Appropriate Use of 7 th Character in ICD 10 CM

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1 Appropriate Use of 7 th Character in ICD 10 CM Jameel Ahmed RHIA,CCS Corporate, Group HIM Manager SEHA - Abu Dhabi Health Services Co

2 SEHA: Abu Dhabi Healthservices 18,000 Employees 12 Hospitals 57 Ambulatory Clinics 3 Mobile Clinics 2 Blood Banks 10 Prevention Screening Centers SEHA is the corporate marketing name of Abu Dhabi Health Services Company, an independent public joint stock company that owns and operates all public hospitals and Ambulatory Healthcare clinics across the emirates of Abu Dhabi. SEHA is a phonetic rendering of the Arabic word for Health. 2

3 Learning Objectives Identify the unique characteristics of ICD-10-CM with the use of 7th Character Specificity Understand Specific Chapters of ICD 10 CM utilizing Seventh character Distinguish between different Clinical Coding Versions based on international standards

4 Greater Specificity: Three to seven characters CM CM Three to five characters

5 7 th Character: Only ICD 10 CM Contains 7 th Character ICD 10 CM Clinical Modification - USA ICD 10 CA Canada ICD 10 AM Australian Modification ICD 10 WHO Pure, World Health Organization

6 Structure of ICD 10 CM ICD-9/10 Code Format ICD-10 CM Code Format category etiology, anatomic site, manifestation category etiology, anatomic site, severity extension

7 ICD 9 CM, ICD 10 AM, ICD 10 CM ICD-9-CM 16,025 Diagnosis Codes ICD-10-CM 68,069 ICD-9-AM ICD-10-AM Diagnosis Codes 14,000 21,885 ICD-9-CA 14,000 Diagnosis Codes ICD-10-CA 30,000

8 ICD-10-CM Indexes - A summary of the chapters Chapter Code Range # of Codes Description 1 A00-B99 1,056 Certain infectious and parasitic diseases 2 C00-D49 1,620 Neoplasms 3 D50-D Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 4 E00-E Endocrine, nutritional and metabolic diseases 5 F01-F Mental, Behavioral and Neurodevelopmental disorders 6 G00-G Diseases of the nervous system 7 H00-H59 2,452 Diseases of the eye and adnexa 8 H60-H Diseases of the ear and mastoid process 9 I00-I99 1,254 Diseases of the circulatory system 10 J00-J Diseases of the respiratory system 11 K00-K Diseases of the digestive system

9 ICD-10-CM Indexes A summary of the chapters found in the Tabular List has been provided below Chapter Code Range # of Codes Description 12 L00-L Diseases of the skin and subcutaneous tissue 13 M00-M99 6,339 Diseases of the musculoskeletal system and connective tissue 14 N00-N Diseases of the genitourinary system 15 O00-O99 2,155 Pregnancy, childbirth and the puerperium 16 P00-P Certain conditions originating in the perinatal period 17 Q00-Q Congenital malformations, deformations and chromosomal abnormalities 18 R00-R Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 19 S00-T88 39,869 Injury, poisoning and certain other consequences of external causes 20 V00-Y99 6,812 External causes of morbidity 21 Z00-Z99 1,178 Factors influencing health status and contact with health services

10 Question : Audience Learning Questions 1. How may chapters of ICD 10 CM have 7 th Character? (out of 21 chapters of ICD 10 CM) 2. 7 th Character in ICD 10 CM contains? letter Alphabet Can have either letter or Alphabet

11 7 th Character: Guideline: Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.

12 Place Holder X: Utilizing Place Holder: ICD 10 CM utilizes a placeholder which is always the letter X and has two uses: As the fifth character for certain six character codes. The X provides for future expansion without disturbing the sixth character structure. When a code has less than six characters and a seventh character is required. The X is assigned for all characters less than six in order to meet the requirement of coding to the highest level of specificity.

13 7 th Character: A code that has an applicable 7th character is considered invalid without the 7th character.

14 7 th Character: Chapters in ICD 10 CM with Seventh Characters: X Pathological or Stress Fracture Seventh Characters Chapter 13 X Coding pathological fractures X Pregnancy, Childbirth and the Puerperium Seven Characters (ICD 10 CM) Chapter 15 Chapter 18 X X Fetus identification Symptoms, Signs and Abnormal Clinical and Laboratory Findings X Coma Scale Chapter 19 X Injury, Poisoning, and Certain Other Consequences of External Causes X Fractures & Poisoning, Adverse Effect, Underdose Chapter 20 X External Causes of Morbidity X Encounter

15 7 th Character: Guideline: Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.

16 7 th Character: The Encounter is the most common value of the 7th character. The most common encounter values are designated as A initial encounter, D subsequent encounter, and S sequela; however, it is important to reference the tabular index for appropriate characters for each category (i.e., categories for traumatic fractures have additional 7th character values). 16

17 7 th Character: While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. 1 17

18 7 th Character: There s no ICD-9 equivalent of the seventh character. In fact, it can be stated that there is no ICD 9, no ICD 10 AM, no ICD 10 CA, no ICD 10 WHO, equivalent of the seventh character 18

19 Initial Encounter Initial encounter: The patient is receiving active treatment for the condition Surgical treatment Emergency department encounter Evaluation and continuing (ongoing) treatment by the same or different physician 19

20 Subsequent Encounter Subsequent encounter After patient received active treatment for the condition and receiving routine care during healing or recovery phase Cast change or removal An x-ray to check healing status of fracture Removal of external or internal fixation device Medication adjustment Other aftercare and follow-up visits following injury treatment 20

21 Sequela: Sequela Complications or conditions that arise as a direct result of a condition Scar formation after burn Use both the injury code that precipitated sequela and code for sequela S added only to injury code, not sequela code S identifies injury responsible for sequela Specific type of sequela (like scar) sequenced first, followed by injury code 21

22 Pathological or Stress Fracture Seventh Characters (M00-M99) A D G K P S Initial encounter Subsequent routine healing Subsequent delayed healing Subsequent nonunion Subsequent malunion Sequela

23 Pathological or Stress Fracture Seventh Characters (M00-M99) Patient originally diagnosed with left upper lobe lung carcinoma 5 years ago is seen for a fracture of the shaft of the right femur. Eight months ago, he was diagnosed with metastatic bone cancer (from the lung) and this fracture is a result of the metastatic disease. This patient s lung cancer was treated with radiation and there is no longer evidence of an existing primary malignancy. M84.551A Pathological fracture in neoplastic disease, right femur, initial encounter for fracture C79.51 Carcinoma (malignant), metastatic, bone, femur, secondary. Z History, personal (of), malignant neoplasm (of), lung Z92.3 History, personal (of), radiation therapy

24 Pregnancy, Childbirth and the Puerperium ( ) Seventh Character 24

25 Pregnancy, Childbirth and the Puerperium ( ) Patient G1P0 at 39 weeks with twin gestation. The delivery was complicated by nuchal cord, without compression, of fetus 2. Both infants were liveborn and healthy. O Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O69.81X2 25 Labor and delivery complicated by cord around neck, without compression, fetus 2 Z3A.39 Pregnancy (single) (uterine), weeks of gestation, 39 weeks Z37.2 Outcome of delivery, twins NEC, both liveborn

26 Symptoms, Signs and Abnormal Clinical and Laboratory Findings Coma Scale (R00-R99) Used with traumatic brain injury or sequelae of cerebrovascular disease codes One from each subcategory (R40.21, R40.22, R40.23) needed Seventh character indicates when recorded - should match 0 Unspecified time 1 In field (EMT or ambulance) 2 At arrival to ER 3 At hospital admission 4 24 hours after admission

27 R Coma, with opening of eyes (never) R Coma, with verbal response (none) R Coma, with motor response (none) R Coma, with opening of eyes, in response to sound R Coma, with verbal response, inappropriate words R Coma, with motor response, flexion withdrawal 27

28 Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) A Initial closed B Initial open D Subsequent routine G Subsequent delayed K Subsequent nonunion P Subsequent malunion S - Sequela 28

29 External Causes of Morbidity (V00-Y99) W13.4XXA W13.4XXD W13.4XXS W13.8XXA W13.8XXD W13.8XXS W13.9XXA W13.9XXD W13.9XXS W14.XXXA W14.XXXD W14.XXXS Fall from, out of or through window, initial encounter Fall from, out of or through window, subsequent encounter Fall from, out of or through window, sequela Fall from, out of or through other building or structure, initial encounter Fall from, out of or through other building or structure, subsequent encounter Fall from, out of or through other building or structure, sequela Fall from, out of or through building, not otherwise specified, initial encounter Fall from, out of or through building, not otherwise specified, subsequent encounter Fall from, out of or through building, not otherwise specified, sequela Fall from tree, initial encounter Fall from tree, subsequent encounter Fall from tree, sequela 29

30 30

31 31

32 ICD-10 CM Training Phase I & Phase II : 350 Coders Training Completed from SEHA Corporate, with each Coder covering 15 hours training 100 Revenue Cycle Employees are trained across SEHA BE s Around 50 Case Managers are trained for SEHA BE s, covering each employee 5 hours of training Region SEHA BE s Scheduled Sessions Status Island Region SKMC, Corniche, 21 st & 22 nd, Sep days (15 hours) Completed SKMC training room 2 Administration Block. 100% Completion & Implementatio n in all SEHA BE s Al Ain Region Al Ain, AHS 19 th & 20 th October 2016 Al Ain Hospital (Block F - Computer Lab 1 Training Room) 2 days (15 hours) Completed Tawam Hospital 17 th & 24 th October 2016, Recreation Training Room, Tawam 2 days (15 hours) Completed Middle Region Al Rahba, Al Mafraq Al Gharbia 11 th & 12 th Oct 2016, Al Rahba Auditorium Administration Block 2 days (15 hours) Completed Gharbia Region Al Gharbia Hospitals 11 th & 12 th Oct 2016, Al Rahba Auditorium Administration Block Middle Region AHS 26 th & 27 th Oct 2016, AHS Training Room, 8 th Floor AHS Headoffice 2 days (15 hours) Completed 2 days (15 hours) Completed ICD 10 Assessment All BE s Nov/Dec 2016, 1 st & 2 nd Week Mandatory Requirement for all Coders across BE s December 2016 (16 hours (2 days) in each SEHA BE) Completed

33 References

34 Questions?

35 Thank You!

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