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About Dr. Mario Fucinari, DC, CCSP, MCS-P
Certified Chiropractic Sports Physician (CCSP)
Certified Insurance Consultant
Certified Medical Compliance Specialist – Physician
Post-Graduate Faculty, Logan College Clinical Sciences, Palmer
College of Chiropractic, Life West Chiropractic, NYCC
ICS Chiropractor of the Year 2012
National Speaker’s Bureau for NCMIC and Foot Levelers
Member of ACA and ICS
Past President of Illinois Chiropractic Society
Chairman of the ICS Medicare Committee
Medicare Chiropractic Carrier Advisory Committee Member 2
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•
•
Medicare Updates
•
ICD-10 Understanding
•
ICD-10 Transition
ICD-10 Implementation •
•
Program Goals
Differences from ICD-9
Why ICD-10?
Impact of ICD-10
Definitions in ICD-10
Structure of the codes
Documentation required
for the codes
• Transition
• Rules
• Workshop
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ICD-10- CM
ICD-10 Deadline
October 1, 2015
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ICD-10 Code
Changes?
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ICD-10
7
ICD-10 Basics
The Health insurance Portability and
Accountability Act (HIPAA) of 1996
includes provisions for the standardization
of health care information
ICD-10
Electronic
Claim
Submissions
Provider
Identifiers
Privacy
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Code Sets
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1500 Health Claim Form

New 1500 Claim Form has been
released. Version 02/12 replaced
version 03/08 as of April 1, 2014.
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Version 02/12
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Version 02/12
IL
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Qualifier 431 Onset of current symptoms or illness
04 03 2015
431
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9
7243
72252
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0
S7001xA
W06xxxA
Y92013
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Box 24E allows up to 4 characters (ABCD)
0
S7001xA
W06xxxA
Y92013
ABC
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Box 24E allows up to 4 characters (ABCD)
0
S7001xA
W06xxxA
Y92013
A-L
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Medicare
9
7393
72252
A
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ICD-10-CM
• Diagnosis has changed. We know more.
• Many sections of the codes are full.
• Uses obsolete technology leading to inaccurate
and limited data
• Need more description. Sprain/Strain
• Takes in Global data
• Medicine advances; codes can’t
Inside ICD-10
•ICD–10–CM is entirely alphanumeric (all
letters except “U” are used)
•ICD–10–CM codes may be up to seven
characters in length
•Some diseases have been reclassified in
ICD-10-CM
•New features have been added to ICD-10CM
Confusion between letters and numbers
•
Examples:
S01.80xA
10D00Z1
Number
Letter
3
S
0
O
1
I
2
Z
• 1993 the 10th Edition of the International
Classification of Disease (ICD-10) was issued
by the World Health Organization (WHO)
• WHO is responsible for maintaining the ICD-10
• Each country is responsible for adapting the
ICD-10 to suit its own country’s needs.
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No!
Follow
Me!
• Worker’s Compensation, auto and personal
injury insurances are exempt from HIPAA and
therefore may not be using ICD-10.
• Your office may have two sets of diagnostic
codes
ICD-9 Diagnostic Codes
ICD-10 Diagnosis Codes
3-5 Characters in length
3-7 Characters in length
Approximately 17,000 codes
Approximately 70,000 available codes
First digit may be alpha; 2nd through 5th is
numeric
Character 1 is alpha; character 2 and 3 are
numeric; character 4 through 6 can be
either. All letters except U are used.
Limited space for adding new codes
Flexible for adding new codes (“x” added)
Lacks detail
Very specific
Lacks laterality
Has laterality
Difficult to analyze data due to non-specific
codes
Specificity improves coding accuracy and
quality of data for analysis
Codes are non-specific and do not
adequately define diagnoses needed for
medical research
Detail improves the accuracy of data used
for medical research including comorbidities
Does not support interoperability because
it is not used by other countries
Supports interoperability and the exchange
of health data between other countries and
the U.S.
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Increased Specificity in ICD-10
Increased Detail in Documentation
Code to the Highest Level of
Specificity
• Unspecified codes have acceptable uses in
some cases.
• Unspecified codes should be reported when
they most accurately reflect what is known
about the patient’s condition at the time of
that particular encounter.
• It would be inappropriate to select a specific
code that is not supported in the
documentation.
• Further testing just to come to a more
specific code is not always medically
necessary
• Avoid excessive use of non-specific codes,
since it decreases the quality of the data.
ICD-10 Specificity
• Side of Dominance
– Right, Left, or ambidextrous (defaults to the right
coding)
• Trimesters and weeks in pregnancy
• Stages of healing
• Laterality
– All paired organs or structures
• Ordinality
– Is this the initial or subsequent visit for the complaint?
– Are these symptoms the sequela of the initial event?
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ICD-10 Specificity
Documentation of diagnoses and
procedures
– Codes must be supported by the patient’s health
documentation
– ICD-10-CM codes are more specific , therefore the
documentation has to be more specific
– Requires more documentation to support codes
– Expect a 15% increase in documentation time (per
AAPC)
– Revenue Impacts due to specificity
• Denials
• Additional Documentation
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ICD-10 Transition
Time is now to have the doctor’s notes
audited to see if they meet the specificity
needed to transition to ICD-10-CM
• ICD-10 readiness assessment
• 65%+ of the time, the notes may not be specific
enough
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The
Consultation
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The Consultation
• Symptoms causing patient to seek
treatment (Chief Complaint)
• 99203 should show PHx, Family Hx,
Social Hx
• Family History
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Family History
• Family History – specific health related
events in the patient’s family. Includes
information about the health status or
cause of death of parents, siblings, and
children and the following diseases:
The BIG
– Orthopedic (arthritis, scoliosis)
FIVE
– neurologic
– pathology (heart disease, cancer, diabetes)
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The Consultation
• Past Health history
– Prior Illness
• Type, date, treatment, current status
– Prior Interventions
• Type, date, treatment, outcome
– Prior Surgery
• Type, date, reason, results, current status
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The Consultation
• Social History
–
–
–
–
–
–
Marital status
Employment history
Occupational history
Use of drugs, alcohol, tobacco
Level of education
Sexual history and social factors
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The Consultation
O,P,Q,R,S,T
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The Consultation
• Mechanism of Trauma
• Onset, duration, intensity, frequency,
location and radiation
• Provoking and Palliative Factors
• Prior interventions, treatments,
medications, secondary complaints
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The Consultation
• Quality and character of
symptoms/problem
• Radiation of symptoms
• Severity
• Time
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S (Subjective)
O (Objective)
A (Assessment)
A (ADL)
P (Plan)
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General Questions
Subjective – What’s going
on?
42
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General Components of
the S (Subjective)




Reporting of patient pain, limitations,
concerns and problems.
Information that cannot be verified or
measured during the encounter.
You may want to use a quote or
summarize what the patient reported.
A well-done interview seems like a
conversation on the surface.
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General Questions
– What’s going on?
 Objective – What did you find?
 Subjective
44
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General Components of
the O (Objective)



Reporting of all measurable, quantifiable,
and observable data obtained during the
encounter.
Present a picture by reporting anything
that the provider used their senses
(vision, hearing, smell, touch)
Does not depend on patient reporting.
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P.A.R.T.

P.A.R.T.
To demonstrate a subluxation based on physical
examination, two of the four criteria mentioned
under the above physical examination list are
required, one of which must be
asymmetry/misalignment or range of motion
abnormality.
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P.A.R.T.
(2 of the 4 Required)
1. Pain/Tenderness - location, quality, intensity
Pain and tenderness findings may be identified
through one or more of the following: observation,
percussion, palpation, provocation, etc. Furthermore
pain intensity may be assessed using one or more of
the following: visual analog scales, algometers, pain
questionnaires, etc.
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P.A.R.T.
2. Asymmetry/misalignment - sectional or segmental level
Asymmetry/misalignment - Asymmetry/misalignment may be
identified on a sectional or segmental level through one or more
of the following: observation (posture and gait analysis), static
palpation for misalignment of vertebral segments, diagnostic
imaging, etc.
3. Range of Motion Abnormality
Range of motion abnormality (changes in active, passive, and
accessory joint movements resulting in an increase or a
decrease of sectional or segmental mobility); and Range of
motion abnormality - Range of motion abnormalities may be
identified through one or more of the following: motion,
palpation, observation, stress diagnostic imaging, range of
motion measurements, etc.
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P.A.R.T.
4. Tissue, tone changes in skin, fascia, muscle, ligament
Tissue, tone changes using descriptions pertaining
to the characteristics of contiguous, or associated
soft tissues, including skin, fascia, muscle, and
ligament. Tissue/Tone texture may be identified
through one or more of the following procedures:
observation, palpation, use of instruments, tests for
length and strength etc.
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Evaluation and
Management
(E/M) Codes
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Determining the Level of Evaluation
and Management (E/M) Code

Seven Components of the E/M service
Key Components
-
History
Examination
Medical decision making
Contributing Components
-
Counseling
Coordination of care
Nature of presenting problem; and
Time
51
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History of Present Illness
HPI is a chronological description of the development of the
patient’s present illness from the first sign and/or symptom or from
the previous encounter to the present. HPI elements are:
•Location (example: left leg);
•Quality (example: aching, burning, radiating pain);
•Severity (example: 10 on a scale of 1 to 10);
•Duration (example: started three days ago);
•Timing (example: constant or comes and goes);
•Context (example: lifted large object at work);
•Modifying factors (example: better when heat is applied); and
•Associated signs and symptoms (example: numbness in toes).
52
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Review of Systems
ROS is an inventory of body systems
obtained by asking a series of questions in
order to identify signs and/or symptoms that
the patient may be experiencing or has
experienced.
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IN THE ABSENCE OF ROS,
THE E/M CODE
AUTOMATICALLY
BECOMES A LEVEL ONE
(99201) CODE
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Cardiovascular: Denies: Shortness
of breath, chest pain. Complains of:
hypertension
Musculoskeletal: Denies: limb
weakness. Complains of: right knee
pain, right leg pain into the fifth toe
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Writing the O - Objective
In summary, the physical exam should
include:







Orthopedic and neurologic tests
Palpation findings
Pinprick sensitivity tests
Reflexes
Range of Motion - Give plane and degrees so it
can be referenced later to show progress. The
more specific the degrees, the better. Note pain.
Muscle strength
Outcome Questionnaires
56
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Check the Shoes
Pronation?
*Orthopedic Physical Assessment, David J. Magee, 2006.
Elsevier Sciences.
57
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ICD-10 Impact in Your Office
Coverage and Payment
• The new coding system will mean new
coverage policies, new health care review
edits, new reimbursement schedules
• Changes will be made to accommodate
increased specificity
• May need to discuss changes with
patients
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ICD-10 Impact in Your Office
Billing and Eligibility
• Updated transactions include support for
ICD-10
• New codes mean more specificity
• Check with your carriers to find out what
their plan is for transition
• Expect increased rejections, denials, and
payment delays as both health plans and
providers get used to new codes
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Questions to Ask Your Practice
Management Vendor
• Will you install products well before the October 1,
2015, deadline, so I can begin testing them in 2014?
• Will support for my current products be discontinued
after the October 1, 2015, ICD-10 deadline?
• When will you update my current products and
applications for ICD-10?
• Will you provide periodic updates for new products?
Will there be a charge for these updates?
• Will I need new hardware to accommodate ICD-10related software changes?
• What are the costs associated with maintaining new
products?
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Questions to Ask Your Practice
Management Vendor
• Will you offer product support? If so, how long will the vendor
support the application?
• How do I report issues and how quickly will you respond?
• Will you provide training on your software?
• Will you offer support during and after internal ICD-10 testing?
• Will you help me test my system with payers and other trading
partners?
• Does your product give me the ability to search for codes by
the ICD-10 alphabetic and tabular indexes? By clinical
concept?
• Will your product allow for coding in both ICD-9 and ICD-10 to
accommodate transactions with dates of service before
October 1, 2015, and transactions with dates of service after
October 1, 2015?
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Questions to Ask Your EHR
Vendor
• Are your EHR products ICD-10 ready? If not,
when will they be?
• Can your products help me with the ICD-10
transition? For example, will the products
suggest ICD-10 codes based on the clinical
data I enter about specific patients?
• Do your products map PM to ICD-10 codes to
help connect clinical and administrative data?
• source: www.CMS.gov/ICD10
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ICD-10 Impact
Planning and Training Yields Success
• Plan early. Time to contact your vendors is
now!
• Train in stages. “Little Bites!” Train doctors,
coders and staff
• Measure productivity and retention to
determine office procedure and policy
changes
• Retrain when necessary
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Change is Difficult
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ICD-10 Transition
Identify your current systems and work
processes that use ICD-9 codes. This could
include your clinical documentation, encounter
forms, superbills, practice management system
and electronic health record systems. It is likely
that wherever ICD-9 codes now appear, ICD-10
codes will take their place.
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Steps to Success
1. Gather your last
40 new patient’s
charts
2. Make a list of the
diagnosis
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Steps to Success
Mario’s Top 40 ICD-10
3. You have your
“Top 40 Playlist”
4. Convert
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www.Chirocode.com
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www.Askmario.com
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I need a
break!
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General Coding Guidelines:
1. ICD-10-CM codes should be listed at their
highest level of specificity and characters.
a. Use three digit codes only if there are no four
digit codes within the coding category. These are
the heading of a category of codes.
b. Use the 4, 5, 6, or 7 digit code to the greatest
degree of specificity available. These provide
further detail
Basic Coding Guidelines:
2. Codes that describe symptoms and signs are only
acceptable if that is the highest level of diagnostic
certainty documented by the doctor. No other diagnosis
has been established (confirmed) by the provider.
3. Signs and symptoms that are associated routinely with a
disease process should not be assigned as additional
codes, unless otherwise instructed by the classification.
4. Additional signs and symptoms that are not routinely
associated with a disease may be reported.
General Coding
Guidelines
o “Code signs and symptoms when a related definitive
diagnosis has not been established (confirmed) by the
provider” (section I.B.6)
o mostly 780-799 in ICD-9
o R00 to R99 in ICD-10
• Example: R45.2 Unhappiness
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General Coding
Guidelines
• “Signs and symptoms that are associated routinely with
a disease process should not be assigned as additional
codes” (section I.B.7)
• Example: R68.84 Jaw pain would not be coded with
o M26.62 temporomandibular joint arthralgia
• “Additional signs and symptoms that may not be
associated routinely with a disease process should be
coded when present.” (section I.B.8)
• Example: R11.0 Nausea and
o S13.4xxA Sprain of ligaments of the cervical spine
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Basic Coding Guidelines:
5. Coding for diagnoses that are probable, suspected, likely
or questionable are not to be coded, because they
indicate uncertainty.
•
•
•
Rule out and working diagnosis are not to be coded.
Other documentation related coding guidance involves
diagnoses documented as “borderline" at the time of
discharge. Unless the classification provides a specific entry
(e.g., borderline diabetes), borderline diagnoses are coded as
confirmed without regard to the care setting (i.e., inpatient
versus outpatient). The guidelines clarify that borderline
conditions are not considered uncertain diagnoses.
As always, coders are encouraged to query the provider for
clarification whenever the documentation is unclear
regarding the condition.
Basic Coding Guidelines:
6. Code all documented conditions that coexist at
the time of the visit that REQUIRE OR AFFECT
patient care. Do not code conditions that no
longer exist.
General Coding Guidelines:
7. Coding for diagnoses that are probable,
suspected, rule out, etc are not allowed for
outpatient s.
8. The term “first-listed” diagnosis is now to be
used instead of the term “principle” diagnosis.
9. The acute condition should always be listed
first.
General Coding Guidelines:
10.Each unique ICD-10 diagnostic code may be
reported only once. If you use a left and right
code, you only list the diagnosis with these
sides once.
11. If the condition is bilateral and there is no
bilateral code, t hen you have to list the left and
right code separately.
12.If a condition is borderline, then it is listed as
confirmed.
13.An unspecified code should be reported only
when it is the code that most accurately reflects
what is known about the patient’s condition at
the time of that particular encounter.
14.It is inappropriate to select a specific code that is
not supported by the health record
documentation or conduct medically unnecessary
diagnostic testing in order to determine a more
specific code.
Inside ICD-10
ICD-10 Chapters
•Chapter 1 – Certain infections and parasitic diseases (A00B99)
•Chapter 2 – Neoplasms (C00-D49)
•Chapter 3 – Diseases of the blood and blood-forming organs
and certain disorders involving the immune mechanism (D50D89)
•Chapter 4 – Endocrine, nutritional and metabolic diseases
(E00-E89)
•Chapter 5 – Mental and Behavior Disorders (F01-F99)
•Chapter 6 - Diseases of the Nervous System (G00-G99)
•Chapter 7 – Diseases of the eye and adnexa (H00-H59)
ICD-10 Chapters
•Chapter 8 – Diseases of the ear and mastoid process (H60-H95)
•Chapter 9 – Diseases of the Circulatory system (I00-I99)
•Chapter 10 – Diseases of the Respiratory system (J00-J99)
•Chapter 11 – Diseases of the Digestive system (K00-K94)
•Chapter 12 – Diseases of the Skin and Subcutaneous tissue (L00L99)
•Chapter 13 – Diseases of the Musculoskeletal system and
connective tissue (M00-M99)
•Chapter 14 - Diseases of the genitourinary system (N00-N99)
•Chapter 15 – Pregnancy, childbirth and the puerperium (O00O99)
ICD-10 Chapters
Chapter 16 – Certain conditions originating in the perinatal period
(P00-P96)
•Chapter 17 – Congenital malformations, deformations and
chromosomal abnormalities (Q00-Q99)
•Chapter 18 – Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified (R00-R99)
•Chapter 19 – Injury, poisoning and certain other consequences
of external causes
•Chapter 20 – External causes of morbidity (V00-Y99)
•Chapter 21 - Factors influencing health status and contact with
health services (Z00-Z99)
ICD-10 Cast of Characters
Placeholder “X” character
The ICD-10-CM utilizes a placeholder character “X” The “X”
is used as a 5th and /or 6th character placeholder at
certain 6 and/or 7 character codes to allow for future
expansion.
ICD-10 Cast of Characters
7th Characters
Certain ICD-10-CM categories have applicable 7th characters.
The applicable 7th character is required for all codes within
the category, or as the notes in the Tabular List instruct. The
7th character must always be the 7th character in the data
field. If a code that requires a 7th character is not 6
characters, a placeholder X must be used to fill in the empty
characters.
Basic ICD-10 Coding
Guidelines:
A – initial encounter for that
provider
D – Subsequent encounter
S – Sequela (late effects)
ICD-10 7th Characters
A - The initial encounter character is used as long
as the patient is receiving active care for that
condition.
ICD-10 –CM 7th Characters
D = Subsequent encounter – After the patient has
received active treatment of the condition and is
receiving routine care for the condition during
the healing or recovery phase.
• Chiropractic treatments and physiotherapy are
examples of subsequent encounters. Maybe.
ICD-10 -CM 7th Characters
S = Sequela – Complications or conditions that
arise as a direct result of a condition.
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General Coding
Guidelines
The seventh character (encounter):
Which character is correct?
•
•
•
•
•
•
Is the patient receiving active treatment?
Is the patient in the middle of an active treatment plan?
Has the patient’s condition stabilized?
Is the patient receiving supportive care?
Is the patient in a healing or recovery phase?
Is the patient being treated for a complication that is the
direct result of some other condition?
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ICD-10 Definitions
•“Includes”
This note appears immediately under a three-digit code title
to further define, clarify, or give examples of the content of a
code category .
•“Excludes”
⁻Excludes 1 – is used when two conditions cannot occur
together or “NOT CODED HERE!” Mutually exclusive codes;
two conditions that cannot be reported together.
⁻Excludes 2 – indicates “NOT INCLUDED HERE.” Although the
excluded condition is not part of the condition, it is excluded
from, a patient may have both conditions at the same time.
The excluded code and the code above the excludes can be
used together if the documentation supports them.
ICD-10 Conventions
“Excludes”
Excludes1 – consider these codes instead
(you can only use 1)
(mutually exclusive)
Excludes2 – consider
these codes in addition
(you may use 2 or more)
(Not included)
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ICD-10 Definitions
• “Code First/Use additional code”
Provides instructions on how to “sequence” the codes.
Signals that that an additional code should be reported to
provide a more complete picture of the diagnosis.
•“Code Also”
Alerts the coder that more than one code may be required to
fully describe the condition. The sequencing of the codes
depends on the severity and/or the reason for the encounter.
ICD-9 Hierarchy
Hierarchy of the codes:
• Neurological diagnosis
• Structural descriptor diagnosis
• Functional diagnosis
• Soft tissue
• Extremity
• Complicating factors
Sequencing of Codes
•Numbers
are reported on the insurance claim form
because you are communicating to a computer.
•Be sure to use the correct numbers, to the highest
specificity.
•The diagnosis you provide directly relates to the
level of care permitted by the third-party payers.
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Sequencing of Codes
Hierarchy in ICD-9 = Sequencing in ICD-10
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Self-Test #1
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Self-Test #1
1. The mandatory implementation date for ICD-10 is
___________________
2. ICD-10 contains how many chapters in the United States?
____________
3. In ICD-10, the placeholder character used for codes that
require a seventh character extender is ______________
4. The National Center for Health Statistics is responsible for
the Clinical Modifications of ICD-10. True
or
False
5. ICD-10 codes start with a letter, except for the letter
_____________
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Self-Test Key #1
1. October 1, 2015
2. 21
3. X
4. True
5. U
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The ICD-10 Crosswalk
106
ICD-9
ICD-10
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ICD-10
ICD-9
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General Equivalence Mapping (GEMs)
• The GEMs will act as a translation
dictionary to bridge the “language gap”
between the two code sets and can be used
to map an ICD-9 code to an ICD-10 code
and vice versa.
• Attempt to include all valid relationships
between the codes in the ICD – 9 and ICD –
10 classification
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Coding Examples
ICD-9 Cervicalgia 723.1
ICD-10 Cervicalgia M54.2
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Coding Examples
ICD-9
724.3 Sciatica
ICD-10
M54.30 Sciatica unspecified side
M54.31 Sciatica Right
M54.32 Sciatica Left
M54.40 Sciatica with lumbago unspecified
M54.41 Sciatica with lumbago right
M54.42 Sciatica with lumbago left
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Choosing the Diagnosis
Name
Abbreviation
Code
Cervical
C1-C7
739.1
Thoracic
T1-T12
739.2
Lumbar
L1-L5
739.3
Sacrum and Coccyx
S or SC
739.4
Ilium/Illi
I or SI
739.5
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739.1 equivalent ICD-10 code
sets
S13.100A-S13.101S S13.10 Subluxation and dislocation of unspecified cervical
vertebrae
S13.110A-S13.111S S13.11 Subluxation and dislocation of C0/C1 cervical vertebrae
S13.120A-S13.121S S13.12 Subluxation and dislocation of C1/C2 cervical vertebrae
S13.130A-S13.131S S13.13 Subluxation and dislocation of C2/C3 cervical vertebrae
S13.140A-S13.141S S13.14 Subluxation and dislocation of C3/C4 cervical vertebrae
S13.150A-S13.151S S13.15 Subluxation and dislocation of C4/C5 cervical vertebrae
S13.160A-S13.161S S13.16 Subluxation and dislocation of C5/C6 cervical vertebrae
S13.170A-S13.171S S13.17 Subluxation and dislocation of C6/C7 cervical vertebrae
S13.180A-S13.181S S13.18 Subluxation and dislocation of C7/T1 cervical vertebrae
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Subluxation Equivalents
Biomechanical Lesion: Chapter 13
739.1 = M99.01 .. segmental and somatic dysf.- cervical region
739.2 = M99.02 .. segmental and somatic dysf.- thoracic region
739.3 = M99.03 .. segmental and somatic dysf.- lumbar region
739.4 = M99.04 .. segmental and somatic dysf.- sacral region
739.5 = M99.05 .. segmental and somatic dysf.- pelvic region
739.6 = M99.06 .. Segmental and somatic dysf. – lower extremity
739.7 = M99.07 .. Segmental and somatic dysf. – upper extremity
739.8 = M99.08 .. Segmental and somatic dysf. – rib cage
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ICD-10 Equivalents
847.2 = S39.012D
Strain of muscle, fascia and tendon of the lower
back, Subsequent Encounter
729.1 = M60.9 -- Myositis, Unspecified
= M79.1 – Myalgia
= M79.7 -- Fibromyalgia
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Chapter 13: Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
RULES ARE RULES
Chapter 13: Rules for Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
• M refers to "diseases of the musculoskeletal
system and connective tissue."
• After the letter are two numbers, separated by a
decimal, which add more specific information.
For example, if you see M21, the 21 refers to
"other acquired deformities of limbs“ (pg 181)
and the numbers to the right indicate where and
what side. Example: M21.172
Chapter 13: Rules for Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
• Site and laterality: For some conditions where
more than one bone, joint or muscle is usually
involved, such as osteoarthritis, there is a
“multiple sites” code. If there is not a multiple
sites code, then use multiple codes to indicate
the multiple sites involved.
• Code by site first, then condition.
Chapter 13: Rules for Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
Site
• Indicates the bone, joint or muscle involved
• There may be “multiple site” codes
• If there is not a multiple site code available, and
you have multiple sites involved, then you have
to use multiple codes to indicate the different
sites involved
Chapter 13: Rules for Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
• Arthritis and osteoarthritis have both site and
laterality designations in ICD-10-CM
• It includes the type of arthritis such as primary,
secondary or post-traumatic.
Chapter 13: Rules for Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
Rheumatoid arthritis (RA)
• Broken down by
– Site
– Laterality
– Complication
– With or without Rheumatoid Factor
Example: M06.022 rheumatoid arthritis without
rheumatoid factor, left elbow
Chapter 13: Rules for Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
• Site represents
– Bone
– Joint
– Muscle
– Multiple site codes
– If there is no multiple site code, multiple codes
should be used
ICD-10 Dissected
ICD-9
ICD-10
XXX.XX
A B
XXX.XXX X
A B C
A = Category of code
B = Etiology, anatomic site, and manifestations
C = Extension used for 7th character for obstetrics,
injuries, and external causes
ICD-10 Dissected
A = Category of code
B = Etiology, anatomic site, and manifestations
C = Extension used for 7th character for obstetrics,
injuries, and external causes
ICD-10 Dissected
2
Extremity:
We are Number One!
We are Number Two!
1
ICD-10 Dissected
M25.619
Stiffness of unspecified
shoulder, not elsewhere
classified.
Stiffness of right shoulder,
not elsewhere classified
Stiffness of left shoulder, not
elsewhere classified
ICD-10 Dissected
M25.619
Stiffness of unspecified
shoulder, not elsewhere
classified.
M25.611
Stiffness of right shoulder,
not elsewhere classified
Stiffness of left shoulder, not
elsewhere classified
ICD-10 Dissected
M25.619
Stiffness of unspecified
shoulder, not elsewhere
classified.
M25.611
Stiffness of right shoulder,
not elsewhere classified
Stiffness of left shoulder, not
elsewhere classified
M25.612
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Chapter 13: Rules for Diseases of the Musculoskeletal
System and Connective Tissue (M00 – M99)
Example:
M25.561 Pain in the Right Knee
M25.562 Pain in the Left Knee
Side is reported in the 6th Character
Spine
Specify by level
Spondylolysis
Spondylolysis is a
defect of a vertebra.
More specifically it
is defined as a
defect in the pars
interarticularis of
the vertebral arch.
Chapter 13: Diseases of the Musculoskeletal System
and Connective Tissue (M00 – M99)
Dorsopathies (M40-M54)
The following supplementary sub classification to indicate the site of involvement is provided for
optional use with appropriate categories in the block on dorsopathies, except categories M50 and
M51; see also note at the beginning of this chapter.
0
1
2
3
4
5
6
7
8
9
Multiple sites in spine
Occipito-atlanto-axial region
Cervical region
Cervicothoracic region
Thoracic region
Thoracolumbar region
Lumbar region
Lumbosacral region
Sacral and sacrococcygeal region
Site unspecified
Chapter 13: Diseases of the Musculoskeletal System
and Connective Tissue (M00 – M99)
M43.00 Spondylolysis, site unspecified
Excludes 1 congenital spondylolysis (O76.2),
spondylolisthesis, (M43.1).
Spondylolysis of Cervical region
Chapter 13: Diseases of the Musculoskeletal System
and Connective Tissue (M00 – M99)
Dorsopathies (M40-M54)
The following supplementary sub classification to indicate the site of involvement is provided for
optional use with appropriate categories in the block on dorsopathies, except categories M50 and
M51; see also note at the beginning of this chapter.
0
1
2
3
4
5
6
7
8
9
Multiple sites in spine
Occipito-atlanto-axial region
Cervical region
Cervicothoracic region
Thoracic region
Thoracolumbar region
Lumbar region
Lumbosacral region
Sacral and sacrococcygeal region
Site unspecified
Chapter 13: Diseases of the Musculoskeletal System
and Connective Tissue (M00 – M99)
M43.00 Spondylolysis, site unspecified
Excludes 1 congenital spondylolysis (O76.2),
spondylolisthesis, (M43.1).
Spondylolysis of Cervical region
M43.02
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Self-Test #2
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1.
2.
3.
4.
5.
6.
7.
Self-Test #2
What is the term for the crosswalk from ICD-9 to ICD-10 or vice versa?
________________________________
The patient presents with lower back and bilateral leg pain, numbness,
and tingling in both legs. Straight leg raise test is positive bilaterally for
sciatica. You suspect disc involvement at L5. Your diagnosis is therefore
listed as _______________________. Code the diagnosis:
_____________________
Rheumatoid arthritis coding requires site, laterality, complications and
_________________
If you are diagnosing arthritis in multiple sites and there is no multiple
site code, what do you do? ___________________________
What is the ICD-9 code for sciatica?
_______________________________
What is the preferred ICD-10 code for a subluxation of the cervical spine?
____________
What is the preferred ICD-10 code for a subluxation at T12?
__________________________
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Self-Test Key #2
1. General Equivalence
Mapping (GEM)
2. Bil Sciatica, M54.41,
M54.42
3. With or without RF
Factor
4. Use multiple codes
5. 724.3
6. M99.01
7. M99.02
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Obstetrics
Chapter 15: Obstetrics Rules
1. Trimesters defined as :
– First trimester – less than 14 weeks 0 days
– Second trimester – 14 weeks 0 days to less
than 28 weeks 0 days
– Third trimester – 28 weeks 0 days until
delivery
Trimesters are counted from the first day of the last menstrual period
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Obstetrics
• In 2012, codes were added to indicate
the weeks of gestation of the pregnancy.
• An additional code is used in category
Z3A weeks of gestation are added to
provide additional information about the
pregnancy.
Example: 18 weeks of gestation is Z3A.18
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Obstetrics
2. Codes for unspecified trimester should never be
reported unless it is impossible to determine the
trimester from the medical record
documentation. The “unspecified trimester”
code should rarely be used. This is only used
when it is not possible to obtain clarification. It
is likely that using the “unspecified trimester”
code will trigger a denial.
3. Trimesters are counted from the first day of the
last menstrual period.
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Obstetrics
4. A code from category Z3A, weeks of gestation
are for use on the maternal record to indicate
the specific week of gestation of the
pregnancy. They are to be appended as
additional codes to the codes from chapter
15.
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Obstetrics
ICD-10 CASE FILE:
A woman presents to the office at 21 weeks of her
pregnancy with back pain caused by her pregnancy.
Examination reveals a positive Kemp’s test for right
sacroiliac joint pain, tenderness to palpation of the
right SI, spasms and edema in the right SI.
DIAGNOSIS:
O33.0 Maternal care for disproportion due to deformity
of maternal pelvic bones
Z3A.21 21 weeks of gestation of pregnancy
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Self-Test #3
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Self-Test #3
1.The patient is seen for her routine visit
during her seventh month of
pregnancy. She is 28 weeks, 3 days.
What is the secondary code for her
visit? ___________________
2 What trimester is 14 weeks, 0 days?
______________
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Self-Test Key #3
1. Z3A.28
2. Second
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Chapter 19: Injury, Poisoning, and Certain Other
Consequences of External Causes (S00 – T88)
• Most categories in chapter 19 have a 7th
character extension requirement for each
applicable code.
• Most categories, except for fractures, will require
an
A – Initial encounter
D – subsequent encounter
S – sequela as the 7th character.
Chapter 19: Injury, Poisoning, and Certain Other
Consequences of External Causes (S00 – T88)
• 7th character A:
– Initial encounter
– Used when the patient is receiving active treatment
for the condition
• Surgical treatments
• Emergency department encounter
• Evaluation and treatment by a new physician
Chapter 19: Injury, Poisoning, and Certain Other
Consequences of External Causes (S00 – T88)
• 7th character D:
– Subsequent encounter
– After treatment in the active phase of care and the
patient is in the healing or recovery phase of care
– Examples of this care are cast change, medication
adjustment, or other aftercare following treatment of
the injury or condition (rehabilitation).
Chapter 19: Injury, Poisoning, and Certain Other
Consequences of External Causes (S00 – T88)
• 7th character S:
– Sequela
– For complication or conditions that arise as a direct
result of a condition, such as deconditioning of
muscle after an injury.
– When using the Sequela codes, it is necessary to use
both the injury code that precipitated the sequela
and the code for the sequela itself.
– The “S” is added to the injury code only, not the
sequela code.
Chapter 19: Injury, Poisoning, and Certain Other
Consequences of External Causes (S00 – T88)
• 7th character S:
– Sequela
– The 7th character “S” identifies the injury responsible
for the sequela.
– The specific type of sequela is sequenced first on the
claim form, followed by the injury code.
Personal Injury
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Sports Injuries
ICD-10 examples
M25.652 Stiffness of left
hip, not elsewhere
classified
159
Self-Test #4
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Self-Test #4
1. What are the three seventh character extension
codes? ______________
2. What extension character is associated with the
healing or recovery phase of care? ________
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Self-Test Key #4
1.A, D, S
2.D
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General Coding
Guidelines
A combination code is a single code
used to classify:
#4
• Two diagnoses, or
• A diagnosis with an associated
secondary process (manifestation)
• A diagnosis with an associated
complication
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ICD-10 By the Numbers
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Coding Examples
S: A patient enters the office today c/o pain in the lower back and
leg. She reports pain for one month duration. Pain is in the
posterolateral aspect of the leg with radiation into the foot
O: SLR positive at 45 degrees. Patellar DTR +1 bilaterally.
Muscle strengths lower extremity +5 bilaterally
Diagnosis:
M54.30 Sciatica unspecified side
M54.31 Sciatica Right
M54.32 Sciatica Left
M54.40 Sciatica with lumbago unspecified
M54.41 Sciatica with lumbago right
M54.42 Sciatica with lumbago left
166
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Coding Examples
S: A patient enters the office today c/o pain in the lower back and
right leg. She reports pain for one month duration. Pain is in
the posterolateral aspect of the leg with radiation into the right
foot
O: SLR positive on the right at 45 degrees. Patellar DTR +1
bilaterally. Muscle strengths lower extremity +5 bilaterally
Diagnosis:
M54.30 Sciatica unspecified side
M54.31 Sciatica Right
M54.32 Sciatica Left
M54.40 Sciatica with lumbago unspecified
M54.41 Sciatica with lumbago right
M54.42 Sciatica with lumbago left
167
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Coding Examples
S: The patient returns today for follow-up pertaining to the
ligament injury in the middle thoracic region. He stated that
his pain is decreased to 4 out of 10, sharp, constant.
O: Hypomobility at T9, Kemp’s test positive on the right, Edema
at T8-T11 bilaterally.
Diagnosis:
S23.3xx
A
D
S
168
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ICD-10 Chapter 20: External
Causes of Morbidity
(V00-Y99)
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ICD-9 E-Codes
• Explain External causes
• They supplement the primary diagnosis
• Explain where rather than why the claim
should be paid
• E-Codes are non-pricing, which means
they are not used as primary codes, but as
secondary to the main ICD-9 codes.
• Currently not often used
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ICD-9 E-Codes
E812.0 Motor Vehicle Collision w/ Another Vehicle (Driver)
E812.1 Motor Vehicle Collision w/ Another Vehicle (Passenger)
E816.1 Motor Vehicle Traffic Accident Due to Loss of Control,
Without Collision on the Highway
E813.0, "motor vehicle traffic accident involving collision with
other vehicle; driver of motor vehicle other than motorcycle,"
E823.0 Motor Vehicle Collision w/ Stationary Object (Driver)
E823.1 Motor Vehicle Collision w/ Stationary Object (Passenger)
E880.0 Accidental Fall on Stairs (@ Home)
E880.3 Accidental Fall on Stairs (@ Industrial Place)
E880.4 Accidental Fall on Stairs (@ Place for Recreation)
E880.6 Accidental Fall on Stairs (@ Public Building)
E885.0 Accidental Fall on Same Level (Slip, Trip, Stumble) (@
Home)
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ICD-9 E-Codes
E927.0
E927.1
E927.2
activity
E927.3
E927.4
Overexertion from sudden strenuous movement
Overexertion from prolonged static position
Excessive physical exertion from prolonged
Cumulative trauma from repetitive motion
Cumulative trauma from repetitive impact
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E-Codes = External Cause Codes
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External Cause Codes
• No national requirement for mandatory
external cause coding
• May be a state-based or payer-based
requirement
• It is encouraged to voluntarily report
external cause codes
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External Cause Codes
• External cause codes and place of
occurrence codes answer the following
questions:
– What was the patient when the injury
happened?
– Where was the patient?
– Did the accident happen on the job?
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Coding of Injuries
• Initial encounters generally require four codes
1. External cause codes
‐
‐
‐
Think of it as a verb
Used for length of the treatment of the patient
Utilizes 7th character extender
•
•
–
–
–
Changes with the status of the patient
A, D, S
Use the full range of external cause codes to fully explain each
cause
Assign as many codes as necessary, however if only one is
used, use the code that most relates to the principal diagnosis
An external cause code can never be a principal (first-listed)
diagnosis
Coding of Injuries
• Initial encounters generally require four codes
2. Place of occurrence (Y92)
‐
‐
‐
Used only once, at the initial encounter
Use it only if you know where was the location of the
injury
Never us an unspecified code here
Coding of Injuries
• Initial encounters generally require four codes
3. Activity codes (Y93)
‐
‐
‐
‐
Used only once, at the initial encounter
Use it only if you know what the activity is
Never us an unspecified code here
Used in conjunction with a place of occurrence code
(Y92)
Coding of Injuries
• Initial encounters generally require four codes
4. External cause status
‐
‐
‐
‐
Used only once at the initial encounter
Was the patient working at the time of the injury?
Military? Hobby?
A work-related activity is any activity for which payment
or income is derived.
Use Y93.9 if the activity of the patient is not stated or is
not applicable
Coding of Injuries
• Regardless of the number of external cause
codes assigned, there should be only one place
of occurrence code and one activity code
assigned to an encounter.
External Cause of Injury
Codes
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181
W59.22XA Struck by Turtle
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W55.12XXA Struck by Horse
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Burn due to water skis on fire; Initial Encounter V91.07XA
184
W61.43 Pecked by a Turkey
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S: The patient presents today after having a new cabinet fall on her last
week, suffering a concussion, as well as neck pain. She was cooking dinner
at her home, which she shares with her husband. The patient did not seek
treatment, prior to our office. She stated that the cabinets were installed
incorrectly in her kitchen. Her husband, who was home with her at the time
of the injury, told her she was “out cold” for about two minutes. The
patient continues to have headaches, primarily in the back of the head,
extending up into the head in the occipital and parietal regions bilaterally.
The headaches come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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186
W20.8xxA Struck by falling object (accidently) Initial encounter
S: The patient presents today after having a new cabinet fall on her last
week, suffering a concussion, as well as neck pain. She was cooking dinner
at her home, which she shares with her husband. The patient did not seek
treatment, prior to our office. She stated that the cabinets were installed
incorrectly in her kitchen. Her husband, who was home with her at the time
of the injury, told her she was “out cold” for about two minutes. The
patient continues to have headaches, primarily in the back of the head,
extending up into the head in the occipital and parietal regions bilaterally.
The headaches come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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Y93.g3
Activity, cooking and baking
S: The patient presents today after having a new cabinet fall on her last
week, suffering a concussion, as well as neck pain. She was cooking dinner
at her home, which she shares with her husband. The patient did not seek
treatment, prior to our office. She stated that the cabinets were installed
incorrectly in her kitchen. Her husband, who was home with her at the time
of the injury, told her she was “out cold” for about two minutes. The
patient continues to have headaches, primarily in the back of the head,
extending up into the head in the occipital and parietal regions bilaterally.
The headaches come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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Initial encounter (A)
S: The patient presents today after having a new cabinet fall on her last
week, suffering a concussion, as well as neck pain. She was cooking dinner
at her home, which she shares with her husband. The patient did not seek
treatment, prior to our office. She stated that the cabinets were installed
incorrectly in her kitchen. Her husband, who was home with her at the time
of the injury, told her she was “out cold” for about two minutes. The
patient continues to have headaches, primarily in the back of the head,
extending up into the head in the occipital and parietal regions bilaterally.
The headaches come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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189
Y92.010
Place of occurrence, house, single family, kitchen
S: The patient presents today after having a new cabinet fall on her last
week, suffering a concussion, as well as neck pain. She was cooking dinner
at her home, which she shares with her husband. The patient did not seek
treatment, prior to our office. She stated that the cabinets were installed
incorrectly in her kitchen. Her husband, who was home with her at the time
of the injury, told her she was “out cold” for about two minutes. The
patient continues to have headaches, primarily in the back of the head,
extending up into the head in the occipital and parietal regions bilaterally.
The headaches come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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190
S06.0x1A Concussion with loss of conciousness 30 min or less
Initial encounter
S: The patient presents today after having a new cabinet fall on her last
week, suffering a concussion, as well as neck pain. She was cooking dinner
at her home, which she shares with her husband. The patient did not seek
treatment, prior to our office. She stated that the cabinets were installed
incorrectly in her kitchen. Her husband, who was home with her at the time
of the injury, told her she was “out cold” for about two minutes. The
patient continues to have headaches, primarily in the back of the head,
extending up into the head in the occipital and parietal regions bilaterally.
The headaches come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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191
Intractable
S: The patient presents today after having a new cabinet fall on her last
week, suffering a concussion, as well as neck pain. She was cooking dinner
at her home, which she shares with her husband. The patient did not seek
treatment, prior to our office. She stated that the cabinets were installed
incorrectly in her kitchen. Her husband, who was home with her at the time
of the injury, told her she was “out cold” for about two minutes. The
patient continues to have headaches, primarily in the back of the head,
extending up into the head in the occipital and parietal regions bilaterally.
The headaches come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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192
S: The patient presents today after having a new cabinet fall on her last
S134xxA
week, suffering
Cervical
a concussion,
Sprain Initial
as well
Encounter
as neck pain. She was cooking dinner
G44.311
at her home,
Acute
which
Postshe
traumatic
shares with
headache
her husband.
Intractable
The patient did not seek
S06.0x1A
treatment, Concussion
prior to our with
office.
loss
She
of stated
conciousness
that the 30
cabinets
min orwere
less installed
Initial
incorrectlyencounter
in her kitchen. Her husband, who was home with her at the time
M99.01
of the injury,
Segmental
told her and
she somatic
was “outdysfunction
cold” for about
of cervical
two minutes.
region The
W20.8xxA
patient continues
Struck to
byhave
falling
headaches,
object (accidently)
primarily in
Initial
the back
encounter
of the head,
Y93.g3
extending Activity,
up into the
cooking
head inand
thebaking
occipital and parietal regions bilaterally.
Y92.010
The headaches
Placecome
of occurrence,
on suddenly,
house,
last single
for long
family,
periods
kitchen
of time, and occur
every day. They are not relieved by Advil.
O: Decreased joint motion at C1 and C7. Tenderness with spasms in the
sub-occipital region, C1 bilaterally and C7 bilaterally. Cervical
compression is negative. Maximum cervical compression is positive
bilaterally at C1 and C7.
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193
Clinical Example:
A patient is a delivery person for a florist. While
delivering a bouquet of flowers to a person at a
workplace, they slip and fall on untreated ice in the
parking lot, at the workplace. In the fall, they fracture
their wrist. Is the party at fault the workplace or is it a
worker’s compensation claim? While they are
deciding, the hospital does not want to wait, so they
say to file it with the health insurance. ICD-10 codes
are used. Three weeks later, it is decided that the claim
will be handled by the worker’s compensation carrier,
since the hotel insurance argued that it was an act of
God.
Coding of Injuries
•
•
•
•
•
•
Broke wrist
At hotel
In parking lot
Walking
Slipped and fell on the ice
Working
The first line of communication with a carrier is the claim form.
Self-Test#5
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Self-Test #5
Self-Test #5
1. In ICD-9, what are the supplemental codes that describe
how or where an injury occurred?
________________________
2. What kind of policies would you use an e-code?
____________________
3. Place these in the correct order: Place of occurrence,
activity, external cause code, external cause status
a.
b.
c.
d.
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197
Self-Test Key #5
1. E-Codes
2. Accident Policies
3. a. External cause
b. Place of occurrence
c. Activity
d. External cause status
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CMS ICD-10 Training
www.cms.gov/icd10
Resources
NCHS – Basic ICD-10-CM Information
http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
CMS – ICD-10-PCS Information
www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp
AHIMA - ICD-10 Education
www.ahima.org/icd10/index.asp
AHIMA has a free monthly ICD-10 Newsletter
www.ahima.org/images/newsletters/ICDTen/subscribe.html
WEDI – ICD-10 Implementation
www.wedi.org
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