Building Blocks of ICD-10-CM. Norma A. Panther, CPC, CPC-I, CIRCC, CEMC, CCS-P, ICDCT- CM, ICDCT-PCS, CHC
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2 Building Blocks of ICD-10-CM Norma A. Panther, CPC, CPC-I, CIRCC, CEMC, CCS-P, ICDCT- CM, ICDCT-PCS, CHC
3 Objectives Comparison of ICD-9 & ICD-1Ø 5 digits vs. 7 Alphanumeric New conventions, such as: Excludes 2 Placeholder x General coding rules Coding We ll use pages from the Ingenix 2013 ICD-1Ø- CM Draft to code using building blocks. The example codes will include at least one placeholder x. 3
4 The same! Alphabetic Index & Tabular Index External Causes Index Codes arranged by chapter, now 21 in the tabular index Neoplasm and Drugs and Chemicals Tables Brackets, Code First, Colon, Excludes, Includes, In diseases classified elsewhere, Parentheses, See, See Also, Use Additional Code 4
5 I-9 vs. I-10 Musculoskeletal System and Connective Tissue 733. Other disorders of bone and cartilage Pathologic fracture Pathologic fracture of tibia or fibula Diseases of the Musculoskeletal System and Connective Tissue M84. Disorder of continuity of bone M84.5 Pathological fracture in neoplastic disease M84.56 Pathological fracture in neoplastic disease, tibia and fibula M Pathological fracture in neoplastic disease, right tibia M84.561A Pathological fracture in neoplastic disease, right tibia, initial encounter for fracture 5
6 Steps to coding: 1. Review conventions and guidelines 2. Locate and look up mainterm in the Alphabetic Index 3. Note nonessential modifiers 4. Follow instructions such as: see, see also, see category, with/without, omit code, due to 5. Verify code choice in the Tabular Index 6. Review instructions in the Tabular Index, such as: includes, excludes, code also, character requirements 7. Are there guidelines for the chapter you are coding? 8. Confirm and assign code
7 General Coding Guidelines Medical Necessity Reasonable and necessary for the diagnosis and/or treatment of an illness or injury, or to improve function of a deformed member Borderline Diagnosis Code as confirmed unless classification provides specific entry (e.g., borderline diabetes) First Listed Diagnosis The most important reason for the care provided to the patient Specificity Assignment of 4 th. 5 th, 6 th or 7 th character to further specify or classify a diagnosis Special Characters Use of placeholder x
8 General Coding Guidelines Impending or Threatened Condition At discharge if diagnosis occurred code it otherwise refer to impending or threatened in the index Laterality If no bilateral code for bilateral condition assign both left and right Signs & Symptoms What prompts a patient to seek treatment. Code when diagnosis is not confirmed. Also code when not routinely associated with disease process.
9 I-10- CM Differences Point dash - Excludes 2 notes Extensions- Alphabetic and Numeric Placeholder x 9
10
11 Point dash - Placeholder for additional digits Alphabetic Index 11
12 Point dash - Placeholder for additional digits Tabular List 12
13 Excludes 2 Code this 2 13
14 Alphabetic Extensions A through S No: I, L, O Most common: A- initial encounter D- subsequent encounter S- sequela plural se quel ae Definition of SEQUELA \si-ˈkwe-lə\ 1: an aftereffect of disease, condition, or injury 2: a secondary result Origin of SEQUELA New Latin, from Latin, sequel First Known Use: circa
15 Alphabetic Extensions 15
16 Numeric Extensions Number of fetuses Stage of disease Time frame 16
17 Placeholder x Used as 4 th, 5 th and/or 6 th character Must be used or code is invalid Use when you see this symbol x7 th 17
18 18
19 DETERMINATION 19
20
21
22 Coding Exercise 22
23 Disclaimer: The information provided in this presentation was obtained from third party sources and is subject to change without notice. It is intended to provide general information for illustrative purposes only. Presenter specifically disclaims liability or responsibility for the results or consequences of any misapplication(s) of the statements, opinions, or suggestions, in this presentation. Sources: Principles of ICD-10-CM Coding; AMA; Deborah J. Grider ICD-10-CM, The Complete Official Draft Code Set; Ingenix Understanding ICD-10-CM and ICD-10-PCS A Worktext; Mary Jo Bowie & Regina Schaffer CMS; various web sources and presentations 23
24 24
o an alphabetical list of terms and corresponding code Tabular List
ICD-10 Coding Guidelines Coding Guidelines Conventions General Guidelines Eye Chapter Specific 18 total 18 total 1 total Coding Guidelines 1. The Alphabetic Index and Tabular List Conventions for ICD-10-CM
Tracking of disease processes Classification of causes of mortality Medical research Evaluation of hospital service utilization
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