Download Official Coding Guidelines - Health Information Management

Official Coding Guidelines
ICD-10-CM and PCS
Presented by:
MONICA LEISCH, RHIA, CCS
AHIMA Approved ICD-10 Trainer
Director of Compliance / HIM Services
Healthcare Cost Solutions, Inc.
[email protected]
May, 2013
Disclaimer
• This material is designed and provided to communicate
information about clinical documentation, coding and
compliance in an educational format and manner.
• The author is 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 is accurate and useful.
• Applying best practice solutions and achieving results
will vary in each hospital or facility’s situation.
Introduction
ICD-10-CM Official Guidelines for
Coding and Reporting 2013 for
Diagnoses and Procedures
Guidelines Defined
The guidelines are a set of rules that have been
developed to accompany and complement the
official conventions and instructions provided
within the ICD itself.
• Developed by The Centers for Medicare and
Medicaid Services (CMS) and the National Center for
Health Statistics (NCHS)
• Based on the coding and sequencing instructions in
the Tabular List and Alphabetic Index
• Required under the Health Insurance Portability and
Accountability Act (HIPAA)
CM vs PCS
• ICD-10-CM (Clinical Modification)
–
–
–
–
Morbidity classification developed by the US
Classifies diagnoses and reason for visit
Applicable to all health care settings
Based on ICD-10 classification system published by
WHO
• ICD-10-PCS (Procedural Coding System)
–
–
–
–
Procedure classification published by the US
Classifies all procedures
Applicable to inpatient care setting only
No such system in the ICD-10 published by WHO
Cooperating Parties
The guidelines have been approved by the four
organizations that make up the Cooperating
Parties:
• American Hospital Association (AHA)
• American Health Information Management
Association (AHIMA)
• The Federal Government represented by Centers
for Medicare and Medicaid Services (CMS) and
the National Center for Health Statistics (NCHS)
Hierarchy
In order of Precedence:
1. Coding Conventions of the ICD Classification
2. Official Coding Guidelines
3. All other, including Coding Clinic, LCDs, etc.
CM Organization
CM guidelines are organized into sections:
• Section I includes the structure and conventions
of the classification and general guidelines
• 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
Excludes Notes
ICD-10-CM
ICD-10-CM has two types of excludes notes.
a. Excludes 1
• 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. Excludes 2
• 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.
Impending or Threatened Condition
ICD-10-CM
Impending or Threatened Condition listed at time
of Discharge:
• If confirmed, code as confirmed diagnosis.
• If it did not occur, check Alphabetic Index for
– subentry for the term impending or threatened and use
that code if listed.
– If no subentry, code the existing underlying condition(s)
and not the condition described as impending or
threatened
Laterality
ICD-10-CM
Laterality
• For bilateral sites, the final character of the
codes in the ICD-10-CM indicates laterality.
• An unspecified side code is also provided
should the side not be identified in the medical
record.
• If no bilateral code is provided and the
condition is bilateral, assign separate codes
for both the left and right side.
Late Effects/Sequela
ICD-10-CM
Late Effects (Sequela)
• A late effect is the residual effect (condition produced) after the
acute phase of an illness or injury has terminated. There is no
time limit on when a late effect code can be used. The residual
may be apparent early, such as in cerebral infarction, or it may
occur months or years later, such as that due to a previous injury.
Coding of late effects generally requires two codes sequenced in
the following order: The condition or nature of the late effect is
sequenced first. The late effect code is sequenced second.
• An exception to the above guidelines are those instances where
the code for late effect is followed by a manifestation code
identified in the Tabular List and title, or the late effect code has
been expanded (at the fourth, fifth or sixth character levels) to
include the manifestation(s). The code for the acute phase of an
illness or injury that led to the late effect is never used with a code
for the late effect.
BMI & Ulcers
ICD-10-CM
Documentation for BMI (Body Mass Index) and
Ulcers for coding:
• Codes may be assigned from clinician, (non
physician) documentation
• The provider responsible for the patient’s care
must provide coordinating diagnosis
• When conflicting documentation is present,
query the responsible provider
• BMI codes should only be secondary diagnosis
codes
Signs, Symptoms
ICD-10-CM
Signs and symptoms
• Codes that describe symptoms and signs, as
opposed to diagnoses, are acceptable for reporting
purposes when a related definitive diagnosis has
not been established (confirmed) by the provider.
• Chapter 18 of ICD-10-CM, Symptoms, Signs, and
Abnormal Clinical and Laboratory Findings, Not
Elsewhere Classified (codes R00.0 - R99) contains
many, but not all codes for symptoms.
Complication of Care
ICD-10-CM
Complications of care
• As with all procedural or post-procedural
complications, code assignment is based on the
provider’s documentation of the relationship between
the condition and the procedure.
• Includes pain, and transplant complications, and
information that complication codes that include the
external cause, and complication of care codes within
the body system chapters.
Borderline Diagnosis
ICD-10-CM
Borderline Diagnosis documented at Discharge:
• Coded as confirmed unless the classification provides
a specific entry
• Borderline conditions are not uncertain conditions so
no distinction between inpatient and outpatient
settings.
• If documentation is unclear, query
Human Immunodeficiency
Virus Infections
ICD-10-CM
HIV Related Condition:
•
Principal diagnosis is B20, HIV disease followed by addition diagnosis codes for the HIV
related condition(s)
HIV Unrelated Condition:
•
Code the unrelated condition first following by B20
Asymptomatic human immunodeficiency virus Z21 is used for:
•
•
•
no documentation of symptoms
HIV positive, known HIV, HIV test positive or similar
Do not use if AIDS is documented, treated for HIV-related illness or described as having
any condition(s) resulting from his/her HIV positive status (use B20 instead)
Patients with inconclusive HIV serology:
•
Assign R75, Inconclusive laboratory evidence of HIV for patients with inconclusive HIV
serology, for patient without definitive diagnosis or manifestations of the illness
Previously diagnosed HIV – related illness:
•
Once a patient has developed an HIV related illness, assign B20 on every subsequent
admission/encounter
Sepsis/Severe Sepsis and
Septic Shock
ICD-10-CM
Sepsis, Severe Sepsis, and Septic Shock
Sepsis:
• assign the appropriate code for the underlying systemic infection.
• Type of infection or causal organism is not further specified, assign
code A41.9, Sepsis, unspecified.
• Do not assign a code from subcategory R65.2, Severe sepsis, unless
severe sepsis or an associated acute organ dysfunction is
documented.
• Negative or inconclusive blood cultures do not preclude a diagnosis
of sepsis in patients with clinical evidence of the condition,
however, query the provider
Septic Shock
ICD-10-CM
Septic shock:
• Code first the systemic infection, followed by
code R65.21, Severe sepsis with septic shock or
code T81.12, Post-procedural septic shock.
• Add codes for other acute organ dysfunctions.
• The code for septic shock cannot be assigned as
a principal diagnosis.
Urosepsis
ICD-10-CM
Urosepsis
•
•
•
•
Nonspecific term.
not to be considered synonymous with sepsis.
Has no default code in the Alphabetic Index.
If used, the provider must be queried for
clarification.
Sequencing of Sepsis
ICD-10-CM
If it is present on admission and meets principal
diagnosis definition:
• not to be considered synonymous with sepsis.
• Has no default code in the Alphabetic Index.
• If used, the provider must be queried for
clarification.
Sepsis/Severe Sepsis with
Infections
ICD-10-CM
If sepsis is present with a localized infection:
• Sequence sepsis codes first
• List localized infections second
If due to a post-procedural infection:
• Sequence the code for the post-procedural infection
first
• List sepsis codes second
• If septic shock is documented, list second as well
Sepsis/Severe Sepsis with
Non-infectious Process
ICD-10-CM
If sepsis is present with a non-infectious process:
• If the sepsis is due to the non-infectious process,
list the non-infectious process first
• List the sepsis codes second
• If the non-infectious process leads to an infection
with sepsis, the infection should be listed first
• Code for Systemic Inflammatory Response
Syndrome (SIRS) of non-infectious origin is not
needed
Death NOS
ICD-10-CM
Death NOS
Code R99, Ill-defined and unknown cause of
mortality,
• Use only, when an expired patient is brought to
the ED other healthcare entity and is
pronounced dead upon arrival
• Does not represent the discharge disposition of
death.
Neoplasms
General Guidelines
ICD-10-CM
• A primary malignant neoplasm that overlaps
two or more contiguous sites should be
classified to subcategory/code .8 (‘overlapping
lesion’), unless the combo is specifically
indexed elsewhere.
• For multiple neoplasms of same site, not
contiguous, assign codes for each
– Example: tumors in different quadrants of same
breast
Neoplasms
General Guidelines (cont.)
ICD-10-CM
• Malignant neoplasms of ectopic tissue are to
be coded to origin of mentioned site
• Example: ectopic pancreatic malignant
neoplasms are coded to pancreas, unspecified
(C25.9)
• Check the Alphabetic Index first before going to
the Neoplasm Table
Neoplasms
Coding & Sequencing of Complications
(Anemia Associated w/ Malignancy)
ICD-10-CM
• When admitted for management of anemia
associated with malignancy & treatment:
– Sequence the code for malignancy as principal
– Followed by appropriate code for anemia
Neoplasms
Coding & Sequencing of Complications
(Anemia assoc. w/ therapies)
ICD-10-CM
• Management of anemia associated with adverse effect
of administration of chemotherapy or immunotherapy
and treatment is only for anemia, sequence the
anemia code first, followed by appropriate codes for
neoplasm and adverse effect
• Management of anemia associated with adverse effect
of radiotherapy, sequence the anemia code first,
followed by appropriate neoplasm code and code
Y84.2, Radiological procedure and radiotherapy as
cause of abnormal reaction of patient . . .
Neoplasms
Malignancy in 2 or more noncontiguous sites
ICD-10-CM
• In case where patient has more than one
malignant tumor in the same organ, different
tumors may constitute different primaries or
metastatic disease, depending on site.
• If documentation unclear, query provider as to
status so that coding is correct
Neoplasms
Admission to Determine Extent of Malignancy
ICD-10-CM
• When the reason for admission is to determine
the extent of the malignancy, list the
malignancy first, even if chemotherapy or
radiotherapy is administered.
Neoplasms
Sequencing of neoplasm codes (cont.)
ICD-10-CM
• Malignant neoplasm in pregnant patient: use
code from subcategory O9A.1-, Malignant
neoplasm complicating pregnancy, childbirth,
and the puerperium, sequenced first, followed
by appropriate code from Chapter 2 to indicate
type of neoplasm
Neoplasms
Sequencing of neoplasm codes (cont.)
ICD-10-CM
• Encounter for complication associated with
neoplasm:
– When encounter is for mgmt of complication
associated w/ neoplasm and treatment is only
for complication, code complication first,
followed by appropriate code for neoplasm
– Exception: Anemia (see slide above)
Neoplasms
Sequencing of neoplasm codes (cont.)
ICD-10-CM
• When encounter is for treatment of
complication resulting from surgical
procedure performed for treatment of
neoplasm, designate complication as principal
diagnosis. (See guideline regarding the coding
of current malignancy vs personal history to
determine if code for neoplasm should also be
assigned)
Neoplasms
Sequencing of neoplasm codes (cont.)
ICD-10-CM
• Pathologic fracture due to neoplasm
-
-
If focus of treatment is the fracture, code from
subcategory M84.5, Pathological fracture in
neoplastic disease, should be sequenced first,
followed by neoplasm code
If focus of treatment is neoplasm with an
associated pathological fracture, code neoplasm
first, followed by code from M84.5 for the
pathological fracture
Neoplasms
Current malignancy vs.
personal history of malignancy
ICD-10-CM
•
•
When primary malignancy has been excised
but further treatment is directed to that site,
use primary malignancy code until treatment
is completed
Use code Z85, Personal history of malignant
neoplasm, to indicate former site of
malignancy once it has been
excised/eradicated, there is no further
treatment directed to that site, and there is no
evidence of existing malignancy
Neoplasms
Leukemia, Multiple Myeloma, and Malignant Plasma
Cell Neoplams in remission vs personal history
ICD-10-CM
•
•
Categories for leukemia, and category C90,
Multiple myeloma and malignant plasma cell
neoplasms, have codes indicating whether or
not the leukemia has achieved remission.
There are also codes for personal history of
leukemia or malignant neoplasms of
hymphoid, hematopoietic and related tissues
Neoplasms
Leukemia, Multiple Myeloma, and Malignant Plasma
Cell Neoplams in remission vs personal history (cont.)
ICD-10-CM
•
If it is unclear in the documentation as to
whether or not the leukemia has achieved
remission, query the provider.
Malignant Neoplasm associated with
Transplanted Organ
ICD-10-CM
•
•
Coded as tranplant complication
Assign the code for the specific malignancy
second
Diabetes
Diabetes Mellitus
ICD-10-CM
• Diabetes mellitus codes are combination codes
to include type of diabetes, body system
affected, and complications affecting that body
system
• Assign as many codes within category as are
necessary to describe all complications of
disease
Diabetes
Underdose of insulin due to
insulin pump failure
ICD-10-CM
• Assign code from subcategory T85.6, Mechanical
complication of other specified internal and
external prosthetic devices, implants, and grafts,
that specifies type of pump malfunction as
principal
• Assign T38.3x6-, Underdosing of insulin and oral
hypoglycemic (antidiabetic drugs) as secondary
• Assign codes for type of diabetes mellitus and
associated complications if appropriate
Diabetes
Overdose of insulin due to
insulin pump failure
ICD-10-CM
• Assign code from subcategory T85.6, Mechanical
complication of other specified internal and
external prosthetic devices, implants, and grafts,
that specifies type of pump malfunction as
principal
• Assign T38.3x1-, Poisoning by insulin and oral
hypoglycemic drugs, accidental as secondary
Diabetes
Secondary Diabetes Mellitus
ICD-10-CM
• Codes under categories E08, Diabetes mellitus
(DM) due to underlying condition, and E09, Drug
or chemical induced diabetes mellitus, show
complications and manifestations associated with
secondary diabetes mellitus
• Secondary DM is always caused by another
condition
Diabetes
Assigning and sequencing secondary
diabetes codes and its causes
ICD-10-CM
• Sequencing of secondary diabetes codes in
relationship to codes for the cause of the
diabetes is based on the Tabular List
instructions for categories E08 and E09.
Mental & Behavioral Disorders
Pain disorders related to psychological factors
ICD-10-CM
• Assign code F45.41, for pain that is exclusively
related to psychological disorders
• Do not assign a code from category G89, Pain, not
elsewhere classified with is code
Mental & Behavioral Disorders
Pain disorders related to psychological factors
ICD-10-CM
• Code 45.42, Pain disorders with related
psychological factors, should be used with a code
from category G89, Pain, not elsewhere classified if
documentation shows a psychological component
for a patient with acute or chronic pain
Mental & Behavioral Disorders
Mental & Behavioral disorders due to
psychoactive substance use
ICD-10-CM
1. In Remission
• Assigned only if so documented.
• Selection of codes for “in remission” categories
F10-F19, Mental and behavioral disorders due to
psychoactive substance use
Mental & Behavioral Disorders
Mental & Behavioral disorders due to
psychoactive substance use
ICD-10-CM
2. Psychoactive Substance Use, Abuse and
Dependence
- When provider documentation refers to use,
abuse and dependence of the same substance,
only one code should be assigned to identify the
pattern of use based on the following:
Mental & Behavioral Disorders
Mental & Behavioral disorders due to
psychoactive substance use
ICD-10-CM
2. Psychoactive Substance Use, Abuse and
Dependence (cont.)
- If both use and abuse are documented, assign
only the code for abuse
- If both abuse and dependence are documented,
assign only code for dependence
- If use, abuse and dependence are all
documented, assign only the code for
dependence
Mental & Behavioral Disorders
Mental & Behavioral disorders due to
psychoactive substance use
ICD-10-CM
2. Psychoactive Substance Use, Abuse and
Dependence (cont.)
- If both use and dependence are documented,
assign only the code for dependence
Mental & Behavioral Disorders
Mental & Behavioral disorders due to
psychoactive substance use
ICD-10-CM
3. Psychoactive Substance Use
- The codes for psychoactive substance use should
only be assigned based on provider
documentation and when they meet the
definition of a reportable diagnosis
- Codes are to be used only when the psychoactive
substance use is associated with a mental or
behavioral disorder, and this relationship is
documented by provider
Nervous System
Dominant/nondominant side
ICD-10-CM
•
Codes from 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
dominant or nondominant side is affected
Nervous System
Dominant/nondominant side (cont.)
ICD-10-CM
•
If the affected side is documented, but it is not
specified as dominant or nondominant, and the
classification system does not indicate a default,
code selection is as follows:
– For ambidextrous pt, default should be dominant
– If left side is affected, default is non-dominant
– If right side is affected, default is dominant
Pain Reporting
General Coding Info
ICD-10-CM
•
•
Only assign code from category G89 if pain is
specified as acute or chronic, post-thoracotomy,
post-procedural, or neoplasm-related
Pain codes are only assigned as principal if:
–
–
–
Pain control or management is reason for encounter
Patient is admitted for insertion of neurostimulator for
pain control
Not for neurostimulator insertion for definitive
underlying cause.
Circulatory System
Hypertensive Heart & Chronic Kidney Disease
ICD-10-CM
•
•
The appropriate code from category N18,
Chronic kidney disease, should be used as a
secondary code with a code from category I13 to
identify the stage of chronic kidney disease
I13 codes are combination codes that include
hypertension, heart disease and chronic kidney
disease
Circulatory System
Hypertensive Heart & Chronic Kidney Disease
ICD-10-CM
•
•
•
The Includes note at I13 specifies that the
conditions included in I11 and I12 are included
together in I13
If a patient has hypertension, heart disease and
CKD then a code from I13 should be used rather
than individual codes
For patients w/ both acute renal failure and CKD
an add’l code for acute renal failure is required
Circulatory System
Hypertensive Retinopathy
ICD-10-CM
•
•
Subcategory H35.0, Background retinopathy and
retinal vascular changes, should be used with a
code from category I10-I15, Hypertensive disease
to include the systemic hypertension
Sequence based on reason for encounter
Circulatory System
Atherosclerotic Coronary
Artery Disease & Angina
ICD-10-CM
•
•
•
Combination codes for atherosclerotic heart
disease with angina pectoris
When using one of these combo codes it is not
necessary to use an additional code for angina
If a patient with coronary artery disease is
admitted due to acute myocardial infarction
(AMI), sequence AMI first
Circulatory System
Intraoperative and Postprocedural
Cerebrovascular Accident
ICD-10-CM
•
•
Proper code assignment depends on whether it
was an infarction or hemorrhage and whether it
occurred intraoperatively or postoperatively.
If it was a cerebral hemorrhage, code assignment
depends on type of procedure performed
Circulatory System
Sequelae of Cerebrovascular Disease
ICD-10-CM
•
•
•
Category I69 indicates conditions classifiable to
categories I60-I67, as causes of sequela
(neurologic deficits). These late effects include
neurologic deficits that persist after initial onset
of the conditions in categories I60-I67.
I69 codes specify hemiplegia, hemiparesis and
monoplegia; whether dominant or nondominant
side affected. No default code is available.
Codes from category I69 should not be assigned if
the patient does not have neurologic deficits.
Circulatory System
Acute myocardial infarction (AMI)
ICD-10-CM
•
•
•
•
For encounters ≤ 4 weeks old, including transfers to
another acute setting or a postacute setting, and
the patient requires continued care for MI, codes
from category I21 may continue to be reported
For encounters > 4 weeks old and patient is still
receiving care related to MI, appropriate aftercare
code should be assigned
If the NSTEMI evolves to a STEMI, assign the STEMI
only
For old or healed MI not requiring care, code I25.2,
Old myocardial infarction
Circulatory System
Subsequent acute myocardial infarction
ICD-10-CM
• Code from category I22, Subsequent ST elevation
(STEMI) and non ST elevation (NSTEMI)
myocardial infarction, is to be used when a
patient who has suffered an AMI has a new AMI
within the 4 week time frame of the initial AMI
• The sequencing of the I22 and I21 codes depends
on the circumstances of the encounter
Circulatory System
Documentation of Ventilator
Associated Pneumonia
A
ICD-10-CM
•
•
•
Code J95.851, Ventilator associated pneumonia,
(VAP), should be assigned only when the provider
has documented VAP
Add’l code to identify organism should also be
assigned
Do not assign add’l code from J12-J19 to identify
the type of pneumonia, unless the VAP develops
after admission, and the patient is admitted with
pneumonia.
Pressure Ulcer Stages
ICD-10-CM
•
•
•
•
Codes from category L89 Pressure Ulcer, combo
codes that show the ulcer as well as the stage
If documented as healed, no code is assigned
If documented as healing, the appropriate code
for type and stage should be assigned.
If the stage evolves into a higher stage, assign only
the highest stage.
Diseases of the Musculoskeletal
System and Connective Tissue
ICD-10-CM
• Site and Laterality
– Site represents bone, joint or muscle
– For conditions where more than one, bone, joint or
muscle are involved there is a multiple sites code
• Bone vs. joint
– Though the portion of bone affected may be the joint,
the site designation will be the bone not the joint
Coding of Pathologic Fractures
ICD-10-CM
7th Character A is for active fracture treatment
surgical
ED
Eval by new physician
7th Character D is used for encounters after the patient
has completed active treatment
Other 7th Characters are used for subsequent encounters
associated with healing such as malunions, nonunions and
sequelae
Chronic Kidney Disease
ICD-10-CM
• Stages of chronic kidney disease (CKD)
– Classify severity
– End stage renal disease with CKD is assigned with
one code N18.6, which include both conditions
• CKD with Transplant
– The presence of CKD alone may not constitute a
transplant complication
– If unclear query
Pregnancy, Childbirth, Puerperium
Final character for trimester
ICD-10-CM
•
•
Majority of Ch 15 codes have a final character
indicating trimester of pregnancy
Where trimester isn’t part of the code it is
because the condition always occurs in a specific
trimester
Pregnancy, Childbirth, Puerperium
Final character for trimester
ICD-10-CM
•
•
Final trimester codes also apply for pre-existing
conditions and those that develop during or are
caused by the pregnancy
If delivery occurs during the current admission and
there is an “in childbirth” option for the obstetric
complication, the “in childbirth” code should be
assigned
Pregnancy, Childbirth, Puerperium
Final character for trimester
ICD-10-CM
•
•
If a patient is admitted to a hospital for
complications of pregnancy during one trimester
and remains in the hospital into the next
trimester, the trimester character for the
antepartum complication code should be
assigned based on the trimester when the
complication developed rather than trimester of
discharge
The unspecified trimester should not be used;
obtain further clarification
Pregnancy, Childbirth, Puerperium
7th character Fetus Identification
ICD-10-CM
•
•
If applicable, a 7th character should be assigned for
certain categories to identify the fetus for which
the complication code applies
Assign 7th character “0”:
– For singe gestations
– When the documentation in the record is
insufficient to determine the fetus affected
– When it is not possible to clinically determine which
fetus is affected
Pregnancy, Childbirth, Puerperium
Pre-existing conditions vs.
conditions due to pregnancy
ICD-10-CM
•
•
Certain categories in Chapter 15 distinguish
between conditions of the mother than existed
prior to pregnancy and those that are a direct
result of the pregnancy
For categories that do not distinguish between
pre-existing and pregnancy-related conditions
may be used for either
Pregnancy, Childbirth, Puerperium
Gestational (pregnancy induced)
diabetes
ICD-10-CM
Gestational (Pregnancy Induced) diabetes
• Codes under subcategory O24.4 include diet
controlled and insulin controlled
• If gestational diabetes is treated with both diet
and insulin, only code insulin-controlled
• Code Z79.4, Long-term (current) use of insulin,
should not be assigned with codes from
subcategory O24.4
• Abnormal glucose tolerance in pregnancy is
assigned a code from subcategory O99.81,
Abnormal glucose complicating pregnancy,
childbirth, and the puerperium
Pregnancy, Childbirth, Puerperium
Alcohol, tobacco use during pregnancy,
childbirth and the puerperium
ICD-10-CM
•
•
Subcategory O99.31, Alcohol use complicating
pregnancy, childbirth, and the puerperium assigned when a mother uses alcohol during the
pregnancy or postpartum
Also assign a secondary code from category F10,
Alcohol related disorders, to identify
manifestations of alcohol use
Pregnancy, Childbirth, Puerperium
Alcohol, tobacco use during pregnancy,
childbirth and the puerperium
ICD-10-CM
•
•
Subcategory O99.33, Smoking (tobacco)
complicating pregnancy, childbirth, and the
puerperium - assign when a mother uses any type
of tobacco product during the pregnancy or
postpartum
Also assign a secondary code from category F17,
Nicotine dependence, or code Z72.0, Tobacco use,
to identify the type of nicotine dependence
Pregnancy, Childbirth, Puerperium
Poisoning, toxic effects, adverse
effects and underdosing in a pregnant patient
ICD-10-CM
•
•
•
Subcategory O9A.2, Injury, poisoning and certain
other consequences of external causes
complicating pregnancy, childbirth, and
puerperium, is sequenced first
Next assign the appropriate injury, poisoning, toxic
effect, adverse effect or underdosing code
Then assign additional code(s) that specifies the
condition causing poisoning, toxic effect, adverse
effect or underdosing
Pregnancy, Childbirth, Puerperium
Pregnancy associated cardiomyopathy
ICD-10-CM
•
•
•
Pregnancy associated cardiomyopathy, code
O90.3, is unique in that it may be diagnosed in the
3rd trimester of pregnancy but may continue to
progress months after delivery
As such, it is referred to as peripartum
cardiomyopathy
Code O90.3 is only for use when the
cardiomyopathy develops as a result of pregnancy
in a woman who did not have pre-existing heart
disease
Sequelae of complication of
Pregnancy, Childbirth, and the
Puerperium
ICD-10-CM
• Use code O94 in cases when an initial
complication of pregnancy develops a sequelae
requiring care or treatment at a future date
• The sequela code is sequenced following the code
for the complication
Abuse in a Pregnant Patient
ICD-10-CM
• Suspected or confirmed cases of abuse in a
pregnant patient are coded from subcategories
O9A.3, Sexual abuse complicating pregnancy,
childbirth and the puerperium, and O9a.5,
Psychological abuse complicating pregnancy,
childbirth, and the puerperium
• See also Section I.C.19, Adult and child abuse,
neglect and other maltreatment
NewBorns
Conditions Originating in the Perinatal
Period
ICD-10-CM
Principal Diagnosis for the Birth Record
• Assign a code from category Z38, Liveborn infants
according to place of birth and type of delivery as
principal diagnosis for the birth episode
• A code from category Z38 should only be used
once
Newborns
Use of Codes from other Chapters
ICD-10-CM
•
•
Codes from other chapters may be used w/
codes from chapter 16 if the codes from the
other chapters provide more specific detail
If the reason for the encounter is a perinatal
condition, the code from chapter 16 should be
principal
Newborns
Low birth weight and immaturity status
ICD-10-CM
•
Codes from category P07, Disorders of newborn
related to short gestation and low birth weight,
not elsewhere classified, are for use for a child or
adult who was premature or had low birth weight
as a newborn newborn and this is affecting the
patient’s current health
Newborns
Bacterial Sepsis of Newborn
ICD-10-CM
•
Category P36, Bacterial sepsis of newborn,
includes congenital sepsis. If a perinate is
documented as having sepsis w/o
documentation of congenital or community
acquired, the default is congenital & a code
from category P36 should be assigned
Newborns
Bacterial Sepsis of Newborn
ICD-10-CM
•
•
If the P36 code includes the causal organism, an
add’l code from category B95 or B96 should not
be assigned
If the P36 code does not include the causal
organism, assign an add’l code from category
B96
Newborns
Stillbirth
ICD-10-CM
•
•
•
Code P95, Stillbirth, is only for use in institutions
that maintain separate records for stillbirth
No other code should be used with P95
P95 should not be used on the mother’s record
Coma Scale
ICD-10-CM
• The coma scale codes are used in conjunction with
traumatic brain injury codes, acute cerebrovascular
disease and cerebrovascular disease codes.
• The 7th character indicates when the scale was
recorded
• At a minimum report the initial score documented
on presentation
• Assign R40.24, Glasgow coma scale, total score,
when only the total score is documented
Injuries
Application of 7th Characters
ICD-10-CM
•
•
Most categories in chapter 19 have a 7th character
requirement for each applicable code
Most categories have three 7th character values
(exception: fracture):
–
–
–
A, initial encounter
D, subsequent encounter
S, sequela
Injuries
Application of 7th Characters
ICD-10-CM
•
•
7th character “A”, intial encounter is used while
the patient is receiving active treatment for the
condition
Examples:
–
–
–
Surgical treatment
ED encounter
Evaluation and treatment by a new physician
Injuries
Application of 7th Characters
ICD-10-CM
•
•
7th character “D”, subsequent encounter is used
for encounters after the patient has received
active treatment of the condition and is receiving
routine care for the condition during
healing/recovery phase
Examples:
–
–
–
Cast change or removal
Removal of external or internal fixation device
Medication adjustment
Injuries
Application of 7th Characters
ICD-10-CM
•
•
•
7th character “S,” sequela, is for use for
complications or conditions that arise as a direct
result of a condition, such as a scar formation
after a burn
When using “S,” it is necessary to use both the
injury code that precipitated the sequela and the
sequela itself
Add “S” only to the injury code, not the sequela
code
Injuries
Application of 7th Characters
ICD-10-CM
•
•
Aftercare Z codes should not be used for aftercare
conditions such as injuries or poisonings, where 7th
characters are provided to identify subsequent care
Example: for aftercare of an injury, assign the acute
injury code with the 7th character “D” (subsequent
encounter)
Injuries
Coding of Traumatic Fractures
ICD-10-CM
•
•
A fracture not indicated as open or closed should
be coded to closed
A fracture not indicated whether displaced or not
displaced should be coded to not displaced
Injuries
Initial vs. Subsequent Encounter
for Fractures
ICD-10-CM
•
When patient is receiving active treatment for
fracture, traumatic fractures are coded using the
appropriate 7th character for initial encounter (A,
B, C)
Injuries
Initial vs. Subsequent Encounter
for Fractures
ICD-10-CM
• For encounters after the patient has completed active
treatment and is receiving routine care during the
healing/recovery phase, fractures are coded with
appropriate 7th character for subsequent care
Injuries
Coding of Burns and Corrosions
ICD-10-CM
•
•
•
•
•
Distinction between burns and corrosions
Burn codes are for thermal burns, except
sunburns, that come from a heat source or burns
resulting from electricity and radiation
Corrosions are burns due to chemicals
Guidelines are the same for both
Non-healing burns are coded as acute burns
Injuries
Encounters for treatment of sequela burns
ICD-10-CM
• Encounters for the treatment of the late effects of
burns or corrosions should be coded with a burn or
corrosion code with the 7th character “S” for
sequela
Injuries
Adverse Effects, Poisoning,
Underdosing & Toxic Effects
ICD-10-CM
•
•
•
Codes in categories T36-T65 are combination
codes that include substance that was taken as
well as the intent
Do not code directly from Table of Drugs; refer
back to Tabular List
If the same code would describe the causative
agent for more than one adverse reaction, toxic
effect or underdosing, assign the code only once
Injuries
Adverse Effect
ICD-10-CM
• When drug was correctly prescribed and properly
administered, assign appropriate code for nature
of adverse effect followed by code for the adverse
effect of the drug (T36-T50)
• Code for the drug should have 5th or 6th character
of 5
Injuries
Poisoning Codes
ICD-10-CM
• Assign code from categories T36-T50 first
• Poisoning codes have an associated intent as their
5th or 6th character
• Use additional code(s) for all manifestations of
poisonings
• Follow with abuse or dependence code, if
applicable
Injuries
Underdosing
ICD-10-CM
•
•
•
Underdosing refers to taking less of a medication
than is prescribed by a provider
For underdosing, assign code from T36-T50 (5th
or 6th character “6”)
Codes for underdosing should not be listed first
Injuries
Underdosing
ICD-10-CM
•
•
If a patient has a relapse of the medical condition
for which drug is prescribed because of
underdosing, the medical condition itself should
be coded
Noncompliance (Z91.12-Z91.13-) or complication
of care (Y63.8-Y63.9) codes are to be used with an
underdosing code to indicate intent, if known
Injuries
Complications of Care: Complication
codes that include the external cause
ICD-10-CM
•
•
•
As with some other T codes, some of the
complications of care codes have the external
cause included in the code
The code includes the nature of the
complication as well as the type of procedure
that caused the complication
No external cause code indicating the type of
procedure is necessary for these codes
External Causes of Morbidity
Introduction
ICD-10-CM
• Codes V01-Y99 are provided for the reporting of
external causes of morbidity
• Always secondary codes
Injuries
Complications of Care: Complication
codes within the body system chapters
ICD-10-CM
•
•
Intraoperative and postprocedural complication
codes are found within the body system
chapters with codes specific to the organs and
structures of that body system
These codes should be sequenced first, followed
by a code(s) for the specific complication
External Causes of Morbidity
General External Cause Coding Guidelines
ICD-10-CM
• An external cause code may be used with any
code in the range A00.0-T88.9, Z00-Z99,
classification that is a health condition due to an
external cause
External Causes of Morbidity
General External Cause Coding Guidelines
ICD-10-CM
• Mostly applicable to injuries
• Also valid for infections or diseases due to an
external source, and other health conditions, such
as a heart attack that occurs during strenuous
physical activity
External Causes of Morbidity
Length of Treatment
ICD-10-CM
• Assign the external cause code with the
appropriate 7th character (initial encounter,
subsequent encounter or sequela) for each
encounter for which the injury or condition is
being treated
External Causes of Morbidity
Combination external cause codes
ICD-10-CM
• Some external cause codes are combination
codes that identify sequential events that result in
an injury, such as a fall which results in striking
against an object
• Assign regardless of seriousness of injury
• Injury may be due to either event or both
External Causes of Morbidity
Place of Occurrence Guideline
ICD-10-CM
• Codes from category Y92, Place of occurrence of
the external cause, are secondary codes for use
after other external cause codes to identify
location of patient at time of injury/condition
• Place of occurrence used at initial encounter w/
no 7th character
External Causes of Morbidity
Unknown or Undetermined Intent Guideline
ICD-10-CM
• If the intent of the cause of injury/other
condition is unknown or unspecified, code intent
as accidental.
• External cause codes for events of undetermined
intent are only for use if the documentation in
the record specifies that the intent cannot be
determined
Factors Influencing Health Status
Aftercare
ICD-10-CM
• Aftercare Z codes should not be used for
aftercare for injuries.
• Use Z codes for care following treatment
• For aftercare of an injury, assign the acute injury
code with the appropriate 7th character for
subsequent encounter
Factors Influencing Health Status
“With” or “without” abnormal findings
ICD-10-CM
•
•
•
•
Some codes for routine health exams distinguish
between “with” and “without” abnormal findings
Code assignment depends on info known at the
time encounter is being coded
E.g. if no abnormal findings were found during
exam, but test results are not in at time of coding,
assign code for “without abnormal findings”
When assigning a code for “with abnormal
findings,” add’l code(s) should identify specific
abnormal findings
Outpatient Coding Guidelines
Encounters for medical exams
w/ abnormal findings
ICD-10-CM
•
•
•
The subcategories for encounters for general
medications, Z00.0-, provide codes for with and
without abnormal findings
Should a general medical exam result in an
abnormal finding, the code for general medical
examination with abnormal finding should be
first-listed diagnosis
A secondary code for the abnormal finding should
also be coded
PCS Organization
ICD-10-PCS
• Conventions
• Medical and Surgical Section Guidelines
–
–
–
–
–
Body System
Root Operation
Body Part
Approach
Device
• Obstetrics Section Guidelines
PCS Conventions
ICD-10-PCS
• Composed of 7 characters
• Characters = numbers 0 through 9 and alpha except I
and O
• The valid values for an axis of classification can be
added as needed
• The meaning of any single value is a combination of its
axis of classification and any preceding values
• With expansion more values will depend on the
preceding value
PCS Conventions continued
•
•
•
•
•
•
ICD-10-PCS
Alphabetic index provides for location table necessary
to construct code
Code may be chosen from the table, (the alpha index
does not need to be consulted first)
All seven characters must be specified to be a valid code
Within a PCS table, valid codes include all combinations
of choices for characters 4 through 7
The term “And” means “and/or”
It is the coder’s responsibility to determine which code
to choose from the documentation
Device
ICD-10-PCS
General Guidelines
• Coded only if it remains after procedure is coded
• Sutures, ligature, radiological markers an
temporary post-operative wound drains are
considered integral to the performance of a
procedure and are not coded as devices
• Procedures performed on a device only and not on
a body part are specified in the root operations:
-change
-irrigation
-removal
-revision
Obstetrics Section
ICD-10-PCS
• Productions of conception
– Procedures performed on the products of conception are
coded to the obstetrics section
• Procedures following delivery or abortion
– All coded to the root operation Extraction and the body part
Products of Conception, Retained.
– Diagnostic or therapeutic dilation and curettage performed
during times other than the postpartum or post-abortion
period are coded in the Medical and Surgical section.
Summary and Questions
• The ICD-10 Official Guidelines mirror the ICD-9
Official Guidelines in most cases
• ICD-10 Official Guidelines contain ICD-9
Coding Clinic Guidelines
Questions?
References:
• ICD-10-CM Official Guidelines for Coding and Reporting 2013
• ICD-10-PCS Official Guidelines for Coding and Reporting 2013