What You Need to Know NOW! - AAPCstatic.aapc.com/3b7310d0-2751-4c51-8dd2-4cc34d8103...ICD-10-CM—What You Need to Know NOW! 2 AAPC 1-800-626-CODE (2633) code and the ICD code is used

ICD-10-CMWhat You Need to Know NOW!

2011

AAPC2480 South 3850 West, Suite BSalt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258www.aapc.com

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ICD-10-CMWhat You Need to Know NOW!

Written by: Kim Reid, CPC, CPMA, CEMC, CPC-I

Director, ICD-10 Development and Training

ii AAPC 1-800-626-CODE(2633)

DisclaimerThis course was current at the time it was written. The materials are offered as a tool to assist the participant in under-standing how to ensure that code selection decisions are accurate and defensible 100 percent of the time as a means of improving reimbursement and avoiding post payment risk. Every reasonable effort has been made to assure the accuracy of the information within these pages. Proper coding may require analysis of statutes, regulations or carrier policies and as a result, the proper code result may vary from one payer to another. As such, rather than attempt to provide the instructions for each, this course is designed to educate you on how to find, interpret and apply the guidance available in each and in circumstances where such guidance is not provided, how to evaluate the quality and applicability of persuasive guidance.

This program is not intended to be legal advice and your attendance should not be construed as a legal opinion of the program developer or as establishing an attorney client relationship with the developer of this program. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course.

USGovernmentRightsThis product includes CPT® which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

NoticesCPT® copyright 2011 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion fac-tors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommendation their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

All Rights Reserved. CPT® is a registered trademark of the American Medical Association (AMA).

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All rights reserved.

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ContentsOverview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Laterality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Combination Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Dummy Placeholder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Prepare Now for Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Areas Impacted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Anatomy and Pathophysiology (A&P) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Blood and Lymphatic Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Coding for Fractures in ICD-10-CM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Eye and Adnexa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Coding for Diabetes and Retinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Example: No . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Example: No . 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Example: No . 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Asthma Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Prepare Now for Changes to Come . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

ICD-10-PCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Slide Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

ICD-10-CM—What You Need to Know NOW!

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ICD-10-CMWhatYouNeedtoKnowNOW!

OverviewIf you have not yet heard that ICD-10-CM implementa-tion is on its way and have not begun planning for the implementation, you are already behind in preparing for the impact the new coding system will have on your prac-tice. While the true impact of ICD-10-CM in a physician’s practice will largely depend on the size of the practice, one thing is certain: every area of an institution, facility or practice will be affected by the change in some way. The two largest areas of impact related to the transition to ICD-10-CM will be in the information technology (IT) department, beginning with the migration to 5010 for elec-tronic transfer of health care information, and documen-tation that will need to be more specific to allow proper assignment of the correct ICD-10-CM code(s). Practices must take an in-depth look at all areas that currently utilize ICD-9-CM information and plan ahead on the changes that may be required for each system to accommo-date the format and structure of ICD-10-CM.

The codes will change in many different ways. The codes in ICD-9-CM are numeric (with the exception of V and E codes) and are coded at the highest level of specificity at the fifth digit level. ICD-10-CM on the other hand, is structured so all codes begin with a letter, and can be alphanumeric throughout the remainder of the code. There are some codes that are specified to the seventh character extender, and a code is not considered valid or complete unless it’s coded to the highest level of specificity in its category. As a result of moving away from a coding system that has approximately 14,000 codes available, to a new coding system that offers over approximately 69,000 codes, the choices will be much more specific and will require more detail in the medical record to assign the most appro-priate code for patient’s conditions.

The transition to ICD-10-CM is all about the data. We are currently unable to share meaningful use regarding clini-cal conditions found in the United States, not only among other countries but also to health plans, other providers, etc. Sometimes it’s very time consuming to provide all the detail necessary to justify a claim such as sending in the entire medical record and supporting documentation. The level of clarity found in ICD-10-CM will change this, making it easier for quicker adjudication of health claims processing.

StructureIt’s important to remember that not all codes are required to be seven characters. Some codes are valid as three char-acter codes, and the ICD-10-CM coding manual is what will be used to guide us in understanding when it’s neces-sary to add additional characters.

Example: J80 Acute respiratory distress syndrome

S01.511A Laceration without foreign body of lip, initial encounter

As indicated by the above example, the three character code for acute respiratory distress syndrome, J80 is a valid code and does not require any additional characters to add more information to that diagnosis code. As indicated by the code for laceration of the lip, without foreign body, the seventh character is required to describe the episode of care for the injury.

LateralitySome of the changes in the codes include the addition of laterality to many diagnosis codes. It will not only be enough to say that a patient presents with hip pain, the diagnosis will also need to indicate which hip is experienc-ing the pain.

Example:M25.551 Pain in right hip

M25.552 Pain in left hip

M25.559 Pain in unspecified hip

As you can see, there will continue to be codes available for “unspecified” conditions in ICD-10-CM, but these should be used with caution. Think of this, if a bill is sent to a payer for an evaluation and management (E/M) service at a level 3, 4, or 5 and the diagnosis is “unspecified hip pain,” the payer may wonder how such an extensive level of ser-vice was performed, because the provider did not identify which hip was hurting.

Example:S86.909- Unspecified injury of unspecified muscle(s) and

tendon(s) at lower leg level, unspecified leg

The word unspecified is present three times in this code. Imagine what the payer would think if they received this claim for a high level of service or for a surgical procedure. Currently, professional claims are paid based on the CPT®


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code and the ICD code is used to support the medical necessity of a claim. In the above example of hip pain, the claim would most likely get paid when submitted to the insurance company; however, if the payer were to come back and perform an audit on the claim, they may recoup their payment based on insufficient supporting documentation.

For most codes in ICD-10-CM that contain laterality the right side is identified with the character “1” and the left side is “2” with bilateral identified with a “3.” Unspecified can be either a “0” or a “9” depending on if it’s the fifth or sixth character.

CombinationCodesICD-10-CM also brings many more combination codes. One code may represent three different aspects of an ill-ness or condition. This helps reduce the number of codes necessary to submit on a claim form, but requires sufficient documentation to assign the appropriate one.

Example:H90.41 Sensorineural hearing loss, unilateral, right ear,

with unrestricted hearing on the contralateral side

H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

As illustrated by the above code, there are four elements of information in just one code. It indicates the type of hear-ing loss, that it’s unilateral, which side is affected, and that the other ear has unrestricted hearing.

Example:I63.331 Cerebral infarction due to thrombosis of right

posterior cerebral artery

I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery

To assign these combination codes, documentation must be specific to include which artery has the thrombosis in it. Again, if the information is missing we can assign the unspecified code, but the unspecified codes should be used infrequently.

The guidelines will change regarding coding for diabe-tes and combination codes will exist in ICD-10-CM to represent:

�� Type of diabetes�� Body system affected �� Complications affecting that body system

As with ICD-9-CM, if the type of diabetes is not docu-mented, the default is type 2. Code Z79.4 Long-term

(current) use of insulin, should also be assigned when the patient has type 2 diabetes and uses insulin.

It’s important for coders and providers to become familiar with the codes to understand and be aware of what is avail-able for code choices to ensure that the most appropriate code is assigned to an encounter. Often, it’s easy to become familiar with using the code sets in one way. ICD-10-CM will force us to take a step back and relearn coding guide-lines and conventions.

It’s imperative to have an in-depth understanding of the ICD-10-CM Official Coding Guidelines for Coding and Reporting, as these are the foundation of how we can tell a precise and informative story to payers regarding the condition(s) of each patient.

DummyPlaceholderCertain codes in ICD-10-CM require a seventh character extender for the code to be valid. For codes that do not contain six characters the addition of a dummy place-holder is needed to maintain the seventh character data. In ICD-10-CM this dummy placeholder is identified as the letter “x.”

Example:T19.0xxD Foreign body in urethra, subsequent encounter

This code is listed in the ICD-10-CM manual as T19.0-, indicating that it requires additional characters to make it a complete code. When it’s referenced in the tabular section of the book it indicates that a seventh character is required to complete this code. As you can see by the code, it only has four characters so the dummy placeholder of ”x” must be added twice to make the code six characters in length. As indicated above, once the code is six characters, the sev-enth character can be added to describe the episode of care.

Example:O35.2- Maternal care for (suspected) hereditary disease

in fetus

This code is indicated as requiring a seventh character extension. Since the code is only four characters in length, we must add two dummy placeholders:

O35.2xx-

The choices for the seventh character are:0= not applicable or unspecified

1= fetus 1

2= fetus 2

3= fetus 3

4= fetus 4


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5= fetus 5

9= other fetus

The appropriate seventh character would be assigned based on which fetus was affecting the management of the mother. The seventh character “0” is for single gesta-tions and multiple gestations where the fetus is unspeci-fied. Seventh characters “1” through “9” are for cases for multiple gestations to identify the fetus for which the code applies. Additional instructions indicate that an appropri-ate code from category O30 Multiple gestation must also be assigned when assigning a code from category O35 that has a seventh character of 1 through 9.

PrepareNowforChangesMany people - especially coders - wonder what steps they can take now to begin preparing for ICD-10-CM, and the changes it will bring. To understand the appropriate steps to take, it’s first important to understand each individual’s role in the implementation process. For each role, a differ-ent approach to ICD-10-CM training will be involved.

An office administrator who is overseeing the implementa-tion project will not need an in-depth understanding of ICD-10-CM; however, IT staff members will need to have a deeper understanding so they can ensure codes are cross walked in their systems appropriately. They do not need to have a complete understanding of ICD-10-CM and the specific guidelines, but they do need to be able to identify which ICD-9-CM codes could accurately translate to an ICD-10-CM code.

Example:ICD-9-CM:

839.11 Dislocation of the first vertebra, open

ICD-10-CM:

S13.111A Dislocation of C0/C1 cervical vertebrae, initial encounter

Code also any associated: Open wound of the neck (S11-) Spinal cord injury (S14.1-)

An additional code would need to be applied depending on the circumstances of the patient:

S11 Open wound of neck

S11.011- Laceration without foreign body of larynx

S11.012- Laceration with foreign body of larynx

S11.013- Puncture wound without foreign body of larynx

S11.014- Puncture wound with foreign body of larynx

S11.015- Open bite of larynx

S11.019-Unspecified open wound of larynx

S11.021-Laceration without foreign body of trachea

S11.022-Laceration with foreign body of trachea

S11.023-Puncture wound without foreign body of trachea

S11.024-Puncture wound with foreign body of trachea

S11.025-Open bite of trachea

S11.039-Unspecified open wound of vocal cord

S11.10- Unspecified open wound of thyroid gland

S11.11- Laceration without foreign body of thyroid gland

S11.12- Laceration with foreign body of thyroid gland

S11.13- Puncture wound without foreign body of thyroid gland

S11.14- Puncture wound with foreign body of thyroid gland

S11.15- Open bite of thyroid gland

S11.20- Unspecified open wound of pharynx and cervical esophagus

S11.21- Laceration without foreign body of pharynx and cervical esophagus

S11.22- Laceration with foreign body of pharynx and cer-vical esophagus

S11.23- Puncture wound without foreign body of pharynx and cervical esophagus

S11.24- Puncture wound with foreign body of pharynx and cervical esophagus

S11.25- Open bite of pharynx and cervical esophagus

S11.80- Unspecified open wound of other specified part of neck

S11.81- Laceration without foreign body of other speci-fied part of neck

S11.82- Laceration with foreign body of other specified part of neck

S11.83- Puncture wound without foreign body of other specified part of neck

S11.84- Puncture wound with foreign body of other specified part of neck

S11.85- Open bite of other specified part of neck

S11.89- Other open wound of other specified part of neck

S11.90- Unspecified open wound of unspecified part of neck

S11.91- Laceration without foreign body of unspecified part of neck

S11.92- Laceration with foreign body of unspecified part of neck

S11.93- Puncture wound without foreign body of unspecified part of neck


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S11.94- Puncture wound with foreign body of unspecified part of neck

S11.95- Open bite of unspecified part of neck

In ICD-9-CM, there is only one code to indicate if the dis-location is open. In ICD-10-CM, there is an instructional note to indicate an additional code must be added for any associated open wound of the neck (S11-). In this example, it would be important for the IT team to understand how to follow the additional guidance in the ICD-10-CM coding manual to ensure that all appropriate codes are assigned (and in some cases sequencing will be important, as well). It’s also important that all ICD-10-CM options for the open wound are made available to the person coding the note so they can assign the code to the highest level of specificity for the injury.

AreasImpactedEvery area of a practice will be affected by ICD-10-CM in some way:

Administrative�� Changes to policies, health plan contracts, and budgets.�� Hardware and software upgrades and training.�� Staff training and productivity issues.

Clinical�� Documentation challenges.�� Revised payer policies.�� Revised Advance Beneficiary Notice (ABN)

requirements.�� Changes in the forms used.�� Changes to paper superbills.

BillingandCoding�� Update of skill sets.�� Dual coding/systems.�� Productivity issues.�� Reworking of claims.�� Provider communications.

IT�� Hardware requirements.�� Internal and external testing.

Even the front desk will be affected by changes in patient’s health care policy coverage, system upgrades, and any changes in contracting that may be necessary.

AnatomyandPathophysiology(A&P)For coders who are not responsible for educating providers on how to improve their documentation, it’s too early to learn the code sets. The codes are in draft format and have the potential to change prior to the implementation date of Oct. 1, 2013. There are similarities in the way codes are assigned from ICD-9-CM to ICD-10-CM; however, there are some major differences, as well. By learning the code sets too early, coders may forget the nuances included in ICD-10-CM and once implementation comes, they will continue using ICD-10-CM the way they have always used ICD-9-CM, making the transition futile. It’s better to wait for the final version of the code set, and then learn it, as the implementation date gets closer. With that being said, it’s NOT a good idea to wait to learn the code set one or two months prior to implementation because that is not allowing enough time to get comfortable with the changes. Timing will be a very important decision so be sure not to rush into anything, but also allow enough time to elimi-nate a sense of panic and apprehension.

It’s also important to understand that an increased level of knowledge in A&P will be required when coding the ICD-10-CM code sets. While it’s very true that codes can only be assigned based on the physician’s documentation, coders must be aware of things that are inferred or assumed in clinical notes. This is often why nurses have a more dif-ficult time becoming a coder because they understand dis-ease processes much more clearly, and they tend to assign codes based on what they know rather than what is actu-ally written in the note.

Example:A patient is found to have a primary malignant neoplasm of the right tibia.

There are two code choices for this condition when it’s looked up in the neoplasm table:

�� Neoplasm, leg NEC, malignant primary C76.51 y C76.51 Malignant neoplasm of right lower limb

�� Neoplasm, tibia (any part), malignant primary C40.21

y C40.21 Malignant neoplasm of long bones of right lower limb

It’s important to understand the differences between the available codes. Here the note indicates the patient has a primary neoplasm of the right tibia.

When the code is looked up in the neoplasm table under:

neoplasm, leg malignant primary, ICD-10-CM directs you to C76.51


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When that code is verified in the tabular section of the ICD-10-CM book, however, it has “NEC” in the descrip-tion. In the example above, the neoplasm IS classified else-where because the neoplasm is specifically stated as being in the bone, so the code should be looked up by:

neoplasm, tibia (any part), malignant primary; ICD-10-CM directs you to C40.21

Code C40.21 gives the highest level of specificity as it explains exactly where the neoplasm is. Code C76.51 pro-vides a general idea, but it does not provide the most accu-rate level of detail indicated in the note. In this example, we must provide the detail that the neoplasm is in the bone not just that it’s in the leg. The long bones of the leg are the femur, tibia, and fibula.

There are many coders who have never taken an A&P course. They were trained how to code on the job, learned various things through the years, and have not had any formal education or training on these topics. It’s highly recommended that each person who has a coding role (whether they are certified or not) should take some sort of A&P training. Some would benefit from a college type course, which may be taken online or in a classroom set-ting. Others will feel more comfortable with taking a refresher course. The AAPC does offer a refresher course on A&P that is specifically related to the transition to ICD-10-CM. There are 14 modules that are offered as online courses. For each module completed, one CEU is awarded.

BloodandLymphaticSystemsThe hemic or blood is how nutrients, gases, hormones, and blood cells pass to and from other cells in the body to help fight diseases, and stabilize body temperature and pH to maintain homeostasis (a sense of balance in the body). The hemic system is made up of blood containing vessels called arteries, capillaries, and veins. The two main functions of this system are to transport oxygen and nutrients to the cells and to remove carbon dioxide and other waste prod-ucts from the cells for elimination.

The lymphatic system is also part of the immune system and has three primary functions:

�� To defend against invading microorganisms and disease.�� Return excess interstitial fluid to the body.�� Absorb fats and fat-soluble vitamins from the diges-

tive system and transport them as chyle to the venous circulation.

Doyouknow?Which organs make up the lymph system, and what is their function?

Lymphadenitis/LymphangitisLymphadenitis is swelling of the lymph nodes. Usually it occurs in the neck, armpits, or groin. It’s relatively common and most likely indicates the presence of a bac-terial, viral, fungal, or parasitic infection. Less commonly, it may be a result of cancerous cells invading the node. The lymph nodes may feel hardened and painful to the touch. The skin covering the lymph node may be hot or slightly red.

A more serious form of lymphadenitis is lymphangitis, which is swelling of the lymph vessels. It almost always indicates the presence of bacterial infection. Its symptoms include high fever, red streaks around the swollen lymph node, throbbing pain in the lymph nodes, and flulike symptoms like lack of appetite, fatigue, and aching mus-cles. Lymphangitis is most associated with strep and staph bacterial infections. Cellulitis, infection of the blood, is a common cause.

The ICD-10-CM codes for lymphadenitis and lymphan-gitis are spread throughout various chapters. To code lym-phangitis in ICD-10-CM, the following is necessary:

�� Lymphadenitis or lymphangitis�� Site of swelling�� Acute or chronic�� Cause

Here are some examples of ICD-10-CM codes for lymph-adenitis and lymphangitis:

L04.0 Acute lymphadenitis of face, head, and neck

L04.1 Acute lymphadenitis of trunk

L04.2 Acute lymphadenitis of upper limb

L04.3 Acute lymphadenitis of lower limb

L04.8 Acute lympadenitis of other site

L04.9 Acute lymphadenitis, unspecified

I88.0 Nonspecific mesenteric lymphadenitis

A18.2 Tuberculous peripheral lymphadenopathy

L03.121 Acute lymphangitis of right axilla

L03.122 Acute lymphangitis of left axilla

L03.123 Acute lymphangitis of right upper limb

L03.124 Acute lymphangitis of left upper limb

I89.1 Lymphangitis (chronic, NOS)

L03.321 Acute lymphangitis of abdominal wall


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L03.322 Acute lymphangitis of back [any part except buttock]

L03.323 Acute lymphangitis of chest wall

L03.324 Acute lymphangitis of groin

Based on the codes listed above, please answer the follow-ing questions:

1. What is the correct ICD-10-CM code for acute lymphadenitis?

2. What is the correct ICD-10-CM code for acute lymphangitis of the left arm?

3. What is the correct ICD-10-CM code for acute lymphangitis of the back?

MusculoskeletalSystemThis system is actually made up of two systems that cannot function without the other. The musculoskeletal system provides the body with a supportive framework that allows flexible movement and protection of the internal organs. This body system includes the muscle structure of the body and the skeletal structure. It’s made up of muscles, bones, and joints as well as ligaments, tendons, and cartilage.

MuscularSystemThe muscular system helps to keep bones in place and provides the pulling power for us to move around. There are more than 650 muscles attached to the skeleton, which makes up nearly half the total weight of the human body.

The majority of these muscles stretch across joints to link one bone with another, and work in groups, in response to nerve impulses. The name of a skeletal muscle may come from its location, action, size, shape, attachment points, number of divisions, or direction of its fiber.

SkeletalSystemThe bones of the body fall into four general categories: long bones, short bones, flat bones, and irregular bones. Long bones are longer than they are wide and work as levers. The bones of the upper and lower extremities (humerus, tibia, femur, ulna, metacarpals, etc.) are of this type. Each long bone can be divided into three regions, namely the epiphysis, the metaphysis, and the diaphy-sis. The epiphysis is the rounded end of the bone. The metaphysis is the part adjacent to the epiphysis in the adult (growth plate has closed). It’s the part adjacent to the physis in children (growth plate being open). The diaphysis is the cylindrical shaft of the bone.

Short bones are short, cube-shaped, and found in the wrists and ankles. Flat bones have broad surfaces for pro-

tection of organs and attachment of muscles (for example, ribs, cranial bones, bones of shoulder girdle). Irregular bones are all others that do not fall into the previous cat-egories. They have varied shapes, sizes, and surfaces fea-tures and include the bones of the vertebrae and a few in the skull.

ICD-10-CM will bring a significant increase in specificity and the amount of codes available when coding for injuries. Coding for some types of fractures will require knowledge of whether the fracture is displaced or nondisplaced, open or closed, and the type of fracture that the patient has.

Doyouknow?Name all the different types of fractures and describe each one.

CodingforFracturesinICD-10-CMThe ICD-10-CM codes used to report fractures are found throughout section 19, Injury, Poisoning and Certain Other Consequences of External Causes, depending on the site of the fracture.

To code a fracture in ICD-10-CM the following is necessary:

�� Anatomic site�� Laterality�� Fracture type

y Displaced or nondisplaced y Open or closed

� Open fractures will be coded based on the Gustilo open fracture classification, which are grouped into three main categories to indicate the mechanism of injury, amount of soft tissue damage, and the degree of skeletal involvement.

� They are designated as type I, type II and type III. Type III is further subdivided into type IIIA, type IIIB, and type IIIC.

Episode of care (assigned as a seventh digit extension)

�� A = Initial encounter for closed fracture.�� B = Initial encounter for open fracture type I or II initial

y Encounter for open fracture NOS.�� C = Initial encounter for open fracture type IIIA, IIIB,

or IIIC.�� D = Subsequent encounter for closed fracture with

routine healing.�� E = Subsequent encounter for open fracture type I or

type II with routine healing.�� F = Subsequent encounter for open fracture type IIIA,

IIIB, or IIIC with routine healing.


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�� G = Subsequent encounter for closed fracture with delayed healing.�� H = Subsequent encounter for open fracture type I or

type II with delayed healing.�� J = Subsequent encounter for open fracture type IIIA,

IIIB, or IIIC with delayed healing.�� K = Subsequent encounter for closed fracture with

nonunion.�� M = Subsequent encounter for open fracture type I or

type II with nonunion.�� N = Subsequent encounter for open fracture type IIIA,

IIIB, or IIIC with nonunion.�� P = Subsequent encounter for closed fracture with

malunion.�� Q = Subsequent encounter for open fracture type I or

type II with malunion.�� R = Subsequent encounter for open fracture type IIIA,

IIIB, or IIIC with malunion.�� S = Sequela (late effect).

Epiphysis fractures (also known as Salter-Harris fractures) are grouped by body site and by Salter-Harris classification as type I, II, III, IV, or other.

Traumatic fractures are coded using the appropriate sev-enth character extension for the initial encounter (A, B, C) while the patient is receiving active medical treatment for the fracture. Examples of active medical treatment are: surgical treatment, emergency department (ED) encoun-ter, and evaluation and treatment by a new physician. Initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Fractures are coded using the appropriate seventh char-acter extension for subsequent care for encounters after the patient has completed active medical treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.

Care of complications of fractures, such as malunion and nonunion, should be coded with the appropriate seventh character extensions for subsequent care with nonunion (K, M, N) or subsequent care with malunion (P, Q, R).

S52.301-Unspecified fracture of shaft of right radius

S52.302-Unspecified fracture of shaft of left radius

S52.309-Unspecified fracture of shaft of unspecified radius

S52.311-Greenstick fracture of shaft of radius, right arm

S52.312-Greenstick fracture of shaft of radius, left arm

S52.319-Greenstick fracture of shaft of radius, unspecified arm

S52.321-Displaced transverse fracture of shaft of right radius

S52.322-Displaced transverse fracture of shaft of left radius

S52.323-Displaced transverse fracture of shaft of unspecified radius

S52.324-Nondisplaced transverse fracture of shaft of right radius

S52.325-Nondisplaced transverse fracture of shaft of left radius

S52.326-Nondisplaced transverse fracture of shaft of unspecified radius

S52.331-Displaced oblique fracture of shaft of right radius

S52.332-Displaced oblique fracture of shaft of left radius

S52.333-Displaced oblique fracture of shaft of unspecified radius

S52.334-Nondisplaced oblique fracture of shaft of right radius

S52.335-Nondisplaced oblique fracture of shaft of left radius

S52.336-Nondisplaced oblique fracture of shaft of unspecified radius

S52.341-Displaced spiral fracture of shaft of radius, right arm

S52.342-Displaced spiral fracture of shaft of radius, left arm

S52.343-Displaced spiral fracture of shaft of radius, unspecified arm

S52.344-Nondisplaced spiral fracture of shaft of radius, right arm

S52.345-Nondisplaced spiral fracture of shaft of radius, left arm

S52.346-Nondisplaced spiral fracture of shaft of radius, unspecified arm

S52.351-Displaced comminuted fracture of shaft of radius, right arm

S52.352-Displaced comminuted fracture of shaft of radius, left arm

S52.353-Displaced comminuted fracture of shaft of radius, unspecified arm

S52.354-Nondisplaced comminuted fracture of shaft of radius, right arm

S52.355-Nondisplaced comminuted fracture of shaft of radius, left arm

S52.356-Nondisplaced comminuted fracture of shaft of radius, unspecified arm

S52.361-Displaced segmental fracture of shaft of radius, right arm


8 AAPC 1-800-626-CODE(2633)

S52.362-Displaced segmental fracture of shaft of radius, left arm

S52.363-Displaced segmental fracture of shaft of radius, unspecified arm

S52.364-Nondisplaced segmental fracture of shaft of radius, right arm

S52.365-Nondisplaced segmental fracture of shaft of radius, left arm

S52.366-Nondisplaced segmental fracture of shaft of radius, unspecified arm

S52.371-Galeazzi’s fracture of right radius

S52.372-Galeazzi’s fracture of left radius

S52.379-Galeazzi’s fracture of unspecified radius

S52.381-Bent bone of right radius

S52.382-Bent bone of left radius

S52.389-Bent bone of unspecified radius

S52.391-Other fracture of shaft of radius, right arm

S52.392-Other fracture of shaft of radius, left arm

S52.399-Other fracture of shaft of radius, unspecified arm

Based on the codes listed above, please answer the follow-ing questions:

1. A 10-year-old boy presented to the ED with a fracture of the shaft of his right radius. The X-ray indicates it’s a transverse fracture. What is the appropriate ICD-10-CM code?

2. A patient was involved in an auto accident and was thrown from the vehicle on impact. They were taken to the ED with a type II open, comminuted, nondisplaced fracture of the shaft of the left radius. What is the appropriate ICD-10-CM code?

3. A patient returns to the clinic for the third time for a routine check-up on a greenstick fracture of the shaft of the radius of the right arm. While in the office the cast was changed and an X-ray indicated that the fracture is healing well, and as expected. What is the appropriate ICD-10-CM code?

EyeandAdnexaThe eyes are the most complex of all the sensory organs involving a much larger area of the brain than other senses. The cells of the eye that support vision are typically acti-vated by a stimulus, such as light. They collect light waves and transmit them as nerve impulses along the visual path-ways to the brain, which translates them to images.

The eye is often compared to a camera. Each eye gathers light and then transforms that light into a “picture.” Both also have lenses to focus the incoming light. A camera uses

the film to create a picture, whereas the eye uses a special-ized layer of cells, called the retina, to produce an image. Several structures compose the eye. Among the most important anatomical components are the cornea, conjunc-tiva, iris, crystalline lens, vitreous humor, retina, macula, optic nerve, and extraocular muscles.

CodingforDiabetesandRetinalDisordersDiabetic retinopathy is a condition that develops in patients with long-term diabetes causing damage to the blood vessels in the retina. It’s the leading cause of blind-ness in the United States as over time the damage to the blood vessels causes a permanent decrease in the sharpness of vision. There are four stages of diabetic retinopathy:

�� Mild nonproliferative retinopathy – This is the earliest stage where small balloon-like swelling occurs in the small vessels.�� Moderate nonproliferative retinopathy – Indicates

progression of the disease where the swelling turns into blockage.�� Severe nonproliferative retinopathy – Condition

has progressed so the retina is being deprived of the necessary amount of blood supply to keep it healthy and signals are sent to the body to grow new vessels to replace the blocked ones.�� Proliferative retinopathy – This is the advanced stage of

diabetic retinopathy where the new vessels have grown, but they have very fragile and thin walls so they are at risk for leaking, which would cause the retina to be blocked resulting in complete blindness.

In severe cases, a surgical procedure called a vitrectomy may be required. A vitrectomy is removal of blood from the center of your eye. Prior to a vitrectomy, laser proce-dures may be performed to slow the leakage and reduce the amount of fluid in the retina.

Doyouknow?1. What are the three layers of tissue that compose the spheri-

cal structure of the eye?

2. What condition of the eye is the leading cause of blindness in the United States?

To code for diabetic retinopathy in ICD-10-CM the following is necessary:

�� Type of diabetes (guidelines state that if type is not documented the default is type 2).�� Severity of nonproliferative condition.�� Proliferative or nonproliferative.�� With or without macular edema.


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E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema

E10.319Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema

E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema

E10.329Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema

E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema

E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema

E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema

E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema

E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema

E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema

E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema

E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema

E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema

E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema

E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema

E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema

E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema

E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema

Example:A patient with type 1 diabetes with diabetic retinopathy is seen for an eye check-up. After a thorough exam, the oph-thalmologist determines the patient has retinal edema.

To code properly for this condition, you must understand that the macula is located in the center of the retina. Rather than coding for two conditions separately - dia-betic retinopathy and retinal edema—use code E10.311. Even though the note does not specifically state “macular edema,” having an understanding of the anatomy of the eye will ensure proper code assignment.

Based on the codes listed above, answer the following questions:

1. What is the appropriate ICD-10-CM code for a patient with type 1 nonproliferative diabetic retinopathy that is at a mod-erate level and is also found to have macular edema?

2. What is the appropriate code for a patient diagnosed with diabetic retinopathy?

3. What is the appropriate ICD-10-CM code for proliferative diabetic retinopathy in a type 1 diabetic patient?

Brushing up on A&P not only assists in applying a diagno-sis code to the highest level of specificity, it also helps the coders have a better understanding of the clinical language used by physicians. There are many instances where physi-cians do not understand the language that coders speak because it does not clinically coincide with how they think. It’s imperative that coder language and provider language is understood by both sides so the story can be accurately relayed to the payer, and they can make payment based on codes rather than requesting additional information or notes in an effort to clarify what was actually performed and why. Once we understand how disease processes work, we will be better equipped to engage providers in understanding why the extra details and additional information is necessary. One thing is for certain, if a provider does not know the important elements of documentation that are necessary for ICD-10-CM, they will never add the information.


10 AAPC 1-800-626-CODE(2633)

Example: No. 1

A 7-year-old patient presents in follow-up for new lesions over the zygomatic arch. We previously identified a common wart, which is now quite sizable, adjacent to the canthus of her left eye. Because of the proximity to the eye, it was felt that it was not safe to apply topical creams to the lesion to attempt to get it to disappear. She underwent surgical excision of the lesion around the left eye with a good result. The parents now relate that there are three small lesions similar to the left-sided lesion present over the zygomatic arch onto the eyelid of the right eye.

The lesions were examined and are noted to be 1 mm or less in diameter.

Surgical intervention is not recommended at this time, and we will see her back in three months to check on the lesions.

The appropriate ICD-10-CM code for this patient is: B07.8 Other viral warts

(note indicates that common warts are included in this classification).

The zygomatic arch is the part of the temporal bone of the skull that forms the prominence of the cheek.

The type of wart is documented.

The canthus is where the upper and lower eyelids meet on either side of the eye.


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Example: No. 2

Preoperative diagnosis: Left Achilles tendon rupture (nontraumatic)

Postoperative diagnosis: Left Achilles tendon rupture (nontraumatic)

Procedure performed: Repair of left Achilles tendon rupture.

Description of procedure: After informed consent was obtained, the patient was taken to the operating room and placed on the table in the supine position. The patient had received 1 g of Ancef preoperatively and a tourniquet was applied to the left proximal thigh. Once satisfactory general anesthesia was accomplished, the patient was then turned to the prone position. The left lower extremity was then prepped and draped in the usual sterile fashion. After several minutes of elevation and exsanguination using a 6-inch Ace wrap, the tourniquet was inflated to 300 mmHg. A sterile marking pen was then used to outline a posteromedial longitudinal incision to the left Achilles tendon. This incision measured approximately 12 cm in length. Great care was taken to avoid placing the incision midline to avoid Chou counter strikes at a later date. Sharp dissection was carried down through skin. Full-thickness flaps were developed. The patient was noted to have a complete frayed rupture of Achil-les tendon at the musculotendinous junction. This rupture was approximately 7 cm proximal to the calcaneus. The tendon sheath with subcutaneous tissue was incised exposing the ruptured proximal and distal ends of the tendon. The frayed tendon was gently freshened to a smooth edge. The proximal tendon was then sutured using No. 2 FiberWire using a whipstitch technique. The distal end was also repaired using No. 2 FiberWire. The wound was irrigated with saline. PRP was injected around the tendon and the 2 columns of No. 2 FiberWire were then approximated with the foot in 5 degrees of equinus. The para Tenon and subcutaneous tissue was closed with 4-0 absorbable sutures. The repair was noted to be secure upon testing. The patient was placed on a sterile dressing and short leg fiberglass cast with the fool in 5-8 degrees of equinus. The patient tolerated the procedure well and was taken to recovery in stable condition. Sponge and needle count were correct. The patient received 1000 mL of crystalloid.

A&P: The Achilles tendon is in the ankle and is part of the gastrocnemius muscle, which is a flexor muscle, so it’s coded as a rupture of the flexor muscle of the ankle.

M66.372 Spontaneous rupture of flexor tendons, left ankle and foot

Indicates sponta-neous rupture.

Procedure performed on left side.


12 AAPC 1-800-626-CODE(2633)

Example: No. 3Chief complaint: cut on lip

HPI: Healthy 3-year-old presents for evaluation of a right lower lip laceration that occurred just prior to arrival in the ED. Patient was at home, playing in the backyard, and while walking around she tripped over a wagon, falling forward, striking the right lower lip on the edge of the wagon. The fall was witnessed by family members. Patient had no other injury from the incident, no other facial injuries and there was some mild bleeding initially from the lacerated site. Otherwise, patient has been acting “normal.” No dental injury, no epistaxis. There were no neurological changes.

Immunizations: Current; All other past medical, surgical, and family history was reviewed per electronic medical record.

Exam: Nursing note and vitals reviewed.

Constitutional: She appears well hydrated, non-toxic. Well-developed, well-nourished 3-year-old watching cartoons in no acute distress.

HENT: Head: Normocephalic. Right ear: External ear normal. Left ear: External ear normal. Nose: normal. Mouth/throat: Oropharynx is clear and moist. No oropharyngeal exudate. There is a ¼ cm vertically lying linear laceration in the right lower lip, crossing the vermillion border. It does gap minimally, but there is no through and through component. The rest of the lip exam is completely intact, and dentition is all firmly seated. No other buccal injury was appreciated, Eyes: Conjunctivae are normal. Neck: Normal range of motion. Lymphade-nopathy: no cervical adenopathy. Neurological: She is alert. Skin: Skin is warm and dry. She is not diaphoretic. Psychiatric: Mood and affect normal. Patient is cooperative and develop-mentally appropriate.

Assessment: Laceration of lip requiring repair

Plan: We discussed several options and decided that placing sutures across the laceration would be appropriate.

Description of procedure: The area was infiltrated with 1 percent plain lidocaine. After excel-lent anesthesia was obtained, we were able to evaluate the wound fully and could appreciate no deeper structure injury. Thereafter, the wound was rinsed with normal saline, and two 5-0 fast absorbing gut sutures were placed. This approximated the edges without difficulty.

Patient tolerated the procedure well. Patient’s mother does verbalize an understanding of the discharge plan and instructions for reevaluation.

Codes:

S01.511A Laceration without foreign body of lip

W18.09xA Striking against other object with subsequent fall, initial encounter

Y92.017 Garden or yard in single-family (private) house as the place of occurrence of the external cause

No mention of foreign body involved so “without foreign body” is assigned.

An activity code is not assigned because the note did not specify the activity of the child other than playing. ICD-10-CM guidelines state: Do not assign Y93.9, unspecified activity, if the activity is not stated.


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DocumentationChallengesICD-10-CM will impose unique challenges to a practice that must be met head on. The fact that we are increasing our code set to over 69,000 diagnostic codes sets the stage for the ability to exchange data in a meaningful way.

The clinical area of a medical practice will be one of the ones facing the most challenges. Because ICD-10-CM is data driven, coding to the highest level of specificity will become increasingly important. ICD-10-CM is an expen-sive and timely program to implement and those who will not use the code set to their full capacity will be doing potential damage to the practice in the long run in addition to making the transition to the new code set futile. Over the past several years many payers have instituted qual-ity measures, disease management tracking programs, and incentives for providers based on medical necessity and qual-ity of care. Correct ICD-10-CM coding will allow you to clinically spell out the whole picture to a payer, allowing for immediate adjudication without the need to send in addi-tional supporting documentation in most circumstances.

Many payers are determining they want to pay for quality, not quantity and practices will need to be able to prove this to payers. ICD-10-CM is one way to be able to accom-plish future data requirements such as this.

We must begin to work with our providers early and often regarding the documentation found in the medical record. There are many concepts in ICD-10-CM that are new, providers will need to be trained on the new code set and the level of specificity found in ICD-10-CM so they can begin to prepare for the changes.

Example:CC: 64-year-old male was last here three weeks ago for wheez-ing and cough. The MID and Prednisone worked great while on the meds, the first week was great. He is sleeping now through the night. He says he is better but not like he felt when on the Prednisone. He feels that the Prednisone is the only thing making him feel better over the last sev-eral months.

History: Patient is a former smoker.

Exam: ENMT: Auditory canals normal. Tympanic membranes are intact. Nasal mucosa is pink and moist. Dentition is in good repair. Oral mucosa: pink, smooth, and moist. Poste-rior pharynx shows no exudate, irritation, or redness.

Neck: Palpitation reveals no lymphadenopathy. No masses appreciated. Thyroid exhibits no thyromegaly. No JVD. Carotids 2+ and equal bilaterally, without bruits.

Resp: Respiration rate is normal. No wheezing. Auscultate good airflow. Lungs are clear bilaterally.

Assessment and Plan: Asthma, refills given on meds and patient educated regarding asthma and triggers. Pt to return following PFT or sooner if not any betterSingulair 10 mg 1 po qdProair HFA 108 (90 base) mcg/ac 2 puffs q4h prnOrders: pulmonary function test

J45.909Unspecified asthma, uncomplicated

There are more specific codes available in ICD-10-CM that should be used if possible. The provider should be educated on the codes available to they can document appropriately.

J45.20 Mild intermittent asthma, uncomplicated

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.30 Mild persistent asthma, uncomplicated

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild persistent asthma with status asthmaticus

J45.40 Moderate persistent asthma, uncomplicated

J45.41 Moderate persistent asthma with (acute) exacerbation

J45.42 Moderate persistent asthma with status asthmaticus

J45.50 Severe persistent asthma, uncomplicated

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

J45.901Unspecified asthma with (acute) exacerbation

J45.902Unspecified asthma with status asthmaticus

J45.990Exercise induced bronchospasm

J45.991Cough variant asthma

J45.998Other asthma

*Useadditionalcodetoidentify:

Exposure to environmental tobacco smoke (Z77.22)

Exposure to tobacco smoke in the perinatal period (P96.81)

History of tobacco use (Z87.891)

Occupational exposure to environmental tobacco smoke (Z57.31)

Tobacco dependence (F17-) Tobacco use (Z72.0)


14 AAPC 1-800-626-CODE(2633)

Above is a chart that helps identify the different types of severity of asthma. You need to pull this type of information out of the chart to assign the appropriate code.

Providers will need education on the code sets to assure they document all necessary elements necessary to assign a code to its full capacity.

AsthmaSeverity

Intermittent Mild PersistentModerate Persistent

Severe Persistent

Symptoms 2 or less days per weekMore than 2 days per week

Daily Throughout the day

Nighttime Awakenings

2 times per month or less 3-4 times per monthMore than once per week but not nightly

Nightly

Rescue Inhaler Use 2 or less days per weekMore than 2 days per week, but not daily

DailySeveral times per day

Interference with Normal Activity

None Minor limitation Some limitation Extremely limited

Lung FunctionFEV1 >80% predicted and normal between exacerbations

FEV1 >80% predictedFEV1 60-80% predicted

FEV1 less than 60% predicted

Sources:

National Heart, Lung, and Blood Institute. Accessed: May 20, 2010. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma


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ExerciseUtilizing the chart on page 14, and the documentation provided, what are the additional documentation elements that should be documented to assign an asthma code to its fullest extent?

Laterality will be another key issue in documentation under certain circumstances. Typically such conditions as cerumen impaction or even foreign body removals in certain body areas will require more concise documentation to assign the proper codes.

Example:Patient presented to ED after the lumber he was hauling at home today splintered and lodged in his ear. Using alligator forceps and under direct visualization I was able to remove a large splinter from the patients left external ear.

ICD-10-CMcode: S00.452A Superficial foreign body of the left ear, initial encounter

The above example shows the documentation needs to include not only laterality, but also enough information to capture the appropriate seventh character extender. In this example the seventh character choices available include:

A initial encounter

D subsequent encounter

S sequela

According to the draft ICD-10-CM guidelines, initial encounter should be reported while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, ED encounter, and evaluation and treatment by a new physician.

What documentation is missing from the following notes?

DescriptionofOperation:Under general anesthesia with the microscope in place, a pearly white plastic ball was seen virtually obstructing the entire ear canal. Gently with a curette, this was teased out of the ear canal atraumatically. The ear canal and eardrum were per-fectly intact. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.

Laterality is not documented in this example.


16 AAPC 1-800-626-CODE(2633)

Operative report

Patient name: Bob Jones MR#19000 Surgeon: Thomas Bell, MD DATE: 08-23-2010 Preoperative diagnosis: Fibular fracture, left ankle Postoperative diagnosis: Fibular fracture, left ankle.Procedure performed: Open reduction and internal fixation of fibular fracture, left ankle.Anesthesia: General. Pneumatic thigh tourniquet set at 350 mmHg. Estimated blood loss: Minimal Material used: 2-0 Vicryl, 3-0 Vicryl, 3-0 nylon, 4-0 nylon, and one 3.5x 20 mm partially threaded cortical screw and one 3.5 x 22 mm partially threaded cortical screw. Injectables: 24 cc of 0.5 percent Marcaine plain and also 12 cc of 0.5 percent Marcaine Complications: None.Specimens: None.

Description of the procedure: The patient was brought into the operating room and placed on the operating room table in the supine position. A 24 cc of 0.5 percent Marcaine plain was injected in an ankle block fashion to the left ankle. A well-padded thigh tourniquet was applied to her left thigh and then left foot and lower leg were scrubbed, prepped, and draped in the usual aseptic manner. At this time, a 5 cm linear incision was made laterally over the fibula and the area with the fracture. This incision was deepened down to bone with care taken to avoid all neurovascular structures. The periosteum was partially reflected and revealed a large spiral fracture with a large posterior fragment. Large amount of hema-toma was noted in and around the fracture site. This was suctioned and removed. There was still quite a bit of swelling in the subcutaneous tissue. Otherwise, the fracture was sig-nificant, but only two pieces were noted. Again, all the hematoma was removed, and then the fracture site was reduced back into alignment and fracture fragments held in position with two bone clamps. C-arm fluoroscopy was utilized with dorsal lateral and ankle view to ensure that the bony fragments were in proper position and they were. Using standard AO technique, one 3.5 x 20 mm partially threaded cortical screw was placed across the fracture site, and then one 3.5 x 22 mm partially threaded cortical screw was also placed across the fracture site. This brought adequate reduction and closure of the fracture. The bone clamps were removed. The C-arm again was utilized with dorsal lateral and ankle view to ensure proper position of all screws and that proper alignment was maintained, and it was. The area was flushed copiously with normal saline and then closure was achieved using 2-0 Vicryl to close periosteum, 3-0 Vicryl for deep closure, and 3-0 nylon to close the proximal aspect of the skin incision and then 4-0 nylon to close the distal aspect of the skin incision. At this time, 12 cc of 0.5 percent Marcaine plain was injected and then around the incision site, and then dressing was applied consisting of Betadine® soaked Adaptic, gauze, Kling, and a pos-terior mold applied in a mildly compressive manner. The thigh tourniquet was released and immediate warmth and perfusion was noted to all digits of the left foot. The patient was then transferred to recovery room with all vital signs stable and neurovascularly intact to the left foot. The patient will follow up as outpatient.

Location is documented.

Type of fracture is documented.


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The note indicates a fibular fracture, left ankle. Reading the operative report, the fracture is further specified as spiral allowing for proper assignment of the correct code.

ICD-10-CM draft guidelines states “A fracture not indi-cated whether displaced or not displaced should be coded to displaced.”

ICD-10-CM code:

S82.442A Displaced spiral fracture of the shaft of the left fibula, initial encounter for fracture

PrepareNowforChangestoComePractices can begin to prepare now for upcoming changes. By performing documentation readiness evaluations pro-viders can begin to take a systematic approach to overcom-ing the clinical hurdles in ICD-10-CM. There are simple steps that practices can begin to take now to properly pre-pare; following these steps will allow providers to strategi-cally begin the implementation process.

1. Run a practice management report of your most frequently used ICD-9-CM diagnosis codes in your practice.

2. Starting with the most frequent ones, begin to pull charts that correlate to these codes.

3. Assess the documentation found in the medical records and ask two simple questions:

a. Is there enough documentation found in the medical to assign an ICD-10-CM code now?

b. What education needs to be performed to get the documentation where it needs to be?

4. Summarize your reports and provide education to the pro-vider so changes can begin to be made.

5. Continue with ongoing evaluations and education.

If you don’t have the resources to accomplish this, look to outside entities to perform documentation evaluations for your practice. This vital piece of assessment and education is a needed component of ICD-10-CM implementation.

ICD-10-PCSICD-10-PCS will replace our current ICD-9-CM Volume III codes. These codes are for use for inpatient facilities and will not affect any outpatient codes. ICD-10-PCS is unlike any other coding system we have used in the past. It is a systematic, logical building process that takes ambi-guity out of the coding process. However, with it comes unique terms, definitions, and skill requirements.

ICD-10-PCS was initially released in 1998. It has been updated annually since that time although not in use. Coders need to develop a good working knowledge of Anatomy and Terminology to code ICD-10-PCS. Developing these skills will help you become a master in ICD-10-PCS.

Individual letters and numbers, called “values,” are selected in sequence to occupy the seven spaces of the code, called “characters.” Once the coding system is learned the process is simplified. All ICD-10-PCS codes are seven characters in length.

The coding in ICD-10-PCS is best understood as the result of a process rather than as an assigned number. This process consists of assigning values from among the valid choices for that part of the system, according to the rules governing the construction of codes. It is logical and systematic in its coding approach. There are 34 differ-ent values for each possible code character. This structure allows for easy updating of codes without disruption to others.

The structure of PCS is consistent:

Character 1 Section

Character 2 Body System

Character 3 Root Operation

Character 4 Body Part

Character 5 Approach

Character 6 Device

Character 7 Qualifier

Each of these characters makes up a unique code. Values can be assigned to each character in a code: the numbers 0–9 and the alphabet (except I and O, because they are easily confused with the numbers 1 and 0).

The hardest part of learning ICD-10-PCS is found in the new terminology and the code look up process. Once you master this aspect of it the rest comes very easily.

ICD-10-PCS is composed of 16 sections, represented by the numbers 0–9 and the letters B–D and F–H. The broad procedure categories contained in these sections range from surgical procedures to substance abuse treatment. The most commonly used section is 0 as this is the section that contains surgical procedures.


18 AAPC 1-800-626-CODE(2633)

Theremainderofthesectionsaredividedassuch:

1 Obstetrics

2 Placement

3 Administration

4 Measurement and monitoring

5 Extracorporeal assistance and performance

6 Extracorporeal therapies

7 Osteopathic

8 Other procedures

9 Chiropractic

In addition, there are ancillary services covered in ICD-10-PCS. Sections B–D and F–H comprise the ancillary sections. These six sections include imaging procedures, nuclear medicine, and substance abuse treatment.

The same convention is followed within each table for the second through the seventh characters—numeric values in order first, followed by alphabetical values in order.

The codes we used are built off of these tables. This example comes from the medical surgical section and shows how a table appears in ICD-10-PCS. To build the code you would assign a character for each field.

0:Medical and Surgical

0:Central Nervous

1:Bypass

Alteringtherouteofpassageofthecontentsofatubularbodypart

Body Part Character 4

Approach Character 5

Device Character 6

Qualifier Character 7

6 Cerebral Ventricle

0 Open 7 Autologous Tissue Substitute

J Synthetic Substitute

K Nonautologous Tissue Substitute

0 Nasopharynx

1 Mastoid Sinus

2 Atrium

3 Blood Vessel

4 Pleural Cavity

5 Intestine

6 Peritoneal Cavity

7 Urinary Tract

8 Bone Marrow

B Cerebral Cisterns

U Spinal Canal 0 Open 7 Autologous Tissue Substitute

J Synthetic Substitute

K Nonautologous Tissue Substitute

4 Pleural Cavity

6 Peritoneal Cavity

7 Urinary Tract

9 Fallopian Tube


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ICD-10-PCS possesses several additional characteristics in response to government and industry recommendations. These characteristics are:

�� Standardized terminology within the coding system.�� Standardized level of specificity.�� No diagnostic information.�� No explicit “not otherwise specified” (NOS) code

options.�� Limited use of “not elsewhere classified” (NEC) code

options.

Words commonly used in Volume 3 of ICD-9 may have multiple meanings throughout the health care industry, and this causes confusion resulting in inaccurate coding and misinterpretation of what was actually performed.

For example, the word “excision” is used to describe a wide variety of surgical procedures but in ICD-10-PCS, the word “excision” describes a single, precise surgical objec-tive, defined as “Cutting out or off, without replacement, a portion of a body part.” There are many other new termi-nology concepts found within ICD-10-PCS as well.

Standardized terminology means that certain procedures that have been named with eponyms or common proce-dure names can only be looked up by the actual name of the procedure, which can be confusing to coders who do not understand the procedure being performed. Working closely with physicians during the transition may be neces-sary as well as a brush-up course on Anatomy and Patho-physiology.

The standardized terminology is not always user friendly. For example, a delivery of a newborn would be coded to “extraction of products of conception,” which would make most laypeople cringe since the fetus is now referred to as a product of conception and not a life form.

Example:The physician delivered a healthy 10 lb baby boy vaginally with the use of vacuum suction due to the baby’s size…

As you can see from the chart below, the completed code for this example would be 10D07Z6.

It is only with time and patience that you will be able to master ICD-10-PCS. Once you allow yourself the time to understand the building of the codes and the new termi-nology, the coding will come easily for you. Learning the new code set could open doors for you in the future with employment. Remember that ICD-10-PCS is only used for inpatient coding and that it will not replace CPT® or HCPCS Level II code sets. With practice you will find that you can master this code set as well as ICD-10-CM.

ConclusionIt’s no doubt that ICD-10-CM implementation will be one of the largest changes to hit health care, but with proper timing and education success can be obtained. Now is not the time to learn the code sets, instead, focus your time and energy on skill set updates. Take a look at the whole picture before determining your implementation plan. Strategic steps need to be taken no matter what your role in health care.

Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7

Section Body System Root Operation Body Part Approach Device Qualifier

Obstetrics Pregnancy Extraction Products of Conception

Via Natural or Artificial Opening

No Device Vacuum

1 0 D 0 7 Z 6


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Slide Presentation


22 AAPC 1-800-626-CODE(2633)

What You Need to Know NOW About ICD-10!

1

Agenda

• Introduction and Overview

• Structure of ICD‐10‐CM

• Anatomy and Pathophysiology

• Documentation Requirements

• Introduction to ICD‐10‐PCS

2


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Overview

• ICD-10 is on its way!– October 1, 2013

• Begin with 5010• Changing codes

– 14,000 to 69,0003 000 to 87 000

3

– 3,000 to 87,000

Structure

• Up to 7 characters– Not all codes are 7 characters– Some are only 3

Example:• J80 Acute respiratory distress syndrome• S01 511A Laceration without foreign body of

4

• S01.511A Laceration without foreign body oflip, initial encounter


24 AAPC 1-800-626-CODE(2633)

Laterality

• Some codes contain laterality i ICD 10 CMin ICD-10-CM

Example:• M25.551 Pain in right hip• M25 552 Pain in left hip

5

M25.552 Pain in left hip• M25.559 Pain in unspecified hip

Unspecified

• Selection for unspecified is found in every tcategory

– Should be used sparingly– How will you get paid? What about medical

necessity?Example:

6

p– S86.909- Unspecified injury of unspecified

muscle(s) and tendon(s) at lower leg level, unspecified leg


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Combination Codes• Used to represent an illness/disease with an

associated sign or symptom or manifestation/complication– Can actually simplify coding

Example:• H90.41 Sensorineural hearing loss, unilateral, right

ear, with unrestricted hearing on the contralateral side

7

, g• H90.42 Sensorineural hearing loss, unilateral, left ear,

with unrestricted hearing on the contralateral side

Example

Example:

• I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery

• I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery

8


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Diabetes Mellitus

• Type of diabetes• Body system affected• Complications affecting that body system• Default if not documented is Type 2

– If long term insulin use is documented use additional code Z79 4

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additional code Z79.4

Dummy Placeholder

• New concept in ICD-10-CMC t i d i 7th h t t d• Certain codes require 7th character extender– But don’t have 6 characters– X is used to fill in to keep 7th character the 7th

character

Example:

10

• T19.0xxD Foreign body in urethra, subsequent encounter


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Example• O35.2- Maternal care for (suspected) hereditary disease

in fetusThis code is indicated as requiring a seventh character• This code is indicated as requiring a seventh characterextension. Since the code is only four characters in length, we must add two dummy placeholders:– O35.2xx-

0 = not applicable or unspecified

4= fetus four

1= fetus one 5= fetus 51= fetus one 5= fetus 5

2= fetus two 9= other fetus

3= fetus three

Prepare Now

• Everyone needs some level of education– Administration– IT

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32 AAPC 1-800-626-CODE(2633)

Anatomy and Pathophysiology

• Where focus should be right now for dcoders

• Still too early to learn code set– Codes are in draft format– Won’t take years to learn– Early training will cause retention issues costing more

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money in retraining


• Much higher level of specificity in ICD-10-CM

• Need to understand all elements documented

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Example• A patient is found to have a primary malignant

neoplasm of the right tibia.• There are two code possibilities for this condition

when it’s looked up in the neoplasm table:

Neoplasm, leg NEC, malignant primary C76.51• C76.51 Malignant neoplasm of right lower limbNeoplasm tibia (any part) malignant primary C40 21

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Neoplasm, tibia (any part), malignant primary C40.21• C40.21 Malignant neoplasm of long bones of right

lower limb

Blood and Lymphatic Systems

• Hemic or blood is how nutrients, gases, hormones and blood cells pass to and fromhormones, and blood cells pass to and fromother cells in the body to help fight diseases and stabilize body temperature

• Made up of blood containing vessels called arteries capillaries and veins

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arteries, capillaries, and veins.


34 AAPC 1-800-626-CODE(2633)

Blood and Lymphatic Systems

• Three main purposes

– To defend against invading microorganisms and disease

– Return excess interstitial fluid to the body– Absorb fats and fat-soluble vitamins from the

digestive system and transport them as chyle to the

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venous circulation

Did You Know?

• Which organs make up the lymph system, d h t i th i f ti ?and what is their function?

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Lymphadenitis/Lymphangitis

• Lymphadenitis is swelling of the lymph nodesL h iti i lli f th l h l• Lymphangitis is swelling of the lymph vessels

• To code in ICD-10-CM we need to know:

– Lymphadenitis or lymphangitis– Site of swelling– Acute or chronic

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– Cause

Examples

• L04.0 Acute lymphadenitis of face, head, and neck

• L04.1 Acute lymphadenitis of trunk

• L04.2 Acute lymphadenitis of upper limb

• I88.0 Nonspecific mesenteric lymphadenitis

• A18.2 Tuberculous peripheral lymphadenopathy

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p p y p p y

• L03.121 Acute lymphangitis of right axilla


36 AAPC 1-800-626-CODE(2633)

Test Your Skills

• What is the correct ICD-10-CM code for acute lymphadenitis?lymphadenitis?

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Test Your Skills

• What is the correct ICD-10-CM code for t l h iti f th l ft ?acute lymphangitis of the left arm?

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Test Your Skills

• What is the correct ICD-10-CM code for acute lymphangitis of the back?lymphangitis of the back?

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Musculoskeletal

• Musculoskeletal system provides the body with a supportive framework that allows flexiblesupportive framework that allows flexiblemovement and protection of the internal organs

• Made up of muscles, bones, and joints as well as ligaments, tendons, and cartilage

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38 AAPC 1-800-626-CODE(2633)

Muscular System

• More than 650 muscles attached to the skeletonM k l t h lf b d i ht– Makes up almost half our body weight

• Name of a skeletal muscle may come from its location, action, size, shape, attachment points, number of divisions, or direction of its fiber

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Skeletal System

• Fall into four general categories:

– Long bones

– Short bones

– Flat bones

I l b

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– Irregular bones


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Do You Know?

• Name all the different types of fractures d d ib hand describe each one.

35

Fractures and ICD-10-CM• Found in chapter 19• To code we need to know:To code we need to know:

– Anatomic site– Laterality– Fracture type– Displaced or nondisplaced– Open or closed

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p– Open fractures will be coded based on the Gustilo

open fracture classification, which are grouped into three main categories


40 AAPC 1-800-626-CODE(2633)

Episodes of Care

• Required on most codes in this chapter• Alphabet soup• Letters can change meaning based on

subcategory– A could mean initial encounter or initial

encounter for closed fracture

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encounter for closed fracture

Examples• S52.302- Unspecified fracture of shaft of left radius

• S52 311- Greenstick fracture of shaft of radius right armS52.311 Greenstick fracture of shaft of radius, right arm

• S52.322- Displaced transverse fracture of shaft of left radius

• S52.332- Displaced oblique fracture of shaft of left radius

• S52 353 Displaced comminuted fracture of shaft of

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• S52.353- Displaced comminuted fracture of shaft ofradius, unspecified arm

• S52.372- Galeazzi’s fracture of left radius


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Test Yourself

A 10-year-old boy presented to the ED with f t f th h ft f hi i ht dia fracture of the shaft of his right radius.

The X-ray indicates it’s a transverse fracture.

– What is the appropriate ICD-10-CM code?

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Test Yourself

A patient was involved in an auto accident d th f th hi land was thrown from the vehicle on

impact. He was taken to the ED with a type II open, comminuted, nondisplaced fracture of the shaft of the left radius. What is the appropriate ICD-10-CM code?

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pp p


42 AAPC 1-800-626-CODE(2633)

Test Yourself

A patient returns to the clinic for the third ti f ti h k ti ktime for a routine check-up on a greenstickfracture of the shaft of the radius of the right arm. While in the office the cast was changed and an X-ray indicated that the fracture is healing well, and as expected.

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What is the appropriate ICD-10-CM code?

Eye and Adnexa

• Eyes are the most complex of all the i l i h lsensory organs involving a much larger

area of the brain than other senses• Collect light waves and transmit• Several layers of structure

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Diabetes and Retinal Disorders

• Diabetic retinopathyD l i ti t ith l t di b t• Develops in patients with long-term diabetes

• One of the leading cause of blindness• Four stages

– Mild nonproliferative retinopathy– Moderate nonproliferative retinopathy

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– Severe nonproliferative– Proliferative

Do You Know

• What are the three layers of tissue that th h i l t t f thcompose the spherical structure of the

eye?

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44 AAPC 1-800-626-CODE(2633)

Do You Know

• What condition of the eye is the leading f bli d i th U it d St t ?cause of blindness in the United States?

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Diabetic Retinopathy

• To code in ICD-10-CM we need to know– Type of diabetes– Severity of nonproliferative condition– Proliferative or noproliferative– With or without macular edema

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Examples

• E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macularunspecified diabetic retinopathy with macularedema

• E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema

• E11 321 Type 2 diabetes mellitus with mild

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• E11.321 Type 2 diabetes mellitus with mildnonproliferative diabetic retinopathy with macular edema

Example

A patient with type 1 diabetes with diabetic ti th i f h k Aftretinopathy is seen for an eye check-up. After a

thorough exam, the ophthalmologist determines the patient has retinal edema.

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46 AAPC 1-800-626-CODE(2633)

Test Yourself

What is the appropriate ICD-10-CM code for a patient with type 1 nonproliferative diabeticpatient with type 1 nonproliferative diabeticretinopathy that is at a moderate level and is also found to have macular edema?

49

Test Yourself

What is the appropriate code for a patient di d ith di b ti ti th ?diagnosed with diabetic retinopathy?

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Test Yourself

What is the appropriate ICD-10-CM code f lif ti di b ti ti th ifor proliferative diabetic retinopathy in a type 1 diabetic patient?

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• Assists in being able to apply the condition t th hi h t l l f ifi itto the highest level of specificity

• Helps the coder to understand the physician language

• Better equips us to work hand in hand with the physicians

52

the physicians


48 AAPC 1-800-626-CODE(2633)

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Documentation Challenges

• Poses a unique challenge to a practiceCli i l ill b f th l t hit• Clinical will be one of the largest hit

• Pay for quality• Need to work early and often with providers

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Example64 YO male here last 3 weeks ago for wheezing and cough. The MID and Prednisone worked great while on the meds, the first week was great, he is sleeping now through the night. He says he is better but not like he felt when on the Prednisone. He feels the Prednisone is the only thing making him feel better over the last several months.History: Patient is a former smokerExam: (refer to handout in your book)Assessment and Plan: Asthma, refills given on meds and patient educated on triggers. Pt to return following PFT or sooner if not any

55

better. Singular 10 mg 1 po qd; Proair HFA 108 (90 bse) mcg/ac 2 puffs q4h prn; Orders: pulmonary function test

Example

• ICD-10-CM J45.909 Unspecified asthma, uncomplicateduncomplicated– Need additional code to identify

• Exposure to environmental tobacco smoke (Z77.22)• Exposure to tobacco smoke in perinatal period (P96.81)• History of tobacco use (Z87.891)• Occupational exposure to environmental tobacco smoke

(Z57 31)

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(Z57.31)• Tobacco dependence (F17-) Tobacco use (Z72.0)


50 AAPC 1-800-626-CODE(2633)

J45.20 Mild intermittent asthma, uncomplicated

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.30 Mild persistent asthma, uncomplicated

J45.31 Mild persistent asthma with (acute) exacerbation

J45 32 Mild persistent asthma with status asthmaticusJ45.32 Mild persistent asthma with status asthmaticus

J45.40 Moderate persistent asthma, uncomplicated

J45.41 Moderate persistent asthma with (acute) exacerbation

J45.42 Moderate persistent asthma with status asthmaticus

J45.50 Severe persistent asthma, uncomplicated

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

J45.901 Unspecified asthma with (acute) exacerbation

J45.902 Unspecified asthma with status asthmaticus

J45.990 Exercise induced bronchospasm

J45.991 Cough variant asthma

J45.998 Other asthma

Intermittent Mild Persistent

Moderate Persistent

Severe Persistent

Symptoms 2 or less days per week

More than 2 days per week

Daily Throughout the day

NighttimeAwakenings

2 X’s per month or less

3-4 X’s per month

More than once per week but not nightly

Nightly

g yRescueInhaler Use

2 or less days per week

More than 2 days per week but not daily

Daily Several times per day

Interferencewith Normal activity

None Minor limitation

Somelimitation

Extremely limited

Lung Function FEVI >80% di t d d

FEVI >80% di t d

FEVI 60-80% di t d

FEVI less than 60% di t d

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predicted andnormalbetween exacerbations

predicted predicted 60% predicted


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Making a Successful Transition

• As shown in the preceding example providers will need to be educated on the codes towill need to be educated on the codes todocument the required components

• Coders will need to have a full understanding of A&P in order to understand the documentation and be able to assign the correct codes

59

and be able to assign the correct codes

Improved Example64 YO male here last 3 weeks ago for wheezing and cough. The MID and Prednisone worked great while on the meds, the first week was great, he is sleeping now through the night. He says he is better but not lik h f lt h th P d i H f l th P d i i th llike he felt when on the Prednisone. He feels the Prednisone is the onlything making him feel better over the last several months. He is having symptoms at least two days a week that interfere with his household tasks. He gets winded easily and finds that he has to sit and rest for a few minutes at a time. He feels like he was waking up at least three times a week with coughing and most weeks he is using his inhaler a couple of times a week. History: Patient is a former smokerExam: (refer to handout in your book)Assessment and Plan: Asthma, refills given on meds and patient educated on triggers. Pt to return following PFT or sooner if not any better. Singular 10 mg 1 po qd; Proair HFA 108 (90 bse) mcg/ac 2 puffs q4h prn; Orders: pulmonary function test


52 AAPC 1-800-626-CODE(2633)

Example

Patient presented to ED after the lumber he was hauling at home today splintered and lodged in hishauling at home today splintered and lodged in hisear. Using alligator forceps and under direct visualization I was able to remove a large splinter from the patients left external ear.

• ICD-10-CM code: S00 452A Superficial foreign body

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• ICD-10-CM code: S00.452A Superficial foreign bodyof the left ear, initial encounter

Example

• Review note on page 16 - What is missing f d t ti thi ?from documentation—anything?

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Prepare Now

• Perform documentation readiness l tievaluations

– Run a PM report of most frequently used codes in ICD-9-CM

– Pull charts to match– Ask two simple questions

63

p q• Is there enough documentation to assign an

ICD-10-CM code?• What education needs to be given?

Prepare Now

• Summarize your report• Continue ongoing providing evaluations

and support to physicians• Resources

– This step is important, if you don’t have them outsource!

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outsource!


54 AAPC 1-800-626-CODE(2633)

ICD-10-PCS

• Replaces current ICD-9-CM Vol. III codes• Used only for inpatient facility coding• Very logical precise code building process• Large learning curve

– Unique terms, definitions and skill requirements

65

requirements

ICD-10-PCS

• Originally released in 1998• Individual letters and numbers are called

values• Codes are all 7 characters in length• ICD-10-PCS coding is a process, not just

a numerical code assignment

66

a numerical code assignment• 34 different values for each possible code

character


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Structure

Character 1 SectionCh t 2 B d S tCharacter 2 Body SystemCharacter 3 Root OperationCharacter 4 Body PartCharacter 5 ApproachCharacter 6 Device

67

Character 6 DeviceCharacter 7 Qualifier

Structure

• Each character makes up unique code• Values are assigned to each character

- Numbers 0-9 are used and the alphabet- However, PCS does not use I or O

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56 AAPC 1-800-626-CODE(2633)

Learning PCS

• Hardest part is learning the new t i l d d l kterminology and code look up process

• Composed of 16 sections• Range from surgical procedures to

substance and abuse treatmentMost commonly used is 0 for surgical

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– Most commonly used is 0 for surgical

Sections1 Obstetrics2 Placement3 Administration4 Measurement and monitoring5 Extracorporeal assistance and

performance6 Extracorporeal therapies6 Extracorporeal therapies7 Osteopathic8 Other procedures9 Chiropractic


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Learning PCS

• The codes we use are built off of these t bltables

• To build a code you assign a character for each field

• Such as:0: Medical and Surgical (Character 1)

71

– 0: Medical and Surgical (Character 1)– 0: Central Nervous (Character 2)– 1: Bypass (Character 3)

Altering the route of passage of the contents of a tubular body part

Body PartCharacter 4

ApproachCharacter 5

DeviceCharacter 6

QualifierCharacter 7

6 CerebralVentricle

0 Open 7 Autologous TissueSubstituteJ Synthetic SubstituteK N t l

0 Nasopharynx1 Mastoid Sinus2 Atrium3 Bl d V lK Nonautologous

Tissue Substitute3 Blood Vessel4 Pleural Cavity5 Intestine6 Peritoneal Cavity7 Urinary Tract8 Bone MarrowB Cerebral Cisterns

U Spinal C l

0 Open 7 Autologous TissueS b tit t

4 Pleural Cavity6 P it l C it

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Canal SubstituteJ Synthetic SubstituteK NonautologousTissue Substitute

6 Peritoneal Cavity7 Urinary Tract9 Fallopian Tube


58 AAPC 1-800-626-CODE(2633)

Additional Characteristics

• Standardized terminology within the coding systemsystem

• Standardized level of specificity• No diagnostic information• No explicit “not otherwise specified” (NOS) code

options

73

• Limited use of “not elsewhere classified” (NEC) code options

Standardized Terminology

• Standardized terminology is not always user friendlyfriendly

• Procedures with eponyms or common procedure names can only be looked up by actual procedure– Confusing to coders used to this

Work with physicians and A&P will be important

74

– Work with physicians and A&P will be important


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Example

• The physician delivered a healthy 10 lb b b b i ll ith th fbaby boy vaginally with the use of vacuum suction due to the baby’s size…

• Completed code 10D07Z6Extraction of products of conception

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– Extraction of products of conception…

ICD-10-PCS

• Time and patience will be necessary to l thi di tlearn this coding system– Can be done!– Once you get it, the rest is easy– Practice, practice, practice

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60 AAPC 1-800-626-CODE(2633)

Conclusion

It’s no doubt that ICD-10-CM implementation ill b f th l t h t hitwill be one of the largest changes to hit

health care, but with proper timing and education success can be obtained.

77

Documents

What You Need to Know NOW! - AAPCstatic.aapc.com/3b7310d0-2751-4c51-8dd2-4cc34d8103...ICD-10-CM—What You Need to Know NOW! 2 AAPC 1-800-626-CODE (2633) code and the ICD code is used