ICD-10-CM Basics
 ICD-10-CM is very similar to
ICD-9-CM as far as look up and basic guideline information
 Total number of codes expands from about 13,000 ICD-9-CM codes to well over 68,000 in
ICD-10-CM
 ICD-10 Uses full code titles,
ICD-9 does not
 Plenty of room for expansion in
ICD-10

Are 3 –5 digits;
•The first digit is alpha (E or V) or numeric
(alpha characters are not case sensitive);
•Digits 2–5 are numeric; and
A decimal is used after the third character. Examples:
• 496 – Chronic airway obstruction, not elsewhere classified (NEC);
• 511.9 – Unspecified pleural effusion; and
• V02.61 – Hepatitis B carrier

Are 3 –7 digits;
•Digit 1 is alpha;
•Digit 2 is numeric;
•Digits 3–7 are alpha or numeric
(alpha characters are not case sensitive); and a decimal is used after the third character.
Examples:
• A78 – Q fever;
• A69.21 – Meningitis due to Lyme disease; and
• S52.131A – Displaced fracture of neck of right * radius, initial encounter for closed fracture.
* the 6 th for left digit is the laterality, in certain codes, and will be 1 for right or 2

ICD-10-CM Code Structure
Category first three characters
M84 Disorders of continuity of bone
Etiology, anatomic site, severity, laterality for fourth, fifth, sixth characters (if
applicable)
M84 .311 Stress
Fracture, right shoulder
Extension seventh character
(if applicable)
M84.311A Stress fracture, right shoulder; initial encounter

• Laterality (Left, Right, Bilateral
681.00 Cellulitis and abscess, unspecified
• Combination codes for certain conditions and common associated symptoms and manifestations
M1A.3120 Chronic gout due to renal impairment, left shoulder without tophus

• Obstetric codes identify trimester instead of episode of care:
1 st Trimester - less than 14 weeks 0 days
2 nd Trimester – 14 weeks 0 days to less than 28 weeks 0 days
3 rd Trimester – 28 weeks 0 days until delivery
024.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
024.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
TIP: THE 6 TH DIGIT FOLLOWS THE TRIMESTER
• Combination codes for poisonings and their associated external cause:
T43.612A Poisoning by caffeine, intentional self harm, initial encounter

Placeholder character
The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a placeholder at certain codes to allow for future expansion. An example of this is at the poisoning, adverse effect and under dosing codes, categories
T36-T50. Where a placeholder exists, the X must be used in order for the code to be considered a valid code.
Example: H40.11
Primary open-angle glaucoma
H40.11X0
…… stage unspecified
H40.11X1
…… mild stage
H40.11X2
…… moderate stage
H40.11X3
…… severe stage
H40.11X4
…… indeterminate stage
H40.11
X 1 Primary open-angle glaucoma mild stage

. 7th Characters
Certain ICD-10-CM categories have 7th characters. The
7th character is required for all codes within the category, or as the notes in the Tabular List instruct.
The 7th character must always be the 7th character in the data field. If a code that requires a 7th character does not have a 6th character for defining the code, a placeholder X must be used to fill in the empty character s .
Example 1:
T79.0
XX A Initial encounter for a traumatic air embolism
Some codes have even more!
Example 2:
W06.
XXX D Subsequent encounter for a fall from a bed

 The 7th character in ICD-10-CM is used in several chapters (for example, the
Obstetrics, Injury, Musculoskeletal, and External Cause chapters). It has a different meaning depending on the section where it is being used (for example, in the Injury and External Cause sections, the 7th character often classifies an initial encounter, subsequent encounter, or sequelae (late effect) but may include others.
 Primarily, changes in ICD-10-CM are in its organization and structure, code composition and level of detail.

Two Types of Excludes Notes
Excludes 1 – Indicates that the code excluded should never be used with the code where the note is located (do not report both codes).
Example:
Q03 – Congenital hydrocephalus.
Excludes 1: Acquired hydrocephalus (G91.-).
Excludes 2 – 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).
Example:
L27.2 – Dermatitis due to ingested food.
Excludes 2: Dermatitis due to food in contact with skin (L23.6, L24.6, L25.4).
7) Inclusion of Clinical Concepts That Do Not Exist in ICD-9-CM (For Example,
Underdosing, Blood Type, Blood Alcohol Level)
Examples:
T45.526D – Underdosing of antithrombotic drugs, subsequent encounter;
Z67.40 – Type O blood, Rh positive; and
Y90.6 – Blood alcohol level of 120 – 199 mg/100 ml.

8) A Number of Codes Are Significantly Expanded (For Example, Injuries,
Diabetes, Substance Abuse, Postoperative Complications)
Examples:
E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy;
F10.182 – Alcohol abuse with alcohol-induced sleep disorder; and
T82.02xA – Displacement of heart valve prosthesis, initial encounter.
9) Codes for Postoperative Complications Are Expanded and a
Distinction is Made Between Intraoperative Complications and
Postprocedural Disorders
Examples:
D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen; and
D78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen.

Specialty
Gastroenterologists
Pulmonologists
Urologists
Endocrinologists
Neurologists
Pediatricians
Infectious Disease
# ICD-9 Codes
596
255
389
335
459
702
1,270
# ICD-10 Codes
706
336
591
675
591
591
1,056

• The majority are in musculoskeletal and injury/poisoning:
Increased specificity of type of fracture, laterality, specific bone and encounter information.*
Increased doesn’t mean increased complexity, if you take away the 7 th character for encounter, the number of codes drop significantly.
*
Tip – documenting these additional elements will simplify the ICD-10 transition.

Z00.121
– Routine infant/child exam with abnormal findings
Does this include a separate and identifiable problem like an ear infection or is this limited to a problem within normal growth and development such as failing a hearing screening Z00.121
Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
P. Encounters for general medical examinations with abnormal findings
The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first-listed diagnosis. A secondary code for the abnormal finding should also be coded.

We frequently use 079.99
– Viral syndrome and have identified a couple of options for coding with
ICD-10:
•B34.9 Viral infection, unspecified, or
•B97.89 Other viral agents as the cause of disease classified elsewhere (Use of this code indicates we have diagnosed a disease.)
– When we see these children, the disease is a basket of symptoms that point to a viral illness. Which one should we use?

ICD-9-CM ICD-10-CM Flag
07999 B9789 10000
080 A750 00000
Meaning
Approximate Match
Exact Match
CAUTION!
You cannot rely simply on the GEMS system to cross-match everything. If the flag is other than “00000” there are other potential possibilities. It’s best to start in the alphabetic index a then complete the look up process in the tabular.

1.Alphabetic Index:
Syndrome
- virus B34.9
1.Tabular Index:
B34.9 Viral Infection Infection, unspecified
-

1. Increase in number of Codes and Specificity
 Addition of more than 50,000 new diagnosis codes
 Will demand a high level of coder expertise in the areas of anatomy, physiology, pathophysiology and medical terminology
2. ICD-10 has tens of thousands of more terms than ICD-9-CM. To use ICD-10 effectively coders must know:
 Greek and Latin prefixes, suffixes, roots and combining forms used as the basis of most medical terms
 Commonly accepted and approved medical abbreviations (AKA Above the Knee
Amputation)
 Eponyms (who it is named after “Achilles tendon”) and names of syndromes (a group of signs or symptoms that create a condition, “Sick Sinus Syndrome”)
 Alternative names and descriptions for diseases (GERD-Gastroesophageal Reflux
Disease)
 Adjectives used to describe and define diseases and disorders (purulent, necrotic, etc.)
 Technology driven and manufacturer given names for tests, devices and procedures

3
.
Changes will impact all departments
 Need multi-disciplinary approach
 Planning needs to include representatives across all departments that are impacted
4. Enormous healthcare-wide impact
 All Providers
 All health plans and payers
 Technology solutions that require coding input
5. First FULL replacement in 30 years
6. Complicated Mapping
 No one-to-one mapping from ICD-9 to ICD-10
 There may be multiple one-to-one possibilities
 There may be multiple cluster possibilities ICD-10 may be a combination of codes to fully describe the patients issues

7 . Anticipated short-term consequences of implementation
 Coding productivity estimated to decline by 10% – 15%
 Declining reimbursements and increased days in A/R (quantify?)
 Increased claims denials
8. Anticipated Long-Term Benefits
 Improved analytics based on increased specificity
 More accurate reimbursements

9
. Extensive foundational Knowledge will be required
 Medical record fundamentals (foundation of)
 Coding fundamentals
 Documentation guidelines
 Anatomy (study of the structure of organisms and their parts)
 Physiology (nature or origin of)
 Pathophysiology (changes associated with a disease or injury)
 Pharmacology (study of drug action)
 Medical and Surgical Procedures
 Medical Terminology

10. Training is Critical
Preparing Outpatient Coders
 It is estimated that approximately 16 hours of coding training are needed for each outpatient coder to learn ICD-10-CM. This estimate presumes that coders already possess the necessary knowledge in the biomedical sciences. More is always better in this case.
 Similar to inpatient coders, outpatient coders should focus on obtaining the foundational knowledge of the biomedical sciences and understanding how ICD-10-CM is different from ICD-9-CM (including familiarity with the maps between them). It is critical that they apply knowledge of anatomy, physiology, and clinical disease processes to support correct coding assignment for diagnoses in ICD-10-CM.
 “Understand how to apply maps and crosswalks between ICD-9-CM and the ICD10 systems “ and most of all how to use your books

Let’s Code-S.O.A.P.
S: (Subjective) Mrs. Finley presents today after having a new cabinet fall on her last week, suffering a concussion, as well as some cervicalgia. She was cooking dinner at the home she
shares with her husband. She did not seek treatment at that time. She states that the people that put in the cabinet in her kitchen missed the stud by about two inches. Her husband, who
was home with her at the time told her she was “out cold” for about two minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long
periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius.
O: (Objective) Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear.
A: (Assessment)
1. Status post concussion with acute persistent headaches
2. Cervicalgia
3. Cervical somatic dysfunction
P: (Plan)The plan at this time is to send her for physical therapy, three times a week for four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month, sooner if needed.

S06.0X1A
Concussion with loss of consciousness of 30 minutes or less, initial encounter
G44.311
Acute post traumatic headache, intractable
M54.2
M99.01
W20.8xxA
Y93.g3
Y92.010
Cervicalgia
Segmental and somatic dysfunction of cervical region
Struck by falling object (accidentally), initial encounter
Remember the alpha characters are not case sensitive
Activity, cooking and baking
Place of occurrence, house, single family, kitchen

rd
• PM/EHR Vendors System capabilities: updates/upgrades/interfaces
– Table redesign/user interface formats
– Dual Coding Capabilities (system)
– Template modifications
– Billing edits
• Clearinghouses/Billing Companies
– Billing edits/other services
– Clearinghouse to Payer transmissions
•Payers End to end testing opportunities
– Changes in coverage determinations or authorization processes

• Identify the top 100 primary care diagnosis codes.
• Identify other specialty codes, if required.
• Map those codes from ICD-9 to ICD-10.
• Identify the specificity which may be required in the ICD-10 documentation for those codes.
• Analyze current work flow processes.
• Identify “gaps” in assigning the codes and in other workflow processes. This may vary depending on how automated your processes are now.
• Identify any changes needed to internal forms, templates, or processes.
• Identify educational needs.

• Identify the educational needs of your staff based on role and responsibilities.
• Develop or seek educational resources which target specific needs.
• Do not over-train beyond scope of practice or duty. Train appropriately.
Train methodically.
• Use applicable case scenarios or actual past encounters as training materials.
• Incorporate the coding guidelines in your training.
• Practice dual coding in both ICD-9 and ICD-10.
• Ensure that education is relevant to the provider’s specialty.
• Select or design training materials carefully.

• Have established internal benchmarks prior to “go live”.
• Identify weaknesses you have in ICD-9 claims now.
• Monitor Claims Submission and Remittance Advises to quickly identify any problems with claims adjudication.
• Monitor % of posted adjustments to identify problems with reimbursement or coverage.
• Know who to contact with each payer or 3rd party.
• Know resubmission and appeal processes in advance.
• Do follow-up auditing to identify areas for re-education and training.


https://www.ahima.org/icd10 /

https://www.ama-assn.org/go/icd-10

https://www.cms.gov/icd10/

: http://www.cdc.gov/nchs/icd/icd10cm.htm

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