Preparing for ICD-10-CM Interest in the Subject Matter of This Presentation

Financial Disclosure

Mary Pat Johnson is a Senior Consultant at Corcoran Consulting Group and acknowledges a financial Preparing for ICD-10-CM interest in the subject matter of this presentation.

Mary Pat Johnson, COMT, CPC, COE, CPMA Senior Consultant Corcoran Consulting Group

Key Points in Code Selection ICD-10-CM Changes Everything

• ICD-10 is more specific than ICD-9 • Attention to detail • Consider primary diagnosis, cause and/or related conditions

Who is Impacted? How does ICD-10 Impact?

• Physicians • Payer policies • Administrators • Pre-authorizations • Coders / Billers •PQRS • Technicians • Tracking of services • Receptionists • Marketing •IT Staff •Forms • Billing companies • Practice management system

• International Classification of Diseases, 10th • ICD-9 is >30 years old, outdated, obsolete Revision, Clinical Modification terminology • Developed by U.S. National Center for Health • Outdated codes producing inaccurate and limited Statistics (NCHS) in 1993 data • ICD-10 copywritten by the World Health • Inconsistent with current medical practice Organization (WHO) • Does not provide enough detail • ICD-10-CM replaces ICD-9-CM, volumes 1 and 2 • United States is one of last countries to adopt ICD- 10

ICD-10-CM ICD-10-CM

• Much greater specificity and clinical information • Codes that allow comparison of mortality and • Use of most specific code(s) is not optional morbidity data • Provides better data to: • Increased number of concepts and codes provided • Measure care • Disease classifications include health related conditions • Process claims • Track public health • Identify fraud and abuse • Conduct research

Benefits of ICD-10 Deadline

• More accurate payment for new procedures • Final rule for adoption of ICD-10-CM • Fewer rejected claims • Published in January 16, 2009 Federal Register (45 • Fewer improper claims CFR part 162) • Better understanding of new procedures • Compliance date is October 1, 2013 • Improved disease management • Initial delay to October 1, 2014

Source: Federal Register, Vol. 74, No. 11 1/16/09

• March 31, 2014 - HR 4302 signed by President ICD-9 ICD-10 Obama • 17 Chapters • 21 Chapters • SGR formula – temporary fix • 14,000 codes • ~ 69,000 codes • ICD-10 delayed … “The Secretary of Health and • 3-5 digits • 3-7 digits Human Services may not, prior to October 1, • First digit is numeric or • Digit 1 is alpha 2015, adopt ICD-10 code sets as the standard alpha (E or V) • Digit 2 is numeric code sets under section 1173(c) of the SSA and • Digits 2-5 are numeric section 162.1001 of 45CFR” • Digits 3-7 are alpha or numeric (alpha digits are not case sensitive)

Compare and Contrast “GEM”

ICD-9 ICD-10 • General Equivalence Mappings Example: Example: • No “simple” crosswalk contained in this file • Central corneal ulcer – • Central corneal ulcer right • GEM file is NOT a crosswalk, it is a mapping 370.03 – H16.011 • Expect annual update of files • Central corneal ulcer left • Eye codes translation is fairly straightforward – H16.012 • Central corneal ulcer bilateral – H16.013 • Central corneal ulcer unspecified – H16.019

“GEM” Files “GEM” Files

• Two sets of files • No decimal point in the codes • ICD-9 to ICD-10 • Three columns • ICD-10 to ICD-9 • Third column describes additional attributes • Each file contains “code pairs” – one from each set • Flags (approximate, no map, combination) • Combination entry • 1 indicates “on” (Approximate) • 0 indicates “off” (Direct hit, but verify)

I-9  I-10 + Flags • Use GEMS 36610 H259 00000 • Translating lists of codes 36611 H2589 10000 • Converting a system or application 36612 H25099 10000 • To study differences in meaning between two 36613 H25039 10000 systems 36614 H25049 10000 36615 H25019 10000 • Use Code Books 36616 H2510 10000 • Translating short list of codes 36617 H2589 10000 • Access to medical record 36618 H2520 10000 36619 H25819 10000 36619 H2589 10000

“1” in the first position in flag column = approximate

Conventions for the ICD-10-CM Organization of ICD-10-CM Format

• Introduction 1. Alphabetic Index • Conventions and Guidelines • Index of Diseases and Injury • Alphabetic Index to Diseases • Index of External Causes of Injury • Neoplasm Table • Table of Neoplasms • Table of Drugs and Chemicals • Table of Drugs and Chemicals • Index to External Causes 2. Tabular List • Tabular List of Diseases • Categories • Subcategories • Codes

Alphabetic Index Notes Tabular List

• Define terms • Categories • Provide direction • 3 characters – Chapter 7 – Disorder of the Eye and Adnexa (H00-H59) • Wound, superficial (see also specified injury type) • Subcategories th • Provide coding instructions •4 character further defines site, etiology, manifestation or state of disease or condition • Trichiasis (eyelid) – H02.059 •5th & 6th character increases specificity • with entropion – see Entropion

•7th Character Extension • A initial encounter • Some categories have applicable 7th characters • D subsequent encounter • Last character • S sequela • If code is not six digits, use “x” as placeholder • “x” as placeholder • For when characters are needed for expansion

Example Example Corneal Abrasion Corneal Abrasion

• Category – Chapter 19 – Injury, Poisoning . . . S05 – Injury of eye and orbit • Subcategory –  5th S05.0 – Injury of conjunctiva and corneal abrasion without foreign body • Specificity –  x 7th S05.01 – Injury of conjunctiva and corneal abrasion without foreign body right eye • Valid code – S05.01xA -- Injury of conjunctiva and corneal abrasion without foreign body right eye; initial encounter

7th Character Extension Example: Glaucoma Staging

For glaucoma staging, 7th denotes severity of disease 7th character “is to be assigned to each code in • 1 = mild 0 = unspecified subcategory H40.12 to designate the stage of glaucoma” • 2 = moderate 4 = indeterminate • Low-tension Glaucoma • 3 = severe •H40.12 • Low-tension Glaucoma, bilateral (cannot stop here!) •H40.123 • Low-tension Glaucoma, right eye, moderate stage •H40.1212 • Low-tension Glaucoma, left eye, severe stage •H40.1223

• Right and left designation •Example 1 = right H25.11 Age-related nuclear 2 = left cataract, right eye 3 = bilateral H25.12 Age-related nuclear 0 or 9 = unspecified cataract, left eye H25.13 Age-related nuclear cataract, bilateral H25.10 Age-related nuclear cataract, unspecified eye

Terminology Terminology “Laterality” “Combination Code”

Exception example (diseases of eyelids) • Single code used to •Examples • H02.011 Cicatricial entropion of right upper eyelid classify two diagnoses E11.321 – Type 2 diabetes • H02.012 Cicatricial entropion of right lower eyelid 1. Diagnosis with an mellitus with mild associated nonproliferative diabetic • H02.013 Cicatricial entropion of right eye, manifestation retinopathy with macular unspecified eyelid 2. Diagnosis with an edema • H02.014 Cicatricial entropion of left upper eyelid associated H59.032 – Cystoid macular • H02.015 Cicatricial entropion of left lower eyelid complication edema following cataract • H02.016 Cicatricial entropion of left eye, surgery, left eye unspecified eyelid • H02.019 Cicatricial entropion of unspecified eye, unspecified eyelid

Terminology Other “Conventions” “Code Also”

• Instructs that two codes •Example may be required to fully H18.03 – Corneal deposits describe a condition; in metabolic disorders sequencing depends on Code also associated severity of conditions and metabolic disorder reason for the encounter.

• “See” follows a main term •Examples • Etiology / manifestation •Example in the index indicating Lesion rule; the underlying H42 – Glaucoma in diseases that it is necessary to go eyelid – see Disorder, condition is listed first classified elsewhere to that term to locate the eyelid with the manifestation Code first underlying condition, correct code. listed second. such as: aniridia (Q13.1)

• “Code first” will be listed Q13.1 – Absence of iris • “See Also” follows a main Retinochoroiditis (see also Inflammation, chorioretinal) at the etiology code; “Use Aniridia term in the index additional code” will be indicating that another Use additional code for listed at the manifestation associated glaucoma (H42) term may also be useful. code.

Terminology Terminology “Excludes” “and”

• “Excludes 1” – excluded • Examples • When the term “and” is •Example code should never be used H01.0 – Blepharitis used in a narrative T26.11 – Burn of cornea at the same time as the Excludes 1 statement, it represents and conjunctival sac, right code above excludes 1 note. blepharoconjunctivitis (H10.5-) and / or. eye • “Excludes 2” – represents “Not included here”; H00.1 – Chalazion Condition excluded not part Meibomian (gland) cyst of condition represented by the code; patient may have Excludes 2 infected meibomian both conditions at the same gland (H00.02-) time; may use both codes when appropriate.

Abbreviations How to find a code

• NEC • “Not elsewhere classifiable” • Represents “other specified” • Detail for which a specific code does not exist •NOS • “Not otherwise specified” • Represents “unspecified” • For when a more specific code cannot be assigned

• Diagnosis codes are to be used and reported to the • Multiple codes may be required for a single condition highest number of characters available. that affects multiple body systems. • Signs and symptoms are acceptable when a • Principal diagnosis should be based on the condition definitive diagnosis has not been established by the that prompted the visit and was the primary focus of provider. treatment. • Do not code diagnoses documented as “probable”, • Code all documented conditions that coexist at the “suspected”, “questionable”, “rule out”, or “working time of the visit, and require or affect patient care diagnosis” or other similar terms indicating treatment or management. uncertainty. • Do not code conditions that were previously treated and no longer exist.

How to Use the ICD-10-CM How to Use the ICD-10-CM (continued)

1. Look up the main term in the Alphabetical Index, 3. Pay attention to the following index instructions in the scan subterm entries if needed. Review continued Alphabetical Index lines / additional subterms. • “see”, “see also”, and “see category” cross- references 2. Note parenthetical terms that help with code selection but do not affect code assignment • “with” and “without” notes • “omit code” notes • “due to” subterms • other instructions found in note boxes, such as “code by site” 4. Do not code from the Alphabetical Index without verifying the accuracy of the code from the Tabular List

How to Use the ICD-10-CM (continued) Cataract Example

5. Read all instructional material in Tabular Index, CC: cataracts, OU, slow decrease VA during including past 6 mos, trouble reading, glare worsening • “includes” and “excludes” notes Dx: Nuclear sclerotic cataracts OD>OS • “use additional code” and “code first underlying Tx: Schedule phaco IOL OD disease” • “code also” ICD-9: 366.16 Nuclear Sclerotic Cataract • fourth-, fifth-, sixth-, and seventh- digit requirements What is the appropriate ICD-10 code? 6. Consult the ICD-10-CM guidelines for use of specific codes 7. Confirm and assign the correct code

Step 1: Alpha Index: Search “cataract” • Step 3: See Cataract Senile Nuclear • - senile H25.9 • Cataract (cortical) (immature) (incipient) H26.9 • - - brunescens —see Cataract, senile, nuclear • - - combined forms H25.81- Step 2: Under “cataract” search “nuclear sclerotic” • - - coronary —see Cataract, senile, incipient • - nuclear • - - cortical H25.01- • - - sclerosis —see Cataract, senile, nuclear • - - hypermature —see Cataract, senile, morgagnian type • - - incipient (mature) (total) H25.09- • - - - cortical —see Cataract, senile, cortical • - - - subcapsular —see Cataract, senile, subcapsular • - - morgagnian type (hypermature) H25.2- • - - nuclear (sclerosis) H25.1-

Cataract Cataract

• Step 4: Go to H25.1- in Tabular List CC: Cataracts, OD, slow decrease VA during • H25.1 Age-related nuclear cataract past 6 mos, trouble reading, glare worsening • Cataracta brunescens Dx: Nuclear sclerotic cataracts OD>OS • Nuclear sclerosis cataract Tx: Phaco IOL OD • H25.10 Age-related nuclear cataract, unspecified eye • H25.11 Age-related nuclear cataract, right eye H25.13 NS, Cataract, OU • H25.12 Age-related nuclear cataract, left eye • H25.13 Age-related nuclear cataract, bilateral • Step 5: No additional instructions in tabular list • Step 6: No additional guidelines • Step 7: Assign code

Chapters Chapters

1. Certain Infectious and Parasitic Diseases (A00- 8. Diseases of Ear and Mastoid Process (H60-H95) B99) 9. Diseases of Circulatory System (I00-I99) 2. Neoplasms (C00-D49) 10.Diseases of Respiratory System (J00-J99) 3. Diseases of the Blood and Blood-forming Organs 11.Diseases of Digestive System (K00-K94) (D50-D89) 12.Diseases of Skin and Subcutaneous Tissue (L00- 4. Endocrine, Nutritional and Metabolic Diseases L99) (E00-E90) 13.Diseases of the Musculoskeletal System and 5. Mental and Behavioral Disorders (F01-F99) connective Tissue (M00-M99) 6. Diseases of Nervous System (G00-G99) 14.Diseases of Genitourinary System (N00-N99) 7. Diseases of Eye and Adnexa (H00-H59)

15.Pregnancy, Childbirth, and the Puerperium (O00- 19.Injury, Poisoning, and Certain Other O99) Consequences of External Causes (S00-T88) 16.Newborn (Perinatal) Guidelines (P00-P96) 20.External Causes of Morbidity (V01-Y99) 17.Congenital Malformations, Deformations, and 21.Factors Influencing Health Status and Contact with chromosomal Abnormalities (Q00-Q99) Health Services (Z00-Z99) 18.Symptoms, Signs, and Abnormal Clinical and Lab Findings, NEC (R00-R99)

Ch. 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) Diabetes Mellitus • Diabetes mellitus • Five diabetes mellitus categories • Combination codes that include • E08 Diabetes mellitus due to an underlying • Type of diabetes mellitus condition • Body system affected • E09 Drug or chemical induced diabetes mellitus • Complications affecting body system • E10 Type 1 diabetes mellitus • Sequenced based on reason for encounter • E11 Type 2 diabetes mellitus • E13 Other specified diabetes mellitus

*Use E11 if record does not indicate type of DM, but does indicate insulin use. Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines

Diabetes Mellitus Diabetes Mellitus Insulin use Examples

• All categories except E10 (Type 1 DM) require use • E11.9 Type 2 DM without complications of additional code to indentify any insulin use • E10.339 Type 1 DM with moderate NPDR without • Z79.4 – Long term (current) use of insulin macular edema

• E11.321 Type 2 DM with mild NPDR with macular edema & • Z79.4 Long-term current use of insulin (if documented)

Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines

While sitting at the 10th tee 19.Injury, Poisoning, and Certain Other box, your patient is struck in Consequences of External Causes (S00-T88) the left eye with a golf ball 20.External Causes of Morbidity (V01-Y99) causing a traumatic 21.Factors Influencing Health Status and Contact with hyphema. Code this Health Services (Z00-Z99) encounter with ICD-10 codes.

Case Study Documentation Considerations ICD-10 Codes

S05.12xA Contusion of eyeball and orbital tissues, • Laterality left eye, initial encounter • Is your assessment specific to which eye or V86.59xA Driver of golf cart injured in nontraffic eyelid? accident • Etiology / Manifestation W21.04xA Struck by golf ball • Does your chart note list both the disease and the associated manifestation? Y92.39 Golf course as place of occurrence • Specificity Y93.53 Activity, golf • Is the impression as specific as possible for a particular condition?

Documentation Considerations Documentation Considerations History – ROS History – HPI & PFSH

Old New Old New • Diabetic • Type II diabetes on insulin • Eyelid laceration • Laceration right eyelid from contact with a chisel • Cataract OD from injury • Cataract OD caused by (workbench tool) • Hypertension driver side airbag • Hypertension; history of • FB sensation OD, poor • FB sensation OD, poor tobacco use “blink” 3 days “blink” 3 days; recent dx of • Shingles Bell’s palsy • HIV positive • Shingles w/ear infection • Asymptomatic HIV • Elevated IOP; seen at • Family history of glaucoma health fair

Old New Old New • Chalazion OS • Chalazion LLL • Myopia • Myopia OU; regular • BDR OU • Type II diabetes with mild astigmatism OD NPDR w/out macula • CME OD after cataract sx edema; taking insulin •CME • Mechanical ptosis OU • Iritis OU • Chronic iritis OU •Ptosis • Hyphema OD • Traumatic hyphema OD • Complex cataract • NS cataract OD, floppy iris syndrome, adverse effect • No maculopathy • RA taking plaquenil; no of Tamsulosin ocular disease

Common Patient Syndromes Key Points in Preparation

• R46.0 – Low level of • R19.6 – Halitosis (bad • History and Timeline personal hygiene breath) • Gather resources • Assess and Improve Documentation • Practice, Practice, Practice • One Step at a Time

Begin Using ICD-10 Codes Begin Using ICD-10 Codes

• Practice early, practice often! • Divide tasks in to workable segments • You are asking people to change habits or • refractive error and cataract codes patterns • glaucoma • This takes time and practice • cornea and external eye codes (plastics) • Continue reporting ICD-9 for claims submission • retina and diabetes code • “Double code” a few of claims with ICD-10 codes • Injuries and infections • Compare your answers with each other • Use this time to assess tools available to you • Use for training and glossary most common codes • Apps, websites etc • Use this time to educate staff • History taking, documentation, anatomy

• www.cms.gov/ICD10/ • www.aapcps.com • www.ahima.org • www.cdc.gov/nchs/icd.htm • www.who.int/en/

Useful Aids More help…

• “Apps” For additional assistance or confidential consultation, • Apple – iPhone please contact us at: • Android • World Health Organization (800) 399-6565 • AAPC Code Translator or • http://www.aapc.com/ICD-10/codes/index.aspx www.CorcoranCCG.com • Others [email protected] • http://www.icd10data.com/

APPENDIX

How To SEARCH For A Code Within ICD‐10‐CM

General guidelines: 1. ALPHABETIC index a place to START 2. TABULAR List is most specific – code from here! 3. Report HIGHEST number of characters possible

Specific guidelines: 1. Identify reason for visit/encounter a. Diagnoses b. Problems c. Complaints d. Signs and symptoms i. Used for reporting when no related definitive diagnosis is established e. Conditions i. Report those that are an integral part of a disease process 1. Do not use additional codes ii. Conditions that are not an integral part of a disease process 1. Code when present (see below if “multiple conditions”)

2. Multiple coding for a single condition a. Required for i. Any condition with a “use additional code” note b. May be needed for i. Fully describing a condition, such as ii. Late effects iii. Complication codes iv. Obstetric codes

3. Acute and chronic conditions a. If both are present i. Code both ii. Sequence acute code first ______560 E. Hospitality Lane ▪ Suite 360 ▪ San Bernardino, California 92408 ▪ Telephone: (800) 399-6565 FAX (909) 890-1333 ▪ www.corcoranccg.com

4. Combination code a. Single code to classify either i. Two diagnoses ii. Diagnosis with associated secondary process iii. Diagnosis with associated complication b. Do not use multiple codes if combination code identifies all elements

5. Late effects (sequelae) a. Residual effect after acute phase of injury/illness b. No time limit c. Condition code sequenced first, late effect code sequenced second d. Do not use with acute injury code

6. Impending or threatened condition a. If condition did occur, code as diagnosis b. If condition did not occur, reference “impending”, “threatened” i. If subentry terms for “impending” or “threatened” are listed: 1. Assign the appropriate code ii. Are not listed: 1. Code existing underlying conditions c. Do not code the impending/threatening condition

7. Reporting same diagnosis code more than once a. Each code may be used once per encounter

8. Laterality a. For codes that can have bilateral sites b. Final character of code indicates laterality (0 or 9, 1, 2, 3) c. If no bilateral code is provided, assign separate codes for right and left sides 9. RARE for Ophthalmology: Documentation for BMI and pressure ulcer stages a. May be based on documentation from clinicians who are not the patient’s provider b. Associated diagnosis must be documented by patient’s provider c. BMI codes are always secondary diagnoses

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