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National Alliance of Medical Auditing Specialists (NAMAS)

ICD-10-CM IntroductionPresented by:

John Burns, CPC, CPMA, CPC-I, CEMCApproved NAMAS Instructor

ICD-10 Ambassador & AHIMA Approved ICD-10 PCS/CM TrainerSenior Consultant

DoctorsManagement, LLC

ICD 10 CM Introduction

• BS Health Science- SUNY Cortland (1995)

• Consultant, Doctors Management, LLC

− 2013 –present

About Your Faculty

• President- Modern Conventions in Compliance, Inc.

− 2004-2012

• Senior Consultant- Medical Management Institute

− 1995-2003

− CPC (2000), CPC-I (2004), CEMC (2009), CPMA (2013)− AHIMA Approved ICD-10 Ambassador/Trainer (2013)

• The sky is not falling…I swear it’s really not!!

− While ICD-10 (CM and PCS) does pose numerous challenges to all constituents of the healthcare industry but many of the general concepts utilized to successfully select ICD-9 codes may be applied to ICD-10.

Take a Deep Breath!

− The major challenge lies with understanding the concepts described in ICD-10-CM and ICD-10-PCS and how they translate from the codes we have become accustomed to

− ICD-10 will impact all aspects of the revenue cycle and requires:

-complete provider documentation-increase appeals in the short-term

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• The primary reasons for the delay were stated to be “issues with 5010 implementation and the need to carefully develop testing plans”

O A t 24 2012 HHS d th d l

HHS Confirms Final Implementation Date for ICD-10 for the “Last” Time

• On August 24, 2012 HHS announced the one year delay would move the implementation one year to October 1, 2014 for printing in the Federal Register on September 5, 2012.

• Did you know: ICD has not been clinically modified since 1977?− ICD-11?

• The last annual update to ICD-9-CM was made on October 1, 2011. − On October 1, 2013 there were only limited code

updates to both the ICD-9-CM and ICD-10 code sets

On October 1 2014 there will be only limited code

Codes Will Change Between Now and Implementation

− On October 1, 2014, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173.

• There will be no updates to ICD-9-CM, as it will no longer be used for reporting

• On October 1, 2015, regular updates to ICD-10 will begin.

• Various parties have estimated that approximately 16 hours of coding training are likely needed for each coding manager to learn ICD-10-CM.− More is required for those actively involved in coding each day

• Estimate at least 2-3 hours of in-depth education for each specialty section

ICD-10-CM Training Before Go-Live

specialty section− We haven’t received any billing guidance yet which will require

far more education and training for everyone in many areas of the revenue cycle

• All affected parties will need to refresh or expand on coders’ knowledge in the biomedical sciences (anatomy, physiology, pharmacology, and medical terminology)

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• Expanded injury codes, grouped by anatomic site(s) rather than injury category (E-codes are no longer)

• Combination diagnosis/symptom or manifestation codes to reduce number of codes needed to fully describe conditions

• Combination codes for poisonings and external causes

Some Enhancements Of ICD-10-CM

• Additions of 6th and 7th characters- 7th digit to describe visit encounter or sequelae for injuries and external causes

• Laterality (right, left, bilateral, unspecified etc.)

• Full code titles for 4th and 5th digits—no more need to refer back to common 4th/5th digits for full code description

• V-Codes and E-Codes are no longer supplemental classifications (placed in applicable sections)

• “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”

Excerpts From Official ICD-10 Guidelines

• “The importance of consistent, complete documentation in the medical record cannot be overemphasized.”− Approach, laterality, encounter (initial, subsequent,

sequela), etc− Orders should contain specific information. Do not

utilize R/O or “suspected” conditions

− Chapter 1: Infectious and Parasitic Disease (A00-B99)− Chapter 2: Neoplasms (C00-D49)− Chapter 3: Diseases of Blood and Blood Forming Organs (D50-D89)− Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E89)

• Diabetes is located in this section (E08-E13)− Chapter 5: Mental and Behavioral Disorders (F01-F99)− Chapter 6: Diseases of the Nervous System and Sense Organs (G00-G99)

Section I: C. Chapter Specific Coding Guidelines

− Chapter 7: Diseases of the Eye and Adnexa (H00-H59)− Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)− Chapter 9: Disease of the Circulatory System (I00-I99)

• Hypertension is located in this section (I10-I15), R03.0 for elevated BP (ICD-9 code 796.2)

− Chapter 10: Diseases of the Respiratory System (J00-J99)− Chapter 11: Diseases of the Digestive System (K00-K94)− Chapter 12: Diseases of Skin and Subcutaneous Tissue (L00-L99)− Chapter 13: Diseases of the Musculoskeletal System and Connective

Tissue (M00-M99)

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− Chapter 14: Diseases of the Genitourinary System (N00-N99)− Chapter 15: Pregnancy, Childbirth, Pueperium (O00-O9A)

• OB, Delivery and Postpartum Services

− Chapter 16: Newborn (Perinatal) Guidelines (P00-P96)• Newborn services and reporting stillborns

− Chapter 17: Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99)

Section I: C. Chapter Specific Coding Guidelines

Abnormalities (Q00 Q99)Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory

Findings, Not Elsewhere Classified (R00-R99)• Codes that describe symptoms and signs are acceptable for reporting purposes when

a related definitive diagnosis has not been established (confirmed) by the provider.

− Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)

− Chapter 20: External Causes of Morbidity (V01-Y99)− Chapter 21: Factors Influencing Health Status and Contact With Health

Services (Z00-Z99)

• The Official Guidelines are broken down in to sections:

• Section I: A. Conventions of ICD-10− Conventions of ICD-10-CM− Alphabetic Indexing and Tabular Listings− Format and Structure− Use of Codes for Reporting Purposes

Pl h ld Ch t “X”

Official ICD-10 Guidelines

− Placeholder Character “X”− 7th Digit Characters− Abbreviations (Index and Tabular)− Punctuation− Use of “And”, “With”, “See Also”, “Code Also”− “Unspecified” Codes, “Includes” and “Excludes”− Etiology/Manifestation Conventions (e.g., “code first”, “use

additional code”, “in diseases classified elsewhere”• Default codes and Syndromes

True or False? Many ICD-10-CM codes will require a 4th, 5th, and/or 6th character that is not listed specifically. In these cases, the coder/auditor will simply insert a “Z” as a placeholder.

TrueIncorrect

Reset Questions

FalseCorrect

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• ICD-10 instructs coders to place an “x” in the 4th, 5th and/or 6th places when a 7th digit is available and the 4th, 5th and/or 6th characters do not exist.

− This convention allows for future code expansion if necessary

The “Dummy” Placeholder

− The dummy placeholder is very prevalent in Chapter 15 (ICD-10-CM)

• Pregnancy, Childbirth & Puerperium

• Example: − O41.90X1- Disorder of amniotic fluid and

membranes, unspecified, first trimester

• Health Insurance Portability and Accountability Act (HIPAA) of 1996 includes provisions for the standardization of health care information− Transaction and Code Set Standards (TCS)

Th N ti l C t f H lth St ti ti (NCHS)

Introduction-Where Did It Come From?

• The National Center for Health Statistics (NCHS) developed ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification)− To assist in the classification of morbidity, mortality,

indexing medical records, medical care review, as well as for basic health statistics

• ICD-10 has only been used in the USA for mortality (death certificates) since 1999…

• A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used…

• Coding of sequela generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first. The sequela code is sequenced second.

New for ICD-10-CM: Sequela (Late Effects)

• An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s).

• The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.

SOURCE: 2013 ICD-10-CM Coding Guidelines

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• General Equivalence Mapping (GEM) -− Conversion of ICD-9 codes to ICD-10 codes

• Require more specificity of documentation (e.g., LT/RT)• Many providers have never really mastered ICD-9 coding

principles – major challenge for ICD-10

Biggest Challenges to Providers

• GEMs can be accessed at CMS website:

− https://www.cms.gov/ICD10/Downloads/GEMs-CrosswalksTechnicalFAQ.pdf

• Its important to mention that though some ICD-9-CM codes can be mapped “one to one” …many ICD-9-CM codes will map to a multitude of ICD-10 listings and vice versa

• ICD-10-CM coding guidelines will only impact those constituents of the healthcare industry who currently use ICD-9-CM (Volumes 1 and 2) to report diagnostic codes identifying signs, symptoms, established acute or chronic conditions, etc. documented by qualified care providers

ICD-10-CM Basics

providers

− Physicians and other care professionals will continue to use the CPT and HCPCS-II codes to report the services that they perform

− Hospitals reporting to Medicare Part A and other payors for their assorted daily inpatient/facility services will not use ICD-10-CM for payment purposes, rather they will use ICD-10-PCS (replaces Vol. III)

• Code set is greater than 30 years old and does not speak to the current medical practice

• Current 3-5 numeric (except V-codes and E-codes) characters do not allow for expansion− Lack anatomic descriptions

Limitations of ICD-9-CM

− Lack of specificity and severity descriptions− Not specific to laterality− No flexibility for future expansion (6th and 7th digits)

• Example:

• 13,000 ICD-9-CM codes versus 68,000 ICD-10-CM codes

ICD-9-CM – 813.15 Open fracture of head of radiusICD-10-CM – S52123C Displaced fracture of head of

unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC

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True or False? One major difference between ICD-9-CM and ICD-10-CM is that rule out conditions are to be reported when reasonably suspected.

TrueIncorrect

Reset Questions

FalseCorrect

• Code reason for visit first

• Code to the highest level of known specificity/certainty• This means the user is to report signs/symptoms in absence of 

definitive dx

What Will Not Change With ICD-10-CM

• Don’t code “probable, suspected, questionable or rule out”

• Code chronic diseases as often and as long as the patient receives treatment for them

• Code coexisting conditions affecting patient care at the time 

of the visit

Comparison of Clinical ModificationsICD-9-CM ICD-10-CM

Three to five characters Three to seven characters

First digit is numeric but can be alpha (E or V)

First character always alpha

2-5 are numeric All letters used except U2 5 are numeric All letters used except U

Always at least three digits Character 2 always numeric: 3-7 can be alpha or numeric

Decimal placed after the first three characters (or with E codes, placed afterthe first four characters)

Always at least three digits and the decimal placed after the first three characters

Alpha characters are not case-sensitive Alpha characters are not case-sensitive

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• First, locate the term in the Alphabetic Index Alphabetical list of terms (e.g., fracture, pain, etc.)

• Next, verify the code in the Tabular ListChapters based on body systems or conditions

1) Index of diseases 2) External Causes 3)

Locating An ICD-10-CM Code

1) Index of diseases, 2) External Causes,3) Neoplasms, 4) Drugs and Chemicals

− This should come by no surprise…it’s what we have always done with ICD-9

− Always consult the instructional notations that appear in both the Index and the Tabular List

ICD-10-CM Index to Diseases and Injuries

• The index is arranged A-Z

• Unlike ICD-9-CM, Neoplasms are not located within the alphabetic index but follows letter “z”

• There are vertical lines used to assist in using the index:Pain(s)− Pain(s)limb M79.609

lower M79.60-toe M79.67-

Never code directly from index…

Alphabetic index, Neoplasm table, Table of Drugs and Chemicals, External Causes, Places of occurrence

Categories (3 characters) [M16] – Osteoarthritis of hipSubcategories [M16.1] – unilateral primary osteoarthritis of hip

Codes [M16.10 (unspecified), M16.11 (RT hip), M16.12(LT hip)

All Categories are 3 characters (decimal follows)

The Tabular List

g ( )A 3-character category without 4th/5th is a reportable code

M25 (Other joint disorder, not elsewhere classified)

A code with an applicable 7th character is invalid without the 7th character… “X” is used as placeholder if 5th/6th characters are not applicable

M48.5--- (Collapsed vertebra) – 5th character describes the vertebral region, 6th character “x”, 7th character describes type of encounter [A-initial, D/G-subsequent, S-sequela]

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Example of a 7th Digit and a Dummy Placeholder (“X” for 6th character)

Collapsed Vertebra M48.5---

AA DD

EXAMPLEM48.5---

Collapsed vertebra

5th character defines vertebral region (e.g., thoracic)

Initial –receiving

active treatment

Subsequent –fracture with

routine healing

G G Delayed healing

SSSequela

( g , )

6th character is “x”

7th character described by one of the alpha characters listed

Code Structure: ICD-10-CM

XX XX XX XX. XX XX XXAAMMMM 44 88 55. 44 XX AA

1st - Alpha (Except U)

2nd

Numeric3 - 7 Numeric or Alpha

“Base code” 5th character describes vertebra

(4 = thoracic)

Added code extensions (7th character) for injuries, and external causes of injury(A = Initial Encounter)

.

Watch for the “dummy” placeholder for the 5th and/or 6th characters

Excludes 1: Used when 2 codes cannot occur together(e.g., congenital versus acquired)

M79.A – Nontraumatic compartment syndromeExcludes 1- fibromyalgia (M79.7)

“Excludes 1” Versus “Excludes 2”

Excludes 2 - used when 2 codes may occur together but separate documentation is required of each condition

M80– Osteoporosis with current pathological fractureExcludes 2- personal history of (healed) osteoporosis fracture

(Z87.310)

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• Certain conditions have both an underlying etiology(cause or origination of disease) and manifestations(symptom resulting from disease)

• In ICD-10-CM, the etiology (underlying condition) is to be reported primary with the manifestation being sequenced second

Etiology/Manifestation Codes

second

• “In diseases classified elsewhere” codes are never to be “first listed” or as “principal” diagnosis codes

• In the Alphabetic Index, etiology code is listed first with the manifestation in [brackets]; the code in brackets is always to be sequenced second.

Specific ICD-10-CM Reporting ParametersOsteoarthritis (Categories M15-M19)

• Unlike ICD-9-CM, Osteoarthritis is provided a unique category for each anatomic structure:− Polyosteoarthritis (M15.0 – M15.9)− Primary osteoarthritis of:

• Bilateral Hip (M16.0)U il l Hi (M16 1 )• Unilateral Hip (M16.1-)

• Bilateral Knee (M17.0)• Unilateral Knee (M17.1-)• Bilateral First Carpometacarpal Joint (M18.0)• Unilateral First Carpometacarpal Joint (M18.1-)

− As you can see, bilateral codes are 4 character codes while unilateral codes are 5 character codes. Never use 2 codes when 1 tells the story

− Osteoarthritis of other joints is reported using M19.- codes

5th character0 – unspecified

1 – right2 - left

ICD-10-CM Reporting – Other Joint Disorders

• Similar coding instructions apply to other joint disorders

− Instability of joint (M25.3--)− Effusion of joint (M25.4--)− Pain in joint (M25.5--)

• Crosswalk on next slide− Pain in Limb coded has been codes 729.5 but will require a 6th digit in

ICD-10 to demonstrate the limb and laterality…documentation will be critical!

− Stiffness of joint (M25.6--)

• Each of these code sets require a 5th digit to identify the joint and a 6th digit to demonstrate laterality (e.g., right, left, unspecified)

• Bilateral codes do not apply so 2 codes may be required (RT/LT)

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ICD-9-CM ICD-10-CM

Pain in Joint

5th digit Joint

719.4 X 1 Shoulder

2 Upper arm

Pain in Joint

Laterality Joint

M25.51 X 1, 2, 9 Shoulder

M25.52 X 1, 2, 9 Elbow

3 Forearm

4 Hand

5 Pelvis/hip

6 Lower leg

7 Ankle/foot

8 Other specified

9 Unspecified

M25.53 X 1, 2, 9 Wrist

M25.55 X 1, 2, 9 Hip

M25.56 X 1, 2, 9 Knee

M25.57 X 1, 2, 9 Ankle andFoot

1=Right

2=Left

9=UNSPEC

ICD-9-CM to ICD-10-CM Mapping

• 724.2 - Lumbago

724 4 Thoracic or lumbosacral

• M54.5 – Low back pain

• M51.14-Intervertebral disc disorders with radiculopathy, thoracic region

• M51.15-thoracolumbar region

• M51.16-lumbar• 724.4 - Thoracic or lumbosacral

neuritis or radiculitis, unspecified

• 723.1 - Cervicalgia

• M51.17-lumbosacral• M54.14-Radiculopathy, thoracic

• M54.15-thoracolumbar• M54.16-lumbar

• M54.17-lumbosacral

• M54.18- sacral and sacrococccygeal

• M54.2 - Cervicalgia

Other ICD-10-CM Reporting ParametersOsteoporosis (Categories M80-M81)

• Unlike ICD-9-CM, Osteoporosis is now reported based on being with (M80.----) or without (M81.-) pathological fracture:

• M80.0--- (Osteoporosis with pathologic fracture)− Requires 7th character:Requires 7 character:

• A – initial encounter for fracture• D – subsequent encounter for fracture with normal healing• G - subsequent encounter for fracture with delayed healing• K - subsequent encounter for fracture with nonunion• P - subsequent encounter for fracture with malunion• S – sequela

• M80.1- (Osteoporosis without pathologic fracture)− Only requires a 4th character (age-related, localized, other)

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Osteoporosis: ICD-9-CM to ICD-10-CM Mapping

• 733.00 - Unspecified osteoporosis

• M81.0 - Age-related osteoporosis without current pathological f t

• 733.90 - Disorder of bone and cartilage, unspecified

fracture

• M85.9 - Disorder of bone density and structure, unspecified

• M89.9 - Disorder of bone, unspecified

• M94.9 - Disorder of cartilage, unspecified

Other ICD-10-CM Reporting ParametersFractures (Pathologic versus Traumatic)

• Stress Fractures (M84.3---) & Pathologic Fractures (M84.4---):− Indexing: Fracture, pathological or stress, specify location− Requires 7th characters:

• A – initial encounter for fracture• D – subsequent encounter for fracture with normal healing• G - subsequent encounter for fracture with delayed healing• G subsequent encounter for fracture with delayed healing• K - subsequent encounter for fracture with nonunion• P - subsequent encounter for fracture with malunion• S – sequela

• Traumatic Fractures (S02.0XX- through S92.919):− Indexing: Fracture, traumatic, specify location (now structured

anatomically)− Located in Chapter 19, Injury, Poisoning & Consequences of External

Causes

• Do not report directly from the index; always refer back to Tabular

ICD-10-PCS: Medical-Surgical Code Structure

Character1

Character2

Character3

Character4

Character5

Character6

Character7

Section Body System

Root Operation

Body Part Approach Device Qualifier

• Objective of procedure• 31 Root operations• Arranged by similar

attributes• Multiple codes• CAUTION: They are easily

confused and may differ from the documentation!

Root Operations Examples: ◦ Bypass◦ Drainage◦ Extirpation◦ Resection◦ Inspection◦ Removal

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SOURCE: Centers for Medicare and Medicaid Services ICD-10 Public Presentation on August 3, 2011 available at CMS.gov)

• History of the development of the ICD, World Health Organization website, http://www.who.int/classifications/icd/en/

• ICD-10-CM Official Guidelines for Coding and Reporting-Centers for Disease Control (CDC), National Center for Health Statistics− http://www.cdc.gov/nchs/icd/icd10cm.htm

Main References

• Centers for Medicare & Medicaid Services ICD-10 page: − http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD1

0

• Assorted guidelines and concepts created and/or approved by the official ICD-10 Cooperating Parties:− American Hospital Association (AHA),− American Health Information Management Association (AHIMA),− Centers for Medicare and Medicaid Services (CMS), and− National Center of Health Statistics (NCHS)

John F. Burns, CPC, CPMA, CPC‐I, CEMCjburns@drsmgmt.com