*Revised* Content now corresponds to the 2012 Official Guidelines for Coding and Reporting

Transcription

1 *Revised* Content now corresponds to the 2012 Official Guidelines for Coding and Reporting COURSE DESCRIPTION On 1/15/2009, the Department of Health and Human Services released the final regulation requiring the implementation of ICD- 10-CM codes on 10/1/2013*. This CE course will provide basic information about ICD-10-CM codes, including reasons for implementation, tasks needed to be performed prior to implementation, code structure, coding book chapters, and general conventions and coding guidelines. *NOTE: On 3/27/2014, Congress voted to delay implementation of ICD-10 code sets until October 1, Rev 6.0 April

2 COURSE TITLE: Introduction to ICD-10-CM: Part 1 - Revised Author: Steve M. Verno, CMBSI, CMSCS, CEMCS, CPM-MCS Billing and Coding Consultant Heal Your Practice Number of Clock Hours Credit: 3.0 Course # P.A.C.E. Approved: Yes X_ No OBJECTIVES Upon completion of this continuing education course, the professional should be able to: 1. Identify the use of ICD-10-CM codes. 2. State the implementation date for ICD-10-CM codes. 3. Describe changes needed in a typical physician practice prior to ICD- 10-CM implementation. 4. Describe the structure of ICD-10-CM codes. 5. Identify benefits of using ICD-10-CM codes that are not present in ICD-9-CM codes. 6. List the chapters in ICD-10-CM coding books and the general codes found in each chapter. 7. State how to locate a code in ICD-10-CM books. 8. Describe the ICD-10-CM conventions and general coding guidelines discussed in this course. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. 2

3 HISTORY OF ICD The classification of disease began as a statistical study of the causes of death entitled the London Bills of Mortality by John Graunt in the 1600s. By the mid-1860s, this classification morphed into the International List of Causes of Death developed by the International Statistical Congress. Eventually, the International Statistical Congress extended the list to include classification of diseases as well as causes of death and this list became known as the International Classification of Causes of Sickness and Death. In 1948 the World Health Organization (WHO) took over the responsibility for the Sixth Revision of the International Classification of Causes of Death and it became known as the International Classification of Diseases (ICD). ICD is copyrighted by WHO and is reproduced by permission for the United States government purposes. For over 100 years, International Classification of Disease (ICD) codes have been seen as the authoritative classification for causes of death and illnesses, and have been available in many official languages and used by many countries. The version currently in use in the United States is ICD-9-CM. HISTORY OF ICD-9-CM There are two related ICD sets with similar titles in the United States. Note: ICD-9*: This is International Classification of Disease, 9 th Revision; these codes are used to code and classify mortality data from death certificates. *NOTE: ICD-10 codes have been used for coding of death certificates since ICD-9 codes were used prior to ICD-9-CM: This is International Classification of Disease, 9 th Revision, Clinical Modification; these codes are used to code and classify morbidity information from records of inpatients, outpatients, and physician office patients, as well as almost all of the National Center for Health Statistics (NCHS) surveys. There is actually a third classification of ICD codes used for functioning and disability. For the purposes of this CE course, only ICD-9-CM and ICD-10-CM codes will be discussed. ICD-10 and ICD-10-CM code sets follow the convention as listed above for ICD-9 and ICD-9-CM. In the United States, in addition to classification of morbidity and mortality information for statistical purposes, ICD-9-CM codes are used for the following purposes. (ICD-10- CM codes will be used for the same purposes.) Report diagnoses and procedures to provide payment for physicians, clinics, hospitals, and other healthcare providers Evaluate utilization patterns Predict healthcare trends Analyze healthcare costs Research healthcare quality Plan for future healthcare requirements 3

4 The use of ICD-9-CM codes in the United States began in 1979 and this code set has reached the end of its usefulness. It does not reflect advances in medical technology and knowledge. New illnesses, new diseases, and new types of injuries have occurred since 1979 and these cannot be accommodated by ICD-9-CM codes. ICD-10-CM Implementation Per a Health and Human Services (HHS) proposal issued on April 9, 2012, on October 1, 2014 ICD-10-CM will replace ICD-9-CM in the United States as the official code set*. Codes will increase from approximately 14,000 to approximately 69,000. There is room for growth of ICD-10-CM codes up to 200,000 codes. This is a significant change that has many repercussions for all areas of healthcare billing and coding. For example, in a typical physician practice, all of the following will need to occur before the ICD-10-CM implementation date. *NOTE: On 3/27/2014, Congress voted to delay implementation of ICD-10 code sets until October 1, Training and Recertification Coders: Coders with training and certification must have ICD-10-CM training to familiarize themselves with the new code formats and use. Untrained staff members in coding positions must undergo more extensive training and they should consider certification as coding professionals. While certification is not mandated by state or federal law, certification assures that the coder is aware of the established standards of coding. Some coding professional organizations are requiring their certificants to document knowledge of ICD-10-CM either by completion of an open book certification examination or documentation of attendance at ICD-10-CM coding workshops. Refresher courses on medical terminology and anatomy may also be helpful to assist with the use of the more specific ICD-10-CM codes. Failure to sufficiently train individuals with coding responsibilities about ICD-10- CM codes can result in individuals assigning the incorrect diagnosis codes. This can result in pended, denied, or delayed claims, or can even place the practice into an audit status, which could delay or deny payment for services rendered. Healthcare providers: Healthcare providers need training to be more detailed with health record documentation and the importance of how their documentation improves coding and practice revenue. 2. New Manuals ICD-10-CM manuals will need to be purchased. 3. Updated Software Medical billing software needs to be updated to include both ICD-9-CM and ICD- 10-CM codes. For a period of time, both code sets will be in use, as many patients will have seen physicians and/or had procedures that were coded with ICD-9-CM and the accounts are still open. ICD-9-CM codes will be used for 4

5 visits and procedures on or before September 30, Use of ICD-10-CM codes will begin on the implementation date of October 1, The Health and Human Services (HHS) final rule to implement the move to ICD-10-CM also required that the HIPAA Version 4010 electronic transaction standards be updated to Version 5010 by June 30, Version 5010 supports the use of ICD-10-CM codes. 4. Updated Policies and Procedures for Vendors and Payer Contracts Payer and vendor agreements should be reviewed to assure that they are ready to accept the new codes. This may include revisions of Local Coverage Decisions (LCDs) and National Coverage Decisions (NCDs), and Advanced Beneficiary Notices (ABNs). Physician offices must be aware of claims payment delays as this can affect contract payment timeframes. 5. Updated Compliance Plans Practices and billing companies should update their compliance plans regarding ICD-10-CM coding. Extra attention should be directed to performing routine internal audits of charts and claims. 6. Updated Coding Denial Appeals Appeals processes should be reviewed and updated to conform to ICD-10-CM standards. 7. Updated Superbills Superbills must be updated with ICD-10-CM codes. (A superbill is a form used by medical practitioners and clinicians that can be quickly completed and submitted to an insurance company for reimbursement.) 8. Fraud and Abuse Fraud and abuse must still be considered. With more codes available, there may be a temptation to upcode; with new codes in use, a temptation to downcode may occur to assure no undesired attention is brought to the practice. Continue to follow the dos and don ts of coding. a. Don t assume anything. b. Do code from the legible documentation. c. Don t assign a diagnosis code to a procedure. d. Do follow current policies and guidelines. e. Do not contribute to or accept fraud or abuse in any form. 9. HIPAA policies HIPAA policies may require revision and if so, patients will need to sign new forms. 5

6 At least 25 countries currently use ICD-10 codes for reimbursement and resource distribution in their health systems. Some of them have made modifications to the codes to make them more useful for their purposes. Coders with training should not be overly alarmed with the conversion to ICD-10-CM. The process of coding doesn t change. The coder reads the documentation created by the provider and converts the written word into numbers. It is important to remember that diseases and illnesses do not change. Measles is still measles, chicken pox is still chicken pox, and chest pain is still chest pain. Only the number assigned to the disease changes. Following is an analogy using the White House in Washington, DC. White House under ICD-9-CM = 1600 Pennsylvania Ave With ICD-10-CM, the building remains the same but the address changes. White House under ICD-10-CM: W06.4 Pennsylvania Avenue The process of coding does not change. When coding, the coder goes to the word and then to the number. Depending on the coding book, the word might be in front or it might be in back. The same is true for the number. The word section is called the Alphabetical Index; the number section is called the Tabular List. Comparisons of ICD-9-CM and ICD-10-CM Under ICD-9-CM, codes are 3, 4 or 5 numbers; ICD-10-CM codes use combinations of letters and numbers that can go to as many as 7 characters. Using chest pain as an example, the table on the following page compares the use of ICD-9-CM codes and ICD-10-CM codes. 6

7 ICD-9-CM Look up chest pain in Alphabetical Index and see chest (central) atypical midsternal musculoskeletal noncardiac substernal wall (anterior) Go to code and see Chest pain ICD-10-CM Look up chest pain in Alphabetical Index and see - chest (central) R anterior wall R atypical R ischemic I musculoskeletal R non-cardiac R on breathing R pleurodynia R precordial R wall (anterior) R07.89 Go to code R07.9 and see R Chest pain, unspecified Chest pain, unspecified The N means that the code is unspecific. Chest pain is coded as Chest pain is coded as R07.9 Most of the guidelines have not significantly changed. For example: ICD-9-CM Signs and Symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the physician. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Illdefined conditions (codes ) contain many, but not all codes for symptoms. ICD-10-CM Signs and Symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R R99) contains many, but not all codes for symptoms. Some guidelines have been deleted. For example: ICD-9-CM 15. Admissions/Encounters for Rehabilitation When the purpose for the admission/encounter is rehabilitation, sequence the appropriate V code from category V57, Care involving use of rehabilitation procedures, as the principal/first-listed diagnosis. The code for the condition for which the service is being performed should be reported as an additional diagnosis. Only one code from category V57 is required. Code V57.89, Other specified rehabilitation procedures, should be assigned if more than one type of rehabilitation is performed during a single encounter. A procedure code should be reported to identify each type of rehabilitation therapy actually performed. ICD-10-CM No analogous guideline exists 7

8 Comparison of Diagnosis Code Sets ICD-9-CM ICD-10-CM 3-5 characters in length 3-7 characters in length Approximately 14,000 codes First character may be alpha (E or V) or numeric Characters 2-5 are numeric Decimal after first 3 characters Limited space for adding new codes Lacks detail Lacks laterality Basal cell carcinoma of eyelid, including canthus Fever, unspecified Hb-SS (sickle cell) disease without crisis Comparison of Code Structure Approximately 69,000 available codes with expansion for growth to 200,000 First character is alpha Characters 2 and 3 are numeric Characters 4-7 are alpha or numeric Decimal after first three characters Flexible for adding new codes Very specific Has laterality (i.e., codes identifying right vs. left) Examples C Basal cell carcinoma of skin of unspecified eyelid, including canthus R Fever, unspecified D Sickle cell disease without crisis ICD-9-CM ICD-10-CM 3, 4, or 5 numbers Some codes have letter preceding the numbers such as V or E o V codes used for factors influencing health status o E codes used to describe how an accident occurred Combination of letters and numbers that can go to as many as 7 characters Characters 1-3: Category Characters 4-6: Etiology, anatomic site, severity, or other clinical detail such as laterality Character 7: Extension (initial encounter, subsequent encounter, sequela, etc.) The increased number of characters in the ICD-10-CM codes allows for greater specificity to identify the disease etiology, anatomic site, and severity. The American Medical Association (AMA) gives an excellent example with fractures of the forearm: S52 Fracture of forearm -S52.5 Fracture of lower end of radius -S52.52 Torus fracture of lower end of radius -S Torus fracture of lower end of right radius -S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture In the above example: S52 = category 4 th and 5 th characters (5 and 2) = additional clinical detail and anatomic site 6 th character (1) = laterality, i.e., right radius 7 th character (A) = additional information, i.e., initial encounter 8

9 Comparison of Coding Book Chapters ICD-9-CM CHAPTER NUMBER CHAPTER TITLE ICD-10-CM CHAPTER NUMBER CHAPTER TITLE 1 Infectious and Parasitic Diseases ( ) 1 Certain Infectious and Parasitic Diseases (A00-B99) 2 Neoplasms ( ) 2 Neoplasms (C00-D49) 3 Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders ( ) 3 Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) 4 Diseases of Blood and Blood Forming Organs ( ) 4 Endocrine, Nutritional and Metabolic Diseases (E00-E89) 5 Mental Disorders ( ) 5 Mental and Behavioral Disorders (F01-F99) 6 Diseases of Nervous System and Sense 6 Diseases of the Nervous System (G00-G99) Organs ( ) 7 Diseases of Circulatory System ( ) 7 Diseases of the Eye and Adnexa (H00-H59) 8 Diseases of Respiratory System ( ) 8 Diseases of the Ear and Mastoid Process (H60-H95) 9 Diseases of Digestive System ( ) 9 Diseases of the Circulatory System (I00-I99) 10 Diseases of Genitourinary System ( ) 10 Diseases of the Respiratory System (J00-J99) 11 Complications of Pregnancy, Childbirth, and 11 Diseases of the Digestive System (K00-K94) the Puerperium ( ) 12 Diseases Skin and Subcutaneous Tissue ( ) 12 Diseases the Skin and Subcutaneous Tissue (L00-L99) 13 Diseases of Musculoskeletal and Connective Tissue ( ) 13 Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) 14 Congenital Anomalies ( ) 14 Diseases of the Genitourinary System (N00-N99) 15 Newborn (Perinatal) Guidelines ( ) 15 Pregnancy, Childbirth and the Puerperium (O00-O99) 16 Signs, Symptoms and Ill-Defined Conditions ( ) 16 Certain Conditions Originating in the Perinatal Period (P00-P96) 17 Injury and Poisoning ( ) 17 Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99) 18 Classification of Factors Influencing Health Status and Contact with Health Service (Supplemental V01-V84) 18 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) 19 Supplemental Classification of External Causes of Injury and Poisoning (E800-E999) 19 Injury, Poisoning and Certain Other Consequences of External Causes (S00-T98) 20 External Causes of Morbidity (V01-Y99) 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99) NOTE: There currently are no U codes. These codes are set aside for potential use for new diseases of uncertain etiology. Locating a Code in ICD-10-CM Perform the following steps to select a code that corresponds to a diagnosis or reason for a visit as documented in the medical record. 1. Locate the term in the Alphabetical Index (hereinafter called Index) and verify the code in the Tabular List (hereinafter called Tabular). 2. Read the instructional notations that appear in both the Index and the Tabular. a. It is essential to use both the Index and Tabular when locating and assigning a code. The Index does not always provide the full code. 9

10 b. Selection of the full code, including laterality and any applicable 7 th character can only be done in the Tabular. c. A dash (-) at the end of an Index entry indicates that additional characters are required. Even if a dash is not included at the Index entry, it is necessary to refer to the Tabular to verify that no 7 th character is required. Example: S00: INJURIES TO THE HEAD S02.0: Fracture of vault of skull S02.0XXA: Fracture of vault of skull, initial encounter for closed fracture The X serves as a placeholder and allows for more code growth. The A signifies the initial encounter. ICD-10-CM CONVENTIONS AND GENERAL CODING GUIDELINES The following are coding guidelines for ICD-10-CM which come from the Centers for Medicare and Medicaid Services (CMS). This information is from the CMS website ( and it is in the public domain, available for downloading and use without copyright infringement. Section I. Conventions, general coding guidelines and chapter specific guidelines (Chapter specific guidelines will be covered in Introduction to ICD-10-CM Parts 2 and 3) The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines. A. Conventions for the ICD-10-CM The conventions for the ICD-10-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the Alphabetical Index and Tabular List of the ICD-10-CM as instructional notes. 1. The Alphabetic Index and Tabular List The ICD-10-CM is divided into the Index, an alphabetical list of terms and their corresponding code, and the Tabular, a chronological list of codes divided into chapters based on body system or condition. The Index consists of the following parts: The Index of Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of Drugs and Chemicals. See Section I.C2. General guidelines See Section I.C.19. Adverse effects, poisoning, underdosing and toxic effects 10

11 2. Format and Structure The ICD-10-CM Tabular contains categories, subcategories and codes. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 4, 5, 6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. All codes in the Tabular of the official version of the ICD-10-CM are in bold. Codes that have applicable 7 th characters are still referred to as codes, not subcategories. A code that has an applicable 7 th character is considered invalid without the 7 th character. The ICD-10-CM uses an indented format for ease in reference. 3. Use of codes for reporting purposes For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required. 4. Placeholder character The ICD-10-CM utilizes a placeholder character X. The X is used as a 5 th character placeholder at certain 6 character codes to allow for future expansion. An example of this is in the Poisoning, Adverse Effect and Underdosing codes, categories T36-T50. Where a placeholder exists, the X must be used in order for the code to be considered a valid code th Characters Certain ICD-10-CM categories have applicable 7 th characters. The applicable 7 th character is required for all codes within the category, or as the notes in the Tabular instruct. The 7 th character must always be the 7 th character in the data field. If a code that requires a 7 th character does not have 6 characters, a placeholder X must be used to fill in the empty characters. 6. Abbreviations a. Index abbreviations NEC Not elsewhere classifiable This abbreviation in the Index represents other specified. When a specific code is not available for a condition, the Index directs the coder to the other specified code in the Tabular. NOS Not otherwise specified This abbreviation is the equivalent of unspecified b. Tabular abbreviations NEC Not elsewhere classifiable This abbreviation in the Tabular represents other specified. When a specific code is not available for a condition the Tabular includes an NEC entry under a code to identify the code as the other specified code. 11

12 NOS Not otherwise specified This abbreviation is the equivalent of unspecified. 7. Punctuation [ ] Brackets are used in the Tabular to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Index to identify manifestation codes. ( ) Parentheses are used in both the Index and Tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. : Colons are used in the Tabular after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category. 8. Use of and When the term and is used in a narrative statement it represents and/or. 9. Other and Unspecified codes a. 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. Index entries with NEC in the line designate other codes in the Tabular. These Index entries represent specific disease entities for which no specific code exists so the term is included within an other code. b. Unspecified codes Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the other specified code may represent both other and unspecified. 10. Includes Notes This note appears immediately under a three-character code title to further define, or give examples of, the content of the category. 11. Inclusion terms List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of other specified codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Index may also be assigned to a code. 12

13 12. Excludes Notes The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other. a. Excludes1 A type 1 Excludes note is a pure excludes note. It means NOT CODED HERE! An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. b. Excludes2 A type 2 excludes note represents Not included here. An Excludes2 note 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. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. 13. Etiology/manifestation convention ( code first, use additional code and in diseases classified elsewhere notes) Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a use additional code note at the etiology code, and a code first note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. In most cases the manifestation codes will have in the code title, in diseases classified elsewhere. Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. In diseases classified elsewhere codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention. There are manifestation codes that do not have in diseases classified elsewhere in the title. For such codes a use additional code note will still be present and the rules for sequencing apply. In addition to the notes in the Tabular, these conditions also have a specific Index entry structure. In the Index both conditions are listed together with the etiology code first followed by the manifestation code in brackets. The code in brackets is always to be sequenced second. 13

14 An example of the etiology/manifestation convention is dementia in Parkinson s disease. In the index, code G20 is listed first, followed by code F02.80 or F02.81 in brackets. Code G20 represents the underlying etiology, Parkinson s disease, and must be sequenced first, whereas codes F02.80 and F02.81 represent the manifestation of dementia in diseases classified elsewhere, with or without behavioral disturbance. Code first and Use additional code notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/ manifestation combination. See Section I.B.7. Multiple coding for a single condition. 14. And The word and should be interpreted to mean either and or or when it appears in a title. 15. With The word with should be interpreted to mean associated with or due to when it appears in a code title, the Index, or an instructional note in the Tabular. The word with in the Index is sequenced immediately following the main term, not in alphabetical order. 16. See and See Also The see instruction following a main term in the Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the see note to locate the correct code. A see also instruction following a main term in the Index instructs that there is another main term that may also be referenced that may provide additional Index entries that may be useful. It is not necessary to follow the see also note when the original main term provides the necessary code. 17. Code also note A code also note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. 18. Default codes A code listed next to a main term in the ICD-10-CM Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned. B. General Coding Guidelines 1. Locating a code in the ICD-10-CM To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the 14

15 Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Index and the Tabular List. It is essential to use both the Index and Tabular List when locating and assigning a code. The Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7 th character can only be done in the Tabular. A dash (-) at the end of an Index entry indicates that additional characters are required. Even if a dash is not included at the Index entry, it is necessary to refer to the Tabular list to verify that no 7 th character is required. 2. Level of Detail in Coding Diagnosis codes are to be used and reported at their highest number of characters available. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth characters, which provide greater detail. A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable. 3. Code or codes from A00.0 through T88.9, Z00-Z99.8 The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit. 4. Signs and symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10- CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R R99) contains many, but not all codes for symptoms. 5. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. 6. Conditions that are not an integral part of a disease process Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. 7. Multiple coding for a single condition In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. Use additional code notes are found in the Tabular at codes that are not part of an etiology/manifestation pair where a secondary code is 15

16 useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, use additional code indicates that a secondary code should be added. For example, for bacterial infections that are not included in chapter 1, a secondary code from category B95, Streptococcus, Staphylococcus, and Enterococcus, as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, may be required to identify the bacterial organism causing the infection. A use additional code note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code. Code first notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a code first note and an underlying condition is present, the underlying condition should be sequenced first. Code, if applicable, any causal condition first, notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis. Multiple codes may be needed for sequela, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for these conditions for further instruction. 8. Acute and Chronic Conditions If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first. 9. Combination Code A combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code. 16

17 10. Sequela (Late Effects) 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. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. 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. 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. See Section I.C.9. Sequelae of cerebrovascular disease See Section I.C.15. Sequelae of complications of pregnancy, childbirth and the puerperium See Section I.C.19. Application of 7 th characters for Chapter Impending or Threatened Condition Code any condition described at the time of discharge as impending or threatened as follows: If it did occur, code as confirmed diagnosis. If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for impending or threatened and also reference main term entries for Impending and for Threatened. If the subterms are listed, assign the given code. If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened. 12. Reporting Same Diagnosis Code More than Once Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code. 13. Laterality For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality. An unspecified side code is also provided should the side not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. 14. Documentation for BMI and Pressure Ulcer Stages For the Body Mass Index (BMI) and pressure ulcer stage codes, code assignment may be based on medical record documentation from 17

18 clinicians who are not the patient s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents the pressure ulcer stages). However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient s attending provider should be queried for clarification. The BMI codes should only be reported as secondary diagnoses. As with all other secondary diagnosis codes, the BMI codes should only be assigned when they meet the definition of a reportable additional diagnosis. 15. Syndromes Follow the Index guidelines when coding syndromes. In the absence of Index guidance, assign codes for the documented manifestations of the syndrome. 16. Documentations of Complications of Care Code assignment is based on the provider s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented. CONCLUSION This CE course has provided basic information about ICD-10-CM codes, including the reasons for implementation, tasks needed to be performed prior to implementation, code structure, coding book chapters, and general conventions and coding guidelines. While implementation of ICD-10-CM codes is a major event for all involved, proper preparation will make the change from ICD-9-CM to ICD-10-CM codes manageable. REFERENCES Grider, Deborah J. Principles of ICD-10-CM Coding. The American Medical Association ICD-10-CM Official Guidelines for Coding and Reporting The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Accessed 28 February ICD-10-CM Drug and Chemical Table World Health Organization. ICD-10-CM Neoplasm Table World Health Organization 18

19 ABOUT THE AUTHOR Steve Verno is a Certified Medical Billing Specialist Instructor, a Certified Emergency Medical Coding Specialist, a Certified Multispecialty Coding Specialist, and a Certified Practice Manager-Medical Coding Specialist. He is a retired American Red Cross Health and Safety Instructor Trainer, a retired American Red Cross Disaster Action Team Captain, a graduate of the American Red Cross College. He is a coding and billing consultant and instructor for Heal Your Practice, The Coding Institute, Lake Sumter Medical Society, Physician Office Managers Association of America, the Professional Association of Healthcare Coding Specialists and he is a member of the Medical Economics Committee with the Florida College of Emergency Physicians and a coding/billing consultant to the Federal Trade Commission. He is an Editorial Board Member of the Medical Association of Billers, Billing-Coding Advantage, Physician Office Managers Association of America and the Professional Association of Healthcare Coding Specialists. Steve s specialties are Emergency Medicine, Family Practice, Urgent care, Internal Medicine, Pediatrics, ERISA, ICD-10, Appeals, AR Recovery, Fraud and Abuse, Health Insurance Contracts, and Compliance. Steve with Don Self, is a co-author of the Layperson s Guide to the Employment Retirement Income Security Act (ERISA). For the last ten years, Steve has been a moderator of the Medical Association of Billers On-Line Medical Billing forum, providing almost 10,000 responses to visitor questions on coding, medical billing, fraud and abuse and compliance. He has had more than 40 articles on coding and billing published in the Billing-Coding Advantage magazine, the Medical Association of Billers, Codetrends Newsletter, and the Professional Association of Healthcare Coding Specialists coding newsletter. He was a contributing editor for the Insurance Handbook for the Medical Office, written by Marilyn Fordney and published by Elsevier Science. He has also developed guidebooks on ERISA, Appeals, and specialty ICD-10-CM training for emergency medicine, family practice, cardiology, general surgery, radiation oncology, sports medicine, and preparing for ICD-10-CM. Steve is also an Adjunct Professor of the Health and Safety Department at Everest University and is presently on medical leave. TEST QUESTIONS Introduction to ICD-10-CM: Part 1 # Directions: Before taking this test, read the instructions on how to complete the answer sheets correctly. If taking the test online, log in to your User Account on the NCCT website Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having difficulty answering a question, go to and select Forms/Documents. Then select CE Updates and Revisions to see if course content and/or a test questions have been revised. If you do not have access to the internet, call Customer Service at In the United States, ICD codes (both ICD-9-CM and ICD-10-CM) are used for. a. evaluation of utilization patterns b. healthcare quality research c. reporting procedures for physician payment d. All of the above 2. Why are ICD-9-CM codes no longer going to be used? a. Insurance companies are requiring the use of ICD-10-CM b. They are no longer useful due to new types of disease, illness, and injuries c. Physicians can make more money using ICD-10-CM codes d. The code sets outdate every 10 years 19

20 3. There will be approximately ICD-10-CM codes upon implementation with growth of up to codes. a. 14,000; 69,000 b. 14,000; 200,000 c. 69,000; 200,000 d. 200,000; 400, In March 2014, Congress voted to delay the implementation of ICD-10 code sets until which one of the following dates? a. October 1, 2012 b. January 1, 2013 c. October 1, 2014 d. October 1, All individuals with coding responsibilities must take an ICD-10-CM certification exam. a. True b. False 6. ICD-10-CM codes can have as many as characters. a. Eight b. Five c. Seven d. Three 7. The first character of an ICD-10-CM code is a/an. a. alpha character b. brackets symbol c. numeric character d. parentheses symbol 8. Characters 1-3 of an ICD-10-CM code represent the. a. category b. etiology c. extension d. severity 9. Which of the following can be represented in characters 4-6 of an ICD-10-CM code? a. Category b. Extension c. Severity d. Year 20

21 10. Laterality can be presented in which of the following characters of an ICD-10-CM code? a. 2 nd b. 7 th c. 3 rd d. 5 th 11. Currently, ICD-10-CM has how many chapters? a. 19 b. 21 c. 23 d Which of the following ICD-10-CM three character codes will be used for diseases of the eye and adnexa? a. A00-B99 b. H00-H59 c. K00-K94 d. S00-T Which chapter of the ICD-10-CM book has codes used for pregnancy and childbirth? a. 5 b. 11 c. 15 d Which chapter of the ICD-10-CM book has codes used for diseases of the genitourinary system? a. 17 b. 14 c. 10 d Which chapter of the ICD-10-CM book has codes used for mental and behavioral issues? a. 5 b. 8 c. 16 d

22 16. Which of the following ICD-10-CM three character codes will be used for certain infectious and parasitic diseases? a. A00-B99 b. D50-D89 c. H60-H95 d. O00-O ICD-10-CM codes L00-L99 are used for diseases of the. a. circulatory system b. endocrine system c. musculoskeletal system d. skin and subcutaneous tissue 18. When locating a code for a diagnosis or reason for a visit in the ICD-10-CM, first locate the term in the Tabular, and then verify the code in the Index. a. True b. False 19. A dash (-) at the end of an Index entry indicates. a. room for expansion of the code b. additional characters are required c. laterality must be included d. the need for a placeholder character 20. Which of the following is found within the ICD-10-CM Index of Diseases and Injuries? a. Codes Q00-Q99 b. Coding category list c. Neoplasm table d. Tabular list 21. If an ICD-10-CM code requires a 7 th character but it is not 6 characters in length, what is used as a placeholder? a. [ ] b. : c. ( ) d. X 22. Brackets [ ] are used in the Tabular to enclose. a. alternative wording b. explanatory phrases c. synonyms d. All of the above 22

23 23. Brackets [ ] are used in the Index to. a. enclose explanatory phrases b. identify manifestation codes c. serve as a placeholder d. All of the above 24. The abbreviation NOS is found only in the Index. a. True b. False 25. When a condition has both an underlying etiology and multiple body system manifestations resulting from the underlying etiology, the ICD-10-CM coding convention requires the manifestations be sequenced first followed by the etiology. a. True b. False 26. A code also note instructs that one code may be required to fully describe a condition, but this note does not provide sequencing direction if two or more codes are recorded. a. True b. False 27. Diagnosis codes are to be used and reported at their highest number of characters available. a. True b. False 28. Codes that describe symptoms and signs, as opposed to diagnoses, are unacceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. a. True b. False 29. There is no time limit on when a sequela code can be used. a. True b. False 30. Each unique ICD-10-CM diagnosis code may be reported multiple times for an encounter. a. True b. False 23

24 31. What does a dash (-) at the end of an Index entry indicate? a. It indicates that additional characters are required. b. It indicates that a laterality code is needed. c. It indicates that the placeholder character X is required. d. It indicates a secondary code should be added. 32. When are codes that describe signs and symptoms, as opposed to diagnoses, acceptable for use? a. When a related definitive diagnosis has not been established b. When the signs and symptoms are associated with the disease c. When a combination code is not available for use d. When the patient has an impending or threatened condition 33. A combination code can be used to classify. a. a diagnosis with an associated complication b. a diagnosis with an associated secondary process c. two diagnoses d. All of the above 34. Which alpha character is not currently used in ICD-10-CM codes? a. U b. V c. W d. X 35. Based on information provided on the structure of ICD-10-CM codes in this course, which of the following is an ICD-10-CM code? a. V8.6 b. E955.0 c d. R07.9 *End of Test* 24