ICD-10 – ORIENTATION IN SNFS INTERNATIONAL CLASSIFICATION OF DISEASES – CM RHONDA L. ANDERSON,...

ICD-10 – ORIENTATION IN SNFSINTERNATIONAL CLASSIFICATION OF DISEASES – CM

RHONDA L. ANDERSON, RHIA

President, AHIS, Inc.

ICD-10 ORIENTATION IN SNFS

Staci LePage, RHIT,

Anderson Health Information Systems, Inc.

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

defined– Some general coding guidelines

Objectives

3

• January 15, 2009 Final Regulation Released

• EXCHANGE the ICD-9 for the ICD-10 on October, 1, 2014

Final Regulation

4

• 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

ICD-10 “Has Two Parts”

5

• 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

HIPAA

6

• 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.

Who Is Affected??

7

• 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

Benefits

8

• 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.

What Does This Mean??

9

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

• ICD-10 PCS (Procedural Code System)• – replaces ICD-9 CM in the inpatient• hospital setting• Current Procedural Terminology (CPT) is

still used for the Physician, and some services, but they must have a diagnosis that is ICD-10 compliant

Key Highlights

10

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

• ICD-10 CM/PCS – Increased level of detail required for medicine advancements in technology, $$, improved data quality for clinical and financial decision making, to support value based purchasing and facilitate quality reporting.

Key Highlights -2

11

• 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

ICD-9-CM Diagnosis Codes

12

• 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.

ICD-9-CM Diagnosis Codes -2

13

• 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-10 CM Structure

14

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

• 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

ICD-10 CM Structure -2

15

• 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

ICD-10-CM Diagnosis Codes – Format & Structure

16

• Codes that have applicable 7th character is considered invalid without the 7th character.

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

etc.)

ICD-10-CM Diagnosis Codes – Format & Structure

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

codes to allow for expansion– See categories T36-T50, poisoning codes

T36.8X1– Also, Pathological vertebral fracture due to

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

Example Of Placeholder “X”

18

• 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.

Example Of Laterality

19

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

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

Example Of Expanded Codes

20

• Diabetic Mellitus – • w/arthropathy NEC#11.618 (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 w/gangrene)

Diabetes

• w/foot ulcer E11.621 (type 2 diabetes with foot ulcer

• (use additional code to identify site)

Diabetes #2

• w/hypoglycemia E11.65• w/kidney complications E11.29

Diabetic #3

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

case Skilled/ICF rules (more on this subject later during full training)

– ICD-10 CM Index – disease and injury and external causes of Injury

ICD-10 CM Structure -

24

– More combined codes, i.e. Diabetic retinopathy is one code

– More specificity, i.e. Alzheimer’s disease with specific details of early or late onset

– G-30.9 et’l’– G30.0 Alzheimer’s with early onset– G30.1 “ with late onset– G30.9 Other Alzheimer’s

ICD-10 CM Structure

• Alzheimers…you may need to use with behavioral disturbance and without behavioral disturbance.

• >>key to psychoactive Drugs!!• ???behavioral disturbance ???justification

for psychotrophics ????

ICD-10 CM Structure

• 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

Conventions For The ICD-10-CM

27

• 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

Conventions For The ICD-10-CM -2

28

• General rules for use of the classification independent of the guidelines– 7th Characters

• 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

Conventions For TheICD-10-CM -3

29

• 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

Examples Of 7th Character

30

– K = subsequent encounter for fracture with nonunion

– P = subsequent encounter for fracture with mal-union

– S = sequela

Examples of 7th Character

• Fracture Traumatic (abduction, adduction, separation)

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

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

FRACTURE

• Fracture of lst lumbar vertebrae – S32.01, wedge compression, stable burse, unestablish, other, unspecified

FRACTURE

• 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.

ICD-10-CM Diagnosis Codes -4

34

• ICD-10 Code Format

Code Format

35

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

• 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

• !!

GEM Files

36

• 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!

GEM FILES

• 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

\WHAT DOES THAT MEAN TO ME?

• 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

WHAT DOES THIS MEAN TO ME?

• Review for Medicare must be more specific

WHAT DOES THIS MEAN TO ME?

• Organization• Structure• Code composition• Level of detail• May consist of 3 to 7 digits, with the

seventh digit extensions representing visit encounter or sequel, as stated above.

ICD-10 & ICD-9 Differences

41

• Includes full code titles for all codes (no reference back to common 4th and 5th digits)

• V and E codes are no longer supplemental classifications, as stated previously

ICD-10 & ICD-9 Differences -2

42

• NEC – Not Elsewhere Classified for conditions not classified elsewhere

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

Abbreviations & Punctuation

43

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

explanatory phrases)– ( ) Parentheses (nonessential modifiers/

supplementary words)– : Colon (used with includes and excludes

notes)

Abbreviations & Punctuation #2

• 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

Instructional Notes

45

• 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

Instructional Notes -2

46

• 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 available

Instructional Notes -3

47

• Locating a code in the ICD-10-CM• Level of detail coding• Code/codes from A00.0 through T88.9,

Z00-Z99.8• Signs and symptoms are acceptable for

reporting purposes when a related diagnosis has not been established

General Coding Guidelines

48

• Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes

CODING GENERAL GUIDELINES #2

• Acute and Chronic Conditions– If the same condition is described as both

acute and chronic, and separate subentries exist, code both and sequence the acute code 1st

• Combination Code– Is a single code used to classify two

diagnoses, or– A diagnosis with an associated complication

or manifestation

General Coding Guidelines -2

50

• Late Effects (Sequela)– Residual effect (condition produced) after the

acute phase of an illness/injury has terminated

– There is no time limit on when a sequela code can be used

– Coding generally requires two codes– Condition/nature of the late effect is

sequenced 1st; the sequela code is sequenced 2nd


51

• Late Effects (Sequela)– Exception is when the sequela code is part of

the 4th, 5th or 6th character of a code – 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


52

• Documentation for BMI and Pressure Ulcer Stages– Assignment may be based on medical record

documentation from clinicians who are not the patient’s provider


53

– Dietitian often documents the BMI and nurse often documents the pressure ulcer stages

– The associated diagnosis must be documented by the patient’s provider

– BMI codes should only be reported as secondary diagnoses

GENERAL CODING GUIDELINES

• Code assignment is based on the provider’s documentation

• Not all conditions that occur during or following surgery are classified as complications

Complications Of Care

55

• When admission is for treatment of a complication, the complication code is sequenced as the principal diagnosis

• 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

COMPLICATIONS OF CARE

• Uniform Hospital Discharge Data Set (UHDDS)/Principal diagnosis is defined as that condition established, after study, to be the chief cause of the admission of the patient to the facility for care

• Condition must be identified in the H&P or documented in the current inpatient medical record

OSHPD / Principal Diagnosis Definition

57

• What that means to a SNF– Acute hospital diagnosis– Late effects– Reason for the admission to Acute and the

SNF (bundled payments) – one facility gets paid and the other is paid by that facility.

ACUTE HOSPITAL – PRINCIPAL DX

• Two or more interrelated conditions with each potentially meeting the definition– Such as diseases in the same ICD-10-CM or

manifestations characteristically associated with a certain disease potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise

Principal Diagnosis

59

• Two or more interrelated conditions that equally meet the definition– When two or more diagnoses equally meet

the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the code book does NOT provide sequencing direction, any one of the diagnoses may be sequenced first

Principal Diagnosis -2

60

• Two or more comparative or contrasting conditions– When two or more diagnoses are documented

as “either/or”, they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission.

– Either diagnosis may be sequenced first.

Other Diagnoses

61

– When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first.

– These should never be principal diagnoses

OTHER DIAGNOSES

• Codes for symptoms, signs, and ill-defined conditions – are NOT to be used as a principal diagnosis when a definitive diagnosis has been established.

• THIS APPLIES TO SNF, ACUTE and other health locations

Signs, Symptoms, Ill-defined Conditions

63

• Uncertain Diagnosis– If the diagnosis documented at the time of

discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed/established

– Applicable only to inpatient admissions to short-term, acute, long-term care & psychiatric hospitals

Uncertain Diagnoses

64

• Determined by the reason for admission/encounter, with the highest acuity diagnoses sequenced 1st

Sequencing Of Codes

65

• With added laterality, need greater documentation from your MD’s

• Hypertensive Retinopathy H35.03– H35.031 right eye– H35.032 left eye– H35.033 bilateral– H35.039 unspecified (this would be a ?? for

billing most likely!!)– Code also any associated hypertension (I10)

Specificity Of Coding

66

• Sepsis– Unspecified organism, A41.9, if type of

infection is not specified– Sepsis d/t MRSA A41.02– B95.62 MRSA as the cause of conditions

classified elsewhere • When the infection does not have a combo code

that includes the causal organism

Chapter 1 – Infectious & Parasitic Diseases A00-B99

67

• HIV infections– Admit for HIV-related condition, principal

diagnosis should be B20, followed by code for HIV-related condition

Chapter 1 – Infectious & Parasitic Diseases A00-B99 -2

68

• UROsepsis – The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. Iy has no default code in the Alpha index.

• QUERY THE DOCTOR!!!• Sepsis with organ dysfunctioin• - follow Severe sepsis guidance

SEPSIS

• Requires two codes• First code for underlying systemic infection

followed by a code from subcategory R65.2

• Casual organism should be documented; if not – assign A41.9 unspecified for the infection. (where would you look)

SEPSIS - SEVERE

• The neoplasm table should be referenced first

• Anemia also w /malignancy– If encounter is for mgmt of anemia asso w

/malignancy, and tx is only for anemia, principal dx = malignancy code, followed by anemia code D63.0

Chapter 2 – Neoplasms C00-d49

71

• Anemia asso w/chemotherapy– Encounter for mgmt of anemia asso

w/adverse effect of chemo or tx, code anemia 1st, followed by neoplasm code and adverse effect

Chapter 2 – Neoplasms C00-d49 -2

• Diabetes Mellitus– Combination codes– Includes the body system affected and

complications affecting the body system– Many codes particular category as are

necessary to describe all of the complications of the disease may be used

– Sequenced base on the reason for a particular encounter

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89

73

• E08 Diabetes d/t underlying condition• E09 Drug or chemical induced diabetes

– Secondary diabetes is always caused by another condition or event

• E10 Type I Diabetes• E11 Type II Diabetes• Z79.4 long-term use of insulin

– Not used when insulin is being used temporarily

Chapter 4 – Endocrine, Nutritional, Metabolic E00-E89) -2

74

• Vascular Dementia • Dementia in other diseases classified

elsewhere• Unspecified Dementia• All of above are coded:

– With behavioral disturbance, or– Without behavioral disturbance

Chapters 5 – Mental & Behavior Disorders F01-F99

75

• Chronic pain syndrome G89.4 vs. chronic pain G89.2– Provider must specifically document which

condition• Hemiplegia - Dominant/non-dominant side

G81– For ambidextrous patients, the default should

be dominant– Left side affected, the default is non-dominant– Right side affected, the default is dominant

Chapter 6 – Diseases Of The Nervous System G00-G99

76

• Pain – category G89– Used in conjunction with codes from other

categories to provide more detail about acute or chronic pain, neoplasm pain, or post-procedural pain

– Can be listed as principal diagnosis– When pain control or pain mgmt is reason for

admit, the underlying cause and site of pain should be reported as additional dx, if known.

Chapter 6 – Diseases Of The Nervous System G00-G99 -2

77

• If encounter is for any other reason, and dx has not been established, assign the code for the site of pain 1st, followed by code from G89

Chapter 6 – Diseases Of The Nervous System G00-G99 -3

• Assigning glaucoma codes:– Assign as many codes from category H40, as

needed, to identify the type of glaucoma, the affected eye, and the glaucoma stage.

Chapter 7 – Diseases Of Eye And Adnexa H00-H59

79

• Combination Codes for Conditions and Common Symptoms or Manifestations

• I25.110 - Arteriosclerotic heart disease of native coronary artery with unstable angina pectoris

Chapter 9 – Diseases Of The Circulatory System I00-I99

80

• Hypertension with Heart Disease I11– Heart conditions classified to I50 or I51.4-

I51.9 are also assigned to, a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive)

– Use an additional code from category I50– Outlines the different conditions, i.e.,

Cardiomegaly, Mycarditis, Left Ventricular failure, etc.

Chapter 9 – Diseases Of The Circulatory System I00-I99 -2

81

• Hypertensive chronic kidney disease/CKD I12 – Cause and effect relationship is presumed– Need add’l code to identify the stage of CKD

• Hypertensive heart and CKD I13– Causal relationship for HTN and heart dx

must be doc’d


82

• Sequelae of cerebrovascular disease I69– Used to indicate conditions in I60-I67 as the

cause of sequelae. The “sequelae” include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition

– I.E., CEREBRAL INFARC – also have to document and code if tPA or rtPA in different facility in 24 hrs. (Z92.82—review)


83

• CEREBROVASCULAR DISEASE• Use added codes – identify presence of

– Alcohol abuse/dependence – (H&P/Social Eval)

– Exposure to tobacco smoke– Hx. Of tobacco use– Hypertension– Occupational exposure to tobacco smoke


• Tobacco dependence• Tobacco Use• (see where the History from the Physician

and the Social Hx. Is Important).


• I21 For encounters occurring while the AMI is equal to, or less tan, four weeks old, including transfers to another acute setting or another acute setting or a post-acute setting and pt requires continued care for the AMI

Chapter 9 – Acute Myocardial Infarction (AMI)

86

• Subsequent acute MI– When a pt who has suffered an AMI has a

new AMI within the 4 wk time frame of the initial AMI, code I22 in conjunction with I21 code

Chapter 9 – Acute Myocardial Infarction (AMI) #2

• Chronic Obstructive Pulmonary Disease (COPD) and Asthma– Acute exacerbation of chronic obstructive

bronchitis and asthma– J44 and J45 distinguish between

uncomplicated cases and those in acute exacerbation

– Acute exacerbation is a worsening or a decompensation of a chronic condition

Chapter 10 – Diseases Of Respiratory System (J00-J99)

88

• Acute and Chronic Respiratory Failure– Principle diagnosis when it is the condition

established after study to be chiefly responsible for admission to the hospital

• Influenza due to certain identified influenza viruses (J09)– Only on confirmed cases– Avian influenza or novel H1N1 or swine flu,

code J09.X_ (depending on associated manifestations)

Chapter 10 – Diseases Of Respiratory System (J00-J99) -2

89

• L89 codes for Pressure Ulcer are combination codes that identify the site as well as the stage of the ulcer

• Assignment of the pressure ulcer stage should be guided by clinical documentation of the stage

• Assign code for the highest stage reported for that site

Chapter 12 – Diseases Of Skin& Subcutaneous Tissue L00-l99

90

• Site and laterality– Designations– Represents the bone, joint or muscle involved– Where more than one bone, joint or muscle is

involved, such as osteoarthritis, use the assigned “multiple sites” code; if not available, use multiple codes to indicate the sites

– Bone vs. Joint – Certain conditions where the bone may be affected at the upper & lower end; site designation will be the bone, not the joint

Chapter 13 – Disease Of Musculoskeletal (M00-M99)

91

• Bone, joint or muscle conditions that are the result of a healed injury are coded to this chapter

• Chronic or recurrent conditions are also coded to this chapter

• Pathologic fractures are coded with 7th character D for encounters after active treatment is completed, if routine healing is occurring

Chapter 13 – Disease Of Musculoskeletal (M00-M99) -2

92

• M80 category is used for any patient with known osteoporosis who suffers fracture, even if pt had minor fall or trauma, if that fall would not usually break a normal bone

• Osteoporosis without pathological fracture M81 is used for patients who do not currently have a pathologic fracture d/t osteoporosis, even if they have had a fracture in the past

Chapter 13 – Osteoporosis

93

• Osteoporosis with pathological fracture, M80, is used for pts who have a current pathologic fracture at the time of the encounter

Chapter 13 – Osteoporosis #2

• Stages of chronic kidney disease (CKD)• If both a stage of CKD and ESRD are

documented, then assign code N18.6 only • Patients who have had kidney transplant

may still have some form of CKD, because the transplant may not fully restore kidney function. Therefore, presence of CKD alone does NOT constitute a transplant complication.

Chapter 14 – Diseases Of Genitourinary (N00-N99)

95

• A41.9 Sepsis, unspecified organism –Septicemia, unspecified (Chapter 1 Infectious & Parasitic Diseases)

• Severe Sepsis – R65.20 – code first underlying infection, and use additional code to identify specific organ

• Urosepsis – cannot code, code to condition

Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab

Findings (R00-R99)

96

• Septic Shock– Circulatory failure associated with severe

sepsis; represents a type of acute organ dysfunction. Underlying infection sequenced first, followed by code R65.21 Severe sepsis with septic shock. Add additional codes for other acute organ dysfunction

Chapter 18 – Symptoms, Signs & Abnormal Clinical & Lab

Findings (R00-R99) -2

97

• Use of symptom codes are acceptable for use when a related diagnosis has NOT been established by the provider

• Use a symptom code with a diagnosis code may be reported when the sign or symptom is NOT routinely associated with that diagnosis

• Signs or symptoms that are associated routinely with a disease process should NOT be assigned as additional codes

Chapter 18 – Signs/Symptoms Codes

98

• R29.6 Repeated falls is used when a patient has recently fallen and reason for the fall is being investigated.

• Z91.81 Hx falls is used when a pt has fallen in the past and is at right for future falls

• When appropriate, both of the above codes may be assigned together

Chapter 18 – Signs/Symptoms Codes -2

99

• R53.2 is the lack of ability to use one’s limbs or to ambulate d/t extreme debility.

• It is NOT associated with neurologic deficit or injury, code R53.2 should NOT be used for cases of neurologic quadriplegia.

• It should only be assigned if functional quadriplegia is specifically documented in the medical record

Chapter 18 – Functional Quadriplegia

100

• An example S42.321D. Displaced transverse fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing

• This means more specific documentation from the physician (the initial encounter of treatment is usually in the Emergency room).

Chapter 19 – Injury, Poisoning & Certain Other Consequences of

External Causes S00-T88

101

• A fracture not indicated as open or closed should be coded to closed

• A fracture not indicated whether displaced or not should be coded to displaced

Chapter 19 – Injury, Poisoning & Certain Other Consequences of

External Causes S00-T88 -2

102

• When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the code for the adverse effect of the drug (T36-T50)

• The code for the drug should have a 5th or 6th character “S”

•

Chapter 19 – Drug Toxicity

103

• When coding a poisoning or reaction to the improper use of a medication, i.e. overdose, wrong substance given or taken in error, assign the appropriate code from categories T36-T50

• The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined)

Chapter 19 – Poisoning

104

• Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction

• Assign T36-T50 with 5th or 6th character of “6”• Codes for underdosing should never be

assigned as principal dx• Noncompliance (Z91.___) or complication of

care (Y63.___) codes are to be used with an underdosing code, if known

Chapter 19

105

• These codes are secondary codes for use in any health care setting

• These codes capture how the injury happened (cause) or the intent

• Assign the external cause code with the appropriate 7th character for each encounter for which the injury or condition is being treated (initial, subsequent or sequela)

• What happened? V03 pedestrian injured in collision with car, pick-up truck or van

Chapter 20 – External Causes of Morbidity (V00-Y99)

106

• For use in any healthcare setting• May be used as either a principal

diagnosis or secondary code• Certain Z-codes may only be used as

principal diagnosis

Chapter 21 – Factors Influencing Health Status and Contact with

Health Services (Z00-Z99)

107

• Z code should not be used if treatment is directed at a current acute disease

• Exceptions– First listed, followed by the diagnosis code

when a patient’s encounter is solely to receive radiation therapy Z51.0

– Code also condition requiring care

Chapter 21 – Z Codes

108

• Factors Influencing Health Status and Contact With Health Services Z00-Z99

• Former V codes are now Z codes• Provided for occasions when circumstances

other than a dx, injury or external cause are recorded

• Several codes have been expanded, i.e. personal and family hx

• Now have a code for patients blood type, i.e. Z67

CHAPTER 21 – Z Codes

109

• No longer have V57 codes • Code the underlying condition, i.e. injury,

etc. with the appropriate 7th character for subsequent encounter

• Z68 BMI is divided into adult and pediatric codes (Adults = age 21 or older)

• RD in facility can assist with documenting the BMI

Chapter 21 – Z Codes -2

110

• Code Z92.82 when tsf facility has admin tPA within 24 hrs prior to admit (usually with new dx of MI or CVD)

• Aftercare Z codes should NOT be used for aftercare of fractures

• For aftercare of fractures, assign fracture code with 7th character D for subsequent encounter

Chapter 21 – Z Codes -3

111

• Now:– V54.81 Aftercare following joint replacement – V43.64 Joint replacement, hip

• Then:– Z47.1 Aftercare following joint replacement

surgery – *only use above code for OA, not injury– Z96.641 Presence of right artificial hip joint

Right Hip Replacement

112

• Resident admitted for physical therapy following CABG– Z48.812 Encounter for surgical aftercare

following surgery on the circulatory system– Z95.1 Presence of aortocoronary bypass graft

Z Code Examples

113

• Status post L BKA admitted for dressing changes following resolved infection of the amputation stump– Z48.01 Encounter for change or removal of

surgical wound dressing– Z89.522 Acquired absence of left knee

More Z Code Examples

114

Questions and Answers

115

Rhonda L. Anderson, RHIA

President, AHIS, Inc.

[email protected]

714-558-3887

mailto:[email protected]

Thanks for attending!!

116

ICD-10 – ORIENTATION IN SNFS INTERNATIONAL CLASSIFICATION OF DISEASES – CM RHONDA L. ANDERSON,...

Documents

Transcript of ICD-10 – ORIENTATION IN SNFS INTERNATIONAL CLASSIFICATION OF DISEASES – CM RHONDA L. ANDERSON,...