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An Overview of the 2013 ICD-10-CM Guidelines

An Overview of the 2013 ICD-10-CM Guidelines. Presenter: Kathy Boomgarden, RHIT, CCS, CCS-P AHIMA-Approved ICD-10-CM/PCS Trainer. Objectives. Review the 2013 ICD-10-CM Official Guidelines for Coding and Reporting Understand the differences between the ICD-9-CM and ICD-10-CM guidelines

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An Overview of the 2013 ICD-10-CM Guidelines

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  1. An Overview of the 2013 ICD-10-CM Guidelines Presenter: Kathy Boomgarden, RHIT, CCS, CCS-P AHIMA-Approved ICD-10-CM/PCS Trainer

  2. Objectives Review the 2013 ICD-10-CM Official Guidelines for Coding and Reporting Understand the differences between the ICD-9-CM and ICD-10-CM guidelines Apply the guidelines to coding scenarios

  3. ICD-10-CM/PCS Users • ICD-10-CM will be used in all healthcare settings, Inpatient and Outpatient and by all types of providers for reporting Diagnoses • Hospitals • Clinics • Home Health Agencies • ICD-10-PCS will be used only by facilities for the reporting of hospital InpatientProcedures • Inpatient procedures only

  4. ICD-10-CM/PCS Users • CPT & HCPCS Level II codes will continue to be used for reporting of physician and other professional services as well as procedures performed in the outpatient setting • All clinic services • Hospital outpatient services only

  5. Organizational and Structural Changes • ICD-10-CM has 21 chapters • ICD-9-CM has 17 chapters • ICD-10-CM incorporates “V” and “E” codes into the main classification • ICD-9-CM has supplemental classifications for “V” and “E” codes • ICD-10-CM groups injuries first by specific site (e.g., head, arm, leg), and then by type of injury (e.g., fracture, open wound) • ICD-9-CM groups injuries by type first then by specific site • ICD-10-CM incorporates postoperative complications into procedure-specific body system chapters • ICD-9-CM has a separate chapter for postoperative complications • ICD-10-CM has added a placeholder X

  6. ICD-10-CM Official Guidelines • There are now two sets of guidelines • ICD-10-CM Official Guidelines for Coding and Reporting • ICD-10-PCS Coding Guidelines • ICD-10-CM follows the same format as ICD-9-CM; • Conventions for ICD-10-CM • General Guidelines • Chapter Specific Guidelines • Selection of Principal Diagnosis • Reporting Additional Diagnosis • Diagnostic Coding & Reporting for Outpatient Services • Present On Admission (POA)

  7. ICD-10-CM and HIPAA “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.”

  8. ICD-10-CM and Documentation “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and conditions treated.”

  9. ICD-10-Conventions (pg 7-12) • Conventions for the ICD-10-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes. • These conventions and instructions take precedence over guidelines.

  10. ICD-10-Conventions (pg 7-12) • The Alphabetic Index and Tabular List • Alphabetic Index • Alphabetical list of terms and their corresponding code • Index of Diseases and Injury • Index of External Causes of Injury • Neoplasm Table • Table of Drugs and Chemicals • Tabular List • Structured list of codes divided into chapters based on body system or condition

  11. ICD-10-Conventions (pg 7-12) • Format and Structure: • ICD-10-CM Tabular List contains Categories, Subcategories and Codes • Categories are 3 characters • If a 3 character category has no further subdivision it is equivalent to a code • Subcategories are either 4 or 5 characters • Each level of subdivision after a category is a subcategory • Codes can be 3, 4, 5, 6, or 7 characters • All codes must be assigned to the highest subdivision or it would not be considered a code • Use of Codes for Reporting Purposes: • For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required

  12. ICD-10-Conventions (pg 7-12) • Placeholder Character • ICD-10-CM utilizes a placeholder which is always the letter X and has two uses; • As the fifth character for certain six character codes. • The X provides for future expansion without disturbing the sixth character structure • Example: S06.0X1A • When a code has less than six characters and a seventh character is required. • The X is assigned for all characters less than six in order to meet the requirement of coding the highest level of specificity • Example: O65.0XX1

  13. ICD-10-Conventions (pg 7-12) • 7th Characters • A 7th character can be used to provide further specificity about the condition being coded • 7th characters may be a number or letter • 7th characters must always be used as the seventh character • Example: Category M80 requires one of the following 7th characters 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

  14. ICD-10-Conventions (pg 7-12) • Alphabetic Index abbreviations • NEC “Not elsewhere classifiable” • This abbreviation represents “other specified”. When a specific code is not available for a condition, the Alphabetic Index directs the coder to the “other specified” code in the Tabular List. • NOS “Not otherwise specified” • This abbreviation is the equivalent of unspecified. • Tabular List abbreviations • NEC “Not elsewhere classifiable” • NOS “Not otherwise specified”

  15. ICD-10-Conventions (pg 7-12) • Punctuation • [ ] Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes. • ( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. • : Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

  16. ICD-10-Conventions (pg 7-12) • Other format issues that are different from ICD-9-CM; • Lozenge (⋄), section mark (§), and braces ({}) are not included in ICD-10-CM • Dashes are used in both the Alphabetic Index and Tabular List • The index uses the dash (-) at the end of a code number to indicate that code is incomplete • Example Fracture, pathological • ankle M84.47- • carpus M84.44- • The tabular list uses a dash preceded by a decimal point (.-) to indicate an incomplete code • Example: J43 Emphysema • Excludes1: emphysematous (obstructive) bronchitis (J44.-)

  17. ICD-10-Conventions (pg 7-12) • Other and Unspecified codes • “Other” codes • Use codes titled “other” or “other specified” when the information in the medical record provides detail for which a specific code does not exist. • “Unspecified” codes • Use codes titled “unspecified” when the information in the medical record is insufficient to assign a more specific code.

  18. ICD-10-Conventions (pg 7-12) • Includes Notes • Used in the Tabular List • Appears under a three character code title • Further defines, or give examples of, the content of the category • Example • K25 Gastric Ulcer Includes: erosion (acute) of stomach pylorus ulcer (peptic) stomach ulcer (peptic)

  19. ICD-10-Conventions (pg 7-12) • Inclusion Terms • Used in the Tabular List • Are a list of conditions that the particular code is used for • The terms may be synonyms of the code title, or in the case of “other specified” codes the terms are a list of the various conditions assigned to that code • Not necessarily an exhaustive list, additional terms found only in the Alphabetic Index may also be assigned to a code • At the code level the word “includes” does not precede the list of terms included in the code

  20. ICD-10-Conventions (pg 7-12) • Inclusion Terms • Example • K31.5 Obstruction of duodenum Constriction of duodenum Duodenal ileus (chronic) Stenosis of duodenum Stricture of duodenum Volvulus of duodenum

  21. ICD-10-Conventions (pg 7-12) • Excludes Notes • ICD-10-CM has two types of excludes notes. Each type of note has a different definition. • Excludes 1 • A pure excludes note “Not Coded Here” • This note is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition • Example • K51.4 Inflammatory polyps of colon • Excludes 1: • adenomatous polyp of colon (D12.6) • polyposis of colon (D12.6) • polyps of colon NOS (K63.5)

  22. ICD-10-Conventions (pg 7-12) • Excludes 2 • Represents “Not Included Here” • The condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time • It is acceptable to use both the code and the excluded code together if the patient has both conditions • Example • J37.1 Chronic laryngotracheitis • Excludes 2: • acute laryngotracheitis (J04.2) • acute tracheitis (J04.1)

  23. ICD-10-Conventions (pg 7-12) • Etiology/manifestation convention (”code first”, “use additional code” and “in diseases classified elsewhere” notes) • Etiology codes are always sequenced first and will include a “use additional code” note • Manifestation codes will include a “code first” note • “Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of the etiology/manifestation combinations

  24. ICD-10-Conventions (pg 7-12) • “And” • The word “and” should be interpreted to mean either “and” or “or” when it appears in a title • “With” • The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index or an instructional note in the Tabular List • “See” and “See Also” • The term “see” following a main term in the Alphabetic Index indicates that another term should be referenced • The “see also” instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional entries that may be useful

  25. ICD-10-Conventions (pg 7-12) • Code Also Note • A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. • Example • C7A Malignant neuroendocrine tumors Code also any associated multiple endocrine neoplasia [MEN] syndromes (E31.2-) • E26.01 Conn’s syndrome Code also adrenal adenoma (D35.0-)

  26. ICD-10-Conventions (pg 7-12) • Default codes • A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code • Default codes represent that condition that is most commonly associated with the main term, or is the unspecified code for the condition • Example • Appendicitis without any additional information, such as acute or chronic defaults to K37 • Appendicitis (pneumococcal) (retrocecal) K37 • K37 Unspecified appendicitis

  27. General Coding Guidelines(pgs 12-16) • Locating a code in the ICD-10-CM • First locate the term in the Alphabetic Index, and then verify the code in the Tabular List • Selection of the full code, including any 7th character and laterality can only be done in the Tabular List • The Alphabetic Index entry includes a dash (-) at the end of a subcategory to indicate that additional characters are required • Example • Bursitis, elbow NEC M70.3- • Requires a 6th character to specify laterality

  28. General Coding Guidelines(pgs 12-16) • Level of Detail in Coding • Diagnosis codes are to be used and reported at their highest number of characters available • ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6, or 7 characters • A code is invalid if it has not been coded to the full number of characters required for the code, including the 7th character, if applicable

  29. General Coding Guidelines(pgs 12-16) • Code or codes from A00.0 through T88.9, Z00-Z99.8 • The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit • Signs and Symptoms • Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider

  30. General Coding Guidelines(pgs 12-16) • Conditions that are an integral part of a disease process • Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification • Conditions that are not an integral part of a disease process • Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present

  31. General Coding Guidelines(pgs 12-16) • Multiple coding for a single condition • In addition to the etiology/manifestation convention that requires two codes, there are other single conditions that also require more than one code • “Use additional code”, “code first” and “code, if applicable, any causal condition first” notes are used to provide guidance when more than one code may be necessary to completely code a condition • Example • E36.8 Other intraoperative complications of endocrine system • Use additional code, if applicable, to further specify disorder

  32. General Coding Guidelines(pgs 12-16) • Acute and Chronic Conditions • If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first. • Example • Abscess • Breast (acute) (chronic) (nonpuerperal) N61 • Broad ligament N73.2 • acute N73.0 • chronic N73.1

  33. General Coding Guidelines(pgs 12-16) • Combination Code • A combination code is a single code used to classify: • Two diagnoses, or • A diagnosis with an associated secondary process (manifestation), or • A diagnosis with an associated complication • Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List • Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. • Example • E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified

  34. General Coding Guidelines(pgs 12-16) • Sequela (Late Effects) • ICD-10-CM always uses the term “Sequela” rather than late effect • The guideline itself is unchanged with the exception of adding reference to specific guidelines for sequela of specific body systems • See Section I.C.9 Sequela of cerebrovascular disease • See Section I.C.15 Sequela of complication of pregnancy, childbirth and the puerperium • See Section I.C.19 Application of 7th characters for Chapter 19

  35. General Coding Guidelines(pgs 12-16) • Sequela (Late Effects) • A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated • The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect • There is no time limit on when a sequela code can be used • Coding of sequela generally requires two codes sequenced in the following order: • The condition or nature of the sequela is sequenced first • The sequela code is sequenced second

  36. General Coding Guidelines(pgs 12-16) • Impending or Threatened Condition • Code any condition documented on discharge as “impending” or “threatened” as follows: • If it did occur, code as a confirmed diagnosis • If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for “impending” and for “threatened” and also reference main term entries for “impending” and for “threatened” • If the subterms are listed, assign the given code • If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened

  37. General Coding Guidelines(pgs 12-16) • Reporting Same Diagnosis Code More Than Once • Each unique ICD-10-CM diagnosis code may be reported only once for an encounter • This applies to bilateral conditions when there are no distinct codes identifying laterality or • Two different conditions classified to the same ICD-10-CM diagnosis code

  38. General Coding Guidelines(pgs 12-16) • Laterality • Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or bilateral • If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side • If the side is not identified in the medical record, assign the code for the unspecified side • Example • Swimmer’s ear • H60.331 Swimmer’s ear, right ear • H60.332 Swimmer’s ear, left ear • H60.333 Swimmer’s ear, bilateral • H60.339 Swimmer’s ear, unspecified ear

  39. General Coding Guidelines(pgs 12-16) • Documentation for BMI, Non-pressure Ulcers and Pressure Ulcer Stages • BMI, depth of non-pressure chronic ulcers and pressure ulcer stage codes can be assigned based on medical record documentation from clinicians who are not the patient’s provider • The associated diagnosis (overweight, obesity, pressure ulcer) must be documented by the patient’s provider • The BMI codes should only be reported as secondary diagnoses. As with all other secondary diagnosis codes, the BMI codes should only be assigned when they meet the definition of a reportable additional diagnosis

  40. General Coding Guidelines(pgs 12-16) • Syndromes • Follow the Alphabetic Index guidance when coding syndromes • In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome • Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code

  41. General Coding Guidelines(pgs 12-16) • Documentation of Complications of Care • Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure • Not all conditions that occur during or following medical care or surgery are classified as complications • This guideline applies to any complications of care, regardless of the chapter the code is located in • There must be a cause and effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication

  42. General Coding Guidelines(pgs 12-16) • Borderline Diagnosis • If the provider documents a “borderline” diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes) • If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such • Borderline conditions are not uncertain diagnoses, therefore there is no distinction between the care setting (inpatient versus outpatient) • Example • Hypertension • Borderline R03.0

  43. Chapter-Specific Coding Guidelines • In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings • 21 Chapters instead of 17 • Eyes and Ears are now separate chapters • External Causes of Morbidity • Factors influencing health status and contact with health services

  44. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) pgs 16-24 • Human Immunodeficiency Virus (HIV) Infections • Code only confirmed cases of HIV infection/illness • Selection and sequencing of HIV codes • If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions • If a patient with HIV disease is admitted for an unrelated condition, the code for the unrelated condition should be the principal diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions

  45. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) pgs 16-24 • Human Immunodeficiency Virus (HIV) Infections • Selection and sequencing of HIV codes • Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision • Asymptomatic HIV infection status (Z21) is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive”, “known HIV”, “HIV test positive”, or similar terminology. Do not use Z21if the term “AIDS” is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases.

  46. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) pgs 16-24 • Human Immunodeficiency Virus (HIV) Infections • Selection and sequencing of HIV codes • Inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code R75, Inconclusive laboratory evidence of HIV • Patients with any known prior diagnosis of an HIV-related illness should be coded to B20 • During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an HIV-related illness should receive a principal diagnosis code of O98.7-, HIV disease complicating pregnancy, childbirth and the puerperium, followed by B20 and the code(s) for the HIV related illness(es).

  47. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) pgs 16-24 • Human Immunodeficiency Virus (HIV) Infections • Selection and sequencing of HIV codes • If a patient is being seen to determine his/her HIV status, use code Z11.4, encounter for screening for HIV • If a patient with signs or symptoms is being seen for HIV testing, code the signs and symptoms. An additional counseling code Z71.7 HIV counseling, may be used if counseling is provided • When a patient returns to be informed of his/her HIV test results and the test result is negative, use code Z71.7, HIV counseling. If the results are positive, see previous guidelines and assign codes as appropriate

  48. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) pgs 16-24 • Human Immunodeficiency Virus (HIV) Infections • Coding Examples • HIV positive male is seen for diagnostic tests which results in a diagnosis of Pneumocystis pneumonia • B20 Human Immunodeficiency Virus (HIV) Disease • B59 Pneumocystosis • HIV seropositive • Z21 Asymptomatic human immunodeficiency virus (HIV) infection status

  49. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) pgs 16-24 • Infectious agents as the cause of diseases classified to other chapters • Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code • An additional code from Chapter 1 should be used to identify the organism • B95, Streptococcus, Staphylococcus, and Enterococcus • B96, Other bacterial agents • B97, Viral agents • An instructional note will be found at the infection code advising that an additional organism code is required

  50. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) pgs 16-24 • Infectious agents as the cause of diseases classified to other chapters - continued • Coding Examples • E. coli Urinary Tract Infection • N39.0 Urinary Tract Infection, site not specified • B96.20 Unspecified E coli as the cause of diseased classified elsewhere • Pseudomonas Pneumonia • J15.1 Pneumonia due to Pseudomonas

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