EXCLUSIVELY SERVING HEALTHCARE
An Introduction to ICD-10-CM/PCS
Michigan Trauma Board – October 2013
Objectives
Why change?
When will this happen?
What are ICD-10-CM and ICD-10-PCS?
Let’s compare ICD-9-CM with ICD-10-CM/PCS
Practice coding
Review
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Page 2
What’s changing, what
isn’t? ICD-10, When?
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Page 3
Why Change?
Federal Register – CMS published Final Regulation January 2009
ICD-9-CM is outdated – can’t take healthcare into the future
30 years old – technology has changed
Many categories full (cannot expand)
Not descriptive enough – data needs have changed
Why not ICD-11??
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Page 4
ICD-10 Around the World
Australia 1998-1999
Brazil 1998
Canada 2001
China 2002
France 2005
Germany 1998
Korea 2008
Netherlands 1994
Russia 1999
South Africa 1996
Sweden 1997
Thailand 2007
United States 2014
United Kingdom 1995
U.A.E (Dubai) 2012
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Page 5
When will this occur?
ICD-9-CM codes will not be
accepted for services
provided on or after
October 1, 2014
ICD-9-CM claims for
services prior to
implementation date will
continue to flow through
systems for a period of time
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CPT and HCPCS codes
will continue to be used for
hospital outpatient
procedures and for
reporting
physicians/professional
services
Page 6
What are ICD-10-CM and ICD-10-PCS?
•
•
•
•
ICD = International Classification of Diseases
10 = 10th Revision
CM = Clinical Modification
PCS = Procedure Classification System
•
ICD-10-CM
•
• Diagnosis code set
ICD-10-PCS
• Procedure code set
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Page 7
Comparing ICD-9 to ICD-10
Diagnoses
Codes
Procedures
Codes
ICD-9-CM
Approximately
14,000
ICD-9-CM
Approximately 4,000
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ICD-10-CM
Approximately
70,000
ICD-10-PCS
Approximately
72,000
Page 8
What about ICD-11?
The following is taken from the World Health Organization Committee for the Coordination of
Statistical Activities Twenty-second Session 4-6 September 2013 discussing ICD 11:
• In conclusion:
•
(a) WHO Secretariat could produce an ICD 2015 ready including Mortality and Morbidity
Linearizations, Reference Guide and Index with the appropriate resolution to go to the World
Health Assembly. This timeframe, however, is extremely tight for paying due diligence to the work
especially in terms of:
•
•
•
•
appropriate consultations with expert groups; and sufficient time for field testing in multiple
countries and settings, and carrying out the resulting edits
(b) If the timeline is advanced to 2016, there will be more time to have ICD 2016 version with
more translations and incorporations of some field tests results.
(c) If the timeline is advanced to 2017, ICD 2017 will be ready with most Field Test results
incorporated and maintenance scheme tested.
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Page 9
What about ICD-11?
“Assuming that ICD-11 becomes available on schedule in 2016, the earliest the United
States could move to ICD-11 would be 2025. That's 12 years from now. Can we really afford
to wait that long? If you don't have the clinical analytics to survive in the changing health
care environment we're facing, you may not survive until 2025 to find out.”
Leon-Chisen, Nelly. "If We Procrastinate Long Enough, Will ICD-11 Be Ready?." H&HN. n.d. n. page. Web. 1 Oct. 2013.
<http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2013/0313HHN_ahavoices&domain=
HHNMAG>.
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Page 10
Benefits of ICD-10-CM
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Page 11
Benefits of ICD-10-CM
ICD-10-CM incorporates much greater clinical detail and specificity
than ICD-9-CM. Terminology and disease classification have been
updated to be consistent with current clinical practice. The modern
classification system will provide much better data needed for:
• Measuring the quality, safety, and efficacy of care
• Reducing the need for attachments to explain the patient’s condition
• Designing payment systems and processing claims for
reimbursement;
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Page 12
Benefits of ICD-10-CM
•
•
•
•
•
•
•
•
•
Conducting research, epidemiological studies, and clinical trials;
Setting health policy;
Operational and strategic planning;
Designing health care delivery systems;
Monitoring resource utilization;
Improving clinical, financial, and administrative performance;
Preventing and detecting health care fraud and abuse; and
Tracking public health and risks.
Note: Some non-specific codes still exist for use when the medical
record documentation does not support a more specific code.
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Page 13
ICD-9-CM/ICD-10-CM:
Similarities and differences
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Page 14
Structural Similarities and Differences between ICD-9-CM and ICD-10-CM Diagnoses
ICD-10-CM
ICD-9-CM
• Has 3 to 5 characters
• First character is numeric or
alpha (E or V)
• Characters 2-5 are numeric
• Always at least 3 characters
• Use of decimal after 3
characters
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•
•
•
•
3 -7 characters
Character 1 is alpha (A-T, V-Z)
Character 2 is numeric
Characters 3 -7 are alpha or
numeric
• Use of decimal after 3 characters
• Use of dummy placeholder “x”
• Alpha characters are not casesensitive
Page 15
ICD-9-CM Structure - Format
X
X
X
X
X
Category
Subcategories
Subclassification
3-5 Characters
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Page 16
ICD-9-CM Structure –Format
•
3 - 5 Characters - Examples
•
•
•
•
•
042 Human immunodeficiency virus disease
496 Chronic airway obstruction, NEC
414 .00 Coronary atherosclerosis of unspecified vessel, native or graft
V 55.3 Attention to artificial openings, colostomy
274.03 Chronic gouty arthropathy with tophus
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Page 17
ICD-10-CM Structure –Format
X
X
X
X
X
X
X
Category
Etiology, Anatomic Site, Severity
7th Character
3-7 Characters
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Page 18
ICD-10-CM Structure –Format
•
3 - 7 Characters - Examples
• B20 Human immunodeficiency virus disease
• J44.9 Chronic obstructive pulmonary disease, unspecified
• I12.510 Atherosclerotic heart disease of native coronary artery without angina
pectoris
• Z43.3 Encounter for attention to colostomy
• M1A.0111 Idiopathic chronic gout, right shoulder, with tophus
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Page 19
ICD-10-CM: Similarities to ICD-9-CM
•
Divided into Alphabetic Index and Tabular List
• Structure and format are the same
• Index is alphabetical list of terms and their corresponding codes
• Alphabetic Index lists main terms in alphabetical order with indented
subterms under main terms
• Index is divided into sections:
•
•
•
•
Index to Diseases and Injuries
Table of Neoplasms
Table of Drugs and Chemicals
External Cause of Injuries Index
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Page 20
ICD-10-CM: Similarities to ICD-9-CM
•
Divided into Alphabetic Index and Tabular List
•
•
•
•
•
Tabular List is a chronological list of codes divided into chapters based on body
system or condition
Tabular List is presented in code letter/number order
Same hierarchical structure
Codes are invalid if they are missing an applicable character
Chapters in Tabular structured similarly to ICD-9-CM, with minor exceptions
• A few chapters have been restructured
• Sense organs (eye and ear) separated from Nervous System chapter and moved to
their own chapters
•
Codes are looked up the same way
• Look up diagnostic terms in Alphabetic Index
• Then verify code number in Tabular List
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Page 21
ICD-10-CM: Similarities to ICD-9-CM
•
•
Many conventions have same meaning
• Abbreviations, punctuation, symbols, notes such as “code first” and “use
additional code”
Nonspecific codes (“unspecified” or “not otherwise specified”) are
available to use when detailed documentation to support more
specific code is not available
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Page 22
ICD-10-CM: Similarities to ICD-9-CM
•
ICD-10-CM Official Guidelines for Coding and Reporting accompany
and complement ICD-10-CM conventions and instructions
• Website for ICD-10-CM guidelines 2014
• http://www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf
•
• Adherence to the official coding guidelines in all healthcare
settings is required under the Health Insurance Portability
and Accountability Act
AHA is publishing information in Coding Clinic for ICD-10-CM/PCS
• Began Fourth Quarter 2012
• Will become exclusively ICD-10-CM/PCS First Quarter 2014
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Page 23
ICD-10-CM: Differences from ICD-9-CM
•
•
•
•
Codes are alphanumeric
• 1st character is always alpha
• characters 2-7 are alphanumeric
Codes can be up to 7 characters in length
Codes are more specific
Code titles are more complete (no need to refer back to a category,
subcategory, or subclassification level to determine complete
meaning of code)
• Example: I12.0 Hypertensive chronic kidney disease with stage 5
chronic kidney disease or end stage renal disease
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Page 24
ICD-10-CM: Differences from ICD-9-CM
•
•
•
•
Laterality (side of the body affected) has been added to relevant
codes
Expanded use of combination codes
• Certain conditions and associated common symptoms or manifestations
• Poisonings and associated external cause
Injuries grouped by anatomical site rather than type of injury
Codes reflect modern medicine and updated medical terminology
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Page 25
New Features
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ICD-10-CM New Features
•
Combination codes for conditions and common symptoms or
manifestation
• Combination Codes –Examples
• I25.110 Atherosclerotic heart disease of native coronary artery with unstable
angina pectoris
• K71.51 Toxic liver disease with chronic active hepatitis with ascites
• K50.012 Crohn’s disease of small intestine with intestinal obstruction
• N41.01 Acute prostatitis with hematuria
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Page 27
Code Comparison – Diagnosis Combination Codes
Diagnosis: Diabetic retinopathy
• ICD-9-CM
•
• 250.50 Diabetes with ophthalmic
manifestations, type II or unspecified
type, not stated as uncontrolled
• 362.01 Background diabetic retinopathy
ICD-10-CM
• E11.319 Type 2 diabetes mellitus with
unspecified diabetic retinopathy without
macular edema
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Page 28
Breakdown of the ICD-10-CM Code
E
1
CategoryType 2 Diabetes
Mellitus
3-7 Characters
3
1
1
9
Etiology, Anatomic Site,
SeverityWith unspecified diabetic
retinopathy without
macular edema
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7th CharacterNo 7th
Character
Page 29
ICD-10-CM New Features
•
•
Combination codes for
poisonings and external causes
• T42.5x5A
Adverse effect of
mixed antiepileptics, initial
encounter
Added laterality
• S80.251A
Superficial
foreign body, right knee, initial
encounter
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Page 30
ICD-10-CM New Features
ICD-10-CM Injury Changes
ICD-9-CM
Fractures
(800-829)
Dislocations
(830-839)
Sprains and
strains
(840-848)
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ICD-10-CM
Injuries to
the head
(S00-S09)
Injuries to
the neck
(S10-S19)
Injuries to
the thorax
(S20-S29)
Page 31
ICD-10-CM New Features: Injuries
ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b
• When coding injuries, assign separate codes for each injury unless a combination code
is provided, in which case the combination code is assigned.
• Code T07, Unspecified multiple injuries should not be assigned in the inpatient setting
unless information for a more specific code is not available.
• Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical
wounds or to identify complications of surgical wounds.
• The code for the most serious injury, as determined by the provider and the focus of
treatment, is sequenced first.
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Page 32
ICD-10-CM New Features: Injuries
ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b, 1
• Superficial injuries such as abrasions or contusions are not coded when associated with
more severe injuries of the same site.
ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b, 2
• When a primary injury results in minor damage to peripheral nerves or blood vessels,
the primary injury is sequenced first with additional code(s) for injuries to nerves and
spinal cord (such as category S04), and/or injury to blood vessels (such as category
S15).
• When the primary injury is to the blood vessels or nerves, that injury should be
sequenced first.
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Page 33
ICD-10-CM New Features: Traumatic Fractures
ICD-10-CM Official Guidelines for Coding and
Reporting 2014 - I, 19, c
• The principles of multiple coding of injuries should be
followed in coding fractures.
• A fracture not indicated as open or closed should be
coded to closed.
• A fracture not indicated whether displaced or not
displaced should be coded to displaced.
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Page 34
ICD-10-CM New Features: Traumatic Fractures
ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, c, 1
• Traumatic fractures are coded using the appropriate 7th character for initial encounter
(A, B, C) while the patient is receiving active treatment for the fracture.
• Examples of active treatment are: surgical treatment, emergency department encounter,
and evaluation and treatment by a new physician.
• The appropriate 7th character for initial encounter should also be assigned for a patient
who delayed seeking treatment for the fracture or nonunion.
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Page 35
ICD-10-CM New Features: Burns and Corrosions
ICD-10-CM Official Guidelines for Coding and Reporting
2014 - I, 19, d
• The ICD-10-CM makes a distinction between burns and
corrosions.
• The burn codes are for thermal burns, except sunburns,
that come from a heat source, such as a fire or hot
appliance.
• The burn codes are also for burns resulting from electricity
and radiation.
• Corrosions are burns due to chemicals.
• The guidelines are the same for burns and corrosions.
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Page 36
ICD-10-CM New Features: Burns and Corrosions
ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, d, 1
• Sequence first the code that reflects the highest degree of burn when more than one
burn is present.
•
•
•
a. When the reason for the admission or encounter is for treatment of external multiple burns,
sequence first the code that reflects the burn of the highest degree.
b. When a patient has both internal and external burns, the circumstances of admission govern
the selection of the principal diagnosis or first-listed diagnosis.
c. When a patient is admitted for burn injuries and other related conditions such as smoke
inhalation and/or respiratory failure, the circumstances of admission govern the selection of the
principal or first-listed diagnosis.
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Page 37
ICD-10-CM New Features: Placeholder “x”
•
Character “x” is used as a 5th character
placeholder in certain 6 character codes to
allow for future expansion and to fill in other
empty characters (e.g., character 5 and/or 6)
when a code that is less than 6 characters in
length requires a 7th character. When
placeholder character applies, it must be used
in order for the code to be considered valid
• Examples:
• T50.2x41A - Poisoning by carbonic-anhydrase
inhibitors, benzothiadiazides and other diuretics,
accidental (unintentional), initial encounter
• T16.2xxA – Foreign body in left ear, initial
encounter.
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Page 38
ICD-10-CM New Features: 7th Character
•
The 7th character in ICD-10-CM is used in several chapters (e.g., the
Obstetrics, Injury, Musculoskeletal, and External Cause chapters).
• It has a different meaning depending on the section where it is being used
• Injury and External Cause sections, the 7th character classifies an initial
encounter, subsequent encounter, or sequelae (late effect)
• Obstetrics the 7th character is used to identify the fetus to which the code
applies (used for single and multiple gestations)
• Must always be used in the 7th character position
• If a code has an applicable 7th character, the code must be reported with
an appropriate 7th character value in order to be valid
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Page 39
ICD-10-CM New Features: 7th Character “A”
•
Injury and External Cause sections, the 7th character classifies an
initial encounter, subsequent encounter, or sequelae (late effect)
• Seventh character “A” initial encounter is used while the patient is
receiving active treatment for the condition.
• Examples of active treatment are: surgical treatment, emergency
department encounter, and evaluation and treatment by a new physician.
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Page 40
ICD-10-CM New Features: 7th Character “D”
•
Injury and External Cause sections, the 7th character classifies an
initial encounter, subsequent encounter, or sequelae (late effect)
• Seventh character “D” subsequent encounter is used for encounters after
the patient has received active treatment of the condition and is receiving
routine care for the condition during the healing or recovery phase.
• Examples of subsequent care are: cast change or removal, removal of
external or internal fixation device, medication adjustment, other aftercare
and follow up visits following treatment of the injury or condition.
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Page 41
ICD-10-CM New Features: 7th Character “S”
•
Injury and External Cause sections, the 7th character classifies an
initial encounter, subsequent encounter, or sequelae (late effect)
• Seventh character “S” sequela, is for use for complications or conditions
that arise as a direct result of a condition, such as scar formation after a
burn. The scars are sequelae of the burn.
• When using 7th character “S”, it is necessary to use both the injury code that
precipitated the sequela and the code for the sequela itself.
• The “S” is added only to the injury code, not the sequela code.
• The 7th character “S” identifies the injury responsible for the sequela.
• The specific type of sequela (e.g. scar) is sequenced first, followed by the
injury code.
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Page 42
ICD-10-CM New Features: Excludes Notes
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). Or,
restated• Means NOT CODED HERE
• Code being excluded is never used with code
• The two conditions cannot occur together
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Excludes1
Page 43
ICD-10-CM New Features: Excludes Notes
Excludes 1, Examples:
• Q03 – Congenital hydrocephalus
Excludes 1: Acquired hydrocephalus (G91.-)
• M21 - Other acquired deformities of limbs
Excludes1: acquired absence of limb (Z89.-)
congenital absence of limbs (Q71-Q73)
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Page 44
ICD-10-CM New Features: Excludes Notes
Excludes 1, Examples:
• E10 - Type 1 Diabetes mellitus
Excludes1: diabetes mellitus due to underlying condition (E08.-)
drug or chemical induced diabetes mellitus (E09.-)
gestational diabetes (O24.4-)
hyperglycemia NOS (R73.9)
neonatal diabetes mellitus (P70.2)
type 2 diabetes mellitus (E11.-)
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Page 45
ICD-10-CM New Features: Excludes Notes
•
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). Or, restated• Means NOT INCLUDED HERE
• Excluded condition is not part of the
condition represented by the code
• Acceptable to use both codes together if
patient has both conditions
Excludes2
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Page 46
ICD-10-CM New Features: Excludes Notes
Excludes 2, Examples:
• L27.2 – Dermatitis due to ingested food.
Excludes 2: Dermatitis due to food in contact with skin (L23.6, L24.6,
L25.4).
• L89 - Pressure ulcer
Excludes2: diabetic ulcers (E08.621, E08.622, E09.621, E09.622,
E10.621, E10.622, E11.621, E11.622, E13.621, E13.622)
non-pressure chronic ulcer of skin (L97.-)
skin infections (L00-L08)
varicose ulcer (I83.0, I83.2)
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Page 47
External Cause of
Morbidity
What we formerly knew as “E-codes”
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Page 48
External Cause of Morbidity
•
•
•
External cause of morbidity codes (categories V01-Y99) are reported with
injury codes.
External cause codes capture:
•
•
•
•
Cause (how an injury occurred)
Intent (accidental or intentional, e.g., suicide or assault)
Person’s status (e.g., civilian, military, etc.)
Place where the injury occurred
Activity codes (category Y93) describe the activity of a person seeking care for
injuries and health conditions:
•
•
When the injury or other health condition resulted from the activity; or
When the activity contributed to the injury or health condition. .
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Page 49
External Cause of Morbidity
•
•
Codes for poisoning, adverse effect, and underdosing
(categories T36-T50) and for toxic effects of substances chiefly
nonmedicinal as to source (categories T51-T65) include
information on the cause and intent.
•
No external cause code from chapter 20 is needed for these codes.
Examples: (Drug is Acetaminophen)
T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental
(unintentional), initial encounter
T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional selfharm, initial encounter
T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial
encounter
T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial
encounter
T39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounter
T39.1X6A Underdosing of 4-Aminophenol derivatives, initial encounter
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Page 50
External Cause of Morbidity: Categories of External Cause Codes
•
Major categories of External cause codes include:
•
•
•
•
•
•
V00-V99
W00-X58
X71-X83
X92-Y09
Y21-Y33
Y35-Y38
•
Y62-Y84
•
Y90-Y99
Transport accidents
Other external causes of accidental injury
Intentional self-harm
Assault
Event of undetermined intent
Legal intervention, operations of war,
military operations, and terrorism
Complications of medical and
surgical care
Supplementary factors related to causes
of morbidity classified elsewhere
Mayhem!
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Page 51
External Cause of Morbidity: External Cause Status
•
External cause status codes (category Y99) describe
work status of individual when the injury or health
condition occurred during:
•
•
•
Military activity.
Non-military person at work.
Student or volunteer involved in non-work activity.
•
•
•
Includes activities done as a hobby, for leisure and
recreation, and volunteer activity and activity of off-duty
military personnel.
Status External cause codes are not applicable to
poisonings, adverse effects, misadventures, or late
effects.
Do not assign code Y99.9, Unspecified external
cause status, if the status is not stated.
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External cause status military activity Y99.1
Page 52
External Cause of Morbidity: Activity Codes
•
Category Y93 captures:
•
•
Activity codes are used only once, at the
initial encounter for treatment.
•
•
•
Activity of the person at the time the
injury or other health condition occurred.
Only one code from Y93 should be
recorded on a record.
These codes are not applicable to
poisonings, adverse effects,
misadventures, or sequela.
Coders should not assign code Y93.9,
Activity, unspecified, if the activity is not
stated.
Activity - mountain climbing Y93.31
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Page 53
External Cause Code Sequencing Hierarchy
•
Follow the sequencing hierarchy for External cause codes:
•
•
•
External cause codes for child and adult abuse take precedence over all other
External cause codes.
External cause codes for terrorism events take priority over all other External cause
codes except child and adult abuse.
External cause codes for cataclysmic events take priority over all External cause
codes except those for child and adult abuse and terrorism.
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Page 54
External Cause Code Sequencing Hierarchy
•
Follow the sequencing hierarchy for External cause codes (cont.):
•
•
•
•
•
Transport accidents take priority over all other External cause codes except those for
cataclysmic events, child and adult abuse, and terrorism.
Assign External cause codes for activity and external cause status following all causal (intent)
External cause codes.
First-listed External cause code should correspond to the cause of the most serious diagnosis
due to an assault, accident, or self-harm, following the order of hierarchy above.
A transport accident (V00-V99) is one in which the vehicle involved must be moving or
running or in use for transport purposes at the time of the accident.
A note at the beginning of the section defines the type of transportation vehicles
included.
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Page 55
Agricultural Equipment
•
Accidents caused by agricultural
equipment are classified as transport
accidents:
•
•
If the equipment involved was a transport
vehicle, when the accident occurred.
Otherwise classified in categories W30 or
W31, with a fourth character indicating
the specific type of equipment.
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Page 56
External Cause of Injury Classified by Intent
•
•
Separate External cause codes classify
cause of injuries due to accident, selfharm, or assault.
Code the intent as accidental when the
intent is unknown or unspecified.
•
•
All transport accident categories (V00V99) assume accidental intent.
The External cause code for
undetermined intent should only be
assigned if documentation specifies that
the intent cannot be determined.
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Page 57
Terrorism
•
•
•
•
•
Report category Y38, Terrorism, to describe
injuries and illnesses due to terrorism.
Codes Y38.0–Y38.9 follow the definition of
terrorism established by the U.S. Federal
Bureau of Investigation (FBI).
Do not classify a death or an injury as terroristrelated unless the incident is designated as
terrorism by the federal government.
Multiple Y38 codes may be assigned if the injury
is the result of more than one mechanism of
terrorism (e.g., destruction of aircraft and
firearm).
Assign also a code from category Y92 to identify
the place of occurrence.
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Page 58
Place of Occurrence
•
•
•
•
•
•
Assign category Y92, Place of occurrence of the external cause, for the place where an
external event occurred.
A place of occurrence code is used only once, at the initial encounter for treatment.
No seventh character values are used with category Y92.
Only one Y92 code is assigned on a record.
Do not assign Y92.9 if place unknown.
Codes from category Y92 refer only to the location, not the activity of the injured patient.
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Page 59
Child and Adult Abuse
•
•
•
Codes for child and adult abuse facilitate the gathering of specific data.
•
Adult abuse is underreported and underdiagnosed.
Report child and adult abuse codes only if the physician documents the
abuse.
Coders should not interpret narrative descriptions as abuse without physician
confirmation.
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Page 60
Child and Adult Abuse
•
ICD-10-CM provides two categories for reporting adult and child abuse,
neglect, or maltreatment:
•
•
Confirmed (category T74)
Suspected (category T76)
• The fourth character for categories T74 and T76 indicates the type of abuse:
•
•
•
•
•
•
Neglect or abandonment
Physical abuse
Sexual abuse
Emotional abuse
Unspecified maltreatment
• The fifth character specifies whether child or adult abuse.
The exception is code T74.4, Shaken infant syndrome: this code defaults to
confirmed abuse.
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Page 61
Child and Adult Abuse
•
ICD-10-CM does not specify the age limit for assignment of child abuse versus adult
abuse codes.
•
Depends on the age of majority, which varies among the states.
•
•
•
When abuse results in physical injuries or other conditions:
•
•
•
If the patient has reached the age of majority per state guidelines, it would be appropriate to assign the
adult abuse codes.
If this information is not documented, the coder should query the provider.
•
Sequence the abuse code first (categories T74 or T76).
Assign additional codes for associated injuries or mental health conditions documented by the
physician.
Assign an External cause code for perpetrator, if known (Y07.-).
Confirmed adult and child abuse, neglect, and maltreatment is classified as assault.
•
Assign code X92-Y09 to indicate the external cause of physical injuries resulting from the
confirmed abuse.
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Page 62
Child and Adult Abuse
•
•
•
Do not report External cause or perpetrator codes for suspected cases of abuse or
neglect.
If suspected abuse, neglect, or mistreatment is ruled out, code Z04.71 or Z04.72 is
assigned.
If suspected rape or sexual abuse is ruled out, code Z04.41 or Z04.42 is assigned.
•
No code from category T76 is used for these encounters.
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Page 63
Let’s code!
ICD-10-CM Practice
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Page 64
ICD-10-CM Coding Exercises
1. Closed traumatic fracture of shaft of left
tibia and fibula, initial encounter.
ICD-9-CM
823.22, Fracture of tibia and
fibula, shaft, closed
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Page 65
ICD-10-CM Coding Exercises
ICD-10-CM Index
Fracture, traumatic
- fibula (shaft) (styloid) S82.40Fracture, traumatic
- tibia (shaft) S82.20-
ICD-10-CM Tabular
S82.2 Fracture of shaft of tibia
S82.20 Unspecified fracture of shaft of
tibia
Fracture of tibia NOS
S82.202 Unspecified fracture of shaft of
left tibia
S82.4 Fracture of shaft of fibula
Excludes2 fracture of lateral malleolus
alone (S82.6-)
S82.40 Unspecified fracture of shaft of
fibula
S82.402 Unspecified fracture of shaft of
left fibula
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Page 66
ICD-10-CM Coding Exercises
S82 Fracture of lower leg, including ankle
Note: A fracture not indicated as displaced
or nondisplaced should be coded to
displaced
A fracture not indicated as open or closed
should be coded to closed
The open fracture designations are based on
the Gustilo open fracture classification
Includes: fracture of malleolus
Excludes1: traumatic amputation of lower
leg (S88.-)
Excludes2: fracture of foot, except ankle
(S92.-)
periprosthetic fracture of prosthetic
implant of knee (T84.042, T84.043)
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The appropriate 7th character is to be added to all codes from category S82
A - initial encounter for closed fracture
B - initial encounter for open fracture type I or II
initial encounter for open fracture NOS
C - initial encounter for open fracture type IIIA, IIIB, or IIIC
D - subsequent encounter for closed fracture with routine healing
E - subsequent encounter for open fracture type I or II with routine healing
F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine
healing
G - subsequent encounter for closed fracture with delayed healing
H - subsequent encounter for open fracture type I or II with delayed healing
J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed
healing
K - subsequent encounter for closed fracture with nonunion
M - subsequent encounter for open fracture type I or II with nonunion
N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
nonunion
P - subsequent encounter for closed fracture with malunion
Q - subsequent encounter for open fracture type I or II with malunion
R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
malunion
S - sequela
Page 67
ICD-10-CM Coding Exercises
1. Closed traumatic fracture of shaft of left
tibia and fibula, initial encounter.
S82.202A Unspecified fracture of shaft of left
tibia, initial encounter
S82.402A Unspecified fracture of shaft of left
fibula, initial encounter
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Page 68
ICD-10-CM Coding Exercises
2. Patient in car crash, brought to the
hospital with a ruptured spleen
and major contusion to the left
kidney. (Diagnosis codes only.)
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Page 69
ICD-10-CM Coding Exercises
ICD-10-CM Index
Rupture, ruptured
- spleen (traumatic) S36.09
- - birth injury P15.1
- - congenital (birth injury) P15.1
- - due to P. vivax malaria B51.0
- - nontraumatic D73.5
- - spontaneous D73.5
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ICD-10-CM Tabular
The appropriate 7th character is to be added to
each code from category S36
A - initial encounter
D - subsequent encounter
S - sequela
S36.0 Injury of spleen
S36.09 Other injury of spleen
Page 70
ICD-10-CM Coding Exercises
ICD-10-CM Index
Contusion (skin surface intact) T14.8
- kidney S37.01- - major (greater than 2 cm) S37.02- - minor (less than 2 cm) S37.01-
ICD-10-CM Tabular
The appropriate 7th character is to be added to
each code from category S37
A - initial encounter
D - subsequent encounter
S – sequela
S37.0 Injury of kidney
Excludes2: acute kidney injury
(nontraumatic) (N17.9)
S37.02 Major contusion of kidney
Contusion of kidney greater than 2 cm
S37.021 Major contusion of right kidney
S37.022 Major contusion of left kidney
S37.029 Major contusion of unspecified
kidney
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Page 71
ICD-10-CM Coding Exercises
2. Patient in car crash, brought to the
hospital with a ruptured spleen
and major contusion to the left
kidney.
S36.09xA Other injury of spleen, initial
encounter
S37.022A Major contusion of left kidney,
initial encounter
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Page 72
ICD-10-CM Coding Exercises
3. Two-year-old patient ingested
an unknown quantity of
mother’s Enovid (birth control
pills.)
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Page 73
ICD-10-CM Coding Exercises
ICD-10-CM TABLE of DRUGS and CHEMICALS
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Page 74
ICD-10-CM Coding Exercises
ICD-10-CM Tabular
The appropriate 7th character is to be added to each code from category T38
A - initial encounter
D - subsequent encounter
S – sequela
T38 Poisoning by, adverse effect of and underdosing of hormones and their synthetic
substitutes and antagonists, not elsewhere classified
T38.4 Poisoning by, adverse effect of and underdosing of oral contraceptives
Poisoning by, adverse effect of and underdosing of multiple- and single-ingredient oral contraceptive preparations
T38.4X Poisoning by, adverse effect of and underdosing of oral contraceptives
T38.4X1 Poisoning by oral contraceptives, accidental (unintentional)
Poisoning by oral contraceptives NOS
T38.4X2 Poisoning by oral contraceptives, intentional self-harm
T38.4X3 Poisoning by oral contraceptives, assault
T38.4X4 Poisoning by oral contraceptives, undetermined
T38.4X5 Adverse effect of oral contraceptives
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Page 75
ICD-10-CM Coding Exercises
3. Two-year-old patient ingested
an unknown quantity of
mother’s Enovid (birth control
pills.)
T38.4X1A Poisoning by oral
contraceptives, accidental
(unintentional), initial encounter
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Page 76
ICD-10-CM Coding Exercises
4. A woman was taking a walk along a rural
road for exercise where she was struck
from behind by a car. The patient
suffered an open fracture of the right hip
and a closed fracture of the ulna, left
arm. The patient had an open reduction
with internal fixation of the right hip. The
left arm fracture was reduced and fitted
with a cast. The patient was discharged
in good condition. (Code the External
Causes of Injuries codes only)
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Page 77
ICD-10-CM Coding Exercises: External Cause of Morbidity
ICD-10-CM External Cause of Injuries Index
Accident (to)
- transport
- - pedestrian
- - - on foot —see also Accident, pedestrian
- - - - collision (with)
- - - - - car V03.90
- - - - - - nontraffic V03.00
- - - - - - traffic V03.10
ICD-10-CM Tabular
The appropriate 7th character is to be added to
each code from category V03
A - initial encounter
D - subsequent encounter
S – sequela
V03.1 Pedestrian injured in collision with
car, pick-up truck or van in traffic accident
V03.10 Pedestrian on foot injured in collision
with car, pick-up truck or van in traffic
accident
Pedestrian NOS injured in collision with car, pick-up
truck or van in traffic accident
V03.11 Pedestrian on roller-skates injured in
collision with car, pick-up truck or van in
traffic accident
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Page 78
ICD-10-CM Coding Exercises: Place of Occurrence
ICD-10-CM External Cause of Injuries Index
Place of occurrence
- river Y92.828
- road Y92.488
- rodeo ring Y92.39
- rugby field Y92.328
ICD-10-CM Tabular
Y92.4 Street , highway and other paved
roadways as the place of occurrence of
the external cause
Excludes1: private driveway of residence
(Y92.014, Y92.024, Y92.043, Y92.093,
Y92.113, Y92.123, Y92.154,Y92.194)
Y92.48 Other paved roadways as the place
of occurrence of the external cause
Y92.480 Sidewalk as the place of occurrence
of the external cause
Y92.481 Parking lot as the place of
occurrence of the external cause
Y92.482 Bike path as the place of occurrence
of the external cause
Y92.488 Other paved roadways as the place
of occurrence of the external cause
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Page 79
ICD-10-CM Coding Exercises: Activity Codes
ICD-10-CM External Cause of Injuries Index
ICD-10-CM Tabular
Activity (involving) (of victim at time of
event)
- wake boarding Y93.17
- walking an animal Y93.K1
- walking (on level or elevated terrain) Y93.01
- - an animal Y93.K1
- wall climbing Y93.31
Y93.0 Activities involving walking and
running
Excludes1: activity, walking an animal
(Y93.K1)
activity, walking or running on a treadmill
(Y93.A1)
Y93.01 Activity, walking, marching and
hiking
Activity, walking, marching and hiking on
level or elevated terrain
Excludes1:activity, mountain climbing
(Y93.31)
Y93.02 Activity, running
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Page 80
ICD-10-CM Coding Exercises: External Cause Status
ICD-10-CM External Cause of Injuries Index
Status of external cause
- leisure activity Y99.8
- military activity Y99.1
- off-duty activity of military personnel Y99.8
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ICD-10-CM Tabular
Y99 External cause status
Note: A single code from category Y99 should be used in
conjunction with the external cause code(s) assigned to a record
to indicate the status of the person at the time the event occurred.
Y99.8 Other external cause status
Activity NEC
Activity of child or other family member assisting in
compensated work of other family member
Hobby not done for income
Leisure activity
Off-duty activity of military personnel
Recreation or sport not for income or while a student
Student activity
Excludes1:civilian activity done for income or
compensation (Y99.0)
military activity (Y99.1)
Page 81
ICD-10-CM Coding Exercises
4. A woman was taking a walk along a rural road for
exercise where she was struck from behind by a car.
The patient suffered an open fracture of the right hip
and a closed fracture of the ulna, left arm. The
patient had an open reduction with internal fixation
of the right hip. The left arm fracture was reduced
and fitted with a cast. The patient was discharged in
good condition. (Code the External Causes of
Injuries codes only)
V03.10xA Pedestrian on foot injured in collision with car, pick-up truck or
van in traffic accident, initial encounter
Y92.488 Other paved roadways as the place of occurrence of the external
cause
Y93.01 Activity, walking, marching and hiking
Y99.8 Other external cause status
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Page 82
ICD-10-PCS
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Page 83
Benefits of ICD-10-PCS
•
•
•
Completeness
• Unique codes for every procedure
Expandability
• Easy to incorporate new technology
Multi-axial codes
• Allows for more specificity in data retrieval by each component –
examples
• All endoscopies or biopsies
• Certain approaches
• Open
• Laparoscopic
• Everything done to one body system
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Page 84
Benefits of ICD-10-PCS
•
•
•
•
•
Standardized terminology
• ICD-10-PCS should not include multiple meanings for the same term
• Each term must be assigned a specific meaning
• There are no eponyms or common procedure terms
Diagnostic information is not included in the procedure description
Not Otherwise Specified (NOS) options are restricted
Limited use of Not Elsewhere Classified (NEC) option
Level of specificity
• All procedures currently performed can be specified in ICD-10-PCS.
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Page 85
ICD-10-PCS Challenges
•
•
Terminology
Definitions
ICD-10-PCS Official Guidelines for Coding and Reporting 2014
A11
• Many of the terms used to construct PCS codes are defined within the system. It is
the coder’s responsibility to determine what the documentation in the medical record
equates to in the PCS definitions. The physician is not expected to use the terms
used in PCS code descriptions, nor is the coder required to query the physician when
the correlation between the documentation and the defined PCS terms is clear.
• Example: When the physician documents “partial resection” the coder can
independently correlate “partial resection” to the root operation Excision without
querying the physician for clarification.
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Page 86
ICD-10-PCS
ICD-10-PCS Structure-Format
Medical and Surgical
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Page 87
Structural Differences between ICD-9-CM and ICD-10-PCS Procedures
ICD-9-CM
• ICD-9-CM has 3-4
characters
• All 4 characters are
numeric
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ICD-10-PCS
• ICD-10-PCS has 7
characters
• Each can be either alpha
or numeric
• Numbers 0-9 are used
• Letters O and I are not
used to avoid confusion
with 0 and 1
Page 88
ICD-10-PCS Structure-Format: Medical and Surgical
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body
Part
Approach
Device
Qualifier
Every unique procedure code “tells a story”
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Page 89
ICD-10-PCS
•
Table driven
• There is an index which leads you to the first 3 or 4 characters of the
code
• Once you have the code basis you go to the table for the appropriate
section to complete the code
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Page 90
ICD-10-PCS Tables (Medical and Surgical Section Example)
Column
Column
Column
Column
4
5
6
7
Body Part
Approach
Device
Qualifier
Row
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ICD-10-PCS codes are found by
finding the first 3 to 7 characters
in the Index, then referring to a
table in the Tabular. The first
three characters appear at the
top of the table. Choices for the
next four characters are made
from the table.
Page 91
Character 1: Section
•
•
The first character always refers to the Section
• Within each section characters 2-7 have a standardized
meaning,
• OR, restated…
• Different sections may have different meanings for
characters 2-7, but they will be consistent within their
section
1
Section
There are 16 sections.
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Page 92
Character 1: Section
•
•
•
•
•
•
•
•
0
1
2
3
4
5
6
7
Medical and Surgical
Obstetrics
Placement
Administration
Measurement and
Monitoring
Extracorporeal Assistance
and Performance
Extracorporeal Therapies
Osteopathic
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•
•
•
•
•
•
8
9
B
C
D
F
•
•
G
H
Other Procedures
Chiropractic
Imaging
Nuclear Medicine
Radiation Therapy
Physical Rehabilitation
and Diagnostic Audiology
Mental Health
Substance Abuse
Treatment
Page 93
Character 2: Body System
•
The second character indicates the general body
system
•
•
There are 31 body systems
Some “traditional” body systems have been assigned
to multiple categories
• Examples
•
•
•
•
Upper bones
Lower bones
Upper arteries
Lower arteries
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2
Body
System
Page 94
Character 2: Body System
•
•
0
1
•
•
•
•
•
•
2
3
4
5
6
7
•
8
Central Nervous System
Peripheral Nervous
System
Heart and Great Vessels
Upper Arteries
Lower Arteries
Upper Veins
Lower Veins
Lymphatic and Hemic
System
Eye
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•
•
•
•
•
9
B
C
D
F
•
•
•
G
H
J
Ear, Nose, Sinus
Respiratory System
Mouth and Throat
Gastrointestinal System
Hepatobiliary System and
Pancreas
Endocrine System
Skin and Breast
Subcutaneous Tissue and
Fascia
Page 95
Character 2: Body System, cont.
•
•
•
•
•
•
•
•
K
L
M
N
P
Q
R
Muscles
Tendons
Bursae and Ligaments
Head and Facial
Bones
Upper Bones
Lower Bones
Upper Joints
S
Lower Joints
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•
•
T
U
•
V
•
W
•
X
•
Y
Urinary System
Female Reproductive
System
Male Reproductive
System
Anatomical Regions,
General
Anatomical Regions,
Upper Extremities
Anatomical Regions,
Lower Extremities
Page 96
Character 3: Root Operations
•
The third character indicates the root operation
• Specifies the objective of the procedure
• There are 31 Root Operations in the Medical
Surgical Section
• Each is specifically defined
• Mastering the definitions and understanding their
specificity is the greatest challenge of I-10 procedural
coding
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3
Root
Operation
Page 97
Character 3: Root Operations
•
Root Operation Principles
• A root operation is coded according to the objective of the procedure
actually performed
• Composite terms are not root operations
• Combination procedures are coded separately
• The complete or partial redo of a procedure is coded to the root operation
performed rather than “Revision”
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Page 98
Character 3: Root Operations, cont.
•
•
•
•
•
•
•
•
•
•
Alteration
Bypass
Change
Control
Creation
Destruction
Detachment
Dilation
Division
Drainage
•
•
•
•
•
•
•
•
•
•
•
Excision
Extirpation
Extraction
Fragmentation
Fusion
Insertion
Inspection
Map
Occlusion
Reattachment
Release
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•
•
•
•
•
•
•
•
•
•
Removal
Repair
Replacement
Reposition
Resection
Restriction
Revision
Supplement
Transfer
Transplantation
Page 99
Character 3: Root Operations
•
•
•
•
•
•
•
•
Alteration
Bypass
Change
Control
Creation
Destruction
Detachment
Dilation
Modifying the anatomic structure of a body part without
affecting the function of the body part
Altering the route of passage of the contents of a tubular
body part
Taking out or off a device from a body part and putting
back an identical or similar device in or on the same body
part without cutting or puncturing the skin or a mucous
membrane
Stopping, or attempting to stop, postprocedural bleeding
Making a new genital structure that does not take over the
function of a body part
Physical eradication of all or a portion of a body part by the
direct use of energy, force or a destructive agent
Cutting off all or part of the upper or lower extremities
Expanding an orifice or the lumen of a tubular body part
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Page 100
Character 3: Root Operations, cont.
•
•
•
•
•
•
•
•
Division
Cutting into a body part without draining fluids and/or
gases from the body part in order to separate or transect a
body part
Drainage
Taking or letting out fluids and/or gases from a body part
Excision
Cutting out or off, without replacement, a portion of a body
part
Extirpation
Taking or cutting out solid matter from a body part
Extraction
Pulling or stripping out or off all or a portion of a body part
by the use of force
Fragmentation
Breaking solid matter in a body part into pieces
Fusion
Joining together portions of an articular body part
rendering the articular body part immobile
Insertion
Putting in a non-biological appliance that monitors, assists,
performs or prevents a physiological function but does not
physically take the place of a body part
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Page 101
Character 3: Root Operations, cont.
•
•
•
•
•
•
•
•
Inspection
Map
Visually and/or manually exploring a body part
Locating the route of passage of electrical impulses and/or
locating functional areas in a body part
Occlusion
Completely closing an orifice or the lumen of a tubular body
part
Reattachment Putting back in or on all or a portion of a separated
body part to its normal location or other suitable location
Release
Freeing a body part from an abnormal physical constraint by
cutting or by use of force
Removal
Taking out or off a device from a body part
Repair
Restoring, to the extent possible, a body part to its normal
anatomic structure and function
Replacement Putting in or on biological or synthetic material that
physically takes the place of all or a portion of a body part
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Page 102
Character 3: Root Operations, cont.
•
•
•
•
•
•
•
Reposition
Moving to its normal location or other suitable location all
or a portion of a body part
Resection
Cutting out or off, without replacement, all of a body part
Restriction
Partially closing an orifice or the lumen of a tubular body
part
Revision
Correcting, to the extent possible, a malfunctioning or
displaced device
Supplement Putting in or on biological or synthetic material that
physically reinforces and/or augments the function of a
body part
Transfer
Moving, without taking out, all or a portion of a body part
to another location to take over the function of all or a
portion of a body part
Transplantation
Putting in or on all or a portion of a living body
part taken from another individual or animal to physically
take the place and/or function of all or a portion of a
similar body part
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Page 103
Character 4: Body Part
•
The body part indicates the specific part of the
body system on which the procedure was
performed (e.g., if the Body System, character
2, was Gastrointestinal then the Body Part,
character 4, could be duodenum).
• Tubular body parts are defined in ICD-10-PCS
as those hollow body parts that provide a route
of passage for solids, liquids, or gases. They
include the cardiovascular system, and body
parts such as those contained in the
gastrointestinal tract, genitourinary tract, biliary
tract, and respiratory tract.
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4
Body
Part
Page 104
Character 5: Approach
•
•
•
•
•
The fifth character is the technique used to reach the site of
the procedure
Open
•
Cutting through the skin or mucous membrane and any other
body layers necessary to expose the site of the procedure
5
Percutaneous
•
Entry, by puncture or minor incision, of instrumentation through
the skin or mucous membrane and/or any other body layers
necessary to reach the site of the procedure
Approach
Percutaneous Endoscopic
•
Entry, by puncture or minor incision, of instrumentation through
the skin or mucous membrane and/or any other body layers
necessary to reach and visualize the site of the procedure
Via Natural or Artificial Opening
•
Entry of instrumentation through a natural or artificial external
opening to reach the site of the procedure
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Page 105
Character 5: Approach, cont
•
Via Natural or Artificial Opening Endoscopic
•
•
Via Natural or Artificial Opening Endoscopic with Percutaneous
Endoscopic Assistance
•
•
Entry of instrumentation through a natural or artificial external opening to reach
and visualize the site of the procedure
Entry of instrumentation through a natural or artificial external opening to reach
and visualize the site of the procedure, and entry, by puncture or minor incision,
of instrumentation through the skin or mucous membrane and any other body
layers necessary to aid in the performance of the procedure
External
•
Procedures performed directly on the skin or mucous membrane and procedures
performed indirectly by the application of external force through the skin or
mucous membrane
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Page 106
Character 6: Device
•
The device character is only used to specify devices
that remain after the procedure is completed.
• Does not include materials incidental to a procedure, such
as sutures
• There are four basic groups:
•
•
•
•
Grafts and Prostheses
Implants
Simple or Mechanicals Appliances
Electronic Appliances
6
Device
• When no device is used, character “Z”, representing
“none,” is used as the sixth character
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Page 107
Character 6: Device, cont.
• Examples of devices:
• Biological or synthetic material that takes the
place of all or a portion of a body part (e.g,
skin graft, joint prosthesis).
• Biological or synthetic material that assists or
prevents a physiological function (e.g., IUD).
• Therapeutic material that is not absorbed by,
eliminated by, or incorporated into a body
part (e.g., radioactive implant).
• Mechanical or electronic appliances used to
assist, monitor, take the place of or prevent a
physiological function (e.g., cardiac
pacemaker, orthopedic pin).
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Page 108
Character 7: Qualifier
•
The seventh character, the qualifier, contains
unique values for individual procedures as
needed.
• Example:
• Used to identify the destination site in a bypass.
• When there is no qualifier, character “Z”,
representing “none,” is used as the seventh
character
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7
Qualifier
Page 109
Code Comparison
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Page 110
Code Comparison - Procedure
Procedure – Transverse colon resection, open
• ICD-9-CM
•
•
45.74 Open/other resection of transverse colon
ICD-10-PCS
•
0DTL0ZZ
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Page 111
Breakdown of the ICD-10-PCS Code
Transverse colon resection, open
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Medical
and
Surgical
Gastrointestinal
System
Resection
Transverse
Colon
Open
No Device
No
Qualifier
0
D
T
L
0
Z
Z
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Page 112
Code Comparison - Procedure
Procedure – Gallbladder resection, laparoscopic
• ICD-9-CM
• 51.23
• ICD-10-PCS
• 0FT44ZZ
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Page 113
Breakdown of the ICD-10-PCS Code
Gallbladder resection, laparoscopic
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
No Device
No
Qualifier
Z
Z
Medical
and
Surgical
0
Hepatobilliary
System and
Pancreas
Resection
Gallbladder
Percutaneous
Endoscopic
F
T
4
4
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Page 114
Coding Exercises
ICD-10-PCS
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Page 115
Take Out Some or All of a Body Part – Exercise 1
Procedure: Rectal polyp fulguration via sigmoidoscope
Fulguration see Destruction
Destruction
Rectum 0D5P
Retina
Left 085F3ZZ
Right 085E3ZZ
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Page 116
Take Out Some or All of a Body Part – Exercise 1
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Page 117
Take Out Some or All of a Body Part – Exercise 1
Rectal polyp fulguration via sigmoidoscope
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Medical
and
Surgical
Gastrointestinal
Destruction
Rectum
No Device
No
Qualifier
0
D
5
P
Z
Z
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Via Natural or
Artificial
Opening
Endoscopic
8
Page 118
Take Out Solids, Fluids, or Gases from a Body Part – Exercise 2
Procedure: Percutaneous mechanical thrombectomy, left brachial artery
Thrombectomy see Extirpation
Extirpation
Artery
Brachial
Left 03C8
Right 03C7
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Page 119
Take Out Solids, Fluids, or Gases from a Body Part – Exercise 2
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Page 120
Take Out Solids, Fluids, or Gases from a Body Part – Exercise 2
Percutaneous mechanical thrombectomy, left brachial artery
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Medical
and
Surgical
Upper
Arteries
Extirpation
Brachial
artery, left
Percutaneous
No Device
No
Qualifier
0
3
C
8
3
Z
Z
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Page 121
Involve Cutting or Separation Only - Exercise 3
Procedure: Laparotomy with lysis of large intestine adhesions
Lysis see Release
Release
Intestine
Large 0DNE
Left 0DNG
Right 0DNF
Small 0DN8
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Page 122
Involve Cutting or Separation Only - Exercise 3
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Page 123
Involve Cutting or Separation Only - Exercise 3
Laparotomy with lysis of large intestine adhesions
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Medical
and
Surgical
Gastrointe
stinal
Release
Large
Intestine
Open
No Device
No
Qualifier
0
D
N
E
0
Z
Z
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Page 124
That Put In/Put Back or Move Some/All of a Body Part: Exercise 4
Procedure: Closed reduction of dislocation of the right shoulder joint
Reduction
Dislocation see Reposition
Fracture see Reposition
Reposition
Joint
Shoulder
Left 0RSK
Right 0RSJ
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Page 125
That Put In/Put Back or Move Some/All of a Body Part: Exercise 4
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Page 126
That Put In/Put Back or Move Some/All of a Body Part: Exercise 4
Closed reduction of dislocation of the right shoulder joint
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Medical
and
Surgical
Upper
joints
Reposition
Shoulder,
joint right
External
No Device
No
Qualifier
0
R
S
J
X
Z
Z
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Page 127
Alter the Diameter/Route of a Tubular Body Part – Exercise 5
Procedure: Laparoscopic bilateral fallopian tube ligation.
Ligation see Occlusion
Occlusion
Fallopian Tube
Left 0UL6
Right 0UL5
Fallopian Tubes, Bilateral 0UL7
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Page 128
Alter the Diameter/Route of a Tubular Body Part – Exercise 5
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Page 129
Alter the Diameter/Route of a Tubular Body Part – Exercise 5
Laparoscopic bilateral fallopian tube ligation
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Percutaneous
Endoscopic
No Device
No
Qualifier
4
Z
Z
Medical
and
Surgical
Female
Reproductive
Occlusion
Fallopian
Tubes,
Bilateral
0
U
L
7
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Page 130
Always Involve a Device – Exercise 6
Procedure: Laparotomy with left ventral hernia repair with Merlex mesh
Herniorrhaphy
see Repair, Anatomical Regions, General 0WQ
see Repair, Anatomical Regions, Lower Extremities 0YQ
with synthetic substitute
see Supplement, Anatomical Regions, General 0WU
see Supplement, Anatomical Regions, Lower Extremities 0YU
Supplement
Abdominal Wall 0WUF
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Page 131
Always Involve a Device – Exercise 6
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Page 132
Always Involve a Device – Exercise 6
Laparotomy with left ventral hernia repair with Merlex mesh
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Medical
and
Surgical
General
Supplement
Abdominal
Wall
Open
Synthetic
Substitute
No
Qualifier
0
W
U
F
0
J
Z
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Page 133
Coding Exercise
ICD-10-CM and ICD-10-PCS
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Page 134
Coding Exercise: ICD-10-CM and ICD-10-PCS
Patient is brought to the hospital by ambulance after
being caught in an avalanche while skiing at a
mountain resort while on vacation.
Patient presented with a displaced fracture
dislocation of the left humerus, surgical neck.
An open reduction with internal fixation was
performed using pins and screws.
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Page 135
Coding Exercise: ICD-10-CM
ICD-10-CM Index
Dislocation (articular)
- with fracture —see Fracture
Fracture, traumatic (abduction)
(adduction) (separation) (see also
Fracture, pathological) T14.8
- humerus S42.30- - surgical neck —see Fracture, humerus,
upper end, surgical neck
- - upper end S42.20- - - surgical neck (displaced) S42.21-
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ICD-10-CM Tabular
The appropriate 7th character is to be added to all
codes from category S42
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
S42.2 Fracture of upper end of humerus
S42.21 Unspecified fracture of surgical neck
of humerus
S42.212 Unspecified displaced fracture of
surgical neck of left humerus
Page 136
Coding Exercise: ICD-10-CM: External Cause of Morbidity
ICD-10-CM External Cause of Injuries Index
ICD-10-CM Tabular
X36 Avalanche, landslide and other earth
movements
Avalanche —see Landslide
Landslide (falling on transport vehicle)
X36.1
- caused by collapse of man-made structure
X36.0
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Includes: victim of mudslide of cataclysmic
nature
Excludes1: earthquake (X34)
Excludes2: transport accident involving collision
with avalanche or landslide not in motion (V01V99)
The appropriate 7th character is to be added to
each code from category X36
A - initial encounter
D - subsequent encounter
S - sequela
X36.0 Collapse of dam or man-made structure
causing earth movement
X36.1 Avalanche, landslide, or mudslide
Page 137
Coding Exercise: ICD-10-CM: Place of Occurrence
ICD-10-CM External Cause of Injuries Index
Place of occurrence
- motorway (interstate) Y92.411
- mountain Y92.828
- movie-house Y92.26
- museum Y92.251
- music-hall Y92.252
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ICD-10-CM Tabular
Y92.8 Other places as the place of
occurrence of the external cause
Y92.83 Recreation area as the place of
occurrence of the external cause
Y92.838 Other recreation area as the place of
occurrence of the external cause
Page 138
Coding Exercise: ICD-10-CM: Activity Codes
ICD-10-CM External Cause of Injuries Index
Activity (involving) (of victim at time of
event)
- skiing (alpine) (downhill) Y93.23
- - cross country Y93.24
- - nordic Y93.24
- - water Y93.17
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ICD-10-CM Tabular
Y93.2 Activities involving ice and
snow
Excludes1: activity, shoveling ice and
snow (Y93.H1)
Y93.21Activity, ice skating
Activity, figure skating (singles) (pairs)
Activity, ice dancing
activity, ice hockey (Y93.22)
Y93.22 Activity, ice hockey
Y93.23 Activity, snow (alpine)
(downhill) skiing, snow boarding,
sledding, tobogganing and snow tubing
Excludes1: activity, cross country skiing
(Y93.24)
Page 139
Coding Exercise: ICD-10-CM: External Cause Status
ICD-10-CM External Cause of Injuries Index
Status of external cause
- leisure activity Y99.8
- military activity Y99.1
- off-duty activity of military personnel Y99.8
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ICD-10-CM Tabular
Y99 External cause status
Note: A single code from category Y99 should be used in
conjunction with the external cause code(s) assigned to a record
to indicate the status of the person at the time the event occurred.
Y99.8 Other external cause status
Activity NEC
Activity of child or other family member assisting in
compensated work of other family member
Hobby not done for income
Leisure activity
Off-duty activity of military personnel
Recreation or sport not for income or while a student
Student activity
Excludes1:civilian activity done for income or
compensation (Y99.0)
military activity (Y99.1)
Page 140
Coding Exercise: ICD-10-PCS
Procedure: An open reduction with internal fixation
was performed using pins and screws.
Reposition
Humeral Head
Left 0PSD
Right 0PSC
Humeral Shaft
Left 0PSG
Right 0PSF
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Page 141
Coding Exercise: ICD-10-PCS
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Page 142
Always Involve a Device – Exercise 6
An open reduction with internal fixation was performed using pins and screws
Character
Character
Character
Character
Character
Character
Character
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Medical
and
Surgical
Upper
Bones
Reposition
Humeral
Head, Left
Open
Internal
Fixation
Device
No
Qualifier
0
P
S
D
0
4
Z
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Page 143
Coding Exercise: ICD-10-CM and ICD-10-PCS
Patient is brought to the hospital by ambulance after
being caught in an avalanche while skiing at a
mountain resort while on vacation.
Patient presented with a displaced fracture
dislocation of the left humerus, surgical neck.
An open reduction with internal fixation was
performed using pins and screws.
S42.212A Unspecified displaced fracture of surgical neck of
left humerus, initial encounter
X36.1 Avalanche, landslide, or mudslide
Y92.838 Other recreation area as the place of occurrence of
the external cause
Y93.23 Activity, snow (alpine) (downhill) skiing, snow
boarding, sledding, tobogganing and snow tubing
Y99.8 Other external cause status
0PSD04Z An open reduction with internal fixation was
performed using pins and screws
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Page 144
How do I get started?
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Page 145
How do I get started?
•
Get out your anatomy and physiology references and renew/expand
your knowledge of the topics
• Greater specificity of the code sets requires more detailed knowledge of
anatomy and physiology to make correct code selections
146
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Page 146
How do I get started?
•
Keep current on ICD-10 topics
• Subscribe to AHIMA ICD-TEN
• http://www.ahima.org/images/newsletters/ICDTen/subscribe.html
• Subscribe to ICD10 WATCH
• http://www.icd10watch.com/
• Find other on-line newsletters and websites
147
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Page 147
How do I get started?
•
Begin reviewing the ICD-10 guidelines
• ICD-10-CM
• http://www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf
• ICD-10-PCS
•
• http://www.cms.gov/Medicare/Coding/ICD10/Downloads/PCS-2014guidelines.pdf
Access the code sets
• ICD-10-CM and ICD-10-PCS
• http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10
148
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Page 148
How do I get started?
•
Visit the websites of the cooperating parties to see what is available
on ICD-10
• American Hospital Association
• www.ahacentraloffice.org
• American Health Information Management Association
• www.ahima.org
• National Center for Health Statistics
• www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
• Centers for Medicare & Medicaid Services
• www.cms.hhs.gov/icd10
149
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Page 149
Questions???
150
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Page 150
How can we help?
Katherine “Kitty” Kremer, BA, RHIT | Director Coding Education
AHIMA Approved ICD-10-CM/PCS Trainer,
AHIMA ICD-10 Ambassador
Anthelio Healthcare Solutions Inc.
Office: (248) 536-4374 | Mobile: (313) 215-3267
Fax: (248) 536-4387 | Email: kitty.kremer@antheliohealth.com
Deidre Brown, BS, CCS | Anthelio ICD-10-CM/PCS Training Specialist
AHIMA Approved ICD-10-CM/PCS Trainer
Anthelio Healthcare Solutions Inc.
Office: (248) 536-4371
Fax: (248) 536-4387 | Email: deidre.brown3@antheliohealth.com
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Page 151
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