ICD-10 Training for Otolaryngologists Sponsored by: Alabama Society of Otolaryngology June 12, 2014 Destin, Florida Presented by: Joy McKusick, RHIA
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Agenda 4 Format and Structure Other Coding Conventions and Guidelines Diseases of the Ear and Mastoid Process (H60 H95) Diseases of the Digestive System (K00 K95) Diseases of the Respiratory System (J00 J99) Neoplasms (C00 D49) Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00 Q99) Diseases of the Skin and Subcutaneous Tissue (L00 L99) Symptoms, Signs and Abnormal Clinical and Laboratory Findings (R00 R99) Injury, Poisoning and Certain other Consequences of External Causes (S00 T88) Getting Ready
Learning Objectives 5 At the conclusion of this activity, participants will be able to: Understand ICD-10 code structure and concepts. Use relevant ICD-10 chapters and codes as they relate to ENT. Identify and address documentation deficiencies. Map current ICD-9 codes to ICD-10 codes.
Resources ICD10data.com commerce.ama-assn.org
ICD-10 Delay AGAIN 7 October 2013 October 2014 October 2015
Implementation 9 Take a breath!
Implementation 10 Now is not the time to put off preparation! Be proactive! Make changes now to lessen problems later!
11 Format and Structure
Format and Structure 12 What s the same and what s different?
Format and Structure 13 Alphabetic Index Contains: -Index to Diseases and Injuries Also includes: Tabular List List of alphanumeric codes divided into chapters based on condition and/or body system -Neoplasm Table -Table of Drugs and Chemicals -Index to External Cause of Injuries Contains categories, subcategories and valid codes
Finding the Code 14 Look up the main term Index instructions Locate code in Tabular List
Finding the Code 15 Read all instructional material Review guidelines Confirm and assign code
Finding the Code 16 A Fracture, mandible
Finding the Code 17 B Complication, postmastoidectomy, granulation *Granulation tissue-see Complications, postmastoidectomy, granulation
Finding the Code 18 C Wound, open, nose
Finding the Code 19 D Pain, ear Index directs user to see subcategory H92.0-
Finding the Code 20 E Foreign body, pharynx
Differences? 21 Chapters Titles Injury codes Postoperative Complications
Comparison of ICD-9 and ICD-10 22 Diagnosis codes 3-5 characters in length First character may be alpha or numeric; characters 2-5 are numeric Limited space for new codes Lacks detail ICD-9 Lacks laterality Diagnosis codes are 3-7 characters in length Character 1 is alpha; 2 is numeric; characters 3-7 are alpha or numeric Utilizes every letter except U Flexible for adding new codes Very specific Has laterality ICD-10
What makes up the code? 23 ICD-9-CM ICD-10-CM
Subcategory S00.53- Code S00.531A Contusion of lip, initial encounter Category S00 Contusion of lip and oral cavity Superficial Injury of the head
25 7 th Character Extension and X Placeholder Applies only to certain categories of codes. 7 th character must always be in the 7 th data field. X placeholder is used to fill in empty characters when the code is not 6 characters.
26 7 th Character Extension
27 7 th Character Extension and X Placeholder
28 7 th Character Extension and X Placeholder Foreign body in right ear T16.1- Incorrect code assignment: T16.1A Correct code assignment: T16.1XXA
7 th Character Definitions 29 Initial encounter = A This extension is used when the patient is receiving active treatment for the condition. Examples include: surgical treatment, emergency department encounter and evaluation and treatment by a new physician.
7 th Character Definitions 30 Subsequent encounter = D This extension is used for encounters after the patient has received active treatment and is now in the healing phase receiving routine care for the condition. Examples include: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition
7 th Character Definitions 31 Sequela = S ICD-10-CM no longer has late effect codes. To indicate a condition is the result of a previous injury, the 7 th character extension S is used on the active injury code. When using this extension it is necessary to use both the injury code that is the cause of the sequela and the code for the sequela itself. Example: L91.0 Hypertrophic scar S01.411S Laceration without foreign body of right temporomandibular area, sequela
Practice Questions
Practice Questions 33 Practice 1.1 Answer: A initial encounter Practice 1.2 Answer: True
Practice Questions 34 Practice 1.3 Answer: Chapter 7 eye/adnexa and Chapter 8 Ear and Mastoid process Practice 1.4 Answer: False
Practice Questions 35 Practice 1.5 Answer: A, D, S Practice 1.6 Answer: A, B, D, G, K, S
Practice Questions 36 Practice 1.7 Answer: False Practice 1.8 S02.3XXD
Practice Questions 37 Practice 1.9 Answer: T17.1XXA Practice 1.10 U
38 Other Coding Conventions and Guidelines
39 Other Coding Conventions and Guidelines Abbreviations and Punctuation
40 Other Coding Conventions and Guidelines Instructional Notes, sequencing and new concepts NEC and NOS Other Info Unspecified
41 Other Coding Conventions and Guidelines Punctuation Brackets [ ] Parentheses ( ) Colons : Dash
Other Coding Conventions and 42 Guidelines Excludes 1 Code should not be used at the same time as the code above the Excludes 1 note. Excludes 2 Acceptable to use both the excluded code and the code above the Excludes 2 note. Excludes 1 Excludes 2
Other Coding Conventions and 43 Guidelines Etiology and manifestation Underlying condition is sequenced first, followed by the manifestation code first Noted at manifestation use additional code Noted at etiology code
44 Other Coding Conventions and Guidelines And With See and See Also Code also
Other Coding Conventions and 45 Guidelines Acute and Chronic conditions If separate entries exist, code both sequencing the acute condition first. Laterality Codes available for right, left and bilateral conditions. If a condition is bilateral, but a bilateral code is not available, assign a code for both the right and left side.
Complications of Care 46 Some complications have been moved to specific body system chapters. Cause-and-effect relationship. Documentation must support that there is a relationship between the care provided and the condition.
Practice Questions
Practice Questions 48 Practice 2.1 Answer: False Practice 2.2 Answer: not coded here/code can t be used at the same time as code above the excludes 1 note
Practice Questions 49 Practice 2.3 Answer: right, left, bilateral, unspecified Practice 2.4 Answer: True
Practice Questions 50 Practice 2.5 Answer: Not otherwise specified, unspecified codes Practice 2.6 Answer: A code for both the right and left side should be assigned
51 Chapter Specifics
52 Chapter 8 Diseases of the Ear and Mastoid Process (H60 H95)
53 Chapter 8 Diseases of the Ear and Mastoid Process Highlights Laterality Conventions Code first underlying disease Use additional code Instructional Notes Excludes 1 and 2
Chapter 8 Diseases of the Ear and Mastoid Process 54 Abscess Cellulitis Infective NOS Circumscribed Infective Otitis Externa 380.10 Diffuse NOS Hemorrhagica
Chapter 8 Diseases of the Ear and Mastoid Process 55 Specified type, NEC Actinic Chemical Other acute otitis externa 380.22 Reactive Eczematoid Contact
Chapter 8 56 Disease of the Ear and Mastoid Process Cerumen removal Laterality Acquired stenosis of external ear canal Changed some of the code titles
Chapter 8 57 Diseases of the Ear and Mastoid Process Nonsuppurative otitis media Inflammation without the production of pus. Instructional notes Tympanic membrane perforation. Smoking use/dependence/exposure
Otitis Media 58 Acute otitis media (AOM) The rapid onset of signs and symptoms of inflammation of the middle ear. Recurrent AOM Three or more well-documented and separate AOM episodes in the past 6 months or at least 4 well-documented and separate AOM episodes in the past 12 months with at lease 1 in the past 6 months. Chronic otitis media with effusion (OME) OME persisting for 3 months or longer from the date of onset or from the date of diagnosis.
Otitis Media 59 Suppurative Purulent (pus) fluid in the middle ear Excludes 1 for tympanic membrane perforation for subcategory H66.01- Use additional code for smoking use/dependence or exposure.
Chapter 8 Diseases of the Ear and Mastoid Process 60 Hearing Loss Unilateral Right or left Types of loss Conductive Sensorineural Mixed
Complications
Documentation Examples 62 What code(s) are assigned for the clinic encounter? H65.91 Unspecified nonsuppurative otitis media, right ear H72.01 Central perforation of tympanic membrane, right ear
Documentation Examples 63 Potential documentation gaps: 1. Laterality is noted for specific code selection. 2. Mucoid fluid is noted in exam, but impression and plan only state otitis media. Be as specific as possible when describing the diagnosis using ICD-10 code language when possible. 3. Acute/chronic is not documented. Forced to use an unspecified OM code. Inclusion terms under the unspecified category list mucoid OM, NOS. Other issues for code selection:
Documentation Examples 64 What code(s) are assigned for the clinic encounter? H91.90 Unspecified hearing loss, unspecified ear H93.19 Tinnitus, unspecified ear R42 Dizziness Potential documentation gaps: Laterality-Specify which ear or if bilateral ears have hearing loss and/or tinnitus Specific type of hearing loss if known. Other issues for code selection: Unilateral/bilateral issue for hearing loss code selection.
65 Chapter 11 Diseases of the Digestive System (K00 K95)
Chapter 11 Diseases of the Digestive System 66 Highlights Conditions reclassified Instructional notes Alcohol use/dependence Smoking
67 Chapter 11 Diseases of the Digestive System Salivary glands 1-1 mapping Sialoadenitis acute recurrent chronic Image Source: http://upload.wikimedia.org/wikipedia/commons/d/df/blausen_0780_salivaryglands.png
68 Chapter 11 Diseases of the Digestive System Mouth Lips Tongue Image Source: http://upload.wikimedia.org/wikipedia/commons/6/6a/illu03_mouth.jpg
69 Chapter 11 Diseases of the Digestive System Gastro-Esophageal Reflux Disease HEARTBURN
Practice Questions
Practice Questions 71 Practice 3.11.1 Answer: Biting Answer: K13.1 Practice 3.11.2 Answer: K21.9 Practice 3.11.3 Answer: T45.1X5 A, D, S Answer: Y84.2
Practice Questions 72 Practice 3.11.4 Answer: K11.21 Practice 3.11.5 Answer: K11.22
Practice Questions 73 Practice 3.11.6 Answer: K14.5 Practice 3.11.7 Answer: K22.711
74 Chapter 10 Diseases of the Respiratory System (J00 J99)
75 Chapter 10 Diseases of the Respiratory System Highlights Instructional notes Excludes 1 and 2
Chapter 10 76 Diseases of the Respiratory System Infectious agent code assignment. Use code for in diseases classified elsewhere A49.02 Methicillin resistant staphylococcus aureus Excludes 1 note indicating not to use with bacterial agent as cause of disease classified elsewhere. B95.62 MRSA as cause of disease classified elsewhere Watch for correct code assignment!
Sinusitis 77 Acute Lasts up to four weeks Recurrent Several attacks in a year Three or more episodes in a year with each lasting two weeks.
Sinusitis 78 Chronic Last more than 12 weeks Three months or more Longer than 8 weeks Pansinusitis All four sinuses are infected
Chapter 10 Diseases of the Respiratory System 79 Tonsillitis Acute Acute recurrent Chronic Streptococcal Other Tonsillitis and Adenoiditis Chronic Hypertrophy Image Source: http://upload.wikimedia.org/wikipedia/commons/thumb/8/89/blausen_0861_tonsils%26thr oat_anatomy2.png/600px-blausen_0861_tonsils%26throat_anatomy2.png
80 Chapter 10 Tonsillitis Acute Fever, sore throat, foul breath, tender cervical lymph nodes. Airway obstruction due to swollen tonsils Symptoms usually resolve in three to four days, may last up to two weeks. Recurrent Multiple episodes of acute tonsillitis in a year. Chronic Individuals have chronic sore throat, halitosis, tonsillitis and persistently tender cervical nodes.
Rhinitis 81 Vasomotor Rhinitis not caused by hay fever or allergies Non-allergic rhinitis Allergic Similar code titles 1-1 mapping
82 1-1 mapping!!!!!
83 Chapter 10 Diseases of the Respiratory System Asthma Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent
84 Chapter 10 Diseases of the Respiratory System Asthma Intermittent Wheezing/coughing no more than 2 days/week Nighttime flare-ups occur twice a month at most Mild persistent Symptoms occur more than twice a week, but less than one per day Nighttime flare-ups occur more than twice/month, but less than once/week
85 Chapter 10 Diseases of the Respiratory System Asthma Moderate persistent Symptoms occur daily Flare-ups occur and usually last several days Severe persistent Symptoms occur daily and often Curtails activities and disrupts sleep Lung function less than 60% without treatment www.healthychildren.org
Chapter 10 86 Diseases of the Respiratory System Intraoperative and Postprocedural Complications Documentation requirements
Documentation Examples 87 What code(s) are assigned for the clinic encounter? J03.01 Acute recurrent streptococcal tonsillitis Potential documentation gaps: 1. Acute vs. recurrent-documentation states patient has had 6 plus infections in the last year. Documentation in plan states acute strep, but would advise physician to use term recurrent to code more specifically to show severity of rate of infections. 2. Would also code for enlarged lymph nodes. R59.0 Localized enlarged lymph nodes. Other issues for code selection:
Documentation Examples 88 What code(s) are assigned for the clinic encounter? J32.4 Pansinusitis NOS J33.0 Polyp of nasal cavity J34.2 Deviated septum Potential documentation gaps: Chronic vs. NOS. If acute or chronic isn t documented, sinusitis codes default to chronic. Asthma is noted in HPI, but isn t addressed in plan and impression. Asthma should be addressed in the plan and impression if it influences the care of the patient. Also, added as an additional diagnosis.
Documentation Examples 89 Other issues for code selection: Acute sinusitis codes now have options for recurrent acute infections. ICD-10- has specific codes available for pansinusitis. New guideline for coding more than one sinus infected, but less than 4. Use other specified sinusitis codes per the guideline.
90 Chapter 2 Neoplasms (C00 D49)
Chapter 2 Neoplasms 91 Neoplasm Table Reference first unless a histologic term is documented Malignant Benign In situ Uncertain histologic behavior Unspecified behavior
Chapter 2 Neoplasms 92 Overlapping sites Separate code within the category. History of vs. active neoplasm Primary malignancy is excised/eradicated and no further treatment is directed to the site, use code from category Z85.
Chapter 2 Neoplasms (C00 C49) 93 Use additional code Includes and Excludes NOS Laterality
Chapter 2 Neoplasms (C00 C49) 94 Malignant neoplasms 1 1 mapping 141.0 = C01 Malignant neoplasm of base of tongue 1 many mapping 146.8 Malignant neoplasm other specified sites of oropharynx C10.4 Malignant neoplasm of branchial cleft C10.8 malignant neoplasm of overlapping sites of oropharynx Expanded for greater specificity of location.
Chapter 2 Neoplasms (C00 C49) 95 Melanoma and other skin cancers Malignant melanoma and melanoma in situ Separate codes to indicate malignant melanoma or in situ. Image source: http://en.wikipedia.org/wiki/file:humanskindiagram.jpg
Skin Cancer 96 Categorized by type of skin cancer, like ICD-9-CM. Basal cell Squamous cell Merkel cell Other specified malignant neoplasm Unspecified malignant neoplasm Source: http://upload.wikimedia.org/wikipedia/commons/thumb/c/c1/ Layers_of_the_skin.jpg/495px-Layers_of_the_skin.jpg
Chapter 2 Neoplasms (C00 C49) 97 Benign neoplasms Similar to malignant neoplasm with many 1-1 mapping. Benign skin neoplasms Melanocytic nevi Other benign neoplasm
Documentation Examples 98 What code(s) are assigned for the clinic encounter? R22.1 Neck mass R09.81 Nasal congestion Z72.0 Tobacco use Potential documentation gaps: For current diagnoses, documentation supports most specific code available. Other issues for code selection: Codes for head and neck mass now have different codes depending on location.
Documentation Examples 99 What code(s) are assigned for the clinic encounter? C07 Malignant neoplasm of parotid gland C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck Z72.0 Tobacco use Potential documentation gaps: Code fully for primary and secondary sites. Document specific location of cancer. Other issues for code selection: Instructional note to add tobacco use/dependence/exposure as well as any alcohol abuse and dependence.
100 Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00 Q99)
101 Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities Highlights Eye, Ear, Face and Neck Respiratory System Nose Larynx Trachea and Bronchus Cleft lip and palate Down Syndrome
Practice Questions
Practice Questions 103 Practice 3.17.1 Answer: Q37.5 Practice 3.17.2 Answer: False
Practice Questions 104 Practice 3.17.3 Answer: Q17.5 Practice 3.17.4 Answer: Q32.0
Practice Questions 105 Practice 3.17.5 Answer: Q30.0 Practice 3.17.6 Answer: True
Practice Questions 106 Practice 3.17.7 Answer: Q31.0
107 Chapter 12 Diseases of the Skin and Subcutaneous Tissue (L00 L99)
108 Chapter 12 Diseases of the Skin and Subcutaneous Tissue Highlights Instructional notes Image Source: http://upload.wikimedia.org/wikipedia/commons/5/5d/anatomy_the_skin_- _NCI_Visuals_Online.jpg
Chapter 12 Diseases of the Skin and Subcutaneous Tissue 109 Infections of the skin and subcutaneous tissue Radiation-related disorders Disorders of skin appendages Complications Other skin disorders
Practice Questions
Practice Questions 111 Practice 3.12.1 Answer: True Practice 3.12.2 Answer: Cyst
Practice Questions 112 Practice 3.12.3 Answer: Use additional code to identify infectious agent Practice 3.12.4 Answer: Additional code to indicate type of retained foreign body
Practice Questions 113 Practice 3.12.5 Answer: Code for the condition being treated first with the active injury code second. Answer: S sequela
114 Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings (R00 R99)
115 Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings Highlights Use of symptom codes Instructional notes
116 Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings 1-1 mapping Same code titles for many conditions. Epistaxis 784.7 = R04.0 Hemorrhage from throat 784.8 = R04.1 Postnasal drip 784.91 = R09.82 Jaw pain 784.92 = R68.84 Others have been expanded R06.5 mouth breathing R06.7 sneezing
Sleep Conditions 117 Most codes were reclassified to the Nervous System chapter. Some sleep codes fall into the Mental, Behavioral and Neurodevelopmental disorders chapter. Obstructive sleep apnea (adult) (pediatric) ICD-10-CM = G47.33
118 Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes (S00 T88)
119 Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes Highlights S-section and T-section 7 th character extension definitions
120 Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes X Placeholder Future code expansion T36.8X1A Fill in empty character positions to assign 7 th character to 7 th data field. S02.2XXA
Practice Questions 121 Practice A: A initial encounter for closed fracture B: D subsequent encounter C: S sequela D: A initial encounter E: A initial encounter
122 Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes Coding guidelines for injuries and fractures KNOW THE RULES!
123 Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes Injuries to the Head and Neck Superficial Open wound Fracture Dislocation and sprain Image Source: http://upload.wikimedia.org/wikipedia/commons/thumb/1/1a/human_skull_front_simplified _%28bones%29.svg/399px-Human_skull_front_simplified_%28bones%29.svg.png
124 Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes Foreign body Superficial Entering through natural orifice Respiratory Tract
125 Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes Complications of Surgical and Medical Care, NEC Wound infections Mechanical complications Disruption of surgical wounds Infections due to prosthetic devices, implants, grafts
Documentation Examples 126 What code(s) are assigned for the clinic encounter? T16.1XXA Foreign body of right ear, initial encounter T16.2XXA Foreign body of left ear, initial encounter What code(s) are assigned for the surgical encounter? T16.1XXA Foreign body of right ear, initial encounter T16.2XXA Foreign body of left ear, initial encounter What codes(s) are assigned for the post-operative visit? T16.1XXD Foreign body of right ear, initial encounter T16.2XXD Foreign body of left ear, initial encounter
Documentation Examples 127 Potential documentation gaps: Laterality is clearly documented 7 th character extension-initial or subsequent Other issues for code selection: X placeholder Assign two codes because there isn t a bilateral option
Documentation Examples 128 What code(s) are assigned for the clinic encounter? S09.22XA Traumatic rupture of left ear drum, initial encounter H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side. What code(s) would be assigned if patient required a paper patch at the next visit and why? S09.22XA Traumatic rupture of left ear drum, initial encounter Surgical care is considered initial encounter. Patient is being actively treated for the condition. Hearing loss code if still present.
Documentation Examples 129 What code(s) would be assigned at the next visit if the patient did not require further treatment and why? S09.22XD Traumatic rupture of left ear drum, subsequent encounter Patient has entered the healing/recovery phase. Hearing loss code if still present. Potential documentation gaps: Laterality-Documentation addresses which ear has the condition. 7 th character extension-initial or subsequent
Documentation Examples 130 Other issues for code selection: X placeholder Codes are assigned to the injury chapter rather than ear and mastoid process chapter. Traumatic ear drum ruptures are not specific to type of perforation (e.g., marginal, central) like the codes from the H72 category in the Ear and Mastoid Chapter.
131 Getting Ready
132 Steps to Implementation
Steps to Implementation 133 1. Form a Team 2. Inventory the Practice 3. Frequency Reports 4. Mapping 5. Gap Analysis
Thank You Joy McKusick, RHIA jmckusick@karenzupko.com 312.642.5616