ICD-10- CM
THE TRANSITION FROM ICD9
June 2014| Nina Campus
WHY THE CHANGE?
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ICD9-CM is 30 years old
Many of the categories are full
Codes are not descriptive enough
Technology has changed
WHEN WILL IT HAPPEN?
• ICD9-CM codes will not be accepted for
services provided on or after 10/1/2015.
• Claims that do not use ICD10 diagnosis
after 10/1/2015 cannot be processed.
• Use ICD9
– Worker’s Compensation & Auto Insurance not
required.
• This applies to resubmission or appealed
claims.
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NEW STRUCTURE ICD-10- CM
ICD9
3-5 digits
Example: 496
ICD10
3-7 digits
Example: A66
Chapters 1-17: codes are all numeric
Example: 511.9
Digit 1 is alpha
Example: A69.20
Supplemental chapters: first digit alpha
and remainder are numeric
Example: V02.61
Digit 2 is numeric
Example: 09A.311
Digit 3 is alpha or numeric
Digits 4-7 are alpha or numeric
Example: S42.001A
ICD-10- PCS is used for the hospitals for inpatient services only
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NEW STRUCTURE
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ICD-10 CHAPTERS
• ICD-9-CM has 17 chapters and ICD-10 CM
has 21 chapters
– Chapter 18 which are V codes
(Classification of Factors
Influencing Health Status and Contact with Health Service)
• Chapter 20 in ICD-10-CM
– Chapter 19 which are E codes
(Supplemental
Classification of External Causes of Injury and Poisoning
• Chapter 21 in ICD-10-CM
– Eye and ear have their own chapter in ICD-10
• Chapter 7 & 8
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ICD-10-CM CHAPTERS
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ICD-10-CM CHAPTER
CATEGORIES
• Chapters are divided in three alphanumeric
character categories.
– also called Rubric
• There are no alphanumeric character
category that start with letter U.
– Use of letter I
– Use of letter O
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CHAPTER CATEGORIES
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ALPHABETIC INDEX
Volume II
• Arranged in alphabetic order by diseases
• Divided into sections and organized by main
terms
–
–
–
–
Index of Diseases and Injury
Index of External Causes of Injury
Table of Neoplasm
Table of Drugs and Chemicals
• Elimination of Hypertension Table
– No more benign or malignant
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ALPHABETIC INDEX
• Main terms describe the disease and/or
condition
– Cross reference “see” “see also”
• Sub-terms are under the main term
following an indented format.
• Supplemental (nonessential) descriptions
are found in parentheses after the main
term.
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Main
term
Supplementary
description
Default
Code
Secondary
sub-term
Sub-term
descriptor
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COMBINATION CODE
• A single diagnosis code that is used to
classify two diagnosis codes
– A diagnosis with associated sign or symptoms
– A diagnosis with associated complication
Example
I25.110
Atherosclerotic heart disease of native coronary
artery with unstable angina pectoris.
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GRANULARITY
• Granularity is referred to the increased
information to the description of the
diagnosis.
– Billing up to the highest level of specificity (5th, 6th,
7th digit)
L02.21 Cutaneous abscess of trunk
L02.211
L02.212
L02.213
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Cutaneous abscess of abdominal wall
Cutaneous abscess of back [any party, except
buttock]
Cutaneous abscess of chest wall
LATERALITY
• Indicates right & left description designation.
H02.84
Edema of eyelid
H02.841 Edema of right upper eyelid
H02.842 Edema of right lower eyelid
H02.843 Edema of right eye, unspecified eyelid
H02.844 Edema of left upper eyelid
H02.845 Edema of left lower eyelid
H02.846 Edema of left eye, unspecified eyelid
H02.849 Edema of unspecified eye, unspecified
eyelid
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LATERALITY
• Right side is usually character 1
– H04.1111 Dacryops of right lacrimal gland
• Left side is usually character 2
– H04.1112 Dacryops of left lacrimal gland
• Bilateral is usually character 3
– H04.113 Dacryops of bilateral lacrimal glands
• Unspecified side is usually character 0 or 9
– H04.129 Dry eye syndrome of unspecified
lacrimal gland
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TABULAR INDEX
Volume I
• CATEGORY
– Three-digit character code that represents a single
condition or disease
Example
Chapter 1 A00-B99 Certain Infectious and Parasitic
Diseases
A00-A09
Intestinal infectious disease
A15-A19
Tuberculosis
A20-A28
Certain zoonotic bacterial disease
A30-A49
Other bacterial diseases
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TABULAR INDEX
• SUBCATEGORY
– Four-digit character code that provides a higher level
of specificity compared category. It defines site,
etiology and manifestation of the disease or condition.
Example
C15 Malignant neoplasm of the esophagus
C15.3 Malignant neoplasm of upper third of
esophagus
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TABULAR INDEX
• SUBCLASSIFICATION
– A five-digit or sixth character code that adds precise
specificity.
Example
J10.82 Influenza due to other identified influenza
virus with myocarditis
M88.861 Other juvenile arthritis, right knee
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TABULAR INDEX
• The seventh-digit character code extension is
required if applicable as defined by the
tabular index.
– Mostly used in injuries and fractures
Example
T65.211A Toxic effect of chewing tobacco,
accidental (unintentional), initial encounter
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TABULAR INDEX
• Dummy Placeholder
– Used as a placeholder to allow for future
expansion or if you code created for that
character.
– When a fifth character code is not created but
required to code to the sixth and seventh digit.
Example
T37.5X1
Poisoning by antiviral drugs,
accidental (unintentional)
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CONVENTIONS
• Code first/use additional code notes
– Etiology/manifestation paired codes have a
specific index structure.
– Signals that additional codes should be reported
to provide a more complete picture of the
patient’s diagnosis.
– Etiology code is first followed by the manifestation
codes.
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CODE FIRST/USE ADDITIONAL
CODE NOTES
• Manifestation codes will have “in disease classified
elsewhere” in the title.
• Possible that more than two codes may be required to
fully describe a condition. ‘Use additional code’ note will
be indicated.
H42
Code
1st
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Glaucoma in disease classified elsewhere
Code first underlying condition, such as:
amyloidsis (E85. - )
aniridia (Q13.1)
Lowe’s syndrome (E72.03)
Reiger’s anomaly (Q13.81)
specified metabolic disorder (E70- E90)
Code 2nd
CODE FIRST
• ‘Code first’ note and an underlying condition is
present, the underlying condition should be
sequenced first.
• ‘Code, if applicable, any causal condition first,’
notes indicates that this code may be assigned
as a principal diagnosis when the causal
condition is unknown or not applicable.
• If the causal condition is know, then the code for
the condition should be sequenced as principal
or first-listed diagnosis.
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CONVENTION – ‘NEC’ ‘NOS’
• NEC directed to an ‘other specified’ code in
the Tabular List. Reference the inclusion
term under the subheading.
– No codes defined for the documentation
• NOS is the equivalent of unspecified.
– More codes defined that was is documented.
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PUNCTUATION
[ ]- used in tabular list to enclose synonyms,
alternative wording or explanatory wording.
Brackets are used to identify manifestation
codes.
( )- used in the alphabetic index and tabular list
and referred to as supplementary descriptions
(nonessential modifiers)
:- Used after an incomplete term that needs
one or more supplementary descriptions.
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PUNCTUATION
• } – series of terms which is modified by the
statement appearing at the right of the brace.
• , - words that are essential descriptors. The
terms in the inclusion note must be present in
the diagnostic statement to assign for this
code.
Example
C50.31 Malignant neoplasm of lowerinner quadrant of breast, female
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‘CODE ALSO’, ‘SEE’, ‘SEE ALSO’
• Code Also – instructs that two codes may be
required to fully describe a condition.
– Sequencing of the two codes depends on the severity
of the condition and the reason for the encounter.
• See- instructions following a main term
indicates another term should be referenced.
• See Also – instructions following a main term
that another main term may also be
referenced.
Amentia – see also Disability, intellectual
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DEFAULT CODES
• A code next to the main term
• Most commonly associated with the main
term
• Unspecified code for the condition
• If condition documented in medical record
does not provide the additional information,
the default code should be assigned.
K37 Appendicitis - not indicated as chronic
or acute
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EXCLUDES NOTES
• Two types of EXCLUDES NOTES
– Type I Excludes notes indicates the codes should
never be used at the same time as the above the
Excludes1 note.
• Two conditions cannot occur together and are mutually
exclusive.
• A Type I Excludes note means NOT CODED HERE!
Example
E11 Type 2 diabetes
Excludes1: gestational diabetes (Q24.4 -)
Type 1 diabetes (E10. - )
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EXCLUDES NOTES
• Type II Excludes note represents ‘Not included
here’. The condition excluded is not part of the
condition represented by the code.
– It is acceptable to use both the code and the excluded
code together.
Example
I10
Essential (primary) Hypertension Includes:
high blood pressure hypertension (arterial) (benign) (essential)
(malignant) (primary) (systemic)
Excludes2: essential (primary) hypertension involving vessels of
brain (I60-I69)
essential (primary) hypertension involving vessels of
eye (H35.0)
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INCLUSION TERM
• List of codes included under some codes.
Additional terms found only in the index may
also be assigned to a code.
Example
Chapter 1
Certain Infectious and Parasitic Diseases
Use additional code to identify resistance to antimicrobial drugs (Z16.-)
Excludes2: carrier or suspected carrier of infectious disease (Z22.-)
B95-B97 Bacterial and viral infectious agents
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USE OF ‘AND’, WITH/WITHOUT
• When the term ‘and’ is used in a narrative
statement, it represents and/or.
• When ‘with’ and ‘without’ are the two options
for the final character of a set of codes, the
default is always ‘without’.
– For five character codes, the 0 (zero) represents
‘without’ and 1 represents ‘with’.
– For six character codes, the 1 represents ‘with’
and 9 represents ‘without’
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GENERAL CODING GUIDELINES
• There are general coding guidelines outlined
in each chapter of the ICD-10-CM.
• To find a code, first locate the term in the
alphabetic index and then verify code in the
tabular list.
• Diagnosis codes are to be used and reported
at their highest number of characters
available.
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GENERAL CODING GUIDELINES
• Three character code is only used if it is not
further subdivided.
• The appropriate codes from A00.0 – T88.9,
Z00-Z99.8 must be used to identify
diagnoses, symptoms, conditions, problems,
complaints, or other reasons for the
encounter/visit.
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GENERAL CODING GUIDELINES
• Codes that describe symptoms and signs, as
opposed to diagnoses, are acceptable for
reporting purposes when the relating
definitive diagnosis has not be established by
the provider. (Reference Chapter 18 of the ICD-10
CM book.)
Abnormal Liver Function Test would be
coded R94.5
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GENERAL CODING GUIDELINES
– Signs or symptoms should not be reported with a
confirmed diagnosis if the symptom is integral to
the diagnosis.
Patient is experiencing ear pain and the diagnosis is otitis
media. the ear pan would be integral to the otitis media and
would not be reported.
– Symptom code is used with a confirmed
diagnosis only when the symptom is not
associated with the confirmed diagnosis.
A patient is diagnosed with epigastric pan and referred the
patient to a gastroenterologist to rule out ulcer.
ICD9-CM
789.06 Abdominal pan, epigastric
ICD10- CM
R10.13 Epigastric pain
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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, unless
otherwise instructed by the classifications.
• Additional signs and symptoms that may not
be associated routinely with a disease
process should be coded when present.
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GENERAL CODING GUIDELINES
• A physician diagnosed a patient with rheumatoid arthritis
of the right ankle and foot who also has rheumatoid
polyneuropathy. The condition is coded in ICD-10-CM
using the combination code.
ICD-9-CM 714.0 Rheumatoid arthritis
357.1 Polyneuropathy in collagen vascular disease
In ICD9, we do not have a combination code to fully describe the
condition and must use two codes when reporting this diagnosis.
ICD-10-CM a combination code is available:
M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of
right ankle and foot
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GENERAL CODING GUIDELINES
Acute and Chronic Conditions
• If the same condition is described as both
acute (sub-acute) and chronic, and separate
subentries exist in the Alphabetic Index at the
same indentation level, code both and
sequence the acute (sub-acute) code first.
Patient was diagnosed with acute maxillary sinusitis
that is chronic report ICD-10 CM codes J01 (Acute
sinusitis) and J32.0 (Chronic maxillary sinusitis)
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GENERAL CODING GUIDELINES
• Late Effects (Sequela)
• Sequela is a condition produced after the
acute phase of an illness or injury has
terminated.
• Not time limit on when sequela can be used.
• Coding sequela generally requires two codes
sequenced as follows:
– Condition or nature of the sequela is first
– Sequela is sequenced second
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Principal Diagnosis Code
• Reported in medical record as the primary
reason or the determination at the end of the
encounter.
• Providers should only be reporting the
diagnosis codes for the conditions they
treated in the encounter.
• Not all diagnosis codes can be listed as the
primary diagnosis code for an encounter.
– Reference ICD-10-CM Draft Official Guidelines for Coding and
Reporting 2014
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Guidelines for Principal DX
• Sign or symptom is not used when a definitive
diagnosis for the sign/symptom has been
established.
• If anticipated treatment is not carried out due to
unforeseen circumstances, the principal code
remains the diagnosis that the provider planned
to treat.
• When the admission is for treatment of a
complication resulting from surgery or other
medical care, the complication code is
sequenced as the principal diagnosis/first-listed
code.
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Secondary Diagnosis Code
• Although a patient has an encounter for the principal
diagnosis, the additional conditions or reasons for
the encounter also need to be coded.
• Other diagnosis codes are additional codes that
affects patient care in terms of requiring clinical
evaluation or therapeutic treatment or diagnostic
procedure or extended length of hospital stay or
increase nursing care and/or monitoring.
• Diagnoses that relate to an earlier episode that have
no bearing on the current hospital stay are to be
excluded.
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Abnormal Test Findings
• Laboratory, x-ray, pathologic and other
diagnostic results are not coded or reported
unless the physician indicates their clinical
significance.
• If the findings are outside the normal range
and the physician has ordered other tests to
evaluate the condition or prescribe treatment,
it is appropriate to ask the physician whether
the abnormal finding should be added.
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Abnormal Test Findings
• If the abnormal finding corresponds to a
confirmed diagnosis, it should be coded in
addition to the confirmed diagnosis.
• If the diagnosis is confirmed (eg, an X-ray,
pathology or laboratory report confirms DX),
prior to coding the encounter, the confirmed
DX code should be used.
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RESOURCES
• CMS ICD10 Website
– www.cms.gov/Medicare/Coding/ICD10
• ICD-10-CM Draft Official Guidelines for Coding
and Reporting 2014
– http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf
• Center for Disease Control (CDC)
– http://www.cdc.gov/nchs/icd/icd10cm.htm
• World Health Organization (WHO)
– http://www.who.int/classifications/icd/en/
• AAPC Website
– http://www.aapc.com/icd-10
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