Transcript Documentation Considerations by Chapters in ICD-10-CM

ICD-10-CM
OVERVIEW OF UPCOMING
DOCUMENTATION
COMPONENTS OF ICD-10-CM
Presenter
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Sue Haley, RHIT, CCS, CCDS
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AHIMA certified ICD-10 instructor
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Over 20 years coding experience
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Both inpatient and outpatient
OCTOBER 2013
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ICD-9-CM
3-5 characters
Only V & E codes start
with letter
Limited space for
adding new codes
Cannot identify
laterality
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ICD-10-CM
3-7 characters
ALL codes start with
letter
Flexible for adding new
codes
Can identify laterality
EXCLUDES NOTES
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ICD-10-CM
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Exclude notes are better defined in ICD-10
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EXCLUDES 1 means don’t code together
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EXCLUDES 2 means “not included here”. Therefore, if both
conditions exist, two codes are necessary
Official Guidelines for Coding &
Reporting Conventions for ICD-10
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www.cdc.gov/nchs/icd/icd10cm.htm
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Many new and revised coding guidelines for
ICD-10-CM but also newly published
guidelines for ICD-10-PCS
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AHA Coding Clinic for ICD-9-CM will not be
converting their guidelines for ICD-10-CM
use
Documentation Considerations by
Chapters in ICD-10-CM
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Infectious & Parasitic Disease
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Blood & Blood Forming Organ
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New terminology to review
Includes the drug resistant classifications
New terminology to review
Greater specificity
Endocrine, Nutritional, Metabolic
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Greater specificity for diabetes & malnutrition
Documentation Considerations by
Chapters in ICD-10-CM
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Mental & Behavioral Disorders
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Nervous System
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Significant changes in the specificity of sleep disorders
Eye & Adnexa (new chapter)
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Many changes to terminology
Tobacco use vs dependence
Terminology changes
Laterality classified
Ears & Mastoid (new chapter)
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Laterality classified
Documentation Considerations by
Chapters in ICD-10-CM
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Circulatory
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Respiratory
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Asthma now classified as mild intermittent & three degree’s of persistentmild, moderate, and severe
Digestive
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Includes gangrene
Hypertension no longer classified malignant, benign, or unspecified.
Definition on coding AMI now 4 weeks
Ulcers no longer specified as obstructive
Bleeding assigned to gastritis, duodenitis, diverticulosis
Crohn’s has specific sites & now identifies that with complications
Skin & Subcutaneous
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More specificity in sites & severity of decubitus ulcers
Documentation Considerations by
Chapters in ICD-10-CM
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Musculoskeletal & Connective Tissue
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Fractures further define encounters as:
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A initial encounter for fracture
B Initial encounter for fracture routine healing
G subsequent encounter for fracture delayed healing
K subsequent encounter for fracture with nonunion
P subsequent encounter for fracture for malunion
S sequela
Documentation Considerations by
Chapters in ICD-10-CM
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Musculoskeletal & Connective Tissue
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Uses the GUSTILO open fracture classification
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Mechanism of injury
Soft tissue damage
Degree of skeletal involvement
Physician teaching opportunity during your
implementation of ICD-10
Documentation Considerations by
Chapters in ICD-10-CM
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GUSTILO open fracture classification
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B
C
E
F
H
J
M
N
Q
R
initial encounter open fx type I or II
initial encounter open fx type IIIA, IIIB, or routine healing
subseq. encounter open fx type I or II with routine healing
subsuq. encounter open fx type IIIA, IIIB, or IIIC with routine
healing
subseq. Encounter open fx type I or II with delayed healing
subseq. Encounter for open fx type IIIA,IIIB, or IIIC with
delayed healing
subseq. Encounter for open fx type I or II with nonunion
subseq. Encounter for open fracture type IIIA, IIIB, or IIIC
with nonunion
subseq. Encounter for open fx type I or II with malunion
subseq. Encounter for open fx
Documentation Considerations by
Chapters in ICD-10-CM
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Musculoskeletal & Connective Tissue
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Laterality
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New definitions associated with classification of joint
involvement (direct, indirect, post-infective)
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Direct
organism invades synovial tissue and
microbial agent is present in joint
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Indirect
no joint involvement
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Post-infective
antigen present
Documentation Considerations by
Chapters in ICD-10-CM
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Musculoskeletal & Connective Tissue
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Pathological fractures have 3 categories:
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Due to neoplastic disease,
Due to osteoporosis,
Due to other specified disease
Documentation Considerations by
Chapters in ICD-10-CM
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Diseases of genitourinary system
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New terminology
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Post-traumatic urethral strictures will need to
identify patients gender
Documentation Considerations by
Chapters in ICD-10-CM
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Pregnancy, childbirth, & periperium
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Episode of care is no longer classified
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Trimester is now used to classify the condition
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1st trimester- less than 14 wks and 0 days
2nd trimester- 14 wks 0 days to less than 28 wks 0 days
3rd trimester- 28 weeks 0 days until delivery
Documentation Considerations by
Chapters in ICD-10-CM
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Pregnancy, childbirth, & periperium
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Physician’s must calculate the weeks, the coder
can not
Coder can use the weeks to determine the
trimester if the physician documents
The time frames for differentiating the abortion
from fetal death have changed from 22 to 20
weeks.
Documentation Considerations by
Chapters in ICD-10-CM
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Signs, Symptoms, and abnormal clinical and
laboratory findings, NEC
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Fairly substantial classification changes to hematuria
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GLASCOW coma scale (TBI/sequelae CVA)
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Primarily used by trauma registries & research
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Organizational decision the frequency of capturing a
Glasgow coma scale scores
Documentation Considerations by
Chapters in ICD-10-CM
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GLASCOW COMA SCALE
7th digit character will indicate:
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0 unspecified time
1 in the field (EMT or ambulance)
2 at arrival to ER
3 at hospital admission
4 24 hours or more after admission
Documentation Considerations by
Chapters in ICD-10-CM
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Injuries, poisoning, & certain other
consequences of external causes
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New category for underdosing
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Taking less of a medication than is prescribed
Classify burns and corrosions (new term ICD-10)
Documentation Considerations by
Chapters in ICD-10-CM
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Injuries, poisoning, & certain other
consequences of external causes
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New extensions for identification of:
 A initial encounter
 D subsequent encounter
 S sequela
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Documentation Considerations by
Chapters in ICD-10-CM
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Injuries, poisoning, & certain other
consequences of external causes
Fractures further define encounters as:
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A initial encounter for closed fracture
B Initial encounter for open fracture
D subsequent encounter fracture routing healing
G subsequent encounter for fracture delayed healing
K subsequent encounter for fracture with nonunion
P subsequent encounter for fracture for malunion
S sequela
Closing Remarks
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Encourage review of ICD-10 coding
guidelines now to become familiar with
similarities and differences
Pay close attention to new guidelines for
PCS and the new guidance being provided
Develop educational plans that incorporate
the new documentation requirements
Don’t wait until 2013 start now!