Mooresville AAPC Chapter
ICD-10 Review Class
Registrant Information
Name: _______________________________________________________________________________________________________
Address:________________________________________________________________________________________________________
_
__________________________________________________________________________________________________________________
Contact Number:_____________________________________________________________________________________________
E-mail: _____________________________________________________________________________
Registrant Information:
ICD-10 Review Class (6CEUs)
Saturday, April 11, 2015
9am-4pm
$60.00
Payment Information:
Please make checks/money orders payable to Mooresville AAPC Chapter
Send Payments to:
Sylvia Hale
192 Crystal Circle
Mooresville, NC 28117
E-mail:
dsahale6@aol.com
Phone: (704)660-0275
Payments must be postmarked no later than 4/1/15 and will be deposited on that date. Only cash
payments will be accepted the day of the class, and registration is first come first serve. Cash
payments should be confirmed by e-mail to dsahale6@aol.com no later than 4/1/15. All payments
are non-refundable, your check will serve as your registration confirmation. Receipts and CEU
certificates will be given out at the conclusion of the class.
All attendees will be responsible for providing their own ICD-10 books for this class, Materials will
be provided for the class
***Sign in starts at 8:30- Please arrive no later than 8:45, as the class will start promptly at 9am***
1
ICD-10-CM
Diagnosis Coding:
Let’s Get Ready!
Taught by
Nancy G. Higgins, CPC,
CPC-I, CIRCC, CPMA, CEMC
© 2015 Nancy G. Higgins
What we are going to cover:
• Introduction to ICD-10-CM
• The benefits of the new system and
how it differs from ICD-9-CM
• ICD-10-CM code format
• Code selection process
• ICD-10-CM book format and how it
differs from ICD-9-CM
• General ICD-10-CM diagnosis coding
guidelines
• Chapter-specific ICD-10-CM diagnosis
coding guidelines that differ from ICD9-CM
• How to get your providers ready for
ICD-10-CM
3
Introduction to ICD-10-CM
• ICD-10-CM = International Classification of
Diseases, 10th Revision, Clinical Modification
• World Health Organization (WHO) developed
the International Classification of Diseases
– Used worldwide
• Clinical Modification was developed by the
National Center for Health Statistics
– Used only in the United States
Implementation date is
October 1, 2015
• Beginning with this date, all HIPAA covered
entities will be required to use ICD-10-CM
codes to report diagnoses
– HIPAA covered entities includes physicians,
hospitals, outpatient hospital departments, etc.
and most payers
– Exception is Workers’ Compensation
4
Benefits of ICD-10-CM
• Significant increase in number of codes
allows for greater specificity in code
definition
ICD-9-CM has approximately 14,000 codes
ICD-10-CM has approximately 68,000 codes!!
• New code format allows for addition of
future codes in appropriate category and
location
• Updated terminology and disease
classifications
• More detailed data for analysis of disease
patterns
• Possibility of new reimbursement methods
that recognize the complexity of treating
more severe conditions
5
Differences between ICD-10CM and ICD-9-CM
ICD-9-CM
ICD-10-CM
Codes consist of up to 5
Codes consist of up to 7
numbers (except V and E
characters (combination
codes – letter and up to 4
of letters and numbers)
numbers)
17 chapters plus sections
for V codes and E codes
21 chapters
Approximately 14,000
codes
Approximately 68,000
codes
6
ICD-10-CM code format…
• Codes have up to 7 characters
• 1st is always a LETTER
• 2nd and 3rd are usually NUMBERS
– First three characters determine the category
of the medical condition
• 4th through 7th can be a LETTER OR A
NUMBER
– 4th, 5th and 6th characters provide
subclassifications with more specificity
– 7th character is reserved for additional info
when needed, e.g., trimester of pregnancy,
episode of care, etc.
It’s important to know the first character is
always a letter because the letter O is used.
It is the letter O, not the number 0 (zero).
Only letter not used is U.
7
How to select a code …
• Determine the main term related to the
disease, condition, or symptom you want to
code
• Look it up in the Alphabetic Index
• Review all possible options listed
• Identify a potential code selection
DO NOT STOP HERE!!!
• Turn to that code in the Tabular Listing and
read all the instructional notes, alternative
listings, etc.
• Determine whether that is the correct code
• Determine whether additional codes are
needed
Be sure you have read all of the guidelines
before you start using the ICD-10-CM book!
8
ICD-10-CM book …
• Introductory material
• ICD-10-CM Draft Official Guidelines for
Coding and Reporting
YOU MUST READ THESE AND UNDERSTAND
THE INFORMATION CONTAINED IN THIS
SECTION!!!
• Volume 2 – Alphabetic Index to Diseases
– Main terms are in bold
– Subterms (variations of main terms)
are indented and in regular font
– Look for condition, disease, symptom
or problem
– Do NOT look under body location or
part … not usually there
– Notice there’s no hypertension table in
ICD-10-CM
9
ICD-10-CM book …
• Volume 2 – Alphabetic Index to
Diseases
– Neoplasm table – moved to the end of
the Alphabetical Index in ICD-10-CM
• Neoplasm = new growth
• Malignant = cancer
• Benign = NOT cancer
• Uncertain behavior = pathology
report specifies that the specimen is
not clearly malignant or clearly
benign; the specimen is of
“uncertain behavior”
• Unspecified = the physician’s
documentation in the chart or EMR
does not state whether the growth is
malignant or benign
10
ICD-10-CM book …
• Volume 2 – Table of Drugs and Chemicals
– Immediately after the Neoplasm Table
– Contains a list of all the drugs and other
chemical substances that can poison a
person
– Series of options for each drug or
substance
• Poisoning, Accidental (Unintentional)
• Poisoning, Intentional Self-Harm
• Poisoning, Assault
• Poisoning, Undetermined
• Adverse Effect – allergic reaction
• Underdosing – patient did not take
correct dosage (took less than
instructed) and became sick or sicker as
a result  new in ICD-10-CM
11
ICD-10-CM book …
• Volume 2 – Alphabetic Index to External
Causes of Injury and Poisoning
– Immediately after the Table of Drugs and
Chemicals
– Contains an alphabetic listing of all the
ways a person could be injured
• Volume 1 – Tabular Listing
– Codes are listed in order beginning with
A00 through Z99.8
– Organized by chapter
– 21 chapters (ICD-9-CM only had 19
chapters)
• Some chapters renamed
• Some chapters moved
• Some chapters reorganized so that sections
have been moved to other chapters
• Codes for eye conditions and ear conditions
have been moved out of the Nervous System
chapter into separate chapters
12
ICD-10-CM book …
Chapter
Title
1
Certain infectious and parasitic diseases
2
Neoplasms
3
Diseases of the blood and blood-forming organs
and certain disorders involving the immune
system
4
Endocrine, nutritional and metabolic diseases
5
Mental, behavioral, and neurodevelopmental
disorders
6
Diseases of the nervous system
7
Diseases of the eye and adnexa
8
Diseases of the ear and mastoid process
9
Diseases of the circulatory system
10
Diseases of the respiratory system
11
Diseases of the digestive system
12
Diseases of the skin and subcutaneous tissue
13
ICD-10-CM book …
Chapter
Title
13
Diseases of the musculoskeletal system and
connective tissue
14
Diseases of the genitourinary system
15
Pregnancy, childbirth and the puerperium
16
Certain conditions originating in the perinatal
period
17
Congenital malformations, deformations and
chromosomal abnormalities
18
Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified
19
Injury, poisoning and certain other consequences
of external causes
20
External causes of morbidity
21
Factors influencing health status and contact with
health services
14
Basic coding conventions …
• Codes can be 3 to 7 characters in length
• Letter X is used as dummy placeholder to
allow for future expansion of codes  new in
ICD-10-CM
• Example: S52.91 Unspecified fracture of right
forearm requires a 7th character to specify the
episode of care so letter “X” is used to hold
the 6th place so that the 7th character will be in
the correct position
• If the encounter is the initial encounter for a
closed fracture, the code would be:
S52.91xA Unspecified fracture of right
forearm, initial encounter for
closed fracture
15
Basic coding conventions …
• ICD-10-CM has two types of Excludes notes
• Excludes1 identifies two conditions that
cannot be reported together
Example: Category G43 Migraine has an Excludes1
note for Headache NOS (R51).
– These two codes should never be reported together
– Headache is a symptom commonly associated with
a migraine
• Excludes2 indicates that the excluded
condition is not part of the condition defined
by the code you are viewing but the patient
may have both conditions at the same time
– The excluded condition is simply not part of the
definition for the code you are viewing
– These two codes CAN be reported together
Example: Category G47 Sleep disorders includes
insomnia, hypersomnia, Circadian rhythm sleep
disorders, sleep apnea, narcolepsy, etc. The category
has an Excludes2 note for nightmares, sleep terrors,
and sleep walking. The patient CAN have insomnia and
nightmares (for example) so both can be coded. The
Excludes2 note indicates that nightmares are not part
of the insomnia definitions.
16
Basic coding conventions …
• Default codes
– In the Alphabetic Index, the default code is
the code listed next to the main term
– Represents condition most commonly
associated with main term
– Assign this code when the documentation
does not provide enough information to
assign a more specific code
• AND
– The term “and” should be interpreted as
“and/or”!!!
I
IMPORTANT!!!
17
Basic coding conventions …
• NEC
– “Not elsewhere classifiable”
– Use when a specific code is not available for
a condition
• NOS
– “Not otherwise specified”
– Equivalent of unspecified
• Etiology/manifestation convention
– Certain conditions have an underlying cause
(etiology) and manifestations due to that
underlying cause
– Code underlying condition first and
manifestation following that unless
otherwise instructed by notes in book
– Look for “use additional code” to identify
manifestations
– Look for “code first” to identify etiology
18
Basic coding conventions …
• WITH
– Should be interpreted to mean “associated
with” or “due to”
• Do not code any condition described in the
physician’s documentation as “probable,”
“suspected” or “rule out”
• If a diagnosis has not been confirmed, code
the patient’s symptoms
• Once a diagnosis has been confirmed, do NOT
code the symptoms routinely associated with
that diagnosis
• Sequela = late effects
– Residual effect after the acute phase of an
illness or injury has terminated
– May be apparent early or may occur
months or years later
19
General coding guidelines…
• The majority of the general coding guidelines in
ICD-10-CM are similar to those in ICD-9-CM
• Concept of laterality is addressed in ICD-10-CM
because it has a huge impact on the code
definitions throughout the book
– In general, the final character of the codes specifies
the side of the body affected
– 1 = right side
– 2 = left side
– 3 = bilateral (note that this option is not always
available)
– 0 or 9 = unspecified depending on whether it is in
the 5th or 6th character position
• Documentation associated with complications is
addressed in ICD-10-CM
– To be classified as a complication, the
documentation must establish a cause-and-effect
relationship between the care provided and the
condition
– Not all conditions that occur during or following
medical care or surgery are classified as
complications
20
General coding guidelines…
• Example of documentation of complications
– Documentation states: Patient suffers from severe
lymphedema resulting from the mastectomy she
underwent six months ago
I97.2 Postmastectomy lymphedema syndrome
 The cause and effect relationship is clear
– Documentation states: Patient suffers from severe
lymphedema. Past medical history significant for
mastectomy six months ago.
I89.0 Lymphedema, not elsewhere classified
 The cause and effect relationship is not
documented
21
General coding guidelines: same or
similar in ICD-9-CM and ICD-10-CM …
• Selection of first-listed diagnosis code
– The diagnosis documented first in the assessment
and plan section (or impression and plan section)
should indicate the main reason for the encounter
and this condition typically should be coded first
– Always follow any instructional notes about
sequencing at the code classification
– If two or more confirmed diagnoses meet the
criteria for first-listed diagnosis, the order does not
matter
• Selection of additional diagnosis codes
– Do not code conditions that no longer exist (except
a code for the history of a previous condition if it
affects patient care or indicates the need for the
patient encounter)
• For a surgical procedure, code the
postoperative diagnosis
• Always code to the highest level of specificity
22
General coding guidelines: same or
similar in ICD-9-CM and ICD-10-CM …
• When a definitive diagnosis has not been
established by the provider, code the signs and
symptoms experienced by the patient
• Signs and symptoms commonly associated
with an established or confirmed diagnosis
should not be coded unless the instructions in
ICD-10-CM direct you to do so
• Signs and symptoms that are not commonly
associated with an established or confirmed
diagnosis should be coded when described in
the documentation
• Acute and chronic conditions
– If the same condition is documented as acute or
subacute and chronic and there are separate codes
for these conditions, report both codes and list the
acute or subacute code first
23
Chapter specific guidelines …
• Some chapters have similar guidelines in ICD10-CM and ICD-9-CM but some have very
different guidelines and should be reviewed
carefully prior to coding
• We will now begin our review of the chapterspecific guidelines focusing on what is
different in ICD-9-CM and ICD-10-CM
24
Chapter 1: Certain infectious and
parasitic diseases (A00 – B99) …
• This chapter includes diseases typically
recognized as communicable or transmissible
• The guidelines in ICD-10-CM are similar to
those in ICD-9-CM with the following
exceptions:
– Term “septicemia” is no longer used because it has
been used to describe multiple conditions by
different providers and has no clear definition
– Term “urosepsis” should not be used because it is
nonspecific and is not the same thing as sepsis
– If a patient develops sepsis due to a postprocedural
infection, the relationship between the infection
and the procedure must be clearly documented
– Because many bacterial infections have become
resistant to antibiotics, if the infection code does
not specify drug resistance in its definition, use the
following code in addition to the infection code:
Z16 Infection with drug resistant microorganisms
25
Chapter 2: Neoplasms (C00 – D49) …
• This chapter includes malignant neoplasms,
carcinoma in situ, benign neoplasms, neoplasms
of uncertain behavior, and neoplasms of
unspecified behavior
• Some benign neoplasms have been moved to
the specific body system chapters in ICD-10-CM
• Note that this chapter has a significant
expansion of codes in ICD-10-CM due to the
incorporation of laterality, more detail regarding
anatomic location, and more detail regarding
neoplasm type or histology
– ICD-9-CM contains approximately 1000 codes in this
chapter while ICD-10-CM contains over 1500 codes
• Some of the malignancy code series now have
an option for primary malignant neoplasm with
overlapping sites
– The malignancy must overlap two or more
contiguous sites (next to each other) specified by
different codes
26
Chapter 2: Neoplasms (C00 – D49) …
• The guideline for Anemia associated with
malignancy is different in ICD-10-CM!
– If the encounter is for evaluation and management
of anemia associated with a malignancy and the
treatment is only for the anemia, sequence the
codes as follows:
1. Code for the malignancy
2. Code for the anemia (D63.0 Anemia in neoplastic
disease)
• The guidelines for anemia associated with
chemotherapy, immunotherapy, or radiation
therapy are expanded in ICD-10-CM
– Code as follows:
1. Code for the anemia
2. Code for the malignancy
3. One of the following codes depending on the
treatment that caused the anemia:
T45.1x5_ Adverse effect of antineoplastic and
immunosuppressive drugs, OR
Y84.2 Radiological procedure and radiotherapy as the
cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the
time of the procedure
27
Chapter 2: Neoplasms (C00 – D49) …
• ICD-10-CM contains a new guideline for
Malignant neoplasm in a pregnant patient that
states the following codes should be assigned:
1.
2.
Code from O9A.1_ Malignant neoplasm
complicating pregnancy, childbirth and the
puerperium
Code for the malignancy
• ICD-10-CM also contains a new guideline that
states that if a patient encounter is solely for
treatment of a complication associated with a
neoplasm, the following codes should be
reported:
1.
2.
Code for complication
Code for malignancy
Remember that the guideline for anemia
associated with a malignancy is an exception to this
guideline.
28
Chapter 2: Neoplasms (C00 – D49) …
• ICD-10-CM contains guidelines about two new
codes and their use:
– C80.0 Disseminated malignant neoplasm,
unspecified should be used when the patient has
advanced metastatic disease and no primary or
secondary sites are documented
– C80.1 Malignant (primary) neoplasm, unspecified is
the equivalent of “Cancer, unspecified”
• There are more chapter-specific guidelines for
chapter 2 but they are unchanged from those in
ICD-9-CM
29
Chapter 3: Diseases of the blood and
blood-forming organs and certain
disorders involving the immune
mechanism (D50 – D89) …
• This chapter has been moved and now includes
the immunity disorders
– Chapter 3 in ICD-9-CM included Immunity Disorders
with Endocrine, Nutritional and Metabolic Diseases
– Chapter 4 in ICD-9-CM contained Diseases of the Blood
and Blood-Forming Organs
• This chapter now has categories of codes while
the chapter in ICD-9-CM had no specific
categories
• Codes for lymphadenitis were previously
included in this chapter but in ICD-10-CM can
now be found in Chapter 9 – Diseases of the
circulatory system
• This chapter, like the others in ICD-10-CM,
contains a significant expansion of codes
• ICD-10-CM contains no chapter-specific
guidelines for this chapter
30
Chapter 4: Endocrine, Nutritional and
Metabolic Diseases (E00 – E89) …
• All of the chapter-specific guidelines in ICD-10CM are for the diabetes codes and are similar to
those found in ICD-9-CM
• The diabetes codes are now combination codes
that include the following:
– Type of diabetes mellitus (Type 1, Type 2, Secondary)
– The body system affected, and
– Complications affecting that body system
• The guidelines state to use as many codes within
a particular category as are necessary to
describe all of the complications experienced by
the patient
• Codes should be sequenced based on the
reason for the encounter
• ICD-10-CM does include guidelines for overdose
or underdose of insulin due to insulin pump
failure
31
Chapter 4: Endocrine, Nutritional and
Metabolic Diseases (E00 – E89) …
• Example of combination code found in ICD-10CM:
Patient is seen and evaluated for Type 2 diabetes with
moderate nonproliferative diabetic retinopathy with
macular edema
ICD-10-CM Code
E11.331
ICD-9-CM Codes
250.50
362.05
362.07
Description
Type 2 diabetes mellitus with
moderate nonproliferative diabetic
retinopathy with macular edema
Description
Diabetes, type II, with opthalmic
manifestations
Moderate nonproliferative diabetic
retinopathy
Diabetic macular edema
32
Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders (F01 – F99) …
• This chapter is similar to the chapter in ICD-9CM
• The biggest change is the incorporation of
guidelines and codes for mental disorders due to
drug use, abuse or dependence
• Guidelines for mental and behavioral disorders
due to psychoactive substance use – new in ICD10-CM
– Codes should be used only when the drug use is
associated with a mental or behavioral disorder AND
the relationship between the two is documented by
the provider
– Hierarchy exists for determining what to code:
• If use and abuse are documented  assign code
for abuse
• If use and/or abuse AND dependence are
documented  assign code for dependence
33
Chapter 6: Diseases of the Nervous System
(G00 – G99) …
• The ICD-10-CM chapter set-up differs
significantly from the ICD-9-CM chapter
– Diseases of the eye and ear have been moved to their
own chapters (chapters 7 and 8)
– New categories of codes have been developed based
on the type of disease or disorder
– The codes are slightly rearranged because of the new
categories
• This chapter also has a significant expansion of
the number of codes
– For example, ICD-9-CM has 10 codes that can be used
to report Migraines while ICD-10-CM has 44 codes in
this category.
– Codes are also expanded due to the incorporation of
laterality (left versus right)
34
Chapter 6: Diseases of the Nervous System
(G00 – G99) …
• The guidelines in ICD-10-CM are the same as
those in ICD-9-CM except for a new section that
addresses dominant versus nondominant side
• Some code categories incorporate code
descriptions that describe the affected side as
dominant or nondominant
• If the documentation does not indicate whether
the affected side is dominant or nondominant,
the code should be selected as follows:
– If the patient is ambidextrous, default = dominant
– If the right side is affected, default = dominant
– If the left side is affected, default = nondominant
35
Chapter 7: Diseases of the Eye and
Adnexa (H00 – H59) …
• Codes for these conditions are included in the
Nervous System chapter in ICD-9-CM
• ICD-10-CM has extensive additions to the codes
because of the addition of laterality and
increased specificity
– Most of the codes have four subcategories as follows:
• Right eye
• Left eye
• Bilateral
• Unspecified eye
• All chapter-specific guidelines relate to
glaucoma coding
– Assign as many codes from category H40 Glaucoma as
needed to identify:
• Type of glaucoma
• Affected eye
• Stage of glaucoma
36
Chapter 8: Diseases of the Ear and
Mastoid Process (H60 – H95) …
• Codes for these conditions are included in the
Nervous System chapter in ICD-9-CM
• ICD-10-CM has extensive additions to the codes
because of the addition of laterality and
increased specificity
– Most of the codes have four subcategories as follows:
• Right ear
• Left ear
• Bilateral
• Unspecified ear
• There are no chapter-specific guidelines for this
chapter
37
Chapter 9: Diseases of the Circulatory
System (I00 – I99) …
• The ICD-10-CM chapter set-up is similar to that
in ICD-9-CM
• Codes are expanded significantly in some areas
– A new code category exists for Subsequent ST
elevation (STEMI) and non-ST elevation (NSTEMI)
myocardial infarctions
– Many code series have been expanded to account for
laterality
• Many guidelines remain the same as those in
ICD-9-CM
• New or modified guidelines in ICD-10-CM relate
to:
– Atherosclerotic coronary artery disease and angina
– Acute myocardial infarctions (AMI)
– Subsequent acute myocardial infarctions
• The chapter also contains many additional
instructional notes regarding use of additional
codes to identify tobacco use and exposure
38
Chapter 9: Diseases of the Circulatory
System (I00 – I99) …
• Atherosclerotic heart disease and angina
– ICD-10-CM contains combination codes for these
conditions
I25.11 Atherosclerotic heart disease of native
coronary artery with angina pectoris
I25.7 Atherosclerosis of coronary artery bypass
graft(s) and coronary artery of transplanted heart
with angina pectoris
– A causal relationship is assumed and does not have to
be documented
• Acute myocardial infarctions (MIs)
– This section contains significant differences from ICD9-CM
– The acute phase was designed as eight weeks or less in
ICD-9-CM but is defined as four weeks (28 days) or less
in ICD-10-CM
– Episode of care concept has been eliminated in ICD-10CM
– Two categories of codes exist – initial MI and
subsequent MI
– Codes for STEMIs have been significantly expanded
– Subsequent MI is defined as occurring with in 4-week
acute phase
39
Chapter 10: Diseases of the Respiratory
System (J00 – J99) …
• The chapter set-up is similar to that found in
ICD-9-CM
• ICD-10-CM contains numerous combination
codes that describe a condition and the
infection that is its underlying cause
Example: J20.2 Acute bronchitis due to streptococcus
• Guidelines in ICD-10-CM address the following:
– Acute exacerbation of chronic obstructive bronchitis
and asthma – An acute exacerbation is a worsening or
a decompensation of a chronic condition, not an
infection superimposed on a chronic condition.
– Sequencing of acute respiratory failure codes
• List first if it is the reason chiefly responsible for
admission to the hospital
• Asthma codes contain options for
– Mild
– Moderate
– Severe
• This chapter contains significant instructional
notes to use additional codes to report tobacco
use or exposure
40
Chapter 11: Diseases of the Digestive
System (K00 – K95) …
• The chapter set-up is similar to that found in
ICD-9-CM although three additional subcategories have been added allowing for more
specificity of category title
• Combination codes also exist in some cases that
include the drug, nature of the condition (e.g.,
adverse effect), and external cause  eliminates
the need for E-codes
Example: Fran was a healthy 30 year old female
diagnosed with a UTI and prescribed a course of
Doxycycline. Approximately one week after beginning to
take her antibiotics, Fran’s UTI had resolved but she
returned to the office with odynophagia, chest pain and
dysphagia. After diagnostic testing, Fran was diagnosed
with an esophageal ulcer. Her physician determined her
ulcer was caused by the antibiotic.
K22.10 Ulcer of esophagus without bleeding
T36.4x5A Adverse effect of tetracyclines, initial
encounter
41
Chapter 11: Diseases of the Digestive
System (K00 – K95) …
• One major change in this chapter is that the
ulcer code definitions no longer mention
obstruction
– This has eliminated approximately 50% of the ulcer
codes since ICD-9-CM typically had options for “with
obstruction” and “without obstruction”
• Codes in ICD-9-CM for dentofacial anomalies
have been moved to the chapter for Diseases of
the Musculoskeletal System in ICD-10-CM
42
Chapter 12: Diseases of the Skin and
Subcutaneous Tissue (L00 – L99) …
• ICD-10-CM has many more subcategories than
ICD-9-CM but the conditions are generally in the
same order as in ICD-9-CM
• There is a significant expansion in the number of
codes for
– Laterality (left versus right)
– Upper limb versus lower limb
• The pressure ulcer codes have been significantly
expanded in ICD-10-CM (almost 6 pages while
ICD-9-CM had less than one page)
• All chapter-specific guidelines in ICD-10-CM
relate to the pressure ulcer codes
43
Chapter 12: Diseases of the Skin and
Subcutaneous Tissue (L00 – L99) …
• Pressure ulcer guidelines state:
– Assign as many codes as needed from the L89 Pressure
ulcer series to identify multiple pressure ulcers by
anatomic site and stage
– Code first any associated Gangrene (I96)
– No code should be assigned for a pressure ulcer
described as “healed”
• Information needed to code a pressure ulcer
– Body area or anatomic site (4th digit)
– Laterality (5th digit)
– Stage of ulcer / depth (6th digit)
• Note that the dermatitis codes have also been
expanded significantly reflecting the cause of
the dermatitis
– Providers may need to add more specific information
to their documentation so that the cause of the
dermatitis can be used to determine the appropriate
code
44
Chapter 13: Diseases of the
Musculoskeletal System and Connective
Tissue (M00 – M99) …
• The chapter in ICD-10-CM again has a significant
expansion of codes due to the addition of
laterality and other specificity
• The chapter includes all diseases typically
associated with the musculoskeletal system and
connected tissue as well as the following:
– Bone, joint or muscle conditions that are the result of a
healed injury
– Recurrent bone, joint or muscle conditions
– Pathological fractures
– Stress fractures
• Current, acute injuries should be coded using
codes form Chapter 19 – Injury, Poisoning and
Certain Other Consequences of External Causes
• The majority of the guidelines in ICD-10-CM
relate to coding pathological fractures
45
Chapter 13: Diseases of the
Musculoskeletal System and Connective
Tissue (M00 – M99) …
• A pathological fracture occurs in a diseased or
weakened bone when either no trauma or only
minor trauma that would not normally break a
healthy bone has occurred
• Pathological fractures are also known as
“spontaneous fractures”
• Bones can become weakened as the result of
many conditions including
–
–
–
–
Malignancies
Osteoporosis
Osteomyelitis
Hyperparathyroidism
• Pathologic fractures also include instructions to
code the underlying condition
• The 7th character specifies the episode of care
and is different from what is seen in ICD-9-CM
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Chapter 13: Diseases of the
Musculoskeletal System and Connective
Tissue (M00 – M99) …
• 7th characters for pathological fractures:
7th Character
Description
A
Initial encounter for fracture
D
Subsequent encounter for fracture with
routine healing
G
Subsequent encounter for fracture with
delayed healing
K
Subsequent encounter for fracture with
nonunion
P
Subsequent encounter for fracture with
malunion
S
Sequela
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Chapter 13: Diseases of the
Musculoskeletal System and Connective
Tissue (M00 – M99) …
• Stress fracture codes are in this chapter
• Stress fractures
– Occur in weight-bearing bones
– Are caused by repeated minimal stresses to the bone
– Should be coded using category M84.3 Stress fracture
• Note that when you code a stress fracture, you
must also select an external cause code to
identify the cause of the stress fracture
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Chapter 14: Diseases of the Genitourinary
System (N00 – N99) …
• In ICD-10-CM, renal manifestations of systemic
diseases classified in other chapters have been
moved to those chapters
Example: Nephrotic syndromes, nephritis, and
nephropathies associated with diabetes have been moved
to chapter 4, Endocrine, Nutritional and Metabolic
Diseases
• The codes in many categories again are
significantly expanded due to the increased
specificity of the definitions
• Some of the terminology used to describe
conditions in this chapter has changed
Example: Benign prostatic hypertrophy (BPH) is called
enlargement of the prostate in ICD-10-CM
• This chapter includes Disorders of the Breast
(N60 – N65) – codes are expanded due to the
addition of laterality
• The dysplasia codes for the cervix and vagina
have been redefined to differentiate the severity
of the condition (mild, moderate, or unspecified;
severe is in chapter 2)
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Chapter 15: Pregnancy, Childbirth and the
Puerperium (O00 – O9a) …
• In ICD-10-CM, the categories and codes are
more detailed
• ICD-10-CM eliminates the concept of
antepartum, delivery, etc. in the code definition
and instead incorporates the trimester of the
pregnancy into many of the codes including
those for supervision of the pregnancy
• The trimesters are defined as follows:
– First trimester – less than 14 weeks
– Second trimester – 14 weeks 0 days to less than 28
weeks
– Third trimester – 28 weeks 0 days until delivery
• The guidelines address the importance of
knowing whether a condition developed due to
the pregnancy or if it was a pre-existing
condition  this will impact the code selection
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Chapter 16: Certain Conditions Originating
in the Perinatal Period (P00 – P96) …
• In ICD-10-CM, the codes have been structured to
bring together related conditions into distinct
code blocks while ICD-9-CM grouped the
conditions into two subchapters
• Remember these codes are used only on the
newborn’s record (birth to 28 days of age)
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Chapter 17: Congenital Malformations,
Deformations and Chromosomal
Abnormalities (Q00 – Q96) …
• The chapter title has been updated in ICD-10CM to reflect the categories in this chapter
– In ICD-9-CM, the chapter title was Congenital
Anomalies
• The chapter has also been moved so that it
follows Chapter 16: Certain Conditions
Originating in the Perinatal Period
• Many of the code definitions from ICD-9-CM
have been modified or grouped as alternate
listings under another code definition
• In ICD-10-CM, the codes are grouped into
categories based on organ system or body area
• The guidelines state that once a congenital
condition has been corrected, a personal history
code should be used to identify the history of
the malformation or deformity
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Chapter 18: Symptoms, Signs and
Abnormal Clinical and Laboratory Findings,
NEC (R00 – R99) …
• Although this chapter is similar to Chapter 16 in
ICD-9-CM, the categories are significantly
different in ICD-10-CM
– Categories for symptoms and signs involving various
organ systems or functions
– Category for General symptoms and signs
– Categories for abnormal findings from test results
– Category for Ill-defined and unknown cause of
mortality
• This chapter also contains an expanded number
of codes due to the increase in specificity of
code definition
• New codes are available in ICD-10-CM for falls
R29.6 Repeated falls
Z91.81 History of falling
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Chapter 19: Injury, Poisoning and Certain
Other Consequences of External Causes
(S00 – T88) …
• Most of the injury coding guidelines remain the
same as those in ICD-9-CM
• ICD-10-CM includes significantly more codes due
to the inclusion of greater specificity, laterality,
and introduction of a new 7th character
extension to indicate the episode of treatment
– Initial encounter – used while patient is receiving
active treatment for the condition
– Subsequent encounter – used while patient is
receiving routine care for the condition during the
healing or recovery phase
– Sequela – used for complications or conditions that
arise as a direct result of a condition (late effect)
• Chapter 19 of ICD-10-CM groups injuries by
specific site/body part, while in ICD-9-CM
injuries are grouped by types of injuries, e.g.,
fractures, dislocations, open wounds, etc.
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Chapter 19: Injury, Poisoning and Certain
Other Consequences of External Causes
(S00 – T88) …
• Coding of traumatic fractures
– Fractures are coded individually by site
– If the documentation does not indicate whether the
fracture is open or closed, select the code for closed
– If the documentation does not indicate whether the
fracture is displaced or nondisplaced, select the code
for DISPLACED  opposite of ICD-9-CM
• ICD-10-CM distinguishes between burns and
corrosions – guidelines are the same by codes
are new and distinct
– Burns – thermal burns that come from a heat source,
burns from electricity and radiation
– Corrosions – burns due to chemicals
– Guidelines for coding burns are the same as those in
ICD-9-CM
• In ICD-10-CM, the poisoning codes are
combination codes that include the substance
that was taken and how the poisoning occurred
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Chapter 19: Injury, Poisoning and Certain
Other Consequences of External Causes
(S00 – T88) …
• Underdosing – new concept in ICD-10-CM!
– Used when a patient has taken less of a medication
than prescribed resulting in illness
– Should NEVER be the first-listed code
– First-listed code is what is wrong with the patient as a
result of the underdosing
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Chapter 20: External Causes of Morbidity
(V00 – Y99) …
• Similar to the E codes in ICD-9-CM
• ICD-10-CM does contain some specific
sequencing guidelines
• If two or more events cause separate injuries, an
external cause code should be assigned for each
cause
– Child and adult abuse take priority over all other
causes
– Terrorism events take priority over all other causes
except child and adult abuse
– Cataclysmic events take priority over all causes except
child and adult abuse and terrorism
– Transport accidents take priority over all causes except
child and adult abuse, terrorism, and cataclysmic
events
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Chapter 21: Factors Influencing Health
Status and Contact with Health Services
(Z00 – Z99) …
• Similar to the V codes in ICD-9-CM
• ICD-10-CM does contain some changes in code
set-up and in guidelines
• Code range Z00 – Z13 is used to describe
encounters related to routine examinations
(general check-ups, sports physicals, preemployment physicals)
– Categories now have options for
• Exam without abnormal findings
• Exam with abnormal findings
– If the exam results show abnormal findings, additional
code(s) should be used to identify those findings
• Pre-operative examination codes are used only
when a patient is being cleared for surgery and
no treatment is rendered
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Educating your providers …
• Dual coding
• Tools you can develop – base them on your
utilization reports
• Other ideas
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Questions?
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