ICD-10-CM/PCS: Coding and Clinical
Documentation Changes
Surgery
Presented by:
Angie Audler, MBA, RHIT, CCS, CPC,
AHIMA Approved ICD-10-CM/PCS Trainer
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Disclaimer
• This PowerPoint presentation is an education tool
to provide basic information for coding. The
information is the sole view of the author and
was put together based on experience, research
and expertise in the coding profession. It is not
intended to be an exhaustive review and should
not be considered a substitution for Coding
Guidelines. The presenter does not accept any
responsibility or liability with regard to errors,
omissions misinterpretations or misuse by the
audience.
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Today’s Topics
•
•
•
•
Brief Overview of ICD-10-CM/PCS
How does ICD-10 Impact you as a Provider
Common Surgery ICD-10 Codes
Clinical Documentation Awareness Tips for
ICD-10
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Compliance Date
• October 1, 2015
– Date of service on or after 10/01/2015 for office and
other outpatient services (including Hospital
Observation)
• ED and Observation services prior to 10/1 with overlap on
or after 10/1 will use ICD9 codes for reporting
– Discharge date on or after 10/01/2015 for hospital
inpatient discharges
– Claims for services prior to 10/1/2015 will continue to
flow through systems utilizing ICD-9-CM diagnosis and
ICD-9-CM Vol. 3 procedure codes (for facilities) for a
period of time
4
CMS Concession
Source: Healthcare IT News 7/6/2015
• CMS has indicated that "a valid ICD-10 code will
be required on all claims starting Oct. 1, 2015.“
– 1. Claims denials. "While diagnosis coding to the
correct level of specificity is the goal for all claims, for
12 months after ICD-10 implementation, Medicare
review contractors will not deny physician or other
practitioner claims billed under the Part B physician
fee schedule through either automated medical
review or complex medical record review based solely
on the specificity of the ICD-10 diagnosis code as long
as the physician/practitioner used a valid code from
the right family," CMS officials wrote in a guidance
document.
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CMS Concession
Source: Healthcare IT News 7/6/2015
• 2. Quality reporting and other penalties. "For all quality
reporting completed for program year 2015 Medicare
clinical quality data review contractors will not subject
physicians or other Eligible Professionals (EP) to the
Physician Quality Reporting System (PQRS), Value Based
Modifier (VBM), or Meaningful Use 2 (MU) penalty during
primary source verification or auditing related to the
additional specificity of the ICD-10 diagnosis code, as long
as the physician/EP used a code from the correct family
of codes," CMS explained. "Furthermore, an EP will not be
subjected to a penalty if CMS experiences difficulty
calculating the quality scores for PQRS, VBM, or MU due to
the transition to ICD-10 codes."
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CMS Concession
Source: Healthcare IT News 7/6/2015
• 3. Payment disruptions. “If Medicare
contractors are unable to process claims as a
result of problems with ICD-10, CMS will
authorize advance payments to physicians,”
AMA president Steven Stack, MD, noted on
the group’s website.
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CMS Concession
Source: Healthcare IT News 7/6/2015
• 4. Navigating transition problems. CMS
intends to create a communication center of
sorts, including an ICD-10 Ombudsman, "to
help receive and triage physician and provider
issues." The center will also "identify and
initiate“ resolution of issues caused by the
new code sets, officials added.
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Brief Overview of ICD-10-CM/PCS
• ICD-10 is composed of two parts:
– ICD-10-CM (clinical modification)
– ICD-10-PCS (procedural coding system)
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The Difference Between ICD-10-CM/PCS
• ICD-10-CM – Replaces ICD-9-CM Vol. 1 & 2 Codes
– ICD-10-CM will be used to identify diagnosis codes in all health
care settings
• ICD-10-PCS – Replaces ICD-9 Vol. 3 Procedure Codes (facility use
only)
ICD-10PCS will be used by facilities to report procedures in the
hospital inpatient setting
• Physicians and Other Healthcare Professionals will continue to use
CPT and HCPCS (Level II) codes to report office and other
procedures and services
• Hospital Outpatient Departments/OPSurgery and Ambulatory
Surgery Centers will also continue to use CPT and HCPCS (Level II)
codes for reporting outpatient procedures and ancillary services
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ICD-10-PCS
• Under ICD-10, new and cutting-edge technology
that have been problematic to code in ICD-9 will
be assigned based on surgeon’s documentation in
the operative note
–
–
–
–
–
–
–
Type of surgery
Body system
Root operation
Body part
Approach
Device
Qualifiers (e.g. biopsy, second site, etc.)
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Overview of ICD-10-CM
• The transition to ICD-10 affects all HIPAA-covered
entities – hospitals, physicians, allied health
professionals, home health, skilled nursing, etc.;
as well as payers, business associates – billing
companies, vendors, clearinghouses
• Non-covered entities (e.g. automobile insurance
and worker’s compensation programs are not
required to transition to ICD-10), although it is
recommended
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ICD-10-CM Changes
• There are three main categories of changes in
ICD-10-CM
- Definition Changes
- Differences in Terminology
- Increased Documentation Specificity
• ICD-10 doesn’t affect coding only; it involves
physician reporting, billing, information
technology, and revenue management
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Comparison
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ICD-10-CM
• Although there are approximately 70,000 codes in
ICD-10, specialists will use only a small subset of
those codes
• You will be surprised at how much of this work you
are already doing
• Over 1/3 of the expansion codes are due to laterality
(physicians are already documenting right, left,
bilateral)
– If bilateral and there is no specific code for bilateral, you
code both right and left sides
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Overview of ICD-10-CM
• ICD-9 codes will no longer be maintained once
ICD-10 is implemented
• A claim cannot contain both ICD-9-CM and
ICD-10-CM (CMS Transmittal 950, effective
10/1/2013)
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Risk Mitigation
• Denials can run high for “not medically
necessary reasons”
• In the beginning there is risk of payers not
fully mapping procedures with new allowed
diagnosis reasons
– Be prepared for short term reduced revenues
17
Louisiana Medicaid
Source: Modern Healthcare, 9/4/2015
•
Four State Medicaid Programs will NOT Transition to ICD-10 by 10/1
•
CMS will allow four states - California, Louisiana, Maryland and Montana - to use a
"crosswalk technique" to continue using the older code sets for Medicaid fee-forservice programs because their claims processing systems in these four states are
unable to use the new ICD-10 codes.
•
Under the crosswalk technique, the Medicaid programs will convert claims using
the ICD10 system into ICD-9 codes to calculate payments
•
Some provider groups and healthIT experts say the use of such a technique could
result in payment delays and other issues.
•
It was not stated whether this applies to straight Medicaid and/or the Medicaid
Bayou Plans.
Stay tuned for additional information to be released
•
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Administrative Considerations
• Reimbursement
• Potential effect of delays, initial decrease in coder
productivity
• (Industry estimates 20-30% reduction in coder
productivity due to additional specificity; physician
queries; loss of memorized codes; learning curve.)
• Decrease in physician/provider productivity due to
additional specificity needed in charting; additional
specificity needed for orders; additional specificity for
authorizations; answering queries; increased selection
on charge tickets and/or order sets
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ICD-10-CM Structure
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ICD-10-CM Structure
•
The seventh character represents a visit encounter or sequelae (condition resulting
from a previous disease; also known as Late Effects) for injuries and external
causes. The seventh character extender must always be the seventh character of a
code.
•
A hyphen “-” at the end of an ICD-10 code in the Alphabetic Index indicates that
additional characters are required.
•
Placeholder: An “x” is used as a fifth character in certain six character codes to
allow for future expansion. An “x” is also used as a placeholder when a code has
less than six characters and the code requires a seventh character.
•
•
•
•
For Example:
Adverse effect of calcium-channel blockers, initial encounter T46.1x5A
Exposure to electric transmission lines, initial encounter W85.xxxA
Post-procedural cardiogenic shock, initial encounter T81.11xA
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Noteworthy Changes that Fall into
Other Specialty Areas
Clinical Area
ICD-9-CM Codes
ICD-10-CM Codes
Fractures
787
17099
Pregnancy
1104
2155
Diabetes
69
239
Hypertension
33
14
ESRD
11
5
Brain Injury
292
574
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Considerations
• Font (System and Penmanship)
– Watch I (alpha) vs. 1 (numeric)
– Watch O (alpha) vs. 0 (numeric)
– Watch Z (alpha) vs. 2 (numeric)
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Reporting Differences, Trending and
Analytic Modifications
• Converting from ICD9 to ICD10 more than triples the
number of available codes
• Looking at historical data becomes problematic
unless you can identify and capture needed
information from the two coding systems
• Simple forward mapping will not be sufficient for
most providers to make a successful transition
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24
ICD-10-CM
• You will need to map your most frequently
used ICD-9-CM codes to ICD-10-CM
• Due to the number of code choices with some
diagnoses, there may be some challenges with
charge ticket/superbill options and EHR
template “drop-downs”
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General Equivalency Maps (GEMS)
• CMS’ GEMS (General Equivalency Maps)
demonstrate the complexity involved in
moving between the two coding systems
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ICD9/ICD10 Relationships
1:1, Cluster, Combination, Complex
• Individual ICD-9 codes that map to several ICD-10 code
alternatives;
• Individual ICD-9 codes that map to a set of two of more ICD10 codes;
• Two or more ICD-9 codes that map to individual ICD-10 codes;
• ICD-9 codes with no representation in ICD-10;
• ICD-9 codes with an exact match in ICD-10; and
• Individual ICD-9 codes that map to codes with similar but not
identical meanings in ICD-10
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27
CMS General Equivalent Mappings
Source: http://firstillinoishfma.org/wp-content/uploads/McGladrey-ICD-10-April-2013.pdf
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28
Documentation Awareness
• Physicians are becoming more
aware of the value of clinical
data and the relationships
between their professional
profiles and the diagnosis
(ICD-9/ICD-10) and procedure
codes (CPT) assigned
• If the clinical documentation
and the codes do not
accurately and specifically
represent the work you do, it
could poorly reflect through
reporting and impact your
future reimbursement
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ICD-10 Will Have a Direct Impact on
Physicians Through…..
• Physician quality profiles (PQRS, VBPM, P4P)
– mortality and morbidity reporting
– Not every insurer is profiling physicians yet, but
there are several other entities that do (e.g.
Health Grades – licensing backgrounds and
disciplinary information)
– Payers that profile use their own home-grown
grading systems that use claims data to determine
both “quality” and “efficiency”
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Provider Profiling
• Not all care or every specialty can be measured
• Most programs focus on specific types of physicians
and services
• Most common specialties profiled:
Cardiology
Pediatrics
Pulmonary
Allergy
OB/GYN
Rheumatology
Endocrinology
Nephrology
Infectious Disease
Family medicine
Neurology
Internal Medicine
Orthopedics
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Provider Profiling
• Most common diagnoses monitored:
– All of the major heart, lung and organ diseases
– The most prevalent viruses and inflammation
– Screening for cancers and depression
– Immunization compliance rates
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Provider Profiling
• Provider Efficiency
- Payers compare a physician’s data to their
local market benchmarks for cost of
resources used in delivering healthcare
- ICD-10 codes will capture the management
of chronically ill patients
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Manage Your Profile
• Payers will provide you with feedback on your
scores in the quality and efficiency areas
profiled
• Reports include details on the patients used
for scoring
• Validate or refute the findings, as these scores
may have an impact on your bottom line in
2017 with governmental and third party
payers
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Do You Code Your Own Services?
• If you do not code your services, then training
will be limited to ICD-10 concepts of the
specialty and documentation changes
• If you do your own coding, then you will need
training on the code set and coding guidelines
– Be sure to read the Chapter Specific Guidelines
located in front of the ICD-10CM coding manual
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HIPAA Regulations
• HIPAA regulations require providers and thirdparty payers to adhere to Official Guidelines
for Coding and Reporting
• A violation of coding guidelines is a violation
of HIPAA
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Unspecified Code Assignment
• Surveys indicate that as much as 50% of
current physician documentation cannot be
coded to appropriate level of specificity with
ICD-10 resulting in unspecified code use
• Many unspecified codes in ICD-10-CM include
the note: *Codes with a greater degree of
specificity should be considered first
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Unspecified Codes
• Sometimes the use of unspecified codes makes
sense
– Early in the course of evaluation
– Secondary diagnoses not directly being treated by that provider
but impacts that encounter
– Generalist vs specialist
• Area of expertise – the diagnosis may not be in the providers scope of
expertise and will need to get the opinion of a specialist
• Payers are discouraging the use of unspecified
codes
– When providers review their severity and risk scores it may
impact their reimbursement because it won’t have the specificity
in their codes that are needed to justify higher levels and better
reimbursement
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Table of Drugs and Chemicals
Underdosing
Adverse Effect
Poisoning,
Assault
Poisoning,
Intentional
Self-harm
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Poisoning,
Undetermined
Substance
Poisoning,
Accidental
(unintentional)
• The Table of Drugs and Chemicals Headings
better describe the circumstance of the
encounter
• It also contains a new columns for “Adverse
Effect” and “Underdosing”
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Underdosing (Of Medication Regimen)
(Z91.12-, Z91.13-)
• New concept term in ICD-10 (patient is taking less of
a medication than prescribed)
• Today’s terminology – Non-compliance of
medication
Documentation Awareness
When documenting Underdosing of medication regimen include:
•
•
•
•
Intentional
Unintentional
Non-compliance
Reason – financial hardship; age related debility
• The medical condition is sequenced first, with the underdosing listed as a
secondary diagnosis
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Underdosing or Failure in Dosage During
Medical or Surgical Care
(Y63.6, Y63.8 - Y63.9)
• Y63- describes the circumstance causing an
injury, not the nature of the injury
• It should not be used as a principal diagnosis
(always list as secondary)
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Initial vs. Subsequent Encounters
• One of the biggest misconceptions inherent to
ICD-10 is the qualifier term “subsequent”
encounter
• The designation subsequent is meant to
describe the patient has received active
treatment (initial) and the physician is now
providing routine care (subsequent) during
the healing or recovery phase
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Physician vs. Facility Requirements
• Although physicians will continue to use CPT
codes to report their procedures and services,
you will need to remain cognizant of the
documentation specificity that hospitals will
need to report procedures/services with ICD10-PCS for inpatients
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ICD-10-PCS Code Structure
Character
1
Character
2
Character
3
Character
4
Character
5
Character
6
Character
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
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Inpatient Procedures
• New and cutting-edge technology that have been
problematic to code for hospitals in ICD-9 will be
assigned in ICD-10-PCS based on surgeon’s
documentation in the operative note
– Type of surgery – e.g. medical, surgical
– Body system – e.g. Heart and Great Vessels
– Root operation – e.g. Ablation, Bypass, Excision, Revision,
etc.
– Body part – e.g. Coronary arteries, veins
– Approach – e.g. open, percutaneous
– Device – e.g. stent, none
– Qualifiers (e.g. biopsy, second site, bifurcation, etc.)
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General Documentation Tips
Incorporating these aspects into your documentation will result
in an accurate picture in the patient’s severity of illness and risk
of mortality
• Use adjectives (acute, chronic, acute-on-chronic, mild,
moderate, severe, persistent)
• Indicate cause and effect (due to or secondary to)
• Be specific about the aspects of the disease (use current
terminology)
• Specify the anatomical site
• Use exact dates
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Clear Clinical Documentation
Avoid using “history of” when documenting a current,
chronic condition; in coding “history of” means the
patient no longer has the condition
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Put M.E.A.T. in Documentation for
Healthy Audits
• Problem lists must show evaluation and
treatment for each condition that relates to a
diagnosis code
• Monitor -signs, symptoms, disease progression,
disease regression
• Evaluate - test results, medication effectiveness,
response to treatment
• Address - ordering tests, discussion, review
records, counseling
• Treat - medications, therapies, other modalities
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Ordering Diagnostic/Therapeutic
Services
• Governmental and third party payers require the
performing provider (hospital ancillary
departments, outpatient freestanding centers,
independent labs, etc.) to provide ICD9/10 codes
for outpatient diagnostic and/or therapeutic
testing/services that they perform and submit for
payment on behalf of your patients
• These providers rely on you, the ordering
physician, to submit the appropriate diagnosis
code at the time of ordering to establish medical
necessity for the test ordered
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CMS FAQ 7579 – Refills
(Medicaid Requirement)
• If a payer/pharmacy requires a diagnosis code for a
prescription and the prescriber reports an ICD-9 diagnosis
code because it is prescribed prior to the October 1, 2015
ICD-10 implementation date, what diagnosis code must be
reported if that same prescription is filled and processed
after the October 1, 2015 ICD-10 implementation date?
• When conducting a standard transaction, medical data code
sets (ICD-9 and ICD-10) that are valid at the time that the
service is provided (prescription fill date) must be used (45
CFR 162.1000).For example: A prescription, reporting an ICD9 diagnosis code, is dated 09/20/2015. The prescription is
filled and processed by the pharmacy on 10/02/2015.
CMS FAQ 7579 - Refills
• The Date of Service reported by the pharmacy
on the claim is 10/02/2015 (even though the
prescription was written 09/20/2015).
• The claim, when submitted on 10/02/2015, is
required to report an ICD-10 diagnosis code. A
prescription, reporting an ICD-9 diagnosis
code, is dated 08/01/2015.
CMS FAQ 7579 - Refills
• Refills for the prescription occur monthly and four refills are
allowed. The prescription is filled and processed by the
pharmacy 08/01/2015. An ICD-9 code is reported, if a
diagnosis code is required.
• The same prescription is refilled and processed by the
pharmacy on 09/01/2015. An ICD-9 is reported.
• The same prescription is refilled and processed by the
pharmacy on 10/01/2015. An ICD-10 code must now be
reported.
• The same prescription is refilled and processed by the
pharmacy 11/01/2015. An ICD-10 code must be reported.
• The refill date of service is the date that the prescription is
filled and processed, not the date the prescription was
written. This is especially relevant for prescriptions that may
be scheduled for automatic refills.
ICD-10 Specialty Specific Diagnoses
• The diagnoses reviewed today are not all-inclusive, but
serve as a guide to improving clinical documentation,
correct coding with ICD-10 and capturing severity,
acuity, and risk of mortality for the patients you serve
• The diagnoses listed are top ICD-9 diagnosis codes
obtained from the Network that providers are using
today. The mappings are a result of current
code/documentation. In order to capture the greatest
level of specificity, compare your current
documentation with code options in the coding manual
to determine opportunities for documentation
improvement.
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Some ICD-10 Areas That Require
Attention
•
•
•
•
•
•
•
Site (upper, mid, lower), especially neoplasms
Laterality (right, left, bilateral)
Severity (acute, chronic, acute-on-chronic)
Cause (etiology, manifestation, complications, organisms)
Acquired vs. congenital conditions
Diagnosis not addressed in note
Diagnosis missing clinical detail such as type of
disease/injury
• Pathology or radiographic findings not documented by
attending provider
• Stage (CKD or pressure ulcer)
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Suture Removal
ICD-9-CM
ICD-10-CM
V58.32 Encounter for removal
of sutures
Z48.02 Encounter for removal of
sutures
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Dysphagia
ICD-9-CM
ICD-10-CM
787.20 Dysphagia, unspecified
R13.10 Dysphagia, unspecified ** There
are more specific code choice selections
available in ICD-10-CM. These include:
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase
R13.13 Dysphagia, pharyngeal phase
R13.14 Dysphagia, pharyngoesophageal
phase
R13.19 Other dysphagia
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Clinical Documentation Awareness Tips
Gastrointestinal Documentation Awareness
Fever
•Document the cause if known e.g. drug induced, post procedural
Diarrhea has many combination codes in ICD-10 where it is included as a manifestation
• Document the cause e.g. Infectious, postgastrectomy, toxic, allergic, drug-induced, etc
Clinical Documentation Awareness Tips
Gastrointestinal Coding Awareness
Etiology if known to identify condition to code in lieu of the sign/symptom of abdominal
pain.
Laterality
e.g. left, right
Anatomical location
e.g. upper, lower, epigastric, etc.
Gastrointestinal
ICD-9-CM
ICD-10-CM
787.01 Nausea & Vomiting
R11.2 Nausea with vomiting, unspecified
787.02 Nausea alone
R11.0 Nausea
787.03 Vomiting alone
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.13 Vomiting of fecal matter
R11.14 Bilious vomiting
564.00 Constipation
K59.00 Constipation, unspecified
K59.01 Slow transit constipation
K59.02 Outlet dysfunction constipation
K59.09 Other constipation
787.91 Diarrhea
R19.7 Diarrhea NOS
K59.1 Functional diarrhea
Barrett’s Esophagus
ICD-9-CM
ICD-10-CM
530.85 Barrett's esophagus
K22.70 Barrett’s esophagus without
dysplasia
K22.710 Barrett’s esophagus with low
grade dysplasia
K22.711 Barrett’s esophagus with high
grade dysplasia
K22.719 Barrett’s esophagus with
dysplasia, unspecified
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CA Esophagus
ICD-9-CM
ICD-10-CM
150.9 Malignant neoplasm of esophagus,
unspecified site
C15.9 Malignant neoplasm of esophagus,
unspecified
* Use additional code to identify:
• alcohol abuse or dependence (F10.-)
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GERD
ICD-9-CM
ICD-10-CM
530.81 Esophageal reflux
K21.0 Gastro-esophageal reflux disease
with esophagitis
K21.9 Gastro-esophageal reflux disease
without esophagitis
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Anemia
Anemia Documentation Awareness
• Documentation of Anemia should include the type of anemia:
-- Nutritional
-- Hemolytic
-- Aplastic
-- Due to blood loss
-- Other (please specify)
• Include in documentation if Anemia is due to nutrition or mineral deficits,
resulting in a nutritional anemia
• Document if the Anemia is due to a neoplasm (primary and/or
secondary)
• Document whether the ANEMIA is “related to or due to” chemo or
radiotherapy treatments
• Document any “cause–and-effect” relationship between the intervention
and the blood or immune disorder
• Document the specific drug if anemia is drug-induced
• Link any laboratory findings to a related diagnosis (if appropriate)
• Document any associated diagnoses/conditions
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Anemia
ICD-9-CM
ICD-10-CM
285.9 Anemia, unspecified
D64.9 *Anemia, unspecified
*There are more specific code choice
selections available in ICD-10-CM. These
include:
D64.81 Anemia due to antineoplastic
chemotherapy
D63.0 Anemia in neoplastic disease
D61.1 Aplastic anemia due to
antineoplastic chemotherapy
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Autoimmune Hemolytic Anemias
ICD-9-CM
ICD-10-CM
283.0 Autoimmune hemolytic anemias
D59.0 Drug-induced autoimmune
hemolytic anemia
D59.1 Other autoimmune hemolytic
anemias
* Use additional code for adverse effect,
if applicable, to identify drug (T36-T50
with fifth or sixth character 5)
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65
Abdominal Pain
ICD-9-CM
ICD-10-CM
789.00 Abdominal pain, unspecified
R10.0 Acute abdomen
R10.10 Upper abdominal pain,
unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain,
unspecified
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.84 Generalized abdominal pain
R10.9 Unspecified abdominal pain
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Anal Fissure
ICD-9-CM
ICD-10-CM
565.0 Anal fissure
K60.0 Acute anal fissure
K60.1 Chronic anal fissure
K60.2 Anal fissure, unspecified
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Clinical Documentation Awareness Tips
Enteritis / Crohn’s Documentation Awareness
Site:
e.g. small, large, both
With complication:
e.g. abscess, fistula, intestinal obstruction, rectal bleeding
Enteritis / Crohn’s Disease
ICD-9-CM
ICD-10-CM
555.9 Regional enteritis of unspecified
site
K50.90 Crohn’s disease, unspecified,
without complications
** Use additional code to identify
manifestations, such as: pyoderma
gangrenosum (L88)
* There are more specific code choice
selections available in
ICD-10-CM. These include:
K50.00 Crohn’s disease of small intestine
without complications
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Crohn’s Disease
ICD-9-CM
ICD-10-CM
K50.011 Crohn’s disease of small intestine
with rectal bleeding
K50.012 Crohn’s disease of small intestine
with intestinal obstruction
K50.013 Crohn’s disease of small intestine
with fistula
K50.014 Crohn’s disease of small intestine
with abscess
K50.018 Crohn’s disease of small intestine
with other complication
K50.019 Crohn’s disease of small intestine
with unspecified complications
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Crohn’s Disease
ICD-9-CM
ICD-10-CM
K50.10 Crohn’s disease of large intestine
without complications
K50.111 Crohn’s disease of large intestine
with rectal bleeding
K50.112 Crohn’s disease of large intestine
with intestinal obstruction
K50.113 Crohn’s disease of large intestine
with fistula
K50.114 Crohn’s disease of large intestine
with abscess
K50.118 Crohn’s disease of large intestine
with other complication
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Crohn’s Disease
ICD-9-CM
ICD-10-CM
K50.119 Crohn’s disease of large intestine
with unspecified complications
K50.80 Crohn’s disease of both small and
large intestine without complications
K50.811 Crohn’s disease of both small and
large intestine with rectal bleeding
K50.812 Crohn’s disease of both small and
large intestine with intestinal obstruction
K50.813 Crohn’s disease of both small and
large intestine with fistula
K50.814 Crohn’s disease of both small and
large intestine with abscess
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Crohn’s Disease
ICD-9-CM
ICD-10-CM
K50.818 Crohn’s disease of both small and
large intestine with other complication
K50.819 Crohn’s disease of both small and
large intestine with unspecified
complications
K50.911 Crohn’s disease, unspecified,
with rectal bleeding
K50.912 Crohn’s disease, unspecified,
with intestinal obstruction
K50.913 Crohn’s disease, unspecified,
with fistula
K50.914 Crohn’s disease, unspecified,
with abscess
K50.918 Crohn’s disease, unspecified,
with other complication
K50.919 Crohn’s disease, unspecified,
with unspecified complications
Diabetes Mellitus
ICD-9-CM
ICD-10-CM
Type
• Type I
• Type 2
• Secondary diabetes mellitus
Type
•
Type 1
•
Type 2
•
Drug/chemical induced
•
Due to underlying condition
•
Specified Type
Control
• Controlled
• Uncontrolled
Control
•
Inadequately controlled
•
Out of control
•
Poorly controlled
•
Hypoglycemia
•
Hyperglycemia
Manifestation/Complication
• Hyperosmolarity
• Ketoacidosis
• Neurological manifestations
• Other coma
• Peripheral circulatory disorder
• Renal Manifestations
• Other specified manifestations
• Without Complications
Manifestation/Complication
•
Arthropathy
•
Circulatory complications
•
Hyperosmolarity
•
Hypoglycemia
•
Ketoacidosis
•
Kidney complications
•
Neurological complications
•
Ophthalmic complications
•
Oral complications
•
Skin complications
•
Without complications
Insulin Use
Insulin Use
•
No longer required for Type 1
•
For Type 2 any long-term or current use is reported
74
Diabetes Mellitus
ICD-9-CM Code
ICD-10-CM Code(s)
250.00 – Diabetes mellitus without
mention of complications type II or
unspecified type, not states as controlled
E11.9 – Type 2 diabetes mellitus without
complications
Diabetes Mellitus Documentation Awareness
Capturing the correct code for Diabetes Mellitus requires clear and precise
documentation of the underlying cause. Diabetes mellitus codes in ICD-10 reflect
combination codes. The components of the combination codes are:
• Type of Diabetes
• Body System Affected
• Specified complications/manifestations affecting the body system
75
Diabetes Mellitus Documentation Awareness
Type of Diabetes
• Drug or Chemical Induced (E09) – (anticonvulsants; antihypertensive drugs
including diuretics and beta blockers; antipsychotic drugs including lithium
and antidepressants; antiretroviral drugs; chemotherapy drugs; hormone
supplements including anabolic steroids, contraceptives, estrogen, growth
hormones and hormones for prostate cancer)
• Due to an underlying condition (E08)
• Type I diabetes (E10) – controlled/not specified; uncontrolled
• Type 2 diabetes (E11) – controlled/not specified; uncontrolled
• Other specified diabetes (E13) – secondary diabetes mellitus –
controlled/not specified; uncontrolled
For Type 2 diabetes mellitus and secondary diabetes mellitus, any long-term
or current use of insulin is reported as an additional code.
You may report more than one diabetes code for patients with multiple
complications or when multiple body systems are affected as a result of the
diabetes.
Secondary diabetes is defined as a diabetic condition with an underlying
cause other than genetics or environmental conditions (includes due to
drugs, chemicals, medical conditions, surgical procedures or trauma)
76
Diabetes
Diabetes Mellitus Documentation Awareness
Body System Affected
• Circulatory complications
• Hyperosmolarity
• Kidney complications
• Ketoacidosis
• Other coma
• Neurological complications
• Ophthalmic complications
• Other specified complications/manifestations
• Unspecified complications/manifestations
• Without complications/manifestations
77
Diabetes Mellitus Documentation Awareness
Specified complications/manifestations affecting the body system
•
•
•
•
•
•
•
•
•
•
Circulatory complications – peripheral
Hyperosmolarity
Hypoglycemia (with or without coma)
Kidney complications – diabetic nephropathy; chronic kidney disease; other
Ketoacidosis – with or without coma
Neurological complications – amyotrophy; autonomic polyneuropathy;
mononeuropathy, polyneuropathy; other; unspecified
Ophthalmic complications – diabetic retinopathy (mild, moderate or severe
nonproliferative with or without macular edema); diabetic cataract; other
Other specified complications/manifestations – skin complications (dermatitis,
foot ulcer; other skin ulcer; other skin complications; oral complications
(periodontal disease; other)
Unspecified complications/manifestations
Without complications/manifestations
78
Clinical Documentation Awareness Tips
Hypertension Documentation Awareness
Type:
e.g. essential or secondary
Causal relationship:
e.g. relationship between hypertension and
renals, pulmonary, heart
• Note: The Hypertension Table in ICD-10-CM has been eliminated. The same code is
used regardless of whether the hypertension is described as benign, malignant or
whether or not a qualifier is used
Hypertension
ICD-9-CM
401.0
Malignant HTN
401.1
Benign HTN
401.9
Unspecified
ICD-10-CM
I10
Essential (primary) hypertension
80
Cleft Palate
ICD-9-CM
ICD-10-CM
749.00 Cleft palate unspecified
749.01 Cleft palate, unilateral, complete
749.02 Cleft palate, unilateral,
incomplete
749.03 Cleft palate, bilateral, complete
749.04 Cleft palate, bilateral, incomplete
749.20 Cleft palate with cleft lip,
unspecified
Q35 Cleft palate
Q35.1 Cleft hard palate
Q35.3 Cleft soft palate
Q35.5 Cleft hard palate with cleft soft
palate
Q35.7 Cleft uvula
Q35.9 Cleft palate, unspecified
Q36 Cleft lip
Q36.0 Cleft lip, bilateral
Q36.1 Cleft lip, median
Q36.9 Cleft lip, unilateral
Q37 Cleft palate with cleft lip
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Cleft Palate
ICD-9-CM
ICD-10-CM
Q37.0 Cleft hard palate with bilateral cleft
lip
Q37.1 Cleft hard palate with unilateral
cleft lip
Q37.2 Cleft soft palate with bilateral cleft
lip
Q37.3 Cleft soft palate with unilateral
cleft lip
Q37.4 Cleft hard and soft palate with
bilateral cleft lip
Q37.5 Cleft hard and soft palate with
unilateral cleft lip
Q37.8 Unspecified cleft palate with
bilateral cleft lip
Q37.9 Unspecified cleft palate with
unilateral cleft lip
Documentation Awareness Tips
Fracture Documentation Awareness
Type:
e.g. open, closed, stress, pathologic, etc.
Anatomical location:
e.g. nasal, distal, proximal, index, ring, etc.
Laterality
e.g. left, right, bilateral
Site:
e.g. distal pole, middle third, body, hook process, larger/smaller multangular, neck,
shaft, base, etc.
Healing status:
e.g. malunion, nonunion, delayed healing, etc.
Encounter of care:
e.g. initial, subsequent, sequelae
Alignment:
e.g. displaced, non displaced
Classification:
e.g. Bennett’s, Rolando’s, etc.
Etiology:
e.g. traumatic, pathologic (age, osteopenia)
Encounter of care
• An initial encounter is used when the patient is receiving active treatment (surgical treatment, ER encounter,
evaluation by a new physician)
• A subsequent encounter is used once active treatment has been completed and is receiving care during the
recovery phase. (cast change, cast removal, medication adjustment, removal of a fixation device, follow-up visits
after fracture treatment)
Documentation Awareness Tips
7th digit for injury section – Fx nasal bones
Category S02, S12, S22, S32, S92,
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
S
Sequela
Fracture Nasal Bones
ICD-9-CM
ICD-10-CM
802.0 Fracture of nasal bones, closed
S02.2xxA Fracture of nasal bones, initial
encounter for closed fracture
S02.2xxD Fracture of nasal bones,
subsequent encounter for fracture with
routine healing
S02.2xxG Fracture of nasal bones,
subsequent encounter for fracture with
delayed healing
S02.2xxK Fracture of nasal bones,
subsequent encounter for fracture with
nonunion
S02.2xxS Fracture of nasal bones, sequela
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Gallstones
ICD-9-CM
ICD-10-CM
574.20 Calculus of gallbladder without
K80.20 Calculus of gallbladder without
mention of cholecystitis, without mention cholecystitis without obstruction
of obstruction
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Inguinal hernia
ICD-9-CM
ICD-10-CM
550.90 Inguinal hernia, without mention
of obstruction or gangrene, unilateral or
unspecified (not specified as recurrent)
K40.90 Unilateral inguinal hernia, without
obstruction or gangrene, not specified as
recurrent
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Sinusitis
ICD-9-CM
ICD-10-CM
473.9 Unspecified sinusitis (chronic)
J32.9 Chronic sinusitis, unspecified
• Use additional code to identify:
Exposure to environmental tobacco
smoke (Z77.22)
• Exposure to tobacco smoke in the
perinatal period (P96.81)
• History of tobacco use (Z87.891)
• Occupational exposure to
environmental tobacco smoke (Z57.31)
Tobacco dependence (F17-)
• Tobacco use (Z72.0)
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Sinusitis
ICD-9-CM
ICD-10-CM
** There are more specific code choice
selections available in ICD-10-CM. These
include:
J32.0 Chronic maxillary sinusitis
J32.1 Chronic frontal sinusitis
J32.2 Chronic ethmoidal sinusitis
J32.3 Chronic sphenoidal sinusitis
J32.4 Chronic pansinusitis
J32.8 Other chronic sinusitis
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Tobacco Abuse/Dependence
ICD-9-CM
305.1 Tobacco abuse/dependence
ICD-10-CM
F17.211 Nicotine dependence , cigarettes, in remission
F17.213 Nicotine dependence, cigarettes, with withdrawal
F17.218 Nicotine dependence, cigarettes, with other nicotineinduced disorders
F17.221 Nicotine dependence , chewing tobacco, in remission
F17.223 Nicotine dependence, chewing tobacco, with withdrawal
F17.228 Nicotine dependence, chewing tobacco, with other
nicotine-induced disorders
Z72.0 Tobacco use
Chronic Tonsillitis
ICD-9-CM
ICD-10-CM
474.00 Chronic tonsillitis
J35.01 Chronic tonsillitis
• Use additional code to identify:
Exposure to environmental tobacco
smoke (Z77.22)
• Exposure to tobacco smoke in the
perinatal period (P96.81)
• History of tobacco use (Z87.891)
Occupational exposure to
environmental tobacco smoke
• (Z57.31)
• Tobacco dependence (F17-)
• Tobacco use (Z72.0)
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Morbid Obesity
ICD-9-CM
ICD-10-CM
278.01 Morbid obesity
E66.01 Morbid (severe) obesity due to
excess calories
* Code first obesity complicating
pregnancy, childbirth and the
puerperium, if applicable (O99.21-)
**Use additional code to identify body
mass index (BMI), if known (Z68-)
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Intensive Behavioral Therapy (IBT) for Obesity
Body Mass Index (BMI), Adult
ICD-9-CM
ICD-10-CM
V85.30 BMI 30.0-30.9, adult
Z68.30 BMI 30.0-30.9, adult
V85.31 BMI 31.0-31.9, adult
Z68.31BMI 31.0-31.9, adult
V85.32 BMI 32.0-32.9, adult
Z68.32 BMI 32.0-32.9, adult
V85.33 BMI 33.0-33.9, adult
Z68.33 BMI 33.0-33.9, adult
V85.34 BMI 34.0-34.9, adult
Z68.34 BMI 34.0-34.9, adult
V85.35 BMI 35.0-35.9, adult
Z68.35 BMI 35.0-35.9, adult
V85.36 BMI 36.0-36.9, adult
Z68.36 BMI 36.0-36.9, adult
V85.37 BMI 37.0-37.9, adult
Z68.37 BMI 37.0-37.9, adult
V85.38 BMI 38.0-38.9, adult
Z68.38 BMI 38.0-38.9, adult
V85.39 BMI 39.0-39.9, adult
Z68.39 BMI 39.0-39.9, adult
Body Mass Index (BMI), Adult
ICD-9-CM
ICD-10-CM
V85.41 BMI 40.0-44.9, adult
Z68.41BMI 40.0-44.9, adult
V85.42 BMI 45.0-49.9, adult
Z68.42 BMI 45.0-49.9, adult
V85.43 BMI 50.0-59.9, adult
Z68.43 BMI 50.0-59.9, adult
V85.44 BMI 60.0-69.9, adult
Z68.44 BMI 60.0-69.9, adult
V85.45 BMI 70 and over, adult
Z68.45 BMI 70 and over, adult
Chronic Suppurative Otitis Media
ICD-9-CM
ICD-10-CM
382.3 Unspecified chronic suppurative
otitis media
H66.3x1 Other chronic suppurative otitis
media, right ear
H66.3x2 Other chronic suppurative otitis
media, left ear
H66.3x3 Other chronic suppurative otitis
media, bilateral
H66.3x9 Other chronic suppurative otitis
media, unspecified ear
*Use additional code for any associated
perforated tympanic membrane (H72-)
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Chronic Suppurative Otitis Media
ICD-9-CM
ICD-10-CM
• Use additional code to identify:
Exposure to environmental tobacco
smoke (Z77.22)
• Exposure to tobacco smoke in the
perinatal period (P96.81)
• History of tobacco use (Z87.891)
• Occupational exposure to
environmental tobacco smoke (Z57.31)
Tobacco dependence (F17-)
• Tobacco use (Z72.0)
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Perforation of Tympanic Membrane
ICD-9-CM
ICD-10-CM
384.20 Perforation of tympanic
membrane, unspecified
H72.90 Unspecified perforation of
tympanic membrane, unspecified ear
** Code first any associated otitis media
(H65-, H66.1-, H66.2-, H66.3-, H66.4-,
H66.9-, H67-)
H72.91 Unspecified perforation of
tympanic membrane, right ear
H72.92 Unspecified perforation of
tympanic membrane, left ear
H72.93 Unspecified perforation of
tympanic membrane, bilateral
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Perforation of Tympanic Membrane
ICD-9-CM
ICD-10-CM
** There are more specific code choice
selections available in ICD-10-CM. These
include:
H72.00 Central perforation of tympanic
membrane, unspecified ear
H72.01 Central perforation of tympanic
membrane, right ear
H72.02 Central perforation of tympanic
membrane, left ear
H72.03 Central perforation of tympanic
membrane, bilateral
H72.10 Attic perforation of tympanic
membrane, unspecified ear
H72.11 Attic perforation of tympanic
membrane, right ear
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Perforation of Tympanic Membrane
ICD-9-CM
ICD-10-CM
H72.12 Attic perforation of tympanic
membrane, left ear
H72.13 Attic perforation of tympanic
membrane, bilateral
H72.2x1 Other marginal perforations of
tympanic membrane, right ear
H72.2x2 Other marginal perforations of
tympanic membrane, left ear
H72.2x3 Other marginal perforations of
tympanic membrane, bilateral
H72.2x9 Other marginal perforations of
tympanic membrane, unspecified ear
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Perforation of Tympanic Membrane
ICD-9-CM
ICD-10-CM
H72.811 Multiple perforations of
tympanic membrane, right ear
H72.812 Multiple perforations of
tympanic membrane, left ear
H72.813 Multiple perforations of
tympanic membrane, bilateral
H72.819 Multiple perforations of
tympanic membrane, unspecified ear
H72.821 Total perforations of tympanic
membrane, right ear
H72.822 Total perforations of tympanic
membrane, left ear
H72.823 Total perforations of tympanic
membrane, bilateral
H72.829 Total perforations of tympanic
membrane, unspecified ear
Screening Codes
• Documentation for screenings must include
any abnormal finding which would be listed
secondary to the screening codes
• Screening codes in ICD-10 can be broken
down by the condition, procedure, or
anatomic location depending on the type of
screening
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101
Screening
ICD-9-CM
ICD-10-CM
V76.2 Special screening examination for
malignant neoplasm of cervix
Z12.4 Encounter for screening malignant
neoplasm of cervix
V74.5 Screening examination for venereal
disease
Z11.3 Screening examination for venereal
disease
V76.44 Special screening for malignant
neoplasm of prostate
Z12.5 Encounter for screening malignant
neoplasm of prostate
V76.51 Special screening for malignant
neoplasms of colon
Z12.11 Encounter for screening malignant
neoplasm of colon
V72.84 Preoperative examination,
unspecified
Z01.812 Encounter for preprocedural
laboratory examination
Z01.818 Encounter for other preprocedural
examination
V77.91 Screening for lipoid disorders
Z13.220 Encounter for screening for lipoid
disorders
V73.81 Special screening for HPV
Z11.51 Encounter for screening for HPV
History of Colon Polyps
ICD-9-CM
ICD-10-CM
V10.05 Personal history of malignant
neoplasm of large intestine
Z85.038 Personal history of other
malignant neoplasm of large intestine
Z85.030 Personal history of malignant
carcinoid tumor of large intestine
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Table of Neoplasms
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Unspecified
Behavior
Uncertain
Benign
CA in-situ
Malignant
Secondary
Neoplasm, neoplastic
Malignant
Primary
• The Neoplasm Table is formatted similarly to
the table in ICD-9-CM and contains the same
Headings
104
Neoplasm Documentation
Neoplasm Documentation Awareness
Documentation should include:
• Behavior
- Malignant (primary, secondary, in-situ)
Document any secondary sites
- Benign
- Unspecified behavior
- Of certain histological behavior
• Laterality (right/left)
• Anatomical site (topography)
• Other condition(s) associated with malignancy – (dehydration, anemia, etc.)
• Complication(s) associated with neoplasm
• Include estrogen receptor status (if applicable)
• History of:
- Has the malignancy been excised or eradicated?
- Is there still treatment being provided for the primary and/or secondary site?
- Is there evidence of remaining malignancy at the primary site?
• Document any associated diagnoses/conditions
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105
Neoplasms
• Overlapping sites
• Laterality – Left vs. Right
• C50.2 Malignant neoplasm, of upper-inner
quadrant of breast)
– C50.21 Malignant neoplasm of upper-inner quadrant
of breast, female
• C50.211 Malignant neoplasm of upper-inner quadrant of
right female breast
• C50.212 Malignant neoplasm of upper-inner quadrant of left
female breast
• C50.219 Malignant neoplasm of upper-inner quadrant of
unspecified female breast
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106
CA of Breast
ICD-9-CM
ICD-10-CM
174.9 Malignant neoplasm of breast
(female, unspecified)
C50.919 Malignant neoplasm of
unspecified site of unspecified
female breast
* Use additional code to identify
estrogen receptor status
(Z17.0, Z17.1)
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107
Postmastectomy Lymphedema
Syndrome
ICD-9-CM
ICD-10-CM
457.0 Postmastectomy lymphedema
syndrome
I97.2 Postmastectomy
lymphedema syndrome
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108
Breast Implants
• Breast implants without complications –
Z98.82
• If the patient previously had breast implants
but they have been removed – Z98.86 (Hx
breast implant removal)
• Complications from breast implants (e.g.
rupture of breast implant) – T85.49xA
– The only code reported is the complication code
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Cosmetic Plastic Surgery, Other (Breast
Augmentation, Face Lift, etc.)
ICD-9-CM
ICD-10-CM
Z41.1: Encounter for cosmetic surgery
Z41.2: Encounter for routine and ritual
male circumcision
Z41.3: Encounter for ear piercing
Z41.8: Encounter for other procedures for
purposes other than remedying health
state
Z41.9: Encounter for procedure for
purposes other than remedying health
state, unspecified
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Swelling, Mass or Lump in Head and
Neck
ICD-9-CM
ICD-10-CM
784.2 Swelling, mass, or lump in head and R22.0 Localized swelling, mass and lump,
neck
head
R22.1 Localized swelling, mass and lump,
neck
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Benign Neoplasm of Colon
ICD-9-CM
ICD-10-CM
211.3 Benign neoplasm of colon
D12.0 Benign neoplasm of cecum
D12.1 Benign neoplasm of appendix
D12.2 Benign neoplasm of ascending
colon
D12.3 Benign neoplasm of transverse
colon
D12.4 Benign neoplasm of descending
colon
D12.5 Benign neoplasm of sigmoid colon
D12.6 Benign neoplasm of colon,
unspecified
D12.7 Benign neoplasm of rectosigmoid
junction
K63.5 Polyp of colon
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CA of Colon
ICD-9-CM
ICD-10-CM
153.9 Malignant neoplasm of colon,
unspecified site
C18.9 Malignant neoplasm of
colon, unspecified
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113
CA of Rectum
ICD-9-CM
ICD-10-CM
154.1 Malignant neoplasm of rectum
C20 Malignant neoplasm of
rectum
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114
CA Pancreas
ICD-9-CM
ICD-10-CM
157.9 Malignant neoplasm of pancreas,
part unspecified
C25.9 Malignant neoplasm of pancreas,
unspecified
* Use additional code to identify:
• alcohol use and dependence (F10.-)
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115
Benign Neoplasm of the Colon
ICD-9-CM
ICD-10-CM
211.3 Benign neoplasm colon
D12.6 Benign neoplasm of colon,
unspecified
• There are more specific code choice
selections available in ICD-10-CM.
• These include:
D12.0 Benign neoplasm of cecum
D12.1 Benign neoplasm of appendix
D12.2 Benign neoplasm of ascending
colon
D12.3 Benign neoplasm of transverse
colon
D12.4 Benign neoplasm of descending
colon
D12.5 Benign neoplasm of sigmoid colon
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Vocal Cord Polyp
478.4 Polyp of vocal cord or larynx
J38.1 Polyp of vocal cord and larynx
* Use additional code to identify:
Exposure to environmental tobacco
smoke (Z77.22)
Exposure to tobacco smoke in the
perinatal period (P96.81)
History of tobacco use (Z87.891)
Occupational exposure to environmental
tobacco smoke (Z57.31)
Tobacco dependence (F17-)
Tobacco use (Z72.0)
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GI Bleeding
ICD-9-CM
ICD-10-CM
578.9 Hemorrhage of gastrointestinal
tract, unspecified
K92.2 Gastrointestinal hemorrhage,
unspecified
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Diverticular Disease
ICD-9-CM
ICD-10-CM
562.10 Diverticulosis of colon
(without hemorrhage)
562.11 Diverticulitis of colon without
mention of hemorrhage
K57.30 Diverticulosis of large intestine
without perforation or abscess without
bleeding
K57.32 Diverticulitis of large intestine
without perforation or abscess without
bleeding
K57.20 Diverticulitis of large intestine
with perforation and abscess without
bleeding
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Urosepsis
• Urosepsis will not be considered synonymous
with sepsis. It has no default code in the
Alphabetic Index.
• Should a Provider use this term he/she must
be queried for clarification
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Urinary Tract Infection
ICD-9-CM
ICD-10-CM
599.0 Urinary Tract Infection, unspecified
N39.0 Urinary Tract Infection, site not
specified
*Use additional code to identify
infectious agent (B95-B97)
**There are more specific code choice
selections available in ICD-10-CM These
include:
N30.00 Acute cystitis without hematuria
N30.01 Acute cystitis with hematuria
N30.10 Interstitial cystitis chronic without
hematuria
N30.11 Interstitial cystitis chronic with
hematuria
N30.20 Other chronic cystitis without
hematuria
N30.21 Other chronic cystitis with
hematuria
Urinary Tract Infection
ICD-9-CM
ICD-10-CM
N30.30 Trigonitis without hematuria
N30.31 Trigonitis with hematuria
N30.40 Irradiation cystitis without
hematuria
N30.41 Irradiation cystitis with hematuria
N30.80 Other cystitis without hematuria
N30.81 Other cystitis with hematuria
N30.90 Cystitis, unspecified without
hematuria
N30.91 Cystitis, unspecified with
hematuria
N15.9 Renal tubulo-interstitial disease,
unspecified
N34.1 Nonspecific urethritis
N34.2 Other urethritis
122
Sepsis
Clinical Documentation Awareness
In ICD-10, there will no longer be a designation for “septicemia”; bacteremia (R78.81)
or bacterial sepsis will be preferred. Specify whether bacteremia is due to septic
condition in the body or is transient due to a procedure or unknown cause
Sepsis documentation should include:
• the source of the infection if known
• the patient’s signs and symptoms of sepsis
• the presence of organ failure (renal, respiratory hepatic, etc.) related to sepsis
• whether positive blood cultures are clinically significant or contaminates
• other factors such as immunocompromise (diabetes, steroid therapy, malnutrition,
immunoglobulin deficiency, chemotherapy)
• the likely relationship to implanted devices
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Sepsis
ICD-9-CM
ICD-10-CM
995.91 Sepsis
A41.9 Sepsis, unspecified organism
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HIV
Source: www.cdc.gov/nchs/icd/icd10cm.htm
Topic
ICD-10-CM Code Ranges
Documentation
Tips/Guidelines
HIV
HIV Asymptomatic
AIDS
Z21 – HIV currently
asymptomatic
B20 - AIDS
Code only confirmed cases
Confirmation does not
require positive serology or
culture for HIV-only;
requires physician
statement
NOTE: Inpatient hospital
guidelines are different.
Known HIV or HIV-positive
should be clearly
documented.
If patient admitted for HIVrelated disease or AIDS,
first listed diagnosis is B20,
then the additional codes
for the related condition 125
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Infectious Diseases
Source: www.cdc.gov/nchs/icd/icd10cm.htm
Topic
ICD-10-CM Code Ranges
Documentation
Tips/Guidelines
Infections Resistant to
Antibiotics
Z16 Resistance to
antimicrobial drug
Specify which antibiotic
the organism is resistant to
in the medical record
MRSA Conditions
MRSA Carrier/Colonization
MRSA
Susceptible/Colonization
Usually appears as
combination code that has
the disease and causal
organism together
Z2.322 Carrier or
suspected carrier of MRSA
Z22321 Carrier or
suspected carrier of
methicillin susceptible
Z22.321 MRSA susceptible
with colonization
Example: Pneumonia due
to MRSA is code J15.212 .
Do not use additional code
for resistance to Penicillin,
Z16.11. If a current
infection does not have a
combination code for
MRSA, use the code to
identify the condition and
use B95.62 for MRSA
organism
Document carrier or
126
susceptibility to MRSA
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Asceptic Necrosis
Source: www.cdc.gov/nchs/icd/icd10cm.htm
Topic
ICD-10-CM Code Range
Documentation
Tips/Guidelines
Asceptic Necrosis
M87.00 – M90.59
Specify in documentation
whether due to drugs,
trauma, idiopathic,
asceptic necrosis or
secondary osteonecrosis.
Specify exact anatomic site
as well as laterality (left or
right).
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Cellulitis
Source: www.cdc.gov/nchs/icd/icd10cm.htm
Topic
ICD-10-CM Code Ranges
Cellulitis
Carbuncle/Furuncle
L02.02 – L02.03
Cellulitis/Abscess/Onchyia/ L02.02 – L03.91
Paronychia
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Documentation
Tips/Guidelines
Specify carbuncle/furuncle
and provide exact site
location.
Document specific body
part, cellulitis, abscess,
lymphangitis as
appropriate
Document right or left as
appropriate
128
Carotid Artery Stenosis
ICD-9-CM
Icd-10-CM
433.10 Occlusion and stenosis of carotid
artery without mention of
cerebral infarction
I65.21 Occlusion and stenosis of right
carotid artery
I65.22 Occlusion and stenosis of left
carotid artery
I65.23 Occlusion and stenosis of bilateral
carotid arteries
I65.29 Occlusion and stenosis of
unspecified carotid artery
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Chronic Pain
338.21 Chronic pain due to trauma
G89.21 Chronic pain due to trauma
** Code also related psychological factors
associated with pain (F45.42)
338.28 Other chronic postoperative pain
G89.28 Other chronic postprocedural pain
** Code also related psychological factors
associated with pain (F45.42)
338.4 Chronic pain syndrome
G89.4 Chronic pain syndrome
** Code also related psychological factors
associated with pain (G54.42-)
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Peripheral Vascular Disease
ICD-9-CM
ICD-10-CM
443.9 Peripheral vascular disease,
unspecified
I73.9 Peripheral vascular disease,
unspecified
** There are more specific code choice
selections available.
These include:
I73.00 Raynaud’s syndrome without
gangrene
I73.01 Raynaud’s syndrome with gangrene
I73.1 Thromboangiitis obliterans
(Buerger’s disease)
I73.81 Erythromelalgia
I73.89 Other specified peripheral vascular
diseases
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Venous Insufficiency
ICD-9-CM
ICD-10-CM
459.81 Venous (peripheral) insufficiency,
unspecified
I87.2 Venous insufficiency (chronic)
(peripheral)
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Follow-up Examination, Following
Surgery, Unspecified
ICD-9-CM
ICD-10-CM
V67.00 Follow-up examination, following
surgery, unspecified
Z09 Encounter for follow-up examination
after completed treatment for conditions
other than malignant neoplasm
** Use additional code to identify any
applicable history of disease code (Z86.-,
Z87.-)
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Clinical Documentation Awareness Tips
Acute Myocardial Infarction Documentation Awareness
Timeframe
An AMI is now considered “acute” (or recent) for 4 weeks
from the time of the incident, which is revised from ICD-9
period of 8 weeks
NOTE: document the date of the recent MI
Episode of care
No longer captured in ICD-10
Subsequent AMI
ICD-10 allows coding of a new MI that occurs during the 4
week acute period of the original AMI
Type
e.g. STEMI, NSTEMI
Site
STEMI requires site e.g. anterior wall, inferior wall
and specific artery e.g. left main coronary artery, LAD
diagonal, RCA, left circumflex oblique marginal
NSTEMI – no additional information needed
Acute Myocardial Infarction
ICD-9-CM
ICD-10-CM
ICD-10-CM
410.0X AMI of
anterolateral
wall
I21.09 STEMI involving other
coronary artery of
anterolateral wall
I22.0 Subsequent STEMI of
anterolateral wall
410.1X AMI of
other anterior
wall
I21.09 STEMI involving other
coronary artery of anterior
wall
I22.0 Subsequent STEMI of
anterior wall
410.2X AMI of
I21.19 STEMI involving other
inferolateral wall coronary artery of
inferolateral wall
I22.1 Subsequent STEMI of
inferolateral wall
410.3X AMI of
inferoposterior
wall
I21.19 STEMI involving other
coronary artery of
inferoposterior wall
I22.1 Subsequent STEMI of
inferoposterior wall
410.4X AMI of
other inferior
wall
I21.19 STEMI involving other
coronary artery of inferior
wall
I22.1 Subsequent STEMI of
inferior wall
410.5X AMI of
121.29 STEMI involving other
other lateral wall sites
I22.8 Subsequent STEMI of
other sites
Acute Myocardial Infarction (cont’d)
ICD-10-CM
I21.01 STEMI involving left
main coronary artery
I21.02 STEMI involving left
anterior descending coronary
artery
I21.11 STEMI involving right
coronary artery
I21.21 STEMI involving left
circumflex coronary artery
Chest Pain and Shortness of Breath
ICD-9-CM
ICD-10-CM
786.50 Chest pain, unspecified
R07.9 Chest pain, unspecified
786.51 Precordial pain
R07.2 Precordial pain
786.52 Painful respiration
R07.1 Chest pain on breathing
786.59 Chest pain, other
R07.89 Chest pain, other
R07.81 Pleurodynia
R07.82 Intercostal pain
786.05 Shortness of Breath
R06.02 Shortness of Breath
Documentation Awareness Tips
Open Wounds Documentation Awareness
Wounds/lacerations require a higher specificity in ICD-10
Type
e.g. puncture, open bite
Location
e.g. thumb, index, ring, little, middle
Laterality
e.g. left, right
Involvement
e.g. With nail damage, with foreign body
Don’t forget the 7th character!
Note: Each finger has a code set specific to the finger.
Open Wound Finger
ICD-9-CM
ICD-10-CM
883.0 Open wound finger(s) w/o mention
of complication
S61.011- Laceration w/o FB of right thumb w/o
damage to the nail
883.1 Open wound finger(s) w/
complication
S61012- Laceration w/o FB of left thumb w/o
damage to the nail
883.2 Open wound finger(s) w tendon
involvement
S61.021- Laceration w/ FB of right thumb w/o
damage to the nail
S61.022- Laceration w/ FB of left thumb w/o
damage to the nail
S61.031- Puncture wound w/o FB of right thumb
w/o damage to nail
S61.032- Puncture wound w/o FB of left thumb
w/o damage to nail
S61.041 -Puncture wound w/ FB of right thumb
w/o damage to nail
S61.042- Puncture wound w/ FB of left thumb
w/o damage to nail
S61.051- Open bite of right thumb w/o damage
to nail
S61.052- Open bite of right thumb w/o damage
to nail
Open Wound Finger (cont’d)
ICD-9-CM
ICD-10-CM
883.0 Open wound finger(s) w/o mention S61.111- Laceration w/o FB of right thumb w/
of complication
damage to the nail
883.1 Open wound finger(s) w/
complication
S61.112- Laceration w/o FB of left thumb
w/damage to the nail
883.2 Open wound finger(s) w tendon
involvement
S61.121- Laceration w/ FB of right thumb w/
damage to the nail
S61.122- Laceration w/ FB of left thumb w/
damage to the nail
S61.131- Puncture wound w/o FB of right thumb
w/ damage to nail
S61.132- Puncture wound w/o FB of left thumb w/
damage to nail
S61.141 -Puncture wound w/ FB of right thumb w/
damage to nail
Open Wound Finger (cont’d)
S61.142- Puncture wound w/ FB of left thumb
w/ damage to nail
S61.151- Open bite of right thumb w/ damage
to nail
S61.152- Open bite of right thumb w/ damage
to nail
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Documentation Awareness Tips
Injury Knee Documentation Awareness
Site:
e.g. anterior horn, posterior horn
Laterality 1: e.g. right, left, bilateral
Laterality 2: e.g. medial, lateral, anterior, posterior
Type:
e.g. complex, bucket handle, peripheral
Status:
e.g. current, old
Knee
ICD-9-CM
ICD-10-CM
836.0 Medial Meniscus Tear, S83.211 Buckle-handle tear of medial meniscus current
knee
injury, right knee
836.1 Lateral Meniscus Tear,
knee
S83.212 Buckle-handle tear of medial meniscus current
injury, left knee
S83.221 Peripheral tear of medial meniscus current
injury, right knee
S83.222 Peripheral tear of medial meniscus current
injury, left knee
S83.231 Complex tear of medial meniscus current
injury, right knee
Knee
ICD-9-CM
ICD-10-CM
S83.232 Complex tear of medial meniscus
current injury, left knee
S83.251 Buckle-handle tear of lateral
meniscus current injury, right knee
S83.252 Buckle-handle tear of lateral
meniscus current injury, left knee
S83.261 Peripheral tear of lateral meniscus
current injury, right knee
S83.262 Peripheral tear of lateral meniscus
current injury, left knee
S83.271 Complex tear of lateral meniscus
current injury, right knee
S83.272 Complex tear of lateral meniscus
current injury, left knee
Knee
ICD-9-CM
ICD-10-CM
717.0 Old bucket handle tear medial
meniscus, knee
M23.211 Derangement of anterior horn of
medial meniscus due to old tear or injury, right
knee
717.1 Old anterior horn tear medial
meniscus, knee
M23.212 Derangement of anterior horn of
medial meniscus due to old tear or injury, left
knee
717.2 Old posterior horn tear medial M23.221 Derangement of posterior horn of
meniscus, knee
medial meniscus due to old tear or injury, right
knee
717.41 Old bucket handle tear lateral M23.222 Derangement of posterior horn of
meniscus, knee
medial meniscus due to old tear or injury, left
knee
717.42 Old anterior horn tear lateral
meniscus, knee
717.43 Old posterior horn tear lateral
meniscus, knee
Knee
ICD-10-CM
M23.241 Derangement of anterior horn of
lateral meniscus due to old tear or injury, right
knee
M23.242 Derangement of anterior horn of
lateral meniscus due to old tear or injury, left
knee
M23.251 Derangement of posterior horn of
lateral meniscus due to old tear or injury, right
knee
M23.252 Derangement of posterior horn of
lateral meniscus due to old tear or injury, left
knee
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Knee
ICD-9-CM
844.2 ACL tear, knee
ICD-10-CM
S83.511- Sprain of anterior cruciate ligament of
right knee
S83.512- Sprain of anterior cruciate ligament of
left knee
S83.521- Sprain of posterior cruciate ligament
of right knee
S83.522- Sprain of posterior cruciate ligament
of left knee
Knee
ICD-9-CM
ICD-10-CM
717.83 Old disruption of ACL
M23.611 Other spontaneous disruption of
anterior cruciate ligament of right knee
717.84 Old disruption of PCL
M23.612 Other spontaneous disruption of
anterior cruciate ligament of left knee
M23.621 Other spontaneous disruption of
posterior cruciate ligament of right knee
M23.622 Other spontaneous disruption of
posterior cruciate ligament of left knee
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Training & Education Resources
• Medkoder, LLC
- http://www.medkoder.com
- aaudler@medkoder.com
• AAPC
- http://www.aapc.com
• AHIMA
- http://www.ahima.org
• CMS
– http://www.cms.gov/Medicare/Coding/ICD10/Index.html
– http://www.roadto10.org
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Questions
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