ICD-10 Guidelines for the CPC Exam · ICD-10-CM Guidelines u The following charts and tables are...

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ICD-10 Guidelines for the CPC ExamPaul Chandler, BS-HRM, AA-C, AA-GTS,

CCAI, CCAL, CCAMB, CCANES, CCASC, CCBMS, CCBT, CCCAR,CCCC, CCCHI, CCCS, CCDEN, CCDERM, CCDR, CCED, CCELE,

CCEM, CCEND, CCFP, CCGER, CCGI, CCGS, CCGYN, CCHCC,CCHEP, CCHON, CCHOS, CCIAC, CCIC, CCID, CCIM, CCIR, CCMH,

CCN, CCNEO, CCNEPH, CCNM, CCNRAD, CCNS, CCOB, CCOM,

CCOO, CCORT, CCOT, CCOTO, CCPC, CCPED, CCPL, CCPM,CCPOD, CCPRS, CCPSY, CCPT, CCPUL, CCRAD, CCRH, CCRO,

CCTS, CCU, CCVS, CPC, CPC-I, COC, CRC, CPC-P, CPMA, CPCO,

CPPM, CPB, CDEO, CANPC, CASCC, CCC, CCVTC, CEDC, CEMC,CENTC, CFPC, CGSC, CGIC, CHONC, CIMC, COBGC, COPC,

COSC, CPCD, CPEDC, CPRC, CRHC, CSFAC, CUC, CCA, CEMA

AAPC Approved InstructorChief Executive Officer

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Overview

• Part 1 - ICD-10 fundamentals and navigation• Part 2 - Coding conventions and guidelines• Part 3 - ICD-10 code selection strategies

• Part 4 - Documentation improvement

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ICD-10 Guidelines for the CPC Exam

Coding Fiesta 2019 Paul Chandler, Specialty Coder Instructor October 26, 2019

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ICD-10 Rules

1. Conventionsu (section I.A)

2. General Coding Guidelinesu (section I.B)

3. Chapter Specific Coding Guidelinesu (section I.C)

4. The Tabular List **takes precedence

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ICD-10 Conventions

u NEC “Not elsewhere classified” or “other specified”u Used when the information in the medical record provides detail for which a specific code does not exist

u NOS “Not otherwise specified” or “unspecified”

u Used when the information in the medical record is insufficient to assign a more specific code

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ICD-10 Conventions

u Includesu This note appears immediately under a three-digit code title to further define,clarify, or give examples of the content of a code category.

u Inclusion terms

u List of conditions assignedto that code

u And

u The word “and” should be interpreted to mean either “and” or “or” when it appears in a title. Such as “either/or”.

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ICD-10 Conventions

u Etiology/manifestationu The condition is sequenced first, followed by the manifestationo Etiology code will have a “use additional” noteo Manifestation code will have a “code first” note

• Also usually says “in diseases classified elsewhere”o Brackets surround the manifestation code in the alpha

indexu Code Alsou Alerts the coder that more than one code may be required to fully describe the condition. The sequencing of the codes dependson the severity and/or the reason for the encounter

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Tabular List Alphabetic Index

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ICD-10 Conventions

u Excludes

u Excludes1 – is used when two conditions cannot occur together or “NOTCODED HERE!” Mutually exclusive codes; two conditions that cannot bereported together.

u Excludes2 – indicates “NOT INCLUDED HERE.” Although the excluded condition is not part of the condition, it is excluded from, a patient may have both conditions at the same time. The excluded code and the code above the excludes can be used together if the documentation supports them.

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ICD-10 Conventions

u Excludes

u Excludes1 – consider these codes instead

u You can only use one

u Mutually exclusive

u Excludes2 – consider these codes in addition

u You may use 2 or more

u Not included

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ICD-10 Conventions

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Is this a valid code?

M25.652 Stiffness of lefthip, not elsewhereclassified

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M25.65- Stiffness of hip,not elsewhere classified

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M25.6- Stiffness of joint,not elsewhere classified

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ICD-10 Conventions

Note: the exclusionnotes apply to all codesthat begin with M25.6

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ICD-10 Conventions

Note: the exclusionnotes apply to all codesthat are in the M25category

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ICD-10 Conventions

Note: the exclusionnotes apply to all codesin the M20-M25 block

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ICD-10 Conventions

Note: the instructionalnotes apply to all codesin chapter 13

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ICD-10 Conventions

Note:In column instructions all the wayback to the first character apply to this code. There were noexclusions at the code, but wefound them in three other placesas we worked backwards.

Coding tip: start with the specificcode and work backwards to findthe relevant instructional notes.

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ICD-10 Conventions

u With/without• “with” means “associated with”

or “due to”• default is always “without”

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ICD-10 Rules

1 . Conventionsu (section I.A)




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General Coding Guidelines

u Code to the highest level of specificity (i.e. u p to seven characters in ICD-10) (section I.B.2)

u “List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chieflyresponsible for the services provided.” (section IV.G)

u “Code signs and symptoms when a related definitive diagnosis has not beenestablished (confirmed) by the provider” (section I.C.18.a)o mostly R00-R99 in ICD-10

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u “Signs and symptoms that are associated routinely with a disease process shouldnot be assigned as additional codes” (section I.B.5)

u “Additional signs and symptoms that may not be associated routinelywith a disease process should be coded when present.” (section I.B.6)

• Example: R11.0 Nausea andu o S13.4xxA Sprain of ligaments of the cervicalspine

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u “Do not code diagnoses documented as ‘probable’, ‘suspected’, ‘questionable’, ‘rule out’, or ‘working diagnosis’ or other similar termsindicating uncertainty.” (section IV.H)

u “Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management.” (section IV.J)

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u Acute and chronicu The acute condition should always be listed before the chronic condition if both

are present. (section 1.B.8)

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u Combination codes are used to classify:

• Two diagnoses, or• A diagnosis with an associated secondary process (manifestation)• A diagnosis with an associated complication• (section 1.B.9)

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u Sequela (late effects)

• Residual effect after the acute phase of an illness or injury has terminatedu Example: paralysis after cerebral infarction

• Code first the condition being treated, and second the illness or injury thatled to it.

• Never code the acute phase of the illness or injury with a sequela• (section 1.B.10)

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u Impending or Threatened conditionu If a condition occurs, code confirmed diagnosis, if only impending or threatened, then code if found in index under those terms• (section 1.B.11)

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u Lateralityo If the condition is bilateral and there is no bilateral code, then you

have to list the left and right code separately.

o Sixth character (usually)• 1=right• 2=left

o List unspecified if laterality is not described• (section 1.B.13)

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u Always document laterality for any body part or organ that is bilateral in nature.u ICD-10-CM does not always provide a bilateral code. Sometimes it is only Right, Left or Unspecified.

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u Be sure that the claim lines match the diagnosis selected to avoid denials. When a CPT service is performed bilaterally, but the diagnosis does not have a bilateral descriptor, be sure to report the CPT with modifiers RT and LT and then match the RT and LT diagnoses with the correct CPT code.

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u 73030-RTu M67.311

u 73030-LT

u M67.312

u Radiologic examination, shoulder, complete, minimum 2 views; right sideu Transient synovitis, shoulder, right

u Radiologic examination, shoulder, complete, minimum 2 views; left side

u Transient synovitis, shoulder, left

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u Placeholder characteru ICD-10-CM utilizes a placeholder character “x” in positions 4, 5, and/or 6 in

certain codes to allow for future expansion.u (section 1.A.4)

u 7th Characters

u Certain ICD-10-CM categories have applicable 7th characters. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder “x” must be usedto fill in the empty characters.

u (section 1.A.5)

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u DIAGNOSIS: Traumatic, closed, nondisplaced transverse fracture of the left patella, initial encounter.

u Code: S82.035A

u DIAGNOSIS: Traumatic, closed, nondisplaced transverse fracture of the left patella, subsequent encounter.

u Code: S82.035D

u DIAGNOSIS: Pain in the left knee one year post traumatic, closed, nondisplaced transverse fracture of the left patella, sequela.

u Code: M35.562 Pain, knee, left S82.035S

Subsequent Encounter

InitialEncounter

Sequela

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u The seventh character (encounter):

• A – initial encounter, while patient is receiving active treatmentincluding continuing treatment by the same or a different physician

• D – subsequent encounter, routine care during the healing or recovery phase, such as aftercare and follow u p

• S – sequela, complications or conditions that arise as a direct result of acondition, such as a scar formation after a burn

• (section 1.B.10)

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u Which character is correct?Is the patient receiving active treatment?

Is the patient in the middle of a treatment plan?

Has the patient’s condition stabilized?

Is the patient receiving supportive care?

Is the patient in a healing or recovery phase?

Is the patient being treated for a complication that is the direct result of some

other condition that is no longer present?

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o An unspecified code should be reported only when it is the code that mostaccurately reflects what is known about the patient’s condition at the time of that particular encounter.

u *Note: payers create their own rules to pay/deny unspecified codeso It is inappropriate to select a specific code that is not supported by the

health record documentationo It is inappropriate to conductmedically unnecessary diagnostic testing in

order to determine a more specific code.o (section 1.B.18)

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ICD-10 Rules





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ICD-10 Rules





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ICD-10-CM Guidelines

u The following charts and tables are included in the AAPC’s 2020 version of the ICD-10-CM coding manual.

u These images are only used for AAPC local chapter presentations.

u Examinees may use any ICD-10-CM publisher for the Certified Professional Coder (CPC) exam by the AAPC.

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ICD-10 Guidelines for the CPC Exam · ICD-10-CM Guidelines u The following charts and tables are...

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