ICD-10 Impact on
Coding and Billing
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
All Rights Reserved.
Use of this handout is for
informational purposes only
Refer to current updated version of ICD-10
manual at the time of implementation to
confirm coding accuracy!
Paul Cadorette CPC, CPC-H, CPC-P, CASCC, COSC
AAPC ICD-10 Proficiency Certified
Director of Education
pcadorette@mdstrategies.com
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
All Rights Reserved
Why the Need for ICD-10?
ICD-10
• A98.4 Ebola virus disease
ICD-9
Other specified diseases due to viruses
Arthropod-borne hemorrhagic fever
• Codes lack specificity which is necessary for identifying Ebola patients
• Makes the process of monitoring and tracking the disease more difficult
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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21 Chapters with alphanumeric codes
ICD-9 14,000 codes vs. ICD-10 68,000
Diseases of nervous
system and sense organs
E codes
V codes
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
ICD-10 Guidelines
For ambulatory surgery, code the diagnosis
for which the surgery was performed. If the
postoperative diagnosis is known to be
different from the preoperative diagnosis at
the time the diagnosis is confirmed, select
the postoperative diagnosis for coding, since
it is the most definitive
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
ICD-10 CONVENTIONS
General rules for the use of the
classification system with instructional notes
that are applicable regardless of the health
care setting
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
All Rights Reserved
ICD-10 Conventions
• “See” - another term should be referenced, it is
necessary for the coder to go to the main term
indicated by the “see” note
Arthritis, arthritic – spine
rheumatoid – see Spondylitis, ankylosing
• “See Also” – another main term can be referenced that
may have additional index entries that may be useful.
When the main term provides an appropriate code, it is
not necessary to follow the “see also” note
Stricture (see also Stenosis)
bladder N32.89
neck N32.0
nasolacrimal duct (see also Stenosis, lacrimal duct)
congenital Q10.5
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
“Excludes” Notes
•
EXCLUDES 1
The two conditions cannot be reported together
When present, the EXCLUCDED code/condition should be reported
instead of the code listed above it
•
It may be appropriate to use both the code listed along
with the excluded code when supported by the medical documentation
EXCLUDES 2
• S92 Fracture of foot and toe, except ankle
EXCLUDES 1
traumatic amputation of ankle and foot (S98.-)
EXCLUDES 2
fracture of ankle (S82.-)
fracture of malleolus (82.-)
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
Anatomy and Terminology
Spondylo- (vertebra or spinal column) -pathy (disease process)
Atlanto-occipital
Expansion of
diagnosis code
sets
Atlanto-axial
- C7-T1
- T12-L1
- L5-S1
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
Anatomy and Terminology
Enthesopathy
• Enthesis – the point where a
tendon or ligament inserts into
a bone
• Enthesopathy – disease
process in the zones of
attachment for ligaments or
tendons to bone, a disorder of
entheses (bone attachments)
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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Anatomy and Terminology
• Spondylopathies (M45-M49)
• spondylo (vertebra) pathy (disease process)
• Spondylosis - a term referring to degenerative osteoarthritis
of the joints between the center of the spinal vertebra
and/or neural foramina
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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S96.2 Injury of Intrinsic Muscle at Ankle
and Foot Level
Dorsal Interossei
C
B
A
A
C
A B
B
A – Flexor digitorum brevis
B – Abductor digiti minimi
C – Abductor hallucis
A - Quadratus plantae
B - Lumbricales
Plantar Interossei
B
A – Flexor hallucis brevis
B – Adductor hallucis
C – Flexor digiti minimi
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
Diagnosis Code Structure
S52.551A
Type of Encounter
Laterality
Other extra-articular fracture lower end of radius
Fracture lower end of radius
Base code - Fracture of forearm
Fracture of right distal radius, extra-articular
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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Diagnosis Code Structure
- Base Codes
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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Diagnosis Code Structure
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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Fractures of Femur
(23 Different Classifications plus 9 Other/Unspecified codes)
Current Procedural Terminology © 2014 American Medical Association.
All Rights Reserved.
ICD-10 Laterality
• RT is usually indicated with 1
• LT is usually indicated with 2
• Bilateral is usually indicated with 3
(When no bilateral code exists,
report both the RT and LT code)
(Bilateral refers to paired organs)
• M20.40 Other hammertoe(s) (acquired), unspecified foot
• M20.41 Other hammertoe(s) (acquired), right foot
• M20.42 Other hammertoe(s) (acquired), left foot
Unspecified character is 0 if in the fifth position or 9 when it is in the sixth position
• M20.011 Mallet finger of right finger(s)
• M20.012 Mallet finger of left finger(s)
• M20.019 Mallet finger of unspecified finger(s)
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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ICD-10 Laterality
NOTE: Although toes are
identified by proximal, medial
or distal phalanx the specific
toe (second, third, fourth or
fifth) is not mentioned
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
CPT Code Sections
•Forearm, Wrist
•Hand, Finger
Select CPT code based on the
anatomical site where at which
the procedure was performed
Hand or Wrist
Wrist and Hand Level
For categories where no multiple site code is provided and
more than one bone, joint or muscle is involved, multiple codes
should be used to indicate the different sites involved
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
ICD-10 Laterality
Exceptions
Other and Unspecified
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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ICD-10 Laterality
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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Eyelid Characters
• .
CPT Code Modifiers
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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Seventh Character Extensions
Additional digits required
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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Seventh Character Extension
7th vs. X7th
• When a diagnosis code requires a 7th character - that character
must always be the 7th character in the data field, which
sometimes necessitates the use of placeholder “X”
• Some codes may be only 4 characters long, but they require a
7th character extension - so placeholder “x” is used twice
S46.011 Strain of muscle(s) and tendon(s)
of the rotator cuff of right shoulder
The appropriate 7
S46.011A
from category S00
th
S43.50 Sprain of acromioclavicular joint
S43.50XA
A
D
S
character is to be added to each code
initial encounter
subsequent encounter
sequela
S33.0 Traumatic rupture of lumbar intervertebral disc
S33.0XXA
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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Encounters
(7th Character Extensions)
• A - Initial encounter – Active treatment
(surgical treatment, emergency department encounter or
evaluation and treatment by new physician)
• D - Subsequent encounter – Routine care during
healing or recovery phase (cast change/removal,
removal of internal/external fixation device,
medication adjustment, follow-up visits)
• S - Sequela - Late effect from initial injury
• Condition that occurs after the acute phase of an injury
• No time limit to identify a late effect
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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Fracture Encounters
Defaults
No open
fx code
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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Implant Removal
Previous Injury
Fracture of 1st metatarsal bone right foot S92.311D
(Subsequent encounter “D” – defaulted to displaced)
Previous Surgery
Austin bunionectomy for hallux valgus Z47.2
(Acquired deformity)
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
Acute vs. Chronic
Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue
Chapter 19. Injury, Poisoning and Certain Other Consequences of External Causes
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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Strains and Sprains
• Strain – injury to a muscle or tendon
• Tendons connect muscle to bone
• Quadriceps tendon to superior pole of patella
• S76.119A Strain of unspecified quadriceps muscle,
fascia and tendon, initial encounter
• Sprain – stretching or tearing of a ligament
• Ligaments connect bone to bone
• Anterior cruciate ligament
• S83.519A Sprain of anterior cruciate ligament of
unspecified knee, initial encounter
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
Herniated Disk 722.10
Chapter 13 - Old/Chronic
Chapter 19 - Acute/Current
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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Barrett’s Esophagus
ICD-9
Same ICD-9 code
Different codes in ICD-10
Precancerous changes
Severe precancerous changes
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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K22.70 Barrett’s esophagus without dysplasia
Barrett’s esophagus NOS
NOS – Not Otherwise Specified
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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Carrier Policy
Treatment of Barrett’s
• Radiofrequency ablation is considered investigational as a
treatment of Barrett’s esophagus in the absence of dysplasia
(Nondysplastic Barrett’s)
• Radiofrequency ablation may be considered medically necessary
for treatment of Barrett’s esophagus with low-grade dysplasia,
when the initial diagnosis of low-grade dysplasia is confirmed by a
second pathologist who is an expert in GI [gastrointestinal]
pathology
• Radiofrequency ablation may be considered medically necessary
for treatment of Barrett’s esophagus with high-grade dysplasia
The diagnosis of high-grade dysplasia should be confirmed by two pathologists prior to
radiofrequency ablation
BCBS of NC
Current Procedural Terminology © 2014 American Medical Association.
All Rights Reserved.
Colon Polyps 211.3
Hyperplastic polyps code to K63.5
Adenomatous polyps are site specific
and code to benign neoplasms
Hyperplastic polyps of
anus/rectum
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
All Rights Reserved
Screening
• Testing for disease in
seemingly well individuals
• Testing to rule out or confirm a
sign or symptom is a diagnostic
exam and not a screening
• List the screening code as the
primary diagnosis
• Conditions found during
screening exam should be
listed as additional diagnoses
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
All Rights Reserved
“Accidental” Dural Puncture 998.2
ICD-9 Diagnosis Coding
1.
2.
1.
2.
3.
4.
5.
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
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.
Complications (998.2 Accidental
puncture or laceration)
Female pelvic pain with lysis of adhesions and destruction of endometriosis.
Colon is perforated during/while lysing adhesions.
K91.71
Accidental puncture and laceration of a digestive
system organ or structure during a digestive
system procedure
K91.72
Accidental puncture and laceration of a digestive
system organ or structure during other procedure
Chapter 11 Diseases of the digestive system K00-K94
While placing tape during a TVT procedure, the bladder is perforated.
N99.71
Accidental puncture and laceration of a
genitourinary system organ or structure during a
genitourinary system procedure
N99.72
Accidental puncture and laceration of a
genitourinary system organ or structure during
other procedure
Chapter 14 Diseases of the Genitourinary System N00-N99
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
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Discontinued Procedure
V64.1 – Surgical or other procedure not carried our because of contraindication
(unacceptable primary diagnosis in ICD-9)
Z53.09 – Procedure and treatment not carried out because of other contraindication
DO NOT USE V64.1 (ICD-9) OR Z53.09 (ICD-10) AS A PRIMARY OR
FIRST LISTED DIAGNOSIS
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
All Rights Reserved.
Chapter 20 External Causes of Morbidity
Chapter 21 Factors Influencing Health Status
ICD-9
ICD-10
Daycare worker bitten by child, bleeding wound
on right forearm
S51.851A Open bite right forearm, initial encounter
Y04.1XXA Assault by human bite, initial encounter
Y92.210 Daycare center as the place of occurrence of the external cause
Y93.F9
Activity, other caregiving
Y99.0
Civilian activity done for income or pay
Unless a provider is subject to state-based reporting or these codes are required by a
specific payer - reporting of External Causes of Morbidity codes is not required
Personal and Family History codes
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
CMS-1500 Claim Forms
Z12.11
D12.3
45385
PT
AB
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
ICD-10 Testing Week:
November 17-21, 2014
• Test claims with ICD-10 codes must be submitted with current dates
of service (i.e. October 1, 2014 through November 17, 2014), since
testing does not support future dated claims.
• Test claims will be subject to all existing EDI front-end edits
including Submitter authentication and NPI validation.
• Test claims will receive the 277CA or 999 acknowledgement as
appropriate, to confirm that the claim was accepted or rejected in the
system.
• Testing will not confirm claim payment or produce remittance advice.
Next test dates - March 2-6, 2015, June 1-5, 2015
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
FUTURE: Local Coverage Determination (LCD): (L35350)
UPPER GASTROINTESTINAL ENDOSCOPY (DIAGNOSTIC AND THERAPEUTIC)
Effective: Oct. 1, 2015 Approximately 290 ICD-10 codes vs 234 ICD-9 codes
• Diagnosis Codes meeting Medical Necessity
• Non-Covered Diagnosis Codes
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
FUTURE: Local Coverage Determination (LCD): (L34974)
Facet Joint Injections
Effective: Oct. 1, 2015
Code Comparison
• Approximately 264 ICD-10 LCD diagnosis codes
• 38 ICD-9 LCD diagnosis codes
• Diagnosis codes with “A” Encounters only
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
FUTURE: Local Coverage Determination (LCD): (L34974)
Facet Joint Injections
Spondylolysis M43.00 – M43.09
• Aka. Pars defect
Spondylolisthesis M43.10 – M43.19
• Pars defect-vertebra slips forward
Spondylosis M47.11 – M47.9
• Osteoarthritis, Osteoarthrosis
Osteoarthropathy
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix.
All Rights Reserved.
ICD-10 Impact on Coding and Billing
Paul Cadorette CPC, CPC-H, CPC-P, CASCC, COSC
AAPC ICD-10 Proficiency Certified
Director of Education
pcadorette@mdstrategies.com
ICD-10-CM Complete Official Draft Code Set © 2014 Ingenix
All Rights Reserved.