9/27/2015
DISCLOSURE ICD-10-CM IS HERE: Kim Pollock, RN, MBA, CPC, CMDP ARE YOU • Employee of KarenZupko & Associates, Inc., a physician practice management consulting company READY?! that helps physicians with practice management issues including improving revenue, decreasing Sponsored by: Presented by: SOHN’s 39th Annual Congress and Nursing Symposium Kim Pollock expenses, streamlining processes and reducing risk. “ORL Nursing: The New Frontier” RN, MBA, CPC, CMDP Dallas, Texas • Does not receive compensation for sales of KZA Tuesday, September 29, 2015 products or any recommended products/services.
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WHEN TO USE WHICH CODES
• Do not BILL ICD-10 Codes for a date of service prior to October 1, 2015. • Do PRECERT ICD-10 codes for a date of service October 1, 2015 and later. • Do not BILL ICD-9 codes for a date of service after September 30, 2015 (unless payer does not accept ICD-10). • ALERT: Claims cannot contain both ICD-9 codes and ICD-10 codes. • E/M inpatient care crossing September 30-October 1? Split the claims so the services prior to October 1, 2015 are billed with ICD-9 codes are on a separate claim.
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WHAT IS ICD-10-CM? WHY ARE WE CHANGING?
• International Classification of Diseases, 10th • ICD-9-CM is out of date and running out Revision, Clinical Modification. of space for new codes. • We are currently using ICD-9-CM. • ICD-10-CM is the international standard to • Codes are used to calculate MS-DRG payments. report and monitor disease and mortality – USA must adopt for reporting and • Compile statistics. surveillance. • Already being used in 138 countries for • ICD codes are core elements of many health mortality reporting, 99 countries for morbidity. information technology systems making the US implemented for mortality on 1/1/99. conversion to ICD-10-CM necessary to fully • Other countries use ICD-10 for reimbursement realize benefits of HIT adoption. or case mix: UK, Denmark, Finland, Iceland, ICD-10-CM Norway, Sweden, France, Australia, Belgium, IMPLEMENTATION DATE: • It’s mandated by CMS for all HIPAA-covered Germany, Canada. OCT 1, 2015 entities!!
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POPULAR IN 1979… FORMAT OF ICD-9-CM VS. ICD-10-CM
•9 Sony introduced the Sony Walkman costing $200. ICD-9-CM ICD-10-CM • Atari 400, one of the earliest 3-5 characters in length 3-7 characters in length home computer systems, was high tech. 1st digit may be alpha, but is usually Character 1 is alpha; character 2 is always numeric; characters 3-7 can are either • Record players were all the rage. numeric; 2nd-5th is numeric alpha or numeric • Gloria Gaynor topped the Approximately 14,000 codes Approximately 69,000 codes charts with “I Will Survive”. Limited space for adding new codes Flexible for adding new codes Lacks laterality Has laterality Sources: http://www.thepeoplehistory.com/1979.html http://en.wikipedia.org/wiki/File:WalkmanTPS-L2.jpg http://en.wikipedia.org/wiki/File:Atari-400-Comp.jpg http://en.wikipedia.org/wiki/File:Romanian_pickup1.jpg http://en.wikipedia.org/wiki/File:I_Will_Survive_Gloria_Gaynor.jpg
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FORMAT OF ICD-9-CM VS. ICD-10-CM FORMAT OF ICD-9-CM VS. ICD-10-CM
Major Differences between ICD-9-CM and ICD-10-CM ICD-9-CM Code Structure ICD-10-CM Code Structure • Laterality (right, left, bilateral) for many diagnoses • Combination codes for certain conditions, common associated symptoms, poisonings and associated external cause • Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character). • Inclusion of clinical concepts that did not exist in ICD-9-CM. • Codes expanded (e.g., injuries, postoperative complications). • Injuries grouped by anatomical site rather than type of injury.
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ICD-10: 3 VOLUMES PLACEHOLDER “X”
13 ICD-10 has Three Volumes (but two types of codes) “X” placeholder is used I: Tabular List of ICD-10-CM is a structured list of codes divided to provide room for into chapters based on body system or condition. future expansion II: Alphabetic Index of ICD-10-CM is an alphabetical list of terms and their corresponding code. This volume is actually listed first in the book. “X” placeholder is used to keep III. Procedures (ICD-10-PCS) applicable 7th character in the 7th • Physicians will not use this code set for professional claims; hospitals and facilities use these codes to describe position when the code is less than procedures performed. 6 characters long. 13 14
PLACEHOLDER “X” FOR FUTURE PLACEHOLDER “X” EXPANSION
15 • H66.3X- Other chronic suppurative otitis media “X” placeholder is used to provide room for future o H66.3X1 Right ear expansion. o H66.3X2 Left ear
o H66.3X3 Bilateral o H66.3X9 Unspecified ear “X” placeholder is used to keep applicable 7th character in the 7th position when the code is less than 6 characters long. 15 16
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7TH CHARACTER EXTENSION AND 7TH CHARACTER EXTENSION AND “X” PLACEHOLDER “X” PLACEHOLDER
The Tabular List will note how many characters are required for a code to be Some codes require a 7th character to be added valid. √ 7th T17.220 Food in pharynx causing asphyxiation for a complete, valid code. When seeing this √ 7th character notation, the applicable seventh character options will be at the code category level and must be appended to report a valid code. Remember not all codes are seven characters. Seventh character extensions are not the same for all code categories as There are valid three, four, five and six character codes. noted by the two examples below. T17 Foreign Body In Respiratory Tract Pertinent codes for otolaryngology that require a seventh The appropriate 7th character is to be added to each code from category T17. character mainly fall into injury categories including: A = initial encounter open wounds, fractures, foreign bodies and certain D = subsequent encounter S = sequela complications. T17.220A Food in pharynx causing asphyxiation, initial encounter
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7TH CHARACTER EXTENSION AND 7TH CHARACTER EXTENSION AND “X” PLACEHOLDER “X” PLACEHOLDER
However, fractures (S02.-) have 6 options for the 7th The 7th character must always be the 7th character in the character. data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty S02 Fracture of Skull and Facial Bones characters. th T16 Foreign Body in Ear The appropriate 7 character is to be added to each code from category S02. th The appropriate 7 character is to be added to each code from category T16. A = initial encounter for closed fracture A = initial encounter B = initial encounter for open fracture D = subsequent encounter
D = subsequent encounter for fracture with routine healing S = sequela G = subsequent encounter for fracture with delayed healing √ x 7th T16.1 Foreign body in right ear K = subsequent encounter for fracture with nonunion S = sequela Incorrect code assignment: T16.1A Correct code assignment: T16.1XXA
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7TH CHARACTER EXTENSION: 7TH CHARACTER DEFINITIONS INITIAL-SUBSEQUENT-SEQUELA
• The healing process guides the extension Initial Encounter = A, B
selection, not chronology of the visits. The 7th character for an initial encounter is used • While the patient may be seen by a new or while the patient is receiving active treatment for the condition. different provider over the course of treatment for an injury, assignment of the 7th character is Examples include: Surgical treatment, emergency department encounter, and evaluation based on whether the patient is undergoing and continuing treatment by the same or active treatment and not whether the provider a different physician. This extension is is seeing the patient for the first time. used when the patient is receiving active treatment for the condition.
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7TH CHARACTER DEFINITIONS 7TH CHARACTER DEFINITIONS
Subsequent Encounter = D, G, K Sequela = S The 7th character for a subsequent encounter, is used for • ICD-10-CM no longer has late effect codes. encounters after the patient has received active treatment • To indicate a condition is the result of a previous injury, the 7th of the condition and is receiving routine care for the character extension “S” is used on the active injury code. A code for condition during the healing or recovery phase. the current condition is also used. • The 7th character “S” sequela is used when there is a residual effect Examples include: Cast change or removal, an x-ray to check (condition produced) after the acute phase of an illness or injury has healing status of fracture, removal of external or terminated. internal fixation device, medication adjustment, • There is no time limit on when a sequela code can be used. other aftercare and follow up visits following treatment of the injury. Examples include: Scar formation resulting from a burn, deviated septum due to a nasal fracture, Subsequent encounter does not equal established patient (E/M code 9921x). and infertility due to tubal occlusion from old tuberculosis 23 24
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OTHER CODING CONVENTIONS AND 7TH CHARACTER DEFINITIONS GUIDELINES
Sequela = S “Other” Codes “Other” and “other specified” are used when the medical record gives Example: Scar resulting from a previous laceration. The detail for a condition or illness, but a specific code does not exist. scar is the “late effect” or “sequela” of the laceration. J33.8 Other polyp of sinus When using this extension it is necessary to use both the Accessory polyp of sinus Ethmoidal polyp of sinus injury code that is the cause of the sequela and the code Maxillary polyp of sinus for the sequela itself. Sphenoidal polyp of sinus *Although the record may have the following information, ICD-10-CM does not Example: L91.0 Hypertrophic scar provide specific codes for the conditions listed here. All conditions would be assigned S01.411S Laceration without foreign body of to the same code. right cheek and temporomandibular area, sequela
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OTHER CODING CONVENTIONS AND OTHER CODING CONVENTIONS AND GUIDELINES GUIDELINES
“Unspecified” Codes Dash - Codes that have “unspecified” in the title are used when Used after a subcategory to indicate code information in the medical record is not sufficient or detailed enough to assign a more specific code. requires further characters to be valid. ICD-10-CM “unspecified” H83.3- Noise effects on inner ear C34.9 Malignant neoplasm of floor of mouth, unspecified H68.029 Chronic Eustachian salpingitis, unspecified ear H83.3X1 Noise effects on right inner J32.9 Chronic sinusitis, unspecified J34.9 Unspecified disorder of nose and nasal sinuses ear S02.609- Fracture of mandible, unspecified (7th character required) S02.9 Unspecified fracture of facial bones
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OTHER CODING CONVENTIONS AND OTHER CODING CONVENTIONS AND GUIDELINES GUIDELINES
Excludes Notes Excludes Notes Two types of excludes notes. Excludes 2 Excludes 1 Different definitions, but similar because they indicate that codes excluded Excludes 2 “NOT INCLUDED HERE” from each other are independent of each other. • The condition excluded is not part of the condition represented Excludes 1 “NOT CODED HERE” by the code, but the patient may have both conditions at the • The code excluded should never be used at the same time as the code same time. above the Excludes 1 note. • Used when two conditions can’t occur together. • It is acceptable to use both the code and the excluded code C00 Malignant neoplasm of lip together, when appropriate. Excludes 1 Malignant melanoma of lip (C43.0) R07.0 Pain in throat Merkel cell carcinoma of lip (C4A.0) Other and unspecified malignant Excludes 2 Dysphagia (R13.1-) neoplasm of skin of lip (C44.0-) Pain in neck (M54.2) 29 30
OTHER CODING CONVENTIONS AND OTHER CODING CONVENTIONS AND GUIDELINES GUIDELINES
A Few More Terms… A Few More Terms… “And” “With” • Means either “and” or “or” when it • Interpreted to mean “associated with” or appears in a code title. “due to” when it appears in a code title. – S01.411A Laceration without foreign body of right cheek and temporomandibular area, initial encounter
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OTHER CODING CONVENTIONS AND OTHER CODING CONVENTIONS AND GUIDELINES GUIDELINES
A Few More Terms… A Few More Terms… “See” and “See Also” “Code also” • In the Alphabetic Index • Indicates two codes may be required to – “See” instruction following a main term indicates another term should be referenced to locate the fully describe the condition. proper code. • Does not provide sequencing direction. – “See Also” instruction following a main term indicates there is another term that may be referenced, but it is not necessary to follow the instruction if the original main term provides necessary detail.
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OTHER CODING CONVENTIONS AND OTHER CODING CONVENTIONS AND GUIDELINES GUIDELINES
Acute and Chronic Conditions Laterality If separate entries exist in the Alphabetic Index at Laterality is a prominent concept in ICD-10-CM. the same indentation level: Some code series reflect right, left and bilateral conditions. 1. Code both. If a bilateral code does not exist, assign separate codes for both 2. Sequence the acute condition first. the right and left side. If the side is not documented, assign the code for unspecified side.
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OTHER CODING CONVENTIONS AND GUIDELINES
Complications of Care • Many complications of care and procedures have been moved to various chapters throughout the ICD-10-CM code set. • Regardless of the code’s location, assigning codes for complications is based on the relationship established in the provider’s documentation between the condition and care or procedure. • There must be a cause-and-effect relationship between the condition and the care provided. C H A P T E R 2 : e.g., Post-op tonsil bleed J95.830 Post procedural hemorrhage and hematoma of a NEOPLASMS respiratory system organ or structure following (C00- D 4 9 ) respiratory system procedure
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CHAPTER 2: NEOPLASMS CHAPTER 2: NEOPLASMS (C00-D49)
39 Type • Malignant – Cancerous and capable of invading normal tissue and spreading to Chapter Organization other sites. C09.0 – Malignant neoplasm of tonsillar fossa Neoplasms C00-D49 • Benign – Does not invade normal tissue and remains localized at the original site. D22.12 – Melanocytic nevi of left eyelid, including canthus Site Laterality • In situ – Is a malignancy which has not yet invaded the basement membrane. D03.21 – Melanoma in situ of right ear and external auricular canal
C • Uncertain behavior – Histologic confirmation whether the neoplasm is malignant or D or benign can not be made. There is a specific pathologic diagnosis. D37.05 – Neoplasm uncertain behavior of pharynx
• Unspecified behavior – Is an appropriate category only if neither the behavior nor the morphology is known by the provider. D49.0 – Neoplasm of behavior of digestive system unspecified
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CHAPTER 2: NEOPLASMS (C00-D49) CHAPTER 2: NEOPLASMS (C00-D49)
Overlapping sites should be classified to .8 History of vs. Active Neoplasm Code (overlapping lesion) codes unless a combination • A primary malignancy has been excised or code exists. eradicated from its site and there is no further treatment and no evidence of any existing primary Example: C02.8 Overlapping malignant malignancy, then use Z85.-. lesion of the tongue Examples: Z85.110 – Personal history of malignant carcinoid tumor of Multiple neoplasms that are not contiguous bronchus and lung should be coded separately. Z85.810 – Personal history of malignant neoplasm of tongue Z85.21 – Personal history of malignant neoplasm of larynx
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CHAPTER 2: NEOPLASMS (C00-D49) MALIGNANT NEOPLASMS (C00-C49)
Melanoma (C43) Example: Surveillance visit 2 years after laryngectomy for cancer Diagnosis codes for melanoma are categorized by 1) Z08 Surveillance either malignant melanoma or melanoma in situ. ICD-9-CM does not have this distinction. 2) Z85.21 Personal history cancer, larynx 3) Z90.2 Acquired absence of larynx Wait for the pathology report before assigning the diagnosis code for the excision of skin lesion CPT codes (114xx, 116xx) as 4) Any additional diagnosis codes for conditions the CPT code is dependent on the final pathology. evaluated (e.g., aphonia, dysphagia) C43.4 Malignant melanoma of scalp and neck
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MALIGNANT NEOPLASMS (C00-C49)
Other Skin Cancers (C4A-C44)
Similar to ICD-9-CM, other and unspecified types of skin cancer are categorized based on location and histology. Basal cell carcinoma C44.311 Basal cell carcinoma of skin of nose Squamous cell carcinoma C44.321 Squamous cell carcinoma of skin of nose Merkel cell carcinoma C4A.31 Merkel cell carcinoma of nose C H A P T E R 8: Other specified malignant neoplasm C44.391 Other specified malignant neoplasm of skin of nose D I S E A S E S OF THE EAR AND Unspecified malignant neoplasm MASTOID PROCESS ( H 6 0 - H 9 5 ) C44.301 Unspecified malignant neoplasm of skin of nose
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CHAPTER HIGHLIGHTS CHAPTER HIGHLIGHTS
New chapter created in ICD-10-CM. Previously, ear and mastoid conditions • Expansion of codes in this chapter increased were found in the Nervous System and Sense Organs chapter of ICD-9-CM. anatomic specificity by adding laterality. H60 - H62 • Diseases of external ear • There are separate codes for right, left and bilateral H65 - H75 • Diseases of middle ear and mastoid ear conditions in most code categories.
H80 - H83 • Diseases of inner ear Example: H60.311 Diffuse otitis externa, right ear H90 - H94 • Other disorders of ear H60.312 Diffuse otitis externa, left ear H60.313 Diffuse otitis externa, bilateral ear • Intraoperative and postprocedural H95 complications and disorders of ear and H60.319 Diffuse otitis externa, unspecified ear mastoid process, not elsewhere classified
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OTITIS EXTERNA (H60.-) SWIMMER’S EAR (H60.33-)
th Ear Otitis Externa No 7 character Type of OE Ear Otitis Externa No 7th character 0 Abscess Laterality 1 Cellulitis 1 Right ear H 6 0 2 Malignant OE H 6 0 3 3 2 Left ear
Category Etiology, Extension 3 Other 3 Bilateral Anatomic Site, Category Etiology, Extension Severity 4 Cholesteatoma Anatomic Site, 9 Unspecified ear H60.0- Abscess of external ear Severity 5 Acute H60.1- Cellulitis of external ear noninfective H60.331 Swimmer’s ear, right ear H60.2- Malignant otitis externa H60.332 Swimmer’s ear, left ear H60.3- Other 6 Unspecified H60.31- Diffuse otitis externa chronic H60.333 Swimmer’s ear, bilateral H60.32- Hemorrhagic otitis externa 8 Other chronic H60.339 Swimmer’s ear, unspecified ear H60.33- Swimmer’s ear 9 Unspecified H60.39- Other infective otitis externa 50 51
ACUTE NON-INFECTIVE IMPACTED CERUMEN (H61.-) OTITIS EXTERNA (H60.5-)
th Ear Otitis Externa Acute Non- 6 : Laterality Other Disorders of the External Ear (H61) Infective 1 Right ear 2 Left ear No 7th Laterality 3 Bilateral Other Disorders Impacted H 6 0 5 character Ear of External Ear Cerumen 0 Unspecified 9 Unspecified ear 1 Right Category Etiology, Extension th 2 Left Anatomic Site, 5 : Type of Acute Severity 3 Bilateral 0 Unspecified H60.50- Unspecified acute noninfective OE 1 Actinic H 6 1 2 H60.51- Acute actinic OE 2 Chemical Impacted cerumen (H61.2-) H60.52- Acute chemical OE Category Etiology, Extension H60.53- Acute contact OE 3 Contact Anatomic Site, H61.20 Impacted cerumen, unspecified ear Severity H60.54- Acute eczematoid OE 4 Eczematoid H61.21 Impacted cerumen, right ear H60.55- Acute reactive OE 5 Reactive No 6th or 7th H61.22 Impacted cerumen, left ear H60.59- Other noninfective acute OE 9 Other characters H61.23 Impacted cerumen, bilateral
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OTITIS MEDIA OTITIS MEDIA
Nonsuppurative Otitis Media (H65) Acute Serous Otitis Media (H65.0-) Instructional notes NEW in ICD-10-CM • Use additional code for any associated perforated tympanic The term recurrent has been added to the description for codes membrane (H72.-). in the acute categories for otitis media.
• Use additional code to identify: H65.01 Acute serous otitis media, right ear – Exposure to environmental tobacco smoke (Z77.22) H65.02 Acute serous otitis media, left ear – Exposure to tobacco smoke in the perinatal period (P96.81) H65.03 Acute serous otitis media, bilateral – History of tobacco use (Z87.891) H65.04 Acute serous otitis media, recurrent, right ear – Occupational exposure to environmental tobacco smoke (Z57.31) H65.05 Acute serous otitis media, recurrent, left ear – Tobacco dependence (F17.-) – Tobacco use (Z72.0) H65.06 Acute serous otitis media, recurrent, bilateral
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OTITIS MEDIA OTITIS MEDIA
Chronic Serous Otitis Media (H65.2-) Suppurative and Unspecified Otitis Media (H66) Ear Chronic Nonsuppurative OM Chronic Serous OM Instructional notes Category H66 has the same instructional note for any smoking use, dependence or exposure, as well as, any associated TM perforation for No 6th or 7th most of the subcategories. H 6 5 2 characters Acute Suppurative Otitis Media H66.0- Under category H72, Category Etiology, Extension Perforation of tympanic Anatomic Site, • Include with or without spontaneous tympanic Severity membrane, there is an 5th Character = • Acute vs. acute recurrent Excludes 1 note for Laterality • Right, left, bilateral subcategory H66.01-. 1 Right H66.00- Acute suppurative OM without A code from H72 is not 2 Left reported in addition as spontaneous rupture of ear drum TM rupture is included 3 Bilateral H66.01- Acute suppurative OM with in the description of 0 Unspecified spontaneous rupture of ear drum the code.
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SUPPURATIVE OTITIS MEDIA OTHER MIDDLE EAR DISORDERS
Eustachian Tube Dysfunction (H69)
H 6 6 ICD-9-CM = 381.81
Category Etiology, Extension H69.80 Other specified Eustachian tube disorder, unspecified Anatomic Site, Severity H69.81 Other specified disorders of Eustachian tube, right ear
4th Character H69.82 Other specified disorders of Eustachian tube, left ear 0 = Acute suppurative…w/ or w/o TM perf (acute H69.83 Other specified disorders of Eustachian tube, bilateral vs. acute, recurrent) [see previous slide] 1 = Chronic tubotympanic suppurative Remember: Document laterality for all ear conditions! 2 = Chronic atticoantral suppurative 3 = Other chronic suppurative Right – Left – Bilateral 4 = Unspecified suppurative OM 9 = Unspecified (OM NOS, AOM NOS, COM NOS) 58 59
CHOLESTEATOMA TYMPANIC MEMBRANE PERFORATION
60 H 7 1 H 7 2
Category Etiology, Extension Anatomic Site, th Severity Category Etiology, Extension 4 Character Anatomic Site, 4th Character Severity 0 = Attic th 5 Character 0 = Central 1 = Tympanum 1 = Right 1 = Attic 2 = Mastoid 2 = Left 2 = Other marginal perforations 3 = Diffuse cholesteatosis 3 = Bilateral 8 = Other (multiple vs. total) 9 = Unspecified 9 = Unspecified
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DISORDERS OF VESTIBULAR FUNCTION DISORDERS OF VESTIBULAR FUNCTION (H81) (H81)
Other code subcategories for vestibular conditions EXCLUDES 1 Epidemic vertigo (A88.1) H81.1- Benign paroxysmal vertigo Vertigo NOS (R42) H81.2- Vestibular neuronitis ICD -9-CM codes for Meniere’s disease ICD-10-CM codes for Meniere’s disease 386.00 Unspecified Meniere’s disease H81.01 Meniere’s disease, right ear H81.3- Other peripheral vertigo 386.01 Active Meniere’s disease H81.02 Meniere’s disease, left ear cochleovestibular H81.03 Meniere’s disease, bilateral H81.31- Aural vertigo 386.02 Active Meniere’s disease, cochlear H81.09 Meniere’s disease, unspecified H81.39- Other peripheral vertigo 386.03 Active Meniere’s disease, vestibular 386.04 Inactive Meniere’s disease Additional character required for laterality – right, left, bilateral, or unspecified Inactive vs. active has been removed, as well as descriptions for cochlear, vestibular, cochleovestibular.
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HEARING LOSS OTALGIA AND EFFUSION OF EAR (H92)
Hearing Loss (H90) Codes are further defined by laterality: right, left, Documentation requires ALERT bilateral. the following information: Currently, ICD-10-CM does Otalgia H92.0- not provide codes for Hearing Loss different types of loss in each Otorrhea H92.1- (H90.-) ear (e.g., conductive loss in the right ear and Excludes 1 Leakage of cerebrospinal fluid sensorineural loss in the left). through ear (G96.0) When both conditions are Type Laterality documented, a code for the Otorrhagia H92.2- - Conductive - Left conductive hearing loss and Excludes 1 Traumatic otorrhagia – Code to injury - Sensorineural - Right sensorineural hearing loss are - Mixed - Bilateral both coded.
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INTRAOPERATIVE AND POSTPROCEDURAL TINNITUS (H93.1-) COMPLICATIONS AND DISORDERS (H95)
• Certain complications have been grouped into specific chapters rather • Subjective and objective tinnitus codes have been than all complications being combined into a single chapter. removed. H95.0- Recurrent cholesteatoma of the post-mastoidectomy cavity H95.1- Other disorders of the ear and mastoid process following • Tinnitus is defined only by laterality in ICD-10-CM. mastoidectomy H95.2- Intraoperative hemorrhage and hematoma of ear and mastoid H93.11 Tinnitus, right ear process complicating a procedure H93.12 Tinnitus, left ear H95.3- Accidental puncture and laceration of ear and mastoid process H93.13 Tinnitus, bilateral during a procedure H95.4- Postprocedural hemorrhage and hematoma of ear and mastoid H93.19 Tinnitus, unspecified ear process following a procedure H95.8- Other intraoperative and postprocedural complications and disorders of the ear and mastoid process, not elsewhere classified 66 67
CHAPTER HIGHLIGHTS
Pertinent coding blocks for otolaryngology. J00 - J06 • Acute upper respiratory infections J30 - J39 • Other diseases of upper respiratory tract J40 - J47 • Chronic lower respiratory diseases
• Intraoperative and postprocedure complications an J95 disorders of reparatory system, not elsewhere classified • Many of the codes in this chapter have 1-1 mapping!!! CHAPTER 10: 474.00 chronic tonsillitis = J35.01 chronic tonsillitis DISEASES OF THE RESPIRATORY 473.2 chronic ethmoidal sinusitis = J32.2 chronic ethmoidal sinusitis • Certain codes have been moved to Chapter 10 from other locations, S Y S T E M ( J 0 0 - J 9 9 ) like streptococcal sore throat (J02.0). Previously was in Infectious and parasitic disease chapter in ICD-9-CM.
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CODING CONVENTIONS AND CODING CONVENTIONS AND INSTRUCTIONAL NOTES INSTRUCTIONAL NOTES
• Some codes have been expanded to include notes Most codes also have instructions to: indicating an additional code should be assigned or an Use additional code to identify: associated condition should be sequenced first. Exposure to environmental tobacco smoke (Z77.22) – Use additional code to identify the infectious agent. Exposure to tobacco smoke in the perinatal – Use additional code to identify the virus. period (P96.81) – Code first any associated lung abscess. History of tobacco use (Z87.891) – Code first the underlying disease. – Use additional code to identify other conditions such. Occupational exposure to environmental tobacco smoke (Z57.31) • J01 Acute Sinusitis Note: Code if infectious agent is known. Tobacco dependence (F17.-) Watch code assignment for If unknown, then an infectious agent Tobacco use (Z72.0) infectious agent! code is not reported.
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ACUTE SINUSITIS J 0 1 CHRONIC SINUSITIS (J32.-) J32.- Chronic sinusitis Acute Sinusitis (J01.-) Category Etiology, Extension ICD-10-CM Anatomic Site, th th Use additional code to identify: ICD-10-CM Severity No 6 or 7 J32.0 Chronic maxillary • The acute characters sinusitis J01.00 Acute maxillary sinusitis, unspecified Exposure to environmental sinusitis codes J01.01 Acute recurrent maxillary sinusitis Location J32.1 Chronic frontal have been tobacco smoke (Z77.22) sinusitis J01.10 Acute frontal sinusitis, unspecified 0 Maxillary expanded to J32.2 Chronic ethmoidal J01.11 Acute recurrent frontal sinusitis 1 Frontal Exposure to tobacco smoke in the state whether sinusitis J01.20 Acute ethmoidal sinusitis, unspecified the infection is 2 Ethmoid perinatal period (P96.81) J01.21 Acute recurrent ethmoidal sinusitis J32.3 Chronic sphenoidal recurrent or not. 3 Sphenoid History of tobacco use (Z87.891) sinusitis J01.30 Acute sphenoidal sinusitis, unspecified 4 Pansinusitis J01.31 Acute recurrent sphenoidal sinusitis J01 Acute Occupational exposure to J32.4 Chronic pansinusitis 8 Other J32.8 Other chronic J01.40 Acute pansinusitis, unspecified sinusitis environmental tobacco smoke J01.41 Acute recurrent pansinusitis Use additional 9 Unspecified sinusitis J01.80 Other acute sinusitis code (B95 – B97) (Z57.31) J32.9 Chronic sinusitis, Episode J01.81 Other acute recurrent sinusitis to identify unspecified 0 Acute Tobacco dependence (F17.-) J01.90 Acute sinusitis, unspecified infectious agent. J01.91 Acute recurrent sinusitis, unspecified 1 Acute Recurrent Tobacco use (Z72.0)
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OTHER SINUSITIS: PANSINUSITIS NEW MEANING IN ICD-10-CM!
Other acute (and acute recurrent) sinusitis J01.80 and J01.81 • In ICD-9-CM pansinusitis was coded “Acute sinusitis involving more than one sinus but not pansinusitis”
under an “other specified” code Other chronic sinusitis J32.8 (ICD-9 = 461.8, 473.8). “Sinusitis (chronic) involving more than one sinus but not pansinusitis”
• In ICD-10-CM, pansinusitis has its own Change: In ICD-9-CM each sinus that was infected was coded separately unless all were infected, but in ICD-10-CM if 2 or 3 sinuses codes (J01.40, J04.41 and J32.4). are documented as infected the “other acute sinusitis” codes will be used rather than coding each one separately.
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EXAMPLES ACUTE TONSILLITIS (J03.-)
• Involvement of 1 Sinus Respiratory No 6th or 7th – 31256-50 473.0 / J32.0 (chronic maxillary sinusitis) Acute Tonsillitis characters • Involvement of 2 or 3 Sinuses – 31255-50 473.2 / J32.8 (other chronic sinusitis) – 31256-50 473.0 / J32.8 (other chronic sinusitis) J 0 3
Category Etiology, Extension • Involvement of All 4 Sinuses Anatomic Site, Severity – 31276-50 473.8 / J32.4 (chronic pansinusitis) Type – 31255-50 473.8 / J32.4 (chronic pansinusitis) 0 Streptococcal Episode – 31287-50 473.8 / J32.4 (chronic pansinusitis) 8 Other specified 0 Acute – 31256-50 473.8 / J32.4 (chronic pansinusitis) organisms 1 Acute recurrent 9 Unspecified 76 Image Source: http://upload.wikimedia.org/wikipedia/commons/thumb/8/89/Blausen_0861_Tonsils%26Throat_Anatomy2.png/600px-Blausen_0861_Tonsils%26Throat_Anatomy2.png 77
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CHRONIC TONSIL / ADENOID DISEASE VASOMOTOR AND ALLERGIC RHINITIS
Vasomotor and Allergic Rhinitis (J30) Chronic Tonsillitis and Adenoiditis, Hypertrophy (J35.-) ICD-10-CM Instructional Note: Use additional code to identify: J30.0 Vasomotor rhinitis Exposure to environmental tobacco smoke (Z77.22) J30.1 Allergic rhinitis due to pollen (hay fever, pollinosis) Exposure to tobacco smoke in the perinatal period (P96.81) J30.2 Other seasonal allergic rhinitis History of tobacco use (Z87.891) J30.5 Allergic rhinitis due to food Occupational exposure to environmental tobacco smoke (Z57.31) J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander Tobacco dependence (F17.-) J30.89 Other allergic rhinitis Tobacco use (Z72.0) J30.9 Allergic rhinitis, unspecified ICD-10-CM ICD-10-CM J35.01 Chronic tonsillitis J35.1 Hypertrophy of tonsils For allergy testing: Also use Z01.82 (Encounter for allergy testing). J35.02 Chronic adenoiditis J35.2 Hypertrophy of adenoids J35.03 Chronic tonsillitis and J35.3 Hypertrophy of tonsils with Symptoms: R06.7 (Sneezing), R05 (Cough), R09.81 (Nasal congestion), adenoiditis hypertrophy of adenoids R09.82 (Postnasal drip)
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COMMON RESPIRATORY SYSTEM COMMON RESPIRATORY SYSTEM DIAGNOSIS CODE MAPPINGS DIAGNOSIS CODE MAPPINGS
Disease of Vocal Cords and Larynx, NEC (J38) The Respiratory chapter has 1:1 mapping from ICD-9-CM to ICD-10-CM for many commonly used otolaryngology codes. J38.0- Paralysis / Unspecified, unilateral, bilateral ICD-9-CM ICD-10-CM J38.1 Polyp 470 Deviated nasal septum J34.2 Deviated nasal septum J38.2 Nodules 471.0 Polyp of nasal cavity J33.0 Polyp of nasal cavity J38.3 Other diseases of vocal cords (e.g., leukoplakia, 472.0 Chronic rhinitis J31.0 Chronic rhinitis granuloma) 472.1 Chronic pharyngitis J31.2 Chronic pharyngitis J38.4 Edema 472.2 Chronic nasopharyngitis J31.1 Chronic nasopharyngitis J38.5 Spasm [use for spasmodic dysphonia] 475 Peritonsillar abscess J36 Peritonsillar abscess J38.6 Stenosis 476.0 Chronic laryngitis J37.0 Chronic laryngitis J38.7 Other diseases of larynx (e.g., cellulitis, ulcer) 476.1 Chronic laryngotracheitis J37.1 Chronic laryngotracheitis
80 81
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INTRAOPERATIVE AND POSTPROCEDURAL ASTHMA (J45.-) COMPLICATIONS, NEC
J95.0- Tracheostomy complications CDI Tip J95.00 Unspecified tracheostomy complication J95.01 Hemorrhage from tracheostomy stoma J95.02 Infection of tracheostomy stoma When documenting asthma the following must be Use additional code to identify type of infection, such as: documented in the patient’s medical record. Cellulitis of neck (L03.8) Sepsis (A40, A41.1-) J95.03 Malfunction of tracheostomy stoma Type of asthma: Status of condition: Mechanical complication of tracheostomy stoma • Mild intermittent • Uncomplicated Obstruction of tracheostomy airway • Mild persistent • With (acute) exacerbation Tracheal stenosis due to tracheostomy J95.04 Tracheo-esophageal fistula following tracheostomy • Moderate persistent • With status asthmaticus J95.09 Other tracheostomy complication • Severe persistent J95.830 Postprocedural hemorrhage and hematoma of a respiratory system organ or structure following a respiratory system procedure • Use for post-op tonsillectomy bleed.
82 83
CODING CONVENTIONS AND INSTRUCTIONAL NOTES Most of the code categories contain the following instructional note: Use additional code to identify: Alcohol abuse and dependence (F10.-) Exposure to environmental tobacco smoke (Z77.22) Exposure to tobacco smoke in the perinatal period (P96.81) History of tobacco use (Z87.891) CHAPTER 11: Occupational exposure to environmental tobacco DISEASES OF THE DIGESTIVE SYSTEM smoke (Z57.31) Tobacco dependence (F17.0-) ( K 0 0 - K 9 5 ) Tobacco use (Z72.0)
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SALIVARY GLANDS SALIVARY GLANDS
Diseases of the Salivary Glands (K11.-) Diseases of the Salivary Glands (K11.-) ICD-10-CM Sialoadenitis (K11.2-) codes have been expanded and will K11.0 Atrophy of salivary gland require documentation to include whether the condition is K11.1 Hypertrophy of salivary gland acute, recurrent or chronic. K11.3 Abscess of salivary gland K11.4 Fistula of salivary gland Includes: Parotitis K11.5 Sialolithiasis K11.6 Mucocele of salivary gland ICD-10-CM K11.7 Disturbance of salivary secretion K11.20 Sialoadenitis, unspecified R68.2 Dry mouth, unspecified K11.21 Acute sialoadenitis K11.8 Other diseases of salivary glands K11.9 Disease of salivary gland, K11.22 Acute recurrent sialoadenitis unspecified K11.23 Chronic sialoadenitis
86 87 Image source: http://upload.wikimedia.org/wikipedia/commons/d/df/Blausen_0780_SalivaryGlands.png
MOUTH, LIPS, AND TONGUE DISEASES OF THE ESOPHAGUS
Oral Mucositis (K12.3-) Gastro-Esophageal Reflux Disease (GERD) (K21.1) K12.30 Oral mucositis (ulcerative), unspecified K21.0 Gastro-esophageal reflux disease with K12.31 Oral mucositis (ulcerative) due to antineoplastic therapy Use additional code for adverse effect, if applicable, to identify antineoplastic and esophagitis immunosuppressive drugs (T45.1X5) Reflux esophagitis Use additional code for other antineoplastic therapy, Such as: Radiological procedure and radiotherapy (Y84.2) K21.9 Gastro-esophageal reflux disease K12.32 Oral mucositis (ulcerative) due to other drugs Use additional code for adverse effect, if applicable, to identify drug without esophagitis (T36 – T50 with fifth or sixth character 5) Esophageal reflux NOS K12.33 Oral mucositis (ulcerative) due to radiation Use additional external cause code (W88 – W90, X39.0-) to identify cause K12.39 Other oral mucositis (ulcerative) Viral oral mucositis (ulcerative)
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SKIN INFECTIONS (L00 – L08)
Infections of the Skin and Subcutaneous Tissue (L00 – L08) Use additional code (B95 – B97) to identify infectious agent. L02.01 Cutaneous abscess of face L02.02 Furuncle of face Boil of face Folliculitis of face L02.03 Carbuncle of face L02.1- Cutaneous abscess, furuncle and carbuncle of neck C H A P T E R 1 2 : L02.11 Cutaneous abscess of neck D I S E A S E S OF THE SKIN AND L02.12 Furuncle of neck Boil of neck SUBCUTANEOUS TISSUE (L00 - L 9 9 ) Folliculitis of neck L02.13 Carbuncle of neck 90 91 Image source: http://upload.wikimedia.org/wikipedia/commons/5/5d/Anatomy_The_Skin_-_NCI_Visuals_Online.jpg
RADIATION-RELATED AND SKIN INFECTIONS (L00 – L08) SKIN APPENDAGE DISORDERS
Infections of the Skin and Subcutaneous Tissue (L00 – L08) Radiation-Related Disorders of the Skin and Subcutaneous Tissue (L55 – L59) L03.21- Cellulitis and acute lymphangitis of face
L03.211 Cellulitis of face L57 Skin changes due to chronic exposure to nonionizing radiation Excludes 2 Cellulitis of ear (H60.1-) Cellulitis of eyelid (H00.03-) Use additional code to identify the source of the ultraviolet Cellulitis of head (L03.811) radiation (W89, X32). Cellulitis of lacrimal apparatus (H04.3) Cellulitis of lip (K13.0) W89 = Exposure to man-made visible Cellulitis of mouth (K12.2) and ultraviolet light Cellulitis of nose (internal) (J34.0) X32 = Exposure to sunlight Cellulitis of orbit (H05.0) Cellulitis of scalp (L03.811) L57.0 Actinic keratosis L03.212 Acute lymphangitis of face Keratosis NOS L03.22- Cellulitis and acute lymphangitis of neck Senile keratosis L03.221 Cellulitis of neck Solar keratosis L03.222 Acute lymphangitis of neck
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RADIATION-RELATED AND OTHER SKIN DISORDERS SKIN APPENDAGE DISORDERS Disorders of Skin Appendages (L60 – L75) Other Skin Disorders
Excludes 1 Congenital malformations of integument (Q84.-) Atrophic (L90) Hypertrophic (L91) Granulomatous (L92) L72 Follicular cysts of skin and subcutaneous tissue
Codes for scars have been classified similarly in ICD-10-CM. Many codes in this category were previously classified to one code in ICD-9-CM, 706.2 Sebaceous cyst. These codes have 1-1 mapping with ICD-9-CM. L72.0 Epidermal cysts L72.1 Pilar and trichodermal cysts L90.5 Scar conditions and fibrosis of skin L91.0 Hypertrophic scar L72.11 Pilar cysts Adherent scar (skin) Keloid L72.12 Trichodermal cyst Cicatrix Keloid scar Disfigurement of skin due to scar L72.2 Steatocystoma multiplex Excludes 2 Acne keloid (L73.0) Fibrosis of skin NOS L72.3 Sebaceous cysts Scar NOS (L90.5) Scar NOS Excludes 2 Pilar cysts (72.11) L92.3 Foreign body granuloma of the skin Trichilemmal (proliferating) cyst (L72.12) Excludes 2 Hypertrophic scar (L91.0) and subcutaneous tissue Keloid scar (L91.0) L72.8 Other follicular cysts of the skin and subcutaneous tissue Use additional code to identify the L72.9 Follicular cyst of the skin and subcutaneous tissue, unspecified type of retained foreign body (Z18.-). 94 95
EYE, EAR, FACE, AND NECK (Q10-Q18)
Other Congenital Malformation Ear (Q17) Q17.0 Accessory auricle Accessory tragus Polyotia Preauricular appendage or tag Supernumerary ear Supernumerary lobule Q17.1 Macrotia CHAPTER 17: Q17.2 Microtia CONGENITAL MALFORMATIONS AND Q17.3 Other misshapen ear Q17.4 Misplaced ear CHROMOSOMAL ABNORMALITIES Q17.5 Prominent ear ( Q 0 0 - Q 9 9 ) Q17.8 Other specified congenital malformation of ear 96 97
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RESPIRATORY SYSTEM (Q30-Q34) RESPIRATORY SYSTEM (Q30-Q34)
Congenital Malformations of Nose (Q30) Congenital Malformations of Larynx (Q31) No 5th, 6th, or 7th characters ICD-10-CM Q30.0 Choanal atresia Q 3 1 Q30.1 Agenesis and underdevelopment of nose Category Etiology, Extension Q30.2 Fissured, notched and cleft nose Anatomic Site, Severity 4th Character Q30.3 Congenital perforated nasal septum 0 Web of larynx Q30.8 Other congenital malformations of nose 1 Congenital subglottic stenosis 2 Laryngeal hypoplasia Q30.9 Congenital malformation of nose, unspecified 3 Laryngocele 5 Congenital laryngocele 8 Other 9 Unspecified 98 99
RESPIRATORY SYSTEM (Q30-Q34) CLEFT LIP AND CLEFT PALATE (Q35-Q37)
Trachea and Bronchus (Q32) Cleft Lip and Cleft Palate (Q35.- to Q37.0) Documentation Tips ICD-10-CM Q32.0 Congenital tracheomalacia 1) Hard vs. soft palate vs. uvula Q32.1 Other congenital malformations of trachea Q32.2 Congenital bronchomalacia 2) Bilateral vs. median vs. unilateral lip Q32.3 Congenital stenosis of bronchus 3) Combined cleft plate and cleft lip Q32.4 Other congenital malformations of bronchus
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OTHER CONDITIONS Q38.1 Ankyloglossia
Q38.2 Macroglossia
CHAPTER 18: SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS ( R 0 0 - R 9 9 )
102 103
CHAPTER HIGHLIGHTS SIGNS AND SYMPTOMS
• The codes from this chapter represent signs, symptoms, abnormal • A number of commonly used codes by otolaryngology results, investigative findings and ill-defined conditions when there is no other diagnosis classifiable elsewhere recorded. practices are found in this chapter. • These codes should be used to describe the patient’s condition • Many of these codes have not been expanded or had when a more definitive diagnosis has not been established or any revision to their titles from ICD-9-CM. confirmed by the provider.
• Codes from this category may be reported with a related definitive Epistaxis 784.7 = R04.0 Epistaxis diagnosis when the sign or symptom is not routinely associated with that diagnosis. The definitive diagnosis should be sequenced Hemorrhage from throat 784.8 = R04.1 Hemorrhage first, followed by the code(s) for the sign(s)/symptom(s). from throat • Codes that are routinely associated with a disease process should Postnasal drip 784.91 = R09.82 Postnasal drip not be reported separately. 784.92 Jaw pain = R68.84 Jaw pain 104 105
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SIGNS AND SYMPTOMS SLEEP DISTURBANCES (G47)
However, some symptoms were assigned specific codes and Sleep Disturbances (G47.-) others were expanded. G47 Sleep disorders • In ICD-9-CM sleep Excludes 2 Nightmares (F51.5) ICD-9-CM ICD-10-CM disturbances fall Nonorganic sleep disorders (F51.-) Sleep terrors (F51.4) 784.99 Other symptoms R06.5 Mouth breathing into the sign and involving head and R06.7 Sneezing Sleepwalking (F51.3) symptoms G47.0- Insomnia neck R06.89 Other abnormalities of breathing G47.1- Hypersomnia R19.6 Halitosis chapter, but in G47.2- Circadian rhythm sleep disorders ICD-10-CM these G47.3- Sleep apnea ICD-9-CM ICD-10-CM sleep problems G47.33 Obstructive sleep apnea (adult) (pediatric) 784.2 Swelling mass or R22.0 Localized swelling, mass and lump, head have been Excludes 1 Obstructive sleep apnea of newborn lump in head and R22.1 Localized swelling, mass and lump, neck (P28.3) neck R90.0 Intracranial space-occupying lesion reclassified to the G47.4- Narcolepsy and cataplexy found on diagnostic imaging of central nervous system G47.5- Parasomnia nervous system G47.6- Sleep related movement disorders chapter. G47.8 Other sleep disorders G47.9 Sleep disorder, unspecified 106 107
CHAPTER HIGHLIGHTS
S00 - S09 •Injuries to the head
S10 - S19 •Injuries to the neck
•Effects of foreign body entering T15 - T19 through natural orifice CHAPTER 19: INJURY, POISONING AND CERTAIN OTHER •Complications of surgical and medical CONSEQUENCES OF EXTERNAL CAUSES T80 - T88 ( S 0 0 - T 8 8 ) care, not elsewhere classified
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CHAPTER HIGHLIGHTS CHAPTER HIGHLIGHTS
• All injuries are now grouped by site then by type of injury. • Injuries to the head (S00 – S09) th th • S00 Superficial injury of head The 7 character must always be in the 7 character • S01 Open wound of head field. When a code is less than 6 characters, an “X”
• This chapter uses the S-section for coding different types of injuries must be used to fill the empty character positions so related to single body regions and the T-section to code injuries to the 7th character can be added in the correct position. unspecified body regions, as well as, poisonings and certain other consequences of external causes. Invalid code = T16.1D Foreign body in right ear, • S11.011A Laceration without foreign body of larynx, initial subsequent encounter encounter • T17.320A Food in larynx causing asphyxiation, initial encounter Valid code = T16.1XXD Foreign body in right ear,
• Another major change is the addition of a 7th character extension to subsequent encounter some of the codes. Most categories in Chapter 19 have a 7th character requirement to make a code valid.
110 111
CHAPTER HIGHLIGHTS CHAPTER HIGHLIGHTS
A, B = Initial Encounter D, G, K = Subsequent Encounter • While the patient may be seen by a new or different provider • Used for encounters after the patient has received over the course of treatment for an injury, assignment of the active treatment of the condition and is receiving 7th character is based on whether the patient is undergoing routine care for the condition during the healing or active treatment and not whether the provider is seeing the recovery phase. patient for the first time. • Examples of subsequent care are: cast change or • The 7th character for an initial encounter is used while the removal, an x-ray to check healing status of fracture, patient is receiving active treatment for the condition. removal of external or internal fixation device, Examples of active treatment are: surgical treatment, medication adjustment, other aftercare and follow up emergency department encounter, and evaluation and continuing treatment by the same or a different physician. visits following treatment of the injury.
112 113
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CHAPTER HIGHLIGHTS CHAPTER HIGHLIGHTS
S = Sequela S = Sequela • Used when there is a residual effect (condition produced) • When using 7th character “S”, it is necessary to use both after the acute phase of an illness or injury has terminated. the injury code that precipitated the sequela and the • There is no time limit on when a sequela code can be used. code for the sequela itself. The residual may be apparent early, such as in cerebral Example: A patient presenting for scar revision of infarction, or it may occur months or years later, such as hypertrophic scar resulting from a severe dog bite that due to a previous injury. of the right cheek. • Examples of sequela include: scar formation resulting from L91.0 Hypertrophic scar a burn, deviated septum due to a nasal fracture, and S01.451S Open bite of right cheek and infertility due to tubal occlusion from old tuberculosis. temporomandibular area, initial encounter 114 115
INJURIES TO THE HEAD (S00-S09) CHAPTER 19: Injuries to the Head (S00 – S09) INJURIES After location, injuries are further differentiated by the type of injury. S00 Superficial injury of head S01 Open wound of head HEAD S02 Fracture of skull and facial bones S03 Dislocation and sprain of joints and INJURIES ligaments of head (S00-S09) S04 Injury of cranial nerve S05 Injury of eye and orbit S06 Intracranial injury S07 Crushing injury of head S08 Avulsion and traumatic amputation of part of head S09 Other and unspecified injuries of head
116 117 Image source: http://upload.wikimedia.org/wikipedia/commons/thumb/1/1a/Human_sk ull_front_simplified_%28bones%29.svg/399px- Human_skull_front_simplified_%28bones%29.svg.png
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INJURIES TO THE HEAD (S00-S09) INJURIES TO THE HEAD (S00-S09)
Superficial Injury of Head (S00) Open Wound of Head (S01) Superficial injuries are further classified by type of injury and • Laceration – with or without foreign body specific location, including laterality. • Puncture – with or without foreign body 1) Type of Injury: abrasion, blister, contusion, superficial foreign • Open bite body, insect bite (nonvenomous), other/unspecified
2) Location: scalp , eyelid, and periocular area (right, left), nose, ALERT ear (right, left), lip and oral cavity, other/unspecified ICD-9-CM classified open wounds either with or without mention of complication. The term complication included delayed healing, delayed 3) 7th character extension is indicated at the code. treatment, foreign body or infection. ICD-10-CM includes with or with foreign body in the code title and The appropriate 7th character is to be added to each code from category S00. instructs the user to add additional codes for any associated wound A initial encounter D subsequent encounter infection. S sequela
118 119
CHAPTER 19: INJURIES INJURIES TO THE HEAD (S00-S09)
120 Fracture of Skull and Facial Bones (S02.-) Fracture of Skull and Facial Bones (S02) Example: A fracture not documented as open or closed should be coded to closed. S02.6- Fracture of the mandible [needs 7 characters] @ = 4th Character for S02.600- Fracture of unspecified part of body of mandible S02.61- Fracture of condylar process of mandible Injury Head Fracture Anatomic Location S02.62- Fracture of subcondylar process of mandible 0 = Vault of skull (e.g., frontal, S02.63- Fracture of coronoid process of mandible parietal) √ x 7th S02.64- Fracture of ramus of mandible 1 = Base of skull S02.65- Fracture of angle of mandible 2 = Nasal bones S02.66- Fracture of symphysis of mandible A, B, 3 = Orbital floor S02.67- Fracture of alveolus of mandible D, G, S02.69- Fracture of mandible of other specified site S 0 2 @ K or S 4 = Malar, maxillary and The appropriate 7th character is to be added to each code from category S02. zygoma A initial encounter for closed fracture 5 = Tooth B initial encounter for open fracture 6 = Mandible D subsequent encounter for fracture wit routine healing Category Etiology, Extension G subsequent encounter for fracture with delayed healing 8 = Other specified bones Anatomic Site, K subsequent encounter for fracture with nonunion Severity 9 = Unspecified S sequela
120 121
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CHAPTER 19: INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES FOREIGN BODIES (T15-T19) • Foreign body (T15-T19) Foreign Body in Ear (T16) Includes foreign body in auditory canal.
. Entering through th The appropriate 7 character is to be added to each code from category T16. natural orifice A initial encounter D subsequent encounter S sequela
√x7th T16.1 Foreign body in right ear √x7th T16.2 Foreign body in left ear √x7th T16.9 Foreign body in ear, unspecified ear
Always remember to document laterality!
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Additional categories to FOREIGN BODIES (T15-T19) FOREIGN BODIES (T15-T19) indicate specific location in the respiratory tract for larynx, trachea, Foreign Body in Respiratory Tract (T17) Foreign Body in Respiratory Tract (T17) bronchus, other and T17.2- Foreign body of pharynx unspecified. For most categories of the respiratory tract, ICD-10-CM has T17.20- Unspecified foreign body (FB) in pharynx codes to indicate the foreign body is either food or gastric √ 7th T17.200 Unspecified FB in pharynx causing asphyxiation √ 7th T17.208 Unspecified FB in pharynx causing other injury contents, as well as, a category for other foreign object causing T17.21- Gastric contents in pharynx asphyxiation or other injury. Aspiration of gastric contents into pharynx Vomitus in pharynx ICD-9-CM didn’t have distinct codes to indicate type of foreign body. √ 7th T17.210 Gastric contents in pharynx causing asphyxiation √ 7th T17.218 Gastric contents in pharynx causing other injury The appropriate 7th character is to be added to each code from category T17. T17.22- Food in pharynx Bones in pharynx A initial encounter Seeds in pharynx D subsequent encounter √ 7th T17.220 Food in pharynx causing asphyxiation S sequela √ 7th T17.228 Food in pharynx causing other injury T17.29- Other foreign object (FO) in pharynx √ 7th T17.290 Other FO in pharynx causing asphyxiation √ 7th T17.298 Other FO in pharynx causing other injury 124 125
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COMPLICATIONS (T80-T88)
Complications of Surgical and Medical Care, Not Elsewhere Classified (T80 – T88) • Although many intraoperative and postprocedural complications fall into specific Oct 16-17 body system chapters, some complications are classified to Chapter 19. Las Vegas, NV • Documentation must clearly indicate the cause-and-effect of the complication. • √ x 7th T81.4 Infection following a procedure Intra-abdominal abscess following a procedure Nov 13-14 Postprocedural infection, not elsewhere classified Chicago, IL Sepsis following a procedure Stitch abscess following a procedure Subphrenic abscess following a procedure Wound abscess following a procedure • √ x 7th T81.31 Disruption of external operation (surgical) wound, not elsewhere classified • √ x 7th T81.32 Disruption of internal operation (surgical) wound, not elsewhere classified 126
THANK YOU
Kim Pollock www.karenzupko.com 312.642.5616 RN, MBA, CPC, CMDP
[email protected] @KarenZupkoAssoc karenzupkoandassociates
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