ICD-10 ORIENTATION IN POST ACUTE CARERhonda Anderson, RHIA

Anderson Health Information Systems, Inc.

Objectives

• Participants will identify:• Dates for New ICD-10• Documentation support• New terms encounter principal diagnosis re-

defined• Some general coding guidelines

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Final Regulation

• January 15, 2009 Final Regulation Released• EXCHANGE the ICD-9 for the ICD-10 on

October, 1, 2014• https://federalregister.gov/a/2012-21238

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ICD-10 “Has Two Parts”

• ICD-10-CM = Clinical Modification, ICD-10 CM – applies to SNF, Intermediate Care, Physician’s Offices, Clinics, Dialysis, Home Health, other health care settings who bill Medicare, MediCal or Private Ins.

• ICD-10 PCS = Procedural Code System (used for Acute Hospital procedures, operations

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HIPAA

• Assigning ICD-10 diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA)

• HIPAA has evolved from 1996 to HITECH which relates to security and breaches

• HIPAA Transactions 5010 went into effect October 2011

• HITECH – HIPAA Privacy and Security final rule was released January 2013

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Who Is Affected??

• All inpatient and outpatient facility visits as well as freestanding providers and ancillary services “that means all of us really” who provide services and bill for them under Medicare, Medi-Cal and private insurances.

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Various Roles That Are Affected

• HIM personnel• Nurse managers• MDS nurses• Nursing unit staff/clerks• Case managers• Administration• Therapy personnel (PT/OT/ST)

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More Affected Roles...

• Corporate Office personnel• Compliance Office personnel working with

ICD coding• Corporate administrative departments• Billing/admitting personnel• Medical Directors/Providers

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Benefits

• More specific coding system• Reflects medical advancements• Standardization, UK implemented in 1995,

used worldwide• The United States is the only industrialized

nation that has not yet implemented ICD-10

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What Does This Mean??

• The guidelines in the ICD-10 manual developed for the provider and the coder….(person who may review the documentation and determine if code is accurate.

• Consistent, complete documentation in the medical record is a major emphasis.

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Key Highlights

• ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings

• Current Procedural Terminology (CPT) is still used for the Physician, and some services, but they must have a diagnosis that is ICD-10 compliant

• Healthcare Common Procedural Coding system (HCPCS Level II) remains the same for outpatient reporting for procedures and services

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ICD-9-CM Diagnosis Codes

• 3-5 characters in length• Approximately 14,000 codes• First digit may be alpha or numeric• Digits 2-5 are numeric• Always at least three digits• Decimal placed after the first three

characters• Limited space for new codes 12

ICD-9-CM Diagnosis Codes -2

• Lacks detail• Lacks laterality, difficult to analyze, dated,

non-specific and does not adequately define diagnoses needed for medical research

• Does not support interoperability because it is not used in other countries

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ICD-10 CM Structure

• Index and Tabular list have the same hierarchical structure as ICD-9

• ICD-10 index larger, categories, subcategories and codes are contacted in the tabular list

• ICD-9 V and E code supplemental classifications are incorporated into the main classification in ICD-10

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ICD-10 CM Structure -2

• ICD-9 V codes are now Z codes and in Chapter 21. Factors Influencing Health Status and Contact with Health Services

• Postoperative complications have been moved to procedure-specific body system chapters

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ICD-10-CM Diagnosis Codes – Format & Structure• 3-7 characters in length and alphanumeric• 21 chapters (compared to 17 in ICD-9)• Approximately 68,000 codes• Digit 1 is always alpha, digit 2 is numeric;

digits 3-7 can be alpha or numeric• Decimal placed after the first 3 characters• Codes that have applicable 7th character is

considered invalid without the 7th character 16

ICD-10-CM Diagnosis Codes – Format & Structure -2

• Expanded codes• Flexible for adding new codes• Addition of placeholder “X”• Has laterality (right, left, lower, upper, outer,

etc.)

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ICD-9-CM vs. ICD-10-CM

ICD-9-CM• 3-5 digits XXX.XX• 19 chapters• 14,000 dx codes• Includes and

excludes notes• Limited text

description• Out-dated

terminology

ICD-10-CM• 3-7 digits

XXX.XXXX• 21 chapters• 70,000 dx codes• Includes and 2 types of

excludes notes• Full text description

with every code• Current terminology 18

Example Of Placeholder “X”

• ICD-10 utilizes a placeholder character “x”• The “x” is used as a placeholder at certain

codes to allow for expansion• Categories T36-T50, poisoning and injury codes

T36.8X1D• Also, Pathological vertebral fracture due to age-

related osteoporosis, subsequent encounter with delayed healing M80.08XG

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Example Of Laterality

• For bilateral sites, the final character of the codes in ICD-10 indicates laterality:• C50.212 Malignant Neoplasm of upper-inner

quadrant of left female breast• H02.835 Dermatochalasis of left lower eyelid• I80.01 Phlebitis and Thrombophlebitis of

superficial vessels of right lower extremity• L89.213 Pressure Ulcer of right hip, Stage 3

• *an unspecified site code is also provided should the site not be identified

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Example Of Expanded Codes

• Expanded Codes (injury, diabetes, alcohol/substance abuse, postoperative complications)

• E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease

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Diabetic Code Examples

• Diabetic Mellitus:• w/arthropathy E11.618 (Type 2 diabetes with

other diabetic arthropathy)• w/cataract E11.36 (Type 2 with diabetic cataract)• w/gangrene E11.52 (Type 2 with diabetic

peripheral angiopathy with gangrene)

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ICD-10-CM Structure

• Requires “use” of proper coding guidelines• Relies on the use of the guidelines and in our

case Skilled/ICF/IRF rules• ICD-10-CM Index – disease, injury and external

causes of Injury

• More combined codes, i.e. Pressure ulcer of right ankle, stage I - L89.511 is now one code

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ICD-10-CM Structure -2

• More specificity, i.e. Alzheimer’s disease with specific details of early or late onset:• G30.0 Alzheimer’s with early onset• G30.1 Alzheimer’s with late onset• G30.8 Other Alzheimer’s disease• G30.9 Alzheimer’s disease, unspecified

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Conventions For The ICD-10-CM

• General rules for use of the classification independent of the guidelines• Alphabetic Index and Tabular List

• Alphabetic Index – List of terms and their corresponding code

• Tabular List – chronological list of codes divided into chapters based on body system/condition

• General coding guidelines are similar to ICD-9 with one additional guideline - laterality

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Conventions For The ICD-10-CM -2

• General rules for use of the classification independent of the guidelines• Format and Structure

• First character is always alpha• Three character category that has no further

subdivision is equivalent to a code• Subcategories are either 4 or 5 characters• Codes may be 3, 4, 5, 6 or 7 characters

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Conventions For The ICD-10-CM -3

• General rules for use of the classification independent of the guidelines• 7th Character extensions:

• Certain ICD-10-CM categories have applicable 7th characters

• Required for all codes within the category or as instructed by the notes in the Tabular List

• Must always be the 7th character in the data field• If a code that requires a7th character is not 6

characters, a placeholder X must be used to fill in the empty characters

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Examples of 7th Character Extensions• Seventh character for a fracture

• 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 mal-

union

• S = sequela

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Fracture

• Fracture Traumatic (abduction, adduction, separation)

• Acetabulum – anterior, displaced, illopubic S32.43__ or non-displaced S32.436_

• Acetabulum – dome (displaced) S32.48__• Fracture, lumbar vertebrae - (NOS)

S32.009_

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Fracture -2

• Fracture of lst lumbar vertebrae – S32.01__• Wedge compression, stable burst, unstable burst,

other, or unspecified?• What type of fx is it?

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ICD-10-CM Diagnosis Codes

• Specificity improves coding accuracy and depth of data for analysis

• Detail improves the accuracy of data used in medical research

• Supports interoperability and the exchange of health care data between other countries and the U.S.

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Code Format

• Code format changes:

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ICD-9-CM Code Format ICD-10-CM Code Format

                                                      

    

                                                  

                                 

GEM Files

• Before we go further- do not despair…your vendor should prepare as much crosswalk as possible. There are “GEM” files.

• General Equivalence Mappings (GEM) • translation dictionary for diagnoses

• There is NOT a one-to-one match between ICD-9 and ICD-10 codes

• We will talk about GEMS later and how to use them. Key to early review!

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What Does That Mean To Me?

• Identify your most common diagnoses• Determine in advance some of the

documentation issues that you will have with the nurses and the physicians

• Discuss the specificity at the QA/PI meetings

• Keep staff informed as we progress

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What Does That Mean To Me? -2

• The organization will need to know for all facilities or your facility what the most common diagnoses that are admitted and focus on those first

• Focus on the documentation to support those• Focus on review of Acute Hospital Records

more closely – Impact Inquiries• Review for Medicare must be more specific

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Abbreviations & Punctuation

• NEC – Not Elsewhere Classified for conditions not classified elsewhere

• NOS – Not Otherwise Specified if condition is insufficient to assign more specific code

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Abbreviations & Punctuation -2

• Punctuation• [ ] Brackets (synonyms, alt wordings,

explanatory phrases)• ( ) Parentheses (nonessential modifiers/

supplementary words)• : Colon (used with includes and excludes notes)

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Instructional Notes

• Inclusion notes further define, or give examples of the content of the category

• Exclusion notes – Excludes1 vs. Excludes2• Excludes1 means “not coded here”• Excludes2 means “not included here” may need

to use both the code and the excluded code together if patient has both conditions

• Code first and Use additional code notes are similar to ICD-9 38

Instructional Notes -2

• Cross Reference Notes advise coder to look elsewhere before assigning code (see, see also, see condition)

• And = and/or• With = associated with or due to• Code also note instructs that two codes may

be required – does NOT pertain to sequencing

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Instructional Notes -3

• Etiology/manifestation - “Code first”, “use additional code” and “in diseases classified elsewhere” notes• Requires that the underlying condition be

sequenced 1st, followed by the manifestation• Provides assistance with proper sequencing order

of the codes• Level of detail in coding• -must use and report the highest number

of characters available40