An Introduction to Organizational & Structural Changes ICD-10-CM Coding Presenter: Mary Valencia, CPC, CMC, CMOM, ICD-10 Instructor
Introduction to ICD-10 • World Health Organization (WHO) • Owns and publishes International Classification of Diseases • Used world-wide for morbidity and mortality reporting • 10th revision (ICD-10) endorsed in 1990 • Many countries have been using ICD-10 or a modified version since 1994 • The U.S. has been using ICD-10 for mortality reporting since 1999, but continues to use a modified version of ICD-9 referred to as ICD-9-CM for morbidity reporting and other purposes January 2009, federal government determined the U.S. would upgrade to the 10th revision of the ICD as of October 1, 2013. This was delayed by one year to October 1, 2014.
Introduction, continued ICD-10-CM Clinical Modification ICD-10-PCS Procedural Coding System Used to assign procedure codes for the inpatient setting Unique to the U.S. and independent of the ICD-10, but designed to complement the structure of ICD-10 Developed by CMS with 3M’s health information systems division • Used to assign diagnosis codes • Clinical modification of ICD-10 was developed by the National Center for Health Statistics, a division of the CDC
Who will be affected? ICD-10-CM ICD-10-PCS Will capture inpatientprocedures for acute care hospital claims. • Used by all healthcare providersin all settings to assign and/or interpret diagnoses. • Principal/Primary diagnosis • Secondary diagnosis • Professionals and the outpatient setting • (Medicare Part B claims) will continue to use • Current Procedural Terminology (CPT) codes.
Why Change?Benefits to ICD-10-CM/PCS • Reduced ambiguity • Current terminology and technology • Relevance to encounters • Data transparency for reimbursement and compliance efforts • Data of new diseases and technologies • HIPAA criteria for 5010 code set standards • Flexibility in adding new codes • Recommended revisions that ICD-9 could not accommodate • Future expansion
ICD-10-CM Format (3-7 Characters) ALPHA Alpha or Numeric # # DECIMAL X X X X X X X Category Etiology, Anatomical Site, Severity Extension
Diagnosis Coding & Data Differences ICD-9-CM ICD-10-CM 3-7 characters in length First character always alpha All letters used except U Always at least three digits Character 2 always numeric: 3-7 can be alpha or numeric Alpha characters are not case sensitive • 3-5 characters in length • First digit is numeric but can be alpha (E or V) • Always at least three digits • Digits 2-5 are numeric • Alpha characters are not case sensitive
ICD-10-CM Organizational Changes • Hierarchal structure is the same • 21 Chapters rather than 19 Chapters • Diseases and Conditions of the Sense Organs (Eyes and Ears) separated from Nervous System Chapter • To reflect current medical knowledge, certain diseases have been reclassified to a more appropriate chapter • Example: Gout moved from Endocrine to Musculoskeletal
ICD-10-CM New FeaturesGreater Specificity • Combination codes for conditions and common symptoms or manifestations • I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris • Combination codes for poisonings and external causes • T42.4X5A Adverse effect of benzodiazepines, initial encounter • Added laterality • H60.332 Swimmer’s ear, left ear
ICD-10-CM New Features • Added seventh-characters for episode of care • M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture • Expanded codes (injuries, diabetes, alcohol and substance abuse, postoperative complications) • E11.341 Type 2 diabetes mellitus with sever nonproliferative diabetic retinopathy with macular edema • Inclusion of trimesters in obstetrics codes (and elimination of fifth digits for episode of care) • O99.013 Anemia complicating pregnancy, third trimester
ICD-10-CM New Features • Changes in time frames specified in certain codes • Acute myocardial infarction • time period changed from 8 weeks to 4 weeks • Added standard definitions for two types of “excludes” notes • Excludes 1 • “Not Coded Here”. The code being excluded is never used with the code. The two conditions cannot occur together. • Excludes 2 • “Not Included Here”. The excluded condition is not part of the condition represented by the code. It is acceptable to use both codes together if the patient has both conditions.
Used In • Seventh Character Obstetrics Injury External Cause Either alpha or numeric Placeholder “x” Meanings vary
GEMS • General Equivalence Mappings • Facilitate transition from ICD-9-CM to ICD-10-CM • Two files available for bidirectional mappings • Designed with programmers in mind • CMS website • http://www.cms.hhs.gov/ICD10 • NCHS website • http://www.cdc.gov/nchs/icd/icd10cm.htm
Organization & Structure of ICD-10-CM • Alphabetic Index • Divided into two parts • Index to Diseases and Injuries including • Neoplasm Table • Table of Drugs and Chemicals • Index to External Causes • Tabular List • 21 Chapters • Order is a bit different from ICD-9-CM • Chapters divided into Subchapters with instructional notes • “other” versus “unspecified”
Terminology Changes Sepsis Septicemia Bleeding Hemorrhage Androgenic Alopecia Baldness
Placeholder Character • The letter “x” has two uses • As a fifth character for certain six character codes • T37.0X1A Poisoning by sulfonamides, accidental (unintentional), initial encounter • When a code has less than six characters but a seventh character is required. • W85.XXXA Exposure to electric transmission lines, initial encounter
7th Characters • Can be either a number or letter • Required for some of the ICD-10-CM codes • Added for increased specificity • Must always be in the 7th character position O 6 5 0 X X 1 Obstructed labor due to deformed pelvis, fetus 1
Abbreviations • NEC (Not Elsewhere Classified) • Describes a code which has not been classified anywhere else in the code set. • NOS (Not Otherwise Specified) • Used when the documentation of the condition identified by the provider is insufficient to assign a more specified code. ICD-10-CM ICD-9-CM H26.8 Other specified cataract 366.8 Other cataract ICD-10-CM ICD-9-CM J12.9 Viral pneumonia, unspecified 480.9 Viral pneumonia, unspecified
Instructional Notes • Includes • Used in Tabular Section • Not an exhaustive list • Excludes • Excludes 1 • Excludes 2 • Code First • Use Additional Code • Cross Reference Notes • See, See Also, and See Condition
Instructional Notes • Relational Terms • And, interpreted as “and/or” • With, interpreted as “associated with” or “due to” • “with” is sequenced immediately after the main term in the Index • Laterality • Left/Right • If no bilateral code provided, code both the left and right. • If the side is not identified in the record, assign the coder for the unspecified side.
Infectious & Parasitic Diseases A00-B99 • Includes diseases generally recognized as communicable or transmissible • Use additional code to identify resistance to antimicrobial drugs (Z16) • When coding sepsis or AIDS, it is important to review the Coding Guidelines and the notes at the category level of ICD-10-CM Ch. 1
Infectious & Parasitic Diseases A00-B99 • Code first condition resulting from (sequela) the infectious or parasitic disease • Bacterial and viral infectious agents (B95-B97) are provided for use as supplementary or additional codes to identify the infectious agent(s) in diseases classified elsewhere • Index • Infection • Organism (Streptococcus)
Infectious & Parasitic Diseases A00-B99 • Coding Note: ICD-10-CM has created a range of codes to identify infections with a predominantly sexual mode of transmission (A50-A64). It is important to note that human immunodeficiency virus (HIV) disease is excluded from this range of codes.
NeoplasmsC00-D49 I.C.2 General Neoplasm Guidelines • The Neoplasm Table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. Ch. 2
NeoplasmsC00-D49 • A primary malignant neoplasm overlapping two or more contiguous (next to each other) sites should be • classified to the subcategory/code .8 (overlapping lesion), • unless the combination is specifically indexed elsewhere. • For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, • codes for each site should be assigned.
Endocrine, Nutritional & Metabolic Diseases E00-E89 Ch. 4 Diabetes mellitus • New subchapter for diabetes and malnutrition • Instead of a single category (250) now there are five categories • Combination codes • No longer classified as controlled or uncontrolled • Inadequately, out of control or poorly controlled coded by type with hyperglycemia
5 Categories of Diabetes • E08, Diabetes mellitus due to underlying condition • E09, Drug or chemical induced diabetes • E10, Type 1 diabetes mellitus • E11, Type 2 diabetes mellitus • E13, Other specified diabetes mellitus
Mental, Behavioral and Neurodevelopmental Disorders F01-F99 • Unique codes for alcohol and drug use, abuse, and dependence • Continuous or episodic no longer classified • History of drug or alcohol dependence coded as “in remission” • Combination codes • Blood alcohol level (Y90.-) Ch. 5
Coding Note: ICD-10-CM provides a code to indicate blood alcohol level. Under the category F10, there is a "use additional code" note for blood alcohol level. Blood alcohol level can be indexed in the Index to External Causes.
Note! • The ICD-10-CM classification system does not provide separate "history" codes for alcohol and drug abuse. These conditions are identified as “in remission” in ICD-10-CM.
Diseases of the Nervous System G00-G99 Ch. 6 • Sense organs (eye/adnexa and ear/mastoid process) moved to their own chapter • Category for Alzheimer’s disease (G30) has been expanded to reflect onset (early versus late) • ICD-10-CM has two codes for phantom limb syndrome, differentiating whether pain is present or not • Organic Sleep Disorders • Moved to Chapter 6 from signs and symptoms • Sleep Apnea has own category (G47.3) with fifth character to specify type
Diseases of the Nervous System G00-G99 • Epilepsy terminology updated • Localization-related idiopathic • Generalized idiopathic • Special epileptic syndromes • Provides specificity for • Seizures of localized onset • Complex partial seizures • Intractable • Status epilepticus
Diseases of Eyes and AdnexaH00-H59 Ch. 7 • Concept of laterality • Right • Left • Bilateral • Unspecified If bilateral is not available, assign code for right and left.
Diseases of Ear and Mastoid ProcessH60-H95 Ch. 8 • Otitis media • Use additional code for any associated perforated tympanic membrane (H72.-) • Use additional code to identify • Exposure to environmental tobacco smoke (Z77.22) • Exposure to tobacco smoke in the perinatal period (P96.81) • History of tobacco use (Z87.891) • Occupational exposure to environmental tobacco smoke (Z57.31) • Tobacco dependence (F17.-) • Tobacco use (Z72.0)
Diseases of the Circulatory SystemI00-I99 Ch. 9 • Type of hypertension not used as an axis • Acute MI codes changed from 8 weeks to 4 weeks or less • I21 Initial AMIs • I22 Subsequent AMIs • A code from category I22 must be used in conjunction with a code from category I21. • Category I22 is never used alone. • The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.
Diseases of the Respiratory SystemJ00-J99 • New terminology for asthma • Mild intermittent • Mild persistent • Moderate persistent • Severe persistent • Respiratory condition in more than 1 site (not specifically indexed) classified to lower anatomic site • Additional code notes Ch.10
Asthma Severity • Frequency of Daytime Symptoms • Intermittent • Less than or equal to 2 times per week • Mild Persistent • More than 2 times per week • Moderate Persistent • Daily. May restrict physical activity • Severe Persistent • Throughout the day. Frequent severe attacks limiting ability to breathe.
Coding Note: In the Tabular there is an Excludes2 note under category J45 for asthma with chronic obstructive pulmonary disease. By definition, when an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together if the patient has both conditions at the same time.
Diseases of the Digestive SystemK00-K95 Ch. 11 • New subchapters • Diseases of the liver • Terminology changes • Hemorrhage is used when referring to ulcers • Bleeding is used when classifying gastritis, duodenitis, diverticulosis, and diverticulitis • K50, Crohn’s disease • Expanded to the fourth, fifth, and sixth character • Specifies the site of the Crohn’s and • If a complication is present
Diseases of Skin and Subcutaneous Tissue L00-L99 • Pressure ulcers • Site, laterality, and severity specified in single code • Severity identified as stage 1–4 • Non-pressure chronic ulcers • Site, laterality, and severity • Important note – category L97 Ch.12
Coding Note: An instructional note appears in the Tabular, under codes L27.0 and L27.1, stating to use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5).
Diseases of Musculoskeletal System & Connective Tissue M00-M99 Ch.13
Definitions • Spontaneous rupture • Occurs when normal force is applied to tissues that are inferred to have less than normal strength • Fragility fracture • Sustained with trauma no more than a fall from a standing height or less occurring under circumstances that would not cause a fracture in a normal healthy bone
Pathologic Fractures • Coding Note:ICD-10-CM has three different categories for pathologic fractures – due to neoplastic disease, due to osteoporosis, and due to other specified disease.
Diseases of the Genitourinary SystemN00-N99 Ch.14 Additional Codes Required
Pregnancy, Childbirth and the Puerperium O00-O9A • 1st Trimester • Less than 14 weeks 0 days • 2nd Trimester • 14 weeks 0 days to less than 28 weeks 0 days • 3rd Trimester • 28 weeks 0 days until delivery Trimester axis of classification rather than episode of care Not all conditions include codes for all three trimesters or is N/A Counted from first day of last menstrual period Ch.15
Pregnancy, Childbirth and the PuerperiumO00-O9A • Codes from this chapter are for use only on maternal records, never on newborn records • Codes from this chapter are for use for conditions related to or aggravated by the pregnancy, childbirth, or by the puerperium (maternal causes or obstetric causes) • Category Z3A – Weeks of Gestation, added to identify specific week of pregnancy