ICD-10-CM Countdown: Are You Ready? Prevalence of conditions Number of codes be converted Number of new patients per month Number of bills sent each month Scope of the Implementation
ICD-10-CM Official Draft Code Set Published effective 10/1 each year Facilities must use current, up--date manual ICD-10-CM Official Draft Coding Guidelines Section I of the ICD-10-CM Manual Set of rules accompany and complement the official conventions and instructions provided within ICD-10-CM itself Adherence these Guidelines is mandary
AHA Coding Clinic Published quarterly by the AHA and endorsed by CMS, based on a long-standing public and private secr collaboration Provides guidance on interpreting and applying the ICD-10-CM and is used in claims review Offers coding guidelines and advice based on adherence the statistical classification scheme of ICD-10-CM The purpose: To promote accuracy and consistency in the use of ICD-10-CM Coding Sources for the SNF Hisry and physical Lab reports can confirm or negate a suspected condition X-ray results can confirm or negate a suspected condition Therapy Progress notes may indicate Incident reports may contain
Code Conversion Using GEMs Used promote consistency ICD-9 and ICD-10 codes are very different and ICD-10 offers much more specificity Software vendors should have them available in their systems However, mapping and conversion always needs human intervention! Code Conversion Using GEMs Some mappings will be an exact match UTI, site not specified ICD-9 = 599.0 ICD-10 = N39.0 Some mappings will be an approximate match that needs confirmation Some mappings will have a cluster of matches when more specificity is offered Some mappings will have no match Encounter for rehabilitation ICD-9 = V57 ICD-10 = Use procedure codes instead
Conversion of Existing Codes Using the GEMs, try translating some ICD-9- CM codes ICD-10-CM codes Identify where human intervention is needed Remember, the purpose of the GEMs is create a useful, practical, code--code translation reference dictionary for both code sets, and offer acceptable translation alternatives wherever possible Using the GEMs for Conversion The ICD-9 ICD-10 (and the reverse) GEMs are in.txt file format with 3 columns ICD-9-CM code ICD-10-CM code Flags 00845 A047 00000 6826 L03119 10000 6826 L03129 10000 The 1 st digit 0 in the Flag column indicates an exact match that needs confirmation The 1 st digit 1 in the Flag column indicates an approximate match that needs confirmation and frequently additional information
Convert CHF From ICD-9 ICD-10 in GEMs 4280 I509 10000 The flag 1 indicates an approximate match Check documentation see if there is additional documentation that could be coded under ICD-10-CM, such as whether the CHF is due hypertension, which requires coding the hypertension first Source system is less specific than many of the alternatives in the target system Convert Type 2 Diabetes From ICD-9 ICD-10 in GEMs 25000 E119 10000 The flag 1 indicates an approximate match Check documentation see if there is additional documentation that could be coded under ICD-10-CM, such as whether there are complications specified If complications are specified, then this would not be the correct code (E118 or other) The target contains many translation alternatives, but the least specific is the one highlighted
Convert Aftercare of Healing Traumatic Fracture of Hip (Right) V5413 ******** 10000 The flag 1 indicates an approximate match There are approximately 70+ possible combinations; all require specificity related the situation and all need confirmation Needs laterality Aftercare of a traumatic fracture is no longer an acceptable alternative Source system is less specific along the laterality axis, and the target system contains the more specific translation alternatives New Encounter Coding Determine how improve the diagnostic information flow from physicians staff. Do you have the specificity you need code? When can you obtain clarification so that it does not impede billing and cash flow?
Updating Existing Codes Make sure build updating in your process May need test with your software vendor Every MDS demands updating codes Every UB-04 demands updating codes Contents of ICD-10-CM Manual ICD-10-CM Official Draft Guidelines for Coding and Reporting Alphabetic Index of Diseases and Injuries (Volume 2) Tabular List of Diseases and Injuries (Volume 1)
Complete Review of the Guidelines Is Mandary for Accurate Coding Section I of the ICD manual contains the official coding guidelines Conventions: New, old, revised Lots of new instructions regarding use of codes located in the 21 chapters, including aftercare Specific instructions on selecting principal diagnosis and secondary diagnoses ICD-10-CM Code Structure ICD-10 format can be 3 7 characters Category Subcategory: Etiology, anamical site, severity Extension X X X X X X X 1st Alpha 2nd Numeric 3rd Alpha/nu meric 4th Alpha/ numeric 5th Alpha/ numeric 6th Alpha/ numeric 7th Alpha/ numeric
Examples of ICD-10-CM Codes Digits Code Description 3 I10 Essential (primary) hypertension 4 N36.0 Urinary tract infection, site not specified 5 I25.10 Arterosclerotic heart disease of native coronary artery without angina pecris (includes CAD and ASHD, NOS) 6 Z96.641 Presence of right artificial hip joint 7 S72.002S Fracture of unspecified part of neck of left femur, sequela Reminder: ICD-10-CM uses updated medical terminology. In the beginning, this may present some challenges. Conventions What s the Same? Brackets [ ] Identify manifestation codes in the Alpha Index Example: Dementia in, Parkinson s disease G20 [F02.80] Identify synonyms or alternative terminology in the Tabular List Example: B96.2 Escherichia coli [E. coli] as the cause of diseases Default code A code listed next a main term in the ICD-10- CM Index
Conventions What s the Same? Parentheses ( ) identify non-essential modifiers in both the Alpha Index and Tabular List NEC identifies other specified codes where the information in the medical record provides detail for which a specific code does not exist NOS identifies unspecified codes where the information in the medical record is insufficient assign a specific code Conventions What s the Same? With or without When the Alpha Index include options for with or without, the default will be without The term and when used in a narrative statement may be interpreted as and/or
Conventions What s the Same? Etiology and manifestation convention ICD-10-CM requires the underlying condition be sequenced first followed by the manifestation mandary sequencing The use additional code instruction will appear at the etiology code and The code first instruction will appear at the manifestation code Conventions What s the Same? Code also Identifies that more than one code may be required fully describe the condition. Sequencing is discretionary (e.g., severity and reason for encounter). Inclusion terms or example conditions Indicates examples of conditions classified a category; may not be all inclusive.
Conventions What s Been Revised? Excludes 1 = Not coded here! Indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note Excludes 2 = Not included here! Indicates that the condition excluded is not part of the condition represented by the code but can be assigned in addition It is acceptable use both the code and the excluded code gether when appropriate New Conventions Placeholders ICD-10 can use a dummy placeholder for the 4th, 5th, or 6th digits of a code. Examples: If a code requires a valid 6th digit, but not a 5th digit, then the x is used as the 5th digit A code may require 4th and 7th digits but not a 5th or 6th digit; in this case, the x is used for the 5th and 6th digits Frequently used in the chapters for injuries, external causes, and obstetrics.
New Conventions 7th Characters Some codes within ICD-10-CM have an applicable 7th character Most commonly used in chapters: 14 Diseases of the Musculoskeletal System and Connective Tissue 15 Pregnancy, Childbirth, and the Puerperium 19 Injury, Poisoning, and Certain Other Consequences of External Causes 20 External Causes of Morbidity New Conventions 7th Characters Generally, most categories have a choice of three 7th characters: A: Initial encounter D: Subsequent encounter S: Sequela (late effect)
7th Characters for Fractures Different categories of fractures may utilize a variety of options for a 7th character, but most identify: Initial vs. subsequent vs. sequela Closed vs. open (closed is the default) Absence or presence of complications during the healing phase Routine healing Delayed healing Nonunion Malunion 7th Characters for Fractures 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 P: Subsequent encounter for fracture with malunion S: Sequela
New Conventions Laterality Some codes indicate laterality (e.g., right/left/bilateral) If there is no bilateral code, assign separate codes for the left and right side If the side is not identified in the medical record, assign the code for unspecified side New Conventions Dash The dash - is used in the Alphabetic Index indicate whether the code needs additional digits that are found in the Tabular List Beware! The dash is NOT used in the Alphabetic Index identify when 7th characters are required Example: Stitch, abscess T81.4 is not a valid code. T81.4xxD is a valid code.
General Coding Guidelines Signs and sympms Codes for sympms and signs are acceptable when a related definitive diagnosis has not been confirmed Multiple coding for a single condition Requires two codes fully describe a single condition or a single condition that requires two codes General Coding Guidelines Acute and chronic conditions If the same condition is both acute and chronic, and separate subentries exist in the Alphabetic Index at the same level, code both and sequence the acute first Remember, some codes have a separate designation for acute on chronic or decompensated
Sequelae or Late Effects Example To locate in the Alpha Index, look under the word Sequelae Infarction I69.3 (Sequela of stroke NOS) Cerebral I69.30 (Sequela CVA, NOS) Aphasia I69.320 Ataxia I69.393 Dysphagia I69.391 Dysphasia I69.321 Hemiplegia I69.35- Sequelae or Late Effects Example To confirm in the Tabular List, look under the word I69.391 Dysphagia following cerebral infarction Use additional code identify the type of dysphagia, if known (R13.1-)
Chapter-Specific Coding Guidelines There is specific coding guidance that applies several areas that impact LTC, including: o o o o o o o o o o o Sepsis coding UTI and organism (infections require organism when available) HTN coding MI coding CVA coding Diabetes coding Wounds (need determine cause) Fractures (traumatic and pathological) COPD (special coding rules for asthma), need specificity CAD Causes of morbidity Principal Diagnosis Condition chiefly responsible for resident s admission the nursing facility Diagnosis that provides reason for resident remaining in the nursing facility In determining principal diagnosis, coding conventions in ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines
Principal Diagnosis Sequencing When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, and no other coding guideline provides sequencing directions, then any one of the diagnoses may be sequenced first Other or Additional Diagnoses For reporting purposes, the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring any of the following: Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or moniring
Coding Clinic for LTC for ICD-10-CM Fourth Quarter 2012 Dynamic coding for LTC Coding Basics After you review all the Guidelines, begin use the Alpha Index and the Tabular List look up codes Locate the condition, diagnosis, or sympm in the Alpha Index Read all instructions, cross-references before going the Tabular List Confirm code or codes found in the Tabular List Read instructions, notes, exclusions, etc. May be located at the beginning of chapter, category, or code level Assign code be sure code specified digits
Alpha Index Use Content of Alpha Index (Volume 2) Alpha Index of Diseases and Injuries Neoplasm Table Table of Drugs and Chemicals Index of External Causes NOTE: The Alpha Index should NOT be used as a source code in most cases (exception rule the Neoplasm Table)
Example of Alpha Index Structure Main term Subterm: 1st level Subterm: 2nd level Infection, infected, infective (opportunistic) B99.9 with drug resistant organism see resistance (), drug lymphangitis see Lymphangitis organ dysfunction (acute) R65.20 abscess (skin) code by site under Abscess Absidia see Mucormycosis Acanthamoeba see Acanthamebiasis Acanthocheilonema (perstans) B74.4 accessory sinus (chronic) see sinusitis acromioclavicular M00.9 Actinobacillus A28.8 mallei A24.0 muris A25.1 Let s Test Your Proficiency Find These Terms in the Alpha Index Chronic obstructive pulmonary disease (COPD) Congestive heart failure (CHF) Diabetes, Type 2 Left hip fracture Let s see what we learn
Chronic Obstructive Pulmonary Disease (COPD) 1. Locate in Alpha under Disease, then site Disease, diseased pulmonary (see also Disease, lung) artery I28.9 chronic obstructive J44.9 with acute bronchitis J44.0 exacerbation (acute) J44.1 lower respirary infection (acute) J44.9 2. Read notes ensure you select the code with the correct information Congestive Heart Failure (CHF) 1. Locate in Alpha under Failure, then site Failure, failed heart (see also Disease, lung) congestive (compensated)(decompensated) I50.9 2. If you started with Heart it tells you: see condition
Diabetes, Type 2 1. Locate in Alpha under Diabetes, then type Diabetes, diabetic type 2 E11.9 (also is the default code if type is not known) 2. A patient may have multiple diabetic codes if he or she has multiple diabetic complications Left Hip Fracture 1. Locate in Alpha under Fracture, then site. Note you need know if the fracture is pathological or traumatic. Fracture, traumatic hip see Fracture, femur, neck (updated terminology) femur, femoral upper end neck S72.00- Fracture, pathological femur (hip) M84.45-2. Ensure that you obtain the information from the physician.
Tabular List Use Tabular List (or Volume 1) Chapter Classification of Diseases Codes 1 Certain Infectious & Parasitic Diseases A00 B99 2 Neoplasms C00 D49 3 Diseases of the Blood & Blood-Forming Organs and D50 D89 Certain Disorders Involving the Immune Mechanism 4 Endocrine, Nutritional, and Metabolic Diseases E00 E89 5 Mental, Behavioral, and Neurodevelopmental F01 F99 Disorders 6 Diseases of the Nervous System G00 G99 7 Diseases of the Eye and Adnexa H00 H59 8 Diseases of the Ear and Masid Process H60 H95 9 Diseases of the Circulary System I00 I99 10 Diseases of the Respirary System J00 J99 11 Diseases of the Digestive System K00 K95
Tabular List (or Volume 1) Chapter Classification of Diseases Codes 12 Diseases of the Skin & Subcutaneous Tissue L00 L99 13 Diseases of the Musculoskeletal System and M00 M99 Connective Tissue 14 Diseases of the Geniurinary System N00 N99 15 Pregnancy, Childbirth, and the Peurperium O00 O9A 16 Certain Conditions Originating in the Perinatal Period P00 P96 17 Congenital Malformations, Deformations, and Q00 Q99 Chromosomal Abnormalities 18 Sympms, Signs, and Abnormal Clinical and R00 R99 Laborary Findings, Not Elsewhere Classified 19 Injury, Poisoning, and Certain Other Consequences of S00 T88 External Causes 20 External Causes of Morbidity V00 Y99 21 Facrs Influencing Health Status and Contact With Health Services Z00 Z99 Example of Tabular List Chapter heading Chapter 10. Diseases of the Respirary System (J00 J99) Chronic Lower Respirary Diseases (J40 J49) J44 Other chronic obstructive pulmonary disease (4th) (Read: Includes notes, Code also note, Use additional code notes, Excludes 1 notes before proceeding) J44.0 Chronic obstructive pulmonary disease with acute lower respirary infection Use additional code identify the infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation Decompensated COPD Decompensated COPD with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified Chronic obstructive airway disease NOS Chronic obstructive lung disease NOS Code block Category Subcategory
Tips for Use of the Tabular List Find the chapter that contains the code you are investigating or confirming from the Alpha Index Read any instructions at start of chapter Locate the section and category Read any additional instructions or clarifications Follow through with instructions Select code Confirm Codes From Alpha Index in Tabular List Congestive heart failure (CHF) Diabetes, Type 2 Left hip fracture
Confirm CHF in Tabular List Chapter 9. Diseases of the Circulary System (I00 I99) Other Forms of Heart Disease (I30 I52) I50 Heart failure (4th) (Read: Code first notes and Excludes 1 notes before proceeding) I50.9 Heart failure, unspecified Biventricular (heart) failure NOS Cardiac, heart or myocardial failure NOS Congestive heart disease Right ventricular failure (secondary left heart failure) Excludes 1 fluid overload (E87.70) AHA: 2012, Q4, 92 Note: Instructions appear at both the category and code level. There was a Coding Clinic released in the 4th quarter of 2012. Confirm Diabetes, Type 2 in Tabular List Chapter 4. Endocrine, Nutritional, and Metabolic Diseases of the Respirary System (E00 E89) Diabetes mellitus (E08 E13) E11 Type 2 diabetes mellitus (Read: Includes notes, Use additional code identify any insulin use (Z79.4), and Excludes 1 notes before proceeding) E11.9 Type 2 diabetes mellitus without complications Note: When reading through the Type 2 diabetes codes, it s clear that specificity is warranted. This is the default code.
Confirm Traumatic Left Hip Fracture in Tabular List Chapter 19. Injury, Poisoning, and Certain Other Consequences of External Causes (S00 T88) Injuries Hip and Thigh (S70 S79) S72 Fracture of femur (4th) (Read: Notes, Excludes 1 note, and Excludes 2 note before proceeding) S72.0 Fracture of head and neck of femur (5th) Excludes 2 physeal fracture of upper end of femur (S79.0-) S72.00 Fracture of unspecified part of neck of femur (6th) Fracture of hip NOS Fracture of neck of femur NOS S72.002 Fracture of unspecified part of neck or left femur (7th) 7th character: If therapy is being provided, then the correct 7th character would be S. If there is no residual related the hip fracture, then D would be the 7th character indicate routine healing. Wrap-Up It s going an exciting and challenging year in long-term care Now is the time begin the process Remember just how many codes there are convert Questions?