Transcript ICD-10 CM Training

ICD-10 CM Training
Cardiology
ICD-10-CM Compliance Dates
• ICD-10-CM will be valid for dates of service on or
after October 1, 2015
– Outpatient dates of service of October 1, 2015 and
beyond.
– Inpatient hospital service claims, is effective for dates of
discharge after September 30, 2015
Covered and Non-Covered Entities
• Covered Entities
– Everyone covered by the Health Insurance Portability
Accountability Act (HIPPA)
• Non-Covered Entities
– Worker’s Compensation
– Auto Insurance
– Non covered HIPAA entities are exempt but are
encouraged to adapt the new code set
ICD-10 Code Structure
• 21 Chapters
• Alpha-numeric codes; not case-sensitive
– Codes begin with Alpha letter, A-Z, excluding U
– Common errors
• I verses 1
• O verses 0
• “X” Placeholder
• 3 to 7 characters
– Decimal following 3rd character
ICD-10 Code Structure
• Placeholder “X”
– Used for future expansion of a code
– Fills in empty characters when a 6th and/or 7th character
apply
– The placeholder may be used in different scenarios but
should never serve as the final character.
Example: W19.XXXA Unspecified fall, Initial Encounter
ICD-10 Code Structure
• 7th Character
– Provides specified information regarding the clinical visit
– Is required for certain categories and must be reported in
the seventh position
– May be alpha or numeric
– Has different meanings depending on the coding category
ICD-10 Code Structure
• Laterality
– Some ICD-10-CM codes indicate laterality, specifying
whether the condition occurs on the left, right or is
bilateral.
– If no bilateral code is provided and the condition is
bilateral, assign separate codes for both the left and right
side.
– If the side is not identified in the medical record, assign the
code for the unspecified side.
OGCR section 1.B.13
ICD-10 Code Structure
• “Other” Codes
– Codes titled “other” or “other specified” are for use when
the information in the medical record provides detail for
which a specific code does not exist.
• “Unspecified” Codes
– Codes titled “unspecified” are for use when the
information in the medical record is insufficient to assign a
more specific code.
OGCR section 1.A.9.a.b
ICD-10 Structure
• Excludes Notes
– Excludes1
•
•
•
•
A type 1 Excludes note is a pure excludes note
It means “NOT CODED HERE”
The code excluded should never be used at the same time
When two conditions cannot occur together
– Excludes2
• 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, when appropriate
OGCR section 1.A.12.a.b
ICD-10 Code Structure
• “Code First” and “Use Additional Code”
– ICD-10 has a coding convention that requires the
underlying condition be sequenced first followed
by the manifestation.
– These instructional notes indicate the proper
sequencing order of the codes.
OGCR section 1.A.13
• The “-” indicates there are additional reporting
options
Most Common Diagnosis Codes
Chest pain
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
786.50
R07.9
Chest pain, unspecified
•
•
•
epidemic myalgia
(B33.0)
There are more specific code choice selections:
786.51
R07.2
Precordial pain
786.52
R07.1
Chest pain on breathing
786.52
R07.81
Pleurodynia
786.59
R07.82
Intercostal pain
786.59
R07.89
Other chest pain
jaw pain R68.84
pain in breast (N64.4)
Documentation Tips
• Type
–
–
–
–
–
Chest pain due to myocardial ischemia
Chest pain on breathing
Intercostal pain
Pleurodynia
Precordial chest pain
Use of a symptom code with a definitive diagnosis code
Codes for signs and symptoms may be reported in addition to a related definitive
diagnosis when the sign or symptom is not routinely associated with that diagnosis, such
as the various signs and symptoms associated with complex syndromes. The definitive
diagnosis code should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process should not be
assigned as additional codes, unless otherwise instructed by the classification.
OGCR Section I.C.18.b
Atherosclerotic heart disease of native coronary artery without angina pectoris
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
414.00
I25.10
N/A
•
•
414.01
I25.10
Atherosclerotic heart
disease of native
coronary artery without
angina pectoris
atheroembolism (I75.-)
atherosclerosis of coronary artery
bypass graft(s) and transplanted heart
(I25.7-)
Applicable To:
• Atherosclerotic heart
disease NOS
No ICD-10 code exists for unspecified vessel; native or bypass graft must be indicated
Use additional code, if applicable, to identify:
• coronary atherosclerosis due to calcified coronary lesion (I25.84)
• coronary atherosclerosis due to lipid rich plaque (I25.83)
•
•
•
•
•
•
chronic total occlusion of coronary artery (I25.82)
exposure to environmental tobacco smoke (Z77.22)
history of tobacco use (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)
Artherosclerotic Heart Disease
Coronary Artery Documentation Tips
• Associated Artery/Lesion Type
–
–
–
–
–
–
–
–
•
•
Native artery
Bypass graft
Bypass graft, autologous artery
Bypass graft, autologous vein
Bypass graft, nonautologous biological
Bypass graft, other
Due to calcified coronary lesion
Due to lipid rich plaque
Native vs Transplanted Heart
Associated angina
–
–
–
Without angina
With unstable angina
With angina and spasm
Atrial fibrillation
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
427.31
I48.91
Unspecified atrial
fibrillation
N/A
N/A
There are more specific code choice selections available below:
I48.0
Paroxysmal atrial fibrillation
I48.1
Persistent atrial fibrillation
I48.2
Chronic atrial fibrillation
Permanent atrial fibrillation
Atrial Fibrillation Documentation Tips
• Type
– Chronic (I48.2)
– Paroxysmal (I48.0)
– Persistent (I48.1)
Cardiac Arrhythmias
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
427.89
I49.8
Other specified cardiac
arrhythmias
•
•
N/A
Applicable To:
• Coronary sinus rhythm
disorder
• Ectopic rhythm disorder
• Nodal rhythm disorder
•
bradycardia NOS (R00.1)
neonatal dysrhythmia
(P29.1-)
sinoatrial bradycardia
(R00.1)
sinus bradycardia (R00.1)
vagal bradycardia (R00.1)
Bradycardia, unspecified
•
N/A
Applicable To:
• Sinoatrial bradycardia
• Sinus bradycardia
• Slow heart beat
• Vagal bradycardia
•
abnormalities originating in
the perinatal period (P29.1-)
specified arrhythmias (I47I49)
neonatal bradycardia
(P29.12)
427.89
R00.1
•
•
•
There are more code choice selections below:
427.9
I49.9
Cardiac arrhythmia, unspecified
Cardiac Arrhythmias Documentation Tips
• Type
–
–
–
–
–
–
–
–
–
–
–
Atrial fibrillation
Atrial flutter
Premature depolarization
Re-entry ventricular arrhythmia
Sick sinus syndrome
Supraventricular tachycardia
Ventricular fibrillation
Ventricular flutter
Ventricular tachycardia
Paroxysmal tachycardia
Cardiac arrhythmia
Cardiac Arrhythmias Documentation Tips
• Fibrillation Type
– Chronic
– Paroxysmal
– Persistent
•
Flutter Type
–
–
•
Typical
Atypical
Premature Depolarization Type
–
–
–
Atrial
Junctional
Ventricular
Cardiac Arrhythmias Documentation Tips
• R00.1 - Use Additional code for adverse effect, if
applicable, to identify drug (T36-T50 with fifth or
sixth character 5)
• I49 - Code first cardiac arrhythmia complicating:
– Abortion or ectopic or molar pregnancy (O00-O07, O08.8)
– Obstetric surgery and procedures (O75.4)
Abnormal electrocardiogram [ECG] [EKG]
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
794.31
R94.31
Abnormal
electrocardiogram [ECG]
[EKG]
•
•
•
long QT syndrome
(I45.81)
abnormal findings
on antenatal
screening of
mother (O28. -)
•
•
•
abnormal findings on
antenatal screening
of mother (O28.-)
certain conditions
originating in the
perinatal period (P04P96)
signs and symptoms
classified in the body
system chapters
signs and symptoms
of breast (N63,
N64.5)
Documentation Tips
• Symptom Codes
– Codes that describe symptoms and signs are acceptable for reporting
purposes when a related definitive diagnosis has not been established
(confirmed) by the provider.
• Use of a symptom code with a definitive diagnosis code
– Codes for signs and symptoms may be reported in addition to a
related definitive diagnosis when the sign or symptom is not routinely
associated with that diagnosis code.
• Signs or symptoms that are associated routinely with a
disease process should not be assigned as additional codes,
unless otherwise instructed by the classification.
Aortic Valve Disorders Nonrheumatic
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
424.1
I35.0
Nonrheumatic
aortic (valve)
stenosis
•
N/A
•
•
•
Aortic valve disorder of unspecified cause but with
diseases of mitral and/or tricuspid valve(s) (I08.-)
Aortic valve disorder specified as congential
(Q23.0, Q23.1)
Aortic valve disorder specified as rheumatic (I06.-)
Hypertrophic subaortic stenosis (I42.1)
There are more specific code choice selections below:
424.1
I35.1
Nonrheumatic aortic (valve) insufficiency
424.1
I35.2
Nonrheumatic aortic (valve) stenosis with insufficiency
424.1
I35.8
Other nonrheumatic aortic valve disorders
424.1
I35.9
Nonrheumatic aortic valve disorder, unspecified
Documentation Tips
• Type
–
–
–
–
Stenosis
Insufficiency
Stenosis with insufficiency
List other
Shortness of breath
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
786.05
R06.02
Shortness of breath
•
N/A
•
•
•
•
•
•
•
•
•
abnormalities originating in
the perinatal period (P29.1-)
specified arrhythmias (I47-I49)
acute respiratory distress
syndrome (J80)
respiratory arrest (R09.2)
respiratory arrest of newborn
(P28.81)
respiratory distress syndrome
of newborn (P22.-)
respiratory failure (J96.-)
respiratory failure of newborn
(P28.5)
tachypnea NOS (R06.82)
transient tachypnea of
newborn (P22.1)
There are more specific code choice selections below:
786.09
R06.00
Dyspnea, unspecified
786.02
R06.01
Orthopnea
786.09
R06.09
Other forms of dyspnea
Documentation Tips
• Dyspnea Type
– Shortness of breath
– Orthopnea
– Other forms
Ventricular premature depolarization
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
427.69
I49.3
Ventricular premature
depolarization
•
•
N/A
•
•
•
bradycardia NOS (R00.1)
neonatal dyrhythmia
(P29.1-)
sinoatrial bradycaria
(R00.1)
sinus bradycaria (R00.1)
vagal bradycaria (R00.1)
There are more specific code choice selections below:
427.69
I49.49
Other premature depolarization
Code first cardiac arrhythmia complicating:
• Abortion or ectopic or molar pregnancy (O00.-O07, O08.8)
• Obstetric surgery and procedures (O75.4)
Documentation Tips
• Type
–
–
–
–
Atrial premature depolarization (I49.1)
Junctional premature depolarization (I49.2)
Ventricular premature depolarization (I49.3)
Other specified cardiac arrhythmias (I49.8)
Ventricular tachycardia
ICD-9 Code
ICD-10 Code
Description
Excludes1
427.1
I47.2
Ventricular tachycardia
•
•
•
Code first cardiac arrhythmia complicating:
• Abortion or ectopic or molar pregnancy (O00.-O07, O08.8)
• Obstetric surgery and procedures (O75.4)
tachycardia NOS
(R00.0)
Sinoatrial
tachycaria (R00.0)
sinus tachycardia
(R00.0)
Excludes2
Other cardiomyopathies
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
425.4
I42.8
Primary cardiomyopathies,
NEC
•
•
•
Ischemic
cardiomyopathy
(I25.5)
Peripartum
cardiomyopathy
(O90.3)
Ventricular
hypertrophy (I51.7)
There are more specific code choice selections below:
425.4
I42.2
Other hypertrophic cardiomyopathy
425.4
I42.5
Other restrictive cardiomyopathy
425.4
I42.9
Cardiomyopathy, unspecified (familial)(idiopathic)
Code first pre-existing cardiomyopathy complicating pregnancy and puerperium (O99.4)
Syncope and collapse
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
780.2
R55
Syncope and
collapse
•
•
•
Applicable To:
• Blackout
• Fainting
• Vasovagal attack
•
•
•
•
•
•
•
•
•
•
•
cardiogenic shock (R57.0)
carotid sinus syncope
(G90.01)
heat syncope (T67.1)
neurocirculatory asthenia
(F45.8)
neurogenic orthostatic
hypotension (G90.3)
orthostatic hypotension
(I95.1)
postprocedural shock
(T81.1-)
psychogenic syncope
(F48.8)
shock NOS (R57.9)
shock complicating or
following abortion or
ectopic or molar pregnancy
(O00-O07, O08.3)
shock complicating or
following labor and delivery
(O75.1)
Stokes-Adams attack (I45.9)
unconsciousness NOS
(R40.2-)
•
•
•
abnormal findings on
antenatal screening
of mother (O28.-)
certain conditions
originating in the
perinatal period (P04P96)
signs and symptoms
classified in the body
system chapters
signs and symptoms
of breast (N63,
N64.5)
Documentation Tips
• Type
– Carotid sinus syncope (G90.01)
– Heat syncope
• Initial encounter (T67.1XXA)
• Subsequent encounter (T67.1XXD)
• Sequela (T67.1XXS)
– Psychogenic syncope (F48.8)
– Stokes-Adams syncope (I45.9)
– Vasovagal syncope (R55)
Cardiomegaly
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
429.3
I51.7
Cardiomegaly
N/A
•
Applicable To:
• Cardiac dilatation
• Cardiac hypertrophy
• Ventricular dilatation
•
•
•
•
•
•
•
•
•
certain conditions originating in
the perinatal period (P04-P96)
certain infectious and parasitic
diseases (A00-B99)
complications of pregnancy,
childbirth and the puerperium
(O00-O9A)
congenital malformations,
deformations, and chromosomal
abnormalities (Q00-Q99)
endocrine, nutritional and
metabolic diseases (E00-E88)
injury, poisoning and certain other
consequences of external causes
(S00-T88)
neoplasms (C00-D49)
symptoms, signs and abnormal
clinical and laboratory findings,
not elsewhere classified (R00-R94)
systemic connective tissue
disorders (M30-M36)
transient cerebral ischemic attacks
and related syndromes (G45.-)
Hypertension
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
401.1
401.9
401.0
I10
Essential (Primary)
Hypertension
Includes: high blood
pressure, Hypertension
(arterial) (benign)
(essential) (malignant)
(systemic)
•
•
•
•
Hypertensive Diseases
Categories (I10-I15)
The use additional codes
and Excludes1 codes apply
for all categories.
(I10-I15)
Use additional code to
identify:
• Exposure to
environmental tobacco
smoke (Z77.22)
• History of tobacco use
(Z87.891)
• Occupational exposure
to environmental
tobacco smoke (Z57.31)
• Tobacco dependence
(F17.-)
• Tobacco use (Z72.0)
•
•
•
Hypertensive disease
complicating pregnancy,
childbirth and the
puerperium (O10-O11,
O13-O16)
Neonatal hypertension
(P29.2)
Primary pulmonary
hypertension (I127.0)
Hypertensive disease
complicating pregnancy,
childbirth and the
puerperium (O10-O11.
O13-O16)
Neonatal hypertension
(P29.2)
Primary Pulmonary
hypertension (I27.0)
•
Essential (primary)
hypertension involving
vessels of brain (I60-I69)
Essential (primary)
hypertension involving
vessels of eye (H35.0-)
Hypertension cont.
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
402.01
402.11
402.91
I11.0
Hypertensive Heart Disease
with heart failure
• Use additional code to
identify type of heart
failure (I50.-)
N/A
N/A
402.00
402.10
402.90
I11.9
Hypertensive Heart Disease
without heart failure
N/A
N/A
403.01
403.11
403.91
I12.0
Hypertensive Chronic
Kidney Disease with stage 5
Chronic Kidney Disease or
end stage renal disease.
• Use additional code to
identify the stage of
chronic kidney disease
(N185.5, N18.6)
•
Hypertension due to
Kidney Disease (I15.0,
I15.1)
Renovascular
Hypertension (I15.0)
Secondary Hypertension
(I115.-)
Acute Kidney Failure (N17.-)
Hypertensive Chronic
Kidney Disease with stage
1-4 Chronic Kidney Disease,
or unspecified Chronic
Kidney Disease.
• Use additional code to
identify the stage of
chronic kidney disease
(N18.1-N18.9)
•
Hypertension due to
Kidney Disease (I15.0,
I15.1)
Renovascular
Hypertension (I15.0)
Secondary Hypertension
(I115.-)
Acute Kidney Failure (N17.-)
403.00
403.10
403.90
I12.9
•
•
•
•
Hypertension cont.
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
404.01
404.11
404.91
I13.0
Hypertensive heart and
chronic kidney disease with
heart failure and stage 1-4
chronic kidney disease, or
unspecified chronic kidney
disease
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
•
•
404.00
404.10
404.90
I13.10
Hypertensive Heart and
Chronic Kidney Disease
without heart failure, with
stage 1-4 chronic kidney
disease, or unspecified
chronic kidney disease.
•
404.02
404.12
404.92
I13.11
I13.2
Use additional code to identify
the stage of chronic kidney
disease (N18.1-N18.4, N18.9)
Hypertensive heart and
chronic kidney disease
without heart failure, with
stage 5 chronic kidney
disease or end stage renal
disease.
•
404.03
404.13
404.93
Use additional code to identify
type of heart failure (I50.-)
Use additional code to identify
stage of chronic kidney disease
(N18.1-NN18.4, N18.9)
Use additional code to identify
the stage of chronic kidney
disease (N18.5, N18.6)
Hypertensive heart and
chronic kidney disease with
heart failure and with stage
5 chronic kidney disease, or
end stage renal disease.
•
•
Use additional code to identify
type of heart failure (I50.-)
Use additional code to identify
the stage of chronic kidney
disease (N18.5. N18.6)
Hypertension cont.
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
405.01
405.11
405.91
I15.0
Renovascular Hypertension
• Code also underlying
condition
Postprocedural
hypertension (I97.3)
•
•
405.91
405.99
405.09
405.19
405.99
405.99
I15.1
I15.2
I15.8
I15.9
Hypertension secondary to
other renal disorders
• Code also underlying
condition
Postprocedural
hypertension (I97.3)
Hypertension secondary to
endocrine disorders
• Code also underlying
condition
Postprocedural
hypertension (I97.3)
Other secondary
hypertension
• Code also underlying
condition
Postprocedural
hypertension (I97.3)
Secondary hypertension,
unspecified
• Code also underlying
condition
Postprocedural
hypertension (I97.3)
•
•
•
•
•
•
•
•
Secondary hypertension
involving vessels of brain
(I60-I69)
Secondary hypertension
involving vessels of eye
(H35.0-)
Secondary hypertension
involving vessels of brain
(I60-I69)
Secondary hypertension
involving vessels of eye
(H35.0-)
Secondary hypertension
involving vessels of brain
(I60-I69)
Secondary hypertension
involving vessels of eye
(H35.0-)
Secondary hypertension
involving vessels of brain
(I60-I69)
Secondary hypertension
involving vessels of eye
(H35.0-)
Secondary hypertension
involving vessels of brain
(I60-I69)
Secondary hypertension
involving vessels of eye
(H35.0-)
Hypertension Documentation Tips
• Hypertension is no longer classified as benign, malignant or unspecified.
• ICD-10 Codes have been grouped according to disease progression:
– I10
– I11.– I12.-
Essential Hypertension
Hypertensive Heart Disease
Hypertensive CKD
»
– I13.-
Hypertensive Heart and CKD
»
– I15.-
Further subdivided by stage of kidney disease
Further subdivided by stage of kidney disease
Secondary Hypertension
• Transient Hypertension
– A code for hypertension is NOT assigned unless the patient has a
documented, established diagnosis of hypertension.
• R03.0 Elevated blood pressure reading without diagnosis of hypertension
• Document requirements
– Type
– Current Status
– Associated relationships
Hyperlipidemia
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
272.4
E78.4
Other
Hyperlipidemia
• Familial
combined
hyperlipidemia
•
N/A
272.4
E78.5
Hyperlipidemia,
unspecified
Sphingolipidosis
(E75.0-E75.3)
There are more specific code choice selections available below:
272.0
E78.0
Pure Hypercholesterolemia
272.1
E78.1
Pure Hypercholesterolemia
272.2
E78.2
Mixed Hyperlipidemia
272.3
E78.3
Hyperchylomicronemia
272.5
E78.6
Lipoprotein deficiency
Hyperlipidemia Documentation Tips
• Type
– Mixed
– Other
– Unspecified
Heart failure, unspecified
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
428.0
I50.9
Heart failure, unspecified
•
N/A
Applicable To:
• Biventricular (heart) failure NOS
• Cardiac, heart or myocardial
failure NOS
• Congestive heart disease
• Congestive heart failure NOS
• Right ventricular failure
(secondary to left heart failure)
•
•
Cardia arrest
(I46.-)
Neonatal
cardiac failure
(P29.0)
fluid overload
(E87.70)
Code first:
• Heart failure complicating abortion or ectopic or molar pregnancy (O00-O07, O08.8)
• Heart failure following surgery (I97.13-)
• Heart failure due to hypertension (I11.0)
• Heart failure due to hypertension with chronic kidney disease (I13.-)
• Obstetrics surgery and procedures (O75.4)
• Rheumatic heart failure (I09.81)
Heart failure, unspecified
Documentation Tips
• Type
– Systolic
– Diastolic
– Combined
• Chronicity
– Acute
– Chronic
– Acute on chronic
Heart failure, unspecified
Documentation Tips
1) Hypertension with Heart Disease
Heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code
from category I11, Hypertensive heart disease, when a causal relationship
is stated (due to hypertension) or implied (hypertensive). Use an
additional code from category I50, Heart failure, to identify the type of
heart failure in those patients with heart failure.
Heart failure, unspecified
Documentation Tips
2) Hypertensive Chronic Kidney Disease
Assign codes from category I12, Hypertensive chronic kidney disease, when
both hypertension and a condition classifiable to category N18, Chronic
kidney disease (CKD), are present. Unlike hypertension with heart disease,
ICD-10-CM presumes a cause-and-effect relationship and classifies chronic
kidney disease with hypertension as hypertensive chronic kidney disease.
The appropriate code from category N18 should be used as a secondary code
with a code from category I12 to identify the stage of chronic kidney disease.
See Section I.C.14. Chronic kidney disease.
If a patient has hypertensive chronic kidney disease and acute renal failure, an
additional code for the acute renal failure is required.
Monitor Claims
On October 01, 2015 we will monitor claims for date of
service rules
• Outpatient claims cannot have crossover dates
• Outpatient claims will be coded according to date of
service
• Inpatient facility claims will be coded per date of discharge
We will monitor claims to resolve any unanticipated
problems with the submission process
Claim Denial and Management
• We will monitor for claim denials
• We will monitor editing trends for ICD-10 Coding
guidelines
• We will provide feedback to the physicians regarding
supporting documentation requirements
• We will monitor WC or Liability carriers for published
rules on use of ICD-9 or ICD-10 code sets
Client Responsibilities
• Client will need to update
–
–
–
–
Templates
Order Sets
Superbills
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• Future Orders
– Remove ICD-9 code add ICD-10 code
Documentation – Start Now
All Conditions treated or assessed must be documented in the medical
record. In addition to the documentation tips reviewed, below are more
areas to document that will ensure proper ICD-10-CM code selection.
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Site specificity
Document notation of qualifiers
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Indicate acute or chronic
Indicate underlying or external cause factors
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Exacerbation
Manifestations
Relapse
Status
Stages
Medication
Smoke
Accidents
Mechanical failure
Laterality
– Bilateral
– Right
– Left
Documentation – Start Now
• Episode of Care for injuries, poisoning, external
causes and other conditions
– Initial Encounter
• Use while the patient is receiving active treatment of the condition
– Active treatment includes surgical treatment, an emergency
encounter, and evaluation and treatment by a new physician
– Subsequent Encounter
• Used on 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.
– Medication adjustments, aftercare, device adjustments, cast change
– Sequela
• Used for complications or conditions that arise as a direct result of
a condition, late effect
Documentation – Start Now
• Combination codes that capture
– Etiology and manifestation
– Related conditions
– Disease, injury or other medical condition and
complications
– Disease or other medical conditions and common signs or
symptoms
• Add ICD-10 Codes to patient Problem List
Questions
[email protected]
Centers for Disease Control and Prevention (ICD-10-CM)
http://www.cdc.gov/nchs/icd/icd10cm.htm