ICD-10-CM. International Classification of Diseases, 10th Revision, Clinical Modification

Transcription

1 ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification

2 ICD-10 stands for the International Statistical Classification of Diseases and Related Health Problems, 10 th revision ICD-10 was first introduced by the World Health Organization (WHO), and implemented by some Member States, in 1994 Consists of two parts ICD-10-CM developed for use in all United States health care treatment settings ICD-10-PCS developed for use in the United States inpatient hospital settings only Revision process ongoing with release of ICD-11 slated for 2018 ICD-10

3 Greater specificity and clinical information: Improved ability to measure health care services Increased sensitivity when refining grouping and reimbursement methodologies Enhanced ability to conduct public health surveillance Decreased need to include supporting documentation with claims Updated medical terminology and classification of diseases Codes that allow comparison of mortality and morbidity data Better data for: Measuring care furnished to patients Designing payment systems Processing claims Making clinical decisions Tracking public health Identifying fraud and abuse Conducting research ICD-10 Department of Health and Human Services, Centers for Medicare & Medicaid Services, 2015

4 Benefits of ICD-10 for rehabilitation Able to identify Laterality Right vs. Left Traumatic vs. Non-Traumatic injury Dominant vs. Non-Dominant side Single condition vs. Bilateral ICD-10

5 ICD characters First character can be numeric or alpha Decimal point occurs after 3 rd character Does not specify side Over 14,000 codes No place holders for expansion ICD characters First character always alpha Second character always numeric Characters 3-7 can be alpha or numeric Specifies side of injury Over 60,000 codes May use placeholder X ICD-9 VS. ICD-10

6 ICD Chapters/Categories of Diseases and Injuries to choose from Skilled Nursing Rehabilitation Although you may need to choose a code from any chapter, rehab may primarily use approximately 7 of the 21 Chapters Tabular List of Diseases and Injuries

7 Chapter 5 Mental behavioral and neurodevelopmental disorders (F01-F99) Example: F01.51 Vascular dementia with behavioral disturbances Chapter 6 Diseases of the nervous system (G00-G99) Example: G30.1 Alzheimer s disease with late onset Chapter 9 Diseases of the circulatory system (I00-I99) I65.01 Occlusion and stenosis of right vertebral artery Chapter 10 Diseases of the respiratory system (J00-J99) J44.1 Chronic obstructive pulmonary diseases with (acute) exacerbation Tabular List of Diseases and Injuries

8 Chapter 13 Diseases of the musculoskeletal system and connective tissue (M00-M99) Example: M16.11 Unilateral primary osteoarthritis, right hip Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Example: R47.82 Fluency disorder in conditions classified elsewhere Chapter 19 Injury, Poisoning and certain other consequences of external causes (S00-T88) Example: S42.025D Non-displaced fracture of shaft of left clavicle, subsequent encounter Tabular List of Diseases and Injuries

9 Letter X Allows for future expansion of code set Used when a code has less than 6 characters and a 7 th character is required 7 th Character options A = Initial Encounter D = Subsequent Encounter S = Sequela ICD-10 7 th Character

10 For our purposes, used primarily in codes taken from Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) Example: S72 = Fracture of Femur Appropriate 7 th character required S72.24 = Non-displaced subtrochanteric fracture of R femur S72.24X = Placeholder for missing 5 th or 6 th character S72.24XD = Subsequent encounter ICD-10 7 th Character

11 ICD = closed fracture of 5 ribs ICD-10 S22 = Fracture of rib(s), sternum and thoracic spine S22.4 = Multiple fractures of ribs (Fracture of 2 or more ribs) S22.41 = Multiple fractures of ribs, right side S22.41X = placeholder, code requires 7 th character S22.41XD = D signifies subsequent encounter for fracture with routine healing S22.41XD = Correct code ICD-9 VS. ICD-10

12 There is no national requirement for mandatory ICD-10-CM external cause code reporting Do not need unless required by a particular payer In general, if you have not been reporting external causes under ICD-9-CM, you do not have to report under ICD-10- CM External Cause and Unspecified Codes Department of Health and Human Services, Centers for Medicare & Medicaid Services, 2015

13 Report specific diagnosis codes as supported by the available medical record documentation and clinical knowledge of the patient s health condition Only use unspecified codes when there is insufficient documentation to code higher Example: ICD = Osteoarthrosis, lower leg, localized ICD-10 M17 = Osteoarthritis of knee M17.1 = Unilateral primary osteoarthritis of the knee M17.11 = Unilateral primary osteoarthritis, right knee M17.11 = Correct code, more specific Coding

14 Look up diagnosis in Index list Verify code in Tabular list Tabular list will assist in determining if 4 th, 5 th, 6 th or 7 th digit is required Links to the Index and Tabular lists are located on the Quality Rehabilitation Services under Employee>Clinical Resources>ICD-10 To search quickly, hit Ctrl-F and type in search word Determining Code

15 Index List Tabular List Right Femur Fracture Correct Code: M84.451D Femur Fracture - Pathological

16 Index List Tabular List Right Femur Fracture Correct Code: S72.24XD Femur Fracture - Traumatic

17 Excludes1 Indicates that codes listed under Excludes1 should never be reported at the same time as the code in which the note is located Example: M20.0 Deformity of fingers Excludes2 Excludes1: M65.3 Trigger finger Indicates that codes listed under Excludes2 are codes that are not represented by the code in which the note is located, but may occur in conjunction with the initial code and may be reported together Example: R29.6 Repeated falls Excludes2: Z91.81 History of falling Excludes Notes

18 All treatments delivered up to and on September 30, 2015, must have ICD-9 codes All treatments delivered on and after October 1, 2015 must have ICD-10 codes Billing submitted for treatment on or after October 1, 2015 that have ICD-9 codes will be denied No billing can contain both ICD-9 and ICD-10 codes Coding and Billing

19 CMS ICD-10 Website CMS Provider Resources CMS Coding Resources (GEMS) Resource only! Do not rely on GEMS for direct conversion of codes Medicare Learning Network (MLN) Resources CMS Sponsored Teleconference Material Resources