Understanding ICD-10 Coding Concepts

ICD-10 Coding Concepts By: Anita Perez, CPC March 12,2014

October 1, 2014 Are you ready?!?

ICD-9-CM is Outdated 30 years old- technology has changed Many disease categories are full Codes are not descriptive enough

Why the need for a new coding system? Reimbursement- enhance accurate payment for service rendered Quality- facilitate evaluation of medical processes and outcomes Flexibility- to quickly incorporate emerging diagnoses and procedure Exact-ability to identify diagnoses and procedures precisely

Major Modifications Added trimesters to obstetrical codes Revised diabetes mellitus codes Expanded codes Added code extensions for injuries and external causes of injuries

Structurally Different Digit 1-3 will now refer to the category Digit 1 is always alphanumeric Digit 2 is always numeric Digit 3 can be either alphabetic or numeric Digit 4-6 will cover clinical details such as severity, etiology, and anatomic site (among others) and are either alphabetic or numeric Digit 7 will serve as an extension when necessary and will be either alphabetic or numeric

ICD-10-CM/PCS will enhance the quality of data: Tracking public health conditions (complications, anatomical location) Improved data for epidemiological research (severity of illness, co-morbidities) Measuring outcomes and care provided to patients Making clinical decisions Identifying fraud and abuse Designing payment systems/processing claims

ICD-9 & ICD-10 Comparison ICD-9-CM ICD-10 code sets Procedure 71924 codes Diagnosis 69823 codes NEW Procedure 3824 codes Diagnosis 14025 codes OLD Diagnosis Structure 3-7 characters Character 1 is alpha Character 2 is numeric Characters 3-7 can be alpha or numeric Procedure Structure ICD-10-PCS has 7 characters Each can be either alpha or numeric Number 0-9; letters A-H,J-N,P-Z Diagnosis Structure 3-5 Characters First character is numeric or alpha Characters 2-5 are numeric Procedure Structure 3-4 characters All characters are numeric All codes have at least 3 characters

ICD-10-CM Chapters 1- Certain Infectious and Parasitic Diseases 2- Neoplasms 3-Diseases of the Blood and Blood-forming Organs and certain Disorders Involving the Immune Mechanism 4-Endocrine, Nutritional and Metabolic Disorders 5- Mental, Behavioral and Neurodevelopmental Disorders 6- Diseases of the Nervous System 7- Disease of the Eye and Adnexa 8- Diseases of the Ear and Mastoid Process 9- Diseases of the Circulatory System 10- Diseases of the Respiratory System 11- Diseases of the Digestive System 12- Diseases of the Skin and Subcutaneous Tissue 13- Diseases of the Musculoskeletal System and Connective Tissue 14- Diseases of the Genitourinary System 15- Pregnancy, Childbirth and the Puerperium 16-Certain Conditions Originating in the Perinatal Period 17- Congenital Malformations, Deformations and Chromosomal Abnormalities 18- Symptoms Signs and Abnormal Clinical and Laboratory Findings, not elsewhere classified 19- Injury, Poisoning and Certain other Consequences of External Causes 20- External Causes of Morbidity 21- Factors Influencing Health Status and Contact with Health Services

Alphabetic Index The Alphabetic Index is divided into sections and is organized by main terms: Index of Diseases and Injury Index of External Causes of Injury Table of Neoplasms Table of Drugs and Chemicals

ICD 10-CM Definitions Combination Code- the term represents a single code used to classify: two diagnoses, either a diagnosis with an associated sign or symptom or a diagnosis with an associated complication. Granularity- as applied to ICD-10, the term refers to the level of hierarchy and the amount of information the increased hierarchy provides to the diagnostic description. Laterality- ICD-10-CM code descriptions include right or left designation. The right side is usually character 1, and the left side character 2. In those cases where a bilateral code is provided, the bilateral code is usually 3. Example: H02.851= Elephantiasis of right upper eyelid H02.852= Elephantiasis of left upper eyelid H02.859= Elephantiasis of unspecified eye, unspecified eyelid

ICD-10-CM Definitions Contd Morbidity- The term refers to the disease rate or number of cases of a particular disease in a given age range, gender, occupation, or other relevant population based grouping Mortality- The term refers to the death rate reflected by the population in a given region, age range, or other relevant statistical grouping. Principal or First-listed Diagnosis- The code sequenced first on a medical record defines the primary reason for the encounter as determined at the end of the encounter. Rubric- The term refers to a group of similar conditions, which in ICD-10-CM denotes either a three-character category or a four-character subcategory

Four Character Categories The four character categories further define the site, etiology, and manifestation or state of the disease or condition. Example: C15 Malignant neoplasm of esophagus C15.3 Malignant neoplasm of upper third of esophagus C15.4 Malignant neoplasm of middle third of esophagus C15.5 Malignant neoplasm of lower third of esophagus C15.8 Malignant neoplasm of overlapping sites of esophagus C15.9 Malignant neoplasm of esophagus, unspecified

Five-Six Character Sub-classifications A fifth or sixth character sub-classifications represents the most accurate level of specificity. Example: J01.8 Influenza due to other identified influenza virus with other manifestations J01.81 Influenza due to other identified influenza virus with encephalopathy J01.82 Influenza due to other identified influenza virus with myocarditis J01.83 Influenza due to other identified influenza virus with otitis media J10.89 Influenza due to other identified influenza virus with other manifestations Example: M88.811 Osteitis deformans of right shoulder

Seventh Character Extension Certain ICD-10 categories have applicable seven characters. The applicable seventh character is required for all codes in that category, or as the notes in the Tabular list instruct. The seventh character must always be the seventh character in the data field. If a code requires a seventh character and is not six characters, a placeholder X must be used to fill in the empty characters.

Seventh Character Example T50.B96A Underdosing of other viral vaccines, initial encounter T50.B96D Underdosing of other viral vaccines, subsequent encounter T50.B96S Underdosing of other viral vaccines, sequela T15.12XS Foreign body in the conjunctival sac, left eye, sequela

General Coding Guidelines Locating a code in the ICD-10-CM- To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Index, and then verify the code in the tabular listing. Level of Detail in Coding- Diagnosis codes are to be used and reported at there highest number of characters available. Code or Codes from A00.0 through T88.9, Z00-Z99.8- The appropriate code or codes from A00.00 through T88.9, Z00- Z99.8 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reasons for the encounter/visit.

General Coding Guidelines Signs and Symptoms- Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a definitive diagnosis has not be confirmed by the provider. Conditions that are an Integral Part of a Disease Process- Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Conditions that are Not an Integral Part of a Disease Process- Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

General Coding Guidelines Multiple Coding for a Single Condition- In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. Acute and Chronic Conditions- If the same condition is describes as both acute and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute code first Combination Code- A combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) or A diagnosis with an associated complication *Assign the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. *Combination codes can actually help simplify the coding process by spelling out the correct clinical condition of the patient without the use of multiple codes.

General Coding Guidelines Complications of Surgery or Other Medical Care- When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the first-listed code. Syndromes- Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Reporting Same Diagnosis Code More than Once- Each unique ICD-10 diagnosis code may be reported only once for an encounter. Impending or Threatened Condition- Code any condition described at the time of discharge as impending or threatened as follows: If it did occur, code as confirmed diagnosis If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for impending or threatened and also reference main term entries for Impending and for Threatened If the subterms are listed, assign the given code If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened

General Coding Guidelines Selection of Secondary Diagnosis- Other diagnosis is an additional code that affects the patient care in terms of requiring clinical evaluation or therapeutic treatment or diagnostic procedures or extended length of hospital stay or increased nursing care and/or monitoring. Symptom Codes with Confirmed Diagnosis- Two Rules: 1. A symptom code should not be used with a confirmed diagnosis if the symptom is integral to the diagnosis. 2. A symptom code should be used with a confirmed diagnosis if the symptom is not always associated with that diagnosis, such as the use of various signs and symptoms associated with complex syndromes. Principal or First-listed Diagnosis- 1. A sign or symptom code is not to be used as a principal diagnosis when a definitive diagnosis for the sign or symptom has been established. 2. A sign or symptom code is to be used as principal diagnosis if no definitive diagnosis is established at the time of coding. 3. If anticipated treatment is not carried out due to unforeseen circumstances, the principal diagnosis code remains the condition or diagnosis the provider planned to treat. 4. When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis.

General Coding Guidelines Previous Conditions- Some physicians include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous visits that have no bearing on the current treatment. Such conditions are not to be reported and are coded only if required by the hospital or physician office policy. Abnormal Test Findings- Abnormal test findings are NOT coded or reported unless the physician indicated their clinical significance. Late Effects (Sequela)- A sequela is residual effect (condition produced) after the acute phase of an illness or injury has been terminated. There is no time limit on when a sequela code can be used. Coding a sequela generally requires two codes in the following order: The condition or nature of the sequela sequenced first. The sequela code is sequenced second.

QUESTIONS?

References AAPC. (2014). ICD-10-CM General Code Set Manual. Salt Lake City: AAPC. Brooks, P., Pickett, D., Leon-Chisen, N., & Bowman, S. (2012, April 1). ICD-10 Overview. Retrieved March 3, 2014, from Centers for Medicare & Medicaid Services: https://www.cms.gov/Medicare/Medicare- Contracting/ContractorLearningResources/downloads/ICD- 10_Overview_Presentation.pdf CDC/National Center for Health Statistics. (2013, November 5). Internation Classification of Disease, (ICD-10-CM/PCS) Transistion. Retrieved March 3, 2014, from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm Salmen, A. (2013, January 9). Top 10 Differences Between ICD-9 & ICD-10. Retrieved March 3, 2014, from HealthWorks Collective: http://healthworkscollective.com/andy-salmen/75121/top- differences-between-icd-9-cm-icd-10-cm