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Michigan Trauma Board – October 2013
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  1. An Introduction to ICD-10-CM/PCS Michigan Trauma Board – October 2013

  2. Objectives

  3. What’s changing, what isn’t? ICD-10, When?

  4. Why Change?

  5. ICD-10 Around the World Australia 1998-1999 Brazil 1998 Canada 2001 China 2002 France 2005 Germany 1998 Korea 2008 Netherlands 1994 Russia 1999 South Africa 1996 Sweden 1997 Thailand 2007 United States 2014 United Kingdom 1995 U.A.E (Dubai) 2012

  6. When will this occur?

  7. What are ICD-10-CM and ICD-10-PCS? • ICD = International Classification of Diseases • 10 = 10th Revision • CM = Clinical Modification • PCS = Procedure Classification System • ICD-10-CM • Diagnosis code set • ICD-10-PCS • Procedure code set

  8. Comparing ICD-9 to ICD-10

  9. What about ICD-11? The following is taken from the World Health Organization Committee for the Coordination of Statistical Activities Twenty-second Session 4-6 September 2013 discussing ICD 11: • In conclusion: • (a) WHO Secretariat could produce an ICD 2015 ready including Mortality and Morbidity Linearizations, Reference Guide and Index with the appropriate resolution to go to the World Health Assembly. This timeframe, however, is extremely tight for paying due diligence to the work especially in terms of: • appropriate consultations with expert groups; and sufficient time for field testing in multiple • countries and settings, and carrying out the resulting edits • (b) If the timeline is advanced to 2016, there will be more time to have ICD 2016 version with more translations and incorporations of some field tests results. • (c) If the timeline is advanced to 2017, ICD 2017 will be ready with most Field Test results incorporated and maintenance scheme tested.

  10. What about ICD-11? “Assuming that ICD-11 becomes available on schedule in 2016, the earliest the United States could move to ICD-11 would be 2025. That's 12 years from now. Can we really afford to wait that long? If you don't have the clinical analytics to survive in the changing health care environment we're facing, you may not survive until 2025 to find out.” Leon-Chisen, Nelly. "If We Procrastinate Long Enough, Will ICD-11 Be Ready?." H&HN. n.d. n. page. Web. 1 Oct. 2013. <http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2013/0313HHN_ahavoices&domain=HHNMAG>.

  11. Benefits of ICD-10-CM

  12. Benefits of ICD-10-CM ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practice. The modern classification system will provide much better data needed for: • Measuring the quality, safety, and efficacy of care • Reducing the need for attachments to explain the patient’s condition • Designing payment systems and processing claims for reimbursement;

  13. Benefits of ICD-10-CM • Conducting research, epidemiological studies, and clinical trials; • Setting health policy; • Operational and strategic planning; • Designing health care delivery systems; • Monitoring resource utilization; • Improving clinical, financial, and administrative performance; • Preventing and detecting health care fraud and abuse; and • Tracking public health and risks. • Note: Some non-specific codes still exist for use when the medical record documentation does not support a more specific code.

  14. ICD-9-CM/ICD-10-CM: Similarities and differences

  15. Structural Similarities and Differences between ICD-9-CM and ICD-10-CM Diagnoses

  16. ICD-9-CM Structure - Format Category Subcategories Subclassification 3-5 Characters

  17. ICD-9-CM Structure –Format • 3 - 5 Characters - Examples • 042 Human immunodeficiency virus disease • 496 Chronic airway obstruction, NEC • 414 .00 Coronary atherosclerosis of unspecified vessel, native or graft • V 55.3 Attention to artificial openings, colostomy • 274.03 Chronic gouty arthropathy with tophus

  18. ICD-10-CM Structure –Format Category Etiology, Anatomic Site, Severity 7th Character 3-7 Characters

  19. ICD-10-CM Structure –Format • 3 - 7 Characters - Examples • B20 Human immunodeficiency virus disease • J44.9 Chronic obstructive pulmonary disease, unspecified • I12.510 Atherosclerotic heart disease of native coronary artery without angina pectoris • Z43.3 Encounter for attention to colostomy • M1A.0111 Idiopathic chronic gout, right shoulder, with tophus

  20. ICD-10-CM: Similarities to ICD-9-CM • Divided into Alphabetic Index and Tabular List • Structure and format are the same • Index is alphabetical list of terms and their corresponding codes • Alphabetic Index lists main terms in alphabetical order with indented subterms under main terms • Index is divided into sections: • Index to Diseases and Injuries • Table of Neoplasms • Table of Drugs and Chemicals • External Cause of Injuries Index

  21. ICD-10-CM: Similarities to ICD-9-CM • Divided into Alphabetic Index and Tabular List • Tabular List is a chronological list of codes divided into chapters based on body system or condition • Tabular List is presented in code letter/number order • Same hierarchical structure • Codes are invalid if they are missing an applicable character • Chapters in Tabular structured similarly to ICD-9-CM, with minor exceptions • A few chapters have been restructured • Sense organs (eye and ear) separated from Nervous System chapter and moved to their own chapters • Codes are looked up the same way • Look up diagnostic terms in Alphabetic Index • Then verify code number in Tabular List

  22. ICD-10-CM: Similarities to ICD-9-CM • Many conventions have same meaning • Abbreviations, punctuation, symbols, notes such as “code first” and “use additional code” • Nonspecific codes (“unspecified” or “not otherwise specified”) are available to use when detailed documentation to support more specific code is not available

  23. ICD-10-CM: Similarities to ICD-9-CM • ICD-10-CM Official Guidelines for Coding and Reporting accompany and complement ICD-10-CM conventions and instructions • Website for ICD-10-CM guidelines 2014 • http://www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf • Adherence to the official coding guidelines in all healthcare settings is required under the Health Insurance Portability and Accountability Act • AHA is publishing information in Coding Clinic for ICD-10-CM/PCS • Began Fourth Quarter 2012 • Will become exclusively ICD-10-CM/PCS First Quarter 2014

  24. ICD-10-CM: Differences from ICD-9-CM • Codes are alphanumeric • 1st character is always alpha • characters 2-7 are alphanumeric • Codes can be up to 7 characters in length • Codes are more specific • Code titles are more complete (no need to refer back to a category, subcategory, or subclassification level to determine complete meaning of code) • Example:I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

  25. ICD-10-CM: Differences from ICD-9-CM • Laterality (side of the body affected) has been added to relevant codes • Expanded use of combination codes • Certain conditions and associated common symptoms or manifestations • Poisonings and associated external cause • Injuries grouped by anatomical site rather than type of injury • Codes reflect modern medicine and updated medical terminology

  26. New Features

  27. ICD-10-CM New Features • Combination codes for conditions and common symptoms or manifestation • Combination Codes –Examples • I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris • K71.51 Toxic liver disease with chronic active hepatitis with ascites • K50.012 Crohn’s disease of small intestine with intestinal obstruction • N41.01 Acute prostatitis with hematuria

  28. Code Comparison – Diagnosis Combination Codes Diagnosis: Diabetic retinopathy • ICD-9-CM • 250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled • 362.01 Background diabetic retinopathy • ICD-10-CM • E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

  29. Breakdown of the ICD-10-CM Code Category- Type 2 Diabetes Mellitus Etiology, Anatomic Site, Severity- With unspecified diabetic retinopathy without macular edema 7th Character- No 7th Character 3-7 Characters

  30. ICD-10-CM New Features • Combination codes for poisonings and external causes • T42.5x5A Adverse effect of mixed antiepileptics, initial encounter • Added laterality • S80.251A Superficial foreign body, right knee, initial encounter

  31. ICD-10-CM New Features

  32. ICD-10-CM New Features: Injuries ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b • When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. • Code T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. • Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. • The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

  33. ICD-10-CM New Features: Injuries ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b, 1 • Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site. ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b, 2 • When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). • When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

  34. ICD-10-CM New Features: Traumatic Fractures ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, c • The principles of multiple coding of injuries should be followed in coding fractures. • A fracture not indicated as open or closed should be coded to closed. • A fracture not indicated whether displaced or not displaced should be coded to displaced.

  35. ICD-10-CM New Features: Traumatic Fractures ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, c, 1 • Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture. • 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.

  36. ICD-10-CM New Features: Burns and Corrosions ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, d • The ICD-10-CM makes a distinction between burns and corrosions. • The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. • The burn codes are also for burns resulting from electricity and radiation. • Corrosions are burns due to chemicals. • The guidelines are the same for burns and corrosions.

  37. ICD-10-CM New Features: Burns and Corrosions ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, d, 1 • Sequence first the code that reflects the highest degree of burn when more than one burn is present. • a. When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree. • b. When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or first-listed diagnosis. • c. When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or first-listed diagnosis.

  38. ICD-10-CM New Features: Placeholder “x” • Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character. When placeholder character applies, it must be used in order for the code to be considered valid • Examples: • T50.2x41A - Poisoning by carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, accidental (unintentional), initial encounter • T16.2xxA – Foreign body in left ear, initial encounter.

  39. ICD-10-CM New Features: 7th Character • The 7th character in ICD-10-CM is used in several chapters (e.g., the Obstetrics, Injury, Musculoskeletal, and External Cause chapters). • It has a different meaning depending on the section where it is being used • Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) • Obstetrics the 7th character is used to identify the fetus to which the code applies (used for single and multiple gestations) • Must always be used in the 7th character position • If a code has an applicable 7th character, the code must be reported with an appropriate 7th character value in order to be valid

  40. ICD-10-CM New Features: 7thCharacter “A” • Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) • Seventh character “A” initial encounter is used while the patient is receiving active treatment for the condition. • Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

  41. ICD-10-CM New Features: 7thCharacter “D” • Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) • Seventh character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. • Examples of subsequent care are: 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.

  42. ICD-10-CM New Features: 7thCharacter “S” • Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) • Seventh character “S” sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. • When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. • The “S” is added only to the injury code, not the sequela code. • The 7th character “S” identifies the injury responsible for the sequela. • The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.

  43. ICD-10-CM New Features: Excludes Notes Two types of Excludes notes • Excludes 1 – • Indicates that the code excluded should never be used with the code where the note is located (do not report both codes). Or, restated- • Means NOT CODED HERE • Code being excluded is never used with code • The two conditions cannot occur together Excludes1

  44. ICD-10-CM New Features: Excludes Notes Excludes 1, Examples: • Q03 – Congenital hydrocephalus Excludes 1: Acquired hydrocephalus (G91.-) • M21 - Other acquired deformities of limbs Excludes1: acquired absence of limb (Z89.-) congenital absence of limbs (Q71-Q73)

  45. ICD-10-CM New Features: Excludes Notes Excludes 1, Examples: • E10 -Type 1 Diabetes mellitus Excludes1: diabetes mellitus due to underlying condition (E08.-) drug or chemical induced diabetes mellitus (E09.-) gestational diabetes (O24.4-) hyperglycemia NOS (R73.9) neonatal diabetes mellitus (P70.2) type 2 diabetes mellitus (E11.-)

  46. ICD-10-CM New Features: Excludes Notes • Excludes 2 – • Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together (both codes can be reported to capture both conditions). Or, restated- • Means NOT INCLUDED HERE • Excluded condition is not part of the condition represented by the code • Acceptable to use both codes together if patient has both conditions Excludes2

  47. ICD-10-CM New Features: Excludes Notes Excludes 2, Examples: • L27.2 – Dermatitis due to ingested food. Excludes 2: Dermatitis due to food in contact with skin (L23.6, L24.6, L25.4). • L89 - Pressure ulcer Excludes2: diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622) non-pressure chronic ulcer of skin (L97.-) skin infections (L00-L08) varicose ulcer (I83.0, I83.2)

  48. External Cause of Morbidity What we formerly knew as “E-codes”

  49. External Cause of Morbidity • External cause of morbidity codes (categories V01-Y99) are reported with injury codes. • External cause codes capture: • Cause (how an injury occurred) • Intent (accidental or intentional, e.g., suicide or assault) • Person’s status (e.g., civilian, military, etc.) • Place where the injury occurred • Activity codes (category Y93) describe the activity of a person seeking care for injuries and health conditions: • When the injury or other health condition resulted from the activity; or • When the activity contributed to the injury or health condition. .

  50. External Cause of Morbidity • Codes for poisoning, adverse effect, and underdosing (categories T36-T50) and for toxic effects of substances chiefly nonmedicinal as to source (categories T51-T65) include information on the cause and intent. • No external cause code from chapter 20 is needed for these codes. • Examples: (Drug is Acetaminophen) T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial encounter T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial encounter T39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounter T39.1X6A Underdosingof 4-Aminophenol derivatives, initial encounter