ICD-10-CM
Diagnosis Coding and Documentation
Teresa Stallman, MBA, RHIT
AHIMA Approved ICD-10 Trainer
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Agenda
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Overview of ICD-10-CM
Challenges
Keys to engaging clinicians
Coding examples
Resources
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Overview of ICD-10-CM
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Overview: ICD-10-CM
• International Classification of Diseases,
Tenth Revision, Clinical Modification
• Effective date: Oct. 1, 2015
• Dates of service:
– Office visits: Oct. 1, 2015
– Inpatient spanning before/after Oct. 1, 2015
– Do not split bill
• Usage:
– Improve health outcomes
– Improve clinical pathways
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Comparison: ICD-9 to ICD-10
*ICD-9-CM/ICD-10CM Official guidelines for coding and reporting
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Challenges
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Challenges
• New coding/reporting system
– Guideline changes for ICD-10
– Training
– Confidence
– EMR software
• Superbill or cheat sheets: Refine
• Clinician’s involvement
– What if my clinicians wish to provide ICD-10-CM
codes?
– Will documentation be complete to allow for ICD10-CM assignment?
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Things to avoid
• Using cheat sheets or coding by memory
• Selecting unspecified code without looking into other
options
• No documentation of cause/effect relationship
• Incorrect use of “history of” terminology
• Conditions not documented as chronic
• Conditions not supported by MEAT (monitored,
evaluated, assessed, treated)
• Incomplete coding of complications and comorbidities
• Unacceptable signatures
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Keys to Engaging with
Clinicians
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Before engaging with clinicians
• Compare ICD-9 and ICD-10 coding guidelines
• Identify the top services for the practice and/or by
clinician
• Review documentation of medical records
• Code medical record ICD-10 scenarios
• Identify gaps in documentation
• Create templates by diagnosis, focusing on necessary
elements: Incorporating identified changes in coding
guidelines for ICD-10
• Identify the clinician(s) who consistently document
fully: Liaison to clinician peers
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Engaging your clinicians
• Present findings
– By identified service
– De-identify provider name
– Include reimbursement
• Develop action plan for improvement
• Repeat audit
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Documentation/Coding
Examples
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Case study #1: Fracture
Chief Complaint: “I think I broke my arm”
HPI: This 24-year-old man with a history of heart
transplant at the age of 12 comes in today due to a
right arm injury that happened a couple of hours ago.
He fell off the roof of his private house while installing
Christmas lights
Diagnosis: Displaced, compound greenstick fracture of
the radial shaft
Treatment Plan: We have requested a consult from
an orthopedic department. They will be able to see him
today at 4pm. The arm was put in the sling and patient
is awaiting his orthopedic appointment
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Case #1: Answer
ICD-10 Codes:
• S52.311A – Displaced greenstick fracture of
shaft of radius, right arm, initial encounter for
closed fracture
• W13.2XXA – Fall from, out of, or through roof
• Y92.019 – Single-family non-institutional
(private) house as the place of occurrence of
the external cause
• Z94.1 – Heart transplant status
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Case study #2: Mental health
Chief Complaint: “I have a lot of stress.”
HPI: Male patient had been seen for anxiety and depression since 2001.
Currently patient has depressive symptoms of crying, insomnia, anorexia
with recent weight loss, and psychomotor retardation. Patient has been
taking Wellbutrin 150mg daily, Lexapro 20 mg daily, and Xanax 1mg 3
times a day. Patient also has asthma, which is well controlled with his
Albuterol. It usually becomes an issue during his panic/anxiety attacks.
Diagnosis: AXIS I
1. Major depressive disorder, recurrent, severe with psychotic
symptoms.
2. Panic/anxiety disorder without agoraphobia.
Treatment Plan: Because of severe psychotic symptoms, this patient will
be transferred to the nearby hospital for inpatient admission to their
psychiatric unit. Patient agrees with this plan
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Case #2: Answer
ICD-10 Codes:
• F33.3 - Major depressive disorder,
recurrent, severe with psychotic
symptoms
• F41.0 – Panic disorder without
agoraphobia
• J45.909 – Unspecified asthma,
uncomplicated
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Case study #3: Primary care
Chief Complaint: Annual physical exam
HPI: This 64-year-old patient comes in for her annual physical
exam. She is also being treated for DM, HTN, and CKD.
Diagnosis:
1. Malignant Hypertension
2. Stage V Chronic Kidney Disease
3. Type 2 Diabetes Mellitus
Treatment Plan: Her HTN and CKD are being monitored and
treated by Dr. Smith. Continue the plan of treatment as
prescribed. Her diabetes is well controlled with Lantus, diet,
and exercise. Continue same medication dosage, monitor
glucose level at home, and return in three months for recheck
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Case #3: Answer
ICD-10 Codes:
• Z00.00 – Encounter for general adult medical
examination without abnormal findings
• I12.0 - Hypertensive chronic kidney disease stage
V chronic kidney disease or end stage renal
disease
• N18.5 - Chronic kidney disease, stage V
• E11.9 - Type 2 diabetes mellitus without
complications
• Z79.4 - Long-term (current) use of insulin
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Case study #4: Pregnancy
Chief Complaint: OB/GYN routine follow-up visit
HPI: This 22-year-old pleasant lady with diabetes
mellitus type 1 in her second trimester of pregnancy
comes in for a follow-up visit.
Diagnosis:
1. Pre-existing DM, Type 1, in pregnancy
2. 18 weeks gestation
Treatment Plan: The patient’s blood sugar is well
controlled and the patient tells us that she is doing well
with her diet and exercise regimen. Patient should
follow up in one month.
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Case #4: Answer
ICD-10 Codes:
• O24.012 – Pre-existing diabetes
mellitus, type 1, in pregnancy, second
trimester
• Z3A.18 – 18 weeks gestation of
pregnancy
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Case study #5: ENT
Chief Complaint: “Sinus pressure. Post-nasal drainage.”
HPI: 65-year-old male with acute sinus pressure in the context of
existing chronic sinus disease and COPD. He has had low-grade fever,
post-nasal drainage, maxillary pressure, and cough for over two weeks
now. No vomiting, shortness of breath, or epistaxis. Symptoms have
not responded to his use of Flonase, oral decongestants, and nasal
irrigation for the last two weeks.
Diagnosis: Acute on chronic maxillary sinusitis
Treatment Plan: Continue Flonase, irrigation, decongestants and start
Bactrim DS twice daily for 14 days. Call or return to clinic if not
improving with this treatment over the next two weeks or new
symptoms develop. Continue current treatment for COPD and contact
PCP as needed.
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ICD-10 Codes:
• J01.00 Acute maxillary sinusitis,
unspecified
• J32.0 Chronic maxillary sinusitis
• J44.9 Chronic obstructive pulmonary
disease, unspecified
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Resources
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Website links
• AHIMA:
www.ahima.org/education/onlineed/Programs
/ICD10
• AAPC: www.aapc.com/medical-coding
• CMS: www.cms.gov/ICD10
• CMS: www.Roadto10.org
• ICD-9 to ICD-10: www.icd10data.com/convert
• OHP: http://www.onehealthport.com/
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Next webinar
• Go! ICD-10 Coding, Risk Adjustment, Audit Preparation
presented by Tonya Owens, Coding Quality Educator.
November 17, 2 p.m. to 3 p.m.
• Contact information
– Call 800-596-3382, option 4
– Email us at:
ProviderEngagementTeamLW@lifewisehealth.com
– Fax: 855-332-4527
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Questions?
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Thank You for Attending
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034229 (09-2015)