ICD-10-CM
Introduction
91304
Carolyn S White, CCS, CCS-P, CPC,
CUC
September 17, 2009
Overview
 Status,
Why?, What?
 Overview of differences/similarities
 Relationship between increased clinical
detail needed for increased
anatomy/physiology knowledge and
improved documentation
2
Status of ICD-10-CM Adoption

In August of 2008, the Centers for Medicare
and Medicaid Services (CMS) issued a notice
of proposed rule making (NPRM) that would
replace the ICD-9-CM code set now used to
report health care diagnosis and procedures
with the greatly expanded ICD-10-CM and ICD10-PCS code sets.
 The implementation date will not be before
2011.
What Is ICD-10-CM?
 Clinical
modification of the World Health
Organization’s ICD-10,
 ICD-10-CM includes the level of detail
needed for morbidity classification and
diagnostic specificity.
 As with ICD-9-CM, ICD-10-CM is
maintained by the National Center for
Health Statistics.
Development of ICD-10
 Goals




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
of the tenth revision:
Expand the content, purpose, and scope
of the system
Include ambulatory care services
Increase clinical skills
Capture risk factors in primary care
Identify emergent diseases
Group diagnoses for epidemiological
purposes
Why ICD-10-CM?
 ICD-9-CM
is outdated and obsolete due
to HIPAA’s requirements for electronic
transactions
 ICD-9-CM was originally designed for
indexing purposes; now, also being used
for reimbursement.
 Enhance the efficiency of clinical data
collection and the quality of
administrative data.
Benefits of ICD-10-CM
 Provides
greater specificity,
 Allows the possibility of greater
expansion of codes.
 Extends beyond classification of
diseases and injuries to include risk
factors in a primary care setting.
Benefits of ICD-10 (Continued)
 Includes
recently identified diseases.
 Updates general terminology and
disease classification to be consistent
with accepted and current clinical
practice.
 Provides more detailed information to
providers, payers, and policy makers.
Improvements in ICD-10-CM
 Conditions
are grouped more logically.
 Subcategory titles are more complete.
 Fifth- and sixth-character
subclassifications are incorporated into
codes.
 Laterality of conditions is incorporated
at the fifth- and sixth-character levels.
 Specificity has been increased.
 Extensions provide more information.
What Is ICD-10-CM?
 The
system consists of more than 68,000
codes, compared to approximately 13,000
ICD-9-CM codes.
 ICD-10-CM codes have the potential to
reveal more about quality of care,
 ICD-10-CM incorporates greater specificity
and clinical detail to provide information for
clinical decision making and outcomes
research.
What Is ICD-10-CM?
 ICD-10-CM
codes may consist of up to
seven digits, with the seventh digit
extensions representing visit encounter or
sequelae for injuries and external causes.
The difference in code structure is shown
in the figure above.
ICD-9-PCS
 ICD-10-PCS
is a procedural coding
system developed under contract by the
Center for Medicare & Medicaid Services
(CMS)
 Replacement of the ICD-9-CM procedural
coding system for hospital reporting of
inpatient procedures.
 7-character alphanumeric code structure.
Brief Comparison of ICD-10-CM
with ICD-9-CM
 General/overall
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improvements:
ICD-10-CM codes are alphanumeric and
include all letters except U.
ICD-9-CM’s V and E codes are
incorporated into the main classification in
ICD-10-CM.
Maximum length of codes in ICD-10-CM is
seven characters.
ICD-10-CM offers information relative to
ambulatory and managed care encounters.
Comparing ICD-9-CM
and ICD-10-CM
Similarities in Structure and
Terms
 ICD-10-CM
has the same type of
hierarchy in its structure as ICD-9-CM.
 All codes have the same first three digits
describing common traits,

each character beyond the first three
providing more specificity
ICD-10-CM Structure
 ICD-10-CM
has an index and tabular list
similar to those of ICD-9-CM.
 ICD-10-CM index is much longer.
 As with ICD-9-CM, ICD-10-CM uses an
indented format for both the index and
tabular list.
 Categories, subcategories, and codes are
contained in the tabular list
Organizational Changes
While ICD-10-CM has the same type of hierarchical
structure as ICD-CM, some differences in organization:
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ICD-10-CM consists of 21 chapters.
Some chapters include the addition of a sixth
character.
ICD-10-CM includes full code titles for all codes
(no references back to common fourth and fifth
digits).
V and E codes are no longer supplemental
classifications.
Organizational Changes

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Sense organs have been separated
from nervous system disorders.
Injuries are grouped by anatomical site
rather than injury category.
Postoperative complications have been
moved to procedure-specific body
system chapter.
New Features
ICD-10-CM has numerous new features
allowing for greater level of specificity
 Combination codes for conditions and
common symptoms or manifestations
 Combination codes for poisonings and
external causes
 Added laterality
New Features
 Added
extensions for episode of care
 Expanded codes (injury, diabetes,
alcohol/substance abuse, postoperative
complications)
 Inclusion of trimester in obstetrics codes
and elimination of fifth digits for episode of
care
New Features
 Expanded
detail relevant to ambulatory
and managed care encounters
 Changes in timeframes specified in certain
codes
 External cause codes no longer a
supplementary classification
 Inclusion of trimester in obstetrics codes
and elimination of fifth digits for episode of
care
New Features
 Expanded
detail relevant to ambulatory
and managed care encounters
 Changes in timeframes specified in certain
codes
 External cause codes no longer a
supplementary classification
New Feature
 An
additional feature is the expansion of
codes for certain conditions.
 Two examples are diabetes mellitus and
postoperative complication codes.
New Features—Diabetes
 Diabetes
mellitus codes are expanded to
include the classification of the diabetes
and the manifestation.
 The category for diabetes mellitus has
been updated to reflect the current clinical
classification of diabetes
 No longer classified a controlled or
uncontrolled:
New Features--Diabetes
 E08.22,
Diabetes mellitus due to an
underlying condition with diabetic chronic
kidney disease
 E09.52, Drug or chemical induced
diabetes mellitus with diabetic peripheral
angiopathy with gangrene
 E10.11, Type 1 diabetes mellitus with
ketoacidosis with coma
 E11.41, Type 2 diabetes mellitus with
diabetic mononeuropathy
New Features--Complications
 ICD-10-CM
provides 50 different codes for
“complications of foreign body accidently
left in body following a procedure,”
compared to only one code in ICD-9-CM.
 Examples include: (next)
New Features--Complications

T81.535, Perforation due to foreign body
accidently left in body following heart
catheterization
 T81.530, Perforation due to foreign body
accidently left in body following surgical
operation
 T81.524, Obstruction due to foreign body
accidently left in body following endoscopic
examination
New Features- Fracture Extensions
 Code
extensions (seventh character) have
been added for injuries and external
causes to identify the encounter:

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A Initial encounter
D Subsequent encounter
S Sequelae
 Fracture
codes require a seventh
character that identifies if the fracture is
open or closed for an initial encounter or if
a subsequent encounter is for routine
healing, delayed healing, nonunion,
malunion, or sequelae.
 The fracture extensions are:
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A Initial encounter for closed fracture
B Initial encounter for open fracture
D Subsequent encounter for fracture with
Laterality in Fracture Coding
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
G Subsequent encounter for fracture with delayed
healing
K Subsequent encounter for fracture with nonunion
P Subsequent encounter for fracture with malunion
S Sequelae
An example is code S42.321A, Displaced
transverse fracture of shaft of humerus, right
arm, initial encounter for closed fracture.
ICD-10-CM Code Examples
 ICD-10-CM
consists of new features and
greater specificity
 Combination Codes for Poisonings and
the External Cause

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T39.011, Poisoning by aspirin, accidental
(unintentional)
T39.012, Poisoning by aspirin, intentional self
harm
T39.013, Poisoning by aspirin, assault
T39.014, Poisoning by aspirin, undetermined
ICD-10-CM Code Examples
 Combination
Codes for Conditions and
Common Symptoms

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I25.110, Arteriosclerotic heart disease of
native coronary artery with unstable angina
pectoris
K50.013, Crohn’s disease of small intestine
with fistula
K71.51, Toxic liver disease with chronic active
hepatitis with ascites
ICD-10-CM Code Examples
Laterality
 C50.212, Malignant neoplasm of upperinner quadrant of left female breast
 H02.835, Dermatochalasis of left lower
eyelid
 I80.01, Phlebitis and thrombophlebitis of
superficial vessels of right lower extremity
 L89.213, Pressure ulcer of right hip, stage
III
Coding System Changes
 CPT
and HCPCS Level II will continue to
be used for:


Physician and other professional services
Procedures performed in hospital outpatient
departments and other outpatient facilities
Improvements in ICD-10-CM
Codes
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Etiologies and manifestations are grouped in
combination codes.
Code titles have been changed to reflect new
technology and recent terminology.
Codes have been added to describe
postoperative or postprocedural conditions.
Trimester specificity has been added.
Many new codes have been added.
Combination Codes Solve
Sequencing Dilemmas
A
single code may be used to classify two
diagnoses, a diagnosis with an associated
sign or symptom, or a diagnosis with an
associated complication.
 This allows one code to be assigned,
resulting in fewer cases requiring more
than one code and reducing sequencing
problems
Sequencing Dilemmas contd.
 Manifestation/etiology
conditions require
two codes with sequencing mandated by
ICD-9-CM.
 Brackets in the index identified that the
etiology (diabetes mellitus) code was
sequenced before the manifestation
(diabetic nephropathy).
Sequencing Dilemmas contd
 In
cases when ICD-9-CM did not indicate
correct sequencing, coding was not clearcut, and Coding Clinic advice was needed
to sequence conditions appropriately.
 The ICD-10-CM use of combination codes
has greatly simplified this process
Sequencing Dilemmas contd
 Combination
codes are also available for
external causes and poisonings, with
information combined into one code
(including the drug involved) making those
difficult sequencing rules obsolete.
Combination Code Examples
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Examples of these combination codes include:
I25.110, Atherosclerotic heart disease of native
coronary artery with unstable angina
pectoris
E10.21, Type 1 diabetes mellitus with diabetic
nephropathy
N30.01, Acute cystitis with hematuria
T39.011A, Poisoning by aspirin, accidental
(unintentional), initial encounter
Full Descriptions Reduce CrossReferencing
 ICD-10-CM
has made every attempt to
write out the full code title for all codes,
decreasing cross-references.
 This change provides greater
comprehension of the meaning of the
code, as well as facilitates computer
applications.
Choosing Sides with Laterality
 ICD-10-CM
includes codes for laterality
(unclassified in ICD-9-CM).
 Codes for left side, right side, and in some
cases bilateral are available in appropriate
chapters.
 If the side is not documented in the
medical record, an unspecified side code
is available.
Choosing Sides with Laterality
 The
majority of the affected codes are in
the neoplasm and injury chapters. The
classification of this information can be
very beneficial in reporting claims for
payment,
Examples of these types of codes
include:
 C50.511,
Malignant neoplasm of lowerouter quadrant of right female breast
 M21.722, Unequal limb length (acquired),
left humerus
 S72.344A, Nondisplaced spiral fracture of
shaft of right femur, initial encounter for
closed fracture
Expanded Codes Capture More
Detail
 Expanded
codes are available in many
sections of ICD-10-CM, particularly in the
injury, diabetes, alcohol and substance
abuse, and postoperative complication
sections.
Expanded Codes Capture More
Detail
There are five categories for diabetes in
ICD-10-CM:
 E08, Diabetes due to underlying condition;
E09, Drug or chemical induced diabetes;
E10, Type 1 diabetes;
 E11, Type 2 diabetes; and
 E13, Other specified diabetes mellitus.
 Controlled or uncontrolled is not a
classification in ICD-10-CM.
Expanded Codes
 Injuries
are grouped by body part rather
than by categories of injury, so that all
injuries of the specific site (such as head
and neck) are grouped together rather
than groupings of all fractures or all open
wounds.
Extensions Specify Encounter
 ICD-9-CM
limitations have created
challenges in assigning codes for specific
aftercare encounters in the outpatient and
postacute care settings.
 ICD-10-CM has added code alpha
character extensions (seventh character)
in appropriate sections to provide specific
information about the characteristics of the
encounter.
Extensions Specify Encounter
 In
the injury and external cause sections,
the extension classifies an initial
encounter, subsequent encounter, or
sequelae of an encounter.
 Extensions have different meanings
depending on the section, but common
extensions are:
Extensions Specify Encounter



 In
A, Initial encounter
D, Subsequent encounter
S, Sequelae
code S81.012, Laceration without
foreign body, left knee, the seventh
character would be A for an initial
encounter, D for subsequent encounter, or
S for sequelae.
Structure of ICD-10-CM
 The
international ICD-10 classification is
published in three volumes:

Volume 1: Tabular List

Volume 2: Guidelines

Volume 3: Alphabetic Index
 ICD-10-CM
includes only two volumes:

Volume 1: Tabular List

Volume 2: Alphabetic Index
ICD-10-CM Alphabetic Index
 The
Alphabetic Index for ICD-10-CM is
similar to the Alphabetic Index for ICD-9CM.
 The index is a list of terms related to
diseases, disorders, conditions,
poisonings and adverse effects, and
external causes.
 The function of the index is to help users
locate codes in the classification.
Mapping Between Old and New
 General
equivalency maps (GEMS) have
been developed
 GEMS are not crosswalks—they are
reference maps

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Backward & forward maps available on CMS
website
Between ICD9CM and ICD10PCS
Between ICD9CM and ICD10CM
Mapping Between Old and New
 Reimbursement
map was added to the
CMS website in 2009

Intended for use by payers as a temporary
mechanism to allow claims to be processed
by legacy systems until internal systems have
been fully converted.
 Maps
should not be used for coding
Training for ICD-10-CM (Continued)
 Because
ICD-10-CM coding requires a
higher level of specificity than ICD-9-CM
coding, experts and planners
recommend users will need a strong
background in anatomy and physiology,
medical terminology, pharmacology, and
medical science to apply the revised
classification system.
Learning the ICD-10-CM
System
 National
Center for Health Statistics Web
site,
http://www.cdc.gov/nchs/icd/icd10cm.htm
ICD-10-CM Guidelines
 The
ICD-10-CM index and tabular list were
released in July 2007; the “Draft ICD-10CM Official Guidelines” were released in
June 2003 (available at
www.cdc.gov/nchs/data/icd9/draft_i10guideln.pdf).
 Monitor
the National Center for Health
Statistics Web site for any new versions of
the guidelines, index, and tabular list
before implementation.
NCHS
National Center for Health Statistics. “ICD-10CM Index and Tabular.” 2007. Available online
at
www.cdc.gov/nchs/about/otheract/icd9/icd10cm.
htm.
 National Center for Health Statistics. “Draft ICD10-CM Official Guidelines.” 2003. Available
online at
www.cdc.gov/nchs/data/icd9/draft_i10guideln.pd
f.

References
 ICD-10-CM
and ICD-10-PCS Preview, Anita
Hazelwood, MLS, RHIA, FAHIMA, Carol A Venable, MPH, RHIA, FAHIMA
AHIMA, 2009
 ICD-10-CM
and ICD-10-PCS Preview, Ann
Barta, MSA, RHIA, AHIMA
 ICD-10-CM
Field Testing Project, Report
on Findings, AHA, AHIMA, September 23, 2003
References
National Center for Health Statistics. “ICD-10CM Index and Tabular.” 2007. Available online
at
www.cdc.gov/nchs/about/otheract/icd9/icd10cm.
htm.
 Article citation:
Zeisset, Ann. "ICD-10-CM Enhancements: A
Look at the Features That Will Improve Coding
Accuracy" Journal of AHIMA 80, no.2 (February
2009): 55-58.

References
 Barta,
Ann; et al.. "ICD-10-CM Primer."
Journal of AHIMA 79, no.5 (May 2008):
64-66.