Who is Using ICD-10-CM?

Conventions and Guidelines You Need to Know Presented by Brenda Edwards, CPC, CPMA, CPB, CPC-I, CEMC, CRC Who is Using ICD-10-CM? 1

Objectives of Presentation Review new conventions and chapter specific guidelines Conventions Excludes1 Excludes2 Etiology/Manifestation Chapter Specific Guidelines HIV Episode of care (7 th characters) Sepsis Fracture care (7 th characters) Anemia with malignancy External Causes Hypertension with heart failure and/or chronic kidney disease 2

Excludes1 Not coded here! Code excluded should never be used at the same time as the code above the Excludes1 note Two conditions cannot occur together Example: H92.2 Otorrhagia Excludes1 traumatic otorrhagia-code to injury Excludes2 Not included here Acceptable to use both the code and the excluded code together, when appropriate Example: An acute exacerbation of a chronic condition J32 Chronic sinusitis Excludes2 acute sinusitis (J01.-) 3

Etiology/Manifestations Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology Underlying condition is coded first followed by manifestation use additional code for etiology code first for manifestation in diseases classified elsewhere (never first listed) Example: F02.8-Dementia in other diseases classified elsewhere Code first the underlying physiological condition, such as: Parkinson s disease (G20) 4

HIV Code only confirmed cases Confirmation does not require documentation of positive serology or culture for HIV; provider s diagnostic statement is sufficient Patient admitted for HIV-related condition B20 HIV virus followed by additional diagnosis codes for all reported HIVrelated conditions Patient admitted for unrelated condition Unrelated condition is primary followed by B20 and all other HIV-related conditions Asymptomatic HIV is coded as Z21 Used for patient without any documentation of symptoms is listed as being HIV positive or known HIV HIV positive Do not use if AIDS is used of patient is treated for any HIV-related illness or conditions (use B20) HIV Inconclusive HIV serology Assign R75 when there is no definitive diagnosis Previously diagnosed HIV related illness Patients with any known prior diagnosis of an HIV-related illness are coded to B20 ICD-9 042 B20 HIV in pregnancy Pregnancy codes (Chapter 15) codes take sequencing priority Symptomatic is coded as O98.7- followed by B20 and codes for HIVrelated illnesses Asymptomatic is coded O98.7- and Z21 V08 Encounters for testing To determine HIV status, use Z11.4 and additional codes for any associated high risk behavior Counseling and reporting negative results is coded with Z71.7 Z21 795.71 R75 647.6X O98.7- V73.89 Z11.4 V65.44 Z71.7 ICD-10 5

HIV Sequencing Scenario HIV related condition is being treated HIV patient is treated/admitted for unrelated condition New diagnosed or previous admissions for HIV conditions HIV positive, Known HIV, HIV test positive AIDS or any HIV related illness Previously diagnosed HIV-related illness Inconclusive HIV serology HIV during pregnancy First Listed Code B20 Unrelated condition Irrelevant Z21 B20 B20 R75 O98.7- Encounter for HIV testing Z11.4 Patient returns to be given test results (negative) Z71.7 11 Sepsis Progression Bacteremia Organism in blood Septicemia More specific and systemic infection Sepsis, with SIRS due to infection Indicates progression into sepsis but no acute organ dysfunction Severe Sepsis With septic shock and acute organ dysfunction Multiple organ dysfunction Death 12 6

Sepsis Assign appropriate code for underlying systemic infection If type of infection or causal organism is not further specified use A41.9 R65.2-Severe sepsis should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented Query provider for: Negative or inconclusive blood cultures Urosepsis is used-it is a non-specific term Sepsis with organ dysfunction not indicated as associated with sepsis Do not assign R65.2- Severe sepsis Acute organ dysfunction must be associated with severe sepsis Query provider if unclear Severe Sepsis Severe sepsis requires a minimum of 2 codes Systemic infection coded first with R65.2- Severe sepsis coded second. If causal organism is not documented, use A41.9 Code also for associated acute organ dysfunction Because of complex nature, provider may need queried for sequencing Septic shock generally refers to circulatory failure associated with severe sepsis, therefore Represents a type of acute organ dysfunction because it associated with severe sepsis Systemic infection is coded first followed by R65.21 (severe sepsis with septic shock) OR T81.12 (postprocedural septic shock). Septic shock cannot be assigned as a principal diagnosis (R65.2-) Code also any other acute organ dysfunctions 7

Severe Sepsis Sequencing severe sepsis Underlying systemic infection is principal diagnosis followed by appropriate code from R65.2- Severe sepsis develops during an encounter-the underlying infection first followed by R65.2- Query provider if documentation is unclear whether severe sepsis was present on admission With localized infection Code underlying systemic infection first followed by code for localized infection Severe sepsis R65.2- would follow when documented Sepsis Due to Postprocedural Infection Code assignment is based on providers documentation of relationship between infection and procedure T80.2- Infection following infusion, transfusion and therapeutic injection, T81.4- Infection following a procedure, T88.0- Infection following immunization, O86.0- Infection of obstetric surgical wound is coded first followed by code for specific infection Severe sepsis is assigned from R65.2- and any acute organ dysfunction would also be coded Postprocedural infection has occurred and resulted in severe sepsis and postprocedural septic shock, code the precipitating complication first followed by R65.21 Severe sepsis with septic shock and a code for systemic infection 8

Sepsis/Severe Sepsis Associated with Noninfectious condition Sepsis/severe sepsis is documented as associated with a noninfectious condition (burn, injury), code the noninfectious condition first followed by code for resulting infection. If severe sepsis is present, assign R65.2- R65.1-Systmic inflammatory response syndrome (SIRS) is not coded for these cases Sepsis and Sequencing A41.9 Type of infection not further specified Negative or inconclusive blood cultures R65.2 Sepsis/Severe Sepsis w/localized infection Only assigned when severe sepsis or associated acute organ dysfunction is documented Requires minimum of 2 codes Underlying systemic infection Severe sepsis R65.2- If causal organism not identified-a41.9 with additional codes for acute organ dysfunction Underlying systemic infection followed by Localized infection AND R65.2 if severe sepsis present List localized infection first followed by sepsis code(s) if admitted with localized infection and sepsis/severe sepsis doesn t develop until after admission Septic Shock (circulatory failure associated w/severe sepsis) Systemic infection followed by R65.21 Severe sepsis with septic shock ort81.12 Postprocedural septic shock AND Other acute organ dysfunction(s) 18 9

Anemia With Malignancy Changes from ICD-9! Anemia associated with malignancy-treatment for anemia Malignancy is sequenced first followed by appropriate code for anemia Anemia associated with chemotherapy, immunotherapy-treatment for anemia Anemia is sequenced first followed by neoplasm and adverse effect (T45.1X5-) Anemia associated with radiotherapy-treatment for anemia Anemia is sequenced first followed by neoplasm code and Y84.2 Radiological procedure and radiotherapy as cause of abnormal reaction Neoplasm With Complications Management of a complication associated with neoplasm, treatment is directed at complication- it is coded first followed by neoplasm except: Anemia associated with malignancy Treatment is only for anemia Anemia associated with chemotherapy, immunotherapy and radiation therapy Treatment is only for anemia Management of anemia associated with adverse effect of radiotherapy Management of dehydration due to malignancy Dehydration being treated Primary DX Malignancy Anemia Anemia Dehydration Anemia Secondary DX Malignancy followed by T45.1X5 Adverse effects of antineoplastic drugs Neoplasm followed by Y84.2 Radiological procedure and radiotherapy as cause of abnormal reaction Malignancy 20 10

Hypertension Hypertension table is deleted I10 is the only code used to report benign or malignant hypertension That doesn t mean documentation can simply state hypertension. Still need the details I10 Essential hypertension (primary) I11 Hypertensive heart disease Use additional code to identify type of heart failure (I50.-) I12 Hypertensive chronic kidney disease Use additional code to identify stage of CKD (N18.1-N18.6, N18.9) I13 Hypertensive heart and chronic kidney disease Use additional code to identify type of heart failure (I50.-) Use additional code to identify stage of CKD (N18.1-N18.6, N18.9) Hypertension With Heart Failure Guidelines are similar to ICD-9 Causal relationship must be stated (due to) or implied (hypertensive) I11.0 Hypertensive heart disease with heart failure Use additional code to identify type of heart failure (I50.-) I11.9 Hypertensive heart disease without heart failure 11

I50 Heart Failure I50.1 Left ventricular failure I50.2- Systolic (congestive) heart failure I50.3- Diastolic (congestive) heart failure I50.4- Combined systolic and diastolic (congestive heart failure) Acute (congestive) heart failure Chronic (congestive) heart failure Acute on chronic (congestive) heart failure I50.9 Heart failure, unspecified Hypertension With CKD Assume a relationship between hypertension and chronic kidney disease (CKD) Primary code I12.- hypertensive CKD I12.0 Hypertensive CKD with stage 5 CKD or ESRD I12.9 Hypertensive CKD with stage 1-4 CKD * Use code from N18.- to identify stage of CKD for I12.0 or I12.9 12

N18 Chronic Kidney Disease N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 N18.3 Chronic kidney disease, stage 3 N18.4 Chronic kidney disease, stage 4 N18.5 Chronic kidney disease, stage 5 Use N18.6 when stage 5 requires chronic dialysis N18.6 Chronic kidney disease, stage 6 Use additional code to identify dialysis status (Z99.2) N18.9 Chronic kidney disease, unspecified Hypertensive Heart and CKD Includes hypertension, heart disease and CKD Includes note at I13 specifies conditions included at I11 and I12 are included together in I13 For patients with both acute renal failure and chronic CKD requires additional code for acute renal failure I13.0 Hypertensive heart and CKD with heart failure and stage 1-4 CKD, or unspecified CKD I13.10 Hypertensive heart and chronic kidney disease without heart failure and stage 1-4 CKD or unspecified CKD I13.11 Hypertensive heart and chronic kidney disease without heart failure and stage 5 or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and stage 5 or end stage renal disease 13

Episode of Care (7 th Characters) Used mostly with Chapter 19 (S00-T88) A=Initial encounter Think ACTIVE treatment Surgical treatment Emergency department encounter Evaluation and treatment by a new physician Episode of Care (7 th Characters) D=Subsequent encounter After patient has received active treatment and is receiving routine care during the healing or recovery phase Cast change or removal Removal of external/internal fixation device Medication adjustment Other aftercare and follow up visits following treatment of condition 14

Episode of Care (7 th Characters) S =Sequela (late effect) Complications or conditions that arise as a direct result of a condition Example-scar formation after a burn scar is the late effect from the burn S is added to injury code, not late effect Late effect is sequenced first followed by injury Fracture Care (7 th characters) Initial Encounter A closed fracture B open fracture type I or II C open fracture type IIIA, IIIB, IIIC Subsequent Encounter D closed fracture with routine healing E open fracture type I or II with routine healing F open fracture type IIIA, IIIB, IIIC with routine healing G closed fracture with delayed healing H open fracture type I or II with delayed healing J open fracture type IIIA, IIIB, IIIC with delayed healing K closed fracture with nonunion M open fracture type I or II with nonunion N open fracture type IIIA, IIIB, IIIC with nonunion P closed fracture with malunion Q open fracture type I or II with malunion R open fracture type IIIA, IIIB, IIIC with malunion 15

Initial Fracture Treatment Traumatic fractures are coded using the appropriate seventh character extension for initial encounter while the patient is receiving active treatment for the fracture A (closed), B (open), C (open) Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion Subsequent Fracture Treatment Subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase D,E,F (routine healing), G,H,J (delayed healing), K,M,N (nonunion), P,Q,R (malunion) Examples of aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment 16

External Causes There is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless a provider is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not required. In the absence of a mandatory reporting requirement, providers are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies. External Causes (V, W, X, Y) Never used as the primary diagnosis Can be used with any code in A00-T88.9, Z00-Z99 Use for each encounter for which the injury or condition is being treated Most codes require 7 th character for episode of care (A, D, S) 7 th character should match those of the associated condition or injury Use as many as needed to fully describe cause, intent, place of occurrence and activity and status of patient 17

External Cause-Type of Accident Transportation Slip, trip, stumble, fall Exposure to inanimate objects (sports equipment, sharp objects, machinery, firearms) and animate objects (contact with animals, insects, marine life, spiders, snakes, alligators) Accidental non-transport drowning and submersion Exposure to temperatures and pressures, smoke, fire and flames, forces of nature Intentional self-harm Assault Legal intervention, war and military operations, terrorism External Cause-Place of Occurrence Identifies the place of occurrence of the external cause Use with an activity code Recorded only at the initial encounter for treatment Specific location (single-family home, apartment, mobile home, institution, dorm, military base, prison, reform school, cultural building, hospital, religious institution, public building, sports area, farm) No 7 th characters are used for Y92 18

External Cause-Activity (Y93) Describes activity of the patient at time of occurrence Only used once at initial treatment Only use one code from Y93 Do no apply to poisonings, adverse effects, sequela External Cause-Status (Y99) Used in conjunction with external cause codes to indicate the status of the person at the time of the event Y99.0 Civilian activity done for income or pay Y99.1 Military activity Y99.2 Volunteer activity Y99.8 Other Hobby, leisure, off-duty military, student activity 19

Example The chain gang was on detail cleaning the prison pool and were given a 10 minute break. Rufus was clowning around for the other inmates when he decided to show off his dance moves. As he danced around the pool, he thought it would be really funny to dance on the diving board. Well, he lost his balance and cut his left forearm on the diving board and did a belly flop into the pool. S51.812A Laceration of left forearm without foreign body W21.4XXA Striking against diving board W16.512A Jumping or diving into a swimming pool striking water surface (belly flop) Y92.146 Swimming-pool of prison as the place of occurrence of the external cause Y93.41 Activity, dancing Conclusion ICD-10 is coming-in fact, it s almost here-55 days!!! ICD-10 is a new code set, not a new concept We were all beginners at one point-this code set takes us back to a new beginning for diagnosis coding Know the book Look up in Alphabetic Index Verify in Tabular Index Check Official Guidelines for further guidance 20

Thank You! 21