Transcript ICD-10-CM: An Introduction for Coders

ICD-10-CM:
An Introduction for Coders
© Irene Mueller, EdD, RHIA
By attending this workshop,
participants will
• Identify the
– Reasons for implementing ICD-10-CM in the
United States
– Settings that will require ICD-10-CM
– Knowledge that coders will need to apply ICD-10CM
– Similarities between ICD-9-CM and ICD-10-CM
– Differences between ICD-9-CM and ICD-10-CM
• Receive
– ICD-10-CM Coding Examples and Cases
– ICD-10-CM Resources Listing for future use
Why Change to ICD-10-CM?
• ICD-9-CM out of space to
accommodate new codes
– Advances in medical
knowledge
– New technology
– Newly identified diseases
• Limited space = Lack
sufficient clinical detail
– Severity or complexity of
diagnoses
http://www.chiropracticmakati.com/Concept-Four.html
Why Change to ICD-10-CM?
• Updated classification system allows ability to
– Measure quality of care
– Initiate pay-for-performance
– Evaluate resource utilization
– Track public health threats, such as avian flu
– Identify medical errors and patient safety issues
– Exchange meaningful health data with other
organizations and government agencies
Reasons for ICD-10-CM
Implementation
• Represents significant improvement
– Designed to overcome issues & limitations of
ICD-9-CM
– Updates healthcare coding with unambiguous
codes for conditions
– More flexibility in adding new codes
• Has greater specificity and clinical detail
– Major improvements in quality & usefulness of
coded data
Reasons for ICD-10-CM
Implementation
• Updated Medical terminology & classification
of diseases to reflect current clinical practice
• Improved structure & capacity for capturing
technological advances
– More flexible
– Accommodates revisions necessitated by
medical advances
Why Change to ICD-10-CM?
•
•
•
•
•
•
•
1990 - ICD-10 first published by WHO
1999 – Australia
1999 – US for death certificate coding
2000 – Canada
2005 – France
2007 - Thailand
2008 – Korea
• 25 countries use ICD-10 for healthcare
reimbursement & resource allocation
• ICD-11 – development from now thru 2015
ICD-10-CM Implementation
• Compliance date =
– Date of discharge for inpatient claims
– Date of service for outpatient claims
ICD-10-CM Control
• Cooperating Parties for ICD-10-CM
•
•
•
•
AHA
AHIMA
CMS
NCHS
ICD
10
CM
Settings requiring ICD-10-CM
• ALL healthcare settings, because ICD-10CM required for ALL diagnosis coding when
implemented
• Will affect every part of HCOs, not just
coders
Knowledge Base for ICD-10-CM
• CMS Final rule Recommends 50
hours of training for
Inpt Coders (16 for
Outpt Coders)
– PRESUMES coding
professionals already
possess required
knowledge in
biomedical sciences
needed to correctly
apply codes using
ICD-10-CM
•
•
•
•
•
Anatomy
Physiology
Pathophysiology
Pharmacology
Medical terminology
Knowledge Base for ICD-10-CM
• Inpatient coders MUST
– Have sufficient foundational knowledge of
biomedical sciences
– Learn how to apply ICD-10-CM codes
correctly on inpatient encounters
– Understand how to apply maps and
crosswalks between ICD-9-CM and ICD10
systems
Knowledge Base for ICD-10-CM
• Outpatient coders MUST
– Have sufficient foundational knowledge of
biomedical sciences
– Learn how to apply ICD-10-CM codes
correctly on outpatient encounters
– Understand how to apply maps and
crosswalks between ICD-9-CM and ICD-10CM
Similarities
Basic ICD-10-CM Coding Steps
•
•
•
•
•
ID all main terms in dx statement
ID all modifiers (subterms) in dx statement
Locate mainterm(s) in AI
Locate subterm(s) (site, etiology, clinical type)
Follow any cross-references IF not under 1st
code
• Verify tentative code in TL
• Follow any instructions
• Assign codes to highest level of specificity
Code Structure
•
•
•
•
Categories
Subcategories
Codes
Three-character category without any
subdivision = Code
• Codes w/o correct # of characters = INVALID
– Codes assigned MUST have highest # of
characters available/highest level of specificity
Structure and Conventions
• Much of hierarchical • Tabular List
structure similar
– Chapters
– Subchapters (Blocks in ICD• Many conventions
10-CM)
similar
• Alphabetic Index
– Two parts
• Index to Diseases and
Injuries
– Neoplasm Table
– Table of Drugs & Chemicals
• Index to External Causes
Similar AI Conventions
• Boldface
Mainterms
• Indented
subterms/essential
modifiers
• Non-essential
modifiers in ( )
• See
• See Also
• See Condition
Similar Conventions
• Abbreviations
– NEC (Other Specified)
• AI and TL
• Instructional Notes
– Includes
• Examples
• Location
– NOS (Unspecified)
• TL only
– Code first
– Use add’l code
– Code Also
• No Sequencing
Instructional Notes Examples
Instructional Notes Examples
Similar Conventions
• Punctuation
– Brackets [ ]
• TL
– Parentheses ( )
• AI and TL
G73. 7
– Colon :
• TL Notes
• And = And/Or (TL)
• With = Associated with/due to
– Code Title, AI, TL
– Subterm sequencing
Similar Conventions Examples
• Brackets
• Parentheses
Differences
ICD-10-CM Codes
• Sub-catergories = 4 or 5 characters
• Codes are 3 – 7 characters
• 1st character is LETTER
– O IS used; U is NOT used
• Code format
Which of the following
is a valid ICD-10-CM code?
•
•
•
•
428.9
L03.313
T37.0XX1A
M12X.58
Tabular List
• TL = 21 chapters
– List of blocks at beginning of each chapter
• Axes of Classification
– Body/organ system
– Etiology/Disease process
– E & V codes NOT supplemental
• Order of Chapters – some reordering
• Some chapters reordered
– Injuries = 1st by specific site, then type of injury
– Postop complications moved to procedure-specific
body system (mostly)
Dashes in AI and TL
• AI – Dash at end of code = incomplete code
– MUST review TL
– Ex: Fracture, pathologic
• Ankle M84.47• Carpus M84.44-
• TL - Dash preceded by decimal point (.-) =
incomplete code
– MUST review referenced code in TL
– Ex: J43 Emphysema
• Excludes1: emphysematous (obstructive) bronchitis
(J44.-)
Exclusion Notes
• Two types
– Located at category, subcategory, or code level
• Excludes1 – Pure, NOT CODED HERE!
– NEVER used with code above note
– Two conditions can’t occur together
• Congenital and Aquired
• Excludes2 – Not coded here
– Condition excluded is NOT INCLUDED HERE
– Patient may have both at same time
– Can code both if both present
Excludes Notes Examples
Morphology Codes
• No longer listed in AI with descriptors and
standard ICD-10-CM codes
• No longer separate appendix in ICD-10CM
NEC and NOS Separated
• Other Specified and Unspecified each
have their own code
• Example:
Placeholder Character (X)
• Two uses
– Future expansion WITHOUT disturbing overall
code structure (5th character for some 6-character
codes)
– Code with less than 6 characters that requires a
7th character extension
• Obstetrics, Injuries, and External causes of injuries
Placeholder Examples
• T37.0X1A, Poisoning by sulfonamides,
accidental (unintentional), initial encounter
• T56.0X2S, Toxic effect of lead and its
compounds, intentional self-harm, sequela
• W42.0XXA, Exposure to supersonic
waves, initial encounter
Placeholder Example TL
Category
Code X12 with
7th Character
Extension
Pregnancy Trimester Coding
• Inclusion of trimesters in obstetrics codes
– Episode of Care 5th Digits Eliminated
• Examples:
– O10.012, Pre-existing essential hypertension
complicating pregnancy, second trimester
– O99.013, Anemia complicating pregnancy,
third trimester
Pregnancy Trimester Example
Seventh Character
• SOME ICD-10-CM categories require 7th
character to further specify condition
– May be number or letter
– MUST always be 7th character
• Examples:
– O65.0XX1, Obstructed labor due to deformed
pelvis, fetus 1
– S02.110B, Type I occipital condyle fracture, initial
encounter for open fracture
– T17.220D, Food in pharynx causing asphyxiation,
subsequent encounter
Specificity
• Laterality
• Other expanded detail
• Combining in single code
– Etiology and manifestations
– Poisoning and external cause
– Diagnosis and symptoms
• Code titles and language complement
accepted clinical practice
Specificity Examples
RU, LU, RL, LL
Specificity Examples
Specificity Examples
Timeframe Changes for
Some Codes
• Examples:
– AMI - Time period changed from 8 wks to 4 wks
– Abortion vs fetal death – Time period changed
from 22 weeks to 20 weeks
Timeframe Examples
Abortion/Fetal Death - TL
ICD-10-CM Coding Guidelines
• Section I
– Structure and
conventions of
classification
– General guidelines
that apply to entire
classification
– Chapter-specific
guidelines that
correspond to
chapters as arranged
in classification
• Section II
– Selection of principal
diagnosis for nonoutpatient settings.
• Section III
– Reporting additional
diagnoses in nonoutpatient settings
• Section IV
– Outpatient coding and
reporting
ICD-10-CM Coding Guidelines
• Similar to ICD-9-CM, EXCEPT
• Laterality (New)
• Documentation of Complications of Care
Laterality Guideline
• For bilateral sites, final character of codes
indicates laterality
• Unspecified site code also provided if side
not identified in medical record
• If no bilateral code provided and condition
bilateral, assign separate codes for both
left and right side
Documentation of
Complications of Care
• Code assignment based on provider’s documentation of
relationship bet. condition and care or procedure
• Guideline extends to any complications of care, regardless
of chapter where code located
• Important to note NOT all conditions occurring
during/following medical care/surgery are classified as
complications
• There must be cause-and-effect relationship between care
provided & condition, and indication in documentation that
it is complication
• Query provider for clarification, if complication not clearly
documented
Break Time
ICD-10-CM Coding Case 1
• Pt seen w/ amenorrhea, characteristics of
masculinization, and high levels of serum
testosterone. Pelvic ultrasound revealed a
left discrete ovarian mass.
• GYN performed laparoscopic unilateral
salpingo-oophorectomy as outpatient.
• Pathologic diagnosis returned as ovarian
Sertoli-Leydig cell tumor.
Case 1 Coding Process - AI
• Tumor —see also Neoplasm, unspecified
behavior, by site
– Sertoli-Leydig cell —see Neoplasm, benign, by
site
• Main Term = Tumor
• Sub Term = Sertoli- Leydig Cell
• Neoplasm Site = Ovary
Case 1 Coding Process –
Neoplasm Table
D27. - What does Dash tell coder???
Case 1 Coding Process - TL
• D 27 Benign neoplasm of ovary
– Use additional code to identify any functional
activity - ????
• Excludes2:
– corpus albicans cyst (N83.2)
– corpus luteum cyst (N83.1)
– endometrial cyst (N80.1)
– follicular (atretic) cyst (N83.0)
– graafian follicle cyst (N83.0)
– ovarian cyst NEC (N83.2)
– ovarian retention cyst (N83.2)
Case 1 Coding Process -TL
• D27.0 Benign neoplasm of right ovary
• D27.1 Benign neoplasm of left ovary
• D27.2 Benign neoplasm of unspecified
ovary
• Do we need a code for masculinization as
a functional activity of the tumor?
• Per Use Add’l Code note at D27
Case 1 ANSWER
• D27.1 Benign neoplasm of left ovary
Do we need a code for masculinization as
a functional activity of the tumor?
Per Use Add’l Code note at D27
NO – Mainterm Masculinzation or
Virilization goes to D27.-
Coding Case 2
• Doctor 16-y-o pt w/ myasthenia gravis &
adolescent idiopathic thoracic scoliosis.
Surgery for spinal fusion cancelled after pt
had positive TB skin test during preop
workup, suggesting latent TB.
• Today’s visit – pt started on Isoniazid 300 mg
daily & instructed on possible side effects.
Will reschedule surgery after two months of
INH treatment.
Case 2 Coding Process - AI
• Findings, abnormal, inconclusive, without
diagnosis —see also Abnormal
– tuberculin skin test (without active tuberculosis)
R76.11
• Myasthenia G70.9
– gravis G70.00
Case 2 Coding Process - AI
• Scoliosis (acquired)
(postural) M41.9
• - - juvenile M41.119
– adolescent (idiopathic) —see
Scoliosis, idiopathic, juvenile
– idiopathic M41.20
- - adolescent M41.129
- - - cervical region M41.122
- - - lumbar region M41.126
- - - thoracic region M41.124
Case 2 Coding Process - TL
• M41 Scoliosis
– Includes: Kyphoscoliosis
– Excludes1: congenital scoliosis NOS (Q67.5)
congenital scoliosis due to bony malformation (Q76.3)
postural congenital scoliosis (Q67.5)
kyphoscoliotic heart disease (I27.1)
postprocedural scoliosis (M96.-)
FYI Juvenile vs Adolescent
• Juvenile idiopathic scoliosis usu. occurs from
about age 4 to puberty-about age 10 or 11 for
girls, age 12 for boys. Usu. R thoracic curves.
• Adolescent idiopathic scoliosis usu. occurs in
early puberty, w/ most rapid worsening during
early growth spurt. Females more than males
– 5:1. Also, usu. R thoracic curves.
Case 2 ANSWER
• R76.11 Findings, abnormal, inconclusive,
without diagnosis, tuberculin skin test
(without active tuberculosis)
• G70.00 Myasthenia gravis
• M41.124 Adolescent idiopathic scoliosis,
thoracic region
Why are codes for this case
sequenced in this order?
Coding Case 3
• 62-y-o female visits her family practice
physician for annual physical and followup on her chronic gout with tophi. She has
her annual Pap smear and flu shot for the
season.
Case 3 Coding Process - AI
• Examination (for) (following) (general)
(of) (routine) Z00.00– annual (adult) (periodic) (physical) Z00.00
- - with abnormal findings Z00.01
- - gynecological Z01.419
- - - with abnormal findings Z01.411
Can both Z00.- and Z01.- be coded?
Case 3 Coding Process - AI
• Z01 Encounter for other special examination w/o
complaint, suspected or reported diagnosis
Includes: routine examination of specific system
Note: Codes from category Z01 represent reason for encounter. A
separate procedure code is required to id any exam or procedures
performed
Excludes1:encounter for examination for administrative
purposes (Z02.-)
encounter for examination for suspected conditions, proven not
to exist (Z03.-)
encounter for laboratory and radiologic examinations as a
component of general medical examinations (Z00.0-)
encounter for laboratory, radiologic and imaging examinations
for sign(s) and symptom(s) - code to sign(s) or symptom(s)
screening examinations (Z11-Z13)
Case 3 Coding Process - AI
• Z01.4 Encounter for gynecological examination
• Excludes2: pregnancy examination or test (Z32.0-)
routine exam for contraceptive maintenance (Z30.4-)
• Z01.41 Encounter for routine gynecological examination
–
–
–
–
Encounter for general gynecological examination w/wo cervical smear
Encounter for gynecological examination (general) (routine) NOS
Encounter for pelvic examination (annual) (periodic)
Use additional code:
• for screening for human papillomavirus, if applicable, (Z11.51)
• for screening vaginal pap smear, if applicable (Z12.72)
• to identify acquired absence of uterus, if applicable (Z90.71-)
– Excludes1:gynecologic examination status-post hysterectomy for
malignant condition (Z08)
screening cervical pap smear not a part of a routine gynecological exam
Z12.4)
Case 3 Coding Process - AI
• Gout, gouty (acute) (attack) (flare) (see
also Gout, chronic) M10.9- tophi —see Gout by type
• Gout, chronic (see also Gout, gouty) M1A.9
Case 3 Coding Process – AI & TL
• Flu Shot
• Immunization —see also Vaccination
– encounter for Z23
• Z 23 Encounter for immunization
Code First: any routine childhood
examination
Note: procedure codes are required to
identify the types of immunizations given
Case 3 Coding Process - TL
• Persons encountering health services for
examinations (Z00-Z13)
– Nonspecific abnormal findings disclosed at the
time of these examinations are classified to
categories R70-R94.
– Excludes1: examinations related to pregnancy
and reproduction (Z30-Z36, Z39.-)
Case 3 Coding Process - TL
• Z00 Encounter for general examination without
complaint, suspected or reported diagnosis
Excludes1: encounter for examination for
administrative purposes (Z02.-)
Excludes2: encounter for pre-procedural
examinations (Z01.81-)
special screening examinations (Z11-Z13)
Case 3 Coding Process - TL
• Z00.0 Encounter for general • Z00.00 Encounter for
adult medical examination
general adult medical
examination without
– Encounter for adult periodic
examination (annual) (physical)
abnormal findings
and any associated laboratory
and radiologicexaminations
• Excludes1: encounter for
examination of sign or
symptom- code to sign or
symptom
general health check-up of
infant or child (Z00.12.-)
– Encounter for adult health
check-up NOS
• Z00.01Encounter for
general adult medical
examination with
abnormal findings
– Use additional code to
identify abnormal findings
Case 3 Coding Process –
Documentation Issue
• Gout, chronic
These sub-terms
require body part
and laterality
– drug-induced M1A.20
– idiopathic M1A.00
– in (due to)renal impairment M1A.30
– lead-induced M1A.10
– primary —see Gout, chronic, idiopathic
– saturnine —see Gout, chronic, lead-induced
– secondary NEC M1A.40
– syphilitic (see also subcategory M14.8-) A52.77
– tophi —see Gout by type
Case 3 Coding Process - TL
• M1A Chronic gout
The appropriate 7th character is to be added
to each code from category M1A
– 0 - without tophus (tophi)
– 1 - with tophus (tophi)
• M1A.9 Chronic gout, unspecified
Case 3 ANSWER
• Z01.419 Examination (for) (following)
(general) (of) (routine), annual (adult)
(periodic) (physical), gynecological
• M1A.9XX1 Gout, chronic, with tophi
• Z23 Vaccination (prophylactic), encounter
for
Coding Case 4
• Office Visit; 36-y-o male pt, primary care physician.
• Hx: Pt here for follow-up of lab work from earlier in
week. Bitten by tick last month & has had body
aches, some swelling to R upper arm, pain &
stiffness in R elbow, as well as feeling fatigued.
Had + Lyme test; pt to have repeat blood test
(Western Blot), as 2ndary follow-up.
• PE: Alert & in no acute distress. Temp 98.4. Pulse
108. Resp 20. BP 118/70.
http://www.nlm.nih.gov/medlineplus/magazine/issues/sprsum10
/articles/sprsum10pg24.html
Coding Case 4
• PE: Weight 296 on a 5’ 9” frame. Up 3 pounds
from last week & 22 pounds up since beginning of
year. Arm continues to display circular
erythematous lesion with 2+ pitting edema. Lesion
hasn’t grown outside perimeter markings from first
visit.
• Impression:
• 1. Localized arthritis, right elbow in Lyme disease
due to tick bite
• 2. Morbid obesity, BMI of 43.7
Coding Case 4
• Pt has blood drawn & was put on Doxycycline
100 mg b.i.d. × 4 weeks.
• Additional educational material on Lyme disease
given. Should follow-up immediately if affected
area grows larger than current, marked area or if
any new symptoms develop.
• We discussed again need for exercise program,
when able, & portion control due to overnourishment status.
•
Case 4 Coding Process - AI
• Localized arthritis, right elbow in Lyme
disease due to tick bite
• Arthritis, arthritic (acute) (chronic)
(nonpyogenic) (subacute) M19.90
- due to or associated with
- - Lyme disease A69.23
Case 4Coding Process - AI
• Bite (s) (animal) (human)
- arm (upper) S41.15- - lower —see Bite, forearm
- - superficial NEC S40.87- - - insect S40.86-
Case 4 Coding Process –
AI for External Causes
• Bite, bitten by
– insect (nonvenomous) W57
• TL = Exposure to animate mechanical
forces (W50-W64)
Excludes1: Toxic effect of contact with
venomous animals and plants (T63.-)
Case 4 Coding Process -TL
• W57 Bitten or stung by nonvenomous
insect and other nonvenomous arthropods
Excludes1: contact with venomous insects
and arthropods (T63.2-, T63.3-, T63.4-)
The appropriate 7th character is to be added
to code W57
A - initial encounter
D - subsequent encounter
S - sequela
Case 4 Coding Process - AI
• Morbid obesity, BMI of 43.7
• Obesity E66.9
- morbid E66.01
- - with alveolar hypoventilation E66.2
- - due to excess calories E66.01
Case 4 Coding Process - TL
Case 4 Coding Process – AI
• BMI, 43.7 – Use Add’l
Note at E66 = Z68.Body, bodies
- mass index (BMI)
- - adult
- - - 19 or less Z68.1
- - - 20.0-20.9 Z68.20
- - - 21.0-21.9 Z68.21
- - - 22.0-22.9 Z68.22
- - - 23.0-23.9 Z68.23
- - - 24.0-24.9 Z68.24
- - - 25.0-25.9 Z68.25
- - - 26.0-26.9 Z68.26
- - - 27.0-27.9 Z68.27
- ------------ - - 35.0-35.9 Z68.35
- - - 36.0-36.9 Z68.36
- - - 37.0-37.9 Z68.37
- - - 38.0-38.9 Z68.38
- - - 39.0-39.9 Z68.39
- - - 40.0-44.9 Z68.41
- - - 45.0-49.9 Z68.42
- - - 50.0-59.9 Z68.43
- - - 60.0-69.9 Z68.44
- - - 70 and over Z68.45
Coding Case 4 ANSWER
• A69.23 Arthritis, arthritic, (acute) (chronic)
(nonpyogenic) (subacute) due to or associated with
Lyme disease
• S40.861S Bite(s), (animal) (human), arm (upper),
superficial NEC, insect..
• E66.01 Obesity, morbid
• Z68.41 Body, bodies, mass index (BMI), adult, 40–
44.9
• W57.XXXS Index to External Causes, Bite, bitten by,
insect, (nonvenomous)
Coding Case 5
• 49-y-o female with CC of painful mouth
ulcers over last month. Treated with
acyclovir for 10 days and penicillin on two
occasions, including tapering doses of
steroids on second occasion. Pt states she
feels somewhat better but continues to have
these ulcers with pain.
• Denies fever, chills, dysphagia, or
lymphadenopathy. No high risk behavior.
Coding Case 5
• PE: Reveals whitish patches measuring 1 mm
× 1 mm on buccal musoca and hard palate;
erythematous and inflamed.
• Assessment: Aphthous ulcers and
herpangina
• Plan: Will start patient on clindamycin
orally for buccal cellulitis and Amlexanox
5% as oral paste along with the Xylocaine
mouth wash. Patient should follow up with me
in 2 weeks.
Case 5 Coding Process - AI
• Aphthous ulcers
• Herpangina
Is there another
diagnosis that
needs to be coded?
Case 5 Coding Process - TL
Case 5 ANSWER
• K12.2 Cellulitis (diffuse) (phlegmonous)
(septic) (suppurative), mouth (floor)
• K12.0 Ulcer, ulcerated, ulcerating,
ulceration, ulcerative, aphthous
(oral)(recurrent)
Sequencing?
• B08.5 Herpangina
Documentation for ICD-10-CM
• AHA/AHIMA field
testing study
– Much of detail in ICD10-CM is ALREADY
incorporated in MR
documentation
– NOT currently needed
for ICD-9-CM coding
AHIMA Required CEUs
• ICD-10-CM/PCS continuing education
units (CEUs)
– CHPS –
– CHDA –
– RHIT –
– RHIA –
– CCS-P –
– CCS –
– CCA –
1 CEU
6 CEUs
6 CEUs
6 CEUs
12 CEUs
18 CEUs
18 CEUs
General Resources
• Frazier, M. S. & Drzymkowski, J. W. Essentials
of Human Diseases and Conditions, 4th ed.,
Saunders, 2009
• Gray, H. Anatomy of the Human Body. 1918
– http://www.bartleby.com/107/
• Scott, A. S. & Fong, E. Body Structures and
Functions, 11th ed., Delmar, 2009
• Whonamedit? A dictionary of medical eponyms
– http://www.whonamedit.com/
Pressure ulcer Case
• A 73 year old male is followed
in your clinic Diagnoses
– Type II Diabetes Mellitus
– Hypertension
– Hyperlipidemia
– CVA 18 mos ago
– Obesity
– 54-pack-year smoking
history (quit 2 years ago)
– Diabetic neuropathy
– Diabetic retinopathy
– Diabetic gastroparesis
• Medications
– 70/30 insulin bid
– Lisinopril
– Simvastation
– Enteric coated aspirin
– Metoclopramide ac and
hs
PU Case
• After stroke 18 months ago, dx w/ depression, tx
for 6 months with sertraline, with improvement of
mood to normal. Drug discontinued.
• Most recent functional assessment by visiting
RN was that pt needed assistance w/bathing,
otherwise independent. HH aide provided
assistance w/ bathing & light housework,
daughter visited almost every day.
PU Case
• Pt brought into ED by ambulance, after his
daughter found him at home lying on floor,
unconscious. ED room physician admits him w/
Dx of pneumonia, fall with long lie, dehydration,
and altered mental status.
• By 2nd hospital day, he developed new pressure
ulcer over right lateral malleolus.
• Examination of ulcer shows a round, 3 cm black
eschar that is debrided to an ulcer that extends
through dermis.
ICD-9-CM Codes
• 486 Pneumonia
• 707.06, 707.22 Pressure
Ulcer R lateral malleolus
• 276.51 Dehydration
• 780.97Altered mental
status
• DM type 2
– Neuropathy
– Retinopathy
– Gastroparesis
• 260.60, 357.2, 563.3
• 250.50, 362.01
•
•
•
•
•
•
•
401.9 HTN
272.4 Hyperlipidemia
278.00 Obesity
V12.54 Hx CVA
V15.82 Hx Smoking
E888.9 Fall
E849.0 At Home
ICD-10-CM Codes
•
•
•
•
J18.9 Pneumonia
L89.513 Pressure Ulcer R lateral malleolus
E86.0 Dehydration
R41.82 Altered mental status
– Altered mental status due to known condition - code to
condition
• DM type 2
– E11.40 Neuropathy
– E11.319 Retinopathy -- MUST know w/wo Macular Edema
– E11.43 Type 2 diabetes mellitus with diabetic autonomic
(poly)neuropathy
• Includes: Type 2 diabetes mellitus with diabetic
gastroparesis
ICD-10-CM Codes
•
•
•
•
•
•
•
I10 HTN - LESS Specific
E78.5 Hyperlipidemia
E66.9 Obesity
Z86.73 Hx CVA
Z87.891 Hx Smoking
W19.XXXA Fall
Y92.009 At Home
General Resources
• Frazier, M. S. & Drzymkowski, J. W. Essentials
of Human Diseases and Conditions, 4th ed.,
Saunders, 2009
• Gray, H. Anatomy of the Human Body. 1918
– http://www.bartleby.com/107/
• Scott, A. S. & Fong, E. Body Structures and
Functions, 11th ed., Delmar, 2009
• Whonamedit? A dictionary of medical eponyms
– http://www.whonamedit.com/
ICD-10-CM Resources
• AAPC. ICD-10 Connect (e-Newsletter)
– https://www.aapc.com/icd-10/icd-10-connect.aspx
• AAPC. ICD-10 Implementation
– http://www.aapc.com/icd-10/index.aspx
• AHIMA. ICD-10-CM/PCS Implementation Toolkit. 2012.
– http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1
_049431.hcsp?dDocName=bok1_049431#reasons
• CDC. International Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10-CM)
– http://www.cdc.gov/nchs/icd/icd10cm.htm
• CDC. ICD-10-CM Official Guidelines for Coding and
Reporting 2012
– http://www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf
ICD-10-CM Resources
• Clinical Documentation Challenges with ICD-10-CM,
11/2011. ICD-10 Taskforce Bulletin. NCHICA.
– http://www.bcbsnc.com/assets/providers/public/pdfs/clinical_docu
mentation_challenges_with_icd-10-cm.pdf
• CMS-AAPC ICD-10 Code-a-thon Video. YouTube. One
hour and 16 minutes.
– http://www.youtube.com/watch?v=IWLkTQARwTo
• Endicott, M. ICD-10-CM/PCS codes for musculoskeletal
system include greater level of specificity. 8/30/2011
– http://justcoding.com/270313/redirect
• Giannangelo, K. and Hyde, L. ICD-10’s impact on quality
measures. Just Coding.
– http://www.justcoding.com/279206/icd10s-impact-on-qualitymeasures
ICD-10-CM Resources
• Grant, C & Wierz, C. An Essential Guide to ICD-10
Implementation. Courtyard Group.
– http://www.himss.org/content/files/CourtyardWhitepaperAnEssentialGui
deICD10.pdf
• Gray, L. ICD-10-CM Coding of Physeal Fractures Using the
Salter-Harris Classification System
– http://www.contexomedia.com/blog/index.php/2011/04/07/icd-10-cmcoding-of-physeal-fractures-using-the-salter-harris-classification-
system/#more-1722
• ICD-10 Articles. Just Coding News. HCPro.
– http://www.justcoding.com/icd-10
• ICD10Data.com. Free 2012 ICD-10 reference, including all
codes, a search engine, ICD-9-CM conversion, all indexes
and 10.6 million instant coding notes.
• http://www.icd10data.com/
ICD-10-CM Resources
• Kostick, K. M. Coding Diabetes Mellitus in ICD-10-CM
• http://journal.ahima.org/2012/05/16/coding-diabetes-mellitus-in-icd-10cm-4/
• Leon-Chisen, N. ICD-10 Overview and How Does ICD-10
Impact Departments? AHA. 11/03/2011
– http://www.gchc.org/wp-content/uploads/2011/10/11-3-11ICD-10-Cincinnati_FINAL-Leon-Chisen.pdf
• Let's Get The Terms Straight. National Scoliosis Foundation.
– http://www.scoliosis.org/resources/medicalupdates/terms.php
• Role-based Model for ICD-10 Implementation: Inpatient
Coders. AHIMA.
– http://library.ahima.org/xpedio/groups/public/documents/ah
ima/bok1_045928.hcsp?dDocName=bok1_045928
ICD-10-CM Resources
• Role-based Model for ICD-10 Implementation: Outpatient
Coders. AHIMA.
– http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_0
45929.hcsp?dDocName=bok1_045929
• Schraffenberger, L. Basic ICD-10-CM/PCS and ICD-9-CM
Coding, 2012 ed. Chicago: AHIMA
• Schreck, B. Late Effects (Sequela) in ICD-10-CM August 10,
2011
– http://www.contexomedia.com/blog/index.php/2011/08/10/late-effects-
sequela-in-icd-10-cm/
• Simmons, C. R. The Musculoskeletal System and ICD-10CM. ICD TEN, April 2011.AHIMA.
– https://newsletters.ahima.org/newsletters/ICDTen/2011/April/April_ICD
.html
ICD-10-CM Resources
• WHO. International Classification of Diseases
(ICD)
– http://www.who.int/classifications/icd/en/
• Zeisset, A. Coding Injuries in ICD-10-CM.
– http://library.ahima.org/xpedio/groups/public/documents
/ahima/bok1_048533.hcsp?dDocName=bok1_048533
• Zeisset, A. ICD-10-CM Enhancements: A Look at
the Features That Will Improve Coding Accuracy
– http://library.ahima.org/xpedio/groups/public/documents
/ahima/bok1_042626.hcsp?dDocName=bok1_042626
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