ICD 10’s and Ambulance Services · •ICD‐10‐CM code descriptions include right or left...

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ICD‐10’s and Ambulance Services

Presenters/Creators

Angela Lehman, RHIAEmergency Medical Services AuthorityAAA Medicare Regulatory Co‐Chair

GREAT RESOURCES• http://www.roadto10.org/

GREAT RESOURCES

• https://www.aapc.com/icd‐10/icd‐10‐codes.aspx

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GREAT RESOURCES

• http://www.ahima.org/icd10

GREAT RESOURCES

• http://the‐aaa.org/member‐center/medicare‐reimbursement‐center/icd‐10‐transition/

What is ICD?

• The International Classification of Disease (ICD) is a system of coding created by the World Health Organization in 1979 that details:– Diseases– Injuries– Symptoms– Procedures and more.

http://searchhealthit.techtarget.com/definition/ICD‐10

Current Ambulance Coding• Effective January 1, 2012, ICD‐9’s were required to be submitted on

electronic ambulance claims to represent a patients condition. Thedetermination of what is submitted is based on the MedicareAdministrative Contractors (MAC’s).

• Option 1: Suppliers may choose codes from the Medical Conditions List provided by theCenters for Medicare & Medicaid Services (CMS) that corresponds to the condition of thebeneficiary at the time of pickup and report the codes in the diagnosis field on the claim. Thecodes in the Medical Conditions List are taken from the ICD‐9‐CM diagnosis code set.

• Option 2: Suppliers may report an ICD‐9‐CM (or ICD‐10‐CM when appropriate) diagnosiscode that is provided to them by the treating physician or other practitioner.

• Option 3: Suppliers may report ICD‐9‐CM diagnosis code 799.9 Unspecified illness.

• Some ambulance services submit ICD‐9 codes based on their MAC’s local coveragedetermination policy (LCD).

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Compliance Date

• On August 24, 2012, the Department of Health and Human Services (HHS) issued a Final Rulethat delays the compliance date for the new ICD‐10 diagnosis and procedure codes until October 1, 2014.

• The previous compliance deadline of October 1, 2014 was delayed again when President Barack Obama signed a ne law on April 1, 2014. This law ordered HHS to not set an ICD‐10 deadline any sooner than October 1, 2015.

• The U.S. Department of Health and Human Services (HHS) issued in September 2014, a rule finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD‐10.

• Any provider covered by the Health Portability and Accountability Act (HIPAA) must make the transition to ICD‐10’s (MLN Matters Number SE1239).

• Claims for services provided on or after the compliance date should be submitted with ICD‐10 diagnosis codes.

• Claims for services provided prior to the compliance date should be submitted with ICD‐9 diagnosis codes.

Update

Update

Free Billing Software• You may download the free billing software that CMS offers via the Electronic Data

Interchange (EDI) via each MAC’s website.• This billing software only works for submitting Fee‐for‐Service claims to Medicare. It is

intended to provide submitters with an ICD‐10 compliant claims submission format; it does not provide coding assistance.

Please note that submitting electronic claims to Medicare using the free billing software does not change the requirement for ICD‐10 compliant claims to be submitted for FROM dates of service on or after October 1, 2015. Any claims containing ICD‐9 codes for FROM dates of service on or after October 1, 2015, will be rejected by Medicare.

Update

Direct data entry• Providers that bill institutional claims are also permitted to submit claims electronically via direct data

entry (DDE) screens. For more information about DDE, go to http://medicare.fcso.com/Direct_data_entry/.• You must submit a request to submit claims via DDE by prior to October 1, 2015.

Please note that claims submitted via DDE must contain ICD‐10 codes for dates of discharge/through dates on or after October 1, 2015. Those submitted containing ICD‐9 codes for dates of discharge/through dates on or after October 1, 2015, will be returned to provider (RTP).

Paper claims• In limited situations, you may submit paper claims with ICD‐10 codes to Medicare. To find more

information on when you may submit paper claims, visit http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ASCAWaiver.html

• You must submit a wavier before October 1, 2015.

Please note that submitting paper claims to Medicare, even if approved for an ASCA waiver, does not change the requirement for ICD‐10 compliant claims to be submitted for FROM dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2015 .

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Update07/06/2015

On July 6, 2015 a letter was sent to providers from CMS

Update07/06/2015

Q&A Clarifying the 7/6/2015 Letter form CMS

Centers for Medicare and Medicaid Services (CMS) and American MedicalAssociation (AMA) calls for Medicare B Fee For Service Providers/Suppliers touse ICD‐10 codes in the correct family in order to qualify for reimbursement.

What is meant by a family of codes? (Revised 7/31/15) Answer 5: “Family of codes” is the same as the ICD‐10 three‐character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition.

Why the Change?

• This is the first major change in U.S. coding in more than 30 years.

• Some call it healthcare’s version of Y2K.

• Expands diagnosis code selections to 68,000+ comparedto 14,000 ICD‐9‐CM selections.

Gearing Up for Change

• Change is not easy to embrace, even if the outcome is for thebetter.

• Reasons for change:– We have to change, because the current process is broke;or

– There is a better way to accomplish a task or goal.

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Clinical

• Better outcomes because of better documentation.

• Improvement of care due to the documentation on higher acuity patients.

• Help to design better protocols.• Improved tracking of patient illnesses.

http://www.roadto10.org/icd‐10‐benefits/

Clinical• Paints a better picture due to specificity, laterality, and more detailed information about the disease process.

• Provides more precise information reporting to the State and other Public Health entities.

• Improved tracking of patient illnesses.


Operational

• Improved definitions of patient conditions.• For institutional providers, helps with greater specificity to define co‐morbidities and complications.

• The ability to share better data based on patient and population.


Financial• Better documentation, which gives ability to understand the

patient complexity and level of care; therefore, supporting reimbursement for the level of care provided.

• Allows for better comparison for benchmarking patient conditions.

• May aide in lowering audits due to more specific codes supported by greater documentation.


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ICD‐10‐CM

Used Across the World Since 1998

ICD‐10‐CM Concepts

ICD‐10‐CM21 Chapters

ICD‐9‐CMOnly 17 Chapters

Documentation Focus AreasICD‐10‐CM

• Disease Type• Disease Acuity• Disease Stage• Site Specific• Laterality• Combination Codes• Changes in timeframes with certain codes

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ICD 9 to ICD‐10: Differences

• A move from a 5 Digit Code to a 7 Digit Code with different logic.• Approximately 8X’s more ICD‐10 codes than ICD‐9 codes. • No E or V codes, they are incorporated into the main classification system.

ICD‐9‐CM

8 1 3 4 2Etiology, Atomic site,

Severity

• 3‐5 Digits• The first digit is alpha or numeric• Digits 2‐5 are numeric; and• A decimal is used after the third character.

• The first 3 digits are the category, and if there are a 4th or 5th digit they are the etiology, atomic site and severity of the patient.

Code Structure:ICD‐10‐CM

Category

A 2 3

“Heading Category”

All diagnoses will have 3 digits:• 1st Is always an alpha character.

• All letters of the alphabet has been utilized, except for “U”.

• 2nd Is always numeric.• 3rd Can be a alpha or numeric.• A decimal is placed after the 3rd

character, if there are more than 3 digits to the code.

All defining the disease, injury or problem.

CMS is now calling the 3 digit category as a “family code”.


Category

A 2 3 4 5 6

Etiology

Atomic Site

LateralityOr

Severity

Etiology: 4th digit is defining the origination of the disease/injury/problem.

Anatomic Site: 5th digit, defines the body part that is affected.

Laterality or Severity of Illness: 6th digit, defines which side of the body is affected.

Then followed by a decimal, if a 7th digit is necessary.

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Laterality• ICD‐10‐CM code descriptions include right or left designation.

– Right side‐Character 1– Left side‐Character 2– Bilateral‐Character 3– Unspecified side is either a character 0 or 9, depending on whether it

is a fifth or sixth character.

Laterality

When an ICD‐10 code allows for laterality AND the condition is bilateral, and bilateral is not an option to code then code both right and left separately.

If the side is not identified as right or left, then code unspecified.


Extension: 7th Digit is a place holder for an extension of a code to increase specifity.

It is only used in certain chapters to provide data and characteristic about an encounter.

The 7th Character is found to mostly identify injuries and fractures.

Seventh Character

Puncture wound w/o FB of Lower BackAnd Pelvis w/o Pentetration into retroperitoneum

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Seventh Character

Puncture wound w/o FB of Lower BackAnd Pelvis w/o Pentetration into retroperitoneum

What Do they Mean?

InitialReceiving active treatment for acondition.

SubsequentHas completed active care, and is in thehealing process.

SequelaA “late effect”. A condition that is theconsequences of a previouscondition/injury.


Category

T 5 6 0 X 2 A

Etiology

Atomic Site

LateralityOr

Severity

Extension/Specify

Place Holder: An “X” is used in place of a numeric number in position of the 4th, 5thand/or 6th digit.

When a code has less than 6 characters and a 7th Character is Required, the X is assigned for all the characters less than 6 as a “dummy placeholder” in order to meet

the requirement of coding to the highest level and for further expansion.

Toxic Effect of lead and its compounds, intentional self‐harm, initial encounter


Category

W 8 5 X X X A

Etiology

Atomic Site

LateralityOr

Severity

Extension/Specify

Exposure to electric transmission lines, initial encounter


Category

P 9 0

Etiology

Atomic Site

LateralityOr

Severity

Extension/Specify

If a Category is not further subdivided, or there is not a need for a 4th, 5th, 6th, or 7thcharacter, then the code is complete because it cannot be coded to further specificity.

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Category

P 9 0

P90: Convulsions of a newborn

CMS is now calling the 3 digit category as a “family code”.

ICD‐10‐CMNot New‐Guidelines existed for ICD‐9‐CM’s too

ICD‐10‐CM

Approved By:• The American Hospital Association (AHA);• The American Health Information Management Association

(AHIMA);• Centers for Medicaid and Medicare (CMS); and• The National Center of Health Statistics (NCHS).

• Adherence to these guidelines are to be used when assigning ICD‐10‐CM diagnosis codes.

• Required by HIPAA.• Adopted for all Healthcare Settings.

ICD‐10‐CM

Alphabetic Index• Divided into 2 Parts:

– Disease and Injuries; and– External Causes Formatted the same as ICD‐9‐CM

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ICD‐10‐CMTabular List• Divided into 21 Chapters.• Each chapter is divided into subcategories that contain 3

letter characters to make up the categories of the ICD‐10‐CM.• The disorders classified in ICD‐10‐CM are different compared

to ICD‐9‐CM.

ICD‐10‐CM

Combination Codes• A single code used to classify two diagnoses or

– A diagnosis with an associated secondary process (manifestation), or

– A diagnosis with an associated complication.

Rarely will ambulance services use Combination codes unless specified by your Carrier

Abbreviations

Not Elsewhere Classified (NEC)• “other specified”• When a specific code is not available for a certain condition; therefore, must be classified as NEC.

Not Otherwise Specified (NOS)• Equivalent of unspecified• Documentation is not specific to the condition; therefore, it is insufficient to assign a more specific code.

ExcludesIn ICD‐9‐CM there were 1 type of Exclude Note• “NOT CODED HERE”. It indicates the two conditions could never

occur at the same time.

In ICD‐10‐CM there are 2 types of Excludes Notes• The exclude note already available in ICD‐9; and• 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).

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ExcludesICD‐10‐CMChapters

Chapters are SubdividedBreak Down of ICD‐10’s

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Break Down of ICD‐10’sGood News/Bad News

• Unspecified codes do exist.• Some conditions do cross walk 1 to 1.

Chest Pain, Unspecified Chest Pain, Unspecified

• BUT…

General Equivalence Mapping (GEMS)Converts ICD‐9‐CM Codes to ICD‐10‐CM codes and Vice Versa

General Equivalence Mapping (GEMS)• Identification of potential corresponding codes between ICD‐9 and

ICD‐10.

• Mappings are bi‐directional, and goes backwards and forwards.

• GEMS are not direct crosswalks, there is not an exact match between more complex ICD‐10‐CM codes.– This may limit the likely hood of an exact match.– A single ICD‐9 code may map to multiple ICD‐10 codes.– There are new concepts in ICD‐10 codes that were not available in

ICD‐9 codes.– More than one ICD‐9‐CM Code may be possible translation of a given

ICD‐10‐CM.– More than one ICD‐9‐CM Code may be required to convey the

complete meaning of a given ICD‐10‐CM.

http://bok.ahima.org/PdfView?oid=300761

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General Equivalence Mapping (GEMS)Converts ICD‐9‐CM Codes to ICD‐10‐CM codes and Vice Versa

https://www.aapc.com/icd‐10/icd‐10‐mapping.aspx

Native Coding and Unspecified Codes• Native coding means to assign an ICD‐10 diagnosis code directly based on

clinical documentation.

• Providers are encouraged to natively code using ICD‐10 code reference sources instead of using crosswalks, which should be used for general knowledge.

• Specific codes reflecting the most appropriate level of certainty known for an encounter should be evaluated first:– Specific diagnosis codes should be reported when they are supported by the

available medical record documentation and clinical knowledge of the patient’s health condition.

– If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.

– When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, coding should comply with the payer guidelines for the use of unspecified codes.

http://www.roadto10.org/icd‐10‐basics/

Ambulance ICD‐9‐CM to ICD‐10‐CM

American Ambulance AssociationCondition Code Cross Walk

American Ambulance AssociationTop Ambulance ICD‐9 Codes evaluated

for the best ICD‐10 codes to use.

Condition Codes

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Payor Specific

Payor SpecificWorkers’ compensation and auto insurance companies are considered non‐covered entities under HIPAA. Will they have to switch to ICD‐10‐CM?

Answer: Workers' compensation and auto insurance companies areconsidered non‐covered entities and are not covered under HIPAA; however,since the ICD‐9‐CM codes will no longer be maintained after theimplementation of ICD‐10‐CM it is recommended that that they use the newcoding system.

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Understanding Medical Terminology

Medical Terminology• Medical billers and medical coders need to be comfortable using and

understanding medical terms in order to apply the correct codes to describe services delivered to patients.

• Very often within the clinical environment, medical terminology is composed of abbreviations and understanding them makes reading documentation much faster and easier.

• Many of the words used by physicians, surgeons, and other healthcare providers consist of Greek and Latin root words that are combined to create a multi‐syllabic term that carries a precise meaning.

Medical Terminology• Most medical terms consist of three basic components:

– root word (the base of the term), – prefixes (letter groups in front of the root word) and – suffixes (letter groups at the end of the root word).

• While a medical biller or coder knows what a layperson means when they say that someone has suffered a heart attack, this term means nothing for coding or billing purposes.

• Medical terminology precisely defines a condition. Professional medical billers are able to understand the specifics of this terminology in order to communicate it to third‐party payers for accurate reimbursement.

Anatomy and Physiology

This helps Billing and Coding to understand the basics of A&P, can help them too:

• Gain understanding how diseases affect healthy functions of the organs and body system.

• Better equip them how to ask intelligent questions if they need query the documentation for clarity to ensure appropriate level of billing.

AnatomyStudy of normal body structures.

PhysiologyStudy of normal, healthy, bodily functions.

PathophysiologyStudy the changes of normal mechanical, physical and biochemical functions.

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Abbreviations

• Billers and Coders need a list of approved abbreviations used by the Paramedics and EMT’s in order to understand their documentation.

• As abbreviations are updated they need to be shared with the billing staff.

Understanding Lab Values and Vitals

A lab value or vital sign reported as lower or higherthan a normal range may not necessarily indicate adisorder, but:

– It can help support medical necessity; therefore, a biller/coder needs to understand the normal values.

– It can tell the story of what is going on with the patient and help to define their disease process.

– Provide information to help a biller/coder to decide the appropriate diagnosis.

Medications

Medication can help a biller/coder to recognize apatient that has a certain condition, such insulin fordiabetes, or a patient on tamoxifen for breastcancer. Billing learns important information frommedications taken by the patients and can:• Help a biller/coder to look for certain conditionsand procedures;

• What level of service to bill;• And to understand some of the signs andsymptoms.

Signs and Symptoms• In medicine a symptom is generally subjective while a sign is objective.

Any objective evidence of a disease, such as blood in the stool, a skin rash, is a sign ‐ it can be recognized by the doctor, nurse, family members and the patient.

However, stomach, lower‐back pain, fatigue, for example, can only be detected or sensed by the patient ‐ others only know about it if the patient tells them.

Light headache ‐ this can only be a symptom.

• A light headache can only be a symptom because it is only ever detected by the patient.

High blood sugar ‐ this can only be a sign

• High blood sugar can only be a sign because the patient cannot detect it; it can only be measured in a medical laboratory.

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Signs and Symptoms Chapter

ICD‐10‐CM• Consist of codes for cases when more specific diagnosis cannot be made even

after all the facts bearing the case have been investigated; and• Signs and symptoms existing at the time of the encounter that proved to be the

reason for the encounter.– Many signs and symptoms are grouped by body part or relevant group.

– In ambulance transports, code the sign and symptom diagnosis that is the reason for transport and use any additional codes to support the need for the transport.

– In ICD‐10 coding guidelines, it is acceptable to use signs and symptoms when a definitive diagnosis cannot be determined, which often times is the case with emergency transports.

– If signs and symptoms are used, it’s a good rule to document in the narrative box 19 on the CMS claim form.

– If a more precise diagnosis is available, refer to your payor guidelines when coding.

Signs and SymptomsPAIN• Pain is the reason for the transport. Acute onset or bed‐confining.

• Pain is severity of 7–10 on 10‐point severity scale despite pharmacologic intervention.

• Patient needs specialized handling to be moved.

• Other emergency conditions are present or reasonably suspected.

• Signs of other life‐ or limb‐threatening conditions are present.

• Associated cardiopulmonary, neurologic, or peripheral vascular signs and symptoms are present.

Signs and Symptoms

780.96 Generalized Pain

If patients complaint is pain everywhere, body aches, and provides no specifics of pain in any certain spot, except he hurts all over. Patient complains pain is 6 out of 10.

R52: Pain, Unspecified

Signs and Symptoms

FEVERSignificantly high fever unresponsive to pharmacologic intervention.

– Adult >102 F after pharmacologic intervention.

– Child > 104 F after pharmacologic intervention.

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Signs and Symptoms

780.96 Generalized Pain

If patients complaint, is pain everywhere, body aches, and provides no specifics of pain in any certain spot. Patient complains pain is 8 out of 10. Patient has taken

Tylenol 2 hours ago and is running 102.5 fever.


R50.9: Fever, Unspecified

780.60 Fever, Unspecified

Signs and Symptoms

HYPOTHERMIA• A disorder characterized by an abnormally low body temperature.

• Treatment is required when the body temperature is 35c (95f) or below.

• Abnormal low body temperature.

• Abnormally low body temperature. Treatment is required when the body temperature is 35c (95f) or below. Symptoms include decreased mental function, lethargy, and disorientation.

Signs and Symptoms

OTHER MALAISE AND FATIGUE• A disorder characterized by a feeling of general discomfort or

uneasiness, an out‐of‐sorts feeling.

• A feeling of general discomfort or uneasiness, an out‐of‐sorts feeling.

• Malaise: a vague feeling of physical discomfort or apprehension.

• The property of lacking physical or mental strength; liability to failure under pressure or stress or strain.

Signs and Symptoms

780.79 Other Malaise and Fatigue

Patient complains of being lethargic, seems very confused and has a body temperature of 94 degree’s. Patient states she does not know why her temperature

is so low.

780.65 Hypothermia not Associated with Weather

R53.83: Other Fatigue

R68.0: Hypothermia, not associated with weather

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Signs and Symptoms

What is under General Symptoms: R68.89

Signs and SymptomsABNORMALITIES OF MOVEMENT• Disorders characterized by lack of coordination of muscle movements resulting in the

impairment or inability to perform voluntary activities. Impairment of the ability to coordinate the movements required for normal ambulation (walking), which may result from impairments of motor function or sensory feedback.

• ICD‐9‐CM 781.2 Abnormal Gait• ICD‐9‐CM 781.3 Lack of Coordination

ICD‐10 Code Code Description

R26.0 Ataxia gait

R26.1 Paralytic gait

R26.89 Other abnormalities of gait and mobility

R26.9 Unspecified abnormalities of gait and mobility

R27.0 Ataxia, unspecified

R27.8 Other lack of coordination

R27.9 Unspecified lack of coordination

R29.6 Repeated falls

Signs and Symptoms

Repeated Falls: R29.6

Patient complains of weakness, this is the third time the patient fell this week and was transported, patient complains of pain all over, with a temperature of 102.5 after

taking Tylenol for two days.

R53.1: WeaknessR50.9: Fever, Unspecified


R29.6: Repeated Falls, NEC

Signs and Symptoms

Repeated Falls: R29.6

If patient only has history of falling in the past and there is the possibility of future falls.

Z29.6: History of falling

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Factors Influencing Health Status and Contact Health Services

LAST CHAPTER

Factors Influencing Health Status and Contact Health Services

• Z Codes Represent Reasons for the encounters.• These codes are provided for occasions whencircumstances other than a disease, injury, or externalcause classifiable to the other categories.

• This occurs two ways: When a person who may or may not be sick

encounters healthcare for some specific purpose;or

When circumstances or problem is present whichinfluences the persons health status but is not initself a current illness or injury.

Other Important Codes

Z20.897 Contact with and Suspected Exposure to Other Communicable Disease‐Viral

Z20.818 Contact with and Suspected Exposure to Other Communicable Disease‐Bacterial

Z99.11 Dependence on a RespiratorZ99.2 Dependence on Renal DialysisZ99.81 Dependence on Supplemental OxygenZ99.89 Dependence on Other Enabling Machines

and Devices

Bed Confined

• The patient must meet all of the following three criteria:– Unable to get up from bed without assistance.– Unable to ambulate– Unable to sit in a chair (including wheelchair)

• Non‐emergency ambulance transportation is not covered for patients who are restricted to bed rest by a physician’s instructions but who do not meet the above three criteria.

• There should be a narrative description that describes the reason the term “bed confined” is being used.

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V49.84 Bed Confined Status

Z47.01: Bed Confined Status

Bed ConfinedGeneral Mobility Issues

• Patient’s physical condition is such that patient risks injury during vehicle movement despite restraints or positioning and/or record demonstrates specialized handling required and provided.

• This may be due to any or multiple of the conditions listed above. All conditions that contribute to general mobility issues must be adequately described.

• Includes conditions such as:– Unstable joints. Includes flail weight‐bearing joints following joint surgery. Includes

other patients who, in the expressed opinion of the operating surgeon, must absolutely bear no weight on a postoperative joint or patients who are incapable of protecting the joint without the assistance of the trained medical ambulance personnel. Patients who have undergone successful weight bearing joint repair/replacement and those who have successfully undergone long‐bone fracture repair (and who are not otherwise immobilized in casts that prohibit sitting) will generally not be included.

– Severely debilitating chronic neurological conditions such as degenerative conditions or strokes with severe sequelae. Neurological deficits must be described.

Z91.81 Risk of Falling

Z74.3 Need for Continuous Supervision

General Mobility Issues Restraints

• Documentation should describe why restraints were used.– Were they combative, danger to themselves or others?

• This does not include routine strapping of patients onto a gurney.

V49.87 Physical Restraint Status

Z78.1: Physical Restraint Status

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Certain Infectious and Parasitic DiseasesCertain Infectious and Parasitic Diseases

This subchapter is grouped by Infections :

• Sexual (A50‐A64)

• Viral Hepatitis (B25‐B34) and

• Other Viral Diseases (B25‐B34)

Many of the codes have been expanded to reflect manifestations of the disease.

and

Septicemia is replaced with Sepsis, ALL bloodstream infections are classified as Sepsis.

Condition ICD‐9

Unspecified Septicemia 038.9

Other Bacteria Infection 041.89

ICD‐10 Condition

A41.9 Sepsis, Unspecified Organism

B96.89Other Specified Bacterial Agents as the

Cause of Classified Elsewhere

Diseases of blood and blood‐forming organs and certain disorders involving the immune

mechanism

Is Grouped by types of Conditions

• Nutritional Anemias• Hemolytic Anemias• Aplastic and Other Anemias and Other Bone Marrow Failure Syndromes.• Coagulation Defects, Purpura and Other Hemorrhagic Conditions.• Other Disorders of Blood Forming Organs.• Intraoperative and postprocedural complications of the spleen.• Certain disorders involving the immune system.

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Hemoglobin

• Protein in red blood cells that carries oxygen• Each red blood cell contains several hundred thousand hemoglobin

molecules which transport oxygen.– Normal values:

• Male: 13.8 to 17.2 gm/dL• Female: 12.1 to 15.1 gm/dL

– Note: gm/dL = grams per deciliter

What can the Blood Glucose Test tell a biller/coder?• Low Hemoglobin could indicate Anemia.

– Signs and Symptoms: Pale skin, weakness, SOB, fainting, palpitations, chest pain, and restless leg syndrome

• High Hemoglobin could indicate a lung disease, bone marrow disorders, overdose or inappropriate use of the drug epoetin alpha.

http://www.emedicinehealth.com/hemoglobin_levels/page5_em.htm#what_does_high_hemoglobin_mean

Hematocrit (Hct)• Number and size of red blood cells• Performed due to anemia, diet deficiency, and leukemia.– Normal values:

•Male: 40.7‐50.3%•Female: 36.1‐44.3%

• Low Hematocrit could indicate Anemia, bleeding, leukemia, malnutrition, iron, folate, B12 & B6 deficiency, or overhydration.

• High Hematocrit could be a sign of right sided heart failure, dehydration, hypoxia, pulmonary fibrosis, bone marrow disease and congenital heart disease.

What can the Blood Glucose Test tell a biller/coder?

Diseases of blood and blood‐forming organs and certain disorders involving the immune

mechanismHemorrhage• Potentially life‐threatening hemorrhage• Uncontrolled bleeding• Signs of shock and active severe bleeding (quantity identified)• Ongoing or recent bleeding, with potential of immediate re‐bleeding.

In ICD‐9‐CM, 459.0‐Hemorrhage could be found in the Disease of the Circulatory System, but now is in Diseases of blood and blood‐forming

organs.

R58: Hemorrhage, Not Elsewhere Classified.

459.0 Hemorrhage, Not Elsewhere Classified

Endocrine, Nutritional and Metabolic Diseases

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Diabetes MellitusIncreased level of specificity

The diabetes mellitus codes are combination codes that includes:• The type of body system effected.• The complications affecting the body system.

Endocrine, Nutritional and Metabolic Diseases Diabetes Mellitus

• Diabetes Mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin.

• Insulin, a hormone released from the pancreas, controls the amount of sugar in the blood. It allows sugar to move from the blood into the cells. Once inside the cells, sugar is converted to energy.

Diabetes Mellitus Type I

• Formerly called insulin‐dependent or juvenile‐onset diabetes.

• More than 90% of the insulin‐producing cells of the pancreas are permanently destroyed.

• The body does not produce enough insulin.

• Most people with type I diabetes develop the disease before age 30.

Diabetes Mellitus type II

• Formerly called non‐insulin dependent diabetes or adult‐onset diabetes.

• The pancreas continues to produce insulin, sometimes even at higher than normal levels.

• Body develops resistance to the effects of insulin, so there is not enough insulin to meet the body’s needs.

• May occur in children and adolescents, but usually begins in people older than 30 and becomes progressively more common with age.

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Lab/Vital InformationBlood Glucose Test• Is a way of testing the concentration of glucose in the blood (glycemia). • A blood glucose test is performed by piercing the skin (typically, on the

finger) to draw blood, then applying the blood to a chemically active disposable 'test‐strip'.

• Different manufacturers use different technology, but most systems measure an electrical characteristic, and use this to determine the glucose level in the blood.

• The test is usually referred to as capillary blood glucose.What can the Blood Glucose Test tell a biller/coder?

https://en.wikipedia.org/wiki/Blood_glucose_monitoring

Diabetes Mellitus

Type:• Type 1• Type 2• Drug or Chemical Induced• Due to Underlying Condition• Other Specified Diabetes

No longer classified as controlled/uncontrolledInadequate Control

Out of ControlPoorly Controlled

• If diabetes is not distinguished between Type I or Type 2, then the default is Type 2.• Code diabetes with Hyperglycemia or Hypoglycemia if “uncontrolled”• IF patient doesn’t have diabetes, code hyperglycemia or hypoglycemia separately.• ICD‐9‐CM features 59 codes for diabetes, while ICD‐10‐CM offers more than 200 codes.

Coding Changes for EMS

Complications:• What if any other body systems are

affected by the diabetes condition?, i.e. foot ulcer.

Treatment:• Is the patient on Insulin?

Diabetes Mellitus– There are five (5) Diabetes Mellitus categories in the ICD‐10‐CM. They

are:• E08 Diabetes Mellitus due to an underlying condition• E09 Drug or chemical induced diabetes mellitus• E10 Type I diabetes mellitus• E11 Type 2 diabetes mellitus• E13 Other specified diabetes mellitus

– Diabetes mellitus codes expanded to include the classification of the diabetes and the manifestation.

– Remember: No longer classified as controlled/uncontrolled

E 1 3 6 5

Other SpecifiedDiabetes

Other SpecifiedComplications

Hyperglycemia


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Hyperglycemia

• High blood glucose happens when the body has too little insulin or when the body can’t use insulin properly.

• Symptoms :– frequent urination– increased thirst– fatigue– nausea and vomiting– dry mouth– rapid heartbeat

Hypoglycemia• Abnormally low levels of sugar (glucose) in the blood, usually less than 70

mg/dl.

• Low levels of sugar in the blood interferes with the function of many organ systems. The brain is particularly sensitive to low sugar levels, because sugar is the brain’s major energy source.

• Symptoms: – shakiness or nervousness– fatigue– sweating– hunger– nausea– irritability– irregular or racing heartbeat– difficulty speaking– confusion

Patient has Type I Diabetes with a blood sugar of 330 and is shaky and feels weird.


E10.65: Type 1 Diabetes Mellitus with hyperglycemia

250.03 Diabetes without mention ofcomplication, Type 1, Uncontrolled

Why would you use E10.65?

Patient has Type I Diabetes with a blood sugar of 55 and is shaky and feels weird.


E10.649: Type 1 diabetes mellitus with hypoglycemia without coma.

250.80 Diabetic hypoglycemia NOS

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Patient states he has never been diagnosed as a diabetic and has a blood sugar of 55 and is shaky and feels weird.


E16.2: Hypoglycemic, Unspecific.

251.2 Hypoglycemic, Unspecified

There is a Z code to support long term insulin use.


Z79.4: Long Term Insulin Use

Patient has is not a diabetic and has a blood sugar of 333 is shaky and feels weird.


R73.09: Other abnormal glucose

790.29 Other Abnormal Glucose

How would this be coded in ICD‐10?

Hypoglycemic Coma

• Life threatening complication that causesunconsciousness.

• Diabetes, with either dangerously high blood sugaror dangerously low blood sugar, can lead to adiabetic coma.

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Patient has Type I Diabetes with a blood sugar of 55 a GCS of 7, unable to answer questions


E10.641: Type 1 diabetes mellitus with hypoglycemia with coma.

250.33 Diabetes with other coma, Type 1,Uncontrolled

Patient is not a diabetic but has a blood sugar of 45 and GCS is 7.


E15: Non‐diabetic hypoglycemic coma

251.0 Hypoglycemic Coma

Obesity

• Documentation should give the patient’s height/weight.

– Why?

• Any special handling and/or equipment used or the use of extra manpower should also be documented.

• BMI > 80 (Morbid Obesity)

A girl that weighs 140 lbs and is 5’ 4” has a BMI of:140/(64X64) X 703

A gentleman that is 5’4” and weighs 250lb has a BMI of ?250/(64X64) X 703


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Other Metabolic ConditionsDehydration• Occurs when the body loses more water than it takes in.• Vomiting, diarrhea, the use of diuretics, profuse sweating, and decreased water intake can all

lead to dehydration.• Symptoms include

– thirst– reduced sweating– reduced skin elasticity– reduced urine production– and dry mouth

Volume DepletionDepletion of total body water.HypovolemiaDepletion of blood volume. Could be caused due to internal bleeding from intestine or stomach, external bleeding from injury or loss of blood volume and body fluid associated with diarrhea, vomiting, dehydration or burns. Signs and symptoms:

– edema– ascites


R19.7 Diarrhea, unspecifiedR50.9 Fever, unspecifiedR11.11 Vomiting without

nauseaE86.0 DehydrationR10.817 Generalized abdominal

tenderness

787.91 Diarrhea

780.60 Fever

33 month old female with severe dehydration after 2 days of watery diarrhea, fever and vomiting with no indication of nausea. Child is holding stomach and is crying with no tears. Mother stated child has had reduced urine output, symptom started after swimming.

Vitals: T 100.1 R 36 P 135 BP 90/55

The abdomen is distended and diffusely tender to palpation. No rebound tenderness, masses or organomegaly.

Dry mouth and tongue, membranes pale. Skin dry and poor skin turgor.

787.03 Vomiting alone

276.51 Dehydration

789.67 Abdominal tenderness, generalized

Mental, Behavioral and Neurodevelopmental Disorders

Behavioral Documentation

• Expressing active signs and/or symptoms of uncontrolled psychiatric condition or acute substance withdrawal.

• Is a threat to self or others requiring restraint (chemical or physical).

• Monitoring and/or intervention of trained medical personnel during transport for patient and crew safety.

• Transport required by state law/court order.

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Behavioral Documentation• Disorientation• Suicidal Ideations• Attempts and gestures• Hallucinations• Violent or disruptive behavior• DT’s• Drug withdrawal symptoms• Severe anxiety• Acute episode or exacerbation of paranoia

Anxiety

Normal human emotion that everyone experiences at times.

There are several types of anxiety disorders including:• Mixed Anxiety• Panic disorder• Social Anxiety Disorder• Specific Phobias• Generalized Anxiety Disorder• Phobias• PTSD and Acute Stress Disorder• Anxiety caused by physiological or external causes• Separation Anxiety• Adjustment Disorder• Anxiety due to Substance

Patient is very shaky, feels faint, has an elevated heart rate, and is very agitated

F41.1: Anxiety State, Generalized


OR

R41.8: Other specified Anxiety Disorder

OR

R41.9: Anxiety Disorder, Unspecified

300.00 Anxiety State, Unspecified

Delirium

• Serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking.

• Delirium can be traced to one or more contributing factors, such as a severe or chronic medical illness, medication, infection, surgery, or drug or alcohol abuse.

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DeliriumSymptoms:• Reduced awareness of the environment

– Inability to stay focused on a topic– Wandering attention– Being easily distracted by unimportant things

• Poor thinking skills (cognitive impairment)– Poor memory, particularly of recent events– Difficulty speaking or recalling words– Difficulty understanding speech

• Behavior changes– Seeing things that don’t exist (hallucinations)– Restlessness, agitation, irritability or combative behavior– Disturbed sleep habits

Delirium Dementia

Symptoms:• Memory impairment, difficulty with speech, difficulty with motor

activity, difficulty identifying objects, and may have the inability to plan and organize.– Generally in older adults

Patient seems to not stay focused, unable to recall current events and unable to sleep at night, patient woke this morning and see’s monsters under his bed.

F05: Delirium due to known physiological condition


OR

R41.0: Disorientation, Unspecified

293.0 Delirium

89 Y Male, with memory impairment, difficulty with speech, difficulty with motor activity, difficulty identifying objects, and may have the inability to plan and organize.

F03: Unspecified Dementia


294.21 Dementia, unspecified with behavioral disturbance

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C: 43 YO MALE C/O SUICIDAL IDEATIONS

H: PT WALKED UP TO STRANGERS HOUSE AND KNOCKED ON DOOR STATING THAT HE WANTED TO DIE AND WAS GOING TO KILL HIMSELF.

A: HEENT;ATRAUMATIC, NORMOCEPHALIC, NO JVD. CHEST;=/BILAT,CLEAR. ABD;SNT. PMS X 4. PT IS WARM AND SWEATING. NO INJURIES NOTED. PT WAS VERY AGITATED AND HARD TO ASSESS .

R: VS. EKG. 18 G IV W/SALINE LOCK EST IN LEFT FOREARM.

T: PT WAS HANDCUFFED BEHIND HIS BACK FOR THE SAFETY OF HIMSELF AND CREW MEMBERS. PT WAS SECURED TO COT USING ALL STRAPS. PT DID TEAR THE SHEET WITH HIS TEETH AND TRY TO CHEW COT MATTRESS. PT REMAINED IN HANDCUFFS AND WAS TRANSFERRED TO HOSPITAL BED IN ER RM 5. REPORT GIVEN TO RN AT PT BEDSIDE. xxxxx PD REMAINED WITH PT AND HE WAS SIGNED OVER TO THEM

Mental, Behavioral and Neurodevelopmental Disorders Alcohol or Drug Intoxication

Symptoms• Severe intoxication • Unable to care for self• Unable to ambulate• Altered level of consciousness

Alcohol WithdrawalSymptoms most often occur within 48‐96 hours after the last drink. Symptoms can include:• Body tremors• Changes in mental function• Agitation, irritability• Confusion, disorientation• Decreased attention span• Delirium• Hallucinations• Quick mood changes• Restlessness, excitement• Sensitivity to light, sound, touch• Stupor, sleepiness, fatigue

Alcohol Withdrawal Delirium (AWD)

• Alcohol withdrawal delirium is the most serious form of alcohol withdrawal. It causes sudden and severe problems in the brain and nervous system.

• AWD is also known as delirium tremens or DT’s. – Is a state of confusion of rapid onset.– Usually occurs 3 days after last use of alcohol– And last 2‐3 days.

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Found 19 Y male, unable to ambulate, slurred speech, not staying focused while questioning and smell of alcohol, but denies drinking, and beer cans are all over the ground.

F10.121: Alcohol Abuse with Intoxication, Delirium


Alcohol Abuse• ICD‐9‐CM subcategory 305.0, alcohol abuse, provides information on

whether the pattern of alcohol use by the patient is continuous, episodic, in remission, or unspecified.

• The classification of continuous or episodic alcohol abuse or dependence is not found in ICD‐10‐CM.

305.00 Alcohol Abuse, Unspecified

42 Y Women, family states patients mental function has changed, she is agitated, can’t sleep and feels bugs are crawling all over her, after interviewing the patient, the patient drinks 3 bottles of wine a day for the last 10 years, and has not had any in 4 days.

F10.231 Alcohol Withdrawal Delirium


291.0 Alcohol Withdrawal Delirium

Hallucinations

• Involves seeing things while awake that appear to be real, but instead have been created by the mind.

• Common hallucinations include:– Feeling bodily sensations, such as a crawling feeling on the skin.

– Hearing sounds, such as music or footsteps.– Hearing voices when no one has spoken.– Seeing patterns, lights, beings, or objects that aren’t there.

– Smelling a foul or pleasant odor.

50 Y Women says she see’s a man sitting in her recliner and he will not move, he has bee’s flying all around him and singing Sweet Home Alabama, she wants him to stop.

R44.2: Other hallucinations


780.1 Hallucinations

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Schizophrenia

• Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others. People with schizophrenia — the most chronic and disabling of the major mental illnesses —often have problems functioning in society, at work, at school, and in relationships.

• There are nearly 40 ICD‐9‐CM codes for Schizophrenia, but only 10 in ICD‐10‐CM.

ICD‐10 Code Description

F20.0 Paranoid schizophrenia

F20.1 Disorganized schizophrenia

F20.2 Catatonic schizophrenia

F20.3 Undifferentiated schizophrenia

F20.5 Residual schizophrenia

F20.8 Other schizophrenia

F208.1 Schizophreniform disorder

F208.9 Other schizophrenia

F20.9 Schizophrenia, unspecified

F21 Schizotypal disorder

Altered Level of Consciousness

Any measure of arousal other than normal.

• Level of consciousness (LOC) Is a measurement of a person’s arousability and responsiveness to stimuli from

the environment.

• Severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep is lethargy.

• State similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states is obtunded.

• Stupormeans that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state.

• Coma is a state of unarousable unresponsiveness.

Altered Level of Consciousness

• Acute condition with Glasgow Coma Scale < 15.

• Transient symptoms of dizziness.

• Associated with neurologic or cardiovascular symptoms and/or signs.

• Abnormal vital signs.

Glasgow Coma Scale (GCS)

• Neurological scale of recording the conscious state of a person.– Severe, with GCS < 8–9– Moderate, GCS 8 or 9–12– Minor, GCS ≥ 13.

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Glasgow Coma Scale (GCS)Today, physicians use the Glasgow Coma Score to assess patient survivability.

• Patients with scores between 13 and 15 are considered mildly impaired and will often fully recover.

• Patients with scores between 9 and 12 are categorized as moderately disabled. A majority of patients will have experienced a loss of consciousness of more than 30 minutes with scores between 9 and 12, and will often have physical and cognitive impairments that may resolve with rehabilitative therapy.

• Patients with GCS scores of 3 to 8 are often comatose, unconscious with no purposeful movements, have no interaction with their environment, or have no localized response to pain.– Approximately 50% of patients with a score of 8 will be unconscious or in a coma, and – Almost all patients with a score of 7 or less will be unconscious or in a coma. – A patient with a GCS of 3 is either dead or in a vegetative state with possible sleep‐wake cycles.


• When a GCS is taken by the EMS provider thefollowing ICD‐10‐CM codes can be utilized if needed orrequired by the payor or to help provide medicalnecessity.

R40.241 Glasgow Coma Scale score 13‐15




ICD‐10‐CM Guidelines• When a Glasgow Coma Scale score is not documented and

the patient is in a coma, or when only a partial score is reported, assign code:

– R40.244, Other coma, without documented Glasgow coma scale score, or with partial score reported.

• Primarily used for registries and research use and never should be used as a primary diagnosis.

– When the total score is provided, then per coding guidelines the ICD‐10‐CM code R40.241‐R40.243 should be used.

– R40.21, R40.22 and R40.23 is to only be used when the total GCS is not available.


• The scale above will be used by most other health care providers not EMSin an emergency situation; however, in non‐emergency this code may beused if the Coma Scale is going to be utilized from another healthcareprovider.

• R40.21, R40.22 and R40.23 is to only be used when the total GCS is notavailable.

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C: 89 Y/O FEMALE PT. UNRESPONSIVE

H: ACCORDING TO STAFF NURSE AN AID WAS IN ROOM WITH PT. WHEN SHE NOTICED THE PT BLUE CYANOTIC. THEY CALLED FOR CODE BLUE. NURSE SAYS 2 MIN OF CPR DONE ON PT AND SHE REGAINED ROSC. EMS WAS THEN CALLED. WE ARRIVED PT IS A&O ABLE TO TRACK US. SHE IS ALSO ASKING ME QUESTIONS. STAFF RESP TECH SAYS PT HAS TO BE SUCTIONED A LOT. ALSO NOTE SOME THICK GREEN SPUTUM IN VENT TUBING.

PT APPEARS TO BE NORMAL FOR HERSELF NOW ACCORDING TO STAFF.

A: A&O X 3. HEENT: NORMAL WITH TRACH IN PLACE BULB INFLATED AND TRACH COLLER IN PLACE. CHEST: NORMAL CLEAR EQUAL LUNG SOUNDS.ABD: SOFT NON TENDER. LEGS/ARMS: NORMAL SKIN: W/D/P TURGOR FAIR.

R: WE PLACED PT ON CM SHOWS NSR AT 96. O2 SAT'S R/A 88% WITH O2 AT 5 LPM AND HER VENT 100% CO2 AT 50 MMHG NORMAL WAVES NOTED. NO IV SITE FOUND WILL DEFER TO ER. VENT MONITOR.

T: PT RESTING IN POC SEMI FOWLER'S. SHE IS STABLE SLEEPING AT THIS TIME. NO OTHER CHANGES RELEASED xxxxx ER RN.

Diseases of the Circulatory System Disease of the Nervous System

Sleep Disorders• Are now in the Disease of the Nervous System instead of Signs and Symptoms.

Alzheimer's• Now reflects onset versus late effects.

Coding Changes

Disease of the Nervous System

Updated Terminology•Localization‐related to idiopathic •Generalized idiopathic•Special epileptic syndromes

Provide Specificity for:•Seizures of localized onset•Complex partial seizures•Intractable •Status epilepticus

–A continuous series of generalized tonic‐clonic seizure without return of consciousness, or any prolonged series of similar seizures without return to full consciousness between them.

Epilepsy

Epilepsy is a disorder that results from the surges in electrical signals inside the

brain, causing recurring seizures. Seizure symptoms vary. Some people with

epilepsy simply stare blankly for a few seconds during a seizure, while others

have convulsions where a person’s muscles contract and relax repeatedly.

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Paralysis–Dominant–Non‐Dominant–Unspecified

Hemiplegia Category (G81) –Monoplegia Category (G83.3) If documentation does not define dominant or non‐dominant:

–Ambidextrous, the default is dominant–Left Side, the default is non‐dominant–Right Side, the default is dominant

Paralysis Seizure

• Physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain.

• The term “seizure” is often used interchangeably with “convulsion”.

• Convulsions occur when a person’s body shakes rapidly and uncontrollably.

• Some seizures only cause a person to have staring spells. These may go unnoticed.

Seizure

• Conditions include:– New onset or untreated seizures– Significant change in baseline control of seizure activity– Ongoing seizure activity– Postictal neurologic dysfunction

C: 55 YO MALE C/O SEIZURE.

H: PT HAD TWO SEIZURES IN MARCH, FIRST TIME HE HAS HAD SEIZURES SINCE WAS TAKING LEVETIRACETAM TO CONTROL SEIZURES, BUT RAN OUT. HAD A SEIZURE TONIGHT, FAMILY DESCRIBED IT AS GRAND MAL ACTIVITY. HE WAS ON HIS BED, NO FALL INVOLVED. PT DID BITE HIS TONGUE. PMHX OF HTN.

A: UOA PT LYING IN BED, ONLY RESPONSIVE TO VERBAL STIMULUS, POSTICTAL.PT WOULD MOAN AND PULL AWAY WHEN QUESTIONED. SKIN PWD. HEENT: PERRL, SOME BLOOD ON RIGHT SIDE OF MOUTH POSSIBLY FROM BITING TONGUE. BS CTA = BI‐LAT RISE. ABD SNT. EXTREMITIES + CMS X 4.

R: PT'S MENTAL STATUS CONTINUALLY IMPROVED. VITALS. 4 LEAD SHOWED SINUS TACH. O2 NC 2 LPM WITH CAPNOGRAPHY. IV, 20 G LEFT AC, SALINE LOCK.

T: TRANSPORT PT To xxxxxxx ER WITH WIFE AS PASSENGER. PT HAD GCS OF 14 UPON ARRIVAL TO ER, NO COMPLAINTS OF PAIN OR INJURIES. PT REPORT GIVEN TO ER NURSE.


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C: 18 MONTH OLD MALE PT. FEBRILE SEIZURE.

H: GRAND MOTHER STATES PT WOKE UP THIS AM WITH FEVER OF 100.4. SAID HE STARTED CRYING AND EYE ROLLED BACK AND HE WENT LIMP. HE CAME AROUND WITH IN 20 SEC. THEY MANAGED TO GET HIM TO TAKE TYLENOL FOR THE FEVER. MOM STATES HE FELT LIKE HE MIGHT BE GETTING SICK OVER PAST FEW DAYS. FELT A LITTLE WARMER AT NIGHT. SHE STATES HE WAS ACTING AND PLAYING JUST FINE TILL THIS AM. HE JUST FINISHED MEDS FOR STREP THAT HIS SISTER HAD. PT IS HAVING PERIODS OF SLEEP INTERRUPTED BY CRYING. LIKE HIS PAIN SOME AND GOES. THEY DID NOT NOTICE IF HE HAS BEEN PULLING AT HIS EARS. HE DOESN'T TAKE A BOTTLE ANYMORE AND HE IS USING SIPPY CUPS AS NORMAL. MOM SAYS URINE OUT PUT IS NORMAL. ABOUT SAME AMOUNT OF DIAPERS DAILY.

A: UPON EXAM PT IS CRYING PULLING AWAY FROM ME AS EXPECTED FOR CHILD HIS AGE. HEENT: NORMAL CHEST: NORMAL CLEAR EQUAL LUNG SOUNDS ABD: SOFT NON TENDER. LEGS/ARMS: NORMAL. SKIN HOTDRY. TURGOR GOOD

R: PT PLACED ON CM DUE TO HIS AGITATION HIS HEART RATE UP TO 188. PT FELL ASLEEP DURING TRANSPORT. THIS ALLOWED HR TO GO DOWN TO 140 ST. R/A SPO2 96‐98% TYMPANIC SHOWS TEMP OF 37.1 (C). WE REMOVED THE ONESIE CLOTHING HE HAD ON TO ALLOW BODY TO COOL.

T: PT IS NOW SLEEPING AND RESTING IN CAR SEAT. MOM AT BABY SIDE. NO OTHER CHANGES ENROUTE TO ER. PT AND REPORT TURNED OVER TO ER STAFF


Transient Ischemic Attack (TIA)Temporary disturbance in brain function resulting from a temporary blockage of the brain’s blood supply.

Cerebrovascular Accident (CVA) A stroke occurs when the blood supply to part of the brain is suddenly interrupted or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells.

Transient Ischemic Attack (TIA)

• TIA’s may be a warning sign of an impendingischemic stroke.

• The symptoms are identical to those of an stroke butare temporary and reversible.

– They usually last 2‐30 minutes and rarely last more than 1‐2 hours.

Symptoms of CVA• Sudden weakness or paralysis of an arm, leg, or one side of the

body.

• Sudden dimness or loss of vision, particularly in one eye.

• Sudden confusion, with difficulty speaking and understanding speech.

• Loss of balance and coordination, leading to falls.

• Sudden severe headache with no apparent cause.

• Abnormal sensations or loss of sensation in an arm or a leg or on one side of the body.

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Coding Changes

Identifies various forms of CVA’s.• Cerebral hemorrhage • Infraction due to thrombosis• Embolism or• Unspecified occlusion or stenosis in the cerebral vessel.

Sequela of Cerebrovascular Disease (Late Effects in ICD‐9‐CM)• Conditions classifiable to categories I60‐I67 as the cause of sequelae

(neurologic deficits) which are classified elsewhere.– The symptoms persist after the initial cerebrovascular disease.– May arise at any time after the onset of the disease.

• Identified by type of stroke– Hemorrhage or infarction

CVA

• G89 Pain, Not Elsewhere Classified Category

• G89.3 Pain due to cancer, primary or secondary malignancy or tumor.

Pain

• This code category is not to be used for generalized pain, or

• Pain disorders exclusively related to psychological factors.

• This code is more for pain management.

• G89.0 Central pain syndrome• G89.11 Acute pain due to trauma• G89.12 Acute post‐thoracotomy pain• G89.18 Other acute postprocedural pain• G89.21 Chronic pain due to trauma• G89.22 Chronic post‐thoracotomy pain• G89.28 Other chronic postprocedural pain• G89.29 Other chronic pain• G89.3 Neoplasm related pain (acute) (chronic)• G89.4 Chronic pain syndrome

Pain Diseases of the Circulatory System

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An abnormal evaluation of systolic and/or diastolic bloodpressure.

Conditions:– Essential, Benign, Malignant– Hypertensive Heart and Chronic Kidney Disease– Secondary Hypertension

Relationship:– Renal– Pulmonary, etc.

Hypertension

CODING CHANGES

Hypertension• Deletion of the codes: benign, malignant and unspecified. • Hypertension table is no longer necessary. • Essential (primary) hypertension I10

Includes: High blood pressure Hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)

I 1 0

Hypertension

Hypertension

SystolicThe top number, higher of the two numbers, measures the pressure in the arteries when the heart beats. (when the heart muscle contracts)

DiastolicThe bottom number, lower of the two numbers, measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood)

Lab/Vital InformationBlood Pressure• When measuring blood pressure, your doctor or nurse will use a stethoscope to

listen to the blood moving through an artery.• The cuff is inflated to a pressure that’s known to be higher than your systolic blood

pressure. As the cuff deflates, the first sound heard through the stethoscope is thesystolic blood pressure. It sounds like a whooshing noise. When this noise goesaway, that indicates the diastolic blood pressure.

• The systolic blood pressure number is always said first, and then the diastolic bloodpressure number is given. For example, your blood pressure may be read as "120over 80" or written as 120/80.

• Blood pressure is measured in millimeters of mercury (mm Hg).

What can the Blood Pressure tell a biller/coder?

http://www.webmd.com/hypertension‐high‐blood‐pressure/guide/diastolic‐and‐systolic‐blood‐pressure‐know‐your‐numbers

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Hypertension

• Uncontrolled‐May be untreated hypertension or hypertension notresponding to current therapeutic regimen.

• Controlled‐This diagnostic statement usually refers to an existing state ofhypertension under control by therapy.– Standard commonly applied is that a sustained diastolic pressure above 90 mm Hg and a

sustained systolic pressure above 140 mm Hg constitutes hypertension.

Pre‐hypertension: Systolic (120‐139) or Diastolic (80‐89)

High Blood Pressure (Stage 1): Systolic (140‐159) or Diastolic (90‐99)

High Blood Pressure (Stage 2): Systolic (160 or higher) or Diastolic (100 or higher)

Hypertensive Crisis: Systolic (Higher than 180) or Diastolic (Higher than 110)

81 Y male, says he doesn’t know what is wrong, but feels weird, he states his face feels hot and he may pass out. He has a history of essential hypertension and takes metoprolol succinate daily. Patient stopped taking due to his financial situation.

His blood pressure is 162/101. His EKG shows nonspecific T‐wave changes.

I10: Essential Hypertension

401.9 Hypertension NOS

Diseases of the Circulatory System

794.31 Nonspecific abnormal EKG

R94.31: Abnormal EKG

Hypotension

When blood pressure is too low, not enough bloodreaches all parts of the body; as a result, cells do notreceive enough oxygen and nutrients, and wasteproducts are not adequately removed.

• Systolic: 90 or less• Diastolic: 60 or less

Symptoms of Hypotension

• Dizziness or lightheadedness• Fainting (syncope)• Lack of concentration• Blurred vision• Nausea• Cold, clammy, pale skin• Rapid, shallow breathing• Fatigue• Depression• Thirst

ICD‐9458.9 Hypotension

ICD‐10I95.9 Hypotension

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Elevated Blood Pressure

ELEVATED BLOOD PRESSURE

Elevated blood pressure reading

Elevated blood pressure reading without diagnosis of hypertension (situation)

Elevated blood‐pressure reading without diagnosis of hypertension

Elevated BP reading without HTN diagnosis

Finding of increased blood pressure

This category is to be used to record an episode of elevated blood pressure

in a patient in whom no formal diagnosis of hypertension has been made, or

as an isolated incidental finding.ICD‐9796.2 Elevated blood pressure

ICD‐10R03.0 Elevated blood pressure

A heart attack occurs when blood flow to a part of the heart is blocked for a long enough time that part of the heart muscle is damaged or dies. The medical term for this is myocardial infarction.

Coding ChangesTimeframe:

An AMI is now “acute” for 4 weeks from the time of incident versus 8 weeks with ICD‐9.

Episode of Care:ICD‐10 does not capture episode of care. (e.g. initial, subsequent)

Subsequent:Use a subsequent code if patient had an MI during the 4 weeks “acute period” of the original AMI. I 2 1 3

STEMI

Unspecified Site

Acute Myocardial Infarction (AMI)

– STEMI (ST Segment Elevation Myocardial Infarction)– Non‐STEMI (NON‐ST Segment Elevation Myocardial Infarction)– Initial– Subsequent (An MI that has occurred within 4 weeks of a prior

MI)And LATERALY is USEDMI’s are now specified by artery causing MIRight Coronary Left CircumflexLeft Main Artery Other SightsLeft Anterior Descending Unspecified Sites

Note: – If a Non‐STEMI evolves to STEMI, then STEMI code is used.– If a STEMI converts to a NSTEMI due to thrombolytic therapy, it is still

coded to STEMI.

Acute Myocardial Infarction (AMI)STEMI: ST Segment Elevation Myocardial Infarction

Acute Myocardial Infarction (AMI)

Non‐STEMI: NON‐ST Segment Elevation Myocardial Infarction

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58 Y male, had a NSTEMI five days ago, today patient woke up with tightness in his chest, and is worried it may be another heart attack. His HR is 85, he feels shaky, and thinks he may faint. He is being treated for hypertension and has a current BP of 157/98.

R07.9: Chest pain, unspecifiedI22.2: Subsequent Non‐ST elevation myocardial infarctionI10: Essential Hypertension

410.72 Subendocardial Infarction subsequent episode of care


401.9 Hypertension

786.50 Chest Pain

Lab/Vital InformationHeart RateThe heart rate, or pulse, is the number of times your heart beats per minute.

What can the Blood Pressure tell a biller/coder?

http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/All‐About‐Heart‐Rate‐Pulse_UCM_438850_Article.jsp

Atrial Fibrillation and Flutter

The two small upper chambers (atria) of the heart do not beat the way they should. Instead of beating in a normal pattern, the atria beat irregularly and too fast, quivering like a bowl of gelatin. Symptoms

– General fatigue– Rapid and irregular heartbeat– Fluttering or thumping in the chest– Dizziness– Shortness of breath and anxiety– Faintness or confusion– Fatigue when exercising– Sweating

Atrial Fibrillation and Flutter

Coding/Documentation

• Location: Atrial, ventricular, supraventricular, etc.

• Rhythm Name: Flutter, fibrillation, sick sinus syndrome.

• Acuity: Acute, chronic, etc.

• Cause: Hyperkalemia, hypertension, alcohol consumption, digoxin, etc.

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Cardiac Arrhythmias

Symptomatic or potentially life‐threatening arrhythmia.

Necessary symptoms include: • Syncope or near syncope. • Chest pain and dyspnea. • Includes severe bradycardia or tachycardia.• Patients are expected to have conditions that require monitoring during

and after transportation.

When to Use I49.8

Palpitations

A disorder characterized by an unpleasant sensation of irregular and/or forceful beating of the heart.

• A rapid or irregular heartbeat that a person can feel.

• An unpleasant sensation of irregular and/or forceful beating of the heart.

• Signs required include severe bradycardia or tachycardia (rate < 60 or > 120).

When to use Bradycardia

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When to use TachycardiaWhen to Use Palpitations and Abnormal Heart

Rate

C: HEART FLUTTERING

H: PT REPORTS EARLIER TODAY SHE STARTED FEELING WEAK AND LETHARGIC.SHE REPORTS STARTED FEELING LIKE HER HEART WAS FLUTTERING. ONSET WHILE AT REST. SHE REPORTS FELT LIKE HER HEART WAS BEATING IRREGULAR. PT DENIES ANY CHEST PAIN. DENIES SYNCOPE. STAFF REPORT PT HAS HX OF AFIB. PT NOT ON ANY MEDS FOR AFIB.

A: 81 Y/O FEMALE, PT SEEMS TO BE A&OX3 TODAY, PT HAS HX OF DEMENTIA/ALZHEIMER'S. HEENT: UNREMARKABLE, CHEST: EQUAL, BBS‐CTA, ABDOMEN: SOFT NON‐TENDER TO PALPATION, EXTREMITIES: CMS+X4 WITH WEAKNESS, SKIN: WARM AND DRY.

R: MONITORED VITAL SIGNS, PULSE OX, 4 LEAD AND 12 LEAD. EST IV LOCK. BLOOD GLUCOSE 116.

T: TRANSPORTED TO xxxxx

Diseases of the Circulatory System Heart Failure

Congestive Heart Failure when fluids build up in various parts of the body.

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Types of Heart Failure• Systolic Heart Failure: Heart muscle contracts with too little force,

causing less oxygen‐rich blood to be pumped (pumping problem).

• Diastolic Heart Failure: Heart contracts normally, but ventricle walls don’t relax enough to let the chamber fill (filling problem).

Symptoms– Shortness of breath– Persistent coughing or wheezing– Buildup of excess fluid in body tissues (edema)– Fatigue– Lack of appetite or nausea– Impaired thinking– Increased heart rate

Heart FailureCoding Changes:

• Acuity: Acute or ChronicDecompensation=ChronicExacerbation=Acute

• Type: Systolic or Diastolic

ICD‐9428.0 Heart Failure Unspecified

ICD‐10I50.9 Heart Failure Unspecified

Chest Pain• Pain usually characterized as severe, tight, dull, crushing,

substernal, epigastric, or left sided.• Associated pain of the jaw, left arm, neck, back• GI symptoms (such as nausea or vomiting)• Arrhythmias• Palpitations• Difficulty breathing• Pallor• Diaphoresis• Alteration of consciousness

C: CHEST PAIN

H: PT IS A 57 Y/O MALE WHO MEETS THE AMBULANCE AT THE DOOR. PT STATES THAT HE STARTED HAVING CHEST PAIN ABOUT 19:20 THIS EVENING WHILE LYING ON THE COUCH. PT DESCRIBES AS DULL PAIN THAT RADIATED DOWN HIS LEFT ARM, PT ALSO STATES HIS LEFT ARM WAS TINGLING. PT DID TAKE 2 OF HIS OWN NITRO AND HAS HAD RELIEF FROM THE CHEST PAIN. PT CURRENTLY RATING CHEST PAIN AT 0 ‐10. PT DID TAKE 324 mg OF ASA PRIOR TO AMBULANCE ARRIVAL. PT DOES GIVE HX OF MI WITH STINT PLACEMENT. PT ALSO HAS HX OF UNCONTROLLED HTN. PT DENIES ANY SHORTNESS OF BREATH. PT DENIES ANY N/V.

A: PT IS AOx4. HEENT IS NORMAL. CHEST HAS EQUAL RISE AND FALL WITH CLEAR LUNG SOUNDS. ABDOMEN IS DISTENDED AND FIRM, NONTENDER. PMS INTACT x4. SKIN IS WARM AND DRY. NO OBVIOUS INJURIES NOTED.

R: ALS ASSESSMENT. 4 LEAD SHOWS SINUS TACH WITH OCCASIONAL PVC'S AND COUPLETS. 12 LEAD SHOWS LBBB. IV ESTABLISHED WITH BLOOD DRAW, AND GLUCOMETER CHECK.

T: PT MONITORED ENROUTE WITH NO CHANGES IN PT CONDITION DURING TRANSPORT. UA TO EASTAR, PT REPORT GIVEN TO RN. PT CARE TRANSFERRED.

Note: This patient’s blood pressure was recorded as:210/120, 190/120, and 198/124 during this transport


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Chief Complaint Chest pain.

History 70 year old female patient presents with complaints of chest pain that awoke her from sleep last night. Patient describes the pain as midsternal “tight, squeezing” and pressure in the epigastric region. Patient reports that the pain was accompanied by diaphoresis and lasted approximately 5‐10 minutes before spontaneously resolving. Patient states she tried sitting up, walking, and taking some liquid antacid but experienced no relief with these measures. Denies change in diet, or any unusual foods yesterday.


T: afebrile, P 90, R 16, BP 160/94 (sitting) 128/78 (lying), 132/82 (standing) Ht: 68in. Wt: 265 lbs

786.50 Chest Pain, Unspecified

278.00 Obesity, Unspecified

V85.4 BMI over 40

265/((68X68)) X 703 = 40 BMI

R07.9 Chest Pain, Unspecified

E66.09 Other obesity due to excess calories

Z48.41 BMI over 40.0‐44.9

Syncope and Collapse• A disorder characterized by spontaneous loss of consciousness caused by

insufficient blood supply to the brain.

• A spontaneous loss of consciousness caused by insufficient blood supply to the brain.

• A spontaneous loss of consciousness caused by insufficient blood to the brain.

• A transient loss of consciousness and postural tone caused by diminished blood flow to the brain (i.e., brain ischemia). Presyncope refers to the sensation of lightheadedness and loss of strength that precedes a syncopal event or accompanies an incomplete syncope.

• Extremely weak; threatened with syncope.

• Fainting due to a sudden fall of blood pressure below the level required to maintain oxygenation of brain tissue.

20 Y Male, patient complains of dizziness, weakness and feeling tired for the last three days, and passed out at school three times, the previous two times he saw the school nurse. Upon questioning the patient he had to lose 11 lbs for the wrestling team. Patient looks exhausted, denies alcohol, drugs, supplements or diuretic use.

Lying BP: 116/78 with HR 56Sitting BP: 107/60 with HR 74Standing BP: 92/49 with HR 112

Mucus membranes pale, skin is dry, with turgor and tenting. Capillary refill in 2‐3 seconds.

EKG shows tachycardia

Patient was give 2L IV NS patient began to improve in route.

Diseases of the Circulatory System780.2 Syncope and Collapse


785.0 Tachycardia, Unspecified

458.0 Orthostatic Hypotension

276.51 Dehydration

276.52 Hypovolemia

R55 Syncope and collapse R00.0 Tachycardia, unspecified I95.1 Orthostatic hypotension (postural hypotension) E86.0 Dehydration E86.1 Hypovolemia

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Cardiac Arrest

• Abrupt loss of heart function in a person who may or may not have diagnosed heart disease.

• The term “heart attack” is often mistakenly used to describe cardiac arrest. While a heart attack may cause cardiac arrest and sudden death, the terms don’t mean the same thing.

Cardiac Arrest (427.5) Goes from 1 Code to 1 of 7 Codes.– Cardiac arrest due to underlying cardiac condition– Cardiac arrest due to other underlying condition

– Cardiac arrest, cause unspecified– Postprocedural cardiac arrest following cardiac surgery– Postprocedural cardiac arrest following other surgery– Intraoperative cardiac arrest during cardiac surgery– Intraoperative cardiac arrest during other surgery


I 4 6 9

Cardiac Arrest

Unspecified

Diseases of the Respiratory System The Respiratory System

• The respiratory system draws oxygen into the body and removes carbon dioxide.

• The body cells use oxygen to release the energy they need to live. Energy is released by a process called cell respiration.

• This process also releases waste carbon dioxide, which has to be removed before it poisons the body.

• The respiratory system consists of the lungs and the air passages that carry air to and from the lungs.

• A person can never take a break from breathing. People breathe around 20,000 times a day because their cells need a constant supply of oxygen.

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Lab/Vital InformationPulse OxA procedure used to measure the oxygen level (oroxygen saturation) in the blood. It is considered to be anoninvasive, painless, general indicator of oxygendelivery to the peripheral tissues (such as the finger,earlobe, or nose).What can the Blood Pressure tell a biller/coder?

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/oximetry_92,P07754/

Lab/Vital InformationETCO2(End‐Titdal CO2)• The level of carbon dioxide released at the end of an exhaled breath (expiration). • Carbon dioxide (CO2) reflects cardiac output and pulmonary blood flow as the gas

is transported by the venous system to the heart and then pumped to the lungs. • Carbon dioxide concentration reaches a maximum at the end of exhalation. • When carbon dioxide diffuses out of the lungs into the exhaled air, the partial

pressure or maximal concentration of the gas at the end of exhalation can be measured.

What can the Blood Glucose Test tell a biller/coder?• A high ETCO2 reading in a patient with altered mental status or severe difficulty

breathing may indicate hypoventilation and a possible need for the patient to be intubated.

• Low ETCO2 readings on patients may indicate hyperventilation.

http://www.nkusa.com/Monitoring/SupportAndEducation/Etco2.aspx

Respiratory Documentation

• Tachypnea• Labored respiration• Hypoxemia• Requiring oxygen administration• Require advanced airway management such as ventilator management

• Apnea monitoring for possible intubation• Deep airway suctioning

ICD‐9‐CM/ICD‐10‐CM differences Chapter 10 is structured to group together related

conditions in a different manner.

ICD‐9‐CM ICD‐10‐CM Acute Anatomic site of infection Other Severity

Pneumonia Cause Chronic Acute, other, then chronic

Diseases of the Respiratory System

Mechanical Ventilation Complications

This was in the Complication Chapter of ICD‐9‐CM, it is now in the Disease of the

Respiratory.

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Asthma

• Asthma is a chronic lung disease that inflames and narrows the airways.

• Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. – The coughing often occurs at night or early in the morning.

Coding ChangesICD‐9‐CM ICD‐10‐CMExtrinsic Mild IntermittentIntrinsic Mild PersistentChronic Severe PersistentObstructive UnspecifiedUnspecified Other

4th character indicates type5th character indicates specificity for uncomplicated, acute exacerbated and

Status Asthmaticus

Status Asthmaticus is when an acute attack does not respond to medications, and symptoms of potential respiratory failure‐Life

Threatening.

Asthma

Stages of AsthmaNAEPP Guidelines COPD

• Chronic obstructive pulmonary disease refers to a group of lung diseases that block airflow and make breathing difficult.

• Two most common conditions that make up COPD:– Chronic bronchitis is an inflammation of the lining of the bronchial tubes, which carry air to and from the lungs.

– Emphysema occurs when the air sacs (alveoli) at the end of the smallest air passages (bronchioles) in the lungs are gradually destroyed.

• The main cause of COPD is tobacco smoking.

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Symptoms of COPD

• Shortness of breath• Wheezing• Chest tightness• Having to clear the throat first thing in the morning due to excess

mucus in the lungs.• A chronic cough that produces sputum that may be clear, white,

yellow or greenish.• Blueness of the lips or fingernail beds (cyanosis).• Frequent respiratory infections.• Lack of energy.• Unintended weight loss (in later stages).

COPD

COPD Exacerbation • Acute exacerbation of chronic obstructive bronchitis and asthma

• Uncomplicated cases • With acute lower respiratory tract infection

Acute Exacerbation• Is not equivalent to an infection superimposed on a chronic condition.

• An exacerbation may be triggered by an infection.

CC EXACERBATION OF COPD

HX : UAA PT A 71 YEAR OLD FEMALE IN ER BED AND IS A/O X 4. PT HAS BIPAP ON IN ER AND IS NOT TOLERATING WELL. PT SATURATIONIS 94 AND ALL OTHER VITALS ARE NORMAL AND PT WISHES EMS TO TAKE BIPAP OFF. PT IS PLACED ON NC WITH CAPNOGRAPHY AND PUT ON 3 L O2. PT BECOMES MORE COMFORTABLE AND SAT GOES UP TO 95. PT WAS BROUGHT IN FOR SOB AND LOW O2 SAT FROM DIALYSIS TODAY. ALL

MEDS WERE GIVEN AND LISTED IN ATTACHED. IV THAT WAS STATED TO BE FLOWING HAD FINISHED WHEN EMS ARRIVED.

PUPILS ARE EQUAL AND REACTIVE. PT EARS NOSE AND THROAT ARE UNREMARKABLE. PT SPEECH IS NON SLURRED AND WORDS ARE APPROPRIATE. PT LUNGS SOUND CONGESTED AND SHE HAS COUGH. CLEAR SPUTUM. PT ABDOMEN IS SOFT AND NON TENDER. PT EXTREMITIES HAVE GOOD PMS X 4 NO OBVIOUS INJURIES.

RX: PT VITALS ARE OBTAINED AND LISTED. PT IS MOVED TO COT WITH SHEET AND SECURED WITH ALL STRAPS. PT IS PLACED ON NC WITH O2 AT 3L WITH CAPNOGRAPHY. CARDIAC MONITOR IS PLACED. IV WAS PRE ESTABLISHED.

T: PT VITALS ARE MONITORED IN ROUTE TO xxxxx HOSPITAL. NO FURTHER INCIDENT IN TRANSPORT. PT REPORT IS GIVEN TO RN. PT IS MOVED

TO HOSPITAL BED WITH SHEET AND RAILS ARE PLACED IN UP POSITION. PT IS LEFT IN CARE OF RN. PT CONDITION STABLE THROUGHOUT TRANSPORT.

Diseases of the Respiratory System HYPOXIA and HYPERCAPNIA

HypoxiaA condition in which the body or a region of the body is deprived of adequate oxygen supply.

HypercapniaA condition of abnormally elevated carbon dioxide (CO2) levels in the blood.

This is important to know, because when coding Respiratory Failure it is with or without Hypoxia or Hypercapnia.

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Respiratory Failure

Respiratory Failure is a condition in which the level ofoxygen in the blood becomes dangerously low or the levelof carbon dioxide becomes dangerously high.Symptoms• Cyanosis• Confusion• Sleepiness• Deep, rapid breathing• Deteriorating consciousness or unconsciousness• Arrhythmias

Respiratory Failure

ICD‐10 Code Code DescriptionR06.00 Dyspnea, unspecifiedR06.02 Shortness of breathR06.09 Other forms of dyspneaR06.3 Periodic breathingR06.4 HyperventilationR06.82 Tachypnea, not elsewhere classifiedR06.83 SnoringR06.89 Other abnormalities of breathing

518.81 Acute Respiratory Failure

J96.00 Acute Respiratory Failure, unspecified whether with hypoxia or hypercapnia

Other respiratory anomalies to utilize when coding.

Complication of Respiratory Ventilator

This was in the Complication Chapter of ICD‐9‐CM

It is now in the Disease of the Respiratory

997.39 Respiratory Complication

J95.85 Other Complication of Respirator (Ventilator

Disease of the Digestive System

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Digestive SystemCoding Changes

Hemorrhage is used for ulcers.

Bleeding is used for gastritis, duodenitis, diverticulosis and diverticulitis.

“Obstruction” is no longer an axis of classification.

ICD‐9‐CMAcute Gastric Ulcer with hemorrhage and Obstruction.

ICD‐10‐CMAcute Gastric Ulcer with Hemorrhage.

Complications of artificial openings, including colostomy, enterostomy and gastrostomy infections and malfunctions are all included in the digestive disease chapter.

Abdominal Pain

• Accompanied by other signs or symptoms.

• Associated symptoms include nausea, vomiting, fainting.

• Associated signs include tender or pulsatile mass, distention, rigidity, rebound tenderness on exam, guarding.

Documentation should reflect:

Location:Generalized, right upper quadrant, periumbilical, etc.

Pain or Tenderness type:Colic, tenderness, rebound, etc.

C‐ ABD PAIN

H‐ PT STATES THAT A FEW DAYS AGO HE WAS CLEANING AROUND HIS FORESKIN AND WHEN HE "ROLLED IT BACK DOWN" HE NOTICED THAT HE COULDN'T GET IT IN THE RIGHT PLACE. SINCE THEN HE HAS BEEN HAVING A HARD TIME URINATING. PT STATES THAT HIS URGE TO URINATE IS MORE FREQUENT, IT IS DIFFICULT TO, AND WHEN HE DOES ONLY A SMALL AMOUNT COMES OUT AND IT BURNS. PT STATES THAT HE IS HAVING TENDERNESS IN HIS LOWER BACK THAT RADIATES TO THE FRONT. HE ALSO STATES THAT HE IS HAVING ABD CRAMPS AND DISTENTION THAT IS NOT NORMAL FOR HIM. PT REPORTS NORMAL BM WITHIN THE LAST HOUR. PT REPORTS NOT TAKING HIS MEDICATIONS FOR THE PAST THREE WEEKS. LIST OF MEDICATIONS IS UNKNOWN. PT STATES HE IS SUPPOSE TO BE TAKING BREATHING TREATMENTS AND WEARING HOME O2 FOR HIS EMPHYSEMA BUT HAS NOT DONE THAT EITHER.

A‐ UAA PT WAS FOUND A&O X'S FOUR. HEENT‐WNL. CHEST‐WHEEZING AND RHONCHI NOTED BILATERALLY WITH ADEQUATE CHEST RISE AND FALL. ABD‐ TENDER UPON PALPATION IN ALL QUADRANTS. PT STATES "IT'S NEVER BEEN THIS FIRM". EXTREMITIES‐ GOOD CMS X'S FOUR. SKIN‐PINK, COOL, DIAPHORETIC. PT DENIES CP AND N/V.

R‐ PULSE OX 96% RA. 4 LEAD‐ NSR WITH PVCS. 12 LEAD‐ NO ST ELEVATION/DEPRESSION OR T WAVE ABNORMALITIES NOTED. DUONEB AND 6 L OF O2 ADMINISTERED VIA NEBULIZER WITH IMPROVEMENTS OF RHONCHI AND WHEEZING. 18 G IV ESTABLISHED IN RIGHT AZ WITH NO COMPLICATIONS. SOLU‐MEDROL ADMINISTERED WITH NO COMPLICATIONS.

T‐ PT TRANSPORTED TO xxxxxxx HOSPITAL WITH NO OTHER CHANGES NOTED. NO INCIDENTS OR INJURIES OCCURRED. FULL CARE AND REPORT TAKEN OVER BY ER RN AT BEDSIDE.

Disease of the Digestive System Diseases of the Musculoskeletal System

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Arthritis

Coding Changes:• There are specific codes for primary and secondary arthritis.

• Within the secondary arthritis codes there are specific codes for post‐traumatic osteoarthritis and other secondary osteoarthritis.

• In ICD‐9, osteoarthritis can be described as degenerative, hypertrophic, or secondary to other factors, and the type as generalized or localized.

• In ICD‐10 provides more options for the coding osteoarthritis related encounters, including:– Generalized forms of osteoarthritis or arthritis where multiple joints are

involved.– Localized forms of osteoarthritis with more specificity that includes primary

versus secondary types, subtypes, laterality, and joint involvement. – Indicate the type, location, and specific bones and joints (multiple sites if

applicable) involved in the disease. In addition, describe any related underlying diseases or conditions.

Back Pain

• Sudden onset, severe non‐traumatic pain suggestive ofcardiac or vascular origin or requiring special positioning onlyavailable by ambulance.

• 7–10 on 10‐point severity scale.

• Neurologic symptoms and/or signs.

• Absent leg pulses.

• Pulsatile abdominal mass, concurrent chest or abdominalpain.

Diseases of the Musculoskeletal SystemCC: Right shoulder pain.

HistoryThis 45 year old female complains of right shoulder pain. This has been ongoing and patient cannot describe any injury prior to the pain beginning, but today is unbearable and limiting your ability to move and has been nauseated and vomiting.

Patient rates the pain at 7/10. Describes pain as constant and achy and awakened her at night. The pain is also exacerbated by throwing, lifting, and carrying activities but not overhead activities, weight‐bearing activities or reaching.

She complains of weakness but no instability, swelling, clicking, numbness, catching, tingling, or neck pain.

Current medications: Ibuprofen for shoulder pain.

Top Musculoskeletal ICD‐10‐CM Codes

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Top Musculoskeletal ICD‐10‐CM Codes Top Musculoskeletal ICD‐10‐CM Codes

C: BACK PAIN / SUICIDAL THOUGHTS

H: 44 YOA MALE WITH COMPLAINT OF BACK PAIN. UAA PT WAS FOUND PRONE ON A COUCH IN THELIVING ROOM OF RESIDENCE. PT IS AWAKE AND ALERT. PT IS COMPLAINING OF BACK PAIN WITHA PAIN SCALE OF 8 ON A 10 SCALE. PT HAS AN ODOR ASSOCIATED WITH AN ALCOHOLIC BEVERAGEABOUT HIS PERSON. THERE WAS ALSO ALCOHOLIC BEVERAGES SCATTERED AROUND THERESIDENCE. PT STATED HE HAS BEEN DRINKING SINCE NOON ON MM/DD/YY. PT STATED HE WOKEUP WITH BACK PAIN AND COULD NOT MOVE. PT ASSESSED AND VITAL SIGNS OBTAINED.PT PACKAGED FOR TRANSPORTTO xxxxxx ER FOR EVALUATION. IN THE BACK OF THEAMBULANCE PT STARTED TALKING ABOUT KILLING HIMSELF AND WANTING TO DIE. PTSTATED THAT HE HAD A GUN AND WAS GOING TO SHOOT HIMSELF. PT STATED THAT HE HAD PUTTHE BARREL OF THE FIREARM IN HIS MOUTH SEVERAL TIMES DURING THE EVENING.

A: HEENT; EYES BLOOD SHOT NO JVD CHEST; =RISE/FALL LUNGS; CA BI‐LATERAL ABD; SOFT NON‐TENDER EXTREMITIES; UNREMARKABLE CMS X 4 SKIN; WARM DRY NEURO; A&O X 2 (PERSON,PLACE). GCS 14

R: MONITORED PT VITAL SIGNS AND 4‐LEAD (NSR). IV STARTED 20 GA LOCK IN RIGHT HAND, PTMONITORED FOR CHANGES IN CONDITION ANDMENTATION, NONE NOTED.

T: PT MOVED TO EMS COT. ALL SAFETY STRAPS USED. PT IN SEMI‐FOWLER'S POC. PT STATED HE HAS APAIN SCALE OF 8 ON A 10 SCALE. PT CONDITION REMAINED UNCHANGED DURING TRANSPORT. PTVITAL SIGNS MONITORED AS NOTED. PT MOVED TO xxxxxx ER BED 9. PT CARE TURNED OVER TOSTAFF WITH WRITTEN AND VERBAL REPORT.

Diseases of the Musculoskeletal System Contractures

Abnormal shortening of muscle tissue, rendering themuscle highly resistant to passive stretching.

• There should be a description about whether the patient has upper or lower limb contracture(s).

• The location and severity/degree of the contracture should be documented.

• Lower extremity contractures must be of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee).

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T‐ 61 YO FEMALE PT HAD BEEN ADMITTED TO xxxxx ER APPROX 6 HRS PTAA. PT WAS SENT BY NH STAFF FOR O2 DESATURATION AND "LOW RESIDUALS", AS REPORTED BY NH STAFF.

R‐ PT WAS ASSESSED AND TREATED IN ER. PT HAD PRE‐EXISTING TRACH WITH STOMA. ER STAFF REPORTED PT WAS EXPERIENCING LARGE MUCOSAL AIRWAY OBSTRUCTION, RELIEVED BY INTER‐TRACH SUCTIONING. PT RECEIVED FURTHER PHYSIOLOGICAL AND NEURO ASSESSMENT BY ER STAFF. ER STAFF REPORTED IMPROVED O2 SATS, LS, AND PT CONDITION POST SUCTIONING.

A‐ UAA PT WAS FOUND LYING SEMI FOWLER IN HOSP TYPE BED. PT WAS ALERT TO VERBAL AND PAINFUL STIMULI, UNABLE TO VOCALIZE COMFORT OR PAIN LEVEL AND UNABLE TO VERBALLY ANSWER QUESTIONS. PT EXHIBITED NEGATIVE S/SX OF SOB, CP, PHYSIOLOGICAL DISTRESS. PT REQUIRED SPECIALIZED HANDLING DUE TO PMH, HPI, AND SEVERE BILATERAL CONTRACTURES TO UPPER AND LOWER EXTREMITIES. EYES PERRLA, NO JVD OR TRACH DEVIATION, STOMA WAS PRE‐EXISTING AND SECURED IN PLACE WITH COMMERCIAL TYPE DEVICE, LS CTA, ABD SNT, SEVERE CONTRACTURES BILAT UPPER AND LOWER EXTREMITIESWITH PULSE AND SENSORY PRESENT IN ALL FOUR, SKIN WD.

N‐ PT WAS BEING DISCHARGED FROM xxxxx ER TO GLC POST STABILIZATION AND SUCTIONING OF STOMA. PT WAS RETURNING TO LONG TERM CARE AT SNH AND REQUIRED TRANS BY EMS DUE TO HPI, PMH, AND NON‐AMBULATORY STATUS.

S‐ PT CONDITION WAS MONITORED BY EMS EN ROUTE BY PULSE OX AND CONTINUOUS DIRECT OBSERVATION. PT EXHIBITED NEGATIVE S/SX OF RESP DISTRESS AND O2 SATS REMAINED AT ACCEPTABLE LEVELS. UAA TO xxxxx NH, PT TRANS BY EMS VIA COT TO ASSIGNED ROOM, TRANS VIA DRAWSHEET TO HOSP TYPE BED, PLACED IN SEMI‐FOWLER POS, RAILS RAISED. PCR AND DOCUMENTATION GIVEN BY EMS TO NSG STAFF. UNIT 4 PLACED BACK IN SERVICE.

Diseases of the Musculoskeletal System

Diseases of the Skin and Subcutaneous Tissue Decubitus Ulcers

Caused by hypoxia secondary to pressure‐inducedvascular insufficiency.Documentation• Location• Size• Stage of the ulcer• Other information that would explain why awheelchair or other means of moving the patientother than an ambulance could not be used.

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Decubitus Ulcer Staging

• Stage I: A reddened area on the skin that, when pressed, does not turn white.

• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.

• Stage III: The skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin.

• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

Decubitus UlcersCoding Changes• Combination codes identify the site of a pressure ulcer as well as the stage of the

ulcer.

• If the pressure ulcer is documented as completely healed than it is not coded.

• If the pressure ulcer is healing it should be coded to the highest stage that ishealing.

• Dermatitis and Eczema are used synonymously.

• Non‐pressure chronic ulcers are also specified by site, laterality, and severity.

• Chronic or non‐pressure ulcers are usually caused by other conditions and shouldbe coded first, if known.

• The 6th Character level in L89 denotes the “depth of the Ulcer”L89.503, “stage 3”, pressure ulcer of the ankle, unspecified.

TRANS 87 Y/O FEMALE PT FROM xxxxx HOSP TO xxxxx NH.

PT TRANS PER ORDER OF DR. xxxxx.

DX OF PNEUMONIA S/P INPT TREATMENT X 4 DAYS.

NO OBVIOUS S/SX OF DISTRESS OR PAIN AT THIS TIME.

TRANS IN FETAL POSITION DUE TO FLEXION CONTRACTURES OF HIPS, KNEES, ARMS/ELBOWS, HANDS.

ALSO HAD STAGE III DECUB TO COCCYX AND L FOOT.

TRANS WITH HEEL PROTECTORS IN PLACE AND PT HAD MITTENS ON HANDS PER DR. ORDER DUE TO PT CONTINUED ATTEMPTS TO PULL OUT HER PEG TUBE.

MANUALLY AND VERBALLY REDIRECTED PT THROUGHOUT TRANS. PT UNABLE TO UNDERSTAND SAFETY DIRECTIONS AND UNABLE TO NOT ENDANGER HERSELF BY REMOVING PEG.

PT ALSO HAD FOLEY IN PLACE. O2 2LPM (UNABLE TO SELF‐ADMINISTER DUE TO DEMENTIA AND LIMITATIONS AS NOTED ABOVE).

SUCTIONING REQUIRED EN ROUTE DUE TO VERY WEAK COUGH REFLEX AND PT UNABLE TO EFFECTIVELY CLEAR HER OWN AIRWAY. ALL OTHER INFO AS DOCUMENTED ON ATTACHED. REPORT TO RN AT NH.

Diseases of the Skin and Subcutaneous TissueDisease of the Genitourinary

System

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A condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance.

Chronic Kidney Failure

• Has five stages based on the patients glomerular filtration rate (GFR).

o Care of a patient with stage IV and V is very intense andcomplicated.

• Conditions in which the function of kidneys deterioratessuddenly in a matter of days or even hours.

End Stage Renal Disease (ESRD)

• Is the final stage of the loss of kidney function (alsoreferred to as “Stage V”).

• This stage will require transplant of renal dialysis forsurvival.

Renal Insufficiency

Poor function of the kidneys that may be due to areduction in blood‐flow to the kidneys caused by renalartery disease.

Acute Renal Failure

• Occurs suddenly, and usually due to trauma,infection, inflammation or toxicity. It developsquickly and usually reversible as theunderlying condition is treated.

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CODING CHANGES• Many diagnoses are based on gender.

• Prostatic hypertrophy is now “enlarged prostrate”.

• There are several notes throughout the chapteridentifying to use additional codes.

Disease of the Genitourinary SystemT: 50 Y/O FEMALE PT GOING TO BACK TO NH FROM DIALYSIS.

R: PT IS BEING TRANSPORTED BACK TO NH AFTER COMPLETING ROUTINE DIALYSIS TREATMENT. PT RECEIVES DIALYSIS 3 TIMES PER WEEK. PT GOES FOR DIALYSIS FOR END STAGE RENAL FAILURE WHICH IS THOUGHT TO HAVE OCCURRED SECONDARY TO RESTRICTIVE CARDIOMYOPATHY FOR WHICH SHE HAD A HEART TRANSPLANT IN 1993. PT ALSO HAS HX OF CHF, PULMONARY HTN, AND GERD.

A: A&OX4, GCS 15 HEENT: UNREMARKABLE, PUPILS PERRL CHEST: CTA, EQUAL AND BILATERAL CHEST RISE AND FALL, DIALYSIS PORT RIGHT UPPER CHEST. ABDOMEN: SOFT, NONTENDER, DENIES N/V EXT'S: CMS INTACT X4, WEAKNESS NOTED, NO EDEMA PRESENT, PILLOW UNDER FEET, BRUISING NOTED ON UPPER EXTREMITIES, SKIN:WARM, DRY, PINK. INJURIES: NONE NOTED

N: PT REQUIRES EMS TRANSPORT DUE TO BEING A HIGH FALL RISK. SHE IS NON‐WEIGHT BEARING DUE TO WOUND ON RIGHT FOOT. PT IS BED CONFINED AND NON AMBULATORY, AND REQUIRES

MEDICAL MONITORING THROUGHOUT TRANSPORT DUE TO O2 ADMINISTRATION. PT ALSO REQUIRES HOSPITAL TYPE BED, AND MUST BE MOVED WITH SHEET.

S: PT WAS PLACED ON COT WITHOUT INCIDENT. VS WERE MONITORED ENROUTE AND AS NOTED. PT'S O2 WAS TRANSFERRED TO EMS COT AT 4LPM VIA NC DUE TO O2 DEPENDENCE AND DR ORDERED. PULSE OX WAS PLACED TO ESTABLISH BASELINE. PT REMAINED UNCHANGED THROUGHOUT TRANSPORT. PT REPORT WAS GIVEN, AND TRANSFER OF CARE WAS COMPLETED TO NURSING STAFF.

Disease of the Genitourinary System

Pregnancy, Childbirth, and the Puerperium

Pregnancy, Childbirth, and the Puerperium

GravidaThe term for the state of pregnancy.

ParaThe number of times a female has given birth, counting twins, and other multiple births as one pregnancy, and usually including sillbirths.

NulligravidaA women who has never been pregnant.

PrimigravidaA women pregnant for the first time and is referred to as a women who is (or has been only) pregnant for the first time.

MultiparousMultiple pregnancies.

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Pregnancy, Childbirth, and the Puerperium Postpartum

• The period begins immediately after delivery and continues forsix weeks following delivery.

• A postpartum complication is any complication occurring withinthe six‐week period.

CODING GUIDELINES• If it is an OB patient with diabetes it’s coded to the Diabetes code in the

pregnancy, childbirth and puerperium chapter.

• If Gestational Diabetes only a code from the pregnancy, childbirth andpuerperium chapter is coded.

• If pregnancy complications occur because of alcohol and tobacco use duringpregnancy, code from the pregnancy, childbirth and puerperium chapter first,followed by a code from chapter 5.

• If there is a poisoning, toxic effects, adverse effects and underdosing in an OBPatient, code first O9A.2 Injury, poisoning and certain other consequences ofexternal causes should be sequenced first, followed by a code to identify thesubstance and the condition that is being treated.

• If a baby is born, then the gestation needs to be coded from the Z34 codes.

Pregnancy, Childbirth, and the Puerperium Birth

If a baby is born while in transport, then an ICD‐10 code from the

Z38 is coded for live born infant.

ICD‐10 Code Code Description

Z38.1 Single live born outside of hospital

Z38.4 Twins live born outside of hospital

Z38.7 Multiple live born outside of hospital

R68.13 Apparent life threatening event of an infant

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31 Y/O FEMALE PT BEGAN HAVING LABOR PAINS AROUND 0000 HRS. AFTER THE PAINS BECAME REGULAR AND MORE INTENSE EMS WAS CALLED.

UAA PT WAS FOUND IN BED C/O LABOR PAIN. PT ADVISED AS WE WERE WALKING IN HER BEDROOM THAT HER WATER WAS BREAKING. PT IS G 3/ P 2. PT HAS HAD GOOD PRENATAL CARE AND CURRENT WITH HER PRENATAL VITAMINS. PT ADVISED SHE HAS HAD NO COMPLICATIONS WITH THIS PREGNANCY. PT ST’D SHE WAS 39 WEEKS PREGNANT WITH A DUE DATE OF MM/DD/YY.

A & O X 4, GSC 15. HEENT: NORMOCEPHALIC, EYES PERRLA, THE REST UN‐REMARKABLE. CHEST: LS CTAB WITH SYMMETRICAL CHEST RISE AND FALL.

ABDOMEN: GRAVIDA. LABOR PAINS 5 MIN APART LASTING 1 MINUTE. VAGINAL: MUCUS DISCHARGE WITH AMNIOTIC FLUID, NO CROWNING NOTED.

EXTREMITIES: MAEW, PMS X 4. SKIN: WARM AND DRY. PT'S SPO2 ON RA WAS 95‐100%. PT WAS ST‐SR ON MONITOR. IV LOCK WAS ESTABLISHED. OB KIT WAS OPENED AND PREPARED FOR DELIVERY.

EN ROUTE TO THE HOSPITAL PT'S LABOR PAINS BECAME 1 MINUTE APART AND MORE INTENSE. RECHECKED PT AND CROWNING WAS PRESENT AT THAT TIME. THE AMBULANCE WAS PULLED OVER ON THE xxxxx TURNPIKE APPROX 1 MILE SOUTH OF THE TOLL GATE. THE MOTHER WAS COACHED TO PUSH. GENTLE PRESSURE WAS APPLIED TO BABY'S HEAD TO HELP GUIDE THE DELIVERY. THE BABY DELIVERED WITHOUT COMPLICATIONS. TIME OF BIRTH 0225 HRS MM/DD/YY. INTAL APGAR WAS 8 & 5 MINUTE APGAR WAS 10.

THE CORD WAS CLAMPED AND CUT W/O COMPLICATION. THE BABY WAS DRIED AND WRAPPED IN BUNTING BLANKET. TRANS STABLE COND AND CARE TRANSX TO RN AT ER.

Pregnancy, Childbirth, and the PuerperiumInjury, Poisoning and Certain Other Consequences

of External Causes

Injury, Poisoning and Certain Other Consequences of External Causes

Episode of Care: Initial, subsequent, sequelae

Injury site: Be as specific as possible

Etiology: How was the injury sustained (e.g. sports, motorvehicle crash, pedestrian, slip and fall, environmentalexposure, etc.)?

Place of Occurrence: School, work, etc.

Initial encounters may also require, where appropriate:

Intent: Unintentional or accidental, self‐harm, etc.

Status: Civilian, military, etc.


Coding Changes:The “S” Codes are for injuries related to a single body region.

The “T” Codes cover injuries to unspecified body regions, as well as poisons.

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InjuriesThe 7th Character extension that describes the:• Type of encounter or stage of the fractures healing, • and any residual effects or sequela from the fracture.

Seventh Digit:• A‐ Initial encounter for closed fracture • B‐ Initial encounter for open 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


Types of fractures

Fractures

• When a fracture is not described as open or closed itshould be coded to a closed fracture.

• Fractures are coded individually to each specific site.

• When there is aftercare of an injury you code theacute injury code with the “subsequent” encounteras the 7th digit.

Fractures

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Pathological Fractures

ICD‐10 identifies for 3 different causes to pathological fractures.• Neoplastic disease• Osteoporosis• Other specified disease

M80 Category should be used when it is known the patient hasOsteoporosis with a fracture.

There are eight codes for pathologic fractures in ICD‐9‐CM, but in ICD‐10‐CM there are more than 150 codes.

5 = Torus2= Lower End of Radius

1 = Right

ICD‐9‐CM813.42 Other closed fractures of distal end of radius (alone)ICD‐10 Code‐Has a meaning:

2S 5 2 5 1 ACategory

Etiology

Anatomic Site

Laterality

Extension

Category: Fracture of ForearmEtiology: Lower End of RadiusAnatomic Site: TorusLaterality: RightExtension: Initial Encounter for Closed Fracture

S52.521.AUnspecified fracture of the lower end of unspecified radius, initial encounter for closed fracture.

ICD‐10’sOpen Wounds

• ICD‐10 provides a laterality distinction to be made and the type of open wound including:– Laceration, with or without foreign body– Puncture wound with or without foreign body– Open bite– Unspecified open wound

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NEW TO ICD‐10BurnsA new term of Corrosion, which are burns due to chemicals.

DrugsAre divided up by:• Poisoning• Adverse Effect• Underdoing

– Is taking less medication than prescribed by a provider, resulting in a negative health consequences.


Burns

First‐degree burns are red, moist, swollen, and painful.

Second‐degree burns are red, swollen, and painful, and they develop blisters that may ooze a clear fluid.

Third‐degree burns usually are not painful because the nerves have been destroyed. The skin becomes leathery and may be white, black, or bright red. No blisters develop.

WHEN CODING BURNS, THE BURN TO THE HIGHEST DEGREE IS CODED FIRST.

BurnsHeat burns (thermal burns) are caused by fire, steam, hot objects, or hotliquids. Scald burns from hot liquids are the most common burns to childrenand older adults.

Electrical burns are caused by contact with electrical sources or by lightning.

Chemical burns are caused by contact with household or industrial chemicalsin liquid, solid, or gas form. Natural foods such as chili peppers, whichcontain a substance irritating to the skin, can cause a burning sensation.

Radiation burns are caused by the sun, tanning booths, sunlamps, x‐rays, orradiation therapy for cancer treatment.

Friction burns are cause by contact with any hard surface such as roads,carpets, or gym floor surfaces.

Burn Documentation

• Partial thickness burns > 10% Total Body SurfaceArea (TBSA).

• Involvement of face, hands, feet, genitalia,perineum or major joints.

• Third degree burns

• Electrical, chemical, inhalation burns with pre‐existing medical disorders.

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CALLED TO SCENE OF MVA WITH ELECTROCUTION OF AT LEAST ONE PERSON FROM DOWNED POWER LINES AFTER VEHICLE STRUCK ELECTRIC POLE.

FOUND PT SITTING ON DIRT ROAD 10 FEET FROM HIS POV. PT IS AWAKE AND TALKING. UPON INITIAL ASSESSMENT, PT DOES NOT HAVE ANY CLOTHS LEFT ON BODY. PT WEARING BOOTS, STILL ATTACHED, BUT BURNED.

PT HAS 2ND AND 3RD DEGREE BURNS ALL OVER HIS BODY FROM NECK DOWN TO HIS BOOTS, FRONT TO BACK, INCLUDING GENITAL AREA. LEFT SIDE OF HEAD HIS HAIR IS SINGED OFF.

PT WAS DRIVER OF VEHICLE AND GOT OUT OF THE VEHICLE AFTER STRIKING ELEC POLE, WHERE HIS BODY CAME INTO CONTACT WITH A LIVE WIRE. PER BYSTANDERS, IT APPEARED THAT THERE WAS NO LOC.

PT'S BURNS COOLED WITH STERILE H2O. BODY COVERED WITH STERILE SHEETS. PT FULLY IMMOBILIZED AND PLACED INTO UNIT. xxxxx HELICOPTER LANDING IN FIELD NEXT TO OUR UNIT. IV ESTABLISHED, MEDICATIONS DRAWN AND DELIVERED. ATTEMPTED TO OBTAIN EKG BUT ELECTRODES NOT WANTING TO STAY ON SKIN. PT SEDATED, INTUBATION OBTAINED. PT DELIVERED TO HELICOPTER VIA OUR COT. HAND OFF PT TO HELICOPTER CREW.

Injury, Poisoning and Certain Other Consequences of External Causes Poisoning

• Requires cardiopulmonary and/or neurologic monitoringand/or urgent pharmacologic intervention.

• When quantity and identity of agent know to be lifethreatening.

• When quantity and identity of agent are not known butthere are signs/symptoms of neurologic dysfunction.

• Poisoning is an overdose of a substance if the wrongsubstance is given or taken in error.

Poisoning

Coding ChangesTypes:• Poisoning, accidental• Poisoning, intentional self‐harm• Poisoning, undetermined• Adverse effect• Underdosing

Poisoning

Coding Changes

UnderdosingRefers to taking less medication than prescribed. Codes for under dosing should never be assigned as a principal diagnosis. The medical condition should be coded first.

Proper administration of drugWhen a medication has been taken properly, code the condition first followed by the adverse effect of the drug “T” code.

Improper use of drugFirst assign the overdose or wrong administration of drug “T” code first, followed by manifestations that occurred, including if abuse, or dependence of the drug.

IntentIf the intent is not documented or not known than the “accidental intent” ICD‐10 code is used. The Undetermined intent is only used when there is not documentation that shows it is undetermined.

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Poisoning Documentation

• Requires cardiopulmonary and/or neurologicmonitoring and/or urgent pharmacologicintervention.

• When quantity and identity of agent know to be life‐threatening.

• When quantity and identity of agent are not knownbut there are signs/symptoms of neurologicdysfunction.

Sudden onset of agitation, palpitations, diarrhea, heavy sweating, fever withshivering, and feeling “out of it” after taking OTC cough medicine.

History45 year old male patient, is a tractor trailer driver, and states he tookdextromethorphan to help with his cough. He has began to have suddenonset of irritability/agitation, palpitations, diarrhea, diaphoresis, fever withshivering, and feeling “out of it”. He is A&OX3

His heart rate is 82.


C: FOUND BY PD POSSIBLE OD OF UNKNOWN MEDICATION

H: PT WAS FOUND BY PD. PT HAS HAD A POSSIBLE OVERDOSE OF UNKNOWN (POSSIBLE OXYCONTIN OR ATIVAN) PT HAD A PLETHORA OF DIFFERENT PILLS IN HER PURSE. PT STATES MEDS WERE GIVEN TO HER BY HER SON AND SHE THINKS SHE WAS GIVEN THE WRONG PILLS. UNK IF ANY LOC. NOTED NO SIGNS OF EMESIS. NOTED NO TX PTAA.

A: FOUND PT TO BE A&OX2. PT LOOKED TO BE UNSTEADY ON FEET. PT WOULD SLUR SPEECH AND TALK IN DISJOINTED SENTENCES. HEENT‐PUPILS PINPOINT CHEST‐CLEAR TO AUSC ABD‐SOFT NON‐TENDER EXTREMITIES/SKIN‐UNREMARKABLE NOTED NO S/SX OF HYPOTHERMIA.

R: PLACED PT ON CARDIAC MONITOR AND ASSESSED VITALS. STARTED IV NSL VIA 20 GA. GAVE PT O2 @ 3 LPM NC. PT STABLE.

T: PLACED PT ON EMS STRETCHER AND TRANSPORTED TO xxxxx W/O ANY FURTHER CHANGE OR INCIDENTS.


Heat Exhaustion

Excessive loss of salts (electrolytes) and fluids due to heat, leading to decreased blood volume that causes many symptoms, sometimes including fainting or collapse.Symptoms:• Dizziness• Light‐headedness• Weakness• Fatigue• Headache• Blurred Vision• Muscle Aches• Nausea/Vomiting

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RESPONDED TO RESIDENCE FOR HEAT EXHAUSTION TO FIND ADULT FEMALE PT IN BED C/O SEVERE NAUSEA AND VOMITING SECONDARY FROM HEAT EXHAUSTION.

PT SAYS THAT SHE WAS MOWING HER GRASS THROUGHOUT THE DAY AND OVER WORKED HERSELF.

TEMP OUTSIDE IS 98F AND HUMID.

PT HAS VOMITED MULTIPLE TIMES TODAY AND HAS NOT BEEN ABLE TO KEEP ANY OF HER ORAL MEDICATION DOWN.

PT IS ALERT AND ORIENTED X 4. TEMP: 101, FSBS 56. IV STARTED IN LEFT ANTECUBITAL 20G AND D50 MIXED INTO NORMAL SALINE BAG OF 1000 CC. PHENERGAN IV ADMINISTERED 50MG.

TRANS TO ER, STABLE. PT STATED THAT THE PHENERGAN IS HELPING AND SHE FEELS SLIGHTLY BETTER.


992.5 Heat Exhaustion, NOS

T67.5XXA: Heat exhaustion, unspecified, initial Encounter

R11.2: Nausea with vomiting, unspecified

Heat Exhaustion

787.01 Nausea and Vomitting

Hypothermia

• Results when the body loses more heat than can be replaced by increasing metabolism or by increasing warming from external sources, such as a fire or the sun.

• Initial symptoms include:– intense shivering and – teeth chattering.

• As body temp falls further, shivering stops and movements become slow and clumsy, reaction time is longer, thinking is blurred, and judgment is impaired.

991.6 Hypothermia

T68.XXXA: Hypothermia, initial encounter

Hypothermia

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Medical Device Failure

• Life‐ or limb‐threatening malfunction, failure orcomplication.

• Malfunction of internal pacemaker, internaldefibrillator, implanted drug delivery device, O2supply malfunction, orthopedic device failure.

996.72 T82.9XXA Unspecified Complication of CardiacComplication and Vascular Prosthetic Device, ImplantOther and Grafts, Initial EncounterCardiac Device

996.77 T849.XXA Unspecified Complication of CardiacComplication and Vascular Prosthetic Device, ImplantInternal Joint Prosthetic and Grafts, Initial Encounter

996.7 T849.XXA Unspecified Complication of InternalComplication Orthopedic Prosthetic Device, Implant andOther Internal and Graft, Initial EncounterOrtho Device

Injury Documentation

Penetrating Extremity Injury• Life‐or‐limb threatening injury• Uncontrolled hemorrhage• Compromised neurovascular supply• Uncontrollable pain requiring pharmacologic intervention.

Accident Where did it occur?

Assault What was the assault and what part of the body?

Asphyxiation Where and how did it occur?

Bites What was the bite from and where did it occur?

Burns Was it 1st, 2nd, or 3rd degree, and what part of the body?

Injury Documentation

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Trauma Documentation• Trauma with one or more of the following:

– Glasgow < 14; – systolic BP < 90; – RR < 10 or > 29– All penetrating injuries to head, neck, torso, extremities

proximal to elbow or knee– Flail chest– Combination of trauma and burns– Pelvic fracture– Two or more long‐bone fractures– Open or depressed skull fracture– Paralysis

Injury Documentation External Causes of Morbidity

• Captures the Cause of the Injury or Health Condition.• The Intent

– Unintentional or accidental;– Suicide or assault.

• The Place the Even Occurred.• The Activity of the Patient at the Time of the Event.• The Person’s Status

– Civilian– Military

External Causes of MorbidityPER CMSWebsite If you have not been reporting ICD‐9‐CM external cause codes,

you will not be required to report ICD‐10‐CM codes found inChapter 20 unless a new State or payer‐based requirement aboutthe reporting of these codes is instituted. If such a requirement isinstituted, it would be independent of ICD‐10‐CMimplementation.

• In the absence of a mandatory reporting requirement, you areencouraged to voluntarily report external cause codes, as theyprovide valuable data for injury research and evaluation of injuryprevention strategies.

External Causes of Morbidity

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A patient took a fall from a step at ahotel while not paying attention towhat she was doing, she wastreated for a possible fracture of herleft knee, and abrasions to her rightknee as well abrasions on her rightand left hands. Her pain was an 8out of 10.

How Many Codes Do You Think Will be Coded?

–What injury occurred–Place of Occurrence–Activity–Status

Correct Diagnosis Code Sequence and Reporting:

ConditionS89.92 Unspecified Injury Lower Left legSuperficial Injuries are not coded if a more

severe injury has occurred.

HowW10.8XXA Fall (on) (from) other stairs and

steps, initial encounter

Place of Occurrence /External CauseY92.59 Other trade areas as the place

of occurrence of the external cause

ActivityY93.01 Activity, walking, marching and hiking

HOW MANY CODES WILL BE CODED

Correct Diagnosis Code Sequence and Reporting:

ConditionT07 Unspecified Multiple Injuries

NOW HOW WILL WE REALLY CODE THIS CLAIM?

General Documentation Guidelines

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Coding in General

• The patients condition should be coded based on thedocumentation from the personnel on scene.

• Non‐Emergency clearly has to already be specific to the patient’scondition and need for the ambulance.

• The Diagnosis Code is to support the reason for transport.

Emergency Documentation• Chief Complaint• History of Present Illness (HPI) has always been critical to obtain• Past Medical History (PMH)• Any pertinent documentation from family or facility• ALS Assessment if performed, documented• Vital signs• Assessment of head to toe• Pain Assessment• Treatment and interventions• Successful or Unsuccessful Attempts• How was the patient moved• Patient status while transported

Did the Documentation Change?

For nonemergency transports, the crew should generally focus more on the patient’s deficits that prevent transportation by another means, rather than what may appear to be the main

diagnosis.

WHY DO YOU HAVE TO BE THERE?

Non‐Emergency Documentation

Pain: What was the scale, where is the pain?

Paralysis: Where? Left? Or Right?

Fall Risk: Is the patient a danger to their self or to others and why?

PressureUlcers: Where? Left or Right? Upper or Lower? And What is the

stage?

Oxygen: Is the patient unable to administer oxygen and why?

BedConfined: Are they able to sit, stand or ambulate?

Other: Does the patient need to be transported by Ambulance?

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T: 72 Y/O FEMALE PT WHO ORIGINALLY WENT TO xxxxx HOSPITAL ON MM/DD/YY FOR SHORTNESS OF BREATH.

R: PT WAS ADMITTED AND UNDERWENT CHEST X‐RAY, LAB WORK, AND IV ANTIBIOTICS. SHE WAS DIAGNOSED WITH PNEUMONIA.

A: UAA, PT IS A & O X 1 (PERSON, NORMAL MENTATION). GCS 5. HEENT‐ UNREMARKABLE, PERRL. CHEST‐ CTA, =RISE/FALL BILAT. ABDOMENSOFT,NON‐TENDER. EXTREMITIES‐ CONTRACTURES X 4. SKIN‐WARM AND DRY. INJURIES‐ STAGE 3 WOUND TO HER LT BUTTOCK.

N: PT IS BEING DISCHARGED TO HER HOME UNDER THE CARE OF HER HUSBAND, xxxxx HOME HEALTH, AND AN UNDETERMINED AT THIS TIME HOSPICE. SHE REQUIRES EMS TRANSPORT DUE TO: CONDITIONS REQUIRING MEDICAL MONITORING DURING TRANSPORT, SUPPLEMENTAL O2 IN WHICH PT CANNOT SAFELY ADMINISTER HERSELF, SEVERE WEAKNESS AND DEBILITATION, NON‐COMMUNICATIVE, REQUIRES HOSPITAL TYPE BED, NON‐AMBULATORY, SEVERE CONTRACTURES X ALL 4 EXTREMITIES AND MAINTAINS IN FETAL POSITION, DECUBITUS, DECREASED LOC, AND FALL RISK.

S: VITALS OBTAINED AND MONITORED AS NOTED. PULSE OX APPLIED/SPO2 MONITORED. ADMINISTERED O2 AT 2 LPM VIA NC. PT WAS MOVED WITH A SHEET AND SECURED TO COT. SHE WAS TRANSPORTED TO HER HOME WITHOUT INCIDENT OR CHANGE. CARE TRANSFERRED TO HER HUSBAND AND xxxxx HOME HEALTH.

Non‐Emergency What Do We Do NOW?

Moving Forward

Plan Your JourneyUnderstand the Impact

Identify the Team

Prepare a Budget and Forecast

Arrange for Training and Education

Early on in your ICD‐10 journey you need to pinpoint where diagnosis codes are used in your practice. You need to prepare an ICD‐10 transition budget.

Pullyourtop25‐50ICD‐9‐CMDiagnosisCodes

Crosswalkthemwithavailableresources

IdentifyinyourorganizationwhereICD‐9‐CM’sarecurrentlyutilizedandwillneedtobeupdated,i.e.NEMSIS.

http://www.roadto10.org/action‐plan/get‐started/

Moving Forward

Train Your TeamClinical Documentation Education

Coding Education

To better assist your service with the transition process, several tools and training sources are available to get you started on the path to ICD‐10 compliance.

• Evaluate the CMS and your MAC’s website.• Order ICD‐10 Code Books and various other resources to help educate your team.• Watch for various webinars available for team training.• Have billing, IT and Operations collaborate in implementing of ICD‐10’s.• When new procedures, protocols, medicines or equipment is being used, provide in‐

services for billing staff.


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Moving Forward

Update Your ProcessesImprove Clinical Documentation

Revise Paper Forms and Templates

Modify Policies and Procedures

Incorporate more detail in clinical documentation is an important step in your ICD‐10 transition. Updating your policies, procedures, forms, and templates is another crucial piece.

• Determine if there are weaknesses in your documentation and begin correcting immediately.

• Update Compliance Plans and policies and procedures to reflect ICD‐10‐CM.• Consider implementing a query processes for your medics when billing staff needs

clarification. This could make a difference in medical necessity and ensuring proper billing.


Moving Forward

Engage Your Vendors and PayersEngage Technology Vendors and Update Systems

Engage Staffing/Billing Vendors and Evaluate Resources

Engage Clearinghouses and Evaluate Readiness

Engage Payers and Readiness

Collaboration with your payers and vendors is an important part of the ICD‐10 transition. Each one's approach to ICD‐10 needs to be assessed so that system updates, set‐up tasks, and compliance risks can be addressed.

• Have a clear understanding how your software vendor is implementing ICD‐10‐CM’s.• If you have contracts with Commercial Carriers, verify their language and ensure the level

of specificity they will require.• Monitor your MAC’s websites for updates and changes.


ZOLL Full List of ICD‐10‐CMhttp://www.cdc.gov/nchs/icd/icd10cm.htm

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Tri‐Tech Tri‐Tech

Moving Forward

Engage Your Vendors and Payershttp://www.roadto10.org/template‐library/

Moving Forward

Test Your Systems and ProcessesPrepare and/or Obtain Test Cases

Perform Internal Testing of Systems and Processes

Conduct External Testing with Partners

Testing is a critical component of the ICD‐10 transition.

• Update you billing system with ICD‐10‐CM’s, test running reports, claims and files.• Once ICD‐10‐CM’s are implemented continue to monitor system to ensure claims are going

out the door appropriately.• Watch for denials due to ICD‐10‐CM’s and monitor closely.

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ICD 10’s and Ambulance Services · •ICD‐10‐CM code descriptions include right or left...

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