ICD-10-CM
The transition . . .
Barbara Parker, CPC, CCS-P
How did the delay happen?
 February 27th CMS announces, “No more delays.”
 March 25th (late in the day) House & Senate leadership
insert ICD-10 language into HR 4302 Sustainable
Growth Rate patch, needed to replace expiring
legislation.
No time for floor debate
No opportunity for edits or amendments
March 26th to March 30th contacts made with
Congress (mobilized by AHIMA)
March 27th – passes in House, March 31st passes in
Senate, April 1st President signs bill
What does it say?
 Section 212
“The Secretary of Health and Human
Services may not, prior to October 1, 2015,
adopt ICD-10 code sets as the standard for
code sets.”
 New implementation date?
To be determined by CMS
April
th
18
 With enactment of the Protecting Access to Medicare Act of
2014, CMS is examining the implications of the ICD-10
provision and will provide guidance to providers and
stakeholders soon. This provision in the statute reads as
follows: “The Secretary of Health and Human Services may
not, prior to October 1, 2015, adopt ICD-10 code sets as the
standard for codes sets under section 1173 (c) of the Social
Security Act (42 U.S.C. 1320d-2 (c)) and section 162.1002 of
title 45, Code of Federal Regulations.”
APCs Insider, April 18, 2014
Practically, the update offers nothing new for
providers left wondering what to do with
training and testing timelines that were
supposed to be nearing their final stages.
Considering it took the agency two weeks from
the signing of the bill to merely post a message
acknowledging its passing, the promise of
guidance “soon” will probably not inspire much
confidence in the healthcare community for a
quick resolution.
Each day that passes without
guidance makes it less likely the
agency will find a way to reinstate
the October 1, 2014 deadline that
providers prefer, according to
several polls.
CMS did not say in its statement
that it would be providing a new
implementation date soon, only
that it is “examining the
implications” of the provision.
This could mean CMS is looking at ways
to reinstate the previous deadline
However, time is a factor and Congress
must still confirm a new secretary of
HHS. October 1, 2015, still seems the
most likely implementation date.
Despite CMS finally offering a comment
on the delay, the landscape still hasn’t
changed for providers. Their best course
of action, to prevent the problems faced
with previous delays, is to keep the
momentum by continuing to fine-tune
coder and physician training, and making
sure systems are ready for ICD-10
implementation—no matter when it is.
Looking forward
Revising the Plan
www.roadto10.org
The Small Practice’s Route to
ICD-10
Your Practice Specialty
Your Practice Size
Your Vendors
Your Payers
Your ICD-10 Readiness
For example:
Family Practice
1-2 Physicians
Electronic Health Records
Commercial Payers, Medicare, Military
Payers
Planning
Key steps are provided
 Plan your journey
 Update you processes
 Engage you vendors and payers
 Test your systems and processes
 Perform internal testing
 Conduct external testing
 Practice and validate
Train Your Team
Underdosing
Underdosing is an important new concept and term in ICD10. It allows you to identify when a patient is taking less
of a medication than is prescribed.
When documenting underdosing, include the following:
Intentional, Unintentional, Non-compliance Is the
underdosing deliberate? (e.g., patient refusal)
Reason Why is the patient not taking the medication? (e.g.
financial hardship, age-related debility)
Underdosing Codes
Z91.120
Patient’s intentional
underdosing of medication
regimen due to financial
hardship
T36.4x6A
Underdosing of tetracyclines,
initial encounter
T45.526D
Underdosing of
antithrombotic drugs,
subsequent encounter
Hypertension
Definition Change
In ICD-10, hypertension is defined as essential
(primary). The concept of “benign or malignant” as it
relates to hypertension no longer exists.
When documenting hypertension, include the following:
Type e.g. essential, secondary, etc.
Causal relationship e.g. Renal, pulmonary, etc.
Hypertension Codes
ICD-10 Code Examples
I10
Essential (primary)
hypertension
I11.9
Hypertensive heart disease
without heart failure
I15.0
Renovascular hypertension
Diabetes Mellitus, Hyperglycemia,
Hypoglycemia

Increased Specificity

The diabetes mellitus codes are combination codes that include the type of
diabetes mellitus, the body system affected, and the complications affecting
that body system.

When documenting diabetes, include the following:

Type e.g. Type 1 or Type 2 disease, drug or chemical induces, due to underlying
condition, gestational

Complications What (if any) other body systems are affected by the diabetes
condition? e.g. Foot ulcer related to diabetes mellitus

Treatment Is the patient on insulin?

A second important change is the concept of “hypoglycemia” and
“hyperglycemia.” It is now possible to document and code for these conditions
without using “diabetes mellitus.” You can also specify if the condition is due to
a procedure or other cause.

The final important change is that the concept of “secondary diabetes
mellitus” is no longer used; instead, there are specific secondary options
Diabetes Mellitus, Hypoglycemia,
and Hyperglycemia Codes
E08.65
Diabetes mellitus due to
underlying condition with
hyperglycemia
E09.01
Drug or chemical induced
diabetes mellitus with
hyperosmolarity with coma
R73.9
Transient post-procedural
hyperglycemia
R79.9
Hyperglycemia, unspecified
Injuries
ICD-9 used separate “E codes” to record external causes of
injury. ICD-10 better incorporates these codes and expands
sections on poisonings and toxins.
When documenting injuries, include the following:
 Episode of Care e.g. Initial, subsequent, sequelae
 Injury site Be as specific as possible
 Etiology How was the injury sustained (e.g. sports,
motor vehicle crash, pedestrian, slip and fall,
environmental exposure, etc.)?
 Place of Occurrence e.g. School, work, etc.
 Initial encounters may also require, where appropriate:
 Intent e.g. Unintentional or accidental, self-harm, etc.
 Status e.g. Civilian, military, etc.
Injury Codes
Example 1: A left knee strain injury that occurred on a
private recreational playground when a child landed
incorrectly from a trampoline:
 Injury: S86.812A, Strain of other muscle(s) and
tendon(s) at lower leg level, left leg, initial encounter
 External cause: W09.8xxA, Fall on or from other
playground equipment, initial encounter
 Place of occurrence: Y92.838, Other recreation area
as the place of occurrence of the external cause
 Activity: Y93.44, Activities involving rhythmic
movement, trampoline jumping
Another Injury
Example 2: On October 31st, Kelly was seen in
the ER for shoulder pain and X-rays indicated
there was a fracture of the right clavicle, shaft.
She returned three months later with
complaints of continuing pain. X-rays indicated a
nonunion. The second encounter for the right
clavicle fracture is coded as
 S42.021K, Displaced fracture of the shaft of
right clavicle, subsequent for fracture with
nonunion.
Documentation for Abdominal Pain
Chief Complaint
“My stomach hurts and I feel full of gas.”
History
47 year old male with mid-abdominal epigastric pain1, associated
with severe nausea & vomiting; unable to keep down any food or liquid.
Pain has become “severe” and constant.
Has had an estimated 13 pound weight loss over the past month.
Patient reports eating 12 sausages at the Sunday church breakfast five
days ago which he believes initiated his symptoms.
Patient admits to a history of alcohol dependence2. Consuming 5
– 6 beers per day now, down from 10 – 12 per day 6 months ago.
States that he has nausea and sweating with “the shakes” when he
does not drink.
Exam
VS: T 99.8°F, otherwise normal.
Mild jaundice noted.
Abdomen distended and tender across upper abdomen3.
Guarding is present. Bowel sounds diminished in all four
quadrants.
Oral mucosa dry, chapped lips, decreased skin turgor.
Assessment and Plan
1. Dehydration and suspected acute pancreatitis.
2. Admit to the hospital. Orders written and sent to on-call
hospitalist.
3. 1L IV NS started in office. Blood drawn for labs.
4. Recommend behavioral health counseling for substance
abuse assessment and possible treatment.
5. Patient’s wife notified of plan; she will transport to hospital
by private vehicle.
Summary of ICD-10-CM Impacts
Clinical Documentation
Describe the pain as specifically as possible based on location.
When addressing alcohol related disorders you should
distinguish alcohol use, alcohol abuse, and alcohol dependence.
ICD-10-CM has changed the terminology and the parameters for
coding substance abuse disorders. In this encounter note, as the
acute pancreatitis is suspected, and the patient’s alcohol intake
status is stated, the associated alcoholism code is listed.
Abdominal tenderness may be coded. Ideally the documentation
should include right or left upper quadrant and indicate if there
is rebound in order to identify a more specific code. Currently
the ICD-10 code would be R10.819, Abdominal tenderness,
unspecified site as the documentation is insufficient in laterality
and specificity.
Comparison of Codes
ICD-9-CM Diagnosis Codes
789.06
Abdominal
pain,
epigastric
ICD-10-CM Diagnosis Codes
R10.13
Epigastric
pain
789.60
Abdominal
tenderness,
unspecified
site
R10.819
Abdominal
tenderness,
unspecified
site
782.4
Jaundice
NOS
R17
Unspecified
jaundice
276.51
Dehydration
E86.0
Dehydration
303.90
Other and
unspecified
alcohol
dependence,
unspecified
F10.20
Alcohol
dependence,
uncomplicate
d
Documentation for Annual Exam
Chief Complaint
“I’m here for my annual check-up.1”
History
73 year old male with history of coronary artery disease, stent
placement, hyperlipidemia, HTN and GERD.
Recent admission to hospital following a hypertensive crisis. Discharged
home on olmesartan medoxomil 20 mg daily.
Patient stopped taking olmesartan medoxomil due to side
effects2,including a headache that began after starting the medication
and still exists, and tiredness.
Regular activity includes walking, golfing. Active social life. No
complaints of chest pain, or dyspnea on exertion.
Last colonoscopy was 9 months ago. No significant pathology found; some
diverticular disease.
Medications were reviewed.
Exam
Chest clear. Heart sounds normal. Mental status exam intact.
EKG shows no changes from prior EKG.
Vitals: BP is 159/95, otherwise normal. Per patient, he had good control
of BP on meds, but it has risen without medication.
BUN/creatinine normal limits.
Assessment and Plan
HTN noted on exam today. Change from olmesartan medoxomil to
metoprolol tartrate 50 mg once daily, will titrate dosage every two
weeks until BP normalizes.
Discussed the importance of daily home BP monitoring, low sodium diet,
and taking BP medication as prescribed; he verbalizes understanding.
Schedule follow-up visit in two weeks to evaluate effectiveness of new
BP medication therapy, and repeat BUN/creatinine.
Summary of ICD-10-CM Impacts
Clinical Documentation
Documenting why the encounter is taking place is important, as the
coder may assign a different code based on the type of visit (e.g.,
screening, with no complaint or suspected diagnosis, for
administrative purposes). In this situation, the patient is requesting
an encounter without a complaint, suspected or reported diagnosis.
Document that the patient is noncompliant with his medication. This
“underdosing” concept can often be coded, along with the patient’s
reason for not taking the prescribed medications. Document if there
is a medical condition linked to the underdosing that is relevant to
the encounter, and ensure the connection is clearly made. The ICD10-CM terms provide new detail as compared to the ICD-9-CM code
V15.81, history of past noncompliance. In this case there was no
noted history of noncompliance. In this note the side effects of
stopping the medication include headache, which remains as a
patient complaint for this encounter. When documenting headache
do differentiate if intractable versus non-intractable.
Comparison of Codes
ICD-9-CM Diagnosis Codes
ICD-10-CM Diagnosis Codes
V70.0
Routine
medical exam
Z00.01
Encounter for
general adult
medical
examination
with abnormal
findings
401.9
Unspecified
essential
hypertension
I10
Essential
(primary)
hypertension
339.3
Drug-induced
headache, not
elsewhere
classified
G44.40
Drug-induced
headache, not
elsewhere
classified, not
intractable
T46.5X6A
Underdosing
of other
antihypertensi
ve drugs,
initial
encounter
Z91.128
Patient’s
intentional
underdosing of
medication
regimen for
other reason
N/A
N/A
Other Impacts
Assess if the new patient-centric preventive health
incentives for annual exams are relevant to your practice.
For hierarchical condition categories (HCC) used in
Medicare Advantage Risk Adjustment plans, certain
diagnosis codes are used as to determine severity of
illness, risk, and resource utilization. HCC impacts are
often overlooked in the ICD-9-CM to ICD-10-CM
conversion. The physician should examine the patient each
year and compliantly document the status of all chronic
and acute conditions. HCC codes are payment multipliers.
Test Your Systems and Processes
Testing of key systems and processes is essential to your
ICD-10 transition success! To this end, your practice
should:
 Prepare test cases to validate.
 Perform internal testing of systems and work flow
processes using ICD-10 diagnosis codes.
 Conduct external testing with vendors and payers using
data that contains ICD-10 diagnosis codes.
 Practice coding in ICD-10 and validate supporting
clinical documentation processes.
Identify test scenarios
Isolate the ICD-9 diagnosis codes
you use the most. Superbills,
encounter forms, system reports,
and the Common Codes in your
action plan can you help you pinpoint
this information.
Find encounters which
represent the scenarios
Locate at least ten (10) existing
encounters/claims which include the ICD9 diagnosis codes you identified in step
one.
Prepare test cases
Prepare test cases using the
encounters identified in step
two. Utilize the ICD-9 codes
found in the encounters/claims
to help identify relevant ICD-10
codes for each scenario.
Suggestions for help

Tabular form of the 2014 release of ICD-10-CM codes and Tabular form of the 2014
release of ICD-10-CM codes and descriptions published by the National Center for Health
Statistics (NCHS) ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2014/
Open the ICD-10CM_FY2014_Full_PDF.zip file then unzip and save the PDF file named
“ICD10CM_FY2014_Full_PDF_Tabular” to your local device

Online ICD-10-CM search tools/applications

Hard copy or electronic publications of 2014 ICD-10-CM code books

Common Codes from your action plan

2014 General Equivalence Mappings (GEMS) Diagnosis Codes and Guide from CMS http://cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html

Crosswalks from your system vendors and largest payers

descriptions published by the National Center for Health Statistics (NCHS) ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2014/
Open the ICD-10CM_FY2014_Full_PDF.zip file then unzip and save the PDF file named
“ICD10CM_FY2014_Full_PDF_Tabular” to your local device Online ICD-10-CM search
tools/applications Hard copy or electronic publications of 2014 ICD-10-CM code books
Common Codes from your action plan 2014 General Equivalence Mappings (GEMS) Diagnosis
Codes and Guide from CMS - http://cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CMand-GEMs.html Crosswalks from your system vendors and largest payers
Test
Test systems which store,
process, send, receive, or
report diagnosis code
information.
What to test
Use your test cases to verify the following system functions
and processes work properly:
 Perform eligibility & benefits verification.
 Process a referral.
 Process an authorization.
 Schedule an office visit.
 Schedule an outpatient procedure.
 Schedule an inpatient admission.
 Prepare to submit quality data.
 Prepare to submit public health data.
 Update a patient’s history & problems.
 Enter and process an order.
 Verify that diagnosis-dependent clinical decision
support rules issue alerts.
 Prepare clinical notes for an encounter.
 Code an encounter.
 Generate and process a claim.
 Perform a claim status inquiry.
 Reconcile and post a payment.
 Run frequently used reports.
 Perform other key tests as needed.
Document test results and
retest as needed.
 Document your test results. Investigate the
cause (data entry, process, system, other) for
tests that failed unexpectedly.
 Report potential system issues to the
applicable technology vendors.
 Test fixes installed and changes made to
address the problems you identified.
Check out AAPC example
documentation
S: Mrs. Finley presents today after having a new cabinet fall
on her last week, suffering a concussion, as well as some
cervicalgia. She was cooking dinner at the home she shares
with her husband. She did not seek treatment at that time.
She states that the people that put in the cabinet in her
kitchen missed the stud by about two inches. Her husband, who
was home with her at the time told her she was “out cold”
for about two minutes. The patient continues to have
cephalgias since it happened, primarily occipital, extending up
into the bilateral occipital and parietal regions. The headaches
come on suddenly, last for long periods of time, and occur
every day. They are not relieved by Advil. She denies any
vision changes, any taste changes, any smell changes. The patient
has a marked amount of tenderness across the superior
trapezius.
O: Her weight is 188 which is up 5 pounds from last time, blood
pressure 144/82, pulse rate 70, respirations are 18. She has full
strength in her upper extremities. DTRs in the biceps and
triceps are adequate. Grip strength is adequate. Heart rate is
regular and lungs are clear.
A:
Status post concussion with acute persistent headaches
Cervicalgia
Cervical somatic dysfunction
P: The plan at this time is to send her for physical therapy,
three times a week for four weeks for cervical soft tissue
muscle massage, as well as upper dorsal. We’ll recheck her in one
month, sooner if needed.
And the codes are:
S06.0x1A
Concussion with loss of
consciousness of 30 minutes
or less, initial encounter
G44.311
Acute post traumatic
headache, intractable
M54.2
Cervicalgia
M99.01
Segmental and somatic
dysfunction of cervical
region
W20.8xxA
Struck by falling object
(accidentally), initial
encounter
Y93.g3
Activity, cooking and baking
Y92.010
Place of occurrence, house,
single family, kitchen
Sample superbill-AAPC Website
Superbills: ICD-9 vs. ICD-10
To show the added complexity that providers will face
when using ICD-10-CM, the Blue Cross Blue Shield
Association converted a superbill from ICD-9-CM to ICD10-CM.
View the original ICD-9-CM superbill
View the ICD-10-CM superbill created using CMS
crosswalks
Recommended Resources
Clinical Documentation
Learn to document patient encounters accurately, in order
to ensure that medical records both capture and support
the specificity and medical necessity of the ICD-10 codes
assigned to the claim.
American Health
Information
Management
Association
(AHIMA)
Clinical
Documentation
for ICD-10
Training
https://securecontent.optimizehi
t.com/ahima/
American
Academy of
Professional
Coders (AAPC)
ICD-10
Documentation
Training for
Physicians
http://www.aapc.c
om/ICD-10/ICD10-physiciandocumentation.asp
x
Coding
Learn about the differences and similarities between ICD-9
and ICD-10, including combination codes, unspecified codes,
addition of a 7th character, excludes notes, and the use of
an “x” placeholder. Learn how to assign ICD-10 codes
through native coding. Learn anatomy and physiology as it
relates to new specificity of ICD-10.
American Academy General ICD-10of Professional
CM Code Set
Coders (AAPC)
Training
http://www.aapc.c
om/ICD-10/onlineicd-10-coding.aspx
World Health
Organization
(WHO)
http://apps.who.in
t/classifications/ap
ps/icd/icd10trainin
g/
ICD-10 Interactive
Self Learning Tool
ICD-10 Overview
Learn about the fundamentals of ICD-10 and how it impacts
compliance as well as your revenue cycle.
http://www.aapc.c
om/ICD10/practice-icd10-training.aspx
American
Academy of
Professional
Coders (AAPC)
ICD-10 Training
Centers for
Medicare and
Medicaid Services
(CMS)
ICD-10: The
Provider
Perspective
(Presented by Dr.
Joe Nichols)
http://www.youtu
be.com/watch?v=L
BXqy386Lfg
Centers for
Medicare and
Medicaid Services
(CMS)
ICD-10: Rural or
urban; It impacts
all providers
(Presented by Dr.
Joe Nichols)
http://narhc.org/
wpcontent/uploads/2
013/09/ICD-10DocumentationRequirements.pdf
When you are done . . . Go bowling