PREPARING FOR
ICD-10 CM
BASIC CONCEPTS
Objectives
• Understand the scope of the ICD-10 transition
• Identify the benefits of changing to ICD-10 and the
association with ICF
• Recognize the similarities and differences between
ICD-9 and ICD-10 coding
• Understand the purpose of the 7th character in ICD10
• Understand unique coding rules for fractures
• Gain understanding of web based resources
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Jenelle Lauchman, PT, DPT, OCS
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16 years as a PT –majority in OP Orthopedics
Select Medical/Select PT locally
Largest Provider of OP Services in the Nation
Center Manager
President of the NvAPTA
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Susan Priestman, PT, DPT, OCS
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•
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30 years as a PT -all in OP Orthopedics
Select Medical/Select PT locally
Largest Provider of OP Services in the Nation
Industry leader /outcomes measurement
Regional Clinical Coordinator in 7 States
AK>OH
• Quality and Compliance -State and Federal
Law
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What is ICD-10?
• 10th revision of the International
Classification of Diseases and Related Health
Problems (ICD)
• Used to code for diseases, signs and
symptoms, abnormal findings, complaints,
social circumstances, and external causes of
injury or diseases
• Developed by the World Health Organization
(WHO) in 1994
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Implementation of ICD-10
• In 2009, the Center for Medicare and
Medicaid (CMS) mandated the adoption of
ICD-10 code sets
• Implementation of ICD-10 for all providers is
October 1, 2015
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BASED ON ICF
International Classification
of Functioning Disability
and Health (ICF)
International Classification of
Functioning Disability and Health
Activities
&
Participation
Body Functions
&
Structures
•
•
Functions
Structures
•
•
Capacity
Performance
Environmental
Factors
•
•
Barriers
Facilitators
http://apps.who.int/classifications/icfbrowser/
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What is ICF?
• A classification system – not a measurement
tool or disease/condition label
• Classifies functioning and disability associated
with health conditions
– Not a way to describe a consequence of disease, but
rather components of health & functioning with the
disease
– Shifts “cause” to impact on the patient or individual
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COMPARING
ICD-9 TO ICD-10
What’s the Difference?
ICD-9- why the change?
• ICD-9…
– produces limited information about
patients’ medical conditions
– Is 30 years old
– has outdated terms
– is inconsistent with current medical
practice.
– structure limits the number of new codes
that can be created, and many ICD-9
categories are currently full.
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Important Features in ICD-10
• Reflect updated medical terminology
• Expanded detail and specificity:
– Injury, fractures and postoperative complications
– Traumatic or non-traumatic injury
– Initial encounter, subsequent encounter, and sequela
• Grouped by anatomical site, then by type of injury
• Laterality: the affected side of the body
– Dominant side or non-dominant side
– Single condition or bilateral condition
• ICD-10-CM Outpatient services and ICD-10-PCS inpatient services (not
discussed here)
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Comparing ICD-9 to ICD-10
ICD – 9-CM
ICD – 10-CM
13,600 codes
69,000 codes
Code book contains 17 chapters
Code book contains 21 chapters
Consists of 3 to 5 characters
Consists of 3 to 7 characters
1st character is alpha or numeric
1st character is alpha
Only utilizes letters E and V
Utilizes all letters (except U)
2nd, 3rd, 4th, and 5th characters are always
numeric
2nd character is always numeric
3rd, 4th, 5th, 6th, and 7th characters can be
alpha or numeric
Shorter code descriptions because
of lack of specificity and
abbreviated code titles
Longer code descriptions because of greater
clinical detail and specificity
and full code titles
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Comparison of ICD-9-CM
& ICD-10-CM
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Structure of ICD-10
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16
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Comparison of ICD 9 to ICD-10
ICD-9
ICD-10
A - Category of code
B - Etiology, anatomical
site, and manifestation
A - Category of code
B - Etiology, anatomical
site, and/or severity
C - Extension
A
B
– 7th character for obstetrics,
injuries, and external causes
of injury
A
B
C
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ICD-10 Sequence
S83.411.D
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Summary of ICD-10 CM
• The first character is always a letter
• The second character is always a number
• The third character may be a number or
letter
• The final characters
– alphabetic extension or
– reserve sub classification (X)
– Placeholder X
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ICD-10 and Laterality
•
•
•
•
•
•
5th or 6th character position
0 = Unspecified
1 = Right
2 = Left
A
B
C
3 = Bilateral
If no bilateral code exists, select codes to indicate the
right and left side
S83.411 Sprain Medial Collateral Ligament –Right
Knee
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ICD-10 Specificity Example
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ICD-10-CM:
UNDERSTANDING
TH
ENCOUNTER & THE 7
CHARACTER
7th Character Extension for
Injuries
• Most categories in the injury chapter (#19) of
ICD-10 have a 7th character extension (lesser
extent Chapters 13 &15)
• The majority of the categories have 3
extension options, with the exception of
fractures which have more.
• A Initial Encounter
• D Subsequent Encounter
• S Sequela
A
B
C
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7th Character Extension for
Injuries
A = Initial Encounter
• Patient is receiving initial, active treatment for a
condition
• Evaluation or treatment by a new physician
• Direct access therapy – Initial assessment for
traumatic injury, illness, sprain/strain or fracture
Example: Initial assessment of a bucket-handle tear of
medial meniscus, left knee
S83.212A
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7th Character Extension for
Injuries
D = Subsequent Encounter
• Patient has previously received initial, active
treatment and is now receiving routine care
during the healing or recovery phase
• Acute condition treated
• Follow-up visits for the treatment of an injury
Example: Sprain of unspecified ligament of right ankle
S93.401D
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7th Character Extension for
Injuries
S = Sequalae Encounter
• Complications or conditions that are a direct
result of an acute condition that is no longer
being treated
Example: Unilateral post-traumatic osteoarthritis, right
knee following old bucket-handle tear of medial
meniscus, right knee
M17.31, S83.211S
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Example
• Displaced, closed fracture of the greater
trochanter of the right femur (S72.111)
• Treated in ED, admitted, and surgery
performed
• The correct ICD-10 code is S72.111A
– Initial encounter for closed fracture
– The A indicates the Initial Encounter
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Example
Referred for outpatient physical therapy
• Primary Diagnosis code for PT:
– S72.111D - for subsequent encounter
• Additional Diagnosis codes:
– M25.551 Pain in right hip
– R26.2 Difficulty in walking, not elsewhere classified
– R60.0 Localized edema
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Summary
Was the Cause a Trauma
or Fracture?
No
Yes
Use S code with 7th Character
A = Initial Encounter
D = Subsequent Encounter
S code and 7th Character not
required
Look in Musculoskeletal
Chapter for M code
S = Sequela Encounter
Identify the injury code that precipitated the
sequela and the code for the sequela itself
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ICD-10-CM CODING
FOR FRACTURES
Coding for Fractures
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•
•
•
Indicate the fracture type
Specific anatomical site
If the fracture is displaced or not
Routine versus delayed healing
Non-union versus mal-union
The side associated with the fracture
Type of encounter
– initial, subsequent, sequela
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Fracture Extensions
•
•
•
•
•
•
•
A- initial for Closed
B- initial for Open Fx
D- subseq. with routine healing
G- subseq. with delayed healing
K- subseq. with non union
P- subseq. with mal union
S- sequella to fracture
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Coding for Open Fractures
• Gustilo open fracture classification
• 7th character designations for open fractures
• classifies open fractures into three categories
depending on:
– Mechanism of the injury
– Soft tissue damage
– Degree of skeletal involvement
• Applies to categories
• S52 Fracture of forearm
• S72 Fracture of femur
• S82 Fracture of lower leg
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Coding for Open Fractures
• The Gustilo classification groups are:
‒ Type I – Wound less than 1 cm, minimal soft tissue
damage
‒ Type II – Wound greater than 1 cm with moderate
soft tissue damage
‒ Type III – Wound greater than 1 cm with extensive
soft tissue damage
o Type IIIA – Adequate soft tissue cover
o Type IIIB – Inadequate soft tissue cover
o Type IIIC – Associated with arterial injury
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Coding for Open Fractures
B Initial encounter for open fracture type I or II
C Initial encounter for open fracture type IIIA, IIIB, or IIIC
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
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
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
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
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Mobile Friendly Website
• www.ICD10data.com
• Can search by name
• Can search by ICD-9
code
• Here is another free
website
http://www.findacode.com
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Examples:
Coding for an ACL Sprain Using
the Tabular List S83.511 A
• Patient is a 16-year-old male.
During a high school soccer •
game last week, he suffered a
right ACL sprain when his
knee contacted an opposing •
player’s leg. He came straight
•
to PT without seeing a
•
physician first.
How to code for this
example:
Primary Codes: S83.511A for
the sprain
W51.XXXA for the external cause
Y92.322 for place of occurrence
• Y93.66 for the activity
– Patient’s condition: Presents
•
with pain, edema, and
instability in his right knee
– Uses crutches for ambulation•
•
– Has pain with walking
•
Additional Codes:R26.2 for difficulty in
walking or R26.89 for other
abnormalities of gait and mobility
M25.561 for right knee pain
M25.361 for the right knee instability
M25.461 for right knee effusion
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ACL Sprain—Tabular
S83 Dislocation and sprain of joints and ligaments of knee
• Includes: avulsion of joint or ligament of knee
• laceration of cartilage, joint or ligament of knee
• sprain of cartilage, joint or ligament of knee
• traumatic hemarthrosis of joint or ligament of knee
• traumatic rupture of joint or ligament of knee
• traumatic subluxation of joint or ligament of knee
• traumatic tear of joint or ligament of knee
• Code also any associated open wound
• The appropriate 7th character is to be added to each code from category
S83
• A -initial encounter
• D -subsequent encounter
• S –sequela
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Gait
• Difficulty Walking
– ICD-10 code R26.2
Difficulty in walking, not
elsewhere classified
– Description synonyms:
Difficulty walking
– Walking disability
• Other Abnormalities of Gait and
Mobility
• ICD-10 code R26.89
–
–
–
–
–
–
–
–
–
Description synonyms:
Cautious gait
Gait disorder due to weakness
Gait disorder, painful gait
Gait disorder, weakness
Gait disorder, postural instability
Gait disorder, multifactorial
Toe walking and toe-walking gait
Limping/limping child
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Y93 Activity codes
• Provided for use to indicate the activity of the person seeking
healthcare for an injury or health condition such as found in
chapter 19 or chapter 13.
• This section contains the following broad activity categories:
•
•
•
•
•
•
•
Y93.0 Activities involving walking and running
Y93.1 Activities involving water and water craft
Y93.2 Activities involving ice and snow
Y93.3 Activities involving climbing, rappelling, and jumping off
Y93.4 Activities involving dancing and other rhythmic movement
Y93.5 Activities involving other sports and athletics played individually
Y93.6 Activities involving other sports and athletics played as a team or
group
• Y93.7 Activities involving other specified sports and athletics
• Y93.A Activities involving other cardiorespiratory exercise
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Coding for a Left Knee Joint
Replacement
• Patient is a 74-year-old male
who underwent a left total
knee replacement one week
ago.
• Patient’s condition: complains
of 6/10 pain in the left knee
• presents with left knee
effusion and impaired range of
motion in left knee extension
and flexion
• has pain with walking
• is WBAT (weight bearing as
tolerated) using a walker
•
•
•
•
•
•
•
•
•
Primary Codes:
R26.2 for difficulty in walking or
R26.89 for other abnormalities of gait
and mobility
M25.562 for left knee pain
M25.462 for left knee effusion
M25.662 for left knee stiffness
M62.552 for muscle atrophy left
quads and hamstrings
Additional Codes:
Z96.652 for presence of left artificial
knee joint
Z47.1 for aftercare following joint
replacement surgery
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Coding for Down Syndrome
• Patient is a 7-yearold male with Down
syndrome (meiotic).
– Patient’s condition:
– generalized muscle
weakness
– abnormal posture
– difficulty walking
– Q90.0 for the Down
syndrome
– R26.2 for the difficulty
walking or R26.89 for
other abnormalities of
gait and mobility
– M62.81 for generalized
muscle weakness
– R29.3 for abnormal
posture
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Coding for Benign Paroxysmal
Vertigo
Patient is a 33-year-old
female who presents to
physical therapy with a
diagnosis of benign
paroxysmal vertigo, right
ear.
– H81.11 for Benign
Paroxysmal Vertigo, right
ear
– R11.0 for nausea
without vomiting
– Patient’s condition:
– Complains of dizziness
and nausea
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Coding for Jack-O-Lantern Injury
Patient is a 34‐year-old female.
While carving a pumpkin, she
accidentally lacerated the digital
nerves at her palm as well as her
flexor tendon superficialis and
profundus tendons on fingers two
through four.
• Patient’s condition:
• Had surgery last week
• Presents with complaints of pain,
swelling, and weakness of the
right wrist, hand, and fingers
• Has sensation of “pins and
needles” in her hand and fingers
•
•
•
•
•
•
•
•
•
•
•
•
M79.641 pain in right hand
M79.644 pain in right fingers
M25.531 pain in right wrist
M25.431 for effusion of right wrist
M25.441 for effusion of right hand
R20.2 paresthesia of skin
Additional codes:
M25.631 stiffness of right wrist
M25.641 stiffness of right hand
M62.531 and M62.541 for muscle
weakness right forearm and hand
S66.120D, S66.122D, S66.124D for
the lacerations
W26.0XXD for contact with knife
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