seventh character extensions are used to indicate bone involved

– “A” initial encounter for fracture– “D” subsequent encounter for fracture with routine healing– “G” subsequent encounter for fracture with delayed healing– “K” subsequent encounter for fracture with non‐union– “P” subsequent encounter for fracture with malunion– “S” Sequela

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• Injury– ICD‐10 groups by body region from head to ankle and foot

– Type of injury is considered a secondary axis– Code all injuries separate unless a combination code is available

– If admission due to multiple injuries, assign the most severe injury as the pdx

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• Fractures– Documentation must include displaced or non‐displaced

• If the documentation does not specify , code as displaced

– Specification of opened or closed is needed• if no specification for opened or closed, code as closed

– Laterality• Right femur• Left femur

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• Fractures– Open fracture terms

• compound• Infected• Missile• Puncture• With foreign body

– Closed fracture terms• Comminuted• Greenstick• depressed

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• Fractures– Characters

• 4th indicate the bone• 5th indicate a more specific part of the bone• 6th indicate indicates laterality

– May also indicate displaced or non‐displaced

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• Fractures– Seventh character extensions for fractures

• Vary based on the bones affected– Fracture of forearm has 16 different 7th character extensions

» A indicates initial encounter for closed fx» B indicates initial encounter for open fx type I or II» C indicates open fx for type IIIA, IIIB or IIIC» D indicates subsequent encounter for closed fx with routine healing

» E indicates subsequent encounter for open fx type I or II with routine healing

» F indicates subsequent encounter for open fx type IIIA, IIIB or IIIC with routine healing

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Chapter Specific Rules» G indicates subsequent encounter for closed fx with delayed healing

» H indicates subsequent encounter for open fx type I or II with delayed healing

» J indicates subsequent encounter for open fx type IIIA, IIIB, or IIIC with delayed healing

» K indicates subsequent encounter for closed fx with non‐union

» M indicates subsequent encounter for open fx type I or II with nonunion

» N indicates subsequent encounter for open fx type IIIA, IIIB, or IIIC with nonunion

» P indicates subsequent encounter for closed fx with malunion

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Chapter Specific Rules» Q indicates subsequent encounter for open fx type I or II with malunion

» R indicates subsequent encounter for open fx type IIIA, IIIB, or IIIC with malunion

» S indicates sequela

– Aftercare• After care for traumatic fx involving healing should be assigned the acute fracture code with the appropriate 7th digit character extension and not an encounter code for orthopedic aftercare

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End of Presentation

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icd 10 basics€¦ · icd‐10 basics learning the rules ... relationship with chronic kidney...

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