MVLTCA – February 25, 2014
Cathryn J. Moore, BS, RHIA, RAC-CT
1. Regulations which mandate
implementation of ICD-10-CM
2. Updates that have occurred for conversion
to the non-acute arena
3. Major differences from ICD-9 to ICD-10
4. Implementation Plan to facilitate a smooth
transition to the new system
Implementation Date: October 1, 2014
Final Rule: August 24, 2012
Available at
http://www.cms.gov/Medicare/Coding/ICD10
/Statute_Regulations.html





ICD-10 was created by the World Health
Organization in1990
Since 2001, most of the world has adopted it
U.S. modified it and added CM (Clinical
Modification)
Review more information at:
http://www.who/int/classifications/icd/imple
mentation/en/index.html
2014 ICD-10-CM is available at
http://www.cdc.gov/nchs/icd/icd10cm.htm or
http://www.cms.hhs.gov/ICD10
 2014 ICD-10-CM Index to Diseases and Injuries
 2014 ICD-10-CM Tabular List of Diseases and Injuries
◦ Instructional Notations
 2014 Official Guidelines for Coding and Reporting
 2014 Table of Drugs and Chemicals
 2014 Neoplasm Table
 2014 Index to External Causes
 2014 Mapping ICD-9-CM to ICD-10-CM and
ICD-10-CM to ICD-9-CM



GEMs (General Equivalence Mappings) are a
tool that can be used to convert data from
ICD-9-CM to ICD-10-CM and vice versa.
Mapping from 10 to 9 is referred to as
backward mapping while 9 to 10 is referred
to as forward mapping
GEMs are a comprehensive translation
dictionary that can be used to accurately and
effectively translate any ICD-9-CM based
data
GEMs (General Equivalence Mappings) can be
used by anyone who wants to convert coded
data, including:









All payers
All providers
Medical researchers
Informatics professionals
Coding professionals
Software vendors
Organizations
Others who use coded data
GEMs (General Equivalence Mappings) are
not a substitute for learning how to use the
ICD-10 codes.
 More information about GEMs and their use
can be found on the CMS website at:
http://www.cms.gov/Medicare/Coding/ICD10/i
ndex.html
 Select from left side of web page to find
most recent GEMs






Medical Coding in U.S. health care settings will
change from ICD-9-CM to ICD-10
Compliance date is firm (no grace period, no
delays)
ICD-10-CM diagnoses codes will be used by
all providers in every health care setting
ICD-10-PCS procedure codes will be used only
for hospital claims for inpatient hospital
procedures
ICD-9-CM codes will not be accepted for
services provided on or after 10-1-14
Check Your Understanding of
Implementation Compliance
Date



ICD-10-CM codes will not be accepted for
services prior to October 1, 2014
Providers must begin using ICD-10-CM codes
to report diagnoses from all ambulatory and
physician services on claims with dates of
service on or after October 1, 2014, and for all
diagnoses on claims for inpatient settings with
dates of discharge that occur on or after
October 1, 2014
ICD-10-PCS (procedure codes) must be used
for all hospital claims for inpatient procedures
on claims with dates of discharge that occur on
or after 10-1-2014





New Classification system will provide
better data needed to:
Measure the quality, safety, and efficacy of
care
Reduce the need for attachments to
explain the patient’s condition
Design payment systems and process
claims for reimbursement
Conduct research, epidemiological studies,
and clinical trials








New Classification system will provide better
data needed to:
Set health policy
Support operational and strategic planning
Design health care delivery systems
Monitor resource utilization
Improve clinical, financial, and administrative
performance
Prevent and detect health care fraud and
abuse
Track public health and risks



Overall number of codes is significantly
increased from approximately 14,000 in
ICD-9-CM to approximately 70,000 in ICD10-CM
ICD-10-PCS codes increased from
approximately 4,000 in ICD-9-CM to
approximately 70,000
ICD-10 codes are longer and use more
alpha characters



Codes allow greater clinical detail and
specificity in describing diagnoses and
procedures
Terminology and disease classification have
been updated to be consistent with current
clinical practice
Last but not least is that system changes are
required to accommodate the ICD-10 codes
Numeric or
(E or V)
Numeric
..
M
X
A
4 1 X
4
Category
X
0 X
0
Etiology, anatomic
site, manifestation
3–5 Characters
17
Alpha
(Except U)
M
X X
A
S
0 X
2
Category
2-7 Numeric or Alpha
.
Additional
Characters
X
6 X
5 X
x
Etiology, anatomic
site, severity
A
X
Added 7th character for
obstetrics, injuries, and
external causes of injury
3–7 Characters
18
Cerebral Vascular Accident with Hemiplegia
ICD-9-CM
438.20
ICD-10-CM
I69.959
Fracture of the left hip
ICD-9-CM
V54.13
ICD-10-CM
S72.002D
Diabetes mellitus with retinopathy
ICD-9-CM
250.50
362.01
ICD-10-CM
E11.319





Combination codes for conditions and
common symptoms or manifestations
Combination codes for poisonings and
external causes
Added laterality
Expanded codes (injury, diabetes,
alcohol/substance abuse, postoperative
complications)
Injuries grouped by anatomical site rather
than injury category





I25.110 Atherosclerotic heart disease of
native coronary artery with unstable angina
pectoris
E11.311 Type 2 diabetes mellitus with
unspecified diabetic retinopathy with macular
edema
K50.012 Crohn’s disease of small intestine
with intestinal obstruction
N41.01 Acute prostatitis with hematuria
T57.0X4A Toxic effect of arsenic and its
compounds, assault




C50.511 Malignant neoplasm of lower-outer
quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer
quadrant of left female breast
C50.519 Malignant neoplasm of lower-outer
quadrant of unspecified female breast
C50.521 Malignancy neoplasm of lower-outer
quadrant male breast




S72.044G Nondisplaced fracture of base of
neck of right femur, subsequent encounter
for closed fracture with delayed healing
I69.351 Sequelae of cerebral infarction,
Hemiplegia and hemiparesis following
cerebral infarction affecting right dominant
side
Z47.81 Encounter for orthopedic aftercare
following surgical amputation
Z48.21 Encounter for aftercare following
heart transplant
Addition of 7th character :
 Used in certain chapters to provide
information about the characteristic of the
encounter
 Must always be used in the 7th character
position
 If a code has an applicable 7th character, the
complete code must be reported with an
appropriate 7th character value in order to be
valid



Character “x” is used as a 5 character
placeholder in certain 6 character codes to
allow for further expansion and to fill in
other empty characters when a code that is
less than 6 characters in length requires a 7th
character
T46.1x5A - Adverse effect of calcium channel
blockers, initial encounter
T15.02xD – Foreign body in cornea, left eye,
subsequent encounter


Excludes 1 – Indicates that the condition
excluded should never be used with the code
noted in the note (do not report both codes)
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 used to capture
both conditions)

R22.2 Localized swelling, mass and lump,
trunk
Excludes 1: intra-abdominal or pelvic mass
and lump (R19.0-)
Excludes 2: breast mass and lump (N63)


Inclusion of clinical concepts that do not
exist in ICD-9-CM (e.g., underdosing, blood
type, blood alcohol level)
A number of codes have been significantly
expanded (e.g., injuries, diabetes, substance
abuse, postoperative complications)



T45.526D – Underdosing of antithrombotic
drugs, subsequent encounter
Z67.40 – Type O blood, Rh positive
Y90.6 – Blood alcohol level of 120-199
mg/100 ml



E10.610 – Type 1 diabetes mellitus with
diabetic neuropathic arthropathy
F10.182 – Alcohol abuse with alcoholinduced sleep disorder
T82.02xA – Displacement of heart valve
prosthesis, initial encounter


Injuries are grouped by anatomical site
rather than by type of injury
Category restructuring and code
reorganization have occurred in a number of
chapters, resulting in the classification of
certain diseases and disorders that are
different from ICD-9-CM



Certain diseases have been reclassified to
different chapters or sections in order to
reflect current medical knowledge
New code definitions (e.g., definition of acute
myocardial infarction is now 4 weeks rather
than 8 weeks)
The V codes and E codes are incorporated
into the main classification rather than
separated into supplementary classifications
as they were in ICD-9-CM



The Uniform Hospital Discharge Data Set
(UHDDS) provides definitions for primary and
secondary diagnoses.
Adapted to fit all non-inpatient settings (postacute) such as home healthcare, hospice, nursing
facilities, and rehab facilities.
In determining principal diagnosis/primary
diagnosis, the coding conventions (instructional
notes incorporated in the codes) take precedence
over the Tabular and Alphabetic Index guidelines.



The condition that caused the admission for
services.
That condition most relevant to the plan of
care.
That diagnosis which represents the most
acute condition and will require the most
intensive services.





Co-Morbidities
Additional Diagnoses used in coding guidelines.
All conditions that coexist during the episode of
care that may affect the plan of care or which
developed subsequently and affect the treatment
or care of the patient.
Entered on the OASIS C (OASIS C-1) in the order
by the degree of which they will impact the plan
of care and the need for homecare services.
Entered on the MDS only if active diagnoses and
impact the plan of care.


A diagnosis related to the prospective
payment system; may involve manifestation
coding.
Medical record documentation must support
the diagnosis reported on the OASIS-C and
485 and the MDS Assessment.

The condition treated by the inpatient facility
or by the physician in an outpatient setting
relevant within the past 14 days.



Any condition that is resolved and is no
longer being treated.
Appropriate for the OASIS C assessment but
not the plan of care.
Not appropriate for MDS assessment.

A resident was admitted to the nursing
facility following foot amputation due to
diabetic peripheral vascular disease. PT and
OT was ordered with the plan for the resident
to return home. Staff is to change dressings
and report any suture site breakdown to the
physician. Other diagnoses include
gastroparesis due to type 2 diabetes
(receiving insulin), mitral valve regurgitation
with aortic stenosis, inguinal hernia,
generalized DJD and COPD.
Assign Codes.

A resident was admitted to the nursing
facility following foot amputation due to
diabetic peripheral vascular disease. PT and
OT was ordered with the plan for the resident
to return home. Staff is to change dressings
and report any suture site breakdown to the
physician. Other diagnoses include
gastroparesis due to type 2 diabetes
(receiving insulin), mitral valve regurgitation
with aortic stenosis, inguinal hernia,
generalized DJD and COPD.
Assign Codes.




Z47.81 Aftercare, following surgery
(for) (on), amputation
E11.51 Diabetes, diabetic (mellitus) (sugar)
Type 2, with peripheral angiopathy
E11.43 Diabetes, diabetic (mellitus) (sugar)
Type 2, with gastroparesis
I80.0
Regurgitation, mitral (valve) – see
Insufficiency, mitral. Insufficiency,
insufficient, mitral (valve), with aortic
valve disease



K40.90 Hernia, hernial (acquired) (recurrent),
inguinal (direct) (external) (funicular)
(indirect) (internal) (oblique) (scrotal)
(sliding)
M15.9 Disease, diseased, joint,
degenerative—see Osteoarthritis.
Osteoarthritis generalized
J44.9
Disease, diseased, pulmonary,
chronic, obstructive

Z79.4

Z89.439
Long-term (current)
(prophylactic)
Absence (of) (organ or part)
(complete or partial), foot
(acquired)

LTC resident returns home with orders for home health care.....

E11.51 DM with PVD
E11.43 DM with gastroparesis
M15.9 OA (debility affecting ADL/IADL)
J44.9
COPD (debility affecting ADL/IADL)
I80.0
Mitral valve regurgitation with aortic
stenosis: monitor signs/symptoms
Z48.01 Change of surgical dressing:
Z79.4
LT insulin use

G54.6






Phantom Limb Syndrome, with pain
**** must be documented by physician
Patient has hypertension. He continues to
experience elevated BP while taking BP medication.
While assessing the patient, the nurse discovers he
was taking his medication once daily instead of
twice (as ordered) because of the cost of the drug.



I10 Essential HTN
T46.5x6D Underdosing of other antihypertensive drug, subsequent encounter
Z59.8 Other problems related to housing and
economic circumstances




Learn about the structure, organization, and
unique feature of ICD-10-CM
Learn about the system impact and 5010
Identify areas of strength/weakness in
medical terminology and medical record
documentation
Review and train to improve knowledge of
medical terminology as needed



Provide intensive coder training
approximately 3-6 months prior to
implementation
Contact vendors to determine their state of
readiness for implementation
Provide additional training to refresh or
expand knowledge in the biomedical
sciences (anatomy, physiology,
pathophysiology, pharmacology, and
medical terminology)


Communicate with all staff who will be
impacted by the change to keep them
updated and to make sure they understand
their role in the transition
Work with physicians to make sure they
understand some of the changes that will
need to be made in documentation to allow
for greater specificity in coding with ICD-10
Three variables which you can control or
influence.
 Human resources (coders, auditors, IT)
 IT systems (internal/external)
 Vendors
**Training
**Practice
**Keep current with industry

Additional Info
◦ http://www.cms.gov/Medicare/CodingICD10/index
.html

Medicare Fee for Service Provider Resources
◦ http://www.cms.gov/Medicare/Coding/ICD10/inde
x.html

Remember to check back regularly for
updated implementation information!!!

Frequently Asked Questions (FAQs) related to
ICD-10
◦ http://www.cms.gov/Medicare/Coding/ICD10/inde
x.html
◦ Select Medicare Fee for Service Provider Resources
link from the menu on left side of page, scroll down
the page to “related links inside CMS” and select
“ICD-10 FAQs”

MLN Matters Additional Info
◦ http://www.cms.gov/Medicare/CodingICD10/index
.html

Medicare Fee for Service Provider Resources
◦ http://www.cms.gov/Medicare/Coding/ICD10/inde
x.html



AHIMA ICD-10 Website
www.ahima.org/icd10
CMS Website
http://cms.hss.gov/Medicare/Coding/ICD10/
index.html
NCHS Website
http://www.cdc.gov/nchs/icd/icd10cm.htm
For coding in any medical institution, you will
need more anatomy and physiology and related
terminology background in order to help you
navigate better through ICD-10.
Everyone will need to take classes for ICD-10
which will be opening up.
YOU ARE ONLY AS GOOD AS YOUR TOOLS…SO
START COLLECTING!!