ICD 10 CM FOR NEUROSURGERY Sponsored by: Congress of Neurological Surgeons Annual Meeting San Diego, California

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1 ICD 10 CM FOR NEUROSURGERY Sponsored by: Congress of Neurological Surgeons Annual Meeting San Diego, California Presented by: Kim Pollock, RN, MBA, CPC, CMDP September 23, 2016 KARENZUPKO & ASSOCIATES, INC KIM POLLOCK: DISCLOSURES KarenZupko & Associates, Inc. provides the following services to physicians: Operational assessments in their offices. Coding and documentation reviews. Assistance with marketing and practice building. We will likely refer to prior engagements to illustrate teaching points. We are not soliciting work from paid participants in educational programs. We have a thriving client base. FULL LIST OF 2017 NEUROSURGERY ICD 10 CM CODE CHANGES URL: Click on Workshops tab This content is Pull down to Course Alumni password protected. Click on Private Course Click on Congress of Neurological Surgeons Find CNS Annual Meeting and click Log in Enter Password: Click Submit Password: CNS AGENDA (12:30 2P) OVERVIEW HOW S IT GOING? HIGHLIGHTS OF CODES FOR NEUROSURGERY UPDATES FOR 2017 INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION, CLINICAL MODIFICATION (ICD 10 CM) Used to describe diagnoses, conditions and/or symptoms. Owned and maintained by the World Health Organization. Used for morbidity and mortality tracking around the globe. Implemented 10/1/15 in the USA. 3 7 alphanumeric codes CNS Annual Mtg_ICD10 Neuro (KP)_

2 ICD 10 CM CODE STRUCTURE 1st character is a letter and defines the organ system of the diagnosis: C = Malignant neoplasm D = Benign, uncertain behavior or unspecified behavior neoplasm G = Nervous system I = Circulatory system M = Musculoskeletal system Q = Congenital disorders S = Injuries T = Complications ICD 10 CM: HOW S IT GOING? 7 ICD 10 CM: HOW S IT GOING? Things to Know Who must use ICD 10 codes? All HIPAA covered entities such as physicians, hospitals/facilities, health insurance companies, Medicare, Medicaid. This includes ICD 10 CM and ICD 10 PCS (more later about PCS). 9 ICD 10 CM: HOW S IT GOING? Things to Know Which payers are not required to use ICD 10 codes? Non HIPAA covered entities such as Work Comp, auto insurance, lawyers (e.g., lien cases, personal liability). Check the Workgroup for Electronic Data Interchange (WEDI) website for more information by state. Property and Casualty ICD 10 State Readiness Resource Center see more at: /workgroups/icd 10/resources/2015/09/03/ property and casualty icd 10 state readinessresource center 10 ICD 10 CM: HOW S IT GOING? Things to Know Updates to the ICD 10 CM system will resume 10/1/2016. This is called the 2017 update. ICD 10 CM: HOW S IT GOING? Things to Know Medicare says: Reprieve ends 10/1/16. Assess your risk for future denied claims by analyzing your past use of unspecified diagnosis codes CNS Annual Mtg_ICD10 Neuro (KP)_

3 USING UNSPECIFIED DIAGNOSIS CODES Medicare requiring the highest level of specificity for ICD 10 CM codes beginning October 1, The year of leniency is coming to a close and there will be no extension of phase in of the specificity requirement when reporting ICD 10 CM codes USING UNSPECIFIED DIAGNOSIS CODES Action: 1) Carefully evaluate your use of unspecified codes to determine who, how and when they have been used in the past year. 2) Do not use an unspecified code when the specific documentation exists in the record. Unspecified codes are acceptable when a specific diagnosis is not documented (e.g., office visits, no pathology report for tumor removal cases). ICD 10 CM: HOW S IT GOING? What Problems Have You Seen? 15 ICD 10 CM: HOW S IT GOING? Precertification denials for imaging studies due to use of unspecified or symptom codes (R codes). Payers requesting precertification from neurosurgeons for ICD 10 PCS codes that the hospital will use. 16 Some of the problems we ve seen: Non Work comp payer notification that utilization of the external cause codes for injuries will be required by 10/1/2016. Changes to diagnosis codes required by LCDs that are inappropriate (have seen in Vascular). WHAT S NEW FOR 2017 Effective October 1, ,305 NEW CODES 553 REVISED CODES 212 DELETED CODES ICD 10 CM PRINCIPLES AND CODING CONVENTIONS AND GUIDELINES Source: AMA CNS Annual Mtg_ICD10 Neuro (KP)_

4 SELECTED CODING CONVENTIONS AND GUIDELINES Use additional code 19 Typically used to provide additional information regarding the etiology (underlying cause) of the primary condition. For example, at the beginning of the Circulatory System chapter (I60 I69): Use additional code to identify presence of: Alcohol abuse and dependence (F10. ) Exposure to environmental tobacco smoke (Z77.22) History of tobacco use dependence (Z87.891) Hypertension (I10 I15) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17. ) Tobacco use (Z72.0) SELECTED CODING CONVENTIONS AND GUIDELINES Coding If the same condition is described as both acute acute (subacute) and chronic, and separate codes exist, code both and sequence the (subacute) acute (subacute) code first. and chronic For example: conditions I62.01 Nontraumatic acute subdural hemorrhage I62.01 subacute I62.03 chronic 20 SELECTED CODING CONVENTIONS AND GUIDELINES Coding Intraoperative and postprocedural complications complication codes are now found of care within the body system chapters with codes specific to organs and structures of that body system. These codes should be sequenced first, followed by a code(s) for the specific complication, if applicable. 2017: POSTPROCEDURAL DIAGNOSIS CODE CHANGES Multiple hemorrhage and hematoma codes revised. Now with separate hemorrhage and hematoma codes. New seroma codes EXAMPLE Code Change Description M Revise Postprocedural hemorrhage and hematoma from of a musculoskeletal structure following a musculoskeletal system procedure M Revise to Postprocedural hemorrhage of a musculoskeletal structure following a musculoskeletal system procedure M Revise from Postprocedural hemorrhage and hematoma of a musculoskeletal structure following other procedure M Revise to Postprocedural hemorrhage of a musculoskeletal structure following other procedure 24 EXAMPLE Code Change Description M Add Postprocedural hematoma of a musculoskeletal structure following a musculoskeletal system procedure M Add Postprocedural hematoma of a musculoskeletal structure following other procedure M Add Postprocedural seroma of a musculoskeletal structure following a musculoskeletal system procedure M Add Postprocedural seroma of a musculoskeletal structure following other procedure 2016 CNS Annual Mtg_ICD10 Neuro (KP)_

5 CODING CO EXISTING CONDITIONS Coding Co Existing Conditions 25 Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. WHY? CODING CO EXISTING CONDITIONS ICD says: Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. 26 Examples: You send the patient to their cardiologist for a pre op evaluation for co existing cardiac conditions. The patient has ESRD and you request clearance by his physicians. 27 CODING CO EXISTING CONDITIONS Action: Code the primary reason for the visit (lumbar stenosis) and the underlying conditions if they affect your treatment/surgical plan. Why? Accurately portray the complexity of your patient population. Patient complexity will impact payment models, risk based contracting, ACOs, and bundled payments. Patient complexity also impacts inpatient status, number of postop visits and more. CODING CO EXISTING CONDITIONS HYPERTENSION/ANGINA/HEART DISEASE ICD 10 CM Descriptor 28 I10 Essential (primary) hypertension [note: this is the default code for hypertension if a higher level of specificity is not known] I15.2 Hypertension secondary to endocrine disorders I15.8 Other secondary hypertension I20.0 Unstable angina I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I5.9 Heart disease, unspecified CODING CO EXISTING CONDITIONS OBESITY/OVERWEIGHT ICD 10 CM Description Morbid (severe) obesity due to excess E66.01 calories E66.09 Other obesity due to excess calories E66.1 Drug induced obesity Morbid (severe) obesity with alveolar E66.2 hypoventilation Note: Use additional E66.3 Overweight code to identify body E66.8 Other obesity mass index (BMI), if E66.9 Obesity, unspecified known (Z68. ) 29 CODING CO EXISTING CONDITIONS ALCOHOL ABUSE/DEPENDENCE/USE (F10. ) Documentation Needs Alcohol abuse 30 Alcohol dependence Alcohol use, unspecified In remission With withdrawal With intoxication Uncomplicated With intoxication Mood disorders Delusions Hallucinations Anxiety Sexual dysfunction Sleep disorder With other disorder 2016 CNS Annual Mtg_ICD10 Neuro (KP)_

6 CODING CO EXISTING CONDITIONS Nicotine/Tobacco Dependence (F17.2 ) Cigarettes Tobacco use (Z72.0) Chewing History of tobacco use tobacco dependence (Z87.891) Other tobacco Exposure to environmental products tobacco smoke (Z77.22) Unspecified Occupational exposure to environmental tobacco smoke (Z57.31) 31 Documentation Needs Uncomplicated In remission With withdrawal With other nicotine induced disorders 32 OTHER VS. UNSPECIFIED CODES 32 Other or Other Specified Codes Use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate other codes in the Tabular List. These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an other code. Example: S09.8 Other specified injuries of head 33 OTHER VS. UNSPECIFIED CODES 33 Unspecified Codes Use when the information in the medical record is insufficient to assign a more specific code For those categories for which an unspecified code is not provided, the other specified code may represent both other and unspecified. Example: S0.90 Unspecified injury of head (Head injury NOS) PLACEHOLDER X X placeholder is used to provide room for future expansion. X placeholder is used to keep applicable 7th character in the 7th position when the code is less than 6 characters long PLACEHOLDER X FOR FUTURE EXPANSION M53.2 Spinal instabilities M53.2X1 Spinal instabilities, occipito atlantoaxial region M53.2X2 cervical region M53.2X3 cervicothoracic region M53.2X4 thoracic region M53.2X5 thoracolumbar region M53.2X6 lumbar region M53.2X7 lumbosacral region M53.2X8 sacral and sacrococcygeal region PLACEHOLDER X X placeholder is used to provide room for future expansion. X placeholder is used to keep applicable 7th character in the 7th position when the code is less than 6 characters long CNS Annual Mtg_ICD10 Neuro (KP)_

7 PLACEHOLDER X FOR 7 TH CHARACTER EXTENSION WHAT IS A 7 TH CHARACTER EXTENSION? 38 For Fractures 6 options The appropriate 7 th character is to be added to each code from category S02 A initial encounter for closed fracture B initial encounter for open fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion S sequela For Non Fractures 3 options The appropriate 7 th character is to be added to each code from category A initial encounter D subsequent encounter S sequela 7 TH CHARACTER EXTENSION 7 TH CHARACTER EXTENSION 39 Fracture of value of skull S02.0 Incorrect code assignment: S02.0A Correct code assignment: S02.0XXA x 7th 40 Complete lesion of cervical spinal cord at C5 S Correct code assignment: S14.115A 7th TH CHARACTER EXTENSION 7th Character The 7th character addresses the encounter (initial or subsequent) and stage of healing. At first glance the meaning of the 7th character extensions may seem apparent. However, these terms can be deceiving. The healing process guides the selection of the extension, not chronology of the visits. 41 ALERT Do not confuse these descriptions of encounters with new and established patient visits (E/M codes) in CPT TH CHARACTER EXTENSION REVISITED Diagnosis (ICD 10 CM) Coding Term Encounter Visit Type Initial: the patient is in the active phase or treatment for an injury or fracture. Subsequent: after the active treatment phase is over. Procedure (CPT) Coding New patient: the patient has not been seen by the physician or other qualified health care provider in the same specialty, same group in the past 3 years. Established patient: the patient has been seen by a physician or other qualified health care provider in the same specialty, same group practice within the past 3 years CNS Annual Mtg_ICD10 Neuro (KP)_

8 DEFINING INITIAL/SUBSEQUENT/SEQUELA Initial Encounter (A, B) = In Active Treatment Examples include: surgical treatment, emergency department encounter and evaluation and continuing treatment by a new or the same physician. DEFINING INITIAL/SUBSEQUENT/SEQUELA Subsequent Encounter (D, G, K, P) = In Healing or Recovery Phase Examples include: 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 treatment of the injury or condition DEFINING INITIAL/SUBSEQUENT/SEQUELA Sequela (S) = Late effect, residual effect of a prior condition not a complication Examples include: scar formation resulting from a burn, deviated septum due to nasal fracture, infertility due to tubal occlusion from prior disease ICD 10 CM: 7 TH CHARACTER Codes that require a seventh character include: Pathological fractures (M codes) Any injury including fractures (S codes) Mechanical and inflammatory complications (T codes) NEW EXTERNAL CAUSE CODING REQUIREMENTS Injuries some payors may require reporting of additional codes from Chapters 19 and 20 when the primary diagnosis is an injury. This means there would be a total of 5 diagnosis codes on the claim form. Injury: medical condition, Activity being performed: traumatic code Y93. External cause: how it Health status: who the happened (V. ) patient is (Y99. ) Place of occurrence: Y92. NEW EXTERNAL CAUSE CODING REQUIREMENTS Example: Patient sustains a skull fracture in an ice skating accident. A 25 year old female ice skating instructor fell while ice skating at work on an outdoor rink and sustained a skull fracture. She was taken by ambulance to the local hospital. The appropriate diagnosis codes for this case are based on injury and external cause coding guidelines required by her Work Comp payer CNS Annual Mtg_ICD10 Neuro (KP)_

9 EXTERNAL CAUSE CODING REQUIREMENTS Primary Diagnosis External Cause Place of occurrence Description Fracture of vault of skull, initial encounter for closed fracture Ice skating accident (fall from ice skates) Recreation area as place of external occurrence (Ice skating rink (indoor) (outdoor) ICD 10 CM Code S02.0XXA V00.211A Y Activity Activity, ice skating Y93.21 Health Status Civilian activity done for income or pay Y99.0 CHAPTER 13: DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE (M00 M99) 49 Chapter Organization M00 M99 M 51 Image sources: Clinical Documentation Improvement Tips for Musculoskeletal /Spine Disorder: #1 Accurate coding of spine disorders requires documentation of the EXACT LEVEL(S) of disease or condition. #2 Always document presence of MYELOPATHY and/or RADICULOPATHY. #3 Always document the TYPE/CAUSE of disorder (e.g., spondylosis, spondylolisthesis, degenerative, herniated disc) 52 Chapter Highlights M Codes Many spine conditions such as spondylosis and disc disorders (but not spinal stenosis) have different codes for the condition: 53 With myelopathy With radiculopathy Without myelopathy or radiculopathy Degeneration Chapter Highlights M Codes Regions of the spine have a higher level of specificity. ICD 10 CM 2016 ICD 10 CM 2017 Occipito atlanto axial (Occiput C2) 2017: Disc disease now codes Cervical (C1 C7) for C3 C4, C4 C5, C5 C6, C6 C7 Cervicothoracic (C7 T1) Thoracic (T1 T12) Thoracolumbar (T12 L1) Lumbar (L1 L5) Lumbosacral (L5 S1) Sacral and sacrococcygeal (S1 coccyx) CNS Annual Mtg_ICD10 Neuro (KP)_

10 55 M43.1 Spondylolisthesis (excludes traumatic and congenital) 0 Site unspecified 5 Thoracolumbar 1 Occipito atlanto axial 6 Lumbar (C1 C2) 7 Lumbosacral 2 Cervical 8 Sacral and 3 Cervicothoracic sacrococcygeal 4 Thoracic 9 Multiple sites Remember: The dash ( ) means an additional character(s) is required. 56 M47. Spondylosis WITH M47.1 Other spondylosis with MYELOPATHY 5 th Character 0 Site unspecified 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal M47.2 Other spondylosis with RADICULOPATHY 5 th Character 1 Occipito atlanto axial (Occiput C2) 2 Cervical (C1 C7) 3 Cervicothoracic (C7 T1) 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) 8 Sacral and sacrococcygeal 9 Site unspecified 57 M47.81 Spondylosis WITHOUT M47.81 Other spondylosis WITHOUT myelopathy or radiculopathy 6 th Character 1 Occipito atlanto axial (Occiput C2) 6 Lumbar (L1 L5) 2 Cervical (C1 C7) 7 Lumbosacral (L5 S1) 3 Cervicothoracic (C7 T1) 8 Sacral and sacrococcygeal 4 Thoracic (T1 T12) 9 Unspecified site 5 Thoracolumbar (T12 L1) 58 M48.0 Spinal stenosis 5 th Character 0Site unspecified 5 Thoracolumbar (T12 L1) 1 Occipito atlanto axial 6 Lumbar (L1 L5) (Occiput C2) 2 Cervical (C1 C7) 7 Lumbosacral (L5 S1) 3 Cervicothoracic (C7 T1) 8 Sacral and sacrococcygeal 59 EXAMPLES Diagnosis L4 L5 spinal stenosis ICD 10 CM Code M48.06 Stenosis lumbar region Note: No equivalent ICD 10 CM code for (with neurogenic claudication). EXAMPLES Diagnosis L4 S1 spinal stenosis 60 ICD 10 CM Code M48.06 Stenosis lumbar region M48.07 Stenosis lumbosacral region Teaching point: 2 diagnosis codes are needed 2016 CNS Annual Mtg_ICD10 Neuro (KP)_

11 Image source: Image source: 9/26/2016 DOCUMENTATION: CERVICAL DISC DISORDERS M50. Cervical requires 5th or 6th character for all subcategories listed below 5 th Character M50.0 With myelopathy 0 Unspecified region M50.1 With radiculopathy 1High cervical region M50.2 Other disc displacement (C2 C3, C3 C4) 2Mid cervical region M50.3 Other disc degeneration (C4 C5, C5 C6, C6 C7) M50.8 Other disc disorders 3Cervicothoracic M50.9 Unspecified region (C7 T1) : CERVICAL DISC CODE CHANGES Cervical Disc Codes (disorder with myelopathy or radiculopathy, displacement or degeneration) Deleted the mid cervical level 5 character codes (inclusive of C4 C5, C5 C6, C6 C7). Added separate 6 character codes for these disorders at C4 C5, C5 C6, C6 C7. o Example: M Cervical disc disorder at C6 C7 level with radiculopathy Added other mid cervical at unspecified level. Added unspecified cervical disc disorder, mid cervical level, unspecified. M51. Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders Requires 5th character for all subcategories listed below with dash ( ). 63 M51.0 With myelopathy M51.1 With radiculopathy M51.2 Other disc displacement (use for herniated disc ) 5 th Character 4 Thoracic (T1 T12) 5 Thoracolumbar (T12 L1) 6 Lumbar (L1 L5) 7 Lumbosacral (L5 S1) M51.3 Other disc degeneration M51.4 Schmorl s nodes M51.8 Other disc disorders M51.9 Unspecified 64 M54.1 Radiculopathy 5 th Character 0Site unspecified 5 Thoracolumbar (T12 L1) 1 Occipito atlanto axial 6 Lumbar (L1 L5) (Occiput C2) 2 Cervical (C1 C7) 7 Lumbosacral (L5 S1) 3 Cervicothoracic (C7 T1) 8 Sacral and sacrococcygeal 4Thoracic (T1 T12) Pathologic Fracture Osteoporosis Related (M80) 65 M80 M80.08 x 7 th Osteoporosis with current pathological fracture, vertebra(e) e.g., M80.08XA Pathologic Fracture in Neoplastic Disease (M84) M84 M84.58 x 7 th Pathological fracture in neoplastic disease, other specified site (vertebrae) e.g., M84.58XA Instructed to code also underlying neoplasm e.g., thoracic met = C CNS Annual Mtg_ICD10 Neuro (KP)_

12 Image source: 9/26/2016 7th Character for Pathologic Fractures For pathological fractures (e.g., M80, M84) The appropriate 7 th character is to be added A initial encounter for fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture with malunion S sequela Diagnosis Patient seen in the ER for a T12 pathologic fracture due to senile osteoporosis 68 ICD 10 CM Code M80.08XA Senile osteoporosis with vertebral fracture Diagnosis T12 pathologic fracture due to metastatic lung cancer to the vertebra at time of vertebral augmentation procedure 69 ICD 10 CM Code M84.58XA Pathologic fracture due to neoplastic disease C79.51 Vertebral mets Teaching point: Code also underlying neoplasm (underlying neoplasm is thoracic met, not lung cancer) M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified M96.0 Pseudoarthrosis after fusion M96.1 Postlaminectomy syndrome (note not specific for regions of the spine as in ICD 9) M96.8 Postop hemorrhage, hematoma, seroma Refer to the T codes for postop wound infection, dehiscence, painful hardware : REMINDER POSTPROCEDURAL DIAGNOSIS CODE CHANGES Multiple hemorrhage and hematoma codes revised. Now with separate hemorrhage and hematoma codes. New seroma codes EXAMPLE Code Change Description M Revise from Postprocedural hemorrhage and hematoma of a musculoskeletal structure following a musculoskeletal system procedure M Revise to Postprocedural hemorrhage of a musculoskeletal structure following a M Revise from M Revise to musculoskeletal system procedure Postprocedural hemorrhage and hematoma of a musculoskeletal structure following other procedure Postprocedural hemorrhage of a musculoskeletal structure following other procedure 2016 CNS Annual Mtg_ICD10 Neuro (KP)_

13 Source: en.svg 9/26/2016 EXAMPLE Code Change Description M Add Postprocedural hematoma of a musculoskeletal structure following a musculoskeletal system procedure M Add Postprocedural hematoma of a musculoskeletal structure following other procedure M Add Postprocedural seroma of a musculoskeletal structure following a musculoskeletal system procedure M Add Postprocedural seroma of a musculoskeletal structure following other procedure CHAPTER 19: INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES (S00 T88) 73 Chapter Organization S00 T88 S or T 75 Image sources: Chapter Highlights Codes are listed by anatomic location then by type of injury Superficial injuries Do not code superficial injuries (e.g., contusion, abrasion) when associated with a more severe injurie of the same site. 76 Chapter Highlights Primary injury with damage to nerves Primary injury to the nerve is sequenced first (e.g., spinal cord injury code then fracture code) Fractures: closed/open and displaced/nondisplaced A fracture not indicated as open or closed is coded to closed (same as ICD 9 CM). A fracture not indicated as displaced or not displaced is coded to displaced (new in ICD 10 CM). 77 7TH CHARACTER EXTENSION FOR TRAUMATIC FRACTURES SIX OPTIONS OF 7TH CHARACTER: S02 Fracture of skull and facial bones 6 options S12 Fracture of cervical vertebra and other parts of neck S22 Fracture of rib(s), sternum and thoracic spine S32 Fracture of lumbar spine and pelvis The appropriate 7 th character is to be added A initial encounter for closed fracture B initial encounter for open fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion S sequela CNS Annual Mtg_ICD10 Neuro (KP)_

14 7 TH CHARACTER EXTENSION FOR NON FRACTURE INJURIES THREE OPTIONS OF 7 TH CHARACTER: 79 S00 Superficial injury of head 3 options S01 Open wound of head S06 Intracranial injury S14 Injury of nerves and spinal cord at neck level S24 Injury of nerves and spinal cord at thorax level S34 Injury of lumbar and sacral spinal cord and nerves at abdomen, lower back and pelvis level The appropriate 7 th character is to be added A initial encounter D subsequent encounter S sequela th Character and Fractures Initial Encounter (A, B) Use initial encounter while the patient is receiving active treatment for the fracture or for a patient who delayed seeking treatment for the fracture or nonunion. Subsequent Encounter (D, G, K) Use subsequent encounter when the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Using the 7th Character: Exercise 1 Patient is seen in consultation by the neurosurgeon in the ER for a C5 fracture. A B D G K S Using the 7th Character: Exercise 2 Patient is taken by the same neurosurgeon, to the OR for repair of the above C5 fracture on a different day. A B D G K S Using the 7th Character: Exercise 3 Patient seen by the neurosurgeon in the office for a 6 week post operative visit after repair of the C5 fracture. A B D G K S Using the 7th Character: Exercise 4 Patient is seen by the neurosurgeon in the office 6 months after repair of the C5 fracture and is doing well. A B D G K S CNS Annual Mtg_ICD10 Neuro (KP)_

15 Using the 7th Character: Exercise 5 Patient is seen in the office 1 year after repair of the C5 fracture with neck pain and imaging suggestive of pseudoarthrosis. A B D G K S CHAPTER 19: INJURIES OVERALL CODE STRUCTURE (S00 S99) S Head = 0 Neck/Cervical = 1 87 Etiology, Anatomic Site, Thorax = 2 Lumbar = 3 OVERALL CODE STRUCTURE (S00 S99) Code Structure Open Wound (S01. ) Open Injury Head Wound Documentation Needs 88 S 0 1 A, D, or S Clinical Documentation Improvement Tips for Scalp Wounds (S01) 1. State TYPE of injury (laceration, puncture) 2. State presence of FOREIGN BODY 3. Phase of HEALING PROCESS 4. CPT coding requires LENGTH of wound repair (cm) and TYPE of repair Code Structure Fracture of Skull/Facial Bones (S02. ) Injury Head Fracture Specific Bone S 0 2 A, B, D, G, K or S 2016 CNS Annual Mtg_ICD10 Neuro (KP)_

16 SKULL FRACTURE CODE CHANGES Base of skull fractures S02.1 Orbital floor fractures S02.3 Malar fractures S02.4 Maxillary fractures S02.4 Zygoma fractures S02.4 Mandible fractures S02.6 Dislocations S03.0 Sprains S : Right Left Don t Forget the Required 7 th Character: Fractures (S02) = A, B, D, G, K, S Other injuries = A, D, S Clinical Documentation Improvement Tips for Skull Fractures (S02) 1. State name of BONE (frontal, parietal, occipital, temporal, etc) 2. State LATERALITY (right, left) 3. If occipital condyle fracture, then state TYPE 4. Phase of HEALING PROCESS Code Structure Intracranial Injuries (S06. ) Injury Head Intracranial Injury S 0 6 A or D or S 94 CODE STRUCTURE INTRACRANIAL INJURIES (S06. ) Type of Injury 4 th Character 0 = Concussion 6 = Subarachnoid 1 = Traumatic cerebral edema hemorrhage 2 = Diffuse traumatic brain injury 8 = Other specified 3 = Focal traumatic brain injury intracranial injuries (e.g., 4 = Epidural hemorrhage internal carotid artery) 5 = Subdural hemorrhage 9 = Unspecified intracranial injury 95 CODE STRUCTURE INTRACRANIAL INJURIES (S06. ) Documentation Needs: Level of Consciousness S06. (5 th and 6 th Characters) Without loss of consciousness Loss of consciousness of 30 minutes or less Loss of consciousness of 31 minutes to 5 hours 59 minutes Loss of consciousness of 6 hours to 24 hours Loss of consciousness greater than 24 hours with return to pre existing conscious level 2017: All time requirements for concussion (S06.0) were deleted. 96 CODE STRUCTURE INTRACRANIAL INJURIES (S06. ) Documentation Needs: Level of Consciousness S06. (5 th and 6 th Characters) Loss of consciousness greater than 24 hours without return to preexisting conscious level with patient surviving Loss of consciousness of any duration with death due to brain injury prior to regaining consciousness Loss of consciousness of any duration without death due to other cause prior to regaining consciousness Loss of consciousness of unspecified duration 2017: All time requirements for concussion (S06.0) were deleted CNS Annual Mtg_ICD10 Neuro (KP)_

17 Clinical Documentation Improvement Tips for Intracranial Injuries (S06) 1. State TYPE of injury (concussion, hematoma, edema, etc) 2. State LOCATION of injury (subdural, subarachnoid, cerebrum, etc) 3. State LATERALITY (right, left) 4. State LEVEL OF CONSCIOUSNESS DURATION and patient OUTCOME (in minutes) 5. Phase of HEALING PROCESS 97 Glasgow Coma Scale Code first any associated fracture of skull (S02. ) and intracranial injury (S06. ) 98 Description/ ICD 10 CM Score R R R R Other coma CHANGES: GLASGOW COMA SCALE Effective 10/1/ CHANGES: GLASGOW COMA SCALE ICD 10 CM Action Description R Delete Glasgow coma scale score R Add Glasgow coma scale score 13 15, unspecified time R Add Glasgow coma scale score 13 15, in the field [EMT or ambulance] R Add Glasgow coma scale score 13 15, at arrival to emergency department R Add Glasgow coma scale score 13 15, at hospital admission R Add Glasgow coma scale score 13 15, 24 hours or more after hospital admission CHANGES: GLASGOW COMA SCALE ICD 10 CM Action Description R Delete Glasgow coma scale score 9 12 R Add Glasgow coma scale score 9 12, unspecified time R Add Glasgow coma scale score 9 12, in the field [EMT or ambulance] R Add Glasgow coma scale score 9 12, at arrival to emergency department R Add Glasgow coma scale score 9 12, at hospital admission R Add Glasgow coma scale score 9 12, 24 hours or more after hospital admission CHANGES: GLASGOW COMA SCALE ICD 10 CM Action Description R Delete Glasgow coma scale score 3 8 R Add Glasgow coma scale score 3 8, unspecified time R Add Glasgow coma scale score 3 8, in the field [EMT or ambulance] R Add Glasgow coma scale score 3 8, at arrival to emergency department R Add Glasgow coma scale score 3 8, at hospital admission R Add Glasgow coma scale score 3 8, 24 hours or more after hospital admission 2016 CNS Annual Mtg_ICD10 Neuro (KP)_

18 CHAPTER 19: NECK/CERVICAL SPINE INJURIES S10 S19 Code Structure Fracture of Cervical Vertebra (S12. ) Injury Neck Fracture Specific Level S 1 2 A, B, D, G, K or S Clinical Documentation Improvement Tips for Cervical Fractures (S12) 1. State specific VERTEBRA (C1, C2, C3, etc.) 2. State TYPE of fracture (stable burst, unstable burst, presence of spondylolisthesis, displaced, non displaced, etc.) 3. State presence of SPINAL CORD INJURY, if applicable 4. Phase of HEALING PROCESS 5. More info specific to C1 and C2 fractures (posterior arch, lateral mass, Type II Dens, etc.) Code Structure Cervical Spinal Cord Injury (S14. ) Injury Neck Nerve S 1 4 A or D or S 107 CODE STRUCTURE CERVICAL SPINAL CORD INJURY (S14. ) Type of Injury/Anatomic Location 4 th Character 0 = Concussion and edema x 7th 1 = Other and unspecified injury 2 = Nerve root x 7th 3 = Brachial plexus x 7th 4 = Peripheral nerves of the neck x 7th 5 = Cervical sympathe c nerves x 7th 8 = Other specified nerves of the neck x 7th 9 = Unspecified nerves of the neck x 7th Clinical Documentation Improvement Tips for Cervical Spinal Cord Injuries (S14) 1. State specific LEVEL of spinal cord (C5, C6, etc.) 2. Or other LOCATION (brachial plexus, nerve root, etc.) 3. State TYPE of injury (central cord syndrome, complete, incomplete, etc.) 4. State presence of vertebra FRACTURE, if applicable 5. Phase of HEALING PROCESS CNS Annual Mtg_ICD10 Neuro (KP)_

19 CHAPTER 19: THORAX/ THORACIC INJURIES S20 S Code Structure Fracture of Thoracic Vertebra (S22. ) Rib(s)/Sternum/ 0 = Thoracic Specific Thoracic Spine Fracture Vertebra Level Injury S A, B, D, G, K or S Type of Injury Clinical Documentation Improvement Tips for Thoracic Fractures (S22) 1. State specific level of VERTEBRA (T1, T11, T12, etc.) 2. State TYPE of fracture (stable burst, unstable burst, etc.) 3. State presence of SPINAL CORD INJURY, if applicable 4. Phase of HEALING PROCESS 111 Code Structure Thoracic Spinal Cord Injury (S24. ) Rib(s)/Sternum/ Injury Thoracic Spine Nerve 112 S 2 4 A or D or S Clinical Documentation Improvement Tips for Thoracic Spinal Cord Injuries (S24) 1. State specific LEVEL of spinal cord (T10, T12, etc.) 2. Or other LOCATION (nerve root, etc.) 3. State TYPE of injury (complete, incomplete, posterior cord, etc.) 4. State presence of vertebra FRACTURE, if applicable 5. Phase of HEALING PROCESS CHAPTER 19: ABDOMEN, LOWER BACK, LUMBAR SPINE, PELVIS AND EXTERNAL GENITALS (S30 S39) CNS Annual Mtg_ICD10 Neuro (KP)_

20 115 Code Structure Fracture of Lumbar/Sacrum Vertebra (S32. ) Injury Abdomen/Lower Back Lumbar Spine/Pelvis S or 1 Fracture A, B, D, G, K or S 0 = Lumbar 1 = Sacrum Clinical Documentation Improvement Tips for Lumbar Fractures (S32) 1. State specific VERTEBRA (L3, L4, etc.) 2. State TYPE of fracture (wedge compression, stable burst, unstable burst, etc.) 3. State presence of SPINAL CORD INJURY, if applicable 4. Phase of HEALING PROCESS 116 Clinical Documentation Improvement Tips for Sacral Fractures (S32) 1. State specific ZONE of sacrum and DISPLACEMENT 2. State TYPE of fracture 3. Phase of HEALING PROCESS 117 Code Structure Lumbar/Sacral Spinal Cord Injury (S34. ) Abdomen/Lower Back Injury Lumbar Spine/Pelvis Nerve 118 S 3 4 A or D or S Clinical Documentation Improvement Tips for Lumbar and Sacral Spinal Cord Injuries (S34) 1. State specific LEVEL of spinal cord (L1, L2, etc.) 2. Or other LOCATION (nerve root, sympathetic nerve, etc.) 3. State TYPE of injury (complete, incomplete, anterior cord, etc.) 4. State presence of vertebra FRACTURE, if applicable 5. Phase of HEALING PROCESS CHAPTER 19: OTHER COMPLICATIONS T Codes: All Require 7th Character Pain Due to Medical Devices T84.84 Painful spinal instrumentation CNS Annual Mtg_ICD10 Neuro (KP)_

21 CHAPTER 19: OTHER COMPLICATIONS T Codes: All Require 7th Character Complication Codes T81.3 Disruption of wound (dehiscence) T81.4XX Infection following procedure T85.0 Mechanical complication of ventricular intracranial shunt T85.1 Mechanical complication of implanted electronic stimulator of nervous system T85.79X Infection due to other internal implant [e.g., infected shunt] 121 CHAPTER 19: OTHER COMPLICATIONS Don t Forget: Some intra op and post op complications codes now found in organ system chapters M96.1 Postlaminectomy syndrome G96.0 CSF leak Hematoma/hemorrhage/seroma codes : COMPLICATION CODES: DEVICES AND IMPLANTS, T CODES Revised language on neurostimulator code complications from breakdown of neurostimulator (electrode) brain to neurostimulator of brain electrode (lead). Same language change for spine and peripheral stimulators. Same language change for other types of complications; displacement and other. Added mechanical breakdown of neurostimulator generator : COMPLICATION CODES: DEVICES AND IMPLANTS, T CODES Revised language for complication codes from epidural or subdural infusion catheters to cranial or spinal infusion catheters. Added 23 new codes for infection and inflammatory reaction due to neurostimulator electrodes or generators (brain, spine, peripheral), cranial or spinal infusion catheters, VP shunts and other nervous system device. Added fibrosis, embolism, stenosis, pain, and hemorrhage of nervous system prosthetic devices, implants or grafts. 124 CHAPTER 6: DISEASES OF THE NERVOUS SYSTEM (G00 G99) CHAPTER 6: NERVOUS SYSTEM Chapter Organization G00 G99 G 126 Image sources: CNS Annual Mtg_ICD10 Neuro (KP)_

22 CHAPTER 6: NERVOUS SYSTEM Chapter Highlights Abscess G06.0 Intracranial G06.1 Intraspinal Parkinson s disease (G20) Multiple sclerosis (G35) 127 Epilepsy (G40 codes) State TYPE (focal, generalized, etc.) State whether INTRACTABLE or NOT intractable State whether with STATUS EPILEPTICUS or WITHOUT CHAPTER 6: NERVOUS SYSTEM Chapter Highlights Cranial Nerve Disorders (G50 G52) Trigeminal nerve (5th CN): G50.0 Trigeminal neuralgia Facial nerve (7th CN): G51. Other cranial nerves: G52. Carpal Tunnel Syndrome (G56.0 ) Right: G56.01 Left: G56.02 Bilateral: G ICD 9 CM Carpal tunnel syndrome New in 2017 G56.03 ICD 10 CM G56.00 Carpal tunnel, unspecified, upper limb G56.01 right upper limb G56.02 left upper limb bilateral CHAPTER 6: NERVOUS SYSTEM Chapter Highlights Hydrocephalus (G91. ) Communicating Obstructive Normal pressure Post traumatic Unspecified 129 Other Arachnoid cyst (G93.0) Benign intracranial hypertension (G93.2) Nontraumatic cerebral edema (G93.6) Chiari type I (G93.5) CSF leak (G96.0) TIA (G45.9) Intraoperative / Postoperative Complications (G97. ) CHAPTER 9: DISEASES OF THE CIRCULATORY SYSTEM (I00 I99) CHAPTER 9: CIRCULATORY SYSTEM Chapter Organization I00 I99 I 131 Image sources: THIS CHAPTER CONTAINS THE FOLLOWING BLOCKS: I00 I02 Acute rheumatic fever 132 I05 I09 Chronic rheumatic heart diseases I 10 I15 Hypertensive diseases I10 I25 Ischemic heart diseases I26 I28 Pulmonary heart disease and diseases of pulmonary circulation I30 I52 Other forms of heart diseases I60 I69 Cerebrovascular diseases (e.g., nontraumatic subarachnoid hemorrhage from specific artery, nontraumatic intracerebral hemorrhage, cerebral infarction, occlusion of precerebral arteries, cerebral aneurysm, moyamoya disease, sequelae of cerebrovascular disease) I70 I79 Diseases of arteries, arterioles and capillaries I80 I89 Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified I95 I99 Other and unspecified disorders of the circulatory system CNS Annual Mtg_ICD10 Neuro (KP)_

23 133 CHAPTER 9: CIRCULATORY SYSTEM Chapter Highlights For Cerebrovascular Diseases (I60 I69) Use additional code to identify presence of: o Alcohol abuse and dependence (F10. ) o Exposure to environmental tobacco smoke (Z77.22) o History of tobacco use dependence (Z87.891) o Hypertension (I10 I15) o Occupational exposure to environmental tobacco smoke (Z57.31) o Tobacco dependence (F17.0 ) o Tobacco use (Z72.0) CHAPTER 9: CIRCULATORY SYSTEM Chapter Highlights For Cerebrovascular Diseases (I60 I69) Laterality exists for many codes o Right = 1 I66.01 Occlusion and stenosis of right middle cerebral artery o Left = 2 I66.02 Occlusion and stenosis of left middle cerebral artery 134 For codes in category I63 Cerebral infarction: o Use additional code, if applicable, to identify status post administration of tpa (rtpa) in a different facility within the last 24 hours prior to admission to current facility (Z92.82). CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Subarachnoid Hemorrhage (Nontraumatic) (I60. ) [includes ruptured cerebral aneurysm] 1. State LOCATION Carotid siphon and bifurcation Middle cerebral artery Anterior communicating artery (no laterality) Posterior communicating artery Basilar artery 135 Vertebral artery Other intracranial arteries 2. State LATERALITY Right Left Note: Use I60.7 for ruptured cerebral aneurysm. 136 CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Subarachnoid Hemorrhage (Nontraumatic) (I60. ) [includes ruptured cerebral aneurysm] ICD 9 CM (1 code) ICD 10 CM (now 19 codes!) 430 Subarachnoid I60.0 Carotid siphon and bifurcation hemorrhage I60.1 MCA I60.2 ACOM I60.3 PCOM I60.4 Basilar artery I60.5 Vertebral Each above has specified RT and LT. More codes for other vessels, unspecified artery, other, unspecified. CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Intracerebral Hemorrhage (Nontraumatic) (I61. ) State LOCATION: Hemisphere, subcortical Brain stem (deep intracerebral) Cerebellum Hemisphere, cortical Intraventricular (cerebral lobe, superficial Multiple localized intracerebral) 137 CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Subdural Hemorrhage (Nontraumatic) (I62. ) Acute Subacute Chronic 138 ICD 9 CM (1) ICD 10 CM (4) Subdural I62.00 Unspecified hemorrhage I62.01 Acute I62.02 Subacute I62.03 Chronic 2016 CNS Annual Mtg_ICD10 Neuro (KP)_

24 CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Cerebral Infarction (I63. ) State Cause Thrombosis Embolism Occlusion or stenosis 2. State specific ARTERY Vertebral Basilar Carotid Cerebral Middle cerebral Anterior cerebral Posterior cerebral Cerebellar Other 3. State LATERALITY Right Left Bilateral (added in 2017) CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Stenosis/Occlusion without Infarction Pre cerebral Arteries (I65. ) State specific ARTERY Vertebral Basilar Carotid 2. State LATERALITY Right Left Bilateral CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Stenosis/Occlusion without Infarction Cerebral Arteries (I66. ) State specific ARTERY Middle cerebral Anterior cerebral Posterior cerebral Cerebellar Other 2. State LATERALITY Right Left Bilateral CHAPTER 9: CIRCULATORY SYSTEM Clinical Documentation Improvement Tips Unruptured Aneurysm State specific ARTERY Vertebral (I72.6) Other pre cerebral (I72.5) All others no specificity (I67.1) CHAPTER 2: NEOPLASMS (C00 D49) CHAPTER 2: NEOPLASMS Chapter Organization C00 D49 C or D 144 Image sources: CNS Annual Mtg_ICD10 Neuro (KP)_

25 CHAPTER 2: NEOPLASMS (C00 D49) GENERAL GUIDELINES 145 Malignant, primary Cancer, first site (C codes) Malignant, secondary Metastatic site (C codes) Carcinoma in situ The risk of transforming to (C codes) cancer is high Benign (D codes) Non cancer CHAPTER 2: NEOPLASMS (C00 D49) GENERAL GUIDELINES 146 Uncertain behavior (D codes) Histologic confirmation whether the neoplasm is malignant or benign cannot be made; the pathology of the tumor determines the diagnosis. NOT you are uncertain. Unspecified (D codes) The pathology is unknown at the time of encounter (e.g., use for office visits). EXCERPTED FROM THE NEOPLASM TABLE (REFER TO THE ICD 10 CM BOOK FOR THE ENTIRE TABLE) Malignant Malignant Ca in Unspecified Location Primary Secondary situ Benign Uncertain Behavior brain NEC C71.9 C79.31 D33.2 D43.2 D49.6 cerebellopontine C71.6 C79.31 D33.1 D43.1 D49.6 angle frontal lobe C71.1 C79.31 D33.0 D43.0 D49.6 meninges C70.0 C79.32 D32.0 D42.0 D49.7 occipital lobe C71.4 C79.31 D33.0 D43.0 D49.6 overlapping C71.8 C79.31 lesion parietal lobe C71.3 C79.31 D33.0 D43.0 D49.6 temporal lobe C71.2 C79.31 D33.0 D43.0 D49.6 EXCERPTED FROM THE NEOPLASM TABLE (REFER TO THE ICD 10 CM BOOK FOR THE ENTIRE TABLE) Malignant Malignant Ca in Unspecified Location Primary Secondary situ Benign Uncertain Behavior spine, spinal C41.2 C79.51 D16.6 D48.0 D49.2 (column) cord (cervical) C72.0 C79.49 D33.4 D43.4 D49.7 (lumbar) (sacral) (thoracic) meninges C70.1 C79.49 C32.1 D42.1 D CHAPTER 17: CONGENITAL MALFORMATIONS (Q00 Q99) CONGENITAL MALFORMATIONS: CHAPTER 17 ORGANIZATION Chapter Organization Q00 Q99 Q CNS Annual Mtg_ICD10 Neuro (KP)_

26 CHAPTER 17: CONGENITAL MALFORMATIONS Arteriovenous Malformation Q28.2 If ruptured, use I60.8 (Nontraumatic subarachnoid hemorrhage, other) CHAPTER 17: CONGENITAL MALFORMATIONS Encephalocele Q01.0 Frontal Q01.1 Nasofrontal Q01.2 Occipital Q01.8 Other sites CHAPTER 17: CONGENITAL MALFORMATIONS Congenital Hydrocephalus Q03.0 Malformation of aqueduct of Sylvius Q03.1 Dandy Walker Syndrome Q03.8 Other congenital hydrocephalus CHAPTER 17: CONGENITAL MALFORMATIONS Spina Bifida Q05. Documentation issues: cervical, thoracic, lumbar with or without hydrocephalus CHAPTER 17: CONGENITAL MALFORMATIONS Chiari Type II IV Remember Type I is G93.5 Type II IV: Q07.0 Documentation issues: with or without spina bifida With or without hydrocephalus 155 CHAPTER 17: CONGENITAL MALFORMATIONS Deformities Q67.3 Plagiocephaly Q75.0 Craniosynostosis CNS Annual Mtg_ICD10 Neuro (KP)_

27 FULL LIST OF 2017 NEUROSURGERY ICD 10 CM CODE CHANGES URL: Click on Workshops tab This content is Pull down to Course Alumni password protected. Click on Private Course Click on Congress of Neurological Surgeons Find CNS Annual Meeting and click Log in Enter Password: Click Submit 157 Password: CNS2016 Kim Pollock, RN, MBA, CPC, CMDP Thank you karenzupkoandassociates karenzupko&associates 2016 CNS Annual Mtg_ICD10 Neuro (KP)_