Transcript Elaine Schmidt, CPC, CPO-C, OCS

Elaine Schmidt,
CPC, CPO-C, OCS
INTERNATION
CLASSIFICATION OF
DISEASES, 10th Edition,
Clinical Modification
(ICD-10—CM)
OVERVIEW
1
DISCLAIMER
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This information is current as to the time it
was prepared and reasonable effort was
made to assure accuracy. There is no
guarantee of being completely error-free.
This presentation is intended to be a tool to
assist and guide understanding.
2
GOALS
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Basic understanding for implementation and
use of ICD-10-CM as it pertains to our world
of Optometric Healthcare
Diagnosis codes
ICD-10-PCS is for PROCEDURES and
ONLY used for inpatient procedures in the
United States
3
4
What is ICD:
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International Classification of Diseases
Came into use by the WHO-World Health
Organization member states in 1994
Origins in the 1850s
1st edition, known as the International List of
Causes of Death, was adopted by the International
Statistical Institute in 1893
WHO took over the responsibility for ICD at its
creation in 1948 when the 6th revision, which
included causes of morbidity for the first time
5
What is ICD:

The World Health Assembly adopted the
WHO nomenclature Regulations that
stipulate the use of ICD in its most current
revision for mortality and morbidity statistics
by all member states in 1967
6
ICD-10 and HIPAA 5010
CONNECTION
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HIPAA (Health Portability and Accountability Act)
5010 was adopted to replace the version of X12 4010 standard that covered entities (health plans,
health plan clearinghouses, and certain health care
providers) conducting electronic transactions
5010 implementation was part of preparing for
ICD-10
The 5010 submission standard will accommodate
the increased size and complexity in ICD-10 codes
7
ICD-10-CM/PCS
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ICD -10 consists of 2 parts:
ICD-10-CM – for diagnosis coding
ICD-10-PCS – for inpatient procedure
coding- Hospitals ONLY
Implementation of I-10-CM does NOT
change our use of CPT Coding set
8
ICD-10-CM Consists of:
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3 Volumes:
-Volume 1 – Tabular List: Alpha-numeric listing of
diseases, disease groups and health related
problems with inclusion & exclusion notes* and
some coding rules
-Volume 2 – Instruction Manual: Descriptions,
guidelines/conventions, coding resources
-Volume 3 – Alphabetical Index: Alphabetical list
of codes from the Tabular List
9
Volumes & Confusion
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Volume 1, Tabular List, uses British spelling
Volume 3, Alphabetical Index, uses American
spelling
Volumes 1 & 3 must be used together
To code correctly, start with (Volume 3), the
Alphabetical Index for the code, THEN confirm in
the Tabular List (Volume 1)
Remember, “List” is the Tabular; “Index” is the
alphabetical
10
Order
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1. Determine the condition/s to be coded from the
documentation; site (cornea, retina, eyelid),
laterality (right, left, OU), location (central,
peripheral)
2. Begin with the Alphabetical Index (Vol 3) to find
the condition and select a code
3. Confirm selected code in the Tabular List (Vol
1)-this must include reviewing the coding
instructions
11
New Features
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Added laterality
Expanded codes (injury, diabetes,
alcohol/substance abuse, postoperative
complications)
Added extensions for episode of care
Excludes 1 and Excludes 2 notes
Combination codes for conditions and common
symptoms or manifestations
12
New Features
Combination codes for conditions and common
symptoms or manifestations
 Ex: H40.10x Unspecified open angle GLC, stage x
x will be assigned 0-4 showing stage of GLC
 Combination codes for poisonings and external
causes
 External cause codes no longer a supplementary
classification
 Changes in time frames specified in certain codes

13
Details are Important
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I’s can look like 1’s
0’s can look like O’s
all O codes are OBG
Placeholder x is lower case
E10- Includes Type 1 diabetes mellitus diagnoses
E11- Includes Type 2 diabetes mellitus diagnoses
When doing a search, it is important to put ICD10-CM (as opposed to ICD-10), otherwise
information for other countries may be shown
14
HIPAA

“Adherence to these guidelines when
assigning ICD-10-CM diagnosis codes is
required under the Health Insurance
Portability and Accountability Act (HIPAA)”

A quote directly from the Official Coding
Guidelines
15
Non-HIPAA Entities

Non-HIPAA covered entities such as workers
compensation, nursing homes, and home
health agencies are not mandated to switch
to the new code set being implemented
October 1, 2014. However, the changing tide
will sweep them along with the complex
transition whether they like it or not.
16
Implementation
Mandatory Implementation is October 1, 2014
 Affected by anyone covered by HIPAA
-Health care providers
-Payers including Medicare & Medicaid
-Clearinghouses
-Some non-HIPAA covered entities: venders,
business associates, worker’s comp programs, life
insurance companies

17
Date of Service


The date of service, NOT the date the claim
is filed, determines use of ICD-9 or ICD-10.
If the date of service is prior to October 1,
2014, the ICD-9 codes are to be used. If the
date of service is October 1, 2014 or after,
use ICD-10
18
NUMBERS:
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Diagnosis codes effectively increase from
14K in ICD-9-CM to more than 70K in ICD10-CM (and will continue to grow)
ICD-10-CM-diagnosis coding in all health
care settings
ICD-10-PCS – procedure codes – do NOT
apply to office or out-patient procedures
21 Chapters
Chapter 7: Diseases of the Eye and Adnexa
19
INTERNATIONAL EMPHASIS
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Other countries have already implemented
ICD-10
United Kingdom – 1995
France – 1997
Australia – 1998
Germany – 2000
Canada – 2001
United States - 2014
20
21
OUTDATED
 Foremost, it is out of room-many I-9 categories are
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full
ICD-9 was originally published in 1977
Over 34 years old; having outdated and obsolete
terminology
Uses outdated codes that produce inaccurate and
limited data
Inconsistent with current medical practice
Cannot accurately describe the diagnoses for care
provided in the 21st century
22
BENEFITS OF I-10

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Accommodates a host of new diagnoses and
procedures
Accurate anatomical descriptions
Combination codes and laterality extensions
allow for greater specificity
Differentiation of risk and severity
Key parameters to differentiate disease
manifestations
23
MORE BENEFITS
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Improves operational processes
-due to detail accuracy and fewer payerphysician inquiries thus decreasing delays
Updated terminology
Increases flexibility for updates
Provides detailed data to analyze disease
patterns
Decreased need to include supporting
documentation with claims- OR, end up sending
documentation due to unclear information on the
claim
24
STILL MORE BENEFITS
Provides better data for:
-measuring care furnished to patients
-designing payment systems
-processing claims
-making clinical decisions
-tracking public health
-identifying fraud and abuse
-conducting research

25
Foreign Language?
I-9 had 3-5 characters
 I-10 has 3-7 characters; alpha and numeric digits:
-digit 1 is alpha (all letters used except U); digits 2 &
3 are numeric; digits 4-7 are alpha (not case
sensitive) OR numeric; and decimal is after the 3rd
digit
 Diagnosis Codes will be grouped by anatomical
site, rather than by type of disease or injury
 Just the Official Guidelines to ICD-10-CM is 113
pages
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26
MAYBE NOT SO FOREIGN
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In many ways, ICD-10 is similar to ICD-9
The guidelines, conventions, and rules are
very similar
Organization of the codes is similar
Almost anyone who is qualified to code ICD-9
should be able to make the transition to
coding ICD-10
27
DIFFERENCES

The big difference between ICD-9 and ICD10 systems are differences that will affect
information technology and software at your
practice
28
IMPROVEMENTS
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A single code can report a disease and its current
manifestation
For example: type II diabetes with diabetic
retinopathy
Due to the increased number of diagnosis codes
under ICD-10, a more precise code
Some of the numbers growth is due to laterality
29
DM with DR

E11.3- Type 2 Diabetes with ophthalmic
complications
E11.31- Type 2 DM with unspec retinopathy
E11.311 Type 2 DM w unspec DR with ME
E11.319 Type 2 DM w unspec DR w/o ME
E11.32- Type 2 DM w mild non-proliferative DR
E11.321 Type 2 DM w mild non-proliferative DR
with ME
E11.329 Type 2 DM w mild non-prolif w/o ME
30
E11.33- Type 2 DM w moderate non-proliferative DR
DM with DR
E11.33- Type 2 DM with mod. Non-proliferative DR
E11.331 Type 2 w mod. nonproliferative DR w ME
E11.339 Type 2 w mod. nonproliferative DR w/o
ME
E11.34- Type 2 DM w severe nonproliferative DR
E11.35- Type 2 DM w proliferative DR
E11.36 Type 2 DM with diabetic cataract
note, no “-”, so complete code
E11.39 Type 2 DM with other diabetic complication
Use addtl code to identify manifestation (H40-H42)
31
Retinopathy
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H35.0- Background retinopathy
H35.00 unspecified background retinopathy
central serous – see Chorioretinopathy, central
serous (H35.71-)H35.7- separation of retinal layers
diabetic – see Diabetes, retinopathy
exudative H35.02hypertensive H35.03proliferative NEC H35.2- (other non-diabetic
proliferative retinopathy)
diabetic – see Diabetes, retinopathy, proliferative
32
H35.02-, H35.03
“-” means incomplete, so (in this example), a 1, 2,
3, or 9 is required for the 6th digit

1= right eye
2= left eye
3= bilateral
9= unspecified
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34
Cautious Help - GEMs
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General Equivalence Mappings
Crosswalk tool developed by CMS and CDC with
input from the AHA and AHIMA for the use of ALL
providers, payers, and data users. They are free
of charge and are in the public domain
Tool to “guide” I-9 codes to I-10 codes
Assist with transitioning between code sets,
identifying the differences
35
GEMS
GEMS are not a substitute for learning how to use
ICD-10
 Designed as a general purpose translation tool to
convert coded data
 The complete meaning of a coded includes:
-tabular instruction, index entries, guidelines, and
applicable coding clinic advice
 GEMS will be maintained for at least 3 years
beyond October 1, 2014
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36
CHANGES?
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GEMS can be helpful when used as a “guide”
Some ICD-10 codes have no predecessor ICD-9
code
If an unspecified I-9 Dx is translated to I-10, it will
do so as an unspecified I-10 – when there is likely
a more specific I-10 available: REMEMBER, we
must code to the greatest specificity
37
Example:
One ICD-10 is represented by multiple ICD-9
codes:
E11.341 – Type 2 DM with severe nonproliferative
diabetic retinopathy with macular edema:
To ICD-9 cluster: (ie, translation)
-250.50 - DM with ophthalmic manifestations, type II
or specified type, not stated as uncontrolled
-362.06 – Severe nonproliferative diabetic
retinopathy
-362.07 – Diabetic macular edema
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38
Example I-9 to I-10
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379.11 – Hordeolum could be:
H00.011 Hordeolum, right upper lid
H00.012 Hordeolum, right lower lid
373.2 – Chalazion could be:
H00.011 Chalazion, right upper lid
H00.012 Chalazion, right lower lid
H00.013 rt eye, unspec lid, H00.014 lt upper lid,
H00.015 lt lower lid, H00.016 lt , unspec lid
H00.019 unspec eye, unspecified eyelid
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Mapping & Conversion
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Available for free and can be downloaded at:
www.cdc.gov/nchs/icd/icd10cm.htm
GEMs files:
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/
Publications/ICD10CM/2010
2010_DiagnosisGEMs.zip
Another good source is:
ICD10Data.com/convert
40
MATCH
Per CMS, there is NOT a one-to-one match
between ICD-9 and ICD-10 for the following
reasons:
-There are new concepts in ICD-10 that are not
present in ICD-9
-For a small number of codes, there is not a
matching code in the GEMS
-There may be multiple ICD-9 codes for a single
ICD-10 code
-There may be multiple ICD-10 codes for a single
ICD-9 code
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GEMs-Words from the AMA
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-an
“attempt to find corresponding….codes between
the two code sets, insofar as this is possible.”
NOT an exact crosswalk
Information cam be lost or gained
Crosswalking is NOT a substitute for learning and
fully implementing ICD-10 into your practice
42
ACCESS
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For a period of two years or more, systems will
need to access both ICD-9 and ICD-10 codes as
the country transitions from ICD-9 to ICD-10
Mapping may be necessary so that equivalent
codes can be found for issues of disease tracking,
medical necessity edits and outcomes studies
43
44
Order of Chapter Groupings
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Information on diseases and conditions and
causes are grouped in the following order:
-Communicable diseases
-General diseases that affect the whole body
-Local diseases arranged by site
-Developmental diseases
-Injuries
-External causes
45
Chapters
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1. (A00-B99): Certain Infectious and Parasitic
Diseases
2. (C00-D48): Neoplasms
3. (D50-D89): Diseases of the Blood and Bloodforming Organs and Certain Disorders Involving
the Immune Mechanism
4. (E00-E90): Endocrine, Nutritional, and Metabolic
Diseases
5. (F01-F99): Mental and Behavioral Disorders
6. (G00-G99): Diseases of the Nervous Systerm
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Chapters
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7. (H00-H59): Diseases of the Eye and Adnexa
8. (H60-H95): Diseases of the Ear and Mastoid
Process
9. (I00-I97): Diseases of the Circulatory System
10. (J00-J99): Diseases of the Respiratory System
11. (K00-K93): Diseases of the Digestive System
12. (L00-L99): Diseases of the Skin and
Subcutaneous Tissue
13. (M00-M99): Diseases of the Musculoskeltal
System and Connective Tissue
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Chapters
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14. (N00-N99): Diseases of the Genitourinary
System
15. (O00-O99): Pregnancy, Childbirth, and the
Puerperium
16. (P04-P94): Certain Conditions Originating in
the Perinatal Period
17. (Q00-Q94): Congenital Malformations,
Deformations, and Chromosomal Abnormalities
18. (R00-R99): Symptoms, Signs, and Abnormal
Clinical and Laboratory Findings, Not Elsewhere
Classified
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Chapters
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19. (S00-T98): Injury, Poisoning, and Certain Other
Consequences of External Causes
20. (V01-Y97): External Causes of Morbidity
21. (Z00-Z99): Factors Influencing Health Status
and Contact with Health Services
(former V codes are now Z codes contained in
chapter 21)
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Signs and Symptoms

Codes that describe symptoms & signs, as
opposed to diagnoses, are acceptable for reporting
purposes when a related DEFINITIVE diagnosis
has not been established by the provider. Chapter
18-Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings, Not Elsewhere Classified
(codes R00.0-R99) contains many but not all
codes for symptoms.
50
CATEGORIES-TABULAR LISTVol 1
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Categories all have 3 characters and are the 1st 3
digits of the diagnosis code
Subcategories are the next 4 or 5 characters
defining the etiology, anatomic site, and severity
The 7th digit extensions would represent visit
encounter or *sequela for injuries and external
causes
Diagnosis codes are to used and reported at their
highest number of characters available; ie,
greatest specificity
51
IMPORTANT LOOKUP
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REMINDER:
Always consult the Alphabetic Index
BEFORE turning to the Tabular List
This is the most critical rule to begin a search
Alpha Index will then direct you on where to
go in the Tabular List to obtain the correct
code
52
EXAMPLE
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Look up cataract in the alpha index
Shows an extensive list of alpha-numeric codes
Go to the tabular index to verify code selection
H25.041
-following is the dissection of the I-10 code
H25 – Age-related cataract (category)
04 – Posterior subcapsular polar
1 – Right eye
53
CODING CONVENTIONS
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There are many abbreviations/acronyms, and
symbols that will be important to learn and
understand with ICD-10
Some are like or similar to ICD-9
NEC = not elsewhere classifiable
NOS = not otherwise specified
54
Punctuation Conventions
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[]
In the tabular index, the bracket is used to enclose
synonyms
In the alpha index, to identify manifestation codes
( ) parentheses enclose supplementary words,
aka, nonessential modifiers
: colons are used after an incomplete term which
needs one or more of the modifiers following the
colon to make it assignable to a given category
55
Punctuation
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- dash
A dash at the end of a code indicates the
code is incomplete
Additional characters are required
56
57
Dummy Placeholder Character
“x” always represents the dummy placeholder
 Used to provider future expansion
 Meet the requirement of coding the highest level of
specificity
 T15.00XA – (ICD-9 was 930.0) Foreign body in
cornea, unspecified eye, initial encounter
 T15.01XA – Rt eye, initial encounter
 T15.01XD – Rt eye, subsequent encounter
(S as the 7th digit would represent sequela)
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Convention Words
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Use of “and” when used in a narrative statement
represents and/or
Codes titled “other” or “other unspecified” are for
use only when the information in the medical
record provides detail for which a specific code
does not exist
Alpha index entries with NEC in the line designate
“other” codes in the Tabular list. Such entries
represent specific disease entities for which no
specific code exists
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Unspecified
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“unspecified” or NOS- not otherwise specified, is
used when the information in the medical record
is insufficient to assign a more specific code.
Those categories for which an unspecified code is
not provided, the “other specified” code may
represent both other and unspecified
“We aren’t sure what’s wrong or the
documentation is not specific”
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Excludes Notes
Excludes1: is a pure excludes note. It means
“NOT CODED HERE!” It indicates that the
code excluded should NEVER be used at the
same time as the code above the Excludes1
note.
Used when 2 conditions cannot occur together,
such as a congenital form versus an acquired
form of the same condition. (patient could not
both be born with a specific diagnosis, and
also acquire/develop the same diagnosis
later)
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Excludes Notes
Excludes2 represent “Not included here”. It
indicates that the condition excluded is not
part of the condition represented by the code,
but a patient may have both conditions at the
same time. With an Excludes2 note, it is
acceptable to use both the code and the
excluded code together, when appropriate.
62
Excludes 2 example
S05: Injury of eye and orbit
In the tabular index, includes and excludes notes
are shown;
Includes: Open wound of eye and orbit
Excludes 2: 2nd cranial [optic] nerve injury (S04.0-)
3rd cranial [oculomotor] nerve injury (S04-1-)
open wound of eyelid and periocular area (S01.1-)
orbital bone fracture (S02.1-,S02.3-,S02.8-)
superficial injury of eyelid (S00.1-S00.2)
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Other notes
Like I-9, some codes require the underlying
condition be sequenced 1st, followed by the
manifestation.
Be observant of instructional notes:
“use additional code”
“code first”
“see” and “see also”
“code also”
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Code 1st , Instruction notes,
Excludes, Use additional code
Patient with glaucoma due to Lowe’s syndrome
 H42 Glaucoma in diseases classified elsewhere
Code first underlying condition, such as:
Lowe’s syndrome (E72.03)
E72.03 Lowe’s syndrome
Use additional code for associated glaucoma (H42)
H42 has Excludes 1: glaucoma (in) *shows list of
exclusions
Principle Dx = E72.03, 2nd Dx = H42
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Specificity
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Diagnosis codes are to be used and reported at
their highest number of characters available
Combination Codes and laterality extensions allow
for this greater specificity
Signs and symptoms that are associated routinely
with a disease process should NOT be assigned
as additional codes, unless instructed by the
classification
Additional signs and symptoms NOT associated
routinely with a disease SHOULD be coded when
present
66
Chapter 7 Categories: H00-H59
Total of 12 defined
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H00-H05: Disorders of eyelid, lacrimal
system and orbit
H10-H11: Disorders of conjunctiva
H15-H22: Disorders of sclera, cornea, iris
and ciliary body
H25-H28: Disorders of lens
H30-H36: Disorders of choroid and retina
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Chapter 7 Categories:
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H40-H42: Glaucoma
H43-H44: Disorders of vitreous body and
globe
H46-H47: Disorders of optic nerve and visual
pathways
H49-H52: Disorders of ocular muscles,
binocular movement, accommodation and
refraction
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Chapter 7 Categories:
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H53-H54: Visual disturbances and blindness
H55-H57: Other disorders of eye and adnexa
H59: Intraoperative and postprocedural
complications and disorders of eye and
adnexa, not elsewhere classified
69
Chapter 7 was detailed to show
OTHER
Diseases of the Eye and Adnexa
CHAPTERS/CATEGORIES
 Other I-10 categories relevant to Eye
Care
 -C69.xxx Malignant neoplasm
 Rxx.xxx Sign & Symptom codes
(headache, weakness, malaise, etc
 R00.xxx Symptoms, signs and
abnormal clinical findings
 Sxx.xxx S codes – injury, poisoning external
 Txx.xxx T codes – FB in cornea
 T74.xxx Adult and child abuse, neglect
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Additional Categories
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X00.xxx Injury and Accident codes (initial,
subsequent, and sequela –late effect)
Y92.xxx Place of occurrence (replaces E
codes)
Y93.xxx Activity codes (replaces E codes)
V01-V099 External causes of Morbidity
Z00-Z99 Replace V codes for screenings and
histories
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FEE DRIVEN TO QUALITY OF
SERVICE
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Emphasis on service is going from a fee driven
reimbursement to quality of service; CPT driven
VS Dx driven
Clinical documentation improvement
National Coverage Determination (NCD) policies
will be ready by year end 2013
Local Coverage Determination (NCD) by April
2014
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DOCUMENTATION
Better reporting, better documentation
 What ordered and why, along with interpretation
and report
 If the final Dx is the RESULT of the signs &
symptoms, just code the final Dx
 Co-morbidities: how do they affect services being
done at a specific encounter?
-then address them in the assessment & plan so
additional diagnoses codes can be used
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TIDBITS
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Uncertain does NOT = unspecified
Concerning diabetes; wording of controlled
and uncontrolled no longer used. Type 1 and
Type 2 are used.
Type 1, category E10, indicates the patient is
not producing insulin
Type 2 is category E11
Category E13 is OTHER specified diabetes
mellitus (NOT the same as unspecified)
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COMPLIANCE
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Implementation date of ICD-10-CM is
October 1, 2014
No delays
No grace period
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CONSIDERATIONS
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Allow time to learn this new language
Once we become familiar with it, the benefits will
be readily experienced
*Oh, and by the way, the I-10 diagnosis for
hypertension (which we may now all have)
is…………
I10
One important benefit: we’ll be using our brain in a
whole (not hole) new way; which will help stave off
dementia (hopefully); or will contribute to or put us
there
77