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ICD-10-CM

ICD-10-CM. OVERVIEW OF UPCOMING DOCUMENTATION COMPONENTS OF ICD-10-CM. Presenter. Sue Haley, RHIT, CCS, CCDS AHIMA certified ICD-10 instructor Over 20 years coding experience Both inpatient and outpatient. ICD-9-CM 3-5 characters Only V & E codes start with letter

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ICD-10-CM

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  1. ICD-10-CM OVERVIEW OF UPCOMING DOCUMENTATION COMPONENTS OF ICD-10-CM

  2. Presenter • Sue Haley, RHIT, CCS, CCDS • AHIMA certified ICD-10 instructor • Over 20 years coding experience • Both inpatient and outpatient

  3. ICD-9-CM 3-5 characters Only V & E codes start with letter Limited space for adding new codes Cannot identify laterality ICD-10-CM 3-7 characters ALL codes start with letter Flexible for adding new codes Can identify laterality OCTOBER 2013

  4. EXCLUDES NOTES • ICD-10-CM • Exclude notes are better defined in ICD-10 • EXCLUDES 1 means don’t code together • EXCLUDES 2 means “not included here”. Therefore, if both conditions exist, two codes are necessary

  5. Official Guidelines for Coding & Reporting Conventions for ICD-10 • www.cdc.gov/nchs/icd/icd10cm.htm • Many new and revised coding guidelines for ICD-10-CM but also newly published guidelines for ICD-10-PCS • AHA Coding Clinic for ICD-9-CM will not be converting their guidelines for ICD-10-CM use

  6. Documentation Considerations by Chapters in ICD-10-CM • Infectious & Parasitic Disease • New terminology to review • Includes the drug resistant classifications • Blood & Blood Forming Organ • New terminology to review • Greater specificity • Endocrine, Nutritional, Metabolic • Greater specificity for diabetes & malnutrition

  7. Documentation Considerations by Chapters in ICD-10-CM • Mental & Behavioral Disorders • Many changes to terminology • Tobacco use vs dependence • Nervous System • Significant changes in the specificity of sleep disorders • Eye & Adnexa (new chapter) • Terminology changes • Laterality classified • Ears & Mastoid (new chapter) • Laterality classified

  8. Documentation Considerations by Chapters in ICD-10-CM • Circulatory • Includes gangrene • Hypertension no longer classified malignant, benign, or unspecified. • Definition on coding AMI now 4 weeks • Respiratory • Asthma now classified as mild intermittent & three degree’s of persistent- mild, moderate, and severe • Digestive • Ulcers no longer specified as obstructive • Bleeding assigned to gastritis, duodenitis, diverticulosis • Crohn’s has specific sites & now identifies that with complications • Skin & Subcutaneous • More specificity in sites & severity of decubitus ulcers

  9. Documentation Considerations by Chapters in ICD-10-CM • Musculoskeletal & Connective Tissue • Fractures further define encounters as: • A initial encounter for fracture • B Initial encounter for fracture routine healing • G subsequent encounter for fracture delayed healing • K subsequent encounter for fracture with nonunion • P subsequent encounter for fracture for malunion • S sequela

  10. Documentation Considerations by Chapters in ICD-10-CM • Musculoskeletal & Connective Tissue • Uses the GUSTILO open fracture classification • Mechanism of injury • Soft tissue damage • Degree of skeletal involvement • Physician teaching opportunity during your implementation of ICD-10

  11. Documentation Considerations by Chapters in ICD-10-CM • GUSTILO open fracture classification • B initial encounter open fx type I or II • C initial encounter open fx type IIIA, IIIB, or routine healing • E subseq. encounter open fx type I or II with routine healing • F subsuq. encounter open fx type IIIA, IIIB, or IIIC with routine healing • H subseq. Encounter open fx type I or II with delayed healing • J subseq. Encounter for open fx type IIIA,IIIB, or IIIC with delayed healing • M subseq. Encounter for open fx type I or II with nonunion • N subseq. Encounter for open fracture type IIIA, IIIB, or IIIC with nonunion • Q subseq. Encounter for open fx type I or II with malunion • R subseq. Encounter for open fx

  12. Documentation Considerations by Chapters in ICD-10-CM • Musculoskeletal & Connective Tissue • Laterality • New definitions associated with classification of joint involvement (direct, indirect, post-infective) • Direct organism invades synovial tissue and microbial agent is present in joint • Indirect no joint involvement • Post-infective antigen present

  13. Documentation Considerations by Chapters in ICD-10-CM • Musculoskeletal & Connective Tissue • Pathological fractures have 3 categories: • Due to neoplastic disease, • Due to osteoporosis, • Due to other specified disease

  14. Documentation Considerations by Chapters in ICD-10-CM • Diseases of genitourinary system • New terminology • Post-traumatic urethral strictures will need to identify patients gender

  15. Documentation Considerations by Chapters in ICD-10-CM • Pregnancy, childbirth, & periperium • Episode of care is no longer classified • Trimester is now used to classify the condition • 1st trimester- less than 14 wks and 0 days • 2nd trimester- 14 wks 0 days to less than 28 wks 0 days • 3rd trimester- 28 weeks 0 days until delivery

  16. Documentation Considerations by Chapters in ICD-10-CM • Pregnancy, childbirth, & periperium • Physician’s must calculate the weeks, the coder can not • Coder can use the weeks to determine the trimester if the physician documents • The time frames for differentiating the abortion from fetal death have changed from 22 to 20 weeks.

  17. Documentation Considerations by Chapters in ICD-10-CM • Signs, Symptoms, and abnormal clinical and laboratory findings, NEC • Fairly substantial classification changes to hematuria • GLASCOW coma scale (TBI/sequelae CVA) • Primarily used by trauma registries & research • Organizational decision the frequency of capturing a Glasgow coma scale scores

  18. Documentation Considerations by Chapters in ICD-10-CM • GLASCOW COMA SCALE • 7th digit character will indicate: • 0 unspecified time • 1 in the field (EMT or ambulance) • 2 at arrival to ER • 3 at hospital admission • 4 24 hours or more after admission

  19. Documentation Considerations by Chapters in ICD-10-CM • Injuries, poisoning, & certain other consequences of external causes • New category for underdosing • Taking less of a medication than is prescribed • Classify burns and corrosions (new term ICD-10)

  20. Documentation Considerations by Chapters in ICD-10-CM • Injuries, poisoning, & certain other consequences of external causes • New extensions for identification of: • A initial encounter • D subsequent encounter • S sequela

  21. Documentation Considerations by Chapters in ICD-10-CM • Injuries, poisoning, & certain other consequences of external causes • Fractures further define encounters as: • A initial encounter for closed fracture • B Initial encounter for open fracture • D subsequent encounter fracture routing healing • G subsequent encounter for fracture delayed healing • K subsequent encounter for fracture with nonunion • P subsequent encounter for fracture for malunion • S sequela

  22. Closing Remarks • Encourage review of ICD-10 coding guidelines now to become familiar with similarities and differences • Pay close attention to new guidelines for PCS and the new guidance being provided • Develop educational plans that incorporate the new documentation requirements • Don’t wait until 2013 start now!

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