ICD-10 & Friends Sampler

Resistance is futile Disclaimer

This presentation is brought to you by Harry Goldsmith, DPM who is solely responsible for its content and delivery so don’t complain to or blame the American Podiatric Medicine Association for any demonstrated insensitivity, poor judgment, unfunny jokes, puns that aren’t punny, or lack of taste. * Always check with individual payers for their policies and guidelines

Disclaimer

The APMA Coding Resource Center is wholly owned and operated by the American Podiatric Medical Association. It is partially sponsored by Mertz North America. Part of the proceeds from each subscription is contributed to the APMA Educational Foundation Student Scholarship Fund. I do not receive any payment for promoting the CRC. Nor am I on scholarship…

APMA Coding Resource Center

www.apmacodingrc.org

“59” Modifier Question

Distinct Procedural Service

• Modifier of last resort (i.e., use more specific modifiers if you can)

• Identifies the procedure(s) as being distinct and separate from other procedures performed the same date

“59” Modifier

• This modifier unbundles CCI or other global bundling edits

• The documentation must clearly evidence that the procedure or service was comprehensive, and not a component of another billed procedure

Introducing January 1, 2015

XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter.

XS - Separate structure, a service that is distinct because it was performed on a separate organ/structure.

XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner.

XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

The ICD-10 “Why” Question

 ICD-9 has been used  HIPAA regulations by the US for 35 years mandate the move to  ICD-9 has outgrown its ICD-10 intended level of  CMS announced it will specificity no longer support ICD-9  ICD-9 cannot  The rest of the world is reasonably moving toward ICD-11 accommodate new codes

The “Why” Question is no longer important

Timing

Less than 1 year away (again)

Transitioning Your Members

1. Someone in the office/group needs to be designated the ICD-10 “project manager”

2. Primary vendors need to be contacted and asked how ready they are for ICD-10

3. Practice major payers need to be contacted about signing up for ICD-10 “testing”

Transitioning Your Members

4. Your state should plan to put on (or contacting APMA for) ICD-10 workshops and learning sessions

5. Members need to begin (and complete) the crosswalking of existing ICD-9 codes used by the practice to ICD-10 codes

Crosswalking ICD-9 to ICD-10

Abrasion ankle, left

What’s the main term?

Crosswalking ICD-9 to ICD-10

Abrasion ankle, left

What’s the main term?

Crosswalking ICD-9 to ICD-10

1. Go to the ICD-10 Index to “Diseases & Injuries”

Crosswalking ICD-9 to ICD-10

1. Go to the ICD-10 Index to “Diseases & Injuries”

2. Look under “A” for “Abrasion”

Crosswalking ICD-9 to ICD-10

1. Search for “Abrasion”

Crosswalking ICD-9 to ICD-10

The Hyphen (or Dash) Educational Moment

A hyphen at the end of an ICD-10 indicates that additional characters are required

You will only see the hyphen on a code in the alphabetic index

Crosswalking ICD-9 to ICD-10

Underscore = Hyperlink Crosswalking ICD-9 to ICD-10

S90.51

Crosswalking ICD-9 to ICD-10 S90.51

Crosswalking ICD-9 to ICD-10

category S90.51

subcategory subcategory subcategory

Let the abrasion be on the right ankle

Crosswalking ICD-9 to ICD-10 S90.511

Let the abrasion be on the right ankle

Crosswalking ICD-9 to ICD-10 S90.511

Let the abrasion be on the right ankle

Crosswalking ICD-9 to ICD-10

5+ 6+ 7+

The “additional character indicator” box located in front of a code is a “hint” that you need one or more additional characters at the end to get to the code of highest specificity

Crosswalking ICD-9 to ICD-10 S90.511

Scrollup

Crosswalking ICD-9 to ICD-10 S90.511

“A” – Initial Encounter S90.511A

Don’t think “encounter” Think “episode of care” or “active treatment” or “phase of treatment”

“A” – Initial Encounter S90.511A

Used while the patient is receiving active treatment for a condition.

“A” – Initial Encounter

“Used while the patient is receiving active treatment for a condition.”

How is “active treatment” defined?

“A” – Initial Encounter S90.511A

Examples of active treatment are: surgical treatment, emergency department encounter, &evaluation and treatment by a new physician.

“A” – Initial Encounter S90.511A

Examples of active treatment are: surgical treatment, emergency department encounter, & evaluation and continued treatment by the same or a different physician. Huh?

“A” – Initial Encounter

There can only be one “initial” episode of care per doctor per condition

So, what is an initial episode of care?

In a hospital, an episode of care is from admission to discharge

“A” – Initial Encounter

Can more than one provider code a 7th character “A” during an episode of care?

A patient goes to the emergency department and the ED physician sees the patient, orders x-rays, has both an infectious disease specialist and a foot and ankle specialist do a consult in the ED, how many physicians get “A”s? …at least 4…

“D” – Subsequent Encounter S90.511D

“D” – Subsequent Encounter

“Used after the patient has received active treatment for the condition during the healing or recovery phase.”

When does active treatment end?

How do you define “healing phase”?

“D” – Subsequent Encounter S90.511D

Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury.

“A” & “D” – A Fly in the Ointment

Disclaimer – Best Current Interpretation

1. If you see a patient in the ED for the first time, it’s an “A” 2. If the patient is admitted and you round 3 times during the admission, it’s an “A” each time 3. If the patient is discharged from the hospital to your care and you see them in the office, it’s a “D” 4. If you reappoint and see the patient for follow-up care, it’s a “D”

“A” & “D” – A Fly in the Ointment

Disclaimer – Best Current Interpretation

5. If the patient was seen by a primary care physician in their office for an injury and then was referred to you for follow-up, the 1st time you see that patient for that condition, it’s an “A” 6. If there is no referral, but instead a patient calls your office and tells you they just twisted their ankle. You tell the patient to come to your office and you see them for the 1st time for that condition, it’s an “A” 7. When the patient returns for follow-up care, it’s a “D”

“A” & “D” – A Fly in the Ointment

Unanswered Questions

1. The “initial encounter” description is definite for “physician”, what about NPs, PAs, PTs, OTs, etc.? 2. If you belong to a podiatry supergroup (7 docs), and one of your partner’s patients with an established condition sees you because you are available, is that an “A” or “D” for you? 3. What if you happened to be a podiatrist in a small orthopedic group (65 docs), same scenario, is that an “A” or “D” for you? 4. Why did CDC/CMS make this so confusing?

“S” – Sequela

Sequela

Some Other Time Crosswalking ICD-9 to ICD-10

ICD-9 916.0 crosswalks to ICD-10 S90.511A (initial encounter)

Tada

Crosswalking ICD-9 to ICD-10

#2 Crosswalking ICD-9 to ICD-10

Crosswalking ICD-9 to ICD-10

ICD-9 355.6 crosswalks to ICD-10 G57.62 (neuroma, left “lower limb”)

Tada

Crosswalking ICD-9 to ICD-10

ICD-9 728.71 crosswalks to ICD-10 M72.2

Tada

Crosswalking ICD-9 to ICD-10

Tada

ICD-10 Educational Moment

“Not coded here” - mutually exclusive; can never occur at the same site along with the primary condition

ICD-10 Educational Moment

New Terms: Excludes1 Excludes2 Excludes1

“Not coded here” - mutually exclusive; can never occur at the same site along with the primary condition Excludes1

“Not coded here” - mutually exclusive; can never occur at the same site along with the primary condition Excludes2 Degenerative joint disease 1st metatarsal- phalangeal joint

“Not included here” – the excluded condition is not part of the condition represented in the primary code. An Excludes2 code can be coded with the primary code as long as it is occurring elsewhere. Whew

Workflow How are you going to manage your

workflow?

Workflow

• 273 codes for fractures of the calcaneus • 252 codes for fractures of the talus • 21 codes for unspecified tarsal bones • 42 codes for fractures of the cuboid • 42 codes for fractures of the lateral cuneiform • 42 codes for fractures of the intermediate cuneiform • 42 codes for fractures of the medial cuneiform • 42 codes for fractures of the navicular of the foot • 231 codes for fractures of the metatarsals • 147 codes for fractures of the great toe • 189 codes for fractures of the lesser toes • 42 codes for unspecified fractures of the foot and toe

That’s 1365 codes for just fractures in the foot.

Workflow

Change to read initial condition Link (R) and (L) to a specific or established condition diagnosis

Change this section to denote Rest of the space can be for specifics such as fracture misc. info information Back to Transitioning

6. Members should prepare because…

…it’s gonna cost something

to implement ICD-10

Bottom Line Preparation Costs?

AAPC Survey of 220 Members (vendor costs, education, consultants – but not including staff time training/education)

• Small practices (fewer than 10 providers) = $750 per provider • Medium practices (10 – 49 providers) = $575 per provider • Large practices (50 or more providers) = $3,500 per provider PMNews ICD-10 Poll (06-30-14)

Failing to Be Prepared

Back to Transitioning

7. Get to know the ICD-10 guidelines, conventions, and definitions now, not later…

APMA Coding Resource Center

www.apmacodingrc.org October 1, 2015

Thank you.

What? I have more time? ICD-10: Clinical Examples

ICD-10 Coding

Ms. Johnson presented to the office complaining of a painful bunion on the left foot. The exam revealed normal motion in the 1st metatarsal-phalangeal joint with pain reported on palpation and with shoewear.

X-rays confirm a bunion presence, hallux abductovalgus, and metatarsus primus adductus.

Main terms (diagnoses)?

ICD-10 Coding

X-rays confirm a bunion presence, hallux abductovalgus, and metatarsus primus adductus.

Diagnoses/Symptoms

1. hallux valgus, acquired, left 2. bunion, acquired, left 3. metatarsus primus adductus, left 4. pain, left

Diagnoses/Symptoms

1. hallux valgus, acquired, left 2. bunion, acquired, left 3. metatarsus primus adductus, left 4. pain, left

Coming to Terms: Hallux Valgus

Coming to Terms: Bunion

Coming to Terms: Hallux Abductus

Coming to Terms: Metatarsus Primus Adductus (Varus)

Coming to Terms: Pain

Diagnoses/Symptoms

1. hallux valgus, acquired, left 2. bunion, acquired, left 3. metatarsus primus adductus, left 4. pain, left

ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding hallux valgus, acquired, left

Diagnoses/Symptoms

1. M20.12 (hallux valgus, acquired, left) 2. bunion, acquired, left 3. metatarsus primus adductus, left 4. pain, left

ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding bunion, acquired, left

Diagnoses/Symptoms

1. M20.12 (hallux valgus, acquired, left) 2. M20.12 (bunion, acquired, left) 3. metatarsus primus adductus, left 4. pain, left

Diagnoses/Symptoms

1. M20.12 (hallux valgus, acquired, left) 2. M20.12 (bunion, acquired, left) 3. metatarsus primus adductus, left 4. pain, left

ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding Diagnoses/Symptoms

1. M20.12 (hallux valgus, acquired, left) 2. Q66.2 (metatarsus primus adductus, left) 3. pain, left

ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding ICD-10 Coding

pain in foot, left Diagnoses/Symptoms

1. M20.12 (hallux valgus, acquired, left) 2. Q66.2 (metatarsus primus adductus, left) 3. M79.672 (pain in foot, left)

Tada

October 1, 2015

Thank you.

Let’s Do Some Coding Diabetic Foot Ulcer

Ms. Green presents to the office with an ulcer, non- draining, sub2nd metatarsal right foot. The subcutaneous tissue is exposed. She is a type 2 diabetic with bilateral partial numbness of both feet. Diagnoses/Symptoms

1. Diabetes, type 2 2. Diabetic foot ulcer, right 3. Diabetic neuropathy bilateral

Diagnoses/Symptoms

1. Diabetes, type 2 2. Diabetic foot ulcer, right 3. Diabetic neuropathy bilateral

Guess What is the Greatest Change in ICD-10 Organization?

The coding of

diabetes mellitus ICD-9 & Diabetes

ICD-9 organizes diabetes under “Diseases of Other Endocrine Glands (249-250) under these categories: • Secondary diabetes (Type 0, 1, 2, 3) (Category 249) • Diabetes (Type 0, 1, 2, 3) (Category 250) Subcategories (4th character) Without mention of complications With ketoacidosis With hyperosmolarity With other coma With renal manifestations With ophthalmic manifestations With neurological manifestations With peripheral circulatory disorders With other specified manifestations ICD-9 & Diabetes

ICD-10 organizes diabetes under “Diabetes Mellitus (E08- E13) under these categories:

• Diabetes mellitus due to underlying condition (E08) • Drug or chemical induced diabetes mellitus (E09) • Type 1 diabetes mellitus (E10) • Type 2 diabetes mellitus (E11) • Other specified diabetes mellitus (E13)

ICD-10 & Diabetes

ICD-10 organizes diabetes under “Diabetes Mellitus (E08- E13) under these categories:

Diabetes: Type 1 (E10) Diabetes: Type 2 (E11) Diabetic Foot Ulcer

Back to our scenario Diabetic Foot Ulcer

1. Diabetes, type 2 2. Diabetic foot ulcer, right 3. Diabetic neuropathy bilateral

Diabetic Foot Ulcer Diabetic Foot Ulcer Diabetic Foot Ulcer

Alternative look-up

Diabetic Foot Ulcer Diabetic Foot Ulcer Diabetic Foot Ulcer Diabetic Foot Ulcer Combination Code

E11.621 combines • Diabetes • Diabetes, type 2 • Diabetic foot ulcer into one code

Diagnoses/Symptoms

1. E11.621 (diabetes, type 2, diabetic foot ulcer) 2. Diabetic foot ulcer, right 3. Diabetic neuropathy bilateral

Diabetic Foot Ulcer Diagnoses/Symptoms

1. E11.621 (diabetes, type 2, diabetic foot ulcer) 2. Diabetic foot ulcer, right (L97.4-; L97.5-) 3. Diabetic neuropathy bilateral

Diabetic Foot Ulcer

“…sub2nd metatarsal right foot. The subcutaneous tissue is exposed…” Diabetic Foot Ulcer

“…sub2nd metatarsal right foot. The subcutaneous tissue is exposed…” Diabetic Foot Ulcer Diabetic Foot Ulcer

 Diabetic Foot Ulcer, 2nd Met Right Diabetic Foot Ulcer, 2nd Met Right Diagnoses/Symptoms

1. E11.621 (diabetes, type 2, diabetic foot ulcer) 2. L97.512 (foot ulcer, subcutaneous tissue exposed, right – non-decubitus) 3. Diabetic neuropathy bilateral

Diagnoses/Symptoms

1. E11.621 (diabetes, type 2, diabetic foot ulcer) 2. L97.512 (foot ulcer, subcutaneous tissue exposed, right – non-decubitus) 3. Diabetic neuropathy bilateral

Diabetic Neuropathy, Bilat Diabetic Neuropathy, Bilat Diabetic Neuropathy, Bilat Diabetic Neuropathy, Bilat Diabetic Neuropathy, Bilat Diagnoses/Symptoms

1. E11.621 (diabetes, type 2, diabetic foot ulcer) 2. L97.512 (foot ulcer, subcutaneous tissue exposed, right – non-decubitus) 3. E11.42 (diabetic neuropathy bilateral)

Tada

Let’s Do Some Coding Decubitus Ulcer

Mr. Smith had not been seen in 8 months. He had just been released from the hospital for treatment of congestive heart failure when his doctor notice a decubitus [pressure] ulcer of the left heel.

Examination confirmed a stage 3 decubitus ulcer of the left heel.

Decubitus Ulcer

Stage 3 Decubitus Ulcer, Left Heel

Main term?

Decubitus Ulcer

Stage 3 Decubitus Ulcer, Left Heel

Main term?

Decubitus Ulcer, Left Heel Decubitus Ulcer, Left Heel Decubitus Ulcer, Left Heel Decubitus Ulcer, Left Heel Decubitus Ulcer, Left Heel Unspecified ICD-10 Educational Moment

Defining

“Unspecified” & “Other” Unspecified

Unspecified means that there is not enough information in the medical record to assign a more specific ICD-10 code

Example:

You forgot to note which ankle was sprained in your medical record

Other

Other means the medical record details a condition, illness, diagnosis, or a place of occurrence that doesn’t have an existing ICD-9 or 10 code Example: What did CMS crosswalk sesamoiditis to?

osteomyelitis

Correct code?

M77.8 Other enthesopathies, not elsewhere classified

Pressure Ulcer, Left Heel Pressure Ulcer, Left Heel, Stage 3 Diagnoses/Symptoms

1. L89.623 (pressure ulcer of left heel, stage 3) Tada

Let’s Do Some Coding Infected Ingrown Nail

Chief Complaint My toe is swollen and painful.

Infected Ingrown Nail

History of Present Illness: The patient who is an 18 year old male presents to the office with a swollen right great toe along the medial nail fold. There is a drainage present coming from the end of the toe. The patient says the site is painful (7/10, 10 being worse). The swelling has been present for 6 days; the drainage for about 2 days. The patient attempted to self-treat using nail clippers, but thinks he made it worse. He has been soaking, occasionally, the foot in warm water. He is unable to wear enclosed shoes because of the swelling and pain. Infected Ingrown Nail

Examination: Dermatology - a swollen right great toe along the medial aspect of the nail fold; there is redness not just around the nail fold but extending 2-3 cm proximal to the metatarsal-phalangeal joint area; there is a pus- like drainage present subungual distal medial nail; the nail appears severely incurvated distally and somewhat loose at its distal, medial portion. Infected Ingrown Nail

Diagnoses:

1. Infection, hallux right 2. Abscess, hallux right 3. Cellulitis, hallux right 4. Ingrown nail, hallux right 5. Pain, hallux right Infected Ingrown Nail, Right Hallux

Treatment:

1. Partial nail avulsion 2. Incision & drainage of abscess 3. Culture 4. Instructions of home self-care 5. Return to office in 4 days CPT Coding

CPT 1. CPT 9920x (E/M service; new patient)* 2. CPT 11730-T5

For non-Medicare payers, add a “-25” modifier on the E/M code

Infected Ingrown Nail, Right Hallux

Diagnoses:

1. Infection, hallux right 2. Abscess, hallux right 3. Cellulitis, hallux right 4. Ingrown nail, hallux right 5. Pain, hallux right Infected Ingrown Nail, Right Hallux

Diagnoses:

1. Infection, hallux right 2. Abscess, hallux right 3. Cellulitis, hallux right 4. Ingrown nail, hallux right 5. Pain, hallux right Infection, Right Hallux Infection, Right Hallux Infection, Right Hallux Infection, Right Hallux Infection, Right Hallux Infection, Right Hallux Infected Ingrown Nail, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. Abscess, hallux right 3. Cellulitis, hallux right 4. Ingrown nail, hallux right 5. Pain, hallux right Abscess, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. Abscess, cellulitis, hallux right 3. Ingrown nail, hallux right 4. Pain, hallux right Abscess, Right Hallux Abscess, Right Hallux Abscess, Right Hallux Abscess, Right Hallux Abscess, Right Hallux Abscess, Right Hallux Abscess, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. L02.611 (abscess, right foot) 3. Cellulitis, hallux right 4. Ingrown nail, hallux right 5. Pain, hallux right Abscess, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. L02.611 (abscess, hallux right) 3. Cellulitis, hallux right 4. Ingrown nail, hallux right 5. Pain, hallux right Cellulitis, Right Hallux Cellulitis, Right Hallux Cellulitis, Right Hallux Cellulitis, Right Hallux Cellulitis, Right Hallux Cellulitis, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. L02.611 (abscess, right foot) 3. L30.031 (cellulitis, right toe) 4. Ingrown nail, hallux right 5. Pain, hallux right Cellulitis, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. L02.611 (abscess, right foot) 3. L30.031 (cellulitis, right toe) 4. Ingrown nail, hallux right 5. Pain, hallux right Ingrown Nail, Right Hallux Ingrown Nail, Right Hallux Ingrown Nail, Right Hallux Ingrown Nail, Right Hallux Ingrown Nail, Right Hallux Infected Ingrown Nail, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. L02.611 (abscess, right foot) 3. L30.031 (cellulitis, right toe) 4. L60.0 (ingrown nail) 5. Pain, hallux right Infected Ingrown Nail, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. L02.611 (abscess, right foot) 3. L30.031 (cellulitis, right toe) 4. L60.0 (ingrown nail) 5. Pain, hallux right Infected Ingrown Nail, Right Hallux

Diagnoses:

1. L08.89 (infection) 2. L02.611 (abscess, right foot) 3. L30.031 (cellulitis, right toe) 4. L60.0 (ingrown nail) Tada

4 Days Later…

Back to our patient

Office Visit Follow-Up (Day 4)

Chief Complaint: Toe is infected History of Present Illness: Doing much better; no more drainage in the right hallux; swelling better, able to wear shoes. Right hallux color improved. Pain 0-1/10, occasionally present Patient taking antibiotics and keeping a Band-Aid on the toe.

Culture returned: staph aureus (methicillin susceptible) Office Visit Follow-Up (Day 4)

Treatment: 1. Continue antibiotics 2. Instructions of home self-care 3. Call office if not continuing to improve; RA prn Office Visit Follow-Up (Day 4)

Diagnoses:

1. Infection, right hallux 2. Staph aureus Office Visit Follow-Up (Day 4)

Diagnoses:

1. Infection, right hallux 2. Staph aureus Office Visit Follow-Up (Day 4)

Diagnoses:

1. L08.89 (infection) 2. Staph aureus Infection, Right Hallux Infection, Right Hallux Follow-Up Ingrown Nail Office Visit Follow-Up (Day 4)

Diagnoses:

1. L08.89 (infection) 2. B95.61 (staph aureus) Office Visit Follow-Up (Day 4)

Diagnoses:

1. L08.89 (infection) 2. B95.61 (staph aureus) Tada

Let’s Do Some Coding Neoplasm of the Skin

37 year old female presents with a 6 month awareness of a somewhat raised pigmented lesion of the anterolateral aspect of the left leg. No unrecognized injury. No itching. No bleeding. No bruising. No recent increase in geographic size, nodularity.

Neoplasm of the Skin

Examination: Fair complexion, red hair, some freckles. The lesion in question is a 6mm in diameter, slightly raised nodule, with symmetry, left leg. No unusual notching. No marginal halo of erythema. No necrosis. No irregularity of coloration. Upon careful examination of both lower extremities, no other rashes or lesions were encountered. Neoplasm of the Skin, Left Leg

Impression: • Neoplasm of skin, perhaps benign

ICD-9 239.2 (neoplasm of unspecified nature; bone, soft tissue, skin)

NOTE: Neoplasms include growth and tumor. A “mass” is not considered a neoplasm.

Uncertain Behavior versus Unspecified Nature • Neoplasm of uncertain behavior is one whose behavior cannot be predicted – transitional, neither benign nor malignant. This term is applied by the pathologist who can’t make the call…yet.

• Neoplasm of unspecified behavior is one whose nature is currently unknown to the doctor. More work-up is need. Can be a “working diagnosis until the lab reasons are received.

Neoplasm of the Skin, Left Leg

Looking for lower leg or lower limb

Neoplasm of the Skin, Left Leg

D23.7- Neoplasm of the Skin, Left Leg

Neoplasm of the Skin, Left Leg

Diagnoses:

1. D23.72 (neoplasm, skin, lower leg, benign, left) Neoplasm of the Skin, Left Leg

Neoplasm of the Skin, Left Leg

Diagnoses:

1. D23.72 (neoplasm, skin, lower leg, benign, left) or 2. D49.2 (neoplasm of unspecified behavior of bone, soft tissue, skin) Neoplasm of the Skin, Left Leg

When the path report comes back… Tada

Let’s Do Some Coding Post Operative Infection

Ms. Scott is a 48 year old female who returned to the office 4 weeks post open reduction internal fixation of the left ankle. She is complaining of drainage from the open wound at the surgical site. Surgical site is gapping. She denies constitutional symptoms. Bone is not infected.

Post Operative Infection

Diagnoses: 1. Infection, left ankle, post operative 2. Dehiscence, surgical site, left ankle

Post Operative Infection

Diagnoses: 1. Infection, left ankle, post operative 2. Dehiscence, surgical site, left ankle

Post Operative Infection

Search Approach: 1. Infection, postoperative 2. Complication, surgical

Post Operative Infection

Diagnoses: 1. T81.4xxA (infection, post operative) 2. Dehiscence, surgical site, left ankle

Post Operative Infection

Dehiscence, Left Ankle

Diagnoses: 1. T81.4xxA (infection, post operative) 2. Dehiscence, surgical site, left ankle

Dehiscence, Left Ankle

Diagnoses: 1. T81.4xxA (infection, post operative) 2. T81.31xA (dehiscence, surgical site)

Dehiscence, Left Ankle

Diagnoses: 1. T81.4xxA (infection, post operative) 2. T81.31xA (dehiscence, surgical site)

Tada

Let’s Do Some Coding ICD-10: Give Me a Break

Mr. Jones, weekend athlete, hit one through the gap. Rounding 1st base, he picked up speed knowing the play was going to be close at second. Out of the corner of his eye he saw the right fielder release the ball. Mr. Jones slid into the bag with his right foot. Good news: He was safe. Bad news: He ‘heard’ a crack and now has a limp and a painful foot and ankle ICD-10: Give Me a Break

Mr. Jones was diagnosed with

1. Closed fracture, non-displaced, base of the 5th metatarsal right foot 2. Ankle sprain, anterior talofibular ligament, right Closed fracture, non-displaced, base of the 5th metatarsal right foot

What is the main term? Closed fracture, non-displaced, base of the 5th metatarsal right foot

Closed fracture, non-displaced, base of the 5th metatarsal right foot

S92.354A ICD-10: Give Me a Break

Mr. Jones was diagnosed with

1. Closed fracture, non-displaced, base of the 5th metatarsal right foot 2. Ankle sprain, anterior talofibular ligament, right Ankle sprain, anterior talofibular ligament, right

What is the main term? Ankle sprain, anterior talofibular ligament, right

Ankle sprain, anterior talofibular ligament, right

ICD-10: Give Me a Break

Diagnoses

1. S92.354A (nondisplaced fracture of the 5th metatarsal base, right foot, closed) 2. S93.491A (sprain of other ligament, right ankle)

So, are you done? Almost

Fracture, 5th metatarsal and ankle sprain, right

Oh, yeah, the injury occurred on a baseball field, didn’t it?

Y92.320 – Baseball field as the place of occurrence of the external cause

Place of Occurrence Codes (Y92-)

1) Billed only once – at the initial encounter for treatment Place of Occurrence Codes (Y92-)

1) Billed only once – at the initial encounter for treatment 2) Billed with an event or activity code (Y93-) e.g., clothing caught fire while burning household trash in backyard of home, causing burn

W03.0xxA + X06.2xxA + Y92.096 + Y93.E9 + Y99.8 Activity Code (Y93-) Activity Code (Y93-) ICD-10: Give Me a Break

Diagnoses

1. S92.354A (fractured 5th metatarsal right) 2. S93.491A (sprained ATF ligament right) 3. Y93.64 (playing baseball) 4. Y92.320 (baseball field)

So, are you done? Yes

Whew

Let’s Do Some Coding Post Matrixectomy Pain

Ms. Grove had a matrixectomy (phenol type, left hallux) performed 2 weeks previously. She had been doing well until, according to her, the left big toe began to throb and become very tender yesterday.

Examination revealed mild redness, slight swelling around the site of the matrixectomy.

Post Matrixectomy Pain

The left hallux was anesthetized proximally and the foot was prepped. A sterile curette was used to debride dried exudate and schmutz from the nail groove allowing clear fluid to drain.

Post Matrixectomy Pain

How are you going to bill this? • CPT 9921x E/M service? • CPT 10060 I&D of abscess? • CPT 10061 I&D of abscess complicated? • CPT 10140 I&D of fluid collection? • CPT 10160 Puncture aspiration bulla? • CPT 10180 I&D, complex, post op wound infect. • Other: ______

Post Matrixectomy Pain

How are you going to bill this? • ICD-10 L02.612 (cutaneous abscess left foot)? • ICD-10 R60.9 (edema, unspecified)? • ICD-10 L98.8 (bulla)? • ICD-10 M79.675 (pain, left toe)? • Other: ______

Post Matrixectomy Discharge

What if the patient returns 2 weeks post matrixectomy and everything is fine – no local swelling, no drainage, no pain, normal color, no limitation…? How are you going to bill this?

CPT 9921x?

What about the ICD-10 code?

ICD-10 Educational Moment

Meet the “Z” Codes ICD-10: “Z” Codes

Factors influencing health status and contact with health services (Z00-Z99)

Z00-Z99 codes are provided for encounters when circumstances other than a specific disease, injury or external cause (i.e., other than A00-Y89 codes) are needed to be recorded as ‘diagnoses’ or ‘problems’ ICD-10: “Z” Codes

Factors influencing health status and contact with health services (Z00-Z99) Circumstances to Use “Z” Codes 1. Person is not currently sick, but has a healthcare encounter for some other reason

2. When circumstances or problems influence a person’s health status but are not in themselves a current illness or injury

ICD-10: “Z” Codes

Factors influencing health status and contact with health services (Z00-Z99) Circumstances to Use “Z” Codes 3. For newborns, to indicate birth status

4. Person is resolving disease or injury or has a chronic, long-term condition requiring continuous care has a healthcare encounter for specific aftercare of that disease or injury

ICD-10: “Z” Codes

Factors influencing health status and contact with health services (Z00-Z99) Circumstances to Use “Z” Codes 3. For newborns, to indicate birth status

4. Person is resolving disease or injury or has a chronic, long-term condition requiring continuous care has a healthcare encounter for specific aftercare of that disease or injury

ICD-10: “Z” Codes

Factors influencing health status and contact with health services (Z00-Z99)

You could use these codes…

When a person who may or may not be sick encounters the health services for some specific purpose, such as to discuss a problem which is in itself not a disease or injury.

ICD-10: “Z” Codes

Factors influencing health status and contact with health services (Z00-Z99) Key documentation terms to look for

Aftercare Attention to

Counseling Encounter for Examination Fitting History of Maintenance Observation Presence of Problem Replacement Screening Status post ICD-10: “Z” Codes

Factors influencing health status and contact

with health services (Z00-Z99) Examples Z48.817 – encounter for surgical aftercare following surgery on the skin and subQ tissue Z96.698 – presence of other orthopedic joint implants Z98.89 – (status) other specified postprocedural states Inclusion Term: personal history of surgery, NEC

ICD-10: “Z” Codes

Factors influencing health status and contact

with health services (Z00-Z99) Z91.81 – history of falling Z16.32 – resistance to antifungal drug(s) Z00.00 – encounter for adult medical examination without abnormal findings Z00.01 – encounter for adult medical examination with abnormal findings Z46.89 – encounter for fitting and adjustment of other specified devices (orthotics)

ICD-10: “Z” Codes

Guidelines for “Z” Code Use

• Z codes represent reasons for encounters that occur without complaints, injuries, symptoms, etc.

• Z codes may be used either as the first-listed diagnosis code or as the secondary diagnosis code

• If a patient comes in for a screening exam and an abnormal is found, code the abnormality second ICD-10: “Z” Codes

Guidelines for “Z” Code Use

• When reporting a category Z16 (resistance to antimicrobial drugs), code first the infection Example: B95.2 (enterococcus) Z16.21 (resistance to vancomycin)

Post Matrixectomy Discharge

Z98.89 – (status post) other specified postprocedural states Tada

More Examples?

Let’s Do Some Coding

Routine Foot Care Diagnoses Routine Foot Care

Chief Complaint: “Need my nails trimmed.”

History of Present Illness: Patient, type II, diabetic with good control. She has +1 dorsalis pedis pulses bilateral; +2 posterior tibial pulse right; +1 posterior tibial pulse left. Her skin exam notes decreased hair bilaterally, long thickened yellow nails, and atrophic (thinning) of skin. There is a corn dorsal 5th right; IPK subtibial sesamoid left. She has mild bilateral swelling in the ankles. Neuro: unremarkable. The patient has no reported complaints at this time. She has returned for her regular nail care. Routine Foot Care

Chief Complaint: “Need my nails trimmed.”

History of Present Illness: Patient, type II diabetic with good control. She has +0/4 dorsalis pedis pulses bilateral; +2/4 posterior tibial pulse right; +0/4 posterior tibial pulse left. Her skin exam notes decreased hair bilaterally, long thickened yellow nails, and atrophic (thinning) of skin. There is a corn dorsal 5th right; IPK subtibial sesamoid left. She has mild bilateral swelling in the ankles. Neuro: unremarkable. The patient has no reported complaints at this time. She has returned for her regular nail care. Routine Foot Care

Pertinent Information

• No pulses on the left foot; +2/4 posterior tibial pulse right foot • Long thicken yellow nails • Corn dorsal 5th right • Callus subtibial sesamoid left.

Routine Foot Care

Diagnoses

• Diabetes, type 2 • Peripheral vascular disease • Mycotic Nails • Corn, dorsal 5th right • Callus subtibial sesamoid left Let’s Look It Up

Answer

• E11.51 (Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene)

• L84 ( Corns and calluses)

• B35.1 (Onychomycosis)

Let’s Do Some Coding

Neuroma Neuroma

A patient complains of having to stop after walking a half a block because of radiating pain between the 2nd and 3rd toes of the right foot. After rubbing the site, the pain goes away.

Neuroma

Diagnosis

• Neuroma, Morton’s type, 2nd webspace, right foot

Let’s Look It Up

Answer

• G57.61 (Lesion of plantar nerve, right lower limb) or • G57.81 (Other specified mononeuropathies, lower limb; e.g., interdigital neuroma of lower limb)

Let’s Do Some Coding

Tinea Pedis Tinea Pedis (Athlete’s Foot)

After several weeks of chronic itching on the bottom of her feet, Ms. Jones decided to see her podiatrist. There was scaly dryness present. Mild redness.

Tinea Pedis (Athlete’s Foot)

Diagnosis

• Tinea pedis, bilateral Let’s Look It Up

Answer

• B35.3 (tinea pedis)

Let’s Do Some Coding

Foreign Body Foreign Body

Working on a housing construction site, Mr. Smith stepped on a nail sticking out of a board. When he saw the doctor, x-rays revealed residual nail in the left foot.

Foreign Body

Diagnoses

• Puncture wound, left foot • Foreign body, metallic, left foot

Let’s Look It Up

Answer

• S91.342 (Puncture wound with foreign body, left foot)

• Z18.12 (Retained nonmagnetic metal fragments)

• Y92.H3 (Activity involving building and construction)

• Y92.61 (Building under construction as the place of occurrence of the external cause)

Let’s Do Some Coding

Retrocalcaneal Bursitis Retrocalcaneal Bursitis

A patient complaining of pain in the back of the left heel, especially with prolonged walking. Exam reveals local swelling and a “sponginess” in the area with light compression.

Retrocalcaneal Bursitis

Diagnosis

• Retrocalcaneal bursitis, left heel

Let’s Look It Up

Retrocalcaneal Bursitis

Is it: Achilles bursitis? M76.62 Retrocalcaneal bursitis? M76.62 Calcaneal bursitis? M77.52 Enthesopathy of ankle, other? M77.52 Other bursal cyst, left ankle/foot? M71.372

Answer

• M76.62 (Achilles tendinitis, left leg) Inclusion Term: Achilles bursitis Let’s Do Some Coding

Ganglion Ganglion

Pre-op diagnosis: ganglion, dorsum left foot

In the operating room, deep dissection noted a ganglion cyst appearing to originate from within the underlying metatarsal-cuneiform joint, left foot.

Ganglion

Diagnosis

• Ganglion, left foot Let’s Look It Up

Answer

M67.472 (ganglion, left ankle and foot) Inclusion Term: Ganglion of joint or tendon (sheath)

Let’s Do Some Coding

Ganglion Cysts, Multiple Ganglion

Pre-op diagnosis: ganglion x2, left foot

In the operating room, deep dissection noted a ganglion cyst originating from the 1st metatarsal- cuneiform joint and a ganglion originating from the extensor tendon sheath overlying the great toe, left foot.

Ganglion

Diagnosis

• Ganglion cysts x2, left foot Let’s Look It Up

Answer

• M67.49 (ganglion, multiple sites) Inclusion Term: Ganglion of joint or tendon (sheath)

Let’s Do Some Coding

Rheumatoid Arthritis Rheumatoid Arthritis

Mr. Lowe, a patient with a known history of rheumatoid polyneuropathy, is also diagnosed to have rheumatoid arthritis of the right ankle and foot.

Rheumatoid Arthritis

Diagnosis

• Polyneuropathy, rheumatoid • Rheumatoid arthritis, right ankle and foot Let’s Look It Up

Answer

• M05.571 (rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot) Inclusion Term: Rheumatoid polyneuropathy with rheumatoid arthritis, tarsus, metatarsus and phalanges

Let’s Do Some Coding

Sesamoid Fracture Sesamoid Fracture

Falling off a ladder at home, Mr. Home Depot experienced a sharp pain in the ball of his left foot. Examination revealed a non-displaced tibial sesamoid fracture.

Sesamoid Fracture

Diagnosis

• Fracture, non-displaced sesamoid, left foot Let’s Look It Up

The long way

Answer

• S82.892 (other fracture of left lower leg)

Let’s Do Some Coding

Your turn… October 1, 2015

Thank you.

ICD-10 Coding ICD-10 Educational Moment

SEQUELA “S” – Sequela Encounter

Sequela – a “late effect” – a residual condition (unplanned; complication) that remains or occurs after the acute phase of an injury or illness.

“S” – Sequela Encounter

Acute phase of an injury or illness – defined as the immediate post-injury healing processes; typically the first 48-72 hours after an injury

“S” – Sequela Encounter

So a sequela (a “late effect”) is a residual condition (unplanned; complication) that remains or occurs any time after 48-72 hours post-injury or illness.

“S” – Sequela Encounter

Examples of Sequela • Keloid post laceration • Joint contracture post fracture near joint • Scarring post burn • Traumatic arthritis due to old fracture

“S” – Sequela Encounter

Surgical complications are not sequela

“S” – Sequela Encounter

Sequela Hint: Documentation Phrases • Late • Old • Due to previous injury or illness • Following previous injury or illness

How Do You Code a Sequela?

You need 2 codes in a specific order:

1. Code the problem the patient is now presenting that resulted from an old injury or illness (the “consequence” due to…)

2. Code the old injury or illness with an “S” as the 7th character

Sequela Example

A patient was referred to you with pain in her right ankle. She has no history of recent trauma, but 4 years ago, she fractured her right ankle (non-displaced fracture lateral malleolus). X-rays reveal arthritic changes to the right ankle.

Impression: arthritis, right ankle; pain

Main term?

Sequela Example

Impression: arthritis, right ankle; pain

Main term?

Arthritis, Post Trauma, Right

Late Effect – Current Problem

M19.171 (post-traumatic osteoarthritis, right ankle and foot)

would be coded first

Arthritis, Post Trauma, Right

Late Effect – Current Problem

M19.171 (post-traumatic osteoarthritis, right ankle and foot)

would be coded first

ICD-10 Educational Moment

ICD-10 defines “and” as

1. and 2. or 3. and/or Arthritis, Post Trauma, Right

Late Effect – Current Problem

M19.171 (post-traumatic osteoarthritis, right ankle) would be coded first ______

Next code…the injury that caused the late effect

The Cause of the Chief Complaint

“The reason the patient is being see is ‘due to’….”

Impression: arthritis, right ankle; pain

Main term?

The Cause of the Chief Complaint

“The reason the patient is being see is ‘due to’….”

Impression: arthritis, right ankle; pain

Main term?

Sequela: Fracture, lateral malleolus, right Sequela: Fracture, lateral malleolus, right Sequela: Fracture, lateral malleolus, right Sequela: Fracture, lateral malleolus, right Sequela: Fracture, lateral malleolus, right Sequela: Fracture, lateral malleolus, right Sequela: Fracture, lateral malleolus, right

S82.64 Sequela: Fracture, lateral malleolus, right

S82.64_ _ 6th 7th The 6th Character

S82.64_ _ 6th The Dummy “x” Placeholder

When the highest level of coding specificity requires a certain number of characters and the code’s 4th, 5th, and/or the 6th character positions are empty, you use the letter “x” to serve as a “placeholder” - filling in the blank for a “not yet assigned” (future expansion) character. In our example,

S82.64_ _ 6th 7th

The Dummy “x” Placeholder

S82.64x _ 6th 7th

The Dummy “x” Placeholder

The 7th Character

S82.64x _ 6th 7th The 7th Character The Sequela Code

S82.64xS Nondisplaced fracture of the lateral malleolus, right fibula, sequela

Sequela: Fracture, lateral malleolus, right

Back to our ankle joint arthritis (the late effect) and cause of the late effect (previous fracture) coding Sequela: Fracture, lateral malleolus, right

Late Effect – Current Problem

M19.171 (post-traumatic osteoarthritis, right ankle) would be coded first ______

“The Cause”

S82.64xS (non-displaced fracture, lateral malleolus, right fibula) would be coded second

Tada

ICD-10 Coding