Download ER Dx Coding in ICD-10-CM

Overview of ER Dx Coding in
ICD-10-CM
OrHIMA Fall Conference
October 2014
Speakers
• Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS
•
•
30+ year HIM professional and Leader
Past-President CHIA
– National Director Coding Quality, Education, Systems and
Support
•
National Revenue Cycle – Program Office (Oakland)
The opinions and comments expressed during this
presentation are those of the speaker and not of
Kaiser Permanente.
Disclaimer
• This material is designed and provided to communicate
information about clinical documentation, coding, and
compliance in an educational format and manner. The
author are not providing or offering legal advice, but rather
practical and useful information and tools to achieve
compliant results in the area of clinical documentation,
data quality, and coding.
• Every reasonable effort has been taken to ensure that the
educational information provided is accurate and useful.
Applying best practice solutions and achieving results will
vary in each hospital/facility and clinical situation.
• This is presentation is only a snapshot of some aspect of
ICD-10-CM and should not be considered complete. All
participants are encouraged to carefully review all chapters
and guidelines relating to ICD-10.
Goals/Objectives
• Review some basic OP Dx Coding Guidelines
for ICD-10
• Learn the ICD-10 coding of common ER
diagnosis
• Understand the specifics of documentation
• Practice with case examples
• Q&A
Today: Patient Story
• The clinical documentation should tell the
patients full story
• Paint the true picture
–
use the right brush and color
• If something isn’t documented then the story
is incomplete
• BUT Caution: to capture and report an
incidental finding . . . This goes into the
patient medical profile
Today: Data Integrity
• A wide spectrum of data is collected in
healthcare and must be collected accurately,
completely, and consistently.
• Electronic documentation tools offer many
features that are designed to increase both
the quality and the utility of clinical
documentation, enhancing communication
between all healthcare providers.
• Coded data is an enabler
• Documentation is the source
Today’s Data: National
• In the United States in 2010, there were 100.7 million
outpatient department visits, 128.7 million ED visits, and 51.4
million procedures according to the Centers for Disease
Control and Prevention (CDC) FastStats. That translates to a
lot of outpatients and even more medical and procedural
documentation.
• The most common reasons for ED visits resulting in discharge:
– fever and otitis media (infants and patients aged 1–17 years),
– superficial injury (all age groups except infants)
– open wounds of the head, neck, and trunk (patients aged 1–17
years and adults aged 85+ years)
– nonspecific chest pain (adults aged 45 years and older)
– abdominal pain and back pain (all adult age groups except those
aged 85+ years).
Source: HCUP Report June 2014: Overview of Emergency Department Visits in the United States, 2011
Today’s Data: National
• Among patients younger than 18 years, the most
common reasons for admission to the hospital
after an ED visit were:
– acute bronchitis (infants younger than 1 year)
– asthma (patients aged 1–17 years)
– pneumonia (infants and patients aged 1–17 years).
• For Adults aged 45–84 years
– septicemia (infection in the bloodstream) was the
most frequent reason for admission to the hospital
after an ED visit.
Today: Medical Record Review of
EMT/Paramedic
• Chief Compliant
• Review the patients vital signs at the time of arrival
in the ER
• Check if O2 sats (see if there is a reading before O2
is given) …. WHY?
• Check for a blood glucose reading …. WHY?
• Breathing status: labored; able to speak in complete
sentences …. WHY?
• Is there a description on the mental status
• Level of consciousness
– Alert or confused, lethargic
– Responsiveness
– Coma scale?
Today: Review the Emergency Room
Notes
•
•
•
•
Chief Compliant
EMT documentation
Circumstances of the encounter
Past Medical History
– Problem List
•
•
•
•
Current medical history
Physical exam
Testing (Lab/Radiology/EKG, etc.) and results
Current Medication and those on the administration
record
• Treatment
• Impression
ICD-10
ICD-10 Delay
• “The Secretary of Health and Human
Services may not, prior to October 1,
2015, adopt ICD-10 code sets as the
standard for code sets under section
1173(c) of the Social Security Act (42
U.S.C. 1320d-2(c)) and section
162.1002 of title 45, Code of Federal
Regulations.”
ICD-10 Final Rule with 10/2015 Date
CMS Resources
ICD-10 Delay:
Immediate Next Steps
• Pause, take stock ICD-10 efforts,
and redeploy resources
appropriately
– Review your timeline
• Continue or not . . . your Code Set
Education, Training and
Awareness
– Refresh in 2015
– Practice and more Practice
• Practice with new documentation
and new codes
– Dual Coding
• Time to Understand MS-DRG
shifts: analyze
– Conduct an audit/review
– Analyze the findings
– Recommendation and
documentation targets
• Review physician awareness and
training plan
– Documentation improvement
• CDI: continue focus on
documentation improvement
activities
– ICD-10 Education
– Dx enhancements
• Coding Tip Sheets – prepare &
continue
• IT & systems programming with ICD10 10/2014 start date
– Rework
• Contracts with ICD-10 10/2014 date
may need to be addressed
Background: ICD-10 Development
•
•
•
•
•
•
•
•
•
1990 –Endorsed by World Health Assembly (diagnosis only)
1994 –Release of full ICD-10 by WHO
1999 – WHO adopts ICD-10
2002 (October) –ICD-10 published in 42 languages (including 6
official WHO languages)
– Implementation138 countries for mortality
– 99 countries for morbidity
January 1, 1999 –U.S. implemented for mortality (death certificates)
2000 – 2009 U.S. continued to work on implementation strategies
January 2009 Final Rule with implementation date of 10/2013
– 5 year timeline with 10/1/2013 go-live date
One Year Delay: October 2014
Now another delay: October 2015
Background: ICD-10-CM Developers
• American Academy of
Dermatology
• American Academy of
Neurology
• American Academy of Oral
and Maxillofacial Surgeons
• American Academy of
Orthopedic Surgeons
• American Academy of
Pediatrics
• American College of
Obstetricians and
Gynecologists
•
•
•
•
•
•
American Burn Association
American Diabetes Association
American Nursing Association
American Psychiatric Association
American Urological Association
ANSI Z16.2 Workgroup (Worker’s
Comp)
• National Association of
Children’s Hospitals and Related
Institutions
ICD-10 Benefits & Goals
• Higher-quality data,
which will result in:
– Improved ability to measure
the quality, efficacy, and safety
of patient care
– Increased sensitivity when
refining grouping and
reimbursement methodologies
– Enhanced ability to conduct
public health surveillance
– Greater achievement of the
anticipated benefits from
electronic health record
adoption
– Improvements in Setting health
policy;
– Operational and strategic planning
• Designing health care
delivery systems;
• Monitoring resource
utilization;
• Improving clinical, financial,
and administrative
performance;
• Preventing and detecting
health care fraud and
abuse; and
• Tracking public health and
risks
ICD-10-CM
• 21 chapters and expanded
codes
– Some chapters reorganized,
some conditions put in to
different chapters
• Alphanumeric – first character
is always a letter
• Addition of up to 7 characters
• 7th character code extensions
in some cases
– Injuries
• Initial encounter
• Subsequent encounter
• Sequela
- Obstetrics
- Glaucoma
• Three primary changes
to the code set:
– Location
– Laterality
– Severity
ICD-9-CM vs ICD-10-CM
• ICD-9-CM Diagnosis Codes
ICD-10-CM
•
3-5 digits
3-7 characters
•
1st digit is numeric (except E and V codes)
•
Digits 2-5 are numeric
1st character is always
alphabetic, including I and O
but not U
Characters 2-7 numeric or
alphabetic
•
Always at least 3 digits
Always at least 3 characters
•
Use of decimal after the 3rd digit
Use of decimal after the 3rd character
ICD-10-CM Code Format
Key ICD-10 Coding Conventions and
Guidelines
• Conventions and guidelines are the foundation.
• Documentation is the mortar to the foundation.
• The granularity of ICD-10-CM and ICD-10-PCS is
vastly improved over ICD-9-CM and will enable
greater specificity in identifying health
conditions.
• It also provides better data for measuring and
tracking health care utilization and the quality of
patient care.
ICD-10-CM Guidelines for Coding and
Reporting
• Guidelines have been approved by the four organizations
that make up the four Cooperating Parties for the ICD-10CM: the American Hospital Association (AHA), the
American Health Information Management Association
(AHIMA), CMS, and NCHS (National Center Health
Statistics).
• The instructions and conventions of the classification take
precedence over guidelines.
• These guidelines are based on the coding and sequencing
instructions in the Tabular List and Alphabetic Index of ICD10-CM, but provide additional instruction.
ICD-10-CM Guidelines for Coding and
Reporting (con’t)
• Adherence to these guidelines when assigning ICD-10-CM
diagnosis codes is required under the Health Insurance
Portability and Accountability Act (HIPAA). The diagnosis
codes (Tabular List and Alphabetic Index) have been
adopted under HIPAA for all healthcare settings.
• The importance of consistent, complete documentation in
the medical record cannot be overemphasized. Without
such documentation accurate coding cannot be achieved.
The entire record should be reviewed to determine the
specific reason for the encounter and the conditions
treated.
ICD-10-CM Guidelines for Coding and
Reporting (con’t)
• The term encounter is used for all settings,
including hospital admissions. In the context of
these guidelines, the term provider is used
throughout the guidelines to mean physician or
any qualified health care practitioner who is
legally accountable for establishing the patient’s
diagnosis.
• Only this set of guidelines, approved by the
Cooperating Parties, is official.
Conventions
• NEW AND DIFFERENT
• Excludes Notes
• The ICD-10-CM has two types of excludes notes. Each type of note has a
different definition for use but they are all similar in that they indicate that
codes excluded from each other are independent of each other.
• a. Excludes1
• A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!”
An Excludes1 note indicates that the code excluded should never be used at
the same time as the code above the Excludes1 note. An Excludes1 is used
when two conditions cannot occur together, such as a congenital form versus
an acquired form of the same condition.
• b. Excludes2
• A type 2 Excludes note represents “Not included here”. An excludes2 note
indicates that the condition excluded is not part of the condition represented
by the code, but a patient may have both conditions at the same time. When
an Excludes2 note appears under a code, it is acceptable to use both the code
and the excluded code together, when appropriate.
ICD-10 Guideline Sections
• Section I includes the structure and conventions of the
classification and general guidelines that apply to the
entire classification, and chapter-specific guidelines that
correspond to the chapters as they are arranged in the
classification.
• Section II includes guidelines for selection of principal
diagnosis for non-outpatient settings.
• Section III includes guidelines for reporting additional
diagnoses in non-outpatient settings.
• Section IV is for outpatient coding and reporting.
• It is necessary to review all sections of the guidelines to
fully understand all of the rules and instructions
needed to code properly.
ICD-10 General 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 Alphabetic Index, and then verify the code in the Tabular List. Read
and be guided by instructional notations that appear in both the
Alphabetic Index and the Tabular List.
• It is essential to use both the Alphabetic Index and Tabular List when
locating and assigning a code. The Alphabetic Index does not always
provide the full code. Selection of the full code, including laterality and
any applicable 7th character can only be done in the Tabular List. A dash
(-) at the end of an Alphabetic Index entry indicates that additional
characters are required. Even if a dash is not included at the Alphabetic
Index entry, it is necessary to refer to the Tabular List to verify that no
7th character is required.
ICD-10-CM General Guidelines
(con’t)
• Signs and Symptoms
– Codes that describe signs and symptoms, as
opposed to diagnoses, are acceptable for reporting
purposes when a related definitive diagnosis has
not been established (confirmed) by the provider
• Chapter 18: Symptoms, Signs, and Abnormal
Clinical and Laboratory Findings, Not Elsewhere
Classified (Codes R00.0 - R99)
– contains many codes for symptoms
ICD-10-CM General Guidelines
(con’t)
• Acute and Chronic
– Code both and sequence the acute
(subacute) code first
• If the same condition is described as both
acute (subacute) and chronic, and separate
subentries exist in the Alphabetic Index at the
same indentation level
Documentation needs to reflect the severity
Section IV. Diagnostic Coding and Reporting
Guidelines for Outpatient Services
•
A. Selection of first-listed condition
–
–
•
•
•
•
•
B. Codes from A00. 0 through T88.9, Z00-Z99.
C. Accurate reporting of ICD-10-CM diagnosis codes
D. Codes that describe symptoms and signs
E. Encounters for circumstances other than a disease or injury
F. Level of Detail in Coding
–
–
•
•
•
•
•
•
•
•
•
•
•
1. Outpatient Surgery.
2. Observation Stay
1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters
2. Use of full number of characters required for a code
G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit.
H. Uncertain diagnosis
I. Chronic diseases
J. Code all documented conditions that coexist
K. Patients receiving diagnostic services only .
L. Patients receiving therapeutic services only
M. Patients receiving preoperative evaluations only
N. Ambulatory surgery
O. Routine outpatient prenatal visits
P. Encounters for general medical examinations with abnormal findings
Q. Encounters for routine health screenings
ICD-10-CM
• The conventions, general guidelines and
chapter-specific guidelines are applicable to all
health care settings unless otherwise indicated.
– In addition to general coding guidelines, there are
guidelines for specific diagnoses and/or conditions in
the classification.
• Unless otherwise indicated, these guidelines
apply to all health care settings.
• The conventions and instructions of the
classification take precedence over guidelines.
Documentation
• ICD-10-CM
• Additional specificity in these key areas to
meet specificity in coding and particularly
in ICD-10 (check your queries):
– Cause of disease or disorder
– Severity
– Acute or chronic
– With or without crisis
– Site
– Etiology
– Secondary disease process
Documentation Basics (con’t)
• Few basics:
– The medical record can be compared to a story book of the
patient.
– Does the documentation paint the complete picture of the
patient?
– Any documentation – the good, the bad and the ugly does affect
ALL: The hospital, the provider, the payer, and specifically, the
patient.
– A basic understanding of documentation requirements is critical.
• Up and Down arrows?
– Do not code on the basis of up and down arrows
– Variable interpretations
– Indicating change
– Query provider regarding meaning
– Applies for both inpatient and outpatient admissions
35
Chapter 1
• Chapter I: Certain Infectious and Parasitic
Diseases (A00-B99)
• Includes diseases generally recognized as
communicable or transmissible.
• This chapter uses additional ….codes to identify
resistance to antimicrobial drugs
• Use additional code to identify resistance to
antimicrobial drugs (Z16)
• There is a new section called ….infections with a
predominantly sexual mode of transmission A50A64
Diagnosis: Sepsis
• Document whether the
sepsis is infectious or
non-infectious
• Include information
regarding any cause and
effective relationship or
another condition or
problem
• Document if “severe
sepsis” is present.
• Document if there is
“organ dysfunction”
present
• State the specific type
of organ that is failing
or has failed ie
respiratory failure,
renal failure, etc.
• Document whether
“septic shock” is
present
Enterovirus
• The following ICD-10-CM Index entries contain back-references
to ICD-10-CM B34.1:
–
–
–
–
–
–
–
Coxsackie (virus) (infection) B34.1
Disease, diseased - see also Syndrome
coxsackie (virus) B34.1
echovirus NEC B34.1
enteroviral, enterovirus NEC B34.1
nonarthropod-borne NOS (viral) B34.9
enterovirus NEC B34.1
• Infection, infected, infective (opportunistic) B99.9
– enterovirus B34.1
– unspecified nature or site B34.1
•
•
•
ICD-10-CM B34.1 is grouped within Diagnostic Related Group(s) (MS-DRG v30.0):
865 Viral illness with mcc
866 Viral illness without mcc
EV-D68: The virus is related to the rhinovirus, which is responsible for the common cold, and causes symptoms similar
to a cold, including runny nose and coughing. But those symptoms can rapidly escalate into more serious symptoms,
such as wheezing, low blood oxygen, and difficulty breathing. The virus can be particularly dangerous for children who
have asthma or other respiratory conditions.
Chapter 2
• Chapter II: Neoplasms (C00-D49)
• Chapter 2 of the ICD-10-CM contains the codes
for most benign and all malignant neoplasms.
Certain benign neoplasms, such as prostatic
adenomas, may be found in the specific body
system chapters. To properly code a neoplasm it
is necessary to determine from the record if the
neoplasm is benign, in-situ, malignant, or of
uncertain histologic behavior. If malignant, any
secondary (metastatic) sites should also be
determined.
Diagnosis: Neoplasm
• Document the specific site of
the neoplasm.
• Document whether the
neoplasm is benign, primary,
secondary, In situ, uncertain
or unknown.
– Always include ALL secondary
neoplasms
• For neoplasms of the lung,
liver and intestines,
document the specific
anatomic location, (ie
quadrant, lobe, section).
– Lower-Outer Quadrant of
Female Breast
• Laterality is needed for paired
organs (ie ovary).
• Document the gender
(male/female) if needed in the
classification ie breast neoplasm
• Complications of the neoplasm
should be documented (ie
anemia).
• Documentation should identify
if the complication is due to any
chemo/radiotherapy treatment.
Chapter 3
• Chapter III: Diseases of the Blood and BloodForming Organs and Certain Disorders Involving
the Immune Mechanism (D50-D89)
• Reserved for future guideline expansion
•
•
•
•
Anemia Groups:
Deficiency anemias
Hemolytic anemias
Aplastic anemia and other bone marrow failure
syndromes
ICD-10 Documentation: Anemia
• Documentation of anemia
should specify type of
anemia: nutritional,
hemolytic, aplastic or due to
blood loss
• Include documentation if the
anemia is due to nutrition or
minerals deficits; resulting in
a nutritional anemia
• Include documentation of
whether the hemolytic
anemia is hereditary,
acquired, enzyme disorder,
autoimmune, or nonautoimmune
• List the name and purpose of any
medications causing the anemia
• Link any laboratory findings to a
related diagnosis (if appropriate)
• Document whether the anemia is
related to chemo or radiotherapy
treatments
• Document if the anemia is caused
by a neoplasm (primary and/or
secondary)
• Document any cause –and-effect
relationship between the
intervention and the blood or
immune disorder
Does your Physician Query Process include this specificity?
Hemolytic Anemia
• Due to “Enzyme Disorders”:
– Glucose-6-phosphate
dehydrogenase
– Glutathion metabolism
– Glycolytic enzymes
– Due to nucleotide
metabolism
• Thalassemias:
– Alpha thalassemia
– Beta thalassemia
– Delta-beta thalassemia
– Thalassemia minor
– Hereditary persistence of
fetal hemoglobin
– Hemoglobin E-beta
thalassemia
•
•
•
Sickle Cell Disorders is present
– Specify if “With or Without
Crisis”
Sickle Cell thalassemia
– Specify if “With or Without
Crisis”
Include documentation of whether
the HEMOLYTIC ANEMIA is:
•
•
•
•
•
•
•
Hereditary
Acquired
enzyme disorder
Autoimmune
Non-autoimmune
Document the disorder/condition
that is causing the anemia
Document any associated
diagnoses/conditions
Guideline Change: Anemia
• Coding and Sequencing of
Complications
– Anemia
• Associated with Malignancyadmission for management of
anemia associated with malignancy
and treatment is only for the
anemia
• Code for malignancy sequenced
first
• Code for anemia, such as D63.0
– Anemia in Neoplastic Disease
• Sequencing is completely
different in ICD-10-CM
– Changes the MS-DRG
• Associated with
Chemotherapy,
Immunotherapy or Radiation
Therapy-treatment only for
anemia
– Anemia code first, neoplasm
code also
– Additional codes
• Adverse effect of chemotherapy
or immunotherapy- also code
– T45.1X5- adverse effects of
antineoplastic and
immunosuppressive drugs
• Adverse effect of radiation
therapy-also code
– Y84.2 – radiological procedure
and therapy as the cause of
abnormal reaction of the
patient, or of later
complication, without mention
of misadventure at the time of
the procedure
Chapter 4
• Chapter IV: Endocrine, Nutritional and
Metabolic Diseases (E00-E89)
• Diabetes mellitus
• The diabetes mellitus codes are combination
codes that include the type of diabetes
mellitus, the body system affected, and the
complications affecting that body system.
Diagnosis: Diabetes
• When there are
manifestations and/or
complications; document
additional details:
–
–
–
–
–
–
–
Arthropathy
Gangrene
Hyperglycemia
Site of ulcer
Severity of retinopathy
Stage of the CKD
Whether with or without
macular edema
• Documentation should
reflect the “type”
• Documentation should
include any
manifestations or
complications of diabetes
• Documentation should
include if “hypoglycemia”
or “hyperglycemia”
• If hypoglycemia is
present; document
whether there is a coma
present
Documentation & Coding
Diagnosis: Obesity
• ICD-9-CM Key aspects
of documentation for
coding:
• Overweight, obesity
and other
hyperalimentation
•
•
Overweight and
obesity
Body Mass Index
(BMI)
• ICD-10-CM Key aspects
of documentation for
coding:
• Overweight and obesity
•
•
•
•
•
•
•
Obesity due to excess
calories
Drug-induced obesity
Morbid (severe) obesity
with alveolar
hypoventilation
Overweight
Other
Unspecified
Body Mass Index (BMI)
47
Documentation: ICD-10 Obesity
• Document whether the
patient is overweight
or Obese
• Specify if the patient
has “morbid obesity”
and if due to excess
calories
• Document the
underlying or causal
condition if known (ie
adverse effect of drug)
• With obesity,
document if
hypoventilation
syndrome is
present
• Also document
the Body Mass
Index (BMI) if
known
Diagnosis: Malnutrition (ICD-9)
• Hospital inpatient MS-DRG
MCC Secondary DX, if
further supported by the
documentation and a plan
of care:
• ICD-9-CM code 260—
kwashiorkor
• ICD-9-CM code 261—
nutritional marasmus
• ICD-9-CM code 262—
other, severe protein
calorie malnutrition
•
The malnutrition diagnoses that
qualify as CC Secondary DXs, if
further supported by the
documentation or in a plan of
care, include these:
• ICD-9-CM code 263.0—
malnutrition of a moderate
degree
• ICD-9-CM code 263.1—
malnutrition of a mild degree
• ICD-9-CM code 263.2—
arrested development
following protein-calorie
malnutrition
• ICD-9-CM code 263.8 –other
protein-calorie malnutrition
• ICD-9-CM code 263.9—
unspecified protein-calorie
malnutrition
49
Documentation & Coding Diagnosis:
Malnutrition
•ICD-9-CM
•260 Kwashiorkor
•261 Nutritional marasmus
•262 Other, Severe protein calorie
malnutrition
•263.0 Malnutrition of a moderate
degree
•263.1 Malnutrition of a mild degree
•263.2 Arrested development
following protein-calorie
malnutrition
•263.8 Other protein-calorie
malnutrition
•263.9 Unspecified protein-calorie
malnutrition
•ICD-10-CM
Type and Degree
•E40 Kwashiorkor
•E41 Nutritional marasmus
•E42 Marasmic kwashiorkor
•E43 Unspecified severe protein-calorie
malnutrition
•E44 Protein-calorie malnutrition of moderate
and mild degree
•
E44.0 Moderate protein-calorie
malnutrition
•
E44.1 Mild protein-calorie
malnutrition
•E45 Retarded development following proteincalorie malnutrition
•E46 Unspecified protein-calorie malnutrition
Mild, Moderate or Severe
50
Diagnosis: Dehydration
•ICD-9-CM
•Dehydration
(cachexia) 276.51
•with
•hypernatremia 276.0
•hyponatremia 276.1
•newborn 775.5
•ICD-10-CM
•Dehydration E86.0
•hypertonic E87.0
•hypotonic E87.1
•newborn P74.1
51
Chapter 5
• Chapter V: Mental, Behavioral and
Neurodevelopmental Disorders (F01-F99)
• Increased need for documentation of etiology
of disease is critical.
• The relationship between two or more
diagnoses (or associated process) cannot be
assumed and provider documentation must
clearly state causal relationship of conditions.
Documentation: Depression
• “Major Depressive Disorder” should specify
or include the following information:
– Single episode vs recurrent
– Mild, moderate, or severe
– With or without psychotic features
– In partial or full remission
Documentation: Anxiety
• Document whether is • There are many codes
to describe the
anxiety if “phobic” or
patients life situation;
“other”
ie problems with life
• Document whether
cycle transitions
the anxiety is
• There are Chapter 18
generalized, a panic
codes to describe
signs and symptoms;
disorder (ie panic
attack), mixed anxiety nervousness,
or anxiety unspecified restlessness and
agitation, worries
Alcohol, Tobacco & Substance Use
• Identify the specific type of drug
or substance
• Describe the frequency of usage
as:
–
–
–
–
Use
Abuse
Dependence
In remission
• Describe mode of nicotine use as
cigarettes, chewing tobacco, pipe,
and/or gum
• Specify intoxication/withdrawal
as “Uncomplicated” or “With
delirium”
• Document any withdrawal
symptoms
• Document any associated
diagnoses/conditions
• List the blood alcohol level, if
available
• State “no related complications,”
when applicable
• Document any related mood
disorder
Chapter 6
• Chapter VI: Diseases of the Nervous System (G00-G99)
•
Additional codes required for:
Alzheimer’s disease with delirium
Alzheimer’s with dementia with behavioral disturbance
Alzheimer’s with dementia without behavioral disturbance
•
•
Dominant/nondominant side
Codes from category G81, Hemiplegia and hemiparesis, and subcategories, G83.1,
Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3,
Monoplegia, unspecified, identify whether the dominant or nondominant side is
affected. Should the affected side be documented, but not specified as dominant
or nondominant, and the classification system does not indicate a default, code
selection is as follows:
–
–
–
For ambidextrous patients, the default should be dominant.
If the left side is affected, the default is non-dominant.
If the right side is affected, the default is dominant.
Diagnosis: Alzheimer’s
• Document whether the
Alzheimer’s disease is with early
onset or with late onset
• Document if Delirium, is present
• Document if there is Dementia
without behavioral disturbance
• Document Alzheimer’s disease
with delirium
• Document Alzheimer’s with
dementia with behavioral
disturbance
• Document Alzheimer’s with
dementia without behavioral
disturbance
• Document Alzheimer's
dementia w delirium
• Specify the following if
applicable:
– Alzheimer's dementia w
delusions
– Alzheimer's dementia w
depressed mood
– Alzheimer's dementia with
delirium
– Alzheimer's dementia with
delusions
– Alzheimer's dementia with
depressed mood
EVERY 67 seconds someone in the United States develops this disease!
Diagnosis: Parkinson Disease
• Document when
“Dementia” is associated
with Parkinson's Disease
• Document when there
are “behavioral
disturbance” associated
with Parkinson Disease
• Document “Paralysis
agitans” if present
• Identify drug induced
Secondary
Parkinsonism or
external agent(s)
Approximately 60,000 Americans are diagnosed with Parkinson's disease each
year, and this number does not reflect the thousands of cases that go
undetected.
An estimated seven to 10 million people worldwide are living with Parkinson's
disease.
Chapter 8
• Chapter VIII: Diseases of the Ear and Mastoid
Process (H60-H95)
• Reserved for future guideline expansion
• Increased specificity for laterality
• Increased specificity for Otitis Externa
• Type must be identified in ICD-10
Documentation: Otitis Media
•
•
Document laterality
– right, left or bilateral
Include documentation of the
severity:
– Acute/subacute
– Acute recurrent
– Chronic
• Document the specific type:
–
–
–
–
–
–
–
Serous
Sanguineous
Suppurative
Allergic
Mucoid
Tubotympanic
Atticoantral
• Document any associated infectious
agent: strep, staph, Scarlett fever,
influenza, Measles or Mumps
•
Document whether tympanic
membrane rupture is present
– Without or without Spontaneous
rupture
•
Document any secondary cause for
otitis ie., tobacco smoke
Chapter 9
• Chapter IX: Diseases of the Circulatory
System (I00-I99)
• Hypertension = I10
• Heart Failure
• AMI
• Cardiac Arrest
• CVA
Hypertension
•
•
•
•
No Hypertension Table in ICD-10-CM
Coding is I10 = Hypertension
–No distinction of benign, malignant, unspecified
Same specific documentation required for
Hypertension with Heart Disease
• Assumed relationship between Hypertensive and
Chronic Kidney Disease
• Combination of Hypertensive Heart and Chronic
Kidney Disease
• Elevated Blood Pressure
– ICD-9-CM 796.2
– ICD-10-CM R03.0
Coding Diagnosis: Heart Failure
•ICD-9-CM Key aspects of
documentation for coding:
•
Failure, heart (acute) (sudden) 428.9
•
congestive (compensated) (decompensated)
(see also Failure, heart) 428.0
with rheumatic fever (conditions
classifiable to 390)
active 391.8
inactive or quiescent (with
chorea) 398.91
fetus or newborn 779.89
hypertensive (see also Hypertension,
heart) 402.91
with renal disease (see
also
Hypertension, cardiorenal) 404.91
with renal failure 404.93
benign 402.11
malignant 402.01
rheumatic (chronic) (inactive) (with
chorea) 398.91
active or acute 391.8
with chorea (Sydenham's)
392.0
•
•
•
•
•
•
•
•
•
•
•
•
•ICD-10-CM Key aspects of
coding:
•
•
Failure, heart
congestive(compensated)
(decompensated) I50.9
with rheumatic fever(conditions
in I00)
active I01.8
inactive or
quiescent(with chorea) I09.81
newborn P29.0
rheumatic(chronic) (inactive) (with
chorea) I09.81
active or acute I01.8
with chorea I02.0
•
•
•
•
•
•
•
64
Documentation: Heart Failure
• Acuity
– Acute
– Chronic
– Acute on Chronic
• Type
– Diastolic
– Systolic
– Combined systolic and
diastolic
• Include whether due to or
associated with
– Cardiac or other surgery
– Hypertension
– Valvular disease
– Rheumatic heart disease
• Endocarditis (valvitis)
• Pericarditis
• Myocarditis
Shortness of breath and/or respiratory distress are
common symptoms.
Chapter 18
• Chapter XVIII: Symptoms, signs, and abnormal clinical and
laboratory findings, not elsewhere classified (R00-R99)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Includes:
Symptoms and signs involving the circulatory and respiratory systems
Symptoms and signs involving the digestive system and abdomen
Symptoms and signs involving the skin and subcutaneous tissue
Symptoms and signs involving the nervous and musculoskeletal systems
Symptoms and signs involving the urinary system
Symptoms and signs involving cognition, perception, emotional state and
behavior
Symptoms and signs involving speech and voice
General symptoms and signs
Abnormal findings on examination of blood, without diagnosis
Abnormal findings on examination of urine, without diagnosis
Abnormal findings on examination of other body fluids, substances and
tissues, without diagnosis
Abnormal findings on diagnostic imaging and in function studies, without
diagnosis
Abnormal tumor markers
Ill-defined and unknown cause of mortality
Documentation & Coding: Cough
•ICD-9-CM
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cough 786.2
with hemorrhage (see also Hemoptysis)
786.39
affected 786.2
bronchial 786.2
with grippe or influenza (see also
Influenza) 487.1
chronic 786.2
epidemic 786.2
functional 306.1
hemorrhagic 786.39
hysterical 300.11
laryngeal, spasmodic 786.2
nervous 786.2
psychogenic 306.1
smokers' 491.0
tea tasters' 112.89
•ICD-10-CM
•
•
•
•
•
•
•
•
•
•
67
Cough(affected) (chronic) (epidemic)
(nervous) R05
with hemorrhage- see Hemoptysis
bronchial R05
with grippe or influenza- see
Influenza, with, respiratory
manifestations NEC
functional F45.8
hysterical F45.8
laryngeal, spasmodic R05
psychogenic F45.8
smokers' J41.0
tea taster's B49
Documentation & Coding: Chest Pain
•ICD-9-CM
•Alphabetic Index
•chest (central) 786.50
•atypical 786.59
•midsternal 786.51
•musculoskeletal 786.59
•noncardiac 786.59
•substernal 786.51
•wall (anterior) 786.52
•ICD-10-CM
•chest(central) R07.9
•anterior wall R07.89
•atypical R07.89
•ischemic I20.9
•musculoskeletal R07.89
•non-cardiac R07.89
•on breathing R07.1
•pleurodynia R07.81
•precordial R07.2
•wall(anterior) R07.89
68
Documentation & Coding: Fever
•ICD-9-CM (long list – ck your
codebook)
•Fever 780.60
•with chills 780.60
•in malarial regions (see also Malaria)
084.6
•abortus NEC 023.9
•aden 061
•African tick-borne 087.1
•American
•mountain tick 066.1
•spotted 082.0
•and ague (see also Malaria) 084.6
•aphthous 078.4
•arbovirus hemorrhagic 065.9
•Assam 085.0
•Australian A or Q 083.0
•...
•ICD-10-CM (long list of diagnosis)
•Fever (inanition) (of unknown origin) (persistent)
(with chills) (with rigor) R50.9
•abortus A23.1
•Aden(dengue) A90
•African tick-borne A68.1
•American
•mountain(tick) A93.2
•spotted A77.0
•aphthous B08.8
•arbovirus, arboviral A94
•hemorrhagic A94
•specified NEC A93.8
•Argentinian hemorrhagic A96.0
•Assam B55.0
•Australian Q A78
•Bangkok hemorrhagic A91
69
Injury ICD-10
Details of the injury
Where were they” Home, SNF, Work,
Restaurant, park, etc.
What were they doing? Pedestrian, riding a bike,
driving a vehicle (car, bus, heavy equipment) or
a passenger
Case Scenario
• A 54 year old female patient was seen in the ER with moderate
weakness and fatigue. She has a history of ovarian carcinoma and
had surgery 3 months ago to remove her Tubes and Ovaries.
• She’s been on chemotherapy for the past 6 weeks and has 2 weeks
more of treatment and had been doing well until 1 week ago. She
has also complained of hip pain off and on over the past 4 weeks.
• During the past week she has been feeling weakness and fatigued.
OP Lab (CBC) work revealed the patient to be anemic and needing
blood transfusion. A blood transfusion of 2 units of PRBC were
transfused on the first hour, followed by an additional 1 unit over a 3
hour period. Her condition improved and she was discharged from
the hospital. Impression: “Anemia due to chemotherapy and history
of ovarian carcinoma”.
• What is documented and can be coded? (correct sequence):
________________________________
Case Scenario
• A 10 year old patient came to the ER with his parents
complaining of ear pain and fever.
• Examination found the patient to have a 100.8 fever and
the right eardrum was red and inflamed. The left ear was
normal. The family history revealed that a relative had been
visiting in the home for the past 3 weeks and they were
smoking.
• Final impression in the medical record was “fever due to
acute Otitis media right ear with 2nd hand smoke exposure”.
• What is documented and can be coded? (correct
sequence): ________________________________
AHA Coding Clinic
• AHA Central Office on ICD-10-CM/PCS is NOT
reverting back to accepting or publishing
questions on ICD‐9‐CM • Coding Clinic will focus
time and attention on
• ICD‐10‐CM and ICD‐10‐PCS to better address
issues in advance of implementation and ensure
a smoother ICD‐10 transition.
• Your HIM Coding Department is great resource
regarding “Coding Clinic”
– Subscription (paper or online)
Summary
•
•
•
•
•
Know the coding convention
Understand the coding guidelines
Apply the chapter specific guidelines
Review each ICD-10-CM chapter closely
Practice coding; repeat and repeat
– Dual coding
• Watch for documentation changes with ICD-10
– New terminology and specificity
• Engage, enhance and educate
• ADVOCATE!
Questions?
Thank you
References/Resources
• ICD-10-CM Draft Codebook 2014
• ICD-10-CM Official Guidelines 2014
– ICD-10-CM Reporting and Coding Guidelines
• 3M Encoder
• Bielby, Judy A. "Coding Neoplasms in ICD-10CM." Journal of AHIMA 82, no.10 (October
2011): 72-74.
• MedicineNet.com